Soc Psychiatry Psychiatr Epidemiol DOI 10.1007/s00127-014-0892-2
ORIGINAL PAPER
Rehospitalization risk of former voluntary and involuntary patients with schizophrenia Carmen Pfiffner • Tilman Steinert • Reinhold Kilian • Thomas Becker • Karel Frasch • Gerhard Eschweiler • Gerhard La¨ngle • Daniela Croissant Wiltrud Schepp • Prisca Weiser • Susanne Jaeger
•
Received: 25 December 2013 / Accepted: 22 April 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Background The aim of the study was to examine the differences between former involuntary and voluntary patients with a schizophrenic disorder with regard to time to and frequency of rehospitalization. Methods In this prospective observational study, 374 patients with a diagnosis of schizophrenia or schizoaffective disorder were included. At the time of inclusion, 290 (77.5 %) were hospitalized voluntarily and 84 (22.5 %)
C. Pfiffner T. Steinert S. Jaeger (&) Department of Psychiatry and Psychotherapy I, Centres for Psychiatry Su¨dwu¨rttemberg, Ulm University, Weissenau, ZfP Su¨dwu¨rttemberg, Versorgungsforschung, Weingartshofer Str. 2, 88214 Ravensburg, Germany e-mail: [email protected] R. Kilian T. Becker K. Frasch Department of Psychiatry and Psychotherapy II, Ulm University, Bezirkskrankenhaus Gu¨nzburg, Gu¨nzburg, Germany G. Eschweiler G. La¨ngle Department of Psychiatry and Psychotherapy, University of Tu¨bingen, Tu¨bingen, Germany G. La¨ngle Centres for Psychiatry Su¨dwu¨rttemberg, Bad Schussenried, Germany D. Croissant PP.rt Hospital for Psychiatry, Psychotherapy and Psychosomatics, Reutlingen, Germany W. Schepp Department of Forensic Psychiatry and Psychotherapy, Bezirksklinikum Regensburg, Regensburg, Germany P. Weiser Department of Psychosomatic Medicine, Psychotherapy/ Psychiatry, University of Mainz, Mainz, Germany
involuntarily. Follow-up assessments were conducted halfyearly over a 2-year period with measures of PANSS, GAF, sociodemographic data and cognitive functioning. These data served as covariates for adjustment in statistical models that included a Cox regression model, a randomeffect logit model and a random-effect tobit model. Results After adjustment for other relevant covariates, the Cox regression showed that involuntary treatment is a significant risk factor of subsequent rehospitalization (HR = 1.53; CI = 1.06, 2.19; p = 0.02). The involuntary group had higher half-year incidence rates of rehospitalization, and in case of rehospitalization the duration of hospital stay was longer. Conclusions Involuntary hospitalization seems to be associated with a higher risk of rehospitalization and longer subsequent hospital stays in patients with schizophrenia and schizoaffective disorders. Further studies are needed to examine in detail the processes and interventions that are suitable for interrupting circles of repeated hospitalizations, especially in former involuntary patients. Keywords Schizophrenia Involuntary hospitalization Rehospitalization Readmission Coercion
Introduction Involuntary hospitalization on a defined legal basis is required if persons with mental illness pose severe danger to themselves or others. Even if the procedures are different across countries, this assumption is basically shared and realized in corresponding legislations [1, 2]. Involuntary treatment occurs in one of ten inpatients [2]. Rates of involuntary inpatient treatment, in European countries, range from 3.2 % in Portugal to 30 % in Sweden [3]. The
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most common diagnoses in people who are treated involuntarily are schizophrenia or other psychoses [2, 4, 5]. Typically, involuntarily hospitalized patients lack insight into their illness and into their treatment. However, insight into illness and positive attitudes toward treatment have been recognized as highly relevant for the positive outcome of schizophrenia in the long term [6]. Although in many cases involuntary hospitalization seems unavoidable, there is a risk that this experience may prompt former involuntary patients to avoid seeking services in the future [7]. This might lead to a deleterious circle of treatment discontinuation and more involuntary rehospitalizations, especially if the patient is suffering from delusions of persecution. Patients often consider an involuntary stay to be unjustified or unnecessary [8]. They perceive their inpatient treatment as highly coerced and their negative attitude toward hospitalization does not necessarily change with improvement of symptoms even if retrospectively some patients concede that they had needed treatment [9–11]. With regard to treatment outcomes such as symptom reduction, there seems to be no difference between voluntarily and in involuntarily hospitalized patients—both groups tend to clinically improve with inpatient treatment [12–14]. This also applies to the improvement of social functioning, although involuntary patients in general showed similar or lower levels of functioning than voluntary [15]. Evidence on a potentially different long-term development of these two groups is rather limited. Studies on the use of outpatient services and medication compliance indicate that there are no substantial differences between former voluntary and involuntary patients [15], although only recently a study pointed out that former involuntary inpatients might more easily feel coerced to participate in outpatient treatment and report a slightly lower medication adherence [16]. Another important indicator of the longterm course of illness is rehospitalization. People with schizophrenia generally have a high risk of recurring readmissions [17] with rates ranging from 50 to 85 % within 20 years after the first episode [18]. Relapses and rehospitalizations cause personal costs such as loss of personal contacts and satisfaction and may be associated with deterioration of illness course [19]. On the other hand, there are societal costs due to both clinical treatment and loss of productivity [20, 21]. Despite the various studies that examined predictors of involuntary hospitalization, only a few clinical studies investigated the potential role of involuntary hospitalization as a predictor of rehospitalization. Although it has been repeatedly confirmed that former involuntarily hospitalized patients have an increased risk of involuntary readmissions as compared to voluntarily hospitalized [5,
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22–24], findings are inconsistent with regard to a general rehospitalization risk [15, 25]. A more recent prospective study with a 2-year follow-up period found a higher number of rehospitalizations after an involuntary inpatient stay, but the difference failed to reach statistical significance [26]. Some older studies also found no significant differences [13, 23, 27–29]. Other studies indicate that involuntary treatment might lead to higher rehospitalization rates in the follow-up period [4, 5, 17, 30, 31], but also lower probabilities of readmission have been found in patients having been hospitalized court-ordered [32]. Most of these studies involved unselected patient samples, not specifically patients with schizophrenia. Data collection were retrospective in some cases, and follow-up periods covered a range from 30 days up to 17 years. The only study with a prospective design, a long-term follow-up of about 3 years, including only patients suffering from schizophrenia or schizoaffective disorder [13] had a small size (N = 52). Only a few studies had included confounding variables such as, e.g., severity of symptoms in their statistical analyses [5, 23, 29]. All in all, there is very limited evidence regarding the possible effects of involuntary treatment in hospital on further hospitalizations in patients with schizophrenia or schizoaffective disorder. The purpose of the present study was to examine whether former voluntary patients are different from involuntary patients with regard to time to subsequent rehospitalization, whether voluntary and involuntary patients have a different risk of rehospitalizations and whether duration of rehospitalization is different. Since a randomized controlled trial was not feasible due to ethical and legal limitations, the participants were recruited in the context of an observational prospective long-term study on the effects of second-generation antipsychotics. In order to account for drawbacks of observational studies, a number of potentially relevant confounding factors were controlled.
Methods Study design and definitions Data were collected in the context of the effects of longterm atypical neuroleptic treatment study (ELAN), a multicenter prospective naturalistic longitudinal research project about the effects of treatment with second-generation antipsychotics on functional impairment, quality of life, treatment costs and course of illness [33–35]. The study protocol was approved by the Ethical Committees of Tu¨bingen University, Ulm University, and of the State Medical Chamber of Baden-Wu¨rttemberg. The study population consisted of 374 adult patients with a diagnosis of schizophrenia or schizoaffective
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disorder who were treated in one of nine psychiatric hospitals in South Germany. Recruitment of participants took place between April 2005 and November 2006, and the assessments were carried out by trained research assistants who were not involved in the medical treatment of the patients. Patients on the wards were screened whether they had an antipsychotic medication of either quetiapine, olanzapine or risperidone (also combined with other psychotropic drugs, but not among themselves) at discharge and a recommendation continuing it for at least 12 months. The treating psychiatrists were not involved in the study, and thus free in their decisions to order or change the psychotropic substances, also over the course of the study. Exclusion criteria of the ELAN study comprised a secondary diagnosis of a substance-dependence syndrome (ICD-10: F1x.2) (except nicotine dependence), organic psychiatric disorder or developmental/learning disability. After complete description of the study to the participants, written informed consent was obtained. The first interview was conducted a few days before discharge, followed by four follow-up interviews every 6 months. To increase the motivation to participate, patients received a monetary reward for each assessment. For this paper, the participants were retrospectively divided into two different groups according to their legal status at index hospitalization (hospitalization at the time of inclusion into the study). The first group consisted of patients whose index hospitalization was completely voluntary (voluntary group: VG). An inpatient stay after emergency involuntary admission was also classified as voluntary if the patient decided to stay in the hospital on a voluntary basis subsequently and application for a court order was not necessary. The second group involved patients whose stay was involuntary, meaning they were treated court-ordered (involuntary group: IG) at least for some period of their stay. Measures At baseline, the following sociodemographic data and data on clinical history were collected: age, sex, education, having a partnership, years since first hospitalization, number of previous hospitalizations, and number of previous suicide attempts. Assessments at all measure points (time varying covariates) included current status of employment (having a regular or at least sheltered job: yes vs. no), living situation (independent vs. assisted), symptoms [positive and negative syndrome scale (PANSS)] [36], functioning [Global Assessment of Functioning Scale (GAF) from the DSM-IV] [37], and cognitive processing speed [Digit Symbol Coding Subtest from the Wechsler Adult Intelligence Scale (ZST)]. Data on intermediate hospital admissions were collected at every follow-up assessment by self-report or, in case of readmission in the same hospital, by the patient’s medical chart.
Statistical analysis To check for possible selection bias in dropouts, participants and dropouts were compared by Fisher’s exact tests, Chi square tests or t tests for independent variables. Group differences between VG and IG were tested with t test for two independent samples and Chi square analysis. To test for differences in time to rehospitalization, a Kaplan–Meier survival analysis was calculated using the log-rank test. To examine the effect of involuntariness on time to rehospitalization after adjustment for other potentially exploratory variables, a Cox proportional hazards model is used. Cox regression goes beyond the Kaplan– Meier method for comparing survival curves of several groups, because it allows analyzing the effect of several risk factors on survival simultaneously. Variables in the model were involuntariness, sex, age, time since first hospitalization, number of previous hospital stays, number of previous suicide attempts, low educational status, having a partner, having a job, and assisted living. To estimate the differences in half-year incidence rates of rehospitalization and in half-year duration of hospital stays, two random-effect regression models were used: For the half-year incidence (discrete variable), a random-effect logit model was created and tested. To test for differences in the duration of hospital stays during the 2 years after discharge of index hospitalization, a random-effect tobit model was calculated. The advantage of random-effects models is the opportunity to include all cases even if not every patient has participated in all interviews. The following baseline (b) and time varying (tv) sociodemographic and clinical variables were integrated in these models: (b) involuntariness, sex, age, low educational status, having a partner, time since first hospitalization, number of previous hospital stays, number of previous suicide attempts, duration of index hospitalization; (tv) having a job, assisted living, cognitive processing speed, GAF, PANSS positive, PANSS negative, and PANSS general. We tested two-sided on a 5 % significance level. The statistical programs used were SPSS 11.5 and STATA 11 for windows.
Results Sample 530 patients were found to be eligible for inclusion and asked for study participation. 374 patients (71 %) agreed to participate and gave informed consent. 156 patients (29 %) refused to participate. Patients who refused to participate, in comparison with those who participated, were
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Soc Psychiatry Psychiatr Epidemiol Table 1 Patient characteristics at study inclusion Variable
VG (N = 290)
IG (N = 84)
Male sex, N (%)
148 (51.0)
48 (57.1)
Age, Mean (±SD)
40.7 (12.9)
37.5 (11.1)
*
Employment/occupation, N (%)
115 (39.7)
23 (27.4)
*
Low educational status, N (%)
152 (52.4)
39 (46.4)
Assisted living, N (%)
50 (17.2)
12 (14.3)
Partnership, N (%)
87 (30.0)
24 (28.6)
GAF, Mean (±SD) PANSS positive, Mean (±SD)
56 (12.5) 11.6 (4.4)
54 (12.3) 12.5 (4.7)
PANSS negative, Mean (±SD)
14.8 (5.7)
13.3 (5.4)
PANSS general, Mean (±SD)
28.9 (7.0)
27.8 (7.6)
7.2 (8.8)
5.9 (6.3)
69.1 (52.8)
84.6 (52.9)
Number of previous hospital stays, Mean (±SD) Duration of index hospitalization (days), Mean (±SD)
*
Risk of rehospitalization
*
Table has been already published in [16] GAF global assessment of functioning scale, PANSS positive and negative syndrome scale * p \ 0.05
significantly younger, they had fewer inpatient episodes and a lower rate of schizoaffective disorder diagnoses. A total of 257 participants (69 %) were assessed at all measurement points. Only 29 participants (8 %) left the study completely after the baseline assessment. At the 24-month follow-up assessment, 300 patients (80 %) still participated in the study. Comparisons of baseline sample characteristics between participants and dropouts at each follow-up did not reveal any systematic difference. 290 patients (78 %) were categorized as belonging to the voluntary group (VG), 84 patients (22 %) as belonging to the involuntary group (IG). Sociodemographic and clinical variables for both groups are listed in Table 1. The mean age of the study population was 40 years (SD = 12.6 years) with 178 women (mean age 43.2 years ± 13.3) and 196 men (mean age 37.1 years ± 11.1). There were significant differences in age, employment status, negative symptoms (PANSS negative) and duration of index hospitalization. Participants of the VG were older (p = 0.04), they were more likely to work (p = 0.04), had more negative symptoms at discharge from index hospitalization (p = 0.03) and had a shorter index hospitalization (p = 0.02). Rehospitalization General characteristics In both groups, we had missing data due to unavailability of information after the first interview [VG: N = 38
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(13 %); IG: N = 13 (15 %)]. 44 (62 %) out of a total of 71 remaining participants of the IG were hospitalized at least once within the follow-up of 2 years compared to 50 % rehospitalized participants in the VG (N = 125 out of a total of 252). At each follow-up, an average of 27 % VG participants, and 37 % of the IG participants reported at least one readmission in the course of the past 6 months (Table 2). In the VG, time to rehospitalization was at a mean of 229 days (SD 211.6), and in the IG at a mean of 200 days (SD 184.3). The majority of readmissions happened within the first 6 months after discharge (VG: median 132 days; IG: median 131 days).
Kaplan–Meier survival analysis showed a non-significant difference between both groups (log-rank test: Q = 3.16; df = 1; p = 0.08). To explore the effect of involuntariness on the risk of rehospitalization after adjustment for other patient characteristics at baseline, a Cox regression model was used. The overall model was significant (v2 = 65.20; df = 15; p = 0.00) indicating a relationship between time and all the covariates in the model. The effect of belonging to the IG was significant (HR = 1.53; CI = 1.06–2.20; p = 0.02) (Table 3). This means, after adjustment for all other variables in the model, the risk of rehospitalization increased about 53 % in case the index hospitalization was involuntary. The variables sex (HR = 0.52; CI = 0.37–0.73; p = 0.00) and number of previous hospitalizations (HR = 1.04; CI = 1.02–1.07; p = 0.00) also showed a significant effect on the risk of rehospitalization. Thus, the risk decreased about 48 % in women, and with each previous hospital stay it increased about 4 %. Figure 1 shows the adjusted cumulative rate of readmitted participants in each group by mean values for each covariate. Half-yearly incidences of rehospitalization The total half-yearly incidences of hospitalizations at the four follow-ups ranged between 26 and almost 29 % with the lowest incidence rate at the second follow-up point. Table 4 shows the results of the random-effect logit model for the half-year incidence of rehospitalization. When controlling for time varying (e.g., symptoms, GAF) and baseline (e.g., age, sex) covariates, belonging to the IG increased the likelihood of rehospitalization by 92 % (OR = 1.92; p = 0.02). Each additional previous hospital stay increased the likelihood of further hospitalization by 8 % (OR = 1.08; p = 0.00). However, female gender (OR = 0.49; p = 0.00) and having a partner (OR = 0.61; p = 0.05) decreased the likelihood of being rehospitalized
Soc Psychiatry Psychiatr Epidemiol Table 2 Rehospitalization in former voluntary and involuntary patients
Baseline
6 months
12 months
18 months
24 months
290
252
242
234
235
79 (31.3)
56 (23.1)
61 (26.1)
69 (29.4)
VG N participants N rehospitalized (%) IG N participants
84
N rehospitalized (%)
71 26 (36.6)
72 27 (37.5)
68 27 (39.7)
65 23 (35.4)
Table 3 The effect of involuntary stay and other patient characteristics on the risk of rehospitalization (Cox regression model) B
SE
Wald
p level
HR (95 % CI)
Involuntary stay (0 = no; 1 = yes)
0.42
0.18
5.29
0.02
1.53 (1.06–2.19)
Sex (0 = male; 1 = female)
-0.66
0.17
14.46
0.00
0.52 (0.37–0.73)
Age
0.01
0.01
1.22
0.27
1.01 (0.99–1.03)
Time since first hospital stay (years)
0.00
0.01
0.00
0.97
1.00 (0.98–1.02)
Number of previous suicide attempts
0.02
0.05
0.15
0.70
1.02 (0.93–1.12)
Low educational status (0 = no; 1 = yes)
0.13
0.17
0.58
0.45
1.13 (0.82–1.57)
Partnership (0 = no; 1 = yes)
0.05
0.19
0.07
0.80
1.05 (0.73–1.52)
Employment/ occupation (0 = no; 1 = yes)
-0.34
0.18
3.66
0.06
0.71 (0.50–1.01)
Assisted living (0 = no; 1 = yes) Number of previous hospital stays
-0.01
0.22
0.00
0.95
0.99 (0.64–1.52)
0.04
0.01
12.74
0.00
1.04 (1.02–1.07)
Bold values indicate significance at the 0.05 level
by 51 and 39 %, respectively. Each additional unit in GAF decreased the likelihood of being rehospitalized within the next 6 months by 2 % (OR = 0.98; p = 0.05). Symptoms, having a job or having an assisted living situation did not show significant effects. Duration of subsequent hospitalization Table 5 presents the results of the random-effect tobit model for the duration of hospital stays per half-year during the 2-year follow-up period. eslope can be interpreted as relative change, analogue to odds ratios in a logit model.
Fig. 1 Cumulative rates of readmitted patients after adjustment with means of covariates (Cox regression)
When controlling for covariates (see above), belonging to the IG had a significant effect on the duration of hospital stays in the 2 years after discharge. In case of hospitalization, participants of the IG had a circa 3.5 times (eslope = 4.68) longer duration of subsequent hospital stays than participants of the VG. Other covariates also had a significant effect on the length of rehospitalizations. Each additional previous suicide attempt led to a proportionate increase of the number of inpatient days by about 52 % (eslope = 1.52). With each additional previous hospitalization, the number of inpatient days during the follow-up periods increased proportionately by 19 % (eslope = 1.19). Furthermore, the duration of the index hospitalization had a
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Soc Psychiatry Psychiatr Epidemiol Table 4 Random-effect logit model for explanation of the half-year incidence of hospitalization during the 2 years of follow-up B Involuntary stay (0 = no; 1 = yes) Sex (0 = male; 1 = female)
0.65
SE
p level
OR
0.27
0.02
1.92
Table 5 Random-effect tobit model of the log-transformated duration of rehospitalization (half-yearly during 2 years of follow-up) B Involuntary stay (0 = no; 1 = yes)
-0.71
0.25
0.00
0.49
0.01
0.01
0.90
1.01
Time since first hospital stay (years)
-0.02
0.02
0.19
0.98
Number of previous suicide attempts
0.08
0.09
0.34
1.08
Digit Symbol Coding Subtest
-0.00
0.04
0.94
1.00
Time since first hospital stay (years)
GAF PANSS positive
-0.02 -0.02
0.01 0.03
0.05 0.44
0.98 0.98
Age
Sex (0 = male; 1 = female) Age
SE
p level
slope
eslope
6.83
2.82
0.02
1.54
4.68
-3.00
2.41
0.21
-0.68
0.51
0.16
0.13
0.21
0.04
1.04
-0.34
0.17
0.05
-0.08
0.93
Number of previous suicide attempts
1.84
0.84
0.03
0.42
1.52
0.25
0.42
0.55
0.06
1.06
PANSS negative
0.00
0.03
0.94
1.00
PANSS general
0.02
0.02
0.49
1.02
Digit Symbol Coding Subtest
Low educational status (0 = no; 1 = yes)
0.14
0.24
0.57
1.15
GAF
-0.31
0.11
0.00
-0.07
0.93
PANSS positive
0.09
0.36
0.81
0.02
1.02
-0.52
0.30
0.08
-0.12
0.89
Partnership (0 = no; 1 = yes)
-0.50
0.25
0.05
0.61
PANSS negative
Employment (0 = no; 1 = yes)
-0.35
0.21
0.10
0.70
PANSS general
0.12
0.24
0.61
0.03
1.03
Assisted living (0 = no; 1 = yes)
-0.21
0.26
0.41
0.81
Low educational status (0 = no; 1 = yes)
-1.43
2.46
0.56
-0.32
0.72
Partnership (0 = no; 1 = yes)
-2.92
2.47
0.24
-0.66
0.52
Employment/occupation (0 = no; 1 = yes)
-1.97
2.21
0.37
-0.45
0.64
Assisted living (0 = no; 1 = yes)
-3.18
2.81
0.26
-0.72
0.49
Bold values indicate significance at the 0.05 level GAF global assessment of functioning scale, PANSS positive and negative syndrome scale, OR odds ratio
Number of previous hospital stays
0.77
0.21
0.00
0.18
1.19
Duration of index hospitalization
0.06
0.02
0.01
0.01
1.02
24.49
12.66
0.05
Number of previous hospital stays
0.08
0.02
0.00
1.08
Duration of index hospitalization
0.00
0.00
0.17
1.00
-0.18
1.20
0.88
0.84
constant Number of measurements Wald v2/Prob [ v2
3.3 66.28/0.00
significant effect. With each additional day of index hospitalization, the duration of subsequent hospital stays changed proportionately by about 2 % (eslope = 1.02). In contrast, each additional year since the first hospital stay (eslope = 0.93) and each additional unit in GAF (eslope = 0.93) proportionately decreased the number of inpatient treatment days by 7 %.
Discussion In this study, we investigated the rehospitalization risk of former voluntary and involuntary inpatients with schizophrenia or schizoaffective disorder over a follow-up period of 24 months. We found that formerly involuntarily hospitalized patients had a higher risk of subsequent hospital admissions during the 2 years follow-up period. The halfyear incidence of rehospitalization was higher in this group, and the hospital stays were significantly longer. Actually, there was no significant difference in survival rates between both groups as seen in Kaplan–Meier survival analysis, similar to the results of McEvoy and colleagues [13]. After adjustment for possible confounding variables in the Cox regression, though, it became apparent
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Constant Number of measurements Wald v2/Prob [ v2
3.3 77.78/0.00
Bold values indicate significance at the 0.05 level GAF global assessment of functioning scale, PANSS positive and negative syndrome scale
that former involuntary inpatients had a higher risk of rehospitalization. Very similar to the results of Szmukler et al. and Rosca et al. [5, 17], 49 % of voluntarily treated patients and 60 % of involuntarily treated patients in our sample had a subsequent hospital stay within 2 years after discharge. Furthermore, the half-year incidence of rehospitalization was highly correlated with previous involuntariness, which increased the likelihood by 92 %. According to that, Opjordsmoen et al. [26] found a small but not statistically significant difference in number of rehospitalizations within 2 years between voluntarily and involuntarily treated first-episode patients. The involuntarily treated patients in our study had a longer index hospitalization. Moreover, the random-effect tobit model showed that involuntariness at index hospitalization was also associated with longer
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inpatient stays that occurred in the follow-up period. In their review, Kallert and colleagues found in 9 out of 17 studies a significant association between the duration of index hospitalization and duration of further hospital stays, as we did in our study [15]. Also seen in previous studies, to have a partner can prevent rehospitalization [31, 38], and men have a higher risk of being rehospitalized [30, 39]. Other factors increasing the risk of subsequent rehospitalization in our study are lower level of functioning (GAF), and a higher number of previous hospital stays, also known from a former study [40]. These might be factors that are associated with integration in society that could prevent further hospitalizations. Apparently negligible with regard to the rehospitalization risk or the duration of subsequent stays were factors such as age, cognitive processing speed, educational status, assisted living, employment, and severity of symptoms. Having a job as a protective factor of rehospitalization fell just short of significance. Indeed, in their study on predictors of relapse, Schennach et al. [41] found that having a job at discharge from hospital was protective against relapse during the follow-up. Similar to recent findings of a European multicenter cohort study [42], in our sample symptom severity was not predictive of rehospitalization. While this sounds counterintuitive, it must be emphasized that at the time of their assessment, symptoms did not differentiate between patients who have been rehospitalized or not rehospitalized within the course of the next 6 months (see also below). The strengths of our study are the prospective, long-term follow-up design of 2 years with half-yearly assessments, a considerable sample size with participants from different study centers, and the adjustment for a broad range of possibly confounding variables, namely current severity of symptoms and indicators of social integration such as maintaining a job or living in a partnership. In former studies, these factors were often missing. Our study has also limitations, though. The study population may not be representative for all hospitalized patients with schizophrenia in Germany or in other countries. The legal status of involuntariness might be influenced among others by specific legislations and regional legal practices in the respective federal states of Germany. Moreover, the sample was recruited in the context of a study on long-term effects of second-generation antipsychotics. Patients who (at the time of recruitment) had a medication of first-generation antipsychotics only could not join in the study. Yet, after the baseline assessment, any change of the medication was possible according to the naturalistic study design, and so the selection bias due to the type of medication is probably neglectable. Moreover, critical to representativity is surely the exclusion of patients with a substance-dependence syndrome. Substance abuse is
not uncommon among schizophrenia patients and it can be a risk factor for involuntary hospitalization [43]. Only patients with a diagnosis of harmful use were allowed in the study. This might limit the generalizability of our results. Finally, the participants of this study deliberately joined in a long-term study. Although, study workers were independent from the wards and not involved in the inpatient treatment, this clearly required a minimum of cooperativeness and trust on the side of our potential study participants and might have led to a selection. By classifying the participants according to their legal status at one single point of time in their history of illness, we ignored the possible impact of previous and future involuntary hospitalizations. In fact, it cannot be ruled out that participants of both groups had significant experiences with both voluntary and involuntary hospitalizations in the past, and these also might have an effect on the results. However, involuntary hospitalizations tend to be followed by more involuntary hospitalizations [5, 13, 22, 23]. We, therefore assume that our involuntary group actually has substantially more experience in being hospitalized involuntarily than our voluntary group and that involuntariness at the index hospitalization indeed is a representative characteristic of this group. It is a shortcoming of this study, though, that we had not assessed the legal status of rehospitalizations during the follow-up. Finally, although it is quite extended, our list of possibly confounding variables might be incomplete and other relevant variables might be missing, e.g., substance abuse which has been found to be an important predictor of early rehospitalization [28]. Our results indicate that involuntary hospitalization is related to the risk and duration of further hospitalizations in patients with schizophrenia or schizoaffective disorder. Caution is necessary in the interpretation of the results: The term risk does not imply that being rehospitalized is necessarily negative. Rehospitalization can not only be the result of dramatically worsened symptoms but also of an increased sensitivity towards personal warning signs that leads to early help seeking and acceptance of hospital treatment. The differing functional levels were found to be predictors of rehospitalization and length of stay in the next 6 months, but not symptoms themselves as assessed by the PANSS subscales. We have no information on the individual circumstances that directly led to the readmission in the patients concerned—and of course we do not claim that it is the experience of involuntariness itself that causes future rehospitalization and longer subsequent stays. But, also in accordance with the results on the increased perception of coercion in the involuntary group of this sample [16], we have to emphasize that we are talking about a particularly vulnerable subgroup that deserves our special attention, efforts and care to establish a sound and trustful working alliance.
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Further studies are needed to examine in detail the processes and interventions that are suitable to interrupt these circles of repeated hospitalizations and involuntariness in former involuntary patients in a broader approach. Although it was not able to demonstrate the effectiveness of Joint Crisis Plans in reduction of coercion and readmissions, only recently a randomized controlled trial [44] offered one promising and useful direction of research in this area. Acknowledgments We wish to thank all participants who partici¨ zfirat, Tanja pated in the study. We also thank Heike Wiesner, Filiz O Gieselmann and Simone Triem for data collection and data entry and Ildiko Baumgartner for her work in processing data. The ELAN study was funded as an investigator-initiated research project by a grant from AstraZeneca Deutschland to the University of Tu¨bingen (Project Nr. 229/2004 V—Version 2, 27.09.04). AstraZeneca had no role in the development of the research questions, the design of the study, the collection, analyses and interpretation of data, and the writing of the manuscript. AstraZeneca had the right to comment on the final draft of the article before the submission to the journal.
12.
13.
14. 15.
16.
17.
18.
Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest. 19.
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ORIGINAL PAPER
Rehospitalization risk of former voluntary and involuntary patients with schizophrenia Carmen Pfiffner • Tilman Steinert • Reinhold Kilian • Thomas Becker • Karel Frasch • Gerhard Eschweiler • Gerhard La¨ngle • Daniela Croissant Wiltrud Schepp • Prisca Weiser • Susanne Jaeger
•
Received: 25 December 2013 / Accepted: 22 April 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Background The aim of the study was to examine the differences between former involuntary and voluntary patients with a schizophrenic disorder with regard to time to and frequency of rehospitalization. Methods In this prospective observational study, 374 patients with a diagnosis of schizophrenia or schizoaffective disorder were included. At the time of inclusion, 290 (77.5 %) were hospitalized voluntarily and 84 (22.5 %)
C. Pfiffner T. Steinert S. Jaeger (&) Department of Psychiatry and Psychotherapy I, Centres for Psychiatry Su¨dwu¨rttemberg, Ulm University, Weissenau, ZfP Su¨dwu¨rttemberg, Versorgungsforschung, Weingartshofer Str. 2, 88214 Ravensburg, Germany e-mail: [email protected] R. Kilian T. Becker K. Frasch Department of Psychiatry and Psychotherapy II, Ulm University, Bezirkskrankenhaus Gu¨nzburg, Gu¨nzburg, Germany G. Eschweiler G. La¨ngle Department of Psychiatry and Psychotherapy, University of Tu¨bingen, Tu¨bingen, Germany G. La¨ngle Centres for Psychiatry Su¨dwu¨rttemberg, Bad Schussenried, Germany D. Croissant PP.rt Hospital for Psychiatry, Psychotherapy and Psychosomatics, Reutlingen, Germany W. Schepp Department of Forensic Psychiatry and Psychotherapy, Bezirksklinikum Regensburg, Regensburg, Germany P. Weiser Department of Psychosomatic Medicine, Psychotherapy/ Psychiatry, University of Mainz, Mainz, Germany
involuntarily. Follow-up assessments were conducted halfyearly over a 2-year period with measures of PANSS, GAF, sociodemographic data and cognitive functioning. These data served as covariates for adjustment in statistical models that included a Cox regression model, a randomeffect logit model and a random-effect tobit model. Results After adjustment for other relevant covariates, the Cox regression showed that involuntary treatment is a significant risk factor of subsequent rehospitalization (HR = 1.53; CI = 1.06, 2.19; p = 0.02). The involuntary group had higher half-year incidence rates of rehospitalization, and in case of rehospitalization the duration of hospital stay was longer. Conclusions Involuntary hospitalization seems to be associated with a higher risk of rehospitalization and longer subsequent hospital stays in patients with schizophrenia and schizoaffective disorders. Further studies are needed to examine in detail the processes and interventions that are suitable for interrupting circles of repeated hospitalizations, especially in former involuntary patients. Keywords Schizophrenia Involuntary hospitalization Rehospitalization Readmission Coercion
Introduction Involuntary hospitalization on a defined legal basis is required if persons with mental illness pose severe danger to themselves or others. Even if the procedures are different across countries, this assumption is basically shared and realized in corresponding legislations [1, 2]. Involuntary treatment occurs in one of ten inpatients [2]. Rates of involuntary inpatient treatment, in European countries, range from 3.2 % in Portugal to 30 % in Sweden [3]. The
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most common diagnoses in people who are treated involuntarily are schizophrenia or other psychoses [2, 4, 5]. Typically, involuntarily hospitalized patients lack insight into their illness and into their treatment. However, insight into illness and positive attitudes toward treatment have been recognized as highly relevant for the positive outcome of schizophrenia in the long term [6]. Although in many cases involuntary hospitalization seems unavoidable, there is a risk that this experience may prompt former involuntary patients to avoid seeking services in the future [7]. This might lead to a deleterious circle of treatment discontinuation and more involuntary rehospitalizations, especially if the patient is suffering from delusions of persecution. Patients often consider an involuntary stay to be unjustified or unnecessary [8]. They perceive their inpatient treatment as highly coerced and their negative attitude toward hospitalization does not necessarily change with improvement of symptoms even if retrospectively some patients concede that they had needed treatment [9–11]. With regard to treatment outcomes such as symptom reduction, there seems to be no difference between voluntarily and in involuntarily hospitalized patients—both groups tend to clinically improve with inpatient treatment [12–14]. This also applies to the improvement of social functioning, although involuntary patients in general showed similar or lower levels of functioning than voluntary [15]. Evidence on a potentially different long-term development of these two groups is rather limited. Studies on the use of outpatient services and medication compliance indicate that there are no substantial differences between former voluntary and involuntary patients [15], although only recently a study pointed out that former involuntary inpatients might more easily feel coerced to participate in outpatient treatment and report a slightly lower medication adherence [16]. Another important indicator of the longterm course of illness is rehospitalization. People with schizophrenia generally have a high risk of recurring readmissions [17] with rates ranging from 50 to 85 % within 20 years after the first episode [18]. Relapses and rehospitalizations cause personal costs such as loss of personal contacts and satisfaction and may be associated with deterioration of illness course [19]. On the other hand, there are societal costs due to both clinical treatment and loss of productivity [20, 21]. Despite the various studies that examined predictors of involuntary hospitalization, only a few clinical studies investigated the potential role of involuntary hospitalization as a predictor of rehospitalization. Although it has been repeatedly confirmed that former involuntarily hospitalized patients have an increased risk of involuntary readmissions as compared to voluntarily hospitalized [5,
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22–24], findings are inconsistent with regard to a general rehospitalization risk [15, 25]. A more recent prospective study with a 2-year follow-up period found a higher number of rehospitalizations after an involuntary inpatient stay, but the difference failed to reach statistical significance [26]. Some older studies also found no significant differences [13, 23, 27–29]. Other studies indicate that involuntary treatment might lead to higher rehospitalization rates in the follow-up period [4, 5, 17, 30, 31], but also lower probabilities of readmission have been found in patients having been hospitalized court-ordered [32]. Most of these studies involved unselected patient samples, not specifically patients with schizophrenia. Data collection were retrospective in some cases, and follow-up periods covered a range from 30 days up to 17 years. The only study with a prospective design, a long-term follow-up of about 3 years, including only patients suffering from schizophrenia or schizoaffective disorder [13] had a small size (N = 52). Only a few studies had included confounding variables such as, e.g., severity of symptoms in their statistical analyses [5, 23, 29]. All in all, there is very limited evidence regarding the possible effects of involuntary treatment in hospital on further hospitalizations in patients with schizophrenia or schizoaffective disorder. The purpose of the present study was to examine whether former voluntary patients are different from involuntary patients with regard to time to subsequent rehospitalization, whether voluntary and involuntary patients have a different risk of rehospitalizations and whether duration of rehospitalization is different. Since a randomized controlled trial was not feasible due to ethical and legal limitations, the participants were recruited in the context of an observational prospective long-term study on the effects of second-generation antipsychotics. In order to account for drawbacks of observational studies, a number of potentially relevant confounding factors were controlled.
Methods Study design and definitions Data were collected in the context of the effects of longterm atypical neuroleptic treatment study (ELAN), a multicenter prospective naturalistic longitudinal research project about the effects of treatment with second-generation antipsychotics on functional impairment, quality of life, treatment costs and course of illness [33–35]. The study protocol was approved by the Ethical Committees of Tu¨bingen University, Ulm University, and of the State Medical Chamber of Baden-Wu¨rttemberg. The study population consisted of 374 adult patients with a diagnosis of schizophrenia or schizoaffective
Soc Psychiatry Psychiatr Epidemiol
disorder who were treated in one of nine psychiatric hospitals in South Germany. Recruitment of participants took place between April 2005 and November 2006, and the assessments were carried out by trained research assistants who were not involved in the medical treatment of the patients. Patients on the wards were screened whether they had an antipsychotic medication of either quetiapine, olanzapine or risperidone (also combined with other psychotropic drugs, but not among themselves) at discharge and a recommendation continuing it for at least 12 months. The treating psychiatrists were not involved in the study, and thus free in their decisions to order or change the psychotropic substances, also over the course of the study. Exclusion criteria of the ELAN study comprised a secondary diagnosis of a substance-dependence syndrome (ICD-10: F1x.2) (except nicotine dependence), organic psychiatric disorder or developmental/learning disability. After complete description of the study to the participants, written informed consent was obtained. The first interview was conducted a few days before discharge, followed by four follow-up interviews every 6 months. To increase the motivation to participate, patients received a monetary reward for each assessment. For this paper, the participants were retrospectively divided into two different groups according to their legal status at index hospitalization (hospitalization at the time of inclusion into the study). The first group consisted of patients whose index hospitalization was completely voluntary (voluntary group: VG). An inpatient stay after emergency involuntary admission was also classified as voluntary if the patient decided to stay in the hospital on a voluntary basis subsequently and application for a court order was not necessary. The second group involved patients whose stay was involuntary, meaning they were treated court-ordered (involuntary group: IG) at least for some period of their stay. Measures At baseline, the following sociodemographic data and data on clinical history were collected: age, sex, education, having a partnership, years since first hospitalization, number of previous hospitalizations, and number of previous suicide attempts. Assessments at all measure points (time varying covariates) included current status of employment (having a regular or at least sheltered job: yes vs. no), living situation (independent vs. assisted), symptoms [positive and negative syndrome scale (PANSS)] [36], functioning [Global Assessment of Functioning Scale (GAF) from the DSM-IV] [37], and cognitive processing speed [Digit Symbol Coding Subtest from the Wechsler Adult Intelligence Scale (ZST)]. Data on intermediate hospital admissions were collected at every follow-up assessment by self-report or, in case of readmission in the same hospital, by the patient’s medical chart.
Statistical analysis To check for possible selection bias in dropouts, participants and dropouts were compared by Fisher’s exact tests, Chi square tests or t tests for independent variables. Group differences between VG and IG were tested with t test for two independent samples and Chi square analysis. To test for differences in time to rehospitalization, a Kaplan–Meier survival analysis was calculated using the log-rank test. To examine the effect of involuntariness on time to rehospitalization after adjustment for other potentially exploratory variables, a Cox proportional hazards model is used. Cox regression goes beyond the Kaplan– Meier method for comparing survival curves of several groups, because it allows analyzing the effect of several risk factors on survival simultaneously. Variables in the model were involuntariness, sex, age, time since first hospitalization, number of previous hospital stays, number of previous suicide attempts, low educational status, having a partner, having a job, and assisted living. To estimate the differences in half-year incidence rates of rehospitalization and in half-year duration of hospital stays, two random-effect regression models were used: For the half-year incidence (discrete variable), a random-effect logit model was created and tested. To test for differences in the duration of hospital stays during the 2 years after discharge of index hospitalization, a random-effect tobit model was calculated. The advantage of random-effects models is the opportunity to include all cases even if not every patient has participated in all interviews. The following baseline (b) and time varying (tv) sociodemographic and clinical variables were integrated in these models: (b) involuntariness, sex, age, low educational status, having a partner, time since first hospitalization, number of previous hospital stays, number of previous suicide attempts, duration of index hospitalization; (tv) having a job, assisted living, cognitive processing speed, GAF, PANSS positive, PANSS negative, and PANSS general. We tested two-sided on a 5 % significance level. The statistical programs used were SPSS 11.5 and STATA 11 for windows.
Results Sample 530 patients were found to be eligible for inclusion and asked for study participation. 374 patients (71 %) agreed to participate and gave informed consent. 156 patients (29 %) refused to participate. Patients who refused to participate, in comparison with those who participated, were
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Soc Psychiatry Psychiatr Epidemiol Table 1 Patient characteristics at study inclusion Variable
VG (N = 290)
IG (N = 84)
Male sex, N (%)
148 (51.0)
48 (57.1)
Age, Mean (±SD)
40.7 (12.9)
37.5 (11.1)
*
Employment/occupation, N (%)
115 (39.7)
23 (27.4)
*
Low educational status, N (%)
152 (52.4)
39 (46.4)
Assisted living, N (%)
50 (17.2)
12 (14.3)
Partnership, N (%)
87 (30.0)
24 (28.6)
GAF, Mean (±SD) PANSS positive, Mean (±SD)
56 (12.5) 11.6 (4.4)
54 (12.3) 12.5 (4.7)
PANSS negative, Mean (±SD)
14.8 (5.7)
13.3 (5.4)
PANSS general, Mean (±SD)
28.9 (7.0)
27.8 (7.6)
7.2 (8.8)
5.9 (6.3)
69.1 (52.8)
84.6 (52.9)
Number of previous hospital stays, Mean (±SD) Duration of index hospitalization (days), Mean (±SD)
*
Risk of rehospitalization
*
Table has been already published in [16] GAF global assessment of functioning scale, PANSS positive and negative syndrome scale * p \ 0.05
significantly younger, they had fewer inpatient episodes and a lower rate of schizoaffective disorder diagnoses. A total of 257 participants (69 %) were assessed at all measurement points. Only 29 participants (8 %) left the study completely after the baseline assessment. At the 24-month follow-up assessment, 300 patients (80 %) still participated in the study. Comparisons of baseline sample characteristics between participants and dropouts at each follow-up did not reveal any systematic difference. 290 patients (78 %) were categorized as belonging to the voluntary group (VG), 84 patients (22 %) as belonging to the involuntary group (IG). Sociodemographic and clinical variables for both groups are listed in Table 1. The mean age of the study population was 40 years (SD = 12.6 years) with 178 women (mean age 43.2 years ± 13.3) and 196 men (mean age 37.1 years ± 11.1). There were significant differences in age, employment status, negative symptoms (PANSS negative) and duration of index hospitalization. Participants of the VG were older (p = 0.04), they were more likely to work (p = 0.04), had more negative symptoms at discharge from index hospitalization (p = 0.03) and had a shorter index hospitalization (p = 0.02). Rehospitalization General characteristics In both groups, we had missing data due to unavailability of information after the first interview [VG: N = 38
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(13 %); IG: N = 13 (15 %)]. 44 (62 %) out of a total of 71 remaining participants of the IG were hospitalized at least once within the follow-up of 2 years compared to 50 % rehospitalized participants in the VG (N = 125 out of a total of 252). At each follow-up, an average of 27 % VG participants, and 37 % of the IG participants reported at least one readmission in the course of the past 6 months (Table 2). In the VG, time to rehospitalization was at a mean of 229 days (SD 211.6), and in the IG at a mean of 200 days (SD 184.3). The majority of readmissions happened within the first 6 months after discharge (VG: median 132 days; IG: median 131 days).
Kaplan–Meier survival analysis showed a non-significant difference between both groups (log-rank test: Q = 3.16; df = 1; p = 0.08). To explore the effect of involuntariness on the risk of rehospitalization after adjustment for other patient characteristics at baseline, a Cox regression model was used. The overall model was significant (v2 = 65.20; df = 15; p = 0.00) indicating a relationship between time and all the covariates in the model. The effect of belonging to the IG was significant (HR = 1.53; CI = 1.06–2.20; p = 0.02) (Table 3). This means, after adjustment for all other variables in the model, the risk of rehospitalization increased about 53 % in case the index hospitalization was involuntary. The variables sex (HR = 0.52; CI = 0.37–0.73; p = 0.00) and number of previous hospitalizations (HR = 1.04; CI = 1.02–1.07; p = 0.00) also showed a significant effect on the risk of rehospitalization. Thus, the risk decreased about 48 % in women, and with each previous hospital stay it increased about 4 %. Figure 1 shows the adjusted cumulative rate of readmitted participants in each group by mean values for each covariate. Half-yearly incidences of rehospitalization The total half-yearly incidences of hospitalizations at the four follow-ups ranged between 26 and almost 29 % with the lowest incidence rate at the second follow-up point. Table 4 shows the results of the random-effect logit model for the half-year incidence of rehospitalization. When controlling for time varying (e.g., symptoms, GAF) and baseline (e.g., age, sex) covariates, belonging to the IG increased the likelihood of rehospitalization by 92 % (OR = 1.92; p = 0.02). Each additional previous hospital stay increased the likelihood of further hospitalization by 8 % (OR = 1.08; p = 0.00). However, female gender (OR = 0.49; p = 0.00) and having a partner (OR = 0.61; p = 0.05) decreased the likelihood of being rehospitalized
Soc Psychiatry Psychiatr Epidemiol Table 2 Rehospitalization in former voluntary and involuntary patients
Baseline
6 months
12 months
18 months
24 months
290
252
242
234
235
79 (31.3)
56 (23.1)
61 (26.1)
69 (29.4)
VG N participants N rehospitalized (%) IG N participants
84
N rehospitalized (%)
71 26 (36.6)
72 27 (37.5)
68 27 (39.7)
65 23 (35.4)
Table 3 The effect of involuntary stay and other patient characteristics on the risk of rehospitalization (Cox regression model) B
SE
Wald
p level
HR (95 % CI)
Involuntary stay (0 = no; 1 = yes)
0.42
0.18
5.29
0.02
1.53 (1.06–2.19)
Sex (0 = male; 1 = female)
-0.66
0.17
14.46
0.00
0.52 (0.37–0.73)
Age
0.01
0.01
1.22
0.27
1.01 (0.99–1.03)
Time since first hospital stay (years)
0.00
0.01
0.00
0.97
1.00 (0.98–1.02)
Number of previous suicide attempts
0.02
0.05
0.15
0.70
1.02 (0.93–1.12)
Low educational status (0 = no; 1 = yes)
0.13
0.17
0.58
0.45
1.13 (0.82–1.57)
Partnership (0 = no; 1 = yes)
0.05
0.19
0.07
0.80
1.05 (0.73–1.52)
Employment/ occupation (0 = no; 1 = yes)
-0.34
0.18
3.66
0.06
0.71 (0.50–1.01)
Assisted living (0 = no; 1 = yes) Number of previous hospital stays
-0.01
0.22
0.00
0.95
0.99 (0.64–1.52)
0.04
0.01
12.74
0.00
1.04 (1.02–1.07)
Bold values indicate significance at the 0.05 level
by 51 and 39 %, respectively. Each additional unit in GAF decreased the likelihood of being rehospitalized within the next 6 months by 2 % (OR = 0.98; p = 0.05). Symptoms, having a job or having an assisted living situation did not show significant effects. Duration of subsequent hospitalization Table 5 presents the results of the random-effect tobit model for the duration of hospital stays per half-year during the 2-year follow-up period. eslope can be interpreted as relative change, analogue to odds ratios in a logit model.
Fig. 1 Cumulative rates of readmitted patients after adjustment with means of covariates (Cox regression)
When controlling for covariates (see above), belonging to the IG had a significant effect on the duration of hospital stays in the 2 years after discharge. In case of hospitalization, participants of the IG had a circa 3.5 times (eslope = 4.68) longer duration of subsequent hospital stays than participants of the VG. Other covariates also had a significant effect on the length of rehospitalizations. Each additional previous suicide attempt led to a proportionate increase of the number of inpatient days by about 52 % (eslope = 1.52). With each additional previous hospitalization, the number of inpatient days during the follow-up periods increased proportionately by 19 % (eslope = 1.19). Furthermore, the duration of the index hospitalization had a
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Soc Psychiatry Psychiatr Epidemiol Table 4 Random-effect logit model for explanation of the half-year incidence of hospitalization during the 2 years of follow-up B Involuntary stay (0 = no; 1 = yes) Sex (0 = male; 1 = female)
0.65
SE
p level
OR
0.27
0.02
1.92
Table 5 Random-effect tobit model of the log-transformated duration of rehospitalization (half-yearly during 2 years of follow-up) B Involuntary stay (0 = no; 1 = yes)
-0.71
0.25
0.00
0.49
0.01
0.01
0.90
1.01
Time since first hospital stay (years)
-0.02
0.02
0.19
0.98
Number of previous suicide attempts
0.08
0.09
0.34
1.08
Digit Symbol Coding Subtest
-0.00
0.04
0.94
1.00
Time since first hospital stay (years)
GAF PANSS positive
-0.02 -0.02
0.01 0.03
0.05 0.44
0.98 0.98
Age
Sex (0 = male; 1 = female) Age
SE
p level
slope
eslope
6.83
2.82
0.02
1.54
4.68
-3.00
2.41
0.21
-0.68
0.51
0.16
0.13
0.21
0.04
1.04
-0.34
0.17
0.05
-0.08
0.93
Number of previous suicide attempts
1.84
0.84
0.03
0.42
1.52
0.25
0.42
0.55
0.06
1.06
PANSS negative
0.00
0.03
0.94
1.00
PANSS general
0.02
0.02
0.49
1.02
Digit Symbol Coding Subtest
Low educational status (0 = no; 1 = yes)
0.14
0.24
0.57
1.15
GAF
-0.31
0.11
0.00
-0.07
0.93
PANSS positive
0.09
0.36
0.81
0.02
1.02
-0.52
0.30
0.08
-0.12
0.89
Partnership (0 = no; 1 = yes)
-0.50
0.25
0.05
0.61
PANSS negative
Employment (0 = no; 1 = yes)
-0.35
0.21
0.10
0.70
PANSS general
0.12
0.24
0.61
0.03
1.03
Assisted living (0 = no; 1 = yes)
-0.21
0.26
0.41
0.81
Low educational status (0 = no; 1 = yes)
-1.43
2.46
0.56
-0.32
0.72
Partnership (0 = no; 1 = yes)
-2.92
2.47
0.24
-0.66
0.52
Employment/occupation (0 = no; 1 = yes)
-1.97
2.21
0.37
-0.45
0.64
Assisted living (0 = no; 1 = yes)
-3.18
2.81
0.26
-0.72
0.49
Bold values indicate significance at the 0.05 level GAF global assessment of functioning scale, PANSS positive and negative syndrome scale, OR odds ratio
Number of previous hospital stays
0.77
0.21
0.00
0.18
1.19
Duration of index hospitalization
0.06
0.02
0.01
0.01
1.02
24.49
12.66
0.05
Number of previous hospital stays
0.08
0.02
0.00
1.08
Duration of index hospitalization
0.00
0.00
0.17
1.00
-0.18
1.20
0.88
0.84
constant Number of measurements Wald v2/Prob [ v2
3.3 66.28/0.00
significant effect. With each additional day of index hospitalization, the duration of subsequent hospital stays changed proportionately by about 2 % (eslope = 1.02). In contrast, each additional year since the first hospital stay (eslope = 0.93) and each additional unit in GAF (eslope = 0.93) proportionately decreased the number of inpatient treatment days by 7 %.
Discussion In this study, we investigated the rehospitalization risk of former voluntary and involuntary inpatients with schizophrenia or schizoaffective disorder over a follow-up period of 24 months. We found that formerly involuntarily hospitalized patients had a higher risk of subsequent hospital admissions during the 2 years follow-up period. The halfyear incidence of rehospitalization was higher in this group, and the hospital stays were significantly longer. Actually, there was no significant difference in survival rates between both groups as seen in Kaplan–Meier survival analysis, similar to the results of McEvoy and colleagues [13]. After adjustment for possible confounding variables in the Cox regression, though, it became apparent
123
Constant Number of measurements Wald v2/Prob [ v2
3.3 77.78/0.00
Bold values indicate significance at the 0.05 level GAF global assessment of functioning scale, PANSS positive and negative syndrome scale
that former involuntary inpatients had a higher risk of rehospitalization. Very similar to the results of Szmukler et al. and Rosca et al. [5, 17], 49 % of voluntarily treated patients and 60 % of involuntarily treated patients in our sample had a subsequent hospital stay within 2 years after discharge. Furthermore, the half-year incidence of rehospitalization was highly correlated with previous involuntariness, which increased the likelihood by 92 %. According to that, Opjordsmoen et al. [26] found a small but not statistically significant difference in number of rehospitalizations within 2 years between voluntarily and involuntarily treated first-episode patients. The involuntarily treated patients in our study had a longer index hospitalization. Moreover, the random-effect tobit model showed that involuntariness at index hospitalization was also associated with longer
Soc Psychiatry Psychiatr Epidemiol
inpatient stays that occurred in the follow-up period. In their review, Kallert and colleagues found in 9 out of 17 studies a significant association between the duration of index hospitalization and duration of further hospital stays, as we did in our study [15]. Also seen in previous studies, to have a partner can prevent rehospitalization [31, 38], and men have a higher risk of being rehospitalized [30, 39]. Other factors increasing the risk of subsequent rehospitalization in our study are lower level of functioning (GAF), and a higher number of previous hospital stays, also known from a former study [40]. These might be factors that are associated with integration in society that could prevent further hospitalizations. Apparently negligible with regard to the rehospitalization risk or the duration of subsequent stays were factors such as age, cognitive processing speed, educational status, assisted living, employment, and severity of symptoms. Having a job as a protective factor of rehospitalization fell just short of significance. Indeed, in their study on predictors of relapse, Schennach et al. [41] found that having a job at discharge from hospital was protective against relapse during the follow-up. Similar to recent findings of a European multicenter cohort study [42], in our sample symptom severity was not predictive of rehospitalization. While this sounds counterintuitive, it must be emphasized that at the time of their assessment, symptoms did not differentiate between patients who have been rehospitalized or not rehospitalized within the course of the next 6 months (see also below). The strengths of our study are the prospective, long-term follow-up design of 2 years with half-yearly assessments, a considerable sample size with participants from different study centers, and the adjustment for a broad range of possibly confounding variables, namely current severity of symptoms and indicators of social integration such as maintaining a job or living in a partnership. In former studies, these factors were often missing. Our study has also limitations, though. The study population may not be representative for all hospitalized patients with schizophrenia in Germany or in other countries. The legal status of involuntariness might be influenced among others by specific legislations and regional legal practices in the respective federal states of Germany. Moreover, the sample was recruited in the context of a study on long-term effects of second-generation antipsychotics. Patients who (at the time of recruitment) had a medication of first-generation antipsychotics only could not join in the study. Yet, after the baseline assessment, any change of the medication was possible according to the naturalistic study design, and so the selection bias due to the type of medication is probably neglectable. Moreover, critical to representativity is surely the exclusion of patients with a substance-dependence syndrome. Substance abuse is
not uncommon among schizophrenia patients and it can be a risk factor for involuntary hospitalization [43]. Only patients with a diagnosis of harmful use were allowed in the study. This might limit the generalizability of our results. Finally, the participants of this study deliberately joined in a long-term study. Although, study workers were independent from the wards and not involved in the inpatient treatment, this clearly required a minimum of cooperativeness and trust on the side of our potential study participants and might have led to a selection. By classifying the participants according to their legal status at one single point of time in their history of illness, we ignored the possible impact of previous and future involuntary hospitalizations. In fact, it cannot be ruled out that participants of both groups had significant experiences with both voluntary and involuntary hospitalizations in the past, and these also might have an effect on the results. However, involuntary hospitalizations tend to be followed by more involuntary hospitalizations [5, 13, 22, 23]. We, therefore assume that our involuntary group actually has substantially more experience in being hospitalized involuntarily than our voluntary group and that involuntariness at the index hospitalization indeed is a representative characteristic of this group. It is a shortcoming of this study, though, that we had not assessed the legal status of rehospitalizations during the follow-up. Finally, although it is quite extended, our list of possibly confounding variables might be incomplete and other relevant variables might be missing, e.g., substance abuse which has been found to be an important predictor of early rehospitalization [28]. Our results indicate that involuntary hospitalization is related to the risk and duration of further hospitalizations in patients with schizophrenia or schizoaffective disorder. Caution is necessary in the interpretation of the results: The term risk does not imply that being rehospitalized is necessarily negative. Rehospitalization can not only be the result of dramatically worsened symptoms but also of an increased sensitivity towards personal warning signs that leads to early help seeking and acceptance of hospital treatment. The differing functional levels were found to be predictors of rehospitalization and length of stay in the next 6 months, but not symptoms themselves as assessed by the PANSS subscales. We have no information on the individual circumstances that directly led to the readmission in the patients concerned—and of course we do not claim that it is the experience of involuntariness itself that causes future rehospitalization and longer subsequent stays. But, also in accordance with the results on the increased perception of coercion in the involuntary group of this sample [16], we have to emphasize that we are talking about a particularly vulnerable subgroup that deserves our special attention, efforts and care to establish a sound and trustful working alliance.
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Soc Psychiatry Psychiatr Epidemiol
Further studies are needed to examine in detail the processes and interventions that are suitable to interrupt these circles of repeated hospitalizations and involuntariness in former involuntary patients in a broader approach. Although it was not able to demonstrate the effectiveness of Joint Crisis Plans in reduction of coercion and readmissions, only recently a randomized controlled trial [44] offered one promising and useful direction of research in this area. Acknowledgments We wish to thank all participants who partici¨ zfirat, Tanja pated in the study. We also thank Heike Wiesner, Filiz O Gieselmann and Simone Triem for data collection and data entry and Ildiko Baumgartner for her work in processing data. The ELAN study was funded as an investigator-initiated research project by a grant from AstraZeneca Deutschland to the University of Tu¨bingen (Project Nr. 229/2004 V—Version 2, 27.09.04). AstraZeneca had no role in the development of the research questions, the design of the study, the collection, analyses and interpretation of data, and the writing of the manuscript. AstraZeneca had the right to comment on the final draft of the article before the submission to the journal.
12.
13.
14. 15.
16.
17.
18.
Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest. 19.
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