Factors affecting rehospitalisation rates of chronic schizophrenic patients living in the community

Use of psychiatric inpatient services by heavy users: Findings from a national survey in Italy

Purpose

To analyze factors associated with a patient's probability of being a Heavy User (HU) of inpatient psychiatric services and to compare the HU inpatient population with Non-Heavy Users (NHUs).

Patients and methods

The survey was conducted among inpatients enrolled in the PROGRES-Acute-project, an Italian nationwide survey of public and private inpatient facilities. Patients with three or more admissions over the last 12 months were considered HUs, and patients who had undergone one or two admissions during the same period made up the NHU group.

Results

Four hundred and thirty-five (40.5%) were HUs, and 640 (59.5%) NHUs. HUs were younger, more frequently unmarried, unemployed, receiving a disability-pension, and either homeless or living in a residential facility. HUs were more likely to have experienced conflicts with their partners or family members during the week prior to admission. A logistic regression analysis revealed that age, age at first admission, number of life-time admissions, and having been the victim of violence were the most important predictive factors for the HU phenomenon.

Conclusion

Our study suggests that specific attention should be given to patients’ family context, due to its crucial role in daily informal care and in the triggering of events leading to rehospitalization.

Five-year rehospitalization experience of a state-wide cohort of persons with schizophrenia

PURPOSE

This study has the objective of assessing the psychiatric rehospitalization experience of a large cohort of persons with schizophrenia and modeling the effects of personal and systemic conditions on rehospitalization risk.

METHODS

The study employs a secondary analysis of US data from Massachusetts' casemix database of all patients discharged from acute general hospital units. It focuses on 11,291 patients during 1994-2000 who were discharged from acute adult psychiatric units. Predictors used include basic demographics, length of stay, continuity of care with doctors and facilities, diagnoses, discharge referral, type of insurance, and distance to and selected socioeconomic characteristics of the patient's home zip code. Data are analyzed with descriptive statistics and modeled with the Cox proportional hazard model. The model was assessed through split-half reliability testing, the generalized R², and Harrell's Concordance Index.

RESULTS

Overall, 13.4% of patients were rehospitalized within 1 month; 38.9% within 1 year; and 64.1% within 5 years. Predictors that are most strongly associated with lower rehospitalization rates include continuity of care, discharge to a chronic hospital, and density of home zipcode, whereas discharge to another acute psychiatric unit had the greatest effect on increasing risk of rehospitalization. Overall the Cox model has generalized R² of 0.343 and a Concordance Index of 0.734.

CONCLUSIONS

The results highlight the need to enhance the continuity of the relationships with providers, whether these are with the assigned psychiatrists or other therapists and case managers, as well as workplace issues involving staff turnover and hospital assignment and admitting policies.

Long-acting antipsychotic drugs for the treatment of schizophrenia: use in daily practice from naturalistic observations

BACKGROUND

Current guidelines suggest specific criteria for oral or long-acting injectable antipsychotic drugs (LAIs). This review aims to describe the demographic and clinical characteristics of the ideal profile of the patient with schizophrenia treated with LAIs, through the analysis of nonrandomized studies.

METHODS

A systematic review of nonrandomized studies in English was performed attempting to analyze the factors related to the choice and use of LAIs in daily practice. The contents were outlined using the Cochrane methods for nonrandomized studies and the variables included demographic as well as clinical characteristics. The available literature did not allow any statistical analysis that could be used to identify the ideal profile of patients with schizophrenia to be treated with LAIs.

RESULTS

Eighty publications were selected and reviewed. Prevalence of LAI use ranged from 4.8% to 66%. The only demographic characteristics that were consistently assessed through retrieved studies were age (38.5 years in the 1970's, 35.8 years in the 1980's, 39.3 years in the 1990's, to 39.5 years in the 2000's) and gender (male > female).Efficacy was assessed through the use of various symptom scales and other indirect measurements; safety was assessed through extrapyramidal symptoms and the use of anticholinergic drugs, but these data were inconsistent and impossible to pool. Efficacy and safety results reported in the different studies yielded a good therapeutic profile with a maximum of 74% decrease in hospital admissions and the prevalence of extrapyramidal symptoms with LAIs consistently increased at 6, 12, 18, and 24 months (35.4%, 37.1%, 36.9%, and 41.3%, respectively).

CONCLUSIONS

This analysis of the available literature strongly suggests that further observational studies on patients with schizophrenia treated with LAIs are needed to systematically assess their demographic and clinical characteristics and the relationships between them and patient outcome.Besides the good efficacy and safety profile of LAIs, health care staff must also take into account the importance of establishing a therapeutic alliance with the patient and his/her relatives when selecting the most appropriate treatment. LAIs seem to be a good choice not only because of their good safety and efficacy profile, but also because they improve compliance, a key factor to improving adherence and to establishing a therapeutic alliance between patients with schizophrenia, their relatives, and their health care providers.

Role of the community pharmacist in the care of patients with chronic schizophrenia in the community

This study, using a postal questionnaire, investigated the involvement of 534 community pharmacists with patients suffering from schizophrenia. The majority of the 236 respondents regularly dispensed medication for patients with schizophrenia and almost three-quarters had been asked for advice about medication from such patients or their carers. However, the majority of respondents believed that the advice they could give to these patients was limited by their knowledge of schizophrenia (86 per cent) and of therapeutics (70 per cent). Other perceived constraints to giving advice included lack of contact with other health professionals, poor communication skills and lack of experience in dealing with the mentally ill. Respondents were significantly less confident about advising patients with schizophrenia than advising other patient groups. The results suggest that there is a need to encourage community pharmacists' participation in continuing education and to improve liaison with other community health professionals such as community psychiatric nurses.

Admission intervention team: medical center based intensive case management of the seriously mentally ill

The purpose of this study was to investigate the effect a medical center based intensive case management team had on utilization of inpatient psychiatric treatment. A frequent user of inpatient psychiatric hospitalization was defined as any patient who had 3 or more admissions during the 12 months prior to referral to the program. A within-subjects design was used comparing rates of hospital admissions and hospital days before and after program enrollment for 185 patients in the program for 1 year, and for 50 of those patients in the program for 7 years. Cost savings across program years 1992 through 2000 were calculated using inpatient per diem rates. The number of admissions, length of stay, and cost of care were significantly reduced during the study period. The results of this study clearly demonstrate that a medical center based intensive case management team can significantly reduce admissions, length of stay, and the cost of care of frequent users of hospital inpatient services. Development of a true multidisciplinary team, enhancement of medication and treatment compliance, and a team case management model were the factors suggested as contributing to the success of this treatment program.

Cannabis and neurological soft signs in schizophrenia: absence of relationship and influence on psychopathology

BACKGROUND

Cannabis is a possible risk factor for the onset of schizophrenia and can induce neurocognitive, behavioural and motor co-ordination alterations. The aim of this study was to evaluate the role of cannabis in the occurrence of neurological soft signs (NSS) and, considering that this drug has been related to positive symptoms, whereas NSS have been linked to negative symptoms, we also examined the role of clinical features.

METHODS

The study investigated NSS in 25 male cannabis-consuming and 25 male non-consuming schizophrenic patients, using the Neurological Evaluation Scale. Clinical features were studied using SANS and SAPS.

RESULTS

Significant differences emerged after comparison analysis, with more NSS in non-consuming patients. The SANS subscales Alogia and Anhedonia-asociality were also statistically significant in this group of patients.

DISCUSSION

If non-consuming patients show a higher incidence of both NSS and negative symptoms, which, according to the literature, seem to be associated, then these findings suggest that NSS are relatively independent from cannabis, but not from clinical features.

Effects of cannabis abuse on people with serious mental health problems

There is clear evidence of illicit drug abuse in psychiatric hospitals (Deahl, 1991), and illicit drug use has been associated with relapse in people with serious mental health problems. Cannabis abuse in the general population is common and has both desirable and undesirable effects on users. However, when cannabis is used by people with serious mental health problems, a more pronounced effect may be seen. There is little evidence to suggest that cannabis 'causes' schizophrenia, but its abuse may prove to be a trigger in vulnerable individuals. Studies have demonstrated that cannabis abuse can exacerbate the symptoms of schizophrenia and may reduce the effectiveness of antipsychotic drugs. Mental health nurses need to develop interventions in order to manage illicit drug abuse effectively in both the hospital and community settings.

Ten-year course of schizophrenia--the Madras longitudinal study

Ninety first-episode patients fulfilling ICD-9 criteria for schizophrenia were followed up prospectively for 10 years. Complete assessments were possible on 76. The pattern of illness was good in 67% of the cases, and the commonest patterns was one with recurrent episodes. Predictors of poor course and longer time spent in psychosis were identified. All positive and negative symptoms showed a steep decline at the end of 10 years. The results are discussed in the context of longitudinal research on the course of schizophrenia in developing countries.