Comparison of quality of life with standard of living in schizophrenic out-patients K Skantze, U Malm, SJ Dencker, PR May and P Corrigan The British Journal of Psychiatry 1992 161: 797-801 Access the most recent version at doi:10.1192/bjp.161.6.797
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British Journal of Psychiatry (1992), 161, 797—801
Comparison
of Quality of Life with Standard Schizophrenic Out-patients
of Living in
KERSTIN SKANTZE, ULF MALM, SVEN J. DENCKER,
PHILIPR. A. MAY and PATRICKCORRIGAN Standardof living reflects the objectivedimensionof how well the basic needsof life are met, while quality of life is the patient's own subjectiveview of well-beingandsatisfaction withher/his life. Sixty-one schizophrenic out-patients completedself-report inventories and
participatedin interviewsaboutquality of life and standardof living. Whenliving standards were met by a well functioning social service system, patients' perceptions of their quality of life and their standard of living appeared to be independent. Subsequent analyses revealed that ‘¿inner experiences' was one quality-of-life domain frequently reported as unsatisfactory. Moreover,differences inquality of life were foundacrosspatients' age,education, and
work status. Mental health professionals are aware of the impoverished lives of patients with chronic schizo phrenia when treated in hospital. Current treatment strategiesmakeit possibleto treat most patientswith schizophrenia in the community with only occasional
admissions.The interaction of antipsychotic drugs, psychiatricrehabilitation, and maintenancetreatment has beenshown to decreasepositive symptoms and to improve patients' repertoiresof socialand coping skills (Anthony et a!, 1978; Goldstein et a!, 1978; Dencker, 1980;Leffet a!, 1982;Liberman et a!, 1986; Hogarty, 1988). Most mental-health rehabilitation programmes seekto increasethe standard of living
report their satisfaction/dissatisfaction with items representingdifferent life domains. In this model, stress, vulnerability, diseaseand impaired quality of lifeinteract (a cybernetic and ecological process). The model hasbeenusedinseveral epidemiological studies on population, environmentand quality of
life in generalpopulations (Levi & Anderson, 1975; Campell et a!, 1976).
Three recent studies (Malm et a!, 1981;Lehman et a!, 1982; Heinrichs et a!, 1984) have generated a number of domains of quality of life, which can be used to assessneedsand quality-of-life goals. The assessments coveredbasicareasof daily needs(United of their patients. However, few studies have attempted Nations, 1990): health care, safety and security, to measure whether positive gains translate into food, housing, knowledge/education, fundamental patients' perceptions of improved qualityof life interpersonal relationships, finance, and activities. Quality-of-life evaluations might also include environ (Corrigan et a!, 1990). Quality of life is a person's own subjective evalu ment, contacts,dependence,mental health, physical ation of her or his life situation. The Organization health, leisure,work, and religion. Moreover, ‘¿inner for Economic Co-operation and Development experiences'could also be measured- for example (OECD) consideredthat growth of standardof living self-fulfilment, self-reliance,inner harmony, pleasure, should not be an aim in itself, but rather this should joy, and love. be to create conditions for people to attain their Whereas quality of life is defined as a subjective own goals concerning their quality of life (Levi & index, standard of living can be assessedobjectively, Anderson, 1975).Preferences,aspirations, dreams, as an observer's evaluation of a patient's current hopes, and ambitions differ depending on genetic life situation (Levi & Anderson, 1975;Campdlleta!, factors, life experiences,and perceptions of reality 1976; Erikson & Aberg, 1984; United Nations, (Abbey & Andrews, 1985). Quality of life and well
1990). Standard of living may comprisean objective
being is influenced by the dynamic gap between aspirations and perceivedreality (Levi & Anderson, 1975; Andrews & Withey, 1976; Campell, 1976; Naess, 1981, 1988;Nuechterlein & Dawson, 1984; United Nations, 1990). This subjective concept of quality of life doesnot require freedom from illness (Rosenthal, 1970; zubin & Spring, 1977). When
assessment of the patient's coping skills and
measuring quality
of life, patients are asked to
dependence on help from others to manage daily
life and survive in the community. Satisfaction of these is necessary for most people to report an
acceptablequality of life. The services provided by community support programmes and case management are aimed at meeting the basic general needs of their clientele,
797
798
SKANTZE ET AL
thereby improving patients' living standards (Intagliata, 1982; Test, 1984). Given the ever increasing number of patients in the community, investigators
have
argued
that
quality
of life,
including cognitive as well as emotional components, may be relatively unrelated to standard of living (Campell et a!, 1976; Lehman, 1983; Avison & Speechley, 1987). Epidemiological studies have suggestedthat above a certain threshold - the United Nations poverty line - general standard of living loses its significance to quality of life (Levi & Anderson, 1975; United Nations, 1990). The aim of this study is to test the relationship
betweenstandardof living and self-evaluatedquality of life. We hypothesisethat there is no correlation between the two constructs when severely mentally ill
people have reacheda minimum standard of living that is adequatefor survival (United Nations, 1990).
health, physicalhealth, leisure,work, and religion.Scores from the domains provide an overall index of quality of life. In a separatestudy, the QLS— 100was administered twice over 7—10 days to 30 patients at the Psychiatric Outpatient Clinic Centrum, Gothenburg. The test—retest reliability
for overall QLS—l00 score was 0.88.
Within threedaysof finishing the QLS-l00, the subjects completeda 40—50—minute QLS interview, in which they were questioned about each item scored as being
unsatisfactory.The format for completingthe instruments andconductingtheinterviewsparalleledsuggestions made by Lehman et a! (1983). Specifically,in the interview subjects were asked: (a) to describe what aspects of
the item wereunsatisfactory,(b) whetherthey wanted to changetheseitems and in what direction, and (c) whether they believed the unsatisfactory items would eventually improve. Statistical analysis Relationships
Method
between quality-of-life
and standard-of-living
variablesweredeterminedusingPearsonproduct-moment correlations. Within subject differences acrossQLS—lOO
domainswereevaluatedby a repeated-measures analysis All 66 out-patientswith a DSM—III-Rdiagnosisof of variance,asweredifferencesin quality of life across schizophrenia (AmericanPsychiatricAssociation,1987), demographicvariables.Thesetestswereconductedusing who receivedmaintenancedepotneurolepticmedication BMDP(Dixon et al, 1989). at thePsychiatricOutpatientClinicof LillhagenHospital, were invited to participate in this study. Diagnoseswere obtained by a review of casenotes and validated by the
Resufts
director of the programme(UM). All subjectsresided
There were 42 men and 19 women. The mean (s.d.) age of the sample was of 35.9 (6.1) years. The patients 5.7 participants ranged in age from 21 to 65 years and had had had a relatively short mean length of illness—¿ no history ofdrugoralcohol abuse.Of the66 patients,(2.3) years since initial referral. No subject had a physical diseaseor defect that confounded psychiatric symptoms. three declined to participate and two were excluded because had neverbeenmarried, four (6°1o) were of poor readingskills. The remaining61subjectscompleted Fifty-four (89°1o) two instruments: the Standard of Living Questionnaire currently married or cohabiting, and four were divorced or widowed. These data resemblethose of other such (SOL-I) and the Quality of Life self-assessment (QLS-l00) samples of chronic schizophrenic out-patients (Doane inventory. The SOL—I (developed by theauthorsand availableet a!, 1985; Mueser et a!, 1990). on request)is a structured interview in which, along with in the Central District of Gothenburg, a city of about
500000 inhabitantson the westcoastof Sweden.The
basic demographic information, data are collected regarding several subscales that together yield an overall evaluation of standard of living. These subscales measure: standard
Standard of living Informationfrom the SOL—Isuggestedthatthepatients
had attained a good standard of living (Table 1). The useof communityservices(transportation,telephoneand standardof housingis basedon presenceof eight facilities: home-helpservice),weeklyactivities,education,current a sink with running water, electricity, stove, refrigerator, employment,andsocialnetwork.In addition,theSOL—I hot running water, central heating, toilet facilities, and providesinformationaboutsocialdependence, thatisneed bath/shower. The maximum scorewas8.0andthe average tolive withothers, needofcompanytotravel, and need score for this sample was 7.7, thereby demonstrating a of help in handling money. Hencethe SOL-I canquantify ceiling effect. Only two patients (3%) lived in temporary each QLS-lOO domain (seebelow), and other objective housing. Forty-two patients (69%) lived in their own measurementsmay be added. homes and seven(11010) sharedhomes withothers. Ten The patients' homes The QLS-l00 (developedby the authorsand availableon (16%) livedwiththeirfamilies. request)is a 100-iteminventory organisedinto 11domains, averaged1.5roomsper occupant. The sample was well educated, 56 patients (92%) and which askspatientsto indicate which they considerto be currently unsatisfactory. The domainsare:housing having had somecollegeeducationor vocational training. (includinghouseholdand self-care),environment(including Twelve patients were in open employment. The sample communityservices), knowledge andeducation, contacts,remained relatively active as well. Forty subjects(66%) of housing, number of rooms per occupant, accessto and
dependence (includingfinances),innerexperiences, mental
reportedweeklyactivities. The patients' supportsystems
QUALITY
799
OF LIFE OF SCHIZOPHRENICS
Table 1 Standard of living for 61 schizophrenicout-patients Mean housing'7.7(0.83)Mean (s.d.) standard of occupant1.5(1.00)% (s.d.) numberofroomsper to:public (n)withaccess transportation100(61)telephone100(61)weekly
activities65.5(40)home-help service22.9(14)%
education92.0(56)% (n)with somecollege/vocational employment19.7(12)% (n)inopen network:family78.7(48)friends67.2(41)mental (n) with social
health personnel100(61)
1. Eight facilities make maximum score of 8.
Table 2 Dissatisfaction with each QLS—100domain DomainMean
(s.d.)No. subjectspercentage
of
ofreportingitems eachdissatisfactiondomain in ratedunsatisfactoryHousing12.4 (13.2)44Environment10.2 (14.3)34Knowledge/education15.0
(18.0)30Contacts25.9 (21.6)45Dependence17.4 (20.2)32Inner (24.9)49Mental experiences27.0 (23.9)43Physical health28.3 (21.3)20Leisure19.1 health13.1 (17.0)44Work20.3 (19.5)41Religion10.9 (20.8)15
were fairly intact, with 48 (7901o)reporting frequent contacts with family or friends. Our sample had attained a standard of living similar to that of the general population in Sweden (Erikson & Aberg, 1984). All Swedish citizens have accessto a community-based social security that provides financial support when no job is available or for someoneunable to work. Moreover, in largecities a variety of community servicesare available, for examplegood public transport, freeaccessto schools,books and papers,cheap home help services, and inexpensive dental and health care. The educational level in our sample was similar to that
of Erikson & Aberg's (1984) sample. However, the general population was more active in outdoor and recreational activities, and, more likely to live with another person (83°lo) than the patients in this sample (41°1@, 25 patients). Quality of life
The frequency of items in each QLS—lOO domain that wererated unsatisfactorywasdeterminedfor eachsubject; the mean and standard deviations of these frequencies arelisted in Table 2. A repeated-measures ANOVA across the 11 subscalesor domains of the QLS—l00showed
that patients had different levels of satisfaction across domams(F(l, 60)= 125.15,P
