A Study of 131 Patients with Schizophrenia and Provision for Them
by Harold Hillman
Note: This paper has been included to illustrate the problems of medical research; in a world of facile comments and supposedly scientific assertions, it's interesting to see how many very simple problems and pitfalls exist - Rae West.
Institute of Biological Psychiatry, Schizophrenia Association of Great Britain, Deiniol Road, Bangor, Gwynedd, LL57 2UW, Wales*

Short title: Schizophrenic patients

Abstract

    One hundred and thirty one patients came to the Institute of Biological Psychiatry at Bangor, accompanied by 161 healthy blood relatives, spouses and friends. A history was taken and a diagnosis of schizophrenia was made using DSM IIIR criteria. The patients were examined to see if they had any concurrent physical disease. Venous blood samples were taken for measurements of chemical constituents believed to be involved in schizophrenia. The population of patients is described, and the views of the patients and their relatives were noted. Recommendations are made about how provision for patients might be improved.

Introduction

    Between October 1990 and March, 1993, 131 patients diagnosed here as schizophrenic, accompanied by 161 healthy relatives or friends, and 33 healthy subjects came to the Schizophrenia Association of Great Britain at Bangor, Wales (Table 1). Other patients who came were diagnosed as not schizophrenic, and are not discussed here. The aims of this study were: (i) to establish the diagnosis, so that blood samples were examined only from patients with schizophrenia, rather than from patients with any other psychiatric, neurological or medical disease. This was to try to detect any specific biochemical lesion in schizophrenia; (ii) to take detailed histories, to find out if particular factors precipitated the initiation or relapse of the condition; (iii) to examine patients clinically to see if they had any concomitant physical disease; (iv) to hear from the patients and their relatives how they felt towards treatment and provision for them, and how it could be improved, if necessary; (v) it also proved to be a useful exercise to survey the difficulties of research in the biological basis of schizophrenia, several of which are shared with other mental illnesses; (vi) finally, it was felt possible to make a number of general recommendations, designed to improve the treatment and life styles of patients with schizophrenia.
    The fact that the patients, their relatives and friends, and the healthy subjects were volunteers meant that none of the groups could be considered random samples of their populations, therefore, they could not be used for statistical studies. However, one could compare the biochemistry of the blood of the following four groups: (i) the patients who were being treated with neuroleptics; (ii) the patients who were not being treated with neuroleptics; (iii) the first degree relatives of the patients; (iv) the healthy control subjects, including non-blood relatives. Some patients of group (ii) did not want to be treated with neuroleptic drugs, others said that they had not taken neuroleptics for the past 3 months or longer.
    The chemistry of the blood from the patients who met the DSM IIIR criteria for schizophrenia (American Psychiatric Association, 1987), and that from healthy blood relatives and healthy control subjects, who were not taking drugs or dietary supplements, which could affect the concentration in their blood of the substances being measured, were compared. The results of the analyses of the blood samples have been published elsewhere (Ramchand et al., 1992,a,b; Wei et al., 1992,a,b).

*Present address:- Unity Laboratory of Applied Neurobiology, 76 Epsom Road, GUILDFORD, Surrey GU1 2BX, England.

Methods and procedure

    The fact that the patients travelled long distances voluntarily had the effect of excluding those who were acutely or severely ill. An arbitrary but useful scale was designed to indicate the seriousness of the patients' clinical state at the time of their visit to the Association: 1 was severely ill; 2 was ill but living at home, with occasional relapses; 3 was stable, but having symptoms; 4 was capable of working part time or working part time; 5 was feeling well, and working full time or retired. These were relatively simple states upon which different observers would agree.
    The patients, relatives and volunteers travelled to Bangor, Wales, from all parts of the United Kingdom. They did not eat or drink (except water) from 22.00 on the day of arrival, until the blood samples were taken between 08.00 and 09.00 on the morning of the following day. They were asked to fill in forms indicating that they did not have bacterial or viral infections. They then signed consent forms for blood samples to be taken, if they fulfilled the criteria for being schizophrenic, healthy blood relatives or control subjects; some also agreed to give skin biopsies.
    Samples of 20-25 ml of blood were taken from the ante-cubital veins, and the blood, plasma and sera were stored, whole or separated at -20øC, until analysed. The patients, relatives and subjects, were then asked to give urine samples for 'Multistix' dip tests (Ames Ltd) for the presence of urobilinogen, blood, bilirubin, ketones, glucose, proteins, and approximate values for pH and specific gravity; they were then given breakfast.
    A history was then taken from the patients in the presence of their relatives or friends, followed by questions designed to find out how many of the DSM IIIR criteria they fulfilled. They were asked about their general health, their family histories, the age of onset of the schizophrenia, their subjective state of health on the day they were attending, what drugs they were taking, any side effects from which they were suffering, any family history of mental disease, how much they smoked, how much alcoholic drinks they imbibed, and whether they had ever taken drugs of addiction. They were not asked whether they had been abused sexually.
    They were then told that information was being sought about the current provisions for schizophrenic patients, how their general practitioners, psychiatrists, hospital nurses, community psychiatric nurses and communal organisations had helped them. They were also invited to comment on the helpfulness (+1), the neutral assessment (0) or the dissatisfaction (-1) of the various personnel with whom the patients and their families had been in contact. Frank and spontaneous but confidential comments were sought in an effort to understand the strengths and weaknesses of current provision for the patients. Of course, since the patients and their relatives, who had volunteered to come to the Schizophrenia Association, were not random, the opinions expressed can only be regarded as those of the more articulate schizophrenic patients and their relatives. However, it is hoped that it may be useful to publish this information as a guide to how the 'consumers' of the services for schizophrenic patients perceive the provisions, and how they would like to see them improved. Nevertheless, one has to bear in mind that some of the patients' complaints arose from the nature of their illness. The patients were always interviewed in the presence of relatives or friends, whenever they were accompanied.
    All patients, but not the relatives or control subjects were then given a simple clinical examination, to find out if they had concurrent physical disease. Their vision, blood pressures, temperatures, heights and weights were also measured. At the time when they visited the Association, three of them were inpatients, three were not being, and had never been, treated by a psychiatrist, but all the rest were having psychiatric treatment, mostly with neuroleptic drugs. No treatment or advice about treatment was given to them, but general advice was proffered (Appendix 1).
    Skin biopsies were taken only from patients and healthy control subjects. The forearm skin was anaesthetised by injection of 0.5 ml of 1% xylocaine subcutaneously, and a 4 mm diameter punch sample was taken. The intention was to grow fibroblasts and keratinocytes in tissue culture, to see if any biochemical abnormalities present in the brains of schizophrenic patients, might also be found in their fibroblasts and keratinocytes grown in tissue culture (Grosshong et al., 1978; Giller, 1980; Mahadik et al., 1991; Schallreuter et al., 1992).
    The patients, relatives and control subjects were informed if any abnormalities were found in their urine samples, or on clinical examination of the patients. We also wrote immediately to their general practitioners, if they wished us to do so.

    With the patients' permission, photographs were taken of the front and side views of the patients, and of their hands, to identify the patients, and to note their postures and the shape of their fingers. Neither of the latter two were abnormal in the first seventy patients, and so these were not pursued or reported. Patients and those accompanying them were asked if they had any queries about the research being done on their blood samples or biopsies. They, and their closest relatives or friends who could observe them, were given stamped addressed envelopes to write to us, if the patients should have a relapse, describing their own and the observers experiences in their own words (Strauss, 1989). Not enough replies were received to permit useful analysis.
    Patients and their relatives were interviewed for 2.5-3.5 hours, including the clinical examination.

Problems of research

    The patients and their relatives came in response to advertisements and were not a random population. Whenever possible, brothers and sisters of the patients were sought, but often the patients were accompanied by their parents, who were, of course, a generation older than themselves; therefore, it was difficult to derive conclusions about blood chemistry which changed with age. However, the blood relatives who were healthy were close genetically to the patients. Some of the patients were taking neuroleptics and some were not, and we also had a group of healthy spouses and control subjects. Thus, one could derive statistically significant results from the biochemical measurements, but not the data in this paper, since it was collected only from, or about, the patients, without a control group for their clinical conditions.
    The information given by the patients and their families was not always reliable. Their memories for past admissions, symptoms and drug treatments were not always good. When persons gave a single number to represent their smoking or drinking habits, or indicated that they had suffered a symptom, it was difficult to establish how that single number could accurately represent the habit or symptom of a lifetime.
    Another problem was that they had heard the leading questions, such as those used in the diagnosis of schizophrenia, many times before. They had 'learnt' to answer them, and their answers were often affected by their mood at the time. Often relatives would give a different answer to a question than the patient would. One did not know how reliable the patients were in their information about compliance with drug treatments. Furthermore, one only interviewed the patients and the accompanying persons once, due to the expense and difficulties of their travelling to the Schizophrenia Association at Bangor.
    A few patients and their relatives found that travelling long distances, staying overnight at a hotel, the prospect of interviews about their illness, the circumstances of the interview, giving the blood samples, and the biopsy of the skin, were stressful and this could have affected the biochemistry of the blood.

Blood

    As can be seen in Table 1, 131 schizophrenia patients were accompanied by 144 healthy first degree relatives and 17 spouses; the spouses and 33 healthy subjects together acted as a control group. Their ages are given, and it can be seen that many of the relatives were older than the patients. There were about twice as many men as women in our sample. The age of onset of the illness was 22.0 ± 6.4 years in the 92 male, and 22.4 ± 9.1 yrs in the 39 female patients; the duration of the illness at the time of attendance was 13.0 ± 9.3 yrs, and 13.8 ± 8.9 yrs, respectively. The number of admissions of male patients were from O to 20, and of female patients 0 to 7 times (Table 2). Although data was collected originally about whether admissions were voluntary, it was not clear how accurate the information was, nor how often the patients were admitted 'voluntarily', because they had been told that they would be 'sectioned', if they did not 'volunteer'. Therefore, they are not divided into two such groups. The severity of the illness at the time when the patients visited the Association was assessed when the blood samples were taken to examine their biochemistry.
    The educational achievements of the patients are given in Table 4, and show the high academic level of those who came here.
    The drugs and the doses that the patients and their relatives said had been prescribed, and were taking, are listed in Table 5. Thirty three patients had never taken any neuroleptic drugs at all, or had not taken them during the 3 months prior to their visits here. Flupenthixol, procyclidine, trifluoroperazine, chlorpromazine, fluphenazine, haloperidol and sulpiride, were the drugs most commonly used. Side effects reported included tiredness, 'twitching legs', inability to concentrate, increased weight, blurred vision, amenorrhea and impotence, but they were very rare. Five of the patients who took no drugs expressed fear of toxic or side effects. Of the patients, 58 were also taking vitamin supplements, such as Multivite, cod liver oil, B12, folic acid, ascorbic acid, or minerals, such as Mg2+, Zn2+ or Fe2+.

    The male schizophrenic patients drank and smoked very much more than the females, although about half of the patients either did not drink or did not smoke at all (Table 6). About the same proportion of patients had never taken drugs of addiction, although those who admitted doing so may have taken them once, regularly or frequently (Table 7). Of those who took such drugs, cannabis was by far the commonest one used. On the information they gave us, women took these drugs less frequently than men.
    Schizophrenia was diagnosed by the presence of the first 12 symptoms listed in Table 8, so it is not surprising that they occurred frequently in this population, where they were in approximately equal incidence in males and females. About one third of the patients had been violent to other people or property, and about 65 % had been unable to work due to their illness. The incidences of first degree family histories of schizophrenia or manic depression, or of diabetes were also high, but the way in which the population was recruited may have contributed to this.
    The patients and their families were told, "we would like to know from you confidentially how helpful the various different people and services have been to you recently, both in good and bad respects. We would like you to suggest ways in which provision might be improved, so we are going to ask you about each of the main persons and services in which you have come into contact. We will mark those as +1 satisfied or good, 0 neutral, -1, dissatisfied or bad. We will then ask you for any comments or suggestions about how the provision for schizophrenic patients can be improved." The answers to these questions are summarised in Tables 9 - 13. In tables 10 - 13, the answers were free and unstructured; they were classified and their incidence counted subsequently.
    Bearing in mind that those who volunteered to travel all the way to Bangor are likely to have been more articulate than other schizophrenic patients and their families, the following general points seem to arise from Tables 9 - 13. Between 25% and 40% of patients gave a positive assessment of their treatment by the four agencies, and about an equal proportion were dissatisfied. There was a tendency for dissatisfaction with psychiatrists in the treatment of both male and female patients. A fairly high proportion of the men would not or could not give us information about their relationships with the different personnel and institutions with whom they were in contact (Table 9). Many of the men had previously had no contact with social services.
    A number of the patients and relatives did not think that their general practitioners knew much about mental illness, that they did not have enough time for patients with mental illness, and that they did not listen to patients (Table 10); more made similar comments about psychiatrists (Table 11). In both cases, they seemed to be wanting more time with their doctors, to be listened to by them, and for the doctors to answer the patients questions more often (Table 12). Many patients and relatives pointed to a shortage of nurses both within the hospital and the community. Some of their comments were similar to those about the doctors. Patients often also had problems in respect of not finding the company of like-minded people in hospitals, and of being bored with life as in-patients.
    The predominant theme about their comments on community provision and the social services, concerned those people who needed care after release, and the lack of employment and educational opportunities for them (Table 13). This may be partly a reflection of the general unemployment in the United Kingdom at this time. The same themes of lack of purposeful activity and desirable company were expressed in respect of the patients' own predicaments (Table 14), but another important point was also made. If patients on illness or unemployment benefit take any part time or full time paid employment, they lose their benefit, and if they can not stay in that employment, it takes several weeks for them to receive the previous benefits again. This has the effect of discouraging patients from seeking paid employment.
    We had news of three patients who committed suicide some months after interview here, and one died of a heart attack.
    It will be seen that the advice we gave the patients concerned their diagnosis, the desirability of them taking the drugs prescribed, living healthy lives, and exploiting abilities they had (Appendix 1). The questions which the patients and their relatives asked are listed (Appendix 2), and they reflected a desire to know more about the disease, its prognosis and a likelihood of a cure being found. Question 7 was the most difficult to answer. Often the illest patients were the most unwilling to seek treatment, yet the relatives and friends were naturally reluctant to force them to be treated against their wishes. Patients could be severely ill and disruptive, but might not be sent into hospital against their will, unless they were a danger to their own lives or those of their families. We were often asked about the efficacy of unorthodox treatments.
    We also answered questions over the telephone about the symptoms of schizophrenia We always advised patients, their relatives or friends, to see their general practitioners, who would refer them to psychiatrists, if necessary. We never advised treatment, nor made diagnoses over the telephone.

Discussion
The population studied
    The disadvantages of studying this population are that our patients were not a random sample of schizophrenic patients in Britain, that there were more than double the number of male patients than females (Table 1), that no severely or acutely ill patients came to Bangor, that there was no way of confirming much of the information given by the patients (particularly that in Tables 5 - 7), and that there was no control population for the study of the patients here; this was because we did not question the relatives, friends or control subjects in depth about themselves, nor did we examine them, although blood samples and skin biopsies were taken from the latter groups. The uncertainty about the veracity and accuracy of information given by patients is a common problem in mental illness, somatic medicine, sociological and psychological studies, but it is assumed that most errors in the information given about patients will be random and, as such, would have relatively little impact on conclusions.
    The advantages of the present study are that a period of 2.5 to 3.5 hours in a relaxed atmosphere, and in the presence of their relatives and friends, gave the patients and those accompanying them much more opportunity to impart information; often the parents or friends would modify answers to questions, and sometimes they would enter into a dialogue with the patients, which they had not done for a long time. The patients and those accompanying them were pleased to talk about the illness at length, and to ask us about it (Appendix 2). The satisfaction they often expressed and the letters received afterwards suggested that the visit to the Association may have helped them. The patients and their relatives were pleased to be able to express their satisfaction or dissatisfaction with those whom they came into contact, and to suggest how provision for them might be improved (Tables 9 - 14). These opinions must be viewed in the light of knowledge of the nature of schizophrenia. All those who treat and care for patients should try to differentiate between, firstly, difficulties due to the disease; secondly, difficulties due to inadequate resources; and, thirdly, inadequacies and inefficiency of those who look after them. The first requires optimal effort in diagnosis and treatment; the second requires pressure of public opinion; and the third necessitates doctors and nurses listening to patients and their carers in order to make a conscious effort to meet the reasonable desires and expectations of the patients, their friends and their families.

Characteristics of this population
    A remarkably high proportion of the population studied here had reached degree or diploma standard (Table 4), although clearly their status as volunteers would tend to select these people from the population at large. At interview, the patients often referred to their interest in writing, music, art and electronics, and we put them in touch with others with similar interests. We also encouraged them to pursue amateur or professional studies in these subjects.
    The range of neuroleptic drugs and their dosages, which the patients reported taking, was large (Table 5). With the exception of drugs given by injection, such as clopenthixol, flupenthixol and pipothiazine, it was difficult to know how good the compliance was, unless the patients lived at home and the relatives or spouses supervised the treatment. Patients reported side effects so rarely that they could not be tabulated, but many of them were treated successfully by procyclidine (Table 5). Fear of toxic or side effects of drugs was sometimes given as a reason for not taking them, and we always encouraged patients to tell their doctors about any side effects as well as if they were varying treatment on their own initiative.
    Approximately, 50-60% of the men and women did not smoke or drink (Table 6); there are no figures for these habits in healthy unemployed persons of the same age available for comparison, but it can be seen that young men smoked heavily. Of the male patients, 57 out of 91, and 25 of 39 female patients had never taken drugs of addiction. The others said that they had taken some occasionally. Cannabis appeared to be the most popular drug, and intravenous drugs were hardly mentioned at all (Table 7). The incidence and the popularity of cannabis in the patients seemed to be similar to those found in the British population as a whole (National Audit of Drug Misuse in Britain, 1992). It would be useful to study in depth whether addiction triggers the manifestation of latent schizophrenia, or actually causes it itself.
    It is not surprising that patients who were diagnosed as schizophrenic on the basis of their having symptoms listed in DSM IIIR should exhibit these symptoms frequently (Table 8). However, of the first 14 symptoms, a mean of 46 out of 92 men, and 23 out of 39 women had each symptom; thus each patient had about half the list of symptoms. It will be seen that fear or dread, silence or withdrawal, voices and paranoia were the commonest symptoms. Schizophrenia had prevented about 65% of the men and women from working. About 43% of the males and 20% of the females reported first degree relatives with schizophrenia or manic depression. This fits in with the view that there is a genetic contribution to schizophrenia (Pollin et al., 1969; Slater and Cowie, 1971; Gottesman and Shields, 1982; Gottesman, 1991), and a smaller, but remarkably high incidence of diabetes mellitus was also found in the families (Table 8).

Treatment and provision for patients
    It is expensive to keep patients in hospital, and not quite so expensive to provide for them in the community (Knapp, et al., 1992; Knapp, et al., 1993). It is desirable for patients to stay in hospital only when their treatment requires it, and it has been British Government policy since the 1980's to close down mental hospitals (Department of Health, 1989; 1992). Some of the problems mentioned by our patients and their families arise from insufficient personnel and resources devoted to treating and caring for the patients, while others are the responsibility of staff, and can be addressed by listening to what the patients and their relatives have said, as classified in Tables 9 - 14. These are best summarised in a series of recommendations.

Recommendations

    1. General practitioners need to be made more aware of the early symptoms of schizophrenia (and other psychoses), so that they may diagnose patients and refer them for treatment sooner. They should always be prepared to see the patients' families and concerned friends. Our experience is that despite some initial embarrassment, it is advantageous to interview the patients with their families or friends, because the interview is then much more productive. General practitioners should also be less unwilling to certify patients under the Mental Health Act (1983). Usually, this is not done until the patients are dangerous to the lives of themselves or others, when they are too psychotic to accept treatment voluntarily.
    2. Some psychiatrists are still unwilling to see members of the patients' families, either because they feel that parents may have contributed to the illness by inappropriate upbringing or physical or sexual abuse. The psychiatrists may not have time to see the patients, After an initial interview for an hour, the patient may only be seen for 15-20 minutes every 1-6 months, which is clearly not enough. The shortness of the interview is exacerbated by the fact that a patient may see a different psychiatrist at each visit; obviously, the personality of the psychiatrist, and the establishment of rapport between patients and their families with their general practitioners and psychiatrists, are important in treatment and drug compliance (Piatkowska & Farrell, 1992).
    3. Patients and families often complained of the unwillingness of general practitioners, psychiatrists and nurses, to explain to them the nature of schizophrenia or the rationale of the particular drug treatment, and sometimes to answer questions at all. This perceived lack of responsiveness of medical staff was sometimes part of the disease, but sometimes arose from the hostility engendered by some organisations towards the drug treatment of schizophrenia. At times, however, it seemed to arise from the behaviour of the medical staff itself,
    4. The patients and their families often mentioned that they thought that the lack of attention was due to there being too few psychiatrists, ward nurses and community psychiatric nurses to give enough time to individual patients. Certainly, the patients were often sympathetic to the fact that each member of staff was often too busy to give them the attention they wanted.
    5. A few schizophrenic patients who had been in hospital several times before mentioned that they had an agreement with the psychiatrist to admit them rapidly when they felt that they were going into relapse. However, many others complained that it was sometimes difficult to obtain admission when they felt they needed it. Some patients and their families are aware that they are becoming iller, but others are not. Considerable research has gone into identifying prodromal symptoms (Doherty et al., 1978; Chapman and Chapman, 1987; Birchwood et al., 1989). Earlier treatment of those patients who recognise the onset of a relapse themselves, or in whom the relatives can see it coming, is highly desirable, but such recognition has to be by lay people and based on simple observations, if it is to be practicable. It should be accompanied by greater willingness and ability of hospitals to admit patients who show prodromal symptoms immediately. The thinking behind this is that those patients in whom a relapse can be anticipated may be kept on lower maintenance doses of neuroleptics, but the doses may be increased immediately a relapse appears imminent.
    6. Patients often found little or nothing for them to do in hospital. That, together with the lack of contact with nurses, often made them feel bored, perhaps they could be encouraged to do such communal activities as sports, plays, concerts, art exhibitions, etc. Some of them could teach others writing reading, languages, skills, etc. A culture of activity involving many of the patients would probably mean more occupational therapists, but it is likely that families of patients would be prepared to help to organise such activities.
    7. Patients and their carers often need holidays either together or separately. The burden of looking after chronically ill patients would be much relieved if they could be admitted to a hospital or a half-way house for a 2-3 week period, or if they could be adequately looked after and supervised, while the carers went on holiday. Of course, the patients should also have their own holidays, with or without carers.
    8. It would be highly desirable to reform the social security scheme to encourage patients, who have been ill, to take part time paid posts, without loss of benefit, because this would assist them to recover more quickly. It would also help the patients very much, if their benefits could be restored rapidly if they failed to keep down a paid job, so that it would be no financial disadvantage for them to try to work.
    9. Toilet facilities should be provided in secure rooms.
    In conclusion, it is worth mentioning perhaps the most difficult problem which we have encountered. The patient, who is not ill enough to be in hospital, who is not dangerous enough to be sectioned and often lives far from relatives or carers, is often unwilling to be treated. He or she is usually paranoid, and quite hostile to the appeal of friends, family, general practitioners, community psychiatric nurses and others, to seek help. Often, such patients have no family or friends near by, and they live rough. Some take drugs. If a general practitioner, an approved social worker or even a member of their family, seeks to help them, they often run away, Sometimes their paranoia leads them to violence or suicide. This problem needs to be addressed by psychiatrists, governments and carers.

Acknowledgements

    I wish to thank Mrs Gwyneth Hemmings, the Director of the Schizophrenia Association of Great Britain for support, Miss Jane Davies, Dr Wei Jun and Dr R Ramchand for help with the patients, and Mrs Helen Lincoln and Mrs Veronica Hanson for organising the project.

TABLES

 Number of personsAge in years (s.d.)
Patients meeting DSM IIIR criteria for schizophrenia13136.0 (11.0)
  of which male9235.7 (10.8)
    female 3936.5 (11.2)
Healthy first degree relatives of schizophrenic patients14452.6 (11.2)
  of which male8153.7 (14.1)
    female6350.1 (17.6)
Healthy spouses of schizophrenic patients1747.9 (11.6)
  of which male 851.1 (12.8)
    female945.1 (9.6)
Healthy control subjects3337.9 (12.5)
    of which male1231.7 (8.2)
      female2141.4 (14.5)
Table 1. Persons from whom blood samples were taken. Full histories were taken, and clinical examinations were made, only on the patients.

 

MaleFemale
Number of admissionsNumber of patients Number of admissionsNumber of patients
09 02
120 112
224 24
36 38
48 44
510 55
67 63
75 71
>73 >70
No. of patients92 No. of patients39
Table 2. Number of admissions of patients to hospitals, reported by the patients and their relatives.

 

 

SeverityMale (number of patients)Female (number of patients)
1.592
2.0105
2.5177
3.02510
3.5167
4.0115
4.511
5.032
No. of patients9239
Table 3. The severity of the illness at the time the patients were seen. The scale is given in the Methods and Procedures Section. It will be noted that no severely ill patients, of severity 1, were seen.

 

 

Examinations passedMale (number of patients)Female (number of patients)
None135
City and Guilds63
GCSE or 'O' levels (1 to 10 subjects)2112
'A' level (1 to 4 subjects)249
Diploma or degree259
No information21
TOTAL9139
Table 4. Highest educational achievements of schizophrenic patients.

 

 

 

 

Neuroleptic drugsDose rangeNumber of patients
NONE 33
Benperidol0.75 mg/d1
Benzhexol10 - 15 mg/d2
Chlorpromazine50 - 700 mg/d18
Clopenthixol30-500 mg/14 d; 20 mg/d4
Clozapine150-600 mg/d3
Fentazine12 mg/d1
Flupenthixol12.5 mg/ 21 d - 300 mg/7 d37
Fluphenazine12.5 mg/ 21 d - 100 mg/7 d14
Fluspirillene3 mg/ 7 d1
Haloperidol3 - 60 mg/d9
Lofepramine140 mg/d1
Loxapine80 mg/d1
Maprotiline75 mg/d1
Mianserin20 mg/d1
Orphenadrine150 - 500 mg/d3
Perphenazine8 mg/d1
Pimozide4 - 12 mg/d2
Pipothiazine100 mg/ 14 d - 50 mg/ 2 d4
Procyclidine5 - 30 mg/d27
Prothiaden25 mg/d1
Remoxipride150 mg/d1
Sulpiride200 - 600 mg/d9
Thioridazine50 - 600 mg/d7
Trifluoroperazine2 - 40 mg/d19

Other psychotropic drugs
Dose rangeNumber of patients
Amitryptyline25 mg/d1
Benztropine mesylate2 mg/d 1
Clomipramine5 - 10 mg/d2
Diazepam30 - 60 mg/d2
Fluoxetine40 mg/d1
Imipramine50 mg/d1
Lithium carbonate120 - 1000 mg/d5
Propanolol10 mg/d1
Temazepam10 - 60 mg/d3
Trimipramine10 mg/d1
Table 5. Drugs and dosages reported by the patients. The compliance was not known. Many patients were taking more than one drug. The number of male or female patients taking most of the drugs was too small to make it useful to indicate their genders.

 

 

DrinkingSmoking
 MaleFemale MaleFemale
Drinks (per week)Number of patientsNumber of patients Cigarettes (per day)Number of patientsNumber of patients
05231 04020
2.5212 -5122
2.5 - 542 -1043
5 - 7.540 -1573
7.5 - 1000 -20155
10 - 12.531 -2543
12.5 - 1520 -3051
15 - 17.541 -3511
17.5 - 2020 -4021
    -4500
   -6010
Table 6. Drinking and smoking habits reported by 92 male and 39 female patients. Four of the latter took short as well as long drinks.

 

 

Drug of addictionNumber of patients
MaleFemale
NONE5725
Cannabis3714
Lysergic acid diethylamide93
Amphetamine61
Methylamphetamine31
Morphine20
Mescaline11
Cocaine11
Psilocybin10
Heroin11
Barbiturate10
Chloroform10
Table 7. Drugs of addiction taken at any time of their lives by schizophrenic patients.

 

 

 

Symptom:-MaleFemale
Fear or dread7133
Period of silence or withdrawal6837
Depressed easily5727
Strange fantasies5331
Voices in head6331
Hallucinations5031
Feeling that people are against patient6329
Controlled from outside or by others4820
Thoughts broadcast to outside4721
Thoughts inserted into brain3619
Thoughts taken out of brain2310
Sleep disorder4017
Tired much of the time2614
Poor concentration53
Violent to other people or property3714
Police involvement for misdemeanour, drug offences or being found wandering359
Multiple jobs in the past3120
Has stopped the patient working now5926
First degree family history of schizophrenia or manic depression408
First degree family history of diabetes mellitus245
TOTAL NUMBER OF PATIENTS:9239
Table 8. Symptoms which the 131 patients complained of at some time during their illnesses, and family history of psychosis and diabetes mellitus.

 

 

AssessmentMaleFemale
General practitionerPsychi-
atrist		NursesSocial servicesGeneral practitionerPsychi-
atrist		NursesSocial services
+14130303823111313
01091993871
-13143271412191414
No contact215220049
No information891191112
Table 9. Assessments of schizophrenic patients and their families about the helpfulness of the different personnel who have treated the patients. +1 is positively helpful, 0 is neutral, -1 is positively unhelpful. No contact means the patient has had no contact with those personnel. No information means the patient would not comment.

 

Their general practitioners:-Number of patients, families or friends commenting
Do not know much about mental illness8
Do not have enough time for patients5
Unaware of the side effects of the drugs they prescribe5
Do not care about the patients4
Do not listen to patients4
Refused to visit patients3
Would not speak to relatives3
Do not tell patients or relatives about schizophrenia3
Do not understand patients2
Do not take patients seriously2
Did not get psychiatric treatment readily enough1
Insensitive to effects of schizophrenia on family1
General practitioner was abusive**1
Table 10. Comments of patients and their families about general practitioners.
* A comment made by several people in respect of one patient is regarded as made by one person.
[** This means irritated or angry; not sexual abuse - RW]
All the comments in table 10 were unstructured and spontaneous.

 

 

Their psychiatrists:-Number of patients, families or friends commenting*
Do not listen to patients or relatives13
Do not communicate with patients13
Do not talk to patients10
Do not spend enough time with patients10
Do not treat acutely ill patients urgently8
Not enough psychiatrists7
Too many different psychiatrists seen5
Too many injections or drugs, not enough psychotherapy5
Do not take the side effects of drugs seriously4
Do not tell patients or relatives about condition4
Psychiatrists aggressive3
Sometimes do not allow relatives to visit3
Not interested in nutrition or food allergies3
Not enough co-ordination with general practitioners2
Language barrier between patient and psychiatrist2
Miscellaneous other individual comments7
Table 11. Comments of patients and their families about psychiatrists. See also legend to Table 10*.

 

Comments about their nurses and hospitalsNumbers of patients, families or friends commenting*
More nurses needed in hospitals9
More community psychiatric nurses needed6
Not enough like-minded people to talk to in hospitals6
Boring life in hospital6
Nurses do not care about patients3
Nurses do not answer questions of patients or relatives3
Nurses allowed wards to get out of control2
Patients need company when they are acutely ill2
No toilet facilities in restricted cells1
Patient said he was beaten in hospital1
Table 12. Comments of patients and their families about nurses and hospitals. See also legend to Table 10*.

Community provision and social services:-Number of patients, families or friends commenting*
Not enough provision for patients when carers are not able to look after patients or are in hospital6
Little provision of holidays for patients and carers5
More workshops needed for patients3
More training and education needed for patients3
Mixing only with ill people not conducive to recovery3
Social services are rationed3
More employment opportunities needed3
Services are rationed3
More half way houses needed for patients discharged from hospital3
No day centre for patients in the area2
Churches could help more2
More help needed for divorced parents of patients1
More resources needed for mental health1
Children at schools should be taught about mental health1
Patients would like their own accommodation1
Table 13. Comments of patients and their families about community provision for them. See also legend to Table 10*.

 

Their own predicaments:-Number of patients, families or friends commenting*
They need something to do all day7
Day centres are boring6
Other people in day centres are mentally ill, hopeless, or boring8
Patients lose benefits if the earn money5
Can not communicate with general practitioners or psychiatrists5
Need education, training, or skill5
Partner does not understand mental illness5
Can not often go on holiday4
Table 14. Comments of patients and their families. See also legend to Table 10*.

Appendix 1.
Advice about the patients given to them and to the persons accompanying them.
  1. Whether they were schizophrenic.
  2. Information about any abnormalities found on physical examination.
  3. That they should comply with treatment given by their general practitioners and psychiatrists, whom they should always consult if they wish to vary it.
  4. That they should report side effects of drugs to their general practitioners and psychiatrists.
  5. That they should give up smoking, excessive drinking and eating, if possible.
  6. That they should stop taking drugs of addiction, seeking professional help to do so, if necessary.
  7. That they should have exercise.
  8. That they should seek employment as soon as they could.
  9. What educational and training opportunities are available to them.
  10. That they should take part in as much social and communal activity as they can.
  11. That they should seek the advice of geneticists on the likelihood of offspring being schizophrenic.
  12. What benefits are available to them and their carers.
  13. That they should join appropriate support groups, if they think that this will help them
  14. That they should exploit any creative abilities they may have in writing, painting, electronics, computing, etc.
  15. That they should avoid seeking expensive biochemical measurements, and ineffective treatments, especially from unorthodox practitioners.
  16. The respective roles of the schizophrenic Association of Great Britain (research), Mind (support group for all mental illness), National Schizophrenia Fellowship (local support groups) and SANE (telephone help line).

 

Appendix 2.
Questions asked by patients and persons accompanying them.
  1. Is the patient schizophrenic?
  2. What is the long term prognosis?
  3. Should they continue to take particular drugs prescribed?
  4. What are the risks of their offspring being schizophrenic?
  5. What is the role of nutrition in schizophrenia?
  6. What likelihood is there that research will produce a cure?
  7. Can the Association help them to obtain treatment, (which is at present inadequate), how they can induce an unwilling patient to seek treatment, or how the authorities can be persuaded that the behaviour of a patient is due to schizophrenia, and not due to criminal intent?
  8. Can the Association advise them about unorthodox treatments?

 

 

References
  1. American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders (DSM IIIR). Washington, D.C. American Psychiatric Association.
  2. Birchwood, M., Smith, J., Macmillan, F., Hogg, B., Prasad, R., Harvey, C. & Berry, S.(1989) Psychological Medicine, 19:649-656.
  3. Chapman, L.J. & Chapman, J.P. (1987). Schizophrenia Bulletin, 13:497-503.
  4. Department of Health (1989). Caring for People: Community Care in the Next Decade and Beyond. White Paper. Cmd 849. London, HMSO.
  5. Department of Health (1992). Health of the Nation: a Strategy for Health in England and Wales. Cm 1523. London, HMSO.
  6. Doherty, J., Van Kammen, D., Siris, S. & Marder, S, (1978). American Journal of Psychiatry, 135:420-426.
  7. Giller, E. (1980). In Hanin, I. & Koslow, S.H. (eds.), Physico-chemical methodologies in psychiatric research. New York, Raven Press, pp. 245-256.
  8. Gottesman, I.I. (1991). Schizophrenia Genesis. The Origin of Madness. New York, Freeman .
  9. Gottesman, I.I. & Shields, J. (1982). Schizophrenia: the Epigenetic Puzzle, Cambridge. New York, Raven Press, pp. 245-256.
  10. Grosshong, R.., Baldessarini, R.J., Gibson, D.A., Lipinski, J.F., Axelrod, D. & Pope, A. (1978). Archives of General Psychiatry, 35: 1198-1205.
  11. Knapp, M., Beecham, J. & Gordon, K. (1992). Journal of Mental Health, 1:315-325.
  12. Knapp, M., Beecham, J., Hallam, A. & Fenyo, A. (1993). Hospital and Social Care, 1:193-201.
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  14. Mental Health Act (1983) London, HMSO.
  15. National Audit of Drug Misuse in Britain (1992) London, Institute for the Study of Drug Dependence.
  16. Piatkowska, O. & Farrell, D. (1992). In Schizophrenia, an Overview and Practical Handbook, Ch.20, Kavanagh, D.J. (ed.) London, Chapman and Hall, pp 339-355.
  17. Pollin, W., Allen, M.G., Hoffer, A., Stabenau, J.R. & Krubec, Z. (1969). American Journal of Psychiatry, 126:597-610.
  18. Ramchand, R., Ramchand, C.N. & Hemmings, G.P. (1992a). Research Communications in Psychological, Psychiatry and Behaviour, 17: 147-152.
  19. Ramchand, C.N., Ramchand, R. & Hemmings, G.P. (1992b). Journal of Nutritional Medicine, 3:303-309.
  20. Schallreuter, K.U., Wood, J.M., Lemke, R., LePoole, C., Das, P., Westerhof, W., Pittelkow, M.R. & Thody, A.J. (1992). Biochemical and Biophysical Research Communications, 189:72-78.
  21. Slater, E. & Cowie, V. (1971). The Genetics of Mental Disorders. London, Oxford University Press.
  22. Strauss, J.S. (1989). Schizophrenia Bulletin, 15: 179-187.
  23. Wei, J., Xu, H., Davies, J. & Hemmings, G. (1992a). Life Sciences, 51:1953-1956.
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