Why do we Talk about Recovery in Severe Mental Illness?

By Marvin Ross

There are some medical conditions where recovery is not only possible but expected. Break a bone, get the flu come to mind easily but there are far more medical conditions that are chronic. You don’t, for example, recover from asthma or diabetes. What you can expect is that the symptoms will be well controlled with inhalers or diet, insulin and other strategies for types I and II diabetes.

But, for some reason, many talk about a recovery from schizophrenia, bipolar and other serious mental illnesses. When people talk about recovery, they usually mean the restoration of a state of good health even though the literature on schizophrenia has always emphasized that full recovery is very rare. The best that can be hoped for is a minimum of symptoms and very few relapses.

The recovery attitude seems most prevalent among those who do not believe in psychiatry and psychiatric medications and consider that psychiatrists and the medication people are given actually make people worse. The definition of recovery for schizophrenia that I’ve always used is to be as well as possible with as few symptoms as possible so the individual can enjoy life as well as possible.

Now, a group of researchers completed a study that looks at a 25 year time span for those diagnosed with schizophrenia to determine the true course of the diseases. The authors looked at data from 591 individuals with schizophrenia spectrum disorders (schizophrenia, schizoaffective disorder and schizophreniform disorder) or other psychotic disorders (bipolar disorder with psychosis, major depression with psychosis, drug-induced psychotic disorders).

Subjects were recruited between 1989-1995 following their first hospitalization for psychosis. In-person interviews were then conducted at 6 months, 24 months, 48 months, then 10, 20 and 25 years to determine their remission (minimal or no symptoms) or recovery (moderate symptom but good functioning) status.

Of those with schizophrenia spectrum disorder, only 14.2% were in recovery at 25 years and 7.4% were in remission. Those with other psychotic disorders did better with 28.1% in recovery and 20.0% in remission. Combining results for all time period assessments, those with schizophrenia spectrum disorders recorded no remission or recovery at all of the periods. Just 0.6% achieved stable recovery. Those with psychotic disorders fared better. 15.1% and 21.1% experienced stable remission or recovery, respectively.

The main finding was “In the baseline cohort and the 25-year subsample, the most common trajectory for individuals with schizophrenia spectrum disorders was no remission and no recovery”

The authors concluded that “Sustained remission and recovery are rare among people with schizophrenia spectrum disorders. Efforts should be directed toward developing more effective treatments for this population.”

Schizophrenia and psychotic diseases are chronic and require long term support to improve outcomes given the less than adequate treatments we have at the present time. That does not mean that all is hopeless unless these ill people are abandoned by society and by healthcare as is often the case today. What they do need is ongoing monitoring and care to minimize the symptom recurrences and frequency of them. That is not something that is regularly done.

The validity of ensuring long term treatment was demonstrated by an earlier study out of Finland. Researchers looked at all patients discharged from hospital with a diagnosis of schizophrenia from 1972–2014. From that group, the researchers chose only those who had not previously taken anti-psychotics prior to that hospitalization and were not rehospitalized or died. There were 4,217 users of anti-psychotics and 3,217 non users who were followed for treatment outcomes.

In the overall comparison between users (N=4,217) and nonusers (N=3,217), treatment failure occurred in 56.5% of the nonusers and in 34.3% of the users. In addition nonusers had a 214% higher risk of death , and early discontinuers had a 174% higher risk of death.

Recovery, like motherhood, is nice and who wouldn’t want people with chronic medical conditions to recover but we need to be realistic. No one is to blame for chronic illnesses but we do need to manage them to reduce the worst of their symptoms as we are able to with our current state of science. We don’t tell insulin deficient diabetics they should recover but we make sure they get the insulin they need and monitor it on an ongoing basis. We shouldn’t push recovery on people with schizophrenia but we should impress upon them what they need to keep symptoms and relapses at bay. And we should have a system that ensures that is done.