Subjective assessments of the quality of life, well-being and self-efficacy in patients with schizophrenia
*Bun Chino, MD, PhD, Ginza Taimei Clinic, da Vinci Ginza Annex, 6-2-3, Ginza, Chuo, Tokyo 104-0061, Japan. Email: email@example.com
Aim: The present study examined three kinds of subjective assessment scales in the same patient group with schizophrenia to analyze the correlations among scores obtained in relation to the background data.
Method: Thirty-six patients with schizophrenia were examined with the 26-item short form of the World Health Organization Quality of Life (WHO-QOL 26), Subjective Well-being under Neuroleptic drug treatment: Short Japanese version (SWNS) and Self-Efficacy for Community Life scale (SECL) for subjective assessment scales, five kinds of neurocognitive tests, Positive and Negative Syndrome Scale (PANSS) for clinical symptom, Social Functioning Scale (SFS), and Global Assessment of Functioning (GAF) scale for social functioning.
Result: The scores for delusions (components of positive syndrome), anxiety and depression (components of general psychopathology) on the PANSS significantly correlated with QoL and subjective well-being scores. In contrast, the scores for components of negative syndrome were not correlated with the subjective assessment scores. Furthermore, none of the clinical symptom scores were correlated with the score in self-efficacy scale. The SFS and GAF scores were significantly correlated with the subjective assessment scores. There were significant correlations among the scores on the three subjective assessment scales.
Conclusion: Each scale has different features and should be utilized depending upon the expected effect of treatment or the purpose of assessment. The treatments provided to patients must be directed at improving both psychological and social impairments, in order to enhance the social functioning and QoL of patients.
SUBJECTIVE ASSESSMENTS, SUCH as of quality of life (QoL)1 are commonly used in the field of psychiatry. Evaluation of QoL has attracted attention since the 1970s in Western countries, and since the 1980s in Japan.2–4 At first, it was used only in treatment for physical ailments, such as in patients undergoing cancer surgery or receiving terminal care, in order to devise appropriate plans for clinical care and as an outcome parameter in health-care services. As for its use in the field of psychiatry, it was in the 1990s that it began to be used in research and clinical care for patients with schizophrenia.
As compared with patients with physical diseases, patients with mental disorders were regarded as being more difficult to assess. One of the reasons for this was because the concept of QoL was ambiguous, and direct comparison among studies was difficult. Another reason was that there was often an overlap between QoL items and psychological symptoms, and QoL by itself could not be assessed independently. In addition, there was the skepticism that patients with severe schizophrenia, in particular, could not be assessed precisely. Lehman et al. found that psychiatric symptoms (anxiety and depression) affected QoL assessments among patients with chronic conditions.5,6 Skantze et al. reported that outpatients with schizophrenia were able to complete self-report inventories, and were moreover able to participate in the interviews on QoL.7 Tomotake et al. suggested that subjective and objective QoL had different predictors and should be considered as separate and complementary outcome variables.8
With the development of atypical antipsychotic drugs and psychosocial treatment modalities, subjective assessments, such as QoL, have been in high demand in the field of clinical psychiatry. Psychiatric policies such as de-institution and community-care have supported use of subjective assessments.9,10 It is recommended that these new assessments should be commonly used for rehabilitation and treatment of patients with schizophrenia.
This study introduces three kinds of subjective assessments: QoL; subjective well-being; and self-efficacy. Subjective well-being is the major component of QoL. Awad defined subjective well-being as ‘changed subjective state after just a few doses of neuroleptic’,11 and Haan defined it more generally as ‘all experiences patients report, whether positive or negative, at the physical, emotional and cognitive levels related to treatment with antipsychotic medication’.12 Naber developed the Subjective Well-being under Neuroleptic Treatment (SWN) scale to compare patient's subjective perceptions of conventional and atypical antipsychotic agents.13
Self-efficacy is the belief that one has the ability to perform a certain task or exhibit a certain behavior. Bandura suggested that decisions to enact most human behaviors depended on beliefs about self-efficacy, which mediates the relationship between coping skills and successful emotional adjustment.14 Lieberman et al. developed the theoretical model that self-efficacy determined the coping effort and psychosocial functioning.15 Ventura et al. indicated that self-efficacy and neurocognition, especially sustained attention, might underlie problem-focused coping.16
Whereas the three kinds of subjective assessment concepts, namely, QoL, subjective well-being and self-efficacy, have been well studied and documented, no studies have been conducted to compare the differences in results of assessment using the three scales in the same patient group, or to explore the validity of underlying concepts. Moreover, the interpretation of relationships between subjective assessment scores and cognitive functions is controversial. Fujii et al. indicated that neurocognition was the predictor of QoL in patients with schizophrenia.17 In contrast, Hofer et al. reported that although cognitive function was the predictor of social functioning, it did not reliably predict the QoL in patients with schizophrenia.18,19
The aim of the present study was to examine correlations among the three kinds of subjective assessments and patient background, cognitive function, clinical symptoms and social functioning in patients with schizophrenia. We then discuss the uniqueness and characteristics of each of these assessments.
The subjects consisted of 36 patients (21 male, 15 female) with schizophrenia. The mean age was 28.0 ± 5.0 years and the duration of illness was 5.5 ± 3.9 years. All were right-handed and none had any history of head injury or serious medical disease. They were diagnosed by trained psychiatrists using ICD-10 criteria20 and were under treatment with antipsychotics, with the mean chlorpromazine-equivalent dose of 317.8 mg/day. The clinical symptoms were measured using the Positive and Negative Syndrome Scale (PANSS),21 in which the scores for components of positive syndrome were low (12.3 ± 3.1) and those for components of negative syndrome were not so high (19.8 ± 4.4) compared to patients with chronic schizophrenia. The scores on Social Functioning Scale (SFS)22,23 and Global Assessment of Functioning (GAF) scale24 were relatively high (SFS, 118.2 ± 24.0; GAF, 62.1 ± 7.9). All the subjects provided verbal as well as written consent for participation in this research.
World Health Organization Quality of Life scale
The 26-item short form of the World Health Organization Quality of Life scale (WHO-QOL 26) is the brief version of the WHO-QOL 100, which was developed to assess subjects around the world, regardless of culture or civilization.25,26 It consists of 26 items that are classified into five domains: physical domain, psychological domain, social relationship, environment domain, and general QoL.
Subjective Well-being under Neuroleptic drug treatment: Short Japanese version
The Subjective Well-being under Neuroleptic drug treatment: Short Japanese version (SWNS) is used to assess the subjective cognition and affect of patients with schizophrenia who are under treatment with antipsychotics.13,27 The short version consists of 20 items that are classified into five categories: mental functioning, self control, emotional regulation, physical functioning and social integration.
Self-Efficacy for Community Life scale
The Self-Efficacy for Community Life scale (SECL) is used to assess the self-efficacy of patients with schizophrenia living in the community.28 It consists of 18 items that are classified into five domains, as follows: daily living, behavior in relation to treatment, behavior in relation to symptoms, social life, and interpersonal relation.
Mini-Mental State Examination
The Mini-Mental State Examination (MMSE) is the screening test used to assess general cognitive impairment, and consists of six domains of orientation, registration, attention, calculation, recall and language.29
Rey Auditory Verbal Learning Test
The Rey Auditory Verbal Learning Test (RAVLT) is the memory test in which subjects are asked to listen to a list of 15 common words and repeat as many of these words as they can remember, in any order.30 This procedure is repeated four times. Then, an examiner asks the subjects to listen to another list of 15 common words and to repeat as many of these words as possible once only. The examiner then asks the subjects to recall as many words as possible again from the previous list of words.
Letter-Cancellation Test (LCT) is the attention test conducted using rows of letters randomly interspersed with the designated target letter.31 Subjects are instructed to cross out all the target letters. Performance is scored according to the number of correct responses and the time taken to complete the test.
Letter and Category Fluency Test
In the Letter and Category Fluency Test subjects are asked to say as many words beginning with a given kana (syllable), ‘shi’, ‘i’, ‘re’, as they can, for Letter Fluency test, and the names of animals, fruits, and transportations for the Category Fluency test within 60 s.32 These tests are more useful to assess elemental fluency as compared with the Optional Thinking Test (OTT).
Optional Thinking Test
The OTT is one kind of fluency test that requires subjects to conceptualize options or alternatives to hypothetical, but typical real-life problems.33 We translated this test version into Japanese with the permission of the original authors and used it to examine patients with schizophrenia and normal control subjects. High inter-rater reliability and validity were also confirmed.34
Statistical analyses were performed using Statcel2 (OMS Publishing, Saitama, Japan). Spearman rank correlation was calculated to evaluate the association between subjective assessments and neurocognition/symptoms/global functioning. For each comparison, P < 0.05 was considered to be statistically significant without any consideration for multiple comparisons.
The schizophrenia patients scored poorly on the subjective assessment scales (Table 1) and neurocognitive tests (Table 2. Patient background and neurocognitive test results were not correlated with any subjective assessment scores. In contrast, the scores for clinical symptoms (Table 3) were inversely correlated with the subjective assessment scores. In particular, the score for delusion 2.2 ± 0.5 (component of positive syndrome 12.3 ± 3.1), anxiety 2.2 ± 0.7 and depression 1.7 ± 0.8 (general psychopathology 33.4 ± 6.0) were correlated with the scores on WHO-QOL 26 and SWNS. In contrast, there were no significant correlations between the scores for negative syndrome and the subjective assessment scores.
Table 1. Subjective assessment scores
|WHO-QOL 26||3.0 ± 0.6||1.5–4.1|
|SWNS||73.3 ± 16.3||37–104|
|SECL||114.1 ± 34.0||20–178|
Table 2. Cognitive function scores
|Mini-Mental State Examination||29.4 ± 0.7||28–30|
|Rey Auditory Verbal Learning Test||11.7 ± 2.4||6–15|
|Letter Cancellation Test (correct responses)||110.5 ± 4.1||96–114|
|Letter Cancellation Test (time)||110.5 ± 24.7||75–150|
|Letter Fluency Test||22.7 ± 7.8||6–41|
|Category Fluency Test||31.7 ± 6.7||18–48|
|Optional Thinking Test (total score)||14.0 ± 6.2||5–27|
Table 3. Correlation between PANSS and subjective assessment in schizophrenia patients
|PANSS Positive syndrome||−0.39*||−0.37*||−0.16|
| Conceptual disorganization||0.0009||−0.14*||−0.05|
| Hallucinatory behavior||0.03||−0.09||0.08|
|PANSS Negative syndrome||−0.06||−0.06||−0.05|
| Blunted affect||0.24||0.22||0.18|
| Emotional withdrawal||0.12||0.13||0.07|
| Poor rapport||0.17||0.18||0.17|
| Passive/Apathetic social withdrawal||−0.14||−0.11||−0.18|
| Difficulty in abstract thinking||0.10||0.06||0.06|
| Lack of spontaneity and flow of conversation||0.18||0.09||0.03|
| Stereotyped thinking||−0.18*||−0.14||−0.09|
|PANSS General psychopathology||−0.43*||−0.49**||−0.28|
| Somatic concern||−0.35**||−0.30*||−0.32*|
| Guilt feeling||0.12||0.08||0.20|
| Mannerisms and posturing||0.27||0.11||0.09|
| Motor retardation||−0.02||0.03||−0.06|
| Unusual thought content||−0.19*||−0.24*||−0.07|
| Poor attention||−0.12||−0.25*||−0.16|
| Lack of judgment and insight||0.001||−0.05||0.09|
| Disturbance of volition||−0.15||−0.21*||−0.21|
| Poor impulse control||−0.01||−0.06||0.16|
| Active social avoidance||−0.22||−0.25*||−0.26*|
The SFS and GAF scores (Table 4) were significantly correlated with subjective assessment scores. There were significant correlations among the scores in three subjective assessment scales (WHO-QOL 26 and SWNS, 0.80; WHO-QOL and SECL, 0.62; and SWNS and SECL, 0.70).
Table 4. Correlations between SFS, GAF and subjective assessments in schizophrenia patients
|Social Functioning Scale|| || || || |
| Withdrawal||10.4 ± 2.3||0.58**||0.68**||0.48**|
| Interpersonal||6.8 ± 2.5||0.44*||0.22||0.44*|
| Independence||23.3 ± 6.7||0.22||0.09||0.38*|
| Recreation||20.0 ± 6.8||0.40*||0.29||0.33|
| Pro-Social||15.2 ± 8.9||0.50**||0.22||0.51**|
| Independence||36.5 ± 2.6||0.56*||0.40*||0.63**|
| Employment||6.0 ± 3.2||0.44*||0.37*||0.42*|
| Total||118.2 ± 24.0||0.52**||0.30||0.55**|
|GAF||62.1 ± 7.9||0.53**||0.48**||0.50**|
All the schizophrenia patients who participated in this study were outpatients who were younger than 40 years of age and were psychologically stable. The inclusion criteria eliminated the influence of long duration of illness and of treatment with high doses of antipsychotics. The mean GAF score of these patients was >61, indicating that none of the patients had severe symptoms or difficulties in their life, and that therefore their global functions were reasonably preserved. The present results, however, showed that the schizophrenia patients had poor QoL and cognitive deficits. The QoL scores and cognitive function in the schizophrenia patients were generally low compared with those of the normal controls. This was consistent with previous reports of lower QoL scores in schizophrenia patients than in normal controls and patients with other mental disorders.35
The scores on QoL and other subjective assessment scales were not correlated with patient background. Previous studies showed that patient background significantly affected QoL. According to several studies, young female and married patients exhibited better QoL scores.36,37 Although marital status was not checked, the sex and age of the patients were considered in the present study. There were no significant differences in the subjective assessment scores between male and female patients. As for age, all the patients were under 40 years old. This is one of the limitations of the present study and different results might be obtained in different age groups.
In addition, there were no correlations between neurocognitive test results and subjective assessment scores in the present study. Several studies have indicated that neurocognitive deficits affected subjective assessment scores. Fujii et al. indicated that neuropsychological parameters, including verbal memory, vocabulary, Digit Span, MMSE, and executive function, might be predictors of QoL in patients with schizophrenia.17 In contrast, Lysaker et al. reported that poorer verbal memory, an executive function, was predictive of higher scores for hope and well-being.38 Prouteau et al. reported that worse baseline attention predicted better QoL.39 These paradoxical results may be explained by the contention that schizophrenia patients with neurocognitive deficits are unable to recognize their social condition as undesirable; in other words, neurocognitive deficits may shield patients with schizophrenia from the feeling of hopelessness that might accompany more realistic and accurate recognition of one's life condition. No consensus has been established as yet and the results may vary depending on the conditions of subjects. The present study did not find any correlation between neurocognitive test results and subjective assessment scores. The present patients were young and their symptoms were mild. This is also a limitation of the present study. The old or severe symptom patients might show different results. The next study should analyze patient background and conditions.
The clinical symptom scores in the present study were significantly correlated with the subjective assessment scores. Associations between depression, anxiety (PANSS General Psychopathology) and QoL have been noted several times. Karow et al. insisted that anxiety was the most important symptom and it should be reduced in order to improve QoL.40 Lehman et al. and Dickerson et al. indicated that depression was one of the symptomatic factors affecting QoL.5,6,41 Consistent with previous reports, psychotic symptoms, delusion and excitement, as components of positive syndrome, were correlated with the subjective assessment scores.42 In contrast, and not consistent with previous reports,43 the scores for components of negative syndrome were not correlated with any of the subjective assessment scores. Green et al. suggested that cognitive and negative symptoms affected social functioning, leading to satisfaction in patients.44 Patients in the present study were relatively young and their negative symptoms were not serious. Thus, the results might differ in old or severe symptom patients as well.
Regarding social functioning, the score for withdrawal, in particular, was significantly correlated with the subjective assessment scores. Similarly, a significant correlation was also found with GAF score. This implies that social functioning or activity contributes significantly to the levels of satisfaction in patients. Furthermore, psychological symptoms also act as background factors. Aki et al. indicated that depressive symptoms predicted subjective QoL, negative symptoms predicted objective QoL, and each of them predicted the level of social skills.45 Therefore, patients should be treated psychologically and socially at the same time in order to improve social functioning and QoL.
Finally, there were significant correlations among the scores in these subjective assessment scales. Although all were self-reporting questionnaires about feeling or cognition in daily life, there were slight differences. The score on WHO-QOL 26 was significantly correlated with both the scores on PANSS and SFS. The SWNS score was significantly correlated with that on the PANSS, but not with the SFS score. And the SECL score was significantly correlated with the SFS score but not the PANSS score. SWNS is used to assess subjective cognition and affect of patients with schizophrenia who are on antipsychotics, and it was developed to examine the effect of drug treatment. SECL is used to assess the self-efficacy of patients with schizophrenia who live in the community and it was developed to examine psychoeducation. Although SWNS assesses the psychological and subjective aspects, SECL assesses social and objective aspects in greater detail. Consequently, each scale should be utilized depending upon the effect of treatment and the objectives of assessment.
In conclusion, patient background and neurocognitive test results were not correlated with subjective assessment scores in the present study. In contrast, the scores for clinical symptoms such as depression or social withdrawal were correlated with scores for social functioning and the subjective assessment scores. The scores for social functioning were also correlated with the subjective assessment scores. Thus, the treatment provided to patients must be directed at improving both psychological and social impairments, in order to enhance social functioning and QoL.