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.

Kraepelin认为减少病程是精神分裂症的标志，但其他人则认为治疗开始后结局通常会稳定或改善。作者在流行病学上定义的患有精神病的队列中调查了此​​问题，该队列在首次住院后随访了20年。

萨福克县精神卫生项目从纽约萨福克县的所有住院部门招募了第一批患有精神病的患者（回应率为72％）。在过去的二十年中，对参与者进行了六次亲自评估；373名患者完成了20年的随访（68％的幸存者）；175人患有精神分裂症/精神分裂症。在每次评估中对整体功能评估（GAF），精神病性症状和情绪症状进行评估。第6个月（当几乎所有参与者都退出指数住院治疗时）被用作参考。

在精神分裂症组中，平均GAF分数从第6个月的49下降到第20年的36。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评分起初较高（平均约为64），但在随访期内下降了9分。恶化在5至8岁之间开始。衰老和抗精神病药物治疗的改变均不能解释下降的原因。在所有疾病中，在过去的20年中，抑郁症均得到改善，躁狂症状仍然很低。

作者发现跨疾病的大量症状负担会随着时间的推移而增加，最终可能会抵消最初的治疗效果。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，这些护理需求通常得不到满足，解决这些护理需求是当务之急。