Is Symptomatic Remission a Necessary Step Towards Better Functional Outcomes for Persons With Schizophrenia Engaged in Community-Based Psychosocial Rehabilitation?

Background: Since the development of the consensus-based criteria for symptomatic remission in schizophrenia by the Remission in Schizophrenia Working Group, the extent to which symptomatic remission impacts on functional outcomes over time remains unclear. The aims of this study were to describe the trajectory of functional outcomes in persons with schizophrenia as they engaged in community-based psychosocial rehabilitation, and to investigate the impact of symptomatic remission on initial differences and rate of change in functional outcomes over one year follow-up.

Methods: Data were derived from two longitudinal studies undertaken in Los Angeles. Participants were recruited at index admission to psychosocial rehabilitation. Participants completed a battery of research assessments at baseline and every six months thereafter over a period of up to two years. Per the proposed criteria, participants with ratings of ≤3 on the core symptomatology of schizophrenia assessed with the Brief Psychiatric Rating Scale and did not require psychiatric hospitalization in the prior 6 months were considered in symptomatic remission. The Strauss and Carpenter Outcome Scale was used to evaluate functional outcomes over a 6-month period in the following domains: psychiatric hospitalization, useful employment, and social contacts. Each item was rated on a 4-point Likert Scale; higher scores reflected less impairment. Analyses were conducted using data collected at baseline, 6- and 12-month follow-up from 244 participants with schizophrenia. Growth curve analysis was used to describe the patterns of change in the aforementioned functional domains and to estimate the effect of symptomatic remission on these outcomes over time. Two-tailed directional tests were set at a significance level of p< 0.05. Analyses were performed using STATA 12. 

Results: The ethnically diverse sample comprised of a majority of male participants (67%). The average age of the sample was 38.08 (SD = 9.25) with a mean duration of illness was 14.44 years (SD = 10.14). The trajectory for psychiatric hospitalization was characterized by a positive linear change (β = 0.19, p < 0.001), reflecting improvement. Likewise, the trajectory for useful employment was characterized by a positive linear change (β = 0.18, p < 0.01). In contrast, a linear individual growth model could not be fitted for social contacts (β = 0.032, p > 0.05); therefore, the impact of symptomatic remission on social contacts over time was not assessed. Compared to unremitted participants, remitted participants had better psychiatric hospitalization scores (3.22 vs. 3.86) and useful employment scores (0.75 vs. 1.05) at admission to psychosocial rehabilitation (all significant at p < 0.001). Remitted participants also had better psychiatric hospitalization scores (β = 0.64, p < 0.001) and useful employment scores (β = 0.30, p< 0.05) over time.

Implications: Our findings indicate that functional outcomes – psychiatric hospitalization and useful employment – improved linearly over time in this sample of individuals with schizophrenia, which could be attributable to engagement in psychosocial rehabilitation. Participants who achieved symptomatic remission showed significantly larger improvements in functioning over time compared to unremitted participants, suggesting that symptom stabilization is an important precedent for achieving gains in functioning among persons with schizophrenia.