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.
Keywords: quality of life; schizophrenia; self‐efficacy; subjective assessment; well‐being
SUBJECTIVE ASSESSMENTS, SUCH as of quality of life (QoL)[
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.[[
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.[[
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',[
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.[
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.[
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 criteria[
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.[[
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.[[
The Self‐Efficacy for Community Life scale (SECL) is used to assess the self‐efficacy of patients with schizophrenia living in the community.[
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.[
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.[
Letter‐Cancellation Test (LCT) is the attention test conducted using rows of letters randomly interspersed with the designated target letter.[
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.[
The OTT is one kind of fluency test that requires subjects to conceptualize options or alternatives to hypothetical, but typical real‐life problems.[
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.
1 Subjective assessment scores
Mean ± SD Range 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
1 SECL, Self‐Efficacy for Community Life scale; SWNS, Subjective Well‐being under Neuroleptic drug treatment: Short Japanese version; WHO‐QOL 26, 26‐item short form of the World Health Organization Quality of Life.
2 Cognitive function scores
Mean ± SD Range 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
3 Correlation between PANSS and subjective assessment in schizophrenia patients
WHO‐QOL 26 SWNS SECL PANSS Positive syndrome −0.39* −0.37* −0.16 Delusion −0.10* −0.14* −0.06 Conceptual disorganization 0.0009 −0.14* −0.05 Hallucinatory behavior 0.03 −0.09 0.08 Excitement −0.21* −0.02 −0.03 Grandiosity 0.03 −0.13 0.18 Suspiciousness −0.17 0.14 0.03 Hostility 0.07 0.12 0.23 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* Anxiety −0.27* −0.30* −0.29* Guilt feeling 0.12 0.08 0.20 Tension 0.04 −0.03 −0.05 Mannerisms and posturing 0.27 0.11 0.09 Depression −0.41** −0.33** −0.20 Motor retardation −0.02 0.03 −0.06 Uncooperativeness −0.32* −0.20 −0.003 Unusual thought content −0.19* −0.24* −0.07 Disorientation 0.34 0.31 0.41 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 Preoccupation −0.21* −0.19* −0.03 Active social avoidance −0.22 −0.25* −0.26*
- 2 * P < 0.05;
- 3 ** P < 0.01.
- 4 PANSS, Positive And Negative Syndrome Scale; SECL, Self‐Efficacy for Community Life scale; SWNS, Subjective Well‐being under Neuroleptic drug treatment: Short Japanese version; WHO‐QOL 26, 26‐item short form of the World Health Organization Quality of Life.
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).
4 Correlations between SFS, GAF and subjective assessments in schizophrenia patients
Mean ± SD WHO‐QOL 26 SWNS SECL 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**
- 5 * P < 0.05;
- 6 ** P < 0.01.
- 7 GAF, Global Assessment of Functioning; SECL, Self‐Efficacy for Community Life scale; SFS, Social Functioning Scale; SWNS, Subjective Well‐being under Neuroleptic drug treatment: Short Japanese version; WHO‐QOL 26, The 26‐item short form of the World Health Organization Quality of Life.
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.[
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.[[
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.[
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.[
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.[
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.
By Bun Chino; Takahiro Nemoto; Chiyo Fujii and Masafumi Mizuno
Reported by Author; Author; Author; Author