Discontinuation vs. continuation treatment with neuroleptics for a better long-term outcome

Background

Long-term functional outcome of dose-reduction/discontinuation strategies in first-episode psychosis (FEP) has not been studied before. The present study compared 7-year outcome of an early antipsychotic dose-reduction/discontinuation (DR) strategy with maintenance treatment (MT). Primary outcome was (symptomatic and functional) recovery; relapse rates, functional and symptomatic remission were secondary outcomes.

Methods

FEP patients (n = 128) symptomatically remitted for 6 m during their first treatment year who completed an 18 months trial comparing MT and DR were followed-up at 7 years. Symptomatic remission criteria were adopted from Andreasen et al., functional remission criteria were based on a functioning scale. Recovery was defined as meeting both criteria sets. MT or DR strategy, and baseline parameters were entered in a logistic regression analysis with symptom and functional remission and recovery at 7-years follow-up as dependent variables.

Results

One hundred and three patients consented to participate. DR-patients showed twice the recovery-rate of MT-patients (40% against 18%), odds ratio 3.5 (P = .014). Symptomatic remission-rates were equal (69% and 67%). Better DR recovery-rates were attributable to higher functional remission-rates (46% vs. 20%) in DR. Predictors of recovery were DR, baseline living together and less severe negative symptoms. During the last 2 years of follow-up the mean daily dose in haloperidol equivalents was 2.20 mg in DR vs. 3.60 mg in MT (P = .031).

Relapse rates were initially higher in DR but leveled at 3 years; 61.5% relapsed in DR and 68.6% in MT in 7 years.

Conclusion

DR of antipsychotics during early stages of remitted FEP significantly improved 7-years outcome in terms of recovery and functional remission compared to maintenance treatment. Though initially relapse rates in GD were higher, these equalled those in MT from 3 years to the end of the study. While the necessity of immediate antipsychotic treatment in FEP and positive symptoms relapse is robustly demonstrated in a great number of studies, this study suggests that we are faced with a dilemma concerning the drawbacks of long-term maintenance antipsychotic treatment on functional capacity. Though antipsychotic discontinuation appears only feasible without relapse in a substantial minority of patients, guided dose-reduction as far as positive symptoms remain subsided and allow it, appears a feasible strategy in view of functional recovery, doing justice to both sides of the dilemma.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

[Routine outcome monitoring and benchmarking: how can treatment results be compared in a responsible manner?]

BACKGROUND

The structural measurement of the results of treatment under the Dutch mental health services and a comparison of these results between mental health centres help to provide insight into the effectiveness of treatment in general practice.

AIM

To provide an overview of the issues that require attention when the results of mental health centres are being compared.

METHOD

Documentation, policy information and practical experience with routine outcome monitoring were analysed.

RESULTS

We describe the problems that can arise when results obtained by mental health centres are compared and we suggest some solutions for these problems. Important factors that have emerged from our study are as follows: working with routine outcome monitoring is a process of natural growth and involves experiences with several solutions and the making of definitive choices on the basis of experience.

CONCLUSION

It is instructive to compare mental health centres with each other and with regards to so-called 'best practices' (benchmarking). However, mental health centres draw on a differing wide mix of patients and use different measurement procedures and instruments. In this article we express the view that in the near future it should be possible to draw meaningful comparisons.

[The Health of Nation Outcome Scale as clinical outcome indicator in elderly psychiatry]

The Health of the Nation Outcome Scales65+(HoNOS65+) seems to be a useful instrument for effect measuring in elderly psychiatry. The instrument is implemented as an outcome measure within a psychiatric unit for older persons. From 244 patients a repeated assessment is completed: at the start of the treatment and at discharge. Our goal is to determine the sensitivity of change of the Health of the Nation Outcome Scales65+ for patients who are in treatment for a limited period. The sensitivity of change is examined for outpatients and inpatients and for four diagnostic groups (mood disorders, organic disorders, psychotic disorders and others) according to their DSM-IV diagnoses. Comparisons between first and second assessment were done using pairwise t-tests. Inpatients as well as outpatients showed a significant change between intake and discharge. This also holds for all four diagnostic groups. The conclusion is that the HoNOS 65+ is sensitive to change and meets the criteria for a clinical outcome indicator in elderly psychiatric patients.

[Routine Outcome Monitoring for patients with severe mental illness: a consensus document]

BACKGROUND

Routine outcome monitoring (ROM) means the assessment of the patient's condition on a routine basis using instruments. So far there is no consensus about which instruments should be used for ROM with severely mentally ill patients (ROM-SMI).

AIM

To reach a consensus about instruments for ROM-SMI in the Netherlands and Belgium and to create possibilities for comparison of ROM data.

METHOD

This article discusses the consensus document of the National Remission Working Group for ROM in patients with smi and covers the following topics: reasons for ROM-SMI, domains for ROM-SMI and appropriate instruments, logistics and analyses of the data.

RESULTS

Patients with SMI have problems in several domains. These can be assessed by collecting information about psychiatric symptoms, addiction, somatic problems, general functioning, needs, quality of life and care satisfaction. Potential instruments for ROM-SMI are short, valid, reliable and assess several domains, taking the patient's perspective into account, and have been used in national and international research. The working group advises institutions to choose from a limited set of instruments. After the scores have been aggregated and standardised, comparisons can be drawn. ROM-SMI data can be interpreted more meaningfully, if outcome data are supplemented with data regarding patient characteristics and the treatment interventions already applied.

CONCLUSION

It should be possible to reach a consensus about instruments for ROM-SMI and the way in which they should be used. The use of identical instruments will lead to improvements in mental health care and create possibilities for comparison (benchmarking) and research.

Positive and Useful Auditory Vocal Hallucinations: Prevalence, Characteristics, Attributions and Implications for Treatment

Objective:

Patients who seek treatment often suffer from negative auditory vocal hallucinations (‘voices’). However, some of these patients also report positive or useful voices, that they wish to preserve. When this wish is neglected by their therapist, this may lead to rejection of therapy or low compliance. This study describes prevalence, characteristics, course of and attributions to these voices in psychotic and non-psychotic patients.

Method:

One hundred and thirty one patients of a Voices Clinic and 65 members of the Dutch Resonance Foundation were assessed with the Positive and Useful Voices Inquiry. Data were analyzed using Pearson's chi-square, one-way ANOVA, Student's T-test and Crohnbach's alpha statistics.

Results:

First voices are most often reported as negative. the lifetime prevalence of positive voices ranged from 50 to 75%, useful voices were reported by 40 to 60% of respondents, with higher prevalences among the members of the Resonance Foundation. Positive voices occur more among non-psychotic patients. No significant association was found between voice characteristics and diagnosis. Attributions of protective power to positive voices has the strongest association with positive experience. Useful voices that are advising are experienced as most useful. Over 30% of respondents want to keep their positive and/or useful hallucinations. This wish is significantly associated with perceived control over the voices.

Conclusions:

The prevalence of positive and useful voices is considerable and therefore clinically relevant. A substantial part of patients want to preserve these voices.

Positive and useful auditory vocal hallucinations: prevalence, characteristics, attributions, and implications for treatment

OBJECTIVE

Auditory hallucinations that are viewed by patients as positive and useful may be barriers to treatment-seeking. The aim was to assess prevalence, impact, and course of, and attributions to, these voices in psychotic and non-psychotic patients.

METHOD

One hundred thirty-one patients of a Voices Clinic and 65 members of the Dutch Resonance Foundation were assessed with the Positive and Useful Voices Inquiry. Data were analyzed using Pearson's chi-square, one-way anova, and Crohnbach's alpha statistics.

RESULTS

First voices are most often reported as negative. Positive voices occur more among non-psychotic subjects, but the specific characteristics and diagnosis are not significantly associated. Lifetime prevalence of positive and useful voices ranged between 40% and 60%, with varied prevalence rates over time. Positive voices are experienced by subjects as direct addresses in the third person. Perceived control of voices is significantly associated with the wish to preserve them. Attribution of protective power to positive voices has the strongest association with positive experience.

CONCLUSION

Many patients express a desire to preserve these voices. Voice characteristics do not allow for validly discriminating psychotic from non-psychotic disorders.

[Implementation of the HoNOS65+]

BACKGROUND

In the last few years mental healthcare has had to become increasingly accountable to health insurance companies, the government and patient groups with regard to the efficacy, appropriateness and patient-friendliness of the care provided. Routine outcome assessment, based on various measuring instruments, is likely to become more and more frequent in the years to come.

AIM

To assess whether the Health of the Nation Outcome Scales for elderly people (HoNOS65+) can be successfully implemented within a psychiatric unit for older persons, whether the instrument is suitable for use in clinical practice and whether it provides an adequate picture of the older population in general.

METHOD

The implementation phase consisted of training 51 social workers within the various sections of the unit. The trained social workers used the HoNOS65+ with 387 patients from various units for older persons within Lentis.

RESULTS

The social workers found the HoNOS65+ to be a useful instrument and for each treatment setting and diagnosis it differentiated significantly between types of behaviour problems, symptoms and social problems.

CONCLUSION

The HoNOS65+ can be used profitably with individual patients and patient groups and it highlights the problems in relevant areas of psychiatry for older persons.

Assertive community treatment in the Netherlands: a randomized controlled trial

OBJECTIVE

Assertive community treatment is rapidly implemented by many European mental health services, but recently the evidence base has been questioned. Positive results of randomized trials in the USA were not replicated in the UK. The question is whether the UK findings are representative for other European countries with modern mental health services.

METHOD

Open randomized controlled trial of long-term severely mentally ill patients [Health of the Nation Outcome Scales (HoNOS) total score >or=15], assigned to assertive community treatment (n = 59) or to standard community mental health care (n = 59).

PRIMARY OUTCOME

sustained contact; housing stability and admission days. This trial is registered as an International Standard Randomized Clinical Trial, number ISRCTN 11281756.

RESULTS

Assertive community treatment was significantly better in sustaining contact with patients, but not in reducing admission days. No differences in housing stability, psychopathology, social functioning or quality of life were found.

CONCLUSION

The results are in agreement with UK studies. However, the sustained contact potential of assertive community treatment is important, as too many patients are lost in standard care.

[Do we really still need psychiatric case registers?]

SUMMARY

A question frequently raised in the Netherlands is whether regional case registers have added value compared to national information systems. Research in regional case registers, however, has shown that they have added value based on longitudinal data-gathering, specialised knowledge of the region concerned and data-processing. Regional case registers reflect developments in the total range of services available (cure and care, including clinics to treat alcoholism and drug addiction). Case register research can also aim at developing outcome measures and creating links between mental health care and other health care areas.

Treatment delay and response rate in first episode psychosis

OBJECTIVE

There is no consistent evidence of long duration of untreated psychosis (DUP) predicting long time to response (TTR) in first psychosis. This study aims to investigate the predictors of DUP and TTR in a first episode patient population.

METHOD

An epidemiologically representative sample of 157 non-affective first psychotic episode patients was interviewed and followed-up for at least half a year.

RESULTS

The mean DUP was 46 weeks, the median 31 days. Long DUP was associated with being unemployed before treatment and male gender. Short DUP, having a job, and living with a partner before treatment predicted early response.

CONCLUSION

Early intervention likely improves short-term treatment response in first episode psychosis. The best strategy to reduce DUP probably is to direct attention to the substantial number of patients who do not engage in regular treatment.

Adaptive functioning and behaviour problems in relation to level of education in children and adolescents with intellectual disability

BACKGROUND

The interrelationship between adaptive functioning, behaviour problems and level of special education was studied in 186 children with IQs ranging from 61 to 70. The objective was to increase the insight into the contribution of adaptive functioning and general and autistic behaviour problems to the level of education in children with intellectual disability (ID).

METHODS

Children from two levels of special education in the Netherlands were compared with respect to adaptive functioning [Vineland Adaptive Behavior Scales (VABS)], general behaviour problems [Child Behavior Checklist (CBCL)] and autistic behaviour problems [Autism Behavior Checklist (ABC)]. The effect of behaviour problems on adaptive functioning, and the causal relationships between behaviour problems, adaptive functioning and level of education were investigated.

RESULTS

Children in schools for mild learning problems had higher VABS scores, and lower CBCL and ABC scores. The ABC had a significant effect on the total age equivalent of the VABS in schools for severe learning problems, the CBCL in schools for mild learning problems. A direct effect of the ABC and CBCL total scores on the VABS age equivalent was found, together with a direct effect of the VABS age equivalent on level of education and therefore an indirect effect of ABC and CBCL on level of education.

CONCLUSIONS

In the children with the highest level of mild ID, adaptive functioning seems to be the most important factor that directly influences the level of education that a child attends. Autistic and general behaviour problems directly influence the level of adaptive functioning. Especially, autistic problems seem to have such a restrictive effect on the level of adaptive functioning that children do not reach the level of education that would be expected based on IQ. Clinical implications are discussed.

Social skills in children with intellectual disabilities with and without autism

BACKGROUND

Social skills were studied in 363 children with mild intellectual disabilities (ID) and 147 with moderate ID with and without autism (age 4 through 18). The objective was to investigate the value of the Children's Social Behaviour Questionnaire (CSBQ), as a measure of subtle social skills, added to a measure of basic social skills with the Vineland Adaptive Behaviour Scales (VABS), in identifying children with ID with or without autism.

METHOD

Children with mild and moderate ID, with and without autistic symptomatology were compared on basic social skills, measured with the Communication and Socialization domains of the VABS, and subtle social skills, measured with the CSBQ.

RESULTS

Measuring basic social skills is not sufficient in differentiating between levels of ID. Communicative skills and subtle social skills, that concern overlooking activities or situations and fear of changes in the existing situation, seem to play a far greater role. Additionally, with respect to identifying autistic symptomatology, basic social skills do not contribute, as opposed to communicative skills and the tendency to withdraw from others.

CONCLUSIONS

The results implicate that the CSBQ not only has specific value as a measure of subtle social skills to identify pervasive developmental disorders, but that the instrument also has a specific contribution to differentiating between the two levels of ID. Furthermore, our outcomes imply a slight difference between limitations in subtle social skills as mentioned by the AAMR (American Association on Mental Retardation 2002) and limitations in subtle social skills as seen in milder forms of pervasive developmental disorders. Clinical and theoretical implications will be discussed.

The effect of deinstitutionalization on the longitudinal continuity of mental health care in the Netherlands

BACKGROUND

Deinstitutionalization has been accompanied by a decreasing continuity of care in a number of countries. This study evaluates the effects of the Dutch model for deinstitutionalizing mental health care.

METHODS

Details of users and their use of community- and hospital-based services between 1990 and 1999 were retrieved from the Groningen case register. The time between discharge from the hospital and the first subsequent community-based contact was the primary indicator for changes in continuity of care.

RESULTS

The total proportion of discharges from hospital-based mental health care followed within 6 months by community-based care increased by 11% due to the improved availability of day treatment and home treatment. In terms of median survival time, aftercare in the years 1998/1999 was delivered more than twice as fast as in the years 1990/1991.

CONCLUSIONS

Study results supported the hypothesis in Dutch deinstitutionalization policy that the continuity of mental health care would benefit as to its longitudinal dimension.

Costs of deinstitutionalization in a rural catchment area in The Netherlands

BACKGROUND

In contrast to many other countries, The Netherlands left the initiative in deinstitutionalizing mental health care to the traditional providers of mental health services. The goal of this study is to determine the effect of this policy on the allocation of mental health care resources to services.

METHOD

All 20- to 64-year old users and their use of community- and hospital-based services between 1990 and 1999 were retrieved from the Groningen case register. Service utilization was combined with the direct unit costs of these services for the 1999 price level. Changes in the population as to size and age were taken into account.

RESULTS

In 1999 the direct costs of mental health care were Euro 268 per adult inhabitant of the register area, which is 9% higher than in 1990. Costs increased most in the early 1990s before deinstitutionalization policy took effect. From 1993 and onwards the reduced length of stay in the hospital was the main cause for the decreased costs of in-patient care. These savings equalled the increased expenditures for day-treatment, sheltered residences and home-treatment, even though the unit costs of these types of community care are much lower than the unit costs of admissions. This was not caused by an increasing number of new clients, but was a result of longer periods of care during a larger number of years.

CONCLUSIONS

These findings are in accordance with Dutch mental health care policy, which aims at prolonged care and aftercare outside the hospital whenever possible.

Propensity to psychiatric and somatic ill-health: evidence from a birth cohort

BACKGROUND

Somatic and psychiatric morbidity may cluster because of reciprocal effects between them but also as a result of common underlying factors.

METHODS

The data come from the 1946 MRC birth cohort (N = 5362). Clustering of 20 chronic medical conditions at the participants' 43rd year was analysed using multi-morbidity coefficients. Associations of somatic and psychiatric morbidity at 43 years, with temperament and behaviour, assessed from adolescence to early adulthood, and background variables like paternal social class, were examined using structural equation modelling. The focus was on whether links applied to both morbidity types or one only, and were direct or were indirect, mediated by prior morbidity.

RESULTS

Reported chronic medical conditions clustered strongly. Somatic multi-morbidity and psychiatric ill-health at 43 years were associated with temperamental and behavioural features assessed between the subjects' 13th and 26th birthday, like neuroticism and aggression, as well as with external variables like parental death before the participants' 16th birthday. However, only neuroticism holds direct links with somatic as well as with psychiatric ill-health, 28% of the former and 52% of the latter association being independent of the simultaneous presence of the other morbidity type and of participants' health status 7 years earlier.

CONCLUSIONS

Personality traits like neuroticism not only raise the risk of psychiatric disorder but also, irrespective of whether manifest psychiatric disorders have developed, of a broad spectrum of chronic somatic diseases. This suggests that clinicians and researchers should focus not only on the psychiatric disorders associated with such personality traits but also on their medical consequences.

Predictors for readmission risk of new patients: the Nordic Comparative Study on Sectorized Psychiatry

OBJECTIVE

Predictors for readmission risk were investigated in this study, which forms part of the Nordic Comparative Study on Sectorized Psychiatry.

METHOD

Included were a total of 837 consecutive 'new' patients (not in contact with the psychiatric services for at least 18 months) admitted to in-patient stay during a period of 1 year to seven psychiatric hospitals in four Nordic countries.

RESULTS

Multivariate survival analyses showed that younger age predicted increased readmission risk. Stratifying on gender, diagnostic group and sector revealed a general pattern concerning age which was the only consistent main effect. Living alone and unemployed increased readmission risk in the non-psychosis group, while receipt of aftercare decreased readmission risk in the psychosis group. A curvilinear relationship was found between availability of psychiatric resources and readmission risk: an intermediate amount of resources was associated with increased risk.

CONCLUSION

Our findings support a hypothesis that readmission risk is multifactorially determined and that interactions have to be considered.

Continuity of care and readmission in two service systems: a comparative Victorian and Groningen case-register study

OBJECTIVE

We compared service consumption, continuity of care and risk of readmission in a record linkage follow-up study of cohorts of patients with schizophrenia and related disorders in Victoria (Australia) and in Groningen (The Netherlands). These areas are interesting to compare because mental health care is in a different stage of deinstitutionalization. More beds are available in Groningen and more community resources are available in Victoria.

METHOD

The cohorts were followed for 4 years, since discharge from inpatient services using record linkage data available in the psychiatric case-registers in both areas. Survival analysis was used to study continuity of care and risk of readmission.

RESULTS

Available indicators showed a higher level of continuity of care in Victoria. While the relative risk of readmission was the same in both areas and not affected by aftercare contact after discharge, the number of days spent in hospital was much higher in the Groningen register area.

CONCLUSION

These findings provide further support for earlier reports that the risk of readmission is predominantly affected by attributes of mental illness. However, the duration of admissions, is strongly affected by service system variables, including the provision of continuity of care.

The Nordic Comparative Study on Sectorized Psychiatry--length of in-patient stay

OBJECTIVE

Length of stay (LOS) of 'first' in-patient episodes was investigated in this study, which is part of the Nordic Comparative Study on Sectorized Psychiatry.

METHOD

A total of 837 consecutive 'new' patients (not in contact with the psychiatric services for at least 18 months) admitted as in-patients during a period of 1 year to seven psychiatric hospitals in four Nordic countries were included.

RESULTS

Survival analyses showed considerable differences in LOS between the hospitals, and the factors analysed in this study could not explain this variance. Older age, being female, having no children at home, psychosis, planned admission and out-patient contacts were all associated with increased LOS.

CONCLUSION

Stratifying on gender, diagnostic group and hospital revealed a general pattern of associations except for age.

The Nordic Comparative Study on Sectorized Psychiatry: continuity of care related to characteristics of the psychiatric services and the patients

The problem addressed in this paper is how continuity of care is related to characteristics of psychiatric services, previous events in a patient's pattern of care and patient characteristics. The present paper is a part of a Nordic Comparative Study on Sectorized Psychiatry in seven catchment areas in four Nordic countries. One-year-treated-incidence cohorts were used. Each patient was followed for 1 year after the first contact with the psychiatric service. Continuity of care was measured by the time from discharge from hospital to the first subsequent day-patient or outpatient contact. Notable findings were large differences in the continuity of care in the seven services, high proportions of discharges without any aftercare contacts and long time lags between discharges and aftercare contacts in most of the catchment areas. A Cox regression analysis revealed that aftercare following hospitalisation seems to be more probable if the outpatient services are located geographically close to the patients, if the hospitalisation lasted between 2 and 4 weeks, if there was a community care contact shortly before the hospital admission and if the patient is not retired and not divorced. Staff resources were not related to continuity of care.

Factors associated with referral to psychiatric care by general practitioners compared with self-referrals

BACKGROUND

The gatekeeper function of the general practitioner (GP) in the pathway to specialized psychiatric services was investigated in this study, which is part of the Nordic Comparative Study on Sectorized Psychiatry. The question addressed in this paper is whether different sociodemographic and clinical factors as well as factors related to service utilization are associated with referral from the GP compared with self-referrals (including referrals from relatives).

METHODS

The study comprised a total of 1413 consecutive patients, admitted during 1 year to five psychiatric centres in four Nordic countries. The centres included in this study were those that accepted non-medical referrals. Only new patients (not in contact with the service for at least 18 months) were included.

RESULTS

Increasing age was the only sociodemographic factor significantly associated with referral by the GP. The clinical factors (psychosis, being totally new to psychiatry and being in need of in-patient treatment) and some treatment characteristics (planned out-patient treatment and involuntary in-patient treatment), were all significantly associated with referral by the GP. Some indication was found that self-referred patients have shorter episodes of care.

CONCLUSIONS

The findings were remarkably stable across the different centres indicating a general pattern. This study extends previous work on the role of GPs in the pathway to specialized psychiatric services and indicates that the GP has an important gatekeeper function for the most disabled patients.

Continuity of care for patients with schizophrenia and related disorders: a comparative south-Verona and Groningen case-register study

BACKGROUND

It is widely believed that for the severely mentally ill continuity of care is essential to ensure a better outcome and prevent long-term hospitalization. However, not much progress has been made in the operationalization and measurement of this concept. We used two indicators to compare continuity of care of schizophrenic patients in two kinds of mental health systems. One is a community mental health system without the back-up of a mental hospital (South-Verona, Italy). The other is an institution-based system in which mental hospitals are still predominant (Groningen, The Netherlands).

METHODS

The first indicator of continuity of care, readiness of aftercare, is the time from discharge from hospital to the first day- or out-patient contact. Survival analysis was applied to correct for censored observations. The second indicator, flexibility of care, is the use of combinations of in-, day- and out-patient care during 2-year follow-up.

RESULTS

More patients in South-Verona received community care within 2 weeks after discharge (71.5%), than in the Groningen register area (54.6%). The survival functions differed significantly. Cox regression analysis revealed that in both systems a contact before admission, the time between this contact and admission and the duration of the admission are predictors for aftercare. A higher percentage of patients made multiple service use (combinations of in-, day- and out-patient care) in South-Verona than in Groningen (62 v. 45%).

CONCLUSIONS

Both indicators showed a higher continuity of care in the South-Verona system.

Prevalence of long-term mental health care utilization in The Netherlands

The objective of this study is to estimate the proportion of the population in The Netherlands who receive long-term care for chronic psychiatric problems. The care needs of this population are assessed in terms both of diagnosis and of specific impairments and disabilities. Data from three surveys and two psychiatric case registers in five different areas of The Netherlands provide an estimate of about 3.5 long-term users of psychiatric care per 1000 members of the population aged 20 years or over. One-third of them receive a diagnosis of schizophrenia and related psychotic disorders. Patients most frequently suffer from impairments of mood and affect, volition and drives. Nearly all patients are disabled in their occupational role (work), and about half of the population have problems with self-care and household tasks. Long-term care is to a large extent (40%) provided in hospitals and sheltered accommodation, and the role of day services is relatively insignificant.

Service utilization research: goals and prospects

Service utilization research is not a homogenous field of research. One might distinguish between the evaluation of treatments and the evaluation of mental health systems. I will restrict myself to the mental health system approach. The first statement that has to be made is that the study of service utilization is not an aim in itself. The ultimate goal is to learn how systems of mental health care function or dysfunction. This knowledge should be helpful for planners to plan services at a more scientific basis.

Another introductory statement is that the objective of system service utilization research is the study of the relationships of a described population with the mental health system available for this population. Otherwise stated, this is an epidemiological approach of service utilization research. In this we will further distinguish between the pathway to care and the pathway through care or patterns of care. The basic questions in the pathway to care are related to the proportion of the population using mental health services; the treated prevalence and incidence. A topic is for example the inequality in service use in different social-economic-status or socio-demographic subgroups. The basic questions in the pathway through care are related to the way in which patients use the mental health system in terms of duration, intensity, setting and relapse for example. In the present paper we will focus on the latter topic mainly.

Service utilization by schizophrenic patients in Groningen and South-Verona: an event-history analysis

The question addressed to in this paper is whether severely mentally ill patients are treated differently in a community mental health service without the back-up of a mental hospital (south-Verona, Italy) compared with an institution-based system in which mental hospitals, although highly modernized, are still predominant (Groningen, The Netherlands). Using the psychiatric case-registers in both areas, the patterns of care in 2 years of follow-up of schizophrenic patients were constructed. Survival analysis was used to analyse in-, day- and out-patient episodes of care. Three-quarters of the Groningen and half of the south-Verona patients experienced at least one episode of hospitalization; 20% of the Groningen and 5% of the south-Verona patients were long-stay patients at the end of the observation period. The south-Verona patients had more episodes of in-patient and especially of day-patient and out-patient care. Cox's regression showed that the duration of episodes controlled for the history of events and sociodemographic characteristics, was significantly shorter in south-Verona. One of the main conclusion was that hospitalizations for the severely mental ill are also needed in a community-based system of care, supporting the assumption of a 'bed-rock' of mental illness. However, the south-Verona community mental health service seems to be able to reduce the duration of hospitalizations considerably.

Inpatient care in an eastern and a western European area. A comparative case-register study

Inpatient point-prevalence and admission rates in both mental hospitals and psychiatric wards in general hospitals in East Bohemia and in Drenthe (the Netherlands) were compared. A higher point-prevalence rate was found in Drenthe as there was a higher rate of long-stay patients. However, in East Bohemia the admission rates were higher for all diagnostic categories, except for neuroses, the admission rates for neuroses were twice as high in Drenthe. The differences were explained by the availability of complementary in-patient services and more developed out- and day-patient facilities in Drenthe.

Social indicators and psychiatric admission rates: a case-register study in The Netherlands

Environmental as well as individual socio-demographic and illness characteristics are related to the risk of admission. This paper addresses the problem of the interrelationships of these factors to admission rates. Using the Groningen Psychiatric Case Register, admission rates (during 1986 and 1987) from 34 administrative areas were calculated. Logit models were fitted in order to test the relationship between the relative risk of being admitted and sex, age, marital status, diagnosis, urbanization and distance from facilities. The effect of urbanization remains under the control of the other independent variables. The concept of 'need for care', related to 'true' and 'treated' incidence, is discussed.

Patterns of psychiatric care in south Verona and Groningen. A case-register follow-up study

The pattern of utilization of mental health services in south Verona (Italy) and in Groningen (the Netherlands) was studied. The local psychiatric case registers were used to select patients aged 15 years or more who had at least one contact in 1982 and no contacts in the previous 365 days. Each patient was followed for 36 months after the first contact in 1982. The 2 cohorts differed in size (373 in south Verona and 590 in Groningen), age, diagnosis and pattern of care, whereas the sex distribution was similar. The cohort in Groningen was characterized by a higher number of elderly people, suffering from organic psychoses. Drug dependence prevailed in south Verona, while alcohol dependence was predominant in Groningen. The pattern of care was classified according to 2 basic measures, the gross duration of care and the net duration of care. In south Verona single consulters were almost 3 times more common than in Groningen. In general, patients in Groningen tended to depend more on the mental health services. Linear regression analysis was used to determine the extent to which the pattern of care was predicted by the sociodemographical and clinical characteristics of the patients. Only the site where the contacts were made (south Verona or Groningen) and the diagnosis were significantly associated with the pattern of care.

The reliability of diagnostic coding in psychiatric case registers

In total, 103 cases were randomly selected from the Groningen, Nottingham and South Verona registers. Six raters (two in each of the register areas) were involved in coding these cases according to the ICD-9. In general, interrater agreement was satisfactory when codes were grouped into a limited number of categories. Nevertheless, considerable variation in agreement rates was found. We distinguished three steps in the diagnostic process. The selected logistic model showed that reliability is significantly affected in each step, but only substantial in the first where clinicians formulate a diagnosis.

Use of mental health services in south Verona and Groningen. A comparative case-register study

A comparison was made of the utilization of mental health services in a psychiatric case register area in Italy (south Verona) and one in the Netherlands (Groningen). All residents living in these areas who contacted a mental health service in 1982 were traced and followed for a period of one year. The year prevalence rates differed considerably (110/10,000 in south Verona and 329/10,000 in Groningen). Rates of single consulters were similar in both areas, while those of chronic inpatients were more than 11 times higher in Groningen than in south Verona. After excluding both single consulters and chronic inpatients, when comparing service consumption according to fixed classes of scores, the category of highest service use accounted for 60% of care provided in Groningen as compared with less than 30% in south Verona. The proportion of total service consumption due to inpatient care was about the same in both areas, but brief admissions were more common in south Verona. Moreover, when service use was considered as a relative construct, about 10% of patients in both areas could be called high users. Finally, long-term patients were more prevalent in Groningen (26%) than in south Verona (13%).

Patterns of care in the field of mental health. Conceptual definition and research methods

The concept "patterns of care" plays a central role in research focusing on the evaluation of mental health care. It is a concept encompassing a number of dimensions. The primary ingredients are the type, the setting, the intensity and the duration of care. In this paper, a critical survey is provided of a total of 7 classifications or scales of patterns of care. An argument is advanced for developing a more systematic working method within this research area, in which new scales of patterns of care are developed, building on the methodology already in existence. Standardization is urgently needed if comparative research is to yield better results than it has in the past.