Insight, grey matter and cognitive function in first-onset psychosis

BACKGROUND: Several studies have suggested that neuropsychological and structural brain deficits are implicated in poor insight. Few insight studies however have combined neurocognitive and structural neuroanatomical measures. AIMS: Focusing on the ability to relabel psychotic symptoms as pathological, we examined insight, brain structure and neurocognition in first-onset psychosis.METHOD: Voxel-based magnetic resonance imaging data were acquired from 82 individuals with psychosis and 91 controls assessed with a brief neuropsychological test battery. Insight was measured using the Schedule for the Assessment of Insight. RESULTS: The principal analysis showed reduced general neuropsychological function was linked to poor symptom relabelling ability. A subsequent between-psychosis group analysis found those with no symptom relabelling ability had significant global and regional grey matter deficits primarily located at the posterior cingulate gyrus and right precuneus/cuneus. CONCLUSIONS: The cingulate gyrus (as part of a midline cortical system) along with right hemisphere regions may be involved in illness and symptom self-appraisal in first-onset psychosis.

Schizophrenia revisited: consensus and confusion

There is no consensus on the rates of schizophrenia among ethnic groups at home in the Caribbean and abroad. Investigations of gender and ethnic differences on the rates of first contact outpatients with schizophrenia in two geographically different areas in Trinidad are reported. In a prospective study, 134 first contact patients with a diagnosis of schizophrenia were selected from two catchment areas in east and Central Trinidad. Almost fifty seven percent (56.7%) of the tested population was of African origin, 32.1% of Indian descent. Gender differences were significant with males accounting for 66.4% 9n=89) of patients with schizophrenia (Chi-square =14.448, df = 1, p=0.0001). Further analysis by age categories revealed significant male predominance at the 20-24 (p=0.0001) and 25-29 (p=0.002 age groups. There was a predominance of young African males (15-19 years, p=0.049) in the east compared to central. The findings revealed an excess of Afro-Trinidadian men in both outpatient clinics (p<0.05).

Perceptions of disadvantage, ethnicity and psychosis.

BACKGROUND: People from Black ethnic groups (African-Caribbean and Black African) are more prone to develop psychosis in Western countries. This excess might be explained by perceptions of disadvantage. AIMS: To investigate whether the higher incidence of psychosis in Black people is mediated by perceptions of disadvantage. METHOD: A population-based incidence and case-control study of first-episode psychosis (Aetiology and Ethnicity in Schizophrenia and Other Psychoses (AESOP)). A total of 482 participants answered questions about perceived disadvantage. RESULTS: Black ethnic groups had a higher incidence of psychosis (OR= 4.7, 95 per cent CI 3.1-7.2). After controlling for religious affiliation, social class and unemployment, the association of ethnicity with psychosis was attenuated (OR=3.0, 95 per cent CI 1.6-5.4) by perceptions of disadvantage. Participants in the Black non-psychosis group often attributed their disadvantage to racism, whereas Black people in the psychosis group attributed it to their own situation. CONCLUSIONS: Perceived disadvantage is partly associated with the excess of psychosis among Black people living in the UK. This may have implications for primary prevention.

Grey matter abnormalities in first-episode schizophrenia and affective psychosis.

BACKGROUND: Grey matter and other structural brain abnormalities are consistently reported in first-onset schizophrenia, but less is known about the extent of neuroanatomical changes in first-onset affective psychosis. AIMS: To determine which brain abnormalities are specific to (a) schizophrenia and (b) affective psychosis. METHOD: We obtained dual-echo (proton density/T2-weighted) magnetic resonance images and carried out voxel-based analysis on the images of 73 patients with first-episode psychosis (schizophrenia n=44, affective psychosis n=29) and 58 healthy controls. RESULTS: Both patients with schizophrenia and patients with affective psychosis had enlarged lateral and third ventricle volumes. Regional cortical grey matter reductions (including bilateral anterior cingulate gyrus, left insula and left fusiform gyrus) were evident in affective psychosis but not in schizophrenia, although patients with schizophrenia displayed decreased hippocampal grey matter and increased striatal grey matter at a more liberal statistical threshold. CONCLUSIONS: Both schizophrenia and affective psychosis are associated with volumetric abnormalities at the onset of frank psychosis, with some of these evident in common brain areas.

Schizophrenia in Trinidad

INTRODUCTION: Within the Caribbean, the majority of studies conducted have reported that significantly more males present with schizophrenia than females. In Trinidad and Tobago, in a cohort of first admissions to an outpatient psychiatric clinic, schizophrenia was reportedly to be twice as common in males when compared to females (16.2 per cent vs. 8.2 per cent, p<0.01) (Hilwig and Maharajh 1992). A similar trend of male preponderance in schizophrenia in Trinidad (75 per cent) was reported (Bhugra et al 1996). In another Trinidadian study, Hutchinson et al. (2003) examined all first admissions to a psychiatric unit at a General Hospital and reported that psychotic illnesses (schizophrenia spectrum and affective psychoses) were significantly more common in men (p<0.01). These studies however, stated total gender rates for all age categories

Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes

CONTEXT Convention suggests uniformity of incidence of schizophrenia and other psychoses; variation would have implications for their causes and biological characteristics. OBJECTIVE To investigate variability in the incidence of psychotic syndromes in terms of place, ethnicity, age, and sex. DESIGN Three-center, prospective, comprehensive survey of clinically relevant first-onset psychotic syndromes over a 2-year period (1997-1999). Census data provided the denominator. SETTING Southeast London, Nottingham, and Bristol, England. PARTICIPANTS One million six hundred thousand person-years yielded 568 subjects aged 16 to 64 years with clinically relevant psychotic syndromes. MAIN OUTCOME MEASURES The World Health Organization Psychosis Screen and the Schedules for Clinical Assessment in Neuropsychiatry to classify, blind to ethnicity, all DSM-IV psychotic syndromes and the subclasses of schizophrenia, other nonaffective disorders, affective disorders, and substance-induced psychosis.

RESULTS All syndromes showed a characteristic age distribution. Schizophrenia was significantly more common in men (incidence rate ratio [IRR], 2.3 [95% confidence interval (CI), 1.7-3.1]); affective disorders occurred equally in men and women (IRR, 1.0 [95% CI, 0.7-1.3]). All psychoses were more common in the black and minority ethnic group (crude IRR, 3.6 [95% CI, 3.0-4.2]). Differences in age, sex, and study center accounted for approximately a quarter of this effect (adjusted IRR, 2.9 [95% CI, 2.4-3.5]) in each psychosis outcome. The age-sex standardized incidence rate for all psychoses was higher in Southeast London (IRR, 49.4 [95% CI, 43.6-55.3]) than Nottingham (IRR, 23.9 [95% CI, 20.6-27.2]) or Bristol (IRR, 20.4 [95% CI, 15.1-25.7]). Rates of all outcomes except affective disorders remained significantly higher in Southeast London when the model was expanded to control for ethnicity. CONCLUSIONS There is significant and independent variation of incidence of schizophrenia and other psychoses in terms of sex, age, ethnicity, and place. This confirms that environmental effects at the individual, and perhaps neighborhood level, may interact together and with genetic factors in the etiology of psychosis.

Gender and ethnic differences in urban and rural first-contact schizophrenia outpatients in Trinidad

This study investigated gender and ethnic differences in the rate of first contact outpatients with schizophrenia in the setting of a more-urban region (MUR) and a less-urban region (LUR) in Trinidad. In a prospective study, 134 first-contact patients with a diagnosis of schizophrenia were selected from two ecologically different regions. Results: Of this population, 56.7 per cent were of African origin and 32.1 per cent were of Indian descent. Gender differences were significant, with males accounting for 66.4 per cent (n=89) of patients with schizophrenia (X2 = 14.45, d.f. = 1, p = 0.0001). Further analysis by age categories revealed a significant male predominance at ages 20-24 (p= 0.0001) and 25-29 (p = 0.002). Young African males (15-19 y, p = 0.049) predominated in MUR compared with LUR. The results showed a marked presence of Afro-Trinidadian males in both outpatient clinics (p < 0.05). We conclude that gender and ethnicity are important variables in the presentation of schizophrenia in Trinidad, whereas neither rural nor urban environments appeared to influence the expression of schizophrenia.

The epidemiology of schizophrenia and other common mental health disorders in the English-speaking Caribbean

OBJECTIVE: To report on the epidemiology of schizophrenia and other mental health disorders in the English-speaking Caribbean. METHODS: The MEDLINE, MEDCARIB and West Indiana electronic databases were searched with phrases Caribbean AND psychiatry OR mental OR suicide, and items with specific reference to epidemiology were culled and reviewed. RESULTS: The age-corrected incidence rate for schizophrenia per 10 000 is 2.09 in Jamaica, 2.2 per 1000 in Trinidad, and 2.92 in Barbados. These rates are lower that the incidence rates reported for white British people, and significantly lower that the 6- to 18-fold higher risk ratio incidence reported for African Caribbeans living in Britain. A comparative diagnostic study carried out in the United Kingdom (UK) suggests that misdiagnosis plays a significant role in this difference. Relatively low incidence figures for affective disorders, anxiety states, suicide and attempted suicide have been reported for Jamaica, Trinidad, and Barbados. DISCUSSION: Most published epidemiological studies of Caribbean populations center on schizophrenia, because of the startling findings of a large increase in risk ratios for African Caribbean people living in England compared to the white native British people. The etiological evidence is shifting toward factors or racism and social alienation experienced by black people in the UK, and to misdagnosis by white British psychiatrists. Studies of the role of colonial enslavement and social engineering raise the etiological possibility of a role for social and structural community organization in the genesis of schizophrenia. The Caribbean thus represents a rich crucible for research in the epidemiology and etiology of mental health disorders (AU)

Urban environment and schizophrenia

Selten et al (2005) cite two reasons for the increased risk of schizophrenia in Surinamese immigrants to The Netherlands. These are an increased base rate in the Surinamese population and exposure to an urban competitive Dutch society. These findings are of particular interest to researchers in Trinidad and Tobago because both countries share a similar mix of African and East Indian population and historically were simultaneously but independently developed by British and Dutch colonisers.

Increased pituitary volume in antipsychotic-free and antipsychotic-treated patients of the Æsop First-Onset Psychosis Study

Subjects at their first psychotic episode show an enlarged volume of the pituitary gland, but whether this is due to hypothalamic–pituitary–adrenal (HPA) axis hyperactivity, or to stimulation of the prolactin-secreting cells by antipsychotic treatment, is unclear. We measured pituitary volume, using 1.5-mm, coronal, 1.5 T, high-resolution MRI images, in 78 patients at the first psychotic episode and 78age- and gender-matched healthy controls. In all, 18 patients were antipsychotic-free (12 of these were antipsychotic-naý¨ve), 26 werereceiving atypical antipsychotics, and 33 were receiving typical antipsychotics. As hypothesized, patients had a larger pituitary volume than controls (+22percent , p=0.001). When divided by antipsychotic treatment, and compared to controls, the pituitary volume was 15 percent larger in antipsychotic-free patients (p¼0.028), 17 percent larger in patients receiving atypicals (p¼0.01), and 30 percent larger in patients receiving typicals (p=0.001). Patients receiving typicals not only had the largest pituitary volume compared to controls but also showed a trend for a larger pituitary volume compared to the other patients grouped together (11 percent, p¼0.08). When divided by diagnosis, and compared to controls, the pituitary volume was 24 percent larger in patients with schizophrenia/schizophreniform disorder (n¼40, p=0.001), 19 percent larger in depressed patients (n¼13, p¼0.022), 16 percent larger in bipolar patients (n¼16, p¼0.037), and 12 percent larger in those with other psychoses (n¼9, p¼0.2). In conclusion, the first-episode of a psychotic disorder is associated with a larger pituitary independently of the presenceof antipsychotic treatment, and this could be due to activation of the HPA axis. Typical antipsychotics exert an additional enlarging effecton pituitary volume, likely to be related to activation of prolactin-secreting cells...

Different effects of typical and atypical antipsychotics on grey matter in first episode psychosis: the AESOP study

Typical antipsychotic drugs act on the dopaminergic system, blocking the dopamine type 2 (D2) receptors. Atypical antipsychotics have lower affinity and occupancy for the dopaminergic receptors, and a high degree of occupancy of the serotoninergic receptors 5-HT2A. Whether these different pharmacological actions produce different effects on brain structure remains unclear. We explored the effects of different types of antipsychotic treatment on brain structure in an epidemiologically based, nonrandomized sample of patients at the first psychotic episode. Subjects were recruited as part of a large epidemiological study (’SOP: aetiology and ethnicity in schizophrenia and other psychoses). We evaluated 22 drug-free patients, 32 on treatment with typical antipsychotics and 30 with atypical antipsychotics. We used high-resolution MRI and voxel-based methods of image analysis. The MRI analysis suggested that both typical and atypical antipsychotics are associated with brain changes. However, typicals seem to affect more extensively the basal ganglia (enlargement of the putamen) and cortical areas (reductions of lobulus paracentralis, anterior cingulate gyrus, superior and medial frontal gyri, superior and middle temporal gyri, insula, and precuneus), while atypical antipsychotics seem particularly associated with enlargement of the thalami. These changes are likely to reflect the effect of antipsychotics on the brain, as there were no differences in duration of illness, total symptoms scores, and length of treatment among the groups. In conclusion, we would like to suggest that even after short-term treatment, typical and atypical antipsychotics may affect brain structure differently.

A five-year outcome study of schizophrenia in Jamaica [abstract]

OBJECTIVE: The prospective comparison of a sub-cohort of persons diagnosed with schizophrenia five years from initial contact with the mental health care system in Jamaica. METHOD: In a five-year follow-up study, a sub-cohort of 54 patients (M=37, F=17 aged 15-55 years was reassessed from the initial cohort of 317 patients identified in 1992 with a CATEGO ñ diagnosis of schizophrenia. The sub-cohort was chosen from one rural parish (St.Thomas) and one mixed urban/rural parish (St.Catherine). The main outcome measures collected from case notes and patient interviews included clinical status and medication usage at contact with clinical service, employment status, outpatient clinical compliance, relapse rate, and Krawiecka and Goldberg rating scale for the severity of psychotic symptoms. RESULTS: Relapse rate at year five was 14 percent. There were no significant differences between the number of relapses in the first year and the fifth year (z= -2.714, p= 0.007, Wilcox sign test). Outpatient compliance five years from onset showed 97.3 percent of patients had been in contact with the community mental service at least twice during the five-year period. CONCLUSIONS: The favourable outcome in the fifth year after first contact is consistent with the previously reported favourable outcome in the first year after initial contact with the mental health care system in Jamaica. More importantly, the relapse rates continue to be well below the present worldwide relapse rate. (AU)

Outcome of first contact schizophrenia in Jamaica

Several previous studies have identified high incidence rates, high relapse rates and poor short term outcome for schizophrenia in African-Caribbeans in the United Kingdom (UK). Studies in the Caribbean have found the incidence of schizophrenia to be within worldwide levels, and one-year outcome to be much lower than that reported for African Caribbean patients in the UK. First contact patients with schizophrenia identified prospectively by the Present Status Examination were followed prospectively for one year. The main outcome measures which were collected from case notes included: clinical status and medication usage at contact with clinical service, employment status, outpatient clinic compliance, relapse rate and in-patient hospital status, after 12 months. Three hundred and seventeen patients between ages 15 and 55 years who had made first contact with the psychiatric service in Jamaica in 1992 received a computer diagnostic programme for the present status examination (CATEGO) diagnosis of schizophrenia. The majority 197 (62 percent) were treated at home, and 120 (38 percent) were admitted to hospital for treatment. Two hundred and sixty four (83 percent) were still being seen after one year. The relapse rate was 13 percent (41 patients), higher for admissions (24, 20 percent) than for those treated at home (17, 9 percent; p<0.001). The relapse rate was higher for patients brought into care by the police and mental health officers (p<0.005). One hundred and thirty five (43 percent) were in gainful employment within the 12 month period of follow up, contrasted with the 40 percent unemployment rate for the 2.4 million population of the island (chi square = 39.322, p<0.001). There was a self-reported use of medication in 213 (67 percent) patients, with 142 (45 percent) on monthly intramuscular depot medication. The low relapse rates and good outcome measures after 12 months of first srevice contact with schizophrenia are related to high levels of gainful employment and good intramuscular medication compliance. The favourable short term outcome in Jamaica does not correspond to the high relapse rate for this condition found in African Caribbeans in the UK. (AU)

Treatment of acute schizophrenia in open general medical wards in Jamaica

OBJECTIVE: The study assessed the efficacy of treating acute psychotic illness in open medical wards of general hospitals. METHODS: The sample consisted of 120 patients with schizophrenia whose first contact with a psychiatric service in Jamaica was in 1992 and who were treated as inpatients during the acute phase of thier illness. Based on the geographic catchment area where they lived, patients were admitted to open medical wards in general hospitals, to psychiatric units in general hospitals, or to acute care wards in a custodial mental hospital. At first contact, patients' severity of illness was assessed, and sociodemographic variables, pathways to care, and legal status were determined. At discharge and for the subsequent 12 months, patients' outcomes were assessed by blinded observers using variables that included relapse, length of stay, employment status after discharge, and clinical status. RESULTS: More that half (53 percent) of the patients were admitted to the mental hospital, 28 percent to general hospital medical wards, and 19 percent to psychiatric units in general hospitals. The three groups did not differ significantly in geographic incidence rates, patterns of symptoms, and s everity of psychosis. The mean length of stay was 90.9 days for patients in the mental hospital, 27.9 days in the general hospital psychiatric units, and 17.3 days in the general hospital medical wards. Clinical outcome variables were significantly better for patients treated in the general hospital medical wards than for those treated in the mental hospital, as were outpatient compliance and gainful employment. CONCLUSIONS: While allowing for possible differences in the three patient groups and the clinical settings, it appears that treatment in general hospital medical wards results in outcome that is at least equivalent to, and for some patients, superior to the outcome of treatment in conventional psychiatric facilities.(Au)

Factors in the onset of schizophrenia: a comparison between London and Trinidad samples

Objective: Sociodemographic factors play an important role in the genesis of mental disorders. High rates of unemployment and other social factors have been reported previously among African-Caribbeans with schizophrenia in London. The aim of the present study was to compare these factors in Trinidad with London African-Caribbeans. METHOD: Using internationally-defined criteria, patients with first-onset schizophrenia were recruited in both countries, and information on the onset of symptoms, help-seeking, pathways into care, premorbid personality and educational and employment status were collected. These two samples are compared on a number of these factors. A total of 56 cases of first-onset of psychosis coming into contact with psychiatric services in Trinidad were studied. Of these, 46 cases were diagnosed as having schizophrenia using the CATEGO program. Over a period of 2 years, 38 African-Caribbean patients with schizophrenia were recruited in London. RESULTS: African-Caribbean patients with schizophrenia in London were more likely to be admitted for perceived threat to others and to have shown loss of interest and serious neglect and to have assaulted others. A lower proportion were admitted via a psychiatrist and a higher proportion by the police. The unemployment rate among the London sample of African-Caribbeans was much higher than in the general population, whereas this was not the case for the Trinidad patients. CONCLUSION: These findings are discussed in the context of culture and aetiology of schizophrenia, and suggestions with regard to future research are made. (AU)

First-contact incidence rate of schizophrenia on Barbados

BACKGROUND: The incidence rate for broad schizophrenia among second-generation African-Caribbean people in the United Kingdom has been reported as high. Ethnicity, migration and psychosocial stressors have been suggested as causal factors. AIMS: To determine the incidence of schizophrenia for the whole population of Barbados using an identical methodology to two previous studies in Trinidad (Bhugra et al, 1996) and London (Bhugra et al, 1997). METHOD: A 12-month study of all persons in the 18-54-year age group presenting with a psychosis for the first time was carried out on the population of Barbados. Information was collected using the World Health Organization screening and measurement instruments. RESULTS: On an island of just over a quarter of a million, 40 out of the 53 patients that met the inclusion criteria were categorized as S+ (narrow) schizophrenia, giving an incidence rate of 2.8/10,000 (95 percent Cl 1.97 - 3.7). The incidence rate for broad schizophrenia was calculated at 3.2/10,000 (95 percent Cl 2.3 - 4.1), which is significantly lower than the comparable rate for London's African-Caribbeans of 6.6/10,000 (95 percent Cl 4.5 - 8.7). CONCLUSIONS: The very high rate for broad schizophrenia among African-Caribbean people in the UK is probably due to environmental factors. (AU)

Suicide rate in Jamaica in 1998 and the prevalence of mental disordes and stressful life events in suicide victims in Kingston, St Andrew and St. Catherine in 1998

The suicide rate of Jamaica was reviewed using available police records. The prevalence of mental disorders and stressful life events in 1998 suicide victims in two parishes in Jamaica was investigated. A psychological autopsy interview method was used to interview relatives and acquaintances of 32 suicide victims over a 4 month period. Hospital records and telephone interviews supplemented information. The DSM IV criteria and a stressful life event categorisation was used to diagnose mental disorders and assess year long exposure to stressful events. It was confirmed that Jamaica's suicide rate (2.8 per 100,000) had increased but remained one of the lowest in the Caribbean. Young men and older men were most at risk. At least 90 percent of the victims were diagnosed as having a mental disorder at the time of suicide. The most common diagnosis was depression, followed by schizophrenia, alcoholism and personality disorder. There was significant comorbidity with substance abuse disorders - marijuana and alcohol abuse. There was a significant level of stressful life events in the suicide victims. The category of interpersonal losses and problems was the most common, followed by health related injuries and living conditions. The category of financial, job related and legal issues was least prominent. The author recognises limitations in time, methodology and analysis. The findings of the prevalence of mental disorders were similar to other psychological autopsy findings. Case controlled studies and regression analysis could give further insight on the role that mental disorders and stressful events play in suicide. Recommendations are made for prevention and control of suicide in Jamaica.(AU)

Dual diagnosis among patients admitted to acute inpatient psychiatric treatment settings in two hospitals in Kingston, Jamaica, 1998-1999

A systematic sample of 174 psychiatric patients who were admitted to two urban acute inpatient psychiatric units between November 1998 and January 1999 was analyzed to determine the prevalence and characteristics of patients with dual diagnosis and to compare those patients with other patients without dual diagnosis. The diagnoses were ascertained with the Structured Clinical Interview for DSM-IV. 100 patients were from Bellevue Hospital and 74 from the University Hospital of the West Indies. The prevalence of dual diagnosis was 32 percent at Bellevue Hospital and 20 percent at University Hospital. Among those with dual diagnosis, schizophrenia and other psychoses (68 percent) was found to be the commonest axis I group disorder, followed by bipolar disorder (17 percent) and major depression (11 percent). Eight-nine percent of patients seen with dual diagnosis had cannabis related diagnosis. Dual diagnosis was more common among male patients (42/47, p<0.001) than among females. When compared to patients who did not have dual diagnosis, these men were found to be younger, in the age range 20-39 years (35/47). Such comparison, also showed that dually diagnosed patients were more likely to have had a previous or current criminal record with odds ratios of 3.67 and 7.44 respectively. The prevalence rates of dual diagnosis in this study are similar to those seen in other countries. Although there were some characterisitcs of the dually diagnosed patients which were similar to that found in studies done in various countries there were few differences. Although not a direct finding of this study, it has been established by previous studies that the fact of having dual diagnosis increases the likelihood of difficulties in diagnosis and treatment. This is further compounded by the absence in Jamaica of any programme to adequately treat these patients. To better inform such treatment planning, future research on dual diagnosis should utilize diverse clinical and functioning measures to make a more detailed needs assessment of these patients (AU)

Knowledge and attitude of primary health care workers and care givers in the Parish of Trelawny towards Schizophrenia and the impact of Schizophrenia on the family

This is a cross sectional study conducted in the parish of Trelawny which investigated the knowledge and attitude of Primary Health Care (PHC) workers and care givers of schizophrenic patients towards schizophrenia, and the impact of schizophrenia on the family. The study population comprised the total population of care givers of schizophrenic patients and primary health care workers in the parish of Trelawny. Care givers numbered 84 and primary health care workers numbered 60. It was observed that the majority of care givers were females and over 50 percent were over the age of 50 years. PHC workers were all female with a wide range of working experience of under one year to over 34 years. Community Health Aides accounted for 57.7 percent of these PHC workers. On the average, knowledge and attitude of PHC workers could be regarded as fair. Knowledge of PHC workers when compared with that of care givers differed significantly but attitude scores did not. It was observed that the knowledge and attitude of PHC workers with family members affected with schizophrenia, when compared with PHC workers without scores did not differ significantly statistically. The degree of burden of schizophrenia on the family was not significant. Less than 50 percent said they were stressed out having to care for the ill family member. However, expressions of fear, anger, love and concern were all noted. The family and the health care provider were the main sources of support for the individuals affected with schizophrenia, and emphasis on the use of medications to control the illness was observed. In spite of the limited health manpower and facilities, care givers of schizophrenic patients appeared satisfied with services provided. Very little in terms of social services and community support groups was evident, but care givers and PHC workers all expressed willingness to be a part of community support groups for families and clients exhausted from the task of care giving (AU)

Treatment of acute schizophrenia in open medical wards

The aim of this study was to compare the pathways to care and outcome of first contact patients with schizophrenia admitted to open medical wards with those treated in closed community psychiatric units and in acute wards of a custodial mental hospital. First contact with patients with schizophrenia who were identified in Jamaica in 1992 and admitted to the three different types of acute treatment facility across the island were followed in a blinded prospective study. Their pathways to care and standard clinical and sociological outcome parameters were identified and compared. 65 first contact patients were admitted to 3 acute wards of the Bellevue Mental Hospital, 20 patients to two closed psychiatric units in general hospitals, and 35 patients admitted to 8 general hospitals islandwide. The mean length of stay in the mental hospital wards was 88.3 days; in the psychiatric units was 29.9 days (p<0.01), and in the general hospitals was 14.1 days (p<0.0001). Clinical outcome variable were significantly better (p<0.03) for patients treated in open medical wards compared with those admitted to acute mental hospital wards. Fewer patients were admitted to open medical wards by the police (p<0.01), or by compulsory legal section (p<0.01). Compared with admissions to conventional psychiatric units, admissions to open medical wards had shorter lengths of stay (p<0.02), fewer admissions by compulsory detention (p<0.05) and had attained relative numerical but not statistical significance for most clinical outcome and pathway to care variables.(AU)