Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Italy
Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Italy
Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Italy
Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Italy
Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Italy
Section of Community Psychiatry (PRiSM), Health Service Research Department, Institute of Psychiatry, London, UK
Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Italy
Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Italy
Correspondence: Mirella Ruggeri, Dipartimento di Medicina e Sanitá Pubblica, Sezione di Psichiatria, Universitá di Verona, Ospedale Policlinico, 37134 Verona, Italy.Tel: +39 045 80 74 441; fax: +39 045 58 58 71; e-mail: mirella.ruggeri{at}univr.it
Declaration of interest None. The study has been supported by a grant from Fondazione Mario Lugli (Roma).
1 Housewife includes both married and unmarried women.
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ABSTRACT |
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Aims To measure changes in psychopathology, functioning, needs for care and quality of life; to develop predictive models for each outcome domain; and to assess the frequency of goodandpoor outcomes, as defined in a series of different definitions that use combinations of the four domains measured.
Method Three-year follow-up of a 1-year-treated prevalence cohort of 107 patients with an ICD10 diagnosis of schizophrenia attending the South Verona community-based mental health service.
Results Mean symptom severity and some types of needs for care worsen, but quality of life shows no change.Functioning shows a non-significant trend to deteriorate.Between 32% and 42% of the variance in the four key outcomes was explained by our model. Different definitions of goodand poor outcome included 031% of patients, depending on the definition used.
Conclusions The 3-year outcome for schizophrenia depends on the domain of outcome used, whether staff or patient ratings are used and the stringency of the definitions used for good and poor outcome.
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INTRODUCTION |
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Study aims
The first aim of this study was to evaluate prospectively the 3-year
outcomes, in terms of four outcome domains (symptoms, functioning, needs and
quality of life), for a cohort of patients with schizophrenia who received
integrated community-based care and to identify the domains likely to improve
or worsen over time. The hypotheses tested in relation to this first study aim
were that at the level of the whole cohort there would be no significant
deterioration in terms of psychopathology and subjective quality of life and
there would be significant deterioration in terms of functioning and
patient-rated needs. Further, at the level of individual patients, we assessed
the proportion of patients who would change their status for symptoms and
functioning (staff-rated) and for needs and subjective quality of life
(patient-rated) when each outcome domain was considered separately. The second
aim of the study was to develop a model to predict the outcomes for
individuals with schizophrenia in such non-experimental clinical settings. The
third aim was to undertake exploratory analyses to assess the frequency of
occurrence of good and poor outcome for this
cohort. For this purpose a series of different definitions of
good and poor outcome at 3 years were considered
that used particular combinations of the four outcome measures.
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METHOD |
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Case identification
The EPSILON Study used the following inclusion criteria: adults aged
1865 years inclusive with an ICD10
(World Health Organization,
1992) research diagnosis of schizophrenia (F20 code, corresponding
to 295 DSMIV code). The exclusion criteria were current residence in
prison, secure residential services or hostels for long-term patients,
coexisting learning disability (mental retardation), primary
dementia or other severe organic disorder and extended in-patient treatment
episodes longer than 1 year. Full details on sample selection have been
published elsewhere (Becker et al,
1999). In the Verona sample, application of these criteria led to
exclusion of only one patient who, although in contact with the South Verona
service, was living in a hostel for long-term patients.
In the first stage of the study an administrative prevalence sample of people with a diagnosis of schizophrenia or other psychotic disorders attending the South Verona CMHS (ICD10, F20F25) was initially identified from the South Verona Psychiatric Case Register. Cases identified were then diagnosed using the Item Group Checklist of the Schedule for Clinical Assessment in Neuropsychiatry (SCAN; World Health Organization, 1992). Only patients with an ICD10 research diagnosis of schizophrenia were finally included as cases.
Baseline assessment
The instruments used at baseline were the official, standardised Italian
versions of the Brief Psychiatric Rating Scale, Expanded Version (BPRS;
Ventura et al, 1993),
the Global Assessment of Functioning (GAF;
American Psychiatric Association,
1987), the Camberwell Assessment of Need (CAN;
Slade et al, 1999)
and the Lancashire Quality of Life Profile (LQoLP;
Oliver, 1991). The latter two
scales were the standardised European Union versions and all scales were known
to have high levels of reliability, as demonstrated in the EPSILON Study
(Gaite et al, 2000; McCrone et al, 2000).
All patients were interviewed only after informed consent had been gained in
each case. The procedure used was that research staff explained the purpose of
the study and gave full details to each patient in writing, making it clear
that participation was entirely voluntary. We told potential subjects that
they could choose whether to agree to participate, to decline or to agree and
then withdraw at a later time, without any detriment to their clinical care.
Confidentiality was fully preserved.
Psychopathology
Psychopathology was measured by the BPRS
(Lukoff et al, 1986;
Ventura et al, 1993),
which consists of 24 items rated on a seven-point Likert scale (1=no symptom;
7=extremely severe symptom). As shown in a factor analysis performed on a
sample of patients with schizophrenia drawn from a multi-centre European Study
(further details available from the authors upon request), items cover four
dimensions: anxiety/depression (constituted by six items: somatic concern,
anxiety, depression, suicidality, guilt, tension); positive symptoms (five
items: grandiosity, suspiciousness, hallucinations, unusual thought content,
conceptual disorganisation); negative symptoms (seven items: blunted affect,
emotional withdrawal, motor retardation, uncooperativeness, self-neglect,
disorientation, mannerisms); and mania (hostility, elevated mood, bizarre
behaviour, self-neglect, uncooperativeness, excitement, distractibility, motor
hyperactivity, mannerisms).
Functioning
Functioning was measured by the GAF scale
(Endicott et al,
1976), which is a measure of individual functioning that includes
the impact of symptoms and disability. Functioning is measured on a continuous
scale from zero, which denotes extremely severe dysfunction, to 90, which
denotes extremely good function.
Needs for care
The assessment of needs was made using the CAN, Patient Version. It is an
instrument of known and acceptable reliability
(Slade et al, 1999) that comprises 22 individual areas grouped into five domains of needs: health
(constituted by seven areas: physical health, psychotic symptoms, drugs,
alcohol, safety to self, safety to others, psychological distress); basic
(three areas: accommodation, food, daytime activities); social (three areas:
sexual expression, company, intimate relationships); service (four areas:
information, telephone, transport, benefits); and functioning (five areas:
basic education, money, child care, self-care, looking after home). Needs are
assessed on a three-point scale: 0=no problem; 1=met problem; 2=unmet
problem.
Subjective quality of life
The LQoLP elicits objective quality-of-life indicators and subjective
quality-of-life appraisal through patients answers to
interviewer-administered questions concerning nine dimensions: work/education,
leisure/participation, religion, finances, living situation, legal and safety,
family relations, social relations, and health. Each question allows patients
to rate their satisfaction on a seven-point life satisfaction scale (1=cannot
be worse, 7=cannot be better). The average of the resulting nine dimension
scores is referred to as the perceived quality of life.
The LQoLP includes two scales for the measurement of affect balance and self-esteem, each constituting of ten items rated on a yes/no categorical scale. The former scale investigates the patients emotional status by assessing the presence of negative and positive feelings; the latter investigates the patients view about him- or herself.
Follow-up assessments
All eligible patients included in the baseline assessment were traced after
3 years and reassessed with the same set of instruments and the same
procedures used at baseline. Service utilisation data for the entire baseline
to follow-up period were extracted for each individual patient from the South
Verona Psychiatric Case Register
(Tansella, 1993).
Study setting
South Verona is a mixed urban and rural area of about 75 000 inhabitants
that includes part of the city of Verona and two neighbouring small towns. The
main agency providing psychiatric care for the adult population is the South
Verona CMHS, which is run by the Section of Psychiatry, Department of Medicine
and Public Health of the University of Verona. The South Verona CMHS supplies
a wide range of comprehensive and well-integrated programmes, including
in-patient care, day care, rehabilitation, out-patient care, home visits, a
24-hour emergency service and residential facilities (three apartments and one
hostel) for long-term patients. This ensures continuity of care through the
different phases of treatment and across the various components of service
provision. The South Verona Psychiatric Case Register covers the same
geographical area and collects demographic, diagnostic and service utilisation
data on all patients seen by public and private ambulatory and hospital
specialist mental health services in the Province of Verona.
Statistical methods
Analysis of changes at follow-up
Changes in BPRS, LQoLP total and dimensional sub-scores, GAF, CAN,
self-esteem and affect balance were first assessed by comparing mean scores at
baseline and follow-up using Wilcoxon tests. The application of Bonferroni
correction is not possible because most dimensions are correlated, so
significance levels are presented without correction. For the purpose of
discussion of the results, however, we set the significance level at 0.01 as a
compromise to the Bonferroni correction
(Pope et al, 2001).
Subsequently, we assessed the percentage of subjects who had changes
(improvement or worsening) or who maintained their previous status
(stability). We have considered as stable a subject with a change not
exceeding ±0.5 (inclusive) for BPRS and LQoLP, ±5 (inclusive)
for GAF and ±1 (inclusive) for CAN, self-esteem and affect balance mean
scores. The selection of the cut-off points was based on identification of the
minimum measurable change detected by the rating scale. Changes in service
utilisation between the year preceding baseline assessment and the 3-year
follow-up period were assessed by means of the McNemar and Wilcoxon tests, as
appropriate.
Predictors of outcome
Bivariate relationships between each outcome domain indicator and the
independent variables were explored and variables were found to be suitable
for regression analysis. To identify the predictors of each outcome domain at
3 years, a series of block-stratified multiple regression models
(Ruggeri et al, 2001)
was constructed with follow-up scores of each indicator used as the dependent
variable. The following baseline independent variables were entered in turn:
demographic characteristics (older than 35 years v. others; single;
higher educational level; living alone v. others, shelter v.
others; employed v. others;
retired/housewife/student1
v. others); duration of illness (years); total mean BPRS score; GAF
mean score; service utilisation in the baselinefollow-up interval
(out-patient and community care contacts; 130 day hospital contacts
v. higher; 190 days of admission v. others); mean
total number of problems detected in the CAN; and mean total LQoLP score. Some
variables had to be categorised because of their skewness. Because the
follow-up period was not exactly 3 years for all patients, service utilisation
variables were standardised to 36 months in order to avoid bias introduced by
slightly varying follow-up periods. The standardisation formula was as
follows: (number of contacts during the follow-up period/length of follow-up)
x 36, months. The baseline scores of each indicator were included in the
final blocks owing to the strong associations between baseline and follow-up
measurements, which could potentially hide important relationships with other
variables. In the block-stratified multiple regression model, significant
(P<0.05) predictors are selected in the first block; subsequently,
the procedure of selection is repeated in the second block, retaining those
variables that were significant in the previous block even if they were no
longer significant after the new selection. The process goes on until the last
block. Only variables surviving all these steps are included in the final
models. This procedure permits forcing the entry of certain variables that are
important for prediction from a conceptual point of view, which otherwise
would be hidden by more correlated predictors. Each ß-coefficient
represents a multivariate value (i.e. the contribution of the corresponding
predictor to the dependent variable) adjusted for the effect of the other
predictors selected by the model. The regression analysis was performed using
SPSS for Windows, release 10.0.7.
Multi-dimensional definitions of good and poor outcome at 3-year follow-up
To explore further the proportion of the cohort that could be considered to
have good or poor outcomes after 3 years, we have made a distinction between
staff-rated (symptoms and functioning) and patientrated (needs and quality of
life) outcomes and then defined a series of conditions that may be combined
either for all four outcomes simultaneously or for combinations of possible
values within the staff-rated and the patient-rated outcomes, respectively.
Eight different options have been considered here as definitions of good
outcome and eight different options as definitions of poor outcome (see Tables
7 and
8).
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RESULTS |
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Follow-up assessments
At the 3-year follow-up, among the 107 subjects belonging to the baseline
cohort 5 people had died. Of the 102 eligible ones, 1 was not traceable and 6
refused to be interviewed at follow-up. A total of 95 individuals (89% of the
eligible) completed the clinical assessment (GAF and BPRS) both at baseline
and at follow-up; 90 completed the CAN and 88 completed the LQoLP. On average,
follow-up assessments were performed 36.1 months (s.d.=5.1, median=36.9,
range=31.943.9) after the baseline assessment.
Socio-demographic and service utilisation data
Socio-demographic and clinical characteristics of the baseline cohort are
given by Gaite et al
(2002). Briefly, the mean age
was 42.6 years and 51% were female. Regarding living conditions, 79.4% were
living with a partner or other family members, 12.2% were living alone and
8.4% were in sheltered accommodation. Over one-quarter (27%) had a secondary
school or higher level of education and 28% were employed. Service utilisation
data (Table 1) in the year
preceding baseline assessment and in the follow-up period show that about
one-quarter of patients were admitted to hospital each year during both time
periods and attended, on average, more than one out-patient visit per week.
The use of sheltered apartments (for long-stay rehabilitation), day care and
domiciliary care all applied to more people over time but with a decreasing
intensity of contacts.
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Psychopathology
Baseline and follow-up psychopathological data are given in
Table 2, which shows that the
total mean scores, and levels of the subscores, indicate relatively low levels
of symptoms; analyses conducted at the individual item level showed that
unusual thought content (mean baseline score 2.2; s.d.=1.6; 95% CI
1.882.52), anxiety (mean baseline score 2.2; s.d.=1.3; 95% CI
1.942.46) and hallucinations (mean baseline score 2.0; s.d.=1.6; 95% CI
1.682.32) are the more commonly present and severe symptoms. At the
3-year follow-up a significant worsening was found in the total mean BPRS
score (P<0.01); there were trends for all BPRS sub-scores to
become worse at follow-up but only negative symptoms deteriorated
significantly (P<0.01). The worsening of negative symptoms was
even more marked at the individual BPRS item level, where highly significant
deterioration was found for all items that contribute to the negative symptom
sub-score (blunted affect P<0.01; emotional withdrawal
P<0.01; uncooperativeness P=0.02; self-neglect
P<0.01), except for motor retardation (P=0.88),
disorientation (P=0.82) and mannerisms (P=0.56).
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Table 2 shows (in the three right-most columns) that for the BPRS total score, and its sub-scores, about two-thirds of patients remained symptomatically stable over the 3-year study period. Where changes did occur, these were more often deteriorations than improvements in mental state. This was especially so for the negative symptom sub-score, and indeed it was the items that contribute to this sub-score that showed the most marked areas of symptomatic deterioration over time and for which, on average, only about one-third of patients were stable.
Functioning
As shown in the last row of Table
2, the mean level of functioning was relatively low both at
baseline (56.5) and at follow-up (53.4). A relatively
substantial mean deterioration for the whole cohort was found but did not
reach significance because the large standard variation was unlikely to be
able to detect a three-point difference based on a 90-point rating scale. For
individuals, only 23% of subjects were stable and 47% deteriorated during the
study.
Needs for care
As shown in Table 3, the
total number of needs for care did not differ between baseline and follow-up.
At the level of the CAN domains, a decrease in health (P=0.04) and
social (P=0.04) needs and an increase in functioning
(P=0.02) needs was detected. More detailed analysis showed that, at
baseline, the needs profile of the cohort had the most favourable ratio
between met and unmet needs in basic, functioning and health domains, where
met needs were clearly prevailing over unmet needs; on the other hand, in the
social domain unmet needs were slightly prevailing over met needs. In all
domains the met/unmet proportion tended to be less favourable at follow-up,
with the most clear-cut deterioration in the area of functioning needs; basic
needs were an exception, with a slight increase in the proportion of met needs
at follow-up.
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Results of changes in needs for care at the individual patient level are shown in Table 4. A different trend for social needs and all other domains was found. Overall, when needs were absent at baseline they tended to remain absent at follow-up; when they were present at baseline (whether met or unmet), a clear general trend towards improvement was detected at follow-up, suggesting that effective treatment had been provided in the interim. In the social domain, however, the majority of patients who had no social needs at baseline also continued to have no needs at follow-up, but when a new social need was detected at follow-up it tended to be more frequently an unmet need. Among those individuals who did have social needs at baseline, most also continued to have these needs at follow-up, indicating that no effective intervention had been applied to these social problems.
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Subjective quality of life
The results of the subjective LQoLP ratings are shown in
Table 5. At the cohort level
there was no overall pattern of any significant changes, either for the total
score or for the domains. At the individual patient level about half of the
patients were stable, a quarter worsened and a quarter improved. There were
some variations for domains of the subjective LQoLP, particularly for
satisfaction with work, where patients more often improved than remained
stable. A different trend was found for the two additional scales included in
the LQoLP, which measure self-esteem and affect balance. At the individual
patient level the trend was similar to the LQoLP domains because about half of
the subjects were stable and for self-esteem equal proportions improved or
deteriorated, whereas for affect balance there was a tendency towards
deterioration.
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Predictors of outcome
Psychopathology
Lower functioning at baseline and higher number of days in hospital in the
follow-up period were the only variables to predict a higher severity of
psychopathology and explained 38% of variance (see
Table 6, column 2). Adding the
BPRS baseline scores did not have any additional impact on the variance
explained, indicating that after having taken into account the variables
included in previous blocks the severity of psychopathology after 3 years was
not predicted by its severity at baseline. Moreover, these results show that
duration of illness was not a predictor of psychopathological severity over
the 3-year follow-up.
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Functioning
Worse functioning at follow-up (rated by the GAF) was best predicted by
male gender, retired/housewife/student, longer history of treatment, higher
level of symptoms (BPRS score), more time in hospital during the follow-up
period and more needs, which together explained 30% of the variance (see
Table 6, column 3). When
baseline GAF was included in the model the variance explained increased to
35%, indicating that follow-up functioning was predicted by baseline
functioning level.
Needs for care
Higher levels of needs at follow-up were significantly predicted by
unemployment, lower functioning and lower quality of life, together explaining
36% of the variance. Baseline total number of needs also contributed to the
increase in variance explained in the follow-up and increased the variance
explained to 42% (see Table 6,
column 4).
Quality of life
Lower quality of life at follow-up was predicted by lower levels of
functioning and by more needs, accounting together for 12% of the variance
explained. This was over-shadowed by the far greater effect of the baseline
LQoLP score, which added a further 20% to the variance explained (see
Table 6, column 5).
Definitions of good and poor outcome at 3-year follow-up
Table 7 displays the eight
different options that we considered here as possible definitions of good
outcome, along with the frequency of their occurrence. The results show that
if we take the most stringent definition of good outcome (i.e. improvement on
all four key outcomes) no patient came into this category. At the other end of
the spectrum, the least stringent definition gave the maximum number of
patients with a good outcome (24%) by using relatively modest criteria, namely
that there is an improvement in at least one of four outcome measures.
Interestingly, this outcome was equally frequent when rated either by staff
(row G) or by patients (row H). Between these extremes, definitions that might
be considered as clinically meaningful are those shown in rows C or D, in
which a good outcome means that at least one measure improves while none
deteriorates. Again it is noteworthy that the frequency of this type of good
outcome was closely similar whether rated by staff (21%) or by patients (17%).
In overview, taking these more modest definitions of good outcome, between one
in four and one in five patients had a good outcome at the 3-year
follow-up.
Turning to poor outcome, Table 8 shows the corresponding combinations of criteria to define poor outcome and their frequency of occurrence. Again, with the narrowest definition (i.e. all four outcomes showing deterioration) this type of poor outcome was rare (3%). The most permissive criteria, in which only one measure shows deterioration, applied to 31% when using staff ratings (row G) and 19% when using patient ratings (row H). The equivalent intermediate definition to that used for good outcome above, namely one measure deteriorates and none improves, shows that 27% of cases fulfilled these criteria when rated by staff (row D) and 16% when rated by patients (row C). Interestingly, the staff ratings were uniformly more pessimistic than the patient ratings.
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DISCUSSION |
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There are two main limitations of this study. The first of these is that the sample was of treated prevalence cases, to establish the outcomes of care, and does not include cases of schizophrenia out of contact with public services or those not in contact with any service. However, previous research in South Verona has shown that very few such patients are treated in private hospitals or in private office practice alone (Tansella, 1993; Balestrieri et al, 1994). Moreover, it is standard practice for general practitioners to refer all psychosis cases to the state mental health services; such specialist services are free at the point of use and have been established since 1978, so it is unlikely that current cases remain out of care. The second limitation is sample size. Although inclusive of all prevalent cases in the service assessed, sample size was relatively small and for this reason we restrict ourselves to the two specific hypotheses and treat the other study aim as allowing exploratory analyses that may be hypothesis-generating. In addition, even if the set of predictors and outcome variables used in this study is one of the most comprehensive ever used, other important predictors (such as major life events, expressed emotion, adherence to prescribed treatment and use of street drugs) or outcomes (such as self-injurious and suicidal behaviours, the use of emergency and crisis intervention services) were not included in the analysis. Finally, in this study predictive patterns have been identified that reflect statistical associations between variables measured on subsequent occasions. Caution should be used in considering the associations found as being representative of causation mechanisms.
Changes occurring at 3 years
The first hypothesis set in this study was that, at the level of the whole
cohort, there would be no significant deterioration in terms of
psychopathology and subjective quality of life. The results require us to
reject this hypothesis with regard to psychopathology because the mean symptom
severity level for the whole group showed a worsening that is more clear-cut
in the case of negative symptoms. Because quality-of-life scores show no
significant change over the study period, data obtained confirmed this part of
the hypothesis, both in the overall LQoLP score and in the various life
domains.
The second hypothesis was that there would be significant deterioration in terms of functioning and patient-rated needs. A trend towards deterioration of functioning was found, although it was not statistically significant owing to the large variation and the small sample size. For these reasons we must reject the second hypothesis with regard to functioning. Concerning the needs for care, overall the total number of needs did not show a significant decrease; however, social and health needs decreased significantly and functioning needs increased. The ratio of met:unmet needs at baseline was especially unfavourable in the case of social needs. At follow-up it tended to worsen further in all domains except basic needs, indicating that needs that continue to be present over time tend to worsen, the most clear-cut worsening being in functioning needs. With regard to needs for care, our findings did not confirm the second hypothesis but pointed to a complex picture where both failure and success of services in meeting patients needs were detected, with the areas of social and functioning needs appearing to be the more critical ones.
Moving to the individual patient analyses, for staff-rated outcomes the results showed that for symptoms the majority of patients (74%) remained stable, whereas for functioning only 23% did so. In relation to the consumer-rated outcomes, patients who had no needs at baseline maintained the same condition in >80% of cases at follow-up, and this was true for all CAN domains. In those patients who had needs at baseline, a trend for improvement was detected over time in all areas, with the exception of social needs, where a considerable proportion of needs remained stable or their severity tended to worsen. For quality of life a consistent pattern emerged in which about half of the patients remained stable, a quarter improved and a quarter deteriorated. By these individual outcome domains, therefore, considerable heterogeneity was demonstrated in the 3-year treated outcomes.
Predictors of outcome
The second aim of the study was to develop a model to predict the outcomes
for individuals with schizophrenia in non-experimental clinical settings. The
results found that such models could explain 3242% of the variance in
the four key outcome variables. Although functioning, number of days of
hospital admission and unemployment were each identified as significant
predictors in two or more of the four models, there was no consistent overall
pattern of variables that predicted all outcomes. These results suggest that
different outcomes have, to some extent, different and specific predictors and
support the view that schizophrenia outcome is a complex and multi-dimensional
function (Strauss & Carpenter,
1977); as a consequence, it may be hypothesised that different
types of intervention (e.g. increasing employment rates among individuals with
schizophrenia) may differentially affect some outcomes more than others.
Good and poor multi-dimensional outcomes
The third aim was to undertake exploratory analyses to assess the frequency
of occurrence of good and poor outcome for this
cohort. For this purpose a series of different definitions of
good and poor outcome have been considered that
use explicit combinations of the four outcome measures. This approach has
produced a clear result, in that staff ratings of poor outcome are more common
than patient ratings of poor outcome. By comparison, the most inclusive
definitions, requiring that one variable improved and the other from either
the staff or the patient perspective remained stable, indicated that 24% of
cases had good outcome and 1931% had poor
outcome. It is noteworthy that the gradient of frequencies of occurrence for
these varying definitions was the same for both good and poor outcome
combinations of variables.
These findings lead us to the view that there may be partially overlapping but distinct domains that can be identified as legitimate outcomes for schizophrenia. Such different domains may not covary directly, they may be influenced by at least partially separate predictors and they may reveal different rates of poor and good outcome depending upon which we accord primacy.
In particular, we consider that the distinction between staff-rated and patient-rated outcome measures warrants further and more detailed investigation. Some comparisons of the patterns and frequencies of outcome using different perspectives have been made (Slade et al, 1998; Lasalvia et al, 2000; Hansson et al, 2001) but multiple-perspective research in the field of mental health is still in its infancy. Such an approach may give greater weight to the view of many patients that treatments and services should give strong emphasis to social as well as pharmacological and psychological approaches, a view reinforced by our own results on unmet needs in this study. In this case, additional treatments targeted at problem areas beyond symptoms become especially important because they may offer more opportunities to reduce disability and to increase quality of life and subjective well-being. This study therefore opens up lines of scientific enquiry to investigate the heterogeneity of outcomes when measured across multiple dimensions and when rated from different perspectives.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Balestrieri, M., Bon, M. G. & Rodriguez-Sacristan, A., et al (1994) Pathways to psychiatric care in south-Verona, Italy. Psychological Medicine, 24, 641 649.[Medline]
Becker, T., Knapp, M., Knudsen, H. C., et al (1999) The EPSILON study of schizophrenia in five European countries. Design and methodology for standardising outcome measures and comparing patterns of care and service costs. British Journal of Psychiatry, 175, 514 521.[Abstract]
Boardman, A. P., Hodgson, R. E., Lewis, M., et al (1999) North Staffordshire Community Beds Study: longitudinal evaluation of psychiatric in-patient units attached to community mental health centres. I: Methods, outcome and patients satisfaction. British Journal of Psychiatry, 175, 70 78.[Abstract]
Carpenter, W. T. Jr & Strauss, J. S. (1991) The prediction of outcome in schizophrenia. IV: Eleven-year follow-up of the Washington IPSS cohort. Journal of Nervous and Mental Disease, 179, 517 525.[Medline]
Drake, R. E., Mueser, K. T., Torrey, W. C., et al (2000) Evidence-based treatment of schizophrenia. Current Psychiatry Report, 2, 393 397.
Endicott, J., Spitzer, R. L., Fleiss, J. L., et al (1976) The Global Assessment of Functioning scale. A procedure for measuring overall severity of psychiatric disturbance. Archives of General Psychiatry, 33, 766 771.[Abstract]
Gaite, L., Váazquez-Barquero, J. L., Arriaga
Arrizabalaga, A., et al (2000) Quality of life in
schizophrenia: development, reliability and internal consistency of the
Lancashire Quality of Life Profile European Version. EPSILON Study 8.
British Journal of Psychiatry,
177 (suppl. 39), s49
s54.
Gaite, L., Vázquez-Barquero, J. L., Borra, C., et al (2002) Quality of life in patients with schizophrenia in five European countries: the EPSILON study. Acta Psychiatrica Scandinavica, 105, 283 292.[CrossRef][Medline]
Hansson, L., Vinding, H. R., Mackeprang, T., et al (2001) Comparisons of key worker and patient assessment of needs in schizophrenic patients living in the community: a Nordic multicentre study. Acta Psychiatrica Scandinavica, 103, 45 51.[CrossRef][Medline]
Harrison, G., Hopper, K., Craig, T., et al
(2001) Recovery from psychotic illness: a 15- and 25-year
international follow-up study. British Journal of
Psychiatry, 178, 506
517.
Harrow, M., Sands, J.R., Silverstein, M.L., et al (1997) Course and outcome for schizophrenia versus other psychotic patients: a longitudinal study. Schizophrenia Bulletin, 23, 287 303.[Medline]
Institute of Medicine (2001) Crossing the Quality Chasm: a New Health System for the 21st Century. Washington, DC: Institute of Medicine.
Jablensky, A., Sartorius, N., Ernberg, G., et al (1992) Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study. Psychological Medicine Monograph Supplement, 20, 1 97.[Medline]
Lasalvia, A., Ruggeri, M., Mazzi, M. A., et al (2000) The perception of needs for care in staff and patients in community-based mental health services. The South-Verona Outcome Project 3. Acta Psychiatrica Scandinavica, 102, 366 375.[CrossRef][Medline]
Leese, M., Johnson, S., Slade, M., et al (1998) User perspective on needs and satisfaction with mental health services. PRiSM Psychosis Study. 8. British Journal of Psychiatry, 173, 409 415.[Abstract]
Leff, J., Sartorius, N., Jablensky, A., et al (1992) The International Pilot Study of Schizophrenia: five-year follow-up findings. Psychological Medicine, 22, 131 145.[Medline]
Lehman, A. F. & Steinwachs, D. M. (1998) Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophrenia Bulletin, 24, 1 10.[Medline]
Lukoff, D., Liberman, R. P. & Nuechterlein, K.H. (1986) Symptom monitoring in the rehabilitation of schizophrenic patients. Schizophrenia Bulletin, 12, 578 602.[Medline]
Mason, P., Harrison, G., Glazebrook, C., et al (1996) The course of schizophrenia over 13 years. A report from the International Study on Schizophrenia (ISoS) coordinated by the the World Health Organization. British Journal of Psychiatry, 169, 580 586.[Abstract]
McCrone, P., Leese, M., Thornicroft, G., et al
(2000) Reliability of the Camberwell Assessment of Need
European Version. EPSILON Study 6. British Journal of
Psychiatry, 177 (suppl. 39), s34
s40.
Oliver, J.P. (1991) The social care directive: development of a quality of life profile for use in community services for the mentally ill. Social Work and Social Science Review, 3, 4 45.
Pope, H. G., Ionescu-Pioggia, M. & Pope, K.W.
(2001) Drug use and life style among college undergraduates:
a 30-year longitudinal study. American Journal of
Psychiatry, 158, 1519
1521.
Ruggeri, M., Bisoffi, G., Fontecedro, L., et al
(2001) Subjective and objective dimensions of quality of life
in psychiatric patients: a factor analytical approach. The South Verona
Outcome Project 4. British Journal of Psychiatry,
178, 268
275.
Singh, S. P., Croudace, T., Amin, S., et al
(2000) Three-year outcome of first-episode psychoses in an
established community psychiatric service. British Journal of
Psychiatry, 176, 210
216.
Slade, M., Phelan, M. & Thornicroft, G. (1998) A comparison of needs assessed by staff and by an epidemiologically representative sample of patients with psychosis. Psychological Medicine, 28, 543 550.[CrossRef][Medline]
Slade, M., Thornicroft, G., Loftus, L., et al (1999) CAN: The Camberwell Assessment of Need. London: Gaskell.
Strauss, J. S. & Carpenter, W.T. Jr (1977) Prediction of outcome in schizophrenia. III. Five-year outcome and its predictors. Archives of General Psychiatry, 34, 159 163.[Abstract]
Tansella, M. (1993) The Research Unit of the Servizio di Psicologia Medica at the Institute of Psychiatry of the University of Verona, 19801991. Psychological Medicine, 23, 239 247.[Medline]
Vázquez-Barquero, J. L., Cuesta, M. J., Herrera, Castanedo S., et al (1999) Cantabria first-episode schizophrenia study: three-year follow-up. British Journal of Psychiatry, 174, 141 149.[Abstract]
Ventura, J., Green, M., Schaner, A., et al (1993) Training and quality assurance with the Brief Psychiatric Rating Scale. Thedrift busters. International Journal of Methods in Psychiatric Research, 3, 221 244.
Wiersma, D., Nienhuis, F. J., Slooff, C. J., et al (1998a) Natural course of schizophrenic disorders: a 15-year follow-up of a Dutch incidence cohort. Schizophrenia Bulletin, 24, 75 85.[Medline]
Wiersma, D., Nienhuis, F. J., Giel, R., et al (1998b) Stability and change in needs of patients with schizophrenic disorders: a 15 and 17-year follow-up from first onset of psychosis, and a comparison between objective and subjective assessments of needs for care. Social Psychiatry and Psychiatric Epidemiology, 33, 49 56.[CrossRef][Medline]
World Health Organization (1992) Schedules for Clinical Assessment in Neuropsychiatry. Geneva: WHO.
Received for publication March 24, 2003. Revision received July 25, 2003. Accepted for publication August 12, 2003.
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