Evidence-Based Reviews

Recovery from schizophrenia: Fact or fiction?

Current Psychiatry. 2004 July;3(7):19-30

References

1. Davidson L. Living outside mental illness: qualitative studies of recovery in schizophrenia. New York: New York University Press, 2003.

2. Kruger A. Schizophrenia: Recovery and hope. Psychiatr Rehabil J 2000;24(1):29-37.

3. Liberman RP, Kopelowicz A, Ventura J, Gutkind D. Operational criteria and factors related to recovery from schizophrenia. Int Rev Psychiatry 2002;14(4):256-72.

4. Torgalsboen AK, Rund BR. Lessons learned from three studies of recovery from schizophrenia. Int Rev Psychiatry 2002;14(4):312-17.

5. Boone EC. A qualitative investigation of the process of recovery in people experiencing schizophrenia. Dissert Abstr Int 1996;57 (5-B):3402.-

6. Andresen R, Oades L, Caputi P. The experience of recovery from schizophrenia: towards an empirically validated stage model. Aust NZ J Psychiatry 2003;37(5):586-94.

7. Noordsy D, Torrey W, Mueser K, et al. Recovery from severe mental illness: an interpersonal and functional outcome definition. Int Rev Psychiatry 2002;14(4):318-26.

8. Modestin J, Huber A, Satirli E, et al. Long-term course of schizophrenic illness: Bleuler’s study reconsidered. Am J Psychiatry 2003;160(12):2202-8.

9. Stephens JH, Richard P, McHugh PR. Long-term follow-up of patients hospitalized for schizophrenia, 1913 to1940. J Nerv Ment Dis 1997;185(12):715-21.

10. Harrow M, Sands JR, Silverstein ML, Goldberg JF. Course and outcome for schizophrenia versus other psychotic patients: a longitudinal study. Schizophr Bull 1997;23:287-303.

11. Craig TJ, Bregman Z. Late-onset schizophrenia-like illness. J Am Geriatr Soc 1988;36(2):104-7.

12. Opjordsmoen S. Long-term course and outcome in unipolar affective and schizoaffective psychoses. Acta Psychiatr Scand 1989;79(4):317-26.

13. Harris G, Hopper K, Craig T, et al. Recovery from psychotic illness: a 15- and 25-year international follow up study. Br J Psychiatry 2001;178:506-17.

14. Kiriakakis V, Bhatia KP, Quinn NP, Marsden CD. The natural history of tardive dystonia. A long-term follow-up study of 107 cases. Brain 1998;121(Pt 11):2053-66.

15. Mala E. Early onset schizophrenia. Cesk Slov Psychiatry 1993;89(5):259-71.

16. Tohen M, Strakowski SM, Zarate C, et al. The McLean-Harvard first episode project: 6-month symptomatic and functional outcome in affective and non-affective psychosis. Biol Psychiatry 2000;48(6):467-76.

17. Kobayashi T. Course types of first admission schizophrenia: A mean 13-year follow back study. Seishin Igaku Clin Psychiatry 2002;44(2):161-8.

18. Sells DJ, Stayner DA, Davidson L. Recovering the self in schizophrenia: An integrative review of qualitative studies. Psychiatr Q. 2004;75(1):87-97.

19. Martens WHJ, Kahn W, Oppenheimer C. Predictors and prevalence of recovery in schizophrenia. W. Kahn Institute of Theoretical Psychiatry and Neuroscience (WKITPN) Publication 36, 2001(5):113-26.

20. Fallot RD. The place of spirituality and religion in mental health services. In: Lamb HR (ed). Best of new directions for mental health services, 1979-2001. San Francisco: Jossey Bass, 2001:79-88.

21. Kane JM. Long-term treatment of schizophrenia: Moving from a relapse-prevention model to a recovery model. J Clin Psychiatry. 2003;64(11):1384-5.

22. Tauscher-Wisniewski S, Zipursky RB. The role of maintenance pharmacotherapy in achieving recovery from a first episode of schizophrenia. Int Rev Psychiatry. 2002;14(4):284-92.

Box

Remission: A new start after 20 years

Ms J, 48, is in recovery from schizophrenia. She has a stable job as a Web designer, is married, and has learned to build and maintain social relationships. Much of her life, however, has been very different.

At age 15 she was diagnosed with schizophrenia, paranoid psychotic type, with occasional comorbid bipolar symptoms. Over the next 20 years, she was admitted to psychiatric hospitals six times for treatment. At age 36, she was hospitalized with psychosis, depressive symptoms, and insomnia. At that point, she was taking carbamazepine, 500 mg/d, for mood stabilization, and haloperidol, 50 mg/d.

Changing medications. Her psychiatriststarted olanzapine, 5 mg/d, and tapered off haloperidol, which appeared to be gradually becoming less effective while causing mood-related side effects. Ms. J’s psychosis persisted, however, with no response to olanzapine.

Her psychiatrist then tapered carbamazepine to 175 mg/d while starting lamotrigine, 150 to 300 mg/d. The rationale for switching mood stabilizers was that lamotrigine may be more effective than carbamazepine in controlling mixed bipolar states, provide a greater antidepressant effect, and cause fewer side effects.

Intensive treatment. Within 10 days, Ms J’s thought form and composition improved, and her psychiatrist immediately started psychotherapy and psychosocial guidance. Carbamazepine was withdrawn 3 months later, but Ms. J remained on olanzapine, 5 mg/d, and lamotrigine, 300 mg/d. With these medications, the paranoid psychosis went into remission.

After 5 months of intensive treatment, Ms. J was discharged. Outpatient treatment included weekly psychotherapy plus psychosocial guidance and social and coping training 6 times per month. These therapies —along with olanzapine, 5 mg/d, and carbamazepine, 300 mg/d—continue today.

Ms. J’s mental and emotional condition stabilized, and her cognitive abilities improved. Education and therapy helped reduce stress within her family. She has not been rehospitalized or suffered a serious relapse in 12 years.

Table 2

Psychosocial interventions for patients in recovery from schizophrenia*

Family intervention (support, management, training, education) Coping skills training Supported employment Intensive community treatment Psychoeducation Improvement of interpersonal functioning, stress management, emotional regulation, and cognitive skills training Social and independent-living skills training
* Psychosocial interventions are most effective when combined with antipsychotic therapy and individualized psychotherapy

Short-term course predicted long-term outcome, and local environment played a significant role in determining symptoms and social disability. The authors concluded that adequate early treatment and an optimum environment might lead to favorable long-term outcome.

In the United Kingdom, 14% of a sample of patients diagnosed by ICD-10 criteria achieved remission across a mean 8.5 years.¹⁴ In a study of Czechoslovakian patients (70 men, 50 women) with early-onset schizophrenia diagnosed by DSM-III-R criteria, 10% recovered during 13 to 42 years of follow-up.¹⁵

Short-term recovery. The McLean-Harvard first-episode project examined outcomes 6 months after schizophrenia diagnosis in 102 patients (55 men, 47 women). Sixty-five percent attained syndromal recovery (significant reduction of diagnostic features), whereas only 33% achieved functional recovery (increased social-emotional, vocational, and coping abilities).¹⁶

In Japan, 62 patients (33 men, 29 women; mean age 25) were followed for 13 years after a first hospitalization for schizophrenia. The authors reported an undulating course with recovery or a mild end-state in 53%, and a simple course of recovery and a moderate or severe end-state in 28%.¹⁷

Conclusions. The evidence suggests that early and lasting treatment of schizophrenic symptoms—even in recovered patients—might prevent frequent rehospitalizations. Thus, patients with schizophrenia must be followed carefully during and after recovery. Health care professionals, colleagues, friends, and relatives can help patients sustain recovery by watching for the earliest signs of deterioration and intervening before relapse occurs.

Strategies for recovery

Therapeutic factors. Many studies suggest psychosocial interventions (Table 2), psychotherapy, and medication are most effective in combination for stabilizing patients with schizophrenia and continuing their recovery. Other patient factors that may contribute to recovery include:

quality of relationships with family, friends, and professional caregivers
ability and motivation to use resources and take responsibility for one’s life
spiritual and religious activities
awareness that recovery is possible.

Sells et al¹⁸ noted that attempting to make new contacts outside of their former spheres (“positive withdrawal”) may allow schizophrenia patients to reconsider and ultimately recover a durable sense of self.

We at the W. Kahn Institute¹⁹ find that all these treatment strategies may be useful and even necessary to continue and stabilize recovery from schizophrenia. We feel they merit the attention of all professionals involved in recovered patients’ aftercare and guidance.

Table 3

Suggested antipsychotic dosages during schizophrenia recovery*

Drug	Dosage (mg/d)	Potential side effects	Positive effects
Aripiprazole	10 to 30	Headache, anxiety, insomnia, lightheadedness	Reduced positive, negative symptoms
Clozapine	300 to 900	Withdrawal, blunted emotions, seizures, lack of motivation	Reduced positive symptoms
Haloperidol	30 to 100	Tardive dyskinesia, parkinsonian symptoms, insomnia, depressive reactions, confusion, drowsiness, hypertension	Reduced mania, hyperactivity, agitation
Olanzapine	5 to 10	Drowsiness, agitation, weight gain, involuntary movements, restlessness	Reduced positive, negative symptoms
Quetiapine	25 to 100	Dizziness, hypotension, increased cholesterol, weight gain	Reduced positive symptoms
Risperidone	2.5 to 5	Anxiety, nervousness, back pain, bleeding, dizziness, irregular blood pressure	Reduced positive, negative symptoms
Ziprasidone	10 to 200	Heart-rhythm irregularity, loss of consciousness, restlessness, weakness, drowsiness	Reduced positive symptoms
* Dosages are individualized and may vary among patients and situations, but most will be gradually reduced to minimum levels during remission.