Psychiatric Quarterly

, Volume 68, Issue 4, pp 377–392 | Cite as

Assessment and Treatment Selection for “Revolving Door” Inpatients with Schizophrenia

  • Peter Weiden
  • William Glazer
Article

Abstract

Goals: The goals of this study are 1) to determine causes and patterns of relapse for a cohort of “revolving door” schizophrenia inpatients, and 2) to assess the feasibility of starting a new psychopharmacologic intervention before discharge, either depot therapy or an atypical antipsychotic. Methods: Consecutive admissions to an acute inpatient unit in New York City were screened for “revolving door” criteria. Patients had to have a primary diagnosis of schizophrenia or schizoaffective disorder and have either 1) two hospitalizations in the last year, or 2) three hospitalizations in the last three years. Patients were then assessed for probable causes of relapse for the index and prior two hospitalizations. Treatment selection, based on this information, was trichotomized to: 1) oral conventional antipsychotic, 2) depot conventional antipsychotic (either haloperidol or fluphenazine decanoate), or 3) atypical antipsychotic (either risperidone or clozapine). Results: Sixty-three out of 131 screened admissions met the above revolving door criteria. They were indeed “revolving”, having an average of 1.3 hospitalizations per year over the last 3 years and were only out of the hospital for five months (median) before index admission. The treatment selection process was hampered by lack of information about events leading to relapse, and by the lack of outpatient participation in the medication selection process. Of the 50 patients with complete histories about precipitants for the index episode, the most common reason for rehospitalization was judged to be medication non-compliance (n = 25; 50%), followed by medication nonresponse (n = 13; 26%). Not surprisingly, medication recommendations were closely linked to the assessed reason for relapse (depot therapy [n = 27; 49%] with medication non-compliance; atypical antipsychotic [n = 20; 37%] with medication nonresponse [X2 = 26.9, p<.001]).These two recommendations were implemented before discharge for about one-half of the cases. Patient refusal was a relatively greater problem for depot recommendation while constraints in the outpatient environment were more problematic for patients recommended for atypical antipsychotics. Conclusions: Medication noncompliance and medication nonresponse, in that order, were judged to be the most common causes of relapse for “revolving door” inpatients. Both depot therapy and atypical antipsychotics were commonly recommended and ultimately accepted by about 2/3rds of patients. Choice between depot and atypical was driven by the assessed cause of relapse. In summary, it seems possible to identify “revolving door” inpatients, and to target specific medication interventions within the time frame of an acute inpatient admission.

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REFERENCES

  1. 1.
    Weiden P, Olfson M. Cost of relapse in schizophrenia. Schizophrenia Bulletin. 1995;21:419–428.Google Scholar
  2. 2.
    Redick RW, Witkin MJ, Atay JE, Manderscheid RW. Availability of psychiatric beds, United States: Selected years, 1970–1990. DHHS Publication No. (SMA) 94–3001. 1994;213:1–7.Google Scholar
  3. 3.
    Dickey B, Normand S-L, Norton E, Azeni H, Fisher W, Altaffer F. Managing the care of schizophrenia: Lessons from the 4-year Massachusetts Medicaid study. Archives of General Psychiatry. 1996;53:945–952.Google Scholar
  4. 4.
    Witkin M, Atay J, Manderscheid R. Trends in state and county mental hospitals in the U.S. from 1970 to 1992. Psychiatric Services. 1996;47:1079–1081.Google Scholar
  5. 5.
    Essock S. Clozapine's effectiveness: Results of a 2-year randomized trial. NCDEU. Boca Raton, FL; 1996.Google Scholar
  6. 6.
    Glazer W, Ereshefsky L. A pharmacoeconomic model of outpatient antipsychotic therapy in “revolving door” schizophrenic patients. Journal of Clinical Psychiatry. 1996;57:337–345.Google Scholar
  7. 7.
    Glazer W, Kane J. Depot neuroleptic therapy: An underutilized treatment option. J. Clin. Psychiatry. 1992;53:426–433.Google Scholar
  8. 8.
    Johnson DAW. Further observations on the duration of depot neuroleptic maintenance therapy in schizophrenia. British Journal of Psychiatry. 1979;135:524–530.Google Scholar
  9. 9.
    Kissling W. The current unsatisfactory state of relapse prevention in schizophrenic psychoses—suggestions for improvement. Clinical Neuropharmacology. 1991;14:33–44.Google Scholar
  10. 10.
    Munk-Jorgensen P, Lutzhoft JH, Jensen J, Stromgren E. Trends in psychiatric hospitalization in Denmark: A 10-year register-based investigation. Acta Psychiatrica Scandinavica. 1992;86:79–83.Google Scholar
  11. 11.
    Weiden P, Aquila R, Standard J. Atypical antipsychotic drugs and long-term outcome in schizophrenia. Journal of Clinical Psychiatry. 1996;57:53–60.Google Scholar
  12. 12.
    Weiden P. Using atypical antipsychotics. Journal of Practical Psychiatry and Behavioral Health. 1995;1:115–119.Google Scholar
  13. 13.
    Sullivan G, Wells KB, Morgenstern H, Leake B. Identifying modifiable risk factors for rehospitalization: A case-control study of seriously mentally ill persons in Mississippi. American Journal of Psychiatry. 1995;152:1749–1756.Google Scholar
  14. 14.
    Nageotte C, Sullivan G, Duan N, Camp P. Medication compliance among the seriously mentally ill in a public mental health system. Social Psychiatry and Psychiatric Epidemiology. 1997;32:49–56.Google Scholar
  15. 15.
    Mechanic D, Surles R. Challenges in state mental health policy and administration. Health Affairs 1992:34–50.Google Scholar
  16. 16.
    Weiden P, Olfson M, Essock S. Medication Noncompliance and Mental Health Policy. In: Blackwell B, ed. Compliance and the Treatment Alliance; 1996:35–60.Google Scholar
  17. 17.
    Kessler R, McGonagle K, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry. 1994;51:8–19.Google Scholar
  18. 18.
    McEvoy J, Weiden P, Smith T, Carpenter D, Kahn D, Frances A. The Expert Consensus Guideline Series: Treatment of Schizophrenia. Journal of Clinical Psychiatry. 1996;(Suppl 12B).Google Scholar
  19. 19.
    Weiden P, Rapkin B, Zygmunt A, Mott T, Goldman A, Frances A. Postdischarge medication compliance of inpatients converted from an oral to a depot regimen. Psychiatric Services. 1995;46:1049–1054.Google Scholar

Copyright information

© Human Sciences Press, Inc. 1997

Authors and Affiliations

  • Peter Weiden
    • 1
  • William Glazer
    • 2
  1. 1.Neurobiologic Disorder ServiceSt. Luke's-Roosevelt Hospital CenterUSA
  2. 2.Harvard Medical School and Massachusetts General HospitalUSA

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