0 1998 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 1998 Volume 2 Pages 139- 141
139
Perceived needs in chronic schizophrenia ANDREW CAR ROLL^ AND ANN MORTIMER~
Int J Psych Clin Pract Downloaded from informahealthcare.com by CDL-UC Santa Cruz on 10/26/14 For personal use only.
‘Research Fellow, Department of Psychiatry, University of Edinburgh and ’Professor, Department of Psychiatry, University of Hull
CorrespondenceAddress Dr Andrew Carroll, Department of
Psychiatry, University of Edinburgh, Morningside Park, Edinburgh, EH10 5HF,UK Tel: +44 (0) 0131 537 6504 Fax: +44 (0) 0131 447 6860 E-mail: [email protected]
Received 11 March 1998; accepted for publication 16 April 1998
Recent approaches to needs assessment involve patients themselves in the process, but little is known about the effects of mental illness on their ability to judge their own needs accurately. The needs of30 subjects with schizophrenia in rehabilitation units were assessed in 19 different domains, by obtaining the views both of the subjects and their keyworkers. For each, the number of domains in which the subjects underestimated their level of need compared with the IeveZ estimated by their keyworker was calculated, to give a ‘disparity score’. Disparity scores were positively correlated with severity of negative symptoms ( d . 3 6 ; P=0.048) but only nonsignificantly negatively correlated with insight (14.31; P=0.098). For the domains of alcohol misuse (P=0.043)and quality of social life (P=0.0005),subjects who underestimated their needs had poorer insight than those who did not do so. Subjects did not necessarily deny their need for help with psychosocial handicaps even if they denied having a mental illness or requiring medication. For the areas of alcohol misuse and social contact, however, additional objective means of assessment may be advisable in patients with poor insight into their illness. The effects of negative symptoms should also be taken into account when assessing needs collaboratively. (IntJ Psych Clin Pract 1998; 2: 139- 141)
INTRODUCTION
U
ntil recently, it was assumed that need is a “normative concept which is to be defined by experts”.’ Now it is considered to be “sociallynegotiated;’ the area of negotiated need comprises the overlap between professionals’ views (influenced by training, culture, politics, ethics, research and personal values) and patients’ demands (influenced by education, prior expectations, past experiences, the media, social factors and clinical factors). This move towards a more collaborative model is part of a general trend in psychiatry. Slade’ argues that even psychotic patients with poor insight into their illness and the need for medication can make valid demands in the needs negotiation process, but there is little hard evidence on this point. Insightless patients may resent staff and so cooperate poorly with a needs assessment, just as they comply poorly with psychosocial programme^.^ This study therefore examines whether patients with poorer insighti.e. with an understanding of their illness different from that of professionals-also disagree with professionals about their nonmedical needs. Awareness of needs may depend upon awareness of
social norms for areas such as self-care and domestic skills. This may be lacking in chronic schizophrenia, due to educational deficits, institutionalization or a restricted social milieu. Negative symptoms may also adversely affect the ability to judge or to voice needs, due to apathy or associated neuropsychological deficits4 The study therefore also examines the relationship between perceived needs and severity of negative symptoms.
METHOD Inpatients from six psychiatric rehabilitation units, with a diagnosis of schizophrenia (according to their case notes) and normal intelligence were invited to participate, unless staff felt it to be contra-indicated. Thirty-four suitable patients were identified and 30 consented to participate. They were interviewed in their place of residence by a psychiatrist (AC) in order to obtain ratings on the following measures: 1. The Insight and Treatment Attitudes Questionnaire (ITAQ).5 This Comprises 11 items enquiring about subject’s views on their illness,. placement in a
Int J Psych Clin Pract Downloaded from informahealthcare.com by CDL-UC Santa Cruz on 10/26/14 For personal use only.
140
A Carroll and A Mortimer
supervised setting and medication. The possible range of scores is 0 to 22, with higher scores indicating better insight. The High Roy& Evaluation of Negativity Scale (HEN).6 This comprises 24 items rating the severity of negative symptoms. The possible range of scores is 0 to 24, with a higher score indicating worse symptoms. The Camberwell Assessment of Need (CAN).’ This assessment tool covers 22 areas of potential social or clinical need. It seeks the views of both staff and patients and applies to the 4 weeks preceding the assessment date. In this study, only the subsection asking about ‘required help’ was used. Scoring was also simplified: for each area a rating of either ‘no perceived problem’ or ‘significant perceived need‘ was given. Each subject’s key worker was interviewed (blind to the subject’s responses) to obtain the staff views. The items on accommodation, child care and sexual expression were omitted.
RESULTS The 30 subjects comprised 22 men and eight women. Their mean age was 38 years, 7 months; their mean duration of illness was 14 years. For each area of potential need, a subject was said to show ‘disparity’ if their key worker believed them to have a significant need but the subject themself did not. For each area of potential need, the ITAQ scores and the HEN scores of those showing disparity were compared with those of the other subjects. The nonparametric Mann-Whitney U-test was used since the data are ordinal. Results are shown in Table 1. Table 1 Disparity between patients’ and key workers’ scores for needs
*p
International Journal of Psychiatry in Clinical Practice 1998 Volume 2 Pages 139- 141
139
Perceived needs in chronic schizophrenia ANDREW CAR ROLL^ AND ANN MORTIMER~
Int J Psych Clin Pract Downloaded from informahealthcare.com by CDL-UC Santa Cruz on 10/26/14 For personal use only.
‘Research Fellow, Department of Psychiatry, University of Edinburgh and ’Professor, Department of Psychiatry, University of Hull
CorrespondenceAddress Dr Andrew Carroll, Department of
Psychiatry, University of Edinburgh, Morningside Park, Edinburgh, EH10 5HF,UK Tel: +44 (0) 0131 537 6504 Fax: +44 (0) 0131 447 6860 E-mail: [email protected]
Received 11 March 1998; accepted for publication 16 April 1998
Recent approaches to needs assessment involve patients themselves in the process, but little is known about the effects of mental illness on their ability to judge their own needs accurately. The needs of30 subjects with schizophrenia in rehabilitation units were assessed in 19 different domains, by obtaining the views both of the subjects and their keyworkers. For each, the number of domains in which the subjects underestimated their level of need compared with the IeveZ estimated by their keyworker was calculated, to give a ‘disparity score’. Disparity scores were positively correlated with severity of negative symptoms ( d . 3 6 ; P=0.048) but only nonsignificantly negatively correlated with insight (14.31; P=0.098). For the domains of alcohol misuse (P=0.043)and quality of social life (P=0.0005),subjects who underestimated their needs had poorer insight than those who did not do so. Subjects did not necessarily deny their need for help with psychosocial handicaps even if they denied having a mental illness or requiring medication. For the areas of alcohol misuse and social contact, however, additional objective means of assessment may be advisable in patients with poor insight into their illness. The effects of negative symptoms should also be taken into account when assessing needs collaboratively. (IntJ Psych Clin Pract 1998; 2: 139- 141)
INTRODUCTION
U
ntil recently, it was assumed that need is a “normative concept which is to be defined by experts”.’ Now it is considered to be “sociallynegotiated;’ the area of negotiated need comprises the overlap between professionals’ views (influenced by training, culture, politics, ethics, research and personal values) and patients’ demands (influenced by education, prior expectations, past experiences, the media, social factors and clinical factors). This move towards a more collaborative model is part of a general trend in psychiatry. Slade’ argues that even psychotic patients with poor insight into their illness and the need for medication can make valid demands in the needs negotiation process, but there is little hard evidence on this point. Insightless patients may resent staff and so cooperate poorly with a needs assessment, just as they comply poorly with psychosocial programme^.^ This study therefore examines whether patients with poorer insighti.e. with an understanding of their illness different from that of professionals-also disagree with professionals about their nonmedical needs. Awareness of needs may depend upon awareness of
social norms for areas such as self-care and domestic skills. This may be lacking in chronic schizophrenia, due to educational deficits, institutionalization or a restricted social milieu. Negative symptoms may also adversely affect the ability to judge or to voice needs, due to apathy or associated neuropsychological deficits4 The study therefore also examines the relationship between perceived needs and severity of negative symptoms.
METHOD Inpatients from six psychiatric rehabilitation units, with a diagnosis of schizophrenia (according to their case notes) and normal intelligence were invited to participate, unless staff felt it to be contra-indicated. Thirty-four suitable patients were identified and 30 consented to participate. They were interviewed in their place of residence by a psychiatrist (AC) in order to obtain ratings on the following measures: 1. The Insight and Treatment Attitudes Questionnaire (ITAQ).5 This Comprises 11 items enquiring about subject’s views on their illness,. placement in a
Int J Psych Clin Pract Downloaded from informahealthcare.com by CDL-UC Santa Cruz on 10/26/14 For personal use only.
140
A Carroll and A Mortimer
supervised setting and medication. The possible range of scores is 0 to 22, with higher scores indicating better insight. The High Roy& Evaluation of Negativity Scale (HEN).6 This comprises 24 items rating the severity of negative symptoms. The possible range of scores is 0 to 24, with a higher score indicating worse symptoms. The Camberwell Assessment of Need (CAN).’ This assessment tool covers 22 areas of potential social or clinical need. It seeks the views of both staff and patients and applies to the 4 weeks preceding the assessment date. In this study, only the subsection asking about ‘required help’ was used. Scoring was also simplified: for each area a rating of either ‘no perceived problem’ or ‘significant perceived need‘ was given. Each subject’s key worker was interviewed (blind to the subject’s responses) to obtain the staff views. The items on accommodation, child care and sexual expression were omitted.
RESULTS The 30 subjects comprised 22 men and eight women. Their mean age was 38 years, 7 months; their mean duration of illness was 14 years. For each area of potential need, a subject was said to show ‘disparity’ if their key worker believed them to have a significant need but the subject themself did not. For each area of potential need, the ITAQ scores and the HEN scores of those showing disparity were compared with those of the other subjects. The nonparametric Mann-Whitney U-test was used since the data are ordinal. Results are shown in Table 1. Table 1 Disparity between patients’ and key workers’ scores for needs
*p
