The Time Is Ripe for a Consensus Definition of Clinical Recovery in First-episode Psychosis

Suggestions Based on a 10-Year Follow-up Study

Gina Åsbø; Torill Ueland; Beathe Haatveit; Thomas Bjella; Camilla Bärthel Flaaten; Kristin Fjelnseth Wold; Line Widing; Magnus Johan Engen; Siv Hege Lyngstad; Erlend Gardsjord; Kristin Lie Romm; Ingrid Melle; Carmen Simonsen

Disclosures

Schizophr Bull. 2022;48(4):839-849. 

In This Article

Abstract and Introduction

Abstract

Objectives: A consensus definition of clinical recovery in first-episode psychosis (FEP) is required to improve knowledge about recovery rates in this population. To propose criteria for a future consensus definition, this study aims to investigate rates of clinical recovery when using a standard definition (full psychotic symptom remission and adequate functioning for minimum one year) across both affective and nonaffective FEP groups (bipolar spectrum and schizophrenia spectrum disorders). Second, we aim to explore changes in rates when altering the standard definition criteria. Third, to examine the extent to which healthy controls meet the functioning criteria.

Study Design: In total, 142 FEP participants and 117 healthy controls preselected with strict criteria, were re-assessed with structured clinical interviews at 10-year follow-up.

Study Results: A total of 31.7% were in clinical recovery according to the standard definition, with significantly higher recovery rates in bipolar (50.0%) than in schizophrenia spectrum disorders (22.9%). Both groups' recovery rates decreased equally when extending duration and adding affective symptom remission criteria and increased with looser functioning criteria. In healthy controls, 18.8% did not meet the standard criteria for adequate functioning, decreasing to 4.3% with looser criteria.

Conclusions: Findings suggest that clinical recovery is common in FEP, although more in bipolar than in schizophrenia spectrum disorders, also when altering the recovery criteria. We call for a future consensus definition of clinical recovery for FEP, and suggest it should include affective symptom remission and more reasonable criteria for functioning that are more in line with the general population.

Introduction

Psychotic disorders continue to be viewed as chronic,[1] although it has been firmly established that many will fully recover.[2–4] As hope is important for recovery, this pessimism is potentially detrimental.[5–7] What the definition of "recovery" should entail for people with psychotic disorders remains unclear.[8–10] A distinction has been made between personal recovery, a process of finding subjective quality of life regardless of symptoms, and clinical recovery, an observer-rated outcome of symptomatic remission and adequate functioning for a given duration.[10] There is no consensus definition for clinical recovery or adequate functioning in psychotic disorders, despite the Remission in Schizophrenia Working Group's (RSWG) consensus definition of symptomatic remission.[11]

Reviews of clinical recovery in psychotic disorders[12–14] have included studies with varied illness durations and follow-up periods, precluding a conclusion regarding long-term outcome. A few long-term (7.5–20 years) follow-up studies have recruited participants within the first year of either onset or treatment of psychosis, known as first-episode psychosis (FEP).[15–19] These studies have established that individuals with FEP can gain stable symptomatic remission,[18] adequate functioning,[15] and clinical recovery with rates ranging from 14% to 35.2%.[16,17,19]

This variance in clinical recovery rates across these FEP studies is partly due to methodological differences.[13] First, the majority defined FEP as nonaffective psychosis (schizophrenia spectrum disorders), excluding affective psychoses (bipolar and major depressive disorder with psychosis).[15,16,20] This reduces the observed clinical recovery rates[13,21] as nonaffective psychosis studies demonstrate lower rates (13.5%)[12] than those including affective psychosis (37.9%).[13] In FEP studies that included affective psychoses[17–19] and in studies within the framework of first-episode affective psychosis (FEAP),[22] the affective samples are rarely divided into unipolar or bipolar disorders. Thus, with the exception of a few studies including first-episode mania (FEM),[23] there is a dearth of knowledge about the long-term course of first-episode psychotic bipolar disorder.

The reviewed FEP studies also differ in their definition of clinical recovery.[12,13] The required duration of the period necessary for recovery varies from 6 months to 2 years across studies. Symptomatic remission of psychosis is generally well-defined and based on the RSWG consensus definition.[11] However, the remission of affective symptoms that make up the diagnostic criteria are not examined in FEP-studies that include affective psychotic disorders, even though it logically should.[17–19]Adequate functioning lacks a unified definition, although consensus criteria have been suggested.[24] Thus, studies differ in requiring any paid-, part-time- or full-time employment to meet functioning criteria.[15,17,20] Establishing consensus criteria for adequate functioning is essential, as functional loss is the greatest barrier to clinical recovery in psychotic disorders.[25] The majority will achieve symptomatic remission (50%–75%), yet half of them will remain functionally impaired,[13] especially related to employment.[17] These criteria do not consider that unemployment or poor occupational functioning could be due to systemic factors that are not illness-related, with full-time employment being particularly difficult to reach. Strict functioning criteria have been used to establish a proof-of-concept that many individuals with psychotic disorders without doubt achieve full clinical recovery. Still, we should consider whether these requirements exceed the functioning level in the general population,[18] thus causing unwarranted pessimism. Investigating to what extent healthy controls meet strict functioning criteria could help evaluate whether they are an unduly stringent norm.

Due to the above unanswered questions we have the following aims: (1) Investigate the rate of clinical recovery in a 10-year follow-up across a sample of first-episode schizophrenia spectrum and psychotic bipolar spectrum disorders, using a standard definition of clinical recovery. (2) Examine how altering the recovery criteria influence recovery rates, by including the addition of affective symptomatic remission and the use of looser criteria for adequate functioning. (3) Investigate the rate of adequate functioning in a healthy control group using both standard and looser criteria. Finally, based on our findings, we will propose criteria for a potential future consensus definition of clinical recovery in psychotic disorders.

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