World Applied Sciences Journal 19 (5): 625-633, 2012ISSN 1818-4952; - PDF document

World Applied Sciences Journal 19 (5): 625-633, 2012ISSN 1818-4952;© IDOSI Publications, 2012DOI: 10.5829/idosi.wasj.2012.19.05.65192Corresponding Author:Nadia Mohamed Mahmoud, Community Health Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt. 625Social Support and Length of Hospital Stay among Schizophrenic PatientsLaila H. Ossman and Nadia M. Mahmoud Department of Psychiatric Nursing, Alexandria University, Egypt Schizophrenia Social Support Social NetworksINTRODUCTIONSomestudies have reported factors that could affect World Appl. Sci. J., 19 (5): 625-633, 2012626In general population, social support buffers againstSubjects:Subjects of the study were “155” male andstressful life events, increases adherence to medicalfemale patients from free and private wards. Patients weretreatments and improves recovery from medical illnesstaken from the randomly selected wards, two male private[10]. Social support as a basic aspect of human life iswards and two male free wards, as well as one femaleoften lacking in the lives of people with serious mentalprivate ward and one female free ward. These wards wereillness. Numerous studies have found people with mentalincluded in the study, based on male wards to femaleillness, particularly schizophrenic disorders, to be sociallywards ratio in El-Maamoura Hospital. The subjects wereisolated. Their networks are small compared with those ofdivided into two main groups: Short hospital stays,persons without mental illness and relationships are oftenpatients who have been staying in the hospital six monthsrestricted to the immediate family, with few other socialor lessand long hospital stays, patients who have beengroups to refer to. The impact of social isolation rangesin the hospital for at least one year or more. The subjectsfrom poor outcomes in terms of quality of life and self-agreed to participate in the study and communicatedesteemto a less favourable illness course with moreclearly were included in the study. psychotic symptoms or more frequent and prolongedhospitalizations [11-13].Tools:Socio-demographic and clinical characteristicsSome studies have noted that persons admittedstructured interview schedule which was developed byfrequently to mental hospitals or those with prolongedthe researcher after review of literature. It included socio-hospitalization have distinctly smaller networks composeddemographic data such as patient’s age, marital status,of fewer close reciprocal relations than persons admittededucational and occupational level and residence. Asfor the first time. Also it will be difficult for individuals toregarding clinical characteristics, these included durationreintegrateinto community after hospitalization [8].of illness, number of hospital admission and duration ofAnother study found that people with a larger network,current hospitalization. withhigh level of support located in family and outsidethefamily, have been rarely hospitalized [14]. Moreover,Norbeck Social Support Questionnaire (NSSQ):only a few studies have examined the relationshipThe tool was originally developed by Norbeck et al. [17]betweensocial support and network and length ofto measure social support and has been proved to behospitalstay, leaving questions about whether thevalid and reliable tool. The questionnaire was designed tohospitalizationaffect social network and social support,measure two main variables; the functional componentsor conversely, perhaps, social networks themselvesof social support and the network structure propertiesprecipitate hospitalization [13, 15].through which social support is provided. TheHence,social support is one area of study that mayfunctional components of social support are affectionenhanceunderstanding of caregiver of hospitalized(the expression of positive effect of one person towardschizophrenic patients. Investigation of theanother), affirmation (endorsement of another person’scontribution of social support to hospitalizedbehaviour, perception or expressed views) and aidschizophrenic patients experience will increase the ability(the giving of symbolic or material aids to another).of health professional to assess the needs of families,Each of these properties were measured by two questionscaregivers and target interventions [16]. So the aim ofwhich covered the patient’s perception of love and care,present study was to identify the relationship betweenrespect and confidence, in addition, to the support ofsocial support and length of hospital stay amongthoughts or actions short term financial aid was providedschizophrenic patients.by supportive person. MATERIALS AND METHODSscale ranging from 1 to 5 with 1 denoting the least supportResearch Design:This study followed a descriptiveAs regards to the structural properties of the socialcorrelational design.support network, it consisted of the number of persons inSetting:The study was conducted at El-Maamouraduration of the relationships and frequency of contact.hospital for Psychiatric Medicine in Alexandria. TheThese properties were measured through the seventh andhospital is affiliated to the Ministry of Health. eighth questions. Each question was rated on a 5-pointEach of these questions were rated on a5-point-likertand its total scores ranged from 6 to 30.the network and their relationships to the patient, World Appl. Sci. J., 19 (5): 625-633, 2012627likert scale separately ranged from 1 to 5, for the eighthRESULTSquestion 1 indicated the minimum frequency of contact.Finallythe last question covered the importantTable 1 shows the socio-demographic and clinicalrelationships recently lost in the patient’s social supportcharacteristics of short and long hospital staynetwork.schizophrenic patients. About two thirds of longMethods:An official approval to carry out the study wasshorthospital stay patients. As regards patients’ ages,obtained from the director of El-Maamoura Hospitalthe age of the total subjects ranges between 17-67 yearsafter explanation of the purpose of the study.with the mean of 34.03 ± 10.235 and 46.95 ± 9.773The socio-demographic and clinical characteristicsrespectively for short and long hospital stay patients.Astructured interview schedule was developed by thestatistical significant difference was found between theresearcher. Norbeck Social Support Questionnaire (NSSQ)two groups where 2 = 42.509. The majority of thewas translated into Arabic language. A jury composed ofpatients were single (72.3%). A high percentage of short4 experts in the psychiatric field examined the contentand long hospital stay patients were completed up tovalidity of the translated tool.secondary school level (26. 6% & 31.1% respectively) asPilotand Reliability Studies: A pilot study was carriedstatistical significant difference between them ( outon 15 patients to assess the clarity and applicability17.051). More than half of the subjects (56.8%) wereof thestudy tool and some modifications were done.unemployed, 75.4% of them from the group of long-The validated tool was tested for its reliability; thehospital stay as compared to 44.75 from the group ofCronbach’s alpha was 0.73. short-hospital stay. A statistical significant difference wasInactual study, the psychiatric wards (4 male and 2found between the two groups ( 2 = 20.752). The majorityfemale wards) were chosen randomly for the study byof long-stays (93.4%) were living in urban as compared tosimple randomization, picked up from 10 psychotic wards62.8%of short stays and there was a statistical significant(six male wards and four female wards). The patients’difference ( 2 = 18.488). records were checked to identify those who fulfilled theConcerning the duration of illness, 56.4% of the shortinclusion criteria, then gained the necessary informationstays and only 4.9% of the long stays had been ill for “10of socio-demographic and clinical data.years or less”, with a total mean of 10.04±7.832 andEthical Consideration:Patients were assured that anysignificantdifference ( 2 = 52.224). Regarding the numberdata will be confidential and their privacy will beof previous hospitalization, patients who were admitted tomaintained. The purpose of the study was explained tohospital five times or more constituted the highestthe patients individually and then oral consent topercentage of the sample (61.9%). The mean score wasparticipate in the study was obtained. 4.38±2.282 and 5.25±2.203 respectively for short and longData Management and Analysis:Data were coded andadmitted to free wards comparing to 72.1% of long staysanalyzed using SPSS version 18. Descriptive analyseswere admitted to private wards, with a statisticalwere conducted to determine the frequency distributionssignificant difference proved between them ( 2 = 34.245).ofthe study variables. Chi-square was used to determineAboutthree quarters of short and long stayswhether significant difference existed between short andreceivedsupport from their social network. The table alsolong stay regarding their source of support. In addition toshows that 51.7% of all subjects were satisfied from theirthiscorrelation analysis was done using person’ssocial support. However, there was no statisticalcorrelation coefficient test to investigate thedifference found between short and long hospital stayrelationships among duration of hospitalization, numberpatients.of supportive persons, frequency of contact and totalTable (2) reveals the distribution of studiedfunctional support properties. The Anova testschizophrenic patients according to their number ofinvestigated the functional properties of social support,supportive persons. Less than one fourth of the studiednumberof supportive persons and frequency of contactsample reported no body in their social network asofshort and long hospital stay patients. The significancesupportive to them. Meanwhile the majority of thelevel was set to or less than P05. patients reported receiving support from one personhospital stay patients were males comparing to 75.5% ofcompared to 26.6 and 4.9% got primary school, witha21.38±7.785 respectively. However, there was a statisticalhospitalstay patients. About 75% of the short stays were World Appl. Sci. J., 19 (5): 625-633, 2012628(62.6%)as compared to only 8.4% of schizophrenicThe table also revealed a positive statistical significantpatients receiving support from two persons in their socialnetwork.Table (3) shows the source of support as perceivedby short and long stay hospitalized schizophrenicpatients.The most supported persons perceived by theshort stay patients were their siblings as they constituted43.1% of the total number of their supportive persons.Next to siblings, fathers who constituted 25% ofsupportive persons. Friends/neighbours constituted16.7% of supportive persons, while relatives constituted13.9%of that population. As regards long stay patients,47.9% of supportive persons were the siblings, next tothem, the relatives (20.8%), then the friends/neighbours(10.4%). A statistical significant difference was foundbetweenthe two groups as related to the supportivefathers and mothers ( 2 = 7.013 and 4.123 respectively).Table (4) shows functional properties of socialsupport, number of supportive persons and frequency ofcontact of short and long hospital stay schizophrenicpatients. In relation to the size of social network, the shortstay hospitalized patients had relatively higher meanscore than long stay (1.42±0.946 and 1.15±0.412respectively).As regards frequency of contact, the shortstay patients received more contact from supportivepersons than long stay, where their mean scores were4.04 ±1.294 and 2.63 ±1.142 respectively. There wasastatistical significant difference between the two group(F= 37.865).Thefunctional properties of social support wereassessed by three dimensions namely affect, affirmationandaid. The short stay patients had higher mean scoresof functional support on the three dimensions of affect,affirmation and aid than long stay patients withastatistical significant difference between them, whereF=5.502, 6.932 and 5.448. Consequently, there wasahighermean score of total functional support of shortstay patients (29.5 ±17.043) with a statistical significantdifference between the two groups, where F=6.320*P=0.013.Table (5) presents the correlation between durationofhospitalization, total functional support properties,number of supportive persons and frequency of contact.Therewas a negative statistical correlation betweenduration of hospital stay and total functional supportproperties and frequency of contact (r=0.159 P o.014,r=0.358P =0.000 respectively). On the other hand,duration of hospital stay was not significantly related tothe number of supportive persons, although there wasatendency for the duration of hospital stay to be inverselycorrelated with the number of supportive persons.correlation between number of supportive persons andtotal functional support properties and frequency ofcontact (r=0.305 P=0.00 r=0.178 P=0.027 respectively). Inaddition, a positive statistical significant correlation wasfound between total functional support properties andfrequency of contact.DISCUSSIONTheprevious researches have demonstrated thatsocial support is a particularly important factor inassisting people with schizophrenia to decrease length ofhospital stay and in turn, reintegrate in the community[14, 18]. Whereas it is the degree to which people withschizophrenia perceive themselves to be supported thatis of crucial importance [12]. So, the present studyfocused on the relationship between perceived socialsupport among short and long hospital stayschizophrenic patients. The present study revealed thataroundone quarter of short and long stay hospitalizedschizophrenic patients reported that they did not receiveany support and the majority of sample received supportfromone person. Meanwhile, the results did suggest thatthestudy population was satisfied with the receivedsupport. This goes with the findings of Cresswelet al.[19] that people with schizophrenia have smaller networks,fewer clusters and more unsupported connectionscompared to non-schizophrenics. It seems that despitesmall networks, the perceived support in this sample ofschizophrenic patients was adequate. Hence, supportfrom one or two close ties may fully compensate for thelack of support from others. Additionally, it may be thatthis population usually found a lower level of supportfromclose relationships more tolerable. This may beaprotectivemechanism, learnt over time so that a personwith schizophrenia avoids engaging in too many stressfulrelationships. Furthermore, a study done by Gigantescoet al. [20] proved that approximately one third ofpsychiatric inpatients had no close relationships or socialsupport.The findings of present study for both short andlong hospital stay indicate that immediate family,mainly siblings, next to them parents, are perceivedas thebest source of support which is congruentwith the literature [11, 21]. However, only a smallproportion of the participants had a spouseorchildren as about three quarters of the studypatients were single. Pilisuk and Parks [22]reported that social network of those withpsychotic illness is around four to five, almost all of themwould be family members. Some researchers proved that World Appl. Sci. J., 19 (5): 625-633, 2012629Table 1: Socio-demographic and Clinical of Short and Long Hospital Stay PatientsLength of hospital stay-------------------------------------------------------------------------------------------------------------------------------------------------------------Short stayLong stayTotalSocio-demographic--------------------------------------------------------------------------------------------------CharacteristicsNo (n=94)%No (n=61)%No (n=155)% SexMale7175.567.272.31.277Female24.52032.827.70.258Age (Years)4.32.642.509*4.922.60.00031.919.727.122.331.125.86.437.718.71.16.63.2Min-Max Mean ± SD34.03 ±10.23546.95 ±9.77339.3 ±11.856Marital StatusSingle6771.373.872.30.128Married13.813.113.50.938Divorced/Widow14.913.114.2Educational LevelIlliterate /Read & write2728.726.227.717.051*Primary26.64.918.10.002Preparatory1010.614.812.3Secondary2526.61928.4University7.42.32113.5OccupationWorking3335.16.623.920.752*Student3.21.90.000Not working44.775.456.8Housewife171117.4ResidenceUrban5962.893.474.818.488*Rural3537.26.625.20.000Clinical Characteristics Duration of Illness (Years)56.44.936.152.224*27.732.829.70.00012.837.722.63.224.611.6Min-Max Mean ± SD10.04 ±7.83221.38 ±7.78514.5 ±9.567Number of current Psychiatric HospitalizationOne1414.96.611.66.531Two13.86.60.163Three1111.713.119Four4.31.63.2Five or more55.372.161.9Min-Max Mean ± SD4.38 ±2.2825.25 ±2.2034.83 ±2.313 WardFree75.51727.956.834.245*Private24.572.16743.20.000No. of supported patientsSupported76.678.712077.40.093Non supported23.421.322.60.761Patients’ satisfaction from the received support Satisfied51.42552.151.70.034 Somewhat satisfied1622.220.821.70.983 Dissatisfied26.427.13226.6*= significant at 0.05 World Appl. Sci. J., 19 (5): 625-633, 2012630Table 2: Distribution of Studied Schizophrenic Patients According to The Number of Their Supportive personsPatients who received support------------------------------------------------------------------------------------------------------Number of supportive persons (size of social network)No (n=155)No support22.6One person62.6Two persons8.4Three persons1.9Four persons3.2Five persons1.3Table 3: Source of support as perceived by short and long stay hospitalized Schizophrenic PatientsLength of hospital stay--------------------------------------------------------------------------------------------------------------------------------------------------------------Short stayLong stayTotal------------------------------------------------------------------------------------------------Source of support +No (n=72)%No (n=48)%No (n=120)% Father6.317.57.013**Mother19.46.314.24.123*Siblings3143.147.90.275Spouse4.24.24.20.000Children2.88.31.871Relatives13.91020.816.71.000Friends/Neighbours1216.710.414.20.925Religious Person2.10.81.513+ multiple responses * = significant at =0.05 ** = Highly significant at =0.01Table 4: Functional and structural properties of social support of short and long hospital stay schizophrenic patients.Length of hospital stay-----------------------------------------------------------------------------------------------------------------------------------Functional and structuralShort stay (n= 72)Long stay (n= 48)Total (n= 120)ANOVAproperties of social supportMean ± SDMean ± SDMean ± SD1- Functional properties of social supportAffect10.02 ±5.7047.77±4.1689.12 ±5.244Affirmation9.56 ±5.8027.03 ±3.9528.55 ±5.2726.932* 0.010Aid9.47 ±6.447.15 ±4.0798.54 ±54485.448* 0.012Total Functional Support29.5 ±17.04326.21 ±15.49326.21 ±15.4936.320* 0.0132- No. of supportive persons1.42 ±0.9461.15 ±0.4121.31 ±0.7863.487 0.0643- Frequency of contact4.04 ±1.2942.63 ±1.1423.48 ±1.41437.865* 0.000*= Significant at 0.05Table 5:Correlation coefficient (r) between duration of hospitalization, number of supportive persons, total functional support properties and frequency ofcontactDuration of hospitalization No. of supportive personsTotal functional support propertiesFrequency of contactDuration of hospitalization- 0.42- 0.159*- 0.358*0.5760.0140.000No. of supportive persons0.305*0.178*0.000Total functional support properties0.216*0.002*= Significant at 0.05 World Appl. Sci. J., 19 (5): 625-633, 2012631Someresearchers proved that most support isFurthermore,the duration of hospitalization hadaperceived in intimate relationships with a partner orsignificant negative correlation with total functionalspouse. However, many people with mental illness lacksupport properties and frequency of contact, this meansSuch a relationship [13, 23]. In controversy to this finding,that short stay hospitalized schizophrenia patientsthestudy of Adegunloys et al. [2] stated that families arehave more support as well as frequent contact.likely to find it increasingly difficult to maintain theirAlso, results showed all dimensions of social supportsupportive role. (affect, affirmation and aid) were significantly positivelyThepresent study findings showed that friendscorrelated with the frequency of contact.This may be/neighbours were perceived more as a source of supportexplained by the fact that the study sample was receivingin short stay schizophrenic patients than long staymore social support due to increase frequency of contactschizophrenic patients. The importance of non-familydespite network was small. These findings suggestedamembers have been highlighted in other studiespowerful argument that despite small network, support[13, 15]. This could be explained in the light of the morefrom one or two close ties can fully compensate for thethe duration of hospitalization increases, the more thelack of support from others. So enhancement of thelinks with the outside community dissolve. Moreover, itbenefits of social support to people with mental illness isis known that the illness characteristics of schizophreniaimportant because people with mental health problems arelike negative symptoms, withdrawal and blunted affectknownto have restricted social networks. Hence, nursescontribute to difficulties in relating socially and thus toshould include an assessment of a person’s socialthereduction of social networks with the other patientsnetwork and social support on a regular basis, such aninside the hospital. Additionally, the stigma of mentalassessment would also contribute to interventionsillnessmay cause the patients’ friends to withdraw fromdesigned to address health status of serious mental illthe network. The present study is consistent with thepatients [15].finding of Holmes-Eber and Stephanie [5]. who haveOne focus of present study has been on socio-looked in more detail at exactly how networkdemographics and clinical characteristics of schizophreniccomposition changes with hospitalization. They foundpatients and their relationships with length of hospitalthat those patients with repeated hospital admissionsstay. More than one third of the long stay patients wereand longhospital stays had networks composedofin the age group of “fifty years and more”. This result isfewerfriends and relatives. In the current study only onenot surprising as older people have been found to staypatient mentioned that he received support from thelonger lengths of hospitalization. This goes with thenursing staff. This is in contrast with the study offinding of Jimeneze et al. [27] who classified age as one ofHolmes-Eber and Stephanie [5] who stated that patientsthefive variables significantly predicting length ofwith repeated hospital admissions have networkshospital stay steadily over time. composed of more mental health and serviceOur findings indicated that unmarried statusprofessionals.is associated with long hospital stay which isMostinvestigators defined social support asaconsistent with results from several previous studiesmultidimensional construct consisting of the provision of[3, 20]. The current results indicated that about threeinformational, emotional and tangible Aid [24, 25]. Socialquarters of the long-hospital stay patients have beensupport has been found to be important in keepingadmitted to private wards. Our finding is consistentmentally ill persons functioning well in the community andwith Gigantesco et al. [20] as they stated thatin reducing the likelihood of recurrence of mental illnessadmission to a private inpatient facility duringsymptoms [15] as well in decreasing the frequency ofhospital stay was the most powerful predictor of longhospitalizations [26].stay.Themain results of this study are that the size of theAs predicted, the results suggested that thesocial network of patients with schizophrenia was smalllength of hospital stay is related to the sourceofwith no significant difference between short and long staysupport, functional properties of social support andhospitalized schizophrenia patients. On the other handthe frequency of contact with the supportivetherewas a significant difference between short and longpersons.stayhospitalized schizophrenia patients and functionalThepresent study has shown the importance ofproperties of social support (affect, affirmation and aid)social support perceived by schizophrenic patients asaand frequency of contact. determinant of length of hospital stay. Also it emphasizes World Appl. Sci. J., 19 (5): 625-633, 2012632that despite small network, support from one or two close4.Bartusch, S., B.R. Brugemmanm, H. Elgeti,ties can fully compensate lack of support from others.Education programs are needed to help schizophrenicpatients to adjust in the community. A longitudinal studydesignedto track patients and their networks over timecould clarify the exact mechanisms by which patients’socialsupport affect and are affected by length ofhospital stay. The findings suggest ways for improving thesocial support available for schizophrenic patients.Firstly, When hospitalization is necessary, both clientand network members should be encouraged to remain incontact with each other throughout. The nurse roleshould include an assessment of a patient’s socialnetwork and social support on a regularly basis.Improving the client’s network building skills throughsocial skills training. This includes strategies to assistclients in improving communication skills, patterns of eyecontact, patterns of physical proximity, posture andgrooming. The nurse should design strategies tostrengthen the linkages between the client’s professionaland personal social networks. This can be achievedthrough family group therapy, where clients’ familiesmeet together for the purpose of sharing informationand gaining social support. Enhance role ofout-patient psychiatric centres / units to play crucialrolein decrease hospitalization among schizophrenicpatients.Limitations of the Study:Assessment of negative andpositive symptoms of schizophrenia could be helpfulbecause it may affect the length of hospital stay and thesocial support available to those patients.REFERENCES1.Thompson, E.E., H.W. Neighbors, C. Munday andS.Trierweiler, 2003. Length of stay, referral to aftercareand rehospitalisation among psychiatricinpatients. Psychiatric Services, 54: 12271-12276. 2.Adegumloye, D.A., A.D. Yussuf, P.O. Ajiboye,B.A.Issa and O.I.N. Buhari, 2009. Correlates ofLengthof stay among psychiatric In-Patients inAtertiaryHealth Institution in Nigeria. ResearchJournal of Medical Sciences, 3: 56-61.3.Stevens, A., K.Hammer and K. Buchkremer, 2001.Astatistical model for length of psychiatricinpatient treatment and an analysisofcontributingfactors. Acta Psychiatrica Scandinavica,103: 203-211.M.Zeigenbein and W. Machleidt, 2007. Hannoverstudyon long-stay hospitalization-part II:characteristicand care conditions of long-stayhospitalizationin cases of chronic mental illness.General Practice and Epidemiology in Mental Health.Availableat: http://www.cpemental health. com/content/3 /1/27. Retrieved on: 11/7/2010.5.Holmes-Eber,P.H. and R. Stephanie, 1990.Hospitalizationand Composition of Mental Patients’Social Networks. Schizophrenia Bulletin, 18: 157-164.6.Buchanan,J., 1995. Social Support andSchizophrenia: A review of the literature. Archives ofPsychiatric Nursing, 9: 68-76.7.Lin,N., M. Woefel and S. light, 1985. The Bufferingeffectsof Social Support subsequent to an importantlife event. Journal of Health and Social Behaviour,26: 247-263.8.McCorkle,B., E.S. Tugers, E.C. Dunn, A. Layas andY.M.Wan, 2008. Increasing social support forindividuals with serious mental illness: Evaluating thecompeer model of intentional friendship. CommunityMental Health Journal, DOI 10.1007/s-008=9137-8. 9.Magliano,L., F. Andrea, M. Claudio, D.R. CorradoandM. Mario, 2006. Social network in long-TermDiseases:A Comparative study in relatives ofpersonswith schizophrenia and physical illnessesversusa Sample from the general population. SocialScience and Medicine, 62: 1392-1402.10.DiMatteo, M.R., 2004. Social Support and Patientadherenceto Medical Treatment: A meta-analysis.Health Psychology, 23: 207-218.11.Sawant, N.S. and K.S. Jethwani, 2010. Understandingfamily functioning and Social Support in unremittingschizophrenia:A study in India. Indian J. Psychiatry,52: 145-149. 12.Chinuman, M.J. R. Eingarten, D. Stayner andL.Davidson, 2001. Chronicity reconsidered:improving person-environment through a consumer-runservice. Community Mental Health Journal, 37:215-29.13.Muller, B., C. Nordt, C. Lauber and W. Rossler, 2007.Changesin Social Network Diversity and perceivedSocialSupport after psychiatric. Hospitalization:Resultsfrom a longitudinal Study. International J.Soc. Psychiatry, 53: 564-575.14.Cechnickim,A. and A. Wojciechowska, 2007.Correlationsbetween features of social network andoutcomesin those suffering from schizophreniaseven years from the first hospitalization. PsychiatricPolicy, 41: 513-525. World Appl. Sci. J., 19 (5): 625-633, 201263315.Huang, C.Y., V.D. Sousa, C.C. Tsai and M.Y. Hwang,22.Pilisuk,M. and S.H. Parks, 1986. The hearing2008.Social support and adaptation of Taiwaneseweb-socialnetworks and human survival. Universityadults with mental illness. Journal of Clinical Nursing,Press of New England. Hanover. New Hampshire. 20: 1795-1802.23.Agerbo,E., M. Byrne, W. Eaton and P. Mortensen,16.Tulloch, A.D., P. Fearon and A.S. David, 2008.2004.Marital and labor market status in the long runThedeterminants and outcomes of long stayinschizophrenia. Archieves of General Psychiatry,psychiatricadmissions. Social Psychiatric61: 28-33.Epidemiology,43: 569-574.24.Calsyn,R.J. and J.P. winter, 2002. Social support,17.Norbeck, J.S., A.M. Lindsey and V.L. Carrieri, 1981.psychiatricsymptoms and housing: a causalThedevelopment of an instrument to measure socialanalysis. Journal of Community Psychology,support. Nursing Research, 30: 264-269.30: 247-259.18.Hiroaki,M., T. Hisateru and T. Tadashi, 2008.25.Giate, L., J.L. Vazquez, C. Bora, J. Ballesteros,Providing support to psychiatric patients living inA. Schene, B. Welcher, G. Thornicroft, T. Becker,thecommunity in Japan: Patient needs and careM.Ruggen and A. Herran, 2002. Quality of life inproviders’perceptions. International Journal ofpatientswith schizophrenia live in EuropeanMental Health Systems, 10: 1752-1771.countries. Acta Psychiatrica Scandinivica,19.Cresswell,C.M., L. Kuipers and M.J. Power, 1992.105: 283-292.Socialnetworks and support in long-term psychiatric26.Cohen, A.N., C.Hammen, R.M. Henry and S.E. Daley,patients. Psychological Medicine, 22: 1019-1026.2004.Effect of stress and social support on20.Gigantesco,A., G. De Girolamo, G. Santone, R. Migliorecurrencein Bipolor disorder. Journal of AffectiveandA. Picardi, 2009. Long-stay in short-stayDisorders, 83: 143-147.inpatientfacilities: risk factors and barriers to27.Jimenez,R.E., R.M. Lam, M. Marot and A. Delgado,discharge.BMC Public Health. Available at:2004.Observed-predicted length of stay for an acutehttp://creativecommons. Retrieved on: 15/5/2010.psychiatricdepartment, as an indicator of patient21.Linda,E.R., 1997. Caring for Caregivers: Perceptionscareinefficiencies. Retrospective case-series study.ofSocial Support.Journal of Psychosocial Nursing,BMCHealth Services Research. Available at:35:17-24.http://www.biomedcentral.com/1472-6963/4/4.Retrieved on: 11/7/2010.