Improving quality of life and physical health in patients with schizophrenia: A 30-month program carried out in a real-life setting

Abstract

Background:

Patients with schizophrenia experience low quality of life (QoL) and poor physical health, which is explained, in part, by unhealthy lifestyle, tobacco smoking, poor diet and sedentary behavior.

Aim:

To measure QoL and physical health in patients with schizophrenia and to quantify associations between QoL and physical health.

Methods:

This was a naturalistic longitudinal 30-month follow-up study including individual guidance, group sessions and treatment as usual.

Results:

We included 190 patients. QoL was low among newly diagnosed patients. Higher body mass index was significantly associated with lower QoL. Newly diagnosed male patients showed lower QoL compared with females. Newly diagnosed patients experienced worsened health during the study period. In contrast, long-term schizophrenic patients started with worse physical health but improved with regard to weight, waist circumferences, intake of fast food and soft drinks, and light physical activity level. Newly diagnosed patients improved their QoL (p = .056), and the psychological domain improved by 8.0 points (p = .003). The number of interventions was positively associated with QoL.

Conclusion:

Patients with schizophrenia presented with low QoL and elevated risk factors for poor physical health. The intervention added onto ‘treatment as usual’ improved some risk factors for poor physical health among long-term patients. The number of interventions had an elevating effect on QoL in patients.

Keywords

Quality of life physical health schizophrenia intervention prevention antipsychotic agents duration of illness

Introduction

Quality of life (QoL) is a person’s sense of well-being, health status and satisfaction with life conditions, including access to resources and opportunities (Norholm & Bech, 2001). Furthermore, QoL provides the patient’s perspective instead of health indicators as mortality and morbidity (Galuppi, Turola, Nanni, Mazzoni, & Grassi, 2010). Patients with schizophrenia experience lower QoL than the general population (Brissos, Balanza-Martinez, Dias, Carita, & Figueira, 2011; Hjorth et al., 2016; Maat, Fett, Derks, & Group Investigators, 2012; Picardi et al., 2006). QoL in patients with schizophrenia is associated with psychiatric symptoms (positive and negative symptoms, depression, anxiety, self-stigma and lack of social support), sociodemographic characteristics, sex, employment status and living situation (Brissos et al., 2011; Heider et al., 2007; Huppert & Smith, 2001). High body mass index (BMI) and increased waist circumference (WC) have been associated with lower QoL scores in patients with schizophrenia (Brissos et al., 2011; Gomes et al., 2016; Heider et al., 2007; Huppert & Smith, 2001; Sugawara et al., 2013).

Physical diseases are likely to affect QoL, and physical diseases have a higher frequency among patients with schizophrenia compared with the general population (Leucht, Burkard, Henderson, Maj, & Sartorius, 2007). The most common cause of premature death in people with schizophrenia is cardiovascular disease (CVD) (Brown, 1997; Lawrence, Kisely, & Pais, 2010; Leucht et al., 2007), resulting in a shorter life expectancy than the general population (Nielsen, Uggerby, Jensen, & McGrath, 2013).

Overweight and obesity among patients are common and lead to negative health consequences (Holt et al., 2010; Leucht et al., 2007). Causes of overweight and obesity are individual and complex, but lifestyle (i.e. poor diet, physical inactivity) and the side effects of psychotropic medication are contributing factors (Gough & O’Donovan, 2005). Hence, prevention and treatment must be tailored to the individual patients and target the range of factors that contribute to weight gain.

Studies have shown that interventions can reduce overweight and obesity in patients with schizophrenia (Direk & Ucok, 2008; Hjorth et al., 2014 b; Melamed et al., 2008; Poulin et al., 2007), and loss of body weight and increased physical activity may reduce some of the health risks associated with obesity (Menza et al., 2004; Wu, Wang, Bai, Huang, & Lee, 2007). Furthermore, increased levels of physical activity independent of any weight loss is associated with some mental health benefits and may enhance QoL (Voruganti et al., 2006).

The side effect of antipsychotic medicine may induce weight gain and worsen metabolic CVD risk factors (Allison et al., 1999; Alvarez-Jimenez et al., 2008; Holt et al., 2010). The association between antipsychotics and QoL has been investigated regarding both types of antipsychotics (Leucht et al., 2009), and monopharmacological versus polypharmacological treatment (Kilian & Angermeyer, 2005), but results are ambiguous.

Rates of tobacco smoking among patients are high (Dixon et al., 2007; Hjorth et al., 2014; McCreadie & Scottish Schizophrenia Lifestyle Group, 2003), and studies have shown that smokers have a lower QoL than non-smokers, both in inpatients with severe mental illness and in the general population (Shields, Garner, & Wilkins, 2013). There is evidence that smoking cessation can increase QoL (Taylor et al., 2014); thus, our understanding of the relation between smoking and QoL in patients with schizophrenia can be further enhanced.

It is of importance to improve both QoL and physical health in patients with schizophrenia. Obesity and high BMI are associated with lower QoL, as is tobacco smoking. Finally, the association between antipsychotics and QoL is uncertain regarding both types of antipsychotics and monopharmacological versus polypharmacological treatment.

Aims

The aims of the study were to measure QoL and physical health in patients with schizophrenia and to quantify associations, during a 30-month intervention program, in QoL and variables for physical health.

Materials and methods

Design

The study was a naturalistic longitudinal 30-month follow-up study, part of the program ‘Preventing of early death from somatic causes in patients with severe mental illness’, the aim of which is to implement well-documented methods for improving physical health in patients with severe mental illness in routine clinical treatment (Blanner Kristiansen et al., 2015; Hansen et al., 2016; Medici et al., 2015). The program was conducted in Central Region, Denmark, as a naturalistic intervention study added to treatment as usual and was arranged to reflect everyday practice in an ordinary outpatient sample through 30 months of clinical work. The program started in January 2013 and was performed in three clinics. Clinic one (C1) treated patients with long-term schizophrenia, and clinics two (C2) and three (C3) treated patients with newly diagnosed schizophrenia, aged 18–45 years (Petersen et al., 2005).

Measures

All measures were obtained at index, when patients entered the program, and continuously during the program. Once annually, QoL was measured and blood tests taken, and weight, WC and body fat percentage were measured on a monthly basis, if possible. A diagnosis of schizophrenia was based on the 10th revision of the International Classification of Diseases’ diagnostic research criteria. The World Health Organization Quality of Life Brief (WHOQoL-BREF 26) questionnaire was used to measure QoL. It consists of 26 questions covering four domains: psychological, physical, social and environmental. The outcome is a score between 0 and 100, with a higher numerical value representing a higher QoL. We used a validated Danish version of QoL BREF 26 (Norholm & Bech, 2001), which is appropriate for use with patients with schizophrenia as long as the patients are not psychotic at the time of carrying out the assessment (Skevington, Lotfy, O’Connell, & WHOQOL Group, 2004). Owing to cognitive and/or reading disabilities (Blanc, Boyer, Le Coz, & Auquier, 2014), the questionnaire was administered as an interview in approximately half of the cases, where the project leader or other staff member guided the patients in answering the questions as precisely as possible.

Weight and body fat percentages were measured with the Tanita Body Composition Analyzer Model TBF-300. WC was included as an outcome variable as a risk of CVD and diabetes (Bigaard et al., 2003; Bosy-Westphal et al., 2010; Henderson et al., 2009) and was measured at the midpoint between the lowest rib and the iliac crest in the mid-axillary line (Wang et al., 2003). All staff was instructed in correct measuring. Information regarding smoking of cigarettes, alcohol consumption, substance use and level of physical activity was obtained via personal interviews as part of the daily routines of the clinic.

Data on age, sex, diagnoses of schizophrenia and use of antipsychotic drugs were extracted from the electronic patient records. We analyzed antipsychotic drugs according to group N05A of the Anatomical Therapeutic Chemical/Defined Daily Doses (DDD) coding system and doses were transformed into DDD and added together to total daily dose (TDD) (Guidelines for ATC classification and DDD assignment, 2010).

Intervention

Patients were offered both individual and group sessions focusing on physical health in combination with treatment as usual. Patients were free to attend the sessions, so the number of sessions attended varied according to the individual. The intervention was based on active awareness methods, group sessions and staff role modeling developed from former studies conducted by the research group (Hjorth, Davidsen, Kilian, Pilgaard Eriksen, et al., 2014; Hjorth, Davidsen, Kilian, & Skrubbeltrang, 2014; Hjorth et al., 2015; Weiser et al., 2009). The intervention was adjusted to the individual patient and integrated into daily practice.

Focus groups

Focus groups were conducted with both patients and staff members separately (each with 3–8 participants). The topics were physical health problems and methods for improving physical health: (1) health risks/health problems, (2) causes of health problems, (3) possibilities for prevention and (4) preventive strategies at the patients’ own facilities. These focus groups were evolved from the European network for promoting the physical health of residents in psychiatric and social care facilities (HELPS) (Weiser et al., 2009). The interviews were recorded digitally, transcribed verbatim and analyzed using a template approach. The findings from the focus-group discussion were used to improve and develop the intervention (Blanner Kristiansen et al., 2015).

Individual sessions

Each patient was offered individual sessions with nursing staff or the project leader, based on motivational interviewing methods, which rely on identifying and mobilizing the patient’s own values and goals to stimulate change (Miller & Rollnick, 2002; Rollnick, Miller, & Burker, 2008; Rubak, Sandbaek, Lauritzen, & Christensen, 2005). The frequency of the sessions was decided in collaboration with the patients, taking individual needs and capabilities into account. The aim of the sessions was to optimize the patient’s physical health and was typically centered around diet and easily enjoyable ways to improve their physical activity level, often in the form of daily walks and, for some patients, regular sports activities. The patients were informed about smoking cessation and possibilities for support and guidance if cessation was required. The duration of the session was planned to be 1 hour.

Group sessions

At C1, group sessions were held weekly, for 8 weeks. Each session lasted 1.5 hours, with 8–10 patients in each. The sessions included education and discussion of following themes: (1) background information on why physical health is of special concern for patients with a diagnosis of schizophrenia; (2) diet – healthy oil and fat; (3) the importance of exercise and easy ways to exercise in a pleasurable way; (4) diet – protein and carbohydrate (where to find them in the right amounts; calorie counts and informative labels of the most common food products); (5) how to plan meals on a daily and weekly basis in a smart, healthy and inexpensive way; (6) how to do sports in the municipality with consultant from ‘Sports for Mentally Ill’ attending (volunteers offer help to patients with mental illness to participate in social and sports activities, part of the municipality’s support for people with mental illness); (7) practical training in the fitness room in the outpatient clinic – there was guidance in training and exercise under instruction from group leaders; and (8) the last session was concluded with a healthy lunch while evaluating the group sessions.

The group sessions were performed by the project leader (P.H.) and a psychiatric nurse, both of whom have long and broad experience in psychiatry, prevention and health promotion.

Walking or running groups

At C1and C2, patients were offered voluntary participation in walking or running groups on a weekly basis. To increase awareness of physical health in general, staff members with patient contact were monitored annually by measuring WC, body fat percentages, BMI and use of alcohol and cigarettes. Furthermore, staff was encouraged to take part in the walking and running groups on a weekly basis at the clinic.

Statistical analyses

QoL was calculated and transformed to a 0–100-point scale. Each domain was calculated independently of the other domains. We stratified the data into newly diagnosed and long-term patients. Then, descriptive statistics were calculated for all outcomes, as well as changes for each outcome measured at an index date and follow-up date. Student’s t-tests or the non-parametric equivalent Wilcoxon’s rank-sum test were applied for each variable that was normally distributed and abnormally distributed, respectively. For normal data, an F-test was applied to ensure variance homogeneity.

Linear regression analyses of changes in each patient’s QoL was performed. Data from all time points for each patient throughout the study were used in the regression analyses. For regression analyses, the backward selection method was used to find the simplest model and all independent variables without a significant level of explanatory effect were removed from the initial model and left out of the final model. Variables in the regression analyses were cigarettes, alcohol, cannabis, coffee and soft drink consumption, age, illness duration, sex, TDD, BMI, weight and WC. Statistical analyses were carried out with Stata version 12.1 (StataCorp, College Station, TX, USA) and the chosen level of significance was 5%.

Ethics

The Danish Research Ethics Committee (Central Region) approved the study as a quality-assurance study of the departments (cf. law 593, §2 No.1, enquiry 197/2012). The study was approved by the Danish Data Protection Agency (2007-58-0010).

Results

A total of 78 newly diagnosed patients with schizophrenia and 45 patients with long-term schizophrenia completed the QoL questionnaire at index, and 53 and 30 completed at follow-up, respectively. Clinical characteristics and QoL at index and follow-up are shown in Table 1 (newly diagnosed) and in Table 2 (long-term).

Table 1.

Clinical measures and mean quality of life by domain in patients newly diagnosed with schizophrenia.

	N	Index (SD) mean	N	Follow-up mean (SD)	Difference (95% CI)	p-value
Sex (female/male)	50/86
Time in project (days)	136	504 (257)
Age (years)	136	27.1 (6.9)
Interventions	136	4.1 (5.1)
Weight (kg)	126	83.96 (22.10)	104	88.14 (24.87)	−4.18 (−10.3, –1.93)	.179
BMI (kg/m²)	124	27.42 (7.36)	95	28.66 (7.76)	−1.24 (−3.27, –0.78)	.227
WC (cm)	116	96.1 (19.2)	81	101.0 (20.1)	−4.9 (−10.5, –0.66)	.084
Fat (%)	21	34.66 (16.06)	12	32.08 (17.35)	2.58 (−9.62, –14.78)	.670
Cigarettes (day)	127	10.11 (9.44)	101	9.77 (9.29)	0.38	.761*
Alcohol^a	119	4.41 (8.90)	99	2.86 (4.79)	1.55	.399*
Cannabis (month)	122	2.25 (6.74)	85	2.53 (9.09)	−0.28	.547*
Coffee (cups/day)	74	3.35 (4.15)	45	3.67 (4.94)	−0.32	.869*
Fast food (week)	97	1.70 (10.10)	62	0.82 (1.27)	0.88	.063*
Soft drinks (L/day)	76	0.71 (1.18)	52	0.44 (0.58)	0.27	.238*
No-sugar soft drinks (L/day)	74	0.78 (1.98)	43	0.43 (0.61)	0.35	.914*
Sleep (min/day)	82	506 (153)	52	488 (127)	17 (−33, 68)	.495
Light physical activity (min/day)	84	325 (421)	55	336 (353)	−11	.459*
Moderate physical activity (min/day)	82	160 (334)	48	115 (162)	45	.941*
Hard physical activity (min/day)	69	27 (62)	37	38 (109)	−12	.921*
TDD^b	106	1.61 (1.22)	84	1.34 (1.06)	0.27	.106*
Overall QoL	77	52.68 (11.79)	47	57.92 (16.07)	−5.51 (−10.21, –0.27)	.056
Physical	79	57.87 (16.53)	51	63.03 (19.78)	−5.16 (−11.51, 1.19)	.111
Psychological	79	40.45 (16.93)	52	48.48 (22.34)	−8.02 (−15.25, –0.80)	.030
Social	78	55.98 (18.06)	49	62.07 (20.20)	−6.09 (−12.92, 0.73)	.080
Environmental	79	55.24 (11.39)	51	58.96 (13.50)	−3.73 (−8.08, 0.63)	.093

SD: standard deviation; CI: confidence interval; TDD: total daily doses; BMI: body mass index; WC: waist circumference; QoL: quality of life.

t-tests (two-sided) were performed on normal variables with the stated p-values indicating the hypothesis of equality between index and follow-up.

Unit per week equivalent to 12 g alcohol.

Antipsychotic.

Non-normal data were analyzed under the same hypothesis with the non-parametric Wilcoxon’s rank-sum test.

Table 2.

Clinical measurements and mean quality of life by domain in patients with long-term schizophrenia.

	N	Index (SD) mean	N	Follow-up (SD)	Difference (95% CI)	p-value
Sex (female/male)	32/22
Time in project (days)	54	513 (236)
Age (years)	54	34.70 (12, 15)
Interventions	54	5.4 (4.8)
Weight (kg)	53	99.43 (25.12)	46	97.78 (26.08)	1.65 (−8.58, 11.87)	.750
BMI (kg/m²)	53	33.00 (8.14)	43	32.57 (7.87)	0.43 (−2.84, 3.70)	.7948
WC (cm)	53	113.75 (20.96)	38	107.13 (16.41)	6.62 (−1.49, –14.73)	.108
Fat (%)	51	37.66 (12.56)	35	36.62 (12.40)	1.03 (−4.42, 6.49)	.708
Cigarettes (day)	52	11.15 (14.38)	47	9.62 (13.88)	1.54	.517*
Alcohol^a	53	3.21 (7.95)	48	4.96 (13.51)	−1.75	.973*
Cannabis (month)	52	0.73 (4.25)	40	0.75 (4.74)	−0.02	.462*
Coffee (cups/day)	46	4.47 (7.01)	33	3.42 (4.12)	1.05	.729*
Fast food (week)	51	1.45 (2.11)	36	0.78 (2.40)	0.67	.010*
Soft drinks (L/day)	50	0.66 (1.28)	38	0.10 (0.20)	0.42	.001*
No-sugar soft drinks (L/day)	48	0.39 (0.64)	33	0.21 (0.33)	0.18	.344*
Sleep (min/day)	49	538 (129)	34	518 (105)	20 (−33, –73)	.453
Light physical activity (min/day)	45	155 (244)	23	312 (624)	−157	.124*
Moderate physical activity (min/day)	36	93 (111)	17	111 (138)	−19	.784*
Hard physical activity (min/day)	30	33 (58)	4	19 (38)	14	.699*
TDD^b	41	1.71 (1.32)	35	1.54 (0.97)	0.17	.843*
Quality of life	45	56.67 (11.67)	29	56.79 (14.63)	−0.12 (−6.24, 6.01)	.970
Physical	45	60.16 (16.42)	30	59.76 (16.85)	0.40 (−7.40, 8.19)	.920
Psychological	45	45.79 (20.13)	31	49.87 (21.90)	−4.07 (−13.78, 5.64)	.406
Social	45	60.56 (16.99)	31	59.41 (20.50)	1.15 (−7.45, 9.75)	.791
Environmental	45	59.17 (12.67)	30	58.60 (12.81)	0.57 (−5.41, 6.54)	.851

SD: standard deviation; CI: confidence interval; TDD: total daily doses; BMI: body mass index; WC: waist circumference.

t-tests (two-sided) were performed on normal variables with the stated p-values indicating the hypothesis of equality between index and follow-up.

Unit per week equivalent to 12 g alcohol.

Antipsychotic.

Non-normal data were analyzed under the same hypothesis with the non-parametric Wilcoxon’s rank-sum test.

The newly diagnosed patients were, on average, 27.1 years of age and, on average, overweight (BMI, 27.4 kg/m²). They had a high consumption of soft drinks and their physical activity level was, on average, below the recommended level. At follow-up, there was a tendency toward a worsened physical profile, despite reductions in the consumption of fast food and soft drinks. Long-term patients were, on average, 7.5 years older than the newly diagnosed patients, and, on average, obese (BMI, 34.0 kg/m²), and with more body fat and higher WCs than newly diagnosed patients. Like the newly diagnosed patients, the physical activity level of long-term patients was low. After the intervention, long-term patients showed significant reductions in the consumption of soft drinks and fast food. Furthermore, long-term patients lost weight and reduced their WCs, and they were physically more active; however, these differences were not statistically significant.

At index, QoL was especially low among newly diagnosed patients. For both newly diagnosed and long-term patients, QoL was low in all four domains, with the physiological domain experiencing the lowest score. For comparison purposes, the QoL of the general Danish population is shown in Table 3.

Table 3.

Quality of life of the general Danish population.

	Male (SD)	Female (SD)
Quality of life	73.2 (19.0)	73.5 (17.7)
Physical	75.5 (18.7)	79.3 (15.3)
Mental	67.1 (16.7)	71.1 (16.0)
Social	69.5 (18.1)	68.2 (18.0)
Environmental	73.8 (15.7)	73.5 (15.5)

Source: Noerholm et al. (2004).

SD: standard deviation.

At follow-up, the two groups of patients had similar scores. The increase in QoL among newly diagnosed patients was statistically significant in the physiological domain and borderline significant in overall QoL. QoL did not change among long-term patients.

Regression analysis of association between QoL and number of interventions showed that newly diagnosed patients had higher QoL (1.60; p = .021) per intervention, and long-term patients had higher QoL (3.97; p < .001) per intervention.

Regression analyses looking for associations between QoL and physical health parameters (BMI, illness duration, cigarettes and antipsychotic treatment) in newly diagnosed and in long-term patients can be seen in Table 4.

Table 4.

Regression coefficients from the regression analyses investigating the association between each quality of life domain and variables.

QoL domain	BMI	Illness duration	Light phys.	Sex	Age	Soft drinks
Newly diagnosed
QoL	−0.434*
Physical	−0.693**	0.002**		−10.54**	−0.001**	−3.527**
Psychological	−0.559**
Social	0.908**	0.003*	0.028**	−8.655**		−4.307**
Environmental	0.526*				−0.001**
Long-term illness
QoL
Physical
Psychological	−1.081*
Social
Environmental		−0.001*

QoL: quality of life; BMI: body mass index.

p < .001; **p < .05.

For newly diagnosed patients, a higher BMI was significantly associated with lower overall QoL, and physical, psychological and environmental QoL. Duration of illness was significantly associated with higher physical and social QoL. Males had lower QoL in the physical and social domains: –10.5 and −8.7 points, respectively, below females. Remarkably, minutes of light physical activity were associated positively with the social domain. Improvement in QoL was associated with older age and more light physical activity.

For long-term patients, BMI was associated with lower psychological QoL. Unexpectedly, we did not find any association between TDD and QoL or between tobacco smoking and QoL.

Discussion

In this 30-month program, aimed at improving physical health as part of daily clinical routines, we found that QoL was low among patients newly diagnosed with schizophrenia and that QoL improved to the level found among patients with long-term schizophrenia. A higher BMI was significantly associated with lower QoL in both patient groups. Newly diagnosed patients showed better physical health than long-term patients at the start of the program but experienced worsened physical health during the intervention. In contrast, long-term patients began the study with worse physical health but improved on weight, WC, consumption of fast food and soft drinks, and light activity level during the program.

Our baseline results are in accordance with earlier studies (Brissos et al., 2011; Noerholm et al., 2004; Picardi et al., 2006), which reported that patients with schizophrenia have a low QoL. Furthermore, the improvement in QoL among newly diagnosed patients in our study was also shown in a community-based care program in people with severe mental health problems (Roeg, van de Goor, Voogt, van Assen, & Garretsen, 2014). Our results might be explained by the nature and organization of treatment and care to newly diagnosed patient in our clinics. In our experience, once patients are diagnosed with schizophrenia, they struggle with numerous psychiatric symptoms and high levels of stress, thus affecting QoL. In the first 2 years after receiving a diagnosis of schizophrenia, patients receive relatively high amounts of treatment, medication and care, and at the same time, we added our intervention to the mix. This may partially explain why patients have a higher QoL after 2 years of initial treatment (Austin et al., 2015; Petersen et al., 2005). Long-term patients had higher QoL than newly diagnosed patients. This can be due to the fact that long-term patients had time to come to live with their diagnosis and all that follows. Furthermore, long-term patients are possibly more likely to be taking accurate medication and thus end up having the incentive and resources to follow through and carrying out lifestyle changes and other factors affecting QoL.

We found a significant association between higher BMI and lower psychological QoL score in both patient groups. According to other studies, overweight and obesity lead to lowered physical QoL (Faulkner, Cohn, Remington, & Irving, 2007; Kolotkin et al., 2008; Sugawara et al., 2013). This was in accordance with our clinical work where patients with overweight and obesity often complain of discomfort and general physical and psychological problems related to overweight and obesity. Overall, this highlights the importance of preventing weight gain leading to overweight and obesity among patients. In newly diagnosed patients, males had significantly lower QoL than females in the physical ((10.5 points) and social domains ((8.7 points). This difference emphasizes the importance of paying special attention to the treatment and care of male patients.

Among newly diagnosed patients, there was a significant association between the amount of soft drinks consumed and lower QoL in the physical and social domains. This might justify the ongoing work we are doing in the clinic to minimize the intake of soft drinks by patients.

At index, we found newly diagnosed patients were, on average, overweight, had a high consumption of soft drinks and their physical activity level was low. At follow-up, we saw in these patients a tendency to worsen their physical profile despite some reductions in the consumption of fast food and soft drinks. This result was unexpected and raises the question of whether the treatment as usual and intervention were appropriate and adequate. Unfortunately, we do not know how to approach this problem differently, but our results must be taken into account when evaluating our treatment services to this group of patients.

Unexpectedly, we did not find any association between number of cigarettes smoked and QoL. This is in contrast to other studies, where smokers have been reported to have a lower QoL, both in patients with severe mental illness and in the general population (Castro, Matsuo, & Nunes, 2010; Dixon et al., 2007; Toghianifar et al., 2012).

It has been shown that development of a therapeutic relationship with staff increases QoL in inpatients with long-term illness (McCabe, Roder-Wanner, Hoffmann, & Priebe, 1999). In addition, adaptation to changing conditions might alter the patient’s goals, expectations, standards and concerns, thereby increasing QoL (Priebe, Roeder-Wanner, & Kaiser, 2000). A therapeutic relationship, non-specific effect and adaptation could have contributed to our results, as well as an actual effect from the intervention. Our results that the number of interventions had an elevating effect on QoL in patients support this.

Strength

The naturalistic design of the program, where patients were included regardless of illness severity, age, sex, sociodemographic background, physical illnesses and antipsychotic treatment, makes our sample representative of daily clinical practice. A validated questionnaire was used to measure QoL. An additional and important strength of our program was the long study duration of 30 months, which is in contrast to other studies that have been limited by much shorter study periods. Furthermore, we succeeded in implementing new research-based knowledge into clinical practice (Munk-Jorgensen et al., 2015). A central part of the study was that the intervention was close to everyday living and, for most patients, will be experienced as enjoyable, for example healthy and tasty food instead of fast food, walks in the neighborhood or forest, and other leisure activities incorporating physical activity. This may be crucial for success when implementing the intervention in daily routine. There are barriers to improving physical health in patients with schizophrenia and ideally, an intervention should have long-term follow-up and a design structured to elicit a high compliance and follow through. On this basis, we suggest that individual health interventions remain a cornerstone in improving physical health with additional focus on newly diagnosed patients. Improving physical health is relevant throughout the entire lifespan of an individual, from early diagnosis and carried out over the long term.

Limitation

The intervention consisted of several components previously proven effective in randomized controlled trials. We do not know which part is the most efficient, as all parts of the intervention were offered simultaneously and we cannot recommend a particular part, but only the whole program, which is still in development, aiming at usability in a wide variety of patients (Blanner Kristiansen et al., 2015; Hjorth et al., 2014; Weiser et al., 2009). Finally, a higher number of patients might have improved the statistical strength of the study; additionally, we had a dropout from treatment who was lost to follow-up and are at risk of selection bias of which we have no data of magnitude or direction. One possible explanation of the dropout might be that patients with schizophrenia may have trouble complying with a program and intervention because of factors related to their illness, for example, cognitive disturbances, negative and positive symptoms, and side effects of psychotropic medication.

Conclusion

Newly diagnosed patients had a low QoL compared with long-term patients, but during the program, newly diagnosed patients improved their QoL to approximately the same level as patients with long-term illness. The magnitude of the improvement can be seen as a success. Newly diagnosed patients had better physical outcomes at the start of the program, but their health worsened during the study period. Patients with long-term illness started the study with worse physical health but improved on some of the indicators tested. Our results suggest that, individually, interventions addressing health were easily integrated into contemporary treatment and could enhance QoL and physical health.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

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