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Schizophrenia outcome

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Manjeet Gangwar

This document discusses long term outcomes and prognosis in schizophrenia based on various studies. Some key points: 1. Studies have shown highly variable outcomes both between and within patients, with less than half showing substantial improvement after 6 years on average. 2. Outcomes have improved over the 20th century but trends reversed after the 1970s. Course descriptors vary by length of follow-up. 3. International studies like IPSS and ISoS found better outcomes in India, Nigeria, and Colombia compared to developed countries, with higher remission rates.

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Long term outcome and prognosis in schizophrenia Manjeet Singh
History • In the pre-kraeplelinian era secondry dementia was considered the outcome of most psychoses now diagnosed as schizophrenia. • Kraepelin pointed out that the deficiency was more in the field of emotion and volition, less in that of judgement or memory. • In bleuler’s view the disturbance of intelligence could not be adequately described as dementia.
History • In 1903 Kraepelin noticed that the basic form of dementia praecox and manic depressive insanity in the Javanese were essentially the same as in Europe. • In a 1953 monograph published by the WHO, John Carothers claimed that the paucity of structural delusional content and lack of systematization of delusion in the African could be explained by congenital underdevelopment of frontal lobe of brain.
Outcome • Short term - < 2 years follow-up. • Mid term - 2-5 year follow-up. • Long term - >5 years follow-up
Dimensions of outcome • Outcome is a multidimensional construct that a minimum requires description of domains for: 1. Clinical (symptoms and treatment). 2. Psychosocial function.
Functional outcome domains • Social • Occupational • Independent living • Rehabilitation success • Substance abuse
Terminology of outcome • Define outcome in terms of: 1. Response 2. Remission 3. Recovery 4. Relapse
Response • Response is some relief of symptoms and some improvement in functioning. The term ‘response’ implies that this improvement arises from treatment, usually because it is associated in time with that treatment.
Remission • Remission is a period of complete relief of symptoms and a return of full functioning, which may be brief. • Remission criteria define remission as a low- mild symptom intensity level, where such absent, borderline, or mild symptoms do not influence an individual’s behavior. * *Liberman RP, Kopelowicz A, Venture J, Gutkind D: Operational criteria and factors related to recovery from schizophrenia. Int Rev Psychiatry 2002; 14:256–272
Recovery • “Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her potential.” Or • Is a period of complete relief of symptoms and a return of full functioning, which is likely to be longer term.
Relapse • Is the return of symptoms, satisfying the diagnostic criteria for the disorder, after a patient has either responded or remitted, but before recovery. • According to Johnstone, relapse could also be defined as Type I, the reappearance of schizophrenic symptoms in a patient who has been free of them following the initial episode, and Type II, the exacerbation of persistent positive symptoms*. *Johnstone EC. Relapse in schizophrenia: what are the major issues? In: Hawton K, editor. Practical problems in clinical psychiatry. Oxford: Oxford University Press; 1992;159-71.
Recurrence • Recurrence is the return of symptoms, satisfying the diagnostic criteria for the disorder, after the patient has recovered.
Need for follow-up study • To know natural history of disease. • Course of disease. • Outcome of disease. • Cultural variation of disease course and outcome. • Effect of drugs on disease progression.
List of selected course and outcome studies in schizophrenia 1972-2005 Author Country Sample size Length of F/U Proportion good outcome Bleuler (1972) Switzerland 208 23 20% remission , 33% mild defect Tsung et al. (1979) USA 186 35 46% recovered or improve significantly Ciompi (1980) Switzerland 289 37 20% recovered, 43% definitely improved Huber et al. (1980) Germany 502 22 26% recovered 31% remission with mild defect Harding et al. (1987) USA 118 32 62% recovered or improved significantly Ogawa et al. (1987) Japan 140 21-27 31% recovered, 46% improved
Author Country Sample size Length of F/U Proportion good outcome Shepherd et al. (1989) UK 107 5 22% rcovered, no relapse Johnstone et al. (1990) UK 530 3-13 14% excellent, 18.5% very good social adjustment Caron et al. (1991) USA 79 5 17% complete remission Marneros et al. (1992) Germany 249 25 Full remission in 24% (broad), 7% pure schizo. Thara et al. (1994) India 90 (1st onset) 10 12% complete recovery, 62% remission Mason et al. (1995) UK 67 13 17% complete recovery, 52% remission Wieselgren & Lindstrom (1996) Sweden 120 5 30% good outcome Wiersma et al. (1998) Holland 82 15 27% complete, 50% partial remission
Author Country Sample size Length of F/U Proportion good outcome Ganev et al. (1998) Bulgaria 60 16 32% complete, 5% partial remission Gureje & Bamidele (1999) Nigeria 120 13 22% unimpaired 19% some impairment Finnerty et al. (2002) Ireland 67 (1st onset) 15 35% complete remission, 46% partial remission Thara (2004) India 90 (1st onset) 20 6% complete recovery, 15% clinically stable Lauronon et al. (2005) Finland 91 (birth cohart members) To age 31 yr 4% complete recovery, 3% partial remission
Indian study author Outcome Clinical Social, occupational Johnson S et al/ 2012/ vellore India 68% remitted, 24% had at least one additional psychotic episode Median WHO-DAS score 8 Srivastava A et al /2009/ Mumbai India 100% had PANSS positive score <21, 88% had PANSS negative score <21 61.7% had GAF > 80 Suresh et al/ 2012/ rural Karnataka India N/A 60% of patient had mild/no disability in work Verghese A et al/ 1989/ Chennai, Vellore, Lucknow India (SOFACOS) 64% in remission, 6% continuous psychosis, 30% other 61% occupational impairment PANSS - Positive and Negative Syndrome Scale GAF - Global Assessment of Function SOFACOS- Study Of Factors Associated With Course and Outcome of Schizophrenia WHODAS, WHO- Disability Assessment Schedule;
The evidence from recent systemic reviews generally support the following conclusion 1. The course of schizophrenia is highly variable both with in patient and between patients. 2. Less then half of patients diagnosed as schizophrenia show substantial clinical improvement after follow-up time averaging 6 years. 3. Examining trend in course and outcome over the past century revealed substantial gains in favorable outcome from the 1920 – 1970 after which time gradient seems to be reversed.
4. Course of descriptors varies as a function of the length of follow-up. 5. On average patient with diagnosis of schizophrenia has the poorest outcome. 6. Course and outcome estimates vary depending on the diagnostic classification used. 7. There is no reliable set of predictors yet identified for course and outcome.
Methodological heterogeneity • Variation in population from which patient are selected. • Variation in diagnostic criteria. • Variation in length of illness before entry in to follow-up. • Variability of attrition rate.
• Variation in methods used to assess course and outcome. • Variation in the characteristics of the general population. • Variation in statistical techniques and adjustment of confounding. • Variation in long term management of schizophrenia.
WHO description of clinical symptoms course and outcome 1. Single psychotic episode followed by complete remission. 2. Single psychotic episode followed by incomplete remission. 3. Two or more psychotic episode with complete remission between episodes. 4. Two or more episodes with incomplete remission between episodes. 5. Continuous (unremitting) chronic psychosis.
International study • WHO Ten Country Study. (short term) • International Pilot study on Schizophrenia.(IPSS) • International study of schizophrenia (ISoS) • The study on determinants of outcome of severe mental disorders.(DOSMeD)
IPSS • IPSS began in 1966 as a large scale cross- cultural collaborative project carried out simultaneously in nine countries that differ widely in their sociocultural and economic characteristics.
Centre for IPSS Country Centre Arthus Denmark Agra India Cali Columbia Ibadan Nigeria London England Moscow U.S.S.R. Taipei China Washington U.S.A. Prague Czechoslovakia
IPSS • In IPSS total 1202 patient has been taken. Out of which 811 received a clinical diagnosis of schizophrenia, 164 affective psychoses, 102 other psychoses. Method – The IPSS was carried out in three phases, a preliminary phase, an initial evaluation phse and a follow up phase. And all the patient interviewed by using “present state examination”
Outcome in IPSS • IPSS found that higher proportion of patients in India, Colombia, and Nigeria had better outcomes on most dimensions than patients in developed countries. • Complete remission of the initial psychiotic episode within 5 years had occurred in as many as 42% of patients in India 33% of patients in Nigeria, whereas the majority of patients in the developed countries had experienced persistent psychotic symptoms.
International study of schizophrenia (ISoS) • It involves 18 research centers in 14 countries, traced 75% of cases assessed in the earlier WHO studies. • It includes cohort from IPSS as well as additional cohort from China, Hong Kong, and India.
Schizophrenia outcome
ISoS summary • 57% patients had experienced a total of less than 9 months of active psychosis, only 22% had been psychotic for 45-60 months.
Outcome of First Episode Schizophrenia 1981 • 15 yr follow-up of FES (Netherlands site DOSMeD study) (Wiersma et al, 1998) • 43% relapsed in 1 yr, 70% by 5 yrs • 11% committed suicide • 26.7% Completely remitted • 50.1 % Partial remission • 11.0% Chronic psychosis • 9/82 chronically psychotic from first episode
Risks for poor recovery • Period of time spent psychotic in first 2 yrs predicted • poor outcome • Younger age • Substance abuse • Blunted affect • Loss of social network • Family involvement
Factors influencing the variation in outcome • Due to additive or interactive effect of genetic difference between populations. • Ethnopsychiatrist Henry Murphy: proposed four criteria for schizophrenia evoking stress- – A situation demanding action or decision – Complexity or ambiguity of the information supplied to deal with the task – Unless resolved the situation demanding action or decision. – The person has no escape route available.
Risk factors for the persistence of schizophrenia • There is strong evidence that child hood cognitive ability is associated with outcome. • Lower intelligence has been shown to predict unfavorable clinical and functional outcomes at follow-up. • Subtle social premorbid adjustment to be associated with less remitting course and poorer functional outcome.
Factors predicting poor outcome Features of the illness • Insidious onset • Long first episode • Previous psychiatric history • Negative symptoms • Younger age at onset Features of the patient • Male • Single, separated, widowed, or divorced • Poor psychosexual adjustment • Abnormal previous personality • Poor employment record • Social isolation • Poor compliance
Natural course of schizophrenia before the neuroleptic era • Study from urban communities in Scotland and India (padmavati et al. 1998) and rural community in China. • Outcome of these sample were hetrogeneous but except for larger proportion of Chinese patients having marked psychotic symptoms. They did not differ much from the outcome from the treated group.
Variation in the outcome in schizophrenia • Systemic investigation in to the course and outcome of schizophrenia were initiated by Kraepelin. • In a historical study of 70 Swedish patients with first admission in 1925, life time records were retrieved and rediagnosed in accordance with DSM-III. None of these patients received neuroleptics. The final outcome was rated as good in 33%, as profoundly deteriorated in 43%, and as intermediate in 24%.
Secular trend In outcome of schizophrenia • A meta-analysis of 320 outcome studies on schizophrenia published between 1895 to 1992, which comprise a total of 51,800 subjects. • Overall about 40% of the patients have been described as improvement after an average length of follow-up 5.6 years. • There was a significant increased in the rate of improvement during 1956-1985 compared to 1895-1955, clearly related to introduction of neuroleptic treatment.
Cognitive dysfunction in schizophrenia • Cognitive dysfunction in areas of: – Attention and concentration – Memory – Planning and executive functions • Important in the determination of long term outcome and social functioning (Green, 1996; Green et al, 2000) • Cognitive remediation strategies
Relationship of Neurocognitive Impairment to Functioning • The three types of functional outcome that most studies of neurocognitive deficits have examined are community (social and occupational) outcome, the ability to solve simulations of interpersonal interactions, and success in psychosocial rehabilitation programs.
• A meta-analysis of 26 randomized clinical trials involving a total of 1,151 patients concluded that neurocognitive remediation produces moderate improvements in neurocognitive performance and, when combined with psychiatric rehabilitation, also improves functional outcomes • Working memory has been described by various authors as a core component of the neurocognitive impairment in schizophrenia and is related to functional outcomes such as employment status and job tenure
Role of imaging in outcome • Poorer outcome was associated with post onset brain changes in patients diagnosed with a first-episode schizophrenia • more pronounced brain changes appear to be associated with poor outcome, more negative symptoms, and poor performance on neurocognitive measures, although the latter are more equivocal.
Prognostic factor Good prognosis Poor prognosis Late age of onset Young onset Obvious precipitating factors No precipitating factors Acute onset Insidious onset Good premorbid, social, sexual and work study Poor premorbid, social, sexual, and work history Mood disorder symptoms Withdrawn, autistic behavior Married Single, divorced, or widowed Family history of mood disorder Family history of schizophrenia Good support system Poor support system Positive symptoms Negative symptoms Neurological sign and symptoms H/O perinatal trauma No remission in 3 years , many relapses
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Schizophrenia outcome

  • 1. Long term outcome and prognosis in schizophrenia Manjeet Singh
  • 2. History • In the pre-kraeplelinian era secondry dementia was considered the outcome of most psychoses now diagnosed as schizophrenia. • Kraepelin pointed out that the deficiency was more in the field of emotion and volition, less in that of judgement or memory. • In bleuler’s view the disturbance of intelligence could not be adequately described as dementia.
  • 3. History • In 1903 Kraepelin noticed that the basic form of dementia praecox and manic depressive insanity in the Javanese were essentially the same as in Europe. • In a 1953 monograph published by the WHO, John Carothers claimed that the paucity of structural delusional content and lack of systematization of delusion in the African could be explained by congenital underdevelopment of frontal lobe of brain.
  • 4. Outcome • Short term - < 2 years follow-up. • Mid term - 2-5 year follow-up. • Long term - >5 years follow-up
  • 5. Dimensions of outcome • Outcome is a multidimensional construct that a minimum requires description of domains for: 1. Clinical (symptoms and treatment). 2. Psychosocial function.
  • 6. Functional outcome domains • Social • Occupational • Independent living • Rehabilitation success • Substance abuse
  • 7. Terminology of outcome • Define outcome in terms of: 1. Response 2. Remission 3. Recovery 4. Relapse
  • 8. Response • Response is some relief of symptoms and some improvement in functioning. The term ‘response’ implies that this improvement arises from treatment, usually because it is associated in time with that treatment.
  • 9. Remission • Remission is a period of complete relief of symptoms and a return of full functioning, which may be brief. • Remission criteria define remission as a low- mild symptom intensity level, where such absent, borderline, or mild symptoms do not influence an individual’s behavior. * *Liberman RP, Kopelowicz A, Venture J, Gutkind D: Operational criteria and factors related to recovery from schizophrenia. Int Rev Psychiatry 2002; 14:256–272
  • 10. Recovery • “Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her potential.” Or • Is a period of complete relief of symptoms and a return of full functioning, which is likely to be longer term.
  • 11. Relapse • Is the return of symptoms, satisfying the diagnostic criteria for the disorder, after a patient has either responded or remitted, but before recovery. • According to Johnstone, relapse could also be defined as Type I, the reappearance of schizophrenic symptoms in a patient who has been free of them following the initial episode, and Type II, the exacerbation of persistent positive symptoms*. *Johnstone EC. Relapse in schizophrenia: what are the major issues? In: Hawton K, editor. Practical problems in clinical psychiatry. Oxford: Oxford University Press; 1992;159-71.
  • 12. Recurrence • Recurrence is the return of symptoms, satisfying the diagnostic criteria for the disorder, after the patient has recovered.
  • 13. Need for follow-up study • To know natural history of disease. • Course of disease. • Outcome of disease. • Cultural variation of disease course and outcome. • Effect of drugs on disease progression.
  • 14. List of selected course and outcome studies in schizophrenia 1972-2005 Author Country Sample size Length of F/U Proportion good outcome Bleuler (1972) Switzerland 208 23 20% remission , 33% mild defect Tsung et al. (1979) USA 186 35 46% recovered or improve significantly Ciompi (1980) Switzerland 289 37 20% recovered, 43% definitely improved Huber et al. (1980) Germany 502 22 26% recovered 31% remission with mild defect Harding et al. (1987) USA 118 32 62% recovered or improved significantly Ogawa et al. (1987) Japan 140 21-27 31% recovered, 46% improved
  • 15. Author Country Sample size Length of F/U Proportion good outcome Shepherd et al. (1989) UK 107 5 22% rcovered, no relapse Johnstone et al. (1990) UK 530 3-13 14% excellent, 18.5% very good social adjustment Caron et al. (1991) USA 79 5 17% complete remission Marneros et al. (1992) Germany 249 25 Full remission in 24% (broad), 7% pure schizo. Thara et al. (1994) India 90 (1st onset) 10 12% complete recovery, 62% remission Mason et al. (1995) UK 67 13 17% complete recovery, 52% remission Wieselgren & Lindstrom (1996) Sweden 120 5 30% good outcome Wiersma et al. (1998) Holland 82 15 27% complete, 50% partial remission
  • 16. Author Country Sample size Length of F/U Proportion good outcome Ganev et al. (1998) Bulgaria 60 16 32% complete, 5% partial remission Gureje & Bamidele (1999) Nigeria 120 13 22% unimpaired 19% some impairment Finnerty et al. (2002) Ireland 67 (1st onset) 15 35% complete remission, 46% partial remission Thara (2004) India 90 (1st onset) 20 6% complete recovery, 15% clinically stable Lauronon et al. (2005) Finland 91 (birth cohart members) To age 31 yr 4% complete recovery, 3% partial remission
  • 17. Indian study author Outcome Clinical Social, occupational Johnson S et al/ 2012/ vellore India 68% remitted, 24% had at least one additional psychotic episode Median WHO-DAS score 8 Srivastava A et al /2009/ Mumbai India 100% had PANSS positive score <21, 88% had PANSS negative score <21 61.7% had GAF > 80 Suresh et al/ 2012/ rural Karnataka India N/A 60% of patient had mild/no disability in work Verghese A et al/ 1989/ Chennai, Vellore, Lucknow India (SOFACOS) 64% in remission, 6% continuous psychosis, 30% other 61% occupational impairment PANSS - Positive and Negative Syndrome Scale GAF - Global Assessment of Function SOFACOS- Study Of Factors Associated With Course and Outcome of Schizophrenia WHODAS, WHO- Disability Assessment Schedule;
  • 18. The evidence from recent systemic reviews generally support the following conclusion 1. The course of schizophrenia is highly variable both with in patient and between patients. 2. Less then half of patients diagnosed as schizophrenia show substantial clinical improvement after follow-up time averaging 6 years. 3. Examining trend in course and outcome over the past century revealed substantial gains in favorable outcome from the 1920 – 1970 after which time gradient seems to be reversed.
  • 19. 4. Course of descriptors varies as a function of the length of follow-up. 5. On average patient with diagnosis of schizophrenia has the poorest outcome. 6. Course and outcome estimates vary depending on the diagnostic classification used. 7. There is no reliable set of predictors yet identified for course and outcome.
  • 20. Methodological heterogeneity • Variation in population from which patient are selected. • Variation in diagnostic criteria. • Variation in length of illness before entry in to follow-up. • Variability of attrition rate.
  • 21. • Variation in methods used to assess course and outcome. • Variation in the characteristics of the general population. • Variation in statistical techniques and adjustment of confounding. • Variation in long term management of schizophrenia.
  • 22. WHO description of clinical symptoms course and outcome 1. Single psychotic episode followed by complete remission. 2. Single psychotic episode followed by incomplete remission. 3. Two or more psychotic episode with complete remission between episodes. 4. Two or more episodes with incomplete remission between episodes. 5. Continuous (unremitting) chronic psychosis.
  • 23. International study • WHO Ten Country Study. (short term) • International Pilot study on Schizophrenia.(IPSS) • International study of schizophrenia (ISoS) • The study on determinants of outcome of severe mental disorders.(DOSMeD)
  • 24. IPSS • IPSS began in 1966 as a large scale cross- cultural collaborative project carried out simultaneously in nine countries that differ widely in their sociocultural and economic characteristics.
  • 25. Centre for IPSS Country Centre Arthus Denmark Agra India Cali Columbia Ibadan Nigeria London England Moscow U.S.S.R. Taipei China Washington U.S.A. Prague Czechoslovakia
  • 26. IPSS • In IPSS total 1202 patient has been taken. Out of which 811 received a clinical diagnosis of schizophrenia, 164 affective psychoses, 102 other psychoses. Method – The IPSS was carried out in three phases, a preliminary phase, an initial evaluation phse and a follow up phase. And all the patient interviewed by using “present state examination”
  • 27. Outcome in IPSS • IPSS found that higher proportion of patients in India, Colombia, and Nigeria had better outcomes on most dimensions than patients in developed countries. • Complete remission of the initial psychiotic episode within 5 years had occurred in as many as 42% of patients in India 33% of patients in Nigeria, whereas the majority of patients in the developed countries had experienced persistent psychotic symptoms.
  • 28. International study of schizophrenia (ISoS) • It involves 18 research centers in 14 countries, traced 75% of cases assessed in the earlier WHO studies. • It includes cohort from IPSS as well as additional cohort from China, Hong Kong, and India.
  • 30. ISoS summary • 57% patients had experienced a total of less than 9 months of active psychosis, only 22% had been psychotic for 45-60 months.
  • 31. Outcome of First Episode Schizophrenia 1981 • 15 yr follow-up of FES (Netherlands site DOSMeD study) (Wiersma et al, 1998) • 43% relapsed in 1 yr, 70% by 5 yrs • 11% committed suicide • 26.7% Completely remitted • 50.1 % Partial remission • 11.0% Chronic psychosis • 9/82 chronically psychotic from first episode
  • 32. Risks for poor recovery • Period of time spent psychotic in first 2 yrs predicted • poor outcome • Younger age • Substance abuse • Blunted affect • Loss of social network • Family involvement
  • 33. Factors influencing the variation in outcome • Due to additive or interactive effect of genetic difference between populations. • Ethnopsychiatrist Henry Murphy: proposed four criteria for schizophrenia evoking stress- – A situation demanding action or decision – Complexity or ambiguity of the information supplied to deal with the task – Unless resolved the situation demanding action or decision. – The person has no escape route available.
  • 34. Risk factors for the persistence of schizophrenia • There is strong evidence that child hood cognitive ability is associated with outcome. • Lower intelligence has been shown to predict unfavorable clinical and functional outcomes at follow-up. • Subtle social premorbid adjustment to be associated with less remitting course and poorer functional outcome.
  • 35. Factors predicting poor outcome Features of the illness • Insidious onset • Long first episode • Previous psychiatric history • Negative symptoms • Younger age at onset Features of the patient • Male • Single, separated, widowed, or divorced • Poor psychosexual adjustment • Abnormal previous personality • Poor employment record • Social isolation • Poor compliance
  • 36. Natural course of schizophrenia before the neuroleptic era • Study from urban communities in Scotland and India (padmavati et al. 1998) and rural community in China. • Outcome of these sample were hetrogeneous but except for larger proportion of Chinese patients having marked psychotic symptoms. They did not differ much from the outcome from the treated group.
  • 37. Variation in the outcome in schizophrenia • Systemic investigation in to the course and outcome of schizophrenia were initiated by Kraepelin. • In a historical study of 70 Swedish patients with first admission in 1925, life time records were retrieved and rediagnosed in accordance with DSM-III. None of these patients received neuroleptics. The final outcome was rated as good in 33%, as profoundly deteriorated in 43%, and as intermediate in 24%.
  • 38. Secular trend In outcome of schizophrenia • A meta-analysis of 320 outcome studies on schizophrenia published between 1895 to 1992, which comprise a total of 51,800 subjects. • Overall about 40% of the patients have been described as improvement after an average length of follow-up 5.6 years. • There was a significant increased in the rate of improvement during 1956-1985 compared to 1895-1955, clearly related to introduction of neuroleptic treatment.
  • 39. Cognitive dysfunction in schizophrenia • Cognitive dysfunction in areas of: – Attention and concentration – Memory – Planning and executive functions • Important in the determination of long term outcome and social functioning (Green, 1996; Green et al, 2000) • Cognitive remediation strategies
  • 40. Relationship of Neurocognitive Impairment to Functioning • The three types of functional outcome that most studies of neurocognitive deficits have examined are community (social and occupational) outcome, the ability to solve simulations of interpersonal interactions, and success in psychosocial rehabilitation programs.
  • 41. • A meta-analysis of 26 randomized clinical trials involving a total of 1,151 patients concluded that neurocognitive remediation produces moderate improvements in neurocognitive performance and, when combined with psychiatric rehabilitation, also improves functional outcomes • Working memory has been described by various authors as a core component of the neurocognitive impairment in schizophrenia and is related to functional outcomes such as employment status and job tenure
  • 42. Role of imaging in outcome • Poorer outcome was associated with post onset brain changes in patients diagnosed with a first-episode schizophrenia • more pronounced brain changes appear to be associated with poor outcome, more negative symptoms, and poor performance on neurocognitive measures, although the latter are more equivocal.
  • 43. Prognostic factor Good prognosis Poor prognosis Late age of onset Young onset Obvious precipitating factors No precipitating factors Acute onset Insidious onset Good premorbid, social, sexual and work study Poor premorbid, social, sexual, and work history Mood disorder symptoms Withdrawn, autistic behavior Married Single, divorced, or widowed Family history of mood disorder Family history of schizophrenia Good support system Poor support system Positive symptoms Negative symptoms Neurological sign and symptoms H/O perinatal trauma No remission in 3 years , many relapses