Living situation, social network and outcome in schizophrenia: a five-year prospective follow-up study

Sources of social support and clinical and functional evolution of people with schizophrenia

PURPOSE

The impact of social support on comprehensive measures of results (clinical and functional) of the course of schizophrenia was studied, understood and evaluated as a multidimensional construct differentiating sources of support (family vs. nonfamily).

METHODS

One hundred fifty-two patients diagnosed with schizophrenia were assessed with the Mannheim Interview on Social Support (MISS) and the Social Functioning Scale (SFS). The hypotheses were explored in a prospective longitudinal design, using a causal correlational analysis for their evaluation by applying structural equation models.

RESULTS

The only explanatory factor of social functioning was Nonfamily social support, while the only explanatory factor of clinical result measurements was Family social support, observing a clearly differentiated impact of the different sources of support on the schizophrenia result measurements. It was also found that while Family social support explained 6.8% of the variance in the clinical result measurements, Nonfamily social support explained 13.7% of the variance in social functioning.

CONCLUSION

The results confirmed the differential importance of social support variables (family vs. nonfamily) in the clinical and functional result measurements of people with schizophrenia.

A Scoping Review of Measures Used in Early Intervention Services for Psychosis

OBJECTIVE

The early intervention service (EIS) model for psychosis has been implemented with increasing frequency; yet, improving outcomes across domains for all patients remains challenging. Measurement-based care can strengthen outcomes by optimizing interventions and promoting alignment with standards, but it is still not widely deployed in EIS. The authors conducted a scoping review by systematically identifying and synthesizing measures used in EIS related to purpose (i.e., to assess patients, families, and programs), domains (e.g., symptoms, quality of life), and reporting perspectives (of patients, families, and clinicians).

METHODS

EMBASE, MEDLINE, PsycINFO, CINAHL, and Cochrane Library databases were searched for pertinent literature published between 2000 and 2020. Two reviewers independently screened titles, abstracts, and full texts and extracted data. Measures were classified as clinician-reported outcome measures (CROMs), patient-reported outcome or experience measures (PROMs/PREMs), or family-reported outcome or experience measures (FROMs/FREMs).

RESULTS

In total, 172 measures of 27 domains were identified from 115 articles. Nineteen measures had been used to assess programs on fidelity, service engagement, and satisfaction; 136 to assess patients on duration of untreated psychosis, symptoms, functioning, quality of life, and others; and 17 to assess families on coping and burden, background, and others. Sixty percent were CROMs, 30% were PROMs/PREMs, and 10% were FROMs/FREMs.

CONCLUSIONS

Greater inclusion of PROMs and FROMs is needed because they align with the EIS philosophy of patient and family engagement and may improve shared decision making and outcomes. A comprehensive, meaningfully synthesized archive of measures can advance measurement-based care, services research, and data harmonization in early psychosis.

Social Networks and Residential Status in Community-Dwelling Older Adults With Schizophrenia: Compensation by Reconfiguration?

OBJECTIVE

To address the paucity of data on the structure and content of social networks of older adults with schizophrenia (OAS).

METHODS

The OAS group comprised 249 persons aged 55 and older with early-onset schizophrenia living in supportive housing (SS; n = 151), independently (SI; n = 70), or with family (SF; n = 28). The community comparison (CC) group comprised 113 individuals. Social network analysis was used. Multinomial logistic regression with p ≤0.001 and p ≤0.05 was used for overall and pairwise comparisons, respectively.

RESULTS

Each OAS subgroup had more total, nonkin, and formal linkages than the CC group. The SS and SI subgroups had fewer kin linkages than the CC group. The CC group had more confidants than the SS subgroup, more reliable linkages than the SS and SI subgroups, and more sustenance linkages than each of the OAS subgroups. Nearly everyone in the CC, SI, and SF subgroups had a confidant, a reliable contact, and a sustenance linkage; 33% of the SS subgroup had no confidants. The SS subgroup displayed more psychiatric symptoms than the SI and SF subgroups. There were no differences in loneliness or relationship satisfaction between the CC and the schizophrenia subgroups.

CONCLUSION

Networks were expressed differentially across residential arrangements and differences may reflect dissimilarities in psychiatric functioning. OAS generally had ample levels of companionship and emotional and instrumental support, often comparable to their age peers. Whereas social networks typically decline at illness onset and may be predominantly family-focused, later life may be a time of network reconfiguration and reconstitution.

Satisfaction with social connectedness as a predictor for positive and negative symptoms of psychosis: A PHAMOUS study

PURPOSE

This study examines satisfaction with social connectedness (SSC) as predictor of positive and negative symptoms in people with a psychotic disorder.

METHODS

Data from the Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS) was used from patients assessed between 2014 and 2019, diagnosed with a psychotic disorder (N = 2109). Items about social connectedness of the Manchester short assessment of Quality of Life (ManSA) were used to measure SSC. Linear mixed models were used to estimate the association of SSC with the Positive and Negative Syndrome Scale (PANSS) after one and two years against α = 0.01. Analyses were adjusted for symptoms, time since onset, gender and age. Additionally, fluctuation of positive and negative symptom scores over time was estimated.

RESULTS

The mean duration of illness of the sample was 18.8 years (SD 10.7) with >65% showing only small variation in positive and negative symptoms over a two to five-year time period. After adjustment for covariates, SSC showed to be negatively associated with positive symptoms after one year (β = -0.47, p < 0.001, 95% CI = -0.70, -025) and two years (β = -0.59, p < 0.001, 95% CI = -0.88, -0.30), and for negative symptoms after one year (β = -0.52, p < 0.001, 95% CI = -0.77, -0.27). The prediction of negative symptoms was not significant at two years.

CONCLUSION

This research indicates that interventions on SSC might positively impact mental health for people with psychosis. SSC is a small and robust predictor of future levels of positive symptoms. Negative symptoms could be predicted by SSC at one year.

Associations of living arrangements with symptoms and functioning in schizophrenia

BACKGROUND

Living arrangements and accommodation are closely related, but no study had concurrently investigated their associations with outcomes in schizophrenia. This study seeks to describe and compare socio-demographic, clinical and functioning profiles of people with schizophrenia in different living arrangements and accommodation, and to examine the associations of living arrangements and accommodation with symptomatic remission and functioning.

METHODS

Community dwelling outpatients with schizophrenia (n = 276) were inquired on living arrangements, accommodation, socio-demographics and assessed on the Positive and Negative Syndrome Scale (PANSS) and the Social and Occupational Functioning Scale (SOFAS). Socio-demographics, symptoms and functioning of outpatients in different living arrangements and accommodation were compared. Symptomatic remission was investigated using logistic regression with living arrangements, socio-demographics and clinical variables as independent variables. Functioning was investigated using multiple regression with the same set of independent variables and the addition of PANSS factors. The same analyses were conducted with accommodation as independent variable.

RESULTS

185 (67.03%) participants lived with family and 195 (70.65%) participants lived in owned accommodation. People living with their spouses had significantly higher SOFAS, lower PANSS Total and PANSS Positive than people living with family, independently, or in rehabilitation centres. They also had lower PANSS Negative than people living with family and a higher likelihood to have achieved symptomatic remission. Types of accommodation was not associated with symptoms, symptomatic remission, and functioning.

CONCLUSION

Living arrangements, but not types of accommodation, were associated with symptoms and functioning in schizophrenia. Family education and support is important to help maintain a conducive environment for people with schizophrenia. People living independently may need more support.

The challenges and opportunities of social connection when hearing derogatory and threatening voices: A thematic analysis with patients experiencing psychosis

OBJECTIVES

Relationships with other people are important determinants of the course of psychosis, yet social isolation is common. This study sought to learn about the patient experience of being around other people when hearing derogatory and threatening voices (DTVs).

DESIGN

A qualitative interview study.

METHODS

Fifteen participants with experience of hearing DTVs in the context of non-affective psychosis were recruited from NHS services. Data were obtained by semi-structured interviews and analysed using thematic analysis.

RESULTS

Three themes were identified: (1) reasons why interacting with people is difficult when hearing DTVs; (2) the relationship between social connection and DTVs; and (3) factors which enable voice hearers to connect with others. A further ten sub-themes are outlined as reasons why hearing DTVs led to lower social connection, including difficulties during conversations (e.g., the concentration required is hard), negative expectations of interactions (e.g., fearing negative judgement from others), and difficulties sharing experiences of voices (e.g., people will be hurt or upset if I tell them about the voices). Isolation was a common response to hearing DTVs but also a time of vulnerability for hearing voices. Managing the challenges of interacting with people led to some improvements in DTVs.

CONCLUSIONS

There are understandable reasons why hearing DTVs leads to lower social connection. Yet isolating oneself can also be a time of vulnerability for DTVs. Social connection might be one vehicle for disengaging from and disputing derogatory and threatening voice content. The effect on voice hearing of social recovery interventions warrants further investigation.

PRACTITIONER POINTS

Participants shared 10 reasons why being around people is challenging when hearing derogatory and threatening voices. These typically affected both daily social experiences and contact with clinicians. Common initial responses to hearing DTVs were to reduce contact with people, experience difficulties connecting during conversations and to avoid sharing the experience of voice hearing. However, social isolation was a time of vulnerability to DTVs, and hence, increasing social connection might be a target for interventions. A range of factors enabled voice hearers to manage social situations, for example: the fostering of trust, self-acceptance, learning when it is better to stay at home, and developing a narrative to explain voice hearing to others. Addressing the barriers to connecting with others might have an important role in personal recovery from voice hearing.

The influence of romantic relationships on mental wellbeing for people who experience psychosis: A systematic review

PURPOSE

Whilst it is generally accepted that supportive relationships facilitate recovery from psychosis, much less is known about the role of romantic relationships in people with psychosis. This review aimed to synthesise quantitative literature regarding the impact of romantic relationships on the mental health and general wellbeing of people who experience psychosis.

METHOD

A systematic review of electronic databases (PsychINFO, PubMed, Web of Science) was carried out using search terms relating to psychosis and romantic relationships. Papers were selected for inclusion by independent reviewers. Quality assessment was completed and a narrative synthesis produced.

RESULTS

Fifty-eight studies reporting the association between romantic relationships and psychotic symptoms, depression, posttraumatic stress disorder, suicidality, quality of life, satisfaction with life and self-esteem were included. Results were mixed but indicated having a romantic partner may be associated with reduced positive and negative symptoms of psychosis, but increased depressive symptoms. Tentative explanations for these findings, such as functioning prior to onset of psychosis, social support and relationship quality are explored.

CONCLUSION

Findings highlight the importance of this often-overlooked area in clinical practice. Studies with robust design, which specifically aim to understand the relationship between romantic relationships and wellbeing for people who experience psychosis are needed.

UP'S: A Cohort Study on Recovery in Psychotic Disorder Patients: Design Protocol

Recovery is a multidimensional concept, including symptomatic, functional, social, as well as personal recovery. The present study aims at exploring psychosocial and biological determinants of personal recovery, and disentangling time-dependent relationships between personal recovery and the other domains of recovery in a sample of people with a psychotic disorder. A cohort study is conducted with a 10-year follow-up. Personal recovery is assessed using the Recovering Quality of Life Questionnaire (ReQoL) and the Individual Recovery Outcomes Counter (I.ROC). Other domains of recovery are assessed by the Positive and Negative Symptom Scale Remission (PANSS-R), the BRIEF-A and the Social Role Participation Questionnaire-Short version (SRPQ) to assess symptomatic, functional and societal recovery, respectively. In addition, multiple biological, psychological, and social determinants are assessed. This study aims to assess the course of personal recovery, and to find determinants and time-dependent relationships with symptomatic, functional and societal recovery in people with a psychotic disorder. Strengths of the study are the large number of participants, long duration of follow-up, multiple assessments over time, extending beyond the treatment trajectory, and the use of a broad range of biological, psychological, and social determinants.

Social support and clinical and functional outcome in people with schizophrenia

PURPOSE

The impact of Social Support (SS) on the clinical and functional evolution of patients diagnosed with schizophrenia was studied from a multidimensional concept of SS in the framework of the vulnerability-stress model.

METHODS

In total, 152 patients diagnosed with schizophrenia according to the International Classification of Diseases, Tenth Edition (ICD-10) treated in a Community Mental Health Unit were assessed using the Mannheim Interview on Social Support (MISS) and the Brief Psychiatric Rating Scale (BPRS). Then they were followed up for 3 years with a final assessment for the period using the Social Functioning Scale. The impact of SS was explored in clinical and functional measurements with a multiple regression analysis in a 3-year longitudinal prospective design.

RESULTS

The quality of Global Social Support (GSS) and satisfaction with GSS appeared to be protective factors from frequency and duration of hospital admissions, with explanatory intensity varying from 9% in survival time to relapse to 13% in number of relapses. Concerning functional measurements, GSS quantity, quality and satisfaction showed an explanatory power for several different dimensions of social functioning, varying from 12% in isolation to 20% in communication.

CONCLUSION

The results confirm SS as a protective factor in the evolution of schizophrenia patients and enable the SS variables with the most explanatory power in their clinical and functional evolution to be identified.

Needs of Patients with Schizophrenia Among an Ethnic Minority Group in Latin America

The aim of the study is to describe the need profile of outpatients with schizophrenia belonging to an Aymara ethnic group in Latin-America and to compare that profile to non-Aymara patients. A sample of 253 patients were evaluated with the Two-Way Communication Checklist (2-COM Checklist) measuring the needs and satisfaction of the patient; Positive and Negative Syndrome scale for Schizophrenia (PANSS) and Attitude to the Drugs (DAI-10). No significant differences were found between Aymara and non-Aymara, either in the total number of needs or in the subscales of satisfaction or in the types of needs. After adjustment for socio-demographic and clinical factors, patients with higher severity (PANSS) had higher number of needs and lower level of satisfaction. Higher score on DAI-10 is related to a higher total number of needs and better satisfaction with medication. Age, sex, ethnicity and employment were also associated with specific needs. The profile of the needs of schizophrenic Aymara patients does not differ from that of non-Aymara patients, and that in both groups it is necessary that the treatment primarily address symptom management and the subjective aspects of quality of life.

Social inclusion and relationship satisfaction of patients with a severe mental illness

BACKGROUND

Research suggests that patients with a severe mental illness (SMI) are among the most social excluded in society. However, comparisons of social network composition and relationship satisfaction between SMI patients and a control group are rare.

AIMS

Our aim was to compare differences in size, satisfaction and composition of the social network between patients with SMI and a control group. Potential sociodemographic and clinical risk factors in relation to social network size in SMI patients were explored.

METHODS

The sample consisted of a control group ( N = 949) and SMI patients ( N = 211) who were under treatment in Dutch mental health care institutions. In these groups, network size, relationship satisfaction, sociodemographic and clinical (patients only) characteristics were assessed.

RESULTS

Social network size was 2.5 times lower in SMI patients, which was also reflected in a lower relationship satisfaction. The composition of the social network of SMI patients differs from that of controls: patients' network seems to consist of a smaller part of friends. Different risk factors were associated with the impoverishment of the social network of family, friends and acquaintances of patients with SMI.

CONCLUSION

SMI patients have very small networks compared to controls. This may be a problem, given the ongoing emphasis on outpatient treatment of SMI patients and self-dependence. This outcome advocates for more attention to social isolation of SMI patients and involvement of family in the treatment and aftercare of SMI patients.

Social network, recovery attitudes and internal stigma among those with serious mental illness

BACKGROUND

Social network size and strength is an important determinant of overall health.

AIMS

This study describes the extent and strength of the social network among a sample of individuals with serious mental illness (SMI) and explores the relationship between an individual's social network and their experience of internal stigma and recovery attitudes.

METHODS

Over a 2-year period, consecutive new patients with SMI attending two community mental health clinics were recruited and interviewed using a comprehensive battery of assessments including assessment of internalized stigma, recovery attitudes and symptom severity.

RESULTS

Among the 271 patients interviewed, social network size was small across all diagnostic categories. In adjusted results, the number of friends and support from relatives and friends was significantly related to the personal confidence and hope recovery attitude ( p < .05). The number of relatives and friends and support from relatives was significantly related to internalized stigma ( p < .05). Frequency of contact with relatives or friends was not related to either recovery factors or internalized stigma.

CONCLUSION

There is a significant positive relationship between the size and perceived strength of an individual's social network and internalized stigma and some recovery attitudes. Clinical programs that address any of these factors could potentially improve outcomes for this population.

Anticipation and experience of emotions in patients with schizophrenia and negative symptoms. An experimental study in a social context

Negative symptoms play a central role in the impairment of social functioning in schizophrenia. Healthy individuals use anticipated emotions to guide their decisions to seek out social interactions. It is unknown whether social withdrawal in negative symptoms is related to a biased anticipation of emotions that will arise in social situations. This study thus examined differences between patients with negative symptoms of schizophrenia and healthy controls in the anticipation and experience of positive and negative emotions related to a social interaction. In a between-subject factorial design, participants were instructed to either predict or to experience emotions related to a simulated social inclusion and exclusion interaction. Overall, patients anticipated more intense negative emotions than controls. Divided by the type of social situation, however, patients reported less intense positive emotions than controls with regard to social inclusion, but not with regard to social exclusion. The lack of an overall deficit in anticipation of positive emotions speaks against the assumption that anticipation abnormalities in negative symptoms are due to a neurocognitive deficit. Rather, the findings seem to reflect negative beliefs about potentially rewarding social situations in people with negative symptoms.

Subclinical negative symptoms and the anticipation, experience and recall of emotions related to social interactions: An experimental study

Healthy individuals use anticipated and recalled emotions to guide their decisions to seek out social interactions. It is unknown whether individuals with negative symptoms of schizophrenia, who are commonly observed to socially withdraw, show a bias in anticipation and recall of emotions related to a social interaction. To close this knowledge gap, this study examines whether higher levels of subclinical negative symptoms are associated with less positive and more negative anticipated and recalled emotions related to a social interaction. In a mixed model design participants were instructed to either predict or to experience and then recall emotions related to a simulated social inclusion- or exclusion-interaction. Disregarding the type of situation, participants with higher levels of subclinical negative symptoms anticipated more intense fear than participants with lower levels of subclinical negative symptoms. Divided by type of situation, however, participants with higher levels of negative symptoms experienced and recalled more sadness related to being socially included and even recalled more positive emotions after being excluded. These specific associations are likely to reflect negative expectations about potentially rewarding social situations in people with negative symptoms. A replication in populations with clinically relevant negative symptoms and inclusion of measures to assess memory is warranted.

Schizophrenia and relationships: the effect of mental illness on sexuality

This paper seeks to investigate the impact of mental illness on the sexuality of patients with a schizophrenic disorder who live in the community in a long-term relationship with a partner. We conducted qualitative, in-depth interviews with five such patients who were in treatment at a psychiatric outpatient clinic, and three of their partners. The data were analyzed by thematic analysis and identified the following areas of concern: relationships outweigh sexuality; uncertainties about one’s sexual capacity; the dwindling of sexual fantasies, feelings of desire, and satisfaction; and, a lack of communication and support in sexual matters. Both patients and partners reported feeling overlooked by psychiatric services as sexual beings. They also expressed dissatisfaction with a patient-therapist treatment model that excluded their partners. Our findings indicate that dysfunctional sexuality affects both patients suffering from severe mental illness and their partners. Patients and partners deplore the lack of opportunity to discuss questions related to their sexuality and long-term relationships with psychiatric clinicians. Sexual problems arising from, or exacerbated by, schizophrenia require supportive services, whether in the form of general, psychiatric, or couples therapy.

Social network activation: the role of health discussion partners in recovery from mental illness

In response to health problems, individuals may strategically activate their social network ties to help manage crisis and uncertainty. While it is well-established that social relationships provide a crucial safety net, little is known about who is chosen to help during an episode of illness. Guided by the Network Episode Model, two aspects of consulting others in the face of mental illness are considered. First, we ask who activates ties, and what kinds of ties and networks they attempt to leverage for discussing health matters. Second, we ask about the utility of activating health-focused network ties. Specifically, we examine the consequences of network activation at time of entry into treatment for individuals' quality of life, social satisfaction, ability to perform social roles, and mental health functioning nearly one year later. Using interview data from the longitudinal Indianapolis Network Mental Health Study (INMHS, N = 171), we focus on a sample of new patients with serious mental illness and a group with less severe disorders who are experiencing their first contact with the mental health treatment system. Three findings stand out. First, our results reveal the nature of agency in illness response. Whether under a rational choice or habitus logic, individuals appear to evaluate support needs, identifying the best possible matches among a larger group of potential health discussants. These include members of the core network and those with prior mental health experiences. Second, selective activation processes have implications for recovery. Those who secure adequate network resources report better outcomes than those who injudiciously activate network ties. Individuals who activate weaker relationships and those who are unsupportive of medical care experience poorer functioning, limited success in fulfilling social roles, and lower social satisfaction and quality of life later on. Third, the evidence suggests that social networks matter above and beyond the influence of any particular individual or relationship. People whose networks can be characterized as having a pro-medical culture report better recovery outcomes.

Empathic accuracy and cognition in schizotypal personality disorder

Interpersonal dysfunction contributes to significant disability in the schizophrenia spectrum. Schizotypal Personality Disorder (SPD) is a schizophrenia-related personality demonstrating social cognitive impairment in the absence of frank psychosis. Past research indicates that cognitive dysfunction or schizotypy may account for social cognitive dysfunction in this population. We tested SPD subjects and healthy controls on the Empathic Accuracy (EA) paradigm and the Reading of the Mind in the Eyes Test (RMET), assessing the impact of EA on social support. We also explored whether EA differences could be explained by intelligence, working memory, trait empathy, or attachment avoidance. SPD subjects did not differ from controls in RMET, but demonstrated lower EA during negative valence videos, associated with lower social support. Dynamic, multimodal EA paradigms may be more effective at capturing interpersonal dysfunction than static image tasks such as RMET. Schizotypal severity, trait empathy, and cognitive dysfunction did not account for empathic dysfunction in SPD, although attachment avoidance is related to empathic differences. Empathic dysfunction for negative affect contributes to decreased social support in the schizophrenia spectrum. Future research may shed further light on potential links between attachment avoidance, empathic dysfunction, and social support.

Social network intervention in patients with schizophrenia and marked social withdrawal: a randomized controlled study

OBJECTIVE

To evaluate the efficacy and feasibility of actions intended to implement or improve patients' social network within the Italian National Health Service community mental health services.

METHODS

We conducted a randomized clinical trial through a network of 47 community mental health services on patients with a diagnosis in the schizophrenia spectrum (F20 in the International Classification of Diseases, 10th Revision), who were young (aged younger than 45 years), and with a poor social network (less than 5 relationships). In addition to routine treatments, for the experimental group, the staff identified possible areas of interest for individual patients and proposed social activities taking place outside the services' resources and with members of the community. The main outcome was an improvement in the patients' social network; secondary end points were clinical outcome, abilities of daily living, and work.

RESULTS

One- and 2-year outcomes of 345 and 327, respectively, of the 357 patients randomized were analyzed by intention-to-treat. A social network improvement was observed at year 1 in 25% of the patients allocated to routine treatment and in 39.9% of those allocated to the experimental arm (OR 2.0, 95% CI 1.3 to 3.1; adjusted OR 2.4, 95% CI 1.4 to 3.9). The difference remained statistically significant at year 2. No significant differences emerged for any of the other end points. However, patients with 1 or more other areas of improvement at year 1 and 2 showed a statistically significant social network improvement.

CONCLUSIONS

The activation of social networks as an activity integrated with standard psychiatric care is practicable, without added economic and organizational costs, and appears to produce an effect persisting well beyond its implementation.

Social networks, support and early psychosis: a systematic review

Background. There is strong evidence that those with a long-standing psychotic disorder have fewer social contacts and less social support than comparison groups. There is less research on the extent of social contacts and support prior to or at the onset of psychosis. In the light of recent evidence implicating a range of social experiences and contexts at the onset of psychosis, it is relevant to establish whether social networks and support diminished before or at the time of onset and whether the absence of such supports might contribute to risk, either directly or indirectly. We, therefore, conducted a systematic review of this literature to establish what is currently known about the relationship between social networks, support and early psychosis. Methods. We identified all studies investigating social networks and support in first episode psychosis samples and in general population samples with measures of psychotic experiences or schizotype by conducting systematic searches of electronic databases using pre-defined search terms and criteria. Findings were synthesized using non-quantitative approaches. Results. Thirty-eight papers were identified that met inclusion criteria. There was marked methodological heterogeneity, which limits the capacity to draw direct comparisons. Nonetheless, the existing literature suggests social networks (particularly close friends) and support diminished both among first episode samples and among non-clinical samples reporting psychotic experiences or with schizotype traits, compared with varying comparison groups. These differences may be more marked for men and for those from minority ethnic populations. Conclusions. Tentatively, reduced social networks and support appear to pre-date onset of psychotic disorder. However, the substantial methodological heterogeneity among the existing studies makes comparisons difficult and suggests a need for more robust and comparable studies on networks, support and early psychosis.

Social support and functional outcomes in an early intervention program

OBJECTIVE

To examine social support at initiation of treatment of psychosis and after one year of treatment as predictors of functioning at five year follow-up.

METHODS

Early social support was assessed for 132 patients. Follow-up assessments included number of weeks of full-time occupation, number of weeks on a disability pension and global assessment of functioning.

RESULTS

One year ratings of social support better predicted occupational activity at follow-up than initial social support. Social support predicted functional outcomes independently of other early characteristics.

CONCLUSIONS

Findings support the importance of interventions to improve the level of support of individuals with psychotic disorders.

Understanding the social costs of psychosis: the experience of adults affected by psychosis identified within the second Australian National Survey of Psychosis

BACKGROUND

Social inclusion is a key priority of the Fourth National Mental Health Plan for Australia (2009-2014), with strong evidence for its protective impact on mental health. Social integration has been associated with enhanced well-being for people with mental illnesses such as psychosis.

OBJECTIVE

To explore the impact of psychosis on an individual's social and community participation.

METHOD

The second Australian national survey of psychosis was conducted across seven Australian sites. Semi-structured interviews with adults living with psychosis assessed mental health status, social and role functioning, life satisfaction and future goals. The cohort comprised 1825 adults with a psychotic illness (59.6% were male; 42.4% were aged 18-34 years; 31.5% had 12 years or more of education) of whom 32.7% had been employed in the past year.

RESULTS

Most adults indicated experiencing loneliness (80.1%) and a need for more friends (48.1%). Men were more likely to have never had a long-term relationship (59.4% M, 33.2% F). Even though women were more likely to experience anxiety in social situations [(χ(2)(1) = 8.95, p < 0.01)], they were more likely to have attended a social activity in the past year [χ(2)(2) = 11.84, p < 0.01]. Just over half of the survey participants (56.7%) reported having daily or nearly daily contact with family members. In the past year, 69% had not attended any social activity and 43% described stigma as a barrier. Although 63.2% showed significant impairment in social functioning, only 29.5% had received help for this in the last year. Social isolation and loneliness were rated as major challenges by 37.2% of the cohort.

CONCLUSIONS

Social isolation and dysfunction experienced by people with psychosis have not decreased since the last Australian national survey of people with psychosis. Alongside education and employment, social functioning and participation must be addressed to improve social inclusion for people with psychosis. Programs targeting social opportunities (befriending, peer support), social anxiety and social functioning for all stages of psychosis are warranted.

One-year functional outcomes of naturalistically treated patients with schizophrenia

Against the background of the growing evidence that the patient's functioning significantly influences the course and outcome of schizophrenia, the aims of this analysis were to examine what proportion of patients achieve functional outcome criteria after 1 year, and to identify clinical and sociodemographic predictive factors for functional remission. Patients with the diagnosis of schizophrenia who were treated as inpatients at the beginning of the study were examined within a naturalistic follow-up trial. The present study reports on the time frame from admission to discharge of an inpatient treatment period and the 1-year follow-up assessment. The Global Assessment of Functioning (GAF) Scale and Social and Occupational Functioning Assessment Scale (SOFAS) were evaluated with respect to functional outcome, whereas Positive and Negative Syndrome Scale (PANSS) scores were rated as psychopathological outcome measures. Functional remission thresholds were defined according to a GAF score of ≥61 points and a SOFAS score ≥61 points. Symptomatic remission criteria were applied according to the remission criteria of the Schizophrenia Working Group. The Strauss-Carpenter Prognostic Scale (SCPS), the Phillips Premorbid Adjustment Scale, medical history, sociodemographic and psychopathologic parameters were evaluated in order to find valuable predictors for functional remission. One year after discharge from inpatient treatment, 211 out of 474 patients were available for analysis according to both rating scales used to assess functional remission (GAF and SOFAS). Forty-seven percent of patients fulfilled criteria for functional remission (GAF and SOFAS) at discharge and 51% of patients at the 1-year follow-up visit. With regard to symptomatic remission criteria, the corresponding remitter rates were 61% of patients at discharge and 54% at the 1-year follow-up visit. Forty-two percent of patients fulfilled both remission criteria at discharge and 37% at the 1-year follow-up visit. A significant association was found between functional and symptomatic remission at discharge and at the 1-year follow-up visit. The strongest predictors for functional remission at the 1-year follow-up visit were: a higher SCPS total score at admission, a lower number of previous hospitalizations, a status of employment, lower scores in all PANSS subscales at discharge, a better premorbid social adjustment, the occurrence of a first psychotic episode, a younger age, a lower PANSS negative subscore at admission, a status of being an early responder, a shorter duration of inpatient treatment, a later age of onset, and female gender.

The labeling paradox: stigma, the sick role, and social networks in mental illness

Although research supports the stigma and labeling perspective, empirical evidence also indicates that a social safety net remains intact for those with mental illness, recalling the classic "sick role" concept. Here, insights from social networks theory are offered as explanation for these discrepant findings. Using data from individuals experiencing their first contact with the mental health treatment system, the effects of diagnosis and symptoms on social networks and stigma experiences are examined. The findings suggest that relative to those with less severe affective disorders, individuals with severe diagnoses and more visible symptoms of mental illness have larger, more broadly functional networks, as well as more supporters who are aware of and sympathetic toward the illness situation. However, those with more severe diagnoses are also vulnerable to rejection and discrimination by acquaintances and strangers. These findings suggest that being formally labeled with a mental illness may present a paradox, simultaneously initiating beneficial social processes within core networks and detrimental ones among peripheral ties.

Social economic inequalities and mental health II. Methodological aspects and literature review

Summary

Objective - This study provides a framework for mental health inequalities beginners. It describes the methods used to measure socio economic inequalities and the inter-relations with different aspects of mental health: residence, mental health services organisation and main diagnostic categories. Method - Literature electronic-search on Medline, Psyclit, Econlit, Social Science Index and SocioSearch usingand relating the key-words inequalities, deprivation, poverty, socio-economic status, social class, occupational class, mental health for the period 1965-2002 (June). The articles selected were integrated with manual search (publications of the same authors, cross-references, working documents and reports of international andregional organisations). Results - Inequality is not an absolute concept and, mainly, it has been changing during the last years. For example, the integration and re-definition of variables that capture, in simple indices, a complex reality; the accent on social more than on economic aspects; the geo-validity and time-reference of the inequality's indices. Moreover, the inequalities could be the result of individual preferences, in this case, the social selectionand social causation issues will raise the suitability for a public intervention. Conclusions - Up to now, research has been mainly concentrated in describing and measuring health inequalities. For designing effective interventions, policy makers need to ground decisions on health-socioeconomic inequalities explanatory models.

Declaration of Interest

this work was partly funded by the Department of the Public Health Sciences “G. Sanarelli” of the University of Rome “La Sapienza” and the Department of Medicine and Public Health of the University of Verona.

Sex differences in schizophrenia

Evidence suggests sex differences in schizophrenia reflect differences in both neurodevelopmental processes and social effects on disease risk and course. Male:female incidence approximates 1.4:1 but at older onset women predominate. Prevalence differences appear smaller. Men have poorer premorbid adjustment and present with worse negative and less depressive symptoms than women, which may explain their worse medium term outcome according to a range of measures. Substance abuse is a predominantly male activity in this group, as elsewhere. Findings of sex differences in brain morphology are inconsistent but occur in areas that normally show sexual dimorphism, implying that the same factors are important drivers of sex differences in both normal neurodevelopmental processes and those associated with schizophrenia. There are sex differences in antipsychotic responses but sex-specific endocrine effects on illness and response to antipsychotics are potentially complex. Oestrogen's role as an adjunctive medication is not yet clear due to methodological differences between the few randomized controlled trials. Services that are sensitive to differences in gender can better meet their patients' specific needs and potentially improve outcome.

Meeting the Needs of Women in Mental Health Rehabilitation Services

A service evaluation investigated the gender sensitivity of a London mental health rehabilitation service, including interventions to increase participation in women-only groups and activities.

Method:

A total of 40 female service users and 13 staff teams from 13 inpatient and community-based rehabilitation projects completed questionnaires regarding the service's gender sensitivity.

Results:

Most projects provided women-only space and the majority of female service users had a female keyworker, but there was limited provision and uptake of women-only groups and activities.

Conclusion:

A focus on collaboration with female service users to identify and establish, where lacking, groups and activities that appeal to women service users is needed to increase meaningful occupation.

Defining and predicting functional outcome in schizophrenia and schizophrenia spectrum disorders

BACKGROUND

To assess criteria and to identify predictive factors for functional outcome. The criteria should cover all domains proposed by the Remission in Schizophrenia Working Group.

METHOD

PANSS ratings were used to evaluate the symptomatic treatment outcome of 262 inpatients with schizophrenia spectrum disorders within a naturalistic multicenter trial. Functional remission was defined as a GAF score >61 (Global Assessment of Functioning Scale), SOFAS score >61 (Social and Occupational Functioning Scale) and a SF-36 mental health subscore >40 (Medical Outcomes Study-Short Form Health Survey). Multivariate logistic regression and CART analyses were used to determine valid clinical and sociodemographic predictors.

RESULTS

In total, 52 patients (20%) fulfilled the criteria for functional remission, 125 patients (48%) achieved symptomatic resolution and when criteria for functional remission and symptomatic resolution were combined 33 patients (13%) achieved complete remission. Younger age, employment, a shorter duration of illness, a shorter length of current episode, less suicidality, and a lower PANSS negative and global subscore at admission were predictive of functional remission. The regression model showed a predictive value of more than 80%.

CONCLUSIONS

A significant association was found between functional remission and symptomatic resolution, indicating reasonable validity of the proposed definition for functional outcome. The revealed predictors for functional treatment outcome emphasize the need for psychosocial and vocational rehabilitation in schizophrenic patients.

Symptoms as mediators of the relationship between neurocognition and functional outcome in schizophrenia: a meta-analysis

BACKGROUND

Neurocognitive functioning in schizophrenia has received considerable attention because of its robust prediction of functional outcome. Psychiatric symptoms, in particular negative symptoms, have also been shown to predict functional outcome, but have garnered much less attention. The high degree of intercorrelation among all of these variables leaves unclear whether neurocognition has a direct effect on functional outcome or whether that relationship to functional outcome is partially mediated by symptoms.

METHODS

A meta-analysis of 73 published English language studies (total n=6519) was conducted to determine the magnitude of the relationship between neurocognition and symptoms, and between symptoms and functional outcome. A model was tested in which symptoms mediate the relationship between neurocognition and functional outcome. Functional outcome involved measures of social relationships, school and work functioning, and laboratory assessments of social skill.

RESULTS

Although negative symptoms were found to be significantly related to neurocognitive functioning (p<.01) positive symptoms were not (p=.97). The relationship was moderate for negative symptoms (r=-.24, n=4757, 53 studies), but positive symptoms were not at all related to neurocogniton (r=.00, n=1297, 25 studies). Negative symptoms were significantly correlated with functional outcome (r=-.42, p<.01), and again the correlation was higher than for positive symptoms (r=-.03, p=.55). Furthermore, our findings support a model in which negative symptoms significantly mediate the relationship between neurocognition and functional outcome (Sobel test p<.01).

CONCLUSIONS

Although neurocognition and negative symptoms are both predictors of functional outcome, negative symptoms might at least partially mediate the relationship between neurocognition and outcome.

Disengagement from mental health services. A literature review

This paper reviews the literature on disengagement from mental health services examining how the terms engagement and disengagement are defined, what proportion of patients disengage from services, and what sociodemographic variables predict disengagement. Both engagement and disengagement appear to be poorly conceptualised, with a lack of consensus on accepted and agreed definitions. Rates of disengagement from mental health services vary from 4 to 46%, depending on the study setting, service type and definition of engagement used. Sociodemographic and clinical predictors of disengagement also vary, with only a few consistent findings, suggesting that such associations are complex and multifaceted. Most commonly reported associations of disengagement appear to be with sociodemographic variables including young age, ethnicity and deprivation; clinical variables such as lack of insight, substance misuse and forensic history; and service level variables such as availability of assertive outreach provision. Given the importance of continuity of care in serious mental disorders, there is a need for a consensual, validated and reliable measure of engagement which can be used to explore associations between patient, illness and service related variables and can inform service provision for difficult to reach patients.

Clinical course and outcome of schizophrenia in a predominantly treatment-naive cohort in rural Ethiopia

The established view that schizophrenia may have a favorable outcome in developing countries has been recently challenged; however, systematic studies are scarce. In this report, we describe the clinical outcome of schizophrenia among a predominantly treatment-naive cohort in a rural community setting in Ethiopia. The cohort was identified in a 2-stage sampling design using key informants and measurement-based assessment. Follow-up assessments were conducted monthly for a mean duration of 3.4 years (range 1-6 years). After screening 68 378 adults, ages 15-49 years, 321 cases with schizophrenia (82.7% men and 89.6% treatment naive) were identified. During follow-up, about a third (30.8%) of cases were continuously ill while most of the remaining cohort experienced an episodic course. Only 5.7% of the cases enjoyed a near-continuous complete remission. In the final year of follow-up, over half of the cases (54%) were in psychotic episode, while 17.6% were in partial remission and 27.4% were in complete remission for at least the month preceding the follow-up assessment. Living in a household with 3 or more adults, later age of onset, and taking antipsychotic medication for at least 50% of the follow-up period predicted complete remission. Although outcome in this setting appears better than in developed countries, the very low proportion of participants in complete remission supports the recent observation that the outcome of schizophrenia in developing countries may be heterogeneous rather than uniformly favorable. Improving access to treatment may be the logical next step to improve outcome of schizophrenia in this setting.

Routine evaluation in first episode psychosis services: feasibility and results from the MiData project

BACKGROUND

Early intervention services (EIS) for psychosis are becoming widespread. Structured methods of assessment are advocated in these services, but a consensus is still needed on a package of measures with good psychometric properties that is feasible and reliable for routine use in this setting.

METHODS

A computerised assessment package (MiData) was designed to provide clinicians with easy-to-understand feedback about clients' progress and to allow evaluation of the whole service for both audit and research purposes. Core areas include symptoms, duration of untreated psychosis (DUP), pathways into care, social functioning, and substance misuse at initial intake and annually thereafter.

RESULTS

MiData has been adopted by EIS throughout London and in some other centres. Baseline data are now available regarding 533 first-episode psychosis patients who presented to 8 London teams. The completeness of the data varied across teams and measures, with fullest completion for sociodemographic data (99% on some measures) and poorest for DUP. The average London EIS client is male, single, unemployed and comes from Black or Minority Ethnic group. Most (70%) demonstrated poor social functioning at intake, over a third (38%) reported substance abuse problems and 23% had harmed themselves or others in the previous 6 months.

CONCLUSIONS

MiData provides a clinician-friendly system of evaluating first-episode psychosis services but requires further refinement and dedicated resources to improve completion rates. This method of collecting routine data is of use to clinicians, managers, health service researchers and commissioners and potentially it may enable naturalistic comparisons between different models of care.

Changes in social network diversity and perceived social support after psychiatric hospitalization: results from a longitudinal study

BACKGROUND

There is a large empirical basis for the importance of social networks and support for people with a mental illness. However, only a few studies have examined the predictors, changes and correlations of these constructs within a longitudinal framework.

AIM

To analyze changes in social network diversity as measured by the number of social roles and perceived social support over the course of three years after a psychiatric hospitalization while controlling for sociodemographic and clinical variables. A further aim was to inquire whether some social roles are perceived as being more supportive than others.

METHOD

Random coefficient models were applied to the data of a longitudinal study on the life circumstances of people with affective disorders or schizophrenia (N = 183).

RESULTS

The majority of participants had relatives, friends and co-workers, while a markedly smaller proportion had a spouse/partner or children. Social network diversity increased during the time period observed while the perception of social support did not change. Being male, without a job (competitive or sheltered), or having a low income predicted less diverse networks. Partners and friends were perceived as most supportive. Persons without a close friendship perceived less overall support, but only at baseline (hospitalization), while persons with a job on the competitive labor market felt better supported.

CONCLUSIONS

Social disintegration in the course of mental illness that is found in some studies has no equivalent in our study in what concerns network diversity and perceived support. According to our results, characteristics of vocational and economic integration are of much greater relevance, as they enhance or hinder access to social participation.

Residential area and social contacts in schizophrenia. Results from the European Schizophrenia Cohort (EuroSC)

BACKGROUND

Social isolation is associated with poor prognosis in schizophrenia. We aim to determine the effect of rural or urban residence on frequency of social and family contacts.

METHOD

We analysed data from the European Schizophrenia Cohort, a two-year follow-up study of 1,208 patients in Britain, France and Germany. Frequency of contact was elicited with Lehman's Quality of Life Inventory. Between-effect error component regression models adjusted the effects of living environment for country, age, gender, education, schizophrenia symptoms and global functioning.

RESULTS

Across all living conditions, contact with family occurred more frequently than contact with others. Family visits, social visits and planned social activities were less common in urban compared to rural settings, whereas no significant differences were found for social and family telephone calls and time spent with a spouse. Patients living with a partner had more family, but fewer social contacts, while women had more contact by phone. Family and social contacts across all categories decreased with age. Employment increased social contacts, but did not affect visits or phone calls within the family. Schizophrenia symptoms, particularly negative symptoms, and impaired global functioning decreased all aspects of social and family contacts.

DISCUSSION

Contrasting with results of previous studies, we found rural living was associated with greater frequency of social contacts in patients suffering from schizophrenia. Beyond living environment, our findings stress the importance both of an adequate control of negative symptoms and of employment opportunities for schizophrenia patients in order to enhance their social networks.

Social support among veterans with serious mental illness

BACKGROUND

We determined whether patients with serious mental illness were more likely to report low social support than those without serious mental illness.

METHOD

We conducted a national, cross-sectional study of VA patients in Fiscal Year 1999 who were diagnosed with a serious mental illness, as well as a random sample of VA patients without a diagnosis of serious mental illness (N = 8,547) from the National Psychosis Registry who also completed the VA's Large Health Survey of Veteran Enrollees (LHSV) 9-item questionnaire on social support. Using generalized estimating equations; we assessed patient's likelihood of reporting low social support, while controlling for patient socio-economic and clinical factors.

RESULTS

In multivariable models adjusting for patient factors, patients with serious mental illness were more likely to report low instrumental support, e.g., having no one to help with chores (OR = 1.41, p < 0.001) and low emotional support, e.g., having no one to relax with (OR = 2.05, p < 0.001).

CONCLUSIONS

Patients diagnosed with serious mental illness reported low social support across different dimensions. Recovery-oriented services for persons with serious mental illness should focus on improving and sustaining emotional and instrumental supports for this vulnerable population.

Social network among people with persistent mental illness: associations with sociodemographic, clinical and health-related factors

BACKGROUND

Social interaction is crucial for whether a person will successfully accomplish important life tasks.

AIM AND METHOD

This study investigated the importance of sociodemographic, clinical and self-perceived health-related factors for social interaction among 103 individuals with persistent mental illness, mainly psychoses, visiting an outpatient unit.

RESULTS

Bivariate analyses pointed to several relationships, especially between the health-related variables and both quantitative and qualitative aspects of the social network. In multivariate analyses, higher levels of quality of life, self-esteem, being a cohabitant, and living in a house were related to higher ratings on different aspects of the social network. Older age was associated with fewer close relationships but more adequate social integration.

CONCLUSIONS

The social network appeared to be a function of both self-perceptions and sociodemographic influences. The influence is probably dynamic and, for example, just as a better quality of life may lead to more social interaction, a more developed social network probably promotes better quality of life. Therefore, interventions in mental health care that target social interaction constitute a powerful resource and should be part of the support for people with severe and persistent mental illness.

The Camden Schizophrenia Surveys. III: Five-year outcome of a sample of individuals from a prevalence survey and the importance of social relationships

BACKGROUND

Most studies of outcome in schizophrenia have focused on incidence cohorts or samples identified through specialist mental health services; population-based samples provide a more complete picture of the effectiveness of community services.

AIMS

To examine whether outcome predictors, derived from studies of selected patients with prolonged schizophrenia, would emerge in a largely community-dwelling population sample.

METHODS

A follow-up sample of 114 adults with schizophrenia was identified via two censuses of key informants conducted for two prevalence surveys in North London, five years apart. Symptomatic, clinical and functional outcomes were assessed after five years. A composite score was derived for each individual. Multiple Linear Regression analyses were conducted in two phases to derive a best subset of predictors for global outcome.

RESULTS

After five years, 33% were worse and 62% were better overall. The four best predictors (social isolation, living apart from relatives, longer illness and being an inpatient at first census) accounted for 32% of the variance in outcome of those with schizophrenia and related diagnoses.

CONCLUSIONS

Social relationships during the course of illness are an important predictor of overall outcome and relationships with friends and family each seem to make a positive contribution. Policy and service developments should focus on improving participation in community life for people with schizophrenia, particularly their social connectedness.

Outcome and its predictors in schizophrenia within the Northern Finland 1966 Birth Cohort

PURPOSE

We report clinical and social outcomes of schizophrenia in the longitudinal, population-based Northern Finland 1966 Birth Cohort, and describe associated demographic, developmental and illness-related factors.

SUBJECTS AND METHODS

Subjects with DSM-III-R schizophrenia (n=59) were followed prospectively from mid-gestation up to age 35 years. Outcome measures included positive and negative symptoms, psychiatric hospitalisations, social and occupational functioning. Several definitions of good and poor outcome were explored, and developmental, socio-demographic and clinical predictors of outcomes were analysed.

RESULTS

Good clinical outcome varied from 10% to 59%, and good social outcome 15-46%, depending on definition. Poor clinical outcome varied 41-77% and poor social 37-54%. Lack of friends in childhood, father's high social class, lower school performance and earlier age of illness onset predicted poor outcomes.

DISCUSSION

The outcomes of schizophrenia in this study depended on definitions used but were relatively poor. The age of illness onset, father's social class, school performance and poor social contacts in childhood were only statistically significant predictors.

CONCLUSION

Definitions of outcome have a major effect on estimates for proportions of good and bad outcomes and on the predictors of outcomes. However, regardless of which definitions were used, the outcome of schizophrenia in this population-based sample was generally bleak.

[One-year follow-up and mobility assessment of schizophrenic patients in the Liege psychiatric care network]

OBJECTIVE

The study was aimed at assessing the clinical evolution and mobility of schizophrenic patients within the healthcare network of the Psychiatric Platform of Liege (Belgium) after a one-year follow-up period.

MATERIAL AND METHODS

The study material consisted of a random sample of 184 patients with schizophrenia drawn from the population of schizophrenic patients treated in the Liege psychiatric care network. The characteristics of these patients have been described previously (18). The 184 patients were followed-up for one-year and reassessed at the end of this period. Mobility (ie, changes between psychiatric care institutions, including home) was recorded for each patient within the institutional network. The diagnosis of schizophrenia was based on the DSM IV. Demographic, social and global functioning (GAF scale) data were collected from the "Résumé psychiatrique Minimum (RPM)", a clinical summary which has been imposed by the Belgian Ministry of Public Health for each psychiatric hospital stay. Symptom components were derived from the Psychosis Evaluation tool for Common Use by Caregivers (PECC).

RESULTS

Among the 184 patients enrolled in the initial analysis, 6 refused to participate in the follow-up study. The 178 remaining schizophrenic patients included 131 men (74%) and 47 women (26%) with a mean age of 43.1 +/- 13.6 and 48.8 +/- 14.9 years, respectively (p<0.05). The majority of patients (53%) suffered from paranoid schizophrenia. At baseline, 63% of the patients were hospitalised full-time, 6% part-time and 31% received ambulatory care. During the one-year follow-up period, 4 patients died, including one from suicide. When considering mobility, 48% of the patients experienced at least one change of institution, whereas 52% of the patients didn't change at all (see figure 1). The total number of changes over the 1-year period amounted 189, yielding a mean value of 1.1 changes per patient per year. Changes mostly occurred between institutions of similar care setting (see figure 2). Transfers (30%) were also observed directly between hospital and home. A multivariate Poisson regression analysis showed that the number of changes was unrelated to gender and initial care setting but decreased with age (p<0.0001). It was also higher for patients with schizo-affective disorders (2.5 +/- 1.9, p<0.01) or with residual type (1.2 +/- 1.8; p<0.05) than for patients with other types of schizophrenia (ranging from 0.3 +/- 0.5 to 0.9 +/- 1.4). No association was found with initial GAF or PECC, except for negative symptoms (p<0.05). After one year, despite the high proportion of institutional changes (48% of the patients), the distribution of the patients according to care setting remained the same (p=0.77). However, GAF scores significantly improved from 39.7 +/- 16.1 to 44.4 +/- 16.1 (p<0.0001) and likewise for total PECC scores (70 +/- 19.1 vs 63.2 +/- 19.4, p<0.001). Excitatory and disease perception items of the PECC remained unchanged.

CONCLUSION

The present study reveals that mobility within the institutional network did affect about half of the schizophrenic patients. Mobility was related to age, type of schizophrenia and disease evolution. Changes occur mainly between psychiatric structures of similar care setting but also directly from hospital to home without passing through an intermediate care structure. Further efforts should be made to provide schizophrenic patients with a more coordinated care provision throughout the course of their disease.

The quality of life of the mentally ill living in residential facilities: findings from a national survey in Italy

Quality of Life (QOL) is an outcome measure particularly useful to assess the effects of deinstitutionalization policies. To date no large-scale study has been conducted in residential facilities (RFs). Participants included 1492 subjects living in 174 RFs (20% of the total) randomly sampled in 15 Italian regions. Assessment instruments included the WHOQOL-Bref, the GAF, and the Physical Health Index (PHI). WHOQOL scores of residents were compared with those of healthy subjects (N = 65) and outpatients with schizophrenia (N = 162). Multivariate analyses were used to examine the relationship between selected patients' characteristics and WHOQOL scores. Mean WHOQOL scores of residents were similar to those of outpatients with schizophrenia, and substantially lower than those of healthy controls. Lower scores on WHOQOL domains were associated with schizophrenia and non-affective psychoses, unipolar depression, anxiety or somatoform disorders, shorter duration of illness, positive, negative or mood symptoms, lower GAF scores, no participation in internal activities, and PHI score. Our findings are consistent with previous studies. The present study highlights a marked difference between patients in RFs and healthy controls in the social domain. This suggests the need of well-designed rehabilitation plans, tailored to patients' needs, to foster the development of their independence and, ultimately, improve their QOL.

Medication decisions and clinical outcomes in the Canadian National Outcomes Measurement Study in Schizophrenia

OBJECTIVE

To evaluate over a 2-year period, patients from academic/non-academic centres, from each region of Canada, to determine whether location or other variables such as medication type, gender or income was associated with outcome as defined by non-hospitalization and persistence on original treatment.

METHOD

A total of 448 patients were recruited from academic and non-academic centres across all provinces of Canada and followed up for 2 years.

RESULTS

Patients from British Columbia had significantly lower rates of hospitalization than patients from other provinces. Male patients showed greater symptomatic improvement at 2 years from initial assessment compared to females. Patients on clozapine, risperidone and olanzapine were least likely to be hospitalized.

CONCLUSION

There were some regional differences noted in both utilization of types of antipsychotic medications and hospitalization rates. In this sample of stable out-patients over 70% who started on monotherapy with clozapine, risperidone, olanzapine and quetiapine remained on the same medication over the 2-year study period.

Social network in long-term diseases: A comparative study in relatives of persons with schizophrenia and physical illnesses versus a sample from the general population

This study compares the social network of a sample of 709 relatives of patients with schizophrenia, 646 relatives of patients with physical diseases, and 714 lay respondents, recruited in 30 randomly selected Italian areas, stratified for geographic location and population density. Each respondent was asked to fill in the Social Network Questionnaire. The social network was less extended and supportive in relatives of patients with schizophrenia than in those of patients with physical diseases and in the general population. Multivariate analyses revealed that social contacts were similarly reduced in relatives of patients with schizophrenia and physical diseases, while social support was significantly lower in relatives of patients with schizophrenia than in the other two groups. Social resources were higher in young respondents and in those living in rural areas. These results highlight the need to provide the families of those with long-term diseases with interventions aimed at increasing their social resources.

Do recent-onset schizophrenia patients experience a "social network crisis"?

It has been proposed that the onset of schizophrenia creates a social network crisis, resulting in a dramatic deterioration of social resources during the period immediately following a first hospitalization from essentially normal pre-hospitalization levels. To evaluate this proposal, recent onset patients (n = 89) completed comprehensive assessments that examined their social networks in the 12 months prior to first hospitalization and, in a subset of patients (n = 34), at a 15-month follow-up. Cross-sectional relationships to social functioning and symptoms were examined at both time points. Compared to existing research, at the initial assessment patients were characterized by several network disturbances, including small network size, a high proportion of family members, and highly dense interconnections among network members; these disturbances generally remained moderately to highly stable at follow-up. Smaller social networks were related to poor current and premorbid social functioning and aspects of clinical functioning, particularly at the 15-month follow-up assessment. Thus, this first repeated assessment of social network characteristics in the early course of schizophrenia does not support the social network crisis concept. Instead, results suggest that functionally relevant social network disturbances often exist by the time of first hospitalization in schizophrenia.

The new paradigm of recovery from schizophrenia: cultural conundrums of improvement without cure

This article is a qualitative investigation of the subjective experience of recovery from the perspective of persons living with schizophrenia-related disorders. An NIMH-sponsored ethnographic study of community outpatient clinics was completed for 90 persons taking second-generation antipsychotic medications. Research diagnostic criteria and clinical ratings were obtained in tandem with an anthropologically developed Subjective Experience of Medication Interview (SEMI) that elicits narrative data on everyday life and activities, medication and treatment, management of symptoms, expectations concerning recovery, and stigma. Ethnographic observations from diverse settings (clinics, public transportation, restaurants, homes) were also obtained. The primary findings are that recovery was experienced in relation to low levels of symptoms, the need to take medications to avoid hospitalization or psychotic episodes, and personal agency to struggle against the effects of illness. The majority of participants articulated their sense of illness recovery and expectation that their lives would improve. Improvement and recovery is an incremental, yet definitively discernable subjective process. Several problems were identified as part of this process surrounding cultural conflicts that generate the experience of ambivalence analyzed here as the "paradox of recovery without cure," irreconcilable "catch-22" dilemmas involving sacrifice (e.g., one must be "fat" or be "crazy"), and substantial stigma despite improvement in illness and everyday life experience.

Subjective experience of recovery from schizophrenia-related disorders and atypical antipsychotics

AIMS

This article investigates the subjective experience of the process of improvement and recovery from the point of view of persons diagnosed (according to research diagnostic criteria) with schizophrenia and schizo-affective disorders.

METHODS

A community study of persons using psychiatric services was conducted for a sample of ninety subjects taking atypical antipsychotic medications. Sociodemographic data and clinical ratings were collected to complement the qualitatively developed Subjective Experience of Medication Interview (SEMI), which elicits narrative data on everyday activities, medication and treatment, management of symptoms, expectations concerning recovery, stigma, and quality of life.

RESULTS

Recovery was observed through: (1) relatively low ratings of psychiatrically observed symptomatology through BPRS scores; (2) the subjective sense among the majority (77.4%) of participants that taking medication plays a critical role in managing symptoms and avoiding hospitalization; and (3) the subjective sense articulated by the vast majority (80%) that they would recover from their illness and that the quality of their lives would improve (70.6%).

CONCLUSION

The overall quality of improvement and recovery is best characterized as an incremental, yet definitively discernable, subjective process.

What do psychotic experiences mean for young men? A qualitative investigation

This study is of a grounded theory analysis of the transcripts of young men talking about their experience of psychosis. Six young men were interviewed twice during the critical period of 3-5 years following their first psychotic episode. The young men were asked to reflect on themselves and their lives before, during, and after having psychotic experiences. The transcripts were considered to have a phenomenological status, in that they represented the participants' perspectives on their experiences. Four themes emerged that were common to all the accounts: experience of psychosis, immediate expression of psychotic experiences, personal and interpersonal changes, and personal explanations. These themes are explored in detail, and their links with existing research and clinical implications are considered.

Community care for people with psychosis: outcomes and needs for care

People with psychosis living in developed countries in the era of community-based care are likely to be socially isolated, unemployed, and have poor quality of life, despite recent advances in the treatment and understanding of psychosis. Recent work in Australia illustrates the needs for care, especially for those with complex disabilities, and even for those in contact with well-organized clinical mental health services. Insufficient evidence in two key areas impedes progress: the use of effective psychosocial interventions; and the impact of changes in the community care system. Follow-up studies of programs and interventions assessing a range of outcomes in local settings are now required to encourage professionals and the community to address these needs.

Characteristics of individuals with severe mental illness who use emergency services

Emergency services are both a safety net and a locus for acute treatment. While the population with severe, persistent mental illness uses emergency services at a high rate, few studies have systematically examined the causes of this service use. This study examines a random sample of 179 people who were high uti- lizers of services from the Los Angeles County Department of Mental Health. Interviews were conducted and 5 years of service use data were studied. Greater use of emergency services was associated with male gender, minority race, severe illness, homelessness, and less family support. Efforts to reduce emergency services need to improve access to appropriate community services, particularly for people who are homeless or lack family support.

Structure of needs among persons with schizophrenia

BACKGROUND

The importance of needs assessment for service development has been widely recognised. Several studies have focused on the associations between ratings of needs by patients and staff and have found clear differences, especially concerning the unmet needs.

METHODS

The present study is part of a Nordic Multicentre study that investigates the life and care of outpatients with a schizophrenia group illness in all the Nordic countries. The aim of this paper is to study the patterns of needs as identified by patients and staff according to the Camberwell Assessment of Needs (CAN). Quality of life, level of functioning, and psychiatric symptoms were assessed.

RESULTS

The sample includes 300 patients, 194 (65%) men and 106 (35%) women. The factor analysis identified five factors for patients and four factors for staff in the questionnaire on ratings of needs. In four of the five patient-related factors a meaningful interpretation was possible, and the factors were named skills, illness, coping, and substance abuse. The staff-related factors were named skills, impairment, symptom, and substance abuse. There were significant associations between the sum scores constructed from the factors and measures of functioning level and symptoms.

CONCLUSIONS

It seems that the sum factor reflecting secondary needs was the most important of the identified factors among both patient and staff ratings. The item-by-item comparisons in previous studies have emphasised differences between patient and staff ratings, but our analysis of the structure of needs also found similarities in the structures and in the associations between the identified sum scores and measures of symptoms, functioning level, and quality of life.