Remission of Schizophrenia: A Possibility?

By Arline Kaplan © 2000 (All Rights Reserved)

Can schizophrenia really remit?

Dilip Jeste, M.D., chief of the Division of Geriatric Psychiatry at University of California, San Diego (UCSD) and the VA San Diego Healthcare System, recently posed this question during his lecture on "Schizophrenia and the Third Age: Old Controversies and New Insights" at the American Psychiatric Association’s 153rd annual meeting in Chicago

"Remission is not common. However, it does occur," Jeste, professor of psychiatry and neurosciences at UCSD, told his standing-room-only audience. "Published studies suggest that 10% to 20% of people with schizophrenia have remission of their illness as they get older, 20% get worse, but in a large majority (60% to 70%), the course of illness remains relatively unchanged."

He suggested that a practical definition of remission for a very chronic, serious and highly stigmatized mental illness such as schizophrenia should be based primarily on psychosocial rehabilitation.

Several studies from Europe (Ciompi, 1980; Huber et al., 1980; Wiersma et al., 1998) and one "very nice study done in Vermont by psychologist Courtenay M. Harding, Ph.D., and her colleagues" in the 1980s showed that contrary to expectations, at least some people with schizophrenia get better as they get older, Jeste said.

In their research, Harding, an associate professor of psychiatry at the University of Colorado, and her colleagues focused on 269 patients diagnosed with schizophrenia who were released from the Vermont State Hospital between 1955 and 1960 into a state-funded, early model biopsychosocial rehabilitation program. The 10-year rehabilitation program (1955 to 1965) relied on a team of caregivers including psychiatrists, a psychologist, a nurse, sociologists and a vocational counselor to maintain a continuity of care for the ex-patients. The team found community housing and provided vocational clinics that led to jobs, education and social supports, individualized treatment planning, as well as social skills training (McGuire, 2000).

In the 1980s, Harding and her team found many of the original 269 patients, rediagnosed them retrospectively according to the criteria for schizophrenia published in the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III) and published the results of their follow-up (Harding et al., 1987; Harding et al., 1987 as cited in Jeste et al., 2000). The researchers found that one-half to two-thirds of 118 patients had achieved considerable improvement or recovered, in contrast to statements in DSM-III that predicted a poor outcome for patients with schizophrenia.

Jeste, who directs the National Institute of Mental Health-funded Geriatric Psychiatry Intervention Research Center at UCSD, said that they also have found patients who after decades of illness seem to be getting better. Factors associated with remission include higher education, better cognitive performance at baseline, later onset of symptoms and probably early initiation of treatment.

Jeste went on to relate "a favorite story," that of John Forbes Nash, Jr., who on Oct. 11, 1994, won the Nobel Prize for his pioneering work involving the mathematical principles of game theory. Sylvia Nasar (1999) chronicles Nash’s life in a book.

In 1950, as a 21-year-old Princeton graduate student, Nash wrote a 27-page doctoral dissertation on game theory—the mathematics of competition. He showed how to construct mathematical scenarios, in which both sides won, drawing the attention of theoretical economists. After brief interludes as an instructor at Princeton and as a consultant at RAND, Nash was recruited to teach at the Massachusetts Institute of Technology (MIT) in 1951. He married in 1957.
During a time when Nash’s wife was pregnant with their son and he was being considered for tenure at MIT, Nash became very suspicious.

"He started writing letters to his promotion committee accusing them of major conspiracy," Jeste said. His wife took him to psychiatrists. He was diagnosed as having paranoid schizophrenia and was committed to McLean Hospital.

For next 30 years, Nash was in and out of hospitals, Jeste said. He was given medications, psychotherapy and other treatments. Fortunately, he got a lot of support.

In 1963, the Nashes divorced, but Mrs. Nash eventually let her ex-husband live at her house. Mrs. Nash supported her former husband and her son by working as a computer programmer with some financial help from family, friends and colleagues (Nasar, 1994). Nash became a sad, ghostly presence around Princeton, hanging around the library reading books or walking between buildings.

But in his late 50s, Nash started getting better, Jeste said.

"When he was 60 years of age, he had no obvious symptoms of schizophrenia, and was able to stop taking medications. More importantly, he went back to work. He wrote a paper for the first time in 30 years, and started writing grants. He learned about the computer. Finally, when he was 66 years old, he was awarded the Nobel Prize in economics for the work he had done in his 20s," Jeste said.

Until recently, Nash refused to speak about his illness. However, he has begun to talk openly about it. Nash delivered a paper at the 10th World Congress of Psychiatry in 1996 describing his illness.

After describing Nash’s story, Jeste reminded clinicians, "There is a small chance that there may be light at the end of the tunnel, that at least a small proportion of patients may get better. That is a positive message to be given to our patients and their caregivers."

References
American Psychiatric Association (1980), Diagnostic and Statistical Manual of Mental Disorders, 3rd Ed. Washington, D.C.: American Psychiatric Association.

Ciompi L (1980), Catamnestic long-term study on the course of life and aging of schizophrenics. Schizophr Bull 6(4):606-618.

Harding CM, Brooks GW, Ashikaga T et al. (1987), The Vermont longitudinal study of persons with severe mental illness, II: long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. Am J Psychiatry 144(6):727-735.

Huber G, Gross G, Schuttler R, Linz M (1980), Longitudinal studies of schizophrenic patients. Schizophr Bull 6(4):592-605.

Jeste DV, Harless KA, Palmer BW (2000), Chronic late-onset schizophrenia-like psychosis that remitted: revisiting Newton’s psychosis? Am J Psychiatry 157:444-449.

McGuire PA (2000), New hope for people with schizophrenia. Monitor on Psychology 32(2). Available at www.apa.org/monitor/feb00/schizophrenia.html. Accessed Aug. 4, 2000.

Nasar S (1999), A Beautiful Mind: A Biography of John Forbes Nash, Jr, Winner of the Nobel Prize in Economics, 1994. Touchstone Books.

Nasar S (1994), The Lost Years of a Nobel Laureate. The New York Times on the Web. Nov. 13. Available at http://phoenix.liunet.edu/~uroy/eco54/histlist/jfnash2.htm. Accessed Aug. 4, 2000.

Wiersma D, Nienhuis FJ, Slooff CJ, Giel R (1998), Natural course of schizophrenic disorders: a 15-year followup of a Dutch incidence cohort. Schizophr Bull 24(1):75-85.