Quality of life in schizophrenia: Long-term follow-up in 362 chronic Spanish schizophrenic outpatients undergoing risperidone maintenance treatment

A Systematic Review on the Effectiveness of Antipsychotic Drugs on the Quality of Life of Patients with Schizophrenia

Pharmacological antipsychotic drug interventions represent the cornerstone of the management of patients with schizophrenia and other psychotic spectrum disorders. The choice of the "best" treatment should be made on the basis of several clinical domains. However, despite available treatments, the quality of life reported by patients with schizophrenia taking antipsychotics is still very poor, and this outcome is rarely taken into account in trials assessing the efficacy and effectiveness of antipsychotic treatments. Therefore, we performed a systematic review in order to assess the impact of antipsychotic treatment on patients' quality of life. In particular, we aimed to identify any differences in the improvement in quality of life according to the (a) type of formulation of antipsychotic drugs (i.e., oral vs. depot vs. long-acting injectable); (b) type of the drug (first vs. second vs. third generation); and (c) patients' clinical characteristics. One hundred and eleven papers were included in the review. The main findings were as follows: (1) quality of life is usually considered a secondary outcome in trials on the efficacy and effectiveness of drugs; (2) second-generation antipsychotics have a more positive effect on quality of life; and (3) long-acting injectable antipsychotics are associated with a more stable improvement in quality of life and with a good safety and tolerability profile. Our systematic review confirms that quality of life represents a central element for selecting the appropriate treatment for people with schizophrenia. In particular, the availability of new treatments with a better tolerability profile, a proven effectiveness on patients' cognitive and social functioning, and with a more stable blood concentration might represent the appropriate strategy for improving the quality of life of people with schizophrenia.

Social functioning as an outcome measure in schizophrenia studies

OBJECTIVE

Deficits in social functioning are a core feature of schizophrenia.

METHOD

A literature search of English language articles published between January 1990 and December 2006 was undertaken to identify: i) scales used most frequently to assess social functioning in schizophrenia; and ii) the most frequently used social functioning scales in randomized, controlled trials of antipsychotics. A further search (without time limits) examined their psychometric properties.

RESULTS

A total of 301 articles employed social functioning scales in the assessment of schizophrenia. These contained 87 potentially relevant measures. Only 14 randomized, controlled studies of antipsychotic agents were identified that examined social functioning. Scales varied greatly in terms of measurement approach, number and types of domains covered and scoring systems. A striking lack of data on psychometric properties was observed.

CONCLUSION

Limited consensus on the definition and measurement of social functioning exists. The Personal and Social Performance Scale is proposed as a useful tool in future research.

Quality of life in schizophrenic patients

In the last decades, there has been increased interest in the field of quality of life in mental disorders in general, and particularly in schizophrenia. In addition, the appearance of the atypical antipsychotic drugs (amisul pride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone, and ziprasidone) with different therapeutic and side-effect profiles, has promoted a greater interest in assessing the quality of life of schizophrenic patients. In this paper we will briefly summarize the difficulties in assessing quality of life in schizophrenic patients, as well as the results concerning their quality of life and the influence of psychopathology, especially negative and depressive symptoms, on it. We will also review data from recent clinical trials showing the impact of antipsychotic treatments and their side effects upon quality of life.

The relationship between patient satisfaction and treatment outcomes in schizophrenia

In recent years, the goals of treatment in schizophrenia have evolved from objective improvements in psychotic symptoms to encompass patient-related factors such as subjective response and quality of life. In order to examine factors that influence patient satisfaction with treatment, subjective quality of life and subjective response to treatment, two literature searches were performed using PubMed. The first searched for articles of any kind with no time limits using the search parameters 'schizophrenia AND satisfaction', 'antipsychotic AND satisfaction', 'schizophrenia AND subjective response', 'schizophrenia AND therapeutic alliance', 'schizophrenia AND psychosocial OR psychoeducation'. Secondly, PubMed was searched between January 1990 and December 2005 using the key words 'satisfaction', 'subjective response' and 'quality of life' in combination with an array of atypical agents. Results demonstrated that patient satisfaction with antipsychotic therapy is influenced by multiple factors. The most frequently reported reasons for dissatisfaction include drug side effects, lack of involvement in treatment planning or decision-making and lack of involvement of family members in the care plan. The majority of studies have demonstrated that the atypical antipsychotics are associated with significant improvements in quality of life, functional status and patient satisfaction compared with conventional agents. The therapeutic alliance is key to achieving optimal outcomes, by providing information and education to meet patients' needs, while facilitating compliance with drug therapy to ensure better clinical outcomes. A long-acting atypical antipsychotic that can ensure medication delivery will provide a platform for psychosocial interventions, and thus may further increase patient satisfaction and, ultimately, improve long-term outcomes in schizophrenia.

Preliminary Study of OCD and Health Disparities at the U.S.-Mexico Border

The widespread and devastating nature of obsessive compulsive disorder (OCD) sharply contrasts with the paucity of research involving Mexican Americans and Mexicans who suffer from this condition. This mixed-methods preliminary study was intended to provide initial data and to pilot the procedures for a larger investigation of the cultural identification, symptomatology, health concerns, coping mechanisms, and quality of life of Mexican Americans and Mexicans with OCD living in the U.S.-Mexico border region of El Paso, Texas and Ciudad Juarez, Mexico. For the sample of six participants, whose symptoms ranged from moderate to extreme, OCD was associated with marked impairment in quality of life, particularly in terms of social functioning, an area of central importance for many Mexican Americans and Mexicans. Areas of further study were identified, with the aim of developing culturally sensitive interventions to decrease health disparities involving OCD.

Disability in schizophrenia: clinical correlates and prediction over 1-year follow-up

Schizophrenia may cause disability leading to restrictions on many domains of daily life such as hygiene, self-management, vocational and leisure activities, and family and social relationships. The aim of this study was to assess the level of disability with the Brief Disability Questionnaire (BDQ), developed by the World Health Organization, and to identify the clinical correlates and predictors of disability during a 1-year follow-up period in 382 patients with schizophrenia. All patients were assessed at the beginning of the study, and 168 (44%) of them were re-evaluated after 1 year. Total disability scores of the patients with schizophrenia were significantly decreased at follow-up. Female patients seemed to be more disabled than males. Disability showed a positive correlation with the total, positive symptoms and negative symptoms scores on the Brief Psychiatric Rating Scale, as well as scores on the UKU Side Effects Rating Scale. Patients with the disorganized subtype of schizophrenia and residual symptoms were more disabled than patients with other subtype diagnoses. Negative symptoms and duration of untreated psychosis were significant predictors of disability after 1 year. Early-onset schizophrenia had a twofold increased risk for developing disability. Disability in schizophrenia is a clinical phenomenon closely linked to negative symptoms and poor outcome.

The effects of antipsychotic treatment on quality of life of schizophrenic patients under naturalistic treatment conditions: An application of random effect regression models and propensity scores in an observational prospective trial

The study examines the effect of different types of antipsychotic treatment on the health related quality of life (HRQL) of people with schizophrenia under naturalistic outpatient treatment conditions. In a prospective study design, 307 schizophrenic patients were followed over a period of 2.5 years. HRQL, clinical characteristics, and type of antipsychotic medication were assessed five times every 6 months. HRQL was assessed by the SF-36. Random effect regression models were computed for the SF-36 mental (MCS) and physical (PCS) component scores. Propensity scores were included in the regression models to reduce a possible sample selection bias. Monotherapeutic treatment with new atypical neuroleptic drugs had a more positive effect on the mental health related quality of life (MCS) in comparison to treatment with polypharmacological treatment but not with oral conventional antipsychotics. Monopharmaceutical treatment with depot-antipsychotic drugs had a more positive effect on the physical health related quality of life (PCS) in comparison to polypharmacological treatment. Study results indicate that atypical antipsychotic drugs are not superior to conventional antipsychotics with regard to the effect on QOL. However, monopharmaceutical treatment can be assumed to be more effective in improving mental and physical related QOL than polypharmaceutical treatment.

Impact of atypical antipsychotics on quality of life in patients with schizophrenia

Schizophrenia is a long-term disabling illness that affects approximately 1% of the population. Its course is generally chronic with acute psychotic exacerbations that may require frequent hospitalisations. The clinical picture includes a range of symptoms such as delusions, hallucinations, agitation, suspiciousness, hostility, conceptual disorganisation, blunted affect, emotional and social withdrawal, lack of spontaneity, poverty of speech and a wide range of neurocognitive deficits. Over the past 50 years, antipsychotic medications have emerged as the cornerstone of management in concert with other important interventions, such as psychosocial and economic support and rehabilitation efforts. However, the unrivalled role of conventional antipsychotic medications has been continuously challenged by the wide range of adverse effects of these medications and their lack of usefulness in the treatment of neurocognitive deficits as well as deficit and negative symptoms. In addition, the lack of subjective tolerability of these agents and their negative impact on quality of life have complicated management for a large number of patients. Over the last 15 years, several new atypical antipsychotic medications have been introduced, including amisulpride, remoxipride, risperidone, sertindole, olanzapine, zotepine, quetiapine, ziprasidone and aripiprazole. In general, the new antipsychotics have shown themselves to be at least comparable in efficacy to conventional antipsychotics but with superior subjective tolerability and a more favourable adverse effect profile. The majority of quality of life studies involving new antipsychotic agents have evaluated the benefits of risperidone, olanzapine and clozapine; only a few studies have examined the effects of other new antipsychotics. While most of these studies have methodological and design limitations, the weight of evidence from them nevertheless points to a trend towards a more positive impact on quality of life with atypical agents. A number of recommendations can be made. First, more independent well designed and controlled studies are urgently needed to evaluate the effects of antipsychotic therapy on quality of life in patients with schizophrenia. New comparative studies should explore not only the differences between new and old antipsychotics but also identify any potential differences between individual new agents. The role of cost-effectiveness studies such as cost utility approaches in schizophrenia needs to be revisited, notwithstanding the fact that these types of studies have been reported to be feasible in schizophrenia. Finally, quality-of-life-based pharmacoeconomic studies of antipsychotic agents should not concentrate solely on cost reduction or containment, as it is likely that in order to maximise the benefits of new antipsychotic medications, greater expenditure on rehabilitation programmes and other support services will be necessary in the short-term at least.

Quality of life in persons with schizophrenia in out-patient treatment with first- or second-generation antipsychotics

OBJECTIVE

Effects of first in comparison with second-generation antipsychotics on the subjective quality of life (QoL) of patients with schizophrenia under routine treatment conditions were examined.

METHOD

In a prospective naturalistic trial the QoL, social, clinical, and treatment-related characteristics and type of antipsychotic medication of 307 patients with schizophrenia (ICD-10 F 20) were assessed five times with 6-month intervals over 2.5 years. Longitudinal and cross-sectional effects of antipsychotic medication were assessed by hierarchical regression models. Selection bias was controlled by propensity scores.

RESULTS

While positive effects of first-generation antipsychotics on subjective QoL in comparison with no antipsychotic treatment were found, second-generation antipsychotics caused no better QoL than first-generation antipsychotics.

CONCLUSION

The hypothesis that second-generation in comparison with first-generation antipsychotics have a better effect on the improvement of subjective QoL of people with schizophrenia in routine out-patient treatment was not supported.

New antipsychotics, compliance, quality of life, and subjective tolerability--are patients better off?

OBJECTIVES

This overview reviews the impact of second-generation antipsychotics on less frequently researched outcomes such as medication-adherence behaviour, quality of life, and subjective tolerability in patients with schizophrenia.

METHODS

We selectively reviewed recent literature and considered our own research and experiences in the field.

RESULTS

Most published studies about second-generation antipsychotics have dealt with issues related to efficacy and safety. So far, not many studies have focused on effectiveness in terms of such important outcomes as medication-adherence behaviour, quality of life, subjective tolerability, and overall satisfaction with treatment. Although most studies are inconclusive and their results are inconsistent--which has to do with several design and methodological limitations--there seems, on balance, to be a trend indicating superiority of second-generation, compared with first-generation, antipsychotics in improving medication-adherence behaviour and quality of life. The trend toward more favourable subjective tolerability and less frequent neuroleptic dysphoria seems to be relatively stronger.

CONCLUSIONS

At present, the state of the art can only indicate a more favourable trend for second-generation antipsychotics in regard to improving medication adherence behaviour, quality of life, and subjective tolerability. It is surprising that such important outcomes, which are likely the defining factors in the superiority of second-generation antipsychotics, have not received adequate research attention. Well-designed, controlled, and adequately powered studies are urgently needed before any firm conclusions can be reached.

Risperidone in acute and long-term therapy of schizophrenia--a clinical profile

Data from a range of well-controlled clinical trials, observational studies, and clinical use support the efficacy of risperidone for both acute and long-term therapy of schizophrenic psychoses. With regard to positive symptoms, the efficacy of risperidone was shown to be at least comparable with that of haloperidol. However, risperidone differs from conventional antipsychotics because it is more effective against the negative symptoms, has beneficial effects on affective and cognitive symptoms, and carries less risk of extrapyramidal side effects (EPS). To date, risperidone is the only atypical antipsychotic to have shown a significantly lower relapse rate compared with haloperidol in a long-term double-blind trial. This review describes comprehensive trial data and therapeutic observations gained with risperidone in the treatment of schizophrenia since its approval.

Quality of life in schizophrenia: a review of the literature from 1995 to 2000

The measurement of the quality of life of patients diagnosed with psychiatric disorders has become central to evaluating the effectiveness of treatments offered by Australian mental health services. The importance of quality of life as an indicator of the outcomes of interventions has been reflected by a large body of research seeking to measure the impact of variables such as gender, ethnicity and duration of illness on the measurable quality of life of an individual diagnosed with schizophrenia. This study aims to review and synthesize the recent literature in which quality of life has been measured by the use of at least one quality of life instrument. It is concludes that while the measurement of quality of life is valuable as a measure of outcomes, it should be treated as only one means of doing so.

Quality of life in schizophrenia measured by the MOS SF-36 and the Lancashire Quality of Life Profile: a comparison

OBJECTIVE

To compare two Quality of Life (QoL) instruments on reliability, feasibility and conceptual overlap in a group of schizophrenic out-patients.

METHOD

The Lancashire Quality of Life Profile (LQoLP) and the MOS SF-36 were used to assess the QoL of 143 schizophrenic out-patients.

RESULTS

Feasibility and reliability for both instruments were satisfying. Second order factor analysis on 10 LQoLP and eight MOS SF-36 scales resulted in three factors: one health related QoL factor and two general QoL factors; an internal and an external factor.

CONCLUSION

QoL measures in schizophrenia studies are not exchangeable. Validity of a specific QoL instrument depends upon the purpose of the study. The LQoLP allows suggestions for specific improvements in mental health care for long-term psychiatric patients. The SF-36 is a good choice when comparison with other patient groups on health related QoL is relevant.

Quality of life and treatment costs in schizophrenic outpatients, treated with depot neuroleptics

Study aim was 1) to find out the influences on quality of life (QoL) of chronic outpatients with schizophrenia; 2) to calculate Quality Adjusted Life Years (QALY); and 3) to estimate direct 1-year treatment costs. In a 20% sample (100 males, 100 females) of schizophrenic outpatients from the Outpatients Clinic in Ljubljana, Slovenia receiving depot neuroleptics demographic, clinical, and treatment data were collected for the year 1996. The Krawiecka Scale, Global Assessment Scale (GAS), Abnormal Involuntary Movement Scale, Rating Scale for Drug-Induced Akathisia, Rating Scale for Extrapyramidal Side Effects, Quality of Life Scale (QLS), EQ-5D and QALY were used. Multivariate linear regression was used with the QLS score as dependent variable. The patients were on average 44 years old and had been treated for 14 years. The average GAS score was 70. GAS was positively related to the QLS score while the parkinsonism score was inversely correlated with QLS. The patients can expect to live for 10. 20 more QALY on average. The QoL on the EQ-5D scale was 0.73. The annual direct treatment costs amounted to $216,216 in 1996 prices. In well-adjusted chronic patients with schizophrenia the QoL seems to depend mostly on their psychosocial performance and side effects. Although rare, re-hospitalisations accounted for one-half of all treatment expenses.

Good tolerability equals good results: the patient's perspective

Although conventional antipsychotics are useful for the treatment of schizophrenia, many patients discontinue taking them within a few months. As well as the positive influence of a good doctor-patient relationship, evidence suggests that the patient's initial subjective experience during antipsychotic therapy is a major predictor of compliance. In addition to motor symptoms, conventional antipsychotics can cause significant adverse effects on drive, emotion and cognition, which are reflected in patients complaining of a reduced quality of life, although may not be detected by objective examination. This syndrome, which is similar to the negative symptoms of schizophrenia, is known by numerous terms including 'pharmacogenic depression' and 'pharmacogenic anhedonia'. The introduction of atypical antipsychotics broadened the criteria for effective antipsychotic treatment to include the subjective assessment of improvement in patients' quality of life. The previous lack of interest in this domain may have been due to the inability to improve it with conventional agents and the misconception that schizophrenic patients were unable to subjectively evaluate their quality of life. However, numerous studies have shown that 63-95% of patients in remission are able to self-rate their affective state of well being or quality of life. Atypical antipsychotics are superior to conventional antipsychotics in improving quality of life and reducing the stigma of schizophrenia, particularly from the patient's perspective and are strong reasons for the widespread use of these drugs.

Quality of life and disability in patients with obsessive-compulsive disorder

The aim of this study is to describe the situation of Spanish obsessive-compulsive disorder (OCD) patients and compare it to that of the general population and other patient groups.

METHODS

Thirty-six OCD patients on maintenance treatment were evaluated using the Y-BOCS, SF-36, and DAS-S. Their SF-36 scores were compared to Spanish norms and to those obtained from U.S. OCD patients, schizophrenic outpatients, depressed outpatients, heroin dependents, patients on hemodialysis, and kidney transplant recipients.

RESULTS

Sixty-one percent of the patients had severe or extremely severe symptoms. Their quality of life was worse when compared with the Spanish norms in all SF-36 areas, but especially with respect to mental health. In contrast to U.S. OCD patients, social functioning is more impaired in the Spanish OCD patients. OCD patients reported the same quality of life as schizophrenics in the areas of mental health, but better in the areas of physical health. Compared with heroin dependents and depressed patients, their quality of life was worse. On mental health scales, OCD patients scored worse than somatic patients.

CONCLUSIONS

OCD in the Spanish population was shown to be associated with worse quality of life than for any other patient group (including physical groups), except schizophrenics.