Year : 2019 | Volume
: 61 | Issue : 6 | Page : 547--548
Recovery in schizophrenia: Nihilism must give way to optimism
Om Prakash Singh
Professor of Psychiatry, WBMES and Consultant Psychiatrist, AMRI Hospitals, Kolkata, West Bengal, India
Prof. Om Prakash Singh
AA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata, West Bengal - 700 094
|How to cite this article:|
Singh OP. Recovery in schizophrenia: Nihilism must give way to optimism.Indian J Psychiatry 2019;61:547-548
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Singh OP. Recovery in schizophrenia: Nihilism must give way to optimism. Indian J Psychiatry [serial online] 2019 [cited 2019 Nov 21 ];61:547-548
Available from: http://www.indianjpsychiatry.org/text.asp?2019/61/6/547/270347
Recovery in schizophrenia seems to be an oxymoron for most mental health professionals and caregivers. Whenever someone is diagnosed with schizophrenia, it sounds akin to a life sentence for him/her and his/her family members. Physicians as well as psychiatrists think in terms of keeping the patient's psychotic symptoms under control, or, at the most, asymptomatic. Remission of symptoms becomes the ultimate treatment goal. We need to probe the reason behind so much nihilism. The early definitions of schizophrenia seem to pervade our consciousness and affect our judgment regarding the course and outcome.
Kreapelin described dementia praecox as a chronic deteriorating illness from which a patient could not fully recover and reach premorbid level of functioning; so much so that if recovery occurred, the diagnosis of schizophrenia became questionable. Bleuler described a group of schizophrenias with ambivalence, autism, disturbances of affect, and association (4 As) as primary diagnostic features. If we classify this group by the current diagnostic systems, it will be largely consisting of patients with predominantly negative schizophrenia, which is known to have a poor prognosis.
But why are we talking of recovery now? It is mainly due to consumer movements which are emphasizing that recovery is possible in schizophrenia based on narratives of patients who have indeed recovered. They are now demanding that mental health professionals should start talking about recovery. However, there are different concepts of recovery which may be subjective or objective.
Mental health recovery is a journey of healing and transformation enabling a person with mental disability to live a meaningful life in the community of his or her choice when striving to achieve his or her full potential. This definition, though useful, is difficult to measure and use in research. Harding et al. have defined recovery as a symptom-free state when the patient is not taking any drug and his social life is indistinguishable from any neighbor holding a job. Liberman et al. defined recovery as Brief Psychiatric Rating Scale score <4 for both positive and negative items. The person should be holding a job or attending school half the time. He/she should be able to manage funds and medication independently. He/she should socialize at least weekly for last 2 years. Torgalsboen and Rund (2002) put forth the criteria for recovery as no hospitalization for 5 years and Global Assessment of Functioning (GAF) score of 65. Whitehorn (2002) proposed Positive And Negative Syndrome Scale for Schizophrenia score of <4 and GAF score of more than 50 maintained for last 2 years.
Recent research on course and outcome of schizophrenia has also pointed to positive outcome. In a study in Norway, Torgalsboen and Rund found that 55% of patients have recovered. Studies from non-Western countries have consistently reported higher percentage of recovery. The World Health Organization-sponsored International Pilot Study of Schizophrenia had clearly shown that schizophrenia has better outcome in economically disadvantaged countries than industrialized nations. Kua et al. found two-thirds of their patients had good or fair outcome at 20 years. An Indian study by Thara in Madras found that only 5 out of 61 patients who followed up over 20 years had been continuously ill. 76% of men in the study were in employment. A meta-analysis, published by Harding et al. of over 1300 patients from five different studies that were followed for at least 20 years, indicated that one-half to two-thirds of the patients studied achieved recovery fully or showed significant improvement by the end of the observation interval.
Nihilism persists despite emerging research evidence to the contrary. Most of the studies on course and outcome of schizophrenia have been carried out on patients who have undergone repeated hospitalization. This obviously implies that such patients have illness of greater severity and poorer prognosis in comparison to patients being managed in the community on an outpatient basis. Moreover, schizophrenia diagnosed by the International Statistical Classification of Diseases 10 and Diagnostic and Statistical Manual of Mental Disorders 5 may not be a singular entity and probably a heterogeneous construct. These subgroups may have different trajectories to recovery. Unfortunately, still most clinicians conceptualize them as unitary illness with uniformly poor prognosis.
While dealing with a case of schizophrenia, we should provide an optimistic outlook when discussing the course and outcome with a goal toward recovery. Some of the targets could be reduction of DUP (duration of untreated psychosis), which is associated with poorer outcome, trying to identify treatment resistance early and using all available resources including psychosocial treatment, assisted employment, and pharmacogenomics to improve the treatment outcome and promote recovery. We must offer hope and optimism to the patients and their caregivers that recovery is not only probable but also possible and drive away nihilism.
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