The long-term outcome of schizophrenia is determined by a number of factors that include gender, age of onset, duration of untreated illness and associated comorbid disorders. Regarding gender, the long-term outcome is better for women than for men. The reason for this gender response is unknown. Patients who present later in life have a better long-term course. Patients who present early in life and have cognitive and intellectual impairments have poorer prognoses.

Dr. Schooler noted the importance of diagnosing comorbid psychiatric conditions and syndromes. Comorbid conditions commonly associated with schizophrenia are anxiety disorders, depression, substance and alcohol use. Comorbid conditions such as these can negatively affect treatment as well as outcome. Dr. Schooler believes the DSM-IV decision tree for schizophrenia is the main reason comorbid conditions are often missed. She explained that this decision-tree directs clinicians to psychotic disorders instead of anxiety or other disorders. Physicians should be aware of this fact when diagnosing comorbid disorders in schizophrenic patients.

Dr. Schooler noted that information on long-term follow-up for schizophrenic patients with comorbid conditions is limited. In fact, many studies exclude patients with comorbid conditions. Dr. Schooler presented data from a long-term (30 to 40 year) outcome study that was conducted at the Iowa State Hospital. Patients were divided into groups according to their medical records on admission to the hospital. The results indicate that schizophrenic patients had the poorest outcome. Schizophrenic patients fared worse than patients with mania, depression and schizoaffective disorders.

Dr. Schooler emphasized the importance of the comorbid conditions of substance and alcohol abuse and dependence in schizophrenic patients. Statistically, 25 to 35% of schizophrenics have comorbid substance abuse and dependence problems. Over the course of a lifetime, these comorbid conditions are manifested by 50% of schizophrenic patients. Dr. Schooler showed data from the Treatment Strategies in Schizophrenia (TSS) study which compared treatments and psychosocial approaches in schizophrenic patients with and without comorbid substance and alcohol use. The results indicate substance use allows patients to function better in social situations.

Schizophrenic patients with these comorbid conditions felt less satisfied with their lives than schizophrenic patients without these comorbid problems.

Schizophrenic patients with comorbid conditions can receive treatment for their comorbid conditions. The clinician should be aware that the comorbid conditions may alter the patient's response to antipsychotic agents. In addition, psychosocial approaches may be different for patients with and without comorbid conditions. Dr. Schooler recommends that clinicians listen to patients and ask questions in a non-threatening way in order to develop a good rapport and relationship with their schizophrenic patients.

(abstract Symposia No. 6D)