Longitudinal studies of outcome and recovery in schizophrenia and early intervention: can they make a difference?

Knowledge about typical course and outcome are valuable for a better understanding of any disorder. In schizophrenia, it is particularly important, since some key concepts of this disorder involve views about its course and outcome. The concept of schizophrenia is linked to early views of a chronic disorder and a decline in functioning, or at least very poor outcome. Thus schizophrenia was once viewed by Kraepelin, who pioneered the concept of dementia praecox, as a disorder with a progressive downhill course (1). Bleuler's later, somewhat more optimistic outlook, still viewed some aspects of psychopathology in schizophrenia as always present, although in reduced form at times (2). If these older, more pessimistic views are examined from a contemporary standpoint, several issues arise. One is whether potential intervals or periods of recovery, and even potential long-term recovery, are frequent in schizophrenia. Despite the earlier pessimistic views, recent longitudinal studies have produced evidence that some, or many, schizophrenia patients do experience periods or intervals of recovery (3-5). However, the answer to how many or what percentage of patients have this potential still awaits further research. Among the many issues that longitudinal research in this area has raised is the question of whether long-term outcome and potential recovery in schizophrenia now differ from outcomes prior to our era of modern treatment and rehabilitation (6). This is the type of issue that can be approached with longitudinal research. Is knowledge about outcome and potential periods of recovery in schizophrenia of any other importance? For several different reasons, there have been affirmative suggestions in regard to this question. As one researcher has pointed out in relation to the value to schizophrenia patients of a more optimistic prognosis, "If you don't know where you should try to go (improvement and recovery), you may never get there" (7). This comment can apply equally well to mental health professionals treating or helping patients with schizophrenia. Aspects of our own longitudinal research program (5,8) and other research programs (3,9) indicate that, while many patients with schizophrenia have poor outcomes, a subgroup of these patients are able to experience intervals or periods of recovery, leave treatment, and leave the mental health system for a period of time. What factors are associated with periods of recovery, and what factors can contribute even further to recovery? Evidence from our research and that of others indicates a combination of the following: initial treatment with antipsychotics to reduce psychosis; other, even earlier factors, such as early interventions to diminish the probability of the emergence of more flagrant psychosis, as discussed by Malla and colleagues in this issue (10); and a third, very important, element. This third element is the influence of protective factors that are related to these patients' own internal resources (including the skills involved in their own premorbid developmental achievements) and that facilitate their later periods of recovery. With regard to inner resources, we must remember that not all schizophrenia patients are alike. For the subsample of patients with schizophrenia who show periods of recovery, some periods last for 1 or 2 years, and others last for 6 or more years. While we now have evidence of periods of recovery in some (but not all) patients with schizophrenia, considerably more research is needed on what factors, other than routine treatment and possible early interventions, are most likely to make a difference in patients' lives. This includes further evidence both on factors that may facilitate potential recovery and on factors that are more likely to contribute to relapses. Contemporary research on expressed emotion and potential factors involved in it (such as possibly living in disapproving and anxiety-arousing settings) represents one example of research on factors that can make a difference in some patients' lives (11,12). …