Recovery, not progressive deterioration, should be the expectation in schizophrenia (2015)

Recovery, not progressive deterioration, should be the expectation in schizophrenia

Since the time of Kraepelin, schizophrenia has been considered to be a progressive deteriorating illness. This perspective has been bolstered by a generation of studies demonstrating deficits in brain volumes on magnetic resonance imaging (MRI) scans and in performance on a broad range of cognitive tasks in individuals with schizophrenia.

Despite the introduction of effective pharmacological treatments and evidence-based psychosocial interventions, fewer than one in seven people affected are considered to meet criteria for recovery. The possibility that the pathophysiology of schizophrenia involves mechanisms that progress over the longitudinal course of the illness is often assumed to explain the poor outcomes observed. Advocates for early intervention have embraced this paradigm as it implies that early treatment has the potential to arrest a disease process that would otherwise continue on an unrelenting march to severe mental deterioration.

While progression of an active disease process would provide a compelling explanation for the poor outcomes so commonly observed, it is not consistent with what we have learned from modern studies of the longitudinal course of structural brain abnormalities, cognitive deficits and clinical outcomes associated with schizophrenia. Rather, schizophrenia appears to be associated with stability of these measures over the longer term. It is time to consider the possibility that clinical stability and recovery rather than progressive deterioration should be the expected outcomes from schizophrenia.

“How recovery from schizophrenia is envisioned is likely to vary greatly between individuals. Psychiatrists have typically embraced a “medical” model of recovery that emphasizes the elimination of symptoms and a return to normal levels of functioning; patients-consumers may find a “rehabilitation model of recovery” more compelling, with its emphasis on creating a meaningful and satisfying life in one’s community. Identifying those personal goals that are of most importance to each individual patient is critical, as outcomes that are not a personal priority are unlikely to be realized.

While there is room for debate about how recovery should be defined, it should be clear that most individuals with schizophrenia have the potential to achieve a stable remission of symptoms and substantial levels of satisfaction and happiness. Future outcome studies will need to incorporate outcomes that reflect the patient experience. Societal resources will also need to be allocated to support the realization of a broader patient-centered conception of recovery.”

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