in Specific psychiatric disorders

Long term outcome in BPAD and Schizophrenia

Catherine commented:

‘I disagree with the comment about bipolar and schizophrenia being chronic, remitting etc. There are a minority who are so badly affected that they never live independently, but the majority go on to either recover, or manage their illness very well, working, hobbies etc and have a good quality of life.’

The point I was making about the chronicity of schizophrenia/bipolar disorders is that in the film ‘Ruth’ is presented to us has having recovered from her mental health crisis with no mention of follow up.  For anyone who doesn’t know, it’s often common practice in healthcare for a patient to be seen by a doctor on at least a short term basis after a problem has resolved as there may be a chance of it coming back, and psychiatry is no exception to this. We know from the film that she already has a diagnosis of BPAD and so she must have had trouble before.  The episode presented to us is quite severe, so I would say that her chance of having another relapse is high, especially with bipolar disease

Schizophrenia is considered to have a wide variety in outcomes, that said, there are not millions of long term studies; here are the ones mentioned in the Shorter Oxford Textbook of Psychiatry:

Kraeplin Dementia praecox and paraphrenia 1919
Concluded that only 17% of his patients were socially well adjusted many years later

Mayer-Gross Die Schizophrenie in Bumke’s Handbuch der Geisteskrankheiten Vol 9 Springer Berlin 1932
Reported social recovery in 30% patients at 16 years all from the same clinic

Brown et al (1966) reported social recovery in 56% in Schizophrenia and social care Maudsley Monography 17 Oxford University Press  London

Manfred Bleuler (1972,1974) followed up 208 patients who had been admitted into hospital in Switzerland between 1942 and 1943.  Twenty years after admission 20% had complete remission of symptoms and 24% were severely disturbed. 

Ciompi did a larger study looking at 1642 records diagnosed as having schizophrenia between 1900 and 1962, with an average follow up of 37 years.  A third of patient were found to have good or fair social outcome.  Symptoms were often less severe in later life. 

Johnstone E.C. (1991) Disabilities and Circumstances in Schizophrenic patients: A follow up study British Journal of Psychiatry  159 supplement 13 5-46, did a 3-13 year follow up of patients with schizophrenia discharged from 1975 – 1985 and found that almost half had a good social outcome. 

Tsoi and Wong (1991) A fifteen year follow up of Chinese Schizophrenic patients Acta Psychiatrica Scandinavica 84 217-220  did a 15 year follow up of 330 patients with first admission Schizophrenia and in this found that almost one third recovered but 17% remained unable to function outside the hospital. 

Finally in the USA Carone et al (1991 – a busy year) found that only 15% of patients meeting DSM-III criteria for schizophrenia recovered after 5 years. 

Full admission: I haven’t read any of these papers/books, and for these papers to be comparable then they should all use similar definitions for schizophrenia and select similar patients – there would be no utility is comparing patients after their first admission and patients who have been admitted countless times.  With these caveats, it appears that prognosis has improved since schizophrenia was first studied.  In the earlier studies the patients would have had no access to modern pharmaceutical treatments 

Schizophrenia outcome is further discussed in  Schizophrenia Research Volume 1, Issue 6, November-December 1988, Pages 373-384

The factors associated with good prognosis in Schizophrenia:

Sudden onset; Short episode;No previous psychiatric history; Prominent affective symptoms; Paranoid type of illness; Older age of onset; Married; No personality disorder; Employed; Good social support; Good compliance with treatment

Poor prognosis is associated with:

Insidious onset; Long episode;Previous psychiatric history; Negative symptoms; Enlarged lateral ventricles; Male gender; Younger age of onset; Single/separated/widowed/divorced; Personality disorder; Poor work record; Social isolation; Poor complicance with treatment

If you’ve still got the strength, read on for outcome of bipolar affective disorder.  Again this is from the Shorter Oxford Textbook of Psychiatry:

The average length of a manic episode (treated or untreated) is six months

At least 90% of patients with mania experience further episodes of mood disturbance

Over a 25 year follow up on average bipolar patients experience 10 further episodes of mood disturbance

The interval between episodes becomes progressively shorter with both age and the number of episodes

Nearly all bipolar patients recover from acute episodes, but less than 20% of patients with this disorder achieve a period of 5 years of clinical stability with good social and occupational peformance

It is estimated that 10% of patient with unipolar depression will eventually turn out to have a bipolar illness.   

So, with both bipolar affective disorder and schizophrenia, I do think that if a patient has one episode they are likely to be troubled by the illness at a later date and this is what I meant by a chronic condition.       

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  1. Great post Frontier – very useful indeed actually!

    I’ve just been reviewing the history of psychosis and the schizophrenia disease entity for some research I’m doing. You rightly draw attention to the problems with comparing the research as they will have differing outcomes according to differing definitions.

    Just to add to that, I’ve been struck that leading historians of psychiatry (e.g., Beer; Berrios) accept that the ‘schizophrenia’ (or ‘dementia praecox’) construct has changed so much since originally conceived by Kraepelin that it’s hard to argue it’s the same thing these days. For instance, here’s a quote from Berrios, Luque and Villagran (2003) :

    "Historical research shows that there is little conceptual continuity between Morel, Kraepelin, Bleuler and Schneider. Two consequences follow from the finding. One is the idea of a linear progression culminating in the present is a myth. The other that the current view of schizophrenia is not the result of one definition and one object of inquiry successively studied by various psychiatric teams but a patchwork made out of clinical features plucked from different definitions. More research is needed to find out what led to this sorry state of affairs. It might simply be the result of historical ignorance or the application of some pedestrian operationalism."

    Furthermore, leading orthodox psychiatrists and nosologists (i.e, Ian Brockington), have accepted the neo-Kraepelinian distinction between BAPD and schizophrenia is scientifically unsustainable.

    Schizophrenia forum links one two three

    Here’s a 2007 quote by Robin Murray and Rita Dutta from the Institute of Psychiatry:

    "We accept that the neo-Kraepelinian view that schizophrenia and bipolar disorder are totally discrete entities is not supported by the available scientific evidence."

    Even Kraepelin himself had doubts about the distinction between manic-depressive insanity and dementia praecox:

    "It is becoming increasingly obvious that we cannot satisfactorily distinguish these two diseases." (Kraepelin, 1920).

    There’s also a degree of circularity where to have ‘schizophrenia’ is to have an illness which follows a chronic unremitting deteriorating course, but where you can only receive such a diagnosis after demonstrating that your illness has a chronic unremitting deteriorating course.

    The legions of people who have psychotic experiences and never encounter psychiatry and the multitudes whose schizophrenia diagnosis shifts to schizoaffective disorder or BAPD after showing improvement suggest that there may be more room for optimism with respect to the experiences themselves. That is, people who get better often get a different diagnosis.

    I think it follows from the above points that the historical research on prognosis you mention needs to be reinterpreted given the inherent circularity and possible invalidity of the diagnoses they are based upon.

    Sorry for these long comments! I’m not even going to mention the recovery approach, iatrogenesis, and the UK-US Diagnostic Project…

  2. I wonder if what you and Catherine are differing on is around what recovery means.

    Lots of people live full and independent lives with mental health symptoms – some receiving help and support from any number of professionals (including psychiatry) and some receiving little or minimal professional support.

    Certainly the shift towards thinking and working within a recovery model has raised a lot of interesting issues within the services that I have worked in as a trainee, although I am not always sure how aware people are of their own assumptions and definitions of what recovery means when they work with individuals – so it can cause interesting ruptures between professionals – but that is probably the topic for another post.

    BTW – I really should say, I am really enjoying your blog. It makes for very interesting reading and discussion.

  3. This may sound frivolous but: I love those cat paintings! Thanks for the link to the original site. Is there a particular story behind these?

  4. I think that the cat pictures are great too. They’re by an artist called Louis Wain. I’ll write a post on him sometime, but in the meantime here’s the wikipedia link. There was no particular reason for choosing this picture for this posting

  5. Thanks! I had a look at his wikipedia entry – he seems to have had an interesting life. He didn’t get ill til he was 57 it seems, and was a well-known illustrator. Fascinating.

    There’s an interesting bit in particular about those 4 pictures – that he may not have done them in order. To me they look more like a series of studies on abstraction done by an artist who is interested in how much you can deviate from an exact replica of the subject and still communicate its essence and its form (oh dear, I sound like a gallery pseud, but you know what I mean). I suspect he knew exactly what he was painting. I have 2 cats and the more abstract pictures make me think of when they cause chaos around here running up and down and round and round cardboard boxes :). Or maybe he saw “modernist” work in the press and played with the geometric shapes a bit – that whole movement was just developing at that time, wasn’t it?

    Links from wikipedia had many many more of his drawings – which has led to me and my co-workers having a somewhat, er, reduced level of productivity this afternoon as we contemplate all the cute kitties :-).


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