vermont study1

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Regular Articles

The Vermont Longitudinal Study of Persons WithSevere Mental Illness, I: Methodology, Study Sample,and Overall Status 32 Years LaterCourtenay M. Harding, Ph.D., George W. Brooks, M.D., Takamaru Ashikaga, Ph.D.,John S. Strauss, M.D., and Alan Breier, M.D.

The authors report the latest findings from a32-year longitudinal study of 269 back-ward patientsfrom Vermont State Hospital. This intact cohortparticipated in a comprehensive rehabilitationprogram and was released to the community in aplanned deinstitutionalization effort during themid-1950s. At their la-year follow-up mark, 70% ofthese patients remained out of the hospital but manywere socially isolated and many were recidivists.Twenty to 25 years after their index release, 262 ofthese subjects were blindly assessed with structuredand reliable protocols. One-half to two-thirds ofthem had achieved considerable improvement orrecovery, which corroborates recent findings fromEurope and elsewhere.(Am J Psychiatry 198?; 144:718-726)Understanding of the long-term course and outcome of patients with prolonged psychiatric disorders is often thwarted by patient an d clinician mobility (1, 2), short-term caseloads shaped by academictraining and service delivery systems (3, 4), the magnitude of methodological hurdles (5-13), and disputesReceived Jan. 31, 1986; revised Ocr. 7, 1986; accepted Dec. 16,1986. From theDepartment of Psychiatry, Yale University School of

Medicine, New Haven, Conn.; the College of Medicine and theCollege of Engineering and Mathematics, University of Vermont,Burlington; and the Clinical Neuroscience Branch, NIMH, Rockville, Md. Address reprint requests to Dr. Harding, 150 CMHC, 34Park St., New Haven, cr 06519."Supported by NIMH grants MH-29575, MH-40607, and MH00340 and by Biomedical grant 50705429 from the College ofMedicine, University of V e r m o n ~ 'Copyright 1987 American Psychiatric Association.

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over the classification of the disorders under study (114-16). These conditions have produced sporadicontradictory data and untested assumptions that udercut attempts to clarify the nature of psychiatrillness, erode the ability to target treatment intervetions, and muddle efforts toward comprehensive 'pulic policies.It is possible, however, to generate a longitudinstudy that overcomes most of these obstacles (7, 17What is required is an intact cohort of pat ientselected for the established chronicity of their illneswho are prospectively followed over many years, wicareful record keeping, structured an d reliable protcols, operational definitions, an d standardized assesments of psychopathology an d psychosocial functioing. The Vermont longitudinal study meets thecriteria.Since the early 1950s, members of the VermoLongitudinal Research Project have been prospectivefollowing the course of an intact cohort of 26 9 patienfrom the back wards of Vermont State Hospital (17-26) in much the same manner as the catamneststudies of Manfred Bleuler at Burgholzli HospitalSwitzerland (27-33) . Known in the l iterature as ThVermont Story cohort (26), the majority of these onprofoundly ill, severely disabled, long-stay patiencame from the sickest group in the hospital an d m, the DSM-I guidelines for the diagnosis of schizophrnia. They part icipa ted in an innovative pioneerinrehabilitation program an d were released to a hospitarun comprehensive community aftercare program btween 1955 and 1965 (26).Ten years after the inception of the program, wconducted a follow-up s tudy, which indicated thtwo-thirds of--the cohort were no t hospitalized bwere being maintained by heavy expenditures of cli

Am J Psychiatry 144:6, June 198 II. J4$. O ( W Z , . ~ . PX 40DWU4CQ Qit!QQ!P au .. 2W 4 ". . Q.kit .x: .WQ.lU l.!CZL XXi . . " .


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Am J Psychiatry 144:6, June 1987

HISTORY OF mE PROJECTPhase I: The Rehabilitation Program in the 19505

In the early 1950s , one 6f us (G.W.B.) began tostudy the efficacy of the then-new drug chlorpromazine( 3 6 ~ . The back-ward"hopeless cases" were chosen assubjects. Some patients responded well and were even~ a l J y released. Other patients did no t respond as well,Ut the effect of the releases 'was to give fresh hope to~ the staff and the patients. In 1955 a mul tid is

, ~ p l m a r y c ~ i n i c a l team, sponsored by the Vermont~ a . t e Hospital and the Vocational Rehabilitation Di

V l ~ l O n of the Vermont State Department of Education,: : ; : ~ a t e d a program of comprehensive rehabilitation. community placement for those back-ward pa-Oents who had not improved sufficiently with chlorP2fomazine. From January 1955 to December 196069 . ,p a t l e ~ t s who were considered among the most~ e r . e l y disabled and chronically mentally ill in theospltal were referred to the program (26). After the

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HARDING, BROOKS, ASHIKAGA, ET AL

At the time of selection, the group averaged 16 years 'duration of illness with an average of ten years of totaldis-ability and six years of continuous hospitalization. Thegroup members had from one to ten hospitalizations, witha median of about two hospitalizations each. They hadcompleted from none to sixteen years of schooling, with amedian of about nine grades. Nearly all had been declaredfinancially incapable of paying anything for their owncare, and were committed to the hospital at State expense.The group was, in other words, quite characteristic of theschizophrenic group as outlined by Hollingshead andRedlich (37). They were middle-aged, poorly educated,lower-class individuals further impoverished by repeatedand prolonged hospitalizations. In addition, this grouphad little social support. About five out of six were single,divorced, widowed, or separated. They were seldom visited by friends or relatives, and received very few packagesor letters. (26, p. 30)At the time the subjects were selected} the research

team also described their presenting disabil it ies andimpairments: . . {h ~ i . 5The patients, as a group, were very slow, concentrated) ~ poorly, seemed confused and frequently had some impair- /ment or distortion of recent or remote memory. They were ( / \touchy, suspicious, temperamental, unpredictable, and f).r1 \over-dependent on others to make minor day-to-day deci- 'r! v \sions for them. They had many peculiarities of appear- 1Aliance, speech, behavior, and a very constricted sense of/ W1l.Otime, space, and other people so that their social judgment, I.was inadequate. Very often they seemed to be goalless or,if they had goals, they were quite unrealistic. They seemedto lack initiative or concern about anything beyond theirimmediate surroundings. Because of their very low socio-economic level and prolonged illness, they suffered from

profound poverty, inadequate educational opportunities,anq:3 very limited experience in the world. .These patients also suffered a high incidence of chronicphysical disabilities. Their psychomotor performance in awide variety of tests was impaired so that their reactiontimes were prolonged and their ability to perform any typeof skilled .or precise activiry was impaired. They sufferedan increased incidence of many degtnerative and chronic Idiseases, including tuberculosis and malignant tumors. I719 Ij

'-re-education of the staff, a program was constructed incollaboration with the patients that consisted of drugtreatment, open-ward care in homelike cond it ions ,group therapy, graded privileges, activity therapy,industrial therapy, vocational counseling, and self-helpgroups. .In the communi ty t reatment component, the sameclinical team went into the community and establishedhalfway houses and outpatient clinics, found job openings, made job placements , and l inked patients tonatural support n ~ r w o r k s . In that era of custodial care,before the advent of community mental health centersand the later deinstitutionalization movement, thiscOmprehensive-program w a - ~ considered unusual andinnovative.

The average age of the subjects was 40 years. Thegroup was described by their clinical team in TheVermont Story as follows:

Mrr,.IS' '2 7

-=,:.,Jt;..effort, time, and money (34). Many of thesepitients were socially isolated while living and workiJ:Jg in other institution-like settings. This follow-upperiod was similar to tha t charted by many longitudiualstudie.s of similar patient groups, studies that haveheavUy influenced our ideas about the long-termoourse and outcome of people with severe and prolonged psychiatric disorders. The Vermont study andother longer studies provide evidence that some psychiatric illnesses require longer time periods to acquireamore complete and accurate picture of course andootcome.lneurdfort to. reassess.me outcome of the Vermontcohort over a longer period ; t i ~ e , we were aDretoaccount for all bu t seven members o f the originalcohort (97%) in the early 1980s. This situation gave usthe opporrunity to find out whether these subjects werestiD as disabled as they had been 20 or more yearsearlier. We conducted both a structured cross-sectionalassessment of the subjects' current status across a widerange of characteristics and a retrospective documentation of what had happened to members of thiscohan in the intervening years. Adding these new datato the prospectively gathered information from theearlier hospitalization and rehabilitation program, wehave been able to provide a more comprehensivepicture of the long-term course of schizophrenia andother severe psychiatric disorders.The specific focus of this report from the Vermontlongitudinal Research Project is a descrip tion of thesample, methodology, and design of the pro ject anddocumenta tion of the' long-term outcome for the cohan as a whole. A companion paper inthis issue of theJournal examines the long- te rm outcome of thosesubjects within the larger cohort who were rediagnosed as meeting the newer DSM-Ill criter ia fer

~ z o p h r e n i a (35).

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METHOD

11 47 3

N %168 6861 25

Subjects Remaining AfterExclusion of 22 WithOrganic Disorders(N=247)'

137

71178TotalGroup

MeasuresBatteries of structured instruments were used forcollecting data. They included interview schedules andrecord abstraction protocols.The Vermont Community Quest ionnai re (VCQ)was a battery of interview instruments designed to ..document and assess a subject'S history and funetion-t:ing in a wide variety of areas across time. Fifteenestablished scales were combined to create the VCQ 'and to acquire such a data base (7). The field inter- ...viewers were blind to hospital records and diagnostic ,information about each subject. . The VCQ consisted of two structured interviews, ieach with standardized probes, ratings, and computer,lcoding. The VCQ-cross-sectional interview (VCQ-C) '1]assessed current status; the VCQ-Iongitudinal inter- :1


'Twenty-two subjects classified as having. organic disorders according to DSM-III criteria at the index admission were excluded fromthe .data analyses. 'bMost of these subjects were interviewed'and gave considerableinformation, but they refused to sign the forms permitting use oftheir data.Phase III: The 20- to 25-Year Follow- Up StudyWe recently completed our latest follow-up of theoriginal 269 subjects. We have follow-up data on the22 subjects with organic disorders but removed them

from our ongoing analyses to make our study comparable to others in the field. Table 1 reveals the cohort'scurrent status.The catamnestic period of the subjects ranges from22 to 62 years, with an average of 32 years, whichmakes this s tudy one of the longest ever conducted.The subjects who were still alive at follow-up (N=168)were divided nearly evenly between the sexes (81 men iand 87 women): The mean age was 59 years ( r a n g e : : : : ~38-83 years), with two-thirds of the group 55 years -_old or older. The year of birth of the subjects r a n g e d , ~from 1897 to 1942. {The remainder of this report focuses on the methodand results of the long-term follow-up s tudy o f thesubjects who were still alive and could be interviewed.

Alive and interviewedDeceased; familyinterviewedAlive; refusedparricipationbCould not be located

Subjecrs'Follow-UpStatus

J.

TABLE 1. Status at 20- to 25-Year Follow-Up of 269 Chronic '5Psychiatric Patients in the Vermont Study *t

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There was a very h igh incidence of needs in such a reas a sdental care, visual corrections, and hearing aids. Manypatients, especially after prolonged phenothiazine treatment, were obese. Care of th e feet had been neglected. Inou r experience, there also seemed to be a high incidence ofchronic skin disorders including eczema-dermatitis, tinea,an d psoriasis. (26, p. 31)

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Phase II: The .1965 Follow-Up StudyIn 1965, after 5 years of the hospital-based rehabilitation program and 5 years during which the p'rimaryfocus was the community component, Deane andBrooks (34) conducted a follow-up study of thesepat ients. They found that two-th irds of the cohor t

c ( ) ! : l l ~ . i?e . _ r : n . a i . n ! a i l 1 ~ c ! . in, ,the S Q q l l l 1 ~ Q i t y if. 5l-!ftic,it;nttransitional facilities and adequate aftercare were provided. Seventy percent of the subjects were out of thehospital a t tha t follow-up: 30% had been d i s c h a r g ~ dand had never returned, and 40% had been readmittedat some time but had been discharged again. Of the30% of the subjects who were in the hospital atfollow-up, 20% had been readmitted and had stayed,and 10% had never been discharged. The averagenumber of readmissions for the recidivists in thecohort was 1.98.

Other findings indicated that being female, schizophrenic, chronically ill, and married during some partof one's life were important predictors of good functioning at follow-up. Age at first admission did notpredict which patients would do better. At the 1965follow-up, most subjects were single (60%), usedcommunity care facilities primarily for socializing, hada tendency to replace the institu tion with shelteredemployment (e.g., a job as a cook in a nursing home,with bed and board), and maintained substantial contact with rehabilitation workers.

Thus, 5-10 years after release from the rehabilitation program, 70% of the pat ients were out of thehospital, which was considered remarkable at the timebecause they had been expected to live out their lives inthe ~ o s p i t a l . However, the study concluded with awarmng:

Implici t in ou r f indings is the fact that any plan forrehabilitation of the chronic patient be conceived as longterm, since all o f o ur evidence suggests that the commitment necessary to the chronic men ta l pati en t has noforeseeable end, and that unless constant a tt en tion begiven to the chronic patient , the end result may be simplythat he is ou t of the hospital, bu t operating at a high levelof inadequacy an d a low level of employment. (34, pp . ii,iii)It is at this point that most follow-up studies stop

and most programs are discont inued. Thus, most ofour understanding of the long-term outcome for severemental disorder is derived from such shorter- term'data. The question asked in the present study was, Dothese patients still continue to display such impairmentand disabilities 20 to 25 years later, as predicted earlierby our own research team?

VERMONT LONGITUDINAL STUDY, I


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j: T ;: : rrrwmt::tSE': "TVHARDING, BROOKS, ASHlKAGA, ET AL

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ew (VCQ-L) documented retrospective data over the:eceding 20-25 years.The major areas of functioning covered by theCQ-C were residence, work, finances, intimate rela:lIiships, family information, social support system,pical weekly activities, basic self-care, utilization ofeatmentlsocial services, contact with the criminalIstice system, community involvement, degree of satfaction, environmental stressors, competence, and5ychopathology. Approximately 1 hour and 15 mintes were required to administer the interview's 135llestions. The rater section of the interview battery: 2 m a i p ~ ~ ~ 8 _ ~ M i ~ i o n a l items based on observationIld other i n f o r m a t i ~ ~ - g a t h ~ ~ e d f i : o m the "su-bJects andleir environment.The second interview (the VCQ-L) required 75linutes and was held within 1 week of the first. The'CQ-L had 156 questions that documented status andvents during the preceding 20 years in a year-by-year)llow-back procedure utilizing a modified Meyer/leighton Life Chart (38). This chart provided a graph: overview of each subject's life and was completedrith a set of structured probes, codes, and protocolsreated for this project. The Life Chart was a large,ned sheet of paper vertically separated into years,rom 1982 at the top to 1955 at the bottom, andorizontally separated into 10 outcome areas. These:lomains included residence, hospitalization, work,Duree of income, important personal relationships,,eaths of important people, other life events, use ofommunity support systems, physical health, and medatioils. A Life Chart was completed for each subject,vho worked with the interviewer on the chart spreadlut on a table.Each of the field interviewers had had 5- 8 years ofevious clinical experience with a range of clients whoere deinstitutionalized and labeled "chronic pats" by their community mental health clinics.A small instrument called the Verinform was deigned to verify the interview information by asking aof informants about the subjects' current statusd historical data. The Verinform was used forerviews with general practitioners, aftercare or voonal rehabilitation counselors; family, or friends,hoever knew the subject well.The Hospital Record Review Form was designed torovide a standardized method for recording datarom Vermont State Hospital records. The interviewtrument known as the Psychiatric and Personalstory Schedule from the World Health Organization

Collaborative Project on Determinants of Outme of Severe Mental Disorders (39), was convertedrom an interview format to a standardized form fortracting record information on psychiatric historya systematic and structured manner. The new fort maintained the coded answers but assigned themdocument five different time periods: first admision, episodes between first and Index admission,admission (the admission preceding entry intoe rehabilitation program-the only common denom-

mJ Psychiatry 144:6, June 1987

inato r across all subjects an d designated arbitrarily asindex for research definition purposes), life history,and episodes during the years in the community afterindex release. In addition, the WH O signs and symptoms checklist was augmented with Strauss's CaseRecord Rating Scale (40), the Strauss-Carpenter Prognostic Scale (41), and the Global Assessment Scale(42). The record reviewer was blind to all outcome andinterview data. She was a clinical psychologist withseveral years of experience with Vermont State Hospital records.The component instruments in each battery thatused the work of others had been tested extensively forrdia&lllry-andvallCIiry"oy-ilieii 6 i l g i n a t o r s ~ - H o w e v e r ,groups of individual questions from each classic scalewere taken from their original context and interwovenwith questions from other instruments (e.g., the questions on social relationships from all instruments wereput together to make a more natural interview sequence); therefore, reliability studies of the entire VCQand Hospital Record Review Form batteries weredeemed essential.Initially, the VCQ-C an d VCQ-L interviews wereeach field-tested with a wide range of communitypeople matched in age to the cohort. These consultantscritiqued the appropriateness of the questions vis-a-vistheir life experiences and suggested that we add questions about powerlessness, disability income, medication compliance, and the increasing number of deathsof people in their personal suppor t systems. Thisstrategy led to improvement in the battery's ability totap relevant issues for people in the age ranges to beassessed and improvement in its construct validity.Changes and deletions of items honed it to the sizeused in the follow-up study.Each field battery was then subjected to two sets of

interrater trials (trial 1, N=21 pairs; trial 2, N =18pairs). The sets were completed 6 months apart to testfor the degree of change in raters' assessments duringthe intervening time period. Both raters attended across-sectional and a longitudinal interview for each ofthe test subjects. Each rater scored the interview independently, and the pairs of ratings were then comparedfor concordance. The kappa coefficients from the firstand second sets of trials are shown in table 2.The Hospital Record Review, with 1,800 items, wasdivided into its five subsections and also subjected totrials of interrater agreement berween the one reviewerwho It:ft the team and the one who subsequently joinedthe project. Kappa coefficients ranged from .40(p


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VERMONT LONGITUDINAL STUDY, I

RESULTS

TABLE 2. Kappa Levels for Interrater Agreement on Trials ofInstrument Batteries Given to Vermont Study Subjects

Overall Psychological and Social FunctioningThe Global Assessment Scale (GAS) (42) was chosento provide a single score that would capture theessence of the subjects' psychological and social func-rioning. Scores on this scale showed that 68% (N=tm114) of the study sample were functioning above thecutoff point of 61 designated by the authors as "somemild symptoms (e.g., depressive mood or mild insomnia) or some difficulties in several areas of functioning,but generally functioning pretty well, has some m e a n ~

had not completed high school. However, an eighthgrade education was considered to be the norm beforethe 19405 in Vermont (43).Nineteen percent (N=32) of the 168 subjects werecurrently married, and seven percent (N= 11) werewidowed. Fifty-one percent (N=86) were still single,and 23% (N=39) were divorced or separated.Eighty-eight percent of the subjects (N= 148) 'livedin residential and rural neighborhoods rather thanindustrial or commercial areas. Fifty percent (N=81)lived in independent housing (house, apartment, mobile home, or rooming house), and 40% (N=64) livedin boarding homes. (This information was coded foran N of 161.) Five single middle-aged men werecurrently in the hospital, seven were in level II nursinghomes (InsiifutlonsfOr inatvtdlia1s, im:luding the mentally retarded, who do not require 24-hour nursingcare but who do require care above the level of roOmand board), and four were in other settings. Of thesubjects receiving boarding home care, seven seemedcapable of living independently, often assisting theboarding home operator and taking responsibility formanagement of the home. An additional 23 wereactively involved in activities within the house, at thelocal community mental health center, or in the communityand were self-motivated. Longitudinal patternsof residence revealed an average of two readmissionsfor the group since release from the iridex hospitalization. The average total length of stay was 2 years orless.Twenty-six percent (N=44) of the 168 subjects wereemployed; half of them were classified as working inunskilled jobs. Thirty-three percent (N=56) were unemployed, 8% (N = 14) were volunteers, and 5% (N=8) were housewives. Due to the advanced ages in thesample, an additional 26% (N=44) were classified aselderly, widowed, or retired. Solid information wasunavailable on four (2%) of the subjects for this rating.

OU f findings also indicated that 85% of the samplehad a gross income of less than $10,000 a year. In1982Vermont ranked 36th in the nation for per capitaincome, with an average of $9,979 (44). Using anassessment from the Community Care Schedule bySchwartz et aI. (45) and budget sheets outlining expenses and income, we rated 77% of the subjects ashaving an adequate income; the schedule's definitionof adequate was that the "amount of money receivedwill cover the subject's basic needs comfortably."

.96 3.59b

,97 3,70b

Kappa

.963,SOb

First Tri al Second Tria lField instruments

Vermont Community QuestionnaireCross-sectionalInterviewRater sectionLongitudinalInterviewRater sectionHospital Record Review FormFirst admissionEpisodes between first

a r u L i . n d ~ J ( " ~ [ t 1 i s s i o nIndex admissionEpisodes after dischargeTopical life histotyLife Chan (experimental)

Demographic Data for the Cohort at Follow-UpFifty-one percent of the 168 subjects who were alive,did not have an organic disorder, and were interviewed

(approximately 1 week apart) at his or her place ofresidence by one of the two interviewers. In addition,two or three people who knew the subject well wereinterviewed in a structured protocol to verify currentstatus and historical data. These people included relatives, general practitioners, counselors, clinicians, andfriends. All but 17 subjects (10%) resided in Vermont.The subjects who lived elsewhere were interviewedwith the same protocol. Strict attention was paid to theprotection of patients' rights such as privacy, confidentiality, refusal, and informed consent.Relatives, friends, and caregivers of the deceasedmembers of the original cohort were also interviewed.A structured protocol documented the lives and thelevels of functioning of these subjects until the time oftheir deaths. The inclusion of these data provided amore balanced view of the long-term course of severepsychiatric disorders than has been available in paststudies, which have relied on data from survivors only.A separate report will be devoted to the deceasedsubjects.

This group of back-ward patients represented themost severely ill group from Vermont's only statehospital. Two to three decades after a comprehensiverehabilitation program and a planned deinstitutionalization, one-half to two-thirds of these patients wererated as considerably improved or recovered. Thefindings also showed a wide variation in many areas offunctioning for these patients.

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'111

IiURE 1. Global Assessment Seale Scores of 168 Subjects in thennont Study Who Were Alive and Were Interviewed at Follow-Up40,-

30 OMen~ W o m e n

20

o 0- 11- 21- 31- 41- 51- 61- 71- 81- 91-10 20 30 40 50 60 70 80 90 100+-- Poor - -+ +-- Fair - -+ +---- Good - - -+

GLOBAL ASSESSMENT SCALE SCORE

ngful relationships and most untrained people wouldlot consider him sick." A 2x2 (GAS by Sex) chi,quare test with Yates' correction revealed no signifi:ant differences between the sexes in level of functionng (X2=0.13, df=l, p=.72), but i t should be noted:hat 68% of those with a GAS score between 31 and70 were men, while 62% of those with a GAS scoreJetween 71 and 90 were women (see figure 1).In order to describe more of the individual components that went into the assessment of overall functioning, the Levels of Function Scale (41) was used. Onthis scale, subjects are scored from 0 (poor) to 4 (best)on nine items of interest; the reliability of the scale hasbeen demonstrated. A product-moment correlationrevealed that the overall total score was highly correlated (r=.88) with the GAS score just reported. Table3 summarizes.the findings from the Levels of FunctionScale. Individual areas of functioning were restored forone-half to four-fifths of this group. Because of thewide variation in outcome functioning at follow-upwithin specific subjects, the global rating of slight or noimpairment was given to only 55% (N=92) of thecohort. No impairment was rated for subjects whowere asymptomatic and living independently, hadclose relationships, were employed or were otherwiseproductive citizens, were able to care for themselves,and led full lives in general. Other subjects did well insome areas of functioning but not so well in others.Theirs was a very mixed picture on a continuumweighted toward dysfunction.DISCUSSIONCurrent assumptions about the long-term course ofschizophrenia and other severe mental illnesses includethe idea that people with repeated episodes are at bestlikely to achieve marginal levels of functioning overtime. Heterogeneity of outcome is expected, with a

m J Psychiatry 144:6, June 1987


TABLE 3. Results From the StraussCarpenter Levels of FunctionScale for the 168 Subjects of the Vermont Study Who Were Aliveand InterviewedArea of Functioning N %Not in hospital in past year 140 83Met with friends every week or two 111 66Had one or more moderately tovery dose friends 128 76Employed in past year" 79 47Displayed slight or no symptoms 121 72Able to meet basic needs 133 79Led moderate to very full life 128 76Slight or no impairment in overallfunction 92 55"Qual[ryof work could not be rated; IssUes of confidentialityprevented visits to subjects' work sites.

dichotomized split between "process" and "reactive"patients (46), good premorbid and poor premorbidfunctioning (47), or type I and type II illness (48), orthe familiar breakdown into "one-third get bet ter,one-third stay the same, and one-third get worse." Thefindings from the Vermont cohort, drawn from themost chronically ill patients (the lowest third of thehospital), revealed that over one-half of these onceprofoundly ill, long-stay patients had achieved a muchhigher level of functioning than had been predicted byour own research team during the early days of thepatients' community tenure. Their achievement is evenmore remarkable given their original levels of chronicity.These findings hold for other subsets of the cohort aswell. For example, our companion paper in this issue(35), about the subjects who were rediagnosed asmeeting the DSM-III criteria for schizophrenia, describes similar proportions of restored and hetewgeneous functioning, as does our forthcoming paperabout the outcome of the deceased subjects before theydied. Another paper will delineate the reduction by46% of the number of individual subjects who currently use the public mental health system in Verinont.It appears that they have left the formal system andturned to natural community supports over time.

Our findings of heterogeneity of outcome, withsignificant improvement or recovery for half the cohort, corroborate the results of four other long-termfollow-up studies conducted within the last 15 years:Manfred Bleuler's 23-year study of 208 patients atBurgholzli Hospital in Zurich (32), Ciampi and MulIer's 37-year study of 289 patients in Lausanne (49),Huber and colleagues' 22-year follow-up study of 502subjects in Bonn (50), and the "Iowa 500" study byTsuang et al. (51). The studies from Europe have notbeen seriously regarded by some investigators becauseof such methodological difficulties as the lack of reliable diagnostic criteria, the number of deceased andmissing subjects at follow-up (especially in the Lausanne and Bonn studies), and the use of less structured. clinical interviews to assess psychopathology and acquire outcome data (9). However, the Iowa and Ver-

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, 'Further; in any discussion of the effect of rural life, it; important to point out that the data from the Bonnnd Zurich studies came from industrialized cities andJat Lausanne is a medium-sized city. Only Iowa andrermont are clearly rural localities, but the trends inlle data across all five studies with different environ:lents are similar.The knowledge gained from our study and othershat there is a wide range of long-term outcomesIrovides an impetus to continue the search, begun byhe investigators in the three European studies, forongitudinal patterns of course of illness demonstratedlYsuhgmups QL p a t i e n t L W h ~ 5 = h i ~ y ~ _ c " o n s i d ~ ~ ~ ~ l emprovement or recovery and those who do not.\.dditional questions to be asked now are: When in the:ourse of their illness did those patients who improved)egin to do so? Are there any predictors of futuremtcome status? Many older concepts of predictorslave not been as strong as once thought (32, 41, 65"":,7, and our companion paper in this issue), and welave begun investigations into these important ques:ions.The answers will begin to reshape our psychologicalmd biological concepts of severe men,tal illness and theway in which service delivery systems and treatmentsare designed.

ACKNOWLEDGMENTSThe following people contributed to this phase of the project:design and methodology: Brendan Maher, Ph.D.; the late RobertShapiro, M.D.; Bonnie Spring, Ph.D.; Joseph L. Fleiss, Ph.D.; JaneMurphy, Ph.D.; Joseph M. Tobin, M.D.; Lee Robins, Ph.D.; LeonaBachrach, Ph.D.; Edward Zigler, Ph.D.; Stanley Herr, J.D.; and JonRolf, Ph.D.; additional aid with instrumentation: William Woodruff, M.D.; Alan Gelenberg, M.D.; Gerard Hogarty, M.S.W.; PaulaClayton, M.D.; Janet Mikkelsen, M.S.W.; and Thomas McGlashan,M.D.; data collection: Paul D. Landed, M.S.W.; Carmine M.Consalvo, Ph.D.; Janet Wakefield, Ph.D.; William Deane, Ph.D.;Barbara Curtis, R.N.; and Robert Lager, B.A.; data management:Susan Childers, A.C.S.W.; Lori Witham; Mary Ellen Fortini, Ph.D.;Sandi Tower; Andrea Pierce; Mary Noonan; Dorothy Myer; andJoanne Gobrecht; manuscript review: Luc Ciompi, Prof.Dr.Med.;Prof. John Cooper; Boris Astrachan, M.D.; Malcolm ~ Bow.ers, ]r.,

M.D.; Richard Musty, Ph.D.; George Albee, Ph.D.; ThomasAchenbach, Ph.D.; Paul Carling, Ph.D.; Lawrence Gordon, Ph.D.;and Frederick Schmidt, Ph.D.; and manuscript preparation: NancyL. Ryan.

REFERENCES1. Bachrach LL: The concept of young adult chronic psychiatricpatients: questions from a research perspective. Hosp Community Psychiatry 1984; 35:573-5802. Community Mental Health Centers and Psychiatrists. Washington, DC, and Rockville, Md, American Psychiatric Associationand National Council of Community Mental Health Centers,19853. Neilsen AC III, Stein Ll, Talbott JA, et al: Encouraging psychiarrists to work with chronic patients: opportunities and limitations of residency education. Hosp Community Psychiatry1981; 32:767-7754. Schwartz SR, Goldfinger SM: The new chronic patient: clinicalcharacteristics of an emerging subgroup. Hosp CommunityPsychiatry 1981; 32:470-4745. Bachrach LL: A note on some recent studies of released mental



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