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Stability of diagnosis: a 20-year retrospective cohort study of Israeli psychiatric adolescent inpatients
Journal of Adolescence 2001, 24, 625–633 doi:10.1006/jado.2001.0423, available online at http://www.idealibrary.com on
Stability of diagnosis: a 20-year retrospective cohort study of Israeli psychiatric adolescent inpatients AVI VALEVSKI, GIDEON RATZONI, JONATHAN SEVER, ALAN APTER, GIL ZALSMAN, RONI SHILOH, ABRAHAM WEIZMAN AND SAM TYANO Outcome according to diagnosis and stability of diagnosis were investigated in a followback study of 351 adolescents with various psychiatric disorders hospitalized in a closed psychiatric ward. The duration of follow-back was 15–19 years. All diagnoses were based on the ICD-9. Data were collected from the Health Ministry registry and, in the patients who could be located, by structured telephone interview. Special attention was directed at the diagnosis of transient adolescent psychosis (TAP) vs. schizophrenia and prognostic indicators of suicide. The results showed that the most stable diagnosis was anxiety disorder. The stability of the different diagnoses over time was greater between the second and last admission than between the first and last (for patients with three or more admissions). Number of hospitalizations correlated negatively with prognosis. TAP at second admission was an unstable diagnosis; 66% of these patients had a final diagnosis of schizophrenia. However, patients with a diagnosis of TAP at first admission had a higher predictive index score and a higher outcome score than schizophrenic patients. TAP appeared to be a valid diagnostic entity, distinguishable from schizophrenia in course, frequency of suicidal behaviour and social-occupational outcome. Suicide victims had a higher cumulative length of stay than age- and sexmatched non-suicidal patients. Fifty per cent of the suicide victims had a final diagnosis of schizophrenia, compared to 30 per cent for the whole sample. In conclusion, these findings indicate that TAP is associated with a relatively good prognosis and should probably be differentiated from schizophrenia. Further retrospective and prospective studies of adolescent psychiatric inpatients may help delineate the nature and course of psychosis and other psychopathology in this age group. r 2001 The Association for Professionals in Services for Adolescents
Introduction A major objective of long-term follow-up studies of adolescent inpatients of psychiatric hospitals is to determine whether there is a continuity of diagnosis from adolescence to adulthood (Tyano and Apter, 1988). In this regard, any changes in the official diagnostic criteria that may have been made over the years must be considered as well (Blotcky et al., 1984; Andreason, 1987). Like other such studies (Blotcky et al., 1984), the present work is a retrospective one, based on register and file data. The outcome of a first psychotic episode is of special interest for evaluating the relationship between diagnosis and prognosis in adolescent psychopathology. Studies of heterogeneous patient groups have reported that the psychoses are associated with poor outcome. Levy (1969) found a strong correlation between severity of disease at diagnosis and patient adjustment 8–23 years later. Schain et al. (1982) reported that almost all psychotic children had required rehospitalization by the 5-year follow-up, and Davis et al. (1986) suggested that little difference exists in prognosis between personality disorders and schizophrenia. However, others have reported that more than 50 per cent of patients Reprint requests and correspondence should be addressed to A. Valevski, MD, Geha Psychiatric Hospital, P.O. Box 102, Petah Tiqva 49100, Israel. (Tel.: 972-3-925-8283; Fax: 972-3-924-1041). 0140-1971/01/050625+09 $3500/0
# 2001 The Association for Professionals in Services for Adolescents
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A. Valevski et al.
described as neurotic or having personality disorders demonstrated a positive long-term outcome (Blotcky et al., 1984). Apparently, although the prognosis of early-onset psychosis is poor (Gillberg et al., 1993), the subclass of patients with acute remitting or transient psychosis (less than 6 months of continuous illness with acute onset) have a better outcome and may be differentiated from schizophrenics (Susser and Wanderling, 1994). These disorders are assumed to occur particularly in adolescence (Blos, 1968), while there are developmental factors pertinent to adolescence that affect the natural development and course of schizophrenia (Werry and Taylor, 1994). It has been our clinical impression that brief psychotic episodes in adolescence have a special character, different from the psychoses found in adults, and we called this entity ‘‘transient adolescent psychosis’’ (TAP) (Tyano and Apter, 1988). The diagnostic criteria for TAP are shown in Appendix A. This diagnostic entity in adolescents overlaps the Brief Reactive Psychosis (DSM-IV) or Acute and Transient Psychotic Disorder (ICD-10) in adults. Suicide resulting from psychiatric morbidity is also an important consideration in the follow-up of adolescent psychiatric inpatients (Rao et al., 1993). The rate of suicide in followup studies of depressed adolescents ranges from 1?2 to 4?4 per cent (Larsen, 1991; Rao et al., 1993). Pokorny (1983) found that the incidence of suicide in psychiatric patients aged 10–19 years to be 3 per cent. In the present retrospective cohort study, we studied the outcome of adolescent inpatients of a psychiatric hospital according to prognosis and stability of diagnosis. Special attention was directed to the prognosis of TAP vs. schizophrenia, the long-term reliability of the diagnosis of TAP, and suicide predictors.
Patients and methods The present study was conducted with a follow-back design, starting in 1993. We reviewed the records of all 351 patients consecutively admitted to the Adolescent Psychiatric Unit of Geha Hospital from 1974–1978. Data on demographic characteristics, psychiatric diagnoses, date and length of hospitalizations, and mortality were retrospectively collected from the computerized registry of the Israel Ministry of Health, where all hospitalizations in the country are recorded. The diagnoses used in the study were those assigned at admission(s) and recorded in the government records. All were based on the International Classification of Diseases, ninth revision (ICD-9). Thereafter, a major effort was made to locate the patients, and those who could be located were interviewed by telephone with a specially formulated questionnaire. The following areas were covered: family status; work history; army service; psychopathology; and quality of life. Owing to concerns about reliability of information and compliance with the interviewer, we did not collect data on drug misuse. For analysis, we calculated the Outcome Score (OS), based on 11 items (Appendix B) reflecting the social, familial and occupational functioning of the patients, and the Predictive Index Score (PIS), based on eight items (Appendix C) reflecting good outcome (both measures developed by the authors). The data for the OS were derived from the direct interview, and the data for the PIS were derived from the patient records. The OS was calculated first. Thereafter, the patient charts at first admission were reviewed by two senior psychiatrists blinded to the OS values for medical variables indicating outcome, and the PIS was calculated. Our clinical experience has shown that both the OS and PIS are sensitive
Stability of diagnosis in Israeli psychiatric adolescent inpatients
627
indicators of outcome and prediction in adolescent patients. However, no reliability or validity studies on these instruments are as yet available, and there are no valid cut-off values. In addition, using only the chart information, we calculated the Suicide Risk Index (SRI) based on nine items (Appendix D), as described by Motto et al. (1985). Stability of diagnosis was analysed only in the patients readmitted to hospital at least twice. The diagnosis made at the first admission and at the second admission was compared with the diagnosis at the last admission.
Statistical analysis Student’s t-test, Chi-square test and kappa scores were used as appropriate; a p value of 40?05 was considered significant. All results are expressed as mean 7S.D.
Results The original cohort included 178 males (50?7%) and 173 females (49?3%). Age range at first admission was 10–21 years (mean 7S.D. 16?672?04 years), and age at follow-up, 27–36 years (mean 33?272?2 years). In Israel, adolescence is defined as age 12–21 years; however, only 8?2% of our cohort was older than 19 and only 2?6% was younger than 13 at first admission. The majority of patients (83%) were born in Israel. The duration of the follow-back period ranged from 15–19 years (16?678 years). The frequencies of the different psychiatric diagnoses at first hospitalization are shown in Table 1. Schizophrenia was the most frequent diagnosis (n=82, 23?4%), followed by TAP (n=64, 18?3%). There was no statistical difference in sex distribution among the diagnostic groups. Rehospitalization was required by 65% of the whole population, and by 79 per cent of the patients with schizophrenia. For the telephone interview, 202 patients (57?5%) of the original cohort could not be located because of the long interval between their last admission and the present study. The non-compliance rate for the remaining 130 patients was 5?4 per cent (n=19), which compares favorably with rates reported in other studies (Morris et al., 1956; Schain et al., Table 1
Demographic data by diagnostic group at first hospitalization
Whole group* Schizophrenia Transient adolescent psychosis (TAP) Personality disorders Affective disorders Anxiety disorders Organic brain syndrome Others *Missing data on 41 patients.
No. of patients (%)
M (%)
F (%)
Age (mean7S.D.)
351 (100%) 82 (23?4%) 64 (18?3%)
178 (50?7) 42 (1?2) 36 (56?3)
173 (49?3) 40 (48?8) 28 (43?8)
16?6172?04 17?072?18 16?871?91
55 (15?7%)
30 (54?5)
25 (45?5)
16?2971.85
11 37 20 82
8 (72?7) 18 (48?6) 6 (30) 39 (47?5)
3 (27?3) 19 (51?4) 14 (70) 43 (52?5)
16?0972?16 15?871?72 16?8572?73 16?5672?06
(3?1%) (10?5%) (5?7%) (23?6%)
A. Valevski et al.
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1982). There was no difference between the located and non-located patients in sex ratio, distribution of diagnoses or number of hospitalizations. Mean age of the located patients at follow-up was 33?872?1 years. The OS was calculated only in the located patients who completed the telephone questionnaire (n=75). Outcome score was found to be good (0?75) in 13 patients (17?3%), moderate (0?26–0?74) in 42 (56%), and poor (o0?25) in 20 (26?7%). There was a negative correlation of OS with number of hospitalizations. The marriage rate was significantly lower for the patients with multiple psychiatric admissions compared to those with single admissions (w2=10?8, df=1, po0?05); this finding was not gender-dependent. Furthermore, the patients with multiple admissions had a significantly greater chance of rejection from the army (w2=4?05, df=1, po0?05) and served less army time. The number of admissions did not affect the rate of unemployment (w2=1?91, df=1, p=NS). When the patients with a first diagnosis of TAP were compared with those with a first diagnosis of schizophrenia, the OS was found to clearly differentiate between the groups (schizophrenia vs. TAP: 0?1570?13 vs. 0?570?18, df=37, t=3?29, po0?05). The TAP patients had fewer hospitalizations than the schizophrenic patients (df=1, t=ÿ3?4, p=0?01), shorter durations of hospitalization throughout the entire follow-up period (2?872?6 vs. 5?574?2 months, df=153, t=3, po0?01), and overall, higher PIS scores (0?5570?18 vs. 0?3570?15, df=37, t=3?29, po0?05), further supporting the need to differentiate between these groups. The findings for stability of diagnosis for the whole cohort are shown in Table 2. The stability of the different diagnoses over time was greater between the second and last admissions than between the first and last admissions. The most stable diagnosis was anxiety disorder, followed by personality disorder. TAP was an unstable diagnosis when made on the second hospitalization. According to the records, 16 of the 64 patients with a diagnosis of TAP on first admission (25%) did not have a repeated admission. Of the 48 remaining patients, TAP was retained as the diagnosis in only 16 (33%), and the others were later diagnosed as having schizophrenia. Of the total cohort, 14 patients (3?9%) died from suicide. The mean interval between the onset of illness and suicide was 0?774?7 years, and the majority of the patients (10 of 14) died during the first year after the last hospitalization. Their demographic data are given in Table 3. When matched for age and sex with 20 control patients from the original sample, no
Table 2
Stability of diagnoses over 15 years in hospitalized adolescents
Diagnosis
Schizophrenia Personality disorders Affective disorders Anxiety disorders Organic brain syndrome Transient adolescent psychosis (TAP) Others
Kappa between the second and last admission
Kappa between the first and last admission
0?57 0?66 0?27 0?79 0?52 0?25
0?18 0?19 ÿ0?02 0?06 ÿ0?03 0?05
0?35
0?09
Stability of diagnosis in Israeli psychiatric adolescent inpatients
Table 3
629
Demographic data of suicide group Sex M
Age at first admission (years)
No. of hospitalizations
F
Length of hospitalizations (weeks) First
Committed 9 5 17?1472?03 suicide 168 169 16?572?04 Nonsuicidal patients p NS NS
Second
Last
5?775?4
13?4711?6
20?8719.1
20.09721?9
3?974?3
16?8719?2
20?2721?2
14?6725?8
NS
NS
NS
NS
Table 4
Diagnostic data of suicide group (ICD-9 criteria)
Sex
Age at No. of first hospitaliadmission zations
Diagnosis First
Second
Last
Observation for mental disorder OBS Anxiety disorder Conduct disorder
Observation for mental disorder Schizophrenia ? Antisocial personality disorder OBS Personality disorder Schizophrenia Adjustment disorder Schizophrenia Schizophrenia Emotional disturbance of adolescents Schizophrenia Schizophrenia Schizophrenia
M
18
2
TAP
F M M
20 19 17
4 16 2
OBS ? Drug dependence
M M M F M F M
19 15 16 18 18 16 14
3 4 1 1 12 6 1
M F M
16 14 20
13 14 2
OBS Anxiety disorder Schizophrenia Adjustment disorder TAP TAP Emotional disturbance of adolescents TAP Bipolar disorder Observation for mental disorder
OBS Anxiety disorder Schizophrenia ? Schizophrenia ? ? Schizophrenia Schizophrenia Schizophrenia
?, diagnosis differed; OBS, organic brain syndrome; TAP, transient adolescent psychosis.
difference was found in sex ratio, age at first admission, number of hospitalizations, and length of first and second hospitalizations. As expected, the suicidal patients exhibited higher SRI scores as compared to age- and sex-matched nonsuicidal patients (0?4970?14 vs. 0?3370?06, t=4?5, df=32, po0?0001). Suicide victims were not hospitalized more frequently than those who did not attempt suicide, but their cumulative length of stay tended to be greater (126?07161?8 vs. 76?67117?6 weeks, t=1?50, df=349, po0?1, NS). Fifty percent of the suicide victims had a final diagnosis of schizophrenia, which was higher than the rate of schizophrenia for the whole sample (30%) at the last admission (Table 4).
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A. Valevski et al.
Discussion Many of the classic theories of adolescent psychopathology, such as those of Blos (1968) and Nicholi (1969), propose that a psychiatric diagnosis should not be made during the adolescent period of stormy development. Specific terms have been suggested to describe the clinical manifestations of stress during adolescence, for example, ‘‘adolescent turmoil’’ and ‘‘identity disturbances’’. Other authors (Masterson, 1967; Offer et al., 1970), however, have advocated the use of descriptive classifications (DSM and ICD) and adult criteria also for adolescents. The application of standardized criteria is important for long-term follow-up and followback studies. Hollis (2000) reported that the prognosis of patients labelled adolescent-onset schizophrenic disorder is associated with malignant course and outcome. Zeitlin (1990) has shown that 80 per cent have more than one hospital admission and 50 per cent more than four. In our cohort, the rate of readmission of the schizophrenic patients was even higher. Interestingly, in our study, all diagnoses made at the second admission were more reliable than those made at the first. This may be at least partly explained by the reluctance of clinicians faced with a young patient to give a final diagnosis of a mental disorder that is associated with a bad prognosis. Many prefer to avoid misdiagnosis until residual or negative symptoms are noted (Loffler et al., 1994). Sixty-five percent of the patients had more than one admission. Studies of prognosis in adolescent psychiatric patients are surprisingly scarce (McClellan et al., 1993), and many issues of adolescent psychosis remain unresolved. In this study we focused on the concept of TAP (Tyano and Apter, 1988), which we suggest is an appropriate diagnostic category for adolescents with acute remitting psychoses that are not due to affective disorders (themselves a critical areas of uncertainty in psychiatric diagnosis) (Susser and Wanderling, 1994). However, the possibility that the TAP group included patients with affective disorders and/or borderline personality disorder (Angold, 1988) cannot be completely ruled out and is, indeed, supported by the low incidence of aggressive disorders in our cohort and the good prognosis of the TAP patients. Since our data are insufficient to provide a definitive answer to this question, it seems reasonable at present to regard TAP as a subtype of non-affective psychotic disorder. The relatively good outcome of the TAP patients is in agreement with the finding of Garralda (1984) that psychotic symptoms such as hallucinations do not necessarily predict a bad prognosis. Susser and Wanderling (1994) reported a ratio of 18 : 82 between nonaffective remitting psychosis (NARP) and schizophrenia in adults. This is comparable to our ratio of 16 : 106 for TAP vs. schizophrenia at the second admission. NARP is considered to be a separate entity or a valid subcategory of schizophrenia in adults. Based on our findings using the OS and the PIS, we suggest that TAP is different from schizophrenia. Interestingly, since NARP is more frequent in non-Western settings, it may be influenced by environmental factors, such as adolescent ‘‘subculture’’. It is of note that the fatal suicide patients exhibited higher SRI scores than their matched controls. From a clinical point of view, this study indicates that the variables included in the SRI can be used as predictors for suicidal behaviour in adolescent psychotic patients. The contribution of each item of the SRI could not be analysed due to the small number of suicide victims (n=14). Our data indicate that the PIS, which is based on clinical and diagnostic parameters, succeeded in discriminating between suicidal and non-suicidal patients.
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This study had several important limitations, including its retrospective case-note nature, small sample size, lack of validity/reliability studies for the instruments, number of patients who could not be located, and high non-compliance rate of those who were. In conclusion, TAP may well be a valid diagnostic entity, differing in course and outcome from schizophrenia and affective disorders. The relatively small number of patients in this study for whom we had complete information on prognosis limits our conclusions regarding the validity of TAP, and further studies are needed to evaluate prognosis and suicidal risk in first-onset psychotic adolescents. These results support the notion that a substantial proportion of adolescent psychotic patients do not develop a schizophrenic disorder, and the diagnosis of schizophrenia should be limited in this age group to clear-cut cases only.
Acknowledgements We would like to thank Mrs M. Poper, Director, Department of Information and Evaluation, Mental Health Services Israel, Israel Ministry of Health, for her assistance in the collection of the computerized data, and Gloria Ginzach for her editorial assistance. The study was supported by a grant from the Chief Scientist, Israel Ministry of Health.
References Andreason, N. C. (1987). The diagnosis of schizophrenia. Schizophrenia Bulletin, 13, 25–38. Angold, A. (1988). Childhood and adolescent depression I. Epidemiological and aetiological aspects. British Journal of Psychiatry, 152, 601–617. Blos, P. (1968). Character formation in adolescence. Psychoanalytic Study of the Child, 23, 245–283. Blotcky, M. J., Dimperio, T. L. and Gossett, J. T. (1984). Follow-up of children treated in psychiatric hospitals: a review of studies. American Journal of Psychiatry, 141, 1499–1507. Davis, A., Ryan, R. and Salvatore, P. (1986). Effectiveness of residential treatment for psychotic and other disturbed children. American Journal of Orthopsychiatry, 38, 469–475. Garralda, M. E. (1984). Hallucinations in children with conduct and emotional disorders: II The follow-up study. Psychological Medicine, 14, 597–604. Gillberg, I. C., Hellgren, L. and Gillberg, C. (1993). Psychotic disorders in adolescence. Outcome at age 30 years. Journal of Child Psychology Psychiatry, 34, 1173–1185. Hollis, C. (2000). Adult outcomes of child- and adolescent-onset schizophrenia: diagnostic stability and predictive validity. American Journal of Psychiatry, 157, 1652–1659. Larsen, F. W. (1991). Thirty year follow-up study of a child psychiatric clientele. Acta Psychiatrica Scandinavica, 84, 65–71. Levy, E. Z. (1969). Long-term follow-up of former inpatients at the Children’s Hospital of the Menninger Clinic. American Journal of Psychiatry, 125, 1633–1639. Loffler, W., Hafner, H., Fatkenheuer, B., Maurer, K., Riecher Rossler, A. and Lutzhoft, J. (1994). Validation of Danish case register diagnosis for schizophrenia. Acta Psychiatrica Scandinavica, 90, 196–203. Masterson, J. F. (1967). The Psychiatric Dilemma of Adolescence. Boston: Little, Brown. McClellan, J. M., Werry, J. S. and Ham, M. A. (1993). Follow-up study of early onset psychosis: comparison between outcome diagnoses of schizophrenia, mood disorders, and personality disorders. Journal of Autism & Developmental Disorders, 23, 243–262. Motto, J. A., Heilborn, D. C. and Juster, R. P. (1985). Development of clinical instruments to estimate suicide risk. American Journal of Psychiatry, 142, 680–686. Morris, H. H., Escoll, P. J. and Wexler, R. (1956). Aggressive behavior disorders in childhood: a followup study. American Journal of Psychiatry, 112, 991–997.
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Nicholi, A. M. (1969). Harvard dropouts: some psychiatric findings. American Journal of Psychiatry, 126, 417. Offer, D., Marcus, D. and Offer, J. L. (1970). A longitudinal study of normal adolescent boys. American Journal of Psychiatry, 126, 917–924. Pokorny, A. D. (1983). Prediction of suicide in psychiatric patients. Archives of General Psychiatry, 40, 249–257. Rao, U., Weissman, M. M., Marin, J. A. and Hammond, R. W. (1993). Childhood depression and risk of suicide: a preliminary report of a longitudinal study. Journal of the American Academy of Child & Adolescent Psychiatry, 32, 21–27. Schain, R. J., Gardella, D. and Pon, J. (1982). Five year outcome of children admitted to a state hospital. Hospital Community Psychiatry, 33, 847–848. Susser, E. and Wanderling, J. (1994). Epidemiology of nonaffective acute remitting psychosis vs. schizophrenia. Archives of General Psychiatry, 51, 294–301. Tyano, S. and Apter, A. (1988). Adolescent psychosis and eight-year follow-up. In A. Z. Schwartzberg (Ed.). International Annals of Adolescent Psychiatry. Chicago: The University of Chicago Press, pp. 317–324. Werry, T. S. and Taylor, E. (1994) Schizophrenic and allied disorders. In M. Rutter, E. Talyor and L. Hersov (Eds). Child and Adolescent Psychiatry: modern Approaches, 3rd edition. Oxford: Blackwell Scientific Publications, pp. 594–615. Zeitlin, H. (1990). Current interests in child-adult psychopathological continuities. Journal of Child Psychology & Psychiatry, 31, 671–679.
Appendix A Diagnostic criteria for Transient Adolescent Psychosis (TAP) 1. Acute onset of delusions or hallucinations. Interval between the first appearance of any psychotic symptoms and the presentation of the fully developed disorder does not exceed 2 weeks. 2. Positive signs, such as hallucinations and delusions, with themes relating to adolescent development (for example, sexual identity). 3. Lack of negative signs, such as blunting of affect, apathy, poverty of speech. 4. No early childhood pathology, such as developmental cognitive impairment and/or attention deficit disorder. 5. Lack of bizarre items (outside of usual human cultural experience) in hallucinations and delusions.
Appendix B Outcome Score (OS) (Clinical outcome variables in adolescent inpatients: social, familial, occupational) 1. 2. 3. 4. 5.
Quality of life (unsatisfactory=0, satisfactory=1) Family status (unmarried=0, married=1) Military health profile (low=0, moderate/high=1) Military service (no=0, yes=1) Military reserve service (no=0, yes=1)
Stability of diagnosis in Israeli psychiatric adolescent inpatients
6. 7. 8. 9. 10. 11.
Work status (unemployed=0, employed=1) Schooling (o8 years=0, 48 years=1) Continuous psychiatric treatment (yes=0, no=1) Leisure activities (no=0, yes=1) Social adjustment (no social interaction=0, engages in social activity=1) Friends (no or only one friend=0, more than 1 friend=1)
Score=total score/11 items. Range of total score=0–11. A higher score indicates better outcome.
Appendix C Predictive Index Score (PIS) (Predictor variables for prognosis in adolescent inpatients: medical) 1. 2. 3. 4. 5. 6. 7. 8.
Time to hospitalization (3 weeks=0, o3 weeks=1) Positive signs (no=0, yes=1) Negative signs (yes=0, no=1) Early childhood pathology (yes=0, no=1) Content of thought characteristic of the usual adolescent world (no=0, yes=1) Bizarre thoughts (yes=0, no=1) Antipsychotic treatment (yes=0, no=1) Family history of psychiatric illness (yes=0, no=1)
Score=total score/8 items. Range of total score=0–8. A higher score indicates better prognosis.
Appendix D Suicide Risk Index (SRI) (Predictor variables for suicide in adolescent inpatients) 1. Previous suicide attempt (no=0, yes=1) 2. Previous suicidal ideation (no=0, yes=1) 3. Family history of suicide (no=0, yes=1) 4. Murder in family (no=0, yes=1) 5. History of aggressive behaviour (no=0 yes=1) 6. Police record (no=0, yes=1) 7. Family pathology (family history of psychiatric disease) (no=0, yes=1) 8. Early childhood psychiatric pathology (no=0, yes=1) Score=total score/8 items. Range of total score=0–8. A higher score indicates higher suicide risk.
633
Stability of diagnosis: a 20-year retrospective cohort study of Israeli psychiatric adolescent inpatients AVI VALEVSKI, GIDEON RATZONI, JONATHAN SEVER, ALAN APTER, GIL ZALSMAN, RONI SHILOH, ABRAHAM WEIZMAN AND SAM TYANO Outcome according to diagnosis and stability of diagnosis were investigated in a followback study of 351 adolescents with various psychiatric disorders hospitalized in a closed psychiatric ward. The duration of follow-back was 15–19 years. All diagnoses were based on the ICD-9. Data were collected from the Health Ministry registry and, in the patients who could be located, by structured telephone interview. Special attention was directed at the diagnosis of transient adolescent psychosis (TAP) vs. schizophrenia and prognostic indicators of suicide. The results showed that the most stable diagnosis was anxiety disorder. The stability of the different diagnoses over time was greater between the second and last admission than between the first and last (for patients with three or more admissions). Number of hospitalizations correlated negatively with prognosis. TAP at second admission was an unstable diagnosis; 66% of these patients had a final diagnosis of schizophrenia. However, patients with a diagnosis of TAP at first admission had a higher predictive index score and a higher outcome score than schizophrenic patients. TAP appeared to be a valid diagnostic entity, distinguishable from schizophrenia in course, frequency of suicidal behaviour and social-occupational outcome. Suicide victims had a higher cumulative length of stay than age- and sexmatched non-suicidal patients. Fifty per cent of the suicide victims had a final diagnosis of schizophrenia, compared to 30 per cent for the whole sample. In conclusion, these findings indicate that TAP is associated with a relatively good prognosis and should probably be differentiated from schizophrenia. Further retrospective and prospective studies of adolescent psychiatric inpatients may help delineate the nature and course of psychosis and other psychopathology in this age group. r 2001 The Association for Professionals in Services for Adolescents
Introduction A major objective of long-term follow-up studies of adolescent inpatients of psychiatric hospitals is to determine whether there is a continuity of diagnosis from adolescence to adulthood (Tyano and Apter, 1988). In this regard, any changes in the official diagnostic criteria that may have been made over the years must be considered as well (Blotcky et al., 1984; Andreason, 1987). Like other such studies (Blotcky et al., 1984), the present work is a retrospective one, based on register and file data. The outcome of a first psychotic episode is of special interest for evaluating the relationship between diagnosis and prognosis in adolescent psychopathology. Studies of heterogeneous patient groups have reported that the psychoses are associated with poor outcome. Levy (1969) found a strong correlation between severity of disease at diagnosis and patient adjustment 8–23 years later. Schain et al. (1982) reported that almost all psychotic children had required rehospitalization by the 5-year follow-up, and Davis et al. (1986) suggested that little difference exists in prognosis between personality disorders and schizophrenia. However, others have reported that more than 50 per cent of patients Reprint requests and correspondence should be addressed to A. Valevski, MD, Geha Psychiatric Hospital, P.O. Box 102, Petah Tiqva 49100, Israel. (Tel.: 972-3-925-8283; Fax: 972-3-924-1041). 0140-1971/01/050625+09 $3500/0
# 2001 The Association for Professionals in Services for Adolescents
626
A. Valevski et al.
described as neurotic or having personality disorders demonstrated a positive long-term outcome (Blotcky et al., 1984). Apparently, although the prognosis of early-onset psychosis is poor (Gillberg et al., 1993), the subclass of patients with acute remitting or transient psychosis (less than 6 months of continuous illness with acute onset) have a better outcome and may be differentiated from schizophrenics (Susser and Wanderling, 1994). These disorders are assumed to occur particularly in adolescence (Blos, 1968), while there are developmental factors pertinent to adolescence that affect the natural development and course of schizophrenia (Werry and Taylor, 1994). It has been our clinical impression that brief psychotic episodes in adolescence have a special character, different from the psychoses found in adults, and we called this entity ‘‘transient adolescent psychosis’’ (TAP) (Tyano and Apter, 1988). The diagnostic criteria for TAP are shown in Appendix A. This diagnostic entity in adolescents overlaps the Brief Reactive Psychosis (DSM-IV) or Acute and Transient Psychotic Disorder (ICD-10) in adults. Suicide resulting from psychiatric morbidity is also an important consideration in the follow-up of adolescent psychiatric inpatients (Rao et al., 1993). The rate of suicide in followup studies of depressed adolescents ranges from 1?2 to 4?4 per cent (Larsen, 1991; Rao et al., 1993). Pokorny (1983) found that the incidence of suicide in psychiatric patients aged 10–19 years to be 3 per cent. In the present retrospective cohort study, we studied the outcome of adolescent inpatients of a psychiatric hospital according to prognosis and stability of diagnosis. Special attention was directed to the prognosis of TAP vs. schizophrenia, the long-term reliability of the diagnosis of TAP, and suicide predictors.
Patients and methods The present study was conducted with a follow-back design, starting in 1993. We reviewed the records of all 351 patients consecutively admitted to the Adolescent Psychiatric Unit of Geha Hospital from 1974–1978. Data on demographic characteristics, psychiatric diagnoses, date and length of hospitalizations, and mortality were retrospectively collected from the computerized registry of the Israel Ministry of Health, where all hospitalizations in the country are recorded. The diagnoses used in the study were those assigned at admission(s) and recorded in the government records. All were based on the International Classification of Diseases, ninth revision (ICD-9). Thereafter, a major effort was made to locate the patients, and those who could be located were interviewed by telephone with a specially formulated questionnaire. The following areas were covered: family status; work history; army service; psychopathology; and quality of life. Owing to concerns about reliability of information and compliance with the interviewer, we did not collect data on drug misuse. For analysis, we calculated the Outcome Score (OS), based on 11 items (Appendix B) reflecting the social, familial and occupational functioning of the patients, and the Predictive Index Score (PIS), based on eight items (Appendix C) reflecting good outcome (both measures developed by the authors). The data for the OS were derived from the direct interview, and the data for the PIS were derived from the patient records. The OS was calculated first. Thereafter, the patient charts at first admission were reviewed by two senior psychiatrists blinded to the OS values for medical variables indicating outcome, and the PIS was calculated. Our clinical experience has shown that both the OS and PIS are sensitive
Stability of diagnosis in Israeli psychiatric adolescent inpatients
627
indicators of outcome and prediction in adolescent patients. However, no reliability or validity studies on these instruments are as yet available, and there are no valid cut-off values. In addition, using only the chart information, we calculated the Suicide Risk Index (SRI) based on nine items (Appendix D), as described by Motto et al. (1985). Stability of diagnosis was analysed only in the patients readmitted to hospital at least twice. The diagnosis made at the first admission and at the second admission was compared with the diagnosis at the last admission.
Statistical analysis Student’s t-test, Chi-square test and kappa scores were used as appropriate; a p value of 40?05 was considered significant. All results are expressed as mean 7S.D.
Results The original cohort included 178 males (50?7%) and 173 females (49?3%). Age range at first admission was 10–21 years (mean 7S.D. 16?672?04 years), and age at follow-up, 27–36 years (mean 33?272?2 years). In Israel, adolescence is defined as age 12–21 years; however, only 8?2% of our cohort was older than 19 and only 2?6% was younger than 13 at first admission. The majority of patients (83%) were born in Israel. The duration of the follow-back period ranged from 15–19 years (16?678 years). The frequencies of the different psychiatric diagnoses at first hospitalization are shown in Table 1. Schizophrenia was the most frequent diagnosis (n=82, 23?4%), followed by TAP (n=64, 18?3%). There was no statistical difference in sex distribution among the diagnostic groups. Rehospitalization was required by 65% of the whole population, and by 79 per cent of the patients with schizophrenia. For the telephone interview, 202 patients (57?5%) of the original cohort could not be located because of the long interval between their last admission and the present study. The non-compliance rate for the remaining 130 patients was 5?4 per cent (n=19), which compares favorably with rates reported in other studies (Morris et al., 1956; Schain et al., Table 1
Demographic data by diagnostic group at first hospitalization
Whole group* Schizophrenia Transient adolescent psychosis (TAP) Personality disorders Affective disorders Anxiety disorders Organic brain syndrome Others *Missing data on 41 patients.
No. of patients (%)
M (%)
F (%)
Age (mean7S.D.)
351 (100%) 82 (23?4%) 64 (18?3%)
178 (50?7) 42 (1?2) 36 (56?3)
173 (49?3) 40 (48?8) 28 (43?8)
16?6172?04 17?072?18 16?871?91
55 (15?7%)
30 (54?5)
25 (45?5)
16?2971.85
11 37 20 82
8 (72?7) 18 (48?6) 6 (30) 39 (47?5)
3 (27?3) 19 (51?4) 14 (70) 43 (52?5)
16?0972?16 15?871?72 16?8572?73 16?5672?06
(3?1%) (10?5%) (5?7%) (23?6%)
A. Valevski et al.
628
1982). There was no difference between the located and non-located patients in sex ratio, distribution of diagnoses or number of hospitalizations. Mean age of the located patients at follow-up was 33?872?1 years. The OS was calculated only in the located patients who completed the telephone questionnaire (n=75). Outcome score was found to be good (0?75) in 13 patients (17?3%), moderate (0?26–0?74) in 42 (56%), and poor (o0?25) in 20 (26?7%). There was a negative correlation of OS with number of hospitalizations. The marriage rate was significantly lower for the patients with multiple psychiatric admissions compared to those with single admissions (w2=10?8, df=1, po0?05); this finding was not gender-dependent. Furthermore, the patients with multiple admissions had a significantly greater chance of rejection from the army (w2=4?05, df=1, po0?05) and served less army time. The number of admissions did not affect the rate of unemployment (w2=1?91, df=1, p=NS). When the patients with a first diagnosis of TAP were compared with those with a first diagnosis of schizophrenia, the OS was found to clearly differentiate between the groups (schizophrenia vs. TAP: 0?1570?13 vs. 0?570?18, df=37, t=3?29, po0?05). The TAP patients had fewer hospitalizations than the schizophrenic patients (df=1, t=ÿ3?4, p=0?01), shorter durations of hospitalization throughout the entire follow-up period (2?872?6 vs. 5?574?2 months, df=153, t=3, po0?01), and overall, higher PIS scores (0?5570?18 vs. 0?3570?15, df=37, t=3?29, po0?05), further supporting the need to differentiate between these groups. The findings for stability of diagnosis for the whole cohort are shown in Table 2. The stability of the different diagnoses over time was greater between the second and last admissions than between the first and last admissions. The most stable diagnosis was anxiety disorder, followed by personality disorder. TAP was an unstable diagnosis when made on the second hospitalization. According to the records, 16 of the 64 patients with a diagnosis of TAP on first admission (25%) did not have a repeated admission. Of the 48 remaining patients, TAP was retained as the diagnosis in only 16 (33%), and the others were later diagnosed as having schizophrenia. Of the total cohort, 14 patients (3?9%) died from suicide. The mean interval between the onset of illness and suicide was 0?774?7 years, and the majority of the patients (10 of 14) died during the first year after the last hospitalization. Their demographic data are given in Table 3. When matched for age and sex with 20 control patients from the original sample, no
Table 2
Stability of diagnoses over 15 years in hospitalized adolescents
Diagnosis
Schizophrenia Personality disorders Affective disorders Anxiety disorders Organic brain syndrome Transient adolescent psychosis (TAP) Others
Kappa between the second and last admission
Kappa between the first and last admission
0?57 0?66 0?27 0?79 0?52 0?25
0?18 0?19 ÿ0?02 0?06 ÿ0?03 0?05
0?35
0?09
Stability of diagnosis in Israeli psychiatric adolescent inpatients
Table 3
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Demographic data of suicide group Sex M
Age at first admission (years)
No. of hospitalizations
F
Length of hospitalizations (weeks) First
Committed 9 5 17?1472?03 suicide 168 169 16?572?04 Nonsuicidal patients p NS NS
Second
Last
5?775?4
13?4711?6
20?8719.1
20.09721?9
3?974?3
16?8719?2
20?2721?2
14?6725?8
NS
NS
NS
NS
Table 4
Diagnostic data of suicide group (ICD-9 criteria)
Sex
Age at No. of first hospitaliadmission zations
Diagnosis First
Second
Last
Observation for mental disorder OBS Anxiety disorder Conduct disorder
Observation for mental disorder Schizophrenia ? Antisocial personality disorder OBS Personality disorder Schizophrenia Adjustment disorder Schizophrenia Schizophrenia Emotional disturbance of adolescents Schizophrenia Schizophrenia Schizophrenia
M
18
2
TAP
F M M
20 19 17
4 16 2
OBS ? Drug dependence
M M M F M F M
19 15 16 18 18 16 14
3 4 1 1 12 6 1
M F M
16 14 20
13 14 2
OBS Anxiety disorder Schizophrenia Adjustment disorder TAP TAP Emotional disturbance of adolescents TAP Bipolar disorder Observation for mental disorder
OBS Anxiety disorder Schizophrenia ? Schizophrenia ? ? Schizophrenia Schizophrenia Schizophrenia
?, diagnosis differed; OBS, organic brain syndrome; TAP, transient adolescent psychosis.
difference was found in sex ratio, age at first admission, number of hospitalizations, and length of first and second hospitalizations. As expected, the suicidal patients exhibited higher SRI scores as compared to age- and sex-matched nonsuicidal patients (0?4970?14 vs. 0?3370?06, t=4?5, df=32, po0?0001). Suicide victims were not hospitalized more frequently than those who did not attempt suicide, but their cumulative length of stay tended to be greater (126?07161?8 vs. 76?67117?6 weeks, t=1?50, df=349, po0?1, NS). Fifty percent of the suicide victims had a final diagnosis of schizophrenia, which was higher than the rate of schizophrenia for the whole sample (30%) at the last admission (Table 4).
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A. Valevski et al.
Discussion Many of the classic theories of adolescent psychopathology, such as those of Blos (1968) and Nicholi (1969), propose that a psychiatric diagnosis should not be made during the adolescent period of stormy development. Specific terms have been suggested to describe the clinical manifestations of stress during adolescence, for example, ‘‘adolescent turmoil’’ and ‘‘identity disturbances’’. Other authors (Masterson, 1967; Offer et al., 1970), however, have advocated the use of descriptive classifications (DSM and ICD) and adult criteria also for adolescents. The application of standardized criteria is important for long-term follow-up and followback studies. Hollis (2000) reported that the prognosis of patients labelled adolescent-onset schizophrenic disorder is associated with malignant course and outcome. Zeitlin (1990) has shown that 80 per cent have more than one hospital admission and 50 per cent more than four. In our cohort, the rate of readmission of the schizophrenic patients was even higher. Interestingly, in our study, all diagnoses made at the second admission were more reliable than those made at the first. This may be at least partly explained by the reluctance of clinicians faced with a young patient to give a final diagnosis of a mental disorder that is associated with a bad prognosis. Many prefer to avoid misdiagnosis until residual or negative symptoms are noted (Loffler et al., 1994). Sixty-five percent of the patients had more than one admission. Studies of prognosis in adolescent psychiatric patients are surprisingly scarce (McClellan et al., 1993), and many issues of adolescent psychosis remain unresolved. In this study we focused on the concept of TAP (Tyano and Apter, 1988), which we suggest is an appropriate diagnostic category for adolescents with acute remitting psychoses that are not due to affective disorders (themselves a critical areas of uncertainty in psychiatric diagnosis) (Susser and Wanderling, 1994). However, the possibility that the TAP group included patients with affective disorders and/or borderline personality disorder (Angold, 1988) cannot be completely ruled out and is, indeed, supported by the low incidence of aggressive disorders in our cohort and the good prognosis of the TAP patients. Since our data are insufficient to provide a definitive answer to this question, it seems reasonable at present to regard TAP as a subtype of non-affective psychotic disorder. The relatively good outcome of the TAP patients is in agreement with the finding of Garralda (1984) that psychotic symptoms such as hallucinations do not necessarily predict a bad prognosis. Susser and Wanderling (1994) reported a ratio of 18 : 82 between nonaffective remitting psychosis (NARP) and schizophrenia in adults. This is comparable to our ratio of 16 : 106 for TAP vs. schizophrenia at the second admission. NARP is considered to be a separate entity or a valid subcategory of schizophrenia in adults. Based on our findings using the OS and the PIS, we suggest that TAP is different from schizophrenia. Interestingly, since NARP is more frequent in non-Western settings, it may be influenced by environmental factors, such as adolescent ‘‘subculture’’. It is of note that the fatal suicide patients exhibited higher SRI scores than their matched controls. From a clinical point of view, this study indicates that the variables included in the SRI can be used as predictors for suicidal behaviour in adolescent psychotic patients. The contribution of each item of the SRI could not be analysed due to the small number of suicide victims (n=14). Our data indicate that the PIS, which is based on clinical and diagnostic parameters, succeeded in discriminating between suicidal and non-suicidal patients.
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This study had several important limitations, including its retrospective case-note nature, small sample size, lack of validity/reliability studies for the instruments, number of patients who could not be located, and high non-compliance rate of those who were. In conclusion, TAP may well be a valid diagnostic entity, differing in course and outcome from schizophrenia and affective disorders. The relatively small number of patients in this study for whom we had complete information on prognosis limits our conclusions regarding the validity of TAP, and further studies are needed to evaluate prognosis and suicidal risk in first-onset psychotic adolescents. These results support the notion that a substantial proportion of adolescent psychotic patients do not develop a schizophrenic disorder, and the diagnosis of schizophrenia should be limited in this age group to clear-cut cases only.
Acknowledgements We would like to thank Mrs M. Poper, Director, Department of Information and Evaluation, Mental Health Services Israel, Israel Ministry of Health, for her assistance in the collection of the computerized data, and Gloria Ginzach for her editorial assistance. The study was supported by a grant from the Chief Scientist, Israel Ministry of Health.
References Andreason, N. C. (1987). The diagnosis of schizophrenia. Schizophrenia Bulletin, 13, 25–38. Angold, A. (1988). Childhood and adolescent depression I. Epidemiological and aetiological aspects. British Journal of Psychiatry, 152, 601–617. Blos, P. (1968). Character formation in adolescence. Psychoanalytic Study of the Child, 23, 245–283. Blotcky, M. J., Dimperio, T. L. and Gossett, J. T. (1984). Follow-up of children treated in psychiatric hospitals: a review of studies. American Journal of Psychiatry, 141, 1499–1507. Davis, A., Ryan, R. and Salvatore, P. (1986). Effectiveness of residential treatment for psychotic and other disturbed children. American Journal of Orthopsychiatry, 38, 469–475. Garralda, M. E. (1984). Hallucinations in children with conduct and emotional disorders: II The follow-up study. Psychological Medicine, 14, 597–604. Gillberg, I. C., Hellgren, L. and Gillberg, C. (1993). Psychotic disorders in adolescence. Outcome at age 30 years. Journal of Child Psychology Psychiatry, 34, 1173–1185. Hollis, C. (2000). Adult outcomes of child- and adolescent-onset schizophrenia: diagnostic stability and predictive validity. American Journal of Psychiatry, 157, 1652–1659. Larsen, F. W. (1991). Thirty year follow-up study of a child psychiatric clientele. Acta Psychiatrica Scandinavica, 84, 65–71. Levy, E. Z. (1969). Long-term follow-up of former inpatients at the Children’s Hospital of the Menninger Clinic. American Journal of Psychiatry, 125, 1633–1639. Loffler, W., Hafner, H., Fatkenheuer, B., Maurer, K., Riecher Rossler, A. and Lutzhoft, J. (1994). Validation of Danish case register diagnosis for schizophrenia. Acta Psychiatrica Scandinavica, 90, 196–203. Masterson, J. F. (1967). The Psychiatric Dilemma of Adolescence. Boston: Little, Brown. McClellan, J. M., Werry, J. S. and Ham, M. A. (1993). Follow-up study of early onset psychosis: comparison between outcome diagnoses of schizophrenia, mood disorders, and personality disorders. Journal of Autism & Developmental Disorders, 23, 243–262. Motto, J. A., Heilborn, D. C. and Juster, R. P. (1985). Development of clinical instruments to estimate suicide risk. American Journal of Psychiatry, 142, 680–686. Morris, H. H., Escoll, P. J. and Wexler, R. (1956). Aggressive behavior disorders in childhood: a followup study. American Journal of Psychiatry, 112, 991–997.
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Nicholi, A. M. (1969). Harvard dropouts: some psychiatric findings. American Journal of Psychiatry, 126, 417. Offer, D., Marcus, D. and Offer, J. L. (1970). A longitudinal study of normal adolescent boys. American Journal of Psychiatry, 126, 917–924. Pokorny, A. D. (1983). Prediction of suicide in psychiatric patients. Archives of General Psychiatry, 40, 249–257. Rao, U., Weissman, M. M., Marin, J. A. and Hammond, R. W. (1993). Childhood depression and risk of suicide: a preliminary report of a longitudinal study. Journal of the American Academy of Child & Adolescent Psychiatry, 32, 21–27. Schain, R. J., Gardella, D. and Pon, J. (1982). Five year outcome of children admitted to a state hospital. Hospital Community Psychiatry, 33, 847–848. Susser, E. and Wanderling, J. (1994). Epidemiology of nonaffective acute remitting psychosis vs. schizophrenia. Archives of General Psychiatry, 51, 294–301. Tyano, S. and Apter, A. (1988). Adolescent psychosis and eight-year follow-up. In A. Z. Schwartzberg (Ed.). International Annals of Adolescent Psychiatry. Chicago: The University of Chicago Press, pp. 317–324. Werry, T. S. and Taylor, E. (1994) Schizophrenic and allied disorders. In M. Rutter, E. Talyor and L. Hersov (Eds). Child and Adolescent Psychiatry: modern Approaches, 3rd edition. Oxford: Blackwell Scientific Publications, pp. 594–615. Zeitlin, H. (1990). Current interests in child-adult psychopathological continuities. Journal of Child Psychology & Psychiatry, 31, 671–679.
Appendix A Diagnostic criteria for Transient Adolescent Psychosis (TAP) 1. Acute onset of delusions or hallucinations. Interval between the first appearance of any psychotic symptoms and the presentation of the fully developed disorder does not exceed 2 weeks. 2. Positive signs, such as hallucinations and delusions, with themes relating to adolescent development (for example, sexual identity). 3. Lack of negative signs, such as blunting of affect, apathy, poverty of speech. 4. No early childhood pathology, such as developmental cognitive impairment and/or attention deficit disorder. 5. Lack of bizarre items (outside of usual human cultural experience) in hallucinations and delusions.
Appendix B Outcome Score (OS) (Clinical outcome variables in adolescent inpatients: social, familial, occupational) 1. 2. 3. 4. 5.
Quality of life (unsatisfactory=0, satisfactory=1) Family status (unmarried=0, married=1) Military health profile (low=0, moderate/high=1) Military service (no=0, yes=1) Military reserve service (no=0, yes=1)
Stability of diagnosis in Israeli psychiatric adolescent inpatients
6. 7. 8. 9. 10. 11.
Work status (unemployed=0, employed=1) Schooling (o8 years=0, 48 years=1) Continuous psychiatric treatment (yes=0, no=1) Leisure activities (no=0, yes=1) Social adjustment (no social interaction=0, engages in social activity=1) Friends (no or only one friend=0, more than 1 friend=1)
Score=total score/11 items. Range of total score=0–11. A higher score indicates better outcome.
Appendix C Predictive Index Score (PIS) (Predictor variables for prognosis in adolescent inpatients: medical) 1. 2. 3. 4. 5. 6. 7. 8.
Time to hospitalization (3 weeks=0, o3 weeks=1) Positive signs (no=0, yes=1) Negative signs (yes=0, no=1) Early childhood pathology (yes=0, no=1) Content of thought characteristic of the usual adolescent world (no=0, yes=1) Bizarre thoughts (yes=0, no=1) Antipsychotic treatment (yes=0, no=1) Family history of psychiatric illness (yes=0, no=1)
Score=total score/8 items. Range of total score=0–8. A higher score indicates better prognosis.
Appendix D Suicide Risk Index (SRI) (Predictor variables for suicide in adolescent inpatients) 1. Previous suicide attempt (no=0, yes=1) 2. Previous suicidal ideation (no=0, yes=1) 3. Family history of suicide (no=0, yes=1) 4. Murder in family (no=0, yes=1) 5. History of aggressive behaviour (no=0 yes=1) 6. Police record (no=0, yes=1) 7. Family pathology (family history of psychiatric disease) (no=0, yes=1) 8. Early childhood psychiatric pathology (no=0, yes=1) Score=total score/8 items. Range of total score=0–8. A higher score indicates higher suicide risk.
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