Quality of Life in Persons with Schizophrenia.

Abstract

De-institualization had been greatly facilitated by novel antipsychotics. Our goal is now to foster an independent life style of the discharged schizophrenic patients. Their subjective views and satisfaction can be statistically assessed via Kilian’s empowerment questionnaire, Bergold’s inventory, or the measures of quality of life. Their medication compliance can hopefully be also enhanced by further pharmacological studies, including also those of herbal preparations such as cannabidiol or ginseng. Our goal is to improve the quality of life of persons diagnosed with psychiatric illness. De-institutionalization movement in psychiatry in 1960s was originally driven by the hope to free the patients from highly contained institutionalized environments. At that time, certain charismatic psychiatrists such as Franco Basaglia insisted that the symptoms such as the word salad, flat affect, the vacant stares, the repetitive gestures and movements would, in fact, abate when the patient benefits from the freedom of living outside, within the community.1 The critics of the de-institionalization pointed out that the patients with schizophrenia and those with bipolar illness were being dumped into the neighborhoods, many of them becoming homeless, or victims of assaults or of suicides, or found themselves in jails.2 Their symptoms had not disappeared. Families of former inpatients felt overwhelmed by having to assume an intensive homecare without outside help, except when their financial situation enabled them to pay for inpatient treatments in private psychiatric hospitals. The antipsychiatric movement often criticized pharmacology as essentially controlling and poisonous, however, it has been also noted in several studies that symptoms such as dyskinesia and parkinsonism occur even in patients never exposed to antipsychotic medication.3 Over more recent decades, the new generation antipsychotics and the network of halfway houses made the process of re-integration into the community less aversive both for the patients and for their families. In particular, with clozapine, the back wards with treatment resistant patients or even entire hospitals were emptied by a few particularly skilled pharmacotherapists, e.g., Charles Byrne in Ireland or Kola Oyewumi in Ontario, in a manner that greatly reduced the severity of symptoms and enhanced the patients’ quality of life. Kilian4 emphasized that the goal of modern psychiatry is to foster an independent lifestyle and autonomous dealing with the illness, as exemplified by the concept of empowerment. Kilian’s team developed a 33-item questionnaire to measure this concept in psychiatric outpatients. The questionnaire covers important aspects of the patient’s life, including financial situation, living arrangements, work activity, social life, participation in therapy, insight, acceptance of illness, medication management, free time activities, political activism, sense of hope, self-efficacy, and family relationships. It is noteworthy that the item content of Kilian’s empowerment questionnaire was derived from focus groups with the participation of patients with major psychiatric illness, their family members, and of experts in psychiatry. At present, we are faced with the task of further reducing the levels of symptoms of patients in halfway houses or those living more independently within the community. Some residual symptoms of schizophrenia in patients on clozapine or other novel antipsychotics such as olanzapine are subjectively upsetting or disruptive and too frequently prevent young adults with schizophrenia from successfully completing university education or from being employable, for example, concurrent symptoms of anxiety or obsessive compulsive symptoms. Supportive psychotherapy can, at times, help to reduce such symptoms. While there is a wide variety of psychotherapeutic approaches, some psychotherapists may insist that their particular technique is the most efficacious. Some others have hypothesized that certain common ingredients in the diverse psychotherapies are the main underlying cause of reduction in overall level of psychopathology. Tschacher, Junghan, and Pfammatter investigated such factors common to various psychotherapeutic approaches:5 they surveyed statistically 68 psychotherapy experts and concluded that the extent of patient engagement, of affective experiencing, and the overall therapeutic alliance were judged as most relevant. The democratization seen in developed countries has its parallel in our interest, as healthcare professionals, in how the patient perceives the therapist. The patients’ perceptions of their therapist can be measured in an encompassing manner via scales such as those of Bergold’s questionnaire:6,7 Genuineness, Emotional Resonance, Empathy, Mutual Liking, Directiveness, Perceived Similarity, Social Reinforcement, Anxiety Inhibition, Modeling, and Expert Status. These studies would hopefully permit us to statistically determine the actual effective ingredients of therapeutic counseling for each group of disorders. The Quality of Life (QOL) research on patients with schizophrenia indicates that the presence of positive and negative symptoms is correlated with poor QOL, as demonstrated by the meta-analysis by Eack and Newhill.8 The Nigerian statistical study (published in the present issue of Mental Illness) shows that higher medication adherence is associated with better QOL. The patients’ compliance with pharmacotherapy can be increased by eliminating side-effects. The search for better medications with more benign profile of sideeffects is important. This may also include exploration of herbal substances. Ginseng has shown some potential for reducing levels of depression in patients with high levels of negative symptoms.9 Cannabis sativa contains numerous chemical compounds most of which have not yet been properly explored. While the administration of tetrahydrocannabinol (THC, derived from cannabis) can trigger symptoms of schizophrenia, another substance from cannabis, the cannabidiol (CBD), is not psychotomimetic and, in fact, reduces schizophrenic symptoms all while showing a marked tolerability and safety when compared to current medications for schizophrenia.10 While modern antipsychotics such as clozapine have made de-institutionalization subjectively more beneficial and tolerable for our patients, an intensified research effort is needed to further reduce their symptoms. Mental Illness 2017; volume 9:7052