Is it realistic for patients with schizophrenia to believe they can recover? Recent observational studies show that some do,1 even though all DSM editions have defined schizophrenia as a chronic disease with a poor outcome.2
Our understanding of schizophrenia is changing as we gain new insights into:
- mechanism of recovery
- efficacy of combined psychotherapeutic, psychosocial, and drug therapies for sustaining remission and recovery
- the value of long-term aftercare. This article examines evidence on:
- achieving recovery from schizophrenia
- factors associated with remission
- treatments that may help prevent relapse and lead to stable, lasting recovery.
What is ‘recovery’?
Diagnostic criteria. Recovery from schizophrenia has social, occupational, symptomatic, and psychostructural dimensions. For clinical practice, Liberman et al3 developed a useful set of 10 criteria for recovery (Table 1) by analyzing the literature and cases of 23 schizophrenia patients who returned to work or school with their symptoms under control.
Recovery from schizophrenia: 10 clinical criteria
|Criteria||Characteristics of recovered patients*|
|Family relationships||70% reported good or very good family relationships|
|Substance abuse||None reported illicit drug use in the past year, and two reported occasional alcohol consumption|
|Duration of untreated psychosis||Only 13% reported >1 year delay between symptom onset and treatment|
|Initial response to medication||87% reported effective symptom control with their first antipsychotic medication|
|Adherence to treatment||All reported adherence to psychiatric care and medication regimens|
|Supportive therapy||91% reported ongoing psychotherapy, and 78% reported that accessible and supportive psychiatrists and therapists aided their recovery|
|Cognitive abilities||Normal or near-normal functioning on tests of flexibility in solving problems, verbal working memory, and perceptual skills|
|Social skills||None showed more than very mild negative symptoms|
|Personal history||70% graduated from college, 13% completed 2 years of college, and 3 of remaining 4 worked full time before becoming ill|
|Access to care||91% received antipsychotics and psychotherapy, 48% social skills training, 57% family participation, 26% vocational rehabilitation, and 61% self-help groups|
|* Based on a study of 23 schizophrenia patients who returned to work or school with their symptoms under control.|
|Source: Reference 3|
Recovery is not a smooth, linear progression. Even when patients attain remission, they often find it hard to make up for “lost life” during years of disability.4 Recovery also can be defined as social, emotional, and biological maturation. This definition considers recovery not as an end-state or cure but as a process of personal growth.5
Several groups proposed recently that recovery from schizophrenia includes four processes:
- finding hope
- re-establishing identity
- taking responsibility for recovery
- finding meaning6 and “getting on with life”7 (Box).
Long-tem vs short-term
Recovery has been studied in many populations, but the evidence is difficult to compare. Data quality is compromised by poorly-defined cohorts, weak study designs, and lack of clear definitions of recovery and its diagnostic criteria. Moreover, empirical evidence is lacking on recovery’s multidimensional nature, including psychosocial, biochemical, genetic, environmental, cultural, and ethnic correlates.
Long-term recovery. Recently, three studies of American populations diagnosed with schizophrenia detected trends toward long-term (>5 years) recovery.
U.S. populations. Modestin et al8 in 2003 re-evaluated diagnoses of 208 patients in Swiss psychiatrist Manfred Bleuler’s influential 1972 study on schizophrenia’s long-term course. Using DSM-III-R, DSM-IV, and International Statistical Classification of Diseases and Related Health Problems (ICD-10) criteria, the authors excluded about 30% of the original patients (most rediagnosed with schizoaffective disorder). Among those remaining, 12% to 15% showed long-term recovery and one-half had an undulating course with remissions.
In 1997, Stephens et al9 examined hospital records from 1913 to 1940 of 484 patients, mean age 27, hospitalized with schizophrenia. Using >5 years of follow-up data and DSM-IV criteria, the authors rated 13% as recovered and 58% unimproved.
Also in 1997, Harrow et al10 evaluated 74 patients diagnosed with schizophrenia by DSM-IV criteria at 2, 4.5, and 7.5 years. In this longitudinal study, one-third (32%) showed complete remission at one follow-up session, compared with 5% at all three evaluations.
This study suggested that schizophrenia patients show relatively poor functioning, compared with other psychotic patients. Over time, however, the likelihood of long-term remission appeared to increase. A similar pattern was seen in a sample of 658 Americans age >65 with schizophrenia diagnosed by DSM-III criteria. As these patients aged, 15% developed long-lasting remission.11
Elsewhere, empirical findings across 15 years from three Norwegian studies indicate that lasting recovery from schizophrenia—with symptom improvement and psychosocial adjustment—is rare (3% to 5% of patients).3 Similarly, only 4% of a Scandinavian sample of 301 patients attained complete, long-term remission during 3 to 39 years of follow-up.12
Across cultures, an international study13 evaluated 15- and 25-year outcomes in 1,633 patients diagnosed with schizophrenia. Approximately 50% had favorable outcomes—stable work, independent from support, no imprisonment, no substance abuse, no rehospitalization, improved social life—but heterogeneity was marked.