1995 - Patients' Assessment Of Treatment Predicting Outcome

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vol. 21, NO. 1, 1995

by Stetan P ebe ancl Thomas Grutners

Patients' Assessmentof 87 TreatmentPredicting Outcome Abstraci Using a visual analog sc:le, 34 s.hizophrenia patients re.eiving long-tem tieatment in .omhunity car€ nted the €xtent to which their lleatment was right for them. w€ investigrted whether thes. assessmentswoul.l predi.t the duration of patient hospitaliz.tion dunng an initi.l followup period of 12 morths and a longei lollowup pedod oI 30 months. Th€ duration of full and partial hospitrlizrtion was ass€ssedby neans of a hospitalizatior index. Pati.nts who assessed their treatmenl more neg. atively had sigtdficantly highe! hospitalization indices in the two folowup periods. The predictiv€ value of th. patients' issessmenti ot treatmert wls not erptained by the influence of othe! ): S.hizophlenid BuI letin, 2111 87-94.1995. How patients ass6s their ongoi.g o. past psychiatric treatment has been investitate.l jn nmerous studies. While patients hay assess diffe.mt but related aspectsof beahnenl, such as how helptul, right, or sattsfactory it is, most studies have focused on satisfaction. Becauseof several methodological problems (Locker and Dlrnt 1978;Lebow 1982),a stmda.dized and widely accepted method of measuring patient satisfaction has not yet been srablished (Gruyt€rs and P.iebe 192); nevenheless, there is sufficient empirical eviddce in support of the overaLl finding that most patients erpress a hiSh level of global satislaction with the treafment they are receivint. This applies to hospital and day hospitai treatment,

outpatieni settirgs, and communjty l98zt care (Weinstein 1979t libos Kalman 1983j Corri8an 1990). However the degree oI satisfac_ tion varies among Patjents,some of whom ar€ less stisfied than others. Satisfaclionis associated with cerlain Patient characteristics, although no .orrelation betwen the two has consistentlybe€n found in sbrdies that have investi gated the issue.Some studies have found that women, older Patients, and patients with less severe cur_ rent psychopathotogicalsymPioms are likely to be more satisfied with treatment {Denner and Hal_ prin 1974;Ei*n and Crob 1979, Lars€n et al. 1979;Levois et al 1981;Hansson et al. 1985;Conte ei al. 1989;Mclniyre et al. 1989; Gruyters and Priebe 1992).Olhers indjcate that Psy.hotic Patients (Getz et al. 1975;Berger 1983), nembers of 3 racial mmonty (Ciarlo and Reihnan 19n, Laren ei al. 1979),unmarried Pahents, and those with a lower level of s.hool €ducation (Berger1983) tend to be less satisfied.Patients whos Past beatment has been re' garded as less successtul,both bY thems€lvesand by the cliniciant are also less satisfied(Edwards et al. 1978;Wille. and Miller 19781 Eisen and Grcb 1979; Fiestet 1979, La.sen et al. 1979;Hansson and Berglund 1987). while patient assesMenls ot tr€atme^t may reflect Past thelapeutic succe$, ihey nay also be predictile of future outcome. Sub_ je
88

hospiial heatment in mixed sdples of patienis iErady et al. 19s9) and in pahents with depression (Pnebe 1987),of day hospital tleat' ment (Pliebe 1992),and of neuloleplic medication in schizoptuenia paiienis (Van Putte and May 1978;Vd Putten et al. 1981,1984; Hotan et al. 1985;Bartk6 et al. 1987).In these studies, subjective respotue was inlestigated dunng the initial stages of tlearment and in.luded the patients' assessmenis of whether the tleatment or medicahon was light for them. lt !emains unclcar, however whether such assessments also have some p!€dictive value {o. the outcone of long term treatment, Using a sample of schizophrenia patients rec€ivin8 long+em treal' meni in commmity ca!e, we investi8ated whether theii global assessmentsof treathent pledi.ted the duation of their tull and/o. paltia1 hospitalizarion within a followup pe.iod or 12 months and a lonSer one of 30 months Hospitalization was used as the oltcome criterion becausethe prevention and shorteninSof periods of hospitalization are central{lthou8h cenainly not soltsgoals of treaiment in community care and be' causeit can be measued exactly.

Method The study was .ariied out in a communrty caie system that serves CharlottenburS,an imer district oI Berlin (Steinlarl and Priebe 1992) The system inctudes three partial hospitalizationprog.ams (day hospital, night cijnic, and therapeutjc printing workshop), .ommunitybased serices (a dav care center, a drop-in cent€r, single dnd group P.otectedtjving aPartments, and valious outpatjent facilities.ln-

SCHIZOPHRENIA BULLETIN

patient treathent is p.ovided in .ooperattun w,th psychiatnc hospitals. Continuity of ca.e is guar' anteed by clinical case nanagers (psychiatristsand social workers) who follow the patients' path through the system's inshhrtions (Thomjcrotl 1990;Priebe and Gruytere 1993)and remain in charge of therapeuticdeci$ons. The sysiem is orienled toward providing longlerm tleatment for pati€nts with severe and chronic At the time of the srudy, approximately 90 schizophreniapa tients were undergoing long tem heatment in the care system (ex€ludin8 the drop-in center).A sample of 47 patients seen consecuiively by thet case managers within a pedod of 4 week took pan in the study. All 47 patients had been diagnosed with schize phJenia according io the DSM lll R (Arnencan PsychiatricAssociation 1987)and had been receiving treatm€ni in the care systen for at least 4 montl$. An inte iewe. not oiheryise involved in treathent asked the patients to assess then beatment ("ls the tieatment you are olrently receiving right for you?"). The answers were self.ated on a l00-mmlong visual analog scale (r/A5; erbeme Points 0 - not ri8ht at all, 100 = completely ngho. Each 10-mm int€flal was marked so that the scale combined qualities of a VAS with featules of an 11-point rating scale (Luia 1975;Cuyatt et al. 1987). This simple hethod was used to reflect the often vague md generalizir8 attitudes of ihe palients and to have a instlment ihat could be easily uderstood by all pahents. ln addition, th€ patients ,ere asked in a standardized open question whether they would like the r.eatment to be different in

any way, md if so, what chdSes they would most urgently like to be made. Sociodemographicvari ables (e.8., 1eve1of school educa tjon, professionalqualifications, family and occlpational statur fj' nancjat situaiion, accommodation) and data from the patients' psy' chiafric histories (e.8., duraiion of illftss, frequency of plevious tuil and paltial hospitalizationr previous medicatiorr and psychotherapy) were recorded in a standaid ized jntefliew. Psychopathologi.ai symPtoms were rated on the Brief PsychiatricRating Scale (BPRS; Overall and Gorham 1962)by the For both followup periods (12 honths and 30 months) we !e€o.ded the total number of days of both full and paitial hospitaliza tio^. A hospitalization inde\ (HI) was .aldlated for €ach of the two periods (Steinhart and Prlcbc 1992).In a nodificahon of sjmilar indices used by Lavjk (1983)and Taruella et al. (1986),the HI re' llects the deSree(full or partial) and duration of all periods of hos' pitalization: (n days in tull hospi talization x 3) + {, days in pd tial hospitalization x 2)/(days in the obseFation pe!iod).

Results By the end of the 3o'month fol' towup pe.iod, 13 of the onginal 47 patients were no lon8er bcin8 tleated in the care system.Thus, the assooation between satisfaction with heatment and the duEtion of hospitalization during followup was establishedfor only 34 Patienis. Alihough these 34 pati.nts had a lonSer duration of illness than the 13 who left the care sys tem durjns ihe followup period, this differen e just failed to reach

89

v o L . 2 1 ,N O .1 , 1 9 9 5

statisticalsiSnjficance(11.0 vs. 6.2 yea.s; t = 1.71,p < 0.10).The two groups did not dilfer sj8nificantly with respe.t to anv other clinical or soctudenographi. va.iabtes No! was there a significant diff€rence in global satjsfaciionw,th beatment, although the d.opouts wele slightly less satisfied \66.2 es. 72.5' not significanr [NS]). The mean age of the 34 patients (18 women, 15 men) &as 41.1 years (range = 2fi4, standard de' liation ISDI = 10.6).Fou! patients had not completed their secondary school educatior! 24 had compleied secondaryschool, and 6 had completed hjgher education Twelve patients had no occupa' tional qualificattuns,19 had completed an apprenti.eslup,and 3 held university degrees.At the rime of the interview, 19 paticnts were living alone, 10 were livinS with partners. 3 were living with paients, and 2 were in therapeutic institutions. Or y 10 had a job (7 full time and 3 part hme) All the paijents were diagnosed as having schizophrenia according to the DSM-III-R (19 disortanized type, 6 paranoid type, md 9 residual type). The dulation of ill' ness varied between 9 months and 31 yeals (nean - 6.2 years, SD = 7.6). The number of prevrous pen ods of full hosprtalizationranged from I kr 17 (hean = 3.6); rhat oi partial hospitalizatioa from 0 to 24 (mean = 4.s). Patientshad been treated within the .orlmsity care system for between 6 months and ls yea6 (mean = 6.s years, SD = 7.4). At the time of the interview, the mean BPRSscore was 28.1 (rm8e = 18'46, SD = 7.6).Twenty seven Panenls were on neu.o'eP' tics, and seven uere not taking any psychdtropic medi.ation. There was no stahshcallysignificant differencebetween the patients who

were .eceivinS medication and ihoe who were not on any othe. valiable re.orded in the siudy; however, patients not on medjcatlon tended to have a higher HI for the longer followup period of 30 months (/ < 0.08). The mean s.ore on the VAS measurin8 global asscssmentof iont'tem tredtment was 72.5 (SD - 24.6).The extent to $.hich pa' tients rated ireatmeni as being light was correlated to a8e (Pearson's r = 0.50, / < 0.01), duration of illness (/ = 0.3,{,p < 0.05),and BPRSs.ore (f = 4.42, p < 0.0r). The women assessedthen ireat' ment mole positively than the men (point-bi*rial t = 0.44, p < 0.01)rpatients stating that they would like some change in t.eat ment assessedthei. treatment dore negatively (poinrbiserial / - 0.43, I < 0.01).Other variables weie not significddy correlated to the patienls' assessments. S€venteenp6tients stated ftat they would like their trcatment to be changed, and 17 did not stale it. lour patients most urgently wanted ihe dosage of then hedi cation to be reduced. One patient would have liked mole independence fron the irotihrtion, one wdted real psvchotherapy,one wanted mo.e theraPeubcgrouP sessions,and one wanted fewer in' fomal Foup meetinSs.Two pafients wanted hore intensive talks with then case managerr another wanted less cliticism from that individual, and another banted mo.e respect.One paiient said he would like no turther change in case anageo another one wished to hav€ fewer symptoms, and three patients expressedwishes that did not Fm to be dilectly reiated to treatment-nameiy, a better aparbhent, a bette! pension, and a resto.ed dliving license.

During the 12 months following the interview, the patients sPcnt between 0 and 100 days in full hospitalization (mean = 12.4,SD = 28.9),and between 0 and 305 days in part,al hospitalization (mcan = 53.5,SD = 951). Within the 30 month followup period, the num ber of days of tuIl hospitalization ranged f.oh 0 to 301 (meaD = 37.4, SD - 63.1),and oI partjal hospitalization,from 0 to 550 (mean - 9.3, SD = 158.7).The mean HI was 0.a0 (SD = 0.65) for the first 12 months and 0.31 (SD = 0.44) for the tull 3o'month follow' ln accordancewith the VAS rat' ings, the patients were divided into two subgiouPs {ne with a more positive md ihe othe. with a more negative (or less porhve) assessmentof treatment. The media (80.0) was ued as the cutofr point so that 17 Patientswe.e .e Saided as having assessedthei treatment more Positively and 17 were reSarded as havrng assessed their treatmeni mo.e negatively. Figu!€ I shows how the nmbers of days of tull and partial hospitalization and the Hls of ihe two groups diffeled during the fnst 12 months after the inteniew. The patienis who assesd their treatment mo.e negahvely spent substaniially nore days in both tull and partial hospitalization CoNquently, the mean HI for this group is more than four times higher thm that for the patients wiih a more posihve assessment. All diffelences are statisticaily siBniticani. Fjgule 2 summarizes the dilferencesin dulation of hospitalization within the 3o-month followup period. The diffe.en.e beiween the numh,erof days of full hospitahzation n the fwo groups, approx' imately 20 days, is not greaier

90

SCHIZOPHRENIA BULLETIN

Figure 1. Days ol full and partialhospitalization and hospitalization index (Hl) in patients giving a rhoaepositive assessmenl and in those giving a more negaiive assessment of treatment at l2-month follovirup(each group r = 't7, all t-tests two-tailed) Oays 100

HI

o_7

More positive assessmenl More negative assessmenl

0.6

80 0.5 60

0.4 0.3

o.2 20 0.1

Oays ol parlial hosp ( r = 2 2 3p < 0 s )

thm that in the firei 12 months and is no longer statisticallysignificdt Howevea th€ patients Mth a more neSaiive assessment spent iive times as many days in partial hospjialization than did those wrth a more positive assess ment. This difference is even gleater than that dunnt the filst 12 monihs. The resulting diffe.ence in the HI is significant (p < 0.01). The VAS scores for Slobal as sessmentot treaiment wele lound to be significantly codelated to the HI for boih the 12-month (Pear' son's r = -{.46, / < 001) and the 30-month (r: -1)49, p < 0.01) fotlowup periods We then examjncd whether these co(elatios were owing to a thild vaiiable that ]n-

Hospiializalion indet ('=226rp<05)

fluen.ed both global assessmentof teatment ud the HIs simitarly o! wheth€r the patients' assessmenis of long'term treaiment would have a predictive quality of their own independent of the pledictive value of &e othe! va.iables. Of all the sociodemog.aphicand cliDcal valiables reco.d€d in this study, five variables-age; the BPRS sm score; md the BPRS items of aryiety, tensior! and hostility-wele significantly cofelaled both to pahent assessmentmd to at least one of the two HIs fo! the lol lonp periods. These coffelatiois a.e summanzed in table 1. The co.relationswe.e then adjusied for the .egressionon each of the 6ve vanables, as shown in table 2. In

each .ase, the adjusted assocjalios are somewhat lower but remain staiistically signifi.ant. Multiple regression analyse. with the two HIs as dependent vanables show that patient assessment of trearm€nt is the best single predjctor of fuiure outcome.The stepwiP in.lu$on of all other variables, including all the data from the patjents' histories such as fte quencv of hospitalizationin the past, does noi siSnificantlyincrease the deSreeof explained vanance.

Discussion The patients' global assessments of long'tenn treatment in conrnunitv the average,fairly positive. The relatiochips betw€en assessmentand age, sex, and psy.hopathology are in line with the findings of resealchon patient satisfaction. However what makes pahents assesslon8-telm treatment morc or l(ss positively i! stiu poorly unde.stood (Berge. 1983). In this study, the patients' wishes conceming changes in hea|nent were re.oided. Some of the paticnls who asssed thei! t.eatnent mole neSativelydid not e\press any wish for change,and some ol the wbh€s thai we.e expressed were not related to what .lini.ians miSht .egard as essentialelements of treatment.Therefo.e,it remains un.led whether what patients would llke to be chanSedreflects the actual reasoru fo. a negahve assessment,and whethe. global as' sessmentot long-term treatment can be irnproved by specially de' signed therapeuhcinteNentions. Patient assessmentof tleatm€nt proved to predict the dulation of hospitalization within a lz-month foliowup penod and, to a simild exteni, within a lon8e! peliod of 30 months, however, this ass€ss-

-ljsss vor. zr, t'ro.

91

and Figure2. Days ol full and partialhospitalization, index (Hl) in patientsgiving a more positive hospitalization assessment and in those giving a more negative assessment of treatment at 3o-month lollowup (each group ,t = 17, all t"tests two-tailed) HI

Days

0.6

Moreposrtve assessmenl M o r e. e g a t r v e a s s e s s m ern6lss

Days ol lll hosp. 0= ro3iNs)

Days ot Parral hosp. (=266 p< 01)

HosPita izalion index (=26oip<.01)

Table 1. Correlationsol age, BPRSscore,and BPRSitems indices(Hl) with assessmentof treatmentand hospitalization for 12 and 30 months

Age

Hostilily

0.50, -0.421 -0.38' -0.553 -0.431

HI {12 months) -o-292 0.332 0.312

o.28' o.342

HI (30 months)

4.32' 0.27 0.302 0.31' 4.25

Nora.-BPFs = Brel Psych,atcRatn! sc6. (ove6l a^d Go am 1s62)

meni may be assumed to cha^8e over time and not be entirely consisientfor 2Y: years (Gruytels

bd P.iebe 1992).For both penods, the difference between the more positive dd mo.e negahve Pa-

hents was not only stahsticaitysi8' nifi.nt but also clinjcally relevant, the HIs for the patients with a mo.e neSattveass€ssmertoemg th.ee to four timcs higher than thos€ for the Patientswith a more positive assessdenl.The median (80 on a 100'nm vAS) was us€d as cutoff po,nt for distjntuishing between the more positive and more negative Pnhent assessments Only four patients rated a sco.e .loser to the negative cxtreme (treaiment was "noi at all" ight) thd to the positile one (tleatment was "completely" .i8h0. Tlerefore, the patients who Save a mole negattve assessmentsmPty ex pressd a less positlve assessment rhan the other g.ouP, and the naionty of then did not Sive an expljcit netaiive assessmentoi long-term treafdent. ln this studv, patient! assessedthe riShtnessof lhei. t.eatment and not then satis_ faction with it becauseitems on perceived .ightn€ss have bcen shown to iredict the outcome of shorl-tem beatment, and ll was in outcome p.edi.iion that we we.e interested.ln th€ case of lonS'ie.m t.eatment, patients satislaclron s'ith treatment and theii assess ment of its liShtness may be as_ suhed to be h,ghll' conelated but not necessanlyidentical. Any interPi€tation of the results must take into account that the sample was faiily small and slective, and that the study was car' ried out n a speoal settinS that is a mod.l inshtution in Gerbany. Thus, unhl th€se results havc been replicated jn diffelent settings,it remans an open queston 6 ro how la. rhey can be geneializecl Mo.eover, while the Prediciive .elationship between Patient assess' ment and duation of hospitalization was not nduenced by any of the oiher variables included in the

A BULLET N SCHIzOPHBEN

92

Table 2. Adiusted correlations between assessment of treatmenl anb hospilalizationindices (Hl) with the inlluence of a third variable eliminated (partial correlations)

Ase BPRSscore BPRSiterns

Adiusled r belween assessmenlor trealmentand Hl (12 months)before adjustment/ = -0.461

Adiusled / beM€en assessmenl of treahenl and Hl {30 monlhs) betofe adjustment r: -0.491

-a.372 -0 38'

-0.39' -0.43,

-0.382

-0..131 -0.402

Hostlly p s v c h a n € R a r : i qS c a e i o v s r a L a n d G o r h a n 1 9 1 t 2 ) rvore--€PRS: Brsr

s1udv. on1! b.$. fnnables lLere rc.o.ded It th€reiore remnlns un ciear tir what P(fcss.s fat'tntr .sscssnrents oi the treatment s nghtn.ss and subsequent Penods oi hosp,talization are iinkcd l'i_ hents assersir\g ther. treatment erthet ma! be l.ss .rore negrhv.h particular form to this responsrle .i lr.rrment-and Fos5rbl! to oth' ma! hale rcceile.l a .rs, kro{r krnd of t.eatment tjccause diter.fi oi poorer compliance o. Iess em_ pnthr and invoLved clse man aseis It might b€ speculatL'd that i, posihve theripeutic relatlonrhrp betqeen patient dnd cise nanage! or a congrucn.e beiseen rne pa' henl s exPectation5 aid the irshtu_ hon s tre.tment rdcologv aLso plays a role On ihe othcr h.nd satis_ Iaction with heatment has been iound to be associatcd {jtn gen_ eral lile satisraction and socral sri uahon (Larsen et al 19?9r Le\:ois €: a- 1981), so oth.r Yariables su.h as percephon or social suP' our f!!t na! have innuenccd indrngs Ho$erei, the Pahents , 3cs€ssm.nt ot an.1 sabslac on Brln

iher life siturtions h.rc rot €\amincd in thrs stu.l\' Conclusions lvhat.!'er th. eaa.t cxPlananon Dav b€. lchizofhrenja Patlcnls glob.l rsses$ent oi Long-lcrm t.catment does P.e.lrct outcom€ rf re.ms of the du.ation or subse quent hosPitanzation Hn!ing dcm onstrated the Prcdichlt ralidiry ol thes€ paiients sublecxve responses to pha.macothe.aP!, Van Putren ard NIay (1978)concLudedthat "ihe consum€r has a Po'nt Accordnrg to the resulis oi th'r stud). their condusion applies not o.!L! to sho.t term neurolePtr. treatment but al5o to hng-tefm treatment in a letting as comPlex as comdunitl cai.. Pati.nts AS_ sessnent of how ritht thcir tuF rent t.eatmcft is mav be regarded ar a relelant crterion ior the eraluihon of p5lchiati. instituhons and should influen.. ihe conceptualizahonof henial.hulth ca.e settjngs on a porrtcar refel Bevond ih,s, our findrngs su8gest

that it also predrcts the outcome of individual treatmenl. I'atient s assessmeniof long-term treatment should b€ taken as a relelant rac' tor sithin the indnidual iheraPcu' tic process,regaidlessof ho{ ra' tional or ii.ational ttie patrenrs reasonsbehind thcii assessments ma) seem to thc clini.ian

Reletences Ameiican Ps)chiabLcAssocranon DSM-lll-Rr Dldsrostli drd si,hsl' .rl \futun| ot l"lentdl Drs./n.re 3r.i ed., rcvised. Nashingtod, DCr The Bartko, C , H..cze8, l; and B6k6sr, Nl. P.edichng outcome or neurolePtic1!entmenton the bas$ oi subiccti!€ resPonscand ealv clinral inrpiovenent idltur 't C i , n i n l f s y . i $ 1 r J , , 1 E : 3 6336 5 , I9IJ; Ecrger, 11 ToFa.d maxrmizilt tht utlitv oaconsumer a n o u t c o m e .l n L a m b e r ,\ l j , Chnsicnsen,E li r ard De JL'l'o, SS., .ds ii!. ,'liscsendlr oi Psv.rn'tl,!rnt'r O!i.rt.. Ne*' Yo.k, NY lohn i\ileY & S.ns 1983. B . ! d ! , J f r Z € l l c r ,W w I a n d Reznikofi, M Aihtudinni la.brs rnlluencrnSoutcome of treat.rent of hospitalized pslchlatnc tancnts JDr/hdl !I ClDIl.4l attd Erletrnetttl lsr/.l,rpdllxl!J!, 2i):321-i-3i11959 C l a r l o ,J . a n d R e $ m a n ,J T h e Den'er Communit) i\'lental Hcalth Questiomaire, Derelopment o1 a multidimensional Program evalua' tion instrurent. lnr Cou.sel, RDI S p e c t e rC , . A ; N l u r . e l l ,S A r i n d Hu!t. B.. eds. I/r8/n,i lrahrttrr lcr If.nl,1 Hlrlii, M.Jidds. Strnr' New York, e{irr crd firii.ldtls NY: C.une & Siratton, 197; PP 131 167.

v o L .2 r , N O 1 . 1 9 9 5

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Conre, H.R; Plut.hik, R.; Buckley, P I i{aren-5pence, D; and Eyram' Karasu, T. Outpahents view iher. psvch,at.i. treatneni Hosfilal ord Catnhtu nn ! Ps! chit n!, 40:611413, 1989

shortiem psychiatric hard: A p.th analysis siudy of the lmpor tan.e of patient involvement in treatment Planning. Errcpeafl Ar chi|t, ol Psychidr/! dnd Ncutatogieat Scienc$, 236:269-274, 1987

dol Scienq dnd Me.!r1ne,12:2A32 9 1 ,1 9 7 8 . Luaa, R.E. The val,dlty and ie liability of the Visual Analogue Nlood Scale.i,)rrrrl of Psvclidti. Ressar./,,12:5157, 1975

Corngan, P.w Consumer sahsfrc hon $1th instituiional and com' munrty care Cozurrily ,\Ie,,rl H l d l l h l o r r n r l , 2 5 : 1 5 11 6 5 ,1 9 9 0 .

Hansson, L.; Be.Blund, M.; Lrljencrantz,C., Ande.sson, G.; and Ohnan, R. Pahent attitudes in shortrerm psychiatrjc care: Rela' tions to social and psychiatric backgiound, clinical symptomt and treatment model. A.ia Psycirr ,tia Sandinarid, 72:193-241, 1985

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Demer, B, and HaLprjn, F Chcnts and thelaprsts evaluate cljnical serlrces.,,l,r.ric,, lannl al Con n t n ttv Psychoios -1i,2:373-37U,1974 Edwards, D ' Ya.vis, R.; Mueller, D.; and Langslev, D Does prtient satisfactioncorr.lat. r'ith success? Haspndldnd Crnnunity Psy.hirt!, 2 9 : 1 8 81 9 0 .1 9 7 8 Eisen. S., and Crob, M Assessjng ronsumer srtisiaction iiom leiters tu the ho-.prtal H.rt1t,il did Cotnnnity Psy.nirtrir, 30:34f3.{6, 1979. ':ieste., A Gonl lttninment and sntisfactionsco.es of C\'IHC .lientt ,4,,rri.d, Iti,nldl Df CDn ! , , t ! | i v ! / r ) i o J v , 7 : 1 E 11 8 8 ,1 9 7 9 c . t z , l ! : F u j i t a ,B I a n d A l l e n , D Thc usc of paraprofessionalsin crisis DrcrventioD !\ rtlcan lo,/,al .I C.d,r,niy Piy./iobgy, 3:135 14'1, 1975. Gruyte.s. T., and Priebc, S fatient s vic* oi psvchiatric treaF ment-A studv on p.oblems oI jls risessme.t and stabilitv over tine tr Cdm.n). r!ris.i/iri. del \.r'olojr. i)sy.lltdt,.. ll33-180, 1992 Curatt, C.H, Toknsend, M.; BeF man, L.8., and Kelle., J.L. A comparnon .f Likelt and visual ana,ogue sc.les f$ measulint chanSe ,n tun.tn)n /{J!rj,l o! Chrar'. Ds39 3E , 7 fri., .1(11129-111 Hans{,n, L, and Berglund, M. facrrs jnfluencint treaiment out .ohe anii p.tient satjsiaciion in a

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SCHIZOPHFENIA BULLETIN

A/chits af Clherdl Pslchittry, 35:177-180.1978.

dtugs A/./rnrs nf CefleralP;lrhiri r l , 3 8 : 1 8 7 - 1 9 01, 9 8 1

\ ' a n P l t t t e n ,T ; M a ) , P R . A r a n d \{arde!. SR Responseto aniipsychoti. mcdication: The docto.'s and ihe consumer'svieF. ,,lD?rt..r Iortnal af Psachiany,141:1G 19, 198.1.

Wensten, R Pahent attitudes tohard ment.l hosprtiljzation: A re' view oI quantitative res€aich./o!r nal .f Hedlth rnd Sacttl Bclloriot :0.237 256, 1979.

Van Putten, T; May, PR.-A.;\1a. de., S.R, and l{itthann, L.A. Sublectrve responseto antipsl. chotrc

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Itiller, R.D., and MiUe., C.H On the relationship ol dient satisfac' tion to client characteristicsand outcom. oi treatment. /o!ftal ot

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Ct$i.dt Pslchalagy,31:157160, 1978.

Stefan Priebe, Prieat-Dozent,lvlD, Drplom Psychoioge,is A.ting Head, and Thomas Cruyt€re, Diplom-Psychologe,is Reserrch Fellow, Depa.trent of Social Psl, chintry, i.eje Unjversrt:itBerlin,

Bulletin,Vo. 19, Schizoph,enia No. 4 1993 Schizophrenia)

Schizaphtenia Buletin: Val. 1A, N o .3 , 1 9 9 2 (lssuetherne:Firsl-Episode Bulletin,Va. 19, Schizophrcnta No 3, 1993 (Fealured iopcsi Eye-Trackrng Dyslunction, Neurob ology.and

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