Assessing health-related quality of life in patients suffering from schizophrenia: a comparison of instruments

Subjective health-related quality of life in community-dwelling middle-aged and older adults with early-onset schizophrenia

Background: Long-term outcome in schizophrenia remains unsatisfactory due to continued premature deaths and insufficient health treatment. Subjective quality of life (SQoL) measurements hold important information and have meaningful implications regarding ways of improving general health status. This study investigated the physical and mental SQoL and associated clinical and sociodemographic outcomes among community-dwelling middle-aged and older people with early-onset schizophrenia.Materials and methods: A cross-sectional interview study where participants residing in the Region of Southern Denmark were identified through The Danish Psychiatric Central Register. Of a total of 278 eligible individuals, 59 people aged 55-82 years old participated. The SQoL measure Medical Outcomes Short Form 36 version 2 (SF36) was used. Scores were compared by age groups with normative data for the Danish population. Associated outcomes were measured using Positive And Negative Symptom Scale Remission and others.Results: Increased mental SQoL was associated with schizophrenia in remission (adjusted B 9.43, p = .001), increased Mental Health Recovery Measure score (adjusted B 0.55, p < .001) and increased GAF score (adjusted B 0.32, p < .001). Comparing with Danish Normative data, mental SQoL was reduced (p = .001) among 55-64-year olds, but presented levels similar to the general population at ages over 65 years. Physical quality of life was similar to the general population.Conclusion: Over 65-year olds with schizophrenia seemed to have SQoL similar to their age peers in the general population. Aiming treatment at achieving state of remission or recovery would be an amenable measure toward increasing mental SQoL among middle-aged people with schizophrenia.

Dopamine D2 Receptor Occupancy Estimated From Plasma Concentrations of Four Different Antipsychotics and the Subjective Experience of Physical and Mental Well-Being in Schizophrenia: Results From the Randomized NeSSy Trial

BACKGROUND

Impaired subjective well-being in schizophrenia patients treated with antipsychotics has often been linked inter alia to the antidopaminergic effects of medication. Thus, it is important to capture the association between striatal dopamine D2 receptor occupancy (D2-RO) and global subjective well-being. We examined this association using data from our multicenter, randomized, double-blind Neuroleptic Strategy Study (NeSSy).

METHODS

An innovative double randomization process was used for allocation of patients to the specific treatment groups. Plasma drug concentrations were measured after 6 and 24 weeks of treatment to obtain the estimated D2-RO (eD2-RO) relative to literature values. We made an exploratory analysis of associations between eD2-RO and subjective well-being scores. One hundred two blood samples from 69 patients were available for the analysis. Because of the lack of a satisfactory occupancy model for quetiapine, only haloperidol, flupentixol, and olanzapine treatment groups were pooled, whereas aripiprazole data were analyzed separately, because of its partial agonistic properties.

RESULTS

In the pooled antagonist group, eD2-RO correlated negatively with the summarized well-being score. In a more detailed analysis, this association could be confirmed for all first-generation antipsychotic-treated patients, but not for the separate second-generation antipsychotic groups. In the aripiprazole group, higher eD2-RO was associated with impaired physical well-being, but had no association with mental well-being.

CONCLUSIONS

Our results suggest that high plasma levels and consequently high occupancy at D2 receptors are disadvantageous for subjective well-being, as distinct from the objective extrapyramidal side effects. To minimize patients' malaise, which disfavors adherence, implementation of therapeutic drug monitoring in the clinical routine may be useful.

Systematic review of global functioning and quality of life in people with psychotic disorders

AimsPeople with psychotic disorders face impairments in their global functioning and their quality of life (QoL). The relationship between the two outcomes has not been systematically investigated. Through a systematic review, we aim to explore the presence and extent of associations between global functioning and QoL and establish whether associations depend on the instruments employed.

METHODS

In May 2016, ten electronic databases were searched using a two-phase process to identify articles in which associations between global functioning and QoL were assessed. Basic descriptive data and correlation coefficients between global functioning and QoL instruments were extracted, with the strength of the correlation assessed according to the specifications of Cohen 1988. Results were reported with reference to the Meta-analysis of Observational Studies in Epidemiology guidelines and PRISMA standards. A narrative synthesis was performed due to heterogeneity in methodological approaches.

RESULTS

Of an initial 15 183 non-duplicate articles identified, 756 were deemed potentially relevant, with 40 studies encompassing 42 articles included. Fourteen instruments for measuring global functioning and 22 instruments for measuring QoL were used. Twenty-nine articles reported linear associations while 19 assessed QoL predictors. Correlations between overall scores varied in strength, primarily dependent on the QoL instrument employed, and whether QoL was objectively or subjectively assessed. Correlations observed for objective QoL measures were consistently larger than those observed for subjective measures, as were correlations for an interviewer than self-assessed QoL. When correlations were assessed by domains of QoL, the highest correlations were found for social domains of QoL, for which most correlations were moderate or higher. Global functioning consistently predicted overall QoL as did depressive and negative symptoms.

CONCLUSIONS

This review is the first to explore the extent of associations between global functioning and QoL in people with psychotic disorders. We consistently found a positive association between global functioning and QoL. The strength of the association was dependent on the QoL instrument employed. QoL domains strongly associated with global functioning were highlighted. The review illustrates the extensive array of instruments used for the assessment of QoL and to a lesser extent global functioning in people with psychotic disorders and provides a framework to understand the different findings reported in the literature. The findings can also inform the future choice of instruments by researchers and/or clinicians. The observed associations reassure that interventions for improving global functioning will have a positive impact on the QoL of people living with a psychotic disorder.

Comparative responsiveness of generic versus disorder-specific instruments for depression: An assessment in three longitudinal datasets

BACKGROUND

Routine outcome monitoring (ROM) may enhance individual treatment and is also advocated as a means to compare the outcome of different treatment programs or providers. There is debate on the optimal instruments to be used for these separate tasks.

METHODS

Three sets with longitudinal data from ROM were analyzed with correlational analysis and repeated measures ANOVAs, allowing for a head-to-head comparison of measures regarding their sensitivity to detect change. The responsiveness of three disorder-specific instruments, the Beck Depression Inventory, the Inventory of Depressive Symptoms, and the Mood and Anxiety Symptoms Questionnaire, was compared to three generic instruments, the Symptom Checklist (SCL-90), the Outcome Questionnaire (OQ-45), and the Brief Symptom Inventory, respectively.

RESULTS

In two of the three datasets, disorder-specific measures were more responsive compared to the total score on generic instruments. Subscale scores for depression embedded within generic instruments are second best and almost match disorder-specific scales in responsiveness. No evidence of a desynchronous response on outcome measures was found.

LIMITATIONS

The present study compares measures head-to-had, and responsiveness is not assessed against an external criterion, such as clinical recovery.

DISCUSSION

Disorder-specific measures yield the most precise assessment for individual treatment and are recommended for clinical use. Generic measures may allow for comparisons across diagnostic groups and their embedded subscales approach the responsiveness of disorder-specific measures.

Correlation of Health-Related Quality of Life in Clinically Stable Outpatients with Schizophrenia

BACKGROUND

Generic health-related quality of life (HRQoL) scales are increasingly being used to assess the effects of new treatments in schizophrenia. The objective of this study is to better understand the usefulness of generic and condition specific HRQoL scales in schizophrenia by analyzing their correlates.

METHODS

Data formed part of the Pattern study, an international observational study among 1379 outpatients with schizophrenia. Patients were evaluated with the Mini International Neuropsychiatric Inventory, the Clinical Global Impression-Schizophrenia (CGI-SCH) Scale and the Positive and Negative Syndrome Scale (PANSS) and reported their HRQoL using the Schizophrenia Quality of Life Scale (SQLS), the Short Form-36 (SF-36), and the EuroQol-5 Dimension (EQ-5D). The two summary values of the SF-36 (the Mental Component Score and the Physical Component Score, SF-36 MCS and SF-36 PCS) were calculated.

RESULTS

Higher PANSS positive dimension ratings were associated with worse HRQoL for the SQLS, EQ-5D VAS, SF-36 MCS, and SF-36 PCS. Higher PANSS negative dimension ratings were associated with worse HRQoL for the EQ-5D VAS, SF-36 MCS, and SF-36 PCS, but not for the SQLS or the EQ-5D tariff. PANSS depression ratings were associated with lower HRQoL in all the scales. There was a high correlation between the HRQoL scales. However, in patients with more severe cognitive/disorganized PANSS symptoms, the SQLS score was relatively higher than the EQ-5D tariff and SF-36 PCS scores.

CONCLUSION

This study has shown substantial agreement between three HRQoL scales, being either generic or condition specific. This supports the use of generic HRQoL measures in schizophrenia.

CLINICALTRIALSGOV IDENTIFIER

NCT01634542 (July 6, 2012, retrospectively registered).

Modernizing quality of life assessment: development of a multidimensional computerized adaptive questionnaire for patients with schizophrenia

OBJECTIVE

Quality of life (QoL) is still assessed using paper-based and fixed-length questionnaires, which is one reason why QoL measurements have not been routinely implemented in clinical practice. Providing new QoL measures that combine computer technology with modern measurement theory may enhance their clinical use. The aim of this study was to develop a QoL multidimensional computerized adaptive test (MCAT), the SQoL-MCAT, from the fixed-length SQoL questionnaire for patients with schizophrenia.

METHODS

In this multicentre cross-sectional study, we collected sociodemographic information, clinical characteristics (i.e., duration of illness, the PANSS, and the Calgary Depression Scale), and quality of life (i.e., SQoL). The development of the SQoL-CAT was divided into three stages: (1) multidimensional item response theory (MIRT) analysis, (2) multidimensional computerized adaptive test (MCAT) simulations with analyses of accuracy and precision, and (3) external validity.

RESULTS

Five hundred and seventeen patients participated in this study. The MIRT analysis found that all items displayed good fit with the multidimensional graded response model, with satisfactory reliability for each dimension. The SQoL-MCAT was 39% shorter than the fixed-length SQoL questionnaire and had satisfactory accuracy (levels of correlation >0.9) and precision (standard error of measurement <0.55 and root mean square error <0.3). External validity was confirmed via correlations between the SQoL-MCAT dimension scores and symptomatology scores.

CONCLUSION

The SQoL-MCAT is the first computerized adaptive QoL questionnaire for patients with schizophrenia. Tailored for patient characteristics and significantly shorter than the paper-based version, the SQoL-MCAT may improve the feasibility of assessing QoL in clinical practice.

Effects of first-generation antipsychotics versus second-generation antipsychotics on quality of life in schizophrenia: a double-blind, randomised study

BACKGROUND

Whether or not second-generation antipsychotics (SGAs) represent an advantage over first-generation antipsychotics (FGAs) in the treatment of schizophrenia is not certain. Effectiveness studies published in the past 10 years have not unequivocally confirmed the superiority of SGAs over FGAs. We aimed to compare quality of life in patients with schizophrenia on an FGA strategy with those on an SGA strategy.

METHODS

In the multicentre, randomised, double-blind Neuroleptic Strategy Study (NeSSy), we recruited participants (aged 18-65 years) with schizophrenia (ICD-10: F20.X) who required treatment initiation or a change in treatment, from 14 psychiatric university hospitals and state hospitals in Germany. Double randomisation allowed for restricted selection of a treatment within each antipsychotic drug group (FGA or SGA) for an individual patient: first, patients were assigned with a random number table to two of six possible drug pairs, each pair consisting of an FGA (haloperidol [3-6 mg] or flupentixol [6-12 mg]) given orally and an SGA (aripiprazole [10-20 mg], olanzapine [10-20 mg], or quetiapine [400-800 mg]) given orally, and the investigator then selected which pair was best suited to the patient; a second, double-blind random assignment allocated either the FGA or the SGA from the investigator-chosen pair to the patient. Treatment duration was 24 weeks. Primary outcomes were change from baseline to week 24 in quality of life (SF-36) and clinical global impression (CGI-I), analysed in all randomly assigned patients who received at least one dose of the study drug. Safety was assessed in a safety set, consisting of all randomly assigned patients who received at least one dose of the study drug, coinciding with the set of the efficacy analyses. The study is registered with ClinicalTrials.gov, number NCT01164059; German Clinical Trials Register, number DRKS00000304; WHO ICTRP, number U1111-1112-9727; and EudraCT, number 2009-010966-47.

FINDINGS

Between April 1, 2010, and May 31, 2013, 149 patients were randomly assigned, 69 to FGA treatment and 80 to SGA treatment. 136 patients received at least one dose of study drug (63 in the FGA group, 73 in the SGA group). Mean area under the curve (AUC) values of SF-36 were significantly higher in the SGA group than in the FGA group (85·1 [SD 14·7] vs 79·7 [17·3], p=0·0112). Mean AUC values for CGI-I scores decreased in both groups, but were not significantly different between the two groups (3·39 [SD 0·89] in the FGA group vs 3·26 [0·92] in the SGA group, p=0·3423). 30 (48%) of 63 patients given FGAs had at least one adverse event compared with 42 (57%) of 73 patients given an SGA (p=0·3019); the most common were nervous system disorders (18 [60%] of 30 in the FGA group vs 19 [45%] of 42 in the SGA group) and psychiatric disorders (ten [33%] vs 16 [38%]). One patient died after cessation of study drug (olanzapine), most likely as a result of an illicit drug overdose. The increase in body-mass index (BMI) was significantly higher in the SGA group than in the FGA group (p=0·0021 at week 6 and p=0·0041 at week 24).

INTERPRETATION

Improvement of patient-reported quality of life was significantly higher in patients with schizophrenia given SGAs than in those given FGAs, when treatment selection was individualised. This advantage, however, has to be weighed against the potential metabolic adverse effects of some SGAs.

FUNDING

German Federal Ministry of Education and Research.

Predictive models to estimate utility from clinical questionnaires in schizophrenia: findings from EuroSC

OBJECTIVE

The clinical symptoms of schizophrenia are associated with serious social, quality of life and functioning alterations. Typically, data on health utilities are not available in clinical studies in schizophrenia. This makes the economic evaluation of schizophrenia treatments challenging. The purpose of this article was to provide a mapping function to predict unobserved utility values in patients with schizophrenia from the available clinical and socio-demographic information.

METHODS

The analysis was performed using data from EuroSC, a 2-year, multi-centre, cohort study conducted in France (N = 288), Germany (N = 618), and the UK (N = 302), totalling 1208 patients. Utility was calculated based on the EQ-5D questionnaire. The relationships between the utility values and the patients' socio-demographic and clinical characteristics (Positive and Negative Syndrome Scale--PANSS, Calgary Depression Scale for Schizophrenia--CDSS, Global Assessment of Functioning--GAF, extra-pyramidal symptoms measured by Barnes Akathisia Scale-BAS, age, sex, country, antipsychotic type) were modelled using a random and a fixed individual effects panel linear model.

RESULTS

The analysis demonstrated the prediction ability of the used parameters for estimating utility measures in patients with schizophrenia. Although there are small variations between countries, the same variables appear to be the key predictors. From a clinical perspective, age, gender, psychopathology, and depression were the most important predictors associated with the EQ-5D.

CONCLUSION

This paper proposed a reliable, robust and easy-to-apply mapping method to estimate EQ-5D utilities based on demographic and clinical measures in schizophrenia.

Patient-oriented randomisation: A new trial design applied in the Neuroleptic Strategy Study

Background:

The ‘gold standard’ for clinical studies is a randomised controlled trial usually comparing specific treatments. If the scientific study expands to strategy comparison with each strategy including various treatments, the research problems are increasingly complicated. The strategy debate in the psychiatric community is the starting point for the development of our new design. It is widely accepted that second-generation antipsychotics are the therapy of choice in the treatment of schizophrenia. However, their general superiority over first-generation antipsychotics could not be demonstrated in recent randomised controlled trials. Furthermore, we are becoming increasingly aware that the experimental conditions of randomised controlled trials, as in the European First Episode Schizophrenia Trial and Clinical Antipsychotic Trials of Intervention Effectiveness Phase 1 studies, may be inappropriate for psychiatric treatments. The high heterogeneity in the patient population produces discrepancies between daily clinical perception and randomised controlled trials results. The patient-oriented approach in the Cost Utility of the Latest Antipsychotic drugs in Schizophrenia Study reflects everyday clinical practice. The results, however, are highly dependent on the physicians’ preferences. The goal of the design described here is to take an intermediate path between randomised controlled trials and clinical studies such as Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study, combining the advantages of both study types.

Methods:

The idea is to randomise two treatment pairs each consisting of one first-generation antipsychotic and one second-generation antipsychotic in a first step and subsequently, to involve the investigators in deciding for a pair most appropriate to the patients’ needs and then to randomise the allocation to one drug (first-generation antipsychotic or second-generation antipsychotic) of that chosen pair. This idea was first implemented in the clinical trial, the Neuroleptic Strategy Study, with a randomised design comparing efficacy and safety of two different strategies: either to use first-generation antipsychotics (haloperidol and flupentixol) or second-generation antipsychotics (olanzapine, aripiprazole and quetiapine) in patients suffering from schizophrenia.

Results:

In the course of the Neuroleptic Strategy Study, feasibility of this design was demonstrated. All aspects of the new design were implemented: randomisation process, documentation of responses from investigators as well as patients and drug logistic experience. In implementing the design, furthermore, we could investigate its theoretical properties. The physicians’ preferences for specific drugs used for the respective patients were analysed.

Conclusion:

The idea of patient-oriented randomisation can be generalised. In light of the heterogeneity and complexity of patient–drug interaction, this design should prove particularly useful.

Psychometric validations and comparisons of schizophrenia-specific health-related quality of life measures

To compare schizophrenia-specific quality of life measures, this study examined an 18-item Chinese version of 41-item Quality of Life Questionnaire in Schizophrenia (S-QoL; S-QoL-18-C) using 41 patients. The S-QoL-18-C was validated and compared with Schizophrenia Quality of Life Scale-Revision 4 (SQLS-R4). Index scores of S-QoL-18-C showed nearly identical psychometrics to S-QoL-C and S-QoL-18. No significant ceiling/floor effects were found, except with psychological and selfesteem subscales. Internal consistency was acceptable for whole scale and all subscales, except family relationships and sentimental life. Test-retest reliability was moderate to high (ICC=0.58-87). Score distributions and reliability of S-QoL-18-C were slightly lower than those of S-QoL-C. Convergent validity was supported by satisfactory correlations between subscales/index scores of S-QoL-18-C and similar scales (r=∣-0.35 ∣ to 0.80) and between corresponding subscales in S-QoL-18-C and S-QoL-C (r=0.85-0.97). S-QoL-18-C and SQLS-R4 demonstrated discriminant validity by differentiating among 30 patients with symptom remission, 30 patients without symptom remission, and 30 healthy individuals. Two patient groups were classified by criteria proposed by Remission in Schizophrenia Working Group. Three groups were controlled for five factors. Furthermore SQLS-R4, but not S-QoL-18-C, differentiated between patient groups with different hospitalization frequencies. Overall, S-QoL-18-C and SQLS-R4 show different advantages psychometrically.

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.

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.

Validation of a functional remission threshold for the Functional Remission of General Schizophrenia (FROGS) scale

OBJECTIVE

The aim of this study was to develop a functional remission threshold for the Functional Remission Of General Schizophrenia (FROGS) scale, and test its validity regarding clinical and quality of life outcomes.

DESIGN

Cross-sectional study.

INCLUSION CRITERIA

Schizophrenia according to DSM-IV-TR criteria.

DATA COLLECTION

Functioning was assessed using the FROGS and the Global Assessment of Functioning (GAF) scales; psychotic symptoms using the Positive and Negative Syndrome Scale; memory, attention, and executive functions were assessed using the California Verbal Learning Test, the D2 attention task, the Stroop color-word test, the verbal fluency test, the Trail Making Test A and B and the Wechsler Adult Intelligence Scale; and quality of life using the schizophrenia quality of life (S-QoL 18) scale.

ANALYSIS

A logistic regression analysis including the different dimensions of the FROGS was used to create a composite score to classify patients into remitted and non-remitted according a gold standard (cut-off: GAF>= 61). Receiver operating characteristics analyses were then performed to determine the area under the curve (AUC).

RESULTS

Of 137 patients enrolled, 26 were functionally remitted and 111 were not remitted according to GAF score. The AUC for the combination of the FROGS's dimensions to detect functional remission was 0.903 (p<0.001). Sensitivity and specificity for the combination of the FROGS dimensions using the Youden index were 88.5 [69.8; 97.6] and 81.1 [72.5; 87.9], respectively. Validity of this combination was satisfactory. Patients in functional remission had a lower severity of the disease, especially for PANSS negative (p<0.001) and general psychopathology (p<0.001) symptoms. Only two cognitive functions (i.e. fluency and episodic memory) were improved in remitted patients. Higher quality of life levels were globally associated with better functioning.

CONCLUSIONS

These findings provide for first accurate FROGS thresholds to detect functional remission in schizophrenia.

Internet-based hearing screening using speech-in-noise: validation and comparisons of self-reported hearing problems, quality of life and phonological representation

OBJECTIVES

For the last decade a host of different projects have been launched to allow persons who are concerned about their hearing status to quickly and at a low cost test their hearing ability. Most often, this is carried out without collecting complementary information that could be correlated with hearing impairment. In this two-part study we first, present the development and validation of a novel Internet-based hearing test, and second, report on the associations between this test and phonological representation, quality of life and self-reported hearing difficulties.

DESIGN

Cross-sectional study.

SETTING

An opportunity sample of participants was recruited at the Stockholm central station for the first study. All parts of the second study were conducted via the Internet, with testing and self-report forms adapted for online use.

PARTICIPANTS

The first part of the study was carried out in direct contact with the participants, and participants from the second study were recruited by means of advertisements in newspapers and on webpages. The only exclusion criterion was that participants had to be over 18 years old. Most participants were between 60 and 69 years old. There were almost an equal number of men and women (total n=316).

OUTCOME MEASURES

48 participants failed the Internet-based hearing screening test. The group failing the test reported more problems on the Amsterdam Inventory of Auditory Disability. In addition, they were found to have diminished phonological representational skills. However, no difference in quality of life was found.

CONCLUSIONS

Almost one in five participants was in need of contacting their local hearing clinic. This group had more complaints regarding tinnitus and hyperacusis, rated their own hearing as worse than those who passed, and had a poorer capability of generating accurate phonological representations. This study suggests that it is feasible to screen for hearing status online, and obtain valid data.

Investigating the safety and efficacy of naltrexone for anti-psychotic induced weight gain in severe mental illness: study protocol of a double-blind, randomized, placebo-controlled trial

BACKGROUND

Obesity is a growing health problem leading to high rates of mortality and morbidity in patients with severe mental illness (SMI). The increased rate of obesity is largely attributed to antipsychotic use. The effect of antipsychotic medications on H1 and 5HT2 receptors has been associated with weight gain, but there is also a substantial amount of evidence showing that D2 receptor blockade may be responsible for weight gain by interacting with the dopamine-opioid system. Unfortunately, current available medications for weight loss have limited efficacy in this population. Naltrexone, an opioid receptor antagonist, may be a promising agent to reduce antipsychotic induced weight gain by decreasing food cravings. We aim to investigate the safety and efficacy of two doses of naltrexone (25 mg & 50 mg) versus placebo for weight and health risk reduction in overweight and obese individuals (BMI ≥ 28) with SMI, who gained weight while being treated with antipsychotics.

METHODS AND DESIGN

One hundred and forty four patients will be recruited throughout the greater New Haven area. The participants will be randomized to naltrexone 25 mg/day, naltrexone 50 mg/day, or placebo in a 1:1:1 ratio. Participants will be on the study medication for 52 weeks, and assessed weekly for the first 4 weeks and bi-weekly thereafter. The primary outcome measurements are weight reduction and percentage achieving clinically significant weight loss (5% of total body weight). Waist circumference, body mass index, serum lipid profile, fasting glucose, and glycosylated hemoglobin are the secondary outcome measures. The effect of naltrexone on other outcome measurements such as schizophrenia symptoms, depression, dietary consumption, quality of life, cognitive functioning, physical activity, metabolism/inflammation markers, serum leptin, ghrelin, peptide YY, adinopectin, high sensitivity CRP, interleukin 6, interleukin-1B, interleukin-18, and tumor necrosis factor alpha (TNF-α) will be evaluated. The data will be analyzed by applying linear mixed effect models.

DISCUSSION

This is the first large scale study investigating the safety and efficacy of naltrexone in antipsychotic induced weight gain; and hopefully, this may lead to a novel pharmacological option for management of this major health problem.

TRIAL REGISTRATION

This trial is registered in http://www.clinicaltrials.gov as NCT01866098.

Self-reported quality of life measure is reliable and valid in adult patients suffering from schizophrenia with executive impairment

BACKGROUND

Impaired executive functions are among the most widely observed in patients suffering from schizophrenia. The use of self-reported outcomes for evaluating treatment and managing care of these patients has been questioned. The aim of this study was to provide new evidence about the suitability of self-reported outcome for use in this specific population by exploring the internal structure, reliability and external validity of a specific quality of life (QoL) instrument, the Schizophrenia Quality of Life questionnaire (SQoL18).

DESIGN

cross-sectional study.

INCLUSION CRITERIA

age over 18 years, diagnosis of schizophrenia according to the DSM-IV criteria.

DATA COLLECTION

sociodemographic (age, gender, and education level) and clinical data (duration of illness, Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia); QoL (SQoL18); and executive performance (Stroop test, lexical and verbal fluency, and trail-making test). Non-impaired and impaired populations were defined for each of the three tests. For the six groups, psychometric properties were compared to those reported from the reference population assessed in the validation study.

RESULTS

One hundred and thirteen consecutive patients were enrolled. The factor analysis performed in the impaired groups showed that the questionnaire 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 non-impaired groups and the reference population.

CONCLUSIONS

Our study suggests that executive dysfunction did not compromise the reliability or validity of self-reported disease-specific QoL questionnaire.

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.

Psychopathology, rehospitalization and quality of life among patients with schizophrenia under home care case management in Taiwan

BACKGROUND/PURPOSE

To study the outcome of a group of patients with schizophrenia receiving community home care case management programs by delineating the relationship among their psychopathology, rehospitalization rates and health-related quality of life (HRQoL).

METHODS

This is a cross-sectional study on HRQoL, functioning and associating factors and a retrospectivehistorical control study by comparing the frequency and duration of rehospitalization in a sample of 60 patients with schizophrenia under nonintensive case management (non-ICM) in Taiwan. All participants were assessed on the Positive and Negative Syndrome Scale for Schizophrenia (PANSS) for psychopathology, on EuroQoL-5D (EQ-5D) and EQ visual analogue (EQ-VAS) for HRQoL, andGlobal Assessment of Functioning (GAF) for socio-occupational dysfunction. Other clinical characteristics are also gathered.

RESULTS

Patients with schizophrenia treated with non-ICM had a significant reduction in admission frequency (-0.10 ± 0.36 times per year, p = 0.042) and length of inpatient stay (-27.8 ± 78.0 days per year, p = 0.008). Better EQ-5D and EQ-VAS are significantly associated with lower general psychopathology score, while better EQ-VAS is significantly associated with older age and higher negative symptoms subscale score. GAF is negatively associated with higher positive symptoms and negative symptoms subscale scores, while positively correlated with a greater reduction in number and frequency of admission.

CONCLUSION

Non-ICM can help to decrease rehospitalization of home care patients. HRQoL and functioning can be assessed by the three perspectives we used, and each measure was correlated to different dimensions of patient psychopathology. It will be better if we include baseline and post-intervention PANSS scores, HRQoL and functioning as outcome indicators.

[Quality of life in patients with schizophrenia: a study of 100 cases]

OBJECTIVE

The aim of the present study was to evaluate the quality of life (QOL) in outpatients with schizophrenia, and to identify factors correlated to an impaired QOL among them.

SUBJECTS AND METHODS

A transversal study, in the form of an inquiry, was conducted in 100 outpatients, during seven months, in the psychiatric department of the Hedi Chaker teaching hospital in Sfax - Tunisia. We used the "36 item Short-Form Health Survey" (SF-36) to assess the QOL; this has been considered as impaired when the global medium score was inferior to 66.7. For the global assessment of functioning and the global assessment of the interference by existing side effects with the patient's daily performance, we have used respectively the Global Assessment of Functioning scale (GAF) and the Udvalg of Kliniske Undersogelser (UKU) side effect rating scale. The positive and negative symptoms added to the general psychopathology were assessed using the Positive and Negative syndrome scale (PANSS).

RESULTS

The QOL was impaired in 34% of the cases. The analysis of the scores of the eight dimensions by the scale SF-36 has shown that the most affected dimensions were, in decreasing order: mental health (MH), general health perceptions (GH), vitality (VT), role limitations due to physical health problems (RP) and role limitations due to emotional problems (RE). The standardization revealed that six dimensions were impaired; these were, in decreasing order: mental health (MH), social functioning (SF), role limitations due to emotional problems (RE), role limitations due to physical health problems (RP), general health perceptions (GH) and physical functioning (PF). The standardization has also revealed an impairment of the psychological component, while the physical component has been conserved. After analysis by multiple linear regression, four factors appeared strongly correlated with the impaired QOL: the professional inactivity, the episodic course with interepisode residual symptoms, the presence of side effects moderately influencing the daily performance, and a general psychopathology score for 26 at least. These four factors affected, in decreasing order of importance, social functioning (SF) (related to two factors), general health perceptions (GH) and role limitations due to emotional problems (RE) (each related to one factor). None of the factors appeared to affect the other dimensions: physical functioning (PF), role limitations due to the physical health problems (RP), bodily pain (BP), mental health (MH) and vitality (VT). The bivariate analysis revealed three other factors correlated, to a lesser degree, to the impairment of the QOL: the disorganized sub-type, a score of (GAF) inferior or equal to 30 and the negative type of schizophrenia.

CONCLUSION

Management of schizophrenic patients should go beyond the remission of the symptoms; it has also to target the improvement in QOL. This needs an action over the factors that affect the QOL, among which residual symptoms and side effects. The atypical antipsychotics would contribute preciously in this way, due to their efficacy on negative symptoms and their better tolerance than the conventional ones.

How valid and responsive are generic health status measures, such as EQ-5D and SF-36, in schizophrenia? A systematic review

OBJECTIVES

Generic health status measures such as the short form health survey (SF-36) and EuroQol-5D (EQ-5D) are increasingly being used to inform health policy. They are claimed to be applicable across disease areas and have started to be used within mental health research. This review aims to assess the construct validity and responsiveness of four generic health status measures in schizophrenia, including the preference-based SF-6D and EQ-5D.

METHOD

A systematic review of the literature was undertaken. Ten databases were searched from inception to August 2009 and reference lists scrutinized to identify relevant studies. Studies were appraised and data extracted. A narrative synthesis was performed of the evidence on construct validity including known groups validity (detecting a difference in health-related quality of life (HRQL) scores between two different groups such as samples from the general population and people with schizophrenia), convergent validity (strength of association between generic HRQL and other measures (e.g., symptom or functional), and responsiveness. Responsiveness was considered by: 1) differences in generic HRQL measure scores in responders/non-responders and 2) correlation between changes on generic HRQL measures and changes in specific measures obtained from patients and clinicians.

RESULTS

Thirty-three studies were identified that provided data on the validity and/or responsiveness of the instruments. Most of the evidence concerns the SF-36 and EQ-5D, and for these instruments there was evidence for known group validity. The evidence for convergent validity and responsiveness was mixed, with studies presenting contradictory results.

CONCLUSION

Although the evidence base is limited in a number of important respects, including problems with the measures used to develop constructs in the validation studies, it is sufficient to raise doubts about the use of generic measures of health like the EQ-5D and SF-36 in patients with schizophrenia.

Divergent trajectories of physical, cognitive, and psychosocial aging in schizophrenia

Aging is not a uniform process. In the general population, there is a paradox of aging: age-associated decline in physical and some cognitive functions stands in contrast to an enhancement of subjective quality of life and psychosocial functioning. This paradox is even more striking in people with schizophrenia. Compared with the overall population, individuals with schizophrenia have accelerated physical aging (with increased and premature medical comorbidity and mortality) but a normal rate of cognitive aging, although with mild cognitive impairment starting from premorbid period and persisting throughout life. Remarkably, psychosocial function improves with age, with diminished psychotic symptoms, reduced psychiatric relapses requiring hospitalization and better self-management. Many older adults with schizophrenia successfully adapt to the illness, with increased use of positive coping techniques, enhanced self-esteem and increased social support. Although complete remission is uncommon, most individuals with schizophrenia experience significant improvement in their quality of well-being. Cohort effect and survivor bias may provide a partial explanation for this phenomenon. However, the improvement also may reflect some brain changes that are beneficial for the course of schizophrenia along with neuroplasticity of aging. The proposed hypothesis has several implications. As significant medical morbidity in schizophrenia takes years to develop, studies of changes in sensitive biomarkers of aging during the course of illness may point to new treatments aimed at normalizing the rate of biological aging in schizophrenia. At the same time, effective psychotherapeutic interventions can affect brain structure and function and produce lasting positive behavioral changes in aging adults with schizophrenia.

The Schizophrenia Caregiver Quality of Life questionnaire (S-CGQoL): development and validation of an instrument to measure quality of life of caregivers of individuals with schizophrenia

OBJECTIVE

This study aims to validate a self-administered, multidimensional QoL instrument based on the point of view of caregivers of individuals with schizophrenia.

METHODS

Data were collected through the departments of six psychiatric hospitals in France (n=246). The item reduction and validation processes were based on both item response theory and classical test theory.

RESULTS

The S-CGQoL contains 25 items describing seven dimensions (Psychological and Physical Well-Being; Psychological Burden and Daily Life; Relationships with Spouse; Relationships with Psychiatric Team; Relationships with Family; Relationships with Friends; and Material Burden). The seven-factor structure accounted for 74.4% of the total variance. Internal consistency was satisfactory; Cronbach's alpha coefficients ranged from 0.79 to 0.92 in the whole sample. The scalability was satisfactory, with INFIT statistics falling within an acceptable range. In addition, the results confirmed the absence of DIF and supported the invariance of the item calibrations.

CONCLUSION

The S-CGQoL is a self-administered QoL instrument that presents satisfactory psychometric properties and can be completed in 5 min, thereby fulfilling the goal of brevity sought in research and clinical practice.

The development of the S-QoL 18: a shortened quality of life questionnaire for patients with schizophrenia

OBJECTIVE

The S-QoL 41 is a French self-administered questionnaire that assesses quality of life (QoL) among people with schizophrenia. This study aims to validate a shortened version of the S-QoL for more widespread use in clinical practice.

METHODS

We used data from four studies conducted in four psychiatric hospitals in France (n=507). The item reduction and validation processes were based on both item response theory and classical test theory. The final version of the S-QoL was tested for construct validity, reliability, external validity, reproducibility and sensitivity to change. In addition, differential item functioning (DIF) analyses were performed to see whether all items behave in the same way in subgroups divided by age, gender, educational level and clinical form.

RESULTS

The S-QoL 18 evaluates eight dimensions: psychological well-being, self-esteem, family relationships, relationships with friends, resilience, physical well-being, autonomy and sentimental life. The factor structure accounted for 78% of the total variance. Internal consistency was satisfactory (item-internal consistency greater than 0.40; Cronbach's alpha coefficients ranged from 0.72 to 0.84). The scalability was satisfactory, with INFIT statistics within an acceptable range. In addition, the results confirmed the absence of DIF and supported the invariance of the item calibrations.

CONCLUSIONS

The S-QoL 18 is a short self-administered QoL instrument that has a high degree of comparability with S-QoL 41 and presents satisfactory psychometric properties. Future studies should confirm its sensitivity to change.

Physical and mental health-related quality of life among older people with schizophrenia

OBJECTIVE

Since the time of Kraeplin, schizophrenia has been thought of as a disorder with progressive deterioration in functioning. An important aspect of functioning is both physical and mental health-related quality of life (HRQoL). The objective of this study was to examine the relationship of age to both mental and physical aspects of HRQoL in individuals with schizophrenia as compared to normal comparison subjects (NCs).

METHODS

Middle-aged and older community-dwelling patients with schizophrenia (N=486) were compared to NCs (N=101). Health related quality of life was measured using the SF-36 Physical Health and Mental Health Component scores. The relationship between age and HRQoL was examined using linear regressions. In addition, we performed exploratory analyses to examine the effects of confounding variables on this relationship, and to examine the effects of age on SF-36 subscales.

RESULTS

Patients with schizophrenia had lower SF-36 Physical and Mental Health Component scores than NCs, and these differences persisted after adjusting for the age difference between the two groups. The relationship between age and mental, but not physical, HRQoL was significantly different between the patients with schizophrenia and the NCs. Specifically, older age was associated with higher mental HRQoL among patients with schizophrenia, but not among the NCs. This difference remained significant after examining multiple potential confounding demographic and clinical variables.

CONCLUSIONS

This study found that older age was associated with greater mental health quality of life. Longitudinal studies are warranted to confirm our finding, and to examine potential mechanisms responsible for possible improvement in mental HRQoL with age.

Adaptation and validation of the quality-of-life scale: Satisfaction with Life Domains Scale by Baker and Intagliata

OBJECTIVES

There are few quality-of-life instruments specifically for schizophrenia; thus, the objective of our study is to adapt and validate the Satisfaction with Life Domains Scale (SLDS) by Baker and Intagliata.

METHOD

This is a validation study in which the subjects were evaluated on 2 occasions (24-48 hours). The sample is composed of people with schizophrenia from 18 to 65 years old and who were seen in one of the following centers: Sant Joan de Déu-SSM, Hospital Clínic, Hospital de Mataró and Hospital Pere Mata. The SLDS was administered, along with Positive and Negative Syndrome Scale, the Clinical General Impression for Schizophrenia, Global Assessment of Function, Disability Assessment Scale--short version, Beck Cognitive Insight, and the Strauss and Carpenter Prognostic Scale. The Cronbach alpha test was carried out, and the intraclass correlation coefficient was used to assess test-retest reliability, along with Pearson correlations for discriminating validity.

RESULTS

The intraclass correlation coefficients oscillated between 0.51 and 0.83. The SLDS did correlate with any of the other instruments with the exception of the Positive and Negative Syndrome Scale general subscale and the Strauss and Carpenter prognostic scale.

CONCLUSIONS

The Spanish version of the SLDS was shown to be valid and reliable and provides a fast and specific measure for schizophrenia.

Health-related quality of life and the practice of electroconvulsive therapy

In the past several decades, health-related quality of life (HRQL) measures have become increasingly important as a type of patient-reported outcome documenting the subjective psychosocial burden associated with chronic illness. This article provides an introduction to HRQL, summarizes the measurement of HRQL in major depression and bipolar disorder, and reviews electroconvulsive therapy (ECT) studies that have measured HRQL. Health-related quality-of-life definitions and instruments vary widely but have nonetheless proven useful for evaluating the effects of disease and its treatment. Psychiatric disorders profoundly affect HRQL and, in many cases, exceed or contribute to the disease burden imposed by serious physical illness. An emerging literature demonstrates the importance of ECT in restoring function and HRQL in depressed patients. To keep pace as medicine is transformed along the dimensions outlined by the Institute of Medicine's Quality Chasm framework, ECT research must provide evidence supporting its safety and effectiveness and also that the treatment is patient-centered. A research agenda to demonstrate the subjective benefits of ECT must be mirrored by a practice of ECT that is increasingly customized to patient needs and values.