Access the most recent version at DOI: 2001, 178:506-517. BJP SKODA, R. THARA, SERGEY J. TSIRKIN, VIJOY K. VARMA, DERMOT WALSH and DURK WIERSMA ANTHONY J. MARSELLA, YOSHIBUMI NAKANE, NORMAN SARTORIUS, YUCUM SHEN, CTIRAD K. HOLMBERG, ALEKSANDAR JANCA, PETER W. H. LEE, CARLOS A. LEÓN, SAVITA MALHOTRA, WANDERLING, K. C. DUBE, KIMON GANEV, ROBERT GIEL, WOLFRAM AN DER HEIDEN, SHARON GLYNN HARRISON, KIM HOPPER, THOMAS CRAIG, EUGENE LASKA, CAROL SIEGEL, JOE follow-up study Recovery from psychotic illness: a 15and 25-year international

Background: The Schedules for Clinical Assessment in Neuropsychiatry (SCAN), the successor of the ninth version of the Present State Examination (PSE-9), is one of the latest instruments developed by the World Health Organisation for the assessment of psychiatric disorders. So far, the psychometric properties have only been established for certain sections of the instrument. The present study is the first to test the psychometric properties of SCAN-2.1 for most of the disorders covered by the SCAN, and was carried out prior to a survey conducted in the Nijmegen Health Area (the Netherlands). Methods: Interviewers were psychology graduates with little clinical experience. Two designs were used. In one design, pairs of independent live interviews with the same respondent were compared (test-retest situation). In the other, ten videotaped interviews by experts were rated by each of the interviewers (standardized situation), and the outcomes were compared with those of the other interviewers as well as with a reference score. Results: In the test-retest situation the κ coefficient for diagnostic caseness was qualified as substantial (0.62) and for diagnostic categories and diagnostic groups as moderate to good (0.24 to 0.64). In the standardized situation using videotaped interviews by experts, sensitivity as well as specificity proved to be substantial to almost perfect. The agreement per interviewer with regard to the reference diagnoses ranged from 87% (diagnostic group) to 94% (diagnostic caseness). Agreement on the syndrome level (without duration and interference criteria of DSM-IV) was excellent. Conclusions: Although the instrument is traditionally used by experienced clinicians, this study shows that less experienced (but well trained) interviewers can apply SCAN reliably. Special attention should be paid to the items without explicit interview questions, as they tend to be more sensitive to neglect than the items with interview questions.

Need for care was studied in a Dutch incidence cohort of patients with schizophrenic disorders 15 and 17 years from first onset of psychosis. Long-term course of the disorders varied from complete remission and full community participation to chronic psychosis and long-term hospital stay. Fifty patients were assessed twice with the Needs For Care Assessment Schedule (NFCAS, Brewin and Wing 1989); at the latter follow-up an assessment was also made using the Camberwell Assessment of Need (CAN, Phelan et al. 1995). The NFCAS is an investigator- or professional-based instrument which provides an 'objective' assessment of needs. Need for care was recorded in 22 areas of clinical and social functioning. Comparison of the two assessments over a 2-year period demonstrated a high stability on the individual items (mean 88%, mostly concerning the absence of a problem twice), but did not show the expected stability of need status among this group of patients with chronic disorders. One in five patients (22%) had no needs at all on both occasions and 56% of the patients showed a change in needs. There was more negative than positive change: 28% suffered from new unmet needs at the 17-year follow-up, while only 12% had improved their status to no needs. About one-third (36%) had at least one unmet need, mostly regarding psychotic symptoms, dyskinesia or underactivity. The CAN provides a 'subjective' assessment of needs according to the view of patients themselves. The problems patients reported most commonly were in the areas of day-time activities, social relationships and information on their condition and treatment, for all which they asked for more help than they received. This patient-based instrument produces slightly higher numbers of problems and unmet needs, and a lower ratio between met and unmet needs. There is an overall percentage of 21% of disagreement between patient and investigator view regarding the unmet need status. Agreement between the two instruments on the nature of the problems with unmet needs was lacking altogether.

Data are presented on the 15-year natural course of schizophrenia and other nonaffective functional psychoses in a cohort of 82 first-contact cases from a circumscribed area in the Netherlands, The subjects were suffering from functional psychosis with International Classification of Diseases-Ninth Revision (ICD-9) diagnoses 295, 297, or 298.3-9 (broad definition of schizophrenia) on entry, Standardized assessments of psychopathology, psychological impairments, negative symptomatology, social disability, and use of mental healthcare were used, The study reveals a pattern of chronicity and relapses with a high risk of suicide: Two-thirds of the subjects had at least one relapse and after each relapse 1 of 6 subjects did not remit from the episode; 1 of 10 committed suicide; and 1 of 7 had at least one episode with affective psychotic symptoms that started on average 6 years after the onset of the schizophrenic disorder, Diagnoses were reclassified in five patients, according to DSM-III-R criteria for a bipolar disorder, The predictive power-in terms of time in psychosis and in partial or full remission-of demographic, illness, and treatment variables at onset of the illness was very limited, Insidious onset and delays in mental health treatment are risk factors that predict a longer duration of first or subsequent episodes, The importance of mental health treatment in regard to outcome is probably subject to change because an early warning and intervention strategy could prevent further damage and deterioration, Our data support the need for an adequate relapse prevention program as a priority for our mental health services.

Severe and long term mental disorders, like schizophrenia, show in general a wide range of psychiatric signs and symptoms, psychological and physiological impairments and social disablement (Shepherd, 1994; Wing, 1982) reflecting a variety of mental health needs. Many studies provide only a cross-sectional view of the clinical and social problems of the patient population, for example at intake or admission to a mental hospital. Longitudinal studies following patients after discharge for some period of months or years show in general the expected improvement of functioning (e.g. Nienhuis et al., 1994), but as far as only chronic patients are concerned such a positive change is much less noted. The concept of chronicity of mental disorders would presume that after some time needs are fairly predictable and stable and do not change much over time. Our investigation on the long-term course of schizophrenia (Wiersma et al., 1996; 1997) enables us to study over a period of two years, from 15 to 17 years since first onset of psychosis, the stability or variability of needs in schizophrenic disorder. We are not aware of empirical studies on changes in needs among patients with long-term disorders.

Assessment of needs for care is crucial in the evaluation of ongoing changes from institutional care to various forms of day- and outpatient treatment. Do patients really do better in the community and are they adequately cared for? The 15-year follow-up of a Dutch incidence cohort of patients with schizophrenia and other functional non-affective psychoses showed that 47 (out of 63) patients had positive ratings of symptoms and disabilities. They were assessed by means of the Needs for Care Assessment Schedule, which articulates the problems and corresponding interventions resulting in a judgement of met or unmet need for treatment or assessment. There was a mean of 2.1 clinical problems and 2.1 social problems per patient. Few problems were considered to generate unmet needs: 14% of the clinical problems and only 7% of the social problems. Nevertheless, 32% of the patients had one or more unmet needs. These results were compared with data from six research centres in the United Kingdom (Camberwell, Oxford and South Glamorgan), Canada (Montreal), Italy (Verona) and Finland (Tampere). Despite differences in health care settings in the four countries, the ratio of met to unmet needs (about 4–5 to 1) among chronic, mostly schizophrenic patients is more or less the same with the exception of an apparently underserved hostel population in Oxford and the Finnish patient population probably due to high expectations with respect to independent community living.

The course of the psychopathology and social functioning in an experimental day-treatment group referred for inpatient psychiatric treatment is compared with that of a control group receiving standard inpatient care. During a follow-up period of 2 years subjects were interviewed three times. The interview comprised information about psychiatric symptoms, psychological functions, psychiatric diagnosis and social-role functioning. Apart from these discrete assessments an effort was made to map episodes of illness throughout the follow-up period. Upon entry the groups did not differ in terms of psychopathology or social functioning. At follow-up both groups had improved significantly with respect to symptomatology, psychological and social functioning. The extent to which the groups improved did not differ significantly regarding pathology, but self-care improved more in the experimental group. The average duration of episodes of illness was similar for the experimental and control group. During the 2-year follow-up patients suffered from a well-defined disorder during an average of 11 months. The fact that approximately 40% of them were still a psychiatric case after 2 years further underscores the severity of their pathology.

Objective: Because previous studies of day treatment as an alternative to inpatient treatment bad major disadvantages or methodological shortcomings, the authors conducted a randomized controlled trial to estimate and predict the extent to which day treatment is feasible for unselected patients referred for inpatient treatment. Method: Of 160 patients, 57 were randomly assigned to the control condition and 103 were assigned to the experimental condition. Control patients received standard clinical care. In the experimental condition, day treatment was attempted as soon as the patient's condition permitted. The average number of nights per week that experimental patients spent away from the hospital was compared to the average number of nights away for patients under standard care. Results: Day treatment was satisfactory for 40% of the experimental patients but was completely infeasible for another 40%. The level of surveillance needed in the first week, physical illness, number of previous admissions, depressive symptoms, and treatment by qualified psychiatrists versus registrars were variables predictive of these differences. Conclusions: In this unselected group of patients, no absolute contraindications against day treatment were found. This suggests that the selection criteria applied in nearly all other controlled studies on the subject were unwarranted. The approach used in this study facilitated treatment in the least restrictive environment possible.

The feasibility of day treatment with community care for schizophrenic patients was tested by means of a longitudinal randomized experiment with 34 experimentals and 16 controls: 38 percent could be treated satisfactorily in a day program that included a very active ambulatory service. The new approach did not improve prognosis with respect to psychiatric symptomatology, social role disabilities, or number of readmissions during the first year of followup. Total cost of treatment was less for day-treatment patients than for ordinary clinical patients.

No drastic changes in inpatient psychiatric care like those that have taken place in the USA, Canada, the United Kingdom, and Italy have occurred in the Netherlands. The number of days spent in mental hospitals per year decreased by 11% during the early 1970s, but it has been stable since 1978. The admission rate is also constant: 3.8–3.9 per thousand of the total population (Haveman 1984). The policy of the Dutch government is nevertheless oriented towards a reduction of mental hospital beds in favour of an extension of outpatient and day care. In the next 5 years 2000 long-stay patients will be transferred to sheltered living arrangements. Further bed reduction is aimed at by preventing admission.

In the recurring discussion of the relationship between social class and mental disorder in psychiatric epidemiology, the significance of the former in terms of its inherent stresses for the individual is more often implied than made explicit. Yet a mental disorder such as schizophrenia is considered not as a class phenomenon, but as an individual hazard encountered somewhat more often — but by no means only — in the lower social strata. Unfortunately, one of the originators of the concept of social class as a moving force, Karl Marx, has not left us with much theory to build on. Dahrendorf (1959) wrote: “Marx postponed the systematic presentation of his theory of class until death took the pen from his hand”. By systematically ordering a number of quotations and connecting them to a coherent text, Dahrendorf undertook to complete Marx’s chapter on “The Classes” from the last volume of Das Kapital. Central themes in this unfinished theory of social class appear the more or less direct “conflict or antagonism” between collectivities (labour, the owners of capital and landowners), and people’s growing awareness of one controlling the other through its authority over society’s resources. Social classes are assumed to gain identity because of this awareness, which produces a sense of belonging to either the collectivity of the haves or that of the have-nots. This is a far cry from the artificially defined socioeconomic stratification current in psychiatric epidemiology, of which the lowest and most morbidly affected one is supposed to be characterized by anomy and alienation rather than a sense of belonging; while the other strata differ only marginally or very gradually with respect to mastery or control over a society’s resources.

To gain more insight into the social (as opposed to clinical) outcome of schizophrenia, a unidimensional, hierarchical scale was constructed. Items were selected from the Disability Assessment Schedule (DAS)–a new instrument, used in the WHO Collaborative Study on the Assessment and Reduction of Psychiatric Disability. Data were derived from the Dutch cohort participating in this study, which consisted of patients with a first life-time episode of a non-affective, functional psychosis. Patients were followed-up during the first three years of their illness, and analyses of the stability and reliability of the scale proved to be satisfactory. It was subsequently used to characterise the course of social disability.

Over a period of 3 years since the first in a lifetime onset of an episode of non-affective functional psychosis a cohort of 82 Dutch patients was studied at set intervals with regard to prognosis and outcome. Prognostic statements on remission, relapse, duration of episode, length of stay in hospital, and occupational, family and overall social adjustment were checked against actual outcome after I year. In general, the research team of three psychiatrists, a psychologist and a sociologist began quite optimistically, but became slightly more pessimistic with time. However, their predictions proved hardly better than chance statements. The team appeared to be more pessimistic about the diagnosis of schizophrenia than about that of reactive psychosis, although they were not correct with one diagnostic category more often than with the other.