Course and Outcome for Schizophrenia
Versus Other Psychotic Patients:
A Longitudinal Study
by Martin Harrow, James R. Sands, Marshall L. Silverstein,
and Joseph F. Qoldberg
Sampson et al. 1988; Johnstone 1990; Breier et al. 1991;
Carpenter and Strauss 1991). Earlier observations by
Kraepelin and others at first suggested that schizophrenia
patients show very poor outcomes (Kraepelin 1919/1921).
The modern neuroleptic era has altered this once
almost totally negative view of outcome in schizophrenia
(Hogarty et al. 1974; May et al. 1981). Neuroleptic treatment, other modern treatment modalities, and modern
trends toward shorter hospitalizations have resulted in
considerably fewer schizophrenia patients with many
years of hospitalization in chronic treatment services.
Supporting a generally optimistic view of outcome for
schizophrenia patients, some recent research with a select
sample of neuroleptic-responsive schizophrenia patients
has suggested that a large percentage of these patients
show relatively favorable outcomes (Harding et al. 1987).
This investigation also did not find large differences in outcome between schizophrenia patients and other psychotic
patients, which is studied in the present research.
Studies finding relatively favorable outcomes in schizophrenia have been questioned by other recent research,
however. Large scale followup research has been conducted by Tsuang and colleagues (1979, 1981) with the
Iowa 500 sample; by McGlashan (1984a, 1984Z>) with a
sample of patients treated at the Chestnut Lodge; and by
Breier and colleagues (1991). These followup studies have
reported a large percentage of schizophrenia patients
showing considerable difficulties in outcome. In addition,
our own followup studies have found a large percentage of
schizophrenia patients with poor outcomes (Harrow et al.
1978; Carone et al. 1991; Grossman et al. 1991; Marengo
etal. 1991).
Our own research program studying schizophrenia
patients at successive followups has found evidence suggesting that one of the distinguishing characteristics of
Abstract
We studied 276 patients longitudinally, beginning at
the acute phase and continuing at three successive followups over 7.5 years, comparing 74 schizophrenia
patients with 74 other psychotic patients and 128
nonpsychotic patients on early course and outcome.
Schizophrenia patients showed significantly poorer
functioning than patients with other psychotic disorders at each of the three followups (p < 0.05). More
schizophrenia patients than other psychotic patients
showed consistent psychopathology and a course in
which there was not complete remission at any of the
three followups (p < 0.05). Most schizophrenia patients
did not show severe decrements hi social activity level.
Poor outcome schizophrenia patients showed significantly slower recovery at each followup than did other
psychotic patients with initial poor outcomes
(p < 0.01). The results indicate that, during the early
course, schizophrenia patients still show relatively
poor outcomes, although a small number of schizophrenia patients enter into complete remission. Over
time, many schizophrenia patients fluctuate between
severe disability and moderate disability rather than
always showing severe disability. Schizophrenia
patients tend to recover more slowly then other psychotic patients. Differences between schizophrenia
patients and other psychotic patients in clinical course
over time may be larger than differences at any single
followup.
Schizophrenia Bulletin, 23(2):287-303,1997.
The current research was designed to investigate early
course and outcome in modem-day schizophrenia and to
compare it with early course and outcome in other psychotic disorders. Outcome in schizophrenia has long been
a central issue in theoretical views of the nature of this
disorder (Vaillant 1978; Tsuang et al. 1979; Angst 1988;
Carpenter and Kirkpatrick 1988; McGlashan 1988;
Reprint requests should be sent to Dr. M. Harrow, Dept. of
Psychiatry (M/C913), The University of Illinois at Chicago, 912 South
Wood St., Chicago, IL 60612-7327.
287
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
M. Harrow et al.
schizophrenia, compared with other psychotic disorders,
may be course over time. Consistent psychopathology
may distinguish schizophrenia patients from other types
of psychotic patients more than psychopathology does at
any single point in time (Harrow et al. 1995; Marengo and
Harrow 1997, this issue). In general, despite many theoretical views about the consistency of disorder over time
in schizophrenia, the issue of persistent schizophrenic
psychopathology and persistent impairment has not been
focused on fully in prospective empirical studies with
multiple assessments over time.
Concerning a closely related issue, it is not clear from
the current literature whether some or many schizophrenia
patients enter into periods of complete remission (including both the absence of major symptoms and adequate
psychosocial functioning) at any point during their early
clinical course. It is also unclear whether schizophrenia
patients differ from other psychotic patients on this
dimension of course over time. This potential type of clinical course is studied in the current research.
In addition, we have proposed that a major feature of
schizophrenia course and outcome is slower recoverability
from major psychopathology (Harrow et al. 1995). Thus,
we have suggested that both schizophrenia patients and
other psychotic patients eventually show at least a partial
recovery from major psychopathology after the more
acute phases, but that schizophrenia patients recover more
slowly and less completely and are subject to more frequent relapses than other psychotic patients.
The importance of more precise knowledge about
schizophrenia course and outcome for theory about the
nature of this disorder and the need for guidelines for the
practicing clinician suggest the need for a series of outcome studies in this area that (1) are prospectively
designed, (2) use modem-day schizophrenia patients, (3)
compare schizophrenia patients on course and outcome
with other psychotic patients, and (4) employ a multifollowup research design to allow assessment of course over
time.
The present research prospectively studies outcomes
of a large sample of relatively early-phase, young schizophrenia patients and a sample of other psychotic patients,
within a multifollowup research design to answer the following specific questions:
of psychotic patients? Is schizophrenia a more continuous
disorder than other psychoses?
4. Does complete remission (including both the
absence of major symptoms and adequate psychosocial
functioning) occur in many schizophrenia patients?
Methods
Sample of Patients. The current investigation is based
on data from the Chicago Followup Study, a prospective,
multidimensional research program studying schizophrenia longitudinally. The investigation was planned (1) to
study prognostic factors and functioning and adjustment
over time in schizophrenia and other psychotic disorders
(Harrow et al. 1978; Westermeyer and Harrow 1984;
Grinker and Harrow 1987; Carone et al. 1991; Marengo et
al. 1991), (2) to investigate thought disorders and positive
and negative symptoms in schizophrenia on a longitudinal
basis (Harrow et al. 1985, 1995; Pogue-Geile and Harrow
1985; Harrow and Marengo 1986; Sands and Harrow
1994), and (3) to explore mechanisms that may be
involved in schizophrenic thought disorders and psychosis
(Harrow et al. 1983, 1989; Harrow and Quinlan 1985; Port
et al., in press).
The current sample of 276 patients, diagnosed by
Research Diagnostic Criteria (RDC; Spitzer et al. 1978),
includes 74 schizophrenia patients, 74 nonschizophrenia
psychotic patients (35 bipolar patients, 23 psychotic
depressive, and 16 other psychotic patients), and 128
nonpsychotic patients. The nonpsychotic patients included
67 nonpsychotic unipolar depressive patients, 10 nonpsychotic bipolar depressives, 12 patients with minor depression or other depression-related disorders, 6 borderline
patients, 7 substance-abuse patients, 6 patients with eating
disorders, and 20 other patients with nonpsychotic disorders (i.e., various types of personality disorders, anxiety
disorders, antisocial personality disorders). The current
report focuses on clinical course and outcome for the 74
RDC schizophrenia patients. However, 64 of these 74
patients also met DSM-III (American Psychiatric Association 1980) diagnostic criteria for schizophrenia. Data
are also reported for the DSM-III group.
The subjects were assessed at index hospitalization
and reassessed in three successive followup interviews
conducted at a mean of 2 years, 4.5 years, and 7.5 years
after index hospitalization. The study sample includes the
276 patients who were alive and studied at the 7.5-year
followup; 267 patients were studied at all three followups,
and 9 were studied at either the 2- and 7.5-year followups
or the 4.5- and 7.5-year followups. Table 1 presents more
detailed information on the number of patients from each
group who completed the followup schedule. Data on
1. Do modern-day schizophrenia patients show
poor outcomes when studied prospectively at the acute
phase and then assessed at three successive followups
over 7.5 years?
2. Do schizophrenia patients show poorer outcomes
than other psychotic patients?
3. Are there important differences in clinical course
over time between schizophrenia patients and other types
288
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
Course and Outcome for Schizophrenia
13.1 years. There were no significant between-group differences in age, but there were significant sex differences
between the diagnostic groups. A higher percentage of the
schizophrenia patients were male (64%), and a higher percentage of the nonpsychotic patients were female (59%).
To control for the sex differences between these two
groups, we conducted separate analyses (1) comparing the
male schizophrenia patients with the other psychotic and
the nonpsychotic male patients, and (2) comparing the
female schizophrenia patients with the other psychotic
and the nonpsychotic female patients. The results of these
analyses on differences in outcome according to diagnosis
were similar to those found when the entire sample of
schizophrenia patients was compared with the entire sample of other psychotic and nonpsychotic patients.
The patient population is rare in the research literature because it includes both young, early-phase schizophrenia patients studied prospectively at hospital admission and other psychotic patient controls studied
prospectively at index, and both groups were assessed
over time at three different followups over a 7-8 year
period.
posthospital status at the 7-8-year followup were available for slightly more than 80 percent of the original sample. These patients did not differ significantly on major
demographic variables from a small subsample of patients
studied at the 2-year followup but not available for assessment at the 7.5-year followup.
The diagnosis for each patient was based on at least
one of two structured interviews that have been used successfully in previous research: (1) the Schizophrenic State
Inventory, with each interview tape-recorded (Grinker and
Harrow 1987), and (2) the Schedule for Affective
Disorders and Schizophrenia (SADS; Endicott and Spitzer
1978). Satisfactory interrater reliability for diagnosis was
obtained with these instruments.
At index hospitalization, the inpatients were given a
series of structured interviews, questionnaires, and tests.
Later followups were conducted by trained interviewers
who were blind to diagnosis and, at the second and third
followups, blind to the results of the previous followup.
Informed written consent was obtained at index hospitalization and at each followup.
In the current prospective research, we studied young
nonchronic inpatients to reduce the effects of long-term
treatment, which can sometimes be a factor when chronically ill patients with years of previous treatment are studied. The mean age of the patient sample was 23.1 years at
index hospitalization; 271 of the 276 patients (98%) were
between the ages of 17 and 30 years when entering the
research program. Fifty-one percent of the patients were
male, 49 percent were female. Racially, 76 percent of the
sample were white, and 24 percent were black. Based on
the Hollingshead-Redlich Scale for Socioeconomic Status
(SES; Hollingshead and Redlich 1958) with parental SES
as the criterion, 59 percent of the sample were from
households with SES of 1-3, 41 percent from households
with SES of 4 or 5. More than 75 percent of this sample
had either one or no previous hospitalizations before the
index hospitalization. The mean educational level was
Medication. As is typical in the natural course of schizophrenia and other psychotic disorders over many years, no
single uniform treatment plan emerged for all the patients
in this naturalistic multiyear study. At the third (7.5-year)
followup, 69 percent of the schizophrenia patients were
receiving medications; 58 percent of the schizophrenia
sample were receiving neuroleptics. At the 2-year followup, 62 percent of the schizophrenia patients were
being treated with neuroleptics, and at the 4.5-year followup 64 percent of the schizophrenia patients were in
neuroleptic treatment.
Although the majority of the schizophrenia patients
were in medication treatment, not all were being medicated, partly because a subgroup of patients choose to
leave the mental health caretaking system. Some members
of this subgroup are schizophrenia patients who have
become discouraged with their treatment; others are former patients who have entered into remission and no
longer want treatment (Fenton and McGlashan 1987;
Carone et al. 1991). These findings suggest that a subgroup
of schizophrenia patients who recover may choose to sustain this recovery without maintenance antipsychotic medications. This thesis is supported by data outlined later on
the functioning of patients in neuroleptic treatment compared with those not on neuroleptics.
Fifty-one percent of the patients who were diagnosed
at index as other (nonschizophrenic) psychoses were
being treated with medications at the 7.5-year followup;
30 percent of them were being treated with neuroleptics
Table 1. Number of patients assessed in each
group at each followup
No. of patients assessed at followup
Diagnostic
group
Schizophrenia
patients
Other psychotic
patients
Nonpsychotic
patients
2.5-year 4.5-year 7-8 year
All 3
followup followup followup followups
71
74
74
71
71
73
74
70
127
127
128
126
289
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
M. Harrow et al.
during the followup year. At both the 2- and 4.5-year followups, a similar percentage of other initially psychotic
patients were being medicated; 28 percent of the initially
nonpsychotic patients were in medication treatment at the
7.5-year followup.
Schizophrenia patients who were on neuroleptics at
the third followup showed significantly poorer overall
functioning than those who were not (t = 2.50;
df-l\\
p < 0.02). There were also significant differences in overall outcome functioning at the third followup between the
other psychotic patients who were on neuroleptics at followup and those who were not (t = 4.79; df - 72; p <
0.001). Since the current research involves followup of a
naturalistic sample, the data on differences between
treated and untreated schizophrenia patients and psychotic
patients were influenced by the tendency for the patients
with greater psychopathology to be kept in medication
treatment.
Followup Assessments. The detailed followup evaluations involved assessments of overall functioning and
adjustment, as well as of psychotic symptoms, anxiety
symptoms, and affective symptoms. They also included
detailed assessments of work and social functioning,
potential rehospitalization, and medications and other
treatment variables.
Symptoms, functioning, and adjustment were
assessed at each of the three followups by using the
Harrow Functioning Interview (Harrow et al. 1978) to
assess work, social activity level, family functioning, and
rehospitalization; a modified version of SADS to assess
psychotic symptoms, affective symptoms, and other
symptoms; performance tasks, including the Proverbs Test
(Gorham 1956), the Object-Sorting Test (Rapaport et al.
1968), the Digit Symbol Test (Wechsler 1955) to assess
cognitive functioning, thought disorder, and deficit symptoms; and the Katz Adjustment Scale (Katz and Lyerly
1963), Anhedonia Scale (Chapman et al. 1976), and other
questionnaires to assess anxiety symptoms, depressive
symptoms, personality variables, and other variables.
The scale used to assess overall functioning and
adjustment was the LKP Scale, developed by Levenstein,
Klein, and Pollack (1966). This scale has been used successfully by our research team and others (Grinker and
Harrow 1987). Ratings on this scale, obtained at each followup, are based on work and social adjustment, level of
self-support, life disruptions, potential symptoms, relapse,
potential suicide, and rehospitalization. In a recent assessment of interrater reliability, we obtained an intraclass
correlation coefficient of 0.92.
On the 8-point LKP scale, ratings for global outcome
in the year before followup range from 1 (adequate func-
tioning or complete remission during the followup year) to
8 (very poor psychosocial functioning, considerable symptoms, and lengthy rehospitalization). The analyses of variance (ANOVAs) of overall adjustment that were used in
the present research are based on data from this 8-point
scale. In addition, in previous research, this scale has been
divided into three broad outcome categories: the first category (scores of 1 or 2) reflecting adequate or good outcome in each area (no major symptoms and adequate psychosocial adjustment, which could be viewed as complete
remission during the followup year); the second category
(scores of 3 to 6) representing moderate impairment
(impairment in some, but not all, areas of functioning); and
the third category (scores of 7 or 8) representing uniformly
poor overall functioning in each major area of adjustment
(major symptoms and poor psychosocial adjustment).
Specific areas of functioning were also rated by separate outcome scales developed by Strauss and Carpenter
(1972), which assess rehospitalization, social adjustment,
work adjustment, and psychiatric symptoms. Adequate
interrater reliability has been established for the StraussCarpenter scales assessing specific areas of outcome, and
these scales have been used in previously reported
research. Scores on psychosis were based on data from
SADS, and determined by a system of assessment used in
previously reported research (Harrow and Silverstein
1977; Harrow etal. 1985, 1995).
Results
Schizophrenia Patients' Outcome at Three Successive
Followups Over 8 Years. Table 2 shows results on
overall adjustment and outcome for the schizophrenia
patients in terms of the percentage with good outcome (or
complete remission during the followup year), moderate
impairment, and poor outcome at each of the three followups.
1. At each of the followups the schizophrenia patients showed very poor overall outcomes when considered as a group.
2. In particular, at the 2-year followup, only a small
percentage of the schizophrenia patients were in complete
remission throughout the followup year. About half of
them showed a uniformly poor outcome (poor functioning
in multiple areas of adjustment).
3. At the second (4.5-year) followup and at the third
(7.5-year) followup, the schizophrenia patients still had
relatively poor outcomes; only slightly more than 20 percent showed good outcomes, or complete remission, at
each of these followup years, and a much larger percentage showed uniformly poor outcomes.
290
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
Course and Outcome for Schizophrenia
Table 2. Overall outcome at three successive
followups over 7-8 years
Outcome %
Followup
(n patients)
Moderate
Impairment
Poor
Outcome
Scale
(UCP)
13
22
.22
37
42
30
51
37
49
Good l.
12
17
17
31
41
30
57
42
53
Good
RDC schizophrenia patients
2-year (n = 71)
4.5-year (n = 74)
7-8-year (n » 74)
DSM-fll schizophrenia patients
2-year (n = 61)
4.5-year (n = 64)
7-8-year (n = 64)
Figure 1. Overall outcome course among three
diagnostic groups for three followups over 7-8
years
2
n»2.58
(1 8 9 ) Other NonPjychotc
Patients
3.
Other Psychon:
PatJtntj
A
Note.—HOC - Research Diagnostic Criteria (Spitzef et al. 1978); DSM-W
- Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. (American
Psychiatric Association 1980).
4. Viewing the data in terms of those schizophrenia
patients experiencing both complete remission of major
symptoms and adequate psychosocial functioning showed
the following: Twenty-three (32%) of the 71 schizophrenia patients for whom we had complete data at all three
followups showed this type of complete remission for at
least one of the followup years assessed. However,
although 23 schizophrenia patients showed complete
remission at one or more of the followups, only 2 of these
23 (less than 5% of the total sample) showed complete
remission consistently over time at all three followups.
Thus, a number of the schizophrenia patients who showed
good functioning at one followup tended to show major
problems at the succeeding followups. Despite this, there
was at least some general consistency over time in adjustment (see "Correlations: Outcome Over Time" section
and tables 5 and 6).
Poor e.
First Foflowup
(2 Years)
[ - 2 3 83. ( f - 2 . 266
D<.001
Second FoBomip
(4.5 Y t i n )
E-18.71, d - 2 271
IXOOl
Third Foflowup
(7.5 Years)
E-40.S0. ( f - 2 . 273
D<.0Ol
LKP . Levenstein, Klein, and Polack scale (Levenstein et al. 1996); m ,
mean.
Schizophrenia Patients' Outcome Compared With
Those of Other Psychotic and Nonpsychotic Patients.
Figure 1, which outlines the clinical course for all three
groups, also reports the mean scores on overall adjustment
and outcome for the schizophrenia patients, the other psychotic patients, and the nonpsychotic patients at 2-, 4.5-,
and 7.5-year followups. The data on overall outcome for
the three diagnostic groups at the three followups were
analyzed by using a 3 X 3 (mixed design) repeated-measures ANOVA in which the two main factors were the
three diagnostic groups and the three followup periods
assessed (a within-subjects analysis).
1. The main effect for diagnosis in the 3 X 3
repeated measures ANOVA showed significant differences
(F = 38.68; df= 2,264; p < 0.001).
2. One-way F tests (reported in figure 1) were signif-
291
icant in comparisons of the overall adjustment and outcome
of the diagnostic groups at each of the three followups;
comparisons were based on the raw data for the three
groups (scores on the 8-point LKP scale). Individual post
hoc comparisons of the diagnostic groups by the NewmanKeuls test for post hoc comparisons showed significant
diagnostic differences at each of the three followups
between the schizophrenia patients and both the other psychotic patients and the nonpsychotic patients (p < 0.05).
3. The more detailed data from figures 1 and 2 and
tables 3 and 7 indicate that, at each of the three followups,
a number of the nonschizophrenia psychotic patients also
showed functioning difficulties. However, in comparison
with the schizophrenia patients, a much smaller percentage of the other psychotic patients showed uniformly poor
outcome at each followup.
4. Similarly, more of the other psychotic patients
showed complete remission.
5. At each followup after the first, more of the other
psychotic patients showed complete remission than
showed uniformly poor outcome. This pattern was different from that shown by the schizophrenia patients.
6. The trend toward more favorable outcome and
M. Harrow ct al.
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
toward more patients showing complete remission than
showed uniformly poor outcome was even more striking
at each of the three followups for the initially nonpsychotic patients.
7. In contrast to the schizophrenia patients, the nonpsychotic sample rarely experienced uniformly poor outcome, although some of the initially nonpsychotic patients
showed problems with symptoms, and some showed difficulty in psychosocial functioning.
found for the RDC sample, except that the DSM-IH schizophrenia patients showed somewhat poorer outcomes and
somewhat poorer clinical courses than the full RDC sample. At each of the three followups, more DSM-III schizophrenia patients showed uniformly poor outcome
(42%-57%) when each followup was considered separately.
The 64 DSM-III schizophrenia patients had poorer
outcomes than did the 10 RDC schizophrenia patients
who did not meet DSM-III criteria for schizophrenia.
These differences were significant according to a 3 X 2
(mixed design) repeated measures ANOVA of scores from
the 8-point LKP outcome scale (F = 9.76; df= 1,69; p <
0.01), using individual tests at each of the three followups
(p < 0.05).
We also analyzed the data for DSM-III schizophrenia
patients and for the full RDC schizophrenia sample by
using an index of consistent psychopathology and consistent impairment based on clinical course over three successive followups. (Findings for the RDC-diagnosed
patients are presented in greater detail below and figure
2.) Significantly more of the DSM-III schizophrenia
patients (X2 = 8.02; df = 1; p < 0.01) showed persistent
psychopathology over time (67%).
Outcome in RDC Versus DSM-III Schizophrenia.
The current research studied clinical course and outcome
among a sample of RDC-diagnosed patients. RDC
employs a modern, narrow concept of schizophrenia.
However, it does not require as long a duration of illness
as DSM-III, DSM-III-R (American Psychiatric
Association 1987), and DSM-IV (American Psychiatric
Association 1994). DSM-III, DSM-III-R, and DSM-IV
require a 6-month duration of illness for a diagnosis of
schizophrenia. The current sample of 74 RDC-diagnosed
schizophrenia patients was separated into those who also
met DSM-III criteria for schizophrenia (n = 64) and those
who did not (n - 10). Of the 10 patients who did not meet
DSM-IH criteria for schizophrenia, 8 were DSM-III
schizophreniform patients.
The outcome results for the DSM-III schizophrenia
patients (see table 2) were similar in principle to those
Outcome in Major Individual Areas of Functioning.
Table 3 shows the average Strauss-Carpenter scales
Table 3. Work functioning, social functioning, symptom level, and rehospitallzatlon for
schizophrenia patients and other psychotic and nonpsychotic patients
Outcome area
First followup
2 years
Second followup
4.5 years
Third followup
7-8 years
Work functioning,1 mean (SD)
Schizophrenia patients
Other psychotic patients
Nonpsychotic patients
1.75
2.322
3.052
(1.65)
(1.65)
(1.39)
1.84
2.752
3.222
(1.71)
(1.53)
(1.32)
1.53
2.702
3.21 2
(1-59)
(1.61)
(1.35)
Social functioning,1 mean (SD)
Schizophrenia patients
Other psychotic patients
Nonpsychotic patients
2.73
3.242
3.482
(1.54)
(1.27)
(1.03)
2.81
3.18
3.25
(1.44)
(1-25)
(1.20)
3.03
3.05
3.27
(1.33)
(1.28)
(1.17)
Psychotic symptoms, %
Schizophrenia patients
Other psychotic patients
Nonpsychotic patients
44
192
92
36
152
72
36
152
52
Rehospitalized, %
Schizophrenia patients
Other psychotic patients
Nonpsychotic patients
54
41
302
39
32
182
39
24 2
122
Note.—SO » standard deviation.
'Based on scores from the Strauss-Carpenter scales (1972). Higher scores on this 0-4-point scale reflect more favorable functioning.
'indicates that the other psychotic patients and the nonpsychotic patients differ slgnfficantty (p < 0.05) from the schizophrenia patients using the NewmanKeuts post hoc tests, derived from the analyses of variance.
292
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
Course and Outcome for Schizophrenia
scores on work and social functioning for RDC-diagnosed
patients at each followup, along with the percentages of
patients who showed definite psychotic symptoms and
patients who were rehospitalized. One-way ANOVAs, followed by Newman-Keuls post hoc tests comparing the
three diagnostic groups, were conducted on data from the
5-point Strauss-Carpenter scales and the quantitative
scale for severity of psychosis. In addition, individual
analyses were done to compare the diagnostic groups at
key cutoff points (e.g., percentage of patients working
half of the time versus percentage working less than half
of the time; percentage of patients with any rehospitalizations versus percentage not rehospitalized).
area between the schizophrenia patients and the other psychotic patients.
Psychosis.
1. More than one-third of the schizophrenia patients
were determined to be psychotic (score of 3 on the 3-point
scale) at each of the three followups, based on the presence of full delusions or hallucinations at some point during the followup year (table 3). Some other studies have
found lower rates of psychosis in posthospital schizophrenia patients. However, these other studies usually used
data from observations rather than direct interviews covering a broad range of potential psychotic phenomena.
2. At each followup, some of the other psychotic
patients, and even some nonpsychotic patients, showed
definite psychosis (full delusions or hallucinations).
3. However, significant differences at all three followups (shown by ANOVAs of the psychosis scores [p <
0.001] followed by Newman-Keuls post hoc tests) indicated that the schizophrenia patients showed significantly
more psychotic activity than both the other psychotic and
the nonpsychotic patients at each followup (p < 0.05).
Instrumental work functioning.
1. Analysis of the data on work functioning by oneway ANOVAs showed significant group differences at
each followup (p < 0.001).
2. There were significant differences in work functioning at each followup between the schizophrenia
patients and both the other psychotic patients (NewmanKeuls test, p < 0.05) and the nonpsychotic patients
(Newman-Keuls test, p < 0.05).
3. On the basis of the detailed data on the percentage of patients working, we found that, at each of the
three followups, less than 50 percent of the schizophrenia
patients were employed or engaged in any type of instrumental work functioning (e.g., homemaking) half of the
time or more during the followup year.
4. In contrast, at all three followups more than 60
percent of the other psychotic patients were working at
least half of the time during the followup year.
5. In addition, by the 7.5-year followup, less than
20 percent of the schizophrenia patients who were not
homemakers or students were working full time.
Rehospitalization. Individual ANOVAs using the
broader 5-point Strauss-Carpenter scale for rehospitalization showed significant diagnostic differences at each followup (p = 0.02).
1. At each of the three followups, the schizophrenia
patients were rehospitalized significantly more frequently
than the nonpsychotic patients (Newman-Keuls test, p =
0.05).
2. Although at some point during each of the three
followup years more than one-third of the schizophrenia
patients were rehospitalized, the differences between the
schizophrenia patients and the other psychotic patients
were much narrower. The schizophrenia patients were
rehospitalized significantly more than the other psychotic
patients at the third followup (Newman-Keuls test, p <
0.05). However, although more schizophrenia patients
were rehospitalized, there were no significant differences
in extent of rehospitalization between the schizophrenia
patients and the other psychotic patients at the 2- and 4.5year followup.
3. The highest rate of rehospitalization for each diagnostic group was at the first followup. After the first few
posthospitalization years, patients from the other psychotic and from the initially nonpsychotic patient groups
were less likely to be rehospitalized (p < 0.05).
Social functioning.
1. The data on the social activity of the schizophrenia
patients was relatively positive; many of these patients had
at least some moderate level of social contacts (table 3).
2. A small subgroup of 14 percent to 25 percent of
the schizophrenia patients showed very poor social functioning, and the schizophrenia patients tended to have less
social activity than the other two diagnostic groups at the
first two followups.
3. However, use of one-way ANOVAs on the data
from the Strauss-Carpenter scale for social contact level,
and subsequent Newman-Keuls post hoc tests, showed the
differences between the schizophrenia patients and the
other two diagnostic groups to be significant only at the
first followup (F = 8.09; df'= 2,266; p < 0.001). By the
third followup, there were almost no differences in this
Relationship Between Major Dimensions of Outcome.
The within-group correlations between the four major
dimensions of outcome (work and social functioning,
293
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
M. Harrow et al.
rehospitalization, and psychosis) at each of the three followups were analyzed. The results of this analysis at the
7.5-year followup are presented in table 4.
In general, the intercorrelations between the four
dimensions of outcome were moderate. In the majority of
comparisons, the relationships were statistically significant, but these relationships only account for a modest
percentage of the variance. The results on the interrelationships between these four dimensions of outcome are
in general agreement with the views on open-linked systems of outcome proposed by Strauss and Carpenter in
their analysis of their data on different dimensions of outcome. The view that these dimensions represent loosely
linked dimensions of functioning and adjustment could fit
the current data.
Table 5. Correlations for overall outcome over
time for schizophrenia patients, other psychotic
patients, and nonpsychotic patients
Social Rehospiactlvlty1 tallzatlon1!Psychosis2
0.51 3
0.274
0.284
0.41 3
0.483
0.335
0.16
0.284
0.12
0.353
0.433
0.283
0.31 3
0.323
0.265
0.61 1
0.531
0.751
Other psychotic patients
First followup (2 years)
Second followup (4.5 years)
0.571
0.431
0.601
Nonpsychotic patients
First followup (2 years)
Second followup (4.5 years)
0.471
0.351
0.601
followup, especially for the other psychotic patients, there
was a clear tendency (p < 0.001), within both of these initially psychotic groups, for patients with good functioning
(or those in complete remission) at one followup to show
good functioning at the next followup, 2.5 to 3 years later.
There was a similar tendency for poorer functioning
patients to continue to experience functioning difficulty at
the next followup.
The high correlations over time, and the tendency for
many patients with poor outcome to show subsequent outcome difficulties years later are consistent with other data
reported in table 6. However, there were patients in each
diagnostic group, at each followup, who showed changes
in outcome level at the next followup.
Intercorrelations between
outcome areas for each
diagnostic group
0.463
0.04
Schizophrenia patients
First followup (2 years)
Second followup (4.5 years)
'p< 0.001.
Table 4. Relationship between major dimensions
of outcome at the 7.5-year followup
0.13
Third
followup
(7-8 years)
r
Diagnostic group
and followup
Correlations: Outcome Over Time. Table S presents
the correlations over time on overall outcome. In general,
the schizophrenia patients and the other psychotic patients
showed consistency in functioning over time. There were
product moment correlations of more than r = 0.50 on
overall adjustment between the first and second followups, and between the second and third followups.
Hence, despite some general improvement after the first
Schizophrenia patients
Work functioning1
Social activity1
Rehospitalization1
Other psychotic patients
Work functioning1
Social activity1
Rehospitalization
Nonpsychotic patients
Work functioning1
Social activity1
Rehospitalization1
Second
followup
(4.5 years)
r
Changes in Overall Outcome Over Time. Potential
changes in overall functioning and adjustment as the three
diagnostic groups moved from the 2-year followup to the
4.5-year followup to the 7.5-year followup were assessed
by using the 3 X 3 repeated-measures ANOVA of the data
on overall outcome for the three diagnostic groups. The
main effect for the followup period assessed was significant (F = 11.16; df= 2,528; p < 0.001), indicating
improvement in overall outcome for the patient sample as
the length of time since index hospitalization increased.
Table 6 displays the percentages of schizophrenia
patients who showed changes in overall outcome over time
(i.e., improved functioning or decline in functioning).
As shown in tables 2, 3, and 6, the mean scores for
the schizophrenia patients at the second followup were
significantly more favorable than the scores at the first followup (' = 2.65; df= 70; p < 0.01). However, the schizophrenia patients did not continue to improve and were not
Note.—Signs for all correlations adjusted so that positive correlations indicate that scores reflecting greater psychopathology on each of the two variables go with each other.
'Based on scores from the Strauss-Carpenter scales (1972).
J
Based on scores for psychosis derived from the Schedule for Affective
Disorders and Schizophrenia (Endicott and Spttzer 1978).
*p< 0.001.
4
p < 0.05.
*p<0.01.
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Schizophrenia Bulletin, Vol. 23, No. 2, 1997
Course and Outcome for Schizophrenia
Table 6. Percentage of schizophrenia patients showing changes in outcome at 4.5-year and 7-8-year
followups
Second followup (4.5 years) status, %
Change in outcome status
Outcome status at first (2 years) followup
Good outcome (n = 9)
Moderate impairment (n = 26)
Poor functioning (n = 36)
Same
status
Improved
functioning
56
54
64
31
36
Decline in
functioning
44
15
Third followup (7-8 years) status, %
Change In outcome status
Outcome status at second (4.5 years) followup
Good outcome (n = 16)
Moderate impairment (n = 31)
Poor functioning (n = 27)
functioning significantly better at the 7.5-year followup
than they had been at the 2- or 4.5-year followups. In
addition, at all followups there continued to be a relatively
large number of schizophrenia patients with uniformly
poor outcome. The above data indicate that for individual
schizophrenia patients the pattern of psychopathology and
level of functioning over time are related to previous
psychopathology and functioning and can be seen in the
relatively high correlations of outcome at successive followups. Also, consistent with the relatively high correlations and indicating a link for many schizophrenia
patients between earlier and later functioning and psychopathology are the within-subjects data on potential
changes (table 6) and potential improvement (table 7)
over time.
Unlike the schizophrenia patients, the combined sample of nonschizophrenia patients tended to show improvement in overall outcome since the index hospitalization
(see figure 1). Thus, outcome for the nonschizophrenia
patients was better at the 7.5-year followup than at the 2year followup (/ = 4.37; df= \97,p< 0.001) and the 4.5year followup (f = 2.18; df= 199; p < 0.05).
Same
status
Improved
functioning
75
42
81
13
19
Decline In
functioning
25
45
recovery among schizophrenia patients with uniformly
poor outcome at each followup in comparison with the
recovery among the parallel sample of other psychotic
and nonpsychotic patients with poor outcome at the same
followup.
At the first followup, 36 of the 71 schizophrenia
patients for whom we had data at this followup showed
uniformly poor outcome. At the second followup, 2.5
years later, 36 percent of these poor outcome schizophrenia patients had improved and were showing either moderate impairment or complete remission. Thirty-nine of
the 198 (19.7%) nonschizophrenia patients (both psychotic and nonpsychotic patients) showed uniformly poor
outcome at the 2-year followup. Fifty-six percent of the
poor outcome nonschizophrenia patients (22 patients)
showed at least some improvement 2.5 years later, at the
second followup. Within the larger group of poor outcome
nonschizophrenia patients, a significantly larger percentage of nonpsychotic patients (63%) than of schizophrenia
patients (13%) showed improvement as they moved to the
4.5-year followup (X2 = 3.67; df=\;p< 0.05).
At the 4.5-year followup, 27 of the poor outcome
schizophrenia patients showed uniformly poor outcome.
At the third followup, 3 years later, 5 of these 27 schizophrenia patients (19%) had improved. None of these
schizophrenia patients were in complete remission at the
third followup, but all five had improved from uniformly
poor outcome to moderate impairment. The rate of improvement at the 7-8 year year followup for patients who
had poor outcomes at the 4.5-year followup was significantly better for both the other psychotic patients (X2 =
7.54; df= 1; p < 0.01) and the nonpsychotic patients (X2 =
9.74; df= 1; p < 0.01) than it was for the schizophrenia
Poor Outcome Patients: Rate of Improvement for
Schizophrenia Patients and Nonschizophrenia Patients.
In previous research we proposed that one of the factors
associated with the poorer outcome of some or many
schizophrenia patients is their slower recovery from psychopathology and psychosocial difficulties (Harrow et al.
1995). To assess this, we compared poor outcome schizophrenia patients with poor outcome nonschizophrenia
patients on rate of recovery over time (table 7).
Table 7 shows the separate analysis of the extent of
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Schizophrenia Bulletin, Vol. 23, No. 2, 1997
Table 7.
M. Harrow et al.
Poor outcome schizophrenia and nonschizophrenia patients: Rate of improvement
Improvement at
4.5-year followup
Still poor outcome
at 4.5-year followup
Poor outcome patients at 2-year followup
n
%
n
%
Schizophrenia patients
Nonschizophrenia patients
Other psychotic patients
Nonpsychotic patients
13
36
23
64
10
12
50
63
10
7
50
37
Improvement at
7.5-year followup
Still poor outcome
at 7.5-year followup
Poor outcome patients at 4.5-year followup
Schizophrenia patients
Nonschizophrenia patients
Other psychotic patients
Nonpsychotic patients
5
19
22
81
10
10
59
67
7
5
41
33
patients. However, a minority of the poor outcome schizophrenia patients did show improvement at both the second
and third followups.
Some diagnostic stability can be seen for the schizophrenia patients (tables 5 and 6), indicating that over half
of the schizophrenia patients showed the same followup
status from one followup to the next. Similarly, the data in
figure 1 and table 3 indicate that at each of the three followups over the 7-8 year period the overall schizophrenia
sample tended to show poorer outcome, poorer work
functioning, and more psychosis than the other patient
groups.
studied. This dimension of clinical course and outcome
was analyzed by using an index that takes the combined
data from all three followups into account. This index,
using the scores for overall outcome from all three followups, was based on the number and percentage of
patients in each group who were not in complete remission at any of the three followups (i.e., who showed either
moderate impairment or uniformly poor outcome at all
followups) and who also showed uniformly poor outcome
during at least one followup. Figure 2 presents the data on
such consistent psychopathology and impairment for each
diagnostic group.
The data from figure 2 indicate that more than 60 percent of the schizophrenia patients showed consistent psychopathology or impairment, as defined above. In contrast, 34 percent of the other psychotic patients showed
persistent functioning difficulties, and only 14 percent of
the nonpsychotic patients showed persistent functioning
difficulties. Thus, on this measure, which takes the results
from all three followups into account, significantly more
of the schizophrenia patients than of the other psychotic
patients (X2 = 9.76; df= \\p< 0.01) and the nonpsychotic
patients (X2 = 45.50; df - 1; p < 0.001) experienced this
type of persistent impairment.
The results on persistent difficulties seem somewhat
more hopeful when one looks at the percentage of patients
with uniformly poor outcome at every followup over the
7.5-year period. A much smaller percentage of patients
from each group showed uniformly poor outcome at all
three followups (28% of the schizophrenia patients and
only 9 percent of the other psychotic patients, X2 = 9.00;
df = 1; p < 0.01). Similarly, significantly fewer nonpsychotic patients (1.6%) than schizophrenia patients showed
Does Initial Avoidance of Poor Outcome Make Subsequent Poor Outcome Unlikely? We also analyzed data
for the subsample of schizophrenia patients who did not
show very poor outcome at either the 2- or 4.5-year followup, to determine whether this rendered future poor
outcome at the 7.5-year followup less likely. The data
indicated that fewer of this subsample of schizophrenia
patients showed very poor outcome at the 7.5-year followup, although some (8 schizophrenia patients) from this
subsample still showed very poor outcome at the 7.5-year
followup. We also analyzed separately the subsample of
schizophrenia patients who had complete remission (a rating of "good" outcome, which also includes adequate
work functioning) at either the 2- or 4.5-year followup.
Even fewer schizophrenia patients from this subsample
showed very poor outcome at the 7.5-year followup.
Consistent Psychopathology and Consistent Functioning Problems. The issue of consistent psychopathology and consistent impairment over time also was
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Schizophrenia Bulletin, Vol. 23, No. 2, 1997
Course and Outcome for Schizophrenia
Figure 2. Percent patients with some or consistent poor outcome and never in complete
remission: Three followups over 7-8 years
4. The data also show that a small number of the
schizophrenia patients had complete remission during the
year before each of the three followups. However, a relatively small number of schizophrenia patients showed
complete remission throughout the year before any one of
the followups (fewer than 25% at any followup). Other
major investigations also have found relatively low rates
of complete recovery or complete remission in schizophrenia. For instance, fewer than 30 percent of schizophrenia patients showed full and sustained remission in
the followup studies of Bleuler (1978), Tsuang et al.
(1979), Ciompi (1980), Huber et al. (1980), Gardos et al.
(1982), McGlashan (1984a, 19846), and Breier et al.
(1991).
5. The data suggest improvements in outcome for
the schizophrenia patients from the 2- to 4.5-year followup but do not indicate further improvement at the 7- to
8-year followups.
6. The data begin to suggest that the gap between
outcome in schizophrenia and outcome in bipolar and
unipolar psychotic affective disorders may widen rather
than narrow as the patients move further in time from
their index hospitalization.
SZ=Schfcophrenia Patients
OP=Other Psychotic Patients
NP=Nonpsycriotic Patients
this type of persistent poor outcome (X2 = 32.34; df= 1;
The results suggest that many schizophrenia patients
have persistent problems and over the years do not enter
into complete remission, but that many fluctuate between
severe disability and moderate disability rather than
always showing severe disability.
Schizophrenia Outcome and Consistent Psychopathology: Comparison With Other Psychoses. The
data comparing course and outcome in schizophrenia
patients with those nonschizophrenia patients who were
psychotic at the acute phase are of particular interest.
Many psychotic patients seem to show at least some outcome difficulties. In this respect, the presence of psychosis at the acute phase is often a negative prognostic
factor (Coryell and Tsuang 1982; Sands and Harrow
1994; Harrow et al. 1995). However, the pattern of uniformly poor outcome and persistent outcome difficulties
is found more often among schizophrenia patients. A
number of the nonschizophrenia psychotic patients also
showed vulnerability to psychopathology and to functioning difficulties (Harrow et al. 1994, 1995; Sands and
Harrow 1994; Marengo and Harrow 1997, this issue).
However, fewer nonschizophrenia psychotic patients
showed as widespread or as persistent psychopathology as
the schizophrenia patients. The results from the current
report suggesting more persistent psychopathology in
schizophrenia patients fit in with other data on the persistence of thought disorder (Marengo and Harrow 1997, this
issue) and of delusional activity (Harrow et al. 1995) in
schizophrenia patients.
The data indicating a trend toward greater diagnostic
differences at the 7.5-year followup than at the 2-year followup deserve further consideration. This trend is due, in
part, to greater improvement over time by the bipolar and
Discussion
Overall, in a sample of early-phase, young schizophrenia
patients and other psychotic patients who entered the hospital in an acute psychotic state, all diagnostic groups
showed some reduction of symptoms as they moved past
the acute phase (Harrow et al. 1985; Carone et al. 1991).
However, the current data comparing the schizophrenia
patients with the nonschizophrenia psychotic patients over
a 7.5-year posthospital period indicate the following:
1. Schizophrenia patients had poorer outcomes than
other psychotic patients at all three followups.
2. A major factor in the poorer outcome of the
schizophrenia patients, compared with the bipolar and
unipolar psychotic patients, was that a larger percentage
of the schizophrenia patients showed uniformly poor outcome or poor outcome in multiple areas of functioning.
3. The longitudinal data from three successive followups indicate that the greater persistence of psychopathology and psychosocial impairment over time
among the schizophrenia patients represents a major difference between these patients and other initially psychotic patients.
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Schizophrenia Bulletin, Vol. 23, No. 2, 1997
M. Harrow et al.
unipolar affectively disordered patients and the nonpsychotic depressives, and to the lack of a parallel improvement by the schizophrenia patients. Some theorists have
taken the view that diagnosis does not matter much. The
current data could indicate that, whatever vulnerabilities
or susceptibilities to current and future psychopathology
are tapped by a diagnosis of schizophrenia, they manifest
themselves in the consistency of psychopathology over
time and may manifest themselves to a greater extent over
time.
Diagnostic Differences in Outcome: Relevance of a
Statistical Model Involving Regression to the Mean.
Looking at the data on changes over time from one perspective, it might be thought that, since the schizophrenia
patients had the poorest functioning at the first (2 year)
and second (4.5 year) followups, it should have been easier for them to show subsequent improvement (since they
had more room to improve). For most of the schizophrenia patients, even functioning at the moderately impaired
level at the 4.5- and 7.5-year followups would mark an
improvement. However, the schizophrenia patients as a
group showed the least improvement.
In regard to the lack of large changes over time, many
have discussed results showing regression to the mean
using models of biometric data in groups showing
extreme scores. Using the model of regression to the
mean, one might expect that schizophrenia patients, who
showed the poorest functioning at the first followup,
would show the greatest improvement at subsequent followups. However, despite their poor functioning at the
first followup, schizophrenia patients did not show a dramatic regression to the mean, and instead showed the least
improvement. In human data, regression to the mean is
usually a statistical expression of biological or psychological factors rather than an entity in itself. It is often influenced by scores collected at the height of pathology, or at
the extreme end of a spectrum, followed by a return to
more typical or routine scores. In the present case, where
the schizophrenia patients did not show regression to the
mean, or greater improvement, in comparison with the
other psychotic patients, this would appear to be related to
biologically, psychologically, and societally induced factors associated with schizophrenia.
Functioning of Schizophrenia Patients in Major Areas.
In modern society, instrumental work functioning is one
of the features that some people use to define their own
adequacy; therefore, poor work functioning can be a
source of considerable distress. The present data on
instrumental functioning reflect the consistent difficulty in
work adjustment experienced by most schizophrenia
298
patients. The poor work performance of the schizophrenia
patients can be contrasted with the significantly higher
percent of other psychotic and nonpsychotic patients with
adequate work functioning and points to one of the major
areas of dysfunction in schizophrenia patients. Although,
during both the 4.5- and 7.5-year followup years, only
about 40 percent of the schizophrenia patients were rehospitalized and many were able to maintain some social
contacts, a large number of the schizophrenia patients
showed considerable difficulty in the area of instrumental
work functioning, and a relatively small percentage
engaged in full-time employment.
The data on level of social activity for the schizophrenia patients were more encouraging. Although these
patients did experience some social difficulty as a group,
the great majority did not show the type of progressive
decline in social functioning or the total social isolation
that was described before the modem era. In addition, after
the 2-year followup, the differences in extent of social
activity between the schizophrenia patients and the other
psychotic patients were relatively small. The results on
social functioning could have been influenced by treatment
factors, including a tendency for many day-treatment programs to emphasize and encourage social interaction.
The current data on psychosis, in conjunction with
other recent data on delusions (Harrow et al. 1995), suggest that some other types of patients in addition to
patients with schizophrenia, are vulnerable to psychosis at
followup. Accordingly, the present data and other results
(Sands and Harrow 1994) indicate that nonschizophrenia
patients who experience psychosis at the acute phase are
vulnerable to subsequent psychotic activity. However,
despite this vulnerability, the subsequent reality distortions found in other psychotic patients are often less flagrant and less persistent than those found in many schizophrenia patients (Harrow et al. 1995).
The consistent trend toward more rehospitalizations
at the 2-year followup (i.e., in the year leading up to the
followup), followed by a reduction in rehospitalizations at
the 4.5- and 7.5-year followups, corresponds to a trend we
observed previously when analyzing schizophrenia
patients over a shorter followup period (Carone et al.
1991) and without a comparison group of other psychotic
patients. The reduction in rehospitalizations after the 2year followup is consistent with a view that, for patients
who were rehospitalized during the first few posthospital
years, the expectations that hospital treatment will lead to
a permanent cure begins to diminish. Thus, after the first
few posthospital years, some patients' relatives are not as
eager to see them rehospitalized and sometimes will not
seek rehospitalization even when there is an increase in
symptoms.
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
Course and Outcome for Schizophrenia
indicating that schizophrenia patients with uniformly poor
outcomes at the 2-year followup were less likely than other
psychotic patients with uniformly poor outcomes to show
improvement at the next followup (see table 7). Parallel
data (table 7) indicated that schizophrenia patients with
uniformly poor outcomes at the 4.5-year followup were
less likely than similar other psychotic patients to show
subsequent improvement.
We have called this factor a rising "threshold of hospitalization" (Carone et al. 1991) after years of psychopathology. Once this factor takes effect, hospitals are less
likely to be seen as able to provide a sustained cure, and
when psychosis becomes more severe, the schizophrenia
patients are less likely to be hospitalized, unless they are
totally unmanageable or other factors necessitate it.
In addition, over the years some psychotic symptoms,
although just as frequently present, may diminish in intensity and become less flagrant; this also could be a factor in
reduced hospitalizations. For some patients, residual
symptoms from their original index illness may persist for
several years and create adjustment difficulties or even
provide the basis for an acute exacerbation of disorder.
However, after the first few posthospital years, the residual symptoms from the acute episode may remit. A fourth
possible factor is a "period effect." Thus, in relation to the
period effect there has been a tendency toward less use of
hospitals in more recent times (or at the later followups)
with this possibly influencing the results in this area.
It is likely that some combination of the above factors
and others may account for the data indicating fewer
rehospitalizations over time for schizophrenia patients and
a lower correlation over time between psychosis and
rehospitalization.
The current article has focused on the differences
between schizophrenia patients and other psychotic
patients in overall outcome, in specific areas of outcome,
and in clinical course over time at multiple assessments.
However, there are other important aspects of course and
outcome not explored in detail in the current report that
deserve further consideration. Of particular interest is
research that analyzes course and outcome based on a
conceptual framework involving three clinical syndromes
as proposed by Liddle (Liddle and Barnes 1990; Liddle et
al. 1994) and others (Bilder et al. 1985; Lenzenweger et
al. 1989;Peraltaetal. 1992; Amdtet al. 1995).
Diagnostic Differences in Outcome: A Product of
Multiple Factors. What factors are responsible for the
differences in outcome between (1) the schizophrenia
patients and (2) the bipolar and psychotic unipolar
patients and other psychotic patients? One could use the
current data on outcome, and data showing increasing
diagnostic differences over time, to support a view that
some factors that are found in most schizophrenia patients
are also associated with consistently poor outcome and
contribute to the relatively unfavorable outcome found in
a large percentage of schizophrenia patients. Among these
might be factors innate to schizophrenia patients that
make it harder for them to use environmental experiences
to acquire greater personal competency over time.
Another factor is the societal impact of having a
severe disorder such as schizophrenia, which improves
slowly and disrupts functioning drastically and, as a
result, sets up societal prejudice against those with the
disorder. As an example, it is harder in our competitive
society to obtain a job after a sustained period of unemployment. Failure in the employment area and memory of
previous work failure can then lead to demoralization and
an increased likelihood of avoiding future frustrations and
disappointments associated with trying to succeed in this
area. Adequate work functioning can become even more
problematic in patients who, because of their disorder or
premorbid personality, have problems undertaking new
initiatives and who may be experiencing negative symptoms (Andreasen and Olsen 1982; Pogue-Geile and Harrow 1985; Andreasen et al. 1990), or depression (Siris
1991; Harrow et al. 1994). Comorbid psychopathology
and substance abuse may further contribute to pervasive
demoralization and unemployment in a number of schizophrenia patients over time. The data indicate that poor
functioning at any given followup assessment tends to
predict later poor functioning, and that persistent poor
functioning, with its psychological and social impact on
the patient, may further increase the chance of poor functioning and disability in the future. It is possible that
greater investment in early treatment and early rehabilitative aid for patients with schizophrenia could help lower
the rates of long-term disability.
Among the other factors that could contribute to
Slower Recoverability Over Time as a Factor In
Course and Outcome for Schizophrenia Patients. We
have suggested that an important characteristic of overall
course and outcome in schizophrenia is schizophrenia
patients' slower recovery (Harrow et al. 1995). Both
schizophrenia patients and other psychotic patients appear
to be vulnerable to psychopathology and especially to
psychotic activity. Both types of patients show some
recoverability after the acute phase. However, schizophrenia patients recover from psychopathology and from psychosis at a slower rate and are more vulnerable to subsequent psychosis, although other types of initially psychotic
patients also show vulnerability to subsequent psychosis.
Consistent with this view of slower recovery are the data
299
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
M. Harrow et al.
1961; McGlashan 1988). In addition, the data presented
by Harding et al. (1987) involve an older sample of
patients. These results could indicate that many schizophrenia patients experience fewer symptomatic problems
as they age, although not all studies have verified this
(e.g., the studies by Tsuang and colleagues). In addition,
when one looks at an older sample, with many studied
after retirement, one is focusing on a period when adequate work performance is no longer an important aspect
of adjustment. At any rate, the issue of whether schizophrenia patients experience fewer symptomatic problems
as they age, raised by the data of Harding and colleagues,
must be regarded seriously and should be resolved with a
sample followed up longitudinally and assessed at multiple
time points.
The current data, using early-phase, young patients,
using other psychotic patients as controls, and looking at
clinical course over time (reassessing patients every few
years), indicate that schizophrenia patients show less
favorable outcomes than other psychotic patients. From
this perspective, outcome and clinical course in schizophrenia, at least during the first 7 to 8 years, is relatively
unfavorable. However, as we have noted in other reports
(Carone et al. 1991; Harrow et al. 1992), the issue of how
optimistic one can be depends on which expectations one
adopts in considering course and outcome.
If one adopts the older outlook, originally proposed
for dementia praecox as a disorder in which many patients
show progressive deterioration or continually show very
poor outcome, our data, based on a multifollowup
research design, indicate that, as a group, schizophrenia
patients do not deteriorate over time. One can be optimistic since, with modern-day treatment, many schizophrenia patients fluctuate over time between severe disability and moderate disability, with some entering into
periodic remissions. Currently, one finds only a moderate
decline in social activity, and most schizophrenia patients
are not continually hospitalized. In this respect, the modern outlook, based in part on modern pharmacological and
psychosocial treatments and on discouragement of multiyear hospitalizations and the type of regression once
found in the back wards of large State hospitals, has produced an improved picture from that reported earlier in
this century.
On the other hand, if one adopts the layman's expectation that success with major disorders occurs when one
is able to treat them successfully and patients can be
returned to normality or to normal functioning, then outcome for the majority of schizophrenia patients would be
seen as poor. Schizophrenia patients show poorer clinical
courses and outcomes than other types of initially psychotic patients; many show very poor work adjustment,
course and outcome differences among the three diagnostic groups are severity of illness and level of functioning
at index hospitalization or at the acute phase of illness. In
separate studies of delusions over time, thought disorder
over time, and the relationship between poor premorbid
work functioning and later prognosis, we have found evidence that the presence of these three types of psychopathology at the acute phase has a relationship to later
psychopathology in the same area, and sometimes to later
overall functioning. However, at best these three factors
account only for part of the variance in later course and
outcome (Westermeyer and Harrow 1984; Harrow et al.
1986, 1995).
A key factor is the greater vulnerability of schizophrenia patients to severe psychopathology after the acute
phase, including ongoing susceptibility in the posthospital
phase to positive symptoms (Harrow and Silverstein 1977;
Harrow et al. 1985, 1995), to lethargy-dullness, and to
akinesia (Bermanzohn and Siris 1992) (some of which
may be influenced by treatment with neuroleptics), and to
depression and negative symptoms, which arc experienced
by a number of schizophrenia patients (Siris et al. 1984;
Pogue-Geile and Harrow 1985; Andreasen et al. 1990;
Siris 1991; Harrow et al. 1994). These psychopathological
factors also contribute to the increasing distance of schizophrenia patients from the other major groups in terms of
poorer overall functioning. As data become available on
the long-term use of newer, atypical neuroleptics such as
clozapine and risperidone, it will be interesting to see
whether use of these medications is associated with
improvements in clinical features such as depression, negative symptoms, lethargy-dullness, and akinesia.
A major question is whether these overall differences
in outcome between diagnostic groups continue to
increase over time. This question is still to be resolved.
Recent Evidence on Outcome in Schizophrenia. The
current data on course and outcome indicating that many
schizophrenia patients experience considerable posthospital problems with both symptoms and instrumental work
adjustment are consistent with results reported by Tsuang
et al. (1979, 1981), McGlashan (1984a, 1984&, 1988),
Johnstone (1990), and Breier et al. (1991). Our data do
not completely support a report by Harding and colleagues (1987) that suggests that outcome in schizophrenia has become optimistic. Rather, our data suggest that
outcome in schizophrenia is relatively unfavorable.
However, the data presented by Harding et al. are based
on a sample that differs from our sample in that most of
the patients were selected on the basis of neuroleptic
responsivity and ability to work with some degree of success in an inpatient vocational program (Chittick et al.
300
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Course and Outcome for Schizophrenia
Bilder, R.M.; Mukherjee, S.; Rieder, R.O.; and
Pandurangi, A.K. Symptomatic and neuropsychological
components of defect states. Schizophrenia Bulletin,
ll(3):409-491, 1985.
and the majority are vulnerable to recurrent psychotic
symptoms and other positive symptoms and to both negative symptoms and depressive symptoms, with more persistent impairment over time.
The data on both schizophrenia patients and on other
psychotic patients would indicate that the presence of psychotic symptoms at the acute phase often is associated
with vulnerability to subsequent symptom and outcome
difficulties. However, the impairments for schizophrenia
patients are often more severe than those of other psychotic patients. Thus, despite optimistic reports by some,
the current data collected at four points over a 7- to 8-year
period (at the acute phase and three successive followups)
suggest that the majority of schizophrenia patients do not
show complete and consistent remission over the long
term. Rather, they experience symptomatic impairment
and difficulty over the years in instrumental work functioning and show more persistent psychopathology and
problems in functioning than other psychotic patients.
Bleuler, M.N. The Schizophrenic Disorders: Long-Term
Patient and Family Studies. New Haven, CT: Yale
University Press, 1978.
Breier, A.; Schreiber, J.D.; Dyer, J.; and Pickar, D.
National Institute of Mental Health longitudinal study of
chronic schizophrenia. Archives of General Psychiatry,
48:236-246, 1991.
Carone, B.J.; Harrow, M.; and Westermeyer, J.F. Posthospital course and outcome in schizophrenia. Archives of
General Psychiatry, 48:247-253, 1991.
Carpenter, W.T., Jr., and Kirkpatrick, B. The heterogeneity
of the long-term course of schizophrenia. Schizophrenia
Bulletin, 14(4):645-652, 1988.
References
Carpenter, W.T., Jr., and Strauss, J. The prediction of outcome in schizophrenia: IV. Eleven-year follow-up of the
Washington IPSS cohort. Journal of Nervous and Mental
Disease, 179:517-525, 1991.
American Psychiatric Association. DSM-llI: Diagnostic
and Statistical Manual of Mental Disorders. 3rd ed.
Washington, DC: The Association, 1980.
Chapman, L.J.; Chapman, J.P.; and Raulin, M.L. Scales
for physical and social anhedonia. Journal of Abnormal
Psychology, 85:374-382, 1976.
American Psychiatric Association. DSM-H1-R: Diagnostic
and Statistical Manual of Mental Disorders. 3rd ed.,
revised. Washington, DC: The Association, 1987.
American Psychiatric Association. DSM-IV: Diagnostic
and Statistical Manual of Mental Disorders. 4th ed.
Washington, DC: The Association, 1994.
Chittick, R.A.; Brooks, G.W.; Irons, F.S.; and Deane,
W.N. The Vermont Story: Rehabilitation of Chronic
Schizophrenic Patients. Burlington, VT: Queen City
Printers, 1961.
Ciompi, L. Catamnestic long-term study on the course of
life and aging of schizophrenics. Schizophrenia Bulletin,
6(4):608-618, 1980.
Andreasen, N.C.; Flaum, M.; Swayze, V.W. II; Tyrrell, G.;
and Arndt, S. Positive and negative symptoms in schizophrenia. Archives of General Psychiatry, 47:615-621,
1990.
Coryell, W., and Tsuang, M.T. Primary unipolar depression and the prognostic importance of delusions. Archives
of General Psychiatry, 39:1181-1184, 1982.
Endicott, J., and Spitzer, R. A diagnostic interview: The
Schedule for Affective Disorders and Schizophrenia.
Archives of General Psychiatry, 35:837-844, 1978.
Andreasen, N.C.; Olsen, S.A.; Dennert, J.W.; and Smith,
M.R. Ventricular enlargement in schizophrenia: Relationships to positive and negative schizophrenia. American
Journal of Psychiatry, 139:297-302, 1982.
Fenton, W.S., and McGlashan, T.H. Sustained remission
in drug-free schizophrenic patients. American Journal of
Psychiatry, 144:1306-1309, 1987.
Angst, J. European long-term followup studies of schizophrenia. Schizophrenia Bulletin. 14(4):501-513, 1988.
Arndt, S.; Andreasen, N.C.; Flaum, M.; Miller, D.; and
Nopoulos, P. A longitudinal study of symptom dimensions
in schizophrenia. Archives of General Psychiatry, 52:352360, 1995.
Bermanzohn, P C , and Sins, S.G. Akinesia: A syndrome
common to Parkinsonian, retarded depression, and negative symptoms of schizophrenia.
Comprehensive
Psychiatry, 33:221-232, 1992.
Gardos, G.; Cole, J.O.; and LaBrie, R.A. A twelve-year
follow-up study of chronic schizophrenics. Hospital and
Community Psychiatry, 33:983-984, 1982.
Gorham, D.R. Proverbs tests for clinical and experimental
use. Psychological Reports, l(Suppl-): 1-12, 1956.
Grinker, R.R., and Harrow, M., eds. A Multidimensional
Approach to Clinical Research in Schizophrenia. Springfield, IL: Charles C Thomas, 1987.
301
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
M. Harrow et al.
Grossman, L.S.; Harrow, M.; Goldberg, J.F.; and Fichtner,
C.G. Outcome of schizoaffective disorder at two longterm followups: Comparisons with outcome of schizophrenia and affective disorders. American Journal of
Psychiatry, 148:1359-1365, 1991.
phrenic patients: II. Two year relapse rates. Archives of
General Psychiatry, 31:603-608, 1974.
Hollingshead, A.B., and Redlich, F.C. Social Class and
Mental Illness. New York, NY: John Wiley & Sons, 1958.
Huber, G.; Gross, G.; SchUttler, R.; and Linz, M. Longitudinal studies of schizophrenic patients. Schizophrenia
Bulletin, 6(4):592-605, 1980.
Harding, CM.; Brooks, G.W.; Ashikaga, T.; Strauss, J.S.;
and Breier, A. The Vermont longitudinal study of persons
with severe mental illness: II. Long-term outcome of subjects who retrospectively met DSM-IH criteria for schizophrenia. American Journal of Psychiatry, 144:727-735,
1987.
Johnstonc, E.C. What is crucial for the long-term outcome
of schizophrenia? In: Hafner, H., and Gattaz, W.F., eds.
Search for the Causes of Schizophrenia. Vol. II. Berlin,
Germany: Springer-Verlag, 1990. pp. 67-76.
Harrow, M.; Carone, B.J.; and Westermeyer, J.F. The
course of psychosis in early phases of schizophrenia.
American Journal of Psychiatry, 146:702-707, 1985.
Katz, M., and Lyerly, S. Methods for measuring adjustment and social behavior in the community: I. Rationale,
description, discriminative validity, and scale developmenL Psychological Reports, 13:503-535, 1963.
Harrow, M.; Carone, B.J.; and Westermeyer, J.F. Subjective conclusions about schizophrenia: In reply. Archives of
General Psychiatry, 49:75-76, 1992.
Kraepelin, E. Dementia Praecox and Paraphrenia. (1919)
Translated by R.M. Barclay. Edinburgh, Scotland: E. & S.
Livingstone, 1921.
Harrow, M.; Grinker, R.R.; Silverstein, M.; and Holzman,
P. Is modern day schizophrenic outcome still negative?
American Journal of Psychiatry, 135:1156-1162, 1978.
Lenzenweger, M.F.; Dworkin, R.H.; and Wethington, E.
Models of positive and negative symptoms in schizophrenia: An empirical evaluation of latent structures. Journal
of Abnormal Psychology, 98:62-70, 1989.
Harrow, M.; Lanin-Kettering, I.; and Miller, J.G. Impaired
perspective and thought pathology in schizophrenic and
psychotic disorders. Schizophrenia Bulletin, 15(4):605623, 1989.
Levenstein, D.S.W.; Klein, D.F.; and Pollack, M. Followup study of formerly hospitalized voluntary patients: The
first two years. American Journal of Psychiatry,
Harrow, M.; Lanin-Kettering, I.; Prosen, M.; and Miller,
J.G. Disordered thinking in schizophrenia: Intermingling
and loss of set Schizophrenia Bulletin, 9(3):354-367, 1983.
10:1102-1109, 1966.
Liddle, P.F., and Barnes, T.R.E. Syndromes of chronic
schizophrenia. British Journal of Psychiatry, 157:558561, 1990.
Harrow, M.; MacDonald, A.W. Ill; Sands, J.R.; and
Silverstein, M.L. Vulnerability to delusions over time in
schizophrenia and affective disorders. Schizophrenia
Bulletin, 21(l):95-109, 1995.
Liddle, P.F.; Carpenter, W.T., Jr.; and Crow, T.J. Symptoms of schizophrenia: Classic literature. British Journal
of Psychiatry, 165:721-727, 1994.
Harrow, M., and Marengo, J.T. Schizophrenic thought disorder at followup: Its persistence and prognostic significance. Schizophrenia Bulletin, 12(3):373—393, 1986.
Marengo, J.T, and Harrow, M. Longitudinal courses of
thought disorder in schizophrenia and schizoaffective disorder. Schizophrenia Bulletin, 23(2):273-285, 1997.
Harrow, M.; Marengo, J.T.; and McDonald, C. The early
course of schizophrenic thought disorder. Schizophrenia
Bulletin, 12(2): 208-224, 1986.
Marengo, J.T.; Harrow, M.; Sands, J.R.; and Galloway, C.
European vs. USA data on the course of schizophrenia.
American Journal of Psychiatry, 148:606-612, 1991.
Harrow, M., and Quinlan, D. Disordered Thinking and
Schizophrenic Psychopathology. New York, NY: Gardner
Press, 1985.
May, P.R.A.; Tuma, A.H.; and Dixon, W.J. Schizophrenia:
A follow-up study of the results of five forms and treatments. Archives of General Psychiatry, 38:776-784, 1981.
Harrow, M., and Silverstein, M.L. Psychotic symptoms in
schizophrenia after the acute phase. Schizophrenia
Bulletin, 3(4):608-616, 1977.
McGlashan, T.H. The Chestnut Lodge followup study.
Archives of General Psychiatry, 41:573-585, 1984a.
Harrow, M.; Yonan, C.A.; Sands, J.R.; and Marengo, J.T.
Depression in schizophrenia: Are neuroleptics, akinesia,
or anhedonia involved? Schizophrenia
McGlashan, T.H. The Chestnut Lodge followup study: II.
Long-term outcome of schizophrenia and the affective disorders. Archives of General Psychiatry, 41:585-601, 19846.
Bulletin,
20(2):327-338, 1994.
McGlashan, T.H. A selective review of recent North
American long-term followup studies of schizophrenia.
Schizophrenia Bulletin, 14(4):515-542, 1988.
Hogarty, G.E.; Goldberg, S.C.; Schooler, N.R.; and Urich,
R.F. Drug and sociotherapy in the aftercare of schizo-
302
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
Course and Outcome for Schizophrenia
term outcome of major psychosis: I. Archives of General
Psychiatry, 36:1295-1301, 1979.
Peralta, V.; de Leon, J.; and Cuesta, M.J. Are there more
than two syndromes in schizophrenia? A critique of the
positive-negative dichotomy. British Journal of
Psychiatry, 161:335-343, 1992.
Tsuang, M.T.; Woolson, R.F.; Winokur, G.; and Crowe,
R.R. Stability of psychiatric diagnosis: Schizophrenia and
affective disorders followed up over a 30- to 40-year
period. Archives of General Psychiatry, 38:535-554,
1981.
Vaillant, G.E. A 10-year followup of remitting schizophrenics. Schizophrenia Bulletin, 4(l):78-85, 1978.
Pogue-Geile, M.F., and Harrow, M. Negative symptoms in
schizophrenia: Their longitudinal course and prognostic
importance. Schizophrenia Bulletin, 11(3):427-439, 1985.
Port, J.; Harrow, M.; Jobe, T; and Dougherty, D. Thought
disorder in adolescent schizophrenics: Towards an integrative model. In: Flaherty, L.T., ed. Annals of Adolescent
Psychiatry. Vol. 21. Hillsdale, NJ: The Analytic Press, in
press.
Rapaport, D.; Gill, M.; and Schafer, R. Diagnostic Psychological Testing. New York, NY: International Universities
Press, 1968.
Samson, J.A.; Simpson, J.C.; and Tsuang, M.T. Outcome
studies of schizoaffective disorders. Schizophrenia
Bulletin, 14(4):543-554, 1988.
Wechsler, D. Wechsler Adult Intelligence Scale. New
York, NY: Psychological Corporation, 1955.
Westermeyer, J.F., and Harrow, M. Prognosis and outcome using broad (DSM-If) and narrow (DSM-Hf) con-
cepts of schizophrenia. Schizophrenia
Bulletin,
10(4):624-637, 1984.
Acknowledgments
Sands, J.R., and Harrow, M. Psychotic unipolar depression at followup: Factors related to psychosis in the affective disorders. American Journal of Psychiatry, 151:9951000, 1994.
Siris, S.G. Diagnosis of secondary depression in schizophrenia: Implications for DSM-IV. Schizophrenia Bulletin,
17(l):75-98, 1991.
Siris, S.G.; Rifkin, A.; Reardon, G.T.; Endicott, J.;
Pereira, D.H.; Hayes, R.; and Casey, E. Course-related depressive syndromes in schizophrenia. American Journal of
Psychiatry, 141:1254-1257, 1984.
This research was supported in part by USPHS grant MH26341 from the National Institute of Mental Health and
by a research grant from Michael Reese Hospital and support from the Anna Lipsky Trust. The authors thank
Robert Faull, B.S., for his help with the data preparation
and statistical analysis.
The Authors
Martin Harrow, Ph.D., is Professor and Director of Psychology, Department of Psychiatry and James R. Sands,
Ph.D., is Assistant Professor, Department of Psychiatry,
University of Illinois College of Medicine, Chicago, IL.
Marshall L. Silverstein, Ph.D., is Professor, Department
of Psychology, Long Island University, Brookville, NY.
Joseph F. Goldberg, M.D., is an Instructor, Department of
Psychiatry, Payne Whitney Clinic, The New York
Hospital-Cornell University Medical Center, Ithaca, NY.
Spitzer, R.L.; Endicott, J.; and Robins, E. Research Diagnostic Criteria: Rationale and reliability. Archives of
General Psychiatry, 35:70-72, 1978.
Strauss, J.S., and Carpenter, W.T., Jr. The prediction of
outcome in schizophrenia: I. Characteristics of outcome.
Archives of General Psychiatry, 27:739-746, 1972.
Tsuang, M.T; Woolson, R.F.; and Fleming, J.A. Long-
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