The characteristics and outcomes of hospitalised and outpatient-treated first-onset schizophrenia patients: a 5-year register linkage study.

AIM: We compared the course and outcome of schizophrenia in two groups: (i) hospitalised patients (HP) (n = 5980) who were identified based on their first hospital admission for schizophrenia and (ii) outpatient-treated patients (OTP) who received disability pension because of schizophrenia but who had no hospital admissions for schizophrenia or other psychotic disorder before having been granted a disability pension for schizophrenia (n = 1220). Outcomes were compared using data on mortality, psychiatric hospital utilisation, relapse rate and occupational functioning. METHODS: A nationwide register-based 5-year follow-up study of all first-onset schizophrenia cases between 1998 and 2003 in Finland. The data were linked with the register information of hospital admissions, disability pensions and National Causes of Death Registers. RESULTS: When outcome of treatment was evaluated using mortality rate, relapses, hospital treatment and involuntary admissions as outcome measures, results indicated that OTP group had got along better with their illnesses than HP group. The mortality rates, number of psychiatric treatment days and relapse rate during the 5-year follow up were significantly lower in OTP group. Within the OTP group, there was a notable subgroup of never HP (n = 737, 60.4%), who did not require any psychiatric hospitalisation during the 5-year follow up. CONCLUSIONS: Patients first identified as outpatients had better outcomes than patients first identified following a hospitalisation. Future studies are required to establish whether outpatient treatment is associated with more favourable prognosis, even after fully adjusting for severity of initial symptoms. The higher suicide mortality of hospital-treated patients suggests that hospital treatment of first-onset patients does not protect from suicide.

Thought Disorder Index: a longitudinal study of severity levels and schizophrenia factors.

BACKGROUND: Thought disturbances are commonly associated with psychiatric disorders, especially schizophrenia. Our aim was to clarify whether thought disorders are only stable at certain severity levels and in the presence of certain schizophrenia factors of the Thought Disorder Index (TDI) scale. Furthermore, we also examined the significance of genetic status and the psychiatric disorder for the persistence of TDI severity levels and factors. METHODS: The thought disorders of 158 adoptees genetically at high-risk or low-risk for schizophrenia participating the Finnish Adoptive Family Study of Schizophrenia were evaluated twice at a mean interval of 11 years. Thought Disorder Index (TDI) was used to assess the severity levels and schizophrenia factors. TDI identifies 23 different items of thinking disturbances, which are weighted along a continuum of severity. RESULTS: Thought disorders at the 0.50 and 0.75 severity levels and idiosyncratic verbalization indicative of the schizophrenia factors turned out to be stable phenomena throughout the follow-up period. The adoptees' genetic or psychiatric status was not associated with the results. CONCLUSIONS: The study shows that the stability of TDI seems to be related to the most severe categories of thought disorders. However, of the specific schizophrenia factors, idiosyncratic verbalization, but not confusion and fluid thinking, showed stability over time. Although idiosyncratic verbalization does not necessarily represent the most severe type of thought disturbance, it turned out relatively stable and we can speculate that idiosyncratic verbalization have some predictive value, too.

Stability of Thought Disorder Index among high-risk and low-risk adoptees in the Finnish adoptive family study of schizophrenia.

The aim of the study was to evaluate whether thought disorders are stable, trait-like features specific to subjects who have a genetic liability to schizophrenia or a psychiatric disorder. The thought disorders of adoptees genetically at high risk (HR) or low risk (LR) for schizophrenia from the Finnish adoptive family study of schizophrenia were evaluated twice at a mean interval of 11 years, using the sum of the Thought Disorder Index (TDI) scores on the Rorschach (TD(R)). At the initial assessment, the mean TD(R) scores of women were significantly higher than those of men, while no association between genetic risk and psychiatric status or their interactions with the TD(R) scores at baseline were found. The main finding was that the initial TD(R) scores statistically significantly predicted the TD(R) scores at follow-up, thus indicating the stability of thought disorder over time. However, neither genetic or psychiatric status nor gender or any interaction between these variables associated with TD(R) at follow-up.

Sex differences in the contact rates and utilization of psychiatric services. A three-year follow-up study in northern Finland.

Sex differences in the use of psychiatric services were studied in the Oulu University Central Hospital in Finland during a three-year follow-up. A one-year treated incidence cohort of new patients was used. The total cohort comprised 537 patients (46.7% were males). The annual incidence rate was 6.7 per 1,000 members of the adult population for both males and females. Compared to females, males were younger, more often unemployed, unmarried and lived alone or with parents, and did not as often have an apartment of their own. Males predominated among organic psychoses, personality disorders and dependencies, females among neurotic disorders. Males more often had had previous inpatient care and inpatient care at index contact, and had more admissions, compulsory admissions and emergency outpatient contacts than females. However, there were no sex differences in the use of planned outpatient contacts, in the duration of hospital care and in the total consumption of psychiatric care. Male gender was an independent predictor of hospital admissions.

Finnish adoptive family study: sample selection and adoptee DSM-III-R diagnoses.

OBJECTIVE: To evaluate the genetic contribution to schizophrenia using an adoption design that disentangles genetic and environmental factors. METHOD: Finnish hospital diagnoses of schizophrenic/paranoid psychosis in a nationwide sample of adopting-away women are compared with DSM-III-R research diagnoses for these mothers. DSM-III-R diagnoses of their index offspring are blindly compared with adopted-away offspring of epidemiologically unscreened control mothers. RESULTS: Primary sampling diagnoses of index mothers were confirmed using DSM-III-R criteria. Lifetime prevalence of typical schizophrenia in 164 index adoptees was 6.7% (age-corrected morbid risk 8.1%), significantly different from 2.0% prevalence (2.3% age-corrected morbid risk) in 197 control adoptees. When adoptees with diagnoses of schizoaffective disorder, schizophreniform disorder, schizotypal disorder and affective psychoses were added, the contrast between the index and control adoptees increased. CONCLUSION: The genetic liability to 'typical' DSM-III-R schizophrenia is decisively confirmed. Additionally, the liability also extends to a broad spectrum of other psychotic and non-psychotic disorders.

Predictors for readmission risk of new patients: the Nordic Comparative Study on Sectorized Psychiatry.

OBJECTIVE: Predictors for readmission risk were investigated in this study, which forms part of the Nordic Comparative Study on Sectorized Psychiatry. METHOD: Included were a total of 837 consecutive 'new' patients (not in contact with the psychiatric services for at least 18 months) admitted to in-patient stay during a period of 1 year to seven psychiatric hospitals in four Nordic countries. RESULTS: Multivariate survival analyses showed that younger age predicted increased readmission risk. Stratifying on gender, diagnostic group and sector revealed a general pattern concerning age which was the only consistent main effect. Living alone and unemployed increased readmission risk in the non-psychosis group, while receipt of aftercare decreased readmission risk in the psychosis group. A curvilinear relationship was found between availability of psychiatric resources and readmission risk: an intermediate amount of resources was associated with increased risk. CONCLUSION: Our findings support a hypothesis that readmission risk is multifactorially determined and that interactions have to be considered.

The Nordic Comparative Study on Sectorized Psychiatry--length of in-patient stay.

OBJECTIVE: Length of stay (LOS) of 'first' in-patient episodes was investigated in this study, which is part of the Nordic Comparative Study on Sectorized Psychiatry. METHOD: A total of 837 consecutive 'new' patients (not in contact with the psychiatric services for at least 18 months) admitted as in-patients during a period of 1 year to seven psychiatric hospitals in four Nordic countries were included. RESULTS: Survival analyses showed considerable differences in LOS between the hospitals, and the factors analysed in this study could not explain this variance. Older age, being female, having no children at home, psychosis, planned admission and out-patient contacts were all associated with increased LOS. CONCLUSION: Stratifying on gender, diagnostic group and hospital revealed a general pattern of associations except for age.

The Nordic comparative study on sectorized psychiatry: rates of compulsory care and use of compulsory admissions during a 1-year follow-up.

BACKGROUND: As part of a Nordic comparative study on contact rates of new patients and use of services in seven catchment areas, rates of compulsory care and use of compulsory admissions were explored and analyzed. The total cohort comprised 2834 patients. RESULTS: A total of 219 patients, 7.7%, were subject to compulsory care during the follow-up. The proportion of compulsorily admitted patients of all admitted patients ranged from 6% to 58% in the seven psychiatric services, and the rate of compulsory care per 1,000 inhabitants, from 0.14 to 0.99. The diagnostic subgroup most commonly committed to inpatient care was functional psychosis, comprising around 50% of all compulsory admissions. The strongest predictor of being compulsorily admitted was the specific psychiatric service the patient was in contact with, followed by having a psychosis diagnosis. High consumption of care was also associated with compulsory care, while social variables played only a minor role in predicting compulsory care. CONCLUSIONS: There was a great variation in rates of compulsory care. No consistent rural-urban pattern in rates of commitment was found. It is discussed whether a formal referral procedure to the psychiatric service is associated with higher rates of compulsory care.

The Nordic Comparative Study on Sectorized Psychiatry: continuity of care related to characteristics of the psychiatric services and the patients.

The problem addressed in this paper is how continuity of care is related to characteristics of psychiatric services, previous events in a patient's pattern of care and patient characteristics. The present paper is a part of a Nordic Comparative Study on Sectorized Psychiatry in seven catchment areas in four Nordic countries. One-year-treated-incidence cohorts were used. Each patient was followed for 1 year after the first contact with the psychiatric service. Continuity of care was measured by the time from discharge from hospital to the first subsequent day-patient or outpatient contact. Notable findings were large differences in the continuity of care in the seven services, high proportions of discharges without any aftercare contacts and long time lags between discharges and aftercare contacts in most of the catchment areas. A Cox regression analysis revealed that aftercare following hospitalisation seems to be more probable if the outpatient services are located geographically close to the patients, if the hospitalisation lasted between 2 and 4 weeks, if there was a community care contact shortly before the hospital admission and if the patient is not retired and not divorced. Staff resources were not related to continuity of care.

Repeated use of psychiatric emergency out-patient services among new patients: a 3-year follow-up study.

The aim of this study was to examine repeated use of psychiatric emergency out-patient services during the second and third years after the first contact. A 1-year treated incidence cohort of 537 new patients was studied in the Department of Psychiatry in Oulu, Finland. Repeat users were defined as patients belonging to the upper 10th percentile of the emergency out-patient contacts. The median of emergency out-patient contacts among repeaters was 4. The repeaters constituted 8% of the cohort and they used 65% of the cohort's emergency contacts. They were more likely to be male and living alone, and they tended to have more serious diagnoses than non-repeaters. Having hospital admissions, planned out-patient contacts and repeated emergency out-patient contacts also during the first year of follow-up was associated with an increased probability of repeatedly using emergency services during the second and third years. Living alone and having hospital admissions during the follow-up period were associated with being a continuous repeat visitor during the whole follow-up period. It is concluded that the extended repeated use of emergency services is associated with inadequate social support and serious psychiatric problems.

The Nordic Comparative Study on Sectorized Psychiatry: patients who use only psychiatric in-patient care in comprehensive community-based services--a 1-year follow-up study.

In the present paper a sample of patients using psychiatric in-patient care only is characterized and analysed with regard to characteristics of the psychiatric services. This paper forms part of the Nordic Comparative Study on Sectorized Psychiatry, designed to investigate contact rates and use of psychiatric care by new patients in 7 catchment areas in 4 Nordic countries during a 1-year follow-up. One-year treated incidence cohorts were used. The logistic regression analysis revealed that the variable 'psychiatric service' was one of the statistically significant determinants of using only in-patient care during the follow-up. The diagnostic groups with the highest probability of using only in-patient care were dependencies and functional psychoses. The following factors were associated with a high risk of using only in-patient care: older age, being referred by another psychiatrist, having received previous psychiatric in-patient care, male sex, being retired, and not living with one's parents or a partner. Patients who used only in-patient care had fewer admissions and days in in-patient care than others during the 1-year follow-up period. Lack of 24-hour emergency services in out-patient care correlated positively with the use of only in-patient care.

The Nordic Comparative Study on Sectorized Psychiatry: contact rates and use of services for patients with a functional psychosis.

As part of a Nordic comparative study on contact rates of new patients and use of services in seven catchment areas, contact rates and use of services for patients with a functional psychosis during a 1-year follow-up period were investigated. The highest contact rates were found in two large city catchment areas in Stockholm and Copenhagen. Compared to other patients in the cohorts, patients with a functional psychosis were more often found to be unemployed and living alone. They also showed more extensive service use in terms of both voluntary and compulsory admissions, and in the use of day-care facilities. In addition, they were more often multiple users of in-patient care (> or =3 admissions during the follow-up period). Large differences in service use among patients with a functional psychosis were discovered between the catchment areas, with the most extensive use of voluntary in-patient care and day-care facilities in Frederiksberg. Patients most frequently had compulsory admissions in Bodö and least frequently had them in Frederiksberg. Out-patient services were most frequently used in Stockholm. Correlations between levels of resources and use of services for patients with a functional psychosis were in general low, except for the rates of short-term beds, which showed a strong and significant correlation with the number of days in voluntary in-patient care (r=0.89).

Factors associated with referral to psychiatric care by general practitioners compared with self-referrals.

BACKGROUND: The gatekeeper function of the general practitioner (GP) in the pathway to specialized psychiatric services was investigated in this study, which is part of the Nordic Comparative Study on Sectorized Psychiatry. The question addressed in this paper is whether different sociodemographic and clinical factors as well as factors related to service utilization are associated with referral from the GP compared with self-referrals (including referrals from relatives). METHODS: The study comprised a total of 1413 consecutive patients, admitted during 1 year to five psychiatric centres in four Nordic countries. The centres included in this study were those that accepted non-medical referrals. Only new patients (not in contact with the service for at least 18 months) were included. RESULTS: Increasing age was the only sociodemographic factor significantly associated with referral by the GP. The clinical factors (psychosis, being totally new to psychiatry and being in need of in-patient treatment) and some treatment characteristics (planned out-patient treatment and involuntary in-patient treatment), were all significantly associated with referral by the GP. Some indication was found that self-referred patients have shorter episodes of care. CONCLUSIONS: The findings were remarkably stable across the different centres indicating a general pattern. This study extends previous work on the role of GPs in the pathway to specialized psychiatric services and indicates that the GP has an important gatekeeper function for the most disabled patients.

The Nordic comparative study on sectorized psychiatry: characteristics of repeat users of emergency outpatient services in two Nordic psychiatric services. A 1-year follow-up study.

To characterise frequent use of psychiatric emergency outpatients services, this paper reports results from a prospective investigation of use of psychiatric services by new patients in two Nordic psychiatric services, Frederiksberg in Denmark and Oulu in Finland. One year treated incidence cohorts were used. Total number of patients included was 1,055. The repeat user was defined as a patient having at least three emergency outpatient contacts during a 1-year follow-up. The repeat users constituted 15.8% of the sample and 70.8% of all the emergency contacts in Frederiksberg. In Oulu the respective figures were 9.3% and 33.8%. The number of planned outpatient contacts or the number of hospital admissions of the repeat users did not differ from the non-repeaters. Repeaters in Frederiksberg were more likely to be self-referrals, male, divorced or unmarried, living with their parents, without their own housing, unemployed, aged between 25 and 44 years, and to have a diagnosis of dependency or personality disorder. In Oulu they did not differ from the other patients with regard to sociodemographic or diagnostic characteristics.

The Nordic comparative study on sectorised psychiatry: repeated emergency admissions to inpatient care during a 1-year follow-up.

The emergency admissions to hospital care in six psychiatric services in four Nordic countries were explored as a part of a Nordic comparative study on sectorised psychiatry. One year treated incidence cohorts were used, with the total cohort comprising 2,454 patients. Of the 803 patients who were admitted to inpatient care during a 1-year follow-up, 82% had at least one emergency admission and 23% repeated emergency admissions. The definition for the repeated emergency admissions was at least two admissions during the follow-up. The mean length of stay in emergency inpatient care per treatment episode for this patient subgroup was 28 days. Their emergency inpatient episodes constituted 30% of all inpatient days during the follow-up. However, the variations between the services and diagnostic subgroups were large. The results of a logistic regression analysis indicated that the following variables predicted repeated emergency admissions: inpatient care at index contact, emergency outpatient contacts or no planned hospital admissions during the follow-up, psychiatric service, age under 45 years, and a diagnosis of psychosis, personality disorder or dependency. The repeated emergency admissions were related to the existence of a special service unit for abusers but not to the rates of outpatient staff or acute beds in the services, to geographical distances, referral practice or existence of emergency services.

Utilization of psychiatric in-patient care among new patients in a comprehensive community-care system: a 3-year follow-up study.

Utilization of psychiatric in-patient care among 537 new patients was studied in the Department of Psychiatry in Oulu, Finland, during a 3-year follow-up period. Hospitalization during the second and third years of the follow-up was predicted by hospitalization and number of emergency out-patient contacts during the first year of the study, diagnosis of functional psychosis or personality disorder, and previous in-patient care. In total, 5% of the cohort fulfilled our criteria for 'revolving-door' patients. The 'revolving-door' phenomenon was associated with in-patient care at the first contact with the psychiatric services and diagnosis of psychosis or personality disorder. In total, 2% of the cohort became long-stay hospital patients, and this was predicted by psychosis diagnosis. The clinical implications of these findings are that increased attention should be paid to the first assessment of new patients and to the interaction between psychiatric services and patients during the first year of care.

The Nordic Comparative Study on Sectorized Psychiatry. Part V. Contact rates, contact patterns and care level at index contact.

As part of a Nordic comparative study on sectorized psychiatry in seven Nordic catchment areas, a prospective investigation of contact rates of new patients and pathways to the psychiatric services was performed. The results showed that there was more than a twofold difference between the services in the total contact rates. Regarding diagnostic groups, contact rates for neurosis were predominant in three of the services, while adjustment disorders, dependencies and personality disorders were predominant in other the services. The contact rate of functional psychosis, as well as the ratio of psychotic patients to the total contact rate were highest in two catchment areas serving inner parts of big cities. The most common way of getting into contact with the services was by self-referral, 39.4% of total referrals, followed by primary care referrals, although there were large differences between the services. Psychotic patients made contact with the services to a significantly less extent by self-referral. The majority of patients were treated in outpatient care at entry to the services, with a large variation between the services. It was also found that inpatient care at index contact was predicted by clinical characteristics-a diagnosis of psychosis and a history of former inpatient care-as well as by social characteristics-male, widowed or divorced, sick pension/old age pension.

The Nordic comparative study on sectorized psychiatry. Utilization of psychiatric hospital care related to amount and allocation of resources to psychiatric services.

As a part of a Nordic comparative study on sectorized psychiatry, utilization of inpatient care was related to resources and dynamic qualities of psychiatric services in seven catchment areas in four Nordic countries. One-year treated incidence cohorts were used. Each patient was followed for 1 year after first contact with the psychiatric service. Data were collected concerning number of beds and staff, number of long-term patients and turnover rate of patients in inpatient care. Findings gave some support to the earlier reports that the utilization of inpatient care is determined by the supply of available beds. Highly staffed community services did not themselves reduce the use of inpatient services, but availability of day care services seemed to reduce utilization of inpatient care among psychotic patients.

The Nordic Comparative Study on Sectorized Psychiatry. III. Accessibility of psychiatric services, degree of urbanization and treated incidence.

As part of a Nordic Comparative Study on Sectorized Psychiatry, accessibility of psychiatric services and degree of urbanization in seven catchment areas were related to treated incidence. One-year treated incidence cohorts were used. Accessibility was assessed according to referral practice, existence of a round the clock emergency service and geographical location of the services. Accessibility was surprisingly weakly associated with treated incidence. Easy access to the psychiatric services was not related to a high treated incidence of less severe psychiatric problems at the expense of patients suffering from severe illness. Geographical distance to the services did not predict the demand for services. A positive correlation was found between the degree of urbanization and treated incidence of psychoses but not of other diagnostic groups.