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Aim: This study explored the associations of personal, disease, family, and social factors with quality of life (QoL) in patients with two common types of chronic mental illness (CMI) living in Kaohsiung City, Taiwan.
Methods: Using a convenience sample and a cross-sectional design, 714 patients (50.1% male, 49.9% female) with CMI (72.1% schizophrenia and 27.9% affective disorder) and their caregivers were recruited. Demographic information was collected via the following questionnaires: 12-Item Short-Form Health Survey (SF-12), five-item Brief Symptom Rating Scale (BSRS-5), Caregiver Burden Scale, and Clinical Global Impressions (CGI-S) Scale. Pearson correlations and hierarchical regression analyses were used to predict QoL.
Results: Disease factors accounted for 17–50% of the change in variance. Predictors of low mental subscale scores included the following: high psychological distress and high family burden as well as a history of suicide attempts, negative caregiver attitudes, and living away from home. Disease factors also explained the greatest variance in the physical subscales. Predictors of low physical subscale scores included the following: high psychological distress, age, unemployment, a history of suicide attempts, high family burden, and living alone.
Conclusions: Disease factors were the most important predictors of QoL in patients with CMI. Family factors were more important than social factors on the mental subscales. Differential relationships were also found for the other two dimensions. Together, these results indicate that a wide range of factors improve the QoL in patients with CMI.
SINCE SHIFTING FROM a focus on improving symptoms to a holistic view of psychiatric illness, research on quality of life (QoL) issues in patients with chronic mental illness (CMI) has received increasing attention. QoL assessment in patients with poor mental health is particularly important because the QoL in psychiatric patients is consistently worse compared to patients with physical diseases and the general population.1,2
Marwaha et al. found that age and education both negatively affect QoL in outpatients with schizophrenia.3 Interestingly, employed outpatients reported higher QoL than those who were unemployed.3,4 Ruesch et al. also found that employed outpatients reported higher subjective QoL, even after controlling for illness characteristics such as diagnosis and psychopathology.5 Generally, certain demographic variables influence QoL in people with mental illness,2 although some studies produced contrasting results due to methodological differences (e.g. sampling and tools used).6
Studies on the impacts of clinical variables have shown that psychiatric symptoms have effects on overall QoL and daily living activities. These studies suggested that psychiatric symptoms (including both positive and negative symptoms) are negatively related to patient-rated QoL.3,7 When psychiatric symptoms are ameliorated, QoL improves.8 Depression symptoms are consistently and strongly related to self-rated QoL.9,10 Morcillo et al. found that the longer the illness duration of outpatients with schizophrenia, the worse they rated their QoL.11 Evidence suggests that substance abuse negatively affects both psychiatric symptom severity and QoL in people with severe mental illness.12 Substance abuse and psychiatric comorbidity are associated with lower QoL in participants in substance abuse treatment and those in psychiatric treatment.13
According to the Taiwan Ministry of the Interior, there were 100 045 people diagnosed with CMI, defined as illness duration of a minimum of 2 years, in Taiwan in 2008. Of these, 7381 were in Kaohsiung City, the second largest city in Taiwan (Ministry of the Interior, unpubl. data, 2008). The majority of Taiwanese patients with CMI are cared for at home by their family. This is consistent with Taiwanese culture wherein traditional Confucian ideas and ideals promote a particular way of caring for loved ones. Some researchers, however, have argued that the act of caregiving may negatively affect the caregiver.14 Family relationships are considered one of the major factors that influence QoL in psychiatric patients. The study by Halford et al. on QoL, family relationships, and attitudes towards care found that the positive expression of emotion in families significantly predicted fewer negative symptoms and a higher QoL for patients after discharge.15 Additionally, negative family relationships predicted rehospitalization.16
Patients with CMI typically report a lower QoL, and those who are homeless report even lower levels compared to those who have homes.17 In addition, Fitzgerald et al. showed that QoL was significantly and positively correlated with social function variables, such as living conditions.9 QoL scores are higher in communal patients compared to those living alone.18
According to the aforementioned literature, many factors affect QoL in patients with CMI, which makes comparing the results of different studies difficult. In addition, although de-institutionalization began in Taiwan many years ago, few studies have examined the QoL of these psychiatric patients.19 QoL is a culture-sensitive construct; therefore, conclusions drawn from Western studies20 cannot necessarily be generalized to Chinese populations. In the current study, we hypothesized that four dimensions or factors (e.g. personal/demographic, disease, family, and social) would affect the QoL of patients with CMI. This study explored the associations between these four dimensions and QoL as well as their ability to predict the QoL of patients with CMI living in Kaohsiung City, Taiwan.
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The objective of the present study was to ascertain the extent to which personal, disease, family and social factors influence the QoL of patients with CMI in Kaohsiung City. The results show that the disease factor explained the most variance in patient QoL, accounting for 15–50% of its variance. Furthermore, the family factor accounted for a 2–10% variance change across all mental subscales as well as RP. The social factor accounted for 4% of the variance change in GH and 3% of the variance change in VT. The personal factor, which did not account for a significant amount of the variance in MCS or the other mental subscales, accounted for 7% of the variance change in GH.
Most of the variables used in this study had a modest correlation with patient QoL. After we entered all of the variables into the model in their specified order, only a few variables remained in the final model with a relationship to overall QoL. If patients with CMI had high psychological distress, had a history of suicide attempts, placed a high burden on their family or did not live in their own home, their mental QoL was low. Additionally, if patients with CMI were older, unemployed, lived alone, had a high amount of psychological distress, had attempted suicide or placed a high burden on their family, they rated their physical QoL as low.
Psychological distress, as measured by BSRS-5, was the strongest negative predictor of both mental and physical QoL subscales in patients with CMI. This result is consistent with the literature10 and supports the finding of Pukrop et al. that current mood influences self-assessed QoL.30 A history of suicide attempts also strongly predicts lower PCS subscale and MH scores. This finding supports the studies in which a history of suicide attempts was negatively correlated with QoL in patients with schizophrenia,30 despite the fact that suicide and QoL are both sensitive to culture effects.
Placing a high burden on their family predicted a lower QoL in patients with CMI on all mental subscales and RP. Caregiver burden was positively related to the family's care attitude. This result is in concordance with Halford et al.15 This result also suggests that not only do exclusive family care attitudes lower patient QoL, they also increase caregiver burden. Conversely, families who accept and demonstrate inclusive care attitudes have less caregiver burden and higher patient QoL.
Living in one's own home positively predicted mental subscale scores, whereas living alone negatively predicted physical subscale scores. As in other studies, housing stability is positively related to QoL.17 The present study also confirmed the Kilian et al. result that the QoL of patients (either medical or psychiatric) who live with others is higher compared to those living alone.18
Many studies have indicated that psychiatric symptoms significantly affect overall QoL and daily living activities.3,7 Some studies have suggested that psychiatric symptoms have weak or non-existent correlations with QoL ratings.31 The present study did not find that the overall severity of psychiatric illness (as measured by CGI-S scores) had a significant effect on patient QoL. The discrepancy between the literature and the present findings might be partly due to differences in the sources of the participants. Because the present patients lived in communities during a stable phase of their illness, their CGI-S scores were mostly mild or borderline. The present study used a simple method (CGI-S) to evaluate the severity of psychiatric illness, whereas specific instruments measured this construct in other studies. Thus, the present results are difficult to compare with others, which is a weakness of this study. Certain personal variables (e.g. education level,32 marital status,3 and sex2) influence QoL in people with mental illness, but we did not observe that these variables were relevant to QoL in the current results.
This study confirms that disease factors explain the most variance in the QoL of patients with CMI and highlights that family factors are more important than social factors with regard to mental subscale scores. In addition, the only positive predictor was living in one's own home. Age, a history of suicide attempts, family burden and living alone negatively predicted PCS and the other physical subscale scores, whereas employment and a history of violence positively predicted these variables.
Current Taiwanese government policy on mental welfare payments is still to focus on individual patients, and a focus on family-centered or family support services is lacking. Therefore, to improve QoL for patients with CMI in Taiwan, the government should consider changing its care policy to make welfare benefits or health insurance more family-centered. Providing a living allowance, providing services to relieve families of physical and mental burdens, promoting family education programs to strengthen the family's understanding of disease and their communication skills could improve the relationships and increase the family's willingness to take care of patients in their homes, in turn, improving the QoL among patients with CMI.
This study is limited by its cross-sectional design, which does not allow the establishment of causal relationships between independent variables and QoL. Although medical compliance was assessed by the counselors, we did not include medication in variables, therefore medication-induced bias could not be ruled out. In addition, because we sampled patients from one specific city, the present results may not be able to be generalized to patients with CMI in other areas of Taiwan.