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Keywords:

  • age of onset;
  • day care;
  • education;
  • hospitalization;
  • schizophrenia

Abstract

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Aim:  A retrospective study was conducted to assess the relationship between patient characteristics and psychiatric day care outcomes in 430 Japanese schizophrenic patients.

Methods:  The patients were divided into psychiatric day care completers and non-completers. Patients who could not be included in these groups were categorized as unclassifiable. The completers were subdivided into four outcome groups: (i) patients who obtained a part-time job, (ii) patients who began working at community workshops for mentally disabled persons, (iii) patients who obtained a full-time job or returned to their former positions, and (iv) patients who entered or returned to school. The non-completers were subdivided into two outcome groups: (i) patients who discontinued psychiatric day care because of worsened schizophrenia, and (ii) patients who were rehospitalized because of worsened schizophrenia. Age, sex, age of onset of schizophrenia, number and duration of previous psychiatric hospitalizations, number of persons living with the patient, educational background, previous employment type, marital status, chlorpromazine-equivalent doses of antipsychotic drugs used, and psychiatric day care outcomes were compared among the outcome groups with logistic regression analysis using the outcomes as target variables.

Results:  A later onset of schizophrenia and fewer previous psychiatric hospitalizations were significantly related with better outcomes. A higher educational background was related with the outcomes without statistical significance.

Conclusions:  Our results suggest that the assessment of the relationship between patient characteristics and psychiatric day care outcomes is essential to enhance therapeutic effectiveness of psychiatric day care by beginning appropriate communication, support, and programs for individual patients at the initiation of the care.

SYCHIATRIC DAY CARE is an ambulatory psychiatric treatment that includes psychosocial reha bilitation and psychosocial treatment for individuals with chronic mental disorders. In Japan, many psychiatric day care services are provided, in combination with traditional outpatient services, systematically by psychiatric day care facilities during the daytime (typically for 6 h per day) approximately 4 days weekly. The services have three major purposes: (i) improvement in social functioning ability after inpatient care in the acute phase of mental disorders; (ii) assistance of patients in living in a better environment and in returning to their community; and (iii) prevention of relapse of mental disorders and improvement in quality of life.1 There are more than 1100 psychiatric day care facilities across Japan.2

In Europe and the United States, partial hospitalization is a general term covering both medical and psychosocial cares that are more intense than traditional outpatient cares for community residents with mental disorders. The partial hospitalization is divided into two types: day hospital (or day treatment) services and psychiatric day care services. These services are differentiated from each other. Day hospital (or day treatment) services refer to a medical service including diagnosis and crisis intervention within an ambulatory setting, while psychiatric day care services focus on psychosocial rehabilitation and psychosocial treatment in the chronic phase of mental disorders.3 Day treatment services focus more on vocational program such as vocational counseling, job coaching and job placement which aims at integrating the patients into normal life. In Japan, no acute-phase treatment has been provided by day hospitals.

Treatment of schizophrenia in Japan has been shifting from long-term inpatient care to short-term inpatient care in the acute phase followed by outpatient care or psychiatric day care. In addition to psychiatric day care facilities, there are approximately 1700 small community workshops that provide a small number of mentally disabled persons with an opportunity to earn some money by performing simple tasks as vocational rehabilitation.4 The workshops function as a non-medical rehabilitation facility for such persons after psychiatric hospitalization or psychiatric day care. Some workshops focus on social education activities so that the persons can keep regular hours and maintain their health.

Psychiatric day care in Japan and partial hospitalization in Western countries have been reported to be effective for improving psychiatric symptoms and social functioning ability of patients with mental disorders as well as outcomes of the disorders and for reducing the rehospitalization rate and the relapse rate.5–9 However, some schizophrenic patients discontinue psychiatric day care early because of worsened disease or rehospitalization.10–16 To reduce the discontinuation, it is important to know what factors of current psychiatric day care influence outcomes of mental disorders. We thus assessed the relationship between patient characteristics and psychiatric day care outcomes in schizophrenic patients.

METHODS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Subjects

The study subjects were 430 Japanese schizophrenic patients whose disease met the Diagnostic and Statistical Manual of Mental Disorders, 4th edn, criteria for schizophrenia who first participated in psychiatric day care programs provided by Treatment Center of Neuropsychiatric Diseases, Kitasato University East Hospital (Sagamihara, Kanagawa, Japan) between May 1986 and August 2004, and who completed or discontinued the psychiatric day care. Schizophrenic patients who had previously received the care at the Center were excluded from the study. Sixty-four schizophrenic patients, who began to participate in psychiatric day care programs between May 1986 and August 2004, and currently continued to participate in the programs, were excluded from the study.

Psychiatric day care

Psychiatric day care was provided by the day care department of the Treatment Center of Neuropsychiatric Diseases, Kitasato University East Hospital. The Center consisted of a psychiatric day care ward, an open ward (60 beds), and a closed ward (69 beds including seven beds in seven separate isolation rooms and 13 beds in a high care unit). In 2005, the average monthly enrollment in our psychiatric day care programs was 115.2, and the average daily attendance at the programs was 52.3. These numbers have been increasing gradually. Our psychiatric day care service was available between 09:00 and 16:00, Monday to Friday. After clinical staff members confirmed patients' attendance and psychiatric day care programs, patients participated in a program in the morning and afternoon. They chose programs by themselves from a wide range of therapeutic activities such as occupational therapy, group psychotherapy, social skills training, vocational preparation, sports, and cooking. Other regular activities included field recreations, volleyball games, Christmas parties, and seminars for patients' families (psychoeducational program, etc.) regarding schizophrenia and its drug therapy, better communication with schizophrenic patients, and the social welfare system available for schizophrenic patients and their families. The duration of psychiatric day care was not limited. Core staff consisted of two psychiatrists, two nurses, two social workers, and one clinical psychologist. These staff members were assigned to individual patients and had interviews with them as necessary, according to their participation and achievement in the programs as well as their mental conditions. The members supported patients comprehensively by, for instance, recommending a rest or consultation to prevent disease progression, giving advice on program selection, and helping in the improvement of social skills.

Procedures

A retrospective study was conducted by collecting the following information of each patient from medical records and psychiatric day care records: age, sex, age of onset of schizophrenia, number and duration of previous psychiatric hospitalizations, number of persons who lived with the patient, educational background, previous employment type, marital status, chlorpromazine-equivalent doses of antipsychotic drugs used,17,18 and the outcome of psychiatric day care. All data presented above were derived from routine assessment for the day care, and informed consent on the care was obtained from all the patients and their families. Personal information of the patients was handled in compliance with the Japanese Act on the Protection of Personal Information. Patient anonymity is preserved in the present paper.

The patients were divided into two groups: patients who completed psychiatric day care (completer group) and patients who discontinued it (non-completer group). The completion of psychiatric day care was defined as at least 1-month continuation of working or going to school after psychiatric day care. The discontinuation of the care was defined as either rehospitalization of any duration or more than 3-month discontinuation of psychiatric day care because of worsened schizophrenia. The discontinuation date was defined as the date of rehospitalization or the date 3 months after the discontinuation of psychiatric day care. Patients who could not be included in the completer or non-completer group (e.g. patients who changed psychiatric day care facilities because of relocation or commuting problems) were categorized as unclassifiable. Patients who discontinued psychiatric day care but achieved a satisfactory re-adjustment to family life at home (e.g. assisting in the family business) without worsening of schizophrenia were also categorized as unclassifiable.

The completer group was subdivided into four groups according to outcomes of psychiatric day care: (i) patients who obtained a part-time job (part-time job group), (ii) patients who began working at small community workshops for mentally disabled persons (workshop group), (iii) patients who obtained a full-time job or returned to their former positions (full-time job group), and (iv) patients who entered or returned to school (school group). The non-completers were subdivided into two groups according to reasons for withdrawal from psychiatric day care: (i) patients who discontinued the care because of worsened schizophrenia (discontinuation group) and (ii) patients who were rehospitalized because of worsened schizophrenia (rehospitalization group).

Statistical analysis

Patient characteristics were compared among the six subgroups. Pearson's χ2 test was used to compare nominal data such as sex, educational background, previous employment type, and marital status. One-way analysis of variance was used to compare continuous data such as age, age of onset of schizophrenia, the number and duration of previous psychiatric hospitalizations, the number of persons who lived with the patient, and the chlorpromazine-equivalent doses of antipsychotic drugs used.

Patient characteristics of the completer group were compared with those of the non-completer group. Pearson's χ2 test was used to compare the nominal data. Student's t-test was used to compare the continuous data. For these two tests, a two-tailed P-value of less than 0.05 was considered to indicate statistical significance.

To eliminate influences of confounding factors on the discrimination of psychiatric day care outcomes, logistic regression analysis was performed with the backward elimination method. The outcomes were used as target variables, and patient characteristics with a statistically significant difference between the completer group and the non-completer group were used as explanatory variables. All the variables with a P-value below 0.05 were entered in the regression model. Statistically insignificant variables were then removed stepwise from the model by excluding the most insignificant variable at each step. The Odds ratio and the 95% confidence interval were determined for each statistically significant variable.

All the statistical analyses were performed with SPSS statistical program (version 13.0 for Windows; SPSS Inc., Chicago, IL, USA).

RESULTS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Tables 1 and 2 present patient characteristics and the results of statistical analysis of the characteristics for each subgroup. Of the 430 schizophrenic patients, 212 completed the psychiatric day care, and 188 discontinued it. The remaining 30 patients were categorized as unclassifiable, mainly because they changed psychiatric day care facilities due to relocation or commuting problems. In the completer group, 66 patients (31.1%) obtained a part-time job; 55 (25.9%) began working at small community workshops for mentally disabled persons; 51 (24.1%) obtained a full-time job or returned to their former positions; and 40 (18.9%) entered or returned to school. In the non-completer group, 115 patients (61.2%) discontinued psychiatric day care because of worsened schizophrenia, and 73 (38.8%) were rehospitalized because of worsened schizophrenia.

Table 1.  Comparison of patient characteristics (nominal data) among outcome groups
CharacteristicPart-time job group (n = 66)Workshop group (n = 55)Full-time job group (n = 51)School group (n = 40)Completer (n = 212)Discontinuation group (n = 115)Rehospitalization group (n = 73)Non-completer (n = 188)Among outcome groupsBetween completers and non-completers
χ2P-valueχ2P-value
  • *

    Statistically significant.

  • Marital status, n = 211 for completers and n = 188 for non-completers; previous employment, n = 206 for completers and n = 185 for non-completers.

  • Chi-square test.

  • All data, number of patients (%).

Male38 (57.6)41 (74.5)30 (58.8)29 (72.5)138 (65.1)72 (62.6)38 (52.1)110 (58.5)9.400.091.830.18
Marital status        20.340.026*1.950.38
 Single64 (97.0)52 (94.5)43 (84.3)39 (100)198 (93.8)112 (97.4)70 (95.9)182 (96.8)    
 Married02 (3.6)5 (9.8)07 (3.3)2 (1.7)1 (1.4)3 (1.6)    
 Divorced2 (3.0)1 (1.8)3 (5.9)06 (2.8)1 (0.9)2 (2.7)3 (1.6)    
Education        29.890.001*14.30<0.001*
 Junior high school graduate8 (12.1)11 (20.0)6 (22.2)12 (30.0)37 (17.4)37 (32.2)21 (28.8)58 (30.9)    
 High school graduate38 (57.6)36 (65.5)27 (52.9)14 (35.0)115 (54.3)59 (51.3)41 (56.2)100 (53.2)    
 College graduate20 (30.3)8 (14.5)18 (35.3)14 (35.0)60 (28.3)19 (16.5)11 (15.1)30 (16.0)    
Previous employment        66.12<0.001*9.190.01*
 Unemployed7 (10.6)6 (10.9)5 (10.2)22 (61.1)40 (19.4)24 (21.1)20 (28.2)44 (23.8)    
 Employed
  Part-time25 (37.9)20 (36.4)16 (32.7)12 (33.3)73 (35.4)58 (50.9)27 (38.0)85 (46.0)    
  Full-time34 (51.5)29 (52.7)28 (57.1)2 (5.6)93 (45.1)32 (28.1)24 (33.8)56 (30.2)    
Table 2.  Comparison of patient characteristics (continuous data) among outcome groups
CharacteristicPart-time job group (n = 66)Workshop group (n = 55)Full-time job group (n = 51)School group (n = 40)Completer (n = 212)Discontinuation group (n = 115)Rehospitalization group (n = 73)Non-completer (n = 188)Among outcome groupsBetween completers and non-completers
FP-valueFP-value§
  • *

    Statistically significant.

  • Age of onset of schizophrenia, n = 212 for completers and n = 186 for non-completers; duration of previous hospitalizations, n = 207 for completers and n = 185 for non-completers; number of previous hospitalizations, n = 210 for completers and n = 187 for non-completers; number of persons living with the patient, n = 168 for completers and n = 156 for non-completers.

  • One-way analysis of variance.

  • §

    T-test.

  • All data, mean (SD).

Age (years)24.7 (4.8)25.7 (5.2)27.6 (7.4)19.4 (2.3)24.6 (5.9)23.0 (5.0)24.9 (6.3)23.8 (5.6)12.65<0.001*2.290.13
Age of onset of schizophrenia (years)21.0 (3.9)21.1 (4.4)21.7 (4.1)17.4 (2.5)20.5 (4.1)18.5 (4.1)19.5 (5.5)18.9 (4.7)8.77<0.001*13.28<0.001*
Durations of previous hospitalization (months)3.9 (4.3)3.9 (4.4)4.5 (5.7)3.5 (2.5)4.0 (4.4)4.1 (4.8)8.0 (10.5)5.6 (7.7)5.150.001*7.000.01*
Number of previous hospitalizations1.1 (1.0)1.0 (0.8)1.2 (1.0)1.0 (0.6)1.1 (0.9)1.2 (1.0)2.0 (1.9)1.4 (1.5)6.25<0.001*10.930.001*
Chlorpromazine-equivalent dose of antipsychotic drugs used (mg)533.0 (609.3)735.0 (724.2)645.2 (519.5)746.1 (587.8)652.6 (619.9)606.2 (563.4)650.7 (644.7)623.5 (595.0)1.000.420.230.63
Number of persons living with patient3.8 (1.0)3.7 (1.0)3.8 (1.0)4.0 (1.0)3.8 (1.0)3.8 (1.0)3.7 (1.0)3.8 (1.0)0.640.670.100.74

The comparison of patient characteristics among the six subgroups revealed a statistically significant difference in age, marital status, educational background, previous employment type, and the number and duration of previous psychiatric hospitalizations. The percentage of patients married was highest in the full-time job group, followed by the workshop group. Most patients were single in other four subgroups. The percentage of college graduates was highest in the full-time job group, followed by the school group and the part-time job group. The percentage of high school graduates was highest in the workshop group. The percentage of junior high school graduates was highest in the discontinuation group, followed by the rehospitalization group. The percentage of patients with previous full-time employment was highest in the full-time job group, followed by the workshop group and the part-time job group. The percentage of patients with previous unemployment was highest in the school group, followed by the rehospitalization group. The percentage of patients with previous part-time employment was highest in the discontinuation group. The mean age and the mean age of onset of schizophrenia were youngest in the school group. The mean number of previous psychiatric hospitalizations was greatest in the hospitalization group. The mean duration of previous psychiatric hospitalizations was longest also in the hospitalization group.

The comparison of patient characteristics between the completer group and the non-completer group revealed a statistically significant difference in educational background, previous employment type, age of onset of schizophrenia, and the number and duration of previous psychiatric hospitalizations. The completer group had fewer junior high school graduates, more college graduates, and more patients with previous full-time employment. The mean age of onset of schizophrenia was older in the completer group. The mean number of previous psychiatric hospitalizations was greater in the completer group. The mean duration of previous psychiatric hospitalizations was shorter in the completer group. No statistically significant difference was noted between the two groups in sex, age, marital status, chlorpromazine-equivalent doses of antipsychotic drugs used, and the number of persons who lived with the patient.

The five patient characteristics with a statistically significant difference between the completer group and the non-completer group (i.e. educational background, previous employment type, age of onset of schizophrenia, and the number and duration of previous psychiatric hospitalizations) were used as explanatory variables in the logistic regression analysis with psychiatric day care outcomes as target variables. The results of the backward elimination method show that the age of onset of schizophrenia (Odds ratio, 1.10; 95% confidence interval, 1.04–1.17) and the number of previous psychiatric hospitalizations (Odds ratio, 0.77; 95% confidence interval, 0.62–0.96) were statistically significant variables (Table 3). Educational background (college graduate) was not a statistically significant variable but was related with the outcomes (Odds ratio, 1.78; 95% confidence interval, 0.97–3.27).

Table 3.  Patient characteristics related with day care outcomes
CharacteristicOdds ratio95% confidence intervalP-value
  • *

    Statistically significant.

  • For completers and non-completers.

Age of onset of schizophrenia1.101.04–1.17<0.001*
Number of previous hospitalizations0.770.62–0.960.02*
College graduate1.780.97–3.270.06

DISCUSSION

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

We assessed the relationship between patient characteristics and psychiatric day care outcomes in Japanese schizophrenic patients by comparing the characteristics and the outcomes of patients who completed the care with those patients who discontinued the care. Our study demonstrated that a later onset of schizophrenia and fewer previous psychiatric hospitalizations were significantly related with better outcomes of psychiatric day care. A higher educational background was related with the outcomes without statistical significance.

Several reports have been published on the relationship between patient characteristics and psychiatric day care outcomes in schizophrenic patients. A 2-year prospective randomized controlled study of psychiatric day care was conducted in 162 schizophrenic patients (80 receiving psychiatric day care and 82 receiving outpatient care) at 10 veterans hospitals.8 This study shows that the patients who received psychiatric day care had fewer psychiatric symptoms and had better social functioning than the patients who received outpatient care at 2 years after the initiation of each care. In addition, patients with motor retardation, emotional withdrawal or anxiety had a higher risk of relapse when receiving psychiatric day care. Two retrospective studies of the relationship between patient characteristics and psychiatric day care outcomes were conducted in 519 patients (schizophrenia, 71%)19 and 69 patients (schizophrenia, 31.9%),20 respectively. These studies show that poor outcomes of psychiatric day care are associated with an early onset of schizophrenia, many previous psychiatric hospitalizations, a young age at admission to psychiatric day care facilities, low intelligence quotient (IQ), and a high parental incidence of mental illness and substance abuse. The patient characteristics related with psychiatric day care outcomes in our study are similar to those of the three studies.

Predictors for good long-term outcomes of schizophrenia include a late and acute onset of the disease; obvious precipitating factors; good premorbid social, sexual, and occupational histories; no low IQ; mood disorder symptoms (particularly depressive disorders); family history of mood disorders; being married; good support systems; positive symptoms of schizophrenia; and short psychiatric hospitalizations.21,22 The patient characteristics related with psychiatric day care outcomes in our study overlap with the characteristics related with long-term outcomes of schizophrenia. This suggests that some predictors for long-term outcomes of schizophrenia are related with psychiatric day care outcomes.

In our study, 188 (43.7%) of 430 schizophrenic patients discontinued psychiatric day care. Of the 188 patients, 73 (38.8%) were rehospitalized. The discontinuation rate of psychiatric day care ranges from 15% to 53% in Japan.10 The discontinuation rate of partial hospitalization ranges from 18.8% to 41% in Europe and the United States.11–16 These findings suggest that therapeutic effectiveness of psychiatric day care should be improved to prevent discontinuation of the care, although the discontinuation rates cannot be compared unconditionally between studies because psychiatric day care programs, follow-up durations, types of mental illnesses, and disease stages (acute or chronic phase) vary with studies and because social backgrounds and psychiatric treatment systems vary with countries and time periods of conducting studies. Identification of factors related with psychiatric day care outcomes, such as patient characteristics that were shown to be related with outcomes in our study, is essential to select more appropriate target populations and programs of psychiatric day care. In addition, it might be possible to help the patients to receive more intensive care, such as Assertive Community Treatment as well as intensive day care in the early stages by identifying factors that were related to psychiatric day care outcomes.

Our study was retrospective and has six major limitations that require careful interpretation of study results. First, we did not include treatment-related variables in the analysis. For example, there are several psychiatric day care programs that are freely chosen by the patients. So programs of psychiatric day care differ among patients. We also did not examine the frequency and duration of psychiatric day care. Some patients participated in psychiatric day care programs once weekly and others were five times weekly. Likewise, there are great individual differences in terms of recovery period, therefore some patients completed the care relatively early while other patients required long periods of time to complete the care. As a result, the individual patient received different types and amounts of care from each other, in both the completer group and the non-completer group. Although our study could assess the relationship between patient characteristics and psychiatric day care outcomes, further studies should include those variables to demonstrate the effect of day care on the outcome.

Second, the length of observation period differed among patients for the reason described above. This factor might affect the result. For example, factors affecting the exacerbation in the early stage of treatment might be different from those in the later stage. If this is the case, we should develop a specific strategy for preventing exacerbation in each stage.

Third, no relationships were assessed between baseline psychiatric symptoms and psychiatric day care outcomes. We did not assess the symptoms with objective methods such as rating scales. The completer group might have had milder psychiatric symptoms at baseline than the non-completer group. Although baseline psychiatric symptoms can influence psychiatric day care outcomes, the potential influence was not eliminated from the study.

Fourth, the interval between the earliest initiation of psychiatric day care and the latest initiation of the care was as long as 18 years. The study included schizophrenic patients who began receiving care between May 1986 and August 2004. Psychiatric day care outcomes might have been influenced by changes in social conditions and psychiatric treatment systems, such as part-time employment situations, employment of people with mental disorders, and the number of community workshops for such people. Drug therapy for mental disorders has also changed, especially since atypical antipsychotic drugs were introduced into the treatment of the disorders. This change could also have influenced psychiatric day care outcomes. In addition, variations in drug therapies used could have influenced the outcomes. We analyzed chlorpromazine-equivalent doses of antipsychotic drugs used at the initiation of psychiatric day care but did not collect information on the types of the drugs.

Fifth, our results may not represent outcomes of psychiatric day care provided by typical psychiatric hospitals in Japan. The subjects of the present study were limited to schizophrenic patients who received psychiatric day care at a university hospital. Such patients are likely to include more patients with an initial episode of schizophrenia and more young schizophrenic patients than patients receiving psychiatric day care at typical psychiatric hospitals.

Finally, the study subjects were those schizophrenic patients who first participated in psychiatric day care programs at the Treatment Center of Neuropsychiatric Diseases between May 1986 and August 2004, and who completed or discontinued the psychiatric day care. We did not include the 64 schizophrenic patients who first participated in psychiatric day care programs between May 1986 and August 2004, and currently continued to participate in the programs. It was unclear that these patients may be related with poor outcomes of psychiatric day care.

In conclusion, we assessed the relationship between patient characteristics and psychiatric day care outcomes in Japanese schizophrenic patients. A later onset of schizophrenia and fewer previous psychiatric hospitalizations were significantly related with better outcomes of psychiatric day care. A higher educational background was related with the outcomes without statistical significance. It is clinically significant that the relationship between patient characteristics and psychiatric day care outcomes was assessed in a sample size as large as 430 schizophrenic patients, although our study was retrospective and has several limitations. Prospective studies of the relationship will be needed with the objective assessment of psychiatric symptoms.

REFERENCES

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES
  • 1
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