Condensed version of the Quality of Life Scale for schizophrenia for use in outcome studies

A Systematic Review and Meta-Analysis of the Association Between Psychopathology and Social Functioning in Schizophrenia

BACKGROUND

Impaired social functioning is a major, but under-elucidated area of schizophrenia. It's typically understood as consequential to, eg, negative symptoms, but meta-analyses on the subject have not examined psychopathology in a broader perspective and there's severe heterogeneity in outcome measures. To enhance functional recovery from schizophrenia, a more comprehensive understanding of the nature of social functioning in schizophrenia is needed.

STUDY DESIGN

In this systematic review and meta-analysis, we searched PubMed, PsycInfo, and Ovid Embase for studies providing an association between psychopathology and social functioning. Meta-analyses of the regression and correlation coefficients were performed to explore associations between social functioning and psychopathology, as well as associations between their subdomains.

STUDY RESULTS

Thirty-six studies with a total of 4742 patients were included. Overall social functioning was associated with overall psychopathology (95% CI [-0.63; -0.37]), positive symptoms (95% CI [-0.39; -0.25]), negative symptoms (95% CI [-0.61; -0.42]), disorganized symptoms (95% CI [-0.54; -0.14]), depressive symptoms (95% CI [-0.33; -0.11]), and general psychopathology (95% CI [-0.60; -0.43]). There was significant heterogeneity in the results, with I2 ranging from 52% to 92%.

CONCLUSIONS

This is the first systematic review and meta-analysis to comprehensively examine associations between psychopathology and social functioning. The finding that all psychopathological subdomains seem to correlate with social functioning challenges the view that impaired social functioning in schizophrenia is mainly a result of negative symptoms. In line with classical psychopathological literature on schizophrenia, it may be more appropriate to consider impaired social functioning as a manifestation of the disorder itself.

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.

The Relationship of Motivation and Neurocognition with Functionality in Schizophrenia: A Meta-analytic Review

The role that neurocognition plays in functionality in schizophrenia has been widely examined, although in recent years increasing attention has been paid to the influence of motivation instead. This study provides a review of the relationship of neurocognition and motivation with functionality in schizophrenia, taking into account objective/subjective functionality assessment, demographic variables, and the different terms used when referring to motivation. A search of electronic databases identified 34 studies that met the inclusion criteria for review. Correlation coefficients between motivation and functionality and between neurocognition and functionality were extracted. For a better understanding, potential moderator variables were also extracted. Meta-analysis showed that both motivation and neurocognition assessments were strongly associated with functioning, with correlations between motivation and functional outcomes being stronger. However, more than three-quarters of the variance in outcome remained unexplained by the moderating factors examined. The paper concludes with recommendations for clinical practice and future research.

Comparison of self-stigma and quality of life in patients with depressive disorders and schizophrenia spectrum disorders - a cross-sectional study

BACKGROUND

The views of one's self-stigma and quality of life (QoL) in patients with schizophrenia and depressive disorders are significant subjective notions, both being proven to affect patient's functioning in life. The objective of this study was to investigate the QoL and self-stigma in connection with demographic factors and compare the two groups of patients in terms of those variables.

METHODS

In a cross-sectional study, the outpatients with schizophrenia spectrum disorders and depressive disorders completed the Quality of Life Satisfaction and Enjoyment Questionnaire, the Internalized Stigma of Mental Illness Scale, and a demographic questionnaire during a routine psychiatric control. Furthermore, both patients and their psychiatrists evaluated the severity of the disorder by Clinical Global Impression-Severity scale.

RESULTS

The QoL of patients with depressive disorders or schizophrenia spectrum disorders did not significantly differ between the two groups. In both groups, unemployment was perceived to be a significant factor decreasing the QoL. Self-stigma was detected to be higher in patients with schizophrenia spectrum disorders than in patients with depressive disorders. A strong correlation was found between the two scales, meaning that those with higher levels of self-stigmatization were less prone to see their life as fulfilling and joyful.

CONCLUSION

This study shows that the degree of the internalized stigma can be an important aspect linked to the QoL irrespective of the diagnostic category.

Reducing outcome measures in mental health: a systematic review of the methods

BACKGROUND

Traditionally, classical test theory (CTT) has been used for instrument development and various methods have since been proposed for reducing outcome measures to shorter versions. These reduction methods have not previously been compared in mental or physical health.

AIM

To identify and compare the various methods used to develop brief versions of outcome measures from existing measures in mental health.

METHOD

A systematic review of the literature in Embase, Medline, PsychInfo and from a grey literature was done. Search strategies were developed in each database to identify all relevant literature based on the inclusion criteria. Each paper identified was briefly described and then assessed using a bespoke assessment checklist developed by the authors. Methods for reducing outcome measures found across all studies were compared.

RESULTS

Ten papers were identified. Five methods were used for scale reduction: Rasch analysis (RA), exploratory factor analysis (EFA), graded response models (GRMs), all-subset regression, and regression. RA was the most widely used process.

CONCLUSION

The Rasch model (RM) is the only model where "'specific objectivity"' is a defining property of the model. This property is necessary for constructing scales in line with the fundamental principles of measurement.

A history of health-related quality of life outcomes in psychiatry

Health-related quality of life (HRQoL) is a multidimensional concept that includes subjective reports of symptoms, side effects, functioning in multiple life domains, and general perceptions of life satisfaction and quality. Rather than estimating it from external observations, interview, or clinical assessment, it is best measured by direct query. Due to a perception that respondents may not be reliable or credible, there has been some reluctance to use self-report outcomes in psychiatry. More recently, and increasingly, HRQoL assessment through direct patient query has become common when evaluating a range of psychiatric, psychological, and social therapies. With few exceptions, psychiatric patients are credible and reliable reporters of this information. This article summarizes studies that highlight the development, validation, and application of HRQoL measures in psychiatry. Thoughtful application of these tools in psychiatric research can provide a much-needed patient perspective in the future of comparative effectiveness research, patient-centered outcomes research, and clinical care.

Validation of an abbreviated quality of life scale for schizophrenia

The field of therapeutics in schizophrenia is redefining optimal outcome, moving beyond clinical remission to a more comprehensive model that also includes functional recovery. The Quality of Life Scale (QLS) has been adopted by many large clinical trials, including CATIE and CUtLASS, as a measure of functioning. The QLS is a 21-item semi-structured interview that takes approximately 45min to administer. Although the QLS is considered comprehensive, its length limits its applicability across studies. To circumvent this issue, short scales of the QLS have been created that estimate total scores with high accuracy. However, these abbreviated measures have not been adequately cross-validated in a large enough sample to allow for subsample estimations nor has its predictive ability been compared to the full scale. Here, we used data from the CATIE trial (n=1460) to demonstrate the validity and utility of an abbreviated 7-item QLS. The shortened QLS was robust in estimating total scores (r=0.953, p<0.001) across subsamples and demonstrated predictive ability similar to the full QLS in multiple regression models. The abridged QLS is recommended as a surrogate measure of psychosocial functioning, especially in cases where functioning is not the primary outcome.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

STAR*D: has it taught us anything about the management of depression?

OBJECTIVE

The aim of this paper was to review the large US National Institute of Mental Health-sponsored depression intervention effectiveness study, STAR*D, in order to evaluate critically its relevance for Australasian clinicians.

CONCLUSIONS

STAR*D is a landmark study which tried to address issues of effectiveness rather than efficacy, of a number of interventions for depression. However, methodological shortcomings limit the utility of the study in informing Australasian clinical practice.

Relationships between cognitive deficits, symptoms and quality of life in schizophrenia

OBJECTIVE

Schizophrenia is a complex disorder characterized by impairment in a number of domains, all of which contribute to disability. The aim of the present study was to investigate the relationships between cognitive function, symptoms and quality of life (QOL) in schizophrenia.

METHOD

This cross-sectional study measured cognition, positive and negative symptom severity, and quality of life (measured with the Quality of Life Scale) in 57 outpatients with schizophrenia. Correlations between the different measures were sought. Multiple regression analyses were used to develop models of the contributions of cognitive deficits and symptomatology to QOL.

RESULTS

More severe positive and negative symptoms and cognitive impairment each correlated with poorer QOL. There was a moderate association between negative symptoms and cognition and a small association between positive symptoms and cognition. Age, gender, and drug and alcohol abuse did not significantly predict QOL. In the multiple regression analysis, entering the total cognition and total symptom scores produced a model that accounted for an additional 57% of the variance in QOL.

CONCLUSIONS

Improving quality of life for people with schizophrenia requires that positive and negative symptoms and cognition are each addressed as separate domains of impairment. But, given that these account for only 57% of the variance in QOL, other factors such as unemployment, poverty, social isolation and stigma may also be important.

Psychiatric symptoms and quality of life in schizophrenia: a meta-analysis

Quality of life (QoL) has been recognized as an important outcome of schizophrenia treatment, yet the determinants of QoL for individuals with schizophrenia are not well known. Research has consistently found psychiatric symptoms to be negatively related to QoL, however, findings concerning the strength of these relationships have been mixed, making it difficult to determine the degree to which such symptoms are related to poor QoL. This research presents a systematic meta-analysis of studies examining the relationship between psychiatric symptoms and QoL in schizophrenia, in an effort to elucidate the determinants of QoL for this population. A total of 56 studies were extracted from literature searches of relevant databases for empirical reports published between 1966 and 2005 examining the relationship between positive, negative, and/or general psychiatric symptoms and QoL. Weighted effect size analyses revealed small relationships between psychiatric symptoms and QoL, with general psychopathology showing the strongest negative associations across all QoL indicators. Moderator analyses indicated that variation in effect sizes could be accounted for by differing operationalizations of QoL, study design, sample, and participant treatment setting. In particular, positive and negative symptoms were more strongly related to poor QoL among studies of schizophrenia outpatients, whereas general psychopathology showed a consistent negative relationship with QoL across all study samples and treatment settings. Implications for future research and treatment development are discussed.