Young cases of schizophrenia identified in a national inpatient register--are the diagnoses valid?

Background: Psychiatric inpatient registers are often used in research in the Nordic countries. We aimed to investigate the validity of recorded diagnoses of schizophrenia in the Swedish National Inpatient Register, in cases of early age at onset. We also wanted to describe the accuracy of the diagnoses in cities/university clinics and country hospitals as well as in child and adolescent psychiatric clinics and clinics for adults. Method: One hundred cases with a diagnosis of schizophrenia, born 1973–1977, were randomly selected. The psychiatric records were scrutinised according to the criteria of DSM-IV. Results: Eighty-six per cent (95 % CI 78–93 %) fulfilled the DSM-IV criteria of schizophrenia syndrome and 76 % (95 % CI 66–86 %) fulfilled the “narrow” definition. There were no large differences in the accuracy of the diagnoses between regions or clinics. Conclusion: The proportion of “true” cases of schizophrenia is high in the Swedish National Inpatient Register. In addition, the results did not support large differences between clinics or regions although a larger sample size would be needed to test this formally. In comparison with earlier studies from the Nordic countries the validity seems to be quite stable over time, between different ages at onset and between Nordic countries. Thus, the registers are well suited to be used in schizophrenia research. Accepted: 17 June 2002 Correspondence to Ch. Dalman     

The temporal relationship between schizophrenia and crime

Background Little is known about the temporal relationship between illness onset and the possible beginning of a criminal career among people with schizophrenia, even though criminality, especially violent criminality, has been shown to be more common among people with schizophrenia than among people in general. Aim: The aim of this study was to analyse the temporal relationship between registered crime and contact to the psychiatric hospital system. Method: This is a register-based study merging data on the psychiatric career with criminal records. Results: Among the males with schizophrenia, 37% started a criminal career and 13% had committed first violent crime before first contact with the psychiatric hospital system. Conclusion: The criminality committed before first contact to the psychiatric hospital system is substantial, especially among males with schizophrenia. Accepted: 22 February 2003 Correspondence to Runa Munkner, MD     

A comparison of clinical and research DSM-III-R diagnoses of schizophrenia in a Finnish national birth cohort

As a prerequisite to the use of the Finnish National Hospital Discharge Register in psychiatric epidemiological research, we studied the diagnostic reliability of the register in terms of the psychiatric morbidity experienced by a national birth cohort. We investigated all entries to the register for a sample based upon the Northern Finland 1966 birth cohort at the age of 16 years (n=11017). Until the end of 1993 (age 27 years), a total of 563 subjects had a register diagnosis indicating a psychiatric illness, 37 of them being schizophrenia. When operational criteria (DSM-III-R) were applied to clinical information in the available original hospital records for cases of psychosis, personality disorder and substance abuse (n=249), 71 fulfilled criteria for schizophrenia, including all of the 37 cases in the register and an additional 34 (48% false-negatives), most frequently diagnosed in the register as schizophreniform or other psychosis. Despite the official use of DSM-III-R nomenclature, it appears that the clinical concept of schizophrenia in Finland, manifest within the register, remains very restrictive. The application of operational criteria is a necessary prerequisite for scientific research on schizophrenia.     

Patients' and their relatives' causal explanations of schizophrenia

Background: Previous studies with schizophrenia patients and their relatives which have been carried out in the western part of Germany and in Austria have demonstrated a strong tendency towards assuming psychosocial stress as a cause of schizophrenia. The question arises as to whether patients with schizophrenia and their relatives in the eastern part of Germany (former German Democratic Republic) share these beliefs. Methods: Problem-centered interviews were conducted with 100 schizophrenia patients living in the catchment area of the university hospital who were in psychiatric outpatient treatment. Thirty-six relatives were also interviewed at the same time. Results: Both patients and relatives most frequently reported psychosocial stress as a cause of the illness. Sixty-two per cent of the patients and 86 % of the relatives reported more than one cause. However, the majority of them did not explicitly link these causes to one another. Discussion: Similarities between the results of this study and those of previous studies prevail. However, there are some differences with regard to the role attributed to socialisation and society. Whereas there is a stronger tendency to hold the family responsible for the illness in the West, in the East the social conditions are more frequently considered to be of etiological relevance. Inconsistencies between patients' and relatives' beliefs and the results of psychiatric research on the causes of schizophrenia suggest a need to provide specific psychoeducation for both. Received: 28 October 2002 / Accepted: 4 November 2002 Correspondence to Dr. Anita Holzinger     

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     

Schizophrenia and substance misuse problems: a comparison between patients with and without significant carer contact

Aim Many researchers and clinicians in the mental health field have given much attention over the last few years to patients with co-morbid problems of schizophrenia and substance use. This population is becoming a focus of attention for all service providers owing to the suggested increase in numbers of patients with these dual diagnoses and the observed negative effects on patients and costs to services. The advantages for providing family interventions in schizophrenia are now well established and increasingly these interventions are being evaluated for families of dual diagnosis patients. Many dually diagnosed patients do not, however, have a great deal of contact with a carer/relative. This paper looks at whether differences exist between patients with a dual diagnosis that have carer contact and those who do not have carer contact in terms of their illness history and type of substance use. For the purpose of this article ‘carer’ refers to an individual who is an informal carer or relative with whom the client has weekly contact of 10h. Many of these carers provide the client with emotional, physical and material support. Method The identification process for both ‘carer contact’ and ‘no carer contact’ patients was conducted through the screening of the hospital's care programme approach (CPA) lists and through contact with care co-ordinators and consultants. Case notes of all patients identified were screened and information on demographic data, duration of illness, admissions and substance use was collected. Results Results indicated that the ‘no carer contact’ group was older and had significantly more days in hospital at last admission. Conclusions It is possible that as patients get older their contact with significant others decreases, i. e. loss of contact with key relatives is due to age rather than severity of substance use. Furthermore, patients' reduced contact results in them having longer stays in hospital possibly because they will not receive additional support when discharged. Accepted: 16 July 2001     

Schizophrenia: illness impact on family members in a traditional society – rural Ethiopia

Background: Studies have consistently shown that both the subjective and objective dimensions of burden among family members of schizophrenia patients and other psychiatric disorders are prevalent. However, as most of these reports were from western societies, we lack information on the subject in developing countries. Method: The study was conducted within the framework of the ongoing epidemiological study of course and outcome of schizophrenia and bipolar disorders in a rural population of 15–49 years of age. Three hundred and one cases of schizophrenia and their close relatives participated in the study. Results: Family burden is a common problem of relatives of cases with schizophrenia. Financial difficulty is the most frequently endorsed problem among the family burden domains (74.4 %). Relatives of female cases suffered significantly higher social burden (Z = 2.103; p = 0.036). Work (Z = 2.180; p = 0.029) and financial (Z = 2.088; p = 0.037) burdens affected female relatives more often than males. Disorganised symptoms were the most important factors affecting the family members in all family burden domains. Prayer was found to be the most frequently used coping strategy in work burden (adj. OR = 1.99; 95 % CI = 1.08–3.67; p = 0.026). Conclusion: Negative impact of schizophrenia on family members is substantial even in traditional societies such as those in Ethiopia where family network is strong and important. The scarce existing services in the developing countries should include family interventions and support at least in the form of educating the family members about the nature of schizophrenia illness and dealing with its stigma and family burden. Received: 15 January 2002 / Accepted: 29 July 2002 Correspondence to Gunnar Kullgren, MD, PhD     

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     

Psychological disorders and symptoms in primary care

Background Psychological symptoms that do not reach the threshold for formal diagnosis are disregarded in prevalence rates and are apparently assumed to be transient and of little clinical importance. Method Consecutive primary care attenders (n = 2379) were screened using the 12-item General Health Questionnaire (GHQ-12) and a stratified random sample (n = 704) completed baseline structured diagnostic interview, disability assessment, and the 28-item version of the GHQ (GHQ-28). Subjects with significant psychiatric symptoms and a random sample of those without (n = 263) were evaluated with the same measures 12 months later. Results While 25 % of the baseline sample scored 5 or more on the GHQ-28, only 10 % met the ICD-10 criteria for one or more disorders. At baseline, caseness on either the GHQ or ICD-10 was associated with poor self-rated overall health, interviewer-rated occupational disability and with more disability days in prior month. At 12-month follow-up, being a case on the GHQ at baseline, but not on ICD-10, was associated with disability, poor health perception and high health service utilization. Conclusion Psychological symptoms that may not reach diagnostic threshold are associated with impaired functioning over 12 months. Individuals with such symptoms may be identified using self-report questionnaires for dimensional symptoms, such as the GHQ-28. Accepted: 8 February 2002     

Diagnosing comorbidity in psychiatric hospital: challenging the validity of administrative registers

Background

This study will explore the validity of psychiatric diagnoses in administrative registers with special emphasis on comorbid anxiety and substance use disorders.

Methods

All new patients admitted to psychiatric hospital in northern Norway during one year were asked to participate. Of 477 patients found eligible, 272 gave their informed consent. 250 patients (52%) with hospital diagnoses comprised the study sample. Expert diagnoses were given on the basis of a structured diagnostic interview (M.I.N.I.PLUS) together with retrospective checking of the records. The hospital diagnoses were blind to the expert. The agreement between the expert’s and the clinicians’ diagnoses was estimated using Cohen’s kappa statistics.

Results

The expert gave a mean of 3.4 diagnoses per patient, the clinicians gave 1.4. The agreement ranged from poor to good (schizophrenia). For anxiety disorders (F40-41) the agreement is poor (kappa = 0.12). While the expert gave an anxiety disorder diagnosis to 122 patients, the clinicians only gave it to 17. The agreement is fair concerning substance use disorders (F10-19) (kappa = 0.27). Only two out of 76 patients with concurrent anxiety and substance use disorders were identified by the clinicians.

Conclusions

The validity of administrative registers in psychiatry seems dubious for research purposes and even for administrative and clinical purposes. The diagnostic process in the clinic should be more structured and treatment guidelines should include comorbidity.     

Diagnostic errors in psychiatry

Although the importance of nosology has been derided as “pigeonholing” by some American psychiatrists, the science of diagnosis has lately enjoyed a renaissance. Actually, whether or not a psychiatrist possessed diagnostic acumen had little effect on the outcome of treatment until the past two decades, because so much of treatment was nonspecific. But the increasing use of drugs, particularly neuroleptics, antidepressants, and lithium, has made precise diagnosis a necessity.In recent years, several authors have commented upon the misdiagnosis of manic-depressive patients—particularly catatonics¹—as schizophrenics² and a multihospital cross-national study³ has suggested that American psychiatrists overdiagnose schizophrenia and underdiagnose affective disorder. The Iowa group⁴ has demonstrated that strict criteria result in a much lower rate of diagnosed schizophrenia than does the “agreement of experienced clinicians” so often set as the standard. With the compilation of diagnostic criteria for psychiatric disorder by Feighner et al.,⁵ it became clear that 80% or more of psychiatric patients can be definitely classified according to standards that permit accurate prediction of treatment and prognosis. But today, the vast majority of psychiatric diagnoses still are not made on the basis of scientific criteria, and the category of “undiagnosed psychiatric disorder,” at least as used by clinicians, is virtually an empty set.To what extent strict criteria are used no one knows, but from anecdotal case reports in the literature they are probably not overutilized. The resulting margin for disagreement and for downright error is probably enormous. We propose now to review the kinds of erroneous diagnoses commonly made, the reasons for these errors, and their possible consequences. This report, based upon the experience of psychiatrists in private practice, deals with the diagnostic pitfalls encountered despite, or in some cases because of, the use of scientific diagnostic criteria.     

Does racial bias influence psychiatric diagnoses assigned at first hospitalization?

BACKGROUND: Research on racial bias in psychiatric diagnosis has largely been limited to studies of admission diagnoses assigned to chronically ill patients. This study tests whether racial bias influences diagnoses assigned to patients at discharge from their first psychiatric hospitalization. METHODS: In a county-wide sample of patients with psychosis, hospital diagnoses were compared with research diagnoses formulated using structured interviews and strict adherence to DSM-III-R. Symptom patterns were also examined. RESULTS: Racial differences were observed in the distribution of both hospital and research diagnoses. Using research diagnoses as the gold standard, the sensitivities and specificities of hospital diagnoses were similar by race (for blacks the sensitivity and specificity of schizophrenia was 0.33 and 0.91, and for whites, 0.43 and 0.89). The only suggestion of possible bias was that more blacks were discharged without a definitive diagnosis (38.7% of blacks vs. 26.3% of whites, chi(2) = 5.80, df = 1, p = 0.02). CONCLUSIONS: We did not observe the expected racial bias in the assignment of diagnoses of schizophrenia and affective disorders. While there was evidence that hospital clinicians had more difficulty diagnosing black patients, the low concordance between hospital and research diagnoses for both black and white patients demonstrates the need to better understand the clinical diagnostic process for all patients with psychotic disorders at their first hospitalization.     

Effectiveness of psychoeducational intervention for rural Chinese families experiencing schizophrenia

Background: The aim of this study was to explore the characteristics and efficacy of psychoeducational family intervention for persons with schizophrenia in rural China. Methods: A cluster randomised controlled trial of psychoeducational family intervention for families experiencing schizophrenia (three groups, 326 cases) was conducted in Xinjin County, Chengdu. Treatment groups consisted of family intervention and medication, medication alone, and a control. Results: The results showed a gain in knowledge, a change in the relatives' caring attitudes towards the patients, and an increase in treatment compliance in the psychoeducational family intervention group (p < 0.05, 0.001). Most importantly, the relapse rate over 9 months in this group (16.3 %) was half that of the drug-only group (37.8 %), and just over one-quarter of that of the control group (61.5 %) (p < 0.05). Antipsychotic drug treatment and families' attitudes towards patients after the 9-month follow-up were significantly associated with clinical outcome (p < 0.05). Conclusions: In rural China, family intervention should focus on improving the relatives' recognition of illness, the caring attitude towards the patients, treatment compliance, relapse prevention, and the training of the patients' social functioning. This trial, one of the largest in the literature, has shown that psychoeducational family intervention is effective and suitable for psychiatric rehabilitation in Chinese rural communities. Received: 16 April 2002 / Accepted: 29 August 2002 Correspondence to Mao-Sheng Ran, M. D., Ph. D.     

Psycho-social determinants for psychiatric hospitalisation for neurotic disorders in women

Background: Much has been written about the determinants of psychiatric hospitalisation, chiefly for psychotic patients in an emergency. This paper reports the results of a comparative study between in-patients and pathological subjects from the general population. The aim of this work is to evidence the psycho-social determinants of hospitalisation in a psychiatric department for neurotic disorders. Methods: This study was conducted on a socially fairly privileged population which was, therefore, also fairly homogeneous. The subjects from the two groups were assessed clinically using standardised instruments both for diagnosis (SCAN) and for psycho-social variables (Stressful Life Events: LEDS; Social Support and Self-esteem: Pearlin checklist; care itinerary). Results: Following the analysis of frequency and a multivariate logistic regression analysis, four risk factors for hospitalisation for neurotic disorders were evidenced, including: severity of neurotic disorders, taking a long time to consult a specialist after first onset of anxiety disorders, poor social support, and having experienced one or more provoking agents (Brown and Harris methodology) in the year previous to hospitalisation. Conclusion: The severity of the mental pathology is largely responsible for hospitalisation in neurotic patients as it is in psychotic patients, but it is not the only determinant for hospitalisation. Accepted: 1 December 2002     

Diagnostic agreement of schizophrenia spectrum disorders among chronic patients with functional psychoses

BACKGROUND: To investigate whether diagnostic agreement across different diagnostic systems improves in a sample of chronic patients suffering from functional psychosis compared to first-admitted patients. SAMPLING AND METHODS: Among 353 patients with a history of functional psychosis, a subset of 100 individuals (35 women and 65 men) were randomly sampled and assessed using the Operational Criteria Checklist for Psychotic Illness and Affective Illness (OPCRIT). Based on the OPCRIT diagnoses the subjects suffering from schizophrenia and schizophrenia spectrum disorders according to seven diagnostic systems were identified. Diagnostic agreement was assessed using unweighted kappa-statistics and pairwise concordance rates (CR). RESULTS: High diagnostic agreement of schizophrenia was observed across the ICD-10 and DSM systems (CR >0.70, kappa >0.70), which all had a significantly lower concordance to the St. Louis Criteria (SLC), research diagnostic criteria and Schneider's first rank symptoms (FRS) (0.32< CR <0.66; -0.10< kappa <0.51). Agreement on schizophrenia across all systems was observed for one fourth of the subjects. Elimination of the diagnostic impact of 'co-occurrence of psychotic and affective symptoms' excluded FRS standalone individuals from the sample, increased overall homogeneity and resulted in a dichotomized sample according to SLC (46 positive vs. 47 negative). SLC status could be predicted in 78% of cases by four items relating to family history and psychosocial function previous to the onset of illness. Similarly high pairwise CR were observed for schizophrenia spectrum disorders across all diagnostic systems. CONCLUSIONS: This study demonstrates that diagnostic agreement is higher among chronic patients than that observed in subjects with a recent onset of psychosis, although considerable discordance is also observed in this chronic sample. However, the discordance among chronic patients with functional psychosis largely derives from the different emphasis that diagnostic systems place on co-occurrence of psychotic and affective symptoms. This may have serious epistemological consequences, thus underlining the conventional nature of the present schizophrenia diagnoses and the need for biologically founded diagnostic criteria.     

To be or not to be married – that is the question of quality of life in men with schizophrenia

Background The association of gender and marital status with quality of life (QoL) was studied in a representative national sample of long-term schizophrenia patients. Methods The study sample consisted of 1,750 male and 1,506 female 15- to 64-year-old schizophrenia patients discharged from mental hospitals in 1986, 1990 and 1994 in Finland. Comprehensive data were collected from hospital and out-patient case records and the psychiatric teams carried out a structured interview regarding the patients' socio-demographic background, living places, living situation, psycho-social state and functioning and life satisfaction three years after the index discharge. Results Female patients were older, more often married, had been ill for a longer time and had moved after discharge from hospital to live alone or with their spouse more often than men. Women and married patients had migrated more often than men and single patients, but single men had more often remained living in a remote rural area than others. The QoL of single men was poorer than others in almost all the areas in which it was measured: housing conditions, working, daily functioning, number of confidants and psycho-social state. Differences between single women and married men or women were much smaller. Women, independently of their marital status, were more satisfied with their life, had more close interpersonal relationships and had done useful work more often than men. Conclusions Single male patients with schizophrenia seem to have dropped out of the development of society. They remain living in their birthplace and are more dependent than other patients. Single women migrate more consistently into urban areas, which may be favourable for their QoL. Married patients with schizophrenia, possibly partly helped by their spouse, can best follow changes in the society. Female gender also seems to have an independent association with life satisfaction and interpersonal aspects of the QoL. The results of this study strongly emphasise that the associations between gender, marital status and QoL to a great extent depend on the study sample and may also vary by study area. Accepted: 16 July 2001     

Lay recommendations on how to treat mental disorders

Background Beliefs about the helpfulness of interventions are influencing the individual help-seeking behavior in case of mental illnesses. It is important to identify these beliefs as professional helpers are asked to consider them in their treatment recommendations. Objective Assessing lay proposals for an appropriate treatment of mental illnesses. Methods We conducted a representative opinion survey in Switzerland. Eighteen treatment proposals were presented with respect to a vignette either depicting schizophrenia or depression. Respondents were asked to indicate the proposals considered to be helpful for treatment and those considered to be harmful, respectively. Results‘Psychologist,’‘general practitioner,’‘fresh air,’ and ‘psychiatrist’ were mostly proposed as being helpful. Among several psychiatric treatment approaches ‘psychotherapy’ was favored, while psychopharmacological treatment and electroconvulsive therapy were only proposed by less than one-fourth of the interviewees. Especially psychotropic drugs were considered to be harmful. Treatment by a psychiatrist was regarded as being more helpful for schizophrenic individuals than for depressive persons. For a person experiencing a life crisis, treatment by a psychiatrist and psychological treatment were viewed as being harmful, and non-medical interventions were preferred. However, for persons thought to be mentally ill, psychiatric and psychopharmacological treatments were recommended. Conclusion Mental health professionals are regarded as being helpful although their treatment methods are seen as being less helpful. A clear distinction is made between lay proposals for depression and schizophrenia. However, the perception of whether a condition is considered to be an illness or a life crisis has significantly more influence on lay treatment proposals than the cited diagnosis in the vignette. Accepted: 3 September 2001     

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     

How the inner world is reflected in relation to perceived ward atmosphere among patients with psychosis

Background: This study focused on how cognitive ability, personality traits, self-rated psychiatric symptoms, and social functioning were related to the way in which patients with psychosis perceived supportive aspects of the ward atmosphere. Methods: Patients at a psychiatric rehabilitation unit (PRU) in southern Sweden completed a ward atmosphere questionnaire (COPES), rated their psychiatric symptoms (SCL-90), self-image (SASB), and were tested on cognitive functioning (WAIS-R) and global social functioning (GAF). They were diagnosed according to ICD-10. Data were analysed by means of logistic regression analyses. Results: Self-monitoring and restraining (self-control), one cluster in the SASB, was the strongest factor associated with how the patients perceived the ward atmosphere. A perceived high level of self-control indicated high levels of perceived Support, Practical orientation, and Order and organisation of the ward atmosphere. A high level of self-rated paranoid symptoms (SCL-90) increased the risk of perceiving a high level of Anger and aggression and a low level of Program clarity. Regarding cognitive ability (WAIS-R), two factors were important for predicting perceived ward atmosphere. A low level of social competence was associated with a low level of perceived Order and organisation. Furthermore, a low level of abstract thinking was related to a low level of perceived Anger and aggression, while a high level of abstract thinking was associated with a low level of Program clarity. Patients with schizophrenia exhibited a lower level of Self-monitoring and restraining than patients with other psychoses. Conclusion: The results from this study indicate that individual factors such as self-control, paranoid symptoms and social competence may be important for how the ward atmosphere is perceived. This is important knowledge when monitoring the ward atmosphere to better fit a unit's target group. Accepted: 18 June 2002 Correspondence to Jan-?ke Jansson, M.Sc.     

Self-perceived social integration and the use of day centers of persons with severe and persistent schizophrenia living in the community: a qualitative analysis

Background The study examined how persons with severe and persistent schizophrenia perceive their social integration and how particular types of social integration are related to the use of day centers and patient clubs. Methods Problem-focused interviews on self-perceived social integration and the use of day structuring services were done with 100 persons with an ICD–9 diagnosis of schizophrenia living in Leipzig. Transcribed interviews were subjected to computer-aided qualitative content analysis. Results Results of the qualitative content analysis show that the study participants can be classified in five different groups according to their self-perceived degree of social integration. The use and the subjective meaning of existing day structuring services was found to be associated with the type of self-perceived social integration. Conclusion The heterogeneous ways persons with chronic schizophrenia organize their social lives lead to different kinds of needs for support. In order to meet the needs of the whole spectrum of patients this heterogeneity must be taken into account in the process of service planning. Accepted: 4 September 2001