Glasgow's community care programme: 10 year follow up of discharged patients with schizophrenia.

In 1986, the rehabilitation of every long stay psychiatric patient in Glasgow was assessed with a view to reducing bed numbers and developing comprehensive community services. Ten years on, we have attempted to trace 91 patients with a diagnosis of schizophrenia assessed at Gartnavel Hospital, in order to repeat assessments of their psychopathology and levels of functioning. We believe this population represents a unique group in terms of their age, length of hospital stay and chronicity of symptoms. Only two patients were untraced but 36% of the original 91 patients were decreased. Discharge to the community and variations in standards of care appeared to have little impact on the symptomatic presentation of the survivors over ten years. The results provide useful information on the success or otherwise of a large scale discharge and community care programme which is continuing in Scotland.

The experiential impact of head injury on adolescents: individual perspectives on long-term outcome.

Thirty-one young people, who were experiencing chronic sequelae of a head injury sustained at least 1 year previously, were interviewed in-depth about the impact head injury had had on their lives. Their functioning was also assessed using the Offer Self-Image Questionnaire (OSIQ-R). The main theme raised by subjects was that they had not received adequate explanation of the emotional problems associated with head injury and relevant support in coming to terms with their condition. Head injury had had a devastating effect on their lives, causing limitations in day-to-day activities, employment, education and relationships, and they scored significantly below norms on the OSIQ-R scale of Self-Confidence. However, these young people had a predominantly positive attitude towards life, which appeared to be related to their appreciation of how fortunate they had been to survive. They scored significantly above norms on the OSIQ-R scale of Social Functioning. Markers of poor functioning were identified and, in clinical practice, could be used as a method of highlighting those head-injured young people who potentially are most in need of support. The findings have implications for future research directions, service delivery and planning, in that particular weaknesses of current provision are demonstrated and recommendations made for improvements.

Monoamine oxidase inhibitors. An update on drug interactions.

After initial enthusiasm, the use of monoamine oxidase inhibitors (MAOIs) has been limited by the wide range of MAOI-drug and MAOI-food interactions that are possible, particularly with sympathomimetic medications or tyramine-containing foods, resulting in hypertensive reactions. Despite their clinical benefits, this has led to a reduction in use of such medications. Discovery of the 2 main subgroups of monoamine oxidase, types A and B, led to the synthesis of MAOIs selective for one or other of these isoenzymes. Consequently, selegiline (deprenyl), a selective MAO-B inhibitor, was developed for the treatment of idiopathic Parkinson's disease. This drug is useful in the treatment of the early stages of the disease and later on as an adjunct to other drug therapies. Although the selective MAO-A inhibitor, clorgiline (clorgyline), was found to be effective in the treatment of depression, it still retained the potential to cause hypertensive reactions. Recently, agents that are not only selective, but reversible in their inhibition of MAO-A (RIMAs) have been synthesised (e.g. moclobemide and toloxatone), and have proven antidepressant efficacy. Whilst they are less likely to induce hypertensive reactions with the concomitant administration of sympathomimetic drugs or with tyramine-rich foodstuffs, it still seems wise to advocate care in co-prescribing potentially interacting medications and to advise a degree of caution with regard to the dietary intake of foodstuffs likely to contain a high tyramine content. Although these newer drugs represent an advance in safety, their use has, as yet, only been established in the treatment of depression. RIMAs also retain a potential for adverse interaction with other drugs. Concomitant prescription of serotonin-enhancing drugs should only be undertaken with caution for patients on moclobemide, toloxatone or selegiline. Coprescription of sympathomimetic drugs should also be avoided with these newer MAOIs and patients should be advised against purchasing over-the-counter preparations that may contain sympathomimetic drugs.

Benzodiazepine dependence.

Anxiety is a common clinical problem and benzodiazepines are frequently prescribed. As many as 200,000 people in the UK may be dependent on benzodiazepines. Dependency is best prevented by carefully monitored, short-term prescription of these drugs, but only where non-drug treatments have been found to be ineffective.

An open study of remoxipride in the long-term treatment of schizophrenia-.

An open non-comparative multicentre study was carried out to evaluate the safety and tolerability of remoxipride over a treatment period of 12 months. The efficacy of the drug in controlling psychotic symptoms was also monitored. Eighty-five men and women aged 18-69 who met the Research Diagnostic Criteria for schizophrenia were entered into the study and after withdrawal of previous antipsychotic medication, treated orally with remoxipride 75-300 mg b.i.d. The treatment was well tolerated and most of the adverse symptoms reported were reduced in incidence at the last rating compared to baseline. Sleep problems (insomnia and increased sleep) and increased thirst showed an increase in incidence during treatment. The incidence of extrapyramidal side effects was low and less than at baseline; there was no evidence that remoxipride produced an increase in abnormal involuntary movements, the median weight of the group did not alter and remoxipride produced no significant effect on cardiovascular, clinical chemistry and haematology variables. It appeared effective in controlling psychotic symptoms and produced some improvement on over one third of the patients despite the fact that the majority of patients entered were not in a productive phase of their illness. The results indicate that remoxipride will be well tolerated and effective when given for the maintenance treatment of schizophrenia.

Rehabilitation in neuropsychiatry.

Patients with neuropsychiatric disorders may present with multiple functional deficits. A rehabilitation approach tends to focus on problems presented and involve multidisciplinary assessment and therapeutic programmes. Ideally the programme should be flexible and tailored to the needs of the individual and his or her family.

Psychosocial consequences of head injury in children and adolescents: implications for rehabilitation.

Studies measuring psychosocial outcome in children and adolescents have shown that head injury leads to cognitive impairment which is directly related to the severity of injury in those with very severe head injury. Psychiatric disorders are also related to the severity of injury but here the relationship suggests that mediating factors are involved. No specific pattern of post-traumatic psychological/psychiatric dysfunction emerges from the studies, but it is clear that, as with adults, psychosocial recovery lags behind physical. Head injury affects the functioning of the young person in the family, at school, and within the wider community, often resulting in a secondary handicap of low self-esteem. The multitude of deficits which are a consequence of severe head injury present a challenge for rehabilitation specialists. A multi-disciplinary, multi-specialist, and multi-agency response is required. As a result, families are often presented with a bewildering array of treatments and programmes at different agencies. A case manager can be helpful in ensuring the appropriate use of available resources and can be the one professional in charge of a coordinating case record.

The Scottish first episode schizophrenia study. VII. Two-year follow-up. Scottish Schizophrenia Research Group.

Of 49 schizophrenic patients followed up 2 years after their first admission to hospital, 37% were well, 47% had been readmitted to hospital at some time over the 2 years, and 38% showed schizophrenic symptoms at follow-up. A poor outcome at 2 years was associated with male sex, poor outcome after the first 5 weeks of the first admission, negative schizophrenic symptoms on first admission, and a diagnosis of definite or probable schizophrenia using the Feighner criteria. Only 23% were in employment. A small double-blind discontinuation study of maintenance antipsychotic medication during the second year found more relapses in those switched to placebo medication. Repeat psychometric assessment at 2 years confirmed modest improvements found at 12 months; that is, there was no evidence of intellectual decline. Relatives showed no more psychosocial distress than that found in a normal community sample; what distress there was correlated with patients' schizophrenic symptoms.

The Glasgow rehabilitation survey.

To assess the future requirements for long-stay psychiatric beds, every consultant psychiatrist in Glasgow was asked to consider whether long-stay patients in his or her wards would be fit for rehabilitation and return to the community. For the purposes of the survey, long stay was defined as a single admission of at least six months, but patients with an organic diagnosis who were aged over 65 were excluded. It was estimated that, with rehabilitation, almost a third of the patients surveyed could return to the community, and that, with more participation in self-care, over 15% might be able to manage in a ward or hostel within the the hospital. Patients judged fit to return to the community were preponderantly younger patients with a shorter period of in-patient care, and those suffering from a functional psychotic illness.

Head injury: the relatives' response.

42 male minor and 56 male severe head injury victims, together with their relatives, were assessed in order to understand the nature of the impact of head injury on a close family member. Relatives experienced significant psychosocial difficulties which persisted throughout the year. A two stage model for understanding the causation of relatives' maladjustment is proposed. Rehabilitation programmes for relatives of severe head injury patients should look for vulnerability factors in the relatives, such as their own illness experience, as well as assessing current life stresses, such as the patient's view of his own progress.

Assessment of need for coordinated approach in families with victims of head injury.

Forty two men with severe head injury, and 41 with minor head injury, together with their families, were assessed at home after the injury. Despite significant impairment with respect to physical symptoms, personality difficulties, and occupational status in severely injured patients after one year, there was a very poor uptake of hospital rehabilitation facilities. In addition, patients' relatives showed significant psychosocial impairment throughout this period. There is a need for a specialist to coordinate rehabilitation services for patients with head injury and their relatives and, in particular, to integrate physical and psychological aspects of management with a multidisciplinary team approach. Although this task will require specialist hospital teams for future development, at present general practitioners have some specialised knowledge that would enable them to coordinate rehabilitation.

Three months after severe head injury: psychiatric and social impact on relatives.

Female relatives of defined groups of consecutive male minor and severe head injury victims were seen at home 3 months after the injury. The relatives of the severely injured suffered significant psychiatric morbidity compared to the minor head injury relatives. They also showed poorer functioning in social roles associated with the home. There was no difference in the vulnerability of either wives or mothers of the head injury victims. It is argued that there is a need for support for the relatives of those who have suffered severe brain injury.

Patient outcome in the year following severe head injury and relatives' psychiatric and social functioning.

Fifty-seven consecutive severe male head injury patients together with a defined female relative were assessed at home 3, 6 and 12 months after injury in order to measure the psychiatric and social impact of the injury on the relative. Relatives were found to have significant and persistent psychiatric and social dysfunction and they considered themselves to have a high burden in caring for the relative throughout the year. No particular relationship was found to be the more vulnerable. The most frequent predictor of the relatives' psychiatric and social status was the level of symptomatic complaints voiced by the patients. The findings suggest the need for comprehensive rehabilitation of head injury patients and their relatives.