John W. Shaffer

A comparison of nine systems to diagnose schizophrenia

The files of 283 hospitalized patients discharged with a diagnosis of schizophrenia, schizoaffective schizophrenia, or paranoid state were examined without knowledge of the patients subsequent history. These patients, most of whom had originally been diagnosed by DSM-I criteria, were retrospectively diagnosed by New York Research Diagnostic Criteria (RDC), the New Have Schizophrenia Index (NHSI), the St. Louis criteria, Taylor-Abrams 1978 criteria, Schneiders first-rank symptoms (FRS), the Washington IPSS 12-Point Flexible System, Astrups process/nonprocess distinction, and DSM-III. Kappa values measuring pairwise diagnostic agreement amont the nine systems were typically low except among RDC, DSM-III, and St. Louis criteria. Long-term followup status was not significantly predicted by the FRS, NHSI, or Taylor-Abrams criteria. Diagnosis by means of the other systems, especially the Astrup process/nonprocess distinction, was significantly correlated with followup. However, Astrups process schizophrenia is not operationally defined and could not be expected to be used with the degree of interrater reliability desired by researchers. On the other hand, of the operationally defined systems, DSM-III schizophrenia has the highest correlation with followup and is thus suggested for use by researchers desiring a highly homogeneous, although narrowly defined, population. Investigators wishing to cast a wider net could use a less restrictive system such as the RDC, with or without schizoaffectives included.

The prediction of suicide in schizophrenia

In view of the fact that the suicide rate among previously diagnosed psychiatric patients is several times that of the general population, the investigation of such groups for factors leading to increased suicidal risk is of great practical and theoretical importance. The present study sought to uncover such factors through the use of case history data collected at the time of admission on 361 schizophrenics hospitalized at the Henry Phipps Psychiatric Clinic. These cases were subsequently followed up for a period of 5 years and the incidence of suicide (12 out of 361) was determined. After deletion of all follow-up information, the case folders of the 12 subsequent suicides were interspersed among those of a random sample of 75 cases drawn from the remaining 349 controls. These 87 cases were then reviewed “blindly” by two experienced psychiatrists who rated each for degree of suicide potential on an 11-point scale. Sociodemographic variables and other diagnostic data were also recorded. Subsequent multivariate analyses were concerned with determining the raters accuracy as well as with retrieving their strategy; with determining the predictive value of isolated clinical and sociodemographic signs; and with assessing the predictive effectiveness of an optimally weighted composite when applied to the entire series of 361 cases. The results indicated that although none of the signs and ratings, either singly or in combination, yielded individual accuracy of prediction superior to classification by base rate, the clinical judgments of the psychiatrist raters were significantly correlated (p < .01) with outcome. Moreover, retrieval of the raters strategy via multiple regression resulted in an equation affording accuracy of prediction equal to the original. As expected, the number of previous suicide attempts was the most important single variable associated with outcome as well as the one which most influenced raters judgments. Previously published risk scales were found largely ineffective in this context. Although the substantive results could be considered disappointing in that hardly more than 5 per cent of the variance of the suicide/non suicide dichotomy could be accounted for in the entire series of 361 cases, such an appraisal overlooks the value of identifying high and low risk groups for further study and possible intervention. Moreover, the ready availability of a mathematical substitute for expert clinical judgment renders such pursuits considerably more feasible.

Inpatient diagnoses during Adolf Meyer's tenure as director of the Henry Phipps Psychiatric Clinic, 1913-1940.

Between 1936 and 1950, detailed abstracts were prepared on all patients admitted to The Phipps Psychiatric Clinic from its opening in 1913 through 1950. Of these abstracts, 74% contained follow-up reports. Except for four papers on schizophrenia and affective disorders published between 1939 and 1943, none of this material has ever been analyzed. The present paper, the first of a series, examines the 8172 first admissions from 1913 through 1940, the period of Adolf Meyers tenure as Clinic Director. Based on discharge diagnoses, we have sorted the patients into eight diagnostic groups with the following frequencies; schizophrenia, 17%; paranoid state, 3%; manic-depressive, 7%; depression, 27%; organic, 20%; neuroses, 15%; substance abuse, 6%; psychopath, 5%. Our manic-depressive group contains cases discharged primarily as hyperthymergasia, mania, or manic depressive insanity (MDI). Of the 349 cases diagnosed MDI at discharge, 10 had neither a history of nor present symptoms of mania, and these were put in the depression group. Frequencies for most of the diagnoses remained remarkably stable over the 28-year period. Only 9% were discharged recovered, whereas 43% were rated unimproved. Mean length of hospitalization was 76 days, with 10% of the patients readmitted. The mean length of follow-up was 9 years. Correlations of diagnoses, year of admission, length of stay, condition at discharge, age, sex, readmissions, change of diagnoses, somatic treatment, length of follow-up, and deaths in the clinic are presented. Meyers influence on diagnostic practice is discussed.