Discriminating Powers of Partial Agreements of Names for Linking Personal Records

The preceeding paper examined the logical basis of an exact way of calculating the discriminating powers of people’s names when they only partially agree. The method has application to automated file searching and record linkage. The present account describes an empirical test of the approach. Use is made of some 2000 comparison pairs of male given names, obtained as a byproduct from an earlier linkage study. The test shows that exact value-specific ODDS can indeed be calculated for common names when compared with their accepted synonyms (e.g. JOSEPH versus JOE). Moreover, the use can be extended to include rare variants, by arranging these into groups defined in value-specific terms (e.g. as selected blocks in an alphabetically sequenced listing, or combinations of such blocks). A majority of all name comparisons may be handled in this manner.

The added precision serves to reduce the numbers of records that are ambiguously linked and require labour intensive clerical resolution.

Discriminating Powers of Partial Agreements of Names for Linking Personal Records

Machines have difficulty when using people’s names to link medical and other records pertaining to the same individuals because of nicknames, ethnic synonyms, truncations, misspellings and typographical errors. Present algorithms used to compute the discriminating powers (or ODDS) associated with partial agreements of names are based, inappropriately, on the degrees of outward similarity alone. They are particularly ineffective in dealing with names that look alike but are unrelated, and with related names that have little apparent similarity. A fundamentally different rationale is, therefore, proposed which, like the human mind, assesses the relatedness of two alternative forms of a name in terms of how often they are used, interchangeably in practice. This must be taken into account if the associated discriminating powers (ODDS) are to be correctly computed. A way of implementing this more precise approach is described and illustrated, using the given names on linked records from an earlier epidemiological study. This first study of two describes the logical basis for record linkage, a second one the empirical test.

Neural changes associated with appetite information processing in schizophrenic patients after 16 weeks of olanzapine treatment

There is evidence that some atypical antipsychotics, including olanzapine, can produce unwanted metabolic side effects, weight gain and diabetes. However, neuronal correlates of change related to food information processing have not been investigated with these medications. We studied the effect of a pharmacological manipulation with an antipsychotic known to cause weight gain on metabolites, cognitive tasks and neural correlates related to food regulation. We used functional magnetic resonance imaging in conjunction with a task requiring visual processing of appetitive stimuli in schizophrenic patients and healthy controls before and after 16 weeks of antipsychotic medication with olanzapine. In patients, the psychological and neuronal changes associated following the treatment correlated with appetite control measures and metabolite levels in fasting blood samples. After 16 weeks of olanzapine treatment, the patients gained weight, increased their waist circumference, had fewer positive schizophrenia symptoms, a reduced ghrelin plasma concentration and an increased concentration of triglycerides, insulin and leptin. In premotor area, somatosensory cortices as well as bilaterally in the fusiform gyri, the olanzapine treatment increased the neural activity related to appetitive information in schizophrenic patients to similar levels relative to healthy individuals. However, a higher increase in sensitivity to appetitive stimuli after the treatment was observed in insular cortices, amygdala and cerebellum in schizophrenic patients as compared with healthy controls. Furthermore, these changes in neuronal activity correlated with changes in some metabolites and cognitive measurements related to appetite regulation.

[Clozapine and pregnancy]

This article reviews the relations between clozapine and pregnancy. Six case reports are identified in the literature of pregnant patients who received clozapine. Novartis at Basle, Switzerland, through its pharmacovigilance and epidemiology, service, has data on nearly 200 cases summarized in this article. We also describe the case of a patient with paranoid schizophrenia who was hospitalized 10 times between the age of 22 to 32. She received clozapine when she was 29 years old and, with a daily dosage of 350 mg, she became asymptomatic. At the age of 33 and 37, she became pregnant and continued clozapine during her 2 pregnancies. During her first pregnancy, she received insulin due to gestational diabetes associated with a body weight mass (BWM) of 30.4 (N = 20 to 25). During her second pregnancy, the BWM was 23.7 and she did not develop diabetes. She delivered at term 2 daughters who are at the time of this report 5 and 3 years old. The two girls are doing well and have no developmental delay. Psychotic symptoms exacerbation: the plasma concentration of clozapine diminishes during pregnancy due to a higher hepatic metabolism and distribution volume. Monitoring plasma concentration of clozapine can help to adjust its dosage. In case of psychotic symptoms exacerbation, the following can be recommended: 1) Increase the clozapine dosage; 2) Add a classic antipsychotic like perphenazine, trifluoperazine or haloperidol. Diabetes: obesity, glucose intolerance or a family history of diabetes are risk factors to develop gestational diabetes. The follow-up of patients, who take an atypical antipsychotic, should include constant monitoring of the blood glucose or Hb1A and lipid dosages. Complications at labor: Clozapine increases the secretion of oxytocine and the contraction of the uterine muscle. But, no studies can explain how clozapine affects the labor exactly. Some case studies report use of forceps, vacuum or cesarean.

CONVULSIONS

Stoner (1997) described neonatal convulsions 8 days after birth. The mother was receiving 350 mg of clozapine, but also lorazepam and haloperidol during her pregnancy. The newborn withdrawal of lorazepam can increase the risk of convulsions and also haloperidol can diminish the convulsion threshold. Floppy infant syndrome: in the case described by Dimichele (1996), the mother received a daily dosage of 300 mg of clozapine and 2.5 mg of lorazepam 3 to 5 times a day. This can explain hypotonia. Stoner (1997) reports a second case where a mother, who received 600 mg of clozapine during pregnancy, gave birth to a child who had no convulsions neither hypotonia.

DEVELOPMENT

The cases described concerning studies of children until age 2 to 3 years by Stoner (1997) and Dickson (1998) and until 6 years old by Barnas (1994), do not mention any developmental problem, similar to the two daughters of our patient. The pharmacovigilance service of Novarits reports 6% of malformations. But these reports must be considered with caution since they represent only the pregnancies reported spontaneously to the pharmaceutical company. This is only a portion of all pregnancies associated with clozapine.

CONCLUSION

No specific risks for the mother and children can be attributed to the use of clozapine during pregnancy. However, the plasma concentration of clozapine is higher in the fetus compared to the mother (Barnas, 1994); therefore, a minimal dosage should be used. Since clozapine is present in the maternal milk, breast feeding should be avoided. The advantages to use clozapine during pregnancy must exceed the risks. It is justified to continue the use of this medication even if data on classic antipsychotics (e.g.: haloperidol) are more extensive. Because the risk of psychotic exacerbation is higher, the substitution of clozapine is not recommended. The psychosocial support and the obstetrical follow-up must be intensive too. An institutional pharmacovigilance service should complement the one provided by the industry. Also, further case-control and cohort studies are essential to better estimate the long-term risks.

DRD3 and DAT1 genes in schizophrenia: an association study

OBJECTIVE

To investigate the role of the dopamine receptor 3 (DRD3) and transporter 1 (DAT1) genes in schizophrenia or in modulating its phenotype.

METHODS

a Ser9Gly polymorphism in codon 9 of the DRD3 and a VNTR polymorphism in the DAT1genes were examined in two groups of schizophrenic patients, one of excellent neuroleptic responders (N=42) and one of nonresponders (N=64). A group of healthy volunteers screened for major psychiatric disorders was also included (N=89). In addition, age at onset of psychotic symptoms, attention performance and family loading for schizophrenia spectrum disorders were compared between patients with different genotypes in the DRD3 and DAT1 genes.

RESULTS

No significant differences in the allelic distribution of the DRD3 and DAT1 polymorphisms were detected between schizophrenic patients and controls. A trend toward an excess of DRD3 genotype Gly/Gly was observed in neuroleptic nonresponder schizophrenic patients compared to controls (chi(2)=3. 30, df=1, p=0.07). No significant differences in age at onset of psychotic symptoms, attention task performance or family loading for schizophrenia spectrum disorders were observed between groups with different DRD3 and DAT1 genotypes.

CONCLUSION

These results do not support the role of either of these genes in increasing susceptibility to schizophrenia or in modulating its phenotype in the studied population.

Association between the methylenetetrahydrofolate reductase 677C-->T missense mutation and schizophrenia

The schizophrenia phenotype is heterogeneous with respect to clinical presentation, long-term response to medication, and outcome, possibly reflecting genetic heterogeneity and/or the presence of modifier genes. Compared to non-responders, schizophrenic patients who are responders to neuroleptic medications are characterized by a high female/male ratio, a better long-term outcome and more frequently disturbed dopamine neurotransmission. In this study, we compared two groups of schizophrenic patients selected on the basis of their long-term response to neuroleptics (excellent responders and non-responders) and a group of healthy volunteers, with regard to a missense mutation (677C-->T) in the methylenetetrahydrofolate reductase (MTHFR) gene. This polymorphism was chosen because it is functional and was previously associated with schizophrenia. The present study revealed a significant association between schizophrenia and allele T of this gene. This association was entirely due to an over-representation of allele T in responder patients compared to controls; nonresponder patients did not differ from controls. Genotype TT was more frequent in responder patients compared to controls, thus replicating the findings of Arinami et al. These results strongly suggest that the MTHFR gene is involved in the pathogenesis of schizophrenia characterized by a rapid and sustained therapeutic response to typical neuroleptics and/or a good long-term prognosis/favorable therapeutic outcome.

Analysis of 14 CAG repeat-containing genes in schizophrenia

Recently, it has been suggested that trinucleotide repeat-containing genes may be involved in the etiology of schizophrenia. This study was aimed at investigating putative associations between allelic variants or expansions of CAG repeat-containing genes (CAGrCG) and schizophrenia or its variability with respect to responsiveness to conventional neuroleptics. CAG repeat allelic variants of 14 expressed sequences were compared among three groups of subjects: neuroleptic-responder (R; n = 43) and neuroleptic-nonresponder (NR; n = 63) schizophrenic patients, and a control group (C; n = 122). No CAG expansions, in the range of those observed in neurodegenerative diseases, were identified in these 14 expressed sequences. The sizes of CAG repeat for the hGT1 gene were marginally different among the three groups of subjects (Kruskal-Wallis H (2, 456) = 10.48, Bonferroni corrected P = 0.047). Comparisons among the different groups indicated that neuroleptic responders have shorter alleles compared to controls (Mann-Whitney adjusted Z = -3.23, P = 0.0012). NR patients were not different from controls. These preliminary results suggest that the hGT1 gene, or a gene in its vicinity, may be involved in the etiology of schizophrenia or in modifying the disease phenotype with regard to outcome and/or neuroleptic responsiveness. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 88:694-699, 1999.

[Atypical neuroleptics and selective attention]

GOALS

The aim of this study was to examine selective attention in patients with chronic and refractory schizophrenia who had been exposed for six months to atypical neuroleptic medications: risperidone or clozapine.

METHOD

17 patients satisfying DSM III-R criteria for schizophrenia were assessed according to BPRS and PANSS and abnormal involuntary movements to ESRS. Selective attention tasks were performed before treatment with risperidone or clozapine and at two times during the treatment (6 weeks, T1, and 24 weeks, T2). Patients' performance data were compared to data from a group of general population at T1. Selective attention refers to the ability to discriminate relevant information from irrelevant one. This was measured by a visual search task. Subjects had to search for a target specified by a conjunction of features (color and shape). The target was a black X, while the distracters were white X's, black O's and white O's. The stimuli were displayed on a Macintosh SE computer. A two-button response box was used for response production and the experiment was run in a dimly lit room. A white-fixation stimulus was shown at the center of the display screen between trials. The number of stimuli displayed on a single trial was 1, 4, 7 or 10. The median RTs and error rates of subjects were computed for each factor (target presence and number of stimuli).

RESULTS

A Group X Number of items X Presence of target ANOVA applied on median correct RTs revealed a significant Group X Presence interaction [F(1,176) = 60.433, p < .0001]. Performances improved with the time (F2, p < .01). Correlations were found between positive score on PANSS and performance on selective attention (r39 = -.391).

CONCLUSION

Atypical neuroleptic do not have a deleterious effect on selective attention but a favorable effect on the schizophrenic patients' performance.

Lack of association between the hSKCa3 channel gene CAG polymorphism and schizophrenia

Genetic anticipation, a phenomenon characterized by increased severity of symptoms and earlier age at onset of a disease in successive generations, is believed to be present in schizophrenia. In several neurodegenerative diseases showing anticipation, the mutation causing the disease is an expanded trinucleotide repeat. Therefore, genes containing trinucleotide repeats prone to expansion have become a suitable family of candidate genes in schizophrenia. A human calcium-activated potassium channel gene (hSKCa3), possibly mapping to chromosome 22q11-13, a region previously linked to schizophrenia, was recently described. This gene contains two contiguous expressed CAG repeat stretches. Recently, long allelic variants of one of these CAG repeats were found to be overrepresented in schizophrenic patients compared to normal controls. In this study we attempted to replicate this result and to study the relationship between the length of this CAG repeat on the one hand and the severity and age at onset of the disease on the other hand. No association with the disease or correlation with the severity of schizophrenia was identified. In addition, hSKCa3 was mapped to chromosome 1. Our results do not support the involvement of this particular CAG repeat-containing gene in schizophrenia.

T102C polymorphism in the 5HT2A gene and schizophrenia: relation to phenotype and drug response variability

Although genes play a major role in the etiology of schizophrenia, no major genes involved in this disease have been identified. However, several genes with small effect have been reported, though inconsistently, to increase the risk for schizophrenia. Recently, the 5HT2A 2 allele (T102C polymorphism) was reported to be over-represented in patients with schizophrenia. Other reports have found an excess of allele 2(C) only in schizophrenic patients who are resistant to clozapine, not in those who respond to clozapine. In this study, the 5HT2A receptor allele 2 frequencies were compared between 2 groups of patients with schizophrenia (39 responders and 63 nonresponders) based on long-term outcome and response to typical neuroleptics. A control group of 90 healthy volunteers screened for mental disorders was also included. Genotype 2/2 tended to be more frequent in patients with schizophrenia with poor long-term outcome and poor response to typical neuroleptics (Bonferroni corrected p = 0.09). This difference was significant in men (Bonferroni corrected p = 0.054) but not in women. In addition, the age at first contact with psychiatric care was significantly younger in the patients with schizophrenia with genotype 2/2 than in patients with genotype 1/1. These result suggest that the 5HT2A-receptor gene may play a role in a subset of schizophrenia characterized by poor long-term outcome and poor response to neuroleptics.

Polyglutamine-containing proteins in schizophrenia

Genetic anticipation, manifested by increased severity and earlier age-at-onset of the disease over successive generations, is reported in schizophrenia. The molecular basis of anticipation in several neurodegenerative diseases is unstable coding CAG repeat expansions. Anticipation was reported in schizophrenia. Recently, studies suggested that enlarged CAG/CTG repeats are over represented in schizophrenic patients compared to normal controls. Together, these observations suggest that unstable CAG repeats may play a role in the etiology of schizophrenia. The purpose of this study is to test for the presence of polyglutamine-expanded tracts, encoded by CAG repeats, in total protein extracts derived from lymphoblastoid cell lines of schizophrenic patients. Proteins from schizophrenic patients (n = 59) and normal controls (n = 73) were separated by means of SDS-polyacrylamide gel electrophoresis, wet blotted onto nitrocellulose membrane and probed with a monoclonal antibody (mab 1C2) recognizing expanded polyglutamine arrays. Three abnormal bands corresponding to protein(s) of molecular weight of approximately 50 kDa were identified in two unrelated schizophrenic patients and in a sibling of one of these patients. None of the normal controls tested positive for this abnormal band. These results suggest that expanded polyglutamine-containing proteins, though rare, may play a role in the pathogenesis of schizophrenia.

[From symptomatology to problem-solving : an integrated approach for people with schizophrenia.]

People with schizophrenia experience difficulties in adapting and managing problematical situations of daily life thus diminishing their social coping skills. Several components such as cognitive deficits and biases associated with symptomatology disrupt their problem-solving skills. In social rehabilitation, it is essential to take into account all characteristics and offer an integrated approach. This article presents an approach to problem-solving skills with a contemporary knowledge of schizophrenia. The functionning of the Clinique Jeunes Adultes of the Louis-H. Lafontaine Hospital is presented and serves as a reference.

Patients versus rehabilitation practitioners: a comparison of assessments of needs for care

OBJECTIVE

A group of 47 young adults suffering from schizophrenia was interviewed to garner their views on their needs for care.

METHOD

Three members of a specialized multidisciplinary rehabilitation team, who had been caring for these patients, on average, for the past 4 years, completed a questionnaire to assess the needs for care of these individuals. Patient and staff assessments were then compared.

RESULTS

Patients and staff do not share similar views on the presence of clinical and social problems. Further analyses of the perceived importance of living-skills deficits, the perceived difficulties in dealing with these, and the recent developments in rehabilitation practices challenge whether patient-staff consensus is indeed essential for rehabilitation.

CONCLUSION

We propose that staff should listen to patients' points of view more carefully, especially in the areas of work, studies, and independent living.

Patterns of geographic mobility of persons with AIDS in Canada from time of AIDS index diagnosis to death

OBJECTIVE

To characterize migration patterns of persons with AIDS in Canada during the period from AIDS diagnosis to death.

DESIGN

Descriptive, population-based study.

SETTING

Canada.

PATIENTS

Canada's AIDS Case Reporting Surveillance System (ACRSS) was linked to deaths in the Canadian Mortality Data Base (CMDB). Probabilistic linkage was based on initials, date of birth, date of death, birthplace, and location at diagnosis and at death. Analysis was restricted to AIDS cases reported from Jan. 1, 1982, to Sept. 30, 1994, and to deaths reported from Jan. 1, 1982, to Dec. 31, 1992.

MAIN OUTCOME MEASURES

Change in usual place of residence; migration rates by region and community size.

RESULTS

A total of 5755 AIDS cases recorded in the ACRSS were linked to deaths in the CMDB. Of these linked cases, 5366 (93%) included information on province or territory of usual residence or community size. A total of 160 (3.0%) persons with AIDS changed their province or territory of residence between the time of their AIDS diagnosis and death. Multivariate analysis indicated that those who changed residences between AIDS index diagnosis and death were more likely than other persons with AIDS to live in provinces other than British Columbia, Ontario and Quebec (p < 0.001), to be diagnosed earlier (p = 0.004), to be younger (p < 0.001) and to be gay or bisexual (p = 0.042).

CONCLUSIONS

Our analysis revealed that only a small proportion of persons changed their residence between AIDS diagnosis and death. Geographic mobility was the greatest among persons with AIDS residing outside of the regions where the overwhelming majority of persons with AIDS in this country reside.

Differential effects of D2- and D4-blocking neuroleptics on the procedural learning of schizophrenic patients

OBJECTIVE

To illustrate the differential effects of D2- and D4-blocking neuroleptics on the procedural learning of patients with schizophrenia.

METHOD

Twenty-nine schizophrenic patients were divided into 3 groups according to their pharmacological treatment: 1) drug naive, 2) haloperidol, and 3) clozapine. They were all assessed on clinical and procedural measures, the latter being the mirror drawing task.

RESULTS

All groups showed progressive learning over the successive trials, and drug-naive patients performed better than the other groups. Patients in the haloperidol group showed many fluctuations over trials, suggesting difficulty in the progressive automation of the task. Such fluctuations did not occur in the clozapine group, but performances per se were worse than in the other groups during the learning trials. Automation of the task occurred at the same point (second block of trials) for all groups.

CONCLUSION

These results suggest that D2- and D4-blocking neuroleptics do not similarly affect striatal dependent procedural learning in schizophrenia.

[Strategies for coping in schizophrenia]

Few studies have documented how schizophrenic patients perceived their needs and which coping skills they have spontaneously developed. All 48 patients of the Louis-H. Lafontaine Young Adults Clinic, a specialised schizophrenia clinic in Montreal, were invited to complete the Task Motivation and Problem Appraisal in Long Term Psychiatric Patients questionnaire. Our study utilised a descriptive approach and a classification of patient's reported problems and their coping skills. A panel of researchers and clinical staff then regrouped patient's perceived problems into four categories: symptoms, coping strategies, organisation of daily activities and interpersonal contacts. The main coping strategies utilised by these young patients are confrontation (52%) emotion-centered coping (57%). Clinical applications can be drawn from paying attention to the reports of schizophrenic patients. For example, rehabilitation activities can be developed which cater to their perceived needs. Because of frontal lobe hypoactivity, which make cognitive appreciation more difficult, their coping strategies should be diversified. Patients suffering from negative symptoms of schizophrenia mainly attempt to modify emotional impact, until they have discovered a way of confronting deficit symptoms. Better motivation to therapeutic programmes would result from paying attention to their perspectives.

Clozapine: current status and role in the pharmacotherapy of schizophrenia

OBJECTIVE

This study evaluates clozapine and its present role in the pharmacotherapy of schizophrenia.

METHOD

Clozapine's current clinical status is reviewed, as is its position with respect to other treatment options.

RESULTS

Clozapine represents the prototype of "atypical" neuroleptics, with evidence of clinical efficacy in both positive and negative symptoms, as well as a diminished risk of extrapyramidal side effects. It is the only neuroleptic to date that has established itself as having little, if any, risk of tardive dyskinesia. More recent research has focused on its potential for overall savings in health care costs, as well as possible benefits in the area of neuropsychological functioning.

CONCLUSION

Evidence suggesting that the course of schizophrenia can be altered by effective treatment favours a systematic approach that optimizes treatment options. While clozapine does not represent a 1st-line agent because of its risk of agranulocytosis, it has an integral role to play in treatment-resistant schizophrenia or in individuals experiencing intolerable side effects with conventional neuroleptics.

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.

[Effect of patient education on neuroleptic treatment of young psychotic patients]

This study verifies the effect of the neuroleptic treatment teaching module, the French translation of the Medication Management Module produced by the social skills training programs. Twenty patients from an outpatient clinic (with schizophreniform or schizoaffective schizophrenia) were assigned at random to a test group (n = 10) or a control group (n = 10). The pre-test evaluation found that the two groups were the same with regard to 13 significant parameters. The experimenters used French translations of well-known instruments, and the double-blind method was applied to their respective observations throughout the study. Results were obtained by applying the neuroleptic treatment teaching module three hours per week for two to three months. The post-test evaluation revealed that patients who had been exposed to the education module had an improved understanding of schizophrenia and the medication required to treat it than patients who had not been exposed. The dose of medication prescribed between pre- and post-test evaluations were able to more effectively stabilize patients who had received education than patients who had not. Nevertheless, the education module continues to have no significant effect on the symptomatology (according to the Brief Psychiatric Rating Scale) and final SAS-II social scores of schizophrenics.

Lower incidence and increased male:female ratio in schizophrenia

Patients with an ICD-9 diagnosis of psychotic disorder were assessed for DSM-III-R schizophrenia. Rates of schizophrenia were found to be higher in males (39.8 per 100,000) than females (22.4 per 100,000). The DSM-III-R incidence supports recent studies which suggest a decrease in rates of schizophrenia across time, and also suggests that men suffer from both more schizophrenia and a more severe form of the disease.

Clozapine in the treatment of refractory schizophrenia: Canadian policies and clinical guidelines

Clozapine is an atypical neuroleptic agent that has recently become available in Canada with potential clinical efficacy in the treatment of refractory schizophrenia, and in patients with schizophrenia neurologically intolerant to conventional neuroleptics. Although it causes few extra-pyramidal symptoms, the drug has a number of other adverse effects including a risk of agranulocytosis in one to two percent of all patients. Because of this, the use of the drug is permitted only if the white blood count is monitored weekly. The monitoring system, outlined in this article, requires a coordinated effort between clinical staff, pharmacy, laboratory and the Clozaril Support and Assistance Network. Clinical guidelines are proposed, detailing the indications and contraindications for treatment and the pharmacokinetics, dosing, adverse effects, and drug interactions with clozapine. In addition, the economics, government policies and implications for future research are considered. Although there are administrative and clinical difficulties associated with its use, clozapine represents an advance in therapeutic research. Patients and family members will be inquiring about the drug and may deserve a trial. This article aims to inform Canadian mental health professionals about the safe and beneficial use of clozapine.

Burden of care of families not living with young schizophrenic relatives

A program that provides comprehensive support services to young schizophrenic adults and their families in Montreal was evaluated after one year to assess the needs of families, especially single-parent families, after the young adult patient left home. Results of the evaluation, which employed a case-control design, showed that compared with families receiving the usual services, families in the program reported feeling less burdened by the patients' personal problems. They also received more services and had more contact with professionals. Patients living away from home spent more than 18 hours a week in face-to-face contact with their families. Single parents of mentally ill young adults spent much less time with their offspring and expressed more need for services and a greater burden of care than married parents.

Application of exact ODDS for partial agreements of names in record linkage

Automated methods for linking records pertaining to the same individuals have in the past made only crude use of the name information. A perceptive filing clerk is more sophisticated because humans retain a lifetime memory of instances in which variant forms of names were employed interchangeably, and of synonyms that sometimes did not even resemble one another. This limitation of the machine can be rectified, but the body of knowledge required to serve as its memory must be large. The needed data have now been brought together on a suitable scale, from many past searches of Canada's Mortality Data Base. Described here are the development and use of the resulting tables of essentially exact discriminating powers (or ODDS) to do with comparisons of male given names. The aim is to reduce the proportion of ambiguously linked pairs of records requiring labor intensive clerical resolution. The tables are intended for general use in this country, and as a model for similar facilities appropriate to other populations.

Discriminating powers of partial agreements of names for linking personal records. Part I: The logical basis

Machines have difficulty when using people's names to link medical and other records pertaining to the same individuals because of nicknames, ethnic synonyms, truncations, misspellings and typographical errors. Present algorithms used to compute the discriminating powers (or ODDS) associated with partial agreements of names are based, inappropriately, on the degrees of outward similarity alone. They are particularly ineffective in dealing with names that look alike but are unrelated, and with related names that have little apparent similarity. A fundamentally different rationale is, therefore, proposed which, like the human mind, assesses the relatedness of two alternative forms of a name in terms of how often they are used, interchangeably in practice. This must be taken into account if the associated discriminating powers (ODDS) are to be correctly computed. A way of implementing this more precise approach is described and illustrated, using the given names on linked records from an earlier epidemiological study. This first study of two describes the logical basis for record linkage, a second one the empirical test.

Discriminating powers of partial agreements of names for linking personal records. Part II: The empirical test

The preceeding paper examined the logical basis of an exact way of calculating the discriminating powers of people's names when they only partially agree. The method has application to automated file searching and record linkage. The present account describes an empirical test of the approach. Use is made of some 2000 comparison pairs of male given names, obtained as a byproduct from an earlier linkage study. The test shows that exact value-specific ODDS can indeed be calculated for common names when compared with their accepted synonyms (e.g. JOSEPH versus JOE). Moreover, the use can be extended to include rare variants, by arranging these into groups defined in value-specific terms (e.g. as selected blocks in an alphabetically sequenced listing, or combinations of such blocks). A majority of all name comparisons may be handled in this manner. The added precision serves to reduce the numbers of records that are ambiguously linked and require labour intensive clerical resolution.

[Treatment of schizophrenia: a new synthesis of the literature]

One can say that a new approach of long-term treatment of schizophrenia is born. In the last years many authors developed a psychoeducational point of view based on the concept of expressed emotions. These works are quite unknown by the French psychiatrists. However, this new way of treating schizophrenics is a very complete pattern. It includes and integrates many datas from psychophysiology to family functioning and seems very promising. The main studies are presented and discussed here.

Teaching therapeutic skills of a psychological nature to future physicians

The majority of patients suffering from emotional problems are treated by non psychiatric physicians. In this context, the improvement of health services to those patients requires the involvement of general practitioners trained in appropriate therapeutic skills. At the present, general practitioners often feel unprepared to treat those patients with non-pharmacologic methods and tend to overuse psychotropic medication. The psychological therapeutic skills expected to be acquired by physicians, are often described in very general terms and remain under evaluated in medical schools. The improvement of these aspects of medical training requires them to be evaluated systematically, similar to the more traditional medical skills and biological knowledge. Such an evaluation is facilitated if the learning objectives are specified. This paper proposes specific learning objectives describing the psychological therapeutic skills expected from medical students at the end of their studies on the one hand, and from family physicians at the end of their family medicine training on the other. The authors' goals are to faciliate the discussion of this complex matter between the many medical (psychiatric or not) groups concerned and, in this manner, to clarify this issue which is fundamental to the teaching and implementation of the biopsychosocial model in clinical practice.

[The family of the schizophrenic : interfering or ally?]

We have presented an overview of the different studies of the family of the schizophrénie completed in the second half of this century. The first studies, of a more descriptive nature, sought to establish the aetiology of schizophrenia; they identified the family as one of the principal causes of the illness. Subsequently, methodological refinements and the contribution of genetic research have brought researchers to consider the family from a different perspective. From that point on, the family appears as an important factor, but it is linked to subtle and complex environmental factors which remain to be determined. Researchers now tend to favour an approach which permits the family to play an active role in relation to the evolution of the illness. The family is perceived more and more as a potential ally of the affected person and efforts are made to incorporate it in the treatment. This is, at least, the goal sought by proponents of the psycho-educational approach, and the therapeutic results appear to be most encouraging at the present time.

[For a multidimensional evaluation]

The methods of evaluating programs, residents and teachers are all interrelated. Although this may appear to be an over-inclusive statement, good training programs designed by competent teachers will produce competent residents. These residents in turn will become good teachers and clinicians. It is therefore in the interest of both residents and teachers to constantly evaluate each other and the programs.

The goal of residency training is to promote the acquisition of both theoretical and clinical skills. The final examination evaluates the resident's theoretical knowledge, but his clinical skills can only be evaluated in his day-to-day practice.

Recommendations: combine these evaluations at the end of training, allowing 50 per cent for the final theoretical examination and 50 per cent for his clinical work during his training.

Some steps to minimize the subjectivity of this clinical assessment follow:

1) Use the average of ratings from a number of supervisors.

2) The criteria to be evaluated should include theoretical knowledge, therapeutic abilities, interpersonal relations and initiative.

3) Periodic evaluations at regular intervals.

4) Feedback to the resident regarding his evaluation.

Taking into account the right and the duty of the teacher to evaluate his residents, and considering its aforementioned difficulties, it is essential that the resident also evaluate his teachers. This is a delicate but necessary task.

Criteria for evaluating teachers are:

1) Theoretical knowledge.

2) Clinical skills.

3) Interpersonal relationships.

4) Ability to communicate knowledge, both theoretical and clinical.

5) Motivation to teach.

6) Ability to inspire (‘feu sacre’).

7) Availability.

This continual evaluation by the residents of the department in which they are working will act as a constant stimulus for the improvement of programs, especially if it is assumed that the resident has a choice in determining his assignment.

To justify the assigning of 50 per cent of the assessment as clinical skills, a uniformity in the quality of training is necessary. This is seen as a uniformity in quality while maintaining differences in approach, and leads to the criteria for accreditation of hospitals.

Recommendations:

a) Formation of an autonomous committee responsible for accrediting the programs in various universities.

b) Plan for continuing research.