Academic Medical Center, University of Amsterdam, MFO Psychiatrie AMC/de Meren, The Netherlands
Correspondence: Marie E. Lenior, Psychiatric Center AMC, Tafelbergweg 25, 1105 BC Amsterdam, The Netherlands
Declaration of interest This study was funded by grants 28-1241-1 and 28-1241-2 from the Dutch Health Research and Development Council and by the Dutch Ministry of Welfare, Health and Cultural Affairs (Project 90-120; CRO 504581).
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ABSTRACT |
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Aims Follow-up assessment of social functioning in young patients with schizophrenia during a 5-year period after intervention.
Method During intervention, families were randomised into two conditions: standard intervention and standard plus family intervention.
Results Although no differential treatment effect with regard to the course of the illness was found, patients from the standard plus family intervention condition stayed for fewer months in institutions for psychiatric patients than patients from the standard intervention condition.
Conclusions Family intervention has helped parents to support their children, thereby diminishing institutional care.
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INTRODUCTION |
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METHOD |
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Of the 97 families who formerly underwent the intervention programme, 73 participated in the follow-up study, after giving written informed consent. Reasons for non-participation were: refusal (4), not traceable (10), emigration (1) and fatal accident (1). Furthermore, eight patients committed suicide: three (14%) from the group that was not randomised (see Linszen et al, 1996); two (5%) from families that received family intervention; and three (8%) from the standard intervention.
Data were available in 58 cases from the patient and one or two parents, and in 13 cases from one or two parents but without the patient. Two patients participated without their parent(s). On average, the interviews took place 7.9 (range 6-10) years after discharge.
The mean age of the patients (51 men and 22 women) at admission was 20.9 (range 16-26) years (Table 1), whereas the mean age at the time of the follow-up interview was 30.5 (range 26-37) years. The mean duration of untreated illness before admission was 5.4 months and half of the patients (52%) had their first psychotic episode before admission. At discharge from the intervention programme, the diagnoses (DSM-III-R; American Psychiatric Association, 1987) were: schizophrenia, 42 (58%); schizoaffective disorder, 15 (21%); schizophreniform disorder, 9 (12%); and other psychotic disorders (e.g. delusional disorder and atypical psychosis), 7 (10%).
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Comparisons between participating patients and non-participants of the follow-up study showed that at admission participants were 1 year older on average than non-participants, that the duration of untreated psychosis was 1 month less on average and that compliance to medication during intervention was higher for participants than for non-participants. Regarding baseline data, no significant differences between the two intervention conditions were found.
Assessments
Patients and parents were interviewed with the Life Chart Schedule (LCS:
World Health Organization,
1992). This instrument elicits data about symptoms, treatment
(rehospitalisation, living in sheltered homes, out-patient treatment) and
social conditions (employment, study, living arrangements) during a given
period. Susser et al
(2000) showed that the LCS
yields reliable ratings of the long-term course of schizophrenia when assessed
by trained raters. Inconsistencies regarding symptoms and treatment
(n=3) were cross-checked with current therapists.
The first follow-up study, which also included the LCS, was carried out in 1992. At that time the follow-up period differed for the successively admitted and discharged patients (17-55 months). At the second follow-up, held in 1997-1998, the data were completed up to and including 5 years after discharge. If the patient and/or parent(s) had participated in 1992, which was the case for all but one patient, the data of that interview were first examined and completed for the 5-year period.
The course of the illness was divided into psychotic and non-psychotic episodes. A psychotic episode was characterised by clearly reported positive symptoms, i.e. delusions, hallucinations and/or formal thought disorders (Nuechterlein et al, 1986). A non-psychotic episode was a period without positive symptoms, with or without residual symptoms and/or negative symptoms. A non-psychotic episode had to last at least 30 days (Wiersma et al, 1998). When there was never a 30-day remission period during follow-up, the patient was considered as having chronic positive symptoms (60 months).
The LCS data were first rated for relapses by one of the authors (D.H.L.) and rated again by a psychiatrist (L.d.H.), who was employed 2 years after the intervention and had not been involved with the patients. Regarding clinical status (no relapse, one or more relapses, chronic), there was disagreement about six patients (8%). For 16 (22%) patients the number of months with psychotic symptoms differed (mean absolute difference=6.7; s.d.=6.8). For the 22 patients about whom there was disagreement, consensus was achieved by re-examination of the data by both raters together.
Analyses
For analyses concerning social functioning, three composite scores were
calculated: living in institutions for psychiatric patients (months in mental
hospitals and/or sheltered homes); structural activities (months of full-time,
part-time or voluntary work, full-time study and/or housekeeping); help from
the family (sum score of help with activities of daily living, accompanying to
out-patient services, checking intake of medication and management of care).
The four items concerning help from the family were scored as follows: 1,
none; 2, part of period; 3, majority of
period (Table 2).
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The duration of psychotic episodes is an important indicator of the severity of the illness. Therefore the course of the illness was expressed as the number of months that patients had psychotic symptoms. For chronic patients this was 60 months.
MannWhitney U-tests were used to compare the three areas of social
functioning by intervention condition and by diagnosis group (schizophrenia
v. schizophrenia-like disorder) as classified at discharge. Testing
associations between the three areas of social functioning and the total
duration of psychotic episodes was done by Spearman's rank correlations
().
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RESULTS |
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Of the patients, 34 held a paid job for at least some period. For these patients the occupational level in 65% of the cases was lower than their level of education: in 62% of the cases, unskilled or semi-skilled jobs. For 74% of the patients who held a paid job, the performance of their work was qualified as good to very good by patient and/or parent(s). This qualification is related to the level of the work (e.g. working in shops, catering, warehouses, light office jobs). Six patients did the housekeeping full-time during some period of the 5 years. For only one of them was the performance in housekeeping qualified as poor. In the 5-year period 21 patients followed full-time study for some of the time. The mean number of months during which patients had structural activities was 26.2 (s.d.=20.0; range=0-60). This implies that they had no structural activities for almost 3 years (34 months).
As mentioned, five patients stayed in institutions for psychiatric patients for 60 months. The patient group stayed for 8 months on average in mental hospitals and for 10 months in sheltered homes. The mean number of months that patients stayed in institutions for psychiatric patients was 17.3 (s.d.=19.4; range=0-60).
During follow-up, patients required some help from their families, mainly parents. Of the patients, 69% received help with the performance of daily activities, mainly housekeeping, almost half of them (32%) during the major part of the 5-year period. Almost half of the patient group (44%) was accompanied by parent(s) when having an appointment for out-patient services. Many parents (34%) checked medication compliance. Finally, it appeared that in 37% of the cases the parents helped the patient with seeking help or making decisions about treatment. The mean sum score for help from the family was 6.5 (s.d.=2.2; range=4-12).
A quarter of the patients (n=19) did not have a psychotic episode during follow-up, half of them (n=36) had one or more episodes and a quarter (n=18) had chronic positive symptoms. In the 55 non-chronic cases, the relapse rate was 42% after 2 years and 65% after 5 years (Fig. 1). If we include chronic cases, 26% did not have a relapse in the 5-year period. For all patients the mean total duration of psychotic episodes was 19.2 (s.d.=24.5; range=0-60) months.
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Intervention condition had no effect on psychotic episodes
(Table 3). Patients at
discharge who had a diagnosis of schizophrenia had 14 more months of psychotic
symptoms, on average, than patients with other diagnoses. This is related to
the fact that the 42 patients with a diagnosis of schizophrenia more often had
a chronic course than the 31 patients with a schizophrenia-like disorder (33%
v. 13%; 2=4.01; d.f.=1; P=0.05).
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For structural activities and help from the family, no significant differences were found between intervention conditions (Table 4). For patients who received additional family intervention, the number of months spent in institutions for psychiatric patients was 10 months less, on average, than for patients from the standard condition.
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Comparisons between diagnostic subgroups (Table 4) reveal that patients with a diagnosis of schizophrenia spent almost 9 months longer in institutions for psychiatric patients than patients with other diagnoses. They also received more help from their families. For structural activities the difference was not significant.
Correlations between total duration of psychotic episodes and the three
areas of social functioning indicate that patients with a longer duration of
psychotic symptoms spent longer in institutions for psychiatric patients
(=0.30; P=0.01), had shorter periods of structural activities
(
=-0.34; P=0.003) and received more help from their families
(
=0.38; P=0.001) than patients with a shorter duration of
psychotic symptoms.
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DISCUSSION |
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An earlier study (Linszen et al, 1996) showed that relapses could be delayed during intervention: 16% of the patients relapsed during the 12-month out-patient phase of the intervention. The results of the present study show that this beneficial effect did not last. After 2 years, 42% of the patients had a relapse. In a review, Mari & Streiner (1994) reported relapse rates of 47-53% within 2 years. In another study with Dutch patients (Wiersma et al, 1998) the relapse rate after 5 years was 72%, which is higher than our relapse rate (65%). Robinson et al (1999) found a higher relapse rate of 82%. Thus, the relapse rate in our study is still lower than in other studies. However, the results of the present study are congruent with the observation of McGlashan & Johannessen (1996) that interventions are effective as long as they are active.
Effect of family intervention
Patients who had received additional family intervention spent fewer months
in institutions for psychiatric patients than patients who had had the
standard intervention. Falloon et al
(1982), Tarrier et al
(1989) and Xiong et
al (1994) also found this
effect, in combination with a differential effect on the occurrence of
relapses. Falloon et al
(1982) suggested that the
reduction of stress in families who received family intervention prevented
relapses and rehospitalisation. Our results do not confirm this supposition
completely, because the intervention condition did not affect the relapse
rate. Because families were allocated randomly to the two conditions, we may
conclude that parents who received family intervention were better equipped to
support their child, but it is hard to say how. In any case, it appears that
in certain cases rehospitalisation or admissions to institutions for
psychiatric patients can be prevented or delayed.
A number of studies showed that family intervention improved the social functioning of patients with schizophrenia (Falloon et al, 1987; Barrowclough & Tarrier, 1990; Xiong et al, 1994). Falloon et al (1987) hypothesised that the problem-solving techniques of the family intervention caused a reduction in positive as well as in negative symptoms, so that patients were able to focus on their social condition. Leff et al (1989) suggested that social functioning depends on negative symptoms, which diminish more slowly than positive symptoms. This supposition was confirmed by Poque-Geile & Harrow (1984) and by Bellack et al (1990). Although negative symptoms were not included in our study, a possible explanation for the absence of association between intervention condition and social functioning (i.e. structural activities for help from the family) might be that the family intervention was focused on the reduction of family stress and not particularly on social rehabilitation. However, in both intervention conditions the patients were given help with seeking education, employment and financial support.
Severity of illness and social functioning
For patients with a poorer course of the illness, whether as predicted by
diagnosis at discharge or as indicated by the number of months with psychotic
symptoms thereafter, social functioning was worse than for patients with a
more favourable course of the illness. Possible explanations for this
relationship were found in the literature.
Johnstone et al (1990) found that occupational functioning was better in patients who received a placebo than in patients on neuroleptic medication. Barrowclough & Tarrier (1990) found a negative association between dose of medication and social functioning. They argued that the tranquillising effect of neuroleptics could decrease the level of activities. In our study the influence of neuroleptic medication could not be assessed, because the LCS comprises only two global items about the prescription of medication. It is possible that patients with more months of psychotic symptoms took higher doses of neuroleptic medication, which could have affected their social functioning.
Bellack et al (1990) mentioned two possible hypotheses: impairment of social functioning as a consequence of negative symptoms or as a consequence of deficits in social skills. Although the association between negative symptoms and social functioning was demonstrated, support was found also for the social deficits hypothesis. No conclusions about the effect of negative symptoms can be drawn from our study, because these symptoms were not assessed for patients with chronic positive symptoms. However, patients with longer periods of positive symptoms functioned less well in the three areas of social functioning than patients with shorter periods of positive symptoms. Therefore, we cannot discount the role of positive symptoms.
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Clinical Implications and Limitations |
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LIMITATIONS
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REFERENCES |
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Barrowclough, C. & Tarrier, N. (1990) Social functioning in schizophrenic patients. I. The effects of expressed emotion and family intervention. Social Psychiatry and Psychiatric Epidemiology, 25, 125 -129.[Medline]
Bellack, A. S., Morrison, R. L., Wixted, T. J., et al (1990) An analysis of social competence in schizophrenia. British Journal of Psychiatry, 156, 809 -818.[Abstract]
Breier, A., Schreiber, J. L., Dyer, J., et al (1991) National Institute of Mental Health longitudinal study of chronic schizophrenia. Prognosis and predictors of outcome. Archives of General Psychiatry, 48, 239 -246.[Abstract]
Engelhardt, D. M. & Rosen, B. (1976) Implications of drug treatment for the social rehabilitation of schizophrenic patients. Schizophrenia Bulletin, 2, 454-462.[Medline]
Falloon, I. R. H., Boyd, J. L., McGill, C. W., et al (1982) Family management in the prevention of exacerbations of schizophrenia. New England Journal of Medicine, 306, 1437 -1440.[Abstract]
Falloon, I. R. H., McGill, C. W., Boyd, J. L., et al (1987) Family management in the prevention of morbidity of schizophrenia: social outcome of a two-year longitudinal study. Psychological Medicine, 17, 59-66.[Medline]
Johnstone, E. C., MacMillan, J. F., Frith, C. D., et al (1990) Further investigation of the predictors of outcome following first schizophrenic episodes. British Journal of Psychiatry, 157, 182 -189.[Abstract]
Leff, J., Berkowitz, R., Shavit, N., et al (1989) A trial of family therapy v. a relatives group for schizophrenia. British Journal of Psychiatry, 154, 58 -66.[Abstract]
Linszen, D., Dingemans, P., Van der Does, J. W., et al (1996) Treatment, expressed emotion and relapse in recent onset schizophrenic disorders. Psychological Medicine, 26, 333 -342.[Medline]
Mari, J. J. & Streiner, D. L. (1994) An overview of family interventions and relapse on schizophrenia: meta-analysis of research findings. Psychological Medicine, 24, 565 -578.[Medline]
McGlashan, T. H. & Johannessen, J. O. (1996) Early detection and intervention with schizophrenia: rationale. Schizophrenia Bulletin, 22, 201 -222.[Medline]
Nuechterlein, K. H., Snyder, K. S., Dawson, M. E., et al (1986) Expressed emotion, fixed-dose fluphenazine decanoate maintenance, and relapse in recent-onset schizophrenia. Psychopharmacology Bulletin, 22, 633 -639.[Medline]
Poque-Geile, M. F. & Harrow, M. (1984) Negative and positive symptoms in schizophrenia and depression: a followup. Schizophrenia Bulletin, 10, 371 -387.[Medline]
Robinson, D., Woerner, M. G., Alvir, J. M. J., et al
(1999) Predictors of relapse following response from a first
episode of schizophrenia or schizoaffective disorder. Archives of
General Psychiatry, 56,
241
-247.
Strauss, J. S. (1975) A comprehensive approach to psychiatric diagnosis. American Journal of Psychiatry, 132, 1193 -1197.[Abstract]
Strauss, J. S. & Carpenter, W. T., Jr. (1974) The prediction of outcome in schizophrenia. II. Relationship between predictor and outcome variables: a report from the WHO International Pilot Study of Schizophrenia. Archives of General Psychiatry, 31, 37 -42.[CrossRef][Medline]
Susser, E., Finnerty, M., Mojtabai, R., et al (2000) Reliability of the Life Chart Schedule for assessment of the long-term course of schizophrenia. Schizophrenia Research, 42, 67 -77.[CrossRef][Medline]
Tarrier, N., Barrowclough, C., Vaughn, C., et al (1989) Community management of schizophrenia. A two-year follow-up of a behavioural intervention with families. British Journal of Psychiatry, 154, 625 -628.[Abstract]
Vaughn, C. E. & Leff, J. P. (1976) The measurement of expressed emotion in the families of psychiatric patients. British Journal of Social and Clinical Psychology, 15, 157 -165.[Medline]
Wiersma, D., Nienhuis, F. J., Slooff, C. J., et al (1998) Natural course of schizophrenic disorders: a 15-year followup of a Dutch incidence cohort. Schizophrenia Bulletin, 24, 75 -85.[Medline]
World Health Organization (1992) WHO Coordinated Multi-Center Study on the Course and Outcome of Schizophrenia. Geneva: WHO.
Xiong, W., Phillips, M. R., Hu, X., et al (1994) Family-based intervention for schizophrenic patients in China. A randomised controlled trial. British Journal of Psychiatry, 165, 239 -247.[Abstract]
Received for publication September 7, 2000. Revision received January 19, 2001. Accepted for publication January 23, 2001.
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