No abstract

Prognosis, the prediction of the outcome of an illness, has long been recognized as a necessary skill of a physician. Hippocrates (translated Chadwick and Mann, 1950) said:“It seems highly desirable that a physician should pay much attention to prognosis. If he is able to tell his patients when he visits them not only about their past and present symptoms, but also to tell them what is going to happen, as well as to fill in the details they have omitted, he will increase his reputation as a medical practitioner … It is impossible to cure all patients: that would be an achievement surpassing in difficulty even the forecasting of future developments … By realizing and announcing beforehand which patients were going to die he would absolve himself from any blame.”In addition to the reasons given by our distinguished forebear we now also require to read into the future so that we can make the best use of the limited facilities available for the sick. This is particularly true for elderly psychiatric patients for whom treatment facilities are still very inadequate. It has been suggested (Cook, Dax and Maclay, 1952) that mentally ill elderly people should by preference be admitted to short-stay units attached to general hospitals for the assessment of prognosis and probable response to treatment. They suggested that a 3-4-months stay might be necessary. Experience in a diagnostic outpatient clinic (Norris and Post, 1954) led one of us (F.P.) to believe that it should be possible to classify patients according to the best method of dealing with them in a shorter time even than the six weeks recommended by the B.M.A. Report (1947). The present study was designed to test this belief. Our hopes were only partly fulfilled, but a post hoc analysis of our original data, in conjunction with the known results of the follow-up of cases, has suggested that with more knowledge of the factors influencing prognosis over a short term, much more accurate forecasts could have been achieved. The second half of this paper is devoted to a discussion of these factors. A preliminary report was given at the Third International Congress of Gerontology (Kay et al., 1954).

The handicap of the single as compared with the married state in respect of the first admission rates to mental hospitals has been demonstrated by several workers. Dayton (1939), Malzberg (1940) and 0degaard (1946), to mention but a few, have all shown that the admission rates for single persons are greater than those for married persons of the same age. Hospital first admission rates for mental disorders are more likely to give reliable estimates of the incidence of mental disease than are hospital rates for other types of illness, nevertheless hospital admissions are but a sample of the sick population in the community and, generally speaking, there is no means of knowing whether or not it is a representative sample of the total sick population. For this reason, in this paper it is only the effect of marital status on the hospital care of the mentally sick that it is to be considered. This appears to be a necessary restriction in view of the fact that the data analysed here relate only to hospital admissions, but ⊘degaard (1946) categorically stated, although his data, too, were derived from mental hospitals:“It is shown beyond doubt that the incidence of mental disease is much higher in the single than in the married, and that this ‘predominance of the single’ among our insane is no statistical figment caused by such factors as differences in age distribution or in the tendency to hospitalize the insane.”The purpose of this paper is not to discuss differential admission rates between single and married, although some data will be presented to show that the difference exists here as well as in Scandinavia and the United States, for I have dealt with that problem elsewhere.∗ The very great differences between the first admission rates for single and married persons led me to ask the question: “What other differences arise between single and married persons with respect to mental hospital care?” The data of a statistical study of mental hospital admissions which I have already completed provide some information on this point.

In a previous enquiry the prognostic significance of diverse aspects of the functional psychoses was examined (Harris and Lubin, 1952; Harris and Norris, in press). Prognosis was evaluated in terms of total length of stay in a mental hospital over a follow-up period of 18 years. Each patient was assigned to one of three major diagnostic groups (schizophrenia, affective psychosis or atypical psychosis), the diagnosis being based on Kraepelinian and Bleulerian criteria. The diagnosis was made by one of the authors (A.H.) on the evidence of 20-year-old case notes written by a large number of different psychiatrists. In this investigation the same author himself examined all the patients included in the series. We felt it would be interesting to compare the predictive value of diagnoses made by the rough and ready method of the earlier survey with that of those made by a detailed examination of the patients concerned, as in the present survey. For reasons previously stated (Harris and Norris, 1954) we feel that only certified patients admitted in the second period are comparable with the types of cases admitted in 1930. If a diagnosis of schizophrenia is held to connote an unfavourable and the remaining categories a favourable outcome then in the first series 60 per cent. of the patients were correctly classified while in the second series 58 per cent. of the certified patients were assigned to their correct diagnostic group. This difference is not significant. Thus it would appear that a more sophisticated application of Bleulerian methods of diagnosis does not necessarily give rise to more reliable evaluation of prognosis. Accordingly we have attempted to dissect these three diagnostic categories to determine whether any of the components show prognostic significance. For this purpose we took the second series because for these patients there were available detailed clinical descriptions made by one of the authors (A.H.) in the observation ward of a general hospital, prior to the patient's transfer to a mental hospital. Unfortunately 13 of the case notes containing these detailed clinical descriptions had been lost, so that we could only use 187 patients out of the total of 200. They were first admitted to hospital in the period May, 1940 to May, 1942 and were followed-up for the next 10 years. The result of the analysis is set out in the table.