Is going into stable symptomatic remission associated with a more positive development of life satisfaction? A 10-year follow-up study of first episode psychosis

Abstract

Background

Quality of life is an important outcome measure for patients with psychosis.

We investigated whether going into stable symptomatic remission is associated with a more positive development of subjective quality of life (S-QoL) and if different patient characteristics are associated with S-QoL depending on remission status.

Methods

Three hundred and one patients with a first-episode psychosis were included at baseline. At 10-year follow-up 186 were reassessed. QoL was assessed by Lehman's Quality of Life Interview. Remission was defined according to criteria proposed by the Remission in Schizophrenia Working Group. One-way ANOVA, mixed model analysis, bivariate correlations and multiple regression analyses were performed.

Results

Patients going into stable symptomatic remission showed a more positive S-QoL-development over the follow-up period and reported higher life satisfaction at 10-year follow-up compared to non-remission. At 10-year follow-up, depressive symptoms and alcohol abuse or dependence explained a significant amount of variance in S-QoL among patients in remission. Among patients in non-remission, PANSS excitative component explained a significant amount of variance in S-QoL. All significant effects were negative.

Conclusions

Stable symptomatic remission is associated with a more positive development of overall life satisfaction. Furthermore, different symptoms influence life satisfaction depending on status of remission. This has important clinical implications. While patients in remission might need treatment for depressive symptoms to increase S-QoL, in non-remission measures aiming to decrease hostility and uncooperativeness should be part of the treatment approach. Alcohol problems should be treated regardless of remission status.

Introduction

Over the last decades, the heterogeneity of long-term outcome in schizophrenia and related psychotic disorders has become increasingly clear. Some patients experience continuous symptoms of psychosis, while others develop stable symptomatic remission (Andreasen et al., 2005, Emsley et al., 2007, Lambert et al., 2008, Wunderink et al., 2009, Hegelstad et al., 2013, Austin et al., 2013). The most commonly used definition of remission today is based on the criteria proposed by The Remission in Schizophrenia Working Group (RSWG) (Andreasen et al., 2005). According to these criteria, being in remission is characterized by lack of both positive symptoms (e.g. hallucinations, delusions and disorganization), and negative symptoms (e.g. blunted affect and avolition) over the last six months (the time criterion). As such, the criteria do not include affective symptoms, substance use problems and other important aspects such as daily life functioning and quality of life (QoL).

QoL is most commonly conceptualized as having both an objective part reflecting socio-economic factors, and a subjective part (S-QoL) reflecting life satisfaction (Katschnig, 2000, Malla and Payne, 2005, Karow et al., 2014, Eack and NewHill, 2007). Life satisfaction is an aspect transcending both symptoms and functioning, and thus a central part of outcome in chronic disorders. We have recently shown that socio-economic factors like more family contact, better financial situation and more daily activities are important for a positive S-QoL-development the first 10 years after a first episode psychosis (FEP) (Gardsjord et al., 2016). Regarding psychiatric symptoms, S-QoL has been shown to be most consistently associated with general psychopathology such as depressive symptoms, while positive psychotic symptoms are probably of less importance (Eack and NewHill, 2007, Priebe et al., 2011).

Previous longitudinal FEP-studies investigating the association between S-QoL and symptomatic remission show mixed results. Both Boden et al. (2009) and Jaracz et al. (2015) found remission at follow-up associated with higher S-QoL-level. In the study by Jaracz et al. (2015), the difference in S-QoL between remission and non-remission was stable over the follow-up period. Hence, one cannot conclude from the study that going into remission is associated with a more positive S-QoL-development. The same applies to the study by Boden et al. (2009) as only data from the follow-up assessment were collected. These studies didn't apply the time criterion when defining remission. Wunderink et al. (2007), applying the time criterion, found a small increase in S-QoL from baseline to follow-up regardless of remission status and no association between remission status and S-QoL at follow-up. This study included patients in remission from positive psychotic symptoms at baseline, and is therefore less suitable to investigate if going into stable remission is associated with a more positive S-QoL-development. To sum up it is unclear if going into stable remission is associated with a more positive S-QoL-development. A follow-up study of FEP included at first treatment is suitable for addressing this question.

Given the heterogeneity in outcomes, patient characteristics associated with S-QoL may be different among patients in remission and non-remission. This has not been investigated according to criteria proposed by the RSWG. In addition, stable remission of symptoms is not necessarily associated with adequate functioning/full recovery (Hegelstad et al., 2012). The impact this has on life satisfaction has not been investigated before.

In the present study we address the knowledge gap described in the previous paragraphs. We aimed to investigate;

• if being in stable symptomatic remission was associated with a higher life satisfaction at 10-year follow-up,

• if being in full recovery is associated with higher life satisfaction compared to patients in remission, but not in full recovery

• if patients that go into stable symptomatic remission show a more positive development of life satisfaction compared to non-remission,

• associations between life satisfaction and psychiatric symptoms, socio-economic factors and substance use problems at 10-year follow-up in groups according to remission status.