Transcript Recovery from schizophrenia – a meta

Recovery from schizophrenia
– a meta-analysis
Erika Jääskeläinen (née Lauronen) and Jouko Miettunen
University of Oulu, Finland
The structure of this presentation
• Background – Recovery and outcome in
schizophrenia
• Recovery in schizophrenia – preliminary
results from a meta-analysis
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
Background - Definitions
1. Treatment response
•
decrease in symptoms, remission as the goal
2. Remission
•
absence of symptoms, lasting for certain length of time
(e.g. 6 months)
3. 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.
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.
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 metaanalytic techniques.
• We aimed also to estimate effect of study
methods on recovery percentages
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 psychos*s” 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).
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
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.
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)
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,
p=0.29).
• 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).
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 (p=0.03) in the
10 samples from Asia, Africa and South America
(24.4%) than in studies from Europe and North
America (15.7%, 40 samples).
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%
Pillmann and Marneros 2005
Hong Kong (WHO)
Harrow et al. 1997
Lauronen et al. 2005
Myers and Witmer 1937
Eitinger et al. 1958
Dublin (WHO)
Nagasaki (WHO)
Selten et al. 2007
McGlashan 1984
Rupp and Fletcher 1940
Auslander and Jeste 2004
DeLisi et al. 1998
Gottlieb 1940
Nyman and Jonsson 1983
Obembe et al. 1995
Mannheim (WHO)
Sofia (WHO)
Beijing (WHO)
Prague (WHO)
Modestin et al. 2003
Walsh et al. 1991
Helgason 1990
Bland and Orn 1978
Robinson et al. 2004
Langfeldt 1937
Stenberg 1948
Angst and Preisig 1995
Achte 1967b
Achte 1967a
Guttmann et al. 1939
Nottingham (WHO)
Silverman 1941
Christensen 1974
Vazquez-Barquero et al. 1999
Rajotte and Denber 1963
Huber et al. 1980
Henisz 1966
Errera 1957
Ciompi 1980
Fallik and Liron 1976
Holmboe and Astrup 1957
Dixon and Innes 1966
Cali (WHO)
Ogawa et al. 1987
Moscow (WHO)
Chennai (WHO)
Opjorsmoen 1988
Chandigarh (rural, WHO)
Agra (WHO)
0.0%
0.0%
2.8%
3.4%
4.4%
4.8%
5.0%
5.8%
6.0%
6.0%
6.4%
7.7%
8.0%
8.0%
9.0%
9.1%
9.1%
10.0%
12.1%
12.5%
12.9%
14.0%
15.9%
16.3%
16.4%
17.0%
17.1%
18.4%
18.6%
18.8%
19.7%
20.4%
20.7%
21.0%
23.0%
24.0%
24.7%
24.7%
25.9%
26.6%
27.7%
29.0%
31.1%
31.8%
32.4%
32.4%
36.4%
36.6%
37.0%
51.9%
Combined
17.4% (95% CI 15.0-19.9%)
0
5
10
15
20
25
30
35
recovery percentage
40
45
50
55
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
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!
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
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.
([email protected] and
[email protected])
Research group
Department of Psychiatry,
University of Oulu, Finland:
Erika Jääskeläinen, MD, PhD
Johanna Heikkinen, MA
Matti Isohanni, MD, PhD
Queensland Centre for Mental
Health Research, Australia:
John McGrath, MD, PhD
Sukanta Saha, MSc
Academy of Finland, Finland:
Jouko Miettunen, PhD
Juha Veijola, MD, PhD
This study has been supported by the Academy of Finland (grant #120 479 )