Quality of life and its predictors in people with schizophrenia

Construction of a quality of life scale for older individuals with neuro-co-cardiological diseases

PURPOSE

This study aimed to develop a Quality of Life (QOL) assessment scale for older patients with Neuro-co-Cardiological Diseases (NCCD) and to evaluate the reliability and validity of the scale.

METHOD

The study participants were derived from the Elderly Individuals with NCCD Registered Cohort Study (EINCCDRCS), a multicenter registry of patients with NCCD. The preliminary testing of the questionnaire was conducted among 10 older individuals aged 65 years and older who had NCCD and were recruited from the registry. Other patients who met the inclusion criteria participated in the field testing. After verifying the unidimensionality, local independence, and monotonicity assumptions of the scale, we employed the Rasch model within Item Response Theory framework to assess the quality of the scale through methods including internal consistency, criterion validity, Wright map, and item functioning differential. Subsequently, we assessed the construct validity of the scale by combining exploratory factor analysis with confirmatory factor analysis.

RESULTS

Based on well-validated scales such as the short-form WHOQOL-OLD, HeartQOL, IQCODE, and SF-36, an original Neuro-co-Cardiological Diseases Quality of Life scale (NCCDQOL) was developed. 196 individuals from the EINCCDRCS were included in the study, with 10 participating in the preliminary testing and 186 in the field testing. Based on the results of the preliminary testing, the original questionnaire was refined through item deletion and adjustment, resulting in an 11-item NCCDQOL questionnaire. The Rasch analysis of the field testing data led to the removal of 21 misfitting individuals. The NCCDQOL demonstrated a four-category structure, achieved by combining two response categories. This structure aligned with the assumptions of unidimensionality, local independence, and monotonicity. The NCCDQOL also exhibited good validity and reliability.

CONCLUSION

The revised NCCDQOL questionnaire demonstrated good reliability and validity in the Rasch model, indicating promising potential for clinical application.

Factors Influencing the Level of Depression and Anxiety of Community-Dwelling Patients with Schizophrenia in China during the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) poses a huge challenge to global public health. People with schizophrenia living in communities urgently need effective interventions to help them adjust to life and work, but they have not received enough attention. This study aims to assess the prevalence of anxiety and depression symptoms in community-dwelling patients with schizophrenia in China during the epidemic and to explore the possible influencing factors.

METHODS

Using a cross-sectional survey, we collected 15,165 questionnaires. Assessments included demographic information, concern about COVID-19-related information, sleep status, anxiety and depressive symptoms, and accompanying illnesses. The 7-item Generalized Anxiety Disorder (GAD-7) and the 9-item Patient Health Questionnaire (PHQ-9) were used to evaluate depression and anxiety levels. Group comparison was conducted by t-test, ANOVA, or chi-square test wherever suitable, with Bonferroni pairwise correction. Multivariate logistic regression was performed to identify predictors for anxiety and depression.

RESULTS

16.9% of patients had at least moderate anxiety, and 34.9% had at least moderate depression. T-test showed that females scored higher on GAD-7 and PHQ-9 than males, and patients without accompanying long-standing diseases, who were not concerned about COVID-19, had lower GAD-7 and PHQ-9 scores. ANOVA showed that participants aged from 30 to 39, with higher education scored higher on GAD-7, and patients with better sleep, and having less concern about COVID-19, had lower GAD-7 and PHQ-9 scores. Regression analysis indicated that participant ages of 30-39 and 40-49 positively predicted anxiety, whereas patient ages of 30-39 years positively predicted depression. Patients with poor sleep, accompanying diseases, and concern about the COVID-19 pandemic were more likely to experience anxiety and depression.

CONCLUSION

During the pandemic, Chinese community-dwelling patients with schizophrenia had high rates of anxiety and depression. These patients deserve clinical attention and psychological intervention, especially those with risk factors.

Bayesian reasoning with emotional material in patients with schizophrenia

Delusions are one of the most classical symptoms described in schizophrenia. However, despite delusions are often emotionally charged, they have been investigated using tasks involving non-affective material, such as the Beads task. In this study we compared 30 patients with schizophrenia experiencing delusions with 32 matched controls in their pattern of responses to two versions of the Beads task within a Bayesian framework. The two versions of the Beads task consisted of one emotional and one neutral, both with ratios of beads of 60:40 and 80:20, considered, respectively, as the “difficult” and “easy” variants of the task. Results indicate that patients showed a greater deviation from the normative model, especially in the 60:40 ratio, suggesting that more inaccurate probability estimations are more likely to occur under uncertainty conditions. Additionally, both patients and controls showed a greater deviation in the emotional version of the task, providing evidence of a reasoning bias modulated by the content of the stimuli. Finally, a positive correlation between patients’ deviation and delusional symptomatology was found. Impairments in the 60:40 ratio with emotional content was related to the amount of disruption in life caused by delusions. These results contribute to the understanding of how cognitive mechanisms interact with characteristics of the task (i.e., ambiguity and content) in the context of delusional thinking. These findings might be used to inform improved intervention programs in the domain of inferential reasoning.

Factors associated with health-related quality of life in long-stay inpatients with chronic schizophrenia

Aim

Few studies have investigated the health-related quality of life (HRQoL) in long-stay inpatients with chronic schizophrenia in Japan. This study aimed to clarify the factors associated with HRQoL among these patients.

Methods

Out of 238 patients with chronic schizophrenia admitted to three hospitals, 101 inpatients provided informed consent to participate in the study. The patients' HRQoL was assessed using two instruments: the EuroQol 5 dimensions (EQ-5D) as a generic index and the Subjective Well-being Under Neuroleptic Treatment Scale, Japanese Version (SWNS-J) as a disease-specific index. We examined the factors associated with these HRQoL indices using multiple linear regression models.

Results

The patients' mean age was 62.9 years, and 51.5% were female. The mean (standard deviation) EQ-5D score and SWNS-J total score were 0.776 (0.177) and 83.5 (16.5), respectively. Multiple linear regression analysis indicated that the EQ-5D score was significantly and negatively associated with the female sex, benzodiazepine use, and Drug-Induced Extrapyramidal Symptoms Scale scores. In contrast, the SWNS-J total score was significantly and negatively associated with first-generation antipsychotics use, Brief Psychiatric Rating Scale scores, Drug-Induced Extrapyramidal Symptoms Scale scores, and Global Assessment of Functioning scale scores.

Conclusion

This study identified the factors associated with two HRQoL indices among long-stay inpatients with chronic schizophrenia in Japan. Although the analyses showed differences in the associated factors between the generic EQ-5D and the disease-specific SWNS-J, extrapyramidal symptoms as adverse effects of antipsychotic treatment were found to be associated with both indices.

Effectiveness and Factors Associated with Improved Life Skill Levels of Participants of a Large-Scale Youth-Focused Life Skills Training and Counselling Services Program (LSTCP): Evidence from India

(1) Background: To empower and facilitate mental health promotion for nearly 18 million youth, a pioneering state-wide Life Skills Training and Counselling Services Program (LSTCP) was implemented in Karnataka, India. This study assesses the changes in life skills scores, level of life skills and factors associated with increased life skills among participants of the LSTCP. (2) Method: This pre-post study design was conducted on 2669 participants who underwent a six-day structured LSTCP. Changes in mean life skills scores and level of life skill categories pre- and post-LSTCP were assessed. Multivariate logistic regression was performed to assess the factors associated with increases in life skills. (3) Results: The LSTCP resulted in significant changes in life skill scores and level of life skills, indicating the effectiveness of the training. All life skill domains, except empathy and self-awareness, increased post-training. There was a positive shift in the level of life skills. Age (AOR = 1.34, CI = 1.11-1.62), gender (AOR = 1.39, CI = 1.15-1.68), education (AOR = 1.44, CI = 1.05-1.97) and physical (AOR = 1.02, CI = 1.01-1.03) and psychological (AOR = 1.02, CI = 1.01-1.03) quality of life was associated with an increase in life skills among participants. (4) Conclusions: The LSTCP is effective in improving the life skills of participants. The LSTCP modules and processes can be used to further train youth and contribute to mental health promotion in the state.

Association of negative symptoms with cognitive impairment in Chinese Han patients with chronic schizophrenia

OBJECTIVE

Cognitive impairment is an essential feature of schizophrenia; however, the relationship between clinical psychiatric symptoms with cognitive impairment is still unclear. Therefore, we aimed to assess cognitive deficits and the relationship between clinical symptoms and cognitive function in patients with chronic schizophrenia, which provide a reference guide for psychiatrists.

METHODS

We compared the cognitive function in 312 schizophrenia inpatients and 397 healthy controls by using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). The positive and negative symptom scale (PANSS) was used to assess the clinical symptoms of the patients.

RESULTS

Analysis of covariance showed that the RBANS total and four index scores (all p < 0.001) were significantly lower in patients than healthy controls. After Bonferroni correction, Pearson correlation analysis showed that there was a significant negative association between PANSS negative symptom subscale and RBANS total score and all 5 domain scores (all p < 0.01). Further regression analysis showed that negative symptoms, age, age of onset, and antipsychotic dose were important independent predictors of cognitive deficits.

CONCLUSIONS

Our findings suggest that patients with chronic schizophrenia exhibit cognitive deficits compared with healthy people. Negative symptoms and some clinical variables are associated with cognitive impairment in patients with schizophrenia.KEYPOINTSThis study indicates that patients with chronic schizophrenia have extensive cognitive impairment shown on RBANS except for the visuospatial/constructional domain.Cognitive impairment in patients is associated with age, negative symptoms, age of onset, and antipsychotic dose.There is a significant negative association between cognitive deficits and negative symptoms in patients with chronic schizophrenia.The results of this study need to be confirmed in future studies with longitudinal designs with a large and sex-balanced sample in first-episode drug naïve patients with schizophrenia.

The cognitive aspect of formal thought disorder and its relationship with global social functioning and the quality of life in schizophrenia

PURPOSE

It was expected that using a comprehensive scale like the Thought and Language Disorder Scale (TALD) for measurement of FTD would enable assessing its heterogeneity and its associations with cognitive impairment and functionality. This study has aimed to analyze the relationship between formal thought disorder (FTD) and cognitive functions, functionality, and quality of life in schizophrenia.

METHODS

This cross-sectional exploratory study included 46 clinical participants meeting the DSM-5 diagnostic criteria for schizophrenia and 35 healthy individuals as the control groups. Data were acquired by means of the Turkish language version of the TALD, the Positive and Negative Syndrome Scale, the Clinical Global Impression Scale, the Functioning Assessment Short Test, the Social Functioning Scale, the World Health Organization Quality of Life Instrument-Short Form, and a neuropsychological test battery on executive functions, working memory, verbal fluency, abstract thinking, and response inhibition. Correlation analyses were conducted to detect significant relationships.

RESULTS

The clinical group scored failures in all cognitive tests. The objective positive FTD was associated with deficits in executive functions and social functioning. The objective negative FTD was associated with poor performance in all cognitive domains, physical quality of life, and social and global functioning. The subjective negative FTD was negatively correlated with psychological quality of life.

CONCLUSION

This study demonstrated that objective FTD factors reflect different underlying cognitive deficits and correlate with different functioning domains. Significant correlation was determined between subjective negative FTD and psychological quality of life. Given the close relationship of FTD with functioning and quality of life, the FTD-related cognitive deficits should be the key treatment goal in schizophrenia.

Facial Affect Recognition by Patients with Schizophrenia Using Human Avatars

People with schizophrenia have difficulty recognizing the emotions in the facial expressions of others, which affects their social interaction and functioning in the community. Static stimuli such as photographs have been used traditionally to examine deficiencies in the recognition of emotions in patients with schizophrenia, which has been criticized by some authors for lacking the dynamism that real facial stimuli have. With the aim of overcoming these drawbacks, in recent years, the creation and validation of virtual humans has been developed. This work presents the results of a study that evaluated facial recognition of emotions through a new set of dynamic virtual humans previously designed by the research team, in patients diagnosed of schizophrenia. The study included 56 stable patients, compared with 56 healthy controls. Our results showed that patients with schizophrenia present a deficit in facial affect recognition, compared to healthy controls (average hit rate 71.6% for patients vs 90.0% for controls). Facial expressions with greater dynamism (compared to less dynamic ones), as well as those presented from frontal view (compared to profile view) were better recognized in both groups. Regarding clinical and sociodemographic variables, the number of hospitalizations throughout life did not correlate with recognition rates. There was also no correlation between functioning or quality of life and recognition. A trend showed a reduction in the emotional recognition rate as a result of increases in Positive and Negative Syndrome Scale (PANSS), being statistically significant for negative PANSS. Patients presented a learning effect during the progression of the task, slightly greater in comparison to the control group. This finding is relevant when designing training interventions for people with schizophrenia. Maintaining the attention of patients and getting them to improve in the proposed tasks is a challenge for today’s psychiatry.

Applying a bagging ensemble machine learning approach to predict functional outcome of schizophrenia with clinical symptoms and cognitive functions

It has been suggested that the relationship between cognitive function and functional outcome in schizophrenia is mediated by clinical symptoms, while functional outcome is assessed by the Quality of Life Scale (QLS) and the Global Assessment of Functioning (GAF) Scale. To determine the outcome assessed by QLS and GAF, we established a bagging ensemble framework with a feature selection algorithm resulting from the analysis of factors such as 3 clinical symptom scales and 11 cognitive function scores of 302 patients with schizophrenia in the Taiwanese population. We compared our bagging ensemble framework with other state-of-the-art algorithms such as multilayer feedforward neural networks, support vector machine, linear regression, and random forests. The analysis revealed that the bagging ensemble model with feature selection performed best among predictive models in predicting the QLS functional outcome by using 20-item Scale for the Assessment of Negative Symptoms (SANS20) and 17-item Hamilton Depression Rating Scale (HAMD17). Moreover, to predict the GAF outcome, the bagging ensemble model with feature selection performed best among predictive models by using SANS20 and the Positive and Negative Syndrome Scale-Positive (PANSS-Positive) subscale. The study indicates that there are synergistic effects between negative (SANS20) and depressive (HAMD17) symptoms as well as between negative and positive (PANSS-Positive) symptoms in influencing functional outcome of schizophrenia using the bagging ensemble framework with feature selection.

Defining quality of life for individuals with neurodevelopmental disorders: Challenges within an inpatient population

PURPOSE

The concept of Quality of Life (QoL) for people with neurodevelopmental disorders primarily focuses on deinstitutionalisation and community inclusion. This population, however, often presents with comorbid diagnoses and is sectioned to treatment facilities under the Mental Health Act. The aim of this paper is to review the existing literature on QoL and discuss the consideration of this specialised population and the environment when measuring QoL.

METHODS

Databases were searched using specific inclusion and exclusion criteria to ensure literature reviewed was relevant to the defined population. The challenges identified from the literature were categorised into interpersonal and intrapersonal factors.

RESULTS

A total of 30 articles were retrieved and considered in this review.

CONCLUSIONS

This paper discusses how these individuals present with different behaviours and opportunities, which subsequently make it difficult to apply existing knowledge of QoL. The need to further examine the QoL in this specific population is discussed.

The association of clinical insight and depression with quality of life in schizophrenia

This study assesses how insight influences depression and Quality of Life (QOL) in schizophrenia-spectrum outpatients and whether depression modifies the relationship between insight and QOL. 141 patients with schizophrenia or schizoaffective disorders with stable disease completed the EUROQOL-5D-5L and SQLS-R4, SAI-E and Calgary scales. Univariate and multivariate linear regression models were fitted to assess whether insight was related to QOL and/or depression. Higher levels of insight were (inversely) only related to EuroQOL-health but showed no relationship with depression. Depression showed an inversely strong relationship with EuroQOL-health. The relationship between clinical insight and QOL does not seem to be associated with depression.

Comparative assessment of quality of life of patients with schizophrenia attending a community psychiatric centre and a psychiatric hospital

BACKGROUND

Over the past few decades, there has been an emphasis on the de-institutionalisation of psychiatric care with a focus on community care. With Quality of Life (QoL) as an outcome measure, this study compared the QoL of patients with schizophrenia attending a psychiatric hospital and a community psychiatric centre.

DESIGN

This was a cross-sectional study in two psychiatric facilities.

METHODS

Data were obtained through a socio-demographic and clinical questionnaire; the QoL was assessed with the WHOQOL-BREF and patient satisfaction with care with CPOSS. Total and domain scores of WHOQOL-BREF for each group were calculated and compared with each other and other group characteristics. Diagnosis of schizophrenia was based on ICD-10.

RESULTS

Participants from the two centres did not differ significantly on any of the socio-demographic characteristics measured. Similarly, there was no significant difference in their overall mean WHOQOL-BREF scores as well as the mean WHOQOL-BREF of domain scores. However, the married and females from both centres significantly had higher mean WHOQOL-BREF scores than their male counterparts. Patients in remission for more than two years or those on a single type of medication (either oral or depot preparation) from both centres significantly had higher mean WHOQOL-BREF score compared with those who had less than two years of remission or on both oral and depot preparations.

CONCLUSION

Overall QoL of patients managed at the two centres was comparable, with similar socio-demographic as well as clinical variables influencing QoL. This suggests that patients with schizophrenia can be well managed at community psychiatric centres.

FUNDING

None declared.

The role of symptoms and insight in mediating cognition and functioning in first episode psychosis

INTRODUCTION

Achieving functional recovery in patients with psychosis is a challenge in clinical practice. Investigating the complex interplay between cognition, symptoms, insight and functional outcome in first episode psychosis will be crucial to understanding the factors leading to better functioning.

METHODS

In this 12-month prospective follow-up study, we investigated how cognition, clinical symptoms, and insight into illness affected overall functioning in 160 patients with first episode psychosis recruited from the Early Assessment Service for Young People with Psychosis (EASY) in Hong Kong from July 1, 2014 to June 30, 2016. Cognition was assessed at baseline while symptoms, insight, and functioning were assessed at 12-month follow-up. Structural equation modelling was used to examine the direct and indirect relationships between functioning and other latent constructs.

RESULTS

Symptoms (negative symptoms and general psychopathology) and insight were shown to be significant mediators between cognition and functioning. The significant direct relationship between cognition and functioning (β = 0.387; p < 0.001) became insignificant (β = 0.079; p = 0.578) after including symptoms and insight in the model. Symptoms and insight were significantly associated with cognition (symptoms, β = -0.469; p < 0.001; insight, β = -0.372; p < 0.001) and predicted functioning (symptoms, β = -0.558; p < 0.001; insight, β = -0.264; p < 0.01).

CONCLUSION

Symptoms and insight mediated the effects of cognition on functioning. Interventions for improving functioning in patients with first episode psychosis should target not only cognition but also symptoms and insight.

Improving the quality of life of people with schizophrenia through community based rehabilitation in Yogyakarta Province, Indonesia: A quasi experimental study

OBJECTIVE

The persistent disability and low Quality of Life (QoL) are the impacts of schizophrenia. Community-Based Rehabilitation (CBR) is recommended for people with schizophrenia. The objective of this study is to analyze the effectiveness of CBR to improve the quality of life of people with schizophrenia.

METHODS

It was a quasi-experimental study, conducted in February-December 2017, in Yogyakarta, Indonesia. Subjectwere people with schizophrenia, 18-56 years old, with their caregiver. CBRintervention using psychoeducation module and social skill module during 12 weeks. It was conducted by local health workers, sub district social welfare workers, community health workers (called Kader in Indonesia) and supervised by a psychiatrist. The QoL was assessed using a validated measuring instrument at the baseline and at the week 16. Hypothesis test using Wilcoxon test RESULTS: There were 100 people with schizophrenia involved in the study. They were divided into intervention group and control group. Every group consists of 50 subjects. Both groups had similar characteristics at the baseline. The intervention group received CBR, whereas the control group didn't. Thirty-four people (68%) of intervention group increased their QoL, whereas in the control group there were twenty-three people (46%) increased their QoL. The QoL decrease occurred in one subject (4%) from the control group. Other subjects had constant QoL. Improvement of QoL in the intervention group is higher than the control group (p < 0.05).

CONCLUSIONS

CBR is effective for improving the QoL of people with schizophrenia in the community. CBR is conducted by the health worker and sub-district social welfare worker.

Association of lifestyle-related factors and psychological factors on quality of life in people with schizophrenia

In people with schizophrenia several factors are associated with poor quality of life (QoL), namely, lifestyle-related factors and psychological factors. However, there has been little research on the impact of these factors on QoL. Therefore, the relation between lifestyle-related factors, psychological factors, and QoL in people with schizophrenia was assessed. A cross-sectional study was conducted among 115 patients (25% women, 50% inpatients). QoL was measured by World Health Organisation Quality of Life- Brief Version. Lifestyle-related factors were assessed, namely physical activity (International Physical Activity Questionnaire- Short Form), sleep quality (Pittsburgh Sleep Quality Index) and dietary intake (Mediterranean Diet score). Psychological factors such as self-esteem (Rosenberg Self-Esteem Scale) and autonomous motivation (Behavioural Regulation Questionnaire- version 3) were also measured. Regression analyses were performed to identify significant predictors of QoL. Results showed that self-esteem predicted better global, physical, psychological and environmental QoL. Physical activity predicted better global and physical QoL, while sedentary time predicted poor social and environmental QoL. Identifying predictors of QoL has implication for the effective design and delivery of lifestyles interventions, including physical activity, dietary education and smoking cessation in people with schizophrenia. Adopting healthy lifestyles may lead to improved physical health, psychological well-being and QoL in this population.

Quality of Life and Explanatory Models of Illness in Patients with Schizophrenia

BACKGROUND

Patients with schizophrenia hold a variety of explanatory models of illness that influence different aspects of their life including their understanding of the disease, ability to cope and sense of well-being.

AIM

To study the association of explanatory models and quality of life in patients with schizophrenia.

MATERIALS AND METHODS

One hundred and thirty consecutive patients with schizophrenia attending a psychiatric outpatient clinic were recruited in the study and administered the Positive and Negative Symptom Scale (PANSS), the modified Short Explanatory Model Interview (SEMI) and the World Health Organization Quality of Life-BREF (WHOQOL-BREF) Scale to assess severity of psychosis, explanatory models of illness, and quality of life. Sociodemographic and clinical details of patients were also recorded. Standard bivariate and multivariable statistics were employed.

RESULTS

Higher quality of life scores were associated with better socioeconomic conditions and lower scores on negative and general psychopathology subscales of PANSS. Quality-of-life scores were significantly higher in patients who did not perceive their illness to have negative effects on the different domains of their functioning.

CONCLUSION

Explanatory models of illness are associated with perceived quality of life in patients with schizophrenia. There is a need to focus on attitudes, perceptions and functioning, rather than symptom reduction alone, to enhance the quality of life in schizophrenia.

Psychotic symptoms and quality of life: A mediation analysis of daily-life coping

Prior studies suggest the relationship between psychotic symptoms and Quality of Life (QoL) may be mediated by diverse constructs. QoL in schizophrenia-related disorders has been related with coping with daily stressors. Based on previous studies, our hypothesis was that coping mediates the relationship between psychotic symptoms and QoL. Therefore, the aim of the study was to test the hypothesis in a sample of people with schizophrenia-related disorders from a community rehabilitation center. Sixty-six patients were assessed using PANSS, WHOQOL-BREF questionnaire, and COPE Inventory. Regression analyses were performed for each WHOQOL-BREF dimension using PANSS and COPE factors as predictors. Mediation analysis was performed for each WHOQOL-BREF dimension using significant PANSS scales as predictors and significant COPE factors as mediators. Sobel test showed that Self-Sufficient (Problem-focused) coping mediates the relationship between PANSS Positive and WHOQOL-BREF Psychological and WHOQOL-BREF Environmental scores. Results suggest that coping style based on personal abilities and oriented to the stressors mediates the relationship between positive symptoms and QoL associated to well-being and environmental features. However, in our study no coping style mediated the relationship between negative symptoms and QoL. Depressive symptoms predicted each QoL dimension and were not mediated by any coping style.

Structural equation modeling approach between salience network dysfunction, depressed mood, and subjective quality of life in schizophrenia: an ICA resting-state fMRI study

PURPOSE

Quality of life (QOL) is an important clinical outcome for patients with schizophrenia, and recent studies have focused on subjective QOL. We evaluated the causal relationship between psychosocial aspect of subjective QOL, symptoms, cognitive functions, and salience network (SN) dysfunction in schizophrenia using structural equation modeling (SEM).

PATIENTS AND METHODS

We performed a cross-sectional study of 21 patients with symptomatically stabilized schizophrenia and 21 age-, sex-, and education level-matched healthy controls who underwent resting-state functional magnetic resonance imaging. We evaluated SN dysfunction in schizophrenia using independent component analysis (ICA). We rated participant psychopathology using the Positive and Negative Syndrome Scale (PANSS), the Brief Assessment of Cognition in Schizophrenia (BACS), and the Calgary Depression Scale for Schizophrenia (CDSS). We rated psychosocial aspect of subjective QOL using the Schizophrenia Quality of Life Scale (SQLS) psychosocial subscale. We applied SEM to examine the relationships between SN dysfunction, PANSS positive and negative scores, CDSS total scores, BACS composite scores, and SQLS psychosocial subscale scores.

RESULTS

In second-level analysis after group ICA, patient group had significant lower right pallidum functional connectivity (FC) within the SN than the controls did (Montreal Neurological Institute [MNI] [x y z] = [22 -2 -6]) (p = 0.027, family-wise error [FWE] corrected). In SEM, we obtained a good fit for an SEM model in which SN dysfunction causes depressed mood, which in turn determines psychosocial aspect of subjective QOL (chi-squared p = 0.9, root mean square error of approximation (RMSEA) < 0.001, comparative fit index [CFI] = 1.00, and standardized root mean square residual [SRMR]= 0.020).

CONCLUSION

We found a continuous process by which SN dysfunction causes depressed moods that determine psychosocial aspect of subjective QOL in schizophrenia. This is the first report that offers a unified explanation of functional neuroimaging, symptoms, and outcomes. Future studies combining neuroimaging techniques and clinical assessments would elucidate schizophrenia's pathogenesis.

From neurological soft signs to functional outcome in young individuals in treatment with secondary services for non-psychotic disorders: a path analysis

BACKGROUND

Functional decline among patients with mental illness is not unique to individuals with psychotic disorders. Despite this, research on early predictors of functional outcome mainly focused on individuals thought to have an 'at risk mental state' (ARMS) for psychosis. There is evidence suggesting that certain early vulnerability markers, such as neurological soft signs (NSS), may explain variability in functional outcomes independent of the level of psychosis risk and the traditional diagnostic classification.

METHOD

Structural equation modeling was applied to baseline data from a prospective longitudinal study of 138 young individuals in treatment with secondary services for non-psychotic disorders. We evaluated theoretically based models of pathways to functional outcome starting from NSS. The intervening variables were established according to previous evidence and drawn from two general categories: cognition (neuro- and social-) and negative symptoms (expressive and experiential).

RESULTS

A final trimmed model was a single path running from NSS to neurocognition to experiential negative symptoms to outcome. It could not be improved by adding or dropping connections that would change the single path to multiple paths. The indirect effect from NSS to outcome was significant. The validity of the model was independent of the ARMS status and the psychiatric diagnosis.

CONCLUSIONS

Our results provide evidence for a single pathway model in which the starting and intervening variables represent modifiable trans-diagnostic therapeutic targets to improve functional trajectories in young individuals with a recent-onset psychiatric diagnosis and different levels of psychosis risk.

The meaning of pharmacological treatment for schizophrenic patients

OBJECTIVE:

to understand the meaning of medication therapy for schizophrenic patients and formulate a theoretical model about the study phenomenon.

METHOD:

a qualitative approach was employed, using Symbolic Interactionism as the theoretical and Grounded Theory as the methodological framework. The research was developed between 2008 and 2010 at three community mental health services in the interior of the State of São Paulo - Brazil. Thirty-six patients and thirty-six family members were selected through theoretical sampling. The data were mainly collected through open interviews and observation and simultaneously analyzed through open, axial and selective coding.

RESULTS:

the meaning of the pharmacotherapy is centered on the phenomenon "Living with a help that bothers", which expresses the patients' ambivalence towards the medication and determines their decision making. The insight, access, limitations for self-administration of the drugs and interactions with family members and the health team influenced the patient's medication-related behavior.

CONCLUSION:

the theory presented in this study provides a comprehensive, contextualized, motivational and dynamic understanding of the relation the patient experiences and indicates potentials and barriers to follow the medication treatment.

[Therapeutic benefit of a registered psychoeducation program on treatment adherence, objective and subjective quality of life: French pilot study for schizophrenia]

INTRODUCTION

In schizophrenic disorders, supportive psychosocial therapies have been used as adjuncts to pharmacotherapy to help alleviate residual symptoms and to improve social functioning and quality of life. Among these therapies, psychoeducational therapies showed a significant efficacy on improving drug adherence and on reducing relapses. However, according to the French Health Agency, fewer than 10% of psychiatric structures in France offer registered psychoeducation programs. Caregiver apprehension of patients' depressive reactions to the awareness of the disease could underlie the underuse of psychoeducation therapies. Indeed, the psychoeducation programs' impact on objective and subjective quality of life is discussed among the literature. In this context, we conducted a retrospective, monocentric, open-labelled and non-controlled pilot study to measure the impact of a registered psychoeducation program on objective and subjective quality of life of patients suffering from schizophrenia. Secondary objectives included measures of the effects on drug observance and awareness of the disease.

METHODS

We included stabilized patients over the age of eighteen suffering from schizophrenia. Referent psychiatrics were asked to inform the patient of the diagnosis and to prescribe psychoeducation therapy. From 2011 to 2014, we offered three ambulatory programs, each program including fifteen two-hour group sessions. The groups were opened for three to six patients and managed by two caregivers. Themes discussed during the sessions included: schizophrenic disease, treatments, relationships to family, diet, social issues, toxics, relaxation. Objective and subjective quality of life were evaluated one month before and one month after the program using respectively the global assessment functioning (GAF) and the subjective quality of life (SQoL) scales. The Medical Adherence Rating Scale (MARS) and the French IQ8 scale evaluated respectively drug adherence and awareness of the disease. All patients gave their written consent for the study. Based on medical records and scales, we compared data before and after the program using the Wilcoxon test, adapted for small samples.

RESULTS

Fourteen patients, with a mean age of 37.6 years, were included. All patients had a chronic antipsychotic treatment and four benefitted from a bitherapy with a mood stabilizer. The mean length of disease was 15.3 years, with a mean number of 3.4 hospitalizations before inclusion. The participation rate was nearly twelve sessions out of fifteen. Mean GAF score before the program was 48/100. After the program, mean GAF score was significantly increased to 54/100 (P=0.008). As to SQoL score, we found a significant difference of the sub item psychological well-being from 3.2/5 before the program to 3.8/5 after the program (P=0.03). Global SQoL score and other sub items (self-esteem, resilience, and physical well-being) showed a slight but not significant improvement. The sub items family relationships and sentimental life were diminished, non-significantly. Concerning the drug adherence, the mean MARS score was significantly increased from 6.1 to 6.4/8 (P=0.03). Comparison of the insight IQ8 scale showed a slight but non-significant increase. When asked to note the program, patients were globally very satisfied, with a mean rate of 8.6/10. Of fourteen patients, one needed to be hospitalized three years after program.

DISCUSSION

This retrospective study on a small sample of patients suffering from schizophrenic disorder pointed out a significant improvement on drug adherence, objective quality of life and psychological well-being, after an eight-month registered program of psychoeducational therapy. These results are in line with a recent report from the Cochrane group who reported a significant raise of GAF associated with psychoeducational therapies. The literature data for subjective quality of life are more contradictory. Despite the small sample and evaluation means that need to be corrected in further studies, we reproduced the results described in the literature regarding the improvement on drug adherence. However, the stability of these effects should be checked in the medium and long term.

CONCLUSION

Adjunctive psychoeducation therapy has a positive impact on reducing relapses in schizophrenia. In this study, we showed a significant benefit on drug adherence, objective quality of life and psychological well-being on a small sample of patients and provide arguments for the development of psychoeducation programs which are currently underrepresented in France. Our results encourage conducting a further prospective multicenter controlled study on a larger sample to clarify the benefit of psychoeducational therapy on objective and subjective quality of life in schizophrenia.

[Quality of life and schizophrenia: Which evaluation scale for which quality of life?]

The concept of quality of life is an old one, but used extensively in the literature since the 90s with a growing number of instruments. Such diversity makes it difficult for clinicians to choose the most appropriate one regarding their divergence on different aspects including how to use them (especially self-questionnaire versus clinician based semi-structure interview), for what aim (from cost perspective, to functionality and/or subjective well-beingness), relying on what dimensions (as the covered quality of life dimensions are not always overlapping), and in which clinical settings (especially according to the availability or not of trained clinicians, and depending of the available time for such assessments). The aim of the literature review is to describe the most frequently used and/or quoted quality of life instruments in schizophrenia, and to describe their different characteristics and specificities in order to help clinicians to find the most appropriate one according to expectancies, possibilities and interests. In this review, we were able to collect 23 instruments, which need between 3 and 60min to fill-in, are relying in between 5 and 146 items, and allowing the assessment of 1 to 14 different quality of life dimensions. The two extremes could be the EuroQOL, which only has 5 self-report questions (with a visual analogical scale, for the rating procedure) and therefore needing only a couple of minutes, and the Quality of Life Scale which needs an initial training for quotation, relies on a semi-structured interview screening 21 items that are used to assess four different dimensions. Because of the heterogeneity of the broad concept of quality of life, and especially the diversity of the expectancies of the different instruments, it is not surprising that so many instruments are being proposed. But this statement reinforces the requirement that clinicians use the most adequate one, not only according to the expectancies, but also taking into account the local possibilities, especially regarding time to fill in the instrument and the possibility for clinicians to be trained if needed.

A cluster-analytical approach toward real-world outcome in outpatients with stable schizophrenia

BACKGROUND

This study aims to empirically identify profiles of functioning, and the correlates of those profiles in a sample of patients with stable schizophrenia in a real-world setting. The second aim was to assess factors associated with best profile membership.

METHODS

Three hundred and twenty-three outpatients were enrolled in a cross-sectional study. A two-step cluster analysis was used to define groups of patients by using baseline values for the Heinrichs-Carpenter Quality of Life Scale (QLS) total score. Logistic regression was used to construct models of class membership.

RESULTS

Our study identified three distinct clusters: 50.4% of patients were classified in the "moderate" cluster, 27.9% in the "poor" cluster, 21.7% in the "good" cluster. Membership in the "good" cluster versus the "poor" cluster was characterized by less severe negative (OR=.832) and depressive symptoms (OR=.848), being employed (OR=2.414), having a long-term relationship (OR=.256), and treatment with second-generation antipsychotics (SGAs) (OR=3.831). Nagelkerke R(2) for this model was .777.

CONCLUSIONS

Understanding which factors are associated with better outcomes may direct specific and additional therapeutic interventions, such as treatment with SGAs and supported employment, in order to enhance benefits for patients, as well as to improve the delivery of care in the community.

Predictors of quality of life among individuals with schizophrenia

PURPOSE

The study reported here aimed to evaluate both biological and psychosocial factors as predictors for quality of life as well as to examine the associations between the factors and quality of life in individuals with schizophrenia.

METHODS

Eighty individuals with schizophrenia were recruited to the study. The Thai version of the World Health Organization Quality of Life-BREF was utilized to measure the quality of life. The five Marder subscales of the Positive and Negative Syndrome Scale were applied. Other tools for measurement included the Calgary Depression Scale for Schizophrenia and six social support deficits (SSDs). Pearson/Spearman correlation coefficients and the independent t-test were used for the statistical analysis to determine the associations of variables and the overall quality of life and the four domain scores. A multiple linear regression analysis of the overall quality of life and four domain scores was applied to determine their predictors.

RESULTS

The Positive and Negative Syndrome Scale total score, positive symptoms, negative symptoms, disorganized thought, and anxiety/depression showed a significant correlation with the overall quality of life and most of the four domain scores. Depression, SSDs, and adverse drug events showed a significant correlation with a poorer overall quality of life. The multiple linear regression model revealed that negative symptoms, depression, and seeing a relative less often than once per week were predictors for the overall quality of life (adjusted R (2)=0.472). Negative symptoms were also found to be the main factors predicting a decrease in the four domains of quality of life - physical health, psychological, social relationships, and environment.

CONCLUSION

Negative symptoms, depression, and poor contact with relatives were the foremost predictors of poor quality of life in individuals with schizophrenia. Positive symptoms, negative symptoms, disorganized thought, anxiety/depression, SSDs, and adverse events were also found to be correlated with quality of life.

Validity of subjective versus objective quality of life assessment in people with schizophrenia

BACKGROUND

Quality of life (QoL) is considered an important outcome in health research. It can be rated by the patient, or by an external assessor. We wished to identify the predictors of any discrepancies between these two approaches in people with schizophrenia.

METHODS

Patients with DSM schizophrenia and related disorders (N = 80) completed both patient-rated (Lancashire Quality of Life Profile; LQOLP) and assessor-rated (Heinrich's Quality of Life Scale; QLS) measures of QoL.

RESULTS

Patient-rated (LQOLP) and assessor-rated (QLS) measures showed a modest correlation (r = 0.38). In a regression analysis, independent predictors of subjectively-rated QoL being higher than objectively-assessed QoL in the same patient, were low insight score (BIS), negative symptoms (PANSS), absence of depression (CDSS), and less positive attitude toward prescribed treatment (DAI).

CONCLUSIONS

In people with schizophrenia, scores on objectively- and subjectively-rated measures of quality of life can differ markedly. When comparing subjective to objective assessments, patients with depressive symptoms will value their QoL lower, and those with low insight will value their QoL higher. This has important implications for the utility and interpretation of QoL measures in schizophrenia.

Effects of exercise training with traditional dancing on functional capacity and quality of life in patients with schizophrenia: a randomized controlled study

OBJECTIVE

To examine the effects of an eight-month exercise training programme with Greek traditional dancing on functional capacity and quality of life in patients with schizophrenia.

DESIGN

Randomized controlled trial.

SETTING

Sports Medicine Laboratory.

SUBJECTS

A total of 31 patients, aged 59.9 ± 14.1 years.

INTERVENTIONS

They were randomly assigned either to a Greek traditional dancing programme (Group A) or to a sedentary control group (Group B).

MAIN MEASURES

A functional capacity assessment was performed at baseline and the end of the study. Global Assessment of Functioning Scale and Positive and Negative Syndrome Scale were also used. Quality of life was examined using the Quality of Life and Satisfaction questionnaire.

RESULTS

After the eight months, Group A increased walking distance in the 6-minute walk test (328.4 ± 35.9 vs. 238.0 ± 47.6 m), sit-to-stand test (19.1 ± 1.8 vs. 25.1 ± 1.4 seconds), Berg Balance Scale score (53.1 ± 2.1 vs. 43.2 ± 6.7), lower limbs maximal isometric force (77.7 ± 25.7 vs. 51.0 ± 29.8 lb), Positive and Negative Syndrome Scale total score (77.0 ± 23.1 vs. 82.0 ± 24.4), Global Assessment of Functioning Scale total score (51.3 ± 15.5 vs. 47.7 ± 13.3) and Quality of Life total score (34.9 ± 5.2 vs. 28 ± 4.5), compared with Group B.

CONCLUSIONS

Our results demonstrate that Greek traditional dances improve functional capacity and quality of life in patients with schizophrenia.

Relative contributions of negative symptoms, insight, and coping strategies to quality of life in stable schizophrenia

The purpose of this cross-sectional study was to examine the relative contributions of negative symptomatology, insight, and coping to quality of life (QOL) in a sample of 92 consecutive outpatients with stable schizophrenia referring to the Department of Neuroscience, Psychiatric Section, University of Turin, Struttura Semplice di Coordinamento a Valenza Dipartimentale (SSCVD), Department of Mental Health ASL TO1, Molinette, Italy, in the period between July 2009 and July 2011. In order to assess the specific effect of negative symptoms on QOL and the possible mediating role of insight and coping, two mediation hypotheses were tested, using multiple regression analyses specified by Baron and Kenny (1986). Our findings suggest that (a) higher negative symptoms predict a worse Quality of Life Scale (QLS) intrapsychic foundations (IF) subscale score; (b) attribution of symptoms and coping-social diversion have a direct and positive association with QLS-IF; (c) patients high in negative symptoms are less likely to use attribution of symptoms and coping-social diversion; and (d) attribution of symptoms and coping-social diversion act as partial mediators in the negative symptoms-QOL relationship. The prediction model accounts for 45.3% of the variance of the QLS-IF subscale score in our sample. In conclusion, our results suggest that insight and coping-social diversion substantially contribute to QOL in patients with higher negative symptoms. These factors are potentially modifiable from specific therapeutic interventions, which can produce considerable improvements in the QOL of this population.

Duration of untreated psychosis as predictor of long-term outcome in schizophrenia: systematic review and meta-analysis

BACKGROUND

Duration of untreated psychosis (DUP) is one of the few potentially modifiable predictors of outcomes of schizophrenia. Long DUP as a predictor of poor short-term outcome has been addressed in previous meta-analyses, but the long-term effects of DUP remain unclear.

AIMS

To analyse the associations between DUP and long-term outcomes of schizophrenia.

METHOD

A systematic literature search was performed using seven electronic databases and manual searches. Random effects weighted meta-analysis with correlation coefficients was used to pool the results.

RESULTS

We identified 3493 unique publications, from which 33 samples met our predefined selection criteria. Long DUP correlated statistically significantly with poor general symptomatic outcome, more severe positive and negative symptoms, lesser likelihood of remission and poor social functioning and global outcome (correlations 0.13-0.18). Long DUP was not associated with employment, quality of life or hospital treatment.

CONCLUSIONS

The small but mostly consistent correlation between long DUP and poor outcome indicates that early intervention in psychosis may have at least subtle positive effects on the long-term course of illness.

Acute and chronic effects of NMDA receptor antagonists in rodents, relevance to negative symptoms of schizophrenia: a translational link to humans

Negative symptoms of schizophrenia remain an unmet clinical need as they are common, persistent, respond poorly to existing treatments and lead to disability. Blunted affect, alogia, asociality, anhedonia and avolition are regarded as key negative symptoms despite DSM-IV-TR specifying a more limited range. The key to development of improved therapies is improved animal models that mimic the human condition in terms of behaviour and pathology and that predict efficacy of novel treatments in patients. Accumulating evidence shows that NMDA receptor (NMDAR) antagonists mimic cognitive deficits of relevance to schizophrenia in animals, along with associated pathological changes. This review examines evidence for the ability of NMDAR antagonists to mimic anhedonia and asociality, two negative symptoms of schizophrenia, in animals. The use of various species, paradigms and treatment regimens are reviewed. We conclude that sub-chronic treatment with NMDAR antagonists, typically PCP, induces social withdrawal in animals but not anhedonia. NMDAR antagonists have further effects in paradigms such as motivational salience that may be useful for mimicking other aspects of negative symptoms but these require further development. Sub-chronic treatment regimens of NMDAR antagonists also have some neurobiological effects of relevance to negative symptoms. It is our view that a sub-chronic treatment regime with NMDAR antagonists, particularly PCP, with animals tested following a wash-out period and in a battery of tests to assess certain behaviours of relevance to negative symptoms and social withdrawal (the animal equivalent of asociality) is valuable. This will enhance our understanding of the psycho and neuropathology of specific negative symptom domains and allow early detection of novel pharmacological targets.

Subjective well-being in schizophrenia: a randomised controlled open-label 12-month non-inferiority study comparing quetiapine XR with risperidone (RECOVER)

This randomised 12-month open study analysed the effectiveness of quetiapine XR (400-800 mg) versus risperidone (2-6 mg) on subjective well-being in schizophrenia (NCT00600756). Primary objective was to demonstrate non-inferiority of quetiapine XR to risperidone in 6-month responder rate using the Subjective Well-Being under Neuroleptics scale (SWN-K) (per-protocol at Month 6 [PP 6] population). Non-inferiority was defined as the lower limit of the 95% confidence interval (CI) greater than -9.7% for the adjusted difference between quetiapine XR and risperidone. Secondary objectives included non-inferiority of quetiapine XR versus risperidone (lower limit of 95% CI greater than -7.5 points) for SWN-K change from baseline to Month 12 (PP 12). 798 patients were randomised (quetiapine XR, n=395; risperidone, n=403); at Month 12, 212 (54%) and 227 (56%) patients, respectively, completed the study. At Month 6, SWN-K responder rate in the PP 6 population was 65% (136/210) with quetiapine XR and 68% (158/232) with risperidone (adjusted treatment difference: -5.7%; 95% CI: -15.1, 3.7); thus, non-inferiority could not be established. SWN-K change from baseline to Month 12 was 23.2 points for quetiapine XR and 21.1 points for the risperidone group; treatment difference was 2.1 (95% CI: -0.8; 5.0); non-inferiority was established (PP 12).

CONCLUSION

SWN-K response at 6 months was comparable between the two antipsychotics. However, with a lower than expected responder rate and a lower than expected number of evaluable patients in the PP 6 population, non-inferiority was not demonstrated. A secondary objective (SWN-K total score) established non-inferiority of quetiapine XR to risperidone at Month 12.

Clinical symptoms, mainly negative symptoms, mediate the influence of neurocognition and social cognition on functional outcome of schizophrenia

BACKGROUND

The functional outcome of schizophrenia is affected by multiple factors such as cognitive function and clinical symptoms. The complex relationship among cognitive function (both neuro- and social-cognitions), clinical symptoms, and functional outcome remains unclear. The current study employed structural equation modeling (SEM) to examine whether clinical symptoms mediate the relationship between cognitive function and functional outcome in a large cohort of patients with schizophrenia.

METHOD

Three hundred and two Han-Chinese patients with chronically stable schizophrenia received evaluation of cognitive function (using the Measurement and Treatment Research to Improve Cognition in Schizophrenia [MATRICS] Consensus Cognitive Battery, including 7 domains covering neurocognition and social cognition), clinical symptoms (including positive, negative and depressive symptoms), and functional outcome as assessed by Global Assessment of Functioning Scale and Quality of Life Scale.

RESULTS

SEM identified clinical symptoms as a mediator between cognitive function (including all 7 domains of MATRICS) and functional outcome in schizophrenia. The relationship between cognitive function and functional outcome was significant in the basic model. In the mediation model, the link between cognitive function and functional outcome was mediated by clinical symptoms, mainly negative symptoms.

CONCLUSION

This study suggests that clinical symptoms, mainly negative symptoms, mediate the influence of neurocognition and social cognition on functional outcome of schizophrenia. Future studies should explore the impact on other functional outcomes in different ethnicities and various illness phases.