BackgroundPoorly defined cohorts and weak study designs have hampered cross-cultural comparisons of course and outcome in schizophrenia.AimsTo describe long-term outcome in 18 diverse treated incidence and prevalence cohorts. To compare mortality, 15- and 25-year illness trajectory and the predictive strength of selected baseline and short-term course variables.MethodHistoric prospective study. Standardised assessments of course and outcome.ResultsAbout 75% traced. About 50% of surviving cases had favourable outcomes, but there was marked heterogeneity across geographic centres. In regression models, early (2-year) course patterns were the strongest predictor of 15-year outcome, but recovery varied by location; 16% of early unremitting cases achieved late-phase recovery.ConclusionsA significant proportion of treated incident cases of schizophrenia achieve favourable long-term outcome. Sociocultural conditions appear to modify long-term course. Early intervention programmes focused on social as well as pharmacological treatments may realise longer-term gains.

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Data are presented on the 15-year natural course of schizophrenia and other nonaffective functional psychoses in a cohort of 82 first-contact cases from a circumscribed area in the Netherlands. The subjects were suffering from functional psychosis with International Classification of Diseases-Ninth Revision (ICD-9) diagnoses 295, 297, or 298.3-9 (broad definition of schizophrenia) on entry. Standardized assessments of psychopathology, psychological impairments, negative symptomatology, social disability, and use of mental healthcare were used. The study reveals a pattern of chronicity and relapses with a high risk of suicide: Two-thirds of the subjects had at least one relapse and after each relapse 1 of 6 subjects did not remit from the episode; 1 of 10 committed suicide; and 1 of 7 had at least one episode with affective psychotic symptoms that started on average 6 years after the onset of the schizophrenic disorder. Diagnoses were reclassified in five patients, according to DSM-III-R criteria for a bipolar disorder. The predictive power--in terms of time in psychosis and in partial or full remission--of demographic, illness, and treatment variables at onset of the illness was very limited. Insidious onset and delays in mental health treatment are risk factors that predict a longer duration of first or subsequent episodes. The importance of mental health treatment in regard to outcome is probably subject to change because an early warning and intervention strategy could prevent further damage and deterioration. Our data support the need for an adequate relapse prevention program as a priority for our mental health services.

SynopsisThis article addresses the issues of recognition and labelling of psychological disorders (PDs) by general practitioners (GPs), and he association of recognition with management and outcome. Nearly 2000 attenders of 25 GPs were screened with the GHQ and a stratified sample of 296 patients was examined twice, using the Present State Examination (PSE) and Groningen Social Disability Schedule (GSDS).Prevalence rates of PDs according to the GHQ, GP and PSE were 46%, 26% and 15% respectively. For the 1450 ‘new’ patients, i.e. patients who had no PD diagnosed by their GP in the 12 months prior to the enrolment visit, these rates were 38%, 14%, and 10%. GPs missed half of the PSE cases and typically assigned non-specific diagnoses to recognized cases. Depressions were more readily recognized than anxiety disorders, and the detection rates for severe disorders were higher than those for less severe disorders.Recognition was strongly associated with management and outcome. Recognized as compared to non-recognized cases were more likely to receive mental health interventions from their GP and had better outcomes in terms of both psychopathology and social functioning. Initial severity, psychological reasons for encounter, recency of onset, diagnostic category, and psychiatric comorbidity were related to both better recognition and outcome. However, these variables could not account for the association of recognition with management and outcome, but some did modify the association. A causal model of the relationships is presented and possible reasons for non-recognition and for the beneficial effects of recognition are discussed.

Need for care was studied in a Dutch incidence cohort of patients with schizophrenic disorders 15 and 17 years from first onset of psychosis. Long-term course of the disorders varied from complete remission and full community participation to chronic psychosis and long-term hospital stay. Fifty patients were assessed twice with the Needs For Care Assessment Schedule (NFCAS, Brewin and Wing 1989); at the latter follow-up an assessment was also made using the Camberwell Assessment of Need (CAN, Phelan et al. 1995). The NFCAS is an investigator- or professional-based instrument which provides an 'objective' assessment of needs. Need for care was recorded in 22 areas of clinical and social functioning. Comparison of the two assessments over a 2-year period demonstrated a high stability on the individual items (mean 88%, mostly concerning the absence of a problem twice), but did not show the expected stability of need status among this group of patients with chronic disorders. One in five patients (22%) had no needs at all on both occasions and 56% of the patients showed a change in needs. There was more negative than positive change: 28% suffered from new unmet needs at the 17-year follow-up, while only 12% had improved their status to no needs. About one-third (36%) had at least one unmet need, mostly regarding psychotic symptoms, dyskinesia or underactivity. The CAN provides a 'subjective' assessment of needs according to the view of patients themselves. The problems patients reported most commonly were in the areas of day-time activities, social relationships and information on their condition and treatment, for all which they asked for more help than they received. This patient-based instrument produces slightly higher numbers of problems and unmet needs, and a lower ratio between met and unmet needs. There is an overall percentage of 21% of disagreement between patient and investigator view regarding the unmet need status. Agreement between the two instruments on the nature of the problems with unmet needs was lacking altogether.