Social Factors and Admission to Psychiatric Hospital: Schizophrenia in Plymouth

While they are a dubious measure of spatial variations in the effectiveness of health care provision, rates of readmission do reflect areal differences in the degree to which hospital admission occurs in the management of schizophrenia.

Abstract

While they are a dubious measure of spatial variations in the effectiveness of health care provision, rates of readmission do reflect areal differences in the degree to which hospital admission occurs in the management of schizophrenia. Areal analysis involving census data can help to identify the causal factors responsible, but the examination of case notes is a necessary extension. In Plymouth such data informed some aspects of the differences between patterns of male and female illness demonstrated by aggregate areal analysis. Nevertheless case-notes data have their own weaknesses. Prospective studies encompassing the complex phenomenology of the referral and admission processes would seem to be necessary for the full understanding of spatial distributions of admissions to psychiatric hospitals. There is a good deal of evidence that the spatial incidence of schizophrenia measured by hospital admission rates, is related to environmental, social and economic variables.' Few inferences as to aetiology are possible, however, from such geographical research. Even if schizophrenia is assumed to have an entirely genetic origin there remains ample scope for the operation of social factors in the admission process.2 Social factors may be crucial in deciding whether the display of schizophrenic symptoms, regardless of their origin, results in admission or not. The source of referral, the status of the decisionmakers, the sex of the patient, the presence of relatives, the availability of beds and the degree of community orientation appear to be among the more important factors.3 These influences continue to operate after the initial diagnosis and may be investigated in patterns of readmissions. Aggregate areal analysis can identify the main factors but the processes that they summarize require an examination of case notes. The linkage of different levels of analysis, which is attempted in this paper, has been recognized as a necessary development in the geography of psychiatric illness.4 Parallel trends have occurred in other branches of urban social geography, particularly in studies of suicide,5 voting behaviour, crime and juvenile delinquency.6 Readmissions are a particular concern in this paper and their context in the psychiatric service needs to be discussed. Since the early 1960s a policy of community care, involving two new out-patient departments and a community nursing service, has been enthusiastically pursued in Plymouth. This community orientation has been seen as the most effective way of providing for the needs of patients. The maintenance of patients in the community has become a service goal the achievement of which seems measurable in terms of the frequency Trans. Inst. Br. Geogr. N.S. 6, 39-52 (1981) Printed in Great Britain This content downloaded from 157.55.39.181 on Thu, 29 Sep 2016 05:52:30 UTC All use subject to http://about.jstor.org/terms 40 IC G. DEAN AND H. D. JAMES of readmissions and the time spent in hospital. Evaluative studies of an out-patient department and the community psychiatric nursing service in Plymouth have used frequency of readmissions and the length of stay as primary indicators.7 However, there are problems in using these indicators to assess the effectiveness of nonresidential care facilities. The Plymouth research into non-residential care suggested that as the amount of observation and support for patients in the community increased so did the rate of readmissions and even the average length of stay in hospital. These findings thus confirm the conclusions of Brown et al. who found, in a study of three psychiatric services, that the most community-orientated had the highest rate of readmissions for schizophrenia.8 They saw greater awareness of the morbidity of the patient on the part of psychiatrists and social workers as the most likely reason for this. Thus, ironically, intervention designed to improve the performance of the system measured against a declared aim may have an opposite effect. System goals regarding the optimum form of treatment are, it seems, being frustrated by the day-to-day practice of doctors. This discrepancy between 'system goal' and 'system practice' has to be seen against the background of the 1959 Mental Health Act which encouraged community orientation.9 The Act sought to produce as normal an environment as possible for mentally ill patients. This meant an emphasis on treatment in the community and the avoidance of institutionalization. At the same time the Act was concerned to protect members of the public. With psychiatric illness, especially psychoses such as schizophrenia, it is not necessarily the patient who suffers most, and psychiatrists are bound to take the well-being of others into account. Thus the social or family setting of the patient, embracing both the availability of care and the likely harmful effects on others, may well influence decisions about the optimum form of treatment. Given this background it would be wrong to suggest that frequent admission, for example, indicates ineffective treatment. It is only ineffective given a system goal of keeping psychiatric patients out of hospital. Thus in analysing, in particular, rates of readmissions our purpose is not to assess the effectiveness of non-residential care but to show how social factors may influence the emphasis on hospitalization as a mode of treatment. AGGREGATE AREAL ANALYSIS For a number of well-documented reasons it is hazardous to proceed from the analysis of aggregate areal data to statements about individuals.10 The ecological fallacy, the coarseness of the independent variables and their precise meaning are among the more obvious difficulties. However, it is legitimate to make statements about spatial patterns of illness and to develop causal hypotheses from what Johnston has called 'areal studies'. Such studies can show which social factors are likely to be most relevant for different populations of admissions defined by sex and the number of previous admissions, although a more direct mode of analysis is required to determine how social factors operate. Data and method of analysis A total of 881 admissions involving a primary diagnosis of schizophrenia occurring in the period 1970-75 were considered. Table I identifies eight admission categories on the basis of sex and the number of previous admissions. As the ratios in respect of admissions from private addresses indicate, the excess of female admissions rises steadily with the number of previous admissions.12 All admissions involved in the aggregate areal analysis were from private households to the one psychiatric hospital serving Plymouth. However, Table I also lists the 84 admissions from non-private addresses that occurred within the study period. Most of these admissions were classified as being from 'no fixed abode' with the remainder This content downloaded from 157.55.39.181 on Thu, 29 Sep 2016 05:52:30 UTC All use subject to http://about.jstor.org/terms Schizophrenia in Plymouth 41