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Neuropsychiatric correlates of quality of life in schizophrenia
216
EVALUATING AN ALTERNATIVE TO HOSPITALIZATION FOR PATIENTS WITH SEVERE AND PERSISTENT MENTAL ILLNESS W.S. Fenton*, L. Mosher, J. Herrell, S. Hedlund, B. Lee
Chestnut Lodge Research Institute, 500 W. Montgomery Ave., Rockville, MD 20850, USA Data are presented from a randomized clinical trial that compares treatment in a community residential alternative with treatment in an acute ward of a general hospital for unscreened voluntary psychiatric patients, most diagnosed with schizophrenia, enrolled in the Montgomery County, Maryland public mental health system. Subjects are interviewed at admission, discharge, and 6-month follow-up to assess clinical status in the domains of symptoms, work, social functioning, recidivism, and satisfaction. Data collected to date indicate length of stay in the residential alternative of 17 days at approximately $150/day and in the hospital unit of 11 days at approximately $600/day. Patients treated in the two settings show comparable levels of clinical improvement over the treatment episode, and comparable levels of satisfaction at the time of discharge. Few outcome differences over the subsequent 6 months emerge. The acute episode treatment failure rate is 20% for the residential alternative but only 7% for the general hospital. Overall, the data suggests that the residential alternative is a cost effective option for many, but not all, patients requiring acute voluntary hospitalization. Data supporting the efficacy of this model compels inclusion of funding streams to support these services in benefit revisions contemplated as part of health reform.
EFFECTS OF EXPRESSIVE BEHAVIOR ON SUBSEQUENT EMOTIONAL EXPERIENCE IN SCHIZOPHRENIA W.F. Flack*, J.D. Laird, L.A. Cavallaro, M.M. Regnier, D.R. Miller
Department of Psychiatry, Baystate Medical Center/Tufts University School of Medicine, Wesson Memorial Unit, West 1, 140 High Street, Springfield, MA 01199, USA Schizophrenics are often believed to lack emotional feelings when they are inexpressive. When expressive, such individuals are commonly thought to experience feelings that do not match their behavior. Recently, investigators have demonstrated that lack of expressiveness is not necessarily associated with deficiency of feeling in this disorder. In this study, we examined the effects of producing expressions of specific emotions on subsequent feelings in schizophrenia. Numerous studies (reviewed by Adelman & Zajonc, 1989; Izard, 1990; Laird & Bressler, 1990) using similar methods have demonstrated that the production of specific facial expressions and postures results in matching emotional feelings in normal subjects. Seventy-five outpatient male veterans, 22 DSM-III-R schizophrenics, 24
DSM-III-R major depressives, and 23 non-psychiatric controls, participated in this study. They were instructed to move various muscles to unknowingly produce expressions of anger, sadness, fear, happiness, and disgust. After each manipulation, they rated their feelings of these emotions on 11-point scales. All three groups responded to a majority of conditions with matching feelings, although some discrepancies of expression and feeling occurred in each group as well. These results call into question the assumption that discrepancies of expression and feeling are either characteristic of, or peculiar to, schizophrenia.
THE NEW MENTAL HEALTH ACT OF BARBADOS AND ITS ROLE ON THE MANAGEMENT OF THE DANGEROUS SCHIZOPHRENIC Newlands E. Greenidge*, R a m m o h a n R a o Malesu
Psychiatric Hospital Black Rock, St Michael Barbados (W.I. ) Mental Health Legislation not only sets laws and guidelines for the management of the mentally ill but also provide a useful safeguard for the protection of the civil rights of patients while rendering humane care. The new Mental Health Act (Cap 45) of Barbados was proclaimed on the 15th February 1989. This paper analyzed the effects of this act on the hospital admissions. We compared the admissions for the four-year period prior to and the four-year period after the implementation of the act. During the first 12-month period immediately following the implementation of the new act, there was a statistically significant increase in the involuntary emergency admissions with a proportionate decrease in the patients remanded from the courts. Most of these admissions (76%) were of dangerous schizophrenic patients with a past history of crime and violence. During this period however, there was no change in the total admissions. Over the next three years there was a statistically significant reduction in the readmissions as the new act provided for better monitoring of the patients in the community. The other beneficial effects of the act including the role of the Mental Health Worker are discussed.
NEUROPSYCHIATRIC CORRELATES OF QUALITY OF LIFE IN SCHIZOPHRENIA R.J. Heslegrave*, L.N.P. Voruganti, A.G. Awad
Department of Psychiatry, University of Toronto, The Wellesley Hospital, 160 Wellesley Street East, Toronto, Ontario M4 Y 1J3, Canada Quality of life is a comprehensive indicator of health that is useful in aiding our understanding the complex interplay between physical, psychological and social factors in schizophrenia. The present study is aimed at examining the role that schizophrenic symptomatology and neurocognitive and neuro-
217
logical factors have in determining the quality of life of chronic schizophrenics. Forty-two stable chronic schizophrenic patients (DSMIll-R), maintained on antipsychotic medication, were assessed on a number of relevant dimensions including quality of life (Sickness Impact Profile (SIP) and Global Assessment of Functioning (GAS)), psychopathology (Positive and Negative Syndromes (PANSS), neurocognitive functioning (COGLAB) and soft neurological signs. In the analysis, quality of life indices were correlated with the latter predictor variables. The results indicated that both GAF and SIP scores showed high correlations with PANSS scores (r=0.72 and 0.54, p<0.0001). GAF scores were also correlated with soft neurological signs (r = 0.57, p < 0.004) and impaired performance on the span of apprehension task during neurocognitive testing (r =0.36-0.45, p <0.05). PANSS scores were also highly correlated with perceptual impairment measured on a visual masking task (r = 0.38-0.40, p < 0.01 ). In conclusion, the degree of psychopathology as well as neurological and neurocognitive deficits are significantly related to schizophrenic patients' psychosocial functioning and quality of life. In addition, perceptual deficits showed some relationship to both quality of life and psychopathology. While these data suggest that these factors influence the subjective, self-reported quality of life of chronic schizophrenics, it seems clear that the interrelationships between psychopathology, neurocognitive impairment and quality of life remain complex and are not yet well understood. Further work exploring the relative contributions of symptoms and neurological impairment should be explored.
THE USE OF THE EXPRESSED
EMOTION
INDEX AS A PREDICTOR OF OUTCOME SCHIZOPHRENIA IN A FRENCH SPEAKING AREA OF SWITZERLAND
OF
SOCIOCULTURAL
DIMENSIONS
OF
"FAMILY BURDEN": THE SPECIFICITY ETHNIC, GENDER AND DIAGNOSTIC EFFECTS
OF
J.H. Jenkins*, M. Warren, M.E. Strauss, F. Bloom, C.J. Jacobson, A. Frasca
Department of Anthropology and Psychiatry, Case Western Reserve University, Cleveland, OH 44106, USA The research construct of "family burden" (FB) provides an index of sociobehavioral difficulties and adverse effects of illness on relatives. In an NIMH longitudinal study of Latino and Euro-American patients (n=80), the cultural and genderspecific dimensions of FB are compared for families living with schizophrenic and depressive disorders. The Social Behavioral Assessment Scale is administered to obtain measures of FB as behavioral disturbance, social performance, and adverse effects on others. Analysis reveals that, in addition to diagnosis, contextual variables such as ethnicity, gender, and behavioral domains of FB must be specified. No significant effects were observed for behavioral disturbance but a main effect for gender was found for social performance: male patients display significantly more deficits in this area. An interactive effect for diagnosis and ethnicity was observed for adverse effects, with Latino relatives of persons with schizophrenia scoring highest. We summarize specific diagnostic, ethnic, and gender effects in relation to FB: (1) ethnic-diagnostic groups appear to react similarly in the domain of "behavioral disturbance"; (2) gender is the only significant effect in the domain of "social performance"; and (3) the adverse effects of psychiatric illness varies cross-culturally in relation to ethnicity and diagnosis. The cultural validity of the FB construct with schizophrenic illness processes are discussed.
Ph. Huguelet, S. Favre, S. Binyet, Ch. Gonzalez, I. Z a b a l a
CAN INSIGHT AND COMPLIANCE IMPROVED IN PSYCHOSIS?
A five year follow-up study of first admitted patients with a diagnosis of schizophrenia was conducted in Geneva, Switzerland. All of the patients were assessed on entry, after one, two and five years with the Present State Examination (PSE/Wing, 1974) and their relatives were assessed at the same periods with the Camberwell Family Interview (CFI/Vaughn & Left, 1976). The predictive power of the EE index was tested on three variables of outcome, namely the presence of schizophrenic symptoms, social adaptation and hospital stays. An association appeared between the EE index and the outcome measures, particularly after three years of follow-up when the high EE group statistically differed from the low EE group with regard to the relapse rate and to the psychosocial adaptation. Relatives' high EE values at inclusion were also associated to some of the patients' poorer premorbid features. Our results give support to the model in which patient characteristics lead to high EE which in turn reinforces the patients' features and lead to poor outcome.
R. Kemp*, J. Hartley, P. Hayward, A. D a v i d
BE
Department of Psychological Medicine, King's College Hospital, London SE5 9RS, UK Lack of insight in schizophrenia is a major determinant of poor medication compliance, and hence outcome. Psychoeducational strategies have been proposed to foster insight and boost compliance but these have been either labour-intensive or didactic in approach, and have concentrated largely upon higher functioning patients. We investigated an adaptation of Motivational Interviewing (M1), a cognitive-behavioural method derived from treatment of substance abuse, in a randomised controlled trial in consecutively admitted psychotic inpatients in inner London. Our data revealed that the cases showed significantly improved attitudes to medication, insight and compliance after 4 6 sessions of MI compared to controls who received an equivalent number of supportive counselling
EVALUATING AN ALTERNATIVE TO HOSPITALIZATION FOR PATIENTS WITH SEVERE AND PERSISTENT MENTAL ILLNESS W.S. Fenton*, L. Mosher, J. Herrell, S. Hedlund, B. Lee
Chestnut Lodge Research Institute, 500 W. Montgomery Ave., Rockville, MD 20850, USA Data are presented from a randomized clinical trial that compares treatment in a community residential alternative with treatment in an acute ward of a general hospital for unscreened voluntary psychiatric patients, most diagnosed with schizophrenia, enrolled in the Montgomery County, Maryland public mental health system. Subjects are interviewed at admission, discharge, and 6-month follow-up to assess clinical status in the domains of symptoms, work, social functioning, recidivism, and satisfaction. Data collected to date indicate length of stay in the residential alternative of 17 days at approximately $150/day and in the hospital unit of 11 days at approximately $600/day. Patients treated in the two settings show comparable levels of clinical improvement over the treatment episode, and comparable levels of satisfaction at the time of discharge. Few outcome differences over the subsequent 6 months emerge. The acute episode treatment failure rate is 20% for the residential alternative but only 7% for the general hospital. Overall, the data suggests that the residential alternative is a cost effective option for many, but not all, patients requiring acute voluntary hospitalization. Data supporting the efficacy of this model compels inclusion of funding streams to support these services in benefit revisions contemplated as part of health reform.
EFFECTS OF EXPRESSIVE BEHAVIOR ON SUBSEQUENT EMOTIONAL EXPERIENCE IN SCHIZOPHRENIA W.F. Flack*, J.D. Laird, L.A. Cavallaro, M.M. Regnier, D.R. Miller
Department of Psychiatry, Baystate Medical Center/Tufts University School of Medicine, Wesson Memorial Unit, West 1, 140 High Street, Springfield, MA 01199, USA Schizophrenics are often believed to lack emotional feelings when they are inexpressive. When expressive, such individuals are commonly thought to experience feelings that do not match their behavior. Recently, investigators have demonstrated that lack of expressiveness is not necessarily associated with deficiency of feeling in this disorder. In this study, we examined the effects of producing expressions of specific emotions on subsequent feelings in schizophrenia. Numerous studies (reviewed by Adelman & Zajonc, 1989; Izard, 1990; Laird & Bressler, 1990) using similar methods have demonstrated that the production of specific facial expressions and postures results in matching emotional feelings in normal subjects. Seventy-five outpatient male veterans, 22 DSM-III-R schizophrenics, 24
DSM-III-R major depressives, and 23 non-psychiatric controls, participated in this study. They were instructed to move various muscles to unknowingly produce expressions of anger, sadness, fear, happiness, and disgust. After each manipulation, they rated their feelings of these emotions on 11-point scales. All three groups responded to a majority of conditions with matching feelings, although some discrepancies of expression and feeling occurred in each group as well. These results call into question the assumption that discrepancies of expression and feeling are either characteristic of, or peculiar to, schizophrenia.
THE NEW MENTAL HEALTH ACT OF BARBADOS AND ITS ROLE ON THE MANAGEMENT OF THE DANGEROUS SCHIZOPHRENIC Newlands E. Greenidge*, R a m m o h a n R a o Malesu
Psychiatric Hospital Black Rock, St Michael Barbados (W.I. ) Mental Health Legislation not only sets laws and guidelines for the management of the mentally ill but also provide a useful safeguard for the protection of the civil rights of patients while rendering humane care. The new Mental Health Act (Cap 45) of Barbados was proclaimed on the 15th February 1989. This paper analyzed the effects of this act on the hospital admissions. We compared the admissions for the four-year period prior to and the four-year period after the implementation of the act. During the first 12-month period immediately following the implementation of the new act, there was a statistically significant increase in the involuntary emergency admissions with a proportionate decrease in the patients remanded from the courts. Most of these admissions (76%) were of dangerous schizophrenic patients with a past history of crime and violence. During this period however, there was no change in the total admissions. Over the next three years there was a statistically significant reduction in the readmissions as the new act provided for better monitoring of the patients in the community. The other beneficial effects of the act including the role of the Mental Health Worker are discussed.
NEUROPSYCHIATRIC CORRELATES OF QUALITY OF LIFE IN SCHIZOPHRENIA R.J. Heslegrave*, L.N.P. Voruganti, A.G. Awad
Department of Psychiatry, University of Toronto, The Wellesley Hospital, 160 Wellesley Street East, Toronto, Ontario M4 Y 1J3, Canada Quality of life is a comprehensive indicator of health that is useful in aiding our understanding the complex interplay between physical, psychological and social factors in schizophrenia. The present study is aimed at examining the role that schizophrenic symptomatology and neurocognitive and neuro-
217
logical factors have in determining the quality of life of chronic schizophrenics. Forty-two stable chronic schizophrenic patients (DSMIll-R), maintained on antipsychotic medication, were assessed on a number of relevant dimensions including quality of life (Sickness Impact Profile (SIP) and Global Assessment of Functioning (GAS)), psychopathology (Positive and Negative Syndromes (PANSS), neurocognitive functioning (COGLAB) and soft neurological signs. In the analysis, quality of life indices were correlated with the latter predictor variables. The results indicated that both GAF and SIP scores showed high correlations with PANSS scores (r=0.72 and 0.54, p<0.0001). GAF scores were also correlated with soft neurological signs (r = 0.57, p < 0.004) and impaired performance on the span of apprehension task during neurocognitive testing (r =0.36-0.45, p <0.05). PANSS scores were also highly correlated with perceptual impairment measured on a visual masking task (r = 0.38-0.40, p < 0.01 ). In conclusion, the degree of psychopathology as well as neurological and neurocognitive deficits are significantly related to schizophrenic patients' psychosocial functioning and quality of life. In addition, perceptual deficits showed some relationship to both quality of life and psychopathology. While these data suggest that these factors influence the subjective, self-reported quality of life of chronic schizophrenics, it seems clear that the interrelationships between psychopathology, neurocognitive impairment and quality of life remain complex and are not yet well understood. Further work exploring the relative contributions of symptoms and neurological impairment should be explored.
THE USE OF THE EXPRESSED
EMOTION
INDEX AS A PREDICTOR OF OUTCOME SCHIZOPHRENIA IN A FRENCH SPEAKING AREA OF SWITZERLAND
OF
SOCIOCULTURAL
DIMENSIONS
OF
"FAMILY BURDEN": THE SPECIFICITY ETHNIC, GENDER AND DIAGNOSTIC EFFECTS
OF
J.H. Jenkins*, M. Warren, M.E. Strauss, F. Bloom, C.J. Jacobson, A. Frasca
Department of Anthropology and Psychiatry, Case Western Reserve University, Cleveland, OH 44106, USA The research construct of "family burden" (FB) provides an index of sociobehavioral difficulties and adverse effects of illness on relatives. In an NIMH longitudinal study of Latino and Euro-American patients (n=80), the cultural and genderspecific dimensions of FB are compared for families living with schizophrenic and depressive disorders. The Social Behavioral Assessment Scale is administered to obtain measures of FB as behavioral disturbance, social performance, and adverse effects on others. Analysis reveals that, in addition to diagnosis, contextual variables such as ethnicity, gender, and behavioral domains of FB must be specified. No significant effects were observed for behavioral disturbance but a main effect for gender was found for social performance: male patients display significantly more deficits in this area. An interactive effect for diagnosis and ethnicity was observed for adverse effects, with Latino relatives of persons with schizophrenia scoring highest. We summarize specific diagnostic, ethnic, and gender effects in relation to FB: (1) ethnic-diagnostic groups appear to react similarly in the domain of "behavioral disturbance"; (2) gender is the only significant effect in the domain of "social performance"; and (3) the adverse effects of psychiatric illness varies cross-culturally in relation to ethnicity and diagnosis. The cultural validity of the FB construct with schizophrenic illness processes are discussed.
Ph. Huguelet, S. Favre, S. Binyet, Ch. Gonzalez, I. Z a b a l a
CAN INSIGHT AND COMPLIANCE IMPROVED IN PSYCHOSIS?
A five year follow-up study of first admitted patients with a diagnosis of schizophrenia was conducted in Geneva, Switzerland. All of the patients were assessed on entry, after one, two and five years with the Present State Examination (PSE/Wing, 1974) and their relatives were assessed at the same periods with the Camberwell Family Interview (CFI/Vaughn & Left, 1976). The predictive power of the EE index was tested on three variables of outcome, namely the presence of schizophrenic symptoms, social adaptation and hospital stays. An association appeared between the EE index and the outcome measures, particularly after three years of follow-up when the high EE group statistically differed from the low EE group with regard to the relapse rate and to the psychosocial adaptation. Relatives' high EE values at inclusion were also associated to some of the patients' poorer premorbid features. Our results give support to the model in which patient characteristics lead to high EE which in turn reinforces the patients' features and lead to poor outcome.
R. Kemp*, J. Hartley, P. Hayward, A. D a v i d
BE
Department of Psychological Medicine, King's College Hospital, London SE5 9RS, UK Lack of insight in schizophrenia is a major determinant of poor medication compliance, and hence outcome. Psychoeducational strategies have been proposed to foster insight and boost compliance but these have been either labour-intensive or didactic in approach, and have concentrated largely upon higher functioning patients. We investigated an adaptation of Motivational Interviewing (M1), a cognitive-behavioural method derived from treatment of substance abuse, in a randomised controlled trial in consecutively admitted psychotic inpatients in inner London. Our data revealed that the cases showed significantly improved attitudes to medication, insight and compliance after 4 6 sessions of MI compared to controls who received an equivalent number of supportive counselling