Kraepelin considered declining course a hallmark of schizophrenia, but others have suggested that outcomes usually stabilize or improve after treatment initiation. The authors investigated this question in an epidemiologically defined cohort with psychotic disorders followed for 20 years after first hospitalization.

The Suffolk County Mental Health Project recruited first-admission patients with psychosis from all inpatient units of Suffolk County, New York (response rate, 72%). Participants were assessed in person six times over two decades; 373 completed the 20-year follow-up (68% of survivors); 175 had schizophrenia/schizoaffective disorder. Global Assessment of Functioning (GAF), psychotic symptoms, and mood symptoms were rated at each assessment. Month 6, when nearly all participants were discharged from the index hospitalization, was used as a reference.

In the schizophrenia group, mean GAF scores declined from 49 at month 6 to 36 at year 20. Negative and positive symptoms also worsened (Cohen’s d values, 0.45–0.73). Among participants without schizophrenia, GAF scores were higher initially (a mean of approximately 64) but declined by 9 points over the follow-up period. Worsening began between years 5 and 8. Neither aging nor changes in antipsychotic treatment accounted for the declines. In all disorders, depression improved and manic symptoms remained low across the 20 years.

The authors found substantial symptom burden across disorders that increased with time and ultimately may undo initial treatment gains. Previous studies have suggested that better health care delivery models may preempt this decline. In the United States, these care needs are often not met, and addressing them is an urgent priority.

克雷佩林认为病程衰退是精神分裂症的标志，但其他人认为治疗开始后，结果通常会稳定或改善。作者在首次住院后跟踪了 20 年的流行病学定义的精神障碍队列中调查了这个问题。

萨福克县心理健康项目从纽约州萨福克县的所有住院病房招募了首次入院的精神病患者（回应率为 72%）。二十年来，参与者接受了六次亲自评估； 373 人完​​成了 20 年随访（幸存者的 68%）； 175 人患有精神分裂症/分裂情感障碍。每次评估时都会对总体功能评估（GAF）、精神病症状和情绪症状进行评级。第 6 个月，几乎所有参与者都从指标住院中出院，被用作参考。

在精神分裂症组中，平均 GAF 评分从第 6 个月时的 49 分下降到第 20 岁时的 36 分。阴性和阳性症状也恶化（Cohen d 值，0.45-0.73）。在没有精神分裂症的参与者中，GAF 分数最初较高（平均约为 64），但在随访期间下降了 9 分。病情恶化在第 5 至 8 岁之间开始。衰老和抗精神病药物治疗的变化都不是造成这种下降的原因。在所有疾病中，抑郁症得到改善，躁狂症状在 20 年间仍然较低。

作者发现，各种疾病的显着症状负担随着时间的推移而增加，最终可能会抵消最初的治疗成果。先前的研究表明，更好的医疗保健提供模式可能会阻止这种下降。在美国，这些护理需求往往得不到满足，解决这些需求是当务之急。