|Year : 2012 | Volume
| Issue : 2 | Page : 104-108
Association of psychopathology with quality of life in acute phase of schizophrenia; an experience from east India
Suravi Patra1, Ajaya Mishra2
1 Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
2 Department of Psychiatry, Mental Health Institute, S.C.B. Medical College, Cuttack, Orissa, India
|Date of Web Publication||9-Oct-2013|
Department of Psychiatry, Government Medical College and Hospital, Chandigarh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: To find the association of patient characteristic and psychopathology with quality of life in acute phase of schizophrenia. Materials and Methods: Socio-demographic variables of patient, psychopathology and quality of life were assessed. Spearman's Correlation coefficients were measured using SPSS version 15.0. Results: Quality of life of the patients varied in different domains. Male gender, unmarried status and higher educational status predicted a poorer quality of life. The domains of physical and psychological well-being of WHO-QOL were correlated with PANSS general and total scores whereas environmental and social health showed no correlation with PANSS scores. Conclusion: Domains of subjective quality of life in acute phase of schizophrenia are associated variedly with socio-demographic variables and symptomatology.
Keywords: Psychopathology, quality of life, schizophrenia
|How to cite this article:|
Patra S, Mishra A. Association of psychopathology with quality of life in acute phase of schizophrenia; an experience from east India. Ind Psychiatry J 2012;21:104-8
Schizophrenia is a severe, chronic and incapacitating mental illness with devastating impact on personal life and social functioning. Current treatment guidelines for schizophrenia emphasize on improvement in adaptive and social functioning, maximizing quality of life (QOL), and prevention of relapse in addition to symptomatic recovery.
QOL is a construct, which includes aspects of an individual's well-being and role functioning and the extent to which he or she has access to resources and opportunities.  World Health Organization (WHO) defines QOL as "an individual's perception of life in the context and value system in which he lives and in relation to his goals, expectations, standards and concerns." While QOL has been defined in different ways; it has been accepted as an important treatment outcome measure in major mental disorders. 
Assessment of QOL remains controversial in patients with schizophrenia owing to presence of psychotic symptoms, cognitive dysfunction as well as impairment of insight. Research has established that measurement of QOL is reliable in patients with psychosis and subjective measurement acceptable both in terms of reliability and consistency. , Research carried out in the Indian setting has demonstrated that subjective QOL can substitute for objective QOL in patients with schizophrenia. 
Primary determinants of QOL include; safety, employment, financial support, family, and social relations. These determinants vary depending on subjective or objective criteria used.  Sense of self, satisfaction with daily activities and activity levels contribute significantly towards subjective perception of QOL in patients with schizophrenia. 
Psychopathology, medication induced side-effects and psychosocial functioning are malleable determinants of QOL whereas non-malleable determinants include: Socio-2demographic factors and certain trait characteristics like acceptance of illness, expectation from life, etc. Changes in self-efficacy, self-esteem and support from others are positively correlated with improvement in domain specific QOL in longitudinal studies of schizophrenia. , Depressive and negative symptoms and specific personality traits which determine social integration and social interactions are also important predictors. Recognition and management of determinants of QOL would help in improving affected domains of QOL. This would help in improving patient's outcome.
| Materials and Methods|| |
Patients presenting to the out-patient department of psychiatry, S.C.B. Medical College, Cuttack from July 2006 to June 2007, diagnosed as schizophrenia using International Classification of Diseases 10, Clinical Descriptions and Diagnostic Guidelines, (ICD-10 criteria) and were in the acute phase were enrolled into the study.  Patients fulfilling the diagnostic criteria and who gave informed consent and were in the age group of 18-58 formed the study subjects. Patients having co-morbid substance dependence, chronic medical illnesses, mental retardation or organic brain diseases formed the exclusion criteria.
- Modified Kuppuswamy Scale:  This scale is based on scoring obtained in three domains: (i) occupation of the head, (ii) education of the head and (iii) family income per month. Based on the total score obtained, socio economic status is classified into lower (<5), upper-lower (5-10), lower-middle (11-15) upper middle (16-25) and upper (26-29)
- Positive and Negative Syndrome Scale (PANSS) (Kay et al. 1987)  Derived originally from the Brief Psychiatric Rating Scale (BPRS) scale, PANSS has 7 items each for positive and negative symptoms and 16 items for measuring general psychopathology. All the 30 items are given a score; from 1 (complete absence of symptoms) to 7 (extreme severity of symptoms) and
- World Health Organisation Quality of Life Scale_ Brief version (WHOQOL-BREF  (Oriya version) formed the study tools to collect individual patient information. WHO-QOL-BREF is based on 4-domain structure with six items in physical, psychological, social and environmental domain and two items from overall QOL and general health. It is a likert-type scale with ratings done from 1 to5. The instrument was translated into Oriya and after a series of translations and back-translations; Oriya version was used after equivalence was established.
Ethical approval was taken from the research committee of the institution.
The data was entered into MS Excel Spreadsheet. Descriptive statistics was used and Spearman's correlation coefficient was calculated using SPSS version 15.0.
| Results|| |
A total of 34 patients were enrolled into the study. The participants were in the age group of 18 years to 58 years with a mean age of 34 years. All were Hindus. Equal numbers of participants were ever married and unmarried ( n=17). Mean years of schooling was 10 years. Majority were of upper-lower socio-economic status as per modified Kuppuswamy scale.
Mean duration of illness was 4.5 years. Out of all patients, 22 were of paranoid type, 11 were of unspecified variety and one was of catatonic subtype. The mean total score on PANSS was 77.88.
QOL was assessed with WHO-QOL BREF and then extrapolated to WHO-QOL 100. Association between positive, negative, general psychopathology and total scores and domains of QOL was assessed using Spearman's correlation coefficient.
All domains of psychopathology were found to be negatively correlated with all the domains of QOL. The correlation of PANSS general and total scores with physical, psychological and environment component of QOL was statistically significant; that with psychological and physical component was highly statistically significant. A negative linear relationship was found between total PANSS score with physical health and psychological health, which was found to be significant ( P<0.01) [Table 1].
|Table 1: Association between positive and negative syndrome scale and world health organization‑quality of life|
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In case of males positive, general and total PANSS symptoms were found to be negatively correlated with psychological health, which was statistically significant while general and total symptoms were found to be significantly correlated with both physical and psychological health. Whereas, in case of females there was a significant correlation between positive, general, and total PANSS scores with environmental domains of QOL [Table 2].
|Table 2: Association of psychopathology with quality of life disaggregated by gender and marital status|
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In case of unmarried people positive, negative, general, and total symptoms were inversely correlated with physical health domain of QOL while positive, general, and total scores on PANSS were inversely related with psychological health. In case of ever married people there exists a statistically significant negative relationship between general and total PANSS components of PANSS and environmental domains of QOL [Table 2].
While examining the relationship in different education status it was found out that people who had more than 10 years of schooling had an inversely significant relationship between PANSS score and its components with physical and psychological domains of QOL.
| Discussions|| |
Previous researchers have found that QOL in patients of schizophrenia is influenced by socio-demographic characteristics, symptoms, insight, medication side-effects. While in the acute phase, QOL is associated with positive symptoms; in the stage of clinical stability it is associated with anxiety and depression.
The findings of the study are in tune with work done by previous researchers, more severe positive as well as negative symptoms predict a poorer QOL. , However, many researchers could not find statistically significant correlation between positive schizophrenia symptoms and QOL.  Our study was done on patients in acute phase and shows that Positive symptoms show statistically significant negative correlation with QOL in psychological domains ( P<0.05). Negative symptoms were associated with a poor QOL in physical domain, which was not statistically significant. It was found that PANNS general and total scores had a highly significant ( P<0.01) negative correlation with physical and psychological health, which is contrary to a significant correlation with social domain in maintenance phase.  The emotional experience of acute phase is usually so severe that one can understand the negative impact on physical and psychological domains of QOL. Maintenance phase is the time when acute psychotic experiences have settled down and the person is usually struggling with negative symptoms.
Male gender, unmarried status, more than 10 years of schooling showed negative correlation of general and total scores of PANSS with physical and psychological domains of WHOQOL. Female gender, married status and lower educational attainment were associated with better QOL with only environmental domain of QOL being adversely affected. Shtasel et al. in their work had noted that females have better QOL than males whereas Meltzer et al. found no association between age, gender, and QOL. , Skantze et al. also found that QOL is independent of gender and marital status. 
Poorer QOL in male subjects, higher education can be explained on the basis of level of expectation, aspiration and perceived control, which is often high in this subgroup.  Indian socio-cultural milieu often expects spouse to stand by the patient as marriages are considered to be sacred union, this might explain the fact that QOL is better in the married than in the unmarried. 
Previous research has demonstrated general PANSS scores to have more strong correlation with all domains of QOL, which was evident in this study also. Depression and anxiety are the strongest predictors of QOL. While symptomatology of schizophrenia changes across the phases of the illness, their relative influence on various domains of QOL also differs.
Research need to be done in identifying determinants of QOL in the different phases of the illness with an aim to target these during treatment interventions. Some of these respond to pharmacotherapy, some to intensive psychosocial interventions and still some other which are not amenable to treatment. Malla et al. have shown that following psychosocial interventions, most dimensions of self-rated QOL show improvement and this improvement is largely independent of improvement in symptoms. 
| Conclusions|| |
Male gender, unmarried status and schooling more than 10 years show inverse correlation of psychopathology with QOL in acute phase of schizophrenia. The domains of physical and psychological well-being of WHO-QOL were correlated with PANSS general and total scores whereas environmental and social health showed no correlation with PANSS scores.
While certain factors influencing QOL are not malleable, malleable factors need to be identified. Effective management of these factors would improve QOL of these patients.
More intensive longitudinal studies are needed to ascertain whether QOL is a different dimension altogether, largely independent of psychopathology.
Being an explorative study, sample size calculation was not undertaken. Longitudinal studies should be undertaken with a larger sample size to validate the results of the present study results.
| Acknowledgment|| |
Dr. Nilamadhab Kar, Department of Psychiatry, Wolverhampton City Primary Care Trust, Corner House Resource Centre, 300 Dunstall Road, Wolverhampton, WV6 0NZ, United Kingdom.
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[Table 1], [Table 2]