Patterns of psychiatric hospitalizations in schizophrenic psychoses within the Northern Finland 1966 Birth Cohort

We report patterns of hospitalization in schizophrenic psychoses by age 34 in a longitudinal population-based cohort. We test the predictive ability of various demographic and illness-related variables on patterns of hospitalization, with a special focus on the length of the first psychiatric hospitalization. All living subjects of the Northern Finland 1966 Birth Cohort with DSM-III-R schizophrenia (n=88) and other schizophrenia spectrum cases (n=27) by the year 1997 in the Finnish Hospital Discharge Register were followed for an average of 10.5 years. Measures of psychiatric hospitalization included time to re-hospitalization (as continuous and as re-hospitalization within 2 years) and the number of hospital episodes. Length of the first hospitalization, other illness-related and various socio-demographic predictors were used to predict hospitalization patterns. After adjusting for gender, age at first admission and number of hospital days a short (1-14 days) first hospitalization (reference >30 days; adjusted odds ratio 6.39; 95% CI 2.00-20.41) and familial risk of psychosis (OR 3.36; 1.09-10.39) predicted re-hospitalization within 2 years. A short first hospitalization also predicted frequent psychiatric admissions defined as the first three admissions within 3 years (OR 13.77; 3.92-48.36). A short first hospitalization was linked to increased risk of re-hospitalizations. Although short hospitalization is recommended by several guidelines, there may be a group of patients with schizophrenic psychoses in which too short a hospitalization may lead to inadequate treatment response.     

Outcome studies on schizophrenic psychoses in Helsinki

This paper deals with the prognosis of schizophrenic psychoses in Helsinki in 1950-1955, 1960-1965, 1965-1970, 1970-1975, and 1975-1980. The first 4 cohorts each include a sample of 100 patients taken in 1950, 1960, 1965, and 1970. The patients were admitted for the first time to a psychiatric hospital because of schizophrenic and paranoid psychoses. The 1975 material includes all (n = 94) first admissions for schizophrenia, fulfilling the DSM-III criteria of schizophrenia or schizophreniform psychosis.     

Admissions to a South African general hospital psychiatric unit

In a study of adminssions to the psychiatric unit of a general hospital from December 1, 1977, to November 30, 1978, data obtained from all 478 admitted patients were analyzed; the most prevalent condition was found to be the neuroses, followed by organic brain syndromes. Most patients admitted fell into the 19–39 age group, with a preponderance of male admissions between the ages of 6–39, but more admissions of females above 40. A significant difference in the occurrence of conditions between the sexes was noted: the most prevalent condition for males between the ages of 6–39 years was schizophrenia, while more females suffered from the neuroses. Males 40 years and older presented predominantly with organic brain syndromes; females in that age group presented predominantly with affective psychoses. The average length of stay for both sexes was eight days. Schizophrenia required the longest hospital stay, an average of 11 days. Seventy-eight patients (16.3%) were admitted more than once during the period of study. Conditions commonly associated with readmission were affective psychoses and schizophrenia. The role of the general hospital psychiatric unit and its advantages and shortcomings are discussed.     

Socio-demographic and clinical predictors of occupational status in schizophrenic psychoses--follow-up within the Northern Finland 1966 Birth Cohort

We studied occupational status of persons with schizophrenic psychoses by age 34 in a longitudinal population-based cohort and predicted which demographic and illness-related factors could support the patients to maintain their occupational capacity. Subjects of the Northern Finland 1966 Birth Cohort with the diagnosis of DSM-III-R schizophrenic psychoses (n=113) by the year 1997 were followed until the end of year 2000. Various illness and socio-demographic factors at the time of onset of illness were used as predictors. At the end of the follow-up time 50 (44%) of patients were not pensioned and 22 (20%) were also working at least half of the time during year 2000. After adjusting for gender, being unemployed at onset, educational level and proportion of time spent in psychiatric hospitals, those who were married or cohabiting at the time of onset of illness were less often on pension than those who were single (OR 6.51; 95% CI 1.83-23.12). Thus, nearly half of the patients with schizophrenic psychoses were not pensioned after an average 10 years follow-up. Based on our findings, those who were single at time of their onset of illness probably need most support to retain their contacts to work life.     

Characteristics of subjects with schizophrenia spectrum disorder with and without antipsychotic medication – A 10-year follow-up of the Northern Finland 1966 Birth Cohort study

ObjectiveTo estimate the prevalence of non-medicated subjects having schizophrenia spectrum disorder and to study how they differ from medicated subjects in terms of sociodemographic and illness-related variables. We also aim to find the predictors for successful antipsychotic withdrawal.MethodsData of 70 subjects with schizophrenic psychoses (mean duration of illness 10.4 years) from the Northern Finland 1966 Birth Cohort were gathered by interview at the age of 34 and from hospital records. The stability of remission was assessed by comparing hospitalization rates between non-medicated and medicated subjects over an 8.7-year additional follow-up period.ResultsTwenty-four (34%) subjects were currently not receiving medication. They were more often males, less often on a disability pension, more often in remission, and had better clinical outcomes. Relapses during the follow-up were equally frequent between non-medicated and medicated subjects (47% vs. 56%). Not having been hospitalised during previous 5 years before the interview predicted long-term successful antipsychotic withdrawal without relapse.ConclusionsDespite a lack of precise predictors, there might be subgroup of schizophrenia spectrum subjects who do not need permanent antipsychotic medication, and a fewer previous psychiatric treatments may indicate such a subgroup.     

The Kraepelinian dichotomy: preliminary results of a 15-year follow-up study on functional psychoses: focus on negative symptoms

In a 15-year follow-up study, we used a comparative approach to assess course and outcome for all functional psychoses. The presented results focus on negative symptoms and refer to a sample of 76 patients with schizophrenia, 38 patients with a schizoaffective disorder and 32 patients with an affective disorder according to ICD-9. These patients were assessed at their first psychiatric hospitalization and 15 years later. In summary, the findings indicate that the course and outcome of schizophrenia is less favorable than that of affective and schizoaffective disorders. Negative symptoms occurred in all functional psychoses, but were more frequent and prominent in the schizophrenic group than in the other two diagnostic groups at any time of assessment. Narrower concepts of negative symptoms, conceptualized as the deficit syndrome, seem to be specific for schizophrenia and appear quite rarely in patients with affective psychoses. Overall, our study supports Kraepelin's original hypothesis that bifurcated the psychoses into the affective psychoses and schizophrenia, whereby the latter have a more deleterious long-term course and outcome.     

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.     

A 10-year follow-up study of an adolescent psychiatric clientele and early predictors of readmission

Over a period of 20 years (from 1968 to 1988) all inpatients (n = 839) who were admitted for the first time to the adolescent psychiatric unit in Copenhagen were registered, and 40 social and psychiatric variables were recorded, to investigate early predictors of later readmission. Overall, 44.8% of the patients were readmitted within a certain observation period (range, 1.5-21.5 years). Among a subsample of 488 patients (58%) who could be followed up for more than l0 years after their first admission 26% became heavy users of psychiatric services, defined as long-term inpatients or revolving-door patients. Severe early diagnoses (schizophrenia and affective psychoses) were strongly associated with rapid relapses and frequent readmissions. A statistical estimate of the risk of later heavy use based on 12 independent variables is presented.     

Validation of Danish case register diagnosis for schizophrenia

The ABC schizophrenia study aims at investigating sex differences in age of onset, symptoms and course of schizophrenic and paranoid disorders. For this purpose, we used case register data from Denmark and Mannheim and a directly examined sample of first admissions (ABC sample). The Danish case register sample included less clinical diagnoses of schizophrenia and more schizophrenia-related disorders (acute paranoid reaction, paranoid states and borderline schizophrenia) than the Mannheim data (case register and ABC sample). The problem therefore was whether the two datasets are comparable and the results are valid. For this reason a randomized, stratified sample of 116 patients was drawn from the Danish case register sample. The case notes of these 116 patients were requested from the hospitals where the patients had been treated and analyzed by means of a scoring sheet based on the Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS). The use of operationalized diagnoses of the CATEGO program, based on PSE items, which are integrated in IRAOS, demonstrated that the samples of the Danish and the Mannheim case registers and the directly investigated ABC sample have comparable diagnostic distributions. Possible explanations for the differences between the clinical and the CATEGO diagnoses in the Danish case register may be the frequent use of diagnoses of borderline schizophrenia and reactive psychoses (previously called psychogenic psychoses), and above all a more narrow concept of schizophrenia; in Denmark, schizophrenia is diagnosed relatively late, i.e., after the presence of enduring negative symptoms, and thus mostly after the appearance of residual state. These diagnostic preferences may help to explain the fall in first admission rates for schizophrenia – above all in women – in Denmark and the low incidence rates of schizophrenia by first contact within the WHO determinants of outcome study. The earlier hospitalization of men could be replicated as well as the course of treatment (readmissions and discharges) of schizophrenic men and women over 10 years after first admission.     

A population based elaboration of the role of age of onset on the course of schizophrenia

BackgroundDespite suggestions that an earlier age of onset and being male confer to a poorer course of schizophrenia, evidence regarding when these effects are most salient appears to be ambiguous.AimsTo examine the relationship of age of first hospitalization and sex with the course of hospitalization in a population based cohort.MethodAll first admissions for schizophrenia in a national population based cohort in Israel from 1978 to 1992 were followed through 1996 (n = 12,071) using data from the National Psychiatric Hospitalization Case Registry of the State of Israel, a complete national registry of psychiatric admissions. Recursive partitioning was conducted to empirically determine cut-off points for age groups showing the greatest difference on the variables of interest.ResultsA younger age of first hospital admission was associated with a greater likelihood of having more than one hospital admission, longer first admissions, more hospital admissions and more inpatient days per year. Of patients with age of first admission below 17, 82.5% had more than one admission which decreased for subsequent age groups to 73.54% (18–28), 69.36% (29–31), 62.88% (32–45), and 50.77% (over 45). Men had an earlier first admission than women, and had slightly more cut-off values. Irrespective of sex, the relationship between age at first admission and later hospitalization conformed to a linear trend.ConclusionsAn earlier onset corresponds linearly with the severity of the course of illness and appears to have prognostic value.     

Increase in first admissions for schizophrenia and other major psychoses in Italy

Despite reports of falling first-admission rates for schizophrenia in some Western countries, methodological problems and bias preclude a definite conclusion about a genuine fall in the incidence of schizophrenia. This study set out to test the hypothesis that first admissions for schizophrenia in Italy have fallen in recent years. All admissions rated as 'first contact' in Italy from 1984 to 1994 for severe mental illnesses to general hospital psychiatric services, as reported in the Italian National Institute for Statistics Health-Care Yearbooks, were considered. Data were analyzed as rates per 100000 in the general population, and changes over time in incidence of schizophrenia, paranoia, affective psychoses and drug-induced psychoses (diagnosed according to ICD 9) were recorded. Changes in rates over time, with rates as the dependent variable and years as the independent variable, were the main outcome measure. First-admission rates for schizophrenia and paranoia increased progressively from 1984 to 1994, as did those for affective psychoses, mania and, to a lesser extent, major depression. In the same period, all admissions (both total and rated as 'first-contact') for mental disorders increased. Although linear regression tests for admission rates in most, but not all, cases indicate a significant ascending linear trend, quadratic model results show a significantly better fit than does the simple linear regression model for the majority of data. The change described by the quadratic model suggests an increase in admission rates more marked in the second half than in the first half of the period of the study. First-admission rates for schizophrenia and, to a lesser extent, paranoia seemed to increase concurrent to a decrease in first-admission rates for 'other' non-organic psychoses. Contrary to reports from other Western countries, hospital incidence in Italy for schizophrenia is on the increase, as is that for other severe psychoses. This increase is likely to be a reflection of changes in mental health-care organisation, in treatment and diagnostic patterns, and in cultural attitudes towards mental illness. Radical changes in the true incidence of psychoses, in particular of mood disorders, as described elsewhere, cannot be ruled out as contributing factors. Data bias and limitations preclude a generalisation of results, however.     

Trends in psychiatric hospitalization in Denmark: a 10-year register-based investigation.

Information about all admissions to psychiatric hospitals and departments in Denmark in 1977, 1982 and 1987 and about all resident patients on census days in the same years were extracted from the central psychiatric register. The number of available beds decreased by 43% from 1977 to 1987. The admission rates decreased for all diagnostic groups but schizophrenia, which increased. The group of younger schizophrenic men declined in size, which is alarming if mentally ill homeless people are considered. The census study shows a decrease in all diagnostic groups, most pronounced in the elderly age groups. Patients with neuroses disappear from the available beds in the mental hospitals and departments. The changes in the psychiatric service system from mostly hospitalization to outpatient treatment and community psychiatric treatment require a comprehensive personal registration of treatment regardless of the administrative affiliations of these services.     

Family study of acute and transient psychotic disorders: comparison with schizophrenia

Background: Acute non-organic psychoses, as often described in European and Indian literature, and categorized as `Acute and transient psychotic disorders' in ICD-10, lack a clear nosological distinction from schizophrenia. Methods: A family study of psychiatric disorders in first-degree relatives (FDRs) of 40 ICD-10-diagnosed probands of acute and transient psychotic disorders (ATP) was carried out using a semi-structured interview schedule. The results were compared with those of 40 schizophrenic probands. Results: FDRs of ATP probands had a higher prevalence of ATP than those of schizophrenic probands. FDRs of schizophrenic probands had significantly higher prevalence of schizophrenia than those of ATP probands. ATP subtypes with schizophrenic symptomatology (ICD-10 codes F 23.1 and F 23.2 ) had more family history of schizophrenia than the rest of the ATP subtypes. Conclusion: ATP as a group has a differential pattern of risk of illness compared to schizophrenia. Further, the subtypes subsumed under ICD-10 ATP may be genetically heterogeneous, those with schizophrenia-like symptomatology being possibly more akin to schizophrenia itself or forming an interface between ATP and schizophrenia. Accepted: 15 February 1999     

Long term course and outcome of first episode schizophrenia: a 27-to-31-year follow-up

Purpose

To describe long term clinical and functional outcomes of schizophrenia in a developed country.

Method

Long term longitudinal study of clinical and functional outcomes of incidence cohort of all consecutive admissions for a first hospitalization for schizophrenia between 1983 and 1987 in Montreal, Canada (n = 142). Data collection was conducted at admission, 5 years, 10–16 years and 27–31 years follow-up by reviewing hospital charts and government linked health administrative databases.

Results

One fifth of patients were never re-hospitalized and 35% were still in contact with the same catchment area psychiatric services. Thirty-four (24%) died on average at 45.5 years. Fourteen (9.9%) died by suicide; half of them did so 10 years after their first hospitalization. Over 20% were exposed to clozapine and nearly 50% to long-acting injectable antipsychotic medication. There were no inmates; an estimated one fifth might be inferred to be living in supervised residential settings and the rest lived alone or with family. Approximately three quarters of the patients under 65 were receiving social assistance benefits at study’s end. From 15 to 25% might have been employed (supported or competitive employment).

Conclusion

This study confirms that the long-term course of schizophrenia is heterogenous and mostly positive with most patients living in the community, although a significant proportion need long term support and an important proportion experience premature death. To mitigate the persistent suicide risk and to respond to their need for support, continuous mental health professional’s involvement is required for many.

     

10‐Year trends in the treatment and outcomes of patients with first‐episode schizophrenia

Nielsen J, le Quach P, Emborg C, Foldager L, Correll CU. 10‐Year trends in the treatment and outcomes of patients with first‐episode schizophrenia. Objective: The first episode of schizophrenia is a critical period for illness course and outcomes. We aimed to investigate treatments and outcomes during the first year after the diagnosis of schizophrenia. Method: Pharmacoepidemiologic inception cohort study of all newly diagnosed patients with schizophrenia in Denmark (n = 13 600) 1996–2005. Results: From 1996 to 2005, the mean age at first diagnosis decreased significantly (29.2–26.1 years), more patients received antipsychotics (67.2–80.7%, annual OR = 1.07, CI: 1.06–1.09, P < 0.001) and antipsychotic polypharmacy for >4 months (16.7–37.1%, OR = 1.14, CI: 1.12–1.57, P < 0.001). The antipsychotic defined daily dosage (DDD) doubled (150–332 DDD, P < 0.001), use of antidepressants (24.3–40.6%, P < 0.001). Bed days [89.9 days (CI: 81.8–98.8) to 71.8 days, CI: 63.7–80.8, P < 0.0001] decreased, whereas outpatient contacts [10.2 (CI: 9.5–11.0) to 21.4 (CI: 19.9–21.0), P < 0.0001] doubled. Conclusion: Between 1996 and 2005, there was an earlier recognition of schizophrenia, intensified outpatient treatment, increased use and dosing of antipsychotics and antidepressants, but also more antipsychotic polypharmacy.     

Premorbid personality in schizophrenia spectrum: A prospective study

Schizophrenia has been linked with premorbid character anomalies since it was first described. However, few prospective studies of premorbid personality characteristics in schizophrenia and related disorders have been conducted. This study evaluates premorbid personality in children who developed schizophrenia spectrum disorder in adult life. In 1972, 265 children at an average age of 12 (90 with at least one schizophrenic parent) from the Copenhagen Perinatal Cohort participated in a 1-day follow-up during which they were in contact with seven examiners who rated their personality by means of an Adjective Check List (ACL). In 1991–93, adult psychiatric status was assessed for 242 of these individuals, who were classified into three categories: schizophrenia spectrum (n=24), other psychiatric diagnoses (n=72) and healthy controls (n=145). Personality characteristics derived from the ACL were linked to these three diagnostic categories. Twelve-year-old children destined to develop a disorder in the schizophrenia spectrum deviated significantly from healthy controls on a number of personality characteristics: they were rated significantly lower than controls on intelligence, concentration, maturity, friendliness, cooperation, self-control and significantly higher on aggression. Non-significant trends indicated that this group displayed more deviant personality scores than psychiatric controls. Children who later develop schizophrenia spectrum disorder differed from normal controls with respect to a number of personality traits. The ACL may be too insensitive to discriminate between premorbid personality in the schizophrenia spectrum and other psychopathology.     

Seasonal influences on admissions for affective disorder and schizophrenia in Ireland: a comparison of first and readmissions.

Although genetic and environmental factors operating before or around the time of birth have been demonstrated to be relevant to the aetiology of the major psychoses, a seasonal variation in the rates of admission of such patients has long been recognised. Few studies have compared first and readmissions. This study examined for seasonal variation of admission in the major psychoses, and compared diagnostic categories by admission status. Patients admitted to Irish psychiatric inpatient facilities between 1989 and 1994 with an ICD-9/10 diagnosis of schizophrenia or affective disorder were identified from the National Psychiatric Inpatient Reporting System (NPIRS). The data were analysed using a hierarchical log linear model, the chi-square test, a Kolmogorov-Smirnov (KS) type statistic, and the method of Walter and Elwood. The hierarchical log linear model demonstrated significant interactions between the month of admission and admission order (change in scaled deviance 28.77, df = 11, P < 0.003). Both first admissions with mania, and readmissions with bipolar affective disorder exhibited significant seasonality. In contrast, only first admissions with schizophrenia showed significant seasonal effects. Although first admissions with mania and readmissions with bipolar disorder both show seasonality, seasonal influences appear to be more relevant to onset of schizophrenia than subsequent relapse.     

Are Psychiatrist Characteristics Associated With Postdischarge Suicide of Schizophrenia Patients?

Information on the relationship between characteristics of mental healthcare providers, including hospitals and psychiatrists, and postdischarge suicide is scanty. This study aims to identify the risk factors for suicide among schizophrenia patients in the 3-month postdischarge period. The study cohort comprised all patients with a principal diagnosis of schizophrenia discharged from psychiatric inpatient care from 2002 to 2004 who committed suicide within 90 days of discharge. The control cohort consisted of all surviving schizophrenia patients discharged from psychiatric inpatient care in the same period and were matched to cases for age, gender, and date of discharge. There were 87 and 348 cases in the study and control cohorts, respectively. For suicide cases, death most frequently occurred on the first day after leaving the hospital (16.1%). The adjusted hazard ratios for committing suicide during the 90-day postdischarge period were 2.639 times greater for patients without previous psychiatric admission than for those hospitalized more than 3 times in the year preceding the index hospitalization. The adjusted suicide hazard for schizophrenia patients treated by male psychiatrists was significantly higher than for patients treated by female psychiatrists, by a multiple of 5.117 (P = .032). The adjusted suicide hazard among patients treated by psychiatrists over age 44 years was 2.378 times (P = .043) that for patients treated by psychiatrists aged younger than 35 years. Risk factors related to psychiatric hospitalization, including number of psychiatric admissions in the previous year and length of stay, together with gender and age of the psychiatrist providing inpatient care, are identified.     

Course of patients diagnosed as having schizophrenia during first episode occurring under age 18 years

Of 118 child and adolescent schizophrenic patients (ICD-9: 295.x; mean onset age 16.0 years), 97 (82.2%) could be completely investigated at follow-up (mean interval 7.4 years; mean age 23.1 years). At followup 30% of the patients were semidependent or dependent, 72% still required psychiatric treatment, 44% were at least moderately impaired with regard to educational/occupational functions and 58% with regard to social functions; 73% had experienced at least one further schizophrenic episode. Comparison with schizophrenia beginning in adulthood showed that the impairment in social function was much greater in the younger group of patients. These results support the belief that schizophrenic psychoses starting in adolescence have a worse outcome than those beginning in adulthood. The most efficient indicators for a worse outcome were long duration of inpatient treatment at first admission, a high number of symptoms and low social competence at discharge.     

Status of first-episode psychosis patients presenting for routine care in a defined catchment area.

OBJECTIVE: To examine the clinical and behavioural status of all first-episode psychosis (FEP) patients admitted to hospital within a defined catchment area. METHOD: We used a structured format to review clinical records of all first admissions to hospitals from a catchment area (population 390 000) with diagnosis of a first episode of nonaffective psychosis over a 3-year period. RESULTS: Patients were somewhat older than usually reported for FEP (mean age 31.3 years). They were mostly male (63.7%), single (80.8%), unemployed (87.4%), with a primary diagnosis of schizophrenia spectrum psychoses (85%), and had spent a mean of 31 days in an open inpatient unit and 2.93 days in an intensive care psychiatric unit during their first admission. Most (60.3%) were admitted involuntarily; 34.2% had a history of legal involvement; 18.8% had attempted suicide prior to admission; 31.5% had demonstrated violence toward people, property, or animals; 14.4% had suffered injuries; and 15.9% had shown aggressive behaviour during the hospital admission. CONCLUSIONS: These results identify some of the potential needs of FEP patients, toward whom early intervention services should be directed.