• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Course and outcome
 

Course and outcome

on

  • 764 views

course and outcome of schizophrenia...a changing scenario

course and outcome of schizophrenia...a changing scenario

Statistics

Views

Total Views
764
Views on SlideShare
764
Embed Views
0

Actions

Likes
0
Downloads
10
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • Schizophrenia is difficult to pronounced and difficult to spell ,has element of fascination and mystics for general people,It is central to all mental disorder,
  • No linkage consistently associated with schizophrenia ,concordance rate of dizygotic twins is 5-15%, and for monozygotic twins is 30-65%(50%)The unaffected child found to have various personality and cognitive abnormalities like paranoid PD,schizoied PD, and otherLater epigenetic model developed by Delisi et al 2002, emphasized that it could be the result of abnormal expression of gene rather than the changed sequenced of gene“heredity is probability not the fate”1q,2q,3p,6p,8p,11q,14p,15q,16q,17q,18q,20q,22q,Birth in winter-spring season increase risk of schizophrenia by 5-8%Influenza A found to be linked Complication(bleeding, diabetes ,Rh+,LBW,head circumference of pregnancy associated significantly (CANNON et al)Perceptual deficit in childhood which remain unrecognized act as building block of psychosis(KIRK) Attention deficit present during childhood (Niemi et al2003)IQ performance decline before emergence (Ang and Tan2004,Fuller et al2002,Zammir et al 2004) Deficit in social skill, organozation ability and intellectual function are predictive of later development of schizophrenia(Davidson et al1999CLINICALLY HIGH RISK GROUP(CHR)-conversion rate is 20%in first yr f/u, additional 15% developed in next yr(CANNON et al2008) urban upbringing associated with increased risk (Boydell & Murray)Increased prevalence in Brahmins (socioeconomic) in West Bangal compared to low prevalence of scheduled cast(Nandi et al)Study of functional psychosis in an urban communities(SOF-PUC) By WHO2 fold increased in premorbide level(Arsenauit et al)8-15% of all schizophrenia attributed to cannabis use
  • Symptoms arranged in decreasing frequency
  • HUBER, KOEHLER AND CONRAD COLLED OUT POST SYNDROM as basic symptoms
  • There was significant in the rate of improvement during 1956-1985,compaired to 1895-1955 d/t introduction of narcoleptic drug(cooper said the improvement noticed even before the introduction of narcoleptics)This table include study from 1972-2005, sample size >50 and duration of f/u >5yrManfred Bleuler’s monograph is account of an intensive study of 208 pt admitted in 1942-1943 and followed up to 22 yrs till his death.Later Ciompi and Huber et al has followed up 504 pt for 23 yrs ,admitted during 1945-1959
  • LOWA=It a retrospective study which is one of the early study to indicate negative out come of schizophreniaConducted in Lowa state psychiatric hospital between 1934-1944, it was using restrictive feighner criteria's(1972) including both affective psychosis and schizophreniaFollow up done between 1972-1976, 35 yrs after the index admissionPt assessed on 4 dimentions (symptoms, work, marital status , and residential status)….Data regress to 3 point scale in terms of poor , fair and good outcome,Results were showing that 200 pt fall in poor outcome, 30% married and 20% were symptoms free(Tsuang and Winokur)CHESTNUT LODGE STUDY= Conducted by McGlashan on chronically ill, medication resistant patients.Follows 532 pts after discharge from Chestnut Lodge, a 90-bed privet tertiary care hospital in Rockville, Maryland, between 1950 and 1975, all pt diagnosed with DSMlll , and 8 deferent diagnostic group were made like schizophrenia , schizophreniform , schizoaffective ,outcome was assessed between 1977-1983 with an average follow up of 15 year duration . 163 schizophrenia pt has distributed as- RECOVERED-6% GOOD- 8% MODERATE -22% MARGINAL 23% CONTINUOUSLY INCAPACITATING 41% GAF 37VERMONT STATE HOSPITAL STUDY=Harding and others conducted a retrospective study of 268 pt, diagnosed with DSM 1(1952)Pt taken in 1955-1960, as 1968 DSM11 came ,this study also incorporated these…but no different in outcome observe , after 20 yrs , 60% of pt scored more then 61 on GAF. And this cohort also scored on Strauss and Carpenter outcome dimension with 68% showing minimal or no symptoms and 61% employed in the last year of studyThe basic differences in outcome in this study and Lowa 500 is diagnostic criteria and positive selection bias and also the fact that vermonts pt got benefited by treatment and outpatient rehabilitationCOLUMBIA PSYCHIATRY INSTITUTE =Stone and others retrospectively examine 552 pt with DSMlll, who were admitted in New York state psychiatric institute…this study used IQ as one of the criteria ( cut off score 90 was used ). Study shows psychiatry pt do better than schizophrenic pt, GAF > 61 only seen in 8% peopleVAILLANT’S FOLLOW UP STUDY=George E Vaillant conducted two studies. Its was a combination of retrospective and prospective studies. First he selected a group and retrospectively studied to collect data to provide information of prognostic factors associated with outcome. Later he selected 51 of 56 pt who achieved remission between 1959-1962 and followed them for 4 to 16 years. Results- 61% has sustained remissions,39% had a chronic course. important thing to say about this study is pt can sustained remission and it also through light on some patient related prognostic factorsPHIPPS CLINIC F/P STUDY=Stephen and others in Phillips Clinic in Baltimore, Maryland , done a large retrospective study of 472 pt, who were discharge from this clinic with the diagnosis of schizophrenia, follow up done for 10 yrs and three outcome categories made 24% complete recovery, 46% improved shown relapse and remission pattern and 30% continued hospitalizationALBERTA FOLLOW UP STUDY=this is one of the north American study conducted by BLAND and others . The first part of alberta study done in 1976 which include 92 pts who met DSMll criteria and admitted in Alberta hospital in 1963.88 pt successfully examine the results were surprising 58% recovered, 8% chronic ill ,among these 45% pt had stopedneurotropic medicationIn second phase of follow up strict Feighner criteria was used and by this the sample reduced to 45 although the same outcome criteria were used the number of recovered pt dropped from 41% to 21% so this study clearly shows the importance of diagnostic criteria's in study of outcomeCHICAGO FOLLOWUP STUDY=It is one of the multi follow up prospective study
  • Research done in Mauritius. That time its population was 600,000 and 2/3 were indian origin and rest were African
  • THE STUDY WAS DONE AT MEDICAL COLLEGE HOSPITAL ON THOSE WHO PRESENTED THERE HENCE THE STUDY SAMPLE IS ILLDEFINED AND CAN NOT BE GENERALIZED TO THE POPULATION . AS WE KNOW SIGNIFICANT NUMBER OF SCHIZOPHRENICS DO NOT SEEK TREATMENT,MANY GO TO TRADTIONAL HEALERS AND OTHER METHODS, SO REPRESENTATIVE SAMPLE HAS NOT BEEN OBTAINED. SO SAMPLING DOES NOT FOLLOW ANY OF THE KNOWN SAMPLING METHODS FOR DEFINED OBJECTIVES.IT IS ALSO IMPORTANT TO KNOW WHAT SCALES WERE USED TO SCREEN THEM,RELIABILITY OF THAT,THE PERSON WHO ADMINSTERS THAT SCALE (MEDICAL-TRAINED/UNTRAINED) . ALSO IN FOLLOW UP IF SAME PERSON DOES THE EXAMINATION THEN HE IS NOT BLIND AND THERE CAN BE BIAS.ALSO IF SCALES FOR SOCIO CULTURE ARE USED THEN THERE SHOULD BE VALIDATION OF IT FOR THAT CULTURE AND IT CAN NOT BE COMPARED WITH DIFFERENT CULTURE. Study does not mention what antipchoyics were used? We are not sure whether all were uniformly treated with same medications? We are not sure whether patients had more advantage in care as they were being studied – andResearch group was not blind? Psychotic episode ? Does it mean features at time of intake? If so ….negative symptoms have more likely to have been missed and categorized as ‘in remission’Study address the following issues-1) Is it possible to identWhy did they choose feighners criteria? Why not dsm or icd?HE WAS FIRST TO DEFINE THE RESEARCH CRITERIA FOR DIAGNOSING SCHIZOPHERNIA. WHICH WAS OPREATIONAL AND STANDERDIZED. HOWEVER THE STUDY WAS LATER REVIEWED WITH ICD-9 CRITERIA ALSO
  • Dosmed has started in 1977, 12 deferent centers in 10 different countries Developing –India, Colombia, NigeriaDeveloped- Denmark, Ireland, USA, Japan, UK ,USSR and CzechoslovakiaInd1a has two centers Agra and ChandigarhThe main aim of this study was to estimate incidence of schizophrenia in deferent culture and definitive evidence about the course and outcome of schizophreniaAge 15-54, Resident for 6 mo in that area , taken from 1978-80, only in 7 centers incidence was measured(Sartorious 1986)Incidence was 1.6 to 4.2 if CATEGO classes were used ie S,P and OAnd a more restrictive definition of CATEGO was used in CATEGO s+
  • Modified Feighner et al(1972) 2 yr f/uFavorable 66%Intermediate 30%Unfavourable4%(1989;Verghese et al ,3 center-Vellor, Madras and Lucknow)
  • Studies from chandigarh, usingsemple size of 112 pt ,f/u for 18-30mo.at the end of study 91 pt remains in study,GCI improved in 66% and 34% not improved or worsened on scale,working condition of pt were good in 56% and 44% were not workingStudy used 5 diagnostic frame work and reported insignificant influence
  • IT’S A 5 YR F/U STUDY,byDube.IPSS cohort traced back after 13-14 yrs,although original cohort has 140 pt ,105 could have traced,resuts shows 66% normal pt,intensity found to decreased with time
  • Taken cohort from ICMR study,total 10 yrs of f/u study,76 pt assessed . A general decline in the intensity on both positive and negative symptoms were found
  • The original study called the “factor affecting course and outcome of schizophrenia” 90 pt of first episodes included by using diagnosis methods ICD 9, 45 male and 45 femaleOut come was good in 13(27.7%), poor in 9 (19%), intermediate in 25(52%), no gender deference was observed 24
  • Cali(colombia )was a FRC of IPSS, Leon 1989, done a 10 yrs f/u study,by taking sample size of 101,
  • This study started around 25 yr after IPSS and DOSMED , it basically designed to assess comparative cost and outcome associated with antipsychotic use in out-patient , mainly Olenzapinevs other antipsychotics . SOHO includes 37 countries has been grouped in 6 regions South Europe, North Europe , central and Eastern EuropeLatin America , North America ,Middle East and East Asia . This world wide data collected and total number of patients were 17384.All pt of age 18 or above included with diagnosis of schizophrenia using DSMIV and ICD-10 ,Clinical global impression- schizophrenia (CGI-SCH) used scoring 1 for no symptoms and 7 for most severe symptomsClinical remission defined as CGI-SCH scored 3 or less than 3, should maintained for two consecutive visits ( 12mo)
  • North Europe-France, Germany, UK, Netherland, Ireland, DenmarkSouth Europe-Spain, Italy, Portugal, Greece, Israel( has been grouped with south Europe on the basis of ethnicity , economic and health care system)CENTRAL AND EASTERN EUROPE-(Czech Republic, Hungary, Lithuania, Poland , Romania, Russia, Slovakia, Slovenia)LATIN AMERICA-Argentina, Chile, Colombia, Csta Rica, El Salvador, Guatemala, Honduras, Mexico, Peru, VenezuelaNORTH AFRICA and MIDDLE EAST- Algeria , Egypt, Saudi Arabia, Turky)EAST ASIA- Korea, Malaysia, Taiwan
  • South Europe , central and eastern shows similar clinical remission but has different economic levelCentral and eastern Europe seems to have lower functional remission rate compared with south Europe, where as north Europe tend to have higher functional remissionThe reasons for the better clinical outcome in low-and middle income countries are unknown but may be related to differences in the balance between treatment and vulnerability experienced by the individualsDifference in functional remission between regions were mostly driven by differences in independent living and paid employmentWomen achieve more remission, younger age , shorter duration of illness, no previous treatment for schizophrenia also found associated with good outcomeStudy also confirm that shorter duration of untreated psychosis is associated with better symptomatic and functional outcome in higher-income and low- and middle- income countriesHigher symptoms severity at baseline interms of +/-, cognitive and overall sypmtomsassociated with
  • CHAPMAN- change first percieved by pt, than family,
  • Alberta follow -up study conducted by Bland et all, DSMll criteria were used , 58% fall in to recovered category only 8% fall in to chronic category. As 10% of these pt has discontinued there medication after 10 months and even shown good outcome so this was the one of the first study which shows good outcome even without medication. Bland farther followed up the same cohort now using the feighner(stricter criteria) criteria, but kept same criteria for outcome categories. Resuls has shown drop of 41% to 21% in recovered category . This study give a strong evidence that how the diagnostic criteria can make a difference
  • Field research center1202 pt were included in study and 909 (76%) were interviewed Pt from Agra, cali and ibadan more asymptomatic , Arhus, London and Washington had more psychotic symptomsPt of cali, agara, and Ibadan spend less periode of f/u, pt of Washington, London had severe social impairment.
  • 1920-there was no definitive treatment and during 1895 to 1925 studies reported 27.6%(SE 3.3%) improvement,1930 with introduction of ECT outcome improved by 34.9%.it further improved in 1956-85 by 48.5% with the introduction on narcoleptics and emphasis on community based intervention

Course and outcome Course and outcome Presentation Transcript

  • COURSE AND OUTCOME SCHIZOPHRENIA PART-I PRESENTOR-DR AJAY KUMAR CHAIRPERSON-DR LAKSHMI PANDIT KEMPEGOWDA INSTITUTE OF MEDICAL SCIENCE -BANGALORE3/14/2013 DR AJAY KUMAR 1
  • What is course? Longitudinal progression of a disease Course defined in terms of mode of onset(sudden, insidious, acute, subacute etc) progression(episodic, continuous ect) What is outcome? Outcome looked in terms of clinical, social, functional, remission, recovery and death The course of schizophrenia is highly heterogeneous, with outcome ranging from complete recovery to chronic incapacity3/14/2013 DR AJAY KUMAR 3
  • PATTERN OF COURSEWHO has described 5 patterns1) Complete or near complete recovery2) Residual personality change3) more relapses or acute exacerbations of psychotic symptoms, following them with no marked personality change or more relapses4) Above with marked personality change5) Continuous psychotic illness.3/14/2013 DR AJAY KUMAR 4
  • PATTERN OF COURSE IN ICD10• F20.00 continuous• F20.01 episodic with progressive deficit• F20.02 episodic with stable dificit• F20.03 episodic remittent• F20.04 incomplete remission• F20.05 complete remission• F20.08 other• F20.09 course uncertain, periode of observation too short3/14/2013 DR AJAY KUMAR 5
  • NATURAL COURSE3/14/2013 DR AJAY KUMAR 6
  • NEUROPSYCHOL REV(2009) 19:280-2933/14/2013 DR AJAY KUMAR 7
  • PREMORBIDGENETIC FACTORSFACTORS DURINGPREGNANCYPREMORBID COGNITIVE AND SCHOLASTIC PERFORMANCEPREMORBID CANNABIS USE3/14/2013 DR AJAY KUMAR 8
  • PRODROME• Recognized in early 20th century• “A heterogeneous group of behaviour temporary related to the onset of psychosis”(Keith and Matthews 1991)• Periods between first change in person to appearance of FRS• Retrospective concept3/14/2013 DR AJAY KUMAR 9
  • SYMPTOME OF PRODROME• Reduced concentration• Attention deficit• Reduced motivation• Depressed mood• Sleep disturbance• Anxiety• Social withdrawal• Suspiciousness• Deteriorate role functioning• irritability3/14/2013 DR AJAY KUMAR 10
  • SIGNIFICANCE• The detection of very early disorder to prevent later serious illness-Cameron• Longer duration associated with longer time in remission, or partial remission• A theory of toxic effect of psychosis on brain (Liebermann et al 1990, Wyatt 1991)• RELAPSE SIGNATURE-Birchwood 1992• OUTPOST SYNDROME3/14/2013 DR AJAY KUMAR 11
  • DURATION OF PRODROME• All pt experienced prodrome ,from a brief periode to several year-CONRAD(1958)• CAMERON- 17 of his 100 pt not experienced prodrome , so it is not mandatory• Duration varies none to 20 yrs- BEISER• Median duration estimated as 52.7wk• Interval same in both gender3/14/2013 DR AJAY KUMAR 12
  • DURATION OF PRODROME• Longer duration of “initial prodrome”while “relapse prodrome is shorter duration• Relapse prodrome is 2- 4wk, long enough to make intervention(Birchwood et al)3/14/2013 DR AJAY KUMAR 13
  • CHILDHOOD SCHIZOPHRENIA• 4% of all cases of schizophrenia found to be less than 15yr old• “PUBESCENT”• If occure before13yr then called as very early onset schizophrenia(VEOS)• Prodrome include decreased in scholastic performance, social withdrawal , bizarre hygiene3/14/2013 DR AJAY KUMAR 14
  • DURATION OF UNTREATED PSYCHOSIS• Independent predictor• Meta analysis of 42 studies shows better response to antipsychotics and improvement in severity of global psychopathology , positive symp, negative symp, functional outcome(Perkins et al 2005)• Cost of care was reduced by 30%• Recent(2011) 5 yr f/u study concluded ED group shows better scoring on negative, depressive and cognitive factors and global assessment3/14/2013 DR AJAY KUMAR 15
  • FIRST ONSET• Adolescence or early adulthood• Average age in women is 29 ,In man 25yrs(Hagner et al 1998;Jablensky and Cole 1997)• 75% has onset in 15-30yrs(Hafner 2000)3/14/2013 DR AJAY KUMAR 16
  • COURSE OF SUBTYPES •PARANOID SCHIZOPHRENIA •Characterized by more acute onset. •Usually these patients experience a longer period of adult life before becoming ill , they attained higher premobid social and occupational skills. •P.S pt. tend to have remittent course and associated with lesser disability. •P.S pt. have the best long-term outcome and overall recovery rate.3/14/2013 DR AJAY KUMAR 17
  • HEBIPRENIC SCHIZOPHRENIA• Insidious onset beginning in adolescence.• Illness is distinctive but relatively unreactive to life events.• Illness course was mostly continuous in most cases.• Majority of patients remained markedly disabled throughout the longterm.• Functional recovery were found to be less.3/14/2013 DR AJAY KUMAR 18
  • DEATH Most devastating outcome Mortality rate as higher as 5 times for man(age matched general population),2 times for women(Brown 1997;Brown et al2000) In addition to suicide ,CVD, diabeties,other accidents3/14/2013 DR AJAY KUMAR 19
  • SUICIDE• Leading course of premature death in pt of schizophrenia(Black et al1985;Osby et al2000)• 10 fold higher rate as compared to general population(Baxter and Appleby1999)• More than 50% occure in first 5 year of illness(Verdoux et al 2001)• 15-25% make an attempt during first episode prior to treatment(J Addington et al 2004, Cohen at al 1994)• 9-24% die by suicide(Caldwell and Gottesman 1992)• 2/3 of completed suicide in 6yr of diagnosis(Westermeyer JF,1991)3/14/2013 DR AJAY KUMAR 20
  • • DEPRESSION • occurs in 15-20% cases in 9-24% months • 10-15% pt kill themselves • Depression even occurs in prodrome in 20% of cases • Drug induced (Johnson, J clin psy 1984)3/14/2013 DR AJAY KUMAR 21
  • • Male • Young age • Unemployment • Depressive symptoms • Family history • Lack of support • Longer duration of illness • Substance use (Black et al;Breire and Astrachan 1984; Caldwell and Gottesman1990)3/14/2013 DR AJAY KUMAR 22
  • • Is depression common in female schizophrenic pt?• Depressive symptoms in early phase predict lower levels of negative symptoms later. moreover depression during psychosis predict good outcome(Emsley et al 1999;McGlashan and Crpenter 1976;Oosthuizen et al 2002)• Depression during remission related to poor outcome(Bartels and Drake 1988;Mandel et al.1982;Siris1991)3/14/2013 DR AJAY KUMAR 23
  • FACTORS ASSOCIATED WITH BETTER OUTCOME• Female gender(Lee et al 1998;leund. Chue 2000; Thara et al 1994)• Married status• Early treatment• Acute onset• Rural back ground and cohesive family• Absence of negative symptoms• Predominance of florid positive symptoms• Short duration of first episode(Perkin et al. 2005)• Few episodes of similar illness in the past• Good premorbid personality and adjustment3/14/2013 DR AJAY KUMAR 24
  • Factors associated with poor outcome• Male (Isohanni et al 2004;Niemi et al 2003)• Unmarried• Early age of onset of illness (Isohanni et al 2004;Niemi et al 2003)• Delayed treatment• Irregular treatment• Gradual onset(Isohanni et al 2004;Niemi et al 2003)• Lack of social support• More negative symptoms(Isohanni et al 2004;Niemi et al 2003)• Positive family history• Poor premorbid level of functioning(Isohanni et al 2004;Niemi et al 2003)• Large ventricle of brain, presence of subtle neurological sign• Substance abuse (Coldham et al. 2002, Hunt et al. 2002)• Excessive criticism, hostility or over involvement in home and family atmosphere• Recent cognitive deficits3/14/2013 DR AJAY KUMAR 25
  • RECOVERY-according to LibermanFollowing should be fulfilled for 2 yr duration1)Remission of symptoms2)Engagement in productive activity3)Independent management of day to day needs4)Cordial family relation5)Recreational activities6)Satisfying peer relationBy in large pt should resume his full participation in workand social life. And absence of clinically significantpsychopathology3/14/2013 DR AJAY KUMAR 26
  • COURSE AND OUTCOME PART II3/14/2013 DR AJAY KUMAR 27
  • Author COUNTRY SAMPLE LENGTH OUTCOME SIZE OF F/UBLEULER(1972) SWITZERLAND 208 23 20%COMP 33%MILD REMISSION DEFECTTSUANG(1979) USA 186 35 46%RECOVEREDCIOMPI(1980) SWITZERLAND 289 37 20%RECOVERED 43%IMPROVE DHUBER(1980) GERMANY 502 22 26% 31MILD DEFECTOGAWA(1987) JAPAN 140 21-27 31%RECOVERED 46%IMPROVE DShepherd et UK 107 5 22% recovered, noal(1989) relapseJohnstone et al UK 530 3-13 14% Excellent,(1990) 18.5% very good social adjustmentLAURONEN(2005) FINLAND 91(BIRTH TILL 31 AGE 4% RECOVERED 3%PARTIAL COHORT) REMISION 3/14/2013 DR AJAY KUMAR 28
  • Author(s)&year COUNTRY YEARS Follow best worst up(yrs)BROWN et al London 1966 34% 28%MURPHY & Mauritius 1971 12 59% 32%RAMANLo & Lo Hong Kong 1977 64% 34%KULHARA & Chandigarh, 1978 30mo 45% 32%WIGWaxler Sri Lanka 1979 64% 29%THARA(1994) INDIA 90(FIRST 1994 10 12%REC 62%RE EPISODE) OVERY MISSIO NTHARA(2004) INDIA 90 2004 20 6%REC 15%STA OVERED BLE 3/14/2013 DR AJAY KUMAR 29
  • Study name /author country years INDIABrown et al London 1966Phipps clinic BaltimoreIPSS WHOISOS WHOBleuler SWITZERLAND 1972Murphy&Raman Mauritius “LOWA500 1972-1975DOSMED WHO 1977, KULHARA &LO&LO Hongkong WIG(1978)WAXELER SrilankaTsung 1979CIOMPI SWITZERLAND 1980Huber Germany 1981 SOFACOSChestnut lodge study USA 1984 Agra Cohort(Dube’s)Colombia psychiatric USA 1986instituteVermount USA 1987 1988 Chandigarh 3/14/2013 1989 DR AJAY KUMAR ICMR 30
  • INDIA Singapore Singapore 1991 study Study from Hongkong HongKong 1994 Madras longitudinal study HARRISON 15 2001 yr f/p BJP W-SOHO multinational 2011 2012 25 yrs of schizophrenia madras study3/14/2013 DR AJAY KUMAR 31
  •  THE LOWA 500 FOLLOW UP STUDY  CHESTNUT LODGE FOLLOW-UP STUDY  VERMONT STATE HOSPITAL FOLLOW-UP STUDY COLUMBIA PSYCHIATRIC INSTITUTE FOLLOW –UP STUDY  VAILLANT’S FOLLOW-UP STUDIES  PHIPP CLINIC FOLLOW-UP STUDY  ALBERTA FOLLOW-UP STUDY  CHICAGO FOLLOW-UP STUDY3/14/2013 DR AJAY KUMAR 32
  • • Murphy and Raman (1971) in idyllic island of Mauritius• Admission in the year 1956 followed up 12 yrs• Finding aroused interest in this area and subsequent study from Hong Kong(Lo&lo1977)• Kulhara and Wig( India1978)• Srilaka(Waxler 1979)3/14/2013 DR AJAY KUMAR 33
  • Course of 12 yrs follow up continuous disability 21% continuous partial 59% disability 15% single episode 5% no episode MURPHY & RAMAN (1971)3/14/2013 DR AJAY KUMAR 34
  • OUTCOME in hospital 16% 19% symptomatic 64% independent MURPHY & RAMAN (1971)3/14/2013 DR AJAY KUMAR 35
  • INTERNATIONAL PILOT STUDY OF SCHIZOPHRENIA• Started in 1966• Objectives1. Do schizophrenia differ in form or content? Does clinical course differs2. Can other functional psychosis also be recognize and do they run a recognizably deferent course?3. Can technique be developed for recording and classifying symptomology reliably?4. can team of research workers be trained to use these techniques3/14/2013 DR AJAY KUMAR 36
  •  Prospective follow up study  15-44 age  PSE data were used to classified computer diagnostic program( CATEGO) • 1202 pt followed up at 1yr ,2yr, and 5 yrs • FRC 9 • Arhus(Denmark) • Agra(India) • Cali(Columbia) • Ibadan(Nigeria) • London(UK) • Moscow(USSR) • Taipei(Taiwan) • Washington(USA) • Prague(Czechoslovakia)3/14/2013 DR AJAY KUMAR 37
  • NUMBER OF PATIENTS IN IPSS SAMPLECenter schizophrenia Affective Paranoid and Neuroses and other psychosis other psychosisAarhus 53 44 18 4Agra 101 28 - 11Cali 101 5 3 18Ibadan 120 13 7 4London 100 14 7 11Moscow 77 13 12 38Taipei 86 10 21 11Wahington 97 8 5 22Prague 76 29 5 6total 811 164 73 125 3/14/2013 DR AJAY KUMAR 38
  • COURSE OF IPSS PATIENTS AT 2 AND 5 YRS Center % with full remission % with continuous illness 2 yr s 5 yrs 2 yrs 5yrs Aarthus 6 6 50 40 Agra 51 42 20 10 Cali 19 11 26 21 Ibadan 58 33 7 10 London 23 5 30 14 Moscow 7 6 18 21 Prague 17 9 30 23 Washington 21 17 47 23 Taipei 27 - 27 -3/14/2013 DR AJAY KUMAR 39
  • % severe social impairment 2yrs 5yrs Aarhus 33 50 Agra 18 13 Cali 22 17 Ibadan 5 19 London 38 27 Moscow 21 23 Taipei 20 - Washington 32 25 Prague 33 303/14/2013 DR AJAY KUMAR 40
  • • There is great variability in the course and out come of schizophrenia• Outcome of schizophrenia not as bleak as was expected to be. More than half persons fall in best outcome groups• About half were still in episode of inclusion or had had subsequent psychotic symptoms at 2yr follow-up• Center in developing countries had better outcome than centre in developed countries.3/14/2013 DR AJAY KUMAR 41
  • Results1. It is possible to carried out a large scale study2. Similar groups of schizophrenic could be identified in every one of the nine countries3. It was possible to develop a valid and reliable research instrument in international psychiatric studies3/14/2013 DR AJAY KUMAR 42
  • • IPSS demonstrated that the course and outcome of schizophrenia was best in developing countries like Ibadan(Nigeria), Agra(india), Cali (columbia), and Taipei(Taiwan) at 2yr f/u (Leff et al.1992; leon, 1989; Dube et al;1984)3/14/2013 DR AJAY KUMAR 43
  • study of factor affecting the course and outcome of schizophrenia SOFACOS Started on oct 1981 at three centers K.G. medical college –Lucknow Madras medical college –Madras Christian medical college –Vellore3/14/2013 DR AJAY KUMAR 44
  • • The project addressed the following research questions: 1. Is it possible to identify sociocultural & clinical variables, which are associated with & might be etiologically related to the course & outcome of schizophrenia. 2. Is the course & outcome of schizophrenia better in a developing country such as India as is suggested by the WHO multi country project – IPSS? 3. Do the three centres in India with different socio- cultural backgrounds differ in the course & outcome of schizophrenia?3/14/2013 DR AJAY KUMAR 45
  • CRITICAL COMMENT ON OBJECTIVES: (1)THE TWO DIFFERENT OBJECTIVES WERE CLUBBED, EACH OF WHICH NEEDS DIFFERENT METHODOLGY TO StTUDY a) sociocultrual, clincal variables associated with course & outcome (ASSOCIATED FACTORS) b) eitologically related to course and outcome (CAUSATIVE FACTORS). Hence the objective was poorly defined.  OBJECTIVE (2) TO KNOW WHETHER SCHIZHOPHRENIA HAS BETTER OUTCOME IN DEVELOPING COUTRIES LIKE INDIA? THE STUDY REQUIRED WAS COMPARTIVE STUDY ? BUT HERE IT DID NOT HAVE ANY COMPARABLE GROUP? SO IT WAS POORLY DESIGNED OBJECTIVE (3) ONLY 3 CENTERS WERE SELECTED OF WHICH TWO WERE FROM SOUTH WHICH WERE JUST 100 MILES APART SO THERE WOULD BE HARDLY ANY DIFFERENCE IN SOCIOCULTURAL FACTORS WHICH STUDY HAD TO EXPLORE. IDEALLY CENTERS SHOULD HAVE BEEN FROM N-S-E-W OR ATLEAST WHERE SUCH FACTORS COULD BE OBTAINED FROM SAMPLES Why was criteria D used? Was it only to see the associations at outcome? Havnt they missed the cases who did not have any of them? THE STUDY TOOK 3MONTHS AS CRITERIA, WHICH WAS NEIGHTHER IN DSM OR ICD NOR FRIEHGNER CRITERIA? SO CRITERIA IS NOT VALIDATED , MOREVER THE ACUTE CASES WITH 1 MONTH DURATION HAVE BEEN MISSED.3/14/2013 DR AJAY KUMAR 46
  • DOSMED DETERMINANTS OF OUTCOME OF SEVERE MENTAL DISORDER OUTCOME INDIA DEVELOPING DEVELOPED CATEGORY COUNTRIES COUNTRIES1.Remitting course 67% 62.7% 36.8%with full remission2.continuous/incom 31.3% 35.7% 60.9% plete remission3.Social functioning 14% 15.7% 41.6%impaired4.Social functioning 44.5% 42.9% 31.6%not impaired3/14/2013 DR AJAY KUMAR 47
  • DOSMED,2YR OUTCOMEMODE OG ONSET DEVELOPING DEVELOPED COUNTRIES COUNTRIESSUDDEN/ 51.4% 29.5%PRECIPITOUSINSIDIOUS 28.4% 52.1%COURSESINGLE EPISODE,FULL 37.0% 15.5%REMISSIONCONTINOUS ILLNESS 11.1% 17.4%3/14/2013 DR AJAY KUMAR 48
  • DOSMED IN INDIASINGLE EPISODE F/BCOMPLETE REMISSION CONTINOUS ILLNESS Sales Sales AGRA CHANDIGARH(U) AGRA CHANDIGARH(U) CHANDIGARH® CHANDIGARH® 12% 34% 44% 31% 57% 22% 2YR OUTCOME3/14/2013 DR AJAY KUMAR 49
  • INCIDENCE RATE PER 10,000 POPULATION AT RISK CATEGO S, p ,o CATEGO S+ 4.2 3.5 2.8 2.2 2 2.21.6 1.6 1.4 1.1 1.2 1 0.7 0.9 0.9 0.9 3/14/2013 DR AJAY KUMAR 50
  • RESUTS1 course of schizophrenia defined by a clinical criteria is highly variable and unrelated to clinical description2 short term outcome of schizophrenia is much better than was previously believed or expected3 majority of patient showed remitting pattern of course over 2 years 50.3% had single episode followed by complete or incomplete remission and 15.7% had unremitting , continuous illness4 Acute onset, living in developing countries ,married status and good premorbid adjustment predicted good outcome3/14/2013 DR AJAY KUMAR 51
  • ICMR FAVORABLE INTERMEDIATE UNFAVORABLE 4% 30% 66% Verghese et al (1989)3/14/2013 DR AJAY KUMAR 52
  • CHANDIGARH STUDY KULHARA & CHANDIRAMANI(1988)GLOBAL CLINICAL IMPROVEMENT WORKING CONDITION IMPROVED NO CHANGE/WORSE WORKING NOT WORKING 34% 44% 66% 56%3/14/2013 DR AJAY KUMAR 53
  • AGRA COH0RT DUBE et al(1984)• Taken cohort from IPSS and done 5 yrs follow up• Results-66% pt were normal• Pointed out decreased intensity of illness with the passage of time3/14/2013 DR AJAY KUMAR 54
  • MADRAS LONGITUDINAL STUDY THARA et al (1994) Saes complete remission 11 resudual symptoms 2 one or more relapse,spent 16% period of in psychosis 37 one or more relapse with incomplete recovery 21 continue illness 6% 3% 14% 28% 49%3/14/2013 DR AJAY KUMAR 55
  • 25 YEARS OF SCHIZOPHRENIA:The Madras Longitudinal Study Thara Rangaswamy Indian journal of psychiatry 54(2)Apr-Jun 20123/14/2013 DR AJAY KUMAR 56
  • OUTCOME 28% good 53% 19% poor intermediate EMPLOYMENT 13/24 male unemployed. 6 female on job MARITAL STATUS > women married and separate. 30 remain married on 25 year of f/p male remains single 8/11 SOURSE OF SUPPORT -32% support financially 36% spouse 17% parents3/14/2013 DR AJAY KUMAR 57
  • SINGAPORE STUDY TSOI & WONG(1991) 5YR 10YR 15YRRATE OF 84% 75% 74%FOLLOW UPWORKING 55% 54% 48%CONTNUE 45% 41% 48%TREATMENT TOTAL SAMPLE SIZE 333, TOTAL DEATH DURING F/U 48,AMONG THEM 34 WERE SUICIDE3/14/2013 DR AJAY KUMAR 58
  • STUDY FROM COLOMBIA LEON(1989)• 10 YRS FOLLOW UP STUDY• RECOVERY 43%COMPLETE RECOVERED 8% PATIALY RECOVERED 51%• COURSE 41% EPISODIC 24% MIXED 35% CONTINUE ILLNESS• SOCIAL OUTCOME 14% NO IMPAREMENT 36% MILD 39% MODERATE 11% SEVERE• CLINICAL OUTCOME 24% GOOD 37% MEDIOCRE 29% POOR3/14/2013 DR AJAY KUMAR 59
  • LONG-TERM(15YR)COURSE OF SCHIZOPHRENIA 1) Acute onset, simple course , good outcome -5% 2)Acute onset, episodic course , good outcome -29% HARRISON G,HOPPER K, CAIG T, et al”Recovery From Psychotic illness:A 150and 25 year international follow-up study”BJP 178;506- 517,2001.3/14/2013 DR AJAY KUMAR 60
  • 3) Insidious onset , simple , good out come -10% 4) insidious, episodic, good outcome -23% HARRISON G,HOPPER K, CAIG T, et al”Recovery From Psychotic illness:”BJP 178;506-517,2001.3/14/2013 DR AJAY KUMAR 61
  • 5) Acute onset, simple course, poor outcome -9% 6) acute, episodic course , poor outcome -5% HARRISON G,HOPPER K, CAIG T, et al”Recovery From Psychotic illness:”BJP 178;506-517,2001.3/14/2013 DR AJAY KUMAR 62
  • 7)Insidious onset, simple course , poor outcome -14% 8)Insidious onset, episodic course, poor outcome; 4% 5+29+10+23=63 Relapse rate in 1yr=43%;in 2yr=55%;in 5yr70% HARRISON G,HOPPER K, CAIG T, et al”Recovery From Psychotic illness: A 15-and 25-year international follow-up study”BJP 178;506-517,2001.3/14/2013 DR AJAY KUMAR 63
  • World wide schizophrenia out patient Health outcome(W-SOHO)• The Schizophrenia Outpatient Health Outcomes(SOHO) is a 3 yr prospective study• In the background of the results IPSS and DOSMED• Published in BJP2011, 199:194-2013/14/2013 DR AJAY KUMAR 64
  • 3/14/2013 DR AJAY KUMAR 65
  • 3/14/2013 DR AJAY KUMAR 66
  • 3/14/2013 DR AJAY KUMAR 67
  • Remission rates for six regions N=11078 Column1 functional outcome clinical outcome 84.4 79.6 79.4 65.1 61.3 66.1 60.1 35 24.6 28.7 25.4 17.8 21.6 20.7 East North Latin Central North South total Asia Africa America and europe Europe and Eastern middle Europe east3/14/2013 DR AJAY KUMAR 68
  • 3/14/2013 DR AJAY KUMAR 69
  • 3/14/2013 DR AJAY KUMAR 70
  • 3/14/2013 DR AJAY KUMAR 71
  • • W-SOHO shows clinical outcome is worse in Europe compared with other region• The frequency of clinical remission was lower in the three European regions (60-65%) than in East Asia , Latin America , and North Africa and Middle East (79-84%)• Participant from Latin America , North Africa and Middle East more likelihood of achieving clinical remission than those in South Europe• Economic development not necessary translated to difference in the course3/14/2013 DR AJAY KUMAR 72
  • 1) Comprehensive text book of psychiatry 2) Rob Nicolson MD,premorbid speech and language impairment in chilhood schizoprenia associated risk factors.Am j .psy,2000 157,794-800 3) R. schennach-wolf, an early improvement threshold to predict response and remission in first episode, Bjpsych 2010.460-4663/14/2013 DR AJAY KUMAR 73
  • 4) Jeferey A.Lieberman MD,text book of schizophrenia5) Harrison G, Recovery from psychotic illness;A15 - 25yr international follow-up study, BJP 178:506- 517,2001.6) Schizophrenia the Indian scene;Parmanand Kulhara,Ajit Avasthi,Santosh7) Menezes NM, Arenovich T,Zipursky RB.A systemic review of longitudinal outcome studies of first episode psychosis(review) Psychol Med 2006,36(10):1346-623/14/2013 DR AJAY KUMAR 74
  • 8) Eton WW, Thara R, Federman B, et al. structure and course of positive and negative symptoms inschizophrenia. Arch Gen Psychiatry 1995;52(2):127- 34 9) Lieberman JA, Perkins D, Belger A, et al. The early stages of schizophrenia: speculation on pathogenesis, pathophysiology, and therapeutic approches, Bio Psychiatry 2001;50(11);884-97 3/14/2013 DR AJAY KUMAR 75
  • 10) Harrison G, Hopper K,Craig T,et al. Recovery from psychotic illness:a 15-and 25yr international follow-up study. Br J psychiatry 2001;178(6)506-1711) Larsen TK,Melle I et al, early detection of psychosis: positive effects on 5-yr outcome,psyhol med 41;1461-1469,2011 3/14/2013 DR AJAY KUMAR 76
  • 12) Focus on psychiarty in India;R.Thara, R Padmavati and T.N.Srinivasan;BJP(2004)184.366-37313) cross-national clinical and functional remission rates: worldwide schizophrenia Outpatients Health Outcomes(W-SOHO)study;josep Maria Haro,Diego Novick et al;BJP2011,199:194-201.14) Hospitalization as an outcome in schizophrenia, Tom Burn ;BJP 2007;191;37-41 3/14/2013 DR AJAY KUMAR 77
  • 15) Identify unmet therapeutic in schizophrenia patients; The Early Contribution of Wayne Fenton From Chestnut Lodge, Thomas H.McGlashan and william T. Carpenter; Schizophrenia Bulletin 33 no 5pp, 1086-1092, 200716) Long-Term Outcome of Patients With Schizophrenia:A review ;Thomas H Jobe, MD,CanJ psychiatry, vol 50,no 14 dec 200517) Twenty-five year of schizophrenia: The Madras Longitidinal study, Thara Rangaswamy:IJP 543(2),Apr-jun 20123/14/2013 DR AJAY KUMAR 78
  • 18) Recovery from Schizophrenia: An International Perspective: AReport from the WHO Collaborative Project, the International Study ofSchizophreniaedited by Kim Hopper, Glynn Harrison, Aleksandar Janca, NormanSartorius19) Natural course of Schizophernia Disorder: A 15 yearsfollowup a Duch Incidence Cohort , Durk Wiersma , Fokko J.Schizophrenia Bulletin Vol. 24 No 1,199820) Long term course of adolescent schizophrenia: chistianFleischhaker , Eberhard Schulz, Kathrin Tepper; schizophrenia bulletinevol. 31 no 3pp , 769-2005 3/14/2013 DR AJAY KUMAR 79
  • 3/14/2013 DR AJAY KUMAR 80
  • MODEL OF PRODROME ATTENEUATED PSYCHOTIC SYPMTNON SPECIFIC PSYCHOTICSYMPT SYMPT BEHAVIORAL CHANGES3/14/2013 DR AJAY KUMAR 81
  • Recovery• Mental health recovery is in a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential3/14/2013 DR AJAY KUMAR 82
  • ASSESSMENT• Psychosis proneness scale• Personal assessment and crisis evaluation• The comprehensive assessment of at risk mental states (CAARMS)3/14/2013 DR AJAY KUMAR 83
  • DISTURBANCVE OF THOUGHT BLOCK SPEECH ATTENTION DISTURBANCEPERCEPTUAL CHANGES MOTILITY DISTURBANCE REACTIVE SYMPT PSYCHOTIC SYMPT BEHAVIOURAL CHANGES3/14/2013 DR AJAY KUMAR 84
  • 3/14/2013 DR AJAY KUMAR 86
  • UNDEFERENTIATED SCHIZOPHRENIA• Similar to hebephrenic in terms of early and insidious onset of illness and poor premorbid functioning.• In majority of cases this illness appeared to be an exacerbation or troubled premorbid personality traits,ideation,affect and behavior.3/14/2013 DR AJAY KUMAR 87
  • • 15 yr f/u relapse rate 43% in 1 yr , 55% in 2 yr 70% in 5yr• 2/3 of completed suicide occures in 6 yr onf diagnosis3/14/2013 DR AJAY KUMAR 88
  • 10 components of recovery• Self-direction• Individualized and person- centered• Empowerment• Holistic• Non-linear• Strength-based• Peer-support• Respect• Responsibility• hope3/14/2013 DR AJAY KUMAR 89
  • • FACTORS- personality factors more stress-full life event living alone early parental loss previous attempt of self-harm more hospital admissions3/14/2013 DR AJAY KUMAR 90
  • Stage0-premorbide=Stage 1a, early prodrom3/14/2013 DR AJAY KUMAR 91
  • • Social isolation long duration of length of episode of inclusion, past history of psychiatric treatment predictive of poor outcome. Similarly insidious onset and marital status of widowhood, divorced or separated predictive of poor outcome3/14/2013 DR AJAY KUMAR 92
  • 3/14/2013 DR AJAY KUMAR 93
  • INTERNATIONAL PIOLET STUDY OF SCHIZOPHRENIA• FRC in 9 countries• Developing –India, Colombia, Nigeria and Taiwan• Developed- USA, UK, Denmark, Czechoslovakia and USSR• 3 phase-one yr f/p, 2 yr f/p, 5 yr f/p• Used PSE3/14/2013 DR AJAY KUMAR 94
  • 3/14/2013 DR AJAY KUMAR 95
  • 100 YRS OF SCHIZOPHRENIA 60 50Mean % improved on f/u 40 30 Series 1 20 10 0 1910 1920 1930 1940 1950 1960 1970 1980 1990 AmJ psy 1994;151;1409-1416 3/14/2013 DR AJAY KUMAR 96
  • • Overall outcome was remarkably more favorable for pt in developing countries• 5yr f/u done by Sartorious et al.(1987) and Leff et al.• Pt from developing countries has better outcome, spend less time in illness, less sever social impairment3/14/2013 DR AJAY KUMAR 97