To have and to hold: a cross-cultural inquiry into marital prospects after psychosis.

Received wisdom and a substantial body of epidemiological work indicate that early psychosis bodes ill for matrimonial prospects. Using follow-up data from ISoS, the WHO-Collaborative International Study of Schizophrenia, we confirm an earlier local finding that marital success, 15 years after first-break psychosis, is quite favourable in India: 74% for women, 71% for men, compared with elsewhere: 48% for women, 28% for men. This comparative advantage applies to both marriages contracted after onset of psychosis as well as those that survive it, and is the more remarkable for occurring in a culture where the stigma attached to mental illness with regard to marriage is especially heavy. The presence of children and availability of household assistance both appear to enhance odds of successful marriage. That expressed worries about marriage proved so poor a guide to actual performance (and, indeed, survive living proof to the contrary in the families reporting the stigma) suggests that inquiries into stigma should be reworked as larger inquiries into local moral economies of worth. In the dharma-governed world of Hindu India resistance to the cultural opprobrium attached to madness is not a strategic assault on a structured source of shame and discrimination, but a tactical manoeuvre in the name of a higher cultural good - family, the lineage and the social order. Restoring this social basis of self-respect repairs what would otherwise be a disabling breach in the normal maturation process; developmental continuity, in turn, may help explain India's favourable rates of recovery from psychotic disorder. By the same token, the lack of coordinate processes in cultures where transitions to adulthood are poorly marked and post-hospital expectations are low may help to explain the common experience of 'social defeat', and poor outcome, in the lives of former psychiatric patients in the West.

Recovery from psychotic illness: a 15- and 25-year international follow-up study.

BACKGROUND: Poorly defined cohorts and weak study designs have hampered cross-cultural comparisons of course and outcome in schizophrenia. AIMS: To describe long-term outcome in 18 diverse treated incidence and prevalence cohorts. To compare mortality, 15- and 25-year illness trajectory and the predictive strength of selected baseline and short-term course variables. METHODS: Historic prospective study. Standardised assessments of course and outcome. RESULTS: About 75% traced. About 50% of surviving cases had favourable outcomes, but there was marked heterogeneity across geographic centres. In regression models, early (2-year) course patterns were the strongest predictor of 15-year outcome, but recovery varied by location; 16% of early unremitting cases achieved late-phase recovery. CONCLUSIONS: A significant proportion of treated incident cases of schizophrenia achieve favourable long-term outcome. Sociocultural conditions appear to modify long-term course. Early intervention programmes focused on social as well as pharmacological treatments may realise longer-term gains.

Statistical cost-effectiveness analysis of two treatments based on net health benefits.

Statistical methods for cost-effectiveness analysis (CEA) for two treatments that mimic the deterministic optimal rules of CEA are presented. In these rules the objective is to determine the treatment with the maximal effectiveness whose unit cost is less than an amount, lambda, that a decision-maker is willing to pay (WTP). This is accomplished by identifying the treatment with the largest positive net health benefit (NHB), which is a function of lambda, while controlling the familywise error rate both when the WTP value is given and when it is unspecified. Fieller's theorem is used to determine a region of WTP values where the NHBs of the treatments are not distinguishable. For each lambda outside of the confidence region, the larger treatment is identified. A newly developed one-tailed analogue of Fieller's theorem is used to determine the WTP values where a treatment's NHB is positive. The situation in which both treatments are experimental is distinguished from the case where one of the treatments is usual care. The one-tailed confidence region is used in the latter case to obtain the lambda values where the NHBs are not different, and determining the region of positivity of the NHBs may be unnecessary. An example is presented in which the cost-effectiveness of two antipsychotic treatments is evaluated.

Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHO collaborative followup project. International Study of Schizophrenia.

This article examines the long-standing and provocative finding of a differential advantage in course and outcome for persons with schizophrenia living in "developing" countries, using results from the newly completed World Health Organization (WHO) collaborative project, the International Study of Schizophrenia (ISoS). The article addresses two questions: Has the differential survived the 13 years since it was last reported? If so, are the results demonstrably not attributable to artifactual confounding? The analysis focuses on the 809 subjects who make up the combined incidence cohort of ISoS. These include members of the original treated incidence cohorts of two earlier WHO studies (the Determinants of Outcome of Severe Mental Disorders and the Reduction of Disability Studies) as well as subjects drawn from two additional samples (Hong Kong and Madras/Chennai). We first review the consistency of the finding of a "developed versus developing" differential in course and outcome and then examine a variety of course and outcome measures for the ISoS incidence cohorts. Evidence of differences in illness trajectory in favor of the developing centers was consistently found. Six potential sources of bias are then examined: differences in followup, arbitrary grouping of centers, diagnostic ambiguities, selective outcome measures, gender, and age. None of these potential confounds explains away the differential in course and outcome. We conclude with suggestions for further research, with particular attention to the need for close documentation of everyday practices in the local moral worlds that "culture" refers to.

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.

Estimating population size when duplicates are present.

Each of K mental health programmes reports the number of patients served in a year. The sum of these numbers, y, is an overcount because some patients are seen in more than one programme. Health care planners need to know the unduplicated number served by the mental health system. Thus, there is an unknown number, M, of distinct individuals who appear on one or more of K lists; some appear on multiple lists and the duplicates are not readily identifiable. Let X be the number of lists on which a randomly selected individual appears. When E(X) is known, y/E(X) is the natural estimator of M. We assume that we know the number of programmes, Xi, used by the ith individual in a random sample of recipients of service. Here, the intuitive estimator, Y/X has desirable statistical properties. We give confidence interval estimators for M. We apply the method to estimate the number of individuals served in 1991 by the mental health programmes in New York State.

Epidemiology of nonaffective acute remitting psychosis vs schizophrenia. Sex and sociocultural setting.

BACKGROUND: This article first examines the epidemiology of nonaffective acute remitting psychosis with respect to variation in incidence by sex and sociocultural setting. Second, it examines whether nonaffective acute remitting psychosis can be epidemiologically differentiated from schizophrenia. METHODS: The data were drawn from the World Health Organization Determinants of Outcome Study. Sex-specific incidence rates were obtained for two sites in the developing-country setting and for six sites in the industrialized-country setting. RESULTS: For nonaffective acute remitting psychosis, the incidence in men was about one-half the incidence in women, and the incidence in the developing-country setting was about 10-fold the incidence in the industrialized-country setting. These associations with sex and with setting were sharply distinct from those of schizophrenia. CONCLUSION: The epidemiologic patterns of this form of psychosis may be distinct from those of schizophrenia and could yield clues to its causes.

New York under the Rivers decision: an epidemiologic study of drug treatment refusal.

OBJECTIVE: To determine the characteristics of cases of drug treatment refusal under the Rivers decision, which mandated court adjudication of such cases, the authors made a retrospective study of all applications for court review during 1 year in New York State inpatient facilities. METHOD: Sociodemographic and clinical characteristics of these 473 cases were compared with those of the 41,535 cases during the same period in which no court review was requested. RESULTS: A 1% prevalence of applications requesting court review for nonemergency administration of medication over objection was found. The patients who refused medication were more likely than the comparison patients to have a crime-associated commitment status, a diagnosis of schizophrenia, and fewer previous hospital days, and they were more likely to be discharged. Medication refusers for whom applications for court review were submitted had relatively longer hospitalizations than the rest of the patients. Almost one-third of the applications submitted were withdrawn before court hearings, yielding a 0.7% prevalence of court-reviewed applications. Ninety-two percent of these applications for medication over objection were approved with virtually no change in the requested orders. CONCLUSIONS: The study findings demonstrate that a front-end judicial determination of competency to refuse medication results in a time-consuming procedure which fails to ensure real due process or provide individualized alternative treatment. A two-tier system with in-house clinical review preceding judicial review is proposed to remedy the deficiencies of the current system.

Ethnic differences in seclusion and restraint.

Data on seclusions or restraints were analyzed by ethnic group for 587 patients in 19 New York State psychiatric hospitals for a 4-week period. No differences among White, Black, or Hispanic patients were found for sex; type of ward where episode occurred; frequency of, length of, or reason for confinement; or the administration of medication as needed. The groups did differ in age, diagnosis, and target of their assaults. When analyzed by age groups, minority patients were not overrepresented in the secluded/restrained sample. Age was the most important variable to account for ethnic differences in confinement.

Pharmacotherapy of the hospitalized young adult schizophrenic patient.

The authors surveyed pharmacotherapy in a group of hospitalized 18 to 35-year-old young adult patients (N = 286) with a DSM-III diagnosis of schizophrenia. Drug use comparisons were made between patients with a 180 day or less hospitalization (short-stay, N = 226) and those with a 366+ day hospitalization (long-stay, N = 60). Psychotropic drug usage during the initial 180 and most-recent 180 days of treatment of the long-stay group was compared with the total episode of the short-stay group. Antiepileptic, antidepressant, lithium and anxiolytic/sedative/hypnotic agents, were used in significantly more of the long-stay than short-stay patients. This increase was not observed between the two groups for the initial 180 days of the long-stay group but was observed during the most recent 180 days of treatment. Antipsychotic mean daily doses and patterns of use in the two length of stay groups were similar. Chlorpromazine (CPZ) dosage was significantly increased in long-stay patients compared with short-stay patients (P less than .05).

Variations in seclusion and restraint practices by hospital location.

Data from a survey of seclusion and restraint practices in New York state hospitals were analyzed to determine if they differed by hospital location. The study included 19 hospitals--five in New York City, four in New York City suburbs, three in large towns, and seven in small towns. Overall, New York City and large-town hospitals had the highest rates of seclusion and restraint, but analysis by age group showed that New York City had the lowest rate for patients under age 35, who constituted the majority of patients who were secluded or restrained, and large towns had the highest rate. Compared with suburban and small-town hospitals, city and large-town hospitals used seclusion more often than restraint and had a higher ward census and a lower-staff patient ratio. In all groups males and blacks were overrepresented compared with the hospital population. The authors believe clarification of regional variations in assaultive behavior is important for treatment and system planning.

Pharmaco-epidemiology in 136 hospitalized schizophrenic patients.

The authors surveyed pharmacotherapy in a group of 136 newly admitted patients with a DSM-III diagnosis of schizophrenia. They found that nine antipsychotic agents were used; the median daily dose (in chlorpromazine equivalents) was 1088 mg (mean +/- SD = 1428 +/- 1260 mg; range = 75-6186 mg). Women received greater mean daily doses of antipsychotics than men (1688 versus 1284 mg). Using a Cox model survival analysis, the authors found no statistical association between length of stay and the mean daily dose of antipsychotic medication. The mean daily dose of high-potency agents was 2.7 times greater than the dose of low-potency agents. The excess exposure to haloperidol alone resulted in 16.3% of the overall neuroactive drug costs.

An analytic approach to quantifying pain scores.

Statistical problems in clinical trials frequently involve fitting regression lines when the underlying data are categorical or ordinal response variables. Usually an ad hoc a priori quantification is used to assign values to these ordinal responses. For pain intensity data collected in analgesic trials, the usual approach is to set none equal to 0, mild equal to 1, moderate equal to 2, and severe equal to 3. While this scheme has been generally accepted, on the basis that for similar clinical trials reasonably similar results are obtained by different investigators, concern exists that the distances between pain scores are probably not equal. A method is presented for quantifying categorical responses so that the resulting scores maximize the simultaneous fit of the dose-response regression lines. The optimal scores derived by this technique may then be used in a bioassay analysis to estimate the relative potency of 2 compounds. As illustrative examples, this method was applied to data from 2 clinical trials and the results were compared to the usual method.

Severe alcoholism in the mental health sector: I. A cost analysis of treatment.

In a country in which the public mental health sector provides services to alcoholics, the costs of direct care to alcoholics were compared with those of other mental health patients. Costs were developed for a 1-yr cohort of patients who had received inpatient care but who had recently come from the community and returned to the community. The costs were based on inpatient and outpatient utilization within 2 yr of follow-up, commencing at discharge from inpatient care. Alcoholics represented the largest single diagnostic group in the cohort (39%), although their cost of care was only 22% of total costs. This is so despite the facts that similar percentages of alcoholics and nonalcoholics required rehospitalization in the 2 yr of follow-up and both groups exhibited similar patterns in the number of readmissions. Alcoholics have lower costs than other patients because they use cumulatively fewer inpatient days and receive fewer days of the most expensive outpatient service of full-day treatment. On the average, the cost to serve alcoholic patients is less than half the cost to serve nonalcoholic patients.

The dynamics of hospitalization in a defined population during deinstitutionalization.

In a sample of 1,032 psychiatric inpatients studied for 1 year, chronic patients (more than 6 months' inpatient stay) represented 17.4%, almost half of whom were discharged during a 2-year follow-up; an additional 19.4% died. The incidence of "new" long-stay patients was 8.6/100,000 population, which, if constant over time, would result in a net increase of long-stay patients. Most chronic long-stay patients had a diagnosis of schizophrenia or organic brain syndrome. The two diagnostic groups had strikingly different patterns of deinstitutionalization. Alcoholic patients and those with "other" diagnoses demonstrated chronic dependence on the hospital, characterized by short inpatient stays and high readmission rates.

Effect of caffeine on acetaminophen analgesia.

Our objective was to determine the value of caffeine in combination with acetaminophen in the relief of pain from uterine cramping, episiotomy, and third molar extraction. In the dental study, 173 patients received two or four tablets of 500 mg acetaminophen or the combination of 500 mg acetaminophen and 65 mg caffeine. In the three postpartum studies, 1345 patients received one, two, or three tablets of acetaminophen, the combination, or a placebo. The mean scores for the summary variable percent sum of the pain intensity differences (% SPID) were higher in all for the combination than for acetaminophen alone, and in two studies the null hypothesis of no differences was rejected. The relative potency estimates for % SPID were 1.9, 1.8, and 1.3 for the three studies in which bioassays could be performed and the pooled relative potency was 1.7 with a 95% confidence interval of 1.1 to 3.1. The results were essentially the same among pain models and among patient groups with similar habitual caffeine consumption. Onset of analgesia was also faster with the combination. We conclude that caffeine enhances the analgesic efficacy of acetaminophen.

Quantitative differences in aspirin analgesia in three models of clinical pain.

An analysis was made of data from over 4000 postepisiotomy, uterine cramping, and postsurgical patients complaining of moderate or severe pain. They had received 325, 650, or 1300 mg aspirin or placebo while they were subjects in 10 analgesic clinical trials. On the average, for the same verbally expressed pain intensity level and the same treatment, more relief was obtained by a patient with uterine cramping than one with episiotomy pain, who in turn obtained more relief than a patient with surgical pain. A new mathematical model which characterizes the probability that an analgesic provides complete relief as a function of dose, severity of pain intensity, and pain etiology is developed. The model utilizes the data itself to estimate the numerical score corresponding to verbal pain intensities. The results indicate that the numerical score quantifying severe surgical pain is 1.4 times greater than the score for severe episiotomy pain, which in turn is 3.2 times greater than the score for severe uterine cramping. Clinical trials must be designed to take these differences into account. Also, clinicians must be cognizant of such differences when choosing among drugs and dosages for patients with different pain intensity and etiology.

Quantitative care norms for a psychiatric ambulatory population in a county medical assistance program.

An approach for developing quantitative care norms for outpatient acute psychiatric patients is presented. Both the methodological concept of the norming procedure and its application to the needs of Medicaid in Rockland County, New York are given. The methodology is totally general in that it could be applied to concerns related to characterization of services rendered in a wide variety of applications ranging from planning to utilization review. The norms developed relate both to monthly quantity of services rendered and length of active treatment period. Further, the impact of a review rule is discussed in terms of its implication to number of cases reviewed.