Long-term outcomes of patients with first-episode schizophrenia-spectrum disorders and the impact of early intervention service in Hong Kong

Abstract

Most of the earlier long-term follow-up studies reported that patients with schizophrenia-spectrum disorders have heterogeneous outcomes with only 20% reaching symptomatic remission. The early intervention services (EIS) for patients with first-episode psychosis (FEP), including schizophrenia-spectrum disorders, were implemented in many different countries aiming to improve the long-term outcomes of the patients by early illness detection and providing intensive bio-psychosocial intervention during the early phase of the illness. Many studies have convincingly reported the short-term positive effect of the EIS on patient outcomes, however, evaluation of impact of EIS on long-term outcomes is limited. In Hong Kong, a 2-year phase-specific early intervention service for patients with FEP was implemented as a region-wide service in 2001. The aim of this thesis is to systematically evaluate the cross-sectional and longitudinal long-term clinical, social and cognitive function outcomes of patients with first-episode schizophrenia-spectrum disorders and the possible impact of the 2-year EIS for FEP in Hong Kong. The role of demographics, premorbid functioning, early clinical and functioning responses to the EIS in predicting the long-term outcomes were studied. At 10-year follow up of the first-episode schizophrenia-spectrum (FES) disorder patients, about half of them achieved clinical remission but only one quarter achieved complete recovery. At 12-year follow up of the first-episode patients, about 15% of them were considered treatment resistant. There is a lack of significant effect of EIS on the cross-sectional clinical remission and functional recovery at 10-year follow up. On the other hand, patients who received the EIS had significantly lower suicide mortality and less hospitalisation over 10-12-year period with a dilution effect over years. Other longitudinal outcome patterns and trajectories of patients with FES explored in this thesis include negative symptoms, employment, relapse, and cognitive functions. Results not only revealed heterogeneity of the long-term outcomes of patients with schizophrenia, but also demonstrated the heterogeneity in responses to the early intervention program. Over two thirds of the patients who received EIS had sustained improvement of employment over 10 years, yet about one third of the patients showed some improvement of employment outcomes but this beneficial effect did not sustain after the completion of EIS. Studies in this thesis have also highlighted that some demographics, premorbid factors and early clinical characteristics have differential prognostic value for different outcomes. Duration of untreated psychosis associated with clinical remission, years of education was related to recovery, premorbid social adjustment was found to be related to the development of treatment resistance. Ongoing treatment outcome indicators including duration of response to antipsychotic medication in the first episode, early relapses, poor medication adherence and early employment were found to be related to different long-term outcomes as well. Therefore, the development of tailored and personalized early intervention programs, based on the individual treatment responses and other relevant biopsychosocial outcome markers, could be the future direction of service development to improve long-term outcomes of patients with schizophrenia.