Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres
art ic l e i nf o
a b s t r a c t
Article history:
Received 29 August 2012
Received in revised form
30 July 2013
Accepted 7 August 2013
To date, few studies have reported analytical data relating to clinical remission, functional remission and
subjective experience. The present study aimed to investigate these aspects in a sample of chronic
outpatients. Methods: 112 schizophrenic or schizoaffective outpatients (Males 60; Females 52; mean
age 43.5 79.42 yr) were evaluated with regard to symptomatology (SCID-I; PANSS, CGI-SCH scales),
functioning (PSP scale), subjective wellbeing (SWN-K scale) and Quality of Life (WHO-QoL-Bref scale).
Results: 50% of patients were found to be in remission. Signicantly higher scores at PANNS, CGI-SCH,
PSP, but not at SWN and WHO-QoL, were found among remitted patients; a relevant proportion of
remitted subjects continued to manifest a moderate level of symptoms (score 4 3) both at PANSS (35%
of cases) and CGI-SCH (29% of cases), signicant functional impairment (total score o 70) at PSP (68% of
cases ), and a lesser degree of wellbeing (total score o80) at SWN-K (34% of cases). Conclusion: patients
in whom clinical remission was conrmed may display persisting symptoms, relevant areas of functional
impairment and a decreased sense of wellbeing.
& 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords:
Remission
Symptomatology
Functioning
Quality of life
Subjective well-being
Schizophrenia
Schizoaffective disorders
1. Introduction
In recent years increasing emphasis has been placed on remission
(Nasrallah and Lasser, 2006) in schizophrenia, following the introduction of a set of well-established criteria by the Remission
Schizophrenia Working Group (RSWG) (Andreasen et al., 2005),
which has been proven to be conceptually viable and easy to use
both in clinical trials and clinical practice (Van Os et al., 2006).
Symptomatic remission is clinically relevant, as demonstrated by its
association with improved functioning (De Hert et al., 2007; Helldin
et al., 2007; Boden et al., 2009) but is not necessarily associated with
functional improvement; indeed approx. 50% of patients treated
achieve clinical remission, but only 20% reach functional remission
(Schennach-Wolff et al., 2009). Moreover, the majority of functionally
remitted patients are in clinical remission, whilst only a minority of
clinically remitted patients achieve functional remission (Wunderink
et al., 2007). The RSWG (Andreasen et al., 2005) underlined how the
proposed criteria were somewhat arbitrary, being based upon only
eight items of the PANSS and a cut-off score below 3, thus not
excluding the presence of still clinically relevant symptoms. A recent
study (Karow et al., 2012) revealed that remitted patients displayed
0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.psychres.2013.08.022
740
Table 1
Characteristics of the sample according to gender.
Items
Males
Females
42.76 (8.32)
45.34 (11.70)
72 (90)
8 (10)
25 (78.1)
7 (21.9)
97 (86.6)
15 (13.4)
2(1) 2.779,
p 0.096
Occupation (N, %)
Unemployed
Employed
60 (75)
20 (25)
23 (71.9)
9 (28.1)
83 (74.1)
29 (25.9)
2(1) 0.116,
p 0.733
10.35 (3.681)
12-06 (4.10)
Diagnosis (N, %)
Schizophrenia
Schizoaffective Dis
36 (45)
44 (55)
10 (31.2)
22 (66.8)
46 (41.1)
66 (58.9)
Total (N, %)
80 (71.4)
32 (28.6)
112 (100)
2.2. Evaluation
In line with procedures applied in previous studies (Carpiniello et al., 2002;
Primavera et al., 2012), retrospective data were collected from standardized clinical
records routinely used in the community mental health centre, as described by the
Italian version of procedures suggested by the Association for Methodology and
Documentation in Psychiatry (AMDP) (Conti et al., 1988). In particular, sociodemographic (gender, age, education, marital status, employment status) and
clinical data, course of illness according to DSMIV-TR course specier criteria for
schizophrenia, inpatient admissions, attempted suicides, legal problems, pharmacological and non pharmacological treatments were taken into account. To enhance
the retrospective evaluation of cases, clinical records were examined to ascertain
their suitability for providing reliable retrospective data. In order to conrm
diagnosis, subjects underwent comprehensive psychiatric evaluation by means of
the Structured Clinical Interview for Diagnosis for Axis I DSM-IV (SCID-I Research
Version) (First et al., 1996) after having signed an informed consent form. Interviews were conducted by residents in psychiatry trained in the use of the
instruments; inter-rater reliability, assessed using Cohen's K before the study,
was higher than 0.80. Personal and social data, and clinical history were collected
on the basis of a structured interview purpose-developed for the present study.
Symptoms were evaluated by means of PANSS (Positive and Negative Syndrome
Scale) (Kay et al., 1987), consisting in 30 items grouped into three distinct clusters
(positive symptoms, negative symptoms, general psychopathological symptoms);
symptoms are rated on a 7-point scale. To evaluate clinical remission, criteria
developed by the RSWG (Andreasen et al., 2005) based on ratings at eight focal
symptoms of PANSS (P1, P2, P3, N1, N4, N6, G5, G9) were applied. Patients are
judged to be in clinical remission when scores obtained at each of these items is
less than or equal to three over a six-month period. Due to the cross-sectional
nature of the study clinical remission was evaluated taking into account only the
severity criterion. Overall clinical status was evaluated by means of the Clinical
Global Impression-Schizophrenia scale (CGI-SCH) (Haro et al., 2003); CGI-SCH is
the adapted version of the CGI (Clinical Global Impression Rating Scale). The CGISCH provides for the assessment of severity and improvement of positive, negative,
cognitive, symptoms and depression over the week before the visit. The CGI scale
comprises three main domains: severity of illness, global improvement and efcacy
index. For the purposes of the present study only the severity score was applied.
Functioning was evaluated by means of PSP (Personal and Social Performance
Scale) (Morosini et al., 2000), an instrument assessing social functioning of patients
with schizophrenia in 4 main areas: social activities, personal and social relationships, self-care and disturbing /aggressive behaviours. For each area a score ranging
from 0 (no disability) to 5 (very severe disability) is attributed according to specic
criteria. A comprehensive overall score ranging from 1 (maximum dysfunction) to
100 (maximum functioning) is attributed, based on score obtained at each single
area. A total score equal to or higher than 80 indicates a condition of functional
remission.
Subjective wellbeing was evaluated by means of Subjective Wellbeing under
Neuroleptics-Short Version (SWN-K) (Naber et al., 2001), a self-administered 20item rating scale aimed at assessing the psychological and physical wellbeing of
patients treated with neuroleptics. An overall score equal to or higher than 80
indicates a state of subjective wellbeing.
Total
Statistics
t (110) 1.138 p 0.261
2(1) 1.786,
p 0.181
3. Results
3.1. Baseline characteristics
For the purpose of this study baseline (Table 1) characteristics of
the cohort enrolled in the study during the year 2010 were taken
into consideration. The sample was made up of 112 patients, 80
males (71.4%) and 32 (28.6%) females, who met the abovementioned inclusion/exclusion criteria; 46 patients (41.1%) were
affected by schizophrenia and 66 (58.9%) by schizoaffective disorder
(58.9%); mean age was 43.579.42 years (range 2568); mean years
of education were 10.8473.9 (range 424); 97 subjects (86.6%) were
single; 83 (74.1%) were unemployed.
3.2. Baseline clinical characteristics
Course of illness was continuous or episodic with interepisodic
residual symptoms in 89 cases (79.4%). Seventy-ve patients (67%)
had been admitted to hospital at least once in their life, with the
most signicant proportion (n38, 33.9%) having had 24 admissions and 10.8% (n12) of which had ve or more admissions.
Thirty-three patients (29.5%) had attempted suicide at least once in
their life (n17, 15.2% two or more attempted suicides); nine subjects
(8.0%) had been prosecuted by a criminal court for acts of violence
(one had been admitted to a Forensic Psychiatric Hospital);
38 patients were taking typical (33. 9%), and 86 (76.8%) atypical
741
Table 2
Sociodemographic and clinical characteristics of remitted and non remitted patients.
Items
Remitted (n 56)
Non-remitted (n56)
Statistic
Education (years)
Occupation (unemployed)
Course of illness (continuous episodic with residual symptoms)
Duration of illness (months)
Treatment (typical atypical)
Mean dosages of AP (CPZ equivalents)
11.55 (4.16)
36 (43.4%)
27 (48.2%)
163.68 (100.01)
5 (8.9%)
272 7162.82
10.13 (3.43)
47 (56.6%)
43 (76.8%)
227.48 (112.58)
13 (23.2%)
358.79 7 266.81
Adherence (CRS)
Good
Poor
Supported employment
CGI-S positive symptoms
CGI-S negative symptoms
CGI-S depressive symptoms
CGI-S cognitive symptoms
CGI-S overall severity
CGI-S Positive Sym, pts with a score 43
CGI-S Negative Sym, pts with a score 43
CGI-S Depressive sym, pts with a score 4 3
CGI-S Cognitive sym, pts with a score 43
CGI-S overall, pts with a score 4 3
PANSS positive scale
PANSS negative scale
PANSS general psychopathology
PANSS Total scale
PANSS positive Pts with at least 1 item 43
PANSS negative Pts with at least 1 item 43
PANSS general psychopathol. Pts with at least 1 item 43
PANSS Total scale Pts with at least 1 item 43
44 (78.6%)
12 (21.6%)
4 (7.1%)
1.60 (0.95)
1.78 (0.91)
1.71 (0.85)
1.84 (1.03)
2.45 (0.95)
5 (8.9%)
3 (5.4%)
2 (3.6%)
6 (10.7%)
16 (28.6%)
8.96 (2.09)
10.57 (3.65)
21.98 (4.87)
41.52 (7.92)
4 (9.1%)
13 (21.7%)
21 (30%)
30 (34.9%)
23 (41%)
33 (59%)
0 (0)
2.95 (1.42)
3.36 (1.27)
2.36 (1.31)
3.18 (1.20)
3.82 (0.76)
27 (48.2%)
29 (51.8%)
15 (26.8%)
25 (44.6%)
50 (89.3%)
14.39 (4.35)
18.70 (5.85)
32.68 (7.48)
65.77 (13.87)
40 (90.9%)
47 (78.3%)
49 (70%)
56 (65.1%)
2(1) 16.382
p o0.00005
2(1) 4.148, p 0.042
t(110) 5.853, po 0.0001
t(110) 7.478, p o0.0001
t(110) 3.076, p 0.003
t(110) 6.298, po 0.0001
t(110) 8.309, po 0.0001
2(1) 21.17, p o0.0001
2(1) 29.57, p o 0.0001
2(1) 11.72, P o0.001
2(1) 16.10, po 0.0001
2(1) 42.64, p o0.0001
t(110) 8.417, p o0.0001
t(110) 8.803, po 0.0001
t(110) 8.964, p o0.0001
t(110) 11.354, p o 0.0001
2(1) 48.513 p o 0.0001
2(1) 41.497, p o0.0001
2(1) 29.867 po 0.0001
2(1) 33.860, p o 0.0001
Rating
Scale;
CGI-S Clinical
Global
Impression
Scale-Schizophrenia;
PANSS Positive
and
Negative
Syndrome
Scale;
PANSS positive scale 1.591; negative scale 1.667; General Psychopathology1.695; total score1.697). Scores obtained at each
single item of PANSS (data not included in Table 2) were signicantly
higher for non-remitted patients, with the exception of items N7
(stereotyped thinking), G8 (uncooperativeness), and G14 (impulse
discontrol). The proportion of patients with at least one item scoring
43 at each subscale and overall PANSS was again signicantly higher
among non-remitters.
3.4. Functioning
Mean scores achieved at PSP (Table 3) were all signicantly
higher among non-remitters, indicating poorer functioning, with
effects of medium effects magnitude for PSP Self-care (Cohen's
d 0.481) and Aggressive-Disturbing Behaviour (Cohen's d0.552)
subscales, medium-large effects for PSP social relationships subscales (Cohen's d0.730) and large effect for PSP Socially Useful
Activities subscales (Cohen's d1.064). Mean total score was signicantly lower among non-remitters, with a large magnitude effect,
indicating a poorer functioning (Cohen's d 0.835). The proportion of patients showing a total score o70 (signicant impairment
of overall functioning) and the percentage of subjects showing a
score 42 at each single PSP subscale (signicant impairment in
functioning) was signicantly higher among non-remitters.
742
Table 3
Functioning in remitted and non remitted patients.
Items
Remitted (n 56)
Non-remitted (n56)
Statistics
PSP -activities
PSP-social rel
PSP -self care
PSP -aggressive and disturbing behaviour
PSP Total
PSP Total Pts with a score o 70
PSP activities Pts with score 42
PSP social rel Pts with score 42
PSP self care Pts with score 42
PSP -aggressive and disturbing behaviour Pts with score 42
1.88
2.02
0.34
0.14
62.27
38
30
38
5
2
3.20
2.86
0.80
0.50
50.38
51
51
49
10
7
(1.27)
(1.15)
(0.69)
(0.44)
(13.65)
(67.9%)
(53.6%)
(67.8%)
(8.9%)
(3.6%)
(1.21)
(1.15)
(1.16)
(0.81)
(14.79)
(91.1%)
(91.1%)
(87.5%)
(17.9%)
(12.5%)
Table 4
Subjective wellbeing in remitted and non-remitted patients.
Items
SWN
SWN
SWN
SWN
SWN
SWN
SWN
mental
Self-control
Physical
emotional control
social
Total
Total Pts with a score o80
Remitted (n 56)
Non-remitted (n 56)
Statistics
16.98
17.59
17.79
16.71
17.57
86.64
19
15.79
16.21
16.98
16.91
16.70
82.59
22
(3.44)
(3.96)
(3.53)
(3.94)
(3.15)
(14.03)
(33.9%)
(4.58)
(4.07)
(3.96)
(4.52)
(4.02)
(15.84)
(39.3%)
4. Discussion
In our sample, 50% of subjects were judged as being in clinical
remission, a result in line with data present in literature (SchennachWolff et al., 2009). As in other studies (Brissos et al., 2011; Karow et al.,
2012) remission was associated with a signicantly better psychopathological prole, as attested by mean scores at PANSS and CGI-SCH.
However, a relevant proportion of remitted subjects displayed symptoms of at least a moderate level (score 43) both at PANSS (35%) and
CGI-SCH (29%). In particular, remitters displayed moderate levels of
positive symptoms (approx. 9% of cases both at PANNS and CGI-SCH),
negative symptoms (approx. 22% of cases at PANNS and 5.5% at CGISCH), and other symptoms such as those included in General
Psychopathology Subscale of PANNS (30% of cases), as well as at
Depression (4% of cases) and Cognitive subscales (11% of cases) of CGISCH. These ndings, which are in line with data of Karow et al. (2012),
on one hand further conrm the empirical validity of the RSWG
criteria (Andreasen et al., 2005; Van Os et al., 2006), whilst on the
other suggesting that being in remission should not imply a substantial absence of symptoms, as commonly conceived. Thus, achieving of remission should not mask the ongoing need for therapeutic
efforts aimed at improving the persisting positive, or more frequently
negative, affective and/or cognitive symptoms exerting a potential
impact on functional status (Green et al., 2000; Kirkpatrick et al.,
743
Table 5
Subjective Quality of Life in remitted and non-remitted patients.
Items
WHO-QoL
WHO-QoL
WHO-QoL
WHO-QoL
WHO-QoL
WHO-QoL
Bref
Bref
Bref
Bref
Bref
Bref
Item G1
Pts with a score o 3 at Item G1
Physical
Psychological
Social Relationships
Environment
Remitted (n 56)
Non-remitted (n 56)
Statistics
3.57
4
14.27
12.22
12.74
12.19
3.36
13
13.18
12.10
12.18
12.16
(0.87)
(7.2%)
(2.37)
(1.51)
(3.1)
(1.61)
(1.03)
(23.2%)
(3.24)
(1.87)
(4.1)
(1.81)
patients relate to the areas of social and daily life, whilst, as expected, a
satisfactory degree of functioning was observed in personal appearance and control of aggressiveness, in the cohort of stable, chronic
patients living in the community included in the present study. In our
study no statistically signicant differences were revealed in terms of
wellbeing between remitters and non remitters, although generally
lower mean scores at SWN were obtained in non-remitters, and the
percentage of subjects manifesting a state of well-being (SWN total
score 80 or over) was higher among remitters. With regard to
subjective quality of life, remitters and non-remitters displayed largely
similar scores at each subscale of WHO-QoL. However, 33% of
remitters were found not to be in a state of well-being and 7%
declared a low quality of life. Taken together, these results seems to
indicate that the subjective experience of life in psychotic patients is
only partially related to their status of remission, thus reecting the
well-known multi-determined nature of both subjective wellbeing
and quality of life constructs. In fact, subjective wellbeing is inuenced
by several different factors, not only illness-related but also affected by
other variables such as the physical side effects of drugs and associated
distress, attitudes towards pharmacological treatment, insight and
psychosocial factors (Karow and Naber, 2002). Quality of life is in turn
a highly complex measure, correlated with a number of factors,
including illness, medication or stress process-related variables, personality traits, and level of social support and psychosocial interventions, which may act as protective factors (de Millas et al., 2006); in
this complex framework, the strength of association of symptomatology and Quality of Life measures, in particular of a subjective nature, is
generally weak (Eack and Newhill, 2007).
5. Conclusions
Before drawing any conclusion, some important limitations of
the present study should be highlighted, such as: the limited
number of cases examined; the fact that only chronic outpatients
who were still in contact with the centre were considered, thus
excluding patients who had moved away, refused to stay in
treatment due to scarce insight and/or very severe illness, or had
no further need of continuing care; the differences in the organisation of the mental health system and the social background of
the study sample, which may have exerted a potential inuence on
outcomes. Bearing in mind these limitations, some results seem to
be worthy of consideration.
Clinical recovery is frequently achieved even by chronic psychotic
patients, a result associated with a signicantly higher level of
functioning. Unfortunately, clinical remission is not necessarily
accompanied by functional remission, which remains largely independent of clinical status. Although approximately 50% of patients
treated in a community setting achieve clinical remission, the
consistent proportion of patients who are still symptomatic and
functionally impaired even when remitted should not be overlooked. Moreover, the remaining 50% do not achieve clinical remission and continue to feature a high degree of functional impairment.
This outcome likely reects, at least in the community context
Acknowledgements
The authors wish to thank the other components of the Cagliari
Recovery Study Group: Davide Aru, Chiara Bandecchi, Elena Corda,
Enrica Diana, Francesca Fatteri, Alice Ghiani, Alice Lai, Serena Lai,
Lorena Lai, Valeria Perra, Sonia Pintore, Silvia Pirarba, Elisabetta Piras,
Sara Piras, Laura Puddu, Rachele Pisu Randaccio, Lucia Sanna,
Manuela Taberlet, Cristina Tocco, Massimo Tusconi, Enrico Zaccheddu
for their contribution to the study, and Ms Anne Farmer for having
revised the English version of the paper.
References
Andreasen, N.C., Carpenter Jr., W.T., Kane, J.M., Lasser, R.A., Marder, S.R., Weinberger, D.R., 2005. Remission in schizophrenia: proposed criteria and rationale for
consensus. American Journal of Psychiatry 162 (3), 441449.
Boden, R., Sundstrom, J., Lindstrom, E., Lindstrom, L., 2009. Association between
symptomatic remission and functional outcome in rst-episode schizophrenia.
Schizophrenia Research 107 (23), 232237.
Brissos, S., Videira Dias, V., Balanz-Martinez, V., Carita, A.I., Figueira, M.L., 2011.
Symptomatic remission in schizophrenia patients: relationship with social
functioning, quality of life, and neuro cognitive performance. Schizophrenia
Research 129 (23), 133136.
Byerly, M., Fisher, R., Whatley, K., Holland, R., Varghese, F., Carmody, T., Magouirk,
B., Rush, A.J., 2005. A comparison of electronic monitoring vs clinician rating of
antipsychotic adherence in outpatients with schizophrenia. Psychiatry
Research 133 (23), 129133.
Cannon-Spoor, H.E., Potkin, S.G., Wyatt, R.J., 1982. Measurement of premorbid
adjustment in chronic schizophrenia. Schizophrenia Bulletin 8, 470484.
Carpiniello, B., Pinna, F., Tusconi, M., Zaccheddu, E., Fatteri, F., 2012. Gender
differences in remission and recovery of schizophrenic and schizoaffective
744