کیفیت زندگی در اختلالات طیف اسکیزوفرنی: انجمن با بینش و آسیب شناسی روانی

Therapeutic interventions in chronic mental illness face the important challenge to pursuit the quality of life (QOL) of patients. Insight into chronic mental illness, though a prerequisite for treatment adherence and a positive therapeutic outcome, has shown adverse associations with subjective QOL. This study aims to explore the contribution of psychopathological symptoms on the ambiguous role of insight on QOL. Seventy-two outpatients with schizophrenia spectrum disorders were assessed using the positive and negative syndrome scale, the scale to assess unawareness of mental disorder, and the WHOQOL-100 instrument for the assessment of quality of life. Insight was found to associate inversely with quality of life. Among psychopathological symptoms, depressive symptoms were the strongest negative contributor on QOL. Mediation analysis revealed that the effects of awareness of the consequences of illness on QOL were largely mediated by depressive symptoms (full mediation for the effect on physical and psychological domain and partial mediation for the effect on independence and environment domain of the QOL). Our results suggest that the inverse relationship between insight and subjective quality of life is partially mediated by depressive symptoms. We discuss theoretical and therapeutic implications of the findings, in conjunction with similar recent research data.

Quality of life is viewed as a complex multidimensional construct that encompasses various domains of life, ranging from physical and psychological health to social functioning and the religious beliefs of a person. The different domains are influenced by personal experiences, beliefs, and expectations (WHOQOL Group, 1993). Subjectivity is inherent in the notion of QOL by definition (WHOQOL Group, 1993 and Gill and Feinstein, 1994), though in the case of persons suffering from chronic mental illnesses such as schizophrenia, its validity has often been questioned for various reasons (Atkinson et al., 1997 and Doyle et al., 1999). More specifically, a number of authors take into account that psychopathology is likely to affect the patients׳ responses about their life satisfaction in various domains (Jenkins, 1992 and Serban and Cidynski, 1979). It is assumed that psychopathology potentially influences the mental, emotional and social judgment of patients, and as a result of this, it can distort the self-report ratings in QOL (Prince and Prince, 2001, DeHaes et al., 1992 and Pavot and Deiner, 1993). There have been recent evaluations of the impact of depressed mood on subjective QOL of persons with schizophrenia. It has been shown that depressed mood affects, strongly and negatively, the evaluation of their own global QoL, as well as the various domains of their QOL (Fitzgerald et al., 2001, Reine et al., 2003 and Sim et al., 2004). The Depression factor of the positive and negative syndrome scale (PANSS) has been found to correlate inversely with global subjective QOL (Dickerson et al., 1997), while higher anxiety and depression ratings as measured by the brief psychiatric rating scale (BPRS) have also been found to correlate inversely with QOL (Huppert et al., 2001 and Orsel et al., 2004). However, the compromised validity of self-administered QOL instruments in chronic mental illness due to psychopathology necessitates reconsideration. This because psychopathological symptoms such as positive and negative symptoms of schizophrenia have been found to account for worse QOL, especially with reference to interviewer assessments of these population groups (Fitzgerald et al., 2001 and Bengtsson-Tops et al., 2005). Therefore, it seems that psychopathology plays a significant role not only in subjectively evaluated QOL, but also in externally assessed QOL. Divergence of the implicated symptoms suggests that the two ways of assessment probably measure complementary components, for instance mainly discomfort experienced by patients due to specific symptoms on one hand, and the social and functional impact of psychotic illness assessed by evaluators on the other. Nevertheless, the influence of these psychopathological symptoms on QOL leads to the same direction. Severity of some aspects of illness produces either less life satisfaction as experienced by the patients, or diminished level of QOL as measured by external evaluators. On the contrary, another psychopathological feature, namely lack of insight, has been speculated to contribute to paradoxically elevated life satisfaction scores in comparison with external evaluations (Jenkins, 1992 and Atkinson et al., 1997). The discordance between subjective and externally assessed QOL has largely attributed to this lack of insight (Doyle et al., 1999, Massie et al., 2003, Hasson-Ohayon et al., 2006 and Hasson-Ohayon et al., 2011). Lack of insight is a commonly observed phenomenon across psychotic illnesses, subject to various explanatory models. Especially for schizophrenia, it seems to be more pervasive, and is apparent in 50–80% of the patients during the course of their illness (Amador and Gorman, 1998). It seems to describe a complex phenomenon that may implicate a range of factors involving neuropsychological parameters (Young et al., 1993, Lysaker and Bell, 1994, Drake and Lewis, 2003 and Koren et al., 2004), coping strategies relevant to psychological denial (Moore et al., 1999 and Lysaker et al., 2007), in addition to combinational concepts suggesting the modulating influences of the latter to the first (Cooke et al., 2005). During the last two decades, insight has also been conceptualized as a complex construct in contrast to the dichotomous approach of the past. Research has demonstrated that there are varying dimensions of insight, including not only recognition of the presence of mental disorder, but also understanding of the consequences of the disorder and appreciating the need for treatment (Amador et al., 1993). Growing evidence also support the fact that unawareness of illness has a negative effect on medication adherence and compliance, social and occupational functioning, and the prognosis and outcome of illness (Mc Evoy et al., 1989, David et al., 1992, Amador et al., 1994, Rossi et al., 2000, Coldham et al., 2002, Perkins, 2002, Yen et al., 2005 and Lincoln et al., 2007). Therefore, in the relevant literature, contribution of insight on quality of life has been described as “the insight paradox” indicating the pattern of apparently contradictory associations with the outcome (Lysaker et al., 2007). The reasoning however behind this contradictory effect of insight has –in our opinion– not been clarified yet. Depressed patients for example are expected to downgrade their life due to their depressed mood, but there is not an obvious and clear reason for a person who lacks insight into his/her illness to overestimate globally the various aspects of his/her own QOL. Indeed, we cannot consider self-evident the contribution of awareness in the evaluation of the QOL patient per se. We generally resort to unconfirmed intermediate paths, as for example, through cognitive impairments linked to unaware patients that affect social judgment, minimal aspirations and motivation to change life circumstances again linked to unawareness, or even distress feelings more pronounced to insightful patients. We consider that each one of these assumptions may have a different impact on the concerns for the validity of self-evaluated quality of life. Therefore, we think that in order to understand better this inexplicit association of insight with QOL, we should examine the role of intermediate variables. Indeed, there have been reports in the literature linking the presence of insight to depressive symptoms. These theories, as already mentioned, conceptualize unawareness as being a form of denial, reflecting a psychological defense mechanism (Moore et al., 1999 and Crumlish et al., 2005) or a cognitive strategy, where patients are aware of their illness in some sense, but are motivated to deceive themselves in order to preserve their self-esteem and maintain a positive outlook (Startup, 1996). Good insight has been found in several studies to correlate positively with depressive symptoms in the early or acute phase of psychosis, as well as in chronic and stable psychoses (Cooke et al., 2005, Saeedi et al., 2007 and Schennach, 2012). This association has also been confirmed in a meta-analysis covering the previous 20 years of published data (Mintz et al., 2003). Taking into consideration the aforementioned work and hypotheses concerning the relation of depression with insight, as well as the relation of depression to QOL, we hypothesize that depressive symptoms could mediate the effect of insight on subjective QOL. To our knowledge, there is no previous work exploring this interrelationship in a similar sample of patients.

Descriptive statistics on psychopathological variables, QOL ratings, and sample clinical characteristics are presented in Table 1. No significant correlations (Pearson׳s r) were revealed between WHOQOL domains and demographic or clinical parameters such as age, duration of illness and total duration (in months) of hospitalization. Moderate correlations were found between the domain of independence of quality of life and the age of patients (r: 0.275, p<0.05). PANSS depressive factor as well as WHOQOL domains did not differ significantly among schizophrenia and schizoaffective patients (independent samples t-test), but all the SUMD items were differing depending on diagnosis, with schizophrenia patients being more unaware than schizoaffective patients. There was a significant difference in the scores for schizophrenia patients and schizoaffective patients on SUMD1 (t(69)=2.54, p:0.01)), SUMD2 (t(69)=2.35, p:0.02)) and SUMD3 (t(69)=2.69, p:0.009) (Independent samples t-test). Nevertheless, because controlling for the effect of diagnosis (hierarchical multiple regression), correlation coefficients among all the tested parameters did not change in significance, we chose to use both diagnostic categories in our analysis. Table 1. Descriptive statistics of clinical characteristics, symptoms, and quality of life measurements (N:72). Minimum Maximum Mean Std deviation Symptom measurements PANSS Positive syndrome 7 28 11.49 4.59 Negative syndrome 7 26 14.57 5.20 Depressive syndrome 4 18 9.07 2.99 SUMD Awareness of mental disorder 1 5 1.98 1.30 Awareness of achieved effects of medication 1 5 1.82 1.15 Awareness of the social consequences of mental disorder 1 5 2.38 1.31 Quality of life (WhoQol domains) Physical 27.08 97.91 63.76 18.03 Psychological 8.75 98.75 58.59 17.66 Independence 7.81 100.00 60.89 17.43 Social 14.58 91.66 54.73 18.32 Environment 20.31 87.50 61.60 13.26 Spirituality 6.25 100.00 60.77 21.93 Sample characteristics Age, years 19 52 36.39 7.96 Education, years 4 18 11.25 3.33 Duration of illness, years 1 34 14.04 7.24 No. of hospitalizations 0 16 2.80 2.89 Total duration of hospitalization (months) 0 192 8.83 23.73 Table options Correlations (Pearson׳s r) between psychopathological symptoms, insight measures, and quality of life domains are presented in Table 2. Table 2. Intercorrelations of variables (N:72). Measure Positive Negative Depressive SUMD1 SUMD2 SUMD3 Physical Psychological Independence Social Environment Spirituality Symptom severity (PANSS) Positive 0.506 b 0.221 0.344 b 0.448 b 0.331 b 0.002 −0.010 −0.044 −0.032 −0.030 −0.038 Negative 0.159 −0.005 0.020 0.162 −0.121 −0.162 −0.105 −0.222 −0.177 −0.168 Depressive −0.131 0.188 −0.276 a −0.412 b −0.589 b −0.576 b −0.273 a −0.365 b −0.228 Insight (SUMD) Awareness of mental disorder (SUMD1) 0.515 b 0.721 b 0.325 b 0.369 b 0.365 b 0.220 0.352 b 0.278 a Awareness of achieved effects of medication (SUMD2) 0.477 b 0.112 0.102 0.184 0.165 0.267 a 0.162 Awareness of the social consequences of mental disorder (SUMD3) 0.301 a 0.362 b 0.439 b 0.088 0.339 b 0.235 Quality of life (WhoQol) Physical 0.637 b 0.668 b 0.335 b 0.603 b 0.389 b Psychological 0.768 b 0.629 b 0.708 b 0.645 b Independence 0.410 b 0.670 b 0.427 b Social 0.603 b 0.337 b Environment 0.484 b Spirituality a p<0.05. b p<0.01. Table options Following Baron and Kenny׳s steps, we performed the mediation analysis (results are presented in Table 3). According to the model, mediation can exist only if step 2 is significant and in our sample of patients, depressive symptoms correlated significantly with the third item of insight, that of awareness of the social consequences of mental illness. Step 4 of this analysis involving the inspection of the coefficients (standardized), indicates that there is a mediation effect, since the coefficient of the effect of the awareness of the social consequences on quality of life is reduced after controlling for the effect of depressive symptoms on quality of life (beta of step1>>beta of step 3). According to our data, there seems to be complete mediation of the depressive symptoms on the effect of the awareness of the social consequences for the cases of the physical and psychological domains of the quality of life (coefficient no longer significant), and partial mediation for the independence and environment domains (coefficient still significant but less than the initial). The schematic representation of the mediation analysis is presented in Graph 1. Table 3. Results of mediated regression analysis. R R2 R2 change Beta Step 1: QOL (physical domain) on SUMD3 0.301 0.091⁎ 0.301⁎ Step 2: Depression on SUMD3 0.276 0.76⁎ 0.276⁎ Step 3: (a) Qol (physical domain) on depression 0.456 0.208⁎⁎ −0.402⁎⁎ (b) Qol (physical domain) on SUMD3 0.486 0.237⁎⁎ 0.028 0.177 Step 1: QOL (psychological domain) on SUMD3 0.362 0.131⁎⁎ 0.362⁎⁎ Step 2: Depression on SUMD3 0.276 0.76⁎ 0.276⁎ Step 3: (a) Qol (psychological domain) on depression 0.584 0.341⁎⁎ −0.523⁎⁎ (b) Qol (psychological domain) on SUMD3 0.615 0.378⁎⁎ 0.037 0.201 Step 1: 0.439 0.193⁎⁎ 0.439⁎⁎ QOL (independence domain) on SUMD3 Step 2: 0.276 0.76⁎ 0.276⁎ Depression on SUMD3 Step 3: (a) Qol (independence domain) on depression 0.592 0.350⁎⁎ 0.073 −0.505⁎⁎ (b) Qol (independence domain) on SUMD3 0.651 0.423⁎⁎ 0.284⁎⁎ Step 1: 0.339 0.115⁎⁎ 0.339⁎⁎ QOL (environment domain) on SUMD3 Step 2: 0.276 0.76⁎ 0.276⁎ Depression on SUMD3 Step 3: (a) Qol (environment domain) on depression 0.341 0.116⁎⁎ −0.260⁎⁎ (b) Qol (environment domain) on SUMD3 0.418 0.175⁎⁎ 0.059 0.255⁎ ⁎ p<0.05. ⁎⁎ p<0.01. Table options Full-size image (31 K) Graph 1. Regression coefficients of the mediation analysis, with the coefficients for the effect of SUMD3 on the QOL domains in both step 1 and step 3, with the latter in parentheses. (1) Schematic representation of the mediation path for the effect of insight item 3 on the physical domain of quality of life. (2) Schematic representation of the mediation path for the effect of insight item 3 on the psychological domain of quality of life. (3) Schematic representation of the mediation path for the effect of insight item 3 on the independence domain of quality of life. (4) Schematic representation of the mediation path for the effect of insight item 3 on the environment domain of quality of life.