Rehabilitation and support to patients living in the community are two main interventions offered to patients with psychosis for maintaining and improving their Quality of Life (QoL). Nowadays much emphasis is placed on developing strategies for maintaining and improving the QoL of patients.1

Community mental health services also pay attention to patients’ QoL since such patients need to continuously adapt to illness-related circumstances and other daily stressful life events that can affect QL.2 QoL has also become an important outcome measure of interventions offered to patients with psychosis.3

Some cross-cultural differences in the QoL of patients with psychosis4 have been found, that could be related to sociodemographic factors (such as living conditions) but also to the criteria these patients have for assessing their QoL.

Several QoL studies have been performed conducted with Spanish patients living in the community.5–8 More QoL studies are needed in order to better understand the situation of patients in our area and compare our data with those from other cultural areas.2

QoL differences have been found between patients with schizophrenia who have or not symptomatic remission.9 Besides, it is suggested the need for a differential analysis of QoL in schizophrenia in the acute and long-term phases.10

Nowadays it is considered patients should assess their QoL (subjective assessment) through PRO (Patient Reported Outcomes) instruments.11–13 This assessment could be complemented with objective data (e.g. functional role in society).3 QoL in schizophrenia is understood to be a multidimensional concept.11,14,15 It is advised to assess QoL through generic QoL questionnaires (that evaluate areas common to various diseases) combined with specific QoL questionnaires for schizophrenia.5 Zeng et al.16 believe that interventions that focus on a single area (such as symptoms) could fail to improve a patient's QoL.

Understanding a patient's perception of his or her QoL and the factors that may determine this QoL is necessary for developing support strategies.12,13 Several studies of the sociodemographic determinants of QoL in patients with psychosis have been conducted.2,17,18 Others have assessed the role of clinical factors such as negative symptoms1,16 and depression11,17 (which are often found to be related to QoL), cognitive dysfunction18,21 and insight4,5,20,22,23 as determinants of QoL. Kao et al.1 report that the extent to which patients are aware of their schizophrenic disorders and its consequences appears to influence QoL, though direction of this influence is unclear.

Studies with a combination of determinants may help to develop more targeted treatments for improving patients’ QL.24 Different studies have combined sociodemographic and clinical QoL determinants11,17,20,23,24 but few have combined demographic factors with symptoms, insight and cognitive functioning in patients with psychosis14 and none has been conducted in our area. More studies of the determinants of subjective QoL are needed.14

Studies of QoL determinants in psychosis have usually administered generic measures, while a combination of generic with disease-specific QoL questionnaires has rarely been used.16

The aims of this study are to assess QoL in a sample of Spanish schizophrenia spectrum outpatients with stable disease and evaluate the determinants of general and disease-specific QoL areas. We expected the determinants of these QoL areas to be a combination of clinical and demographic variables.

A total of 61 patients out of 65 candidates were interviewed. Reasons for not completing the questionnaires were administrative failure (2 cases) and patient refusal (2).

All questionnaires included in the study had over 80% of their items answered. The sociodemographic and clinical characteristics of the patients are shown in Table 1: 61% of the patients were living with their family of origin; 5% were working (with a salary), while 43% were unemployed (considered candidates for a job – including at special working centers; some of them could be receiving unemployment benefit or state financial aid), and 41% were pensioners (who could no longer work and were receiving a pension); 20% attended an occupational center and 21% attended a leisure center. There are no significant differences between the two treatment centers (Rehabilitation service, Outpatient clinic) in the clinical and sociodemographic characteristics of the patients, except in time since diagnoses (p=0.002, U-Mann Whitney), that is higher in the outpatients clinic (mean 7.3 years higher).

Table 2 shows that the mean scores were moderate in most subjective QoL areas: between 49.2 and 62.7 in the WHOQOL BREF, 58.8 in the EUROQOL health and 0.8 in the EUROQOL value, and between 38.9 and 43.3 in the SQLS-R4 (this last questionnaire assesses QoL limitations).

No significant relationship was found between cohabitance, family life, income, diagnosis, number of acute episodes, cognitive impairment (total score and subscales) and any of the QoL areas. Negative symptoms (SANS) and depression showed a significant relationship with the nine QoL areas studied. Age, gender, social activities, employment status, time since diagnosis, center and SAIE individual areas and global score were also related to QoL (see Table 3). A higher age, a higher score in negative symptoms, depression and SAIE disease, and being unemployed were related to lower QoL. More time since diagnosis, being a woman, being treated at the outpatient clinic, having more social activities, and a higher score in SAIE symptoms, SAIE treatment and SAIE total were related to higher QoL.

The best multivariate models to explain each of the subjective QoL areas presented R2 between 0.25 and 0.56 (see Table 4). The determinants more often found to be related with QoL areas were negative symptoms and depression, where higher values were associated with lower QoL in both cases.

This study shows that general and specific QoL of patients with schizophrenia spectrum disorders with stable disease and mild or no positive symptoms treated at a Spanish rehabilitation service and at an outpatients clinic is moderate, and that it is related both to sociodemographic characteristics such as age, gender, employment status and social activities, and to disease-related clinical aspects, such as time since diagnosis, depression, negative symptoms, insight, and treatment center.

Scores in the SQLS-R4 are in line with those from other European studies: of outpatients and inpatients from the UK29 and of outpatients with prominent negative symptoms from several cultural areas (including European countries).37 Scores in vitality and psychosocial feelings were slightly worse in our study (7–14 points lower in the QoL areas) than in two studies conducted in different cultural areas: Malasia38 with outpatients and China39 with inpatients and outpatients. A study conducted in Korea with outpatients40 found better vitality (7) and lower psychosocial feelings (13). Our scores in the SQLS-R4 were slightly higher than those from a study conducted in Taiwan41 on inpatients with non-symptom remission (≥8 points in psychosocial, vitality and total QoL).

Scores in the WHOQOL-BREF were in line with those from other studies performed with outpatients from Spain5 and other cultures: Thailand3 and Taiwan.2 Scores in the EUROQOL-health were in line with those of a study with Spanish outpatients8 and a study of outpatients from 10 countries (including Spain).7

Our study found few relationships between the sociodemographic variables and QoL. Other studies have shown that sociodemographic variables are less strongly correlated with subjective QoL than clinical variables.2,17 Social activities have also been related to higher QoL (EUROQOL) in outpatients from 10 countries (including Spain).7,19 Social activities have a key role in our cultural area, where fostering supportive social relationships in patients is considered highly important.18 Unemployed patients had lower QoL in several areas than the other patients. Other studies have found higher QoL scores in employed patients than in those who did not have a job (we included more categories in the employed patients group). Higher QoL has been related to being employed in outpatients from 10 countries (including Spain),7,19 from France20 and in outpatients from another cultural area (Taiwan)2 (in these two last studies other QoL questionnaires were administered). Differences in income may be a reason for the relationship between employment status and QoL in our study, since unemployed patients had lower incomes than the rest of the patients (data not shown). There were no significant differences between unemployed patients and patients with a different employment status with regard to the frequency of attendance at occupational centers or leisure centers (data not shown). We understand that these two factors did not influence the differences in QoL between employment status groups in our study.

Age and gender were related to just one QoL area. Few or no relationships have been found between age and QoL in other studies. Mas-Expósito et al.5 found no relationship among Spanish outpatients between age and the WHOQOL-BREF areas included in our study, while Lanfredi et al.18 found a relationship with just one WHOQOL-BREF area among Italian inpatients: as in our study, a younger age was related to a higher QoL. Hsiao et al.2 (Taiwan) and Nakamura et al.13 (Japan) found no relationship between age and any QoL area in outpatients (in both those studies, other QoL were administered). With regard to gender, no relation with the WHOQOL-BREF was found in Spanish outpatients,5 and also no relation between gender and other QoL questionnaires in outpatients from four European countries (including Spain),4 or from Japan.13

Like other European studies (with similar or other QoL instruments),18,20 we did not find cohabitance to be a QoL determinant. We should point out that a high percentage of patients in our sample live with their family of origin, which may have influenced these analyses. This high percentage may be particular to Spain and could indicate the need for the support of relatives (who may well be elderly).

Factors more often related to QoL in our study were negative symptoms and depression. It is also remarkable that negative symptoms and depression are the factors that have been found as determinants of specific QoL (and also Employment status in one SQLS-R4 area), whereas the other demographic and clinical factors have just been found as determinants of general QoL.

Negative symptoms also appeared as determinants of lower QoL in other studies conducted on outpatients from our cultural area (and with the same QoL questionnaires) in Spain5 (WHOQOL-BREF), from 10 countries (including Spain, EUROQOL-5D),6 and from other cultural areas: Japan (SQLS)42 and Thailand3 (WHOQOL-BREF). Strauss et al.43 consider that negative symptoms may be a more prominent determinant of well-being during the chronic phase of illness.

Depression has been considered a key determinant of subjective QoL in schizophrenia.11,17,42 One explanation for this is that patients with depression may have negative views of their situation that could negatively influence how they evaluate their QL.24 Depression has been associated with low QoL in Spanish22 and French44 outpatients (Calgary scale and a different QoL questionnaire in both studies) as well as in studies of outpatients from other cultures that used similar questionnaires to ours: Thailand3 (Calgary and WHOQOL-BREF), Japan42 (Calgary and SQLS questionnaire), and other Depression and QoL questionnaires in USA.24 Contrary to these results, Mas-Expósito et al.5 found no relationship between depression and QoL in Spanish outpatients (WHOQOL-BREF): in that study, depression was assessed with just the PANNS general item.

Like in our study, Boyer et al.20 found a positive relationship between insight on symptoms and QoL but a negative relationship between insight on illness and QoL in French outpatients (using different questionnaires). These authors consider that a better insight on symptoms may help develop care skills that mitigate these symptoms, whereas a better insight on illness may be related to lower QoL, since patients may better understand the negative consequences of their illness (including stigmatization). Moreover, patients with a lower insight on their illness may consider themselves more competent and overestimate their QoL. Other studies (using different instruments), such as that by Kurtz and Tolman14 also found that subjective QoL was lower in outpatients from the USA with a better insight on their illness.

SCIP scores show moderate limitations and are in line with the scores found in the standardization study for Spanish patients with schizophrenia or schizoaffective disorder.34 Other studies also found no relationship between subjective QoL and cognitive dysfunction when assessed in areas similar to ours: Lanfredi at al.18 between attention, verbal fluency, denomination, visospacial skill, immediate verbal learning, delayed verbal and historical learning and the WHOQOL-BREF in Italian inpatients; Fujimaki et al.11 between verbal fluency and the SQLS in Japanese inpatients; Boyer et al.20 between verbal and visual learning, attention and executive function and a different QoL questionnaire in French outpatients; and Ueoka et al.21 between the BACS questionnaire (verbal and working memory, motor function, verbal fluency, processing speed and executive function) and the SQLS in Japanese outpatients. Unlike our study, Kurtz and Tolman14 found lower subjective QoL (a different questionnaire) in outpatients from USA with lower cognitive functioning (attention, working memory, problem solving).

Studies of cognitive dysfunction and QoL have produced results that may be considered contradictory. Tolman and Kutz15 assert that this may partly be due to the fact that some studies assessed objective QoL while others subjective QoL. Some studies have shown weaker relationships between cognitive dysfunction and subjective QoL than between cognitive dysfunction and objective QoL: PANNS cognitive dysfunction had a greater influence on objective QoL than on subjective QoL (SQLS) in Japanese outpatients45 and was related to objective QoL but not with subjective QoL (WHOQOL-BREF) in Chinese inpatients.1

A higher QoL in patients with more time since diagnosis may be related to a process involving patients adapting to their situation.1 This relationship has appeared in just two QoL areas in our study, while Mas-Expósito et al.5 found no relationship in Spanish outpatients (WHOQOL-BREF). Diagnosis was not found to be a QoL determinant in our study, perhaps because patients with just schizophrenia or schizoaffective disorder were included. Fleury et al.17 found a relationship between diagnosis and QoL but their study also included patients with a variety of diagnoses (such as mood disorders). Like in our study, Hsiao et al.2 found no relationship between QoL and the number of hospitalizations in Taiwanese outpatients (WHOQOL-BREF).

These patients might benefit from multidisciplinary treatment to improve their QoL. Interventions aimed at negative and depressive symptoms43 (through behavioral therapy or cognitive social skills training) may improve patients’ subjective QoL.11,12,44,45 Boyer et al.20 assert that it would be good to treat patients’ perceptions of disease-related stigma in order to improve its negative effect on QoL.

The patients from the present study might benefit from multidisciplinary treatment to improve their QoL. Interventions aimed at negative and depressive symptoms42 (through behavioral therapy or cognitive social skills training) may improve patients’ subjective QoL11,12,43,44 Boyer et al.20 assert that it would be good to treat patients’ perceptions of disease-related stigma in order to improve its negative effect on QoL.

The strengths of this study are the combination of determinants evaluated, that general and disease-specific QoL areas have been assessed, and the fact that it was conducted in Spain. However, it could have benefited from a larger sample and a longitudinal design in which QoL was measured before and after an intervention in order to identify risk and protective QoL factors more accurately. It would be interesting to study QoL in patients at the acute disease phases, with positive symptoms45 and to include other cognitive determinants such as social cognition or metacognitve skills.

Sociodemographic and clinical factors have been found to be determinants of general and specific QoL in a sample of Spanish schizophrenia and schizoaffective outpatients with stable disease and mild or no positive symptoms. More in detail, the demographic factors being a woman (WHOQOL-BREF) and having more social activities (WHOQOL-BREF and EUROQOL-5D), and the clinical factors more time since diagnosis (WHOQOL-BREF and EUROQOL-5D), being treated at the outpatient clinic (WHOQOL-BREF), and a higher score in SAIE symptoms (EUROQOL-5D), SAIE treatment (WHOQOL-BREF) and SAIE total (EUROQOL-5D), have been related to higher QoL. A higher age (EUROQOL-5D), being unemployed (EUROQOL-5D and SQLS-R4), a higher score in SAIE disease (EUROQOL-5D), have been related to lower QoL. Negative symptoms and depression showed a negative relationship with all the QoL areas studied.

The authors have no conflict of interest to declare.

The present study has not received the support from any grant.