Recovery Rates from First Episode Psychosis Vary Depending on the Definition of “Recovery”

Clinical recovery from first episode psychosis may need to be redefined as many "healthy" subjects do not meet functional criteria.

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A new article published in Schizophrenia Bulletin finds that recovery from first-episode psychosis (FEP) varies wildly depending on how “recovery” is defined. Additionally, people diagnosed with schizophrenia were much less likely to recover when compared to people diagnosed with bipolar disorder.

The authors, led by Gina Åsbø from the Oslo University Hospital in Norway, note that clinical recovery is common for FEP. However, they suggest the psy-disciplines need a consensus definition of recovery that maps better to real-world functioning. They write:

“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.”

The current work has three goals. First, to assess recovery rates for FEP when defining recovery as “full psychotic symptom remission and adequate functioning for minimum one year.” Second, to explore how changing the criteria for recovery influences recovery rates. Finally, to investigate how often “healthy” subjects meet the functional criteria used to determine recovery from FEP.

To accomplish these goals, the authors used data from the Thematically Organized Psychosis study at the Norwegian Centre for Mental Disorder Research. In total, they examined data from 142 participants that had a first experience of psychosis that led to either antipsychotic drugs being administered until remission or psychiatric hospitalization.

To be included in the study, each participant needed to meet DSM-IV criteria for either schizophrenia spectrum disorder or bipolar disorder, have adequate Scandinavian language skills, be between ages 18-65, and have the ability to give informed consent. In addition, participants were excluded if they experienced a brain injury requiring hospitalization or had any other medical condition that could cause psychotic symptoms.

Participants were assessed for psychiatric symptom remission and function (in terms of employment, at one and ten years post-FEP. The 142 participants in the FEP group were compared to 117 randomly selected “healthy” control subjects. Control subjects were excluded based on the same criteria as the FEP group. Additionally, control subjects were excluded if they had substance abuse and dependence issues in the last six months or a family/personal history of severe psychiatric disorder.

At the ten-year follow-up, 31.7% of the FEP group was in clinical recovery. In addition, 59.9% met the criteria for psychotic symptom remission for at least one year, and 32.4% met the criteria for adequate functioning. However, many participants did not meet the functional criteria due to a lack of full-time employment.

People with a bipolar diagnosis had a clinical recovery rate of 50% compared to those with a schizophrenia spectrum diagnosis at 22.9%. Within the schizophrenia spectrum diagnosis group, those diagnosed with schizophrenia fared the worst (10.9%), followed by schizoaffective disorder (33.3%) and “other psychosis” (40%). Psychotic symptom remission and adequate functioning were significantly higher in the bipolar group. There was no significant difference between the bipolar and schizophrenia spectrum groups regarding social functioning.

When altering the criteria to include remission of five years rather than one, the recovery rate for both groups was cut in half. The authors note that while the recovery rate for the bipolar group was still double that of the schizophrenia spectrum group, it was no longer a significant difference. Adding a requirement for affective symptom remission (such as anxiety, sadness, irritability, etc.) dropped the recovery rate from 31.7% to 26.8% for the total participant sample. The bipolar group still recovered at about twice the rate of the schizophrenia spectrum group.

With less strict adequate functioning criteria (part-time rather than full-time work and having a close friend rather than weekly contact), the overall recovery rate for the entire participant population increased to 40.8%. With the initial definition of functioning, 18.8% of the “healthy” participant control group did not meet the criteria for adequate functioning. This was mainly a result of restricted social functioning. Only 4.3% of “healthy” participants could not meet the less strict adequate functioning criteria. According to the authors, this finding suggests that the standard adequate functioning criteria may need to change as so many “healthy” people cannot meet them.

The authors acknowledge that a high attrition rate was a fundamental limitation of the current work. They attribute this attrition rate to the length of assessments. The low number of participants and their recruitment from one specific region significantly lowers the generalizability of this study to other, more diverse populations. The authors conclude:

“Our findings suggest that half of people with bipolar spectrum disorders and a quarter with schizophrenia spectrum disorders will clinically recover ten years after treatment start. Additionally, that a more meaningful consensus definition of clinical recovery, suitable also for affective psychosis and more in line with the general population, would benefit from the inclusion of affective remission and less stringent criteria for adequate functioning. Ultimately, we highly welcome a debate regarding a future consensus defnition of clinical recovery in psychotic disorders.”

Researchers have debated what it means to recover from mental illness, with “professional” opinions often differing greatly compared to service user experience. Research has found that social recovery therapy, social inclusion, and stipends can all help in recovering from mental illness. One study found that recovery rates are six times higher for those who stop antipsychotic drug use within two years. Researchers have also argued that neuroleptics reduce recovery rates from as high as 80% to 5%.

Research has found that antipsychotics worsen cognitive functioning in FEP. One study found that racism and coercion in FEP treatment can cause loneliness and mistrust in black men. Cognitive behavioral therapy may be useful in recovery from first episode psychosis. Research has also found that social relationships are integral to FEP recovery.

 

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Åsbø, G., Ueland, T., Haatveit, B., Bjella, T., Flaaten, C. B., Wold, K. F., Widing, L., Engen, M. J., Lyngstad, S. H., Gardsjord, E., Romm, K. L., Melle, I., & Simonsen, C. (2022). The time is ripe for a consensus definition of clinical recovery in first-episode psychosis: Suggestions based on a 10-year follow-up study. Schizophrenia Bulletin, 48(4), 839–849. https://doi.org/10.1093/schbul/sbac035 (Link)

13 COMMENTS

  1. “we highly welcome a debate regarding a future consensus definition of clinical recovery in psychotic disorders.”

    “many participants did not meet the functional criteria due to a lack of full-time employment.”

    Particularly since the “mental health workers” I encountered consider being an active volunteer and stay at home mom (not to mention, also an artist working on my portfolio) to be “w/o work, content, and talent” and “unemployed” … w/o ever looking at my work or asking me what I do.

    I do think a better definition of “full-time employment” is needed. Since declaring all “woman’s work,” volunteer work – not to mention all artists’ portfolio creation – to be “unemployed” … as the “mental health” workers have been doing for decades … is a staggeringly paternalistic attitude. Not to mention ungodly disrespectful to all artists.

    And I will say, withdrawal from the psych drugs can take years. So expecting all people … including those who can afford to not go back to work full time … to have to be “employed full time” within a year, is absurd.

    Especially since the “mental health” workers usually do not even tell their clients about this made up definition of “recovery.”

    • Just an FYI, my first drug withdrawal induced “super sensitivity manic psychosis” didn’t happen until 6 months after I was weaned from the psych drugs. But it did result in a hospitalization, misdiagnosis as “a return of the disorder,” and brief re-drugging.

      My second, and last, drug withdrawal induced “super sensitivity manic psychosis,” did not happen until 25 months after I was weaned off the psych drugs for the second, and last, time.

      Possibly, IMHO, because I was too busy with my full time kitchen bath designer job, and my research into anticholinergic toxidrome poisoning. Which, of course, is the real etiology of the “psychotic” illnesses, that are created with the antidepressants and antipsychotics.

      https://en.wikipedia.org/wiki/Toxidrome

      • Do we get to vote on the recovery rate of psychiatrists, possibly having realized that the bulk of their education is grounded in an ideology that doesn’t pan out: their “treatments” cause chemical imbalance rather than treat it?

        And what are the levels of recovery? And what are the symptoms? If a person has seen said ad on TV, or talked to a counselor or social worker, and has been told they should be on meds, is the psychiatrist going to even actually tell them the truth regarding the medications: how addictive they are, how they disable natural brain functions, how they correlate statistically with less recovery and more relapsing, loss of life expectancy, and of course phobia against symptoms that are suppressed rather than an attempt is made or even allowed to understand them!?

        And what are the symptoms?

        1) They think the chemical imbalance theory is a necessary fairy tail akin to Santa Clause and the Easter Bunny and does no harm despite the statistics in its correlation with less recovery, loss of life, and more relapsing.

        2) They get floridly philosophical, disregarding the grounded science that shows the dangers of psychiatric drugs, will haul out “evidence” of a whole array of “clients” they feel are helped, deny that said clients aren’t even allowed to express it when the “method” isn’t helping, as they would be seen as non compliant; and then also angrily accuse anyone pointing out the naked statistics and science of not helping, while denying that alternative methods not allowed have been shown to be more effective.

        3) Lack the ability to question whether they are helping, become aggressive and show signs of depression, manic depression, bipolar (when they are in charge they get manic, when it’s not working depressed), schizophrenic (no ability to see true perspective regarding the reality of cause and effect with their treatment) when their method fails, or “clients” show signs of dissent and possible look towards ways of disabling their own brain from the stress of having to actually use it.

        I’m trying to be funny, but this is tragic. There are multiple stories of families who find their loved one imprisoned by the system, and they can’t do anything to get the system to stop destroying their loved ones lives, and then their loved one dies, clearly affected by the mental health system emotionally or filled with such toxic medications that the treatment killed them, only to have this billed as a tragedy needing more of the treatment that exactly caused the problem and the loss.

        Voting happens in a democracy, but this is more a totalitarian system.

        And all the rest of it. Substances that are highly addictive, not acknowledged as giving harsh withdrawal symptoms, no attention to withdrawal, and then the whole cocktail changed when symptoms the psychiatrists have no ability to understand aren’t suppressed. People forced on said “medications” they can’t refuse, then used in clinical trials and abruptly taken off of the medications to have the withdrawal symptoms listed as signs of the disease, while none of what is listed as the disease would be occurring without the “treatment.”

        • It’s paternalistic, alright, and in all the worst ways.

          All it proves is that people, both men and women, take for granted someone running their home or having their kids.

          They need to remember that people are PAID for doing housework, and that women can now RENT OUT THEIR WOMB—and if THAT isn’t “work”, I don’t know what is.

          And that’s a lot more work than any man will ever do.

          • Artistic ability is one of the greatest gifts to give the world. But unfortunately, most of it isn’t respected unless it’s profitable.

            But I think it goes deeper than that, as art sometimes reflects things people aren’t willing to see. And a lot of the hostility comes from jealousy.

    • Someone Else says, “….declaring all “woman’s work” volunteer work…is a staggeringly paternalistic attitude.”

      Some do “woman’s work” for a living. They’re called nannies, housekeepers and cooks.

      Some unfairly judge and denigrate for a living. A lot of them are psychiatrists and therapists.

  2. Sorry, but find it hard to see people treating a whole conglomeration of extremely vulnerable people, people who already statistically have been lied to regarding the cause of what’s labeled as a disease, not really inform them of what they needed to know before they ever ended up on the other side of the discussion with said “mental health” clinician, and then evaluate how they are doing. I find it hard to file this as “science.”

    • For some reason editing comments is turned off, which before was an interim when work was being done on this site.

      I wanted to add in my prior comment that it seems a bit cruel to categorize these vulnerable people with psychiatric diagnosis, and then go about seeing whether they “recover,” from it. It’s like going to a war zone where there’s lack of basic necessities, put who is missing what in different categories, not attend to what they need, and then decide who doesn’t die from the lack of it as having “recovered” from said disease.

  3. “Researchers have debated what it means to recover from mental illness, with “professional” opinions often differing greatly compared to service user opinions.”

    I think psychiatrists are extremely arrogant to think they’re the ones to decide what “recovery”means.

    And most think you’re “sick” if you’re not punching someone else’s time clock.

    • “And most think you’re ‘sick’ if you’re not punching someone else’s time clock.”

      Yes, the “mental health” industry is very talented at neglecting to timely tell the public about what their insane beliefs (or laws or bizarre definitions of words) are.

      * I was never informed that being self employed was proof I would never be able to “recover” from the “mental health” workers’ iatrogenic illnesses … good thing I happened to take that job working for someone else. And that 30% raise after my first year there, probably helped me, during my second hospitalization – by a foreign psychiatrist who seemingly just checks her patients’ tax records to find out whether they are employed, rather than actually talking to her clients. But the ethical head of family medicine, at one of the most well respected hospitals in the nation, who I medically explained how I was made sick, did take the prior psychiatric defamation off my medical records … so people can heal.
      * I learned the hard way, that my “mental health’ workers believe that all who partake in legal activities – like moderate smoking or drinking – are considered “mentally ill.”
      * I was never told that losing weight, upon the recommendation of a doctor, via exercise – as opposed to dieting – was a symptom of “bipolar.” I learned this from reading my medical records and the DSM.
      * I think it was at least a year into my “mental health” treatment, prior to being told to stop exercising, by my psychiatrist. And to this day, I’m still shocked the “mental health professions” are only now learning that regular moderate exercise is healthy.
      * I was never told the “mental health” workers couldn’t bill to help legitimately distressed individuals, like child abuse survivors; so any mother with concerns of the abuse of her child should stay as far away as possible from the systemic child abuse and rape covering up “mental health” criminals.
      * I wasn’t told, until I was picking up my former psychologist’s medical records, that she believed distress caused by a distressing event – in my case 9.11.2001 – was distress caused by a “chemical imbalance” in my brain alone. WTF?

      Personally, I think the beliefs of the “mental health” system are intrusive, insane, and void of common sense.

      But as to the debate at hand, since the “mental health” system attacks both the poor and the wealthy. And since full time employment by others may be neither a need nor desire for the wealthy, nor the self employed. I don’t think one’s employment status, nor tax records, should have any relevance to the medical definition of the word “recovery.”

      Definition #2, “A return to a normal or healthy condition” should be the definition of recovery that all health professionals use. But it does seem the “mental health” industry wants to utilize some sort of bizarre distortion of definition #3, “The act of obtaining usable substances from unusable sources,” as their definition of “recovery”?

      https://www.thefreedictionary.com/recovery

      But that is just because they are Big Pharma neurotoxin forcers, who want to put all smokers on antidepressants, under the false guise they’re “safe smoking cessation meds.” And their goal is seemingly also to DSM defame, and neurotoxic poison, anyone they can get their hands on, for profit.

      But the bottom line is, for those who hope to actually “recover” from psychiatric iatrogenesis, the daunting and dangerous task of slowly weaning from the psychiatric neurotoxins, is likely your best bet.