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Suzuki
Regular Article
Associated factors of rehospitalization among
schizophrenic patients
YURIKO SUZUKI, md, phd,1 SEIJI YASUMURA, md, phd,2 AKIRA FUKAO, md, phd3
AND KOICHI OTANI, md, phd4
1
Nihonmatsu-kai Kaminoyama Hospital, Kaminoyama City, Departments of 3Public Health and
4
Neuropsychiatry, Yamagata University School of Medicine, Yamagata and 2Department of Public Health,
Fukushima Prefectural Medical School, Fukushima, Japan
Abstract The purpose of the present study was to identify the associated factors of rehospitalization in
schizophrenic patients. A case-control study was conducted. The cases consisted of rehospitalized
patients (n = 67) and controls selected from the outpatients who were matched by age, gender, and
the period after the last discharge (n = 62). In the multiple logistic regression analysis, no clinic vis-
its in the second month prior to entry, the number of clinic visits in the previous month, and junior
high school graduation as education level were significantly (P < 0.01) associated with rehospital-
ization after controlling their present function as assessed by the Global Assessment of Function-
ing. Close monitoring of clinic visits and outreach service appear to be important in preventing
rehospitalization of schizophrenic patients. These identified modifiable factors suggest further
needs for development and implementation of integrated mental health services in the community.
Key words case–control studies, mental health services, patient readmission, schizophrenia.
factors related to psychiatric treatments, mental health 21.0%, outpatient group). However, there was no sta-
and welfare service utilization. tistically significant difference between the two groups.
toms became steady enough for the acceptance of the (OR) and 95% confidence intervals (95%CI). We put
interview. The outpatients were interviewed on their the present function as assessed by GAF into the
regular clinic visits. model as a controlling variable because the score of
The primary psychiatrists assessed the level of psy- GAF was considered as a confounder. The backward
chiatric symptoms according to the Clinical Global stepwise procedure of multiple logistic regression anal-
Impressions (CGI) scale,15 and the present function ysis was employed for the purpose of including a wide
and the best function in the past 1 year by the Global number of potential variables in the relatively small
Assessment of Functioning (GAF) scale.12 In CGI a number of samples. The criterion for removal in the
greater score indicates a worse clinical state of the multiple logistic regression analysis was P > 0.1. All
patient (range: 0–7). The GAF has a range of 0–100, analyses were performed using spss 6.1 (SPSS, Chi-
and a full point means superior functioning and no cago, IL, USA) of the Macintosh statistical software.
symptom. The time point for the assessment of the
present function was at the admission for the rehospi-
talized patients and at the latest clinic visit for the out- RESULTS
patients. Maximal attention to privacy was paid during
Bivariate analyses
data collection, and written informed consent was
obtained before interviewing the subjects. The indicators of clinical status in each group are
shown in Table 1. Twenty-two patients in the case
group were diagnosed as having the paranoid type of
Statistical analyses
schizophrenia, while there were 11 such patients in the
Sixty-seven cases and 62 controls underwent statistical control group. The mean of the CGI scores was higher
analysis. On interviewing subjects, there were four (4.4 vs 4.0), and the mean of the present GAF score
drop-outs: two subjects (one case and one control) was lower (40.1 vs 54.9) in the rehospitalized group
moved to other hospitals from reason not related to the than in the outpatient group at the recruitment period.
present study; and two subjects (one case and one con- However, the mean of the best GAF scores in the past
trol) were lost to follow up. Therefore, 65 cases and 60 1 year showed no significant difference between the
controls were analyzed for the interview. Means and two groups (56.0 vs 59.4).
standard deviations were calculated for the following The results of the bivariate analyses of potential
variables: age at onset of schizophrenia; psychotic associated factors are shown in Table 2. Junior high
symptom; and GAF score. For the bivariate analyses, school graduation as educational level; total number of
c2 tests were used for categorical variables and t-tests admissions of more than 11 times; number of clinic vis-
were used for continuous variables. The variables its in the previous month; no clinic visit in the second
showing significant association in the bivariate analyses month prior to the entry; and no utilization of psychi-
were entered into the unconditional multiple logistic atric day-care units were positively associated with
regression analysis to obtain the adjusted odds ratios rehospitalization. The dose of neuroleptics and poor
Table 1 Comparison of the clinical status in the rehospitalized and outpatient groups
Rehospitalized
patients Outpatients
Variables n = 67 % n = 62 % P
DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th edn; CGI, Clinical Global Impressions Scale; GAF,
Global Assessment of Functioning Scale; NS, not significant.
c2 tests or t-tests were used.
558 Y. Suzuki et al.
Rehospitalized
patients Outpationts
Variable n = 67 % n = 62 % P
The c2 tests of Fisher’s exact test were used in the nominally scaled variables, and the Mann–Whitney test was used in the
ordinally scaled variables.
†
Chlorpromazine equivalents.
medication compliance (score <2 on the scale, i.e. com- score of GAF as a confounder to represent the clinical
plete refusal or partial refusal) were associated with status. The following variables were tested in the
rehospitalization. Recent experience of life events model: present GAF score; education level (junior
showed a significant difference between the two high school/higher); experience of life events (yes/no);
groups. A familial supportive comment toward the number of clinic visits in the previous month; clinic vis-
patient was negatively associated with rehospitaliza- its in the second month prior to the entry (yes/no); total
tion (statistically at a borderline level; P = 0.052). number of admissions; use of psychiatric day-care units
Those who participated in the day-care unit at the pub- (yes/no); compliance score (2/3 or more); and dose of
lic health center (P = 0.063) and attended workshops neuroleptics. The adjusted OR (95%CI) were 29.2
(P = 0.073) tended to be rehospitalized. The other psy- (4.5–188.4) in no clinic visit in the second month prior
chiatric treatments and mental health service utiliza- to the entry, 3.6 (1.2–14.7) in the number of clinic visits
tion showed no association statistically. in the previous month, and 4.8 (1.6–14.7) for junior
high school graduation as education level (P < 0.01;
Table 3).
Multivariate analysis
Backward stepwise unconditional multiple logistic
DISCUSSION
regression analysis was performed using the variables
that showed significant associations in the bivariate It has been shown that approximately 30–40% of
analyses. Because the psychiatric symptom and func- patients with mental illness including schizophrenia
tional level were highly correlated, we employed the have several clinically severe episodes during their
Rehospitalization of schizophrenia 559
Table 3 Adjusted OR and 95% CI of association of rehospi- where mental health service plays a major role in com-
talization in the multiple logistic regression analysis† munity care for the mentally ill. However, the commu-
nity care by mental health services has not been
Variables OR 95% CI P
developed sufficiently in Japan, and the aftercare for
No clinic visit in the second 29.2 4.5–188.4 <0.01 those who are discharged from psychiatric hospitals is
month prior to entry mostly organized by the outpatient units in the hospi-
No. clinic visits in the previous 3.6 1.2–14.7 <0.01 tals. The close monitoring of clinic visits or outreach by
month nurses are mostly hospital-based. Therefore, these
Junior high school graduation 4.8 1.6–14.7 <0.01 approaches may produce outcomes that are different
from those in Europe, especially England.
OR, odds ratio; 95% CI, 95% confidence interval; GAF, Interestingly, the utilization of the day-care unit at
Global Assessment of Functioning Scale. the public health center and workshops in the commu-
†
The present function (GAF score) was entered as a nity were related to rehospitalization. Presumeably,
controlling variable.
when patients attending these facilities deteriorate
clinically, the staff have few choices other than to
long course of illness in Europe.16,17 Meanwhile, the advise them to visit an outpatient clinic or to admit to
relapse rate of schizophrenia has been reported to be hospital, which then leads to rehospitalization. There
50–60% within 5–6 years in Japan.18,19 The majority of are options other than rehospitalization such as home
these patients are rehospitalized, indicating that rehos- visits by public health nurses. Although these systems
pitalization is very common for schizophrenic patients are not functioning well at present, they should be inte-
in Japan. However, there have been very few studies on grated with medical approaches.
the risk factors of rehospitalization and the efficacy of Junior high school graduation as education level was
community care in schizophrenic patients in Japan. revealed to be another risk factor of rehospitalization.
A study on the readmission of schizophrenic patients In other words, educational level is an important factor
discharged after long-term hospitalization was con- in secondary prevention of schizophrenic episodes.
ducted by Higuchi and Hayashi.18 This study was con- While most Japanese go to senior high school, those
ducted in one of the largest psychiatric hospitals in who did not enter senior high school or those who quit
Japan but its subjects did not have a comparison group. senior high school were at risk of rehospitalization in
The present study was conducted in the more common, the present study. It is possible that this reflects a prob-
middle-sized hospitals with a case–control design. lem of social function such as school refusal or being
the object of bullying, as well as being a problem of
intelligence. This social dysfunction may be ascribable
Risk factors of rehospitalization
to a premorbid state or onset of schizophrenia. From a
The multiple logistic regression analysis revealed that point of view of primary prevention, the early detec-
the pattern of psychiatric treatment is associated with tion of this population is required because treatment
rehospitalization. Those who did not visit clinics in the delay may affect the course of schizophrenia. In the
second month prior to the entry and those who visited study by Johnstone et al., untreated illness was the
clinics more frequently than five times in the previous strongest predictor of relapse.23 Moreover, Loebel et al.
month were liable to readmit to the hospitals. These showed that the time to remission as well as the degree
results may be interpreted such that absence of clinic of remission were closely related to duration of
visit induces clinical exacerbation, resulting in frequent untreated psychosis when other prognostic variables
clinic visits followed by rehospitalization. Ohara et al. were controlled.24 As stated by Birchwood et al., these
reported that those who changed doctors or took med- findings may be the result of type of illness (those with
ication discontinuously were readmitted more signifi- an inherently high risk of relapse may include symp-
cantly.9 The importance of continuous clinic visits to toms that delay treatment) or the result of psychosocial
continuance of living in the communities was empha- disruption arising from a long period of untreated psy-
sized even though clinical status was steady.20 This chosis.25 In the present study, age of onset and type of
result indicates the importance of regular clinic visits. schizophrenia were not related to rehospitalization,
Therefore, to prevent the irregular pattern of clinic vis- suggesting that psychosocial disruption resulting from
its, close monitoring of the number of clinic visits and untreated illness is more important than type of illness
use of the outreach team would be of help to those in influencing the course of schizophrenia including
patients who are reluctant to come to the hospital. rehospitalization. Therefore, we suggest that early
The efficacy of the aforementioned approaches is intervention is important for those who show any signs
still controversial in Europe, especially in England,21,22 during school age. The education level itself, however,
560 Y. Suzuki et al.
would not be a modifiable factor. We should intervene irrespective of the compliance problem,29 although it
to expose such vulnerable people to a better social was not clear as to which domain of life events was
experience. more influential. Many of the life events in the present
Poor medication compliance was not significant in study were problems in the primary support group,
the multivariate analysis, although previous studies by especially families. These may be the results of patient–
Sullivan et al. and Corrigan et al. revealed it to be a family interactions such as over-involvement in patient
strong indicator of rehospitalization.26,27 One may symptoms or an excess burden of patient care. Accord-
wonder if there is a limitation in the way we assessed ing to the study by Tanaka et al., emotions of the family
compliance (i.e. the use of compliance scale of Kemp influence the course of schizophrenia.30
et al.13). However, as pointed out by Kemp et al., there Finally, because the present study was conducted
are problems associated with more direct measures.13 with a case–control design, we could not clarify the
Urine tests may overestimate compliance when drugs causal relationship. A further prospective study should
have a long half-life. Serum assays are invasive and are be conducted to elucidate the causal relationship
of limited value in assessing partial compliance. Pill between the factors presented here and rehospitaliza-
counts are widely considered a useful measure but tion of schizophrenic patients.
this method has a potential for dissimulation and
inaccuracy.
Sullivan et al. indicated that non-compliance was ACKNOWLEDGMENTS
associated with lack of insight (i.e. denial of mental ill- We would like to acknowledge the invaluable assis-
ness), a history of fewer outpatient appointments, and tance of patients, social workers, and clinical staff of
being single.26 In another study the most powerful the hospitals. We also acknowledge the contribution of
indicators of compliance were reported as being a good the psychiatrists in the participating hospitals: Nihon-
attitude to treatment and insight into illness.28 The matsu-kai Yamagata Hospital, Director, Dr Tobisawa,
average age of the patients in the study by Sullivan Dr Hirose, Dr Oyama, Dr Miura, Dr Uchigasaki, Dr
et al. study was 34.5 years,26 which is younger than that Tanaka, Dr, Ichikawa, Dr Ito, Dr Kyono, Dr Iwabuchi,
in the present study by more than 10 years. Taking this Dr Takahashi; Nihonmatsu-kai Kaminoyama Hospital,
age difference into account, it is suggested that the sub- Director, Dr Yokokawa, Dr Tomita, Dr Igarashi, Dr
jects in our study accepted the illness and took medi- Eguchi, Dr Ohori, Dr Kuwayama, Dr Yamada, Dr
cation, in comparison with the patients of Sullivan et al. Goto; Shinoda Kosei-kai Chitose Shinoda Hospital,
In further studies, not only the therapeutic behaviors as Director, Dr Yoshida, Dr Kato, Dr Yoshimura, Dr
evaluated in the present study but also the attitude Kimura, Dr Kizu. Dr Ihara and Dr Oiji provided help-
toward medication therapy including insight into the ful comments and suggestions on an earlier draft of this
illness, should be examined. paper. Dr Imuta, Dr Abe, Dr Goto, and Dr Nishise
Incidentally, poor medication compliance was asso- kindly commented on the study. We thank Ms Joy
ciated with rehospitalization in the bivariate analyses. Norton, who reviewed the English manuscript of this
Because compliance was moderately correlated with article.
the present GAF scores (r = 0.31), the possibility that
controlling the latter factors produced the negative
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