Psychiatric Out-Patient Services Bruderholz
Department of Psychiatry, University of Zurich
Department of Psychiatry, University of Bern, Switzerland
Kinder- und Jugendpsychiatrie Virngrund Klinik, Ellwangen, Germany
Division of Psychiatry Research, University of Zurich, Switzerland
for the Swiss Early Psychosis Project
Correspondence: Dr Daniel Umbricht, Psychiatric University Hospital Zurich, Lenggstrasse 31, 8029 Zurich, Switzerland. Tel: +411 384 2555; fax: +411 384 3396; e-mail: umbricht{at}bli.unizh.ch
Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To obtain information about the number of patients in the early and chronic stages of schizophrenia seen in general practice; the needs and attitudes of GPs, their diagnostic knowledge concerning early phases of schizophrenia and their knowledge and practice concerning treatment of patients with first-episode and multi-episode schizophrenia.
Method A postal survey was conducted among randomly selected GPs in Switzerland.
Results A total of 1089 GPs responded to the survey. Early psychosis had a low prevalence in general practice, and GPs expressed a wish for specialised, low-threshold referral services. Diagnostic and treatment knowledge showed inconsistencies. Most GPs said they would treat first-episode schizophrenia with antipsychotics, but only a third recommended maintenance treatment after a first episode of schizophrenia that would conform with international recommendations.
Conclusions Easily accessible, low-threshold referral services are pivotal in supporting GPs in the management and treatment of emerging schizophrenia in primary healthcare patients.
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INTRODUCTION |
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METHOD |
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Questionnaire
The 23-item questionnaire (see Appendix) consisted of 4 demographic items,
and 19 (partly multi-item) questions which assessed:
The questionnaires were anonymous. In order to match the forms of GPs who responded to both surveys, a coding system was used which conformed to the criteria of anonymity and was given oral approval by the Eidgenössisches Büro für Datenschutz, the Federal Office of Data Protection. Respondents had to provide the day and the year of birth of their mother, the day of birth of their father, as well as their own gender. Thus, the chance of a false positive match was theoretically 1 in 190 278.
Analysis
Data were analysed using the Statistical Package for the Social Sciences,
version 11 for Windows. To discriminate between different levels of knowledge,
we calculated a score from the two multi-item questions covering diagnostic
knowledge and steps taken to corroborate a diagnosis (questions 8 and 10). The
list of items in each of these questions was divided into three different
score levels, ranging from 2 (highest score) to 0. In question 8, social
withdrawal and functional decline scored 2, hallucinations/delusions,
suicidality, depression/anxiety and bizarre behaviour scored 1 and the
remaining items scored 0. In question 10, family history, information from
significant others and observation over several months scored 2; personal
history and neuropsychological assessment scored 1 and the remaining items
scored 0. The sum of all score-2 items from these two questions constituted
the core score, and the sum of all score-1 and score-2 items the total score.
We based the scoring of the items on results of previous research on
predictors of early schizophrenia and on considerations of what can
practically be expected from GPs in detecting these predictors (see
Discussion).
The core score allowed us to constitute subgroups of knowledge, ranging
from a score of 0 (no score-2 item identified) to 10 (all five score-2 items
identified). We analysed the frequencies of core score sub-groups as well as
the frequencies with which the separate score-2 items had been identified
across the core score subgroups using 2 tests. To assess
within-group profiles, we performed a
2 test against the mean
frequency with which the five items had been identified. To evaluate
differences in the response profile between the different knowledge groups, we
normalised the distributions using the item social withdrawal as
scaling factor. In addition, we analysed the frequencies with which score-1
items had been indicated across the core score subgroups.
Continuous variables were compared with t-tests or analyses of
variance (ANOVA), categorical variables with 2 tests. An alpha
level of 0.05 was considered significant.
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RESULTS |
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The mean number of patients with established schizophrenia treated by GPs was 3.2 (s.d.=2.7); the mean number of patients whom GPs see annually and suspect to be in the early phases of schizophrenia was 1.6 (s.d.=1.2) (Table 1). Respondents who did not correctly identify any of the score-2 items indicated much more often that they never see patients in whom they suspect early schizophrenia, compared with their colleagues with core scores of 2 and higher (Mann-Whitney U-test, P<0.001).
Attitudes and needs
The majority of GPs (720; 66%) expressed satisfaction with collaboration
with specialists, whereas 249 (23%) did not. As
Table 1 shows, the vast
majority of GPs stay in collaboration with specialists (question 4:
2=1280.00, d.f.=1, P<0.001). General practitioners
with a core score of 0 preferred to refer patients to specialists compared
with those with a core score of 2 or more (
2=37.72, d.f.=2,
P<0.001). A fifth of GPs (230; 21%) reported no problems when
treating patients with established schizophrenia; 608 (56%) judged the
patients behaviour to be problematic but continued care in their
practice, and 144 (13%) preferred to refer patients because of their
problematic behaviour. In addition, the more GPs considered the
patients behaviour to be problematic, the more often they referred them
to specialists and did not seek collaboration (
2=114.715,
d.f.=10, P<0.001).
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Diagnostic knowledge
Ninety per cent of the responding GPs indicated that a first episode of
schizophrenia was preceded by early warning signs. Frequencies of identified
score-2 items (questions 8 and 10) are summarised in
Table 2, and distributions of
the core and total scores are shown in Figs
1 and
2. When examining the
frequencies with which score-2 items had been identified across the core score
subgroups, two items were significantly under-identified by GPs: these were
functional decline and observation over several
months. Chi-squared tests of profiles against an even distribution were
as follows: group with core score of 2, 2=46.89; group with
core score of 4,
2=119.38; group with core score of 6,
2=130.42; group with core score of 8,
2=75.74;
d.f.=4 for all groups; P<0.001 for all groups
(Fig. 3). After normalisation
of the group profiles, no between-group difference could be detected
(
2=18.17, d.f.=12, P>0.1). When examining the
frequencies with which score-1 items had been indicated across the core score
subgroups, two clinical features, hallucinations/delusions (mean
frequency 62%) and bizarre behaviour (mean frequency 56%) were
predominantly identified. The composite mean frequency of these two score-1
items (59%) was almost twice as high as the composite mean frequency (33%) of
the two most regularly under-identified score-2 items, functional
decline and observation over several months.
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With regard to diagnostic knowledge, GPs who did not correctly identify any
of the score-2 items indicated much more often that they never saw patients in
whom they suspected the onset of schizophrenia, compared with their colleagues
with core scores of 2 and higher (Mann-Whitney U-test,
P<0.001). Interestingly, although GPs with psychiatric training
had a higher mean core score than those without such training - 5.85
(s.d.=2.56) v. 4.98 (s.d.=2.76) - the profiles of identified score-2
items for these two groups were similar: 2=4.08, d.f.=4, NS.
Similarly, recent education in the field of early psychosis had no significant
influence on score-2 item profile:
2=1.10, d.f.=4, NS.
Treatment of first-episode and chronic schizophrenia
Question 12, concerning the form of therapy the respondent would recommend
for a patient with a suspected first episode of schizophrenia, was answered by
1026 GPs (94%). Four choices were given: psychotherapy, pharmacotherapy,
family therapy and observe and wait. Multiple responses were
permitted. Pharmacotherapy, alone or in possible combination with other types
of therapy, was selected by 88% of GPs. Psychotherapy alone or in combination
was recommended by 47%, but only 1% recommended psychotherapy alone. Family
therapy alone or in combination was recommended by 30%, but only 0.2%
recommended family therapy alone. The 122 GPs (11%) who did not include
pharmacotherapy in their recommendations demonstrated significantly worse
diagnostic knowledge: mean core score 2.7 (s.d.=3.2) v. 5.5
(s.d.=2.5), t=11.46, d.f.=1087, P<0.001.
Two-thirds of respondents (n=732) indicated what kind of medication they would prescribe for the treatment of a first episode of schizophrenia. At most four drugs could be mentioned. We analysed only the frequency with which medication groups were recommended. Of the total of 1542 recommendations, 98.5% were for antipsychotics: 58.7% for atypical and 40.7% for typical antipsychotics. However, 84% of all GPs providing drug treatment recommendations mentioned an atypical antipsychotic at least once. Among the GPs who mentioned only one antipsychotic, 69% recommended an atypical agent. Higher levels of diagnostic knowledge were associated with a significantly higher percentage of atypicals prescribed (median split on total score: 64% v. 58%, t=2.25, d.f.=728, P<0.05).
Estimates of relapse rate and duration of maintenance treatment
An estimate of the relapse risk of untreated patients in the first year
after a first episode was given by 877 GPs (81%); the mean figure was 52%
(s.d.=22). An estimate of 60-90% was considered correct and was given by 32%
of respondents. Two-thirds (68%) estimated the relapse risk as less than 60%.
Eight out of ten GPs estimated the course after a first episode as being
favourable (one or several episodes with possible maintenance of social
functioning).
In response to question 14, 930 GPs (85%) indicated how long they would
maintain antipsychotic treatment after a first episode of schizophrenia, and
919 (84%) how long they would do so in patients with multi-episode
schizophrenia. We considered a treatment period after a first episode of
schizophrenia of less than 6 months as insufficient, a treatment period of
6-12 months as acceptable and treatment for more than 12 months as meeting
international treatment recommendations
(Work Group on Schizophrenia,
1977). Thus, 32% of all respondent GPs would recommend an
insufficient duration of treatment, 38% an acceptable duration and 30% a
duration in accordance with international recommendations. We considered
treatment of a patient with multi-episode schizophrenia for less than 3 years
as insufficient, and treatment for more than 3 years as meeting international
treatment recommendations (Work Group on
Schizophrenia, 1977). Thus, 52% of respondents to this question
(44% of the total sample) would provide maintenance treatment in patients with
chronic illness according to international guidelines. To assess associations
of treatment strategies with diagnostic knowledge, we divided all GPs into two
groups with high and low levels of diagnostic knowledge, respectively, using
the median split of the total score. There was no significant difference with
regard to maintenance treatment after a first episode or in multi-episode
schizophrenia between the two knowledge groups. Significantly more GPs with
correct estimates of relapse rates after a first episode would provide
maintenance treatment in first-episode patients according to international
recommendations (2=13.01, d.f.=2, P=0.001). Also, GPs
providing acceptable or correct maintenance treatment recommended atypical
antipsychotics significantly more often than the other GPs (67% and 65%,
respectively, v. 50%; ANOVA F2,707=15.48,
P50.001; post hoc tests P50.001 for both
comparisons).
Among GPs with former psychiatric training, 58% would provide maintenance
treatment according to international guidelines, whereas only 49% without
former psychiatric training would do so (2=7.80, d.f.=1,
P=0.005). Treatment strategies in first-episode schizophrenia were
highly associated with treatment strategies in multi-episode illness
(
2=121.76, d.f.=2, P50.001. When considering the
number of patients treated by each GP, the percentages of GPs recommending
acceptable maintenance treatment in patients with multi-episode schizophrenia
translate into 54% of all patients with chronic schizophrenia receiving
internationally recommended maintenance treatment.
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DISCUSSION |
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Importance of GPs in the treatment of chronic schizophrenia
Our survey indicated that a single GP treats on average about three
patients with established schizophrenia annually, which is consistent with the
results of previous studies (Lewin &
Carr, 1998). Assuming that this number represents the average
number of patients seen by all Swiss GPs, one can extrapolate that about 19
000 patients with established schizophrenia are treated by GPs alone or in
collaboration with specialists. Based on a lifetime risk of schizophrenia of
1% (Jablensky et al,
1992) and a total population in Switzerland of approximately 7
million inhabitants, the expected prevalence rate for Switzerland amounts to
70 000 patients with established schizophrenia. Thus, more than a quarter of
all patients with schizophrenia are treated by GPs in Switzerland (the number
of patients who are seen by GPs but referred for all treatment to a specialist
amounts to only 3% of all patients seen). Our results suggest that GPs in
Switzerland are involved in the treatment of approximately a quarter of
patients with chronic schizophrenia. Therefore, for a considerable number of
patients with chronic schizophrenia, GPs in Switzerland have an important
role. In the Swiss healthcare system a minority of patients participate in
gatekeeper models. Thus, it is questionable to which extent these results can
be generalised to the UK and other countries with nationalised gatekeeper
systems. However, in studies conducted in the UK it was found that up to a
quarter of patients with long-term mental illness depend solely on GPs for
their care (Johnstone et al,
1984; Kendrick et al,
1994), suggesting that the results obtained in our survey may also
apply to other healthcare systems. Furthermore, preliminary results of an
international multicentre survey of GPs indicate that the mean numbers of
patients with chronic schizophrenia seen by GPs are similar across many
countries and healthcare systems (Simon
et al, 2004).
Early psychosis is a low-prevalence disorder in general practice
Considering the overall number of GPs in Switzerland (n=6046) and
the mean annual number of patients seen by GPs and suspected to be in an early
phase of psychosis (1.6), the total number of such patients can be
extrapolated to approximately 10 000 cases per year. Using the incidence
values of the World Health Organization ten-country study
(Jablensky et al,
1992) for Aarhus and Nottingham (21 per 100 000), approximately
1500 new cases of schizophrenia per year can be expected in Switzerland. Our
results suggest, on the one hand, that a substantial proportion of patients
with emerging schizophrenia are seen at some point along their help-seeking
pathway to care by a GP, even if emerging schizophrenia is a low-prevalence
disorder in the individual general practice. However, compared with the
estimated annual incidence rate of 1500 new cases of schizophrenia in
Switzerland, GPs may suspect the onset of schizophrenia in a large number of
cases in which the disorder will never develop. The fact that GPs with a
higher knowledge level reported seeing more patients in whom they suspected
early-onset schizophrenia suggests that they may be too quick to develop this
suspicion when they identify a possible prodromal symptom, but fail to conduct
a thorough assessment that could corroborate or refute their suspicion.
Interestingly, this did not apply for GPs with a low knowledge score, who more
often seemed to overlook a first episode of schizophrenia.
To our knowledge, no previous study has investigated the prevalence of suspected early schizophrenia among patients in general practice. However, preliminary analyses of the international survey among GPs cited above found that GPs see about 1.4 patients a year in whom they suspect emerging schizophrenia (Simon et al, 2004).
Definition of score-2 items
With regard to the definition of score-2 items, all of them were either
potential precursors of a first episode of schizophrenia or important aspects
in the assessment of such patients. However, our choice was guided by two
considerations: first, the reported results of studies on early phases of
schizophrenia, and second, consideration of what can be practically expected
from GPs in terms of recognition of precursors and diagnostic steps. Two of
the score-2 items, social withdrawal and functional
decline, have frequently been reported in the prodromal phase of
schizophrenia (Hafner et al,
1999). Indeed, in a retrospective study of 200 patients with a
first onset of functional psychosis, McGorry et al
(2000) reported that a
prolonged functional deterioration was likely to predict a diagnosis of
schizophrenia. Social withdrawal has been carefully described in a study of
the subjective experiences of patients with early psychosis
(Moller & Husby, 2000).
Both social withdrawal and functional decline are often sealed
over (Birchwood et al,
1998) by such patients. Therefore, information from
significant others (another score-2 item) is an indispensable tool for
GPs in their assessment of social withdrawal and functional decline.
High prevalence rates in the prodromal phase of schizophrenia have been found for depression and anxiety (Hafner et al, 1999), drug misuse (Hambrecht & Hafner, 1996) and, to a lesser extent, suicidality (Verdoux et al, 2001). Typically, these findings stem from first-episode studies, i.e. from patients who already have a clinical manifestation of a first episode of schizophrenia. The only prospective study that controlled for the diagnostic efficiency of initial prodromal symptoms (Klosterkötter et al, 2001) showed that, using the Bonn Scale for the Assessment of Basic Symptoms (Gross et al, 1997), the cluster containing affective disorders had the highest sensitivity, but comparatively low specificity and predictive power. Suicidality is a serious phenomenon in adolescents and young adults, particularly in the prepsychotic phase (Mortensen & Juel, 1993), but psychosis does not feature in the primary pathology in most studies of suicidal adolescents. These findings and reflections led us to define depression/anxiety and suicidality as score-1 items. Another example that illustrates our procedure in defining item scores is drug misuse. Drug misuse, in particular misuse of cannabis, is a frequent finding in early psychosis (Hambrecht & Hafner, 1996); however, the use of cannabis is steadily growing in society, particularly among adolescents and young adults, and we therefore rated drug misuse as a score-0 item. Hallucinations and delusions (a score-1 item) often require information from significant others for their detection, yet their presence indicates that these patients have already converted from prodromal stages to frank psychosis.
A positive family history is associated with an increased risk of schizophrenia, but the vast majority of people with schizophrenia have no positive family history (Gottesman, 1991). None the less, in our analysis we defined the assessment of family history as a score-2 item, since it is an easily applicable tool and may, in the case of positive findings, provide important information. Personal history is of no lesser importance, but we supposed this to be a basic part of any medical assessment.
The forgotten insidious features of early psychosis
Although the majority of GPs believed in the existence of early warning
signs prior to a first episode of schizophrenia, their diagnostic knowledge
showed inconsistencies. Two score-2 items, functional decline
and observation over several months, i.e. sustained functional
deterioration, were regularly under-identified across all knowledge subgroups.
In contrast, GPs were more likely to look out for frank psychotic symptoms
such as hallucinations and delusions as well as bizarre behaviour.
These findings highlight the importance that future educational programmes for GPs should put more emphasis on these hidden features and on careful history-taking. However, given that in our study the vast majority of GPs expressed a wish for collaboration with secondary care services and preferred low-threshold referral services to educational programmes, the value of the latter must be questioned. Indeed, knowledge profiles did not differ between GPs with and without former psychiatric training and between GPs who had attended educational programmes on early psychosis and those who had not. Thus, given the low prevalence of early psychosis in private practice, it may be strongly assumed that mere educational programmes may be insufficient tools to improve qualitative knowledge levels among GPs. Rather, our results warrant the simultaneous provision of specialised and easily accessible, low-threshold counselling and assessment facilities for professionals in primary care such as GPs.
Treatment recommendations
The vast majority of GPs surveyed would treat a first episode of
schizophrenic psychosis pharmacologically, indicating that they consider this
to be a state requiring biological treatment. Therefore, this aspect of
current treatment practice corresponds to treatment guidelines based on
reviews of placebo-controlled studies in the acute and maintenance treatment
of patients with first-episode and chronic psychosis
(Work Group on Schizophrenia,
1977).
Among all the drug treatment recommendations (each GP could provide up to four) atypical antipsychotics were recommended only in 58%; however, 83% of the GPs who replied to this question mentioned atypical antipsychotics at least once. Thus, GPs in Switzerland, at least in their intended behaviour, seem to follow currently recommended use of atypical antipsychotics as first-line treatment for patients in their first episode of schizophrenia (Marder et al, 2002).
General practitioners tend to underestimate the relapse risk in untreated patients after a first episode of schizophrenia. Only a third of all GPs provided estimates that we considered correct. Consistently, 80% of the GPs considered the course of schizophrenia as favourable and only a third of GPs recommended maintenance treatment after a first episode of schizophrenia that conformed to internationally accepted guidelines. Even among the GPs who gave correct estimates of the relapse risk, only 37% would provide adequate maintenance treatment after a first schizophrenic episode. Surprisingly, GPs who had trained in psychiatry (usually 1 year in Switzerland) and those who had attended recent education courses about schizophrenia fared no better than those without psychiatric training or recent education. If one considers that the GPs responding in this survey are likely to be those who have some interest in schizophrenia, it has to be assumed that the overall number of GPs providing adequate treatment is even smaller.
With regard to maintenance treatment of patients with multiple episodes of psychosis, a slightly better picture emerged. About 51% of GPs would treat for at least 3-5 years. Those GPs with psychiatric training fared somewhat better on this question. Not surprisingly, GPs who provide correct maintenance treatment after a first episode significantly more often provide correct maintenance of multi-episode illness compared with the rest of the GPs.
Using the mean figure of 3.2 patients with established schizophrenia who are treated by GPs, it can be extrapolated that about a quarter of patients with schizophrenia (i.e. approximately 19 000) are treated by GPs in Switzerland. Thus, up to 9000 patients may potentially receive inadequate maintenance treatment. Even if these numbers are an overestimate, a considerable number of patients may experience relapses due to ill-considered treatment recommendations, leading to substantial subjective suffering and considerable health costs. Thus, it seems important to educate mental healthcare providers about evidence-based treatment recommendations.
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APPENDIX |
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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The study was supported by an unrestricted grant from Sanofi-Synthélabo SA, Switzerland, to the Swiss Early Psychosis Project.
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Received for publication January 26, 2004. Revision received October 25, 2004. Accepted for publication October 30, 2004.
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