Differences between patients with schizophrenia within and without a high security psychiatric hospital.

OBJECTIVE: To report and discuss differences between schizophrenic patients in the community and those in maximum security care. METHOD: Comparison of 193 community schizophrenic patients with 169 in high security care. Data included case notes, interviews and cognitive tests. RESULTS: Compared to high security patients, community patients tended to be female and married. They had higher school achievement, higher premorbid IQ and better occupational levels, were less likely to have a family history of alcohol abuse, to have had police contact and to have attempted suicide. They had more frequent shorter psychiatric admissions and fewer current and lifetime schizophrenic symptoms. Logistic regression models discriminated the groups with considerable accuracy. CONCLUSION: Patients needing high security care may be recognizable when schizophrenia is first diagnosed. Progression to the State Hospital seems to result from schizophrenia together with other factors such as deprivation rather than from a worse schizophrenic process per se.

Service provision for people with schizophrenia. I. Clinical and economic perspective.

BACKGROUND: The aim of this study was to provide information on patients current service use which could inform future decisions on service planning and resource allocation. METHOD: Individuals with a diagnosis of schizophrenia, who had received in-patient care in the previous five years, were identified from the Lothian Case Register. Information was obtained from 193 subjects. Patients' service use over a six-month period was examined. The costs incurred in service provision were determined. RESULTS: Patients differed markedly in their use of services. This was not found to be related to their mental state. Average care costs were high. In-patient care accounted for most of the overall expenditure. CONCLUSIONS: There is considerable variation in the services used by patients with schizophrenia and in the costs incurred in service provision. When planning services it is therefore important that detailed information on the patient population is available if resources are to be allocated cost-effectively.

Service provision for people with schizophrenia. II. Role of the general practitioner.

BACKGROUND: This second report of a study of service provision for patients with schizophrenia describes patients' contact with general practice and general practitioners' (GPs') views of the mental health services. METHOD: A postal questionnaire was sent to the GPs, and patients' primary care records were examined. RESULTS: Data were collected on 131 subjects. The majority of patients (96) (73%) were in regular contact with their GP and were consulting for many different reasons; 27 (21%) were posing particular difficulties for the primary care team. GPs reported that 27 (21%) patients required additional support and that the care arrangements for 50 (38%) patients could be improved if alterations were made to the roles of the professionals already involved. CONCLUSIONS: GPs are central to service provision for patients with schizophrenia. Both additional resources and changes in working practices are required to improve patient care. The service implications of these findings are discussed.

Determinants of the extremes of outcome in schizophrenia.

BACKGROUND: Although poor prognosis has been considered a defining characteristic of schizophrenia, long-term studies show marked heterogeneity of outcome. METHOD: Assessments of positive and negative symptoms, premorbid and current IQ, and months of in-patient care made in an outcome study of 342 schizophrenic patients were categorised by severity. Determinants of these categorisations were sought from the historical variables available, using analysis of variance. Vignettes of patients with the best and worst symptomatic outcomes were then compared. RESULTS: Negative symptoms were associated with early onset, male sex and poor academic record. Positive symptoms were associated with occupational decline. Cognitive decline was associated with occupational variables, and in-patient care with academic and occupational variables. The vignettes showed that good outcome was associated with family psychiatric history and poor outcome with unavailability of family history. CONCLUSIONS: The findings support the view that the most malignant form of schizophrenia is neurodevelopmental, but poor outcome was clearly associated with family fragmentation.