Psychiatric Rehabilitation Journal

219

Psychiatric Rehabilitation Journal

2007, Volume 30, No. 3, 219–222 Copyright 2007 Trustees of Boston University

DOI: 10.2975/30.3.2007.219.222

Brief report

Quality of Life for Persons Living with Schizophrenia:

More Than Just Symptoms

t

Shaun M. Eack, Christina E. Newhill, Carol M. Anderson

and Armando J. Rotondi

University of Pittsburgh Quality of life is an important outcome for persons living with schizophrenia and for

the treatment of schizophrenia. However, studies of quality of life among persons

living with schizophrenia have focused primarily on the symptoms experienced by

the individual. This study sought to determine the influence of unmet need and social

support on the quality of life of individuals with schizophrenia. Thirty-two persons

living in the community with schizophrenia or schizoaffective disorder were assessed

on quality of life, psychopathology, unmet need and social support. Hierarchical

regression analyses indicated that unmet need and social support are important

contributors to the quality of life of a person with schizophrenia, even after control-

ling for symptoms. Implications for schizophrenia treatment are discussed.

Keywords: schizophrenia, quality of life, recovery, functional outcome

Schizophrenia is a psychiatric dis- ability that presents a range of chal- lenges for those with the illness and their families. With advances in neu- roleptic and psychosocial interven- tions, treatments have expanded beyond simply reducing the symptoms associated with schizophrenia. Treatments today increasingly focus on improving quality of life, which can be broadly conceptualized as 1) objective quality of life, or a person’s health sta- tus and access to resources and op- portunities, and 2) subjective quality of life, or a person’s sense of well- being and satisfaction with life (Lehman, 1988). This emphasis has ne- cessitated the elucidation of factors

that affect quality of life for persons with schizophrenia. To date, most re- search on the determinants of quality of life in schizophrenia has focused on the impact of psychiatric symptoms, and indicated that anxiety and depres- sive symptoms, in particular, have an important negative impact on quality of life (see Lambert & Naber, 2004 for review). Unfortunately, investigations into the psychosocial influences of quality of life have been sparse, which has narrowed treatment development efforts and provided a limited picture with regard to the quality of life indi- viduals with schizophrenia can attain, as if control of symptoms is the most that can be expected.

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Psychiatric Rehabilitation Journal Quality of Life for Persons Living with Schizophrenia

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The studies that have investigated the role of factors other than psychiatric symptoms in the quality of life of indi- viduals with schizophrenia have sug- gested that both social support and the meeting of basic needs (e.g., housing) have an important positive impact on quality of life (e.g., Becker, Leese, Krumm, Ruggeri, & Vazquez-Barquero, 2005; Ritsner, 2003). For example, a re- cent study found that improvement in social support was a significant predic- tor of improved quality of life among individuals with schizophrenia living on inpatient units (Ritsner, 2003). While compelling, these studies have primarily relied on subjective measure- ment strategies and focused largely on persons residing on inpatient units. This is limiting because different fac- tors may influence the quality of life of individuals living in community set- tings, and individuals with schizophre- nia may throttle their expectations for quality of life, such that subjective evaluations are inflated compared to objective life circumstances (Katschnig, 1997). As such, it is neces- sary to examine the influence of social support and unmet need on subjective and objective quality of life among in- dividuals living in the community. To date, the importance of these factors, above and beyond symptoms, to indi- viduals residing in community settings is largely unknown. Such information is vital to guiding the development of community-based interventions for en- hancing quality of life among individu- als with schizophrenia.

Method

This research was conducted as part of a clinical trial of a novel online psy- choeducation program for individuals with schizophrenia and their families. Participants included 32 individuals

with schizophrenia/schizoaffective dis- order, confirmed by the Structured Clinical Interview for DSM-IV. As can be seen in Table 1, participants were all adults, predominantly female, racially diverse, and most were not employed.

Quality of life was assessed using the brief version of the Lehman Quality of Life Interview (Lehman, 1988; QOLI), a reliable and valid measure of quality of life for persons with psychiatric disabil- ity. Because of the comprehensiveness of the QOLI and its large number of subscales, we computed composite in- dexes of both objective and subjective

quality of life, by averaging across the various objective and subjective sub- scales.1 The objective quality of life composite included participation in leisure and daily living activities, ade- quacy of financial resources, and fre- quency of different social and familial contacts. The subjective composite in- cluded general well-being, and satis- faction with one’s familial and non-familial relations, health and safe- ty, finances and employment, living sit- uation, and leisure and daily living activities. The reliability of these com- posites were within acceptable ranges

Table 1—Sample Demographic and Clinical Characteristics

Measure n (%)

Gender (female) 21 (66%)

Mean (SD) Age 37.84 (10.65)

Race (Caucasian) 15 (47%)

Marital Status (married) 6 (19%)

Education (high-school or above) 26 (81%)

Employed 2 (6%)

Mean (SD) Age at Diagnosis 24.74 (9.23)

Mean (SD) BPRS Total 31.34 (8.26)

Mean (SD) Needs Met 3.30 (.49)

Mean (SD) Perceive Social Support 1.81 (.78)

Mean (SD) Subjective Quality of Lifea 4.22 (.72)

Mean (SD) Objective Quality of Life

Daily Activitiesb 3.06 (1.44)

Financial Adequacyc 3.88 (1.62)

Social Relationsd 3.50 (.82)

Family Relationsd 4.05 (.94)

Note. BPRS = Brief Psychiatric Rating Scale

a Subjective items are rated on a scale between 1 “terrible” and 7 “delighted,” with higher scores reflecting better quality of life.

b Subscale ranges from 0 to 6, with higher scores reflecting more involvement in activities of daily living and leisure.

c Subscale ranges from 0 to 5, with higher scores reflecting greater financial adequacy.

d Items are rated on a scale between 1 “not at all” to 5 “daily,” with higher scores reflecting more social and family involvement.

1 The objective composite excluded the items “time spent reading a book and going for a ride,” and money spent on self/month, employment status, victimization, and arrest history subscales due to low reliability or variability.

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symptoms, of unmet need and social support on quality of life, by removing shared variance between the BPRS and QOLI prior to examining the influence of these factors. Results indicated that neither demographic characteristics nor psychiatric symptoms were signifi- cantly related to objective quality of life, R2 = .04, F (1, 27) = .48, ns. Further, unmet need and perceived so- cial support also did not explain a sig- nificant amount of variance in objective quality of life, beyond symptoms (DR2

= .16, F (2, 25) = 2.48, p = .10), with so- cial support (b = .36, sr2 = .10, p = .09) having a marginal, non-significant con- tribution, and unmet need making no significant contribution (b = .16, ns). When examining the influences of sub- jective quality of life, psychiatric symp- toms did have a substantial negative influence on quality of life, R2 = .17, F (1, 27) = 6.28, p < .05. However, both fewer unmet needs (b = .34, sr2 = .09, p < .05) and greater perceived social support (b = .37, sr2 = .11, p < .05) were also significantly related to better qual- ity of life, and continued to explain over 25% of the variance in subjective quality of life above and beyond symp- toms, DR2 = .27, F (2, 25) = 7.50, p < .01. Such findings highlight the importance not only of symptoms, but also unmet need and social support to the quality of life of persons with schizophrenia.

Discussion

As newer medications are developed and control of the most troublesome symptoms of schizophrenia becomes a reality for most individuals, quality of life is emerging as an important treat- ment outcome. Most quality of life re- search has focused on the influence of symptoms, and research investigating other factors has been limited to sub- jective evaluations by persons residing on inpatient units. The findings from this study make an important contribu-

(range of a = .70 to .87). Perceived so- cial support was assessed with the self-report emotional/informational support subscale of Medical Out- comes Study Social Support Survey (Sherbourne & Stewart, 1991). Psychiatric symptoms experienced by individuals with schizophrenia were assessed using the expanded version of the Brief Psychiatric Rating Scale (BPRS; Lukoff, Liberman, & Nuechter- lein, 1986). Both of these instruments have well-documented reliability and validity. Unmet need was assessed using a 36-item self-report scale asking participants to rate between 1 (“not at all”) and 5 (“extremely well”), how well various basic and illness-related needs were being met (Rotondi, Eack, Newhill, & Anderson, 2006). Needs ranged from basic needs related to fi- nances and transportation, to needs surrounding information about schizo- phrenia and its treatment, to needs related to building friendships and community integration. We found the reliability of this instrument to be good (a = .83).

Participants were recruited by staff re- ferral from community clinics (n = 27) and acute inpatient units (n = 5) in a large urban area in an eastern state, and interviewed using the aforemen- tioned instruments. Participants were recruited if they had a diagnosis of schizophrenia/schizoaffective disor- der, were 14 years or older, and had at least one psychiatric hospitalization within the past 2 years. This study was approved by the University of Pittsburgh Institutional Review Board, and all participants gave written in- formed consent prior to participation.

Results

A series of hierarchical regression analyses, controlling for age, race, and gender effects, were conducted to ex- amine the influence, above and beyond

tion to the existing literature by demonstrating the importance of unmet need and perceived social sup- port to the subjective quality of life of individuals living in the community with this disability. Although this study is limited by its cross-sectional design and small sample size, which may re- strict the representativeness of our sample and generalizability of these results, these findings do provide fur- ther evidence that community-based interventions designed to improve quality of life should encompass both treatment to reduce the symptoms ex- perienced by individuals with schizo- phrenia, along with interventions designed to enhance social support and address unmet needs, such as basic financial needs and the need for information about the illness. For psy- chosocial rehabilitation researchers, these findings are not surprising. In fact, an understanding of the impor- tance of unmet need and social sup- port has been the impetus for the development of many of the psychoso- cial rehabilitation services that exist today, yet research on quality of life seems to have neglected these factors. Furthermore, community treatment continues to consist primarily of pro- phylactic antipsychotic medication and little, if any evidence-based psycho- social interventions. This research sug- gests that if we want to help individu- als with schizophrenia lead full and satisfying lives, treatment developers need to attend to the psychosocial in- fluences of quality of life, and substan- tial work needs to be done to ensure these interventions reach persons in the community, as these interventions are the most likely to satisfy unmet needs and enhance social support, and therefore improve the quality of life of the many individuals living in the com- munity who experience this disability.

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