I. M. MARKS,
R. E. LAWRENCE,
J. CONNOLLY
and V. WATTS
assessed at 30, 34, and 45 months. Phase I control patients (n = 70) were assessed again
at month 45. Measuresused were number and duration of in-patient admissions, independent
ratings of clinical and social function, and patients' and relatives' satisfaction.
Results. The slim clinical and social gains from home-basedv. out-tin-patient care during Phase
I were largely lost in Phase II. Duration of crisis admissions increased from Phase I to Phase
II in both DLPII and DLP-control patients. During Phase II, patients' and relatives' satisfaction
remained greater for home-based than out-fin-patient care patients. At 45 months, compared
with the Phase I controls, DLPII patients and relatives were more satisfied with care. Such
satisfaction was independent of clinical/social gains.
Conclusions.The lossof PhaseI gainswere perhapsdue to attenuationof home-basedcare
quality and to benefits of Phase I home-based care lingering into Phase II in DLP-controls.
care
Method
From January 1990to December 1992,SM! patientswho
had begun DLP care in Phase! of the study (October
1987to December 1989)were randomised at 30months
after trial entry into Phase I! for a further 15 months
of study in the BethlemMaudsleyHospital while:
(a) continuing with DLP care (DLPII patients) or
(b) having control out-/in-patient care (DLP
control patients).
Phase II began a mean of 10 months after Phase
I ended (Fig. 1). Before entry into Phase II, DLP
patients and their relatives gave written agreement to
whichever care would be offered (DLPII or DLP
control). Patients who had been randomised in Phase I
to the original control in-/out-patient care group con
tinued with it in Phase I! and were followed up at a
mean of 45 months after trial entry (Phase I controls).
Selection criteria
204
189SMI
I- 1@33
66 DLP patients
randomlsed
patients
randomised
Phase
17
Pre-audit
L new controls
(DLP-control
patients)
Controla =97,
Month6@
I continuing
DIP(DLPIIpatients)
Phase
II
3@O
II
34
4'5
Post-audit
Audit
Fig.I Studydesign.
(a)
(b)
(c)
(d)
(e)
(f)
205
(PSE;
206
AUDINI ET AL
SAS),
except
for DLP!!
patients
on PSE-SNR
HOME-BASED
V. OUT-/IN-PATIENT
CARE
207
Table 1
Outcome of clinical and satisfaction measures
(s.e.)nGAS30
I control
CIANCOVA
MonthDLPII
PPhase
mean(se.)rol n95%
mean(se.)nDLP-cont
mean
NS58.4
NS41.2
8.4(1.7) 30
7.2(1.3) 31
34
(2.4)70PSE-DAH30457.0(1.6)
28NS
10.6(2.3)32
7.6(1.5)32
308.2(1.7)
(0.5)
(0.5)
1.6 (0.7) 30
1.6 (0.6) 31
34
(1.0)70PSE-BSO30451.3 2.6 (0.9)32 300.9 2.1 (0.9)32 28NS
(0.4)
(0.7)
1.1 (0.4) 30
1.5 (0.5) 31
34
(0.7)70PSE-SNR30451.7 2.5 (0.6)32 301.4 1.7 (0.6)32 28NS
(0.5)
(0.3)
30
1.3(0.4)
31
1.6(0.4)
34
2.5)0.01'4.6(0.8)70PSE-NSN30
281.5
451.1 0.5(0.2)32
301.6 2.0(0.6)32
(1.1)
(0.7)
4.1 (1.0) 30
31
34
2.9(0.6)
(1.05)70Patient's3027.4
452.8 2.1 (0.5)32 304.3 4.7 (1.3)32 282.4
(1.8)32satisfaction34
(0.9)3223.8
NS19.0
NS3.7
NS3.3
(0.4to
(0.2to 4.9)0.07'7.3
to 1.5)
(0.6)70Relative's3058.4
0.007'23.4
3.3
(5.6to 1.0)0.001'
22.9 (1.7)30 263.3(5.1
26.6 (0.9)31 2821.4(1.7)
4527.6(0.7)
(2.3)550.0(3.5)11satisfaction34
(3.4)
(3.5)
42.6 (3.2)14 1319.1 (32.8to 5.2)0.03'45.7
4552.3 58.0 (1.4)7 944.7
(2.8)70
DAH, delusional and hallucinatory; BSO, behaviour, speech and other; SNR, specific neurotic; NSN. non-specific neurotic.
in
favour of DLPII patients.
Groups overall
Table 2
Outcome of all measures for DLPII and DLP-control v. Phase I controls
(0.3)
1.6 (0.2)
7.6(1.5)
0.5(0.2)
2.1 (0.5)
45
45
45
45
CIt-test
I con
MonthDLPII
P'SAS
mean (se.)trol
a95%
7
30
30
30
(0.2)
2.0 (0.5)
10.6 (2.3)
2.0(0.6)
4.7 (1.3)
6
28
28
28
(0.2)
2.7 (0.3)
19.0(2.4)
4.6(0.8)
7.3 (0.8)
23
70
70
70
28
22.9 (0.7)
26
23.5 (0.6)
64
(1.3to 0.1)
1.1
(2.1to 0.1) 0.04
11
(18
to 4) 0.004
4.2
(6.6
to 1.8) 0.001
5.2
(8.3to 2.1) 0.001
Patient's
satisfaction
Relative's
0.005,in
satisfaction45
45
26.6 (0.9)
0.005
12.3(4.1to20.5)0.02
453.0 58.0(1.4)30 92.9 42.6(3.3)28 133.7 45.7(2.8)66 170.7
208
AUDINI ET AL
and DLP-control
patients
Both DLPI!
and DLP-control
patients
@30
(0.005)
CD25
20
0.001
0.001
o.@b'i' 0.007
Phase I
Phase II
:15
@10
-5
R.ndo,,, OLP
i
0
0
@60
20
-@l
30
34
(b)Relative's
satisfaction
45
(0.005)
@.
CD50
.-.
*..
0.002
0.03
Phase I
Phase II
dip controls
(n=23) (n=15)
dipli
(n=9)
dlp.controls
14
10
L
0
20
R.ndom OLP
@ithd@@i
]
30
34
45
Monthsafter
entry
Fig.2 Satisfaction
scales:
mean scores
(a)Patients'
satisfaction.
Patient's scale: The difference favouring DLPII
Phase I:, DLP(n=68); --, controls (n=67). Phase II: -,
patients on the total score became significant by 34 DLPII (n= 32);$@4DLP-controls
(n= 32).(b)Relatives'
satisfaction. Phase I: ,DLP (n = 23); ,
controls (n = 15).
months (P< 0.001) and remained so at 45 months
@4, DLP-controls (n= 14).
(P< 0.007);
itwas alsosignificant
on eachoftheeight Phase II: -,DLPII (n=9);
P=0.005, for DLPII v. PhaseI controls. P=0.00I etc. for DLP
scale items. DLPI! patients' satisfaction was greater v. Phase I controls and DLPII v. DLP-controls in Phase II.
(ANCOVAs
Schizophrenics:
DLPII
on all measures)
and dip-control
patients
months,
patients.
SAS global
Non-schizophrenics:
(0.04) favoured
DLPII
patients'
new
superior to DLP-control
patients at 34 months on
differences
favoured
HOME-BASED
DLPII
patients,
symptoms,
largely
V. OUT-/IN-PATIENT
on neurotic
in the non-schizophrenic
DLP
209
CARE
3045, reducing
their
from this.
AUDINI ET AL
210
thanks
are
extended
to
the
Wolfson
Foundation
for
References
AMERICAN PSYCHIA1RIC AasOCwnON
(1987) Diagnostic
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and Program
Planning,
2, 197207.
D. R. (1962) The Brief Psychiatric
Reports,
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J.
K.,
COOPER,
J.
B.
&
SARTORIUS,
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(1974)
The
Bernard Audim, Bsc, Research Unit, Royal College of Psychiatrists; Isaac M. Marks, FRCPsych,Institute
of Psychiatry and Bethlem-Maudsley Hospital; Robin Lawrence, MRCPsych,West Lambeth Community
Care Trust, London; Joseph Connolly, FRCPsych,Bethlem-Maudsley Hospital; V. Wafts, MRCPsych,
Maudsley Hospital, London
Correspondence:
Professor
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