Psychometric properties of the schedules for clinical assessment in neuropsychiatry (SCAN-2.1).

BACKGROUND: The Schedules for Clinical Assessment in Neuropsychiatry (SCAN), the successor of the ninth version of the Present State Examination (PSE-9), is one of the latest instruments developed by the World Health Organisation for the assessment of psychiatric disorders. So far, the psychometric properties have only been established for certain sections of the instrument. The present study is the first to test the psychometric properties of SCAN-2.1 for most of the disorders covered by the SCAN, and was carried out prior to a survey conducted in the Nijmegen Health Area (the Netherlands). METHODS: Interviewers were psychology graduates with little clinical experience. Two designs were used. In one design, pairs of independent live interviews with the same respondent were compared (test-retest situation). In the other, ten videotaped interviews by experts were rated by each of the interviewers (standardized situation), and the outcomes were compared with those of the other interviewers as well as with a reference score. RESULTS: In the test-retest situation the kappa coefficient for diagnostic caseness was qualified as substantial (0.62) and for diagnostic categories and diagnostic groups as moderate to good (0.24 to 0.64). In the standardized situation using videotaped interviews by experts, sensitivity as well as specificity proved to be substantial to almost perfect. The agreement per interviewer with regard to the reference diagnoses ranged from 87% (diagnostic group) to 94% (diagnostic caseness). Agreement on the syndrome level (without duration and interference criteria of DSM-IV) was excellent. CONCLUSIONS: Although the instrument is traditionally used by experienced clinicians, this study shows that less experienced (but well trained) interviewers can apply SCAN reliably. Special attention should be paid to the items without explicit interview questions, as they tend to be more sensitive to neglect than the items with interview questions.

Stability and change in needs of patients with schizophrenic disorders: a 15- and 17-year follow-up from first onset of psychosis, and a comparison between 'objective' and 'subjective' assessments of needs for care.

Need for care was studied in a Dutch incidence cohort of patients with schizophrenic disorders 15 and 17 years from first onset of psychosis. Long-term course of the disorders varied from complete remission and full community participation to chronic psychosis and long-term hospital stay. Fifty patients were assessed twice with the Needs For Care Assessment Schedule (NFCAS, Brewin and Wing 1989); at the latter follow-up an assessment was also made using the Camberwell Assessment of Need (CAN, Phelan et al. 1995). The NFCAS is an investigator- or professional-based instrument which provides an 'objective' assessment of needs. Need for care was recorded in 22 areas of clinical and social functioning. Comparison of the two assessments over a 2-year period demonstrated a high stability on the individual items (mean 88%, mostly concerning the absence of a problem twice), but did not show the expected stability of need status among this group of patients with chronic disorders. One in five patients (22%) had no needs at all on both occasions and 56% of the patients showed a change in needs. There was more negative than positive change: 28% suffered from new unmet needs at the 17-year follow-up, while only 12% had improved their status to no needs. About one-third (36%) had at least one unmet need, mostly regarding psychotic symptoms, dyskinesia or underactivity. The CAN provides a 'subjective' assessment of needs according to the view of patients themselves. The problems patients reported most commonly were in the areas of day-time activities, social relationships and information on their condition and treatment, for all which they asked for more help than they received. This patient-based instrument produces slightly higher numbers of problems and unmet needs, and a lower ratio between met and unmet needs. There is an overall percentage of 21% of disagreement between patient and investigator view regarding the unmet need status. Agreement between the two instruments on the nature of the problems with unmet needs was lacking altogether.

Assessment of the need for care 15 years after onset of a Dutch cohort of patients with schizophrenia, and an international comparison.

Assessment of needs for care is crucial in the evaluation of ongoing changes from institutional care to various forms of day- and outpatient treatment. Do patients really do better in the community and are they adequately cared for? The 15-year follow-up of a Dutch incidence cohort of patients with schizophrenia and other functional non-affective psychoses showed that 47 (out of 63) patients had positive ratings of symptoms and disabilities. They were assessed by means of the Needs for Care Assessment Schedule, which articulates the problems and corresponding interventions resulting in a judgement of met or unmet need for treatment or assessment. There was a mean of 2.1 clinical problems and 2.1 social problems per patient. Few problems were considered to generate unmet needs: 14% of the clinical problems and only 7% of the social problems. Nevertheless, 32% of the patients had one or more unmet needs. These results were compared with data from six research centres in the United Kingdom (Camberwell, Oxford and South Glamorgan), Canada (Montreal), Italy (Verona) and Finland (Tampere). Despite differences in health care settings in the four countries, the ratio of met to unmet needs (about 4-5 to 1) among chronic, mostly schizophrenic patients is more or less the same with the exception of an apparently underserved hostel population in Oxford and the Finnish patient population probably due to high expectations with respect to independent community living.

Assessment of the prevalence of psychiatric disorder in young adults.

BACKGROUND: The effectiveness of different assessment procedures for determining prevalence rates of psychiatric disorder in young adults was investigated. METHOD: In a two-stage multi-method procedure, the Young Adult Self-Report, the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), the Structured Interview for Personality Disorders (Revised), and the Global Assessment of Functioning (GAF) Scale were used to assess prevalence rates in 706 19-24-year-olds from the general population. Furthermore, individuals' subjective perception of distress and referral to mental health services were assessed. RESULTS: The prevalence of any SCAN/DSM-III-R disorder was 19.3% (95% confidence interval: 11.2-27.4%). Most subjects who received a SCAN/DSM-III-R diagnosis were only mildly impaired. The highest prevalence rates of dysfunctioning (GAF score below 61) without referral to mental health services were for dissociative disorder (2.3%), sleep disorder (2.1%), alcohol dependence (1.3%) and affective disorder (1.8%). CONCLUSION: Instruments that assess functional impairment in addition to DSM-III-R diagnoses are indispensable in prevalence studies.

Costs and benefits of hospital and day treatment with community care of affective and schizophrenic disorders.

BACKGROUND: A randomised controlled trial of day treatment with community care for patients with schizophrenic and affective disorders, referred for in-patient psychiatric treatment, was conducted to evaluate patterns of treatment and the course of illness with its psychosocial consequences over a period of two years. METHOD: Seventy patients, of whom 34 had affective and 36 had schizophrenic disorder, were assigned to the experimental condition (day treatment with ambulatory and domiciliary care), and 33 patients, of whom 16 had affective and 17 had schizophrenic disorder, were assigned to the control condition of standard clinical care. RESULTS: Day treatment with community care was feasible for 40.6% of the affective patients and 33.3% of the schizophrenic patients. The direct treatment costs of both disorders, based on numbers of in- and day-patient days and out-patient contacts over two years, appeared more or less the same. Patients benefited equally from day treatment as from in-patient treatment, although there were some gains in self-care and in functioning in the household among experimentals. Although schizophrenics were socioeconomically worse off, and also suffered from more (severe) symptoms and social disabilities than the affective patients at entry into the study, they were similar at two years. This finding is unexpected, compared with other follow-up studies. Extra cost for patients and families were not observed. Patients and their families in the experimental condition were significantly more satisfied with the treatment. Experimental patients spent much more time at home during admission, remained much less time in secluded wards, and were more compliant with treatment. CONCLUSIONS: Day treatment could be considered a cost-effective alternative to in-patient treatment.

Costs and benefits of day treatment with community care for schizophrenic patients.

The feasibility of day treatment with community care for schizophrenic patients was tested by means of a longitudinal randomized experiment with 34 experimentals and 16 controls: 38 percent could be treated satisfactorily in a day program that included a very active ambulatory service. The new approach did not improve prognosis with respect to psychiatric symptomatology, social role disabilities, or number of readmissions during the first year of followup. Total cost of treatment was less for day-treatment patients than for ordinary clinical patients.

SCAN. Schedules for Clinical Assessment in Neuropsychiatry.

After more than 12 years of development, the ninth edition of the Present State Examination (PSE-9) was published, together with associated instruments and computer algorithm, in 1974. The system has now been expanded, in the framework of the World Health Organization/Alcohol, Drug Abuse, and Mental Health Administration Joint Project on Standardization of Diagnosis and Classification, and is being tested with the aim of developing a comprehensive procedure for clinical examination that is also capable of generating many of the categories of the International Classification of Diseases, 10th edition, and the Diagnostic and Statistical Manual of Mental Disorders, revised third edition. The new system is known as SCAN (Schedules for Clinical Assessment in Neuropsychiatry). It includes the 10th edition of the PSE as one of its core schedules, preliminary tests of which have suggested that reliability is similar to that of PSE-9. SCAN is being field tested in 20 centers in 11 countries. A final version is expected to be available in January 1990.

Use of mental health services in south Verona and Groningen. A comparative case-register study.

A comparison was made of the utilization of mental health services in a psychiatric case register area in Italy (south Verona) and one in the Netherlands (Groningen). All residents living in these areas who contacted a mental health service in 1982 were traced and followed for a period of one year. The year prevalence rates differed considerably (110/10,000 in south Verona and 329/10,000 in Groningen). Rates of single consulters were similar in both areas, while those of chronic inpatients were more than 11 times higher in Groningen than in south Verona. After excluding both single consulters and chronic inpatients, when comparing service consumption according to fixed classes of scores, the category of highest service use accounted for 60% of care provided in Groningen as compared with less than 30% in south Verona. The proportion of total service consumption due to inpatient care was about the same in both areas, but brief admissions were more common in south Verona. Moreover, when service use was considered as a relative construct, about 10% of patients in both areas could be called high users. Finally, long-term patients were more prevalent in Groningen (26%) than in south Verona (13%).

General practitioners' characteristics and the assessment of psychiatric illness.

We put forward the hypothesis that general practitioners (GPs) with a family medicine orientation are more sensitive to the presence of mental health problems than GPs with a clinical orientation. To test it, GPs were divided into three subgroups on the basis of an attitude questionnaire. The General Health Questionnaire (GHQ) and the Present State Examination (PSE) were used as criteria. No differences in sensitivity to psychiatric illness were observed using either scale. Results of factor analysis with the subscales of the GP attitude questionnaire and the indices 'bias' and 'accuracy' were similar to those reported by GOLDBERG and associates. 'New' patients were defined as patients in whom the GP had not identified a mental health problem (MHP) in the past year. 'Old' patients were defined as 'not new'. GPs tended to under-identify MHPs in 'new' and over-identify them in 'old' patients. Recognition of psychiatric illness was better in 'old' than in 'new' patients. In 'new' patients, recognition depended on psychiatric diagnosis. Among 'old' patients, older people and people (especially women) with low education predominated. In their assessments GPs used information not contained in the GHQ.

Patterns of mental health care in two European areas: Mannheim, Federal Republic of Germany; and Groningen, The Netherlands.

All consecutive cases entering the mental health services cooperating with the cumulative psychiatric case register of Mannheim between 1-31 July 1976 were followed up until the end of June 1978 and compared with the consecutive cases entering the mental health services cooperating with the psychiatric case register of Groningen between 1 January and 1 May 1979. Patterns of in-, day- and outpatient care delivered to these 2 cohorts of patients, who were greater than or equal to 15 years of age, and who had not been in contact with one of the services for at least 6 months prior to entry, were compared by diagnostic category. The most common episode of care was the relatively brief outpatient one. Mixed types of care and chronic cases were more common among patients with a psychosis or an addiction than in other diagnostic categories. Between 6 and 24 months after first contact 76% of the patients in Mannheim and 43% of the patients in Groningen had no more contacts. Between 18 and 24 months after the first contact the percentages had increased to 90 and 72% (respectively). In Groningen a higher percentage of patients received outpatient care only. Although a larger percentage of patients in Mannheim received inpatient care, the accumulation of "new chronic" patients was larger in Groningen, as a result of a greater length of stay in Groningen.

The feasibility of cost-benefit studies of mental health care. An attempt with a Dutch Case Register.

A cohort of 928 people, aged 20 to 60 years, were entered in a Dutch Case Register for the first time as outpatients during the period from 1974 to 1977. They were each followed up for 1 year in order to identify patterns of care and calculate their cost. The latter was calculated for groups of patients, according to diagnosis and type of service at entry. This approach required registering face-to-face contacts for each patient, and close collaboration with the services involved, to calculate costs.

The WHO collaborative study on strategies for extending mental health care, II: The development of new research methods.

Teams in seven developing countries under sponsorship of the World Health Organization have been carrying out collaborative operational research on providing mental health care through primary health care services. New techniques of identifying mental disorders in children and adults have been developed and tested. Methods of assessing the skills and attitudes of health workers toward mental health work and of gauging community attitudes toward mental illness have also been developed. Results have been directly applied in planning better mental health care. The authors conclude that cross-cultural collaborative research is effective in improving mental health care for those in greatest need.

The burden of mental illness on the family. Results of observations in four developing countries. A report from the WHO Collaborative Study on Strategies for Extending Mental Health Care.

As part of the WHO Collaborative Study on Strategies for Extending Mental Health Care 259 families in four developing countries (Colombia, India, Sudan and the Philippines) were screened with regard to the social burden caused by mental illness of one of its members. Levels of subsistence, previous illness, financial burden, personal relations and social acceptance were studied. The social burden was greatest in the urban areas.

Social class and schizophrenia in a Dutch cohort.

Recent data from a 2-year follow-up of functional non-affective psychosis, and particularly schizophrenia, favoured social selection rather than social causation theory. Data concerning the cohort were compared with inter- and intra-generational mobility in a random Dutch sample. The results indicate that the educational and occupational mobility of patients, relative to their fathers, was greater than expected. Although patients were better educated than the random sample, they fared less well occupationally. An analysis of patterns of occupational mobility before and after the onset of psychosis also showed that social selection played a major role in achieving social status. The outcome of patients' occupational career at follow-up was poor, and only a minority succeeded in obtaining or keeping a regular job.

On vagrancy and psychosis.

Paradoxically, due to recent mental health legislation, the mentally handicapped of the developed world find themselves in the same situation as the majority of those in the developing world who never had contact with a mental health service. A survey of the literature and of the situation in Egypt and Lesotho suggests marked coincidence of vagrancy and chronic mental illness. In both the developed and developing world, adequate services to support these people are lacking.