Quality of life in schizophrenia: a comparison of instruments. Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia

Health-related quality of life among patients with treated alcohol use disorders, schizophreniform disorders or affective disorders and the influence of flexible and integrative psychiatric care models in Germany (PsychCare)

Introduction

Flexible and integrated treatment options (FIT) have been established in German psychiatric hospitals to enhance continuous and patient-centered treatment for patients with mental disorders. We hypothesized that patients with experience in FIT treatment showed higher health-related quality of life (HRQoL) and comparable symptom severity compared with patients treated as usual (TAU). Further, we expected that some sub-dimensions of HRQoL determined HRQoL results clearer than others, while certain factors influenced HRQoL and symptom severity stronger in the FIT compared to the TAU group. In addition, we hypothesized that HRQoL is correlated with symptom severity.

Methods

We undertook a controlled, prospective, multicenter cohort study (PsychCare) conducted in 18 psychiatric hospitals in Germany, using the questionnaires Quality of Well Being Self-Administered (QWB-SA) (HRQoL) and Symptom-Checklist-K-9 (SCL-K-9) (symptom severity) at recruitment (measurement I) and 15 months later (measurement II). We assessed overall HRQoL (measured in health utility weights (HUW) and symptom severity score for patients from FIT and TAU treatment. We investigated the QWB-SA dimensions and separated the results by diagnosis. We used beta regressions to estimate the effect of multiple co-variates on both outcomes. To investigate the correlation between HRQoL and symptom severity, we used Pearson correlation.

Results

During measurement I, 1,150 patients were recruited; while 359 patients participated during measurement II. FIT patients reported higher HUWs at measurement I compared to TAU patients (0.530 vs. 0.481, p = 0.003) and comparable HUWs at measurement II (0.581 vs. 0.586, p = 0.584). Symptom severity was comparable between both groups (I: 21.4 vs. 21.1, p = 0.936; II: 18.8 vs. 19.8, p = 0.122). We found lowest HRQoL and highest symptom severity in participants with affective disorders. HRQoL increased and symptom severity decreased over time in both groups. The QWB-SA dimension acute and chronic symptoms was associated with highest detriments in HRQoL. We identified risk/protective factors that were associated with lower quality of life and higher symptom severity in both groups. We confirmed that HRQoL was negatively associated with symptom severity.

Discussion

Health-related quality of life (during hospital treatment) was higher among patients treated in FIT hospitals compared to patients in routine care, while symptom severity was comparable between both groups.

Developing and testing unconditional cash transfer strategies among young adults with first-episode psychosis in South Africa: a study protocol for a pilot randomised control trial (PRS-FEP trial)

INTRODUCTION

Access to mental health services is a challenge, especially for young people who are over-represented in the unemployment and poverty index in South Africa. Therefore, continuing care is a problem after hospital discharge for young people with first-episode psychosis (FEP) due to a lack of clinical engagement and follow-up, for which they need support, including financial, to improve their outcomes. This pilot randomised control trial (RCT) aims to assess the feasibility and acceptability of financial support, in the form of an unconditional cash transfer (UCT), among young patients with FEP to prevent relapse.

METHODS AND ANALYSIS

This study will use a 1:1 ratio two-arm open-label pilot RCT of 60 young participants (18-29 years) with FEP in remission, who will be recruited from specialised psychiatric facilities in KwaZulu-Natal Province, South Africa. This study will implement an UCT and assess its feasibility, acceptability and preliminary clinical outcomes (ie, medication adherence, relapse, quality of life, personal and social function). The follow-up time will be 3 months, the outcomes being measured at baseline, months 1 and 3. Descriptive and conventional content analysis will be done for quantitative and qualitative data, respectively.

ETHICS AND DISSEMINATION

The study obtained provisional approval from the Biomedical Research Ethics Committee at the University of KwaZulu-Natal(#BREC/00004117/2022). Also is registered on the South African National clinical trial registry (#DOH-27-092022-5894) and approved by the KwaZulu-Natal department of health (#NHRD Ref: KZ_2002209_033). The results from this investigation will be actively disseminated through peer-reviewed journal publications, conference presentations and stakeholder engagement.

TRIAL REGISTRATION NUMBER

DOH-27-092022-5894.

Smartphone-based mobility metrics capture daily social motivation and behavior in schizophrenia

Impaired social functioning contributes to reduced quality of life and is associated with poor physical and psychological well-being in schizophrenia, and thus is a key psychosocial treatment target. Low social motivation contributes to impaired social functioning, but is typically examined using self-report or clinical ratings, which are prone to recall biases and do not adequately capture the dynamic nature of social motivation in daily life. In the current study, we examined the utility of global positioning system (GPS)-based mobility data for capturing social motivation and behavior in people with schizophrenia. Thirty-one participants with schizophrenia engaged in a 60-day mobile intervention designed to increase social motivation and functioning. We examined associations between twice daily self-reports of social motivation and behavior (e.g., number of social interactions) collected via Ecological Momentary Assessment (EMA) and passively collected daily GPS mobility metrics (e.g., number of hours spent at home) in 26 of these participants. Findings suggested that greater mobility on a given day was associated with more EMA-reported social interactions on that day for four out of five examined mobility metrics: number of hours spent at home, number of locations visited, probability of being stationary, and likelihood of following one's typical routine. In addition, greater baseline social functioning was associated with less daily time spent at home and lower probability of following a daily routine during the intervention. GPS-based mobility thus corresponds with social behavior in daily life, suggesting that more social interactions may occur at times of greater mobility in people with schizophrenia, while subjective reports of social interest and motivation are less associated with mobility for this population.

Quality of life after involuntary psychiatric admission

Studies seeking predictors of outcomes after involuntary admission, including quality of life (QoL), are limited and results inconsistent. We aimed to describe QoL 3 months after involuntary psychiatric admission and to investigate associated factors. One hundred and fifty-three involuntarily admitted inpatients were assessed for a range of sociodemographic and clinical variables. Structured scales included the Brief Psychiatric Rating Scale (BPRS), the MacArthur Admission Experience Survey, the Heinrichs Quality of Life Scale and the World Health Organisation Quality of Life Brief Assessment (WHOQOL-BREF, n = 124). The mean total score on the Heinrichs QoL scale at 3 months was 69.3 (SD = 24.1). Predictors of higher 3 month QoL after involuntary admission in a multiple regression model (adjusted R² = 0.37, F = 7.1 (14, 138), p ≤0.001) were less severe negative symptoms on the BPRS at baseline (B = -4.56, p < 0.001), improvement in negative symptom scores between baseline and follow up (B = 4.58, p < 0.001) and higher current social class (B = -14.31, p = 0.001). Events during involuntary admission, such as being subject to coercive experiences, were not significantly associated with QoL after admission. The results suggest that a core determinant of service users' QoL after involuntary admission is negative symptom severity and change over time.

A Methodological Review of Quality of Life Scales Used in Schizophrenia

BACKGROUND AND PURPOSE

Evidence is lacking with regard to the most suitable instrument for measuring quality of life (QOL) in patients with schizophrenia. The researchers carried out a methodological review of literature pertaining to scales used to measure QOL in this population.

METHODS

Twenty-eight studies, assessing nine different QOL scales, were reviewed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.

RESULTS

While the content of most scales proved valid, the Lancashire Quality of Life Profile (LQOLP), Self-Report Quality of Life Scale (SQOL), and Quality of Life in Schizophrenia (QLiS) outscored the other scales in almost every other domain measured by COSMIN.

CONCLUSION

LQOLP and SQOL stand out among QOL scales for patients with schizophrenia, but further evidence is required to verify this finding, and no one scale appears ideal for all patients with schizophrenia.

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.

Quality of life and its social determinants for patients with schizophrenia and family caregivers in Cambodia

Due to inadequate human and financial resource support, the development of mental health services in Cambodia has been undertaken by various non-governmental organizations (NGOs). Schizophrenia is the most common functional psychotic disorder, causing severe and chronic symptoms, and the programs provided by the NGOs should have enhanced the quality of life (QoL) of patients and their caregivers; however, epidemiological research, which is a driving force behind the recognition of mental health as a global public health concern, is lacking for schizophrenia in Cambodia. This study therefore aimed to create QoL evaluation questionnaires available in Khmer (the Cambodian language) for patients with schizophrenia and family caregivers, and to identify the social determinants and predictors of their QoL. This cross-sectional study recruited 59 patients and 59 caregivers attending three clinics operated by two NGOs: the Transcultural Psychosocial Organization (TPO) Cambodia and the Supporters for Mental Health (SUMH) Cambodia. We conducted linguistic validation of the Schizophrenia Quality of Life Questionnaire 18-item version (S-QoL 18) and the Schizophrenia Caregiver Questionnaire (SCQ), then analyzed correlations between the QoL dimensions and socio-demographic factors. The main findings of this study were as follows: 1) the newly created Khmer versions of S-QoL 18 and SCQ are relatively good psychometric tools that are suitable for research to identify patients’ and caregivers’ needs to improve their QoL; and 2) engaging in paid work or being of the post-Khmer Rouge generation results in higher QoL for patients, but having low household economic status or being affected by chronic disease leads to lower QoL for family caregivers. These findings are useful for enabling community mental health professionals and aid organizations to create programs to lessen the patient and caregiver burden in Cambodia. Further research is necessary to develop practical projects that will improve patients’ and caregivers’ QoL in various clinical settings in Cambodia.

Health-related quality of life associated with different symptoms in women and in men who suffer from schizophrenia

Health-related quality of life (HRQoL) in patients with schizophrenia is related to the severity of psychiatric symptoms. The objective of this study is to analyze whether the symptoms that influence HRQoL are similar in women and men. Data were part of the Pattern study, an international observational investigation which collected data from 1379 outpatients with schizophrenia. Patients were evaluated with the Mini International Neuropsychiatric Inventory, the Clinical Global Impression-Schizophrenia, and the Positive and Negative Syndrome Scale (PANSS), and reported their quality of life using the Schizophrenia Quality of Life Scale (SQLS), the Short Form-36 (SF-36), and the EuroQol-5 Dimension (EQ-5D). Men reported higher HRQoL on all scales. PANSS total score was 80.6 (SD 23.6) for women and 77.9 (SD 22.1) for men. In women, a higher PANSS negative score and a higher PANSS affective score were associated with a lower SQLS score. In men, a higher PANSS positive score and a higher PANSS affective score were associated with a lower SQLS score. The same pattern appeared with EQ-VAS and EQ-5D tariff. In women, greater age and higher PANSS affective score were associated with a lower SF-36 mental component score. In men, higher PANSS affective, positive, and cognitive scores were associated with a lower SF-36 mental component score. This study shows that HRQoL is influenced by different psychiatric symptoms in women and men. This may have significant implications when deciding the main treatment target in patients with schizophrenia.ClinicalTrials.gov Identifier: https://clinicaltrials.gov/ct2/show/NCT01634542.

Metacognitive self-reflectivity moderates the relationship between distress tolerance and empathy in schizophrenia

Deficits in empathy seen in schizophrenia are thought to play a major role in the social dysfunction seen in the disorder. However, little work has investigated potential determinants of empathic deficits. This study aimed to fill that gap by examining the effects of two variables on empathy - distress tolerance and metacognitive self-reflectivity. Fifty-four people with schizophrenia-spectrum disorders receiving services at an urban VA or community mental health center were assessed for empathy, metacognition, and distress tolerance. Bivariate correlations and moderation methods were used to ascertain associations amongst these variables and examine interactions. Results revealed that, against hypotheses, empathy was not related at the bivariate level to either distress tolerance or metacognitive self-reflectivity. However, consistent with hypotheses, moderation analyses revealed that participants with higher self-reflectivity showed no relationship between distress tolerance and empathy, while those with lower self-reflectivity showed a relationship such that reduced ability to tolerate distress predicted reduced empathy. Taken together, results of this study suggest that lack of distress tolerance can negatively affect empathy in people with schizophrenia with lesser capacity for metacognitive self-reflection; thus, fostering self-reflectivity may help overcome that negative impact. Future work is needed investigating the impact of metacognitively-tailored interventions on empathy in this population.

Health-related quality of life in outpatients with schizophrenia: factors that determine changes over time

PURPOSE

The objective of this study was to analyze the clinical factors associated with changes in HRQoL in outpatients with schizophrenia using both generic and condition-specific HRQoL scales.

METHODS

Adult outpatients with schizophrenia at least 18 years of age who did not have an acute psychotic exacerbation in the 3 months prior to baseline were recruited. PANSS dimensions were calculated based on Lindenmayer et al.'s five factors. HRQoL data were assessed by patients using the Schizophrenia Quality of Life Scale (SQLS), the Short Form-36 (SF-36), and the EuroQol-5 Dimension (EQ-5D) questionnaires.

RESULTS

Out of the 1345 patients included at baseline, 1196 (89%) were evaluated at 12 months. Regression models showed that the factor most consistently associated with HRQoL at endpoint was change in the PANSS negative symptoms score. A decrease in the PANSS negative symptoms score from baseline to 1 year was associated with a decrease in HRQoL during the same period. There were also significant associations of the change in PANSS excitatory factor with all the HRQoL scales except the SF-36 PCS. Female gender was associated with a decrease in all HRQoL ratings. There was also a relationship between years since onset and HRQoL. The longer the time since illness onset, the larger the decrease in HRQoL.

CONCLUSIONS

This study has found that, in outpatients with schizophrenia, changes in negative and excitement symptoms may have a greater an association with HRQoL than changes in positive, cognitive and depressive symptoms.

Childhood trauma, depression and negative symptoms are independently associated with impaired quality of life in schizophrenia. Results from the national FACE-SZ cohort

OBJECTIVES

Depression and negative symptoms have been associated with impaired Quality of life (QoL) in schizophrenia (SZ). However, childhood trauma may influence both QoL and depression in SZ patients, with consequences for the management of impaired QoL in SZ patients. The aim of the present study was to determine if childhood trauma was associated with impaired QoL in schizophrenia.

METHOD

A sample of 544 community-dwelling stabilized SZ patients enrolled in FACE-SZ cohort were utilized in this study (74.1% males, mean aged 32.3years, mean illness duration 10.6years). QoL was self-reported with the S-QoL18 questionnaire. Childhood trauma was self-reported with the Childhood Trauma Questionnaire. Depression was measured by the Calgary Depression Rating Scale for Schizophrenia. Psychotic severity was measured by the Positive and Negative Syndrome Scale for Schizophrenia (PANSS). Other clinical factors, treatments, comorbidities, functioning and sociodemographical variables were also recorded, with validated scales.

RESULTS

Overall, 151 participants (27.8%) had a current major depressive episode and 406 (82.5%) reported at least one episode of historical childhood trauma. In multivariate analyses, lower QoL total score was associated with a history of childhood trauma (β=-0.21, p<0.0001), psychotic negative symptoms (β=-0.11, p=0.04), current depression (β=-0.0.38, p<0.0001) and male gender (β=-0.16, p<0.0001).

CONCLUSION

Impaired QoL is independently associated with negative symptoms, depression and childhood trauma in schizophrenia.

Impact of child maltreatment on meaning in life in psychiatric patients

Child maltreatment (CM) worsens prognosis and quality of life in several psychiatric conditions. Meaning in life is a construct which relates to the sense of purpose that one can perceive in life, and is a key aspect of recovery in psychiatric patients. The lasting impact of CM on meaning in life and its mediating variables have not been studied in patients with chronic persistent psychiatric conditions. One hundred and sixty-six patients with bipolar disorder (N=35), psychotic disorder (N=73), anorexia nervosa (N=30) or borderline personality disorder (N=28) were assessed for meaning in life (revised version of the Life Regard Index (LRI-R)), for CM (Childhood Trauma Questionnaire (CTQ)) and for internalized/externalized psychopathology. CM was associated with a lower LRI score. Structural Equation Modeling showed that internalized psychopathology (depression, hopelessness and low self-esteem) was the main mediator of the impact of CM on meaning in life. The direct effect of CM on meaning in life was not significant. Having suffered from negligence or abuse during childhood is associated with lower meaning in life in adults with persistent and pervasive psychiatric disorders. Treating depressive symptoms and improving self-esteem may improve meaning in life in patients with severe mental disorders who were affected by CM.

Interventions for reducing self-stigma in people with mental illnesses: a systematic review of randomized controlled trials

Background: Self-stigma occurs when people with mental illnesses internalize negative stereotypes and prejudices about their condition. It can reduce help-seeking behaviour and treatment adherence. The effectiveness of interventions aimed at reducing self-stigma in people with mental illness is systematically reviewed. Results are discussed in the context of a logic model of the broader social context of mental illness stigma.

Methods: Medline, Embase, PsycINFO, ERIC, and CENTRAL were searched for randomized controlled trials in November 2013. Studies were assessed with the Cochrane risk of bias tool.

Results: Five trials were eligible for inclusion, four of which provided data for statistical analyses. Four studies had a high risk of bias. The quality of evidence was very low for each set of interventions and outcomes. The interventions studied included various group based anti-stigma interventions and an anti-stigma booklet. The intensity and fidelity of most interventions was high. Two studies were considered to be sufficiently homogeneous to be pooled for the outcome self-stigma. The meta-analysis did not find a statistically significant effect (SMD [95% CI] at 3 months: –0.26 [–0.64, 0.12], I²=0%, n=108). None of the individual studies found sustainable effects on other outcomes, including recovery, help-seeking behaviour and self-stigma.

Conclusions: The effectiveness of interventions against self-stigma is uncertain. Previous studies lacked statistical power, used questionable outcome measures and had a high risk of bias. Future studies should be based on robust methods and consider practical implications regarding intervention development (relevance, implementability, and placement in routine services).

Antidepressant Controlled Trial For Negative Symptoms In Schizophrenia (ACTIONS): a double-blind, placebo-controlled, randomised clinical trial

BACKGROUND

Negative symptoms of schizophrenia represent deficiencies in emotional responsiveness, motivation, socialisation, speech and movement. When persistent, they are held to account for much of the poor functional outcomes associated with schizophrenia. There are currently no approved pharmacological treatments. While the available evidence suggests that a combination of antipsychotic and antidepressant medication may be effective in treating negative symptoms, it is too limited to allow any firm conclusions.

OBJECTIVE

To establish the clinical effectiveness and cost-effectiveness of augmentation of antipsychotic medication with the antidepressant citalopram for the management of negative symptoms in schizophrenia.

DESIGN

A multicentre, double-blind, individually randomised, placebo-controlled trial with 12-month follow-up.

SETTING

Adult psychiatric services, treating people with schizophrenia.

PARTICIPANTS

Inpatients or outpatients with schizophrenia, on continuing, stable antipsychotic medication, with persistent negative symptoms at a criterion level of severity.

INTERVENTIONS

Eligible participants were randomised 1 : 1 to treatment with either placebo (one capsule) or 20 mg of citalopram per day for 48 weeks, with the clinical option at 4 weeks to increase the daily dosage to 40 mg of citalopram or two placebo capsules for the remainder of the study.

MAIN OUTCOME MEASURES

The primary outcomes were quality of life measured at 12 and 48 weeks assessed using the Heinrich's Quality of Life Scale, and negative symptoms at 12 weeks measured on the negative symptom subscale of the Positive and Negative Syndrome Scale.

RESULTS

No therapeutic benefit in terms of improvement in quality of life or negative symptoms was detected for citalopram over 12 weeks or at 48 weeks, but secondary analysis suggested modest improvement in the negative symptom domain, avolition/amotivation, at 12 weeks (mean difference -1.3, 95% confidence interval -2.5 to -0.09). There were no statistically significant differences between the two treatment arms over 48-week follow-up in either the health economics outcomes or costs, and no differences in the frequency or severity of adverse effects, including corrected QT interval prolongation.

LIMITATIONS

The trial under-recruited, partly because cardiac safety concerns about citalopram were raised, with the 62 participants recruited falling well short of the target recruitment of 358. Although this was the largest sample randomised to citalopram in a randomised controlled trial of antidepressant augmentation for negative symptoms of schizophrenia and had the longest follow-up, the power of statistical analysis to detect significant differences between the active and placebo groups was limited.

CONCLUSION

Although adjunctive citalopram did not improve negative symptoms overall, there was evidence of some positive effect on avolition/amotivation, recognised as a critical barrier to psychosocial rehabilitation and achieving better social and community functional outcomes. Comprehensive assessment of side-effect burden did not identify any serious safety or tolerability issues. The addition of citalopram as a long-term prescribing strategy for the treatment of negative symptoms may merit further investigation in larger studies.

FUTURE WORK

Further studies of the viability of adjunctive antidepressant treatment for negative symptoms in schizophrenia should include appropriate safety monitoring and use rating scales that allow for evaluation of avolition/amotivation as a discrete negative symptom domain. Overcoming the barriers to recruiting an adequate sample size will remain a challenge.

TRIAL REGISTRATION

European Union Drug Regulating Authorities Clinical Trials (EudraCT) number 2009-009235-30 and Current Controlled Trials ISRCTN42305247.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 29. See the NIHR Journals Library website for further project information.

Validity of a common quality of life measurement in homeless individuals with bipolar disorder and schizophrenia

OBJECTIVE

To provide new evidence regarding the validity, reliability, sensitivity to change and acceptability of a schizophrenia (SCZ) quality of life measurement (S-QoL 18) in homeless people with bipolar disorder (BPD).

METHODS

This multi-centre prospective study was conducted in the following 4 French cities: Lille, Marseille, Paris and Toulouse. In addition to the S-QoL 18, data on sociodemographic information, disease severity using the Modified Colorado Symptom Index (MCSI), recovery using the Recovery Assessment Scale (RAS) and QoL using the Short-Form Health Survey (SF-36) were collected. The S-QoL 18 was tested for construct validity, reliability, external validity, sensitivity to change and acceptability.

RESULTS

In total, 216 homeless patients with BPD participated in this study. The eight-factor structure of the S-QoL 18 was confirmed by confirmatory factor analysis (RMSEA=0.058, CFI=0.98, TLI=0.966). The scalability was satisfactory, with INFIT statistics within an acceptable range (from 0.77 to 1.20). The internal consistency (from 0.43 to 0.76) and reliability coefficients (Cronbach's alpha from 0.65 to 0.86) were satisfactory for all dimensions. The external validity testing revealed that the S-QoL 18 dimension scores were significantly correlated with the MCSI, the RAS and the SF-36 scores. The percentage of missing data for the dimensions (<15%) and sensitivity to change were satisfactory.

CONCLUSIONS

These results demonstrate adequate acceptability and psychometric properties of the S-QoL 18 among homeless patients with BPD. The S-QoL 18 can be a common instrument for measuring QoL in homeless people with SCZ and BD.

Comparison of burden among family members of patients diagnosed with schizophrenia and bipolar disorder in a large acute psychiatric hospital in China

BACKGROUND

The difference of burden between caregivers of acute patients with schizophrenia and bipolar disorder has not been well studied in China, a culture where family responsibility has a very high value. Our aim is to compare family burden in these two categories diagnosis and to identify predictors of family burden in a large psychiatric hospital in China.

METHODS

Two hundred forty-three schizophrenic patients and 200 bipolar patients were enrolled in a cross-sectional study. Patients were independently evaluated on symptoms, insight, attitudes toward medication, quality of life during the first week of their admissions. The prime caregiver for each patient was also evaluated with a standard measure of family burden within 1 week of patients' admission.

RESULTS

Caregiver perceptions of violent behavior and suicidal risk among patients with bipolar disorder were significantly greater than among families of those with schizophrenia. Hierarchical regression analyses demonstrated differential correlates of burden for all predictive factors with R(2) values ranging from 0.14 to 0.27 in the five burden factors in schizophrenia families; and from 0.12 to 0.24 in bipolar disorder families. Symptoms severity explained the greatest proportion of variance, whereas patient and caregiver demographic variables explained much less variance.

CONCLUSION

Family burden, especially the caregiver perceptions of violent and suicidal behaviors were greater in care givers of acute bipolar disorder patients than among caregivers of schizophrenia patients in the present sample. However, in families of patients with both disorders clinical features were the strongest predictor of caregiver burden.

Metacognition moderates the relationship between dysfunctional self-appraisal and social functioning in prolonged schizophrenia independent of psychopathology

OBJECTIVES

Both dysfunctional self-appraisal and metacognitive deficits, or impairments in the ability to form complex and integrated ideas about oneself and others, may contribute to social deficits in schizophrenia. Little is known, however, about how they interact with each other. In this study, we examined the hypothesis that both higher metacognition and more positive self-appraisal are necessary for increased social functioning.

METHODS

Concurrent assessments of self-appraisal, metacognition, and social functioning were gathered from 66 adults with schizophrenia in a non-acute phase of disorder. Three forms of self-appraisal were used: self-esteem, hope and self-efficacy. Metacognition was assessed using the Metacognitive Assessment Scale-Abbreviated, and social functioning with the Quality of Life Scale. Measures of psychopathology, neurocognition and social cognition were also gathered for use as potential covariates.

RESULTS

A single index of self-appraisal was generated from subjecting the assessments of self-appraisal to a principal components analysis. Linear regression analyses revealed that after controlling for severity of psychopathology, metacognition moderated the effect of the self-appraisal factor score upon social functioning. A median split of metacognition and the self-appraisal index yielded four groups. ANCOVA analyses revealed that participants with higher levels of metacognition and more positive self-appraisal had greater capacities for social relatedness than all other participants, regardless of levels of positive and negative symptoms. Correlational analyses revealed that metacognition but not self-appraisal was related to the frequencies of social contact independent of the effects of psychopathology. Assessments of social cognition and neurocognition were not significantly linked with social dysfunction.

CONCLUSION

Greater social functioning is made possible by a combination of both more positive self-appraisals and greater metacognitive capacity. Individuals with schizophrenia who struggle to relate to others may benefit from interventions which address both their beliefs about themselves and their capacity for metacognition.

Quality of Life for Individuals with Schizophrenia: Validating an Assessment That Addresses Client Concerns and Occupational Issues

This article describes the initial validation study of the Quality of Life Measure for Persons With Schizophrenia (QOLM-S). This new assessment is grounded in a holistic conceptual framework, addresses occupational issues, and was developed on the basis of qualitative data collected from individuals with schizophrenia. Data were collected from 91 individuals with schizophrenia to examine aspects of reliability and validity. Results support both the internal consistency of the QOLM-S, with a Cronbach's alpha reliability coefficient of 0.97 for the overall scale, and concurrent validity. Correlations between the domain and total scores of the QOLM-S provide initial support for construct validity. This study supports the use of the QOLM-S as a descriptive tool. Future research to enhance the clinical utility and further examine the psychometric properties of the QOLM-S are suggested.

Functional brain substrate of quality of life in patients with schizophrenia: A brain SPECT multidimensional analysis

The aim of this study was to investigate the functional brain substrate of quality of life (QoL) in patients with schizophrenia. Participants comprised 130 right-handed patients with schizophrenia who underwent whole-brain single photon emission computed tomography (SPECT) with (99m)Tc-labeled ethylcysteinate dimer ((99m)Tc-ECD) for exploring correlations of regional cerebral blood flow (rCBF) with the eight dimensions score of the Schizophrenia Quality of Life questionnaire (S-QoL 18). A significant positive correlation was found between the global index of the S-QoL 18 and rCBF in the right superior temporal sulcus and between psychological well-being dimension and rCBF in Brodmann area (BA)6, BA8, BA9, and BA10 and between self-esteem dimension and rCBF in striatum and between family relationship dimension and rCBF in BA1, BA2, BA3, BA4, BA8, BA22, BA40, BA42 and BA44 and between relationship with friends dimension and rCBF in BA44 and between physical well-being dimension and rCBF in parahippocampal gyrus, and finally between autonomy dimension and rCBF in cuneus and precuneus. A significant negative correlation was found between resilience dimension and rCBF in precuneus and between sentimental life dimension and rCBF in BA10. Our findings provide neural correlates of QoL. Brain regions involved in cognitions, emotional information processing and social cognition underlie the different QoL dimensions.

A structural equation modelling approach to explore the determinants of quality of life in schizophrenia

OBJECTIVE

This study aimed to analyse the relationships among psychotic symptoms, depression, neurocognition and functioning as determinants of quality of life (QoL) in patients with schizophrenia.

METHODS

In this cross-sectional study, we evaluated QoL with the Schizophrenia Quality of Life 18-item scale (S-QoL 18), neurocognition with multiple tests exploring memory, attention and executive functions, the severity of psychotic symptoms with the Positive and Negative Syndrome Scale (PANSS), depression with the Calgary Depression Scale for Schizophrenia (CDSS) and functioning using the Functional Remission Of General Schizophrenia (FROGS) scale. We used Structural Equation Modelling (SEM) to describe the relationships among the severity of psychotic symptoms, depression, neurocognition, functioning and QoL.

RESULTS

Two hundred and seventy-one outpatients with schizophrenia participated in our study. SEM showed good fit with χ(2)/df=1.97, root mean square error of approximation=0.06, comparative fit index=0.93 and standardized root mean square residuals=0.05. This model revealed that depression was the most important feature associated with QoL, mainly for the self-esteem, autonomy and resilience dimensions (direct path coefficient=-0.46). The direct path between functioning and QoL was also significant (path coefficient=0.26). The severity of psychotic symptoms and neurocognitive impairment were weakly and indirectly associated with QoL via functioning (path coefficients=-0.18 and 0.04, respectively).

CONCLUSIONS

This study contributes to a better understanding of the determinants of QoL in schizophrenia. Our findings should be considered in developing effective strategies for improving QoL among this population.

Beyond symptom management: Family relations, unmet needs of persons living with severe mental illnesses, and potential implications for social work in South Africa

This study examined the quality of family relationships and its associations with the severity of unmet needs of individuals admitted to a tertiary psychiatric hospital in South Africa. The quality of family relations and perceived unmet needs were assessed using the Lehman Quality of Life Interview and Camberwell Assessment of Needs, respectively. The results show that higher total unmet needs were associated with lower quality of family relations. The main areas of serious unmet needs included accessing government benefits and information, and establishing social relations. The results have implications for hospital-based social workers beyond managing psychiatric symptoms in South Africa.

Neural substrate of quality of life in patients with schizophrenia: a magnetisation transfer imaging study

The aim of this study was to investigate the neural substrate underlying quality of life (QoL) and to demonstrate the microstructural abnormalities associated with impaired QoL in a large sample of patients with schizophrenia, using magnetisation transfer imaging. A total of 81 right-handed men with a diagnosis of schizophrenia and 25 age- and sex-similar healthy controls were included and underwent a 3T MRI with magnetization transfer ratio (MTR) to detect microstructural abnormalities. Compared with healthy controls, patients with schizophrenia had grey matter (GM) decreased MTR values in the temporal lobe (BA21, BA37 and BA38), the bilateral insula, the occipital lobe (BA17, BA18 and BA19) and the cerebellum. Patients with impaired QoL had lower GM MTR values relative to patients with preserved QoL in the bilateral temporal pole (BA38), the bilateral insula, the secondary visual cortex (BA18), the vermis and the cerebellum. Significant correlations between MTR values and QoL scores (p < 0.005) were observed in the GM of patients in the right temporal pole (BA38), the bilateral insula, the vermis and the right cerebellum. Our study shows that QoL impairment in patients with schizophrenia is related to the microstructural changes in an extensive network, suggesting that QoL is a bio-psychosocial marker.

Biomarkers of treatment outcome in schizophrenia: Defining a benchmark for clinical significance

Emerging data from on imaging and genetic studies have generated interest in "clinically significant" biomarkers to predict response and prognosis. What constitutes "clinical significance" and how a biomarker would reach that threshold are unclear. To develop a benchmark we reviewed different approaches for defining "clinical significance" applied in schizophrenia research and identified that an improvement of 15 points on the PANSS Total is considered meaningful in clinical settings. Using this benchmark and we simulated thousands of schizophrenia trials, using characteristics derived from the NEWMEDS database with over 8000 patients with schizophrenia, to the kind of imaging, genetic, and other biomarkers that could attain clinical significance. We plotted the interaction between frequency-of-occurrence, the effect size of biomarkers and their relationship to the clinical significance threshold. Results show that categorical biomarkers are likely to attain clinical significance when they occur in 20-50% of the clinical population, and can predict at least a 8-10 point PANSS scale difference. Genetic markers are likely to have clinical significance when they occur in 20-50% of the population and can predict 7-9 points on the PANSS scale. A marker with a lower frequency or lesser effect size would find it hard to meet clinical significance thresholds for schizophrenia. The assumptions and limitations of this approach are discussed. Compared with standards in the rest of medicine, biomarkers that can attain this benchmark will be cost-effective and are likely to be adopted by clinical systems.

Postsecondary academic achievement and first-episode psychosis: A mixed-methods study

Background.

Postsecondary academic achievement as an area of functional recovery for young adults living with mental illness has received little research attention.

Purpose.

This study had three purposes: to compare rates of participation, performance, and satisfaction in postsecondary education between young adults with first-episode psychosis and closely matched young adults; to identify characteristics associated with academic participation; and to explore the processes associated with educational experiences.

Method.

One hundred young adults ages 18 to 30 participated in the study. Quantitative data on academic engagement, performance, and satisfaction, and qualitative data ( n = 52) on academic experiences were integrated through pattern analyzes.

Findings.

Young adults with psychosis were significantly less likely to be engaged in postsecondary education. No difference appeared for the extent of engagement, but performance and satisfaction were lower among participants with psychosis. Participants engaged in reflexive decision making to access postsecondary education and to maintain adequate academic performance. Strategies used by successful students with mental illness were identified.

Implications.

Assessment and intervention focused on educational needs and skills should become landmark practices for psychiatric rehabilitation practitioners, including occupational therapists.

How to interpret multidimensional quality of life questionnaires for patients with schizophrenia?

PURPOSE

The classification of patients into distinct categories of quality of life (QoL) levels may be useful for clinicians to interpret QoL scores from multidimensional questionnaires. The aim of this study had been to define clusters of QoL levels from a specific multidimensional questionnaire (SQoL18) for patients with schizophrenia by using a new method of interpretable clustering and to test its validity regarding socio-demographic, clinical, and QoL information.

METHODS

In this multicentre cross-sectional study, patients with schizophrenia have been classified using a hierarchical top-down method called clustering using unsupervised binary trees (CUBT). A three-group structure has been employed to define QoL levels as "high", "moderate", or "low". Socio-demographic, clinical, and QoL data have been compared between the three clusters to ensure their clinical relevance.

RESULTS

A total of 514 patients have been analysed: 78 are classified as "low", 265 as "moderate", and 171 as "high". The clustering shows satisfactory statistical properties, including reproducibility (using bootstrap analysis) and discriminancy (using factor analysis). The three clusters consistently differentiate patients. As expected, individuals in the "high" QoL level cluster report the lowest scores on the Positive and Negative Syndrome Scale (p = 0.01) and the Calgary Depression Scale (p < 0.01), and the highest scores on the Global Assessment of Functioning (p < 0.03), the SF36 (p < 0.01), the EuroQol (p < 0.01), and the Quality of Life Inventory (p < 0.01).

CONCLUSION

Given the ease with which this method can be applied, classification using CUBT may be useful for facilitating the interpretation of QoL scores in clinical practice.

Validity of subjective versus objective quality of life assessment in people with schizophrenia

BACKGROUND

Quality of life (QoL) is considered an important outcome in health research. It can be rated by the patient, or by an external assessor. We wished to identify the predictors of any discrepancies between these two approaches in people with schizophrenia.

METHODS

Patients with DSM schizophrenia and related disorders (N = 80) completed both patient-rated (Lancashire Quality of Life Profile; LQOLP) and assessor-rated (Heinrich's Quality of Life Scale; QLS) measures of QoL.

RESULTS

Patient-rated (LQOLP) and assessor-rated (QLS) measures showed a modest correlation (r = 0.38). In a regression analysis, independent predictors of subjectively-rated QoL being higher than objectively-assessed QoL in the same patient, were low insight score (BIS), negative symptoms (PANSS), absence of depression (CDSS), and less positive attitude toward prescribed treatment (DAI).

CONCLUSIONS

In people with schizophrenia, scores on objectively- and subjectively-rated measures of quality of life can differ markedly. When comparing subjective to objective assessments, patients with depressive symptoms will value their QoL lower, and those with low insight will value their QoL higher. This has important implications for the utility and interpretation of QoL measures in schizophrenia.

Importance of remission and residual somatic symptoms in health-related quality of life among outpatients with major depressive disorder: a cross-sectional study

BACKGROUND

Major depressive disorder (MDD) is strongly associated with an impaired quality of life (QoL), which is itself affected by various factors. Symptom-oriented ratings poorly reflect the impact of disease on the QoL and level of functioning of the mental health of subjects. The purpose of this study was to assess health-related QoL (HRQoL) using preference-based measures in outpatients with MDD with regard to their remission achievement and clinical factors affecting the HRQoL.

METHODS

This was a cross-sectional observational study. We recruited 811 patients with MDD from 14 psychiatric outpatient clinics in Korea. They were divided into three groups as follows: a new visit group (n = 287), a remitted group (n = 235), and a non-remitted group (n = 289). The 17-item Hamilton Depression Rating Scale was used to assign patients to the remitted or non-remitted group. The general HRQoL was assessed with the EuroQol 5D (EQ-5D), using both the EQ-5D index score and the EuroQol Visual Analog Scale (EQ-VAS). The disease-specific HRQoL was assessed with the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF).

RESULTS

The non-remitted group showed a significant impairment of HRQoL in view of the subscales of EQ-5D index scores, EQ-VAS, and Q-LES-Q-SF. The EQ-5D index score in the remitted group was 0.77 ± 0.10, while it was 0.57 ± 0.23 in the non-remitted group and 0.58 ± 0.24 in the new visit group (p < 0.0001). The EQ-VAS scores for the remitted and non-remitted groups were 72.5 ± 16.6 and 50.9 ± 20.3, respectively (p < 0.0001). Likewise, patients with remission had the Q-LES-Q-SF total score of 46.5 ± 8.8, whereas those with non-remission reported 36.7 ± 7.7 (p < 0.0001). The symptom severity measured by the Depression and Somatic Symptoms Scale was significantly correlated with the HRQoL. Furthermore, patients with severe somatic symptoms showed a significantly lower EQ-5D index score (0.54 ± 0.24) than those with mild/moderate somatic symptoms (0.75 ± 0.12; p = 0.002).

CONCLUSION

Non-remitted MDD patients, especially those with more severe somatic symptoms, show a distinct impairment of HRQoL and more clinical symptoms, suggesting the importance of achieving remission in the treatment of MDD.

Relative contributions of negative symptoms, insight, and coping strategies to quality of life in stable schizophrenia

The purpose of this cross-sectional study was to examine the relative contributions of negative symptomatology, insight, and coping to quality of life (QOL) in a sample of 92 consecutive outpatients with stable schizophrenia referring to the Department of Neuroscience, Psychiatric Section, University of Turin, Struttura Semplice di Coordinamento a Valenza Dipartimentale (SSCVD), Department of Mental Health ASL TO1, Molinette, Italy, in the period between July 2009 and July 2011. In order to assess the specific effect of negative symptoms on QOL and the possible mediating role of insight and coping, two mediation hypotheses were tested, using multiple regression analyses specified by Baron and Kenny (1986). Our findings suggest that (a) higher negative symptoms predict a worse Quality of Life Scale (QLS) intrapsychic foundations (IF) subscale score; (b) attribution of symptoms and coping-social diversion have a direct and positive association with QLS-IF; (c) patients high in negative symptoms are less likely to use attribution of symptoms and coping-social diversion; and (d) attribution of symptoms and coping-social diversion act as partial mediators in the negative symptoms-QOL relationship. The prediction model accounts for 45.3% of the variance of the QLS-IF subscale score in our sample. In conclusion, our results suggest that insight and coping-social diversion substantially contribute to QOL in patients with higher negative symptoms. These factors are potentially modifiable from specific therapeutic interventions, which can produce considerable improvements in the QOL of this population.

Spanish cross-cultural adaptation and psychometric properties of the Schizophrenia Quality of Life short-version questionnaire (SQoL18) in 3 middle-income countries: Bolivia, Chile and Peru

OBJECTIVE

The aim of this study was to adapt the Schizophrenia - Quality of Life short-version questionnaire (SQoL18) for use in three middle-income countries in Latin America and to evaluate the factor structure, reliability, and external validity of this questionnaire.

METHODS

The SQoL18 was translated into Spanish using a well-validated forward-backward process. We evaluated the psychometric properties of the SQoL18 in a sample of 253 patients with schizophrenia attending outpatient mental health services in three Latin American countries. For participants in each country (Bolivia, N=83; Chile, N=85; Peru, N=85), psychometric properties were compared to those reported from the reference population (507 patients with schizophrenia) assessed in the validation study. In addition, differential item functioning (DIF) analyses were performed to see whether all items behave in the same way in each country.

RESULTS

Factor analysis performed in the 3 countries showed that the questionnaire's structure adequately matched the initial structure of the SQoL18. The unidimensionality of the dimensions was preserved, and the internal/external validity indices were close to those of the reference population. However, one dimension of the SQoL18 (resilience) presented some unsatisfactory properties including low Cronbach's alpha coefficients, one INFIT value higher than 1.2, and one item showing DIF between the 3 countries.

CONCLUSIONS

These results demonstrate the satisfactory acceptability and psychometric properties of the SQoL18, suggesting the relevance of this questionnaire among patients with schizophrenia in these 3 Latin American countries.

Effect of antipsychotic medication on overall life satisfaction among individuals with chronic schizophrenia: findings from the NIMH CATIE study

The field of schizophrenia is redefining optimal outcome, moving beyond clinical remission to a more comprehensive model including functional recovery and improved subjective well-being. Although numerous studies have evaluated subjective outcomes within the domain of subjective quality of life in patients with schizophrenia, less is known about global evaluations of subjective well-being. This study examined the effects of antipsychotic medication on overall life satisfaction in patients with chronic schizophrenia. Data were drawn from the Clinical Antipsychotic Trial of Intervention Effectiveness (CATIE) study, where participants with a DSM-IV diagnosis of schizophrenia were randomized to receive olanzapine, perphenazine, quetiapine, risperidone or ziprasidone under double-blind conditions (N=753). The primary outcome measure was prospective change in subjectively evaluated overall life satisfaction scores following 12 months of antipsychotic treatment. Psychopathology, medication side effects and functional status were also evaluated, among other variables. Patients experienced modest improvements in overall life satisfaction (d=0.22, p<0.001), with no differences between antipsychotic medications (all tests, p>0.05). Change in severity of positive, negative, and depressive symptoms as well as functional status each demonstrated a small, albeit statistically significant, association with change in life satisfaction (r=0.10-0.21, p׳s<0.01). In a multivariate regression model, change in clinical symptoms and functional status had limited independent predictive value for change in life satisfaction scores (explained variance <3%). These data suggest that despite antipsychotic medications being effective for symptom-based psychopathology, such clinical effectiveness does not necessarily translate to improved general satisfaction with life. Clinicians should be aware that these two domains are not inextricably linked.

Quality of life in stable schizophrenia: the relative contributions of disorganization and cognitive dysfunction

OBJECTIVE

The purpose of this study was to examine the relative contributions of disorganization and cognitive dysfunction to quality of life (QOL) in patients with stable schizophrenia.

METHODS

A total of 276 consecutive outpatients with stable schizophrenia were enrolled in a cross-sectional study. We performed a mediation analysis to assess the specific effect of disorganization on QOL, as assessed by the Heinrichs-Carpenter Quality of Life Scale (QLS), and the possible mediating role of cognitive dysfunction.

RESULTS

Our findings were as follows: (i) disorganization was negatively related to the total QLS score; (ii) disorganization was negatively related to two of the four QLS domains, namely the role-functioning domain (occupational/educational) and the intrapsychic functioning domain (e.g., motivation, curiosity, and empathy); and (iii) verbal memory was a partial mediator of the relationship between disorganization and QLS (the total score and the two above-mentioned domains).

CONCLUSIONS

Disorganization demonstrated direct and indirect effects via verbal memory on two domains of functioning, as measured by the QLS. These results highlight the importance of improving disorganization and cognition (particularly verbal memory) to improve the functional outcomes of patients with schizophrenia.

Mediation analysis of critical time intervention for persons living with serious mental illnesses: assessing the role of family relations in reducing psychiatric rehospitalization

OBJECTIVE

Critical Time Intervention (CTI) is a time-limited care coordination intervention designed to reduce homelessness and other adverse outcomes for persons living with serious mental illness during the transition period between institutions and community living. This study assesses whether CTI improves the quality of family relationships between family members and individuals living with serious mental illness, and examines whether changes in quality of family relationship mediated the association between the intervention and psychiatric rehospitalization outcomes.

METHOD

This study utilizes data from a randomized controlled trial that assessed the effect of CTI in preventing homelessness. Following discharge from inpatient psychiatric treatment in New York City, 150 previously homeless persons living with serious mental illness were randomly assigned to receive usual services only or 9 months of CTI in addition to usual services.

RESULTS

Findings from mixed-effects regression models indicated that those assigned to the CTI group reported greater frequency of family contact and greater improvement in satisfaction with family relations than the comparison group during the 18-month follow-up period. Mediation analysis revealed that greater improvement in satisfaction with family relations mediated the effect of CTI on psychiatric rehospitalization outcome, but only at a modest level.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

These findings suggest that a relatively brief but targeted intervention delivered at the point of hospital discharge may contribute to strengthening family relations and that improvement in perceived family relationship quality can contribute to a reduction in psychiatric rehospitalization.

Measuring quality of life in patients with schizophrenia:an overview

Quality of life (QoL) is of great importance to patients with schizophrenia and their families. Although the use of QoL measures may contribute to better adherence to therapeutic interventions, more satisfaction with care, improved health outcomes and reduction of health costs, QoL assessment remains underutilized in clinical practice. In this review, the authors propose a reflection on the limitations and lack of impact of QoL measures in clinical care. Our argument is based on three challenges regarding conceptual aspects and metrics, use and limits and the usefulness of measuring QoL. For each challenge, the authors have suggested pragmatic proposals and new research directions to promote the use of QoL measures in the future. These avenues of research involve a shared responsibility between QoL researchers, the medical community and decision makers. Close collaboration between all parties is necessary to promote the use of QoL measures in schizophrenia.

Health-related quality of life and metabolic risk in patients with psychosis

Improved Health-related quality of life (HRQoL) is an alternative treatment goal for individuals with psychosis, who have up to two times greater prevalence of type 2 diabetes, hypertension and obesity than the general population.

AIM

to compare HRQoL in patients with psychosis, especially schizophrenia, with a reference sample and explore the relationship between HRQoL and metabolic risk factors in these patients.

METHODS

a prospective cohort study was carried out in specialized psychiatric outpatient departments in Sweden. The patients were invited consecutively. A prospective population-based study of public health in the south-east of Sweden served as reference group. Patients were assessed with psychiatric questionnaires that included Global Assessment of Functioning (GAF). Health-related quality of life was assessed using the questionnaire EQ5D, both for patients and the population, and several other health status outcomes were used.

RESULTS

At 73%, schizophrenia and schizoaffective disorder were the most common diagnoses in the patient group. The results in patients (n=903) and population (n=7238) showed significant differences in lower EQ5D among patients. According to the definition by the International Diabetes Federation (IDF), elevated blood pressure was the only metabolic risk associated with lower HRQoL in patients. Raised LDL-cholesterol levels were also significantly related to lower HRQoL.

CONCLUSION

patients suffering from psychosis had significantly lower HRQoL regarding all components in EQ5D, except for the pain/discomfort component. Almost half of the patient group met the criteria for metabolic syndrome. According to the IDF criteria, elevated blood pressure was the only metabolic risk factor that had an impact on HRQoL.

Toward meeting the needs of homeless people with schizophrenia: the validity of quality of life measurement

OBJECTIVE

To provide new evidence regarding the suitability of using quality of life (QoL) measurements in homeless people with schizophrenia, we assess the acceptability and psychometric properties of a specific QoL instrument (S-QoL 18) in a population of homeless people with schizophrenia, and we compare their QoL levels with those observed in non-homeless people with schizophrenia.

METHODS

This multi-centre prospective study was conducted in the following 4 French cities: Lille, Marseille, Paris and Toulouse. Two hundred and thirty-six homeless patients with schizophrenia were recruited over a 12 month-period. The S-QoL 18 was tested for construct validity, reliability, external validity and sensitivity to change. The QoL of the 236 homeless patients was compared with 236 French age- and sex-matched non-homeless patients with schizophrenia.

RESULTS

The eight-factor structure of the S-QoL 18 was confirmed by confirmatory factor analysis (RMSEA = 0.035, CFI = 0.95, GFI = 0.99 and SRMR = 0.015). Internal consistency, reliability and sensitivity to change were satisfactory. External validity was confirmed via correlations between S-QoL 18 dimension scores and SF-36, symptomatology and recovery scores. The percentage of missing data did not exceed 5%. Finally, homeless patients had significantly lower QoL levels than non-homeless patients with schizophrenia.

CONCLUSIONS

These results demonstrate the satisfactory acceptability and psychometric properties of the S-QoL 18, suggesting the validity of QoL measurement among homeless patients with schizophrenia. Our study also reported that QoL levels in homeless patients with schizophrenia were dramatically low, highlighting the need for new policies to eradicate homelessness and tackle poverty.

The Relationship between Impulsivity and Quality of Life in Euthymic Patients with Bipolar Disorder

OBJECTIVE

Bipolar disorder (BD) is characterized by elevated impulsivity, even during periods of remission. Many recovered BD patients have functional impairments, which can lead to poor quality of life (QoL). The aim of this study was to investigate the association between impulsivity and QoL in euthymic BD patients.

METHODS

A total of 56 remitted or recovered patients with type I or II BD, diagnosed based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, were recruited. Psychiatrists administered the Clinical Global Impression (CGI) for BD and the Global Assessment of Functioning (GAF) scales and then interviewed the subjects to assess clinical variables. Patients completed the Barratt Impulsiveness Scale (BIS-11) and the World Health Organization Quality of Life Assessment Instrument-Brief Form (WHOQoL-BREF). Pearson correlations, univariate regression analyses, and multiple linear regression analyses were performed.

RESULTS

The BIS-11 total score was significantly correlated with the WHOQoL-BREF total score (r=-0.55, p<0.01) and with the WHOQoL-BREF subscales. After controlling for GAF score and other clinical variables, the BIS-11 total score (β=-0.43, p=0.001) was independently associated with overall QoL. Additionally, the BIS-11 total score was particularly strongly associated with the physical, psychological, and social domains of the multi-dimensional QoL scale.

CONCLUSION

Our results suggest that high impulsivity is related to low QoL in euthymic BD patients. Further studies are needed to examine whether interventions for high impulsivity effectively improve QoL in patients with BD.

Improved quality of life over one year is associated with improved adherence in patients with schizophrenia

AIM

Quality of life (QoL) is increasingly considered an important outcome in health research. We wished to explore the determinants of change in QoL in patients with schizophrenia over the course of a one-year RCT.

METHODS

Predictors of change in observer-rated QoL (Quality of Life Scale: QLS) were assessed in 363 patients with schizophrenia during the CUtLASS clinical trial.

RESULTS

Change in QLS score over the course of a year correlated with change in psychotic and depressive symptoms and treatment adherence. Linear regression showed that improvement in QoL was predicted by reduction in negative and depressive symptoms and improvement in adherence rating. These three change scores together explained 38% of the variance in QLS change. Exploration of the direction of any possible causal effect, using TETRAD, indicated that improved adherence leads to improved QoL, and that change in depression also leads to QoL change. The relationship between QoL and negative symptoms suggests that greater social activity (reflected as better QoL scores) improves negative symptoms. Such a direct relationship between treatment adherence and QoL has not been reported before.

CONCLUSION

Improving adherence to medication would appear to be a key approach to improving measured quality of life in people with schizophrenia.

Transitions to adulthood in first-episode psychosis: a comparative study

AIM

The first aim of this study is to compare attainment of five markers of transition to adulthood between young adults with first-episode psychosis and young adults without any psychopathology. The second aim is to examine if the association between age group and transition to adulthood is similar for individuals who experience first-episode psychosis versus those who do not.

METHODS

Participants were 50 young adults with first-episode schizophrenia aged between 18 and 30 years old, and 50 volunteers without any psychopathology matched for sex and age. Participants were assessed with the Quality of Life Scale and a questionnaire on markers of transition to adulthood.

RESULTS

Significant differences appear between the groups for three of the five markers of transition to adulthood, namely: residential/financial independence, educational attainment and involvement in a romantic relationship. The effect of age on several markers is significant for the comparison group only.

CONCLUSION

Rehabilitation interventions should be informed by a developmental perspective on community functioning for young adults with first-episode schizophrenia. Vocational rehabilitation should be extended to focus more extensively on supported education and not only on supported employment, and interventions targeting residential independence should be granted more attention.

Quality of life is predictive of relapse in schizophrenia

BACKGROUND

The objective of this study was to evaluate whether quality of life (QoL), as measured by the SF36 and the Quality of Life Interview (QoLI), is predictive of relapse for patients with schizophrenia.

METHODS

Using data from a multicenter cohort study conducted in France, Germany, and the United-Kingdom (EuroSC), we performed Cox proportional-hazards models to estimate the associations between QoL at baseline and the occurrence of relapse over a 24-month period, with adjustment for age; gender; positive, negative and general psychopathology PANSS factors; functioning (GAF); medication; side-effects; and compliance measures.

RESULTS

Our sample consisted of 1,024 patients; 540 (53%) had at least one period of relapse, and 484 (47%) had no relapse. QoL levels were the most important features predicting relapse. We found that a higher level of QoL predicts a lower rate of relapse at 24 months: HR = 0.82 (0.74; 0.91), p < 0.001 for the SF36-Physical Composite Score; and HR = 0.88 (0.81; 0.96), p = 0.002 for the SF36-Mental Composite Score. These results were not confirmed using the QoLI: HR = 0.91 (0.81; 1.01), p = 0.083. To a lesser extent, older age, better functioning, and a higher compliance score also predict a lower rate of relapse at 24 months (HRs from 0.97 to 0.98; p < 0.05).

CONCLUSIONS

QoL, as assessed by the SF36, is an independent predictor of relapse at a 24-month follow-up in schizophrenia. This finding may have implications for future use of the QoL in psychiatry. Moreover, our findings may support the development and monitoring of complementary therapeutic approaches, such as 'recovery-oriented' combined with traditional mental health cares to prevent relapse.

Empirically driven definitions of "good," "moderate," and "poor" levels of functioning in the treatment of schizophrenia

Purpose

This study used an empirical approach to identify and validate the classification of patients with schizophrenia in “good,” “moderate,” or “poor” functioning groups based on the assessment of functional measures.

Methods

Using data from a study of schizophrenia outpatients, patients were classified into functional groups using cluster analysis based on the Heinrich–Carpenter Quality of Life Scale (QLS), the 36-item Short-Form Health Survey (SF-36) Mental Component Summary Score, and a productivity measure. A three-cluster solution was chosen. Concurrent, convergent, and discriminant validity were assessed. Criteria for classifying patient functioning as “good,” “moderate,” or “poor” were established using classification and regression tree analysis.

Results

The three clusters consistently differentiated patients on the QLS, SF-36 Mental Component Summary Score, and productivity measure. The clusters also differed on other functional measures and were concordant with previous functional classifications. Concurrent, convergent, and discriminant validity were good. “Good” functioning was identified as a QLS total score ≥84.5; “moderate” and “poor” functioning were separated by a cutoff score of 15.5 on the QLS intrapsychic foundation domain. Sensitivity ranged from 86 to 93 % and specificity from 89 to 99 %.

Conclusions

The heterogeneity in functioning of schizophrenia patients can be classified reliably in an empirical manner using specific cutoff scores on commonly used functional measures.

Measuring patient-reported outcomes in psychosis: conceptual and methodological review

BACKGROUND

There are calls to use patient-reported outcomes (PROs) routinely across mental health services. However, the use of PROs in patients with psychosis has been questioned.

AIMS

To examine the concepts and measures of four widely used PROs: treatment satisfaction, subjective quality of life, needs for care and the quality of the therapeutic relationship.

METHOD

We conducted a literature search of academic databases on concepts, characteristics and psychometric properties of the four PROs in patients with psychosis.

RESULTS

Although numerous concepts and measures have been published, evidence on the methodological quality of existing PROs is limited. Measures designed to assess distinct PROs showed a considerable conceptual, operational and empirical overlap, and some of them also included specific aspects. The impact of symptoms and cognitive deficits appears unlikely to be of clinical significance.

CONCLUSIONS

The popularity of PROs has not been matched with progress in their conceptualisation and measurement. Based on current evidence, some recommendations can be made. Distinct and short measures with clinical relevance and sufficient psychometric properties should be preferred. Future research should optimise the validity and measurement precision of PROs, while reducing assessment burden.

Reliability and validity of the Personal and Social Performance scale in patients with schizophrenia

OBJECTIVE

The construct validity and test-retest reliability of the Personal and Social Performance (PSP) scale were used to assess social functioning in a cohort of ethnically diverse UK patients with schizophrenia.

METHODS

A total of 73 patients with schizophrenia took part in the study. At baseline, the PSP, two symptomatology scales and two other functioning scales were administered. A subset of the sample (N=40) took part in a retest where the Clinical Global Impression-Severity (CGI-S) and PSP scales were administered 8-10 days later.

RESULTS

PSP significantly correlated with all other measures, Positive and Negative Syndrome Scale (PANSS), Global Assessment of Functioning (GAF) and Quality of Life Scale (QLS) at baseline (p<0.02) and with CGI-S at follow-up (p<0.01). In addition, the PSP scale was moderately sensitive to the severity of illness. Test-retest reliability for the PSP score was 0.45 and the scale was able to discriminate between known groups (mild and severe patients).

CONCLUSION

The PSP was easy to administer in this predominantly inpatient cohort and was moderately correlated with all other functioning measures tested. Due to patient homogeneity, the test-retest reliability statistic of the PSP was lower than that observed in other studies.

Validation of the Schizophrenia Quality of Life Scale Revision 4 among Chronic Schizophrenia Patients in Malaysia

OBJECTIVES

To explore the validity and reliability of a disease-specific health-related quality-of-life questionnaire-the Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4)-in patients with schizophrenia in Malaysia.

METHODS

A total of 222 outpatients with schizophrenia receiving treatment at the Universiti Kebangsaan Malaysia Medical Centre completed the SQLS-R4 in either the Malay or the English language. A generic self-report health-related quality-of-life measure-the EuroQoL group EuroQol five-dimensional questionnaire-and a measure of symptom severity-the Clinical Global Impression-Schizophrenia scale-were also administered to assess validity.

RESULTS

Good internal consistency reliability was found for both the psychosocial and vitality domains (Cronbach's α = 0.95 and 0.85, respectively). Most items were also significantly correlated with their own scale score (r_s ranging from 0.29 to 0.74). There was a moderate correlation between the SQLS-R4 "vitality" domain and the EuroQol five-dimensional questionnaire "usual activities" domain (r_s = 0.44) and a large correlation between the SQLS-R4 "psychosocial" domain and the EuroQol five-dimensional questionnaire "anxiety/depression" domain (r_s = 0.44-0.57). Most of the symptom dimensions of the Clinical Global Impression-Schizophrenia scale were also moderately correlated with the SQLS-R4 subscale scores.

CONCLUSIONS

The SQLS-R4 is a valid and reliable health-related quality-of-life instrument for use in minimally ill patients with schizophrenia in Malaysia, but some of the items may be redundant and irrelevant. Validation of SQLS-R4 in different types of patients and various levels of illness severity is required to further verify its application.

Development of personal narratives as a mediator of the impact of deficits in social cognition and social withdrawal on negative symptoms in schizophrenia

Although negative symptoms are a barrier to recovery from schizophrenia, little is understood about the psychological processes that reinforce and sustain them. To explore this issue, this study used structural equation modeling to test whether the impact of social withdrawal and emotion recognition deficits upon negative symptoms is mediated by the richness or poverty of personal narratives. The participants were 99 adults with schizophrenia spectrum disorders. Social cognition was assessed using the Bell-Lysaker Emotional Recognition Task; social withdrawal, using the Quality of Life Scale; narrative coherence, using the Scale To Assess Narrative Development; and negative symptoms, using the Positive and Negative Syndrome Scale. The findings reveal that although social cognition deficits and social withdrawal are significantly associated with negative symptom severity, these relationships become nonsignificant when personal narrative integrity is examined as a mediating factor. These results indicate that the development of personal narratives may be directly linked to the severity of negative symptoms; this construct may be a useful target for future interventions.

Insight into illness, neurocognition and quality of life in schizophrenia

OBJECTIVE

The aim of this study was to assess the impact of insight into illness on self-reported quality of life (QoL) for patients with schizophrenia.

METHODS

This cross-sectional study was conducted in the psychiatric department of a French public university teaching hospital. The data collected included socio-demographic information, clinical characteristics, medications, cognitive performance assessments, insight into illness, and the S-QoL 18. A multivariate analysis using multiple linear regressions was performed to determine variables potentially associated with QoL levels.

RESULTS

One hundred and thirteen outpatients with stable schizophrenia were enrolled in our study. Significant associations were found between QoL and socio-demographic characteristics: a higher QoL was associated with marital status (in couple) and employment. Concerning insight into illness, lower QoL levels were associated with better awareness of the mental disorder, whereas higher QoL levels were associated with better awareness of positive and negative symptoms. Elementary neuropsychological measures were not statistically associated with QoL.

CONCLUSION

Insight into illness, marital status and employment were the most important features associated with QoL, whereas there was no evidence that elementary neurocognition directly influenced QoL. The different facets of insight into illness should be considered to guide the development of specific interventions intended to improve QoL. Moreover, this study highlights the need for clinicians to pay more attention to the personal impact of schizophrenia, especially upon family life and work.

Quality of life among caregivers of individuals with affective disorders

OBJECTIVE

The aims of this study were as follows: 1. to assess the quality of life (QoL) of caregivers of individuals with affective disorders (major depressive disorder and bipolar disorder); 2. to compare QoL levels with those observed in caregivers of individuals with schizophrenia and in the general population; 3. to determine the impact of sociodemographic and clinical factors on the caregivers' QoL.

METHODS

Data were collected from the psychiatric departments of a French public teaching hospital. QoL was measured with the SF-36 questionnaire. The QoL of 232 caregivers of individuals with affective disorders was compared with 246 caregivers of individuals with schizophrenia and 232 French age-sex-matched controls.

RESULTS

Caregivers of individuals with affective disorders experienced lower QoL levels than French age-sex-matched controls. The most severe impairment concerned psychological distress, social and role disability due to emotional problems (SF36-mental composite score=38.2). In contrast, caregivers of individuals with affective disorders reported higher SF36 dimension scores than caregivers of individuals with schizophrenia. Among caregivers of individuals with affective disorders, women (p=0.010), parents/family or spouse (p=0.017), caregivers living in the same home (p=0.003) and caregivers of individuals with MDD (p=0.005) were significantly associated with a lower SF36-mental composite score.

CONCLUSION

The QoL of caregivers of individuals with affective disorders is seriously impaired, mainly because of an altered psychological or mental well-being and social life. QoL adds interesting and complementary information to information that has been traditionally collected (burden, stress, perceived stigma) and facilitates the identification of specific needs that should be addressed in support groups for caregivers.

Effectiveness studies: advantages and disadvantages

In recent years, so-called “effectiveness studies,” also called “real-world studies” or “pragmatic trials, ” have gained increasing importance in the context of evidencebased medicine. These studies follow less restrictive methodological standards than phase III studies in terms of patient selection, comedication, and other design issues, and their results should therefore be better generalizable than those of phase III trials. Effectiveness studies, like other types of phase IV studies, can therefore contribute to knowledge about medications and supply relevant information in addition to that gained from phase III trials. However, the less restrictive design and inherent methodological problems of phase IV studies have to be carefully considered. For example, the greater variance caused by the different kinds of confounders as well as problematic design issues, such as insensitive primary outcome criteria, unblinded treatment conditions, inclusion of chronic refractory patients, etc, can lead to wrong conclusions. Due to these methodological problems, effectiveness studies are on a principally lower level of evidence, adding only a complementary view to the results of phase III trials without falsifying their results.

Metacognition and social function in schizophrenia: associations over a period of five months

INTRODUCTION

Deficits in the ability to think about thinking have been widely observed in persons with schizophrenia and linked with concurrent assessments of various forms of function. Less is known though about their links to outcome over time. To address this issue, the current study explores whether Mastery, a domain of metacognition that reflects the ability to use knowledge about one's own mental states and those of others to respond to psychological challenges, is related to the frequency of social contact and persons' capacity for social relatedness.

METHODS

Participants were 72 adults with schizophrenia spectrum disorders enrolled in vocational rehabilitation; these patients completed a baseline assessment as well as a follow-up assessment 5 months later. Mastery was assessed using the Metacognitive Assessment Scale and social functioning by the Quality of Life Scale.

RESULTS

Using structural equation modelling, the proposed model demonstrated acceptable fit even when a range of possible confounding variables were entered as covariates.

CONCLUSIONS

. Results are consistent with the possibility that certain forms of metacognition affect social function among persons with schizophrenia, both concurrently and over time.