Determinants of quality of life in first-episode psychosis

Subjective quality of life among first-episode psychosis patients in Chennai, India and Montreal, Canada

Differences in subjective quality of life among persons receiving early intervention for psychosis in varying geo-sociocultural contexts have rarely been examined. Our prospective longitudinal study compared the quality of life of persons with first-episode psychosis receiving two years of similar early intervention in Chennai, India and Montreal, Canada. We hypothesized that general life satisfaction would be higher in Chennai compared to Montreal, and that social relations (a specific quality of life component) would also be higher in Chennai and positively contribute to general life satisfaction. Participants completed the general satisfaction and social relations domains of the Wisconsin Quality of Life Index at baseline, months 12 and 24. Baseline weighted mean general satisfaction and social relations scores were in the low to moderate range. Generalized estimating equation analyses showed that general satisfaction scores increased with time [Wald χ² (1) = 125.28, p < 0.001] and were higher in Chennai than in Montreal [Wald χ² (1) = 7.50, p = 0.006]. Social relations scores showed the highest association with general satisfaction scores (B = 0.52), followed by positive symptom remission (B = 0.24) and gender (B = 0.18) with Chennai males having the highest general satisfaction scores. Social relations weighted mean scores increased with time [Wald χ² (1) = 87.30, p < 0.001] and were positively associated with years of education [Wald χ² (1) = 4.76, p = 0.029] and early negative symptom remission [Wald χ² (1) = 7.38, p = 0.007]. Our results suggest that subjective quality of life may improve following early intervention for psychosis across contexts. Our findings advance knowledge about the role of sociocultural (e.g., gender) and clinical factors in influencing subjective outcomes in psychosis, and point to social support networks and symptom remission as avenues to boost quality of life.

Relationship of subjective quality of life with symptomatology, neurocognition and psychosocial functioning in first-episode psychosis: a structural equation modelling approach

Subjective quality of life (SQoL) represents an important outcome of psychotic disorders. However, determinants of SQoL and their complex inter-relationships in the early course of illness remain to be clarified. Association between neurocognitive impairment and SQoL in first-episode psychosis (FEP) is understudied. This study employed structural equation modeling (SEM) to examine relationships among SQoL, depressive, positive and negative symptoms, neurocognition, and psychosocial functioning in FEP patients. Three hundred and forty-seven patients aged 25-55 years presenting with FEP to early intervention program in Hong Kong were recruited. Assessment encompassing symptom profiles, psychosocial functioning and a battery of neurocognitive tests were conducted. SF-12 mental component summary scores were computed as the primary measure of SQoL. Our correlation analyses revealed differential relationships between negative symptom subdomains and SQoL, with amotivation, but not diminished expression, being related to SQoL. Final SEM model yielded a good model fit (comparative fix index = 0.94; root mean square error of approximation = 0.05; standardized root mean square residuals = 0.07) and demonstrated that depression, positive symptoms and psychosocial functioning were directly associated with SQoL, with depression showing the strongest effect. Amotivation, neurocognition and positive symptoms had an indirect effect on SQoL via the mediation of psychosocial functioning. This study affirms depression as a critical determinant of subjective mental wellbeing, and underscores an intermediary role of psychosocial functioning in linking amotivation, neurocognitive impairment and positive symptoms to SQoL in FEP patients. Depression and functional impairment thus constitute as crucial therapeutic targets for improvement of SQoL in the early illness stage.

Quality of life in first episode psychosis: a cluster analytic approach

PURPOSE

Quality of life is increasingly recognised as an important outcome for young people with first episode psychosis (FEP). The first aim was to determine whether distinct homogenous subgroups of young people with FEP could be delineated based on profiles on quality of life domains (Physical Health, Psychological, Social relationships and Environmental). The second aim was to examine the discriminant validity of these subgroups with respect to demographic, functioning and clinical features of FEP.

METHOD

Quality of life, demographic characteristics, clinical characteristics, cognition and functioning were assessed in 145 people with FEP. Cluster analysis using Ward's methods and Squared Euclidean Distance with a k-means verification were employed to identify subgroups with homogenous quality of life profiles. The clusters were externally validated using multinomial logistic regressions.

RESULTS

Three distinct quality of life profiles were identified: one with good quality of life across all domains (30%), one with poor quality of life particularly in Psychological and Social relationships domains (28%), and one 'intermediate' group with comparatively low Psychological quality of life (42%). Depression, semantic verbal fluency, social inclusion and social/occupational functioning showed associations with group membership.

CONCLUSION

Our results suggest the potential of maintaining relatively good quality of life despite the experience of FEP. Future research on interventions to improve quality of life may consider the potential of addressing depression, social inclusion and social/occupational functioning.

Patterns and predictors of trajectories for subjective quality of life in patients with early psychosis: Three-year follow-up of the randomized controlled trial on extended early intervention

OBJECTIVE

Subjective quality of life is an important outcome of psychotic disorders. However, longitudinal course of subjective quality of life in the early illness stage is under-studied. We aimed to investigate the patterns and baseline predictors of subjective quality of life trajectories over 3 years in early psychosis patients, utilizing growth mixing modeling analysis, in the context of a 3-year follow-up of a randomized controlled trial comparing 1-year extension of early intervention with step-down psychiatric care for first-episode psychosis.

METHOD

One hundred sixty Chinese patients were recruited from specialized early intervention program for first-episode psychosis in Hong Kong after they had completed this 2-year early intervention service, and underwent 1-year randomized controlled trial as well as 2-year post-randomized controlled trial follow-up (i.e. 3-year follow-up). Assessments on premorbid adjustment, onset profile, psychopathology, functioning and treatment characteristics were conducted. Individual class membership of subjective quality of life trajectory derived from growth mixing modeling was based on the 36-Item Short Form Health Survey mental component summary scores measured at four different time-points (baseline, 1, 2 and 3 years) among 142 participants across 3-year follow-up.

RESULTS

Three distinct subjective quality of life trajectories were identified including higher-improving (68.3%, n = 97), lower-stable (24.6%, n = 35) and deteriorating (7%, n = 10) trajectories. Age of onset; duration of untreated psychosis; depressive, positive and negative symptoms; and intervention condition were significantly different between good (higher-improving trajectory) and poor (combined lower-stable and deteriorating trajectories) trajectory groups. Multiple regression analysis revealed that younger age of onset, more severe depression and receipt of step-down care independently predicted poor subjective quality of life trajectory.

CONCLUSION

Approximately one-third of patients displayed poor subjective quality of life trajectory in the early phase of psychotic illness. Our results affirm depression as a critical determinant of prospective subjective quality of life and underscores positive effect of extended early intervention on sustained subjective quality of life improvement. Further longitudinal research is warranted to facilitate better characterization of subjective quality of life course patterns and development of targeted intervention to optimize subjective quality of life in patients with early psychosis.

The interplay between functioning problems and symptoms in first episode of psychosis: An approach from network analysis

The relationship between psychotic symptoms and global measures of functioning has been widely studied. No previous study has assessed so far the interplay between specific clinical symptoms and particular areas of functioning in first-episode psychosis (FEP) using network analysis methods. A total of 191 patients with FEP (age 24.45 ± 6.28 years, 64.9% male) participating in an observational and longitudinal study (AGES-CM) comprised the study sample. Functioning problems were assessed with the WHO Disability Assessment Schedule (WHODAS), whereas the Positive and Negative Syndrome Scale (PANSS) was used to assess symptom severity. Network analysis were conducted with the aim of analysing the patterns of relationships between the different dimensions of functioning and PANSS symptoms and factors at baseline. According to our results, the most important nodes were "conceptual disorganization", "emotional withdrawal", "lack of spontaneity and flow of conversation", "delusions", "unusual thought content", "dealing with strangers" and "poor rapport". Our findings suggest that these symptoms and functioning dimensions should be prioritized in the clinical assessment and management of patients with FEP. These areas may also become targets of future early intervention strategies, so as to improve quality of life in this population.

Relationships Between Depressive Symptoms, Other Psychological Symptoms, and Quality of Life

Depressive disorders are common, heterogeneous conditions involving physical and psychological symptoms, and substantial impairment in quality of life (QoL). However, relationships between depressive symptoms and QoL are poorly understood, and little research has directly compared relationships between subtypes of depressive symptoms, other psychological symptoms and QoL. This research aimed to examine how symptoms of depression and other mental health conditions are related to QoL. Participants (N=559) completed the World Health Organization Quality of Life - BREF questionnaire, demographic information, the Brief Symptom Inventory, the Beck Depression Inventory II, and the Depression, Anxiety and Stress Scales. Relationships between psychological symptoms and QoL were assessed using correlations and linear multiple regressions. QoL was inversely related to all types of psychopathology. Depressive symptoms were the strongest predictors of lower overall QoL. Both somatic and psychological depressive symptoms negatively predicted QoL, with somatic symptoms being stronger predictors. Conclusions: While many types of psychological symptoms were negatively correlated with QoL, depressive symptoms, particularly somatic symptoms, were the strongest predictors of impaired QoL. These findings provide new information about specific relationships between symptom profiles and QoL which may lead to greater understanding of the underlying mechanisms and to improved interventions.

Measuring quality of life in first-episode psychosis

Quality of life (QoL) measures are increasingly recognized as necessary parts of outcome assessments in psychosis. The present paper is a comprehensive study of patients with first-episode psychosis where QoL is measured by the commonly used Lehman Quality of Life Interview (L-QoLI). The aim is to examine if the L-QoLI maintain its original structure when used in a group of patients with first-episode psychosis, and to investigate what determines global subjective QoL with a specific emphasis on premorbid adjustment, duration of untreated psychosis (DUP) and clinical symptoms. The study indicates that the psychometric properties of the L-QoLI do not change significantly when used in first-episode samples. The patients report subjective and objective QoL in the fair to good range, with only a moderate association between the objective and subjective measures. Poor global satisfaction is predicted by being single, abusing drugs, being depressed, having a diagnosis of psychotic affective disorder, having poor premorbid social adjustment and DUP over 10 weeks. The study supports the notion that patients with first-episode psychosis construct QoL in the same way as other groups, and that longer durations of compromised function at this stage produces poor satisfaction with life rather than a downward readjustment of expectations.

A meta-analysis of factors associated with quality of life in first episode psychosis

OBJECTIVE

Improving quality of life for people with first episode psychosis is an important aspect of recovery. Our objective was to review the associative factors on quality of life in first episode psychosis. A meta-analysis was conducted on the associations between quality of life, symptom severity, and duration of untreated psychosis.

METHOD

Fifty-one articles were identified (published through 08/29/2016) that provided data on the relationship between quality of life and at least one other outcome measure of interest in first episode psychosis. Of those studies, 21 were included in a meta-analysis (n = 3992) of the relationship between quality of life, severity of psychosis, and duration of untreated psychosis.

RESULTS

Meta-analysis identified significant negative correlations between quality of life and severity of symptoms (total symptom scores: r = -0.32, p < 0.001) and quality of life and duration of untreated psychosis (r = -0.21, p < 0.001). Heinrich's quality of life scale emerged as being more sensitive to the presence of psychotic symptoms than other measures of quality of life.

CONCLUSIONS

Associations were found between certain disease specific variables and quality of life in first episode psychosis, highlighting the relationship between symptom presentation and quality of life and the need for early intervention. Proper assessment of quality of life is important to promote improved quality of life in patients with first episode psychosis. Future research is needed to examine the interacting effects of symptom presentation, duration of untreated psychosis, and other variables, such as neurocognition, on quality of life.

Schizophrenia and dissociation: Its relation with severity, self-esteem and awareness of illness

This article describes the conclusions of an investigation done with 120 Spanish patients: the finding of a new psychopathological profile within a subgroup of patients suffering from schizophrenia. The patients were evaluated through different questionnaires about sociodemographic data, traumatic events, the severity index (both clinical and psychopathological), self-esteem and consciousness of the illness. From the scores obtained on a scale of dissociative experiences, they were classified into two groups: high dissociative symptomatology or HD, and low dissociative symptomatology or LD. The HD group contained 44 patients (36.7% of the total population). The groups LD and HD show meaningful differences with respect to dissociative symptomatology levels, general psychopathology and level of traumatic events suffered. The percentage of patients with low self-esteem was higher in group HD than in group LD (M=25.52 front 28.76 of group LD; t (118)=2.94, p=.00). In addition, the group HD was more conscious of having a mental disorder, of the beneficial effects of medication and of the social consequences of their illness: F (1)=10.929, p=.001; ƞ2pt=0.083; 1-β=0.907. The results show the existence of a subgroup of schizophrenic patients with higher levels of dissociation and trauma that were related with higher levels of symptomatology, lower self-esteem and higher consciousness of the illness, building a population of higher severity in which it would make sense to implement coadjutant treatments specifically oriented to these variables and, in addition, opening a therapeutic possibility for the patients with refractory schizophrenia.

Subjective and objective quality of life at first presentation with psychosis

AIM

Quality of life (QOL) in first-episode psychosis (FEP) is impaired when compared to non-clinical controls and several clinical factors including symptoms and untreated psychosis have been linked with poorer QOL. Measurement methods are varied, however, resulting in inconsistent findings and there is a need to simultaneously combine subjective and objective measures of QOL.

METHODS

We examined both subjective (n = 128) and objective QOL (n = 178) in a catchment area cohort of individuals with FEP (n = 222) to determine correspondence between patient satisfaction and clinician-rated functional domains. We also examined the contribution of sociodemographic and clinical characteristics to both subjective and objective QOL.

RESULTS

There were complex relationships between subjective and objective QOL domains in that patient's assessments of health status (psychological well-being, symptoms/outlook, physical health) were not correlated with clinicians but there were strong correlations between social functioning domains (occupation, social relations, financial status and activities of daily living) assessed by patients and clinicians. Longer duration of untreated psychosis, being treated as an inpatient, higher positive symptoms and poorer social functioning in client-rated QOL domains predicted poorer objective QOL.

CONCLUSION

We found that both subjective and objective assessments of QOL displayed a degree of clinical utility demonstrated by relationships between clinical factors and both QOL perspectives. Moreover, the lack of association between patient characteristics and QOL shows some potential malleability of QOL outcomes through intervention as there were several clinical factors linked with both subjective and objective QOL.

Predictors of change in social networks, support and satisfaction following a first episode psychosis: A cohort study

BACKGROUND

Diminished social networks are common in psychosis but few studies have measured these comprehensively and prospectively to determine how networks and support evolve during the early phase. There is little information regarding perceived support in the early phase of illness. The aim of this study was to describe social support, networks and perceived satisfaction, explore the clinical correlates of these outcomes and examine whether phases of untreated psychosis are linked with social network variables to determine potential opportunities for intervention.

METHODS

During the study period, we assessed 222 people with first-episode psychosis at entry into treatment using valid and reliable measures of diagnosis, positive and negative symptoms, periods of untreated psychosis and prodrome and premorbid adjustment. For follow-up we contacted participants to conduct a second assessment (n=158). There were 97 people who participated which represented 61% of those eligible. Social network and support information obtained at both time points included the number of friends, self-reported satisfaction with support and social network size and clinician's evaluation of the degree of support received through networks. Mixed effects modelling determined the contribution of potential explanatory variables to social support measured.

RESULTS

A number of clinical variables were linked with social networks, support and perceived support and satisfaction. The size of networks did not change over time but those with no friends and duration of untreated psychosis was significantly longer for those with no friends at entry into treatment (n=129, Median=24.5mths, IQR=7.25-69.25; Mann-Whitney U=11.78, p=0.008). Social support at baseline and at one year was predicted by homelessness (t=-2.98, p=0.001, CI -4.74 to -1.21), duration of untreated psychosis (t=-0.86, p=0.031, CI -1.65 to -0.08) and premorbid adjustment (t=-2.26, p=0.017, CI -4.11 to -0.42). Social support improved over time but the duration of untreated psychosis was not linked with the rate of improvement in this outcome.

CONCLUSIONS

Improved social support could indicate greater reliance on social support or becoming more adept at mobilising resources to meet social needs. Particularly vulnerable groups with very long duration of untreated psychosis confirm the need for earlier intervention or targeted social network interventions to preserve social connectedness.

The associations between quality of life and clinical symptoms in individuals with an at-risk mental state and first-episode psychosis

Quality of life (QOL) is strongly associated with severity of clinical symptoms and is often compromised in patients with chronic or first-episode psychosis (FEP). However, it remains unclear whether baseline QOL in individuals with an at-risk mental state (ARMS) for psychosis is higher or lower than that in patients with FEP, or what specific clinical symptoms relate to a decreased QOL in individuals with ARMS and FEP. The World Health Organization's WHOQOL-BREF, an instrument assessing QOL, was administered to 104 individuals with ARMS and 53 with FEP. Clinical symptoms were assessed by the Positive and Negative Syndrome Scale and the Beck Depression Inventory-II. We compared the four domain scores of the WHOQOL-BREF between the two groups, and calculated Pearson correlations between each WHOQOL-BREF domain score and the clinical symptoms and compared these correlations between the groups. We observed significant correlations between poor QOL and severity of depressive symptoms in both the FEP and ARMS group. No between-group differences were found in any correlation coefficients between WHOQOL-BREF domains and clinical symptoms. Thus, depressive symptoms should be investigated as a key factor relating to poor QOL in both individuals with ARMS and those with FEP.

Clinical and treatment-related determinants of subjective quality of life in patients with first-episode psychosis

Subjective quality of life (SQoL) has been increasingly studied in first-episode psychosis (FEP). Prior research primarily examined the impact of psychiatric symptoms on SQoL. Relationship between treatment-related factors and SQoL is under-studied. In this study, 159 Chinese patients who had completed 2-year treatment from early intervention service in Hong Kong were recruited. Assessments on premorbid adjustment, clinical profiles including social anxiety measure, functioning, antipsychotic-induced extrapyramidal side-effects and attitude toward medication treatment were conducted. SQoL was evaluated by Chinese version SF36 which generated mental and physical component summary (MCS and PCS) scores for analysis. Our results showed that more severe positive symptoms, higher level of depression, greater social anxiety, more negative attitude toward antipsychotic medications and greater degree of akathisia independently predicted lower MCS score. Higher social anxiety level and poorer functioning predicted lower PCS score. Our results indicate that affective and positive symptoms, functioning, and treatment-related variables are critical determinants of SQoL in FEP patients. These identified factors thus represent potentially malleable therapeutic targets for early detection and prompt intervention to promote enhancement of SQoL in the early stage of illness.

Associations of Quality of Life with Service Satisfaction in Psychotic Patients: A Meta-Analysis

BACKGROUND

Quality of life (QoL) has gained increasing attention as a desired outcome of psychosocial treatments targeting psychotic patients. Yet, the relationship between the patients' satisfaction with services and QoL has not been clearly established, perhaps due to the multidimensionality of the QoL concept and the variability in its assessment.

AIM

This is the first systematic meta-analysis of all available evidence assessing the relationship between QoL and service satisfaction.

METHODS

In all, 19 studies reporting data of 21 independent samples (N = 5,337) were included in the present meta-analysis. In moderator analyses, effects of age, sex, diagnoses (schizophrenia vs. other psychoses), treatment context (inpatients vs. outpatients), study design (cross-sectional vs. longitudinal), and QoL domain (subjective vs. health-related) were examined.

RESULTS

Analyses revealed a highly significant medium-sized effect (r = .30, p < .001) for the associations of QoL and service satisfaction. Effect sizes were significantly stronger for subjective than health-related quality of life (r = .35 vs. r = .14, respectively). Moreover, associations with subjective QoL remained largely robust when accounting for moderating variables, although there was a trend of stronger associations for outpatients compared to inpatients. In contrast, effect sizes for health-related QoL were small and only observable for samples with longitudinal designs.

CONCLUSION

Associations between QoL and service satisfaction appear to be robust but are differentiated in regard to QoL domain. Our findings suggest that agents responsible for service design and implementation need to take the patients' perception of the service adequacy for achieving QoL enhancement into account.

Subjective quality of life in At-Risk Mental State for psychosis patients: relationship with symptom severity and functional impairment

AIMS

The understanding of factors related to poor subjective quality of life (sQoL) in early psychosis patients is important for both research and treatment efforts. This study examined how sQoL is associated with age at onset of prodromal symptoms, duration of untreated illness (DUI), symptom severity, premorbid functioning and current functional impairment in At-Risk Mental State (ARMS) for psychosis patients.

METHODS

Forty ARMS patients were assessed for sQoL, symptom severity, premorbid functioning, and social and role functioning.

RESULTS

As expected, a large number of significant and negative correlations between sQoL domains and several symptom dimensions emerged, especially for negative symptoms, behavioural change and depression. Poor premorbid functioning in late adolescence was associated with impairments in the psychological health and social relationship domains of sQoL. Current functional impairment was associated with all sQoL domains. Neither age at onset of prodromal symptoms nor DUI was related with sQoL.

CONCLUSIONS

Findings indicate that different domains of sQoL are differentially and meaningfully associated with symptom severity and functional impairment, suggesting that greater symptom severity and poor functioning are already related with decreased sQoL in the ARMS for psychosis stage. Furthermore, findings highlight the importance of examining functional impairment and affective-motivational symptoms in future research on sQoL in ARMS populations due to their strong relationship with poor sQoL. Finally, findings underscore the importance of addressing the social and occupational dysfunctions already present in early psychosis with psychosocial interventions.

The RAISE Connection Program for Early Psychosis: Secondary Outcomes and Mediators and Moderators of Improvement

The aims of this study were to explore secondary outcomes of a coordinated specialty care program for persons with early psychosis, including quality of life and recovery, as well as to explore mediators and moderators of improvement in occupational and social functioning and symptoms. Sixty-five individuals across two sites were enrolled and received services for up to 2 years. Trajectories for individuals' outcomes over time were examined using linear and quadratic mixed-effects models with repeated measures. In addition, baseline prognostic factors of participant improvement in social and occupational functioning were explored based on previous literature and expert opinion of the analytic team. Results demonstrate that the program was effective in improving quality of life and recovery over time. Furthermore, processing speed was identified as a significant moderator of improvement in occupational Global Assessment of Function, and treatment fidelity, engagement, and family involvement were identified as mediators of improvement in social and occupational functioning.

Self-reported quality of life in a Scottish first-episode psychosis cohort: associations with symptomatology and premorbid adjustment

BACKGROUND

There is increased interest in quality of life (QoL) as a clinically relevant factor in adjustment to, and recovery from, first-episode psychosis (FEP). Given the subjective nature of QoL, it is proposed that this variable may be associated with compromised functioning prior to the onset of psychosis, and may also have an impact on an individual's adjustment to psychosis after treatment is initiated.

AIM

The current study aims to explore associations between subjective QoL, symptomatology, premorbid adjustment, duration of untreated psychosis (DUP) and engagement with services after onset of treatment.

METHOD

A cross-sectional cohort of Scottish individuals undergoing treatment for FEP were characterized in terms of psychotic symptomatology, premorbid adjustment, DUP and service engagement. Self-reported QoL was measured using the World Health Organization Quality of Life Brief Scale, allowing for the measurement of physical, psychological, social relational and environmental aspects of QoL.

RESULTS

Higher scores for subjective QoL components were associated with better premorbid adjustment, lower positive psychotic symptoms, lower negative symptoms and less cognitive disorganization. Childhood premorbid adjustment predicted both physical and social relationship QoL.

DISCUSSION

Subjective QoL domains differ in their associations with clinical and premorbid factors. The relationship between premorbid adjustment and QoL requires further exploration in FEP.

Revisiting the therapeutic effect of rTMS on negative symptoms in schizophrenia: a meta-analysis

This study sought to determine the moderators in the treatment effect of repetitive transcranial magnetic stimulation (rTMS) on negative symptoms in schizophrenia. We performed a meta-analysis of prospective studies on the therapeutic application of rTMS in schizophrenia assessing the effects of both low-frequency and high-frequency rTMS on negative symptoms. Results indicate that rTMS is effective in alleviating negative symptoms in schizophrenia. The effect size was moderate (0.63 and 0.53, respectively). The effect size of rTMS on negative symptoms in sham-controlled trials was 0.80 as measured by the SANS and 0.41 as measured by the PANSS. A longer duration of illness was associated with poorer efficacy of rTMS on negative symptoms. A 10 Hz setting, at least 3 consecutive weeks of treatment, treatment site at the left dorsolateral prefrontal cortex (DLPFC) and a 110% motor threshold (MT) were found to be the best rTMS parameters for the treatment of negative symptoms. The results of our meta-analysis suggest that rTMS is an effective treatment option for negative symptoms in schizophrenia. The moderators of rTMS on negative symptoms included duration of illness, stimulus frequency, duration of illness, position and intensity of treatment as well as the type of outcome measures used.

Anxiety and depression in psychosis: a systematic review of associations with positive psychotic symptoms

OBJECTIVE

This review explores the influence of anxiety and depression on the experience of positive psychotic symptoms, and investigates the possibility of a causal role for anxiety and depression in the emergence and persistence of psychosis.

METHOD

A systematic literature search was undertaken, producing a number of papers which comment on the links between anxiety and depression, and the experience of delusions and hallucinations. In addition, evidence which could contribute to our understanding of the causal role of anxiety and depression was highlighted.

RESULTS

The findings show that both anxiety and depression are associated in meaningful ways with the severity of delusions and hallucinations, the distress they elicit and their content. However, the cross-sectional nature of the majority of studies and the focus on certain symptom subtypes tempers the validity of the findings. Data from non-clinical samples, studies which track the longitudinal course of psychosis and those which examine the impact of anxiety and depression on the prognosis for people experiencing psychosis, offer some support for the possibility of an influential role for anxiety and depression.

CONCLUSION

We conclude that anxiety and depression are related to psychotic symptom severity, distress and content and are also linked with sub-clinical experiences, symptom development, prognosis and relapse. These links may imply that anxiety and depression could be targets for therapeutic intervention. The article concludes with suggestions for further research, highlighting avenues which may circumvent the limitations of the body of work as it stands.

Comparison of generic and disease-specific measures of quality of life in first-episode psychosis

BACKGROUND

Quality of life (QOL) is now recognised as an important measure of outcome that could potentially influence clinical decision-making for those with a first-episode psychosis (FEP). A number of QOL instruments are available however; many differ in their conceptual orientation which may have serious implications for the outcome of QOL studies, interpretation of findings and clinical utility. We aimed to compare two commonly used tools representing both generic and disease-specific constructs to examine whether both tools appraise the same underlying QOL traits and also whether disease-specific tools retain their psychometric properties when used in FEP groups.

METHODS

We assessed 159 consecutive individuals presenting with FEP in a defined catchment area with two commonly used QOL tools and examined the findings using the multi-trait multi-method matrix.

RESULTS

Similarly named domains of QOL between both tools (Psychological Wellbeing, Physical Health, Social Relations) showed good convergent validity using confirmatory factor analysis. However, discriminant validity was not established given that domains loading onto their indicated latent factors were more strongly correlated with their non-corresponding latent factors.

CONCLUSIONS

A major consideration in undertaking the present study was to assess the extent to which the outcome of QOL studies in FEP were valid and that systematic error did not provide another plausible explanation for findings. Establishing convergent validity demonstrates that either tool could be used satisfactorily to measure the QOL construct identified however; we did not establish discriminant validity. Doing so would have demonstrated that QOL domains are substantively different in that they contain some unique piece of information determining clinical utility. These findings are important for our understanding of multi-dimensional models of QOL.

Patient satisfaction with treatment in first-episode psychosis

PURPOSE

To examine first-episode psychotic patients' satisfaction with elements of a comprehensive 2-year treatment program.

SUBJECTS AND METHOD

The TIPS (Early Treatment and Intervention in Psychosis) project provided a 2-year treatment program consisting of milieu therapy (inpatient), individual psychotherapy, family intervention and medication. Of 140 patients at baseline, 112 were included at 2-year follow-up. Eighty-four participants were interviewed using a questionnaire eliciting levels of satisfaction with different treatment elements at two of the four sites.

RESULTS

Participants and non-participants did not differ on demographic or clinical data at baseline. Of those participating, 75% were satisfied with treatment in general. Individual and milieu therapy received higher rating than medication or family intervention. No predictors of general satisfaction with treatment were found, but continuously psychotic patients were the least satisfied with medication treatment.

DISCUSSION

As in most patient satisfaction studies within mental health treatment networks, there was high level of general satisfaction with the total package of treatment but considerable variation in satisfaction for specific interventions. In this sample of first-episode psychosis patients, there was general satisfaction with treatments based on one-to-one relationships while multi-family group intervention was consistently valued less enthusiastically.

Happiness in first-episode schizophrenia

Happiness is a core dimension of a person's life, related to both functioning and success. As patients with schizophrenia experience marked functional deficits, it would be informative to investigate their level of happiness. There are limited data currently available, perhaps due to the longstanding belief that anhedonia is an inherent feature of this illness. The present study set out to specifically assess happiness in schizophrenia in relation to both clinical and functional measures of outcome.

METHOD

Thirty-one first-episode remitted patients and 29 age- and sex-matched controls participated in the study. Patients' clinical status was assessed and a series of self-report questionnaires were used to measure levels of happiness, life satisfaction, success and functioning in both patients and controls.

RESULTS

Patients experienced marked functional impairment versus healthy controls (p<0.001), while reporting comparable levels of happiness (p=0.113) and satisfaction with life (p=0.350). In the patient group, we found that higher happiness ratings were significantly associated with less depression, less negative symptoms, less social withdrawal, greater life satisfaction, and higher social and occupational functioning. Both cognitive functioning and insight had no significant direct effects on ratings of happiness in the patient group.

CONCLUSIONS

Despite marked functional impairment, individuals with first-episode schizophrenia are as happy as controls. Mechanisms that might allow for this are discussed, as are the implications for rehabilitation efforts that assume an individual holds to the same drives and goals as before the illness onset and/or is unhappy with their present functional status.

Association of psychopathology with quality of life in acute phase of schizophrenia; an experience from east India

OBJECTIVE

To find the association of patient characteristic and psychopathology with quality of life in acute phase of schizophrenia.

MATERIALS AND METHODS

Socio-demographic variables of patient, psychopathology and quality of life were assessed. Spearman's Correlation coefficients were measured using SPSS version 15.0.

RESULTS

Quality of life of the patients varied in different domains. Male gender, unmarried status and higher educational status predicted a poorer quality of life. The domains of physical and psychological well-being of WHO-QOL were correlated with PANSS general and total scores whereas environmental and social health showed no correlation with PANSS scores.

CONCLUSION

Domains of subjective quality of life in acute phase of schizophrenia are associated variedly with socio-demographic variables and symptomatology.

Depression and quality of life in first-episode psychosis

AIM

Quality of life (QOL) has gained recognition as a valid measure of outcome in first-episode psychosis (FEP). This study aimed to determine the influence of specific groups of depressive symptoms on separate domains of subjectively appraised QOL.

METHODS

We assessed 208 individuals with first-episode non-affective psychosis using measures of diagnosis (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), symptoms (Scale for the Assessment of Positive Symptoms, Scale for the Assessment of Negative Symptoms, and Calgary Depression Scale for Schizophrenia), functioning (Global Assessment of Functioning), insight (Birchwood Scale), duration of untreated psychosis (Beiser Scale), and QOL World Health Organisation Quality of Life Instrument (WHOQOL-Bref). We used multiple regression to determine the contribution of depressive symptoms to QOL domains while controlling for socio-demographic and other clinical characteristics.

RESULTS

There were complete data for 146 individuals with FEP. Quality-of-life domains were consistently predicted by depressive symptoms including depressive mood and hopelessness rather than biological symptoms of depression with those experiencing more depressive symptoms reporting worse QOL. Those who were treated as in-patients reported improved QOL, and hospitalization was an independent predictor of most QOL domains. In-patients displayed greater levels of positive symptoms with those involuntarily detained displaying greater levels of bizarre behavior, thought disorder, and delusions.

CONCLUSIONS

These findings suggest that QOL is heavily influenced by depressive symptoms at initial presentation; however, as QOL domains are also influenced by admission status with in-patients being more symptomatic in terms of positive symptoms, subjective QOL assessment may be compromised during the acute phase of illness by both positive and depressive symptom severity.

The 2nd Schizophrenia International Research Society Conference, 10-14 April 2010, Florence, Italy: summaries of oral sessions

The 2nd Schizophrenia International Research Society Conference, was held in Florence, Italy, April 10-15, 2010. Student travel awardees served as rapporteurs of each oral session and focused their summaries on the most significant findings that emerged from each session and the discussions that followed. The following report is a composite of these reviews. It is hoped that it will provide an overview for those who were present, but could not participate in all sessions, and those who did not have the opportunity to attend, but who would be interested in an update on current investigations ongoing in the field of schizophrenia research.

Quality of life in patients who have remitted from their first episode of psychosis

BACKGROUND

Quality of life (QoL) in first-episode psychosis (FEP) is strongly related to levels of psychopathology and may vary as a function of illness phase. QoL remains poorly understood in FEP.

AIM

Characterise the nature and predictors of QoL in patients who have remitted from their first-episode of psychosis.

METHOD

Demographic characteristics, diagnoses, and psychopathology were assessed in 81 FEP patients. The World Health Organization Quality of Life Scale-Bref (WHOQoL-Bref) was used to assess QoL in these patients. Carer-related variables (expressed emotion and burden of care) were ascertained from 63 relatives.

RESULTS

Poorer QoL was associated with personality disorder, depression, mild psychotic positive symptoms, and impaired functioning. Carer-related factors such as emotional overinvolvement and burden of care were also associated with a reduction in patients' QoL.

CONCLUSIONS

Depression, functioning and family variables impacted on QoL, and need to be considered in terms of ongoing patient management.

Determinants of subjective quality of life in first-episode schizophrenia: perspective from Malaysia

AIM

This study sought to examine the determinants of subjective quality of life among patients with first-episode schizophrenia in a developing country.

METHOD

One-hundred and twenty patients registered with National Mental Health Registry for Schizophrenia from 1 January 2003 to 31 August 2005 were included. They were diagnosed with first-episode schizophrenia, schizoaffective and schizophreniform disorders and had been compliant to treatment. Sociodemographic data were obtained and the Brief Psychiatric Rating Scale-Anchored Version, Health of The Nation Outcome Scales, Simpson-Angus Extrapyramidal Side Effects Scale, Barnes Akathisia Scale and the World Health Organization Quality of Life were used to assess psychopathology, side effects from antipsychotics and subjective quality of life.

RESULTS

Gender, positive and disorganized symptoms of schizophrenia, and cognitive and physical impairments appeared to be the most important predictors of subjective quality of life among the patients from this centre in Malaysia.

CONCLUSION

Different domains of self-rated quality of life correlated with different sociodemographic and clinical characteristics. Some of the characteristics were malleable and a better understanding of these could lead to improvements in the management of patients with schizophrenia.

Recovery components as determinants of the health-related quality of life among patients with schizophrenia: structural equation modelling analysis

OBJECTIVE

The Substance Abuse and Mental Health Services Administration (SAMHSA) National Consensus Statement on Mental Health Recovery proposed 10 recovery components as guiding principles for fostering recovery among people with severe mental illness. Although researchers have recognized a close association between patient-oriented recovery and health-related quality of life (HRQOL), the relation between the recovery components and patients' self-reported HRQOL is still unknown. The purpose of the present study was therefore to use structural equation modelling to predict HRQOL of schizophrenia outpatients from the recovery components proposed by SAMHSA.

METHODS

The recovery status of 201 outpatients with schizophrenia, schizophreniform, or schizoaffective disorder was measured using 12 variables that indicate the outcome of 10 recovery components. Canonical correlation analysis was applied to screen variables that are highly correlated with HRQOL. Valid variables were then used to build a structural model that predicted individuals' HRQOL as indicated by the World Health Organization Quality of Life Measure Abbreviated (WHOQOL-BREF (HK)).

RESULTS

The bestfit model was able to explain 80.7% of the variance in WHOQOL-BREF outcome. The model demonstrated significant direct and indirect effects of five recovery components on HRQOL. The effect of psychosocial symptoms on HRQOL was highest (total beta = -0.64), followed by sense of personal agency (total beta = 0.58), sense of optimism (total beta = 0.54), perceived support (total beta = 0.47), and internal stigma (total beta = -0.42).

CONCLUSION

The recovery components proposed by the SAMHSA consensus statement provided a useful framework to explain HRQOL of outpatients with schizophrenia. The present model indicated a moderate to large effect of five major recovery components on HRQOL. It showed that patients' perceptions of support, optimism, and personal agency were influenced by psychosocial symptoms and internal stigma. This empirical study supported the use of recovery principles, such as resilience building or mastery-based intervention to improve the QOL of community dwellers with schizophrenia.

The quality of life among first-episode psychotic patients in the OPUS trial

BACKGROUND

From an 'objective' perspective, treatment of first-episode psychosis has improved in many ways with the development of specialised early and intensive team-based treatment like e.g. the 'OPUS' treatment. However, the patients' perspective is also important and was investigated in the 'OPUS' study by analysing data concerning quality of life.

AIM

We aimed to investigate the 'quality of life from patients' perspective' among a cohort of young adults with a first-episode psychosis at the time of treatment initiation and after two years. Especially, we were interested in analysing if there were any significant effects on the subjective quality of life of receiving an intensive psychosocial assertive community treatment called 'OPUS' compared to standard treatment (ST).

METHOD

This study is part of the Danish 'OPUS' trial, a randomised controlled trial (RCT) comparing 'treatment as usual' (standard treatment, ST) with 'OPUS' treatment. The Lancashire Quality of Life Profile (LQoLP), which is a combined objective and subjective instrument, was administered at baseline and after two years of treatment, N=280.

RESULTS

The intensive 'OPUS' treatment did not affect the quality of life measured by Lancashire QoLP in a significantly different way from the standard treatment (ST). There were no significant differences in quality of life between the ST group and the OPUS group concerning the 9 life domains. Quality of life correlated with psychopathology (both psychotic and negative symptoms) to a minor extent and more strongly with the affective balance and level of self-esteem.

Quality of life across the schizotypy spectrum: findings from a large nonclinical adult sample

OBJECTIVE

It is well documented that patients with schizophrenia have impoverished quality of life (QOL). Efforts to determine the underpinnings of this impoverishment have implicated negative symptoms more than positive or disorganized symptoms. However, only a minority of individuals with the liability to schizophrenia will ever show manifest illness, and it is presently unclear the degree to which QOL is affected in individuals with subclinical symptoms of the disorder (ie, schizotypy). The present study examined the relative contributions of negative, positive, and disorganized schizotypy symptoms to QOL.

METHODS

Measures of schizotypal symptoms and subjective and objective QOL were obtained from a sample of 1395 adults.

RESULTS

Measures of schizotypal symptoms significantly corresponded to all measures of QOL, although the magnitude of correlations were significantly larger for subjective than objective measures. The negative symptom dimension explained a substantial portion of unique variance in the social domains of QOL above and beyond that accounted for by the other schizotypy dimensions.

CONCLUSIONS

These findings highlight the deleterious impact of schizotypal symptoms, particularly negative symptoms. Further research clarifying the mechanism underlying this relationship is called for.

Are symptoms associated with increased levels of perceived stress in first-episode psychosis?

Several studies report on the presence of external stress and life events prior to the onset and exacerbation of psychotic illness. However, the relationship between the subjective appraisal of stress at first presentation with psychosis is less well understood. This paper reports on the relationship between the individual perception of stress and symptomatology in individuals with first-episode psychosis at presentation to community mental health services. We assessed 123 individuals using standardized measures of symptoms, quality of life, perceived stress, global functioning, and duration of untreated psychosis. At first presentation, people with more depressive symptoms and reduced overall functioning were more likely to report increased levels of perceived stress. In addition, people with less positive symptoms of psychosis were experiencing higher levels of subjective stress. In terms of stress vulnerability models, it is important to consider how functioning and symptoms can influence individual appraisal of stress. Acknowledging this interaction can provide opportunities for nursing interventions directed at enhancing adaptive coping and provide benchmarks for assessing the effectiveness of nursing interventions provided in the acute phase of psychosis. Further research should focus on the interaction between symptoms and individually-appraised stress over time.

Reduced subjective quality of life in persons at risk for psychosis

OBJECTIVE

Subjective quality of life (sQoL) and potentially contributing factors were investigated in individuals putatively in an early (EIPS) or late initial prodromal state (LIPS) and healthy controls (HC).

METHOD

Participants comprised 58 EIPS individuals, 157 LIPS individuals and 87 HC individuals. sQoL was assessed together with locus of control (LoC), coping, demography and psychopathology.

RESULTS

Putatively prodromal groups exhibited markedly lower sQoL than HC (all domains P < 0.00001). EIPS and LIPS individuals did not differ significantly. Depression was the most consistent explaining variable of sQoL in EIPS and LIPS individuals. In EIPS individuals, LoC emerged as an additional predictor.

CONCLUSION

Individuals at risk for psychosis experienced a marked impairment of sQoL across all domains. This was evident even in the early state, showed no significant further deterioration during the late state and was predominantly explained by non-specific symptoms.

Premorbid adjustment, symptom development and quality of life in first episode psychosis: a systematic review and critical reappraisal

OBJECTIVE

To systematically review the relationship of premorbid adjustment to symptomatology in first episode psychosis (FEP), taking into account the influence of duration of untreated psychosis (DUP).

METHOD

Electronic databases were searched to identify relevant studies.

RESULTS

A variety of approaches to the reporting of premorbid adjustment were identified. There was no significant association between premorbid adjustment and DUP, supporting the proposition that they are independent constructs. The effect of premorbid adjustment upon positive symptomatology was negligible. Premorbid adjustment had a modest effect upon negative symptoms and quality of life, increasing over duration of follow-up.

CONCLUSION

Premorbid adjustment remains a valid construct in the study of FEP. Both premorbid adjustment and DUP confer independent effects on aspects of symptomatology in FEP. Results for premorbid adjustment are similar to previous findings in more chronic samples. The potential for conceptualizing premorbid functioning by developmental, academic/social and typological approaches is currently underexploited.

Outcome on quality of life in a Canadian national sample of patients with schizophrenia and related psychotic disorders

OBJECTIVE

To examine changes in subjective and objective dimensions of quality of life (QoL) in a large Canadian sample of patients with diagnosis of schizophrenia or schizoaffective disorder treated in academic and non-academic settings over a 2-year period.

METHOD

Patients recruited in the study across the country were assessed for QoL and functioning using the Client and Provider versions of the Wisconsin Quality of Life Questionnaire (WQoL) and the Short Form-36 (SF-36) at baseline (n = 448), 1 year (n = 308-353) and 2 years (188-297). Data were analyzed to examine change across time using multivariate analyses controlling for potential influence of variables such as age, regional variation, gender, duration of illness, type of treatment taken and baseline measures of symptoms and QoL.

RESULTS

The weighted quality of life index (W-QoL-I) showed a significant change on both the client and the provider versions of the WQoL while the physical and mental composites of the SF-36 showed change only at 2 years. These changes were influenced significantly by baseline scores on W-QoL-I and in the case of provider version of the WQoL by baseline Brief Psychiatric Rating Scale (BPRS) scores. Regional variation or type of medication had no impact on improvement in QoL.

CONCLUSION

Within a naturalistic sample of schizophrenia patients treated and followed in routine care the overall QoL showed an improvement over time but this improvement was not influenced by the type of medication prescribed.

Medication decisions and clinical outcomes in the Canadian National Outcomes Measurement Study in Schizophrenia

OBJECTIVE

To evaluate over a 2-year period, patients from academic/non-academic centres, from each region of Canada, to determine whether location or other variables such as medication type, gender or income was associated with outcome as defined by non-hospitalization and persistence on original treatment.

METHOD

A total of 448 patients were recruited from academic and non-academic centres across all provinces of Canada and followed up for 2 years.

RESULTS

Patients from British Columbia had significantly lower rates of hospitalization than patients from other provinces. Male patients showed greater symptomatic improvement at 2 years from initial assessment compared to females. Patients on clozapine, risperidone and olanzapine were least likely to be hospitalized.

CONCLUSION

There were some regional differences noted in both utilization of types of antipsychotic medications and hospitalization rates. In this sample of stable out-patients over 70% who started on monotherapy with clozapine, risperidone, olanzapine and quetiapine remained on the same medication over the 2-year study period.

Social support and three-year symptom and admission outcomes for first episode psychosis

This paper presents the first published findings examining the relationship of social support to three-year symptom outcome and hospitalizations for a group of first episode patients with psychotic disorders. Social support was measured using items from the provider version of the Wisconsin Quality of Life Scale as assessed at the time of initiation of treatment for 113 patients. Outcome was assessed by level of positive and negative symptoms at three-year follow-up and number of psychiatric admissions during those three years. Higher levels of social support were found to correlate with lower levels of positive symptoms and few hospitalizations at follow-up. The relationship of social support to follow-up symptoms and hospitalization was independent of other potential predictors such as gender, age, premorbid adjustment and duration of untreated illness.

First-episode psychosis, early intervention, and outcome: what have we learned?

OBJECTIVE

There has been increased interest in the potential of early intervention to positively influence outcome in first-episode psychosis (FEP) and, consequently, to influence mental health policy and practice. This study's objective was to examine the concept of early intervention and the evidence that currently exists to support such a shift in the delivery of care.

METHOD

We examined the evidence for phase-specific treatment of FEP, looking for interventions that attempt to arrest the transition from a putative prodromal state to full psychosis, as well as for interventions that attempt to reduce delay in treatment.

RESULTS

Some evidence supports specialized FEP interventions for short-term outcome in terms of symptom reduction, relapse rates, and greater adherence to and retention in treatment. As well, there is modest support for benefits to aspects of social and community functioning and satisfaction with life. Limited evidence supports a positive effect of community-wide case detection in terms of reduced delays in treatment and pharmacologic and psychological interventions in the prodromal phase.

CONCLUSIONS

The field of early intervention in psychosis is young, with encouraging preliminary results, especially for improving outcome in established FEP. It requires further study, especially of longer-term outcome. Further studies need to examine the effects of a specialized approach on longer-term outcome and to explore cost-effective methods to reduce delays in treatment and provide interventions in the prodromal phase.

Reducing the duration of untreated first-episode psychosis -- effects on baseline social functioning and quality of life

OBJECTIVE

Long duration of untreated psychosis (DUP) is associated with poorer outcome. The TIPS study demonstrated that DUP can be reduced through early detection (ED). As quality of life (QoL) is associated with DUP it is expected that reduction of DUP leads to better QoL.

METHOD

Consecutive first-episode patients with a DSM-IV diagnosis of non-organic, non-affective psychosis were included, 281 patients gave informed consent and 263 completed a full evaluation of QoL.

RESULTS

There were no differences in subjective QoL between ED and No-ED groups attributable to reduction in DUP. There were significant bivariate differences in frequency of family and social contacts in favor of the ED group, but multivariate analyses indicated that these differences were based on differences in sample characteristics.

CONCLUSION

Deterioration in QoL may precede overt symptom formation. Focus on functional loss in ED educational campaigns may identify risk subjects earlier in the course of the disorder.