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Factors associated with recurrent hospitalization of psychiatric patients Brumwell, Joan Marion 1981

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FACTORS ASSOCIATED WITH RECURRENT HOSPITALIZATION OF PSYCHIATRIC PATIENTS by JOAN MARION BRUMWELL B.S.N., The University of British Columbia, 1955 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES School of Nursing We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA April 1981 © Joan M. Brumwell, 1981 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make i t freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Wo rs i ^ ,The University of British Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 C^vd ^fr, SI. i i ABSTRACT The purpose of this retrospective study was to investigate factors associated with recurrent hospitalization of psychiatric patients. A set of selected characteristics was used to describe and compare the 401 patients whose f i r s t psychiatric hospitalization occurred at the Health Sciences Centre - Psychiatric Unit, University of British Columbia in 1976 or 1977. Sixty-seven of these patients returned at least once to this Psychiatric Unit only within two years of their f i r s t hospitalization. Data gathered from the c l i n i c a l records of these patients were analyzed according to comparisons of sub-groups of non-returned and returned patients at f i r s t hospital-ization, non-returned and returned patients at second hospitalization and returned patients at f i r s t and second hospitalizations. The analysis revealed that patients who had a history of drug abuse, who were employed during the six months prior to hospitalization and males who were young, single, and schizophrenic at f i r s t hospital-ization had a s t a t i s t i c a l l y greater chance of returning to hospital. At second hospitalization these patients were significantly different from patients who did not return in the following areas: history of drug abuse and history of suicide attempts. Implications of these and other findings of interest related to rehospitalization are discussed and areas for further study are identified. i i i TABLE OF CONTENTS CHAPTER I INTRODUCTION TO THE STUDY 1 Introduction and Rationale for the Study 1 Purpose of the Study 3 Set of Selected Characteristics 3 Assumption 4 Limitations 4 II REVIEW OF THE LITERATURE 5 The Emergence of the Phenomenon of Recurrent Hospitalization 6 Studies That Attempt to Isolate Factors Associated with Relapse 8 Studies Comparing Groups of Patients, Non-Rehospitalized and Rehospitalized 15 Summary and Conclusions 21 III METHODOLOGY 24 Design 24 Data Collection 24 Data Analysis 25 Setting 25 Selection of the Sample 26 Set of Selected Characteristics 27 iv CHAPTER IV FINDINGS AND DISCUSSION 30 Description of the Total Sample and Subgroups 30 Characteristics of the Diagnostic Subgroups of the Total Sample 39 Characteristics at the Time of Second Hospitalization 54 Some Characteristics of Patients Who Returned to Hospital More Than Once Within Two Years of First Hospitalization 57 Results of the Within Group Comparison 57 Results of the Between Group Comparison: Not Returned and Returned 62 Results of the Between Group Comparison: First Hospitalization and Second Hospitalization . . . . 62 Discussion and Interpretation 63 V SUMMARY, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS FOR FURTHER STUDY 70 Summary and Conclusions . . . . . 70 Implications 74 Recommendations for Further Study 77 •APPENDICES A Table A - l : Chi-Square, Degrees of Freedom and P Value for Selected Demographic and C l i n i c a l Patient Characteristics Comparing First Hospitalization Returned (n=67) and Not-Returned (n=334); First and Second Hospitalizations (n=67, n=67); and First Hospitalization, Not-Returned (n=334) and Second Hospitalization (n=67) Table A-2: Chi-Square, Degrees of Freedom and P Value for Sex, Marital Status and Diagnosis of Patients at First Hospitalization: Returned (n=67), Not-Returned (n=334) B Table B-l: Psychiatric Units, First Hospitalization, 1976. Percent Female and Age: Canada, British Columbia and Health Sciences Centre - Psychiatric Unit v i LIST OF TABLES Table Page 1. Frequency Data for Selected Demographic and C l i n i c a l Characteristics at First Hospitalization of Total Sample (n=401); Returned (n=67) and Not-Returned (n=334) and at Second Hospitalization (n=67) 31 2. Number and Percent of Patients by Diagnostic Category and Selected Demographic and Cl i n i c a l Characteristics (n=401) 40 3. Number and Percent of Patients by Diagnostic Category Rehospitalized Within Two Years According to Age and Sex at Firs t Hospitalization (n=401) 51 4. Number and Percent of Patients by Diagnostic Category Rehospitalized Within Two Years According to Marital Status and Sex at First Hospitalization (n=401) . . . . 52 5. Number and Percent of Patients by Diagnostic Category and History of Drug Abuse at First Hospitalization; Returned (n=6'7) and Not-Returned (n=334) 58 6. Composition of the Sample According to Sex and Type of Drug Abuse for Patients at First Hospitalization; Returned Only (n=67) 59 7. Number of Patients by Diagnostic Category and Type of Drug Abuse for Patients at Firs t Hospitalization; Returned Only (n=6'7) 60 v i i LIST OF FIGURES Figure Page 1. Proportions of Males and Females by Diagnostic Category at First Hospitalization (n=401) and Second Hospitalization (n=67) 49 2. Age Distribution of Total Sample at First Hospitalization Compared with the Age Distribution of the General Population (Canada - 1976) 53 3. Number of Days Elapsed to Rehospitalization; for Patients Who Returned to Hospital (n=67) Grouped by Diagnostic Category 56 4. Employment Status on Admission by Diagnostic Category (n=401) 61 v i i i ACKNOWLEDGEMENTS I wish to thank the members of my thesis committee for their support and guidance: Dr. Marilyn Willman for her professional exper-tise as a mentor and editor and for her patience and accessibility; and Dr. Harry Klonoff his enthusiasm, encouragement and humour as he guided me through the practical aspects of the research process. Special thanks to the people of the Health Sciences Centre -Psychiatric Unit who enabled me to undertake and complete this study, especially to Sheila Ryan and Linda Lauritzen for their encouragement and forebearance and to Liz Hammer for her computer expertise and advice. Lastly, I wish to express appreciation to my family and friends whose understanding and co-operation maintained me throughout the period of the study. CHAPTER I INTRODUCTION TO THE STUDY Introduction and Rationale for the Study The 1960's heralded a major change in emphasis of delivery of mental health services to psychiatric patients from prolonged i n s t i t u -tional care in large mental hospitals to treatment in local community treatment centres and psychiatric units of general hospitals (Glick 1979, p . l ) . Discovery and use of psychotropic drugs, the advent of community mental health f a c i l i t i e s and government support of policies for early discharge are influences affecting the change. In Canada between 1967 and 1977 the number of patients in public health hospi-tals was reduced by 49.2 percent (Mental Health Statistics 1977, p.33) The increasing incidence of short recurrent hospitalizations which accompanied the change can be "conceptualized as one of long-stay chronicity giving away to intermittent patienthood" (Munley 1977, p.1093). In British Columbia the latest readmission rate is 68.5 per-cent (Statistical Report Mental Health Programs B.C. 1976, p.68). The phenomenon of recurrent hospitalization has given rise to a numb"er of studies on personal, social and environmental factors asso ciated with i t . A review of the literature discloses that researchers seeking predictors of rehospitalization have investigated the problem from diverse points of view. Some have concentrated on.the patient's 2 diagnosis, interpersonal s k i l l s , treatment and degree of improvement at discharge. Others have concentrated on the patient's success in the community and the various factors thought to be associated with relapse and rehospitalization, such as compliance with medication regimes, use of leisure time, a b i l i t y to find and keep a job, and ab i l i t y to interact with an available social network. Few significant findings have emerged from the studies, a fact that is l i k e l y related to the number and complexity of factors. In the reported studies there is diversity of patient symptoms and diag-noses, of levels of susceptibility and severity of il l n e s s , of responses to stress, of the individual's perception of symptoms and characteris-t i c physiological and psychological responses; as well as diversity in models of mental ill n e s s , treatment modalities and accessibility and availability of mental health services and social support systems. Also, many of the findings from the studies conducted in large American and British public mental hospitals may have l i t t l e generalizability to psychiatric units in Canada. Currently, costs of health care, productivity of professionals and quality of care are of increased interest to Canadian governments, both federally and provincially, and to consumers. In order for pro-grams to meet the needs of psychiatric patients who are recurrently hospitalized and the requirements of governments for cost effective-ness, i t is necessary to increase knowledge pertaining to characteris-tics of individuals who return to hospital, and individuals who do not, so that patients may receive appropriate care without overuse of 3 hospital. For these reasons, this retrospective study attempts to identify characteristics of patients that are associated with recurrent hospitalization. Purpose of the Study The purpose of this study is to compare in terms of a set of selected characteristics a group of patients who, after a f i r s t hos-pitalization, were not rehospitalized within two years of discharge and a group of patients who, after f i r s t hospitalization, were rehos-pitalized in the same psychiatric unit only within two years of discharge. Set of Selected Characteristics Two categories of characteristics have been selected for study: demographic and c l i n i c a l . Demographic characteristics are defined as sex, marital status, age, education, occupation, employment, geographical location of residence, financial support, living situation on admission, nearest kin. C l i n i c a l characteristics are defined as f i n a l diagnosis, suicide attempt ever, suicide attempts prior to or within one month of admission, sub-jective statement of depression on admission, drug abuse, referral source, days hospitalized, voluntary or involuntary status, absent without leave during hospitalization and nature of hospital termination. 4 Assumption It i s assumed that, although the use of a retrospective record audit allows no control over the data base, i t is an appropriate way to collect the data required for this study. Limitations The following are the limitation of the study: 1. The data in the health record were accepted as recorded and were not interpreted or validated. 2. The exclusion of patients requiring special monitoring or management of physical symptoms may have biased the sample. 3. The ease of access to hospitals in general and psychiatric units in particular, made possible by medicare and hospital insurance, may influence the use of such f a c i l i t i e s for purposes other than temporary intensive treatment of the out-of-control, destructive or self-destructive individual. Thus, some subjects may be included in the sample who, under other circumstances or in other health care sys-tems, might not have been hospitalized. 4. The study was restricted to patients i n one psychiatric unit; therefore, the findings cannot be generalized beyond that unit. 5 CHAPTER II REVIEW OF THE LITERATURE The literature review includes relevant readmissions studies conducted between 1960 and 1980, particularly those studies which focussed on characteristics of psychiatric patients associated with recurrent hospitalization. The studies varied widely in purpose, design, population studied, length of study, setting, the country in which the research was conducted and in the professional discipline of the investigator. A l l of the researchers sought to identify factors associated with rehospitalization that could be manipulated for the patient's benefit. A few signposts have been identified, but there have been few definitive answers. The review is organized into three sections. Section one pre-sents a brief review of the emergence of the phenomenon of recurrent hospitalization. The next section includes a review of studies that attempt to isolate factors associated with relapse and/or rehospitali-zation. In section three the review focusses on studies comparing psychiatric patients who were rehospitalized and those who were not. A summary of the literature concludes this chapter. 6 The Emergence of the Phenomenon  of Recurrent Hospitalization Thirty years ago for most of the approximately 5 percent of the general population functionally incapacitated by mental illness for long periods (Editorial, CMA Journal 1978, p.223) custodial care would have been the main mental health service provided. Then, in the late 1950's, Canada, like much of the Western world, moved away from the emphasis on custodial care of psychiatric patients to brief active treatment programs in psychiatric units of general hospitals, followed by community care in local mental health centres. In British Columbia, the trend toward regionalization of mental health services was influenced by the successful operation of the Burnaby Mental Health Centre with i t s outpatient follow-up and daycare services (Colls 1976, p.22). In 1962, the Provincial Mental Health Services established and staffed the Broadway Clinic for follow-up of patients discharged from the Provincial Mental Hospital. Two boarding homes - Venture and Vista - were also established at this time. From 1964 to 1976, the Provincial Mental Hospital reduced i t s beds from 4,569 to 1,130 (Annual Report 1976, Ministry of Health, B.C., p.150). By 1966, ten community mental health centres were in operation with a case-load of 5,877 patients which increased to a 1974 case-load of 12,950 with the addition of twenty-one centres (Colls 1976, p.27). In 1972, in a Plan for Vancouver, Cumming proposed a group of services "readily available with a minimum of environmental dislocation", for "the management of the seriously i l l adult psychotic . . . who is overplaced in inpatient f a c i l i t i e s " which therapeutically and f i s c a l l y minimize inpatient hospitalization (Cumming 1976, p.S.2). Cumming adds that often patients who are less impaired are more gratifying to treat and often monopolize available resources. In the United States this community mental health movement with i t s l i b e r a l values came to fruition in the I960's, "a period character-ized by so c i a l - p o l i t i c a l reform and a revival of humanistic concerns for the disadvantaged, the oppressed and the powerless" (Hersch 1972, p.749). Those committed to the philosophy of community mental health believed social adjustment to be the primary goal of treatment (Wilson and Kneisl 1979, p.753). As in the United States, British Columbia community mental health centres provided comprehensive mental health programs while hospitals provided direct care to psychiatric patients. With the use of psychotropic drugs, the establishment of com-munity mental health cli n i c s and community care teams for the management of the seriously i l l adult psychotic, the annual census of public mental hospitals has decreased, but the number of admissions to these f a c i l i t i e s and to psychiatric units in general hospitals has increased. A growing proportion of those admissions are readmissions and Bassuk and Gerson (1978) claim that "about half of the released inpatients are readmitted within a year of discharge" (p.49). Solomon and Doll (1979) suggest that rehospitalization of psychiatric patients may reflect one, or more than one, of the following factors: 1. the patients' solutions to emotional problems; 8 2. a function of demographics (age, sex, race, marital status, social class); 3. family tolerance; 4. community tolerance; 5. care-givers' reactions to deviant (noncompliant) patient behaviour; 6. patient characteristics (attractiveness, previous history, l i k e a b i l i t y ) ; 7. care-giver characteristics (attitudes, experience, status in system); and 8. the nature of the mental health delivery system (policies, census, available alternatives). Many researchers have attempted to identify relationships be-tween factors such as these and the phenomenon of recurrent hospitali-zation. Some studies related to this phenomenon w i l l be discussed i n the next two sections. Studies That Attempt to Isolate Factors  Associated with Relapse The quest for predictors of relapse and/or rehospitalization began in the early 1960's. Most of the investigators conducted their studies, especially the large scale ones, in the large public mental hospitals and veterans hospitals on groups of schizophrenic patients. An early study by William and Walker (1961) set out to determine the relationship between the degree of remission of schizophrenic patients on discharge and a twelve-month uninterrupted stay in the community. Their 9 hypothesis that the degree of recovery at discharge has p r e d i c t i v e value with respect to relapse ( r e h o s p i t a l i z a t i o n ) was not supported even when a medication regime was followed. Subsequently, Gurel and Lo r e i (1972), i n a study of 959 schizophrenics released from twelve Veterans Administration Hospitals, confirmed the conclusion of William and Walker. K r i s (1963) ca r r i e d out a five-year follow-up study of 300 patients, 80 percent of whom were diagnosed schizophrenic and found that the return rate f o r both acutely i l l and c h r o n i c a l l y i l l patients was 37 percent. Of the patients who returned to h o s p i t a l , 63 percent were homemakers, r e t i r e d or unemployed. The patients with the lowest rate (18 percent) of return were those who were f u l l y self-supporting. The following year L o r e i (1964) attempted to predict a nine-month length of stay out of h o s p i t a l for 104 p s y c h i a t r i c patients released from a Veterans Administration H o s p i t a l . His hypothesis that i n t e r -personal t r a i t s as measured by the C a l i f o r n i a Psychology Inventory would predict length of stay out of h o s p i t a l was not supported, though he did f i n d that employment for at l e a s t s i x months i n the l a s t f i v e years was p o s i t i v e l y correlated with length of stay out of h o s p i t a l , while a past h i s t o r y of drinking was correlated with f a i l u r e to remain out of h o s p i t a l . Cunningham et a l . (1969) did a three-phase, five-year study to determine whether i t was possible to i d e n t i f y patients of veterans h o s p i t a l s who would make a successful adjustment i n the community. Part I of the study was an exploration by s t a t i s t i c a l analysis of the c h a r a c t e r i s t i c s of a l l patients who were placed i n community placement 10 homes (defined as half-way houses and rest homes). Phase II was a descriptive study of characteristics of patients that could be eval-uated in terms of effect on adjustment. In Part III of the study the investigators looked for the direction and change in psychiatric con-ditions and social adjustment after community placement. Of the 111 patients in the sample, 95 percent had a diagnosis of schizophrenia. There was a significant relationship between a longer stay in the com-munity and the patient activity in the community (i.e., held jobs, attended day centres and/or veterans rehabilitative training). Twenty percent of the patients in the sample remained out of hospital for more than one year. Another study by Ellsworth (1968) attempted to find a relationship between hospital and community adjustment as perceived by psychiatric patients, their families and staff. Again, schizophrenic veterans were studied; this time male schizophrenics only. Multiple scales and ratings were used both in the hospital and the community in an effort to find "congruence of hospital and community adjustment . . . and an economically feasible approach to the measurement of patient improvement and program effectiveness" (Ellsworth 1968, p.3). Ellsworth concluded "that rehospitalization occurred less often when the patient was placed in a setting highly tolerant of marginal adjust-ment" (Ellsworth 1968, p.11), and that "hospital staff might well improve the effectiveness of their own programs i f they identify clearly patients' relevant problems from the standpoint of their behaviour in the community" (Ellsworth 1968, p.31). In 1974, Peretti, using an interview guide, asked 100 former Chicago halfway house residents what had precipitated their readmission 11 to hospital. The responses suggested that vocational, social and "s e l f " factors, in that order, had precipitated the readmission. The findings of Peretti and of the investigators in studies thus far reviewed indicate that there is an association between employment and rehospitalization. This factor was accordingly taken into account when the present study was designed. In 1974, Rosenblatt and Mayer compiled and reviewed 118 research studies on readmission of patients to mental hospitals. They reported that rehospitalization was "not materially affected by pathology" and "that only one variable consistently predicted rehospitalization . . . the number of previous admissions" (Rosenblatt and Mayer 1974, pp.697-8). Gurel and Lorei, in 1972, had reached this conclusion also. Neverthe-less, investigators have continued the search for predictors. As had many of their colleagues in the past, the next two researchers studied schizophrenic patients only. Heffner et a l . (1975) examined the relationship between I.Q. and rehospitalization. They found that, whereas seventy percent of patients above the median I.Q. were not rehospitalized within 3 years of discharge, eight percent of the patients whose I.Q.'s were less than the median were rehospitalized at least twice during this time period. Heffner et a l . suggested that because of alterations in cognitive functioning of schizophrenic patients longitudinal study of patient cohorts is necessary. Main-tenance antipsychotic pharmacotherapy, relapse and length of stay out of hospital was the subject of a study by Manos (1977). His findings indicate that patients "remain out of hospital almost the same length of time with or without medication, and that the time interval u n t i l they relapsed was not influenced by whether or not they were taking medication" (Manos 1977, p.362). This finding is i n contradiction with the earlier findings of a British retrospective study by Denham and Adamson (1971) on 103 schizophrenic patients receiving long-acting Fluphenazine. They found that in the twelve-month follow-up period twenty-two patients had one hospitalization only and twelve patients had two to four hospitalizations. Prior to the commencement of the use of long-acting injectable phenothiazines this same patient group had had a total of 191 hospitalizations. In the latter study, however, the schedule and route of medication necessitated frequent contact with the personnel administering the drug, and this contact may have enhanced the patients' compliance with the medication regime. The f i n a l three studies reviewed in this section examined per-sonal and family characteristics of patients, not exclusively schizo-phrenic. Munley's (1977) study of 202 veterans in five psychiatric units used twenty-two demographic and c l i n i c a l variables. The data analyses included a step-wise multiple regression analysis to determine whether these variables were associated with rehospitalization within three months of discharge. Six variables were identified as predictors of rehospitalization: type of discharge, number of prior hospitaliza-tions, race, suicide attempt within one month prior to admission, sub-jective expression of depression on admission, and occupational level. Age, length of hospitalization and diagnosis were not significant pre-dictors. These findings may not be generalizable to non-U.S. veterans, though they do suggest direction for further studies. Exner and Murillo (1975) concentrated on family variables 13 related to prediction of post-hospital relapse. In this prospective study, a replication of a retrospective study by Michaux (1969), 148 patients with schizophrenia and a variety of affective and character disorders, discharged from a New York state hospital, were followed for one year or u n t i l hospitalization prior to one year. The ex-patients were interviewed seven to nine weeks after discharge by psychologists not previously known to them and unfamiliar with their records. A number of scales and questionnaires were used to determine differences between patient reports and family reports of the performance of the patient out of hospital. At four and six months after discharge, two biographical-medical-occupational questionnaires were completed. The results indicated that no apparent relationship existed between relapse and length of hospitalization, type of treatment or abrupt changes in medication regimes (planned or unplanned). However, data from the scales and questionnaires were useful in identifying ex-patients who were lik e l y to relapse (i.e., to require rehospitalization or to become completely debilitated). The investigation suggested that differences in patient and family ratings of post-hospital performance may reflect "early decompensation of relapsers, or may be some index of limited per-sonal contact between the ex-patient and his significant others" (Exner, p.237). In the study just described, the amount of contact between the ex-patient and a significant other was variable and did not presuppose a shared liv i n g arrangement. At times, living with family can be very stressful for ex-patients. Brown, Birley and Wing (1972) found that rehospitalization of schizophrenic patients increased when their families 14 were hostile, c r i t i c a l , and/or emotionally overinvolved. Vaughn and Leff (1976) replicated this study using a patient sample drawn from two c l i n i c a l groups, patients with a schizophrenic psychosis and patients with depressive neuroses. They coined the term "expressed emotion" to describe the kind of family interaction they wished to measure, that i s , the family's use of c r i t i c a l or hostile comments such as resentment, disapproval, dislike and rejection and the family's emotional involvement. The amount of behaviour described by this term was used as an index measure with which to predict the relapse of ex-patients. They found that a score of six or greater of "expressed emotion" was a predictor of relapse and concluded that: the response of the relative, rather than the severity of the illness i s the best predictor of whether the patient w i l l break down again within a specified time period (p.135). The latter studies highlight the importance of the influence of family dynamics on the a b i l i t y of the ex-patient to function in the community. A warm accepting family was associated with a low rate of patient relapse, while with a c r i t i c a l , hostile, emotionally over-involved family the relapse rate was high. In summary, the studies reviewed in this section identified the following factors as associated with relapse: the demographic factors - race, employment and occupational status; the personal factors - I.Q., abuse of alcohol and subjective expression of depression; the family factors - tolerance of marginal adjustment, emotional overinvolvement, expression of criticism and attitudes toward mental illness and the type of of termination of hospitalization. 15 Studies Comparing Groups of Patients,  Non—Rehospitalized and Rehospitalized This section of the literature review addresses readmission studies that use comparison groups to determine differences between non-rehospitalized and rehospitalized patients. Unlike the samples in the previous section which were mainly drawn from public mental hospi-tals, the samples in the studies to be reported were drawn from a variety of psychiatric f a c i l i t i e s , and the patients in these samples had a variety of psychiatric diagnoses rather than schizophrenia only. Additional patient characteristics investigated i n these studies include past history of suicidal behaviour, living situation on admis-sion, use of non-medically prescribed drugs and use of leisure time. The f i r s t two studies compare patients who were rehospitalized and patients who were not rehospitalized. Patients in these samples had differing numbers of hospitalizations prior to the time of the study. Tuckman and Lavell (1965) studied a sample of 801 patients, 139 rehos-pitalized within one year and 662 not rehospitalized, and found l i t t l e difference in diagnoses or in number of previous hospitalizations between the two groups. Franklin (1975) used fifty-two personal and environmental factors to study differences between thirty-six patients who returned to hospital and seventy-one patients who did not. The source of income and number of previous hospitalizations were the only s t a t i s t i c a l l y significant findings. He noted, however, that patients rehospitalized tended to be single, separated or divorced, had more contact with community health f a c i l i t i e s after dis-charge, engaged in fewer leisure time activities and were more lik e l y to report drinking problems (p.749). 16 Although these data were not s t a t i s t i c a l l y significant they were seen as factors of importance in relation to rehospitalization. The next group of studies compared patients who had been hospitalized once only and patients who had multiple hospitalizations. Lahnier and White (1976) looked for differences between the number of stressful l i f e events experienced by a group of individuals prior to f i r s t hospitalization and by a group of individuals prior to rehospitali-zation, based on diagnostic classification (i.e., schizophrenia, depres-sive neurosis, alcohol addiction) and sex, and found that the difference in the amount of stress experienced prior to hospitalization between the two groups was not significant. A large scale retrospective study by Viesselmen et a l . (1976), conducted in a community mental health centre sought answers to the question of who i s rehospitalized. In the study year, the number of hospitalizations was 2199 of which 1087 were f i r s t admissions. After tabulating demographic and diagnostic data by groups, f i r s t admitted and readmitted, the researchers used the results of their s t a t i s t i c a l analysis to create a patient profile that would predict rehospitaliza-tion. They found that the readmitted patients were more frequently male, aged 25-35, not married and of lower socioeconomic status. Serban (1975) also studied patient groups of f i r s t and multiple hospitalizations. His sample was comprised of schizophrenic patients in a state mental hospital. The multiple hospitalization group included patients who had been hospitalized one to two years over the ten years prior to the study. He examined the differences between the two groups in comprehensive functioning using a measure of the following aspects 17 of social functioning - social performance, family interaction, and social and interpersonal performance. In his study he attempted to establish the value of using this social performance measure as a pre-dictor of subsequent hospitalization. He found that the measure varied in predictive value for the two groups of patients studied and that i t correctly predicted the return of 94 percent of the patients in the f i r s t hospitalization group and only 75 percent patients in the multi-ple hospitalization group. Wilier and Biggin (1976) were less successful in their attempt to develop a measure of community adjustment. The sample of comparison groups, rehospitalized and not rehospitalized, was comprised of a total of 326 admissions and the patients from this group who returned within six months. A f i f t y - f i v e item Self-Assessment Guide covered physical health, general affect, interpersonal s k i l l s , personal relations, use of leisure time, control of aggression and economic support. The Guide was not able to discriminate between patients of short versus long community tenure. In the only Canadian study in the literature review, Voineskos and Denault (1978) investigated patients at high risk for recurrent hospitalization. They compared three patient groups: patients recur-rently hospitalized at least five times in the previous two years, patients hospitalized less than five times, and patients hospitalized for the f i r s t time. The sample included a l l patients admitted to an urban mental hospital during a one-year period. A l l of the 572 patients in the sample were followed for one year after discharge to determine the number of rehospitalizations. The patients i n the recurrently hospitalized group were significantly different from those in the remaining groups. Like Viesselman, the investigators found that, among those recurrently hospitalized, there were more men, more single, divorced and separated individuals and fewer patients employed at admission, Further i t was found that they had significantly longer hospitalizations than patients admitted for the f i r s t time. They also found that more of the patients lived alone, many in boarding homes, and that fewer had been referred by a physician or accompanied by a relative. No significant differences were found among the groups in religion, country of birth, length of residence in Ontario, frequency of criminal record, against medical advice discharges or diagnosis. When the subgroup of patients hospitalized for the f i r s t time was com-pared with the group of patients recurrently hospitalized, significant differences were found in diagnosis, in length of stay, and in the number of readmissions to the service during the follow-up year. The Glick and Hargreaves (1979) controlled c l i n i c a l t r i a l was designed to study the relative cost-effectiveness of short term hospi-talization as an alternative to long-term hospitalization for schizo-phrenic and non-schizophrenic patients. It is included in this review because the study demonstrated no significant relationship between the length of stay of the schizophrenic patient and the number of patients rehospitalized, computed at one and two years. This confirms the finding of Voineskos and Denault regarding the association of length of stay and rehospitalization. The last group of studies in the section includes a cohort of f i r s t patient admissions that was followed after discharge for a limited period of time to determine the number of rehospitalizations. Selig (1977) attempted to study a cohort of 116 f i r s t admission patients to discover reasons for the readmission of those who were readmitted within one year. He used a semi-structured questionnaire consisting of items in six domains: social and demographic factors, symptoms, hospital variables, individual motivation, interpersonal networks, and follow-up care. Of the 116 patients i n the sample, at least one-half of the patients to be followed could not be found at the end of a year and/or would not complete the questionnaires. This study was included because i t was conducted in the same setting as the proposed study and did use a patient sample from the year 1977. It indicates some of the d i f f i c u l t i e s in conducting prospective studies. A study of the effect of sex, marital status and age at f i r s t hospitalization on the rehospitalization of schizophrenics during two years following discharge was conducted by Watt and Szulecka (1979) in a comprehensive psychiatric hospital in London. Findings revealed that more single males were rehospitalized than single females, though there was no difference in the proportion of married males and females rehos-pitalized. Significant differences were also found between the propor-tion of men and women less than 29 years of age who were rehospitalized. The investigators concluded that insofar as male schizophrenics have an earlier onset, are rehospitalized more frequently, and show a greatly reduced marriage rate compared with the general popu-lation, they are more severely affected than females (p.525). They agree with Mayer-Gross et a l . (1969) that the onset in males occurs when they are psychologically immature and that interrupted education 20 and lack of work s k i l l s , as well as lack of stable relationships out-side the family, contribute to the individual's vulnerability to lasting di s a b i l i t y . The study has value in helping to identify the correctly diagnosed schizophrenic individual who is lik e l y to return to hospital. Freeman et a l . (1979), in a study of use of hospital psychia-t r i c services by chronic schizophrenics i n the community during a twelve-month period, sought to establish a correlation between the severity of illness and use of service. The patients' severity of illness was determined by the use of an instrument to assess c l i n i c a l condition, the Patient State Examination, and a questionnaire to assess social situation. The assessment was made at the beginning and end of the one-year study. Throughout the year, the type and frequency of use of the hospital psychiatric services was monitored. The major finding was that there was no c l i n i c a l change in the sample as a whole over the year of study, and that the analysis of comparative levels of service use showed that the majority of patients in the sample made relatively small demands on psychiatric services. There was no correlation between severity of illness and use of services. The investigators did point out, however, that there may be discrepancies between the patient's perception of illness and that of the observers and between the degree of health exhibited in hospital and the degree of health exhibited in the community. The finding that a patient's functioning in hospital may not coincide with community functioning and adjustment is consis-tent with that of Ellsworth et a l . (1968) whose study was reviewed earlier. 21 Summary arid Conclusions Prior to 1975, much of the literature on rehospitalization of psychiatric patients focussed on patient populations in large mental hospitals and the relationship of various factors thought to be asso-ciated with patient relapse and/or rehospitalization. The schizophrenic patient group was the one most frequently studied and often these studies were conducted in Veterans Administration Hospitals. Of the many variables tested for association with patient rehospitalization, prior hospitalization was the only one consistently found to be signi-ficant. Some notable trends reported to be linked with the phenomenon were periods of unemployment prior to hospitalization and a history of heavy drinking. Diagnosis, chronicity of illness, condition of patient on discharge lacked usefulness as associated factors. Studies completed in the last five years were conducted in a wider variety of settings and the samples were chosen from a broader spectrum of psychiatric conditions. Some of the s t a t i s t i c a l l y s i g n i -ficant predictors found to be associated with rehospitalization were: the demographic factors - age, sex, marital status (of schizophrenic patients), race, occupational status, financial status; the c l i n i c a l factors - suicide attempt within one month prior to hospitalization, subjective statement of depression on admission, number of previous psychiatric hospitalizations and type of hospital termination. Some variables tested i n these studies and ruled out as being associated with rehospitalization were: the degree of stress exper-ienced prior to admission, the taking of medications in or out of hos-p i t a l , the length of stay in hospital and the amount of time elapsed 22 between hospitalizations. Some findings noted in these latter studies, though not s t a t i s t i c a l l y significant, have related the personal charac-teristics of lower than average I.Q., ab i l i t y to structure leisure time and lack of interest in looking for a job, and rehospitalization. Although many variables associated with rehospitalization have been identified, the factors involved in the individual's emerging pat-tern of recidivism, or pattern of recurring mental disorder, and use of hospital are not well understood. Recommendations for future studies have been suggested by Voineskos and Denault (1978) and by Munley et a l . (1977). The former researcher suggests that specific groups of psychi-atric patients be investigated in order to compare precise characteris-tics of these individuals at f i r s t and subsequent hospitalizations. The latter researchers found that certain demographic and c l i n i c a l characteristics do afford some information in predicting return to hospital but that a question yet to be answered is whether an extension of the follow-up period would change the usefulness of these character-i s t i c s when they are applied to returning patients with differing diag-noses or to patients whose admission was precipitated by non-suicidal causes. A search of the literature revealed few studies that concen-trated on the characteristics of patients hospitalized for a f i r s t time in order to distinguish between patients who returned to hospital and patients who did not. Therefore, i t was decided that further explora-tion of such a group was appropriate. A retrospective study was designed that would provide a data base for a future prospective study of a cohort of patients hospitalized for a f i r s t time. 23 The variables chosen for the set of characteristics which formed the basis for comparison i n the study were those sociodemographic and c l i n i c a l ones found in previous studies to be associated with rehos-pitalization of psychiatric patients. Differences at f i r s t hospitali-zation were sought in order to determine whether patterns associated with patients who were readmitted were manifest at this time. 24 CHAPTER III METHODOLOGY Design In order to determine whether a relationship exists between a set of selected characteristics and rehospitalization in psychiatric units, a descriptive-correlational design was used. The study was retro-spective i n nature and involved review of c l i n i c a l records of patients admitted to a psychiatric unit during a specified time period as well as c l i n i c a l records of patients who returned within two years of the f i r s t admission to the unit. Because i t is not possible to control variables in descriptive studies, there is more risk of erroneous interpretation of results. However, Polit and Hungler (1978) suggest that this is a useful method of collecting large amounts of data in a relatively short period of time . . . and these studies are typically strong in terms of their realism (Polit and Hungler 1978, p.192). Kerlinger states that "the r e l i a b i l i t y of personal factual items, like age and income is high . . . within sampling error" (Kerlinger 1973, p.417 and 422). Data Collection The investigator used the hospital data bank to collect data from the chart abstracts. A l l other data were collected personally from the patient records and were recorded by record number only. 25 Data Analysis The data collected were coded and entered in a computer f i l e created for this study and then analyzed using procedures in the University of British Columbia St a t i s t i c a l Package for the Social Sciences, Version 7.01 (under MTS). Within group and between group comparisons by selected characteristics were f i r s t described by fre-quency distributions and means, medians, range and standard deviations where appropriate. Then chi square and analysis of variance tests were used to test relationships between individual characteristics and the comparison groups. Comparison subgroups of patients grouped by diagnostic category were then analyzed using the same procedures as above. Setting The study was conducted at the 60-bed Psychiatric Unit of the Health Sciences Centre Hospital, University of British Columbia. This teaching hospital provides adult psychiatric services, i s operated as an open-door unit and accepts voluntary and involuntary patient admis-sions. Individuals who require care for acute physical problems are excluded as are j a i l inmates. Other individuals may be referred by physicians, agencies or by self. The geographical location of the hospital i s Vancouver, a British Columbia seaport whose 1976 population was about one-half of the total population of British Columbia. (Canada Year Book 1978, pp. 155 and 157). Of this mobile population, 57.7 percent of the 1976 26 population moved, and of this group 32.6 percent moved out of the province (Canada Year Book 1978, p.175). The hospital serves patients in i t s own catchment area as well as patients referred from other parts of the province. The C l i n i c a l Chief of each inpatient ward is a member of the Faculty of Medicine, Department of Psychiatry, and is a c l i n i c a l psychiatrist. The philos-ophy of the unit supports an interdisciplinary approach to patient care. Several treatment modalities are offered and, though intensive treat-ment is the focus, the hospital also functions as a base for assessment and referral to other treatment f a c i l i t i e s . Psychiatric residents and medical student interns, supervised by the C l i n i c a l Chief, are respon-sible for the primary therapy of the patient. Each patient is also assigned a primary nurse for the period of the hospitalization. Other team members are social workers, psychologists, occupational therapists (both student and staff) and psychiatric assistants. Selection of the Sample Four hundred and one patients whose f i r s t psychiatric hospitali-zation occurred at the Health Sciences Centre Psychiatric Unit, University of British Columbia between January 1, 1976 and December 31, 1977, were included in the sample. These patients met the following c r i t e r i a : 1. not"hospitalized with a primary diagnosis of epilepsy convulsions, mental retardation or organic brain syndrome; 2. not hospitalized primarily for seizure monitoring; 3. never previously hospitalized in an inpatient psychiatric f a c i l i t y . 27 The patients excluded on the basis of diagnosis represented 9 percent of the total f i r s t hospitalizations, while the sample repre-sented 24 percent of the 1620 total hospitalizations in the Unit during this period. For purposes of comparison, the sample was divided into two groups: a group who did not return to this unit (n=334) and a group who did return to this unit (n=67) within two years of the date of admission. Of the 401 patients in the sample, 67 patients returned a total of eighty-four times to the Health Sciences Centre - Psychiatric Unit only in the two year period following the f i r s t hospitalization (54 patients returned once only, 9 patients returned twice and 4 patients returned three times). Set of Selected Characteristics The following set of demographic and c l i n i c a l characteristics was used for comparison of the sample subgroups. Demographic Sex (male ; female) Marital Status (living with partner; not livi n g with partner) Age (in years) Education (in years) Occupation (Professional, Skilled, Unskilled, Housewife or Student) Employed ever (Yes; No) Employed in 6 months prior to f i r s t admission (Yes; No) Employment Status on Admission (Employed, Unemployed, Housewife or Student) Census Tract (Greater Vancouver, Lower Fraser Valley, Other Parts of British Columbia) Living Situation on Admission (Alone; With others) Nearest Kin (Spouse, Parent, Other) Financial Support (Self, Family, State) Referral Source (Self, Physician, Hospital or Agency) Final Diagnosis Category 1. Schizophrenia (DSN II* - 295) Category 2. Affective Disorders and Other Psychoses (DSN II 300 Neuroses 302 Sexual Deviances 305 Psychophysiological 306 Anorexia Nervosa) Category 4. Personality Disorder (DSN II 301) Category 5. Situational Disturbances (DSN II 307 Transient Situational Disturbance 308 Behaviour Disorder of Children 316 Social Maladjustment) Suicide attempt ever (Yes; No) Suicide attempt within one month prior to admission (Yes; No) Subjective statement of depression on admission (Yes; No) _ DSN II - Diagnostic and S t a t i s t i c a l Manual, Mental Disorders-; Drug abuse ever (Yes; No) (1. Street; 2. No; 3. Not Known; 4. Prescription Drugs; 5. Street and Prescription Drugs; 6. Alcohol; 7. Alcohol and Prescription Drugs; 8. Alcohol and Street Drugs; 9. A l l Drugs) Days Hospitalized Absent without o f f i c i a l leave during hospitalization (Yes; No) Involuntary Status (Yes; No) Termination (Separated, Against medical advice, Agency or Institution) 30 CHAPTER IV FINDINGS AND DISCUSSION The study findings are presented in three sections. In the f i r s t section is a description of the total sample and subgroups: 1) charac-teri s t i c s on f i r s t hospitalization of the sample as a whole (n=401) and subgroups: not-returned (n=334) and returned (n=67); 2) characteristics of the diagnostic subgroups of the total sample (n=401); 3) characteris-tics at the time of second hospitalization of the patients who returned to the Psychiatric Unit only (n=67); and 4) characteristics of the t h i r -teen patients who returned to the Psychiatric Unit more than once in a two year period. The second section presents the results of the compar-isons as follows: 1) results of the within group comparison (n=334 and n=67); 2) results of the between group comparison of patients not-returned and patients returned to the Psychiatric Unit only within two years of the f i r s t hospitalization (n=334 and n=67); and 3) results of the between group comparison of returning patients at f i r s t and second hospitalization (n=67 and n=67). In the third section is discussion and interpretation of the results and findings previously presented. Description of the Total Sample (n=401)  and Subgroups (n=334 and n=67) The total sample and subgroups are described according to the set of selected characteristics previously outlined in Chapter III. Data are presented in Table 1. 31 TABLE 1 FREQUENCY DATA FOR SELECTED DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF TOTAL SAMPLE AT FIRST HOSPITALIZATION (n=401); RETURNED (n=67) AND NOT-RETURNED (n=334) AND AT SECOND HOSPITALIZATION (n=67) First Hospitalization Second Hospitalization Characteristic 401 334 n=67 n= n= n=67 Number Percent Number Percent Number Percent Number Percent Sex Male 167 41.6 141 42.2 26 38.8 26 38.9 Female 234 58.3 193 57.7 41 61.1 41 61.1 Marital Status Living with partner 239 59.6 204 61.0 35 52.2 27 40.2 Not livi n g with partner 162 40.3 130 38.9 32 47.7 40 59.7 Age Mean 32. 3 32. 4 32.2 32.7 Education Mean 11. 1 11. 1 11.7 11.6 Occupation Professional 50 12.8 41 12.7 9 13.6 9 13.6 Skilled 112 28.8 90 27.9 22 23.3 25 37.3 Unskilled 110 29.8 95 29.5 15 22.7 15 22.7 Housewife/ Student 116 29.8 96 29.8 20 30.3 18 26.8 Missing data 13 12 1 0 Employed Ever Yes 315 78.5 260 77.8 56 83.5 56 83.5 No 85 21.1 73 21.8 11 16.4 11 16.4 Employed Past Six Months Yes 155 38.6 121 36.2 34 50.7 28 41.8 No 246 61.3 213 63.8 33 49.2 39 58.2 32 TABLE l ~ C o n t i n u e d .First H o s p i t a l i z a t i o n Second H o s p i t a l i z a t i o n C h a r a c t e r i s t i c n= 401 n= 334 n= 67 n= 67 .Number Percent Number Percent Number Percent Number Percent Employment Status on Admission* Employed 136 34.0 113 34.0 23 34.3 16' 23.9 Unemployed 146 36.6 128 38.5 18 26.8 29 43.2 Housewife/ Student 117 29.3 91 27.4 26 38.9 22 32.9 Census Tract Greater Vancouver 283 70.6 240 71.8 43 64.2 45 67.2 Lower Fraser Val l e y 62 15.5 47 14.1 15 23.4 10 14.9 B r i t i s h Columbia -Other 56 13.9 47 14.1 9 13.4 12 17.9 L i v i n g S i t u a t i o n on Admission* Alone 66 16.8 54 16.6 12 17.9 13 19.4 With Others 326 83.2 271 83.4 55 82.1 54 80.6 Nearest Kin* Spouse 156 39.7 125 39.2 31 47.7 29 43.3 Parent 156 39.7 136 41.6 20 30.8 25 37.3 Other 80 20.4 66 20.2 14 21.5 13 19.4 F i n a n c i a l Support Self 158 39.4 128 38.3 30 44.7 27 40.9 Family 159 39.7 131 39.2 28 41.8 27 40.9 State 84 20.9 75 22.5 9 13.5 12 18.2 33 TABLE 1—Continued C h a r a c t e r i s t i c F i r s t H o s p i t a l i z a t i o n Second H o s p i t a l i z a t i o n n=401 n=334 n=67 n=67 Number Percent Number Percent Number Percent Number Percent Referred by Se l f 38 9 5 38 11. 4 11 16. 4 11 16.4 Phys i c i an 182 45 4 189 56. 6 31 46. 3 26 38.8 H o s p i t a l / Agency 181 45 1 106 31. 8 25 37. 3 30 44.8 F i n a l Diagnosis Schizo-phrenia 93 23 2 73 21. 8 20 29. 8 18 26.8 Major A f f e c t i v e 57 14 2 46 13. 8 11 16. 4 14 20.8 Neurosis 154 39 4 132 39. 5 22 32. 8 23 34.3 P e r s o n a l i t y Disorder 38 9 5 33 9. 9 5 7. 4 5 7.4 S i t u a t i o n a l Disturbance 59 14 7 50 15. 0 9 15. 3 5 7.4 Alcohol i sm 1 1.4 Ep i l epsy 1 1.4 Suic ide Attempt Ever Yes 69 17. 2 56 16. 7 13 19. 5 19 28.4 No 332 82 7 ' 278 83. 3 54 80. 5 48 71.6 Suic ide Attempt W i t h -i n One Month of Admission Yes 52 12 9 43 12. 8 9 13. 5 6 8.9 No 349 87 1 291 87. 2 58 86. 5 61 91.1 34 TABLE 1—Continued First Hospitalization Second Hospitalization Characteristic ,n= 401 n= 334 n= 67 n=67 Number Percent Number Percent Number Percent Number Percent Subjective Report of Depression on Admission Yes 210 52.4 172 51.5 38 56.7 38 56.7 No 191 47.6 162 48.5 29 43.3 29 43.3 Drug Abuse Ever Yes 190 47.4 148 44.3 42 62.6 42 62.6 No 195 48.6 171 51.2 24 35.8 24 35.8 N/K 16 4.0 15 4.5 1 1.5 1 1.5 Age Group < 29 208 51.8 171 51.2 37 55.2 36 53.7 > 29 193 48.2 163 48.8 30 44.8 33 49.3 Days Hospitalized Mean 26. 3 26. 2 27. 2 27.8 AWOL Yes 32 7.9 29 8.7 3 4.5 6 9.0 No 369 92.1 305 91.3 64 95.5 61 91.0 Involuntary Status Yes 14 3.4 14 4.2 0 0.0 3 4.4 No 387 96.6 320 95.8 67 100.0 64 95.6 Termination* Separated 263 65.7 223 66.9 40 59.7 36 53.7 Against Medical Advice 41 10.2 31 9.4 10 14.9 6 8.9 Agency/ Institution 96 24.0 79 23.7 17 25.4 25 37.4 *Missing data - Totals may not always equal 'n 's because of unavailability of data. 35 The majority (58.3 percent) of the sample were females. See Appendix B for percent female according to age group of patients at f i r s t hospitalization: Canada, British Columbia and Health Sciences Centre - Psychiatric Unit. Also, a majority (59.6 percent) were livi n g with a partner. The mean age was 32.3, with 51.8 percent of the total over 29 years of age. The mean for years of education was 11.1 years. In terms of occupation, 12.8 percent were professional and approximately equal percentages (28.8, 28.8 and 29.8) were skilled workers, unskilled workers, housewives or students, respectively. Over 78 percent of the subjects had been employed at some time in their lives, while only 38.6 percent had been employed in the last six months and 34 percent had been employed at the time of admission to hospital. Most (70.6 percent) of the subjects lived in the Greater Vancouver area, while the remainder of the subjects (15.5 and 13.9 per-cent) were from the Lower Fraser Valley and other parts of British Columbia, respectively. The majority (83.2 percent) of the subjects lived with others and an equal number (39.7 percent) named a parent or spouse as next of kin, while 20.9 percent named someone other. The same proportions (39.4, 39.7 and 20.9 percent) of the subjects were financially supported by themselves, their families or welfare or other government support. Only 9.5 percent of the subjects were self-referred with approx-imately equal percentages (45.4 and 45.1) being referred by a physician or hospital/agency. By diagnostic category, the subjects were distributed as f o l -lows: 23.2 percent schizophrenia, 14.2 percent major affective disorder, 36 39.4 percent neuroses, 9.5 percent personality disorder, and 14.7 per-cent situational disturbance. Over 17 percent had a history of suicide attempt(s) and, of this group of subjects, 12.9 percent had attempted suicide within one month of admission. Just over one-half (52.4 percent) had reported that they were depressed at admission, and nearly one-half (47.4 percent) had abused drugs at some time in their lives. The mean total days hospitalized was 26.3. Of the total sample, 7.9 percent of the patients were absent without leave during their hospitalization, 3.4 percent had been committed and 10.2 percent l e f t hospital against medical advice, while 65.7 percent were separated and 24 percent were separated and referred to other agencies/institutions. The sample (n=401) consisted of two subgroups; those who did not return to hospital (n=334) and those who did (n=67). The former sub-group w i l l be described f i r s t . In this subgroup, 57.7 percent of the subjects were female and 61.0 percent were livi n g with a partner. The mean age was 32.4 and mean years of education also 11.1 years. The dis-tribution by occupational category was: 12.7 percent professional, 27.9 percent skilled, 29.5 percent unskilled, 29.8 percent housewife or student. Most (77.8 percent) of the subjects had been employed at some time in l i f e ; 36.2 percent in the six months previous to admission. Thirty-four percent were employed at the time of admission while 38.5 percent were unemployed and 27.4 percent were housewives or students. Over 71 percent of the subgroup subjects were from Greater Vancouver and equal percentages (14.1; 14.1) were from the Lower Fraser Valley and other parts of British Columbia. Nearly 17 percent of these subjects lived alone and over 41 percent of the subjects named a parent 37 as next of kin, while 38.2 percent named a spouse and 20.2 percent named other than these persons. Approximately equal percentages (38.8 and 39.2) of the subgroup were supported by self or family while 22.5 per-cent received some kind of government support. The majority (56.6 per-cent) of the sample were physician referred; 31.8 percent were referred from a hospital or agency and 11.4 percent were self-referred. The ^  diagnostic distribution of the subjects was as follows: 21.8 percent schizophrenia, 13.8 percent major affective disorder, 39.5 percent neurosis, 9.9 percent personality disorder and 15.0 percent situational disturbance. Relatively few (16.7 percent) of the subjects had a history of suicide and 12.8 percent had made an attempt within one month of admis-sion. Many (51.5 percent) had reported feelings of depression on admission and slightly more than one-half (51.2 percent) had never abused drugs. The mean number of days hospitalized was 26.1. In this subgroup, 8.7 percent had been absent without leave while hospitalized, 4.2 percent were committed and 9.4 percent were discharged against medical advice, while 66.9 percent were separated and 23.7 percent separated and referred to other agencies/institutions. The following is a description of the second subgroup consisting of the 67 patients who, within two years of the f i r s t hospitalization, returned to this Psychiatric Unit only. This subgroup had the highest number (61.1 percent) of females and 52.2 percent of the subjects lived with a partner. The mean age was 32.2 and 55.1 percent of the sample were older than 29 years. The mean number of years of education was 11.7. The largest occupational group was housewives or students (30.3 38 percent), followed by skilled (23.3 percent), unskilled (22.7 percent) and professional (13.6 percent). The majority (83.5 percent) of the subjects had been employed at some time; 50.7 percent in the six months prior to admission and 34.3 percent at the time of admission. Most (64.2 percent) of the subjects were from Greater Vancouver, 23.4 percent from the Lower Fraser Valley and 13.4 percent from other parts of British Columbia. The majority (82.1 percent) lived with others and 47.7 percent named a spouse as next of kin; while 30.8 per-cent named a parent and 21.5 percent named someone else. Most (44.7 percent) subjects in this subgroup were se l f -supporting, while 41.8 percent were family-supported and 21.5 percent were supported by welfare or other government funds. Most (46.3 per-cent) subjects were referred by a physician; 37.3 percent by a hospital or agency; and 16.4 percent were self-referred. The diagnostic distribution was: 29.8 percent schizophrenic, 16.4 percent major affective disorder, 32.8 percent neurosis, 7.4 per-cent personality disorder and 15.3 percent situational disturbance. Approximately one-fifth (19.5 percent) of the subjects had a history of suicide attempts and 13.5 percent had attempted suicide within one month prior to admission. Over one-half (56.7 percent) stated on admis-sion that they were depressed and 62.6 percent had abused drugs at one time. The mean number of days hospitalized was 27.2; 4.5 percent of the subjects were absent without leave during their hospitalization, none were committed and 14.9 percent l e f t against medical advice while nearly 60 percent were separated and 25.4 percent were referred to other agencies/institutions. 39 Characteristics of the Diagnostic Subgroups  of the Total Sample (ri=401) To f a c i l i t a t e the presentation of data and to provide profiles of the diagnostic subgroups, the data were tabulated according to these subgroups. Table 2 presents the number and percent of patients by diag-nostic category and selected demographic and c l i n i c a l characteristics. Of the 93 schizophrenic patients, 59.1 percent were female, 84.9 percent lived with a partner, the mean age was 25.92 and 75.2 percent of this group were less than or equal to 29 years of age. The mean years of education was 12.2. Occupationally, few subjects (3.2 percent) in this group were professionals, 44.1 percent were unskilled, 23.7 percent housewives or students and 27.5. percent were skilled workers. Sixty-eight percent had been employed at some time, 30.1 percent in the six months prior to hospitalization and only 19.3 percent were employed at the time of admission. Most (76.3 percent) of the subjects were from Greater Vancouver while 12.9 percent and 10.8 percent were from the Lower Fraser Valley and other parts of British Columbia, respectively. A total of 22.8 per-cent lived alone, 60.2 percent gave parents, 14.8 percent spouse and 25 percent other persons as next of kin. 24.7 percent only were se l f -supporting, 39.8 percent were supported by families and 35.5 percent were supported by government funds. Only 10.8 percent were self-referred; the balance were physician (48.4 percent) or hospital (40.9 percent) referred. Few (8.6 percent) of this subgroup of subjects had a history of suicide attempts, just over one-quarter (28.0 percent) stated they were depressed at admission and 52 percent abused drugs. TABLE 2 NUMBER AND PERCENT OF PATIENTS BY DIAGNOSTIC CATEGORY AND SELECTED DEMOGRAPHIC AND CLINICAL CHARACTERISTICS (n=401) Characteristics Schizophrenic Major Affective Neuroses Personality Disorder Situational Disturbance n=93 n=57 n= 154 n=38 n=59 Number Percent Number Percent Number Percent Number Percent Number Percent Sex Male 55 59.1 21 36.8 51 33.1 18 47.3 22 37.2 Female 38 40. 9 36 63.2 103 66.9 20 52.7 37 62.7 Marital Status With partner 79 84.9 23 40.3 79 51.2 22 57.9 36 61.0 Without partner 14 15.1 34 59.7 75 49.8 16 42.1 23 39.0 Age on Admission Mean 25.9 39.9 35. 2 31.4 28.3 Age Group Less than or equal to 29 years 70 75.2 19 33.3 61 39.6 23 60.5 35 59.3 Greater than 29 years 23 24.8 38 66.6 93 60.4 15 39.5 24 48.7 Education Mean 12.2 11.6 12. 1 13.2 11.9 Occupation* Professional, Semi-professional 3 03.2 8 14.0 25 16.8 9 24.9 5 9.1 Skilled 25 27.5 14. 24.6 47 31.8 11 30.6 15 27.3 Unskilled 41 44.1 13 22.8 35 23.5 11 30.6 10 18.2 Housewife/Student 22 23.7 22 38.6 42 28.2 5 13.9 25 45.5 TABLE 2—Continued Characteristics Schizophrenic Major Affective Neuroses Personality Disorder Situational Disturbance n= 93 n=57 n= 154 n= 38 n= 59 Number Percent Number Percent Number Percent Number Percent Number Percent Employed Ever* Yes 64 68.8 49 86.0 133 86.9 30 78.8 39 66.1 No 29 31.2 8 14.0 20 13.1 8 21.1 20 33.9 Employed Last Six Months Yes 28 30.1 23 40.4 64 41.6 16 42.1 24 43.7 No 65 69.9 34 59.6 90 58.4 22 57.9 35 59.3 Employed on Admission* Employed 18 19.3 18 31.6 64 42.9 13 36.1 19 34.5 Unemployed 54 58.7 16 28.1 43 28.8 16 44.4 12 21.8 Housewife/Student 19 20.7 23 40.3 42 28.2 7 19.5 24 43.6 Census Tract Greater Vancouver 71 76.3 43 75.4 104 67.5 24 63.2 41 69.5 Fraser Valley 12 12.9 7 12.3 24 15.6 9 23.7 10 16.9 British Columbia - Other 10 10.8 7 12.3 26 16.9 5 13.2 8 13.6 Living Situation on Admission* Alone 21 22.8 3 5.5 20 20.0 8 21.6 4 6.9 With Others 71 77.2 52 94.5 , 120 80.0 29 78.4 54 93.1 .TABLE 2—Continued Characteristics Schizophrenic Major Affective Neuroses Personality Disorder Situational Disturbance n= 93 n=57 n= 154 n= 38 n= 59 Number Percent Number Percent Number Percent Number Percent Number Percent Nearest Kin* Spouse 13 14.8 32 56.1 74 48.7 16 42.1 21 3 6.8 Parents 53 60.2 12 21.1 45 29.6 16 42.1 30 52.6 Other 22 25.0 13 22.8 33 21.7 6 15.8 6 10.5 Financial Status Self 23 24.7 28 49.1 65 42.2 19 50.0 23 39.0 Family 37 39.8 20 35.1 66 42.9 10 26.3 26 44.1 State 33 .35.5 9 15.8 23 14.9 9 23.7 10 16.9 Referred by* Self 10 10.8 1 1.8 20 13.0 8 21.1 10 17.2 Physician 45 48.4 30 52.6 88 57.1 22 57.9 35 60.3 Hospital 38 40.9 26 45.6 46 29.9 8 21.1 13 22.4 Suicide Attempt Ever Yes 8 8.6 8 14.0 35 22.7 6 15.8 12 20.3 No 85 91.4 49 86.0 119 77.3 32 84.2 47 79.7 Suicide Attempt Within One Month of Admission Yes 7 7.5 4 7.0 27 17.5 4 10.5 10 16.9 No 86 92.5 53 93.0 127 82.5 34 89.5 49 83.1 TABLE 2—Continued Characteristics Schizophrenic Ma j or Affective Neuroses Personality Disorder Situational .Disturbance 93 .ii=57 n= 154 n=3 8 n=59 Number Percent Number Percent Number Percent Number Percent Number Percent Subjective Statement of Depression on Admission Yes 26 28.0 41 71.9 98 63.6 18 47.4 27 45.8 No 67 72.0 16 28.1 56 36.4 20 52.6 32 54.2 Drug Abuse * Yes 47 52.2 17 32.6 70 48.0 25 67.5 31 54.4 No 43 47.8, 35 67.4 79 52.0 12 32.5 26 45.6 Days Hospitalized Mean 36. 0 30.0 23. 0 20.5 20.1 Absent Without Leave Yes 12 12.9 4 7.0 5 3.2 4 10.5 7 11.9 No 81 87.1 53 93.0 149 96.8 34 89.5 52 88.1 Involuntary Status Yes 5 5.4 5 8.8 2 13.0 0 0.0 2 3.4 No 88 94.6 52 91.2 152 98.7 38 57 96.6 Type of Termination* Separated 48 51.6 48 84.2 104 67.5 22 57.9 41 70.7 Against Medical Advice 11 11.8 4 7.0 16 10.4 6 15.8 4 6.9 Agency or Other 34 36.6 5 8.8 34 22,1 10 2,5 1.3 22.4 *Missing data - Totals may not always equal 'n's because of unavailability of data. 44 In this subgroup, the mean number of days hospitalized was 35.9, the rate of absence without leave 12.9 percent, committed 5.4 percent and number discharged against medical advice, 11.8 percent, while 51.6 percent were discharged and 36.6 percent were referred to other agencies/institutions. In the diagnostic category, major affective disorder, 63.2 per-cent of the subjects were female and 59.7 percent were without partners. The mean age was 39.9 years and 66 percent of the sample were over 29 years of age. Nearly 40 percent (38.6) of this group were housewives or students, 22.8 percent were unskilled and 24.6 percent were skilled while 14.0 percent were in professional occupations. Only 14 percent had never been employed; 40.4 percent had been employed in the six months prior to admission. Just over 30 percent (31.6) of the subjects were employed at admission, while 28.1 percent were unemployed and 40.3 percent were housewives or students. Most (75.4 percent) of the subjects were from Greater Vancouver and equal percentages (12.3) were from the Lower Fraser Valley and other parts of British Columbia. Only 5.5 percent lived alone and 21.1 per-cent gave parents as next of kin. Approximately 49 percent (49.1) were self-supporting while 35.1 percent were supported by their families and 15.8 percent were supported by government funds. Only 1.8 percent were self-referred, the balance being physician (52.6 percent) or hospital (45.6 percent) referred. Few (14 percent) of the subjects had a history of suicide attempts and only 7 percent had attempted suicide in the month prior 45 to hospitalization. Just over 70 percent (71.9) stated they were depressed at admission and 32.6 percent abused drugs. The mean length of stay was 30.0 days and few subjects (7.0, 8.8 percent) were absent without leave or committed. Seven percent were discharged against medical advice while 84.7 percent were separ-ated and 8.8 percent were separated and referred to other agencies/ institutions. The majority (66.9 percent) of the subjects in the neuroses category were female and just over one-half (51.2 percent) of the patients in this subgroup were living with a partner. The mean age was 35.2 years and 60.4 percent of the subjects were older than 29 years of age. This subgroup had 16.8 percent of subjects in professional and 31.8 percent in skilled occupations while 23.5 percent were unskilled and 28.2 percent were housewives or students. Only 13 percent had never been employed and approximately 42 percent were employed at six months before and at admission, while 28.8 percent were unemployed and 28.2 percent were housewives or students. Nearly 17 percent were from other parts of British Columbia, 67.5 percent were from Greater Vancouver and slightly over 15 percent were from the Lower Fraser Valley. Eighty percent live with others and 48.7 percent named a spouse as next of kin, 29.6 parents and 21.7 other individuals as next of kin. Thirteen percent were self-referred, 57 percent were referred by physicians and 30 percent were referred by other hospitals. Over 22 percent of the subjects had a history of suicide and 17.5 percent had made an attempt within one month prior to hospitalization. 46 Nearly two-thirds (63.6 percent) said they were depressed at admission and 48.8 percent had abused drugs at some time. The mean days hospitalized was 23. A very few (3.2 percent) of subjects were absent without leave during their hospitalization, 1.3 percent were committed and 10.4 percent were discharged against medical advice, while 67.5 percent were separated and 22.1 percent were separ-ated and referred to other agencies/institutions. In the category, personality disorder, there were 52.7 percent females, 42.1 percent of the subjects were without partners, the mean age was 31.4 years and approximately one-quarter (24.9 percent) of these subjects were employed in professional occupations. An equal number (30.6 percent) were skilled and unskilled and there were few (13.9 per-cent) housewives or students. About 20 percent of the subjects had never been employed and 44.4 percent were unemployed at admission while 36.1 percent were employed and 19.5 percent were housewives or students. Nearly one-quarter (23.7 percent) were from the Lower Fraser Valley, 63.2 percent from Greater Vancouver and 13.2 percent from other parts of British Columbia. Nearly 22 percent lived alone, an equal number (42.1 percent) of the subjects named spouse or parents as next of kin and 21.7 named other persons. Just over 20 percent were self-referred or hospital referred and nearly 60 percent were referred by a physician. Those who had ever attempted suicide numbered 15.8 percent and 10.5 percent had made an attempt within one month of readmission. Less than one-half (47.4 percent) stated they were depressed while over two-thirds (67.5 percent) abused drugs. The mean length of stay was 20.5 days, 10 percent of the patients 47 went absent without leave during their hospitalization, none were com-mitted and 15.8 percent were discharged against medical advice, while nearly 60 percent were separated and 25 percent were separated and referred to other agencies/institutions. In the last category, situational disturbance, nearly 63 percent of the patients in the subgroup were female and 61 percent lived with a partner. The mean age was 28.3 and nearly 60 percent were 29 years of age or younger. The housewife and student category accounted for 45.5 percent of the total subgroup, skilled category 27.3 percent, unskilled 18.2 percent and professional 9.1 percent. One-third of this subgroup had never been employed and one-third were employed at admission while nearly 22 percent were unemployed and 43.6 percent were housewives or students. Nearly 70 percent were from Greater Vancouver, 16.9 percent from the Lower Fraser Valley and 13.6 percent from other parts of British Columbia. Only 7 percent lived alone and over one-half of the subjects named parents, 36.8 percent, spouses and 10.5 percent, other individuals as next of kin. Seventeen percent were self-referred, 60.3 percent were referred by physicians and 22.4 percent were referred from other hospitals. Twenty percent of the subjects had attempted suicide in the past; 16.9 percent within one month of admission. Fifty-four percent of the subjects did not say they were depressed and the same percentage abused drugs. The mean days in hospital were 20.1 and 11.9 percent of the patients i n the subgroup were absent without leave during their hospitali-zation. Three and four-tenths percent were committed and nearly 7 percent 48 were discharged against medical advice while 70.7 percent were separ-ated and 22.4 percent were separated and referred to other agencies/ institutions. A brief comparison of the diagnostic categories indicates that in the schizophrenic group (n=93) were found: patients with the lowest mean age, 25.9 years, the highest percentage of males (59.1) and of single males (91 percent), the highest unemployment rate (53.9 percent), unskilled rate (46.5 percent) and the highest percentage of individuals less than or equal to the median age of 29 years (75.6 percent). In the major affective diagnostic group (n=57) subjects had the highest mean age (39.8 years) and there was the largest percentage of housewives and students (41.6 percent), of single individuals (59.6 per-cent) and the lowest percentage of drug abusers (33.3). In the diagnostic category, neurosis (n=154), females out-numbered males by a ratio of two to one (103 to 51) and accounted for one-quarter of the aggregate total of the sample (103 of 401). As well, twice as many females were married (52 to 23) and this group had the highest percentage of patients over the median age of 29 years (60.3 percent). In the remaining two diagnostic categories, personality disorder (n=38) and transient situational disturbance (n=59), the patients were mostly single (60.5 percent), under 29 years of age (59.3 percent) and had the lowest average of total days hospitalized, 20.5. The proportions of male and female patients at f i r s t and second hospitalization per diagnostic category appear in Figure 1. It is of note that, while patients in the diagnostic categories major affective Female n = 234 First Hospitalization (n = 401) | 1 Schizophrenia j j Major affective disorder |np;:| Neuroses Personality disorder Situational disturbance Second Hospitalization (n = 67) Figure 1. Proportions of Males and Females by Diagnostic Category at First Hospitalization (n=401) and Second Hospitalization (n=67) 50 disorder and situational disturbance did not vary widely in proportion between males and females and between hospitalizations, there were more male than female schizophrenic patients and considerably more male schizophrenic patients returned to hospital. Also, the greater propor-tion of female patients were in the category neuroses at both f i r s t and second hospitalizations. In the subgroup of patients at second hospi-talization a greater proportion of female than male patients with a diagnosis of personality disorder returned to hospital. As many of the studies reviewed i n this paper investigated schizophrenic subjects only, and since sex, marriage and age at f i r s t admission of schizophrenics have been reported to have a relationship with the rehospitalization of some of these subjects (Watt and Szukcka 1979), these characteristics were selected for further comparison. Table 3 presents the data for the number and percent rehospitalized within two years of admission according to age at f i r s t hospitalization, sex and diagnostic category. Table 4 presents the data for the same subgroups of subjects in terms of marital status and sex. Although the mean age of the sample as a whole was 32.3 years, the patients who at f i r s t hospitalization were between the age of 20 and 24 years were more frequently rehospitalized than patients in other age groups. Also, the proportion of individuals in this age group is markedly higher than for the general population, as shown in Figure 2, where a comparison is made with figures from the 1976 population s t a t i s -tics for Canada. 51 TABLE 3 NUMBER AND PERCENT OF PATIENTS BY DIAGNOSTIC CATEGORY REHOSPITALIZED WITHIN TWO YEARS ACCORDING TO AGE AND SEX AT FIRST HOSPITALIZATION (n=401) Males Females Age at First Hospitalization Age at First Hospitalization Diagnostic <29 years >29 years <29 years >29 years Category Number Number Number Number and and and and Total Percent Total Percent Total Percent Total Percent Number Returned Number Returned Number Returned Number Returned Schizo-phrenia 41 9 22 14 3 21 29 6 21 9 2 22 Major Affective Disorder 6 1 17 15 3 20 13 5 38 25 2 9 Neuroses 17 2 12 34 3 9 44 8 18 59 9 15 Person-a l i t y Disorder 9. 0 0 9 1 11 14 3 21 6 1 17 Situa-tional Distur-bance 11 1 9 11 3 27 24 2 8 13 3 23 52 TABLE 4 NUMBER AND PERCENT OF PATIENTS BY DIAGNOSTIC CATEGORY REHOSPITALIZED WITHIN TWO YEARS ACCORDING TO MARITAL STATUS AND SEX AT FIRST HOSPITALIZATION (n=401) Single Married Male Female Male Female Diagnostic Number Number Number Number Category and and and and Total Percent Total Percent Total Percent Total Percent Number Returned Number Returned Number Returned Number Returned Schizo-phrenic 50 10 20 29 6 21 5 2 40 9 2 22 Major Affective Disorder 7 1 14 16 3 19 14 3 21 20 4 20 Neuroses 28 1 4 51 7 14 23 4 17 52 10 19 Person-al i t y Disorder 9 0 0 13 0 0 9 1 11 7 4 57 Situa-tional Distur-bance 12 2 17 24 5 21 10 2 20 13 0 0 Figure 2. Age D i s t r i b u t i o n of Total Sample at F i r s t H o s p i t a l i z a t i o n Compared with the Age D i s t r i b u t i o n of the General Population (Canada-1976) Ui OJ 54 Characteristics at the Time of  Second Hospitalization (h=67) As shown in Table 1, the majority .'(61.1 percent) of this patient subgroup were female and 59.7 percent of the subgroup were not l i v i n g with a partner. The mean age was 32.7 years with 53.7 percent of the subjects exceeding the median age of 29 years. The mean number of years of education was 11.6. The largest occupational subcategory was skilled (37.3 percent), followed by housewife or student (26.8 percent), unskilled (22.7 percent), and professional (13.6 percent). Most subjects (83.5 percent) had been employed at some time; 41.8 percent within the six months prior to hospitalization. Nearly 24 percent (23.9) were employed at admission while 43.2 percent were unemployed and 32.9 percent were housewives or students. The majority of the subjects (67.2 percent) were from Greater Vancouver, while 17.9 percent were from other parts of British Columbia and 14.9 percent were from the Lower Fraser Valley. Nearly one-fifth of this subgroup (19.4 percent) lived alone and the nearest kin named by most (43.3 percent) subjects was spouse, followed by parents (37.3 percent) and other individuals (19.4 percent). An equal number (40.9 percent) of subjects were self-supported or family-supported, while the remainder (18.2 percent) were supported by government funds. Most (44.8 percent) patients in this subgroup were referred by a hospital/agency, 38.8 percent were referred by physicians and only 16.4 percent were self-referred. The diagnostic category neuroses had the highest percentage of subjects (34.3) f o l -lowed by schizophrenia with 26.8 percent, personality disorder and 55 situational disturbance with 7.4 percent each. ' Nearly 3 percent of the subjects on second hospitalization had a primary diagnosis of alcohol-ism or epilepsy. Several subjects (28.4 percent) had a history of suicide attempts, while only 8 percent had had an attempt within one month prior to hospitalization. The majority (56.7 percent) of the sub-groups reported feelings of depression on admission and 62.6 percent had a history of drug abuse. The mean number of days hospitalized was 27.8. Nine percent of the subjects were absent without leave during their hospitalization, 4.4 percent were committed and 8.9 percent were discharged against medical advice while 53.7 percent were separated and 37.4 percent were separated and referred to other agencies/institutions. Figure 3 graphs the number of days elapsed to hospitalization by diagnostic group. Patients in the neuroses category had the high-est return in the 1 to 30 day category, while schizophrenic patients returned more frequently between 181 and 365 days from f i r s t hospitali-zation. In the major affective disorder category an almost equal number of patients returned between 181 to 365 days and over 365 days. 56 22 20 18 16 Number of Patients per Days Elapsed Before Rehospitalization 14 12 10 8 H 366* day. * % % % \ \ ,8, -365 day, <fc \ \ O \ 9 , - , 80day s \ \ * \ \ 31—90 day* T V <P Q \f* I I 0 - 3 0 day. <J> ^ (1 misting data—diagnosis; drug abuse: 366+) Figure 3- Number of Days Elapsed to Rehospitalization; for Patients Who Returned to Hospital (n=67) Grouped by Diagnostic Category .Some Characteristics of Patients Who Returned  to Hospital More Than Once Within Two  Years of First Hospitalization Nine patients of the total sample (n=401) returned to the hospital three times only. Two of these patients had a consistent diagnosis. Four patients were hospitalized four times in this Psychiatric Unit only, and none of these patients retained the same diagnosis. The mean length of stay for the patients at third hospi-talization was 30.4 days. Ten (79.9 percent) of the patients were unemployed at the time of admission, eight (61.5 percent) had a his-tory of drug abuse, seven (53.8 percent) were under 29 years of age and six (46.2 percent) were diagnosed major affective disorder. Of the patients who were hospitalized four times, three were 22 years of age or under, two were diagnosed major affective disorder, two abused street drugs and a 38 year old female patient, diagnosed neurotic, abused both alcohol and prescription drugs. Results of the Within Group Comparison  (n=334) and (n=67) There were three s t a t i s t i c a l l y significant differences at f i r s t hospitalization between patients who returned and those who did not. Abuse of drugs, including alcohol, (X2=6.5, df=2, P<0.01), employment in the six months prior to hospitalization (X2=4.96, df=l, P<0.02) and the age and marital status of schizophrenic patients (X2=3.74, df=l, P<0.05) were characteristics associated with return to hospital. The results of the chi-square test for the other characteristics appear in Appendix A. In order to more fu l l y describe the characteristics of the patient who abuses drugs, some further analyses of the data were car-ried out. F i r s t , the total sample; not-returned (n=334) and returned (n=67) were compared by diagnostic category and history of drug abuse, as shown in Table 5. TABLE 5 NUMBER AND PERCENT OF PATIENTS BY DIAGNOSTIC CATEGORY AND HISTORY OF DRUG ABUSE AT FIRST HOSPITALIZATION; RETURNED (n=67) AND NOT-RETURNED (n=334) Diagnostic Category Not Returned Abused Number Drugs Abused Percent Returned Number Drugs Percent Schizophrenic 70 33 47.0 20 12 60.0 Major Affective Disorder 42 9 21.0 10 6 60.0 Neuroses 127 46 36.0 22 14 63.6 Personality Disorder 32 20 62.0 5 3 60.0 Situational Disturbance 48 17 35.0 9 7 77.7 Missing Observations 15 "not returned" 1 "returned" It is noted that over 75 percent of patients hospitalized for transient situational disturbances and 60 percent or more of patients in a l l other diagnostic categories later rehospitalized, had a history of drug abuse. Although the data for drug abuse were contracted from an expanded code to a yes-no response in order to have large enough cells for the chi-square test, they are presented now in the original form in order to describe the frequency and type of drug abuse encountered among the subjects. Table 6 presents these frequency data by number and percent according to sex and type of drug abuse at f i r s t hospi-talization; returned only (n=67). TABLE 6 COMPOSITION OF THE SAMPLE ACCORDING TO SEX AND TYPE OF DRUG ABUSE FOR PATIENTS AT FIRST HOSPITALIZATION; RETURNED ONLY (n=67) Type of DrUg Male Number Percent Female Number Percent Total Number Percent Street 7 10.4 "7 10.4 14 20.8 Prescription 0 - 8 11.9 8 11.9 Street and Prescription 0 _ :o _ _ Alcohol 3 4.4 7 10.4 10 14.8 Alcohol and Prescription 1 1.4 2 2.9 3 4.4 Alcohol and Street 3 4.4 2 2.9 5 7.3 A l l Drugs 2 2.9 .0 - 2 2.9 No Use 7 10.4 16 23.8 23 34.3 Not Known 1 1.4 1 1.4 2 2.9 Table 7 presents the data for types of drugs abused and diag-nostic category for the same patient group. 60 TABLE 7 NUMBER OF PATIENTS BY DIAGNOSTIC CATEGORY AND TYPE OF DRUG ABUSE FOR PATIENTS AT FIRST HOSPITALIZATION; RETURNED ONLY (n=67) Street Alcohol Diagnostic Category Pre-scrip-and Pre-scrip-and Pre-scrip-Alcohol and Not Street tion tion Alcohol tion Street None Known Total Schizo-phrenia 8 1 0 1 0 3 7 0 20 Major Affective Disorder 2 1 0 1 0 1 4 1 10 Neuroses 2 4 0 5 2 2 8 0 23 Person-a l i t y Disorder 0 1 0 1 1 0 2 0 5 Situa-tional Distur-bance 2 0 0 2 0 1 2 1 9 Street drugs were abused more frequently than other drugs. This abuse occurred mainly in the schizophrenic subgroup and occurred equally between males and females. Alcohol was the next most frequently abused drug and the majority of alcohol use was by females. Females, mainly in the neurotic subgroup, accounted for a l l the drug use in the prescription drug category, and for most of the use in the combined categories of alcohol and prescription drug abuse. Seventy percent of total female drug use was attributed to these latter categories. Nearly 63 percent of the patients who later returned to hospital (n=67) abused drugs com-pared with 39.1 percent of the patients who did not return. The second significant difference between patients who returned to hospital and those who did not was that more patients who had been employed six months prior to hospitalization returned to hospital than did patients in the unemployed category, although of the total sample (n=401), 246 (61 percent) had been unemployed in this period. Figure 4 presents the data for employment status on admission by diagnostic category. Figure 4. Employment Status on Admission by Diagnostic Category (n=401) The last significant finding in the within group comparison was the association of diagnostic category and rehospitalization. In the total sample (n=401) were 106 single males and 133 single females. Forty-seven percent of the single males and 71.4 percent of the return-ing single males were schizophrenic, compared with 22.1 percent of the single females and 28.5 percent of returning single females. Also, 5.3 percent of male and 9.6 percent of female schizophrenics were married. See Appendix A for the chi-square results of this comparison. Results of the Between Group Comparison: Not  Returned (n=334) and Returned Once (n=67) In this comparison the two significant findings related to rehospitalization were: a'history of suicide attempt(s) (X2=4.93, df=l, P<0.02) and drug abuse within the six months prior to admission (X2=7.27, df=2, P<0.02). The characteristics unemployed at time of admission and type of discharge approached s t a t i s t i c a l significance. See Appendix A for the chi-square results for this comparison. Results of the Between Group Comparison;  First Hospitalization (n=67) and  Second Hospitalization (n=67) There were no significant differences in the characteristics of patients at f i r s t hospitalization and at second hospitalization within the following two years. One characteristic employment status on admis-sion approached significance (X2=6.35, df=l, P<0.06). Significantly more patients were unemployed at the time of second than at f i r s t hospitali-zation. 63 Discussion and Interpretation The increase in the rehospitalization rates in psychiatric hos-pitals, a phenomenon that followed the shift in the locus of delivery of mental health services, precipitated a flurry of rehospitalization studies. Many different factors thought to be related to this phenomenon have been investigated in a variety of settings using a variety of var-iables and comparison groups. Several of these studies found no rela-tionship between such c l i n i c a l factors as diagnosis, the use of medica-tions and of other inpatient therapies, the patient's condition at the time of discharge and rehospitalization of discharged patients (Rosenblatt 1974; Tuckman and Lavell 1965; Gurel and Lorei 1972; Manos 1977; Munley et a l . 1977; and Voineskos and Denault 1978). However, personal and social factors found to be implicated were: history of alcohol abuse (Lorei 1964; Franklin 1975; and Viesselman 1975); employ-ment (Gurel and Lorei 1972; Serban 1975 and Peretti 1974); family involvement (Exner and Murillo 1975; Ellsworth 1968; Brown et a l . 1972; and Vaughn and Leff 1976); use of leisure time and community adjustment (Wilier 1976); and type of discharge, number of previous hospitaliza-^ tions, race, suicide attempt within one month prior to admission, sub-jective report of depression upon admission and occupation level (Munley 1977). One of the significant and interesting findings in this study was the association of drug abuse and rehospitalization. Previous studies have not specifically explored drug abuse as a characteristic related to rehospitalization, although Lorei (1964) and Franklin et a l . (1975) found that a history of alcohol use was associated with return to hospital. Many investigators excluded from samples subjects who abused drugs, and indeed, in this study, subjects with organic symptoms due to drug abuse were also excluded. As has been stated previously, nearly two-thirds of the sub-jects in this study who returned to hospital within two years had a history of drug abuse at f i r s t hospitalization. When these data were analyzed, two patterns of drug abuse emerged: the abuse of street drugs by young psychotic subjects and the abuse of prescription drugs and alcohol by middle-aged neurotic females. It was found that patient in the psychotic groups, particularly the schizophrenic group, had high rates of street drug use. The schizophrenic group also had the lowest mean age of the diagnostic groups in the sample, but i t is d i f f i c u l t to determine whether the use of street drugs by these younger patients reflects a general pattern of drug use by individuals in this age group or whether other factors such as l i f e s t y l e or pre-morbid personality of the particular subjects in this subgroup are implicated in the associ-ation of drug abuse and rehospitalization for this group. In this study, and that of Watt and Szulecka (1979), a sta t i s -t i c a l l y significant finding was the association of age, sex, marital status and a diagnosis of schizophrenia and rehospitalization, Young, single schizophrenic males returned to hospital more frequently than did other subjects. These factors too, may be related to the drug abuse pattern described above. The earlier age of onset of schizo--phrenia, as Mayer-Gross et a l . (1969) have pointed out, interrupts psychic development and education and training, and inhibits the development of work patterns and stable relationships outside the family rendering the individual more vulnerable to lasting disability. Serban (1975, p.455) suggests that social disorganization of these patients precedes by a long time the development of c l i n i c a l symptoms. It may be that this process of social disorganization influences the i n d i v i -dual's mode of need satisfaction. Many of the schizophrenic subjects in this study were unemployed, unskilled and lived alone, indicating that their social functioning was already impaired at the time of hospitalization. Perhaps these circumstances also contribute to the use of street drugs by this patient group. A l l of the prescription drug abuse and most of the alcohol abuse in this study were accounted for by the middle-aged females in the sample who were diagnosed neurotic. Archer and Banner (1980, p.891) in a Canadian study of women's use of psychotropic medication, concluded that women in our society are allowed, i f not encouraged, to seek medical attention for mild symptoms of distress. In particular middle-aged women facing such crises as separation, divorce, children leaving home, perceived loss of usefulness, may find themselves using prescrip-tion drugs, such as the minor tranquilizers in an attempt to deal with these stressful situations. Because these women appear to be using drugs and hospitalizations as a coping mechanism, the writer br i e f l y reviewed recent literature to determine whether this finding i s sup-ported. Gallin (1980), in a study of uti l i z a t i o n of medical services, stated that women whose social resources are only nominally effective in mediating the pressures in their lives tend to seek medical inter^ vention, including hospitalization, for the distress they are exper-iencing (p,262). Again, disruption in social functioning appears to be a factor in the degree of use of hospital. This patient group had the highest rate of use of the Psychiatric Unit. One-quarter of the patients in this diagnostic category had a history of suicide attempt(s). Indeed, statis t i c s for the leading causes of death among females in 1976 (Canada Year Book 1978, p.175) indicate suicide to be the leading cause in the 30 to 34 age group, and the second leading cause in the 35 to 39 age group. Certainly, depression appears to be a predominant factor in both the use of hospital and the suicide rate of women in middle-age. It is not known whether there is any theoretical basis for a sex difference related to depression and an individual's res-ponse to i t . Klerman and Weissman (1980, p.63) state that theories about depression ascribe i t to biological factors, social causes, stress reaction and recently to social labelling. They suggest that a mixture of external stress and an individual pattern of dependency, passivity and helplessness may predispose women to depression, but that future theory w i l l link loss and separation changes, physiological and psychological balance and the genetic vulnerability to depression. Kessler et a l . (1981) looked at sex differences in psychiatric problems reaching a conclusion that women tend to seek psychiatric help at a higher rate than men with comparable emotional problems. Further, they concluded that men are less l i k e l y to associate their symptoms with depression and are less likely to obtain professional help volun-tar i l y for psychiatric problems. This could account for the over-representation of middle-aged women in psychiatric units. It may be that a lack of knowledge or a lack of alternative resources may affect the use of hospital by this group of women. If dependency is a pattern of behaviour (as with the drug dependent patient) i t may be that alternatives such as consciousness raising groups, self-help groups and assertiveness training w i l l have no appeal to those who identify hospitals and doctors as solutions to these problems. Nor does Canada's medicare system, which is per-ceived by many as a free service, encourage the use of other resources which the individual perceives as costly. The next significant finding for discussion was found in the within group comparison of patients who returned and who did not return to hospital. Here the serendipitous finding was a significant difference in the employment status of patients at admission; patients employed in the six months prior to hospitalization were more likely to return to hospital than those who were unemployed. Though a greater proportion of the patients who had been employed than unem-ployed at f i r s t hospitalization returned to hospital, by the second hospitalization there was nearly a 17 percent change in status in this group from employed to unemployed. Studies by Voineskos and Denault (1978) and Peretti (1974) indicate that patients who had a pattern of recurrent hospitalization had usually been unemployed for some time. However, they did not indicate whether these patients had been unemployed at the time of their f i r s t hospitalization. Thus, although this characteristic may not be useful at f i r s t hospitalization as a predictor of return to hospital, at second hospitalization i t has already emerged as a fac-tor of increasing influence in the phenomenon of recurrent hospitalization. Possible explanations for the findings of this study could be that work in the post-hospital period provided an additional stress that contributed to rehospitalization or that the ex-patient had d i f f i c u l t y becoming re-established as an employee. A third finding of significance was the association of a history of suicide attempt(s) and rehospitalization. This finding, not significant at f i r s t hospitalization, had reached significance by the second hospitalization, confirming the conclusion of Munley et a l . (1977). These researchers found that patients who had attempted suicide tended to be re-admitted. Since hospitalization and treatment of patients with suicidal behaviour is one of the main functions of an acute care psychiatric hospital, the a b i l i t y to be able to predict the likelihood that these patients w i l l be rehospi-talized i s important to their discharge planning and to the hospital goals for treatment while the patient is hospitalized. Although i t is not known whether there is an association between the number of individuals who attempt suicide, and the number who are successful, i t i s known that, i n 1976, suicide was one of the three leading causes of death in the age group 15 to 45 years. Seen from this perspective the use of suicide attempts as a predictor of rehospitali-zation does seem to be of practical importance for personnel involved in mental health services. In this study, the factors associated with rehospitalization (i.e., drug abuse, a history of suicide attempts, employment status on admission and age, sex and marital status of the schizophrenic patient group) were more related to social and personal than to c l i n i c a l factors. It is apparent that individuals vary in their use of psychiatric hospitals and that some patients who return to hospital may be unaware of alternatives to hospitalization or may choose to cope with their l i f e situation through the use of same. If psychi-atric units are to serve only the acutely i l l patient who requires temporary intensive treatment or assessment (Adult Psychiatric Services provided by General Hospitals Guidelines 1979, p . l ) , then new programs w i l l be required. These w i l l need to provide the kind of comprehensive community care that, integrated with acute care in hospitals, allows individuals to cope with the additional stresses that mental and emotional illnesses impose and s t i l l allows each person self-respect and a sense of continuity with his past and future (Dinsdale 1978, p.404). 70 CHAPTER V SUMMARY, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS FOR FURTHER STUDY Summary and Conclusions The delivery of mental health services, influenced by the advent of psychotropic drugs and the deinstitutionalization of patients from large mental hospitals, has changed and evolved from a major emphasis on custodial care to a major emphasis on community care. Psychiatric units in general hospitals along with other com-munity support systems such as community mental health centres, family services, drug and alcohol abuse programs and private practice physicians provide for a continuum of care for individuals requiring psychiatric services. Coinciding with the shift in the delivery of care within the mental health system was a rise in rehospitalization rates. This phenomenon of recurrent hospitalization has been the focus of many studies through which investigators endeavoured to identify factors associated with rehospitalization. Among the factors found to be associated with the phenomenon were: demographic characteristics, such as occupational level, unemployment, source of income; I.Q.; c l i n i c a l characteristics, such as suicide attempt(s) within one month prior to hospitalization, subjective report of depression on admis-sion, history of alcohol abuse, sex and mental status of schizophrenic patients, type of discharge; and social characteristics, such as family expectations and tolerance for marginal adjustment of ex-patient, use of leisure time and the number of previous psychiatric hospitalizations. Most of these studies focussed on the characteris-tics of patients who had an established pattern of recidivism. For example, i t has been determined that the number of previous hospitali-zations is a consistently good predictor of future hospitalizations, but that this factor is of no help when the patient is hospitalized for the f i r s t time. As opposed to studies which concentrate on patients with multiple hospitalizations, the intent of this retrospective study was to determine whether there are differences in characteristics between patients who return to hospital and patients who do not. A second purpose was to determine whether patient characteristics identified at f i r s t hospitalization change over time for patients who are recurrently hospitalized. The characteristics chosen for purposes of comparison were both demographic and c l i n i c a l and had been identi-fied in previous studies as being associated with the rehospitaliza-tion phenomenon. The patients in this study, conducted at the Health Sciences Centre - Psychiatric Unit of the University of British Columbia, had had a f i r s t psychiatric hospitalization in this Unit during 1976 or 1977. Only patients whose f i n a l diagnosis indicated a functional, rather than organic, disturbance were included. The number of patients included i n the sample was 401. Of this total, 67 patients did and 334 did not return to this Unit only within the two years following the f i r s t hospitalization. The 67 returning patients had a total of 84 rehospitalizations, thus the 401 patients in the sample had a total of 485 hospitalizations during the period of the study. The data were collected by the investigator from the hospital data bank and from personal review of the c l i n i c a l records and were entered in a computer f i l e . They were then grouped, tabulated and tested using the U.B.C. St a t i s t i c a l Package for the Social Sciences to describe and compare characteristics of patients who did and did not return, patients at f i r s t and second hospitalization and patients at second hospitalization and patients who did not return to this Psychiatric Unit only within two years. The following are the major findings of the study: 1. Drug abuse and employment within the six months prior to hospitalization were found to differentiate between patients at f i r s t hospitalization who later returned and those who did not. 2. Patients in the diagnostic category schizophrenia were significantly different in age, sex and marital status from patients in the other diagnostic categories: major affective disorder, neuroses, personality disorder and situational disturbances. 3. Two significant differences, drug abuse and a history of suicide attempt, and one difference approaching significance, unem-ployment, were associated with rehospitalization when patients rehospitalized once were compared with patients not rehospitalized at this Unit. 4. There were no significant differences in rates of return to hospital between psychotic and non-psychotic patients. 5. Although not s t a t i s t i c a l l y significant, there was an increase in numbers of patients who were unemployed and/or state supported by their second rehospitalization. These have been identi-fied as significant factors in other studies. 6. Also non-significant s t a t i s t i c a l l y , but of interest was the fact that one-third of the patients hospitalized twice were in the diagnostic category neuroses and that three-quarters of this group were women. This finding suggests the possibility of sex-differences such as response to stress , physiological and psychological balance and pattern of dependency with regard to women and depression since women were not over-represented in other diagnostic categories. 7. Other findings of interest, though not s t a t i s t i c a l l y significant, were in the area of drug abuse. Three-quarters of the patients who later returned to hospital and abused street drugs were under twenty-nine years of age, while three-quarters of the returning patients who abused alcohol and prescription drugs were over the age of twenty-nine years. A l l of the prescription drug abuse and most of the alcohol abuse in the latter group were attributed to female patients. When compared with the age, sex and diagnostic distribution of patients of other psychiatric units i n the province and in Canada, the Psychiatric Unit had a typical age and sex distribution for females in the sample and a slight over-representation of the total sample in the age group 20 to 29 years. As well, the sample had slightly fewer female psychotic patients and slightly more male neurotic patients (Mental Health Statistics 1976, p.175). (See Appendix B for details of these comparisons.) The findings of this study are generalizable only to patients whose subsequent hospitalizations following their f i r s t admission were in the Health Sciences Centre - Psychiatric Unit. It is likely that an additional number of patients from the original sample returned to other units since the patient population, like the popu-lation of the province, is mobile. Also, many ex-patients present themselves or are taken to emergency wards of major general hospitals and are either discharged after a brief stay in psychiatric assess-ment units, or, i f they require hospitalization, are triaged to psychiatric units with available beds. Other factors which may affect generalizability are: 1) the data collected were accepted as recorded, and were not interpreted, and 2) decisions were made by the investigator without consultation about the grouping of various diag-noses into diagnostic categories. For example, patients with psychotic diagnoses were separated into two categories, schizophrenia and major affective disorder. The latter category included a l l non-organic diagnoses of psychoses other than schizophrenia. Implications The association of drug abuse (i.e., a past or present depend-ency on drugs), unemployment and a history of suicide attempt(s) with rehospitalization has implications for government programs, profes-sionals in the health care system generally, and in the mental health care system particularly, and professionals working in psychiatric units. If 5 percent of the population are functionally incapacitated 75 by mental illness for long periods of time, (Canadian Medical Association Editorial 1978, p.223), and i f the biological, psycho-logical and social factors influencing the behaviour of psychiatric patients are interactive, then i t is not sufficient that the health care system alone bear the responsibility for the level of health of this sector of the population. The coordination of health systems with social and educational institutions is essential. A l l p o l i t i c a l and economic re a l i t i e s of the desirability of hospital care for psychi-atric patients aside, the reality is that the needs of this population for expanded mental health services are unquestionable. What is in question is how these services and related support systems can be most effectively provided. It is important for policy makers and planners at the govern-ment level to address issues related to mental health services at the preventive and rehabilitative level as well as at the treatment level. Collaboration among departments of education, health, and human resources is required i f the concomitant social and vocational prob-lems affecting delivery of mental health services are to be addressed. For example, the association of drug abuse and repeated use of psychiatric units by individuals requires the joint planning and coordination of drug and alcohol services, preventive health ser-vices and education with mental health services i f cost effective programs are to be provided. An implication of the study findings for mental health systems is the necessity of addressing the needs of specific groups, such as, female, depressed patients who abuse prescription drugs. Educational programs need to be developed and implemented that w i l l increase the awareness of the public generally, and physicians and females par-ticularly, of the problems associated with use of drugs by women. Another implication for the mental health system is to address the serious lack of supervised housing, sheltered workshops, hostels and half-way houses for patients who have few coping s k i l l s and few social supports. Nurses and other health team personnel in psychiatric units responsible for planning and evaluating unit programs should address the particular needs of specific groups of patients, such as the young male schizophrenic and the middle-aged depressed woman. Too often the structures of ward activities and groups are designed to include patients of varying ages and with differing problems, degrees of il l n e s s , dependency needs and degrees of social and personal s k i l l s instead of being designed to meet the common needs of specific patient groups. Nurses, as skilled observers of behaviour, can identify these needs and work with other team members to plan, implement and eval-uate specialized programs. Another implication for nursing is the need to be aware of the importance of social and community networks to the psychiatric patient who is returning to the community. As the member of the team charged with coordination of the discharge planning the nurse is in a unique position to help the patient establish linkages with these networks before he/she leaves hospital. 77 Recommendations for Further Study There is a need for more data about patients who repeatedly seek care in psychiatric units and about what happens to patients after they are discharged. The investigator recommends the following: 1. A retrospective study using Hospital Programs data to determine the extent and rate of use of inpatient psychiatric f a c i l -i t i e s in the province of British Columbia by psychiatric patients who are recurrently hospitalized. This would provide a data base for future decision-making about mental health services programs. 2. A prospective study of a cohort of psychiatric patients hospitalized for the f i r s t time to determine during follow-up the characteristics of patients who remain out of hospital and to deter-mine which characteristics of the returning patients are related to the consequences of psychiatric i l l n e s s . 3. A prospective study of psychiatric patients hospitalized for the f i r s t time who have a concomitant drug dependency problem to determine whether a relationship exists between the psychiatric prob-lem and the patient's drug dependency. 4. A study of clients of drug and alcohol services to deter-mine the extent and degree of psychiatric illness among them. 5. A controlled study of two groups of depressed women to compare the difference in effectiveness of a program planned to meet their needs and a traditional ward program. BIBLIOGRAPHY Adult Psychiatric Services Provided by General Hospitals. 1979. Ottawa: Health Services Directorate Health Sciences and Promotion Branch. Annual S t a t i s t i c a l Report Mental Health Programs. 1976. Ministry of Health B.C. Archer, C., and Benner, M. 1980. Women's Use of Psychotropic Medication: A Community Survey. Canadian Family Physician 26:6:867-871. Bassuk, E.L., and Gerson, S. 1978. Deinstitutionalization and mental health services. Scientific American 238:2:46-53. Brown, G.W.; Birley, J.L.T.; and Wing, J.K. 1972. Influence of family l i f e on the course of schizophrenic disorders: a replication study. British Journal of Psychiatry 129:121-258. Canada Year Book 1978-79. 1978. Hull, Quebec: Printing and Publishing Supply and Services Canada. Colls, H. 1976. The Role of the Mental Hospital in the Provision of Service to the Adult Psychotic Patient by The Government of British Columbia. Unpublished Thesis. Cumming, J. 1972. Plan for Vancouver. Unpublished Paper. Cunningham, M.; Botwinik, W.; Dolson, J.; and Weickert, A. 1969. Community Placement of Released Mental Patients: A Five-Year Study. Social Work 14:54-61. Denham, J., and Adamson, L. 1971. The Contribution of Fluphenazine Enanthate and Decanoate in the Prevention of Readmission of Schizophrenic Patients. Acta Psychiatria Scandinavia 47:420-429. Dimsdale, J.E. 1978. Coping - Every Man's War. American Journal of  Psychotherapy 23:3:402-404. Diagnostic and St a t i s t i c a l Manual, Mental Disorders (DSM II). 1968. Washington: American Psychiatric Association. Editorials Psychiatric Care and P o l i t i c s . 1978. Canadian Medical  Association Journal 118:2:223-226. Ellsworth, R.B.; Foster, L. ; Childers, B.; Arthur, G.; and Kroeker, D. 1968. Hospital and Community Adjustment as Perceived by Psychiatric Patients, Their Families, and Staff. Journal of  Consulting and Cli n i c a l Psychology Monograph Supplement 32:5: Part 2. Exner, J.E., and Murillo, L. 1975. The Early Prediction of Post-Hospitalization Relapse. Journal of Psychiatric Research 12:231-237. Franklin, J.L.; Kettredge, L.D.; and Thrasher, J.M. 1975. A Survey of Factors Related to Mental Hospital Readmissions. Hospital  and Community Psychiatry 26:11:749-751. Freeman, H.; Cheadle, A.J.; and Korer, J.R. 1979. Use of Hospital Services by Chronic Schizophrenics in the Community. British  Journal of Psychiatry 134:417-421. Gallin, R. 1980. D i f f i c u l t i e s , Coping, and the Use of Medical Services. Culture, Medicine and Psychiatry 4:249-269. Glick, I.D., and Hargreaves, W.A. 1979. Psychiatric Hospital  Treatment for the 1980s. Toronto: Lexington Books. Gurel, L., and Lorie, T. 1972. Hospital and Community Ratings of Psychopathology As Predictors of Employment to Readmission. Journal of Consulting and Cli n i c a l Psychology 39:286-297. Heffner, P.A., and Strauss, M.E. 1975. Rehospitalization of Schizophrenics as a Function of Intelligence. Journal of  Abnormal Psychology 84:6:735-736. Hersch, C. 1972. Social History, Mental Health and Community Control. American Psychologist 27:749-754. Kerlinger, F.N. 1973. Foundations of Behavioural Research. 2nd. ed. New York: Holt, Reinhart & Winston, Incorporated. Kessler, R.C.; Brown, R.L.; and Broman, CL. 1981. Sex Differences in Psychiatric Help-Seeking: Evidence of Four Large Scale Surveys. Journal of Health and Social Behaviour 22:1:49-64. Kita, S. 1978. UBC SPSS St a t i s t i c a l Package for the Social Sciences Version 7.01 (Under MTS). Vancouver: Computer Centre, University of British Columbia. Klerman, G.L., and Weissman, M.M. 1980. Depressions Among Women: Their Nature and Causes. The Mental Health of Women. Edited by M. Guttentag. New York: Academic Press. Kris, E. 1963. Five-Year Community Follow-Up Patients Discharged from a Mental Hospital. Current Therapeutic Research 5:10:451-462. Lahniers, C.E., and White, K. 1976. Changes in Environment Life Events and Their Relationship to Psychiatric Hospital Admissions. Journal of Nervous and Mental Disease 163:3:154-158. s Lorei, T.W. 19 64. Prediction of Length of Stay Out of the Hospital for Released Psychiatric Patients. Journal of Consulting  Psychology 28:4:358-363. Manos, N.; Taratsidis, I.; Pappas, K.; and Routsonis, C. 1977. Main-tenance Antipsychotic Pharmacology, Relapse, and Length of Stay Out of Hospital in the Chronic Schizophrenic in Greece. The  Journal of Nervous and Mental Disease 165:5:361-363. Mayer-Gross, W.; Slater, E.; and Roth, M. 1969. C l i n i c a l Psychiatry. London: Bulliere, Tindall and Cassell. Mental Health Statistics Canada - 1977. Volume III. Mental Health Statistics Canada - 1976. Volume II. Michaux, W.W. et a l . 1969. The Fir s t Year Out. Boston: Johns Hopkins Press. Munley, P.H. ; Devone, N. ; Eignhorn, CM.; Gash, I.A. ; Hyer, L. ; and Kuhn, K.C 1977. Demographic and C l i n i c a l Characteristics As Predictors of Length of Hospitalization and Readmission. Journal of American Psychology 33:10:1093-1099. Peretti, P.O. 1974. Precipitating Factors of Readmission of Psychiatric Patients. Community Mental Health Journal 10:1:89-92. Polit, D.F., and Hungler, B.P. 1978. Nursing Research: Principles  and Methods. Toronto: J.B. Lippincott Company. Rosenblatt, A., and Mayer, J.E. 1974. The Recidivism of Mental Patients: A Review of Last Studies. American Journal of  Orthopsychiatry 44:10:497-706. Selig, A. 1977. Those Back in One Year to a University Health Sciences Centre Psychiatric Unit. Unpublished Paper. Serban, G. et a l . 1975. Social Performance and Readmission in Acute and Chronic Schizophrenia: A Comparison of Two Approaches. Behavioural Neuropsychiatry 7:1-12:6-12. 81 Solomon, P., and Doll, W. 1979. The varieties of readmission: the case against use of recidivism rates as a measure of program effectiveness. American Journal of Orthopsychiatry 49:4: 230-239. Sta t i s t i c a l Report Mental Health Programs. 1976. Ministry of Health B.C. Tuckman, J., and Lavell, M. 1965. A Comparison of Readmission and Not-Readmission of Psychiatric Patients. Journal of General  Psychology 75:369-372. Vaughn, C.E., and Leff, J.P. 1976. The Influence of Family and Social Factors on the Course of Psychiatric Illness. British Journal  of Psychiatry 129:125-137. Viesselman, J.O.; Spalt, L.H.; and Tuason, V.B. 1975. Psychiatric Disorders i n a Community Mental Health Center. II Who Gets Admitted? Comprehensive Psychiatry 16:5:485-494. Voineskos, G., and Denault, S. 1978. Recurrent Psychiatric Hospitali-zations. Canadian Medical Association Journal 118:2:247-250. Watt, D.C, and Szulecka, T.K. 1979. The Effect of Sex, Marriage and Age at First Admission on the Hospitalization of Schizophrenics During 2 Years Following Discharge. Psychological Medicine 9:529-539. Wilier, B., and Biggin, P. 1976. Comparison of Rehospitalized and Non-Rehospitalized Psychiatric Patients on Community Adjust-v ment: Self Assessment Guide. Psychiatry 39:8:239-244. Williams, R.A., and Walker, R.G. 1961. Schizophrenia at Time of Discharge. Archives of General Psychiatry 4:1:113-116. Wilson, H.S., and Kneisl, CR. 1979. Psychiatric Nursing. Don Mills, Ontario: Addison-Wesley Publishing Company. 82 APPENDIX A TABLE A-1 CHI-SQUARE, DEGREES OF FREEDOM AND P VALUE FOR SELECTED DEMOGRAPHIC AND CLINICAL PATIENT CHARACTERISTICS COMPARING FIRST HOSPITALIZATION RETURNED (n=67) AND NOT-RETURNED (n=334); FIRST AND SECOND HOSPITALIZATIONS (n=67, n=67); AND FIRST HOSPITALIZATION, NOT-RETURNED (n=334) AND SECOND HOSPITALIZATION (n=67) First Hospitalization n=334 and n=67 First and Second Hospitalization n=67 and n=67 First Hospitalization, Not-Returned and Second Hospitalization n=334 and n=67 X 2 df P Value X 2 df P Value X2 df P Value Sex 0.26 1 0.60 0.0 1 1.0 0.26 1 0.60 Marital Status 1. 81 1 0.17 0.75 1 0.38 0.04 1 0.83 Occupation 1.47 3 0.68 0.38 3 0.94 3.31 3 0.34 Employed Ever 0.53 1 0.46 0.05 1 0.81 1.01 1 0.31 Employed With Previous Six Months 4.96 1 0.02* 1.08 1 0.29 0.73 1 0.38 Employed at Admission 4.55 2 0.10 4.16 1 0.12 2.67 2 0.26 Census Tract 2.97 2 0.22 0.18 2 0.91 1.24 2 0.53 Living Situation at Admission 0.06 1 0.79 0.06 1 0.79 0.36 2 0.54 Nearest Kin 2.86 2 0.23 0.62 2 0.73 0.62 2 0.72 Financial Support 2.85 2 0.24 0.59 2 0.74 0.59 2 0.74 Referred By 2.76 2 0.25 0.57 2 0.74 3.36 2 0.18 Final Diagnosis 2.89 4 0.57 3.63 4 0.60 15.50 5 0.008* *Sta t i s t i c a l l y significant findings. TABLE—Continued First Hospitalization n=334 and n=67 -First and Second Hospitalization n=67 and n=67 -First Hospitalization, Not-Returned and Second Hospitalization n=334 and n=67 X 2 •df P Value -X2 -df P Value X2 df P Value Suicide Attempt Ever 0.27 1 0.60 1.47 1 0.22 4.93 1 0.02 Suicide Attempt Within One Month of Admission 0.01 1 0.90 0.67 1 0.41 0.79 1 0.37 Subjective Statement of Depression on Admission 0.60 1 0.43 0.60 1 0.43 0.60 1 0.43 Drug Abuse Ever 6.50 2 0.01 0.51 2 0.77 3.19 .2 0.20 Drug Abuse Past Six Months 6.50 1 0.01 0.66 1 0.41 7.27 2 0.02* Age Group 0.36 1 0.54 0.03 1 0.86 0.14 1 0.70 AWOL 1.34 1 0.24 X 2 not valid - 50% of cells have fre-quency <5.0 0.005 1 0.94 Involuntary Status X 2 not cells <5.0 valid - 25% of have frequency X 2 not valid - 50% of cells have fre-quency <5.0 X2 not cells <5.0 valid - 25% of have frequency Termination 2.22 2 0.32 2.73 2 0.25 5.47 2 0.06 *S t a t i s t i c a l l y significant findings. 85 TABLE A-2 CHI-SQUARE, DEGREES OF FREEDOM AND P VALUE FOR SEX, MARITAL STATUS AND DIAGNOSIS OF PATIENTS AT FIRST HOSPITALIZATION: RETURNED (n=67),NOT-RETURNED(n=334) Schizophrenic X2=3.74 df=l P<0.05 Major Affective Disorder X2=0.68 df=l P<0.40 Neuroses X2=0.39 df=l P<0.52 Personality Disorder X2=0.87 df=l P<0.34 Situational Disturbance X2=0.61 df=l P<0.43 86 APPENDIX B TABLE B-l PSYCHIATRIC UNITS, FIRST HOSPITALIZATION, 1976. PERCENT FEMALE AND AGE: CANADA, BRITISH COLUMBIA AND HEALTH SCIENCES CENTRE - PSYCHIATRIC UNIT. 0-4 5-9 10-14 15-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 Canada Percentage Female 40.0 18.9 57.0 57.7 57.4 61.0 60.3 61.1 60.6 61.6 56.2 British Columbia Percentage Female 18.1 20.5 41.1 60.0 58.4 60.7 59.3 61.3 58.9 55.8 50.8 Health Sciences Centre - Psychiatric Unit Percentage Female 57.2 56.0 59.7 57.9 60.9 56.4 52.0 (76-77) Source: Mental Health Statistics, 1976:175. 

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