Psychosis Recovery Rates Greater Than Earlier Estimates

Deborah Brauser

February 14, 2018

The incidence rates of remission and recovery for adults after first-episode psychosis (FEP) are greater than earlier estimates — although there's still a long way to go, new research suggests.

The meta-analysis of 79 studies showed a 58% pooled rate of remission over 5 years of follow-up among more than 12,000 patients with FEP. A systematic review published in 2012 showed a mean remission rate of 40%

In the current study, which included more than 9600 patients, the pooled rate of recovery over a mean of 7 years of follow-up was 38%, vs a much lower 13.5% reported in 2013 research.

In addition, the recovery rate was 30% among the subgroup of patients with first-episode schizophrenia.

"Our original instinct, based on previous data, was to be somewhat pessimistic; but we were pleased to find that our data indicated a more positive outcome," lead author John Lally, MB, Department of Psychosis Studies at the Institute of Psychiatry, Psychology, and Neuroscience at King's College London, United Kingdom, told Medscape Medical News.

Dr John Lally

"This is important information, not only for patients themselves but also for families and carers. The recovery rates are better than previously indicated, which I think is a more hopeful message," said Lally.

However, they also found that recovery rates have not improved during the past 20 years, "raising questions about the effectiveness of services," write the investigators.

"It does raise questions about what deficiencies currently exist in how we are managing and treating patients to ensure they can obtain recovery," added Lally.

The findings were published recently in the British Journal of Psychiatry.

Good News, Bad News

"To our knowledge, only three systematic reviews and two meta-analyses have [previously] considered recovery or remission in FEP and/or schizophrenia," the investigators write.

They note that these reports used varying definitions of outcomes and included patients with FEP and those with multi-episode psychosis, which is a more chronic or treatment-resistant form of the disorder.

Lally noted that the new research is the first meta-analysis to assess remission and recovery rates in only patients with FEP and/or first-episode schizophrenia.

The investigators assessed 79 studies with a total 19,072 patients with FEP, including schizophrenia and affective psychosis. All of the studies had a follow-up of at least 12 months and were published "from database inception" through June 2016.

Among the studies, 44 reported on remission rates, 19 on recovery rates, and 16 on both, with some overlapping. This resulted in 12,301 and 9642 patients for whom remission and recovery data were available, respectively.

The coprimary outcome showed a 57.9% pooled rate of remission (95% confidence interval [CI], 52.7 - 62.9). After assessing only the 25 studies that used the Remission in Schizophrenia Working Group criteria for remission, the pooled rate was similar, at 56.9% (95% CI, 48.9 - 64.5).

The pooled rate of recovery, the other primary outcome, was 37.9% (95% CI, 30.0 - 46.5).

In subgroup analyses, the prevalence rates of remission were 56.0% and 78.7% in those with schizophrenia and affective psychosis, respectively. The rates of recovery were 30.3% and 84.6%.

The highest pooled remission rate came from studies conducted in Africa (73.1%), followed by studies in Asia (66.4%) and in North America (65.2%).

Yet North America had higher rates of recovery (71.0%) than Asia (35.1%), Australia (28.1%), and Europe (21.8%).

There were no differences in overall remission rates by study period, averaging around 59% before 1976 through 2016. However, the overall recovery rates decreased from 44.5% before 1976 and from 45.2% in the 1976-1997 period to 32.1% in the 1997-2016 period.

"This finding...indicates that thus far the dedicated and intensive specialist care provided for patients with FEP over the past two decades has not resulted in improved recovery rates," write the investigators.

Lally noted that they did not have information on interventions used for individual patients or on treatments that were or were not received during the follow-up period.

"What I think happened is that a lot of people are very much delayed in initialization of the medication clozapine, which is the only effective medication for treatment-resistant schizophrenia. That might be why we haven't seen improvement in recovery rates over the past 20 years, which have remained quite high," he said.

The researchers are now looking more deeply into why these rates haven't improved and will be conducting a meta-analysis on rehospitalization rates after FEP.

"Real Challenge"

Paddy Power, MD, St. Patrick's University Hospital and Department of Psychiatry at Trinity College, Dublin, Ireland, writes in an accompanying editorial that although the investigators "provide an insight" into some questions raised about FEP, others were left unanswered.

"The meta-analysis...provides a robust evidence base of overall outcomes for patients with FEP," writes Power. Although the new report showed "intriguing differences in outcomes" between continents, "it cannot make distinctions on an individual level," he adds.

"Ideally, what we and our patients need now is an evidence base that can inform us better at an individual level about how different treatment and lifestyle choices...have an impact on outcomes."

In addition, Power notes that recovery is not just an ending of psychotic symptoms but a complex process that needs more than "just a passive response to treatment."

"It may not necessarily result in one returning to one's previous developmental trajectory as what is required is adaptation to a new set of circumstances," he writes.

For recovery to be successful, a patient needs to accept their past experience in a way that resolves contributing factors and decreases the risk for additional episodes, writes Power. However, "influencing and measuring these outcomes is the real challenge."

The study authors and Dr Power report no relevant financial relationships.

Br J Psychiatry. 2017;211:331-333, 350-358. Abstract , Editorial

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