Brit.J. Psychic!.(1979), 135,35—41
Treatment Settings in Psychiatry: Long-term Family and Social Findings By A. A. ROBIN, J. B. COPAS and D. L. FREEMAN-BROWNE SUMMARY Treatment in a psychiatric unit, as distinct from a psychiatric hospital, held no benefits in the long term (5-8 years after admission) as far as the patient's mental and behavioural status and employment, or the family's burdens, health needs or attitude were concerned. Schizophrenic patients from both settings received more hospital treatment and medication, were more often unemployed, and had more adverse effect on relatives' health than neurotic or depres sive patients. Hospital attendence identified relatives who expressed a need for support. Introduction Copas, Fryer and Robin (1974) describe an investigation to ‘¿ determinedifferences in out come which may be attributed to treatment under
different
administrative
conditions
antidepressants.
A
month
after
admission
a
marked and equal degree of clinical improve ment (measured by the Present State Examin ation) was seen in the patients of both hospitals. At six months the pattern of treatment differed; psychiatric unit patients spent almost half the time as day patients and correspondingly less as
by
comparing (in patients from the same geographic area) the results of a psychiatric unit in a general in-patients, while psychiatric hospital patients hospital and its associated day hospital with were treated mostly as inpatients and for only a those of a large modern psychiatric hospital also twelfth of the time as day patients. The overall receiving day patients'. Differences were demon strated in the ward environments of the two periods of treatment were, however, similar for the matched patients in each hospital. hospitals, in the attitudes of patients and their At five years after first admission (Copas, families towards the hospitals, in the patterns of Freeman-Browne and Robin, 1977) the total admission and in ease of contact with the period of treatment in each setting remained community. Ninety-eight patients undergoing the unit continued to use more day first admission to the psychiatric unit were Jomparable: patient care, while readmission was commoner individually paired with the next patient of the same sex, age and diagnosis undergoing first to the psychiatric hospital. admission to the psychiatric hospital. In retro Patients' homes were visited by a social spect these patients were also shown to resemble worker at the time of admission, and at one each other in numerous other ways—in marital month, ten weeks and six months after ad status, employment status, previous personality, mission (Copas, Fryer and Robin, 1974). education, family size, family history, previous Enquiry was made regarding the effect of the neurotic traits, drinking habits, and recent patient's illness on the family. Problems created physical ill-health to take some examples. The by the illness (‘familyburdens') were identified, 98 pairs were also shown to be closely com e.g. financial difficulties when the patient had parable in clinical state assessed with the been a wage-earner or when the patient's Present State Examination (Wing, 1970), illness prevented other members of the family while their hospital involved treatment working; equal the disruption of the family when children had to go into care; interference with amounts of ECT, major tranquilizers and 35
36
TREATMENTSETFINGSIN PSYCHIATRY: LONG-TERMFAMILYAND SOCIALFINDINGS
In a few further cases, when the patient no and leisure activities. The effect of these longer lived in the district, contact was made by problems was assessed in terms of the relatives' letter. From a total of 171 probable survivors attitude, health and needs. The patients' social adjustment was determined by ratings of from the original study, some information was finally obtained for 154 patients—l32 treated mental, behavioural and occupational status. in one hospital (general hospital unit or psychi At six months no essential differences were seen atric hospital) and 22 patients who, in the between the outcomes from the two treatment course of the follow-up changed hospital, to be settings. The patients' homes were revisited at 5 to 8 years after first admission and similar treated in both. Comparisons between the hospitals were again made on the basis of data information was gathered to that obtained in the earlier visits. This paper examines the following from matched pairs of patients, one treated in each hospital respectively. questions: 1. Comparing treatment in a general hospital Results psychiatric unitand a psychiatric hospital, which of the two promotes the patient's 1. Patients' social adjustment readjustment to a greater degree? (a) Mental and behavioural status 2. Comparing treatment in a psychiatric unit Ratings of patients' mental and be and a psychiatric hospital, which of the two havioural status showed an overall relieves the patients' familiesto a greater progressive increase in the number of degree? patients free of symptoms (Table I), and 3. Does any diagnostic category give rise to a corresponding decrease in the number greater difficulties in social readjustment for of patients reported to be suffering from the patient or greater problems for the subjective distress and to be prone to patient's family? violence or threatening violence to themselves or others. On the other hand, Method in relation to the six months' follow up, an increase in self-neglect and more A social worker (D.L. F-B) revisited all surviving and locally resident patients' families 5 particularly of altered behaviour was observed. Examples of the latter were to 8 years after the patient's first admission and ‘¿ outbursts of temper', ‘¿ screaming and collected information on a standard form similar shouting', ‘¿ refusing to let people in the to that employed in the earlier investigation. social
T@I2
I
Mental/behavioural status on admission andfollow-up
yearsRHRGHTotalRHRGHTotalRHRGHTotalNotknowntitial6
Asymptomatic
Subjective distress Self neglect Strangetalk
Altered
behaviour
Socialreasons Threatened or actual violence to self andothers
N.A./Lost
to follow-up6
—¿
—¿
56 2 5 20 1
66 1 6 11
8 —¿ 8
RH —¿ Runwell Hospital (Psychiatric Hospital) RGH—Rochford
General Hospital (Psychiatric Unit)
—¿
months5
—¿
122 3 11 31 1
40 32 1 —¿
1
41 37 —¿ —¿
1
6
14
5
4
—¿ 14
—¿ 19
—¿ 15
—¿ 34
81 69 1 —¿
2 9 —¿ 8
50 16 2 1 5
47 18 3 1 5
97 34 5 2 10
—¿
—¿
—¿
1615
923 25
37
A. A. ROBIN, J. B. COPAS AND D. L. FREEMAN-BROWNE TAsut
II
Occupation on admission andfollow-up
yearsRHRGHTotalRHRGHTotalRHRGHTotalHousewifeInitial6
@
months5
—¿ ISo1e occupation
5 7 17 Outsidejob P/T 2 4 5 2 6 12 11Others 241 578 732 434 366 726 626 552 1. F/T37 employed262248192140201939Others(Retired,etc.)235224628Unemployed201737201939121022Dead52716925Notkno
RH —¿ Runwell Hospital (Psychiatric Hospital) RGH—Rochford
General Hospital (Psychiatric Unit)
house', ‘¿ withdrawal',and ‘¿ drinking ex cessively'. No differences were seen between the hospitals. (b) Employment The
number
of employed
housewives
both in part-time and in full-time jobs doubled at the long-term follow-up (Table II). This change, and the slight increase in ‘¿ retired' patients and in the number of patients dead might simply reflect the passage of time and the increased age Of both patients and dependants.
2. Family problems (a) Family burdens The mean number of burdens that relatives carried,i.e.totalburdens for group divided by number of relatives, fell throughout the study (Table III), and no differences were found in the TAsi..E III
Mean number of burdens carried by patient's relative or
distribution of burdens between the families ofpatients ineither hospital. (b) Effect on relatives' health The number of adult relatives themselves unwell as a result of the patient's condition fell from 17 at the time of admission
to
one
in
the
long-term
follow-up, and the number under strain from 124 to 16, while those with no complaints rose from 37 to 123. Children under strain fell from 25 to 3. No
differences were seen between the hos pitals. (c) Needs of relatives Relatives' needswere assessed under the
headings ‘¿ financial',‘¿ general supportive care', ‘¿ assistancewith housing', ‘¿ assist
ance with children', ‘¿ period of rest'. The number of families who felt they needed any kind of support fell from 72 to 15, while those not requiring
help rose from
96 to 123. There was no difference between the hospitals.
closest contact
Runwell
Rochford
admission1.421.33At On month0.730.71Attenweeks0.360.33Atsixmonths0.240.31At one five + years0.100.08
(d) Attitude of relatives The attitudes of the relatives were assessed as previously reported (Copas, Fryer and Robin, 1974). The number of relatives lacking insight into the patient's condition decreased progressively (Table
IV), as did the numbers of over-anxious
38
TREATMENTSETTINGSIN PSYCHIATRY: LONG-TERMFAMILYAND SOCIALFINDINGS and over-protective reluctant
to
have
relatives the
and those
patient
at
there
There was an increase in the accepting relatives and in the number who did not require any sort of help or support. On the whole, psychiatric unit relatives tended to be ‘¿ understanding' rather than ‘¿ accepting', although at the five-year follow-up the reverse seemed to be the case for the psychiatric hospital relatives. Family
attitudes
home',
or over-protective',
and
grouped
‘¿ negative', while
standing',
again
no
difference
between
of ‘¿ refusingor reluctant
to have the patient were
was
the relatives of patients from the two hospitals, but the overall percentage of ‘¿ negative'families had gone down to 11 per cent. Although the difference was no longer significant, a trend was maintained for a higher incidence of readmission for the patients of ‘¿ negative' families (46 per cent) when compared vith ‘¿ positive' families (28 per cent).
home.
together those
differences (Combining ‘¿ over-anxious 3. Diagnostic patients from both hospitals)
and who
‘¿ accepting' or
classified were
(a) Medical service
as
An examinationof diagnosis(forthe
‘¿ under
‘¿ welcoming',
major groups) and type of medical service received at follow-up (Table V) shows that a higher proportion of schizophrenic, compared with neurotic or depressive patients received hospital treatment as in-patients, day patients or out-patients. Equal proportions of
were classedas ‘¿ positive' families. Initi
ally, 43 per cent of psychiatric hospital patients' families and 36 per cent of psychiatric unit's patients' families were ‘¿ negative', i.e. 39.5 per cent of the whole group. In the long-term follow-up
TABLE IV
Attitude of relative on admission andfollow-up Initial
Attitude of relatives TotalNotknown
23No
RH
insight 8Understanding 72Overanxious/overprotective
1Welcoming
4Accepting 53Reluctant
5N.A.
4
RGH 6
1 month Total
26 39
51 73
5
7
12
20
18
38
2
4
—¿ —¿ 8
2
—¿
RH
10
25 34
30RH
RGH
10
8
18 28
RH
18
13
RGH 9
41 69
5 38
11 49
6
12
3
4
25
13
38
27
3
2
5
7
—¿
8
Total
23 41
6
0
8
4 1
yearsRH
6 months
4 9
1
4
Total5
RGH
229
14
163 8729
5 43
71
0
19
4632
21
5
1217
13
1
0
23 44
1 1
Hospital).RGH—Rochford —¿ RunwellHospital (Psychiatric
General Hospital (Psychiatric Unit).TABLE VDiagnosis
and medical follow-upSchizophrenic servicefor patients contacted at
(%)Attending (10)Attending hospital general practitioner (23)No
medical contact
the
‘¿ lackinginsight'
(%) 14 7
(47) (23)
9 (30) (67)30 (100)
Neurotic 8 10
22
(%)Depressive (20)7 (25)16
(55)47
40 (100)70
(100)
39
A. A. ROBIN, J. B. COPAS AND D. L. FREEMAN-BROWNE
patients in these three attended their general depressive group had tact with any medical up.
diagnostic groups practitioners. The overall least con service at follow
(b) Medication Forty-two per cent of patients were found to possess medication for use during the day and 13 per cent had night sedation.Day time medication was being receivedby 68 per cent of th schizophrenic group, 44 per cent of neurotics, and 32 per cent of depressives; and 6 per cent of schizophrenics, 13 per cent depressives, and 18 per cent of neurotics had night sedation. The pro portion of schizophrenic patients having day time medication was significantly greaterthan thatforthe neuroticand depressive groups. (c) Mental and behavioural status No ‘¿ altered behaviour' figured in the depressive or manic groups at follow-up. Subjective distress and self-neglect (which was much less common) were reported roughly equally in the main diagnostic groups. Reports of abnormality in mental and behavioural status, regardless of type, were equally frequent in the schizophrenic and neurotic groups and less common at follow-up in depressives. (d)Employment Unemployment due to mental illness occurred more frequently with schizo phrenic patients (8 of 34) than with neurotic (5 of 38) and depressive patients (0of74). (e) Family burdens No differences were found in the distribution of burdens between the families of patients in the main diagnostic groups. (f) Relatives' health A higher proportion of families of schizophrenic patients (8 of 34) reported
effects on their health, compared with either depressive (8 of 74) or neurotic patients (4of38). (g)Relatives' needs The relatives of schizophrenic (5 of 34) and neurotic (5 of 38) patients felt more need for support than those of depressive patients (5 of 74). The relatives of patients attending hospital expressed a greater need for support than those of patients
attending
their
general
prac
titioners or not in.contact with the medi cal services (Table VI). This expression of need presumably reflects the severity of illness, which may be taken to be represented by the type of service supplied. TAsut VI Medical service and relatives' needs when contacted at follow up Need supportNo needof
supportAttending hospitalIl18Attending practitioner
general
7815128 232
No medical contact2
(h) Relatives' attitudes Relatives of schizophrenic and neurotic patients were less satisfied with the patients' progress than those of the depressive
phrenic
Depressive
According
know what
group.
(Dissatisfied:
8 of 34, Neurotic 10 of 74).
Discussion to Kathleen Jones
happens
to (the patient)
Schizo
8 of 38,
(1976)
‘¿ We
while he is
in hospital, or while he is in touch with a social worker; in many cases, these periods are comparatively brief, and separated by long spells of non-contact. . .‘She therefore points to an urgent need for ‘¿ large-scale tracer studies which will chart the social experience of mental illness..
.‘Grad
and Sainsbury
(1968)
in their
40
TREATMENT SETTINGS IN PSYCHIATRY: LONG-TERM FAMILY AND SOCIAL FINDINGS
study of the Chichester (community) and Salisbury (hospital-based) psychiatric services reported that severe burdens were equally relieved by both types of service—all burdens less so by the community service. A group of young, mainly neurotic patients were identified as causing their families problems in the Chichester service. Sainsbury reviewed this and further studies in 1976. He points out that the mental health of the closest relatives was more affected in the Chichester service area, yet families expressed more satisfaction with this service. Like us, he found the services he studied were rated similarly by relatives as far as outcome for the patient was concerned, but psychiatrists and patients reported more benefit from the mental hospital than the community service.
Sainsbury
suggests,
therefore,
that
social rather than clinical behaviour was the probable basis lot' relatives' reports. Our study does not compare exactly similar services to those in Chichester, in that day patient care was most often used after admission, tending to shorten it rather than avoid it. Initially, and in both treatment settings, 70 per cent of the nearest adult relatives of a group of closely matched patients complained of strain, and just under 10 per cent felt themselves ill as a result of the patient's illness—most of the latter being under medical care. Of the children exposed to the patient's illness 40 per cent were also reported as showing strain (Copas, Fryer and Robin, 1974), but by six months families were to a large extent and equally relieved in each treatment setting and continued to be so at follow-up
from
5 to 8 years
At the same time, family attitudes
after
inception.
became more
positive towards the patients. Throughout the 5—8years of our study, ratings of mental, behavioural and occupational status showed an equal degree of improvement in patients treated in each setting. The small number of in-patients (1 .5 per cent) at 5 years from first admission does not reflect the problems or service requirements of either patients or their families. It will be seen that more schizophrenic patients received hospital treatment of all types or day medication from any source, were unemployed, and had families in which there was evidence of strain;
while both schizophrenic and neurotic patients as distinct from depressed patients, continued to show mental or behavioural abnormality, and had relatives who were dissatisfied with their progress and who expressed a need for support. Tooth and Brooke (1961) showed that at two years 9 per cent and 10 per cent of cohorts from 1954 and 1956 respectively were still in hospital. Our two-year figure would have been little different from the five-year figure already given; not, unfortunately, because our patients had recovered: 1 .5 per cent were day patients, 14 per cent were out-patients, a further 20 per cent attended their general practitioners—in short, over a third continued to receive medical care in the community. While there is some evidence that a hospital-based social worker may
be
associated
with
diminished
in-patient
chronicity (Robin and Hakki, 1972), this study, like those of Brown et al (1966) and Hoenig and Hamilton (1969), who failed to show a reduction of morbidity with increased social work contact, does not suggest that the family's needs were satisfied by such a department, which existed at the time of the study. Nevertheless, hospital attendance by the patient identified those families expressing a need for support, and a hospital-based department would therefore he rationally placed to seek appropriate solutions. Acknowledgement The authors would like to thank Mrs P. Thomas for her assistance in preparing the data and the consultants at Runwell Hospital who agreed to the examination of their patients. Some data were collected in the course of a study supported by the Department of Health and Social Security. The views expressed are those of the authors. References BROWN, G. W., BONE, M., DALI50N, B. & WING, J. K.
(1966) Schizophreniaand SocialCare. O.U.P., London.
CopAs, J. B., FREEMAN-BROWNE,D. L. & ROBIN, A. A. (1977) Treatment settings in psychiatry: the use of hospital services: long-term follow-up. British Journal of Psychiatry, 130,365. —¿
FRYER,
Settings
M.
in
&
ROBIN,
Psychiatry.
A.
London:
A.
(1974)
Henry
Treatment
Kimpton
Publishers. Ga@D,J. & SAINSBURY, P. (1968) The effects that patients have on their families in a community care and a control psychiatric
114,265—78.
service. British Journal of Psychiatry,
A. A. ROBIN, HOENIG,
J.
& HAMILTON,
M.
W.
(1969)
J. B. COPAS AND D. L. FREEMAN-BROWNE The
Desegregation
of the Mentally 111.London: Routledge & Kegan Paul.
JoNEs, K. (1976) ‘¿ No easy solutions': ‘¿ Better Services for the Mentally
the White Paper on Ill'. In The Tear Book
of SocialPolicyin Britain 1975 (ed.Jones, K.). London: Routledge & Kegan Paul.
ROBIN,
A.
A.
& HMUU,
neighbouring East Medicine, 2, 176.
A.
(1972)
London
Use
of hospital
boroughs.
beds
in
Psychological
SAIN5BURY, P. community
(1976) The problems of evaluating a psychiatric service. Communit, Development
Journal, 11,215. Toom, G. C. & BRoosca, E. M. (1961) Trends in the
mental health population and their effect on future planning. Lancet, i, 710. WINO,J. K. (1970) A standard form of psychiatric present state examination. In Psychiatric Epidemiolo@ (eds. E. H. Hare andJ. K. Wing). London: O.U.P.
A. A. Robin, M.D.,F.R.C.PIYC1I., ConsultantPsychiatrist, Runwell Hospital, Wickford, Essex,
J. B. Copas,B.Sc@, Ph.D.. Professor ofStatistics, University ofSalford,Salford,Lancs, D. L. Freeman-Browne, (Received 3 March 1978)
41
Psychiatric Social Worker, Runwell Hospital, Wickford, Essex
Treatment Settings in Psychiatry: Long-term Family and Social Findings By A. A. ROBIN, J. B. COPAS and D. L. FREEMAN-BROWNE SUMMARY Treatment in a psychiatric unit, as distinct from a psychiatric hospital, held no benefits in the long term (5-8 years after admission) as far as the patient's mental and behavioural status and employment, or the family's burdens, health needs or attitude were concerned. Schizophrenic patients from both settings received more hospital treatment and medication, were more often unemployed, and had more adverse effect on relatives' health than neurotic or depres sive patients. Hospital attendence identified relatives who expressed a need for support. Introduction Copas, Fryer and Robin (1974) describe an investigation to ‘¿ determinedifferences in out come which may be attributed to treatment under
different
administrative
conditions
antidepressants.
A
month
after
admission
a
marked and equal degree of clinical improve ment (measured by the Present State Examin ation) was seen in the patients of both hospitals. At six months the pattern of treatment differed; psychiatric unit patients spent almost half the time as day patients and correspondingly less as
by
comparing (in patients from the same geographic area) the results of a psychiatric unit in a general in-patients, while psychiatric hospital patients hospital and its associated day hospital with were treated mostly as inpatients and for only a those of a large modern psychiatric hospital also twelfth of the time as day patients. The overall receiving day patients'. Differences were demon strated in the ward environments of the two periods of treatment were, however, similar for the matched patients in each hospital. hospitals, in the attitudes of patients and their At five years after first admission (Copas, families towards the hospitals, in the patterns of Freeman-Browne and Robin, 1977) the total admission and in ease of contact with the period of treatment in each setting remained community. Ninety-eight patients undergoing the unit continued to use more day first admission to the psychiatric unit were Jomparable: patient care, while readmission was commoner individually paired with the next patient of the same sex, age and diagnosis undergoing first to the psychiatric hospital. admission to the psychiatric hospital. In retro Patients' homes were visited by a social spect these patients were also shown to resemble worker at the time of admission, and at one each other in numerous other ways—in marital month, ten weeks and six months after ad status, employment status, previous personality, mission (Copas, Fryer and Robin, 1974). education, family size, family history, previous Enquiry was made regarding the effect of the neurotic traits, drinking habits, and recent patient's illness on the family. Problems created physical ill-health to take some examples. The by the illness (‘familyburdens') were identified, 98 pairs were also shown to be closely com e.g. financial difficulties when the patient had parable in clinical state assessed with the been a wage-earner or when the patient's Present State Examination (Wing, 1970), illness prevented other members of the family while their hospital involved treatment working; equal the disruption of the family when children had to go into care; interference with amounts of ECT, major tranquilizers and 35
36
TREATMENTSETFINGSIN PSYCHIATRY: LONG-TERMFAMILYAND SOCIALFINDINGS
In a few further cases, when the patient no and leisure activities. The effect of these longer lived in the district, contact was made by problems was assessed in terms of the relatives' letter. From a total of 171 probable survivors attitude, health and needs. The patients' social adjustment was determined by ratings of from the original study, some information was finally obtained for 154 patients—l32 treated mental, behavioural and occupational status. in one hospital (general hospital unit or psychi At six months no essential differences were seen atric hospital) and 22 patients who, in the between the outcomes from the two treatment course of the follow-up changed hospital, to be settings. The patients' homes were revisited at 5 to 8 years after first admission and similar treated in both. Comparisons between the hospitals were again made on the basis of data information was gathered to that obtained in the earlier visits. This paper examines the following from matched pairs of patients, one treated in each hospital respectively. questions: 1. Comparing treatment in a general hospital Results psychiatric unitand a psychiatric hospital, which of the two promotes the patient's 1. Patients' social adjustment readjustment to a greater degree? (a) Mental and behavioural status 2. Comparing treatment in a psychiatric unit Ratings of patients' mental and be and a psychiatric hospital, which of the two havioural status showed an overall relieves the patients' familiesto a greater progressive increase in the number of degree? patients free of symptoms (Table I), and 3. Does any diagnostic category give rise to a corresponding decrease in the number greater difficulties in social readjustment for of patients reported to be suffering from the patient or greater problems for the subjective distress and to be prone to patient's family? violence or threatening violence to themselves or others. On the other hand, Method in relation to the six months' follow up, an increase in self-neglect and more A social worker (D.L. F-B) revisited all surviving and locally resident patients' families 5 particularly of altered behaviour was observed. Examples of the latter were to 8 years after the patient's first admission and ‘¿ outbursts of temper', ‘¿ screaming and collected information on a standard form similar shouting', ‘¿ refusing to let people in the to that employed in the earlier investigation. social
T@I2
I
Mental/behavioural status on admission andfollow-up
yearsRHRGHTotalRHRGHTotalRHRGHTotalNotknowntitial6
Asymptomatic
Subjective distress Self neglect Strangetalk
Altered
behaviour
Socialreasons Threatened or actual violence to self andothers
N.A./Lost
to follow-up6
—¿
—¿
56 2 5 20 1
66 1 6 11
8 —¿ 8
RH —¿ Runwell Hospital (Psychiatric Hospital) RGH—Rochford
General Hospital (Psychiatric Unit)
—¿
months5
—¿
122 3 11 31 1
40 32 1 —¿
1
41 37 —¿ —¿
1
6
14
5
4
—¿ 14
—¿ 19
—¿ 15
—¿ 34
81 69 1 —¿
2 9 —¿ 8
50 16 2 1 5
47 18 3 1 5
97 34 5 2 10
—¿
—¿
—¿
1615
923 25
37
A. A. ROBIN, J. B. COPAS AND D. L. FREEMAN-BROWNE TAsut
II
Occupation on admission andfollow-up
yearsRHRGHTotalRHRGHTotalRHRGHTotalHousewifeInitial6
@
months5
—¿ ISo1e occupation
5 7 17 Outsidejob P/T 2 4 5 2 6 12 11Others 241 578 732 434 366 726 626 552 1. F/T37 employed262248192140201939Others(Retired,etc.)235224628Unemployed201737201939121022Dead52716925Notkno
RH —¿ Runwell Hospital (Psychiatric Hospital) RGH—Rochford
General Hospital (Psychiatric Unit)
house', ‘¿ withdrawal',and ‘¿ drinking ex cessively'. No differences were seen between the hospitals. (b) Employment The
number
of employed
housewives
both in part-time and in full-time jobs doubled at the long-term follow-up (Table II). This change, and the slight increase in ‘¿ retired' patients and in the number of patients dead might simply reflect the passage of time and the increased age Of both patients and dependants.
2. Family problems (a) Family burdens The mean number of burdens that relatives carried,i.e.totalburdens for group divided by number of relatives, fell throughout the study (Table III), and no differences were found in the TAsi..E III
Mean number of burdens carried by patient's relative or
distribution of burdens between the families ofpatients ineither hospital. (b) Effect on relatives' health The number of adult relatives themselves unwell as a result of the patient's condition fell from 17 at the time of admission
to
one
in
the
long-term
follow-up, and the number under strain from 124 to 16, while those with no complaints rose from 37 to 123. Children under strain fell from 25 to 3. No
differences were seen between the hos pitals. (c) Needs of relatives Relatives' needswere assessed under the
headings ‘¿ financial',‘¿ general supportive care', ‘¿ assistancewith housing', ‘¿ assist
ance with children', ‘¿ period of rest'. The number of families who felt they needed any kind of support fell from 72 to 15, while those not requiring
help rose from
96 to 123. There was no difference between the hospitals.
closest contact
Runwell
Rochford
admission1.421.33At On month0.730.71Attenweeks0.360.33Atsixmonths0.240.31At one five + years0.100.08
(d) Attitude of relatives The attitudes of the relatives were assessed as previously reported (Copas, Fryer and Robin, 1974). The number of relatives lacking insight into the patient's condition decreased progressively (Table
IV), as did the numbers of over-anxious
38
TREATMENTSETTINGSIN PSYCHIATRY: LONG-TERMFAMILYAND SOCIALFINDINGS and over-protective reluctant
to
have
relatives the
and those
patient
at
there
There was an increase in the accepting relatives and in the number who did not require any sort of help or support. On the whole, psychiatric unit relatives tended to be ‘¿ understanding' rather than ‘¿ accepting', although at the five-year follow-up the reverse seemed to be the case for the psychiatric hospital relatives. Family
attitudes
home',
or over-protective',
and
grouped
‘¿ negative', while
standing',
again
no
difference
between
of ‘¿ refusingor reluctant
to have the patient were
was
the relatives of patients from the two hospitals, but the overall percentage of ‘¿ negative'families had gone down to 11 per cent. Although the difference was no longer significant, a trend was maintained for a higher incidence of readmission for the patients of ‘¿ negative' families (46 per cent) when compared vith ‘¿ positive' families (28 per cent).
home.
together those
differences (Combining ‘¿ over-anxious 3. Diagnostic patients from both hospitals)
and who
‘¿ accepting' or
classified were
(a) Medical service
as
An examinationof diagnosis(forthe
‘¿ under
‘¿ welcoming',
major groups) and type of medical service received at follow-up (Table V) shows that a higher proportion of schizophrenic, compared with neurotic or depressive patients received hospital treatment as in-patients, day patients or out-patients. Equal proportions of
were classedas ‘¿ positive' families. Initi
ally, 43 per cent of psychiatric hospital patients' families and 36 per cent of psychiatric unit's patients' families were ‘¿ negative', i.e. 39.5 per cent of the whole group. In the long-term follow-up
TABLE IV
Attitude of relative on admission andfollow-up Initial
Attitude of relatives TotalNotknown
23No
RH
insight 8Understanding 72Overanxious/overprotective
1Welcoming
4Accepting 53Reluctant
5N.A.
4
RGH 6
1 month Total
26 39
51 73
5
7
12
20
18
38
2
4
—¿ —¿ 8
2
—¿
RH
10
25 34
30RH
RGH
10
8
18 28
RH
18
13
RGH 9
41 69
5 38
11 49
6
12
3
4
25
13
38
27
3
2
5
7
—¿
8
Total
23 41
6
0
8
4 1
yearsRH
6 months
4 9
1
4
Total5
RGH
229
14
163 8729
5 43
71
0
19
4632
21
5
1217
13
1
0
23 44
1 1
Hospital).RGH—Rochford —¿ RunwellHospital (Psychiatric
General Hospital (Psychiatric Unit).TABLE VDiagnosis
and medical follow-upSchizophrenic servicefor patients contacted at
(%)Attending (10)Attending hospital general practitioner (23)No
medical contact
the
‘¿ lackinginsight'
(%) 14 7
(47) (23)
9 (30) (67)30 (100)
Neurotic 8 10
22
(%)Depressive (20)7 (25)16
(55)47
40 (100)70
(100)
39
A. A. ROBIN, J. B. COPAS AND D. L. FREEMAN-BROWNE
patients in these three attended their general depressive group had tact with any medical up.
diagnostic groups practitioners. The overall least con service at follow
(b) Medication Forty-two per cent of patients were found to possess medication for use during the day and 13 per cent had night sedation.Day time medication was being receivedby 68 per cent of th schizophrenic group, 44 per cent of neurotics, and 32 per cent of depressives; and 6 per cent of schizophrenics, 13 per cent depressives, and 18 per cent of neurotics had night sedation. The pro portion of schizophrenic patients having day time medication was significantly greaterthan thatforthe neuroticand depressive groups. (c) Mental and behavioural status No ‘¿ altered behaviour' figured in the depressive or manic groups at follow-up. Subjective distress and self-neglect (which was much less common) were reported roughly equally in the main diagnostic groups. Reports of abnormality in mental and behavioural status, regardless of type, were equally frequent in the schizophrenic and neurotic groups and less common at follow-up in depressives. (d)Employment Unemployment due to mental illness occurred more frequently with schizo phrenic patients (8 of 34) than with neurotic (5 of 38) and depressive patients (0of74). (e) Family burdens No differences were found in the distribution of burdens between the families of patients in the main diagnostic groups. (f) Relatives' health A higher proportion of families of schizophrenic patients (8 of 34) reported
effects on their health, compared with either depressive (8 of 74) or neurotic patients (4of38). (g)Relatives' needs The relatives of schizophrenic (5 of 34) and neurotic (5 of 38) patients felt more need for support than those of depressive patients (5 of 74). The relatives of patients attending hospital expressed a greater need for support than those of patients
attending
their
general
prac
titioners or not in.contact with the medi cal services (Table VI). This expression of need presumably reflects the severity of illness, which may be taken to be represented by the type of service supplied. TAsut VI Medical service and relatives' needs when contacted at follow up Need supportNo needof
supportAttending hospitalIl18Attending practitioner
general
7815128 232
No medical contact2
(h) Relatives' attitudes Relatives of schizophrenic and neurotic patients were less satisfied with the patients' progress than those of the depressive
phrenic
Depressive
According
know what
group.
(Dissatisfied:
8 of 34, Neurotic 10 of 74).
Discussion to Kathleen Jones
happens
to (the patient)
Schizo
8 of 38,
(1976)
‘¿ We
while he is
in hospital, or while he is in touch with a social worker; in many cases, these periods are comparatively brief, and separated by long spells of non-contact. . .‘She therefore points to an urgent need for ‘¿ large-scale tracer studies which will chart the social experience of mental illness..
.‘Grad
and Sainsbury
(1968)
in their
40
TREATMENT SETTINGS IN PSYCHIATRY: LONG-TERM FAMILY AND SOCIAL FINDINGS
study of the Chichester (community) and Salisbury (hospital-based) psychiatric services reported that severe burdens were equally relieved by both types of service—all burdens less so by the community service. A group of young, mainly neurotic patients were identified as causing their families problems in the Chichester service. Sainsbury reviewed this and further studies in 1976. He points out that the mental health of the closest relatives was more affected in the Chichester service area, yet families expressed more satisfaction with this service. Like us, he found the services he studied were rated similarly by relatives as far as outcome for the patient was concerned, but psychiatrists and patients reported more benefit from the mental hospital than the community service.
Sainsbury
suggests,
therefore,
that
social rather than clinical behaviour was the probable basis lot' relatives' reports. Our study does not compare exactly similar services to those in Chichester, in that day patient care was most often used after admission, tending to shorten it rather than avoid it. Initially, and in both treatment settings, 70 per cent of the nearest adult relatives of a group of closely matched patients complained of strain, and just under 10 per cent felt themselves ill as a result of the patient's illness—most of the latter being under medical care. Of the children exposed to the patient's illness 40 per cent were also reported as showing strain (Copas, Fryer and Robin, 1974), but by six months families were to a large extent and equally relieved in each treatment setting and continued to be so at follow-up
from
5 to 8 years
At the same time, family attitudes
after
inception.
became more
positive towards the patients. Throughout the 5—8years of our study, ratings of mental, behavioural and occupational status showed an equal degree of improvement in patients treated in each setting. The small number of in-patients (1 .5 per cent) at 5 years from first admission does not reflect the problems or service requirements of either patients or their families. It will be seen that more schizophrenic patients received hospital treatment of all types or day medication from any source, were unemployed, and had families in which there was evidence of strain;
while both schizophrenic and neurotic patients as distinct from depressed patients, continued to show mental or behavioural abnormality, and had relatives who were dissatisfied with their progress and who expressed a need for support. Tooth and Brooke (1961) showed that at two years 9 per cent and 10 per cent of cohorts from 1954 and 1956 respectively were still in hospital. Our two-year figure would have been little different from the five-year figure already given; not, unfortunately, because our patients had recovered: 1 .5 per cent were day patients, 14 per cent were out-patients, a further 20 per cent attended their general practitioners—in short, over a third continued to receive medical care in the community. While there is some evidence that a hospital-based social worker may
be
associated
with
diminished
in-patient
chronicity (Robin and Hakki, 1972), this study, like those of Brown et al (1966) and Hoenig and Hamilton (1969), who failed to show a reduction of morbidity with increased social work contact, does not suggest that the family's needs were satisfied by such a department, which existed at the time of the study. Nevertheless, hospital attendance by the patient identified those families expressing a need for support, and a hospital-based department would therefore he rationally placed to seek appropriate solutions. Acknowledgement The authors would like to thank Mrs P. Thomas for her assistance in preparing the data and the consultants at Runwell Hospital who agreed to the examination of their patients. Some data were collected in the course of a study supported by the Department of Health and Social Security. The views expressed are those of the authors. References BROWN, G. W., BONE, M., DALI50N, B. & WING, J. K.
(1966) Schizophreniaand SocialCare. O.U.P., London.
CopAs, J. B., FREEMAN-BROWNE,D. L. & ROBIN, A. A. (1977) Treatment settings in psychiatry: the use of hospital services: long-term follow-up. British Journal of Psychiatry, 130,365. —¿
FRYER,
Settings
M.
in
&
ROBIN,
Psychiatry.
A.
London:
A.
(1974)
Henry
Treatment
Kimpton
Publishers. Ga@D,J. & SAINSBURY, P. (1968) The effects that patients have on their families in a community care and a control psychiatric
114,265—78.
service. British Journal of Psychiatry,
A. A. ROBIN, HOENIG,
J.
& HAMILTON,
M.
W.
(1969)
J. B. COPAS AND D. L. FREEMAN-BROWNE The
Desegregation
of the Mentally 111.London: Routledge & Kegan Paul.
JoNEs, K. (1976) ‘¿ No easy solutions': ‘¿ Better Services for the Mentally
the White Paper on Ill'. In The Tear Book
of SocialPolicyin Britain 1975 (ed.Jones, K.). London: Routledge & Kegan Paul.
ROBIN,
A.
A.
& HMUU,
neighbouring East Medicine, 2, 176.
A.
(1972)
London
Use
of hospital
boroughs.
beds
in
Psychological
SAIN5BURY, P. community
(1976) The problems of evaluating a psychiatric service. Communit, Development
Journal, 11,215. Toom, G. C. & BRoosca, E. M. (1961) Trends in the
mental health population and their effect on future planning. Lancet, i, 710. WINO,J. K. (1970) A standard form of psychiatric present state examination. In Psychiatric Epidemiolo@ (eds. E. H. Hare andJ. K. Wing). London: O.U.P.
A. A. Robin, M.D.,F.R.C.PIYC1I., ConsultantPsychiatrist, Runwell Hospital, Wickford, Essex,
J. B. Copas,B.Sc@, Ph.D.. Professor ofStatistics, University ofSalford,Salford,Lancs, D. L. Freeman-Browne, (Received 3 March 1978)
41
Psychiatric Social Worker, Runwell Hospital, Wickford, Essex
