The course of schizophrenia: Progressive deterioration, amelioration or both?

doi:10.1016/j.schres.2006.12.013

Schizophrenia Research

Volume 91, Issues 1–3, March 2007, Pages 254-258

https://doi.org/10.1016/j.schres.2006.12.013 Get rights and content

Abstract

Background

Schizophrenia may follow a course of amelioration, deterioration or stability. It is possible that deterioration at the aggregate level may be due to a sub-group of patients with a tendency to deteriorate.

Aims

To examine the course of schizophrenia in a national population-based cohort.

Methods

All first admissions for schizophrenia in Israel 1978–1986 were followed for readmissions in the Israeli psychiatric hospitalization registry for 10 years (n = 6865). Readmission rates were examined using cluster analysis. This was followed by an examination of changes in readmission patterns.

Results

Cluster analysis identified a small cluster of patients who spent more days in the hospital over time and two clusters that improved. A priori classification of the patients into deteriorating, improving and stable (based on days hospitalized per year) revealed that approximately 75% of patients improved over time.

Conclusions

Over time a majority of patients appear to improve and a minority appear to deteriorate.

Introduction

Schizophrenia was originally thought to follow a course marked by deterioration in the ability to function (Kraepelin, 1971) and more recently to follow ‘a relapsing course for life in most sufferers’ (Davies, 1994), a view that remains widely accepted (Walker et al., 2004). Contrary to the notion of progressive deterioration, others propose and demonstrate that the course of schizophrenia improves with time and is thus best described as following a course of ‘progressive amelioration’ (Eaton et al., 1992a, Eaton et al., 1992b, Eaton et al., 1998, Mortensen and Eaton, 1994, Munk-Jörgensen et al., 1991).

These divergent views of the course of schizophrenia have recently been re-evaluated by examining readmission rates following an initial psychiatric hospitalization using data from a psychiatric registry in Denmark (Olesen and Mortensen, 2002, Olesen and Parner, 2006). Readmissions are a proxy measure of symptomatic exacerbation. When studying readmission risk, it is appropriate to account for the possible presence of a sub-group characterized by high readmission rates (Olesen and Mortensen, 2002). Research of hospital admission rates indicates that at the aggregate level there is an increase over time, thus suggesting that schizophrenia follows a deteriorating course. Some research, however, suggests that this is due to a small sub-group with a very poor course (Olesen and Mortensen, 2002).

Clarifying the course of the patients with high readmission rates appears to be relevant from a public health perspective since patients with schizophrenia occupy approximately one-quarter of all psychiatric hospital beds and represent about half of admissions to hospital (Mueser and McGurk, 2004). At present, however, the proportion of patients in the population whose course of readmission is marked by deterioration or amelioration, to our knowledge, is not documented. It appears possible, however, to document the course of readmission in the population by change in hospitalization rates over time.

The current study aims to distinguish between suggestions that the course of schizophrenia is characterized by (a) amelioration, (b) deterioration, or (c) stability. To compare these positions a cluster analysis was conducted to classify patients based on their lengths of hospitalization and a descriptive classification of change in the course was conducted. Approximate patterns of readmission by change are reported. This study, undertaken in Israel, resembles similar research undertaken in Denmark as it relies on population-based data from a national registry (Mortensen and Eaton, 1994, Munk-Jörgensen et al., 1991, Olesen and Mortensen, 2002).

Section snippets

Case registry

The Israeli National Psychiatric Case Registry contains a complete listing of psychiatric hospitalizations in Israel, and includes the ICD-9 (World Health Organization, 1977) diagnoses assigned at admission and discharge by an Israeli medical board-certified psychiatrist. Diagnoses recorded in earlier ICD codes are routinely updated by the registry. All in-patient psychiatric hospital admissions and discharges in Israel, including those to non-psychiatric hospitals, are required by law to be

Results

Cluster analysis identified 3 groups with different hospitalization trends (Fig. 1). The first group was smallest and consisted of 324 (5.41%) patients who we regarded as having a deteriorating course since they consistently spent more days in the hospital with the exception of the final year. The second group consisted of 764 (12.75%) patients who improved, as suggested by spending fewer days in the hospital over the follow-up period. The third and largest group was characterized by an initial

Discussion

Using longitudinal national population-based data, this study examines the natural course of schizophrenia. The findings, based on the cluster analysis and descriptive classification are consistent with the hypothesis that what appears at the collective level to reflect a progressively deteriorating course of illness is attributable to a sub-group of patients who are characterized by high readmission rates (Häfner and an der Heiden, 2003, Olesen and Mortensen, 2002). The results suggest that

Acknowledgements

Funded by the German Federal Ministry of Education and Research (BMBF) within the framework of German Israeli Project Cooperation (DIP).

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View full text

The course of schizophrenia: Progressive deterioration, amelioration or both?

Abstract

Background

Aims

Methods

Results

Conclusions

Introduction

Section snippets

Case registry

Results

Discussion

Acknowledgements

Lancet

Schizophr. Res.

Compr. Psychiatry

Schizophr. Res.

Compr. Psychiatry

Cluster Analysis

Psychosocial factors and relapse of schizophrenia

BMJ

Long-term course of hospitalization for schizophrenia: part II. Change with passage of time

Schizophr. Bull.

Long-term course of hospitalization for schizophrenia: part I. Risk for rehospitalization

Schizophr. Bull.

Remission and relapse in schizophrenia: the Madras Longitudinal Study

J. Nerv. Ment. Dis.