Division of Psychiatry, University of Bristol, Bristol
Department of Social Medicine, University of Bristol, Bristol
Trafford General Hospital, Manchester
Queen's Medical Centre, Nottingham
Correspondence: Dr Attila Sipos, Division of Psychiatry, University of Bristol, 41 St Michael's Hill, Bristol BS 2 8 DZ; e-mail: Attila.Sipos{at}bristol.ac.uk
Declaration of interest Funded by NHS Executive Trent Research and Development.
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ABSTRACT |
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Aims To identify the pattern and predictors of hospitalisation of patients with a first psychotic episode making their first contact with specialist services.
Method Three-year follow-up of a cohort of 166 patients with a first episode of psychosis making contact with psychiatric services in Nottingham between June 1992 and May 1994.
Results Eighty-eight (53.0%) patients were admitted within 1 week of presentation; 32 (19.3%) were never admitted during the 3 years of follow-up. Manic symptoms at presentation were associated with an increased risk of rapid admission and an increased overall risk of admission; negative symptoms and a longer duration of untreated illness had an increased risk of late admission.
Conclusions Community-oriented psychiatric services might only delay, rather than prevent, admission of patients with predominantly negative symptoms and a longer duration of untreated illness. First-episode studies based upon first admissions are likely to be subject to selection biases, which may limit their representativeness.
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INTRODUCTION |
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METHOD |
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Follow-up procedure
Follow-up assessments took place between 1 June 1995 and 31 May 1997 and
occurred in chronological order of initial contact, as close as possible to 3
years after first contact with psychiatric services. Clinical and social
outcomes, their methods of assessment and distribution across diagnostic
groups have previously been reported by Singh et al
(2000).
Briefly, 164 subjects (99%) were traced to residence. Face-to-face interviews were obtained with 135 (81%) and another eight (5%) were interviewed by telephone. Two subjects had died, including one by suicide. Of the direct assessments, 97% were carried out 35-37 months after inclusion in the original cohort, thus ensuring that subjects were homogeneous with respect to time since contact with services.
Outcome measures
Our main outcome measure was time to admission.
Following graphical analysis of survival times (using the Kaplan-Meier procedure, see Fig. 1), the sample was divided into three subgroups (see Fig. 2):
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Explanatory variables
Socio-demographic variables
Standard socio-demographic information was available for all patients.
Patients were classified as being not married if they were
neither married nor cohabiting at the time of first contact with services.
Unemployed was defined as no paid part- or full-time employment.
At least one parent of African-Caribbean patients had been born
in the Caribbean.
History of aggressive incidents
A history of aggressive incidents - defined as aggressive behaviour against
persons or property at any time before illness onset - was obtained for all
patients in the cohort. Information regarding such incidents was available
from the PPHS, psychiatric and general practitioner case notes and in some
cases legal reports. A full description of the methodology to obtain these
data can be found in Milton et al
(2001).
Substance misuse
Information regarding alcohol or drug misuse was available from items in
the PPHS. Drug misuse was defined as the daily use of illicit substances for a
period of at least 2 weeks over the preceding year. Alcohol misuse was defined
as daily use for at least 2 weeks in the preceding year, associated with
evidence of significant psychological or social harm, or dependence. Patterns
of substance misuse for this cohort have been previously described
(Cantwell et al,
1999).
Symptoms
Complete SCAN interviews at first service contact were achieved for 71% of
the sample. Where it was not possible to carry out a direct interview with the
patient, the Item Group Checklist (IGC) was completed according to SCAN rules,
using case notes and any other information available for the patient. Item
group (IG) ratings from the checklist were used to compare differences in
psychopathology at baseline between those admitted and those not admitted to
hospital.
We defined four symptom clusters for further analysis as follows:
Each of these four clusters should not, of course, be equated with a specific diagnosis.
Global Assessment of Functioning measures
Global Assessment of Functioning (GAF) scales for symptoms and disability
derived from the Global Assessment Scale
(Endicott et al, 1976) were used to assess global outcomes at 3 years
(Singh et al, 2000)
and were available for 160 patients. The GAF rates the severity of symptoms
and disability in the past month with scores from one (most severe) to 90 (no
symptoms). Scores of 61 and above are generally taken to represent a
favourable outcome (Harrison et
al, 1996). Reliability data for these measures are reported
in Singh et al
(2000).
Duration of untreated illness
Illness onset was defined as the date of first symptoms or first change in
behaviour that was attributable to illness - not necessarily the date of
detection of first positive psychotic symptoms. We used the best estimate of
the time that elapsed between the date of the first change in symptoms or
behaviour attributed to mental illness and the first contact with secondary
mental health services. This was based upon both patient and informant reports
in the baseline and follow-up assessments.
Data analysis
Fisher's exact, 2 and Kruskal-Wallis tests were used as
appropriate to test for statistically significant differences between
subgroups. Factors independently associated with overall risk of admission and
risk of rapid admission were identified using logistic regression analysis.
Variables associated with admission at a significance level of <0.20 in
univariable regression analysis were then entered into a final multivariable
model.
All statistical analysis was performed using Stata Release 6.0 (StataCorp, 1999).
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RESULTS |
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Of those patients not admitted to hospital only five had follow-up periods of less than 3 years. Four of these patients had been followed up for periods only 13 or fewer days short of 3 years and these four patients were included as never admitted in all analyses. One patient was lost to followup at 2.2 years and this case was excluded from the analysis looking at differences in patient characteristics between subgroups and the logistic regression analysis for factors associated with overall risk of admission. However, we included this case in the logistic regression analysis for factors associated with rapid admission.
Timing of admission
The median time between first contact with services and admission to
hospital was 1 day (range 1-1097). Figure
1 displays the Kaplan-Meier survival curve for the risk of
admission for patients from the time of their first contact with services.
Frequency and total length of admissions
The median number of admissions was one (range 0-7). The median number of
total in-patient bed-days per subject was 46.5 (range 0-971).
Admission rates and subgroups for further analysis
Following the graphical analysis of survival times
(Fig. 1), we used 7 days as a
cut-off time to distinguish between rapid and late admission.
Figure 2 shows the division of
the whole sample into three subgroups. One week was judged to be a clinically
relevant duration to define rapid admission and was also reasonably near to
the median duration of time to admission in this sample. Just over half of the
subjects (53.0%, n=88) were admitted rapidly, 27.1% (n=45)
were admitted late and 19.3% (n=32) were not admitted at all during
the follow-up period of 3 years.
Differences in patient characteristics between subgroups
Table 2 compares the
characteristics of patients who were admitted rapidly, late or not at all.
Significant differences between groups were present for two psychopathological
variables: manic symptoms (P=0.02) and negative symptoms
(P<0.01). Manic symptoms were more common in the rapid admission
group and negative symptoms were more frequent among those with late
admissions. The duration of untreated illness was longer in those admitted
late (median 168 days v. 44 days in those admitted rapidly and 124
days in those never admitted, P<0.01 for differences between
groups). The differences between the three groups approached conventional
levels of statistical significance for the proportion of male patients
(P=0.05), GAF disability scores (P=0.06) and total bed-days
(P=0.08). GAF disability scores were lower, the number of total
bed-days and proportions of male patients were higher, in those admitted
late.
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Factors associated with risk of rapid admission
In univariable analyses manic symptoms (odds ratio 2.44, 95% CI 1.21-4.90)
and drug misuse (odds ratio 2.41, 95% CI 1.02-5.69) were associated with an
increased risk of rapid admission. Negative symptoms (odds ratio 0.29, 95% CI
0.12-0.68) and duration of untreated illness of more than 6 months (odds ratio
0.32, 95% CI 0.16-0.63) were associated with a reduced likelihood of rapid
admission. In the multivariable analysis manic symptoms (odds ratio 2.16, 95%
CI 1.02-4.60) remained independently associated with increased risk, and
negative symptoms (odds ratio 0.37, 95% CI 0.15-0.94) with decreased risk of
rapid admission. Associations with drug misuse (odds ratio 2.16, 95% CI
0.86-5.42) and duration of untreated illness longer than 6 months (odds ratio
0.53, 95% CI 0.25-1.14) were attenuated.
Factors associated with overall risk of admission
In the univariable analyses manic symptoms at first presentation were
associated with over a three-fold increased likelihood of admission (odds
ratio 3.70, 95% CI 1.22-11.20). This effect remained significant (odds ratio
3.67, 95% CI 1.19-11.32) after controlling for gender, marital status and
ethnicity in multivariable analysis.
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DISCUSSION |
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The Kaplan-Meier survival curve for the risk of admission for patients from the time of their first contact with services (Fig. 1) suggests that patient admissions to hospital occurred in two phases. Just over half of all patients (53.0%) were admitted within the first week of contact with services and a further 27.1% were admitted at a slower rate over the next 3 years.
The comparison of characteristics of patients with rapid, late and no admissions revealed important differences. Patients admitted late were more likely to have presented with negative symptoms and a longer duration of untreated illness. Other findings in this group only approached conventional levels of statistical significance, but viewed together could be pointing towards a clinically important patient group characterised by higher proportions of males, lower GAF scores (indicating a worse functional outcome at 3 years) and higher numbers of total inpatient bed-days over the 3-year follow-up (see Table 2).
Multivariable logistic regression analyses showed that manic symptoms at presentation were associated with an increased overall risk of admission and an increased risk of rapid admission while negative symptoms were associated with a lower risk of rapid admission.
Strengths and weaknesses of the study
A clear strength of this study is the high quality of data obtained on the
studied sample: case ascertainment and assessment of the inception cohort was
almost complete and comprehensive. A high proportion of face-to-face
interviews at baseline and follow-up was achieved; standardised assessment
tools with high interrater reliability and operationalised criteria for
diagnosis were used throughout.
The relatively small sample size, however, limited the statistical power of this analysis and clinically important associations may not have been detected.
In addition, these data are based upon only one particular service model (albeit a homogeneous and by the time of this study already well-established model) limiting external validity. However, these data could form the basis of a meaningful comparison of patterns of hospitalisation across different models of service delivery.
Comparison of findings with other research
Previous studies reported high admission rates for patients with psychotic
disorders at first contact with psychiatric services. Eighty per cent of
patients with a diagnosis of schizophrenia on the Camberwell Diagnostic
Register were admitted at first contact
(Castle et al, 1994)
and 73% within 90 days of first contact (compared with 65.1% in our sample) in
a sample in Edinburgh (Geddes et
al, 1995). The low admission rate at first contact of 53.0%
in this Nottingham cohort of first-episode psychoses is in keeping with the
substantial decline of first-admission rates from around 80% in 1975 to under
50% by 1986, as reported by Harrison et al
(1991). This low rate reflects
a shift towards more community-oriented treatment strategies for patients with
psychosis in Nottingham. However, in the present study, at the end of the
3-year follow-up period, the proportion of patients admitted to hospital had
risen to 80.7%, with only 32 patients avoiding admission completely. Overall
admission rates remained high therefore, and it is clear that in-patient
admission remains a key component of care for the majority of first-episode
cases, at least in a community service based upon conventional community
mental health teams.
Castle et al (1994) found bizarre behaviour and grandiose delusions to be predictors of admission in their sample and these concepts probably capture similar psychopathological features as our manic symptoms variable. In contrast to our findings Castle et al (1994) reported a history of juvenile delinquency or adult criminality to be less common among those admitted to hospital. Geddes & Kendell (1995), however, described a significant association between aggression or violence and admission.
Future research
Further studies of patterns of in-patient service utilisation in different
service settings are required. These studies should especially focus on the
potential association between late initial admission and less favourable
functional outcome at follow-up. Randomised controlled trials are required to
investigate whether earlier admission of this vulnerable group of patients
affects outcome.
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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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Received for publication July 25, 2000. Revision received December 14, 2000. Accepted for publication December 15, 2000.
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