Aging and schizophrenia: current health services research and recommendations

Little is known about the functioning and health care use of older patients with schizophrenia. Understanding the use patterns of older patients with schizophrenia, a rapidly growing population, will inform health care planners and policy makers who make decisions about resource allocation and program development. The results are presented from a large-scale study to examine the relationship between age and the use of health services and level of functioning in patients with schizophrenia. Older adults with schizophrenia experienced fewer psychiatric hospitalizations but, once hospitalized, had longer inpatient stays. In contrast, older patients had fewer outpatient psychiatric visits and more medical outpatient visits and medical hospitalizations than younger individuals. The relatively lower use of outpatient psychiatric care by older patients with schizophrenia suggests that there may be barriers to accessing these services. When older patients are hospitalized for psychiatric reasons, their stays are longer. The implications of these findings are discussed.     

Can involuntary outpatient commitment reduce hospital recidivism?: Findings from a randomized trial with severely mentally ill individuals

OBJECTIVE: The goal of this study was to evaluate the effectiveness of involuntary outpatient commitment in reducing rehospitalizations among individuals with severe mental illnesses. METHOD: Subjects who were hospitalized involuntarily were randomly assigned to be released (N = 135) or to continue under outpatient commitment (N = 129) after hospital discharge and followed for 1 year. Each subject received case management services plus additional outpatient treatment. Outpatient treatment and hospital use data were collected. RESULTS: In bivariate analyses, the control and outpatient commitment groups did not differ significantly in hospital outcomes. However, subjects who underwent sustained periods of outpatient commitment beyond that of the initial court order had approximately 57% fewer readmissions and 20 fewer hospital days than control subjects. Sustained outpatient commitment was shown to be particularly effective for individuals with nonaffective psychotic disorders, reducing hospital readmissions approximately 72% and requiring 28 fewer hospital days. In repeated measures multivariable analyses, the outpatient commitment group had significantly better hospital outcomes, even without considering the total length of court-ordered outpatient commitments. However, in subsequent repeated measures analyses examining the role of outpatient treatment among psychotically disordered individuals, it was also found that sustained outpatient commitment reduced hospital readmissions only when combined with a higher intensity of outpatient treatment. CONCLUSIONS: Outpatient commitment can work to reduce hospital readmissions and total hospital days when court orders are sustained and combined with intensive treatment, particularly for individuals with psychotic disorders. This use of outpatient commitment is not a substitute for intensive treatment; it requires a substantial commitment of treatment resources to be effective.     

Outreach visits improve referral of alcohol dependent patients from psychiatric hospital to continued care. A randomized trial

Purpose: Many patients with alcohol use disorder (AUD) fail to initiate outpatient treatment after being discharged from inpatient detoxification. The aim of the present study was to investigate the effect of outreach visits (OV) on subsequent attendance in outpatient AUD treatment.

Methods: Patients admitted to a detoxification unit at a mental health hospital were randomized to either referral as usual (TAU) or OV. OV involved a nurse from the outpatient clinic meeting the patients at the hospital and advising them about outpatient treatment, presenting an ‘attendance contract’ and offering a first appointment.

Results: One hundred consecutive patients were randomized while hospitalized, 55 received TAU and 45 OV. About 84.4% OV patients presented for treatment at the outpatient clinic compared to 58.2% TAU-patients (p?=?.004). About 46.7% OV patients received continuing care for at least 3 months compared to 23.6% TAU-patients (p?=?.016).

Conclusion: OV are an effective strategy for ensuring continued treatment.     

Three years' maintenance neuroleptic treatment in schizophrenia--before and beyond.

A group of patients with schizophrenia, initially 67 patients, was studied over a period of 3 years. After three years 36 out of 67 patients were still on the same depot neuroleptic. The main aim was to describe and compare maintenance neuroleptic therapy using two depot neuroleptics, fluphenazine decanoate and pipotiazine palmitate, given monthly. Before the outpatient care the patients had participated in the department's comprehensive hospital treatment including depot neuroleptic medication. After a 1-year clinical trial with frequent assessments of the patients, significant symptom reductions were found on all rating scales. During the last 2 years of the study only drug therapy was given. Improvement concerning social function in the community and work level as well as the low-rated psychopathology noted at the start of study also persisted at the 3-year follow-up. The side effects were low in frequency and quality. These results show the clinical value of long-term maintenance treatment with depot neuroleptics. The results also confirm that the favourable effects of the hospital treatment demonstrated before the start of the clinical trial could be maintained. The possibilities of further improving aftercare and outpatient treatment beyond medication alone are discussed.     

The Impact of Stigma of Mental Illness in a Canadian Community: A Survey of Patients Experiences

We examined stigma experiences and its impact among patients (n = 41) hospitalized for mental illness. We studied their characteristics contributing to the expectation, intensity, and frequency of stigma they could experience. Opinions were compared on the Experiences with the Stigma of Mental Illness scale measuring stigma experiences and impact. There were differences on perceived stigma in: being 19 years or younger at first symptom or treatment, having had one previous psychiatric hospitalizations and having attended one or more outpatient sessions. Those having attended outpatient sessions, being previously hospitalized or younger suffered more impact.     

Psychiatric treatment in a delimited population-with particular reference to outpatients. A demographic study.

The present investigation analyses the psychiatric service available to and utilized by a population in a geogrphically delimited area, namely the Randers area with a population of 108.928. During the period 1970-74, the average yearly rate of patients admitted to the three psychiatric institutions covering this area was per 1,000: 7.9 males and 9.1 females. During 1970-71, 1.2 males and 1.8 females per 1,000 were treated as outpatients in a psychiatric clinic affiliated to a psychiatric hospital, and a psychiatric outpatient clinic in a general hospital discharged 4.1 males and 7.7 females per 1,000. It seems probable that despite outpatient treatment the number of admissions increases slightly rather than decreases, and consequently, outpatient treatment cannot replace psychiatric admission.     

Recent treatment history vs clinical characteristics in the prediction of use of outpatient psychiatric services

Background The use of outpatient psychiatric services has been shown to be a complex function of sociodemographic, clinical, and pathway variables. The relative contribution of each variable or groups of variables in explaining the variability in the use of outpatient psychiatric services, however, remains poorly documented. Methods The subjects (N=382) were all patients admitted to an outpatient psychiatric clinic serving mostly a minority and low-income population. The charts of the patients were reviewed for sociodemographic, clinical, and pathway variables and the number of outpatient visits. The pathway variables studied were source of referral and most recent psychiatric treatment service used. Both bivariate and multivariate statistics were used to analyze the data. Results Pathway variables were better predictors of the number of outpatient visits than clinical variables after controlling for sociodemographic variables. Conclusion Patients recently hospitalized may be sicker or have fewer social supports and therefore require more outpatient visits. Recent treatment history stands out as an important variable in the prediction of the number of outpatient mental health visits. More research is needed to examine the influence of pathway variables on treatment decisions.     

The Long-Term Effect of Outpatient Commitment on Service Use

The long-term effect of outpatient commitment on service use was evaluated in 81 patients with serious and persistent mental illness. An increased number of outpatient visits and a decreased number of hospital admissions, total hospital days, and lengths of stay were observed during commitment periods of greater than 1 year relative to levels of use in the same patients over the 12-month period preceding commitment. This study provides support that outpatient commitment improves compliance with outpatient treatment and reduces hospital use in patients who are on outpatient commitment to a single treatment agency for periods up to 5 years.     

The effects of long-term clozapine add-on therapy on the rehospitalization rate and the mood polarity patterns in bipolar disorders

OBJECTIVE: We investigated the effect long-term clozapine add-on therapy has on rehospitalization rate and mood polarity patterns in patients with bipolar disorders. METHOD: Clinical data from medical records of 51 patients with bipolar disorder (DSM-IV) treated with clozapine add-on for more than 6 months at the Refractory Bipolar Disorders Clinic of Seoul National University Hospital were retrospectively analyzed. Patients had been registered from 1995 to 2004. Rehospitalization rates were compared before and after clozapine add-on. The clinical polarity of episodes resulting in hospitalizations was also compared. Twenty-seven bipolar patients treated with clozapine add-on for more than 3 years were further analyzed for long-term stability. RESULTS: The number of hospital days per year was reduced in 90.2% of patients after clozapine add-on. Total number and duration of hospitalizations per year decreased, and the effect size of clozapine add-on was substantially large (Wilcoxon z = -5.48, p < .01 for number of hospitalizations/year; Wilcoxon z = -5.32, p < .01 for hospital days/year; r = -0.54 and -0.53, respectively). Significant reductions were found in the number and duration of hospitalizations associated with manic, depressive, and hypomanic episodes. Number and duration of hospitalizations associated with mixed episodes did not show significant changes. The long-term efficacy of clozapine add-on was supported by continuous reduction in hospital days per year in the 27 selected patients. CONCLUSION: Long-term clozapine add-on therapy was effective in reducing the number and duration of rehospitalizations of bipolar patients resistant to conventional treatment. A significant reduction was found in rehospitalizations associated with manic, depressive, and hypomanic episodes, whereas mixed episode-associated rehospitalizations did not show significant changes.     

Patients dropping out of treatment in Italy

The aim of this study was to explore the extent and the specific features of drop-out for patients having a first contact with an university psychiatric outpatient clinic in Italy over the course of 1 year and to determine which variables were associated with early termination of treatment. Of the 158 patients selected for this study, there was an overall 3-month drop-out rate following the first visit of 63 %. Of the 59 patients who had returned once after the initial contact, 28 interrupted subsequently the treatment, although the therapist's plan included further visits. The overall drop-out rate at 3 months was thus 82%. The only 2 variables associated with drop-out rates were the patients’ perception of the severity of their disorder and the psychiatric history: continuing patients were more frequently in agreement with the clinician's judgment as compared with those who dropped out and were more likely to have already been in psychiatric treatment.     

Use of Psychiatric Advance Directives During Psychiatric Crisis Events

This paper presents the first empirical data regarding the rates and predictors of using psychiatric advance directives. Directives were accessed in only 20% of crisis events for the 69 participants selected on the basis of frequent use of psychiatric emergency and hospital services. Directives were 10 times more likely to be accessed when a surrogate decision-maker was involved in the crisis event. Directives were also more likely to be accessed over time and for people who had repeated crises, fewer prior hospitalizations, no substance use, and no prior outpatient commitment orders. Creation of more directives to increase clinician and system familiarity and more consistent appointment of surrogate decision-makers could increase use of directives.     

Health service use among persons with comorbid bipolar and substance use disorders

OBJECTIVE: This study tested the hypothesis that patients with comorbid bipolar and substance use disorders use health services to a greater extent than patients with either bipolar or substance use disorder alone. METHODS: A retrospective chart review was conducted among patients who used health services at the Ralph H. Johnson Department of Veterans Affairs medical center in Charleston, South Carolina, and had bipolar disorder alone, substance use disorder alone, and comorbid bipolar and substance use disorders. Patients with a psychiatric admission between 1999 and 2003 were included in the study. Information was collected on the use of health services one year before and including the index admission. RESULTS: The records of 106 eligible patients were examined for this study: 18 had bipolar disorder alone, 39 had substance use disorder alone, and 49 had both bipolar and substance use disorders. Compared with the other two groups, the group with comorbid bipolar and substance use disorders was significantly more likely to be suicidal. Compared with the group with bipolar disorder alone, the group with comorbid disorders had significantly fewer outpatient psychiatric visits and tended to have shorter psychiatric hospitalizations. Among patients with an alcohol use disorder, those who also had bipolar disorder were significantly less likely than those with an alcohol use disorder alone to have had an alcohol-related seizure. Patients with comorbid bipolar and substance use disorders were significantly less likely than those with substance use disorder alone to be referred for intensive substance abuse treatment, even though both groups were equally likely to enter and complete treatment when they were referred. CONCLUSIONS: Despite significant functional impairment among patients with comorbid bipolar and substance use disorders, they had significantly fewer psychiatric outpatient visits than those with bipolar disorder alone and were referred for intensive substance abuse treatment significantly less often than those with substance use disorder alone.     

Impact of Psychiatrists’ Qualifications on the Rate of Compulsory Admissions

Despite efforts to reduce coercion in psychiatry, involuntary hospitalizations remain frequent, representing more than half of all admissions in some European regions. Since October 2006, only certified psychiatrists are authorized to require a compulsory admission to our facility, while before all physicians were, including residents. The aim of the present study is to assess the impact of this change of procedure on the proportion compulsory admissions. All medical records of patients admitted respectively 4 months before and 4 month after the implementation of the procedure were retrospectively analyzed. This search retrieved a total of 2,227 hospitalizations for 1,584 patients. The overall proportions of compulsory and voluntary admissions were 63.9 % and 36.1 % respectively. The average length of stay was 32 days (SD ± 64.4). During the study period, 25 % of patients experienced two hospitalizations or more. The most frequent patients’ diagnoses were affective disorders (30 %), psychotic disorders (18.4 %) and substance abuse disorders (15.7 %). Compared with the period before October 2006, patients hospitalized from October 2006 up were less likely to be hospitalized on a compulsory basis (OR = 0.745, 95 % CI: 0.596–0.930). Factors associated with involuntary admission were young age (20 years or less), female gender, a diagnosis of psychotic disorder and being hospitalized for the first time. Our results strongly suggest that limiting the right to require compulsory admissions to fully certified psychiatrists can reduce the rate of compulsory versus voluntary admissions.     

Social aspects of therapy with depot neuroleptics in the Federal Republic of Germany

The authors compare 76 patients (50% paranoid schizophrenics, 30% residual psychotics) successively treated with oral and depot neuroleptics: the mean number of rehospitalizations has dropped from 2.5 to 0.8, while the mean duration of hospital treatment has dropped from 34 to 8 weeks (t test significant). The relationship between the type of treatment and sociodemographic data was analyzed by means of correlation coefficients and variance analyses. There was no relation of age, sex, age of onset, school background, social class and professional achievement, but a significant superiority of depot medication in single patients. The choice of the depot preparation depends on habits, scientific attitudes and year: in 1976-1977, fluphenazine decanoate was prescribed in 70% of all cases; but penfluridol, fluspirilene and to a lesser extent flupentixol decanoate were also administered. Depot forms make for 32% of all neuroleptics. There is no evidence as to whether long-term neuroleptic medication has a prophylactic effect on relapses beyond the third year of treatment; but, without these drugs, it would have been impossible to return many patients to their environment; social psychiatry has received a new impetus from depot neuroleptics; the size of psychiatric hospitals could be reduced by one-third.     

Practices preventing rehospitalization of individuals with schizophrenia

While psychosocial care approaches such as assertive community treatment or partial hospitalization can help prevent psychiatric inpatient stay, the ability of specific services to prevent admission is less clear (e.g., recognizing signs of impending relapse, promoting daily structure). Therefore, within 3 months of psychiatric hospital discharge, this study examined the extent to which inpatient readmission among 264 persons with schizophrenia was averted by interventions addressing medication education, symptom education, service continuity, social skills, daily living, daily structure, and family issues. After accounting for demographic characteristics in logistic regression equations, findings suggested that interventions addressing symptom education, service continuity, and daily structure were most effective in preventing inpatient stay among individuals with four or more prior hospitalizations. However, these services became statistically insignificant in preventing readmission among counterparts with fewer previous inpatient stays. While protective effects may differ among persons with varying hospitalization histories, results indicate that resource-poor outpatient centers could focus on these three interventions when care must be limited to rehospitalization prevention.     

The community clinic — its advantages and disadvantages

A traditional hospital outpatient clinic for the follow-up of patients with mental illness in old age was replaced by home visits (the community clinic). As a preliminary study, the first six community clinics were compared with six outpatient clinics and found to be superior on several practical measures (including the percentage of booked patients who were successfully seen and the number of carers seen) as well as in terms of information obtained. The DHSS does not monitor this activity but it is an important development of specialist services for the elderly mentally ill.     

New vs. old antipsychotics: the Texas experience

A study was conducted in Texas state psychiatric facilities of 299 patients with schizophrenia who were taking clozapine, comparing them with 223 matched controls taking traditional neuroleptics. From 12 months before until 54 months after clozapine was begun, hospital bed days and the associated costs were determined for both groups. The clozapine group had appreciably fewer hospital bed days throughout the study period. Substantially fewer clozapine-treated patients than neuroleptic-treated patients required 180 continuous days of hospitalization during the study. By 48 months after initiation of clozapine, hospital inpatient costs were $27,850/patient/year lower in the clozapine group than in the traditional neuroleptic group. Agranulocytosis occurred in < 1% of patients taking clozapine; all recovered quickly. In a separate study, clozapine therapy was shown to produce a 5-fold decrease in the rate of suicide among patients with schizophrenia. Administration of clozapine appears to lower the overall cost of treating schizophrenia by reducing the costs associated with hospitalizations.     

The relationship of demographic, clinical, and outcome variables to neuroleptic treatment requirements

A retrospective study of 61 acute schizophrenic patients examined whether any demographic, clinical, and outcome characteristics distinguished patients who improved with placebo or low dosages of antipsychotics (PLD patients) from patients who required high conventional dosages of antipsychotics (HCD patients). Patients in the PLD group (n = 30) and HCD group (n = 31) were similar in overall level of psychopathology at admission. Prominent excitement and certain somatic and auditory hallucinations were significantly more frequent in the HCD patients. PLD patients were more likely to be female, were hospitalized more rapidly after the onset of psychosis, and were more often first admissions. Although paranoid symptoms and premorbid schizoid personality did not differentiate the two groups, nonschizoid patients who were nonparanoid tended to be in the PLD group while nonschizoid patients who were paranoid tended to be in the HCD group. PLD patients were less psychotic at discharge, remained out of the hospital for longer periods, and had fewer rehospitalizations. These results confirm other reports of better outcome for patients successfully treated without medication. PLD patients were also functioning better as family members 1 year after discharge. Further research is indicated to improve the prediction of which acute psychotic patients will respond without medication or to low dose neuroleptic treatment and to determine if these predictions are generalizable to other treatment settings.     

A randomized controlled trial of outpatient commitment in North Carolina

OBJECTIVE: A randomized controlled trial of outpatient commitment was conducted in North Carolina to provide empirical data on involuntary outpatient commitment and to evaluate its effectiveness in improving outcomes among persons with severe mental illnesses. METHODS: A total of 331 involuntarily hospitalized patients awaiting discharge under outpatient commitment were randomly assigned to be released or to undergo outpatient commitment. Each received case management services and outpatient treatment. Participants in both groups were monitored for one year. After the initial 90-day outpatient commitment order, a patient could receive a renewable 180-day extension. Patients in the control group were immune from outpatient commitment for one year. Information was obtained from self-reports and reports of several informants as well as from outpatient treatment, hospital, and arrest records. RESULTS: In most bivariate analyses, outcomes for the outpatient commitment group and the control group did not differ significantly when the duration of outpatient commitment was not taken into account. However, patients who underwent sustained outpatient commitment and who received relatively intensive outpatient treatment had fewer hospital admissions and fewer days in the hospital, were more likely to adhere to community treatment, and were less likely to be violent or to be victimized. Extended outpatient commitment was also associated with fewer arrests of participants with a combined history of multiple rehospitalizations and previous arrests. The intervention was particularly effective among individuals with psychotic disorders. CONCLUSIONS: Outpatient commitment can improve treatment outcomes when the court order is sustained and combined with relatively intensive community treatment. A court order alone cannot substitute for effective treatment in improving outcomes.