- Email: [email protected]
Patients with schizophrenia in a general hospital: Reasons for psychiatric consultation
132
outcome of schizophrenia in Afro-Caribbeans. Patients were recruited from the Maudsley Functional Psychosis Series which included 35 AC and 42 Caucasian British-born controls who fulfilled RDC criteria for schizophrenia. These patients were interviewed four years after index admissions using the following assessment instruments: Present State Examination, Strauss Carpenter Outcome Scale (SCOS), Global Assessment Scale, the WHO Life Chart and the Disability Assessment Schedule (DAS). 32% of AC and 15% of controls were continuously psychotic since the index admission. 54% of ACs and 61% of controls were not psychotic at follow-up. There were no differences in total SCOS scores (mean score in ACs=7.6, controls=8.3, p=O.46), or in course type of illness between groups. ACs and controls received similar amounts of neuroleptics, but AC patients were less likely to have been prescribed antidepressants and were more likely to have been admitted to hospital on compulsory orders. We conclude that schizophrenia in British Afro-Caribbean patients has a similar course and outcome to white British-born patients.
A FAMILY HISTORY STUDY IN BRITISH AFRO-CARIBBEAN SCHIZOPHRENIC PATIENTS Thomas Fahy*, Peter Jones, Pak Sham, Robin Murray Institute of Psychiatry, UK
De Crespigny Park, London SE5 8AF,
Several carefully designed studies have reported an excess of schizophrenia in the British Afro-Caribbean population. The cause of this excess remains unclear. We report the results of a family history study which assesses the relative contribution of genetic and environmental factors to this increased risk. The families of 89 white British-born and 40 Afro-Caribbean DSM 111 schizophrenic patients were investigated using the Family History RDC method. The lifetime morbid risk of schizophrenia in first degree relatives of white patients was 2.5 compared with 4.4 for the relatives of Afro-Caribbean patients. The risk for parents of Afro-Caribbean and white patients was similar, but the siblings of Afro-Caribbean patients had a higher risk (5.6) than the siblings of white patients (2.5). The risk for siblings of second generation Afro-Caribbean patients was greater (9.9) than the risk for siblings of first generation Afro-Caribbean (2.4) or white (2.5) patients. These results suggest that the excess incidence of schizophrenia in the British Afro-Caribbean population is be due to environmental rather than genetic factors.
SCHIZOPHRENIA IN AFRO-CARIBBEANS IN THE UK FOLLOWING PRENATAL EXPOSURE TO THE 19.57 A2 INFLUENZA PANDEMIC T.A. Fahy*,
P.B. Jones, PC. Sham, N. Takei, R.M. Murray
Institute of Psychiatry, UK
De Crespigny Purk, London SE-5 8AF,
The reason why the British Afro-Caribbean population has greatly increased risk for schizophrenia is not understood. The authors hypothesise that environmental factors, which may include prenatal exposure to influenza infection, contribute to this increased risk. The aim of this study was to investigate the association between prenatal exposure to the 19.57 A2 influenza epidemic (which reached Caribbean islands and Britain in September 1957) and adult schizophrenia in Afro-Caribbean and Caucasian British-born populations. Dates of birth were collected on inpatients with a diagnosis of schizophrenia in six English hospitals over an 1 l-year period, i.e., 962 white British-born cases, 444 first generation Afro-Caribbeans and 316 second generation AfroCaribbeans. There was a significant excess of Afro-Caribbean schizophrenic patients, mainly first generation, born 1958, and a significantly greater than predicted number born in March 1958. This excess was not evident in white subjects. These results add to the accumulating evidence of an association between prenatal exposure to influenza epidemics and schizophrenia, and suggest that a proportion of the excess of schizophrenia among the AfroCaribbean population in the UK may be attributable to greater vulnerability to the effects of prenatal influenza infection or associated factors.
PATIENTS WITH SCHIZOPHRENIA IN A GENERAL HOSPITAL: REASONS FOR PSYCHIATRIC CONSULTATION J.H. Gilmore*,
D. 0. Perkins, B.A. Lindsey
Department of Psychiatry, Hill. NC 27599, USA
University of North Carolina, Chapel
Patients with schizophrenia have excessive morbidity and mortality from a variety of medical illnesses. Little is known, however, about the fate of patients with schizophrenia during medical hospitalization, a stressful event that could exacerbate their psychiatric illness. In order to explore the impact of medical hospitalization on patients with schizophrenia, we reviewed the records of all adult patients with schizophrenia and schizoaffective disorder admitted to the non-psychiatric services of the University of North Carolina Hospitals from 1988 through 1991. On average, psychiatric consultations are requested on only 46% of patients with schizophrenia and schizoaffective disorder. Of these consultations. 42% were for non-acute reasons: assessment of past psychiatric history (18%) and assessment of psychotrophic medication (24%). The remainder of the consultations were for behavioral problems (16%), assessment of suicidality (20%). and other more acute reasons (22%). Consultations to patients with
133
schizophrenia represented only 3.5% of all psychiatric consultations We conclude that most patients with schizophrenia do well during admission to a general hospital service, with only 27% requiring active psychiatric intervention.
SIGNS
AND
SYMPTOMS
LYSOSOMAL
ENZYME
SCHIZOPHRENIC
CHARACTERIZlNG DISORDERS
FOUND
IN
PEDIGREES
A.B. Goodman* Statistical
Sciences and Epidemiology
Kline Institute
,for-Psychiatric
Division.
Research,
The Nathan
Orangeburg.
S.
NY 10962.
USA
Two previous epidemiologic studies have demonstrated increased risk for schizophrenia in Ashkenazi Jews. Symptoms characterizing adult variants of the lysosomal enzyme disorders, Tay Sachs and Gaucher disease, recessive genetic illnesses with increased prevalence among Ashkenazi Jews, were systematically collected by family history from twelve extended families (974 relatives) identified by a volunteer DSM-III-R schizophrenic proband of Ashkenazi descent, and a group of seven Ashkenazi normal control families (425 relatives). Relatives in six schizophrenic families evidenced amyotrophic lateral sclerosis’(age specific Morbid Risk = 150.00) or other severe muscle disease resulting in death. Five of the schizophrenic families evidenced Iymphomas/leukemias (age specific Morbid Risk = 5.86). Rates for neurological stigmata of Tay Sachs disease (e.g., tremor, weak ness, ataxia, dementia, stuttering, scoliosis, hammertoes) and Gaucher-related signs and symptoms (e.g., blood dyscrasias, anemia, excessive bleeding or bruising, arthritis-like bone disease or pain, kidney disease or absence, macular degeneration) are significantly elevated (Wilcoxon) in the schizophrenic families. The presence of mutations causing one or both of these lysosomal enzyme disorders may increase vulnerability to schizophrenia in Ashkenazi Jews. Both disorders have been known to present with psychosis in their adult forms. Such mutations are being sought in these schizophrenic families,
REGIONAL RATES
FOR
COMPARISON
VARIATIONS
IN ADMISSION
SCHIZOPHRENIA OF
IN ENGLAND:
GEOGRAPHIC
AND
A
SOCIAL
FACTORS Sunjai Institute
Gupta*
of Psychiatry,
De Crespigny
Park, London
S.E.5 8AF.
UK
The cross-national studies carried out by the World Health Organization have demonstrated significant differences between
different countries in the outcome of schizophrenia, and in its incidence when broadly defined. Other studies have also shown that there are variations in schizophrenia within individual countries such as the United States. Various theories have been put forward to explain these differences. The purpose of the present study was to compare some of these hypotheses using data supplied by the Department of Health for the fourteen Regions of England. The mean annual first admission rate for schizophrenia for each of these Regions (1982-1986) was found to show significant correlations with three out of six geographical and climatic variables: altitude (positively), mean air temperature (negatively), and mean daily hours of bright sunshine (negatively). The schizophrenia index was also found to show a (barely) significant correlation with one out of three indices of social deprivation: the Jarman index (positively). Methodological factors (including the choice of variables included in the analysis) need to be considered in interpreting the results, and further research is needed to clarify their meaning. However, the findings could have important implications for theories of the aetiology of schizophrenia and for service planning and resource allocation.
SUICIDAL
BEHAVIOR
COURSE-OF-ILLNESS
IN SCHIZOPHRENIA: PREDICTORS
Gretchen L. Haas, Larry Glanz, John Mann, John A. Sweeney Department Medicine,
of Psychiatry, Pittsburgh,
Elizabeth
University
Radomsky,
of Pittsburgh
J.
School of
PA 15213. USA
Suicide is the leading cause of death in young schizophrenic patients, with completed suicides occurring in approximately 10% of this population. Many more individuals with schizophrenia attempt suicide and a majority of suicide attempts occur within the first 5 years of illness. This study aimed to identify clinical and course-of-illness characteristics associated with suicidal behavior. A consecutive admission series of 150 SCID-diagnosed DSM-IIIR schizophrenic patients was evaluated with a battery of clinical symptom measures, premorbid adjustment scales (Cannon-Spoor Premorbid Adjustment Scale) and suicidal behavior assessments. Results indicated that 25% (38 out of 150) of the patients had a history of one or more suicide attempts. 89% of first attempts occurred within the first live years following first hospitalization or before. Clinical characteristics occurring most frequently at the time of suicide attempt included acute psychosis (61 %) and demoralization (59%). The clinical history of suicide attempters revealed a pattern of longer neuroleptic exposure and more frequent hospitalization as compared with non-attempters over the same period of risk. Family history of suicidal behavior was also more common among attempters than non-attempters (p ~0.05). These findings suggest that risk for suicidal behavior is highest during the early phase of illness. Efforts to identify specific risk factors need to focus on such factors as demoralization, frequent hospitalization, and family history of suicidal behavior.
outcome of schizophrenia in Afro-Caribbeans. Patients were recruited from the Maudsley Functional Psychosis Series which included 35 AC and 42 Caucasian British-born controls who fulfilled RDC criteria for schizophrenia. These patients were interviewed four years after index admissions using the following assessment instruments: Present State Examination, Strauss Carpenter Outcome Scale (SCOS), Global Assessment Scale, the WHO Life Chart and the Disability Assessment Schedule (DAS). 32% of AC and 15% of controls were continuously psychotic since the index admission. 54% of ACs and 61% of controls were not psychotic at follow-up. There were no differences in total SCOS scores (mean score in ACs=7.6, controls=8.3, p=O.46), or in course type of illness between groups. ACs and controls received similar amounts of neuroleptics, but AC patients were less likely to have been prescribed antidepressants and were more likely to have been admitted to hospital on compulsory orders. We conclude that schizophrenia in British Afro-Caribbean patients has a similar course and outcome to white British-born patients.
A FAMILY HISTORY STUDY IN BRITISH AFRO-CARIBBEAN SCHIZOPHRENIC PATIENTS Thomas Fahy*, Peter Jones, Pak Sham, Robin Murray Institute of Psychiatry, UK
De Crespigny Park, London SE5 8AF,
Several carefully designed studies have reported an excess of schizophrenia in the British Afro-Caribbean population. The cause of this excess remains unclear. We report the results of a family history study which assesses the relative contribution of genetic and environmental factors to this increased risk. The families of 89 white British-born and 40 Afro-Caribbean DSM 111 schizophrenic patients were investigated using the Family History RDC method. The lifetime morbid risk of schizophrenia in first degree relatives of white patients was 2.5 compared with 4.4 for the relatives of Afro-Caribbean patients. The risk for parents of Afro-Caribbean and white patients was similar, but the siblings of Afro-Caribbean patients had a higher risk (5.6) than the siblings of white patients (2.5). The risk for siblings of second generation Afro-Caribbean patients was greater (9.9) than the risk for siblings of first generation Afro-Caribbean (2.4) or white (2.5) patients. These results suggest that the excess incidence of schizophrenia in the British Afro-Caribbean population is be due to environmental rather than genetic factors.
SCHIZOPHRENIA IN AFRO-CARIBBEANS IN THE UK FOLLOWING PRENATAL EXPOSURE TO THE 19.57 A2 INFLUENZA PANDEMIC T.A. Fahy*,
P.B. Jones, PC. Sham, N. Takei, R.M. Murray
Institute of Psychiatry, UK
De Crespigny Purk, London SE-5 8AF,
The reason why the British Afro-Caribbean population has greatly increased risk for schizophrenia is not understood. The authors hypothesise that environmental factors, which may include prenatal exposure to influenza infection, contribute to this increased risk. The aim of this study was to investigate the association between prenatal exposure to the 19.57 A2 influenza epidemic (which reached Caribbean islands and Britain in September 1957) and adult schizophrenia in Afro-Caribbean and Caucasian British-born populations. Dates of birth were collected on inpatients with a diagnosis of schizophrenia in six English hospitals over an 1 l-year period, i.e., 962 white British-born cases, 444 first generation Afro-Caribbeans and 316 second generation AfroCaribbeans. There was a significant excess of Afro-Caribbean schizophrenic patients, mainly first generation, born 1958, and a significantly greater than predicted number born in March 1958. This excess was not evident in white subjects. These results add to the accumulating evidence of an association between prenatal exposure to influenza epidemics and schizophrenia, and suggest that a proportion of the excess of schizophrenia among the AfroCaribbean population in the UK may be attributable to greater vulnerability to the effects of prenatal influenza infection or associated factors.
PATIENTS WITH SCHIZOPHRENIA IN A GENERAL HOSPITAL: REASONS FOR PSYCHIATRIC CONSULTATION J.H. Gilmore*,
D. 0. Perkins, B.A. Lindsey
Department of Psychiatry, Hill. NC 27599, USA
University of North Carolina, Chapel
Patients with schizophrenia have excessive morbidity and mortality from a variety of medical illnesses. Little is known, however, about the fate of patients with schizophrenia during medical hospitalization, a stressful event that could exacerbate their psychiatric illness. In order to explore the impact of medical hospitalization on patients with schizophrenia, we reviewed the records of all adult patients with schizophrenia and schizoaffective disorder admitted to the non-psychiatric services of the University of North Carolina Hospitals from 1988 through 1991. On average, psychiatric consultations are requested on only 46% of patients with schizophrenia and schizoaffective disorder. Of these consultations. 42% were for non-acute reasons: assessment of past psychiatric history (18%) and assessment of psychotrophic medication (24%). The remainder of the consultations were for behavioral problems (16%), assessment of suicidality (20%). and other more acute reasons (22%). Consultations to patients with
133
schizophrenia represented only 3.5% of all psychiatric consultations We conclude that most patients with schizophrenia do well during admission to a general hospital service, with only 27% requiring active psychiatric intervention.
SIGNS
AND
SYMPTOMS
LYSOSOMAL
ENZYME
SCHIZOPHRENIC
CHARACTERIZlNG DISORDERS
FOUND
IN
PEDIGREES
A.B. Goodman* Statistical
Sciences and Epidemiology
Kline Institute
,for-Psychiatric
Division.
Research,
The Nathan
Orangeburg.
S.
NY 10962.
USA
Two previous epidemiologic studies have demonstrated increased risk for schizophrenia in Ashkenazi Jews. Symptoms characterizing adult variants of the lysosomal enzyme disorders, Tay Sachs and Gaucher disease, recessive genetic illnesses with increased prevalence among Ashkenazi Jews, were systematically collected by family history from twelve extended families (974 relatives) identified by a volunteer DSM-III-R schizophrenic proband of Ashkenazi descent, and a group of seven Ashkenazi normal control families (425 relatives). Relatives in six schizophrenic families evidenced amyotrophic lateral sclerosis’(age specific Morbid Risk = 150.00) or other severe muscle disease resulting in death. Five of the schizophrenic families evidenced Iymphomas/leukemias (age specific Morbid Risk = 5.86). Rates for neurological stigmata of Tay Sachs disease (e.g., tremor, weak ness, ataxia, dementia, stuttering, scoliosis, hammertoes) and Gaucher-related signs and symptoms (e.g., blood dyscrasias, anemia, excessive bleeding or bruising, arthritis-like bone disease or pain, kidney disease or absence, macular degeneration) are significantly elevated (Wilcoxon) in the schizophrenic families. The presence of mutations causing one or both of these lysosomal enzyme disorders may increase vulnerability to schizophrenia in Ashkenazi Jews. Both disorders have been known to present with psychosis in their adult forms. Such mutations are being sought in these schizophrenic families,
REGIONAL RATES
FOR
COMPARISON
VARIATIONS
IN ADMISSION
SCHIZOPHRENIA OF
IN ENGLAND:
GEOGRAPHIC
AND
A
SOCIAL
FACTORS Sunjai Institute
Gupta*
of Psychiatry,
De Crespigny
Park, London
S.E.5 8AF.
UK
The cross-national studies carried out by the World Health Organization have demonstrated significant differences between
different countries in the outcome of schizophrenia, and in its incidence when broadly defined. Other studies have also shown that there are variations in schizophrenia within individual countries such as the United States. Various theories have been put forward to explain these differences. The purpose of the present study was to compare some of these hypotheses using data supplied by the Department of Health for the fourteen Regions of England. The mean annual first admission rate for schizophrenia for each of these Regions (1982-1986) was found to show significant correlations with three out of six geographical and climatic variables: altitude (positively), mean air temperature (negatively), and mean daily hours of bright sunshine (negatively). The schizophrenia index was also found to show a (barely) significant correlation with one out of three indices of social deprivation: the Jarman index (positively). Methodological factors (including the choice of variables included in the analysis) need to be considered in interpreting the results, and further research is needed to clarify their meaning. However, the findings could have important implications for theories of the aetiology of schizophrenia and for service planning and resource allocation.
SUICIDAL
BEHAVIOR
COURSE-OF-ILLNESS
IN SCHIZOPHRENIA: PREDICTORS
Gretchen L. Haas, Larry Glanz, John Mann, John A. Sweeney Department Medicine,
of Psychiatry, Pittsburgh,
Elizabeth
University
Radomsky,
of Pittsburgh
J.
School of
PA 15213. USA
Suicide is the leading cause of death in young schizophrenic patients, with completed suicides occurring in approximately 10% of this population. Many more individuals with schizophrenia attempt suicide and a majority of suicide attempts occur within the first 5 years of illness. This study aimed to identify clinical and course-of-illness characteristics associated with suicidal behavior. A consecutive admission series of 150 SCID-diagnosed DSM-IIIR schizophrenic patients was evaluated with a battery of clinical symptom measures, premorbid adjustment scales (Cannon-Spoor Premorbid Adjustment Scale) and suicidal behavior assessments. Results indicated that 25% (38 out of 150) of the patients had a history of one or more suicide attempts. 89% of first attempts occurred within the first live years following first hospitalization or before. Clinical characteristics occurring most frequently at the time of suicide attempt included acute psychosis (61 %) and demoralization (59%). The clinical history of suicide attempters revealed a pattern of longer neuroleptic exposure and more frequent hospitalization as compared with non-attempters over the same period of risk. Family history of suicidal behavior was also more common among attempters than non-attempters (p ~0.05). These findings suggest that risk for suicidal behavior is highest during the early phase of illness. Efforts to identify specific risk factors need to focus on such factors as demoralization, frequent hospitalization, and family history of suicidal behavior.