ASSESSMENT AND TREATMENT SELECTION FOR REVOLVING-DOOR INPATIENTS WITHSCHIZOPHRENIA

Goals: The goals of this study are 1) to determine causes and patterns of relapse for a cohort of ''revolving door'' schizophrenia inpatient s, and 2) to assess the feasibility of starting a new psychopharmacolo gic intervention before discharge, either depot therapy or an atypical antipsychotic. Methods: Consecutive admissions to an acute inpatient unit in New York City were screened for ''revolving door'' criteria. P atients had to have a primary diagnosis of schizophrenia or schizoaffe ctive disorder and have either I) two hospitalizations in the last yea r, or 2) three hospitalizations in the last three years. Patients were then assessed for probable causes of relapse for the index and prior two hospitalizations. Treatment selection, based on this information, was trichotomized to: 1) oral conventional antipsychotic, 2) depot con ventional antipsychotic (either haloperidol or fluphenazine decanoate) , or 3) atypical antipsychotic (either risperidone or clozapine). Resu lts: Sixty-three out of 131 screened admissions met the above revolvin g door criteria. They were indeed ''revolving'', having an average of 1.3 hospitalizations per year over the last 3 years and were only out of the hospital for five months (median) before index admission. The t reatment selection process was hampered by lack of information about e vents leading to relapse, and by the lack of outpatient participation in the medication selection process. Of the 50 patients with complete histories about precipitants for the index episode, the most common re ason for rehospitalization was judged to be medication noncompliance ( n = 25; 50%), followed by medication nonresponse (n = 13; 26%). Not su rprisingly, medication recommendations were closely linked to the asse ssed reason for relapse (depot therapy [n = 27; 49%] with medication n on-compliance; atypical antipsychotic [n = 20; 37%] with medication no nresponse [X-2 = 26.9, p<.001]). These two recommendations were implem ented before discharge for about one-half of the cases. Patient refusa l was a relatively greater problem for depot recommendation while cons traints in the outpatient environment were more problematic for patien ts recommended for atypical antipsychotics. Conclusions: Medication no ncompliance and medication nonresponse, in that order, were judged to be the most common causes of relapse for ''revolving door'' inpatients . Both depot therapy and atypical antipsychotics were commonly recomme nded and ultimately accepted by about 2/3rds of patients. Choice betwe en depot and atypical was driven by the assessed cause of relapse. In summary, it seems possible to identify ''revolving door'' inpatients, and to target specific medication interventions within the time frame of an acute inpatient admission.