Introduction
Schizophrenia and Dysthymia are debilitating disorders that affect general health and functioning. Studies show that both vastly affect the quality of life (QOL) of patients and cause great amount of disability.
Objective
To evaluate and compare the QOL and Disability between patients with Schizophrenia and Dysthymia.
Materials and Methods
A cross divtional, observational, comparative study was done in a randomly chosen sample of 30 outpatients each of schizophrenia and dysthymia. QOL was assessed using WHOQOL-BREF scale and disability was assessed using the Indian Disability Evaluation and Assessment Scale (IDEAS).
Results
Patients of schizophrenia showed greater disability and poorer QOL than patients of dysthymia. The ‘Social Relationships’ domain of the WHOQOL-BREF scale was the worst affected domain in both groups of patients. Patients with dysthymia also did significantly (p=0.040) better in the ‘Psychological’ domain; while patients with schizophrenia were significantly (p=0.029) better in the ‘Physical Health’ domain. Patients with schizophrenia showed greater disability than patients with dysthymia in all the 4 domains of the IDEAS, significantly in the areas of Self care (p<0.001) and Communication-Understanding (p<0.001).
Conclusion
Schizophrenia is a more debilitating disorder than Dysthymia. This assumes significance when planning rehabilitation models for these disorders.
Introduction
The concept of quality of life (QOL) refers to the subjective satisfaction experienced by an individual with regard to his/her physical, mental and social spheres. QOL becomes more important in disorders that run a chronic and debilitating course or where treatment continues over a long period. QOL research in psychiatry is still in its infancy, although in recent years attempts have been made to improve its understanding [1,2]. Schizophrenia is a severe and debilitating mental disorder, which affects general health, functioning, autonomy, subjective well being, and life satisfaction of those who suffer from it [3]. Dysthymia is a state of chronic depression that persists for more than two years [4]. Schizophrenia and Dysthymia greatly affect the quality of life of patients who suffer from them. Despite significant improvement with pharmacological treatments of schizophrenia and dysthymia, studies [2,5] have shown that there is poor QOL in these disorders.
Disability associated with mental illness is a major contributor to the global burden of disease [6]. Psychiatric disorders account for 5 out of the 10 leading causes of disability as measured by years lived with a disability [7]. Despite 50 years of pharmacological and psychosocial intervention, schizophrenia remains one of the top causes of disability in the world [2]. In 1990, the worldwide global burden of disease for neuropsychiatric disorders, as measured by disability adjusted life years (DALYs), was estimated to be 6.8% [8] and projected to increase to 15% by the year 2020 [6]. A study by Balhara et al., revealed that the highest disability in schizophrenia was observed in the work domain [9]. Some studies have observed the self care domain to be associated with disability while Narayan et al., found communication and understanding to be adversely affected [10]. Dysthymia has also been reported to be a disease with high levels of disability [11]. The disorder assumes great significance as according to WHO depression is expected to be the second greatest cause of disability by 2020 [6]. A study by Subodh et al., showed high levels of behavioural and socio-occupational disability among patients of dysthymia [12].
Thought abundant research has been done on these disorders individually, there is a dearth of research drawing comparisons between quality of life and disability in these patients in the Indian scenario.
Aim
To evaluate and compare the QOL and Disability in Schizophrenia and Dysthymia patients at a tertiary care teaching hospital.
Materials and Methods
Permission from Institutional Ethics Committee was obtained prior to the onset of this study. The procedures followed were in accordance with the Ethical standards of the committee on human experimentation and with the Helsinki Declaration of 1975 that was revised in 2000. This was a cross sectional, observational, comparative study carried out over 2 months (June- July 2013) as a part of the Short Term Studentship research project of the Indian Council of Medical Research (ICMR-STS).
Adult patients diagnosed with either Schizophrenia or Dysthymia and attending the psychiatry outpatient department at a tertiary care teaching hospital in Navi Mumbai, India were included in this study. Patients were randomly selected and assigned to two groups. Group ‘A’ comprising of 30 patients with schizophrenia and group ‘B’ comprising of 30 patients with Dysthymia. As per the DSM-5 criteria, [13] we included schizophrenic patients with duration of symptoms of illness minimum of 6 months, and dysthymic patients with duration of symptoms of illness minimum of 2 years. A written informed consent was obtained from each participant patient and his/her legal guardian before recording the socio-demographic data by a self- designed structured proforma.
WHOQOL-BREF Scale [14] was administered to assess quality of life of the participants. This scale assesses quality of life in four domains: Physical, Psychological, Social and Environmental. They were also administered the Indian Disability Evaluation and Assessment Scale (IDEAS) [15] for assessing disability. This scale assesses disability in 4 domains viz. self care, interpersonal activities/social relationships, communication/understanding and work with higher scores indicating a greater amount of disability. Patients who were illiterate, having any other co-morbid psychiatric or major medical disorders, not willing for informed consent and those with severe illnesses such as those with history of violence or requiring to be hospitalized were excluded from the study.
Statistical Analysis
Data was analysed with t-test for quantitative data, Pearson’s Chi-Square test for categorical data and Mann Whitney U-test for non-parametric data using the Statistical Package for the Social Sciences (SPSS) version-17 software with probability p-value of less than 0.05 considered as statistically significant.
Results
The mean age of patients with schizophrenia was 34.66±11.71 years and in dysthymic patients it was 46.1±9.41 years. The mean illness duration in patients with schizophrenia was 4.6±1.24 years, and 6.5±2.19 years for patients with dysthymia. Other socio-demographic details are summarized in [Table/Fig-1].
On comparing of the QOL assessments between the two groups, it was found that patients with dysthymia reported a significantly higher impairment in the ‘Physical Health’ domain while patients of schizophrenia reported higher impairment in the ‘Social Relationships’ domain. The scores in ‘Psychological’ and ‘Environment’ domains were equally poor in both groups [Table/Fig-2].
Regarding comparative disability assessments, patients with schizophrenia showed significantly higher disability in all 4 domains when compared with dysthymic patients especially in the domains of ‘Self Care’ and ‘Communication and understanding’ [Table/Fig-3]. Global disability scores were also more severe in the patients having schizophrenia [Table/Fig-4].
Discussion
The results of the study documented a poor overall quality of life (QOL) and a high degree of disability in both groups of illnesses. On comparing the quality of life assessments between the 2 groups, it was found that patients with schizophrenia reported a better QOL in the ‘Physical Health’ domain. This finding is consistent with those of other studies where it was found that patients of schizophrenia tend to rank their health utility higher than healthy people or even higher than what mental health professionals would estimate [16,17]. This tendency by patients of schizophrenia to rate their QOL as high is explained by researchers that these patients have reduced expectations, tend to adapt better to the nature of the illness and were satisfied with their life in general [5,17,18]. Poor QOL scores amongst patients of dysthymia in the physical domain can be attributed to the multiple physical complaints exhibited by these patients such as disturbances in sleep and appetite, and vague non-specific somatic complaints that do not have any medical origin [4]. Bell et al., reported that persons with dysthymia were more likely to have worse health status, worry more about their health, and report levels of pain that impaired their function [11]. Gupta et al., pointed out that dissatisfaction amongst patients of dysthymia is because of the depressive nature of the illness whereby, because of the negative cognitions, patients tend to view matters in a negative frame of mind [5].
Both schizophrenia and dysthymia are characterized by a decline in cognitive functions and this could be seen by the poor ratings of both groups on the ‘Psychological Domain’ [3,4]. This could be attributed to the perceived stigma with concurrent low self-esteem and low self-efficacy seen in both these disorders [19,20]. Negative coping strategies and poor problem-solving abilities are also seen [11,19,21]. Studies have also noted the importance of cognitive adverse effects of medications as well as a negative attitude of these patients towards them [3,16].
Patients of both schizophrenia and dysthymia reported maximum impairment in the ‘Social Relationships’ domain. These findings were similar to those of other studies [5,11,12], and may be accounted for by the presence of anhedonia (a disinterest in social contact characterized by social withdrawal) and a decreased interest in social and pleasurable situations, which is seen in both dysthymia as well as schizophrenia [3,4,22]. Also, patients of schizophrenia are subjected to a lot of discrimination which may lead to social stigma and isolation from family and society [23]. A strong relation between schizophrenia and poor social relationships has been reported in literature [3] stating that impairment may be caused by loneliness, asociality and an unsatisfactory amount of contact with family members [24,25]. Poor social life may also attributed to the negative symptoms of schizophrenia like apathy, avolition, and alogia [3].
On comparing the disability between the two illnesses, patients with schizophrenia had significantly higher disability in all domains. Though mean illness duration was higher in dysthymia, disability was significantly greater in schizophrenia which was similar to the findings from other studies [9,10]. This could be explained by the observations of Honkonen et al., who stated that patients with schizophrenia had difficulties in taking responsibility for their own care, work and integrating into social life [26].
The strength of the current study is that it is one of the few comparative studies done in an Indian scenario. However, there are certain limitations as well. The findings are from a cross-sectional small sample study, based on exclusively hospital-based outpatient setting. Also, assessments of QOL and disability were done using subjective scales.
Socio-demographic profiles of the two groups (Schizophrenia and Dysthmia)
| Parameter | Schizophrenia (n=30) | Dysthymia (n=30) | Chi square | df | p-value |
|---|
| Gender | Male | 19 | 10 | 5.41 | 1 | 0.02 |
| Female | 11 | 20 |
| Occupation | Employed | 8 | 19 | 8.28 | 1 | 0.004 |
| Unemployed | 22 | 11 |
| Marital Status | Married | 5 | 19 | 15.2 | 2 | 0.0005 |
| Unmarried | 10 | 7 |
| Separated | 15 | 4 |
| Education | Up to secondary school | 23 | 11 | 15.13 | 1 | 0.0001 |
| Beyond secondary school | 7 | 19 |
| Family type | Staying alone | 18 | 9 | 6.63 | 1 | 0.01 |
| Nuclear | 12 | 21 |
| Family history of mental illness | Present | 19 | 10 | 5.41 | 1 | 0.02 |
| Absent | 11 | 20 |
Comparison of quality of life in schizophrenia and dysthymia patients
| Parameter | Schizophrenia n=30 | Dysthymia n=30 | p-value* |
|---|
| WHO-QOL-BREF† | Physical Health – D1 Median (Inter quartile range) | 31 (31, 38) | 22 (19, 38) | 0.026 |
| Psychological – D2 Median (Inter quartile range) | 31 (23.5, 32.75) | 31 (31, 39) | 0.033 |
| Social Relationships - D3 Median (Inter quartile range) | 6 (.0, 19) | 19 (6, 25) | 0.001 |
| Environment – D4 Median (Inter quartile range) | 38 (31, 38) | 38 (31, 44) | 0.086 |
*p-value for between group comparisons by Mann Whitney U test.
†WHOQOL-BREF: World health organization quality of life instrument
Comparison of disability in schizophrenia and dysthymia patients
| Parameter | Schizophrenia n=30 | Dysthymia n=30 | p-value* |
|---|
| IDEAS† | Self care Median (Inter quartile range) | 3 (2, 3) | 2 (2, 2) | <0.001 |
| Interpersonal Activities Median (Inter quartile range) | 2 (2, 3) | 2 (1, 2) | 0.029 |
| Communication and Understanding Median (Inter quartile range) | 2.5 (2, 3) | 2 (1, 2) | <0.001 |
| Work Median (Inter quartile range | 3 (2.75, 3) | 2.5 (2, 3) | 0.029 |
*p-value for between group comparisons by mann whitney U test
†Ideas : Indian disability evaluation and assessment scale
Comparison of global disability (ideas ) in schizophrenia and dysthymia patients
| Parameter | Schizophrenia n=30 | Dysthymia n=30 | Fischer’s Exact test | p-value* |
|---|
| *IDEAS -Global | Mild to Moderate | 20 | 30 | 9.720 | 0.001 |
| Severe | 10 | 0 |
*Ideas : Indian disability evaluation and assessment scale
Conclusion
Both patients of schizophrenia as well as patients of dysthymia experience significantly impoverished quality of life and moderate to severe amount of disability. Patients of schizophrenia showed poorer quality of life and greater disability in all domains in comparison to patients of dysthymia. More studies can help delineate the compounding factors and domains that influence QOL and disability thus helping clinicians in long term management and rehabilitation strategies in both of these debilitating disorders. This assumes significance when planning rehabilitation models for such chronic psychological illnesses as they can increase burden on family and pose great challenge for their rehabilitation.
Acknowledgments
Indian Council of Medical Research - Short Term Studentship program 2013 (ICMR-STS-2013).
*p-value for between group comparisons by Mann Whitney U test.†WHOQOL-BREF: World health organization quality of life instrument*p-value for between group comparisons by mann whitney U test†Ideas : Indian disability evaluation and assessment scale*Ideas : Indian disability evaluation and assessment scale
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