Service use and unmet needs in youth suicide: a study of trajectories

OBJECTIVE

While 90% of suicide victims have suffered from mental health disorders, less than one-half are in contact with a mental health professional in the year preceding their death. Service use in the last year of life of young suicide victims and control subjects was studied in Quebec. We wanted to determine what kinds of health care services were needed and if they were actually received by suicide victims.

METHOD

We recruited 67 consecutive suicide victims and 56 matched living control subjects (aged 25 years and younger). We evaluated subjects' psychopathological profile and determined which services would have been indicated by conducting a needs assessment. We then compared this with what services were actually received.

RESULTS

Suicide victims were more likely than living control subjects to have a psychiatric diagnosis. They were most in need of services to address substance use disorder, depression, interpersonal distress, and suicide-related problems. There were significant deficits in the domains of coordination and continuity of care, mental health promotion and training, and governance.

CONCLUSIONS

Our results show that we need to urgently take action to address these identified deficits to prevent further loss of life in our young people.

A patient with medication-resistant epilepsy featuring psychosensorial and psychotic symptoms presenting with significant functional improvement on psychotherapeutic treatment: a case report

Background

Partial complex epilepsy with psychosensorial and psychotic symptoms remains a relatively rare condition that can sometimes be mistaken for an axis I psychiatric disorder. There is no specific treatment for this particular type of epilepsy, anti-epileptic medication being the cornerstone of therapeutic intervention with the occasional addition of neuroleptics. Lack of response to anti-epileptic agents is often a sign of poor prognosis and requires risky and sometimes invasive interventions with high morbidity for patients.

Case presentation

We report the case of a 21-year-old right-handed Caucasian man of French-Canadian descent who was living with his mother immediately before being hospitalized in a psychiatric setting for the first time. He seemed obsessed with developing new concepts to reach a more ‘perfect’ existence. He also claimed feeling odd sensations in his mind and in his body that could be linked to some sort of ‘evolutionary’ process resulting from spiritual uplift. He reported non-specific visual hallucinations and what sounded like auditory hallucinations and telepathic powers. The first diagnosis was a possible schizophreniform disorder and our patient was hospitalized. Shortly afterwards, an electroencephalogram showed an important subcortical epileptic activity, compatible with partial complex epilepsy with psychosensorial and psychotic symptoms. Despite a negative response to medication, symptoms proper to this type of epilepsy were substantially alleviated using a psychotherapeutical treatment intended for patients with psychotic disorders, namely integrated psychological therapy (IPT). Significant functional improvement in our patient has been achieved since then.

Conclusions

This case report illustrates that despite a negative response to medication, symptoms proper to this type of epilepsy could be substantially alleviated using psychotherapeutical treatment modalities. To the best of our knowledge, this is the first time such a finding has been reported in the scientific literature. This could open the way for new research themes and therapeutic interventions for such patients.

Staff perceptions and organizational factors as predictors of seclusion and restraint on psychiatric wards

OBJECTIVE

Several factors have been shown to be involved in decisions to use seclusion and restraint in psychiatric inpatient settings. This study examined whether staff perceptions of factors related to the care team and violence on the ward predicted use of seclusion and restraint in psychiatric wards.

METHODS

A total of 309 staff members (nurses, rehabilitation instructors, and nurse's aides) providing care to patients with serious mental disorders were recruited from eight university psychiatric hospitals and general-hospital psychiatric units in the province of Quebec. Factors assessed included sociodemographic characteristics, psychological distress, staff perceptions of aggression and of interaction between members of the psychiatric team (team climate), and organizational factors.

RESULTS

Bivariate analyses showed that certain aspects of the team climate, staff perceptions of aggression, and organizational factors were associated with greater use of seclusion and restraint. The final multivariate model indicated that the following factors independently predicted greater use: type of hospital ward (emergency department and intensive care unit), staff perception of a higher level of expression of anger and aggression among team members, perception of the frequency of incidents of physical aggression against the self among patients, and perception of insufficient safety measures in the workplace.

CONCLUSIONS

These findings represent the first stage of a research program aimed at reducing use of seclusion and restraint in psychiatric settings. They underscore the importance of evaluating a variety of factors, including perceptions of safety and violence, when examining reasons for use of these controversial interventions.

The longitudinal association from obesity to depression: results from the 12-year National Population Health Survey

Prior observational studies have investigated the association between obesity and depression but evidence remains weak and mixed. There has been a call for high-quality longitudinal studies to elucidate the etiologic relationship from obesity to depression. The main objective of this study was therefore to investigate whether obesity was a risk factor for depression in a nationally representative sample followed for 12 years. Seven waves of data collection (1994-1995 to 2006-2007) were obtained from the National Population Health Survey (NPHS). Our analyses included 10,545 adults without depression at baseline. Past-year major depression episode (MDE) was assessed from the Composite International Diagnostic Interview-Short Form for Major Depression (CIDI-SFMD). Obesity was estimated using baseline BMI from self-reported weight and height (obesity: BMI > or =30 kg/m(2)). Kaplan-Meier survival curves were generated and Cox proportional hazard regression modeling was used to estimate the risk of MDE by obesity status, controlling for sociodemographic and health and lifestyle variables. We found that obesity at baseline did not significantly predict subsequent MDE in women (adjusted hazard ratio (AHR): 1.03, 95% confidence interval (CI) 0.84-1.26) and negatively predicted MDE in men (HR: 0.71, CI 0.51-0.98), after adjusting for important confounders. In summary, our findings suggest that obesity is a significant (negative) predictor of depression in adult men but not in women. These results moderate prior evidence supporting a positive link from obesity to depression.

Development and validation of the RQC: a daily contact log for ACT and ICM teams

AIM

Instruments to measure the process--the daily activities of home care workers--have received little attention and may impede research in refining the active ingredients, the clientele best served and continuous quality improvement. We developed a decade ago in Quebec, Canada, a new daily contact log (relevé quotidien des contacts or RQC) that has now reached in practice 1 million entries.

METHODS

Three features distinguish the RQC development, namely, practical ergonomics, a clear logic, and response categories easy to understand and retain. The instrument is filled following any 10-minute or more contact with or about the client, and covers the location, time and actors of the episode of care, and the nature of the intervention (crisis, representing, accompanying, discussing) in 10 areas (i.e. medication, daily living activities, housing, relationships, substance abuse, legal, etc.). Inter-rater agreement for each RQC response category and rater agreement with a criterion measure (coded vignettes) were evaluated.

RESULTS

Kappa coefficients and intra-class correlation coefficients yielded results ranging from at least moderate to generally substantial agreement for all 77 response categories.

CONCLUSIONS

The new RQC may support international studies of the implementation and application of various forms of intensive home care, refining its indications, and serves as a clinical and managerial tool to ensure quality of the interventions.

The psychosocial work environment and evidence utilization by health professionals

The purpose of this study was to investigate the relationships between dimensions of the psychosocial work environment and health professionals' use of evidence in their practice. A correlational descriptive design was developed. Health professionals working in mental health units at 2 hospitals were asked to complete a questionnaire about their perceptions of the psychosocial work environment and their use of evidence. Correlations and regression analyses were performed. Use of evidence was found to be correlated with social support and decision latitude. Results of multiple regression analyses found perceived social support (beta = .27, p < .01) and perceived decision latitude (beta = .25,p < .01) to be significant predictors of the use of evidence. The authors conclude that good social support and decision latitude among interprofessional groups may promote use of evidence by health professions in their practice.

Évaluation des habiletés de vie autonome chez les personnes psychotiques

Ce texte détaille les caractéristiques métrologiques de l'Échelle des habiletés de Vie Autonome (EHVA) mesurant les habiletés requises chez des personnes psychotiques, pour fonctionner de façon autonome au sein de la communauté. Ce questionnaire, qui comprend 65 items répartis en dix échelles d'habiletés, a été administré à 276 personnes psychotiques. Les résultats indiquent que, dans l'ensemble, la fidélité de cet instrument est bonne, mesurée par l'accord interjuges et les coefficients alpha. Trois des 10 échelles, soit les échelles Déplacement, Recherche d'emploi et Maintien de l'emploi, n'ont pu être conservées dans la version finale. Les quatre aspects de la validité examinés dans cette étude se révèlent très satisfaisants; il s'agit du degré de convergence entre l'évaluation faite par les participants eux-mêmes et par un membre du personnel soignant, des analyses discriminantes, des corrélations convergentes-divergentes avec d'autres instruments de mesure du fonctionnement psychosocial et de l'analyse factorielle exploratoire. Après ces analyses, la version finale de l'EHVA comprend 48 items répartis sous sept échelles. La discussion fait ressortir les qualités psychométriques d'un tel instrument en langue française et suggère des pistes de recherche pour poursuivre le développement de l'EHVA.

Données récentes d’études scandinaves. Traiter la dépression : une stratégie efficace de prévention du suicide?

Cet article vise à éclairer les planificateurs en santé publique, le personnel clinique et les intervenants en prévention du suicide au Québec ainsi que les familles et le public francophone à propos de récentes études sur le traitement de la dépression comme stratégie de prévention du suicide. Les auteurs en résument les conclusions, passent en revue les méthodes et examinent les résultats dans une perspective de santé publique visant à établir une stratégie efficace de prévention. Ils soulignent que le traitement de la dépression pourrait non seulement réduire les taux de suicide mais avoir des effets importants sur la santé publique en réduisant les incapacités liées à la dépression, en plus d'avoir un impact sur les futures générations à risque. Les obstacles au développement d'une telle stratégie sont soulignés en référence spécifique à la situation du Québec.

Risk factors for suicide completion in major depression: a case-control study of impulsive and aggressive behaviors in men

OBJECTIVE

Major depression is a major risk factor for suicide. However, not all individuals with major depression commit suicide. Impulsive and aggressive behaviors have been proposed as risk factors for suicide, but it remains unclear whether their effect on the risk of suicide is at least partly explained by axis I disorders commonly associated with suicide, such as major depression. With a case-control design, a comparison of the level of impulsive and aggressive behaviors and the prevalence of associated psychopathology was carried out with control for the presence of primary psychopathology.

METHOD

One hundred and four male suicide completers who died during an episode of major depression and 74 living depressed male comparison subjects were investigated with proxy-based interviews by using structured diagnostic instruments and personality trait assessments.

RESULTS

The authors found that current (6-month prevalence) alcohol abuse/dependence, current drug abuse/dependence, and cluster B personality disorders increased the risk of suicide in individuals with major depression. Also, higher levels of impulsivity and aggression were associated with suicide. An analysis by age showed that these risk factors were more specific to younger suicide victims (ages 18-40). A multivariate analysis indicated that current alcohol abuse/dependence and cluster B personality disorder were two independent predictors of suicide.

CONCLUSIONS

Impulsive-aggressive personality disorders and alcohol abuse/dependence were two independent predictors of suicide in major depression, and impulsive and aggressive behaviors seem to underlie these risk factors. A developmental hypothesis of suicidal behavior, with impulsive and aggressive behaviors as the starting point, is discussed.

Psychiatric risk factors for motor vehicle fatalities in young men

BACKGROUND

Motor vehicle accident (MVA) fatalities are an important cause of death in young men. Psychiatric disorders have been shown to be risk factors for MVA, but only a few studies have investigated MVA fatalities.

METHOD

A case-control study was carried out comparing 61 young male MVA fatalities in which the subject was the driver with an equal number of living male subjects matched for age (case by case with no more than 1 year's difference between case subjects and control subjects) with the accident group. We assessed both groups, using structured interviews and psychological autopsies.

RESULTS

Our results suggest that cluster B personality disorders (borderline and [or] antisocial) (OR 3.54; 95%CI, 1.38 to 16.01) and substance use disorders in the last 6 months (OR 4.33; 95%CI, 1.42 to 9.25) increased the risk of dying in MVAs. In addition, we observed an age effect, where differences in cluster B personality disorders and substance use disorders in the last 6 months were only significantly more prevalent in case subjects aged 26 years or over, compared with control subjects of the same age. Drivers under age 25 years appeared to be comparable with control subjects on all measures of psychopathology. Finally, this interaction between cluster B personality disorders and age over 26 years was the only significant predictor of car fatalities (adjusted OR 16.25; 95%CI, 1.67 to 158.10).

CONCLUSION

Borderline and antisocial personality disorders in which impulsive-aggressive behaviours play a central role and substance use disorders appear to be risk factors for young male deaths in MVAs. Interestingly, this effect seems to be specific to MVA case subjects aged 26 years or over.

Is violent method of suicide a behavioral marker of lifetime aggression?

OBJECTIVE

The main purpose of this study was to investigate whether the method of suicide is a valid behavioral marker of a lifetime history of aggression.

METHOD

The authors applied the psychological autopsy method to investigate 310 individuals who committed suicide. They used structured clinical assessments and personality trait scales in interviews with family members of the deceased.

RESULTS

Violent method was associated with a higher level of lifetime aggression and a higher level of impulsivity. In addition, violent method was associated with lifetime substance abuse or dependence and psychotic disorders. Controlling for age, sex, substance disorders, and other major psychopathology, the authors found that lifetime aggression and the interaction between impulsivity and aggressive behavior remained associated with violent method.

CONCLUSIONS

These results support the use of violent method of suicide as a behavioral marker of a higher level of lifetime impulsive-aggressive behaviors.

Familial aggregation of suicidal behavior: a family study of male suicide completers from the general population

OBJECTIVE

This study compared suicidality in families of adult male suicide completers and community comparison subjects.

METHOD

Two hundred forty-seven relatives of 25 male suicide completers and 171 relatives of 25 matched comparison subjects were assessed for recurrent risk of suicidal and related behaviors. Analyses were performed on a subgroup of relatives of suicide completers with cluster B personality disorders.

RESULTS

Relatives of suicide completers were over 10 times more likely than relatives of comparison subjects to attempt or complete suicide after the authors controlled for psychopathology. Relatives of suicide completers were not more likely to exhibit suicidal ideation but had more severe suicidal ideation than relatives of comparison subjects. These findings were stronger for the suicide completers diagnosed with cluster B personality disorders.

CONCLUSIONS

Suicide has a familial component independent of psychopathology that may be mediated by a combination of factors, including more severe suicidal ideation and aggressive behavior.

Seasonal differences in psychopathology of male suicide completers

Suicide is known to vary according to season, with peaks in the spring and troughs in the winter. The presence of psychopathology is a significant predictor of suicidality, and it is possible that the seasonal variation of suicide completion may be related to seasonality in the manifestation of psychiatric disorders common to suicide completers. In the current study, we evaluated 115 French-Canadian male suicide completers from the Greater Montreal Area for DSM-IV psychiatric disorders using proxy-based diagnostic interviews. Subjects were assessed for seasonal differences in the prevalence of DSM-IV psychiatric diagnoses just before their deaths. Diagnoses of major depressive disorder (MDD) without comorbid cluster B personality disorders, and schizophrenia were differently distributed between seasons. Most (63.4%) subjects with MDD committed suicide in the spring/summer (P =.038). However, closer examination revealed that depressed suicides with comorbid cluster B personality disorders did not show seasonality, while 83.3% of depressed suicides without comorbid cluster B personality disorders committed suicide in the spring/summer (P =.019). 87.5% of those suicides with schizophrenia committed suicide in the fall/winter (P =.026), and the only suicide with schizophrenia who died in the spring/summer was also the only one without positive symptomology. Our study is limited to male suicide completers, and results should not be generalized to women. We conclude that seasonal variation in suicide manifests itself differently in patients with different psychopathology. These findings indicate that assessment of suicide risk may need to include consideration of possible seasonal effects, depending on psychopathology.

Toward benchmarks for tertiary care for adults with severe and persistent mental disorders

BACKGROUND

Scarce attention has been paid to establishing benchmarks for tertiary care for adults with severe mental disorders. Yet, the availability and efficient utilization of residential resources partly determines the capacity of a comprehensive system of care to avoid clogging ever-shrinking acute care bed facilities.

OBJECTIVES

To describe the actual utilization of and projected needs for residential resources, one part of tertiary care, in the catchment area of a psychiatric hospital in east-end Montreal. To compare results obtained against actual utilization and projected needs evaluated in other Canadian provinces and in other countries, with a view to establishing national benchmarks.

METHODS

Two surveys were undertaken to establish the number of places in these facilities that were utilized and needed for adults aged 18 to 65 years with severe mental disorders, without a primary diagnosis of mental retardation or organic brain syndrome, and originally from the catchment area. A first survey ascertained the number of places utilized and of those needed for residential care among all long-stay inpatients and all adults in supervised residential facilities. A second survey identified the need for such long-stay hospitalization, nursing homes, and supervised facilities as an alternative or as a complement to hospitalization among acute care inpatients.

RESULTS

The actual ratio of places in long-stay hospital units, nursing homes, and supervised residential facilities was 150:100,000 inhabitants. The ideal ratio, according to estimated needs, is 171:100,000. The figure breakdown is as follows: 20:100,000 for long-stay hospital units, 20:100,000 for nursing homes, 40:100,000 for group homes, 40:100,000 for private hostels or foster families, and 51:100,000 for supervised apartments. The needs of this urban, blue-collar population for supervised residential places hovered in the upper range of utilization and standards for European countries and within the proposed standards for Canadian provinces.

DISCUSSION

Needs for long-stay hospitalization or for supervised residential facilities cannot be treated as absolute. For example, evaluation conducted in this hospital-led system of psychiatric care may produce higher estimates of institutional care. Comparing actual utilization and projected needs in this urban catchment area with current utilization in other jurisdictions in Canada and Europe should contribute to establishing sound national benchmarks within ranges.

CONCLUSIONS

It is possible to establish benchmarks that guide the development of supervised residential settings to best meet the needs of the population of adults with severe and persistent mental disorders. The methods used here to assess needs should serve as guidelines for future research, because they were designed to contain the bias of over- or underprovision of care in the current utilization.

Factor structure of the Multnomah Community Ability Scale

More and more, Intensive Community Treatment programs in Canada use questionnaires to evaluate the health and social functioning of individuals suffering from a severe mental illness. However, seldom are these tools subject to psychometric analyses to establish their validity on independent samples. This article presents the results of the validation of the French version of the Multnomah Community Ability Scale. Confirmatory factor analyses were carried out to assess the factorial structure. The factor structure, four dimensions with three items, emerging from a first sample was replicated with data from a different sample of clients. Moreover, these four dimensions respect the initial factor solution of the Multnomah Community Ability Scale, which are a) interference with functioning, b) adjustment to living, c) social competence, and d) behavior problems. The study shows the structural validity of this brief questionnaire, which could be useful both for clinical and research settings to evaluate the effectiveness of interventions.

Alternatives to acute hospital psychiatric care in east-end Montreal

OBJECTIVE

As pressure mounts to reduce the number of costly acute care beds, governments and the literature propose top-down ratios. Is this reasonable and fair to the responsible medical officers who, as the key care providers, will need to admit patients and develop discharge plans in a reduced-beds environment?

METHOD

Treating physicians of all acute care inpatients on a given day (n = 212) and all new acute care admissions over a 2-week period (n = 125) completed an adapted version of the Nottingham Acute Beds Use Survey (NABUS) Questionnaire.

RESULTS

On a given day, only 62 of 212 inpatients were unsuited for any alternative to acute care hospitalization. A floor ratio of 18 acute care beds per 100,000 inhabitants seems adequate for the catchment area in question, provided that alternatives to hospitalization are fully and efficiently available. Alternatives essentially involve an array of the following: supervised residential settings, day hospitals, and intensive home care (2 to 6 hours weekly). The ratio of intensive home care workers required would be 25 per 100,000 inhabitants.

[Treating depression is an effective population suicide prevention strategy: recent evidence from Scandinavian studies.]

This article's objective is to signal to the Quebec and the francophone audience of public planners and decision makers, clinical and suicide prevention workers, staff, relatives as well as the public of these recent breakthrough findings that provides strong evidence now that increasing the treatment of depression is an effective suicide prevention strategy. The article summarizes the evidence published recently and then critically reviews the methods and if the evidence fits within a complete public health perspective demonstration of an effective suicide prevention strategy. It highlights that the treatment of depression may not only decrease suicide rates but have much more larger public health effects by decreasing the disability associated with depression and have impact on future generations at risk of depression and suicide. The obstacles to developing such nation-wide strategy of increasing the treatment of depression will be highlighted with specific reference to the situation in Quebec.

[Validation of the French version of the Health of the Nation Outcome Scales (HoNOS-F)]

OBJECTIVE

This study reports the validation of the French version of the Health of the Nation Outcome Scales (HoNOS-F), a questionnaire developed to measure health and social functioning of people with mental illness.

METHOD

Once each statement was tested for readability, the scale was administered to 3 samples of people suffering from severe mental disorders to estimate its reliability and validity. More specifically, tests were run to establish the internal consistency, the stability, and the interrater reliability of the HoNOS-F. Confirmative factor analyses and mean differences according to age, sex, and diagnosis were also conducted to evaluate respectively construct- and criterion-related validity.

RESULTS

Coefficients obtained from the various tests show that the scale is reliable only when the total score is used. The confirmatory factor analyses indicate that the observed data do not fit the 2 proposed models, a unidimensional model and a 4-dimension model. However, the scale did show criterion-related validity.

CONCLUSIONS

Results of the present study converge with those obtained on the original widely used English version. Therefore, we suggest that clinicians use the questionnaire by referring to each item separately and by considering such patient characteristics as age, sex, and diagnosis. We also suggest that researchers wishing to evaluate health and social functioning of persons with serious mental disorders use the total score. Caution is, however, warranted when interpreting the total score for a French-speaking population, because the factorial solution 1-dimension model did not prove to be satisfactory.

["What's up, doc?" The context, limitations, and issues for clinicians in evidence-based medicine]

BACKGROUND

The evidence-based medicine approach could be considered a new name given to the contemporary medicine dialectics between the practice of an art and the insight provided by the best scientific data.

METHODS

In this 3-part article, the background is introduced, then the design limits of the approach are shown through an example of metaanalysis applied to 4 psychiatric situations, and the conclusion is left to a clinician.

RESULTS

In the background, evidence-based medicine is first associated with the period of budget cuts, then with the widespread popularity of the Internet. A few snags in this seemingly flawless system are seen when the subjective items involved in metaanalysis are taken into account. There are also problems linked to unpublished data, homogenization of populations studied, and the assumption that only random studies lead to valid scientific knowledge. The clinician will probably not be surprised and will link this to the old debate between empiricists and rationalists.

CONCLUSION

In its purest form, evidence-based medicine supports the necessary continuous inquiry about our practices.

Organizational analysis of deinstitutionalization in a psychiatric hospital

BACKGROUND

Few studies have been conducted of the organizational aspects that impact on the course of psychiatric deinstitutionalization.

METHOD

A case study was undertaken of 10 years of deinstitutionalization in a Montreal psychiatric hospital.

RESULTS

Deinstitutionalization has forged ahead in the hospital over the past few years, although the course it has taken is not the one initially plotted by its promoters. Care management of deinstitutionalized patients remains under the control of the psychiatric hospital and its physicians. However, the patients' well-being has remained a focus of concern and does not seem to have been detrimentally affected by this development.

CONCLUSION

Deinstitutionalization is both a solution to the criticisms levelled at the hospital-psychiatric approach of managing persons with severe and persistent mental disorders and an extremely useful tool in the power struggle among the various stakeholders in mental health services reform. Deinstitutionalization has become unavoidable.

Cost-effectiveness analysis of psychiatric deinstitutionalization

BACKGROUND

The cost-effectiveness of the eventual deinstitutionalization of patients with severe and persistent mental disorders who are currently hospitalized in long-term care remains a controversial matter.

METHODS

A retrospective cohort of 96 pairs of psychiatric hospital patients with 1 member deinstitutionalized between 1989 and 1998 was followed up for nearly 10 years. All use of medical and social services was documented. Patients were evaluated at the start and end of the study on various clinical and social dimensions, as well as on quality of life.

RESULTS

On several dimensions, deinstitutionalized patients scored more positively than did those patients still hospitalized. The lower daily cost of living accommodations for deinstitutionalized patients easily offsets the cost of services required for treatment in the community.

CONCLUSION

Deinstitutionalization, as implemented in the hospital studied, remains for many patients a less costly option than continued hospitalization and is likely to improve their mental state and well-being.

Downsizing psychiatric hospitals: needs for care and services of current and discharged long-stay inpatients

BACKGROUND

With the psychiatric deinstitutionalization movement in its fourth decade, questions are being raised concerning its relevance for long-stay inpatients with severe disabilities and the risk that those discharged into the community may be abandoned.

METHODS

A random sample taken in 1989 of long-stay inpatients at Louis-H Lafontaine Hospital made it possible to examine 96 pairs of patients. Each pair included 1 patient discharged between 1989 and 1998 and 1 patient hospitalized. Pairs were matched for sex, age, length of stay, and level of psychiatric care in 1989. Patients and staff were interviewed using standardized questionnaires, and case notes were reviewed to assess symptoms, daily living skills, residential status, quality of residential setting, and clinical and social problems and needs.

RESULTS

The investigation revealed that discharged patients moved to highly supervised settings, which included professionally supervised group homes, supervised hostels, and foster families. About 20% went to nursing homes owing to loss of autonomy from physical disorders. Only 4 discharged patients were lost to follow-up, of whom 2 were probable vagrants. Both those discharged and those remaining as inpatients presented with major clinical problems and daily living skill deficits. The care needs of discharged patients were generally met, and placement in the community was considered appropriate. Of those who had remained hospitalized, over one-half could be moved to supervised settings immediately, or after 1 to 2 years' preparation in a discharge unit, while 13% could be moved to nursing homes. Over 25% required intensive, individualized rehabilitation treatment targeting engagement, psychotic symptoms, withdrawal, and dangerous and socially embarrassing behaviours.

CONCLUSION

Deinstitutionalization in the largest Canadian psychiatric hospital did not lead to patient abandonment in the community.

Evaluating the closure or downsizing of psychiatric hospitals: social or clinical event?

OBJECTIVES

The evaluation matrix recently proposed by Tansella and Thornicroft suggests that the field of social and epidemiological psychiatry has focussed more on the individual/patient level of mental health care services than the system level. Moreover, phenomena such as deinstitutionalization have been examined more as clinical events than as social ones. The aims here are to deepen our understanding of deinstitutionalization, particularly as regards the downsizing/closure and role of psychiatric hospitals.

METHODS

I begin by reviewing the manifest and latent functions of psychiatric hospitals. This is followed by a discussion of how these functions must be met by any comprehensive community-oriented system of mental health care for severely mentally ill patients. Also, in order to reframe the downsizing/closure of psychiatric hospitals as a social event for the field of social psychiatry and psychiatric epidemiology, I posit that the process of deinstitutionalization is driven today by the same forces that were present at the outset of the movement.

RESULTS

I review four recent series of studies addressing primarily the outcomes, but also other aspects, of the downsizing/closure of psychiatric hospitals, with a view to illustrating the methods used, the results obtained and the blind angles missed in this research.

CONCLUSIONS

Lessons are drawn on how to fill certain vacant cells of the matrix.

Assessment of a new rehabilitative coping skills module for persons with schizophrenia

A rehabilitative coping skills module employing problem solving and cognitive behavioral therapy and an experimental repeated-measure design was tested on 55 randomly selected persons severely handicapped by schizophrenia, most of whom had lived almost half of their lives in psychiatric wards. Unlike the control group of 44 comparable schizophrenics, the experimental group exhibited a significant decrease in delusions and increase in self-esteem, and maintained hygiene levels.

[Implementation of intensive follow-up in the community: lessons to be considered]

OBJECTIVE

To examine various issues concerning the implementation of a program for assertive community treatment (ACT).

METHOD

In-depth interviews were conducted with participants of an ACT project implemented in the 1970s. A quality analysis was undertaken, assessing the issues that prevented the expansion of such an approach as well as issues to be considered in future implementation of ACT.

RESULTS

Social, cultural, organizational, professional, and economic factors were identified that will continue to play decisive roles in the integration of such a program. The ACT implementation in question occurred at the same time as the shift to community psychiatry, without having been linked to that approach. Currently, social factors such as self-help groups and parents foster the implementation of such programs. The organizational factors include the importance of linking ACT to existing health care services, as well as adapting ACT to these services. The association of this type of project with a research team did not ensure a successful implementation. A third factor is the psychiatrist's training and motivation with respect to the practice of this approach. Finally, economic issues are playing a larger role in the implementation of this approach.

CONCLUSION

This study relates different issues regarding the implementation of an ACT. The results represent assumptions that need to be confirmed by assessing ACT implementation in Quebec as well as in the rest of Canada.

Prediction of level of serotonin 2A receptor binding by serotonin receptor 2A genetic variation in postmortem brain samples from subjects who did or did not commit suicide

OBJECTIVE

Postmortem studies have indicated that suicide victims have greater serotonin receptor 2A (5-HTR2A) binding in prefrontal brain regions. However, there remains some controversy regarding the biological specificity of these findings. The authors hypothesized that the variance observed in brain 5-HTR2A binding is genetically mediated, at least in part.

METHOD

Postmortem data from 56 subjects who had committed suicide and 126 normal comparison subjects were studied; brain tissue was available from 11 subjects who committed suicide and 11 comparison subjects. Homogenate binding assays were carried out with [3H]ketanserin. Variation at the 5-HTR2A gene (HTR2A) was investigated by means of two polymorphisms: T102C and A-1438G.

RESULTS

5-HTR2A binding was greater in the prefrontal cortex of the subjects who committed suicide. In addition, the findings suggest that HTR2A variation significantly affects 5-HTR2A binding. However, no interaction between suicidal behavior and this locus was observed.

CONCLUSIONS

These results confirm previous reports of greater 5-HTR2A binding in subjects who committed suicide; they also provide preliminary evidence suggesting that the number of 5-HTR2A receptors is genetically mediated.

Efficacy of a self-esteem module in the empowerment of individuals with schizophrenia

To enhance empowerment and improve self-esteem among individuals with severe and persistent mental illness, a 12-week "module" (a self-contained program of activities) was created and tested in a randomized clinical trial. Fifty-one individuals with schizophrenia were assigned to the experimental group in addition to regular treatment, and 44 individuals participated in a control group that continued with regular treatment only. Psychosocial, diagnostic, neurocognitive, and symptomatology measures were taken for all 95 subjects before treatment (T0), after treatment (T1), and at a 6-month follow-up (T2). Results indicated module effects on coping skills (active coping skills significantly increased) and psychotic symptoms (positive symptoms significantly decreased), demonstrating the efficacy of this particular type of intervention. Interpretation of the results highlighted the significance of the environment and the role it could potentially play in supporting the empowerment of severely mentally ill individuals.

Depression in Ontario: under-treatment and factors related to antidepressant use

Our study examines how depression is treated in Ontario, with particular examination of the correlates of antidepressant utilization using a broad model of individual (clinical), demographic, and health system determinants of treatment. From a community epidemiologic survey, a sample of 333 individuals with major depression in the past year was identified. More than half received no treatment (untreated n = 170, 51.1%), while 74 (22.2%) received treatment without medication, 29 (8.7%) received treatment mainly with anxiolytics, and only 60 (18.0%) were treated with antidepressants. All four groups had similar rates of alcohol and substance abuse. Disability and comorbid anxiety were common, with the least in the untreated group and the most in the antidepressant group. Increased use of antidepressants was associated with psychiatrist contact, while family physicians treated a substantial minority primarily with anxiolytics. Under a universal health care system, no differential access to antidepressants was found in terms of demographic characteristics. Clinical severity and contact with a psychiatrist correlate with antidepressant treatment of depression.

Major depression in individuals with a history of childhood physical or sexual abuse: relationship to neurovegetative features, mania, and gender

OBJECTIVE

Numerous studies have linked childhood trauma with depressive symptoms over the life span. However, it is not known whether particular neurovegetative symptom clusters or affective disorders are more closely linked with early abuse than are others. In a large community sample from Ontario, the authors examined whether a history of physical or sexual abuse in childhood was associated with particular neurovegetative symptom clusters of depression, with mania, or with both.

METHOD

The World Health Organization Composite International Diagnostic Interview was used to assess 8,116 individuals aged 15-64 years. Each subject was asked about early physical and sexual abuse experiences on a structured supplement to the interview. Six hundred fifty-three cases of major depression were identified. Rates of physical and sexual abuse in depressive subgroups defined by typical and reversed neurovegetative symptom clusters (i.e., decreased appetite, weight loss, and insomnia versus increased appetite, weight gain, and hypersomnia, respectively) and by the presence or absence of lifetime mania were compared by gender.

RESULTS

A history of physical or sexual abuse in childhood was associated with major depression with reversed neurovegetative features, whether or not manic subjects were included in the analysis. A strong relationship between mania and childhood physical abuse was found. Across analyses there was a significant main effect of female gender on risk of early sexual abuse; however, none of the group-by-gender interactions predicted early abuse.

CONCLUSIONS

These results suggest an association between early traumatic experiences and particular symptom clusters of depression, mania, or both in adults.

Mental health treatment in Ontario: selected comparisons between the primary care and specialty sectors

OBJECTIVE

Epidemiologic research has demonstrated that the majority of mental illness in the community is not treated. Primary care physicians and the specialty mental health sector each have an important role in the provision of mental health services. Our goal is to clarify the extent of undertreatment of selected mental illnesses in Ontario and to examine how treatment is divided between the primary care and specialty sectors. In particular, we are interested in both the relative numbers and the types--based on sociodemographic and severity indicators--of patients found in each sector, as well as in confirming the key role of primary care in the provision of mental health services.

METHODS

Data were taken from the Mental Health Supplement to the Ontario Health Survey, a community survey of 9953 individuals. All subjects who met DSM-III-R criteria for a past year diagnosis of mood, anxiety, substance abuse, bulimic, or antisocial personality disorders were categorized by their use of mental health services in the preceding year--into nonusers, primary care only patients, specialty only patients, and both sector patients. The 3 groups utilizing services were then compared by demographic, clinical, and disability characteristics.

RESULTS

Only 20.8% of subjects with a psychiatric diagnosis reported use of mental health services, but 82.9% of these same individuals used primary care physicians for general health problems. Among those who used mental health services, 38.2% used family physicians only for psychiatric treatment, compared with 35.8% who used only specialty mental health providers, and 26.0% who used both sectors. The 3 groups of users showed only modest differences on sociodemographic characteristics. Patients in the specialty only sector reported significantly higher rates of sexual and physical abuse. On specific disability measures, all 3 groups were similar.

CONCLUSION

The vast majority of individuals with an untreated psychiatric disorder are using the primary care sector for general health treatment, allowing an opportunity for identification and intervention. Primary care physicians also treat the majority of those seeking mental health services, and individuals seen only by these primary care physicians are probably as ill as those seen exclusively in the specialty mental health sector. From a public health perspective, future policy interventions should aim to improve collaboration between the 2 sectors and enhance the ability of primary care physicians to deliver psychiatric services.

Telephone surveys as an alternative for estimating prevalence of mental disorders and service utilization: a Montreal catchment area study

BACKGROUND

Large-scale mental health surveys have provided invaluable information regarding the prevalence of specific mental disorders and service use for mental health reasons. Unfortunately, because vast surveys conducted face to face are very costly, many countries and provinces do not embark upon this path of research, thus depriving themselves of a rich source of data useful for service planning.

METHOD

As an alternative, the authors undertook a telephone survey with a sample of 893 residents from a Montreal catchment area. Mental disorders were assessed by the Composite International Diagnostic Interview Simplified (CIDIS), an instrument especially designed to be used in mail or telephone surveys. Service utilization was measured by an instrument similar to those used in recent large Canadian or American surveys.

RESULTS

The prevalence rate for any mental disorder was lower in this study than in some large-scale epidemiological surveys reviewed. This could be explained by methodological differences, such as number of disorders covered and period of reference. With regard to specific mental disorders, results appeared very similar to those of other studies. Concerning service utilization, rates tended to be higher than in other studies, and this finding could reflect real differences between Quebec and other Canadian provinces or the United States.

CONCLUSIONS

Aside from being lower in cost, telephone surveys can yield results comparable to those obtained in large-scale epidemiological surveys conducted by means of face-to-face interviews.

One hundred in-patient suicides

BACKGROUND

The study aimed to define the characteristics and assess the clinical predictability and possible prevention of psychiatric in-patient suicides.

METHOD

The coroner's files on all suicides in the Greater Montreal Region from 1 April 1986 to 31 March 1991 were examined. The medical records of each case of suspected in-patient suicide were then reviewed and rated for predictability and preventive measures taken.

RESULTS

A total of 3079 suicides were recorded over this five-year period (mean annual rate of 16.4 per 100,000 inhabitants). Of these, 104 (3.4%) involved hospital in-patients. Nearly half (48%) of these in-patient suicides occurred outside the hospital setting. The methods most frequently employed were hanging (36%) and jumping from high places (24%). Patients suffering from an affective disorder (45%) or schizophrenia (35%) comprised the majority of the sample. Suicides were significantly more predictable in general hospital psychiatric wards. Suicide prevention measures did not differ significantly across settings.

CONCLUSIONS

The majority of in-patient suicides were not highly predictable. For highly predictable suicides, the results underline the importance of actively treating and protecting these patients.

Family physicians and the mental health system. Report from the Mental Health Supplement to the Ontario Health Survey

OBJECTIVE

To determine family physicians' role in the mental health care system.

DESIGN

The Mental Health Supplement to the Ontario Health Survey is an epidemiologic, retrospective, home-interview survey. Results reported here are based on responses of a weighted sample of patients aged 15 to 64.

SETTING

Ontario, 1990 to 1991.

PARTICIPANTS

Random sample of 9953 household residents.

MAIN OUTCOME MEASURES

Standardized assessment of mental disorders, associated risk factors and disability, and patterns of use of mental health services.

RESULTS

More people seek mental health services from their family physicians (FPs) than from psychiatrists, social workers, or psychologists. Among patients who consulted for mental health purposes, more than 35.4% saw FPs only, 24.7% saw FPs and other mental health care providers (psychiatrists, psychologists, social workers, others), and 40% saw other mental health care providers only. There were few sociodemographic, diagnostic, or clinical severity differences between the FP-only group and the other two groups. Some evidence suggested FPs saw more recent onset cases, but they were also involved in joint care for more complex or disabled cases. More than 57% of those seeing FPs received medication; 43% received other forms of care. Those seeing FPs only made four visits per year; those who consulted other mental health professionals made 14 to 20.

CONCLUSIONS

Our study confirms FPs' important role in the current mental health care system.

Estimating local-area needs for psychiatric care: a case study

BACKGROUND

Different approaches to estimating local catchment-area needs for psychiatric services are illustrated and compared.

METHOD

Data from an epidemiological morbidity survey of a random sample of 496 adults were available, as were actual service utilisation rates. Four types of utilisation were modelled (i.e. overall, out-patient, in-patient, emergency clinic) using social indicators available from Statistics Canada census-tract data. Finally, a case-control study compared out-patients from a deprived and an affluent catchment area, matched case by case for primary diagnosis, age, sex and residential status (n = 52).

RESULTS

Modelling proved highly predictive of utilisation, the overall-use model accounting for 73% of the variance. The case-control study indicated a higher rate of Axis II traits, substance abuse and needs for social care in the deprived catchment area.

CONCLUSIONS

Resource allocation based on the social indicators modelling method was more consistent with sensible distribution of human resources. None of the methods, however, appear to reflect adequately the severity of caseloads evidenced in the case-control study.

The reliability of the community version of the MRC Needs for Care Assessment

One hundred and nine adults were screened in the community using the abridged version of the CIDI (CIDIS). The subjects comprised DSM-III-R current cases (N = 48), lifetime cases (N = 31) and non-cases (N = 30). The interviews with the 109 subjects were conducted by one of two pairs of clinicians and videotaped. Each interviewer-pair included a psychiatrist and a clinical psychologist. They rated the community version of the Needs for Care (NFCAS-C) by consensus. The other pair of judges then viewed the video and rated the NFCAS-C independently. The agreement on overall needs was excellent (kappa = 0.75), and very good for four of the seven specific sections (from kappa = 0.61 to 0.81). One section could not be rated because of low prevalence, and agreement was less good for the remaining two sections. Agreement was good on specific interventions (medication, kappa = 0.60; specific psychotherapy, kappa = 0.55), but poor on non-specific interventions. The majority of disagreements were due to differences in clinical judgement rather than to technical errors. A new instruction manual has been produced and should help training as well as stabilizing reliability. In devising reliable and valid instruments based on clinical judgement, a balance must be achieved between enhancing reliability with more precise rules and constraining clinical judgement so tightly that validity is lost.

Psychiatrists' ratings of expressed emotion

The purpose of this study was to determine the extent to which psychiatrists are familiar with the concept of expressed emotion and to determine the extent of its use in their day-to-day practices. We also wished to test the ability of psychiatrists to estimate the expressed emotion status of the relatives of their patients. Following the assessment of expressed emotion in 96 relatives using the Camberwell Family Interview, the psychiatrists treating the schizophrenic patients were surveyed about their knowledge of expressed emotion and were asked to estimate the expressed emotion of their relatives. Thirty-five percent of the respondents use the expressed emotion concept daily in their practice. When the Camberwell Family Interview ratings of expressed emotion were compared with those from the psychiatrists, the agreement rate was no better than chance (45.7%). Without formal training in the use of the Camberwell Family Interview, practitioners are cautioned against ascribing an expressed emotion status to the relatives of their patients.

Suicide and mental disorders: a case-control study of young men

OBJECTIVE

By means of the psychological autopsy method and a case-control design, the authors examined the association of specific mental disorders and comorbidity with suicide among young men.

METHOD

Seventy-five men aged 18-35 years whose deaths were adjudicated as completed suicides by coroners of greater Montreal and Quebec City were matched to 75 living young men for age, neighborhood, marital status, and occupation. For each subject in both groups a key respondent best acquainted with the subject was interviewed by clinicians using standardized schedules. Information from the coroner and medical records was also collected. Two experienced psychiatrists, blind to outcome, established best-estimate DSM-III-R diagnoses.

RESULTS

Six-month prevalence rates for all axis I diagnoses for the suicide and comparison groups were 88.0% and 37.3%, respectively; major depression was present in 38.7% and 5.3%, alcohol dependence in 24.0% and 5.3%, psychoactive substance dependence in 22.7% and 2.7%. Borderline personality disorder was identified in 28.0% and 4.0%, respectively. Of the suicide subjects, 28.0% had at least two of the following disorders: major depression, borderline personality disorder, and alcohol or drug dependence; the rate was 0.0% among the comparison subjects.

CONCLUSIONS

In young men, completed suicide is linked to specific mental disorders, namely, major depression, borderline personality disorder, and substance abuse. Comorbidity involving any of these disorders is frequently associated with completed suicide.

Problems and needs for care of patients suffering from severe mental illness

Recently, evaluative research has yielded a procedure, the Needs for Care Assessment Schedule (NFCAS), which articulates the problems and the corresponding interventions required by psychiatric patients in a systematic and reproducible manner that is of interest to both administrators and clinicians. Although the NFCAS decisions are ultimately subjective and there is no absolute standard, the procedure limits variation and offers a framework for comparison and further elaboration. A group of 98 patients who were receiving treatment at the Louis-Hippolyte Lafontaine Psychiatric Hospital in Montréal, Québec and who were suffering from severe mental disorders were assessed with the NFCAS procedure. Subjects were selected from four treatment settings representing different levels of problems and needs: long-term in- and outpatients and short-term in- and outpatients. Results of the NFCAS were examined, along with those of standardized questionnaires. The NFCAS allowed a comprehensive understanding of the clinical realities for problem and need assessment. There was an average of 3.9 clinical problems and 4.5 social problems per patient. Long-term patients and patients residing in the hospital had more problems. A total of 76% of the problems assessed were rated as receiving appropriate interventions, whereas 17% of the problems assessed were considered in need of an assessment or in need of treatment. A greater need for intervention was found for social problems than for clinical problems.

Further reliability and validity studies of a procedure to assess the needs for care of the chronically mentally ill

The Needs for Care Assessment Schedule (NFCAS; Brewin et al. 1987) is an itemized and systematic procedure that aims to evaluate the needs for care of long-term mentally ill patients. The present study pursues reliability and validity related issues with the NFCAS in a different cultural context applying the procedure to 98 severely mentally ill patients belonging to different patient groups: short-term, long-term, in-patient and out-patient. Inter-rater reliability was found to be excellent. The results suggest that a clinician with little practical experience and adequate training may effectively use the procedure. The assessment of clinical relevance suggested that the procedure is both applicable and pertinent to all the patients in the study. Additional guidelines were developed for its use with long-term in-patients.

Assessment of independent living skills for psychotic patients. Further validity and reliability

It is well known that psychotic patients have severe social and life-skill deficits. Psychiatric rehabilitation programs are designed to teach these skills to patients. Before implementing such a program, patient deficits should be evaluated with reliable measures. The present study assessed the psychometric properties of the French version of the "Independent Living Skills Survey" (ILSS) developed by Wallace, Kochanowicz and Wallace (Wallace C J, Kochanowicz N, Wallace J [1985] Independent living skills survey. Unpublished manuscript, Mental Health Clinical Research Center for the Study of Schizophrenia, West Los Angeles Veterans Administration Medical Center, Rehabilitation Medicine Service [Brentwood Division], Los Angeles, CA). Although widely used, the patient version of this scale has unknown psychometric properties. The ILSS was composed of 75 items, rated as present or absent and distributed in 10 scales. The French version was administered to 145 patients with a psychotic diagnosis who were living in the community. All scales had very good psychometric qualities with the exception of the job-maintenance scale. The test-retest reliability varied from .48 to .85, and alpha coefficients were good for seven of the nine scales. Various aspects of construct validity were explored. The scales discriminated between patients as a function of their subgroups, sex, and diagnosis. Concurrent validity confirmed the specificity of the ILSS dimensions. Factor analysis revealed two factors, one for basic skills and one representing higher order skills. Recommendations for future development of the ILSS are proposed.

Homicide followed by suicide: a Quebec case series, 1988-1990

Homicide followed by suicide is a rare but tragic event. Psychiatrists and mental health professionals are often called upon to comment publicly on the event or to help the "hidden victims," the survivors of the tragedy. There were 39 such cases in Quebec between 1988 and 1990, and they have been reviewed through the examination of the coroner's files. The epidemiological rates of homicide, suicide, homicide-suicide and the sociodemographic and clinical characteristics of the perpetrators and victims are presented and compared with the international literature. Sociological and psychopathological hypotheses are presented with a special reference to the possibility of various subgroups of perpetrators. Research needs to be pursued along the lines of more detailed case studies of psychopathological characteristics using the psychological autopsy approach. The reconstruction of the couple's relationship and of the final circumstances leading up to the tragedy may provide warning indices that could be helpful in preventing such tragedies.

Comprehensive community care without long stay beds in mental hospitals: trends from an Italian good practice area

Despite the scientific evidence that long stays in mental hospitals are clinically deleterious, inhumane and probably not cost-effective, this practice still occurs in most Western countries. The continued use of long stay beds in mental hospitals is a policy decided by many authorities, including psychiatrists. Alternatives to the mental hospital exist and may limit the use of hospital beds through comprehensive community care that also includes proper residential provisions. Alternatives may also decrease, but not impede the tendency to chronicity in some patients, who become long term users of these community services. Italy passed a law in 1978 prohibiting admissions to mental hospitals and encouraging the development of community care. In South Verona, Italy, the policy has been properly implemented and evaluated. Data from the case register and intensive studies of a cohort of patients will be used to show that long stay hospitalization can be discontinued while meeting the needs of the most severely handicapped patients. Implications of South Verona's experience for future training of psychiatrists will also be discussed.

Assessing the needs for care of non-psychotic patients. A trial with a new standardized procedure

Recent psychiatric epidemiological studies using standardized interviews in the community have yielded high rates of non-psychotic disorders. The implications for service provision in terms of treatment and planning remain unclear. No methodology exists to link the individual needs for care and services to problems associated with disorders. The Needs for Care Assessment Schedule (NFCAS) is a relatively new procedure for assessing the needs of long-term mentally ill patients, mostly psychotic and attending psychiatric services. We report here a trial application of a modified version of the NFCAS on a sample of 39 non-psychotic patients, most of whom were attending psychiatric outpatient services. The results show that the modified procedure requires further refinement to achieve acceptability and reliability. Some improvements are suggested for refining items and for the collation of others. The difficulties encountered underline the key issues in developing such technology: specifying the threshold for recognizing the problems, detailing the interventions considered appropriate, defining the model of care and specifying the composition of the research team.

[Training of interviewers in the utilization of standardized questionnaires in psychiatry: studies realized with the Present State Examination (PSE)]

Interview questionnaires offer more validity than self-administered format in exploring psychopathological or psychosocial phenomena of interest in psychiatric research. If used, special care needs to be paid to interviewers' training and ensuring that they maintain their reliability. No widespread training standards exist and each schedule may carry its own procedure. Our aims are to indicate how we trained interviewers with the French version of the Present State Examination (Wing, Cooper and Sartorius, 1974) and how we checked and kept acceptable interraters reliability during one study. We will provide data on the interraters reliability during the training and the study, as well as the test-retest reliability. These results will be used to support some guidelines when using this sort of psychiatric research questionnaires in order to ensure comparability both within the study and between studies.

Reliable use of the Present State Examination by psychiatric nurses for clinical studies of psychotic and nonpsychotic patients

Four psychiatric nurses were trained with the French version of the Present State Examination, 9th edition (PSE-9). Reliability was tested on 18 cases of psychotic and nonpsychotic patients. The reliability indexes were comparable to those reported for the English version of PSE-9. These preliminary results indicate that further training may improve reliability for the nurses. It also warrants other trials in which psychiatric nurses will be used as interviewer with instruments that require clinical judgement.

Excess mortality by natural causes of Italian schizophrenic patients

The risk of mortality over a 5- to 8-year period for a total 1-year prevalence cohort of schizophrenic patients extracted by means of the South-Verona Psychiatric Case Register (Italy) was assessed using three methods: (1) case control with both non-psychotic patients and the general population matched for sex and age; (2) indirect standardization using mortality tables; (3) a recently described method using survival tables. All methods yielded an excess mortality associated with schizophrenia, close to the two-fold increase described in other studies, while the survival tables method produced a higher standardized mortality ratio (SMR). The increased SMR did not appear solely attributable to suicide. Most deaths were attributable to natural causes. This is a departure from other recently reported mortality studies. The possible reasons are discussed.

Mobility of schizophrenic patients, non-psychotic patients and the general population in a case register area

This preliminary study attempts to evaluate the effect of a community psychiatric service on residential mobility by comparing a cohort of schizophrenic patients over a 5-year period with that of non-psychotic and general population control groups in South Verona, a case register area in Northern Italy. No significant differences were found between the groups for different types of movement (within South Verona/outside catchment area of South Verona/outside City of Verona), except for movements within South Verona between the schizophrenic group and neurotic group. The former tended to move less than the latter. The sociodemographic factors associated with movements of the general population in Verona were being male and single, whereas place of birth was less important. The results showed that in the two patient groups as well as in the general population in South Verona, the percentages of those who moved outside the case-register area ranged between 1.5%-4.4% over a one-year period, and between 7.3%-13.8% over a five-year period, indicating a relatively consistent denominator for the Case Register.

Social factors affecting clinical caseload in Italian good practice areas

Italian statistics indicate that fewer people are living alone than in Great Britain. Psychiatric Case Register figures show that the treated prevalences are nearly half those found in British Case Register areas. The level of staffing in good practice areas like South-Verona or Trieste is at least similar and at times higher than British or American counterparts. The clinical caseload of Italian clinical teams is therefore lower. The Italian patients may have a greater social network's availability by the mere fact of living in the same household of relatives. It is hypothesized that these elements affect a clinical team's availability to offer alternatives to hospitalisation. A ratio caseload/staff should be taken into account in assessing the Italian psychiatric reform and alternatives to hospitalisation.