Subjective quality of life, psychopathology, satisfaction with care and insight: an exploratory study

Understanding the health context for implementation of a new digital psychosocial intervention for improvement of the mental health in North Macedonia

The aim of this study was to identify the contextual attributes in North Macedonia and their characteristics relevant to the implementation of a new digital intervention to improve mental health, called DIALOG+. This research is the first of its kind in North Macedonia due to the analysis of contextual attributes that may affect the effectiveness of the intervention and its acceptability in various settings of mental health care. Some of the data processed in this paper were provided and analyzed by the National Mental Health Strategy 2018-2025 and other relevant accompanying documents from the World Health Organization and action plans, as well as through interviews with stakeholders (patients, carers, clinicians and policy makers) for their opinion before introducing the DIALOG + intervention and the report on the assessment of the situation in the centers where the implementation of the intervention should have started. The collected data were then mapped to a framework developed by the Ottawa Implementation Group, which included 14 contextual attributes. The results are summarized in 2 subgroups, and are presented as facilitators and barriers to implementation, specific to the mental health system in North Macedonia. The characteristics of DIALOG + (widely applicable psychosocial intervention) are in accordance with modern assumptions for psychosocial rehabilitation of patients with psychosis. Hence, we can conclude that it is a useful tool for professionals in monitoring and achieving the true vision and mission of these institutions. It will help patients reintegrate into society, become more independent and use their full potential in the pursuit of healthy and functional living.

The insight paradox in schizophrenia: A meta-analysis of the relationship between clinical insight and quality of life

Poor clinical insight affects people with schizophrenia and has been cited as a chief cause of poor outcomes. As such, clinical insight is often a target of intervention; however, increases in insight have shown associations with decreased quality of life in a phenomenon known as the "insight paradox." Understanding the relationship between insight and quality of life is important as clients often feel hopeless when quality of life decreases. This meta-analysis sought to clarify relationships between clinical insight, its subdomains, and quality of life in schizophrenia. Further, we explored the role of two moderators (quality of life measurement type, symptom severity) on the insight-quality of life relationship. Studies were identified according to PRISMA guidelines through a focused literature search extending to March 1, 2019. Correlations between clinical insight, its subdomains, and quality of life were extracted and used to calculate overall mean weighted effect sizes using a random-effects model. In support of the insight paradox, overall clinical insight was inversely related to quality of life. Symptom severity moderated the relationship between clinical insight and quality of life, such that greater symptom severity weakened the inverse relationship between overall insight and quality of life. Regarding subdomains of clinical insight, awareness of illness was inversely associated with quality of life; however, other subdomains failed to reach significance. Our findings support the notion that increased insight is associated with lower quality of life and highlight the need for further exploration of the role of meaning-making processes on this relationship.

[Relationship between the evaluation of the health system personnel by their users and their subjective well-being: A cross-sectional study]

Introduction

This cross-sectional study sought to examine the relationships between the perception of efficiency and quality of the service provided by the staff of the health system with users well-being (satisfaction with life), in the Chilean context. Based on the literature review, we hypothesized that satisfaction with the services provided by the health system would be associated with the well-being of its users.

Objective

To determine the relationship between the evaluation of the health system, medical staff, and perceived efficiency, with users subjective well-being.

Methods

On a sample of 1,201 respondents (52.4% women, mean age 42.82 years), descriptive analysis, bivariate analysis, and a structural equation model were performed between the evaluation of the health system, medical staff, and perceived efficiency with users subjective well-being.

Results

These three variables are positively related to each other and have effects on subjective well-being.

Discussion

Health systems also influence the subjective well-being of their users and can be associated with indicators of quality of life. Some implications and considerations related to the Chilean health system are discussed. Also, some of the possible limitations of the study are mentioned. Lastly, the importance of the health systems as part of the state and government functions is discussed.

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.

Patients' satisfaction with hospital health care: Identifying indicators for people with severe mental disorder

BACKGROUND

Patients' perception of psychiatric healthcare is a critical indicator in measuring service quality. The aim of the study was to determine patient's level of satisfaction with the quality of health care delivered at the inpatient departments, and to identify the service quality factors that were important to patients.

METHOD

The Satisfaction with Psychiatry Care Questionnaire-22 was administered to 125 consecutive inpatients with schizophrenia or schizoaffective disorder in a stable condition. Sociodemographic and background variables, illness and symptom severity, insight, social anhedonia, self-esteem, perceived social support, and satisfaction with quality of life were collected.

RESULTS

Although the participants generally expressed satisfaction with the inpatient services, they indicated that the weakest aspects of the service were in the domains of 'personal experience', 'information' and 'activity'. Women were significantly more dissatisfied than men with 'staff', 'care', and by general satisfaction. Multiple regression analysis revealed that satisfaction with hospital health care was associated with five indicators: insight, satisfaction with physical health, self-efficacy, family support, and social anhedonia.

CONCLUSION

Personality related factors rather than psychopathological symptoms were associated with a satisfaction with care of admitted patients with severe mental illness. These factors could be targets for interventions aimed to improve treatment and hospital services.

Intensive case management for severe mental illness

BACKGROUND

Intensive Case Management (ICM) is a community-based package of care aiming to provide long-term care for severely mentally ill people who do not require immediate admission. Intensive Case Management evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (fewer than 20) and high-intensity input.

OBJECTIVES

To assess the effects of ICM as a means of caring for severely mentally ill people in the community in comparison with non-ICM (caseload greater than 20) and with standard community care. We did not distinguish between models of ICM. In addition, to assess whether the effect of ICM on hospitalisation (mean number of days per month in hospital) is influenced by the intervention's fidelity to the ACT model and by the rate of hospital use in the setting where the trial was conducted (baseline level of hospital use).

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (last update search 10 April 2015).

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community care setting, where ICM is compared to non-ICM or standard care.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, assessed quality, and extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated mean difference (MD) between groups and its 95% CI. We employed a random-effects model for analyses.We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect. We assessed overall quality for clinically important outcomes using the GRADE approach and investigated possible risk of bias within included trials.

MAIN RESULTS

The 2016 update included two more studies (n = 196) and more publications with additional data for four already included studies. The updated review therefore includes 7524 participants from 40 randomised controlled trials (RCTs). We found data relevant to two comparisons: ICM versus standard care, and ICM versus non-ICM. The majority of studies had a high risk of selective reporting. No studies provided data for relapse or important improvement in mental state.1. ICM versus standard careWhen ICM was compared with standard care for the outcome service use, ICM slightly reduced the number of days in hospital per month (n = 3595, 24 RCTs, MD -0.86, 95% CI -1.37 to -0.34,low-quality evidence). Similarly, for the outcome global state, ICM reduced the number of people leaving the trial early (n = 1798, 13 RCTs, RR 0.68, 95% CI 0.58 to 0.79, low-quality evidence). For the outcome adverse events, the evidence showed that ICM may make little or no difference in reducing death by suicide (n = 1456, 9 RCTs, RR 0.68, 95% CI 0.31 to 1.51, low-quality evidence). In addition, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment due to very low-quality evidence (n = 1129, 4 RCTs, RR 0.70, 95% CI 0.49 to 1.0, very low-quality evidence).2. ICM versus non-ICMWhen ICM was compared with non-ICM for the outcome service use, there was moderate-quality evidence that ICM probably makes little or no difference in the average number of days in hospital per month (n = 2220, 21 RCTs, MD -0.08, 95% CI -0.37 to 0.21, moderate-quality evidence) or in the average number of admissions (n = 678, 1 RCT, MD -0.18, 95% CI -0.41 to 0.05, moderate-quality evidence) compared to non-ICM. Similarly, the results showed that ICM may reduce the number of participants leaving the intervention early (n = 1970, 7 RCTs, RR 0.70, 95% CI 0.52 to 0.95,low-quality evidence) and that ICM may make little or no difference in reducing death by suicide (n = 1152, 3 RCTs, RR 0.88, 95% CI 0.27 to 2.84, low-quality evidence). Finally, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment as compared to non-ICM (n = 73, 1 RCT, RR 1.46, 95% CI 0.45 to 4.74, very low-quality evidence).3. Fidelity to ACTWithin the meta-regression we found that i.) the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36, 95% CI -0.66 to -0.07); and ii.) the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20, 95% CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but the 'baseline hospital use' result still significantly influences time in hospital (regression coefficient -0.18, 95% CI -0.29 to -0.07, P = 0.0027).

AUTHORS' CONCLUSIONS

Based on very low- to moderate-quality evidence, ICM is effective in ameliorating many outcomes relevant to people with severe mental illness. Compared to standard care, ICM may reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. Intensive Case Management is at least valuable to people with severe mental illnesses in the subgroup of those with a high level of hospitalisation (about four days per month in past two years). Intensive Case Management models with high fidelity to the original team organisation of ACT model were more effective at reducing time in hospital.However, it is unclear what overall gain ICM provides on top of a less formal non-ICM approach.We do not think that more trials comparing current ICM with standard care or non-ICM are justified, however we currently know of no review comparing non-ICM with standard care, and this should be undertaken.

Association between antidepressant side effects and functional impairment in patients with major depressive disorders

Patients with depression may not well be aware of antidepressant adverse events (AEs); however, no studies have assessed how these AEs affect their daily function. Therefore, to evaluate the relationship between the quality of AEs and functional impairment, we studied 482 outpatients with depressive disorders who were not receiving any antidepressant treatment prior to the baseline visit and started it thereafter in usual clinical settings. The Quick Inventory for Depressive Symptomatology Self-Report Japanese version and antidepressant AEs for subjective assessment (antiAS) were performed at baseline and 10 days after antidepressant initiation (i.e. second visit). Functional impairment was evaluated with the Sheehan Disability Scale (SDS) on the second visit. As a result, the SDS was positively associated with the number of AEs (β=0.089, p=0.022) in multiple linear regression analysis (adjusted R(2)=0.357, p<0.001). Subjects who experienced vertigo, nausea and insomnia had significantly more functional impairment than those who did not. Additionally, the number of severe AEs (β=0.151, p<0.001) was associated with a higher SDS score, and those AEs with a negative causal attribution to antidepressants in the antiAS significantly affected the SDS (β=0.105, p=0.008). AEs of antidepressants should be carefully monitored since they could negatively affect their daily function.

Predictors of quality of life in a longitudinal study of users with severe mental disorders

Background

Since the end of the 20th century, quality of life has become a key outcome indicator in planning and evaluation of health services. From a sample of 297 users with severe mental disorders from Montreal (Canada), this study aimed to identify the key predictors of subjective quality of life (SQOL).

Methods

Users were recruited and interviewed from December 2008 to September 2010 and re-interviewed approximately 18 months later. A comprehensive framework including socio-demographic data, clinical, needs and functionality variables, negative life events, social support and healthcare service use, and appreciation data were considered as predictors. Clinical records and eight standardized instruments were used.

Results

Lower severity of needs, schizophrenia, better social integration, better reassurance of worth, fewer drug abuse problems, and living in supervised housing are predictors of SQOL. With regard to needs, absence or lower severity of needs in the areas of company, daytime activities, social exclusion, safety to self, and benefits are linked to SQOL.

Conclusion

Reducing the severity of needs is especially beneficial to ensure a higher SQOL for users with severe mental disorders. To improve SQOL, priority must be given to programs and interventions that promote the development of a stimulating and supportive social network, and maintain a plurality of residential services matching the functional abilities of users.

Is Health Related Quality Of Life of people living with chronic conditions related to patient satisfaction with care?

More than 50% of people over the age of 30 live with at least one chronic condition that influences their Health Related Quality of Life (HRQOL). No uniform framework for conceptualization of HRQOL is currently recognized, although several important domains have been identified. Recently, satisfaction with care has been suggested as an important component to be included in the measures of HRQOL.

PURPOSE

The objective of this review is to explore what is known from the literature about the relationship between satisfaction with care and HRQOL in patients living with chronic conditions.

METHODS

A scoping review methodology guided this work.

RESULTS

The results support the observation of a positive correlation between satisfaction with care and HRQOL; however, the directionality of the relationships could not be established. Although change in the way we organize and provide treatment might not be expected to lead to a significant change in functional performance of the individuals, we can potentially affect people's perception of disability, and improve their control and coping with the illness.

CONCLUSIONS

The review highlights the importance of using appropriate and psychometrically sound measures when assessing HRQOL. Studies are needed that explore longitudinally the relationships between the care experiences and HRQOL.

Ten-year quality of life outcomes among patients with schizophrenia and schizoaffective disorders: I. Predictive value of disorder-related factors

PURPOSE

To provide data on long-term health-related quality of life (HRQL) outcomes among patients with schizophrenia (SZ) and schizoaffective (SA) disorders and determine the predictive value of disorder-related factors.

METHODS

A total of 108 patients with SZ/SA were assessed during stabilization phase and over 10 years with the Quality of Life Enjoyment and Life Satisfaction Questionnaire (Q-LES-Q), Clinical Global Impression Scale, Positive and Negative Syndromes Scale (PANSS), Distress Scale for Adverse Symptoms (DSAS), Talbieh Brief Distress Inventory (TBDI), Brief Symptom Inventory-Somatization Scale (BSI-S), and Global Assessment of Functioning Scale (GAF). Variability and relationships between Q-LES-Q and disorder-related dimensions over time were analyzed.

RESULTS

There were no differences in Q-LES-Q dimensions between patients with SZ and SA disorders. Poor outcomes were found among 76% of the patients with SZ/SA disorders who remained dissatisfied (64%) or worsened (12%) with their HRQL over time. However, 24% of patients reported improved quality of life (16%), or remained satisfied (8%). Changes in TBDI, DSAS, BSI-S, PANSS, and GAF measures accounted for 20-50% of the total variance in satisfaction changes in Q-LES-Q domains across time.

CONCLUSIONS

Long-term quality of life outcomes are characterized by four different types that fit changes over time in emotional distress, side effects, somatization, symptom dimensions, and general functioning scores. Revealed predictors are factors that can be ameliorated and thereby enhance satisfaction with quality of life over time.

Factors associated with hospital service satisfaction in a sample of Arab subjects with schizophrenia

Background

Assessment of patients' satisfaction with health care services could help to identify the strengths and weaknesses of the system and provide guidance for further development. The study's objectives were to: (i) assess the pattern of satisfaction with hospital care for a sample of people with schizophrenia in Kuwait, using the Verona Service Satisfaction Scale (VSSS-EU); ii) compare the pattern of satisfaction with those of similar studies; and iii) assess the association of VSSS seven domains with a number of variables representing met and unmet needs for care, family caregiver burden, severity of psychopathology, level of psychosocial functioning, socio-demographic characteristics, psychological well-being and objective quality of life.

Methods

Consecutive outpatients in stable condition and their family caregivers were interviewed with the VSSS-EU and measures of needs for care, caregiver burden, quality of life and psychopathology.

Results

There were 130 patients (66.1%m, mean age 36.8). While over two-thirds expressed satisfaction with the domains of "overall satisfaction", "professionals' skills", "access", "efficacy", and "relatives' involvement", only about one-third were satisfied with the domains of "information" and "types of intervention". The later two domains were the areas in which European patients had better satisfaction than our patients, while our patients expressed better satisfaction than the Europeans in the domain of "relatives' involvement". In multiple regression analyses, self-esteem, positive and negative affect were the most important correlates of the domains of service satisfaction, while clinical severity, caregiver burden and health unmet needs for care played relatively minor roles.

Conclusion

The noted differences and similarities with the international data, as well as the predictive power of self-esteem and affective state, support the impression that patients' attitudes towards psychiatric care involve a complex relationship between clinical, personal and socio-cultural characteristics; and that many of the factors that impact on satisfaction with service relate to individual psychological characteristics. The weaknesses in the system, highlighted by the pattern of responses of the participants, indicate possible gaps in the provision of comprehensive psychiatric care in the country and obviate the need for public mental health education and development of services to enhance the quality of care.

Intensive case management for severe mental illness

BACKGROUND

Intensive Case Management (ICM) is a community based package of care, aiming to provide long term care for severely mentally ill people who do not require immediate admission. ICM evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (less than 20) and high intensity input.

OBJECTIVES

To assess the effects of Intensive Case Management (caseload <20) in comparison with non-Intensive Case Management (caseload > 20) and with standard community care in people with severe mental illness. To evaluate whether the effect of ICM on hospitalisation depends on its fidelity to the ACT model and on the setting.

SEARCH STRATEGY

For the current update of this review we searched the Cochrane Schizophrenia Group Trials Register (February 2009), which is compiled by systematic searches of major databases, hand searches and conference proceedings.

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community-care setting, where Intensive Case Management, non-Intensive Case Management or standard care were compared. Outcomes such as service use, adverse effects, global state, social functioning, mental state, behaviour, quality of life, satisfaction and costs were sought.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For binary outcomes we calculated relative risk (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data we estimated mean difference (MD) between groups and its 95% confidence interval (CI). We employed a random-effects model for analyses.We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect.

MAIN RESULTS

We included 38 trials (7328 participants) in this review. The trials provided data for two comparisons: 1. ICM versus standard care, 2. ICM versus non-ICM.1. ICM versus standard care Twenty-four trials provided data on length of hospitalisation, and results favoured Intensive Case Management (n=3595, 24 RCTs, MD -0.86 CI -1.37 to -0.34). There was a high level of heterogeneity, but this significance still remained when the outlier studies were excluded from the analysis (n=3143, 20 RCTs, MD -0.62 CI -1.00 to -0.23). Nine studies found participants in the ICM group were less likely to be lost to psychiatric services (n=1633, 9 RCTs, RR 0.43 CI 0.30 to 0.61, I²=49%, p=0.05).One global state scale did show an Improvement in global state for those receiving ICM, the GAF scale (n=818, 5 RCTs, MD 3.41 CI 1.66 to 5.16). Results for mental state as measured through various rating scales, however, were equivocal, with no compelling evidence that ICM was really any better than standard care in improving mental state. No differences in mortality between ICM and standard care groups occurred, either due to 'all causes' (n=1456, 9 RCTs, RR 0.84 CI 0.48 to 1.47) or to 'suicide' (n=1456, 9 RCTs, RR 0.68 CI 0.31 to 1.51).Social functioning results varied, no differences were found in terms of contact with the legal system and with employment status, whereas significant improvement in accommodation status was found, as was the incidence of not living independently, which was lower in the ICM group (n=1185, 4 RCTs, RR 0.65 CI 0.49 to 0.88).Quality of life data found no significant difference between groups, but data were weak. CSQ scores showed a greater participant satisfaction in the ICM group (n=423, 2 RCTs, MD 3.23 CI 2.31 to 4.14).2. ICM versus non-ICM The included studies failed to show a significant advantage of ICM in reducing the average length of hospitalisation (n=2220, 21 RCTs, MD -0.08 CI -0.37 to 0.21). They did find ICM to be more advantageous than non-ICM in reducing rate of lost to follow-up (n=2195, 9 RCTs, RR 0.72 CI 0.52 to 0.99), although data showed a substantial level of heterogeneity (I²=59%, p=0.01). Overall, no significant differences were found in the effects of ICM compared to non-ICM for broad outcomes such as service use, mortality, social functioning, mental state, behaviour, quality of life, satisfaction and costs.3. Fidelity to ACT Within the meta-regression we found that i. the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36 CI -0.66 to -0.07); and ii. the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20 CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but 'baseline hospital use' result is still significantly influencing time in hospital (regression coefficient -0.18 CI -0.29 to -0.07, p=0.0027).

AUTHORS' CONCLUSIONS

ICM was found effective in ameliorating many outcomes relevant to people with severe mental illnesses. Compared to standard care ICM was shown to reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. ICM is of value at least to people with severe mental illnesses who are in the sub-group of those with a high level of hospitalisation (about 4 days/month in past 2 years) and the intervention should be performed close to the original model.It is not clear, however, what gain ICM provides on top of a less formal non-ICM approach.We do not think that more trials comparing current ICM with standard care or non-ICM are justified, but currently we know of no review comparing non-ICM with standard care and this should be undertaken.

Needs and risks of patients in a state-wide inpatient forensic mental health population

Routine needs assessments have become mandated requirements for public mental health services. However, the appropriateness of these generic health needs assessments to specialist populations remains questionable. This study sought to assess individual needs assessed using a widely used clinician rated assessment (Health of the Nation Outcome Scales-Secure; HoNOS-Secure), a subjective needs assessment that considers both staff and patient perspectives (Camberwell Assessment of Need-Forensic version; CANFOR), and a measure of risk for general criminal recidivism (Level of Service Inventory: Screening Version; LSI:SV) in a secure forensic mental health service. Results revealed significant positive correlations between staff ratings on HoNOS-Secure, CANFOR total needs, and CANFOR met needs scores, but no significant association between CANFOR ratings or HoNOS-Secure ratings and LSI:SV scores. Although patients and staff reported the same number of needs overall according to CANFOR (7.2 vs. 7.5, P > 0.05), patients reported that more of these needs were unmet (3.1 vs. 2.3, P < 0.05). Differences between staff and patient ratings of need suggest that needs assessments should include patient perspectives to facilitate more collaborative and comprehensive care planning. Divergent perspectives between patients and staff may impair patient engagement in treatment and therefore negatively impact on outcome. Service planning issues and opportunities for future research are discussed.

Case management relationships and a recovery orientation: a consumer survey of class members in the Arnold case

The purpose of this study was to examine the relative contributions of the working alliance in predicting a recovery orientation. An additional aim was to determine whether a measure of case management fairness contributed any additional proportion of explained variance in a recovery orientation beyond what is accounted for by the working alliance. The study blended structured interview and clinical judgment measures with survey research methods to obtain data about consumer relationships with their case managers, as well as their recovery attitudes. The sample consisted of (N = 167) priority-class members involved in the Arnold v. Arizona Department of Health Services class-action lawsuit in Maricopa County, Arizona. The results showed that the working alliance and case management fairness variables accounted for more of the explained variance in a recovery orientation, than any of the other known correlates of recovery. The results also provided some preliminary support for the inclusion of case management fairness as a predictor variable of a recovery orientation, in that the study's measure of case management fairness contributed a small proportion of additional variance beyond what was explained by the working alliance in predicting a dimension of a recovery orientation. The implications of the study's findings for practice and future research are discussed.

Association between quality of life and self-stigma, insight, and adverse effects of medication in patients with depressive disorders

BACKGROUND

The aims of this study were to examine whether different domains of quality of life (QOL) are differently affected by depressive disorders by comparing QOL of subjects with and without depressive disorders, and to examine the association of QOL with self-stigma, insight and adverse effects of medication among subjects with depressive disorders.

METHOD

The QOL on the four domains of the WHOQOL-BREF Taiwan version were compared between the 229 subjects with depressive disorders and 106 control subjects. Among the depressive subjects, the association between the four QOL domains and subjects' self-stigma, insight, and adverse effects of medication were examined using multiple regression analyses by controlling for the influence of depression, socio-demographic and clinical characteristics and family function.

RESULTS

Depressive subjects had poorer QOL on the physical, psychological and social relationship domains than the non-depressive control group. The depressive subjects who had more severe self-stigma had poorer QOL on all four domains. The depressive subjects who perceived more severe adverse effects from medication had poorer QOL on the physical, psychological and environmental domains. However, insight was not associated with any domain of QOL in patients with depressive disorders.

CONCLUSIONS

The results of this study demonstrate that different domains of QOL are differently affected by depressive disorders, and that clinicians must consider the negative influences of self-stigma and adverse effects from medication on QOL of subjects with depressive disorders.

Illness intrusiveness and subjective well-being in schizophrenia

This study evaluated the extent to which schizophrenia and its treatment interferes with participation in valued life activities and its impact on subjective well-being. The Illness Intrusiveness Ratings Scale was completed by 78 individuals with schizophrenia on 3 measurement occasions. Clinicians working with participants, plus a relative/friend of each participant also provided independent ratings of the person. The Illness Intrusiveness Ratings Scale displayed internal consistency (coefficient alpha = 0.82), and temporal stability across 1 day (r = 0.89), 1 week (r = 0.51), and 1 month (r = 0.78). Reported intrusiveness was high (M = 50.5) and was among the highest compared with populations with other serious medical and psychiatric illnesses. Ratings correlated with staff and family/friends' ratings of intrusiveness (r = 0.33 and r = 0.40), measures of symptomatology (average r = 0.25), and subjective well-being (average r = 0.41). Path analysis indicated that lifestyle disruption mediates the impact of symptoms and treatment on well-being. Implications for these findings and future directions for research are discussed.

Quality of life and its association with insight, adverse effects of medication and use of atypical antipsychotics in patients with bipolar disorder and schizophrenia in remission

OBJECTIVE

The present study aimed: (i) to compare the level of quality of life (QOL) among subjects with bipolar disorder (BD) and schizophrenia who were in remission and healthy control subjects and (ii) to examine the association of QOL with insight, adverse effects of medication and use of atypical antipsychotics among subjects with BD and schizophrenia who were in remission by controlling other confounding factors.

METHODS

The QOL on the four domains of the World Health Organization Questionnaire on Quality of Life: Short Form - Taiwan version (WHOQOL-BREF) were compared between 96 subjects with BD in remission, 96 subjects with schizophrenia in remission and 106 healthy control subjects. The association between the four QOL domains and subjects' insight, adverse effects of medication and use of atypical antipsychotics were examined using multiple regression analyses in the subjects with BD and schizophrenia in remission.

RESULTS

The results demonstrated that the subjects with BD in remission had similarly poor levels of QOL in all four domains as those subjects with schizophrenia in remission, and both subjects with BD and schizophrenia had poorer QOL than those in the control group. For both subjects with BD and schizophrenia in remission, insight was negatively associated with QOL on the physical domain, and adverse effects of medication were negatively associated with QOL on the physical and environment domains. Use of atypical antipsychotics was not associated with QOL, but subjects with BD receiving olanzapine perceived better psychological QOL than those receiving risperidone and better psychological and social relationship QOL than those receiving no atypical antipsychotic.

CONCLUSIONS

The results of the present study indicate that subjects with BD are dissatisfied with their QOL, even when they are in a remitted state. Clinicians must consider the negative influences of insight and adverse effects of medication on QOL of patients with BD and schizophrenia in remission.

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.

Evaluation of schizophrenic patients quality of life

<zakljucak> I pored metodoloskih i epistemioloskih nedostataka istrazivanja kvaliteta zivota shizofrenih bolesnika (manjkavost jedinstvenog metodoloskog pristupa, sto povlaci za sobom neodredjenosti u definisanju problema istrazivanja i teskoce u operacionalizaciji) ova ispitivanja su se pokazala kao pouzdan indikator ishoda (outcome indicator) razlicitih oblika tretmana shizofrenih bolesnika, primene lekova, posebno. I ako rezultati ovih, u sustini multidimenzionih, istrazivanja zavise od depresivnog raspolozenja, crta licnosti i mehanizama prilagodjavanja koje shizofreni ispitanik koristi, istrazivanja kvaliteta zivota shizofrenih bolesnika ce ostati pouzdan, naucno verifikovan pokazatelj humanog statusa najbrojnijih medju teskim psihijatrijskim bolesnicima. Sto se instrumenata istrazivanja kvaliteta zivota tice, izdvojili bismo tri. Prvi od njih, Upitnik o kvalitetu zivota (QLS), najstariji je i dugo se, zbog dobrih metrickih svojstava, koristio u istrazivanjima ove vrste u svetu, ukljucujuci i domace autore 84. Sledeci, Mancesterski upitik o kvalitetu zivota (MANSA) relativno je kratak i primenjivan je u novijim istrazivanjima kvaliteta zivota psihijatrijskih bolesnika u svetu i kod nas. Najzad, izdvojili bismo onaj koji se najvise koristi. To je WHO-QOL-Brief, kraca verzija Upitnika o kvalitetu zivota shizofrenih bolesnika SZO. On se vrlo cesto pojavljuje u najnovijim istrazivanjima ove vrste (poslednjih pet godina) u svetu, a posebno u studijama sa transkulturnim obelezjima. Izbor ovog poslednjeg instrumenta omogucio bi nasim istrazivacima, ne samo brzo prikupljanje podataka, nego i validnije poredjenje sopstvenih rezultata istrazivanja sa slicnima u svetu. Istrazivanja kvaliteta zivota psihijatrijskih bolesnika, a shizofrenih bolesnika posebno, smatramo nezaobilaznim, ne samo u naucnim studijama vezanim za probleme najrasirenijeg psihoticnog poremecaja, nego i vaznim za planiranje i evaluaciju programa pomoci hronicnim psihoticnim bolesnicima uopste, posebno ako se imaju u vidu ambiciozne reforme institucijske psihijatrijske zastite zapocete kod nas.

The reliability and validity of the forensic Camberwell Assessment of Need (CANFOR): a needs assessment for forensic mental health service users

No instrument exists that measures the individual needs of forensic mental health service users (FMHSUs). The aim of this study was therefore to develop a valid and reliable individual needs assessment instrument for FMHSUs that incorporated staff and service user views and measured met and unmet needs. The Camberwell Assessment of Need was used as a template to develop CANFOR. Consensual and content validity were investigated with 50 forensic mental health professionals and 60 FMHSUs. Both were found to be satisfactory. Concurrent validity was tested using the Global Assessment of Functioning and a five-point needs scale, and again was found to be satisfactory. Reliability studies were carried out with 77 service users and 65 staff in high and medium security psychiatric services in the UK. Inter-rater reliability, rating whether a need was present or not, was high for service users (0.991) and staff (0.998). Similarly high reliability was found for unmet needs (0.985 and 0.972, respectively). Test-retest reliability was found to be moderately high for service users (0.795) and staff (0.852) when ratings were made two weeks apart. Similar levels were found for ratings of unmet needs (0.813 and 0.699, respectively). The average interview time was 23 minutes. CANFOR has good validity and reliability, and is suitable for further testing with other service user groups.

Are factors associated with subjective quality of life in people with severe mental illness consistent over time?--A 6-year follow-up study

OBJECTIVE

To investigate the cross-sectional relationship between subjective quality of life and sociodemographic clinical and social factors over three points of assessment during a 6-year follow-up, and to investigate longitudinal predictors of subjective quality of life.

METHOD

We investigated a sample of people with severe mental illness (n = 92), mainly with a psychosis diagnosis, at baseline and at an 18-month and 6-year follow-up. Measures included the Lancashire quality of life profile, Manchester short assessment of quality of life, Symptom Check List 90, Camberwell Assessment of Needs and the Interview Schedule for Social Interaction.

RESULTS

Cross-sectionally subjective quality of life was associated to self-reported symptoms, social network and unmet needs. However, these determinants varied in importance between points of assessment. Longitudinal predictors of subjective quality of life were changes in self-reported symptoms and social network.

CONCLUSION

There was a rather consistent set of determinants of subjective quality of life over time. Social network seems to be an important factor with relevance for improvements in subjective quality of life, however largely overlooked in earlier studies within the field.

Determinants of Changes in Perceived Quality of Life in the Course of Schizophrenia

This study aimed to identify factors that influence changes in satisfaction with quality of life (QOL) of schizophrenia patients. Baseline and follow up data for 148 schizophrenia patients were obtained at hospital admission and 16 months later. Relationships between changes over time in the general QOL index, and various factors were investigated using factor, multiple regression, and partial correlation analyses. Findings indicate that baseline levels of activation symptoms, emotional distress, task oriented coping, self-esteem and friend support together explain 41% of the variability in the general QOL index 16 months later. Changes in the general QOL of schizophrenia patients over time is associated with anergia, and paranoid symptoms, emotional distress, side effects, self-esteem, emotion and avoidance related coping styles, expressed emotion, and other social support. Determinants of change in QOL of patients were different being in hospital or out of hospital in the real world. No significant association of age, education, and follow up duration, with general QOL. Based on obtained data three types of overlapping factors were defined: (1) distressing, and protective; (2) primary and secondary; and (3) factors that remained constant or changed over time. Presented data are discussed within the framework of the Distress/Protection model of QOL. The conceptualization of three types of factors influencing QOL outcomes in this model demonstrates their predictive value, and may assist investigators and mental health workers in the interpretation of QOL data that may be used to improve patients' QOL outcomes.

PANSS syndromes and quality of life in schizophrenia

BACKGROUND

Results from factor analysis studies have suggested that a five-dimensional structure appears to be a better representation of the psychopathological data of the PANSS. The purpose of this study was the detailed investigation of the association of schizophrenia syndromes and single symptoms with quality of life (QOL) in acute and remitted patients. The leading hypotheses were: (1) affective symptoms, especially depression and anxiety, are mostly associated with QOL longitudinally and (2) in the acute phase, QOL is also associated with positive schizophrenia symptoms.

METHODS

For the present study, schizophrenia and schizophreniform patients were studied on admission, at the end of the acute phase and 6 months after hospitalization. Psychopathology was measured using the PANSS syndromes, QOL was assessed using disease-specific (SWN) and generic (MLDL, EDLQ) scales.

RESULTS

Eighty-four patients entered the study and were assessed during the acute phase taking into account their history and actual treatment. Results revealed anxiety as the most important symptom and depression as the most important syndrome associated with different areas of QOL during and after hospitalization. Also cognitive and negative symptoms were associated with different QOL domains, but both positive symptom clusters showed no substantial association with QOL.

CONCLUSIONS

Results of this longitudinal study investigating psychopathology and QOL in schizophrenia provide further support for the need to consider the psychopathological state and treatment setting when measuring QOL in schizophrenia and the need for a differential analysis of schizophrenia symptoms and QOL in the acute, mid-term and long-term phase. Anxiety reduction should be a critical goal of treatment in order to prevent further QOL impairment.

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.

Subjective well-being and community integration among clients of assertive community treatment

Three aspects of community integration (i.e., physical, social, and psychological integration) were examined in relation to subjective well-being (SWB) in a sample of 92 persons with psychiatric disabilities receiving services from assertive community treatment (ACT) teams. Although two of the integration variables, namely physical and psychological integration, were related to SWB at the bivariate level, these relationships were not maintained following sequential multiple regression analysis. Findings support previously established relationships between SWB and psychiatric symptoms and between SWB and self-esteem. Results also emphasize the importance of client perceptions of social support that may be attributable, in part, to ACT services.

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.

What determines patients' satisfaction with their mental health care and quality of life?

OBJECTIVES

This study investigated whether patients' satisfaction with their mental health care and quality of life is related to their age, gender, psychiatric diagnosis, and duration of mental disorder.

METHOD

120 adults of working age who were receiving input from a community mental health team in North Yorkshire were invited to complete the Carers' and User's Expectations of Services, User Version (CUES-U) questionnaire. This 16 item self rated outcome measure covers the issues that those using mental health services have identified as being their priorities.

RESULTS

CUES-U ratings were lowest for "Social life" (49% satisfied) and highest for "Relationships with physical health workers" (88% satisfied). Satisfaction with psychiatric services correlated significantly with patients' age (Spearman's r = 0.444, p<0.001) and their satisfaction in other areas of their lives such as housing, money, and relationships (r = 0.575, p<0.001). Those with psychotic disorders rated their quality of life as higher than other respondents (median total satisfaction score 12 v 9, Mann-Whitney U = 377, p = 0.001). Gender and duration of disorder were unrelated to service satisfaction.

CONCLUSIONS

Patient satisfaction ratings have been promoted as an outcome measure when evaluating the quality of their mental health services. Certain factors influencing an individual's satisfaction with the care provided (such as their age and general quality of life) are not directly under the control of professionals.

Predicting changes in domain-specific quality of life of schizophrenia patients

The author sought to determine domain-specific quality of life (QOL) changes over time and to identify predictors of change in life satisfaction among schizophrenia patients. He assessed 148 schizophrenia inpatients at admission and 16 months later. Multiple regression analysis identified predictors of domain-specific changes in QOL from changes in psychopathology, emotional distress, side effects, insight, and stress process-related factors ratings. On the group level, satisfaction with subjective feelings and leisure activities improved significantly during the follow-up period. Individual changes in specific QOL domains are influenced by different patterns of predictors that accounted for 12% to 36% of variance. Emotional distress, paranoid symptoms, side effects, and insight inversely associated with variability of scores in domain-specific QOL. Changes in self-efficacy, self-esteem, and support from others were positively correlated to improvement in QOL domain ratings. Schizophrenia patients may experience improvement in specific QOL domains. Changes in stress process-related factors are stronger predictors of fluctuations in QOL domains than changes in illness symptoms and should be considered when evaluating life satisfaction.

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.