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.Sc,  The U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1978  A THESIS SUBMITTED IN PARTIAL  FULFILLMENT  OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK  in  The F a c u l t y o f Graduate S t u d i e s School o f S o c i a l Work  We a c c e p t t h i s t h e s i s as conforming to t h e r e q u i r e d s t a n d a r d  The U n i v e r s i t y o f B r i t i s h Columbia J u n e , 1984 ©  Simon D a v i s , 1984  {  In p r e s e n t i n g  t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of  requirements f o r an advanced degree a t the  the  University  o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make it  f r e e l y a v a i l a b l e f o r reference  and  study.  I  further  agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying o f 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  department o r by h i s o r her  the head o f  representatives.  my  It is  understood t h a t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain  s h a l l not be  allowed w i t h o u t my  permission.  Department o f The U n i v e r s i t y o f B r i t i s h 1956 Main Mall Vancouver, Canada V6T 1Y3  DE-6  M/Rn  Columbia  written  ii.  ABSTRACT  A group o f s c h i z o p h r e n i c s  living  i n the community were  followed  f o r a two y e a r p e r i o d , u s i n g 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 c a r e teams they were a t t e n d i n g . t a i n e d to the s u b j e c t s '  Information c o l l e c t e d  per-  current l i v i n g s i t u a t i o n , s t y l e of 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  services.  S o c i a l a d j u s t m e n t o f the sample was measured by employment s t a t u s and rehospitalization rate.  The r e s u l t i n g d e s c r i p t i o n o f the  population  i n d i c a t e d a group w i t h a high degree o f d i s a b i l i t y and dependency; 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 . that r e s i d e n t i a l  The study  rates  indicated  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  stable  o v e r the two y e a r 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 u n s t a b l e than the o l d e r s u b j e c t s ; the younger group had a significantly  h i g h e r 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  h e a v i e r consumers o f p s y c h i a t r i c s e r v i c e s . 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  In  looking for factors  that  community a d j u s t m e n t i t was found  that  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 p e r i o d tended to be y o u n g e r , u n employed, more r e c e n t l y  i n h o s p i t a l , and more f r e q u e n t v i s i t o r s  community c a r e teams; those who were unemployed a t the end o f follow-up  period  tended  to " b e  to  the  the.  m a l e , u n m a r r i e d , and p o s s e s s i n g 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 o f the s t u d y 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 r e a t m e n t 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 m i g h t be more " a t r i s k " than o t h e r s .  It  was a l s o suggested t h a t some o f the s o c i o - d e m o g r a p h i c v a r i a b l e s used i n t h i s study might be u s e f u l  diagnostically.  i v.  TABLE OF CONTENTS Page ABSTRACT  ii  LIST OF TABLES  vi  CHAPTER 1  PROBLEM FORMULATION AND RATIONALE FOR THE STUDY  2  1  LITERATURE REVIEW A)  3  6  Sociodemograhpic C h a r a c t e r i s t i c s o f Schizophrenics  ,6  B)  S t a b i l i t y o f Features Over Time  12  C)  Factors Associated with 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  13  D)  Sub-groups w i t h i n t h e S c h i z o p h r e n i c  E)  Summary  Population..  21 23  RESEARCH DESIGN  25  A)  Summary  25  B)  Level o f Design  25  C)  Nature o f t h e Sample  27  D)  Source o f I n f o r m a t i o n  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 o f Measures Used  46  H)  Timing o f Measurements  54  I)  Ethical  57  J)  S t r a t e g y o f Data A n a l y s i s  Issues  57  V.  CHAPTER 4  Page RESULTS A)  5  Sociodemograhpic C h a r a c t e r i s t i c s the P o p u l a t i o n  ,  of 59 J^-  B)  S t a b i l i t y Measures o f the P o p u l a t i o n  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 S c h i z o p h r e n i a Outcome Measures  DISCUSSION A)  Methodological  B)  Sociodemograhpic C h a r a c t e r i s t i c s o f Population..  Issues  ?4.  8  9  8  9  the 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 S c h i z o p h r e n i a Outcome Measures  log  Summary  120  E) REFERENCES  5 9  and C o n c l u s i o n s  125  LIST OF TABLES Table  Page  1  C r o s s t a b u l a t i o n o f Sex by Age f o r t h e Study P o p u l a t i o n  60  2  C r o s s t a b u l a t i o n o f Sex by Employment S t a t u s f o r t h e Study P o p u l a t i o n  60  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 t a t u s f o r t h e Study P o p u l a t i o n  61:.  4  Summary o f Age D i f f e r e n c e s f o r t h e Study P o p u l a t i o n  63-  5  C r o s s t a b u l a t i o n o f Age by Age a t F i r s t Hospitalization  .66:.  3  6 7 8  9  D i s t r i b u t i o n o f Age o f F i r s t Study P o p u l a t i o n  Psychiatric  P s y c h i a t r i c Contact f o r 68:'  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 f o r Study P o p u l a t i o n  Hospitalization '  69,  D i s t r i b u t i o n o f 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 f o r Study P o p u l a t i o n  70.  Change i n C l i e n t S t a t u s o v e r a Two Year P e r i o d  75  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  'Ti-  ll  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 by Employment S t a t u s f o r t h e Study P o p u l a t i o n 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 t h e Study P o p u l a t i o n  .80-'  12 13 14 15 16  81  C r o s s t a b u l a t i o n o f Employment S t a t u s by R e s i d e n t i a l S i t u a t i o n f o r t h e Study P o p u l a t i o n  83  C r o s s t a b u l a t i o n o f Employment S t a t u s by Employment H i s t o r y f o r t h e Study P o p u l a t i o n  83~!  C r o s s t a b u l a t i o n o f Employment S t a t u s by L i v i n g f o r t h e Study P o p u l a t i o n  85:  M u l t i p l e Regression of Interval Three Outcome V a r i a b l e s  Level  Variables  Situation with 8T.  1.  Chapter 1  INTRODUCTION:  PROBLEM FORMULATION AND RATIONALE FOR THE STUDY  T h i s study was a d e s c r i p t i v e community-based s c h i z o p h r e n i c s ,  living  i n v e s t i g a t i o n o f a group o f i n Vancouver,  and a t t e n d i n g the  community c a r e teams o f t h e G r e a t e r Vancouver Mental H e a l t h  Service.  The purpose o f the study was to d e s c r i b e t h e 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  histories,  their  o f l i v i n g and employment, and t h e i r use o f p s y c h i a t r i c s e r v i c e s . study was l o n g i t u d i n a l  patterns The  i n d e s i g n , t h a t i s , i t f o l l o w e d t h e same group  o f people f o r a p e r i o d o f two y e a r s .  As w e l l as d e s c r i b i n g t h e sample  i n g e n e r a l , t h e s t u d y had as an a d d i t i o n a l  purpose to l o o k f o r v a r i -  a b i l i t y w i t h i n the s a m p l e , t h a t i s , to t r y and see i f some o f t h e 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 e x p e r i e n c e a p s y c h i a t r i c  rehospitalization.  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 t h e 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 t h e communi ty. .care teams. seemed l o g i c a l  to t a k e advantage o f t h i s r e s o u r c e  in that i t  It  represented  a c e n t r a l i z e d , r e a s o n a b l y s y s t e m a t i c source o f i n f o r m a t i o n , t h a t had  2.  not been u t i l i z e d to any g r e a t e x t e n t p r e v i o u s l y . little  had been done by the G . V . M . H . S .  In t h a t  relatively  i n terms o f a comprehensive  e x a m i n a t i o n o f 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 c o u l d s e r v e an e x p l o r a t o r y  p u r p o s e , to c o n f i r m (or  disconfirm)  b e l i e f s t h a t may have p r e v i o u s l y  been t a k e n f o r g r a n t e d .  As w e 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 p o p u l a t i o n on d i f f e r e n t outcome measures ( e . g . rehospitalization)  i t was hoped t h a t  employment and  factors associated with better  (or  worse) outcome, c o u l d be i d e n t i f i e d , or t h a t poorer outcome ( " h i g h r i s k " ) groups w i t h i n t h e p o p u l a t i o n c o u l d 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 c o u l d have some c o n c r e t e , p r o g r a m / p o l i c y  implica-  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 o r groups who may r e q u i r e more p s y c h i a t r i c / rehabilitative attention. 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 s e v e r a l r e a s o n s .  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 ;  approximately  50% o f the G . V . M . H . S . c l i e n t s had a p r i m a r y d i a g n o s i s o f a c c o r d i n g to the 1982 Annual R e p o r t .  schizophrenia  Schizophrenia represents a serious  problem to a l l community mental h e a l t h programs because o f the d i s a b l i n g nature o f the d i s o r d e r and the c h r o n i c i t y o f the c o n d i t i o n . epidemiological illness:  Some  i n f o r m a t i o n g i v e s an i n d i c a t i o n o f the impact o f  about 1% o f 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  this  episode  d u r i n g t h e i r 1 i f e t i m e - [ 1 ] ; a s t u d y o f p o p u l a t i o n s t a t i s t i c s shows  that  those people a t g r e a t e s t r i s k f o r d e v e l o p i n g s c h i z o p h r e n i a (age 1 5 - 3 4 ) make up the l a r g e s t c o h o r t i n our t o t a l will  p o p u l a t i o n [ 2 ] , and most o f these  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% o f a l l  patients  a d m i t t e d 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 schizophrenic  [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  is  indicated  by the f i n d i n g t h a t o n l y about 25% o f r e l e a s e d s c h i z o p h r e n i c  patients  are a b l e to f i n d any employment i n the two y e a r p e r i o d a f t e r  hospital  discharge [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 o f s c h i z o p h r e n i a  Americans was e s t i m a t e d i n 1971 a t 14 B i l l i o n d o l l a r s a y e a r  to  [5].  Because o f 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 e x p e r i e n c e many mental h e a l t h t h e r a p i s t s view  schizo-  p h r e n i a 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 g o a l s o f t h i s study was to see i f  was the c a s e ; were t h e r e w i t h i n t h i s study p o p u l a t i o n o f some s u b j e c t s who were d o i n g b e t t e r than o t h e r 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 s t u c k w i t h the l a b e l  t h i s , in  schizophrenics,  The importance o f  l a b e l l i n g ; once an i n d i v i d u a l  " s c h i z o p h r e n i c , " the tendency i s to r e g a r d him 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 e r e 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 i m p o r t a n t t h a t the attempt was made to compare a s p e c t s o f t h i s study w i t h f i n d i n g s on s i m i l a r g r o u p s .  that  in  population  In f a c t , many o f the hypotheses  s o u r c e s o f >variabil i t y w i t h i n the group were suggested by o t h e r  element  this  is  (perhaps u n j u s t l y ) as e x a c t l y a l i k e o t h e r s w i t h the same l a b e l .  findings;  fact,  about  research  i n t h i s s e n s e , the study can be s a i d to have a r e p l i c a t i v e to It  it. has been s t a t e d t h a t t h e c u r r e n t study d e s c r i b e d  schizophrenics  on the b a s i s o f sociodemographic v a r i a b l e s , such as a g e , s e x ,  residence,  employment, m a r i t a l s t a t u s , p a s t h o s p i t a l  The  h i s t o r y and so o n .  study  4.  d i d not f o c u s on the symptomatic e x p r e s s i o n s o f the d i s o r d e r , h a l l u c i n a t i o n s and d e l u s i o n s .  e.g.  In p a r t t h i s i s a l i m i t a t i o n o f the s o u r c e  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 f a c e to f a c e  i n t e r a c t i o n , not through r e c o r d e d m a t e r i a l which was the b a s i s o f study.  this  The o t h e r i s s u e i s t h a t symptom e x p r e s s i o n has not been p a r t i c u l a  u s e f u 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  t h a 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 p s y c h o t 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 r e l e v a n c e to the p r e s e n t study  is  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 d i a g n o s i s does n o t p r o v i d e any u n i q u e l y r e l e v a n t i n f o r m a t i o n about the s u b j e c t ' s rehabilitation potential. This f i n d i n g i s r e a l l y not t h a t s u r p r i s i n g i n t h a t the p s y c h i a t r i c d i a g n o s t i c system was developed t o c a t e g o r i z e symptom p a t t e r n s , not t o p r o v i d e i n f o r m a t i o n about a p s y c h i a t r i c a l l y d i s a b l e d person's r e h a b i l i t a t i v e p r o s p e c t s . "  Anthony goes on to propose t h a t sociodemographic background m a t e r i a l on the c l i e n t (such as h i s 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 o f the d i s o r d e r measured by employment and r e h o s p i t a l i z a t i o n ) can h e l p to i d e n t i f y experience d i f f i c u l t y  and thus t h i s  (as  information  " h i g h 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 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 p r e s e n t community mental h e a l t h system i s t h a t l i n e workers a r e o f t e n not p r o v i d e d w i t h t h i s n e c e s s a r y background i n f o r m a t i o n : "A c r i t i c i a l component o f s e r v i c e d e l i v e r y i s a c a p a c i t y to p r o v i d e workers a t these s i t e s w i t h sufficient background i n f o r m a t i o n on p r e s e n t i n g i n d i v i d u a l s t o permit a p p r o p r i a t e d i a g n o s t i c and treatment p l a n n i n g 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)  l o o k 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 t h e r r e s e a r c h e r s c o u l d be a p p l i e d to a c c o u n t 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 c o u l d be i d e n t i f i e d as "high r i s k " (poorer r e h a b i l i t a t i o n  potential).  6.  Chapter 2  LITERATURE REVIEW  T h i s s t u d y 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 p h r e n i a 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 ) variables.  The l i t e r a t u r e r e v i e w a t t e m p t s to f o l l o w t h e sequence o f  the data a n a l y s i s , which r o u g h l y takes t h e f o l l o w i n g f o r m : s e n t a t i o n o f the i n d i v i d u a l  (A) A p r e -  sociodemographic v a r i a b l e s as they a p p l y  to the s t u d y s a m p l e ; (B) A l o o k a t the s t a b i l i t y o f the sample as measured by changes i n these same v a r i a b l e s o v e r t h i m e ; (C) A l o o k a t factors  that are associated with 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 l o o k a t t h e 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 s u b - g r o u p s the s c h i z o p h r e n i c  population.  There i s one note o f c a u t i o n :  within most o f  the s t u d i e s a r e A m e r i c a n , and t h e r e may be some problems i n comparing American data to t h e Canadian s c e n e . more d e t a i l  A.  This point w i l l  be d i s c u s s e d i n  i n Chapter 3.  Sociodemographic C h a r a c t e r i s t i c s o f S c h i z o p h r e n i c s 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 t h a t t h e r e i s an  equal p r e v a l e n c e and i n c i d e n c e o f s c h i z o p h r e n i a among men and women [10].  7.  There d o e s , however,  seem to be a d i f f e r e n c e i n age o f o n s e t f o r men  and women; i n r e v i e w i n g a number o f s t u d i e s Lewine [11] c o n c l u d e s  that  men are a t g r e a t e s t r i s k f o r f i r s t  their  psychiatric hospitalization in  t w e n t i e s , whereas women a r e 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  ii)  Age of Onset.  As noted above,  sex d i f f e r e n c e i n age o f o n s e t .  thirties.  t h e r e appears to be a  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 t w e n t i e s and e a r l y t h i r t i e s This r e f e r s  [12].  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 s h o u l d be noted  some s t u d i e s use age o f f i r s t  psychiatric  that  h o s p i t a l i z a t i o n as t h e i r  standard.  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 e p i s o d e and not be h o s p i t a l i z e d .  One study  t h a t t h e r e was a " l a g " between symptom o n s e t and f i r s t  hospitalization  23 months i n a sample o f s c h i z o p h r e n i c s  iii)  [13].  t h a t may e x p e r i e n c e 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 In r e v i e w i n g a number o f s t u d i e s , S t r a y h o r n 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 s c h i z o p h r e n i c discharge.  hospitalizations.  [14] c o n c l u d e s t h a t  the  i s 4 0 - 6 0 per c e n t w i t h i n  In another review Anthony [15]  talks  o f a r e c i d i v i s m "base r a t e " o f about 4 0 - 5 0 per c e n t f o r a one y e a r following hospital discharge. hospitalized psychiatric  of  S c h i z o p h r e n i c s a r e t y p i c a l l y a group  Hospitalization.  two y e a r s o f h o s p i t a l  noted  In t h i s summary Anthony i s t a l k i n g  p a t i e n t s i n g e n e r a l , not j u s t  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 n o t a f f e c t the r e c i d i v i s m r a t e [ 1 6 ] .  It  period about  schizophrenics, significantly  s h o u l d be noted t h a t whether or  not  8.  a person i s a d m i t t e d and how much time he spends i n h o s p i t a l  is  affected  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 t h e r than s i m p l y h e a l t h o f the i n d i v i d u a l .  More w i l l  the  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 c o p i n g 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 i n North America o v e r 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  in  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 t a y 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 s t u d y done by the Canadian Mental A s s o c i a t i o n i n Saskatchewan noted t h a t f i r s t l y , 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 to 246 a n d , s e c o n d l y , fell  Health  from 1957 to 1979 the  mental h o s p i t a l s f e l l  from 3400  the median l e n g t h o f s t a y a t p r o v i n c i a l  from 100 days i n 1948 to 22 days i n 1975 [ 1 7 ] .  institutions  W h i l e the  duration  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 , t h e r e has a t  the  same time been a t r e n d i n r e c e n t y e a r s o f more f r e q u e n t r e a d m i s s i o n s to and d i s c h a r g e s 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  iv) situational  door syndrome"  [18].  Employment. Although employment r a t e s a r e s u b j e c t  f l u c t u a t i o n s , employment s t a t u s i s n e v e r t h e l e s s  commonly  used as a measure o f s u c c e s s f u l c o p i n g i n s c h i z o p h r e n i a s t u d i e s . 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 a r e l o w . m a r i z e s the s i t u a t i o n i n the f o l l o w i n g  to  In  K e i t h [19] sum-  passage:  " I t Is e s t i m a t e d t h a t o n l y 15 to 40% o f s c h i z o p h r e n i c s f u n c t i o n a t an 'average' l e v e l ( e . g . a r e a b l e to work o r keep house). Discharged s c h i z o p h r e n i c s a r e l i k e l y to be c h r o n i c a l l y o r p e r i o d i c a l l y unemployed, thus c o n t r i b u t i n g t o the heavy burden o f unemployment i n society. F i n a l l y , the l a c k o f o p p o r t u n i t y f o r p r o p e r training 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 u s u a l l y become i l l between the ages o f 18 and 35 - the prime p r o d u c t i v e and c a r e e r - f o r m a t i v e years o f l i f e . "  Anthony and B u e l l  [20] propose a t y p i c a l  full  time employment r a t e  25 per c e n t f o r p s y c h i a t r i c p a t i e n t s one y e a r f o l l o w i n g h o s p i t a l the a u t h o r s a l s o note t h a t the s i t u a t i o n may w e l l be worse f o r p h r e n i c s than f o r p s y c h i a t r i c  v)  Suie'irfes.  for schizophrenics. o f the general schizophrenic  vi) are t y p i c a l l y  patients with other  rate  Status.  [22].  The m a r r i a g e r a t e s f o r  lower than the general  to male s c h i z o p h r e n i c s .  that  Another e s t i m a t e proposes t h a t 10% o f  p a t i e n t s w i l l d i e by s u i c i d e  adult schizophrenics  schizo-  One e s t i m a t e puts the r a t e a t twelve times  Marital  discharge;  diagnoses.  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  public [21].  of  schizophrenics  population, p a r t i c u l a r l y with  As an example, a S c o t t i s h study  found t h a t ,  [23] o f 375  f o r the men, 21% were c u r r e n t l y  5% s e p a r a t e d 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 . 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%.  regard  For  For the  married, the total  sample 58% had never been m a r r i e d w h i l e 35% were c u r r e n t l y m a r r i e d . reviewing several  In  s t u d i e s , T e s t and B e r l i n [24] c o n c l u d e t h a t the m a r r i a g e  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 r e l e s s than the male general  population.  considerably  Whether or not a s c h i z o p h r e n i c  has been m a r r i e d 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  traditional  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.  vii)  Mortality  I t would appear t h a t  Rates.  have a h i g h e r m o r t a l i t y r a t e than the general  schizophrenics  population.  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 inpatients  (of which o n l y 14 were over 50 a t time o f d i s c h a r g e )  d i e d w i t h i n the twelve y e a r p e r i o d a f t e r h o s p i t a l  viii) more f r e q u e n t l y  Living  discharge.  Schizophrenics  Situation.  35% had  tend to be l o c a t e d  i n the poorer urban a r e a s ; i n a r e v i e w Neale and Oltmanns  c o n c l u d e t h a 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 l m o s t found i n the l o w e s t s o c i a l c l a s s " [ 2 7 ] .  invariably  The i n f o r m a t i o n about  style  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 differences.  In Europe extended f a m i l y s u p p o r t i s emphasized to a  greater extent,  and i n any g i v e n area the c h o i c e o f accommodation i s  l i m i t e d by how many community mental h e a l t h r e s o u r c e s a r e a v a i l a b l e . Nevertheless,  i t would seem t h a t many p a t i e n t s are dependent  for support.  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  Miller  [28] found t h a t the m a j o r i t y  sort of family l i v i n g s i t u a t i o n .  (78%) were d i s c h a r g e d i n t o some  In A f f l e c k ' s 12 y e a r  s t u d y , e a r l i e r c i t e d , the a u t h o r s found t h a t 55% o f the  follow-up  schizophrenics  s t u d i e d were d i s c h a r g e d to a f a m i l y s e t t i n g , and t h a t 12 y e a r s t h i s d i s c h a r g e 47% were s t i l l l i v i n g w i t h f a m i l y [ 2 9 ] . . c a u t i o n e d 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 also detected a  Recent American l i t e r a t u r e  young, c h r o n i c a l l y mentally i l l  individual  following  I t s h o u l d be  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 at f o l l o w - u p .  patients,  She found t h a t 10% went to a group  home, and 12% to independent l i v i n g .  relatives  on f a m i l y  with  indicates that  the  tends to r e l y m a i n l y on f a m i l y  11.  s u p p o r t 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 s u p e r v i s e d group homes o r b o a r d i n g homes. s t u d y o f 120 y o u n g , c h r o n i c a l l y m e n t a l l y i l l  For example, i n a  a d u l t s i n New Y o r k ,  Caton  [30] found t h a t 42 per c e n t 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 c e n t i n s i n g l e room occupancy h o t e l s , and 28 per c e n t were l i v i n g a l o n e i n t h e i r own a p a r t m e n t s .  F i n d i n g s on the "new, young c h r o n i c  patients"  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 r e q u e n t moves w i t h i n and between major c i t i e s , and one worker has dubbed them " t h e new d r i f t e r s " [31].  ix)  Use of Services.  to the h e a l t h c a r e s y s t e m .  S c h i z o p h r e n i a r e p r e s e n t s a major problem  For example, i n 1973 a l o n e more than 140,000  s c h i z o p h r e n i c s were a d m i t t e d to s t a t e and county mental h o s p i t a l s the U.S.  [32].  An O n t a r i o s t u d y  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 a r e more  l i k e l y to be r e a d m i t t e d to h o s p i t a l than people w i t h o t h e r diagnoses [ 3 3 ] .  psychiatric  In the community s c h i z o p h r e n i c s may be c o n s i d e r e d  "unpopular" c l i e n t s . by the N a t i o n a l  in  T h i s 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  I n s t i t u t e f o r Mental H e a l t h i n the U.S.  [34]:  collected  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% o f p a t i e n t c a r e e p i s o d e s , whereas f o r the Community mental h e a l t h c e n t r e s i t comprised o n l y 10% o f p a t i e n t c a r e e p i s o d e s .  In a-<Danish s t u d y ,  Christensen  found t h a t o f 100 d i s c h a r g e d s c h i z o p h r e n i c s who were r e f e r r e d  [35]  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 i d a t t e n d many a t t e n d e d o n l y v e r y i n f r e q u e n t l y o f equal o r g r e a t e r than two months.  i.e.  30 a t t e n d e d a t  intervals  Anthony L36] conducted a s t u d y  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.  a t t e n d e d 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 g r o u p s .  Despite t h i s  finding,  a sex e f f e c t has been noted by a number o f w o r k e r s , 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 , t h e r e has been some r e c e n t 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 o u t o f t r e a t m e n t ) and " i n a p p r o p r i a t e l y , "  "drain  the time and energy o f c l i n i c i a n s "  B.  i n ways t h a t  [38].  S t a b i l i t y o f Features o v e r Time In r e v i e w i n g 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  that  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 r o u g h l y 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 y e a r Harrow [40] r e p o r t e d i n a n o t h e r study t h a t about 15% o f were f u n c t i o n i n g e f f e c t i v e l y  (without relapses)  c h a r g e , w h i l e 50% had a d j u s t e d v e r y p o o r l y .  follow-ups.  schizophrenics  three years a f t e r  dis-  In t h i s study the a u t h o r  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 t h e r 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. study, 10%  B l e u l e r [ 4 1 ] , i n another  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% r e c o v e r e d  remained  entirely,  s e r i o u s l y i l l , and 65% had c a r e e r s o f a l t e r n a t i n g  between p s y c h o t i c  phases and p e r i o d s o f 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 o v e r time ( f o l l o w i n g  hospital discharge)  but r a t h e r seem to  13.  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 In a 5 y e a r f o l l o w - u p study S t r a u s s  patients.  [43] compared the outcome measures  f o r h i s 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 y e a r 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 v e r y h i g h ,  concluding  t h a t "a two y e a r f o l l o w - u p study can be c o n s i d e r e d a r e l a t i v e l y substitute  for a longer i n v e s t i g a t i o n . "  adequate  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 r a u s s c o n c l u d e s t h a t " s c h i z o p h r e n i c 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 t h e r s e v e r e f u n c t i o n a l  patients, psychiatric  d i s o r d e r s , have a s i g n i f i c a n t but o n l y moderate s h i f t towards the s i d e o f the continuum c u r v e o f outcome d y s f u n c t i o n " a r t i c l e the a u t h o r q u a l i f i e s h i s f i n d i n g s  [44].  poorer  In the same  by s a y i n g t h a t i n h i s  study  t h e r e was no e v i d e n c e o f a homogeneously poor outcome i n s c h i z o p h r e n i a , nor i s t h e r e a b i - m o d a l d i s t r i b u t i o n o f outcome, i . e . range o f outcome types r a t h e r and "poor"  C.  there i s a  than two c l e a r c u t groups o f "good" '  outcome.  Factors Associated with D i f f e r e n t i a l i)  Outcome i n  Schizophrenia  Measures of Outcome. Outcome i n s c h i z o p h r e n i a can be  a s s e s s e d a c c o r d i n g to many d i m e n s i o n s , 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 o f s c h i z o p h r e n i a  outcome  are r a t h e r l o w , t h a t i s , good outcome i n one dimension does not  necessarily  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 .  conceives  o f the major outcome f u n c t i o n s  S t r a u s s [46]  (employment, r e h o s p i t a l i z a t i o n ,  r e l a t i o n s and symptoms) as b e i n g p a r t i a l l y l i n k e d o p e n - s y s t e m s , each a f f e c t e d p a r t l y  social  independent and as f o r m i n g by the o t h e r 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 p r e s e n t  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: t i o n and employment r a t e s .  rehospitaliza-  These were used i n p a r t because they c o u l d  be r e l i a b l y d i s c e r n e d 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 t h e r  researchers.  A number o f r e s e a r c h e r s have t r i e d to d i s c o v e r f a c t o r s  that  a r e 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 , w i t h the i d e a b e i n g 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 b e s t p r e d i c t o r of f u t u r e b e h a v i o u r i s behaviour.  past  T h i s author goes on to argue t h a t i f outcome p r e d i c t o r s  known, they can h e l p 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 (or  that  lesser)  are  need g r e a t e r  rehabilitative assistance.  ii)  Rehospitalization.  The b e s t p r e d i c t o r s o f f u t u r e  t a l i z a t i o n seem to be past r e c o r d s o f h o s p i t a l i z a t i o n .  In r e v i e w i n g a  number o f s t u d i e s Anthony [48] c o n c l u d e s t h a t the best p r e d i c t o r f u t u r e h o s p i t a l i z a t i o n i n p a s t number o f h o s p i t a l i z a t i o n s (a correlation).  rehospi-  T h i s 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  of  positive patients  i n g e n e r a l , however the same f i n d i n g has been made r e p e a t e d l y i n s t u d i e s t h a t have l o o k e d 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  [49].  S t r a u s s [50] i n a major s t u d y 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 o n l y by r e h o s p i t a l i z a t i o n but s e v e r a l i n d i c a t o r s ) was p r e v i o u s d u r a t i o n tions.  other  ( r a t h e r than numbers) o f h o s p i t a l i z a -  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 r e a t e 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 .  T h i s f i n d i n g has been c o n t r a d i c t e d somewhat by  the r e c e n t 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  15.  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 r e p o r t e d d e s p i t e the f a c t  that  the m a j o r i t y o f the s u b j e c t s 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 o f  past  h o s p i t a l i z a t i o n [51].  (It  s h o u l d be n o t e d , however,  t h a 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 i n S t r a u s s ' s s t u d y . ) [52] -  Some s t u d i e s - such as one by C h r i s t e n s e n  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 r e a t e r d u r a t i o n o f p a s t 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  relative  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 a u t h o r has argued t h a t a b e n e f i t o f l o n g - t e r m 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 discharge [53].  Still  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 r e c e n c y o f 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 o f r e h o s p i t a l i z a t i o n than p r e v i o u s numbers o f h o s p i t a l i z a tions [54].  T h i s r a i s e s q u e s t i o n s about the l e n g t h o f the  p e r i o d used i n s c h i z o p h r e n i a s t u d i e s :  follow-up  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 t h e r a u t h o r s argue t h a 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 r e a t throughout the e n t i r e y e a r o f  the  f o l l o w up p e r i o d [ 5 6 ] , and i n f a c t most f o l l o w up p e r i o d s a r e a t l e a s t a year in l e n g t h . As w e l l as h o s p i t a l h i s t o r y ,  a number o f r e s e a r c h e r s  l o o k e d 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 determine i f  have to  t h i s c o u l d 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 .  f o r t u n a t e l y , many o f the r e s u l t s a r e c o n f l i c t i n g .  Un-  Three major types  l i v i n g arrangement are 1) a l o n e , 2) w i t h s p o u s e , 3) w i t h f a m i l y as  of  16.  dependent.  Most s t u d i e s have i n d i c a t e d t h a t b e i n g w i t h f a m i l y as  dependent i s more l i k e l y to l e a d 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  alone,  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 M i c h a u x , f i n d i n g t h a 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 r e h o s p i t a l i zed more o f t e n than those i n p a r e n t a l s e t t i n g s  were  [59].  Michaux's  f i n d i n g s would seem to i m p l y t h a 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 the r o l e o f spouse i s i n f a c t more demanding. reported  Some r e s e a r c h e r s  that  have  t h a t m a r r i e d 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  and M i l l e r [61] concluded t h a t m a r r i e d s have the, l o w e s t r e t u r n r a t e any l i v i n g arrangement.  of  This l a t t e r f i n d i n g can i n t u r n 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 a u t h o r s  that marital status i s  unrelated  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 C h r i s t e n s e n t h a t the group w i t h the l o w e s t h o s p i t a l isolates.  [60]  [62]  r e t u r n r a t e a r e the s o c i a l  In summary, the f i n d i n g s r e g a r d i n g m a r i t a l s t a t u s a r e  murky and are confounded by some m e t h o d o l o g i c a l  problems.  rather  For example,  i s the m a r i t a l s t a t e i t s e l f p r o d u c i n g an e f f e c t t h a t l e a d s to g r e a t e r l e s s e r h o s p i t a l i z a t i o n , o r i s the person who becomes m a r r i e d  or  inherently  different  (and more f u n c t i o n a l )  than the person who does not become  married?  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 c o u l d 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 mentally healthy.  More w i l l  be s a i d on t h i s i n Chapter 3 .  R e l a t e d 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 o f 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 s u p e r v i s e d and accommodation.  Christensen  [63] r e p o r t e d  the  independent  t h a t i n h i s f o l l o w up s t u d y ,  17.  o f the " s u c c e s s e s " (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 ( w i t h p a r e n t s , i n n u r s i n g homes or h a l f w a y than the f a i l u r e s .  In summarizing a number o f s t u d i e s Anthony  concludes that t r a n s i t i o n a l f a c i l i t i e s ( i . e .  houses) [64]  f a m i l y c a r e homes and h a l f -  way houses) do lower t h e r e c i d i v i s m r a t e f o r people who remain i n the facility;  t h e author notes t h a t r e h o s p i t a l i z a t i o n r a t e s i n c r e a s e  people d i s c h a r g e d 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 o f the r a t e o f people i n u n s h e l t e r e d  for that  settings.  A number o f s t u d i e s have t r i e d to l o o k a t the q u e s t i o n 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 . r e s u l t s are c o n f l i c t i n g .  Once a g a i n ,  A number o f s t u d i e s , such as one by Winston  e t a l . [ 6 5 ] , c o n c l u d e 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 a r e r e h o s p i t a l i z e d a t a h i g h e r r a t e than those who d o .  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 a t t e n d a n c e and r e c i d i v i s m i s n o t 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  chronicity  [66] and type o f t r e a t m e n t [67] must be taken i n t o a c c o u n t .  There i s  a l s o the p r e v i o u s l y c i t e d C h r i s t e n s e n [68] s t u d y which found t h a t the d i s c h a r g e d s c h i z o p h r e n i c s w i t h the l o w e s t 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 t e n d a f t e r c a r e a t a l l .  In h i s r e v i e w Anthony  [69]  suggests t h a t t h e r e a r e 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 t e n d a f t e r c a r e c l i n i c s .  Anthony s p e c u l a t e s t h a t the s u c c e s s o f  such t r e a t m e n t c e n t r e s may be due e i t h e r to the nature o f people who v o l u n t a r i l y a t t e n d 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 p s y c h o t r o p i c m e d i c a t i o n .  As Bachrach [70] n o t e s , the c o n -  f o u n d i n g e f f e c t o f the drug t r e a t m e n t v a r i a b l e s h o u l d be taken i n t o a c c o u n t 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 o f the a p p a r e n t s u c c e s s o f community s u p p o r t systems i n the t r e a t m e n t o f c h r o n i c mental  patients."  A number o f o t h e r sociodemographic v a r i a b l e s p r e d i c t i n g have been i n v e s t i g a t e d , one o f them b e i n g a g e .  Anthony [71]  recidivism  suggests  t h a t the r e s u l t s a r e " 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 M e s s i e 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 r e a d m i t t e d than the o l d e r one.  T h i s 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 r e c e n t  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 t h r e g a r d to the v a r i a b l e  sex,  a l t h o u g h some r e s e a r c h e r s , such as Hogarty [ 7 3 ] , have d e t e c t e d a lower r a t e o f 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 t h a 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 r e v i e w Anthony [75] suggests t h a t employment h i s t o r y and o c c u p a tional  l e v e l a r e u n r e l a t e d to r e c i d i v i s m .  In the same r e v i e w  Anthony  concludes t h a t f i n d i n g s r e g a r d i n g e d u c a t i o n a l l e v e l and r a c e have been " q u i t e c o n s i s t e n t " i n t h a t t h e r e 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 r a c e 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 c o m b i n a t i o n w i t h r a c e was s i g n i f i c a n t l y associated  with readmission, i . e .  t h e r e 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 l a c k s and w h i t e s , o r between the employed and unemployed, but among the unemployed a h i g h e r number o f r e a d m i s s i o n s were b l a c k . It  s h o u l d 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  did  19.  not c o n t r o l  f o r f a c t o r s such as r a c e , u s i n g m a i n l y " W . A . S . P . "  sampl e s . In summary, a l t h o u g h a number o f r e s u l t s a r e 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 b e : p r e v i o u s numbers o f h o s p i t a l i z a t i o n s ; p r e v i o u s d u r a t i o n o f h o s p i t a l i z a tion;  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 ; l e v e l o f independence o f  a t t e n d a n c e a t an a f t e r c a r e c l i n i c ; a n d , t e n t a t i v e l y ,  iii)  age.  Employment. With r e g a r d to d i s c h a r g e d p a t i e n t s  employment d u r i n g 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 a r e s i m i l a r to those f o r r e h o s p i t a l i z a t i o n . and d u r a t i o n [78] o f p r e v i o u s  residence;  finding factors  In p a r t i c u l a r , number  [77]  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 , n e g a t i v e 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 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 o f the 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 t h a s u p e r i o r  that  variance  p a s t work  r e c o r d tend to be employed to a g r e a t e r e x t e n t a f t e r d i s c h a r g e from hospital.  Anthony  [80] suggests t h a t employment h i s t o r y  most i m p o r t a n t p r e d i c t o r o f p o s t - h o s p i t a l  employment.  a l s o seems to be a s s o c i a t e d w i t h employment, i . e .  i s the  Marital  single status  p a t i e n t s who a r e m a r r i e d  seem to be a b l e to o b t a i n and hold jobs to a g r e a t e r e x t e n t than s i n g l e or divorced i n d i v i d u a l s level  [81].  There i s some e v i d e n c e t h a t o c c u p a t i o n a l  is a significant predictor,  i.e.  a h i s t o r y of being a s k i l l e d  worker l e a d s to a b e t t e r employment outcome than f o r t h e u n s k i l l e d individual  [82].  Results f o r the v a r i a b l e  "age" a r e c o n f l i c t i n g ; some  a u t h o r s c o n c l u d e t h a t age i s not r e l a t e d to re-employment [ 8 3 ] ,  however  20.  the more r e c e n t "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 s t u d y by Schwartz [84] based i n San F r a n c i s c o found an unemployemnt r a t e o f about 90% f o r t h e p r i m a r i l y young s a m p l e , a f i g u r e h i g h e r  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 a u t h o r s have found r a c e 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 b e i n g w h i t e g i v e s 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  [85].  There i s , o f c o u r s e , an o b v i o u s q u a l i f i c a t i o n w i t h r e g a r d to v a r i a b l e s such as age and r a c e i n t h a t the unemployment r a t e s o f the young or nonw h i t e s may be lower i n the general p o p u l a t i o n as w e l l  [86].  In h i s  review Anthony [87] c o n c l u d e s t h a t the v a r i a b l e s " s e x " and " e d u c a t i o n a l l e v e l " a r e u n r e l a t e d to re-employment r a t e s .  Most o f the s t u d i e s  reviewed  seemed to bear o u t t h i s f i n d i n g , a l t h o u g h some more r e c e n t 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 r e c o r d 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 h e a l t h f a c i l i t y o r l i v e s i n d e p e n d e n t l y .  Some s t u d i e s  have i n f a c t r e p o r t e d a h i g h e r employment r a t e f o r people i n group homes [ 8 9 ] .  However, i n h i s r e v i e w Anthony [90] c o n c l u d e s t h a t w h i l e  transitional  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 n o t 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 t h a 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  facility.  In summary, t h e 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 employment s t a t u s seem to b e :  number and d u r a t i o n o f p r e v i o u s  hospitalizations;  21.  employment h i s t o r y ; m a r i t a l s t a t u s ; o c c u p a t i o n 1 e v e l ,  and,"tentatively,  age.  D.  Sub-Groups w i t h i n the S c h i z o p h r e n i c  Population  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 a r e v a l i d to the e x t e n t  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 , and t r e a t m e n t o f the d i s o r d e r . ones found i n the D . S . M . I l l , u s u a l l y been v e r y u s e f u l  Traditional  onset,  subdivisions,  outcome  such as the  based on symptom e x p r e s s i o n , have not  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  have had low r e l i a b i l i t y r a t e s i t has o f t e n been more u s e f u l sociodemographic v a r i a b l e s .  [91].  As we have seen i n the l a s t  section  to s u b d i v i d e s u b j e c t s on the b a s i s Examples t h a t have been d i s c u s s e d  of  earlier  a r e 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 b a s i s 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 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 .  and  of  distinguishing  F a c t o r s r e l a t i n g to  subject's  past h i s t o r y a r e o f t e n i m p o r t a n t i n p r e d i c t i n g outcome, and these  factors  ( 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 o f r e s i d e n c e )  of  have the advantage  being a n t e c e d e n t to the outcome o f the d i s o r d e r . have t r i e d to d i s t i n g u i s h the b a s i s o f h i s t o r i c a l suggests  A number o f workers  "good" and "poor" outcome s c h i z o p h r e n i a on  f a c t o r s ; one s t u d y by Knesevish e t a l .  t h a 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  ( u s u a l l y before 3 5 ) , a l e n g t h i e r o n s e t , and an i n f e r i o r  hospitalization history,  p a s t j o b and s o c i a l r e c o r d .  Other  have l o o k e d 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 among s c h i z o p h r e n i c s .  [92] onset  a more gradual researchers  distinguishing  In her r e v i e w , Seeman [93] notes t h a t  schizophrenic  22.  women have a l a t e r o n s e t o f 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 employment and r e h o s p i t a l i z a t i o n r a t e s ) . are t e n t a t i v e ,  Although her f i n d i n g s about outcome  the f i n d i n g s about age o f o n s e t have been c o n f i r m e d i n a  number o f o t h e r s t u d i e s  [94] which i s s i g n i f i c a n t i n t h a t age o f  has been found to be a s s o c i a t e d w i t h (good v s .  poor) outcome.  onset  It  has  been s p e c u l a t e d 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 t h 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 protective  physiological  f a c t o r s which c o u l d a f f e c t the m a n i f e s t a t i o n o f an i l l n e s s  such as s c h i z o p h r e n i a  [95].  One v a r i a b l e t h a t has become prominent i n r e c e n t y e a r s as a means o f 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 young c h r o n i c s " have a l r e a d y been mentioned s e v e r a l  "new,  times i n t h i s  T h i s group has been g i v e n o t h e r t i t l e s such as "the new d r i f t e r s " "chronic c r i s i s patients"  [96].  In summary, t h i s  paper. and  i s a group t h a 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 activity  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 ,  p r e d o m i n a n t l y 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 but i n an " i n a p p r o p r i a t e way" [ 9 9 ] ,  services,  is often "intensely d i s l i k e d "  t h e r a p i s t s , and tends to l e a d 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 [100].  Bassuk [101] seeS some v a l i d i t y  as a " d i s c r e t e c l i n i c a l  group."  i n r e g a r d i n g these  by existence  individuals  The main common denominator f o r  group i s t h a t they are m o s t l y young tively  is  (usually  this  under 35) and have a r e l a -  s h o r t 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 h a t i s , they have grown up  d u r i n g 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 . " as to why t h e s e people form a d i s c r e t e g r o u p :  It  is interesting  to  speculate  as one a u t h o r n o t e s , i t  is  23.  a p p a r e n t l y t h e 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 America, 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  the new, young c h o r n i c  [102].  l i t e r a t u r e and i n c l i n i c a l patients are heavily  It  North "created"  has a l s o been o b s e r v e d , both i n the  experience,  t h a t many o f the "new c h r o n i c "  i n v o l v e d w i t h s t r e e t drugs and t h a t some o f  e x p r e s s i o n s o f the i l l n e s s may be t r i g g e r e d  E.  e x i s t i n g i n much o f  by the d r u g - t a k i n g  the  [103].  Summary In  summary, the l i t e r a t u r e  schizophrenics are t y p i c a l l y  i n d i c a t e s t h a t community-based  a d e b i l i t a t e d , dependent g r o u p ,  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 o f  particularly 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 b e i n g schizophrenic.  I t was noted t h a t the s c h i z o p h r e n i c r e p r e s e n t s a c o n s i d e r -  able 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  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  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 , i n d e f i n i t e period  of time.  -*n  Despite these f i n d i n g s ,  t h a t t h e r e was some v a r i a b i l i t y  and the com-  some i t was  the  cases proposed  i n the outcome o f 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 t h a 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 t h b e t t e r or poorer outcome, as measured p r i m a r i l y by and employment r a t e s . hospital history,  In p a r t i c u l a r ,  rehospitalization  i t was proposed t h a t a c l i e n t ' s  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 i s a t t e n d a n c e a t  after-  c a r e c l i n i c s c o u l d s e r v e 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  rehospi-  tal i z a t i o n .  that  S i m i l a r l y , w i t h r e g a r d to employment, i t was noted  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  linked with potential  f o r f u t u r e , employment.  In the l a s t s e c t i o n ,  was proposed t h a t c e r t a i n sociodemographic f e a t u r e s o f the  it  schizophrenic  p o p u l a t i o n could 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 t h a t d i f f e r e d from the r e s t on the b a s i s o f the o n s e t 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  rubric  "schi zophrenia." 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 s t a n d a r d s  comparison i n the p r e s e n t s t u d y , a d e s c r i p t i v e study of schizophrenics.  Vancouver  The study was guided by the f o l l o w i n g q u e s t i o n s :  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 and are they d o i n g as badly (or as w e l l ) in other studies?  for  i n the  as the s c h i z o p h r e n i c s  study  described  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  p o p u l a t i o n d i s t i n g u i s h them from o t h e r s t u d y groups?  what  study  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 a r e a s s o c i a t e d w i t h a b e t t e r outcome, and a r e these the same c h a r a c t e r i s t i c s seen i n o t h e r s t u d i e s ? i s t h i s a u n i f o r m g r o u p , o r do s u b - g r o u p s sub-groups Vancouver  e x i s t and a r e they the same  t h a t have been d e t e c t e d by o t h e r w o r k e r s ? have the d i s t i n c t i v e  Finally,  For example, does  "new, young c h r o n i c " p o p u l a t i o n  has been d e s c r i b e d i n o t h e r American c e n t r e s ?  that  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  schizophrenics,  comparisons w i t h o t h e r groups are c r u c i a l because d i f f e r e n c e s  in  o f t e n l e a d to u s e f u l  findings  i n s i g h t s about the n a t u r e o f the s u b j e c t group and  the c a r e 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 o f Research Design T h i s s t u d y had as i t s sample a group o f s c h i z o p h r e n i c s ,  i n the community, and a t t e n d i n g the Vancouver 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  Community Care Teams.  i)  The  a b i l i t y w i t h i n the group c o u l d be d e t e c t e d and p r e d i c t e d .  the  using 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  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  of  to note the s t a b i l i t y o f  sample o v e r time as measured by these same v a r i a b l e s ; i i i )  Level o f  purpose  to d e s c r i b e the sample on the b a s i s  a number o f sociodemographic v a r i a b l e s ; i i )  B.  The  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. o f the study was t h r e e f o l d :  living  vari-  These e l e m e n t s ,  be d i s c u s s e d i n more d e t a i l  below.  Design  T h i s study was d e s c r i p t i v e  i n the sense t h a t a l t h o u g h  differences  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 a r e n o t e d , i s not i m p l i e d .  A study can be termed e x p e r i m e n t a l  to the e x t e n t t h a 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 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 out.  causality it  of  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 p e r f o r m e d , but r a t h e r hand from r e c o r d s .  i n f o r m a t i o n was gathered s e c o n d -  C o n s e q u e n t l y , v a r i a b l e s c o u l d not be m a n i p u l a t e d a n d ,  as w i l l be n o t e d , e f f e c t s o f extraneous v a r i a b l e s c o u l d not be r u l e d o u t . Although c a u s a l i t y i s n o t 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 s t u d y were suggested by o t h e r 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 s t u d y i s c o m p a r a t i v e or r e p l i c a t i v e to an e x t e n t i n f i n d i n g s from t h i s s t u d y a r e c o n t r a s t e d w t i h those o f o t h e r Because o f problems w i t h e x t e r n a l  validity,  studies.  d i s c u s s i o n was l i m i t e d  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 .  that  To the e x t e n t t h a t  largely rela-  t i v e l y l i t t l e s y s t e m a t i c r e s e a r c h 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 s t u d y a l s o l e g i t i m a t e l y be termed  could  exploratory.  The s t u d y 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 , t h a 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 l o s e d - e n d e d i n  i t was assumed t h a t they possessed f a c e v a l i d i t y .  nature;  Such an approach was  n e c e s s i t a t e d by the n a t u r e o f the f i l e s t h a t were examined i n t h a t  it  i s d i f f i c u l t to r e l i a b l y a s s e s s more s u b j e c t i v e measures o f c l i e n t  func-  t i o n i n g (such as q u a l i t y o f 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 q u a n t i t a t i v e 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 d r o p p e d .  An advantage o f a q u a n t i t a t i v e  orientation  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 analyzed.  The main d i s a d v a n t a g e i s t h a t q u a n t i t a t i v e s t u d i e s do not p e r m i t  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 q u a n t i t a t i v e s t u d i e s have argued  t h a t a t b e s t the r e s u l t s p r o v i d e o n l y 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 b e i n g used a r e u n c e r t a i n ; these p o i n t s w i l l  be addressed f u r t h e r  in this section.  27.  C.  Nature o f the Sample The p o p u l a t i o n t h a t the s t u d y sample was drawn from c o n s i s t e d  o f a group o f people w i t h a p r i m a r y 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 G r e a t e r Vancouver Mental H e a l t h S e r i v c e . clinical ill  The G . V . M . H . S .  provides  s e r v i c e s and p s y c h o - s o c i a l s u p p o r t to the community based m e n t a l l y  o f Vancouver and Richmond through e i g h t l o c a l community c a r e teams.  The people i n c l u d e d i n t h i s s t u d y were a c t i v e c l i e n t s of the  G.V.M.H.S.  between November 1 9 8 1 , and November 1 9 8 3 ; t h i s two year s t r e t c h sented the s t u d y p e r i o d .  The sample was f u r t h e r  repre-  l i m i t e d as f o l l o w s :  s u b j e c t s 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 .  ("Prior"  i n t h i s c a s e means  p r i o r to November 1 9 8 1 , which was the s t a r t o f the s t u d y  period.)  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 t h 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 t h the as o f November, 1 9 8 1 . sampled.  G.V.M.H.S.  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  Of the 345 a c t i v e i n November 1981 i t was d i s c o v e r e d t h a t 111  s u b s e q u e n t l y dropped o u t o f t r e a t m e n t i n the f o l l o w i n g two y e a r s and d i d not r e t u r n to t h e G . V . M . H . S .  T h i s l e f t a group o f 234 who were a c t i v e  i n November 1981 and November 1 9 8 3 , i . e . who shared t h e same two y e a r study p e r i o d .  T h i s group o f 234 formed the sample f o r t h i s  study.  The purpose i n t h i s s t u d y was to s t a r t out w i t h a  reasonably  homogeneous s a m p l e ; the reason f o r t h i s i s t h a 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 sample.  the  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 c h o s e n .  As w e l l , c l i e n t s w i t h a v e r y 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 .  T h i s 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, t h a t p a s t h o s p i t a l h i s t o r y can a c c o u n t 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 t h v e r y few h o s p i t a l i z a t i o n s might be c o n s i d e r e d p r o g n o s t i c a l l y d i f f e r e n t from a group w i t h 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 t h a 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 g r o u p ; the s t r a t e g y i n t h i s s t u d y was to t a k e 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 t h e r 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 for t h e i r e f f e c t subsequently,  i n the data a n a l y s i s .  to  control  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 s a m p l i n g was " a g e " ; the sample had a f a i r l y wide age r a n g e , from 20 to 5 0 . b e c a u s e , as was noted i n the l i t e r a t u r e r e v i e w ,  This i s  people a l i v e a t  significant different  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 tion.  The o l d e r c l i e n t was around when a l o n g e r d u r a t i o n of h o s p i t a l  s t a y was t h e norm; i f ,  as S t r a u s s [104]  suggests, duration of  prior  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 s u b j e c t s who a r e not s i m i l a r i n a g e . However, i t was attempted to a c c o u n t f o r t h i s by examining the e f f e c t 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 , institutional  of  and  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 p a r t  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  of  later  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 p r o b l e m a t i c i n t h i s s t u d y was t h a t  of  d i a g n o s i s ; i t was assumed f o r the purposes o f the s t u d y t h a 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 i v e n by the community c a r e team p s y c h i a t r i s t s t h e s u b j e c t s - was i n f a c t c o r r e c t .  to  T h i s 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 of p s y c h i a t r i c diagnosis i s r e l a t i v e l y may be l a b e l l e d d i f f e r e n t l y  p o o r , t h a t i s , t h e same person  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 s e v e r a l times over the c o u r s e of h i s " c a r e e r "  [105],  I d e a l l y i n a s t u d y one would l i k e the d i a g n o s i s to be i n d e p e n d e n t l y c o n 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 time and r e s o u r c e tions.  limita-  One plus was t h a t most o f the people i n the s t u d y had had h i s t o r i e s  l o n g 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 . 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 e x t e n t by s e v e r a l  (I.e.  inter-  independent  diagnoses.) 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  for  i n t r a - g r o u p d i f f e r e n c e s ; t h e r e i s a l s o a problem i n t r y i n g to e v a l u a t e 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 e x t e n t was the sample i n t h i s s t u d y d i f f e r e n t from o r n o n - r e p r e s e n t a t i v e o f o t h e r of schizophrenics?  groups  One o b v i o u s . p o i n t i s t h a 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 m i g h t 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 As was noted i n the l i t e r a t u r e r e v i e w ,  after-care.  i t appears t h a t people who e l e c t  to a t t e n d 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] s p e c u l a t e s 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 , o r to the n a t u r e o f the people who e l e c t to a t t e n d a f t e r c a r e 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 r e a t m e n t v a r i a b l e i s presumably c o n s t a n t w i t h i n the s a m p l e . )  ?6V  Although r e s u l t s o f 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 a r e commonly compared, t h e r e a r e obvious between s e t t i n g s i n terms o f t r e a t m e n t and housing r e s o u r c e s ,  differences political  and economic c l i m a t e and so on t h a t c o u l d c o n c e i v a b l y a f f e c t the outcome variables.  The q u e s t i o n r e m a i n s :  do d i f f e r e n c e s i n outcome d e t e c t e d  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 the sample or a d i f f e r e n c e i n the system o f c a r e w i t h which the interacts?  in  individual  A r e c e n t , l o c a l s t u d y attempted to answer t h i s ' q u e s t i o n 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 t h a s i m i l a r group i n P o r t l a n d , Oregon [ 1 0 7 ] .  The r e s e a r c h e r s 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 characteristics.  The s u b j e c t s were f o l l o w e d up a p p r o x i m a t e l y one y e a r  a f t e r d i s c h a r g e 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 ,  at  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 t h a t 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 o f readmissions -  .8 f o r Vancouver,  2 . 0 f o r P o r t l a n d ) and more o f the  group was employed (employment r a t e - 33% f o r Vancouver;  15% f o r  The c o n c l u s i o n s o f the a u t h o r s was t h a t the s u c c e s s o f the  Vancouver  Portland).  Vancouver  group was due to a d i f f e r e n c e i n the s y s t e m , 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 . a u t h o r s 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 P o r t l a n d i n t h a t i t was more e x t e n s i v e , h e n s i v e and a f f o r d a b l e .  The  compre-  The i m p l i c a t i o n s o f t h i s l a t t e r s t u d y f o r  c u r r e n t p r o j e c t were as f o l l o w s :  firstly,  this  that differences in schizophrenic  p o p u l a t i o n s 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 o f  differences  i n the system of c a r e a n d , s e c o n d l y , t h a t because o f t h i s the outcome f o r t h e 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 d e t e c t e d  in  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  Information  As noted e a r l i e r , the i n f o r m a t i o n f o r t h i s s t u d y was gathered from c l i n i c a l  files.  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 time a t low c o s t and w i t h minimal i n t r u s i v e n e s s . t h i s was a r e t r o s p e c t i v e ,  T h i s was p a r t i c u l a r l y t r u e i n  r a t h e r than p r o s p e c t i v e s t u d y .  that  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 r e c o r d e d may depend on the whim o f  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 a t t e m p t to  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 o f the v a r i a b l e s  get  (usually  q u a n t i t a t i v e ) t h a t 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 . was n e v e r t h e l e s s  It  p r e d i c t e d t h a t t h e r e 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 t u d y .  A p r o s p e c t i v e f i l e study would have the  advantage o f b e i n g a b l e to s p e c i f y ahead o f time the v a r i a b l e s o f  interest,  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 t h o u g h a p r o s p e c t i v e s t u d y would t a k e l o n g e r than a r e t r o s p e c t i v e o n e .  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 o f c o n s i s t e n c y o v e r time i n t h a t r e c o r d i n g change.  procedures  T h i s was n o t a major problem w i t h t h i s study i n t h a t the same  historical  p e r i o d (Nov.  1981-November 1983) was used f o r a l l  subjects.  The i n f o r m a t i o n i n the f i l e s was o f two major k i n d s : i t was i n f o r m a t i o n r e c o r d e d by the G . V . M . H . S .  part  t h e r a p i s t , and p a r t o f  was r e c o r d s and documents from o t h e r i n d i v i d u a l s and a g e n c i e s .  The  of it  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 consisted of i n i t i a l  updated p s y c h i a t r i c a s s e s s m e n t s , ongoing progress medical/social s i t u a t i o n , prescriptions  notes about the  f i l l e d o u t when t h e r e was a s e r i o u s i n c i d e n t c o n c e r n i n g the well being ( t y p i c a l l y  client's  and i n f o r m a t i o n about the  drug r e g i m e n , and "unusual o c c u r r e n c e " forms t h a t were r e q u i r e d  a serious suicide attempt).  and  current  to be  client's  For c e r t a i n k i n d s  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 had been a d m i t t e d to Venture he came to the team.  he  (the s h o r t s t a y c r i s i s h o s t e l ) and how o f t e n  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  recorded;  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 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 , 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 .  than  his  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 w o r d ; f o r e x a m p l e , 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 , o r 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 r e c o r d e d - 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 c o n f i r m e d by c o n t a c t w i t h institution.  Unfortunately,  a s y s t e m a t i c r e c o r d of t h e c l i e n t ' s  the  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 G . V . M . H . S .  t h e r a p i s t c o n t a i n e d i n f o r m a t i o n about the c l i e n t ' s  history,  The i n i t i a l assessment performed by  the o n s e t 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 .  o f t h i s was g o t t e n from the c l i e n t h i m s e l f , o r from a " s i g n i f i c a n t  past Some other,"  and much o f t h i s was d e r i v e d from h o s p i t a l r e c o r d s or documents from o t h e r  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 .  H o s p i t a l r e c o r d s 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 c o m p l e t e ; even when the c l i e n t had an o u t o f p r o v i n c e h o s p i t a l i z a t i o n the r e c o r d s were s e n t for.  H o s p i t a l r e c o r d s were the most r e l i a b l e source o f 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  of  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 a d m i s s i o n and d i s c h a r g e were always i n c l u d e d on the h o s p i t a l records.  R i v e r v i e w h o s p i t a l always had a summary s h e e t o f p a s t h o s p i t a l i z a -  t i o n s as p a r t o f t h e i r r e c o r d . on the c l i e n t ' s e a r l y l i f e ,  H o s p i t a l r e c o r d s u s u a l l y a l s o had i n f o r m a t i o n  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 psychiatric hospitalization.  A d m i t t e d l y , not a l l  were c o m p r e h e n s i v e , and a l s o the G . V . M . H . S . all  hospital  records  f i l e s d i d not sometimes possess  t h e 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  c l i e n t was m o b i l e and became h o s p i t a l i z e d o u t o f p r o v i n c e .  the  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 t h e r r e c o r d s were sometimes i n the G . V . M . H . S .  file,  such as correspondence from the p o l i c e , from r e l a t i v e s , from i n s u r a n c e companies and so o n . In S e c t i o n E below each v a r i a b l e i s d e f i n e d and a l s o the s o u r c e 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 a d d r e s s e d .  E.  Variables  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 s t u d y 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 s o u r c e from where the i n f o r m a t i o n was d e r i v e d (where  necessary).  3'4. i)  Sex.  ii)  Age.  T h i s r e f e r r e d to age ( i n y e a r s )  November, 1981 (the s t a r t o f the study  iii) (in years)  Age of first  psychiatric  o f the c l i e n t on  period).  contact.  This was the age  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 c a r e system  f o r p s y c h i a t r i c problems. f i r s t became  "Onset" u s u a l l y r e f e r s to the age when symptoms  a p p a r e n t ; 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-  c h i a t r i c c o n t a c t i t may r e q u i r e people (such as the c l i e n t or  v  relatives)  to r e c a l l when i t o c c u r r e d 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 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 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 r e c o r d e d on h o s p i t a l o r d o c t o r ' s f o r m s . t h i s p r e s e n t s t u d y the v a r i a b l e  In the case o f  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  u s u a l l y d e r i v e d from h o s p i t a l or d o c t o r ' s r e c o r d s i n c l u d e d i n the  was file;  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  t i v e ) r e c a l l i n g age o f 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  rela-  therapist.  At o t h e r t i m e s , the r e f e r e n c e to age o f f i r s t c o n t a c 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 c o u l d not be r e c o r d e d .  i v ) - Age of first  psychiatric  hospitalization.  This  variable  was s i m i l a r t o number i i i a b o v e , and a g a i n was used as an i n d i c a t o r o f age o f o n s e t o f i l l n e s s .  A p e r s o n ' s f i r s t p s y c h i a t r i c c o n t a c 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 t h e r e may be a " l a g "  35  between f i r s t c o n t a c t and f i r s t h o s p i t a l i z a t i o n . hospitalization  Nevertheless,  first  i s a u s e f u l v a r i a b l e i n t h a t i t can u s u a l l y be r e l i a b l y  d e r i v e d form f i l e i n f o r m a t i o n .  In the case o f t h i s s t u d y 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 time from h o s p i t a l r e c o r d s i n c l u d e d i n the f i l e s .  v)  Duration of prior  T h i s was the amount"  hospitalization.  o f t i m e , i n months, t h a t the c l i e n t had s p e n t as a p s y c h i a t r i c p r i o r to November, 1 9 8 1 . month.)  (The f i g u r e was rounded o f f to the n e a r e s t  The i n f o r m a t i o n i n t h i s s t u d y was d e r i v e d from h o s p i t a l  i n c l u d e d i n the f i l e s .  records  H o s p i t a l r e c o r d s r e l i a b l y r e c o r d a d m i s s i o n and  d i s c h a r g e d a t e s , however, hospital  inpatient  f o r a number o f f i l e s , not a l l t h e  relevant  r e c o r d s 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 c o u l d not be  recorded..  vi)  T h i s r e f e r r e d to how  Time since last hospitalization.  l o n g 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. was r e l i a b l y r e c o r d e d i n the G . V . M . H . S . f i l e , to a r e c e n t e v e n t .  information  since i t usually  referred  The h o s p i t a l r e c o r d was i n c l u d e d i n the m a j o r i t y  c a s e s , and was the major s o u r c e o f i n f o r m a t i o n . were r e f e r r e d to i n the G . V . M . H . S . back s e v e r a l months or y e a r s . the G . V . M . H . S .  This  As w e l l , h o s p i t a l i z a t i o n s  progress n o t e s , which u s u a l l y went  H o s p i t a l i z a t i o n s were always r e c o r d e d by  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 c o n t a c t w i t h h o s p i t a l  personnel.  vii)  of  Previous number of hospitalizations.  This was the  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 p r i o r to November, 1 9 8 1 .  This  36  i n f o r m a t i o n was d e r i v e d from h o s p i t a l r e c o r d s i n c l u d e d i n t h e  files.  H o s p i t a l r e c o r d s had a l i s t i n g o f p r i o r a d m i s s i o n s to the same h o s p i t a l , and i n many c a s e s , to o t h e r 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 o f p r o v i n c e ,  this  i n f o r m a t i o n was not a v a i l a b l e .  viii) question:  "In  Employment history.  the p r e v i o u s 5 y e a r s  T h i s was a " y e s - n o " answer to t h e  ( d a t i n g back from November 1981) has  the c l i e n t h e l d a c o m p e t i t i v e job - f u l l t i m e o r p a r t time 6 months c o n s e c u t i v e l y ? "  for at  This i n f o r m a t i o n was d e r i v e d from the  notes w r i t t e n by the G . V . M . H . S .  therapist.  least  progress  Where the progress notes d i d  n o t extend back f a r enough (5 y e a r s ) the i n f o r m a t i o n c o u l d 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 r e c o r d s t h a t preceded the c l i e n t ' s c o n t a c t w i t h t h e 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 . 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 c o n f i r m e d f i r s t  One problem hand by the  t h e r a p i s t , but r a t h e r taken from t h e c l i e n t h i m s e l f .  ix) the c l i e n t h a d .  Schooling.  This was how many y e a r s of f o r m a l e d u c a t i o n  This was u s u a l l y r e c o r d e d on h o s p i t a l r e c o r d s , o r  some cases was taken from the i n i t i a l assessment done by the therapist.  in  G.V.M.H.S.  U l t i m a t e l y , t h i s was a p i e c e o f i n f o r m a t i o n g i v e n 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.  T h i s was composed o f t h r e e  catgories:  A) s i n g l e , never m a r r i e d ; B) m a r r i e d ; C) s e p a r a t e d o r d i v o r c e d . i n f o r m a t i o n was d e r i v e d from the progress  The  notes o f the G . V . M . H . S .  as w e l l as from c l i e n t h i s t o r i e s r e c o r d e d i n h o s p i t a l r e c o r d s . the G . V . M . H . S . situation (e.g.  this information f i r s t  hand.  to c o n f i r m  to wife/husband i n the c o n v e n t i o n a l  Employment status.  s e n s e , not common-law w i f e .  There were n i n e c a t e g o r i e s  t i m e ; D) s h e l t e r e d p a r t t i m e ; E) v o l u n t e e r work;  r e g u l a r , open market j o b .  I)  unemployed.  F) v o c a t i o n a l  here: full  training;  " C o m p e t i t i v e " meant a  " S h e l t e r e d " meant the p e r s o n ' s  psychiatric  d i s a b i l i t y had been taken i n t o a c c o u n t and hence the pace or o f the work was geared down.  of,  specifically  t i m e ; B) c o m p e t i t i v e p a r t t i m e ; C) s h e l t e r e d  G) i n s c h o o l ; H) between j o b s ;  relation-  t h a t were hard to keep t r a c k  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  A) c o m p e t i t i v e f u l l  living  Some c l i e n t s had o n - a g a i n , o f f - a g a i n  ships with 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  xi)  Usually  t h e r a p i s t was f a m i l i a r enough w i t h the c l i e n t ' s by home v i s i t s o r by t a l k i n g to the spouse)  files,  difficulty  Examples o f t h i s were s h e l t e r e d w o r k s h o p s ,  and "Community I n c e n t i v e 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 t e n d and h e l p o u t 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 . vs.  "vocational  "In  s c h o o l " meant high school upgrading or  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  s k i l l or t r a d e to improve Subsequently,  college,  vocational  employability. 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 w o r k " ;  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 w o r k " ; 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 v e r y 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 d e r i v e d from the notes o f the G . V . M . H . S .  file.  progress  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 , n e v e r t h e l e s s much o f i n f o r m a t i o n came second hand, from the c l i e n t .  this  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 t h o u g h sometimes v e r y sudden and temporary changes i n the c l i e n t ' s s t a t u s c o u l d o c c u r , and c o n s e q u e n t l y 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 t h a t they were s t e a d i l y unemployed.  xii)  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 p e n s i o n ( t h i s i s a k i n to w e l f a r e but i s a somewhat g r e a t e r amount g i v e n to i n d i v i d u a l s - by the M.H.R.  -  w i t h a d e s i g n a t e d 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 . G)  upon p a r e n t or g u a r d i a n ) ;  F) s a v i n g s or  investment;  other. S u b s e q u e n t l y , i n the a n a l y s i s , t h e c a t e g o r i e s were c o l l a p s e d :  A and F became " i n d e p e n d e n t " s o u r c e o f income; B, C, D and E became "dependent" s o u r c e o f income; G was d i s c a r d e d 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 d e r i v e d from the notes o f G . V . M . H . S .  files.  progress  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 t h e m p l o y e r s , 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 f o 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 o f  this  i n f o r m a t i o n came second-hand from the c l i e n t .  xiii)  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 t h f a m i l y as dependent; C) w i t h p a r t n e r ( m a r r i e d o r commonlaw);  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 ;  (i.e.  b o a r d i n g home); G) o t h e r .  ("F"  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  r e f e r s to a rooming house, b o a r d i n g  house s e t t i n g where s l e e p i n g q u a r t e r s are t y p i c a l l y s h a r e d , and meals as well are shared.  T h i s 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 q u a r t e r s a r e p r i v a t e . )  Subsequently,  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 d e r i v e d from the notes o f the G . V . M . H . S .  files.  progress  Once a g a i n , a l t h o u g h 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 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 ; 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  xiv)  Residence.  of.  There were ten c a t e g o r i e s h e r e :  (apartment o r hosue) w i t h homemaker; B) p r i v a t e  (apartment o r  A)  private  house)  w i t h o u t 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 facility;  E) group home o r s u p e r v i s e d a p a r t m e n t ; F) f a m i l y c a r e home:  G) mental h e a l t h b o a r d i n g home; H) i n h o s p i t a l ; I) unit;  J)  in short stay  crisis  no f i x e d a d d r e s s . A " r e s i d e n t i a l h o t e l " was a h o t e l  t h a t r e n t e d rooms by the month.  (usually  near s k i d row)  C a t e g o r i e s D, E, F and G had the f o l l o w i n g  40  distinctions:  a mental h e a l t h b o a r d i n g home was a s u p e r v i s e d group  r e s i d e n c e f o r ( u s u a l l y 1 5 - 2 5 ) 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 s u p e r v i s e d apartments were s i m i l a r to the b o a r d i n g homes except t h a t , f i r s t l y ,  they c o n t a i n e d fewer  people  ( 1 - 4 ) , and s e c o n d l y , t h e r e was a lower degree o f s u p e r v i s i o n ; f a m i l y c a r e homes were s m a l l p r i v a t e houses, l i c e n s e d to s e r v e 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 l o n g the l i n e s o f a f o s t e r home. more p r i v a t e ( i . e .  In t h i s c a t e g o r i z a t i o n the group home i s  no l i v e - i n s t a f f ) whereas the mental h e a l t h b o a r d i n g  horn and f a m i l y c a r e 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 h e a l t h b o a r d i n g home, e x c e p t c e r t a i n c l i e n t features  that  (alcoholsim, criminal records, antisocial  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 " s h o r t s t a y c r i s i s u n i t "  behaviour) referred  to r e s i d e n c e f o 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 . Subsequently, follows:  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  A, B, and C became "independent h o u s i n g ; " and D, E, F and G 1  became "dependent h o u s i n g . "  H. I and J 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  d a t a ) because o f t h e i r v e r y low numbers, and a l s o because b e i n g  "in  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 normally l i v e s  in.  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 d e r i v e d from the notes o f the G . V . M . H . S .  files.  progress  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 supervised  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 r e s e a r c h e r  in  41  this study,  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 o f 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  xv)  Vancouver.  T h i s r e f e r r e d to t h e number o f times  Rehospitalization.  t h e 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 s t u d y p e r i o d  (Nov.  1981-Nov. 1 9 8 3 ) .  the  G.V.M.H.S.  The i n f o r m a t i o n came from the progress notes o f  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 c o n f i r m e d by the  t h e r a p i s t making d i r e c t c o n t a c t w i t h the h o s p i t a l . h o s p i t a l r e c o r d was i n c l u d e d as w e l l .  O f t e n the  Somtimes i n a b r i e f  relevant  hospitalization  t h e r e was no c o n t a c t between h o s p i t a l and t h e r a p i s t and the  therapist  would have to r e l y on the s u b j e c t  it.  xvi)  (or a r e l a t i v e )  Admissions to Venture.  u n i t o p e r a t e d by the G . V . M . H . S .  to r e p o r t  "Venture" i s a short stay  People a r e r e f e r r e d t h e r e 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 hospitalization.  require  T h i s v a r i a b l e r e f e r r e d to the number o f times the  was a d m i t t e d i n the s t u d y p e r i o d . G.V.M.H.S.,  crisis  subject  Because Venture i s o p e r a t e d by the  r e c o r d s 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 a d m i t t e d to V e n t u r e ;  these  r e c o r d s were the s o u r c e 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 .  xvii)  Criminal activities.  T h i s r e f e r r e d to how many times  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 s t u d y T h i s 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 file.  period.  G.V.M.H.S.  Sometimes i t had been c o n f i r m e d f i r s t - h a n d by w r i t t e n or  telephone  c o n t a c 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 s e c o n d - h a n d , from the c l i e n t .  42:.  xviii)  Mortality.  This r e f e r r e d  to how many s u b j e c t s  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 , 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  xix)  Suicides.  s u i c i d e i n the study p e r i o d .  This r e f e r r e d  Suicide  etc.  T h i s i n f o r m a t i o n was c o n f i r m e d  attempts.  first-  to how many s u b j e c t s d i e d by  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  xx)  confirmed  died  first-hand  authorities.  I t was i n i t i a l l y hoped to r e c o r d how  many s u b j e c t s made s u i c i d e attempts i n the study p e r i o d .  T h i s was found  to be i m p o s s i b l e to do r e l i a b l y u s i n g f i l e i n f o r m a t i o n ; i t seemed t h a t 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 v e r y 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 t h e 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 a t t e m p t ?  As w e l l , i t was r a r e  -  that  the t h e r a p i s t c o u l d c o n f i r m an a t t e m p t f i r s t hand, u n l e s s i t was a v e r y serious attempt that l e f t physical  evidence.  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 p r o b l e m s , i t was not u s e d .  xxi)  Address changes.  This r e f e r r e d  s u b j e c t changed r e s i d e n c e i n the study p e r i o d . from the p r o g r e s s  notes o f the G . V . M . H . S .  files.  to how many times t h e The i n f o r m a t i o n was Unfortunately,  the community c a r e 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 new addresses w i t h the f i l e ; moved too f r e q u e n t l y residence f i r s t  derived  most o f recorded  the main argument was t h a t c l i e n t s sometimes  to be kept tabs o n .  Therapists  could confirm  hand i n a number o f cases ( p a r t i c u l a r l y  with a stable  43  client)  however when the c l i e n t made s e v e r a l  q u i c k moves i t was hard to  m o n i t o r and i n f o r m a t i o n had to come second hand from the  xxii) changes.  Team changes.  It referred  central registry  This v a r i a b l e was s i m i l a r to address  to how many times the s u b j e c t s w i t c h e d community  c a r e teams i n the study p e r i o d . from a g e o g r a p h i c a l  client.  (The c a r e teams o p e r a t e by t a k i n g c l i e n t s  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  o f the G . V . M . H . S . which was t h e source f o r t h i s  particular  variable.  xxiii)  Closures and veopenings.  This r e f e r r e d ' to how many  times a c l i e n t was c l o s e d (dropped o u t o f t r e a t m e n t ) a t a community c a r e team and then s u b s e q u e n t l y was r e a c t i v a t e d ; i . e .  one " c l o s u r e and  r e o p e n i n g " would mean the s u b j e c t dropped o u t and then dropped back i n (once) d u r i n g the study p e r i o d . the c e n t r a l  registry  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  o f the G . V . M . H . S . ,  which became the s o u r c e f o r  this  variable.  xxiv)  Change in employment status.  times the s u b j e c t ' s For example, i f  This r e f e r r e d  employment s t a t u s changed d u r i n g the study  to how many period.  the person was employed and became unemployed, t h i s  would  be one c h a n g e ; i f the person was employed, then unemployed, then employed a g a i n , t h i s would be two changes. (variable  no. x i ) ,  T h i s i n f o r m a t i o n , l i k e employment s t a t u s  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 ; 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  therapist.  44. xxv)  Change in source of income.  to n o . x x i v a b o v e ; i t r e f e r r e d  This v a r i a b l e i s s i m i l a r  to how many times the s u b j e c t ' s  o f income changed i n the s t u d y p e r i o d .  source  For example, from employment,  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  d e r i v e d from the progress notes o f the G . V . M . H . S .  f i l e ; a change would  to  u s u a l l y be n o t a b l e and be r e c o r d e d 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  their  source o f income.  xxvi)  Hours per month at the team. T h i s v a r i a b l e was unique  i n t h a 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 , c l i e n t census t a k e n by t h e G . V . M . H . S .  but r a t h e r came from a  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 time the c l i e n t s p e n t a t the community c a r e 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  therapist.  This  r e s e a r c h e r had a c c e s s to the r e s u l t s o f t h i s c e n s u s , and used the i n f o r m a tion for t h i s v a r i a b l e .  " C l i n i c a l time" refers  to time s p e n t d e a l i n g  w i t h p s y c h i a t r i c p r o b l e m s , m e d i c a t i o n 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 .  xxvii)  Visits  to the team. T h i s 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 c a r e team d u r i n g the study  period.  Such i n f o r m a t i o n was g e n e r a l l y r e c o r d e d 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 .  file;  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 t h e r s and t h i s i n f o r m a t i o n was then not available.  45.  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 s t u d 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 l o o k e d  a t ; t h u s , some o f t h e 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 o f t h e word "dependent" i n t h i s c o n t e x t i s s u s p e c t b e c a u s e , as has been noted e a r l i e r , no independent v a r i a b l e i s b e i n g m a n i p u l a t e d , and the p o s s i b l y c o n t a m i n a t i n g e f f e c t s of extraneous t h i r d v a r i a b l e s (for  t h e most p a r t ) be c o n t r o l l e d f o r .  cannot  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 t h e data c o l l e c t i o n .  For  example, the r a c e o f the s u b j e c t was  n o t accounted f o r i n t h i s s t u d y , which c o u l d 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 r e v i e w ) have d e t e c t e d 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 r e v i e w some v a r i a b l e s a r e regarded as  "predictors"  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 e x t e n 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 a n t e c e d e n t to the c r i t c o m e v a r i a b l e . cases t h i s i s t r u e :  In some  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 r e c e d e s , 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 r e c e d e s , employment s t a t u s i n the follow-up period.  Other v a r i a b l e s , however, seem to be c o n c u r r e n t  the outcome v a r i a b l e .  with  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 t h e 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 t h e r v a r i a b l e ? mutual e f f e c t .  C o n c e i v a b l y t h e r e c o u l d be a  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 p e r s o n ' s employment s t a t u s o r v i c a v e r s a ?  In s h o r t , a l t h o u g h a number o f a s s o c i a t i o n s  46  were l o o k e d 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 of e f f e c t ;  directionality  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 c o u l d c o n c e i v a b l y be e f f e c t i n g "independent"  G.  the  variable.  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 . t i o n t h a t these v a r i a b l e s  There i s the  g i v e an i n d i c a t i o n o f community  implica-  functioning,  and i n f a c t t h e s e 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 o f " s u c c e s s " or " f a i l u r e . "  There has b e e n , however,  some c r i t i c i s m o f 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 q u e s t i o n e d the v a l i d i t y o f particular  this  variable. What i s the r a t i o n a l e f o r u s i n g r e h o s p i t a l i z a t i o n  Anthony [108] suggests  rates?  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 a u t h o r 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  better  o f f i f he can a v o i d r e t u r n i n g i t i s l e s s expensive hospital."  to a p s y c h i a t r i c i n s t i t u t i o n ;  economically,  f o r t h e t a x p a y e r i f the p a t i e n t remains o u t o f  the  A s i d e 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 u s e f u 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 i e w p o i n t as f o l l o w s : "Readmission s t a t i s t i c s a r e easy t o o b t a i n and a r e , 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 hospital administrators. Moreover, the d a t a c o l l e c t e d are h i g h l y r e l i a b l e . A former p a t i e n t  4 7 .  i s e i t h e r r e a d m i t t e d or n o t r e a d m i t t e d ; a c c o r d i n g l y , t h e r e i s every l i k e l i h o o d t h a t 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 arrive at similar results. F i n a l l y , i t i s very easy t o q u a n t i f y the m a t e r i a l o b t a i n e d . These methodol o g i c a l a s s e t s have l e d r e a d m i s s i o n s t a t i s t i c s to become the i n d i c a t o r 'par e x c e l l e n c e ' o f h o s p i t a l e f f e c t i v e n e s s and have made them o f c r u c i a l concern t o h o s p i t a l a d m i n i s t r a t o r s and o t h e r s . "  There have been c r i t i c i s m s o f A n t h o n y ' s p o s i t i o n t h a t the patient is "psychologically better off"  i f he can a v o i d 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  follow-up  s t u d y o f d i s c h a r g e d s c h i z o p h r e n i c s by C h r i s t e n s e n [ 1 1 0 ] : i n t h i s study a u t h o r concluded  the  that:  "The p a t i e n t ' s a b i l i t y to keep out o f h o s p i t a l f o r a s h o r t o r l o n g p e r i o d i s no c r i t e r i o n o f s a t i s f a c t o r y treatment. Many p a t i e n t s who had n o t been r e a d m i t t e d were l i v i n g under poorer c o n d i t i o n s and were a l s o more m e n t a l l y i l l than others, who were r e a d m i t t e d . "  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 r e a d m i t t e d 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 t h e p a t i e n t who has t h e 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 c o n s i d e r e d more m e n t a l l y  healthy.  What o t h e r 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] c o n c l u d e s  that:  "Continued community tenure i s due i n p a r t t o the s o c i a l c o n d i t i o n s and the c o n t e x t o f l i f e i n which the former p a t i e n t f i n d s h i m s e l f and i s n o t merely a f u n c t i o n o f the a b s o l u t e l e v e l o f performance o r the o b j e c t i v e degree o f p s y c h i a t r i c impairment o r distress."  Whether o r not a p a t i e n t i s r e a d m i t t e d and how l o n g he w i l l s u b s e q u e n t l y s t a y 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 r e a d e r is  d i r e c t e d to a r t i c l e s by S t r a u s s [ 1 1 2 ] , Bachrach [113] and Freeman  [114]  48,  for a review. as:  In summary, r e a d m i s s i o n may be a f f e c t e d by f a c t o r 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 ; treatment philosophies of  staff;  the d i s t a n c e the p a t i e n t l i v e s  the a v a i l a b i l i t y of e i t h e r f a m i l y support or p u b l i c resources whether the h o s p i t a l  hospital  from the h o s p i t a l ; the s i z e o f  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  community;  such  the  voluntary; i n the  i s public 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 g a i n a d m i s s i o n , r e a d m i s s i o n 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  patient's  behaviour.  [115]  With r e g a r d to t h i s l a s t p o i n t , a s t u d y by Michaux  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 findings:  A) t h e r e 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  psychopathological  symptoms and h i s r e a d m i s s i o n to h o s p i t a l ; B) t h e r e was,  however, a c o r r e l a t i o n between r e a d m i s s i o n and the r e l a t i v e ' s judgment o f the p a t i e n t ' s  subjective  p a t h o l o g y as w e l l as the r e l a t i v e ' s ] l a c k  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  of  activities.  Another i s s u e c o n f o u n d i n g 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 o f 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 a p p a r e n t l y a s s o c i a t e d wi th how many times the has p r e v i o u s l y  been i n h o s p i t a l .  individual  Thus, b e i n g 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 o f the p e r s o n ' 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 p e r s o n ' s i n s t i t u t i o n a l  history.  T u r n i n g 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 t h a t has p s y c h o l o g i c a l  "working  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  a v o i d s government a i d payments." and employment, i n A n t h o n y ' s  (It  i s notable that  rehospitalization  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 logical  functioning element.)  I t was assumed f o r the sake o f  study t h a t employment s t a t u s , to a d e g r e e , r e f l e c t e d s o c i a l  psycho-  this  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 o t h e r people and must perform a t a s k w h i l e under p r e s s u r e from t i m e , s u p e r v i s o r s  etc.  It  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  func-  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 f o 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 o f t h i s  t i c u l a r measure i s t h a t i n some s t u d i e s clearly defined:  does i t mean f u l l  "employment s t a t u s " i s  time, part time,  u n s h e l t e r e d , and f o r what d u r a t i o n ?  not  sheltered,  Because o f t h i s problem i t  sometimes d i f f i c u l t to compare r e s u l t s .  par-  F i n a l l y , as Bachrach  is  [117]  n o t e s , a study o f employment s t a t u s s h o u l d i d e a l l y get a sense o f change o v e r t i m e , o r change a f t e r h o s p i t a l d i s c h a r g e , i n upward o r downward  to measure t r e n d s  mobility.  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 included'several  study  o t h e r 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 a d m i t t e d to the s h o r t s t a y c r i s i s u n i t . assumed to r e p r e s e n t 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 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 ' Another measure used was  suicide  and  was prompted by the r e s e a r c h f i n d i n g s  This was the  rehospitalization.  s u i c i d e attempts; that schizophrenics  this  inclusion  have a high  50.  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 t e m p t i n g 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 , for help."  The v a r i a b l e  cannot c o p e , or i s  criminal a c t i v i t i e s  "crying  was i n c l u d e d w i t h  assumption t h a t t u r n i n g to c r i m e r e p r e s e n t e d a poorer s o c i a l F i n a l l y , s e v e r a l measures o f c l i e n t s t a b i l i t y such as and  change i n source o f income  were i n c l u d e d .  the  adjustment.  address  changes  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 a d j u s t m e n t . Such an assumption must be q u a l i f i e d , however; tion,  as noted w i t h  rehospitaliza-  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 b e i n g r e a d m i t t e d  a t the same time may be m e n t a l l y u n w e l l . may be a f f e c t i n g measures o f s t a b i l i t y .  In a d d i t i o n , o t h e r  variables  One such v a r i a b l e i s a g e ;  i t i s l i k e l y t h a t young people a r e more m o b i l e than o l d e r l e s s o f whether or not they a r e p s y c h i a t r i c  people  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  and hence i n f e r e n c e s s h o u l d not be a t an e x p l a n a t o r y descriptive level, i.e. d i f f e r e n c e means. . . . "  " t h e r e i s a d i f f e r e n c e " r a t h e r than  validity  "this  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  measures o f s c h i z o p h r e n i a outcome.  different  A study by Schwartz [118] examined  mental s t a t u s , s o c i a l adjustment and r o l e  p e r f o r m a n c e , 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 . 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 d i f f e r e n t measures ( i . e .  out-  but r a t h e r a t a  i s a l s o a p p a r e n t when one l o o k s a t concordance r a t e s between  f o u r outcome measures:  regard-  patients.  In summary, i t has been shown t h a t some s c h i z o p h r e n i a come measures, p a r t i c u l a r l y  but  because a person does w e l l  does not n e c e s s a r i l y mean he w i l l  do w e l l  The. general  low between the i i n one d i m e n s i o n  i n another)  a n d , most c r u c i a l  f o r t h i s study was t h e 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 " t h e phenomenon" o f r e h o s p i t a l i z a t i o n i s an s e p a r a t e d i m e n s i o n o f t r e a t m e n t outcome," a f f e c t e d by a s e t o f  entirely variables  and c o n t i n g e n c i e s t h a t a r e a p p a r e n t l y f a i r l y unique to t h i s one measure alone [119].  Schwartz goes on to say t h a t " s i n c e t r e a t m e n t 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 c o n t i n u e as v i t a l  procedures"  [120].  Thus, we are not c e r t a i n what  exactly  r e h o s p i t a l i z a t i o n i s m e a s u r i n g , and i t s h o u l d be regarded as a s e p a r a t e measure.  A range o f d i f f e r e n t measures are needed to a s s e s s the  total  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 c o n s i d e r e d to have tapped i n t o a comprehensive picture of c l i e n t f u n c t i o n i n g . was r a t h e r l i m i t e d (not  In t h i s study the range o f measures  i n c l u d i n g , f o 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 c o n t e n t v a l i d i t y o f the measures used the e x t e n t to which they i n c o r p o r a t e d was presumably l i m i t e d .  the concept o f " s o c i a l  One problem here may be t h a t " s o c i a l  i s a r a t h e r b r o a d , vague, a b s t r a c t c o n c e p t u a l As w e l l as problems w i t h v a l i d i t y ,  adjustment") adjustment"  category. t h e r e 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 Some o f t h e s e problems have a l r e a d y been d i s c u s s e d , and they 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 the data b a s e .  study.  represent  i n f o r m a t i o n as  Of the v a r i a b l e s d e s c r i b e d 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 r e c o r d e d o r 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 ; were f e l t to r e p r e s e n t 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 . were:  (i.e.  these  These v a r i a b l e s  s e x , a g 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 , m a r i t a l  status,  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 c h a n g e s ,  52i  c l o s u r e s and r e o p e n i n g s , hours per month a t team, and number o f to the team.  visits  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 t h e s e m i s s i n g cases were not i n c l u d e d 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 o f 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 will  be d i s c u s s e d f u r t h e r .  Of the r e m a i n i n g v a r i a b l e s , some were o f  a k i n d t h a t were t y p i c a l l y r e c o r d e d i n a s y s t e m a t i c f a s h i o n , but i n the case o f t h i s study the p a r t i c u l a r r e l e v a n t r e c o r d s 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  required  the use o f h o s p i t a l / m e d i c a l r e c o r d s t h a t might not have been i n the G.V.M.H.S.  file.  These v a r i a b l e s w e r e :  age o f f i r s t  psychiatric  c o n t a c t , age o f 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  hospitalizations,  number o f p r e v i o u s 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 o t h e r s t h e r e 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 r e c o r d s were m i s s i n g were e i t h e r because the events zation)  for  (e.g.  had o c c u r r e d o u t o f p r o v i n c e o r e l s e the p e r s o n ' s  a hospitali-  hospitalization  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 g a t h e r a l l the n e c e s s a r y r e c o r d s and make an a c c u r a t e e s t i m a t e of how many times they had been in h o s p i t a l .  Consequently,  i t c o u l d be argued t h a t i n some i n s t a n c e s  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 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  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 tions  present,  over-represented  p r e v i o u s number o f h o s p i t a l i z a -  c o u l d c o n c e i v a b l y be an u n d e r e s t i m a t i o n o f the t r u e v a l u e .  As w e l l , a number o f the m i s s i n g cases i n v o l v e d m o b i l e and  i n d i v i d u a l s who were  had been h o s p i t a l i z e d o u t o f p r o v i n c e ;  i f p a t i e n t s who a r e  53.  g e o g r a p h i c a l l y m o b i l e are i n some sense d i f f e r e n t from those who a r e more s t a b l e , then the m i s s i n g cases may r e p r e s e n t a b i a s .  (Regarding  t h i s l a s t p o i n t , one American s t u d y 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 [ 1 2 1 ] . ) 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 s y s t e m a t i c a l l y i n the f i l e s , in their written  The l a s t  recorded  t h a t i s , some t h e r a p i s t s were more e x t e n s i v e  passages than o t h e r s .  These v a r i a b l e s concerned  events and were w r i t t e n up i n the -progress n o t e s .  They w e r e :  ment, s t a t u s , s o u r c e o f income, employment h i s t o r y ,  living  current  employ-  situation,  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 e x t e n t on second-hand i n f o r m a t i o n from the c l i e n t s 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 ) lacking in r e l i a b i l i t y .  (vs.  and hence were c o n s i d e r e d  There were two i s s u e s h e r e .  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 c h a n g e s , had happened, i t was l i s t e d as missing.  Hence, the people w i t h more f r e q u e n t o c c u r r e n c e o f  events may have been o v e r - r e p r e s e n t e d  these  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" c o u l d be an u n d e r e s t i m a t i o n o f true value.  the  The o t h e r 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 p r o v i d e him w i t h i n f o r m a t i o n , the " s o c i a l o f the response comes i n t o p l a y . about h i s c r i m i n a l a c t i v i t i e s c l a i m he i s w o r k i n g when he i s  desirability"  Thus, a . c l i e n t might d i s t o r t the t r u t h  (i.e. not.  u n d e r e s t i m a t e them) or  perhaps  5 4 ;  In summary, the v a r i a b l e s used i n t h i s study p r e s e n t e d 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 the r e s u l t s o f the data a n a l y s i s  H.  qualify  process.  Timing .of Measurements T h i s s t u d y was r e t r o s p e c t i v e  in design, that i s , i t  collected  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 .  prospective - viewpoint is  d a t a can be gathered more q u i c k l y and e c o n o m i c a l l y . naturalistic  (non-experimental)  that  As w e l l , i n a  s t u d y , a p r o s p e c t i v e d e s i g n 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 v a r i a b l e s , as Reid and Smith [122] n o t e .  f o r the e f f e c t o f  A c r i t i c i s m of  extraneous  retrospective  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 p a s t 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 interviews  but r a t h e r from r e c o r d s 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 s t u d y would o f f e r some advantages  in  t h a t s t a n d a r d i z e d d a t a c o l l e c t i o n forms c o u l d be s e t up ahead o f time 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 n o t e d , and the r e s u l t s in 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 g e n e r a l  would criticism  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 p r e s e n t 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 n o n - e x p e r i m e n t a l 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 s s u e concerns how many measurements a r e taken i n < follow-up studies.  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 b a s i s  in  t h a t they t a k e 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 y e a r 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 t h e r e 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 measurements 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 s t a n d a r d number o f measures s h o u l d be taken:  one a t a p o i n t p r e c e d i n g the t r e a t m e n t i n t e r v e n t i o n , one a t  b e g i n n i n g o f t h e t r e a t m e n t p e r i o d , one a t the end o f the t r e a t m e n t 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 . . . I n r e f e r s m a i n l y to a p s y c h i a t r i c was no " t r e a t m e n t " e f f e c t :  this  hospitalization.  instance  the period,  "treatment"  In t h i s study  s t a r t o f the f o l l o w - u p p e r i o d d i d  there not  n e c e s s a r i l y i m m e d i a t e l y 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 r e a t m e n t was a c o n s t a n t ( i . e .  the community c a r e t e a m s ) .  The  length  o f the f o l l o w - u p p e r i o d was 2 y e a r s , which i s comparable to some o t h e r s t u d i e s , but e x t r a p o l a t i o n n i g h t be needed to compare r e s u l t s  with  those from s t u d i e s w i t h s h o r t e r o r l o n g e r f o l l o w - u p  As noted  i n the l i t e r a t u r e s t a b i l i t y exists  review,  Strauss  [124] i n d i c a t e s a f a i r amount o f  i n outcome o v e r t i m e , and suggests  f o l l o w up r e s u l t w i l l  periods.  t h a t a two y e a r  c o r r e l a t e highly with that o f a 5 year  study.  In t h i s study two main measures were t a k e n , one a t the s t a r t o f study p e r i o d (Nov. such as  employment  and one f o r 1983.  T|981) and one a t the end (Nov. and  -residence  1983).  Hence,  the variables  had 2 v a l u e s e a c h , one f o r 1981  In a d d i t i o n to t h e s e two measures, v a r i a b l e s were *  56,  i n c l u d e d to a t t e m p t to r e c o r d what happened between 1981 and 1 9 8 3 ; t h e s e were v a r i a b l e s such as i n employment s t a t u s ,  and  rehospitalization, . address changes.  changes  The r a t i o n a l e i n  i n s t a n c e was to a t t e m p t to have a l o n g i t u d i n a l a c r o s s - s e c t i o n a l one.  number o f  d e s i g n , r a t h e r than s i m p l y  In a d d i t i o n to v a r i a b l e s  that referred  study p e r i o d (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 happened p r i o r history of  this  to  the  that  to the study p e r i o d , such as employment h i s t o r y  or  hospitalization. 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 . " p h r e n i a f o l l o w - u p study t y p i c a l l y discharge.  As n o t e d , a s c h i z o -  t a k e s as the s t a r t i n g p o i n t a h o s p i t a l  In t h i s study the s t a r t i n g p o i n t was an a r b i t r a r y  a time l i n e a t November, 1981.  one,  simply  This c o u l d be c o n s i d e r e d a f l a w i n  the  d e s i g n i n t h a t the s u j b e c t s d i d n o t have a common s t a r t i n g p o i n t , 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  hospitali-  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 . c o u l d r a t i o n a l i z e t h i s i n s a y i n g t h a t t h i s was a f a i r l y sample:  One  homogeneous  s c h i z o p h r e n i c c l i e n t s o f community c a r e 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 . t h a t the v a r i a b l e  However, the problem remains  l e n g t h o f 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 -  has been  shown to have a s i g n i f i c a n t  ( n e g a t i v e ) c o r r e l a t i o n w i t h the  rehospitalization  To t r y and get around t h i s problem the  [125].  v a r i a b l e ' l e n g t h o f 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 n t o the s t u d y , analysis.  i.e.  was  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  variable  incorporated the data  57  One a s s e t of t h i s study was t h a t a l l s u b j e c t s shared the e x a c t same h i s t o r i c a l  p e r i o d 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 In t h i s l a t t e r  instance h i s t o r i c a l  times.  p e r i o d c o u l d be a c o n f o u n d i n g  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  rehospitalization  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  policies  change  over time.  I.  Ethical  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,  since  the s u b j e c t s were not. a c t u a l l y b e i n g a f f e c t e d by an i n t e r v e n t i o n . main c o n c e r n 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 . identifying  No names or  i n f o r m a t i o n were used i n the r e s u l t s ; d u r i n g 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 t h e s e numbers were revealed.  Raw data was u l t i m a t e l y d e s t r o y e d .  l o o k a t t r e n d s shown i n a r e l a t i v e l y specific  J.  The  not  The study attempted to  l a r g e s a m p l e , not to focus on  individuals.  S t r a t e g y o f Data A n a l y s i s The data a n a l y s i s proceeded through s e v e r a l  stages.  F i r s t was a s i m p l e 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.  T h i s 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 v a r i o u s Secondly was an attempt to see i f (i.e.  distinguishable  sociodemographic  variables.  t h e r e had been changes over time  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 o f the p o p u l a t i o n .  Thirdly,  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 o f  rehospitalization  and employment, these two r e f e r r i n g to the p e r i o d Nov. 1981-Nov. 1 9 8 3 . The " i n d e p e n d e n t " v a r i a b l e s were v a r i o u s o f the o t h e r 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  c e r t a i n a s p e c t s o f the study p o p u l a t i o n (such as a g e , s e x , s i t u a t i o n ) were a s s o c i a t e d w i t h a more (or l e s s )  if  residential  " 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 d e t e c t e d by outcome measures and o t h e r v a r i a b l e s , to t r y and see i f sub groups w i t h i n the p o p u l a t i o n c o u l d be d e t e c t e d .  distinctive  The common theme  i n t h e s e v a r i o u s s t a g e s was the a t t e m p t to l o o k f o r , and i f account f o r , v a r i a n c e w i t h i n the study  possible  population.  Reid and Smith [126] note t h a t a s t u d y can have more than one "knowledge b u i l d i n g f u n c t i o n , " i . e . testing.  In t h i s s t u d y ,  data g a t h e r i n g and h y p o t h e s i s  p a r t o f the s t u d y c o u l d be d e s c r i b e d as s i m p l e  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, testing of a s o r t .  involved  hypothesis  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 t h a t the  study was n o n - e x p e r i m e n t a 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 c o u l d be r e a c h e d .  As w e l l , a number o f d i f f e r e n t  hypotheses  were l o o k e d 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 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 . t i o n s were not a r b i t r a r i l y or randomly c h o s e n , however;  per-  The a s s o c i a -  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 r e s e a r c h l i t e r a t u r e on schizophrenia.  The "comparison groups" t h e n , were o t h e r  f i n d i n g s , hence t h i s s t u d y c o u l d be a l s o t i t l e d in nature.  research  replicative/comparative  5 9 .  Chapter 4'  RESULTS  A.  Sociodemographic 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 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 o r d e r 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 below f o r the v a r i a b l e i n q u e s t i o n .  noted  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  instances  the 100% f i g u r e does n o t i n f a c t reach the t o t a l n o f 234.  ii)  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 a r e summarized i n Tables 1 - 3 .  The male s u b j e c t s tended to be y o u n g e r , w i t h 33% o f the men under 30 y e a r s o f age v s . o n l y 16% o f the women (X  = 9.19, 2 d . f . ,  p = .01).  The females had a b e t t e r employment r e c o r d a t t h e end o f the f o l l o w up p e r i o d ; 58% were unemployed and 19% w o r k i n g c o m p e t i t i v e l y , w h i l e  the  2 figures  f o r the men were 72% and 9% r e s p e c t i v e l y  p = .04).  (X  = 6.27, 2  d.f.,  F i n a l l y , the females had a h i g h e r m a r r i a g e and d i v o r c e  rate;  82% o f the men were s i n g l e , never m a r r i e d , and o n l y 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 o f Sex by Age  Age  mal e  .  20 - 30  31 - 40  41 - 150  Row T o t a l s  45 (33.3°/)  52 (38.5%)  38 (28.1%)  135 (100%)  15 (15.6%)  58 (50.0%)  33 (34.4%)  96 ; (100%)  OCA"  female missing cases = 3 X  = 9 . 1 8 9 6 , 2 degrees o f freedom, p = .0101  2  Table 2 C r o s s t a b u l a t i o n of Sex by Employment S t a t u s (1983)  Empl oyment Unemployed  She!tered Work  Competitive Work  Row Total s  Male  92 (72.4%)  24 (18.9%)  11 (8.7%)  127 (100%)  Female  52 (58.4%)  20 (22.5%)  17 (19.1%)  89 (100%)  Sex  m i s s i n g c a s e s = 18 X  2  = 6 . 2 6 9 , 2 degrees o f freedom, 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 t a t u s  (1983)  Marital Status Single, Never Married  Married  Male  108 (82.4%)  5 (3.8%)  18 (13.7%)  131 (100%)  Fema1e  51 (53.1%  18 (18.8%)  27 (28.1%)  96 (100%)  Sex  M i s s i n g cases = 7 2 X  = 2 4 . 7 7 , 2 degrees o f freedom, p = .000  Separated, Divorced  Row T o t a l s  62.  w h i l e the f i g u r e s  f o r the women w e r e , r e s p e c t i v e l y ,  the end o f the study  53% and 19% a t  period.  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  for  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 .  iii)  Age.  The age r a n g e , 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 t a n d a r d 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 a g e .  These a r e 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.  Forty-three  per c e n t o f those under 40 were r e h o s p i t a l i z e d i n the  s t u d y p e r i o d , compared to 25% f o r t h e o v e r 4 0 ' s .  The younger s u b j e c t s  had a l s o had more r e c e n t 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 p r e c e d i n g two y e a r s , compared to 51% o f the 3 1 - 4 0 y e a r o l d s and o n l y 33% f o r the 4 1 - 5 0 y e a r o l d s .  The i n -  s t a b i l i t y o f the younger s u b j e c t s was i l l u s t r a t e d by the f i n d i n g they had s i g n i f i c a n t l y more  address c h a n g e s ,  that  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 older subjects.  With r e g a r d to address changes, i t was found  that  65% o f the under 3 0 ' s moved a t l e a s t once i n the s t u d y p e r i o d , compared to 41% o f the 3 1 - 4 0 y e a r  o l d s and 2 4 % ; f o r the 4 1 - 5 0 y e a r o l d s .  young s u b j e c t s were a l s o more f r e q u e n t v i s i t o r s  The  to the community c a r e  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 t w i c e per month, compared to 34% o f the 4 1 - 5 0 y e a r  olds.  There was, as noted e a r l i e r , a sex d i f f e r e n c e : s u b j e c t s tended to be m a l e . status:  the younger  There was a d i f f e r e n c e on the b a s i s o f m a r i t a l  90% o f the under 3 0 ' s were s i n g l e (never m a r r i e d ) compared to  63.  Table 4 Differences  i n the Sample on the B a s i s o f Age  A s s o c i a t i o n s t h a t Reached Statistical Significance (p < .05) Age o f F i r s t P s y c h i a t r i c P e a r s o n ' s " r " = .4567 p = .000  Contact  A s s o c i a t i o n s t h a t Approached Significance (.1 > p > .05) A d m i s s i o n s to Venture P e a r s o n s ' s " r " = - .1056 p =.054  Age o f F i r s t H o s p i t a l i z a t i o n P e a r s o n ' s " r " = .4969 p = .000  Hours Per Month a t Team Pearson's " r " = - . 0 9 9 p = .064  Rehospitalization Pearson's "r" = - . 1 8 0 3 p = .003  Changes i n Source o f Income Pearson's "r" = -.1047 p = .0616  Time Since L a s t H o s p i t a l i z a t i o n P e a r s o n ' s " r " = .3359 p = .000 Address Changes Pearson's "r" p = .000  = -.2124  V i s i t s to- the Team Pearson's " r " = - . 1 2 7 8 p = .037 C l o s u r e s and Reopenings Pearson's " r " = - . 1 4 8 9 p = .011 Team Changes Pearson's "r" p = .002  SGX  X  2  = -.1882  = 9.1895, 2 d . f . ,  M a r i t a l S t a t u s (1983) X = 17.77, 4 d . f . ,  p = .0101 p = .0014  CONTINUED  6.4',  Table 4 (Continued)  A s s o c i a t i o n s t h a t Reached Statistical Significance (p > .05) Changes i n Employment S t a t u s Pearson's "r" = - . 1 6 9 p = .0076 Duration of P r i o r H o s p i t a l i z a t i o n P e a r s o n ' 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 P e a r s o n ' s " r " = .1435 p = .027  A s s o c i a t i o n s " t h a t Approached Significance (.1 > p > .05)  .65  68% o f the 3 1 - 4 0 y e a r o l d s and 58% f o r the 4 1 - 5 0 y e a r 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% o f the 3 1 - 4 0 y e a r o l d s and 17% f o r the 4 1 - 5 0 y e a r 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 p a s t 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 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 .  first  The mean 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 f o r those under 35 was 1 9 . 9 y e a r s  (standard  d e v i a t i o n = 4 . 8 3 ) , and 2 7 . 9 y e a r s f o r those o v e r 35 ( s t a n d a r d 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 2 1 . 5 f o r those under 35 ( s t a n d a r d d e v i a t i o n = 4 . 1 3 ) and 2 7 . 9 f o r those o v e r 35 ( s t a n d a r d deviation = 7.05). 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 t h a t o f the s u b j e c t s o v e r  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 o f 2 5 , and t h a t o f those over 4 5 , 56% had had t h e i r f i r s t  hospitalization  a f t e r the age o f 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 T a b l e 4 ) .  I t was found t h a t the  younger c l i e n t s tended to be a d m i t t e d more f r e q u e n t l y to Venture than the o l d e r o n e s , 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 time a t the community c a r e teams, and t h a t the younger c l i e n t s more changes i n t h e i r s o u r c e o f income o v e r the two y e a r period.  experienced follow-up  •66i  Table 5 C r o s s t a b u l a t i o n o f S u b j e c t Age by Age o f  First  Psychiatric Hospitalization Age of First Psychiatric Hospitalization 2Q 21-25 26-30 Over 30 U  e r  20-25  ,15 (78.9%)  4 (21.1%)  26-30  13 (36.1%)  15 (41.7%)  31-35  14 (26.4%)  36-40  0  19 (100%)  8 (22.2%)  0  36 (100%)  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%)  41-45  7 (25.9%)  9 (33.3%)  5 (18.5%)  6 (22.2%)  27 (100%)  46-50  2 (5,6%)  8 (22.2%)  6 (16.7%)  20 (55.6%)  36 (100%)  Subject Age  Column T o t a l s  58  69  0  Row T o t a l s  42  38  67  iv)  Previous Psychiatric  History.  The d i s t r i b u t i o n o f  sample by 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 i s shown i n Table 6 .  the  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 c o n t a c t i n l a t e t e e n s , and the majority  (58%) had a p s y c h i a t r i c c o n t a c t by age 2 5 ; the median v a l u e  was 2 1 . 6 8 y e a r s .  T h i s 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 o f the sample by age o f f i r s t h o s p i t a l i z a t i o n i s shown i n Table 7.  psychiatric  The m a j o r i t y had t h e i r  first  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 v a l u e was 2 3 . 7 years.  T h i s v a r i a b l e had 26 m i s s i n g cases For d u r a t i o n o f p r i o r  (11%).  h o s p i t a l i z a t i o n , the f i n d i n g was  that  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 p r e v i o u s 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 v a l u e was 7.12 months.  This v a r i a b l e had 48% o f the cases  missing. For p r e v i o u s 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 v a l u e was 4 . 2 6 .  In t h i s c a t e g o r y 23% o f the cases were m i s s i n g . For 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 , the median v a l u e was  2 4 . 3 3 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 o f zero the f o l l o w up p e r i o d ) f o r 22 y e a r s ) .  (were i n h o s p i t a l a t the s t a r t  of  to a high o f 265 months (have s t a y e d o u t o f h o s p i t a l  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 T a b l e 8 ,  was b i - m o d a l and appeared to d e l i n e a t e two major g r o u p s : 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 been h o s p i t a l i z e d f o r over t h r e e y e a r s  those who  year'. (31%) and those who had not (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 f o r Study  Contact  Population  49 (31 .4%) 42 (26.9%)  24 (15.4%)  26 (16.7%)  15 (9.5%) 0  Under 15  16-20  Age a t F i r s t  21-25  Psychiatric  M i s s i n g cases = 78  26-30  Contact  Over  30  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 f o r Study P o p u l a t i o n  69 (33.2%) 59 (28.4%) 42 (20.2%)  Under  21-25  20  Age a t F i r s t  26-30  38 (18.3%)  Over  Psychiatric Hospitalization  M i s s i n g cases = 36  30  70  Table 8 D i s t r i b u t i o n o f Time S i n c e L a s t P s y c h i a t r i c  Hospitalization  f o r Study P o p u l a t i o n  78 (35.5%) 69 (31 A%)  42 (19.1%)  >-  31 (14.1%) Cr  0-12 months  13-24 months  Time S i n c e L a s t  25-36 months  Over 36 months  Hospitalization  M i s s i n g cases = 14  71.  v)  Rehospitalization.  T h i r t y - s e v e n per c e n t 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 s t u d y p e r i o d .  Controlling  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 t h a t  of  those s u b j e c t s who had been i n h o s p i t a l i n the two y e a r s p r e c e d i n g  the  s t u d y p e r i o d , 50% were r e h o s p i t a l i z e d i n the s t u d y Regarding a d m i s s i o n s to V e n t u r e , the s u b j e c t s were a d m i t t e d to Venture  period.  i t was found t h a t 18% o f  i n the s t u d y p e r i o d ; t h i s  figure  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 p r e c e d i n g y e a r s .  vi)  Employment. S e v e n t y - t h r e e  per c e n t o f the sample had  not worked f o r s i x c o n s e c u t i v e months a t a c o m p e t i t i v e job i n the y e a r s p r e c e d i n g the f o l l o w - u p p e r i o d . p e r i o d the m a j o r i t y  At the end o f the  five  follow-up  (66%) o f the sample was unemployed; 21% were d o i n g  s h e l t e r e d work and 13% were d o i n g 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 majority (for  the  (81%) o f the sample d i d not have a change i n employment s t a t u s  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  particular  v a r i a b l e had 12% o f cases m i s s i n g . With r e s p e c t to s o u r c e o f income, a t the end o f the s t u d y p e r i o d 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 s a v i n g s 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 i d not e x p e r i e n c e a change i n t h e i r principal  s o u r c e o f 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  s o u r c e o f income f o r t h e two y e a r s .  7 2 .  vii)  Style of Cohabitation.  At the end o f the s t u d y  period  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 shared, non-familial setting ( i . e .  a b o a r d i n g home), 17% were l i v i n g  w i t h p a r e n t a l f a m i l y , and 14% were l i v i n g w i t h spouse or common-law partner. 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 o f the study p e r i o d 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 v o r c e d o r 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 p e r i o d t h a t 60% o f the sample was l i v i n g i n d e p e n d e n t 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.  viii)  Client Mobility.  Regarding the v a r i a b l e address c h a n g e s ,  i t was found t h a t 42% o f the sample moved a t l e a s t once d u r i n g the 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 c e n t o f  follow-  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% o f the sample s w i t c h e d to a d i f f e r e n t community c a r e team d u r i n g the f o l l o w - u p  period.  The v a r i a b l e c l o s u r e s and r e o p e n i n g s i n d i c a t e d t h a t 17% o f the sample had one o r more c l o s u r e s and r e o p e n i n g s  (i.e.  dropped o u t  of  t r e a t m e n t 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 c a r e teams) w h i l e 83% o f the sample s t a y e d a c t i v e c l i e n t s o f the f o r the e n t i r e two y e a r  ix)  Client  G.V.M.H.S.  duration.  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 t h a t about h a l f (53%) o f the sample s p e n t l e s s than  <  73.  t h r e e hours per month a t the community c a r e team, 27% spent 3 - 5 h o u r s , and 20% s p e n t o v e r 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% o f  sample averaged a t l e a s t two v i s i t s o v e r the two y e a r f o l l o w - u p p e r i o d . than two v i s i t s  for this  per month to the community c a r e team Fifty-three  per c e n t averaged  per month, and 14% o f the sample averaged l e s s  one v i s i t every two months.  the  less  than  S i x t e e n per c e n t o f the cases were m i s s i n g  variable.  x)  Client  d u r i n g the f o l l o w - u p  There was o n l y one m o r t a l i t y - a s u i c i d e  Mortality. period.  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 , 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  during  reliably  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 ; c o n s e q u e n t l y ,  the  variable  was not u s e d .  xi)  Criminal Activities.  F i v e per c e n t o f the sample were  charged w i t h c r i m i n a l o f f e n s e s d u r i n g the f o l l o w - u p  xii)  Schooling.  period.  F o r t y - t w o per c e n t 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 o n l y 9% had n o t had some high School university this  Fourteen s u b j e c t s degrees.  variable.  (six  % o f the sample) had completed  Eleven per c e n t o f the cases were m i s s i n g w i t h  -  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 i v e 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  p o i n t s i n t i m e , the b e g i n n i n g o f the f o l l o w - u p p e r i o d (1981) and the end o f the f o l l o w - u p p e r i o d ( 1 9 8 3 ) .  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 , s o u r c e o f income and m a r i t a l status.  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 m e a s u r e s ; i n t h i s s e c t i o n the 1981 and 1983 measures a r e 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 :  with regard  to  r e s i d e n t i a l s i t u a t i o n , t h e r e was a s l i g h t net s h i f t o f the sample toward dependent h o u s i n g from i n d e p e n d e n t , 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 o f 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 i n 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 s o u r c e 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 o v e r two y e a r s ; most o f t h i s change seemed to be a t the expense o f c o m p e t i tive  (vs.  two y e a r s .  s h e l t e r e d ) work, where t h e r e was a drop o f about 9% over S i m i l a r l y , w i t h r e g a r d to s o u r c e of income, the  proportion  o f the sample c l a s s i f i e d as "dependent" had i n c r e a s e d by 10% o v e r the p e r i o d 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 , t h e r e 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 S c h i z o p h r e n i a Outcome Measures An a t t e m p t 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 o f s c h i z o p h r e n i a outcome measures, i . e .  to t r y and  identify  75.  Table 9 Change i n C l i e n t S t a t u s Over a Two Year P e r i o d  November, 1981 Residential Situation^  Living „ Situation  Employment Status 3  Source o f Income^  Mari t a l Status 5  November, 1983  Independent H o u s i n g :  6 5 . 2%  Independent H o u s i n g :  60.0%  Dependent H o u s i n g :  34. 8%  Dependent H o u s i n g :  40 .0%  Alone  3 7 . 9%  Alone  38 .0%  With Famil,y as Dependent  20. 1%  With Family as Dependent  17 .6%  With S p o u s e / P a r t n e r  i  - 1 2 . 1%  With Spouse/Partner  - 14 .6%  Shared  2 9 . 9%  Shared  29 .8%  Unemployed  56. 1%  Unemployed  66 .5%  S h e ! t e r e d Work  2 2 . 4%  S h e l t e r e d Work  20 .6%  C o m p e t i t i v e Work  2 1 . 5%  C o m p e t i t i v e Work  12 .8%  Dependent  7 7 . 0%  Dependent  87 .3%  Independent  2 3 . 0%  Independent  12 .7%  S i n g l e , never Married  7 0 . 7%  S i n g l e , never Married  69 .9%  Married  10 .0%  Separated/ Divorced  20 .1%  Married Separated/ Divorced  n = 223 ( 1 9 8 1 ) , 221 (1983), n = 214 ( 1 9 8 1 ) , 216 (1983), n = 225 ( 1 9 8 1 ) , 220 (1983), n = 224 ( 1 9 8 1 ) , 222 (1983), 229 ( 1 9 8 1 ) , 229 (1983),  9 . 2% 2 0 . 1%  7.6.  f e a t u r e s o f the p o p u l a t i o n t h a t were a s s o c i a t e d w i t h b e t t e r community a d j u s t m e n t .  (or worse)  The t h r e e v a r i a b l e s used to measure community  a d j u s t m e n t i n the p r e s e n t study were 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 and employment; i t was assumed t h a t lower h o s p i t a l and Venture a d m i s s i o n r a t e s and h i g h e r 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 adjustment.  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  a d m i s s i o n s made d u r i n g the f o l l o w - u p p e r i o d . referred  community  The employment  to employment s t a t u s a t the end o f the f o l l o w - u p  to  variable  period.  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 t h r e e 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 , u s i n g P e a r s o n ' s r (where two  interval-  2 level  v a r i a b l e s were i n v o l v e d ) and X  was i n v o l v e d ) .  (where a n o m i n a l - l e v e l  2  For the purposes o f the X  categorized as:  A) none, B) o n e , C) two  was c a t e g o r i z e d a s : categorized as:  t e s t s , r e h o s p i t a l i z a t i o n was or more.  A) none, B) one or more.  A) two o r more v i s i t s  variable  Venture a d m i s s i o n s  Visits  to the team was  per month, B) between two  visits  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 1 0 .  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 t h a g e ,  employment s t a t u s  ( a t the end o f t h e f o l l o w - u p p e r i o d ) ,  hospitalization, visits c l o s u r e s and r e o p e n i n g s , hospitalizations.  last  to t h e team, address changes, team c h a n g e s , Venture a d m i s s i o n s and p r e v i o u s  number o f  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 y o u n g e r ,  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 r e q u e n t v i s i t o r s more f r e q u e n t l y  time s i n c e  a d m i t t e d to V e n t u r e ,  to the team,  having a g r e a t e r number o f  prior  h o s p i t a l i z a t i o n s , and having more address changes, team changes and  T a b l e 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 Rehospitalization  Venture A d m i s s i o n s  Age  Sex  (Pearson's " r " = - . 1 8 p = .003)  (SO Independent Var iables Rea ched Sig nificanc Q.  {r = 6 . 2 7 , 9  2 d.f.,  p = .043)  Employment 1983 X - 12.26, 4 d . f . , p = .015  Residence 1981 (X^ = 2 9 . 1 3 , 2 d . f . , p = .000)  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 (Pearson's "r" = - . 2 6 7 p = .000)  R e s i d e n c e 1983 (X = 25.16, 2 d . f . , p = .000)  2  V  Employment S t a t u s 1983  2  <D  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 t o t h e Team ( P e a r s o n ' s " r " = .235) p = .000)  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)  Address Changes ( P e a r s o n ' s " r " = .286 p = .000)  Address Changes ( P e a r s o n ' s " r " = .155 p = .015)  Employment H i s t o r y (X2 = 6 8 . 6 9 , 2 d . f . , p = .000)  - 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 " = .141 p = .016)  -  Rehospitali zation ( P e a r s o n ' s " r " = .358 p = .000)  Team Changes (Pearson's " r " = .313) p = .000)  -Venture Admissions ( P e a r s o n ' s " r " = .358 p = .000) CONTINUED  Table 10 (Continued) Dependent Rehospitalization  V  -Q  LT> O  P r e v i o u s Number o f H o s p i t a l i z a t i o n s ( P e a r s o n ' s " r " = .1154 p = .061)  Variables  Venture Admissions  Employment S t a t u s 1983  L i v i n g S i t u a t i o n 1981 (X = 7.39, 3 d . f . , p = .06)  L i v i n g S i t u a t i o n 1983 X = 11.59, 6 d . f . , P = .07)  Age  V i s i t s to the Team X = 9.29, 4 d . f . , p = .054  2  (Pearson's "r" = - . 1 0 6 p = .054  2  2  <T5  C l o s u r e s and Reopenings ( P e a r s o n ' s " r " = .105 p = .056  a> T3 C <u Q.  -o  -a  01 <_> to o s_  D. O.  Duration of H o s p i t a l i z a t i o n Pearson's " r " = .1497 p = .051 Time S i n c e L a s t Hospital i z a t i o n P e a r s o n ' s "r p = .088)  1  .0916  ~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  it  can be seen t h a t those r e h o s p i t a l i z e d d u r i n g the f o l l o w - u p p e r i o d had h i g h e r 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 t h a t the 2 0 - 3 0 y e a r o l d s 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 f i g u r e was 42% f o r the 3 1 - 4 0 y e a r o l d s , and 25% f o r the over 4 0 ' s . to 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 , o f those who had a h o s p i t a l A  w i t h i n the p r e v i o u s y e a r ,  57% r e t u r n e d to h o s p i t a l i n the  the  With regard  discharge  follow-up  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 hospital  f o r t h r e e y e a r s o r 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 t w i c e a month o r 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 a d m i s s i o n s were a s s o c i a t e d w i t h v i s i t s  to t h e team,  address changes, team c h a n g e s , 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 ( 1 9 8 1 ) , a g e , c l o s u r e s and r e o p e n i n g s , d u r a t i o n o f p r i o r 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 .  h o s p i t a l i z a t i o n , and  In g e n e r a l , t h o s e a d m i t t e d to  tended to be y o u n g e r , more f r e q u e n t v i s i t o r s  Venture  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 r e a t e r  duration  o f past h o s p i t a l i z a t i o n s , and h a v i n g more address changes, team changes and c l o s u r e s and r e o p e n i n g s .  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 1 2 .  The f o u r d i f f e r e n t l i v i n g  situations  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 t h  parental  f a m i l y were a d m i t t e d a t a r a t e o f 7%, whereas those l i v i n g w i t h spouse o r common-law p a r t n e r were a d m i t t e d a t a r a t e o f 27%.  With r e s p e c t to  a g e , i t was noted t h a t those under 40 were a d m i t t e d a t a r a t e o f 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 S t a t u s (1983)  zation  Employment S t a t u s Sheltered Work  Competitive Work  Row T o t a l s  82 • (59.4%)  37 (26.8%)  19 (13.8%)  138 (100%)  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%)  Unemployed  ro None Rehos  Q.  M i s s i n g cases = 16 2 X  = 1 2 . 2 5 8 , 4 degrees o f freedom, p = .015  81.  Table 12 C r o s s t a b u l a t i o n o f Venture A d m i s s i o n s and L i v i n g S i t u a t i o n (1981)  Living Alone  Situation  With P a r e n t a l Family  With Spouse (or CommonLaw)  Shared, Non-familial  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 Totals  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 r e e d o m , p = .06  82.  compared to a r a t e o f 10% f o r those o v e r 4 0 .  With r e s p e c t to v i s i t s  to  the team, i t was noted t h a t those who averaged two o r more team v i s i t s a month were a d m i t t e d 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  duration  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 t h a 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 t a y were a d m i t t e d a t a r a t e o f 16%, compared to 21% f o r those w i t h 1 - 2 y e a r s h o s p i t a l s t a y , and 27% f o r those w i t h o v e r two y e a r s o f p r i o r  hospitalization.  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 p e r i o d ( 1 9 8 3 ) . 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 , to the team.  (It  Employment s t a t u s 1983 was a s s o c i a t e d  and the v a r i a b l e f r e q u e n c y o f  s h o u l d be noted t h a t the independent v a r i a b l e s  visits that  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 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 s u b j e c t s had h i g h e r 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 r e p o r t e d earlier,  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 s e e n , 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 h o u s i n g 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 o f 20%, compared to 2% f o r those i n s h e ! t e r e d / d e p e n d e n t  housing,  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 h o u s i n g . ment h i s t o r y ,  With r e s p e c t to employ-  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 r e c o r d 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 S t a t u s (1983) by Residence (1983) Employment Unemployed  Sheltered Work  Competitive Work  Row T o t a l s  Independent Housing  85 (68%)  15 (12%)  25 (20%)  125 (100%)  Dependent/ Sheltered 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 S t a t u s (1983) by Employment H i s t o r y  Employment Unemployed 6 months competitive work i n previous 5 years Has l e s s than 6 months competitive work i n p r e vious 5 years  Sheltered Work  Competitive Work  Row T o t a l s  24 (44.4%)  6 (11.1%)  24 (44.4%)  54 (100%)  115 (74.2%)  38 (24.5%)  2 (1.3%)  155 (100%)  M i s s i n g cases = 25 2 X = 6 8 . 5 9 8 , 2 degrees o f freedom, p = .000  84.  and h i g h e r r a t e s o f c o m p e t i t i v e employment (44% v s .  1%).  With r e s p e c t  t o l i v i n g s i t a u t i o n , i t can be seen from Table 15 t h a t the unemployment r a t e s f o r the f o u r 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 , non-familial  r e s i d e n c e s had the h i g h e s t 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 p a r t n e r had the r a t e o f c o m p e t i t i v e work (21%).  highest  F i n a l l y , w i t h r e g a r d to v i s i t s to the  team, i t was found t h a t those who v i s i t e d the team more o f t e n had h i g h e r 2 r a t e s o f 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 r e e d o m , p = . 0 5 4 ) .  The a s s o c i a t i o n s w i t h  =  living  s i t u a t i o n 1981 and r e s i d e n c e 1981 were not i l l u s t r a t e d w i t h t a b l e s ;  it  can be noted t h a t the a s s o c i a t i o n s w i t h 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 t h l i v i n g s i t u a t i o n 1983  and r e s i d e n c e  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  particular  e f f e c t o f each independent v a r i a b l e a l o n e by u s i n g a s t e p w i s e 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 t h r e e outcome v a r i a b l e s . the a n a l y s i s i s needed:  Some e x p l a n a t i o n  of  i n t h i s i n s t a n c e 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  for  the n o m i n a l - l e v e l v a r i a b l e s o f 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  S p e c i f i c a l l y , employment was o r d e r e d a s :  1 = better  work  history,  data.  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 ordered a s :  level  2  =  poorer  history  was  work h i s t o r y ;  finally,  r e s i d e n c e was o r d e r e d as 1 • = independent h o u s i n g , - 2 = dependent h o u s i n g .  >  T a b l e 15 C r o s s t a b u l a t i o n o f Employment S t a t u s (1983) by L i v i n g S i t u a t i o n (1983)  Employment Unemployed  Sheltered Work  Competitive Work  Row T o t a l s  Alone  51 (67.1%)  17 (22.4%)  8 (10.5%)  76 (100%)  With Parental Family  23 (65.7%)  5 (14.3%)  7 (20.0%)  35 (100%)  19 (67.9%)  3 (10.7%)  6 (21.4%)  28 (100%)  35 (59.3%)  20 (33.9%)  4 (6.8%)  59 (100%)  With Spouse, Common law Partner In Shared, NonFamiliai Residence  M i s s i n g cases = 36 X  2  = 1 1 . 5 8 8 , 6 degrees o f f r e e d o m , p = .07  86.. •:  The r e s u l t s o f t h e r e g r e s s i o n a r e shown i n Table 1 6 ; the  independent  v a r i a b l e s a r e rank o r d e r e d i n each c o l u m n , w i t h 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 t h e g r e a t e s t amount o f 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 t h 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 r e o p e n i n g s , 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 r e a t e r e x t e n t e x p e r i e n c e d 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 c a r e teams. ( b e f o r e the f o l l o w - u p p e r i o d )  The v a r i a b l e r e f e r r i n g to past events  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 i m e 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 a d m i s s i o n s was f r e q u e n c y o f v i s i t s  to t h e team,  t h a t i s , those people more f r e q u e n t l y a d m i t t e d to Venture were a l s o more frequent v i s i t o r s  to the community c a r e teams.  The v a r i a b l e  referring  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 a d m i s s i o n was duration of prior tional  h o s p i t a l i z a t o n , that i s , those with a l e n g t h i e r  institu-  h i s t o r y tended to be a d m i t t e d more f r e q u e n t l y to Venture i n the  follow-up period.  F i n a l l y , w i t h r e s p e c 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 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  greatest record  p r i o r to the f o l l o w - u p p e r i o d was a s s o c i a t e d w i t h a b e t t e r employment outcome.  Tabl'e 16 M u l t i p l e Regression of 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  Variables  Multiple R  R Square  Beta  1)  C l o s u r e s and Reopenings  .4243  .1801  .35091  2)  Venture Admissions  .5016  .25101  .27657  3)  Team Changes  .3511  .1233  -.12089  4)  Time s i n c e l a s t hospitali zation  .1995  .0398  -.11099  5)  V i s i t s t o the Team  .25816  .06665  .11104  6)  Address Changes  .33297  .11087  ,10362  7)  Age  .11833  .01400  .07814  8)  Employment 1983  .08537  .0072  .05237  9)  P r e v i o u s number of hospitalizations  .08488  .0072  .01641  1)  V i s i t s t o the team  .2296  .0527  .13525  2)  Duration of p r i o r hospitalization  .1598  .0255  .11398  3)  Rehospitalization  .2439  .0595  .09395  4)  Team Changes  .1669  .0279  -.07835  5)  Closures and Reopenings  .1103  .0122  .07497  continued  Table 16  Independent co  cu c s- o +-> C  CO CO  Variables  (continued)  Multiple R  R Square  Beta  6.  Time s i n c e l a s t hospitalization  .0991  .0098  -.06931  7)  Address Changes  .17581  .0309  .02377  8)  Age  .1106  .0122  -.02239  1)  Employment  History  .4054  .1643  -.39293  2)  V i s t i s to the Team  .1201  .0144  -.06958  3)  Residence 1981  .1571  .0247  .04413  4)  Residence 1983  .1564  .0244  -.02405  T3  E  3 >->4-> O ro i — 4-> Q.CO  CO CO OI ^  89  Chapter 5  DISCUSSION  A.  Methodological i)  Issues  Reliability  of Information  and Missing Data.  Studies  t h a t r e l y on i n f o r m a t i o n from r e c o r d s or f i l e s may have problems  with  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 e x p e r i e n c e d i n the p r e s e n t s t u d y .  In p a r t i c u l a r ,  variables  living  that  employment, because  they  referred  form  of  often  from the c l i e n t .  to  current  cohabitation  etc.)  r e l i e d on r e p o r t s  conditions  had  that  those (e.g.  reliability came  As w e l l , t h e r e was v a r i a b i l i t y  problems  second hand  fromwiter  to  i n the comprehensiveness o f progress  notes.  some cases not a l l  (such as h o s p i t a l r e c o r d s )  p e r t i n e n t records  I t was a l s o noted t h a t  i n c l u d e d i n the f i l e s ; t h e 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 to the c l i e n t ' s e a r l y h i s t o r y was o f t e n not a v a i l a b l e .  (such as age o f f i r s t  in  were referring  psychiatric  contact)  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 o f the r e l i a b i l i t y o f t h a t variable;  writer  f o r i n s t a n c e , age o f f i r s t  particular  h o s p i t a l i z a t i o n was u s u a l l y  to d e t e r m i n e , and had fewer m i s s i n g c a s e s , than age o f f i r s t  easier  psychiatric  c o n t a c t , hence i t was f e l t t h 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 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  psychiatric contact.  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 p r o b a b l y a case o f c h o o s i n g a  v a r i a b l e t h a t was not " h a r d " enough, o r a b l e to be o b j e c t i v e l y  defined.  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,  it  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 i g h e r f r e q u e n c i e s o f the v a r i a b l e i n q u e s t i o n . 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  Consequently,  f o r some  h o s p i t a l i z a t i o n , previous  o f h o s p i t a l i z a t i o n s , and address changes -  number  the m i s s i n g cases may have  r e p r e s e n t e d s u b j e c t s w i t h h i g h e r 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 u n d e r e s t i m a t e d the t r u e v a l u e o f the v a r i a b l e . There were some recommendations: f i l e r e s e a r c h e r s an adequate p r e - t e s t  f i r s t of a l l , that for  be done to i n s u r e t h a t the  o f i n t e r e s t can be r e l i a b l y d i s c e r n e d from the f i l e s . complete h o s p i t a l r e c o r d s  be i n c l u d e d i n the f i l e s .  future  variables  S e c o n d l y , t h a t more T h i r d l y , that  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 r e c o r d e d by the t h e r a p i s t ;  standardized  forms c o u l d be used to guide the w r i t t e n  every  progress  passages ( i f  not f o r  note a t l e a s t f o r the r e v i e w s ) to i n s u r e t h a t a l l b a s i c p i e c e s  o f i n f o r m a t i o n (such as employment s t a t u s )  ii)  Nature of the Sample.  were i n c l u d e d .  The d i a g n o s i s o f  schizophrenia  was not i n d e p e n d e n t l y c o n f i r m e d i n the p r e s e n t s t u d y , and i t t h a t such a c o n f i r m a t i o n ( i f  possible)  be attempted i n f u t u r e  In the p r e s e n t study the sample possessed s e v e r a l 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  is  proposed  studies. different  of other  groups  91  of schizophrenics.  In p a r t i c u l a r , t h e s u b j e c t s were a l l  voluntary  c l i e n t s o f a community c a r e 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 a r e a t h a t , i n the e s t i m a t i o n o f 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 . Health A s s o c i a t i o n survey concluded that i n Vancouver a r e p a r t i c u l a r l y  noteworthy"  (A Canadian Mental  "the a f t e r c a r e s e r v i c e s [127].)  provided  T h i s 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 chronicity  patient  (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  the h e a l t h c a r e s y s t e m , r a t h e r than s i m p l y an i n h e r e n t o f the i n d i v i d u a l .  of  characteristic  In the p r e s e n t 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 o u t o f t r e a t m e n t , o r r e f u s e d 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 ,  treatment  however,  would be h a r d e r to t r a c k down, o r r e f u s e 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 .  iii)  Timing of Measiwement. I t was noted i n t h i s study  that  t h e r e were some problems a s s o c i a t e d w i t h the t i m i n g o f measurement. To b e g i n w i t h , the f o l l o w - u p p e r i o d was two y e a r s  in duration;  must be kept i n mind when comparisons are made w i t h s t u d i e s f o l l o w - u p periods of d i f f e r i n g l e n g t h . t i o n t h a t the s u b j e c t s point,  i.e.  discharge. relatively  this  having  I t was a l s o a r e c o g n i z e d  limita-  i n t h i s study d i d not have a common s t a r t i n g  the f o l l o w - u p p e r i o d 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 One can j u s t i f y  t h i s i n s a y i n g t h a t one i s d e a l i n g w i t h a  homogeneous g r o u p , o r by u s i n g the f i n d i n g t h a t t h e r e  a p p a r e n t l y no " c r i t i c a l  period" following hospital discharge  [129],  or by u s i n g t h a t f i n d i n g t h a t s c h i z o p h r e n i a outcome seems to show o v e r time and t h a t a f i v e y e a r f o l l o w - u p  is  stability  i s v e r y s i m i l a r to a two y e a r  92.  f o l l o w - u p , hence the 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 s a p p a r e n t l y crucial  [130].  not  N e v e r t h e l e s s t h e r e i s the f i n d i n g i n the l i t e r a t u r e  that  time o u t o f h o s p i t a l . i s a s s o c i a t e d w i t h r e t u r n r a t e [131] and the v a r i a b l e t i m e 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 s t u d y when c o n t r o l l e d f o r  ( a l t h o u g h the e f f e c t was not the unique  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 ) .  It  i s t h e r e f o r e recommended t h a t  f u t u r e r e s e a r c h e r s 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 subjects  effect  all  i n the r e s e a r c h d e s i g n 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 p e r i o d o f s t a n d a r d i z e d l e n g t h .  (The  problem w i t h  following  s u b j e c t s from h o s p i t a l d i s c h a r g e 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 i s c h a r g e d a t about the same p o i n t  in  time you may be d e a l i n g w i t h small numbers, and a l s o t h e r e i s no guarantee all  these people can be f o l l o w e d up o r w i l l agree to p a r t a k e i n the s t u d y . )  iv)  Validity  of Outcome Measures.  I t was d i s c u s s e d i n  Chapter 3 t h a t i t i s n o t 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  represents,  i n t h a t 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 t h e r than s i m p l y the l e v e l o f f u n c t i o n i n g o f subject.  the  B e a r i n g t h i s l i m i t a t i o n i n m i n d , 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 p r e s e n t s t u d y i n p a r t because i t was r e l i a b l y r e c o r d e d i n the f i l e s , and can be used as the b a s i s f o r c o m p a r i s o n , 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 one group a r e s i m i l a r to those a f f e c t i n g i t f o r a n o t h e r g r o u p .  in  I t was  assumed i n the p r e s e n t s t u d y 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 a d m i s s i o n s were s i m i l a r measures o f outcome; a l t h o u g h 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  strong  93.  ( P e a r s o n ' s r = . 3 6 , from Table 1 0 ) . some d i f f e r e n c e s  As w e l l , t h e r e were found to be  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  t h e s e outcome measures.  Because o f t h i s ,  i t was f e l t t h a t these two  outcome measures s h o u l d be regarded s e p a r a t e l y ,  i.e.  i t seemed a p p a r e n t  t h a t they were not measuring e a c t l y the same t h i n g . It  i s recommended t h a t f o r f u t u r e r e s e a r c h e r s a broad range  o f outcome measures be u s e d , 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 . be used to complement the u b i q u i t o u s  Q u a l i t a t i v e measures c o u l d  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 d e s i g n s would l e n d themselves w e 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 f e a t u r e s interest  of  (such as employment) a r e a t a low l e v e l o f a b s t r a c t i o n and c o u l d  be r e a d i l y d e f i n e d  v)  operationally.  Effects  of Extraneous Variables.  i t was n o t p o s s i b l e to c o n t r o l on the d i s c o v e r e d a s s o c i a t i o n s .  In the p r e s e n t  f o r the e f f e c t s o f extraneous  variables  This i s , i n g e n e r a l , a problem w i t h  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 . 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 frequently  study  I f one i s a s k i n g  r e t u r n to the h o s p i t a l more  than o t h e r s ? , " then one i s i m m e d i a t e l y c o n f r o n t e d w i t h  problem t h a t 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 t h a m y r i a d 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 ,  different  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 issues.  In the p r e s e n t study some a t t e m p t was made' to a c c o u n t f o r  predisposing conditions  the  i n the data c o l l e c t i o n , but i n the f i n a l  political these result  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 u n i v e r s e o f c o n t a m i n a t i n g variables. A m u l t i p l e r e g r e s s i o n was used i n the p r e s e n t s t u d y i n an a t t e m p t 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 u s e d . The way t h i s s t a t i s t i c was used had s e v e r a l l i m i t a t i o n s ; o r d i n a l - l e v e l (e.g.  employment) was t r e a t e d as i n t e r v a l  not used ( e . g .  living situation).  and nominal l e v e l  Because  of  this,  data was  some  associa-  t i o n s i n v o l i v n g nominal v a r i a b l e s c o u l d n o t be examined to any extent;  data  great  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 such as age have an e f f e c t ?  variable  One c o u l d s u g g e s t t h a t f o r f u t u r e  researchers  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  i n t h i s i n s t a n c e they c o u l d not be indexed as o r d i n a l or i n t e r v a l One t e c h n i q u e f o r d e a l i n g w i t h them i s to use c r o s s t a b u l a t i o n s control  variables.  that  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 a g e ,  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 i n the present  study, but was not u l t i m a t e l y used f o r two reasons.  F i r s t of a l l ,  only one-third v a r i a b l e can be c o n t r o l l e d f o r at a time (unlike m u l t i p l e regression) and the choice of the t h i r d v a r i a b l e may become rather arbitrary.  Secondly, when a t h i r d v a r i a b l e i s c o n t r o l l e d f o r the number 2  of cases w i t h i n categories gets smaller, hence tests such as X , which require a minimum number of cases to make the t e s t v a l i d , cannot be applied unless one has a very large i n i t i a l sample. vi)  Relationships  between Variables.  The v a r i a b l e s used  i n the present study were regarded as "independent" and "dependent" (or outcome), however i t was recognized  that the use o f these terms was rather  suspect i n that the study was uncontrolled.  In the l i t e r a t u r e i t had  been found that c e r t a i n v a r i a b l e s are used as "predictors" of schizophrenia outcome; f o r the sake o f 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 v a r i a b l e referred to events that had occurred  p r i o r to the follow-up  period (e.g. duration o f 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 d i r e c t i o n o f e f f e c t between independent and dependent v a r i a b l e i s confused when the two events may be occurring a t the same time.  B.  Sociodemographic C h a r a c t e r i s t i c s of the Study Population i)  The Sample as a Whole. I t was apparent that t h i s was a  dependent population; a t the end o f the follow-up period 66% o f the sample  96-.  was unemployed, and o n l y 13% were doing c o m p e t i t i v e work,  further,  o n l y 27% o f the p o p u l a t i o n had h e l d 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 i n the p r e c e d i n g 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 s t u d y p e r i o d 87% o f the sample was dependent i n t h e i r s o u r c e o f income. One gets a sense o f how high t h e s e unemployment r a t e s a r e 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 l a b o u r f o r c e f o r  those  o v e r 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. f i n d i n g s o f t h e p r e s e n t s t u d y r e f l e c t e d those o f o t h e r  In s h o r t ,  the  schizophrenia  s t u d i e s i n t h a t the d i s a b l i n g n a t u r e o f the i l l n e s s was m a n i f e s t e d 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 lived a rather isolated existence.  Seventy per c e n t 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% s e p a r a t e d or d i v o r c e d and o n l y 10% m a r r i e d 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 t h e f o l l o w - u p p e r i o d , 36% o f 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% with  spouse/partner. R e g a r d i n g m a r r i a g e 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 o f those o v e r 15 y e a r s 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 m a r r i e d i i i 1 9 8 1 , 7% were s e p a r a t e d o r d i v o r c e d , and 58% were m a r r i e d .  The h i g h e r d i v o r c e and lower m a r r i a g e 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 n e g a t i v e impact on the f o r m i n g o f s o c i a l r e l a t i o n s h i p s .  Compared to  o t h e r 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 s t u d y had a somewhat  91.  lower m a r r i a g e r a t e ; A f f l e c k ' s study found a m a r r i a g e r a t e o f 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 It  i s d i f f i c u l t to make much o f t h i s ; one c o u l d t e n t a t i v e l y  [134]. propose  t h a t the sample i n the p r e s e n t 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 however the two samples may not be comparable because o f differences,  debility),  cultural  etc.  Regarding sex and m a r r i a g e r a t e s , the f i n d i n g made s t u d i e s was a l s o made i n the p r e s e n t s t u d y ,  in  other  namely t h a t female s c h i z o -  p h r e n i c s have a h i g h e r m a r r i a g e r a t e than m a l e s .  The 1983 m a r r i a g e  rate  i n t h i s study was o n l y 4% f o r the men (82% never m a r r i e d ) and 19% f o r the women (53% never m a r r i e d ) . while s t i l l  not c l o s e to the r a t e s o f the general  c o n f i r m the h y p o t h e s i s f o r the t r a d i t i o n a l role.  The female r a t e s f o r the p r e s e n t  p u b l i c , do tend to  t h a t the symptoms o f the d i s o r d e r are l e s s  female r o l e i n c o u r t i n g  An a l t e r n a t i v e  study,  hypothesis  crucial  than f o r the t r a d i t i o n a l male  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 o n s e t 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 m a r r i e d b e f o r e the i l l n e s s becomes " f u l l comment s h o u l d be.made:  blown."  One q u a l i f y i n g  i t was found i n the p r e s e n t 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 c o u l d , of course, a f f e c t m a r i t a l  that  status.  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 l o n e i n  this  sample) i s a p p a r e n t 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 ; t h e 1981 census i n d i c a t e d t h a t o n l y 9% o f Canadians l i v e and f o r t h o s e under 55 the f i g u r e 20-54 [135].  alone,  i s l e s s , r o u g h l y 6% f o r those from  S c h i z o p h r e n i c symptoms a r e p o o r 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 a r e withdrawn because they f i n d s o c i a l situations stressful  [136].  In t h i s study a t o t a l o f 31% o f 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% w i t h t h i s f i g u r e seems to be somewhat lower than most o f the findings  (e.g.  spouse/partner); literature  47% w i t h f a m i l y i n A f f l e c k ' s [137] s t u d y ) and i t seems  r e a s o n a b l e to s p e c u l a t e t h a t t h i s may i n p a r t be due to h o u s i n g r e s o u r c e s a v a i l a b l e i n Vancouver  alternative  (such as mental h e a l t h b o a r d i n g  homes) t h a t may not be a v a i l a b l e to the same e x t e n t i n o t h e r In f a c t , i n t h i s s t u d y i t was noted t h a t a t the end o f the  centres.  follow-up  p e r i o d 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 mental h e a l t h b o a r d i n g home, group home, f a m i l y c a r e home or apartment.)  supervised  This f i g u r e i s h i g h e r than t h a t seen f o r most o t h e r  studies  t h a 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 s t u d y f o r example, showed t h a t o n l y 10% o f mental p a t i e n t s came out o f hospital  (i.e.:  i n t o s h e l t e r e d h o u s i n g , and the "new, young c h r o n i c "  [138], the  literature  a l s o showed low r a t e s o f s h e l t e r e d housing o c c u p a n c y . 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 was 37%, i . e .  study  37% had a t 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 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 t h a t o f those s u b j e c t s who had been i n h o s p i t a l i n the p r e c e d i n g 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 p r e c e d i n g 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  o f o t h e r r e s e a r c h e r s , such as S t r a y h o r n  findings  [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 y e a r s o f h o s p i t a l  discharge.  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 s c h a r g e d 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 t h e r e 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 a n o t h e r group t h a t has been o u t 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 a r e more c l e a r l y  i n Table 8, which shows a b i - m o d a l d i s t r i b u t i o n . c o m p o s i t i o n o f the two g r o u p s ,  delineated  In s p e c u l a t i n g on the  i t was noted t h a t t h e r e 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) the most r e c e n t l y h o s p i t a l i z e d group being y o u n g e r .  with  More s p e c i f i c a l l y ,  i t was found t h a t o f the 2 0 - 3 0 y e a r o l d s , 71% had been i n h o s p i t a l i n the two y e a r s p r e v i o u s to the f o l l o w - u p p e r i o d , w h i l e o f the o v e r 4 0 ' s o n l y 33% were i n h o s p i t a l i n the two y e a r s p r e v i o u s to the f o l l o w - u p It  period.  i s n o t a b l e i n the p r e s e n t s t u d y 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  relatively  high even though the sample were ( f o r  t r e a t e d a t a community c a r e team.  It  the most p a r t )  being  i s d i f f i c u l t to comment on t h i s  p o i n t , e x c e p t to propose t h a t the s c h i z o p h r e n i c seen a t the community c a r e teams may r e p r e s e n t a poorer p r o g n o s i s group (the than the ones seen i n o t h e r s e t t i n g s  "difficult  (such as p r i v a t e  patient")  practice).  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 r e a t m e n t s e r v i c e s , 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 o f the sample (47%) v i s i t e d community c a r e teams a t l e a s t t w i c e per month. visits  it  the  The modal v a l u e of two  per month may have been d i c t a t e d to a l a r g e e x t e n t by the m e d i c a t i o n  regimen, 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 a r e g i v e n b i - W e e k l y .  The tendency seemed to be t h a 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 t h r e e hours c l i n i c a l make the  time per month.  One can  observation that treamtent of psychotic i n d i v i d u a l s i s  often  100.  c e n t r e d around the i s s u e o f m e d i c a t i o n , and c o n v e n t i o n a l i s f e l t to not be an e f f e c t i v e approach [ 1 4 0 ] .  psychotherapy  The f i n d i n g t h a t women  a r e 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 this study; (The  in  f o r one t h i n g , the m a j o r i t y o f the S u b j e c t s were male (59%).  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 p o p u l a t i o n a t l a r g e i s  to be about equal f o r t h e 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 r e q u e n c y o f v i s i t s interestingly,  the v a r i a b l e  believed  to the team, a n d ,  "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 a p p a r e n t l y r e q u i r e d more c l i n i c a l time than the f e m a l e s . '  ( S i x t y per c e n t o f t h e females s p e n t fewer than t h r e e  per month a t the team compared to 48% f o r the m a l e s . )  hours  One c o u l d propose  t h a t the male c l i e n t e l e a r e 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 t h a t the males s u b j e c t s were younger than the f e m a l e s .  F i n a l l y , w i t h r e s p e c t to use o f  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  services,  patient  seen by community mental h e a l t h a g e n c i e s 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 p r e s e n t  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 a d m i t t e d 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 time a t the teams (see Table Address changes was f e l t to be one measure o f c l i e n t  4).  stability;  the o b s e r v a t i o n - h a d been made by o t h e r r e s e a r c h e r s 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 g r o u p . was found t h a t 42% o f the sample had moved a t l e a s t once i n the p e r i o d , which seemed to bear o u t the f i n d i n g s o f o t h e r comments need to be made:  It  study  researchers.  Some  f i r s t o f a l l , the f i g u r e o f 42% may be an  u n d e r e s t i m a t i o n because o f the m e t h o d o l o g i c a l problems d e s c r i b e d  earlier;  101.  secondly;  t h e sample i n t h i s study a l l remained i n t r e a t m e n t f o r t h e two  y e a r 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 based m e n t a l l y i l l  of other  community  i n t h a t by v i r t u e o f s t a y i n g i n t r e a t m e n t 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 Vancouver c o n t a i n s a f a i r l y  Metropolitcan  transient population in general.  The 1981  census i n d i c a t e d t h a t o f those over f i v e y e a r s o f a g e , 54% had moved a t l e a s t once i n the p r e v i o u s Mortality figures suicide)  f i v e years  [141].  i n d i c a t e d o n l y one o f the s u b j e c t s d i e d  i n the study p e r i o d , out o f a t o t a l o f 2 3 4 .  Admittedly,  (a  in  this  s t u d y the sample was under 50 y e a r s o f age and the s t u d y p e r i o d was o f o n l y two y e a r s d u r a t i o n .  Nevertheless,  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 d e t e c t e d a v e r y h i g h m o r t a l i t y r a t e f o r community based s c h i z o phrenics.  If  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 r e a t m e n t o f f e r e d through the community c a r e system s e r v e s m o n i t o r 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 f o r those not i n  different  treatment.  A comment s h o u l d be made on the v a r i a b l e s p e r t a i n i n g to numbers and d u r a t i o n o f p a s t h o s p i t a l i z a t i o n s f o r the s a m p l e . tribution  to  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  previous  The d i s -  institutionalization  had not been e x t e n s i v e  ( t w o - t h i r d s had f i v e or fewer p a s t  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 ) .  hospitalizations  This  s h o u l d be q u a l i f i e d by the m e t h o d o l o g i c a l problems i n v o l v e d  finding in acquiring  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 , t h e r e were a l a r g e number o f m i s s i n g c a s e s , and these cases may have r e p r e s e n t e d a group w i t h a l e n g t h i e r institutional  history,  underestimation.  hence the r e p o r t e d r e s u l t s may i n f a c t be an  As w e l l , i t i s c o n c e i v a b l e t h a t the younger c l i e n t s  102,  c o u l d 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  duration"  end o f the s c a l e . With r e g a r d 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 c o n t a c 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 cases.  The f i n d i n g i n t h i s s t u d y t h a t the m a j o r i t y o f s u b j e c t s  their f i r s t  experienced  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 t w e n t i e s i s more  o r l e s s c o n s i s t e n t w i t h o t h e r f i n d i n g s i n the l i t e r a t u r e . methodological  (There i s a  problem here i n t h a t the younger s u b j e c t s 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 o n s e t was n o t d e t e c t e d to any g r e a t e x t e n t i n t h i s 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  sample;  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,  (schizophrenics)  the f i n d i n g by Lewine [143] t h a t "women  are at greatest 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 during  t h e i r t h i r t i e s " d i d not h o l d u p , 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 b e f o r e 30 (the same f i g u r e as f o r the men). s i g n i f i c a n c e of t h i s i s that i f , an i n d i c a t o r o f p r o g n o s i s  The  as has been p r o p o s e d , age o f o n s e t i s  [ 1 4 4 ] , i t would seem t h a t the community c a r e  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  prognosis  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 o n s e t women were b e i n g s e r v e d 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 g r o u p , as noted by the low employment and high rehospital i-zation r a t e s .  The dependency o f 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 s o u r c e o f  103.  income and the number of subjects l i v i n g i n sheltered housing.  Some  i n d i c a t i o n of the s o c i a l 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 r a t e s .  It  seemed that more of the study population were l i v i n g i n sheltered housing and fewer with family than had been detected i n other s t u d i e s ; i t was hypothesized  that one reason for t h i s may  more sheltered housing resources.  be because Vancouver o f f e r s  Regarding sex d i f f e r e n c e s , a sex e f f e c t  was seen i n marriage rates and employment, but the sex differences i n use of services and age of onset that had been detected by other were not noted i n t h i s study.  researchers  There were also some age differences found  i n the population; these w i l l be discussed at more length below.  ii)  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 w i t h i n the sample seemed to be accounted for by the age v a r i a b l e ; consequently, i t i s proposed that one  can  l e g i t i m a t e l y 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 w i t h i n the l a r g e r population. The age differences were summarized i n Table 4; i n b r i e f , they indicated that the younger group i n the sample was  predominantly male, consumed  proportionately more p s y c h i a t r i c s e r v i c e s , 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 r a t e , a higher Venture admission r a t e , an e a r l i e r f i r s t contact with the p s y c h i a t r i c system, and a lower marriage rate (assuming marriage i s a mechanism").  "screening  With respect to consumption of s e r v i c e s , 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 o f t e n ,  104.  and r e q u i r e d more c l i n i c a l to i n s t a b i l i t y ,  time (hours per month a t t e a m ) .  With r e s p e c t  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 s o u r c e o f income. The f e a t u r e s seen i n t h i s p a r t i c u l a r s u b - g r o u p mesh c l o s e l y w i t h t h o s e d e s c r i b e d by o t h e r s 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 e v i e w ,  the "new young c h r o n i c " forms a s u b - g r o u p  t h a t i s coming i n t o prominence i n North A m e r i c a ; t h i s i s an i n d i v i d u a l who i s y o u n g , p r e d o m i n a n t l y 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 t h a t a l t h o u g h they have r e l a t i v e l y  short  d u r a t i o n s o f p r i o r h o s p i t a l i z a t i o n , they n o n e t h e l e s s d i s p l a y s i g n s 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 t h a t p r e v i o u s l y  of  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  (in  l a r g e p a r t ) a f u n c t i o n o f the l e n g t h 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 , 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  as patient  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 l o c u s t r e a t m e n t has s h i f t e d from the mental h o s p i t a l to the community. a p p a r e n t t h a t the needs o f t h i s group a r e not b e i n g met by the community mental h e a l t h system t h a t e x i s t s Some have suggested t h a t the d e l i v e r y  for I t seems  current  i n much o f North A m e r i c a .  system i t s e l f i s i n f a c t  contributing  to the c h r o n i c i t y o f t h i s g r o u p , and t h a t new t r e a t m e n t approaches must be employed, such as a move away from the c u r r e n t emphasis on  brief  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 discharge [147]. residential  Others have suggested t h e need f o r more  programs f o r the young c h r o n i c ; the p r e s e n t s t u d y  indicated  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 , t h e r e 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 .  It  has a l s o been s u g g e s t e d ,  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 p r o v i d e 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 s o c i o d e m o g r a p h i c outcome p r e d i c t o r s examined i n the p r e s e n t s t u d y , s i n c e s i m p l e symptomatology i s n o t 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 [149].  potential  I t has a l s o been proposed t h a t , whatever t r e a t m e n t 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 , produce c h r o n i c dependency i n the i n d i v i d u a l , and thus s u p p o r t programs w i l l  that w i l l  treatment/  need to be o f i n d e f i n i t e d u r a t i o n .  It  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 the community ( v s .  in  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 t e p toward c u r i n g the p r o b l e m ; 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 r e g a r d s t h e young mental p a t i e n t as a d i s c r e t e  clinical  g r o u p , one must a l s o bear i n mind t h a t e a r l y a d u l t h o o d i s a t u r b u l e n t t i m e 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 r e a s o n a b l e tosuppose t h a t the i n s t a b i l i t y o f the young mental p a t i e n t i s i n p a r 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  in general. 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 c o n t a c t w i t h the p s y c h i a t r i c system was a s i g n o f g r e a t e r  initial  disability,  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 c o n t a c t s than the o l d e r s u b j e c t s .  has been found  It  that  age o f o n s e t 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 o n s e t i n d i c a t i n g a poorer p r o g n o s i s  [152].  I t was found i n the  p r e s e n t s t u d y 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  first  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 a r e summarized i n Table 5 .  The problem  i s t h a 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 t h a t a younger s u b j e c t definition will  by  have an e a r l i e r age o f f i r s t c o n t a c t s i m p l y because he  has not l i v e d l o n g 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 results.  The f i n d i n g s a r e not c o m p l e t e l y a r t i f a c t u a l , however.  o f o n s e t i s a s i g n o f p r o g n o s i s , and i f t h i s sample were  If  age  prognostically  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 , s u g g e s t i n g 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 g r o u p .  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 ) 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 y e a r s ago as i t younger c l i e n t  to be h o s p i t a l i z e d t o d a y .  T h i s seems  f o r an  is for a  to be a r e a s o n a b l e  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 a r e more s t r i c t than they were i n the p a s t .  currently  I f one examines Table 5 , which l o o k s 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 o f  first  psychiatric contact),  First  there are several  interesting findings.  107-.  o f a l l , the l a t e o n s e t o f 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 t h o s e o v e r 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 age o f 3 0 .  Regarding t h i s l a t t e r p o i n t , i t i s the e x p e r i e n c e o f  researcher that i t  the  this  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 s or l a t e r , u n l e s s i t i s a case o f 1  late onset, better prognosis, schizophrenia.  The o t h e r i n t e r e s t i n g  finding  i s t h a t i t seems from t h i s t a b l e t h a t many o f the c l i e n t s who a r e being served by t h e community c a r e teams have had r e l a t i v e l y r e c e n t  contact  w i t h the p s y c h i a t r i c s y s t e m ; one can s p e c u l a t e t h a t of t h e c u r r e n t l y  older  s c h i z o p h r e n i c s who had an e a r l y o n s e t 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 , o r be i n h o s p i t a l , or do not r e q u i r 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 ,  service.  t h e 4 6 - 5 0 y e a r o l d s , i t can be  seen from Table 5 t h a 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 l e a d s 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  in  t h i s sample a r e i n some sense more s t a b l e , i s i t b e c a u s e , as some s u g g e s t , they have been i n the system a l o n g 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 o n s e t a r e prognosis schizophrenics? m i g h t be u s e f u l i n a f u t u r e  better  An i n v e s t i g a t i o n o f these competing hypotheses study.  To summarize t h i s s e c t i o n , i t was found t h a t the younger s u b j e c t s i n the s t u d y sample showed a g r e a t e 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-group.  The f i n d i n g s i n the p r e s e n t s t u d y 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 s u b - g r o u p came to e x i s t ,  i t seems t h a t the same f o r c e s t h a t  have  c r e a t e d t h i s group i n o t h e r c e n t r e s have c r e a t e d i t i n Vancouver. was proposed t h a t the community mental h e a l t h d e l i v e r y  s y s t e m , 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 needs and may be c o n t r i b u t i n g  to the p r o b l e m .  client's  I t was a l s o suggested  the i n s t a b i l i t y d e t e c t e d may be i n p a r t a r e f l e c t i o n o f the o f young people i n g e n e r a l .  It  instability  F i n a l l y , a q u i r k o f the sample was noted  t h a t many ;of. t h e 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  that  late i n i t i a l  in  contact  w i t h the p s y c h i a t r i c s y s t e m , and on t h i s b a s i s , might be c o n s i d e r e d prognostically  C.  superior  to t h e younger  S t a b i l i t y Measures o f the  subjects.  Population  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 , t h o s e people  i n t h e i r s o u r c e o f income i n c r e a s e d from.77% to 87%. c o n s i s t e n t with Anthony's  dependent  This f i n d i n g  [153] p r o p o s i t i o n t h a t employment r a t e s  o v e r t i m e ; i t a l s o seems to bear o u t S t r a u s s ' h y p o t h e s i s  that  is decline  schizo-  p h r e n i c s 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 continuum c u r v e o f outcome d y s f u n c t i o n  [154].  (One must bear i n mind t h a t  employment s t a t u s i s o n l y one measure o f s c h i z o p h r e n i a outcome.) findings  These  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 w o r s e n i n g , d i s a b i l i t y f o r  study population over time.  the  the  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 g o i n g down, s i n c e t h e r e a r e 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 n a t u r e 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 g e n e r a l p u b l i c changed o v e r the same time p e r i o d . other c o n s i d e r a t i o n :  There i s one  t h i s s t u d y o n l y f o l l o w e d those who s t a y e d i n  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 g r o u p , and t h a t whose s t a t u s improved d u r i n g the two year f o l l o w - u p p e r i o d ( i . e .  treatthose  secured  employment) dropped o u t and hence were not i n c l u d e d i n the s t u d y .  If  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 c a r e teams were d e a l i n g w i t h a more d i s a b l e d segment o f a l l those r e f e r r e d f o r To c o n f i r m t h i s h y p o t h e s i s i t w o u l d - b e a u s e f u l f u t u r e s t u d y to  treatment. contrast  the c h a r a c t e r i s t i c s o f those i n d i v i d u a l s who s t a y i n t r e a t m e n t v s . who drop o u t a f t e r a s h o r t t i m e .  It  those  s h o u l d be noted t h a 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 S c h i z o p h r e n i a Outcome Measures The t h r e e outcome measures used i n t h i s s t u d y were r e h o s p i t a l i  t i o n , a d m i s s i o n s to Venture and Employment s t a t u s . sidered  These w i l l  be c o n -  separately.  i)  Rehospitalization.  There were n i n e v a r i a b l e s t h a 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 t h r e h o s p i t a l i z a t i o n .  Some  o f t h e s e a s s o c i a t i o n s c o u l d be c o n s i d e r e d to be t r i v i a l o r "commonsensical."  For i n s t a n c e , i t i s not s u r p r i s i n g t h a t a person who was  r e h o s p i t a l i z e d i n the study p e r i o d would a l s o tend to have more address c h a n g e s , team c h a n g e s , c l o s u r e s and r e o p e n i n g s , Venture a d m i s s i o n s , or be unemployed a t the end o f the s t u d y p e r i o d .  T h i s i s because b e i n g  110.  r e h o s p i t a l i z e d r e p r e s e n t s an upheaval  i n the c l i e n t ' s l i f e ;  the  might be d i s c h a r g e d 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 thus a c c o u n t i n g f o r a change i n a d d r e s s .  client residence,  The community c a r e teams have a  geographical  catchment a r e a , thus an address change c o u l d a c c o u n t f o r a  team change.  R e h o s p i t a l i z a t i o n could a l s o c o i n c i d e with being closed  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 Or,  to keep the c l i e n t ' s f i l e a c t i v e a t the team.  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 s c h a r g e was reopened a g a i n .  An  a s s o c i a t i o n between Venture a d m i s s i o n s 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 t h a t people u n s t a b l e 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 s o m e e a s e s a Venture a d m i s s i o n would i m m e d i a t e l y precede (or f o l l o w )  a hospital admission.  Finally,  if  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 p e r i o d i n  that  he has j u s t r e c e n t l y been through a time 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  previously.  One c o u l d propose an a l t e r n a t e h y p o t h e s i s with  address changes;  f o r the a s s o c a t i o n  i n s t e a d o f s u p p o s i n g t h a t address changes a r e  c r e a t e d by b e i n g r e h o s p i t a l i z e d , i t may be t h a t t h e s e two v a r i a b l e s more or l e s s i n d e p e n d e n t , and t h a t both a r e measures o f c l i e n t  are  instability,  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 t e n d i n g to be y o u n g e r .  This i s  w i t h 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 , p a r t i c u l a r l y  consistent  the r e c e n t  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 h i g h  studies  recidivism  111.  rate.  In t r y i n g  to a c c o u n t 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 " b u r n t u 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 s y s t e m , and thus more s e t t l e d in his p o s i t i o n .  T h i s r e l a t e s to the h y p o t h e s i s by G l i c k [155] t h a t  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 ferent hospital policies)  the  dif-  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 s c h a r g e , presumably due to the e f f e c t o f the i n s t i t u t i o n a l i s m . In t h i s p r e s e n t study t h e r e 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 p a s t 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  consistent  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 h i g h r e h o s p i t a l i z a tion rate despite short i n s t i t u t i o n a l h i s t o r i e s . to the p r o p o s i t i o n by S t r a u s s  It  i s , however,  [156] t h a t d u r a t i o n o f p r i o r  i s the b e s t 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 . 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  counter  hospitalization  (One m u s t , however,  bear  in  p r e d a t e the "new, young c h r o n i c "  literature.) B e a r i n g 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  n o n e t h e l e s s f e l t to be u s e f u l to r e g a r d 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 q u e s t i o n  concerned events t h a t were a n t e c e d e n t to the outcome e v e n t s .  For example,  a f i n d i n g made by many o t h e r workers i s t h a t p a s t numbers o f h o s p i t a l i z a tions  (as opposed to d u r a t i o n )  is a strong predictor of 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 b e i n g t h a t past b e h a v i o u r i s o f t e n the b e s t of future behaviour.  T h i s f i n d i n g was i n f a c t upheld i n the  s t u d y ; however, what was found to be b e s t " p r e d i c t o r " o f  predictor  present  rehospitalization  was 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 , 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 s t u d y p e r i o d ) 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 .  b e i n g the ones more l i k e l y to T h i s 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  hospitalized  may i n some sense r e p r e s e n t a " h i g h r i s k " g r o u p , r e q u i r i n g g r e a t e r  attention  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  fre-  quency o f v i s i t s to the community c a r e 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 e x p e r i e n c e d more r e h o s p i t a l i z a tions.  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 o f 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 help."  for  On the o t h e r hand, t h i s f i n d i n g seems t o run c o u n t e r to the c o n -  c l u s i o n o f Anthony [158] and o t h e r s who s a i d t h a t g r e a t e r f r e q u e n c y  of  a t t e n d a n c e a t a f t e r c a r e 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 tion rates. I t was a l s o proposed by some r e s e a r c h e r s 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 h o u s i n g e x p e r i e n c e d a lower  rehospitalization  r a t e than those i n u n s h e l t e r e d , independent h o u s i n g .  T h i s f i n d i n g was  not upheld i n the p r e s e n t s t u d y ;  i t was found t h a t those who were  in  independent h o u s i n g a t the s t a r t o f the s t u d y p e r i o d 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 e x t e n t than those i n dependent h o u s i n g .  It  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 c o u l d 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 h o u s i n g i s a f a c t o r h e r e .  It  could  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 h o u s i n g r e p r e s e n t e d areas where t h e r e was a s h o r t a g e o f t h i s housing and where p o o r 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 h o u s i n g 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 r e s o u r c e s  e x i s t ; a C.M.H.A. B.C.  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  that  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 r e s o u r c e s f o r the m e n t a l l y  113  ill.  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 a r e g e t t i n g i t , making those i n s h e l t e r e d ( v s .  indepen-  d e n t ) 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 c o n f o u n d i n g comparisons r e c i d i v i s m r a t e s between the two g r o u p s . other variables all  subjects,  It  is also possible  that  (such as the t r e a t m e n t v a r i a b l e , which was the same f o r  r e g a r d l e s s o f housing type) were more c r u c i a l  outcome i n t h i s  in  effecting  instance.  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 t h the time  s i n c e h i s / h e r 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 r e q u e n c y o f h i s / h e r to the team, and w i t h the p r e v i o u s  number o f p s y c h i a t r i c  of future 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 o t h e r r e s e a r c h e r s  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  ii)  predictor  t h a t had  s i t u a t i o n and d u r a t i o n  h o s p i t a l i z a t i o n were not upheld i n t h i s s t u d y  reach or approach s t a t i s t i c a l  visits  hospitalizations.  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 b e s t h i s t o r i c a l  of prior  of  (i.e.  they d i d not  significance).  Admissions to Venture.  I t was expected t h a t t h i s  variable  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 f o u n d .  The r e a s o n i n g was t h a t V e n t u r e ,  being a c r i s i s  unit,  r e p r e s e n t e d a " m i n i - h o s p i t a l , " w i t h t h e same s o r t s o f people being a d m i t t e d to Venture as would be a d m i t t e d 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 (It  reasons.  was r e c o g n i z e d t h a t an a d m i s s i o n 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 m a t t e r than a h o s p i t a l ' a d m i s s i o n , i . e . 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  episode.)  a brief,  situational  crisis,  114.  The a s s o c i a t i o n s d i s c o v e r e d (summarized i n Table 10) seemed to f o l l o w the same t r e n d t h a t had been seen f o r r e h o s p i t a l i z a t i o n , a l t h o u g h t h e r e were some d i f f e r e n c e s . visits  To begin w i t h , the same a s s o c i a t i o n s w i t h  to the team, address changes, team changes, c l o s u r e s and r e o p e n i n g s ,  a g e , 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 t h Venture a d m i s s i o n s 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 a d m i t t e d 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 r e a d e r 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  a d m i s s i o n s the a s s o c i a t i o n w i t h 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 , t h a 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  history  tended to be a d m i t t e d t o Venture more.  In f a c t , 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 was the b e s t 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 1 6 .  prior  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 a d m i s s i o n s and not f o r talization?  rehospi-  One h y p o t h e s i s was t h a t those a d m i t t e d to Venture might be  o l d e r than t h o s e who were r e h o s p i t a l i z e d , thus they would have institutional  histories.  longer  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 t h a 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 n the same way  I t was thus c o n -  c l u d e d t h a t g i v e n the l i m i t a t i o n s o f the p r e s e n t s t u d y ,  l i t t l e c o u l d 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 a d m i s s i o n s 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 a d m i s s i o n s to a g r e a t e r e x t e n 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 a d m i t t e d 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 . produced ( p r o p o r t i o n a t e l y ) spouse/partner;  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  t h e most Venture a d m i s s i o n s were:  1) wtth  2) b o a r d i n g 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 t h 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 o n l y  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 o r d e r o f 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 ) a d m i s s i o n s was d i f f e r e n t .  They w e r e :  more h o s p i t a l  1) w i t h f a m i l y as dependent;  2) w i t h s p o u s e / p a r t n e r ; 3) b o a r d i n g home; 4) a l o n e .  In o t h e r w o r d s ,  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 e a s t 1 i k e l y to be a d m i t t e d to V e n t u r e .  pattern  T h i s d i f f e r e n c e between the  o f h o s p i t a l a d m i s s i o n and Venture a d m i s s i o n i s v e r y d i f f i c u l t to  interpret.  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,  is speculation.  All  that  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 t h Venture a d m i s s i o n a r e different  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 ,  a g a i n l e n d i n g s u p p o r t to the c o n t e n t i o n t h a t these two outcome measures should be c o n s i d e r e d s e p a r a t e l y .  (If  one goes back to the  r e v i e w 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  literature 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 w i t h p a r e n t a l f a m i l y produces the h i g h e s t h o s p i t a l r e t u r n r a t e ; l i t e r a t u r e i n t h i s a r e a has a number of c o n f l i c t i n g f i n d i n g s , To summarize t h i s s e c t i o n :  is  the  however.)  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  a d m i s s i o n s 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 w i t h r e h o s p i t a l i z a t i o n , however t h e r e were a s s o c i a t i o n s found w i t h 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 t h a t were not  living  significant  116.  for r e h o s p i t a l i z a t i o n . be the b e s t h i s t o r i c a l i n the study p e r i o d .  Duration of prior  h o s p i t a l i z a t i o n was found to  p r e d i c t o r o f a s u b j e c t being a d m i t t e d to  Venture  B e c a u s e , o f the d i f f e r e n c e s f o u n d , i t was concluded  t h a t Venture a d m i s s i o n s must be regarded as s e p a r a t e and d i s t i n c t rehospitalization  i i i)  from  as an outcome measure.  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 a t the end o f t h e study p e r i o d was a good work h i s t o r y ; h i s t o r y was the b e s t h i s t o r i c a l  employment  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 o f o t h e r 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 r e n d o f c o n t i n u i n g o r worsening 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 , best p r e d i c t o r of future behaviour  in this  past behaviour  disability  is s t i l l  the  instance.  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  that  those l i v i n g w i t h spouse o r common-law p a r t n e r had a h i g h e r r a t e o f c o m p e t i t i v e employment than the o t h e r  three l i v i n g s i t u a t i o n s .  (It  s h o u l d 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 r e p o r t e d  i n the r e s u l t s s e c t i o n - Table 10 -  because the numbers .were too small to meet the v a l i d i t y r e q u i r e m e n t s  of  2 the X  test.  T h i s 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 c o n f i r m s  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.,  the  a t the end o f the s t u d y p e r i o d 29%  o f the m a r r i e d s u b j e c t s were w o r k i n g c o m p e t i t i v e l y , the s i n g l e , s e p a r a t e d and d i v o r c e d s u b j e c t s . )  compared to 11% f o r  The f i n d i n g t h a t being  m a r r i e d i s a s s o c i a t e d w i t h h i g h e r employment r a t e s has been made by a number o f o t h e r s c h i z o p h r e n i a r e s e a r c h e r s .  It  is a finding that  is  117.  d i f f i c u l t to i n t e r p r e t  r e g a r d i n g cause and e f f e c t .  For example i s  it  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 a r e the  people  t h a t become m a r r i e d i n some ways b e t t e r s o c i a l l y a d j u s t e d and hence, prognostically  superior  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] p r o p o s e , m a r r i a g e may s e r v e as a s c r e e n i n g mechanism i n  schizophrenia,  and one m i g h t l e g i t i m a t e l y propose t h a t the m a r r i e d s u b j e c t s c o u l d be c o n s i d e r e d as d i s t i n c t from the u n m a r r i e d s .  I t s h o u l d be n o t e d ,  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 ( T a b l e 1 5 ) , t h a t t h e r e was some v a r i a b i l i t y ,  although  the unemployment r a t e s were f a i r l y  and q u i t e h i g h , f o r a l l f o u r d i f f e r e n t l i v i n g g r o u p s , s i g n i f i c a n t degree o f d i s a b i l i t y ,  with  similar,  indicating a  regardless of l i f e s t y l e .  In t h i s study t h e r e 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 ( T a b l e 1 3 ) ; i t was found t h a t those i n independent housing had h i g h e r 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 housing had h i g h e r r a t e s o f s h e l t e r e d employment.  In f a c t , those  (sheltered) in  s h e l t e r e d housing had the h i g h e s t 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  m a i n l y 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 . ) w r i t e r w h i l e w o r k i n g w i t h the G . V . M . H . S .  I t was found by  this  t h a t many o f the mental h e a l t h  b o a r d i n g homes r e q u i r e d some form o f job commitment from the  residents;  i f they were not c a p a b l e o f c o m p e t i t i v e employment (which most were as i n d i c a t e d by the low r a t e s o f c o m p e t i t i v e employment f o r o f s h e l t e r e d housing i n Table 13)  then  at  least  some  not,  residents  form  118.  of volunteer  job or work i n a s h e l t e r e d workshop was encouraged.  Thus,  one can see the i m p o r t a n t r o l e o f the b o a r d i n g home i n m a i n t a i n i n g some level of 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  n o t be m a i n t a i n e d i f these same people were i n an i n d e p e n d e n t , nons u p e r v i s e d r e s i d e n c e where s t a f f guidance was not a v a i l a b l e . i n the l i t e r a t u r e r e v i e w ,  f i n d i n g s on the e f f e c t o f s t y l e o f  As was noted residence  on employment r a t e s a r e i n c o n c l u s i v e , a l t h o u g h some s t u d i e s do r e p o r t s l i g h t l y h i g h e r 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 vs. control  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 a c c o u n t f a c t o r s such as whether the r e s i d e r . e e had a r e h a b i l i t a t i o n f o c u s ( v s .  b e i n g a " h o l d i n g t a n k " ) 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 d e t e c t e d between sex and employment, w i t h the female s u b j e c t s b e i n g employed to a g r e a t e r and a h i g h e r l e v e l Table  2).  extent,  ( i . e . more i n c o m p e t i t i v e j o b s ) than the males  (see  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 d e t e c t e d i n the  l i t e r a t u r e ; Seeman, i n her r e v i e w on gender and s c h i z o p h r e n i a , does  cite  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 e v i d e n c e f o r her general c o n c l u s i o n t h a 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 p r o g n o s i s than women" [ 1 6 2 ] , The a s s o c i a t i o n between sex and employment i n t h i s p r e s e n t 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 s u b j e c t s had a b e t t e r employment r e c o r d than the males (X  = 2.85, 1 d.f.,  p = .09).  In  past this  s t u d y one must t a k e i n t o a c c o u n t q u i r k s o f the sample t h a t c o u l d have a b e a r i n g on the a s s o c i a t i o n between sex and employment; f o r example, the  119.  male s u b j e c t s were younger than the f e m a l e s : 3 0 , compared to 15% o f the f e m a l e s . m a r r i e d (Nov.  1983):  33% o f the males were under  As w e l l , more o f the females were  19% compared to 4% o f the m a l e s .  o f the males had r e c e n t l y been i n h o s p i t a l :  F i n a l l y , more  58% o f the males had been  h o s p i t a l i z e d i n the two y e a r s p r e c e d i n g the study p e r i o d , compared to 42% of the females. 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 hospitalizations.  T h i s f i n d i n g was hot upheld i n the p r e s e n t  study.  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 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  of  that  h i g h e r unemployment r a t e ;  t h e r e 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 study,  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 p e r i o d 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 41-50.  those  T h i s 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  t h a t the.unemployment r a t e i s g e n e r a l l y h i g h e r f o r the under 3 0 ' s i n the g e n e r a l 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 1 5 - 2 4 i n M e t r o p o l i t a n compared to 3.4% f o r those 25 and over  Vancouver,  [163].)  One o t h e r 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 p e r i o d and f r e q u e n c y of 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 .  the unemployed were more f r e q u e n t v i s i t o r s than the employed.  This i n d i c a t e d that  to the cummunity c a r e teams  T h i s 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 ;  for  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 time i n which to  visit  120,,.  the teams, and as w e l l the unemployed may r e p r e s e n t a more d i s a b l e d g r o u p , 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 o f the s u b j e c t , the r e s i d e n t i a l  situation,  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 the s u b j e c t .  of  Employment h i s t o r y was found to be the b e s t 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 t h e r  researchers.  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 past number and d u r a t i o n o f  psychiatric  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 p r e s e n t  E.  study.  Summary and C o n c l u s i o n s This study,  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  a l m o s t as many q u e s t i o n s as i t sought to answer; because o f d e s i g n  to limita-  t i o n s many o f the a s s o c i a t i o n s d i s c o v e r e d c o u l d o n l y be s p e c u l a t e d 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 c o u l d be d i s c e r n e d from the d a t a , and these a r e d i s c u s s e d below.  i)  The m e t h o d o l o g i c a l 1 i m i t a t i o n s i n t h i s s t u d y 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 c a r e 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 c a r e team a t t e n d e r s .  I t was  f e l t t h a t a comparison s t u d y o f c h a r a c t e r i s t i c s o f a t t e n d e r s and nona t t e n d e r s would be u s e f u l .  Other m e t h o d o l o g i c a l l i m i t a t i o n s concerned  121.  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  in  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 quest i o n a b l e v a l i d i t y o f some o f the outcome measures used i n studies.  schizophrenia  I t was suggested t h a t the f i l e s i n q u e s t i o n c o u l d be improved  i n r e s p e c t to b e i n g more comprehensive and s y s t e m a t i c i n the 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  inclusion  schizophrenia  f o l l o w - u p s t u d i e s s h o u l d be s t a n d a r d i z e d w i t h r e g a r d to sample m a k e - u p , outcome measures u s e d , and. t i m i n g o f measurement.  Finally,  i t was  proposed  t h a t q u a n t i t a t i v e s t u d i e s (such as,, the p r e s e n t one) c o u l d 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 .  ii)  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  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 In p a r t i c u l a r ,  the s u b j e c t s e x p e r i e n c e d  low r a t e s o f employment. found i n the l i t e r a t u r e  revealed  isolation.  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  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 f o r o t h e r groups o f s c h i z o p h r e n i c s .  The  level  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 f o r a c c e s s i b l e treatment f a c i l i t i e s , t a t i o n programs and s h e l t e r e d  iii)  income s e c u r i t y ,  vocational  those  need  rehabili-  residences.  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 o v e r the two y e a r study p e r i o d ; w h i l e t h i s may be open to v a r i o u s  interpretations,  i t seemed to s u p p o r t the general f i n d i n g  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 o f i n d e f i n i t e d u r a t i o n , and hence 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 . recognized  that  support  I t was a l s o  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 g r o u p , and those more c a p a b l e 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 r e a t m e n t 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  iv)  I t was found t h a t t h e r e was some v a r i a b i l i t y w i t h i n  s a m p l e , d e s p i t e the g e n e r a l l y  v)  high l e v e l o f  the  disability.  F a c t o r s were found to be a s s o c i a t e d w i t h  differential  outcome, as measured by employment s t a t u s and a d m i s s i o n s to and V e n t u r e .  practitioner.  hospital  Because these f a c t o r s were not the same f o r the t h r e e measures  i t was assumed t h a t the measures s h o u l d be regarded as s e p a r a t e and d i s t i n c t , a f i n d i n g more o r 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 o f s c h i z o p h r e n i a outcome.  vi)  I t was f o u n d , f o r t h i s s a m p l e , t h a t the b e s t  historical  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 in hospital. frequently  I t was a l s o found t h a t those a d m i t t e d to h o s p i t a l more  tended to be younger ( i . e .  under 3 0 ) , more f r e q u e n t  to the community c a r e teams, and w i t h a h i s t o r y o f g r e a t e r past h o s p i t a l i z a t i o n s .  visitors  numbers o f  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 .  vii)  I t was found t h a t the b e s t h i s t o r i c a l  Venture a d m i s s i o n s 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  predictor  of  hospitalizations.  I t was a l s o found t h a t those a d m i t t e d to Venture tended to be y o u n g e r , more f r e q u e n t v i s i t o r s came p r o p o r t i o n a t e l y of  cohabitation).  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  more o f t e n from l i v i n g w i t h spouse ( v s .  other  styles  123..  viii)  I t was found t h a t the b e s t h i s t o r i c a l  employment s t a t u s was employment h i s t o r y .  predictor  I t was a l s o found t h a t  unemployed i n the sample tended to be m a l e , s i n g l e o r d i v o r c e d , were more f r e q u e n t v i s i t o r s  of  to the community c a r e teams.  the  and  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 a r e a p p a r e n t l y a b l e to m a i n t a i n a r e l a t i v e l y employment f o r the r e s i d e n t s ,  high r a t e o f  residences  sheltered  i n d i c a t i n g the importance o f these r e s i d e n c e s  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 .  ix)  I t was found t h a t , w i t h r e s p e c t to time s i n c e  hospitalization,  the sample formed two d i s t i n c t g r o u p s ,  last  those  recently  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 of years.  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 m o n i t o r i n g by mental  health  personnel.  x)  I t was found t h a t the younger s u b j e c t s  to form a d i s c r e t e g r o u p ;  i t c o u l d be s a i d i n general  more d i s a b l e d , more u n s t a b l e , and h e a v i e r consumers o f services.  psychiatric rehospitaliza-  to t h e team, and more f r e q u e n t  address  These f i n d i n g s r e f l e c t e d those o f o t h e r r e s e a r c h e r s who have  investigated  the e x i s t e n c e o f the "new, young c h o r n i c " mental  as a d i s c r e t e c l i n i c a l  group.  teams i s t h a t t h i s group w i l l attention.  t h a t they were  In p a r t i c u l a r , t h i s group was found to have h i g h e r  t i o n r a t e s , more f r e q u e n t v i s i t s changes.  (under 30) seemed  patient.  The i m p l i c a t i o n f o r the community c a r e r e q u i r e a c o n s i d e r a b l e amount o f  I t was suggested i n the l i t e r a t u r e  that i f  clinical  the c u r r e n t  style  124.  of treatment i s not working with this, group, new treatment approaches (such as long-term h o s p i t a l i z a t i o n ) 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 p s y c h i a t r i c system. The i m p l i c a t i o n was that the G.V.M.H.S. i s not a t t r a c t i n g 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 i n the sample are more stable i t may be i n part due to the l a t e r age o f onset, i n d i c a t i n g 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 d i s g n o s t i c a l l y could be included on a systematic basis i n the c l i n i c a l f i l e s o f 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 o f previous h o s p i t a l i z a t i o n s , employment h i s t o r y , marital status and so on.) 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