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Clinical correlates of objective and subjective quality of life among middle-aged and elderly female inpatients with chronic schizophrenia
Asian Journal of Psychiatry 6 (2013) 389–393
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Clinical correlates of objective and subjective quality of life among middle-aged and elderly female inpatients with chronic schizophrenia Seishu Nakagawa a,b,*, Naoki Hayashi a,c,d a
Department of Psychiatry, Tokyo Metropolitan Matsuzawa Hospital, 2-1-1 Kamikitazawa, Setagaya-ku, Tokyo 156-0057, Japan Department of Functional Brain Imaging, Institute of Development, Aging and Cancer (IDAC), Tohoku University, Sendai, Japan c Schizophrenia Research Team, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan d Department of Psychiatry, Teikyo University Hospital, Tokyo, Japan b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 6 November 2012 Received in revised form 16 March 2013 Accepted 30 March 2013
Objective: The aim of this study was to illustrate the relationship between objective and subjective measures of quality of life (QOL) and to identify the factors influencing QOL in a sample of middle-aged and elderly female patients with schizophrenia in Japan. Methods: Middle-aged and elderly female inpatients with schizophrenia (n = 66; mean age [SD]: 68.0 [8.0]) were assessed using the Quality of Life Scale (QLS), Lancashire Quality of Life Profile (LQLP), Positive and Negative Symptoms Scale (PANSS), and Rehabilitation Evaluation Hall and Baker (REHAB). Correlation analyses among the measures and regression analyses of objective and subjective QOL measures (QLS and LQLP) were conducted. Explanations of results for the two types of QOL measures in terms of psychotic symptomatology and adjustment variables (PANSS and REHAB) are discussed. Results: There was no salient correlation between objective and subjective QOL measures. The regression analyses identified PANSS anergia and REHAB community skills as factors influencing objective QOL, whereas PANSS depression and paranoid/belligerence were factors influencing subjective QOL. Conclusions: Results indicated that objective and subjective QOL domains should be treated separately in clinical practice for this patient population. Some QOL factors identified in the regression analyses can be used as targets to improve QOL. The findings have important clinical implications for the assessment and treatment of this patient population. ß 2013 Elsevier B.V. All rights reserved.
Keywords: Female Inpatient Life satisfaction Quality of life Schizophrenia
1. Introduction Quality of life (QOL) of patients with schizophrenia has been highlighted in the field of psychiatric practice as an important clinical index. The improvement of QOL is one aim of treatment for schizophrenia. However, its assessment method has been a focus of intense controversy because QOL is composed of multiple factors, e.g., the condition of the patient’s adjustment, social environment, psychiatric and physical conditions, and the patient’ s view of life’s value (Eack and Newhill, 2007; Priebe, 2007). In addition, the discrepancy between subjective and objective QOL evaluations (Eack and Newhill, 2007; Tolman and Kurtz, 2012) has been the major issue in patient QOL assessment. While subjective
* Corresponding author at: Department of Functional Brain Imaging, Institute of Development, Aging and Cancer (IDAC), Tohoku University, Seiryo-machi 4-1, Aoba-ku, Sendai 980-8575, Japan. Tel.: +81 22 717 7988; fax: +81 22 717 7988. E-mail addresses: [email protected], [email protected] (S. Nakagawa). 1876-2018/$ – see front matter ß 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajp.2013.03.015
evaluation of QOL must have a certain importance in itself, it was affected by psychotic symptoms such as poor insight and delusional beliefs (Reininghaus et al., 2012). In contrast, objective QOL evaluation is not directly related to the neurocognitive distortions, and its quite insufficient to cover all the domains of personal well-being that the concept of QOL implies. The consequence is that there have been a wide variety of QOL assessment methods and many inconsistencies in the results of different studies. To remedy the situation, Eack and Newhill (2007) and Priebe et al. (2010) recommended that studies be conducted to address the QOL features of a specified patient population. Under this specification, chronicity (older age) and gender are essential factors. There have been some studies dealing with the QOL of patients with chronic schizophrenia (Nakamae et al., 2010; Tomida et al., 2010; Kao et al., 2011; El Sheshtawy, 2011) or middle-aged and elderly patients with schizophrenia (Cohen et al., 2003; Bankole et al., 2007; Roseman et al., 2008; Bartels and Pratt, 2009; Priebe et al., 2010). The review revealed a tendency for older patients to have higher subjective QOL scores beginning around middle-age (mean age
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[SD]: 39.4 [11.4]) (Priebe et al., 2010). Concerning gender difference, Andia et al. (1995) reported that women exhibited better psychosocial functioning while the severity of their symptoms and neurocognitive status were equivalent to those of men. Likewise, Salokangas et al. (2006) found that being female was one of the important factors of life satisfaction among long-term hospitalized patients with schizophrenia. In addition, Roder-Wanner et al. (1997) stressed that determinants of the subjective QOL measure were not equal for both sexes. Leung and Chue (2000) added that better social functioning appeared to contribute to elevating QOL among women with schizophrenia more so than men. It is expected from these studies that by using an age and gender specified patient population, an investigation of QOL will obtain clearer and simpler results. Dealing with a specified sample of middle-aged and elderly female inpatients with chronic schizophrenia, the present study attempted to elucidate the interrelationships among subjective and objective QOL domains and factors of adjustment conditions and psychotic symptoms that are theoretically considered to have an influence on QOL. It is hypothesized that the QOL domains would have different patterns of influencing factors that need respective approach means. The factors influencing each of the QOL domains this study attempts to identify can be usable for contriving individualized approaches to improve QOL for this patient population. 2. Methods 2.1. Subjects Subjects of this study (n = 66) were female inpatients from the two long-stay wards of Tokyo Metropolitan Matsuzawa Hospital, a large psychiatric center for regional psychiatric services and the treatment of difficult patients in central Tokyo. Both wards were composed mostly of middle-aged and elderly patients with chronic schizophrenia of similar demographics that needed enduring rehabilitative services. The patients were not restricted from participating in social communication outside the hospital. Routine recreational and rehabilitative activities, including chorus or dance meetings, excursions, and occupational therapy were also carried out in the hospital. The levels of physical independence, assessed based on the Japanese Ministry of Health, Labor and Welfare criteria (Hirakawa et al., 2005) were ‘‘independent’’ or ‘‘house-bound’’ i.e., better than ‘‘chair-bound’’ and ‘‘bed-bound’’. Criteria for the inclusion of subjects were a diagnosis of schizophrenia, an age equal to or over 50 years and absence of unequivocal organic cognitive impairment or mental retardation. The diagnosis of the subjects was made on the basis of examining case records according to DSM-IV criteria. The subjects gave written informed consent to participate in the study and patient anonymity has been preserved. This study was approved by the ethical committee of Tokyo Metropolitan Matsuzawa Hospital. 2.2. Assessment Objective QOL was measured with the Quality of Life Scale (QLS) (Heinrichs et al., 1984). The QLS is a disease-specific and clinicianrated measure of QOL for persons with schizophrenia. The QLS was developed for the evaluation of patients’ objective QOL by means of assessing deficit symptoms and functional status. A higher score means better QOL. The scale has 21 items and four subscales including ‘interpersonal relations’, ‘instrumental role’, ‘intrapsychic foundations’ and ‘common place objects and activities’. However, the QLS item 12 was excluded in the assessment because it was applicable solely to regular workers. While the validation study of the Japanese version (Kaneda et al., 2002) of the QLS has
already been published, our study group conducted an inter-rater reliability study prior to beginning our study. The study, in which two psychiatrist raters made independent ratings of the QLSs on the basis of a single interview for 20 patients, gave satisfactory results. The average (SD, range) of analyses of variance intraclass coefficients (ANOVA ICC) of the subscales was 0.76 (0.12, 0.41– 0.95). The average of Cronbach’s alpha coefficients was 0.83 (0.06, 0.78–0.92). The measure of subjective QOL was the Lancashire Quality of Life Profile (LQLP) which was devised by Oliver et al. (RoderWanner et al., 1997). The LQLP consists of a 7-point, 10-item selfreport scale that inquired into satisfaction with ‘life in general’, ‘mental health’, ‘work situation’, ‘finances’, ‘living situation’, ‘personal safety’, ‘leisure activities’, ‘family’, and ‘getting on with others and friends’. In this study, the LQLP items related to ‘‘work situation’’, which were hardly applicable to the subject, were excluded. The scale was orally administered in an interview. Prior to or in this study, our study group conducted a test–retest reliability study. The nine item LQLP assessment of 21 subjects was carried out twice at an approximately 2-month interval. The reliability proved to be moderate (ANOVA ICC = 0.59, p = 0.002). Internal consistency of the LQLS assessment in this study was permissible (Cronbach’s alpha = 0.71). The measure used for assessing psychotic symptomatology was the Positive and Negative Symptoms Scale (PANSS) (Kay et al., 1988, 1991), which is a 7-point, 30-item rating scale widely used for evaluating symptoms of patients with psychoses; a reliability study of the Japanese version of the PANSS by our study group provided favorable results (Igarashi et al., 1998). In this study, scores of symptom clusters derived from the five-factor model by Kay et al. and an item score of lack of judgment and insight (G12) were used. The PANSS five-factor model (Anergia, Thought Disturbance, Activation, Paranoid Belligerence, and Depression) has been adopted in the PANSS user manual as the legitimate symptom cluster model. Scores are used to depict the dimensions of the patient’s psychopathology (Kay et al., 1991). The psychiatrist raters of this study (SN and NH) had fulfilled Kay’s criteria for reliable assessment (Kay et al., 1988). During the study period, we also conducted a confirmation of their skills by attaining a consensus PANSS rating from the raters. The measure of adjustment conditions was the Rehabilitation Evaluation Hall and Baker (REHAB) (Baker and Hall, 1983, 1988), which is a behavior rating scale for assessing the daily life activities of people with psychiatric disabilities (Baker and Hall, 1988). This study used the part of the REHAB for assessing general behavior, which is composed of 16-item visual analog scales. The subscales used in this study were ‘social activity’, ‘disturbed speech’, ‘self care’, and ‘community skills.’ A higher score denoted a lower level of functioning. The nurse in charge of the subjects conducted the ratings. The Japanese version of the REHAB has been confirmed to have sufficient reliability and validity (Yamashita et al., 1995). Beforehand we also conducted a test–retest reliability study, and obtained a favorable result. In this preparation study, REHAB assessment of 17 subjects was conducted twice at an approximately 2-month interval. The test–retest reliability proved to be moderate (ANOVA ICC = 0.76, p < 0.001). The total score of REHAB in this study had permissible internal consistency (Cronbach’s alpha = 0.77). 2.3. Data analysis We used Pearson product moment correlations to examine relationships of demographic and clinical characteristics with the QOL scores. Pearson product moment correlations were also used to examine relationships among scores of the QLS subscales, the LQLP, the PANSS symptom clusters and lack of judgment and
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insight (G12) and the REHAB subscales. For the purpose of seeking the factors influencing QOL, stepwise forward selection regression analyses (Entry; p < 0.05, Removal; p < 0.10) were conducted with the QLS total score and subscales scores and the LQLP score as dependent variables and scores of the PANSS and the REHAB that were used in the previous correlation analyses as independent variables. A significance level of 0.05 and two-sided probability in the correlation analyses were applied. The SPSS Release 16.0.2 statistical package (SPSS Inc., Chicago, IL, 2008) was used for all the analyses. 3. Results Pearson correlations of the demographic and clinical characteristics with QLS and LQLP scale scores are shown in Table 1. Most of the patients were in their sixties, and had a long treatment history. Sixty patients were voluntarily admitted, and the remainders were compulsorily admitted with the consent of the family guardian. The age at the time of this investigation was significantly related to all the QLS subscores. There was no significant relationship between neuroleptic daily dose and all the QLS and the LQLP scores. The neuroleptic daily dose was significantly associated with the PANSS total score, subscores of ‘thought disturbance’, and ‘paranoid/belligerence (r = 0.31, p = 0.012; r = 0.35, p = 0.004; and r = 0.31, p = 0.013, respectively). Table 2 shows the scores of the QLS, LQLP, PANSS and REHAB. Averages (SDs) of the total scores of the QLS, PANSS and REHAB were 28.9 (11.8), 98.6 (13.5) and 56.0 (26.6), respectively. The PANSS total score indicated that the subjects were suffering from high positive and negative symptoms. The total score of the REHAB general behavior scale also indicated that they had severe handicaps and a low potential for discharge according to the criterion of Ruud et al. (1998). The results of correlation analyses did not reveal any salient association between scores of the QLS subscales and the LQLP. The score for lack of judgment and insight (PANSS G12) was moderately severe and was negatively related to the QLS subscale scores except for its instrumental role. The results of regression analyses in Table 3 showed that the PANSS anergia symptom cluster and the REHAB community skills had an influence on the QLS subscale scores, and the PANSS depression and paranoid/belligerence had an influence, on the LQLP score. 4. Discussion First, this study demonstrated that age at the time of this investigation was significantly associated with lower objective scores in female patients with chronic schizophrenia. This seems to
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explain the trend toward increased illness severity in accordance with decreased estrogen after menopause (Hafner, 2003; Agius et al., 2009). Physiological evidence is also accumulating indicating that estrogen exerts neuroprotective effects via its interaction with brain-derived neurotrophic factor (BDNF) and promotes synaptic plasticity and maintains neuronal viability (Wu et al., 2013). Therefore, decreased estrogen with aging may be related to poorer cognitive function, such as verbal memory and social cognition, with consequences for objective QOL (Kurtz et al., 2012). On the other hand, we did not find a significant relationship between age and subjective QOL score. This outcome may be due to the difference in the age of participants between this study (mean age [SD]: 68.0 [8.0]) and the reviews (mean age [SD]: 39.4 [11.4]) (Priebe et al., 2010). The second finding from the attempt was that objective and subjective QOL were not associated with each other. This is in line with previous studies which found that the discrepancy between the two types of QOL measurements is a characteristic of patients with schizophrenia (Ruggeri et al., 2001; Eack and Newhill, 2007). Ruggeri et al. (2001) used data from the oldest sample among the studies in reporting that subjective and objective QOL data were distinct types of information with an average age (SD) of 47.1 (15.5). In addition, the findings of this study suggested that the discrepancy would persist even when the patients became much older. One possible explanation for the discrepancy would be that psychotic cognitive distortions such as poor insight and delusional thought affected the QOL evaluations (Cooke et al., 2007; Roseman et al., 2008). The life situations of the subjects might also have skewed self-appraisal. The study by Priebe showed that patients’ perception was determined by a comparison of their achievements with those of surrounding people and of their adjustment to their present condition with their past conditions (Priebe, 2007). Since the two QOL types of different natures are indispensable in the assessment and treatment of patients, they are to be treated in different ways. Anergia, which represents negative symptoms in psychotic symptomatology, was found to have an influence on most of the objective QOL domains. This is consistent with the findings of previous studies (Baker and Hall, 1988; Ritsner et al., 2006; Eack and Newhill, 2007). Community skill was also indicated as a factor influencing objective QOL. Compared to anergia, community skills would be a more feasible target for psychosocial treatments for middle-aged and elderly female patients with schizophrenia. In the same vein, Bartels and Pratt (2009) contended that psychosocial rehabilitation was potentially effective in improving QOL among elderly patients with severe mental illnesses. To improve community skills, it would be particularly contributory to provide a better environment and amenities for the patients, especially ones in a community life setting.
Table 1 Pearson correlations of demographic and clinical characteristics with QLS and LQLP scale scores (n = 66). Mean (SD) Age at investigation Age at onset (years old) Age at first admission (years old) Full-time education (years) Duration of current hospitalization (years) Numbers of admissions Neuroleptic daily dosea (mg) *
QLS interpersonal relations
68.0 (8.0) 30.1 (13.4) 31.3 (13.7) 10.1 (2.6) 18.1 (16.5) 4.2 (3.3) 740 (582)
p < 0.05. p < 0.01. a Chlorpromazine equivalents. QLS, Quality of Life Scale; LQLP, Lancashire Quality of Life Profile. **
0.54** 0.19 0.16 0.18 0.38** 0.11 0.23
QLS instrumental role 0.58** 0.16 0.12 0.39** 0.23 0.08 0.24
QLS intrapsychic foundations 0.37** 0.28* 0.24 0.28* 0.45** 0.20 0.09
QLS common place objects and activities 0.60** 0.26* 0.26 0.29* 0.35** 0.01 0.17
LQLP 0.16 0.20 0.22 0.03 0.32* 0.32* 0.05
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Table 2 Clinical evaluations and Pearson correlations among scale scores of the QLS, the LQLP, the PANSS, and the REHAB. Mean (SD) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
QLS interpersonal relations Instrumental role Intrapsychic foundations Common place objects and activities LQLP PANSS anergia Thought disturbance Activation Paranoid/belligerence Depression Lack of judgment and insight (G12) REHAB social activity Disturbed speech Self care Community skills
1
2
3
4
5
6
7
8
9
10
11
9.9 4.3 10.6 4.1
(5.3) (2.1) (5.6) (2.1)
– 0.40** 0.45** 0.31*
– 0.57** 0.62**
– 0.42**
–
41.8 14.8 13.2 8.7 8.6 9.2 4.8
(6.7) (3.1) (3.3) (1.6) (2.3) (2.3) (0.8)
0.09 0.48** 0.09 0.13 0.03 0.20 0.29*
0.03 0.57** 0.01 0.08 0.06 0.06 0.15
0.11 0.68** 0.12 0.37** 0.23 0.18 0.46**
0.20 0.66** 0.05 0.20 0.03 0.17 0.35**
– 0.19 0.11 0.17 0.22 0.39** 0.19
– 0.19 0.36** 0.12 0.23 0.45**
– 0.31* 0.49 0.02 0.20
– 0.56** – 0.05 0.26* 0.35** 0.22
– 0.30* –
28.5 4.4 12.2 10.6
(11.5) (3.7) (11.1) (5.4)
0.19 0.08 0.02 0.20
0.48** 0.26* 0.53** 0.74**
0.46** 0.27* 0.32* 0.55**
0.54** 0.22 0.58** 0.71**
0.05 0.12 0.16 0.07
0.56** 0.41** 0.44** 0.68**
0.02 0.13 0.04 0.11
0.09 0.18 0.09 0.24
0.17 0.19 0.15 0.01
0.05 0.06 0.06 0.09
0.30* 0.10 0.25* 0.34**
12
13
14
15
– 0.56** – 0.61** 0.44** – 0.61** 0.35** 0.63** –
*
p < 0.05. p < 0.01. QLS, Quality of Life Scale; LQLP, Lancashire Quality of Life Profile; PANSS, Positive and Negative Symptoms Scale; REHAB, Rehabilitation Evaluation Hall and Baker. **
Table 3 Determinants of the QLS and the LQLP scores: Multiple stepwise regression analyses with the PANSS and the REHAB scores. Dependent variables
Independent variables
R
Adjusted R2
QLS QLS QLS QLS QLS
PANSS anergia PANSS anergia REHAB community skills PANSS anergia REHAB community skills PANSS anergia PANSS depression PANSS paranoid/belligerence
0.75 0.48 0.74 0.68 0.75
0.57 0.22 0.53 0.45 0.55
0.49
0.21
total interpersonal relations instrumental role intrapsychic foundations common place objects and activities
LQLP
b 0.75* 0.48* 0.74* 0.68* 0.50* 0.33* 0.44* 0.29*
* p < 0.01. QLS, Quality of Life Scale; LQLP, Lancashire Quality of Life Profile; PANSS, Positive and Negative Symptoms Scale; REHAB, Rehabilitation Evaluation Hall and Baker.
Regarding subjective QOL, one adverse effect of depression that this study has indicated has also been reported in a number of previous studies (Huppert and Smith, 2001; Karow et al., 2005; Eack and Newhill, 2007). Depression should be an important focus for treatment. Likewise, the paranoid/belligerence symptom cluster was indicated as a factor that heightens subjective QOL, probably because it strengthens patients’ denial of reality. It would be desirable to keep the patient’s perception realistic while treating them with respect in order to avoid lowering subjective QOL. Another question to be answered is what relation lies between insight into illness and QOL. Specifically, lack of insight is considered to affect subjective QOL by compromising selfevaluation capabilities (Kao et al., 2011). This study indicated no significant association between insight into illness and subjective QOL. Likewise, Nakamae et al. (2010) reported no association between subjective QOL and insight into illness among longhospitalized middle-aged patients with schizophrenia. In contrast, this study showed that insight into illness was negatively related to most objective QOL measures. However, this finding appeared to be produced by a mediation of negative symptoms and reduced community skills that were correlated with lack of judgment and insight and objective QOL. Finally, the limitations of this study should be mentioned. Firstly, this study was cross-sectional, and therefore could not determine the causality among the factors. The second limitation is that the study design did not have a control group, and basically did not permit the extraction of the studied sample’s characteristics. Although QOL was not affected by the factors we measured, it may have been affected by multiple other factors. For example,
elderly patients often have physical illness that effects their QOL, thus leading some to question whether we could control for the effects of physical illness. The next was that the side effects of the neuroleptics, which might affect the QOLs of the subjects (Kao et al., 2011), have not been assessed in this study. However, this limitation does not seem detrimental because there were no significant correlations between neruoleptic daily doses and all scores of QOL. Lastly, given that the subjects were not representative patients, we could not control for selection bias. In other words, the generalization potential of the findings is to be questioned since the studied sample consisted of inpatients of one public psychiatric hospital. To be more concrete, as more than 80% of the psychiatric hospitals are private hospitals that are in general equipped with a smaller number of staff in Japan (Ohnishi et al., 2010), future multi-center studies of patients in both public and private hospitals and in the community would remedy this restriction. 5. Conclusion The present study that dealt with an age and gender specified population: middle-aged and elderly female inpatients with schizophrenia showed that objective and subjective QOLs were of different nature and needed to be approached in separate ways. This study also suggested different influencing factors for objective and subjective QOL types: negative symptoms, community skills, depression symptoms and paranoid/belligerence symptoms, respectively. Some of these factors are to be used as targets of individually programmed interventions for improving QOL of this specific group of patients. Further studies are needed to investigate
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the complicated make-up of QOL, and to examine the effectiveness of interventions to address the influencing factors for the purpose of developing means to improve QOL of patients of this specified population. Funding This study was not supported by a particular research fund or grant-in-aid, and was conducted by using ordinary research expenditure of Tokyo Metropolitan Matsuzawa Hospital. Conflict of interest The authors declare that they have no competing interests. Acknowledgements We appreciate the cooperation of the nursing staff at Tokyo Metropolitan Matsuzawa Hospital in the present study. We also thank Ms. Sarah Michael for assistance in editing the manuscript. References Agius, M., Hockings, H., Wilson, C., Lane, D., 2009. Is oestrogen neuroprotective? Psychiatria Danubina 21 (Suppl. 1) 120–127. Andia, A.M., Zisook, S., Heaton, R.K., Hesselink, J., Jernigan, T., Kuck, J., Morganville, J., Braff, D.L., 1995. Gender differences in schizophrenia. Journal of Nervous and Mental Disease 183, 522–528. Baker, R., Hall, J.N., 1983. Users Manual: for Rehabilitation Evaluation, Hall and Baker. Vine, Aberdeen. Baker, R., Hall, J.N., 1988. REHAB: a new assessment instrument for chronic psychiatric patients. Schizophrenia Bulletin 14, 97–111. Bankole, A.O., Cohen, C.I., Vahia, I., Diwan, S., Kehn, M., Ramirez, P.M., 2007. Factors affecting quality of life in a multiracial sample of older persons with schizophrenia. American Journal of Geriatric Psychiatry 15, 1015–1023. Bartels, S.J., Pratt, S.I., 2009. Psychosocial rehabilitation and quality of life for older adults with serious mental illness: recent findings and future research directions. Current Opinion in Psychiatry 22, 381–385. Cohen, C.I., Ramirez, P.M., Kehn, M., Magai, C., Eimicke, J., Brenner, R., 2003. Assessing quality of life in older persons with schizophrenia. American Journal of Geriatric Psychiatry 11, 658–666. Cooke, M., Peters, E., Fannon, D., Anilkumar, A.P., Aasen, I., Kuipers, E., Kumari, V., 2007. Insight, distress and coping styles in schizophrenia. Schizophrenia Research 94, 12–22. Eack, S.M., Newhill, C.E., 2007. Psychiatric symptoms and quality of life in schizophrenia: a meta-analysis. Schizophrenia Bulletin 33, 1225–1237. El Sheshtawy, E.A., 2011. Coping with stress and quality of life in schizophrenic patients. Asian Journal of Psychiatry 4, 51–54. Hafner, H., 2003. Gender differences in schizophrenia. Psychoneuroendocrinology 28 (Suppl. 2) 17–54. Heinrichs, D.W., Hanlon, T.E., Carpenter Jr., W.T., 1984. The Quality of Life Scale: an instrument for rating the schizophrenic deficit syndrome. Schizophrenia Bulletin 10, 388–398. Hirakawa, Y., Masuda, Y., Kimata, T., Uemura, K., Kuzuya, M., Iguchi, A., 2005. Effects of home massage rehabilitation therapy for the bed-ridden elderly: a pilot trial with a three-month follow-up. Clinical Rehabilitation 19, 20–27. Huppert, J.D., Smith, T.E., 2001. Longitudinal analysis of subjective quality of life in schizophrenia: anxiety as the best symptom predictor. Journal of Nervous and Mental Disease 189, 669–675. Igarashi, Y., Hayashi, N., Yamashina, M., Otsuka, N., Kuroki, N., Anzai, N., Kazamatsuri, H., 1998. Interrater reliability of the Japanese version of the Positive and
393
Negative Syndrome Scale and the appraisal of its training effect. Psychiatry and Clinical Neurosciences 52, 467–470. Kaneda, Y., Imakura, A., Fujii, A., Ohmori, T., 2002. Schizophrenia Quality of Life Scale: validation of the Japanese version. Psychiatry Research 113, 107–113. Kao, Y.C., Liu, Y.P., Chou, M.K., Cheng, T.H., 2011. Subjective quality of life in patients with chronic schizophrenia: relationships between psychosocial and clinical characteristics. Comprehensive Psychiatry 52, 171–180. Karow, A., Moritz, S., Lambert, M., Schoder, S., Krausz, M., 2005. PANSS syndromes and quality of life in schizophrenia. Psychopathology 38, 320–326. Kay, S.R., Opler, L.A., Lindenmayer, J.P., 1988. Reliability and validity of the positive and negative syndrome scale for schizophrenics. Psychiatry Research 23, 99– 110. Kay, S.R., Opler, L.A., Fiszbein, A., 1991. Positive and Negative Syndrome Scale. MultiHealth Systems, Toronto. Kurtz, M.M., Bronfeld, M., Rose, J., 2012. Cognitive and social cognitive predictors of change in objective versus subjective quality-of-life in rehabilitation for schizophrenia. Psychiatry Research 200, 102–107. Leung, A., Chue, P., 2000. Sex differences in schizophrenia, a review of the literature. Acta Psychiatrica Scandinavica. Supplementum 401, 3–38. Nakamae, T., Kitabayashi, Y., Okamura, A., Shibata, K., Iwahashi, S., Naka, F., Morinobu, M., Watanabe, M., Narumoto, J., Kitabayashi, M., Fukui, K., 2010. Insight and quality of life in long-term hospitalized Japanese patients with chronic schizophrenia. Psychiatry and Clinical Neurosciences 64, 372–376. Ohnishi, K., Ohgushi, Y., Nakano, M., Fujii, H., Tanaka, H., Kitaoka, K., Nakahara, J., Narita, Y., 2010. Moral distress experienced by psychiatric nurses in Japan. Nursing Ethics 17, 726–740. Oliver, J.P., Huxley, P.J., Bridges, K., Mohamad, H., Lehman, A., 1996. Quality of Life and Mental Health Services. Routledge, London. Priebe, S., 2007. Social outcomes in schizophrenia. British Journal of Psychiatry. Supplement 50, s15–s20. Priebe, S., Reininghaus, U., McCabe, R., Burns, T., Eklund, M., Hansson, L., Junghan, U., Kallert, T., van Nieuwenhuizen, C., Ruggeri, M., Slade, M., Wang, D., 2010. Factors influencing subjective quality of life in patients with schizophrenia and other mental disorders: a pooled analysis. Schizophrenia Research 121, 251–258. Reininghaus, U., McCabe, R., Burns, T., Croudace, T., Priebe, S., 2012. The validity of subjective quality of life measures in psychotic patients with severe psychopathology and cognitive deficits: an item response model analysis. Quality of Life Research 21, 237–246. Ritsner, M., Gibel, A., Ratner, Y., 2006. Determinants of changes in perceived quality of life in the course of schizophrenia. Quality of Life Research 15, 515–526. Roder-Wanner, U.U., Oliver, J.P., Priebe, S., 1997. Does quality of life differ in schizophrenic women and men? An empirical study. International Journal of Social Psychiatry 43, 129–143. Roseman, A.S., Kasckow, J., Fellows, I., Osatuke, K., Patterson, T.L., Mohamed, S., Zisook, S., 2008. Insight, quality of life, and functional capacity in middle-aged and older adults with schizophrenia. International Journal of Geriatric Psychiatry 23, 760–765. Ruggeri, M., Bisoffi, G., Fontecedro, L., Warner, R., 2001. Subjective and objective dimensions of quality of life in psychiatric patients: a factor analytical approach: the South Verona Outcome Project 4. British Journal of Psychiatry 178, 268–275. Ruud, T., Martinsen, E.W., Friis, S., 1998. Chronic patients in psychiatric institutions: psychopathology, level of functioning and need for care. Acta Psychiatrica Scandinavica 97, 55–61. Salokangas, R.K., Honkonen, T., Stengard, E., Koivisto, A.M., 2006. Subjective life satisfaction and living situations of persons in Finland with long-term schizophrenia. Psychiatric Services 57, 373–381. Tolman, A.W., Kurtz, M.M., 2012. Neurocognitive predictors of objective and subjective quality of life in individuals with schizophrenia: a meta-analytic investigation. Schizophrenia Bulletin 38, 304–315. Tomida, K., Takahashi, N., Saito, S., Maeno, N., Iwamoto, K., Yoshida, K., Kimura, H., Iidaka, T., Ozaki, N., 2010. Relationship of psychopathological symptoms and cognitive function to subjective quality of life in patients with chronic schizophrenia. Psychiatry and Clinical Neurosciences 64, 62–69. Wu, Y.C., Hill, R.A., Gogos, A., van den Buuse, M., 2013. Sex differences and the role of estrogen in animal models of schizophrenia: interaction with BDNF. Neuroscience 67–83. Yamashita, T., Fuji, N., Tahara, A., 1995. Utility of the Behavior Rating Scale (REHAB) in psychiatric rehabilitation. Clinical Psychiatry 37 (2) 199–205 (in Japanese).
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Clinical correlates of objective and subjective quality of life among middle-aged and elderly female inpatients with chronic schizophrenia Seishu Nakagawa a,b,*, Naoki Hayashi a,c,d a
Department of Psychiatry, Tokyo Metropolitan Matsuzawa Hospital, 2-1-1 Kamikitazawa, Setagaya-ku, Tokyo 156-0057, Japan Department of Functional Brain Imaging, Institute of Development, Aging and Cancer (IDAC), Tohoku University, Sendai, Japan c Schizophrenia Research Team, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan d Department of Psychiatry, Teikyo University Hospital, Tokyo, Japan b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 6 November 2012 Received in revised form 16 March 2013 Accepted 30 March 2013
Objective: The aim of this study was to illustrate the relationship between objective and subjective measures of quality of life (QOL) and to identify the factors influencing QOL in a sample of middle-aged and elderly female patients with schizophrenia in Japan. Methods: Middle-aged and elderly female inpatients with schizophrenia (n = 66; mean age [SD]: 68.0 [8.0]) were assessed using the Quality of Life Scale (QLS), Lancashire Quality of Life Profile (LQLP), Positive and Negative Symptoms Scale (PANSS), and Rehabilitation Evaluation Hall and Baker (REHAB). Correlation analyses among the measures and regression analyses of objective and subjective QOL measures (QLS and LQLP) were conducted. Explanations of results for the two types of QOL measures in terms of psychotic symptomatology and adjustment variables (PANSS and REHAB) are discussed. Results: There was no salient correlation between objective and subjective QOL measures. The regression analyses identified PANSS anergia and REHAB community skills as factors influencing objective QOL, whereas PANSS depression and paranoid/belligerence were factors influencing subjective QOL. Conclusions: Results indicated that objective and subjective QOL domains should be treated separately in clinical practice for this patient population. Some QOL factors identified in the regression analyses can be used as targets to improve QOL. The findings have important clinical implications for the assessment and treatment of this patient population. ß 2013 Elsevier B.V. All rights reserved.
Keywords: Female Inpatient Life satisfaction Quality of life Schizophrenia
1. Introduction Quality of life (QOL) of patients with schizophrenia has been highlighted in the field of psychiatric practice as an important clinical index. The improvement of QOL is one aim of treatment for schizophrenia. However, its assessment method has been a focus of intense controversy because QOL is composed of multiple factors, e.g., the condition of the patient’s adjustment, social environment, psychiatric and physical conditions, and the patient’ s view of life’s value (Eack and Newhill, 2007; Priebe, 2007). In addition, the discrepancy between subjective and objective QOL evaluations (Eack and Newhill, 2007; Tolman and Kurtz, 2012) has been the major issue in patient QOL assessment. While subjective
* Corresponding author at: Department of Functional Brain Imaging, Institute of Development, Aging and Cancer (IDAC), Tohoku University, Seiryo-machi 4-1, Aoba-ku, Sendai 980-8575, Japan. Tel.: +81 22 717 7988; fax: +81 22 717 7988. E-mail addresses: [email protected], [email protected] (S. Nakagawa). 1876-2018/$ – see front matter ß 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajp.2013.03.015
evaluation of QOL must have a certain importance in itself, it was affected by psychotic symptoms such as poor insight and delusional beliefs (Reininghaus et al., 2012). In contrast, objective QOL evaluation is not directly related to the neurocognitive distortions, and its quite insufficient to cover all the domains of personal well-being that the concept of QOL implies. The consequence is that there have been a wide variety of QOL assessment methods and many inconsistencies in the results of different studies. To remedy the situation, Eack and Newhill (2007) and Priebe et al. (2010) recommended that studies be conducted to address the QOL features of a specified patient population. Under this specification, chronicity (older age) and gender are essential factors. There have been some studies dealing with the QOL of patients with chronic schizophrenia (Nakamae et al., 2010; Tomida et al., 2010; Kao et al., 2011; El Sheshtawy, 2011) or middle-aged and elderly patients with schizophrenia (Cohen et al., 2003; Bankole et al., 2007; Roseman et al., 2008; Bartels and Pratt, 2009; Priebe et al., 2010). The review revealed a tendency for older patients to have higher subjective QOL scores beginning around middle-age (mean age
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[SD]: 39.4 [11.4]) (Priebe et al., 2010). Concerning gender difference, Andia et al. (1995) reported that women exhibited better psychosocial functioning while the severity of their symptoms and neurocognitive status were equivalent to those of men. Likewise, Salokangas et al. (2006) found that being female was one of the important factors of life satisfaction among long-term hospitalized patients with schizophrenia. In addition, Roder-Wanner et al. (1997) stressed that determinants of the subjective QOL measure were not equal for both sexes. Leung and Chue (2000) added that better social functioning appeared to contribute to elevating QOL among women with schizophrenia more so than men. It is expected from these studies that by using an age and gender specified patient population, an investigation of QOL will obtain clearer and simpler results. Dealing with a specified sample of middle-aged and elderly female inpatients with chronic schizophrenia, the present study attempted to elucidate the interrelationships among subjective and objective QOL domains and factors of adjustment conditions and psychotic symptoms that are theoretically considered to have an influence on QOL. It is hypothesized that the QOL domains would have different patterns of influencing factors that need respective approach means. The factors influencing each of the QOL domains this study attempts to identify can be usable for contriving individualized approaches to improve QOL for this patient population. 2. Methods 2.1. Subjects Subjects of this study (n = 66) were female inpatients from the two long-stay wards of Tokyo Metropolitan Matsuzawa Hospital, a large psychiatric center for regional psychiatric services and the treatment of difficult patients in central Tokyo. Both wards were composed mostly of middle-aged and elderly patients with chronic schizophrenia of similar demographics that needed enduring rehabilitative services. The patients were not restricted from participating in social communication outside the hospital. Routine recreational and rehabilitative activities, including chorus or dance meetings, excursions, and occupational therapy were also carried out in the hospital. The levels of physical independence, assessed based on the Japanese Ministry of Health, Labor and Welfare criteria (Hirakawa et al., 2005) were ‘‘independent’’ or ‘‘house-bound’’ i.e., better than ‘‘chair-bound’’ and ‘‘bed-bound’’. Criteria for the inclusion of subjects were a diagnosis of schizophrenia, an age equal to or over 50 years and absence of unequivocal organic cognitive impairment or mental retardation. The diagnosis of the subjects was made on the basis of examining case records according to DSM-IV criteria. The subjects gave written informed consent to participate in the study and patient anonymity has been preserved. This study was approved by the ethical committee of Tokyo Metropolitan Matsuzawa Hospital. 2.2. Assessment Objective QOL was measured with the Quality of Life Scale (QLS) (Heinrichs et al., 1984). The QLS is a disease-specific and clinicianrated measure of QOL for persons with schizophrenia. The QLS was developed for the evaluation of patients’ objective QOL by means of assessing deficit symptoms and functional status. A higher score means better QOL. The scale has 21 items and four subscales including ‘interpersonal relations’, ‘instrumental role’, ‘intrapsychic foundations’ and ‘common place objects and activities’. However, the QLS item 12 was excluded in the assessment because it was applicable solely to regular workers. While the validation study of the Japanese version (Kaneda et al., 2002) of the QLS has
already been published, our study group conducted an inter-rater reliability study prior to beginning our study. The study, in which two psychiatrist raters made independent ratings of the QLSs on the basis of a single interview for 20 patients, gave satisfactory results. The average (SD, range) of analyses of variance intraclass coefficients (ANOVA ICC) of the subscales was 0.76 (0.12, 0.41– 0.95). The average of Cronbach’s alpha coefficients was 0.83 (0.06, 0.78–0.92). The measure of subjective QOL was the Lancashire Quality of Life Profile (LQLP) which was devised by Oliver et al. (RoderWanner et al., 1997). The LQLP consists of a 7-point, 10-item selfreport scale that inquired into satisfaction with ‘life in general’, ‘mental health’, ‘work situation’, ‘finances’, ‘living situation’, ‘personal safety’, ‘leisure activities’, ‘family’, and ‘getting on with others and friends’. In this study, the LQLP items related to ‘‘work situation’’, which were hardly applicable to the subject, were excluded. The scale was orally administered in an interview. Prior to or in this study, our study group conducted a test–retest reliability study. The nine item LQLP assessment of 21 subjects was carried out twice at an approximately 2-month interval. The reliability proved to be moderate (ANOVA ICC = 0.59, p = 0.002). Internal consistency of the LQLS assessment in this study was permissible (Cronbach’s alpha = 0.71). The measure used for assessing psychotic symptomatology was the Positive and Negative Symptoms Scale (PANSS) (Kay et al., 1988, 1991), which is a 7-point, 30-item rating scale widely used for evaluating symptoms of patients with psychoses; a reliability study of the Japanese version of the PANSS by our study group provided favorable results (Igarashi et al., 1998). In this study, scores of symptom clusters derived from the five-factor model by Kay et al. and an item score of lack of judgment and insight (G12) were used. The PANSS five-factor model (Anergia, Thought Disturbance, Activation, Paranoid Belligerence, and Depression) has been adopted in the PANSS user manual as the legitimate symptom cluster model. Scores are used to depict the dimensions of the patient’s psychopathology (Kay et al., 1991). The psychiatrist raters of this study (SN and NH) had fulfilled Kay’s criteria for reliable assessment (Kay et al., 1988). During the study period, we also conducted a confirmation of their skills by attaining a consensus PANSS rating from the raters. The measure of adjustment conditions was the Rehabilitation Evaluation Hall and Baker (REHAB) (Baker and Hall, 1983, 1988), which is a behavior rating scale for assessing the daily life activities of people with psychiatric disabilities (Baker and Hall, 1988). This study used the part of the REHAB for assessing general behavior, which is composed of 16-item visual analog scales. The subscales used in this study were ‘social activity’, ‘disturbed speech’, ‘self care’, and ‘community skills.’ A higher score denoted a lower level of functioning. The nurse in charge of the subjects conducted the ratings. The Japanese version of the REHAB has been confirmed to have sufficient reliability and validity (Yamashita et al., 1995). Beforehand we also conducted a test–retest reliability study, and obtained a favorable result. In this preparation study, REHAB assessment of 17 subjects was conducted twice at an approximately 2-month interval. The test–retest reliability proved to be moderate (ANOVA ICC = 0.76, p < 0.001). The total score of REHAB in this study had permissible internal consistency (Cronbach’s alpha = 0.77). 2.3. Data analysis We used Pearson product moment correlations to examine relationships of demographic and clinical characteristics with the QOL scores. Pearson product moment correlations were also used to examine relationships among scores of the QLS subscales, the LQLP, the PANSS symptom clusters and lack of judgment and
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insight (G12) and the REHAB subscales. For the purpose of seeking the factors influencing QOL, stepwise forward selection regression analyses (Entry; p < 0.05, Removal; p < 0.10) were conducted with the QLS total score and subscales scores and the LQLP score as dependent variables and scores of the PANSS and the REHAB that were used in the previous correlation analyses as independent variables. A significance level of 0.05 and two-sided probability in the correlation analyses were applied. The SPSS Release 16.0.2 statistical package (SPSS Inc., Chicago, IL, 2008) was used for all the analyses. 3. Results Pearson correlations of the demographic and clinical characteristics with QLS and LQLP scale scores are shown in Table 1. Most of the patients were in their sixties, and had a long treatment history. Sixty patients were voluntarily admitted, and the remainders were compulsorily admitted with the consent of the family guardian. The age at the time of this investigation was significantly related to all the QLS subscores. There was no significant relationship between neuroleptic daily dose and all the QLS and the LQLP scores. The neuroleptic daily dose was significantly associated with the PANSS total score, subscores of ‘thought disturbance’, and ‘paranoid/belligerence (r = 0.31, p = 0.012; r = 0.35, p = 0.004; and r = 0.31, p = 0.013, respectively). Table 2 shows the scores of the QLS, LQLP, PANSS and REHAB. Averages (SDs) of the total scores of the QLS, PANSS and REHAB were 28.9 (11.8), 98.6 (13.5) and 56.0 (26.6), respectively. The PANSS total score indicated that the subjects were suffering from high positive and negative symptoms. The total score of the REHAB general behavior scale also indicated that they had severe handicaps and a low potential for discharge according to the criterion of Ruud et al. (1998). The results of correlation analyses did not reveal any salient association between scores of the QLS subscales and the LQLP. The score for lack of judgment and insight (PANSS G12) was moderately severe and was negatively related to the QLS subscale scores except for its instrumental role. The results of regression analyses in Table 3 showed that the PANSS anergia symptom cluster and the REHAB community skills had an influence on the QLS subscale scores, and the PANSS depression and paranoid/belligerence had an influence, on the LQLP score. 4. Discussion First, this study demonstrated that age at the time of this investigation was significantly associated with lower objective scores in female patients with chronic schizophrenia. This seems to
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explain the trend toward increased illness severity in accordance with decreased estrogen after menopause (Hafner, 2003; Agius et al., 2009). Physiological evidence is also accumulating indicating that estrogen exerts neuroprotective effects via its interaction with brain-derived neurotrophic factor (BDNF) and promotes synaptic plasticity and maintains neuronal viability (Wu et al., 2013). Therefore, decreased estrogen with aging may be related to poorer cognitive function, such as verbal memory and social cognition, with consequences for objective QOL (Kurtz et al., 2012). On the other hand, we did not find a significant relationship between age and subjective QOL score. This outcome may be due to the difference in the age of participants between this study (mean age [SD]: 68.0 [8.0]) and the reviews (mean age [SD]: 39.4 [11.4]) (Priebe et al., 2010). The second finding from the attempt was that objective and subjective QOL were not associated with each other. This is in line with previous studies which found that the discrepancy between the two types of QOL measurements is a characteristic of patients with schizophrenia (Ruggeri et al., 2001; Eack and Newhill, 2007). Ruggeri et al. (2001) used data from the oldest sample among the studies in reporting that subjective and objective QOL data were distinct types of information with an average age (SD) of 47.1 (15.5). In addition, the findings of this study suggested that the discrepancy would persist even when the patients became much older. One possible explanation for the discrepancy would be that psychotic cognitive distortions such as poor insight and delusional thought affected the QOL evaluations (Cooke et al., 2007; Roseman et al., 2008). The life situations of the subjects might also have skewed self-appraisal. The study by Priebe showed that patients’ perception was determined by a comparison of their achievements with those of surrounding people and of their adjustment to their present condition with their past conditions (Priebe, 2007). Since the two QOL types of different natures are indispensable in the assessment and treatment of patients, they are to be treated in different ways. Anergia, which represents negative symptoms in psychotic symptomatology, was found to have an influence on most of the objective QOL domains. This is consistent with the findings of previous studies (Baker and Hall, 1988; Ritsner et al., 2006; Eack and Newhill, 2007). Community skill was also indicated as a factor influencing objective QOL. Compared to anergia, community skills would be a more feasible target for psychosocial treatments for middle-aged and elderly female patients with schizophrenia. In the same vein, Bartels and Pratt (2009) contended that psychosocial rehabilitation was potentially effective in improving QOL among elderly patients with severe mental illnesses. To improve community skills, it would be particularly contributory to provide a better environment and amenities for the patients, especially ones in a community life setting.
Table 1 Pearson correlations of demographic and clinical characteristics with QLS and LQLP scale scores (n = 66). Mean (SD) Age at investigation Age at onset (years old) Age at first admission (years old) Full-time education (years) Duration of current hospitalization (years) Numbers of admissions Neuroleptic daily dosea (mg) *
QLS interpersonal relations
68.0 (8.0) 30.1 (13.4) 31.3 (13.7) 10.1 (2.6) 18.1 (16.5) 4.2 (3.3) 740 (582)
p < 0.05. p < 0.01. a Chlorpromazine equivalents. QLS, Quality of Life Scale; LQLP, Lancashire Quality of Life Profile. **
0.54** 0.19 0.16 0.18 0.38** 0.11 0.23
QLS instrumental role 0.58** 0.16 0.12 0.39** 0.23 0.08 0.24
QLS intrapsychic foundations 0.37** 0.28* 0.24 0.28* 0.45** 0.20 0.09
QLS common place objects and activities 0.60** 0.26* 0.26 0.29* 0.35** 0.01 0.17
LQLP 0.16 0.20 0.22 0.03 0.32* 0.32* 0.05
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Table 2 Clinical evaluations and Pearson correlations among scale scores of the QLS, the LQLP, the PANSS, and the REHAB. Mean (SD) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
QLS interpersonal relations Instrumental role Intrapsychic foundations Common place objects and activities LQLP PANSS anergia Thought disturbance Activation Paranoid/belligerence Depression Lack of judgment and insight (G12) REHAB social activity Disturbed speech Self care Community skills
1
2
3
4
5
6
7
8
9
10
11
9.9 4.3 10.6 4.1
(5.3) (2.1) (5.6) (2.1)
– 0.40** 0.45** 0.31*
– 0.57** 0.62**
– 0.42**
–
41.8 14.8 13.2 8.7 8.6 9.2 4.8
(6.7) (3.1) (3.3) (1.6) (2.3) (2.3) (0.8)
0.09 0.48** 0.09 0.13 0.03 0.20 0.29*
0.03 0.57** 0.01 0.08 0.06 0.06 0.15
0.11 0.68** 0.12 0.37** 0.23 0.18 0.46**
0.20 0.66** 0.05 0.20 0.03 0.17 0.35**
– 0.19 0.11 0.17 0.22 0.39** 0.19
– 0.19 0.36** 0.12 0.23 0.45**
– 0.31* 0.49 0.02 0.20
– 0.56** – 0.05 0.26* 0.35** 0.22
– 0.30* –
28.5 4.4 12.2 10.6
(11.5) (3.7) (11.1) (5.4)
0.19 0.08 0.02 0.20
0.48** 0.26* 0.53** 0.74**
0.46** 0.27* 0.32* 0.55**
0.54** 0.22 0.58** 0.71**
0.05 0.12 0.16 0.07
0.56** 0.41** 0.44** 0.68**
0.02 0.13 0.04 0.11
0.09 0.18 0.09 0.24
0.17 0.19 0.15 0.01
0.05 0.06 0.06 0.09
0.30* 0.10 0.25* 0.34**
12
13
14
15
– 0.56** – 0.61** 0.44** – 0.61** 0.35** 0.63** –
*
p < 0.05. p < 0.01. QLS, Quality of Life Scale; LQLP, Lancashire Quality of Life Profile; PANSS, Positive and Negative Symptoms Scale; REHAB, Rehabilitation Evaluation Hall and Baker. **
Table 3 Determinants of the QLS and the LQLP scores: Multiple stepwise regression analyses with the PANSS and the REHAB scores. Dependent variables
Independent variables
R
Adjusted R2
QLS QLS QLS QLS QLS
PANSS anergia PANSS anergia REHAB community skills PANSS anergia REHAB community skills PANSS anergia PANSS depression PANSS paranoid/belligerence
0.75 0.48 0.74 0.68 0.75
0.57 0.22 0.53 0.45 0.55
0.49
0.21
total interpersonal relations instrumental role intrapsychic foundations common place objects and activities
LQLP
b 0.75* 0.48* 0.74* 0.68* 0.50* 0.33* 0.44* 0.29*
* p < 0.01. QLS, Quality of Life Scale; LQLP, Lancashire Quality of Life Profile; PANSS, Positive and Negative Symptoms Scale; REHAB, Rehabilitation Evaluation Hall and Baker.
Regarding subjective QOL, one adverse effect of depression that this study has indicated has also been reported in a number of previous studies (Huppert and Smith, 2001; Karow et al., 2005; Eack and Newhill, 2007). Depression should be an important focus for treatment. Likewise, the paranoid/belligerence symptom cluster was indicated as a factor that heightens subjective QOL, probably because it strengthens patients’ denial of reality. It would be desirable to keep the patient’s perception realistic while treating them with respect in order to avoid lowering subjective QOL. Another question to be answered is what relation lies between insight into illness and QOL. Specifically, lack of insight is considered to affect subjective QOL by compromising selfevaluation capabilities (Kao et al., 2011). This study indicated no significant association between insight into illness and subjective QOL. Likewise, Nakamae et al. (2010) reported no association between subjective QOL and insight into illness among longhospitalized middle-aged patients with schizophrenia. In contrast, this study showed that insight into illness was negatively related to most objective QOL measures. However, this finding appeared to be produced by a mediation of negative symptoms and reduced community skills that were correlated with lack of judgment and insight and objective QOL. Finally, the limitations of this study should be mentioned. Firstly, this study was cross-sectional, and therefore could not determine the causality among the factors. The second limitation is that the study design did not have a control group, and basically did not permit the extraction of the studied sample’s characteristics. Although QOL was not affected by the factors we measured, it may have been affected by multiple other factors. For example,
elderly patients often have physical illness that effects their QOL, thus leading some to question whether we could control for the effects of physical illness. The next was that the side effects of the neuroleptics, which might affect the QOLs of the subjects (Kao et al., 2011), have not been assessed in this study. However, this limitation does not seem detrimental because there were no significant correlations between neruoleptic daily doses and all scores of QOL. Lastly, given that the subjects were not representative patients, we could not control for selection bias. In other words, the generalization potential of the findings is to be questioned since the studied sample consisted of inpatients of one public psychiatric hospital. To be more concrete, as more than 80% of the psychiatric hospitals are private hospitals that are in general equipped with a smaller number of staff in Japan (Ohnishi et al., 2010), future multi-center studies of patients in both public and private hospitals and in the community would remedy this restriction. 5. Conclusion The present study that dealt with an age and gender specified population: middle-aged and elderly female inpatients with schizophrenia showed that objective and subjective QOLs were of different nature and needed to be approached in separate ways. This study also suggested different influencing factors for objective and subjective QOL types: negative symptoms, community skills, depression symptoms and paranoid/belligerence symptoms, respectively. Some of these factors are to be used as targets of individually programmed interventions for improving QOL of this specific group of patients. Further studies are needed to investigate
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the complicated make-up of QOL, and to examine the effectiveness of interventions to address the influencing factors for the purpose of developing means to improve QOL of patients of this specified population. Funding This study was not supported by a particular research fund or grant-in-aid, and was conducted by using ordinary research expenditure of Tokyo Metropolitan Matsuzawa Hospital. Conflict of interest The authors declare that they have no competing interests. Acknowledgements We appreciate the cooperation of the nursing staff at Tokyo Metropolitan Matsuzawa Hospital in the present study. We also thank Ms. Sarah Michael for assistance in editing the manuscript. References Agius, M., Hockings, H., Wilson, C., Lane, D., 2009. Is oestrogen neuroprotective? Psychiatria Danubina 21 (Suppl. 1) 120–127. Andia, A.M., Zisook, S., Heaton, R.K., Hesselink, J., Jernigan, T., Kuck, J., Morganville, J., Braff, D.L., 1995. Gender differences in schizophrenia. Journal of Nervous and Mental Disease 183, 522–528. Baker, R., Hall, J.N., 1983. Users Manual: for Rehabilitation Evaluation, Hall and Baker. Vine, Aberdeen. Baker, R., Hall, J.N., 1988. REHAB: a new assessment instrument for chronic psychiatric patients. Schizophrenia Bulletin 14, 97–111. Bankole, A.O., Cohen, C.I., Vahia, I., Diwan, S., Kehn, M., Ramirez, P.M., 2007. Factors affecting quality of life in a multiracial sample of older persons with schizophrenia. American Journal of Geriatric Psychiatry 15, 1015–1023. Bartels, S.J., Pratt, S.I., 2009. Psychosocial rehabilitation and quality of life for older adults with serious mental illness: recent findings and future research directions. Current Opinion in Psychiatry 22, 381–385. Cohen, C.I., Ramirez, P.M., Kehn, M., Magai, C., Eimicke, J., Brenner, R., 2003. Assessing quality of life in older persons with schizophrenia. American Journal of Geriatric Psychiatry 11, 658–666. Cooke, M., Peters, E., Fannon, D., Anilkumar, A.P., Aasen, I., Kuipers, E., Kumari, V., 2007. Insight, distress and coping styles in schizophrenia. Schizophrenia Research 94, 12–22. Eack, S.M., Newhill, C.E., 2007. Psychiatric symptoms and quality of life in schizophrenia: a meta-analysis. Schizophrenia Bulletin 33, 1225–1237. El Sheshtawy, E.A., 2011. Coping with stress and quality of life in schizophrenic patients. Asian Journal of Psychiatry 4, 51–54. Hafner, H., 2003. Gender differences in schizophrenia. Psychoneuroendocrinology 28 (Suppl. 2) 17–54. Heinrichs, D.W., Hanlon, T.E., Carpenter Jr., W.T., 1984. The Quality of Life Scale: an instrument for rating the schizophrenic deficit syndrome. Schizophrenia Bulletin 10, 388–398. Hirakawa, Y., Masuda, Y., Kimata, T., Uemura, K., Kuzuya, M., Iguchi, A., 2005. Effects of home massage rehabilitation therapy for the bed-ridden elderly: a pilot trial with a three-month follow-up. Clinical Rehabilitation 19, 20–27. Huppert, J.D., Smith, T.E., 2001. Longitudinal analysis of subjective quality of life in schizophrenia: anxiety as the best symptom predictor. Journal of Nervous and Mental Disease 189, 669–675. Igarashi, Y., Hayashi, N., Yamashina, M., Otsuka, N., Kuroki, N., Anzai, N., Kazamatsuri, H., 1998. Interrater reliability of the Japanese version of the Positive and
393
Negative Syndrome Scale and the appraisal of its training effect. Psychiatry and Clinical Neurosciences 52, 467–470. Kaneda, Y., Imakura, A., Fujii, A., Ohmori, T., 2002. Schizophrenia Quality of Life Scale: validation of the Japanese version. Psychiatry Research 113, 107–113. Kao, Y.C., Liu, Y.P., Chou, M.K., Cheng, T.H., 2011. Subjective quality of life in patients with chronic schizophrenia: relationships between psychosocial and clinical characteristics. Comprehensive Psychiatry 52, 171–180. Karow, A., Moritz, S., Lambert, M., Schoder, S., Krausz, M., 2005. PANSS syndromes and quality of life in schizophrenia. Psychopathology 38, 320–326. Kay, S.R., Opler, L.A., Lindenmayer, J.P., 1988. Reliability and validity of the positive and negative syndrome scale for schizophrenics. Psychiatry Research 23, 99– 110. Kay, S.R., Opler, L.A., Fiszbein, A., 1991. Positive and Negative Syndrome Scale. MultiHealth Systems, Toronto. Kurtz, M.M., Bronfeld, M., Rose, J., 2012. Cognitive and social cognitive predictors of change in objective versus subjective quality-of-life in rehabilitation for schizophrenia. Psychiatry Research 200, 102–107. Leung, A., Chue, P., 2000. Sex differences in schizophrenia, a review of the literature. Acta Psychiatrica Scandinavica. Supplementum 401, 3–38. Nakamae, T., Kitabayashi, Y., Okamura, A., Shibata, K., Iwahashi, S., Naka, F., Morinobu, M., Watanabe, M., Narumoto, J., Kitabayashi, M., Fukui, K., 2010. Insight and quality of life in long-term hospitalized Japanese patients with chronic schizophrenia. Psychiatry and Clinical Neurosciences 64, 372–376. Ohnishi, K., Ohgushi, Y., Nakano, M., Fujii, H., Tanaka, H., Kitaoka, K., Nakahara, J., Narita, Y., 2010. Moral distress experienced by psychiatric nurses in Japan. Nursing Ethics 17, 726–740. Oliver, J.P., Huxley, P.J., Bridges, K., Mohamad, H., Lehman, A., 1996. Quality of Life and Mental Health Services. Routledge, London. Priebe, S., 2007. Social outcomes in schizophrenia. British Journal of Psychiatry. Supplement 50, s15–s20. Priebe, S., Reininghaus, U., McCabe, R., Burns, T., Eklund, M., Hansson, L., Junghan, U., Kallert, T., van Nieuwenhuizen, C., Ruggeri, M., Slade, M., Wang, D., 2010. Factors influencing subjective quality of life in patients with schizophrenia and other mental disorders: a pooled analysis. Schizophrenia Research 121, 251–258. Reininghaus, U., McCabe, R., Burns, T., Croudace, T., Priebe, S., 2012. The validity of subjective quality of life measures in psychotic patients with severe psychopathology and cognitive deficits: an item response model analysis. Quality of Life Research 21, 237–246. Ritsner, M., Gibel, A., Ratner, Y., 2006. Determinants of changes in perceived quality of life in the course of schizophrenia. Quality of Life Research 15, 515–526. Roder-Wanner, U.U., Oliver, J.P., Priebe, S., 1997. Does quality of life differ in schizophrenic women and men? An empirical study. International Journal of Social Psychiatry 43, 129–143. Roseman, A.S., Kasckow, J., Fellows, I., Osatuke, K., Patterson, T.L., Mohamed, S., Zisook, S., 2008. Insight, quality of life, and functional capacity in middle-aged and older adults with schizophrenia. International Journal of Geriatric Psychiatry 23, 760–765. Ruggeri, M., Bisoffi, G., Fontecedro, L., Warner, R., 2001. Subjective and objective dimensions of quality of life in psychiatric patients: a factor analytical approach: the South Verona Outcome Project 4. British Journal of Psychiatry 178, 268–275. Ruud, T., Martinsen, E.W., Friis, S., 1998. Chronic patients in psychiatric institutions: psychopathology, level of functioning and need for care. Acta Psychiatrica Scandinavica 97, 55–61. Salokangas, R.K., Honkonen, T., Stengard, E., Koivisto, A.M., 2006. Subjective life satisfaction and living situations of persons in Finland with long-term schizophrenia. Psychiatric Services 57, 373–381. Tolman, A.W., Kurtz, M.M., 2012. Neurocognitive predictors of objective and subjective quality of life in individuals with schizophrenia: a meta-analytic investigation. Schizophrenia Bulletin 38, 304–315. Tomida, K., Takahashi, N., Saito, S., Maeno, N., Iwamoto, K., Yoshida, K., Kimura, H., Iidaka, T., Ozaki, N., 2010. Relationship of psychopathological symptoms and cognitive function to subjective quality of life in patients with chronic schizophrenia. Psychiatry and Clinical Neurosciences 64, 62–69. Wu, Y.C., Hill, R.A., Gogos, A., van den Buuse, M., 2013. Sex differences and the role of estrogen in animal models of schizophrenia: interaction with BDNF. Neuroscience 67–83. Yamashita, T., Fuji, N., Tahara, A., 1995. Utility of the Behavior Rating Scale (REHAB) in psychiatric rehabilitation. Clinical Psychiatry 37 (2) 199–205 (in Japanese).