Abstract
The importance of gender differences has been ignored in schizophrenia research until the past few years [1]. There are no differences in acute symptom profiles between men and women in schizophrenia [2, [3]], although men have onset at an earlier age than women [4, [5]]. In addition, men have a more unfavourable early [6] and mid [7] disease course. In late life, these differences tend to attenuate but do not disappear even over very long time periods [8]. Deficiencies in living skills and social functioning are also more common in men than in women [2, [3], [5], [9]].
Reliable measures for social and everyday living skills are needed for evaluating treatment and rehabilitation programs targeted at patients with schizophrenia. Some scales including the Life Skills Profile [10, [11]], Independent Living Skills Survey [12] and Basic Everyday Living Skills [13] have been developed and used in research. Nevertheless, in clinical practice, the Global Assessment of Functioning (GAF) scale [14], being the fifth axis of the DSM system, is probably one of the most frequently used scales for assessing treatment and rehabilitation outcome in schizophrenia. In the GAF scale, psychiatric symptoms and social, domestic and professional functional capacities are combined into a single score. The validity of the GAF scale has been studied relatively little, considering how widely it is used [15, [16]].
Even subsyndromal depressive symptoms have been found to impair functioning in a general population [17]. Depression is common in patients who have suffered from schizophrenia for a long time [18]. However, the associations between depression and overall functioning in persons with schizophrenia are unknown.
In the present study, we investigated skills in personal and domestic activities among female and male outpatients with schizophrenia. We were particularly interested in whether there were associations between measures in the GAF scale and independent living skills. We also studied the impact of depressive mood on functional capacity.
Method
This study is a part of a larger survey of treatment received by patients in the Department of Psychiatry, Kuopio University Hospital, Finland, in May 1993. During that time the hospital provided all psychiatric inpatient services for a population numbering 200 000. Outpatient psychiatric services were provided by community mental-health clinics associated with the hospital, in the context of a regionally comprehensive psychiatric care model. In practice, all patients with schizophrenia in the area having severe psychotic symptoms or a need for multidisciplinary treatment and rehabilitation programs were treated within these services; most of others were followed up by general practitioners in public primary care settings. Only a few patients with schizophrenia were treated by private psychiatrists or psychotherapists at the time of the study.
The population surveyed consisted of all outpatients in May 1993 who had paid at least three previous outpatient visits in 1993, and all inpatients in the first week of May 1993. Data were collected with the help of two questionnaires. One was given to patients, to be completed and returned by post (45 items in all). The other was completed by the therapist and/or psychiatrist (23 items in all). A total of 1744 sets of the study questionnaires were distributed. The patients returned 1290 questionnaires (74%) and the therapists 1683 questionnaires (97%).
Patients were asked to answer questions relating to basic sociodemographic characteristics (age, gender, marital status), and living (alone, with family, sheltered home) and working conditions (at work, unemployed, on sick leave, on disability pension, retired). Inquiry was also made about the frequency of consumption of alcohol. Individuals who reported consuming alcohol at least once a week were regarded as drinking alcohol regularly. The patient questionnaire included also the 13-item Beck Depression Inventory (BDI) [19].
Therapists/psychiatrists recorded ages of patients at the time of onset of symptoms and start of treatment, current treatment setting, frequency of treatment contacts, and the use of neuroleptic and antidepressive medication. They also assessed (yes/no) whether the patient had independent skills in six personal or domestic activities (personal hygiene, homemaking, management of financial affairs, shopping, decision-making, getting about). Therapists/psychiatrists also assessed the severity of numerous psychiatric symptoms (including hallucinations, delusions and suicidality) using Likert scales (none–many). All assessments were based on both medical histories and personal therapeutic relationships.
Staff assessed levels of patient's psychosocial functioning with the help of the GAF scale [14]. Attending psychiatrists defined a main psychiatric diagnosis for each patient, in accordance with DSM-III-R criteria [14].
We found 425 outpatients with DSM-III-R schizo-phrenia. The final study population (n == 302) included those patients for whom an assessment was obtained by the patients themselves and the staff.
Univariate statistical analyses were carried out using the χ2-test for class variables, and Student's t-test or Mann–Whitney U-test together with confidence intervals (CI) for continuous variables. Finally, we studied both in men and women whether the associations between GAF score and skills in personal and domestic activities were independent according to multivariate analyses (forward stepwise logistic regression). To control confounding factors, age, marital status, employment status, living conditions, consumption of alcohol, duration of illness, duration of treatment, frequency of treatment contacts, use of neuroleptic or antidepressive medication, BDI score, and severity of hallucinations, delusions and suicidality were included in the analysis.
There were no significant differences between the loss (n == 123; 29%) and the final study sample with regards to the mean age at which the symptoms started (22.3 vs 23.2 years) or the treatment was initiated (23.6 vs 24.6 years), or in any treatment variable (data not shown). Subjects in the loss group had slightly lower current GAF scores than those in the study group (mean == 50.5, 95% CI == 48.2–52.8 vs 54.0, 95% CI == 52.6–55.4, p < 0.05). Hallucinations (41 vs 25%, p < 0.01) and delusions (43 vs 31%, p < 0.05) as assessed by the staff were also more common in the loss group, respectively.
Methods
Sociodemographic and clinical characteristics of the study population
Percentages of subjects without independent skills in basic personal and domestic activities by gender
Mean Global Assessment of Functioning (GAF) and Beck Depression Inventory (BDI) scores with 95% confidence intervals (CI) by gender and functional capacity
In a subgroup having GAF scores less than 50, women (n == 51) had more often than men (n == 51) independent skills in personal hygiene (94 vs 72%, χ == 8.82, df == 1, p < 0.01), homemaking (78 vs 44%, χ2 == 12.63, df == 1, p < 0.001) and management of financial affairs (67 vs 43%, χ2 == 5.72, df == 1, p < 0.05). There were no statistically significant differences between men and women in the frequency of hallucinations (44 vs 26%), delusions (42 vs 45%) or in any treatment variable (data not shown) in this subgroup. Women were more often married or cohabiting than men (29 vs 6%, χ2 == 9.71, df == 1, p < 0.01). Moreover, women were also more often at work as compared to men (12 vs 4%) but the difference was not statistically significant.
There was a trend that BDI scores in patients having independent skills in personal and domestic activities were lower than scores observed in patients lacking such skills. However, the only statistically significant differences were found in men, in relation to homemaking and the ability to shop independently (Table 3).
According to multivariate analyses, the GAF score was in men independently and positively associated with all independent skills studied: hygiene (Odds ratio [OR] == 1.17, 95% CI == 1.05–1.31), homemaking (OR == 1.07, 95% CI == 1.03–1.12), management of financial affairs (OR == 1.12, 95% CI == 1.06–1.18), shopping (OR == 1.11, 95% CI == 1.03–1.19), decision-making (OR == 1.13, 95% CI == 1.07–1.20) and getting about (OR == 1.14, 95% CI == 1.04–1.25). In women, a corresponding independent association was observed in relation to homemaking (OR == 1.08, 95% CI == 1.02–1.16), management of financial affairs (OR == 1.07, 95% CI == 1.02–1.13) and decision-making (OR == 1.07, 95% CI == 1.02–1.12). The BDI score was independently associated only in women with an independent skill to get about without support from others (adjusted OR == 0.91, 95% CI == 0.82–1.00).
Discussion
Deficiencies in living skills were found to be common especially among male outpatients with schizophrenia. The results of our study suggest that overall assessments on the GAF scale describe skills in personal and domestic activities independently of sociodemographic and clinical variables in this patient group. In a previous study, evidence has been found for a limited validity of the GAF scale among psychiatric inpatients [15]. Nevertheless, our results support the use of the GAF scale as a tool to assess overall functioning and living skills among outpatients with schizophrenia.
The GAF scores of less than 50 should indicate at least some severe symptoms or deficiencies in functioning [14]. We found that women in this subgroup more often than men had independent living skills in personal hygiene, homemaking and management of financial affairs but there were no differences in prevalence of psychotic symptoms. Furthermore, women were more often living with a partner or were at work. These observations suggest that clinicians's assessments in the GAF scale had been biased toward poor functioning in women. This view is supported also by the finding that in the whole sample men had deficiencies in living skills more often than women but there were no difference in mean GAF scores. It may be that the clinician raters give lower GAF scores to women as compared to men because they expect that all women, whether suffering from mental illness or not, should be able to do housework which expectation they do not have for men. Some previous studies have also suggested that gender-role values and attitudes of treatment personnel may influence their clinical judgements [20, [21], [22]].
According to the results of our study, depressed mood was not significantly associated with deficiencies in living skills. This result is different from observations made in relation to a general population [17]. However, comparisons between these studies are difficult because of differences in rating instruments. In evaluating this finding it should also be kept in mind that severity of depression was assessed by the patients themselves, and their functional capacity was assessed by the staff. Patients and staff do not necessarily share similar views on the presence of clinical and social problems [23]. In any case, according to these results it may be that depression is not a major threat to independent skills in personal or domestic activities among outpatients with schizophrenia. Nevertheless, this will not reduce the need to assess and treat comorbid depression in schizophrenia. Studies have shown that drugs having anti-depressive effects promote wellbeing [24, [25]] and may reduce the risk of suicide [26] in schizophrenia.
One strength of this study is that the sample was fairly large, and representative of outpatients with schizophrenia in a specific geographical area. The duration of disease varied but most patients had suffered from schizophrenia for a long time. Overall treatment times including both inpatient and outpatient periods were also lengthy. One of the limitations is that we did not assess the interrater reliability of the clinician-rated independent skills. Another major limitation is that we lost one-third of the patients from the final sample. The patients belonging to the loss group had more often psychotic symptoms than those belonging to the study group. We suggest that our results should be generalised only to outpatients having long-term schizophrenia and being in a stable phase of the disease.
This study has some implications on treatment of outpatients with schizophrenia. First, since deficiencies in living skills are common especially among men, domestic skills training [13] should be included in optimal treatment strategies for schizophrenia [27]. Second, the GAF scale is useful in assessing overall functioning and living skills during treatment and rehabilitation processes in both genders. However, one should be cautious in comparing male and female GAF scores because there may be an assessment bias toward poor functioning in women. Finally, depression should be evaluated and treated separately from psychosocial functioning in schizophrenia.