Community Rehabilitation and Hospitalizations Among People With Chronic Psychotic Disorder: Is There a Differential Association by Co-occurring Substance Use Disorder?

Objective: Co-occurrence of chronic psychotic disorders and substance use disorder (SUD) is clinically challenging and increasingly prevalent. In 2000, legislation was passed in Israel to foster rehabilitation and integration in the community of persons with mental health disorders. In 2010, the need to allocate resources for patients with these co-occurring disorders (COD) was officially recognized. Yet, most rehabilitation services were not specifically designed for COD. This study examines the relationship between duration of community rehabilitation and number of psychiatric hospitalization days among persons with/without COD in Israel. Methods: Data from the National Psychiatric Case Register on 18,684 adults with schizophrenia/schizoaffective disorders hospitalized in 1963–2016, was merged with data from the Israel Mental Rehabilitation Register. Associations and interactions between COD-status (COD/non-COD), time-period (Period(1): 2001–2009, Period(2): 2010–2016), duration of housing or vocational rehabilitation on hospitalization days per year were analyzed using repeated-measures ANOVA. Results: The proportion of non-COD chronic psychotic patients who received rehabilitation services increased from 56% in Period(1) to 63% in Period(2), as it did among COD patients—from 30 to 35%. The proportion of non-COD patients who received longer-duration vocational rehabilitation (≥1 year) was significantly higher (43%) than among COD patients (28%) in both time periods. For housing rehabilitation, these proportions were 79 and 68%, respectively. Persons with COD experienced more hospitalization days annually than non-COD patients. Duration of rehabilitation (less/more than a year) was inversely associated with annual number of hospitalization days (p < 0.0001). This pattern was noted in both COD and non-COD groups and remained significant after controlling for age, sex, COD group, percent of hospitalizations with SUD, and age at first hospitalization. Conclusions: COD patients with prolonged rehabilitation seemingly achieve long-term clinical improvement similar to non-COD patients, despite most rehabilitation settings in Israel not being designed for COD patients. Yet, COD patients receive overall less rehabilitation services and for shorter periods than non-COD patients. Long-term rehabilitation services should be provided to COD patients, who may need more time to commit to treatment. To achieve better long-term mental health improvements, a continued expansion of community-based integrative treatment and rehabilitation services for COD patients is needed in Israel.