Alcoholics in psychiatric institutions

Summary Two epidemiologically defined cohorts of first-referred clients to outpatient clinics for alcoholics (1972 and 1982) were followed up. It was found that previous hospitalization is a pointer to admission to psychiatric institutions. More females are admitted than males and they are more often diagnosed as depressive. Over an 11-year follow-up period, the admitted males of the 1972 cohort spent an average of 112 days in psychiatric institutions, and the females an average of 132 days.     

First-admission rates and marital status of schizophrenics

All patients who were first-admitted to Danish psychiatric institutions in the calendar years 1970, 1973, 1976, 1979, and 1982 and who were diagnosed as schizophrenics at least once within a 2-year period of observation from the first day of the first admission are followed up by means of the nation-wide Danish Psychiatric Register (totally 1,175 males and 665 females). Sex and age specific first-admission rates of schizophrenia show that the difference between male and female rates especially appears in the age group 15-24 years. In this age group the peak incidence is found for both sexes, also if the patients only diagnosed as schizophrenics at a later admission are included. The ratio of male to female incidence rates are not changed by inclusion of the latter patients. A higher frequency of married or formerly married patients is found among the schizophrenics who were diagnosed late in the course of treatment than among those who were so at first-admission. This might be a manifestation of a less severe symptomatology which could explain the tendency to hesitate in diagnosing patients as schizophrenics.     

Who became revolving door patients?

A cohort representing all first-time admissions to Danish psychiatric institutions during the period April 1, 1970 to March 31, 1971 was followed for 10 years in the psychiatric register. The cohort comprised 5,881 males and 6,856 females aged 15 years or above. The revolving door population was delineated as (1) patients with minimum four admissions and no admission or discharge period lasting for more than one fourth of the observation period or (2) patients with minimum four admissions during the first one fourth of the observation period. The incidence rate was 3.14 males and 3.55 females per 1,000. Revolving door patients were younger than others, single or divorced, and lived in larger cities. They were more frequently referred to out-patient aftercare and discharged to their own home. A male diagnostic profile of schizophrenia, demential or organic psychoses, personality disorders and abuse emerged together with a female profile of manic depressive and psychogenic psychosis and neurosis. Twenty-one point nine percent of males and 13.0% of females had more than 10 admissions and 4.5% of males and 3.7% of females spent more than 5 years in hospital. High risk groups were 15-24 years old as 21% and 13% of young males respectively females became revolving door patients, and schizophrenics, as 46% of male and 30% of female schizophrenics became revolving door patients.     

Prediction and profile of the long-stay population. A nation-wide cohort of first time admitted patients

A nation-wide cohort of 12,737 first admitted patients aged 15 years or more to Danish psychiatric institutions was followed in the Danish Case Register for a 10-year period. Long stay patients were delineated as: 1) patients whose first admission lasted for more than 1 year (new long-stay); or 2) patients who later had an admission lasting for more than 1 year (late long-stay). Together they comprised 420 males and 527 females with an incidence rate of 0.22 males and 0.27 females per 1,000. Up to age 65 males dominated, after 65 females dominated. Thirty-three percent of demential disordered and 24 of schizophrenics became long-stay patients. A multiple contingency analysis showed that the variables "age group", "main diagnosis", "size of municipality of residence" and "marital status" were independently associated with the outcome "long-stay". The two long-stay groups differed. New long-stay patients tended to be females, older, suffering from demential disorders and with a total hospital stay shorter than that of the long-stay population. In a multiple contingency analysis the variables "age group" and "main diagnosis" were independently associated with the outcome "new long-stay" and the variables "age groups", "main diagnosis" and "size of municipality of residence" with the outcome "late long-stay".     

The schizophrenia diagnosis in Denmark. A register-based investigation

Patients, Danish citizens only, admitted for the first time in 1972 to a Danish psychiatric institution were selected from the national psychiatric register. To be included, the probands had to have been diagnosed as schizophrenics at least once in the period from their first admission to 1 September 1983. The study comprised 370 males and 217 females with a total of 5,298 admissions. The probands' diagnostic pattern during the above period was investigated. More males (51.9%) than females (39.2%) (P less than 0.01) were diagnosed as schizophrenics during their first admission. The average period from a patient's first contact with an in-patient institution until schizophrenia was diagnosed for the first time was 2.2 years for females and 1.7 years for males (P less than 0.05). Personality disorders, reactive psychoses, and not classifiable psychoses were the most frequent diagnoses prior to the first schizophrenia diagnosis. The diagnostic stability of schizophrenia as main diagnosis, after its first application, was 73.6% for males among a total of 2,539 admissions and 71.2% for females among 1,141 admissions. There was greater correlation between the latest and former diagnoses than between the first and subsequent diagnoses. This is valid both when distinguishing between schizophrenia and non-schizophrenia and when focusing on schizophrenia subtypes. The results are discussed, particularly the problem concerning the selection of representative cohorts for schizophrenia research projects.     

The use of a psychiatric register in predicting the outcome "revolving door patient". A nation-wide cohort of first time admitted psychiatric patients

A nation-wide cohort of all first admitted patients to all Danish psychiatric institutions over a 1 year period and aged 15 years or more was followed for 10 years in the Danish psychiatric register. Revolving door patients were defined as patients with a minimum of four admissions and 1) no admission or discharge period lasting for more than 1/4 of the observation period or 2) at least four admissions over the first 1/4 of the observation period. The revolving door population comprised 1,397 patients with an incidence rate of 0.42 males and 0.32 females per 1,000. Forty-three point five percent belonged to the same diagnostic group at first and last diagnostic assessment ranging from 28.3% in "organic psychosis" to 57.6% in "neurosis". A multiple contingency analysis showed a number of variables at first admission significantly associated with the outcome "revolving door". Many were conditioned by others and the independent variables were "age group", "main diagnosis" and "sex". Patients aged 15-24 years constituted a high risk group among schizophrenics. The 15-24 age group was further at high risk among females with personality disorder or abuse and males with manic depressive and psychogenic psychosis. Living close to a psychiatric institution was in males associated with the outcome independently of age and diagnosis, in females it was restricted to personality disorder. Revolving door patients were significantly younger than others and more likely to suffer from schizophrenia or alcohol/substance abuse.     

14-year outcome in early schizophrenia

Of 45 first admission schizophrenics from 1963, an incidence by first admission group for northern Alberta, 43 were followed-up 14 years later. Based on these figures the expectancy was found to be 0.49 %. The proportion of patients who were married was less than expected in comparison with the general population, but amongst the married, fertility was probably comparable to the population's. At follow-up about half the patients were managing well with little or no disability, one quarter had moderate to marked disability and the remainder were socially, psychiatrically and occupationally disabled. From the time of first admission, patients had spent an average of 15 % of their time in hospital and lost 28 % of the total time due to psychiatric disability.     

The new revolving-door patients: results from a national cohort of first admissions

A cohort of all first admissions to New Zealand psychiatric hospitals and psychiatric wards of general hospitals in 1980 and 1981 was followed up for 5 years. The cohort consisted of 3875 males and 3965 females aged from 15 to 64 years. Of these subjects, 59.4% had only one admission; 14.6% met our criteria for a revolving-door patient, as they had 4 or more admissions within the 5-year follow-up period. Based on first-admission information, patients who were younger and had a psychotic diagnosis had an increased likelihood of becoming a revolving-door patient. Stepwise logistic regression showed that younger age and psychotic diagnosis independently and in interaction were associated with a high probability of becoming a revolving-door patient. Although patients with a first-admission diagnosis of schizophrenia constitute a large group of the new revolving-door patients for both males and females, for women those with affective disorders and for men those with substance abuse comprise the largest proportion of the new revolving-door patients. This is because affective disorders in women and substance abuse in men are the most common diagnoses on first admission, rather than because the disorders themselves are associated with a high probability of the patients having multiple admissions.     

Is schizophrenia really on the decrease?

Summary Directly age standardized rates of first admission schizophrenia in Denmark (1991: 5.1 million inhabitants) decreased significantly with a slope of –0.16 and –0.13/100,000 inhabitants fifteen years and above for males and females respectively from 1971 to 1991 when examined by help of the Danish nation-wide psychiatric case register in the Institute of Psychiatric Demography, Aarhus. A control for changes in diagnostic delay/changing diagnostic patterns does not affect the findings. Various nosological factors might cause the decrease, e.g. changing structure in organization of treatment facilities, decreasing number of beds (50% in Denmark during the period investigated) and correlated with this: increasing suicide rates among pretreatment schizophrenics, increasing rates of schizophrenics not yet diagnosed in shelters for homeless and in institutions for criminals. The decrease might be genuine. In connection with this the theories about damage to the fetus during the gestation period are briefly discussed.     

Why has the incidence of schizophrenia in Danish psychiatric institutions decreased since 1970?

From The Danish Psychiatric Register five cohorts of all first-admitted patients to Danish psychiatric institutions from the years 1970, 1973, 1976, 1979, and 1980 have been followed, and trends in age-standardized rates of schizophrenia investigated. The first-admission rates have decreased in both sexes, significantly in males. In addition, the cumulated schizophrenia rates for the cohorts, including those of patients diagnosed as schizophrenics only at a later admission within periods of 2 and 5 years, decreased. This decrease is significant at 2 years of observation in both sexes and at 5 years in females. The decreasing first-admission rates might be explained partly by changes in diagnostic habits. The differential diagnoses of schizophrenia (paranoid states (ICD-8:297), paranoid reactive psychoses (298.3), unspecified psychoses (298.9 and 299), and borderline states (ICD-8 Danish version: 301.83] are increasingly used as first-admission diagnosis for patients later to be diagnosed as schizophrenic, possibly owing to a tendency to avoid the diagnosis of schizophrenia, when treatment of a patient is possible. A method of calculating the hospital incidence of schizophrenia approaching the real incidence better than the incidence of first-admission diagnoses is suggested.     

Sex differences in the utilization of mental health services: a nation-wide register study

A nation-wide investigation of a cohort of first admissions during the period April 1, 1970 to March 31, 1971 to psychiatric institutions was followed in the Danish Psychiatric Register for a 10 year period. The cohort comprised 5,881 males and 6,856 females with an annual incidence rate of 3.14 males and 3.55 females per 1,000. Males were significantly younger than females and more frequently involuntarily admitted. Males predominated among schizophrenics and addictive disorders, females among neurotics and manic-depressive psychotics. Young males required longer hospital stays and more admissions than young females. The opposite was the case among patients over 65 years. Three outcome groups were delineated and the incidence rate calculated to: the "short term" group comprising 1.64 males and 1.90 females per 1,000, the "long-stay" group comprising 0.22 males and 0.27 females per 1,000 and the "revolving door" group comprising 0.42 males and 0.32 females. Multiple contingency analyses showed that only the outcome "revolving door" was independently associated with the sex of the patients with males being a high risk group.     

The epidemiology of anorexia nervosa in Denmark from 1973 to 1987: a nationwide register study of psychiatric admission

A nationwide register study of psychiatric admission for anorexia nervosa in Denmark yielded average incidence rates of 1.9 per 100,000 per year for females and 0.17 per 100,000 per year for males. The prevalence was 6.7 per 100,000 per year for females and 0.6 per 100,000 per year for males. The female-male ratio for first admissions was 11.8:1. The incidence of anorexia nervosa showed no trend in the general population, but an increase was found among psychiatric inpatients. This increase was explained by a reduction by one third in all psychiatric first admissions and in available psychiatric beds and augmented by an increase in readmissions of anorectic patients. Males were younger than females at first admission. Females were older at first admission from 1973 to 1977 than in later periods. Of males readmitted for non-eating disorders, more were psychotics and fewer psychopaths than among females. Age-period and age-cohort analysis of the 10- to 24-year-old females showed that only age exerted a significant independent influence on first-admission rates, whereas all 3 factors exerted significant independent influence on readmission rates. This might reflect changes in admission policy, greater diagnostic vigilance and changes in attitude towards weight, shape and fitness.     

Elderly first admissions to psychiatric institutions: Findings of a nationwide Danish cohort

A nationwide cohort of first-time admitted patients aged 65 years or more to Danish psychiatric institutions was followed over a 10-year period in the Danish psychiatric register. The annual incidence rate was 3.4 males and 3.9 females per 1000. Females were more likely to get an age-related diagnosis, had more admissions and longer stays than males. 62.6% of the males and 53.9% of the females died as patients or were discharged within one year and not readmitted. More frequently this short-term group had a non-psychotic disorder. 21.9% of the males and 27.2% of the females became long-stay patients and were characterized by organic disorders. 1.9% of the males and 3.2% of the females became revolving-door patients and were characterized by manic depressive psychoses and organic disorders. In total the annual incidence rate of ‘heavy users’ was estimated to be 0.81 males and 1.14 females per 1000.     

A 30-year follow-up study of a child psychiatric clientele. II. Psychiatric morbidity

Psychiatric morbidity, expressed as hospital admissions during a 30-year follow-up period, was studied among 322 former child psychiatric patients, who were admitted from 1949-1951, and who were followed up as of December 31, 1980. A total of 115 patients (36%)--55 boys (29%) and 60 girls (45%)--had been admitted to an adult psychiatric department, with 50 patients having only one admission. The mean age at the time of the study was 39 years. The former child psychiatric patients were admitted to adult psychiatric hospitals 50 times more often than comparable age groups from the general population. At all times women had a higher prevalence of admission. The cumulative percentage of first admissions of men was almost unchanged during the last 10 years of the follow-up period, and the figure for women was gradually increasing. The longitudinal course of mental disorders in the sample, measured as psychiatric admissions, was studied in relation to age at the time of admission to the child psychiatric department. The results consistently showed that older age of admission as a child meant fewer psychiatric admissions as an adult during the follow-up period. A total of 39 of the psychiatrically admitted patients (34%) had been granted a disability pension. A total of 7 patients (6%) died during the study period, including 2 patients who committed suicide. By the variables employed, 37% of the sample were judged to have had a good overall outcome, with diagnosis being an inconsistent predictor of outcome.(ABSTRACT TRUNCATED AT 250 WORDS)     

Immigration,moving house and psychiatric admissions

This study was designed to elucidate psychiatric admission rates for native Swedes and foreign-born individuals during the period 1991–1994, when Sweden had a great influx of refugees. During the same period, and even earlier, psychiatric in-patient care had been reduced. Tests of differences between Swedes and foreign-born individuals in first psychiatric admission rates were performed using Poisson regressions, and the risk of a readmission was assessed using a proportional hazard model. Foreign-born individuals and native Swedes, both males and females, showed a similar admission pattern with regard to the number of admissions. Foreign-born males under 55 years of age and foreign-born females under 35 years of age had significantly higher admission rates than native Swedes. In total, native Swedes, both males and females, were hospitalized for a significantly longer period than the foreign-born subjects. About 43% of the patients were readmitted. The risk of a readmission was significantly increased among those with a high rate of internal migration. The high admission rates for young foreign-born individuals might be explained by a high incidence of mental illness owing to the trauma of being violently forced to migrate, acculturation difficulties, or unsatisfactory social circumstances such as high unemployment. The shorter hospitalization time could be due to undertreatment or less serious mental illness.     

Time trends in first admissions for schizophrenia and paranoid psychosis in Stockholm County, Sweden

Several studies have reported decreasing time trends in first diagnosed schizophrenia patients. The aim of this study was to analyze time trends for first admissions with a diagnosis of schizophrenia or a diagnosis of either schizophrenia or paranoid psychosis during 1978-1994 in Stockholm County, Sweden, with a population of around 1.8million. Information about first psychiatric admission with the diagnosis schizophrenia or paranoid psychosis for residents of Stockholm County was obtained from the Swedish population-based psychiatric inpatient register. Age-adjusted average yearly changes in first hospitalization rates were estimated in a Poisson regression model. Time trends in first admission rates were calculated from 1978 to 1994, while admissions during 1971 to 1977 were observed only to eliminate later re-admissions. First admissions for schizophrenia declined by 1.9% annually for females and by 1.3% for males, while first admissions for schizophrenia and paranoid psychosis together were unchanged over the study period for both genders. Our results indicate that the incidence of schizophrenia and paranoid psychosis taken together was essentially the same over the studied time period in Stockholm County, and that the apparent decline in first admission rates for schizophrenia may be an effect of changes in clinical diagnosis over time.     

Duration of inpatient treatment of various psychiatric disease categories. A follow-up study]

The frequency and duration of in-patient treatment in psychiatric and general hospitals was observed over an average 14-year period for 328 patients with different psychiatric diseases. Schizophrenics were more frequently admitted and spent longer in psychiatric institutions than all other diagnostic groups, but were admitted less frequently and for shorter periods to general hospitals. Patients suffering from organic mental illness and those with neurotic disorders had more frequent and longer periods of general hospital care. Drug dependent and neurotic patients were hospitalised more frequently and longer for psychiatric rather than for medical reasons in general hospitals. The total frequency and duration of psychiatric in-patient treatment was distinctly less frequent and of shorter duration for neurotic disorders as compared with schizophrenic or affective psychoses.     

A follow-up study of a child psychiatric clientele with special regard to the diagnosis of psychosis

A 20-year follow-up of a child psychiatric clientele of 322 patients demonstrates that nearly one third have been admitted to psychiatric departments or mental hospitals in adulthood. One tenth belonged to the group with psychoses either as a child or grown-up. While the incidence of manic-depressive psychosis did not differ from a normal population of the same sex and age, the child psychiatric clientele is overrepresented by psychotic patients later on diagnosed as schizophrenia. The outcome of infantile psychosis was in half of the cases chronic psychosis; five of 10 psychosis proto-infantilis patients were diagnosed schizophrenia in adulthood. This result is not in accordance with the modern view that psychosis proto-infantilis is a special disease with no clinical connection to schizophrenia. The clinical entity of infantile psychosis and borderline psychosis seems to be affirmed by a common clinical and diagnostic course into borderline psychosis or schizoid character disorders. Nine patients with psychosis in adulthood did not belong to the group of psychosis in childhood.     

Hospitalization patterns in schizophrenia. A 13-year follow-up

All first admitted patients in 1972 from a catchment area of 582,000 inhabitants aged 15 years or more who were diagnosed as schizophrenic at least once from 1972 until September 1983 (n = 53) were followed-up on average 13 years after first admission. About 20% of the cohort was hospitalized on any given day throughout the length of the follow-up period. The duration of hospitalization decreased from a mean of 8.2 months for the first admission to 1.7 months for the tenth or later admission. The readmission risk increased as a function of the number of previous admissions. Patients with income from occupation or from grants for education had shorter duration of first in-patient period. If the patients were diagnosed as schizophrenics already during the first hospitalization the risk for prolonged duration of the first in-patient period was increased but the readmission risk diminished. Furthermore, readmission risk after the first discharge was diminished by own income and by out-patient treatment and increased by low social status. High proportion of follow-up time in hospital (greater than or equal to 30%) was correlated to affective flattening present at first admission. Of the cohorts' total number of admissions (n = 493) 12% were involuntary. Involuntary admissions were more frequent in the first half of the follow-up period and were correlated to a previous involuntary admission.     

The relatives of the mentally ill. A comparative trial of community-oriented and hospital-oriented psychiatric care

One hundred and twenty patients presenting for admission were randomly allocated into two groups. Control patients received standard psychiatric hospital care and aftercare. Experimental patients were not admitted, if possible; they and their relatives were provided with comprehensive community treatment, including a 24-hour crisis service. Patients with a diagnosis of alcohol or drug dependence, organic brain disorder, or mental retardation were excluded. The great majority of patients were diagnosed as suffering from one of the functional psychoses--mainly schizophrenia. During the study year, control patients spent an average of 53.5 days in psychiatric hospitals, experimental patients spent an average of 8.4 days. Psychiatric patients were treated more effectively and economically in the community, without shifting the burden onto the relatives. Nearly all the relatives of experimental patients preferred community treatment; they considered it to be significantly more helpful to the patients and themselves than standard psychiatric hospital care and aftercare.