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.
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