Hospital and community-based care for patients with chronic schizophrenia in Hong Kong

Background: There have been few studies on the impact of de-institutionalization on psychiatric patients' lives in Chinese culture. The objectives of the present study were: (1) to compare quality of life (QOL) of Chinese patients with schizophrenia living in three different treatment settings (hospital, long-stay care home and half-way house) in Hong Kong, and (2) to identify factors associated with patients' subjective well-being. Method: A matched-group design was used. Subjects (n = 204) living in the three treatment settings were matched according to age, sex, educational level, marital status, length of psychiatric illness and number of previous psychiatric admissions. Multiple measures for the evaluation of QOL included the Satisfaction With Life Scale (SWLS), WHO Quality of Life Measure-Abbreviated version-Hong Kong (WHOQOL-BREF-HK), Life Event List (LEL) and the Global Assessment Scale (GAS). Psychiatric symptoms were evaluated with the Brief Psychiatric Rating Scale (BPRS). Results: Significant differences in objective QOL indices (global level of functioning, number of life events and income) between subjects staying in hospital and community-based residential services were found in favour of the less restrictive community settings. However, with respect to global life satisfaction, subjects preferred the more secure settings despite their restrictiveness. Predictors of subjective well-being were educational level, negative life events and the BPRS items of somatic concern, anxiety and guilt feelings. The impact of negative life events on subjective well-being decreased over time. Conclusion: In a cohort of Chinese patients with chronic schizophrenia, community-based treatment settings had a positive impact on objective QOL indices but not on subjective well-being. Negative life events, education level, and the BPRS items of somatic concern, anxiety and guilt feelings were predictors of subjective well-being which seemed to adapt to external circumstances over time. Accepted: 1 October 2002 Correspondence to Dr. G. S. Ungvari     

Excess mortality among long-stay psychiatric patients in Northern Finland

Background: According to several studies, mortality in psychiatric patients is higher than in the general population, but cause-specific mortality analyses in long-stay psychiatric patients have not been studied very much. Individual follow-ups have been called for in order to identify possible treatment deficiencies and to make recommendations for clinical practices. In this study, mortality of long-stay psychiatric patients has been monitored for the years 1992–2000 and contrasted with that prevalent in the general population. Method: Data on psychiatric patients (N = 253) who were treated without a break for at least 6 months during 1992 in the Department of Psychiatry at Oulu University Hospital were linked with the National Death Register. Standardised mortality rates (SMRs) were determined according to gender, age groups, and different causes of death. Results: Of the total study population, 80.2 % had schizophrenia, 5.1 % other functional psychoses, 9.5 % organic mental disorders, 2.4 % personality disorders and 2.8 % mood disorders. Sixty-nine (27.3 %) of the patients (aged 31–88 years) had died before the end of the year 2000. The all-cause death risk for both males and females was four times that of the general population. The mortality risk was over ten-fold for males and almost 30-fold for females in the youngest age group (25–34 years), with suicides explaining about 75 % of these deaths. SMRs were found to decrease at older age, mortality thus approaching that of the general population. Diseases of the circulatory system were the most common single cause of death in both genders and mortality due to that cause exceeding mortality in the general population nearly 3.6-fold. However, the probability of death was highest (SMR 17.5) in connection with diseases of the digestive system. Increased risks of death due to respiratory complications (SMR 9.3), accidents (SMR 5.1) and neoplasms (SMR 2.1) were also noted. The overall death rates did not differ in relation to social class or professional education. Conclusions: Long-stay psychiatric patients were found to die from the same natural causes as the rest of the general population. However, the mortality risk of the long-stay psychiatric patients compared with that of the general population was notably higher, despite ongoing improvements in medical care and facilities. Inadequately organised somatic care and the prevailing culture of “non-somatic” treatment in psychiatry were suggested to, at least in part, explain this phenomenon. Attention ought to increasingly focus on somatic examinations and various health educational programmes specially designed for psychiatric patients and involving matters like healthy diet, smoking cessation and physical exercise. These practices should be a regular part of any patient's treatment programme. Also, the need to recognise factors associated with a patient's psychiatric disorder that could limit that patient's ability to communicate somatic symptoms and/or even lead to a refusal by that patient to have somatic diseases treated was seen as essential for providers of psychiatric services. Accepted: 4 December 2002 Correspondence to Sami R?s?nen, M. D., Ph. D.     

Predictors of treatment discontinuity in outpatient mental health care

Background Discontinuity of service utilisation among newly referred community outpatients is a common concern. However, knowledge about factors associated with service utilisation is inconsistent. Method This study examined service utilisation of 323 newly referred patients in three community mental health centres (CMHCs) in Vienna, Austria over a 4-month period. Of this original cohort, 111 patients were interviewed at treatment start to identify factors associated with treatment discontinuity. Results After 4 months, one-third of the 323 newly referred patients had dropped out of CMHC treatment; one-third discontinued treatment at the CMHCs because of referrals or mutual agreement on treatment termination, and one-third was still in CMHC treatment. Multivariate analyses yielded a negative association between treatment discontinuity and the diagnosis of schizophrenia, availability of home care, living alone, and a high quality of life in the domains living situation and family/significant others. A positive association was found with unemployment, previous psychiatric admissions, low patient satisfaction with staff competence, and high self-assessment in global functioning. Conclusion In treatment, differing perceptions of a patient's health status by the patient and by the psychiatrist should be addressed. Professionals should be aware that patients' difficulties in private social relations might affect both treatment alliance and service utilisation. Accepted: 4 February 2002     

Well-being in Australia--findings from the National Survey of Mental Health and Well-being

Background: The National Survey of Mental Health and Well-being in Australia has provided a rare opportunity to investigate not only the sociodemographic distribution of well-being, but also how it is related to impaired mental or physical health, to specific groups of psychiatric disorders and disability in daily life. Methods: A national household sample of 10,641 individuals (response rate 78 %) representative of the adult population was interviewed with the Composite International Diagnostic Interview and completed scales measuring recent symptoms, disablement and well-being. The latter was measured by the single item Life Satisfaction Scale of Andrews and Withey (1976) expressed as percentage, with 100 % being “delighted”. Results: The mean score for the Australian adult population was 70.4 % (95 % CI 70.0, 70.8), which matches the proposed universal norm. Men and women had very similar mean scores. Well-being was higher in persons with tertiary education and in those owning or purchasing their homes. It was lower in persons with physical or mental disorders, particularly depression. For alcohol use, a U-shaped relationship was found, whereby well-being was lower both in abstainers and in heavy users. Multiple regression analysis showed that when adjustment is made for confounders, women had higher life satisfaction than men and that high life satisfaction became less common with age in men, but even more so in women. Life satisfaction was impaired for respondents with high psychological distress, especially in the unemployed, the divorced and those with tertiary education, whether or not their symptoms led to a CIDI-A diagnosis of depression. Conclusion: The correlates of well-being are essentially in the expected direction. Depressive disorder has a stronger association with low well-being than other psychiatric diagnoses. Of particular interest is the existence of a small number of persons with current anxiety or depressive disorders who report having high life satisfaction. This deserves further investigation. Accepted: 4 July 2002 Correspondence to Dr. Keith Dear     

Do long-term hospitalised patients benefit from discharge into the community?

Objective The study investigated whether long-stay patients would benefit from discharge into the community in Berlin, Germany. Method In a prospective controlled study, all long-term hospitalised psychiatric patients from a defined catchment area were assessed using established standardised instruments. Quality of life, treatment satisfaction, needs and psychopathology were re-assessed in 63 non-discharged patients 1.5 years later, and in 65 resettled patients 1 year after discharge. Results Discharged patients were younger and had spent less time in psychiatric hospitalisation. Whilst patients who remained in hospital care did not show significant changes over time, discharged patients did. Changes in subjective quality of life and total number of needs – but not in psychopathology, unmet needs, and treatment satisfaction – were significantly more favourable in resettled patients as compared to the control group. Conclusion The findings are in line with other studies and suggest that long-stay patients can benefit from discharge into the community, particularly with respect to their quality of life. Positive changes in the process of deinstitutionalisation seem not dependent on the specific national context, and also apply to younger patients who have not yet spent 10 or more years in psychiatric hospitals. Accepted: 16 March 2002     

Patient satisfaction and ward atmosphere during a crisis in an open psychiatric ward

Background There is great need for useful indicators of quality of care for inpatient psychiatric treatment. The study examines whether patient satisfaction and ward atmosphere can be used as a means of evaluating an assumed decline in quality of care during a crisis in an open psychiatric ward. Methods Twice a year for 2 years ten patients filled out a standardized patient satisfaction questionnaire developed by the Swedish Institute for Health Services Development (SPRI) on their day of departure. At the same time all the patients in the ward evaluated the ward atmosphere using the Ward Atmosphere Scale (WAS). In the third study period the ward went through a crisis where quality of care was expected to be lower. Results The SPRI questionnaire confirmed the decline in patients' perceived quality of care on six of 41 questions, WAS was markedly lower on five of ten subscales. Conclusions Both WAS and the SPRI questionnaire gave useful information on how the ward was affected by the crisis. WAS seemed to be a more sensitive way of measuring quality of care, while the SPRI questionnaire indicated more clearly the practical consequences. Accepted: 12 August 2001     

Bed/population ratios in South African public sector mental health services

Background In post-apartheid South Africa, mental health service planners face critical decisions regarding appropriate and affordable inpatient care. Before a fashion of deinstitutionalisation is followed blindly in South Africa, effective community services should be in place and sufficient psychiatric beds should remain in hospitals for those who cannot be catered for in the community. In order to maintain the delicate balance between hospital and community-based services, it is essential that useful indicators of inpatient care are established. This study documents current bed/population ratios per 100 000 population in public sector mental health services in South Africa. Method A questionnaire was distributed to provincial mental health coordinators requesting psychiatric bed numbers in acute and medium-long stay facilities across all service levels. The information was supplemented by consultations with mental health coordinators in each of the nine provinces. Population data were obtained from preliminary findings of the 1996 census. Results For acute facilities, the mean bed/population ratio was 13 (provincial range: 6–18) per 100 000 population. For medium-long stay facilities, it was 16 (provincial range: 0–29) excluding contracted facilities, and 35 (provincial range: 0–83) including contracted facilities per 100 000 population. Conclusions There were low levels of inpatient service provision in South Africa, and there was considerable variability between provinces. This study gives further support to the need to develop acute inpatient psychiatric services, reduce levels of chronic care where appropriate, and redirect resources towards the development of community-level residential and day-care services. It is crucial to develop accurate indicators to monitor this process. Accepted: 1 March 2002     

Children in families with a severely mentally ill member. Prevalence and needs for support

Background The prevalence of minor children in families with a severely mentally ill member, these children's needs for support and the situation of the spouses were investigated as part of a multi-centre study of the quality of the mental health services in Sweden performed in 1986, 1991 and 1997. Methods The sample was drawn from relatives of compulsorily and voluntarily admitted inpatients to acute psychiatric wards. The instrument used was a semi-structured questionnaire, interviewing relatives about the burden of relatives, their needs for support and participation in care and items concerning the situation of the under-aged children in these families. Results The results over the years investigated showed the same proportion of patients admitted to hospital who were also parents to minor children and a decreasing proportion of patients who had the custody of their children. Female patients were more often a parent and also more often had the custody of the children. The majority of the children had needs for support caused by their parent's illness and these needs were met in half of the cases. The healthy spouses in families with minor children more often had to give up their own occupation and to a higher extent experienced own needs for care and support from psychiatric services compared to spouses without minor children. Conclusions The study supports that there is an urgent need for the psychiatric services to initiate parental issues in programmes for treatment and rehabilitation to ensure that the specific needs of minor children are met. Accepted: 28 November 2001     

Cross-cultural differences in the conceptualisation of patients' satisfaction with psychiatric services

Background: The VSSS is a multi-dimensional questionnaire developed to address methodological concerns about measurement of satisfaction with services on the part of psychiatric patients. The acceptability, sensitivity, content validity and test-retest reliability of the original version of the VSSS, in Italian, have already been demonstrated [1, 2]. The internal consistency [3] and test-retest reliability [4] of the English translation have been shown to be within acceptable ranges. The content validity of the original 82-item and the 54-item English version has not yet been assessed. Aims: The aims of this study were to assess the content validity of the English translation of the VSSS and to compare it with that of the original version in Italian. Method: We used data collected as part of the first wave (T1) of the PRiSM Psychosis Study [5] and repeated the methods used to assess the content validity of the original Italian version of the VSSS [1, 2]. Content elements derived from answers to four open questions were rated independently by CH and HH in terms of their equivalence to VSSS items or dimensions. Results: were compared to those from the content validity study of the Italian version. Results Inter-rater agreement was very high. The largest proportion of the content elements of the answers were rated as equivalent or related to a questionnaire item or a dimension of the VSSS. The dimension ‘Professionals' Skills and Behaviour’ appears the most significant contributor to satisfaction, as it was most often related to content elements in answers to all four key questions (39.1 %). The second most frequently mentioned dimension was that of ‘Types of Intervention’ for three out of four open questions, while ‘Access’ was second most frequent for the fourth. Of the content elements, 17.2 % did not include items or dimensions covered by the VSSS; the three most frequently mentioned were other patients, food and security. Conclusions: The 82-item English version of the VSSS captures sharply most contents relevant to patients' satisfaction. Consideration of contributors to satisfaction so far neglected may refine the conceptualisation of satisfaction. Accepted: 2 September 2002 Correspondence to Claire Henderson     

Evaluating a model of caregiving for people with psychosis

Background: The caregiving experience has been conceptualised as distress or satisfaction attributed to various factors in the carer's external and internal world. Aims: The aim of this study was to test how such factors relate to one another in the framework of a ‘stress-coping’ model using data from a group of carers of people with psychosis. Method: Standard univariate analyses and graphical modelling techniques were applied to baseline and follow-up interview data available from a clinical trial of a support package offered to 77 carers in contact with a community psychiatric service. Results: Results at baseline were consistent with a stress-coping model. Carer distress was most strongly associated with coping. In turn, coping was associated with two sets of factors – one related to appraisal and caregiving difficulty, the other to social support. Using a small sample of longitudinal data (n = 38), most individual measures were predictable from baseline. However, there was again a strong association between carer distress and current coping. Support from confidants assumed an important relationship to effective coping. The level of effective coping increased over time while caregiving difficulty decreased, but carer appraisal and distress did not change. Conclusions: The findings provide some support for an interactive, stress-coping model of caregiving in psychosis. Effective coping in caregivers may improve with support from confidants. Carer distress may not change while caregiving continues. Accepted: 8 October 2002 Correspondence to Professor E. Kuipers     

Accessibility and pathways to psychiatric care in a community-based mental health system

Background The careful analysis of pathways to specialist mental health care, within the context of community-based services, is important because it allows a detailed understanding of the inter-relationship between the component parts of the whole system of care. Moreover, it permits a comparison of service functioning to made over time, and is one way to operationalise the measurement of accessibility to services. The aims of this study are to describe: (i) the pathways followed by patients with new episodes of care to community-based mental health services, (ii) the time intervals from onset of the problem to first contact with services, and then to onward referral to specialist care (accessibility), and (iii) to explore the short-term costs associated with different pathways. Methods Using data from the South-Verona Psychiatric Case Register, all new patients referred to any of the facilities which are part of the South-Verona Community Psychiatric Service (CPS) over a 6-month period (November 1999 – May 2000) were eligible to enter the study. Patients were interviewed by telephone using the Italian translation of the WHO Encounter Form. The costs of care provided in the 3 months following the index contact were assessed for all patients. Results The most common route to mental health services is via a GP (40 %), followed by a referral from a hospital doctor (26 %) and self-referral (23 %). The median interval from onset to direct contact with the South-Verona CPS (12 weeks) was shorter than the intervals from onset to direct contact with other service providers (the median interval for contact with GPs and hospital doctors was 24 weeks). The intervals varied considerably from 1 week (for attempted suicide), to 1.5 years (for disturbed behaviour). The results of backward regression modelling revealed a significant relationship between patients' characteristics and community costs or total psychiatric costs (44 % and 53 % of the variance explained respectively). Conclusion When the results are compared with a directly comparable earlier study in South-Verona, it is apparent that between 1991 and 1999 an increasing proportion of patients with insomnia and somatic disorders presented first to GPs, while a decreasing proportion of patients over the years sought care directly from specialist care. An increase in the role of local GPs as gatekeepers has, therefore, emerged. A prompt assessment by the South-Verona CPS of the patients' presenting problems was also confirmed, and this can be explained by the ‘drop-in’ approach at the Mental Health Centre, where patients can seek specialist care directly, without previously attending GPs. This method of measuring time intervals along pathways is proposed as a way to operationalise accessibility to services in future. Accepted: 16 July 2001     

Child Behavior Checklist item scores in Norwegian children

In an epidemiological study of children aged four to 16, 1170 parents responded to the Child Behavior Checklist (CBCL). Similar effects of age and socio-economic status (SES) on item scores as those reported in several international studies with the CBCL were found in the total sample. Contrary to the results of other studies, differences related to gender were found for only a few items. A subgroup of 41 children and 36 adolescents and their parents were interviewed with psychiatric interviews. Several CBCL problem items were good predictors of psychiatric disorder in the interviewed children and adolescents. High positive and negative predictive values were found for the items clumsy and the item unhappy, sad or depressed in this sample. Accepted: 7 May 1999     

The TAPS project 40: quality of care provisions for the elderly mentally ill—traditional vs alternative facilities

The study evaluates some aspects of care reprovision for psychogeriatric patients. Seven hospital wards are compared with four community settings, established as part of the reprovision programme for Friern Hospital in London. Each facility was assessed for policy and programme, social climate and physical characteristics; staff attitudes in regard to their tasks, training needs and job satisfaction were also explored. Community settings were superior to hospital wards in providing more privacy for the residents and were better equipped with physical amenities and safety features. There were relatively small differences between the way staff perceived the social climate in community homes and in hospital. The former were regarded as encouraging greater independence. Care staff in the hospital were more likely to express dissatisfaction with pay, working conditions and social status, while community staff were more dissatisfied with the quality of cooperation between staff members. Clients transferred to Social Services facilities had a higher level of functioning and needed less on-site medical care. This was further reflected by the lower frequency of nursing care tasks being performed by staff in community facilities. Overall, the shift towards a less medical model of care in community-based homes appears to be beneficial to psychogeriatric patients, provided that current and prospective physical needs of the residents are adequately addressed. © 1998 John Wiley & Sons, Ltd.     

Stroke and mental health care: a record linkage study

Background Stroke is associated with psychiatric morbidity but little is known about mental health care use in stroke patients. Method A probability record linkage study was conducted linking stroke cases admitted to a teaching hospital serving a catchment area between 1987 and 1995 with records from a psychiatric case register covering the same area. Results Stroke patients had a more than twofold increased risk of contact with mental health care than individuals in the general population (yearly prevalences of respectively 88 and 39 per 1000; risk ratio 2.24; 95 % CI 2.04–2.45). One-third of all stroke admissions had had mental health care before and more than half had had mental health care after the stroke. In the year of admission for stroke, the probability of receiving mental health care was highest, while in the more remote years the risk was lower. Conclusion Stroke is associated with an increased probability of contact with mental health services. The pattern of mental health care of a stroke patient is different from that of other mental health patients: more episodic and concentrated around the time of admission for stroke. Accepted: 19 September 2001     

Outcome of case management based on the strengths model compared to standard care. A randomised controlled trial

Background The outcome of less intensive case management services, such as the strengths model, is still inconclusive, which suggests a need for more controlled studies. The aim of the present study was to investigate the outcome of a strengths model of case management service (SCM) compared to standard care. Methods Seventy-seven clients with a mental illness and a serious impairment in functioning in social contacts, housing or work situation were randomly allocated to SCM or standard care. Outcome was assessed with regard to use of psychiatric services, changes in symptomatology, psychosocial functioning, social network, needs for care, quality of life and client satisfaction with care. The follow-up period was 36 months. Results The results showed a greater reduction in needs for care in clients receiving SCM. No differences in clinical or social outcome were shown. Clients receiving SCM also used significantly less days in psychiatric inpatient services and were generally more satisfied with the psychiatric services offered. Conclusions SCM failed to improve clinical and social outcome compared to standard care, but was more successful in reducing days spent in hospital, and the clients were also more satisfied with the service compared to standard care. Accepted: 5 January 2001     

Major depressive episode and health care use among adolescents and young adults

Objective: The aim was to analyze how major depressive episode (MDE), chronic illness and their co-existence are associated with health care use in young people. Method: As part of the Finnish Health Care Survey 1996, a random sample of 942 15 to 24-year-olds was interviewed. DS M-III-R MDE over the previous 12 months was assessed using the University of Michigan Composite Diagnostic Interview Short Form (UM-CIDI SF). Results: Of the study population, 43.7% (n=439) reported recent use of services for physical illness, the highest proportion being among respondents with both MDE and chronic illness (73.9 %). In multivariable logistic regression analysis, disabling chronic illness (OR 2.59; 95% CI 1.51, 4.45) was related to treatment use for physical causes while MDE alone (OR 1.56; 95% CI 0.95, 2.58) or accompanied with chronic illness (OR 2.47; 95% CI 0.99, 6.14) showed borderline associations. In all, 1.5% (n=14) of the respondents reported recent health care use for any mental health problems. Of the 68 subjects with MDE, 51.5% (n=35) were estimated to be in need of treatment while 20.6% (n=14) had actually sought care for depression during the preceding year. Psychosocial impairment showed borderline association with treatment use (OR 3.77; 95% CI 0.97, 14.7). Only two subjects (14 %) reported recent use of antidepressant medication. Conclusions: MDE in adolescents and young adults is undertreated. An tidepressant medication was seldom used in Finland in 1996. Young people suffering from both MDE and chronic illness are likely to use services other than psychiatric services, and systematic screening for depressive symptoms in these treatment settings is recommended. Accepted: 21 January 2003 Correspondence to Dr. Linnea Haarasilta     

Prevalence of depression and depression recognition in nursing homes

Background The aim of this study was to estimate the prevalence of depression among nursing home residents, and the extent of depression recognition among nursing home staff. Random samples totaling 319 nursing home residents, drawn from a simple random sample of six downstate New York nursing homes were evaluated psychiatrically for depression. Samples of nurse aides, nurses and social workers also assessed the same residents for the presence of depressive symptomatology. Method Psychiatrists assessed residents using the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) criteria. Depression measures used were the Cornell Scale for Depression in Dementia, the Feeling Tone Questionnaire, the Hamilton Depression Rating and the Structured Clinical Interview for DSM-III-R Personality Disorders Scale. Nursing and social services staff assessed residents using Depression Recognition Measures. Results Based on psychiatric evaluation, the prevalence estimate for probable and/or definite major depressive disorder among testable subjects was 14.4 % (95 % CI of 10.6 %–19.3 %); 15.4 % were not able to be assessed due to their refusal, impairment of consciousness, or severe physical illness. The estimate for minor depression was 16.8 % (95 % CI of 12.6 %–21.9 %). The prevalence of significant depressive symptomatology (including the category of possible depression) was 44.2 % (95 % CI of 38.2 %–50.3 %). The corresponding estimates of any depression were 19.7 % for social workers, 29 % for nurses and 32.1 % for nurse aides. Conclusions The prevalence of depressive disorders among nursing home residents is high; depression recognition is relatively low, with only 37 %–45 % of cases diagnosed by psychiatrists recognized as depressed by staff. A structured Depression Recognition Scale increased the rates of recognition (sensitivity of staff ratings) to 47 %–55 %, demonstrating the utility of the scale in increasing awareness of symptomatology. Accepted: 2 August 2001     

The quality of interactions between staff and psychiatric inpatients in a Nigerian general hospital

We examined the quality of the staff's interactions with patients, and its relationship with ward structure, patients' satisfaction and outcome. The Quality of Interactions Schedule was used to observe interactions with patients in two acute admission wards. In 40 h, 101 interactions were observed; 60.4% were of negative quality, 35.6% were positive and 3.9% were neutral. The majority (42.6%) were of the negative restrictive type, with the patients' freedom being curtailed without explanation. Significantly more interactions occurred at the proximal sections of the wards, where most ward activities took place. There were no significant gender and interward differences. Interactions were not associated with clinical outcome. The patients were significantly not satisfied with the items that related to the curtailment of their freedom. They are sensitive to the quality of staff interactions while appreciating staff contribution to their care. Training programs should include staff attitudes for the improvement of the overall quality of care.     

Predictors of improvement in quality of life of severely mentally ill substance abusers during 18 months of co-operation between psychiatric and social services

Background: The aim of this study was to investigate predictors of Quality of Life in a group of severely mentally ill substance abusers. These patients took part in a multi-centre study aimed at improving co-operation between psychiatric and social services in Sweden during the years 1995 to 1998. Methods: Two hundred and eighty-eight patients, 62.4 % men, were included in the study. The criteria to enter the study were to have a diagnosis of severe mental illness and a diagnosis of substance dependence according to the DSM-III-R criteria. Quality of Life (QoL) was measured by a global assessment, Cantril's ladder (1965). Initially and after 18 months the following measurements were also used: Addiction Severity Index (ASI), Symptom Check List 90 (SCL–90) and The Clinical Rating Scale (CRS) for Alcohol Use (AUS) and Drug Use (DUS). Results: Initially those who were older and those who had an apartment of their own or who lived in sheltered living had a higher QoL than the others. Those belonging to the borderline personality disorder subgroup had a lower QoL than those belonging to other psychiatric diagnostic subgroups. At follow-up QoL had improved significantly. Improvement in QoL was related to improvements in physical health, legal and family problems, psychiatric symptoms and a reduction of alcohol and drug problems (ASI), global functioning (GAF) and psychological problems (SCL–90). A multiple stepwise regression analysis showed that improvement in QoL primarily was predicted by improvements in psychiatric symptoms. Number of months without alcohol and drugs were positively associated with improvement in QoL. As a whole, at follow-up the QoL is still not high. Conclusions: In this group of severely mentally ill substance abusers, improvement in QoL was primarily predicted by improvements in psychiatric symptoms. Further, less alcohol and drug abuse seems to augment the subjective feeling of QoL. Received: 8 May 2002 / Accepted: 10 September 2002 Correspondence to Ingela Schaar     

A brief scale for assessing patients' satisfaction with care in outpatient psychiatric services

OBJECTIVE: The authors evaluated the reliability and preliminary validity of the Charleston Psychiatric Outpatient Satisfaction Scale, a 15-item measure of patients' satisfaction designed for use in outpatient settings. The instrument uses a 5-point Likert-type response format that minimizes positive response bias and optimizes variability and predictive validity. METHODS: The Charleston Psychiatric Outpatient Satisfaction Scale was administered to 282 patients seen in psychiatric outpatient clinics affiliated with a public-academic psychiatric institution over a one-week period in 1995. RESULTS: The internal reliability of the instrument was high (alpha=.87), and its convergent validity was supported by the significant correlation of all items with anchor items that measured overall satisfaction with care and likelihood of recommending the clinic to others. The best predictors of overall ratings of care were the items measuring patients' satisfaction with helpfulness of the services and with the respect shown for patients' opinions about treatment. The best predictors of recommendation of the program to others were the items measuring satisfaction with matching of the treatment plan to patients' individual needs and with the respect shown for patients' opinions about treatment. Mean scores for all items ranged from 3.6 (satisfaction with parking) to 4.5 (satisfaction with helpfulness of the secretary and with the overall quality of care), indicating that overall satisfaction in this sample was high. CONCLUSIONS: The results provide preliminary support for the reliability and validity of the Charleston Psychiatric Outpatient Satisfaction Scale: