Met and Unmet Needs of Schizophrenia
Patients in a Spanish Sample
by S. Ochoa, J.M. Haro, J. Autonell, A. Pendas, F. Teba, M. Marque?:,
and the NEDES Qroup
Abstract
Deinstitutionalization of people with schizophrenia
increases the importance of evaluating their needs.
This study set out to identify the most common needs
of people with schizophrenia who live in the commu-
nity, analyze how those needs differ when evaluated by
staff or by patients, describe the kind of help patients
receive, and find out the variables that correlate with
having unmet needs. A random sample of 231 outpa-
tients with schizophrenia were evaluated with the
Camberwell Assessment of Need and other predictor
and outcome variables. Staff detected more needs than
patients did. Mean number of needs as rated by
patients was 5.36 and staff 6.6 (p < 0.001). Mean num-
ber of unmet needs was also greater when assessed by
staff than by patients: 1.38 versus 1.82 (p < 0.001). The
most frequently detected needs by patients involved
psychotic symptoms, house upkeep, food, and infor-
mation. Staff most often detected needs involving psy-
chotic symptoms, company, daytime activities, house
upkeep, food, and information. In a multiple regres-
sion model, needs were weakly associated with the
clinical variables and quality of life. Needs assessment
is complementary to clinical evaluation in schizophre-
nia.
Keywords: Schizophrenia, needs assessment, psy-
chopathology, disability, quality of life.
Schizophrenia Bulletin, 29(2):201-210,2003.
The development of a system of comprehensive commu-
nity services and the deinstitutionalization process started
in Barcelona at the beginning of the 1980s. The system
that was created is organized into sectors of around
100,000 inhabitants. Each sector has a mental health care
center (MHCC) that is the central element of the commu-
201
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nity's mental health care. The MHCC has an intense rela-
tionship with primary health care and other psychiatric
services. Besides the MHCC, each sector either has or has
access to a number of psychiatric services, including day
centers, day hospitals, acute inpatient units, and long-stay
inpatient units. Sheltered accommodation and sheltered
work are still uncommon in Barcelona. Community ser-
vices are either public or publicly funded, and all citizens
have access to care. Although services have been much
improved during the past 2 decades, many gaps still exist.
The main duty of public mental health care services in
Spain is caring for the most severely ill, many of them
people with schizophrenia. When treatment plans for peo-
ple with schizophrenia are designed, two complementary
approaches can be taken. First, designers can focus on the
patient's disabilities or handicaps and identify which ser-
vices or elements are most appropriate to help the patient
overcome those limitations. The second, more comprehen-
sive alternative, one more focused toward specific inter-
ventions, involves identifying the patient's needs. Needs
have been defined as "the requirements of individuals to
enable them to achieve, maintain or restore an acceptable
level of social independence or quality of life" (Depart-
ment of Health Social Services Inspectorate 1991). In psy-
chiatry, need is employed to inform service provision and
plan individual care (Slade 1994). Therefore, a more use-
ful definition of need would be "the ability to benefit in
some way from health care" (Stevens and Gabbay 1991).
Need is a dynamic and context-dependent concept (Netten
and Beecham 1993; Slade et al. 1996; Andrew and Hen-
derson 2000).
Send reprint requests to Dr. S. Ochoa, Unitat de Formaci6 i Investigari6,
Sant Joan de Dgu-Serveis Salut Mental, C/ Dr. Pujades, 42, Sant Boi de
Llobregat, Barcelona, Spain; e-mail: susana.ocho@lettera.neL.
Schizophrenia Bulletin, Vol. 29, No. 2, 2003
Before deinstitutionalization, patients with severe
schizophrenia lived in hospitals and most of their basic
needs were met by the institutions. Nowadays in Spain,
with admission to long-stay inpatient units very uncom-
mon, patients live in the community, most of them with
their parents or siblings (Haro et al. 1998). Community ser-
vices, family members, and friends take care of patient
needs. But it is not clear how and to what degree they do it.
Although several instruments have been developed to
evaluate needs (Needs for Care Assessment Schedule
[Brewin and Wing 1987]; Cardinal Needs Schedule [Mar-
shall 1994]), during recent years the most widely used has
been the Camberwell Assessment of Need (CAN) (Phelan
et al. 1995). The CAN allows us to determine patient and
staff perception of needs in 22 areas. It was designed to
inform researchers and mental health professionals in the
assessment of patient service needs.
Different studies published in Europe have identified
various numbers and types of needs. Most studies that use
the CAN have found that patients detect more needs than
staff (Slade et al. 1996, 1998, 1999). In a sample of psy-
chotic outpatients, Slade et al. (1998) found a mean number
of needs of 6.1 per patient when assessed by staff, and 6.7
when assessed by patients. The areas of need more fre-
quently reported by staff were psychotic symptoms, day-
time activities, company, and transport; by patients, they
were psychotic symptoms, transport, daytime activities,
company, and food. In a study from the Netherlands
(Wiersma et al. 1998), the most common needs identified
by patients were psychological distress, intimate relation-
ships, sexual expression, and daytime activities. Using a
sample of schizophrenia outpatients from Nordic countries,
Hansson et al. (2001) reported that staff detected more
needs than patients did. Staff-assessed needs mainly
involved company, psychotic symptoms, and daytime
activities, and patient-assessed needs involved company,
intimate relationships, and psychological distress.
McCrone et al. (2001) found varying numbers of needs
among the cities studied, with Amsterdam having the high-
est level of need and Santander (Spain) the lowest. Some of
these differences in type and number of needs could be
explained by differences in sample selection, because there
was no homogeneity in diagnosis and treatment context
(Thornicroft et al. 1996). Agreement in need detection by
staff and patients is said to be better in areas where there is
a specific service for a concrete need (Slade et al. 1998).
The objectives of our study were to identify the most
common needs of schizophrenia patients who live in the
community, analyze how the needs differ when evaluated
by staff or by patients, describe what kind of help and
whose help people with schizophrenia receive for covering
their needs, and find the sociodemographic, social, and
clinical correlates of the presence of needs.
202
S. Ochoaetal.
Patients and Methods
Two hundred and thirty-one persons with schizophrenia
were randomly selected from a computerized register that
included all patients under treatment in the five mental health
care centers that participated in the study. The register
included personal information (name, address, identification
number, etc.), sociodemographic information (date of birth,
gender, etc.), diagnosis, and the data from and type of visits
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for all patients that had ever been seen at the centers. The
five catchment areas (Cerdanyola, Ciutat Vella, Cornelia,
Gava, El Prat) contain a population of 440,000 adults from
the city of Barcelona and its surroundings and house people
of different sociodemographic backgrounds.
Inclusion criteria were (1) to have a primary diagnosis
of schizophrenia according to DSM-FV criteria, (2) to be
between 18 and 65 years old, (3) to live in the catchment
area, and (4) to have had at least an outpatient visit during
the 6 months prior to the beginning of the study. Patients
with a diagnosis of mental retardation or neurological dis-
order were excluded.
The diagnosis of all the selected individuals was
reviewed by their treating psychiatrist. In case of discrep-
ancy between the treating psychiatrist's diagnosis and the
diagnosis of schizophrenia that was in the register, the case
was evaluated by two psychiatrists to make a final deci-
sion regarding the inclusion of the patient.
Selected individuals were informed by their psychia-
trist about the objectives and methodology of the study
and provided verbal informed consent to participate.
Evaluation
All patients were evaluated with the following instru-
ments:
1. A sociodemographic and clinical questionnaire that
included information on psychiatric history and comor-
bidity
2. The Positive and Negative Syndrome Scale (PANSS),
Spanish version (Kay et al. 1986; Peralta and Cuesta
1994)
3. The Global Assessment of Functioning Scale (GAP),
Spanish version (Endicott et al. 1976; APA 1995)
4. The Disability Assessment Schedule (DAS), short ver-
sion (Sartorius et al. 1986; World Health Organization
1992)
5. The Quality of Life questionnaire (QOL), Spanish ver-
sion (Baker and Intagliata 1982; Bobes et al. 1995)
6. The CAN, Spanish version (Phelan et al. 1995; Rosales
1999; McCrone 2000). The CAN evaluates the presence
of needs in 22 areas: accommodation, food, house
upkeep, self-care, daytime activities, physical health,
Patients in a Spanish Sample Schizophrenia Bulletin, Vol. 29, No. 2, 2003

psychotic symptoms, information, psychological dis- Table 1. Demographic and clinical characteristics
tress, risk to self, risk to others, alcohol, drugs, com- of the sample (n = 231)
pany, intimate relationship, sexual expression, child Characteristic
care, education, telephone, transport, money, and bene-
fits. In each of these areas the CAN determines whether Male, n (%) 147 (63.6)
a need exists, whether it is met, who provides the help Marital status, n (%)
(formal and informal care), and whether the help is Single 154(66.7)
appropriate. The questionnaire is actually two in one
Married 49 (21.2)
because it is evaluated by both the staff members who

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treat the patients and the patients, independently. Divorced 26(11.3)
Widowed 2 (0.9)
The sociodemographic and clinical questionnaire, the Living situation, n (%)
PANSS, the DAS, and the GAP were administered by the Alone 29(12.6)
patient's treating psychiatrist. The CAN and the QOL were With parents 117(50.6)
completed by the center's social worker. All the evaluators
With other family members 15(6.5)
participated in a training course.
With spouse/children 58(25.1)
In residence/sheltered housing 9 (3.9)
Statistical Analysis In other situation 3(1.3)
We first report on descriptive statistics of met and unmet Occupational status, n (%)
needs. Cohen's kappa was calculated to determine the Employed 19(8.2)
agreement between patients and staff when rating the pres- On permanent sick leave 153(66.2)
ence of needs. According to Landis and Koch (1977), a With other occupational status 59 (25.6)
kappa coefficient of 0.4 to 0.6 indicates moderate agree- Age, mean (SD) 39(12.1)
ment, 0.6 to 0.8 indicates substantial agreement, and 0.8 to
Age at onset, mean (SD) 23 (7.4)
1.0 indicates almost perfect agreement. Comparison
between number of needs assessed by patients and staff Note.—SD = standard deviation.
was made with the Wilcoxon matched pairs test.
To determine the association of total number of needs
Patients were more often single, lived with parents, and
and number of unmet needs with the sociodemographic
were not working because they were on permanent sick
and clinical variables, a stepwise multiple linear regres-
leave. Mean age was 39 years, and mean length of illness
sion was used. Sex, age (categorized in three strata), mari-
15 years. The evaluation was completed for 195 patients,
tal status, age of onset, the PANSS, the GAF, the DAS, and
84.4 percent of the total sample. There were no significant
the QOL were included in the models.
differences in any of the sociodemographic variables
To study the influence of sociodemographic and clini-
shown in table 1 between the people who answered the
cal factors on the presence of each need, a logistic regres-
questionnaire and those who did not.
sion analysis was performed. Twenty-two models, one per
Staff detected more needs than patients did. Mean
need as dependent variable, were fitted. Independent pre-
number of needs as rated by patients was 5.36 (standard
dictor variables were gender, marital status, age, age of
deviation [SD] = 2.71), while staff detected a mean of 6.6
onset, length of illness, PANSS subscales, the GAF, the
(SD = 3.17) per patient. These differences are statistically
DAS, and the QOL. Before regression, exploratory analy-
significant (p < 0.001). Mean number of unmet needs was
sis was performed. Variables that showed a relationship
also greater when assessed by staff than by patients: 1.38
with need were entered into the model one by one. Only
(SD = 1.75) versus 1.82 (SD = 1.98) (p < 0.001).
those variables showing statistical significance using max-
imum likelihood estimates were fitted. A final model is The most frequently detected needs by patients
reported. All statistical analyses were calculated with involved psychotic symptoms, house upkeep, food, and
SPSS for Windows 6.0 (Norusis 1993). information (table 2). Staff most often detected needs in
the areas of psychotic symptoms, company, daytime activ-
ities, house upkeep, food, and information (table 2). The
Results main discrepancies arose in company, daytime activities,
psychotic symptoms, and self-care. Physical health, psy-
Table 1 shows the characteristics of the patients included chological distress, and benefits were the only areas in
in the study. Approximately two-thirds of them were male. which patients detected more needs than staff. Unmet need

203
 Table 2. Percentage of patients with need and unmet need as rated by staff and patients, agreement between their ratings, and
percentage of needs detected by only staff or patient
Patients for Patients for Agreement
Patients for whom Agreement whom staff Patients for on the
S'

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Presence Presence whom staff patients on the Presence of Presence of detect more whom patients presence of
of need of need detect more detect more presence of unmet need unmet need unmet needs detect more unmet need
than unmet needs (kappa
rated by rated by needs than needs than need (kappa
value)
rated by
staff (%)
rated by
patient (%) patients (%) than staff (%) value)
I"
staff (%) patient (%) patients (%) staff (%)
£
Accommodation 9.2 8.7 1.1 1.1 0.84 2.1 2.6 0 0.5 0.89 to
vo
Pood 51.8 46.2 7.9 2.6 0.80 3.1 2.1 1.6 0.5 0.59
House upkeep 57.4 50.3 8.9 2.6 0.75 4.1 3.2 1.6 0.5 0.70
Self-care
Daytime activities
27.7
54.9
14.9
35.9
13.2
20.5
0
2.6
0.59
0.53
4.1
29.2
0.5
13.7
3.7
17.4
0
2.1
0.21
0.44
I
Physical health 23.6 28.2 4.2 8.9 0.66 1.5 2.6 0.5 1.6 0.49
Psychotic symptoms 96.4 68.2 27.4 0.5 0.17 13.3 8.4 6.3 1.6 0.59
Information 46.7 42.1 11.1 6.8 0.61 2.1 8 1.6 6.8 0.08
Psychological distress 31.8 33.3 4.7 6.8 0.73 7.2 11.6 1.6 6.3 0.53
Risk to self 13.3 9.2 5.3 1.6 0.64 4.2 4.2 1.6 1.6 0.61

g Risk to others 6.2 5.1 2.1 1.6 0.52 3.6 1.1 2.5 0.5 0.24
0.30
Alcohol 16.4 8.2 7.9 0 0.62 3.1 0.5 2.5 0
Drugs 9.7 2.6 6.8 0 0.39 4.7 1.1 3.2 0 0.39
Companionship 58.5 39.5 18.9 1.1 0.59 38.5 22.8 17.4 2.5 0.53
Intimate relationship 26.2 23.6 5.8 3.2 0.71 17.4 17.3 3.7 3.7 0.71
Sexual expression 14.9 14.4 2.6 1.6 0.77 16.3 13.8 2.5 1.6 0.76
Child care 7.7 4.6 4.2 1.6 0.46 2.6 1.6 1.6 1.1 0.27
Education 22.6 16.9 4.2 1.6 0.80 12 10.1 3.2 1.6 0.75
Telephone 4.6 3.6 1.6 0.5 0.74 3.6 2.1 1.6 0 0.72
Transport 19.0 18.5 2.6 2.1 0.85 5.6 3.7 2.5 0.5 0.65
Money 39.0 37.4 4.7 2.6 0.79 5.6 4.3 2.5 1.1 0.57
Benefits 20.5 22.1 4.7 5.8 0.65 7.6 10.9 2.1 4.2 0.59

9
Patients in a Spanish Sample Schizophrenia Bulletin, Vol. 29, No. 2, 2003

was concentrated in daytime activities, company, and inti-
mate relationship for both staff and patients. Again, staff
detected more unmet needs than patients, but patients
detected more unmet needs in psychological distress,
physical health, information, accommodation, and bene-
fits.
Agreement of rating between patients and staff in
presence of needs was almost perfect (kappa > 0.80) in the
areas of accommodation, food, education, and transport.
The analysis of the discrepancies showed that for
most needs, the percentage of needs or unmet needs
detected by patients but not by staff was low (table 2).
Only for physical health, information, psychological dis-
tress, intimate relationship, and benefits did patients detect
more needs than staff.
The second objective of our study was to know where
patients receive help for covering their needs. Table 3
shows the percentage of people who receive help and who

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Substantial agreement (kappa between 0.6 and 0.8) was
found in money, sexual expression, house upkeep, tele-
phone, intimate relationship, psychological distress, bene-
fits, physical health, risk to self, information, and alcohol.
The areas of moderate agreement were self-care, company,
daytime activities, child care, and risk to others. Finally,
fair agreement was found in drugs and psychotic symp-
toms. The agreement on the presence of unmet needs is
worse, probably partly because of the low frequency of the
presence of unmet needs. Agreement was low (kappa val-
ues lower than 0.4) in self-care, information, risk to others,
alcohol, drugs, and child care.
provides that help. Included are not only people with an
unmet need but people with a nonsevere need. That is why
some patients in this category are not receiving any formal
or informal help. We show the results for only patients
because the results for staff are in general similar; we pre-
fer to show the results for patients because they describe
perceived help. We found that patients receive more infor-
mal than formal help: 75 percent of the people with a met
need are receiving informal help, whereas less than 50 per-
cent are receiving formal help. Many people with unmet
needs also receive formal and informal help (data not
shown), but this help is not sufficient to cover the need.

Table 3. Percentage of informal and formal help received by patients with met needs
Receiving Receiving
Patients, n (%) informal help (%) formal help (%)
Accommodation 11 (5.6) 45 55
Food 86(44.1) 94 10
House upkeep 92 (47.2) 92 5
Self-care 28(14.4) 96 11
Daytime activities 49(25.1) 86 51
Physical health 50 (25.6) 56 70
Psychotic symptoms 117(60.0) 80 94
Information 67 (34.4) 54 87
Psychological distress 43(22.1) 65 84
Risk to self 10(5.1) 60 80
Risk to others 8(4.1) 63 50
Alcohol 15(7.7) 93 80
Drugs 3(1.5) 100 100
Companionship 33(16.9) 76 58
Intimate relationship 15(7.7) 67 20
Sexual expression 6(3.1) 50 17
Child care 6(3.1) 67 33
Education 20(10.3) 75 35
Telephone 3(1.5) 100 0
Transport 29 (14.9) 55 34
Money 65 (33.3) 95 3
Benefits 21 (10.8) 90 90

205
Schizophrenia Bulletin, Vol. 29, No. 2, 2003
When analyzing whether people with met needs receive
more help than people with unmet needs, we found that
people with met needs tend to receive more help than peo-
ple with unmet needs. Patients with met needs in daytime
activities, information, and intimate relationship receive
more informal help and people with met needs in informa-
tion, company, and social benefits receive more formal
help than people with unmet needs in those categories (all
p values below 0.05 or 0.01).
Multiple linear regression was used to determine the
association between the sociodemographic and clinical
variables and total number of needs and unmet needs. Four
different models were created, two for staff-determined
needs (met and unmet) and two for patient-determined
needs. None of the sociodemographic factors was associ-
ated with number of needs. In general, needs were weakly
associated with the clinical correlates and QOL (R2 lower
than 0.3 in all models). Correlates of number of needs dif-
fer between staff and patients, with patients giving more
weight to disability and QOL and staff to severity of
symptoms (table 4).
Twenty-two multiple logistic regression models were
created to determine the influence of sociodemographic,
clinical, and social variables on the presence or absence of
each need (table 5). Men have more problems in the areas
of food and house upkeep and women in the areas of trans-
port and benefits. Marital status has a significant role in
only daytime activities for unmarried people. Younger
people have more problems in the areas of house upkeep
and daytime activities and older people in accommoda-
tion. People with a longer duration of illness have more
problems in psychotic symptoms and risk to others, but
less in transport. Psychopathology is associated with pres-
ence of need in psychological distress, risk to others, risk
to self, education, telephone, and money. A worse GAF
score is related to the presence of need in food, house
upkeep, and daytime activities and with absence of need in
psychotic symptoms. Worse QOL is related to the pres-
Table 4. Influence of severity of symptoms, disability, and quality of life on total number of needs and
unmet needs
Number of Needs
Patient Staff
PANSS 0.04(0.01, 0.08) 0.05 (0.01,0.09)
GAF — -0.06 (-0.09, -0.02)
DAS (global) 0.11 (0.01, 0.21) — —
QOL — —
2
fl 0.11 0.25
Note.—DAS = Disability Assessment Schedule; GAF = Global Assessment of Functioning Scale; PANSS = Positive and Negative Syn-
drome Scale; QOL = Quality of Life questionnaire. Numbers shown are coefficients in a linear regression analysis.
206
S. Ochoa et al.
ence of need in accommodation, company, intimate rela-
tionship, daytime activities, and sexual expression.
Discussion
We have found that people with schizophrenia who live in
the community in Barcelona have a mean number of needs
around 6, with one-quarter of those needs unmet. These
figures are similar to those found in England and in Nordic
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countries (Slade et al. 1998; Hansson et al. 2001) using the
CAN interview but higher than the numbers found in Italy
(Lasalvia et al. 2000). In a European study (McCrone et al.
2001), the number of needs found in Santander (Spanish
area) is about 5. In analyzing the differences, we need to
take into account that two of the studies (Slade et al. 1998;
Lasalvia et al. 2000) included patients with psychosis
other than schizophrenia. However, the CAN is more an
inventory of needs than a questionnaire for which we can
obtain a global rating. Although the total number of needs
and unmet needs seem to be useful measures because they
indicate the amount of service requirements, the hetero-
geneity of the needs contained in the questionnaire implies
that analysis should be focused on each individual need.
Most of the needs patients have are met. In the cases
where the need is unmet, more than half of the people are
receiving some kind of help (informal or formal). Why
then do these patients who are receiving help still have an
unmet need? It could be because services or informal care-
givers do not provide enough help to overcome the need or
the patients are not willing to receive all the help that is
available. Another possible reason why help might not
change an unmet into a met need is that the need is
unmeetable, irrespective of help given. The characteristics
of the CAN do not allow us to differentiate between the
options.
The most frequent need that we have found is in the
area of psychotic symptoms, which makes sense because
we have studied the situation of outpatients with schizo-
Number of Unmet Needs
Patient Staff
— 0.03(0.01, 0.06)
— —
0.11 (0.04, 0.18)
-0.044 (-0.02, -0.06) —
0.10 0.15
 Table 5. Multiple logistic regression: Presence or absence of each need as assessed by the patient as a function of sociodemo- 2?
graphic, clinical, and functioning predictor variables |
5?

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Gender Marital Length of General Negative Positive 5
status Age illness PANSS PANSS PANSS GAF DAS QOL £
Accommodation 0.46*** 0.95* 1
Food 1.70*** 0.95**** |
House upkeep 1.61** 1.43* 0.95*** I
Self-care 1.20*** «
Daytime activities 0.60* 0.55**** 0.97* 0.97*
Physical health
Psychotic symptoms 0.97* 1.03*
Information
Psychological distress 1.02*
Risk to self 1.06**
Risk to others 0.90* 1.03*
Alcohol
Drugs
to Companionship 0.97*
O
Intimate relationship 0.97*
Sexual expression 0.96*
Child care
Education 1.04*
Telephone 1.11*
Transport 0.57** 1.04* ^
Money 1.05*** j |
Benefits 0.65*
|
Note.—DAS = Disability Assessment Schedule; GAF = Global Assessment of Functioning Scale; PANSS = Positive and Negative Syndrome Scale; QOL = Quality of Life question-
naire. Numbers shown are coefficients of the model.
* p < 0.05; ** p < 0 . 0 1 ; ' " p< 0.005; **** p < 0.001
Schizophrenia Bulletin, Vol. 29, No. 2, 2003
phrenia. Besides psychotic symptoms, the most common
needs found are food, house upkeep, daytime activities,
and company. This is in accordance with the work of other
investigators, who reported that company, daytime activi-
ties, and psychotic symptoms were the most common
needs (Hansson et al. 1995, 2001; Wiersma et al. 1998).
However, these other studies have also detected psycho-
logical distress, physical health, and information to be
common needs. Other Spanish studies also found psy-
chotic symptoms, daytime activities, and company to be
the most common needs (Rosales 1999; McCrone et al.
2001).
In spite of the development of psychiatric community
services, patients receive more informal than formal help.
Except for the areas where clinical treatment and outpa-
tient services directed to them are very clearly identified
(psychotic symptoms, physical health, information, risk to
self, accommodation, and psychological distress), infor-
mal help is more common than formal help. The deinstitu-
tionalization process relies more on support given by the
family and the social network of the patient than on sup-
port from the health services (Denker and Denker 1994).
Formal care services (both mental health care and social
services) have a low impact on needs related to basic
activities of daily living and social and family relations.
Patients may rely on their family and social networks to
cover their deficits in these areas. Maybe that is why these
areas are highly correlated with family burden (Magliano
et al. 2000). Mental and social services should address
these necessities if family QOL is to be improved.
We have found that many people with needs and
unmet needs do not receive help from formal services. The
first interpretation we have made is that services are not
appropriate to cover these needs, but it could also be true
that services are offered to patients but that patients choose
not to receive that help. This, however, would also mean
that services are not tailored enough to patients' prefer-
ences, because people who could benefit from them prefer
not to use them.
Number of needs and the presence of each need are
weakly related to the sociodemographic and clinical vari-
ables. People with more severe clinical symptoms and
higher disability have more unmet needs. In accordance
with Slade et al. (1999), patients with a worse QOL have
more unmet needs. However, clinical symptoms, global
functioning, QOL, and disability as assessed by the
PANSS, the GAF, the QOL, and the DAS predict only
between 10 and 25 percent of the variance of number of
needs. Measurement variance probably has a low influ-
ence on this finding: correlation coefficients between the
PANSS, the GAF, and the DAS are high (p < 0.001). When
evaluating needs we are assessing something that is only
partially related to the clinical status and disability of the
208
S. Ochoa et al.
patient. This finding reinforces the need to specifically
evaluate patient needs, because to limit the evaluation to
functioning, disability, or clinical variables is clearly
insufficient when deciding the services a patient may
require.
Staff detect more needs than patients do. Agreement
between them was generally fair when evaluating the
presence of needs and substantially lower in the evalua-
tion of unmet needs. Slade et al. (1998) suggested that
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agreement is better when there is a service that covers
that particular need. Our findings do not support this
hypothesis. For example, although a specific service
addresses problems with use of drugs or psychotic symp-
toms, agreement between staff and patient detection of
needs was not good. Awareness of illness and negative
and cognitive symptoms may be causing this discrep-
ancy. Although administration of the CAN to both
patients and staff provides the most comprehensive eval-
uation, it is also time-consuming. Taking into account the
agreement between staff and patients, and the fact that
staff detect more needs, the CAN may not need to be
administered to both of them; administration to staff only
can be sufficient. In this case, the patient should evaluate
his or her needs in physical health, psychological dis-
tress, and benefits because these are the areas where
patients detected more needs than staff. With this short-
ened administration one could save time and make the
instrument more appropriate for day-to-day practice.
When interpreting the results of the study, we need to
take into account that our sample is representative of the
patients that receive outpatient treatment for schizophrenia
in the public sector. We have not included in the study peo-
ple who are not receiving treatment, people who are
receiving it in only the private sector, and patients who are
living in long-stay units (who should have a higher num-
ber of needs). To be informed about the representativeness
of the sample, we should consider that the 6-month treat-
ment prevalence for schizophrenia in the MHCCs included
in the study was 0.28 percent (a total of 1,223 patients in a
catchment area that included 439,300 adults), which is
similar to the figures in other countries (Thornicroft et al.
1993).
The analysis of the needs of the patients has use not
only to design treatment plans for individual patients but
also to study the limitations of mental health care services.
Many questions remain unanswered regarding how needs
are covered by formal services and informal help and how
this treatment or help influences the course and the pres-
ence of needs. Because the study we present has a cross-
sectional design, the findings can be interpreted as only
correlations between variables, and no causal inferences
should be made. Only followup studies with representative
samples of patients will be able to clarify this issue.
Patients in a Spanish Sample
The study has several clinical implications:
1. The evaluation of needs and unmet needs is necessary
and complementary to clinical evaluation when design-
ing treatment plans for people with schizophrenia.
2. People with schizophrenia receive more informal than
formal care to cover their needs.
3. For most of the needs, staff evaluation may be suffi-
cient, but for some needs patient participation in the
evaluation is required.
There are also several limitations to the study:
1. The cross-sectional design of the study determines that
no causal relationship can be established from the find-
ings.
2. The CAN is more an inventory of needs than an instru-
ment to measure overall level of need.
3. We studied only patients who had been in outpatient
care.
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Acknowledgments
This project has received the financial help of the Spanish
Fondo de Investigaciones Sanitarias (FIS 97/1275) and an
unrestricted educational grant from Eli Lilly and Co.
(ESQ00196).
The Authors
S. Ochoa, M.D., is Psychologist, Sant Joan de D6u-
SSM, Sant Boi, Spain. J.M. Haro, M.D., Ph.D., is Psy-
chiatrist, Sant Joan de D6u-SSM, Sant Boi, Spain. J.
Autonell, M.D., is Psychiatrist, Sant Joan de Deu-SSM,
Sant Boi, Spain. A. Pendas, M.D., is at Sant Joan de
Deu-SSM, Cerdanyola, Spain. F. Teba, M.D., is at Sant
Joan de D6u-SSM, Gava, Spain. M. Marquez, M.D.,
Ph.D., is at Sant Joan de Deu-SSM, Cerdanyola, Spain.
The NEDES group is a multidisciplinary group of
researchers that includes S. Araya, P. Asensio, J.
Autonell, A. Benito, E. Busquets, C. Carmona, P.
Casacuberta, M. Castro, N. Diaz, M. Dolz, A. Foix, J.M.
Giralt, A. Gost, J.M. Haro, M. Marquez, F. Martinez, R.
Martinez, J. Miguel, M.C. Negredo, S. Ochoa, Y. Oso-
rio, E. Paniego, L. Pantinat, A. Pendas, C. Pujol, J.
Quilez, J. Ramon, M.J. Rodriguez, B. Sanchez, A. Soler,
F. Teba, N. Tous, J. Usall, M. Valdelomar, J. Vaquer, E.
Vicens, and M. Zamora.