The importance of social factors in schizophrenia

Clinical course and social disability

Schizophrenia remains a mental illness characterised by a wide variety of outcomes (Shepherd et al., 1989). After a first episode around one quarter of sufferers will recover and need no further input. Another two-thirds will have a variable course with recurrent relapses. A final 10% will remain severely disabled and in need of continuing and high contact care from services. Women have a consistently better outcome than men. Unusually for a long-term illness, over the very long term (i.e. two to three decades from the 1950s) there has been a substantial improvement in recovery rates.

It is important to distinguish between clinical and social outcomes. A minority of patients continue to have medication resistant positive symptoms such as voices or delusional ideas which may be distressing. Estimates of the frequency of these phenomena range from around 5–7% (Leff & Wing, 1971), through 23% (Curson et al., 1985) to 55% (Harrow, Carone & Westermeyer, 1985; Harrow, Ratenbury & Stoll, 1988). There is also evidence that depression is found in a considerable number (25–40%) of those with psychosis (Hemsley, 1992; Johnstone et al., 1991), and that the suicide rate is around 10% (Hirsch, Walsh & Draper, 1982).

Social outcome is often linked to clinical outcome – a poorer clinical outcome is likely to lead to social impairment, but not inevitably so. Shepherd et al. (1989), found two-fifths of their sample to have no more than mild impairment after five years, although men were more impaired than women.