Predictability of rehospitalization for schizophrenia

Caregiver Burden and Disability in Somatoform Disorder: An Exploratory Study

BACKGROUND

Very few Indian studies have explored disability among patients with somatoform disorder and the burden experienced by their caregivers. We aimed to assess the levels of disability among patients with somatoform disorder and the levels of burden among their caregivers and compare these parameters against patients with schizophrenia.

METHODS

Participants included adults with a diagnosis of somatoform disorders (F45.0-F 45.9) (n = 28) or schizophrenia (F20.0-F20.9) (n = 28) diagnosed as per the International Classification of Diseases, Tenth Revision (ICD-10), clinical descriptions, and diagnostic guidelines, as well as their caregivers. The WHO Disability Assessment Schedule 2.0 and Family Burden Interview Schedule were used to assess patient disability and caregiver burden, respectively. Independent Student's t-test or chi-square test was used to compare relevant sociodemographic and clinical parameters.

RESULTS

Out of 56 patients, the mean (±SD) age of the sample was 38.6 (±10.5) years. Females constituted a slender majority of the sample (n = 29, 51.8%). The mean disability score of patients with somatoform disorders was slightly higher (83.6 ±20.9) than that of patients with schizophrenia (82.3 ±16.7). Similarly, the mean burden score of caregivers of patients with somatoform disorders was nominally higher (18.96 ±9.9) than that of caregivers of patients with schizophrenia (15.7 ±9.7). Neither of these differences approached statistical significance (P > 0.05).

CONCLUSION

Patients with somatoform disorders experience considerable levels of disability, and their caregivers go through various levels of burden in their daily life that is comparable to schizophrenia.

The relapse rate and predictors of relapse in patients with first-episode psychosis following discontinuation of antipsychotic medication

BACKGROUND

To determine the "real world" relapse rate in patients with first-episode psychosis (FEP) who had discontinued antipsychotic medication and identify socio-demographic and clinical factors associated with the risk of relapse.

METHODS

Quantitative data were obtained via case-note review on 63 patients with FEP who had discontinued antipsychotic medication from Birmingham Early Intervention Service between 2012 and 2015. The follow-up period was until either: an occurrence of a relapse; end of 12-month study period; end of patient's case-note record. Relapse was defined as a return of symptoms requiring one of the following: home treatment, hospital admission or was based on clinical teams' decision as having a relapse. A pro-forma targeted pre-defined socio-demographic and clinical factors. Survival analysis was undertaken to estimate the 12-month relapse rate following discontinuation of antipsychotics and Cox regression performed to identify relapse predictors.

RESULTS

The Kaplan-Meier 12-month relapse estimate was 67% (95% confidence interval, 54%, 80%). Significant factors (P < .05) independently associated with an increased risk of relapse following discontinuation of antipsychotic medication were: male gender, not being in education, employment or training (NEET) and number of previous psychiatric hospital admissions.

CONCLUSIONS

Relapse is common after discontinuation of antipsychotic medication following recovery from a FEP. It is important that patients who wish to discontinue their medication are informed of the high relapse rates and the associated risks. Furthermore, male patients, patients with NEET status and those who have had previous hospital admissions may require closer monitoring.

Predicting 1-year risk for relapse in patients who have discontinued or continued quetiapine after remission from first-episode psychosis

OBJECTIVE

Relapse is common among patients with psychotic disorders. Identification of relapse predictors is important for decision regarding maintenance medication. Naturalistic studies often identify medication non-adherence as a dominant predictor. There are relatively few studies for predictors where adherence is already known. It is this situation i.e., discontinuation of medication that predictors will be most useful. We identify predictors for relapse in situations of (i) discontinuation and (ii) continuation of maintenance medication.

METHOD

Analysis of relapse predictors is based on a randomized controlled study (n=178) comparing relapse rates between patients who discontinued or continued medication for at least 1 year following first-episode psychosis. Demographic, clinical and neurocognitive variables were assessed at baseline as predictors of relapse within 1 year.

RESULTS

Risk of relapse was 79% in the discontinuation group and 41% in the maintenance group. Predictors in the discontinuation group were diagnosis of schizophrenia, poorer semantic fluency performance, and higher blink rate. Predictors in the continuation group were disinhibition soft signs and more general psychopathology symptoms.

CONCLUSION

Different predictors of relapse were identified for first episode psychosis patients who discontinued and continued maintenance medication. Neurocognitive dysfunctions are important predictors for both groups. While signs of frontal dysfunction and dopamine hyperactivity predict relapse in the discontinuation group, sign of cognitive disinhibition predicts relapse in the continuation group.

A 3-year retrospective cohort study of predictors of relapse in first-episode psychosis in Hong Kong

OBJECTIVE

Relapses in psychosis are costly and may have irreversible consequences. Relapse prevention is thus critical in the treatment of schizophrenia. Apart from medication discontinuation, a consistent relapse predictor has not been identified due to limitations in previous studies. We aim to investigate relapse predictors in a large cohort of patients with first-episode psychosis.

METHOD

This is a retrospective cohort study designed to evaluate relapses in first-episode psychosis patients in 3 years. A total of 1400 patients' case records were retrieved from a hospital database. Potential relapse predictors including demographic variables, baseline clinical measures, medication adherence, and residual positive symptoms upon clinical stabilization were collected.

RESULTS

The cumulative relapse rates were 19.3% by year 1, 38.4% by year 2, and 48.1% by year 3. Multivariate Cox-proportional hazards regression analysis revealed that medication non-adherence, smoking, schizophrenia diagnosis, younger age, and shorter baseline hospitalization were associated with an increased risk of relapse in 3 years.

CONCLUSIONS

Nearly half of patients relapsed after 3 years following their first-episode psychosis. Smoking as a predictor of relapse is an intriguing new finding supportive of a link between nicotinic receptors and the dopamine system. Their relationship deserves further investigations with potential clinical implications for relapse prevention.

Hospitalisation for schizophrenia in acute psychiatric wards of the Lazio region: a 4-year follow-up study

Aim – To determine the rates of psychiatric hospitalisation and to evaluate the predictors of readmissions in a cohort of 887 schizophrenic patients at their “first” psychiatric admission. Methods – Data were collected using the hospital dis-charge database of the Lazio region, Italy. The cohort included patients admitted to a psychiatric ward in 1999, with a main diagnosis of schizophrenia and no prior psychiatric hospitalisation during the 5 years preceding the index admission. Psychiatric read-missions were considered up to year 2004. Kaplan-Meier survival curves and logistic procedures were performed to estimate the cumulative readmission incidence and ORs of readmissions for potential confounders. Results – During the 4-year follow-up, 44.3% of the patients were readmitted at least once. An active treatment among community psychiatric facilities at the time of index admission predicted a higher readmission risk. However, for those who experienced their first admission in a private ward read-mission risk was consistently higher, whether or not having had such a treatment. Conclusions – Risk of readmission in a psychiatric ward appears to be related to the level of integration with mental health community facilities, while length of stay is strongly affected by service system variables. Possible uses of medical information systems in this field are described.

Declaration of Interest: none.

Evidence that better outcome of psychosis in women is reversed with increasing age of onset: a population-based 5-year follow-up study

BACKGROUND

Female gender and later onset of psychosis are both associated with better outcome. However whether their effects are independent, is not known.

METHOD

In 379 incident cases of psychoses, from an epidemiologically defined catchment area, admixture analysis was employed to generate age of onset classes. Five year course and outcome measured across clinical and social domains were used as dependent variables in regression analyses, to estimate associations of outcomes with gender, age of onset and gender by age of onset interaction.

RESULTS

Three age of onset classes were identified: early (14-41 years), late (42-64 years) and very late onset psychosis (65-94 years). Overall, women had better outcomes, including milder delusions, fewer negative symptoms, less deterioration from baseline functioning, fewer hospital readmissions and shorter psychotic episodes. Later age of onset was also associated with better outcome, although in the very late onset class the results were mixed. There was a statistically significant gender by age of onset interaction (in the ratio scale) within this sample with men displaying poorer outcome in the early/late onset class, whereas women tended to have a worse outcome in the very late onset class.

CONCLUSIONS

The favourable outcome in women becomes reversed in old age, suggesting gender-age-related differences in the distribution of aetiological factors for psychosis.

Factors affecting outcome in schizophrenia and their relevance for psychopharmacological treatment

A major focus of current treatment research in schizophrenia is the determinants of long-term outcome, including functional outcome and general medical well being, rather than just specific domains of psychopathology such as positive and negative symptoms, mood symptoms, and cognitive impairment. This focus does not negate the importance of the latter issues but sees them as factors contributing to long-term outcome to variable extents. A long-term treatment focus facilitates a more clinically relevant assessment of benefits versus risks of available treatments. For instance, atypical antipsychotic drugs as a group have clear advantages for several important domains of efficacy that may influence long-term outcome, but are also more expensive over the long term. Use of some agents may also result in deleterious physical health consequences as well as large additional costs over the long term owing to metabolic adverse effects. The present paper focuses on several key issues in schizophrenia which are important determinants of long-term outcome in schizophrenia, or influence choice of antipsychotic drugs, or both, including: (i) duration of untreated psychosis; (ii) impact of relapse on long-term outcome; (iii) limited efficacy for specific domains of psychopathology of current treatments; (iv) mortality owing to suicide; and (v) mortality owing to other causes (e.g. cardiovascular disease).

Social predictors of out-patient mental health contact in schizophrenia patients

INTRODUCTION

Since community-based health care was introduced, the use of mental health services by patients with serious mental disorders has been an issue of much interest. However, our knowledge of intervening factors is both scarce and partial.

OBJECTIVE

To study socio-demographic variables which may predict time-lapse (in days) between each out-patient contact among a cohort of schizophrenia patients.

METHOD

Data comes from the South Granada Schizophrenia Case Register. We used Cox's regression analysis to study the influence of the socio-demographic variables in the time lapsed between out-patient contacts.

RESULTS

After adjusting for all other socio-demographic variables included, we found that to live in a rural area and being younger independently predicted a longer time-lapse between out-patient contacts while being retired predicted a shorter interval between such contacts. Other variables such as sex, educational level and marital status did not determine such length between out-patients contacts.

CONCLUSION

Socio-demographic variables, and not only psychopathological ones, determine mental health out-patient service use.

Modifiable risk factors for hospitalization among people with psychosis: evidence from the National Study of Low Prevalence (Psychotic) Disorders

OBJECTIVE

Relatively little has been published on dynamic, that is, modifiable, as opposed to static risk factors for hospitalization in the research literature on risk factors for hospitalization in serious mental illness. The aim of this study was to develop a model to determine modifiable predictors of hospitalization using data from the Australian National Study of Low Prevalence (Psychotic) Disorders.

METHOD

The Study of Low Prevalence Disorders used a two-phase design to estimate the prevalence of psychoses and identify characteristics of people with psychotic illness. This paper compares people hospitalized at the time of census and those using outpatient services. Logistic regression was used to examine the relative impact of dynamic characteristics including service utilization, symptom profile and risky behaviours on a base model for risk of hospitalization.

RESULTS

In the base model, course of disorder and age but not type of psychosis were significantly associated with hospitalization. Among symptoms, delusions (but not hallucinations) and negative symptoms significantly increased the odds of hospitalization. Service utilization, especially case management, reduced the odds significantly and substantially. Results for risky behaviours (e.g. substance abuse, offending) were ambiguous.

CONCLUSIONS

The results highlight the impact of dynamic factors, particularly case management, over and above static factors in reducing the risk of hospitalization in psychosis, and point to a potential for targeted interventions to avert some of the burden, both emotional and financial, associated with the hospitalization of people with psychotic disorders. These findings have important clinical and policy implications.

Comparison of time to rehospitalization among schizophrenic patients discharged on typical antipsychotics, clozapine or risperidone

BACKGROUND

The purpose of this study was to compare the time to rehospitalization of schizophrenic patients who were discharged from a psychiatric hospital while being treated with typical antipsychotics, clozapine or risperidone. We also assessed other possible predictors of time to rehospitalization.

METHODS

The study monitored the rehospitalization status of all the schizophrenic patients who were discharged from a psychiatric hospital between July 1, 2001 and June 30, 2002 while they were taking typical antipsychotics (n=272), clozapine (n=61) or risperidone (n=49). Rehospitalizations were tracked over a 2-year period using the Kaplan-Meier method. Risk factors associated with rehospitalization were examined by the Cox proportional hazards regression model.

RESULTS

No significant differences in time to rehospitalization were observed among the groups in the first or second year after discharge. Age at onset of schizophrenia was a risk factor for time to rehospitalization over the 1- and 2-year periods.

CONCLUSION

This study demonstrated that atypical antipsychotics did not lengthen the time to rehospitalization. The earlier the age at onset of schizophrenia, the shorter is the time to rehospitalization. Some other factors thought to impact rehospitalization need to be further assayed.

Fostering Recovery from Life-Transforming Mental Health Disorders: A Synthesis and Model

In the past, "recovery" from serious mental health problems has been variously defined and generally considered rare. Current evidence suggests that some form of recovery is both possible and common, yet we know little about the processes that differentiate those who recover from those who do not. This paper discusses approaches to defining recovery, proposes a model for fostering, understanding, and studying recovery, and suggests questions for clinicians, researchers, and policy makers. The proposed model is a synthesis of work from the field of mental health as well as from other disciplines. Environment, resources, and strains, provide the backdrop for recovery; core recovery processes include development, learning, healing, and their primary behavioral manifestation, adaptation. Components facilitating recovery include sources of motivation (hope, optimism, and meaning), prerequisites for action (agency, control, and autonomy), and capacity (competence and dysfunction). Attending to these aspects of the recovery process could help shape clinical practice, and systems that provide and finance mental health care, in ways that promote recovery.

A comparison of olanzapine and risperidone on the risk of psychiatric hospitalization in the naturalistic treatment of patients with schizophrenia

Background

Decreasing hospital admissions is important for improving outcomes for people with schizophrenia and for reducing cost of hospitalization, the largest expenditure in treating this persistent and severe mental illness. This prospective observational study compared olanzapine and risperidone on one-year psychiatric hospitalization rate, duration, and time to hospitalization in the treatment of patients with schizophrenia in usual care.

Methods

We examined data of patients newly initiated on olanzapine (N = 159) or risperidone (N = 112) who continued on the index antipsychotic for at least one year following initiation. Patients were participants in a 3-year prospective, observational study of schizophrenia patients in the US. Outcome measures were percent of hospitalized patients, total days hospitalized per patient, and time to first hospitalization during the one-year post initiation. Analyses employed a generalized linear model with adjustments for demographic and clinical variables. A two-part model was used to confirm the findings. Time to hospitalization was measured by the Kaplan-Meier survival formula.

Results

Compared to risperidone, olanzapine-treated patients had significantly lower hospitalization rates, (24.1% vs. 14.4%, respectively, p = 0.040) and significantly fewer hospitalization days (14.5 days vs. 9.9 days, respectively, p = 0.035). The mean difference of 4.6 days translated to $2,502 in annual psychiatric hospitalization cost savings per olanzapine-treated patient, on average.

Conclusions

Consistent with prior clinical trial research, treatment-adherent schizophrenia patients who were treated in usual care with olanzapine had a lower risk of psychiatric hospitalization than risperidone-treated patients. Lower hospitalization costs appear to more than offset the higher medication acquisition cost of olanzapine.

Influence of gender on social outcome in schizophrenia

OBJECTIVE

To study the relevance of gender on social functioning in schizophrenia.

METHOD

A sample of 200 schizophrenic (DSM-IV criteria) out-patients were followed-up during 2 years and were administered the following instruments: Positive and Negative Symptom Scale (PANSS), Disability Assessment Scale (DAS-sv), and Global Assessment of Functioning (GAF) Scale. A regression model was created with DAS and GAF as dependent variables, and gender, PANSS, age of onset, duration of illness and marital status as independent variables. Separate regression models were then generated for females and males.

RESULTS

Gender influenced significantly on DAS and GAF, with men showing worse functioning. In gender specific analyses, we found a significant influence of illness duration and Positive and Negative PANSS on social functioning in men, and of age at onset and Negative PANSS in women.

CONCLUSION

Gender had a significant influence on social functioning in schizophrenia, even after adjusting for the other independent variables.

Relapse and rehospitalisation rates in patients with schizophrenia: effects of second generation antipsychotics

Recent studies suggest that the risk of relapse in patients with schizophrenia is approximately 3.5% per month. Predictors of more frequent relapses include poor compliance with antipsychotic drug treatment, severe residual psychopathology, poor insight into the illness and the need for treatment, comorbid substance abuse, and poor relationships between patients, families and care providers. Although conventional antipsychotic drugs, such as haloperidol and fluphenazine, are effective in preventing relapse, second generation antipsychotic drugs, such as clozapine, risperidone and olanzapine, appear to be superior in preventing relapse and improving the patient's quality of life. The development of adverse events can undermine treatment response and relapse prevention. Minimising adverse effects thus helps to improve treatment compliance and prevent relapse. Second generation antipsychotic drugs tend to have fewer adverse effects than conventional agents, especially pseudoparkinsonism and akathisia. The societal costs of treating patients with schizophrenia can be lessened by employing strategies that decrease relapse and the need for rehospitalisation, the most costly treatment alternative.