THE DISABILITIES AND MENTAL STATUS OF PATIENTS WITH CHRONIC SCHIZOPHRENIA

Transcription

1 Research Paper Malaysian Journal of Psychiatry Vol.3, No.2 Sept.1995 THE DISABILITIES AND MENTAL STATUS OF PATIENTS WITH CHRONIC SCHIZOPHRENIA Lau Kim Kah Institutionalised long stay schizophrenic patients constitute a severely handicapped group. In this study, the typical patient was single, male, aged around 47 years and likely to have been ill for 24 years or so, with half of those years in hospital. Eighty-four per cent had either positive or negative symptoms or both. Forty-one per cent showed severe occupational impairment and 36% showed severe overall dysfunction. The handicaps seen were in part due to the disease process, in part due to the prolonged stay. Prospects of discharge were minimal. Key words: Disabilities, mental state, chronic, schizophrenia, institutions. INTRODUCTION Disabilities of schizophrenic patients may be divided into 3 large groups (1); a) Premorbid handicapping factors b) Disabilities which are part of the illness i.e. the primary handicaps c) Secondary handicaps due to institutionalisation. It is often impossible to distinguish secondary handicaps from those that are part of the disease process (2). Schizophrenic negative symptoms are rather similar to those described by Barton's institutional neurosis. Most people see the chronic long stay schizophrenic patients as people who have deteriorated to a shabby, inactive, apathetic, withdrawn state as a result of long exposure to an institutional regime that is unstimulating, depersonalising and that restricts freedom. There is evidence that negative symptoms can improve or worsen, subject to environmental influence. Four major conclusions were drawn (1): a) Increase of deficit symptoms if the social environment becomes unstimulating b) Reversal deficit symptom by making the environment socially stimulating c) Anoptimal social environment must be sustained d) Social treatments to reduce deferioration hold wherever patients are treated. It is common to classify the abnormalities in the mental status of chrome schizophrenia into positive and negative symptoms. Certain generalisations about the 2 symptoms' groups may be drawn (3): a) Positive features are characteristic of earlier phases of the illness and negative ones of later phases of the illness b) Effects of drugs upon positive features are more than those on negative features 65

2 Lau Kim Kah c) Positive features are said to be relatively variable and negative features relatively stable. OBJECTIVE To study the psychopathology and disabilities of the long stay schizophrenic population and to examine how psychopathologic features and disabilities are related. METHODS Inclusion and criteria. All patients with a principal diagnosis of schizophrenia according to DSM-III, admitted at least 1 year prior to the study and being long stay residents, were included. Patients over the age of 60, those with a principal diagnosis of organic brain disease, substance abuse and those with major sensory deficits and loss of limbs were excluded. Patients satisfying inclusion criteria were divided into 3 main racial groups, and listed in alphabetical order. The first patient and every subsequent alternate patient on these 3 lists were selected for the study. The Sarawak Mental Hospital. The hospital, built in 1957, with 338 beds is located 7 miles outside the city of Kuching. The treatment facilities are largely utilised by the population of Kuching, the racial breakdown being Chinese 44%, Malays 36%, Ibans 6%, Bidayuh 11%, and others 3%. Data Collection The following data were extracted from case records: a) Age, sex, ethnic group, b) Marital status, c) Length of illness, d) Length of stay of present admission, e) Number of previous admissions, f) Treatment (equivalent dose of Chlorpromazine) using the following conversion table Drug Chlorpromazine Thioridazine Trifluoperazine Haloperidol Modecate 25mg/month Equivalent potency 100 mg 100 mg 5 mg 2.5 mg 200 mg

3 The Disabilities and Mental Status of Patients with Chronic Schizophrenia Rating scales All patients were assessed by the author assisted by the nursing staff identified to be most familiar with the patient, using 2 scales namely: a) the Krawiecka Scale (4) for chronic psychosis b) the WHO-Disability Assessment Schedule (DAS) (5). The Krawiecka (Manchester) Scale assesses 9 symptoms grouped into 3 broad categories; a) Florid psychotic symptoms, b) Deficit symptoms, c) Neurotic or affective symptoms. Only 2 sections of the WHO-DAS applicable to chronic inpatients were used: a) Section 1- Dysfunctional Overall Behaviour Schedule (DOBS) b) Section 3- Behaviour in Hospital Schedule (BIHS). Statistical treatment of results The Pearson's product-moment coefficient of correlation was used to calculate the " r" which would be tested for significance by the t-ratio. RESULTS The mean length of stay was found to be years. Patients had been ill for an average of years and were diagnosed at a mean age of 22.9 years. The mean number of admissions was 5.14 times. Table 1. Marital Status Married (%) Single (%) Separated (%) Divorced (%) Widowed(%) Male 1(1.7) 27 (46.5) 2 (3.4) 0 0 Female 2 (3.5) 19 (32.8) 3 (5.2) 2 (3.4) 2 (3.4) Total 3 (5.2) 46 (79.3) 5 (8.6) 2 (3.4) 2 (3.4) The vast majority of patients n = 46 (79.3%) were single while the separated, divorced, widowed group comprised 15.4% (n=9). 67

4 Lau Kim Kah Figure 1. Disability Ratings of Sample Overall Dysfunctional Score obv. 21(36%) min. 111(19%) Dysfunction nil 0-3 ( minimum) 4-6 (obvious) >_7 nil. '' "` 26 (46%) number of patients Socially Withdrawn Behaviour sev. 5 (9%) 21 (36%) mod. min. 32 (55%) S.W. scores minimum 0-4 moderate 5-9 severe 6-8 number of patients sev. mod. Socially Embarassing Behaviour S.E Scores minimum 0-2 moderate 3-5 severe 6-8 min. ^9%) number of patients Nurses Opinion poor 119 (33%) fair 14 (24%) Opinion Scores good 0-2 fair 3-5 poor 6-9 good 25 (43%) number of patients Patients Occupation Occupation good 8-11 poor 36 (62%) fair 4-7 poor 0-3 fair 20 (34%) good 2 (4%) number of patients

5 The Disabilities and Mental Status of Patients with Chronic Schizophrenia The sample constituted a rather disabled group with 36% showing obvious dysfunction, 45% moderate to severe withdrawn behaviour, 11% exhibiting moderate to severe socially embarrassing symptoms. Sixty-two pet cent of the patients were found to be poor in occupational functioning. Table 2. Medications Received Females (%) Males (%) All (%) Treatment (n=28) (n=30) (n=58) Oral only 9(15.5) 9(15.5) 18 (31.0) Depot injections only 0, (0.0) 4 (6.9) 4 (6.9) Tablet + Depot injections 16 (27.6) 15 (25.9) 31 (53.4) No antipsychotics 3 (5.2) 2 (3.4) 5 (8.6) Anticholinergics 21 (36.2) 17 (29.3) 38 (65.5) Mean Equivalent Dose CPZ (Chlorpromazine) (mg) Of the 58 patients, only 5 (8.6%) were not on any antispychotics. In 65.5% an anticholinergic was prescribed together with the antipsychotics. Female patients received a higher dose than their male counterparts although the difference was not significant. Table 3. Mental Status and Dose of CPZ (Chlorpromazine) Florid Deficit Both(3) Neither(4) All Symptoms(1) Symptoms(2) n= 19 (33%) 14 (24%) 12 (21%) 13 (22%) 58(100%) ** ** Equ. Dose CPZ (mg) (1) scores >_ 3 on the florid symptom scale. (2) scores? 3 on the deficit state scale. (3) scores >_ 3 on each of the 2 scales. (4) scores <_ 2 in either of the 2 scales. ** - p < 0.01, Florid v. Deficit. There were 3 broad groups of patients; those with only florid symptoms (Crow's Type I), those with only deficit symptoms (Type II) and a large group with both positive and negative symptoms. There is a significant difference in doses used to treat those with florid states as compared to those with deficit states.

6 Lau Kim Kah Table 4. Relationship between length of stay and mental status. Length of n Florid Deficit stay (yrs) symptom symptom * > * * -p<0.05, 1-5 yrsv?16yrs Deficit symptoms increased with increasing length of stay (P<0.05) Table 5. Relationship between illness and mental status. Length of n Florid Deficit illness (yrs) symptom symptom < There was a reduction in florid symptoms with increasing length of illness (however r=0.2, N. S.). There was a significant increase in deficit symptoms with increasing length of illness (r=0.28, P<0.05). Table 6. Relationship between length of stay and disability Length of Overall S. W.* S.E. stay (yrs) dysfunctional score * Socially withdrawn behaviour ** Socially embarrassing behaviour 70

7 The Disabilities and Mental Status of Patients with Chronic Schizophrenia Table 7. Relationship between length of illness and disability Length of Overall S. W.* S.E.** illness dysfunction X >_ * Socially withdrawn behaviour ** Socially embarrassing behaviour There was an increase in both socially withdrawn behaviour (S. W.) as well as socially embarrassing behaviour (S.E.) with increasing length of illness but the correlation was not significant (r=0.19) Table 8. Relationship between age of diagnosis and disability Age of Overall S.W.* S.E.** Patient Diagnosis Dysfunction occupation < >_ * Socially withdrawn behaviour * * Socially embarrassing behaviour Earlier age of onset was associated with greater dysfunction, poorer occupational functioning, more deficit symptoms and more socially embarrassing symptoms. Table 9. Mental Status and Overall Dysfunction Florid Sx Deficit Sx Both Neither n=19 n=14 n=12 n=13 Overall Dysfunction 4.00* ** 1 - scores >_3 in the florid symptom scale 2 - scores?3 in the deficit state scale 3 - scores >_3 on each of the 2 scales 4 - scores <_2 in either of the 2 scales * - p < 0.05, 1 vs. 2 ** - p <0.01, 4 vs. 1, 4 vs. 2 Sx - Symptoms 71

8 Lau Kim Kah Table 10. Relationship between mental status and S.E.(Sociallyembarassing and S.W.(Socially withdrawn behaviour) Florid Sx Deficit Sx Both Neither n=19 n=14 n=12 n=13 S. W. 3.47* 7.21 ** S.E ** * p < 0.05, 1 v. 2 ** p < 0.01, 2 v. 4, 1v.4 Those who exhibited only florid psychotic symptoms scored significantly better in overall dysfunction scale and were significantly less withdrawn when compared to those with deficit state symptoms only. Correlation of mental status to disability: i) Florid symptoms were not correlated with Overall Dysfunctional behaviour (r = 0.08, N. S.). ii) Florid symptoms correlated well with Socially Embarrassing Behaviour (r = 0.43, p < 0.01) iii) Deficit state symptoms correlated with Overall Dysfunctional behaviour (r =0.59, p < 0.01) iv) Deficit state symptoms correlated well with Socially Withdrawn behaviour (r = 0.48, p < 0.01) DISCUSSION Relatively high doses of medication were used, in particular, amongst the female patients. The large numbers of patients still on medications, probably reflects fear that patients would relapse if their medications were discontinued. This is in marked contrast to Jones (6) who found that in at least 60% ofchronic schizophrenic inpatients, antipsychotic can be withdrawn without further deterioration in their mental status. It is not surprising that patients with symptoms received significantly higher dosage than those with deficit symptoms or those with neither symptoms. It was noted that those with both florid as well as negative symptoms received the highest dosage of all. As such, it was unclear whether the high dose of medications had produced some of the negative symptoms seen in this group. The high closes of medications given would have affected some of the WHO-DAS scores in the poor direction. Increasing length of stay was seen to correlate with an increase in deficit symptoms (P < 0.05) and this was to be expected and was seen in various studies such as Wing & Brown (1), and Johnstone (3). However, the length of stay seemed to have no effect on the florid symptoms. Increasing length of illness produced an increase in deficit symptoms (P<0.05) and a reduction in florid symptoms (NS). These results would concur with the study done by Owen & Johnstone (7). However, the contribution of increasing length of stay to these results was unknown as those who stayed the longest would also be those who had been ill the longest, although the reverse was not 72

9 The Disabilities and Mental Status of Patients with Chronic Schizophrenia true Although the results of the effect of age of diagnosis on mental status was not significant, it did indicate that those whose disease started off in the teenage years had more deficit symptoms and this concurred with the study by Kay and Opler (8). The study by Johnstone et al (3) however found positive symptoms to be associated with younger age of first contact and that negative symptoms were positively associated with age. However, as mentioned earlier, the age of diagnosis was probably not reliable as there would be a number of patients whose illness came earlier but due to delay in getting help, were diagnosed as older at age of onset, thereby blurring the differen.;e in the two groups. While the study by Johnstone (1) showed negative symptoms being associated with males, this finding was not replicated in this study. Increasing length of stay was associated with a deteriorating overall dysfunctional score (P <0.01), increasing socially withdrawn behaviour (P <0.05), deterioration in occupational function (N.S.) and reduction in contact with the outside world (N. S.) and no correlation with socially embarrassing behaviour. This was to be expected as a consequence to the prolonged exposure to a non stimulating environment. Mc Creadie (9) suggested 2 reasons for the increase in socially withdrawn behaviour with increasing length of time. Firstly, social withdrawal may actually be symptomatic of long stay or it may reflect severe deficit symptoms which were resistant to treatment, had persisted and had prevented discharge of the patient. Secondly, in this study that included some elderly patients, advancing age was also associated with some flattening of affect and poverty of speech. With increasing length of illness, there was deterioration of the overall dysfunction score, patient's occupation score, and worsening of the "social withdrawal" and the "social embarrassing" scores. All these figures were however not significant. It would seem that the impoverished environment has a greater impact on the disabilities than the duration of illness. This would be in keeping with the conclusion by Wing. It had been suggested by Breier et al (10) that the course of schizophrenia may comprise 3 phases - an acute phase, a early phase of deterioration which may continue for up to 10 years or more, followed by a period of gradual improvement. Bleule (11) expressed similar views. The present study however suggests that patients continue to deteriorate in function rather than improve. Those with younger onset of the illness appeared to be poorer off in overall dysfunctional scores, 'Social Withdrawal' and 'Social Embarassing' scores. However the results were not significant. An earlier age of onset may suggest a developmental disorder and it was therefore not surprising that there was some correlation seen above. Presence of either florid or deficit state symptoms was associated with poorer overall dysfunction scores, higher Social Withdrawn and Social Embarssing scores, poorer nurse's opinion and poorer occupational functioning compared to those where such symptoms were absent or present to a mild degree. Comparing those with symptoms, those with deficit symptoms fared significantly poorly compared to those with positive symptoms. 73

10 Lau Kim Kah Curson et al (12) found that 50% of his sample had one or more florid symptoms and he suggested that those who remained in the hospital had symptoms that were refractory to organic therapy and hence were handicapped. In the present study, 33% had florid symptoms only, 24% had only deficit symptoms and in 21% both were present. It was interesting to note that those with both florid and deficit symptoms seemed to fall mid way between those who had either one of the symptoms. This group received the largest dose of medication. It was therefore difficult to say what roles the florid symptoms or the deficit state symptoms or the dosage of drugs had on the disabilities of this group of patients.. CONCLUSION It would seem that the schizophrenic patients who were institutionalised constituted a fairly severely handicapped group. The typical patient in this study was single, slightly more likely to be male, aged 47 or so, and likely to have been ill for 24 years and having spent 12 years or so in hospital. Forty-five out of 58 (84%) patients were handicapped by either florid symptoms or deficit symptoms or both. This would suggest that the patients who were left in the hospital appeared to be a hard core group who had non responsive deficit symptoms or who had treatment resistant florid symptoms. Twenty-four (41%) patients scored 1 or less in their occupational score indicating almost virtual inactivity and severe occupational impairment. Twenty-one (36%) scored 7 or more on the overall dysfunctional scale indicating obvious to serious dysfunction and 26 (46%) was regarded as moderately to severely withdrawn. The handicaps seen here could be attributed to the disease process and also partly to the length of stay in a non stimulating environment with little social interaction and a lot of time idling away in inactivity. The handicaps seen might have been compounded by the effects of medications, which themselves have contributed towards affective blunting, more withdrawn behaviour and psychomotor retardation Due to their handicaps, the possibility of discharge from the hospital would be minimal. There is a need for newer medications which would not compound negative symptoms while targeting positive symptoms resistant to existing antidopaminergic antipsychotics. 74

11 The Disabilities and Mental Status of Patients with Chronic Schizophrenia REFERENCES 1. Wing JK, Brown GW. Institutionalism and schizophrenia. A comparative study of 3 mental hospitals Cambridge University Press, Wing Jk. Rehabilitation of psychiatric patients. British Journal of Psychiatry 1963; 109: Johnstone EC et al. Disabilities and circumstances of schizophrenia patients. A follow up study. British Journal of Psychiatry 1991; 159 (13): Krawiecka Met al. A standardised psychiatric assessment scale for rating chronic psychotic' patients. Acta Psy. Scandinavica 1972; 55: WHO Psychiatric Assessment Schedule (WHO-DAS) WHO. Geneva, Jones IH. Evaluation of the neuroleptic drugs as a treatment for schizophrenia. Australia and New Zealand Journal of Psychiatry 1968; 2: Owens DGC, Johnstone EC. The disabilities of chronic schizophrenia. Their nature and factors contributing to their development. British Journal of Psychiatry 1980; 136: Kay SR, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin 1987; 13: Mc Creadie RG et al. The Scottish Survey of old long stay inpatients. British Journal of Psychiatry 1991; 155: Breier A. et al. National Institute of Mental Health longitudinal study of chronic schizophrenia. Archives of General Psychiatry 1991; 48: Bleule M. Long term course of the schizophrenic psychosis. Psychological Medicine 1974; 4: Curson et al. Psychiatric morbidity of a long stay hospital population with chronic schizophrenia and implication for future community care. British Medical Journal 1988; 297: Corresponding Address: Dr.Lau Kim Kah MPM (UM) Sarawak Mental Hospital Batu 7, Jalan Penrissen, Kuching, Sarawak 75

12 Point of View Malaysian Journal of Psychiatry Vol.3, No.2 Sept.1995 MANAGED CARE AND PSYCHIATRIC PRACTICE M.P. Deva Psychiatric illnesses have often been at the raw end of third party reimbursements in many developed countries. Unlike many developing countries where psychiatric care no matter how rudimentary, is virtually free except for private practice psychiatry which is often expensive, the developed countries have for decades allowed a limited cover for many psychiatric illnesses. Psychiatric illnesses being often prolonged ones, psychiatric cover even in developed countries is often restricted. Many insurance schemes give only a couple of weeks of hospitalization benefits and limit what are considered expensive treatments such as psychotherapy. In the past ten years or so, in North America and slowly in the United Kingdom, managed care has begun to make itself felt. The proponents of managed care argue that no medical care organization (government or insurance company that provides reimbursement) can go on providing unlimited cover for all misfortunes of health from cradle to grave; that at some stage, the costs have to be "managed" better - by those who pay for this. They call for an organized system of examination, investigations and treatment that calls for standardization and hopefully reduction in costs. To understand the North American model and need for managed care, one should understand the enormous costs of medical care in general, from salaries of medical and nursing staff in inpatient units to often carte-blanche reimbursement by insurance companies for clinic visits. A day in a hospital bed may cost US $600/-, while an hour of psychotherapy may cost US $200. By comparison, Malaysian private hospitals and clinics may charge fees about three times lower for inpatient or outpatient services. Needless to say, such high fees for services that are charged in North America have reached a level that even Americans with their affluence have not been able to keep up with. Sophisticated investigations and treatment cost money, but often costs keep climbing to meet funding available. As a law of Parkinson states expenditure rises to meet income. The seemingly endless charging of investigations and treatment possible had to reach a limit. The managed care may be an answer to free spending, but it also seems a challenge by the payment system to the way doctors do things in North America. How will managed care suit Malaysia? The recent interest in managed care in Malaysia seems to be designed to move health care to follow the example of countries like North America, but with one big difference. The expenditure on health care is a good half to two-thirds that of the richer countries. Needless to say, availability of sophisticated investigations and treatment in Malaysia is limited to the larger towns at best. Also, the insurance system is very limited so that most general practitioners only live by the fee for service practices. The medical companies that have contracts with doctors hardly allow the kind of reimbursement that is available in North America. Superficially, it appears medically speaking, we live rather frugally. Some may argue that costs are rising. If they are, it is certainly difficult to see whether our doctors are carte-blanche, a wasteful lot. Individually, a few black sheep or some avaricious ones may be taking some patients for a ride. In psychiatry for instance, the average patient who is seen in the private health system is not 76