Évolution de l'autonomie sociale chez des patients schizophrènes selon les prises en charge. L'étude ESPASS

It is becoming clear to clinicians that functional prognosis is the issue that should be guiding their choice of therapeutic strategy offered to people with schizophrenic disorders. An individual's degree of social autonomy is one of the principal factors determining functional prognosis, and it has become essential to identify the variables that influence it. The ESPASS survey was set up to follow a cohort of 6000 schizophrenic patients in a naturalistic setting, and was conducted over six months by 1170 psychiatrists. Patients were required to meet DSM-IV TR criteria for schizophrenia, with the exception of those suffering from an acute psychotic episode, and to either need a change in their antipsychotic treatment or its initiation. Data collected included patients' sociodemographical characteristics, types of treatment (pharmacological and non-pharmacological), illness characteristics (as determined by the DSM-IV TR criteria), degree of social autonomy (EAS), effectiveness (IAQ scale), overall severity of the illness (CGI - S scale) and patient satisfaction with medical treatment (PASAP self-questionnaire). Concerning the non-pharmacological aspects of treatment that offer patients programmes to increase their autonomy, the survey made it possible to collect data describing real practices and to measure the actual availability of rehabilitation services. It has been verified that the sample of psychiatrists included in this survey, as well as the schizophrenic patients under evaluation, were representative of the French psychiatrist and patient populations. Most importantly, the survey made it possible to objectively evaluate the healthcare services available in France. It seems that the vast majority of public-service psychiatrists have access to hospital and ambulatory facilities for treatment (medical-psychological centers, day-care hospitals and rest centers), as well as access to facilities providing simulated real-life activities. Psychiatrists who are private practitioners have less access to such arrangements for their patients. The vast majority of psychiatrists in both categories are unable to offer their patients active rehabilitation techniques: training in social skills (25%), cognitive remediation (16%), cognitive-behavioral therapies (20%), even though psychoeducation is quite widespread (44%). However, the survey demonstrated that the actual use of these methods was much lower still (2%, 1% and 2%, respectively), although the use of alternative facilities to hospitalization was quite high (day-care hospitals 9%, rest-centers 8%). In total, at the end of the study, the proportion of patients benefiting from some kind of programme to increase their level of autonomy was 41%. These results have demonstrated a link between the evolution of patients' clinical symptoms and their social autonomy. Within the findings, the items that varied most were patient's level of personal care and relations with others, whereas the ability to manage resources seems difficult to influence. Moreover, the results have shown that better development of social autonomy is significantly correlated with the prescription of second-generation antipsychotics. Regarding non-pharmacological treatment, better development of social autonomy is significantly correlated with setting up programmes to achieve this objective, including the use of active rehabilitation techniques. Overall, the survey confirmed the results of earlier work to validate the scale of social autonomy (EAS), and confirmed the robustness of its objective measurements.