The International Journal of Psychosocial Rehabilitation
Disability in Schizophrenia:
Do Short Hospitalizations have a Role?

 
 
A Gupta, MBBS, DNB
Psychiatrist,
RML Hospital, New Delhi 110001 India
 
Formerly Senior Resident in Psychiatry,
Institute of Human Behaviour & Allied Sciences
Delhi 110095 India
E Mail   anjusimran_2003@yahoo.co.in
 
R K Chadda, MBBS, MD, MAMS, MRCPsych *
Professor of Psychiatry,
All India Institute of Medical Sciences,
Delhi-110029 India
 
Formerly Professor of Psychiatry,
Institute of Human Behaviour & Allied Sciences
Delhi 110095 India
E mail drrakeshchadda@hotmail.com
 


 Citation:
Gupta A. & Chadda R.|K.   (2008). Disability in Schizophrenia:Do Short Hospitalizations have a Role?
   International Journal of Psychosocial Rehabilitation. 13(1), 91-96
 
 
 

Abstract 
Long term hospitalization was considered an important factor in development of disability in patients with schizophrenia. Do short hospitalizations, as  is the practice now,  also lead to disability, has not been studied.  The present study was conducted to compare the disability amongst two groups of patients with schizophrenia, previously hospitalized (PH) and never hospitalized (NH), and to understand the role of hospitalization in causing disability. Sixty patients with DSM-IV diagnosis of schizophrenia (30 each in PH and NH groups) attending follow up in a psychiatric outpatient service in a public funded hospital were assessed for disability, psychopathology and various clinical characteristics. The two groups of patients suffered similar levels of disability in personal and social areas as well as global disability, but the occupational disability was higher in the PH group than in the NH group.  A positive correlation was observed between disability and the number of admissions, total duration of hospitalization, negative symptoms, cognitive deficit and number of exacerbations. The study concludes that short periods of hospitalization do not appear to contribute to disability in personal and social areas, but may affect occupational disability. 
 
Key words: Disability, schizophrenia, hospitalization, India. 
 

Introduction
Schizophrenia is definitely the most disabling psychiatric disorder. Long-term hospitalization has been recognized as an important factor contributing to the disability associated with schizophrenia (Johnstone et al, 1981).  Following deinstitutionalization a number of studies have found decrease in disability associated with the illness and improvement in social functioning (Dickey et al, 1981; Barbato et al, 2004).  Disability has been found to be affected by characteristics like age of onset, duration of illness, severity and type of symptoms, duration of untreated psychosis, cognitive deterioration, and intellectual functioning (Alptekin et al, 2005).  
 
With the deinstitutionalization on scene for the last 3-4 decades and more and more emphasis on shorter hospitalizations and community care, long term hospitalizations have become less frequent, though short hospitalizations are still required in a number of patients with schizophrenia. Some patients suffering from schizophrenia may need to be hospitalized a number of times in the course of their illness. The potential of such repeated short hospitalizations as a contributor to disability has not been studied. The present study reports on the effect of short hospitalizations on development of disability in patients of schizophrenia.   
 
Material and Methods
Selection of subjects: The study was carried out in outpatient setting at the Institute of Human Behaviour and Allied Sciences, a public funded neuropsychiatric hospital in the city of Delhi in India. Inclusion criteria were DSM IV diagnosis of schizophrenia, age 18-55 and a minimum duration of illness of one year. Only clinically stable patients were included for the study to control for the effect of acute exacerbations on disability, since the study had a cross sectional design. Clinical stability was empirically defined as the patient requiring no changes in medication and no more than 25% change in the dosage during three months prior to inclusion in the study. Subjects with history of any co-morbid chronic medical illness, axis-II diagnosis, substance abuse (except nicotine), mental retardation and physical handicap were excluded from the study. Sample consisted of two groups; previously hospitalized (PH) and never hospitalized (NH) patients. To be included in the PH group, the last hospitalization should have been at least six months prior to the inclusion in the study. About 200 patients were screened in the outpatient clinic for the study over a period of about 6 months (October 2001 – March 2002) to get a sample of 60 patients with 30 in each group. Sample was of convenience.
 
Assessments: Sociodemographic characteristics and clinical details of the subjects were collected on a semi-structured proforma, designed for the study. Clinical details included age of onset, total duration of illness, duration of untreated psychosis at onset, number of exacerbations or relapses during life time, number of hospitalizations in the past and total duration of hospitalization. Patients and key relatives were interviewed to collect the information.
 
Psychopathology was assessed on the Positive and Negative Syndrome Scale (PANSS) (Kay & Lindenmayer, 1987). PANSS gives scores on positive symptoms, negative symptoms and general psychopathology. Psychiatric disability was assessed on the Schedule for Assessment of Psychiatric Disability (SAPD) (Thara et al, 1988), a modification of Disability Assessment Schedule II of WHO.  Mini Mental Status Examination – MMSE was used to assess the cognitive functions.   Written informed consent was taken from all the subjects or their caregivers, if the subject was not competent to give the consent. The study was approved by the Institute’s Ethics Committee.
 
Analysis: T test and chi-square statistics were used to study the differences between the two groups. Correlations between psychiatric disability and various sociodemographic and clinical characteristics were studied using Pearson’s product moment correlation co-efficient.  
 
Results
Mean age of patients was 32.73 ± 9.44 and 36.50 ± 8.63 in the PH and NH groups respectively. About 70% patients were in the age range of 20-40.     Number of males was higher than the females (63.3% in PH group and 76.7% in NH group).  All the patients were living with their families. Around 3/4th of the patients in each group were married. The two groups did not differ significantly on various socio demographic variables. 
 
Total duration of illness varied from 2.5 to 32 years (Mean 13.27 ± 8.39) in the PH group and 1.5-18 (Mean 8.17 ± 4.95) years in the NH group (p .006).  Patients in the PH group had been hospitalised on one to 20 occasions (Mean 2.57 ± 3.77) for a total period of 7 to 900 days (Mean 116.7 ± 176.96).   Number of exacerbations suffered during the course of illness varied from 1-20 (Mean 4.25 ± 3.76) in the PH group and 1-6 (Mean 2.83 ± 1.46) in the NH group. The mean duration of untreated psychosis at the first contact was 17.36 ± 31.36 and 14.23 ± 33.48 months in the PH and NH groups respectively.  The two groups did not differ form each other in the number of exacerbations and duration of untreated psychosis.
 
Patients in the PH group were more severely ill than those in the NH group as indicated by higher scores on positive symptoms (p .023). No significant differences were observed in the scores on negative symptoms and general psychopathology subscales of PANSS. The two groups suffered similar levels of disability in personal and social areas as well as global disability, though the PH group got higher scores on occupational disability than the NH group (p .007) (Table 1). 

Table 1: Scores on PANSS,   MMSE and SAPS in previously hospitalized (PH) and never hospitalized (NH) groups (N 60)    
 
Variables
 
PH Group
(N 30)
 
NH Group
(N 30)
 
t value
 
df
 
Significance
 
 
Positive Score
 
 
12.33 ± 5.67 



9.36 ± 4.02
 
 
-2.34
 
 
58
 
 
0.023
 
Negative Score
 
 
 
12.3 ± 3.68
 
11.87 ± 5.46
 
-0.36
 
58
 
0.72
 
General Psychopathology Score
 
 
 
 
25.76 ± 7.31
 
29.46 ±8.52
 
1.80
 
 
 
58
 
.08
 
MMSE score
 
 
26.80 ± 3.03
 
26.66 ± 2.32
 
-0.19
 
58
 
0.849
Personal Disability:
 
0.89 ± 0.18
 
 
0.83 ± 0.20 -1.22
 
 
58
 
 
0.230
Social Disability:
 
1.08 ± 0.28
 
 
1.03 ± 0.26
 
 
-0.72 58 0.48
Occupational Disability:
 
1.26 ± 0.44
 
 
1.00 ± 0.26
 
 
-2.79 58 0.007
Global Disability:
 
1.20 ± 0.41
 
 
 
1.03 ± 0.32
 
 
 -1.79 58 0.079
 
 
A positive correlation was seen between disability in various areas, and the number of hospitalizations and total duration of hospitalization. Males showed higher social disability than females. The unmarried patients suffered higher disability in personal area than the married patients. Disability showed a positive correlation with negative symptoms and negative correlation with MMSE score.  A positive correlation was seen between disability in occupational area and total number of exacerbations.
   
Discussion 
Patients in the PH group had been ill for a longer period and had higher scores on positive symptoms as compared to the NH group. But the two groups did not differ on      negative symptoms and cognitive functioning, reported to be two important contributors to disability (Klapow et al, 1997). The PH group had been hospitalised for about 4 months on an average during the whole course of their illness with the number of hospitalizations varying from 1 to 20. The two groups suffered similar levels of disability except in the occupational area, in which the PH group had higher scores. The interruptions in the routine functioning due to hospitalisations followed by a latency period to resume work could   be the reason. There is also a possibility that occupational disability is more vulnerable and observable indicator of functional deterioration and is easy to recall.
 
In the past, a number of researchers have reported on the role of long term hospitalisation in causing disability (Klapow et al, 1997; Leffe et al, 1996; Okin et al, 1995).    Half of our patients had been hospitalized for different periods in the past. A positive correlation was seen between disability in various areas, and the number of hospitalizations and total duration of hospitalization.  This indicates that even frequent short hospitalizations may have some role in causing disability. Higher scores on positive symptoms and longer duration of illness in the PH group were other confounding variables which could have affected disability.
 
Disability in patients with schizophrenia has been reported to be related to negative syndrome   cognitive symptoms (Klapow et al, 1997; Lysaker et al, 1995), and positive symptoms (Alptekine et al, 2005). In the present study also, disability scores showed a positive correlation with scores on negative symptoms, and a negative correlation with MMSE scores (cognitive functioning). However, in case of positive symptoms, significant correlation was present only with the global disability, and not with disability in individual areas. Probably, a small sample size was not able to elicit all the correlations.  
 
The study had a few limitations like a small sample size, absence of longitudinal assessment and lack of randomization. There is also a possibility of recall bias as the patients had been ill for a long duration going up to 20 years.
 
The findings are difficult to generalize considering a small sample. Prospective studies with larger samples are required to elucidate the role of multiple short hospitalisations in causing disability.
 
Acknowledgment:
The authors are grateful to Dr Narendra Singh, formerly Assistant Professor of Psychiatry, Institute of Human Behaviour and Allied Sciences, Delhi for his help and guidance during the study.
  
 

References
 
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Thara, R.,  Rajkumar, S.,  Valecha, V. , 1988.  The   Schedule for the Assessment of  Psychiatric  Disability -  A  modification  of  DAS II. Indian   J Psychiatry 30, 47-53.
   
 



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