Only a very small number of people never return to psychiatric services after being admitted once. That is the conclusion by a new study from the University of Copenhagen, which followed 150 young people for 20 years after their first psychiatric admission.
A full 95 per cent of the patients were either readmitted or continued in long-term treatment over the following two decades. Many also faced significant challenges related to education, family life and health compared with their peers.
"We were surprised by how few people never returned to psychiatry after a first admission," says Julie Nordgaard, clinical professor at the Department of Clinical Medicine at the University of Copenhagen and one of the study's lead authors.
"This suggests that admission to a psychiatric ward is in itself a serious warning sign, and that we should make an extra effort for this group of patients," she says.
Thorough diagnostic assessments improve accuracy
Schizophrenia
A severe mental illness characterised by an inability to distinguish between reality and imagination. Typical signs of schizophrenia include psychotic symptoms such as hallucinations and delusions, as well as difficulties in relating to other people.
Schizotypal disorder
A milder condition within the same spectrum as schizophrenia. It is often characterised by social difficulties, odd or suspicious thinking, and brief psychosis-like symptoms.
Personality disorders
A broad term covering very different types of disorders that manifest in different ways. Personality traits often deviate significantly from what is considered normal and socially accepted, and this usually has a major impact on everyday life and relationships with others.
Source: Danish Mental Health Foundation
What sets the study apart is that all patients underwent thorough assessments by experienced psychiatrists at their first admission, including interviews lasting up to five hours. This gave researchers a unique opportunity to examine how well-substantiated diagnoses developed over time.
Schizophrenia and schizotypal disorder proved to be stable diagnoses, with around 80 per cent of patients receiving the same diagnosis again during the 20-year study period. Personality disorders, by contrast, were far less stable, with almost two out of three patients later receiving a different diagnosis. Some patients went on to develop a more severe condition than the one identified at their first admission.
"This shows that when we have time to assess patients thoroughly the first time, we can in many cases make accurate diagnoses that remain valid over time. This is important, because the diagnosis determines the treatment," says Mads Gram Henriksen, professor in philosophy and psychiatry at the Department of Communication and co-author of the study.
However, this type of in-depth assessment also requires more time and specialised expertise - something that is often lacking in psychiatry today.
Social challenges
The study also shows that patients generally experienced more difficult life trajectories than their peers. Only 40 per cent of participants completed a higher education programme, compared with 53 per cent in the rest of the population. Similarly, only 43 per cent of participants had children, compared with more than 80 per cent of the general population.
Mortality rates were also higher, and one third of deaths were due to suicide. This corresponds to a suicide rate around ten times higher than in the rest of the population. It is, however, important to note that only four out of the 150 participants died by suicide, and caution is therefore needed when generalising from such small a sample size.
"Having children or completing a higher education is not a goal on its own. But when we follow this group over many years, we see that their life trajectories differ markedly from those of the general population. This says something about the far-reaching consequences mental illness can have on people's lives," says Julie Nordgaard.
Targeted support
The researchers point out that the first admission should therefore be seen as a unique opportunity to provide much stronger and more targeted support - both psychiatric and social. This may include specialised treatment programmes, as well as support to help patients remain in education or employment, avoid substance misuse, or manage finances, housing and social relationships.
"If we support patients better at the outset, we may be able to prevent some of the social challenges we otherwise see. Many end up dropping out of education or losing their networks - not because they lack motivation, but because their illness makes it difficult to stay on track," says Julie Nordgaard.
