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3 Skizo
3 Skizo
Social functioning and the course were referred to psychiatric services in their
area of residence.
Of the 97 families who formerly under-
of early-onset schizophrenia went the intervention programme, 73
participated in the follow-up study, after
Five-year follow-up of a psychosocial intervention giving written informed consent. Reasons
for non-participation were: refusal (4), not
MARIE E. LENIOR, PETER M. A. J. DINGEMANS, DON H. LINSZEN, traceable (10), emigration (1) and fatal
LIEUWE DE HA AN and AART
A ART H. SCHENE accident (1). Furthermore, eight patients
committed suicide: three (14%) from the
group that was not randomised (see Linszen
et al,
al, 1996); two (5%) from families that
Background Schizophrenia implies For many years research on schizophrenia received family intervention; and three
severe social impairments. Since the was focused on psychotic symptoms (8%) from the standard intervention.
(Strauss, 1975; Engelhardt & Rosen, 1976). Data were available in 58 cases from
treatment of patients with schizophrenia
However, schizophrenia implies severe the patient and one or two parents, and in
shifted from long-term hospital psychosocial limitations. For this reason 13 cases from one or two parents but
admissions to community services, social functioning as an outcome measure without the patient. Two patients partici-
research on social functioning has in psychiatric research has gained attention. pated without their parent(s). On average,
become increasingly important. Engelhardt & Rosen (1976) remarked that the interviews took place 7.9 (range 610)
psychosocial handicaps are the most severe years after discharge.
Aims Follow-up assessment consequences of schizophrenia. Strauss & The mean age of the patients (51 men
Carpenter (1974) noted that in research on and 22 women) at admission was 20.9
of social functioning in young patients
the course of schizophrenic illness, social (range 1626) years (Table 1), whereas
with schizophrenia during a 5-year functioning is an important outcome the mean age at the time of the follow-up
period after intervention. measure. In this follow-up study we describe interview was 30.5 (range 2637) years.
aspects of social functioning and the course The mean duration of untreated illness
Method During intervention, of psychotic symptoms in young patients before admission was 5.4 months and half
families were randomised into two with early-onset schizophrenia and related of the patients (52%) had their first
conditions: standard intervention and disorders 5 years after intervention. The dif- psychotic episode before admission. At dis-
standard plus family intervention. ferential effect of two intervention conditions charge from the intervention programme,
on social functioning and the course of the the diagnoses (DSMIIIR; American
Results Although no differential illness is evaluated. Finally, we investigate Psychiatric Association, 1987) were: schizo-
treatment effect with regard to the course the association between social functioning phrenia, 42 (58%); schizoaffective disorder,
and severity of the illness (e.g. diagnostic 15 (21%); schizophreniform disorder, 9
of the illness was found, patients from the
grouping and the course of the illness). (12%); and other psychotic disorders (e.g.
standard plus familyintervention condition delusional disorder and atypical psychosis),
stayed for fewer months in institutions 7 (10%).
for psychiatric patients than patients METHOD Comparisons between participating
patients and non-participants of the follow-
from the standard intervention condition. Subjects up study showed that at admission partici-
Conclusions Family intervention has This study concerns the 5-year follow-up of pants were 1 year older on average than
a 15-month intervention in the Adolescent non-participants, that the duration of
helped parents to supporttheir children,
Clinic of the Psychiatric Department of the untreated psychosis was 1 month less on
thereby diminishing institutional care. Academic Medical Center in Amsterdam. average and that compliance to medication
Before the controlled trial began, families during intervention was higher for partici-
Declaration of interest This study
were stratified into high and low expressed pants than for non-participants. Regarding
was funded by grants 28-1241-1and emotion (Vaughn & Leff, 1976) and random- baseline data, no significant differences
28-1241-2 from the Dutch Health ised into two conditions: standard inter- between the two intervention conditions
Research and Development Council vention or standard plus behavioural family were found.
intervention. The intervention programme
and by the Dutch Ministry of Welfare,
and the two intervention conditions are
Health and Cultural Affairs (Project described in detail elsewhere (Linszen et al,
al, Assessments
90 -120; CRO 504581). 1996). Briefly, the programme consisted Patients and parents were interviewed with
of a 3-month in-patient phase and an out- the Life Chart Schedule (LCS: World
patient phase of 12 months. Family inter- Health Organization, 1992). This instrument
vention consisted of supporting parents, elicits data about symptoms, treatment
and psychoeducation, training in commu- (rehospitalisation, living in sheltered
nication skills and problem-solving techni- homes, out-patient treatment) and social
ques with families. After discharge, patients conditions (employment, study, living
53
L E NI O R E T A L
T
Table
able 1 Demographic and psychiatric characteristics of participants and non-participants
Statistic1 P
Age at admission, mean (s.d.) 20.5 (2.5) 19.5 (2.6) 20.9 (2.4) 624 0.03
Gender, n (%)
Female 26 (27) 4 (17) 22 (30) 1.67 0.20
Male 71 (73) 20 (83) 51 (70)
Education, n (%)
5Secondary school 21 (22) 6 (25) 15 (21) 0.21 0.65
5Secondary school 76 (78) 18 (75) 58 (80)
Socio-economic status, n (%)
Low (III^V) 73 (75) 20 (83) 53 (73) 1.12 0.29
High (I^II) 24 (25) 4 (17) 20 (27)
Age of onset of schizophrenia, mean (s.d.) 19.1 (2.6) 18.5 (2.8) 19.3 (2.5) 759 0.32
Prior psychotic episodes, n (%)
None 55 (57) 17 (71) 38 (52) 2.59 0.11
One or more 42 (43) 7 (29) 35 (48)
Prior admissions, n (%)
None 57 (59) 18 (75) 39 (53) 3.47 0.06
One or more 40 (41) 6 (25) 34 (47)
DSM^III^R schizophrenia, n (%)
No 41 (42) 10 (42) 31 (42) 50.01 0.95
Yes 56 (58) 14 (58) 42 (58)
Months of untreated illness, mean (s.d.) 5.6 (10.2) 6.3 (6.1) 5.4 (11.2) 589 0.05
Sum score of positive and negative symptoms,2 mean (s.d.) 15.1 (4.7) 15.6 (3.4) 14.9 (5.0) 730 0.22
Compliance with antipsychotic medication,3 mean (s.d.) 3.7 (0.7) 3.4 (1.0) 3.8 (0.4) 665 0.04
2
1. For categorical variables the statistic is w (d.f.1);
(d.f. 1); for continuous variables the statistic is U (Mann^Whitney test, two-tailed).
2. Positive symptoms: unusual thought content, hallucinatory behaviour, conceptual disorganisation, distractability; negative symptoms: motor retardation, blunted affect, emotional
withdrawal (Breier et al,
al, 1991). Items were scored from 1 (not present) to 7 (very severe).
severe).The
The mean item scores of the previous 2 months of in-patient treatment were used.
3. Mean compliance during in-patient and out-patient treatment was used. Compliance was scored from 1 (no compliance: 0%) to 4 (100% compliance, including depot).
arrangements) during a given period. Susser delusions, hallucinations and/or formal there was disagreement, consensus was
et al (2000) showed that the LCS yields thought disorders (Nuechterlein et al,
al, 1986). achieved by re-examination of the data by
reliable ratings of the long-term course of A non-psychotic episode was a period with- both raters together.
schizophrenia when assessed by trained out positive symptoms, with or without
raters. Inconsistencies regarding symptoms residual symptoms and/or negative symp-
and treatment (n (n3)3) were cross-checked toms. A non-psychotic episode had to last Analyses
with current therapists. at least 30 days (Wiersma et al, al, 1998). For analyses concerning social functioning,
The first follow-up study, which also When there was never a 30-day remission three composite scores were calculated:
included the LCS, was carried out in period during follow-up, the patient was living in institutions for psychiatric patients
1992. At that time the follow-up period considered as having chronic positive (months in mental hospitals and/or sheltered
differed for the successively admitted and symptoms (60 months). homes); structural activities (months of full-
discharged patients (1755 months). At the The LCS data were first rated for time, part-time or voluntary work, full-time
second follow-up, held in 19971998, the relapses by one of the authors (D.H.L.) study and/or housekeeping); help from the
data were completed up to and including 5 and rated again by a psychiatrist (L.d.H.), family (sum score of help with activities of
years after discharge. If the patient and/or who was employed 2 years after the inter- daily living, accompanying to out-patient
parent(s) had participated in 1992, which vention and had not been involved with services, checking intake of medication and
was the case for all but one patient, the data the patients. Regarding clinical status (no management of care). The four items con-
of that interview were first examined and relapse, one or more relapses, chronic), cerning help from the family were scored
completed for the 5-year period. there was disagreement about six patients as follows: 1, `none'; 2, `part of period'; 3,
The course of the illness was divided (8%). For 16 (22%) patients the number `majority of period' (Table 2).
into psychotic and non-psychotic episodes. of months with psychotic symptoms The duration of psychotic episodes is an
A psychotic episode was characterised by differed (mean absolute difference6.7;
difference 6.7; important indicator of the severity of the
clearly reported positive symptoms, i.e. s.d.6.8).
s.d. 6.8). For the 22 patients about whom illness. Therefore the course of the illness
54
S O C I A L F UN C T I ONI
ONINN G A N D T H E C OU R S E OF E A R LY- ON S E T S C H I ZO P H R E NI A
was expressed as the number of months Table 2 Socio-demographic characteristics according to the Life Chart Schedule (World Health
that patients had psychotic symptoms. For Organization, 1992) during the 60-month follow-up period (n
(n73)
73)
chronic patients this was 60 months.
MannWhitney U-tests were used to Item Category Mean (n
(n) s.d. (%)
compare the three areas of social functioning
by intervention condition and by diagnosis Living arrangements
group (schizophrenia v. schizophrenia-like Months within the community 41.8 20.0
disorder) as classified at discharge. Testing With parents1 No 43 63
associations between the three areas of social Yes 25 37
functioning and the total duration of psy- Work
chotic episodes was done by Spearman's Paid jobs Never 39 53
rank correlations (r
(r). Some period 34 47
Months of full-time jobs 5.2 12.8
Months of part-time jobs 4.8 9.6
Performance in jobs held2 Poor 9 26
RESULTS Good 17 50
Very good 8 24
On average, patients lived within the com-
Type of usual job2 Unskilled 7 21
munity for 42 of the 60 months (Table 2).
Semi-skilled 14 41
Of the patients, 40% lived alone for the
Skilled 13 38
major part of the 5-year period; 34% lived
Level of usual job2 Much lower 6 18
for the most part with parent(s); 12% lived
Lower 16 47
with a partner; 7% lived otherwise (not in
About the same 12 35
institutions for psychiatric patients); and
Months of full-time housekeeping3 2.1 8.9
7% lived for the total 5-year period in
Global score for work/housekeeping4 Poor 17 25
institutions for psychiatric patients. Seven
Fair 36 52
patients were homeless for some days (n(n3)
3)
Good 16 23
or some months (n (n4),
4), meaning that they
had no steady place of residence during that Months of voluntary work 7.6 11.7
period, or that their place of residence was Months of full-time study 6.7 15.1
unknown. One patient stayed in prison for Months of receiving disability pension 40.2 25.9
1 month. Months unemployed 6.8 15.8
Of the patients, 34 held a paid job for Follow-up treatment
at least some period. For these patients Months in mental hospital 7.8 11.6
the occupational level in 65% of the cases Number of hospital admissions 1.4 1.7
was lower than their level of education: in Duration of longest admission (months) 5.5 9.0
62% of the cases, unskilled or semi-skilled Months in sheltered homes 9.5 16.7
jobs. For 74% of the patients who held a Day treatment Never 41 56
paid job, the performance of their work Some period 32 44
was qualified as `good' to `very good' by Out-patient services Never 17 23
patient and/or parent(s). This qualification Some period 56 77
is related to the level of the work (e.g. Family therapy Never 64 88
working in shops, catering, warehouses, Some period 9 12
light office jobs). Six patients did the Help from the family
housekeeping full-time during some period Daily activities None 23 32
of the 5 years. For only one of them was Part of period 27 37
the performance in housekeeping qualified Majority of period 23 32
as `poor'. In the 5-year period 21 patients Accompanying for out-patient services None 41 56
followed full-time study for some of the Part of period 24 33
time. The mean number of months during Majority of period 8 11
which patients had structural activities was Checking medication compliance None 48 66
26.2 (s.d.20.0;
(s.d. 20.0; range060).
range 060). This implies Part of period 19 26
that they had no structural activities for Majority of period 6 8
almost 3 years (34 months). Management of care None 46 63
As mentioned, five patients stayed in Part of period 14 19
institutions for psychiatric patients for 60 Majority of period 13 18
months. The patient group stayed for 8
months on average in mental hospitals and 1. Five patients never lived outside institutions for psychiatric patients.
2. Thirty-nine patients never held a paid job.
for 10 months in sheltered homes. The 3. In the sense of caring for a family member.
mean number of months that patients 4. Four patients never had a paid job and never lived outside institutions for psychiatric patients.
55
L E NI O R E T A L
56
S O C I A L F UN C T I ONI
ONINN G A N D T H E C OU R S E OF E A R LY- ON S E T S C H I ZO P H R E NI A
Table 4 Social functioning during 60 months of follow-up by intervention condition and by diagnostic group (n
(n73)
73)
Living in institutions for psychiatric Structural activities Help from the family
patients (months) (months) (sum score)
Intervention condition2
Standard 33 21.18 20.34 363 0.04 21.94 18.70 408 0.16 6.48 2.12 504 0.92
Standard+family 31 10.87 16.15 28.84 19.96 6.45 2.16
Schizophrenia3
No 31 12.13 15.76 479 0.05 28.65 19.47 553 0.27 5.84 1.86 456 0.03
Yes 42 21.07 21.10 24.45 20.40 7.02 2.32
effect did not last. After 2 years, 42% of the A number of studies showed that family on neuroleptic medication. Barrowclough
patients had a relapse. In a review, Mari & intervention improved the social functioning & Tarrier (1990) found a negative associa-
Streiner (1994) reported relapse rates of of patients with schizophrenia (Falloon et al,
al, tion between dose of medication and social
4753% within 2 years. In another study 1987; Barrowclough & Tarrier, 1990; functioning. They argued that the tranquil-
with Dutch patients (Wiersma et al, al, 1998) Xiong et al,al, 1994). Falloon et al (1987) lising effect of neuroleptics could decrease
the relapse rate after 5 years was 72%, hypothesised that the problem-solving tech- the level of activities. In our study the influ-
which is higher than our relapse rate niques of the family intervention caused a ence of neuroleptic medication could not be
(65%). Robinson et al (1999) found a high- reduction in positive as well as in negative assessed, because the LCS comprises only
er relapse rate of 82%. Thus, the relapse symptoms, so that patients were able to two global items about the prescription of
rate in our study is still lower than in other focus on their social condition. Leff et al medication. It is possible that patients with
studies. However, the results of the present (1989) suggested that social functioning more months of psychotic symptoms took
study are congruent with the observation of depends on negative symptoms, which higher doses of neuroleptic medication,
McGlashan & Johannessen (1996) that diminish more slowly than positive symp- which could have affected their social
interventions are effective as long as they toms. This supposition was confirmed by functioning.
are active. Poque-Geile & Harrow (1984) and by Bellack et al (1990) mentioned two
Bellack et al (1990). Although negative possible hypotheses: impairment of social
symptoms were not included in our study, functioning as a consequence of negative
Effect of family intervention a possible explanation for the absence of symptoms or as a consequence of deficits
association between intervention condition in social skills. Although the association
Patients who had received additional family
and social functioning (i.e. structural activ- between negative symptoms and social
intervention spent fewer months in institu-
ities for help from the family) might be that functioning was demonstrated, support was
tions for psychiatric patients than patients
the family intervention was focused on the found also for the social deficits hypothesis.
who had had the standard intervention.
reduction of family stress and not parti- No conclusions about the effect of negative
Falloon et al (1982), Tarrier et al (1989)
cularly on social rehabilitation. However, symptoms can be drawn from our study,
and Xiong et al (1994) also found this
in both intervention conditions the patients because these symptoms were not assessed
effect, in combination with a differential
were given help with seeking education, for patients with chronic positive symptoms.
effect on the occurrence of relapses. Falloon
employment and financial support. However, patients with longer periods of
et al (1982) suggested that the reduction of
positive symptoms functioned less well in
stress in families who received family inter-
Severity of illness and social the three areas of social functioning than
vention prevented relapses and rehospitalis-
functioning patients with shorter periods of positive
ation. Our results do not confirm this
symptoms. Therefore, we cannot discount
supposition completely, because the inter- For patients with a poorer course of the ill-
the role of positive symptoms.
vention condition did not affect the relapse ness, whether as predicted by diagnosis at
rate. Because families were allocated ran- discharge or as indicated by the number
domly to the two conditions, we may con- of months with psychotic symptoms there- REFERENCES
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58
Social functioning and the course of early-onset schizophrenia:
Five-year follow-up of a psychosocial intervention
MARIE E. LENIOR, PETER M. A. J. DINGEMANS, DON H. LINSZEN, LIEUWE DE HAAN and AART H.
SCHENE
BJP 2001, 179:53-58.
Access the most recent version at DOI: 10.1192/bjp.179.1.53
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