Blackwell Science, LtdOxford, UKPCNPsychiatry and Clinical Neurosciences1323-13162003 Blackwell Science Pty LtdDecember 2003576555561Original ArticleRehospitalization of schizophreniaY.

Suzuki

Psychiatry and Clinical Neurosciences (2003), 57, 555–561

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.

INTRODUCTION phenomenon is often observed when reducing beds in

mental hospitals.7 The discontinuation of social life
The care of schizophrenic patients has been hospital-
would cause deterioration of patient satisfaction and
oriented in Japan, leading to the serious problem of the
quality of life.8 Therefore, clarification of the risk fac-
accumulation of long-stay inpatients in mental hospi-
tors of rehospitalization is a prerequisite for promoting
tals.1 In 1995 the Law Concerning Mental Health and
community care of schizophrenic patients. However,
Welfare for the Mentally Disabled, and the Government
epidemiological studies for schizophrenia especially on
Action Plan for Persons with Disabilities were drawn
rehospitalization and community care are rare in
up in Japan to promote community care of schizo-
Japan, where the registration system of patients with
phrenic patients. It has been shown that community
mental illness has not been established in the commu-
care is economically comparable2 and as cost-effective
nity.9,10 The present study was conducted to identify the
as hospital-based treatment.3 Moreover, it has been
risk factors for rehospitalization in schizophrenic
suggested that the patient’s subjective quality of life is
patients in Japan.
improved by community care,4,5 although there has also
been a negative result on this issue.6 However, as
pointed out by Weiden and Glazer, the revolving-door METHODS
In the present study the schizophrenic episode was
et al.
examined using the stress–vulnerability model.11 We
regarded rehospitalization not as a simple product of
Correspondence address: Dr Yuriko Suzuki, UCLA School of Public
the exacerbation of clinical status, but as the complex
Health, Department of Community Health Sciences, 36-071 Center
for the Health Sciences, Box 951772, Los Angeles, CA 90095-1772,
outcome of illness, familial support, and mental health
USA. Email: yrsuzuki@ucla.edu and welfare service utilization. Therefore, we investi-
Received 14 June 2001; revised 2 April 2003; accepted 6 April gated the risk factors of rehospitalization in the follow-
2003. ing domains: patient’s personal factors, familial factors,
556
factors related to psychiatric treatments, mental health
and welfare service utilization.
Study area and hospitals
Patients were recruited from three private psychiatric
hospitals in and around Yamagata City, where one pub-
lic health center covers mental health services in the
community. The number of beds in each hospital was
337, 460, and 265, respectively. The three hospitals
offer similar types of outpatient clinics, inpatient
wards, and rehabilitation resources such as day-care
units and occupational therapy units. The average
number of schizophrenic outpatients in each hospital
was 554.8, 315.8, and 99.8 per month in 1998.
Patient selection
We designed a case–control study. Case subjects con-
sisted of readmitting patients, while control subjects
were chosen from the outpatient population. Inclusion
criteria for case subjects were (i) rehospitalization and
a chart diagnosis of schizophrenia without mental
retardation; (ii) age between 20 and 69 years; and (iii)
having a history of previous admission to the same hos-
pital. During the recruitment period (July–October
1998), the number of eligible cases was 75. We
excluded three patients who did not meet the diagnos-
tic criteria of schizophrenia in Diagnostic and Statistical
Manual of Mental Disorders (4th edn; DSM-IV),12 and
five readmitted patients who had returned from gen-
eral hospitals where they had received more intensive
medical treatment for physical conditions during their
long-term stay in the mental hospitals. After we
selected 67 subjects, control subjects were chosen from
the outpatient lists in the hospitals with matching age
(± 2 years), gender, and period after the last discharge
(± 90 days). Five controls were not found because
there were no eligible subjects who met the matching
factors. When any of the control subjects was rehospi-
talized during the recruitment period, they were
replaced by one of the other outpatients. The final
number of control subjects was 62.
Approximately a half of the subjects were female
(53.7%, rehospitalized group; 51.6%, outpatient
group), and most of the subjects were middle-aged.
The mean age ± SD was 46.0 ± 11.4 years for the rehos-
pitalization group and 46.0 ± 11.3 years for the outpa-
tient group. Approximately 60% lived in communities
less than 1 year from the last discharges (61.2%, rehos-
pitalized group; 62.9%, outpatient group). The outpa-
tient group had a higher proportion of people who
spent more than 3 years in communities after the
last rehospitalization (14.9%, rehospitalization group;
Y. Suzuki et al.
21.0%, outpatient group). However, there was no sta-
tistically significant difference between the two groups.
Assessment
We investigated 58 variables in the following six
domains.
(1) The patient’s background and history including
marital status, age at onset of schizophrenia, the legal
form of the previous hospitalization, and education
level were collected from the medical records.
(2) The patient’s personal factors, for example,
employment, medication compliance, and experience
of life events were examined. Medication compliance
were evaluated by the primary psychiatrists of the sub-
jects using the compliance scale developed by Kemp
et al.13 Each of the levels were referred to as follows: (i)
complete denial; (ii) partial refusal, for example, refus-
ing depot drugs or accepting only the minimum dose;
(iii) reluctant acceptance: accepting only because treat-
ment is compulsory or questioning the need for treat-
ment often (every 2 days); (iv) occasional reluctance
about treatment: questioning the need for treatment
once a week; (v) passive acceptance; (vi) moderate par-
ticipation: some knowledge of, and interest in, treat-
ment and no prompting needed to take drugs; and (vii)
active participation, ready acceptance, and taking
some responsibility for treatment. The subjects were
asked if they experienced life events in the past
3 months according to the categories of axis IV in
DSM-IV.12 The problems were grouped into the follow-
ing categories: problems with primary support group;
problems related to the social environment; educa-
tional problems; occupational problems; housing prob-
lems; economic problems; problems with access to
health-care services; and problems related to interac-
tion with the legal system or crime.
(3) Information about cohabitants and about their
mood of relationships (e.g. critical or supportive com-
ments) were obtained by the social workers in each
hospital.
(4) The information on psychiatric treatments was
obtained from the medical charts. It contained the
number of clinic visits, the types and routes of medica-
tion therapy, neuroleptic dosage converted in chlorpro-
mazine equivalents,14 use of anxiolytic drugs and mood
stabilizers, and other comorbid illness.
(5) Information on the welfare service utilization
was gathered by the social workers in each hospital.
(6) The information on psychiatric treatments and
health services utilization was obtained by one of the
authors (YS) with face-to-face interviews on service
contacts in the past 1 year. Readmitted patients were
interviewed in the admission wards after their symp-
Rehospitalization of schizophrenia 557

toms became steady enough for the acceptance of the
interview. The outpatients were interviewed on their
regular clinic visits.
The primary psychiatrists assessed the level of psy-
chiatric symptoms according to the Clinical Global
Impressions (CGI) scale,15 and the present function
and the best function in the past 1 year by the Global
Assessment of Functioning (GAF) scale.12 In CGI a
greater score indicates a worse clinical state of the
patient (range: 0–7). The GAF has a range of 0–100,
and a full point means superior functioning and no
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-
patients. Maximal attention to privacy was paid during
data collection, and written informed consent was
obtained before interviewing the subjects.
Statistical analyses
Sixty-seven cases and 62 controls underwent statistical
analysis. On interviewing subjects, there were four
drop-outs: two subjects (one case and one control)
moved to other hospitals from reason not related to the
present study; and two subjects (one case and one con-
trol) were lost to follow up. Therefore, 65 cases and 60
controls were analyzed for the interview. Means and
standard deviations were calculated for the following
variables: age at onset of schizophrenia; psychotic
symptom; and GAF score. For the bivariate analyses,
c2 tests were used for categorical variables and t-tests
were used for continuous variables. The variables
showing significant association in the bivariate analyses
were entered into the unconditional multiple logistic
regression analysis to obtain the adjusted odds ratios
(OR) and 95% confidence intervals (95%CI). We put
the present function as assessed by GAF into the
model as a controlling variable because the score of
GAF was considered as a confounder. The backward
stepwise procedure of multiple logistic regression anal-
ysis was employed for the purpose of including a wide
number of potential variables in the relatively small
number of samples. The criterion for removal in the
multiple logistic regression analysis was P > 0.1. All
analyses were performed using spss 6.1 (SPSS, Chi-
cago, IL, USA) of the Macintosh statistical software.
RESULTS
Bivariate analyses
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
schizophrenia, while there were 11 such patients in the
control group. The mean of the CGI scores was higher
(4.4 vs 4.0), and the mean of the present GAF score
was lower (40.1 vs 54.9) in the rehospitalized group
than in the outpatient group at the recruitment period.
However, the mean of the best GAF scores in the past
1 year showed no significant difference between the
two groups (56.0 vs 59.4).
The results of the bivariate analyses of potential
associated factors are shown in Table 2. Junior high
school graduation as educational level; total number of
admissions of more than 11 times; number of clinic vis-
its in the previous month; no clinic visit in the second
month prior to the entry; and no utilization of psychi-
atric day-care units were positively associated with
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

Type (DSM-IV) Paranoid 22 32.8 11 17.7 NS

Disorganized 6 9.0 11 17.7
Catatonic 6 9.0 4 6.5
Undifferentiated 12 17.9 8 12.9
Residual 21 31.3 28 45.2
Symptom (CGI) Mean (SD) 4.40 (1.0) 4.00 (1.2) < 0.05
Present function (GAF) Mean (SD) 40.1 (16.1) 54.9 (17.7) < 0.01
Best function in the past 1 year (GAF) Mean (SD) 56.0 (17.6) 59.4 (17.5) NS

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.

Table 2 Results of potential risk factors of rehospitalization of schizophrenia by bivariate analyses

Rehospitalized
patients Outpationts
Variable n = 67 % n = 62 % P

Education level Junior high school 20 29.9 9 14.5

<0.05
High school 40 59.7 46 74.2
College and others 7 10.4 7 11.3
Total no. admissions 1–10 48 71.6 55 88.7 <0.05
11+ 19 28.4 7 11.3
Clinic visits in the None 5 7.5 0 0.0 <0.05
previous month 1–2 18 26.9 38 62.3
3–4 28 41.8 21 34.4
5+ 16 23.9 2 3.3
Clinic visits in the second month prior None 13 22.8 3 5.1
to the entry 1–2 26 45.6 39 66.1 <0.01
3–4 11 19.3 16 27.2
5+ 7 12.4 1 1.7
Neuroleptic dose† (mg) 1–500 19 31.1 32 53.3 <0.05
501–1500 34 55.7 21 35.0
1501–2500 8 13.1 7 11.7
Medication compliance (score) 1–2 13 19.4 3 4.8 <0.05
3–7 54 80.6 59 95.2
Use of
Paychiatric day-care Yes 7 10.4 17 25.4 <0.05
Day-care at the public health center Yes 13 20.0 5 8.3 <0.1
Workshop Yes 17 26.2 8 13.3 <0.1
Supportive comments Yes 21 31.3 29 61.7 <0.1
Life events Yes 41 63.1 23 38.3 <0.01

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-
plete refusal or partial refusal) were associated with
rehospitalization. Recent experience of life events
showed a significant difference between the two
groups. A familial supportive comment toward the
patient was negatively associated with rehospitaliza-
tion (statistically at a borderline level; P = 0.052).
Those who participated in the day-care unit at the pub-
lic health center (P = 0.063) and attended workshops
(P = 0.073) tended to be rehospitalized. The other psy-
chiatric treatments and mental health service utiliza-
tion showed no association statistically.
Multivariate analysis
Backward stepwise unconditional multiple logistic
regression analysis was performed using the variables
that showed significant associations in the bivariate
analyses. Because the psychiatric symptom and func-
tional level were highly correlated, we employed the
score of GAF as a confounder to represent the clinical
status. The following variables were tested in the
model: present GAF score; education level (junior
high school/higher); experience of life events (yes/no);
number of clinic visits in the previous month; clinic vis-
its in the second month prior to the entry (yes/no); total
number of admissions; use of psychiatric day-care units
(yes/no); compliance score (2/3 or more); and dose of
neuroleptics. The adjusted OR (95%CI) were 29.2
(4.5–188.4) in no clinic visit in the second month prior
to the entry, 3.6 (1.2–14.7) in the number of clinic visits
in the previous month, and 4.8 (1.6–14.7) for junior
high school graduation as education level (P < 0.01;
Table 3).
DISCUSSION
It has been shown that approximately 30–40% of
patients with mental illness including schizophrenia
have several clinically severe episodes during their
Rehospitalization of schizophrenia
Table 3 Adjusted OR and 95% CI of association of rehospi-
talization in the multiple logistic regression analysis†
Variables OR 95% CI P
No clinic visit in the second 29.2 4.5–188.4 <0.01
month prior to entry
No. clinic visits in the previous 3.6 1.2–14.7 <0.01
month
Junior high school graduation 4.8 1.6–14.7 <0.01
OR, odds ratio; 95% CI, 95% confidence interval; GAF,
Global Assessment of Functioning Scale.
†
The present function (GAF score) was entered as a
controlling variable.
long course of illness in Europe.16,17 Meanwhile, the
relapse rate of schizophrenia has been reported to be
50–60% within 5–6 years in Japan.18,19 The majority of
these patients are rehospitalized, indicating that rehos-
pitalization is very common for schizophrenic patients
in Japan. However, there have been very few studies on
the risk factors of rehospitalization and the efficacy of
community care in schizophrenic patients in Japan.
A study on the readmission of schizophrenic patients
discharged after long-term hospitalization was con-
ducted by Higuchi and Hayashi.18 This study was con-
ducted in one of the largest psychiatric hospitals in
Japan but its subjects did not have a comparison group.
The present study was conducted in the more common,
middle-sized hospitals with a case–control design.
Risk factors of rehospitalization
The multiple logistic regression analysis revealed that
the pattern of psychiatric treatment is associated with
rehospitalization. Those who did not visit clinics in the
second month prior to the entry and those who visited
clinics more frequently than five times in the previous
month were liable to readmit to the hospitals. These
results may be interpreted such that absence of clinic
visit induces clinical exacerbation, resulting in frequent
clinic visits followed by rehospitalization. Ohara et al.
reported that those who changed doctors or took med-
ication discontinuously were readmitted more signifi-
cantly.9 The importance of continuous clinic visits to
continuance of living in the communities was empha-
sized even though clinical status was steady.20 This
result indicates the importance of regular clinic visits.
Therefore, to prevent the irregular pattern of clinic vis-
its, close monitoring of the number of clinic visits and
use of the outreach team would be of help to those
patients who are reluctant to come to the hospital.
The efficacy of the aforementioned approaches is
still controversial in Europe, especially in England,21,22
559
where mental health service plays a major role in com-
munity care for the mentally ill. However, the commu-
nity care by mental health services has not been
developed sufficiently in Japan, and the aftercare for
those who are discharged from psychiatric hospitals is
mostly organized by the outpatient units in the hospi-
tals. The close monitoring of clinic visits or outreach by
nurses are mostly hospital-based. Therefore, these
approaches may produce outcomes that are different
from those in Europe, especially England.
Interestingly, the utilization of the day-care unit at
the public health center and workshops in the commu-
nity were related to rehospitalization. Presumeably,
when patients attending these facilities deteriorate
clinically, the staff have few choices other than to
advise them to visit an outpatient clinic or to admit to
hospital, which then leads to rehospitalization. There
are options other than rehospitalization such as home
visits by public health nurses. Although these systems
are not functioning well at present, they should be inte-
grated with medical approaches.
Junior high school graduation as education level was
revealed to be another risk factor of rehospitalization.
In other words, educational level is an important factor
in secondary prevention of schizophrenic episodes.
While most Japanese go to senior high school, those
who did not enter senior high school or those who quit
senior high school were at risk of rehospitalization in
the present study. It is possible that this reflects a prob-
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
to a premorbid state or onset of schizophrenia. From a
point of view of primary prevention, the early detec-
tion of this population is required because treatment
delay may affect the course of schizophrenia. In the
study by Johnstone et al., untreated illness was the
strongest predictor of relapse.23 Moreover, Loebel et al.
showed that the time to remission as well as the degree
of remission were closely related to duration of
untreated psychosis when other prognostic variables
were controlled.24 As stated by Birchwood et al., these
findings may be the result of type of illness (those with
an inherently high risk of relapse may include symp-
toms that delay treatment) or the result of psychosocial
disruption arising from a long period of untreated psy-
chosis.25 In the present study, age of onset and type of
schizophrenia were not related to rehospitalization,
suggesting that psychosocial disruption resulting from
untreated illness is more important than type of illness
in influencing the course of schizophrenia including
rehospitalization. Therefore, we suggest that early
intervention is important for those who show any signs
during school age. The education level itself, however,
560
would not be a modifiable factor. We should intervene
to expose such vulnerable people to a better social
experience.
Poor medication compliance was not significant in
the multivariate analysis, although previous studies by
Sullivan et al. and Corrigan et al. revealed it to be a
strong indicator of rehospitalization.26,27 One may
wonder if there is a limitation in the way we assessed
compliance (i.e. the use of compliance scale of Kemp
et al.13). However, as pointed out by Kemp et al., there
are problems associated with more direct measures.13
Urine tests may overestimate compliance when drugs
have a long half-life. Serum assays are invasive and are
of limited value in assessing partial compliance. Pill
counts are widely considered a useful measure but
this method has a potential for dissimulation and
inaccuracy.
Sullivan et al. indicated that non-compliance was
associated with lack of insight (i.e. denial of mental ill-
ness), a history of fewer outpatient appointments, and
being single.26 In another study the most powerful
indicators of compliance were reported as being a good
attitude to treatment and insight into illness.28 The
average age of the patients in the study by Sullivan
et al. study was 34.5 years,26 which is younger than that
in the present study by more than 10 years. Taking this
age difference into account, it is suggested that the sub-
jects in our study accepted the illness and took medi-
cation, in comparison with the patients of Sullivan et al.
In further studies, not only the therapeutic behaviors as
evaluated in the present study but also the attitude
toward medication therapy including insight into the
illness, should be examined.
Incidentally, poor medication compliance was asso-
ciated with rehospitalization in the bivariate analyses.
Because compliance was moderately correlated with
the present GAF scores (r = 0.31), the possibility that
controlling the latter factors produced the negative
result in the multivariate analysis cannot be excluded
entirely.
We asked the subjects if they experienced life events
in the past 3 months. On the interview we categorized
the life events according to axis IV in DSM-IV, which
was developed to describe patients in a biological, psy-
chological and social model in a clinical situation. The
answers to this question may reflect subjective experi-
ence of the interviewees. Because we employed the
stress–vulnerability model of schizophrenia, in which
stress plays an important role in understanding the epi-
sode of schizophrenia, the results of this life event are
still informative for risk factors of rehospitalization.
In the multiple logistic regression models, life events
did not remain at a significant level. The previous study
suggested that life events were associated with relapse
Y. Suzuki et al.
irrespective of the compliance problem,29 although it
was not clear as to which domain of life events was
more influential. Many of the life events in the present
study were problems in the primary support group,
especially families. These may be the results of patient–
family interactions such as over-involvement in patient
symptoms or an excess burden of patient care. Accord-
ing to the study by Tanaka et al., emotions of the family
influence the course of schizophrenia.30
Finally, because the present study was conducted
with a case–control design, we could not clarify the
causal relationship. A further prospective study should
be conducted to elucidate the causal relationship
between the factors presented here and rehospitaliza-
tion of schizophrenic patients.
ACKNOWLEDGMENTS
We would like to acknowledge the invaluable assis-
tance of patients, social workers, and clinical staff of
the hospitals. We also acknowledge the contribution of
the psychiatrists in the participating hospitals: Nihon-
matsu-kai Yamagata Hospital, Director, Dr Tobisawa,
Dr Hirose, Dr Oyama, Dr Miura, Dr Uchigasaki, Dr
Tanaka, Dr, Ichikawa, Dr Ito, Dr Kyono, Dr Iwabuchi,
Dr Takahashi; Nihonmatsu-kai Kaminoyama Hospital,
Director, Dr Yokokawa, Dr Tomita, Dr Igarashi, Dr
Eguchi, Dr Ohori, Dr Kuwayama, Dr Yamada, Dr
Goto; Shinoda Kosei-kai Chitose Shinoda Hospital,
Director, Dr Yoshida, Dr Kato, Dr Yoshimura, Dr
Kimura, Dr Kizu. Dr Ihara and Dr Oiji provided help-
ful comments and suggestions on an earlier draft of this
paper. Dr Imuta, Dr Abe, Dr Goto, and Dr Nishise
kindly commented on the study. We thank Ms Joy
Norton, who reviewed the English manuscript of this
article.
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