Recovery: quanto e come è possibile Dipartimento di Scienze mediche e Sanità Pubblica Università di Cagliari S.C. Clinica Psichiatrica AOU Cagliari Recovery: quanto e come è possibile Bernardo Carpiniello

Schizophrenia: two ways to conceptualize the disorder “Two conceptualizations of serious mental illness- the “broken brain” and the “recovery model”- have dominated recent attempts to understand and treat severe and persistent mental disorders such as schizophrenia…” As Liberman pointed out a few years ago, the “broken brain” paradigm has confronted in the last years with the “recovery” paradigm Lieberman J et al, Psych Serv,2008,59:487-496

Recovery “ …a more hopeful view of the course of illness emerges from the recovery movement, which emphasizes developing a meaningful life beyond illness…» This paradigm is based upon a substantially positive view of the illness and of its course, which is in turn supprted by encouraging findings from the long term outcome studies of shizophrenia Lieberman J et al, Psych Serv,2008,59:487-496

Il recovery secondo la prospettiva dei pazienti

“processo unico, profondamente personale di cambiamento dei propri atteggiamenti, valori, sentimenti, obiettivi, abilità e/o ruoli. Rappresenta una modalità di vivere una vita soddisfacente, carica di speranza e ricca di spunti pur con le limitazioni causate dalla malattia. La ripresa coinvolge lo sviluppo di nuovi significati e scopi della propria vita, al di là degli effetti catastrofici della malattia mentale”. Anthony,1993

“ Mental health recovery is a journey of healing and trasformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice, while striving for achieve his or her full potential” National Consensus Statement on Mental Health Recovery Definition, Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration (SAMHSA) From the patients’ point of view , recovery is a process leading to meaningful life, independent of symptom and deficits

Il recovery secondo la prospettiva dei clinici From the clinicians’ point of view recovery is to day the ultimate target of interventions

Targets of treatments in schizophrenia Recovery Clinical Stabilization/Adequate Functioning/Well being Remission Absence of significant Symptoms /clinical sta bilization The goal of treatments has become increasingly ambitious with the passing of time and now recovery is considered the real target of interventions Response Significant improvement of symptoms 9

Recovery is possible “ Now is accepted that recovery is possible, even to the extent of full absence of all symptoms and disabilities and that optimal recovery should be a goal for people with schizophrenia,although not all the individual with the illness will make significant progress toward this goal” Recovery is nowadays considered possible, even thoug not for all patients Harvey P.D,Bellack AS,Toward a terminology for functional Recovery in Schizophrenia: Is Functional Remission a Viable Concept? Schiz Bull,35,300-6, 2009

Multidimensionalità (ed eterogeneità dei criteri di valutazione) del «recovery» dal punto di vista clinico

“Recovery encompasses both symptom remission and functiontal elements such as cognition, social functioning and quality of life” In other definitions cognition and quality of life are considered too Luecht S,Lasser R,The concept of remission and recovery In Schizophrenia,Pharmacopsychiatry,39:161-70,2005

“ There are multiple elements of recovery “ There are multiple elements of recovery. These include freedom from troubling psychotic symptoms and relapses, satisfaction with life and daily activities and suitable functioning in everyday life” Generally speaking recovery is conceived as a multi-level dimension, including clinical and functional remission,togheter with life-satisfaction Harvey P.D,Bellack AS,Toward a terminology for functional Recovery in Schizophrenia: Is Functional Remission a Viable Concept? Schiz Bull,35,300-6, 2009

Engagement in productive activity (Work,school) Remission of symptoms Engagement in productive activity (Work,school) Independent management of day-to-day needs Cordial family relations Recreational activities Satisfying peer relationships In some cases a more detailed range of fulfillments are taken into account Liberman RP,Recovery from disability.Manual of psychiatric Rehabilitation,Am Psych Publishing,Washington DC,2008

Clinical Models of Recovery unidimensional Sustained (long term) Symptoms’ Remission An overall model of recovery encompassing clinical and functional remission and a subiective weel-being was adopted in most of the studies

Clinical Models of Recovery Bidimensional Functional Remission Symptoms Remission recovery An overall model of recovery encompassing clinical and functional remission and a subiective weel-being was adopted in most of the studies

Clinical Models of Recovery Tridimensional Functional Remission recovery Symptoms Remission Well being /Qol An overall model of recovery encompassing clinical and functional remission and a subiective weel-being was adopted in most of the studies

Clinical Models of Recovery Pluridimensional Functional Remission recovery Symptoms Remission Well being /Qol Neurocognitive symptoms social cognition An overall model of recovery encompassing clinical and functional remission and a subiective weel-being was adopted in most of the studies

Eterogeneità dei dati sul recovery: i dati più ottimistici degli studi meno recenti

Recovery «……long-term outcome studies….consistenlty show heterogeneity, with many patients improving and in some cases achieving substantial remission…” This paradigm is based upon a substantially positive view of the illness and of its course, which is in turn supprted by encouraging findings from the long term outcome studies of shizophrenia Lieberman J et al, Psych Serv,2008,59:487-496

(DIAGNOSIS AND EVALUATIONS) RECOVERY RATES ACCORDING TO BROAD DIAGNOSTIC CRITERIA (DIAGNOSIS AND EVALUATIONS) The evidence from numerous long-term follow-up studies has supported heterogeneity, the capacity for symptomatic remission and functional improvement early in the course of the illness, and also, though less completely, improvements in later life. Mental health advocates have embraced the longitudinal research as evidence of the potential for recovery. 21

Eterogeneità dei dati sul recovery: i dati meno ottimistici degli studi più recenti

Remissione sintomatologica,funzionale,soggettiva 24 mesi in 2960 pazienti Remissione funzionale Benessere soggettivo % NO 35,08 SI 11,12 7,19 8,30 4,37 18.86 2.24 12.84 Lambert et al. J Clin Psychiatry 2006;67:1690-1697

Recovery rates in recent studies using different criteria for “recovery” 22.4 19 12.8 10 Recovery rates in our study are lower than other european and north american studies

24 months recovery rates (SOHO Study) 55 47,2 42,2 45 35,1 35 26,6 Patients (%) 25 15 12,8 Lo studio SOHO = Schizophrenia Output Health Outcomes La diapositiva mostra le percentuali ottenute per ogni tipo di remissione a 2 anni, nello studio SOHO. Si distinguono la remissione sintomatologica, funzionale, relativa al benessere soggettivo del paziente. Se il paziente soddisfaceva contemporaneamente i criteri di tutte e tre, veniva considerato in remissione completa. Come si può vedere, la remissione sintomatologica è stata raggiunta da quasi la metà dei pazienti, quella funzionale dalla percentuale più bassa di pazienti (26,6%). Il 12,8% dei pazienti ha raggiunto la remissione completa, mentre il 35% non ha raggiunto nessun tipo di remissione. Lambert et al. J Clin Psychiatry 2006;67:1690–1697 5 Symptoms Functioning Subjestive wb Clinical+Functional Absence of remssion Lambert et al. J Clin Psychiatry 2006;67:1690-1697

Analizzando il medesimo campione arruolato, una parte dei dati emersi dal presente studio e riferibili al baseline, ma che non sono oggetto della trattazione odierna, sono stati già pubblicati o sono attualmente in fase di pubblicazione (i successivi riferimenti non verranno presentati oralmente nella comunicazione, ma sono nelle note per conoscenza) Nel 2012 si esaminavano le stime preliminari inerenti le differenze di genere nella remissione e nel recovery che identificavano, come già accennato, maggiori tassi di remissione e recovery nel sesso femminile al baseline nel 2013 si comparavano i criteri di remissione clinica elaborati dal Remission of schizophrenia working group di Nancy Andreasen con una criteriologia più restrittiva in rapporto all’outcome neurocognitivo e funzionale, desumendo come l’utilizzo di criteri stringenti di remissione sembri correlarsi ad una più precisa identificazione di soggetti effettivamente versanti in condizioni di remissione nel dicembre del medesimo anno si analizzavano i pazienti in remissione clinica, funzionale ed in stato di benessere soggettivo utilizzando criteri operativi, riscontrando nei medesimi soggetti la sussistenza di alterazioni sintomatologiche, di un rilevante impairment funzionale e di una persistente percezione di mancato benessere soggettivo in ultimo, nel Gennaio 2014 si comparavano i tassi di remissione e di recovery in una coorte di soggetti affetti da schizofrenia e disturbo schizoaffettivo. Quest’ultimi, più frequentemente di sesso femminile, palesavano un miglior adattamento premorboso, esperendo, tuttavia, nell’ambito del decorso clinico, più frequenti ospedalizzazione e manifestando incrementata suicidalità. I parametri di outcome, in ultimo, risultano più frequentemente soddisfatti nei soggetti estrinsecanti una componente affettiva 26 26

24 Months recovery rates Carpiniello unpubl data 2016

Quanto dura nel tempo il recovery ? La schizofrenia comporta tassi di recovery diversi rispetto alle altre psicosi? Esistono differenze di genere nei tassi di recovery?

Grossman L, et al

Grossman L, et al

Carpiniello et al

Cagliari Remission-Recovery Study 24 Months Recovery Rates Recovery criteria Males Females Total Clinical+ function. remission+ Well being 6.3% 18.8% 9.8% Full recovery (considered ad clinical remission plus functional remission and welle being) was reached by only 7% of pts. Of course, a larger proprtion of pts could be considered as recovered if less stringent criteria were adopted (i.e clinical puls well being or clinical+ functuonal remission) p=.045 Carpiniello unpubl data 2016

I tassi di recovery sono diversi se si considerano i soli pazienti all’esordio?

Revier CJ et al

Lambert M, et al

Lambert M, et al

Wunderink L et al

Cumulative Recovery Rates per year in FEP patients Yrs Cumulative rates (%) lower confidence limits 95% upper confidence limits 95% 3 9.7 3.7 15.8 4 12.3 5.4 19.1 5 13.7 6.4 20.9 Robinson DG et al. Am J Psychiatry. 2004;161:473-479. 41 41

Albert N et al

Albert N et al

Austin SF et al

Austin SF et al

Recovery: evidenze meta-analitiche

When deciding the recovery criteria, we acknowledged the recommendations of using multidimensional definitions, including at least 2 domains, one related to clinical remission and another related to broader social functioning outcome, and persistence of good outcome for a minimum of 2 years.

16%

Perché i tassi di recovery sono tuttora bassi e non sembrano essere migliorati nel tempo?

Mucci A et al It is increasingly acknowledged that the alleviation of schizophrenia symptoms obtained with available treatments is not accompanied by a parallel improvement of patients' functional impairments The relationship between symptoms and functioning is modest: individuals with relatively severe symptoms may function moderately well,while patients with mild symptoms may not function adequately in their daily activities From 30% to 70% of people with schizophrenia do achieve symptom remission, but the percentage of patients showing adequate functioning in real life is remarkably lower Symptomatic remission contributes to improved functioning in real life, but is not sufficient to attain it.

Galderisi S et al

Galderisi S et al

Galderisi S et al

Four years ago a study regarding 19 Mental Health Departiment in Italy was promoted by the Italian Society for Psychiatric Epidemiology, in order to evaluate discrepancies between routine practices adopted in Italy and what shoud be done by services in promoting recovery according to scientific evidences Epidemiol Psych Soc, 2008, 17: 331-348

As expected the study showed a picture of italian mental health services with brigth and dark areas. However the study was ficused on processes , not on outcomes Epidemiol Psych Soc, 2008, 17: 331-348

Green CA et al