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Natural course of schizophrenic disorders: a 15-year follow-up of a Dutch incidence cohort.

Wiersma D, Nienhuis FJ, Slooff CJ, and Giel R (1998).

Schizophrenia Bulletin 24: 75-85.

The study’s finding of a relationship between delays in mental health treatment and a longer duration of psychosis supports existing evidence that early intervention with antipsychotic medications improves the long-term course of schizophrenia. Because patients with more relapses tended to do worse, the study further suggests that preventing relapses may be important because it could have the power to change a patient’s mental health outcome by preventing further damage and deterioration.

Because most studies of schizophrenia do not control for patients’ stage of illness, patients with a heterogeneous course, or those with a chronic form of the illness, tend to be overrepresented in these studies. In contrast, this study looked at the course of schizophrenia over 15 years in a group of 82 first-contact cases in the Netherlands. Thus, the authors had a chance to determine whether the illness gradually worsens or improves over time, and they were also able to determine an overall pattern for the course of illness, and whether any factors predicted outcome.

They used a broad definition of schizophrenia (ICD-9 295, 297, 298.3-9), and found a pattern of chronicity and relapses with a high risk of suicide. In this study, 12% of the patients experienced a complete remission after one episode; another 14.6% had two or more episodes followed by a complete remission; 17% had one or more episodes followed by partial remission, usually characterized by anxiety and depression; 11% had only one episode but remained chronically psychotic because they never fully recovered from that episode over the 15-year evaluation period; 33% developed a negative syndrome after one or more episodes; and 12% were lost to follow-up.

The study also found that two-thirds of the subjects had at least one relapse, and after each relapse one out of every six subjects did not recover; one out of every 10 committed suicide; and one out of every seven had at least one episode with affective psychotic symptoms that started on average six years after the onset of schizophrenia. One third of the patients had three or more psychotic episodes, occurring six years after their first episode; with each episode there was an increased probability of chronic psychosis or persistent negative symptoms. With the exception of the first episode, there was also a gradual increase in mean duration of each subsequent psychotic episode (second episode=9 months, third episode=15 months, and fourth episode=27 months).

The authors also studied risk and predictive factors, and found that demographic, illness, and treatment variables at onset of the illness had very little predictive ability, although being married, not dependent on social assistance, having good premorbid functioning, an acute onset and immediate treatment predicted shorter first and subsequent psychotic episodes. In contrast, insidious onset of illness and delays in mental health treatment were risk factors that predicted the longer duration of first or subsequent episodes.

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