Psychiatry Research 210 (2013) 739744

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Is it true remission? A study of remitted patients affected

by schizophrenia and schizoaffective disorders
Federica Pinna, Luca Deriu, Tiziana Lepori, Raffaela Maccioni, Paola Milia,
Elisabetta Sarritzu, Massimo Tusconi, Bernardo Carpiniello n,
for the Cagliari Recovery Study Group
Department of Public Health, Clinical and Molecular Medicine-Section of Psychiatry, University of Cagliari, Via Liguria 13, 09127 Cagliari, Italy

art ic l e i nf o

a b s t r a c t

Article history:
Received 29 August 2012
Received in revised form
30 July 2013
Accepted 7 August 2013

To date, few studies have reported analytical data relating to clinical remission, functional remission and
subjective experience. The present study aimed to investigate these aspects in a sample of chronic
outpatients. Methods: 112 schizophrenic or schizoaffective outpatients (Males 60; Females 52; mean
age 43.5 79.42 yr) were evaluated with regard to symptomatology (SCID-I; PANSS, CGI-SCH scales),
functioning (PSP scale), subjective wellbeing (SWN-K scale) and Quality of Life (WHO-QoL-Bref scale).
Results: 50% of patients were found to be in remission. Signicantly higher scores at PANNS, CGI-SCH,
PSP, but not at SWN and WHO-QoL, were found among remitted patients; a relevant proportion of
remitted subjects continued to manifest a moderate level of symptoms (score 4 3) both at PANSS (35%
of cases) and CGI-SCH (29% of cases), signicant functional impairment (total score o 70) at PSP (68% of
cases ), and a lesser degree of wellbeing (total score o80) at SWN-K (34% of cases). Conclusion: patients
in whom clinical remission was conrmed may display persisting symptoms, relevant areas of functional
impairment and a decreased sense of wellbeing.
& 2013 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Remission
Symptomatology
Functioning
Quality of life
Subjective well-being
Schizophrenia
Schizoaffective disorders

1. Introduction
In recent years increasing emphasis has been placed on remission
(Nasrallah and Lasser, 2006) in schizophrenia, following the introduction of a set of well-established criteria by the Remission
Schizophrenia Working Group (RSWG) (Andreasen et al., 2005),
which has been proven to be conceptually viable and easy to use
both in clinical trials and clinical practice (Van Os et al., 2006).
Symptomatic remission is clinically relevant, as demonstrated by its
association with improved functioning (De Hert et al., 2007; Helldin
et al., 2007; Boden et al., 2009) but is not necessarily associated with
functional improvement; indeed approx. 50% of patients treated
achieve clinical remission, but only 20% reach functional remission
(Schennach-Wolff et al., 2009). Moreover, the majority of functionally
remitted patients are in clinical remission, whilst only a minority of
clinically remitted patients achieve functional remission (Wunderink
et al., 2007). The RSWG (Andreasen et al., 2005) underlined how the
proposed criteria were somewhat arbitrary, being based upon only
eight items of the PANSS and a cut-off score below 3, thus not
excluding the presence of still clinically relevant symptoms. A recent
study (Karow et al., 2012) revealed that remitted patients displayed

Corresponding author. Tel.: 39 307041518; fax: 39 70480083.

E-mail address: bcarpini@iol.it (B. Carpiniello).

0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.psychres.2013.08.022

persisting symptoms of emotional distress, decits in different areas

of functioning and reduced sense of wellbeing. The aim of the
present study was to assess whether remitted patients according to
RSWG severity criteria: (1) display a better symptomatic and functional status respect to non remitted patients, and the magnitude of
these differences; (2) continued to manifest clinically relevant
symptoms, although their symptomatic status was signicantly
better than that observed in non-remitted patients; (3) continued
to display decits in different areas of functioning, despite an overall
better functioning compared to non-remitted patients; (4) continued
to display impaired wellbeing and subjective quality of life, despite
an overall higher level of wellbeing and subjective quality of life
compared to non-remitted patients.

2. Materials and methods

2.1. Sample
In the context of an ongoing prospective naturalistic follow-up study of chronic
outpatients routinely treated in a community setting (Carpiniello et al., 2012), all
patients with a diagnosis of schizophrenia or schizoaffective disorder according to
DSM-IV-TR attending a university community mental health centre in the year 2010
were enrolled consecutively. Patients with other comorbid disorders, including
patients with substance use disorders were included in the study, with the exception
of those with comorbid mental retardation or organic brain diseases. Standard care

740

F. Pinna et al. / Psychiatry Research 210 (2013) 739744

Table 1
Characteristics of the sample according to gender.
Items

Males

Females

Age (mean yrs7 S.D.)

42.76 (8.32)

45.34 (11.70)

Marital status (N, %)

Single
Married

72 (90)
8 (10)

25 (78.1)
7 (21.9)

97 (86.6)
15 (13.4)

2(1) 2.779,
p 0.096

Occupation (N, %)
Unemployed
Employed

60 (75)
20 (25)

23 (71.9)
9 (28.1)

83 (74.1)
29 (25.9)

2(1) 0.116,
p 0.733

Education (mean yrs 7 S.D.)

10.35 (3.681)

12-06 (4.10)

Diagnosis (N, %)
Schizophrenia
Schizoaffective Dis

36 (45)
44 (55)

10 (31.2)
22 (66.8)

46 (41.1)
66 (58.9)

Total (N, %)

80 (71.4)

32 (28.6)

112 (100)

generally provided in community mental health centres in Italy (pharmacological

treatment; clinical monitoring at least on a monthly basis; home care when required,
psychosocial and rehabilitation interventions tailored to patient's needs) was provided
to patients included in the study.

2.2. Evaluation
In line with procedures applied in previous studies (Carpiniello et al., 2002;
Primavera et al., 2012), retrospective data were collected from standardized clinical
records routinely used in the community mental health centre, as described by the
Italian version of procedures suggested by the Association for Methodology and
Documentation in Psychiatry (AMDP) (Conti et al., 1988). In particular, sociodemographic (gender, age, education, marital status, employment status) and
clinical data, course of illness according to DSMIV-TR course specier criteria for
schizophrenia, inpatient admissions, attempted suicides, legal problems, pharmacological and non pharmacological treatments were taken into account. To enhance
the retrospective evaluation of cases, clinical records were examined to ascertain
their suitability for providing reliable retrospective data. In order to conrm
diagnosis, subjects underwent comprehensive psychiatric evaluation by means of
the Structured Clinical Interview for Diagnosis for Axis I DSM-IV (SCID-I Research
Version) (First et al., 1996) after having signed an informed consent form. Interviews were conducted by residents in psychiatry trained in the use of the
instruments; inter-rater reliability, assessed using Cohen's K before the study,
was higher than 0.80. Personal and social data, and clinical history were collected
on the basis of a structured interview purpose-developed for the present study.
Symptoms were evaluated by means of PANSS (Positive and Negative Syndrome
Scale) (Kay et al., 1987), consisting in 30 items grouped into three distinct clusters
(positive symptoms, negative symptoms, general psychopathological symptoms);
symptoms are rated on a 7-point scale. To evaluate clinical remission, criteria
developed by the RSWG (Andreasen et al., 2005) based on ratings at eight focal
symptoms of PANSS (P1, P2, P3, N1, N4, N6, G5, G9) were applied. Patients are
judged to be in clinical remission when scores obtained at each of these items is
less than or equal to three over a six-month period. Due to the cross-sectional
nature of the study clinical remission was evaluated taking into account only the
severity criterion. Overall clinical status was evaluated by means of the Clinical
Global Impression-Schizophrenia scale (CGI-SCH) (Haro et al., 2003); CGI-SCH is
the adapted version of the CGI (Clinical Global Impression Rating Scale). The CGISCH provides for the assessment of severity and improvement of positive, negative,
cognitive, symptoms and depression over the week before the visit. The CGI scale
comprises three main domains: severity of illness, global improvement and efcacy
index. For the purposes of the present study only the severity score was applied.
Functioning was evaluated by means of PSP (Personal and Social Performance
Scale) (Morosini et al., 2000), an instrument assessing social functioning of patients
with schizophrenia in 4 main areas: social activities, personal and social relationships, self-care and disturbing /aggressive behaviours. For each area a score ranging
from 0 (no disability) to 5 (very severe disability) is attributed according to specic
criteria. A comprehensive overall score ranging from 1 (maximum dysfunction) to
100 (maximum functioning) is attributed, based on score obtained at each single
area. A total score equal to or higher than 80 indicates a condition of functional
remission.
Subjective wellbeing was evaluated by means of Subjective Wellbeing under
Neuroleptics-Short Version (SWN-K) (Naber et al., 2001), a self-administered 20item rating scale aimed at assessing the psychological and physical wellbeing of
patients treated with neuroleptics. An overall score equal to or higher than 80
indicates a state of subjective wellbeing.

Total

Statistics
t (110)  1.138 p 0.261

t(110)  2.152 p 0.034

2(1) 1.786,
p 0.181

Subjective quality of life was evaluated by means of the Subjective Wellbeing

under Neuroleptics-Short Version and WHO Quality of Life Brief questionnaire
(WHOQOL-Brief) (Skevington et al., 2004), a self-evaluated 26-item questionnaire.
WHOQOL-Bref yields four subscores focusing on different domains (physical,
psychological, social relationships, environment). Two additional items evaluate
the overall subjective quality of life and overall perceived quality of personal health.
A number of other standardised measures were used to obtain a comprehensive evaluation of patients. In particular, premorbid adjustment was evaluated by
means of PAS (Premorbid Adjustment Scale) (Cannon-Spoor et al., 1982); adherence
was assessed by means of CRS (Clinical Rating Scale) (Byerly et al.,2005); attitudes
towards treatments was measured by means of DAI-10 (Drug Attitudes Inventory)
(Hogan et al., 1983); side effects were assessed by means of DOTES (Dosage and
Treatment Emergent Symptoms Scale) (Guy, 1976).

2.3. Statistical analysis

Categorical data were analysed using Pearson's 2 Test (Chi-square) or Fisher's
exact test; continuous variables were assessed by means of Student's t test for
independent samples. The magnitude of differences in mean scores obtained at
different rating scales was calculated by means of Cohen's d. Data analyses were
performed using SPSS 19.0. Level of signicance was set at a p value o 0. 05 for
two-tailed hypothesis.

3. Results
3.1. Baseline characteristics
For the purpose of this study baseline (Table 1) characteristics of
the cohort enrolled in the study during the year 2010 were taken
into consideration. The sample was made up of 112 patients, 80
males (71.4%) and 32 (28.6%) females, who met the abovementioned inclusion/exclusion criteria; 46 patients (41.1%) were
affected by schizophrenia and 66 (58.9%) by schizoaffective disorder
(58.9%); mean age was 43.579.42 years (range 2568); mean years
of education were 10.8473.9 (range 424); 97 subjects (86.6%) were
single; 83 (74.1%) were unemployed.
3.2. Baseline clinical characteristics
Course of illness was continuous or episodic with interepisodic
residual symptoms in 89 cases (79.4%). Seventy-ve patients (67%)
had been admitted to hospital at least once in their life, with the
most signicant proportion (n38, 33.9%) having had 24 admissions and 10.8% (n12) of which had ve or more admissions.
Thirty-three patients (29.5%) had attempted suicide at least once in
their life (n17, 15.2% two or more attempted suicides); nine subjects
(8.0%) had been prosecuted by a criminal court for acts of violence
(one had been admitted to a Forensic Psychiatric Hospital);
38 patients were taking typical (33. 9%), and 86 (76.8%) atypical

F. Pinna et al. / Psychiatry Research 210 (2013) 739744

741

Table 2
Sociodemographic and clinical characteristics of remitted and non remitted patients.
Items

Remitted (n 56)

Non-remitted (n56)

Statistic

Education (years)
Occupation (unemployed)
Course of illness (continuous episodic with residual symptoms)
Duration of illness (months)
Treatment (typical atypical)
Mean dosages of AP (CPZ equivalents)

11.55 (4.16)
36 (43.4%)
27 (48.2%)
163.68 (100.01)
5 (8.9%)
272 7162.82

10.13 (3.43)
47 (56.6%)
43 (76.8%)
227.48 (112.58)
13 (23.2%)
358.79 7 266.81

t(110) 1.981, p 0.05

2(1) 5.630, p 0.018
2(1) 9.775, p o 0.0001
t(110)  3.171, p 0.002
2(1) 4.236, p 0.040
t(104)  2-01, p o 0.047

Adherence (CRS)
Good
Poor
Supported employment
CGI-S positive symptoms
CGI-S negative symptoms
CGI-S depressive symptoms
CGI-S cognitive symptoms
CGI-S overall severity
CGI-S Positive Sym, pts with a score 43
CGI-S Negative Sym, pts with a score 43
CGI-S Depressive sym, pts with a score 4 3
CGI-S Cognitive sym, pts with a score 43
CGI-S overall, pts with a score 4 3
PANSS positive scale
PANSS negative scale
PANSS general psychopathology
PANSS Total scale
PANSS positive Pts with at least 1 item 43
PANSS negative Pts with at least 1 item 43
PANSS general psychopathol. Pts with at least 1 item 43
PANSS Total scale Pts with at least 1 item 43

44 (78.6%)
12 (21.6%)
4 (7.1%)
1.60 (0.95)
1.78 (0.91)
1.71 (0.85)
1.84 (1.03)
2.45 (0.95)
5 (8.9%)
3 (5.4%)
2 (3.6%)
6 (10.7%)
16 (28.6%)
8.96 (2.09)
10.57 (3.65)
21.98 (4.87)
41.52 (7.92)
4 (9.1%)
13 (21.7%)
21 (30%)
30 (34.9%)

23 (41%)
33 (59%)
0 (0)
2.95 (1.42)
3.36 (1.27)
2.36 (1.31)
3.18 (1.20)
3.82 (0.76)
27 (48.2%)
29 (51.8%)
15 (26.8%)
25 (44.6%)
50 (89.3%)
14.39 (4.35)
18.70 (5.85)
32.68 (7.48)
65.77 (13.87)
40 (90.9%)
47 (78.3%)
49 (70%)
56 (65.1%)

2(1) 16.382
p o0.00005
2(1) 4.148, p 0.042
t(110)  5.853, po 0.0001
t(110)  7.478, p o0.0001
t(110)  3.076, p 0.003
t(110)  6.298, po 0.0001
t(110)  8.309, po 0.0001
2(1) 21.17, p o0.0001
2(1) 29.57, p o 0.0001
2(1) 11.72, P o0.001
2(1) 16.10, po 0.0001
2(1) 42.64, p o0.0001
t(110)  8.417, p o0.0001
t(110)  8.803, po 0.0001
t(110)  8.964, p o0.0001
t(110)  11.354, p o 0.0001
2(1) 48.513 p o 0.0001
2(1) 41.497, p o0.0001
2(1) 29.867 po 0.0001
2(1) 33.860, p o 0.0001

AP Antipsychotics; CRS Clinical

CPZ Chlorpromazine.

Rating

Scale;

CGI-S Clinical

Global

Impression

antipsychotics; 18 patients (6.1%) had been prescribed treatment

with both a typical and an atypical antipsychotic; 64 patients (57.1%)
were on benzodiazepines, 28 (25%) antidepressants, 25 (22.3%) mood
stabilisers, 19 (17%) anticholinergic drugs; 14 patients (12.5%) were
receiving psychotherapy, and 23 patients (20.5%) were taking part in
rehabilitation programmes.
3.3. Clinical remission
Remission criteria were met by 56 subjects (50%). Remitted and
non-remitted patients featured several different characteristics
(Table 2). A lower level of education and a higher proportion of
unemployment were found among non-remitted patients; no signicant differences were detected for gender, age, marital status, living
conditions (living alone or with others), or mean monthly income. A
more severe course of illness, a longer duration of illness, and more
frequent treatment with combined antipsychotic therapy (atypicaltypical), signicantly higher mean dosages of antipsychotics, a
lower adherence to treatments as evaluated by means of CRS and a
less frequent supported employment were found among nonremitted patients. No signicant differences were found between
groups as regard to number and overall severity of side effects
evaluated by means of DOTES and to attitudes towards treatments,
evaluated by means of DAI (data hot reported). Mean scores at CGISCH were all signicantly higher among non-remitted patients yielding effects of large (Cohen's d for CGI positive symptoms 1.117;
negative symptoms1.430; cognitive symptoms1.191; total score
1.592) or medium magnitude (Cohen's d for CGI-depressive symptoms
0.588). Moreover, the proportion of patients achieving a score 43
(indicating at least a moderate severity of symptoms) at CGI total scale
and subscales was signicantly higher among non-remitters. Signicantly higher mean scores were also found among non-remitted
patients at PANSS for positive, negative and general psychopathology
subscales, with effects of extremely large magnitude (Cohen's d for

Scale-Schizophrenia;

PANSS Positive

and

Negative

Syndrome

Scale;

PANSS positive scale 1.591; negative scale 1.667; General Psychopathology1.695; total score1.697). Scores obtained at each
single item of PANSS (data not included in Table 2) were signicantly
higher for non-remitted patients, with the exception of items N7
(stereotyped thinking), G8 (uncooperativeness), and G14 (impulse
discontrol). The proportion of patients with at least one item scoring
43 at each subscale and overall PANSS was again signicantly higher
among non-remitters.

3.4. Functioning
Mean scores achieved at PSP (Table 3) were all signicantly
higher among non-remitters, indicating poorer functioning, with
effects of medium effects magnitude for PSP Self-care (Cohen's
d 0.481) and Aggressive-Disturbing Behaviour (Cohen's d0.552)
subscales, medium-large effects for PSP social relationships subscales (Cohen's d0.730) and large effect for PSP Socially Useful
Activities subscales (Cohen's d1.064). Mean total score was signicantly lower among non-remitters, with a large magnitude effect,
indicating a poorer functioning (Cohen's d  0.835). The proportion of patients showing a total score o70 (signicant impairment
of overall functioning) and the percentage of subjects showing a
score 42 at each single PSP subscale (signicant impairment in
functioning) was signicantly higher among non-remitters.

3.5. Subjective wellbeing

No signicant differences were observed in mean scores
obtained at each SWB subscale and total scale (Table 4). On taking
into consideration patients with a total score o80 (absence of
subjective wellbeing), a similar proportion of remitters and nonremitters was detected.

742

F. Pinna et al. / Psychiatry Research 210 (2013) 739744

Table 3
Functioning in remitted and non remitted patients.
Items

Remitted (n 56)

Non-remitted (n56)

Statistics

PSP -activities
PSP-social rel
PSP -self care
PSP -aggressive and disturbing behaviour
PSP Total
PSP Total Pts with a score o 70
PSP activities Pts with score 42
PSP social rel Pts with score 42
PSP self care Pts with score 42
PSP -aggressive and disturbing behaviour Pts with score 42

1.88
2.02
0.34
0.14
62.27
38
30
38
5
2

3.20
2.86
0.80
0.50
50.38
51
51
49
10
7

t(110)  5.642, p o 0.0001

t(110)  5.642, p o 0.0001
t(110)  2.559, p o 0.012
t(110)  2.896, p o 0.005
t(110) 4.419, p o0.0001
2(1) 9.247, p o 0.002
2(1) 17.84, p o 0.0001
2(1) 5.149 p 0.0023
2(1) 1.650 p 0.199
2(1) 1.650 p 0.199

(1.27)
(1.15)
(0.69)
(0.44)
(13.65)
(67.9%)
(53.6%)
(67.8%)
(8.9%)
(3.6%)

(1.21)
(1.15)
(1.16)
(0.81)
(14.79)
(91.1%)
(91.1%)
(87.5%)
(17.9%)
(12.5%)

PSP Personal and Social Performance Scale.

Table 4
Subjective wellbeing in remitted and non-remitted patients.
Items
SWN
SWN
SWN
SWN
SWN
SWN
SWN

mental
Self-control
Physical
emotional control
social
Total
Total Pts with a score o80

Remitted (n 56)

Non-remitted (n 56)

Statistics

16.98
17.59
17.79
16.71
17.57
86.64
19

15.79
16.21
16.98
16.91
16.70
82.59
22

t(110) 1.561, p 0.121

t(110) 1.811, p 0.073
t(110) 1.133, p 0.260
t(110)  0.245 p 0.807
t(110) 1.281, p 0.203
t(110) 1.433, p 0.155
2(1) 0.346, p 0.556

(3.44)
(3.96)
(3.53)
(3.94)
(3.15)
(14.03)
(33.9%)

(4.58)
(4.07)
(3.96)
(4.52)
(4.02)
(15.84)
(39.3%)

SWNSubjective Wellbeing under Neuroleptics-Short Version.

3.6. Subjective quality of life

No signicant differences were found in mean scores obtained
at WHO-QoL-Bref (Table 5) by remitters and non-remitters; a
signicantly higher mean score, indicating better quality of life,
was found among remitters only in Physical subscale, although
with a somewhat small effect size (Cohen's d 0.384). Mean score
at item G1 (overall evaluation of quality of life) was similar among
remitters and non-remitters, although the proportion of subjects
with a score o3, indicating a negative or neutral evaluation of
their quality of life, was signicantly higher among non-remitters.

4. Discussion
In our sample, 50% of subjects were judged as being in clinical
remission, a result in line with data present in literature (SchennachWolff et al., 2009). As in other studies (Brissos et al., 2011; Karow et al.,
2012) remission was associated with a signicantly better psychopathological prole, as attested by mean scores at PANSS and CGI-SCH.
However, a relevant proportion of remitted subjects displayed symptoms of at least a moderate level (score 43) both at PANSS (35%) and
CGI-SCH (29%). In particular, remitters displayed moderate levels of
positive symptoms (approx. 9% of cases both at PANNS and CGI-SCH),
negative symptoms (approx. 22% of cases at PANNS and 5.5% at CGISCH), and other symptoms such as those included in General
Psychopathology Subscale of PANNS (30% of cases), as well as at
Depression (4% of cases) and Cognitive subscales (11% of cases) of CGISCH. These ndings, which are in line with data of Karow et al. (2012),
on one hand further conrm the empirical validity of the RSWG
criteria (Andreasen et al., 2005; Van Os et al., 2006), whilst on the
other suggesting that being in remission should not imply a substantial absence of symptoms, as commonly conceived. Thus, achieving of remission should not mask the ongoing need for therapeutic
efforts aimed at improving the persisting positive, or more frequently
negative, affective and/or cognitive symptoms exerting a potential
impact on functional status (Green et al., 2000; Kirkpatrick et al.,

2006). Accordingly, our ndings related to functioning seem to

support this possibility. Indeed, the outcome of this study largely
conrms the ndings present in literature, underlining how remission
is associated with a improved functioning (Lambert et al.,2006; Van Os
et al., 2006; De Hert et al., 2007; Boden et al., 2009), as clearly
demonstrated by the signicant differences observed in mean scores
obtained by remitters and non-remitters at PSP together with the
large effect sizes yielded. In our study, clinical remission was associated with a better adherence to treatments, a nding consistent with
literature data emphasising the role of adherence in explaining better
outcomes in schizophrenia, both from a clinical and psychosocial point
of view (Kane, 2007; Llorca, 2008). Moreover, it is worth of consideration the fact that psychopharmacological treatment was in some way
less burdening in remitted patients, as indicated by lower mean
dosages of antipsychotics prescribed and lower frequency of associations between typical and atypical antipsychotics, a nding that may
contribute to explain the better functioning of these subjects. This
notwithstanding,, a very large proportion of patients among clinical
remitters (68%) are functionally non remitters (PSP total score o70).
Furthermore, only 32% of patients were found to be in both clinical
and functional remission, a result consistent with the ndings of a
recent study, showing how 42% of subjects met remission criteria for
both clinical and functional dimension on discharge from hospital, but
only 37% continued to meet these criteria at one-year follow-up
(Spellmann et al., 2012). Indeed, despite the existence of a correlation
between symptomatic remission and functioning, remission status
does not appear to be closely associated with functional recovery,
suggesting that the current focus on symptomatic remission may
reect an overtly restricted goal (Oorshot et al., 2012). The only partial
relationship between clinical remission and functioning clearly
emerges from data relating to specic areas of functioning at PSP:
54% of remitters continue to display manifest impairment in daily
activities (work, leisure, study etc.) and a more relevant proportion
(68%) in social activities, a percentage which falls to less than 10% only
when self-care and disturbed behaviours are taken into consideration.
These results are largely consistent with those of Karow et al. (2012)
showing that the most frequent problems encountered by remitted

F. Pinna et al. / Psychiatry Research 210 (2013) 739744

743

Table 5
Subjective Quality of Life in remitted and non-remitted patients.
Items
WHO-QoL
WHO-QoL
WHO-QoL
WHO-QoL
WHO-QoL
WHO-QoL

Bref
Bref
Bref
Bref
Bref
Bref

Item G1
Pts with a score o 3 at Item G1
Physical
Psychological
Social Relationships
Environment

Remitted (n 56)

Non-remitted (n 56)

Statistics

3.57
4
14.27
12.22
12.74
12.19

3.36
13
13.18
12.10
12.18
12.16

t(110) 1.186, p 0.0238

2(1) 4.438 p 0.035
t(110) 2.035, p 0.044
t(110) 0.368, p 0.714
t(110) 0.819, p 0.415
t(110) 0.364, p 0.699

(0.87)
(7.2%)
(2.37)
(1.51)
(3.1)
(1.61)

(1.03)
(23.2%)
(3.24)
(1.87)
(4.1)
(1.81)

WHO-QoL Bref WHO Quality of Life Brief questionnaire.

patients relate to the areas of social and daily life, whilst, as expected, a
satisfactory degree of functioning was observed in personal appearance and control of aggressiveness, in the cohort of stable, chronic
patients living in the community included in the present study. In our
study no statistically signicant differences were revealed in terms of
wellbeing between remitters and non remitters, although generally
lower mean scores at SWN were obtained in non-remitters, and the
percentage of subjects manifesting a state of well-being (SWN total
score 80 or over) was higher among remitters. With regard to
subjective quality of life, remitters and non-remitters displayed largely
similar scores at each subscale of WHO-QoL. However, 33% of
remitters were found not to be in a state of well-being and 7%
declared a low quality of life. Taken together, these results seems to
indicate that the subjective experience of life in psychotic patients is
only partially related to their status of remission, thus reecting the
well-known multi-determined nature of both subjective wellbeing
and quality of life constructs. In fact, subjective wellbeing is inuenced
by several different factors, not only illness-related but also affected by
other variables such as the physical side effects of drugs and associated
distress, attitudes towards pharmacological treatment, insight and
psychosocial factors (Karow and Naber, 2002). Quality of life is in turn
a highly complex measure, correlated with a number of factors,
including illness, medication or stress process-related variables, personality traits, and level of social support and psychosocial interventions, which may act as protective factors (de Millas et al., 2006); in
this complex framework, the strength of association of symptomatology and Quality of Life measures, in particular of a subjective nature, is
generally weak (Eack and Newhill, 2007).

5. Conclusions
Before drawing any conclusion, some important limitations of
the present study should be highlighted, such as: the limited
number of cases examined; the fact that only chronic outpatients
who were still in contact with the centre were considered, thus
excluding patients who had moved away, refused to stay in
treatment due to scarce insight and/or very severe illness, or had
no further need of continuing care; the differences in the organisation of the mental health system and the social background of
the study sample, which may have exerted a potential inuence on
outcomes. Bearing in mind these limitations, some results seem to
be worthy of consideration.
Clinical recovery is frequently achieved even by chronic psychotic
patients, a result associated with a signicantly higher level of
functioning. Unfortunately, clinical remission is not necessarily
accompanied by functional remission, which remains largely independent of clinical status. Although approximately 50% of patients
treated in a community setting achieve clinical remission, the
consistent proportion of patients who are still symptomatic and
functionally impaired even when remitted should not be overlooked. Moreover, the remaining 50% do not achieve clinical remission and continue to feature a high degree of functional impairment.
This outcome likely reects, at least in the community context

investigated in the present study, not only the limited effectiveness

of pharmacological treatments (Levine et al., 2011), but also the
paucity of psychosocial and other interventions specically-targeted
for neurocognitive and social cognitive decits which are considered
fundamental for promoting recovery (Mueser et al., 2013).
Indeed, almost all patients considered in this study were
undergoing psychopharmacological treatment, whilst only 12.5%
were referred for psychotherapy (individual or group therapy), and
approx. 21% rehabilitation interventions, without any statistical
difference between remitters and non remitters; only remitted
patients (7%) were engaged in supported employment programs,
likely reecting their better clinical status and functioning. No
patients underwent cognitive remediation or other interventions
devoted to enhancing cognitive functioning and only approximately 10% of families took part in psychoeducation sessions.
Overall, these data conrm the difculties in promoting recovery
of schizophrenic patients and the discrepancies detected between
routine practice and evidence-based intervention in Italian community services (Semisa et al., 2008).
Beyond these considerations, data emerging from the present
and other studies indicate that clinical remission would not seem
to be sufcient for use as a measure of outcome in schizophrenia
and related disorders. A more comprehensive construct, such as
clinical recovery, including at least symptomatic and functional
remission, may better describe the overall conditions of patients.

Acknowledgements
The authors wish to thank the other components of the Cagliari
Recovery Study Group: Davide Aru, Chiara Bandecchi, Elena Corda,
Enrica Diana, Francesca Fatteri, Alice Ghiani, Alice Lai, Serena Lai,
Lorena Lai, Valeria Perra, Sonia Pintore, Silvia Pirarba, Elisabetta Piras,
Sara Piras, Laura Puddu, Rachele Pisu Randaccio, Lucia Sanna,
Manuela Taberlet, Cristina Tocco, Massimo Tusconi, Enrico Zaccheddu
for their contribution to the study, and Ms Anne Farmer for having
revised the English version of the paper.
References
Andreasen, N.C., Carpenter Jr., W.T., Kane, J.M., Lasser, R.A., Marder, S.R., Weinberger, D.R., 2005. Remission in schizophrenia: proposed criteria and rationale for
consensus. American Journal of Psychiatry 162 (3), 441449.
Boden, R., Sundstrom, J., Lindstrom, E., Lindstrom, L., 2009. Association between
symptomatic remission and functional outcome in rst-episode schizophrenia.
Schizophrenia Research 107 (23), 232237.
Brissos, S., Videira Dias, V., Balanz-Martinez, V., Carita, A.I., Figueira, M.L., 2011.
Symptomatic remission in schizophrenia patients: relationship with social
functioning, quality of life, and neuro cognitive performance. Schizophrenia
Research 129 (23), 133136.
Byerly, M., Fisher, R., Whatley, K., Holland, R., Varghese, F., Carmody, T., Magouirk,
B., Rush, A.J., 2005. A comparison of electronic monitoring vs clinician rating of
antipsychotic adherence in outpatients with schizophrenia. Psychiatry
Research 133 (23), 129133.
Cannon-Spoor, H.E., Potkin, S.G., Wyatt, R.J., 1982. Measurement of premorbid
adjustment in chronic schizophrenia. Schizophrenia Bulletin 8, 470484.
Carpiniello, B., Pinna, F., Tusconi, M., Zaccheddu, E., Fatteri, F., 2012. Gender
differences in remission and recovery of schizophrenic and schizoaffective

744

F. Pinna et al. / Psychiatry Research 210 (2013) 739744

patients: preliminary results of prospective color study. Schizophrenia Research

Treatment, http://dx.doi.org/10.1155/2012/576369. (in Medline the citation is
2012:12:576369 followed by doi).
Conti, L., DellOsso, L., Cassano, G.B., 1988. Il sistema AMDP. Manuale per la
valutazione e la Documentazione della Psicopatologia. Versione Italiana.
Milano, Mazzuchelli.
De Hert, M., van Winkel, R., Wampers, M., Kane, J., van Os, J., Peuskens, J., 2007.
Remission criteria for schizophrenia: evaluation in a large naturalistic cohort.
Schizophrenia Research 92 (13), 6873.
de Millas, W., Lambert, M., Naber, D., 2006. The impact of subjective well-being
under neuroleptic treatment on compliance and remission. Dialogues Clinical
Neuroscience 8 (1), 131136.
Carpiniello, B., Baita, A., Carta, M.G., Sitzia, R., Macciardi, A.M., Murgia, S., Altamura,
A.C., 2002. Clinical and psychosocial outcome of patients affected by panic
disorder with or without agorafobia: result of a naturalistic follow-up study.
European Psychiatry 17, 394398.
Eack, S.M., Newhill, C.E., 2007. Psychiatric symptoms and quality of life in
schizophrenia: a meta-analysis. Schizophrenia Bulletin 33 (5), 12251237.
First, M.B., Spitzer, R.L., Williams, J.B.W., Gibbon, M., 1996. Structured Clinical
Interview for DSM IV Axis I Disorders-Research Version (SCID-I, Version 2. 0).
Biometrics Research Department. New York State Psychiatric Institute,
New York.
Green, M.F., Kermn, R.S., Braff, D.L., Mintz, J., 2000. Neurocognitive decits and
functional outcome in schizophrenia: are we measuring the right stuff?
Schizophrenia Bulletin 26 (1), 119136.
Guy, E., ECDEU Assessment Manual for Psychopharmacology Revised, 1976. DHEW
Publication, N. (ADM), Washington, pp. 76338.
Haro, J.M., Kamath, S.A., Ochoa, S., Novick, D., Rele, K., Fargas, A., Rodrguez, M.J.,
Rele, R., Orta, J., Kharbeng, A., Araya, S., Gervin, M., Alonso, J., Mavreas, V.,
Lavrentzou, E., Liontos, N., Gregor, K., Jones, P.B., SOHO Study Group, 2003. The
clinical global impression-schizophrenia scale: a simple instrument to measure
the diversity of symptoms present in schizophrenia. Acta Psychiatrica Scandinavica Suppl 416, 1623.
Helldin, L., Kane, J.M., Karilampi, U., Norlander, T., Archer, T., 2007. Remission in
prognosis of functional outcome: a new dimension in the treatment of patients
with psychotic disorders. Schizophrenia Research 93, 160168.
Hogan, T.P., Awad, A.G., Eastwood, R., 1983. A self report scale predictive of drug
compliance in schizophrenics: reliability and discriminative validity. Psychological Medicine 13, 177183.
Kane, J.M., 2007. Treatment adherence and long-term outcomes. CNS Spectrum 12
(supp 17), 2126.
Kay, S.R., Fiszbein, A., Opler, L.A., 1987. The positive and negative syndrome scale
(PANSS) for schizophrenia. Schizophrenia Bulletin 13 (2), 261276.
Karow, A., Naber, D., 2002. Subjective well-being and quality of life under atypical
antipsychotic treatment. Psychopharmacology (Berl) 162 (1), 2428.
Karow, A., Moritz, S., Lambert, M., Schottle, D., Naber, D., 2012. On behalf of the
EGOFORS initiative, 2012. Remitted but still impaired? Symptomatic versus
functional remission in patients with schizophrenia. European Psychiatry 27
(6), 401405.
Kirkpatrick, B., Fenton, W.S., Carpenter Jr., W.T., Marder, S.R., 2006. The NIMHMATRICS Consensus statement on negative symptoms. Schizophrenia Bulletin
32 (2), 214219.
Lambert, M., Schimmelmann, B.G., Naber, D., Schacht, A., Karow, A., Wagner, T.,
Czekalla, J., 2006. Prediction of remission as a combination of symtpmatic and

functional remission and adequate subjective well-being in 2690 patients with

schizophrenia. Journal of Clinical Psychiatry 67 (11), 16901697.
Levine, S.Z., Rabinowitz, J., Ascher-Svanum, H., Faries, D.E., Lawson, A.H., 2011.
Extent of attaining and maintaining symptom remission by antipsychotic
medication in the treatment of chronic schizophrenia: evidence from the CATIE
study. Schizophrenia Research 133 (13), 4246.
Llorca, P.M., 2008. Partial compliance in schizophrenia ant the impact on patient
outcomes. Psychiatry Research 161 (2), 235247.
Morosini, P.L., Magliano, L., Brambilla, L., Ugolini, S., Pioli, R., 2000. Development,
reliability and acceptability of a new version of the DSM-IV Social and
Occupational Functioning Assessment Scale (SOFAS) to assess routine social
functioning. Acta Psychiatrica Scandinavica 101 (4), 323329.
Mueser, K.T., Deavers, F., Penn, D.L., Cassisi, J.E., 2013. Psychosocial treatments for
Schizophrenia. Annual Review Clinical Psychology 9, 465497.
Naber, D., Moritz, S., Lambert, M., Pajonk, F.G., Holzbach, R., Mass, R., Andresen, B.,
2001. Improvement of schizophrenic patients' subjective well-being under
atypical antipsychotic drugs. Schizophrenia Research 50 (12), 7988.
Nasrallah, H.A., Lasser, R., 2006. Improving patients' outcomes in schizophrenia:
achieving remission. Journal of Psychopharmacology 20 (6 Suppl), 5761.
Oorshot, M., Lataster, T., Thewissen, V., Lardinois, M., van Os, J., Delespaul, P.A.,
Myin-Germeys, I., 2012. Symptomatic remission in psychosis and real life
functioning. British Journal of Psychiatry 201 (3), 215220 (Epub ahead of
print).
Primavera, D., Bandecchi, C., Lepori, T., Sanna, L., Nicotra, E., Carpiniello, B., 2012.
Does duration of untreated psychosis predict very long term outcome of
schizophrenic disorders? Results of a retrospective study. Annals of General
Psychiatry 11 (1), 21, http://dx.doi.org/10.1186/1744-859X-11-21.
Schennach-Wolff, R., Jager, M., Seemuller, F., Obermeier, M., Messer, T., Laux, G.,
Pfeiffer, H., Maber, D., Schmidt, L.G., Gaebel, W., Huff, W., Heuser, I, Maier, W.,
Lemke, M.R., Ruther, E., Buchkremer, G., Gastpar, M., Moller, H.J., Riedel, M.,
2009. Dening and predicting functional outcome in schizophrenia and
schizophrenia-spectrum disorders. Schizophrenia Research 13 (2-3), 210217.
Semisa, D., Casacchia, M., Di Munzio, W., Neri, G., Buscaglia, G., Burti, L., Pucci, C.,
Corlito, G., Bacigalupi, M., Parravani, R., Roncone, R., Cristofalo, D., Lora, A.,
Ruggeri, M., 2008. and the group SIEP-Direct, 2008. Promoting recovery of
schizophrenic patients: discrepancy between routine practice and evidence.
The SIEP-DIRECT'S Project. Epidemiologia e Psichiatria Sociale 14 (4), 331348.
Spellmann, I., Riedel, M., Schennach-Wolff, R., Seemuller, F., Obermeier, M., Musil,
R., Jager, M, Schmauss, M., Laux, G., Pfeiffer, H., Naber, D., Schmidt, L.G., Gaebel,
W., Klosterklotter, J., Heuser, I., Maier, W., Lemke, M.R., Ruther, E., Klingberg, S.,
Gastpar, M., Moller, H.J., 2012. One-year functional outcomes of naturalistically
treated patients with schizophrenia. Psychiatry Research 198 (3):378385 (Mar
13 (Epub ahead of print).
Skevington, S.M., Lofty, M., OConnel, K.A., 2004. The WHOQoL Group. The World
Health Organization's WHOQoL Bref quality of life assessment: psychometric
properties and results of the international eld trial. A report from the
WHOQoL group. Quality of Life Research 13 (2), 299310.
Van Os, J., Drukker, M., Campo, J., Meijer, J., Back, M., Delespaul, P., 2006.
Validation of remission criteria for schizophrenia. American Journal of
Psychiatry 163 (11), 20002002.
Wunderink, L., Nihenhuis, F.J., Sytema, S., Wiersma, D., 2007. Predictive validity of
proposed remission criteria in rst-episode schizophrenic patients responding
to antipsychotics. Schizophrenia Bulletin 33 (3), 792796.