An optimistic twist for schizophrenics.
By the early 1980s, however, the same patients had punched holes in the pessimistic predictions of their psychiatrists. A majority were living in the community and leading much fuller lives than anyone had expected, according to several Yale University researchers whose surprising findings were presented last week in Dallas at the annual meeting of the American Psychiatric Association.
"These were bottom-of-the-barrel patients," says study director Courtenay M. Harding. "Some of them were not expected to ever leave the hospital. But it appears that in many cases schizophrenia may take 10 to 20 years to turn around. Still, we can't predict who will eventually improve and who won't."
About 1 percent of the U.S. population has schizophrenia. The latest manual of psychiatric diagnoses, published in 1980, states that patients with repeated bouts of schizophrenia are likely to get worse, while recovery is rare. Yet the Vermont patients, whose original conditions were re-diagnosed using current psychiatric criteria, do not fit this picture, contend Harding and her co-workers.
They located nearly all 269 patients originally labeled as schizophrenic or suffering from some other severe mental disorder. Case records, minus diagnoses, were analyzed and assigned up-to-date psychiatric labels. The investigators selected 118 subjects as having met modern criteria for schizophrenia. Interviews were conducted with 82 of them who were still alive over 20 years after receiving intensive job and psychological rehabilitation upon release from the hospital. (At the time, a national effort to get patients out of state mental hospitals had just begun.) Friends and families of 28 deceased patients were also interviewed. Eight patients refused interviews or could not be located.
One-half to two-thirds of these once "chronic" schizophrenics showed -- or had shown before their deaths -- varied degrees of productivity and social involvement, says Harding. Most displayed slight or no schizophrenic symptoms, had one or more moderately to very close friendS, required little or no help meeting basic needs and led relatively full lives. Only 40 percent of the subjects reported full-time employment in the previous year, but this may have been due primarily to their age, which averaged 61 years at follow-up, points out Harding.
She says that significant improvement on most outcome measures was found for almost 80 percent of the living subjects in the study.
Their adjustment took a variety of forms. Some had a virtually full recovery; others had devised ways to control their symptoms in social situations. A number of subjects were working but were otherwise socially isolated, while some had warm relations with family and friends but did not work.
The Vermont data parallel the findings of four similar long-term studies of schizophrenics reported in the 1970s, says Harding. Researchers in Europe and the United States followed a total of more than 1,100 subjects for up to 37 years and reported that about half of them recovered or improved significantly. The Yale investigators are the first, however, to examine subjects who have been rediagnosed according to the current--and most stringent--definition of schizophrenia.
"The current psychiatric diagnostic system can't predict the long-term outcome of schizophrenics," asserts Harding. Several follow-ups conducted five years after patients have left the hospital indicate that most schizophrenics either deteriorate or do not improve. Much of the Vermont sample was doing poorly five years after leaving the hospital, she says, yet many of the same patients slowly recovered over the next one or two decades.
Other investigators at the meeting were encouraged by the positive findings, but also expressed reservations.
"Schizophrenics may do much better than we suspected all along," says psychiatrist Stephen I. Kramer of the University of North Carolina at Chapel Hill. But, he adds, the Yale researchers were at a disadvantage in having to rediagnose the original patients using only case records. Also, the effect of different treatments and family support on recovery is not clear, continues Kramer. Schizophrenia encompasses a range of disorders, and some, such as those marked by paranoia, may have a better outcome than others, he notes.
"Harding's sample got special [rehabilitation] programs," says psychiatrist Martin Harrow of the Michael Reese Hospital and Medical Center in Chicago. "The results may show the importance of these kinds of programs for recovery. I'm still not sure that there's an upward transition for schizophrenics after 20 years or more."
There are problems in rediagnosing patients, acknowledges Harding, but it is clear that at least half of the severely ill subjects eventually improved. There is reason for optimism about the future for "hard-core" schizophrenics, she says; treatment should foster the slow struggle back to healthy functioning.
"If you're a schizophrenic, you don't have to be a burned-out shell of a person," explains Harding. "You can be a phoenix."
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|Date:||Jun 1, 1985|
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