A confluence of demographic and clinical trends makes this a good time to reconsider the outcome of older adults with early-onset schizophrenia.
Over the next 2 decades, the doubling of the number of people with schizophrenia aged 55 years and older–who will then represent roughly a quarter of all people with the disorder–will place enormous strains on a care system structured to treat younger patients.
For much of the last century, schizophrenia was seen as a bleak prognosis. In 1896, Dr. Emil Kraepelin first called it dementia praecox, and in 1980, the DSM-III still described the most common course as “one of acute exacerbations with increasing residual impairment between episodes.”
However, in the last quarter of the 20th century, 10-year long-term follow-up studies around the world showed an array of life courses, and roughly half of those diagnosed had favorable outcomes, that is, complete symptomatic remission or mild end states.
The most severe end state, the one seen as characteristic of schizophrenia by Dr. Kraepelin, was found in only about 15% of cases. Fortunately for our patients, the notion of a progressive downward spiral with a grim end point has been discredited.
Given these realities, we need a new paradigm that conceptualizes schizophrenia as a multifarious illness consisting of largely nonoverlapping indicators. Such a shift in thinking would enable us to better serve older patients who were diagnosed with schizophrenia while young.
A positive step toward that end would be to capture this complexity in our references. The latest edition of the American Psychiatric Publishing Textbook of Geriatric Psychiatry (Washington: American Psychiatric Publishing, 2009), for example, states that the course for most people is “largely unchanged over time.” This is not incorrect. It's just that increasingly, the approach to outcome has become more nuanced. This nuanced approach considers individual and global measures that incorporate elements of the recovery model in schizophrenia and the successful aging model in gerontology.
In addition, this conceptual shift implies that under optimal circumstances, ideal states might be achieved, thereby suggesting possibilities for altering individual and societal conditions to attain those states.
For people with schizophrenia, the ideal life trajectory can be viewed as a process moving from diminishing psychopathology and impaired functioning to normalization to positive health and well-being. The process of transitioning from psychopathology to community integration is the principal feature of the recovery model, and the transition to a positive state of mental and physical well-being in later life is the key feature of the successful aging model.
Studies of specific outcome measures conducted with community-dwelling middle-aged and elderly adults with schizophrenia by research groups in New York City and San Diego have shown about 50% prevalence rates for having none or mild levels of positive symptoms, negative symptoms, cognitive impairment, and adaptive dysfunction. About two-thirds of these adults have depression, and it appears that the proportion is equally divided between subsyndromal and syndromal depression.
What is interesting is that the correlations among these outcome categories are modest. The correlations ranged from .01 to .54 (median value of .21 or 4% shared variance). Thus, a person doing well in one category is only somewhat more likely to be doing well in another.
My colleagues and I at the SUNY Downstate Medical Center have examined global outcome measures based on the life trajectory perspective described above. In our study of 198 people aged 55 and older living with schizophrenia and living in New York City, we found a range of favorable outcomes: clinical remission (median 49%), objective recovery (17%), community integration (23%), and successful aging (2%) (Psychiatr. Services 2008;59:232–9).
Among a comparable group of age peers in the community, 19% and 41% met criteria for successful aging and community integration.
Only modest associations were found among the global outcome indicators, with the median shared variance being 13% in the schizophrenia group.
Therefore, each measure offered a different perspective on outcome.
Older people with schizophrenia scored significantly lower than their community age peers on the community integration and successful aging measures, but had they averaged one component higher on each of those measures, they would have approached the levels of their age peers.
Finally, we found that individual and global outcome measures are associated with a variety of potentially ameliorable social and clinical variables, such as positive symptoms, negative symptoms, cognitive functioning, depression, physical health, locus of control, and the number of confidants.
Clearly, the research supports the notion that older persons with schizophrenia have a range of favorable outcomes and that given this, a new paradigm is needed.