1. Remission in Schizophrenia: Clinical and PsychoSocial Dimensions
Prof Yoram BARAK, MD, MHA.
ABARBANEL M.H.C.
Bat-Yam,
ISRAEL
Prof Y Barak

2. Remission in Schizophrenia
the Road to Recovery
Prof Y Barak

3. Sustained Remission > 6 months Remission/ Functional Remission
Current and Future Directions
Cure
Recovery
Maintain
(normal without treatment)
Sustained Remission > 6 months
(“normal”)
Remission/ Functional Remission
Resolution
Attain
Stable
(virtual absence of diagnostic symptoms for 6 monts)
Response
(no obvious evolution)
(virtual absence of diagnostic symptoms)
Acute Phase
(decrease of symptoms)
(ill)
Prof Y Barak

4. Long-term outcomes in schizophrenia
Focus on functionality
Potential for remission
2000+
Increase ‘stable’ periods
Minimise negative symptoms
1990s
Reduce relapse
Minimise positive symptoms
1980s
‘Survive’ out of hospital
De-institutionalisation
Improve self-care
Reduce aggression
Reduce self-injury s
Pre-1960s
Prof Y Barak

5. Expanded model of remission in schizophrenia
Increasing severity
Symptoms absent
Symptoms ‘mild’ or less
Diagnostic threshold
RESOLUTION
6 months
‘Normalcy’ threshold
RELAPSE
RESPONSE
REMISSION
Prof Y Barak
Peuskens J & Kane J. In preparation.

6. Remission in Schizophrenia Improvement dependency
Functional
and
Social Autonomy
Recovery
Maintaining Stability
Response
Functional,
Quality of Life
Remission
Prof Y Barak
Adapted from Weiden et al, J Clin Psych 1996; 57: 53-60

7. What is Remission? Remission in nonpsychiatric illnesses:
The reduction or the complete absence of disease symptoms.
Remission in psychiatric illnesses:
Defined not by the complete absence of symptoms but by minimal symptoms with mild disability.
Prof Y Barak

8. Prof Y Barak

9. StoRMi - Study Design:
Schizophrenia or any other psychiatric disorders requiring long-term antipsychotic treatment
Symptomatically stable patients on any previous antipsychotic medication for 1 month
Length of treatment: 6 months +6 months
22 participating countries
Number of recruited patients: 1,909
Prof Y Barak

10. Treatment
25 מ"ג של זריקת ריספרידון לטווח ארוך ניתנה אחת לשבועיים במשך 6 חודשים.
באם לא הייתה הטבה בסימפטומים או אם לא הושגה תגובה מספקת לטיפול, ניתן היה להעלות במינון 2-4 שבועות לאחר הזריקה האחרונה למינון של 37.5 או 50 מ"ג אחת לשבועיים.
הטיפול האנטיפסיכוטי הקודם ניתן במשך 3 שבועות הראשונים לזריקה.
Prof Y Barak

11. Treatment change from Other 87 = 5% Conv. Oral 254 = 14% Risperidone
Olanzapine
Quetiapine
Amisulpiride
Risperidone
732 = 39%
Ziprasidone
Conv Depot
Conv. Depot
813 = 43%
Conv. Oral
Other
More than 1 drug per patient possible
Olanzapine 192 = 10%
Quetiapine 49 = 3%
Ziprasidone 6 = 0%
Amisulpiride 57 = 3%

12. StoRMi trial
תוצאות
Prof Y Barak

13. PANSS total score: by baseline severity
PANSS Ranges at Baseline
Moderate >
Mild < 74.5
Severe > 106.5 58 91
126 56 86
116 54
106 81 52 96 76 50 86 71 48 76 46 66 66
Baseline
Months 1
Months 3
Months 6
Endpoint
Baseline
Months 1
Months 3
Months 6
Endpoint
Baseline
Months 1
Months 3
Months 6
Endpoint
P  at all timepoints compared to baseline
Prof Y Barak

14. StoRMi - סיכום תוצאות יעילות
ספקטרום רחב של חולים פסיכוטיים עשוי ליהנות מהמעבר ל RC.
חולים יציבים הראו שיפור נוסף בבקרה על הסימפטומים וסבילות לטיפול.
איכות החיים והפונקציונליות של החולים מצביעה על איכות טיפולית חדשה.
התחלת טיפול עם RC נמצאה יעילה.
Prof Y Barak

15. Prof Y Barak

16. “Remission in Schizophrenia: Proposed Criteria and Rationale for Consensus” Am J Psychiatry 2005; 162:441–449
Nancy C. Andreasen, M.D., Ph.D.
William T. Carpenter, Jr., M.D.
John M. Kane, M.D.
Robert A. Lasser, M.D.
Stephen R. Marder, M.D.
Daniel R. Weinberger, M.D.
Prof Y Barak

17. Abstract (1)
New advances in the understanding of schizophrenia etiology, course, and treatment have increased interest on the part of patients, families, advocates, and professionals in the development of consensus-defined standards for clinical status and improvement, including illness remission and recovery.
Prof Y Barak

18. Abstract (2)
As demonstrated in the area of mood disorders, such standards provide greater clarity around treatment goals, as well as an improved framework for the design and comparison of investigational trials and the subsequent evaluation of the effectiveness of interventions.
Prof Y Barak

19. Abstract (3)
Unlike the approach to mood disorders, however, the novel application of the concept of standard outcome criteria to schizophrenia must reflect the wide heterogeneity of its long-term course and outcome, as well as the variable effects of different treatments on schizophrenia symptoms.
Prof Y Barak

20. Abstract (4)
As an initial step in developing operational criteria, an expert working group reviewed available definitions and assessment instruments to provide a conceptual framework for symptomatic, functional, and cognitive domains in schizophrenia as they relate to remission of illness.
Prof Y Barak

21. Abstract (5)
The first consensus-based operational criteria for symptomatic remission in schizophrenia are based on distinct thresholds for reaching and maintaining improvement, as opposed to change criteria, allowing for alignment with traditional concepts of remission in both psychiatric and nonpsychiatric illness.
Prof Y Barak

22. Abstract (6)
This innovative approach for standardizing the definition for outcome in schizophrenia will require
further examination of its validity and utility, as well as future refinement, particularly in relation to psychosocial and cognitive function and dysfunction.
These criteria should facilitate research and support
a positive, longer-term approach to studying outcome in patients with schizophrenia.
Prof Y Barak

23. Prof Y Barak

24. Combining Clinical & PsychoSocial Domains: The Israeli Project
We aim to create a 2-pronged scale
Clinical – as defined by Andreasen et al.
Psychosocial –reflecting:
Quality of Life
Needs
I-ADL
Prof Y Barak

25. Remission Criteria in Schizophrenia Patient achieves intensity level…
…on all 8 symptom items
P1 Delusions
P2 Conceptual disorganization
P3 Hallucinatory behavior
G9 Unusual thought content
G5 Mannerisms and posturing
N1 Blunted affect
N4 Social withdrawal
N6 Lack of spontaneity/flow of conversation
Absent
Minimal
Mild
Moderate
Moderate severe
Severe
Extreme 1 2 3 4 5 6 7
…PANSS scale level of mild or less
Time criteria of at least 6 months
Prof Y Barak

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30. Prof Y Barak

31. Improved Understanding and Treatment of Schizophrenia.
European Neuropsychopharmacology (2007) 17, iii
Contents:
Improved Understanding and Treatment of Schizophrenia.
From the symposium ‘Acute to Long-term Treatment in Schizophrenia: Effectiveness is a Moving Target’ at the 19th European Congress of Neuropsychopharmacology, September 16– , Paris, France
Prof Y Barak

32. A. Fagiolini and A. Goracci (USA, Italy) S123
European Neuropsychopharmacology (2007) 17, iii
Risk factors for schizophrenia — All roads lead to dopamine. M. Di Forti, J.M. Lappin and R.M. Murray (UK) S101
Management of agitation in the acute psychotic patient — Efficacy without excessive sedation F. Can˜as (Spain) S108
The stable patient with schizophrenia — From antipsychotic effectiveness to adherence. P. Thomas (France) S115
The long term — Maximising potential for rehabilitation in patients with schizophrenia.
A. Fagiolini and A. Goracci (USA, Italy) S123
Prof Y Barak

33. Aims of rehabilitation in schizophrenia:
The long term — Maximising potential for rehabilitation in patients with schizophrenia.
Aims of rehabilitation in schizophrenia:
Therapeutic programmes that are developed to optimize the potential for rehabilitation in patients with schizophrenia should aim to maximise the patients' daily functioning in an attempt to enable them to engage in employment and increase their self-sufficiency.
Rehabilitation should also attempt to enable patients with schizophrenia to integrate into society, improving their social interactions and activities.
The complex nature of health-related quality of life (QoL) in schizophrenia patients has been recognised and another aim of rehabilitation is to improve this aspect.
All of these aims should be considered when evaluating the effectiveness of any treatment that patients receive.
Prof Y Barak

34. Aims of rehabilitation in schizophrenia:
The long term — Maximising potential for rehabilitation in patients with schizophrenia.
Aims of rehabilitation in schizophrenia:
The employment prospects for patients with schizophrenia may be impeded by clinical symptoms, and data from the CATIE study clearly illustrate this (Rosenheck et al., 2006).
No employment activity was reported for 72.9% of the patients in the month before the baseline assessment; 14.5% of the patients had been engaged in competitive employment, and the remaining 12.6% had participated in non-competitive employment.
Less severe symptoms of schizophrenia, better neurocognitive functioning and higher intrapsychic functioning scores (which evaluated a range of psychological characteristics) were associated with participation in employment.
Prof Y Barak

35. Aims of rehabilitation in schizophrenia:
The long term — Maximising potential for rehabilitation in patients with schizophrenia.
Aims of rehabilitation in schizophrenia:
Sociocultural context may be one of the major factors that can influence rehabilitation in patients with schizophrenia, and policy makers should give consideration to the creation of resources for the rehabilitation of schizophrenia patients within communities that complement the success that can be achieved with regard to reducing their psychotic symptoms (Mubarak, 2005).
Prof Y Barak

36. Aims of rehabilitation in schizophrenia:
The long term — Maximising potential for rehabilitation in patients with schizophrenia.
Aims of rehabilitation in schizophrenia:
Almost half (46.5%) of schizophrenia patients report dissatisfaction with their overall QoL.
By creating opportunities to improve social functioning, it may also be possible to improve patients' subjective QoL;
treatment that addresses psychotic symptoms in isolation from these factors may not facilitate QoL improvements.
Prof Y Barak

37. Prof Y Barak

38. Real World research Findings
Schizophr Res Mar 27; [Epub ahead of print]
Remission in prognosis of functional outcome: A new dimension in the treatment of patients with psychotic disorders.
Helldin L, Kane JM, Karilampi U, Norlander T, Archer T.
Prof Y Barak

39. Real World research Findings
INTRODUCTION:
The aim of the present study was to investigate whether or not the new concept of remission in the treatment of schizophrenia is of importance for functional outcome.
The hypothesis was that patients having attained remission would function at a higher level and have a lower care requirement than those who had not attained remission.
Prof Y Barak

40. Real World research Findings
MATERIALS AND METHODS:
Remission is defined through the application of the Positive and Negative Syndrome Scale (PANSS) instrument whereby none of the eight chosen items, representing core symptoms, should be found to present a value exceeding 3 points.
The utility of attaining the severity criteria for remission, or not, was examined with regard to activity of daily living (ADL) ability, establishment of social functioning and social network, and amount of health care and community support that the patient consumed.
Two hundred and forty-three patients were examined, of whom 93 patients (38%) had attained remission and 150 patients (62%) had not. The present patient population, consisting of 50% of all available patients with schizophrenia spectrum disorder within a homogeneous catchment area in NU Health Care, western Sweden, meeting the right diagnostic criteria, were in their habitual condition and were unaffected by any other functionally debilitating disorder, in particular dementia.
As a control patients diagnoses were used as the independent variable to exclude that they better explain outcome than remission.
Prof Y Barak

41. Real World research Findings
RESULTS:
It was found that patients that attainted the specified remission criteria showed a significantly superior outcome in all assessed areas with regard to activity of daily life, social functioning in society and consumption of health care.
Remission patients functioned more effectively in social contexts in association with superior education, more often had occupations, possessed more established social networks and were more likely to be found living under family-like conditions.
They exhibited a lower need for support in order to fulfill their everyday activities.
Also, patients in remission required markedly less health care resources, both in the form of psychiatric treatment and community habitation support. In contrast diagnoses only made difference in 4 of 14 outcome parameters.
Prof Y Barak

42. Real World research Findings
DISCUSSION:
The results suggest that the concept of remission has important implications for the treatment of patients with chronic psychosis.
One possible conclusion is that if more patients attain remission, the patient's and society's burden resultingfrom the illness will decrease.
Prof Y Barak

43. תודה על ההקשבה ו:
שאלות
Prof Y Barak