Physical and mental health-related quality of life among older people with schizophrenia
Introduction
Schizophrenia, long considered one of the most serious mental illnesses, results in an annual cost to society exceeding $62 billion (Wu et al., 2005). The functional limitations caused by schizophrenia include impairments in neurocognition (Green, 2006, Savla et al., 2007) working (Lieberman, 2006, Palmer et al., 2002), self-care (Friedman et al., 2002), interpersonal relationships, and daily living skills (Siegel et al., 2006). Although, historically, the expected clinical course of a patient with schizophrenia was thought to be one of functional decline (e.g., Kraeplin's depiction of dementia praecox') (Feighner et al., 1972, Lieberman, 2006, Harvey et al., 1999, Spitzer et al., 1975), data from our group (Heaton et al., 2001, Nayak-Salva et al., 2006, Palmer et al., 2003) and others (Rund, 1998, Kurtz, 2005) have shown that, among non-institutionalized people with schizophrenia, the actual course of the disorder is remarkably stable across the life-span (Heaton et al., 2001, Savla et al., 2007, Palmer et al., 2003, Eyler-Zorrilla et al., 2000). Similarly, psychiatric symptoms tend to be less severe in older compared to younger persons with schizophrenia (Jeste et al., 2003, Huber et al., 1980, Harding et al., 1987).
Although cognition and psychiatric symptoms are important outcomes for patients with schizophrenia, quality of life may be the most meaningful outcome. Health-related quality of life (HRQoL), defined as a patient's self-reported perception of his or her physical, emotional, mental, and functional well-being (Gill and Feinstein, 1994), is a way of measuring the impact that a chronic disease has on a person's life and functioning (Guyatt et al., 1993). Prior studies have reported poor HRQoL in patients with schizophrenia, comparable to that of ambulatory patients with AIDS (Patterson et al., 1996). Factors contributing to poorer quality of life in these patients include depression (Reine et al., 2005) and younger age of onset (Sciolla et al., 2003, Patterson et al., 1997). The SF-36 is the most widely used measure of HRQoL, and has been used across a wide range of disease states (Meijer et al., 2002).
In the general population physical HRQoL declines with age, whereas mental HRQoL is stable (Ware et al., 1994), and chronically institutionalized persons with schizophrenia may be at increased risk of age-related functional decline (a key component of HRQoL) (Harvey et al., 2003). Among community dwelling persons, who make up the vast majority of older patients with schizophrenia, data on the relationship between age and HRQoL has been less clear (Reine et al., 2005).
In this study, we examine the relationship between age and physical and mental HRQoL in a sample of 101 normal comparison subjects (NCs) and 486 older adults with schizophrenia. We hypothesized that patients would have worse physical and mental HRQoL than NCs, and that within both groups, older age would be associated with worse physical and mental HRQoL. In addition, we planned to perform two sets of exploratory analyses. First, we explored the relationship between age and SF-36 subscales, to better understand which aspects of HRQoL were most highly correlated with age. In addition, we examined whether demographic and clinical factors that have been previously related to HRQoL (Patterson et al., 1997, Sciolla et al., 2003, Reine et al., 2005) confounded the relationship between age and SF-36 scores.
Section snippets
Study sample
Patients were enrolled as part of clinical research at the University of California San Diego's Advanced Center for Innovation in Services and Intervention Research (ACISIR) between February 1994 and September 2006. The patients with schizophrenia were recruited from outpatient clinics of the San Diego County Adult Mental Health Services, UCSD Healthcare System, board-and-care homes, and the VA. None of the patients met the criteria for remission (Auslander and Jeste, 2004) at the time of study
Demographic characteristics and severity of psychopathology
As shown in Table 1, relative to NCs, patients with schizophrenia were younger, more likely to be male, less likely to be married, and had fewer years of education. The NCs also had a greater number of medical conditions than did the patients with schizophrenia, however after adjusting for the age differences between the two groups, this difference was not significant (F = 1.15, p = .28). As expected, the patients with schizophrenia had greater severity of schizophrenia and depressive symptoms, and
Discussion
The principal findings of this study were: 1. Patients with schizophrenia had lower SF-36 PHC and MHC scores than NCs, and these differences persisted after adjusting for the age and gender difference between the two groups; 2. The relationship between age and mental health-related quality of life (HRQoL) was different between the patients with schizophrenia and the NCs. Specifically, older age was associated with higher mental HRQoL among patients with schizophrenia, but not among the NCs.
Role of funding source
Funding for this study was provided by National Institute of Mental Health grants 067895, 066248, MH64722, by the Department of Veterans Affairs, and by the Veterans Affairs Center for Excellence on Stress and Mental Health (CESAMH). The NIMH and the VA had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Contributors
David Folsom, Thomas Patterson and Dilip Jeste developed the initial concept for the paper. David Folsom, Colin Depp and Brent Mausbach performed the initial analyses of the data. Ian Fellows, Shahrokh Golshan and Helena Kraemer directed or performed the final analyses. Barton Palmer and Veronica Cardenas provided critical reviews and contributed to the content of the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
Dr. Dilip Jeste has the following conflicts of interest:
- 1.
Donation of medication for an NIH-funded grant: AstraZeneca, Bristol–Myers Squibb, Eli Lilly, Janssen
- 2.
Unrestricted educational supplement to an NIH-funded research training grant: Janssen
- 3.
Honoraria and Consultation: Abbott, Bristol–Myers Squibb, Eli Lilly, Janssen, Solvay-Wyeth, Otsuka
None of the other authors have any conflicts of interest to report.
Acknowledgements
This work was supported, in part, by the National Institute of Mental Health grants 067895, 066248, MH64722, by the Department of Veterans Affairs, and by the Veterans Affairs Center for Excellence on Stress and Mental Health (CESAMH).
References (46)
- et al.
Cognitive decline in late-life schizophrenia: a longitudinal study of geriatric chronically hospitalized patients
Biol. Psychiatry
(1999) - et al.
Reliability and validity of the positive and negative syndrome scale for schizophrenics
Psychiatry Res.
(1988) Neurocognitive impairment across the lifespan in schizophrenia: an update
Schizophr. Res.
(2005)- et al.
Heterogeneity in functional status among older outpatients with schizophrenia: employment history, living situation, and driving
Schizophr. Res.
(2002) - et al.
Quality of well-being in late life psychosis
Psychiatry Res.
(1996) - et al.
Self-reported social functioning among older patients with schizophrenia
Schizophr. Res.
(1997) - et al.
Assessing health-related quality of life in patients suffering from schizophrenia: a comparison of instruments
Eur. Psychiatr.
(2005) - et al.
Sustained remission of schizophrenia among community-dwelling older outpatients
Am. J. Psychiatry
(2004) - et al.
The moderator–mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations
J. Pers. Soc. Psychol.
(1986) Scientific and consumer models of recovery in schizophrenia: concordance, contrasts, and implications
Schizophr. Bull.
(2006)
A power primer: quantitative methods in psychiatry
Psychol. Bull.
Assessing quality of life in older schizophrenic persons
Am. J. Geriatr. Psychiatry
Cross-sectional study of older outpatients with schizophrenia and healthy comparison subjects: no differences in age-related cognitive decline
Am. J. Psychiatry
Diagnostic criteria for use in psychiatric research
Arch. Gen. Psychiatry
Correlates of change in functional status of institutionalized geriatric schizophrenic patients: focus on medical comorbidity
Am. J. Psychiatry
A critical appraisal of the quality of quality-of-life measurements
JAMA
Cognitive impairment and functional outcome in schizophrenia and bipolar disorder
J. Clin. Psychiatry
Measuring health-related quality of life
Ann. Intern. Med.
A rating scale for depression
J. Neurol. Neurosurg. Psychiatry
The Vermont longitudinal study of persons with severe mental illness, I. Methodology, study sample and overall status 32 years later
Am. J. Psychiatry
The course of functional decline in geriatric patients with schizophrenia: cognitive functional and clinical symptoms as determinants of change
Am. J. Geriatr. Psychiatry
Stability and course of neuropsychological deficits in schizophrenia
Arch. Gen. Psychiatry
Toward terminological, conceptual, and statistical clarity in the study of mediators and moderators: examples from the child-clinical and pediatric psychology literatures
J. Consult. Clin. Psychol.
Cited by (56)
Aging well with psychosis
2021, Journal of Aging StudiesPrevalence of Mental Health Disorders in Elderly U.S. Military Veterans: A Meta-Analysis and Systematic Review
2018, American Journal of Geriatric PsychiatryCitation Excerpt :The pooled prevalence of schizophrenia was 11.2%. This is higher than rates found in similarly aged U.S. community samples,54,55 although some studies report that schizophrenia may be present in 13% of all U.S. nursing home residents.56 Considerably greater prevalence rates of schizophrenia were reported in two studies,24,35 where participants were recruited after VA mental health treatment often for severe and persistent mental illness.
A Longitudinal Analysis of Quality of Life and Associated Factors in Older Adults with Schizophrenia Spectrum Disorder
2017, American Journal of Geriatric PsychiatryReactivity of Health-Related Quality of Life to Perceived Stress: The Buffering Role of Psychosocial Resources in a Longitudinal Study of Adults with and Without HIV
2024, Journal of Clinical Psychology in Medical Settings