Long-term course of hospitalization for schizophrenia: Part II. Change with passage of time

Differential Effect of Community Rehabilitation Reform on Hospitalizations of Patients with Chronic Psychotic Disorders With and Without Substance Use Disorder, Israel, 1991-2016

The co-occurrence of schizophrenia and substance use disorder (SUD) is clinically challenging and increasingly prevalent. This study compares trends in hospitalization characteristics of chronic psychotic patients with and without SUD in Israel, before and after introduction of the Community Rehabilitation of Persons with Mental Disability Law in 2000. The National Psychiatric Case Registry provided data on 18,684 adults with schizophrenia/schizoaffective disorders, hospitalized in 1991-2016 (at least once in 2010-2015). Repeated-measures ANOVA was used to measure the effect (and interactions) of group (patients with and without co-occurring disorders (COD)), time-period (Period₁: 1991-2000, Period₂: 2001-2009, Period₃: 2010-2016) and age, on hospitalization measures-average length of stay (LOS), annual number of hospitalizations and hospitalization days. Among non-COD patients hospitalized in all three periods, LOS declined by half from 133.3 days in Period₁ to 63.2 in Period₃, and the annual number of hospitalizations increased slightly from 0.45 to 0.56. Among COD patients, LOS declined moderately from 82.7 days to 58.3 days, while annual hospitalizations increased dramatically from 0.56 to 0.82. The annual average number of hospitalization days/capita declined from 49.7 in Period₁ to 26.3 in Period₃ among non-COD patients, yet remained virtually unchanged among COD patients-39.6 and 37.4 in the two periods, respectively. Since introduction of the law, a significant improvement in hospitalization characteristics of chronic psychotic non-COD patients has been noted, whereas the situation worsened somewhat for COD patients. Community rehabilitation services for COD patients in Israel have yet to develop as a suitable alternative to hospitalization, and additional rehabilitation services are urgently needed.

Schizophrenia as a progressive brain disease

There is convincing evidence that schizophrenia is characterized by abnormalities in brain volume. At the Department of Psychiatry of the University Medical Centre Utrecht, Netherlands, we have been carrying out neuroimaging studies in schizophrenia since 1995. We focused our research on three main questions. First, are brain volume abnormalities static or progressive in nature? Secondly, can brain volume abnormalities in schizophrenia be explained (in part) by genetic influences? Finally, what environmental factors are associated with the brain volume abnormalities in schizophrenia?

Based on our findings we suggest that schizophrenia is a progressive brain disease. We showed different age-related trajectories of brain tissue loss suggesting that brain maturation that occurs in the third and fourth decade of life is abnormal in schizophrenia. Moreover, brain volume has been shown to be a useful phenotype for studying schizophrenia. Brain volume is highly heritable and twin and family studies show that unaffected relatives show abnormalities that are similar, but usually present to a lesser extent, to those found in the patients. However, also environmental factors play a role. Medication intake is indeed a confounding factor when interpreting brain volume (change) abnormalities, while independent of antipsychotic medication intake brain volume abnormalities appear influenced by the outcome of the illness.

In conclusion, schizophrenia can be considered as a progressive brain disease with brain volume abnormalities that are for a large part influenced by genetic factors. Whether the progressive volume change is also mediated by genes awaits the results of longitudinal twin analyses. One of the main challenges for the coming years, however, will be the search for gene-by-environment interactions on the progressive brain changes in schizophrenia.

Psychiatric hospitalization following psychosis onset: A retrospective cohort study using health administrative data

AIM

There is limited evidence examining admissions in early psychosis. We sought to estimate the proportion of people with a psychiatric admission within 2 years of the first diagnosis of psychosis, and to identify associated risk factors.

METHOD

We constructed a cohort of incident non-affective psychosis cases using health administrative data and identified the first psychiatric hospitalization after psychosis onset. We compared hospitalization rates across sociodemographic, clinical and service-use factors.

RESULTS

One in three patients had an admission within 2 years of first diagnosis. Younger age, migrant status, diagnosis of psychosis not otherwise specified, and prior substance use were associated with increased hospitalization rates, whereas family physician involvement in diagnosis was protective.

CONCLUSIONS

Adolescents, immigrants and people presenting with diagnostic instability or prior substance use issues may benefit from interventions aimed at reducing hospitalization risk. Increasing primary care access and utilization among youth with early psychosis may also reduce hospitalization rates.

Age at onset and the outcomes of schizophrenia: A systematic review and meta-analysis

The aim of this study was to analyse the effect of age at onset on the long-term clinical, social and global outcomes of schizophrenia through a systematic review and a meta-analysis. Original studies were searched from Web of Science, PsycINFO, Pubmed and Scopus, as well as manually. Naturalistic studies with at least a 2-year follow-up were included. Of the 3509 search results, 81 articles fulfilled the inclusion criteria. The meta-analysis was performed in Stata as a random-effect analysis with correlation coefficients between age at onset and the outcomes (categorized into remission, relapse, hospitalization, positive symptoms, negative symptoms, total symptoms, general clinical outcome, employment, social/occupational functioning and global outcome). There was a statistically significant (P < .05) correlation between younger age at onset and more hospitalizations (number of studies, n = 9; correlation, r = 0.17; 95% confidence interval, CI 0.09-0.25), more negative symptoms (n = 7; r = 0.14; 95% CI 0.01-0.27), more relapses (n = 3; r = 0.11; 95% CI 0.02-0.20), poorer social/occupational functioning (n = 12; r = 0.15; 95% CI 0.05-0.25) and poorer global outcome (n = 13; r = 0.14; 95% CI 0.07-0.22). Other relationships were not significant. This was the first systematic review of the effects of age at onset on the long-term outcomes of schizophrenia. The results show that age at onset has a small, but significant impact on some of the outcomes of schizophrenia.

Regional differences in treatment response and three year course of schizophrenia across the world

Data from the Worldwide-Schizophrenia Outpatient Health Outcomes (W-SOHO) study was used to determine the frequency of response and describe the course of disease in outpatients with schizophrenia in different regions of the world. The W-SOHO study was a 3-year, prospective, observational study that included over 17,000 outpatients with schizophrenia from 37 countries classified into six regions (Northern Europe, Southern Europe, Latin America, East Asia, Central & Eastern Europe, North Africa & Middle East). Cox proportional-hazards regression was employed to assess the factors associated with response. Multinomial logistic regression was used to assess the correlates of disease course. We found that approximately two-thirds of the patients (66.4%) achieved response during the 3-year follow up. Response rates varied across regions, and were highest in North Africa & Middle East (84.6%) and Latin America (78.6%) and lowest in Southern Europe (62.1%) and East Asia (60.9%). There were significant differences between the regions in the proportion of patients experiencing continuous remission, remission plus relapse and a persistent symptomatic course, and between the regions in the duration of remission. Overall, Latin America, East Asia, and North Africa & Middle East had more favorable outcomes because they had the largest proportion of people who achieved continuous remission, the longest time in remission and lowest percentage with a persistent symptomatic course. Having good social functioning at baseline was consistently associated with better clinical outcome. These results seem to indicate that patients from Latin America, East Asia, North Africa & Middle East may have a more favorable disease course than patients from European nations.

Register-based studies of mental disorders

Introduction: Denmark has been pioneering international psychiatric register research for decades. In this article we review central publications, by Danish and international authors, based on data from the Danish Psychiatric Central Research Register and other related registers. Research topics: Our aim was to describe the history, development and achievements of psychiatric research, based on the Danish national registers. The studies considered in this review can be categorized as follows: i) health service research, mainly studies on prevalence and incidence, ii) studies on the outcome of mental disorders, iii) studies on the aetiology of mental disorders. Conclusion: Studies based on Danish registers have provided significant contributions to international psychiatric research. The major advantage of the registers is that they cover the entire population, which makes the conduction of nationwide population-based studies possible. Furthermore, all information in the registers is connected to each citizen’s unique personal identification number, which enables linkage between various registers and biobanks. Such linkage studies have provided important knowledge on the aetiology of mental disorders. Despite inherent limitations about internal and external validity, the Danish national registers have been extremely valuable to international psychiatric research and will continue to play an important role in years to come.

Analysis of recurrent gap time data using the weighted risk-set method and the modified within-cluster resampling method

The gap times between recurrent events are often of primary interest in medical and epidemiology studies. The observed gap times cannot be naively treated as clustered survival data in analysis because of the sequential structure of recurrent events. This paper introduces two important building blocks, the averaged counting process and the averaged at-risk process, for the development of the weighted risk-set (WRS) estimation methods. We demonstrate that with the use of these two empirical processes, existing risk-set based methods for univariate survival time data can be easily extended to analyze recurrent gap times. Additionally, we propose a modified within-cluster resampling (MWCR) method that can be easily implemented in standard software. We show that the MWCR estimators are asymptotically equivalent to the WRS estimators. An analysis of hospitalization data from the Danish Psychiatric Central Register is presented to illustrate the proposed methods.

Trajectories of the course of schizophrenia: from progressive deterioration to amelioration over three decades

BACKGROUND

The extent of heterogeneity in the long-term course of schizophrenia is unclear.

AIMS

To examine the course of schizophrenia in a population-based cohort.

METHODS

This study included all Israeli individuals born in 1970-1988, of North African or European origin (N=2290), entered in the National Psychiatric Hospitalization Case Registry with a last discharge diagnosis of schizophrenia (1978-2004) and followed to 2009. Linked socio-demographic information was extracted from the Population Registry. Based on the number of hospitalized days at each age, trajectory groups were empirically derived, plotted and compared on psychiatric hospitalization measures of the course of illness, social factors and family stressors.

RESULTS

Trajectory analysis identified four course groups. Group I (57%) assumed a prototypical course, had an average first hospitalization age of 20, deteriorated until 23 and then ameliorated. Group II (15.5%) assumed an early-onset protracted course, had an average first hospitalization age of 17.1, and deteriorated until 21. Group III (15%) assumed a late-onset with longest deterioration period course, had an average first hospitalization age of 22.7, and deteriorated until 29. Group IV (12%) assumed an early-onset refractory illness course, had an average first hospitalization age of 18, and had the longest hospitalization period. Groups significantly differed on hospitalization (i.e., onset), social (i.e., socioeconomic and ethnic status) and familial factors (i.e., parental death). Despite group differences all deteriorated and then ameliorated on average by the age of 23.

CONCLUSIONS

The course of schizophrenia was heterogeneous, yet evolved from deterioration to assume a course consistent with amelioration.

Schizophrenia, an illness with bad outcome: myth or reality?

OBJECTIVE

Different myths about schizophrenia endorsed by clinicians maintain the pessimism about outcome thus reducing chances of improvement. There are no recent North American studies on the long-term outcome of first-episode schizophrenia to clarify if these beliefs are myths or reality. Our study describes the long-term outcome (10 to 16 years) of a first-episode schizophrenia incidence cohort (n = 142) in a Canadian urban centre between 1983 and 1999.

METHOD

Clinical and social functioning at different time points were assessed retrospectively from medical files of a catchment area hospital in Montreal. Service use and deaths were noted from provincial databases of physician billings, hospitalization, and vital statistics.

RESULTS

Hospitalization days decreased considerably after the first year, with a small minority still needing it episodically after 4 years. Marital and occupational status were generally stable over time, but autonomy in living arrangements worsened. Thirty-three percent of subjects quit the Catchment Area Specialized Psychiatric Services. This group showed better social functioning while they were followed, were hospitalized less afterwards, and had fewer suicides, therefore indicating a better outcome for them. At the end of our study, 15% of the patients still alive were well enough to function without seeking medical help and 25% were not taking antipsychotic medication. Better outcome was predicted by older age at admission, being married, higher premorbid autonomy in living arrangements, and female sex.

CONCLUSION

A significant proportion of first-episode schizophrenia patients achieve moderate long-term outcome, and the stability of global functioning is more frequent than deterioration, as shown in most industrialized countries.

Trajectories and antecedents of treatment response over time in early-episode psychosis

BACKGROUND

Little is known about the extent of heterogeneity of symptomatology in treated early-onset psychosis. The current study aims to quantify the extent of heterogeneity in trajectories of treated symptom severity in early-episode psychosis and their antecedents.

METHODS

Data were from 491 persons with early-episode psychosis from a clinical trial of haloperidol and risperidone. Positive and Negative Syndrome Scale (PANSS) administrations were used to measure symptom severity trajectories for (a) rapid treatment response scores over 4 weeks and (b) medium-term course over 24 weeks. Baseline antecedents included sex, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis, age of onset, the Premorbid Adjustment Scale, and a cognitive test battery. Symptom severity trajectories were calculated with mixed mode latent class regression modeling from which groups were derived.

RESULTS

Five groups based on PANSS scores over time were identified. Over 4 weeks, 3 groups with varied baseline PANSS scores (54-105) did not surpass 30% PANSS improvement. Another group improved and then was stable (n = 76,15.3%), and another showed marked improvement (n = 94,18.9%). Logistic regression showed that membership in the best response trajectory was associated with not having a diagnosis of schizophrenia, good premorbid functioning, and higher cognitive functioning, whereas membership in the poor response trajectory was associated with earlier age of onset and poorer cognitive functioning.

CONCLUSION

Amelioration generally characterizes treated symptom severity. Age of onset, diagnosis, cognitive functioning, and premorbid functioning have prognostic value in predicting treatment response trajectories.

Multifamily psychoeducation for first-episode psychosis: a cost-effectiveness analysis

OBJECTIVE

Family psychoeducation is considered part of optimal treatment for first-episode psychosis, but concerns about the cost of this intervention have limited its availability. Although evidence suggests that family psychoeducation is cost-effective, many cost-effectiveness analyses have suffered from limitations that reduce their utility in guiding decisions to incorporate this intervention within existing clinical services. These include not presenting results in present-day dollars and not examining whether the intervention would remain cost-effective in situations where the clinical benefits achieved were smaller than those reported in past studies. Thus the goal of this study was to investigate the cost of providing a specific psychoeducation program-multifamily group psychoeducation-to individuals with first-episode psychosis and their families.

METHODS

Statistical simulation was used to estimate the cost and burden of illness associated with usual treatment versus usual treatment plus multifamily group psychoeducation. In addition, the simulation model was rerun to test whether multifamily psychoeducation would remain cost-effective in situations where the clinical benefits achieved were smaller than those reported in past studies.

RESULTS

When provided for two years, multifamily group psychoeducation ranged from a cost-effective to a cost-saving intervention, depending on the clinical benefits achieved by staff delivering the intervention. When provided for longer durations (five, ten, or 20 years), multifamily psychoeducation was a cost-saving intervention even in scenarios where the clinical benefits of the intervention were reduced by 90%.

CONCLUSIONS

The results suggest that multifamily group psychoeducation may not only be a cost-effective intervention for first-episode psychosis but may often be a cost-saving intervention.

Auditory cortex asymmetry, altered minicolumn spacing and absence of ageing effects in schizophrenia

The superior temporal gyrus, which contains the auditory cortex, including the planum temporale, is the most consistently altered neocortical structure in schizophrenia (Shenton ME, Dickey CC, Frumin M, McCarley RW. A review of MRI findings in schizophrenia. Schizophr Res 2001; 49: 1-52). Auditory hallucinations are associated with abnormalities in this region and activation in Heschl's gyrus. Our review of 34 MRI and 5 post-mortem studies of planum temporale reveals that half of those measuring region size reported a change in schizophrenia, usually consistent with a reduction in the left hemisphere and a relative increase in the right hemisphere. Furthermore, female subjects are under-represented in the literature and insight from sex differences may be lost. Here we present evidence from post-mortem brain (N = 21 patients, compared with 17 previously reported controls) that normal age-associated changes in planum temporale are not found in schizophrenia. These age-associated differences are reported in an adult population (age range 29-90 years) and were not found in the primary auditory cortex of Heschl's gyrus, indicating that they are selective to the more plastic regions of association cortex involved in cognition. Areas and volumes of Heschl's gyrus and planum temporale and the separation of the minicolumns that are held to be the structural units of the cerebral cortex were assessed in patients. Minicolumn distribution in planum temporale and Heschl's gyrus was assessed on Nissl-stained sections by semi-automated microscope image analysis. The cortical surface area of planum temporale in the left hemisphere (usually asymmetrically larger) was positively correlated with its constituent minicolumn spacing in patients and controls. Surface area asymmetry of planum temporale was reduced in patients with schizophrenia by a reduction in the left hemisphere (F = 7.7, df 1,32, P < 0.01). The relationship between cortical asymmetry and the connecting, interhemispheric callosal white matter was also investigated; minicolumn asymmetry of both Heschl's gyrus and planum temporale was correlated with axon number in the wrong subregions of the corpus callosum in patients. The spacing of minicolumns was altered in a sex-dependent manner due to the absence of age-related minicolumn thinning in schizophrenia. This is interpreted as a failure of adult neuroplasticity that maintains neuropil space. The arrested capacity to absorb anomalous events and cognitive demands may confer vulnerability to schizophrenic symptoms when adult neuroplastic demands are not met.

Recovery as perceived by people with schizophrenia, family members and health professionals: A grounded theory

BACKGROUND

Advances in knowledge in the biomedical and psychosocial sciences have expanded our understanding of schizophrenia and of how it evolves in people living with it. These individuals are no longer viewed as being 'ill' and requiring long-term hospitalisation. We have come instead to have a much more positive view of them and of the role they can play in coming to terms both with their health condition and with society. In the majority of cases, schizophrenia sufferers have the potential to recover.

AIMS

The purpose of this study is to propose a theoretical explanation of recovery based on the concept of human responses put forward by the American Nurses' Association.

PARTICIPANTS

Data were collected from 41 participants (16 people living with schizophrenia, 5 family members, 20 health professionals). Selection criteria required the people living with schizophrenia to be in stable health, see themselves as being in the process of recovery, and be able to speak about it. Family members were expected to have displayed a strong bond with their relative living with schizophrenia, and the health professionals to have had at least 3 years experience dealing with schizophrenia patients.

METHOD

The Grounded Theory approach was selected because it allows for diversified data sources to be used in the empirical study of a phenomenon. It is an appropriate approach for the conceptualization of complex phenomena and the development of middle-range theory. To ensure a variety of subjects were involved, semi-structured interviews were conducted in three different settings: a specialised psychiatric hospital, a self-help group, and a community setting.

FINDINGS

Seven categories emerged from the analysis and conceptualization: perceiving schizophrenia as a 'descent into hell'; igniting a spark of hope; developing insight; activating the instinct to fight back; discovering keys to well-being; maintaining a constant equilibrium between internal and external forces; and, finally, seeing light at the end of the tunnel. Comparison of these categories led to their being consolidated into a core category in which recovery is defined as a 'process involving intrinsic, non-linear progress that is primarily generated by the role as actor that the individual adopts to rebuild his or her sense of self and to manage the imbalance between internal and external forces with the objective of charting a path through the social world and regaining a sense of well-being on all biopsychosocial levels.'

CONCLUSION

This study of recovery from schizophrenia is conceptualised from the nursing perspective: the concept of 'Human Responses' [American Nurses Association (ANA), 1980. Nursing: A Social Policy Statement. ANA, Kansas City, MO; American Association of Neuroscience Nurses (AANN's), 2001. AANN's Neuroscience Nursing: Human Responses to Neurologic Dysfunction, second ed. W. B. Saunders Company, Philadelphia]. It was possible to go beyond a descriptive analysis and bring out the dynamics of the process through a detailed, in-depth presentation of the recovery process. The theoretical explanation we have postulated is based on the inner resources of individuals diagnosed with schizophrenia and their potential to make a recovery.

Predictors of the course of illness in outpatients with schizophrenia: a prospective three year study

The course of schizophrenia includes a combination of periods of remission and relapse. Previous studies focused on simple dichotomous outcomes and did not take into account the complexity of the course. Using data from a large 3-year follow-up study of schizophrenia, we described the different courses of schizophrenia. Of the 5950 patients with complete 3-year data, 38.7% never achieved remission (prolonged course), 15.7% achieved remission but relapsed and 45.7% achieved and maintained remission (persistent remission). Females, patients with better social functioning at baseline (living independently, in paid employment, socially active or having a spouse or partner) and with a shorter duration of illness had a more favourable course. Patients prescribed risperidone, quetiapine or depot typicals at the baseline visit were more likely to have a prolonged course than patients who started olanzapine. The results show that description of the long-term outcome of schizophrenia cannot be summarized with just one outcome variable.

Social predictors of out-patient mental health contact in schizophrenia patients

INTRODUCTION

Since community-based health care was introduced, the use of mental health services by patients with serious mental disorders has been an issue of much interest. However, our knowledge of intervening factors is both scarce and partial.

OBJECTIVE

To study socio-demographic variables which may predict time-lapse (in days) between each out-patient contact among a cohort of schizophrenia patients.

METHOD

Data comes from the South Granada Schizophrenia Case Register. We used Cox's regression analysis to study the influence of the socio-demographic variables in the time lapsed between out-patient contacts.

RESULTS

After adjusting for all other socio-demographic variables included, we found that to live in a rural area and being younger independently predicted a longer time-lapse between out-patient contacts while being retired predicted a shorter interval between such contacts. Other variables such as sex, educational level and marital status did not determine such length between out-patients contacts.

CONCLUSION

Socio-demographic variables, and not only psychopathological ones, determine mental health out-patient service use.

The course of schizophrenia: progressive deterioration, amelioration or both?

BACKGROUND

Schizophrenia may follow a course of amelioration, deterioration or stability. It is possible that deterioration at the aggregate level may be due to a sub-group of patients with a tendency to deteriorate.

AIMS

To examine the course of schizophrenia in a national population-based cohort.

METHODS

All first admissions for schizophrenia in Israel 1978-1986 were followed for readmissions in the Israeli psychiatric hospitalization registry for 10 years (n=6865). Readmission rates were examined using cluster analysis. This was followed by an examination of changes in readmission patterns.

RESULTS

Cluster analysis identified a small cluster of patients who spent more days in the hospital over time and two clusters that improved. A priori classification of the patients into deteriorating, improving and stable (based on days hospitalized per year) revealed that approximately 75% of patients improved over time.

CONCLUSIONS

Over time a majority of patients appear to improve and a minority appear to deteriorate.

Remission and relapse in the outpatient care of schizophrenia: three-year results from the Schizophrenia Outpatient Health Outcomes study

Remission and relapse are clinical outcomes of increasing interest in schizophrenia. We analyzed remission and relapse, and the sociodemographic and clinical factors associated with these outcomes, in the usual care of schizophrenia using the 3-year, follow-up data from a large cohort of outpatients with schizophrenia taking part in the prospective, observational, European Schizophrenia Outpatient Health Outcomes study. Of the 6516 patients analyzed for remission, 4206 (64.6%) achieved remission during the 3-year, follow-up period. Logistic regression analysis revealed that being female, having a good level of social functioning at study entry, and a shorter duration of illness were factors significantly associated with achieving remission. Treatment with olanzapine was also associated with a higher frequency of remission compared with other antipsychotic agents. A Kaplan-Meier survival curve estimated that relapse occurred in approximately 25% of the patients who achieved remission, with the risk of relapse remaining constant during the follow-up period. Shorter duration of illness, having hostile behaviors, and substance abuse were factors associated with a higher risk of relapse, whereas good level of social functioning and the use of olanzapine and clozapine were associated with a lower risk of relapse. In conclusion, the 3-year results of the Schizophrenia Outpatient Health Outcomes study indicate that the likelihood of remission decreases over the longitudinal course of schizophrenia, but risk of relapse is maintained even after 3 years of achieving remission severity levels. Results suggest that treatment with olanzapine is associated with a better chance of achieving remission than other antipsychotics. Moreover, the use of olanzapine and clozapine is associated with a lower risk of relapse compared with risperidone, quetiapine, and typical antipsychotics. The results should be interpreted conservatively because of the observational, nonrandomized study design.

Early-onset of symptoms predicts conversion to non-affective psychosis in ultra-high risk individuals

OBJECTIVE

We examined if age of onset of psychiatric symptoms and/or sex predict conversion to non-affective or affective psychosis in individuals considered to be at ultra-high risk for schizophrenia.

METHOD

Participants (n=86) were offered treatment and monthly follow-up until transition to psychosis, or for 12 months if they did not meet exit criteria for psychotic disorder. Individuals without transition to psychosis at 12-month were reassessed approximately 3 years after the end of the treatment phase. Ultra-high risk was defined by the presence of subthreshold and/or self-limiting psychotic symptoms and/or having a family history of psychotic disorder combined with functional decline. Cox regressions after adjustment for treatment interventions were applied to investigate associations between age of onset, sex, and other baseline measures with progression to psychotic outcomes.

RESULTS

Early age of onset of psychiatric symptoms, in particular onset before age 18 was the only tested variable that significantly predicted non-affective psychosis. Independent significant predictors of affective psychosis were poor functioning, female sex and the presence of a combination of intake criteria (family history of psychosis plus drop in functioning, and attenuated and/or brief limited psychotic symptoms) at baseline.

CONCLUSIONS

Age of onset of psychiatric symptoms is the single most important factor associated with conversion to non-affective psychosis in ultra-high risk individuals.

Pattern of health service utilization and predictors of readmission after a first admission for psychosis: a 2-year follow-up study

OBJECTIVE

To explore the pattern of health service utilization over 2 years following a first admission for psychosis and the baseline characteristics predicting readmission.

METHOD

Patients included in a cohort of first-admitted subjects with psychosis (n = 84) were assessed at the end of a 2-year follow-up using multiple sources of information.

RESULTS

At the end of the follow-up, one of three subjects had no contact with any mental health professional, and 38% of subjects had no contact with a psychiatrist. Half of the patients were readmitted over the 2-year follow-up. The baseline characteristics independently predicting psychiatric readmission were a high number of helping contacts before first admission and persistence of psychotic symptoms at discharge.

CONCLUSION

Decreasing the frequency of readmission in the early course of psychosis is a public health priority. Development of psychotherapeutic programs for subjects with early psychosis who have enduring psychotic symptoms at first discharge should be promoted.

Assessment of service use patterns in out-patients with schizophrenia: a Spanish study

OBJECTIVE

The objective is to describe and characterize patterns of service use by out-patients with schizophrenia in Spain.

METHOD

A representative treated prevalence sample of cases with schizophrenia was selected from four Spanish health areas. The evaluation included health service use, clinical severity, functioning and disability. Statistical analysis was based on hierarchical clustering methods.

RESULTS

A total of 356 patients were included in the analysis. Five patterns of health service use were defined: heavy out-patient mental health users; mental health and general health service users; heavy hospital service users; nursing service users; low users of mental health services. Patients in each group showed differences in clinical and disability status. Patterns of health service use showed consistency, but also variability, among the geographical areas.

CONCLUSION

Development and organization of mental health services should take into account the combinations of services patients most frequently use.

Community care for people with psychosis: outcomes and needs for care

People with psychosis living in developed countries in the era of community-based care are likely to be socially isolated, unemployed, and have poor quality of life, despite recent advances in the treatment and understanding of psychosis. Recent work in Australia illustrates the needs for care, especially for those with complex disabilities, and even for those in contact with well-organized clinical mental health services. Insufficient evidence in two key areas impedes progress: the use of effective psychosocial interventions; and the impact of changes in the community care system. Follow-up studies of programs and interventions assessing a range of outcomes in local settings are now required to encourage professionals and the community to address these needs.

Stability and prediction of schizophrenia from adolescence to adulthood

Stability of schizophrenia diagnosis from adolescence to adulthood, antecedents of schizophrenia, and differences in developmental and behavioural histories between subjects with early onset schizophrenia (EOS) and with adult onset schizophrenia (AOS) were investigated in 145 adult subjects diagnosed with mental disorders in adolescence and re-diagnosed on the basis of medical records according to DSM-IV.A very high diagnostic stability schizophrenia was demonstrated at the 28-year follow-up. Several factors, including neurological adversities, delayed language development, low IQ, and congenital functional disability, differentiated significantly between schizophrenic subjects and non-schizophrenic subjects. Histories of concussion, physical abuse, parental divorce, and unstable familial context differentiated significantly between EOS and AOS subjects. Our findings support earlier evidence of schizophrenia being a chronic disorder with high diagnostic stability, and confirm the importance of neurological adversities, delayed language development, and low IQ as factors predictive of schizophrenia. Exploration of four case histories of AOS subjects delineates "pre-schizophrenic warning cluster" where combination of neurological adversities, temperamental problems, antisocial behaviour, preference for solitary play, and unstable family system constitute main factors.

Brain volumes as predictor of outcome in recent-onset schizophrenia: a multi-center MRI study

Gray matter brain volume decreases have been found in patients with schizophrenia as compared to healthy control subjects measured by using Magnetic Resonance Imaging (MRI). An association has been suggested between decreased gray matter volume and poor outcome in chronically ill patients with schizophrenia. The present longitudinal multi-center study investigated whether gray matter volume at illness onset can predict poor outcome in recent-onset schizophrenia after a follow-up of approximately 2 years. An MRI calibration study was performed since scans of patients with recent-onset psychosis were conducted at three sites with 1.5 T MR scanners from two different manufacturers. Applying a linear scaling procedure on the histogram improved comparability between volume measurements acquired from images from the different scanners. Brain scans were obtained from 109 patients with recent-onset schizophrenia. Volumes of intracranium, total brain, cerebral gray and white matter, third and lateral ventricles, and cerebellum were measured. After a mean follow-up period of approximately 2 years, measurements of symptoms, functioning, need for care, and illness history variables were assessed. No significant correlations were found between the brain volume measures and any of these measures. Gray matter volume at illness onset does not predict outcome after 2 years in recent-onset schizophrenia.

Testing hypotheses about the relationship between cannabis use and psychosis

AIM

To model the impact of rising rates of cannabis use on the incidence and prevalence of psychosis under four hypotheses about the relationship between cannabis use and psychosis.

METHODS

The study modelled the effects on the prevalence of schizophrenia over the lifespan of cannabis in eight birth cohorts: 1940-1944, 1945-1949, 1950-1954, 1955-1959, 1960-1964, 1965-1969, 1970-1974, 1975-1979. It derived predictions as to the number of cases of schizophrenia that would be observed in these birth cohorts, given the following four hypotheses: (1) that there is a causal relationship between cannabis use and schizophrenia; (2) that cannabis use precipitates schizophrenia in vulnerable persons; (3) that cannabis use exacerbates schizophrenia; and (4) that persons with schizophrenia are more liable to become regular cannabis users.

RESULTS

There was a steep rise in the prevalence of cannabis use in Australia over the past 30 years and a corresponding decrease in the age of initiation of cannabis use. There was no evidence of a significant increase in the incidence of schizophrenia over the past 30 years. Data on trends the age of onset of schizophrenia did not show a clear pattern. Cannabis use among persons with schizophrenia has consistently been found to be more common than in the general population.

CONCLUSIONS

Cannabis use does not appear to be causally related to the incidence of schizophrenia, but its use may precipitate disorders in persons who are vulnerable to developing psychosis and worsen the course of the disorder among those who have already developed it.

The goals and method of the Andalusian Case Register for Schizophrenia

BACKGROUND

Psychiatric case registers have been acknowledged as a valuable source of data, a long time ago. However, a growing interest exists in data on service utilization by patients belonging to groups with a related diagnosis to enable adequate planning of health resources.

AIMS

The aims of the Andalusian Case Register for Schizophrenia are to determine the prevalence of schizophrenia of those cared for by the public network of mental health services and to describe their pattern of care.

METHODS

Cases included on the Register are those persons resident in South Granada area with a diagnosis of schizophrenia and related disorders. The agencies which sent the information to the Register are all the mental health facilities in the catchment area.

CONCLUSIONS

The Register is a flexible instrument to use for epidemiological research and mental health care planning.

Nonparametric and semiparametric trend analysis for stratified recurrence times

Recurrent event data are frequently encountered in longitudinal follow-up studies when the occurrences of multiple events are considered as the major outcomes. Suppose that the recurrent events are of the same type and the variable of interest is the recurrence time between successive events. In many applications, the distributional pattern of recurrence times can be used as an index for the progression of a disease. Such a distributional pattern is important for understanding the natural history of a disease or for confirming long-term treatment effect. In this article, we discuss and define the comparability of recurrence times. Nonparametric and semiparametric methods are developed for testing trend of recurrence time distributions and estimating trend parameters in regression models. The construction of the methods is based on comparable recurrence times from stratified data. A real data example is presented to illustrate the use of methodology.

Using health production functions to evaluate treatment effectiveness: an application to a community mental health service

The randomized controlled trial (RCT) is the recommended means of evaluating health care effectiveness and cost-effectiveness. Whilst representing a 'gold-standard' in health services research, RCT evidence on the clinical and economic desirability of services and treatments is often absent. Where RCT evidence is lacking, or where it is infeasible to implement randomized controlled comparisons, longitudinal observational and naturalistic data sources when analysed appropriately can yield useful insights regarding the clinical effectiveness and economic efficiency of treatments. In this paper we demonstrate the utility of applying panel estimation methods to data from an Italian psychiatric case register as a means of modelling the mental health outcomes of patients referred to a community-based mental health service. Emphasis is placed on quantifying the clinical effectiveness of consultations with different mental health professionals (including in-patient days) and whether service outcomes are affected by psychiatric diagnosis. The impact of service consultations and their interaction with different types of psychiatric diagnosis on a measure of patient mental health are found to be statistically significant, although the size of these effects are not substantial from a clinical perspective.

Duration of untreated psychosis in first-episode schizophrenia: marker or determinant of course?

The natural history of schizophrenia is often chronic and debilitating, an enduring fact that draws attention to the first episode and early course of the disorder when neurobiological deficits apparently form. Many recent studies have focused on the duration of untreated psychosis (DUP) in first-episode patients for reasons that are reviewed here. DUP is often months or years in length, making it a major public mental health problem. Reducing DUP through early detection may be possible from a service systems perspective. This may be very important because earlier treatment not only reduces acute psychotic symptoms, but may also improve long-term prognosis by attenuating the deficit processes active at this time; processes that are either signaled by or a product of DUP. Finally, DUP appears to influence sampling in first-episode research in that longer DUP is associated with higher recruitment refusal rates to studies. For all of these reasons, DUP should be added to the battery of descriptive variables routinely collected on all patients with schizophrenia, whether for treatment or research.

Nonparametric Estimation of a Recurrent Survival Function

Recurrent event data are frequently encountered in studies with longitudinal designs. Let the recurrence time be the time between two successive recurrent events. Recurrence times can be treated as a type of correlated survival data in statistical analysis. In general, because of the ordinal nature of recurrence times, statistical methods that are appropriate for standard correlated survival data in marginal models may not be applicable to recurrence time data. Specifically, for estimating the marginal survival function, the Kaplan-Meier estimator derived from the pooled recurrence times serves as a consistent estimator for standard correlated survival data but not for recurrence time data. In this article we consider the problem of how to estimate the marginal survival function in nonparametric models. A class of nonparametric estimators is introduced. The appropriateness of the estimators is confirmed by statistical theory and simulations. Simulation and analysis from schizophrenia data are presented to illustrate the estimators' performance.

The effects of early and sustained intervention on the long-term morbidity of schizophrenia

By examining the literature concerning early intervention with antipsychotic medications, and how it affects long-term morbidity, this article will review the concept that early intervention with antipsychotic medications improves the long-term course of schizophrenia. It also looks at the potential long-term effects of discontinuing antipsychotic medications early in the course of schizophrenia. It appears that early intervention with antipsychotic medications decreases some of the long-term morbidity associated with schizophrenia. Some of the implications of this finding are discussed in the context of both clinical practice and clinical research.

Collaboration with drug treatment by schizophrenic patients with and without psychoeducational training: results of a 1-year follow-up

Within a controlled prospective intervention study, schizophrenic outpatients randomly assigned to four treatment groups and one control group were assessed with regard to collaboration with drug treatment. In total, 39.3% of 84 regular attenders of the psychoeducational training programme and 26.6% of 64 control patients reported having persuaded their psychiatrists to modify their medication prescriptions. A total of 8.3% and 7.8%, respectively, modified their medication on their own initiative, although with subsequent approval by the psychiatrist, and 20.2% and 15.6%, respectively, modified their medication after consulting their psychiatrist. With regard to medication management, the groups did not differ either at post-treatment or at follow-up. At follow-up, regular attenders showed a reduced fear of side-effects, increased confidence in their medication and stable confidence in their physician. Among the control subjects, confidence in the medication and in their physician declined, and fear of side-effects increased. Psychoeducational training therefore led to an optimization of patients' attitudes toward treatment, but not to changes in medication management.

Costs of schizophrenia

BACKGROUND

Schizophrenia is a common and burdensome illness, with implications not only for the health service but for a host of other care agencies--public and private--as well as for patients, families and the wider society.

METHOD

The paper reviews available UK evidence on the cost of schizophrenia (broadly defined) and on the cost-effectiveness of treatment options and alternative care arrangements. New evidence potentially alters our view of the costs of this illness.

RESULTS

Aggregating the identifiable direct and indirect costs of schizophrenia for England suggests an annual cost of 2.6 billion pounds, but even this sum omits some indirect impacts which cannot currently be costed. Just over half the identified total is accounted for by the direct costs falling to the NHS, local authorities, charities and the criminal justice system. In helping to tackle this cost burden, there is now a body of evidence on cost-effective community care arrangements, antipsychotic drugs and psychological interventions.

CONCLUSIONS

Although the costs of schizophrenia are considerable, there are treatments and care arrangements which can reduce this aggregate burden while maintaining or improving effectiveness.

Modeling the lifetime costs of treating schizophrenia in Australia

Schizophrenia is arguably one of the most costly mental illnesses in terms of its impact on the economy, on the health system, and on patients and their families. This paper provides a framework for analyzing schizophrenia; this framework, in a limited data environment, generates estimates of the costs and outcomes of this disease based on location of treatment. This model differs from previous cost-of-illness studies in that it uses a Markov framework to estimate the incidence costs associated with schizophrenia based on a projected amount of a patient's lifetime spent in these treatment locations. The author believes this is the first time such a model has been developed and applied to estimating not only the community costs of schizophrenia but also the cost implications of treatment options and policy choices in Australia. Using a fundamental matrix solution, lifetime costs of illness are calculated and the principal cost drivers in schizophrenia treatment are identified.

The varied outcomes of schizophrenia

OBJECTIVE

To review variations in outcomes in schizophrenia across individual, historical, and cross-cultural boundaries, as well as within specific domains of functioning.

METHOD

Research literature on the outcomes of schizophrenia appearing within the last 8 years was reviewed.

RESULTS

First, a review of follow-up studies published in the developed world suggests that heterogeneity in outcome across individuals with schizophrenia remains the rule, with affective symptoms, later and acute onset, and responsiveness to biological treatments predictive of good outcome. Negative symptoms are associated with poor outcome, cognitive impairments, and incapacity in social and work domains. Deterioration appears to occur within the first few months of onset if not already in the prodrome, with recent early-course studies finding longer duration of untreated psychosis associated with insidious onset, negative symptoms, social and work incapacity, and poor outcome. Second, a review of recent cross-cultural and historical studies provides evidence that outcome varies across time and place, schizophrenia having a more favourable outcome in the developing world and becoming a more benign disorder over the course of this century. Third, a review of studies of the domains of functioning within individuals identifies 4 relatively independent dimensions of depression and negative, psychotic, and disorganized symptoms. Cognitive deficits, which are associated with negative symptoms, also constitute a relatively stable dimension over time, showing neither marked deterioration nor improvement once established early in the course of disorder.

CONCLUSIONS

The early appearance and stability over time of negative symptoms and cognitive impairments call for assertive intervention efforts early in the course of disorder to prevent chronicity and prolonged disability.

The Iowa Longitudinal Study of Recent Onset Psychosis: one-year follow-up of first episode patients

The natural history of schizophrenia remains unclear. One strategy to further inform this area is to prospectively evaluate individuals early in the course of the disorder, both in terms of symptomatic and psychosocial/occupational functioning. Subjects were recruited into the study if they were in the midst of their first psychiatric hospitalization for a non-'organic' psychotic disorder. Subjects were extensively evaluated at index with semi-structured interviews including the Comprehensive Assessment of Symptoms and History (CASH), and followed at 6-month intervals. Data are presented on 35 subjects who were followed through 1 year. There was a significant improvement in overall symptomatology during index hospitalization, but this was accounted for primarily by improvement of positive symptoms, with negative symptoms remaining prominent. No further improvement was noted between discharge and 1-year follow-up in any of the symptom measures. Employment, interpersonal relationships, and sexual activity remained markedly impaired throughout the follow-up period. These data demonstrate that; (1) negative symptoms are prominent and stable early in the course of the disorder; (2) symptom severity at discharge from index hospitalization is predictive of symptom severity at 1 year; and (3) despite substantial overall symptomatic improvement during the first hospitalization, psychosocial and occupational functioning were found to be markedly impaired at 1-year follow-up.

Assessment of needs for care among patients with schizophrenic disorders 15 and 17 years after first onset of psychosis

Severe and long term mental disorders, like schizophrenia, show in general a wide range of psychiatric signs and symptoms, psychological and physiological impairments and social disablement (Shepherd, 1994; Wing, 1982) reflecting a variety of mental health needs. Many studies provide only a cross-sectional view of the clinical and social problems of the patient population, for example at intake or admission to a mental hospital. Longitudinal studies following patients after discharge for some period of months or years show in general the expected improvement of functioning (e.g. Nienhuis et al., 1994), but as far as only chronic patients are concerned such a positive change is much less noted. The concept of chronicity of mental disorders would presume that after some time needs are fairly predictable and stable and do not change much over time. Our investigation on the long-term course of schizophrenia (Wiersma et al., 1996; 1997) enables us to study over a period of two years, from 15 to 17 years since first onset of psychosis, the stability or variability of needs in schizophrenic disorder. We are not aware of empirical studies on changes in needs among patients with long-term disorders.

The course of schizophrenia over 13 years. A report from the International Study on Schizophrenia (ISoS) coordinated by the World Health Organization

BACKGROUND

This paper describes the 13 year course of illness in an epidemiologically defined and representative cohort of patients selected when they were experiencing their first episode of schizophrenia.

METHOD

In a 13-year follow-up study of 67 patients with ICD-9 schizophrenia, identified in Nottingham in 1978-80, the course of illness (symptoms, disability and hospitalisation) was assessed using standardised instruments, applied at onset, 1,2, and 13 years. Time to first relapse and first readmission were calculated and plotted as survival curves and patients were assigned to the course types described by Ciompi.

RESULTS

The survival curves show that first relapses and first readmissions occur during the first five years. The amount of time spent in psychotic episodes and in hospital is greatest in the first year of follow-up, but stable thereafter. Social adjustment improves from entry to the study to the first follow-up year, but there is a small deterioration in social adjustment between 2 and 13 years.

CONCLUSIONS

The findings reported suggest that after the initial episode the course of schizophrenia is relatively stable. The data support neither concepts of progressive deterioration nor progressive amelioration. There was no evidence of a "late recovery'.

The changing careers of patients with chronic mental illness: a study of sequential patterns in mental health service utilization

The aim of this study was to describe patterns of service use over time by a group of persons with chronic mental illness who were homeless at the time of the index admission. Subjects were all persons admitted to Skid Row Mental Health Services in a recent year who had 25 or more previous admissions to any Los Angeles County Department of Mental Health service (N = 49). Sequences of type of service at each of the 25 admissions were compared with optimal matching and categorized with cluster analysis. Patients in earlier clusters had many inpatient admissions; those in later clusters had many admissions to outpatient, residential, and jail services. Service use by individuals in each cluster showed the same trends. However, there were also different patterns of service use for patients in cluster within the same tie frame. Analyzing multiple admissions sequentially helps to locate likely places to intervene in downward-spiraling careers.

A prospective 1-5 year outcome study in first-admitted and readmitted schizophrenic patients; relationship to heredity, premorbid adjustment, duration of disease and education level at index admission and neuroleptic treatment

In a prospective outcome study, 120 DSM-III-R schizophrenic patients were followed for up to 5 years after index admission, when a comprehensive clinical and demographical examination was undertaken with the aim to find early prognostic factors for outcome. They were 86 males (72%) and 34 females (28%), and 66 (55%) were first-admitted and never before treated at index admission from a geographically defined area. Outcome was evaluated 1, 3 and 5 years after index admission by use of a Strauss-Carpenter outcome scale. At year five, 101 patients could be evaluated. Seven (7%) patients had committed suicide during the 5 years' follow-up period. 30% of the patients was considered to have a good, 14% a poor and 56% an intermediate outcome. It was found that 58% had not been in hospital during the last year, 27% were employed on the open market, 25% met friends regularly and 38% had no or only mild symptoms at the five years' follow-up evaluation. Females had a significantly better outcome than males. High education level and absence of premorbid deviant behaviour at index admission predicted a good outcome whereas problems in school (with friends and/or teachers) reported by relatives predicted poor outcome. No relationship was found between outcome and age at onset of the disorder and no gender difference in age at onset of the disorder. Patients with a family history of schizophrenia improved more between year one and five as compared with those without a family history, but heredity in itself was not an important factor for outcome. At 5 years after index admission, 40% of patients were on classical neuroleptics and 33% on clozapine whereas 19% were without medication. Of the total sample of 101 patients, 10% were drug-free and had a very good outcome at the 5 years' evaluation. The data indicate that there is a substantial subgroup of schizophrenic patients with a good prognosis and they can be characterized by female sex (even in a group without gender difference in age at onset), absence of premorbid deviant behaviour and a high education level at index admission.

Episodes of care for first-ever psychiatric patients. A long-term case-register evaluation in a mainly urban area

BACKGROUND

Psychiatric case registers (PCRs) are particularly useful for studying patterns of care over time. Methods of 'survival analysis' have rarely been used for assessing such data.

METHOD

A longitudinal study was conducted over 10 years (1 January 1982 to 31 December 1991) on 1423 first-ever psychiatric patients, using the PCR of South Verona, Italy. The product-limit method, the log-rank test, the Cox regression model and the Poisson regression analysis were used to analyse episodes of care and relapses.

RESULTS

The duration of the episodes of care increased consistently from the first to the fifth episode. The probability of opening a new episode of care after the first one increased consistently from the second to the sixth episode. The only variable significantly associated with the length of the first episode of care was diagnosis (highest probability of having longer episodes for schizophrenic patients), while the length of the breaks following the first episode of care was associated with diagnosis, sex and occupational status (highest probability of opening a second episode of care for schizophrenic subjects and those with alcohol and personality disorders, for males, and for unemployed patients). The probability of opening a new episode of care decreased with time since last contact and increased with number of previous contacts.

CONCLUSIONS

The community psychiatric service in South Verona is fulfilling its original aim, that is, to give priority to the continuity of care for patients with chronic and severe mental illnesses. Survival analyses proved to be useful methods for assessing episodes of care.

Age and other factors relevant to the rehospitalization of schizophrenic outpatients

In this study 50 of 51 schizophrenic long-term patients treated by a community-based outpatient service were followed-up for 2 years. Factors known to be relevant for rehospitalization were correlated with the rate of hospitalizations 1) in the past, 2) during the last year and 3) during the follow-up period. We were particularly interested in the influence of the patient's age on readmission. In agreement with previous research, the results showed that the best predictor of future admissions was the number of previous hospitalizations. Age also has a high predictive value and correlates not only significantly with the hospitalization rates but also with other factors relevant for readmission such as drug compliance, antisocial behavior and suicidal risk. This, however, only partly explains the frequency of rehospitalization, as partial correlation shows. Although items concerning compliance were highly correlated with previous hospitalizations, they had less predictive value, contrary to the findings in the literature.

Predictors for readmission risk in schizophrenia

Readmission risk was assessed at the first and subsequent discharges in a total Danish national sample consisting of 8705 first admitted patients who had been discharged alive at least once with a diagnosis of schizophrenia. Predictors for readmission risk were identified using the Cox proportional hazards model. Following the first discharge, 19% of the surviving patients had not been readmitted after 10 years of follow-up. Readmission risk increased with the number of previous admissions. At the first discharge readmission risk decreased with increasing age and was significantly predicted by clinical subtype and gender. At later discharges (5th, 10th, and 15th) the effect of these variables gradually disappeared. At the 15th discharge readmissions were mainly predicted by the duration of the latest admission and discharge periods. Both the increase in readmission risk with the number of previous admissions and the evolving pattern of predictors for readmission risk are interpreted as supporting the existence of a smaller subpopulation among schizophrenic patients with frequent relapses.

Predictability of rehospitalization for schizophrenia

This analysis examines the predictability of the course of schizophrenia using long-term follow-up data on hospital episodes in a cohort of patients from a psychiatric case register in Denmark. We focus on whether clinical and sociodemographic data collected during the first episode are related to the number of hospitalizations during follow-up and the association of patients' course of hospitalizations with the risk of being rehospitalized. A Poisson regression model and a proportional hazards model were used to address these questions. Age of onset and time to the first rehospitalization were strong early predictors of chronicity of course, as measured by the number of psychiatric hospitalizations for each schizophrenic patient. The results also show that the risk of rehospitalization depends on the previous tenures in the community.

The Danish psychiatric register as a tool in epidemiology

The electronic part of the nationwide Danish Psychiatric Central Register is now almost 25 years old. In this period it has proved its high value in administration, planning, treatment of patients, and not least in psychiatric research. Due to its national coverage, the register makes it easy to conduct epidemiological studies, such as analysis of trends, register linkage research, identification of representative cohorts for further analysis and follow-up studies of clinically identified cohorts. After many years of political turmoil, the register now seems to have assumed a more reasonable form, making allowance for both research interest and data protection. A proposed directive on the protection of medical data from the European Community may be a serious threat to the register and will probably eliminate all epidemiological and clinical research based on registers.