Schizophrenia Course and Outcome

Short-term course

Child and adolescent onset schizophrenia characteristically runs a chronic course, with only a small minority of cases making a full symptomatic recovery from the first psychotic episode.

In the Maudsley study of child and adolescent onset psychoses (Hollis 2000), only 12% of schizophrenic cases were in full remission at discharge, compared with 50% of cases with affective psychoses. The short-term outcome for schizophrenia presenting in early life appears to be worse than that of first-episode adult patients (Robinson et al. 1999). If full recovery does occur then it is most likely within the first 3 months of onset of psychosis. In the Maudsley study, those adolescent onset patients who were still psychotic after 6 months had only a 15% chance of achieving full remission, while over half of all patients who made a full recovery had active psychotic symptoms for less than 3 months (Hollis 1999). The clinical implication is that the early course over the first 6 months is the best predictor of remission and that longer observation over 6 months adds relatively little new information.

Long-term outcome

A number of long-term follow-up studies of child and adolescent onset schizophrenia all describe a typically chronic unremitting long-term course with severely impaired functioning in adult life (Eggers 1978; Werry et al. 1991; Schmidt et al. 1995; Eggers & Bunk 1997; Hollis 2000). Several common themes emerge from these studies. First, the generally poor outcome of early onset schizophrenia conceals considerable heterogeneity. About one-fifth of patients in most studies have a good outcome with only mild impairment, while at the other extreme about one-third of patients are severely impaired requiring intensive social and psychiatric support. Hence, for an individual patient diagnosis alone is a relatively crude prognostic indicator. Secondly, after the first few years of illness there is little evidence of further progressive decline. This suggests that in the first 10 - 15 years of illness, at least, the course is relatively stable, although further progression may occur later in life.

Thirdly, child and adolescent onset schizophrenia has a worse outcome than either adolescent onset affective psychoses or adult onset schizophrenia. This suggests that outcome and clinical severity are related to both diagnosis and the age at onset.

Fourthly, social functioning, in particular the ability to form friendships and love relationships, appears to be very impaired in early onset schizophrenia. Taken together, these findings confirm that schizophrenia presenting in childhood and adolescence lies at the extreme end of a continuum of phenotypic severity.

Mortality

The risk of premature death is increased in child and adolescent onset psychoses. In the Maudsley study (Hollis 1999), there were nine deaths out of the 106 cases followed up (8.5%). The standardized mortality ratio (SMR) was 1250 (95% CI 170 - 5500), which represents a 12-fold increase in the risk of death compared with an age- and sex-matched general UK population over the same period. Of the nine deaths in the cohort, seven were male and seven had a diagnosis of schizophrenia.