Elsevier

Schizophrenia Research

Volume 195, May 2018, Pages 469-474
Schizophrenia Research

An examination of components of recovery after five years of treatment in an early intervention program for psychosis

https://doi.org/10.1016/j.schres.2017.08.054Get rights and content

Abstract

Recovery from psychotic disorders includes both symptomatic and functional components. Progress in understanding recovery requires careful replication and extension of findings using comparable measures. In the current paper, we present a study of five year recovery rates in an early intervention program in London, Canada with the same operational criteria as those used in a previous report from the OPUS cohort in Denmark. Our analysis extends the OPUS reports by including additional potential predictors of overall recovery, such as cognitive functioning, adherence to medication and early social support, and examining rates and predictors of individual components of recovery at five year follow-up. Consistent with reports from OPUS, we found younger age of onset and lower initial severity of negative symptoms to predict greater likelihood of overall recovery. Different patterns of predictors emerge when we examine individual components of recovery. Adherence to medication during the first year was the sole independent predictor of remission of positive symptoms, while early social adjustment and social support were more likely to predict negative symptom and functional aspects of recovery at five years. Cognitive functioning, as represented by IQ, did not predict any aspects of recovery. Our findings suggest the importance of examining the predictors of individual components in the quest to improve overall recovery.

Introduction

Recovery from psychotic disorders should, at least, include symptom remission and good psychosocial functioning (Harvey and Bellack, 2009, Jăăskeläinen et al., 2013, Liberman, 2002, Whitley and Drake, 2010). Prospective studies from initial treatment are particularly important in establishing rates and predictors of recovery. Such studies, which include long term follow-ups, use varying operational definitions of recovery, although a combination of symptom remission and scoring above 60 on the Global Assessment of Functioning (GAF) or Social and Occupational Functioning Assessment Scale (SOFAS) are the most common elements (Albert et al., 2011, Austin et al., 2013, Chang et al., 2012, Mason et al., 1995, Verma et al., 2012).

Among the most specific and conservative criteria are those in follow-up studies of the OPUS program (Albert et al., 2011, Austin et al., 2013, Petersen et al., 2008), which require stable remission of both positive and negative symptoms, no psychiatric admissions and independent living over two years, as well as employment and a GAF-function score of over 60 [GAF-F; (Pedersen et al., 2007)]. Albert et al. (2011) report 15% of patients in their cohort met these criteria at five years with independent predictors of recovery being female sex, younger age of onset, better premorbid adjustment and lower negative symptoms at presentation. In a 10 year follow-up of the same cohort, Austin et al. (2013) found sex no longer predicted recovery, but younger age and initial negative symptoms did. These authors noted the importance of replication and the desirability of assessing other predictors of recovery.

Relationships between symptom remission and psychosocial functioning, can be modest (Carpenter and Strauss, 1991, Revier et al., 2015) and, therefore, insight into predictors of recovery requires investigation with reference to each its components.

Why identify predictors of recovery? One purpose relates to understanding intrinsic variations in course. For instance, it has been suggested that an acute onset can denote an illness with more benign course (Harrison et al., 1996, Jablensky et al., 1992, Röpcke and Eggers, 2005, Wiersma et al., 1998). Acuity of onset, however, is unlikely to be modifiable and, therefore, of limited interest as a target of intervention. Prognostic indicators could also inform decisions about service provision. Demographics or early course characteristics, if predictive of recovery, could have implications for the type or intensity of service provision. Finally, prognostic indicators, which are potentially modifiable, could be targets for intervention. For instance, to the extent that early adherence to treatment or social support predict recovery, there are implications for interventions addressing these factors.

Here we examine rates of overall recovery and constituent elements at five years, as well as the significance of early characteristics in predicting them for patients in the Prevention and Early Intervention Program for Psychosis (PEPP) in London, Canada.

Section snippets

Method

Participants entered treatment between March 18, 1997 and February 20, 2002. Criteria for inclusion were having a diagnosis of a psychotic disorder, not previously treated with antipsychotic medication, living within the catchment region and between age 16 and 50. The PEPP treatment protocol is described elsewhere (Malla et al., 2003, Norman et al., 2011).

There were 233 individuals admitted to PEPP during the recruitment period, of whom 188 (81%) agreed to participate, and provided informed

Results

It was possible to complete assessments up to five years for 132 individuals recruited into the study (70.2%). There were no significant differences in early characteristics between those who were and were not retained. To facilitate comparisons to Albert et al. (2011) we restricted our analysis to the 116 clients who did not have an affective or substance-induced psychotic disorder. Clinical and demographic characteristics are in Table 1. Only ten individuals (7.1%) dropped out of treatment in

Discussion

We used common methods in an effort to replicate and extend findings of a previous prospective study of first treated episode psychosis patients (Albert et al., 2011, Austin et al., 2013). Extensions included examination of components of recovery in addition to the composite index and inclusion of additional predictors, including cognitive functioning, mode of onset and early treatment adherence.

Conclusions

While it is important to acknowledge that results of prospective analyses, such as we have presented, do not convincingly demonstrate causality; the finding that adherence predicts remission of positive symptoms is consistent with literature demonstrating causality (Carbon and Correll, 2014). Similarly, the finding of social support during early treatment predicting aspects of functional outcome independently of premorbid social adjustment is consistent with findings on the beneficial effects

Funding body agreements and policies

This research was supported by grant #MOP-57925 from the Canadian Institutes of Health Research. Aside from funding, the Canadian Institutes of Health Research had no further role in the design of the research, collection, analysis and interpretation of data, writing of the paper and decision to submit the paper for publication.

Contributors

Ross Norman had primary responsibility for the conception and design of the study, as well as the analysis and interpretation of results. Arlene MacDougall contributed to the rationale of the report and analysis and interpretation of the findings and writing of the manuscript. Rahul Manchanda and Raj Harricharan contributed to the completion of the study and revising and finalizing the paper.

Conflict of interest

All authors declare that they have no conflict of interest.

Acknowledgements

he authors also wish to acknowledge the support of staff and clients of the Prevention and Early Intervention Program for Psychoses (PEPP) in London, Canada.

References (52)

  • D. Roe et al.

    The relation between objective and subjective domains of recovery among persons with schizophrenia-related disorders

    Schizophr. Res.

    (2011)
  • R. Schennach-Wolff et al.

    Defining and predicting functional outcome in schizophrenia and schizophrenia spectrum disorders

    Schizophr. Res.

    (2009)
  • N.C. Andreasen

    Scale for the Assessment of Negative Symptoms

    (1983)
  • N.C. Andreasen

    Scale for the Assessment of Positive Symptoms

    (1984)
  • N.C. Andreasen et al.

    Remission in schizophrenia: proposed criteria and rationale for consensus

    Am. J. Psychiatry

    (2005)
  • S. Arndt et al.

    A longitudinal study of symptom dimensions in schizophrenia

    Arch. Gen. Psychiatry

    (1995)
  • M. Becker et al.

    A new patient focused index for measuring quality of life in persons with severe and persistent mental illness

    Qual. Life Res.

    (1993)
  • M. Bleuler

    The Schizophrenic Disorders: Long-term Patient and Family Studies

    (1978)
  • H.E. Cannon-Spoor et al.

    Measurement of premorbid adjustment in chronic schizophrenia

    Schizophr. Bull.

    (1982)
  • M. Carbon et al.

    Clinical predictors of therapeutic response to antipsychotics in schizophrenia

    Dialogues Clin. Neurosci.

    (2014)
  • W.T. Carpenter et al.

    The prediction of outcome in schizophrenia. IV: eleven-year follow-up of the Washington IPSS cohort

    J. Nerv. Ment. Dis.

    (1991)
  • C.M. Cassidy et al.

    A comparison study of multiple measures of adherence to antipsychotic medication in first-episode psychosis

    J. Clin. Pharmacol.

    (2010)
  • S.K. Chan et al.

    10-year outcome study of an early intervention program for psychosis compared with standard care service

    Psychol. Med.

    (2015)
  • W.C. Chang et al.

    Prediction of remission and recovery in young people presenting with first-episode psychosis in Hong Kong: a 3-year follow-up study

    Aust. N.Z. J. Psychiatry

    (2012)
  • W.T. Chien et al.

    The schizophrenia care management program for family caregivers of Chinese patients with schizophrenia

    Psychiatr. Serv.

    (2010)
  • M.T. Compton et al.

    Mode of onset of psychosis and family involvement in help-seeking as determinants of duration of untreated psychosis

    Soc. Psychiatry Psychiatr. Epidemiol.

    (2008)
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