Social morbidity of a long-stay mental hospital population with chronic schizophrenia

STEVENMILNE,Senior Registrar, St Nicholas Hospital, Jubilee Road, Gosforth, Newcastle upon Tyne NE3 3XT; DAVIDCURSON, Honorary Senior Research Fellow, Charing Cross and Westminster Medical School, Academic Unit, Horton Hospital, Epsom, Surrey and Medical Director, Department of Psychological Medicine, The Royal Masonic Hospital, Ravenscourt Park, London, W6; ALCUINWILKIE, Registrar, Horton Hospital, Epsom, Surrey KT19 8PZ; and CHRISTOS PANTELIS, Associate in Psychiatry, Mental Health Research Institute, Royal Park Hospital, Park Street, Parkville, Victoria 3052, Australia

As part of the shift towards community care, a number of the large mental hospitals throughout the United Kingdom have now closed and many more are due for closure. In a review of deinstitutionalisation, Thornicroft & Bebbington (1989) concluded that the run-down of hospitals was outstripping the provision of new community facilities. Between 1974 and 1984 the mental hospital population fell by 25,000. However, the increase in residential places provided by local authorities and by the private and voluntary sectors totalled only 3,000. Inadequate planning and provision could give rise to discharged patients facing the prospect of isolated, segregated and impoverished lives with a high likelihood of homelessness and recurrent admission.
Studies have demonstrated considerable psychi atric and social morbidity as well as cognitive impair ments in long-stay mental hospital populations. Owens & Johnstone (1980) reported marked impair ment in the behavioural performance of 510 patients with schizophrenia and this correlated with mental state diagnostic category but with little else. The authors suggested that such deficits were an integral part of the disease process. In a survey of 194 longstay patients with a DSM-III diagnosis of schizo phrenia, Curson et al (1988) found that nearly two-thirds were rated as severely mentally ill and that almost half suffered from delusions, halluci nations or both. Carson et al (1989) investigated the social morbidity of 641 long-stay patients of all diag noses in Claybury Mental Hospital by means of the Rehabilitation Evaluation of Hall&Baker(REHAB) behaviourratingscale.Only 15% of their sample were found to have "potential for discharge" whereas 63% were categorised as "severely handicapped".
We present the results of a survey of the longstay patients of Horton Hospital, a large asylum due for closure, using the same assessment instrument, the REHAB. Our cohort was the same long-stay population in whom Curson el al (1988) reported significant psychiatric morbidity except that patients transferred from another similar hospital (Banstead Hospital) before its closure were included.

The study
All patients who were resident for one year or more were surveyed using a measure of dependency factors developed by the Community Psychiatric Research Unit of Hackney Hospital. This instrument provides a crude measure of the dependency level of patients in hospital and is heavily biased towards items measur ing physical dependency. Patients with the highest levels of physical dependence were excluded from the analysis as they were considered to have little prospect for discharge. Of the remaining patients, those conforming to DSM-III-R criteria for a diag nosis of schizophrenia were assessed using the REHAB. Experienced psychiatric nurses familiar with the patients on each long-stay ward were instructed in how to complete the evaluation questionnaire.
The REHAB is a 23-item ward behaviour rating scale developed for use in chronic psychiatric patients. It consists of two sections; deviant behav iour and general behaviour. The former assesses the amount of difficult or socially embarrassing behav iour. The latter consists of sub-sections measuring the amount of social activity, speech disturbance, self care skills and community skills. Higher scores indicate greater impairment. The general behaviour score provides a measure of the patient's level of dependency. In previous studies a score of 0-40 on the general behaviour section has been taken to indi cate potential for discharge whereas a score of 66 or more has been taken to indicate high dependency with patients requiring 24-hour nursing care and having little prospect of successful community placement. We await studies of the scale's predictive validity.

Findings
From a total of 579 patients, 214 were excluded on the basis of high, largely physical dependency. These patients were mainly elderly and required continued hospital care because of severe dementia. Of the remaining 365 patients with a range of diagnoses, 254 (69.6%) met DSM-III-R criteria for schizophrenia; 166 (65.4%) were men and 88 (34.6%) were women. The mean age was 62.3 year (range 24 to 89). Men were significantly younger than women (f = 0.0001).
Data on social behaviour were collected on all 254 patients. Patients were divided into three categories of dependency according to their scores for general behaviour on the REHAB (see Table I). Roughly one-third fell into each category. There was no sig nificant difference in mean age between the three groups. No significant sex differences emerged.
The sub-sections making up the general behaviour score had a high correlation with the total general behaviour score (/3<0.001 in all cases). The single global item -"overall assessment of the patients gen eral behaviour during the previous week" -had a high correlation with total general behaviour score The deviant behaviour score also correlated with the general behaviour score (P< 0.001) and, with the exception of social activity, with each of the other sub-sections making up the general behaviour score. There was a weak negative correlation between age and deviant behaviour score (P<0.05), that is, the younger patients tended to exhibit more difficult or socially embarrassing behaviour.
Advancing age was significantly associated with two items of general behaviour: these were social activity (P = 0.002), indicating that older patients were less active, and speech skills (P< 0.001), indica tive of a reduction in the amount of speech with age. These two results may account for the trend towards older patients having higher general behaviour scores (/>= 0.086).

Comment
There have been previous studies reporting the social morbidity of long-stay mental hospital populations irrespective of diagnosis (for example Carson et al, 1989). In this study, we assessed the social function ing of 254 patients with schizophrenia who were resident in a long-stay hospital but who were not precluded from any hope of discharge because of high levels of physical dependency. We are aware that, although most of the excluded patients were demented, a small proportion may have suffered from schizophrenia. This could introduce bias into our results. We would argue, however, that the numbers of patients suffering from schizophrenia in the excluded group would be small. If this group had an effect on our results, it would be meagre and tend to result in an underestimate of the degree of impaired social functioning in the total long-stay schizophrenic population. In a mental hospital scheduled for closure, ward nurses, faced with the prospect of redundancy or a change in professional roles, may be partial in their assessment of patients' functioning. A systematic bias would, however, seem improbable given that assessments involved large numbers of nurses on dif ferent wards. In addition, there was a high corre lation between the single item of overall assessment of the patient's general behaviour and the total gen eral behaviour score, suggesting that the ratings were internally consistent.
Older patients showed a trend towards greater impairment of general behaviour. This may be explained by higher scores in two items which might be expected in any ageing population: less social activity and a reduction in the amount of speech. Younger patients tended to exhibit more difficult or socially embarrassing behaviour. However, all age groups were just as likely to fall into the "potential for discharge" category.
These results, together with the findings from the previously reported study of psychiatric morbidity in the same hospital population (Curson et Â«/, 1988), demonstrate that long-stay in-patients with chronic schizophrenia have active psychotic symptomatology and severe social dysfunction. Nevertheless, it is notable that a third of the patients had a reasonable expectation of semi-independent community place ment and that a further third could do well provided that adequate support was provided for them in the community. The provision of adequate postdischarge care of the chronic in-patient population requires assessment of their dependency needs, as in the present study. A large number of patients demonstrated significant morbidity and planning for community care must take account of the levels of functioning that such patients can be expected to achieve and the high level of ongoing psychiatric and social care which community services will be required to provide. If these patients' handicaps are not adequately addressed, then community care runs the risk of falling into disrepute. This is particularly important given that, currently, public opinion seems to be divided as to the merits of community care.