Mohammed T. Abou-Saleh

518 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYENVIRONMENTAL, SOCIAL AND CULTURALFACTORS AND OUTCOME OF SCHIZOPHRENIAThere is evidence that environmental factors play a major part inthe outcome of schizophrenia, although this is clearly not asmarked as was first claimed in the early descriptions ofinstitutionalization by Barton 15 and Goffman 16 . They consideredthat the disabilities of long-stay patients were primarily due to thepsychiatric institutions in which they lived. In a major study ofthese institutions, Wing 17 studied the outcome of patients whowere managed in three hospitals with very different policies ofcare. He concluded that institutionalization had contributedsignificantly to the patients’ disabilities.The influence of environment and culture was also illustrated bythe WHO international pilot study of schizophrenia 18 , in which1202 patients diagnosed as having schizophrenia in 10 differentcountries were followed up over a 2 year period. The heterogeneityof outcome was again underlined, but patients sufferingfrom schizophrenia in the developing countries had a betteroutcome than those in the developed countries. The reportconcluded that the diagnosis of schizophrenia alone did notprovide sufficient grounds for a firm statement about the patient’slikely pattern or course, probability of relapses and admissions, orthe degree of social impairment in the future.Similar findings emerge from a 5 year follow-up study ofpatients living in the peasant society of Sri Lanka, described byWaxler 19 . She concluded that in Western society, expectation anda belief about mental illness and the process by which treatment isprovided alienate patients suffering from schizophrenia from theirnormal roles, and thus prolong illness. In contrast, the beliefs andpractices in non-industrial societies encourage a quick return tonormality.THE ROLE OF REHABILITATIONAlthough the recent outcome studies have shown that theprognosis of schizophrenia is not as poor as had previouslybeen considered, it is also clear that outcome is mixed, with somepatients showing no improvement and remaining severelydisabled. Continuing care services for people suffering fromschizophrenia should aim to reduce these disabilities whereverpossible and to meet the needs of those who remain severelydisabled into old age.The care of patients with schizophrenia has moved from longtermhospital to care in the community. This international changeoccurred with very little contemporary evidence to support it.However, the controlled studies that exist 20,21 demonstrate thatpatients treated in the community did not experience increases inhomelessness, mortality or suicide and did not need excessivereadmissions to hospital. Importantly, patients taking part inthese studies preferred treatment outside hospital.Intercultural studies would support the concept that environmentalfactors can have an effect on outcome. However, althoughone would expect that the socioenvironmental factors involved incommunity care would improve the prognosis, this has been verydifficult to demonstrate in practice. Wing’s Three Hospital Studyis one of the few papers that supports this view. There is littleevidence that psychiatric symptomatology or psychosocial functionimprove when patients are treated in the community.In the UK the view that all patients with schizophrenia canhave long-term care in the community has been revised, and thereis provision for 24 hour nursing care 22 . Treiman 23 demonstratedthat this care can be successful in reducing severely disruptedbehaviours. However, this group of patients are different from thelong-stay hospital population. They are younger, suffer from morepsychotic symptoms and often have multiple problems, such ascognitive deficits, substance misuse and violence. Their self-careskills are often intact.CHANGES IN REHABILITATIONOne problem in interpreting these studies is that the term‘‘rehabilitation’’ may mean very different things to differentpeople, and indeed, in recent years the term ‘‘rehabilitation’’ hassometimes even become synonymous with discharge fromhospital. This use of the word is misleading. Bennett 24 consideredthat the goal of rehabilitation was to enable the individual ‘‘tomake the best use of his residual abilities in order to function at anoptimum level in as normal a social context as possible’’. Heintroduced the concept of rehabilitation as a continuous andrecursive process, applicable in many service settings, which couldbe independent of the discharge process. He considered theinteraction between the individual and the environment to beparticularly important. Rehabilitation should entail both workingwith patients to enhance their confidence and coping skills and theprovision of such ‘‘prosthetic environments’’ and social, emotionaland material support as may be necessary to maintain theiroptimal level.The concept of helping a patient to cope with his/her disabilityis central to rehabilitation and forms the basis of cognitivebehaviouraltherapy for schizophrenia 25 . Patients may deny thatthey are unwell and this may make engaging them in treatmentdifficult. It is important to approach their problems from theirpoint of view and work with them to reduce the problems theyperceive as important. Education about their illness and medicationmay be helpful. It is also helpful to discuss exacerbatingfactors, such as stress and substance misuse. Discussion of earlysigns of relapse, such as unusual behaviour or prodromalsymptoms, may enable patients to prevent a serious relapse. Theinvolvement of family and friends is often helpful. If assessment ofrisk reveals a substantial risk to the patient or others, thenpatients should be engaged in the process of reducing the risk.The Royal College of Psychiatrists report on Rehabilitationemphasized the importance of primary, secondary and tertiarydisability 26 . The primary disabilities are emotional, cognitive,motivational and behavioural dysfunction. Secondary handicapsinclude loss of self-esteem and confidence, social withdrawal andloss of social roles and networks. Unemployment, homelessness,poverty and stigmatization are the tertiary handicaps. Oftenpatients’ main concerns are about the secondary and tertiaryproblems and it is important to address these to achieve aneffective treatment plan.Deegan 27 has described how Mental Health Service usersemphasize the importance for them of feeling ‘‘in the driver’sseat’’—empowerment. She uses the word ‘‘recovery’’ rather than‘‘rehabilitation’’, highlighting the fact that patients recover andprofessionals rehabilitate. She describes the importance of peoplebecoming experts in their own self-care.THE PRACTICE OF REHABILITATIONRehabilitation is based on assessment, development of treatmentplans and monitoring. In the UK this forms the basis of the careprogramme approach. The assessments are based on patients’abilities and difficulties in a wide range of areas. These shouldinclude the following.. Psychiatric illness: positive and negative symptoms; insight;compliance with medication; self-medication ability.