1995 - Initial Assessment Of Hospital Treatment By Patients With Paranoid Schizophrenia - A Predictor Of Outcome
This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA
Overview
Download & View 1995 - Initial Assessment Of Hospital Treatment By Patients With Paranoid Schizophrenia - A Predictor Of Outcome as PDF for free.
More details
- Words: 3,394
- Pages: 5
I
PSYCHIATRY RDSEARCH P \ . h ' a l r t R e F a r c h5 81 1 9 9 5r)l 8
Brief report
Initial assessment of hospitaltreatmentby patientswith paranoidschizophrenia: A predictorof outcome Matthias Brdker', Frank R
ptulun.ruIee
t9 t405tj Bctlin G.tnarl An Wdtdha^ t-ts t|t29 A?rh, C?tnan)
Rcivcd 6 S.pr.mb.r 1994.rcvisro.r.ce'ved6 Jaiulry 1995.acc.prcd4 Apirl t995
T h c v a l u co i s c h t r o p h r e n iicn p a t i e n t sr n n ' a l g l o b a l a $ e \ s m e n r o s t r r e a r d e n rI n r h e p r c d i c r r o no t o u r c o m e w a s I n venreated Wirhin I days ofadmisson. lt paricnrs wnh !n acure parrnord schrTophren].psy.hons accordrnBro tCDl0 rated on a v6ual aralog scale to whar exrert the! btlieved lhe trcalmc.l rhey *cR recervrngwas righr for then Outcome crilefla werc overall.lnrcal changesmeasuredon rhc Aact Psychralflc R,Ing Scateaod rhe tntenrronat ), S.ale Th. parient innial slobal asFssmenrsol t.edrmenr we.c srsn,fic.nrty co'retared ro borh ourcome cflrena. ,nd r c a t r n gt h a t p r l i e n r sw r t h a m o r e p o y r r l e i n n r a l r s * s m c n l o f l i e d t m e n lu i r r m a r e t yb r . c f i t c d n o r e r h d n t h o * w I h r Dore neSarrveapprarsal The predictive corcl{lons were indep€ndenror rhc Influer.e oforher v!nabtes recorded I n r h en u d y P a l i e n r sr n i r i d l g l o b aal s s e s s m e nsths o u l db e r a k e ns c h o u s t ! n . | n r . a t p r a c l c c a n d n u d r e ds y s r c m a r r c a l h
Kdrn,rl'
P.ognoy\. Mr|cu lherap!, :,,leu.olep!. lrc!lnrenl
L InFoductiotr The in'tial subjecriveresponsesof schrzoph.en,c palrentshale repearedlybeenshown to predicl lhe outcome of neu.oleptic lh€rapy Van Purlen and M a y a n d c o - w o r k e r s( v a n P u u e n a n d M a y , I 9 7 8 i V a n P u r l e ne l d l . . 1 q 8 0 .r ' ) 8 1 )I n r e , r r B a r . J, u h j e r tive response4-48 h after a lesl dose of neurotep' Coi..rpondrngaurhor Tet +,19l0
0 1 6 5 . 1 1 3 1 ' 9 5 rt 0 t 0 9 ! l 1 9 9 5E s e v r e5c r ence lreland Lrtl Al t s D / 0 1 6 5r 1 8k 9 5 t 0 : rt 3 - c
t r c m e d r c a t r o n( M a y e ! a l . I 9 7 6 ) P a l r e n l sS a v c l h e r rr € s p o n s eosn a s h o r l s c a l et h a l r n c l u d e di t e m s about pe.ceiled elTectsand side ellecls as werl as a q u e s t ' o na s k r n gw h e t h e rt h e y b € l i e v e dt h a l t h e m e d i c a t i o nw a s r i g h r f o r r h e m . P a r i e n r sw i t h a m o . e p o s i l r v er n i i r a lr e s p o n s es h o w e ds i g n i fci a n r l y 8.eate. improvem€nt afier 4 weeks.The predicrive power ofsubjective inirial r€sponsefor shon rerm o u t c o m eo l n e u . o l e p t r ct r e a r m e n rh a s b € e n s u p p o f l e d b y t h e f i n d i n g so f o l h € r s t u d i e s( S j n g ha n d S m r t h , l 9 7 l : S i n 8 h . 1 9 7 6 :S r n g ha n d K a y . I 9 7 9 1
M Rr.*er.t
al / Ptychott
While Van Puttener al. (1981,1984)assumedthat a negativeinitial responsemainly rcflecredexlrapyramidalsideeffects.theirassump(ionhasnor b€en confirmedby further srudies(Fink et al., 1982;Awad and Hogan. 1985;Hoganet al., t985i Hosan and Awad. 1992). Schizophrenic patientsinitial reaclionsro rrear, m€nthavealsob€enfound aopredicrrhe ourcome ofday hospitaltreahenr. In a studyconducredby our own res€archgroup, schizophrenicparienrs ass€ssed wheth€rlreatmenrin a day hospitalwas right for themon rhedayafreradrnission. Th's rnrajalglobalass€ssment of rrearmentwassignificanrly assocrated with the dcgrceof sympromatotogy during trea(meDtand with outcomear discharge. - s€lf-racdon A mor€positiveinitial ass€ssm€nt a onc-itcm raring scale - predicted a more favorable cbanSe in symptomatoloSy(Priebe, l92i Pricbeaod cruyters, 194). To whal exrenr lhc outcomcof a complexhospitaltreahent thar combincsvarioursomaticand psycbosocial tnerapeuocapprorcbesis predictedby patients'inirial ass€ssmcnts has been iovesrigat€din depressron (Priebe. 1987; Priebe and Cruyters, 1995b) bul has not pr€viously been examined in schizophrenia. ln thisproipecrrve andnatural\rrcsrud).se rnv€strgatedin a group of acute paranoid schizophrenic inpatients whether the'r Slobal assessmenb of trearmenlraredwirhin rhe firsl l daysafteradmission wouldpredicrrhe ourcomeof a subs€quentcornpl€x hospiral rreahenr. The criterion for outcome was rhe overall clinical changea1 drscharge.Il was hypothesizedthd a more posrlrveinitial assessmenl would b€ cor, rciated to a nore favorablechanse of psychopathologicalsymplomsat discharge 2. MetMs Thestudywascar.i€dout in a psychiarrichosprtal 'n Berlin.The criteriafor inclusionwerea diagnosis of paranoid s{hizophreniaaccording ro ICD-10(world HeahhOrganization, 1992)and a tolal psychopathological baselineeore belween .{l and 65 on th€ Brief Psychiat.icRalrng Scale (BPRSIOve.allandGo.ham,1962)The rangeof baselrneBPRS s.o.es was limired to achievca
Reseat.h 58 | tA95l 77 8l
somewhathomogeoeousgroup in which symptomaticchangewould nol be undulyinfluencldby lhe initial BPRSscor€s.All parienrsweretr€ared 'n a mrlieurherapyse(ing.In addirionto the regular ward program,parientsparticiparedin occupational therapy daily and in supporrive group thcrapytwic€a we€k. W,lhin the lirst 3 daysafrer admission,rhe pahentsweregrvena s€lf,raringscalewith onesrmpte qucstion: "Is the tr€atmenr you are curr€nrly receivingrighr for you?" The parienrs answers were grvenon an ll-point markedvisual anatog scale(VAS) from 0 (= nor al alt) ro t0 (= €ntirely riSht) and laken as pr€dicrors (Priebe and Gruylers,1993,1995a)The patients'sympromswereassessed afrer admissionat rhc sametim€ rhar patientsraredtheir initial asscssmcnr of rreatmcntand at dis.harge. Th€ inlcrviewer, who ass€ssedthe patienrs psychopathological saatusand adminisreredrhe s€lf-ratingscale,wasnor involvedin thetreahenr. Psychopa&ological synptoms we.e raredon the BPRSand on rh€ InrenrionaliryScate(tnska), a 6Gitem cerman-languagesale especiatlycon, structcdfor rhe ass€ssm€nl of negativesymptoms rn schizophrenia (Mundr er al., 198J,1989).The clnicianwasnor rnformed dbourrhepalienr\'rnr tial globalass€ssm€nls of trearmenlo..abour rhe ratjngsof psychoparhological synproms.Th€ cfl, lena for predicrionwerechangesin l€v€lsofsymptomatologyasass€ssed by the BPRSand rheInska betweenadmissionand discharge 3. Re$lts Thirry-one consecutiv€ly admittedrnpal;enG {I5 qomen.l6 menrs hd metrhec re!'alor rnctu\run wereexamrned.Their agesrang€dfrom t9 ro 5{J years(mean= 142, SD = 9.4). Frfteenpatrents w€relvrng alone.four wrrh pa(ners, sevenwith par€nts,four in aparrmenrsharingarrangemenrs, and one in a th€rapeuricinsrirution.Two patien(s hadnoi compleledth€ir primaryschooleducar,on. 15 had completedsecondaryschool,and t4 had compleredadvancedschooleducarionElevenparrenlshad no occupalional qualifications. I7 nao compleled an apprenticeship, and rhreeheld unrve.srrydeSrees Ten parientshad a tob. six were
U
Arolcr.tdl
P \ t , h t o n )R . : t r a ^ 5 R t t @ \ ) - ' t l
still in professional training, tl wer€unemptoyed. andfour werepremarurely relired.Thedur.rronot illnessvariedb€tween0 and l0 years(mean= 6 j. SD = 7.2),and the numb€rof previoushospiral admissionsranged from 0 ro l3 (mean=4.t.
sD = 4.0).
By the rimeof rhe initiat interyiew,neurolepric medicationhad startedin 28 patienrsjin ihreepalients, ( beganlater. Th€ duration of hosptrar lreatmenl rang€d from 19 to t68 days (nean = 66.0, SD = 39 3) The mean neuroteptic dosageat dischargewas equivatenrro 104 mg (sD -- 208)chlorpromazine (Davis, 1976). The patienls'initialglobalassessments of treatment,measured on the VAS, werestighllypositive (mean= 5.8, sD = 3.0).The init al slobal ass€ssment was no( significanttycorretat€dwjtb the bas€line(olal scoresofrh€ BPRSor the Inska. Ir also was not significanrlycorrelalcdwirh any of th€ BPRSsubscales, with any BPRSsingl€,rems, or witb akinesiaasass€ssed by the Inska. B€lween admissionand discharge,rhe mean s.ore on th€ BPRSchangedsignificanrlyfrom 52 3 (SD = 7 0) to 34.7 (SD = 7.8r I r€sr for paired samptes: t = to.], df=10, P < 0.001)and thal on lhe lnska from 38.4{SD = 12.8)ro 20 8 (SD = 122. I = 8 . 6 1d. f = 3 0 , P < O . $ t ) . The VAS scoresfor Slobalassessment of 1.ealment werefound io be significanllycorrelatedto the overall clinrcal changeon bolh the BPRS ( P e a r s os n . = 0 5 0 ,P < 0 . 0 1o, n e , t a i t e d l arnnoe l n s k a ( ' = 0 4 6 .P < 0 . 0 1 )p. a t i e n lws h oi n i r i ay asses*dlherrtrealmenlasb€in8moreappropnatc showed a significanrly rmprovement ar dis S.eater chargethan rhose wilh a more negatile inilial To examrne wherherthe predrctrve corretat|ons wereinfluenced by a rhi.dvariabl€ lhatwasasrucl aledw(h borhp.ediclorand oulcorn€variabtcs,. a rmrlar wry. the correlarions wereadjunedror rhe res.essroD on so€rodemographrc (gender.dse. educatron, professional qualifi carion.tivingenvjronmen(,and occupalronal starus). ctrnical(prc v'oushospilalizalrons a.d durarron of illness,. and trealmenlvarjables(dosageof neurolepricmedic.rt'on anddu.alronofcu.renrhospitatiralron) The partial corelations .emarnedrgnrficant and rlmo\rur(hdngerl. rhedoju.reJ.nrretdfiur nr n
tral assessmen( of trealmentwith overall clini€al changeon the BPRSvariedb€tween| = 0.46and r = 0.52.ard thos€with changeon th€ lnska belween| = 0.36and | = 0.47.Thus, the predictive rrlu€ o[pafientsrnrfidlglobalass€\rmenr wasrnd€pendent of innuencesby othervariablesrecord, ed in thissrudy. 4. Discrrssioo Patients'jnrtial global assessmenr of rrearmenr was positivelycorrelaredro rhe overalt ctinical changeachievedduring complex hospiratrreac ment.This 6ndir8 is corsistenlwith rhe hypolhe, sis rhat parienls who had a more posrnve ass€ssment of the appropriateness of tr.armenr within the first 3 days would ulrimarely show grcaterbenefitfrom trealment.The samecorrelalron emergedr€gardless of whetherchangcswere ass€sscd with rhe BPRS or rh€ lnska. Sralislicat significanc.wasachieveddespitethe facrsihat th€ patjenl group was small and heterogen€ous rn somerespecls, thar the rrearmenrvaried,and thal only one quesrionwas usedro measuretbe iniliat assessmenr of lreahenr. The resultis in line wirh findingsfrorn .esearch on treurolepncdrug lreahenl (Van Puten and M a y .1 9 7 8V; a n P u t i e n e t a l1. 9 . 8 0l .9 8 t ) a n o o a y ho.p:tdl rreatmentut .chr,,ophrenr! pdlrenl. (Priebe,1992:Prieb€and c.uylers, 1994).It remarnsunclearjhow€ver.wherh€rthe proc€ss€s re sporsiblefor rhe p.edrctivecorretarionb€tween rnrtralreac(ionsand outcomeare sifiitar or dif ferent for Iheseforms of rrearmenr.The facrors thal medraterhe predicrrvepowerof ihe parienls' rn(ralasseslm€nrs of trcatmenr a.estillunknuwn In rhisnudy,variables suchassociodemographrc, clnical.and treahenl dala failedto exptainthc co.relanonbetweenparienrsinillal statemenls andoverallchnicalchanse. However, onty rheIn, fluence of basicvariableswasexaminedCausatartributrons. controlexpectancies. and heatthbeticf rrtrruJe\lfor\lerling. 1988.Pnebernd Sliegll,,. 1990)thal mighl funclionas med;a1ing va abtes qe.e not inlenrgatedWherherpat;enlsrnitral at terstrn som€patrcnts due lo elTectsof specificlrcatmenlcomponenlssuch as nedroleDr'r meJi.rr,.r remdrn\dn openqu<\rrun
-tl
M A.olet.t ol
Pst.hnn\ R.tcrhh 5di/w5r
(Awad, 1989. l99li Pri€b€, 1992). Ir may be sp€culated whetherrheparr€ntsinitial ass€ssmenls .eflectedearlyellectsofselting and mili€u factors or qualitiesof a therapeuticrelarionship(prieb€ and Gruyters,1993)that during the cours€of hospilal treahent led to a differencein oul, com€.The relevanrrherapeutjcr€larionshipmighr be a dyadicon€ in convenrionalpsychotherapy or rn a more complexway formed by interactions with varioussraffmemb€rs(Salrzmanet al., 1976: Bordin,1979t Luborskyeral., I985;Ctarkinerar.. 1987;Horvathand Symonds, l99l). Wecooclud€rharpalients'assessmen rsofhosprtai treatm€ntshouldbe notedand takens€riousty in clinical practiceeven during the first I days followingadmissionor €venif(hey s€€mirratronat to the clinician. In research.schizophrenicpatients' initial global assessmenrs of rreath€nr shouldbe studiedsysr€matically and regardedasa potcntial prldictor of outcome nol on,y !r neurol€p6cdrug therapy, bur also rn comptex treatmerl programs. R€fere*es Awad, A G (19391Drug (h.rapy 'n rh'zophren'a vafiJbri' ry ofolrcoh. and prediclon dt $sd.'ne ( dh J p\tthnnl (i9931 Subjccrve r.sponse ro ncuottpric\ rn AG ahtbphrcntz S. ht:aph. Aull 19, 6a$ 616 Awad A G ancl Hogan. T P tl935t Eany rrearmenr cvtnr\ rnd pred'cr'on ofr.sp.nr ro neurol.prcs rn {h'zophr.nLa Pnt N.ttopr..hophana..l &,/ P'r.rzrL 9. 585 588 A o r d ' n E S ( 1 9 7 9 )T h c C . n € r a l L u a b L Ior fyr h e p t y c h o a r Jy 1 ( conccpr oa *ork'ne ,lhance P\t.hnthrt lh...t R(\ Par t 16.252-260 Clark,n.If .Hu(.SW a n , l C n l l y .l L t 1 9 8 7 I) h e r a n e u r . llr'ance and hospiral tr.arnen\.utcoie lt.^p (t),nutl A*ad.
A}.r!/r, 13. 871 375 Dav6. J M i1976) Comparatec dors and con\ oi dnr p s y c h d n .m e d r c a r i o nt n h C e n P \ \ . h t u r \ l l a i a 3 h l F , n i E a . B r a d e n .W a n d Q u r J l ! . C B t l 9 8 : l P r e d ' . r n B pharmacorherapy ourcome by subjc.rve .espon* ,/ (r" P\y.ht.kr 41.111-215 F o ( r r l l n g . F 1 1 9 8 8 ) , t r r b r n , n T h ? o t \t h ( l n n r t p r t h o h ? l W ' l c y . C h , c h e n e r .l l K Hogan. T P and Awad. A C r1992) Subj€.rve respon\c ro n.uror.pnc\ and our.ohc 'n shrzophren'a d .c .xam'.aton companngr*o me:\ures P'r./o/ ,,/ 2: H o g a n .T P . A * a L t . A C a n d h n l o l d M R rt935r Lan) subjeclle r\pon\e rnd predic|on oi our.ome ro n.urot.p
?- d/
nc drql4rh.rapt rn {hizophrcnra Can J Psr.h'ant J0. Hodalh. AO and Synon{rr.8D (l9l} Rclario. b.rw6n working alliane and ourcon. rn psychorhcrapya mra^n ltstt J Couns.lPr'.ho|18. lJ9-119 LuboBty- L. Mcl.llan. T. Woody.O E.. O ari.n. C P ,.d A u . ' b r !h . A r r 9 8 5 rl h c r a p ^ tr u e . s r ' n d i \ d . r . m . n , n r \ lr.h Gc, P'lc^iatt 42, (A2 6tl May, P R A . Van Pud... I. Yalc. C. Porcpan.P.. ,.nd... D J . F a n c h i l dM . D . c o i d s t . ' n .M . , d n d D x o n . r v J (1976)P..dicri.g 'ndividualrcsponesro druBtr.,tn.nr 'n rh'zophrenra:a rdr do{ mod.l J Nctt Ment Dis t61. t77 l3l Mund1.ch , Frcdr..,P., P.achr.a and Rerlig.R (l985) rnsla (int.nnonalrraBslala) .i. ncuc5psychoparhom.k$her lnslrumcnrzur qua.tnar!.n ErfassunB d.r shizophr.n.n Rcsiduahlmptom.t,kNete.,at:t 56, tt6-t49 Mundr,Ch. KatF . S and Huerkamp.M (1939)The diag: nont lp€ificny of n.8.tiv. synprons and rhctr psychoparholor.al conrcxt Bt J Psr.hnh) ts'tsuppt 1t, l2-16 o v . r a l l - , E a n . lC o r h r m ,D R ( 1 9 6 2 ) T n .B n e f P s y c h ' a k E R^rtnAs.aL Pst.hol Rep lO.199-812 Pri.b.. S. (1987iE.dy subrdnr rcacrionspr.ddn8 rh. our. com of hGp,r.l t..atmnr in d.pEss'lc palEnB ,,trl, Ptf.hlt, S..nd 76. l\4-118 Pn E.S ll992l D. A.d.ututS.br Pollottnn!^un| lntul. A.wdng ud y.tlaul ptr\tui^.het Thptupt. HoEt.t.. Pn.b.. S rnd G.uyr.rs.T (199:l)Thr r.le of hclprnBatt,ance rn psyciErnccomnu.try crr. ! prosp€.tle $ody J l\.n M?nt Dh tat. t52 551 P e h r \ d n d C ' r , r c ' \ . I i t o 9 4 ,P d r , e . hr n d . d ' c g r \ " . n ' { trl ,sfsmenh of da} hosp'ralrcdrncnr and courF of t n p b m \ ( r ' 7 r P , , J r d l . r 1 5 . 2 : 1 ,21l l l Preb€ S ahd (;utre^. f 1 99511Pdrcnu a\Fssmenrot rfetrrh.nr predicrLnghospnttt.x.on Sthta,phr Aut! 2 . Pncbr. s and cr!yr.^. T I he rmpodrnccof rh. fi6r rhree dry! prcdicroo ^ frrea(men o ru r c o m c ,Jne p r e $ e Idn p a . ucnt\ Br J (tt. P\th.t. t995b.t4. 229-2U6 P n e b .S . a n dS r . B l i r zR, D ( 1 9 9 0E ) x r e r n a l . r h b o r ' o .asn d out.ome rn d.pr.$lve tn-p^rt^r\ Bt J ( ]n Prthol 29. S a l u m a nC . . L u e i A . n .M , . R o r h .( t i . C r c t r * r . i r n d H o * a r d .L I l 9 ? 6 tF o r m a r o no i a r h . r d F u r ' cr e l a r ' o n s h r p errEn.ncesduhng rhe ,nr'al phaseol psychorhcrrnrr\ pred'.ro6 ol t.arn.nr durar'onand ourcomc -/ C!a,k, Clih Pt.r.hal14, 546-tt5 S'ngh.M M 11976)Dysphoncrespon* ro netrrcl.pucrrear. mc.r rn *hrophren'a 3nd b pro8nonrcnanricance Dr .r.'L 5Lr 17.L9l 196 S r n 8 hM . M , n d K a y . S R r l 9 7 9 r D l r o h o n . r c \ p o n \ er . ' n { h z o p h . c n r xr 6 r e t r r o n s h p ro r u r o n o n r ca . o u s a la n d p r d g h o j \ & d / / 1 ' , r , , r L l 1 5 r n g 5M . V r n l S n i n hi M 1 9 1 l r K ' n c r r . \r n d d t i a m r \ o l
--]
M
Arok( tt tl . P:khtuit
! . s p o n r t o h a l o p e n d o l r n a c u t . s h r z o p h r n 'a l o n & r u dinalsudyofth€[email protected] l9l al.l v a n P u r t . nT. a n d M a y . P R A ( 1 9 7 8S) u b F c n vree s p o n sr s. a prcd,crorof ourcomeIn phama.otherapy ,{..1 Of, Pst.hnnt 3t,111 480 Van Punen.T. May. P R A a.d Marder.S R (1930)Subtcc. rlvc Espones ro rhiorhrxin. .nd .hlorpromaz'n. Psvr.tiano.ol atll 16 \6 \ti
R.aar.h 53 | 1995i 1/ 31
v a n P u G . , T . M a y . P R A a n d M a r d . r ,S R ( 1 9 8 4 )R . r p o n e r o a n n p s y c h o rm c e d i c . r o nr h c d c r o r s a n d ' h . consumclsvieq ,tn J P\t.htoir 141 16-19 v a n P u r e n .a . M ! y . P R A . M a r d e r S , R. and wrltdann. LA (1981)Subjdr vc r.spon* io anlipsychol'. drugs lrch A.n Ptt.hont la. la7 l9{) wofld H.alrh Or8.n,zton 11991,fh? ICD lO aloslironan of Mmtot and Behariau.alD^drl.rr wHO. Oencva
|
PSYCHIATRY RDSEARCH P \ . h ' a l r t R e F a r c h5 81 1 9 9 5r)l 8
Brief report
Initial assessment of hospitaltreatmentby patientswith paranoidschizophrenia: A predictorof outcome Matthias Brdker', Frank R
ptulun.ruIee
t9 t405tj Bctlin G.tnarl An Wdtdha^ t-ts t|t29 A?rh, C?tnan)
Rcivcd 6 S.pr.mb.r 1994.rcvisro.r.ce'ved6 Jaiulry 1995.acc.prcd4 Apirl t995
T h c v a l u co i s c h t r o p h r e n iicn p a t i e n t sr n n ' a l g l o b a l a $ e \ s m e n r o s t r r e a r d e n rI n r h e p r c d i c r r o no t o u r c o m e w a s I n venreated Wirhin I days ofadmisson. lt paricnrs wnh !n acure parrnord schrTophren].psy.hons accordrnBro tCDl0 rated on a v6ual aralog scale to whar exrert the! btlieved lhe trcalmc.l rhey *cR recervrngwas righr for then Outcome crilefla werc overall.lnrcal changesmeasuredon rhc Aact Psychralflc R,Ing Scateaod rhe tntenrronat ), S.ale Th. parient innial slobal asFssmenrsol t.edrmenr we.c srsn,fic.nrty co'retared ro borh ourcome cflrena. ,nd r c a t r n gt h a t p r l i e n r sw r t h a m o r e p o y r r l e i n n r a l r s * s m c n l o f l i e d t m e n lu i r r m a r e t yb r . c f i t c d n o r e r h d n t h o * w I h r Dore neSarrveapprarsal The predictive corcl{lons were indep€ndenror rhc Influer.e oforher v!nabtes recorded I n r h en u d y P a l i e n r sr n i r i d l g l o b aal s s e s s m e nsths o u l db e r a k e ns c h o u s t ! n . | n r . a t p r a c l c c a n d n u d r e ds y s r c m a r r c a l h
Kdrn,rl'
P.ognoy\. Mr|cu lherap!, :,,leu.olep!. lrc!lnrenl
L InFoductiotr The in'tial subjecriveresponsesof schrzoph.en,c palrentshale repearedlybeenshown to predicl lhe outcome of neu.oleptic lh€rapy Van Purlen and M a y a n d c o - w o r k e r s( v a n P u u e n a n d M a y , I 9 7 8 i V a n P u r l e ne l d l . . 1 q 8 0 .r ' ) 8 1 )I n r e , r r B a r . J, u h j e r tive response4-48 h after a lesl dose of neurotep' Coi..rpondrngaurhor Tet +,19l0
0 1 6 5 . 1 1 3 1 ' 9 5 rt 0 t 0 9 ! l 1 9 9 5E s e v r e5c r ence lreland Lrtl Al t s D / 0 1 6 5r 1 8k 9 5 t 0 : rt 3 - c
t r c m e d r c a t r o n( M a y e ! a l . I 9 7 6 ) P a l r e n l sS a v c l h e r rr € s p o n s eosn a s h o r l s c a l et h a l r n c l u d e di t e m s about pe.ceiled elTectsand side ellecls as werl as a q u e s t ' o na s k r n gw h e t h e rt h e y b € l i e v e dt h a l t h e m e d i c a t i o nw a s r i g h r f o r r h e m . P a r i e n r sw i t h a m o . e p o s i l r v er n i i r a lr e s p o n s es h o w e ds i g n i fci a n r l y 8.eate. improvem€nt afier 4 weeks.The predicrive power ofsubjective inirial r€sponsefor shon rerm o u t c o m eo l n e u . o l e p t r ct r e a r m e n rh a s b € e n s u p p o f l e d b y t h e f i n d i n g so f o l h € r s t u d i e s( S j n g ha n d S m r t h , l 9 7 l : S i n 8 h . 1 9 7 6 :S r n g ha n d K a y . I 9 7 9 1
M Rr.*er.t
al / Ptychott
While Van Puttener al. (1981,1984)assumedthat a negativeinitial responsemainly rcflecredexlrapyramidalsideeffects.theirassump(ionhasnor b€en confirmedby further srudies(Fink et al., 1982;Awad and Hogan. 1985;Hoganet al., t985i Hosan and Awad. 1992). Schizophrenic patientsinitial reaclionsro rrear, m€nthavealsob€enfound aopredicrrhe ourcome ofday hospitaltreahenr. In a studyconducredby our own res€archgroup, schizophrenicparienrs ass€ssed wheth€rlreatmenrin a day hospitalwas right for themon rhedayafreradrnission. Th's rnrajalglobalass€ssment of rrearmentwassignificanrly assocrated with the dcgrceof sympromatotogy during trea(meDtand with outcomear discharge. - s€lf-racdon A mor€positiveinitial ass€ssm€nt a onc-itcm raring scale - predicted a more favorable cbanSe in symptomatoloSy(Priebe, l92i Pricbeaod cruyters, 194). To whal exrenr lhc outcomcof a complexhospitaltreahent thar combincsvarioursomaticand psycbosocial tnerapeuocapprorcbesis predictedby patients'inirial ass€ssmcnts has been iovesrigat€din depressron (Priebe. 1987; Priebe and Cruyters, 1995b) bul has not pr€viously been examined in schizophrenia. ln thisproipecrrve andnatural\rrcsrud).se rnv€strgatedin a group of acute paranoid schizophrenic inpatients whether the'r Slobal assessmenb of trearmenlraredwirhin rhe firsl l daysafteradmission wouldpredicrrhe ourcomeof a subs€quentcornpl€x hospiral rreahenr. The criterion for outcome was rhe overall clinical changea1 drscharge.Il was hypothesizedthd a more posrlrveinitial assessmenl would b€ cor, rciated to a nore favorablechanse of psychopathologicalsymplomsat discharge 2. MetMs Thestudywascar.i€dout in a psychiarrichosprtal 'n Berlin.The criteriafor inclusionwerea diagnosis of paranoid s{hizophreniaaccording ro ICD-10(world HeahhOrganization, 1992)and a tolal psychopathological baselineeore belween .{l and 65 on th€ Brief Psychiat.icRalrng Scale (BPRSIOve.allandGo.ham,1962)The rangeof baselrneBPRS s.o.es was limired to achievca
Reseat.h 58 | tA95l 77 8l
somewhathomogeoeousgroup in which symptomaticchangewould nol be undulyinfluencldby lhe initial BPRSscor€s.All parienrsweretr€ared 'n a mrlieurherapyse(ing.In addirionto the regular ward program,parientsparticiparedin occupational therapy daily and in supporrive group thcrapytwic€a we€k. W,lhin the lirst 3 daysafrer admission,rhe pahentsweregrvena s€lf,raringscalewith onesrmpte qucstion: "Is the tr€atmenr you are curr€nrly receivingrighr for you?" The parienrs answers were grvenon an ll-point markedvisual anatog scale(VAS) from 0 (= nor al alt) ro t0 (= €ntirely riSht) and laken as pr€dicrors (Priebe and Gruylers,1993,1995a)The patients'sympromswereassessed afrer admissionat rhc sametim€ rhar patientsraredtheir initial asscssmcnr of rreatmcntand at dis.harge. Th€ inlcrviewer, who ass€ssedthe patienrs psychopathological saatusand adminisreredrhe s€lf-ratingscale,wasnor involvedin thetreahenr. Psychopa&ological synptoms we.e raredon the BPRSand on rh€ InrenrionaliryScate(tnska), a 6Gitem cerman-languagesale especiatlycon, structcdfor rhe ass€ssm€nl of negativesymptoms rn schizophrenia (Mundr er al., 198J,1989).The clnicianwasnor rnformed dbourrhepalienr\'rnr tial globalass€ssm€nls of trearmenlo..abour rhe ratjngsof psychoparhological synproms.Th€ cfl, lena for predicrionwerechangesin l€v€lsofsymptomatologyasass€ssed by the BPRSand rheInska betweenadmissionand discharge 3. Re$lts Thirry-one consecutiv€ly admittedrnpal;enG {I5 qomen.l6 menrs hd metrhec re!'alor rnctu\run wereexamrned.Their agesrang€dfrom t9 ro 5{J years(mean= 142, SD = 9.4). Frfteenpatrents w€relvrng alone.four wrrh pa(ners, sevenwith par€nts,four in aparrmenrsharingarrangemenrs, and one in a th€rapeuricinsrirution.Two patien(s hadnoi compleledth€ir primaryschooleducar,on. 15 had completedsecondaryschool,and t4 had compleredadvancedschooleducarionElevenparrenlshad no occupalional qualifications. I7 nao compleled an apprenticeship, and rhreeheld unrve.srrydeSrees Ten parientshad a tob. six were
U
Arolcr.tdl
P \ t , h t o n )R . : t r a ^ 5 R t t @ \ ) - ' t l
still in professional training, tl wer€unemptoyed. andfour werepremarurely relired.Thedur.rronot illnessvariedb€tween0 and l0 years(mean= 6 j. SD = 7.2),and the numb€rof previoushospiral admissionsranged from 0 ro l3 (mean=4.t.
sD = 4.0).
By the rimeof rhe initiat interyiew,neurolepric medicationhad startedin 28 patienrsjin ihreepalients, ( beganlater. Th€ duration of hosptrar lreatmenl rang€d from 19 to t68 days (nean = 66.0, SD = 39 3) The mean neuroteptic dosageat dischargewas equivatenrro 104 mg (sD -- 208)chlorpromazine (Davis, 1976). The patienls'initialglobalassessments of treatment,measured on the VAS, werestighllypositive (mean= 5.8, sD = 3.0).The init al slobal ass€ssment was no( significanttycorretat€dwjtb the bas€line(olal scoresofrh€ BPRSor the Inska. Ir also was not significanrlycorrelalcdwirh any of th€ BPRSsubscales, with any BPRSsingl€,rems, or witb akinesiaasass€ssed by the Inska. B€lween admissionand discharge,rhe mean s.ore on th€ BPRSchangedsignificanrlyfrom 52 3 (SD = 7 0) to 34.7 (SD = 7.8r I r€sr for paired samptes: t = to.], df=10, P < 0.001)and thal on lhe lnska from 38.4{SD = 12.8)ro 20 8 (SD = 122. I = 8 . 6 1d. f = 3 0 , P < O . $ t ) . The VAS scoresfor Slobalassessment of 1.ealment werefound io be significanllycorrelatedto the overall clinrcal changeon bolh the BPRS ( P e a r s os n . = 0 5 0 ,P < 0 . 0 1o, n e , t a i t e d l arnnoe l n s k a ( ' = 0 4 6 .P < 0 . 0 1 )p. a t i e n lws h oi n i r i ay asses*dlherrtrealmenlasb€in8moreappropnatc showed a significanrly rmprovement ar dis S.eater chargethan rhose wilh a more negatile inilial To examrne wherherthe predrctrve corretat|ons wereinfluenced by a rhi.dvariabl€ lhatwasasrucl aledw(h borhp.ediclorand oulcorn€variabtcs,. a rmrlar wry. the correlarions wereadjunedror rhe res.essroD on so€rodemographrc (gender.dse. educatron, professional qualifi carion.tivingenvjronmen(,and occupalronal starus). ctrnical(prc v'oushospilalizalrons a.d durarron of illness,. and trealmenlvarjables(dosageof neurolepricmedic.rt'on anddu.alronofcu.renrhospitatiralron) The partial corelations .emarnedrgnrficant and rlmo\rur(hdngerl. rhedoju.reJ.nrretdfiur nr n
tral assessmen( of trealmentwith overall clini€al changeon the BPRSvariedb€tween| = 0.46and r = 0.52.ard thos€with changeon th€ lnska belween| = 0.36and | = 0.47.Thus, the predictive rrlu€ o[pafientsrnrfidlglobalass€\rmenr wasrnd€pendent of innuencesby othervariablesrecord, ed in thissrudy. 4. Discrrssioo Patients'jnrtial global assessmenr of rrearmenr was positivelycorrelaredro rhe overalt ctinical changeachievedduring complex hospiratrreac ment.This 6ndir8 is corsistenlwith rhe hypolhe, sis rhat parienls who had a more posrnve ass€ssment of the appropriateness of tr.armenr within the first 3 days would ulrimarely show grcaterbenefitfrom trealment.The samecorrelalron emergedr€gardless of whetherchangcswere ass€sscd with rhe BPRS or rh€ lnska. Sralislicat significanc.wasachieveddespitethe facrsihat th€ patjenl group was small and heterogen€ous rn somerespecls, thar the rrearmenrvaried,and thal only one quesrionwas usedro measuretbe iniliat assessmenr of lreahenr. The resultis in line wirh findingsfrorn .esearch on treurolepncdrug lreahenl (Van Puten and M a y .1 9 7 8V; a n P u t i e n e t a l1. 9 . 8 0l .9 8 t ) a n o o a y ho.p:tdl rreatmentut .chr,,ophrenr! pdlrenl. (Priebe,1992:Prieb€and c.uylers, 1994).It remarnsunclearjhow€ver.wherh€rthe proc€ss€s re sporsiblefor rhe p.edrctivecorretarionb€tween rnrtralreac(ionsand outcomeare sifiitar or dif ferent for Iheseforms of rrearmenr.The facrors thal medraterhe predicrrvepowerof ihe parienls' rn(ralasseslm€nrs of trcatmenr a.estillunknuwn In rhisnudy,variables suchassociodemographrc, clnical.and treahenl dala failedto exptainthc co.relanonbetweenparienrsinillal statemenls andoverallchnicalchanse. However, onty rheIn, fluence of basicvariableswasexaminedCausatartributrons. controlexpectancies. and heatthbeticf rrtrruJe\lfor\lerling. 1988.Pnebernd Sliegll,,. 1990)thal mighl funclionas med;a1ing va abtes qe.e not inlenrgatedWherherpat;enlsrnitral at terstrn som€patrcnts due lo elTectsof specificlrcatmenlcomponenlssuch as nedroleDr'r meJi.rr,.r remdrn\dn openqu<\rrun
-tl
M A.olet.t ol
Pst.hnn\ R.tcrhh 5di/w5r
(Awad, 1989. l99li Pri€b€, 1992). Ir may be sp€culated whetherrheparr€ntsinitial ass€ssmenls .eflectedearlyellectsofselting and mili€u factors or qualitiesof a therapeuticrelarionship(prieb€ and Gruyters,1993)that during the cours€of hospilal treahent led to a differencein oul, com€.The relevanrrherapeutjcr€larionshipmighr be a dyadicon€ in convenrionalpsychotherapy or rn a more complexway formed by interactions with varioussraffmemb€rs(Salrzmanet al., 1976: Bordin,1979t Luborskyeral., I985;Ctarkinerar.. 1987;Horvathand Symonds, l99l). Wecooclud€rharpalients'assessmen rsofhosprtai treatm€ntshouldbe notedand takens€riousty in clinical practiceeven during the first I days followingadmissionor €venif(hey s€€mirratronat to the clinician. In research.schizophrenicpatients' initial global assessmenrs of rreath€nr shouldbe studiedsysr€matically and regardedasa potcntial prldictor of outcome nol on,y !r neurol€p6cdrug therapy, bur also rn comptex treatmerl programs. R€fere*es Awad, A G (19391Drug (h.rapy 'n rh'zophren'a vafiJbri' ry ofolrcoh. and prediclon dt $sd.'ne ( dh J p\tthnnl (i9931 Subjccrve r.sponse ro ncuottpric\ rn AG ahtbphrcntz S. ht:aph. Aull 19, 6a$ 616 Awad A G ancl Hogan. T P tl935t Eany rrearmenr cvtnr\ rnd pred'cr'on ofr.sp.nr ro neurol.prcs rn {h'zophr.nLa Pnt N.ttopr..hophana..l &,/ P'r.rzrL 9. 585 588 A o r d ' n E S ( 1 9 7 9 )T h c C . n € r a l L u a b L Ior fyr h e p t y c h o a r Jy 1 ( conccpr oa *ork'ne ,lhance P\t.hnthrt lh...t R(\ Par t 16.252-260 Clark,n.If .Hu(.SW a n , l C n l l y .l L t 1 9 8 7 I) h e r a n e u r . llr'ance and hospiral tr.arnen\.utcoie lt.^p (t),nutl A*ad.
A}.r!/r, 13. 871 375 Dav6. J M i1976) Comparatec dors and con\ oi dnr p s y c h d n .m e d r c a r i o nt n h C e n P \ \ . h t u r \ l l a i a 3 h l F , n i E a . B r a d e n .W a n d Q u r J l ! . C B t l 9 8 : l P r e d ' . r n B pharmacorherapy ourcome by subjc.rve .espon* ,/ (r" P\y.ht.kr 41.111-215 F o ( r r l l n g . F 1 1 9 8 8 ) , t r r b r n , n T h ? o t \t h ( l n n r t p r t h o h ? l W ' l c y . C h , c h e n e r .l l K Hogan. T P and Awad. A C r1992) Subj€.rve respon\c ro n.uror.pnc\ and our.ohc 'n shrzophren'a d .c .xam'.aton companngr*o me:\ures P'r./o/ ,,/ 2: H o g a n .T P . A * a L t . A C a n d h n l o l d M R rt935r Lan) subjeclle r\pon\e rnd predic|on oi our.ome ro n.urot.p
?- d/
nc drql4rh.rapt rn {hizophrcnra Can J Psr.h'ant J0. Hodalh. AO and Synon{rr.8D (l9l} Rclario. b.rw6n working alliane and ourcon. rn psychorhcrapya mra^n ltstt J Couns.lPr'.ho|18. lJ9-119 LuboBty- L. Mcl.llan. T. Woody.O E.. O ari.n. C P ,.d A u . ' b r !h . A r r 9 8 5 rl h c r a p ^ tr u e . s r ' n d i \ d . r . m . n , n r \ lr.h Gc, P'lc^iatt 42, (A2 6tl May, P R A . Van Pud... I. Yalc. C. Porcpan.P.. ,.nd... D J . F a n c h i l dM . D . c o i d s t . ' n .M . , d n d D x o n . r v J (1976)P..dicri.g 'ndividualrcsponesro druBtr.,tn.nr 'n rh'zophrenra:a rdr do{ mod.l J Nctt Ment Dis t61. t77 l3l Mund1.ch , Frcdr..,P., P.achr.a and Rerlig.R (l985) rnsla (int.nnonalrraBslala) .i. ncuc5psychoparhom.k$her lnslrumcnrzur qua.tnar!.n ErfassunB d.r shizophr.n.n Rcsiduahlmptom.t,kNete.,at:t 56, tt6-t49 Mundr,Ch. KatF . S and Huerkamp.M (1939)The diag: nont lp€ificny of n.8.tiv. synprons and rhctr psychoparholor.al conrcxt Bt J Psr.hnh) ts'tsuppt 1t, l2-16 o v . r a l l - , E a n . lC o r h r m ,D R ( 1 9 6 2 ) T n .B n e f P s y c h ' a k E R^rtnAs.aL Pst.hol Rep lO.199-812 Pri.b.. S. (1987iE.dy subrdnr rcacrionspr.ddn8 rh. our. com of hGp,r.l t..atmnr in d.pEss'lc palEnB ,,trl, Ptf.hlt, S..nd 76. l\4-118 Pn E.S ll992l D. A.d.ututS.br Pollottnn!^un| lntul. A.wdng ud y.tlaul ptr\tui^.het Thptupt. HoEt.t.. Pn.b.. S rnd G.uyr.rs.T (199:l)Thr r.le of hclprnBatt,ance rn psyciErnccomnu.try crr. ! prosp€.tle $ody J l\.n M?nt Dh tat. t52 551 P e h r \ d n d C ' r , r c ' \ . I i t o 9 4 ,P d r , e . hr n d . d ' c g r \ " . n ' { trl ,sfsmenh of da} hosp'ralrcdrncnr and courF of t n p b m \ ( r ' 7 r P , , J r d l . r 1 5 . 2 : 1 ,21l l l Preb€ S ahd (;utre^. f 1 99511Pdrcnu a\Fssmenrot rfetrrh.nr predicrLnghospnttt.x.on Sthta,phr Aut! 2 . Pncbr. s and cr!yr.^. T I he rmpodrnccof rh. fi6r rhree dry! prcdicroo ^ frrea(men o ru r c o m c ,Jne p r e $ e Idn p a . ucnt\ Br J (tt. P\th.t. t995b.t4. 229-2U6 P n e b .S . a n dS r . B l i r zR, D ( 1 9 9 0E ) x r e r n a l . r h b o r ' o .asn d out.ome rn d.pr.$lve tn-p^rt^r\ Bt J ( ]n Prthol 29. S a l u m a nC . . L u e i A . n .M , . R o r h .( t i . C r c t r * r . i r n d H o * a r d .L I l 9 ? 6 tF o r m a r o no i a r h . r d F u r ' cr e l a r ' o n s h r p errEn.ncesduhng rhe ,nr'al phaseol psychorhcrrnrr\ pred'.ro6 ol t.arn.nr durar'onand ourcomc -/ C!a,k, Clih Pt.r.hal14, 546-tt5 S'ngh.M M 11976)Dysphoncrespon* ro netrrcl.pucrrear. mc.r rn *hrophren'a 3nd b pro8nonrcnanricance Dr .r.'L 5Lr 17.L9l 196 S r n 8 hM . M , n d K a y . S R r l 9 7 9 r D l r o h o n . r c \ p o n \ er . ' n { h z o p h . c n r xr 6 r e t r r o n s h p ro r u r o n o n r ca . o u s a la n d p r d g h o j \ & d / / 1 ' , r , , r L l 1 5 r n g 5M . V r n l S n i n hi M 1 9 1 l r K ' n c r r . \r n d d t i a m r \ o l
--]
M
Arok( tt tl . P:khtuit
! . s p o n r t o h a l o p e n d o l r n a c u t . s h r z o p h r n 'a l o n & r u dinalsudyofth€[email protected] l9l al.l v a n P u r t . nT. a n d M a y . P R A ( 1 9 7 8S) u b F c n vree s p o n sr s. a prcd,crorof ourcomeIn phama.otherapy ,{..1 Of, Pst.hnnt 3t,111 480 Van Punen.T. May. P R A a.d Marder.S R (1930)Subtcc. rlvc Espones ro rhiorhrxin. .nd .hlorpromaz'n. Psvr.tiano.ol atll 16 \6 \ti
R.aar.h 53 | 1995i 1/ 31
v a n P u G . , T . M a y . P R A a n d M a r d . r ,S R ( 1 9 8 4 )R . r p o n e r o a n n p s y c h o rm c e d i c . r o nr h c d c r o r s a n d ' h . consumclsvieq ,tn J P\t.htoir 141 16-19 v a n P u r e n .a . M ! y . P R A . M a r d e r S , R. and wrltdann. LA (1981)Subjdr vc r.spon* io anlipsychol'. drugs lrch A.n Ptt.hont la. la7 l9{) wofld H.alrh Or8.n,zton 11991,fh? ICD lO aloslironan of Mmtot and Behariau.alD^drl.rr wHO. Oencva
|
