Social skills training for chronic psychotic patients: A French study

The aim of this article is to describe the cognitive-behavioral methods for social rehabilitation and psychotherapy of chronic psychotic patients which are nowadays available in French-speaking countries, then to propose a theoretical framework to help integrate these various methods for use in our duly pratice and, finally, to expose our research in this field, especially concerning the topic of quality of life and social skills training programs. We present a study we designed in order to assess the impact of a comprehensive social skills training program upon quality of life of chronic schizophrenic patients. Starting from the point of view that a good psychosocial rehabilitation program is one that improves social skills and social functioning without negative effects on quality of life, we tried to show such qualities in a quite comprehensive rehabilitation program using social skills training methods corresponding to the social readaptative “modules” from Liberman and Wallace's Social and Independant Living Skills Program — “medication management module” — followed by “basic conversational skills module”, and finally, a brief adapted version of “interpersonal problem solving skills module”. We were able to observe the evolution of social skills and functioning of eight schizophrenic patients having benefited from this program, over a one year period, and we compared results regarding quality of life with two control groups made of schizophrenic patients, one of them having benefited from a supportive group therapy in order to study the impact of non-specific factors. The results indicate a clear dissociation between direct benefits of social skills training (knowledge, social skills, social functioning and symptomatology) which all showed a significant improvement in the experimental group, and subjective benefits (self-esteem, sense of self-efficacy, quality of life) which showed no change, as well when consider no intra-group as well as between group comparisons.

Social disparities in musculoskeletal disorders and associated mental malaise: findings from a population-based survey in France

AIMS

Various types of musculoskeletal disorders (MSDs) have comorbid mental disorders, which may in turn have a negative influence on disease course and role impairment, but the contribution of social factors to this type of comorbidity is a much under-researched area. This study investigates whether there is a socially patterned association of MSDs with different dimensions of mental malaise.

METHODS

The sample included 3,368 economically active participants aged 18-64 years, randomly selected from the Lorraine region in north-eastern France. Information was provided through a post-mailed questionnaire on fatigue, sadness/depression (Duke questionnaire) and cognitive disability during the last eight days.

RESULTS

MSDs were significantly more prevalent in manual workers, clerks and other occupations than in upper and intermediate professionals, and similar occupational disparities were found for cognitive disability, fatigue and sadness/ depression. Stratifying the sample, we found the occupational disparities in cognitive disability to be much stronger among participants suffering from MSDs than among participants not suffering from MSDs, and the occupational disparities in fatigue and sadness/depression to be limited to the subsample of subjects suffering from MSDs.

CONCLUSIONS

The findings demonstrate that the association of MSDs with mental malaise is much stronger in the lower occupational groups than in the higher groups. Given that psychological factors are implicated in disease prognosis and in the development of disabilities, awareness of the social dimension of the association and treatment of the comorbid mental disorders could open a promising avenue for reducing social inequalities in disability related to MSDs.

Un modèle de qualité de la vie subjective adapté aux essais thérapeutiques : intérêt chez les patients dépressifs

Cet article présente les bases conceptuelles qui ont présidé à l'élaboration d'un questionnaire (« Profil de la Qualité de Vie Subjective » ou « PQVS ») évaluant la qualité de vie subjective des patients en pathologie somatique et psychiatrique. Une description de l'instrument précède les données concernant la validation de ce questionnaire ainsi que les résultats déjà obtenus sur environ 1500 sujets présentant des pathologies différentes. Les premiers résultats montrent qu'à chaque pathologie correspond un profil différent de patients; qu'il est possible, grâce à ce nouvel instrument d'évaluation, de mettre en évidence des changements spécifiques et parfois inattendus chez les patients; et qu'enfin, dans un certain nombre de cas, l'on peut dégager des hypothèses explicatives de ces changements.

Life satisfaction and disability after severe traumatic brain injury

OBJECTIVE

To assess the relationships between life satisfaction and disability after a severe traumatic brain injury (TBI).

DESIGN

Cross-sectional study, including 75 patients 2 years or more after a severe TBI.

METHODS

Life satisfaction was assessed with the Subjective Quality of Life Profile. Impairments, activities and participation were assessed with standardized tests.

RESULTS

The satisfaction profile was flat, i.e. the majority of items obtained mean satisfaction scores close to 0, suggesting that participants felt indifferent to these items or in other words that they were neither satisfied nor unsatisfied. Patients were on average slightly dissatisfied with their cognitive functions, physical abilities and self-esteem. A factor analysis revealed three underlying factors. The main finding was that the relationships between life satisfaction and disability were not linear: the lowest satisfaction scores were reported by participants with moderate disability rated by the Glasgow Outcome Scale, while individuals with severe disability did not significantly differ from the good recovery group.

CONCLUSION

Life satisfaction is not linearly related to disability after severe TBI.

Quality of life of children and adolescents after kidney or liver transplantation: child, parents and caregiver's point of view

A cross-sectional study was performed to assess quality of life (QoL) after kidney or liver transplantation during childhood. Self-questionnaires explored children, adolescent and parent QoL. Seventy-five transplant children, 36 transplant adolescents, 67 mothers, 34 fathers and 67 caregivers filled out the questionnaires; they were compared with a reference population. Children reported a rather good QoL, but their extra-family involvement appeared not as satisfactory as that of the reference population children. Adolescents reported a very high QoL when completing the structured format scale; however, their responses to open-ended questions showed qualitative differences compared with those of a reference population: they expressed concern about their body or health, less pleasure than ordinary adolescents to manage by themselves, and a poor relationship with peers. Mothers indicated a deep impact of the child's illness on their own QoL, and the need for psychological support. In conclusion, a rather good QoL is a long-lasting feature of kidney and liver transplantation in children. Such an assessment is mandatory to identify remaining impairments in some selected areas, either in the recipient or family.

[Child and adolescent quality of life: study analysis]

As with adults, the quality of life of children is a multi-dimensional concept, therefore, in theory, evaluations cannot be carried out except by the subject, given the very subjective nature of this procedure. There are obstacles in pediatrics with this postulate, as one would prefer to implement a procedure of evaluation regarding the child's own characteristics in order to determine the cognitive limits of his/her development. We have attempted to summarize this subjective aspect by adapting tools for evaluation suitable for both the child and adolescent. 1) The AUQUEL questionnaire. Targeted to nursery school or primary school children, it consists of a closed scale comprised of thirty-one items: the phases of satisfaction are presented with the use of four aspects which express different emotional conditions. It also includes an open question. 894 French children so far have filled out this questionnaire: 491 from the general population, 403 were evaluated under specific contexts, either organic illnesses, psychological problems, or in the context of social personalities. Differences can be observed, depending on the contexts, in a closed scale or an open question. We will look at the example of a kidney transplant to illustrate our point. 2) The "OKadolescent" questionnaire Similar in structure to an adult questionnaire; it differs, however, by the themes that are adopted to the life and preoccupations of an adolescent. It is made up, as with the questionnaire for children, of a closed scale (26 items), and an open question. Here, 268 adolescents from the general population can be compared with adolescents evaluated in either a somatic or war-zone context. We will take as an example adolescents who have undergone kidney transplants or have suffered from hepatitis, to demonstrate the paradoxical characteristics of the evaluation of the adolescents quality of life. 3) Conclusion Our experience in this domain of the evaluation of a child's quality of life enables us to confirm its feasibility, on the condition of using specific tools, for the clinician (the best representation for the impact of pathology on a child's quality of life), and its relevance as an element for evaluating the needs linked with the health of the given population.

[Concept of quality of life, results of studies of 13,000 subjects]

A questionnaire (Subjective Quality of Life Profile, or SQLP) was finalized at the end of the eighties by our team. It was endorsed and tested on more than 13,000 subjects recruited outside of any medical context, or suffering from any somatic or psychological pathologies. On a conceptual framework, the questionnaire takes into account the subject's history independent from the context of his/her personal objectives. It differentiates quality of life from health, and stresses its multi-factorial aspect. The questionnaire is made up of 28 "inevitable" items covering four domains: relational, somatic, contextual and psycho-affective, as well as a list of optional items. Two types of questions pertaining to history are applied to each item, as well as to the anticipated expectations. The results are of interest in the following domains: 1) To specify the demands and complaints of subjects afflicted with various illnesses, and comparing them with healthy subjects. 2) To demonstrate the impact of various factors on the quality of life. 3) To observe patients' development following long-term or difficult therapy. 4) To be able to compare (once the questionnaires are filled out by different contributors), the patient's responses to those of his family or caregiver. 5) To take into account the patients' illness in order to provide the most pertinent results. These illnesses are always higher in psychiatry (and in particular those suffering from addictions): and are an unfavorable prognoses. Once the patient improves clinically, their illness decreases. 6) Regarding associates whose illnesses are at a "normal" level, the illness does not prove to be more serious than in exposed situations (either medical or social). At the moment it seems that the evaluation of a patient's quality of life brings an enriching, clarification to the appreciation of traditional medicine. Avoiding a social "desirability" criteria, we believe the responses relative to the illnesses will provide the best indication of the subjects' quality of life.

[Validation of the combined SF36/MSQOL test of evaluation of quality of life in migraine patients in France]

The impact of migraine on patients quality of life is great, even between attacks. The aim of this study was to assess the properties of a French language quality of life questionnaire, which associates the Medical Outcome Study Short Form (MOS SF 36) with the Migraine-Specific Quality of Life (MSQOL). Data were obtained from 110 consultant patients of neurology units located in three University hospitals in the center of France. The results indicated a good acceptability of the association of the two questionnaires with a 84p.cent response rate. The Principal Component Analysis showed no change in both SF-36 and MSQOL structures. It also suggested that the two questionnaires were complementary. The high values of the Cronbach alpha coefficients for each scale indicated a high level of internal consistency. The quality of life scores were correlated with external parameters such as frequency, intensity and length of migraine attacks, and social activity reduction due to these attacks. In conclusion, the association of the SF-36 with the MSQOL has the interest of associating generic and specific questionnaire, in a complementary way. This association has good psychometric properties, and can be used to evaluate migraineurs quality of life in French speaking countries.

[Assessment of quality of life for home ventilated patients with Duchenne muscular dystrophy]

A social and psychological survey was conducted for patients with DMD submitted to home mechanical ventilation for more than one year. Thirty six were tracheostomized and 16 were using non invasive ventilation. Fifty two patients were recruited: 36 were tracheostomized and 16 were using non invasive ventilation. Mean age was 25 +/- 5 years. In the two groups: 1- the main disagreement was air leaking and cutaneous erosions. 2- when present, headache, dyspnea, sleep troubles and general fatigue were improved by mechanical ventilation. 3- ventilation was considered as improving health but with an increasing of dependencies. 4- Majors disappointment are sexual life (70 percent) and physical status (40 percent) but patients spent more than half time with positive feeling (92 percent). There was no difference between satisfaction evaluation and type of ventilation. Home ventilated patients with DMD have positive assessment of satisfaction. Despite technical disagreement as air leaking, patients feel an improvement of their life and advise other DMD to use early home ventilation.

[Quality of life of a population of 54 ambulatory children with cerebral palsy. A cross-sectional study]

To evaluate the impact of handicap on quality of life in children with cerebral palsy and living in family.

METHOD

A descriptive study by investigation was conducted in children with cerebral palsy, with the ability to walk, from 4 to 12 years of age, and in their family. Quality of life was evaluated with the AUQUEI questionnaire. Another questionnaire was given to the parents to collect the different variables, which could influence quality of life of the child.

RESULTS

The mean age was 9 years. Associations between the studied variables and the quality of life were observed for motor function, number of siblings and the quantity of hours of reeducation given by the family. Parents evaluated their quality of life on the visual scale at 72.23 mm (95CI: 51.60-92.84). There was no correlation between the assessment of quality of life of parents and children.

DISCUSSION-CONCLUSION

The better the child's motor function the less satisfied he was. This result shows the poor correlation between quality of life and general condition, impairment or disability. The greater the number of children in the family the less satisfied the child was within the family and the more satisfied the child was at school. A handicapped child has perhaps a more difficult place in the close family and an easier time in a school where the environment is more neutral. The more time that is devoted by the family to reeducation the less the child is satisfied. Quality of life seems to be influenced negatively by the demands of physical therapy, which do not correspond to the reality of the abilities of the child.

[Quality of life of lumbago patients cared for in a pain center]

OBJECTIVE

To evaluate the quality of life of patients treated in a pain center.

METHOD

Sixty eight patients were assessed during their first consultation, then 6, 12 and 18 months later, using a quality of life questionnaire "SQVP or Subjective Quality of Life Profile" validated in French populations and a panel of questionnaires for the monitoring of chronic pain, recommended by the ANAES (French Agency for Health Assessment).

RESULTS

Results showed that: the patients' quality of life was clearly deteriorated (lowest quality in the data base--14,000 patients--with regard to the SQVP); the profile obtained (severe handicap) suggests that the lumbagos are part of a psychiatric context; the patients' quality of life clearly improves after 6 months' treatment, but the pain only stabilizes later.

Quality of life in patients at risk of medullary thyroid carcinoma and followed by a comprehensive medical network: trends for future evaluations

BACKGROUND

As shown in a previous study, the knowledge of the genetic risk in individuals belonging to families at risk of medullary-thyroid carcinoma (MTC) could be associated with impaired quality of life (QoL).

PATIENTS AND METHODS

In the present study, we compared the QoL scores obtained in the same period with the subjective quality of life profile (SQLP): in 82 individuals at risk of MTC who had been tested for Ret-mutations; in 200 women at risk of familial breast/ovarian cancer syndrome (BOC); and in a control population of 3,501 healthy volunteers.

RESULTS

Significant differences were observed in favour of healthy volunteers as well as individuals at risk of MTC, over women at risk of BOC (mean scores: 0.89, 0.85, and 0.64, respectively, P < or = 0.001), but QoL scores were not statistically different between individuals at risk of MTC and the control population (P = 0.2). However, they were significantly inferior in the subgroup of germline Ret-mutation carriers, as compared to the control population (mean scores: 0.73 and 0.89, P = 0.04). In the latter, the relationships with the children and the family were the most important facets of their QoL.

CONCLUSION

Our results confirm the potentially negative impact of the knowledge of the genetic risk of cancer and its consequences in terms of morbidity and follow-up, on the QoL in people followed at oncogenetic visits.

[Quality of life study in chronic psychotic patients using a day hospital]

This survey concerned 24 adult patients, who are chronic psychotics, living in town and followed by a day hospital team. Their life quality was evaluated with the help of a validated questionnaire, "Subjective Life Quality Profile" ("PQVS"). The same version of this questionnaire was filled in by the patients and their referent nurse, two times, at six month interval. In the mean-time, the service psychiatrist also filled in questionnaires, assessing the psychiatric symptomatology. The main results confirm the reliability of the tool used and the feasibility of this type of survey with a population of chronic psychotics. The results are coherent at six month interval, and the points of view correspond between the patient and this referent. Finally the life quality is less good when the symptomatology quotation is bad. The aim of this work was to give an account of the patient's life, as seen by himself and by the caretakers.

[Personal sports training in the management of obese boys aged 12 to 16 years]

OBJECTIVE

Estimation of both physical and psychological effects of an adapted physical training on children undergoing an obesity treatment.

MATERIAL AND METHODS

The survey was carried out on 36 obese boys (ages = 12-16 years) who stayed in the medical center for at least four months. Eighteen of them were trained with the SELF method (the SELF-training is global, progressive, adapted to each boy, controlled and takes place within a ten-week period with five sessions a fortnight, each session lasting 30 to 40 minutes). The parameters that were studied concerned auxology, breathing function exploration, aerobic and anaerobic capacities, muscle strength and psychomotor qualities; the subjective effects of the training were estimated with a questionnaire about life quality, and the hand test. At inclusion the results were reported to a standard kind of population. At the end of the training the results of the 18 boys that were trained were compared to those of the 18 controls.

RESULTS

Compared to a standard population, the obese children' aerobic capacity is diminished for the maximum power but is identical in absolute value for the VO2 max; their anaerobic capacities, muscle strength and psychomotor capacities are lower and their psyche is affected by the disease. After a three-month training period and after comparison with the 'control' group, there can be noticed a significant improvement in the psychomotor capacities, a major tendency for the improvement of the aerobic capacities and very positive effects on the psyche.

CONCLUSION

SELF-training in association with dietetics appears to be very useful in the therapeutic care of obese children. For the follow-up at home it would need to be registered within the domain of physiotherapy.

[Quality of life of children: importance of its evaluation. Comparison of children in good health with those at risk (psychological, social, somatic)]

A multicentric study was performed in France and Spain: 490 children were evaluated with a previously validated questionnaire including open-ended questions and structured response format questions. Children are either in good health or suffering from somatic diseases, psychological problems or social difficulties; 38% of the children are Spanish, 62% are French; the questionnaire validation was checked again, and confirmed. Children are happy about their leisure, and unhappy when separated from their families. Among the factors affecting the answers to the structured format questions the most important are the social difficulties and to a lesser extent the psychological problems. Somatic diseases impair the child's quality of life in Spain. Children differ according to the country where they live. Among children in good health, Spanish children report a better quality of life than French children. Open-ended answers were only studied in France. They were very different when children with social difficulties or psychological problems filled out the questionnaire and were compared to children in good health or with somatic diseases. Both children with psychological and social difficulties mention more often the relationship domain. Children with social problems never mention their activities as a source of happiness.

[Evaluation of the quality of life of infants and very young children: validation of a questionnaire. Multicenter European study]

In the last few years, evaluating quality of life in children has become possible using specific instruments; nevertheless, there is still an unsolved issue concerning the earliest ages, when the child is not able to give his/her own opinion. QUALIN, a new instrument designed to assess an infant's quality of life (between the ages of three months and three years) was developed from the study of spontaneous criteria used by parents or caregivers (paediatricians or nurses) when they think about the quality of life of a baby (preliminary survey including 800 open-ended questionnaires).

PATIENTS AND METHODS

One thousand four hundred and twelve children under the age of three were included in this validation study. QUALIN questionnaire is a 34-item scale and can be completed by parents or caregivers. Two forms are available: one form is designed for children under the age of one and the other is designed for children between the ages of one and three. The QUALIN questionnaire was translated into English, Italian and Spanish, and a European multicentric validation study was conducted in Belgium, France, Italy, Luxembourg, Spain and Switzerland. Data were collected with QUALIN questionnaires from children's parents and paediatricians.

RESULTS

The psychometric properties of the scale are satisfactory (acceptability 90%, Cronbach's coefficient alpha over 0.75, correlations between two raters over 0.50, construct validity with principal component analysis showed emerging factors in agreement with the hypotheses linked to the questionnaire construction). The results are interesting, showing significant differences according to the health status of the children and their country of origin.

CONCLUSION

The QUALIN questionnaire can be used for studies concerning the quality of life of children less than three years of age.

Psychosocial impact of genetic testing in familial medullary-thyroid carcinoma: a multicentric pilot-evaluation

BACKGROUND

Many crucial problems are associated with the diagnosis of inherited cancer susceptibility. One of the most important is related to the psychosocial consequences of the knowledge by the patients and their relatives of their own genetical status. Little data are available in the literature, mainly from studies including small numbers of selected and motivated patients.

PATIENTS AND METHODS

From January till December 1997, we studied the psychometric and quality of life parameters of 77 subjects followed in two French specialized centers. These subjects had been treated for either sporadic or familial or were at risk for medullary thyroid carcinoma. All patients had previously attended genetic counselling with detection of germline Ret-mutations, were informed on their own genetic risk, had good short-term prognosis and performance status and did not receive recent cancer treatment. Each patient was invited to answer two questionnaires, the hospital anxiety and depression scale (HADS) and the subjective quality of life profile (SQLP).

RESULTS

We report herein the descriptive results of this study (HADS and SQLP scores and distributions) and describe the individual clinical covariates that might explain the observed differences between subgroups of individuals. Although psychometric scores appeared similar in these subgroups, quality of life scores were lower in Ret-mutation carriers. Genetically-predisposed patients were less satisfied and expressed more expectations for favourable change in their quality of life.

CONCLUSION

This finding suggests a high level of frustration and latent unsatisfaction related either to the management of the genetic information given by the clinicians and its psychosocial consequences or simply to the knowledge of the genetic risk of cancer. Further studies on the individual consequences of genetic testing, information delivery and when necessary psychotherapeutic interventions, are needed to insure the quality of presymptomatic genetic testing in this field of oncology.

[Infant quality of life: criteria of parents and professionals. Development of an evaluation instrument]

A survey was performed using open-ended questionnaires to be completed by parents or care-givers dealing with very young children (less than 3 years old) in order to study their opinions concerning the child's quality of life. About 800 questionnaires were analyzed with a content-analysis method. Nine categories and about 40 elementary criteria were distinguished. Some criteria were widely quoted. Others appeared useful to discriminate between care givers and parents, between different situations encountered by the child, and his/her age. This information will be used to develop a young child's quality of life scale.

Quality of life assessment in psychiatry: the Subjective Quality of Life Profile (SQLP)--first results of a new instrument

This article describes early results of a new instrument for measuring quality of life--the French Subjective Quality of Life Profile (SQLP) questionnaire. This 36-item, self-administered questionnaire has been previously validated in a large sample population with somatic disorders. It is characterized by its multidimensional pattern and subjective approach (i.e., the degree of satisfaction with various domains of life, the degree of change anticipated and the importance attributed to these domains). The SQLP was tested with three psychiatric patient samples: people with depression, psychosis or substance abuse. Preliminary findings indicate that the questionnaire is useful in describing psychiatric patients, their characteristics, and explaining some of their changes.

[Psychosocial impact of the first oncogenetic consultation in a familial context of cancers of the breast and the ovary]

The purpose of the oncogenetic consultation, is to respond to persons who wonder about their risk of developing a tumour and wish to learn about ways of prevention and detection. The object of this investigation is (1) to study the impact of a first consultation in genetics on the quality of life and the psychology of women with a family history of cancer, and women with or without family antecedents but who suffered themselves from breast cancer at an early age (< or = 35 years); (2) to evaluate their risk perception and their comprehension of the information after the consultation. The study was performed on 200 women attending a first consultation at Institut Curie. Fifty-nine of them had no cancer. Among the 141 consultants with cancer, 54 had developed breast cancer at an early age (< or = 35 years). Their quality of life, their psychological state and their knowledge of the risk of breast tumour were evaluated before consulting and 6-8 months afterwards. Before consulting, their quality of life was altered in some (non-relational) fields but their psychic condition was relatively maintained. Six-nine months after consulting, their quality of life had not deteriorated, but tests results on their psychological state were not as good. The initial psychic condition, itself related to the medical status of the consulting women, was the most significant predictor of their quality of life a few months after their first genetics consultation. After consulting, the women expressed satisfaction with the information delivered by the genetician and their appreciation of tumour risks was improved.

[Evaluation of the quality of life of chronic psychotic patients living in supportive housing]

This study concerns 46 chronically mentally ill patients living in community support systems. Their quality of life was measured with a validated questionnaire: the "Subjective Quality of Life Questionnaire" ("SQLP"). Both patients and their care givers separately completed the same version of the questionnaire. This study first shows the feasibility of such inquiries with chronically mentally ill patients. It gives a description of the patient's feeling which is different from the usual medical point of view. The life domains the patient is very satisfied with are mostly restricted to food, material conditions, and relationship with the care-givers, but exclude the other relationships. Our data also allow to estimate the degree of agreement and disagreement between the care-givers and their patients.

[Evaluation of the quality of life in pediatrics: how to collect the point of view of children]

There are very few available child quality of life questionnaires. We describe here a French questionnaire (AUQUEI) which consists of a structured format scale (26 items). The first part of the questionnaire studies child satisfaction. Response levels are measured by checking faces expressing different emotional states. The validation is satisfactory, and the questionnaire is able to differentiate healthy children from sick children (HIV positive). A second part of the questionnaire focuses on the child's own quality of life, and is based upon open-ended questions. This second approach allows to broaden the structured format scale and improves the understanding of the child's quality of life. It constitutes a necessary complement to the first part as it avoids using mechanically adult-specific concepts for children. We also found it to be sensitive enough to distinguish sick children from healthy ones. The AUQUEI questionnaire with its two complementary parts appears to be a potentially valuable tool to better understand the experience of sick children, in the various aspects of their life, and to follow their evolution.

[Evaluation of care: taking into account the patients' quality of life and relational elements]

This paper offers a new perspective concerning care evaluation. Patients' quality of life is measured as well as relational and subjective parameters. A questionnaire "SQLP" ("subjective quality of life profile") has been constructed and validated on several thousands subjects. The results obtained have several points of interest. First the questionnaire allows us to describe various populations and their needs; it also allows to track the effects of different treatments and compare them. Finally it also allows to understand some of the treatments' mechanisms of action. The therapeutic relationship has been extensively studied in psychotherapy research. It may be usefull in other therapeutic settings. Various examples are given. A particular attention has been given to the evaluation of the patient/care-giver agreement.

Evaluation of life quality for children infected by HIV: validation of a method and preliminary results

The authors discuss a method developed for the evaluation of quality of life (QoL) of children infected by HIV. The method consists of several questionnaires intended for different evaluators (doctor, nurse, psychologist, and parents), and for the infected child. The protocol was administered to 47 families (interviewed in five centers in the south of France). A descriptive overview of this population notes the state of health and autonomy of the children and parents, and reveals important social difficulties within and beyond the family unit for 75% of the families. The results obtained furnish points to consider in the planning of psychosocial support systems. The reactions of the evaluators to the questionnaires as well as other elements of validation are presented: level of responses (acceptance), internal consistency, agreement between evaluators, and reliability and definition of the main indicators for QoL for the children. Questionnaires were simplified for a second survey so as to test the sensitivity of the method to time variations, improve acceptability, and test validity for the evaluation of QoL. The authors hope their method will interest specialized teams in the fields of therapeutic research and/or psychosocial support.

[Evaluating quality of life of depressed patients in ambulatory care treatment]

This study concerns 1257 depressed outpatients, whose quality of life was evaluated before the beginning of a fluvoxamin treatment and six weeks later. We used the "Subjective Quality of Life Profile", questionnaire which has been previously validated in somatic diseases. The validation performed with these depressed patients appears to be quite satisfactory. The results provide a good description of the patients before the treatment: they seem to be indifferent to most domains by their health which they describe as very unsatisfactory. Contrasting with these results, patients' expectations appear to be very important in most domains, and the greater these initial expectations the poorer the evolution of their quality of life. After six weeks the patients' improvement in their quality of life is quite obvious especially in the somatic area. Another interesting finding concerns the high initial level of patients' expectations as compared with patients having somatic diseases. The higher these expectations, the poorer the outcome. It thus appears that a very sensitive self-questionnaire dealing with patients' quality of life in depression is available.

[Psychotherapy in the institutional environment]

A methodology has been set up for evaluating the effects of psychotherapeutic treatment by surveying psychiatric French-speaking institutions. Our approach consisted in modeling the questions of the clinicians and to develop multi-dimensional questions, covering the different aspects of the care, the different points of view from which one can consider a patient: symptomatic, psychodynamic, or from the point of view of his quality of life. In the following text we present descriptive or explanatory results obtained in different contexts.

[Levels of the training of psychotherapists and results of analytic psychotherapy]

The purpose of this study was to investigate therapists experience as predictor of psychotherapy outcome. We studied consecutive patients (n = 76) assigned to psychoanalytic psychotherapy after being referred to the Geneva University Psychiatric Center for psychiatric treatment. Fifty-seven subjects were treated by trainees and nineteen had certified psychotherapists. Each treatment was carefully evaluated at intake, at the sixth session and at 1-year follow-up. Those patients treated by trainees appeared to be clearly improved (p < 0.01), but 49.1% of them did not completed the psychotherapy. In addition, increased therapist's training and experience (certified psychotherapist vs trainee) was associated with better global outcome, reduced early termination and more improvement after six psychotherapy sessions (p < 0.01). The present data indicate that increased therapist's experience is associated with more compliance and more improvement after the initial phase of the treatment in psychiatric subjects assigned to psychoanalytical psychotherapy.

[Psychotherapeutic process in a day hospital: results of a survey and importance of qualitative data]

This survey was carried out in a psychiatric day hospital over three years on all patients admitted. The aim was to assess the patients' state at discharge, and to identify the factors to explain the clinical changes, in particular to evaluate the impact of the various types of therapy proposed. The patients were evaluated when they entered the hospital and at discharge using mainly validated translated English-language questionnaires ("Health Sickness Rating Scale" of Luborsky, "Helping Alliance questionnaire" of Luborsky), but also two instruments developed and validated by our team: "Clinical Evaluation Profile", and the "Commitment Scale". The results provide not only a good description of the patients' state at arrival but also of their evolution. The factors found to be important in the evaluation were similar to those identified in most of previous studies, i.e. the initial severity, and quality of the therapeutic relationship, but we also found that the degree of commitment of the patients to the various therapies offered was important. In addition, we found that, when using the commitment scale in homogeneous subgroups of patients (identified using the CIM 9 diagnostic scale) were examined, the favourable outcome of a given psychotherapeutic approach was dependent on the type of the pathology. Thus, patients with personality disorders and high scores at the commitment scale benefited above all from group therapy. The reverse was found for patients with neurotic disorders. For patients suffering from schizophrenia the most important factor was the commitment to the background milieu of the hospital. These observations are in contradiction with some of the main conclusions (known as the equivalence paradox) from english and american studies over the last 40 years of Psychotherapy Research, which state that all psychotherapies are equivalent, and that the reason why some give successful results, and other do not can, only be by non specific factors (i.e. the quality of the therapeutic bond, patients' motivations, etc.). From our results, if homogeneous subgroups of patients are considered and if we use subjective (commitment to the therapy) instead of hard data (as for example having this type of therapy or an other one, or the length of therapy, ect.), we can distinguish the effect of the various psychotherapeutic approaches at least in a psychiatric institution.

[Quality of life of patients during treatment of type I diabetes. Importance of a questionnaire focused on the subjective quality of life]

The aims of this study were 1) to study the quality of life in diabetic patients receiving one of two different forms of insulin delivery and 2) to check in this disease, the reliability and responsiveness of a questionnaire (SQLP: subjective quality of life profile) which we have previously used and validated in other pathological states. A total of 743 Type 1 diabetic subjects, receiving two different forms of insulin injection completed this questionnaire twice, at a monthly interval. These patients stressed a certain number of somatic manifestations as well as their difficulty to move around or perform every-day life activities. The results from this trial show that the questionnaire was capable of demonstrating that the easiest mode of insulin injection was selectively and significantly related to a higher satisfaction with being able to move around.

Evaluation of treatment effects on patients' quality of life: what approach? From the concepts to the instruments

A critical review of currently used methods to evaluate quality of life in therapeutic trials (economic approach and medical approach) is presented. A new approach focused on subjective quality of life was developed. As efficient as the others it has the advantage to refer to a greater extent to the initial concepts which contributed to the emergence of this new field of research and to bring forward the patient point of view.

Crisis intervention in depressed patients with and without DSM-III-R personality disorders

We compared the relationships between response to a crisis intervention program and long-term outcome in 31 depressed outpatients with and without DSM-III-R personality disorders (PD). The presence of PD predicted a poorer 2-year outcome. PD subjects with better working alliance and increased insight at termination of crisis intervention had increased compliance with long-term psychiatric treatment (p < .005) and better 2-year outcome (p < .005). Increased compliance with long-term psychiatric treatment predicted better long-term outcome in PD patients (p < .005). None of these significant relationships was observed in the comparison group without PD, suggesting that establishing an effective treatment process may be especially important for outcome in PD patients.

[Quality of life in children with chronic disease. Review of the literature and conceptual aspects]

Most studies of the literature concerning the quality of life of children with chronic illness have been conducted in the somatic field, using objective criteria. However the concept of quality of life has evolved: while the first studies took into consideration the effects of somatic diseases on children or on their families, the recent studies tend to focus on the coping strategies developed by the families. The authors emphasize two main points concerning the evaluation and the concept of quality of life: 1) the measures of the quality of life should be "dynamic", i.e. they should deal with the developmental changes of the child; 2) due to the difficulty to clearly define the concept and to the variability of the available informations, a "convergence" notion should be preferably used: i.e. information should be collected from several sources (professionals, families and children) and should concern most domains of the child's life: school, health, games, relational life.

[Crisis intervention: assessment process and long-term follow-up of patients]

The aim of this work, which was performed in a Crisis Centre in Geneva, Switzerland, was to study the relationship between a patient's long-term follow-up and the range of the patient's difficulties as assessed during screening by a clinician. Out of the 78 patients who were referred to the Centre during a two-month period in 1985, 31 were followed-up during a complete crisis intervention program. All these patients with severe symptoms would have been hospitalized if they had not been transferred to this program. The clinician's opinion of these patients' difficulties was obtained by using a questionnaire containing open-response questions. The data obtained was then subjected to specific content analysis. The patients' clinical state, diagnosis and changes during therapy were also assessed, using various questionnaires. Our results show that there is a negative correlation between the number or range of difficulties attributed and noted by the clinician and the long-term evolution of the patient, especially after two years. This relationship is dependent on the number, not the type of difficulties noted. Thus, although it is not possible to generalize these results, we have shown that it is possible to study parameters involved in the process of a psychotherapeutic-type treatment, using a questionnaire. We have also shown that crisis intervention can be considered as an especially interesting analogue of the early steps of psychotherapy, spread over a longer period. This is an aspect which is rarely studied.

Quality of life assessment in therapeutic trials: rationale for and presentation of a more appropriate instrument

In therapeutic trials, quality of life studies are usually based on a health model which results in a restrictive view. Therefore, it is important to clearly define the concept of the quality of life, since ambiguous concepts can alter the results. The key to this problem is the clear distinction between the two components of the quality of life, ie subjective and objective. This latter component is the only one considered in the current medical approach. The use of the subjective quality of life introduces a number of methodological problems not found when the objective quality of life is assessed, and thus requires a specific model which can be derived from the model of life goals used by sociologists. This model is presented here and illustrated with some results obtained with a new questionnaire, the Subjective Quality of Life Profile (SQLP) questionnaire. We suggest that both subjective and objective quality of life studies should be considered in order to emphasize the humanistic approach to therapeutic indications.

[Research on psychotherapies. Methodology]

"Assessment" (of outcome and of factors of outcome) and "psychotherapy" are first defined. Although the aims of these surveys are deeply varying depending on their initiators (therapists or administrations), they share the same objects and the same methodological problems. This common problematic is specific, different from those prevailing for epidemiology or therapeutic trials; it also varies depending on the psychiatric and cultural background (for instance, depending on the side of the ocean). The choice of variables is discussed for objects (patients, families, therapists, institutions), sources (self and hetero-questionnaires) and exploratory levels (from symptoms to subjective quality of life). This leads to the choice of instruments, the interest of open ended questions and specific modalities of responses being emphasized. After a discussion of several methods of outcome assessment, the study of factors of change includes a comparison of the naturalistic and experimental approaches. Although these studies encounter some risks and limitations, they have an obvious clinical interest.

[The questionnaire "Profile of the subjective quality of life". First data of validation]

The questionnaire "Profile of the Subjective Quality of Life" (in french, PQVS) is devoted to the assessment of quality of life in therapeutic trials. On a sample of 588 subjects, factorial analysis confirm that it is not restricted to the assessment of the health, as most of the instruments actually available for that purpose. Its internal consistency is high. Correlations clearly show that its specific questions assessing the degrees of a) satisfaction and b) involvement (concerning each item) are clearly understood as having different meanings. Multiple regressions demonstrate that these specific questions strongly contribute to the explanation of the global quality of life or of the satisfaction concerning each item. Its reliability is good. It is very well accepted, and completed in no more than 15 to 30 minutes. This questionnaire is thus matching the criteria defining an effective assessment of the quality of life.

[Quality of life assessment in therapeutic trials. Conceptual aspects and presentation of a questionnaire]

The importance of assessing the quality of life is more and more emphasized when therapeutic effects are to be studied. However, if its theoretical bases appeared as rather well established, they are not yet effectively translated into the presently available instruments: there is not yet any "gold exchange standard" in this field. This fact is the result of the difficulty of this translation and of the medical tendency to reduce the assessment of the quality of life to the assessment of the health. The second part of this paper is thus devoted to the presentation of a new instrument ("PQVS" in french, or "QLPI" for "Quality of Life Profile Inventory"). It was devised for applying the theoretical bases of the study of the quality of life. It thus allows for the assessment: 1) of the quality of the global life, 2) of the quality of what is experienced in several dimensions of the life, and 3) of the individual structure of the quality of life.

ACTH regulation of adrenal mRNA coding for total and specific adrenal proteins

The effects in vivo ACTH administration on the synthesis of mRNA coding for total adrenal proteins and for protein E a specific marker of ACTH action, have been studied. After 4 h of in vivo ACTH treatment, protein E is one of the major translational products. Its electrophoretic characteristics in a 2D gel acrylamide system are defined (molecular mass = 36,000 daltons, pHi = 7). We have investigated the effects of ACTH on both poly(A)-RNA coding for total adrenal proteins, and non-poly(A)-RNA. The time course of these effects is different: the effect on mRNA is maximal at 48 h whereas the effect on non-poly(A)-RNA continues to increase until the end of the experiment (5 days). In vitro translocational assays of mRNA indicate that the highest efficiency (protein synthesis/microgram of mRNA) is observed after 4 h of ACTH treatment in vivo. After 5 days this efficiency is similar to that of mRNA extracted from non ACTH-treated rats.

Hormonal regulation of proteins secreted by cultured pig Sertoli cells: characterization by two-dimensional polyacrylamide gel electrophoresis

Using a primary culture of immature porcine Sertoli cells, we studied the effect of porcine FSH (pFSH), testosterone and retinoic acid on the labelled secreted protein. Cells were cultured in a chemically defined medium for 3 days and, on day 3, they were incubated for different times in another medium containing labelled amino acids either in the presence or absence of pFSH (50 ng/ml or 2 micrograms/ml), or testosterone (10(-6) M), or retinoic acid (10(-7) M), either alone or in several combinations. After 4 and 8 h of incubation, 20 and 30 secreted peptides were detected respectively by a two-dimensional polyacrylamide gel electrophoresis of the radiolabelled secreted proteins. During these 2 periods, the effect of pFSH was negligible. After 25 h, about 84 spots (pI in the range of 5-8) were identified on the autoradiograms. pFSH (2 micrograms/ml) induced an increase of 14 spots, and a decrease of 7, but at 50 ng/ml only 5 spots were increased and one decreased. Retinoic acid alone induced the increase of one peptide, while testosterone alone or in combination with pFSH (50 ng/ml) did not modify the electrophoretic pattern. When pig Sertoli cells were treated with retinoic acid, testosterone and pFSH (50 ng/ml), the effects on secreted proteins were higher than those induced by pFSH (50 ng/ml) alone.

FSH stimulation of cytosolic protein synthesis in cultured pig Sertoli cells

The effects of FSH on the cytosolic protein synthesis by a primary culture of immature porcine Sertoli cells were studied. Cells were cultured in a chemically-defined medium for 3 days and, on day 3, they were incubated for 40 h in another medium containing labelled amino-acids either in the presence or absence of 50 ng/ml porcine FSH (pFSH). In control cells, about 107 spots (pI in the range of 5 to 8) were identified by a two-dimensional polyacrylamide gel electrophoresis of the radiolabelled cytosolic proteins. pFSH treatment produced a marked increase of seven proteins whose molecular weights and isoelectric points are respectively comprised between 25 to 58 K and 5.5 to 5.8. In addition, pFSH treatment induced a slight but constant increase of two other proteins (mol. wt: 24 and 12 K and isoelectric point: 5.3).