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Aim: The purpose of this naturalistic study was to investigate the rate and predictors of remission at medium-term follow up of individuals with schizophrenia in a community setting in Bali.
Methods: Subjects comprised 37 individuals with schizophrenia, including 19 never-treated cases, screened from 8546 general residents. Outcome was evaluated using the standardized symptomatic remission criteria based on Positive and Negative Syndrome Scale scores and operational functional remission criteria at 6-year follow up.
Results: Ten individuals (27%) achieved symptomatic remission, 12 (32%) achieved functional remission, and 10 (27%) achieved complete remission (i.e. symptomatic and functional remission). Lower Positive and Negative Syndrome Scale negative symptom score at baseline and receipt of psychiatric treatment for more than half of the follow-up period were predictors of complete remission.
Conclusions: The majority of community-screened individuals with schizophrenia failed to achieve complete remission at the 6-year follow up. These results suggest that strategies promoting mental health service utilization among individuals with schizophrenia are essential in Bali.
REMISSION IS ONE of the major issues in current outcome studies in schizophrenia. For many years, schizophrenia was regarded as an illness inevitably leading to a non-remitting end state, described by Kraepelin as dementia praecox. However, recent long-term outcome studies have revealed that the course of schizophrenia is more heterogeneous, with a significant portion of patients exhibiting remission.1,2 This altered viewpoint necessitated the development of a new and operationalized definition of attainable treatment outcomes in patients with schizophrenia.3 In this context, standardized remission criteria for schizophrenia were proposed by the Remission in Schizophrenia Working Group.4 These criteria have been clinically validated and demonstrated to be more useful than prior subjective and heterogeneous evaluations of clinical stability.5–7 In addition to symptomatic remission, another treatment goal in schizophrenia is functional remission, which allows the reintegration of patients into the community and workplace and reduces social burden.8,9 Little is known, however, about the symptomatic and functional remission status of individuals with schizophrenia in community settings in developing countries.
We previously reported the clinical condition of community-screened individuals with schizophrenia evaluated by the Positive and Negative Syndrome Scale (PANSS);10 however, we were unable to determine the symptomatic remission rate of the participants due to the cross-sectional study design, which did not enable us to include a 6-month time criterion. Furthermore, we did not determine the functional remission rate in the previous study. The present study therefore aimed to examine the outcome, indicated by the rates of symptomatic and functional remission based on operational criteria with a 6-month time criterion, and predictors of remission at the 6-year follow up of community-screened individuals with schizophrenia in Bali, approximately half of whom had never received treatment at baseline.
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In this naturalistic study, we clarified the rate and predictors of remission among community-screened individuals with schizophrenia. To our knowledge, this is the first study to examine symptomatic remission of schizophrenia using the standardized remission criteria proposed by the Schizophrenia Working Group in developing countries. The strengths of this study include its low attrition rate and the community-based sampling method, which ensured that subjects were representative of individuals with schizophrenia in Bali, where many affected people do not receive psychiatric treatment. The results demonstrated that 27% of subjects achieved complete remission, and those with less severe negative symptoms at baseline and those who had received psychiatric treatment for more than half of the follow-up period were more likely to achieve complete remission at medium-term follow up.
In previous studies investigating symptomatic remission of schizophrenia using standardized remission criteria in developed countries, the reported remission rates range from 24% to 55%.3,25–27 The rates of functional remission employing similar criteria in developed countries are between 13% and 46%.20–23 Although different study designs and sample characteristics make it difficult to compare remission rates among studies, rates of symptomatic and functional remission in the present study (27% and 32%, respectively) were within the range of those found in developed countries, indicating that symptomatic and functional outcomes in Bali are comparable to those found in developed countries. Therefore, our study results support the findings reported by Cohen et al.,28 suggesting that it is time to re-examine the commonly held notion that schizophrenia outcomes in low- and middle-income countries are better than those in high-income countries, which was supported by three WHO studies.29–31 Alem et al.32 also recently reported that schizophrenia outcome in developing countries is heterogeneous rather than uniformly favorable.
In the present study, all individuals who achieved symptomatic remission concurrently achieved functional remission, and rates of symptomatic and functional remission were 27% and 32%. In contrast, in a study of 10 European countries, Lambert et al.21 demonstrated that 47% of patients achieved symptomatic remission, whereas only 27% achieved functional remission. San et al.33 also reported that 45% of patients achieved clinical remission but only 10% showed adequate social and/or vocational functioning in an outpatient setting in Spain. The difference between our study results and those from developed countries may result from different employment rates among study sites. A European schizophrenia cohort study revealed that the employment rate of individuals with schizophrenia was 12.9% in the UK, 11.5% in France and 30.3% in Germany.34 The employment rate in the present study (51%) was much higher. In the present study, as most of the subjects were farmers or household industry workers rather than employees at competitive jobs as is common in Western countries, they did not need to apply for jobs and were allowed to work according to their decreased level of ability. Such a social background may have caused the functional remission rate to be higher than the symptomatic remission rate in the present study, a result that contrasts sharply with the large drop in functional remission rates as compared to symptomatic remission rates observed in developed countries.
Receipt of psychiatric treatment for more than half of the follow-up period was a significant predictor of complete remission. This finding is similar to that reported in a community-based study conducted in Ethiopia.32 As antipsychotic medication is the cornerstone of treatment for individuals with schizophrenia, reducing the medication access barrier is an important strategy that should be addressed in developing countries. Meanwhile, it is reported that symptom-free patients tend to discontinue treatment completely over the long term, and thus sustained symptomatic recovery is most commonly observed outside of the clinical setting.35 Further investigation of whether those with complete remission in the present study eventually attain recovery without medication may shed light on the long-term outcome of schizophrenia.
Higher PANSS negative symptom score at baseline predicted a lower likelihood of complete remission at 6-year follow up in the present study. This finding is consistent with other studies demonstrating that a higher level of negative symptoms at baseline predicted a longer time to response to treatment36 and lower remission rate.23,26,37,38
This study has several limitations. First, the small number of participants made the interpretation of the results rather difficult. Second, evaluation of symptoms and function was conducted only at baseline, 5.5 years, and 6 years. Third, neurocognitive function, which is a potential predictor of remission, was not investigated at baseline. Fourth, the rater was not blind to treatment status and previous evaluations. Future studies should address these problems and comprehensively investigate recovery from schizophrenia and the factors associated with non-receipt of treatment in order to increase mental health service utilization among individuals with schizophrenia in Bali.