Schizophrenia is a mental disorder characterized by abnormal perception and expression of reality. Relapses and recurrent admissions are common as a result of certain risk factors, such as poor compliance to medication, comorbidity with drug abuse, stressors, nature of the disorders, among others. Fortunately, most of these risk factors are controllable and relapses can be delayed or minimized.
This cross sectional study was conducted at Abha Psychiatric Hospital (APH), the only governmental hospital specialized in management of psychiatric disorders in Abha and nearby villages and towns. It has a 100-bed capacity. The objectives of the study was to investigate the risk factors responsible for relapses and recurrent admissions of schizophrenic patients in order to provide recommendations for possible solutions for their prevention and control. Data was collected by review of medical records. The sample included all schizophrenic patients who had been admitted into the hospital three times or more per year, in the period from July 2007 to July 2009.
A total of 140 schizophrenic patients met the inclusion criteria. Their age ranged from 17 to 60 years (mean 38 ±10). The highest age group was between 36-45 years old (47.1%). All patients were Saudis; 98 (70.0%) were males and 42 (30.0%) were females. The age of onset of schizophrenia ranged between 15-34 years (mean 22.4 ± 4.5). The majority of relapsing schizophrenics were males; in the age group 36-45 years (mean 38 ±10). Most were single, never married (58.6%), with poor educational level (31.4% illiterates and 40.0% primary school level). The number of times of readmission into hospital in the previous 2 years as a result of relapses were 3 times (22 patients 15.7%), 4 times (36 patients 25.7%), 5 times (24 (17.1%), and 6 times and above (58 patients 41.4%). Average durations of hospitalization is demonstrated in Figure 1.
The most common reasons for relapses and readmission were poor compliance to treatment followed by comorbidity of substance abuse. The majority (78.6%) had been readmitted for the first time as a result of poor compliance to treatment, followed by comorbidity of substance abuse (15.7%). Reasons for the second readmission were also poor compliance to treatment (64.3%), followed by substance abuse (18.6%). Reasons for the third readmission were also poor compliance to treatment (62.9%), followed by substance abuse (22.9%).
Twenty four percent of patients were on old generation antipsychotic tablets only, 74.3% were on depot of long acting antipsychotics besides the tablets, and only 1.4% was on new generation antipsychotic tablets as pre-lapse medication. Discharge medication of old generation antipsychotic tablets was given to 2.9% of patients, old antipsychotic tablets with depot injection to 48.6% and new antipsychotics tablets with depot injection to 32.9%. Patients on atypical antipsychotic tablets with depot long acting injections of typical antipsychotics as a treatment in the post-relapsing stage were found to have fewer relapses.
Editorial note:
Schizophrenia is a social, economic and health burden on patients’ families, the community and the ministry of health of any country.1 Many intervention programs have been designed worldwide to prevent relapses of schizophrenic patients.2A study conducted in New York, USA, showed that crises intervention by increasing antipsychotic medication through a program for relapse prevention among schizophrenics applied to detect prodromal symptoms of relapse was very effective in reducing relapses and re-hospitalization.3
Some psychiatric patients stay in the hospitals for months or even years for social reasons, thus permanently occupying hospital beds, causing the bed capacity of a psychiatric hospital to be actually lower that it should. The turnover in such hospitals is faster for some patients in order to cope with others who are in need for admission. A policy implemented in some psychiatric hospitals, known as ‘premature discharge’, allows the hospital to discharge some patients if they were partially improving on psychiatric medication if there were no vacant beds in order to be able to admit others.
Poor compliance or non-adherence to antipsychotic medication in addition to comorbidity with substance abuse were the most common risk factors of relapses and frequent readmissions. Stressful life events, short stay of hospitalization, and residing close to the hospital also contributed to readmission into hospital, which is in concordancewith findings of other studies.4,5
The study also demonstrated that patients who were on the new generation of antipsychotics (atypical antipsychotics) had less number of admissions compared to those who were still on old generation antipsychotics, which is also similar to findings of previous studies.6
It was recommended to increase the bed-capacity of the hospital, and provide it with an equipped addiction department in order to prevent relapses and readmissions as a result of substance abuse. The duration of hospitalization of schizophrenic patients should be revised by the treating psychiatrists to control for premature discharge and future relapses. New generation antipsychotics should be considered to prevent relapses as a result of poor compliance to treatment due to the unpleasant side effects of the old generation of antipsychotics. Patients should be encouraged towards adherence to antipsychotic treatment.
References:
1.Serretti A, et al. The socio-economical burden of schizophrenia: A simulation of cost-offset of early intervention program in Italy. European Psychiatry. 2009; 24(1):11-16
2.Spaniel F et al. The information technology aided relapse prevention programme in schizophrenia: an extension of a mirror-design follow-up. International journal of clinical practice. 2008; 62(12):1943-1946.
3.Hertz MI et al. A program for relapse prevention in schizophrenia. Arch General Psychiatry. 2000; 57(3): 277-283.
4.Morken G, Widen JH, Grawe RW. Non-adherence to antipsychotic medication, relapse and rehospitalisation in recent-onset schizophrenia. BMC Psychiatry. 2008;8: 32.
5.Silva NC, Bassani DG, Palazzo LS. A Case-Control Study of Factors Associated With Multiple Psychiatric Readmissions. Psychiatr Serv. 2009; 60: 786-791.
6.Schooler NR. Relapse and rehospitalization: comparing oral and depot antipsychotics. J Clin Psychiatry. 2003; 64(16): 14-7.