UBC Theses and Dissertations

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UBC Theses and Dissertations

A descriptive study of the community adjustment of a group of Vancouver schizophrenics Davis, Simon 1984

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A DESCRIPTIVE STUDY OF THE COMMUNITY ADJUSTMENT OF A GROUP OF VANCOUVER SCHIZOPHRENICS by SIMON DAVIS B . S c , The U n i v e r s i t y o f B r i t i s h Columbia , 1978 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK in The Facu l t y o f Graduate Stud ies School o f S o c i a l Work We accept t h i s t h e s i s as conforming to the r e q u i r e d standard The U n i v e r s i t y o f B r i t i s h Columbia June, 1984 © Simon D a v i s , 1984 { In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements fo r an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y a v a i l a b l e f o r reference and study. I further agree that permission for extensive copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head of my department or by h i s or her representatives. I t i s understood that copying or p u b l i c a t i o n of t h i s t h e s i s for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 DE-6 M/Rn i i . A B S T R A C T A group o f s c h i z o p h r e n i c s l i v i n g i n the community were f o l l o w e d f o r a two year p e r i o d , us ing i n f o r m a t i o n c o l l e c t e d from f i l e s a t the community care teams they were a t t e n d i n g . In format ion c o l l e c t e d per -ta ined to the s u b j e c t s ' c u r r e n t l i v i n g s i t u a t i o n , s t y l e o f c o h a b i t a t i o n , source o f income, geographic m o b i l i t y and use o f c l i n i c a l s e r v i c e s . S o c i a l adjustment o f the sample was measured by employment s t a t u s and r e h o s p i t a l i z a t i o n r a t e . The r e s u l t i n g d e s c r i p t i o n of the p o p u l a t i o n i n d i c a t e d a group w i th a high degree of d i s a b i l i t y and dependency; r a t e s o f unemployment and r e h o s p i t a l i z a t i o n were h i g h . The study i n d i c a t e d tha t r e s i d e n t i a l s t a t u s and s t y l e o f c o h a b i t a t i o n remained f a i r l y s t a b l e over the two year p e r i o d , but t h a t employment s t a t u s worsened somewhat. The data d e l i n e a t e d a s u b - p o p u l a t i o n o f young s c h i z o p h r e n i c s who seemed to be more uns tab le than the o l d e r s u b j e c t s ; the younger group had a s i g n i f i c a n t l y h igher r e h o s p i t a l i z a t i o n r a t e , were more m o b i l e , and were heav ie r consumers o f p s y c h i a t r i c s e r v i c e s . In l o o k i n g fo r f a c t o r s t h a t were a s s o c i a t e d w i t h d i f f e r e n t i a l community adjustment i t was found t h a t those r e h o s p i t a l i z e d i n the f o l l o w - u p per iod tended to be younger , un -employed, more r e c e n t l y i n h o s p i t a l , and more f requent v i s i t o r s to the community care teams; those who were unemployed a t the end o f t h e . f o l l o w - u p per iod tended to " b e male , unmarr ied , and possess ing a i i i . poor work h i s t o r y . The d e s c r i p t i o n of the study p o p u l a t i o n i n d i c a t e d t h a t t h i s group would r e q u i r e c o n s i d e r a b l e ongoing t reatment and s u p p o r t , and t h a t some i n d i v i d u a l s might be more "at r i s k " than o t h e r s . I t was a l s o suggested t h a t some of the soc io -demographic v a r i a b l e s used i n t h i s study might be use fu l d i a g n o s t i c a l l y . i v . TABLE OF CONTENTS Page ABSTRACT i i LIST OF TABLES v i CHAPTER 1 PROBLEM FORMULATION AND RATIONALE FOR THE STUDY 1 2 LITERATURE REVIEW 6 A) Sociodemograhpic C h a r a c t e r i s t i c s of Sch i zophren ics ,6 B) S t a b i l i t y o f Features Over Time 12 C) Factors A s s o c i a t e d w i t h D i f f e r e n t i a l Outcome i n Sch izophren ia 13 D) Sub-groups w i t h i n the Sch i zophren ic P o p u l a t i o n . . 21 E) Summary 23 3 RESEARCH DESIGN 25 A) Summary 25 B) Level o f Design 25 C) Nature o f the Sample 27 D) Source o f Informat ion 31;' E) V a r i a b l e s Used 33 F) R e l a t i o n s h i p s between V a r i a b l e s 45 G) V a l i d i t y and R e l i a b i l i t y of Measures Used 46 H) Timing o f Measurements 54 I) E t h i c a l Issues 57 J) S t rategy o f Data A n a l y s i s 57 V . CHAPTER Page 4 RESULTS 5 9 , A) Sociodemograhpic C h a r a c t e r i s t i c s o f the P o p u l a t i o n 59 B) S t a b i l i t y Measures of the P o p u l a t i o n J^-C) D i f f e r e n c e s w i t h i n the P o p u l a t i o n Based on Sch i zophren ia Outcome Measures ?4. 5 DISCUSSION 8 9 A) Methodolog ica l Issues 8 9 B) Sociodemograhpic C h a r a c t e r i s t i c s o f the P o p u l a t i o n . . 95 ; C) S t a b i l i t y Measures o f the P o p u l a t i o n IQQ D) D i f f e r e n c e s w i t h i n the P o p u l a t i o n Based on Sch i zophren ia Outcome Measures l o g E) Summary and Conc lus ions 120 REFERENCES 125 LIST OF TABLES Table Page 1 C r o s s t a b u l a t i o n of Sex by Age f o r the Study Popu la t ion 60 2 C r o s s t a b u l a t i o n o f Sex by Employment Status f o r the Study P o p u l a t i o n 60 3 C r o s s t a b u l a t i o n o f Sex by M a r i t a l S tatus f o r the Study Popu la t ion 61:. 4 Summary o f Age D i f f e r e n c e s f o r the Study Popu la t ion 63-5 C r o s s t a b u l a t i o n of Age by Age a t F i r s t P s y c h i a t r i c H o s p i t a l i z a t i o n .66:. 6 D i s t r i b u t i o n o f Age o f F i r s t P s y c h i a t r i c Contact f o r Study P o p u l a t i o n 68:' 7 D i s t r i b u t i o n o f Age o f F i r s t P s y c h i a t r i c H o s p i t a l i z a t i o n f o r Study P o p u l a t i o n ' 69, 8 D i s t r i b u t i o n o f Time s i n c e Last H o s p i t a l i z a t i o n f o r Study P o p u l a t i o n 70. 9 Change i n C l i e n t Status over a Two Year Per iod 75 1 0 Summary o f S i g n i f i c a n t B i v a r i a t e A s s o c i a t i o n s ' T i -l l C r o s s t a b u l a t i o n of R e h o s p i t a l i z a t i o n by Employment Status f o r the Study Popu la t ion .80-' 1 2 C r o s s t a b u l a t i o n o f Venture Admissions by L i v i n g S i t u a t i o n f o r the Study P o p u l a t i o n 8 1 1 3 C r o s s t a b u l a t i o n o f Employment Status by R e s i d e n t i a l S i t u a t i o n f o r the Study P o p u l a t i o n 83 1 4 C r o s s t a b u l a t i o n o f Employment Status by Employment H i s t o r y fo r the Study P o p u l a t i o n 83~! 1 5 C r o s s t a b u l a t i o n o f Employment Status by L i v i n g S i t u a t i o n f o r the Study P o p u l a t i o n 85: 1 6 M u l t i p l e Regress ion o f I n t e r v a l Level V a r i a b l e s w i th Three Outcome V a r i a b l e s 8T. 1. Chapter 1 INTRODUCTION: PROBLEM FORMULATION AND RATIONALE FOR THE STUDY This study was a d e s c r i p t i v e i n v e s t i g a t i o n o f a group o f community-based s c h i z o p h r e n i c s , l i v i n g i n Vancouver, and a t t e n d i n g the community care teams o f the Greater Vancouver Mental Heal th S e r v i c e . The purpose o f the study was to d e s c r i b e the sample i n terms o f a number o f sociodemographic v a r i a b l e s ; t h e i r c l i n i c a l h i s t o r i e s , t h e i r pat te rns o f l i v i n g and employment, and t h e i r use of p s y c h i a t r i c s e r v i c e s . The study was l o n g i t u d i n a l i n d e s i g n , tha t i s , i t fo l l owed the same group o f people f o r a per iod o f two y e a r s . As w e l l as d e s c r i b i n g the sample i n g e n e r a l , the study had as an a d d i t i o n a l purpose to look f o r v a r i -a b i l i t y w i t h i n the sample, t h a t i s , to t r y and see i f some o f the s u b j e c t s were more (or l e s s ) " s u c c e s s f u l " than o t h e r ' s u b j e c t s i n a d j u s t i n g to community l i f e , as measured p r i n c i p a l l y by r a t e s o f employment and tendency to exper ience a p s y c h i a t r i c r e h o s p i t a l i z a t i o n . The r e s e a r c h e r , as an employee o f the G . V . M . H . S . , had access to the c l i e n t s ' c l i n i c a l f i l e s l o c a t e d a t the communi ty. .care teams. I t seemed l o g i c a l to take advantage o f t h i s resource i n t h a t i t represented a c e n t r a l i z e d , reasonably sys temat i c source o f i n f o r m a t i o n , tha t had 2 . not been u t i l i z e d to any g reat ex tent p r e v i o u s l y . In t h a t r e l a t i v e l y l i t t l e had been done by the G . V . M . H . S . i n terms o f a comprehensive examinat ion of the c l i e n t p o p u l a t i o n , i t was f e l t t h a t the present study cou ld serve an e x p l o r a t o r y purpose, to c o n f i r m (or d i s c o n f i r m ) b e l i e f s t h a t may have p r e v i o u s l y been taken f o r g r a n t e d . As we l l as g i v i n g a d e s c r i p t i o n o f the study p o p u l a t i o n i n g e n e r a l , by d i s t i n g u i s h i n g the popu la t ion on d i f f e r e n t outcome measures ( e . g . employment and r e h o s p i t a l i z a t i o n ) i t was hoped t h a t f a c t o r s a s s o c i a t e d w i t h b e t t e r (or worse) outcome, cou ld be i d e n t i f i e d , or t h a t poorer outcome ("h igh r i s k " ) groups w i t h i n the p o p u l a t i o n cou ld be i d e n t i f i e d ; i n so d o i n g , i t was hoped t h a t the f i n d i n g s cou ld have some c o n c r e t e , program/pol icy i m p l i c a -t i o n s by i n d i c a t i n g i n d i v i d u a l s or groups who may r e q u i r e more p s y c h i a t r i c / r e h a b i l i t a t i v e a t t e n t i o n . S c h i z o p h r e n i c s were chosen as the d i a g n o s t i c group i n t h i s study f o r severa l reasons . F i r s t o f a l l , s c h i z o p h r e n i c s make up a c o n s i d e r a b l e p r o p o r t i o n of the G . V . M . H . S . case l o a d ; approx imate ly 50% o f the G . V . M . H . S . c l i e n t s had a pr imary d i a g n o s i s of s c h i z o p h r e n i a accord ing to the 1982 Annual Repor t . S c h i z o p h r e n i a represents a s e r i o u s problem to a l l community mental hea l th programs because of the d i s a b l i n g nature of the d i s o r d e r and the c h r o n i c i t y of the c o n d i t i o n . Some e p i d e m i o l o g i c a l i n f o r m a t i o n g ives an i n d i c a t i o n of the impact o f t h i s i l l n e s s : about 1% of the p o p u l a t i o n w i l l have a s c h i z o p h r e n i c episode dur ing t h e i r 1 i f e t i m e - [ 1 ] ; a study o f p o p u l a t i o n s t a t i s t i c s shows t h a t those people a t g r e a t e s t r i s k f o r deve lop ing s c h i z o p h r e n i a (age 15-34) make up the l a r g e s t cohor t i n our t o t a l p o p u l a t i o n [ 2 ] , and most of these w i l l r e l y on community-based programs; s c h i z o p h r e n i c s have a high r a t e of 3 . h o s p i t a l i z a t i o n i n d i c a t e d by the f i n d i n g t h a t i n 1975 36% of a l l p a t i e n t s admitted to s t a t e and county mental h o s p i t a l s i n the U.S . were diagnosed s c h i z o p h r e n i c [ 3 ] ; the low e m p l o y a b i l i t y o f the s c h i z o p h r e n i c i s i n d i c a t e d by the f i n d i n g t h a t on ly about 25% of r e l e a s e d s c h i z o p h r e n i c p a t i e n t s are ab le to f i n d any employment i n the two year per iod a f t e r h o s p i t a l d i scharge [ 4 ] ; the t o t a l d i r e c t and i n d i r e c t c o s t of s c h i z o p h r e n i a to Americans was est imated i n 1971 a t 14 B i l l i o n d o l l a r s a year [ 5 ] . Because of the p e s s i m i s t i c l i t e r a t u r e on s c h i z o p h r e n i a , and a l s o based on t h e i r c l i n i c a l exper ience many mental h e a l t h t h e r a p i s t s view s c h i z o -phrenia as a r a t h e r hopeless c o n d i t i o n , t h a t i s , having a u n i f o r m l y poor outcome. One o f the goals o f t h i s study was to see i f t h i s , i n f a c t , was the c a s e ; were there w i t h i n t h i s study p o p u l a t i o n o f s c h i z o p h r e n i c s , some s u b j e c t s who were doing b e t t e r than o t h e r s ? The importance of t h i s r e l a t e s to the i s s u e o f p s y c h i a t r i c l a b e l l i n g ; once an i n d i v i d u a l i s s tuck w i t h the l a b e l " s c h i z o p h r e n i c , " the tendency i s to regard him (perhaps u n j u s t l y ) as e x a c t l y a l i k e others w i t h the same l a b e l . Another reason why s c h i z o p h r e n i a was chosen as the t o p i c f o r t h i s study was t h a t there i s c o n s i d e r a b l e l i t e r a t u r e on t h i s a r e a ; t h i s was important i n t h a t the attempt was made to compare aspects o f t h i s study p o p u l a t i o n w i t h f i n d i n g s on s i m i l a r groups. In f a c t , many o f the hypotheses about sources o f >variabil i t y w i t h i n the group were suggested by o ther research f i n d i n g s ; i n t h i s sense , the study can be s a i d to have a r e p l i c a t i v e element to i t . I t has been s t a t e d t h a t the c u r r e n t study desc r ibed s c h i z o p h r e n i c s on the b a s i s o f sociodemographic v a r i a b l e s , such as age , sex , r e s i d e n c e , employment, m a r i t a l s t a t u s , past h o s p i t a l h i s t o r y and so o n . The study 4. d i d not focus on the symptomatic express ions of the d i s o r d e r , e . g . h a l l u c i n a t i o n s and d e l u s i o n s . In par t t h i s i s a l i m i t a t i o n of the source o f i n f o r m a t i o n ; symptomatology can o n l y be v e r i f i e d through face to face i n t e r a c t i o n , not through recorded m a t e r i a l which was the b a s i s o f t h i s s tudy . The o ther i s s u e i s t h a t symptom express ion has not been p a r t i c u l a usefu l i n d i s t i n g u i s h i n g among groups o f s c h i z o p h r e n i c s . Most s t u d i e s tha t have compared "good outcome" and "poor outcome" s c h i z o p h r e n i c s have found the a c t u a l psychot i c symptoms o f the two groups have been q u i t e s i m i l a r . [6]. . M o r e o v e r , a n d ' o f re levance to the present study i s the o b s e r v a t i o n by Anthony [7] t h a t : "The p s y c h i a t r i c diagnosis does not provide any uniquely relevant information about the subject's r e h a b i l i t a t i o n p o t e n t i a l . This f i n d i n g i s r e a l l y not that s u r p r i s i n g i n that the p s y c h i a t r i c diagnostic system was developed to categorize symptom patterns, not to provide information about a p s y c h i a t r i c a l l y disabled person's r e h a b i l i t a t i v e prospects." Anthony goes on to propose tha t sociodemographic background m a t e r i a l on the c l i e n t (such as h is h o s p i t a l i z a t i o n h i s t o r y ) can account f o r a c o n s i d e r a b l e amount o f the v a r i a n c e i n the outcome of the d i s o r d e r (as measured by employment and r e h o s p i t a l i z a t i o n ) and thus t h i s i n f o r m a t i o n can help to i d e n t i f y "h igh r i s k " i n d i v i d u a l s who "are most l i k e l y to exper ience d i f f i c u l t y i n the community and thus most i n need o f s p e c i f i c r e h a b i l i t a t i o n programs" [8]. Schwartz [9] argues t h a t one o f the weak-nesses o f our present community mental hea l th system i s t h a t l i n e workers are o f t e n not provided w i t h t h i s necessary background i n f o r m a t i o n : "A c r i t i c i a l component of service d e l i v e r y i s a capacity to provide workers at these s i t e s with s u f f i c i e n t background information on presenting i n d i v i d u a l s to permit appropriate diagnostic and treatment planning d e c i s i o n s . " 5. Based on these f i n d i n g s , the s t r a t e g y was adopted i n t h i s study to (a) look f o r v a r i a n c e i n the study p o p u l a t i o n , (b) see i f the same sociodemographic f a c t o r s seen by o ther researchers cou ld be a p p l i e d to account f o r v a r i a n c e i n the study p o p u l a t i o n and (c) f o l l o w i n g from t h i s , see i f p a r t i c u l a r groups or i n d i v i d u a l s cou ld be i d e n t i f i e d as "h igh r i s k " (poorer r e h a b i l i t a t i o n p o t e n t i a l ) . 6. Chapter 2 LITERATURE REVIEW This study sought to d e s c r i b e the m a n i f e s t a t i o n o f s c h i z o -phrenia i n terms o f sociodemographic (rather than c l i n i c a l / d i a g n o s t i c ) v a r i a b l e s . The l i t e r a t u r e review attempts to f o l l o w the sequence o f the data a n a l y s i s , which roughly takes the f o l l o w i n g fo rm: (A) A p r e -s e n t a t i o n o f the i n d i v i d u a l sociodemographic v a r i a b l e s as they apply to the study sample; (B) A look a t the s t a b i l i t y of the sample as measured by changes i n these same v a r i a b l e s over th ime; (C) A look a t f a c t o r s tha t are a s s o c i a t e d w i t h a d i f f e r e n t i a l outcome i n s c h i z o p h r e n i a ; (D) A look a t the p o s s i b l e e x i s t e n c e o f d i s t i n c t i v e sub-groups w i t h i n the s c h i z o p h r e n i c p o p u l a t i o n . There i s one note o f c a u t i o n : most o f the s t u d i e s are Amer ican, and there may be some problems i n comparing American data to the Canadian scene . Th is p o i n t w i l l be d i scussed i n more d e t a i l i n Chapter 3. A. Sociodemographic C h a r a c t e r i s t i c s o f Sch i zophren ics i ) Sex. The m a j o r i t y o f s t u d i e s i n d i c a t e tha t there i s an equal preva lence and i n c i d e n c e of s c h i z o p h r e n i a among men and women [10]. 7. There does , however, seem to be a d i f f e r e n c e i n age o f onset f o r men and women; i n rev iewing a number o f s t u d i e s Lewine [11] concludes t h a t men are a t g r e a t e s t r i s k f o r f i r s t p s y c h i a t r i c h o s p i t a l i z a t i o n i n t h e i r t w e n t i e s , whereas women are a t g r e a t e s t r i s k d u r i n g t h e i r t h i r t i e s . i i ) Age of Onset. As noted above, there appears to be a sex d i f f e r e n c e i n age o f o n s e t . Peak i n c i d e n c e i s reached by men i n e a r l y t w e n t i e s , and f o r women i n l a t e twent ies and e a r l y t h i r t i e s [ 1 2 ] . This r e f e r s to f i r s t s c h i z o p h r e n i c e p i s o d e , but i t should be noted tha t some s t u d i e s use age o f f i r s t p s y c h i a t r i c h o s p i t a l i z a t i o n as t h e i r s t a n d a r d . This i s s i g n i f i c a n t because i t i s presumably p o s s i b l e f o r a person to have a s c h i z o p h r e n i c episode and not be h o s p i t a l i z e d . One study noted tha t there was a " l a g " between symptom onset and f i r s t h o s p i t a l i z a t i o n o f 23 months i n a sample of s c h i z o p h r e n i c s [ 1 3 ] . i i i ) Hospitalization. S c h i z o p h r e n i c s are t y p i c a l l y a group tha t may exper ience a c o n s i d e r a b l e number o f p s y c h i a t r i c h o s p i t a l i z a t i o n s . In rev iewing a number o f s t u d i e s , Strayhorn [14] concludes t h a t the r e h o s p i t a l i z a t i o n r a t e fo r the s c h i z o p h r e n i c i s 40 -60 per cent w i t h i n two years o f h o s p i t a l d i s c h a r g e . In another review Anthony [15] t a l k s o f a r e c i d i v i s m "base r a t e " o f about 40 -50 per cent f o r a one year per iod f o l l o w i n g h o s p i t a l d i s c h a r g e . In t h i s summary Anthony i s t a l k i n g about h o s p i t a l i z e d p s y c h i a t r i c p a t i e n t s i n g e n e r a l , not j u s t s c h i z o p h r e n i c s , but makes the c l a i m t h a t d i a g n o s t i c d i f f e r e n c e s do not s i g n i f i c a n t l y a f f e c t the r e c i d i v i s m r a t e [ 1 6 ] . I t should be noted t h a t whether or not 8 . a person i s admitted and how much time he spends i n h o s p i t a l i s a f f e c t e d by a number o f f a c t o r s - many o f them p o l i t i c a l - o ther than s imply the hea l th o f the i n d i v i d u a l . More w i l l be s a i d on the v a l i d i t y o f a r e h o s p i t a l i z a t i o n as a measure o f s u c c e s s f u l coping i n Chapter 3 . There has been a p o l i c y o f d e i n s t i t u t i o n a l i z a t i o n in North America over the l a s t t h i r t y y e a r s , and i n general the number o f p a t i e n t s i n l a r g e mental i n s t i t u t i o n s and t h e i r d u r a t i o n o f s tay has been d e c r e a s i n g . As an i l l u s t r a t i o n of t h i s , a study done by the Canadian Mental Heal th A s s o c i a t i o n i n Saskatchewan noted tha t f i r s t l y , from 1957 to 1979 the t o t a l number o f p a t i e n t s i n p r o v i n c i a l mental h o s p i t a l s f e l l from 3400 to 246 a n d , s e c o n d l y , the median l e n g t h o f s tay a t p r o v i n c i a l i n s t i t u t i o n s f e l l from 100 days i n 1948 to 22 days i n 1975 [ 1 7 ] . Whi le the d u r a t i o n o f p a t i e n t h o s p i t a l i z a t i o n seems to be d i m i n i s h i n g , there has a t the same time been a t rend i n r e c e n t years o f more f requent readmiss ions to and d i scharges from community i n p a t i e n t f a c i l i t i e s , a phenomenon known as the " r e v o l v i n g door syndrome" [ 1 8 ] . i v ) Employment. Although employment ra tes are s u b j e c t to s i t u a t i o n a l f l u c t u a t i o n s , employment s t a t u s i s never the less commonly used as a measure o f s u c c e s s f u l coping i n s c h i z o p h r e n i a s t u d i e s . In g e n e r a l , employment r a t e s f o r s c h i z o p h r e n i c s are low. Ke i th [19] sum-marizes the s i t u a t i o n i n the f o l l o w i n g passage: " I t Is estimated that only 15 to 40% of schizophrenics function at an 'average' l e v e l (e.g. are able to work or keep house). Discharged schizophrenics are l i k e l y to be c h r o n i c a l l y or p e r i o d i c a l l y unemployed, thus contributing to the heavy burden of unemployment i n society. F i n a l l y , the lack of opportunity f o r proper t r a i n i n g i s p a r t i c u l a r l y c r i t i c a l f o r schizophrenics 9. because they usually become i l l between the ages of 18 and 35 - the prime productive and career-formative years of l i f e . " Anthony and Bue l l [20] propose a t y p i c a l f u l l t ime employment r a t e o f 25 per cent f o r p s y c h i a t r i c p a t i e n t s one year f o l l o w i n g h o s p i t a l d i s c h a r g e ; the authors a l s o note tha t the s i t u a t i o n may w e l l be worse f o r s c h i z o -phrenics than f o r p s y c h i a t r i c p a t i e n t s w i t h other d i a g n o s e s . v) Suie'irfes. Most s t u d i e s i n d i c a t e a high s u i c i d e r a t e f o r s c h i z o p h r e n i c s . One es t imate puts the r a t e a t twelve times t h a t o f the general p u b l i c [ 2 1 ] . Another es t imate proposes t h a t 10% o f s c h i z o p h r e n i c p a t i e n t s w i l l d i e by s u i c i d e [ 2 2 ] . v i ) Marital Status. The marr iage r a t e s fo r s c h i z o p h r e n i c s are t y p i c a l l y lower than the general p o p u l a t i o n , p a r t i c u l a r l y w i t h regard to male s c h i z o p h r e n i c s . As an example, a S c o t t i s h study [23] o f 375 a d u l t s c h i z o p h r e n i c s found t h a t , f o r the men, 21% were c u r r e n t l y m a r r i e d , 5% separated or d i v o r c e d , and 74% s i n g l e and never m a r r i e d . For the women, the f i g u r e s were r e s p e c t i v e l y 47%, 10% and 43%. For the t o t a l sample 58% had never been marr ied w h i l e 35% were c u r r e n t l y m a r r i e d . In rev iew ing severa l s t u d i e s , Test and B e r l i n [24] conclude tha t the marr iage r a t e s o f the female c h r o n i c a l l y m e n t a l l y i l l approach those o f females i n g e n e r a l , whereas the r a t e s o f the male m e n t a l l y i l l a re c o n s i d e r a b l y l e s s than the male general p o p u l a t i o n . Whether or not a s c h i z o p h r e n i c has been marr ied i s taken as a u s u a l l y r e l i a b l e measure o f premorbid adjustment [ 2 5 ] , but moreso f o r men than women, s i n c e the t r a d i t i o n a l male r o l e i n c o u r t i n g u s u a l l y r e q u i r e s more a s s e r t i v e n e s s and s o c i a l competency. 10. v i i ) Mortality Rates. I t would appear tha t s c h i z o p h r e n i c s have a h igher m o r t a l i t y r a t e than the general p o p u l a t i o n . In a f o l l o w -up study A f f l e c k e t a l . [26] found t h a t f o r a group o f 153 s c h i z o p h r e n i c i n p a t i e n t s (of which on ly 14 were over 50 a t time o f d i s c h a r g e ) 35% had d ied w i t h i n the twelve year per iod a f t e r h o s p i t a l d i s c h a r g e . v i i i ) Living Situation. Sch i zophren ics tend to be l o c a t e d more f r e q u e n t l y i n the poorer urban a r e a s ; i n a review Neale and Oltmanns conclude tha t "the h i g h e s t r a t e s o f s c h i z o p h r e n i a are a lmost i n v a r i a b l y found i n the lowest s o c i a l c l a s s " [ 2 7 ] . The i n f o r m a t i o n about s t y l e o f accommodation v a r i e s somewhat because o f c u l t u r a l and r e g i o n a l d i f f e r e n c e s . In Europe extended f a m i l y support i s emphasized to a g rea te r e x t e n t , and i n any g iven area the cho ice o f accommodation i s l i m i t e d by how many community mental h e a l t h resources are a v a i l a b l e . N e v e r t h e l e s s , i t would seem t h a t many p a t i e n t s are dependent on f a m i l y f o r suppor t . In a study o f 1045 C a l i f o r n i a s t a t e mental h o s p i t a l p a t i e n t s , M i l l e r [28] found t h a t the m a j o r i t y (78%) were d ischarged i n t o some s o r t o f f a m i l y l i v i n g s i t u a t i o n . She found t h a t 10% went to a group home, and 12% to independent l i v i n g . In A f f l e c k ' s 12 year f o l l o w - u p s t u d y , e a r l i e r c i t e d , the authors found tha t 55% of the s c h i z o p h r e n i c s s t u d i e d were d ischarged to a f a m i l y s e t t i n g , and t h a t 12 years f o l l o w i n g t h i s d i scharge 47% were s t i l l l i v i n g w i th f a m i l y [ 2 9 ] . . I t should be caut ioned t h a t t h i s was a European s e t t i n g . A f f l e c k a l s o detected a sex d i f f e r e n c e , w i t h s i g n i f i c a n t l y more women than m e n . l i v i n g w i t h r e l a t i v e s a t f o l l o w - u p . Recent American l i t e r a t u r e i n d i c a t e s t h a t the young, c h r o n i c a l l y m e n t a l l y i l l i n d i v i d u a l tends to r e l y main ly on f a m i l y 1 1 . support or to l i v e i n s o l i t a r y , independent d w e l l i n g s ; few seem to be l i v i n g i n superv i sed group homes or boarding homes. For example, i n a study o f 120 young, c h r o n i c a l l y m e n t a l l y i l l a d u l t s i n New York , Caton [30] found t h a t 42 per cent were l i v i n g w i t h t h e i r f a m i l i e s , 24 per cent i n s i n g l e room occupancy h o t e l s , and 28 per cent were l i v i n g a lone i n t h e i r own apar tments . F ind ings on the "new, young c h r o n i c p a t i e n t s " a l s o i n d i c a t e t h a t these i n d i v i d u a l s make f requent moves w i t h i n and between major c i t i e s , and one worker has dubbed them "the new d r i f t e r s " [ 3 1 ] . i x ) Use of Services. Sch i zophren ia represents a major problem to the h e a l t h care system. For example, i n 1973 a lone more than 140,000 s c h i z o p h r e n i c s were admitted to s t a t e and county mental h o s p i t a l s i n the U.S. [ 3 2 ] . An Ontar io study i n d i c a t e d t h a t s c h i z o p h r e n i c s are more l i k e l y to be readmit ted to h o s p i t a l than people w i t h o ther p s y c h i a t r i c diagnoses [ 3 3 ] . In the community s c h i z o p h r e n i c s may be cons idered "unpopular" c l i e n t s . This i s r e f l e c t e d i n the f o l l o w i n g f i g u r e s c o l l e c t e d by the Nat iona l I n s t i t u t e f o r Mental Health i n the U.S. [ 3 4 ] : i n 1971 f o r s t a t e and county h o s p i t a l s , s c h i z o p h r e n i a comprised 38% of p a t i e n t care e p i s o d e s , whereas f o r the Community mental h e a l t h cent res i t comprised on ly 10% of p a t i e n t care e p i s o d e s . In a-<Danish s t u d y , Chr i s tensen [35] found t h a t o f 100 d ischarged s c h i z o p h r e n i c s who were r e f e r r e d to o u t -p a t i e n t s e r v i c e s , 34 made no c o n t a c t a t a l l and of the ones who d id at tend many attended o n l y very i n f r e q u e n t l y - i . e . 30 attended a t i n t e r v a l s o f equal o r g r e a t e r than two months. Anthony L36] conducted a study t h a t compared demographic c h a r a c t e r i s t i c s o f p s y c h i a t r i c p a t i e n t s who 12. attended a t e r - c a r e c l i n i c s w i t h those o f p a t i e n t s who d i d not a t t e n d , and found no d i f f e r e n c e between the two groups. Despi te t h i s f i n d i n g , a sex e f f e c t has been noted by a number o f workers , namely t h a t women more commonly seek a t t e n t i o n f o r p s y c h i a t r i c d i s o r d e r s than men [ 3 7 ] . As w e l l , there has been some recent l i t e r a t u r e on the "new, young c h r o n i c " mental p a t i e n t , who uses mental h e a l t h s e r v i c e s r e p e t i t i v e l y (dropping i n and out o f t reatment) and " i n a p p r o p r i a t e l y , " i n ways t h a t " d r a i n the t ime and energy o f c l i n i c i a n s " [ 3 8 ] . B. S t a b i l i t y o f Features over Time In rev iewing the l i t e r a t u r e , the general c o n c l u s i o n i s t h a t s c h i z o p h r e n i a remains d i s a b l i n g f o r a l o n g , sometimes i n d e f i n i t e p e r i o d . In a review o f 38 s t u d i e s , Stephens [39] concluded t h a t roughly 60% o f s c h i z o p h r e n i c s were not improved a f t e r f i v e or ten year f o l l o w - u p s . Harrow [40] repor ted i n another study t h a t about 15% o f s c h i z o p h r e n i c s were f u n c t i o n i n g e f f e c t i v e l y (wi thout r e l a p s e s ) three years a f t e r d i s -charge , w h i l e 50% had ad jus ted very p o o r l y . In t h i s study the author found t h a t comparison groups, o f p s y c h i a t r i c p a t i e n t s w i t h o ther diagnoses were f u n c t i o n i n g much b e t t e r a t f o l l o w up. B l e u l e r [ 4 1 ] , i n another s t u d y , proposed t h a t f o r h i s s c h i z o p h r e n i c c l i e n t e l e 25% recovered e n t i r e l y , 10% remained s e r i o u s l y i l l , and 65% had careers o f a l t e r n a t i n g between psychot ic phases and per iods of r e m i s s i o n . Using r e h o s p i t a l i z a -t i o n and employment as measures o f f u n c t i o n i n g , Anthony [42] proposes t h a t on the average r e h o s p i t a l i z a t i o n and employment r a t e s do not improve over t ime ( f o l l o w i n g h o s p i t a l d i scharge ) but r a t h e r seem to 1 3 . i n d i c a t e steady or i n c r e a s i n g d e b i l i t a t i o n f o r p s y c h i a t r i c p a t i e n t s . In a 5 year f o l l o w - u p study S t rauss [43] compared the outcome measures f o r h is sample o f s c h i z o p h r e n i c s w i t h the measures taken a t a two year i n t e r v a l , and found t h a t the c o r r e l a t i o n s were very h i g h , conc lud ing tha t "a two year f o l l o w - u p study can be cons idered a r e l a t i v e l y adequate s u b s t i t u t e f o r a longer i n v e s t i g a t i o n . " In a r e l a t e d a r t i c l e , d i s c u s s i n g outcome i n s c h i z o p h r e n i a , S t rauss concludes t h a t " s c h i z o p h r e n i c p a t i e n t s , compared to p a t i e n t s h o s p i t a l i z e d f o r o ther severe f u n c t i o n a l p s y c h i a t r i c d i s o r d e r s , have a s i g n i f i c a n t but on ly moderate s h i f t towards the poorer s i d e o f the continuum curve o f outcome d y s f u n c t i o n " [ 4 4 ] . In the same a r t i c l e the author q u a l i f i e s h i s f i n d i n g s by say ing t h a t i n h i s study there was no evidence o f a homogeneously poor outcome i n s c h i z o p h r e n i a , nor i s there a b i -modal d i s t r i b u t i o n o f outcome, i . e . there i s a range of outcome types r a t h e r than two c l e a r cut groups of "good" ' and "poor" outcome. C. Factors A s s o c i a t e d w i t h D i f f e r e n t i a l Outcome i n Sch i zophren ia i ) Measures of Outcome. Outcome i n s c h i z o p h r e n i a can be assessed a c c o r d i n g to many d imens ions , and as Schwartz [45] has demon-s t r a t e d , the concordance o f m u l t i p l e assessments of s c h i z o p h r e n i a outcome are r a t h e r l ow , t h a t i s , good outcome i n one dimension does not n e c e s s a r i l y c o r r e l a t e w i t h good outcome i n another d i m e n s i o n . St rauss [46] conce ives o f the major outcome f u n c t i o n s (employment, r e h o s p i t a l i z a t i o n , s o c i a l r e l a t i o n s and symptoms) as being p a r t i a l l y independent and as forming l i n k e d open -sys tems, each a f f e c t e d p a r t l y by the o ther areas and a l s o by v a r i a b l e s which are more s p e c i f i c to i t a l o n e . In the present study 14. two v a r i a b l e s were used as the main i n d i c a t o r s o f outcome: r e h o s p i t a l i z a -t i o n and employment r a t e s . These were used i n par t because they cou ld be r e l i a b l y d i sce rned from f i l e i n f o r m a t i o n and a l s o because they have been used by a number o f o ther r e s e a r c h e r s . A number o f researchers have t r i e d to d i s c o v e r f a c t o r s t h a t are a s s o c i a t e d w i t h outcome i n s c h i z o p h r e n i a , wi th the idea being t h a t c e r t a i n f a c t o r s can be used as " p r e d i c t o r s " o f outcome. O f t e n , as Anthony [47] n o t e s , the best p r e d i c t o r of f u t u r e behaviour i s past behav iour . Th is author goes on to argue tha t i f outcome p r e d i c t o r s are known, they can help us p i n p o i n t i n d i v i d u a l s who w i l l need g reate r (or l e s s e r ) r e h a b i l i t a t i v e a s s i s t a n c e . i i ) Rehospitalization. The best p r e d i c t o r s o f f u t u r e r e h o s p i -t a l i z a t i o n seem to be past records o f h o s p i t a l i z a t i o n . In rev iew ing a number o f s t u d i e s Anthony [48] concludes t h a t the best p r e d i c t o r o f f u t u r e h o s p i t a l i z a t i o n i n past number o f h o s p i t a l i z a t i o n s (a p o s i t i v e c o r r e l a t i o n ) . This f i n d i n g concerns h o s p i t a l i z e d p s y c h i a t r i c p a t i e n t s i n g e n e r a l , however the same f i n d i n g has been made repeated l y i n s t u d i e s that have looked s p e c i f i c a l l y a t s c h i z o p h r e n i c s , such as one by L o r e i and Gurel [ 4 9 ] . S t rauss [50] i n a major study found t h a t the s i n g l e v a r i a b l e t h a t accounted f o r the g r e a t e s t amount o f v a r i a n c e i n s c h i z o p h r e n i a outcome (as measured not on ly by r e h o s p i t a l i z a t i o n but severa l o ther i n d i c a t o r s ) was prev ious d u r a t i o n ( ra the r than numbers) o f h o s p i t a l i z a -t i o n s . In s h o r t , the g r e a t e r the d u r a t i o n , the g reate r the l i k e l i h o o d of r e h o s p i t a l i z a t i o n . This f i n d i n g has been c o n t r a d i c t e d somewhat by the recent l i t e r a t u r e on the "new, young c h r o n i c " mental p a t i e n t where 1 5 . high r a t e s o f r e h o s p i t a l i z a t i o n have been repor ted d e s p i t e the f a c t t h a t the m a j o r i t y o f the sub jec ts have.had r e l a t i v e l y s h o r t d u r a t i o n s of past h o s p i t a l i z a t i o n [ 5 1 ] . ( I t should be n o t e d , however, tha t the "new young c h r o n i c " samples r e p r e s e n t a d i a g n o s t i c a l l y more d i v e r s e group than the one in S t r a u s s ' s s t u d y . ) Some s t u d i e s - such as one by Chr i s tensen [52] - have found t h a t the s u b j e c t s l e a s t l i k e l y to be r e h o s p i t a l i z e d are the ones i n f a c t w i t h a g reate r d u r a t i o n o f past h o s p i t a l i z a t i o n s . There has been a f a i r amount o f debate i n the l i t e r a t u r e about the r e l a t i v e m e r i t s o f b r i e f v s . extended h o s p i t a l i z a t i o n f o r the m e n t a l l y i l l ; a t l e a s t one author has argued t h a t a b e n e f i t o f l ong - te rm h o s p i t a l i z a t i o n i s t h a t the p a t i e n t i s more " f i r m l y engaged i n the system o f c a r e " a f t e r d i scharge [ 5 3 ] . S t i l l on the t o p i c o f h o s p i t a l h i s t o r y , some s t u d i e s have found t h a t the recency of the l a s t h o s p i t a l i z a t i o n i s a b e t t e r p r e d i c t o r of r e h o s p i t a l i z a t i o n than prev ious numbers o f h o s p i t a l i z a -t i o n s [ 5 4 ] . This r a i s e s quest ions about the leng th o f the f o l l o w - u p per iod used i n s c h i z o p h r e n i a s t u d i e s : i t has been suggested t h a t there i s a " c r i t i c a l p e r i o d " o f about s i x months f o l l o w i n g d i s c h a r g e when r e h o s p i t a l i z a t i o n i s more l i k e l y [ 5 5 ] ; o ther authors argue tha t the r i s k o f r e h o s p i t a l i z a t i o n i s e q u a l l y g reat throughout the e n t i r e year o f the f o l l o w up pe r iod [ 5 6 ] , and i n f a c t most f o l l o w up per iods are a t l e a s t a year i n l e n g t h . As we l l as h o s p i t a l h i s t o r y , a number o f researchers have looked a t the c l i e n t s ' l i v i n g s i t u a t i o n i n the community to t r y to determine i f t h i s could be used as a r e h o s p i t a l i z a t i o n p r e d i c t o r . Un-f o r t u n a t e l y , many o f the r e s u l t s are c o n f l i c t i n g . Three major types o f l i v i n g arrangement are 1) a l o n e , 2) w i t h spouse , 3) w i t h f a m i l y as 16. dependent. Most s t u d i e s have i n d i c a t e d t h a t being w i th f a m i l y as dependent i s more l i k e l y to l ead to r e h o s p i t a l i z a t i o n ; t h i s was found by Brown [57] i n comparing a.dependent group to a group l i v i n g a l o n e , and i t was found by Michaux i n comparing a dependent group to a group l i v i n g w i t h spouse [ 5 8 ] . Freeman and Simmons however had an o p p o s i t e f i n d i n g to Michaux, f i n d i n g tha t p a t i e n t s i n m a r i t a l s e t t i n g s were r e h o s p i t a l i zed more o f t e n than those i n parenta l s e t t i n g s [ 5 9 ] . Michaux 's f i n d i n g s would seem to imply tha t the c h i l d r o l e i s somehow more s t r e s s f u l f o r the s c h i z o p h r e n i c , whereas Freeman and Simmons have the f i n d i n g tha t the r o l e o f spouse i s i n f a c t more demanding. Some researchers have reported t h a t marr ied p a t i e n t s have a lower r e t u r n r a t e than s i n g l e s [60] and M i l l e r [61] concluded t h a t marr ieds have the, lowest r e t u r n r a t e o f any l i v i n g arrangement. This l a t t e r f i n d i n g can i n turn be c o n t r a s t e d by the f i n d i n g s o f a number o f authors t h a t m a r i t a l s t a t u s i s un re la ted to r e c i d i v i s m and the somewhat s u r p r i s i n g f i n d i n g by Chr i s tensen [62] tha t the group w i t h the lowest h o s p i t a l r e t u r n r a t e are the s o c i a l i s o l a t e s . In summary, the f i n d i n g s regard ing m a r i t a l s t a t u s are r a t h e r murky and are confounded by some methodo log ica l problems. For example, i s the m a r i t a l s t a t e i t s e l f producing an e f f e c t t h a t leads to g r e a t e r or l e s s e r h o s p i t a l i z a t i o n , or i s the person who becomes marr ied i n h e r e n t l y d i f f e r e n t (and more f u n c t i o n a l ) than the person who does not become marr ied? Another i s s u e concerns the measure o f r e h o s p i t a l i z a t i o n ; a person cou ld c o n c e i v a b l y be a v o i d i n g r e h o s p i t a l i z a t i o n and y e t not be m e n t a l l y h e a l t h y . More w i l l be s a i d on t h i s i n Chapter 3 . Related to l i v i n g s i t u a t i o n i s the s t y l e o f r e s i d e n c e of the i n d i v i d u a l , e s p e c i a l l y the d i s t i n c t i o n between superv i sed and independent accommodation. Chr i s tensen [63] repor ted tha t i n h i s f o l l o w up s t u d y , 17. o f the "successes" (people who d i d not r e t u r n to h o s p i t a l ) more were i n s h e l t e r e d housing (wi th p a r e n t s , i n nurs ing homes or halfway houses) than the f a i l u r e s . In summarizing a number of s t u d i e s Anthony [64] concludes t h a t t r a n s i t i o n a l f a c i l i t i e s ( i . e . f a m i l y care homes and h a l f -way houses) do lower the r e c i d i v i s m r a t e f o r people who remain i n the f a c i l i t y ; the author notes t h a t r e h o s p i t a l i z a t i o n ra tes i n c r e a s e f o r people d ischarged from the t r a n s i t i o n a l f a c i l i t i e s and approach t h a t o f the r a t e o f people i n unshe l te red s e t t i n g s . A number o f s t u d i e s have t r i e d to look a t the quest ion o f how a t t e n d i n g an a f t e r - c a r e c l i n i c a f f e c t s r e c i d i v i s m r a t e s . Once a g a i n , r e s u l t s are c o n f l i c t i n g . A number o f s t u d i e s , such as one by Winston et a l . [ 6 5 ] , conclude t h a t s c h i z o p h r e n i c p a t i e n t s who do not enter a f t e r c a r e are r e h o s p i t a l i z e d a t a h igher r a t e than those who do. Other s t u d i e s suggest t h a t the r e l a t i o n s h i p between a f t e r - c a r e attendance and r e c i d i v i s m i s not c l e a r c u t , and f a c t o r s such as p a t i e n t c h r o n i c i t y [66] and type o f t reatment [67] must be taken i n t o account . There i s a l s o the p r e v i o u s l y c i t e d Chr i s tensen [68] study which found t h a t the d ischarged s c h i z o p h r e n i c s w i t h the lowest h o s p i t a l r e t u r n r a t e were the ones who d i d not a t tend a f t e r care a t a l l . In h i s rev iew Anthony [69] suggests tha t there are lower r e c i d i v i s m r a t e s f o r the people who e l e c t to a t tend a f t e r care c l i n i c s . Anthony specu la tes t h a t the success o f such t reatment cent res may be due e i t h e r to the nature of people who v o l u n t a r i l y a t tend c l i n i c s or to the c l i n i c ' s r o l e i n m a i n t a i n i n g the p a t i e n t on psychot rop ic m e d i c a t i o n . As Bachrach [70] n o t e s , the c o n -founding e f f e c t o f the drug t reatment v a r i a b l e should be taken i n t o account i n s c h i z o p h r e n i a outcome s t u d i e s , s i n c e "drugs may account f o r a 18. s u b s t a n t i a l p o r t i o n of the apparent success o f community support systems i n the t reatment o f c h r o n i c mental p a t i e n t s . " A number o f o ther sociodemographic v a r i a b l e s p r e d i c t i n g r e c i d i v i s m have been i n v e s t i g a t e d , one o f them being age. Anthony [71] suggests t h a t the r e s u l t s are " c o n f l i c t i n g " i n t h i s a r e a , and notes t h a t many s t u d i e s have shown no age e f f e c t f o r r e h o s p i t a l i z a t i o n . Most s t u d i e s t h a t do show an age e f f e c t , such as the one by Mess ie r [ 7 2 ] , tends to show t h a t the younger c l i e n t i s more l i k e l y to be readmit ted than the o l d e r one. This f i n d i n g i s p a r t i c u l a r l y apparent i n the more recent a r t i c l e s on the "new, young c h r o n i c " p a t i e n t mentioned e a r l i e r . There i s l i t t l e consensus w i th regard to the v a r i a b l e s e x , a l though some r e s e a r c h e r s , such as Hogarty [ 7 3 ] , have detected a lower r a t e of r e h o s p i t a l i z a t i o n f o r women. Jansen and N i c k l e s [74] r e p o r t tha t a b i l i t y to remain i n the community i s s i g n i f i c a n t l y a s s o c i a t e d w i t h employment h i s t o r y , however i n h i s rev iew Anthony [75] suggests t h a t employment h i s t o r y and occupa-t i o n a l l e v e l are u n r e l a t e d to r e c i d i v i s m . In the same rev iew Anthony concludes t h a t f i n d i n g s regard ing educat iona l l e v e l and race have been " q u i t e c o n s i s t e n t " i n t h a t there i s a p p a r e n t l y no r e l a t i o n s h i p between these two v a r i a b l e s and r e h o s p i t a l i z a t i o n r a t e . One o f the few a r t i c l e s which showed a race e f f e c t was the Wessler study [ 7 6 ] , which concluded t h a t unemployment s t a t u s i n combinat ion w i t h race was s i g n i f i c a n t l y a s s o c i a t e d w i t h r e a d m i s s i o n , i . e . there was no d i f f e r e n c e i n r e c i d i v i s m r a t e s between b lacks and w h i t e s , o r between the employed and unemployed, but among the unemployed a h igher number o f readmiss ions were b l a c k . I t should be noted t h a t many o f the f o l l o w - u p s t u d i e s reviewed d i d 1 9 . not c o n t r o l f o r f a c t o r s such as r a c e , us ing main ly " W . A . S . P . " sampl e s . In summary, a l though a number o f r e s u l t s are c o n f l i c t i n g , the f a c t o r s most s t r o n g l y a s s o c i a t e d w i t h r e h o s p i t a l i z a t i o n appear to be : prev ious numbers o f h o s p i t a l i z a t i o n s ; prev ious d u r a t i o n o f h o s p i t a l i z a -t i o n ; t ime s i n c e l a s t h o s p i t a l i z a t i o n ; l e v e l o f independence o f r e s i d e n c e ; attendance a t an a f t e r care c l i n i c ; a n d , t e n t a t i v e l y , age . i i i ) Employment. With regard to d ischarged p a t i e n t s f i n d i n g employment dur ing the f o l l o w - u p p e r i o d , some o f the a s s o c i a t e d f a c t o r s are s i m i l a r to those fo r r e h o s p i t a l i z a t i o n . In p a r t i c u l a r , number [77] and d u r a t i o n [78] o f prev ious p s y c h i a t r i c h o s p i t a l i z a t i o n s seems to have a s i g n i f i c a n t , negat i ve c o r r e l a t i o n w i t h employment s t a t u s . •» Most s t u d i e s measuring re-employment r a t e s have found tha t employment h i s t o r y accounts f o r a s i g n i f i c a n t amount of the v a r i a n c e i n the outcome [ 7 9 ] ; s p e c i f i c a l l y c l i e n t s w i th a s u p e r i o r past work record tend to be employed to a g r e a t e r ex tent a f t e r d i s c h a r g e from h o s p i t a l . Anthony [80] suggests t h a t employment h i s t o r y i s the s i n g l e most important p r e d i c t o r of p o s t - h o s p i t a l employment. M a r i t a l s t a t u s a l s o seems to be a s s o c i a t e d w i th employment, i . e . p a t i e n t s who are marr ied seem to be ab le to o b t a i n and hold jobs to a g rea te r ex tent than s i n g l e o r d i v o r c e d i n d i v i d u a l s [ 8 1 ] . There i s some evidence tha t o c c u p a t i o n a l l e v e l i s a s i g n i f i c a n t p r e d i c t o r , i . e . a h i s t o r y o f being a s k i l l e d worker leads to a b e t t e r employment outcome than f o r the u n s k i l l e d i n d i v i d u a l [ 8 2 ] . Resu l t s f o r the v a r i a b l e "age" are c o n f l i c t i n g ; some authors conclude t h a t age i s not r e l a t e d to re-employment [ 8 3 ] , however 20. the more recent "new, young c h o r n i c " l i t e r a t u r e suggests a d i s p r o p o r -t i o n a t e l y high unemployment r a t e among the younger p a t i e n t s . For example, a study by Schwartz [84] based i n San F ranc isco found an unemployemnt r a t e of about 90% f o r the p r i m a r i l y young sample , a f i g u r e h igher than the " b a s e l i n e " unemployment r a t e o f about 75% proposed by Anthony (mentioned e a r l i e r i n t h i s p a p e r ) . Some authors have found race to be r e l a t e d to unemployment, s p e c i f i c a l l y , t h a t being wh i te g ives one a b e t t e r chance o f s e c u r i n g employment a f t e r h o s p i t a l d i s c h a r g e [ 8 5 ] . There i s , of c o u r s e , an obvious q u a l i f i c a t i o n w i t h regard to v a r i a b l e s such as age and race i n t h a t the unemployment r a t e s o f the young or non-whi tes may be lower i n the general p o p u l a t i o n as we l l [ 8 6 ] . In h i s review Anthony [87] concludes t h a t the v a r i a b l e s "sex" and "educat iona l l e v e l " are u n r e l a t e d to re-employment r a t e s . Most of the s t u d i e s reviewed seemed to bear out t h i s f i n d i n g , a l though some more recent s t u d i e s , such as one by A f f l e c k [ 8 8 ] , r e p o r t a s u p e r i o r work record f o r female s c h i z o -phrenics f o l l o w i n g h o s p i t a l d i s c h a r g e . The f i n a l v a r i a b l e t h a t w i l l be d i s c u s s e d i s s t y l e o f r e s i d e n c e , i . e . whether the c l i e n t l i v e s i n a s u p e r v i s e d mental hea l th f a c i l i t y or l i v e s independent l y . Some s t u d i e s have i n f a c t repor ted a h igher employment r a t e f o r people i n group homes [ 8 9 ] . However, i n h i s rev iew Anthony [90] concludes t h a t w h i l e t r a n s i t i o n a l f a c i l i t i e s may lower r e c i d i v i s m r a t e s o f the r e s i d e n t s , they do not seem to s i g n i f i c a n t l y improve employment r a t e s ; the author goes on to note tha t where employment r a t e improvements have been d e t e c t e d , these do not seem to p e r s i s t once the i n d i v i d u a l has l e f t the f a c i l i t y . In summary, the f a c t o r s most s t r o n g l y a s s o c i a t e d w i t h employ-ment s t a t u s seem to be: number and d u r a t i o n o f prev ious h o s p i t a l i z a t i o n s ; 2 1 . employment h i s t o r y ; m a r i t a l s t a t u s ; occupat ion 1 e v e l , a n d , " t e n t a t i v e l y , age . D. Sub-Groups w i t h i n the S c h i z o p h r e n i c P o p u l a t i o n There have been v a r i o u s attempts to s u b d i v i d e the general heading o f " s c h i z o p h r e n i a . " Such s u b - d i v i s i o n s are v a l i d to the ex tent t h a t they d i s t i n g u i s h people on the b a s i s o f e t i o l o g y , o n s e t , outcome and t reatment o f the d i s o r d e r . T r a d i t i o n a l s u b d i v i s i o n s , such as the ones found i n the D .S .M. I l l , based on symptom e x p r e s s i o n , have not u s u a l l y been very usefu l i n d i s t i n g u i s h i n g groups o f s c h i z o p h r e n i c s and have had low r e l i a b i l i t y r a t e s [ 9 1 ] . As we have seen i n the l a s t s e c t i o n i t has o f t e n been more use fu l to s u b d i v i d e sub jec ts on the b a s i s o f sociodemographic v a r i a b l e s . Examples t h a t have been d i s c u s s e d e a r l i e r are m a r i t a l s t a t u s as a way o f d i s t i n g u i s h i n g s u b j e c t s on the bas i s o f re-employment r a t e s , and s t y l e o f r e s i d e n c e as a way o f d i s t i n g u i s h i n g s u b j e c t s as measured by r e h o s p i t a l i z a t i o n . Factors r e l a t i n g to s u b j e c t ' s past h i s t o r y are o f t e n important i n p r e d i c t i n g outcome, and these f a c t o r s ( u n l i k e m a r i t a l s t a t u s and s t y l e of r e s i d e n c e ) have the advantage o f being antecedent to the outcome o f the d i s o r d e r . A number o f workers have t r i e d to d i s t i n g u i s h "good" and "poor" outcome s c h i z o p h r e n i a on the b a s i s of h i s t o r i c a l f a c t o r s ; one study by Knesevish e t a l . [92] suggests tha t the "poor outcome" s c h i z o p h r e n i c has an e a r l i e r onset ( u s u a l l y before 3 5 ) , a l e n g t h i e r h o s p i t a l i z a t i o n h i s t o r y , a more gradual o n s e t , and an i n f e r i o r past job and s o c i a l r e c o r d . Other researchers have looked a t the v a r i a b l e sex as a p o t e n t i a l way o f d i s t i n g u i s h i n g among s c h i z o p h r e n i c s . In her r e v i e w , Seeman [93] notes t h a t s c h i z o p h r e n i c 22. women have a l a t e r onset of the d i s r o d e r than men, and appear i n some cases to have a s u p e r i o r outcome (as measured by f a c t o r s such as employ-ment and r e h o s p i t a l i z a t i o n r a t e s ) . Although her f i n d i n g s about outcome are t e n t a t i v e , the f i n d i n g s about age o f onset have been conf i rmed i n a number o f o ther s t u d i e s [94] which i s s i g n i f i c a n t i n tha t age o f onset has been found to be a s s o c i a t e d w i t h (good v s . poor) outcome. I t has been specu la ted t h a t s c h i z o p h r e n i a may r e p r e s e n t a d i f f e r e n t d i s e a s e i n men than women, or i t may be the same d i s o r d e r w i th a t i m i n g d i f f e r e n c e ; i n her a r t i c l e Seeman notes t h a t women possess a number o f p h y s i o l o g i c a l p r o t e c t i v e f a c t o r s which could a f f e c t the m a n i f e s t a t i o n of an i l l n e s s such as s c h i z o p h r e n i a [ 9 5 ] . One v a r i a b l e tha t has become prominent i n recent years as a means of d i s t i n g u i s h i n g mental p a t i e n t s i s t h a t o f " a g e " ; the "new, young c h r o n i c s " have a l r e a d y been mentioned severa l times i n t h i s paper . This group has been given o ther t i t l e s such as "the new d r i f t e r s " and "ch ron ic c r i s i s p a t i e n t s " [ 9 6 ] . In summary, t h i s i s a group tha t has a high s u i c i d e r a t e , a high r e h o s p i t a l i z a t i o n r a t e , a high c r i m i n a l a c t i v i t y r a t e [ 9 7 ] , a high m o b i l i t y r a t e , a low employment r a t e , i s predominant ly s i n g l e [ 9 8 ] , i s a "heavy consumer" o f p s y c h i a t r i c s e r v i c e s , but i n an " i n a p p r o p r i a t e way" [ 9 9 ] , i s o f t e n " i n t e n s e l y d i s l i k e d " by t h e r a p i s t s , and tends to l ead a more s o c i a l l y i s o l a t e d s t y l e o f e x i s t e n c e [100] . Bassuk [101] seeS some v a l i d i t y i n regard ing these i n d i v i d u a l s as a " d i s c r e t e c l i n i c a l g roup . " The main common denominator f o r t h i s group i s t h a t they are most l y young ( u s u a l l y under 35) and have a r e l a -t i v e l y s h o r t d u r a t i o n of h o s p i t a l i z a t i o n , t h a t i s , they have grown up dur ing the era o f " d e i n s t i t u t i o n a l i z a t i o n . " I t i s i n t e r e s t i n g to s p e c u l a t e as to why these people form a d i s c r e t e group: as one author n o t e s , i t i s 2 3 . apparent l y the r e s u l t o f a " l a c k o f f i t " between c l i e n t s t y l e and the community mental h e a l t h s e r v i c e s c u r r e n t l y e x i s t i n g i n much o f North A m e r i c a , i . e . i t would appear t h a t d e i n s t i t u t i o n a l i z a t i o n has " c r e a t e d " the new, young c h o r n i c [ 1 0 2 ] . I t has a l s o been o b s e r v e d , both i n the l i t e r a t u r e and i n c l i n i c a l e x p e r i e n c e , t h a t many o f the "new c h r o n i c " p a t i e n t s are h e a v i l y invo l ved w i t h s t r e e t drugs and tha t some o f the express ions o f the i l l n e s s may be t r i g g e r e d by the d r u g - t a k i n g [103] . E. Summary In summary, the l i t e r a t u r e i n d i c a t e s t h a t community-based s c h i z o p h r e n i c s are t y p i c a l l y a d e b i l i t a t e d , dependent group, p a r t i c u l a r l y as measured by high r a t e s o f h o s p i t a l i z a t i o n , high r a t e s of unemployment, s u i c i d e r a t e s and the poor economic c o n d i t i o n s a s s o c i a t e d w i t h being s c h i z o p h r e n i c . I t was noted t h a t the s c h i z o p h r e n i c represents a c o n s i d e r -ab le r e s p o n s i b i l i t y f o r the r e l a t i v e s o f the i n d i v i d u a l and the com-munity mental h e a l t h system i n g e n e r a l . I t was a l s o noted t h a t the d i s a b i l i t y o f t h i s group may p e r s i s t f o r a l o n g , -*n some cases i n d e f i n i t e per iod o f t i m e . Despi te these f i n d i n g s , i t was proposed t h a t there was some v a r i a b i l i t y i n the outcome of s c h i z o p h r e n i a , and • t h a t a range o f outcome types e x i s t e d . I t was noted tha t c e r t a i n s o c i o -demographic c h a r a c t e r i s t i c s o f the s u b j e c t group seemed to be a s s o c i a t e d w i th b e t t e r or poorer outcome, as measured p r i m a r i l y by r e h o s p i t a l i z a t i o n and employment r a t e s . In p a r t i c u l a r , i t was proposed t h a t a c l i e n t ' s h o s p i t a l h i s t o r y , h i s r e s i d e n t i a l s i t u a t i o n and h is at tendance a t a f t e r -care c l i n i c s cou ld serve as " p r e d i c t o r s " o f the c l i e n t ' s f u t u r e r e h o s p i -t a l i z a t i o n . S i m i l a r l y , w i t h regard to employment, i t was noted t h a t 24. employment h i s t o r y , h o s p i t a l h i s t o r y and m a r i t a l s t a t u s seemed to be l i n k e d w i th p o t e n t i a l f o r fu tu re , employment. In the l a s t s e c t i o n , i t was proposed t h a t c e r t a i n sociodemographic fea tu res o f the s c h i z o p h r e n i c p o p u l a t i o n cou ld i n f a c t d e l i n e a t e d i s t i n c t i v e sub-groups w i t h i n the p o p u l a t i o n that d i f f e r e d from the r e s t on the b a s i s o f the onset and outcome o f the i l l n e s s s . In p a r t i c u l a r , age and sex were put f o r t h as v a r i a b l e s t h a t might l e g i t i m a t e l y d i s c r i m i n a t e w i t h i n the r u b r i c " sch i z o p h r e n i a . " The f i n d i n g s i n the l i t e r a t u r e were used as standards f o r comparison i n the present s t u d y , a d e s c r i p t i v e study of Vancouver s c h i z o p h r e n i c s . The study was guided by the f o l l o w i n g q u e s t i o n s : what i s the c u r r e n t s t a t u s o f the community-based s c h i z o p h r e n i c s i n the study and are they do ing as badly (or as w e l l ) as the s c h i z o p h r e n i c s d e s c r i b e d i n o ther s t u d i e s ? S i m i l a r l y , do the h i s t o r i c a l f e a t u r e s o f the study p o p u l a t i o n d i s t i n g u i s h them from o ther study groups? Can c h a r a c t e r i s t i c s o f the p o p u l a t i o n be found t h a t are a s s o c i a t e d w i t h a b e t t e r outcome, and are these the same c h a r a c t e r i s t i c s seen i n o ther s t u d i e s ? F i n a l l y , i s t h i s a uni form group, o r do sub-groups e x i s t and are they the same sub-groups t h a t have been detected by other workers? For example, does Vancouver have the d i s t i n c t i v e "new, young c h r o n i c " p o p u l a t i o n t h a t has been d e s c r i b e d i n o ther American c e n t r e s ? Although t h i s study seeks p r i m a r i l y to examine v a r i a b i l i t y w i t h i n a p a r t i c u l a r group o f s c h i z o p h r e n i c s , comparisons w i t h o ther groups are c r u c i a l because d i f f e r e n c e s i n f i n d i n g s o f t e n lead to use fu l i n s i g h t s about the nature o f the s u b j e c t group and the care system w i t h which t h a t group i n t e r a c t s . 25. Chatper 3 RESEARCH DESIGN A. Summary of Research Design This study had as i t s sample a group o f s c h i z o p h r e n i c s , l i v i n g i n the community, and a t t e n d i n g the Vancouver Community Care Teams. The study can be c a l l e d q u a n t i t a t i v e - d e s c r i p t i v e i n d e s i g n ; i n f o r m a t i o n was gathered from the c l i n i c a l f i l e s o f the Community Care Teams. The purpose o f the study was t h r e e f o l d : i ) to d e s c r i b e the sample on the b a s i s o f a number o f sociodemographic v a r i a b l e s ; i i ) to note the s t a b i l i t y o f the sample over t ime as measured by these same v a r i a b l e s ; i i i ) us ing r e h o s p i -t a l i z a t i o n and employment s t a t u s as dependent v a r i a b l e s to see i f v a r i -a b i l i t y w i t h i n the group cou ld be detected and p r e d i c t e d . These e lements , and the a s s o c i a t e d l i m i a t i o n s , w i l l be d i s c u s s e d i n more d e t a i l below. B. Level o f Design This study was d e s c r i p t i v e i n the sense tha t a l though d i f f e r e n c e s between i n d i v i d u a l s and a s s o c i a t i o n s between v a r i a b l e s are n o t e d , c a u s a l i t y i s not i m p l i e d . A study can be termed exper imental to the ex ten t t h a t i t i s c o n t r o l l e d , an independent v a r i a b l e i s m a n i p u l a t e d , and e f f e c t s of i n t e r v e n i n g v a r i a b l e s are r u l e d o u t . In t h i s p a r t i c u l a r study no a c t u a l 26. i n t e r v e n t i o n was performed, but r a t h e r i n f o r m a t i o n was gathered second-hand from r e c o r d s . Consequent ly , v a r i a b l e s cou ld not be manipulated a n d , as w i l l be no ted , e f f e c t s o f extraneous v a r i a b l e s cou ld not be r u l e d o u t . Although c a u s a l i t y i s not i n f e r r e d , the p a r t i c u l a r a s s o c i a t i o n s examined i n t h i s study were suggested by o ther f i n d i n g s from s i m i l a r groups i n the l i t e r a t u r e ; the study i s comparat ive or r e p l i c a t i v e to an ex tent i n tha t f i n d i n g s from t h i s study are c o n t r a s t e d wt ih those o f o ther s t u d i e s . Because of problems w i t h e x t e r n a l v a l i d i t y , d i s c u s s i o n was l i m i t e d l a r g e l y to i n t r a r a t h e r than i n t e r - g r o u p d i f f e r e n c e s . To the ex tent that r e l a -t i v e l y l i t t l e sys temat i c research had p r e v i o u s l y been done on the sample i n q u e s t i o n , and thus c e r t a i n outcomes were unknown, t h i s study cou ld a l s o l e g i t i m a t e l y be termed e x p l o r a t o r y . The study i s q u a n t i t a t i v e i n o r i e n t a t i o n , tha t i s , the v a r i a b l e s a s c e r t a i n e d were r e l a t i v e l y h a r d , d i s c r e t e and c losed -ended i n n a t u r e ; i t was assumed t h a t they possessed face v a l i d i t y . Such an approach was n e c e s s i t a t e d by the nature o f the f i l e s t h a t were examined i n that i t i s d i f f i c u l t to r e l i a b l y assess more s u b j e c t i v e measures o f c l i e n t f u n c -t i o n i n g (such as q u a l i t y of l i f e ) from f i l e i n f o r m a t i o n . As i t turned o u t , even some a p p a r e n t l y quant i tat ive measures were d i f f i c u l t to e s t i m a t e r e l i a b l y . a n d had to be dropped. An advantage o f a quant i tat ive o r i e n t a t i o n i s t h a t r e l a t i v e l y l a r g e amounts o f i n f o r m a t i o n can be c o l l e c t e d and a n a l y z e d . The main d isadvantage i s t h a t quant i tat ive s t u d i e s do not permit one depth o f i n v e s t i g a t i o n . C r i t i c s o f quant i tat ive s t u d i e s have argued t h a t a t best the r e s u l t s p rov ide on ly s u p e r f i c i a l d e s c r i p t i o n s , and a t worst they may be m i s l e a d i n g i f the v a l i d i t y o f the measures being used are u n c e r t a i n ; these po in ts w i l l be addressed f u r t h e r i n t h i s s e c t i o n . 27. C. Nature o f the Sample The p o p u l a t i o n that the study sample was drawn from c o n s i s t e d o f a group of people w i t h a pr imary d i a g n o s i s o f s c h i z o p h r e n i a who were l i v i n g i n the community i n Vancouver and Richmond and who were c l i e n t s o f the Greater Vancouver Mental Heal th S e r i v c e . The G .V .M.H .S . prov ides c l i n i c a l s e r v i c e s and p s y c h o - s o c i a l support to the community based m e n t a l l y i l l o f Vancouver and Richmond through e i g h t l o c a l community care teams. The people i n c l u d e d i n t h i s study were a c t i v e c l i e n t s of the G . V . M . H . S . between November 1981, and November 1983; t h i s two year s t r e t c h r e p r e -sented the study p e r i o d . The sample was f u r t h e r l i m i t e d as f o l l o w s : sub jec ts i n c l u d e d ranged i n age from 20 to 5 0 , and a l l had had a t l e a s t two p r i o r p s y c h i a t r i c h o s p i t a l i z a t i o n s . ( " P r i o r " i n t h i s case means p r i o r to November 1981, which was the s t a r t o f the study p e r i o d . ) There were 690 s c h i z o p h r e n i c c l i e n t s , aged 2 0 - 5 0 , w i th a t l e a s t two p r i o r p s y c h i a t r i c h o s p i t a l i z a t i o n s , who were a c t i v e w i th the G .V .M .H .S . as of November, 1981. O n e - h a l f o f t h i s number - 345 - were s y s t e m a t i c a l l y sampled. Of the 345 a c t i v e i n November 1981 i t was d i scove red tha t 111 subsequent ly dropped out o f t reatment i n the f o l l o w i n g two years and d i d not r e t u r n to the G .V .M .H .S . Th is l e f t a group o f 234 who were a c t i v e i n November 1981 and November 1983, i . e . who shared the same two year study p e r i o d . This group o f 234 formed the sample f o r t h i s s t u d y . The purpose i n t h i s study was to s t a r t out w i th a reasonably homogeneous sample ; the reason f o r t h i s i s tha t a more homogenous sample helps narrow down the p o s s i b l e i n t e r p r e t a t i o n s o f v a r i a n c e w i t h i n the sample. Hence, a sample w i t h a s i m i l a r d i a g n o s t i c s t a t u s was chosen. As w e l l , c l i e n t s w i t h a very l i m i t e d i n s t i t u t i o n a l h i s t o r y (fewer than two 28. p r i o r h o s p i t a l i z a t i o n s ) were not i n c l u d e d . This r e l a t e s to a p o i n t made i n the l i t e r a t u r e r e v i e w , namely, tha t past h o s p i t a l h i s t o r y can account f o r a c o n s i d e r a b l e p r o p o r t i o n o f the v a r i a n c e i n s c h i z o p h r e n i a outcome, hence, a group w i th very few h o s p i t a l i z a t i o n s might be cons idered p rog -n o s t i c a l l y d i f f e r e n t from a group wi th a l a r g e number o f h o s p i t a l i z a t i o n s . Of c o u r s e , i t i s i m p o s s i b l e to c o n t r o l f o r a l l the v a r i a b l e s tha t might be a f f e c t i n g v a r i a n c e w i t h i n a group; the s t r a t e g y i n t h i s study was to take i n t o account v a r i a b l e s which might have an e f f e c t on outcome (based on o ther s t u d i e s ) d u r i n g the data c o l l e c t i o n , and then to t r y to c o n t r o l f o r t h e i r e f f e c t subsequent l y , i n the data a n a l y s i s . For example, a v a r i a b l e t h a t was not i n i t i a l l y c o n t r o l l e d f o r i n the sampl ing was " a g e " ; the sample had a f a i r l y wide age range , from 20 to 50 . This i s s i g n i f i c a n t because, as was noted i n the l i t e r a t u r e r e v i e w , people a l i v e a t d i f f e r e n t eras are s u b j e c t to d i f f e r e n t p o l i c i e s r e g a r d i n g p s y c h i a t r i c h o s p i t a l i z a -t i o n . The o l d e r c l i e n t was around when a longer d u r a t i o n of h o s p i t a l s tay was the norm; i f , as S t rauss [104] s u g g e s t s , d u r a t i o n o f p r i o r h o s p i t a l i z a t i o n i s a s s o c i a t e d w i t h a d i f f e r e n t i a l outcome i n s c h i z o p h r e n i a , then i t i s d i f f i c u l t to compare sub jec ts who are not s i m i l a r i n age. However, i t was attempted to account fo r t h i s by examining the e f f e c t o f age d i f f e r e n c e s i n the data a n a l y s i s . S i m i l a r l y , v a r i a b l e s such as s e x , r e s i d e n c e , l i v i n g s i t u a t i o n , m a r i t a l s t a t u s , employment h i s t o r y , and i n s t i t u t i o n a l h i s t o r y were accounted f o r by i n c o r p o r a t i n g them as par t o f the data c o l l e c t e d , and then examining the e f f e c t o f each v a r i a b l e l a t e r on i n the data a n a l y s i s s t a g e . One v a r i a b l e t h a t was prob lemat ic i n t h i s study was tha t o f d i a g n o s i s ; i t was assumed f o r the purposes o f the study tha t the d i a g n o s i s 29. o f s c h i z o p h r e n i a - as g iven by the community care team p s y c h i a t r i s t s to the s u b j e c t s - was i n f a c t c o r r e c t . This was a c o n s i d e r a b l e assumption s i n c e i t has been e s t a b l i s h e d i n a number o f s t u d i e s t h a t the r e l i a b i l i t y o f p s y c h i a t r i c d i a g n o s i s i s r e l a t i v e l y poor , t h a t i s , the same person may be l a b e l l e d d i f f e r e n t l y by d i f f e r e n t p r a c t i t i o n e r s or i n f a c t a person may be r e c a t e g o r i z e d severa l t imes over the course of h i s " c a r e e r " [ 1 0 5 ] , I d e a l l y i n a study one would l i k e the d i a g n o s i s to be independent ly con -f i r m e d ; t h i s was i m p o s s i b l e i n t h i s case because o f t ime and resource l i m i t a -t i o n s . One plus was t h a t most o f the people i n the study had had h i s t o r i e s long and e s t a b l i s h e d enough to make d i a g n o s i s more c e r t a i n . ( I . e . i n t e r -r a t e r r e l i a b i l i t y was e s t a b l i s h e d to some ex tent by severa l independent d i a g n o s e s . ) So f a r the d i s c u s s i o n has been about t r y i n g to c o n t r o l f o r i n t r a - g r o u p d i f f e r e n c e s ; the re i s a l s o a problem i n t r y i n g to eva luate the e f f e c t o f i n t e r - g r o u p d i f f e r e n c e s , t h a t i s , to what ex tent was the sample i n t h i s study d i f f e r e n t from or n o n - r e p r e s e n t a t i v e of o ther groups of s c h i z o p h r e n i c s ? One o b v i o u s . p o i n t i s tha t the s u b j e c t s were a l l v o l u n t a r y c l i e n t s o f an a f t e r - c a r e c l i n i c , and hence might not have been comparable to s c h i z o p h r e n i c s not r e c i e i v n g - or r e f u s i n g - a f t e r - c a r e . As was noted i n the l i t e r a t u r e r e v i e w , i t appears t h a t people who e l e c t to a t tend a f t e r - c a r e have lower r e h o s p i t a l i z a t i o n r a t e s than those who do not a t t e n d ; Anthony [106] specu la tes t h a t t h i s may be due to the e f f e c t o f the t r e a t m e n t , to the r o l e o f the c l i n i c i n m a i n t a i n i n g the c l i e n t on a n t i p s y c h o t i c m e d i c a t i o n , or to the nature o f the people who e l e c t to at tend a f t e r care c l i c n i c s . (One advantage o f having a sample a l l a t t e n d i n g a c l i n i c i s t h a t the t reatment v a r i a b l e i s presumably cons tan t w i t h i n the sample . ) ?6V Although r e s u l t s of s c h i z o p h r e n i a outcome s t u d i e s performed i n d i f f e r e n t s e t t i n g s are commonly compared, there are obvious d i f f e r e n c e s between s e t t i n g s i n terms o f t reatment and housing r e s o u r c e s , p o l i t i c a l and economic c l i m a t e and so on t h a t cou ld c o n c e i v a b l y a f f e c t the outcome v a r i a b l e s . The ques t ion remains : do d i f f e r e n c e s i n outcome detected between s e t t i n g s r e p r e s e n t an i n h e r e n t d i f f e r e n c e i n the i n d i v i d u a l s i n the sample or a d i f f e r e n c e i n the system of care w i th which the i n d i v i d u a l i n t e r a c t s ? A r e c e n t , l o c a l study attempted to answer t h i s ' ques t ion by comparing a group o f community based s c h i z o p h r e n i c s i n Vancouver w i th a s i m i l a r group i n P o r t l a n d , Oregon [107] . The researchers matched the two groups as c l o s e l y as p o s s i b l e f o r sociodemographic and d i a g n o s t i c c h a r a c t e r i s t i c s . The s u b j e c t s were f o l l o w e d up approx imate ly one year a f t e r d i scharge from a p s y c h i a t r i c h o s p i t a l . I t was found t h a t , a t f o l l o w up, the Vancouver group had been more " s u c c e s s f u l " i n that s i g n i f i -c a n t l y fewer had been h o s p i t a l i z e d i n the i n t e r i m (average number of readmiss ions - .8 f o r Vancouver, 2 .0 f o r P o r t l a n d ) and more o f the Vancouver group was employed (employment r a t e - 33% f o r Vancouver; 15% f o r P o r t l a n d ) . The c o n c l u s i o n s o f the authors was t h a t the success o f the Vancouver group was due to a d i f f e r e n c e i n the sys tem, r a t h e r than the i n d i v i d u a l s , s i n c e the two samples had been matched as c l o s e l y as p o s s i b l e . The authors proposed t h a t the community mental h e a l t h system i n Vancouver was s u p e r i o r to t h a t o f Po r t land i n tha t i t was more e x t e n s i v e , compre-hensive and a f f o r d a b l e . The i m p l i c a t i o n s of t h i s l a t t e r study f o r t h i s c u r r e n t p r o j e c t were as f o l l o w s : f i r s t l y , t h a t d i f f e r e n c e s i n s c h i z o p h r e n i c popu la t ions i n d i f f e r e n t s e t t i n g s e x i s t and may be a r e s u l t of d i f f e r e n c e s i n the system of care and , s e c o n d l y , t h a t because of t h i s the outcome f o r the s c h i z o p h r e n i c i n Vancouver may be s u p e r i o r to outcomes detected i n 31> other s e t t i n g s . Hence, the c o m p a r a b i l i t y o f the Vancouver group i s 1imi t e d . n. source of In format ion As noted e a r l i e r , the i n f o r m a t i o n fo r t h i s study was gathered from c l i n i c a l f i l e s . The main advantage o f t h i s approach i s t h a t a l a r g e amount o f i n f o r m a t i o n can be surveyed i n a r e l a t i v e l y s h o r t t ime a t low c o s t and w i th minimal i n t r u s i v e n e s s . This was p a r t i c u l a r l y t r u e i n tha t t h i s was a r e t r o s p e c t i v e , r a t h e r than p r o s p e c t i v e s tudy . The main d i s -advantage o f f i l e s t u d i e s , as a l l u d e d to e a r l i e r i s t h a t i n f o r m a t i o n i s o f t e n not r e l i a b l y r e c o r d e d . What i s recorded may depend on the whim of the i n d i v i d u a l w r i t e r and gaps o f t e n e x i s t . One way to attempt to get around t h i s problem i s i n a c a r e f u l s e l e c t i o n of the v a r i a b l e s ( u s u a l l y q u a n t i t a t i v e ) that can be most r e l i a b l y a s c e r t a i n e d from the f i l e s . I t was never the less p r e d i c t e d t h a t there might be a c o n s i d e r a b l e amount o f m i s s i n g data i n t h i s s tudy . A p r o s p e c t i v e f i l e study would have the advantage of being a b l e to s p e c i f y ahead o f t ime the v a r i a b l e s o f i n t e r e s t , and thus data c o l l e c t i o n would be more s y s t e m a t i c , a l though a p r o s p e c t i v e study would take longer than a r e t r o s p e c t i v e one. F i n a l l y , i t i s usual t h a t f i l e s show a l a c k of c o n s i s t e n c y over t ime i n tha t r e c o r d i n g procedures change. Th is was not a major problem w i t h t h i s study i n t h a t the same h i s t o r i c a l p e r i o d (Nov. 1981-November 1983) was used f o r a l l s u b j e c t s . The i n f o r m a t i o n i n the f i l e s was of two major k i n d s : pa r t of i t was i n f o r m a t i o n recorded by the G . V . M . H . S . t h e r a p i s t , and par t of i t was records and documents from o ther i n d i v i d u a l s and a g e n c i e s . The 32, i n f o r m a t i o n recorded by t h e . G . V . M . H . S . t h e r a p i s t c o n s i s t e d of i n i t i a l and updated p s y c h i a t r i c assessments , ongoing progress notes about the c l i e n t ' s m e d i c a l / s o c i a l s i t u a t i o n , p r e s c r i p t i o n s and i n f o r m a t i o n about the c u r r e n t drug reg imen, and "unusual occur rence" forms t h a t were r e q u i r e d to be f i l l e d out when there was a s e r i o u s i n c i d e n t concern ing the c l i e n t ' s we l l be ing ( t y p i c a l l y a s e r i o u s s u i c i d e a t t e m p t ) . For c e r t a i n k inds of i n f o r m a t i o n , the ongoing notes by the t h e r a p i s t were q u i t e r e l i a b l e : i n p a r t i c u l a r , whether or not the c l i e n t was h o s p i t a l i z e d , whether he had been admitted to Venture (the s h o r t s tay c r i s i s h o s t e l ) and how o f t e n he came to the team. Other i n f o r m a t i o n seemed to be l e s s r e l i a b l y r e c o r d e d ; some c l i n i c i a n s took more i n t e r e s t i n the c l i e n t ' s s o c i a l s i t u a t i o n than o t h e r s , and thus i n f o r m a t i o n about the c l i e n t ' s l i v i n g s i t u a t i o n , h i s source of income and so on were not c o n s i s t e n t l y r e c o r d e d . In some cases i n f o r m a t i o n about the c l i e n t ' s l i v i n g s i t u a t i o n was not v e r i f i e d by the t h e r a p i s t and he would have to take the c l i e n t a t h i s word; f o r example, the c l i e n t would say he had been charged by the p o l i c e , or t h a t he had a new j o b , or t h a t he was back w i t h h i s w i f e , and t h i s would then be recorded - second hand - by the t h e r a p i s t . By c o n t r a s t , whether the c l i e n t was i n h o s p i t a l or not was always conf i rmed by c o n t a c t w i t h the i n s t i t u t i o n . U n f o r t u n a t e l y , a s y s t e m a t i c record of the c l i e n t ' s address changes was sometimes not k e p t ; i t was argued t h a t some c l i e n t s moved too f r e q u e n t l y to be kept tabs o n . The i n i t i a l assessment performed by the G . V . M . H . S . t h e r a p i s t conta ined i n f o r m a t i o n about the c l i e n t ' s past h i s t o r y , the onset o f h i s i l l n e s s , and h i s e a r l y h o s p i t a l i z a t i o n s . Some o f t h i s was gotten from the c l i e n t h i m s e l f , or from a " s i g n i f i c a n t o t h e r , " and much o f t h i s was de r i ved from h o s p i t a l records or documents from other 33 p r o f e s s i o n a l s the p a t i e n t had c o n t a c t e d . Hosp i ta l records were i n c l u d e d i n the G . V . M . H . S . c l i e n t f i l e and were u s u a l l y f a i r l y complete ; even when the c l i e n t had an out of p rov ince h o s p i t a l i z a t i o n the records were sent f o r . Hosp i ta l records were the most r e l i a b l e source of i n f o r m a t i o n about the c l i e n t ' s h o s p i t a l h i s t o r y and e a r l y l i f e . Numbers and d u r a t i o n o f h o s p i t a l i z a t i o n s were t a b u l a t e d , and were updated i n the new r e c o r d s . Dates o f admiss ion and d i s c h a r g e were always inc luded on the h o s p i t a l r e c o r d s . R iverv iew h o s p i t a l always had a summary sheet o f past h o s p i t a l i z a -t i o n s as par t o f t h e i r r e c o r d . H o s p i t a l records u s u a l l y a l s o had i n f o r m a t i o n on the c l i e n t ' s e a r l y l i f e , such as age o f f i r s t p s y c h i a t r i c c o n t a c t or f i r s t p s y c h i a t r i c h o s p i t a l i z a t i o n . A d m i t t e d l y , not a l l h o s p i t a l records were comprehensive, and a l s o the G . V . M . H . S . f i l e s d i d not sometimes possess a l l the c l i e n t ' s h o s p i t a l r e c o r d s ; t h i s was p a r t i c u l a r l y a problem i f the c l i e n t was mobi le and became h o s p i t a l i z e d out o f p r o v i n c e . In a d d i t i o n to h o s p i t a l r e c o r d s , o ther records were sometimes i n the G . V . M . H . S . f i l e , such as correspondence from the p o l i c e , from r e l a t i v e s , from insurance companies and so on . In S e c t i o n E below each v a r i a b l e i s de f ined and a l s o the source o f i n f o r m a t i o n f o r each v a r i a b l e i s d e s c r i b e d . L a t e r , i n S e c t i o n G, the r e l i a b i l i t y o f t h i s f i l e i n f o r m a t i o n i s f u r t h e r addressed . E. V a r i a b l e s Used Below i s a l i s t i n g o f the v a r i a b l e s t h a t were used to d e s c r i b e the study p o p u l a t i o n , t h e i r o p e r a t i o n a l d e f i n i t i o n s , and. the source from where the i n f o r m a t i o n was de r i ved (where n e c e s s a r y ) . 3'4. i ) Sex. i i ) Age. Th is r e f e r r e d to age ( i n years ) of the c l i e n t on November, 1981 (the s t a r t o f the study p e r i o d ) . i i i ) Age of first psychiatric contact. This was the age ( i n years ) the c l i e n t f i r s t made c o n t a c t w i t h the h e a l t h care system f o r p s y c h i a t r i c problems. "Onset" u s u a l l y r e f e r s to the age when symptoms f i r s t became apparent ; because t h i s may not n e c e s s a r i l y i n v o l v e a psy- v c h i a t r i c con tac t i t may r e q u i r e people (such as the c l i e n t or r e l a t i v e s ) to r e c a l l when i t occur red by memory, which may be u n r e l i a b l e . Hence, i t was f e l t t h a t age of f i r s t p s y c h i a t r i c contac t was more r e l i a b l e s i n c e t h i s was u s u a l l y recorded on h o s p i t a l o r d o c t o r ' s forms. In the case of t h i s present study the v a r i a b l e age o f f i r s t p s y c h i a t r i c con tac t was u s u a l l y de r i ved from h o s p i t a l or d o c t o r ' s records i n c l u d e d i n the f i l e ; sometimes, however, t h i s i n f o r m a t i o n was taken from an assessment done by the G . V . M . H . S . t h e r a p i s t which might i n v o l v e the c l i e n t (or h i s r e l a -t i v e ) r e c a l l i n g age of f i r s t c o n t a c t and t e l l i n g t h i s to the t h e r a p i s t . At o ther t i m e s , the re fe rence to age o f f i r s t contac t i n the f i l e was r a t h e r obscure (not r e f e r r e d to by G .V .M .H .S . t h e r a p i s t or h o s p i t a l record ) and cou ld not be r e c o r d e d . i v ) - Age of first psychiatric hospitalization. This v a r i a b l e was s i m i l a r to number i i i above, and again was used as an i n d i c a t o r o f age o f onset of i l l n e s s . A person 's f i r s t p s y c h i a t r i c con tac t may not n e c e s s a r i l y i n v o l v e a h o s p i t a l i z a t i o n and hence there may be a " l a g " 35 between f i r s t con tac t and f i r s t h o s p i t a l i z a t i o n . N e v e r t h e l e s s , f i r s t h o s p i t a l i z a t i o n i s a usefu l v a r i a b l e i n that i t can u s u a l l y be r e l i a b l y der i ved form f i l e i n f o r m a t i o n . In the case of t h i s study the v a r i a b l e " f i r s t h o s p i t a l i z a t i o n " was taken the m a j o r i t y o f the t ime from h o s p i t a l records i n c l u d e d i n the f i l e s . v) Duration of prior hospitalization. This was the amount" o f t i m e , i n months, t h a t the c l i e n t had spent as a p s y c h i a t r i c i n p a t i e n t p r i o r to November, 1981. (The f i g u r e was rounded o f f to the nearest month.) The i n f o r m a t i o n i n t h i s study was de r i ved from h o s p i t a l records inc luded i n the f i l e s . Hosp i ta l records r e l i a b l y record admiss ion and d i scharge d a t e s , however, f o r a number o f f i l e s , not a l l the r e l e v a n t h o s p i t a l records were a v a i l a b l e and hence t h i s i n f o r m a t i o n cou ld not be r e c o r d e d . . v i ) Time since last hospitalization. This r e f e r r e d to how long ago ( i n months) was the c l i e n t ' s l a s t d i s c h a r g e from a p s y c h i a t r i c i n p a t i e n t f a c i l i t y , d a t i n g back from November 1981. This i n f o r m a t i o n was r e l i a b l y recorded i n the G . V . M . H . S . f i l e , s i n c e i t u s u a l l y r e f e r r e d to a recent event . The h o s p i t a l record was inc luded i n the m a j o r i t y o f c a s e s , and was the major source o f i n f o r m a t i o n . As w e l l , h o s p i t a l i z a t i o n s were r e f e r r e d to i n the G . V . M . H . S . progress n o t e s , which u s u a l l y went back s e v e r a l months or y e a r s . H o s p i t a l i z a t i o n s were always recorded by the G . V . M . H . S . t h e r a p i s t and i n v o l v e d c o n f i r m a t i o n by con tac t w i t h h o s p i t a l p e r s o n n e l . v i i ) Previous number of hospitalizations. This was the number of p s y c h i a t r i c h o s p i t a l i z a t i o n s p r i o r to November, 1981. This 36 i n f o r m a t i o n was der i ved from h o s p i t a l records inc luded i n the f i l e s . H o s p i t a l records had a l i s t i n g o f p r i o r admiss ions to the same h o s p i t a l , and i n many c a s e s , to o ther h o s p i t a l s as w e l l . In some c a s e s , however, p a r t i c u l a r l y when the c l i e n t had been h o s p i t a l i z e d out of p r o v i n c e , t h i s i n f o r m a t i o n was not a v a i l a b l e . v i i i ) Employment history. This was a " yes -no" answer to the q u e s t i o n : "In the prev ious 5 years ( d a t i n g back from November 1981) has the c l i e n t he ld a c o m p e t i t i v e job - f u l l t ime or p a r t t ime - f o r a t l e a s t 6 months c o n s e c u t i v e l y ? " This i n f o r m a t i o n was der i ved from the progress notes w r i t t e n by the G . V . M . H . S . t h e r a p i s t . Where the progress notes d i d not extend back f a r enough (5 years ) the i n f o r m a t i o n cou ld not be d e r i v e d , except where i t may have been a l l u d e d to on h o s p i t a l records t h a t preceded the c l i e n t ' s c o n t a c t w i t h the G . V . M . H . S . Changes i n employment s t a t u s were u s u a l l y noted i n the progress n o t e s , a l t h o u g h , as was mentioned e a r l i e r , some t h e r a p i s t s were more d i l i g e n t than o t h e r s . One problem was t h a t o f t e n t h i s i n f o r m a t i o n was not conf i rmed f i r s t hand by the t h e r a p i s t , but r a t h e r taken from the c l i e n t h i m s e l f . i x ) Schooling. This was how many years of formal educat ion the c l i e n t had. This was u s u a l l y recorded on h o s p i t a l r e c o r d s , or i n some cases was taken from the i n i t i a l assessment done by the G .V .M .H .S . t h e r a p i s t . U l t i m a t e l y , t h i s was a p iece o f i n f o r m a t i o n g iven by the c l i e n t i n most c a s e s , and was d i f f i c u l t to c o n f i r m . 37. x) Marital Status. This was composed o f th ree c a t g o r i e s : A) s i n g l e , never m a r r i e d ; B) m a r r i e d ; C) separated o r d i v o r c e d . The i n f o r m a t i o n was der i ved from the progress notes o f the G . V . M . H . S . f i l e s , as we l l as from c l i e n t h i s t o r i e s recorded i n h o s p i t a l r e c o r d s . U s u a l l y the G .V .M.H .S . t h e r a p i s t was f a m i l i a r enough w i th the c l i e n t ' s l i v i n g s i t u a t i o n ( e . g . by home v i s i t s or by t a l k i n g to the spouse) to c o n f i r m t h i s i n f o r m a t i o n f i r s t hand. Some c l i e n t s had o n - a g a i n , o f f - a g a i n r e l a t i o n -sh ips w i th l i v e - i n b o y f r i e n d s / g i r l f r i e n d s tha t were hard to keep t r a c k o f , however i n t h i s v a r i a b l e " m a r r i e d " or " s e p a r a t e d " r e f e r r e d s p e c i f i c a l l y to wife/husband i n the convent iona l sense , not common-law w i f e . x i ) Employment status. There were n ine c a t e g o r i e s here : A) c o m p e t i t i v e f u l l t i m e ; B) c o m p e t i t i v e par t t i m e ; C) s h e l t e r e d f u l l t i m e ; D) s h e l t e r e d p a r t t i m e ; E) vo lun teer work; F) v o c a t i o n a l t r a i n i n g ; G) i n s c h o o l ; H) between j o b s ; I) unemployed. "Compet i t i ve " meant a r e g u l a r , open market j o b . " S h e l t e r e d " meant the person 's p s y c h i a t r i c d i s a b i l i t y had been taken i n t o account and hence the pace or d i f f i c u l t y o f the work was geared down. Examples o f t h i s were s h e l t e r e d workshops, and "Community Incent i ve P r o j e c t s " where the M.H.R. paid an employer ( u s u a l l y a s o c i a l agency) to have the c l i e n t a t tend and help out f o r a few hours a week. The f i n a n c i a l reward to the c l i e n t f o r most s h e l t e r e d p o s i t i o n s was m i n i m a l . "In s c h o o l " meant high school upgrading or c o l l e g e , v s . " v o c a t i o n a l t r a i n i n g " which meant a c q u i r i n g a s p e c i f i c v o c a t i o n a l s k i l l or t rade to improve e m p l o y a b i l i t y . Subsequent l y , i n the a n a l y s i s , the c a t e g o r i e s were c o l l a p s e d : A nd B were c o l l a p s e d to form " c o m p e t i t i v e work" ; C, D and E were 38V c o l l a p s e d to form " s h e l t e r e d work" ; H and I were c o l l a p s e d to form "unemployed; F and G were d i s c a r d e d ( i . e . t r e a t e d as m i s s i n g ) because o f t h e i r very low numbers. The i n f o r m a t i o n f o r t h i s v a r i a b l e was der i ved from the progress notes o f the G . V . M . H . S . f i l e . The t h e r a p i s t u s u a l l y had some f i r s t hand f a m i l i a r i t y w i t h the c l i e n t ' s s i t u a t i o n , never the less much o f t h i s i n f o r m a t i o n came second hand, from the c l i e n t . Changes i n employment s t a t u s were u s u a l l y noted i n the f i l e , a l though sometimes very sudden and temporary changes i n the c l i e n t ' s s t a t u s cou ld o c c u r , and consequent ly would be hard to keep t r a c k o f . Most o f the c l i e n t s , however, were s t a b l e i n that they were s t e a d i l y unemployed. x i i ) Source of income. There were seven c a t e g o r i e s here : A) employment; B) w e l f a r e ; C) handicapped pension ( t h i s i s a k i n to w e l f a r e but i s a somewhat g rea te r amount g iven to i n d i v i d u a l s - by the M.H.R. -w i t h a des ignated p h y s i c a l or mental h a n d i c a p ) : D) unemployment i n s u r a n c e ; E) dependent ( i . e . upon parent or g u a r d i a n ) ; F) sav ings or inves tment ; G) o t h e r . Subsequent ly , i n the a n a l y s i s , the c a t e g o r i e s were c o l l a p s e d : A and F became " independent" source o f income; B, C, D and E became "dependent" source o f income; G was d i sca rded because o f low numbers. The i n f o r m a t i o n f o r t h i s v a r i a b l e was de r i ved from the progress notes o f G . V . M . H . S . f i l e s . The t h e r a p i s t s had some f i r s t hand f a m i l i a r i t y about t h i s m a t t e r ; t h i s came from c o n s u l t i n g w i th employers , w e l f a r e w o r k e r s , p a r e n t s , and being i n v o l v e d i n the a p p l i c a t i o n fo r a handicapped 39 pension (which r e q u i r e s medical a u t h o r i z a t i o n ) However, some of t h i s i n f o r m a t i o n came second-hand from the c l i e n t . x i i i ) Living situation. There were seven c a t e g o r i e s here : A) a l o n e ; B) w i th f a m i l y as dependent; C) w i t h par tner (marr ied or common-l a w ) ; D) s i n g l e p a r e n t ; E) w i t h f r i e n d s ; F) s h a r e d , n o n - f a m i l i a l s e t t i n g ( i . e . board ing home); G) o t h e r . ("F" r e f e r s to a rooming house, boarding house s e t t i n g where s l e e p i n g quar te rs are t y p i c a l l y s h a r e d , and meals as we l l are shared . This i s d i s t i n g u i s h e d from "A" which r e f e r s to a s e t t i n g where meals and s l e e p i n g quar te rs are p r i v a t e . ) Subsequent ly , i n the a n a l y s i s , c a t e g o r i e s , D, E. and G. were d i s c a r d e d ( t r e a t e d as m i s s i n g ) because o f t h e i r low numbers. The i n f o r m a t i o n f o r t h i s v a r i a b l e was de r i ved from the progress notes o f the G . V . M . H . S . f i l e s . Once a g a i n , a l though the t h e r a p i s t had some f i r s t - h a n d knowledge o f the c l i e n t ' s s i t u a t i o n , some of t h i s i n f o r m a -t i o n came second-hand from the c l i e n t ; a t t i m e s , because o f sudden changes, the c l i e n t ' s s t a t u s was hard to keep t r a c k o f . x i v ) Residence. There were ten c a t e g o r i e s h e r e : A) p r i v a t e (apartment o r hosue) w i th homemaker; B) p r i v a t e (apartment o r house) w i thout homemaker; C) r e s i d e n t i a l h o t e l ; D) hard to house r e s i d e n t i a l f a c i l i t y ; E) group home or superv i sed apartment ; F) f a m i l y care home: G) mental h e a l t h boarding home; H) i n h o s p i t a l ; I) i n s h o r t s tay c r i s i s u n i t ; J) no f i x e d address . A " r e s i d e n t i a l h o t e l " was a hote l ( u s u a l l y near s k i d row) that rented rooms by the month. Categor ies D, E, F and G had the f o l l o w i n g 40 d i s t i n c t i o n s : a mental hea l th boarding home was a superv i sed group r e s i d e n c e f o r ( u s u a l l y 15-25) mental p a t i e n t s , l i c e n s e d by the c i t y and the M i n i s t r y o f H e a l t h ; group homes and superv i sed apartments were s i m i l a r to the board ing homes except t h a t , f i r s t l y , they conta ined fewer people ( 1 - 4 ) , and s e c o n d l y , there was a lower degree o f s u p e r v i s i o n ; f a m i l y care homes were smal l p r i v a t e houses, l i c e n s e d to serve as homes f o r a few (1 -3 ) mental p a t i e n t s , w i t h a f a i r l y high degree o f s u p e r v i s i o n , a long the l i n e s o f a f o s t e r home. In t h i s c a t e g o r i z a t i o n the group home i s more p r i v a t e ( i . e . no l i v e - i n s t a f f ) whereas the mental h e a l t h boarding horn and f a m i l y care home had 24 hour a day s u p e r v i s i o n . "Hard to House F a c i l i t y " was s i m i l a r to the mental hea l th boarding home, except tha t c e r t a i n c l i e n t fea tu res ( a l c o h o l s i m , c r i m i n a l r e c o r d s , a n t i s o c i a l behaviour ) were t o l e r a t e d to a g r e a t e r e x t e n t . The "shor t s tay c r i s i s u n i t " r e f e r r e d to res idence fo r u s u a l l y o n l y a few days i n an emergency s h e l t e r or h o s t e l . Subsequent ly , i n the a n a l y s i s , c a t e g o r i e s were c o l l a p s e d as f o l l o w s : A, B, and C became " independent housing; 1 " and D, E, F and G became "dependent h o u s i n g . " H. I and J were d i sca rded ( t r e a t e d as m i s s i n g data) because o f t h e i r very low numbers, and a l s o because being " i n h o s p i t a l " does not i n d i c a t e the s o r t o f community r e s i d e n c e the person normal l y l i v e s i n . The i n f o r m a t i o n f o r t h i s v a r i a b l e was de r i ved from the progress notes o f the G .V .M .H .S . f i l e s . The t h e r a p i s t o f t e n h a d f i r s t hand knowledge o f the c l i e n t ' s s i t u a t i o n , p a r t i c u l a r l y because the r e f e r r a l to a superv i sed f a c i l i t y o f t e n came through the t h e r a p i s t , however some times t h i s i n f o r m a t i o n came second-hand from the c l i e n t . As w e l l , the researcher i n 41 t h i s s t u d y , because o f job e x p e r i e n c e s , had f i r s t - h a n d knowledge of most o f the s h e l t e r e d f a c i l i t i e s i n Vancouver. xv) Rehospitalization. This r e f e r r e d to the number of t imes the s u b j e c t had a p s y c h i a t r i c h o s p i t a l i z a t i o n i n the study p e r i o d (Nov. 1981-Nov. 1983) . The i n f o r m a t i o n came from the progress notes o f the G . V . M . H . S . f i l e s ; t h i s i n f o r m a t i o n had u s u a l l y been conf i rmed by the t h e r a p i s t making d i r e c t con tac t w i t h the h o s p i t a l . Often the r e l e v a n t h o s p i t a l record was i n c l u d e d as w e l l . Somtimes i n a b r i e f h o s p i t a l i z a t i o n there was no con tac t between h o s p i t a l and t h e r a p i s t and the t h e r a p i s t would have to r e l y on the s u b j e c t (or a r e l a t i v e ) to r e p o r t i t . x v i ) Admissions to Venture. "Venture" i s a s h o r t s t a y c r i s i s u n i t operated by the G . V . M . H . S . People are r e f e r r e d there when i n a temporary c r i s i s s t a t e and when deemed to be not i l l enough to r e q u i r e h o s p i t a l i z a t i o n . This v a r i a b l e r e f e r r e d to the number o f t imes the s u b j e c t was admit ted i n the study p e r i o d . Because Venture i s operated by the G . V . M . H . S . , records are kept a t the c e n t r a l r e g i s t r y o f the G . V . M . H . S . as to whether and how o f t e n a person has been admitted to Venture ; these records were the source o f i n f o r m a t i o n f o r t h i s p a r t i c u l a r v a r i a b l e . x v i i ) Criminal activities. This r e f e r r e d to how many t imes the s u b j e c t had been charged w i t h a c r i m i n a l o f f e n s e i n the study p e r i o d . This i n f o r m a t i o n was der i ved from the progress notes o f the G . V . M . H . S . f i l e . Sometimes i t had been conf i rmed f i r s t - h a n d by w r i t t e n or telephone con tac t between the t h e r a p i s t and l e g a l a u t h o r i t i e s ; much o f the t i m e , however, the i n f o r m a t i o n came second -hand , from the c l i e n t . 42:. x v i i i ) Mortality. This r e f e r r e d to how many s u b j e c t s d ied i n the study p e r i o d ; such i n f o r m a t i o n was, o b v i o u s l y , conf i rmed f i r s t -hand by the t h e r a p i s t c o n t a c t i n g p o l i c e , h o s p i t a l s e t c . x i x ) Suicides. This r e f e r r e d to how many s u b j e c t s d ied by s u i c i d e i n the study p e r i o d . This i n f o r m a t i o n was conf i rmed f i r s t - h a n d by the t h e r a p i s t c o n t a c t i n g the a p p r o p r i a t e a u t h o r i t i e s . xx) Suicide attempts. I t was i n i t i a l l y hoped to record how many sub jec ts made s u i c i d e attempts i n the study p e r i o d . This was found to be i m p o s s i b l e to do r e l i a b l y us ing f i l e i n f o r m a t i o n ; i t seemed that many o f the c l i e n t s made s u i c i d a l g e s t u r e s , some s e r i o u s , some not very s e r i o u s ; i t was d i f f i c u l t to d i s t i n g u i s h the s e r i o u s from the not s e r i o u s -e . g . i s t a k i n g ten a s p i r i n s a s u i c i d e attempt? As w e l l , i t was ra re t h a t the t h e r a p i s t cou ld c o n f i r m an attempt f i r s t hand, un less i t was a very s e r i o u s attempt t h a t l e f t p h y s i c a l ev idence . Because t h i s v a r i a b l e had so many a s s o c i a t e d problems, i t was not used. x x i ) Address changes. This r e f e r r e d to how many times the s u b j e c t changed res idence i n the study p e r i o d . The i n f o r m a t i o n was d e r i v e d from the progress notes o f the G .V .M .H .S . f i l e s . U n f o r t u n a t e l y , most o f the community care teams d i d not keep a form t h a t s y s t e m a t i c a l l y recorded new addresses w i t h the f i l e ; the main argument was t h a t c l i e n t s sometimes moved too f r e q u e n t l y to be kept tabs o n . Therap is ts cou ld c o n f i r m r e s i d e n c e f i r s t hand i n a number o f cases ( p a r t i c u l a r l y w i t h a s t a b l e 43 c l i e n t ) however when the c l i e n t made severa l qu ick moves i t was hard to moni tor and i n f o r m a t i o n had to come second hand from the c l i e n t . x x i i ) Team changes. This v a r i a b l e was s i m i l a r to address changes. I t r e f e r r e d to how many t imes the s u b j e c t swi tched community care teams i n the study p e r i o d . (The care teams operate by t a k i n g c l i e n t s from a geographica l catchment a r e a . ) This i n f o r m a t i o n was t a b u l a t e d a t c e n t r a l r e g i s t r y o f the G . V . M . H . S . which was the source fo r t h i s p a r t i c u l a r v a r i a b l e . x x i i i ) Closures and veopenings. This r e f e r r e d ' to how many t imes a c l i e n t was c l o s e d (dropped out o f t reatment) a t a community care team and then subsequent ly was r e a c t i v a t e d ; i . e . one " c l o s u r e and reopen ing" would mean the s u b j e c t dropped out and then dropped back i n (once) d u r i n g the study p e r i o d . This i n f o r m a t i o n was a l s o t a b u l a t e d a t the c e n t r a l r e g i s t r y o f the G . V . M . H . S . , which became the source f o r t h i s v a r i a b l e . x x i v ) Change in employment status. This r e f e r r e d to how many times the s u b j e c t ' s employment s t a t u s changed dur ing the study p e r i o d . For example, i f the person was employed and became unemployed, t h i s would be one change; i f the person was employed, then unemployed, then employed a g a i n , t h i s would be two changes. This i n f o r m a t i o n , l i k e employment s t a t u s ( v a r i a b l e no. x i ) , was der i ved from the progress notes o f the G . V . M . H . S . f i l e s ; much o f t h i s i n f o r m a t i o n came second hand from the c l i e n t and was recorded by the t h e r a p i s t . 44. xxv) Change in source of income. Th is v a r i a b l e i s s i m i l a r to no. xx i v above; i t r e f e r r e d to how many times the s u b j e c t ' s source o f income changed i n the study p e r i o d . For example, from employment, to U . I . C . , to w e l f a r e , would r e p r e s e n t two changes. The i n f o r m a t i o n was der i ved from the progress notes o f the G . V . M . H . S . f i l e ; a change would u s u a l l y be notab le and be recorded by the t h e r a p i s t , however i n many cases the i n f o r m a t i o n p e r t a i n i n g to the change had come second hand from the c l i e n t . As i t turned o u t , most c l i e n t s were f a i r l y s t a b l e i n t h e i r source o f income. x x v i ) Hours per month at the team. This v a r i a b l e was unique i n tha t i t was not c o l l e c t e d by t h i s r e s e r c h e r , but r a t h e r came from a c l i e n t census taken by the G .V .M .H .S . i n November o f 1 9 8 1 , and r e f e r r e d to the amount o f c l i n i c a l t ime the c l i e n t spent a t the community care team per month, based on the e s t i m a t i o n o f the c l i e n t ' s t h e r a p i s t . This researcher had access to the r e s u l t s o f t h i s census , and used the i n f o r m a -t i o n fo r t h i s v a r i a b l e . " C l i n i c a l t ime" r e f e r s to t ime spent d e a l i n g wi th p s y c h i a t r i c problems, med icat ion e t c . r a t h e r than r e c r e a t i o n a l or drop i n t i m e . x x v i i ) Visits to the team. This v a r i a b l e r e f e r r e d to how o f t e n the s u b j e c t v i s i t e d the community care team dur ing the study p e r i o d . Such i n f o r m a t i o n was g e n e r a l l y recorded i n a s y s t e m a t i c f a s h i o n i n the progress notes o f the G . V . M . H . S . f i l e ; some o f the t h e r a p i s t s , however, were l e s s s y s t e m a t i c than o thers and t h i s i n f o r m a t i o n was then not a v a i l a b l e . 4 5 . F. R e l a t i o n s h i p s Between V a r i a b l e s In t h i s study a number of b i v a r i a t e a s s o c i a t i o n s were looked a t ; t h u s , some o f the v a r i a b l e s were t r e a t e d as "dependent" v a r i a b l e s . The use of the word "dependent" i n t h i s contex t i s suspect because, as has been noted e a r l i e r , no independent v a r i a b l e i s being m a n i p u l a t e d , and the p o s s i b l y contaminat ing e f f e c t s of extraneous t h i r d v a r i a b l e s cannot ( f o r the most p a r t ) be c o n t r o l l e d f o r . In some cases the e f f e c t o f a t h i r d v a r i a b l e i s unknown because the p a r t i c u l a r v a r i a b l e was not accounted f o r i n the data c o l l e c t i o n . For example, the race o f the s u b j e c t was not accounted f o r i n t h i s s t u d y , which cou ld c o n c e i v a b l y be s i g n i f i c a n t i n t h a t some s t u d i e s (mentioned i n the l i t e r a t u r e review) have detected a race e f f e c t i n employment outcome. Another i s s u e concerns the d i r e c t i o n a l i t y o f e f f e c t ; as noted i n the l i t e r a t u r e rev iew some v a r i a b l e s are regarded as " p r e d i c t o r s " o f outcome, a p o i n t which can be regarded as v a l i d o n l y to the ex ten t t h a t the p r e d i c t o r v a r i a b l e i s antecedent to the c r i t come v a r i a b l e . In some cases t h i s i s t r u e : f o r example, h i s t o r y o f h o s p i t a l i z a t i o n appears to have an e f f e c t o n , and p recedes , r e h o s p i t a l i z a t i o n ; o r , employment h i s t o r y appears to have an e f f e c t o n , and p recedes , employment s t a t u s i n the f o l l o w - u p p e r i o d . Other v a r i a b l e s , however, seem to be concur rent w i t h the outcome v a r i a b l e . For example, i n an a s s o c i a t i o n between how o f t e n one v i s i t s an a f t e r - c a r e c l i n i c and the tendency to be r e h o s p i t a l i z e d , which v a r i a b l e i s e f f e c t i n g the o ther v a r i a b l e ? Conce ivab ly there cou ld be a mutual e f f e c t . S i m i l a r l y , i n an a s s o c i a t i o n between employment s t a t u s and s t y l e o f r e s i d e n c e , i s the r e s i d e n t i a l s i t u a t i o n e f f e c t i n g the person 's employment s t a t u s or v i c a versa? In s h o r t , a l though a number of a s s o c i a t i o n s 46 were looked a t i n t h i s s t u d y , l i t t l e can be i n f e r r e d about d i r e c t i o n a l i t y o f e f f e c t ; t h u s , the d e s i g n a t i o n "dependent v a r i a b l e " i s a r b i t r a r y i n the sense t h a t the "dependent" v a r i a b l e could conce i vab l y be e f f e c t i n g the " independent" v a r i a b l e . G. V a l i d i t y and R e l i a b i l i t y o f Measures Used In t h i s s t u d y . t h e two main v a r i a b l e s used to measure "outcome" were r e h o s p i t a l i z a t i o n r a t e and employment s t a t u s . There i s the i m p l i c a -t i o n t h a t these v a r i a b l e s g ive an i n d i c a t i o n o f community f u n c t i o n i n g , and i n f a c t these two v a r i a b l e s are commonly used i n s c h i z o p h r e n i a outcome s t u d i e s as measures of " s u c c e s s " or " f a i l u r e . " There has been, however, some c r i t i c i s m of the o v e r - r e l i a n c e on r e h o s p i t a l i z a t i o n r a t e s as an outcome measure; a number o f workers have i n f a c t quest ioned the v a l i d i t y o f t h i s p a r t i c u l a r v a r i a b l e . What i s the r a t i o n a l e f o r us ing r e h o s p i t a l i z a t i o n r a t e s ? Anthony [108] suggests t h a t i t makes "economic and p s y c h o l o g i c a l sense" to use r e c i d i v i s m as an outcome measure; the author s t a t e s t h a t : "Con-c e r n i n g r e c i d i v i s m ; , most would agree t h a t one i s p s y c h o l o g i c a l l y b e t t e r o f f i f he can avo id r e t u r n i n g to a p s y c h i a t r i c i n s t i t u t i o n ; e c o n o m i c a l l y , i t i s l e s s expensive f o r the taxpayer i f the p a t i e n t remains out o f the h o s p i t a l . " As ide from i m p l i c a t i o n s about c l i e n t f u n c t i o n i n g , one o f the most use fu l c h a r a c t e r i s t i c s o f r e c i d i v i s m i s i t s ease o f measurement. R o s e n b l a t t [109] summarizes t h i s v iewpo in t as f o l l o w s : "Readmission s t a t i s t i c s are easy to obtain and are, i n f a c t , r o u t i n e l y c o l l e c t e d by most h o s p i t a l administrators. Moreover, the data c o l l e c t e d are highly r e l i a b l e . A former patient 4 7 . i s e i t h e r readmitted or not readmitted; accordingly, there i s every l i k e l i h o o d that d i f f e r e n t i n v e s t i g a t o r s w i l l a r r i v e at s i m i l a r r e s u l t s . F i n a l l y , i t i s very easy to quantify the material obtained. These methodo-l o g i c a l assets have led readmission s t a t i s t i c s to become the i n d i c a t o r 'par excellence' of h o s p i t a l effectiveness and have made them of c r u c i a l concern to h o s p i t a l administrators and others." There have been c r i t i c i s m s o f Anthony 's p o s i t i o n tha t the p a t i e n t i s " p s y c h o l o g i c a l l y b e t t e r o f f " i f he can avo id r e h o s p i t a l i z a t i o n . A good example o f t h i s i s the p r e v i o u s l y mentioned Danish f o l l o w - u p study o f d ischarged s c h i z o p h r e n i c s by Chr i s tensen [ 1 1 0 ] : i n t h i s study the author concluded t h a t : "The patient's a b i l i t y to keep out of h o s p i t a l f o r a short or long period i s no c r i t e r i o n of s a t i s f a c t o r y treatment. Many patients who had not been readmitted were l i v i n g under poorer conditions and were also more mentally i l l than others, who were readmitted." One can e a s i l y e n v i s i o n a s c e n a r i o where the p a t i e n t who i s not readmit ted l i v e s an i s o l a t e d , v e g e t a t i v e e x i s t e n c e whereas the p a t i e n t who has the energy and i n i t i a t i v e to demand r e h o s p i t a l i z a t i o n might c o n c e i v a b l y be cons idered more m e n t a l l y h e a l t h y . What o ther f a c t o r s may be a f f e c t i n g r e h o s p i t a l i z a t i o n r a t e ? Clausen [111] concludes t h a t : "Continued community tenure i s due i n part to the s o c i a l conditions and the context of l i f e i n which the former patient finds himself and i s not merely a function of the absolute l e v e l of performance or the objective degree of p s y c h i a t r i c impairment or d i s t r e s s . " Whether or not a p a t i e n t i s readmit ted and how long he w i l l subsequent ly s tay may be a f f e c t e d by a v a r i e t y o f v a r i a b l e s ; the reader i s d i r e c t e d to a r t i c l e s by S t rauss [ 1 1 2 ] , Bachrach [113] and Freeman [114] 48, f o r a r e v i e w . In summary, readmiss ion may be a f f e c t e d by f a c t o r s such a s : h o s p i t a l a d m i n i s t r a t i v e p o l i c i e s ; t reatment p h i l o s o p h i e s of h o s p i t a l s t a f f ; the d i s t a n c e the p a t i e n t l i v e s from the h o s p i t a l ; the s i z e of the h o s p i t a l ; the l e g a l s t a t u s o f the p a t i e n t , whether committed or v o l u n t a r y ; the a v a i l a b i l i t y o f e i t h e r f a m i l y support or p u b l i c resources i n the community; whether the h o s p i t a l i s p u b l i c or p r i v a t e ; s o c i a l c l a s s of the p a t i e n t ; the p a t i e n t ' s r o l e i n the f a m i l y ; the m a n i p u l a t i o n by p h y s i c i a n s , f a m i l i e s and p a t i e n t s themselves to ga in a d m i s s i o n , readmiss ion or r e l e a s e ; a n d , the l e v e l o f t o l e r a n c e among r e l a t i v e s o f the p a t i e n t ' s behav iour . With regard to t h i s l a s t p o i n t , a study by Michaux [115] o f p s y c h i a t r i c p a t i e n t s l i v i n g w i t h t h e i r f a m i l i e s came up w i t h the f o l l o w i n g f i n d i n g s : A) there was no s i g n i f i c a n t c o r r e l a t i o n between the p a t i e n t ' s psychopatho log ica l symptoms and h i s readmiss ion to h o s p i t a l ; B) there was, however, a c o r r e l a t i o n between readmiss ion and the r e l a t i v e ' s s u b j e c t i v e judgment o f the p a t i e n t ' s pathology as w e l l as the r e l a t i v e ' s ] l a c k of s a t i s f a c t i o n w i t h the p a t i e n t ' s performance i n s o c i a l a c t i v i t i e s . Another i s s u e confounding the v a l i d i t y o f r e h o s p i t a l i z a t i o n as an outcome measure concerns the e f f e c t o f h o s p i t a l i z a t i o n i t s e l f ; as was d i s c u s s e d i n S e c t i o n C of the L i t e r a t u r e Review, the tendency to become r e h o s p i t a l i zed i s apparent l y a s s o c i a t e d wi th how many times the i n d i v i d u a l has p r e v i o u s l y been i n h o s p i t a l . Thus, being r e h o s p i t a l i z e d i s not o n l y a f u n c t i o n of the person 's c u r r e n t mental h e a l t h but a l s o a f u n c t i o n o f the person 's i n s t i t u t i o n a l h i s t o r y . Turning from r e h o s p i t a l i z a t i o n to employment, Anthony. [115] views employment r a t e s as a l e g i t i m a t e outcome i n d i c a t o r i n that "working has p s y c h o l o g i c a l b e n e f i t s ; e c o n o m i c a l l y , work produces tax d o l l a r s and 49 avoids government a i d payments." ( I t i s notab le tha t r e h o s p i t a l i z a t i o n and employment, i n Anthony's c o n c e p t u a l i z a t i o n , each have a prominent economic j u s t i f i c a t i o n as outcome i n d i c a t o r s i n a d d i t i o n to the psycho-l o g i c a l f u n c t i o n i n g e lement . ) I t was assumed f o r the sake o f t h i s study t h a t employment s t a t u s , to a degree , r e f l e c t e d s o c i a l competency i n t h a t a worker t y p i c a l l y must i n t e r a c t w i t h other people and must perform a task w h i l e under pressure from t i m e , s u p e r v i s o r s e t c . I t must a l s o be noted t h a t f a c t o r s o t h e r than the p a t i e n t ' s l e v e l o f f u n c -t i o n i n g may a f f e c t employment r a t e s ; l o c a l economic c o n d i t i o n s must be accounted fo r as they w i l l i n f l u e n c e employment r a t e s f o r the general p u b l i c as w e l l as the mental p a t i e n t . Another c r i t i c i s m of t h i s pa r -t i c u l a r measure i s tha t i n some s t u d i e s "employment s t a t u s " i s not c l e a r l y d e f i n e d : does i t mean f u l l t i m e , par t t i m e , s h e l t e r e d , u n s h e l t e r e d , and f o r what d u r a t i o n ? Because o f t h i s problem i t i s sometimes d i f f i c u l t to compare r e s u l t s . F i n a l l y , as Bachrach [117] n o t e s , a study o f employment s t a t u s should i d e a l l y get a sense of change over t i m e , or change a f t e r h o s p i t a l d i s c h a r g e , to measure t rends i n upward o r downward m o b i l i t y . In a d d i t i o n to r e h o s p i t a l i z a t i o n and employment, t h i s study i n c l u d e d ' s e v e r a l o ther v a r i a b l e s which were taken as measures o f com-munity f u n c t i o n i n g . One o f these was Venture a d m i s s i o n s , n o t i n g how o f t e n the s u b j e c t was admitted to the s h o r t s tay c r i s i s u n i t . This was assumed to rep resent a " m i n i - h o s p i t a l i z a t i o n , " and to i n v o l v e the same c o n s i d e r a t i o n s o f v a l i d i t y as the v a r i a b l e ' r e h o s p i t a l i z a t i o n . Another measure used was s u i c i d e and s u i c i d e a t tempts ; t h i s i n c l u s i o n was prompted by the research f i n d i n g s t h a t s c h i z o p h r e n i c s have a high 5 0 . s u i c i d e r a t e and was based on the assumption t h a t a person a t tempt ing s u i c i d e i s e s s e n t i a l l y unhappy w i t h l i f e , cannot cope, or i s " c r y i n g f o r h e l p . " The v a r i a b l e c r i m i n a l a c t i v i t i e s was inc luded w i t h the assumption t h a t t u r n i n g to cr ime represented a poorer s o c i a l ad jus tment . F i n a l l y , severa l measures o f c l i e n t s t a b i l i t y such as address changes and change i n source o f income were i n c l u d e d . I t was assumed t h a t a more s t a b l e c l i e n t was d i s p l a y i n g more s u c c e s s f u l community ad jus tment . Such an assumption must be q u a l i f i e d , however; as noted w i t h r e h o s p i t a l i z a -t i o n , a c l i e n t may be s t a b l e i n t h a t he i s not being readmit ted but a t the same time may be m e n t a l l y u n w e l l . In a d d i t i o n , o ther v a r i a b l e s may be a f f e c t i n g measures o f s t a b i l i t y . One such v a r i a b l e i s age ; i t i s l i k e l y t h a t young people are more mobi le than o l d e r people r e g a r d -l e s s o f whether or not they are p s y c h i a t r i c p a t i e n t s . In summary, i t has been shown that some s c h i z o p h r e n i a o u t -come measures, p a r t i c u l a r l y r e h o s p i t a l i z a t i o n , have u n c e r t a i n v a l i d i t y and hence i n f e r e n c e s should not be a t an exp lanatory but r a t h e r a t a d e s c r i p t i v e l e v e l , i . e . " there i s a d i f f e r e n c e " r a t h e r than " t h i s d i f f e r e n c e means. . . . " The l i m i t a t i o n o f h o s p i t a l i z a t i o n as a measure i s a l s o apparent when one looks a t concordance r a t e s between d i f f e r e n t measures o f s c h i z o p h r e n i a outcome. A study by Schwartz [118] examined four outcome measures: mental s t a t u s , s o c i a l adjustment and r o l e performance, consumer s a t i s f a c t i o n , and r e h o s p i t a l i z a t i o n . The. general f i n d i n g was t h a t c o r r e l a t i o n r a t e s were r e l a t i v e l y low between the i d i f f e r e n t measures ( i . e . because a person does we l l i n one dimension does not n e c e s s a r i l y mean he w i l l do we l l i n another ) a n d , most c r u c i a l f o r t h i s study was the f i n d i n g t h a t r e h o s p i t a l i z a t i o n had the lowest 51.. c o r r e l a t i o n r a t e o f a l l among the d i f f e r e n t measures. The a u t h o r s ' c o n c l u s i o n was t h a t " the phenomenon" o f r e h o s p i t a l i z a t i o n i s an e n t i r e l y separate dimension of t reatment outcome," a f f e c t e d by a s e t o f v a r i a b l e s and c o n t i n g e n c i e s t h a t are apparent l y f a i r l y unique to t h i s one measure a lone [119] . Schwartz goes on to say t h a t " s i n c e t reatment outcome i s m u l t i f a c e t e d and m u l t i d e t e r m i n e d , m u l t i p l e assessments must con t inue as v i t a l procedures" [ 1 2 0 ] . Thus, we are not c e r t a i n what e x a c t l y r e h o s p i t a l i z a t i o n i s measur ing , and i t should be regarded as a separate measure. A range of d i f f e r e n t measures are needed to assess the t o t a l outcome p i c t u r e , but d i f f e r e n t measures may not be comparable and no one measure should be cons idered to have tapped i n t o a comprehensive p i c t u r e o f c l i e n t f u n c t i o n i n g . In t h i s study the range of measures was r a t h e r l i m i t e d (not i n c l u d i n g , fo r example, mental s t a t u s or consumer s a t i s f a c t i o n ) and thus the content v a l i d i t y o f the measures used ( i . e . the extent to which they inco rpora ted the concept o f " s o c i a l ad justment" ) was presumably l i m i t e d . One problem here may be t h a t " s o c i a l adjustment" i s a r a t h e r b road , vague, a b s t r a c t conceptual c a t e g o r y . As w e l l as problems w i t h v a l i d i t y , there were found to be problems i n the r e l i a b i l i t y o f the i n f o r m a t i o n c o l l e c t e d i n t h i s s t u d y . Some o f these problems have a l r e a d y been d i s c u s s e d , and they represent a p a r t i c u l a r weakness o f s t u d i e s t h a t r e l y on recorded i n f o r m a t i o n as the data base . Of the v a r i a b l e s desc r ibed i n s e c t i o n E, some were s y s t e m a t i c a l l y recorded or were e a s i l y and r e a d i l y v e r i f i a b l e ; these were f e l t to rep resent f a i r l y r e l i a b l e i n f o r m a t i o n . These v a r i a b l e s were: sex , age , t ime s i n c e l a s t h o s p i t a l i z a t i o n , m a r i t a l s t a t u s , r e h o s p i t a l i z a t i o n , Venture a d m i s s i o n s , m o r t a l i t y , s u i c i d e s , team changes, 5 2 i c l o s u r e s and reopen ings , hours per month a t team, and number o f v i s i t s to the team. Other v a r i a b l e s were f e l t to be l e s s r e l i a b l e ; where r e -l i a b i l i t y was u n c e r t a i n the case was not i n c l u d e d , and these m i s s i n g cases were not inc luded by the computer i n the s t a t i s t i c a l a n a l y s i s . Some of the v a r i a b l e s had c o n s i d e r a b l e numbers o f m i s s i n g c a s e s , which w i l l be d i scussed f u r t h e r . Of the remaining v a r i a b l e s , some were o f a k ind tha t were t y p i c a l l y recorded i n a sys temat ic f a s h i o n , but i n the case of t h i s study the p a r t i c u l a r r e l e v a n t records were o f t e n m i s s i n g . These were u s u a l l y v a r i a b l e s t h a t r e f e r r e d to past events and t h a t r e q u i r e d the use o f h o s p i t a l / m e d i c a l records t h a t might not have been i n the G .V .M .H .S . f i l e . These v a r i a b l e s were: age o f f i r s t p s y c h i a t r i c c o n t a c t , age of f i r s t h o s p i t a l i z a t i o n , d u r a t i o n o f p r i o r h o s p i t a l i z a t i o n s , number of prev ious h o s p i t a l i z a t i o n s , and school h i s t o r y . As n o t e d , some o f the c l i e n t s had t h i s i n f o r m a t i o n on o l d , r e c o r d s , but f o r o thers there were m i s s i n g p i e c e s . For these v a r i a b l e s , the reason the records were m i s s i n g were e i t h e r because the events ( e . g . a h o s p i t a l i -z a t i o n ) had occur red out o f p rov ince o r e l s e the person 's h o s p i t a l i z a t i o n h i s t o r y was so e x t e n s i v e i t was too d i f f i c u l t to gather a l l the necessary records and make an accura te es t imate of how many times they had been i n h o s p i t a l . Consequent ly , i t cou ld be argued t h a t i n some ins tances the m i s s i n g cases were s y s t e m a t i c a l l y d i f f e r e n t from the cases p r e s e n t , i . e . the people w i t h e x t e n s i v e h o s p i t a l h i s t o r i e s were o v e r - r e p r e s e n t e d i n the m i s s i n g c a s e s , thus the v a r i a b l e prev ious number of h o s p i t a l i z a -t i o n s cou ld c o n c e i v a b l y be an underes t imat ion of the t rue v a l u e . As w e l l , a number o f the m i s s i n g cases invo lved i n d i v i d u a l s who were mobi le and had been h o s p i t a l i z e d out o f p r o v i n c e ; i f p a t i e n t s who are 53. g e o g r a p h i c a l l y mobi le are i n some sense d i f f e r e n t from those who are more s t a b l e , then the m i s s i n g cases may represent a b i a s . (Regarding t h i s l a s t p o i n t , one American study found an a s s o c i a t i o n between mental p a t i e n t r e h o s p i t a l i z a t i o n r a t e and geographic m o b i l i t y [121] . ) The l a s t group o f v a r i a b l e s were ones f o r which i n f o r m a t i o n was not recorded s y s t e m a t i c a l l y i n the f i l e s , t h a t i s , some t h e r a p i s t s were more ex tens i ve i n t h e i r w r i t t e n passages than o t h e r s . These v a r i a b l e s concerned c u r r e n t events and were w r i t t e n up i n the -progress no tes . They were: employ-ment, s t a t u s , source o f income, employment h i s t o r y , l i v i n g s i t u a t i o n , r e s i d e n c e , c r i m i n a l a c t i v i t i e s , address changes, change i n employment s t a t u s , changes i n source o f income. These v a r i a b l e s r e l i e d to a c o n -s i d e r a b l e ex tent on second-hand i n f o r m a t i o n from the c l i e n t s ( vs . f r i s t - h a n d v e r i f i c a t i o n by the t h e r a p i s t ) and hence were cons idered l a c k i n g in r e l i a b i l i t y . There were two i ssues here . F i r s t of a l l , i n f o r m a t i o n on v a r i a b l e s such as address changes, changes i n employment s t a t u s and c r i m i n a l a c t i v i t i e s were harder to keep t r a c k o f the more f r e q u e n t l y the event o c c u r r e d ; where i t was not p o s s i b l e to e s t a b l i s h how many, f o r example address changes, had happened, i t was l i s t e d as m i s s i n g . Hence, the people w i th more f requent occur rence o f these events may have been o v e r - r e p r e s e n t e d i n the m i s s i n g data and thus a v a r i a b l e such as "address changes" cou ld be an underes t imat ion of the t rue v a l u e . The o ther i s s u e was t h a t where the t h e r a p i s t r e l i e s on the c l i e n t to prov ide him w i t h i n f o r m a t i o n , the " s o c i a l d e s i r a b i l i t y " o f the response comes i n t o p l a y . Thus, a . c l i e n t might d i s t o r t the t r u t h about h i s c r i m i n a l a c t i v i t i e s ( i . e . underest imate them) or perhaps c l a i m he i s working when he i s n o t . 5 4 ; In summary, the v a r i a b l e s used i n t h i s study presented a number o f problems i n v a l i d i t y and r e l i a b i l i t y o f measurement; the l i m i t a t i o n s brought up i n t h i s s e c t i o n must be born i n mind to q u a l i f y the r e s u l t s o f the data a n a l y s i s p r o c e s s . H. Timing .of Measurements This study was r e t r o s p e c t i v e i n d e s i g n , t h a t i s , i t c o l l e c t e d i n f o r m a t i o n on events t h a t had happened p r e v i o u s l y and been r e p o r t e d . The advantage o f a r e t r o s p e c t i v e - v s . p r o s p e c t i v e - v iewpo in t i s t h a t data can be gathered more q u i c k l y and e c o n o m i c a l l y . As w e l l , i n a n a t u r a l i s t i c (non -exper imenta l ) s t u d y , a p r o s p e c t i v e des ign o f f e r s no r e a l advantage i n terms o f a b i l i t y to c o n t r o l f o r the e f f e c t o f extraneous v a r i a b l e s , as Reid and Smith [122] n o t e . A c r i t i c i s m of r e t r o s p e c t i v e s t u d i e s i s t h a t they r e q u i r e people to r e c a l l past e v e n t s , which may be an u n r e l i a b l e way o f i n f o r m a t i o n g a t h e r i n g ; t h i s was not i n f a c t the case i n t h i s study s i n c e the i n f o r m a t i o n was not gathered from personal i n t e r v i e w s but r a t h e r from records t h a t were w r i t t e n when the i n f o r m a t i o n was c u r r e n t . A p r o s p e c t i v e f i l e study would o f f e r some advantages i n tha t s t a n d a r d i z e d data c o l l e c t i o n forms cou ld be se t up ahead o f t ime w i t h the s p e c i f i c v a r i a b l e s o f i n t e r e s t no ted , and the r e s u l t s would i n a l l l i k e l i h o o d be more complete and r e l i a b l e . The general c r i t i c i s m t h a t r e t r o s p e c t i v e s t u d i e s r e q u i r e one to r e c o n s t r u c t the p a s t , whereas i n p r o s p e c t i v e s t u d i e s one i s present to observe the presumed e f f e c t o f the independent v a r i a b l e , i s somewhat academic i n non-exper imental s t u d i e s (such as t h i s one) where c o n d i t i o n s are u n c o n t r o l l e d and no m a n i p u l a t i o n o f the independent v a r i a b l e i s t a k i n g p l a c e . 5 5 . Another i ssue concerns how many measurements are taken i n < f o l l o w - u p s t u d i e s . Many s t u d i e s can be c r i t i c i z e d on t h i s bas i s i n t h a t they take b a s i c a l l y j u s t one measurement, t y p i c a l l y a t one year f o l l o w i n g h o s p i t a l d i s c h a r g e ; such a s t r a t e g y does not t e l l one about changes i n c l i e n t s t a t u s i n the i n t e r i m , nor indeed do such s t u d i e s o f t e n t e l l us about c l i e n t s t a t u s p r i o r to h o s p i t a l i z a t i o n . Bachrach [123] notes t h a t there i s c o n s i d e r a b l e i n c o n s i s t e n c y i n t i m i n g o f measure-ments i n f o l l o w - u p s t u d i e s (some are 6 months p o s t - d i s c h a r g e , some 5 y e a r s ) and argues t h a t i d e a l l y a standard number of measures should be t a k e n : one a t a p o i n t preceding the treatment i n t e r v e n t i o n , one a t the beginning o f the t reatment p e r i o d , one a t the end of the t reatment p e r i o d , and one a t some s p e c i f i e d f o l l o w - u p d a t e . . . In t h i s i n s t a n c e " t rea tment" r e f e r s main l y to a p s y c h i a t r i c h o s p i t a l i z a t i o n . In t h i s study there was no " t reatment" e f f e c t : s t a r t o f the f o l l o w - u p per iod d i d not n e c e s s a r i l y immediately f o l l o w h o s p i t a l d i s c h a r g e , and the community t reatment was a cons tant ( i . e . the community care teams) . The length o f the f o l l o w - u p per iod was 2 y e a r s , which i s comparable to some other s t u d i e s , but e x t r a p o l a t i o n n igh t be needed to compare r e s u l t s w i t h those from s t u d i e s w i t h s h o r t e r or longer f o l l o w - u p p e r i o d s . As noted i n the l i t e r a t u r e rev iew , S t rauss [124] i n d i c a t e s a f a i r amount o f s t a b i l i t y e x i s t s i n outcome over t i m e , and suggests t h a t a two year f o l l o w up r e s u l t w i l l c o r r e l a t e h i g h l y w i th t h a t o f a 5 year s t u d y . In t h i s study two main measures were t a k e n , one a t the s t a r t of the study per iod (Nov. T|981) and one a t the end (Nov. 1983) . Hence, v a r i a b l e s such as employment and - res idence had 2 values each , one f o r 1981 and one f o r 1983. In a d d i t i o n to these two measures, v a r i a b l e s were * 56, i nc luded to attempt to record what happened between 1981 and 1983; these were v a r i a b l e s such as r e h o s p i t a l i z a t i o n , . number o f changes i n employment s t a t u s , and address changes. The r a t i o n a l e i n t h i s i n s t a n c e was to attempt to have a l o n g i t u d i n a l d e s i g n , r a t h e r than s imply a c r o s s - s e c t i o n a l one. In a d d i t i o n to v a r i a b l e s t h a t r e f e r r e d to the study per iod (1981-1983) i n f o r m a t i o n was c o l l e c t e d on events tha t happened p r i o r to the study p e r i o d , such as employment h i s t o r y or h i s t o r y o f h o s p i t a l i z a t i o n . One i s s u e t h a t has been a l l u d e d to but t h a t r e q u i r e s more a t t e n t i o n i s the problem o f the " s t a r t i n g p o i n t . " As no ted , a s c h i z o -phrenia f o l l o w - u p study t y p i c a l l y takes as the s t a r t i n g p o i n t a h o s p i t a l d i s c h a r g e . In t h i s study the s t a r t i n g po in t was an a r b i t r a r y one , s imply a t ime l i n e a t November, 1981. This could be cons idered a f law i n the des ign i n tha t the s u j b e c t s d i d not have a common s t a r t i n g p o i n t , i . e . on November 1981 some may have j u s t r e c e n t l y had a p s y c h i a t r i c h o s p i t a l i -z a t i o n and some may have been s t a b l e i n the community f o r y e a r s . One cou ld r a t i o n a l i z e t h i s i n say ing t h a t t h i s was a f a i r l y homogeneous sample: s c h i z o p h r e n i c c l i e n t s o f community care teams who have a l l had a t l e a s t two p r i o r h o s p i t a l i z a t i o n s . However, the problem remains t h a t the v a r i a b l e length o f t ime s i n c e l a s t h o s p i t a l i z a t i o n - has been shown to have a s i g n i f i c a n t (negat ive ) c o r r e l a t i o n w i th the v a r i a b l e r e h o s p i t a l i z a t i o n [ 1 2 5 ] . To t r y and get around t h i s problem the v a r i a b l e ' l e n g t h o f t ime s i n c e l a s t h o s p i t a l i z a t i o n was inco rpora ted i n t o the s t u d y , and i t s e f f e c t was noted s u b s e q u e n t l y , - i n the data a n a l y s i s . 57 One a s s e t of t h i s study was t h a t a l l sub jec ts shared the exact same h i s t o r i c a l pe r iod as the study p e r i o d , i . e . : i t was not a case o f comparing people who were i n the community a t d i f f e r e n t t i m e s . In t h i s l a t t e r i ns tance h i s t o r i c a l per iod cou ld be a confounding v a r i a b l e t h a t would e f f e c t outcome v a r i a b l e s such as r e h o s p i t a l i z a t i o n and employment, s i n c e economic c o n d i t i o n s and h o s p i t a l p o l i c i e s change over t i m e . I. E t h i c a l Issues The e t h i c a l i s s u e s i n t h i s study were r e l a t i v e l y few, s i n c e the sub jec ts were not. a c t u a l l y being a f f e c t e d by an i n t e r v e n t i o n . The main concern was to p r o t e c t c l i e n t c o n f i d e n t i a l i t y . No names or i d e n t i f y i n g i n f o r m a t i o n were used i n the r e s u l t s ; dur ing the data c o l l e c -t i o n c l i e n t s were i d e n t i f i e d o n l y by number, and these numbers were not r e v e a l e d . Raw data was u l t i m a t e l y d e s t r o y e d . The study attempted to look a t t rends shown i n a r e l a t i v e l y l a r g e sample , not to focus on s p e c i f i c i n d i v i d u a l s . J . S t ra tegy o f Data A n a l y s i s The data a n a l y s i s proceeded through severa l d i s t i n g u i s h a b l e s t a g e s . F i r s t was a s imple t a b u l a t i o n and p r e s e n t a t i o n o f the v a r i a b l e l i s t d e s c r i b e d i n s e c t i o n E above. This was to r e p r e s e n t a d e s c r i p t i o n o f the p o p u l a t i o n i n terms o f the va r ious sociodemographic v a r i a b l e s . Secondly was an attempt to see i f there had been changes over time ( i . e . from Nov. 1981-Nov. 1983) i n v a r i a b l e s such as employment s t a t u s . 58. This was to be a measure o f the s t a b i l i t y of the p o p u l a t i o n . T h i r d l y , a number o f b i v a r i a t e a s s o c i a t i o n s were drawn up. The "dependent" v a r i a b l e s were p r i n c i p a l l y the outcome measures of r e h o s p i t a l i z a t i o n and employment, these two r e f e r r i n g to the per iod Nov. 1981-Nov. 1983. The " independent" v a r i a b l e s were va r ious o f the o ther sociodemographic v a r i a b l e s used to d e s c r i b e the p o p u l a t i o n . The purpose was to see i f c e r t a i n aspects o f the study popu la t ion (such as age , s e x , r e s i d e n t i a l s i t u a t i o n ) were a s s o c i a t e d w i th a more (or l e s s ) " s u c c e s s f u l " outcome. F i n a l l y , on the b a s i s o f d i f f e r e n c e s w i t h i n the p o p u l a t i o n , as detected by outcome measures and o ther v a r i a b l e s , to t r y and see i f d i s t i n c t i v e sub groups w i t h i n the p o p u l a t i o n cou ld be d e t e c t e d . The common theme i n these va r ious stages was the attempt to look f o r , and i f p o s s i b l e account f o r , v a r i a n c e w i t h i n the study p o p u l a t i o n . Reid and Smith [126] note t h a t a study can have more than one "knowledge b u i l d i n g f u n c t i o n , " i . e . data g a t h e r i n g and hypothes is t e s t i n g . In t h i s s t u d y , pa r t o f the study cou ld be d e s c r i b e d as s imple data g a t h e r i n g ; the b i v a r i a t e a s s o c i a t i o n s , however, i n v o l v e d hypothes is t e s t i n g o f a s o r t . This' l a t t e r p o i n t must be q u a l i f i e d i n tha t the study was non-exper imenta l and hence no r e a l c o n c l u s i o n s ( about cause and e f f e c t cou ld be reached . As w e l l , a number o f d i f f e r e n t hypotheses were looked a t ( r e f l e c t e d by the number o f b i v a r i a t e a s s o c i a t i o n s per -formed) r a t h e r than an i n v e s t i g a t i o n o f a s i n g l e h y p o t h e s i s . The a s s o c i a -t i o n s were not a r b i t r a r i l y or randomly chosen, however; each was guided by a s s o c i a i o n s t h a t had been suggested i n the research l i t e r a t u r e on s c h i z o p h r e n i a . The "comparison groups" t h e n , were o ther research f i n d i n g s , hence t h i s study cou ld be a l s o t i t l e d r e p l i c a t i v e / c o m p a r a t i v e i n n a t u r e . 5 9 . Chapter 4' RESULTS A. Sociodemographic C h a r a c t e r i s t i c s of the P o p u l a t i o n i ) Comment on Missing Data. Most o f the v a r i a b l e s used had some m i s s i n g c a s e s ; i n most i n s t a n c e s t h i s was o f the order o f 0 - 7 % . Where the number o f m i s s i n g cases was more s u b s t a n t i a l , t h i s i s noted below f o r the v a r i a b l e i n q u e s t i o n . For the sake o f the computer a n a l y s i s the m i s s i n g cases were not i n c l u d e d ; hence, i n a number of ins tances the 100% f i g u r e does not i n f a c t reach the t o t a l n o f 234. i i ) Sex. One hundred and t h i r t y - s i x o f the s u b j e c t were men (59%) and 96 were women (41%). There were found to be some s i g n i f i c a n t d i f f e r e n c e s i n the p o p u l a t i o n on the b a s i s o f s e x . These are summarized i n Tables 1 - 3 . The male s u b j e c t s tended to be younger , w i t h 33% o f the men under 30 years o f age v s . on l y 16% of the women (X = 9 . 1 9 , 2 d . f . , p = . 0 1 ) . The females had a b e t t e r employment record a t the end o f the f o l l o w up p e r i o d ; 58% were unemployed and 19% working c o m p e t i t i v e l y , w h i l e the 2 f i g u r e s f o r the men were 72% and 9% r e s p e c t i v e l y (X = 6 . 2 7 , 2 d . f . , p = . 0 4 ) . F i n a l l y , the females had a h igher marr iage and d i v o r c e r a t e ; 82% o f the men were s i n g l e , never m a r r i e d , and on ly 4% c u r r e n t l y m a r r i e d , 60. Table 1 C r o s s t a b u l a t i o n of Sex by Age Age 20 - 30 31 - 40 41 - 150 Row T o t a l s mal e 45 . (33.3°/) 52 (38.5%) 38 (28.1%) 135 (100%) O C A " female 15 (15.6%) 58 (50.0%) 33 (34.4%) 96 ; (100%) m i s s i n g cases = 3 X 2 = 9 . 1 8 9 6 , 2 degrees o f f reedom, p = .0101 Table 2 C r o s s t a b u l a t i o n of Sex by Employment Status (1983) Empl oyment Unemployed She! te red Work Compet i t i ve Work Row Tota l s Sex Male 92 (72.4%) 24 (18.9%) 11 (8.7%) 127 (100%) Female 52 (58.4%) 20 (22.5%) 17 (19.1%) 89 (100%) m i s s i n g cases = 18 X 2 = 6 . 2 6 9 , 2 degrees o f f reedom, p = .043 61. Table 3 C r o s s t a b u l a t i o n o f Sex by M a r i t a l S tatus (1983) M a r i t a l S tatus S i n g l e , Never Mar r ied Mar r ied Separated , Divorced Row Tota ls Male Sex Fema1e 108 (82.4%) 5 (3.8%) 18 (13.7%) 131 (100%) 51 (53.1% 18 (18.8%) 27 (28.1%) 96 (100%) M i s s i n g cases = 7 2 X = 2 4 . 7 7 , 2 degrees of f reedom, p = .000 62. w h i l e the f i g u r e s fo r the women were, r e s p e c t i v e l y , 53% and 19% a t the end o f the study p e r i o d . There were found to be no s i g n i f i c a n t sex d i f f e r e n c e s f o r age o f f i r s t p s y c h i a t r i c con tac t or f i r s t p s y c h i a t r i c h o s p i t a l i z a t i o n . i i i ) Age. The age range , by sample d e f i n i t i o n , was 2 0 - 5 0 . The mean age was 3 6 . 1 6 , s tandard d e v i a t i o n = 7 . 8 8 . There were found to be a number o f s i g n i f i c a n t d i f f e r e n c e s i n the p o p u l a t i o n on the b a s i s o f age . These are summarized i n Table 4 . The younger s u b j e c t s tended to be r e h o s p i t a l i z e d more o f t e n than the o l d e r ones. F o r t y - t h r e e per cent of those under 40 were r e h o s p i t a l i z e d i n the study p e r i o d , compared to 25% fo r the over 4 0 ' s . The younger sub jec ts had a l s o had more recent p r i o r h o s p i t a l i z a t i o n s ; 71%.of the under 3 0 ' s had had a h o s p i t a l i z a t i o n i n the preceding two y e a r s , compared to 51% of the 31-40 year o lds and o n l y 33% f o r the 41 -50 year o l d s . The i n -s t a b i l i t y o f the younger sub jec ts was i l l u s t r a t e d by the f i n d i n g tha t they had s i g n i f i c a n t l y more address changes, team changes, c l o s u r e s and reopenings a t the teams, and changes i n employment s t a t u s than the o l d e r s u b j e c t s . With regard to address changes, i t was found t h a t 65% o f the under 3 0 ' s moved a t l e a s t once i n the study p e r i o d , compared to 41% o f the 31-40 year o l d s and 24%;for the 41-50 year o l d s . The young s u b j e c t s were a l s o more f requent v i s i t o r s to the community care teams; 60% o f the under 3 0 ' s v i s i t e d the teams a t l e a s t tw ice per month, compared to 34% of the 41-50 year o l d s . There was, as noted e a r l i e r , a sex d i f f e r e n c e : the younger s u b j e c t s tended to be male . There was a d i f f e r e n c e on the bas i s of m a r i t a l s t a t u s : 90% of the under 3 0 ' s were s i n g l e (never marr ied ) compared to 63. Table 4 D i f f e r e n c e s i n the Sample on the Bas is o f Age A s s o c i a t i o n s t h a t Reached A s s o c i a t i o n s t h a t Approached S t a t i s t i c a l S i g n i f i c a n c e S i g n i f i c a n c e (p < .05) ( .1 > p > .05) Age o f F i r s t P s y c h i a t r i c Contact Pearson 's " r " = .4567 p = .000 Age of F i r s t H o s p i t a l i z a t i o n Pearson 's " r " = .4969 p = .000 R e h o s p i t a l i z a t i o n Pearson 's " r " = - . 1 8 0 3 p = .003 Time Since Las t H o s p i t a l i z a t i o n Pearson 's " r " = .3359 p = .000 Address Changes Pearson 's " r " = - . 2 1 2 4 p = .000 V i s i t s to- the Team Pearson 's " r " = - . 1 2 7 8 p = .037 Closures and Reopenings Pearson 's " r " = - . 1 4 8 9 p = .011 Team Changes Pearson 's " r " = - . 1 8 8 2 p = .002 S G X X 2 = 9 . 1 8 9 5 , 2 d . f . , p = .0101 M a r i t a l Status (1983) X = 1 7 . 7 7 , 4 d . f . , p = .0014 Admissions to Venture Pearsons 's " r " = - .1056 p =.054 Hours Per Month a t Team Pearson 's " r " = - . 0 9 9 p = .064 Changes i n Source o f Income Pearson 's " r " = - . 1 0 4 7 p = .0616 CONTINUED 6.4', Table 4 (Continued) A s s o c i a t i o n s t h a t Reached A s s o c i a t i o n s " t h a t Approached S t a t i s t i c a l S i g n i f i c a n c e S i g n i f i c a n c e (p > .05) (.1 > p > .05) Changes i n Employment Status Pearson 's " r " = - . 1 6 9 p = .0076 Durat ion o f P r i o r H o s p i t a l i z a t i o n Pearson 's " r " = .2835 p = .001 Number of P r i o r H o s p i t a l i z a t i o n s Pearson 's " r " = .1435 p = .027 .65 68% o f the 31-40 year o l d s and 58% fo r the 41 -50 year o l d s . Only 2% o f the under 3 0 ' s were c u r r e n t l y m a r r i e d , compared to 8% of the 31-40 year o l d s and 17% f o r the 41-50 year o l d s . I t was found t h a t the younger c l i e n t s had had fewer numbers and d u r a t i o n of past h o s p i t a l i z a t i o n . I t was a l s o found t h a t the younger c l i e n t s had had e a r l i e r ages o f f i r s t p s y c h i a t r i c con tac t and f i r s t p s y c h i a t r i c h o s p i t a l i z a t i o n . The mean age o f f i r s t p s y c h i a t r i c con tac t f o r those under 35 was 19.9 years (s tandard d e v i a t i o n = 4 . 8 3 ) , and 27 .9 years f o r those over 35 (standard d e v i a t i o n = 1 0 . 8 3 ) ; the mean age f o r f i r s t h o s p i t a l i z a t i o n was 21 .5 fo r those under 35 (standard d e v i a t i o n = 4 .13) and 27 .9 f o r those over 35 (s tandard d e v i a t i o n = 7 . 0 5 ) . The a s s o c i a t i o n o f age and f i r s t p s y c h i a t r i c h o s p i t a l i z a t i o n i s i l l u s t r a t e d i n Table 5 . I t can be seen tha t o f the sub jec ts over 3 5 , 57% had had t h e i r f i r s t p s y c h i a t r i c h o s p i t a l i z a t i o n a f t e r the age of 2 5 , and t h a t of those over 4 5 , 56% had had t h e i r f i r s t h o s p i t a l i z a t i o n a f t e r the age of 3 0 . There were some age d i f f e r e n c e s t h a t approached but d i d not reach s t a t i s t i c a l s i g n i f i c a n c e (see Table 4 ) . I t was found t h a t the younger c l i e n t s tended to be admit ted more f r e q u e n t l y to Venture than the o l d e r ones , t h a t the younger c l i e n t s r e q u i r e d more c l i n i c a l t ime a t the community care teams, and t h a t the younger c l i e n t s exper ienced more changes i n t h e i r source o f income over the two year f o l l o w - u p p e r i o d . •66i Sub jec t Age Table 5 C r o s s t a b u l a t i o n o f Subject Age by Age of F i r s t P s y c h i a t r i c H o s p i t a l i z a t i o n Age of First Psychiatric Hospitalization  U 2 Q e r 21-25 26-30 Over 30 20-25 26-30 31-35 36-40 41-45 46 -50 Row To ta l s , 1 5 (78.9%) 4 (21.1%) 0 0 19 (100%) 13 (36.1%) 15 (41.7%) 8 (22.2%) 0 36 (100%) 14 (26.4%) 23 (43.4%) 13 , (24.5%) 3 (5.7%) 53 (100%) 7 (19.4%) 10 (27.8%) 10 (27.8%) 9 (25.0%) 36 (100%) 7 (25.9%) 9 (33.3%) 5 (18.5%) 6 (22.2%) 27 (100%) 2 (5,6%) 8 (22.2%) 6 (16.7%) 20 (55.6%) 36 (100%) Column Tota ls 58 69 42 38 67 i v ) Previous Psychiatric History. The d i s t r i b u t i o n o f the sample by age of f i r s t p s y c h i a t r i c contac t i s shown i n Table 6. A s i g n i f i c a n t p r o p o r t i o n had t h e i r f i r s t con tac t i n l a t e t e e n s , and the m a j o r i t y (58%) had a p s y c h i a t r i c con tac t by age 2 5 ; the median v a l u e was 21.68 y e a r s . This v a r i a b l e had a l a r g e number o f m i s s i n g c a s e s : 78 (33%). The d i s t r i b u t i o n of the sample by age o f f i r s t p s y c h i a t r i c h o s p i t a l i z a t i o n i s shown i n Table 7. The m a j o r i t y had t h e i r f i r s t p s y c h i a t r i c h o s p i t a l i z a t i o n by age 25 (62%); the median va lue was 23.7 y e a r s . This v a r i a b l e had 26 m i s s i n g cases (11%). For d u r a t i o n o f p r i o r h o s p i t a l i z a t i o n , the f i n d i n g was tha t 63% o f the sample had a h o s p i t a l d u r a t i o n o f l e s s than s i x months. Only 17% o f the sample had a prev ious d u r a t i o n of g r e a t e r than two y e a r s . The median va lue was 7.12 months. This v a r i a b l e had 48% of the cases m i s s i n g . For prev ious number o f h o s p i t a l i z a t i o n s , t w o - t h i r d s (67%) o f the sample had f i v e or fewer past h o s p i t a l i z a t i o n s ; the median va lue was 4 . 2 6 . In t h i s category 23% o f the cases were m i s s i n g . For t ime s i n c e l a s t h o s p i t a l i z a t i o n , the median va lue was 24.33 months ( i . e . two y e a r s ) . The v a r i a b l e produced a c o n s i d e r a b l e range o f r e s u l t s , from a low of zero (were i n h o s p i t a l a t the s t a r t o f the f o l l o w up per iod) to a high of 265 months (have stayed out o f h o s p i t a l f o r 22 y e a r s ) . The d i s t r i b u t i o n f o r t h i s v a r i a b l e , shown i n Table 8 , was b i -modal and appeared to d e l i n e a t e two major groups: those who had been h o s p i t a l i z e d w i t h i n the l a s t year'. (31%) and those who had not been h o s p i t a l i z e d fo r over th ree years (33%). Table 6 D i s t r i b u t i o n o f Age o f F i r s t P s y c h i a t r i c Contact fo r Study Popu la t ion 49 (31 .4%) 15 (9.5%) 42 (26.9%) 24 (15.4%) 26 (16.7%) 0 Under 15 16-20 21-25 26-30 Over 30 Age a t F i r s t P s y c h i a t r i c Contact M i s s i n g cases = 78 Table 7 D i s t r i b u t i o n o f Age a t F i r s t P s y c h i a t r i c H o s p i t a l i z a t i o n fo r Study Popu la t ion 69 (33.2%) 59 (28.4%) 42 (20.2%) 38 (18.3%) Under 20 21-25 26-30 Over 30 Age a t F i r s t P s y c h i a t r i c H o s p i t a l i z a t i o n M i s s i n g cases = 36 70 Table 8 D i s t r i b u t i o n o f Time S ince Last P s y c h i a t r i c H o s p i t a l i z a t i o n f o r Study Popu la t ion 78 (35.5%) 69 (31 A%) >-Cr 42 (19.1%) 31 (14.1%) 0-12 months 13-24 months 25-36 months Over 36 months Time S ince Last H o s p i t a l i z a t i o n M i s s i n g cases = 14 71. v) Rehospitalization. T h i r t y - s e v e n per cent o f the sample was r e h o s p i t a l i z e d ( a t l e a s t once) d u r i n g the study p e r i o d . C o n t r o l l i n g f o r the v a r i a b l e time s i n c e l a s t h o s p i t a l i z a t i o n i t was found tha t o f those sub jec ts who had been i n h o s p i t a l i n the two years preceding the study p e r i o d , 50% were r e h o s p i t a l i zed i n the study p e r i o d . Regarding admiss ions to Ventu re , i t was found t h a t 18% of the sub jec ts were admitted to Venture i n the study p e r i o d ; t h i s f i g u r e was 20% f o r those who had been h o s p i t a l i z e d i n the two preceding y e a r s . v i ) Employment. Seventy - th ree per cent of the sample had not worked f o r s i x consecut i ve months a t a c o m p e t i t i v e job i n the f i v e years preceding the f o l l o w - u p p e r i o d . At the end o f the f o l l o w - u p per iod the m a j o r i t y (66%) o f the sample was unemployed; 21% were doing s h e l t e r e d work and 13% were doing c o m p e t i t i v e work. The v a r i a b l e change i n employment s t a t u s i n d i c a t e d t h a t the m a j o r i t y (81%) of the sample d i d not have a change i n employment s t a t u s ( f o r the b e t t e r or the worse) i n the f o l l o w - u p p e r i o d . This p a r t i c u l a r v a r i a b l e had 12% of cases m i s s i n g . With r e s p e c t to source o f income, a t the end o f the study per iod 87% o f the sample was "dependent" i n t h e i r source o f income ( i . e . r e c e i v i n g w e l f a r e , a handicapped p e n s i o n , U . I . C . , or a pa.rent/guardians income) w h i l e 13% o f the sample was independent ( r e l y i n g on employment o r sav ings and i n v e s t m e n t s ) . The m a j o r i t y o f s u b j e c t s d id not exper ience a change i n t h e i r p r i n c i p a l source of income d u r i n g the f o l l o w - u p p e r i o d ; 89% had the same source o f income f o r the two y e a r s . 7 2 . v i i ) Style of Cohabitation. At the end o f the study p e r i o d i t was found t h a t 36% o f the sample was l i v i n g a l o n e , 28% were i n a s h a r e d , n o n - f a m i l i a l s e t t i n g ( i . e . a boarding home), 17% were l i v i n g wi th parenta l f a m i l y , and 14% were l i v i n g w i th spouse or common-law p a r t n e r . With r e s p e c t to m a r i t a l s t a t u s , i t was found a t the end of the study per iod t h a t 70% of the sample was s i n g l e (never m a r r i e d ) , 20% were d i vo rced or s e p a r a t e d , and 10% were m a r r i e d . With r e s p e c t to r e s i d e n c e , i t was found a t the end o f the study pe r iod t h a t 60% of the sample was l i v i n g independent l y , w h i l e 40% were l i v i n g i n dependent, s h e l t e r e d accommodation. v i i i ) Client Mobility. Regarding the v a r i a b l e address changes, i t was found t h a t 42% o f the sample moved a t l e a s t once dur ing the f o l l o w -up p e r i o d , and 19% moved two o r more t i m e s . F i f t e e n per cent of the cases i n t h i s v a r i a b l e were m i s s i n g . The v a r i a b l e team changes i n d i c a t e d t h a t 16% of the sample switched to a d i f f e r e n t community care team dur ing the f o l l o w - u p p e r i o d . The v a r i a b l e c l o s u r e s and reopenings i n d i c a t e d tha t 17% o f the sample had one o r more c l o s u r e s and reopenings ( i . e . dropped out o f t reatment and then were r e a c t i v a t e d a t the same or d i f f e r e n t community care teams) w h i l e 83% of the sample stayed a c t i v e c l i e n t s o f the G .V .M.H .S . f o r the e n t i r e two year d u r a t i o n . i x ) Client use of Services. The v a r i a b l e hours per month a t team i n d i c a t e d that about h a l f (53%) o f the sample spent l e s s than < 73. three hours per month a t the community care team, 27% spent 3 - 5 hours , and 20% spent over 5 hours per month. The v a r i a b l e v i s i t s to the team i n d i c a t e d t h a t 47% of the sample averaged a t l e a s t two v i s i t s per month to the community care team over the two year f o l l o w - u p p e r i o d . F i f t y - t h r e e per cent averaged l e s s than two v i s i t s per month, and 14% of the sample averaged l e s s than one v i s i t every two months. S i x t e e n per cent o f the cases were m i s s i n g f o r t h i s v a r i a b l e . x) Client Mortality. There was on ly one m o r t a l i t y - a s u i c i d e -dur ing the f o l l o w - u p p e r i o d . Regarding the v a r i a b l e s u i c i d e a t t e m p t s , i t was f e l t , d u r i n g the data c o l l e c t i o n p r o c e s s , t h a t i t was too d i f f i c u l t to r e l i a b l y a s c e r t a i n t h i s v a r i a b l e from f i l e i n f o r m a t i o n ; consequent l y , the v a r i a b l e was not used. x i ) Criminal Activities. F i ve per cent o f the sample were charged w i t h c r i m i n a l o f fenses dur ing the f o l l o w - u p p e r i o d . x i i ) Schooling. For ty - two per cent o f the sample had a grade 12 e d u c a t i o n , 71% had a grade 10 e d u c a t i o n , and on ly 9% had not had some high School Fourteen s u b j e c t s ( s i x % o f the sample) had completed u n i v e r s i t y degrees . Eleven per cent o f the cases were m i s s i n g w i t h t h i s v a r i a b l e . 74.. B. S t a b i l i t y Measures o f the P o p u l a t i o n F ive o f the v a r i a b l e s c o l l e c t e d were a c t u a l l y measured a t two po in ts i n t i m e , the beg inn ing of the f o l l o w - u p per iod (1981) and the end o f the f o l l o w - u p pe r iod (1983) . These v a r i a b l e s were r e s i d e n t i a l s i t u a -t i o n , l i v i n g s i t u a t i o n , employment s t a t u s , source o f income and m a r i t a l s t a t u s . The f i g u r e s f o r these v a r i a b l e s r e p o r t e d . i n the l a s t s e c t i o n were the 1983 measures; i n t h i s s e c t i o n the 1981 and 1983 measures are c o n t r a s t e d , as shown i n Table 9 . The r e s u l t s can be summarized as f o l l o w s : w i t h regard to r e s i d e n t i a l s i t u a t i o n , there was a s l i g h t net s h i f t o f the sample toward dependent housing from independent , i . e . more were r e l y i n g on supported types o f d w e l l i n g s a t the end of the f o l l o w - u p than a t the b e g i n n i n g . There was r e l a t i v e l y l i t t l e change in l i v i n g s i t u a t i o n . The most s i g n i -f i c a n t change came i n employment s t a t u s and source o f income. There was a net i n c r e a s e o f 10% i n the unemployed p o r t i o n o f the sample over two y e a r s ; most o f t h i s change seemed to be a t the expense o f compet i -t i v e ( v s . s h e l t e r e d ) work, where there was a drop o f about 9% over two y e a r s . S i m i l a r l y , w i t h regard to source of income, the p r o p o r t i o n o f the sample c l a s s i f i e d as "dependent" had inc reased by 10% over the per iod o f two y e a r s . As f o r m a r i t a l s t a t u s , there was l i t t l e change from 1981 to 1983. C. D i f f e r e n c e s w i t h i n the P o p u l a t i o n Based on Sch izophren ia  Outcome Measures An attempt was made to d i s t i n g u i s h the study p o p u l a t i o n on the b a s i s of s c h i z o p h r e n i a outcome measures, i . e . to t r y and i d e n t i f y 75. Table 9 Change i n C l i e n t Status Over a Two Year Per iod November, 1981 November, 1983 R e s i d e n t i a l Independent Housing: 6 5 . 2% Independent Housing : 60.0% S i t u a t i o n ^ Dependent Housing: 34. 8% Dependent Hous ing : 40 .0% Alone 3 7 . 9% Alone 38 .0% L i v i n g „ With Famil,y as Dependent 20. 1% i With Family as Dependent 17 .6% S i t u a t i o n With Spouse/Partner - 1 2 . 1% With Spouse/Partner - 14 .6% Shared 2 9 . 9% Shared 29 .8% Unemployed 56. 1% Unemployed 66 .5% Employment S t a t u s 3 She! te red Work 2 2 . 4% S h e l t e r e d Work 20 .6% Compet i t i ve Work 2 1 . 5% Compet i t i ve Work 12 .8% Source of Dependent 77 . 0% Dependent 87 .3% Income^ Independent 2 3 . 0% Independent 12 .7% S i n g l e , never Mar r ied 70 . 7% S i n g l e , never Marr ied 69 .9% Mari t a l S t a t u s 5 Marr ied 9 . 2% Marr ied 10 .0% Separated/ Divorced 2 0 . 1% Separated/ Divorced 20 .1% n = n = n = n = 223 (1981) , 221 (1983), 214 (1981) , 216 (1983), 225 (1981) , 220 (1983), 224 (1981) , 222 (1983), 229 (1981) , 229 (1983), 7.6. fea tu res o f the p o p u l a t i o n tha t were a s s o c i a t e d wi th b e t t e r (or worse) community ad justment . The three v a r i a b l e s used to measure community adjustment i n the present study were r e h o s p i t a l i z a t i o n , Venture admiss ions and employment; i t was assumed t h a t lower h o s p i t a l and Venture admiss ion r a t e s and h igher r a t e s o f employment i n d i c a t e d more s u c c e s s f u l community ad justment . The h o s p i t a l i z a t i o n and Venture v a r i a b l e s r e f e r r e d to admissions made d u r i n g the f o l l o w - u p p e r i o d . The employment v a r i a b l e r e f e r r e d to employment s t a t u s a t the end o f the f o l l o w - u p p e r i o d . In the a n a l y s i s a s s o c i a t i o n s were made between the th ree outcome v a r i a b l e s and a number o f independent v a r i a b l e s , us ing Pearson's r (where two i n t e r v a l -2 l e v e l v a r i a b l e s were invo l ved ) and X (where a n o m i n a l - l e v e l v a r i a b l e 2 was i n v o l v e d ) . For the purposes o f the X t e s t s , r e h o s p i t a l i z a t i o n was c a t e g o r i z e d a s : A) none, B) one , C) two or more. Venture admiss ions was c a t e g o r i z e d a s : A) none, B) one or more. V i s i t s to the team was c a t e g o r i z e d a s : A) two o r more v i s i t s per month, B) between two v i s i t s per month and one every two months, C) fewer than one v i s i t every two months. The r e s u l t s o f the d i f f e r e n t a s s o c i a t i o n s are summarized i n Table 10 . R e h o s p i t a l i z a t i o n was found to be a s s o c i a t e d w i th age , employment s t a t u s (a t the end o f the f o l l o w - u p p e r i o d ) , t ime s i n c e l a s t h o s p i t a l i z a t i o n , v i s i t s to the team, address changes, team changes, c l o s u r e s and reopen ings , Venture admiss ions and prev ious number of h o s p i t a l i z a t i o n s . In g e n e r a l , those r e h o s p i t a l i z e d tended to be younger , more r e c e n t l y l a s t i n h o s p i t a l , more f requent v i s i t o r s to the team, more f r e q u e n t l y admit ted to Ventu re , having a g rea te r number o f p r i o r h o s p i t a l i z a t i o n s , and having more address changes, team changes and Table 10 Summary o f S i g n i f i c a n t B i v a r i a t e A s s o c i a t i o n s Dependent V a r i a b l e s R e h o s p i t a l i z a t i o n Venture Admissions Employment Status 1983 (SO Age (Pearson ' s " r " = - . 1 8 p = .003) Employment 1983 X 2 - 1 2 . 2 6 , 4 d . f . , p = .015 Sex 9 {r = 6 . 2 7 , 2 d . f . , p = .043) Residence 1981 (X^ = 2 9 . 1 3 , 2 d . f . , p = .000) iables V Q. <D Time S ince Last H o s p i t a l i z a t i o n ( P e a r s o n ' s " r " = - . 2 6 7 p = .000) Residence 1983 (X 2 = 2 5 . 1 6 , 2 d . f . , p = .000) dent Var nificanc V i s i t s to the Team ( P e a r s o n ' s " r " = .271 p = .000) V i s i t s to the Team (Pearson 's " r " = p = .000) .235) L i v i n g S t i u a t i o n 1981 (X2 = 1 5 . 1 4 , 6 d . f . , P = .019) Indepen ched Sig Address Changes ( P e a r s o n ' s " r " = .286 p = .000) Address Changes (Pearson 's " r " = p = .015) .155 Employment H i s t o r y (X2 = 6 8 . 6 9 , 2 d . f . , p = .000) Rea - C l o s u r e s and Reopenings ( P e a r s o n ' s " r " = .349 p = .000) - Team Changes ( P e a r s o n ' s " r " = .313) p = .000) - V e n t u r e Admiss ions ( P e a r s o n ' s " r " = .358 p = .000) Team Changes (Pearson 's " r " = p = .016) R e h o s p i t a l i z a t i o n (Pearson 's " r " = p = .000) .141 .358 CONTINUED Table 10 (Continued) Dependent V a r i a b l e s R e h o s p i t a l i z a t i o n Venture Admissions Employment S ta tus 1983 V - Q <T5 a> T3 C <u Q . -o LT> O -a 01 <_> to o s_ D. O. Prev ious Number of H o s p i t a l i z a t i o n s (Pearson 's " r " = .1154 p = .061) L i v i n g S i t u a t i o n 1981 (X 2 = 7 . 3 9 , 3 d . f . , p = .06) Age (Pearson's " r " = - . 1 0 6 p = .054 Closures and Reopenings (Pearson 's " r " = .105 p = .056 Durat ion o f H o s p i t a l i z a t i o n Pearson's " r " = .1497 p = .051 Time Since Last Hosp i ta l i z a t i o n Pearson 's "r 1 p = .088) .0916 L i v i n g S i t u a t i o n 1983 X 2 = 1 1 . 5 9 , 6 d . f . , P = .07) V i s i t s to the Team X 2 = 9 . 2 9 , 4 d . f . , p = .054 ~3 CO 79. c l o s u r e s and reopenings i n the f o l l o w - u p p e r i o d . The a s s o c i a t i o n between r e h o s p i t a l i z a t i o n and employment i s shown i n Table 1 1 . From t h i s i t can be seen t h a t those r e h o s p i t a l i z e d dur ing the f o l l o w - u p pe r iod had h igher r a t e s o f unemployment a t the end o f the f o l l o w - u p p e r i o d . I t was found that the 20-30 year o lds had a 43% r e h o s p i t a l i z a t i o n - r a t e , w h i l e the f i g u r e was 42% f o r the 31-40 year o l d s , and 25% f o r the over 4 0 ' s . With regard to t ime s i n c e l a s t h o s p i t a l i z a t i o n , o f those who had a A h o s p i t a l d i scharge w i t h i n the prev ious y e a r , 57% re turned to h o s p i t a l i n the f o l l o w - u p p e r i o d ; by c o n t r a s t , the f i g u r e was 19% f o r those who had not been i n h o s p i t a l f o r th ree years or more. With r e s p e c t to v i s i t s to the team, those who v i s i t e d the team twice a month or more were r e h o s p i t a l i z e d a t a r a t e o f 43%, compared to a r a t e o f 27% f o r those who averaged l e s s than two v i s i t s a month to the team. Venture admiss ions were a s s o c i a t e d w i th v i s i t s to the team, address changes, team changes, r e h o s p i t a l i z a t i o n , l i v i n g s i t u a t i o n (1981) , age , c l o s u r e s and reopen ings , d u r a t i o n o f p r i o r h o s p i t a l i z a t i o n , and t ime s i n c e l a s t h o s p i t a l i z a t i o n . In g e n e r a l , those admitted to Venture tended to be younger , more f requent v i s i t o r s to the teams, more o f t e n r e h o s p i t a l i z e d , more r e c e n t l y l a s t i n h o s p i t a l , w i t h a g rea te r d u r a t i o n o f past h o s p i t a l i z a t i o n s , and having more address changes, team changes and c l o s u r e s and reopen ings . The a s s o c i a t i o n between Venture and l i v i n g s i t u a t i o n i s shown i n Table 12. The four d i f f e r e n t l i v i n g s i t u a t i o n s produced d i f f e r e n t r,ates of Venture a d m i s s i o n s ; those l i v i n g w i th parenta l f a m i l y were admit ted at a r a t e o f 7%, whereas those l i v i n g w i t h spouse or common-law par tner were admitted a t a r a t e o f 27%. With r e s p e c t to age , i t was noted t h a t those under 40 were admit ted a t a r a t e of 21%, 80. Table 11 C r o s s t a b u l a t i o n o f R e h o s p i t a l i z a t i o n and  Employment Status (1983) Employment Status zation Unemployed S h e l t e r e d Work Compet i t i ve Work Row To ta l s ro Q. None 82 • (59.4%) 37 (26.8%) 19 (13.8%) 138 (100%) Rehos Once 34 (72.3%) 7 (14.9%) 6 (12.8%) 47 (100%) Twice or More 29 (87.9%) 1 ( 3.0%) 3 ( 9.1%) 33 (100%) M i s s i n g cases = 16 2 X = 1 2 . 2 5 8 , 4 degrees of f reedom, p = .015 81. Table 12 C r o s s t a b u l a t i o n o f Venture Admissions and L i v i n g  S i t u a t i o n (1981) L i v i n g S i t u a t i o n Alone With Parenta l Family With Spouse (or Common-Law) Shared , N o n - f a m i l i a l None 68 (85.0%) 39 (92.9%) 19 (73.1%) 48 (75.0%) Once or More 12 (15.0%) 3 ( 7.1%) 7 (26.9%) 16 (25.0%) Column Tota ls 80 (100%) 42 (100%) 26 (100%) 64 (100%) M i s s i n g cases = 22 2 X = 7 . 3 9 2 , 3 degrees o f f reedom, p = .06 82. compared to a r a t e o f 10% f o r those over 4 0 . With respec t to v i s i t s to the team, i t was noted t h a t those who averaged two or more team v i s i t s a month were admitted a t a r a t e o f 22%, v s . a r a t e o f 13% f o r those who averaged l e s s than two v i s i t s a month. F i n a l l y , w i t h r e s p e c t to d u r a t i o n o f p r i o r h o s p i t a l i z a t i o n , i t was noted tha t those w i t h l e s s than one y e a r ' s d u r a t i o n of h o s p i t a l s tay were admitted a t a r a t e o f 16%, compared to 21% f o r those w i t h 1 -2 years h o s p i t a l s t a y , and 27% fo r those w i t h over two years o f p r i o r h o s p i t a l i z a t i o n . The t h i r d outcome measure used was employment s t a t u s a t the end o f the f o l l o w - u p per iod (1983) . Employment s t a t u s 1983 was a s s o c i a t e d w i t h the sex o f the s u b j e c t , the r e s i d e n t i a l s i t u a t i o n , the l i v i n g s i t u a t i o n , the employment h i s t o r y , and the v a r i a b l e f requency o f v i s i t s to the team. ( I t should be noted t h a t the independent v a r i a b l e s t h a t reached a s i g n i f i c a n t a s s o c i a t i o n w i th employment 1983 a l s o reached a s i g n i f i c a n t a s s o c i a t i o n w i t h employment 1981.) In summary, i t was found t h a t the female sub jec ts had h igher r a t e s o f employment than the males a t the end o f the f o l l o w - u p p e r i o d ; t h i s a s s o c i a t i o n was repor ted e a r l i e r , i n Table 2 . With r e s p e c t to r e s i d e n c e , i t can be seen , as shown i n Table 1 3 , t h a t the unemployment r a t e f o r those i n s h e l t e r e d housing was s i m i l a r to t h a t o f those i n independent h o u s i n g , 63% v s . 68%. However, those i n independent housing worked c o m p e t i t i v e l y a t a r a t e of 20%, compared to 2% f o r those i n she!tered/dependent hous ing , w h i l e those i n s h e l t e r e d housing had s h e l t e r e d employment a t a r a t e o f 35%, compared to 12% f o r those i n independent hous ing . With r e s p e c t to employ-ment h i s t o r y , i t can be seen from Table 14 t h a t those w i t h a s u p e r i o r employment record had c o n s i d e r a b l y lower unemployment r a t e s (44% v s . 74%) 83 Table 13 C r o s s t a b u l a t i o n o f Employment Status (1983) by Residence (1983) Employment Unemployed S h e l t e r e d Work Compet i t i ve Work Row Tota ls Independent Housing 85 (68%) 15 (12%) 25 (20%) 125 (100%) Dependent/ She l te red Housing 54 (62.8%) 30 (34.9%) 2 (2.3%) 86 (100%) M i s s i n g cases = 23 X 2 = 2 5 . 1 5 7 , 2 degrees o f freedom, p = .000 Table 14 C r o s s t a b u l a t i o n o f Employment Status (1983) by Employment H i s t o r y Employment Unemployed S h e l t e r e d Work Compet i t i ve Work Row Tota ls 6 months c o m p e t i t i v e work i n prev ious 5 years 24 (44.4%) 6 (11.1%) 24 (44.4%) 54 (100%) Has l e s s than 6 months com-p e t i t i v e work i n p re -v ious 5 115 (74.2%) 38 (24.5%) 2 (1.3%) 155 (100%) years M i s s i n g cases = 25 2 X = 6 8 . 5 9 8 , 2 degrees o f f reedom, p = .000 8 4 . and h igher r a t e s o f c o m p e t i t i v e employment (44% vs . 1%). With r e s p e c t to l i v i n g s i t a u t i o n , i t can be seen from Table 15 tha t the unemployment r a t e s f o r the four c a t e g o r i e s were f a i r l y s i m i l a r , whereas those i n s h a r e d , n o n - f a m i l i a l res idences had the h ighest r a t e of s h e l t e r e d employment (40%) and those l i v i n g w i t h spouse/common law par tner had the h ighes t r a t e of c o m p e t i t i v e work (21%). F i n a l l y , w i th regard to v i s i t s to the team, i t was found that those who v i s i t e d the team more o f t e n had higher 2 r a t e s of unemployment and lower r a t e s o f c o m p e t i t i v e employment (X = 9 . 2 9 , 4 degrees o f f reedom, p = . 0 5 4 ) . The a s s o c i a t i o n s w i th l i v i n g s i t u a t i o n 1981 and res idence 1981 were not i l l u s t r a t e d w i th t a b l e s ; i t can be noted tha t the a s s o c i a t i o n s wi th these v a r i a b l e s was o f a s i m i l a r s t r e n g t h and d i r e c t i o n as noted w i th l i v i n g s i t u a t i o n 1983 and res idence 1983. Because a number o f the dependent and independent v a r i a b l e s were i n t e r c o r r e l a t e d , an attempt was made to determine the p a r t i c u l a r e f f e c t o f each independent v a r i a b l e alone by us ing a stepwise m u l t i p l e r e g r e s s i o n f o r each o f the three outcome v a r i a b l e s . Some e x p l a n a t i o n o f the a n a l y s i s i s needed: i n t h i s i ns tance the independent v a r i a b l e s used were those having i n t e r v a l - l e v e l d a t a ; as w e l l , a n . index was c r e a t e d f o r the n o m i n a l - l e v e l v a r i a b l e s of employment, work h i s t o r y , and r e s i d e n c e , p u t t i n g them i n an o r d i n a l form and t r e a t i n g them as i n t e r v a l l e v e l d a t a . S p e c i f i c a l l y , employment was ordered a s : 1 = unemployed, 2 = s h e l t e r e d work and 3 = c o m p e t i t i v e work; employment h i s t o r y was ordered a s : 1 = b e t t e r work h i s t o r y , 2 = poorer work h i s t o r y ; f i n a l l y , res idence was ordered as 1 • = independent h o u s i n g , - 2 = dependent hous ing . > Table 15 C r o s s t a b u l a t i o n o f Employment Status (1983) by  L i v i n g S i t u a t i o n (1983) Employment Unemployed S h e l t e r e d Work Compet i t i ve Work Row T o t a l s Alone 51 (67.1%) 17 (22.4%) 8 (10.5%) 76 (100%) With Parenta l Family 23 (65.7%) 5 (14.3%) 7 (20.0%) 35 (100%) With Spouse, Common law Par tner 19 (67.9%) 3 (10.7%) 6 (21.4%) 28 (100%) In Shared, Non-F a m i l i a i Residence 35 (59.3%) 20 (33.9%) 4 (6.8%) 59 (100%) M i s s i n g cases = 36 X 2 = 1 1 . 5 8 8 , 6 degrees o f f reedom, p = .07 86.. •: The r e s u l t s of the r e g r e s s i o n are shown i n Table 1 6 ; the independent v a r i a b l e s are rank ordered i n each column, w i th the r e s p e c t i v e beta v a l u e s , and the f i r s t ranked v a r i a b l e i n d i c a t e s the one t h a t accounted f o r the g r e a t e s t amount of v a r i a n c e i n the outcome v a r i a b l e s . From Table 16 i t can be seen t h a t the v a r i a b l e most s t r o n g l y a s s o c i a t e d w i th r e h o s p i t a l i z a t i o n was c l o s u r e s and reopen ings , t h a t i s , people who were r e h o s p i t a l i z e d to a g reate r ex tent exper ienced more c l o s u r e s and r e a c t i -v a t i o n s a t the community care teams. The v a r i a b l e r e f e r r i n g to past events (before the f o l l o w - u p per iod) t h a t accounted f o r the g r e a t e s t amount o f v a r i a n c e i n r e h o s p i t a l i z a t i o n was t ime s i n c e l a s t h o s p i t a l i z a t i o n , t h a t i s , people who were r e h o s p i t a l i z e d more tended to have had a more recent l a s t h o s p i t a l i z a t i o n . The v a r i a b l e t h a t accounted f o r the most v a r i a n c e i n Venture admiss ions was frequency o f v i s i t s to the team, t h a t i s , those people more f r e q u e n t l y admitted to Venture were a l s o more f requent v i s i t o r s to the community care teams. The v a r i a b l e r e f e r r i n g to past events most s t r o n g l y a s s o c i a t e d w i t h Venture admiss ion was d u r a t i o n o f p r i o r h o s p i t a l i z a t o n , t h a t i s , those w i th a l e n g t h i e r i n s t i t u -t i o n a l h i s t o r y tended to be admit ted more f r e q u e n t l y to Venture i n the f o l l o w - u p p e r i o d . F i n a l l y , w i th respec t to employment s t a t u s a t the end o f the f o l l o w - u p p e r i o d , the v a r i a b l e t h a t accounted f o r the g r e a t e s t amount o f v a r i a n c e was employment h i s t o r y , t h a t i s , a b e t t e r work record p r i o r to the f o l l o w - u p per iod was a s s o c i a t e d w i th a b e t t e r employment outcome. Tabl'e 16 M u l t i p l e Regress ion o f I n t e r v a l - L e v e l Independent V a r i a b l e s w i t h Outcome V a r i a b l e s Independent V a r i a b l e s M u l t i p l e R R Square Beta 1) C losures and Reopenings .4243 .1801 .35091 2) Venture Admissions .5016 .25101 .27657 3) Team Changes .3511 .1233 - . 1 2 0 8 9 4) Time s i n c e l a s t h o s p i t a l i z a t i o n .1995 .0398 - . 1 1 0 9 9 5) V i s i t s to the Team .25816 .06665 .11104 6) Address Changes .33297 .11087 ,10362 7) Age .11833 .01400 .07814 8) Employment 1983 .08537 .0072 .05237 9) Prev ious number of h o s p i t a l i z a t i o n s .08488 .0072 .01641 1) V i s i t s to the team .2296 .0527 .13525 2) Durat ion o f p r i o r h o s p i t a l i z a t i o n .1598 .0255 .11398 3) R e h o s p i t a l i z a t i o n .2439 .0595 .09395 4) Team Changes .1669 .0279 - . 0 7 8 3 5 5) C losures and Reopenings .1103 .0122 .07497 cont inued Table 16 (cont inued) c o cu c s- o +-> CO C CO T3 E 3 CO >->4-> CO O ro OI i — 4-> ^ Q.CO Independent V a r i a b l e s M u l t i p l e R R Square Beta 6. Time s i n c e l a s t h o s p i t a l i z a t i o n .0991 .0098 - .06931 7) Address Changes .17581 .0309 .02377 8) Age .1106 .0122 - . 0 2 2 3 9 1) Employment H i s t o r y .4054 .1643 - . 3 9 2 9 3 2) V i s t i s to the Team .1201 .0144 - . 0 6 9 5 8 3) Residence 1981 .1571 .0247 .04413 4) Residence 1983 .1564 .0244 - . 0 2 4 0 5 89 Chapter 5 DISCUSSION A. Methodolog ica l Issues i ) Reliability of Information and Missing Data. S tud ies t h a t r e l y on i n f o r m a t i o n from records or f i l e s may have problems w i t h the r e l i a b i l i t y o f t h i s i n f o r m a t i o n , and some of these s o r t s o f problems were exper ienced i n the present s t u d y . In p a r t i c u l a r , those v a r i a b l e s t h a t r e f e r r e d to c u r r e n t l i v i n g c o n d i t i o n s ( e . g . employment, form of c o h a b i t a t i o n e t c . ) had r e l i a b i l i t y problems because they o f t e n r e l i e d on r e p o r t s t h a t came second hand from the c l i e n t . As w e l l , there was v a r i a b i l i t y f r o m w i t e r to w r i t e r in the comprehensiveness o f progress n o t e s . I t was a l s o noted that i n some cases not a l l p e r t i n e n t records (such as h o s p i t a l records ) were inc luded i n the f i l e s ; the r e s u l t o f t h i s was t h a t i n f o r m a t i o n r e f e r r i n g to the c l i e n t ' s e a r l y h i s t o r y (such as age of f i r s t p s y c h i a t r i c contac t ) was o f t e n not a v a i l a b l e . The amount o f m i s s i n g data f o r a p a r t i c u l a r v a r i a b l e gave some i n d i c a t i o n of the r e l i a b i l i t y o f t h a t p a r t i c u l a r v a r i a b l e ; fo r i n s t a n c e , age of f i r s t h o s p i t a l i z a t i o n was u s u a l l y e a s i e r to de te rmine , and had fewer m i s s i n g c a s e s , than age o f f i r s t p s y c h i a t r i c c o n t a c t , hence i t was f e l t tha t age of f i r s t h o s p i t a l i z a t i o n was a more r e l i a b l e (though not n e c e s s a r i l y more v a l i d ) i n d i c a t o r of i l l n e s s onset 90 than age o f f i r s t p s y c h i a t r i c c o n t a c t . The v a r i a b l e s u i c i d e attempts was too d i f f i c u l t to r e l i a b l y a s c e r t a i n from the f i l e s , and had to be d i s c a r d e d , as noted e a r l i e r ; t h i s was probably a case of choos ing a v a r i a b l e t h a t was not "hard" enough, or ab le to be o b j e c t i v e l y d e f i n e d . I t was assumed f o r the data a n a l y s i s t h a t the m i s s i n g cases were not s y s t e m a t i c a l l y d i f f e r e n t from the a v a i l a b l e c a s e s . However, i t was found to be more d i f f i c u l t to keep tabs on the s u b j e c t s who had h igher f r equenc ies o f the v a r i a b l e i n q u e s t i o n . Consequent ly , f o r some v a r i a b l e s - such as d u r a t i o n o f p r i o r h o s p i t a l i z a t i o n , prev ious number o f h o s p i t a l i z a t i o n s , and address changes - the m i s s i n g cases may have represented s u b j e c t s w i t h h igher v a r i a b l e f r e q u e n c i e s , and hence the a v a i l a b l e cases may have underest imated the t rue va lue o f the v a r i a b l e . There were some recommendations: f i r s t o f a l l , t h a t f o r f u t u r e f i l e researchers an adequate p r e - t e s t be done to i n s u r e t h a t the v a r i a b l e s o f i n t e r e s t can be r e l i a b l y d i sce rned from the f i l e s . Second ly , t h a t more complete h o s p i t a l records be i n c l u d e d i n the f i l e s . T h i r d l y , t h a t the i n f o r m a t i o n be more s y s t e m a t i c a l l y recorded by the t h e r a p i s t ; s t a n d a r d i z e d forms cou ld be used to guide the w r i t t e n passages ( i f not fo r every progress note a t l e a s t f o r the rev iews) to i n s u r e t h a t a l l b a s i c p ieces o f i n f o r m a t i o n (such as employment s t a t u s ) were i n c l u d e d . i i ) Nature of the Sample. The d i a g n o s i s o f s c h i z o p h r e n i a was not independent ly conf i rmed i n the present s t u d y , and i t i s proposed t h a t such a c o n f i r m a t i o n ( i f p o s s i b l e ) be attempted i n f u t u r e s t u d i e s . In the present study the sample possessed severa l d i f f e r e n t c h a r a c t e r i s t i c s t h a t may have made i t n o n - r e p r e s e n t a t i v e o f o ther groups 91 of s c h i z o p h r e n i c s . In p a r t i c u l a r , the sub jec ts were a l l v o l u n t a r y c l i e n t s o f a community care s e r v i c e , and a l s o were r e s i d e n t s o f an area t h a t , i n the e s t i m a t i o n of many, had r e l a t i v e l y good community mental h e a l t h programs, by North American s t a n d a r d s . (A Canadian Mental Heal th A s s o c i a t i o n survey concluded t h a t "the a f t e r c a r e s e r v i c e s prov ided i n Vancouver are p a r t i c u l a r l y noteworthy" [127] . ) This r e l a t e s to a p o i n t made i n the study by B e i s e r [128] c i t e d e a r l i e r , namely t h a t p a t i e n t c h r o n i c i t y (as measured by r e h o s p i t a l i z a t i o n r a t e ) may be a f u n c t i o n o f the h e a l t h care sys tem, r a t h e r than s imp ly an i n h e r e n t c h a r a c t e r i s t i c o f the i n d i v i d u a l . In the present study i t would have been i n t e r e s t i n g to f o l l o w the c l i e n t s who dropped out o f t rea tment , or re fused t reatment from the community mental h e a l t h , s e r v i c e ; such i n d i v i d u a l s , however, would be harder to t r a c k down, o r re fuse to become i n v o l v e d , hence the " i n - t r e a t m e n t " group has the advantage o f being e a s i e r to m o n i t o r . i i i ) Timing of Measiwement. I t was noted i n t h i s study t h a t there were some problems a s s o c i a t e d w i th the t i m i n g o f measurement. To begin w i t h , the f o l l o w - u p per iod was two years i n d u r a t i o n ; t h i s must be kept i n mind when comparisons are made w i th s t u d i e s having f o l l o w - u p per iods o f d i f f e r i n g l e n g t h . I t was a l s o a recognized l i m i t a -t i o n tha t the s u b j e c t s i n t h i s study d i d not have a common s t a r t i n g p o i n t , i . e . the f o l l o w - u p per iod d i d not n e c e s s a r i l y f o l l o w a h o s p i t a l d i s c h a r g e . One can j u s t i f y t h i s i n say ing tha t one i s d e a l i n g w i t h a r e l a t i v e l y homogeneous group, or by us ing the f i n d i n g tha t there i s apparent l y no " c r i t i c a l p e r i o d " f o l l o w i n g h o s p i t a l d i scharge [ 1 2 9 ] , or by us ing t h a t f i n d i n g tha t s c h i z o p h r e n i a outcome seems to show s t a b i l i t y over time and t h a t a f i v e year f o l l o w - u p i s very s i m i l a r to a two year 92. f o l l o w - u p , hence the t ime s i n c e l a s t h o s p i t a l i z a t i o n i s a p p a r e n t l y not c r u c i a l [130] . Nevertheless there i s the f i n d i n g i n the l i t e r a t u r e t h a t t ime out of h o s p i t a l . i s a s s o c i a t e d w i th r e t u r n r a t e [131] and the v a r i a b l e t ime s i n c e l a s t h o s p i t a l i z a t i o n was seen to have some e f f e c t i n t h i s study when c o n t r o l l e d fo r (a l though the e f f e c t was not the unique e f f e c t o f the s i n g l e v a r i a b l e i n i s o l a t i o n ) . I t i s t h e r e f o r e recommended tha t f u t u r e researchers i n c o r p o r a t e a more s i m i l a r s t a r t i n g p o i n t f o r a l l sub jec ts i n the research design o f t h e i r f o l l o w - u p s t u d i e s , and a l s o to use a f o l l o w - u p per iod o f s t a n d a r d i z e d l e n g t h . (The problem wi th f o l l o w i n g s u b j e c t s from h o s p i t a l d i scharge i s t h a t , f o r one t h i n g , to i n s u r e you are f o l l o w i n g a group t h a t was d ischarged a t about the same p o i n t i n t ime you may be d e a l i n g w i t h smal l numbers, and a l s o there i s no guarantee a l l these people can be fo l lowed up or w i l l agree to par take i n the s t u d y . ) i v ) Validity of Outcome Measures. I t was d i scussed i n Chapter 3 tha t i t i s not c l e a r as to what r e h o s p i t a l i z a t i o n r e p r e s e n t s , i n that some s t u d i e s have shown r e c i d i v i s m r a t e to be a f f e c t e d by a v a r i e t y o f f a c t o r s o ther than s imply the l e v e l o f f u n c t i o n i n g o f the s u b j e c t . Bear ing t h i s l i m i t a t i o n i n mind , r e h o s p i t a l i z a t i o n was used as an outcome measure i n the present study i n par t because i t was r e l i a b l y recorded i n the f i l e s , and can be used as the b a s i s fo r compar ison , p r o v i d i n g , o f c o u r s e , t h a t the f a c t o r s a f f e c t i n g r e h o s p i t a l i z a t i o n i n one group are s i m i l a r to those a f f e c t i n g i t f o r another group. I t was assumed i n the present study t h a t the v a r i a b l e s r e h o s p i t a l i z a t i o n and Venture admiss ions were s i m i l a r measures o f outcome; a l though the a s s o c i a t i o n between these two was s i g n i f i c a n t , i t was not p a r t i c u l a r l y s t r o n g 9 3 . (Pearson 's r = . 3 6 , from Table 1 0 ) . As w e l l , there were found to be some d i f f e r e n c e s i n the independent v a r i a b l e s t h a t were a s s o c i a t e d w i t h these outcome measures. Because o f t h i s , i t was f e l t t h a t these two outcome measures should be regarded s e p a r a t e l y , i . e . i t seemed apparent t h a t they were not measuring e a c t l y the same t h i n g . I t i s recommended t h a t fo r f u t u r e researchers a broad range of outcome measures be used , i f p o s s i b l e , s i n c e the range o f items used i n t h i s study was somewhat l i m i t e d . Q u a l i t a t i v e measures cou ld be used to complement the ub iqu i tous q u a n t i t a t i v e measures. In a d d i t i o n , i t seemed t h a t the new s i n g l e case des igns would lend themselves we l l to the study o f p s y c h i a t r i c r e h a b i l i t a t i o n i n t h a t the fea tu res o f i n t e r e s t (such as employment) are a t a low l e v e l o f a b s t r a c t i o n and cou ld be r e a d i l y de f ined o p e r a t i o n a l l y . v) Effects of Extraneous Variables. In the present study i t was not p o s s i b l e to c o n t r o l f o r the e f f e c t s o f extraneous v a r i a b l e s on the d i scovered a s s o c i a t i o n s . This i s , i n g e n e r a l , a problem wi th any n a t u r a l i s t i c study o f mental p a t i e n t s l i v i n g i n the community i n t h a t , by d e f i n i t i o n , the environment i s u n c o n t r o l l e d . I f one i s a s k i n g the q u e s t i o n "Why do some s c h i z o p h r e n i c s r e t u r n to the h o s p i t a l more f r e q u e n t l y than o t h e r s ? , " then one i s immediately conf ronted w i t h the problem that h o s p i t a l r e t u r n r a t e i s a s s o c i a t e d w i th a myr iad d i f f e r e n t f a c t o r s , some p e r t a i n i n g to the c l i e n t ' s past h i s t o r y , some p e r t a i n i n g to the immediate l i v i n g s i t u a t i o n , and some p e r t a i n i n g to broader p o l i t i c a l i s s u e s . In the present study some attempt was made' to account f o r these p r e d i s p o s i n g c o n d i t i o n s i n the data c o l l e c t i o n , but i n the f i n a l r e s u l t 94. one can o n l y i n c o r p o r a t e a s e l e c t i o n o f the un ive rse o f contaminat ing v a r i a b l e s . A m u l t i p l e r e g r e s s i o n was used i n the present study i n an attempt to s o r t out the d i f f e r e n t independent v a r i a b l e s t h a t were used . The way t h i s s t a t i s t i c was used had severa l l i m i t a t i o n s ; o r d i n a l - l e v e l data ( e . g . employment) was t r e a t e d as i n t e r v a l and nominal l e v e l data was not used ( e . g . l i v i n g s i t u a t i o n ) . Because of t h i s , some a s s o c i a -t i o n s i n v o l i v n g nominal v a r i a b l e s cou ld not be examined to any g reat e x t e n t ; f o r example i t was found t h a t the males i n the sample were unemployed to a g r e a t e r degree than the f e m a l e s : was d i f f e r e n c e i n employ-ment a unique e f f e c t o f the sex v a r i a b l e , o r d i d some t h i r d v a r i a b l e such as age have an e f f e c t ? One cou ld suggest tha t f o r f u t u r e r e s e a r c h e r s a better solution would be to dummy code a l l the nominal variables in the multiple regression. This would avoid a distortion in the findings which occurs as a result of omitting some of the independent variables from the equation, which was the case in the present study. The findings therefore must be interpreted with caution in that a different number of independent variables in the equation will affect the variance accounted for by any one variable. Another strategy would be to quantify nominal variables to a greater extent, thus creating interval data; in the present study, employment could have been measured in weeks, instead of having a dichotomous category (yes - no). Some •nominal v a r i a b l e s ( e . g . sex) were not used i n the m u l t i p l e r e g r e s s i o n , because in t h i s i ns tance they cou ld not be indexed as o r d i n a l or i n t e r v a l v a r i a b l e s . One technique f o r d e a l i n g w i th them i s to use c r o s s t a b u l a t i o n s t h a t c o n t r o l f o r o n e - t h i r d v a r i a b l e a t a t i m e , e . g . sex X employment X age, and then see (wth a X t e s t ) i f the a s s o c i a t i o n between the f i r s t two 95. variables i s affected. Such an analysis was attempted in the present study, but was not ultimately used for two reasons. F i r s t of a l l , only one-third variable can be controlled for at a time (unlike multiple regression) and the choice of the thi r d variable may become rather a r b i t r a r y . Secondly, when a t h i r d variable is controlled for the number 2 of cases within categories gets smaller, hence tests such as X , which require a minimum number of cases to make the test v a l i d , cannot be applied unless one has a very large i n i t i a l sample. v i ) Relationships between Variables. The variables used in the present study were regarded as "independent" and "dependent" (or outcome), however i t was recognized that the use of these terms was rather suspect in that the study was uncontrolled. In the l i t e r a t u r e i t had been found that certain variables are used as "predictors" of schizophrenia outcome; for the sake of the present study i t was f e l t to be useful to regard some independent variables as outcome predictors i f the independent variable referred to events that had occurred prior to the follow-up period (e.g. duration of previous h o s p i t a l i z a t i o n s ) . Such predictors can be contrasted with independent variables that referred to events that occurred during the follow-up period (e.g. address changes), since dir e c t i o n of effect between independent and dependent variable i s confused when the two events may be occurring at the same time. B. Sociodemographic Characteristics of the Study Population i ) The Sample as a Whole. I t was apparent that this was a dependent population; at the end of the follow-up period 66% of the sample 96-. was unemployed, and on ly 13% were doing c o m p e t i t i v e work, f u r t h e r , o n l y 27% o f the p o p u l a t i o n had he ld a c o m p e t i t i v e job o f s i x months d u r a t i o n in the preceding f i v e y e a r s . I t was a l s o noted t h a t a t the end o f the study per iod 87% of the sample was dependent i n t h e i r source of income. One gets a sense o f how high these unemployment ra tes are when one compares them to. S t a t i s t i c s Canada f i g u r e s ; a c c o r d i n g to the 1981 census '[132] the p a r t i c i p a t i o n r a t e i n the labour f o r c e f o r those over 25 i n M e t r o p o l i t a n Vancouver was 81% f o r men and 53% f o r women; the unemployment r a t e was 3.4% f o r men and 5.0% f o r women. In s h o r t , the f i n d i n g s o f the present study r e f l e c t e d those of o ther s c h i z o p h r e n i a s t u d i e s i n t h a t the d i s a b l i n g nature o f the i l l n e s s was mani fes ted i n poor employment r e c o r d s . The l i v i n g s i t u a t i o n f o r the s u b j e c t s i n d i c a t e d t h a t many l i v e d a r a t h e r i s o l a t e d e x i s t e n c e . Seventy per cent o f the s u b j e c t s were s i n g l e , never m a r r i e d , 20% separated or d i v o r c e d and on ly 10% marr ied a t the end o f the f o l l o w - u p p e r i o d . I t was noted t h a t , as o f the end o f the f o l l o w - u p p e r i o d , 36% of the s u b j e c t s were l i v i n g a l o n e , 28% i n a boarding-home s t y l e accommodation, 17% w i t h p a r e n t s , and 14% w i t h spouse/par tner . Regarding marr iage r a t e s , the f i g u r e s from the 1981 census [133] i n d i c a t e d t h a t of those over 15 years o f age i n M e t r o p o l i t a n Vancouver, 28% were s i n g l e , never marr ied i i i 1981, 7% were separated or d i v o r c e d , and 58% were m a r r i e d . The h igher d i v o r c e and lower marr iage r a t e s of the s c h i z o p h r e n i c would seem to i n d i c a t e the i l l n e s s has a s i g n i f i c a n t negat ive impact on the forming o f s o c i a l r e l a t i o n s h i p s . Compared to o ther groups o f s c h i z o p h r e n i c s , the sample i n t h i s study had a somewhat 91. lower marr iage r a t e ; A f f l e c k ' s study found a marr iage r a t e of 35% and a "never m a r r i e d " r a t e o f 58% f o r h i s sample o f s c h i z o p h r e n i c s [ 1 3 4 ] . I t i s d i f f i c u l t to make much o f t h i s ; one cou ld t e n t a t i v e l y propose t h a t the sample i n the present study was a more d e b i l i t a t e d group than A f f l e c k ' s sample (assuming m a r i t a l s t a t u s i s an i n d i c a t i o n o f d e b i l i t y ) , however the two samples may not be comparable because o f c u l t u r a l d i f f e r e n c e s , e t c . Regarding sex and marr iage r a t e s , the f i n d i n g made i n other s t u d i e s was a l s o made i n the present s t u d y , namely tha t female s c h i z o -phrenics have a h igher marr iage r a t e than m a l e s . The 1983 marr iage r a t e i n t h i s study was o n l y 4% f o r the men (82% never marr ied) and 19% f o r the women (53% never m a r r i e d ) . The female r a t e s f o r the present s t u d y , w h i l e s t i l l not c l o s e to the ra tes o f the general p u b l i c , do tend to conf i rm the hypothes is tha t the symptoms o f the d i s o r d e r are l e s s c r u c i a l f o r the t r a d i t i o n a l female r o l e i n c o u r t i n g than f o r the t r a d i t i o n a l male r o l e . An a l t e r n a t i v e hypothes is i s t h a t , s i n c e s c h i z o p h r e n i a tends to have a l a t e r onset i n women than men, a number o f female s c h i z o p h r e n i c s may get mar r ied before the i l l n e s s becomes " f u l l b l o w n . " One q u a l i f y i n g comment shou ld be.made: i t was found i n the present study t h a t the female s u b j e c t s were somewhat o l d e r than the males (see Table 1 ) , a r e s u l t t h a t c o u l d , of c o u r s e , a f f e c t m a r i t a l s t a t u s . The i s o l a t i o n o f the s c h i z o p h r e n i c (36% l i v i n g a lone i n t h i s sample) i s apparent when one compares i t w i t h the f i g u r e f o r the general p u b l i c ; the 1981 census i n d i c a t e d t h a t o n l y 9% of Canadians l i v e a l o n e , and fo r those under 55 the f i g u r e i s l e s s , roughly 6% f o r those from 20-54 [135] . S c h i z o p h r e n i c symptoms are poor l y t o l e r a t e d by most i n d i v i d u a l s ; 98 as w e l l , many s c h i z o p h r e n i c s are withdrawn because they f i n d s o c i a l s i t u a t i o n s s t r e s s f u l [ 1 3 6 ] . In t h i s study a t o t a l o f 31% of the s u b j e c t s were l i v i n g w i t h f a m i l y (17% w i t h parents and 14% wi th s p o u s e / p a r t n e r ) ; t h i s f i g u r e seems to be somewhat lower than most o f the l i t e r a t u r e f i n d i n g s ( e . g . 47% w i t h f a m i l y i n A f f l e c k ' s [137] s tudy) and i t seems reasonable to specu la te tha t t h i s may i n par t be due to a l t e r n a t i v e housing resources a v a i l a b l e i n Vancouver (such as mental h e a l t h boarding homes) that may not be a v a i l a b l e to the same ex tent i n o ther c e n t r e s . In f a c t , i n t h i s study i t was noted t h a t a t the end o f the f o l l o w - u p per iod 40% o f the sample was l i v i n g i n dependent ( s h e l t e r e d ) housing ( i . e . : mental hea l th boarding home, group home, f a m i l y care home or superv i sed apar tment . ) This f i g u r e i s h igher than tha t seen f o r most o ther s t u d i e s tha t were r e a d , p a r t i c u l a r l y the American s t u d i e s ; M i l l e r ' s study [ 1 3 8 ] , f o r example, showed t h a t on ly 10% o f mental p a t i e n t s came out o f the h o s p i t a l i n t o s h e l t e r e d hous ing , and the "new, young c h r o n i c " l i t e r a t u r e a l s o showed low r a t e s o f s h e l t e r e d housing occupancy. The r e h o s p i t a l i z a t i o n r a t e f o r the t o t a l sample i n t h i s study was 37%, i . e . 37% had at l e a s t one p s y c h i a t r i c h o s p i t a l i z a t i o n i n the two year f o l l o w - u p p e r i o d . C o n t r o l l i n g f o r t ime s i n c e l a s t h o s p i t a l i z a t i o n , i t was found t h a t o f those sub jec ts who had been i n h o s p i t a l i n the preceding two y e a r s , 50% were r e h o s p i t a l i z e d i n the study p e r i o d ; of those who had been i n h o s p i t a l i n the preceding y e a r , 57% were r e h o s p i t a l i z e d i n the study p e r i o d . These f i g u r e s are f a i r l y c l o s e to the f i n d i n g s o f o ther r e s e a r c h e r s , such as St rayhorn [139] who found a r e c i d i v i s m r a t e o f 40-60% f o r s c h i z o p h r e n i c s w i t h i n two years of h o s p i t a l d i s c h a r g e . The f i g u r e s a l s o suggest t h a t the s u b j e c t r e c e n t l y d i scharged from h o s p i t a l 9 9 . may i n some sense be more a t r i s k f o r r e h o s p i t a l i z a t i o n . The i m p l i c a t i o n seems to be t h a t there i s one group t h a t has been r e c e n t l y i n h o s p i t a l , and i s l i k e l y to r e t u r n , and another group that has been out f o r a w h i l e and i s l e s s l i k e l y to r e t u r n . These two groups are more c l e a r l y d e l i n e a t e d i n Table 8 , which shows a b i -modal d i s t r i b u t i o n . In s p e c u l a t i n g on the compos i t ion o f the two groups , i t was noted t h a t there was an a s s o c i a t i o n Kound between age and time s i n c e l a s t h o s p i t a l i z a t i o n (see Table 4) w i th the most r e c e n t l y h o s p i t a l i z e d group being younger . More s p e c i f i c a l l y , i t was found t h a t o f the 20-30 year o l d s , 71% had been i n h o s p i t a l i n the two years prev ious to the f o l l o w - u p p e r i o d , w h i l e o f the over 4 0 ' s on ly 33% were i n h o s p i t a l i n the two years prev ious to the f o l l o w - u p p e r i o d . I t i s no tab le i n the present study t h a t the r e h o s p i t a l i z a t i o n r a t e was r e l a t i v e l y high even though the sample were ( f o r the most pa r t ) being t r e a t e d a t a community care team. I t i s d i f f i c u l t to comment on t h i s p o i n t , except to propose tha t the s c h i z o p h r e n i c seen a t the community care teams may r e p r e s e n t a poorer prognosis group (the " d i f f i c u l t p a t i e n t " ) than the ones seen i n o ther s e t t i n g s (such as p r i v a t e p r a c t i c e ) . In l o o k i n g a t how the s u b j e c t s u t i l i z e d t reatment s e r v i c e s , i t was noted t h a t a s i g n i f i c a n t p r o p o r t i o n of the sample (47%) v i s i t e d the community care teams a t l e a s t tw ice per month. The modal va lue of two v i s i t s per month may have been d i c t a t e d to a l a r g e ex tent by the medicat ion reg imen, i . e . : many i n j e c t i b l e a n t i p s y c h o t i c drugs are g iven b i - W e e k l y . The tendency seemed to be tha t team v i s i t s were o f s h o r t d u r a t i o n : the v a r i a b l e Hours Per Month a t Team gave the r e s u l t t h a t most o f the c l i e n t e l e (53%) r e q u i r e d l e s s than three hours c l i n i c a l t ime per month. One can make the o b s e r v a t i o n tha t t reamtent of p s y c h o t i c i n d i v i d u a l s i s o f t e n 100. cent red around the i ssue o f m e d i c a t i o n , and convent iona l psychotherapy i s f e l t to not be an e f f e c t i v e approach [140] . The f i n d i n g t h a t women are g r e a t e r consumers o f mental h e a l t h s e r v i c e s was not observed i n t h i s s t u d y ; fo r one t h i n g , the m a j o r i t y o f the Subjects were male (59%). (The i n c i d e n c e o f s c h i z o p h r e n i a i n the popu la t ion a t l a r g e i s b e l i e v e d to be about equal f o r the s e x e s ) . There was found to be no s i g n i f i c a n t d i f f e r e n c e between the sexes i n f requency of v i s i t s to the team, and, i n t e r e s t i n g l y , the v a r i a b l e "Hours per month a t team produced a r e s u l t t h a t the male c l i e n t e l e apparent l y r e q u i r e d more c l i n i c a l t ime than the f e m a l e s . ' ( S i x t y per cent of the females spent fewer than three hours per month a t the team compared to 48% f o r the m a l e s . ) One cou ld propose t h a t the male c l i e n t e l e are i n some sense more d i s a b l e d than the f e m a l e s ; t h i s p r o p o s i t i o n must be q u a l i f i e d by the f i n d i n g tha t the males s u b j e c t s were younger than the females . F i n a l l y , w i th r e s p e c t to use of s e r v i c e s , the l i t e r a t u r e proposes t h a t the "new, young c h r o n i c " mental p a t i e n t seen by community mental h e a l t h agencies i n North America consumes a d i s p r o p o r t i o n a t e amount o f c l i n i c a l s e r v i c e s ; i n f a c t , the present study i n d i c a t e d t h a t the younger c l i e n t e l e were admitted to Venture more f r e q u e n t l y and d i d r e q u i r e more c l i n i c a l t ime a t the teams (see Table 4 ) . Address changes was f e l t to be one measure o f c l i e n t s t a b i l i t y ; the o b s e r v a t i o n - h a d been made by o ther researchers t h a t the community based m e n t a l l y i l l , p a r t i c u l a r l y the young, were a t r a n s i e n t group. I t was found t h a t 42% o f the sample had moved a t l e a s t once i n the study p e r i o d , which seemed to bear out the f i n d i n g s o f o t h e r r e s e a r c h e r s . Some comments need to be made: f i r s t o f a l l , the f i g u r e o f 42% may be an underes t imat ion because o f the methodolog ica l problems d e s c r i b e d e a r l i e r ; 101. s e c o n d l y ; the sample i n t h i s study a l l remained i n t reatment f o r the two year f o l l o w - u p , which may make them n o n - r e p r e s e n t a t i v e o f o ther community based m e n t a l l y i l l i n that by v i r t u e o f s t a y i n g i n t reatment they have shown a c e r t a i n s t a b i l i t y ; a f i n a l o b s e r v a t i o n i s t h a t M e t r o p o l i t c a n Vancouver con ta ins a f a i r l y t r a n s i e n t p o p u l a t i o n i n g e n e r a l . The 1981 census i n d i c a t e d t h a t o f those over f i v e years o f age , 54% had moved a t l e a s t once i n the prev ious f i v e years [141] . M o r t a l i t y f i g u r e s i n d i c a t e d on ly one of the s u b j e c t s d ied (a s u i c i d e ) i n the study p e r i o d , out o f a t o t a l o f 234. A d m i t t e d l y , i n t h i s study the sample was under 50 years o f age and the study per iod was of on ly two years d u r a t i o n . N e v e r t h e l e s s , some r e s e a r c h e r s , such as A f f l e c k [ 1 4 2 ] , had detected a very h igh m o r t a l i t y r a t e f o r community based s c h i z o -p h r e n i c s . I f the f i g u r e s f o r t h i s sample are good, one can s p e c u l a t e t h a t the t reatment o f f e r e d through the community care system serves to monitor and m a i n t a i n c l i e n t h e a l t h , w h i l e the s i t u a t i o n may be d i f f e r e n t f o r those not i n t rea tment . A comment should be made on the v a r i a b l e s p e r t a i n i n g to prev ious numbers and d u r a t i o n o f past h o s p i t a l i z a t i o n s f o r the sample. The d i s -t r i b u t i o n i n d i c a t e d t h a t i n most cases the h ' s t o r y o f i n s t i t u t i o n a l i z a t i o n had not been ex tens i ve ( t w o - t h i r d s had f i v e or fewer past h o s p i t a l i z a t i o n s and 63% had a h o s p i t a l d u r a t i o n o f l e s s than a y e a r ) . This f i n d i n g should be q u a l i f i e d by the methodolog ica l problems i n v o l v e d i n a c q u i r i n g t h i s i n f o r m a t i o n ; s p e c i f i c a l l y , there were a l a r g e number of m i s s i n g c a s e s , and these cases may have represented a group w i th a l e n g t h i e r i n s t i t u t i o n a l h i s t o r y , hence the repor ted r e s u l t s may i n f a c t be an u n d e r e s t i m a t i o n . As w e l l , i t i s c o n c e i v a b l e tha t the younger c l i e n t s 1 0 2 , cou ld have been skewing the r e s u l t s toward the " s h o r t e r h o s p i t a l d u r a t i o n " end o f the s c a l e . With regard to age o f o n s e t , age o f f i r s t p s y c h i a t r i c h o s p i t a l i -z a t i o n was found to be a more r e l i a b l y a s c e r t a i n e d v a r i a b l e than age o f f i r s t p s y c h i a t r i c contac t as r e f l e c t e d by the s m a l l e r number o f m i s s i n g c a s e s . The f i n d i n g in t h i s study t h a t the m a j o r i t y o f s u b j e c t s exper ienced t h e i r f i r s t p s y c h i a t r i c h o s p i t a l i z a t i o n i n t h e i r e a r l y twent ies i s more or l e s s c o n s i s t e n t w i t h other f i n d i n g s i n the l i t e r a t u r e . (There i s a methodolog ica l problem here i n t h a t the younger sub jec ts may be skewing the r e s u l t s i n the d i r e c t i o n o f an e a r l i e r h o s p i t a l i z a t i o n ; more w i l l be s a i d on t h i s i n the next s e c t i o n . ) I n t e r e s t i n g l y , the sex d i f f e r e n c e i n age o f onset was not detected to any g reat ex tent i n t h i s sample ; the female s u b j e c t s d i d tend to have t h e i r f i r s t h o s p i t a l i z a t i o n somewhat l a t e r (65% o f the men had been h o s p i t a l i z e d by age 25 compared to 57% o f the women however, the f i n d i n g by Lewine [143] t h a t "women ( s c h i z o p h r e n i c s ) are a t g r e a t e s t r i s k f o r f i r s t h o s p i t a l i z a t i o n d u r i n g t h e i r t h i r t i e s " d i d not hold up , i n t h a t 82% o f the women i n t h i s sample had been h o s p i t a l i z e d before 30 (the same f i g u r e as fo r the men). The s i g n i f i c a n c e o f t h i s i s t h a t i f , as has been proposed, age o f onset i s an i n d i c a t o r o f prognosis [ 1 4 4 ] , i t would seem t h a t the community care teams were a t t r a c t i n g p r o p o r t i o n a t e l y more e a r l y o n s e t , poor prognos is women i n t h e i r c a s e l o a d ; presumably, t h e n , the l a t e onset women were being served somewhere e l s e . In summary, the d e s c r i p t i o n o f the study p o p u l a t i o n i n d i c a t e d t h a t i t was a d i s a b l e d group, as noted by the low employment and high r e h o s p i t a l i - za t ion r a t e s . The dependency of the p o p u l a t i o n was a l s o r e f l e c t e d by the high percentage who were dependent i n t h e i r source o f 103. income and the number of subjects l i v i n g in sheltered housing. Some indication of the social i s o l a t i o n of the subjects was given by the large number l i v i n g alone and the low marriage and high divorce rates. I t seemed that more of the study population were l i v i n g in sheltered housing and fewer with family than had been detected in other studies; i t was hypothesized that one reason for this may be because Vancouver offers more sheltered housing resources. Regarding sex differences, a sex effect was seen in marriage rates and employment, but the sex differences in use of services and age of onset that had been detected by other researchers were not noted i n this study. There were also some age differences found in the population; these w i l l be discussed at more length below. i i ) The lounger Client: a proposed sub-group. In the present study much of the v a r i a b i l i t y within the sample seemed to be accounted for by the age variable; consequently, i t i s proposed that one can legitimately sub-divide the population by age, and regard the younger c l i e n t e l e as part of a d i s t i n c t i v e sub-group within the larger population. The age differences were summarized in Table 4; in b r i e f , they indicated that the younger group in the sample was predominantly male, consumed proportionately more psychiatric services, and had a higher degree of d i s a b i l i t y and i n s t a b i l i t y . With respect to d i s a b i l i t y , i t was noted that the younger subjects had a higher hospital return rate, a higher Venture admission rate, an e a r l i e r f i r s t contact with the psychiatric system, and a lower marriage rate (assuming marriage i s a "screening mechanism"). With respect to consumption of services, i t was found that the younger c l i e n t s tended to v i s i t the community care teams more often, 104. and r e q u i r e d more c l i n i c a l t ime (hours per month a t team). With r e s p e c t to i n s t a b i l i t y , i t was found t h a t the younger c l i n e t s had more address changes, more team changes, more c l o s u r e s and reopenings a t the team, more changes i n employment s t a t u s , and more changes i n source o f income. The fea tu res seen i n t h i s p a r t i c u l a r sub-group mesh c l o s e l y w i t h those desc r ibed by o thers r e s e a r c h i n g the "new, young c h r o n i c " mental p a t i e n t . To r ev iew , the "new young c h r o n i c " forms a sub-group t h a t i s coming i n t o prominence i n North Amer ica ; t h i s i s an i n d i v i d u a l who i s young, predominant ly m a l e , t r a n s i e n t , s o c i a l l y i s o l a t e d , consumes p s y c h i a t r i c s e r v i c e s i n a heavy but " i n a p p r o p r i a t e " manner, and has a p r o p e n s i t y f o r being f r e q u e n t l y r e h o s p i t a l i z e d [ 1 4 5 ] , The s i g n i f i c a n c e o f t h i s group l i e s i n the f a c t tha t a l though they have r e l a t i v e l y s h o r t du ra t ions of p r i o r h o s p i t a l i z a t i o n , they nonetheless d i s p l a y s igns o f c h r o n i c dependency; t h i s i s s i g n i f i c a n t i n tha t p r e v i o u s l y i t has always been assumed t h a t the c h r o n i c dependency o f a mental p a t i e n t was ( i n l a r g e pa r t ) a f u n c t i o n o f the leng th o f h i s i n s t i t u t i o n a l h i s t o r y , as c h r o n i c l e d by w r i t e r s such as Goffman [ 1 4 6 ] . The younger mental p a t i e n t has grown up i n the era o f d e i n s t i t u t i o n a l i z a t i o n , where the locus f o r t reatment has s h i f t e d from the mental h o s p i t a l to the community. I t seems apparent t h a t the needs o f t h i s group are not being met by the c u r r e n t community mental h e a l t h system t h a t e x i s t s i n much o f North Amer ica . Some have suggested tha t the d e l i v e r y system i t s e l f i s i n f a c t c o n t r i b u t i n g to the c h r o n i c i t y o f t h i s group, and t h a t new treatment approaches must be employed, such as a move away from the c u r r e n t emphasis on b r i e f h o s p i t a l i z a t i o n back to a p o l i c y o f l o n g e r - t e r m h o s p i t a l i z a t i o n which would r e s u l t i n the s u b j e c t being more " f i r m l y engaged" i n the system o f 105. care a f t e r d i s c h a r g e [ 1 4 7 ] . Others have suggested the need f o r more r e s i d e n t i a l programs fo r the young c h r o n i c ; the present study i n d i c a t e d t h a t w h i l e not a f f e c t i n g r e h o s p i t a l i z a t i o n r a t e s , there was some a s s o c i a -t i o n between r e s i d e n c e and employment r a t e s . I t has a l s o been sugges ted , w i t h r e s p e c t to the young c h r o n i c , t h a t i n f o r m a t i o n systems need to be developed t h a t would prov ide l i n e workers w i t h b e t t e r d i a g n o s t i c background m a t e r i a l on the c l i e n t s [ 1 4 8 ] , m a t e r i a l such as the sociodemographic outcome p r e d i c t o r s examined i n the present s t u d y , s i n c e s i m p l e sympto-matology i s not always u s e f u l as an i n d i c a t o r o f r e h a b i l i t a t i v e p o t e n t i a l [ 1 4 9 ] . I t has a l s o been proposed t h a t , whatever t reatment system i s u s e d , s c h i z o p h r e n i a remains an i n h e r e n t l y d i s a b l i n g d i s o r d e r , t h a t w i l l produce c h r o n i c dependency i n the i n d i v i d u a l , and thus t reatment/ support programs w i l l need to be o f i n d e f i n i t e d u r a t i o n . I t was, f o r i n s t a n c e , assumed by many t h a t p l a c i n g the mental p a t i e n t i n the community ( v s . the mental h o s p i t a l ) would i n and o f i t s e l f be a s tep toward c u r i n g the problem; i t i s now f e l t by many t h a t : " i t is time to leave the model that suggests a curative goal and concentrate instead on aiding the development and maintenance of optimum levels of functioning." [150] When one regards the young mental p a t i e n t as a d i s c r e t e c l i n i c a l g roup , one must a l s o bear i n mind t h a t e a r l y adul thood i s a t u r b u l e n t t ime f o r most i n d i v i d u a l s , and t h a t , as Lamb [151] s a y s : "there is a tendency to forget the long-term, severely mentally i l l patients are affected by the stresses and concerns of each phase of the life cycle, and that they have the same existential concerns as do we a l l . " 106. Hence, i t seems reasonable tosuppose tha t the i n s t a b i l i t y of the young mental p a t i e n t i s i n par t a r e f l e c t i o n of the i n s t a b i l i t y o f young people i n g e n e r a l . I t was mentioned e a r l i e r i n t h i s s e c t i o n t h a t an e a r l y i n i t i a l c o n t a c t w i th the p s y c h i a t r i c system was a s i g n o f g rea te r d i s a b i l i t y , and t h a t the younger s u b j e c t s i n the sample ( i . e . under 35) had had e a r l i e r p s y c h i a t r i c contac ts than the o l d e r s u b j e c t s . I t has been found tha t age o f onset i n s c h i z o p h r e n i a i s a s s o c i a t e d w i t h p r o g n o s i s , w i t h an e a r l i e r onset i n d i c a t i n g a poorer prognosis [ 1 5 2 ] . I t was found i n the present study t h a t the younger s u b j e c t s had an e a r l i e r age o f f i r s t p s y c h i a t r i c c o n t a c t and f i r s t p s y c h i a t r i c h o s p i t a l i z a t i o n . The f i n d i n g s r e g a r d i n g f i r s t h o s p i t a l i z a t i o n are summarized i n Table 5 . The problem i s tha t the f i n d i n g s are p a r t l y a r t i f i c t u a l i n that a younger s u b j e c t by d e f i n i t i o n w i l l have an e a r l i e r age o f f i r s t con tac t s imply because he has not l i v e d long enough to have had a l a t e c o n t a c t , thus b i a s i n g the r e s u l t s . The f i n d i n g s are not complete ly a r t i f a c t u a l , however. I f age o f onset i s a s i g n of p r o g n o s i s , and i f t h i s sample were p r o g n o s t i c a l l y u n i f o r m , i t would be expected t h a t the o l d e r s u b j e c t s would a l s o have had a s i m i l a r l y e a r l y o n s e t , which i s not the c a s e , suggest ing the o l d e r c l i e n t s may be a p r o g n o s t i c a l l y d i s t i n c t group. The assumption t h a t must be made here i s t h a t i t was e q u a l l y easy (or d i f f i c u l t ) f o r an o l d e r c l i e n t to have been h o s p i t a l i z e d 20 years ago as i t i s f o r a younger c l i e n t to be h o s p i t a l i z e d today . This seems to be a reasonable assumption s i n c e , i f a n y t h i n g , h o s p i t a l p o l i c i e s are more s t r i c t c u r r e n t l y than they were i n the p a s t . I f one examines Table 5 , which looks a t age o f f i r s t h o s p i t a l i z a t i o n (a more r e l i a b l e v a r i a b l e than age of f i r s t p s y c h i a t r i c c o n t a c t ) , there are severa l i n t e r e s t i n g f i n d i n g s . F i r s t 107-. of a l l , the l a t e onset of the o l d e r c l i e n t s i s noted i n t h a t o f those over 3 5 , 57% had t h e i r f i r s t p s y c h i a t r i c h o s p i t a l i z a t i o n a f t e r the age o f 2 5 ; f u r t h e r , o f those over 3 5 , 35% had t h e i r f i r s t h o s p i t a l i z a t i o n a f t e r the age o f 30 . Regarding t h i s l a t t e r p o i n t , i t i s the exper ience o f t h i s r e s e a r c h e r tha t i t i s g e n e r a l l y unusual f o r a s c h i z o p h r e n i c to have had h i s f i r s t h o s p i t a l i z a t i o n i n h i s 3 0 1 s or l a t e r , un less i t i s a case o f l a t e o n s e t , b e t t e r p r o g n o s i s , s c h i z o p h r e n i a . The o ther i n t e r e s t i n g f i n d i n g i s t h a t i t seems from t h i s t a b l e tha t many o f the c l i e n t s who are being served by the community care teams have had r e l a t i v e l y recent con tac t w i t h the p s y c h i a t r i c sys tem; one can s p e c u l a t e tha t of the c u r r e n t l y o l d e r s c h i z o p h r e n i c s who had an e a r l y onset o f the i l l n e s s , many must be r e c e i v i n g s e r v i c e somewhere e l s e , or be i n h o s p i t a l , or do not r e q u i r e s e r v i c e . For i n s t a n c e , i n the o l d e s t age c o h o r t , the 46-50 year o l d s , i t can be seen from Table 5 tha t 56% o f them were not h o s p i t a l i z e d u n t i l a f t e r age 30. This leads to an i n t e r e s t i n g h y p o t h e s i s : i f the o l d e r c l i e n t s i n t h i s sample are i n some sense more s t a b l e , i s i t because, as some s u g g e s t , they have been i n the system a long t i m e , and have been c o n d i t i o n e d and burnt out? Or i s i t because the o l d e r c l i e n t s have a c t u a l l y not been i n the system t h a t l o n g , and by v i r t u e o f t h e i r l a t e r onset are b e t t e r prognosis s c h i z o p h r e n i c s ? An i n v e s t i g a t i o n of these competing hypotheses might be use fu l i n a f u t u r e s t u d y . To summarize t h i s s e c t i o n , i t was found t h a t the younger sub jec ts i n the study sample showed a g rea te r degree o f i n s t a b i l i t y and d i s a b i l i t y than the o l d e r s u b j e c t s , and might be regarded as a d i s t i n c t sub -g roup . The f i n d i n g s i n the present study were s i m i l a r to those proposed i n the "new, young c h r o n i c " l i t e r a t u r e . In examining the q u e s t i o n o f how 108. such a sub-group came to e x i s t , i t seems t h a t the same fo rces t h a t have c reated t h i s group i n o ther cent res have c reated i t i n Vancouver. I t was proposed t h a t the community mental h e a l t h d e l i v e r y sys tem, and a p o l i c y o f s h o r t - t e r m h o s p i t a l i z a t i o n , may not be meeting the c l i e n t ' s needs and may be c o n t r i b u t i n g to the problem. I t was a l s o suggested t h a t the i n s t a b i l i t y detected may be i n par t a r e f l e c t i o n o f the i n s t a b i l i t y o f young people i n g e n e r a l . F i n a l l y , a q u i r k o f the sample was noted i n t h a t many ;of. the o l d e r c l i e n t e l e had had a r e l a t i v e l y l a t e i n i t i a l c o n t a c t w i t h the p s y c h i a t r i c system, and on t h i s b a s i s , might be cons idered p r o g n o s t i c a l l y s u p e r i o r to the younger s u b j e c t s . C. S t a b i l i t y Measures o f the P o p u l a t i o n The changes i n c l i e n t s t a t u s were summarized i n Table 9 . The most s i g n i f i c a n t f i n d i n g was t h a t employment s t a t u s worsened over the two y e a r s , from 22% i n c o m p e t i t i v e work and 56% unemployed to 13% i n c o m p e t i t i v e work and 66% unemployed. S i m i l a r l y , those people dependent i n t h e i r source o f income inc reased from.77% to 87%. This f i n d i n g i s c o n s i s t e n t w i th Anthony's [153] p r o p o s i t i o n tha t employment r a t e s d e c l i n e over t i m e ; i t a l s o seems to bear out S t r a u s s ' hypothes is t h a t s c h i z o -phrenics have a s i g n i f i c a n t , moderate s h i f t toward the poorer s i d e o f the continuum curve o f outcome d y s f u n c t i o n [ 1 5 4 ] . (One must bear i n mind tha t employment s t a t u s i s on ly one measure o f s c h i z o p h r e n i a outcome.) These f i n d i n g s i n d i c a t e a c o n t i n u i n g , or p o s s i b l y worsen ing , d i s a b i l i t y f o r the study p o p u l a t i o n over t i m e . I t would be d i f f i c u l t to s p e c u l a t e on why • the employment r a t e s are going down, s i n c e there are l i k e l y a number o f .109. f a c t o r s a t work h e r e ; i n a d d i t i o n to the i n h e r e n t l y d i s a b l i n g nature o f the d i s e a s e , one would a l s o have to see how employment o p p o r t u n i t i e s f o r the general p u b l i c changed over the same time p e r i o d . There i s one o ther c o n s i d e r a t i o n : t h i s study on ly fo l l owed those who s tayed i n t r e a t -ment; i t i s p o s s i b l e t h a t t h i s was a more d i s a b l e d group, and t h a t those whose s t a t u s improved dur ing the two year f o l l o w - u p pe r iod ( i . e . secured employment) dropped out and hence were not i n c l u d e d i n the s t u d y . I f t h i s i s the c a s e , i t would i n d i c a t e t h a t the community care teams were d e a l i n g w i t h a more d i s a b l e d segment of a l l those r e f e r r e d f o r t rea tment . To conf i rm t h i s hypothes is i t would-be a usefu l f u t u r e study to c o n t r a s t the c h a r a c t e r i s t i c s of those i n d i v i d u a l s who s tay i n t reatment v s . those who drop out a f t e r a s h o r t t i m e . I t should be noted tha t the d i f f e r e n c e m i s s i n g cases between 1981 and 1983 was not s i g n i f i c a n t . D. D i f f e r e n c e s w i t h i n the P o p u l a t i o n Based on Sch i zophren ia  Outcome Measures The three outcome measures used i n t h i s study were r e h o s p i t a l i t i o n , admissions to Venture and Employment s t a t u s . These w i l l be c o n -s i d e r e d s e p a r a t e l y . i ) Rehospitalization. There were n ine v a r i a b l e s tha t reached or approached a s i g n i f i c a n t a s s o c i a t i o n w i th r e h o s p i t a l i z a t i o n . Some o f these a s s o c i a t i o n s could be cons idered to be t r i v i a l or "common-s e n s i c a l . " For i n s t a n c e , i t i s not s u r p r i s i n g tha t a person who was r e h o s p i t a l i z e d i n the study pe r iod would a l s o tend to have more address changes, team changes, c l o s u r e s and reopen ings , Venture a d m i s s i o n s , or be unemployed a t the end o f the study p e r i o d . This i s because being 110. r e h o s p i t a l i z e d represents an upheaval i n the c l i e n t ' s l i f e ; the c l i e n t might be d ischarged to a d i f f e r e n t s e t t i n g , such as a s h e l t e r e d r e s i d e n c e , thus account ing f o r a change i n a d d r e s s . The community care teams have a geographica l catchment a r e a , thus an address change cou ld account f o r a team change. R e h o s p i t a l i z a t i o n c o u l d a l s o c o i n c i d e w i t h being c losed as a team; i f the h o s p i t a l i z a t i o n was o f extended d u r a t i o n , i t may have been of l i t t l e u t i l i t y to keep the c l i e n t ' s f i l e a c t i v e a t the team. Or , i t may have been t h a t the c l i e n t was r e f u s i n g s e r v i c e , became s i c k , became r e h o s p i t a l i z e d , and a f t e r d i scharge was reopened a g a i n . An a s s o c i a t i o n between Venture admiss ions and r e h o s p i t a l i z a t i o n i s probably not s u r p r i s i n g i n tha t people uns tab le enough to need Venture would a l s o o f t e n need h o s p i t a l i z a t i o n ; i n someeasesa Venture admiss ion would immediately precede (or f o l l o w ) a h o s p i t a l a d m i s s i o n . F i n a l l y , i f the person had been r e h o s p i t a l i z e d i n the study p e r i o d , i t would be l e s s l i k e l y t h a t he would be employed a t the end o f the study pe r iod i n t h a t he has j u s t r e c e n t l y been through a t ime o f c r i s i s and may i n f a c t have l o s t what employment he had p r e v i o u s l y . One cou ld propose an a l t e r n a t e hypothes is f o r the a s s o c a t i o n w i t h address changes; i n s t e a d o f supposing tha t address changes are c reated by being r e h o s p i t a l i z e d , i t may be tha t these two v a r i a b l e s are more or l e s s independent , and t h a t both are measures of c l i e n t i n s t a b i l i t y , thus the c o r r e l a t i o n . There was an a s s o c i a t i o n between age and r e h o s p i t a l i z a t i o n , w i t h those r e h o s p i t a l i z e d tending to be younger . This i s c o n s i s t e n t w i t h the f i n d i n g s o f o ther r e s e a r c h e r s , p a r t i c u l a r l y the r e c e n t s t u d i e s o f the "New, young c h r o n i c " p a t i e n t , who d i s p l a y s a high r e c i d i v i s m 111. r a t e . In t r y i n g to account f o r t h i s , one common e x p l a n a t i o n proposed i s t h a t the o l d e r mental p a t i e n t i s c a l m e r , more "burntu o u t , " more c o n d i t i o n e d to the mental h e a l t h d e l i v e r y system, and thus more s e t t l e d i n h i s p o s i t i o n . Th is r e l a t e s to the hypothes is by G l i c k [155] t h a t the o l d e r p a t i e n t who has had l o n g e r - t e r m h o s p i t a l i z a t i o n s (because o f d i f -f e r e n t h o s p i t a l p o l i c i e s ) i s more " f i r m l y engaged i n the system of c a r e " a f t e r d i s c h a r g e , presumably due to the e f f e c t of the i n s t i t u t i o n a l i s m . In t h i s p resent study there was no s i g n i f i c a n t a s s o c i a t i o n found between past d u r a t i o n o f h o s p i t a l i z a t i o n and r e h o s p i t a l i z a t i o n ; t h i s i s c o n s i s t e n t w i t h the "new, young c h r o n i c " f i n d i n g s t h a t demonstrate a high r e h o s p i t a l i z a -t i o n r a t e d e s p i t e s h o r t i n s t i t u t i o n a l h i s t o r i e s . I t i s , however, counter to the p r o p o s i t i o n by S t rauss [156] tha t d u r a t i o n o f p r i o r h o s p i t a l i z a t i o n i s the best p r e d i c t o r o f r e h o s p i t a l i z a t i o n . (One must , however, bear i n mind t h a t S t r a u s s ' i n v e s t i g a t i o n s predate the "new, young c h r o n i c " l i t e r a t u r e . ) Bear ing i n mind t h a t t h i s was an u n c o n t r o l l e d s t u d y , i t was nonetheless f e l t to be usefu l to regard some independent v a r i a b l e s as " p r e d i c t o r s " o f outcome i f i t was c l e a r t h a t the v a r i a b l e i n ques t ion concerned events t h a t were antecedent to the outcome events . For example, a f i n d i n g made by many other workers i s t h a t past numbers o f h o s p i t a l i z a -t i o n s (as opposed to d u r a t i o n ) i s a s t r o n g p r e d i c t o r o f r e h o s p i t a l i z a -t i o n , the i m p l i c a t i o n being tha t past behaviour i s o f t e n the best p r e d i c t o r o f f u t u r e behav iour . This f i n d i n g was i n f a c t upheld i n the present s t u d y ; however, what was found to be best " p r e d i c t o r " o f r e h o s p i t a l i z a t i o n was the v a r i a b l e t ime s i n c e l a s t h o s p i t a l i z a t i o n , w i t h those most r e c e n t l y h o s p i t a l i z e d ( p r i o r to the study per iod ) being the ones more l i k e l y to be r e h o s p i t a l i z e d i n the study p e r i o d . This f i n d i n g had a l s o been made 112. by M i l l e r [ 1 5 7 ] . The i m p l i c a t i o n seems to be t h a t the r e c e n t l y h o s p i t a l i z e d may i n some sense represent a "h igh r i s k " group, r e q u i r i n g g rea te r a t t e n t i o n and m o n i t o r i n g from the h e l p i n g p r o f e s s i o n a l . There was an i n t e r e s t i n g a s s o c i a t i o n w i t h the v a r i a b l e f r e -quency o f v i s i t s to the community care team; i t was found t h a t those who v i s i t e d the team more f r e q u e n t l y a l s o exper ienced more r e h o s p i t a l i z a -t i o n s . On the one hand, t h i s was not s u r p r i s i n g ; both v a r i a b l e s are measures of c l i e n t i n s t a b i l i t y i n some s e n s e , both r e p r e s e n t a "cry f o r h e l p . " On the o ther hand, t h i s f i n d i n g seems to run counter to the con -c l u s i o n o f Anthony [158] and o thers who s a i d t h a t g rea te r f requency o f attendance a t a f t e r care c l i e n c s was a s s o c i a t e d w i t h lower r e h o s p i t a l i z a -t i o n r a t e s . I t was a l s o proposed by some researchers t h a t those i n d i v i d u a l s i n s h e l t e r e d o r dependent housing exper ienced a lower r e h o s p i t a l i z a t i o n r a t e than those i n u n s h e l t e r e d , independent hous ing . This f i n d i n g was not upheld i n the present s t u d y ; i t was found t h a t those who were i n independent housing a t the s t a r t o f the study per iod were not h o s p i t a l i z e d to any s i g n i f i c a n t l y g r e a t e r ex ten t than those i n dependent hous ing . I t i s d i f f i c u l t to draw too many c o n c l u s i o n s from t h i s ; one cou ld s p e c u l a t e t h a t the a v a i l a b i l i t y o f s h e l t e r e d housing i s a f a c t o r here . I t cou ld be t h a t s t u d i e s t h a t found a lower r e c i d i v i s m r a t e f o r those i n s h e l t e r e d housing represented areas where there was a shortage o f t h i s housing and where poor l y f u n c t i o n i n g i n d i v i d u a l s who needed s h e l t e r e d housing c o u l d not get i t . In Vancouver, by c o n t r a s t , more s h e l t e r e d housing resources e x i s t ; a C .M.H.A . n a t i o n a l survey [ 1 5 9 ] , c i t e d e a r l i e r , concluded t h a t B .C . had the g r e a t e s t a v a i l a b i l i t y o f housing resources f o r the m e n t a l l y 113 i l l . Thus, i t i s p o s s i b l e t h a t more o f the d i s a b l e d people who need s h e l t e r e d housing are g e t t i n g i t , making those i n s h e l t e r e d ( vs . indepen -dent) housing d i a g n o s t i c a l l y d i s s i m i l a r , and confounding comparisons o f r e c i d i v i s m r a t e s between the two groups. I t i s a l s o p o s s i b l e tha t o t h e r v a r i a b l e s (such as the t reatment v a r i a b l e , which was the same fo r a l l s u b j e c t s , r e g a r d l e s s o f housing type) were more c r u c i a l i n e f f e c t i n g outcome i n t h i s i n s t a n c e . To summarize t h i s s e c t i o n : r e h o s p i t a l i z a t i o n was found to be s i g n i f i c a n t l y a s s o c i a t e d w i t h the age o f the s u b j e c t , w i th the t ime s i n c e h i s/her l a s t h o s p i t a l i z a t i o n , w i t h the f requency o f h i s/her v i s i t s to the team, and w i t h the prev ious number o f p s y c h i a t r i c h o s p i t a l i z a t i o n s . Time s i n c e l a s t h o s p i t a l i z a t i o n seemed to be the best h i s t o r i c a l p r e d i c t o r o f f u t u r e h o s p i t a l i z a t i o n . The f i n d i n g s by other researchers t h a t had r e h o s p i t a l i z a t i o n being a s s o c i a t e d w i t h r e s i d e n t i a l s i t u a t i o n and d u r a t i o n o f p r i o r h o s p i t a l i z a t i o n were not upheld i n t h i s study ( i . e . they d i d not reach or approach s t a t i s t i c a l s i g n i f i c a n c e ) . i i ) Admissions to Venture. I t was expected t h a t t h i s v a r i a b l e would be s i m i l a r to " r e h o s p i t a l i z a t i o n , " t h a t i s , the same a s s o c i a t i o n s would be found. The reason ing was tha t Venture , being a c r i s i s u n i t , represented a " m i n i - h o s p i t a l , " w i t h the same s o r t s o f people being admitted to Venture as would be admitted to h o s p i t a l , f o r s i m i l a r s o r t s o f r e a s o n s . ( I t was recogn ized t h a t an admiss ion to Venture was u s u a l l y f o r a l e s s s e r i o u s matter than a h o s p i t a l ' a d m i s s i o n , i . e . a b r i e f , s i t u a t i o n a l c r i s i s , r a t h e r than a f u l l - b l o w p s y c h o t i c e p i s o d e . ) 114. The a s s o c i a t i o n s d i scovered (summarized i n Table 10) seemed to f o l l o w the same trend t h a t had been seen fo r r e h o s p i t a l i z a t i o n , a l though there were some d i f f e r e n c e s . To begin w i t h , the same a s s o c i a t i o n s w i t h v i s i t s to the team, address changes, team changes, c l o s u r e s and reopen ings , age , and time s i n c e l a s t h o s p i t a l i z a t i o n were noted w i th Venture admissions as w i t h r e h o s p i t a l i z a t i o n . As w i t h r e h o s p i t a l i z a t i o n , those who tended to be admit ted to Venture more were younger and more r e c e n t l y i n h o s p i t a l . The reader i s r e f e r r e d back to the d i s c u s s i o n on r e h o s p i t a l i z a t i o n f o r an i n t e r p r e t a t i o n o f these a s s o c a t i o n s . One d i f f e r e n c e was t h a t , u n l i k e r e h o s p i t a l i z a t i o n , w i t h Venture admissions the a s s o c i a t i o n w i th d u r a t i o n o f p r i o r h o s p i t a l i z a t i o n approached s i g n i f i c a n c e , tha t i s , those w i t h a l e n g t h i e r i n s t i t u t i o n a l h i s t o r y tended to be admitted to Venture more. In f a c t , d u r a t i o n o f p r i o r h o s p i t a l i z a t i o n was the best h i s t o r i c a l " p r e d i c t o r " o f Venture a d m i s s i o n s , as noted i n the m u l t i p l e r e g r e s s i o n i n Table 16. The q u e s t i o n a r i s e s : why was t h i s a s s o c i a t i o n found f o r Venture admissions and not f o r r e h o s p i -t a l i z a t i o n ? One hypothes is was t h a t those admit ted to Venture might be o l d e r than those who were r e h o s p i t a l i z e d , thus they would have longer i n s t i t u t i o n a l h i s t o r i e s . This was not the case however, s i n c e i t was found t h a t the younger c l i e n t e l e used Venture more f r e q u e n t l y i n the same way tha t the younger s u b j e c t s were r e h o s p i t a l i z e d more. I t was thus c o n -c luded t h a t g iven the l i m i t a t i o n s o f the present s t u d y , l i t t l e cou ld be s a i d about the d i f f e r e n c e between r e h o s p i t a l i z a t i o n and Venture admiss ions on t h i s b a s i s . Another d i f f e r e n c e found was t h a t l i v i n g s i t u a t i o n a f f e c t e d Venture admiss ions to a g r e a t e r ex ten t than r e h o s p i t a l i z a t i o n . I t was found 115, t h a t those admitted to Venture came p r o p o r t i o n a t e l y more o f t e n from l i v i n g w i t h spouse or p a r t n e r . In d e c l i n i n g o r d e r , the s e t t i n g s which produced ( p r o p o r t i o n a t e l y ) the most Venture admissions were: 1) wtth spouse/par tner ; 2) boarding home; 3) a l o n e ; 4) w i t h f a m i l y as dependent. In c o n t r a s t i n g t h i s w i th r e h o s p i t a l i z a t i o n , i t was found t h a t not on ly was the a s s o c i a t i o n not as s t r o n g , but t h a t w i t h r e h o s p i t a l i z a t i o n the order of the s e t t i n g s which produced ( p r o p o r t i o n a t e l y ) more h o s p i t a l admiss ions was d i f f e r e n t . They were: 1) w i t h f a m i l y as dependent; 2) w i th spouse/par tner ; 3) boarding home; 4) a l o n e . In o ther words, the c l i e n t w i t h f a m i l y as dependent was most l i k e l y to be r e h o s p i t a l i z e d but 1 east 1 i k e l y to be admitted to Venture . This d i f f e r e n c e between the p a t t e r n of h o s p i t a l admiss ion and Venture admiss ion i s very d i f f i c u l t to i n t e r p r e t . I t may be t h a t f a m i l i e s tend to bypass Venture when t h e i r c h i l d i s unwell and opt i n s t e a d f o r h o s p i t a l ; t h i s , however, i s s p e c u l a t i o n . A l l tha t can be s a i d i s t h a t the f a c t o r s a s s o c i a t e d w i th Venture admiss ion are d i f f e r e n t i n t h i s i n s t a n c e from those a s s o c i a t e d w i t h h o s p i t a l a d m i s s i o n , aga in l end ing support to the c o n t e n t i o n t h a t these two outcome measures should be cons idered s e p a r a t e l y . ( I f one goes back to the l i t e r a t u r e review on f a m i l y s e t t i n g s and performance l e v e l s , i t w i l l be r e c a l l e d t h a t a number o f s t u d i e s suggest t h a t the s e t t i n g where the p a t i e n t i s w i t h parenta l f a m i l y produces the h ighest h o s p i t a l r e t u r n r a t e ; the l i t e r a t u r e i n t h i s area has a number of c o n f l i c t i n g f i n d i n g s , however.) To summarize t h i s s e c t i o n : the v a r i a b l e s t h a t a s s o c i a t e d w i t h admiss ions to Venture were more or l e s s s i m i l a r to those t h a t a s s o c i a t e d wi th r e h o s p i t a l i z a t i o n , however there were a s s o c i a t i o n s found w i t h l i v i n g s i t u a t i o n and d u r a t i o n o f p r i o r h o s p i t a l i z a t i o n tha t were not s i g n i f i c a n t 116. f o r r e h o s p i t a l i z a t i o n . Durat ion o f p r i o r h o s p i t a l i z a t i o n was found to be the best h i s t o r i c a l p r e d i c t o r o f a s u b j e c t being admitted to Venture i n the study p e r i o d . Because ,o f the d i f f e r e n c e s found , i t was concluded t h a t Venture admiss ions must be regarded as separate and d i s t i n c t from r e h o s p i t a l i z a t i o n as an outcome measure. i i i ) Employment Status. The v a r i a b l e most s t r o n g l y a s s o c i a t e d w i t h a good employment outcome at the end o f the study per iod was a good work h i s t o r y ; employment h i s t o r y was the best h i s t o r i c a l p r e d i c t o r o f employment outcome, a f i n d i n g t h a t has been made by a number of o ther r e s e a r c h e r s . The i m p l i c a t i o n seems to be t h a t , d e s p i t e the t rend o f c o n t i n u i n g or worsening d i s a b i l i t y seen i n many s c h i z o p h r e n i a outcome s t u d i e s , past behaviour i s s t i l l the best p r e d i c t o r of f u t u r e behaviour i n t h i s i n s t a n c e . With r e s p e c t to l i v i n g s i t u a t i o n (Table 15) i t was found t h a t those l i v i n g w i t h spouse or common-law par tner had a h igher r a t e o f c o m p e t i -t i v e employment than the other three l i v i n g s i t u a t i o n s . ( I t should be noted t h a t a c r o s s t a b u l a t i o n was performed on employment and m a r i t a l s t a t u s , however t h i s was not repor ted i n the r e s u l t s s e c t i o n - Table 10 -because the numbers .were too smal l to meet the v a l i d i t y requirements o f 2 the X t e s t . Th is c r o s s t a b u l a t i o n produced a r e s u l t t h a t conf i rms the s i g n i f i c a n c e of m a r i t a l s t a t u s , i . e . , a t the end o f the study per iod 29% of the marr ied s u b j e c t s were working c o m p e t i t i v e l y , compared to 11% f o r the s i n g l e , separated and d i vo rced s u b j e c t s . ) The f i n d i n g t h a t being marr ied i s a s s o c i a t e d w i t h h igher employment r a t e s has been made by a number o f o ther s c h i z o p h r e n i a r e s e a r c h e r s . I t i s a f i n d i n g t h a t i s 117. d i f f i c u l t to i n t e r p r e t regard ing cause and e f f e c t . For example i s i t the m a r i t a l s t a t e i t s e l f t h a t somehow a i d s e m p l o y a b i l i t y , or are the people t h a t become marr ied i n some ways b e t t e r s o c i a l l y ad justed and hence, p r o g n o s t i c a l l y s u p e r i o r to o t h e r s c h i z o p h r e n i c s ? As Held and Cromwell [160] propose, marr iage may serve as a s c r e e n i n g mechanism i n s c h i z o p h r e n i a , and one might l e g i t i m a t e l y propose t h a t the marr ied s u b j e c t s cou ld be cons idered as d i s t i n c t from the unmarr ieds . I t should be n o t e d , w i t h r e s p e c t to employment and l i v i n g s i t u a t i o n (Table 1 5 ) , tha t a l though there was some v a r i a b i l i t y , the unemployment r a t e s were f a i r l y s i m i l a r , and q u i t e h i g h , f o r a l l fou r d i f f e r e n t l i v i n g groups , i n d i c a t i n g a s i g n i f i c a n t degree of d i s a b i l i t y , r e g a r d l e s s o f l i f e s t y l e . In t h i s study there was an a s s o c i a t i o n between r e s i d e n c e and employment (Table 1 3 ) ; i t was found t h a t those i n independent housing had h igher r a t e s o f c o m p e t i t i v e employment, w h i l e those i n dependent ( s h e l t e r e d ) housing had h igher r a t e s o f s h e l t e r e d employment. In f a c t , those i n s h e l t e r e d housing had the h ighest r a t e s o f s h e l t e r e d employment of any o f the d i f f e r e n t c a t e g o r i z a t i o n s o f l i v i n g s i t u a t i o n (see Table 1 5 : the f o u r t h l i v i n g c a t e g o r y , " s h a r e d , n o n - f a m i l i a l " r e s i d e n c e , was comprised main ly o f those people i n s h e l t e r e d r e s i d e n c e s . ) I t was found by t h i s w r i t e r w h i l e working w i t h the G . V . M . H . S . t h a t many o f the mental hea l th boarding homes r e q u i r e d some form o f job commitment from the r e s i d e n t s ; i f they were not capable o f c o m p e t i t i v e employment (which most were n o t , as i n d i c a t e d by the low r a t e s of c o m p e t i t i v e employment f o r r e s i d e n t s o f s h e l t e r e d housing i n Table 13) then a t l e a s t some form 118. of vo lun teer job or work i n a s h e l t e r e d workshop was encouraged. Thus, one can see the important r o l e o f the boarding home i n m a i n t a i n i n g some l e v e l o f a c t i v i t y from the c l i e n t ; i t i s l i k e l y t h a t such a c t i v i t y would not be mainta ined i f these same people were i n an independent , non-superv i sed res idence where s t a f f guidance was not a v a i l a b l e . As was noted i n the l i t e r a t u r e r ev iew , f i n d i n g s on the e f f e c t o f s t y l e of r e s i d e n c e on employment r a t e s are i n c o n c l u s i v e , a l though some s t u d i e s do r e p o r t s l i g h t l y h igher employment r a t e s f o r those i n r e h a b i l i t a t i o n r e s i d e n c e v s . c o n t r o l groups [ 1 6 1 ] . In l o o k i n g a t t h i s p a r t i c u l a r a s s o c i a t i o n one would have to take i n t o account f a c t o r s such as whether the resider .ee had a r e h a b i l i t a t i o n focus ( vs . being a " h o l d i n g tank" ) and a l s o how many s h e ! t e r e d job o p p o r t u n i t i e s e x i s t e d i n the community. In t h i s study an a s s o c i a t i o n was detected between sex and employment, w i t h the female s u b j e c t s being employed to a g reate r e x t e n t , and a h igher l e v e l ( i . e . more i n c o m p e t i t i v e jobs ) than the males (see Table 2 ) . By and l a r g e t h i s a s s o c i a t i o n has not been detected i n the l i t e r a t u r e ; Seeman, i n her rev iew on gender and s c h i z o p h r e n i a , does c i t e some s t u d i e s where female s c h i z o p h r e n i c s had a b e t t e r employment outcome, and uses t h i s as p a r t i a l ev idence f o r her general c o n c l u s i o n tha t male s c h i z o p h r e n i c s have a " g e n e r a l l y poorer prognosis than women" [162] , The a s s o c i a t i o n between sex and employment i n t h i s present study was c o n s i s t e n t w i t h the f i n d i n g t h a t the female sub jec ts had a b e t t e r past employment record than the males (X = 2 . 8 5 , 1 d . f . , p = . 0 9 ) . In t h i s study one must take i n t o account q u i r k s of the sample tha t cou ld have a bear ing on the a s s o c i a t i o n between sex and employment; f o r example, the 119. male sub jec ts were younger than the females : 33% o f the males were under 3 0 , compared to 15% o f the females . As w e l l , more o f the females were marr ied (Nov. 1983) : 19% compared to 4% o f the m a l e s . F i n a l l y , more o f the males had r e c e n t l y been i n h o s p i t a l : 58% of the males had been h o s p i t a l i z e d i n the two years preceding the study p e r i o d , compared to 42% o f the f e m a l e s . In the l i t e r a t u r e r e v i e w , the f i n d i n g was noted t h a t there was an a s s o c i a t i o n between employment and past number and d u r a t i o n of h o s p i t a l i z a t i o n s . Th is f i n d i n g was hot upheld i n the present s t u d y . There was a l s o the i n d i c a t i o n i n the "new, young c h r o n i c " s t u d i e s t h a t the younger c l i e n t e l e have a d i s p r o p o r t i o n a t e l y h igher unemployment r a t e ; there was a s l i g h t a s s o c i a t i o n between age and employment found i n the present s t u d y , however i t d i d not approach s t a t i s t i c a l s i g n i f i c a n c e . S p e c i f i c a l l y , the unemployment r a t e a t the end o f the study per iod was found to be 75% f o r those 2 0 - 3 0 ; 66% f o r those 3 1 - 4 0 , and 60% f o r those 4 1 - 5 0 . This a s s o c i a t i o n would have to be q u a l i f i e d by the o b s e r v a t i o n tha t the.unemployment r a t e i s g e n e r a l l y h igher f o r the under 3 0 ' s i n the general p o p u l a t i o n as w e l l . (For example, the 1981 census i n d i c a t e d an unemployment r a t e o f 9.5% f o r males 15-24 i n M e t r o p o l i t a n Vancouver, compared to 3.4% f o r those 25 and over [ 1 6 3 ] . ) One other a s s o c a t i o n was found t h a t approached s i g n i f i c a n c e ; t h i s was employment s t a t u s a t the end o f the f o l l o w - u p per iod and frequency o f v i s i t s to the team d u r i n g the f o l l o w - u p p e r i o d . This i n d i c a t e d t h a t the unemployed were more f requent v i s i t o r s to the cummunity care teams than the employed. This i s not a p a r t i c u l a r l y s u r p r i s i n g f i n d i n g ; f o r one t h i n g , the employed s u b j e c t s have l e s s a v a i l a b l e t ime i n which to v i s i t 120, , . the teams, and as we l l the unemployed may represent a more d i s a b l e d group, and hence r e q u i r e more c l i n i c a l a t t e n t i o n . To summarize t h i s . s e c t i o n : a s s o c i a t i o n s were found between employment s t a t u s and the sex of the s u b j e c t , the r e s i d e n t i a l s i t u a t i o n , the l i v i n g s i t u a t i o n , and the m a r t i a l s t a t u s and employment h i s t o r y o f the s u b j e c t . Employment h i s t o r y was found to be the best h i s t o r i c a l p r e d i c t o r o f outcome, a f i n d i n g upheld by a number o f o ther r e s e a r c h e r s . The f i n d i n g i n the l i t e r a t u r e tha t past number and d u r a t i o n of p s y c h i a t r i c h o s p i t a l i z a t i o n s can a c t as a p r e d i c t o r o f employment outcome was not upheld i n the present s tudy . E. Summary and Conc lus ions This s t u d y , because o f i t s e x p l o r a t o r y n a t u r e , gave r i s e to almost as many quest ions as i t sought to answer; because o f des ign l i m i t a -t i o n s many o f the a s s o c i a t i o n s d iscovered cou ld on ly be specu la ted o n , and h o p e f u l l y examined i n f u t u r e s t u d i e s . N e v e r t h e l e s s , some general c o n c l u s i o n s could be d i sce rned from the d a t a , and these are d i s c u s s e d below. i ) The methodolog ica l 1 i m i t a t i o n s i n t h i s study l i m i t e d the g e n e r a l i z a b i l i t y o f the f i n d i n g s . In p a r t i c u l a r , because the s u b j e c t s were c l i e n t s o f community care teams, i t was d i f f i c u l t to assume these people were r e p r e s e n t a t i v e o f non-community care team a t t e n d e r s . I t was f e l t tha t a comparison study o f c h a r a c t e r i s t i c s of a t tenders and non-a t tenders would be u s e f u l . Other methodolog ica l l i m i t a t i o n s concerned 1 2 1 . an i n a b i l i t y to c o n t r o l f o r the e f f e c t , o f extraneous v a r i a b l e s i n the s t u d y , a l a c k o f r e l i a b i l i t y o f the f i l e i n f o r m a t i o n , and the ques-t i o n a b l e v a l i d i t y o f some of the outcome measures used i n s c h i z o p h r e n i a s t u d i e s . I t was suggested t h a t the f i l e s i n quest ion cou ld be improved i n r e s p e c t to being more comprehensive and s y s t e m a t i c i n the i n c l u s i o n o f needed i n f o r m a t i o n . I t was a l s o suggested t h a t s c h i z o p h r e n i a f o l l o w - u p s t u d i e s should be s tandard i zed w i t h regard to sample make-up, outcome measures used , and. t im ing o f measurement. F i n a l l y , i t was proposed tha t q u a n t i t a t i v e s t u d i e s (such as, , the present one) cou ld be complemented w i t h more q u a l i t a t i v e s t u d i e s and a l s o s i n g l e system d e s i g n s . i i ) A general d e s c r i p t i o n o f the study p o p u l a t i o n revea led a c o n s i d e r a b l e degree o f d i s a b i l i t y , dependency and s o c i a l i s o l a t i o n . In p a r t i c u l a r , the sub jec ts exper ienced high r a t e s o f r e h o s p i t a l i z a t i o n and low r a t e s o f employment. The r e h o s p i t a l i z a t i o n r a t e was s i m i l a r to those found i n the l i t e r a t u r e f o r o ther groups o f s c h i z o p h r e n i c s . The l e v e l o f d i s a b i l i t y o f t h i s p o p u l a t i o n would seem to i n d i c a t e a p a r t i c u l a r need f o r a c c e s s i b l e t reatment f a c i l i t i e s , income s e c u r i t y , v o c a t i o n a l r e h a b i l i -t a t i o n programs and s h e l t e r e d r e s i d e n c e s . i i i ) I t was noted t h a t the employment s t a t u s o f the sample a c t u a l l y worsened over the two year study p e r i o d ; w h i l e t h i s may be open to va r ious i n t e r p r e t a t i o n s , i t seemed to support the general f i n d i n g tha t s c h i z o p h r e n i c d i s a b i l i t y may be of i n d e f i n i t e d u r a t i o n , and hence support s e r v i c e s would need to be o f i n d e f i n i t e d u r a t i o n a l s o . I t was a l s o recogn ized t h a t the c l i e n t e l e o f the G . V . M . H . S . may r e p r e s e n t a more 122 d i s a b l e d group, and those more capable s c h i z o p h r e n i c s may e i t h e r not be i n t reatment or be t r e a t e d somewhere e l s e , such as a t a p r i v a t e p r a c t i t i o n e r . i v ) I t was found t h a t there was some v a r i a b i l i t y w i t h i n the sample , d e s p i t e the g e n e r a l l y high l e v e l o f d i s a b i l i t y . v) Factors were found to be a s s o c i a t e d w i t h d i f f e r e n t i a l outcome, as measured by employment s t a t u s and admiss ions to h o s p i t a l and Venture . Because these f a c t o r s were not the same f o r the three measures i t was assumed t h a t the measures should be regarded as separate and d i s t i n c t , a f i n d i n g more or l e s s c o n s i s t e n t w i t h the o b s e r v a t i o n o f low concordance r a t e s between d i f f e r e n t dimensions of s c h i z o p h r e n i a outcome. v i ) I t was f o u n d , f o r t h i s sample , t h a t the best h i s t o r i c a l p r e d i c t o r o f r e h o s p i t a l i z a t i o n was how r e c e n t l y the s u b j e c t had l a s t been i n h o s p i t a l . I t was a l s o found t h a t those admitted to h o s p i t a l more f r e q u e n t l y tended to be younger ( i . e . under 3 0 ) , more f requent v i s i t o r s to the community care teams, and w i t h a h i s t o r y o f g rea te r numbers o f past h o s p i t a l i z a t i o n s . This l a s t a s s o c i a t i o n was one commonly made i n s c h i z o p h r e n i a outcome s t u d i e s . v i i ) I t was found t h a t the best h i s t o r i c a l p r e d i c t o r o f Venture admiss ions was the s u b j e c t ' s d u r a t i o n o f p r i o r h o s p i t a l i z a t i o n s . I t was a l s o found t h a t those admit ted to Venture tended to be younger , more f requent v i s i t o r s to the team, more r e c e n t l y l a s t i n h o s p i t a l , and came p r o p o r t i o n a t e l y more o f t e n from l i v i n g w i th spouse ( v s . o ther s t y l e s o f c o h a b i t a t i o n ) . 123.. v i i i ) I t was found t h a t the best h i s t o r i c a l p r e d i c t o r o f employment s t a t u s was employment h i s t o r y . I t was a l s o found t h a t the unemployed i n the sample tended to be m a l e , s i n g l e or d i v o r c e d , and were more f requent v i s i t o r s to the community care teams. An a s s o c i a t i o n was found between employment and r e s i d e n c e , namely t h a t s h e l t e r e d res idences are apparent l y ab le to m a i n t a i n a r e l a t i v e l y high r a t e of s h e l t e r e d employment f o r the r e s i d e n t s , i n d i c a t i n g the importance o f these res idences i n i n s u r i n g t h a t some l e v e l o f a c t i v a t i o n i s kept up by the c l i e n t s . i x ) I t was found t h a t , w i t h r e s p e c t to t ime s i n c e l a s t h o s p i t a l i z a t i o n , the sample formed two d i s t i n c t g roups , those r e c e n t l y i n h o s p i t a l , and a group t h a t had been s t a b l e i n the community f o r a number o f y e a r s . I t was a l s o found t h a t the r e c e n t l y h o s p i t a l i z e d group were a t s i g n i f i c a n t l y g r e a t e r r i s k f o r r e h o s p i t a l i z a t i o n , the i m p l i c a t i o n being t h a t these i n d i v i d u a l s r e q u i r e more c a r e f u l mon i to r ing by mental h e a l t h p e r s o n n e l . x) I t was found t h a t the younger s u b j e c t s (under 30) seemed to form a d i s c r e t e group; i t cou ld be s a i d i n general tha t they were more d i s a b l e d , more u n s t a b l e , and heav ie r consumers o f p s y c h i a t r i c s e r v i c e s . In p a r t i c u l a r , t h i s group was found to have higher r e h o s p i t a l i z a -t i o n r a t e s , more f requent v i s i t s to the team, and more f requent address changes. These f i n d i n g s r e f l e c t e d those o f o ther researchers who have i n v e s t i g a t e d the e x i s t e n c e o f the "new, young c h o r n i c " mental p a t i e n t . as a d i s c r e t e c l i n i c a l group. The i m p l i c a t i o n f o r the community care teams i s t h a t t h i s group w i l l r e q u i r e a c o n s i d e r a b l e amount of c l i n i c a l a t t e n t i o n . I t was suggested i n the l i t e r a t u r e tha t i f the c u r r e n t s t y l e 1 2 4 . of treatment is not working with this, group, new treatment approaches (such as long-term hospitalization) might have to be employed. xi ) I t was found that many of the older c l i e n t e l e (over 35) had had r e l a t i v e l y recent i n i t i a l contats with the psychiatric system. The implication was that the G.V.M.H.S. is not attracting as many of the long term mental patients as may have been assumed, and that i f the older c l i e n t e l e in the sample are more stable i t may be in part due to the la t e r age of onset, indicating better prognosis. • x i i ) A f i n a l suggestion was that some of the sociodemographic variables that have been found to be useful disgnostically could be included on a systematic basis i n the c l i n i c a l f i l e s of the c l i e n t , or as part of the i n i t i a l assessment. (For example, time since l a s t h o s p i t a l i z a t i o n , duration and number of previous hospitalizations, employment history, marital status and so on.) This relates back to a point made in the Introduction, that sociodemographic background information on the c l i e n t can account for much of the variance in the outcome of the disorder, and thus help identify "high r i s k " individuals. x i i i ) As a concluding statement, the following could be said: the study population was considerably disabled, and this d i s a b i l i t y was of an apparently long duration; nevertheless, there was some v a r i a b i l i t y in outcome, and i t was f e l t that the sociodemographic characteristics associated with better or worser outcome could be useful diagnostically. .125 REFERENCES H. B a b i g i a n , " S c h i z o p h r e n i a : Epidemiology" i n A. Freedman ( e d . ) : Comprehensive Textbook o f P s y c h i a t r y , 2d e d . , W i l l i a m s & W i l k i n s C o . , 1975, p. 860. L. S tone , Aspects o f P o p u l a t i o n Aging i n Canada, A S t a t i s t i c s Canada P u b l i c a t i o n , 1981. J . Strayhorn, Foundations of C l i n i c a l P s y c h i a t r y , Year Book Medical P u b l i s h e r s , 1982, p. 131. N,. R e t t e r s t o . l , . Paranoid and Paranoiac Psychoses , Scandinav ian U n i v e r s i t y Books, 1966. L . Mosher, D. F e i n s i l v e r , S p e c i a l Repor t : S c h i z o p h r e n i a , U.S. Dept. 5f H e a l t h , Educat ion and- W e l f a r e , 1971 . J . Knesevich e t a l . , " S i x Year Fo l low-Up o f P a t i e n t s w i th Good and Poor - Prognosis S c h i z o p h r e n i a , " American Journal o f P s c h i a t r y , V o l . 140, No. 1 1 , Nov. 1983, p. 1507. W. Anthony, The P r i n c i p l e s o f P s y c h i a t r i c R e h a b i l i t a t i o n , U n i v e r s i t y Part P r e s s , 1980, p. 4 5 . W. Anthony, 1980, i b i d . , p. 3 9 . S . Schwar t z , S . G o l d f i n g e r , "The New Chronic P a t i e n t : C l i n i c a l C h a r a c t e r i s t i c s o f an Emerging Subgroup," Hosp i ta l and Community  P s y c h i a t r y , V o l . 3 2 , No. 7 , Ju l y 1981, p. 474. M. Seeman, "Gender D i f f e r e n c e s i n S c h i z o p h r e n i a , " Canadian Journal  o f P s y c h i a t r y , V o l . 2 7 , March 1982, p. 107. R. Lewine, "Sex D i f f e r e n c e s i n S c h i z o p h r e n i a , " P s y c h o l o g i c a l  B u l l e t i n , 1981, V o l . 9 0 , No. 3 , p. 432. M. Seeman, op . c i t . R. Lewine, "Sex D i f f e r e n c e s i n Age of Onset and F i r s t H o s p i t a l i z a t i o n i n S c h i z o p h r e n i a , " American Journal o f O r t h o p s y c h i a t r y , A p r i l 1980, p. 316. 1 2 6 . J . S t r a y h o r n , 1982, op . c i t . W. Anthony, 1980, cop . c i t . , p. 7 . W. Anthony, 1980, op . c i t . , p. 4 3 . Appendix 5 i n J . Toews, G. Barnes , "Chronic Mental D isorders i n Canada: A Needs Assessment P r o j e c t , " A Canadian Mental Heal th A s s o c i a t i o n P u b l i c a t i o n , 1982. S . Schwartz , S . G o l d f i n g e r , 1981, op . c i t . , p. 470. S . K e i t h e t a l . , " S p e c i a l Repor t : S c h i z o p h r e n i a 1 9 7 6 , " Sch izophren ia B u l l e t i n , 1976, 2 , 5 0 9 - 5 6 5 . G. B u e l l , W. Anthony, "Demographic C h a r a c t e r i s t i c s as P r e d i c t o r s o f R e c i d i v i s m and P o s t h o s p i t a l Employment," Journal o f Counsel ing  Psychology , 1973, V o l . 2 0 , No. 4 , 3 6 1 - 3 6 5 . K. Bernheim, R. Lewine, S c h i z o p h r e n i a : Symptoms, Causes and  Treatment, W.W. Norton & Co. 1979, p. 158. C. M i l e s , " C o n d i t i o n s P r e d i s p o s i n g to S u i c i d e , " Journal o f Nervous  and Mental D i s o r d e r s , 1977, 164: 2 3 1 - 2 4 6 . A. F o r r e s t and A. Hay, "The In f luence o f Sex on S c h i z o p h r e n i a , " Acta P s y c h i a t r i c a S c a n d i n a v i c a , V o l . 4 8 , 1972, page 4 9 . M. T e s t , S . B e r l i n , " Issues o f Spec ia l Concern to C h r o n i c a l l y M e n t a l l y 111 Women," P r o f e s s i o n a l Psycho logy , V o l . 1 2 , No. 1 , Feb./ 8 1 , p. 136. J . H e l d , R. Cromwel l , "Premorbid Adjustment i n S c h i z o p h r e n i a , " Journal o f Nervous and Mental D i s e a s e , 1968, 146, pp. 2 6 4 - 2 7 2 . J . A f f l e c k e t a l . , "Long Term Fol low-Up o f ' S c h i zophrenic P a t i e n t s i n Ed inburgh , " Acta P s y c h i a t r i c a S c a n d i n a v i c a , 1976, V o l . 5 3 , p. 227. J . Nea le , T. OTtmanns, S c h i z o p h r e n i a , John Wi ley and! Sons , 1980, p. 292. D. M i l l e r , " R e t r o s p e c t i v e A n a l y s i s of P o s t h o s p i t a l Mental P a t i e n t s ' W o r l d s , " Journal o f Heal th & S o c i a l B e h a v i o r , 1967, V o l . 8 , p. 136. J . A f f l e c k e t a l . , 1976, op . c i t . C. Caton , "The New Chronic P a t i e n t and the System of Community •Care," H o s p i t a l and Community P s y c h i a t r y , V o l . 3 2 , No. 7 , J u l y 1981, p. 477. 1 2 7 . H. Lamb, "Young A d u l t Chronic P a t i e n t s : The New D r i f t e r s . " H o s p i t a l and Community P s y c h i a t r y , 1982, V o l . 3 3 , p. 4 6 5 . J . Neale , T. Oltmanns, 1980, op . c i t . , page 1 . C. Woogh e t a l . , " P s y c h i a t r i c H o s p i t a l i z a t i o n i n O n t a r i o , " Canadian  Medical A s s o c i a t i o n J o u r n a l , A p r i l 1977, V o l . 116, p. 876. R. R i e d e r , " H o s p i t a l s , P a t i e n t s & P o l i t i c s , " Sch i zophren ia B u l l e t i n , 1974, V o l . 1 1 . J . C h r i s t e n s e n , "A F ive Year Fol low-Up Study o f Male S c h i z o p h r e n i c s , " Acta P s y c h i a t r i c a S c a n d i n a v i c a , 1974, V o l . 5 0 , page 60. W. Anthony, G. B u e l l , " P s y c h i a t r i c A t e r c a r e C l i n i c E f f e c t i v e n e s s as a Funct ion o f P a t i e n t Demographic C h a r a c t e r i s t i c s , " Journal  o f C o n s u l t i n g & C l i n i c a l Psychology , 1973, 4 3 , page 116. M. Seeman, 1982, op., c i t . B. Pepper e t a l . , "The Young A d u l t Chronic P a t i e n t : Overview of a P o p u l a t i o n , " Hosp i ta l and Community P s y c h i a t r y , V o l . 3 2 , No. 7 , 1981, p. 463 . J . S tephens , "Long Term Prognosis and Fol low-Up In S c h i z o p h r e n i a , " Sch i zophren ia B u l l e t i n , 1978, Vol 4 , page 2 5 . M. Harrow, " Is Sch i zophren ia Outcome S t i l l N e g a t i v e ? , " American  Journal o f P s y c h i a t r y , 1978, V o l . 135, p. 1156. M. B l e u l e r , "The Long Term Course o f S c h i z o p h r e n i a , " i n L. Wynne et a l . ( e d s . ) : The Nature o f S c h i z o p h r e n i a , John Wi ley & Sons, 1978, p. 631. W. Anthony, 1980, op . c i t . , p. 8 . J . S t r a u s s , W. Carpenter , "The P r e d i c t i o n of Outcome i n Sch i zophren ia P a r t T h r e e , " A rch i ves o f General P s y c h i a t r y , V o l . 3 4 , 1977, page 159. J . S t r a u s s , W. C a r p e n t e r , "The P r e d i c t i o n o f Outcome i n S c h i z o p h r e n i a , Par t One," A rch ives o f General P s y c h i a t r y , V o l . 2 7 , Dec. 1972, p. 745. C. Schwartz e t a l . , "Concordance o f M u l t i p l e Assessments o f S c h i z o p h r e n i a Outcome," A rch i ves o f General P s y c h i a t r y , 1975, V o l . 3 2 , Oc t . p. 1221. J . S t r a u s s , W. Carpenter , 1972, op . c i t . W. Anthony, 1980, op . c i t . , page 44 . 128. [48] W. Anthony, 1980, op . c i t . , page 44 . [49] T. Lo re i and L. G u r e l , "Demographic C h a r a c t e r i s t i c s as P r e d i c t o r s o f P o s t - H o s p i t a l R e a d m i s s i o n , " Journal of C o n s u l t i n g and C l i n i c a l  Psycho logy , 1973, page 426. [50] J . S t r a u s s , W. Carpente r , "The Predict ion* o f Outcome i n S c h i z o p h r e n i a , P a r t Two," A rch i ves o f General P s y c h i a t r y , Ju l y 1974, p. 3 7 . [51] C. Caton , 1981 , op . c i t . [52] J . C h r i s t e n s e n , 1974, op . c i t . [53] I. G l i c k , W. Hargreaves , P s y c h i a t r i c Hosp i ta l Treatment f o r the  1 9 8 0 ' s , Lex ington Books, W7T. [54] G. M i l l e r , B. W i l i e r , " P r e d i c t o r s of Return to a P s y c h i a t r i c II H o s p i t a l , " Journal o f C o n s u l t i n g and C l i n i c a l Psycho logy , 1976, V o l . 4 4 , No. 6 , p. 898 . [55] B. Pasamanick e t a l . , S c h i z o p h r e n i c s i n the Community, A p p l e t o n -Century C r o f t s , 1967. [56] H. Freeman, 0 . Simmons, The Mental P a t i e n t Comes Home, W i l e y -New York , 1963. [57] G. 3rown et a l . , Sch i zophren ia and S c o i a l Care , Oxford U n i v e r s i t y P r e s s , 1966. [58] W. Michaux, e t a l . , The F i r s t Year Out, Johns Hopkins P r e s s , 1969. [59] H. Freeman, 0 . Simmons, "Mental P a t i e n t s i n the Community," American S o c i o l o g i c a l Review, V o l . 2 3 , Feb. 1958, p. 147. [60] C. Gregory , M. Downie, " P r o g n o s t i c Study o f P a t i e n t s Who L e f t a P s y c h i a t r i c H o s p i t a l , " Journal o f Counsel ing Psychology , 1968, 1 5 , p. 232. [61] D. M i l l e r , 1967, p. c i t . [62] J . C h r i s t e n s e n , 1974, op . c i t . [63] J . C h r i s t e n s e n , 1974, op . c i t . , p. 62 . [64] W. Anthony, 1980, p. c i t . , p. 1 3 . [65] A. Winston e t a l . , " A f t e r c a r e of P s y c h i a t r i c P a t i e n t s and i t s R e l a t i o n to R e h o s p i t a l i z a t i o n , " Hosp i ta l and Community P s y c h i a t r y , Feb. 1977, V o l . 2 8 , No. 2 . [66] S . K i r k , „ " E f f e c t i v e n e s s o f Community S e r v i c e s f o r Discharged Mental P a t i e n t s , " American Journal o f O r t h o p s y c h i a t r y , Oct . 1976, p. 646. 1 2 9 . [67] L. Webb et a l . , "The R e l a t i o n s h i p between Outcome and Number of V i s i t s , " A d m i n i s t r a t i o n i n Mental H e a l t h , V o l . 8 , No. 1 , F a l l 1980, page 2 3 . [68] J . C h r i s t e n s e n , 1974, op . c i t . [69] W. Anthony, 1980, o p . c i t . , p. 1 1 . [70] L. Bachrach , "Assessment o f Outcomes i n Community Support Sys tems," S c h i z o p h r e n i a B u l l e t i n , V o l . 8 , No. 1 , 1982, page 46 . [71] W. Anthony, 1980, op . c i t . , p. 4 3 . [72] R. Wess le r , D. I ven , " S o c i a l C h a r a c t e r i s t i c s of P a t i e n t s Readmitted to a Community Mental Heal th C e n t r e , " Community Mental Health  J o u r n a l , V o l . 6 , No. 1 , 1970, page 6 9 . [73] G. Hogarty e t a l . , "Drug and Soc io therapy i n the A f t e r c a r e o f S c h i z o p h r e n i c P a t i e n t s , " A rch ives o f General P s y c h i a t r y , 1978, page 1169. [74] D. Jansen , L. M i c k l e s , " V a r i a b l e s t h a t D i f f e r e n t i a t e between S i n g l e and M u l t i p l e Admission P s y c h i a t r i c P a t i e n t s a t a S t a t e H o s p i t a l , " Journal o f C l i n i c a l Psycho logy , 1973, V o l . 2 9 , page 8 3 . [75] W. Anthony, G. b u e l l , "The R e l a t i o n s h i p Between P a t i e n t Demographic C h a r a c t e r i s t i c s and P s y c h i a t r i c R e h a b i l i t a t i o n Outcome," Community  Mental Heal th J o u r n a l , V o l . 1 1 , No. 2 , 1975, p. 208. [76] R. W e s s l e r , D. I ven , 1970, op . c i t . [77] T. Wi lson e t a ! . , " C h a r a c t e r i s t i c s Related/to Vocat iona l Succes Among P s y c h i a t r i c P a t i e n t s , " Voca t iona l Guidance Q u a r t e r l y , 1969, 1 8 , p. 110. [78] J . S t r a u s s , W. C a r p e n t e r , 1974, op . c i t . , p. 4 2 . [79] T. L o r e i , L. Gurel , 1973, op . c i t . [80] W. Anthony, 1980, op . c i t . , p. 44 . [81] A. Goss , K. P a t e , " P r e d i c t i n g Vocat iona l R e h a b i l i t a t i o n Success f o r P s y c h i a t r i c P a t i e n t s , " P s y c h o l o g i c a l R e p o r t s , 1967, 2 1 , page 297. [82] J . H a l l e t a l . , "Employment Prob lems 'o f Sch i zophren ic P a t i e n t s , " American Journal of P s y c h i a t r y , 1966, 1 2 3 , p. 536. [83] E. P e r k i n s , A. M i l l e r , " P r e d i c t i n g the V o c a t i o n a l Outcomes o f P s y c h i a t r i c P a t i e n t s , " Personnel and Guidance J o u r n a l , 1969, 4 7 , p. 456. 130. [84] S . Schwar tz , S . G o l d f i n g e r , 1981, op. c i t . , p. 4 7 1 . [85] T. L o r e i , " P r e d i c t i o n of Employment f o r Released P s y c h i a t r i c P a t i e n t s , " Journal o f C o u n s e l l i n g Psychology , 1967, 3 1 , page 349. [86] J . H a l l , 1966, op . c i t . [87] W. Anthony, 1980, op . c i t . , p. 4 3 . [88] J . A f f l e c k , 1976, o p . c i t . , [89] G. Fa i rweather e t a l . , Community L i f e f o r the M e n t a l l y 111, Ch icago : A l d i n e , 1969. [90] W. Anthony, 1980, op . c i t . , p. 13 . [91] J . N e a l e , T. Oltmanns, 1980, o p . c i t . , page 60. [92] J . Knesevich e t a l . , 1983, op . c i t . [93] M. Seeman, 1982, o p . c i t . [94] R. Lewine, 1981, op . c i t . . [95] M. Seeman, 1982, op . c i t . [96] E. Bassuk, S . Gerson, "Chronic C r i s i s P a t i e n t s : A D i s c r e t e C l i n i c a l Group," American Journal o f P s y c h i a t r y , 1 3 7 : 1 2 , Dec. 1980, p. 1513. [97] C. Caton , 1981, op . c i t . [98] S . Schwar tz , S . G o l d f i n g e r , 1981, op . c i t . , p. 470. [99] B. Pepper, 1981, o p . c i t . [100] E. Bassuk, 1980, op . c i t . [101] I b i d . [102] C. Caton , 1 9 8 1 , o p . c i t . [103] S . Schwartz , S . G o l d f i n g e r , 1981, op . c i t . , p. 4 7 1 . [104] J . S t r a u s s , W. C a r p e n t e r , 1974, op . c i t . [105] G. D a v i s o n , J . N e a l e , Abnormal Psycho logy , John Wi ley & Sons, 1978, p. 6 2 . [106] W. Anthony, 1980, op . c i t . , p. 1 1 . [107] M. B e i s e r e t a l . , "Does Community Care f o r the M e n t a l l y 111 Make a D i f f e r e n c e ? " Submitted to H o s p i t a l and Community P s y c h i a t r y , 1983. 131. 108] W. Anthony, 1980, op . c i t . , p. 7 . 109] A. R o s e n b l a t t , J . Mayer, "The R e c i d i v i s m o f Mental P a t i e n t s : A Review o f Past S t u d i e s , " American Journal o f O r t h o p s y c h i a t r y , V o l . 4 4 , No. 5 , Oct . 1974, page 698. 110] J . C h r i s t e n s e n , 1974, o p . c i t . , page 70 . I l l ] G. C l a u s e n , "Some Problems o f Design and Inference i n S tud ies o f Community Tenure , " Journal of Nervous and Mental D i s e a s e , V o l . 155 , 1972, No. 1 , page 3 1 . ,112] J . S t r a u s s , W. Carpente r , 1972, op. c i t . , p. 744. 113] L. Bachrach , "A Note on Some Recent S tud ies o f Released Mental H o s p i t a l P a t i e n t s i n the Community," American Journal of P s y c h i a t r y , V o l . 3 3 , No. 1 , J a n . 1976, p. 74. 114] H. Freeman, J . G iovannon i , " S o c i a l Psychology o f Mental H e a l t h , " i n G. L i n d s e y , e d . : The Handbook o f S o c i a l Psycho logy , V o l . 5 , Add ison -Wes ley , 1969, p. 660. 115] W. Michaux, 1969, p. c i t . 116] W. Anthony, 1980, op. c i t . , p. 7 . 117] L. Bachrach , 1976, op . c i t . 118] C. Schwar tz , 1975, op . c i t . 119] C. Schwar tz , 1975, op . c i t . , p. 1225. 120] C. Schwartz , 1975, p. c i t . 121] E. Lambert e t a l . , " P r e d i c t i n g R e c i d i v i s m a t Tennessee's S t a t e P s y c h i a t r i c H o s p i t a l s , " H o s p i t a l & Community P s y c h i a t r y , Oct . 1983 , p. 951. 122] W. R e i d , A. S m i t h , Research i n S o c i a l Work, Columbia U n i v e r s i t y P r e s s , 1982, p. 84 . 123] L. Bachrach , 1982, o p . c i t . , p. 4 7 . 124] J . S t r a u s s , 1977, op . c i t . , p. 162. 125] G. M i l l e r , B. W i l i e r , 1976, op . c i t . 126] W. R e i d , A. S m i t h , 1982, op . c i t . , p. 7 9 . 127] J . Toews, G. Barnes , 1982, o p . c i t . , p. 36 . 1 3 2 . 128] M. B e i s e r , op . c i t . , 1983. 129] G. C l a u s e n , 1972, op . c i t . , p. 26. 130] J . S t r a u s s , W. Carpente r , 1977, op. c i t . , p. 162. 131] G. M i l e r , B. W i l i e r , 1976, op . c i t . 132] 1981 Canada Census, Catalogue 9 5 - 9 4 5 , V o l . 3 : P r o f i l e S e r i e s B, S t a t i s t i c s Canada. 133] 1981 Canada Census, Catalogue 9 3 - 9 2 2 , V o l . 2 : P r o v i n c i a l S e r i e s , Table 8 , S t a t i s t i c s Canada. 134] J . A F f l e c k e t a l . , 1976, o p . c i t . 135] 1981 Canada Census, Catalogue 9 9 - 9 3 4 , " L i v i n g A l o n e . " 136] J . N e a l e , T. Oltmanns, 1980, op . c i t . , p. 304. 137] J . A f f l e c k e t a l . , 1976, op . c i t . ; i38] D. M i l l e r , 1967, op. c i t . , p. 137. 139] J . S t r a y h o r n , 1982, op. c i t . 140] K. Bernheim, R. Lewine, S c h i z o p h r e n i a : Symptoms, Causes & Treatments , W.W. Norton & C o . , 1979, p. 136. 141] 1981 Canada Census, Catalogue 9 5 - 9 4 5 , V o l . 3 : P r o f i l e S e r i e s B, Table 1 , S t a t i s t i c s Canada. 142] J . A f f l e c k e t a l . , 1976, op . c i t . 143] R. Lewine, 1981, op . c i t . , p. 433. 144] R. Lewine, 1981, op . c i t . , p. 438. 145] S . Schwar tz , S . G o l d f i n g e r , 1981, op . c i t . , p. 470. 146] E. Goffman, Asy lums, A l d i n e Ch icago , 1961. 147] I. G l i c k , W. Hargreaves , 1979, op . c i t . 148] S . Schwar tz , S . G o l d f i n g e r , 1981, op . c i t . 149] W. Anthony, 1980, op. c i t . 150] J . Toews, G. Barnes , 1982, op . c i t . , p. 23 . 151] H. Lamb, 1982, op . c i t . 152] J . Knesevich e t a l . , 1983, op . c i t . 133. [153] W. Anthony, 1980, op . c i t . , p. 8 . [154] J . S t r a u s s , W. Carpenter , 1972, op . c i t . , p. 739. [155] I. G l i c k , W. Hargreaves , 1979, o p . c i t . [156] J . S t r a u s s , W. Carpente r , 1974, op . c i t . [157] G. M i l l e r , 1976, op . c i t . [158] W. Anthony, 1980, op. c i t . , p. 1 1 . [159] J . Toews, G. Barnes , 1982, op . c i t . , p. 33 . [160] J . H e l d , R. Cromwel l , 1968, op . c i t . , p. 264. [161] J . Beard e t a l . , " E v a l u a t i n g the E f f e c t i v e n e s s of a P s y c h i a t r i c R e h a b i l i t a t i o n Program," American Journal of O r t h o p s y c h i a t r y , 1963, 3 3 : page 701. [162] M. Seeman, 1982, op . c i t . [163] 1981 Canada Census, Catalogue 9 5 - 9 4 5 , V o l . 3 : P r o f i l e S e r i e s B, Table 1 , S t a t i s t i c s Canada. 

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