Mobility of schizophrenic patients, non-psychotic patients and the general population in a case register area

Persons with schizophrenia migrate towards urban areas due to the development of their disorder or its prodromata

BACKGROUND

Many studies have identified urban-rural differences in the occurrence of schizophrenia. Though unknown, the underlying causes responsible for these differences have been hypothesized to include urban-rural differences in toxic exposures, diet, infections, stress, or an artifact due to selective migration. Freeman hypothesized that persons with schizophrenia migrate towards larger cities due to development of their disorder or its prodromata. Based on this, the reason for the high frequency of schizophrenia in urban areas is not that those affected have lived in environmentally unfavorable areas, but that people with schizophrenia selectively migrate towards urban areas due to disease onset. No population-based studies accessed the extent and potential impact of this artifact of selective migration.

METHODS

Utilizing a population-based sample of the Danish population, it was investigated if persons with schizophrenia more often migrated towards larger cities due to disease onset. The impact of selective migration on the urban-rural differences was quantified comparing a prospective and a retrospective study.

RESULTS

Compared to healthy controls, persons with schizophrenia spectrum disorder migrate to a higher degree of urbanization due to disease onset (OR=1.18 (1.14-1.23)). However, the bias in urban-rural effect sizes due to this artifact of selective migration was limited.

CONCLUSION

Persons with schizophrenia drift towards urban areas as a consequence of the disorder or its prodromata, but this drift has only limited impact on the urban-rural differences. Therefore, prospective and retrospective studies are both informative on the unknown underlying factor or factors responsible for the urban-rural differences in schizophrenia risk.

Treatment prevalence and incidence of schizophrenia in Quebec using a population health services perspective: different algorithms, different estimates

PURPOSE

Using a population health services perspective, this article defines and assesses an efficient criteria-based algorithm to identify treatment prevalent and incident cases of schizophrenia. We refer here "treatment" prevalence and incidence since its evaluation depends on a patient receiving a health care service with a diagnosis of schizophrenia.

METHODS

A population-based cohort study was conducted among all adults having a hospital discharge or a physician claim for schizophrenia in the public health plan databases between January 1996 and December 2006. Four algorithms to characterize patients with schizophrenia were defined. To identify treatment incident cases in 2006, we removed from the treatment prevalent pool patients with a previous record of schizophrenia between 1996 and 2006 (10-year clearance period). Using this 10-year period as reference, Kappa coefficients (KC) and positive predictive values (PPV) were calculated to determine the "optimal" length of clearance period to identify incident cases.

RESULTS

The lifetime treatment prevalence and incidence of schizophrenia varied from 0.59 to 1.46% and from 42 to 94 per 100,000, respectively. When compared to the 10-year clearance period, the KC is excellent in a clearance period of 6-7 years. To achieve a PPV of 90%, a clearance period of 7-8 years would be necessary.

CONCLUSIONS

With an appropriate algorithm, treatment prevalence and incidence of schizophrenia can be conveniently estimated using administrative data. These estimates are a vital step toward appropriate planning of services for schizophrenia.

Psychiatric bed usage under different systems of care. A comparison of South Verona (Italy) and Canberra (Australia)

Scopo - Confrontare l'uso dei servizi ospedalieri per le principali malattie psichiatriche in una struttura che offre un «servizio psichiatrico territoriale» (Verona-Sud, Italia) con l'uso di questi servizi in una struttura più «tradizionale», dove l'ospedale è il centro dell'attività (Canberra, Australia). Disegno - Sono stati esaminati i registri dei ricoveri per i malati da psicosi schizofreniche e distimiche negli anni 1986, 1987 e 1988. Sono state comparate le seguenti caratteristiche: la mappa socio-demografica ed i tassi dei ricoveri per i pazienti, la durata del ricovero iniziale ed i tassi di ri-ricovero per questi pazienti nei dodici mesi seguenti. Risultati - Il servizio psichiatrico territoriale (Verona-Sud) ha ricoverato meno pazienti con psicosi schizofreniche e distimiche ma questi risultavano più gravi, restavano degenti più a lungo ed avevano una probabilità maggiore di essere ricoverati nuovamente. Il servizio psichiatrico «tradizionale» (Canberra) ha usato l'ospedale per una gamma più ampia di malattie, incluse le malattie con buona prognosi. La degenza in Canberra è stata più breve ed il ri-ricovero meno frequente. Sembra che il servizio «tradizionale» sia più orientato ad usare l'ospedale per l'inizio o per la stabilizzazione della terapia. Il servizio psichiatrico territoriale non portava ad una degenza più breve o ad un numero minore di ricoveri successivi al primo. Le differenze nella morbilità psichiatrica incontrata nelle popolazioni ha nascosto l'effetto della struttura del servizio sull'uso. Questa differenza nella distribuzione della morbilitù psichiatrica concentrata nel gruppo di più giovane età, rimane senza spiegazione.

1. Trends in the provision of psychiatric care 1979–1988

The aim of this chapter is to present data on psychiatric care provided to adult South-Verona residents over the 10-year period (1979–88) following the psychiatric reform and the implementation of a new community-based service. These data have been collected using the South-Verona Psychiatric Case Register (PCR), which started operating immediately after the establishment of the new service.

5. Psychiatric morbidity in general practice

It is well known that the great majority of patients presenting psychiatric symptoms are treated by GPs rather than by specialist psychiatric personnel (Shepherd et al. 1966). Goldberg & Huxley (1980) have proposed a model to describe psychiatric disorders and their care, consisting of five levels and four filters. Level 1 refers to psychiatric and emotional disorders in the community as a whole, and filter 1 represents the decision to, and act of, consulting a GP. Level 2 consists of all psychiatric morbidity that presents to GPs, although a proportion is not recognized as such (the hidden psychiatric morbidity – HPM). Filter 2 is thus the process of identification, and level 3 refers to the morbidity so identified (the conspicuous psychiatric morbidity – CPM). Filter 3 is the process of referral to the specialist psychiatric services, the patients of which are designated as level 4. A proportion of patients at this level will be admitted to hospital (i.e. will pass through filter 4) and reach level 5 (psychiatric in-patients).

2. Psychopathology and social performance in a cohort of patients with schizophrenic psychoses. A seven-year follow-up study

The Italian psychiatric reform has attracted much interest and controversy around the world. While quantitative evidence on its implementation has already been provided (Tansella et al. 1987; de Girolamo, 1989), studies of the effects of the reform on patients are lacking.

3. Standardized assessment of the needs for care in a cohort of patients with schizophrenic psychoses

There is a well-established tradition in standardized evaluation of the symptomatology and the social performance of psychiatric patients (Wing et al. 1974; WHO, 1983b; Platt, 1983) together with instruments for describing the pattern of contacts with services, like Psychiatric Case Registers (Wing & Hailey, 1972; ten Horn et al. 1986). Interest in a systematic assessment procedure for recording which action should be taken by services in the presence of a problem is more recent. Instruments for these evaluations are still experimental.

6. Community care without mental hospitals: ten years' experience

‘That over-used word community’ (Acheson, 1985, p. 3) has tended to degenerate into a slogan, losing its meaning and becoming a generic expression to label different, not homogeneous functions and institutions. The numerous definitions of community psychiatric services and community care as well as their implications have been discussed elsewhere (Tansella, 1986).

Mental health and the city: Intra-urban mobility among individuals with schizophrenia

Intra-urban residential mobility of a cohort with schizophrenia was compared to a matched cohort with no mental illness using population-based administrative data. The percentage of individuals with one or more changes in postal code in the three-year mobility study period was examined, along with measures of the movement between different intra-urban areas. The schizophrenia cohort was more likely to move than the matched cohort; however, this depends on their age, income level, and area of residence at baseline. Age, gender, marital status, income quintile, and use of physicians and hospitalizations were associated with mobility. Individuals in the schizophrenia cohort were significantly more likely to move from the suburb to the inner city, and significantly less likely to move from the inner city to the suburb than those with no mental illness. Implications of the findings and directions for future research are discussed, with particular attention paid to the utility of administrative data for further mental health research.

Residential mobility of individuals with diagnosed schizophrenia: a comparison of single and multiple movers

BACKGROUND

Several studies have compared the residential mobility of individuals with schizophrenia to mobility of individuals with other mental disorders or with no mental disorders. Little research has been undertaken to describe differences between single (i.e., infrequent) and multiple (i.e., frequent) movers with schizophrenia, and the association between frequency of mobility and health and health service use.

METHODS

The data source is population-based administrative records from the province of Manitoba, Canada. Hospital separations and physicians claims are linked to health registration files to identify a cohort with diagnosed schizophrenia and track changes in residential postal code over time. Single movers (N = 736), who had only one postal code change in a 2.5-year observation period, are compared to multiple movers (N = 252), who had two or more postal code changes. Differences in demographic, socioeconomic, and geographic characteristics, measures of health service use, and the prevalence of several chronic diseases were examined using chi(2) tests, logistic regression, and generalized linear regression.

RESULTS

Multiple movers were significantly more likely to be young, live in socioeconomically disadvantaged neighborhoods, and reside in the urban core. The prevalence of a co-occurring substance use disorder and arthritis was higher for multiple than single movers. Use of acute and ambulatory care for schizophrenia, other mental disorders, as well as physical disorders was generally higher for multiple than single movers.

CONCLUSIONS

Frequency of mobility should be considered in the development of needs-based funding plans and service delivery interventions. Other opportunities to use record-linkage techniques to examine residential mobility are considered.

Residential Mobility and Severe Mental Illness: A Population-based Analysis

This research uses population-based administrative data linking health service use to longitudinal postal code information to describe the residential mobility of individuals with a severe mental illness (SMI), schizophrenia. This group is compared to two cohorts, one with no mental illness, and one with a severe physical illness of inflammatory bowel disease. The percentage of individuals with one or more changes in postal code in a 3-year period is examined, along with measures of rural-to-rural regional migration and rural-to-urban migration. Demographic, socioeconomic, and health service use characteristics are examined as determinants of mobility. The odds of moving were twice as high for the SMI cohort as for either of the other two cohorts. There were no statistically significant differences in rural-to-rural or rural-to-urban migration among the cohorts. Marital status, income quintile, and use of physicians are consistent determinants of mobility. The results are discussed from the perspectives of health services planning and access to housing.

A census-based socio-economic status (SES) index as a tool to examine the relationship between mental health services use and deprivation

This paper discusses the development and application of a socio-economic status (SES) index, created to explore the relationship between socio-economic variables and psychiatric service use. The study was conducted in a community-based mental health service (CMHS) in Verona, Northern Italy, utilising service use data from 1996. An ecological SES index was constructed through a factor analysis from 1991 Census data, at census block level. Three factors reflected the following domains: the educational-employment sector (with four components), the relational network (with three components) and the material conditions (with three components). All service users were assigned a SES value, according to their place of residence in 1996. When these data were explored spatially, using ArcView 8.3, an association was observed between socio-economic deprivation and psychiatric service use. The SES index was then successfully validated using occupational status at the individual level. This study confirms the usefulness of developing and validating an ecological census-based SES index, for service planning and resource allocation in an area with a community-based system of mental health care.

Does socioeconomic status affect the use of community-based psychiatric services? A South Verona case register study

OBJECTIVE

To assess the effect of socioeconomic status (SES) on psychiatric service use in an Italian area with a well-developed community-based psychiatric service.

METHOD

An index of SES was calculated from nine census variables and grouped into four categories, ranging from SES-I-affluent to SES-IV-deprived, for each of 328 census blocks (CB). Fifteen indicators of psychiatric service use were collected using the psychiatric case register. All patients resident in the catchment area, who had at least one psychiatric contact in 1996 (n=989), were included in the study.

RESULTS

Indicators of in-patient, day-patient, out-patient and community service use showed an inverse association with SES. Only first-ever and long-term psychotic patients were equally distributed in the four SES groups.

CONCLUSION

The inverse association between SES and most indicators of psychiatric service use suggests that the planning of community-based services and resource allocation should take into account the SES of residents.

Gender-specific decline and seasonality of births in operationally defined schizophrenics in Italy

All clinical records of schizophrenic patients included in the period 1979-1995 in the South Verona Psychiatric Case Register were reviewed and diagnoses operationally defined according to ICD-10 criteria using OPCRIT 3.1. Among the 335 scrutinized, 205 patients met the ICD-10 criteria for paranoid or undifferentiated schizophrenia. No seasonality of birth was found in these patients using a log-linear equiprobability model. The incidence and seasonality of birth were then analysed on the subsample of 106 patients born in 1947-1974 for whom corresponding data for the Verona general population were available. Schizophrenic males displayed a significant excess of birth in November-January with respect to the Verona population (chi 2 = 10.93, p = 0.012). The time series of the incidence of schizophrenia by cohort of birth 1947-1974 had a linearly decreasing trend, steeper in males than in females. The significant increase in age at first ever psychiatric contact, observed in both males and females throughout the period considered, cannot completely account for the gender-specific decline of birth of schizophrenics.

The Hampstead Schizophrenia Survey 1991. II: Incidence and migration in inner London

BACKGROUND

The previous paper reports a high prevalence of schizophrenia (broad definition) in an inner London area. In this paper we test hypotheses for this finding and examine the characteristics of people with schizophrenia who move frequently.

METHOD

People with schizophrenia in the Hampstead area were identified by key informant methodology, at two censuses five years apart. This allowed identification of incident cases during these five years and identification of people who had moved into and out of the area.

RESULTS

The incidence of DSM-III-R schizophrenia in Hampstead between 1986 and 1991 was at least 0.21 per 1000 of the population aged 15 to 54. There was a significant movement of people with schizophrenia to this inner London area from outer London between 1986 and 1991. People with schizophrenia who were relatively mobile were significantly more likely to be male, to suffer with prominent hallucinations, and to have no contact with a GP.

CONCLUSIONS

The high prevalence of broad schizophrenia in this inner London area is, in part, due to geographical drift. A significant excess of the people with schizophrenia who move frequently are men with positive symptoms.

Are social deprivation and psychiatric service utilisation associated in neurotic disorders? A case register study in south Verona

Measures of service utilisation from the South Verona psychiatric case register in North-East Italy for the years 1983, 1986 and 1989 were used to identify possible associations with sociodemographic variables from the 1981 census for neurotic disorders. There were no consistent patterns of associations between local social and demographic predictors and rates of psychiatric service utilisation. This contrasts markedly with the associations found previously in England (for all psychiatric admissions) and in Italy (for various measures of service utilisation concerning contacts both in and outside hospital for schizophrenic as well as for all psychiatric patients) where social deprivation factors proved to be strong predictors of service use.

Urban-rural differences in the associations between social deprivation and psychiatric service utilization in schizophrenia and all diagnoses: a case-register study in Northern Italy

Service utilization measures from the psychiatric case registers for urban South-Verona and rural Portogruaro in North East Italy for the period 1983-9 were used to identify associations with socio-demographic variables from the 1981 census in schizophrenia and related disorders as well as in all diagnoses. The patterns of service use were broadly similar, except that Portogruaro has significantly more community contacts, and has about twice the treated incidence and prevalence of schizophrenia. The census data showed that unmarried and unemployed people were more likely to live alone in the urban than in the rural area. In South-Verona the most strongly associated predictor variables, both for schizophrenia and all diagnoses, are: living alone, unemployment, percentage of the total population who are dependents and the percentage who are divorced, separated or widowed. In contrast, in Portogruaro there were no consistent associations between census and service use variables. Stepwise multiple regression models using three census predictor variables accounted for over 85% of the variance in South-Verona utilization rates. The results indicate that the strongly predictive associations previously described in England hold in urban South-Verona, but not in rural Portogruaro, and may be related to the effect of cities in clustering seriously disabled psychiatric patients in areas of low-cost housing where they live in relative social isolation.

Patterns of care for chronic patients after the Italian psychiatric reform. A longitudinal case register study

A comprehensive and well-integrated community-based system of psychiatric services has been developed in South-Verona since the Italian psychiatric reform. Using the South-Verona Psychiatric Case Register, we identified chronic psychiatric patients in the community over a 6-year period after the reform. Six first-contact sociodemographic variables (sex, age, marital status, living situation, education, occupational status) and two clinical variables (ICD-9 diagnosis and past history of state psychiatric hospital admission) were studied for these patients. Four full cohort-years of post-reform chronic patients were followed for a 2-year period to determine their subsequent patterns of care. Logistic analysis was used to examine the interaction of cohort-year with outcome and the above sociodemographic and clinical variables studied individually and in combination. We found that 36.4% of post-reform chronic patients in the community remained in long-term contact with psychiatric services for 2 years after they were first identified. Logistic analysis revealed that none of the sociodemographic and clinical variables studied individually or in combination were predictive of the probability of remaining in long-term contact with community psychiatric services.