Attitudes toward COVID-19 pandemic measures and clinical symptom severity in schizophrenia patients: a preliminary cross-sectional study

Abstract

Objectives

The study aim was to compare clinical symptom severity and quality of life (QoL) among schizophrenia patients according to their attitudes toward pandemic measures and reported lockdown-related disruption.

Methods

Patients with schizophrenia attending follow-up sessions at two community mental health centers were included in this cross-sectional study. Sociodemographic and clinical characteristics of patients were assessed using a standardized form and the following psychometric instruments: the Positive and Negative Syndrome Scale, Brief Psychiatric Rating Scale, State-Trait Anxiety Inventory, Heinrich–Carpenter Quality of Life Scale and Clinical Global Impressions Ratings-Severity scale. Patients were grouped according to their attitudes toward pandemic measures (positive attitudes or non-positive attitudes).

Results

No significant differences were found in sociodemographic and clinical variables, clinical symptom severity or QoL between schizophrenia patients with positive attitudes and those without positive attitudes toward pandemic measures. Guilt feelings and trait anxiety levels were positively related to lockdown-related disruption.

Conclusions

Positive attitudes toward pandemic measures may be affected by factors other than the sociodemographic and clinical status of schizophrenia patients. It is important that such factors are assessed in future studies to better manage pandemic-related challenges among schizophrenia patients.

Keywords

COVID-19 pandemic attitude knowledge schizophrenia quality of life clinical symptom severity cross-sectional

Introduction

The SARS-CoV-2 (COVID-19) pandemic has led to a range of harmful effects globally. Although the end of the pandemic has been declared, its diverse effects on general healthcare and economic systems are likely to be long-lasting.¹ In many countries, the robust preventive measures (e.g. social distancing and isolation) adopted to slow the spread of the virus presented challenges to social life and medical care. A growing number of studies have identified pandemic-related psychological effects in the general population. In addition, there are reports that the mental status of patients with severe mental disorders such as schizophrenia worsened during the pandemic.² COVID-19 patients with schizophrenia had higher mortality rates and poorer prognosis than COVID-19 patients in the general population.^3,4 Because of their poor insight and impaired judgement, together with comorbidities and poor hygiene, schizophrenia patients had an increased risk of being infected with COVID-19.^5,6 It is clear that people’s knowledge and attitudes toward pandemic preventive measures were important in slowing the spread of the virus. For this reason, recent studies conducted in different countries have focused on attitudes toward COVID-19-related preventive measures.^7,8 Recent findings suggest that the general level of awareness and knowledge related to COVID-19 transmission and symptoms in the general population is moderate to good.^9,10 However, limited knowledge about COVID-19 has been reported in patients with psychosis spectrum disorders, a finding attributed to low socioeconomic and literacy levels as well as low environmental support.¹¹ In contrast, a recent study showed that most hospitalized patients with severe mental disorders had positive attitudes toward COVID-19 preventive measures.¹² However, some schizophrenia-related factors may negatively affect knowledge and attitudes toward COVID-19 preventive measures, particularly taking into account problems with access to mental health services.¹³ Adaptive coping strategies, which are associated with positive attitudes, were also less apparent in psychiatric patients during the pandemic lockdown.¹⁴ To our knowledge, no studies have investigated the relationship between clinical symptom severity and attitudes toward COVID-19 preventive measures in schizophrenia patients. Thus, in this study, we aimed to assess differences in clinical symptom severity, quality of life (QoL) and demographic variables in schizophrenia patients with differing attitudes toward COVID-19 pandemic preventive measures.

Materials and methods

Participants

Patients diagnosed with schizophrenia were recruited from two community mental health centers (CMHC) affiliated to Erenköy Mental Health and Neurology Training and Research Hospital, Kadıköy, İstanbul. Patients who attended the CMHC for their routine visits between July 2020 and October 2020 were enrolled in the study. The inclusion criteria were 1) a diagnosis of schizophrenia; 2) literacy; 3) adequate intellectual capability to provide informed consent and to complete psychometric scales; 4) adequate knowledge about COVID-19 and its transmission, confirmed by answering “yes” to the first two questions on a COVID-19 survey. Patients who had psychiatric diagnoses other than schizophrenia, had had a change in their antipsychotic medication in the last month, had a clinical condition that required hospital admission or who were unable to fully cooperate with the clinician were excluded from the study. Patients were consecutively recruited from routine referrals to CMHC. A power analysis was conducted based on findings that higher educational levels were associated with greater COVID-19 knowledge and higher positive attitudes toward COVID-19 preventive measures in patients with severe mental illness. This analysis showed that at least 56 patients were needed for the study, with 80% power and an alpha level of 0.05.¹²

Procedure

Following a briefing about the study objectives by the CMHC clinicians, written informed consent was obtained from all participants. All relevant patient details were de-identified to ensure confidentiality. The study population was grouped according to attitude scores on pandemic preventive measures. Individuals were assessed using a sociodemographic form and a survey on COVID-19 prepared by the researchers. The following psychometric scales were also used: the Positive and Negative Syndrome Scale (PANSS), Brief Psychiatric Rating Scale (BPRS), State-Trait Anxiety Inventory (STAI), Heinrich–Carpenter Quality of Life Scale (QLS) and Clinical Global Impressions Ratings-Severity (CGI-S) scale. The study was conducted in accordance with the Declaration of Helsinki. The reporting of this cross-sectional study conforms to STROBE guidelines.¹⁵

Ethics

Ethical approval was granted by the local ethics committee for clinical research (Erenköy Mental Health and Neurology Training Hospital Ethics Committee for Clinical Trials; date: 08.06.2020, reference number: 17) and participants’ written consent was obtained.

Instruments

Sociodemographic–clinical status survey

The sociodemographic variables of age, sex, marital status, education, occupation, monthly income and household were assessed using a standardized sociodemographic survey form prepared by the researchers. Information about clinical variables regarding previous hospitalization, suicide attempts, substance use and ongoing antipsychotic medications were also assessed using the same form.

COVID-19 survey

A clinician-administered survey form was prepared by the researchers to obtain information about the knowledge and attitudes of participants toward COVID-19. The survey included 11 questions with yes/no response options (Appendix 1). This structured questionnaire was designed by reviewing relevant literature in Turkish and translated to English; a review process was followed to ensure consistency.^16,17

Survey responses were scored as 0 for “no” and 1 for “yes.” A total score of no less than 5 points on questions 3 to 7 indicated a positive attitude toward COVID-19 pandemic measures. A total score of no less than 3 points on questions 8 to 10 indicated experience of lockdown-related disruption.

Positive and Negative Syndrome Scale (PANSS)

This clinician-administered questionnaire is widely used to measure positive, negative and general psychopathology symptoms of schizophrenia spectrum disorders.^1,3 The PANSS consists of 30 items (7 items for positive symptoms, 7 items for negative symptoms and 16 items for general psychopathology). Responses are scored on a scale of 1 to 7 according to symptom severity.^18,19

Brief Psychiatric Rating Scale (BPRS)

The BPRS is a clinician-administered scale used to assess positive, negative, somatic and affective symptoms. It comprises 18 items, scored from 0 (not present) to 6 (extremely), which assess the following symptoms: somatic concerns, anxiety, emotional withdrawal, conceptual disorganization, guilt feelings, tension, mannerisms and posturing, grandiosity, depressive mood, hostility, suspiciousness, hallucinatory behavior, motor retardation, uncooperativeness, unusual thought content, blunted affect, excitement, and disorientation.^20,21

State-Trait Anxiety Inventory (STAI)

The STAI is a self-report instrument that measures anxiety on two domains: state anxiety, which reflects the respondent’s current situational anxiety level, and trait anxiety, which reflects a more general tendency to express anxiety toward environmental perceived threats.^22,23 This scale consists of 40 items. Responses are scored from 1 to 4; the total score on each domain ranges from 20 to 80.

Heinrich–Carpenter Quality of Life Scale (QLS)

This scale mainly measures deficit syndrome symptoms, including current social status, personal experiences, the quality of interpersonal relationships, compatibility and productivity of outpatients with schizophrenia.^24,25 The scale comprises 21 items on four dimensions: Intra-psychic Foundations (motivation, curiosity, empathy, the ability to feel pleasure and emotional interaction); Interpersonal Relations (the quality and quantity of social relationships); Instrumental Role Functioning (productivity in occupational aspects and social roles) and Common Objects and Activities (involvement in regular activities, participation in society). Each item score ranges from 0 to 6 according to the level of functioning.

Clinical Global Impressions Ratings-Severity scale (CGI-S)

The CGI-S scale is a practical clinician-administered rating tool that can be used for all psychiatric disorders. It assesses the average level of illness severity based on observed and reported symptoms, behavior and function, as well as previous experiences with the patient.²⁶ The clinician rates the patient’s illness severity level from 1 (normal, not ill) to 7 (extremely ill).

Statistical analyses

Statistical analyses were carried out using IBM SPSS Statistics for Windows, Version 26 (IBM Corp., Armonk, NY, USA). Normality of variable distributions was assessed using the Shapiro–Wilk test. The categorical variables of age, marital status, educational level, occupation, monthly income, household situation, previous hospitalizations, suicide attempts, substance use, number of ongoing antipsychotics in current medication, and clozapine and long-acting injectable antipsychotic use were analyzed as descriptive statistics. The Mann–Whitney U test was used to compare mean scores on the psychometric scales (PANSS, BPRS, STAI, QLS and CGI-S) between groups defined according to positive/non-positive attitudes. To compare the categorical variables between independent groups, chi-square or Fisher’s exact test were used. Sociodemographic and clinical factors that were potential predictors of positive attitude were tested using a multiple binary logistic regression model. The relationships between psychometric scores and positive attitude scores as well as lockdown disruption scores were analyzed using the Spearman rank correlation test. Statistical significance was defined as p < 0.05.

Results

A flowchart explaining the selection of patients for the study is shown in Figure 1. Forty-eight patients who fulfilled the inclusion criteria constituted the sample. Three patients (6.3%) had a previous COVID-19 infection diagnosis and 45 patients had had no COVID-19 infection before the study, as confirmed by their medical records. Five patients (10.4%) had a relative diagnosed with COVID-19 in the same household. Ten patients (20.8%) had at least one comorbid chronic medical condition other than schizophrenia (e.g. diabetes mellitus, hypertension, coronary artery disease). All patients were smokers (at least 20 cigarettes per day).

Figure 1.

Flowchart of participants included in study.

Patients were divided into two groups according to their attitudes toward COVID-19 preventive measures; 24 patients had positive attitudes and 24 did not. Sociodemographic and clinical variables and their association with positive attitudes toward COVID-19 preventive measures are shown in Table 1. Only 7 (14.6%) participants reported lockdown-related disruption. There were no significant sociodemographic or clinical differences between participants who had positive attitudes and those who did not. A regression model in which sociodemographic and clinical variables were the independent factors identified no predictors of positive attitudes (−2 log likelihood = 53.66, Nagelkerke R square = 0.31, Table 1).

Table 1.

Sociodemographic and clinical factors associated with patients’ positive attitudes toward COVID-19 pandemic-related measures

		Positive attitude (+)		Positive attitude (−)				Positive attitudes(Dependent factor) Multiple logistic regression
Independent factors	Total (n)	n	%	n	%	Chi-square	p	p	OR	95% CI
Sex
Female	11	7	63.6	4	36.4	1.06	0.30	0.48	1.93	0.30–12.24
Male	37	17	45.9	20	54.1
Age (years)
<30*	14	7	50	7	50	1.88	0.38	0.35
30–45	18	7	38.9	11	61.1			0.95	1.06	0.14–7.77
46–57	16	10	62.5	6	37.5			0.25	0.34	0.05–2.15
Marital status
Never married*	35	16	45.7	19	54.3	0.94	0.33	0.63	0.56	0.05–6.24
Married/divorced	13	8	61.5	5	38.5
Educational level
Primary school and below*	21	10	47.6	11	52.4	0.08	0.77	0.54	0.58	0.10–3.31
Secondary school and above	27	14	51.9	13	48.1
Occupation
Unemployed*	38	17	44.7	21	55.3	2.02	0.15	0.70	0.55	0.02–12.08
Employed/retired	10	7	70	3	30
Income (monthly)
<$200*	31	13	41.9	18	58.1	2.27	0.13	0.49	0.42	0.03–4.88
≥$200	17	11	64.7	6	35.3
Household
1^st degree relatives*	33	14	42.4	19	57.6	2.42	0.11	0.64	0.61	0.07–4.96
Other	15	10	66.7	5	33.3
Prior hospitalization
No*	7	4	57.1	3	42.9		1	0.66	0.60	0.06–5.76
Yes	41	20	48.8	21	51.2
Suicide attempt
No*	37	20	54.1	17	45.9			0.10	0.18	0.02–1.42
Yes	11	4	36.4	7	63.6	1.06	0.30
Substance use
No*	44	22	50	22	50		1	0.77	0.68	0.05–9.34
Yes	4	2	50	2	50
Number of ongoing APs
<2	19	11	57.9	8	42.1			0.40	1.94	0.41–9.19
≥2	29	13	44.8	16	55.2	0.78	0.37
Clozapine use
No*	35	17	48.6	18	51.4	0.10	0.74	0.19	0.29	0.04–1.88
Yes	13	7	53.8	6	46.2
LAI use
No*	25	15	60	10	40	2.08	0.14	0.30	2.15	0.49–9.35
Yes	23	9	39.1	14	60.9

−2 log likelihood = 53.66, Nagelkerke R square = 0.31, *Reference Group. AP, antipsychotic; CI, confidence interval; LAI, long-acting injectable antipsychotic; OR, odds ratio.

Table 2 shows a comparison of psychometric measurement scores between groups according to positive attitudes. There was no significant between-group difference in clinical symptom severity (as measured by the PANSS, BPRS, and CGI-S), state and trait anxiety levels (STAI-T and STAI-S) or QoL (QLS) scores. The mean positive attitude score was 4.18 ± 1.38 out of 5, and the mean lockdown disruption score was 0.95 ± 0.16 out of 3. A correlation analysis showed no significant relationship between positive attitude and psychometric scores.

Table 2.

Comparison of psychometric measurement scores between patients according to positive attitude toward COVID-19 pandemic-related measures.

	Positive attitude (+)(n = 24)		Positive attitude (−)(n = 24)
	Mean	SD	Mean	SD	z	p
PANSS
Positive	13.66	7.44	14.04	4.96	−1.11	0.26
Negative	18.87	5.31	17.87	5.01	−0.36	0.71
General psychopathology	35.2	7.38	34.5	8.19	−0.29	0.76
Total	67.5	18.57	66.54	15.63	−0.01	0.99
BPRS total	24.08	12.89	23.62	11.07	−0.09	0.92
STAI-S	44.54	12.62	49.04	12.31	−1.21	0.22
STAI-T	46.66	11.54	48.79	8.20	−0.79	0.42
QLS
Intra-psychic Foundations	20	3.79	19.41	3.37	−0.02	0.98
Interpersonal Relations	21.79	7.43	22	5.33	−0.09	0.92
Instrumental Role Functioning	9.12	4.83	8.29	4.30	−0.52	0.59
Common Objects and Activities	5.70	1.87	5.45	1.61	−0.32	0.74
Total	56.62	16.78	55.2	12.69	−0.23	0.81
CGI-S	3.91	1.05	4.12	1.07	−0.73	0.46

BPRS, Brief Psychiatric Rating Scale; CGI-S, Clinical Global Impressions Ratings-Severity scale; PANSS, Positive and Negative Syndrome Scale; QLS, Heinrich–Carpenter Quality of Life Scale; SD, standard deviation; STAI, State-Trait Anxiety Inventory.

The only significant relationships between experience of lockdown disruption and clinical symptom severity were for the BPRS guilt feelings score (r = 0.28, p = 0.04) and the STAI-T score (r = 0.36, p = 0.01).

All patients with a positive attitude reported that they would agree to be vaccinated, and 13 patients (53.2%) without a positive attitude also agreed to be vaccinated. Only four patients with a positive attitude (16.7%) and one patient without a positive attitude (4.2%) reported possibly having a current COVID-19 infection.

Discussion

The study aim was to investigate differences in clinical symptom severity and QoL between schizophrenia patients who had positive attitudes toward COVID-19 preventive measures and those who did not. To the best of our knowledge, this is the first study to compare clinical symptom severity and QoL according to attitudes toward COVID-19 in schizophrenia patients, who were considered to be a vulnerable population during the pandemic. We found no significant difference between groups in terms of clinical severity or QoL, and no relationship between positive attitude scores and clinical measurement scores on psychosis, anxiety or QoL. Considering that all participants had a basic, adequate knowledge of COVID-19 infection (as confirmed by responses to the first two questions on the COVID-19 survey), these results suggest that attitudes toward the pandemic and lockdown disruption may be related to factors other than clinical status, such as environmental factors or the type of knowledge sources.

Data on the psychiatric effect of the COVID-19 lockdown in people diagnosed with a psychiatric illness suggest a substantial worsening of psychological status during the pandemic and the associated strict lockdown measures.²⁷ A recent study by Zhu et al. showed that 83.6% of inpatients with schizophrenia had positive attitudes toward preventive measures during the COVID-19 pandemic.¹² However, in the present study, 50% of schizophrenia patients had positive attitudes. This disparity may reflect differences in patient profile; the Zhu et al. study was conducted with an inpatient population whereas our study population was obtained from patients attending CMHC follow-ups. Furthermore, previous reports show that knowledge and attitudes toward the pandemic may be associated with several different factors, including source of knowledge, age, education level, monthly income and public health information disseminated through the media.^12,28 However, we found no significant sociodemographic differences between schizophrenia patients according to having positive attitudes. These controversial findings could be explained by differences in study design and study period, and by methodological differences in assessing concepts such as knowledge and attitudes toward the COVID-19 pandemic. Thus, the present study data are insufficient to exclude the effect of such factors, which may be related to participants’ attitudes toward the pandemic. However, as many studies on different populations worldwide have shown that most participants have satisfactory knowledge and positive attitudes toward pandemic measures, the proportion of participants with positive attitudes in the present study could be considered mostly in line with previous recent data.²⁹ Additionally, despite the attitude differences observed among our participants, no sociodemographic predictors were identified, which is inconsistent with findings from a previous study that showed that marital status and educational level were associated with positive attitudes toward pandemic preventive measures.¹² Another point that should be considered when interpreting this finding is that our participants had no additional or specific education or information on the COVID-19 pandemic beyond that available to the general population. Lockdown-related disruption was found to be relatively low (reported by only 14.7% of participants). This result may reflect existing social isolation characteristic of the chronic progressive course of schizophrenia. Reduced social drive is a frequently observed negative clinical symptom of schizophrenia.³⁰ A recent study suggested that a focus on negative symptoms was pivotal in interventions for schizophrenia patients during the pandemic because lockdown worsened negative symptoms.³¹ Another study found that negative symptoms worsened whereas positive symptoms were alleviated after isolation in schizophrenia inpatients with COVID-19.³² A large proportion of schizophrenia patients, particularly those with deficit syndrome, spend most of their time isolated at home. From this perspective, lockdown may be a condition that is familiar to most schizophrenia patients. However, some previous reports indicate that perceived stress is higher in patients with severe mental illness than in the general population, and that lockdown restrictions may trigger psychotic episodes in schizophrenia patients.^33,34 However, none of the participants enrolled in our study had had a recent psychotic exacerbation that required a medication change or hospital admission. The effect of differences in patient evaluation periods and preventive measures during the lockdown period in studies from different countries should be considered. In addition, data from clinically stable patients may be more consistent regarding attitudes toward the pandemic and lockdown disruption.

We found that guilt feelings and trait anxiety levels were positively related to lockdown disruption. This could be attributed to an increase in general anxiety and intrapsychic guilt feelings (e.g. self-oriented negative thoughts, self-blame and regret) owing to containment and social isolation. Social isolation is an important factor that raises anxiety levels; one study showed that patients with high anxiety were less tolerant to COVID-19 pandemic restrictions.³⁵ Social isolation during lockdown may also increase patients’ self-focus and guilt feelings, which may lead to depression. There is evidence that depression levels increased during the COVID-19 pandemic.³⁶ In addition, although we did not evaluate burnout in this study, the condition was associated with psychiatric burden, depression, anxiety and insomnia during the pandemic period.³⁷ The concept of burnout as related to the COVID-19 pandemic has been expanded; new psychometric tools have been developed and the research area is growing.³⁸ From this perspective, the relationship between lockdown disturbance and guilt feelings may be associated with pandemic burden and depressive symptoms.

Several study limitations should be considered when interpreting the present findings. This study was under-powered and had a relatively small sample, which was below the target sample size as determined in a power analysis prior to study enrollment. However, this small sample size reflects the reduction in applications to health services during the pandemic. The other main limitations were the cross-sectional design and use of unstandardized methods for assessing pandemic-related knowledge, attitudes and lockdown disruption. Previous data indicate that higher levels of neuropsychiatric symptoms were observed during hospitalized COVID-19 patients than in a psychiatric population.³⁹ However, only three patients in the present study had a previous COVID-19 infection. However, lack of assessment to determine direct COVID-19 infection-related psychological effects from a neuropsychiatric perspective is another potential limitation.³⁹

In conclusion, this study showed that sociodemographic and clinical factors were not associated with attitudes toward the COVID-19 pandemic and related preventive measures. Future studies with larger sample sizes and longitudinal designs are warranted to identify factors associated with clinical outcomes during periods characterized by extraordinary challenges such as the COVID-19 pandemic. More research is also needed on attitudes toward related preventive measures in schizophrenia patients, who experience challenges in both medical care and adherence to public preventive measures.

Footnotes

Acknowledgements

We wish to thank all the patients who participated in the study and all the staff at the psychosis clinic for their help in recruiting patients.

Availability of data and material

The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.

Declaration of conflicting interests

The authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

ORCID iD

Durmaz Onur

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