|Year : 2020 | Volume
| Issue : 1 | Page : 21-29
Naturalistic clinical and psychosocial outcome of incident cases of schizophrenia in Enugu Federal Psychiatric Hospital: A preliminary report at 4-month follow-up
Justus Uchenna Onu1, Jude Uzoma Ohaeri2
1 Mental Health Unit, Faculty of Medicine, Nnamdi Azikiwe University, Awka, Anambra State, Nigeria
2 Department of Psychological Medicine, University of Nigeria, Enugu Campus, Nsukka, Enugu State, Nigeria
|Date of Submission||21-Aug-2019|
|Date of Acceptance||20-Nov-2019|
|Date of Web Publication||14-Jan-2020|
Dr. Justus Uchenna Onu
Mental Health Unit, Department of Internal Medicine, Faculty of Medicine, Nnamdi Azikiwe University, Awka, Anambra State
Source of Support: None, Conflict of Interest: None
Introduction: Longitudinal outcome studies based on incident and predominantly neuroleptic-naïve cases of schizophrenia are uncommon in the modern literature. Aims: To determine the proportion of persons with schizophrenia with different levels of clinical and functional outcome at monthly intervals of naturalistic treatment follow-up for 4 months: response, remission and recovery; and to examine the predictors of outcome. Subjects and Methods: Consecutive incident cases that fulfilled stringent criteria for schizophrenia were recruited into the study. After a baseline assessment, 160 incident cases of schizophrenia were followed up 4-weekly for indicators of symptomatic and functional outcome for 16 weeks. Standard rating scales were used to assess clinical and functional outcome. Sociodemographic and clinical variables were evaluated as predictors of outcome using multiple regression analysis. Results: The attrition rate at week 16 was 29.4%; hence, 113 subjects (out of 160) were available for assessment at the end of follow-up. Of the 113, 66.4%, by Brief Psychiatric Rating Scale (BPRS), met criteria for response (i.e., >50% reduction), while 20.3% could be judged to be clinically non-responsive to treatment (i.e., <20% decrease). Also, 60.2%, by BPRS, met the criteria for remission, while 44.5% met the criteria for recovery. The most important predictor, at week 16, of clinical and psychosocial outcome was social support (48.7%–51.8% of variance). Conclusion: Although as a preliminary report, the present findings are hypothesis-generating, the implication of the results is that, as a group, over a 4-month period of modern hospital treatment, schizophrenia patients who were incident cases progressively experienced significant reduction in psychopathology. The findings, therefore, support earlier international cross-cultural reports of relatively good clinical outcome from developing countries, thereby encouraging the idea of treatment optimism in schizophrenia in Africa.
Keywords: Incident cases, naturalistic, outcome, predictors, schizophrenia
|How to cite this article:|
Onu JU, Ohaeri JU. Naturalistic clinical and psychosocial outcome of incident cases of schizophrenia in Enugu Federal Psychiatric Hospital: A preliminary report at 4-month follow-up. Niger Postgrad Med J 2020;27:21-9
|How to cite this URL:|
Onu JU, Ohaeri JU. Naturalistic clinical and psychosocial outcome of incident cases of schizophrenia in Enugu Federal Psychiatric Hospital: A preliminary report at 4-month follow-up. Niger Postgrad Med J [serial online] 2020 [cited 2020 Jul 4];27:21-9. Available from: http://www.npmj.org/text.asp?2020/27/1/21/275805
| Introduction|| |
There is a large scientific literature characterising the course and outcome of schizophrenia in the developed world.,, The prevailing views of the outcome of schizophrenia in the developing countries stem from a series of studies conducted by the World Health Organization (WHO)., The WHO International Multicenter Studies (International Study of Schizophrenia-ISoS, and its precursor, the International Pilot Study of Schizophrenia [IPSS]) reported that the clinical outcome of schizophrenia was generally better in developing than in developed countries., However, these findings have remained controversial. First, there have been expressions of concern on whether the participants from the better outcome sites are representative of the developing countries in general. In addition, some reviewers have raised issues with these findings on methodological grounds.,, Despite the application of well-defined operational criteria, the fact that broad diagnostic classes were incorporated to represent schizophrenia may have introduced heterogeneity in the sampled population; a point that may affect the validity of the conclusions regarding outcome. Second, in countries like Nigeria, the controversies raised in cross-cultural studies about the differences in clinical manifestation and outcome across cultures for schizophrenia have not been addressed in longitudinal studies. For example, the findings of the IPSS indicated that schizophrenia in developing countries (of which Nigeria was a collaborating centre) manifests more with acute symptoms and appears to have a better clinical prognosis than in developed countries where the disorder is of more insidious onset and the so called “negative symptoms” are more evident., Meanwhile, it is well over three decades now since the conclusion of the WHO-coordinated studies which described the outcome as favourable in the Ibadan Center. Since the conclusion of that study, new diagnostic tools (e.g., International Classification of Mental and Behavioral Disorder [ICD-10/11] and DSM-4/5) and standardised instruments to measure outcome have been introduced. Hence, the time is ripe to revisit the issue of outcome of schizophrenia in Nigeria, using a sample that was followed up naturalistically in the short term.
Despite the controversies, most recent studies continue to support the view of cross-cultural differences in manifestation and clinical outcome of schizophrenia., The exceptions apparently appear to be the longitudinal follow-up studies from Ethiopia and South Africa.,, However, it was noted that of the 321 Ethiopian patients with diagnosis of schizophrenia followed up for 5 years, only 6% had continuously received antipsychotics. In other words, the Ethiopian (mostly neuroleptic naïve) cohorts were different from the IPSS and ISoS cohorts who were under follow-up treatment. Nevertheless, at 5 years of follow-up, 20% of the Ethiopian subjects experienced continuous remission, an outcome that was significantly predicted by being on antipsychotics for at least 50% of the time. Similarly for the South African study, it was noted that, of the 116 first-episode patients initially seen at hospitalisation, only 42 could be located for interview 3 years later. Of the 42, only 55% were attending follow-up and only 19% had been seen by a psychiatrist in that period. Accordingly, 50% were currently experiencing hallucinations and/or delusions, and most performed poorly in functional outcome. We suggest that the Ethiopian and South African cohorts are not comparable to the WHO and SOHO cohorts, and cannot be used as proof of treatment outcome of schizophrenia, especially as it has been shown that follow-up treatment with antipsychotics is important to prevent relapse. With regard to the impact of treatment on outcome, Hegarty et al., in a meta-analysis of 100 years of outcome studies in schizophrenia, noted that neuroleptic treatment was associated with the highest mean percentage of improved subjects, and while diagnostic system and neuroleptic treatment were strong predictors of outcome, duration of follow-up was not.
To emphasise the need for further studies in this area in developing countries, some researchers have questioned the notion that schizophrenia has better outcome in developing countries.,, It has been suggested that it is important to re-examine the impression of better outcome in developing countries for the following reasons: First, globalisation has caused enormous changes in the socio-cultural and socioeconomic lives of people in low- and middle-income countries. The rapid social and economic changes in the decades since the WHO studies, is undermining the family care system (a care system that is thought to be contributory to the observed better clinical outcome) for people with mental disorders in developing countries. Second, noted earlier are the methodological limitations of the initial WHO studies.,
In our review of the literature, including recent reviews from the region,,,, we found that there are no recent reports from Africa on schizophrenia follow-up studies for patients on regular psychiatric treatment, using modern diagnostic and outcome criteria. In particular, the precise proportion of subjects with good outcome in developing countries is less clearly understood. To fill this gap in knowledge, we commenced a longitudinal follow-up study of incident cases of schizophrenia in our practice setup. In this preliminary report, we present the findings at 4 months. We chose the 4-month cut-off because: (i) evolving from the Kane et al. criteria for treatment resistance in schizophrenia, the international consensus appears to be that 12 weeks is an adequate period for initial optimum psychopharmacological treatment of first episode schizophrenia;,,,, (ii) hence, the 16-week period would give the subject some reasonable time to live in the community, posthospitalisation, so that functional (psychosocial outcome) assessment would be in the setting of living in the community.
The objectives of the study were:
- To assess the proportion of incident cases of schizophrenia with levels of clinical and functional outcome (i.e., response, remission and recovery – defined below) at 4 months of naturalistic follow-up
- To examine the sociodemographic, clinical and psychosocial predictors of outcome.
| Subjects and Methods|| |
Ethical approval was obtained from the Ethical Committee of the Federal Neuropsychiatric Hospital with protocol number FNHE/HCS and T/REA/VOL. 1/187 issued on the June 17, 2015. Ethical norms and standards as stated in the Helsinki declaration were strictly adhered to; written informed consent was obtained from all the participants. Participation was voluntary.
Study design and population
This was a naturalistic longitudinal follow-up outcome study which took place at the Federal Neuropsychiatric Hospital, Enugu, Nigeria. All the participants were recruited from April to July 2016. Consecutive incident cases of schizophrenia, who presented at the hospital, aged 18–49 years, and with traceable home address around Enugu metropolis, and mobile telephone, were included in the study. Patients with schizophrenia of suspected organic aetiology, including substance use disorders, medical or psychiatric comorbidities or both were excluded. Patients were interviewed when they were in a stable clinical condition (i.e., fully conscious and could optimally participate during the interview).
The study used a convenience sampling method to recruit consecutive consenting patients who met the inclusion criteria. Consecutive incident cases of schizophrenia seen at the emergency and crisis intervention unit of the Federal Neuropsychiatric Hospital were recruited until the required number was obtained. In computing the required sample size for the study, we used the findings of Teferra et al. in Ethiopia. Based on their finding that 20% of patients with schizophrenia had “good outcome” and 30.3% had “poor outcome,” the challenge for sample size calculation, therefore, was to determine the number of schizophrenia subjects to be studied to give at least 10.3% good outcome (i.e., 30.3%–20.0%), with 80% power and 95% confidence. We computed the required sample size using these figures to substitute the Cochran formula for proportion (z2 pq/e2) and arrived at 156 after allowing for 10% attrition.
All the resident doctors in the various units were informed about the study and were requested to contact the research team when suspected cases of schizophrenia presented. At the end of the recruitment period, 199 incident cases with diagnosis of schizophrenia were brought to the attention of the research team. Eleven of the subjects who initially had diagnosis of schizophrenia by the resident doctors did not meet the ICD-10 diagnostic criteria for schizophrenia when further interviewed. Twenty persons were excluded because of comorbid psychiatric/substance use disorder. Another three who had comorbid physical conditions were excluded after a detailed medical history and physical examination. Five persons declined consent to participate in the study. A total of 160 participants were followed up for this report.
Clinical outcome was measured by the reduction of scores on the psychiatric rating scales: the Brief Psychiatric Rating Scale (BPRS), Andreasen's Schedule for Assessment of Negative Symptoms (SANS) and Clinical Global Impression (CGI – severity) scale, in line with the concepts of response, remission and recovery as defined below. Psychosocial outcome was measured by improvement in scores from the General Assessment of Functioning scale (GAF) and WHO Disability Assessment Scale (WHODAS). Response: Was defined as symptom reduction >50% of the baseline scores in BPRS and SANS during each period of follow-up. Accordingly, poor response was defined as symptom reduction of 20%–50%, while non-response was defined as failure to achieve 20% reduction in total BPRS and SANS score during each period of follow-up. Symptomatic remission: Was defined as a rating of 'mild' or less, concurrently on the following 7 BPRS items (BPRS only criteria): Grandiosity, suspiciousness, unusual thought content, hallucinatory behaviour, conceptual disorganisation, mannerism/posturing and blunted affect. In addition, as suggested by Andreasen when using SANS, a score of 2 or less on the following 4 SANS items: Affective flattening, avolition-apathy, anhedonia-asociality and alogia (SANS criteria). Functional remission: was based on both clinical and psychosocial functional dimensions as proposed by Jääskeläinen et al. Hence, functional remission in this study was defined as: (a) maintaining remission as described above through the particular follow-up period; and (b) having a GAF score ≥61. This GAF score indicates that the subject is judged to be capable of returning to the premorbid level of psychosocial functioning. Social recovery was defined in this study as the maintenance of clinical remission in addition to GAF score ≥61.
Procedure and measurement
Most of the new cases of schizophrenia were offered hospitalisation, and their initial assessments were completed in the wards after obtaining a written informed consent. Consenting subjects who were not admitted were seen monthly at the outpatient clinic, and a relative ensured that they were compliant with their medications. The diagnostic interview was conducted by the principal investigator, JUO. Diagnosis was based on the ICD-10, Diagnostic Criteria for Research version and also on the DSM-5. The inclusion of the DSM-5 was to address the doubts in the literature about the rigor of diagnosis. First, using the screening sections of the modules of the Mini International Neuropsychiatric Interview (MINI), the interviewer sought to screen out the presence of comorbid major mental disorders. Thereafter, the criteria for schizophrenia were confirmed using the MINI (psychotic disorders) module. For individuals who neither met the diagnostic criteria nor gave consent to participate in the study, records of their diagnoses and reasons for refusal were documented. After a detailed medical history, a trained research assistant did a full physical examination (including neurological examination) to exclude the presence of comorbid physical conditions.
The baseline assessments were completed at the emergency and crisis intervention unit or within 1 week of admission for admitted participants. The interviewer assessed baseline clinical profile using the BPRS, the SANS and the CGI (severity). Then, in order to avoid bias in ratings, another interviewer assessed the baseline psychosocial functioning of the participants using the WHODAS and the GAF. Subsequent follow-up interviews were similarly conducted by the 2 raters, who were trained in the use of the instruments by a senior psychiatrist with years of experience in the use of the instruments. The social support scale, the multidimensional scale of perceived social support, was also applied. In order to ensure uniformity of assessment, the items of the WHODAS and social support scale were read aloud for the patient to indicate the answer as it applied to him/her.
For follow-up, participants were assessed for the second time, 4 weeks after the baseline, then subsequently 4 weekly. Hence, a total of 4 intervals of assessments were made in this period of 16 weeks. Participants were assessed using the same instruments to measure the clinical variables and psychosocial functioning during each visit as described for the baseline assessment. In addition, the follow-up assessments included the CGI-improvement. Participants and their relatives were contacted via telephone calls or text messages a week prior to the follow-up date, and then further reminded a day to the date of follow-up. Participants who missed their appointment were traced using contact phone numbers, family contact, and next of kin's address or phone number. A record of participants lost to follow-up was made. No death was recorded during the period of study.
Psychopathology and psychosocial assessment tools
Brief Psychiatry Rating Scale
The BPRS is a widely used instrument for assessing the severity of positive, negative, general and affective symptoms of individuals who have severe mental disorders, especially schizophrenia. The BPRS consists of 18-symptom constructs and takes 20–30 min for the interview and scoring. It is rated on a Likert scale of 1 (not present) to 7 (extremely severe).
Clinical Global Impression Scale
The CGI Scale evaluates the overall severity of mental disorders. The CGI is an observer-rated scale that measures illness severity (CGI-S), i.e., assessment of the current severity of symptoms on a 7-point response option-CGI severity. A version of it is also used to assess global improvement-CGI-improvement.
Scale for the Assessment of Negative Symptom
The SANS was developed by Nancy Andreasen and was first published in 1984. SANS is a rating scale to measure negative symptoms in schizophrenia. It is split into five domains, and within each domain, separate symptoms are rated from 0 (absent) to 5 (severe).
The Global Assessment of Functioning Scale
The Global Assessment of Functioning scale (American Psychiatric Association, 1994) is utilised by a clinician to gauge an individual's overall level of functioning and his/her ability to carry out activities of daily living. The Global Assessment of Functioning Scale is a 100-point scale that measures a patient's overall level of psychological, social and occupational functioning on a hypothetical continuum. It is an observer-rated single rating of functioning.
World Health Organization Disability Assessment Schedule 2.0
The adult self-administered version of the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) is a 36-item measure that assesses disability in adults aged eighteen years and older. It assesses disability across six domains, including understanding and communicating, getting around, self-care, getting along with people, life activities (i.e., household, work and/or school activities), and participation in the society. Each item on the self-administered version of the WHODAS 2.0 asks the individual to rate how much difficulty he or she has had in specific areas of functioning during the past 30 days, rated on a Likert scale of 1–4 (1-none, 2-mild, 3-moderate and 4-severe). Psychosocial outcome was defined as decrease in WHODAS scores at intervals of assessment. As earlier noted, this instrument was interviewer-administered, to ensure uniformity of application, especially for subjects without formal education.
Analysis of the results was done using the Statistical Package for the Social Sciences (SPSS Inc., Chicago; III; USA), version 18. First, data were scrutinised for incorrectly filled information and normality of distribution of data, using frequency counts and graphical displays. Repeated measures analysis of variance was used to assess significant differences in change in psychopathology scores across the period of follow-up. Multivariate analyses using step-wise multiple regressions were used to assess predictors of outcome. All tests of significance were two-tailed at the 5% level of significance and confidence interval estimation of 95%.
| Results|| |
[Table 1] shows the sociodemographic and some clinical characteristics of the 160 participants. They were mostly young (mean age 31.13 ± 12.50), the mean age at onset of schizophrenia and duration of illness were 26.33 ± 12.15 years and 63.18 ± 74.15 months, respectively. Majority (51.2%) were females, never married (66.3%), with at least high school education (74.4%), and unemployed (63.8%). The attrition rate at week 16 was 29.4%; hence 113 subjects (out of 160) were available for assessment of response, remission and recovery at the end of follow-up. Of the 113 at this point, 75 (66.4%) by BPRS and 65 (57.5%) by SANS met criteria for response; 15 (13.3%) by BPRS and 17 (15.0%) by SANS met the criteria for poor response [Table 2], while 23 (20.3%) by BPRS and 31 (27.4%) by SANS met the criteria for non-response [Table 3]. In addition, 68 (60.2%) by BPRS and 65 (57.5%) by SANS met the criteria for remission [Table 4]. Among those who did not respond at the end of the follow-up, 4 (3.5%) by BPRS and 14 (12.4%) by SANS had a recrudescence of their symptoms rather than reduction [Table 3]. The repeated measures ANOVA showed that there was a consistent significant gradient of decrease in scores of psychopathological measures (BPRS and SANS) between subsequent follow-up periods [Table 2] (F = 67.57; df = 4, 108; P > 0.001). For example, there was a consistent gradient of fall in mean BPRS score (45.3–16.9) and SANS score (83.1–40.0) between baseline and the 16th week [Table 2]. In line with this, the gradient of increase of the proportion with response (from 39.2% to 66.4% for BPRS and 30.4% to 57.5% for SANS) [Table 2] was paralleled by a gradient of decrease in the proportion of subjects with non-response (from 40% to 20.3% for BPRS and 54.8% to 27.4% for SANS) [Table 3].
|Table 1: Sociodemographic and clinical characteristics of the participants|
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|Table 2: Response using Brief Psychiatric Rating Scale and Schedule for assessment of negative symptoms criteria|
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|Table 3: Non-response using Brief Psychiatric Rating Scale and Schedule for assessment of negative symptoms criteria|
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|Table 4: Remission per period of follow.up using Brief Psychiatric Rating Scale and Schedule for assessment of negative symptoms criteria|
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Similarly for the data on functional remission or social recovery, [Table 5] shows that there was an increasing gradient of subjects who met the operational criteria (i.e., clinical remission plus GAF score ≥61): from 6/135 (4.4%) at week 4, to 50/113 (44.3%) at week 16, using the BPRS (The results were similar for the SANS). In addition, clinical remission and social recovery were increasingly highly correlated, so that, by week 16, 73.5% (50/68) of those with clinical remission also achieved social recovery. In line with this, psychosocial outcome (assessed by WHODAS) indicated a significant gradient of decrease in mean WHODAS score for subjects with clinical remission (83.0–49.9) across the intervals of follow-up (P < 0.001) [Table 6]. In the multivariate analyses using stepwise linear regression model, the most important predictor, at week 16, of clinical (i.e., BPRS) and psychosocial outcome (i.e., WHODAS) was social support (48.7%–51.8% of variance). However, being married (2.4%–3.3% of variance), longer duration of illness (3.7%–3.8% of variance), mode of onset (2.8% of variance) and baseline GAF social functioning (2.4%–7.2% of variance) were also significant predictors of clinical outcome. Baseline negative symptoms (SANS) played a minor role in predicting poor psychosocial functioning (1.8% of variance) [Table 7] and [Table 8].
|Table 5: Functional remission per period of follow-up using Brief Psychiatric Rating Scale and General Assessment of Functioning criteria|
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|Table 6: Mean World Health Organization Disability Assessment Scale score by functional remission per period of follow-up using Brief Psychiatric Rating Scale and World Health Organization Disability Assessment Scale*|
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|Table 7: Summary of stepwise regression result of sociodemographic and clinical predictors of clinical outcome (Brief Psychiatric Rating Scale) step 2|
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|Table 8: Summary of stepwise regression result of sociodemographic and clinical predictors of functional outcome (World Health Organization Disability Assessment Scale) step 2|
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Of note, gender, level of education, family history of illness and age at onset of psychosis were not significantly associated with clinical and functional remission (P > 0.05).
| Discussion|| |
The study was aimed at a naturalistic follow-up of 160 incident cases of schizophrenia over a 16-week period, with a view to highlighting clinical and psychosocial outcomes and their correlates using standard rating scales. This is the first longitudinal outcome study of incident cases of schizophrenia on follow-up treatment from Africa that used modern research criteria for response, remission and recovery. Previous studies in Africa, for example, the Ethiopian study utilised prevalent cases mostly neuroleptic naïve from the community as against the incident cases of whom all were under treatment used in the present study.
The sociodemographic and clinical profile of the participants shows that they were mostly young (mean age 31.13 ± 12.15), single (66.3%), unemployed (63.8%), had at least high school education (74.4%), and living with a first-degree relative (69.4%) – consistent with the widely noted prominent social support role of family caregivers in developing countries., The mean age at onset was 26.33 ± 12.15, and the mean duration of illness was 63.18 ± 74.15 months. These indicate that the participants in this study were similar to schizophrenia cases reported in previous longitudinal studies in Nigeria and abroad.,
At each month of follow-up, an increasing proportion of patients met the criteria for response (39.2%–66.6%) and clinical remission (27.4%–60.2%), in line with the consistent gradient of decrease in psychopathological scores (BPRS mean: 45.3–16.9; SANS: 83.1–39.9), and paralleling the increasing gradient of social recovery (from 6/135 [4.4%] at week 4, to 50/113 [44.3%] at week 16) [Table 4] and [Table 5]. In the literature on naturalistic outcome studies of schizophrenia, there are widely varying estimates of clinical remission and social recovery (or functional remission), even when the operational definitions are similar to those of Jääskeläinen et al. In a systematic review and meta-analysis of 50 studies, Jääskeläinen et al. reported that 13.5% recovered. In a review of 37 outcome studies, Menezes et al. concluded that 42% had good outcome. Werner reviewed 114 published follow-up studies and concluded that 11%–33% were completely recovered, while 22%–53% were socially recovered. In large scale cross-cultural studies, the ISoS reported that the proportion of incident cases never psychotic in the last 2 years (i.e., clinical remission) versus those continuously psychotic in the developed countries was 37% versus 38%, while for developing countries, it was 53% versus 27%. Using the criterion of GAF score >60, the proportion with social recovery for developed countries was 41%, versus 65% for developing countries. In the worldwide SOHO, involving outpatients needing a change of medication or initiating medication from 37 countries in 4 continents, 66.1% achieved clinical recovery in 3 years (range: 60.1% in North Europe, to 84% in East Asia), while 25.4% achieved functional recovery (range: 17.8% North Africa and Middle East, to 35.0% in North Europe). In a Dutch study of 125 incident cases followed up for 2 years, Wunderink et al. reported that 52% had symptomatic remission, 26.4% had functional remission, while 19.2% met both criteria and were considered recovered.
In comparing the results of the above longer term studies with ours, we suggest that the present findings are hypothesis-generating for our longer term follow-up study. We also note the finding from a meta-analysis of schizophrenia outcome studies, that duration of follow-up was not a significant predictor of outcome. With these caveats, our proportions for clinical response and remission are closer to those of the SOHO report and higher than those from ISoS and the Dutch studies., Furthermore, the finding of a consistent gradient of increase in the proportion of subjects with response, remission and recovery, gives support to the idea of treatment optimism in schizophrenia, as opposed to the traditional view of poor outcome in schizophrenia.
As for the factors associated with outcome, the consensus of opinion in the literature appears to be that: (i) more individuals achieve clinical remission than functional remission; (ii) clinical and functional remission are highly correlated; (iii) recovery is more prevalent in first episode cases, as well as those with good premorbid social functioning and social support, while poor outcome is predicted by long duration of untreated psychosis and negative symptoms.,
Our results resonate with these consensus findings. Of note are the findings that social support was the most important predictor of outcome, and that all those with poor treatment response belonged to the group with long duration of untreated illness. As expected, more participants met the criteria for response using the BPRS criteria compared with the proportion using SANS criteria (60.2% vs. 51.7%). This may be due to the finding that negative symptoms are more resistant to pharmacotherapy, and/or the fact that majority of the participants in this study were on typical antipsychotics (67.5%), which research has shown to be less effective in tackling negative symptoms. The issue then is whether the rate of remission reported in this study is sustainable over a longer period of follow-up. We hope to report the longer-term outcome of this cohort as they are still being followed up. The cumulative percentage attrition in this study, 29%, is at the lower end of the range of 30%–70% previously reported in a meta-analysis of attrition rates in longitudinal studies, most probably because of the much shorter period of follow-up. However, the design of the study included measures that would encourage compliance with clinic appointment, such as, recruiting only subjects living around Enugu, reminding them by phone to attend clinic, and making the routine clinic visit less cumbersome. These strategies have been reported to reduce attrition by 45%.
One of the limitations of this study was the use of institution-based samples (care seekers); although it saved cost and time, and is the predominant methodology in the literature, a community sample would have been more representative. The second limitation was the length of follow-up which fell short of the duration criteria for remission (i.e., 6 months). A longer follow-up period would have enquired into the sustainability of the outcome. Third, the attrition rate in this study might have introduced some bias as the outcome for those lost to follow-up was not known. Finally, the fact that neurocognition and extrapyramidal side effects were not assessed as these are known to affect clinical and psychosocial outcome.
| Conclusion|| |
As a preliminary report, our findings act as a bench mark for treatment optimism in schizophrenia, away from the long held impression of poor outcome. Whereas clinicians practicing in our national setting have long known that acutely ill patients get discharged from hospital admission in good condition within 6 weeks, we had no reliable figures on the proportions that achieve clinical response, remission and social recovery, even in the short-term. This study adds to the body of research that indicates fairly good prognosis of schizophrenia in developing countries, as first noted by the widely reported WHO IPSS study. Furthermore, the finding of the prominent role of perceived social support as a predictor of outcome supports the factor that has been popularly associated with good outcome in the literature. In a resource–challenged Nigeria, which has been experiencing a worsening economic situation, these findings give some encouragement to clinicians about the usefulness of psychosocial methods-for example, family caregiver education, in improving outcome. As regards treatment-resistance, the finding on the contribution of longer duration of illness encourages clinicians to invest in research on early detection and treatment, by cost-effective public mental health education and establishment of “early psychosis” programs, especially for subjects at higher risk for mental illness.
The authors would like to thank Dr. J.U. Onwukwe, the Medical Director, Federal Neuropsychiatric Hospital, Enugu, for providing the enabling environment and some logistic support for this study. Additionally, we thank Mr. Louis Okachi of the Federal School of Statistics for his insightful comments on the statistical methods. We are grateful to the patients and their relatives, for freely giving of their time to participate in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sartorius N, Gulbinat W, Harrison G, Laska E, Siegel C. Long-term follow-up of schizophrenia in 16 countries. A description of the international study of schizophrenia conducted by the World Health Organization. Soc Psychiatry Psychiatr Epidemiol 1996;31:249-58.
Craig TJ, Siegel C, Hopper K, Lin S, Sartorius N. Outcome in schizophrenia and related disorders compared between developing and developed countries. A recursive partitioning re-analysis of the WHO DOSMD data. Br J Psychiatry 1997;170:229-33.
Haro JM, Novick D, Bertsch J, Karagianis J, Dossenbach M, Jones PB. Cross-national clinical and functional remission rates: Worldwide Schizophrenia Outpatient Health Outcomes (W-SOHO) study. Br J Psychiatry 2011;199:194-201.
Sartorius N, Jablensky A, Shapiro R. Two-year follow-up of the patients included in the WHO International Pilot Study of Schizophrenia. Psychol Med 1977;7:529-41.
Hopper K, Wanderling J. Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: Results from ISoS, the WHO collaborative followup project. International Study of Schizophrenia. Schizophr Bull 2000;26:835-46.
Edgerton RB, Cohen A. Culture and schizophrenia: The DOSMD challenge. Br J Psychiatry 1994;164:222-31.
Cohen A. Prognosis for schizophrenia in the third world: A re-evaluation of cross-cultural research. Cult Med Psychiatry 1992;16:53-75.
Cohen A, Patel V, Thara R, Gureje O. Questioning an axiom: Better prognosis for schizophrenia in the developing world? Schizophr Bull 2008;34:229-44.
Alem A, Kebede D, Fekadu A, Shibre T, Fekadu D, Beyero T, et al
. Clinical course and outcome of schizophrenia in a predominantly treatment-naive cohort in rural Ethiopia. Schizophr Bull 2009;35:646-54.
Kebede D, Alem A, Shibre T, Negash A, Deyassa N, Beyero T, et al
. Short-term symptomatic and functional outcomes of schizophrenia in Butajira, Ethiopia. Schizophr Res 2005;78:171-85.
Burns JK. The social determinants of schizophrenia: An African journey in social epidemiology Public Health Rev 2012;34:1-8.
Emsley R, Nuamah I, Gopal S, Hough D, Fleischhacker WW. Relapse after antipsychotic discontinuation in schizophrenia as a withdrawal phenomenon vs. illness recurrence: A post hoc
analysis of a randomized placebo-controlled study. J Clin Psychiatry 2018;79. pii: 17m11874.
Hegarty JD, Baldessarini RJ, Tohen M, Waternaux C, Oepen G. One hundred years of schizophrenia: A meta-analysis of the outcome literature. Am J Psychiatry 1994;151:1409-16.
Gureje O, Cohen A. Differential outcome of schizophrenia: Where we are and where we would like to be. Br J Psychiatry 2011;199:173-5.
Chidarikire S, Cross M, Skinner I, Cleary M. Treatments for people living with schizophrenia in Sub-Saharan Africa: An adapted realist review. Int Nurs Rev 2018;65:78-92.
Purgato M, Adams C, Barbui C. Schizophrenia trials conducted in African countries: A drop of evidence in the ocean of morbidity? Int J Ment Health Syst 2012;6:9.
Jääskeläinen E, Juola P, Hirvonen N, McGrath JJ, Saha S, Isohanni M, et al
. A systematic review and meta-analysis of recovery in schizophrenia. Schizophr Bull 2013;39:1296-306.
Kane J, Honigfeld G, Singer J, Meltzer H. Clozapine for the treatment-resistant schizophrenic. A double-blind comparison with chlorpromazine. Arch Gen Psychiatry 1988;45:789-96.
American Psychiatric Association. Guideline for the treatment of schizophrenia. American Psychiatric Association Publishing Inc., 2nd
ed. Washington, DC: American Psychiatric Association 2010.
Suzuki T, Remington G, Mulsant BH, Uchida H, Rajji TK, Graff-Guerrero A, et al
. Defining treatment-resistant schizophrenia and response to antipsychotics: A review and recommendation. Psychiatry Res 2012;197:1-6.
Conley RR, Buchanan RW. Evaluation of treatment-resistant schizophrenia. Schizophr Bull 1997;23:663-74.
Brenner H, Merlo M. Definition of therapy-resistant schizophrenia and its assessment. Eur Psychiatry 1995;10 Suppl 1:11s-7s.
Solanki RK, Singh P, Munshi D. Current perspectives in the treatment of resistant schizophrenia. Indian J Psychiatry 2009;51:254-60.
] [Full text]
Teferra S, Shibre T, Fekadu A, Medhin G, Wakwoya A, Alem A, et al
. Five-year clinical course and outcome of schizophrenia in Ethiopia. Schizophr Res 2012;136:137-42.
Cochran WG. Sampling Techniques. 2nd
ed. New York: John Wiley and Sons, Inc.; 1963.
Overall JE, Gorham DR. The Brief Psychiatric Rating Scale. Psychol Rep 1962;10:799-812.
Andreasen NC. The Scale for the Assessment of Negative Symptoms. Iowa City: University of Iowa; 1983.
Guy W. Clinical Global Impression. In: Early Clinical Drug Evaluation Unit Assessment Manual for Psychopharmacology (Revised). Rockville, MD: National Institute of Mental Health; 1976. p. 217-21.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th
ed. Washington DC: American Psychiatric Association; 1994.
World Health Organization. Measuring Health and Disability: Manual for WHO Disability Assessment Schedule (WHODAS 2.0). Geneva: World Health Organization; 2010.
Andreasen NC, Carpenter WT Jr., Kane JM, Lasser RA, Marder SR, Weinberger DR. Remission in schizophrenia: Proposed criteria and rationale for consensus. Am J Psychiatry 2005;162:441-9.
Goldman HH, Skodol AE, Lave TR. Revising axis V for DSM-IV: A review of measures of social functioning. Am J Psychiatry 1992;149:1148-56.
World Health Organization. International Classification of Diseases and Related Health Problems. 10th
ed. Geneva: World Health Organization; 1994.
Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al
. The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59 Suppl 20:22-33.
Zimet GD, Dahlem NW, Zimet SG, Farley G. The multidimensional scale of perceived social support. J Pers Assess 1988;52:30-41.
Chadda RK. Psychiatric patient in the community: Challenges and solutions. J Ment Health Hum Behav 2001;6:7-15.
Ohaeri JU. Caregiver burden and psychotic patients' perception of social support in a Nigerian setting. Soc Psychiatry Psychiatr Epidemiol 2001;36:86-93.
Ohaeri JU. Long-term outcome of treated schizophrenia in a Nigerian cohort. Retrospective analysis of 7-year follow-ups. J Nerv Ment Dis 1993;181:514-6.
Makanjuola RO. Clinical and socio-cultural parameters in Nigerian psychiatric patients. A prospective study. Acta Psychiatr Scand 1985;72:512-21.
Menezes NM, Arenovich T, Zipursky RB. A systematic review of longitudinal outcome studies of first-episode psychosis. Psychol Med 2006;36:1349-62.
Warner R. Recovery of Schizophrenia: Psychiatry and Political Economy. London: Routledge; 2004.
Sarkar S, Hillner K, Velligan DI. Conceptualization and treatment of negative symptoms in schizophrenia. World J Psychiatry 2015;5:352-61.
Fischer EH, Dornelas EA, Goethe JW. Characteristics of people lost to attrition in psychiatric follow-up studies. J Nerv Ment Dis 2001;189:49-55.
Boys A, Marsden J, Stillwell G, Hatchings K, Griffiths P, Farrell M. Minimizing respondent attrition in longitudinal research: Practical implications from a cohort study of adolescent drinking. J Adolesc 2003;26:363-73.
Otote DI, Ohaeri JU. Neuropsychiatric features of schizophrenia and their stability in a Nigerian acute admission facility Psychopathol Afr 2000;3:307-25.
Ukpong D, Mosaku S. Demographic and clinical correlates of length of stay in a Nigerian university hospital psychiatric unit. Turk Psikiyatri Derg 2009;20:49-55.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]