The Suffolk County Mental Health Project:
10 Year Findings and Lessons Learned
Evelyn Bromet, Ph.D.
Roman Kotov, Ph.D.
Department of Psychiatry
SUNY Stony Brook
Funded by NIMH 44801 since 1988
Presentation Outline
1. Aims and design of Suffolk County Mental
Health Project (SCMHP)
2. Preliminary findings on diagnostic shift from 210 yrs: risk factors, course, outcome
3. Analyses of improvement (Roman Kotov)
4. Conclude with whether our data fit Harrow’s
conclusions about long-term outcome of sz
Original Aims
1988:
• Clinical epidemiologic study of the “natural
history” of schizophrenia
• Examine contributions of established prognostic
factors (gender/age; premorbid func; duration of
untx psychosis) to early course (first 2 yrs)
• Examine contributions of less studied prognostic
factors (substance abuse and suicidality)
Implications of Original Aims
1. Epidemiology requires a representative sample
2. Low base rate Ædraw sample from range of
treatment settings
3. Schizophrenia diagnosis requires 6 month
durationÆneed a 6-month follow-up to have a
reliable study diagnosis (DSM-III-R)
Expanded Aims
1990:
• Examine dx consistency from baseline to 6-month
1992:
• Examine dx consistency from 6-24 month
• Psychotic mood disorders
• Mental health service experiences
• Added 4 year assessment
Re-expanded Aims
1999:
• Outcome at 10 years
2001:
• Long-term diagnostic stability (retrospective on
“true” study dx)
Eligibility Criteria - WHO Mirror
Inclusion criteria
• 1st admission to 12 hosps in Suffolk County
(or 1st admission occurred w/in 6 mos)
• Network of liaisons in every facility (head
social worker or head nurse)
Design: Other Inclusion Criteria
•
•
•
•
Psychosis (or possibly psychotic)
Age 15-60
Resident of Suffolk County
Able to give informed consent
Design: Exclusion Criteria
• Significant mental retardation
• Non-English speaking
• Documented organic cause for psychosis
Design: Lessons Learned
Lesson:
• Baseline time varied
• Interviewed people toward end of their stay
when less psychotic and had capacity to
understand consenting process
By 1993, length of stay shorter, discharged
very ill, response rate plummeted
Design: Plummeting medians (Mojtabai: AJP 2005)
60
State Facilities
50
Other Facilities
Inpatient Days
40
30
20
10
0
89-90
90-91
91-92
92-93
Admission Cohorts
93-94
94-95
Follow-Up Design
• In-person interviews by mental health professional
(mostly social workers) at baseline, 6-months, 2
yr, 4 yr, 10 yr follow-ups
• Kept same interviewer with respondent
• In hosp; in homes, libraries, cars, coffee shops…
• 2 assessments at the major follow-ups (plus S.O.)
• Interval telephone contact every 3 months from
BL-2 yrs, and every 6 months from 2-4 yrs
• Annual tracking calls, cards, etc after 4 yr point
Measures: Overview
• SCID at all in-person contacts (ratings w/ records)
• Premorbid adjustment: Cannon-Spoor
• Current functioning (self-report sx; Quality of Life
measures; physical health; and too much more)
• Treatment experiences
• Interviewer ratings: BPRS, SANS, SAPS, Ham-D
• Interview narratives
• Lesson: interviews too long
Research Diagnosis
• Baseline: Consensus of two psychiatrists using the
SCID-P
• 6 & 24 mos: Consensus of 6+ psychiatrists using
all information (incl. school records) except
previous research diagnosis; strictly adhered to
DSM criteria
• 10 yrs: Consensus of 6 psychiatrists using all
information (don’t fill in criteria sheets)
Lesson: analysis of 10 yr temporal stability of dx is
contaminated
Numbers Contacted
Baseline
Baseline(695)
(695)
Hosp
Hosp&
&Eligible
Eligible(628)
(628)
66Months
Months(591)
(591)
24
24Months
Months(550)
(550)
48
48Months
Months(514)
(514)
10-Year Status
•
•
•
•
•
•
•
46 died: 15 by 4 years; 31 later
27 lost
61 refused
9 left country
10 too sick to consent or institutionalized
11 significant other interference
N=470 (422 personal interviews)
Causes of Death and Mean Age at BL
•
•
•
•
•
•
Medical = 18 (7 CVD; 6 CA; 5 other) 37+10
Suicide = 8 (1 made attempt before BL) 30.5+10
Accidental Overdose = 2 24.5+5
HIV/AIDS = 7 (out of 12 HIV+) 31+10
Homicide/accident = 6 32.5+11
Unknown = 5 22.4+5
Preliminary Findings on Attrition at 10 yrs
Preliminary analysis of contacted, refused, lost, died
• Not significantly related to:
- gender
- BL substance abuse
- BL clinical or research dx=sz/sa
- DUP
- BPRS hostility
- Facility type
Preliminary Findings on Attrition at 10 yrs
• Significantly related to:
-whether interviewed at prior points
-age (younger=interviewed or lost; older=refused or dead)
-race (more Black Rs lost; fewer Blacks refused)
-SES (upper end more likely to refuse)
-GAF best before BL (refused had higher GAF)
-complete remission period by 2 yrs (more likely to refuse)
Characteristics of Original Cohort
Demographics
59% male
58% age ≤30 adm
59% never married
26% in special educ
15% black
26% low ses origin
44% not working or school
14% living alone
22% very involved in
religion
History
52% LT alc/sub dx
20% prior antipsy med
45% insidious onset
34% public hosp
60% involuntary adm
23% dx by hosp SZ
DUP:
<1 mo. 46%
1-6 mos. 22%
6-12 mos. 6%
>1 yr 26%
Distribution of Research Diagnoses at Each Point
Diagnosis
BL
N=628
6 mos
N=561
24 mos
N=589
10 yrs (11/07)
N=449
Sz/S-A
23.7%
32.2%
37.7%
47.8%
Schizophreniform
5.4
2.1
1.2
0.2
BP
21.2
26.0
25.1
25.6
MDD
16.9
19.3
17.7
11.4
Other psychoses
28.3
11.9
10.4
6.7
Drug induced
4.5
8.4
8.0
8.2
2-10 yr Shifts in Diagnosis
10 yr Sz
BP
MDD
Other
Drug
4
1
3
2
2 year
Sz spectrum (172) 162 94%
BP (121)
14
97 80%
0
6
4
MDD (77)
18
6
47 61%
5
1
Other psy (41)
13
5
3
16 39%
4
3
0
0
25 76%
Drug induced (33) 5
Shift into Schizophrenia between 2-10 yrs
•
•
•
•
162 had a consistent diagnosis of sz/sa/sf
222 were never dx as sz/sa/sf
50 shifted into sz at 10 years
10 shifted out of sz at 10 years
PPV for 2 yr sz spec = 94.2% (162/172)
Sensitivity = 76.4% (162/212)
Analysis of Shift into Schizophrenia
• Comparisons of 3 groups: Always, shifted, never sz
Early risk factors
GAF scores at each point
Symptoms at each point
Role functioning
Financial situation
Treatment exposure at 10 yr
Premorbid Adjustment: (high=worse)
0.45
0.4
0.35
0.3
0.25
0.2
Child
Alw ays sz
F(gp)=ns; F(age group)*; F(interaction)=ns
Age 11
Shifted
Later adol
N ever sz
Risk factors for schizophrenia (all signif)
%
80
70
60
50
40
30
20
10
0
Male
Age 26+
Always sz
Low IQ
Shifted
Fam hx sz
Never sz
Risk factors for schizophrenia (all signif)
%
90
80
70
60
50
40
30
20
10
0
DUP >1 yr
Onset 23+
Always sz
Schneiderian
Shifted
Ham18+
Never sz
GAF best in yr <BL and prior to follow-ups
70
65
60
55
50
45
BL
2 yrs
Always
4 yrs
Shifted
Repeated measures: F(gp)=***; F(time) ns; F(interaction)=*
10 yrs
Never
SAPS Psychotic: Sum of 16 items coded 0-5 (marked)
16
14
12
10
8
6
4
2
0
BL
2 yrs
Always
4 yrs
Shifted
Repeated measures: F(gp)=***; F(time) ***; F(interaction)=?
10 yrs
Never
SAPS Disorganized: Sum of 13 items coded 0-5 (marked)
8
7
6
5
4
3
2
1
0
BL
2 yrs
Always
4 yrs
Shifted
Repeated measures: F(gp)=***; F(time) ***; F(interaction)=ns
10 yrs
Never
SANS BL and at follow-ups: Sum of 18 items coded 0-5 (marked)
30
25
20
15
10
5
0
BL
2 yrs
Always
4 yrs
Shifted
Repeated measures: F(gp)=***; F(time) ns; F(interaction)=?
10 yrs
Never
WHO Scale: Consensus of Interviewers and Psychiatrists that
Substantial Full Remission Is Present in Overall Course
80
70
60
50
%
40
30
20
10
0
Always
Shifted
2 yrs
4 yrs
Never
10 yrs
Percent not working/in school 10 yrs
%
80
70
60
50
40
30
20
10
0
Always
Baseline
Shifted
2 yrs
Never
4 yrs
10 yrs
10 Year Outcomes
%
100
90
80
70
60
50
40
30
20
10
0
Public asst
Lives w/ family
Always
Shifted
Socially
withdrawn
Never
Treatment at 10 years
%
90
80
70
60
50
40
30
20
10
0
Psy ER past yr
2+ hosp 4-10 yrs
Always
Shifted
Cont tx
Never
Shift Group
• Misclassified initially because older, less
negative sx, more depressed
• Outcome was as poor as consistently
diagnosed with sz
Schizophrenia: Who got better?
Schizophrenia: Who got better?
• Heterogeneity within diagnosis
• N = 229 (24-mo diagnosis)
• Illness Indexes
–
–
–
–
Psychotic: SAPS – P (16 items)
Disorganized: SAPS – D (13 items)
Negative: SANS (18 items)
Overall illness severity: GAF (past year high)
• Latent Class Growth Models in Mplus
25%
50%
25
Count
20
15
10
5
10
20
30
SAPS-P
40
50
Psychotic Symptoms
10%
90%
50%
25%
50
Count
40
30
20
10
0
5
10
15
20
SAPS-D
25
30
35
Disorganized Symptoms
7%
7%
11%
75%
50%
25%
20
Count
15
10
5
0
0
10
20
30
SANS
40
50
60
Negative Symptoms
7%
15%
36%
42%
50%
50%
25%
40
Count
30
20
10
30
40
50
GAF
60
70
80
Illness Severity
10%
31%
59%
Good outcome
Index
1
2
1. Psychotic
90%
2. Disorganized
76%
0.21
3. Negative
42%
0.00
0.09
4. GAF
10%
0.03
0.04
3
0.16
Overall
None
4%
1
15%
2
46%
3
28%
All
7%
Conclusions
Martin Harrow’s review of long-term outcome:
1. “natural course of schizophrenia …[has] a
threefold division of mild, moderate and severe”
2. “sz … poorer courses and outcomes than
patients with other psychotic … disorders”
3. “subgroups ... had extended periods of recovery”
4. “subgroups…did not show a progressive
downhill course”
Collaborators
Gabrielle Carlson
Thomas Craig
Laura Fochtmann
Ramin Mojtabai
Jonathan Prince
Jonathan Rabinowitz
Marsha Tanenberg-Karant
Janet Lavelle
Su-wei Chang
Anil Malhotra+
Joseph E. Schwartz
Stephen Finch
Ezra Susser+
Shmuel Fennig
Alan Miller
Ranga Ram
Nancy Sohler
Yuval Neria
Bushra Naz
Beatrice Kovasznay