Clinical outcomes in schizophrenia patients during first years of diagnosis, a cohort study

Introduction: The first years after the diagnosis of schizophrenia are crucial for the establishment of parameters involved in the outcome and long term remission. It is a risk period involving hazards like withdrawal from the general health system, relapses and suicide. This period also concurs with major challenges in development: stable identity, pair’s network, vocational training and intimate relationships.
Methods: Observational study of a cohort of 50 patients with a recent diagnosis of schizophrenia (within five years of baseline visit), followed up during at least three years and up to five years, with periodic evaluations every three months. No changes were made in therapeutic schemes. This registry had the objective to describe the clinical outcomes in this particular group of patients: relapses, total or partial hospitalizations, days free of symptoms; and to suggest possible factors related to that evolution.
Diagnosis was confirmed with M.I.N.I. interview; during follow up we evaluate: Severity of symptoms (with Clinical Global Impression – CGI); degree of functioning (through Global Assessment of Functioning – GAF, and Personal and Social Performance Scale – PSP), satisfaction and adherence to treatment, and health resources utilization.
A written informed consent was taken before the entry into the registry.
The data set was analyzed in Stata version 11.
Results: Most patients were men, single with secondary school grades. Details of demographic characteristic are described in table 1.
80% of patients experienced prodromal symptoms with a median duration of 426 days (interquartile range – IR 90–914)
Patients expended a median of 423 days since the beginning of psychotic symptoms (IR 77–823), before the schizophrenia diagnosis were made.
Before entering to the cohort the patients had experienced a median of 2 psychotic episodes (IR 2–4), and 2 psychiatric hospitalizations (IR 2–4). The rate of substance use observed was 36% (Graphic 1).
Most patients (96%) were treated with atypical antipsychotic, 16% were in treatment with depot medication, 64% of patients were receiving concomitant medications, and only 8% of patients were receiving non pharmacological treatment.
Satisfaction with medication was negative in 10%, neutral in 20% and positive in most patients (70%). Adherence was described by patient and relatives as high (mean 89%).
According to CGI-S scores most patients were rated as mild to without clinical compromise; However they exhibited mild to moderate compromise in functioning as median values of PSP were 55 (IR 45–60) and GAF 55 (IR 50–65), with a small improvement during the first years and a slow decline throughout the follow up (Graphic 2).
During the first 5 year after the diagnosis most patients (86%) experienced at least one relapse of psychotic symptoms (Graphic 3), most patients with a relapse required hospitalization to manage their symptoms. A higher proportion of relapses and hospitalizations was found in patients with comorbid substance abuse (Graphic 4).
Patients expended an average of 229 days with psychotic symptoms during the follow up. 3 patients attempted against their lives and 2 committed suicide.
Discussion: There were a higher proportion of males, which could not reflect exactly the whole spectrum of this population. It is noticeable the long period of time the patient spends with prodromal and psychotic symptoms before the diagnosis was made, especially regarding the known impact of the duration of untreated psychosis in the final outcome of patients. The evolution of functioning impairment found in patients suggests that, in spite of the actual compromise, during the first five years there is still no marked deterioration, opening the opportunity to implement rehabilitation interventions.
There is a strong association between schizophrenia and cannabis, the rate of substance use observed in our cohort was 36%, higher than general population and similar to previous descriptions on literature.
Most patients with schizophrenia will have at least one relapse within the first five years, in our sample 86% relapsed within the first five years, following the described trend.