Social conditions in a total population with long-term functional psychosis in three different areas of Stockholm County

Clients with long-term mental disabilities in a Swedish county—conditions of life, needs of support and unmet needs of service provided by the public health and social service sectors

Objective

The purpose of the study was to identify and describe conditions of life and needs of support and public service for clients with a mental disability in a Swedish county population.

Methods

Public health care and social service providers identified clients and completed a questionnaire concerning the clients’ conditions of life and their special needs. A consecutively recruited sample of clients completed a similar questionnaire.

Results

Totally, 1261 clients were identified. The prevalence of clients with mental disabilities was in the urban and rural areas, 6.4/1000 inhabitants and 4.5/1000 inhabitants, respectively. The most prevalent unmet need (42.9%) was to participate in social and scheduled activities. Almost half of the group was reported to need support in activities of daily living. Clients living in urban settings more often needed support with activities of daily living (P < 0.001), whereas clients living in rural settings more often needed support with job training (P < 0.001) or finding work (P < 0.01). Clients and psychiatric care providers reported the needs of the clients in the same areas; however, clients reported a fewer number of needs than did the care providers.

Conclusions

By using both psychiatric care and social service providers, effective case findings of clients with a mental disability were possible to achieve. In general, there was high agreement between psychiatric care providers and clients regarding the clients’ number of needs of support and their unmet needs of service. However, at the individual level, the agreement between client and psychiatric care providers was lower.

The ICD-10 and DSM-IV diagnostic criteria and the prevalence of schizophrenia

In the present study, all patients who met the diagnostic criteria for a long-term functional psychosis (LFP) were identified within a defined uptake area in the northern part of the county of Uppsala, Sweden. LFP includes patients 1) with productive psychotic symptomatology, not caused by organic disease, for 1 week or more, at least once during the course of the illness; 2) having been affected by a psychosis for a continuous period of at least 6 months on the same occasion; 3) having shown psychotic features or residual symptoms during the index year; and 4) older than 18 years of age. Primarily, all diagnoses were made according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III-R. The prevalence of schizophrenia was 4.2 per 1,000 inhabitants. The prevalence of schizoaffective disorder was 0.7 per 1,000 inhabitants and for delusional disorder, 0.1 per 1,000 inhabitants. When the patients were rediagnosed according to DSM-III, DSM-IV and International Statistical Classification of Disease (ICD)-10, it was found that the prevalence of schizophrenia, schizoaffective disorder and delusional disorder was somewhat lower according to the DSM-III criteria, while the same number of patients fulfilled the criteria according to DSM-IV. If ICD-10 was used, it resulted in a broader concept of schizophrenia and a somewhat more narrow concept of schizoaffective disorder. Thus, the introduction of the new parallel diagnostic systems, ICD-10 and DSM-IV, will result in different, but comparable, prevalence estimates concerning schizophrenia, schizoaffective disorder and delusional disorder.

Needs assessed by psychiatric health care and social services in a defined cohort of clients with mental disabilities

BACKGROUND

The identification of needs for support and service in clients with long-term mental disabilities is usually not done by staff personnel from both psychiatric care and social services. However, such a process is probably necessary in order to provide adequate psychiatric care and social services.

AIMS

To estimate the prevalence of mentally disabled clients and investigate whether staff from psychiatric care and social services identified the same individuals and the same number of needs in the same areas.

METHODS

Clients from a defined catchment area were identified during a three-month period. A questionnaire was developed to collect socio-demographic information and to assess needs for support and service.

RESULTS

The study identified 1,290 clients with needs with a prevalence of 5.72/1000 inhabitants. More than half of the clients needed support in activities of daily living. Only 18.1% of the clients were identified by both organizations. In general, the staff from psychiatric care and social services identified the same needs at a group level. However, at the individual level, agreement was quite low.

CONCLUSIONS

The staffs from both psychiatric care and social services are necessary to evaluate the needs of support and services in clients with mental disabilities.

The Need of Support and Service Questionnaire (NSSQ): a brief scale to assess needs in clients with long-term mental disabilities

We present the Need of Support and Service Questionnaire (NSSQ), a new instrument developed to provide professionals in psychiatric care and community social services with a tool to assess needs of support and service in mentally disabled clients. The final version of the instrument was designed after comments from professionals in psychiatric care, community social services, and the clients and their relatives. A reliability study (test-retest, n=77), inter-rater (n=69) and a validity study (n=529) were performed. In the validity study, comparisons were done with the Camberwell Assessment of Need (CAN) scale, the Global Assessment of Functioning (GAF) scale and the Social and Occupational Functioning Assessment Scale (SOFAS). The test-retest and inter-rater reliability were 0.86 and 0.76, respectively. The percentage of agreement on the individual items ranged from 83.1% to 100.0% (test-retest) and 76.8% to 100.0% (inter-rater reliability). The corresponding kappa coefficients ranged from 0.63 to 1.00 (test-retest) and 0.33 to 1.00 (inter-rater reliability). The comparison between NSSQ and CAN items demonstrated high sensitivity and specificity as well as satisfactory likelihood ratios (LRs). The correlations between GAF and SOFAS scores and the number of needs of support, number of needs of service and the total number of needs of support and service were -0.49, -0.32 and -0.47, and -0.48, -0.26 and -0.45, respectively. All correlations were statistically significant (P<0.01). The results demonstrated that the psychometric characteristics of the NSSQ were satisfactory. Moreover, professionals without any formal training easily used it.

Effect of second-generation antipsychotics on employment and productivity in individuals with schizophrenia: an economic perspective

Schizophrenia is a serious mental illness that imposes a considerable burden not only on those who are ill, but also on their families, neighbours and the wider society. Costs associated with treating people with schizophrenia are those derived from the use of a wide range of services provided by public psychiatric facilities and/or by voluntary and private agencies. In addition, a large part of the economic impact of schizophrenia is related to the difficulties that patients encounter in finding and keeping paid employment. The introduction of second-generation antipsychotics (SGAs), also defined as atypicals, has increased the therapeutic options available for individuals with schizophrenia. Potential benefits of these agents include a more favourable profile in terms of positive and negative symptoms, less adverse effects and better cognitive functioning than first-generation antipsychotics (FGAs). As a consequence, SGAs might favourably affect the capacity, seriously impaired in schizophrenia, of finding and keeping paid employment. To date, only 13 published studies have investigated the effect of SGA agents on employment and work productivity. Clozapine was studied in eight studies, while both olanzapine and risperidone were studied in three. Clozapine emerged as the SGA with at least some effect on work status. However, all but one clozapine study enrolled only a few individuals and did not adopt an experimental design, making it very difficult to judge the validity and generalisability of findings. Taken together, studies found little benefit, in terms of employment and work productivity, for the use of SGAs compared with FGAs. The evidence available suggests that until data demonstrate a robust effect of newer agents on employment, it remains mandatory for mental health professionals to use the most effective drug treatment together with non-pharmacological interventions, such as vocational rehabilitative programmes nested into models of community psychiatric care, which have proven effect on the capacity of finding and keeping paid employment. This will ensure that the economic impact of schizophrenia is most effectively contained.

Anxiety and substance use comorbidity among inpatients with schizophrenia

OBJECTIVE

To determine the association between lifetime anxiety symptoms and anxiety disorders and substance use disorders among patients with schizophrenia.

METHOD

Participants were 184 inpatients with schizophrenia at the Schizophrenia Research Unit (SRU) at the New York State Psychiatric Institute (NYSPI). Multivariate logistic regression analyses were used to determine the relationship between specific anxiety symptoms and anxiety disorders and substance use disorders among inpatients with schizophrenia.

RESULTS

Anxiety symptoms and anxiety disorders were prevalent among 31.5% of the sample. Panic attacks were associated with a significantly increased odds (OR=7.4 (1.2, 47.1)) of comorbid alcohol or substance use disorders (lifetime). This association was specific to panic attacks and persisted after adjusting for differences in sociodemographic characteristics and comorbid anxiety symptoms and anxiety disorders.

CONCLUSIONS

These findings are consistent with and extend previous data by providing evidence of an association between panic attacks and increased likelihood of substance use disorders among inpatients with schizophrenia. Future studies that determine the nature of this relationship, the sequence of symptom onsets, and examine whether treatment of anxiety can influence the onset or outcome associated with substance use are needed.

Patient compliance with drug therapy in schizophrenia. Economic and clinical issues

The effectiveness of drug treatment in clinical practice is considerably lower than the efficacy shown in controlled studies. The lower effectiveness in practice presumably leads to lower cost effectiveness of drug treatment in real-life situations compared with that demonstrated by studies based on results from controlled trials. Improved cost effectiveness in routine clinical practice would be a significant advantage in the treatment of schizophrenia, one of the most costly diseases in society. The aetiology of schizophrenia is unknown, and there is no cure. The main aims of therapy with antipsychotic medication include the effective relief of symptoms without the introduction of adverse effects or serious adverse events, improved quality of life, cost effectiveness and a positive long term outcome. The older classical antipsychotic drugs do not always meet these requirements because of their well-known limitations, such as a lack of response in a subgroup of individuals with schizophrenia and intolerable adverse effects. There has long been a need for new antipsychotics that can ameliorate more symptoms and have no or few adverse effects. Some of the recently introduced antipsychotics have been shown to be more effective in certain clinical situations and to have a more favourable adverse effect profile than the classical antipsychotics. A major factor contributing to the lower effectiveness of drug treatment is noncompliance, which may be very high in schizophrenia. There are several factors influencing compliance, including drug type and formulation, patient, disease status, physician, health care system, community care and family. There have been very few studies of compliance improvement strategies in schizophrenia or, indeed, in medicine in general. Current methods are relatively complex and there are differing opinions on their effectiveness. There are several ways to increase compliance in schizophrenia--the evidence is strongest for psychoeducative methods, changing to a new drug or using a depot formulation. However, considerably more research is needed in the field of compliance strategies.

Rationale and design. PRiSM Psychosis Study I

BACKGROUND

This paper sets out the rationale for the PRiSM Psychosis Study, and the research design used. Nine accompanying papers present the main results. The questions addressed by the PRiSM Psychosis Study are: can the gains of experimental studies which have demonstrated benefits arising from treatment by community mental health teams be translated to routine settings? If so, are the benefits diluted in ordinary clinical practice? What are the costs?

METHOD

A prospective nonrandomised controlled trial of two types of community mental health service, in two phases: case identification followed by patient interviews. For the case identification the research team conducted the complete ascertainment of all prevalent cases of psychosis in the two study catchment areas in the index year (1991-1992). From all 514 patients with psychotic disorders thus identified, 302 were randomly allocated for interview, along with a key informant clinician and a carer. Interviews were under taken at two time points, two years apart.

RESULTS

This paper presents the socio-demographic, clinical and ethnic characteristics of the patients.

CONCLUSIONS

The people with psychosis interviewed for the PRiSM Psychosis Study are representative of the whole epidemiologically based patient population identified.

One-year prevalence of long-term functional psychosis in three different areas of Uppsala

The 1-year prevalence of long term functional psychoses (LFP) in Uppsala was found to be 0.73%, with a clear gradient from the central city area (0.87%) to the rural area (0.60%). The highest prevalence was found in the 35-54 years age group (1.01%), and the lowest prevalence in the 18-34 years age group (0.45%). There were no pronounced sex differences. The majority of the LFP patients were diagnosed as having schizophrenia. The 1-year prevalence of schizophrenia was 0.42%, with a clear gradient from the central city area to the rural area (0.53%, 0.44% and 0.30%, respectively). The same gradient was not observed with regard to the other diagnostic subgroups relating to LFP.