Clinical, cognitive and functional characteristics of long-stay patients with schizophrenia: a comparison of VA and state hospital patients

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Abstract

Long-stay patients constitute a small proportion of all patients with schizophrenia, but in both VA and state psychiatric systems these patients account for a majority of the costs associated with treatment of the illness. VA and state patients would be expected to differ in several respects, including age at onset and premorbid educational status. Little additional information is available about the differences between these samples. Seventy-four long-stay male patients at a chronic state psychiatric center were compared with 50 male veterans from long-stay psychiatric facilities on positive and negative symptoms, cognitive deficits and functional status. The two samples did not differ on positive symptom severity, but the state patients had more severe negative and cognitive symptoms as well as functional deficits. Of all of the variables measured, deficit in self care was the only variable that entered a stepwise discriminant analysis. The correlation between functional and symptomatic variables was the same in both groups, and the group differences and correlations were not influenced by differences in educational status. These data indicate that VA patients may have reduced severity of functional and cognitive impairments relative to state hospital patients, but that the relationship between the different illness variables was similar in the two groups.

Introduction

Long-stay poor outcome patients with schizophrenia represent the largest single health-care cost expenditure in the Department of Veterans Affairs as well as in public psychiatric care. There are several previously identified factors that contribute to extended hospital stays for patients with schizophrenia (Perlick et al., 1992, White et al., 1997). These include severe cognitive impairments, deficits in functional and social skills, severe negative symptoms, and belligerence and dangerous behavior. Although psychiatric service systems are under considerable pressure to reduce their census of long-stay patients with schizophrenia, many patients still remain in psychiatric inpatient units for 50 consecutive years or more (Fisher et al., 1996).

Poor outcome patients in veterans hospitals might differ in several ways from state hospital patients. Since they were inducted into the military, they would be expected to have a later age of onset than state hospital patients, and possibly to have higher levels of education as well. These differences in premorbid functioning might predict a better overall outcome (DeLisi, 1992). Gender differences would also be expected, with the preponderance of VA patients being male and the greater number of chronically institutionalized state patients previously found to be female (Davidson et al., 1996, Fisher et al., 1996). Finally, since many long-stay VA patients receive disability payments that are related to continued illness, VA patients might be expected to have a response tendency toward reporting more symptoms that they believe are intrinsically related to the presence of schizophrenia, such as delusions and hallucinations. If their report of symptoms was in any way exaggerated, they might not realize that other symptoms of schizophrenia, such as negative symptoms and cognitive and functional deficits, are also quite significant in long-stay patients.

There are few comparative studies of VA compared with state hospital patients. In one previously published paper (Marsh et al., 1999), state hospital patients were found to have greater symptom severity and volumetric deficits on MRI scans in the fronto-parietal areas, while VA patients had greater deficits in temporal lobe measures. In a previous study by this same group (Sullivan et al., 1998), however, state hospital patients had been reported to have relatively greater temporal deficits. These results do not yet suggest a consistent pattern of clinical or neurobiological differences between these two patient samples. In addition, the VA patients in those studies were acute admissions, while the state hospital patients were chronically institutionalized at a long-stay hospital dedicated to poor outcome patients. Thus, the differences in course of illness between the samples might be responsible for differences in presentation as differences in premorbid functions.

This paper reports a comprehensive comparison of VA and state hospital patients who had experienced extended institutional stays. Male patients who were long-stay residents at a state psychiatric center were compared with VA patients who were also chronically institutionalized. Measures of demographic characteristics, clinical symptoms, cognitive deficits, and functional impairments were compared between these two groups, as were as the correlations between these aspects of the illness. It was hypothesized that state hospital patients might have more serious cognitive and functional deficit, and that these greater impairments might be due to differences in either premorbid educational attainment or age of onset. It was further hypothesized that the correlations between different dimensions of the illness, such as between positive, negative, and cognitive symptoms and functional status, would be very similar across the two samples of patients. This hypothesis was based on our recent study (Harvey et al., 1998), where we found that acutely admitted geriatric VA patients and chronic state hospital geriatric patients had similar profiles, but differing severities, of cognitive and functional deficits.

Section snippets

Subjects

Subjects in this study were long-stay inpatients at either a large state psychiatric facility or one of two different long-stay VA neuropsychiatric hospitals. All patients who were hospitalized there with chart diagnoses of schizophrenia were considered for participation. All patients were re-diagnosed with a comprehensive chart review procedure that has been described in several previous publications (Davidson et al., 1995, Harvey et al., 1998).

The data from both state and VA patients were

Results

Fifty-four male VA patients met all of the entry criteria; they were compared with 75 male patients from the state psychiatric center. Descriptive characteristics of the patients are presented in Table 1. t-Tests revealed that the VA patients had a significantly later age at first psychiatric admission, higher levels of education, and a much shorter current hospital stay than the state hospital patients. There were no significant differences in age between the two groups.

Data on clinical

Discussion

When institutionalized VA and state hospital patients are compared, there are a number of areas of difference between the groups. Differences in onset age and education were expected, on the basis of the fact that the VA patients all had some amount of military service. Furthermore, the state hospital patients were institutionalized for a longer period of time, with these patients having a very extended institutional stay. Some of the correlates of extended institutional stay that were

Acknowledgements

This research was supported by the assessment core (P.D.H.) of the Mt. Sinai Mental Health Clinical Research Center (K.L.D.) and by the Geriatric Assessment Initiative, MIRECC, VISN 3. The authors would like to thank the following staff members who contributed to this study: Janice McCrystal, Stephanie Bowler, Rita Ohsiek, Susan Shady, and Cynthia Blum.

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