Validity of a short clinical interview for psychiatric diagnosis: the mini-SCAN.

BACKGROUND: To promote clinical application of the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) system a shorter version (the mini-SCAN) was devised. Its psychometric properties were unknown. AIMS: To establish the validity and practical properties of the mini-SCAN. METHOD: One hundred and six participants were interviewed twice, once with the SCAN and once with the mini-SCAN. The level of agreement was established for the categories: no disorder, affective disorders, anxiety disorders, non-affective psychotic disorders, affective psychotic disorders. RESULTS: The mini-SCAN is a valid instrument. Most kappa values were around 0.90. Only for the class of affective psychotic disorders was the agreement moderate. Mean duration of the mini-SCAN interviews was 25 min shorter than the SCAN interviews. Participants and interviewers were generally satisfied with the interview format and questions. CONCLUSIONS: The mini-SCAN can be used as a diagnostic instrument for clinical purposes and for clinical studies when the present episode is the focus of attention.

Economic consequences of alternative medication strategies in first episode non-affective psychosis.

BACKGROUND: Maintenance treatment appears to be successful in preventing relapses in first episode psychosis, but is also associated with side effects. Guided discontinuation strategy is a less intrusive intervention, but may lead to more relapses. In the current economic evaluation, costs and health outcomes of discontinuation strategy will be compared with the results of maintenance treatment in patients with remitted first episode psychosis. METHOD: The study was designed as a randomised clinical trial. In total 128 patients were prospectively followed for 18 months after six months of stable remission. The economic evaluation was conducted from a societal perspective. Quality-adjusted life years (QALYs) were used as primary health outcome in the economic evaluation. Relapse rates were assessed in addition to various other secondary outcomes. RESULTS: There were no relevant differences in mean costs between groups during the study. Total costs were largely influenced by costs related to admissions to psychiatric hospitals. No differences between groups were found for QALY results. CONCLUSIONS: There were no indications that either of the examined interventions is superior to the other in terms of costs or QALY results. Additional results indicated that the relapse rate in discontinuation strategy was twice as high, but without an increase in hospital admissions or negative consequences on other clinical outcomes. For a minority of remitted first episode patients, guided discontinuation strategy may offer a feasible alternative to maintenance treatment.

Treatment delay and response rate in first episode psychosis.

OBJECTIVE: There is no consistent evidence of long duration of untreated psychosis (DUP) predicting long time to response (TTR) in first psychosis. This study aims to investigate the predictors of DUP and TTR in a first episode patient population. METHOD: An epidemiologically representative sample of 157 non-affective first psychotic episode patients was interviewed and followed-up for at least half a year. RESULTS: The mean DUP was 46 weeks, the median 31 days. Long DUP was associated with being unemployed before treatment and male gender. Short DUP, having a job, and living with a partner before treatment predicted early response. CONCLUSION: Early intervention likely improves short-term treatment response in first episode psychosis. The best strategy to reduce DUP probably is to direct attention to the substantial number of patients who do not engage in regular treatment.

Hallucination focused integrative treatment improves quality of life in schizophrenia patients.

OBJECTIVE: Psychosocial treatment seems to be effective in the management of schizophrenia, although less in the area of quality of life and social functioning. To study the effectiveness of a hallucination focused integrated treatment with cognitive-behaviour therapy and coping training among schizophrenia patients suffering from 'hearing voices'. METHOD: In a randomized controlled trial (RCT) with 31 patients in the integrated treatment condition and 32 patients in the routine care condition, quality of life was assessed with the self-report questionnaire of the WHO (Bref), and social role functioning with an interviewer based schedule, at entry and 9 (post-treatment) and 18 months later. RESULTS: Follow-up data suggest a significant improvement of quality of life and in particular in social role functioning (effect size 0.64) in favour of the integrated treatment. CONCLUSION: The integrated treatment seems to be effective in reducing overall disability levels and number of patients with serious disabilities.

Cost-effectiveness of the HIT programme in patients with schizophrenia and persistent auditory hallucinations.

OBJECTIVE: To examine the cost-effectiveness of Hallucination focused Integrative Treatment (HIT) in patients with schizophrenia and a history of persistent auditory hallucinations. METHOD: Costs, in and outside the health care sector, and outcomes were registered prospectively during a period of 18 months for patients who received the HIT programme and for patients in the care as usual (CAU) condition. The Positive and Negative Syndrome Scale (PANSS) was used as main outcome measure in the cost-effectiveness analysis. Bootstrap analyses provided additional information on the skewly distributed costs. RESULTS: Mean costs per patient in the HIT group (18,237 dollars) were lower than the mean costs per patient in the CAU group (21,436 dollars). Results of the PANSS were slightly in favour of the HIT group. CONCLUSION: There appears to be no significant cost-effectiveness advantage of the HIT programme over CAU. Additional analyses indicated that future application of the HIT programme will, in most cases, lead to a reduction of (non) medical costs.

Cognitive behaviour therapy with coping training for persistent auditory hallucinations in schizophrenia: a naturalistic follow-up study of the durability of effects.

OBJECTIVE: To investigate the durability of positive effects of cognitive behaviour therapy (CBT) with coping training on psychotic symptoms and social functioning. METHOD: Forty patients with schizophrenia or related psychotic disorders and refractory auditory hallucinations were given CBT and coping training in an integrated single family treatment programme. In a naturalistic study patients were followed after 2 and 4 years since the start of treatment. RESULTS: The treatment improved overall burden of 'hearing voices', with a generalization into daily functioning. Improvement with regard to fear, loss of control, disturbance of thought and interference with thinking was sustained by 60% of the patients while one-third improved further. Complete disappearance of hallucinations occurred in 18% of the patients. CONCLUSION: CBT with coping training can improve both overall symptomatology and quality of life, even over longer periods of time, but a status of persistent disablement indicates a continuing need for mental health care.

Psychometric properties of the schedules for clinical assessment in neuropsychiatry (SCAN-2.1).

BACKGROUND: The Schedules for Clinical Assessment in Neuropsychiatry (SCAN), the successor of the ninth version of the Present State Examination (PSE-9), is one of the latest instruments developed by the World Health Organisation for the assessment of psychiatric disorders. So far, the psychometric properties have only been established for certain sections of the instrument. The present study is the first to test the psychometric properties of SCAN-2.1 for most of the disorders covered by the SCAN, and was carried out prior to a survey conducted in the Nijmegen Health Area (the Netherlands). METHODS: Interviewers were psychology graduates with little clinical experience. Two designs were used. In one design, pairs of independent live interviews with the same respondent were compared (test-retest situation). In the other, ten videotaped interviews by experts were rated by each of the interviewers (standardized situation), and the outcomes were compared with those of the other interviewers as well as with a reference score. RESULTS: In the test-retest situation the kappa coefficient for diagnostic caseness was qualified as substantial (0.62) and for diagnostic categories and diagnostic groups as moderate to good (0.24 to 0.64). In the standardized situation using videotaped interviews by experts, sensitivity as well as specificity proved to be substantial to almost perfect. The agreement per interviewer with regard to the reference diagnoses ranged from 87% (diagnostic group) to 94% (diagnostic caseness). Agreement on the syndrome level (without duration and interference criteria of DSM-IV) was excellent. CONCLUSIONS: Although the instrument is traditionally used by experienced clinicians, this study shows that less experienced (but well trained) interviewers can apply SCAN reliably. Special attention should be paid to the items without explicit interview questions, as they tend to be more sensitive to neglect than the items with interview questions.

Social disability in schizophrenia: its development and prediction over 15 years in incidence cohorts in six European centres.

BACKGROUND: This paper focuses on the long-term course of social disability in schizophrenia assessed at first onset, and after 1, 2 and 15 years in incidence cohorts in six European centres in Bulgaria, Germany, Ireland, The Netherlands, the Czech Republic and the United Kingdom. The study population comprises 349 patients comprising 75% of the original cohorts. METHODS: Social disability was assessed in a standardized way with the WHO Disability Assessment Schedule. RESULTS: Social disability in schizophrenia appears to be a persistent phenomenon. Its severity decreased overall in the period of follow-up, but this was not so in a small group traced to hospital or sheltered accommodation. Only 17% of subjects had no disability and 24% still suffered from severe disability. The great majority lived with their family, a partner, or alone. A deteriorating course was more frequent than late improvement. Gender, age, onset, duration of untreated psychosis or type of remission during the first 2 years did not predict the long-term outcome of disability. Severity of disability at the first three assessments of the illness contributed significantly to the explanation of its variance at 15 years. CONCLUSION: Disability generally ameliorates, but less than expected or hoped. It needs continuing attention and care in this era of de-institutionalization.

Stability and change in needs of patients with schizophrenic disorders: a 15- and 17-year follow-up from first onset of psychosis, and a comparison between 'objective' and 'subjective' assessments of needs for care.

Need for care was studied in a Dutch incidence cohort of patients with schizophrenic disorders 15 and 17 years from first onset of psychosis. Long-term course of the disorders varied from complete remission and full community participation to chronic psychosis and long-term hospital stay. Fifty patients were assessed twice with the Needs For Care Assessment Schedule (NFCAS, Brewin and Wing 1989); at the latter follow-up an assessment was also made using the Camberwell Assessment of Need (CAN, Phelan et al. 1995). The NFCAS is an investigator- or professional-based instrument which provides an 'objective' assessment of needs. Need for care was recorded in 22 areas of clinical and social functioning. Comparison of the two assessments over a 2-year period demonstrated a high stability on the individual items (mean 88%, mostly concerning the absence of a problem twice), but did not show the expected stability of need status among this group of patients with chronic disorders. One in five patients (22%) had no needs at all on both occasions and 56% of the patients showed a change in needs. There was more negative than positive change: 28% suffered from new unmet needs at the 17-year follow-up, while only 12% had improved their status to no needs. About one-third (36%) had at least one unmet need, mostly regarding psychotic symptoms, dyskinesia or underactivity. The CAN provides a 'subjective' assessment of needs according to the view of patients themselves. The problems patients reported most commonly were in the areas of day-time activities, social relationships and information on their condition and treatment, for all which they asked for more help than they received. This patient-based instrument produces slightly higher numbers of problems and unmet needs, and a lower ratio between met and unmet needs. There is an overall percentage of 21% of disagreement between patient and investigator view regarding the unmet need status. Agreement between the two instruments on the nature of the problems with unmet needs was lacking altogether.

Natural course of schizophrenic disorders: a 15-year followup of a Dutch incidence cohort.

Data are presented on the 15-year natural course of schizophrenia and other nonaffective functional psychoses in a cohort of 82 first-contact cases from a circumscribed area in the Netherlands. The subjects were suffering from functional psychosis with International Classification of Diseases-Ninth Revision (ICD-9) diagnoses 295, 297, or 298.3-9 (broad definition of schizophrenia) on entry. Standardized assessments of psychopathology, psychological impairments, negative symptomatology, social disability, and use of mental healthcare were used. The study reveals a pattern of chronicity and relapses with a high risk of suicide: Two-thirds of the subjects had at least one relapse and after each relapse 1 of 6 subjects did not remit from the episode; 1 of 10 committed suicide; and 1 of 7 had at least one episode with affective psychotic symptoms that started on average 6 years after the onset of the schizophrenic disorder. Diagnoses were reclassified in five patients, according to DSM-III-R criteria for a bipolar disorder. The predictive power--in terms of time in psychosis and in partial or full remission--of demographic, illness, and treatment variables at onset of the illness was very limited. Insidious onset and delays in mental health treatment are risk factors that predict a longer duration of first or subsequent episodes. The importance of mental health treatment in regard to outcome is probably subject to change because an early warning and intervention strategy could prevent further damage and deterioration. Our data support the need for an adequate relapse prevention program as a priority for our mental health services.