Social deficit in schizophrenia patients. Implication of the term.
Dr Olga Randles

26 Oct 2006

Keywords: Health Administration; Health Policy; Homelessness; Mental Health; Social Science; Socioeconomic Factors

Dr. OLGA RANDLES, East London and The City Mental Health NHS Trust

Address: Academic Unit of Social and Community Psychiatry, Queen Mary University of London, Newham Centre for Mental Health, Glen Road, London, E13 8SP, United Kingdom
Tel: +447918637957, Fax: +442075402976, Email: randles_olga@yahoo.co.uk

 

Abstract.

 

Schizophrenia as a single disease crashes many aspects of the patients' functioning. It is believed to be widespread with worldwide lifetime prevalence rates estimated to be at 0.2 % to 1.5% of the general population, meaning approximately 1% of the population develop schizophrenia during their lives. All areas of social and psychological needs as activities of daily living, leisure, recreation, social relationships, family and friendship, meals and self-care decline under the pressure of illness in schizophrenia patients and need our assessment in clinical, psychological, social aspects and development pharmacological treatment and rehabilitation programs. With the progression of the disease social deficit is taking out almost all social aspects of schizophrenia patients’ life, leads to unemployment, poverty and homeless. 

These factors require a serious attention of Health Service providers, local communities and policy makers willing to stop the development of poverty, asocial behaviour and risk mortality of 1% of the population and decrease the financial burden of schizophrenia. Effective collaboration of policy makers shall make clear the practical solutions. 

 

 

 

Schizophrenia as a single disease crashes many aspects of the patients' functioning. It is believed to be widespread with worldwide lifetime prevalence rates estimated to be at 0.2 % to 1.5% of the general population, meaning approximately 1% of the population develop schizophrenia during their lives, with men and women being equally affected. In 2001 WHO points out the prevalence of the disease: Around 24 million people worldwide suffer from schizophrenia. Goeree R.⁸ underlines the annual incidence rates of 1-4 per 10 000 adults aged 15-54 years and an average lifetime prevalence of between 0.5-1%.

 

There are countless studies of large and small groups of patients with severe mental disease and mixed groups with different mental illnesses and just a few investigations of schizophrenia patients. For investigation of the social aspects in schizophrenia we separated the studies as Classification in DSM-IV separates schizophrenia from schizoaffective disorder, delusional disorder, brief psychiatric disorder, schizophreniform disorder, Shared psychotic disorder and Psychiatric disorder not otherwise specified to identify a narrowly delineated group of cases. Hegarty J.D.¹⁰ provides the comparing of the Kraerprlinian and Non-Kraepelinian diagnostic systems and show that studies using broad Non-Kraepelinian consistently showed better outcomes than those using narrow Kraepelinian criteria (ratio=1.70; t=8.3, df=178, p<0.0001) It is essential to separate schizophrenia as a deficit form disease from non-deficit cases which may often include schizophrenic syndrome of different mental illnesses as functional, organic, epileptic psychosis, show different development of illness and result better outcome. Freeman H. and Alpert M.⁶ supposed that the disorder delays further social development. All shown positions of schizophrenia diagnosis are very important for understanding the foundation of social deficit typical for this disease.

 

There is a concern about the quality of life for schizophrenia patients. A person with schizophrenia usually has some deficits in the social aspects of life which prevent him/her from participating in a valued life. Long duration of schizophrenia gives a poor social adaptation, poor interpersonal communication, decline of social functioning: interpersonal relations as partnership and friendship, work, or self-care. One of the most significant difficulties for schizophrenia patients is finding and keeping a job.

Survey results on employment rates of persons discharged from psychiatric hospitals show that the figures of full-time competitive employment range from 20% to 30%. For schizophrenia patients the figure drops to about 15%. Some authors suppose that employment problems for people with schizophrenia are the result of social behaviour at work and lack the social competence. These schemes were not evenly distributed and need to be investigated.

 

Social deficit

 

The importance of understanding the social deficit in patients with mental health problems and changes in quality of life of people who experience a schizophrenia disease is clear.

All areas of social and psychological needs as employment, finance, accommodation, activities of daily living, leisure, recreation, social relationships, family and friendship, meals and self-care decline under the pressure of illness in schizophrenia patients and need our assessment in clinical, psychological and social aspects. Schizophrenia leads patients to lack of energy and encapsulation in their life keeping low level of outstanding stimulations. With the progression of the disease social deficit is taking out almost all social aspects of schizophrenia patients’ life. (Table 1)

 

Table 1 Social deficit in schizophrenia patients.

 

 

 

 

 

 

			Social aspects of patient’s life * decline of the social relationships,    partnership, friendship * refuse social activity * decline of social skills * decline of quality of life * dependent accommodation * homeless * decline of professional skills * lack of qualifications * need for training * poor prospects * pressure and stress in the workplace         * no work opportunities * unemployment * financial difficulties * poverty * risk mortality

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

	Outcome - Social deficit in schizophrenia patient

 

 

 

 

 

Patients need support and help in all aspects of everyday life including  housing support, provision and supervision, physical health, safety, meals/nutrition, self-care and leisure, child care, adolescents and old age services, training and occupation, employment and income support/finance. As well as an income, employment makes available social contacts and social support, status and individuality, a possibility of structuring time and a sense of personal realization.

 

Clinical and psychological aspects of schizophrenia and their influence on social aspects of patient’s life

 

The clinical factors have an impact on an individual's well-being including social relationships, socio-economic status, housing and employment. A large amount of people schizophrenia has a long duration of the illness and some patients with schizophrenia are unable to return to work. Delusions, hallucinations, disorganized speech, disorganized or catatonic behaviour and negative symptoms lead the patients to the social segregation, and like other disabled people, people with schizophrenia are fully excluded from society activities. Unemployment is one of the most typical and demonstrative results this segregation.

Rosenheck R.¹⁹ Employment of people with schizophrenia is delayed by clinical symptoms and poorer neurocognitive and intrapsychic functioning. The poverty of speech, blunting of affect, lack of volition, low motivation and drive, disorganization of thought, and social withdrawal rising with the development of the negative symptoms and schizophrenia patients create ego-pathology, decline of emotions, will and energy, intellectual ataxia, lost of interests and social activity with raising social isolation and social deficit.

Slade E. and Salkever D. ²² suppose that negative symptoms, depression and extrapyramidal side effects have significant effects on participation in both non-supported jobs and in sheltered or supported jobs. The links between employment status and schizophrenia symptoms are clear demonstrated in the investigation of Slade E. and Salkever D. ²² (Table 2)

 

Table 2 Distribution of symptom scores, by employment status (Slade E. and Salkever D.²²)

 

Symptom Scale/Quartile	Not Employed	Sheltered/Supported Employment	Not Supported Employment
Negative Symptoms:
Minimum	6	7	7
25th Percentile	14	13	11
50th Percentile	18	18	15
75th Percentile	23	22	29
Maximum	41	32	34
Positive Symptoms:
Minimum	7	7	7
25th Percentile	12	11	11
50th Percentile	16	16	15
75th Percentile	20	19	19
Maximum	37	34	33
Depressive Symptoms:
Minimum	0	0	0
25th Percentile	6	5	4
50th Percentile	13	11	11
75th Percentile	22	19	19
Maximum	49	45	40
Extrapyramidal Side-Effects:
Minimum	0	0	0
25th Percentile	1	1	0
50th Percentile	3	3	2
75th Percentile	6	6	4
Maximum	20	21	14

 

 

We can see that symptom levels in general are lowest for the patients employed in non-supported jobs.

Dr Slade²² underlines that the secondary effect on employment of a reduction in negative symptoms is several times greater than the effect of a similar reduction in positive symptoms.

 

Cognition is important for independent living and independent functioning in a work and social situation. As the deficits in general cognition interfere with information processing, the incapability to learn and reason and problem functioning in interpersonal, social and occupational areas, the processes of comprehending of world affairs follow-up the deficits in social cognition. Many authors highlight also the importance of the cognitive dysfunctions in schizophrenia people. (Bell M.D.^1-2; Green M.F. ⁹; Lysaker P.¹⁴) The difficulties that schizophrenia people have in language, reasoning, memory, attention, all of the cognitive abilities are manifesting at the onset of illness. Cognitive deficits have influence on the social and vocational functioning on the patients. Vauth R.²³  names cognitive dysfunctions and negative symptoms as the "rate-limiting factors" for community outcome and response to psychosocial intervention in people with schizophrenia and underlines the importance of improvement in short- and long-term verbal memory and cognitive training in successful job placement for schizophrenia patients in the follow-up. McGurk S.R. and Meltzer H.Y.¹⁷ found in an ANCOVA analysis of people entering a vocational programme (N = 38), the patients were employed full time did significantly better on tests of working memory, vigilance and executive functioning than the unemployed. Deficit in cognitive processing underlies the problems of social integration, social and professional skills and is associated with poor social skills functioning and problem solving.

 

For a significant period of the time since the onset of the disorder, social functioning is declining and one of the main areas of social functioning such as interpersonal relations or self-care are markedly below the level achieved prior to the onset. Chan S. and Yu IuW.⁵ highlight schizophrenia patients often have poor self-care, no social life, the lowest rating for sexual activity by both male and female participants, dissatisfaction with sexual activity. Psychotropic medication can give rise to impotency. Many clients have poor self-esteem and self-image that build a barrier for development the intimate and satisfactory relationships.

 

One of the main reasons for excess mortality in this population is due to higher than normal rates of suicide. The lifetime risk of suicide in the general population is approximately 0.5-1%, compared to people with schizophrenia the rates of suicide is approximately 15-25 times higher (Caldwell C.B. and Gottesman I.I.⁴) Suicidality of the patients is usually linked with social aspect of illness, hopelessness, isolation and stigma. Siris S.G.²¹ highlights that suicidal behaviour in schizophrenia is associated with young age, not being married, coming from a high socioeconomic family background, having high intelligence, having high expectations, lacking social supports. Author also put emphasis on depressive symptoms and the depressive syndrome, reduced self-esteem, severe psychotic and panic-like symptoms, treatment non-compliance and substance abuse, and being recently discharged from the hospital.

 

Problem use of alcohol and drugs has large influence on schizophrenia patients’ life; often result the depression, loosing the interpersonal relationships, social isolation and unemployment. McCreadie R.G. and Scottish Comorbidity Study Group¹⁶ updates the situation in rural, urban and suburban areas of Scotland more patients than controls reported problem use of drugs in 2001 (7%v2%), problem use of alcohol in the past year (17%v10%) and currently smoking (65%v40%).

 

Society influence on social aspects of patient’s life

 

Social isolation often begins in early age. Family investigations show that the relatives of schizophrenia patients have often schizotypal disorders, “schizophrenogenic” mother as an example. Some patients use the isolation as a way of decreasing social stimulation. People with schizophrenia often live alone, unmarried, have a few friends. Separation from relatives and friends and collapse of nuclear families often lead the patients to homelessness. Up to 30% of the homeless population have some form of mental illness. Housing problem is an important cause of stress amongst people with schizophrenia.

 

Individuals with schizophrenia in developed society often become restricted in their social networks, and they and their families become relatively estranged from society. Patients with schizophrenia in developing countries have better outcome at 2 years, but various explanations, as better family support, greater preservation of social role and reduced stigmatisation in developing countries, have not been confirmed the forceful arguments. The World Psychiatric Association has identified a number of factors in the developing world that promote greater tolerance and community support for people with serious mental illness including the rural agrarian nature of the society and the strength of the extended family system. But in spite of The WPA Global Programme to Reduce Stigma and Discrimination because of Schizophrenia (1996) and The Disability Discrimination Act 1995 (UK) the employment rate of schizophrenia patients is low. Even nowadays stigma toward the illness, discrimination and social isolation are the most negative social factors in schizophrenia patients’ ability for adaptation. Marwaha S. and Johnson S.¹⁵ show that the recent European studies report rates of schizophrenia patients’ employment between 10 % and 20% and for example the employment rate in schizophrenia shows visible decline over the last 50 Years in the UK. Mechanic D.¹⁸ pointed out that persons with schizophrenia were least likely to be employed and percent of employed full time people with schizophrenia is almost twice less than percent for people with serious mental illness (24% to 12%).

Most individuals with schizophrenia would like to work, and some hold jobs requiring high levels of functioning but clients encounter many problems, stigmatization of and discrimination against people with schizophrenia which are significant barriers to social integration into society and lead to additional marginalisation and demotion.

Schizophrenia people giving up work mark as a cause stigma and discrimination, lack of qualifications, lack of support, pressure and stress in the workplace, poor prospects, and problems with benefit.

Labour market needs work adjustment skills. The ability to communicate with people at work, ability to do the job and being responsible are important. It is possible that some of these skills could be taught to schizophrenia patients and so very low employment rates reflect interaction between the social and economic pressures that patients face into the labour market.

The benefit system is also one of the powerful barriers. Up to 70% of the patients uninterested in employment worries over the benefits and have fear of benefits loss.

The financial burden of schizophrenia is significant and we can mark the increasing interest to the development of different forms of rehabilitation, social skills trainings and supported employment programs helping people with severe mental illness, and particularly those with a schizophrenia diagnosis to return to competitive employment market. The true costs of schizophrenia, in the structural association with hospitalisation and treatment, rehabilitation and training programs, unemployment, productivity losses and disability payments, associates with large amount of national healthcare expenditures. Rupp A, Keith SJ. (1993) estimated that schizophrenia medical costs in the United States had been between $16 and $19 billion for 1990 alone, accounting for 2.5% of the total of total annual health care expenditures the U.S., they constitute about 10% of the totally and permanently disabled population, and comprise as high as about 14% of the homeless population in some large urban areas. Goeree R, et al. (2005) show the estimated number of people with schizophrenia in Canada in 2004 was 234 305 (95% CI, 136 201-333 402) with the direct healthcare and non-healthcare costs were estimated to be CAN$2.02 billion, 1.7% of national healthcare expenditures in Canada, compared with CAN$1.12 billion in 1996 and the estimated cost of schizophrenia in Canada in 2004 CAN$6.85 billion is compared with CAN$2.35 billion in 1996 and underline that this data meet the similarity with the investigations of other researchers the schizophrenia cost in different countries: costs associated with schizophrenia is ranging from 1.5% to 3% of national healthcare expenditures in The United Kingdom, The United States,  Australia, Belgium, Denmark, France,  Germany, Hungary, Italy, The Netherlands, Norway, Puerto Rico, Spain, Sweden, Taiwan.

 

These negative expenses of schizophrenia offer a powerful stimulus for developing biomedical and rehabilitative interventions and services research. Goeree R, et al. (1999) suppose that programs aspire the improvement of schizophrenia patients’ employment have the visible potential to make a significant contribution in reducing the cost of this severe mental illness. These programs may be promoted by the availability of rehabilitation services. Most patients want the programs helping them in time and stress management and developing the problem-solving skills and support in the workplace. The best outcomes are likely when both medications and employment services are considered together. The use of new atypical antipsychotic drugs gives the reason optimism in the pharmacological management of schizophrenia. Unfortunately, vocational rehabilitation is often not included in the care plans of people with schizophrenia (Lehman A.F. and Steinwachs D.M.¹²). More than half of the people who said that they wanted to work had received no help from vocational services. By the data of Kelly C.¹¹ it is only a fifth of out-patients getting main support from a voluntary agency. Regrettably, most vocational rehabilitation programs have a positive influence on work-related activities, but most have failed to show significant and permanent influence on independent, competitive employment.

 

Outcome - social deficit in schizophrenia patient

 

Clinical and psychological aspects of schizophrenia and society influence on social aspects of patient’s life have visible impact on the social outcome and patients and their families’ quality of life. Deficit syndrome of schizophrenia diagnosis, development of negative symptoms, deficit of cognitive function, poor self-care, extra pyramidal side- effects and depression with poor self-confidence, problem with drugs, alcohol and smoking together with stigma toward the illness, discrimination and social exclusion lead the patients to the social isolation, decline of partnership and friendship, collapse of the nuclear families and satisfactory relationships, refuse social activity, homeless and suicidal tendencies. The schizophrenia people have often difficulties in learning process and the lack of qualification that together with decline of social and professional skills following up the illness with the decline of emotions, will and energy, intellectual ataxia, loss of interests and social activity, lack of support for and from employers and non-adequate disability payments build the barrier for competitive employment and adequate functioning in a subsistence economy and labour market, create poor professional prospects, pressure and stress in the workplace and unemployment. Health care, social and rehabilitation services develop new neuroleptics with less extra pyramidal and depressive side- effects, treatment and rehabilitation programs targeted to improve schizophrenia patients’ symptoms, social and professional skills, and functioning in society and labour market but until nowadays these don’t meet full volume of needs in effective management with development new forms of treatment and medication curing the negative symptoms and cognitive deficit and adequate vocational training with support on the work-place.

All described negative process including refuse of social functioning, social isolation, homeless, unemployment, financial difficulties and decline of quality of life, following-up the progress of schizophrenia disease lead the patients to the development of significant social deficit with poverty, asocial behaviour and risk mortality.

 

Discussion

 

The manifestation of social deficit, combined with the decrease of living skills, quality of life, and dependency in accommodation, can be devastating to the individuals with schizophrenia and their relatives and increase the cost of schizophrenia for community. These factors require a serious attention of Health Service providers, local communities and policy makers willing to stop the development of poverty, asocial behaviour, risk mortality of 1% of the population and decrease the financial burden of schizophrenia. The availability of rehabilitation services in each community, increase of adequate functional skills training programs and integrated treatment models addressed to schizophrenia patients, development of atypical antipsychotic medications with significant effect on negative symptoms and cognitive deficit and without side effects are required. Effective collaboration of policy makers shall make clear the practical solutions to the growth of the social deficit in schizophrenia patients.

 

Conflict of interest: None.

 

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Author Affiliation

Olga Randles, MD, is a Doctor Psychiatrist, Fellow of the Royal Society of Medicine, working in research in Social Psychiatry, East London and The City Mental Health NHS Trust, UK.  Correspondence to: randles_olga@yahoo.co.uk