Validity of a short clinical interview for psychiatric diagnosis: the mini-SCAN.

BACKGROUND: To promote clinical application of the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) system a shorter version (the mini-SCAN) was devised. Its psychometric properties were unknown. AIMS: To establish the validity and practical properties of the mini-SCAN. METHOD: One hundred and six participants were interviewed twice, once with the SCAN and once with the mini-SCAN. The level of agreement was established for the categories: no disorder, affective disorders, anxiety disorders, non-affective psychotic disorders, affective psychotic disorders. RESULTS: The mini-SCAN is a valid instrument. Most kappa values were around 0.90. Only for the class of affective psychotic disorders was the agreement moderate. Mean duration of the mini-SCAN interviews was 25 min shorter than the SCAN interviews. Participants and interviewers were generally satisfied with the interview format and questions. CONCLUSIONS: The mini-SCAN can be used as a diagnostic instrument for clinical purposes and for clinical studies when the present episode is the focus of attention.

Economic consequences of alternative medication strategies in first episode non-affective psychosis.

BACKGROUND: Maintenance treatment appears to be successful in preventing relapses in first episode psychosis, but is also associated with side effects. Guided discontinuation strategy is a less intrusive intervention, but may lead to more relapses. In the current economic evaluation, costs and health outcomes of discontinuation strategy will be compared with the results of maintenance treatment in patients with remitted first episode psychosis. METHOD: The study was designed as a randomised clinical trial. In total 128 patients were prospectively followed for 18 months after six months of stable remission. The economic evaluation was conducted from a societal perspective. Quality-adjusted life years (QALYs) were used as primary health outcome in the economic evaluation. Relapse rates were assessed in addition to various other secondary outcomes. RESULTS: There were no relevant differences in mean costs between groups during the study. Total costs were largely influenced by costs related to admissions to psychiatric hospitals. No differences between groups were found for QALY results. CONCLUSIONS: There were no indications that either of the examined interventions is superior to the other in terms of costs or QALY results. Additional results indicated that the relapse rate in discontinuation strategy was twice as high, but without an increase in hospital admissions or negative consequences on other clinical outcomes. For a minority of remitted first episode patients, guided discontinuation strategy may offer a feasible alternative to maintenance treatment.

Treatment delay and response rate in first episode psychosis.

OBJECTIVE: There is no consistent evidence of long duration of untreated psychosis (DUP) predicting long time to response (TTR) in first psychosis. This study aims to investigate the predictors of DUP and TTR in a first episode patient population. METHOD: An epidemiologically representative sample of 157 non-affective first psychotic episode patients was interviewed and followed-up for at least half a year. RESULTS: The mean DUP was 46 weeks, the median 31 days. Long DUP was associated with being unemployed before treatment and male gender. Short DUP, having a job, and living with a partner before treatment predicted early response. CONCLUSION: Early intervention likely improves short-term treatment response in first episode psychosis. The best strategy to reduce DUP probably is to direct attention to the substantial number of patients who do not engage in regular treatment.

Hallucination focused integrative treatment improves quality of life in schizophrenia patients.

OBJECTIVE: Psychosocial treatment seems to be effective in the management of schizophrenia, although less in the area of quality of life and social functioning. To study the effectiveness of a hallucination focused integrated treatment with cognitive-behaviour therapy and coping training among schizophrenia patients suffering from 'hearing voices'. METHOD: In a randomized controlled trial (RCT) with 31 patients in the integrated treatment condition and 32 patients in the routine care condition, quality of life was assessed with the self-report questionnaire of the WHO (Bref), and social role functioning with an interviewer based schedule, at entry and 9 (post-treatment) and 18 months later. RESULTS: Follow-up data suggest a significant improvement of quality of life and in particular in social role functioning (effect size 0.64) in favour of the integrated treatment. CONCLUSION: The integrated treatment seems to be effective in reducing overall disability levels and number of patients with serious disabilities.

Cost-effectiveness of the HIT programme in patients with schizophrenia and persistent auditory hallucinations.

OBJECTIVE: To examine the cost-effectiveness of Hallucination focused Integrative Treatment (HIT) in patients with schizophrenia and a history of persistent auditory hallucinations. METHOD: Costs, in and outside the health care sector, and outcomes were registered prospectively during a period of 18 months for patients who received the HIT programme and for patients in the care as usual (CAU) condition. The Positive and Negative Syndrome Scale (PANSS) was used as main outcome measure in the cost-effectiveness analysis. Bootstrap analyses provided additional information on the skewly distributed costs. RESULTS: Mean costs per patient in the HIT group (18,237 dollars) were lower than the mean costs per patient in the CAU group (21,436 dollars). Results of the PANSS were slightly in favour of the HIT group. CONCLUSION: There appears to be no significant cost-effectiveness advantage of the HIT programme over CAU. Additional analyses indicated that future application of the HIT programme will, in most cases, lead to a reduction of (non) medical costs.

Cognitive behaviour therapy with coping training for persistent auditory hallucinations in schizophrenia: a naturalistic follow-up study of the durability of effects.

OBJECTIVE: To investigate the durability of positive effects of cognitive behaviour therapy (CBT) with coping training on psychotic symptoms and social functioning. METHOD: Forty patients with schizophrenia or related psychotic disorders and refractory auditory hallucinations were given CBT and coping training in an integrated single family treatment programme. In a naturalistic study patients were followed after 2 and 4 years since the start of treatment. RESULTS: The treatment improved overall burden of 'hearing voices', with a generalization into daily functioning. Improvement with regard to fear, loss of control, disturbance of thought and interference with thinking was sustained by 60% of the patients while one-third improved further. Complete disappearance of hallucinations occurred in 18% of the patients. CONCLUSION: CBT with coping training can improve both overall symptomatology and quality of life, even over longer periods of time, but a status of persistent disablement indicates a continuing need for mental health care.

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.

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.

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.

Natural course of schizophrenic disorders: a 15-year followup of a Dutch incidence cohort.

Data are presented on the 15-year natural course of schizophrenia and other nonaffective functional psychoses in a cohort of 82 first-contact cases from a circumscribed area in the Netherlands. The subjects were suffering from functional psychosis with International Classification of Diseases-Ninth Revision (ICD-9) diagnoses 295, 297, or 298.3-9 (broad definition of schizophrenia) on entry. Standardized assessments of psychopathology, psychological impairments, negative symptomatology, social disability, and use of mental healthcare were used. The study reveals a pattern of chronicity and relapses with a high risk of suicide: Two-thirds of the subjects had at least one relapse and after each relapse 1 of 6 subjects did not remit from the episode; 1 of 10 committed suicide; and 1 of 7 had at least one episode with affective psychotic symptoms that started on average 6 years after the onset of the schizophrenic disorder. Diagnoses were reclassified in five patients, according to DSM-III-R criteria for a bipolar disorder. The predictive power--in terms of time in psychosis and in partial or full remission--of demographic, illness, and treatment variables at onset of the illness was very limited. Insidious onset and delays in mental health treatment are risk factors that predict a longer duration of first or subsequent episodes. The importance of mental health treatment in regard to outcome is probably subject to change because an early warning and intervention strategy could prevent further damage and deterioration. Our data support the need for an adequate relapse prevention program as a priority for our mental health services.

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.

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.

Efficacy of psychiatric day treatment. Course and outcome of psychiatric disorders in a randomised trial.

The course of the psychopathology and social functioning in an experimental day-treatment group referred for inpatient psychiatric treatment is compared with that of a control group receiving standard inpatient care. During a follow-up period of 2 years subjects were interviewed three times. The interview comprised information about psychiatric symptoms, psychological functions, psychiatric diagnosis and social-role functioning. Apart from these discrete assessments an effort was made to map episodes of illness throughout the follow-up period. Upon entry the groups did not differ in terms of psychopathology or social functioning. At follow-up both groups had improved significantly with respect to symptomatology, psychological and social functioning. The extent to which the groups improved did not differ significantly regarding pathology, but self-care improved more in the experimental group. The average duration of episodes of illness was similar for the experimental and control group. During the 2-year follow-up patients suffered from a well-defined disorder during an average of 11 months. The fact that approximately 40% of them were still a psychiatric case after 2 years further underscores the severity of their pathology.

Predicting feasibility of day treatment for unselected patients referred for inpatient psychiatric treatment: results of a randomized trial.

OBJECTIVE: Because previous studies of day treatment as an alternative to inpatient treatment had major disadvantages or methodological shortcomings, the authors conducted a randomized controlled trial to estimate and predict the extent to which day treatment is feasible for unselected patients referred for inpatient treatment. METHOD: Of 160 patients, 57 were randomly assigned to the control condition and 103 were assigned to the experimental condition. Control patients received standard clinical care. In the experimental condition, day treatment was attempted as soon as the patient's condition permitted. The average number of nights per week that experimental patients spent away from the hospital was compared to the average number of nights away for patients under standard care. RESULTS: Day treatment was satisfactory for 40% of the experimental patients but was completely infeasible for another 40%. The level of surveillance needed in the first week, physical illness, number of previous admissions, depressive symptoms, and treatment by qualified psychiatrists versus registrars were variables predictive of these differences. CONCLUSIONS: In this unselected group of patients, no absolute contraindications against day treatment were found. This suggests that the selection criteria applied in nearly all other controlled studies on the subject were unwarranted. The approach used in this study facilitated treatment in the least restrictive environment possible.

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.