Social and functional capacity of schizophrenia patients: A cross-sectional study

Abstract

Background:

The chronic course of schizophrenia typically results in severe social, vocational and functional impairment, interferes with patients’ autonomy, reduces quality of life and increases disability.

Aims:

The aim of our study was: (1) to assess social and functional impairment in schizophrenia outpatients from the Czech Republic and Slovakia; and (2) to examine a relationship between functioning and antipsychotic treatment and demographic variables.

Methods:

Schizophrenia outpatients in a stable phase of illness, treated with current antipsychotic medication for a minimum of one month, were enrolled for the study. Demographic and medication data were recorded. The Personal and Social Performance (PSP), Subjective Well-Being under Neuroleptics (SWN) and Clinical Global Impressions (CGI) scales were administered.

Results:

The total number of study subjects was 926. Most PSP values were within the interval of moderate impairment. Functional performance correlated positively with subjective satisfaction with medication and negatively with symptom severity. Higher education predicted better functioning on PSP. The best performance was associated with a stable relationship and a useful work role. Patients who showed the best level of functioning were more likely to be treated with antipsychotic monotherapy. No difference among drugs in monotherapy was found in subjective satisfaction.

Conclusions:

The PSP values of stable schizophrenia outpatients indicated a moderate degree of impairment. Improvement of functional capacity remains one of the unmet needs of schizophrenia patients.

Keywords

Schizophrenia patient outcome assessment functional outcome well-being antipsychotic drugs

Introduction

Schizophrenia is typically an illness with a long-term, chronic course and a significant negative impact on patients, their families and society. A recent representative European survey examining the burden of brain disorders showed that with a prevalence of 1.2%, schizophrenia afflicts approximately five million Europeans (Wittchen et al., 2011). The illness represents a considerable economic strain; the total cost of treatment of psychotic disorders (sum of direct and indirect medical and non-medical expenses) is €94 billion, almost €19,000 per patient per year (Olesen et al., 2012). In the Czech Republic, schizophrenia causes nearly 6,000 hospitalizations every year and the mean duration of sick leave due to the illness exceeds 100 days (Institute of Health Information and Statistics of the Czech Republic, personal communication).

The chronic course of schizophrenia results in severe social, vocational and functional impairment, interferes with patients’ autonomy, reduces quality of life and increases disability (Tandon, Nasrallah & Keshavan, 2009). Thus, there is a need to reliably detect and assess the presence, severity and course of impairment in functioning.

Most of the available rating scales measuring functional capacity are non-specific instruments used across the wide spectrum of medical diagnoses: for example, Disability Assessment Schedule (WHO, n.d.), Sheehan Disability Scale (Sheehan, 1983) or International Classification of Functioning, Disability and Health ( WHO, 2001 ). The Personal and Social Performance Scale (PSP) is an example of an instrument specifically designed to assess impairment in schizophrenia (Morosini, Magliano, Brambilla, Ugolini & Pioli, 2000). PSP is based on the Global Assessment of Functioning DSM-IV (APA, 2000) and was developed from the Social and Occupational Functioning Assessment Scale (Morosini et al., 2000). The scale evaluates functioning in four categories: (1) socially useful activities; (2) personal and social relationships; (3) self-care; and (4) disturbing and aggressive behaviour. The final score is within a range of 1–100: 1–30 indicates poor functioning sufficient to require intensive support or supervision; 31–70 varying degree of disability; and 71–100 absence of disability or only mild problems (Morosini et al., 2000). PSP has been used to measure functional impairment in numerous drug trials, and has shown good validity and capacity to predict risk of hospitalization and chance for early discharge (Kozma, Dirani, Canuso & Mao, 2010).

Up to now, no representative information about the degree of functional impairment in schizophrenia patients and its relationship to the current antipsychotic treatment in the Czech Republic and Slovakia has been available. We have tried to remedy the lack of data with the present study.

Aims of the study

The study goals were: (1) to assess social and functional impairment in a sample of schizophrenia outpatients from the Czech Republic and Slovakia; and (2) to examine relationships between functional impairment, current antipsychotic treatment and selected demographic variables.

Method

This was a naturalistic, non-interventional, cross-sectional study. Patients were eligible if diagnosed with schizophrenia according to the International Classification of Diseases, 10th Revision (WHO, 2004), aged 18 years and older, with a minimum of one month on current antipsychotic medication and in a stable phase of illness as judged by their psychiatrist. Study design was approved by the ethical committees of the Prague Psychiatric Centre and University Hospital in Bratislava. The study was conducted in 50 outpatient offices in the Czech Republic and 50 offices in Slovakia. Psychiatrists were trained in the administration of rating instruments by the authors (PM and JP). The study took place over the course of two weeks in the spring of 2010. Enrolled were the first ten patients who visited an office during the specified time interval, met the entry criteria and agreed to participate. Estimated sample size, based on the number of sites and required enrollment rate, was 1,000.

All study participants signed an informed consent form. The following instruments were administered: PSP (Morosini et al., 2000); Subjective Well-Being under Neuroleptics (SWN; Naber, 1995); and Clinical Global Impressions (CGI; Guy, 1976). Recorded were the patients’ names and doses of antipsychotic drugs, concomitant medication and the following demographic data: diagnosis, age, sex, duration of illness, marital status, education, employment and living situation.

Statistical methods used the non-parametric paired Wilcoxon test to compare mean values of the defined parameters. Relationships between variables were assessed with regression analysis. Results were analysed in the total study sample and for gender and age differences. A significance level of p = .05 was adopted for all analyses.

Results

Demographic data

The total study sample consisted of 926 subjects (482 from the Czech Republic and 444 from Slovakia), 411 females and 515 males. Mean age of all patients was 40.5 years (SD = 12.5), women being older than men (43.0 vs 38.5, p < .005). The most frequent diagnosis was paranoid schizophrenia (77.8%), followed by residual (10.1%), undifferentiated (4.3%) and simplex schizophrenia (2.3%). Mean duration of illness was 14.1 years (SD = 10.0).

The distribution of the highest education levels achieved was secondary without graduation (35.9%), secondary with graduation (32.8%), elementary (17.7%), university degree (9.0%) and college degree (2.8%). No significant sex difference was found. The majority of study subjects were receiving full disability pension (65.6%). Lower percentages received a partial disability pension (8.0%), were full-time employed (7.9%), unemployed (6.2%), held a part-time job (5.0%), had a volunteer job (3.8%), were students (2.7%) or retired (0.8%). Only eight women (1.8% of all women) and none of men were receiving a retirement pension.

Examining marital status showed that most subjects were single (62.5%), then married (19.8%), divorced (14.2%), widowed (1.9%) and with a partner (1.5%). Men were more likely than women to be single (74.9% vs 47.0%); and women were more likely than men to be married (29.7% vs 12.0%), divorced (18.5% vs 10.8%) and widowed (3.6% vs 0.6%). The highest proportion of patients lived with their families (64.8%), followed by independent living (17.9%), with a partner (8.2%), in supervised housing (3.8%) and other (5.4%). More women than men lived independently (20.4% vs 15.9%) and with a partner (11.9% vs 5.2%); more men than women stayed with a family (69.2% vs 59.1%) and in a supervised setting (4.8% vs 2.4%).

Functional capacity and relationship to clinical and demographic variables

The mean value of the final PSP score was 58.43 (SD = 17.5). Grouped according to the interval of impairment severity in the PSP (Table 1), most of the patients (70.1%) scored within the range of medium severity (PSP score 31–70). A lower number of females than males was in this interval of moderate impairment; the difference failed to reach statistical significance.

Table 1.

Severity of functional impairment measured by PSP score.

PSP interval	Male		Female		All
	n	%	n	%	n	%
1–30	34	6.6	40	9.8	74	8.0
31–70	376	73.4	270	66.0	646	70.1
71–100	102	19.9	99	24.2	201	21.8
Total	512	100	409	100	921	100.0

PSP = Personal and Social Performance Scale.

The mean CGI score was 3.5 (SD = 1.3) and the mean value of the SWN was 85.7 (SD = 19.7). Linear regression analysis was used to examine the relationship between PSP and SWN scales (Figure 1). The result was statistically highly significant, with a positive correlation (R² = 0.3226; Fisher-Snedecor test: F = 4.31, p = .000). A similar test of the relationship between PSP and CGI yielded a significant negative correlation (R² = 0.5116; Fisher-Snedecor test: F = 6.91, p = .000).

Figure 1.

Relationship between PSP and SWN.

No relationship was observed between the PSP score and age. A statistically significant correlation was found between the PSP score and the level of education for the whole study sample (R² = 0.0654; Fisher-Snedecor test: F = 6.32, p = .000), as well as for males (R² = 0.0895; Fisher-Snedecor test: F = 4.94, p = .000) and females (R² = 0.0429; Fisher-Snedecor test: F = 1.78, p = .000).

Frequency analysis of the PSP score intervals according to the demographic parameters showed that the most common level of functioning in all categories was medium (PSP score 31–70). The only difference was found in the category ‘full-time job’, where the most frequent score interval was 71–100 (the highest level) and none of the patients scored within the range of poor functioning (PSP score 1–30). As for the living condition, the medium level of functioning was statistically more frequent than the poor level in almost all categories, with the exception of ‘supervised housing’ and ‘other’.

A detailed comparison of the group with the highest level of functioning (PSP 71–100) with the group of other patients (PSP 1–70) showed that the former patients were significantly more likely to have a full-time job (23.5% vs 3.8%), part-time job (6.0% vs 2.3%), paid voluntary work (5.0% vs 0.8%) or to study (4.0% vs 1.6%). In total, 38.5% of the patients had any useful activity (job, volunteer work, study) in the group of PSP 71–10, compared to 8.2% in the PSP 1–70 group.

The trend for well-functioning patients (PSP 71–100) to be more likely in a stable relationship than the rest of the sample (PSP 1–70) did not reach statistical significance: married (25.9% vs 18.0%), living with a partner (10.9% vs 7.9%), single (56.7% vs 64.4%).

Post-hoc analyses examined inter-country differences in the primary measures. While no difference was found in the PSP scores, mean values of the SWN scores were significantly higher in the Czech Republic than in Slovakia (87.9 (SD = 18.2) vs 83.4 (SD = 20.35); t-test, p = .001). This finding can be largely explained by a contribution of higher SWN scores found among Czech females (median = 91) as compared to lower scores of Slovak women (median = 85) (Figure 2).

Figure 2.

SWN scores according to the patient groups.

Antipsychotic treatment and its relationship to functional capacity and subjective satisfaction

Analysis of antipsychotic medication indicated that the most frequently prescribed drugs in the study sample were olanzapine (n = 186), risperidone (n = 177), risperidone long-acting injections (LAI) (n = 129), paliperidone (n = 117), clozapine (n = 115) and quetiapine (n = 110). A significantly higher proportion of males than females were administered olanzapine (118 vs 68; χ² = 13.4), risperidone (102 vs 75; χ² = 4.1), clozapine (73 vs 42; χ² = 8.4), levomepromazine (50 vs 21; χ² = 11.8) and fluphenazine depot (34 vs 18; χ² = 4.9); no other sex difference was detected.

The most frequently prescribed adjuvant medication were antidepressants (28.2% of all patients), anxiolytics and benzodiazepines (27.6%), anticholinergics/antiparkinsonics (18.1%), mood stabilizers (14.9%) and hypnotics (11.2%). No difference between males and females was observed.

The patients who were treated with a single antipsychotic drug (monotherapy) reached a significantly higher mean PSP score (62.2, SD = 16.8) than those who were administered a combination of antipsychotics (52.8, SD = 16.6; t-test, p = .001). Moreover, patients with the best functioning score (PSP 71–100) were more likely to be treated with monotherapy than the rest of study sample (81.6% vs 54.8%).

A detailed scrutiny of monotherapy with individual drugs failed to find a significant difference between drugs in their effect on PSP score. The drugs of highest frequency in the PSP 71–100 interval were ziprasidone (45.0%), quetiapine (40.5%), oral risperidone (37.0%), paliperidone (33.3%), oral flupenthixol (33.3%), olanzapine (32.4%), haloperidol (28.6%) and risperidone LAI (26.8%). The highest rate of the PSP 1–30 interval was observed in monotherapy with oral flupenthixol (8.3%), aripiprazole (6.3%), risperidone LAI (5.6%) and ziprasidone (5.0%). Furthermore, no statistically significant differences between antipsychotics in monotherapy were found in subjective satisfaction with medication as measured by the SWN. Analysis of the antipsychotic group in monotherapy differences (oral atypical, oral typical, depot atypical, depot typical) showed a lower proportion of patients treated with typical depot in the PSP 71–100 interval (Table 2). No significant group difference in the SWN mean values was observed (Figure 3). Post-hoc analyses of various drug combinations suggested that a combination of an atypical oral drug and a typical depot drug could yield a non-significantly better functional performance than any other combination (24.6% of patients within the 71–100 interval). No effect of various combinations on SWN score was detected.

Table 2.

Antipsychotic groups and PSP score interval.

	PSP 1–30		PSP 31–70		PSP 71–100		Total
	n	%	n	%	n	%	Total
Atypical oral	17	3.4	326	66.1	150	30.4	493
Typical oral	2	5.6	24	66.7	10	27.8	36
Atypical depot	4	5.6	48	67.6	19	26.8	71
Typical depot	3	8.8	26	76.5	5	14.7	34

PSP = Personal and Social Performance Scale.

Figure 3.

Antipsychotic groups and SWN score.

Discussion

To our knowledge, this is the first representative survey of functional capacity, treatment satisfaction and their relationship to antipsychotic therapy of schizophrenia outpatients in the Czech Republic and Slovakia. Although no specific sampling method was used, participating sites were selected from all areas across the countries covered by psychiatric services: both rural and urban, including small towns and large cities. Their distribution thus reflects the diversity of various groups of schizophrenia patients. The results showed that the mean values of the PSP in the study population were within the medium interval, indicating a moderate degree of functional impairment. Highly significant correlations of the PSP scores with subjective satisfaction with medication (positive) and psychopathology (negative) imply external validation of the rating scale. Moreover, higher education also predicted better social performance. Considering the domains assessed by the PSP (i.e. social relationships, meaningful activities), it comes as no surprise that the highest scores were achieved by patients who were well adjusted, in a relationship with a spouse or a partner and had paid work.

The methods used in our study allow us to compare the results with the data from other countries. A comprehensive review previously suggested an employment rate among schizophrenia patients in Europe of 10% – 20% (Marwaha & Johnson, 2004). A more recent European survey of almost 4,000 schizophrenia patients from four countries found the mean rate of full-time and part-time employment to be 9.4% and 12.3%, respectively (Papageorgiou, Cañas, Zink & Rossi, 2011). While the highest number of employed patients was in Greece (total of 40.1%), the work status of the Czech and Slovak patients was closest to that observed in Italy (full-time job 7.9% and 7.6%; part-time job 5.0% and 5.5%). Although it may be difficult to draw a comparison across different educational systems, the number of patients with secondary education in our sample (68.7%) was comparable to the German population (61.7%) and the number of university or college graduates (11.8%) was similar to Germany (14.1%) and Spain (14.0%). The proportion of patients living with family or a partner in the Czech Republic and Slovakia (73.0%) was surprisingly closer to the Mediterranean countries (73% – 76%) than to Germany (50%) (Papageorgiou et al., 2011). The marital status of the Czech and Slovak patients (63% single, 20% married) matched that of patients from five European urban centres in the Netherlands, Denmark, the UK, Spain and Italy: 65% single, 17% married (Thornicroft et al., 2004). Although our study sites also covered major metropolitan areas, no homeless schizophrenia patients were enrolled. This fact reflects both the accessibility of inpatient psychiatric care in the Czech Republic and Slovakia and the limited knowledge of the actual prevalence of mental illness among homeless people. A similar pattern was observed in Greece (zero homelessness rate) and Germany (0.6%) (Papageorgiou et al., 2011). The mean value of the PSP scores in our study sample (58.4) corresponded fully to the PSP values of patients participating in clinical trials and studies investigating psychometric properties of the PSP scale (Nasrallah, Morosini & Gagnon, 2008; Patrick et al., 2010).

The fact that patients who showed the best level of functioning were more likely to be treated with antipsychotic monotherapy should be viewed with caution. Obviously, there may well be an alternative plausible interpretation of the causal link: the more severely ill patients, who perform poorly, require combined treatment with different drugs. Similarly, our cross-sectional study design prevents a generalization of the observation that some drugs in monotherapy (ziprasidone, quetiapine, oral risperidone, paliperidone, oral flupenthixol) are associated with the highest social functioning, whereas other drugs (typical depot) are not. No difference in subjective satisfaction with medication was found among the individual drugs in monotherapy.

Treatment data provide an informative insight into current clinical practice. There was a wide range of prescribed antipsychotics; nonetheless, in monotherapy the first six top-prescribed drugs were atypical antipsychotics. Various prescription rates in the Czech and Slovak sub-samples reflect specific national regulatory rules, restrictions and drug availability. Despite the fact that the patients were diagnosed with schizophrenia only, there was a high rate of concomitantly prescribed antidepressants (28%) and mood stabilizers (15%). Since no patients with schizoaffective or bipolar disorder were enrolled, those subjects may have received off-label prescriptions. Due to the absence of additional data, we can only speculate whether the patients presented with mood, negative or behavioural symptoms.

The lack of more detailed information on the clinical status, medication adherence, non-pharmacological treatments or family socio-economic status represents the main study limitations. Moreover, as mentioned above, a cross-sectional study design does not allow a more accurate evaluation of the effect of treatment on functional capacity. The study lacked the power to analyse further groups of antipsychotics, individual drugs or their various combinations.

Due to the geographical, demographical, social, economic and cultural proximity of both nations with a shared history, we considered the study population as a homogenous sample. However, post-hoc analysis revealed some country differences. In addition to the varying prescribing patterns, the most notable difference was the result suggesting better subjective satisfaction with medication in the Czech sub-sample. Since the country variations in the antipsychotic prescription are not large enough, there might be other reasons that could explain this finding. The major contribution to the difference in subjective satisfaction was the higher SWN score among Czech women. This finding fully corresponds to the results from our previous separate analysis of a Czech sub-sample of 482 outpatients (Mohr et al., 2012). Specifically, a significantly greater number of Czech women than men reached the highest level of functioning according to the PSP. Similar reports support assumptions that the prognosis of schizophrenia is more favourable in females (Ochoa, Usall, Cobo, Labad & Kulkarni, 2012). Nevertheless, it should be noted that the trend favouring better functional performance of female patients lost statistical significance in our current larger study sample.

In summary, our findings confirmed that functional capacity can be easily assessed in everyday clinical practice. Moderate scores in stable outpatients suggest that improvement of real-life functioning remains one of the unmet needs of schizophrenia patients.

Footnotes

Acknowledgements

The authors are deeply grateful to all psychiatrists from both countries who participated in the research.

Funding

This study was supported by the project MH CZ-DRO (PCP, 00023752) and by Janssen-Cilag Czech and Slovak Republics.

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