www.elsevier.es/ejpsy
REVIEW
ARTICLE
Quality
of
Life
Scale
and
symptomatology
of
schizophrenic
patients
---
A
systematic
review
L.M.G.
de
Pinho
a,∗,
A.M.S.
Pereira
a,
C.M.C.B.
Chaves
b,
P.
Batista
caDepartamentodeEducac¸ãoePsicologia,CIDTFF,CINTESIS,UniversityofAveiro,Aveiro3810-193,Portugal
bEscolaSuperiordeSaúdedeViseu,IPV,CI&DETS,Viseu3500-843,Portugal
cUniversidadeCatólicaPortuguesa,RuaDiogodeBotelho,1327,4169-005Porto,Portugal
Received2May2017;accepted8August2017 Availableonline3September2017
KEYWORDS
Schizophrenia; Qualityoflife; Functioning; QualityofLifeScale (QLS);
Symptomatology
Abstract
Background: The Quality ofLifeScale (QLS) was developed toassess the quality oflife of patientswithschizophrenia,byHeinrichs,HanlonandCarpenter,in1984.
Objectives: Thissystematic reviewanalysed thescientific evidence producedfrom theQLS resultsanditsrelationshipwiththesymptomatologyofpatientswithschizophrenia.
Methods:AnelectronicsearchwasconductedonPubmed/MedlineandScopustoidentify rele-vantpaperspublishedwithinthelasttenyears(January2007toDecember2016).Theinclusion criteria were: studieswhose samples included onlyoutpatients with schizophrenia;studies whoseaimwastocomparetheQLSresultswiththesymptomatologyofschizophrenia;studies writteninEnglish.ThePRISMAcriteriaforreportingsystematicreviewsandmeta-analyseswere used.
Results:Twelvestudieswereincludedinthissystematicreview.Atotalof1645patientswith schizophreniafromfourdifferentcountrieswereanalysed.Tenarticlesusedacross-sectional studymethodologyand2articlesinvolvedalongitudinalstudy.
Conclusions: Synthesissuggeststhatqualityoflife/functioninginpatientswithschizophrenia can be influenced by negativesymptoms. Nevertheless, inrelationto positive and depres-sivesymptoms,theresultsarenotcongruentnorconsistent.Therefore,thisliteraturereview indicatedthatmoreresearchisneededinordertoobtainbetterevidencewithregardstothe influenceofthatsymptomatologyonthequalityoflife/functioninginpatientswith schizophre-nia.
©2017Asociaci´onUniversitariadeZaragozaparaelProgresodelaPsiquiatr´ıaylaSaludMental. PublishedbyElsevierEspa˜na,S.L.U.Allrightsreserved.
∗Correspondingauthor.
E-mailaddress:larapinho@ua.pt(L.M.G.dePinho).
https://doi.org/10.1016/j.ejpsy.2017.08.002
0213-6163/©2017Asociaci´onUniversitariadeZaragozaparaelProgresodelaPsiquiatr´ıaylaSaludMental.PublishedbyElsevierEspa˜na, S.L.U.Allrightsreserved.
2 L.M.G.dePinhoetal.
Introduction
Schizophrenia is a severe mental disorder characterised by delusions, hallucinations, disorganised speech, grossly disorganised or abnormal motor behavior and negative symptoms. In most cases still appear cognitive impair-mentsandaffectivesymptoms.Thispathologyisassociated withsignificantsocialandoccupationaldysfunctions.1These deficitsarepresentinover60%ofpatientswith schizophre-nia and normally arise during the first five years of the disease’s progression.2 The best predictors of the deterioration of social functioning seem to be negative symptoms.3
Thesymptomsofthismentalillnessareassociatedwith economic, professional, social and functional difficulties inpatientswhohavelong hospitalisationperiods,delayed recoveryandpoortreatmentoutcomes,whichconsiderably damagetheirqualityoflife.4
For all these reasons, patients with schizophrenia have a poor quality of life as indicated in several studies.5---10 Mostoftherecentstudiesrelatedtothe rela-tionship between quality of life and the symptoms of schizophrenia indicate that negative and positive symp-toms, as well as depression and anxiety, are related to a lower quality of life.5,8,11---14 Other studies delve into the relationship between quality of life and socio demo-graphiccharacteristics,includingage,employmentandlife conditions.6,9,14,15
There are many scales toevaluate the quality of life, but not all are appropriate for mental illness. The Qual-ityofLifeScale(QLS)wasdevelopedbyHeinrichs,Hanlon and Carpenter, in 1984, to assess the quality of life of patientswithschizophrenia.16 TheQLShasbeenan impor-tantassessmentinstrumentinagreatdealofresearch.Ina reviewofqualityoflifescalesusedinstudiesinvestigating thequalityoflifeinpatientswithschizophreniaconducted fromJanuary2009toDecember 2013,theresults demon-strate that the most widely used schizophrenia-specific quality of life scale was QLS.17 In addition to assessing the quality of life, the QLS is recurrently used to assess functional outcomes in schizophrenia18 and is the most widely used scale in research on assessing functioning.19 The QLS stands out fromthe other scales as it measures the functioning of patients with schizophrenia and con-siders negative symptoms, regardless of the presence or absence of positive symptoms. This instrument assesses personalexperience, thequality of personalrelationships and productivity in their occupational role.16 Moreover, the QLS has been validated in a number of countries including the United States, France, Portugal, Spain, Brazil and India, with good psychometric qualities in all validation studies.16,20---24 For all of these reasons, in this review,wechosetoassessmanuscriptswhichhadusedthe QLS.
Theaimofthisstudyistoanalysethescientificevidence producedfromtheQLSresultsanditsrelationshipwiththe symptomatologyofpatientswithschizophrenia.
Method
Datasourcesandsearches
The PRISMA criteria were applied for meta-analyses and systematic reviews (Prisma).b The EndNote bibliographic computerprogramwasusedinthisstudy.
Weconductedastudyoftheliteraturereviewusing digi-taldatabaseresearch,Medline/Pubmed,andScopus,inthe lasttenyears(2007to2016).We recognisedarticles pub-lished in international journals which used the QLS. The descriptors‘‘schizophreniaANDQLS’’wereused.Oursearch wasrestrictedtoarticlespublishedinEnglish.
QualityofLifeScale(QLS)
AQualityofLifeScale(QLS)wasdevelopedin1984by Hein-richs,HanlonandCarpenter.Itsinitialpurposetomeasure thedeficit syndromeinpatientswithschizophreniawithin the last four weeks. It consists of a semi-structured 21-item interview with 7 points for each item. It should be appliedby aclinicianandtakes approximately45minutes tobeapplied.Itisdividedintofourdimensions: Intrapsy-chicFoundations---IF(whichassessesmotivation,curiosity, empathy,theabilitytofeelpleasureandemotional inter-action); Interpersonal Relations --- IR (which assesses the quality and quantity of social relationships); Instrumen-tal Role Functioning --- IRF(which assesses productivity in their occupational role, whether at work, at school or in householdchores/parentalrole)andCommonObjectsand Activities---COA(whichassessesthepossessionofcommon objects,suchasawatchtoseethetimeandinvolvementin regularactivitieswhichassumeactiveparticipationin soci-ety,suchasusingpublictransport).Thetotalscoreofthe scaleandeachofthedomainsrangesfrom0to6.Ascore between5and6isconsideredunaltered,from2to4reveals considerable loss, and a score between 0 and 1 suggests seriousimpairmentinfunctioning.
Subsequently, abbreviated versions of the scale which demonstrated good psychometric properties were con-structed to facilitate their application in clinical settings.25---27 In one of the studies, the results showed that anabbreviated version ofthe 7-itemscale predicted a total score of 21 items with high precision, obtaining reliable results.25 Recently, anotherstudy validated these results,usinga sample of1430participants, for thesame 7-itemscale.AnotherstudyvalidatedaQLS5-itemscale.27 In2016theQLSwasrevisedusingexploratoryfactor anal-ysesand confirmatoryfactor analysestoassess thefactor structure of the QLS. The sample was comprised of two
bPRISMA Transparency reporting of systematic reviews and
meta-analyses. Available in PRISMA Transparency reporting
of systematic reviews and meta-analyses. Available from:
groups, a mixed diagnostic sample of multi-episode par-ticipants (N=247) anda sample ofindividuals witha first psychoticepisode(N=337).Theresultsshowedthestrength of the 3-factor model of the QLS-R in schizophrenia and mixeddiagnosticsamples.18
Eligiblecriteria
Allofthearticleswereevaluatedaccordingtothefollowing criteria:(1)thestudysamplesincludeonlyoutpatientswith schizophrenia; (2) theaim of thestudies wastocompare theQLSresultswiththesymptomatologyofschizophrenia; (3)studies written in English.The inclusionand exclusion criteriaaredescribedinTable1.Studiesthatdidnotmeet theabovecriteriawereexcluded.
Dataextraction
Pertinentdata were extracted bytwo reviewers indepen-dentlyanddivergenceswereresolvedbydiscussionandnew analysesofthearticle.Whenevernecessary,athirdreviewer was consulted. The studies were compiled in a summary table for a better understanding of the systematic liter-ature review. This table was compiled under nine items: author, year, sample, country, methodology, instruments, dimensionsevaluated,resultsandaimofthestudiesreview (Table2).
Selectionprocess
In the first search, when the descriptors ‘‘QLS AND schizophrenia’’wereused,wefound 79articlespublished inMedline/PubMedand 91publishedin Scopus.A number of the same scientific papers had been published in both databases.Nevertheless,wefound15differentpublications inScopus,sothattherewere94publicationstoanalysein all.
89 full-text publications were analysed and 77 were excluded: 12 articles were related to patients living in institutions or patients with other pathologies associated with schizophrenia; 56 publications did not compare the QLS resultswiththesymptomatologyof schizophrenia(27 publicationswereconcernedwithmedicationortreatment in schizophrenia, 2 publications focused on the abbrevi-atedQLSscale,1publicationdealtwithconfirmatoryfactor analysisoftheQLS,6articleswereaboutthepsychometric characteristicsofother scales;and20publicationshadan anotheraim),5articleshadnotbeenwritteninEnglishand 4articleswerenotprimarystudies.
Inall,12studieswereincludedinthisreview.Thestudy selectionprocessisshowninthefollowingflowchart(Fig.1).
Results
Twelvecompletearticleswhichmetthecriteriawere ana-lysed and used in this review (Table 2). A total of 1645 patientswithschizophrenia(1023males and622females) fromfour differentcountries (Brazil,Italy, United States, Japan)werealsoanalysed.
All ofthe studies usedinternationallyrecognised diag-nostic criteria for schizophrenia with 10 studies using
the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR or DSM-IV), 1 article using the International Classification of Diseases (ICD-10) and one study apply-ingtheMiniInternationalNeuropsychiatricInterview(MINI) to confirm diagnoses. All of the samples were made up of patients at a stablestage of the disease in outpatient treatment.
Tenarticleswerestemmedfromcross-sectionalstudies while2articleswerebasedonlongitudinalstudies.
Datacollectionof allof the studieswascarried outin health institutions, such as departments of psychiatry or psychosocialrehabilitationcentresandadhered toethical principles,withpermissionobtainedfromethicscommittees andfromtheinstitutionswherethestudieswereconducted. Participants’informedconsentwasalsoobtained in allof thestudies. The assessment instruments wereapplied by experiencedresearchers.
Allof the studiesevaluatedpsychotic symptomswhich arecharacteristicofschizophrenia(negativesymptomsand positivesymptoms).Toevaluatethesesymptoms,10studies usedthePositiveandNegativeSyndromeScale(PANSS),one studyusedtheScaleforAssessmentofNegativeSymptoms (SANS)andtheScale forAssessmentof PositiveSymptoms (SAPS)anda studyusedtheBriefPsychiatricRating Scale (BPRS).
Withrespecttonegativesymptoms,PANSSevaluatesthe presence and degree of blunted affect, emotional with-drawal,poorrapport,passive/apatheticsocialwithdrawal, difficultyinabstractthinking,lackofspontaneityandflow ofconversationandstereotypedthinking.Regardingpositive symptoms,it evaluates the presence and degree of delu-sions, conceptual disorganisation, hallucinatory behavior, excitement, grandiosity, suspiciousness/persecution, and hostility.
Sevenstudiesalsoevaluateddepressivesymptomatology. TheyallusedtheCalgaryDepressionScale for Schizophre-nia(CDSS),whichhasbeenspeciallydevelopedtoevaluate depressive symptoms in patients with schizophrenia, dis-tinguishingitfrompsychoticsymptomsandsideeffectsof antipsychotics.
One study evaluated the basic symptoms assessed by theItalianversionoftheFrankfurtComplaintQuestionnaire (FCQ),called FBF, evaluating:loss of control,simple per-ception,complexperception, language,thought,memory, motility,lack of automatism,anhedonia,anxiety and sen-soryoverstimulation.
Regarding the aims of the studies, 8 had stated that one of their specific aims was to evaluate the relation-ship between qualityof life/functioning assessed through the QLS and the symptomatology. One of these only assessed the symptom disorganisation and 4 specifically assessed the clinical factors, including symptomatology, andqualityoflife/functioning. Ofthesestudies, fouralso evaluatedcognitivedysfunction;oneevaluatedinsightand coping, one assessed levels of life skills and one self-perceived recovery. Two also studied sociodemographic data.
In one study,28 the results demonstrated that the best predictorsofqualityoflifearenegativesymptomsand cog-nitive deficits. Better QLS results were found in patients withfewernegativesymptomsregardless oftheresultsof theSchizophreniaCognitionRatingScale(SCoRS).Moreover,
4 L.M.G.dePinhoetal.
Table1 Inclusion/exclusioncriteria.
Inclusioncriteria Exclusioncriteria Justificationofcriteria Studiesinwiththe
sampleonlyincluded outpatientswith schizophrenia
Thesampleofthestudies whichincludedpatientswith otherpathologiesassociatedor patientslivingininstitutions
Weincludedonlystudiesthatexamine outpatientswithschizophreniaandexcluded studiesthatanalysedpatientslivingininstitutions orpatientswithotherpathologies,forexample, schizophreniformdisorder,delusionaldisorderor firstpsychoticepisode
Theaimofthestudies wastocomparethe resultsoftheQLSwith symptomatologyof schizophrenia
Publicationsthatdidnot comparetheresultsofQLS withthesymptomatologyof schizophrenia
Weexcludedpublicationsthat:
comparetheresultsofQLSwithmedicationor othertypesoftreatment;
comparetheresultsoftheQLSwithcognitive impairments;
evaluatedthepsychometriccharacteristicsofthe QLSorotherscales;
compareapatient-ratedsubjectiveQoLscale withanobserver-ratedQoLscale;
and
otherarticlesthatdidnotcomparetheresultsof theQLSwiththesymptomatologyofschizophrenia StudieswritteninEnglish StudiesnotwritteninEnglish OnlystudieswritteninEnglishwereincluded Primarystudies Bookschapters,conference
abstracts;commentaries; reviews;dissertations.
Studieswererestrictedtoprimarystudieswith empiricalliterature E ligi b ili ty
Records identified through database searching MEDLINE/PUBMED (n = 79) S cr e e ni ng Inc lude d Id e n ti fi c at
ion Records identified through database
searching SCOPUS (n = 91)
Records after duplicates removed (n = 94)
Records screened (n = 94)
Records excluded (n = 5)
Full-text articles assessed for eligibility (n = 89)
Full-text articles excluded, with reasons
(n = 77)
Studies included in quantitative synthesis
(n = 12)
12 related to patients living in institutions or with other pathologies
the aim of 56 is not in line with this study
5 had not been written in English
of Life Scale and symptomatology of schizophrenic patients 5
Table2 Summaryofinformationfromseventeenrelevantarticleswhichmetourinclusioncriteriainthestudyof‘‘QualityofLifeinPatientswithSchizophreniaevaluated withtheQualityofLifeScale(QLS)’’.
Author/year Sample Country Methodology Instruments Dimensionsevaluated Aim Results
Cruzetal., 201628 N=79outpatients withschizophrenia (MINIcriteria) Brazil Cross-sectional study QLS-BR SCoRS PANSS CDSS Qualityoflife Cognition Severityofsymptoms Toevaluatethe correlation betweenQOL, symptomsand cognition.
Thebestpredictorsofqualityoflife(QOL) werecognitivedeficits(p<0.001)andnegative symptoms(p<0.001).Regardless,positive symptomsalsoinfluencequalityoflife (p=0.026).
AbetterQOLwasfoundinpatientswithalow degreeofnegativesymptoms,regardlessof SCoRSrating.Betweenparticipantswithmore severenegativesymptoms,aworseQOLwas foundinpatientswithelevatedcognitive impairment. Roccaetal., 201629 N=323outpatients withschizophrenia (DSM-IV-TR) Italy Cross-sectional study QLS PANSS CGI-S CDSS GAF SUMD Qualityoflife Symptoms Levelsoffunctioning Toidentifyprofiles offunctioningin patientswith schizophrenia empirically; Toassessfactors associatedwith thebestprofile membership.
Theresultsdemonstratethatfewernegative symptoms,lessseveredepressivesymptoms, beingemployed,havingalong-term relationship,andtreatmentwithSGAswere associatedwithgoodfunctioning.
Montemagni etal.,201430 N=92outpatients withschizophrenia (DSM-IV-TR) Italy Cross-sectional study QLS CGI-S PANSS CDSS GAF SUMD WCST RSES CISS Qualityoflife Globalillnessseverity Negativesymptoms Insight Coping Toassessthe relativeinfluences ofnegative symptomatology, insightandcoping onQOL.
Theresultssuggestthatforpatientswith highernegativesymptoms,insightand coping-socialdiversioncontributetoQOL: highernegativesymptomspredictworse intrapsychicfoundations(QLS-IF)subscale scoresandsymptomsandcoping-social diversionsuggestapositiveQLS-IF.
Kuklaetal., 201431 N=68outpatients withschizophrenia (DSM-IV-TR) United States Cross-sectional study QLS PANSS RAS Qualityoflife Perceptionsof recovery Symptomatology Toevaluatethe relationship between self-perceived recovery,
symptoms,andthe socialcomponents ofqualityoflife.
Theresultsdemonstratethattheparticipants withmoreseverelevelsofpositivesymptoms andastrongersubjectiverecoveryachieved higherlevelsintheQLSIntrapsychic FoundationsandtheQLSinstrumentalrole functioningcomparedtoparticipantswithhigh positivesymptomsbutlowerlevelsofrecovery.
6 L.M.G. de P inho et al. Table2 (Continued)
Author/year Sample Country Methodology Instruments Dimensionsevaluated Aim Results
Roccaetal., 201432 N=92outpatients withschizophrenia (DSM-IV-TR) Italy Cross-sectional study QLS PSP CDSS CGI-S SANS SAPS Real-world functioning Negativesymptoms (DE---affective flatteningandalogia; AA---avolitionand anhedonia) Toassessthe relationshipof specificnegative symptoms’ components(DE, AA)withseparate domainsofreal worldoutcomes (thePSPand selecteditemsof theQLS)and recent employmentand marriage.
AAwasassociatedwiththeleveloftheQLS interpersonalrelationsandsocialnetwork,and thepersonalandsocialperformancemeasured bythePSP.
TheAAsubdomainwasasignificantpredictor ofthesocialoutcome,marriage.
TheDEsubdomaindoesnotappeartohavean impactonreal-worldfunctionalperformance.
Sigaudoetal., 2014 N=276outpatients withschizophrenia (DSM-IV-TR) Italy Cross-sectional study QLS CGI-S PANSS StroopTest TMT CVLT WCST Qualityoflife Disorganisation Cognitivedysfunction Toevaluatethe relative contributionsof disorganisation andcognitive dysfunctionto QOL.
Disorganisationhadanegativerelationship withQOL,withtherole-functioningdomain andtheintrapsychicfunctioningdomain. Verbalmemorywasapartialmoderatorofthe associationbetweendisorganisationandQOL.
Silvaetal., 201134 N=79outpatients withschizophrenia (ICD-10) Brazil Cross-sectional study QLS-BR PANSS Qualityoflife Social-demographic factors Clinicalfactors
ToassessQOLand the sociodemographic andassociated clinicalfactorsin patientswith schizophrenia.
Occupationalperformancewasthemost frequentlyaffectedarea.Maritalstatus,race, occupation,cohabitation,homelessness, havingchildren,previouspsychiatric hospitalisationandnegativesymptomswere thevariablesthatindicatedasignificant associationwithsevereimpairmentofQOL. Ueokaetal., 201135 N=61outpatients withschizophrenia (DSM-IV) Japan Longitudinal study QLS BACS PANSS CDSS DIEPSS Qualityoflife Cognitivefunction Toanalysethe association betweenclinical factors,especially cognitive dysfunction,and QOLin schizophrenia.
Theresultsfoundthatnegativeanddepressive symptomsareimportantfactorsforQOLin patientswithschizophrenia.
Moreover,therewasasignificantandpositive correlationwiththeQLSandtheBACS compositescore,theattentionandspeedof informationprocessingscoreandtheverbal memoryscore.
Moreover,cognitiveperformanceprovidesa determinantofQOL.
of Life Scale and symptomatology of schizophrenic patients 7
Author/year Sample Country Methodology Instruments Dimensionsevaluated Aim Results
Roccaetal., 201036 N=118outpatients withschizophrenia (DSM-IV-TR) Italy Cross-sectional study QLS GAF PANSS FBF CDSS Qualityoflife Globalfunctioning Basicsymptoms(BS) Toanalysethe relationshipofBS withobjective symptoms, functioningand QOLina populationof outpatientswith schizophrenia.
Theresultsdemonstrateasignificant
correlationwithQOLandfunctionaloutcome. BSshowedasignificantrelationshipwiththe depressivedimension(p<0.001)andglobal functioning(p<0.05)andsomeaspectsof QOL,QLS-IF(p<0.05). Perlicketal., 200837 N=309outpatients withschizophrenia (DSM-IV United States Longitudinal study QLS PANSS WCST TMT Functionalstatus Neurocognitive factors Toanalysethe relationship betweenpositive andnegative symptoms,aswell asof neurocognition withfunctional statusinpatients with schizophrenia.
ThePANSSexplained16%additionalvariancein QLStotalscoreafteraccountingfor
demographicsandvisitnumber.
Theneurocognitivefactorsexplainedonly4% additionalvariancebeyondtheeffectofthe symptoms.
Theseresultssuggestthatsymptomsmaypose anequalorgreaterimpedimenttofunctional capacityindependentofneurocognitionin patientswithschizophrenia.
Akietal., 200838 N=64outpatients withschizophrenia (DSM-IV) Japan Cross-sectional study QLS SQLS LSP BPRS CDSS Subjectivequalityof life Objectivequalityof life Lifeskills Symptoms Toevaluatethe associations between subjectiveand objectiveQOL, levelsoflifeskills andclinical determinantsin patientswith schizophrenia.
Theresultsshowedthatthepatients’QOL couldbepredictedbytheirlifeskillsmeasured byafamilymember.
Theresultssuggestthatnegativesymptoms predictQOLevaluatedbytheQLS.However, positivesymptomsdidnotpredictQOL. Theresultssuggestedthatactivetreatment fordepressiveandnegativesymptomsmight berecommendedtoimproveschizophrenic QOLandlifeskills.
Yamauchietal., 200839 N=84schizophrenia outpatients(DSM-IV) Japan Cross-sectional study QLS SQLS PANSS DIEPSS Subjectivequalityof life Objectivequalityof life Clinicalvariables Extrapyramidal symptoms Tocomparethe association betweenclinical variablesand subjectiveand objectiveQOLin patientswith schizophrenia.
Cognitivedysfunctionhadabettereffecton objectiveQOLthansubjectiveQOL.
Negativesymptomswerenegativelycorrelated withobjectiveQOL(evaluatedbyQLS).
BACS(BriefAssessmentofCognitioninSchizophrenia);BPRS(BriefPsychiatricRatingScale);CDSS(CalgaryDepressionScaleforSchizophrenia);CGI-S(ClinicalGlobalImpression-Severity Scale);CISS(CopingInventoryforStressfulsituations);CVLT(CaliforniaVerbalLearningTest);DIEPSS(Drug-InducedExtrapyramidalSymptomsScale);FBF (Frankfurter-Befindlichkeits-Skala);GAF(GlobalAssessmentofFunctioningScale);LSP(LifeSkillsProfile);PANSS(PositiveandNegativeSyndromeScale);PSP(PersonalandSocialPerformanceScale);RAS(Recovery AssessmentScale);RSES(RosenbergSelf-EsteemScale);SANS(ScaleforAssessmentofNegativeSymptoms);SAPS(ScaleforAssessmentofPositiveSymptoms);SCoRS(TheSchizophrenia CognitionRatingScale);SUMD(ScalefortheAssessmentofUnawarenessofMentalDisorder);TMT(TrailMakingTest);WCST(WisconsinCardSortingTest).
8 L.M.G.dePinhoetal. among schizophrenics with more severe negative
symp-toms,QLS scores were lowerin thosewithhigh cognitive deficits. Depressive symptoms did not influence the QLS results.
Onestudy29groupedtheparticipantswithschizophrenia byperformancelevelsassessedby QLS,dividedintothree groups,‘‘GoodQOL’’, ‘‘moderateQOL’’and‘‘poorQOL’’ andrelatedthesethreegroupswithsociodemographicand clinicalfactors,Including negative/positivesymptomsand depressivesymptoms.Theauthorsconcludedthatthegood QOLgrouphadlowerseveritylevelsofnegativeand depres-sivesymptoms.
In another study,30 which related negative symptoms, copingandinsight,insightandcoping-socialdiversionwere found to contribute to improving the quality of life in patientswithhighnegativesymptoms.
In another study,31 the results demonstrated that for patientswithconsiderablepositivesymptoms,higherlevels of subjective recovery were related to better instrumen-talrolefunctioningand intrapsychicfoundationalabilities evaluatedbytheQLS.
Oneof the studies32 evaluatedspecific negative symp-toms(DE---affectiveflatteningandalogia;AA---avolitionand anhedonia)andrelatedthemtothreeQLSdomains (exclud-ingthe IFdomain which evaluates negative symptoms)in ordertoevaluaterealworldfunctioning.AAwasfound to bethemost stronglyassociatedwiththelevel of theQLS interpersonal relations (p<0.001). The DE subdomain did notappeartohaveanimpactonreal-worldfunctional per-formanceevaluatedbytheQLS.
One study33 found that there wasa negative relation-shipbetweendisorganisationandQOLintherolefunctioning domainandtheintrapsychicfunctioningdomain.
Onestudy,34 which evaluatedtherelationship between QOL and sociodemographic and clinical factors, obtained statistically significant results between QOL and negative symptoms,findingthat negativesymptoms influencedthe QLSresults.Positive symptomsdidnotproducesignificant results.
Anotherstudyfoundthatnegativeanddepressive symp-tomsareimportantfactorstoQOL,obtainingnegativeand significantcorrelationsbetweentheQLSandPANSSandCDSS values.35
Thestudy36whichevaluatedthebasicsymptomsthrough the FBF demonstrated a significant correlation between themandtheintrapsychicfunctioningdomain.
Inonestudy37 thatrelatednegativeandpositive symp-tomsandneurocognitivefunctioningtothefunctionallevel ofschizophrenics, PANSS wasfound toexplain 16%of the variance in the total QLS score. Neurocognitive factors only explain 4%, such that it was found that symptoms impairfunctionallevelasmuchormorethanneurocognitive deficits.
Inthestudy38 whichusedBPRS,significantresultswere obtainedbetweentotalQLSandBPRSfornegativesymptoms (R2=0.329;ˇ=−0.573;p<0.001).
In another study,39 negative symptoms were nega-tively associated with QOL (=−0.535; p<0.001). There was no significant correlation between QOL and positive symptoms.
Discussion
The quality of life and level of functioning are consid-ered important results in the recovery of patients with schizophrenia,withparticularattentionbeingpaidtothese areasinrecentyears.Somestudieshavedemonstratedthe association of some clinical andsociodemographic factors withqualityoflifeandleveloffunctioning.However,many ofthescalesusedarenotspecifictoschizophreniaand,in addition,theapplicationofdifferentassessmenttoolsinthe various studies may influence the scientific evidence.For this reason,thisreview was carriedout,which evaluated only studies thatusedthe QLS asaninstrument toassess thequalityoflife/functioning,comparingtheresultswith thesymptomsofpatientswithschizophrenia.
Analysis of the results showed that most of the stud-ies found a negative correlation between quality of life/functioningandthenegativesymptomsof schizophre-nia. Given that negative symptoms interfere in social relationships andin leisure activitiesdue totheir charac-teristics, onewouldexpectthemtointerferewithquality oflifeorfunctionallevel.Oneofthestudieswentfurther andevaluatedspecificnegativesymptoms,classifyingthem asDE(affectiveflatteningandalogia)andAA(avolitionand anhedonia)andcomparingthemwiththreedomainsofthe QLS, reachingtheconclusionthatavolition andanhedonia stronglyinfluencetheinterpersonalrelationsdomainsofthe QLS,whereasaffectiveflatteningandalogiadidnotappear tohavealargeimpactonQLSresults.32Giventhatavolition isconcernedwithalackofwillandanhedoniawithalackof pleasureinactivities, theyareunderstoodtoaffect inter-personalrelationships,astheyencouragethepatienttostay athome,leadingtoisolation.Onestudyalsoconcludedthat negativesymptomsinfluencethequalityofliferegardlessof cognitivedeficits.28
With regard to positive symptoms in schizophrenia, in onestudy29disorganisationhadanegativerelationshipwith qualityoflifeintwodomains:therolefunctioningandthe intrapsychicfunctioning.Inanotherstudy,37 positive symp-toms negatively influence the QLS total score and all of thesubscales.However,inanotherstudy,36 positive symp-tomswereassociatedonlywiththepsychosocialfunctioning domainoftheQLS.Wefoundthat,regardingtheinfluence ofpositivesymptomsonQLS,theresultsarenotsimilar,so that wecannot considerthat positivesymptoms influence thequalityoflife.
As far as depressive symptoms are concerned, two studies showed that they negatively influence quality of life/functioning in patients with schizophrenia.29,35 However, the remaining studies that studied depressive symptoms found no correlation between these and the QLS.28,30,36,38
Finally, the study that evaluated the basic symptoms demonstrateda significant correlation between theseand theintrapsychicfunctioningdomainoftheQLS.36
In additionto these results, one study30 found that in agroup ofpatientswithseverenegativesymptoms,those with better insight and coping strategies had a better qualityoflife. Anotherstudy31 found thatamongpatients withmore positive symptoms,thosewith betterlevels of
subjectiverecoveryperformedbetterontheQLS instrumen-talrolefunctioningandintrapsychicfoundationaldomains. Theseresultssuggestthatsymptomatologyinfluencesthe qualityoflife,especiallynegativesymptoms.Forthis rea-son, we consider it very important that interventionsfor patientswithschizophreniadonotjustfocusondecreasing positivesymptoms,butalsoonreducingnegativesymptoms. Summaryofmethodologicallimitations
Themethodologyforinclusionandexclusioncriteriaofthe systematic reviews always restricted the results obtained andcanleaveoutseveralimportantstudies.Inthisstudy, oneinclusioncriterionwasstudiedthatusedtheQLS.This factexcludednumerousstudiesthatusedotherscales. How-ever,weconsideritveryimportanttoconductastudythat onlyusedonescaletomeasurethesameconstructbecause the existing scales are very different and comparing the resultswouldnotbeveryreliable.Thus,withthesecriteria, webelieveourstudyallowedustomakeamoreaccurate andjudiciouscomparisonofthevariablesidentified.
There wasonelimitationwe foundin thearticles ana-lysed:smallsamples.28,31,34,35,38
Implications
for
practice
Schizophreniaisaseverementalhealthdisorderwithserious challengestoqualityoflife/functioning.Thus,thisdiseaseis surelyaconsiderableprobleminhealthsciences.Moreover, themechanismsofthismentalhealthconditionarestillfar frombeingelucidatedandmorestudiesshouldbeconducted tobetterunderstandthisdisease.
Nowadays,thereisnosystematicliteraturereviewthat providesameta-analysisintothequalityoflife/functioning in patients with schizophrenia evaluated by the QLS and theassociationwithsymptomatology.Theaimofthisstudy wastoascertainwhathasbeendoneandtoaccentuatethe importanceofcarryingoutfutureresearch.
Thisresearchsuggestsnewandmorelongitudinalstudies arenecessaryandthatitisimportanttoextendthesestudies toothercountries.
Conclusion
Thisreviewhasidentifiedcommonconcernsreportedin dif-ferentstudies.
The studiesanalysed, therefore,suggest thatthe qual-ity of life/functioning in patients with schizophrenia can be influenced by symptomatology (negative, positive and depressivesymptoms). As regardsnegative symptoms the studies appear to be consistent. Nevertheless, in with regardstopositiveanddepressivesymptoms,theresultsare notcongruentorconsistent.
We can thus conclude that the results of the studies analyseddemonstratethatthenegativesymptomsinfluence thequalityoflifeofpatientswithschizophrenia.However, several other studies do not offer conclusive evidence as to whether it is possible to obtain a comprehensive understanding regarding other symptoms influencing the qualityoflifeofpatientswithschizophrenia,owingtopoor
samples,lack ofgeneralisability and theheterogeneity of theseinvestigations.
This literature review indicated that more research is needed to find better evidence as to the symptoms that influencethequalityoflifeinpatientswithschizophrenia.
Itisalsosuggestedthatasystematicreviewofthe liter-atureshouldbeperformedtoevaluatethestrategiesused inpsychosocialrehabilitationanditseffectivenessin reduc-ingthe negativesymptomsof patients withschizophrenia consequentlyimprovingthequalityoflife/functioning.
Funding
Therewasnofundingforthiswork.
Conflicts
of
interest
Theauthorshavenoconflictofinteresttodeclare.
References
1.American Psychiatric Association. Diagnostic and Statistical ManualofMentalDisorders(DSM-5).5thed.Washington,DC: AmericanPsychiatricAssociation;2013.
2.Ochoa S, Usall J, Villalta-Gil V, Vilaplana M, Márquez M, ValdelomarM,etal.Influenceofageatonsetonsocial func-tioning in outpatients with schizophrenia. Eur J Psychiatry. 2006;20:157---63.
3.CoutureSM,GranholmEL,FishSC.Apathmodelinvestigation of neurocognition, theory of mind,social competence, neg-ative symptomsand real-worldfunctioning inschizophrenia. SchizophreniaRes.2011;125:152---60.
4.AddingtonJ,AddingtonD.Socialandcognitivefunctioningin psychosis.SchizophreniaRes.2008;99:176---81.
5.AlessandriniM, Lanc¸onC,FondG, Faget-AgiusC,RichieriR, FaugereM,etal.Astructuralequationmodellingapproachto explore thedeterminants ofqualityof lifeinschizophrenia. SchizophreniaRes.2016;171:27---34.
6.ChouCY,MaMC,YangTT.Determinantsofsubjective health-relatedqualityoflife(HRQoL)forpatientswithschizophrenia. SchizophreniaRes.2014;154:83---8.
7.MeestersPD,ComijsHC,deHaanL,SmitJH,EikelenboomP, BeekmanATF, etal. Subjective qualityoflifeand its deter-minants in a catchment area based population of elderly schizophreniapatients.SchizophreniaRes.2013;147:275---80. 8.BrissosS,Balanzá-MartinezV,DiasVV,CaritaAI,FigueiraML.
Is personal and socialfunctioning associated withsubjective qualityoflifeinschizophreniapatientslivinginthecommunity? EurArchPsychiatryClinNeurosci.2011;261:509---17.
9.Cesari L, Bandeira M. Avaliac¸ão da qualidade de vida e percepc¸ãodemudanc¸aempacientescomesquizofrenia.JBras Psiquiatria.2010;59:293---301.
10.AkiH,TomotakeM,KanedaY,IgaJI,KinouchiS,Shibuya-Tayoshi S, et al. Subjective and objective quality of life, levels of lifeskills,andtheirclinicaldeterminants inoutpatients with schizophrenia.PsychiatryRes.2008;158:19---25.
11.Gómez-de-RegilL.Cursodelaenfermedadycalidaddevidaen pacientesmexicanosconpsicosis.RevPsiquiatríaSaludMental. 2015;8:218---23.
12.Górna K, Jaracz K, Jaracz J, Kiejda J, Grabowska-Fudala B, Rybakowski J. Social functioning and quality of life in schizophreniapatients---relationshipwithsymptomatic remis-sionanddurationofillness.PsychiatriaPolska.2013;48:277---88.
10 L.M.G.dePinhoetal. 13.SongYY,KimKR,ParkJY,LeeSY,KangJI,LeeE,etal.Associated
factorsofqualityoflifeinfirst-episodeschizophreniapatients. PsychiatryInvestig.2011;8:201---6.
14.HeiderD,AngermeyerMC,WinklerI,SchomerusG,Bebbington PE, BrughaT,et al.Aprospective studyofQualityoflifein schizophreniainthreeEuropeancountries.SchizophreniaRes. 2007;93:194---202.
15.Cardoso CS,Caiaffa WT,BandeiraM,SiqueiraAL, Abreu MN, Fonseca JO. Qualidade de vida e dimensão ocupacional na esquizofrenia: umacomparac¸ão porsexo Quality oflife and occupationaldomain inschizophrenia: agender comparison. CadernosSaúdePública.2006;22:1303---14.
16.Heinrichs DW,Hanlon TE, CarpenterWT. The quality oflife scale: aninstrumentfor ratingtheschizophrenicdeficit syn-drome.SchizophreniaBull.1984;10:388---98.
17.KarowA,WittmannL, SchöttleD,SchäferI,LambertM.The assessmentofqualityoflifeinclinicalpracticeinpatientswith schizophrenia.DialogClinNeurosci.2014;16:185---95.
18.MueserKT,KimM,AddingtonJ,McGurkSR,PrattSI, Adding-ton DE. Confirmatory factor analysis of the quality of life scale and new proposed factor structure for the quality of life scale-revised. Schizophrenia Res. 2017;181:117---23, http://dx.doi.org/10.1016/j.schres.2016.10.018.
19.Fervaha G, Foussias G, Siddiqui I, Agid O, Remington G. Abbreviatedqualityoflifescalesforschizophrenia: compari-sonandutilityoftwobriefcommunityfunctioningmeasures. SchizophreniaRes.2014;154:89---92.
20.Vallerand R. Vers une methodologie de validation tran-sculturelle de questionnaires psychologiques. Can Psychol. 1989;30:662---80.
21.GuedesdePinhoL,PereiraA,ChavesC.Portugueseadaptation ofthequalityoflifescaleforpatientswithschizophrenia.Rev IberoamDiagEvalPsicològ.2017[inpress].
22.RodríguezA, SolerRM,RodríguezA,Esparcia AJJ,MiaronsR. Estudiofactorialyadaptacióndelaescaladecalidaddevidaen laesquizofrenia(QLS).RevPsicologGenApl:RevFedEspa˜nola AsocPsicolog.1995;48:353---64.
23.Cardoso CS, BandeiraM,Caiaffa WT,FonsecaJOP.Escala de qualidade de vida para pacientes com esquizofrenia QLSBR: adaptac¸ão transcultural para o Brasil. J Bras Psiquiatria. 2002;51:31---8.
24.GuptaN,MattooSK,BasuD,LobanaA.Psychometricproperties ofqualityoflife(QLS)scale:abriefreport.IndianJPsychiatry. 2000;42:415.
25.BilkerWB, BrensingerC,Kurtz MM,Kohler C,Gur RC, Siegel SJ,etal.Developmentofanabbreviatedschizophreniaquality oflifescaleusinga newmethod.Neuropsychopharmacology. 2003;28:773---7,http://dx.doi.org/10.1038/sj.npp.1300093. 26.Fervaha G, RemingtonG. Validation of anabbreviated
qual-ityoflifescaleforschizophrenia.EurNeuropsychopharmacol. 2013;23:1072---7.
27.Ritsner M, Kurs R, Ratner Y, Gibel A. Condensed
ver-sion of the Quality of Life Scale for schizophrenia for use in outcome studies. Psychiatry Res. 2005;135:65---75, http://dx.doi.org/10.1016/j.psychres.2005.01.007.
28.CruzBF,ResendeCBD,CarvalhaesCF,CardosoCS,TeixeiraAL, KeefeRS,etal.Interview-basedassessmentofcognitionis a strongpredictorofqualityoflifeinpatientswithschizophrenia andseverenegativesymptoms.RevBrasPsiq.2016;38:216---21. 29.Rocca P, Montemagni C,Mingrone C, Crivelli B, Sigaudo M, BogettoF.Acluster-analyticalapproachtowardreal-world out-comeinoutpatientswithstableschizophrenia.EurPsychiatry. 2016;32:48---54.
30.MontemagniC,CastagnaF,CrivelliB,DeMarziG,FrieriT,Macrì A,etal.Relativecontributionsofnegativesymptoms,insight, andcopingstrategiestoqualityoflifeinstableschizophrenia. PsychiatryRes.2014;220:102---11.
31.KuklaM,Lysaker PH,RoeD.Strong subjectiverecovery as a protectivefactoragainsttheeffectsofpositivesymptomson qualityoflifeoutcomesinschizophrenia.Comprehen Psychia-try.2014;55:1363---8.
32.RoccaP,MontemagniC,ZappiaS,PiteràR,SigaudoM,BogettoF. Negativesymptomsandeverydayfunctioninginschizophrenia: across-sectionalstudyinarealworld-setting.PsychiatryRes. 2014;218:284---9.
33.SigaudoM,CrivelliB,CastagnaF,GiugiarioM,MingroneC, Mon-temagniC,etal. Qualityoflifeinstableschizophrenia:the relativecontributionsofdisorganizationandcognitive dysfunc-tion.SchizophreniaRes.2014;153:196---203.
34.Silva TFCD, Mason V, Abelha L, Lovisi GM, Cavalcanti MT. Qualityoflifeassessmentofpatientswithschizophrenic spec-trumdisorders from PsychosocialCare Centers. JBras Psiq. 2011;60:91---8.
35.UeokaY,TomotakeM,TanakaT,KanedaY,TaniguchiK,Nakataki M,et al. Quality oflifeand cognitive dysfunctioninpeople withschizophrenia.ProgNeuro-PsychopharmacolBiol Psychi-atry.2011;35:53---9.
36.RoccaP,PulvirentiL,MontemagniC,RasettiR,RoccaG,Bogetto F.Basicsymptomsinstableschizophrenia:relationswith func-tioningandqualityoflife.ClinNeuropsychiatry.2010;7:100---10. 37.Perlick DA, Rosenheck RA, Kaczynski R, Bingham S, Collins J. Association of symptomatology and cognitive deficits to functional capacity in schizophrenia. Schizophrenia Res. 2008;99:192---9.
38.Aki H, Tomotake M, Kaneda Y, Iga JI, Kinouchi S, Shibuya-Tayoshi,etal.Subjectiveandobjectivequalityoflife,levels oflifeskills,andtheirclinicaldeterminantsinoutpatientswith schizophrenia.PsychiatryRes.2008;158:19---25.
39.YamauchiK,Aki H,TomotakeM, IgaJI,Numata S,Motoki I, et al. Predictors of subjective and objective quality of life in outpatients with schizophrenia. Psychiatry Clin Neurosci. 2008;62:404---41.
