[Schizophrenic patients' length of stay: clinical factors of variability and consequences].
BACKGROUND
Schizophrenia is characterized by profound disruption in cognition and emotion, affecting the most fundamental human attributes: language, thought, perception, affect and sense of self. The clinical picture is further complicated by the multiple secondary consequences of the disorder; notably disrupted education, unemployment, impoverished social relationships, isolation, legal difficulties, family stress and substance abuse. Not surprisingly, the disorder is also associated with suicidal behaviour. The management of schizophrenia is thus extremely difficult with high rates of relapse, treatment refusal and poor treatment outcome. In Europe and the United States there has been a general trend towards decreasing the former long duration of hospital care in favour of short-term pharmacological stabilization in the hospital setting, followed by longer multidisciplinary follow-up within the community. This change reflects, on the one hand, the evolution in aetiological conceptions towards a predominantly neurobiological model of the disorder, with complex social consequences and also social and economic constraints. The clinical consequences of these changes were not, however, evaluated prior to the implementation of these changes.


RESULTS
Several studies have shown a clear relationship between reductions in duration of stay and increases in readmission rates and suggest that the development of community services may not in fact significantly improve clinical outcome, and may also possibly increase relapse rates due to the instability of the clinical condition at first discharge. There has been some unsettling evidence to suggest that shortening hospital stays may not be a general panacea. Authors reported in 1999 that deinstitutionalization policies in Denmark had led to premature discharge and subsequently a 100% increase in suicide, a doubling of the rates of criminal acts committed by psychotic patients, and increases of 80 to 100% in acute admission rates. A large follow-up study of psychotic patients in the USA found that hospital stays of less than 14 days were significantly associated with increased suicide risk; on the other hand, shortening hospital stays appears to be linked to higher rates of care satisfaction.


CONCLUSIONS
Indeed, studies of patients returning to the community compared to those remaining in institutions show not only better quality of life and larger friendship networks, but also reductions in dependence on pharmacotherapy and lower mortality rates. The essential question of whether shortened hospital care may lead to premature discharge or, on the other hand, decreased patient dependency and social deviance, has not been adequately addressed.
Capdevielle
D
D
Service universitaire de psychiatrie adulte, hôpital La-Colombière, centre hospitalier universitaire, Montpellier cedex 5, France. delphine.capdevielle@free.fr
Ritchie
K
K
Villebrun
D
D
Boulenger
J-P
JP
D001521:Behavior Therapy; D015928:Cognitive Behavioral Therapy; D003131:Combined Modality Therapy; D003156:Community Mental Health Services / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D010043:Outcome and Process Assessment, Health Care; D010359:Patient Readmission / Q000706:statistics & numerical data*; D017060:Patient Satisfaction; D011788:Quality of Life / Q000523:psychology; D012008:Recurrence; D012306:Risk; D012559:Schizophrenia / Q000188:drug therapy* / Q000453:epidemiology; D012565:Schizophrenic Psychology; D013405:Suicide / Q000706:statistics & numerical data