Symptom rating scales are now well established in schizophrenia research buttheir scores are notthe same as outcome

To appraise the usefulness of symptom rating scales in evaluating the outcome of people with schizophrenia

Literature on the use of the Brief Psychiatric Rating Scale (BPRS) the Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impression (CGI) in schizophrenia research was studied

Scales were designed to make diagnoses, to categorise patients, syndromes or both, and to demonstrate antipsychotic efficacy, as well as to measure outcome. There is much redundancy both between and within scales. Early work suggests limited concurrent validity with external outcome variables. Data are at best ordinal and there are particular difficulties in equating outcome with percentage changes in scores. The concept of remission, which uses absolute item score thresholds with a duration criterion, is a promising outcome measure

Symptom rating scale scores can only comprise a limited part of outcome measurement. Standardised remission criteria may present advantages in outcome research

Outcomes reflecting the social situation are widely considered as important in the treatment of people with schizophrenia

To review concepts of social outcomes in schizophrenia and the corresponding assessment instruments

Non-systematic literature review and reflection on conceptual and methodological issues

Concepts of social outcomes in schizophrenia lack agreed definitions and theoretical models. A fundamental issue is the distinction between objective and subjective indicators. More research has focused on subjective indicators, which are only weaklly correllated with objective life situation and show consistent correlations with mood. Various assessment instruments have been developed pragmatically, particularly to measure quality of life and social functioning, and the literature provides extensive data for comparison

Established instruments exist to measure social outcomes in schizophrenia. Their use requires an awareness of the specific strengths and limitations

Patient-reported outcomes are increasingly used to evaluate the care of people with schizophrenia

To review established and emerging patient-reported outcomes in schizophrenia research, assessment tools and key findings

A non-systematic review addressing relevant constructs, the associated scales and key empirical findings

Patient-reported outcomes in schizophrenia relate either to evaluation of illness and benef it from treatment or to resilience of the self. Of the former, needs for care, treatment satisfaction and the therapeutic relationship are most common. Less common are symptoms, insight, attitude towards medication, and clinical communication. Increasing expectations of treatment have led to new measures assessing resilience of the self, including empowerment, self-esteem, sense of coherence and recovery Scores of different patient-related outcomes overlap and are influenced by a general tendency, largely influenced by mood, for more or less positive appraisal

The conceptual and empirical basis for different patient-reported outcomes varies, with most data available for treatment satisfaction. More than one such outcome should be used only if there is a specific hypothesis. For new patient-reported outcomes, relative independence from existing constructs should be demonstrated

Schizophrenia is known to be associated with a range of adverse outcomes, which have an impact at the societal level and are therefore of public concern

To examine the epidemiology and methods for measuring six adverse outcomes in schizophrenia: violence, victimisation, suicide/self-harm, substance use, homelessness and unemployment

Areview of the literature was carried out for each adverse outcome, with attention to critical appraisal of existing measurement tools

Schizophrenia is associated strongly with all six outcomes, although research has mainly focused on violence. Each outcome acts as a risk factor for at least some of the other outcomes. There are few standardised or validated measures for these'hard' outcomes. Each measure has inherent biases but a growing trend is for these to be minimised by using multiple measures

Asingle instrument which systematically measures multiple societal outcomes of schizophrenia would be extremely useful for both clinical and research purposes

People with schizophrenia comprise the majority of patients with severe mental illness recruited to recent mental health service studies of new teams (e.g. assertive outreach, crisis resolution). Reduction in hospitalisation has been the most consistent outcome measure in these studies, but results are inconsistent

To understand inconsistency of results from studies using hospitalisation as an outcome measure

The advantages and disadvantages of hospitalisation are explored, including the ways in which it is recorded. Regional variation in outcomes and the impact of control services are reviewed

Hospitalisation has face validity as an outcome but translates poorly between differing healthcare contexts. These variations can be exploited positively to distinguish potentially effective ingredients in community care (outreach, combined health and social care, team structure) from redundant components

Hospitalisation is a good proxy outcome measure in schizophrenia care in randomised controlled trials, but the dangers of extrapolating to new contexts require care

It is essential in economic evaluations of schizophrenia interventions that all relevant costs are identified and measured appropriately Also of importance is the way in which cost data are combined with information on outcomes

To examine the use of health economicsin evaluations of interventions for schizophrenia

Areview of the key methods used to estimate costs and to link costs and outcomes was conducted

Costs fall on a number of different agencies and can be short term or long term. Cost-effectiveness analysis and cost-utility analysis are the most appropriate methods for combing cost and outcome data

Schizophrenia poses a number of challenges for economic evaluation

Cognitive deficits are a core feature of schizophrenia. These deficits are not caused by medication or symptoms, and have a dramatic negative effecton real-world functioning

To critically examine a selection of the most common batteries used to assess cognition in schizophrenia

Literature review of cognitive assessment batteries for use in schizophrenia

A wide variety of neuro-cognitive test batteries have been developed or adapted to assess cognition in schizophrenia. These differ in time requirements, repeatability, ease of administration, degree of face validity, availability of co-normative data and degree to which results can be parsed into separate domains of cognitive functioning. The most appropriate depends on the setting and the question being addressed

Cognitive outcome measures have reshaped our understanding of schizophrenia and will be essential tools for unravelling the aetiology of the disease and designing more effective interventions

As understanding of the pathobiology of schizophrenia increases, the challenge is to relate such measures to outcome at a functional level

To consider our current understanding of how neurobiological variables relate to functional outcome and might constitute outcome measures in their own right

Critical appraisal of recent evidence on structural and functional imaging, neurological evaluation, early neurodevelopmental indices, genomics, proteomics, metabolomics and apoptotic mechanisms in relation to outcome

Studies conducted prospectively from the first episode of schizophrenia are generating more reliable findings but currently lack predictive power. Prediction of transition from ‘high-risk’ status to first episode has proved somewhat more fruitful, but the gain has been modest and circumscribed

Our current level of understanding does not yet allow the generation of predictive models on an individual patient basis. Genomic and metabolomic studies hold particular potential for generating clinically meaningful ‘biomarkers’ but considerable further work is necessary

Duration of untreated psychosis (DUP) is considered an important predictor of short-term clinical outcome

To explore the evolution of the concept of DUP, synthesise the evidence for its predictive value, highlight the problems in measurement, and consider the potential pitfalls of using DUP as a measure of the effectiveness of early intervention services

A survey of recent literature was conducted

Several studies and two systematicreviews confirm that DUP has a robust but moderate effecton outcome in schizophrenia. Studies vary widely in how DUP is defined and measured, since identifying precise time points when psychosis emerges and remits is conceptually ambiguous and clinically difficult

Standardised measurement of DUP is a vital first step in allowing comparisons between studies. Duration of untreated psychosis is a relevant measure only of the early detection function of early intervention services

Antipsychotic drugs are associated with adverse effects that can lead to poor medication adherence, stigma, distress and impaired quality of life

To review the use of adverse effects of antipsychotic drugs as outcome measures, with a particular emphasis on methodological issues

Review of data on adverse effects from sources including randomised controlled trials (RCTs), post-marketing surveillance and naturalistic studies

All have advantages and disadvantages and the best overview comes from considering all sources of data together. Adverse effects are inconsistently reported, hampering cross-study comparisons. Many outcome measures lack clinical meaning. In both naturalistic studies and RCTs adverse effects often account for less treatment discontinuation than lack of efficacy

Standardisation in the reporting of adverse effects is needed. Patients' subjective experience of medication should be given more consideration. Total discontinuation rates provide a useful global outcome measure that incorporates tolerability and efficacy as well as patient and clinician viewpoints. Patients should be informed of common side-effects prior to treatment and monitored for their occurrence during treatment

Outcome of schizophrenia has been described as favourable in low-and middle-income countries. Recently, researchers have questioned these findings

To examine the outcome studies carried out in different countries specifically looking atthose from low-and middle-income countries

Long-term course and outcome studies in schizophrenia were reviewed

A wide variety of outcome measures are used. The most frequent are clinical symptoms, hospitalisation and mortality (direct indicators), and social/ occupational functioning, marriage, social support and burden of care (indirect indicators). Areas such as cognitive function, duration of untreated psychosis, quality of life and effect of medication have not been widely studied in low-and middle-income countries

The outcome of schizophrenia appears to be better in low-and middle-income countries. A host of sociocultural factors have been cited as contributing to this but future research should aim to understand this better outcome. There is a need for more culture-specific instruments to measure outcomes

Randomised controlled trials (RCTs) are the gold standard for evaluating treatment efficacy. However, the outcomes of RCTs often lackclinical utility and usually do not address real-world effectiveness

To review how traditional RCTs may be triangulatedwith other methodologies such as observational studies and pragmatic trials by highlighting recently reported studies, outcomes used and their respective merits

Literature review focusing on drug treatment

Recently reported observational and some pragmatic studies show a degree of consistency in reported results and use outcomes that have face validity for clinicians

No single experimental paradigm or outcome provides the necessary data to optimise treatment of mental illness in the clinical setting