Recovery from schizophrenia a metaanalysis

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Recovery from schizophrenia a meta-analysis

• Erika Jääskeläinen (née Lauronen) and Jouko
  Miettunen
• University of Oulu, Finland

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The structure of this presentation

• Background Recovery and outcome in
  schizophrenia
• Recovery in schizophrenia preliminary results
  from a meta-analysis

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Background - Exploring recovery and the course
of illness

• Why is it important to study prognosis and
  recovery in schizophrenia (and other serious
  mental disorders)?
• brings new information about the aetiology and
  prognosis of the disorder information for the
  patient, the significant others and nursing staff
• it may be a proxy measure of the quality of life
  as well
• brings information about the quality and
  effectiveness of treatment ? developing better
  treatments and treatment models

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Background - Definitions

• Treatment response
• decrease in symptoms, remission as the goal
• Remission
• absence of symptoms, lasting for certain length
  of time
• (e.g. 6 months)
• Recovery
• when remission has lasted longer ? but how long?
• quality of life, functioning (working ability),
  social relationships, need for treatment, use of
  health care services
• returning to premorbid level of functioning ?
  realistic? and what is the premorbid level of
  functioning?
• There is no structured or generally accepted
  definition or criteria for recovery.
• But During last years increasing interest on
  the topic, and Andreasen N et al. Am J Psychiatry
  2005 have proposed structured criteria for
  remission in schizophrenia.

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Background - Earlier literature

• In a meta-analysis of Hegarty et al (Am J
  Psychiatry) 1994
• appr. 40 of schizophrenia cases good outcome,
  though the good outcome has slightly declined
  during last decades
• In some classic studies amount of recovered
  individuals is proposed to be 6-58 (Bland et
  al. 1976, Ciompi 1980, Bleuler 1987, McGlashan
  1984)
• In population based studies the rate of recovery
  have varied from 3 to 16 (Goater et al. 1999,
  Harrison et al. 2001, Ran et al. 2001, Svedberg
  et al. 2001)
• In our own study in the Northern Finland 1966
  Birth Cohort recovery percentage was 3.4
  (Lauronen et al. J Clin Psychiatry 2005)
• But the rate of recovery very much depents on
  the methods of the study!
• There is no systematic review or consensus about
  the rate of recovery in schizophrenia.

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Aims

• What is the best estimate percentage of recovered
  individuals with schizophrenia?
• Our aim was to collate studies related to this
  topic and to synthesize these data with
  meta-analytic techniques.
• We aimed also to estimate effect of study methods
  on recovery percentages

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Methods literature search

• PsycINFO, Pubmed, Ovid, Web of Science, Elsevier
  Science Direct, EBSCOhost, CINAHL - Nursing
  Allied Health
• Manual literature search
• As a title search we used keywords schizo or
  psychotic or psychoss and recovery or
  remission or outcome or course or prognosis or
  longitudinal or follow-up.
• The second search in abstracts included keywords
  schizophrenia and recovery or remission. 
• All abstracts and articles were critically
  analyzed by two authors (E Jääskeläinen and J
  Miettunen).

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Methods - Criteria for inclusion to analyses

• sample included individuals with schizophrenia,
• schizophreniform, or schizoaffective disorder
• follow-up and data about some outcome measure
• at least for 2 years
• outcome criteria including both clinical and
  social
• dimensions
• subjects not selected a priori for good or poor
• outcome
• number of cases at least 15
• English language article
• not drug or other trial

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Methods - Statistical methods

• Recovery rates are presented by using
• forest plots
• The rates are pooled using random effects
• Meta regression was used to estimate
• effect of study years, length of follow-up,
• location, diagnostic system and sex
• The analyses were done with STATA 9
• programme.

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Results - Results from literature search

• The search from databases identified 5950
  unique articles.
• After further screening, we have identified 746
  articles for inclusion.
• So far in total appr. 85 of these articles have
  been evaluated.
• From these 50 studies have met all our criteria
  and were included to deeper examination and
  statistical analyses.
• From these 13 samples were from the World Health
  Organization (WHO) incidence and prevalence
  cohorts (unpublished data from Dr Kim Hopper)

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Results Recovery percentage

• 0 - 52 of the subjects recovered (mean 17.4,
  median 16.7).
• In the 20 older studies (started -1965) on
  average 20.8 of the subjects recovered, while in
  the 20 more recent studies (started 1965-), 16.8
  of the subjects recovered (meta-regression, z
  test 1.07, p0.29).
• Recovery percentages were 9.8 in studies using
  DSM diagnostic system (9 studies), 18.7 in ICD
  (18 studies), and 19.5 in other studies (23,
  mainly older studies).

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Results Recovery percentage

• In the 28 studies with at least 10 year follow-up
  the recovery percentage was in average 18.9 and
  in studies with shorter follow-up it was 15.6.
• Recovery percentages were larger (p0.03) in the
  10 samples from Asia, Africa and South America
  (24.4) than in studies from Europe and North
  America (15.7, 40 samples).

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Results Recovery percentage

• So far 12 studies have reported recovery
  percentages by sex
• In 9 studies men have higher percentage and in 3
  women
• When pooled recovery percentages do not differ
• men 19.1 and women 18.4

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0
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recovery percentage
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Discussion

• First systematic review and meta-analysis on the
  topic
• Large differences between studies
• The proportion of patients meeting recovery
  criteria appears lower in Western studies and
  studies using DSM diagnostics system

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Discussion

• Despite several studies on outcomes, this
  systematic review has identified a relative
  paucity of primary data about recovery (taking
  into account both clinical and functional
  dimensions) in schizophrenia.
• Various conceptual and methodological pitfalls
  cause challenges when studying this topic. Thus,
  more accurate reporting of multidimensional
  recovery is needed!

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Discussion

• In the future we should focus on
• larger samples, general population samples
• longer follow-ups
• multi-dimensional assessment of outcomes
• general definition for recovery and good outcome!
  
• efforts in tracking the loss-to follow-up cases

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Discussion

• In the future we aim to analyze results of all
  published recovery studies, with special
  reference to diagnosis (schizophrenia vs.
  schizoaffective vs. schizophreniform), different
  follow-up times and criteria for recovery.
• We hope other researchers to contact us if they
  know schizophrenia studies reporting recovery as
  defined here.
• (jouko.miettunen_at_oulu.fi and erika.jaaskelainen_at_o
  ulu.fi)

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Research group
Queensland Centre for Mental Health Research,
Australia John McGrath, MD, PhD Sukanta Saha,
MSc

• Department of Psychiatry,
• University of Oulu, Finland
• Erika Jääskeläinen, MD, PhD
• Johanna Heikkinen, MA
• Matti Isohanni, MD, PhD
• Academy of Finland, Finland
• Jouko Miettunen, PhD
• Juha Veijola, MD, PhD

This study has been supported by the Academy of
Finland (grant 120 479 )