Title presentation

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Remission in Schizophrenia Clinical and
PsychoSocial Dimensions Prof Yoram BARAK, MD,
MHA. ABARBANEL M.H.C. Bat-Yam, ISRAEL
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Remission in Schizophrenia the Road to Recovery
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Current and Future Directions
Cure
Recovery
Maintain
(normal without treatment)
Sustained Remission gt 6 months
(normal)
Remission/ Functional Remission
Resolution
Attain
Stable
(virtual absence of diagnostic symptoms for 6
monts)
Response
(no obvious evolution)
(virtual absence of diagnostic symptoms)
Acute Phase
(decrease of symptoms)
(ill)
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Long-term outcomes in schizophrenia
Focus on functionality Potential for remission
2000
Increase stable periods Minimise negative
symptoms
1990s
Reduce relapse Minimise positive symptoms
1980s
Survive out of hospital De-institutionalisation
Improve self-care Reduce aggression Reduce
self-injury
1960-70s
Pre-1960s
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Expanded model of remissionin schizophrenia
Peuskens J Kane J. In preparation.
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Remission in Schizophrenia Improvement dependency
Adapted from Weiden et al, J Clin Psych 1996 57
53-60
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What is Remission?

• Remission in nonpsychiatric illnesses
• The reduction or the complete absence of disease
  symptoms.

• Remission in psychiatric illnesses
• Defined not by the complete absence of symptoms
  but by minimal symptoms with mild disability.

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StoRMi - Study Design

• Schizophrenia or any other psychiatric disorders
  requiring long-term antipsychotic treatment
• Symptomatically stable patients on any previous
  antipsychotic medication for ?1 month
• Length of treatment 6 months 6 months
• 22 participating countries
• Number of recruited patients 1,909

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Treatment

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Treatment change from
Other 87 5
Risperidone
Conv. Oral 254 14
Olanzapine
Quetiapine
Amisulpiride
Risperidone 732 39
Ziprasidone
Conv Depot
Conv. Oral
Conv. Depot 813 43
Other
More than 1 drug per patient possible
Olanzapine 192 10
Quetiapine 49 3
Ziprasidone 6 0
Amisulpiride 57 3
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StoRMi trial

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PANSS total score by baseline severity
PANSS Ranges at Baseline
Moderate gt74.5- 106.5
Mild lt 74.5
Severe gt 106.5
58
91
126
56
116
86
54
106
81
52
96
76
50
86
71
48
76
46
66
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Baseline
Baseline
Endpoint
Endpoint
Months 1
Months 3
Months 6
Months 1
Months 3
Months 6
Baseline
Months 1
Months 3
Months 6
Endpoint
P ? 0.001 at all timepoints compared to baseline
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StoRMi - ????? ?????? ??????

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Remission in SchizophreniaProposed Criteria
and Rationale for ConsensusAm J Psychiatry
2005 162441449

• Nancy C. Andreasen, M.D., Ph.D.
• William T. Carpenter, Jr., M.D.
• John M. Kane, M.D.
• Robert A. Lasser, M.D.
• Stephen R. Marder, M.D.
• Daniel R. Weinberger, M.D.

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Abstract (1)

• New advances in the understanding of
  schizophrenia etiology, course, and treatment
  have increased interest on the part of patients,
  families, advocates, and professionals in the
  development of consensus-defined standards for
  clinical status and improvement, including
  illness remission and recovery.

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Abstract (2)

• As demonstrated in the area of mood disorders,
  such standards provide greater clarity around
  treatment goals, as well as an improved framework
  for the design and comparison of investigational
  trials and the subsequent evaluation of the
  effectiveness of interventions.

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Abstract (3)

• Unlike the approach to mood disorders, however,
  the novel application of the concept of standard
  outcome criteria to schizophrenia must reflect
  the wide heterogeneity of its long-term course
  and outcome, as well as the variable effects of
  different treatments on schizophrenia symptoms.

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Abstract (4)

• As an initial step in developing operational
  criteria, an expert working group reviewed
  available definitions and assessment instruments
  to provide a conceptual framework for
  symptomatic, functional, and cognitive domains in
  schizophrenia as they relate to remission of
  illness.

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Abstract (5)

• The first consensus-based operational criteria
  for symptomatic remission in schizophrenia are
  based on distinct thresholds for reaching and
  maintaining improvement, as opposed to change
  criteria, allowing for alignment with traditional
  concepts of remission in both psychiatric and
  nonpsychiatric illness.

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Abstract (6)

• This innovative approach for standardizing the
  definition for outcome in schizophrenia will
  require
• further examination of its validity and utility,
  as well as future refinement, particularly in
  relation to psychosocial and cognitive function
  and dysfunction.
• These criteria should facilitate research and
  support
• a positive, longer-term approach to studying
  outcome in patients with schizophrenia.

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Combining Clinical PsychoSocial DomainsThe
Israeli Project

• We aim to create a 2-pronged scale
• Clinical as defined by Andreasen et al.
• Psychosocial reflecting
• Quality of Life
• Needs
• I-ADL

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Remission Criteria in Schizophrenia Patient
achieves intensity level

• on all 8 symptom items
• P1 Delusions
• P2 Conceptual disorganization
• P3 Hallucinatory behavior
• G9 Unusual thought content
• G5 Mannerisms and posturing
• N1 Blunted affect
• N4 Social withdrawal
• N6 Lack of spontaneity/flow of conversation

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European Neuropsychopharmacology (2007) 17, iii

• Contents
• Improved Understanding and Treatment of
  Schizophrenia.
• From the symposium Acute to Long-term Treatment
  in Schizophrenia Effectiveness is a Moving
  Target at the 19th European Congress of
  Neuropsychopharmacology, September 1620 2006,
  Paris, France

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European Neuropsychopharmacology (2007) 17, iii

• Risk factors for schizophrenia All roads lead
  to dopamine. M. Di Forti, J.M. Lappin and R.M.
  Murray (UK) S101
• Management of agitation in the acute psychotic
  patient Efficacy without excessive sedation.
  F. Canas (Spain) S108
• The stable patient with schizophrenia From
  antipsychotic effectiveness to adherence. P.
  Thomas (France) S115
• The long term Maximising potential for
  rehabilitation in patients with schizophrenia.
• A. Fagiolini and A. Goracci (USA, Italy) S123

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The long term Maximising potential for
rehabilitation in patients with schizophrenia.

• Aims of rehabilitation in schizophrenia
• Therapeutic programmes that are developed to
  optimize the potential for rehabilitation in
  patients with schizophrenia should aim to
  maximise the patients' daily functioning in an
  attempt to enable them to engage in employment
  and increase their self-sufficiency.
• Rehabilitation should also attempt to enable
  patients with schizophrenia to integrate into
  society, improving their social interactions and
  activities.
• The complex nature of health-related quality of
  life (QoL) in schizophrenia patients has been
  recognised and another aim of rehabilitation is
  to improve this aspect.
• All of these aims should be considered when
  evaluating the effectiveness of any treatment
  that patients receive.

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The long term Maximising potential for
rehabilitation in patients with schizophrenia.

• Aims of rehabilitation in schizophrenia
• The employment prospects for patients with
  schizophrenia may be impeded by clinical
  symptoms, and data from the CATIE study clearly
  illustrate this (Rosenheck et al., 2006).
• No employment activity was reported for 72.9 of
  the patients in the month before the baseline
  assessment 14.5 of the patients had been
  engaged in competitive employment, and the
  remaining 12.6 had participated in
  non-competitive employment.
• Less severe symptoms of schizophrenia, better
  neurocognitive functioning and higher
  intrapsychic functioning scores (which evaluated
  a range of psychological characteristics) were
  associated with participation in employment.

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The long term Maximising potential for
rehabilitation in patients with schizophrenia.

• Aims of rehabilitation in schizophrenia
• Sociocultural context may be one of the major
  factors that can influence rehabilitation in
  patients with schizophrenia, and policy makers
  should give consideration to the creation of
  resources for the rehabilitation of schizophrenia
  patients within communities that complement the
  success that can be achieved with regard to
  reducing their psychotic symptoms (Mubarak, 2005).

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The long term Maximising potential for
rehabilitation in patients with schizophrenia.

• Aims of rehabilitation in schizophrenia
• Almost half (46.5) of schizophrenia patients
  report dissatisfaction with their overall QoL.
• By creating opportunities to improve social
  functioning, it may also be possible to improve
  patients' subjective QoL
• treatment that addresses psychotic symptoms in
  isolation from these factors may not facilitate
  QoL improvements.

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Real World research Findings

• Schizophr Res. 2007 Mar 27 Epub ahead of print
• Remission in prognosis of functional outcome A
  new dimension in the treatment of patients with
  psychotic disorders.
• Helldin L, Kane JM, Karilampi U, Norlander T,
  Archer T.

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Real World research Findings

• INTRODUCTION
• The aim of the present study was to investigate
  whether or not the new concept of remission in
  the treatment of schizophrenia is of importance
  for functional outcome.
• The hypothesis was that patients having attained
  remission would function at a higher level and
  have a lower care requirement than those who had
  not attained remission.

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Real World research Findings

• MATERIALS AND METHODS
• Remission is defined through the application of
  the Positive and Negative Syndrome Scale (PANSS)
  instrument whereby none of the eight chosen
  items, representing core symptoms, should be
  found to present a value exceeding 3 points.
• The utility of attaining the severity criteria
  for remission, or not, was examined with regard
  to activity of daily living (ADL) ability,
  establishment of social functioning and social
  network, and amount of health care and community
  support that the patient consumed.
• Two hundred and forty-three patients were
  examined, of whom 93 patients (38) had attained
  remission and 150 patients (62) had not. The
  present patient population, consisting of 50 of
  all available patients with schizophrenia
  spectrum disorder within a homogeneous catchment
  area in NU Health Care, western Sweden, meeting
  the right diagnostic criteria, were in their
  habitual condition and were unaffected by any
  other functionally debilitating disorder, in
  particular dementia.
• As a control patients diagnoses were used as the
  independent variable to exclude that they better
  explain outcome than remission.

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Real World research Findings

• RESULTS
• It was found that patients that attainted the
  specified remission criteria showed a
  significantly superior outcome in all assessed
  areas with regard to activity of daily life,
  social functioning in society and consumption of
  health care.
• Remission patients functioned more effectively in
  social contexts in association with superior
  education, more often had occupations, possessed
  more established social networks and were more
  likely to be found living under family-like
  conditions.
• They exhibited a lower need for support in order
  to fulfill their everyday activities.
• Also, patients in remission required markedly
  less health care resources, both in the form of
  psychiatric treatment and community habitation
  support. In contrast diagnoses only made
  difference in 4 of 14 outcome parameters.

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Real World research Findings

• DISCUSSION
• The results suggest that the concept of remission
  has important implications for the treatment of
  patients with chronic psychosis.
• One possible conclusion is that if more patients
  attain remission, the patient's and society's
  burden resultingfrom the illness will decrease.

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