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[What impedes discharge support for persons with schizophrenia in psychiatric hospitals?].

OBJECTIVE
This study examines the factors that may impede discharge support for persons with schizophrenia who are receiving standard psychiatric services in Japan.


SUBJECTS
Two hundred and ninety-two in-patients from nine psychiatric hospitals diagnosed with schizophrenia agreed to participate in this study. The mean duration of hospitalization at the time of the survey was approximately 10 years.


METHODS
Variables that were evaluated in the baseline assessment were as follows: demographic features such as age and duration of hospitalization, primary psychiatrist's evaluation (the Brief Psychiatric Rating Scale, Global Assessment of Functioning, Assessing List of Patients' Needs of Psychiatric Rehabilitation, and so on), ward nurses' evaluation (the Discharge Difficulty Scale and the Hall and Baker's Rehabilitation Evaluation), and self administered questionnaires (the Self-Efficacy for Community Life Scale, Client Satisfaction Questionnaire, MOS Short-Form 36-Item Health Survey, and Drug Attitude Inventory Short Form). In the follow-up one year later, the subjects were divided into two groups: patients discharged and patients still hospitalized.


RESULTS
Eight factors were identified by factor analysis of the Discharge Difficulty Scale. They were insight and treatment compliances, anxieties over discharge, activities of daily living (ADL), problem behaviors, autistic behaviors, medical complications, suicidal behaviors, and family problems. Five clusters were found on cluster analysis; cluster 1 (multiple factors of discharge difficulty), cluster 2 (insight, adherence, and autistic behavior factors of discharge difficulty), cluster 3 (few factors of discharge difficulty), cluster 4 (anxiety and autistic behavior of discharge difficulty), and cluster 5 (insight and adherence, anxiety, and deviant behavior factors of discharge difficulty). In the follow-up one year later, 60 and 157 subjects were divided into the discharge and continued-hospitalization groups, respectively. Six factors were detected by factor analysis that examined the variables which showed significant differences between the two groups in the baseline assessment: 1) discharge difficulties observed by ward nurses, 2) interpersonal difficulties attributed to negative symptoms, 3) hostility, excitement, and suspiciousness, 4) self-efficacy of patients in the community, 5) possible exacerbation of medical diseases, and 6) physical complaints related to the adverse effects of medication. On logistic regression analysis, the hostility, excitement, and suspiciousness and self-efficacy of patients in the community were found to be the two significant contributing factors to the outcome.


DISCUSSION
Effective treatments promoting discharge support for long-term in-patients with schizophrenia are discussed according to the five clusters found. By clustering discharge difficulties, the treatment team will be provided with the necessary medical and social resources. In conclusion, a desirable supportive relation between patients and the team, basic skills to motivate the patients, and cooperative relations among the members of the treatment team are crucial in order to improve the outcomes of patients with discharge difficulties.