Quality of life in chronically mentally ill patients in day treatment

Quality of life and its associated factors among patients with two common types of chronic mental illness living in Kaohsiung City

AIM

This study explored the associations of personal, disease, family, and social factors with quality of life (QoL) in patients with two common types of chronic mental illness (CMI) living in Kaohsiung City, Taiwan.

METHODS

Using a convenience sample and a cross-sectional design, 714 patients (50.1% male, 49.9% female) with CMI (72.1% schizophrenia and 27.9% affective disorder) and their caregivers were recruited. Demographic information was collected via the following questionnaires: 12-Item Short-Form Health Survey (SF-12), five-item Brief Symptom Rating Scale (BSRS-5), Caregiver Burden Scale, and Clinical Global Impressions (CGI-S) Scale. Pearson correlations and hierarchical regression analyses were used to predict QoL.

RESULTS

Disease factors accounted for 17-50% of the change in variance. Predictors of low mental subscale scores included the following: high psychological distress and high family burden as well as a history of suicide attempts, negative caregiver attitudes, and living away from home. Disease factors also explained the greatest variance in the physical subscales. Predictors of low physical subscale scores included the following: high psychological distress, age, unemployment, a history of suicide attempts, high family burden, and living alone.

CONCLUSIONS

Disease factors were the most important predictors of QoL in patients with CMI. Family factors were more important than social factors on the mental subscales. Differential relationships were also found for the other two dimensions. Together, these results indicate that a wide range of factors improve the QoL in patients with CMI.

The Role of Perceived Control for the Perception of Health by Patients with Persistent Mental Illness

Perceived control has been found to be of significance for patients with psychiatric disorders and may be regarded as an aspect of empowerment. Moreover, a sense of control has been identified as important for occupational performance, both in empirical research and in occupational therapy theory. This study aimed at investigating factors that might be of importance for perceived control: sociodemographic, clinical, and well-being variables. Another aim was to investigate whether perceived control served as a mediator between clinical variables, in terms of psychopathology, and well-being variables, in terms of perceived health. Sociodemographic data were collected from 177 subjects, most of them with psychosis diagnoses. They were also assessed regarding perceived control (locus of control and self-mastery) and different aspects of health and well-being. The findings showed that both clinical and well-being variables were consistently related to both aspects of perceived control. Moreover, the roles of self-mastery and locus of control as mediators of perceived health were identified. The results also identified some important sociodemographic factors that might promote a sense of control and empowerment, mainly educational level and friends. This study provided detailed knowledge of the role of perceived control for well-being among people with mental disorders. Strategies for how occupational therapists may promote a sense of control in this group are discussed.

Correlates of subjective quality of life in people with schizophrenia: findings from the EuroSC study

Quality of life (QOL) is an important outcome for people with schizophrenia, but most previous studies of its correlates have had small sample sizes or explored a limited number of variables. We conducted an analysis of the baseline data from the European Schizophrenia Cohort (EuroSC) study, a naturalistic investigation of people with schizophrenia living in France, Germany, and the United Kingdom (N = 1208). German participants had the highest subjective QOL. Country of residence, depression, accommodation status, and employment were the most important factors in explaining subjective QOL. Many correlates of subjective QOL in people with schizophrenia were similar to those in the general population. Many of the factors important in explaining subjective QOL in people with schizophrenia are not readily amenable to change. Differences in mental health service provision in the United Kingdom and Germany may in part explain variations in the QOL of people with schizophrenia resident there.

Empirical evidence for using subjective quality of life as an outcome variable in clinical studies A meta-analysis of correlates and predictors in persons with a major mental disorder living in the community

This paper presents data from a systematic review and meta-analysis of published quality of life (QOL) studies on the subjective general well-being (GWB) of persons with major mental disorder (MMD) who live in the community. Four research questions were addressed: (1) What is the subjective QOL in persons with MMD who live in the community? (2) Are any specific subjective subdomains of QOL superior predictors of subjective GWB? (3) Is there an association between measures of psychopathology and subjective GWB? (4) Is there an association between sociodemographic variables and subjective GWB? We initially considered 134 potentially relevant articles, but only 42 studies reporting on 49 study units (N=6774 persons with MMD) met criteria of acceptable quality or relevance to be included in the meta-analysis. First, we found that measures of subjective GWB were relatively high. Second, certain subdomains such as Leisure and Social relations were strong predictors of subjective GWB, while the links between both Personal safety and Work, and GWB were weak. Third, we found that the empirical basis for using subjective QOL as an outcome variable in clinical research is scant. In particular, the relationship between changes in measures of psychopathology and subjective QOL appears to be obscure. Finally, the present study failed to confirm any stable relationship between sociodemographic factors and subjective GWB in persons with MMD who live in the community. Consequences of the findings for clinical practice and research are discussed. Limitations inherent in the meta-analytic approach in general, and the lack of homogeneity in the reviewed studies, need to be considered when interpreting the results of this meta-analysis.

Living among strangers: the needs and functioning of persons with schizophrenia residing in an assisted living facility

OBJECTIVES

The purposes of this research were to describe the quality of care for severe and persistent mentally ill persons with schizophrenia who reside in an assisted living facility and to explore the characteristics related to the identification of need and the level of functioning of these individuals. The specific objectives of the study were to (a) describe characteristics of the residents, (b) identify relationships among characteristics of residents and the level of functioning, and (c) analyze relationships among these characteristics and resident needs.

DESIGN

Correlational, quasi-experimental design. POPULATION/ SAMPLE/SETTING: Face-to-face semistructured interviews were conducted with 58 ALF residents with schizophrenia and eight direct caregivers from eight assisted living facilities in Florida, resulting in representation of 20% of the public assisted living facilities in one county.

METHOD

Face to face, semi-structured interviews utilizing multiple scales and instruments.

FINDINGS

Findings indicated that the profile of a typical resident living in a public ALF consisted of a 43-year-old, never married Caucasian male who dropped out of high school and had suffered from a psychiatric illness for over 21 years. The most frequent reported current mental health treatment modality of residents was attendance at a community mental health center. This average resident had five inpatient psychiatric hospitalizations, had not been an inpatient at a state psychiatric facility, and was prescribed an average of four different psychiatric medications. Spearman correlational coefficients and stepwise multiple regression analyses revealed that significant relationships existed between level of functioning and the following characteristics: positive symptoms (p = 0.0003), negative symptoms (p = 0.003), medication knowledge (p = 0.0001), and GAF scores, current (p = 0.01) and past (p = 0.009). No significant relationships were indicated among resident characteristics and resident needs.

CONCLUSIONS

This descriptive, correlational study provides the foundation for further research on the quality of care for individuals with severe and persistent mental illnesses who reside in assisted living facilities. Understanding the interactions among symptoms of schizophrenia, level of functioning, and unmet needs may provide a future focus for mental health treatment planning and intervention.

IMPLICATIONS

National and international agencies develop and implement assisted living facility standards that impact the lives of residents with moderate levels of functioning and multiple unmet needs, having implications for both practice and mental health policy.

Socio-demographic and clinical predictors of quality of life in patients with schizophrenia or schizo-affective disorder

This article discusses the relationships between socio-demographic, clinical characteristics and Quality of Life (QOL) of individuals with schizophrenia. The client version of the Canadian version of the Wisconsin Quality of Life Index (CaW-QLI) was used with a population of 182 individuals with either schizophrenia or schizo-affective disorder. Multivariate analyses of variance with Tukey post hoc tests were used to assess differences between groups defined according to socio-demographic and clinical characteristics on all sub-scale scores in addition to the global score on the CaW-QLI. Relationships between socio-demographic characteristics and QOL were found for gender, age, education, employment status and living arrangement. Differences in QOL were found between groups with different clinical characteristics, such as diagnosis, hospitalization during the last 12 months and age at first hospitalization. Using socio-demographic and clinical variables in addition to psychosocial variables appears to be promising for understanding QOL in psychotic patients. Methodological considerations for future research are discussed.

Positive Psychology in Clinical Practice

Positive psychology is the scientific study of positive experiences and positive individual traits, and the institutions that facilitate their development. A field concerned with well-being and optimal functioning, positive psychology aims to broaden the focus of clinical psychology beyond suffering and its direct alleviation. Our proposed conceptual framework parses happiness into three domains: pleasure, engagement, and meaning. For each of these constructs, there are now valid and practical assessment tools appropriate for the clinical setting. Additionally, mounting evidence demonstrates the efficacy and effectiveness of positive interventions aimed at cultivating pleasure, engagement, and meaning. We contend that positive interventions are justifiable in their own right. Positive interventions may also usefully supplement direct attempts to prevent and treat psychopathology and, indeed, may covertly be a central component of good psychotherapy as it is done now.

A 'bittersweet pill to swallow': learning from mental health service users' responses to compulsory community care in England

Two forms of compulsory mental healthcare and supervision in the community are provided within the Mental Health Act 1983: Supervised Discharge Orders (SDOs) and guardianship. At a time when the Government are proposing to extend powers of supervision over people with severe mental illness in the community, it is appropriate that service users' experiences of existing legislation are examined and reported. Despite a range of literature that presents mental health service users' views and experiences, it remains unclear how service users respond to compulsory community mental healthcare in England. The present paper presents the findings of a qualitative investigation into service users' perceptions and experiences of living with SDOs. In the interviews, service users communicated their understanding of why mental health professionals placed them on the order and how their lives have been affected. Individual service users are capable of seemingly contradictory responses, simultaneously accepting and resisting the orders. This paper presents a typology of the range of responses. These responses are fatalism and resignation, dependency, ownership, bargaining, cooperation, resistance, and rejection. The study provides a model with which we can begin to understand how service users respond to compulsory community care where their options are legally constrained.

Religious coping and psychological wellbeing in carers of relatives with schizophrenia

OBJECTIVE

To examine the use of religious coping and its relation to psychological wellbeing in carers of relatives with schizophrenia.

METHOD

Sixty carers of patients with an ICD-10 diagnosis of schizophrenia, were assessed on strength of religious belief, perceived burden, religious and other coping strategies and psychological wellbeing.

RESULTS

Coping strategies of denial and problem solving, strength of religious belief and perceived burden were significant predictors of wellbeing.

CONCLUSION

Strength of religious belief plays an important role in helping family members to cope with the stress of caring for a mentally ill relative. In addition to psychoeducation and problem solving coping, the role of religious coping in enhancing wellbeing of carers needs to be considered in family intervention programmes.

Measuring subjective quality of life in people with serious mental illness using the SEIqoL-DW

In response to suggestions that available measures may not adequately reflect the idiosyncratic nature of subjective quality of life, the schedule for the evaluation of individual quality of life (SEIQoL) was developed to allow individuals first to select and define their own dimensions of quality of life, and then to assign a relative weight to each of the dimensions they have chosen. A simplified version of the instrument, the SEIQoL-direct weighting (SEIQoL-DW), can be used to elicit similar information from subjects with impaired cognitive functioning. The present study explored the feasibility of using this technique with a sample of 35 clients with serious mental illness served by assertive community treatment (ACT) teams. The SEIQoL-DW was well accepted by the study cohort. The SEIQoL-DW's global index was correlated with the satisfaction with life scale (SWLS), and with the quality of life inventory (QOLI). The SEIQoL-DW may have potential as a clinical planning tool that allows respondents to define personally relevant quality of life dimensions upon which attainable goals can be based.

Subjective quality of life in the evaluation of programs for people with serious and persistent mental illness

Despite the widespread application of the concept of quality of life in mental health evaluation, it has been observed that subjective quality of life measures do not reliably capture changes expected to result from intervention efforts. Moreover, because the domains selected to assess subjective life quality are typically generated by investigators or health professionals, the validity of subjective quality of life measures has also been questioned. Although it represents a conceptual shift from investigator-generated domains to client-elicited domains, it is suggested that a client-elicited approach to measuring subjective quality of life may provide fruitful avenues for resolving some of the conceptual and practical issues associated with understanding and measuring the impact of community-based programs on clients with serious mental illness. Accordingly, while acknowledging the utility of assessing the objective circumstances of people's lives, this paper suggests that client-elicited subjective quality of life domains have the potential to resolve the failure of existing measures to register meaningful change. Unlike previous general reviews of quality of life that have emphasized measurement issues, the present review considers some of the fundamental barriers to our ability to adequately understand and document the experiences of people adjusting to community living with a psychiatric disability.

Care of patients with chronic mental illness: comparison of home and half-way house care

Community-based services are being developed as mental health services. The purpose of this study was to examine the effect between home care and half-way house services on patients with schizophrenia. The design was quasi-experimental and used repeated measurements. There were 60 subjects, 37 receiving home care and 23 receiving half-way house care which were affiliated with one general hospital in the south of Taiwan. Of the 60 chronic schizophrenic patients, there were 34 males and 26 females with an average age of 34 years. The Quality of Life Scale was applied to measure each patient four times, at an interval of two months. These follow-up data were analyzed by Generalized Estimating Equation-I (GEE-I) because repeated observations on an individual may be correlated. The result showed that the total QOL in patients receiving home care programs was significantly higher than those receiving half-way house service. The total scores of QOL in patients under half-way house and home care services did not show secular change. The patients under home care program showed a somewhat improvement for a short period of time. However, as time went on, the patients showed no obvious improvement in their life quality. The dimensions of independence and social activity in QOL also showed significantly different between these two groups. The results may provide guides on designing programs and activities for the chronic mental patients. However, the best decision to apply which program for patients need continouous and comprehensive assessment.

A comparison of the quality of life of severely mentally ill people in UK & German samples

The improvement of the quality of life of people with a severe mental illness is a key policy objective and an important outcome for clinical services. Drawing on cases assessed using the Lancashire Quality of Life Profile and its German translation (The Berliner Lebensqualitatprofil), this paper explores the relationship between personal characteristics, objective well being, subjective well being and overall well being. These variables are compared in two large data sets of people with severe mental illness, one from the UK (n = 1279) and the other from Germany (n = 386). The comparison shows that UK cases have significantly lower subjective well-being in almost all life domains (except safety, living situation and employment). UK cases reported slightly but not significantly higher levels of satisfaction with employment but German cases are more often employed than their UK counterparts. The German samples reported substantially better subjective well-being ratings for health, finances, family, leisure and social life. Exploration of the predictors of overall well-being shows that in both countries depression has the effect of reducing subjective well-being scores, except in relation to work (both samples), religion (UK), finance and safety (Germany). Regression analysis confirms that age, depression and objective circumstances make a small contribution to overall well-being but that subjective ratings in individual life domains make the major contribution. The most important individual predictors of overall well-being for the two samples combined include being a victim of crime, depression and satisfaction with leisure, work, health and mental health, family, living situation, finance and social contacts. Factor analysis indicates that the variance in global well-being explained in both samples combined is 36% (31% in the German samples and 38% in the UK sample).

The association between needs and quality of life in an epidemiologically representative sample of people with psychosis

The impact of meeting needs on quality of life in the severely mentally ill is investigated in this study. An epidemiologically representative sample of 133 patients meeting ICD-10 criteria for psychosis completed standardized instruments for measuring needs and quality of life. Covariance structure modelling was used to investigate the extent to which latent factors of met and unmet need were associated with latent quality of life. Patients rated about 0.7 more total (met plus unmet) needs than staff, mainly due to differences in rating unmet need. Patient ratings were more reliable than ratings by others of unmet need and quality of life. Both underlying unmet need and met need were negatively associated with underlying quality of life, but unmet need was the stronger relationship. The patient's perspective on their difficulties (especially their unmet needs) must be central to mental health care.

Self-reported life satisfaction and treatment factors in patients with schizophrenia, major depression and anxiety disorder

Our aim was to study the associations between life satisfaction and treatment factors and how depression affects these associations among patients with schizophrenia (n=403), major depression (n=349) and anxiety disorder (n=139) from a defined area. Treatment satisfaction and compliance were high, but life satisfaction was low regardless of diagnostic group. Patients with schizophrenia recorded better life satisfaction than patients with the other disorders. There were few independent associations between life satisfaction and treatment factors. Fortunately, factors amenable to treatment intervention, such as depression, problem-solving ability and social support, were independently related to life satisfaction in every diagnostic group. Depression decreased these associations significantly only in patients with schizophrenia. Life satisfaction and treatment satisfaction should be included as separate variables in treatment outcome studies.

Subjective quality of life in female in-patients with depression: a longitudinal study

This study investigated Subjective Quality of Life (SQOL) in 42 women with depression, 70 women with alcoholism, and 73 women with schizophrenia within 3 weeks after hospital admission. Twenty-eight of the depressive patients were re-examined after 6 months. SQOL was assessed using the German version of the Lancashire Quality of Life Profile. On average, depressive women expressed dissatisfaction with life as a whole and with 4 out of 8 life domains, and had a lower SQOL than the other two diagnostic groups. Differences remain statistically significant when the influence of age and anxiety/depression is controlled for. SQOL in depressive women improved significantly within the follow up period. Positive SQOL change was moderately correlated with an improvement of depressive symptoms. The results indicate that depressive women after hospital admission express an unusually low SQOL, which seems to have some diagnostic specificity and improves over time. Changes in depressive symptoms do not fully explain SQOL changes.

The Lancashire Quality of Life Profile: first experiences in The Netherlands

In the Netherlands, as in many other European countries, there is a strong desire for a reliable, valid and feasible instrument to assess the quality of life of people with long-term mental illness. After careful evaluation, it was decided to translate and adapt the Lancashire Quality of Life Profile (LQOP) developed by Oliver and associates. This article presents the preliminary results of a pilot study using the LQOLP. Emphasis is given to describing the psychometric properties of the extended Dutch version and its clinical applicability. Results indicate that the psychometric properties of the translated LQOLP are encouraging and that the instrument can be used for people with mental illness who live in the Netherlands.

Subjective quality of life in out-patients with schizophrenia: clinical and utilization correlates

The relationship between subjective quality of life (QOL), clinical measures, and service utilization was measured in out-patients with schizophrenia. A total of 72 subjects completed the Quality of Life Interview and were also assessed by means of the Positive and Negative Syndrome Scale, a battery of neuropsychological tests, and two measures of social functioning. Use of psychiatric services over a 2-year period was ascertained from comprehensive records. Global subjective QOL was lower than patients' satisfaction with specific life domains. There were few significant correlations between satisfaction with, and objective measures of, specific life areas. In a multiple regression, patients' global subjective QOL was inversely related to their scores on the PANSS depression factor, and to the number of psychiatrist out-patient visits.

A study of the quality of life of the severely mentally ill

As part of a larger study, the Lehman Quality of Life Interview (QOLI) was conducted a total of 85 times with 55 clients with serious mental illness. Results revealed widespread adverse objective circumstances (unemployment, poverty and social isolation) despite which most clients rated their satisfaction levels about average (about equally satisfied and dissatisfied). As expected, subjective quality of life indicators were generally better predictors of global well-being (GWB) (itself based on subjective ratings) than were objective indicators. Correlations between objective and subjective indicators were very low and insignificant. Moderate relationships were found between GWB and levels of personal functioning, and changes in levels of personal functioning, as rated by mental health workers. Retests showed that subjective quality of life was relatively stable over intervals of several months. The findings suggest that leisure and social relations would be suitable areas for interventions that might improve clients' quality of life.

Does quality of life differ in schizophrenic women and men? An empirical study

In our study of 617 schizophrenic patients, we tested the hypothesis that women have a better objective and subjective quality of life than men. Better social integration of women was confirmed. Objective conditions had a significant but quantitatively small impact on satisfaction with specific life domains. Better social integration did not, however, lead to more satisfaction among schizophrenic women. Satisfaction with life in general was better predicted by satisfaction in different life domains than by objective circumstances. Predictors of satisfaction with life were not equal for both sexes. Rather than confirming quantitative differences in subjective quality of life, our data support the existence of gender-specific processes and contexts of subjective valuation.

A conceptual model of quality of life in schizophrenia: description and preliminary clinical validation

The utility of quality of life (QOL) as an evaluative tool in clinical psychiatric research and drug trials could be enhanced by developing appropriate conceptual models of QOL, specific for psychiatric disorders. In our proposed model, QOL of individuals maintained on antipsychotic drug therapy for schizophrenia, is viewed as the subject's perception of the outcome of an interaction between severity of psychotic symptoms, side-effects including subjective responses to antipsychotic drugs, and the level of psychosocial performance. In order to test the validity of the model in clinical setting, we selected a sample of 62 schizophrenic patients clinically stabilized on antipsychotic drug therapy, and measured their subjective QOL and other potentially relevant clinical and psychosocial factors. Standardized scales including the positive and negative syndromes scale (PANSS), abnormal involuntary movements scale (AIMS), Hillside Akathisia scale (HAI), and the social performance schedule (SPS) were used for this purpose. Results of a multiple regression analysis using subjective quality of life as the outcome variable, indicated that severity of schizophrenic symptoms (partial R2 = 0.32, p < 0.0001) and subjective distress caused by akathisia (partial R2 = 0.11, p < 0.01) and neuroleptic dysphoria (partial R2 = 0.06, p < 0.05), accounted for nearly half of the variance, while the contribution from the psychosocial indicators was negligible. These results broadly endorse key aspects of the proposed model, and suggest further studies in this direction. These results experiences during antipsychotic therapy can enhance patients' QOL. This conceptual model has been developed with particular focus on the impact of antipsychotic medications on the QOL of persons with schizophrenia. As such, it is more applicable to clinical trials of new antipsychotic medications but may not be broad enough to be applicable for other social or vocational interventions.

Approaches to measuring quality of life and their relevance to mental health

OBJECTIVES

This paper describes the 'sociological' and health-related approaches to the measurement of quality of life and aims to describe their major findings, shortcomings and potential uses with mental health problems.

METHOD

The literature is selectively reviewed to illustrate the major developments and conclusions.

RESULTS

Despite the lack of an accepted definition of quality of life, sociological approaches have repeatedly shown in general populations, the mentally ill and the elderly that subjective assessments are more influential in determining expressions of happiness, wellbeing and life satisfaction than are the objective circumstances of a person's life. This supports the use of subjective judgements as the basis for quality-of-life determinations..

CONCLUSIONS

The quality-of-life approaches can help to answer a broad range of questions of interest to psychiatry. Health-related quality-of-life approaches are potentially useful methods of demonstrating the impact of mental illness and the benefit of interventions. Further work is required to determine whether the commonly used measures are sensitive to change.

Measures of quality of life among persons with severe and persistent mental disorders

In order to provide clinicians, researchers, program evaluators, and administrators with current information on the assessment of humanistic outcomes of services for persons with severe and persistent mental illnesses (SPMI), the literature on measuring quality of life (QOL) for these persons is summarized. The literature on QOL assessment procedures up to the end of October 1992 for persons with SPMI is reviewed, covering QOL measures that at a minimum assess subjective well-being. Measures are summarized according to purpose, content, psychometric properties, patient subgroups with whom used, and key references. Ten QOL measures are summarized and reflect considerable variability on the parameters examined. Comprehensive, reliable, and valid measures of QOL are available although further development of QOL assessment methodologies is needed. More importantly, we must strive for a better understanding of how to interpret and use QOL outcome information.

Convergent validation of quality of life assessments for persons with severe mental illnesses

The impact of interventions on the quality of life (QOL) experienced by persons with severe and persistent mental illnesses (SPMI) has attracted considerable political, clinical and research attention over the past decade, and continues to do so. This study examines the convergent validity of two commonly used QOL measures for this group of patients, the Lehman Quality of Life Interview and the Heinrichs-Carpenter Quality of Life Scale, computing the correlations between comparable constructs from the two measures administered at the same time and 2 months apart. Correlations were positive and significant although low to moderate in magnitude. Considering the considerable differences in the methods of assessment employed by the two measures, the lack of precise congruence between their constructs, and the 2-month time interval, these findings support their convergent validity. Various conceptual issues regarding the validity and interpretation of QOL assessments for persons with SPMI are discussed.

A new patient focused index for measuring quality of life in persons with severe and persistent mental illness

The quality of life in persons with severe and persistent mental illness is often poor. Most treatment programmes have the goal of increasing quality of life. Unfortunately, existing methods to assess quality of life are cumbersome and oriented towards research rather than clinical settings. This study describes preliminary steps in the development, testing and application of a new patient focused index for measuring quality of life in persons with severe mental illness. The Quality of Life Index for Mental Health (QLI-MH) differs from existing instruments in that it is based on an easy to use, self-administered questionnaire that assesses nine separate domains that together encompass quality of life. Each domain can be individually weighted depending on its relative importance to the patient. Different parts of the instrument solicit information from the patient, the primary clinician, and, when available, the family. The instrument and its scoring system address limitations of previous approaches to quality of life measurement.