Department of Psychiatry, University of Illinois College of Medicine, Chicago, IL
Department of Psychology, University of Chicago, IL, USA
Correspondence: Dr M. Harrow, Department of Psychiatry (M/C 912), University of Illinois College of Medicine, 1601 W. Taylor St., Chicago, IL 60612, USA
Declaration of interest Supported by a research grant from the National Institute of Mental Health, USA.
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To provide longitudinal data on clinical course and outcome in schizoaffective disorders versus schizophrenia and affective disorders, and determine whether mood-incongruent psychotic symptoms have negative prognostic implications.
Method A total of 210 patients with schizoaffective disorders, schizophrenia, bipolar manic disorders and depression were assessed at hospitalisation and then followed up four times over 10 years.
Results At all four follow-ups, fewer patients with schizoaffective disorders than with schizophrenia showed uniformly poor outcome. Patients with mood-incongruent psychotic symptoms during index hospitalisation showed significantly poorer subsequent outcome (P < 0.05).
Conclusions Schizoaffective outcome was better than schizophrenic outcome and poorer than outcome for psychotic affective disorders. Mood-incongruent psychotic symptoms have negative prognostic implications. The results could fit a symptom dimension view of schizoaffective course.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The sample is derived from the Chicago Follow-up Study, a rare sample of schizophrenia, schizoaffective, bipolar and other affective disorders studied prospectively at the acute phase and then studied longitudinally at successive follow-ups over many years. The investigation was planned to study prognosis, course and outcome longitudinally (Grossman et al, 1984; Harrow et al, 1990; Grossman et al, 1991; Goldberg et al, 1995; Harrow et al, 1997; Sands & Harrow, 1999) and to investigate factors involved in thought disorder and positive and negative symptoms on a longitudinal basis (Grossman et al, 1986; Sands & Harrow, 1994; Harrow et al, 1995; Harrow et al, 2000).
The diagnoses were based on structured research interviews administered at
index hospitalisation: the Schedule for Affective Disorders and Schizophrenia
(SADS) and/or theSchizophrenia State Interview (see
Grinker & Harrow, 1987).
Using to assess interrater reliability for diagnosis for the largest
group - the schizophrenia patients - we obtained
=0.08.
At index hospitalisation the patients were consecutive or successive admissions within the limitation of giving preference to younger (17-30 years at index) patients with fewer previous hospitalisations. This was done to study relatively early young patients, thus diminishing the effects of long-term treatment and chronicity (Grinker & Harrow, 1987; Harrow et al, 1997). Patients were assessed prospectively at index and then reassessed at four successive follow-ups (at 2, 4.5, 7.5 and 10 years after the index hospitalisation). Outcome data at the 10-year follow-up were available for slightly over 80% of the original sample studied as inpatients. Of the 210 patients in the current sample, all had a 10-year follow-up, with 191 (91%) having four successive follow-ups and the other 19 (9%) having three of the four follow-ups, including a 10-year follow-up. Within each diagnostic group, patients in the current sample did not differ significantly in age, education, gender distribution or number of pre-index hospitalisations from the subsample of patients who were assessed at the 2-year follow-up but not assessed at the 10-year follow-up. In addition, there were no significant differences at the 2-year follow-up on overall outcome, on working functioning or on rehospitalisations between the current sample of patients with schizoaffective disorders and the small subsample who also were assessed at the 2-year follow-ups but were not available for assessment at the 10-year follow-ups (P>0.20).
The mean age of the sample was 22.9 years at index hospitalisation. Seventy-two per cent had either one or no previous hospitalisations prior to index hospitalisation. The mean education level was 13.2 years at index. There were no significant age differences between the diagnostic groups. Written informed consent was obtained from all subjects.
Forty-seven per cent of the patients with schizoaffective disorder were women. A larger percentage of the patients with unipolar disorders were women and a larger percentage of the patients with schizophrenia were men. These gender differences are in accord with the typical, modern distribution of depression and schizophrenia.
Follow-up assessments
The sample was followed up at a mean of 2, 4.5, 7.5 and 10 years after
initial assessment at index hospitalisation, using the SADS and the Harrow
Functioning Interview (Grinker &
Harrow, 1987; Harrow et
al, 1997).
To rate overall post-hospitalisation functioning and adjustment at each follow-up we employed the Levenstein-Klein-Pollack (LKP) scale (Levenstein et al, 1966) and a system to evaluate instrumental work performance and rehospitalisation developed by Strauss & Carpenter (1972). The LKP scale has been used successfully by our research team and others (Levenstein et al, 1966; Grinker & Harrow, 1987; Goldberg et al, 1995; Harrow et al, 1997). The eight-point LKP scale takes into account work and social functioning, life adjustment, self-support, major symptoms, relapses and rehospitalisations. In assessing interrater reliability for the LKP scale, we obtained an intraclass correlation coefficient of r=0.92 (P<0.01). The LKP scale also allows for separation of the sample into three groups: good outcome, remission or recovery during the follow-up year (scores of 1 or 2), indicating adequate or near-adequate functioning in all areas in the past year; moderate impairment (scores of 3 to 6), indicating difficulties in some but not all areas of adjustment during the year; and uniformly poor outcome during the past year (scores of 7 or 8), indicating uniformly poor functioning, including poor psychosocial functioning and major symptoms. We found a correlation of r=0.85 (P<0.001) between the eight-point LKP scale and scores on the Global Assessment Scale, providing an indication that different outcome measures often tap similar concepts and produce similar results, although this does not guarantee validity.
The SADS data on psychosis at index hospitalisation were used to assess mood congruence or incongruence of psychotic symptoms for those patients who had both psychotic symptoms and a full affective syndrome (the patients with schizoaffective disorder and the patients with psychotic depression). We employed the definitions of mood congruence from DSM-III-R and DSM-IV (American Psychiatric Association 1987, 1994). Because many patients had both some mood-congruent and some mood-incongruent psychotic symptoms, the preponderance of mood congruence at index hospitalisation was determined by whether the majority of psychotic symptoms were mood congruent or incongruent (number of mood-congruent psychotic symptoms divided by total number of psychotic symptoms). This rating scale was applied at index to a subsample of 47 patients with schizoaffective (n=31) and psychotic affective disorders (n=16). Among the patients with schizoaffective disorders for whom complete assessments in this area were possible, all had some mood-incongruent psychotic symptoms and most (25/31 or 81%) had psychotic symptoms that were predominantly mood incongruent. Among 16 patients with psychotic depression most, but not all (9/16 or 56%), had psychotic symptoms that were predominantly mood congruent.
Statistical analysis
The data on overall outcome for the four diagnostic groups at the four
successive follow-ups were analysed using a 4 x 4 (mixed design)
repeated-measures analysis of variance (ANOVA), with diagnosis as a
between-subjects factor and time as a within-subjects factor. One-way ANOVAs
were conducted to test for differences between the diagnostic groups at each
follow-up, with contrasts (cf. Rosenthal
& Rosnow, 1991) used to test predictions regarding the rank
ordering of group performance in each analysis. Newman-Keuls post hoc
analyses were also used to test differences between individual diagnostic
groups. In some cases logistic regression analyses were used to test the
relationship between diagnosis and outcome
(Hosmer & Lemeshow, 1989).
Again, more specific hypotheses regarding the rank ordering of diagnostic
group were tested via linear contrasts.
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
|
Outcome and medication
At the 10-year follow-up 50% of the patients with schizoaffective
disorders, 26% of those with non-schizophrenic psychotic disorders and 56% of
those with schizophrenia were being treated with antipsychotic medication,
either alone or in combination with other medication. At the 10-year follow-up
46% of the subsample of patients with bipolar manic disorders and 20% of those
with schizoaffective disorders were on mood stabilisers. Similarly, at the
10-year follow-up 18% of the patients with non-psychotic depression were on
antidepressants, as were 17% of those with schizoaffective disorders and 7% of
those with psychotic affective disorders.
Comparisons of outcome for patients on antipsychotic medication with schizophrenia, schizoaffective disorders and psychotic affective disorders produced results similar to the comparisons found using the entire sample. Thus, at the 10-year follow-up, the patients with schizoaffective disorders who were on antipsychotic medication showed poorer outcome than those with psychotic affective disorders on antipsychotic medication and slightly better outcome than those with schizophrenia on antipsychotic medication. However, these differences were not statistically significant.
Comparisons of the subsample of patients not on any medication showed some similarity in results, with the patients with schizoaffective disorders showing slightly better outcome than those with schizophrenia but slightly poorer outcome than those with psychotic affective disorders. These differences were not statistically significant, partly due to the small sample sizes.
Instrumental work functioning and rehospitalisation over 10
years
Table 1 reports the mean
scores on the Strauss-Carpenter Work Functioning and Rehospitalisation Scales
for the four diagnostic groups at each follow-up.
|
Schizoaffective disorder and acute-phase mood-incongruent psychotic
symptoms: prognostic significance
Figure 2 presents data on
potential differences in later outcome between patients with psychotic and
affective disorders who, during the acute phase at index hospitalisation, had
a predominance of mood-incongruent psychotic symptoms compared with patients
with a predominance of mood-congruent psychotic symptoms.
|
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Overall outcome at four successive follow-ups over 10 years
On some outcome dimensions the patients with schizoaffective disorders
looked more like those with psychotic affective disorders and on other
dimensions they looked more like those with schizophrenia. Thus, unlike the
psychotic affective disorders, at each follow-up year only a limited number of
patients with schizoaffective disorders (less than 40%) showed complete
recovery.
The overall outcome of the patients with schizoaffective disorders was consistently better than that of those with schizophrenia and poorer than that of those with psychotic affective disorders over the 10-year period. The mean outcome scores for schizoaffective disorders lay between those for schizophrenia and the psychotic affective disorders.
Uniformly poor outcome
Although uniformly poor outcome was extremely prominent for many patients
with schizophrenia, at each follow-up a larger percentage of schizoaffective
than psychotic affective or non-psychotic disorders showed uniformly poor
outcome. The linear ranking of the four diagnostic groups in the logistic
regression analysis (schizophrenia, schizoaffective disorders, psychotic
affective disorders and non-psychotic depression) best accounted for variance
in the contribution of diagnosis to poor outcome (P<0.01).
These and other data (Grossman et al, 1984, 1991) suggest that fewer patients with schizoaffective disorders and some of those with psychotic depression show the uniformly poor outcome in multiple areas shown by a number of those with schizophrenia.
Does acute-phase psychosis matter?
The current data indicating large differences in outcome between patients
with schizoaffective disorders (who initially had an affective syndrome) and
those with non-psychotic depression (who also had an affective syndrome) are
not in accord with proposals that de-emphasise the importance of psychotic
symptoms.
The large significant differences in course and outcome between patients with schizoaffective disorders and those with unipolar non-psychotic depression fit with theoretical views suggesting the importance of delusions and psychosis (Bentall, 1988; Brockington, 1991; Harrow et al, 1995), and with data indicating poorer outcome for patients with schizophrenia and those with psychotic affective disorders compared with those with non-psychotic depression. The current data and other data (Sands & Harrow, 1994; Harrow et al, 1995) suggest that patients with psychotic symptoms at the acute phase are more vulnerable to subsequent recurrence of psychosis and subsequent difficulties in outcome.
Does mood-incongruent psychosis matter?
Although the data indicate that psychosis is a risk factor, the issue of
the prognostic significance of mood-incongruent psychotic symptoms is also
important and is closely linked to basic issues about schizophrenia and
schizoaffective disorders. The present research investigated whether poor
outcome for patients with schizoaffective disorders and some patients with
psychotic depression is associated with their vulnerability to
mood-incongruent psychotic symptoms.
Previous research (Coryell & Tsuang, 1985; Tohen et al, 1992; Davies & Harrow, 1994) has suggested that the presence of mood-incongruent, schizophrenic-like psychotic symptoms at initial acute hospitalisation may mark a potential vulnerability to poor outcome, both in patients with schizoaffective disorders who have major affective symptoms and in those with schizophrenia who do not have major affective symptoms during acute hospitalisation.
The current data support the hypothesis that patients with a predominance of mood-incongruent psychotic symptoms are more vulnerable to subsequent outcome difficulties in other areas. Surprisingly, the results did not show more subsequent psychosis by patients with mood-incongruent psychotic symptoms. This is in accord with other data on the presence of mood-incongruent psychotic symptoms (Davies & Harrow, 1994).
It is possible that the presence of acute-phase psychotic symptoms indicates a trait-like tendency to subsequent psychosis (Harrow et al, 1995), but this tendency may not be increased by the presence of mood-incongruent psychotic symptoms. Rather, mood-incongruent psychotic symptoms may be associated with personal vulnerabilities that can negatively influence later adjustment and dysfunction in multiple areas other than psychosis, and may affect the severity of subsequent psychotic symptoms when they do occur (Harrow et al, 1995).
Symptom dimension view of schizoaffective outcome
An alternative outlook to help account for the results obtained on outcome
of patients with schizoaffective disorders over time involves a dimensional
view of symptoms (Bentall et al,
1988; Bentall,
1990; Costello,
1993; Harrow et al,
1995). This approach de-emphasises the importance of specific
diagnostic labels (such as schizoaffective disorder, schizophrenia and
psychotic affective disorder) and instead focuses on major symptoms such as
psychosis, affective syndromes and mood-incongruent delusions.
Using this view, which de-emphasises diagnosis and focuses on separate features and symptoms, psychosis (associated with poor prognosis), affective symptoms (at the acute phase traditionally associated with more favourable prognosis for psychotic patients) and mood-incongruent psychotic symptoms (a negative prognostic feature) are seen as symptom dimensions that can account for some of the variance associated with functioning and outcome years later. Thus, at the acute phase, patients with schizophrenia have negative features on all three of these dimensions, patients with schizoaffective disorders have negative features on two of them, patients with psychotic affective disorders have negative features on one of them and patients with non-psychotic affective disorders have negative features on none of them. Outcome predictions from this constellation of symptoms match the results obtained at all four follow-ups from the contrast analysis presented in the Results. Overall, if one adopts a symptom dimension view concerning the major aspects of psychopathology, the model accounts for some of the outcome differences that emerged. The most promising view could be an outlook that utilises a combination approach in which both diagnosis and symptom dimensions are important, with each involving factors contributing to major features of outcome. However, functioning and outcome are obviously complex variables with multiple determinants.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM-IV). Washington, DC: APA.
Bentall, R. P. (1990) The syndromes and symptoms of psychosis: or why you can't play twenty questions with the concept of schizophrenia and hope to win. In Reconstructing Schizophrenia (ed. R. P. Bentall), pp. 23-60. London: Routledge.
Bentall, R. P., Jackson, H. F. & Pilgrim, D. (1988) Abandoning the concept of schizophrenia: some implications of validity arguments for psychological research into psychotic phenomena. British Journal of Clinical Psychology, 27, 303-324.[Medline]
Brockington, I. (1991) Factors involved in delusion formation. British Journal of Psychiatry, 159 (suppl. 14), 42-45.
Brockington, I. & Leff, J. P. (1979) Schizo-affective psychosis: definitions and incidence. Psychological Medicine, 9, 91-99.[Medline]
Coryell, W. & Tsuang, M. (1985) Major depression with mood-congruent or mood-incongruent psychotic features; outcome after 40 years. American Journal of Psychiatry, 142, 479-482.[Abstract]
Costello, C. (1993) Advantages of the symptom approach to schizophrenia. In Symptoms of Schizophrenia (ed. C. Costello), pp. 1-26. New York: John Wiley & Sons.
Davies, E. & Harrow, W. (1994) Does mood congruence of psychotic symptoms matter? In Scientific Proceedings of 147th Annual Meeting of the American Psychiatric Association, p. 40. Washington, DC: American Psychiatric Association.
Fennig, S., Bromet, E., Karant, M., et al (1996) Mood-congruent versus mood-incongruent psychotic symptoms in first-admission patients with affective disorder. Journal of Affective Disorders, 27, 23-29.
Goldberg, J. F., Harrow, M. & Grossman, L. S. (1995) Recurrent affective syndromes in bipolar and unipolar affective mood disorders at follow-up. British Journal of Psychiatry, 166, 382-385.[Abstract]
Grinker, R., Sr & Harrow, M. (1987) Clinical Research in Schizophrenia: A Multidimensional Approach. Springfield, IL: Charles C. Thomas.
Grossman, L. S., Harrow, M., Fudala, J. L., et al (1984) The longitudinal course of schizoaffective disorders. A prospective follow-up study. Journal of Nervous and Mental Disease, 172, 140-149.[Medline]
Grossman, L. S., Harrow, M., & Sands, J. R. (1986) Features associated with thought disorder in manic patients at 2-4-year follow-up. American Journal of Psychiatry, 14, 306-311.
Grossman, L. S., Harrow, M., Goldberg, J. F., et al (1991) Outcome of schizoaffective disorder at two long-term follow-ups: comparisons with outcome of schizophrenia and affective disorders. American Journal of Psychiatry, 148, 1359-1365.[Abstract]
Harrow, M. & Grossman, L. S. (1984) Outcome in schizoaffective disorders: a critical review and reevaluation of the literature. Schizophrenia Bulletin, 10, 87-108.[Medline]
Harrow, M., Goldberg, J., Grossman, L., et al (1990) Outcome in manic disorders. Archives of General Psychiatry, 47, 665-671.[Abstract]
Harrow, M., MacDonald, A., Sands, J., et al (1995) Vulnerability to delusions over time in schizophrenia and affective disorders. Schizophrenia Bulletin, 21, 95-109.[Medline]
Harrow, M. Sands, J. R., Silverstein, M. L., et al (1997) Course and outcome for schizophrenia versus other psychotic patients: a longitudinal study. Schizophrenia Bulletin, 23, 287-303.[Medline]
Harrow, M., Green, K., Sands, J., et al (2000) Thought disorder in schizophrenia and mania: impaired context. Schizophrenia Bulletin, 26, 879-891.[Medline]
Hosmer, D. W. & Lemeshow, S. (1989) Applied Logistic Regression. New York: John Wiley & Sons.
Kendler, K. S., McGuire, M., Gruenberg, A. M., et al (1995) Examining the validity of DSM-III-R schizoaffective disorder and its putative subtypes in the Roscommon Family Study. American Journal of Psychiatry, 152, 755-764.[Abstract]
Levenstein, S., Klein, D. & Pollack, M. (1966) Follow-up study of formerly hospitalized voluntary psychiatric patients: the first two years. American Journal of Psychiatry, 122, 1102-1109.[Medline]
Maj, M. (1989) A family study of two subgroups of schizoaffective patients. British Journal of Psychiatry, 154, 640-643.[Abstract]
Marneros, A., Deister, A. & Rohde, A. (1989) Quality of affective symptomatology and its importance for the definition of schizoaffective disorders. Psychopathology, 22, 152-160.[Medline]
Marneros, A., Deister, A. & Rohde, A. (1992) Comparison of long-term outcome of schizophrenic, affective and schizoaffective disorders. British Journal of Psychiatry, 161 (suppl. 18), 44-51.[Abstract]
McGlashan, T. & Williams, P. (1990) Predicting outcome in schizoaffective psychosis. Journal of Nervous and Mental Disease, 178, 518-520.[Medline]
Rosenthal, R. & Rosnow, R. (1991) Essentials of Behavioral Research: Methods and Data Analysis. New York: McGraw-Hill.
Sands, J. R. & Harrow, M. (1994) Psychotic unipolar depression at follow-up: factors related to psychosis in the affective disorders. American Journal of Psychiatry, 151, 995-1000.[Abstract]
Sands, J. R. & Harrow, M. (1999) Depression during longitudinal course of schizophrenia. Schizophrenia Bulletin, 25, 157-171.[Medline]
Stephens, J. H., Richard, P. & McHugh, P. R. (1997) Long-term follow-up of patients hospitalized for schizophrenia, 1913 to 1940. Journal of Nervous and Mental Disease, 185, 715-721.[CrossRef][Medline]
Strauss, J. & Carpenter, W. (1972) The prediction of outcome in schizophrenia: 1. Characteristics of outcome. Archives of General Psychiatry, 27, 739-746.[CrossRef][Medline]
Tohen, M., Tsuang, M. & Goodwin, D. (1992) Prediction of outcome in mania by mood-congruent or mood-incongruent psychotic features. American Journal of Psychiatry, 149, 1580-1584.[Abstract]
Van Praag, H. & Nijo, L. (1984) About the course of schizoaffective psychoses. Comprehensive Psychiatry, 25, 9-22.[Medline]
World Health Organization (1992) Tenth Revision of the International Classification of Diseases and Related Health Problems (ICD-10). Geneva: WHO.
Received for publication January 17, 2000. Revision received May 30, 2000. Accepted for publication June 9, 2000.