Schizophrenia Research, 1 (1988) 339-349 Elsevier SRS 00033 Outcome of schizophrenia in India using various diagnostic systems Parmanand Kulhara’ and Kishore Chandiramani2 1 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh. India. and ‘Department of Psychiatry, R.N.7: Medical College, Udaipur, Rajasthan. India (Received 11 February 1988, revised received 17 May 1988, accepted 17 May 1988) A group of 112 patients diagnosed to be suffering from schizophrenia according to ICD-9 concept of this disorder were followed-up for a period of 18-30 months. Five diagnostic systems for schizophrenia: CATEGO, Research Diagnostic Criteria, Feighner’s Criteria, DSM-III and Schneider’s First Rank Symptoms were also applied to the study group at the beginning of the investigation. The outcome was assessed in the areas of clinical improvement, course, severity of illness and work. The course of the disorder and outcome in various definitions did not reveal significant variability though patients diagnosed to be schizophrenics according to DSM-III tended to display more psychopathology and impaired work efficiency at the time of follow-up. Key words: Outcome; Course INTRODUCTION Since the studies by Kraepelin (1950) and Bleuler (1950), schizophrenia is generally regarded as an illness with poor outcome. There have been numer- ous follow-up studies which have attempted to elucidate the nature of outcome and course of schizophrenia (Langfeldt, 1956; Vaillant, 1962, 1964; Stephens and Astrup, 1963; Brown et al., 1966; Stephens et al., 1966; Achte, 1967). The study of Murphy and Raman (1971) pointed to a rela- tively better outcome of schizophrenia in patients from the Third World, an observation which has since been confirmed by other investigations (WHO, 1979; Sartorius et al., 1986) though one study from India (Kulhara and Wig, 1978) failed to replicate the findings of Murphy and Raman (1971). Correspondence to: P. Kulhara, Postgraduate Institute of Medical Education and Research, Chandigarh-160012, India. Most of the studies cited above were conducted in an era devoid of operationalized definitions and empirically tested diagnostic systems for the diag- nosis of schizophrenia. With the popularization of research diagnostic criteria for this disorder (Schneider, 1959; Feighner et al., 1972; Wing et al., 1974; Spitzer et al., 1978; APA, 1980), many resear- chers have carried out investigations to ascertain the influence and contribution of various defi- nitions of schizophrenia on its course and outcome. Research interest in the areas of validation of diagnostic systems for schizophrenia, comparison of various definitions of schizophrenia and evalu- ation of relationship between diagnostic criteria and outcome began to emerge after the studies of Robins and Guze (1970) and Feighner et al. (1972). Utilizing the case material of the International Pilot Study of Schizophrenia (IPSS) (WHO, 1973), Strauss and Carpenter (1974) and Hawk et al. (1975) compared outcome in various definitions of schizophrenia. The finding that outcome scores in four areas of functioning did not differ sig- nificantly in three diagnostic systems studied 0920-9964/88/$03.50 0 1988 Elsevier Science Publishers B.V. (Biomedical Division)
Transcript
Schizophrenia Research, 1 (1988) 339-349 Elsevier
SRS 00033
Outcome of schizophrenia in India using various diagnostic systems
Parmanand Kulhara’ and Kishore Chandiramani2
1 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh. India. and ‘Department of Psychiatry, R.N.7: Medical College, Udaipur, Rajasthan. India
(Received 11 February 1988, revised received 17 May 1988, accepted 17 May 1988)
A group of 112 patients diagnosed to be suffering from schizophrenia according to ICD-9 concept of this disorder were followed-up for a period of 18-30 months. Five diagnostic systems for schizophrenia: CATEGO, Research Diagnostic Criteria, Feighner’s Criteria, DSM-III and Schneider’s First Rank Symptoms were also applied to the study group at the beginning of the investigation. The outcome was assessed in the areas of clinical improvement, course, severity of illness and work. The course of the disorder and outcome in various definitions did not reveal significant variability though patients diagnosed to be schizophrenics according to DSM-III tended to display more psychopathology and impaired work efficiency at the time of follow-up.
Key words: Outcome; Course
INTRODUCTION
Since the studies by Kraepelin (1950) and Bleuler (1950), schizophrenia is generally regarded as an illness with poor outcome. There have been numer- ous follow-up studies which have attempted to elucidate the nature of outcome and course of schizophrenia (Langfeldt, 1956; Vaillant, 1962, 1964; Stephens and Astrup, 1963; Brown et al., 1966; Stephens et al., 1966; Achte, 1967). The study of Murphy and Raman (1971) pointed to a rela- tively better outcome of schizophrenia in patients from the Third World, an observation which has since been confirmed by other investigations (WHO, 1979; Sartorius et al., 1986) though one study from India (Kulhara and Wig, 1978) failed to replicate the findings of Murphy and Raman (1971).
Correspondence to: P. Kulhara, Postgraduate Institute of
Medical Education and Research, Chandigarh-160012, India.
Most of the studies cited above were conducted in an era devoid of operationalized definitions and empirically tested diagnostic systems for the diag- nosis of schizophrenia. With the popularization of research diagnostic criteria for this disorder (Schneider, 1959; Feighner et al., 1972; Wing et al., 1974; Spitzer et al., 1978; APA, 1980), many resear- chers have carried out investigations to ascertain the influence and contribution of various defi- nitions of schizophrenia on its course and outcome. Research interest in the areas of validation of diagnostic systems for schizophrenia, comparison of various definitions of schizophrenia and evalu- ation of relationship between diagnostic criteria and outcome began to emerge after the studies of Robins and Guze (1970) and Feighner et al. (1972).
Utilizing the case material of the International Pilot Study of Schizophrenia (IPSS) (WHO, 1973), Strauss and Carpenter (1974) and Hawk et al. (1975) compared outcome in various definitions of schizophrenia. The finding that outcome scores in four areas of functioning did not differ sig- nificantly in three diagnostic systems studied
prompted Strauss and Carpenter (1974) to put forward the view that symptom criteria alone cannot account for a poor outcome concept of schizophrenia. Similarly, Hawk et al. (1975) also failed to demonstrate significant variability in out- come in patients diagnosed as schizophrenics ac- cording to the definitions of Langfeldt (1937) Schneider (1959) and Carpenter et al. (1973). Hawk et al. (1975) felt that the ability of characteristic symptoms to define schizophrenia with a deteri- orating course had been greatly overestimated. In a subsequent study, Strauss and Carpenter (1977) described a 5 year follow-up of the Washington cohort of IPSS patients and demonstrated that Schneiderian First Rank Symptoms (FRS) and CATEGO criteria (Wing et al., 1974) were poor predictors of outcome thus lending further support to earlier studies.
From the United Kingdom, Brockington et al. (1978) and Kendell et al. (1979) have conducted studies in which the influence of various definitions of schizophrenia on its course and outcome has been examined. On comparing ten definitions of schizophrenia, Brockington et al. (1978) found that the definition of Feighner et al. (1972) was too restrictive and that Schneiderian FRS were poor predictors of clinical and social recovery. Prognos- tic implications of six definitions of schizophrenia were investigated by Kendell et al. (1979). These workers found that in all of the test definitions of schizophrenia more than 50% of schizophrenic patients did not recover from the index episode. Kendell et al. (1979) concluded that all six defi- nitions were more successful at predicting a poor symptomatic outcome than a poor social outcome. CATEGO criteria and Schneider’s FRS were found to be least impressive in predicting prognosis.
Introduction of DSM-III (APA, 1980) provided new vistas for research in this area. Helzer et al. (1981) compared predictive validity of DSM-III and Feighner’s definitions of schizophrenia with Research Diagnostic Criteria (RDC) of Spitzer et al. (1978) and CATEGO (Wing et al., 1974) criteria of schizophrenia and found that patients meeting DSM-III and Feighner’s definitions had more severe ratings of defect symptoms than the latter two definitions. The outcome data of Helzer et al. (1981) show that though schizophrenic patients satisfying test definitions had significantly different outcome than the series as a whole, no significant
differences were discernible in comparison among various test definitions. However, the authors noted significant difference between DSM-III schizophrenia and DSM-III schizophreniform dis- orders in general outcome measures. Helzer et al. (1981) also confirmed the observations of Morrison et al. (1972, 1973) and Tsuang et al. (1979) that Feighner’s definition of schizophrenia was the best predictor of outcome and that the diagnosis of schizophrenia according to Feighner’s criteria was more stable. To counter the views that the chroni- city of schizophrenia in DSM-III and Feighner’s definitions was due to a ‘6 month duration cri- terion’, Helzer et al. (1983) conducted another in- vestigation in which this variable was controlled. These workers observed that despite controlling for
this variable, outcome was still worse for DSM-III and Feighner’s schizophrenics. Helzer et al. (1983) concluded that though the ‘6 month duration criterion’ is an important component of these definitions, it is not the sole reason for the predic- tive power of these definitions.
Whether, subtyping of schizophrenia according to various diagnostic systems for schizophrenia affects the outcome was the subject of the study of Kendler et al. (1984). These investigators studied 187 schizophrenic patients fulfilling Feighner’s criteria for the diagnosis of schizophrenia and subtyped them according to ICD-9 (WHO, 1978) DSM-III (APA, 1980) RDC (Spitzer et al., 1978) and Tsuang and Winokur (1974) criteria. It was observed that the paranoid subtype by all defi- nitions had better outcome. Importance of subtyp- ing in predictive validity was stressed by these authors (Kendler et al., 1984). Predictive validity of four diagnostic systems was tested by McGlashan (1984) and it was shown that outcome in schizo- phrenics as identified by the systems studied was significantly poorer than non-criterion schizo- phrenic patients. McGlashan (1984) also noted that Feighner’s schizophrenia had the worst outcome whilst RDC and DSM-III schizophrenics had rela- tively better outcome. These data, however, were not subjected to statistical comparison because of overlap in the diagnostic systems.
The foregoing review permits formulation of few tentative conclusions. Firstly, it is clear that certain characteristic symptoms and cross-sectional phenomenology of schizophrenia are poor indi- cators of outcome, a point which has been cogently
put forward by Pope and Lipinsky (1978). Sec- ondly, outcome in criterion schizophrenics, i.e., schizophrenics satisfying any of the diagnostic defi- nitions, has been shown to be poor. Thirdly, DSM- III and Feighner’s definitions of schizophrenia have greater stability and predictive power. Lastly, the role played by socio-demographic variables in- corporated in some of the diagnostic systems in influencing outcome has not been accorded due significance.
From the Indian subcontinent, no research re- port is available which describes the course and outcome of schizophrenia in various definitions of this disorder. This singular but significant lack of information encouraged us to undertake the pres- ent investigation. In one of our earlier works
(Kulhara et al., 1986), cross-sectional concordance of five diagnostic systems for schizophrenia with each other and with an index diagnosis of schizo- phrenia according to ICD-9 (WHO, 1978) have been presented. The same cohort of patients was followed-up for 18-30 months and the outcome and course were determined. Our aim has been to study whether or not the outcome and course of schizophrenic disorder in various definitions of schizophrenia are similar.
MATERIALS AND METHODS
The location of the study, the method of patient selection and the procedure adopted for categoriz- ing patients in various test definitions have been described in detail in an earlier communication (Kulhara et al., 1986). Therefore, only a brief description of the methodology at intake is pro- vided here.
Consultant colleagues were requested to refer to the research team patients with a clinical diagnosis of schizophrenia. The research team evaluated the patients and formulated the diagnosis of schizo- phrenia using the following systems: (1) CATEGO class S+ of Wing et al. (1974); (2) Research Diag- nostic Criteria (RDC) of Spitzer et al. (1978); (3) Schneider’s First Rank Symptoms (FRS) (Schneider, 1959); (4) Criteria of Feighner et al. (1972); and (5) DSM-III (APA, 1980). The rationale for selecting these systems for the diagnosis of schizophrenia has been provided by us in an earlier
341
work (Kulhara et al., 1986). Of the many available definitions of schizophrenia, these five systems were selected by us because of their widespread use in research pertaining to schizophrenia in India and the West. Diagnosis according to ICD-9 (WHO, 1978) was the index diagnosis.
The duration of follow-up ranged from 18 to 30 months at which point in time the patients were reassessed using Present State Examination (PSE) (Wing et al., 1974) and the Brief Psychiatric Rating Scale (BPRS) (Overall and Gorham, 1962). The patients were assessed along with reliable infor- mants. Some of the assessments were carried out by undertaking home visits. In some cases, inform- ation about the follow-up status of the patient was obtained through correspondence with a close relative or next of kin.
One of us (P.K.), on the basis of PSE (Wing et al., 1974), assessed global clinical improvement and assigned the patients to one of the four outcome categories:
(1)
(2)
(3)
(4)
Very much improved: patients found to be asymptomatic or having minimal symptoms of non-psychotic nature were assigned to this category. Improved: patients found to have mild to moderate symptoms. No change: patients in whom the illness had continued unabated. Worse: patients who had deteriorated during follow-up period.
The course of the disorder was also assessed by one of us (P.K.) and the patient was assigned to one of the following categories:
(1) Improving: patients who were reported to be continually improving since initial contact.
(2) Episodic: where the course of the illness had clear remissions and relapses.
(3) Static or deteriorating: where the patient’s condition during follow-up period had either remained unchanged or had worsened.
Effect of the illness on working capacity of the patients was assessed by one of us (K.C.). Working status of the patients was classified as below:
(1) Working without any impairment: patients who had worked during the follow-up period with the same degree of efficiency as before
342
(2)
(3)
becoming ill were placed in this category. Housewives and students were judged on the basis of their efficiency in household work or academic performance. Work efficiency impaired: patients who had displayed fall in the quality and/or quantity of work, efficiency as a housewife or deterior- ation in scholastic performance. Not working: where the patient had given up work, housewife was not performing house- hold work at all or students had curtailed studies.
For assessing work performance, information was gathered both from the patient and relatives. Factors like regularity, change of jobs, time spent in work, time taken off work, quality of work, satisfac- tion of self or others with work done etc were taken into consideration while assigning a category to the patient.
On the basis of BPRS (Overall and Gorham, 1962), KC. also rated the patients on severity of psychopathology. The severity of illness at follow- up was classified as:
(1) Normal/not at all ill. (2) Borderline mentally ill. (3) Mildly ill. (4) Moderately ill. (5) Markedly ill. (6) Severely ill.
For assessing the severity of illness at follow-up K.C. used his clinical judgement as well as total score of the patient on BPRS (Overall and Gorham, 1962). Where follow-up information was obtained through correspondence, evaluations about global improvement, course and work were arrived at by consensus of both investigators.
The data were analysed by x2 test, Z test and ANOVA. x2 test was used for non-parametric variables and Z test and ANOVA were used for comparing means. For x2 test, Yates correction for continuity was applied in all 2 x 2 tables.
RESULTS
The duration of follow-up was from 18 to 30 months (mean 22.9 months, SD 4.23 months). Of the
112 patients seen, 91 patients were followed-up and reassessed. This gives a follow-up rate of 81.2%. In 79 patients follow-up information was obtained by clinical interviews held at the clinic, nine patients were visited at their homes and in three cases information was gathered through correspondence only. Of the 91 patients followed three patients died during the follow-up period (two committed suicide and one died of pyogenic meningitis). Rest 21 could not be traced. A comparison of the follow-up and dropout groups is shown in Table 1 from where it can be seen that these two groups do not differ significantly on any of the demographic and clinical variables.
Of the three patients who died during the period of follow-up, the patient who died of meningitis was psychiatrically asymptomatic but the two who committed suicide were definitely disturbed and both of them were on regular follow-up.
Of the 91 patients studied, 43 had been attending the psychiatric clinic regularly, 26 were irregular in attending and 22 did not attend the clinic after initial contact. Similarly, 40 patients had been on either oral or long acting neuroleptic treatment all through the follow-up period, 21 were taking the prescribed treatment albeit irregularly and 30 were not on any medication for 3 months or more at the time of follow-up evaluations.
During the follow-up period four patients were admitted to a mental hospital and nine were ad- mitted/readmitted to our own psychiatric inpatient facility.
Results pertaining to assessment of global im- provement in various definitions of schizophrenia are shown in Table 2. In the index diagnosis, i.e., ICD-9 (WHO, 1978) as well as diagnosis according to CATEGO, RDC and FRS, the percentage of patients placed in ‘very much improved’ or ‘improved’ categories ranged from 65 to 69% but in the group of patients fulfilling Feighner’s criteria, or DSM-III criteria for the diagnosis of schizophrenia, the percentage of ‘very much improved or ‘improved’ patients fell to 5&55%. However, on applying the x2 test, no signifi- cant differences emerged among the various definitions.
Assessment of the course of the disorder in various definitions also showed results similar to the ones seen earlier in relation to global improve- ment. The course of the illness did not show any
343
TABLE 1
Comparison between follow up and dropout groups”
Variable
Age in years
Mean
SD
Sex
Male Female
Formal education
Up to 10 years More than 10 years
Residence
Urban
Rural
Duration of illness
Up to 6 months More than 6 months
Treatment status at intake
Treated as outpatient
Hospitalized
Family history of schizophrenia
Present
Absent
Marital status
Single Married
Severity of illness at intake
Mean
SD
Follow-up group (n = 91) Dropout group (n = 21)
28.64 28.04
8.42 9.66
52 7
39 14
42 14
49 I
63 15
28 6
36 8
55 13
48 8
43 13
25 2
66 19
38 7
53 14
5.16 4.90
0.71 0.70
‘x2 test or Z test did not reveal any significant difference.
statistically significant difference when compa- risons were made among various definitions.
Comparison of work efficiency of patients in various definitions of schizophrenia at the time of follow-up also did not reveal significant differences though relatively more patients diagnosed schizo- phrenic according to Feighner’s and DSM-III cri- teria were not working at the time of follow-up. Comparison between CATEGO S+ and DSM-III schizophrenia with regard to work at the time of follow-up almost reached statistical significance (x2 = 5.96 at df = 2). These results are shown in Table 2.
The severity of illness across various definitions and the index diagnosis, both at intake and follow- up did not show any significant variability (Table 3). Though at intake the mean BPRS scores (Over- all and Gorham, 1962) did not differ significantly
among various definitions, at follow-up, schizo- phrenics belonging to DSM-III group were found to have the highest mean BPRS score. Comparison of mean BPRS score at follow-up between ICD-9 definition patients and DSM-III criteria patients revealed significant difference (Z = 2.41, P < 0.05), indicating that patients who met DSM-III criteria had more manifest psychopathology at the time of follow-up. For the comparison of change scores, i.e., BPRS score at follow-up minus score at intake, one-way ANOVA was carried out which failed to reveal any significant difference among the various diagnostic systems. These results are shown in Table 4.
To test whether outcome depends on duration of illness prior to admittance into the study, two-way analysis of variance (ANOVA) was carried out.
344
TABLE 2
Global improvement, course and work status in various definitions at follow-up”
Work Working/no impairment 36 25 24 18 13 10 Impaired 15 11 8 7 7 5 Not working 40 26 24 18 23 29
“No significant differences observed in global improvement, course and work among various definitions (x2 test).
Mean duration of illness for the entire cohort was 30.13 months with SD of 42.18 months. For this particular analysis the outcome categories ‘no change’ and ‘worse’ were lumped together. The other two outcome classes ‘very much improved’ and ‘improved’ were retained as such. The results of
ANOVA are shown in Table 5. Three hypotheses were tested out by employing two-way ANOVA: (i) there is no interaction between duration of illness and diagnostic system in determining outcome; (ii) the effects of various diagnostic systems on out- come are the same; and (iii) the effects of different duration on outcome are the same. For the first hypothesis F 10, 321 was found to be 1.29 which is not significant. For the second hypothesis F value at df 5, 331 was 0.29 which is also not significant. For the third hypothesis F value at df 2, 331 was found to be 179.31 which is significant (Table 5). This indicates that outcome depends on the dur- ation of illness.
Outcome in various diagnostic systems accord- ing to the gender of the patients was also analysed. On applying the x2 test, no significant difference emerged (x2 = 16.00 at df 22, P > 0.05). These results are shown in Table 6.
In the sample of patients who were followed, there were 15 patients who at intake met all of the test definitions and 11 patients did not satisfy any of the test definitions for the diagnosis of schizo- phrenia at intake. Patients who satisfied one, two,
three or four definitions were 12, 17, 18 and 18 respectively. Comparison in outcome between pa- tients satisfying all definitions and none of the test definitions was attempted by reducing outcome categories to two, i.e., (i) improving, and (ii) not improving. The group of patients meeting all defi- nitions and the group meeting no test definitions did not differ significantly in outcome at follow-up (x2 with Yates correction = 2.98 at df 1, P > 0.05).
DISCUSSION
In the present investigation, 91 patients of the original cohort of 112 were followed for a period ranging from 18 to 30 months. This gave a follow- up rate of 82% which compares favourably with the follow-up rate of other published works. The follow-up and dropout groups did not differ signifi- cantly on any of the socio-demographic and clinical variables, therefore, the results of this study can be extended and generalized to the entire study cohort. However, as the sample of patients studied cannot be said to be representative of the catch- ment area population, the findings cannot be consi- dered to be representative of the catchment area population and cannot be generalized to this region of North-West India.
The present investigation has some limitations
TA
BL
E
3
Seve
rity
of
ill
ness
at
inta
ke a
nd fo
llow
-up
Seve
rity
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ICD
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R
DC
FR
S FC
D
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ll
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take
Fo
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Foll
ow-u
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take
Fo
llow
-up
Inta
ke
Foll
ow-u
p In
take
Fo
llow
-up
1. N
orm
al/N
ot
at
all
ill
30
22
20
15
10
9
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Bor
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tally
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4.
Mod
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ely
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17
11
I 6
6 6
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9 8
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5.
Mar
kedl
y ill
42
19
29
12
25
8
21
8 19
12
22
14
6.
Seve
rely
ill
32
10
26
9
25
10
18
I 15
6
17
7
TA
BL
E
4
BP
RS
scor
es a
t in
take
and
foll
ow-u
p
BP
RS
scor
es
ICD
-9
(n =
91)
C
AT
EG
O
S+
(n =
62)
RD
C
/n
= 56
1 FR
S (n
= 4
3)
FC
(n =
431
D
SM-I
II
(n =
44)
At
inta
ke
At
follo
w-u
p
Dif
fere
nceb
Mea
n SD
23.9
9.
35
13.1
6”
11.2
5
10.7
4 11
.05
Mea
n SD
25.0
4 10
.18
14.0
12
.2
11.0
4 11
.98
Mea
n SD
24.4
2 8.
33
13.8
9 12
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10.5
3 11
.87
Mea
n SD
24.7
4 9.
65
14.4
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10.3
3 11
.56
Mea
n SD
23.8
8 7.
45
14.7
6 10
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9.12
11
.00
Mea
n SD
25.6
8 7.
82
18.2
5”
11.6
8
7.43
11
.66
“Com
pari
son
betw
een
ICD
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and
DS
M-I
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at
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P <
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tical
ly
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ific
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-way
A
NO
VA
: F
(333
, 5)
=
1.73
(no
t si
gnif
ican
t).
TA
BL
E
5
Effe
ct
ofdu
rati
on
of i
llnes
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mon
ths
on o
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IAN
OV
A”)
Out
com
e IC
D-Y
(n
= 9
1)
Mea
n SD
CA
TE
GO
(n
= 6
2)
Mea
n SD
RD
C
(n =
56)
Mea
n SD
FRS
in
= 43
)
Mea
n SD
Feig
hner
’s
(n =
43)
Mea
n SD
DSM
-III
(n
= 4
4)
Mea
n SD
Ver
y m
uch
impr
oved
Impr
oved
No
chan
ge/w
orse
“AN
OV
A
tabl
e
17.4
1 36
.68
12.0
4 23
.24
6.76
8.
47
16.1
3 28
.02
26.4
1
30.0
9 26
.22
35.4
1 30
.34
45.2
1 23
.05
34.4
7 26
.55
38.5
5 26
.61
34.5
4 44
.91
51.6
8 35
.71
42.4
8 44
.22
45.8
8 56
.63
58.0
2 55
.11
50.9
7 55
.66
54.6
2 56
.94
49.0
7 61
.18
49.5
5
Sour
ce
of v
aria
tion
df
ss
ss
So
urce
of
var
iati
on
Dur
atio
n (a
djus
ted)
2
6245
32.5
7 90
346.
38
Dur
atio
n (u
nadj
uste
d)
Dia
gnos
tic
syst
em
(una
djus
ted)
5
2513
2.10
25
58.7
9 D
iagn
ostic
sy
stem
(a
djus
ted)
In
tera
ctio
n 10
22
361.
50
2236
1.50
In
tera
ctio
n
Bet
wee
n ce
lls
17
1179
66.6
8 11
7966
.68
Bet
wee
n ce
lls
With
in
cells
32
1 55
4059
.50
5540
59.5
0 W
ithin
ce
lls
Tot
al
338
6720
26.1
8 67
2026
.18
Tot
al
TA
BL
E
6
Out
com
e an
d ge
nder
oJ
the
pat
ient
x2 =
16.
00
at
df 2
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> 0
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.
Out
com
e IC
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(n
= 9
1 J
CA
TE
GO
(n
= 6
2)
RD
C
(n =
56)
FR
S (n
= 4
3)
Feig
hner
’s
(n =
43)
D
SM-I
II
(n =
44)
Mal
e Fe
mal
e M
ale
Fem
ale
Mal
e Fe
mal
e M
ale
Fem
ale
Mal
e Fe
mal
e M
ale
Fem
ale
Ver
y m
uch
impr
oved
16
18
11
12
11
10
9
6 5
7 5
4 Im
prov
ed
15
11
10
9 9
9 7
6 7
5 6
7 N
o ch
ange
/wor
se
21
10
7 10
10
7
10
5 11
8
15
7
which can compromise our findings. In the present study, no standardized instrument to assess work outcome was employed. Instead, a semistructured interview technique was adopted which very heav- ily relied on the narratives of the patients and their relatives. This could have biased the ratings. An- other drawback of the present work is that both investigators knew the patients well and were aware of their diagnosis according to various defi- nitions. This knowledge can also influence the assessment of course and outcome. Ideally, in an investigation like this, the assessor should be blind to the index diagnosis. Lastly, outcome diagnosis according to various definitions should also have been formulated which would have given an esti- mate of the stability of diagnosis and its relation- ship with course and outcome. Lack of availability of trained personnel and lack of financial support to employ such trained people were the reasons for not rating outcome blindly and formulating out- come diagnoses.
A striking finding of the present work is the uniformity in outcome for this cohort of patients across various definitions. Though outcome in the index definition, i.e., ICD-9 (WHO, 1978) and RDC (Spitzer et al., 1978) and CATEGO S+ (Wing et al., 1974) definitions appear to be relatively better than Feighner’s (1972) and DSM-III (APA, 1980) defi- nitions, the differences seen do not reach statistical significance. Because of differences in methodology adopted for evaluation of patients as well as dif- ferences in statistical procedures employed for ana- lysing data, it is not possible to compare the
findings of the present work with the findings of other workers like Strauss and Carpenter (1974) Hawk et al. (1975), Kendell et al. (1979) and Helzer et al (1981).
Another important finding of this study is good outcome at the end of follow-up with about 50-69% patients, showing symptomatic improve- ment regardless of diagnostic definition. In this respect, our findings are in agreement with the observations of the 2 year follow-up study of the IPSS (WHO, 1979) and the WHO Collaborative Study of Determinants of Outcome of Severe Mental Disorders (Sartorius et al., 1986). Com- parison of global outcome of our patients (both ICD-9 and CATEGO S+ categories of schizo- phrenia) with a recently published work by Prudo and Blum Munroe (1987) revealed better outcome
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for our patients. Thus, our work lends support to the notion of transcultural variability in the out- come of schizophrenic disorder. This study also reinforces the view that schizophrenic patients from developing countries have relatively good outcome. It has been suggested by Helzer et al. (1981) that good outcome of IPSS (WHO, 1979) schizophrenic patients from developing countries could be due to ‘bias towards ascertainment’ as well as absence of ‘duration of illness criterion’ in CATEGO defi- nition of schizophrenia. More recently, Stevens (1987) and Stevens and Wyatt (1987) have argued that contamination of patient sample by inclusion of patients with shorter duration of illness who otherwise will not be diagnosed as schizophrenics if ‘duration of illness criterion’ is employed, is the major reason for good outcome in IPSS patients from developing countries. Our observations show that irrespective of the diagnostic system, patients with good outcome have shorter duration of illness. Analysis of our data further shows that there is no significant interaction between outcome on one hand and the combination of duration of illness and diagnostic system on the other hand. It is also evident from our results that diagnosis by a parti- cular system by itself does not influence outcome.
The course of the disorder over the follow-up period also showed a reasonable degree of uniform- ity. Though patients diagnosed to have schizo- phrenia according to DSM-III and Feighner’s definitions tended to have relatively more static or deteriorating course than patients with RDC or CATEGO definitions of schizophrenia, these dif- ferences also did not reach statistical significance. The pattern of course displayed by our patients is similar to the pattern of the course of patients from Agra in the IPSS follow-up study (WHO, 1979).
Occupational status of the patients at the time of follow-up did show some variability across various definitions and this variability almost approached statistical significance. Patients satisfying DSM-III
and Feighner’s definitions of schizophrenia were occupationally more impaired than patients ful- filling RDC or CATEGO definitions. One obser- vation is certain that DSM-III patients had signifi- cantly more manifest psychopathology at the time of follow-up as measured by BPRS (Overall and Gorham, 1962). This appears to be the only link with poor work performance at follow-up in pa- tients meeting DSM-III criteria for schizophrenia.
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Acute disturbance, young age at onset and short duration of illness are traditionally considered to be predictors of good outcome in schizophrenia (Vail- lant, 1962,1964; Stephens and Astrup, 1963; Prudo and Munroe Blum, 1987). Our patients were young and nearly 40% had been ill for less than 6 months. As such, they carried better prognosis. In addition, certain socio-cultural factors prevalent in our set- ting may have augmented recovery. In the context of family interactions and outcome in schizophrenia, research of recent past indicates that schizo- phrenics living with ‘high expressed emotions’ (EE) relatives are more likely to have relapses (Vaughn and Leff, 1976; Falloon et al., 1982, 1985; Leff et al., 1982, 1985; Vaughn et al., 1984). It has been shown by Wig et al. (1987) that proportion of relatives classed as ‘high EE’ in Chandigarh, India, is signifi- cantly less compared with relatives in Aarhus, Denmark, and this has been considered by Leff et al. (1987) to be one of the major variables re- sponsible for better 1 year outcome in schizo- phrenics from Chandigarh, India. However, in the absence of comparative groups which control for certain key factors, it will be premature to conclude that a causal link exists between better outcome and expressed emotions in the present cohort.
The discrepancy between the outcome of this sample and the earlier study by Kulhara and Wig (1978) deserves comments. Methodological dif- ferences appear to be the major reason for these disparate results. The present work has followed a prospective design and has employed established criteria for diagnosis and a reliable method of mental status examination. In the earlier work by Kulhara and Wig (1978) the nature of case material was retrospective based on somewhat arbitrary diagnostic criteria and the assessment of mental status was by an eclectic clinical method. Moreover, the rate of follow-up in the two studies is different and comparison between follow-up and dropout groups is not available for the two studies.
Conclusion Despite methodological limitations, the present investigation shows that outcome does not dis- tinguish different diagnostic systems for schizo- phrenia. This perhaps implies that the course and outcome are probably not dependent on the con- ceptual framework of diagnosis, but are influenced more by clinical and background variables.
ACKNOWLEDGEMENTS
The authors are grateful to Prof. V.K. Varma, Department of Psychiatry, PGIMER, Chandigarh, for his valuable comments and access to his pa- tients. The authors are also grateful to other con- sultant colleagues for permission to follow their patients. The authors are also deeply indebted to Dr. SK. Verma and Miss D. Kaur for assisting in the statistical analysis.
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