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Predictors of Social deficit in
Schizophrenia Patients. Systematic Review. Protocol.
First published
Reviewers
Priebe
S, Randles O
Dates
Date
edited:
Date of last substantive update:
Contact reviewer
A/Prof
Stefan Priebe
The Head of the Unit
Academic Unit for Social and Community Psychiatry
Queen Mary University of London
Glen Road
London
London UK
E13 8SP
Telephone 1: 020 7540 4210
Facsimile: 020 7540 2976
E-mail: s.priebe@qmul.ac.uk
Secondary contact person's name: Dr Olga Randles
Abstract
Background
There
is 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. The importance of
investigation 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. 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%. This manifestation of social deficit and decline the quality of
life can be devastating to the individuals with schizophrenia and their
relatives and increase the cost of schizophrenia for community.
With the progression of the disease social deficit is taking out almost all
social aspects of schizophrenia patients' life.
Objectives
This
is a Systematic Review of quantitative studies of employment, housing and
living circumstances in schizophrenia patients. Our aim is
1. to investigate and identify factors / characteristics that explains poor
social outcome (as social deficits) in schizophrenia patients;
2. identifying a decline in social and occupational functioning of the
individuals with schizophrenia;
3. assess the methodological analysis of the findings.
We hypothesised that employment index indicates a
social deficit of the schizophrenia patients most significantly and
unemployment is the most significant predictor of the social deficit in
patients with schizophrenia.
Search strategy
The
search strategy required to identify all published and unpublished research
studies that investigated employment, housing, and living circumstances of
adults with a diagnosis of schizophrenia.
It was undertaken the Electronic search of electronic databases and Hand search
of references in libraries. References of all articles included in the review
were hand searched too.
Research of the materials of the conferences, abstracts, books.
Selection criteria
Studies
were included if they met the following criteria:
1. at least abstracts were published in English;
2. participants were adult in age diapason of 18 - 78;
3. studies from 1960 to 2006;
4. sample larger than 100 participants;
5. 100% of participants of the study have been diagnosed as schizophrenia
patients (ICD-10 F20);
6. abstracts, articles, reviews, systematic reviews, the materials of the
conferences, and books reflecting the quantitative data of the employment,
accommodation, living circumstances and demographic characteristics of
schizophrenia patients.
Data collection & analysis
Two
reviewers independently examined the citations identified from the search.
Potentially relevant abstracts, articles and reviews were identified and full
papers well-ordered and reassessed for inclusion and methodological quality.
Any disagreement was discussed and reported. We printed out a list of all
titles including the author's names, institutions, and journal titles.
Reviewers independently undertook data extraction using Data Extraction Sheet.
Form was piloted by each reviewer independently to assess their reliability,
the results of the pilot showing a high level of agreement between reviewers.
Any disagreement was discussed, the decisions accepted.
Main results
The
main findings are the 8 studies which include the data of schizophrenia
patients' social deficit. Size of studies: from 133 to 1643 participants in 18
- 78 years, more than 85% participants are single. Level of education was
considerably different in different studies. Less than 14% of participants were
employed. Employment index indicates a social deficit of the schizophrenia
patients most significantly.
Reviewers' conclusions
The
study reflects that the higher percent of schizophrenia patients are male,
unemployed, single, having accommodation with relatives, taking antipsychotic
medication. The higher percent of employed schizophrenia patients are single,
independent, living in rented house/apartment, having middle/low rate of family
contacts and high rate of visiting friends, lack money to enjoy life and wish
to move but unable to realise this.
Text of review
Background
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.
Objectives
This
is a Systematic Review of quantitative studies of employment, housing and
living circumstances in schizophrenia patients. Our aim is
1. to investigate and identify factors / characteristics that explains poor
social outcome (as social deficits) in schizophrenia patients;
2. identifying a decline in social and occupational functioning of the
individuals with schizophrenia;
3. assess the methodological analysis of the findings.
We hypothesised that employment index indicates a
social deficit of the schizophrenia patients most significantly and
unemployment is the most significant predictor of the social deficit in
patients with schizophrenia.
Criteria for
considering studies for this review
Types of studies
Studies
were included if they met the following criteria:
1. at least abstracts were published in English;
2. studies from 1960 to 2006;
3. sample larger than 100 participants;
4. abstracts, articles, reviews, systematic reviews, the materials of the
conferences, and books reflecting the quantitative data of the employment,
accommodation, living circumstances and demographic characteristics of
schizophrenia patients.
Types of participants
1.
Participants were adult in age diapason of 18 - 65;
2. 100% of participants of the study have been diagnosed as schizophrenia
patients (ICD-10 F20).
Types of interventions
Any
types of interventions included data for employment, housing, and living circumstances
of adults with a diagnosis of schizophrenia.
Types of outcome measures
Any
types of outcome measures.
Search strategy for identification
of studies
The
search strategy required to identify all published research studies included
data for employment, housing, and living circumstances of adults with a
diagnosis of schizophrenia, research of the materials of the conferences, full
articles, abstracts, books.
It was undertaken the Electronic search of electronic databases MEDLINE,
EMBASE, PsychINFO, CINAHL, PubMed,
The Cochrane Database of Systematic Reviews, PILOTS, Allied & Complementary
Medicine, DH-DATA, British Nursing Index (total number of citations 143) during
the period 30/01/2006 - 19/09/2006 and hand search of Psychiatric
Rehabilitation Journal, American Journal of Occupational Therapy, American
Journal of Psychiatric Rehabilitation, American Journal of Psychiatry, Archives
of General Psychiatry, Australian Occupational Therapy Journal, British Medical
Journal, British Journal of Occupational Therapy, Canadian Journal of
Occupational Therapy, Canadian Journal of Psychiatry, Chinese Journal of
Clinical Rehabilitation, Community Mental Health Journal, International Journal
of Psychosocial Rehabilitation, International Journal of Social Psychiatry,
Journal of Advanced Nursing, Journal of Applied Rehabilitation Counseling,
Journal of Career Assessment, Journal of Clinical Psychiatry, Journal of
Cognitive Psychotherapy, Journal of Mental Health, Journal of Nervous and
Mental Disease, Journal of Psychiatric Practice, Journal of Rehabilitation,
Journal of Rehabilitation Research and Development, Journal of Traumatic
Stress, Journal of Vocational Rehabilitation, Open University Press,
Psychiatric Rehabilitation Journal, Psychosocial Rehabilitation Journal,
Schizophrenia Bulletin, The Australian and New Zealand Journal of Psychiatry,
The British Journal of Psychiatry, The Canadian Journal of Occupational
Therapy, The Journal of Nervous and Mental Disease, Acta
Psychiatrica Scandinavica,
other ( total number of citations 355)
References of all articles included in the review were hand searched too.
The search terms:
SCHIZOPHRENIA / *RH (rehabilitation), SCHIZOPHRENIA AND EMPLOYMENT/
WORK/JOB/ UNEMPLOYMENT, SCHIZOPHRENIA AND ACCOMMODATION/ HOUSING/HOME/ HOMELESS/
RESIDENTIAL-FACILITIES, SCHIZOPHRENIA AND LIVING SITUATION.LIVING
CIRCUMSTANCES/ LIVING WTH FRIENDS/ PARTNERS/ FAMILY, MENTAL or PSYCHIATRY, also
free search. Search was adapted for the different databases.
Methods of the review
This
is a Systematic Review of quantitative studies of employment, housing and
living circumstances in schizophrenia patients.
Design:
The Cochrane Systematic Review.
Review question:
What factor indicates a social deficit of the schizophrenia patients most
significantly?
Data extraction and study quality
assessment:
Two reviewers independently examined the citations identified from the
search. Potentially relevant abstracts, articles and reviews were identified
and full papers well-ordered and reassessed for inclusion and methodological
quality. Any disagreement was discussed and reported. We printed out a list of
all titles including the author's names, institutions, and journal titles.
Reviewers independently undertook data extraction using Data Extraction Sheet. Form
was piloted by each reviewer independently to assess their reliability, the
results of the pilot showing a high level of agreement between reviewers. Any
disagreement was discussed, the decisions accepted.
The overall quality score for the studies reviewed using them was calculated as
a percentage.
The narrative analysis is completed with tabulated data.
Inclusion procedure
Selection by reviewers
Once the search phase of the review had ended; made copies of the articlers; data extracting sheets applied inclusion
criteria for each trial included.
Trial blinding
Prior to assessment of the trials the titles, names, authors affiliations,
sponsors, abstract section, introduction, results, discussion, acknowledgements
and bibliography sections were removed from the copies and the blinded table
made.
Trial quality assessment
Reviewers independently applied the quality assessment criteria on the same
trials reviewed.
Assessment of blinded trial quality was made according to:
1. generation of participants personal data
2. measures taken to implement the diagnosis schizophrenia
3. number of participants for the analysis of the trial
4. measures taken to implement double blinding
5. measures taken to implement population or multisided investigation
Quality of allocation concealment was
assessed as follows:
Category A: adequate - in the following circumstances:
used some form of randomization, multisided or investigation of the population;
there were numbered identical looking records which were administered
sequentially to register participants;
all data have been assigned using an on-site computer for a locked file which
could be accessed only after inputting the details of the participants.
Category B: inadequate - in the following circumstances:
when alternation was used; the meaning of schizophrenia was used for a wide
range of psychopathological conditions with different development and clinical
outcome.
Category C: unclear - in the following circumstances:
when alternation was used; the meaning of schizophrenia was used for a wide
range of psychopathological conditions with different development and clinical
outcome; personal data as age, gender, level of education etc. for
schizophrenia patients no specified; no quantitative data specified for
schizophrenia patients regarding employment.
Arbitration procedure:
when there was disagreement among blinded reviewers on the quality of a
trial or its suitability for inclusion in the review, the trial was placed in a
list of trials awaiting assessment.
The results of the quality assessment of trials were incorporated in the review
by categorising as "A" trials which scored
on all four items, as Category "B" those trial reports which scored
on at least two items and as Category "C" all others.
DATA
COLLECTION
Data were extracted and loaded onto RevMan software and checked. Data on the
following issues were extracted and recorded:
methodological quality of trials;
characteristics of participants;
characteristics of interventions;
characteristics of outcome measures;
date of trial;
location of trial;
publication status;
data known to have been collected by trialists but
not included in the report (where possible).
DATA
SYNTHESIS
Heterogeneity
he significance of discrepancies in the estimates of the data rom the different trials was assessed by means of Cochran's
test for heterogeneity. If any significant heterogeneity was detected it was
point out in the review.
Choice of summary statistics and estimate of overall effect.
We combined data using the Peto Odds Ratio (OR)
within 95% confidence intervals, expressing the strength of the associations of
quantitative data from different studies.
Description of
studies
We
review all studies that estimate an indicated effect, either using a control
Group, using an estimated counterfactual outcome. This includes randomised controlled trials, social investigations, and
econometric studies based on observational data (which may be either survey or
register data). We included the population and large international studies in
schizophrenia in the review.
The studies included in the review
are described as follows:
The European Schizophrenia Cohort (EuroSC): a naturalistic prognostic and
economic study.
Objectives:
Compare the costs and outcomes of schizophrenia treatment in three European
countries;
Analyse the effects of psychiatric treatment on the
objective and subjective quality of life of patients with schizophrenia.
The primary objective of the European Schizophrenia Cohort (EuroSC) is to
relate the types of treatment and methods of care to clinical outcome.
Secondary objectives include the assessment of treatment needs in relation to
outcome, the calculation of resource consumption associated with different methods
of care, and the identification of prognostic factors.
Assessment:
Data were obtained at a baseline assessment and at four follow-ups by
psychiatrists and clinical psychologists between September 1998 and March 2001.
Client Sociodemographic and Service Receipt Interview
(CSSRI), the Positive and Negative Syndrome Scale (PANSS), the Calgary
Depression Scale for Schizophrenia (CDSS), the DSMIV Global Assessment of
Relational Functioning (GARF) and the Social and Occupational Functioning
Assessment Scale (SOFAS), the Quality of Life interview (QOLI) and the Short
Form 36 (SF-36) were used.
Hansson
L et al (2001)
Comparison of key worker and patient assessment of needs in schizophrenic
patients living in the community: a Nordic multicentre
study.
Objectives:
Investigation of the life and care situation of community samples of
schizophrenic patients; examination of the agreement between patients and their
key worker concerning the presence of met and unmet needs in a number of life
domains, and support given in these domains.
A number of social and clinical background characteristics were also
registered.
Assessment:
The comparisons were based on 300 matched pairs of assessments of need using
the Camberwell Assessment of Need interview (CAN)
including staff and patient assessments of needs for care in 22 different
domains, divided into met and unmet needs, as well as support and help offered
in these domains, and has been tested for reliability and validity. Quality of
life was assessed with the Lancashire Quality of Life Profile (LQOLP). Symptoms
were rated with the 18-item version of the Brief Psychiatric Rating Scale
(BPRS). Diagnoses were set according to ICD-10. Social network was investigated
by means of a self-report scale, the abbreviated version of the Interview
Schedule for Social Interaction (ISSI) including 30 items divided in four
subscales, availability of social integration (AVSI), adequacy of social
integration (ADSI), availability of emotional relations (AVAT) and adequacy of
emotional relations (ADAT). An overall measure of the quality of the social
network may also be obtained. The reliability and validity of the scale has
been tested and found satisfactory.
Hansson
L et al (2002)
Living situation, subjective quality of life and social network among
individuals with schizophrenia living in community settings.
Objectives:
investigation of the relationships between characteristics of the living
situation in the community and subjective quality of life and social network
among community-based individuals with schizophrenia;
testing whether characteristics of the housing situation among community-based
individuals with schizophrenia were related to subjective quality of life, to
satisfaction with qualities of the housing situation, and to quantitative and
qualitative aspects of the social network.
Assessment:
Quality of life was assessed with the Lancashire Quality of Life Profile
(LQOLP) in nine life domains: work, leisure, religion, finances, living
situation, personal safety, family relations, social relations and health, a
global well-being scale, a patient global assessment of quality of life (Cantril's ladder), an affect balance scale, a self-esteem
scale, and a happiness scale. Symptoms were rated with the 18-item version of
the Brief Psychiatric Rating Scale (BPRS). The Global Assessment of Functioning
Scale (GAF) in DSM IV was used to assess psychosocial functioning. Diagnoses
were set according to ICD-10. Social network was investigated by means of a
self-report scale, the abbreviated version of the Interview Schedule for Social
Interaction (ISSI). Assessment of needs was investigated in both the patients
and a key worker nominated by the patient using the Camberwell
Assessment of Needs interview (CAN).
Kelly
C et al (1998)
Nithsdale schizophrenia surveys 17. Fifteen year
review.
Objectives:
The population with schizophrenia were compared on clinical and social
variables. The whereabouts in 1996 of the 1981 population was determined.
Assessment:
Mental state of patients was assessed by three psychiatrists using the
Manchester Scale for chronic psychotic patients. Parkinsonism was assessed by
the same psychiatrists, using the Targeting Abnormal Kinetic Effects Scale
(TAKE) and dyskinesia using the Abnormal Involuntary Movements Scale (AIMS).
The presence of tardive dyskinesia (TD) was defined using the Schooler & Kane criteria. The social adjustment of
non-inpatients in 1982 and 1996 were assessed by the Social Adjustment Scale
Self-Report. Patients completed the 52-item questionnaire under the supervision
of a CPN or psychiatrist.
McCreadie
RG (2002)
Use of drugs, alcohol and tobacco by people with schizophrenia; case- control
study.
Objectives:
To determine the use of drugs, alcohol and tobacco by people with schizophrenia
drawn from rural, suburban and urban settings, and to compare use by general
population control subjects.
Assessment:
Use of drugs and alcohol was assessed by the Schedules for Clinical Assessment
in Neuropsychiatry (SCAN), a five-point scale: abstinence, use without
impairment, misuse, dependence and severe dependence. Use of tobacco was
assessed by a questionnaire.
Rosenheck
R, et al (2006)
Barriers to Employment for People With Schizophrenia.
Objectives:
Examination of the factors associated with participation in competitive
employment or other vocational activities in a large group of patients with
schizophrenia who participated in the Clinical Antipsychotic Trials of
Intervention Effectiveness (CATIE) study, a multisite
clinical trial comparing the effects of first- and second-generation
antipsychotics. The current study relied exclusively on baseline data collected
before randomization and the initiation of experimental treatments.
Assessment:
Questions concerning sociodemographic status were
used to document age, race, gender, marital and educational status, and sources
of income, including earned income, Social Security payments or Supplemental
Security Income and Department of Veterans Affair compensation and pension
payments. The diagnosis of schizophrenia was confirmed with the Structured
Clinical Interview for DSM-IV. Symptoms of schizophrenia were assessed with the
rater-administered Positive and Negative Syndrome Scale (PANSS). The Heinrichs-Carpenter Quality of Life Scale was used. Medication
side effects were assessed with the Barnes Rating Scale for Drug-Induced
Akathisia, the Abnormal Involuntary Movement Scale for tardive dyskinesia and
the Simpson-Angus Rating Scale for extrapyramidal symptoms. Depression was
measured with the Calgary Depression Rating Scale and substance use was
measured with the Alcohol Use Scale and Drug Use Scale. Neurocognitive
functioning was assessed with Grooved Pegboard score, WAlS-R
digit symbol test score, the average of the scores on the Controlled Oral Word
Association Test and Category Instances), Hopkins Verbal Learning Test,
Continuous Performance Test, the Wisconsin Card Sorting Test and WISC-R mazes
test.
Slade
E & Salkever D (2001)
Effects on Employment in a Structural Model of Mental Illness and Treatment:
Analysis of Patients with Schizophrenia.
Objectives:
proposal of a structural model for understanding mental illness impacts on
employment; empirical estimate of one element of this structural model that
links symptoms of schizophrenia to patients' employment status; employment of
the empirical estimates to simulate employment consequences of more effective
treatment and reductions in symptom levels.
Assessment:
The Schizophrenia Care and Assessment Program (SCAP) database, Clinical assessments,
which were conducted by trained clinical assessors, the Positive and Negative
Syndrome Scale (PANSS), the Montgomery-Asberg
Depression Rating Scale (MADRS), and the Simpson-Angus Scale (SA), a rating of
Extrapyramidal side effects of antipsychotic treatment were used. Employment
information is self-reported retrospectively for the four-week period preceding
the interview.
Methodological quality of included
studies
Most
studies are based on observational data due to the nature of the interventions
we are considering we will assess. The method using to estimate the incentive
effect is based on the identification assumption used in the study.
Consequently, we had particular interest to the identification of the incentive
effect. For each study, we collected the information about the identification
statements used in the indicated spectrum of our review. We observe the impact
of methodological quality on the results of studies, applying advances in
methodology, and developing systems for quality improvement.
Several types of outcomes are measured within the same studies. In such cases,
the outcome measures are taken on the same sample without independent estimates
of the effects unrelated to the review question. An explanation of the criteria
used to determine whether multiple outcomes and the outcome measures unrelated
evaluations have been carefully spelled out.
Each of the included trial reports was blinded and sent to both reviewers for
their evaluation. The reviewers were asked to evaluate four methodological
aspects of each trial. Studies having adequate allocation concealment have been
included in the review.
The following trial report summaries are based on agreement between the blinded
reviewers:
The report of the European Schizophrenia Cohort (EuroSC) study describes the
adequate methodology and includes the data indicated in our review. It includes
the naturalistic prognostic and economic study in 3 European countries, sample
size 1,208 participants with schizophrenia, the Personal/Demographic
characteristics: age, gender, marital status; living conditions and employment
status of the participants.
Hansson
L et al (2001)
The report of the Nordic multicentre study describes
the adequate methodology and includes the data from the investigation of the
life and care situation of community samples of schizophrenic patients,
indicated in our review. Data include the sample size 300 participants with
schizophrenia, Personal/Demographic characteristics: age, gender, marital
status; accommodation, living situation, employment status; duration of
illness, results of BPRS and GAF investigation of the participants.
Hansson
L et al (2002)
The report of the cross-sectional multi-center study comprising of individuals
with schizophrenia in all the five Nordic countries (10 sites) study describes
the adequate methodology and includes the data from living situation,
subjective quality of life and social network among individuals with
schizophrenia living in community settings, indicated in our review. Data
contain the sample size 418 participants with schizophrenia,
Personal/Demographic characteristics: age, gender, marital status, have
children; accommodation, living situation, employment status; duration of
illness, results of BPRS and GAF investigation of the participants.
Kelly
C et al (1998)
The report of the study of the population with schizophrenia describes the
adequate methodology and includes the data from the investigation of the
clinical and social variables. Data contain the sample size 133 participants
with schizophrenia of a rural population of
McCreadie
RG (2002)
The report of the study of the use of drugs, alcohol and tobacco by people with
schizophrenia from rural, suburban and urban population of Scotland describes
the adequate methodology and includes data from living situation and social
network, indicated in our review. Data contain the sample size 316 participants
with schizophrenia, Personal/Demographic characteristics: age, gender, marital
status; living situation, employment status; duration of illness.
Rosenheck
R, et al (2006)
The report of the study describes the adequate methodology and includes the
data from a large group of patients with schizophrenia who participated in the
Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study,
indicated in our review. The current study relied exclusively on baseline data
collected before randomization and the initiation of experimental treatments.
Data contain the sample size 1,438 participants with schizophrenia,
Personal/Demographic characteristics: age, gender, education, marital status;
employment status.
Slade
E & Salkever D (2001)
The report of the analysis of patients with schizophrenia and proposal of a
structural model for understanding mental illness impacts on employment
describes the adequate methodology and includes the data indicated in our
review. Data contain the sample size 1,643 participants with schizophrenia,
Personal/Demographic characteristics: age, gender, education; employment
status; taking typical antipsychotic medication by schizophrenia patients.
Results
The
main findings are the 8 studies which include the data of schizophrenia patients'
social deficit. Size of studies from 133 to 1643 participants in 18 - 78 years.
Most of accounted amount of participants are single (85.5%v14.5%), unemployed
(81.5%) and have independent accommodation (67%v33%). It was similarity in
living circumstances, participants were living alone and with relatives in
nearly equal proportion (42%v43.5%). Level of education was considerably
different in different studies. Employment index and marital status indicate a
social deficit of the schizophrenia patients most significantly.
Discussion
The
most important individual predictors of overall well-being include satisfaction
with leisure, work, health and mental health, family, living situation, finance
and social contacts. Illness-related factors, including limitation of
interests, restricted affect, and reduction of sense of purpose and of social
drive can block any kind of social and vocational activity. Mechanic D et al.
(2002) highlights the association of schizophrenia with high impairment; only
12 percent patients are working full time.
Some patients use the isolation as a way of decreasing social stimulation.
People with schizophrenia often live alone, unmarried, have a few friends.
Decline of the social skills, social isolation and unemployment lead the patients
to the development of depression and deficit of communication, identification
of emotion from human shapes and body motion (Bigelow NO et al (2006) and
deficits in the appraisal of socially relevant stimuli. Hansson L et al (2002)
highlight that the difference in needs was reduced, but still significant, when
problems of accommodation were not included (5.6 vs. 6.5; P = 0.018). People
with an independent housing situation had a somewhat better psychosocial
functioning (GAF) (49.5 vs. 44.4; P = 0.001) and a lower number of needs for
care (5.9 vs. 7.1; P = 0.01).
Schmiedebach HP, et al. (2002) Both areas, housing
and work, were - slowly and in discontinuity - established as criteria of
integration of people with mental illnesses, which was increasingly accepted as
an aim of mental health care.
Rosenheck R, et al (2006) reflect the effect for negative symptoms that was
significant over and above the effect for positive symptoms, and the effect of
intrapsychic functioning was significant over and above the effect of negative
symptoms for both types of employment. Neurocognitive impairment may interfere
with learning, independent living and functioning in a work situation or social
circumstances.
Slade E & Salkever D. (2001) agreed that negative symptoms have a
substantial adverse impact on participation in both non-supported jobs and in
sheltered or supported jobs. Significant effects are also found for symptoms of
depression.
Rosenheck Robert, et al. (2006); Blank RM, et al. (2004) report about measures
that differentiated patients who were competitively employed from those who
either participated in other employment activities or who did not work at all.
These measures were more social than clinical in nature. In the current study
(2006) Dr Rosenheck highlight that competitively employed patients were younger
than nonworkers, were less likely to be black, and
received lower public support payments on average (especially SSD and SSI
payments).
Kelly C et al. (1998) stress the decline of the mental health in a community of
people with schizophrenia living in a rural area in 1996 compared with 1981.
Open employment fell from a low level in 1981 to an even lower one in 1996.
Nevertheless Carpenter and Strauss (1991) assessed 40% of the original WashingtonDC sample of the IPSS at 11 years and found
little change in the functioning of patients (i.e., in terms of social
contacts, symptoms, employment, etc).
The longer the duration of schizophrenia disorder, higher levels of mental
health problems, higher numbers of previous hospitalizations, problems in the
community, decline of the social relationships and unemployed status are
associated with the perception of lower quality of life.
Reviewers'
conclusions
Implications
for practice
The
conclusion is grounded on the results of our analysis.
The study reflects that the higher percent of schizophrenia patients are
unemployed and single. These factors predict the social deficit in
schizophrenia patients, decline of the social communication, social and
professional skills.
We advise the development of the complex rehabilitation programs including the
psychosocial training (problem-solving, money management, and social skills),
extension through multiple family groups and professional skills training with
direct placement in a real work role.
Implications
for research
We
expect to meet investigation of the associations between employment status and
additional characteristics as employment history, profession, work adjustment
skills and positive attitude to work in employed and unemployed groups of
participants with schizophrenia. We suggest Social Security and other funding
agencies adapt their policies to support research programs that meet these
objectives.
Educational and occupational profiles and professional skills of schizophrenia
patients have positive and negative effect on supported and non-supported
employment. Educational attainment is the strongest predictor of employment in
high-ranking occupations and patients often keep such jobs as administrative,
managerial, or professional specialty occupations. Poor educational attainment
might have been related to prodromal deficits that preceded the full onset of
schizophrenia.
Potential conflict of interest
None
Characteristics
of included studies
|
Study |
Methods |
Participants |
Interventions |
Outcomes |
Notes |
Allocation concealment |
|
|
EuroSC
is a naturalistic follow-up of a cohort of people aged 18 to 64 years,
suffering from schizophrenia and in contact with secondary psychiatric
services at nine European centres; duration
1997-2002. Participants were interviewed at 6-monthly intervals for a total
of 2 years. |
People
with schizophrenia in |
Prospective
observational multi-site study with 5 follow-ups at 9 study sites in |
More
patients were males 61.5%, unemployed 87.9%, single 79%, living with
relatives 46.6%. |
The
clinical and socio-demographic differences between patients from the different
countries were small. However, patients from |
A |
|
Hansson
L et al |
A
Nordic multi-centre study (10 centres). The
comparisons were based on 300 matched pairs of assessments of need using the Camberwell Assessment of Need interview. |
People
with schizophrenia at |
A
cross-sectional multi-center study investigating the life and care situation
of community samples of schizophrenic patients. The specific aim of the
present part of the study was to examine the agreement between patients and
their key worker concerning the presence of met and unmet needs in a number
of life domains, and help or support given in these domains. |
More
patients were male 65%, unemployed 89%, having own accommodation 64%, living
alone 56%; duration of illness in years, mean (SD) 15 (9); Sum score BPRS,
mean (SD) 33 (10); GAF- score, mean (SD) 49 (15) |
Key
workers and patients disagree particularly concerning unmet needs and that
this is potentially related to a number of factors associated with the key
worker and patient. |
A |
|
Hansson
L. et al |
A
cross-sectional multi-center study comprising of individuals with
schizophrenia in all the five Nordic countries (10 sites) |
People
with schizophrenia in Sweden, Denmark, Norway, Iceland, Finland; sample size
(N) 418; Personal/Demographic characteristics: Age years, (SD): 39 (9);
Gender, % male: 65; Marital status, %: Single 78, Separated/Widowed 15,
Married/with partner 7, have children 25; Accommodation, %: own accommodation
70, sheltered housing 26, homeless 4; Living situation, %: alone 60;
Unemployed, %: 88. Duration of illness in years (SD): 15 (9); GAF-score mean
(SD): 48 (15); Sum score BPRS, mean (SD): 35 (10). |
Study
of quality of life and social network among individuals with schizophrenia. |
More
patients were male 65%, unemployed 88%, own accommodation 70%, living alone
60%; duration of illness in years, mean (SD) 15 (9); Sum score BPRS, mean
(SD) 35 (10); GAF- score, mean (SD) 48 (15). People with an independent
housing situation had a somewhat better psychosocial functioning (GAF) (49.5
vs. 44.4; P = 0.001) and a lower number of needs for care (5.9 vs. 7.1; P =
0.01). The difference in needs was reduced, but still significant, when
problems of accommodation were not included (5.6 vs. 6.5; P = 0.018). |
People
with schizophrenia with an independent housing situation have a better
quality of life associated with more favourable
perceptions of independence, influence, and privacy. There were no
significant differences in symptom severity (BPRS) between groups living in
an independent vs. sheltered housing situation, living with family vs. not
living with family, or living alone vs. not living alone. |
A |
|
Kelly
C. et al |
In
Nithsdale, |
A
rural population of 56 000, |
Research
in community care. Population research, examination of patients with a
clinical diagnosis of schizophrenia. |
More
patients were males 52%, unemployed 81%, single 78%, living with relatives
55%, taking antipsychotic medication 76%. |
The
mental health of a community of people with schizophrenia living in a rural
area in 1996 was poorer than in 1981. More people with schizophrenia in 1996,
compared with those in 1981, were deluded, depressed and anxious. More people
with schizophrenia in 1996 were on oral medication and there was an increase
in tardive dyskinesia. The deterioration in patients' mental health may be
related to the shift to community care. |
A |
|
Kelly
C. et al |
In
Nithsdale, |
A
rural population of 57 000, Scotland, UK; 1996; sample size (N) 168;
Personal/Demographic characteristics: Age, years (SD): 50 (17); Gender, %
male: 52; Marital status, %: Single 60, Married/with partner 18,
Separated/Divorced 16, Widow 6; Living situation, %: alone 29, living with
spouse/parents 37, supported accommodation 18, nursing home 4, other 12;
Unemployment, %: 92. |
Research
in community care. Population research, examination of patients with a
clinical diagnosis of schizophrenia. |
More
patients were males 52%, unemployed 92%, single 82%, living with relatives
37%, taking antipsychotic medication 95%. Open employment fell from a low
level in 1981 to an even lower one in 1996. With general unemployment high,
work will rarely be an option for people with schizophrenia in the
foreseeable future. |
The
mental health of a community of people with schizophrenia living in a rural
area in 1996 was poorer than in 1981. More people with schizophrenia in 1996,
compared with those in 1981, were deluded, depressed and anxious. More people
with schizophrenia in 1996 were on oral medication and there was an increase
in tardive dyskinesia. The deterioration in patients' mental health may be
related to the shift to community care. |
A |
|
McCreadie
R.G. |
People
with schizophrenia and general population controls of similar gender
distribution, age and postcode area of residence were identified in rural,
urban and suburban areas of |
People
with schizophrenia, |
Research
in use of drugs, alcohol and tobacco by people with schizophrenia. Population
research, examination of patients with a clinical diagnosis of schizophrenia.
|
More
patients were males 62%, single 85%, lived alone 45%, unemployed 92%. Males
were less likely to be employed. |
Problem
use of drugs and alcohol by people with schizophrenia is greater than in the
general population, but absolute numbers are small. Tobacco use is the
greatest problem. In rural, urban and suburban areas of Scotland more
patients than controls reported problem use of drugs in the past year (22
(7%) v five (2%)) and at some time before then (50 (20%) v 15 (6%)) and
problem use of alcohol in the past year (42 (17%) v 25 (10%)) but not at some
time previously (99 (40%) v 84 (34%)). More patients were current smokers
(162 (65%) v 99 (40%)). Specialised services should
be developed to help people with schizophrenia and associated substance
misuse. |
A |
|
Rosenheck
R. et al |
Baseline
data on more than 1,400 patients with a diagnosis of schizophrenia were
collected before their entry into the Clinical Antipsychotic Trials of Intervention
Effectiveness (CATIE) study from 2001 to 2003. Multinomial logistic
regression was used to examine the relationship between participation in
either competitive employment or other vocational activities and sociodemographic characteristics, schizophrenia symptoms,
neurocognitive functioning, intrapsychic functioning, availability of
psychosocial rehabilitation services, and local unemployment rates. |
Patients
with a diagnosis of schizophrenia at more than 50 |
The
Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, a multisite clinical trial comparing the effects of first-
and second-generation antipsychotics. |
More
patients were males 76%, unemployed/other/non-competitive employment activity
85.5%, and single 88%. Competitively employed patients were younger than nonworkers, were less likely to be black, and received
lower public support payments on average (especially SSD and SSI payments).
There were no significant differences between the groups on measures of
depression, substance abuse, tardive dyskinesia, akathisia, and
extrapyramidal symptoms and no significant difference on the waist-to-hip
ratio. The effect for negative symptoms was significant over and above the
effect for positive symptoms, and the effect of intrapsychic functioning was
significant over and above the effect of negative symptoms for both types of
employment. |
In
this study, data from a large group of people with schizophrenia suggested
that although overall employment may be impeded by clinical problems,
including symptoms of schizophrenia and poorer neurocognitive and
intrapsychic functioning, participation in competitive employment may be
specifically impeded by the potentially adverse incentives of disability
payments and by racial discrimination and its consequences and may be
promoted by increased availability of rehabilitation services. |
A |
|
Slade
E. et al |
Empirical
analyses for 1,643 adults with a schizophrenia diagnosis, consumers range in
age from 18 to 78 years old with an average age of 42. Analyses include
measures of demographic characteristics, illness history, location
differences, and detailed symptom measures. |
Patients
with a diagnosis of schizophrenia at 6 US localities as academic health centres, community mental health centres,
and Veterans Affairs (VA) providers; sample size (N) 1,643;
Personal/Demographic characteristics: Age, years: 42; Gender, % male: 63;
Completed a high school education, %: 70. Unemployed, %: 78.2, employed 11.6,
supported employment 10.2 |
The
study of adults with a schizophrenia diagnosis for understanding mental
illness impacts on employment. |
More
patients were male 63%, unemployed 88.4%; taking typical antipsychotic
medication: 90%, taking an atypical antipsychotic medication: 50%. |
We
find that negative symptoms have a substantial adverse impact on
participation in both non-supported jobs and in sheltered or supported jobs.
The impacts on employment of other symptoms of schizophrenia are not as
large, but significant effects are also found for symptoms of depression.
Simulations suggest, however, that only one-third of consumers would be
employed in any type of job even given a large reduction in symptom levels. |
A |
References to
included studies
Bebbington PE et al {published data only}
*
Bebbington PE, Angermeyer
M, Azorin JM, Brugha T, Kilian R, Johnson S, Toumi M, Kornfeld A; EuroSC Research Group.. The European
Schizophrenia Cohort (EuroSC): a naturalistic prognostic and economic study.
[The European Schizophrenia Cohort (EuroSC): a naturalistic prognostic and
economic study.]. Social psychiatry and psychiatric epidemiology
2005;40(9):707-717.
Hansson L
et al
{published data only}
*
Hansson L, Vinding HR, Mackeprang
T, Sourander A, Werdelin G,
Bengtsson Tops A, Bjarnason
O, Dybbro J, Nilsson L, Sandlund
M, Sørgaard K, Middelboe T.
Comparison of key worker and patient assessment of needs in schizophrenic
patients living in the community: a Nordic multicentre
study. [Comparison of key worker and patient assessment of needs in
schizophrenic patients living in the community: a Nordic multicentre
study.]. Acta psychiatrica Scandinavica 2001;103(1):45-51.
Hansson
L. et al
{published data only}
*
Hansson Lars, Middelboe T, Sorgaard
KW, Bengtsson Tops A, Bjarnason
O, Merinder L, Nilsson L, Sandlund
M, Korkeila J, Vinding HR.
Living situation, subjective quality of life and social network among
individuals with schizophrenia living in community settings. [Living situation,
subjective quality of life and social network among individuals with
schizophrenia living in community settings.]. Acta Psychiatrica Scandinavica
2002;106(5):343-350.
Kelly C.
et al
{published data only}
*
Kelly C, McCreadie R G, MacEwan T, Carey-S. Nithsdale schizophrenia surveys 17. Fifteen year review. [Nithsdale schizophrenia surveys 17. Fifteen year review.].
British Journal of Psychiatry 1998;172(June):513-517.
McCreadie R.G. {published data only}
*
McCreadie Robin G.. Use of drugs, alcohol and tobacco by people with
schizophrenia; case- control study. [Use of drugs, alcohol and tobacco by
people with schizophrenia; case- control study.]. British Journal of Psychiatry
2002;181(Oct.):321-325.
Rosenheck
R. et al
{published data only}
*
Rosenheck Robert, Douglas Leslie, Richard Keefe, Joseph McEvoy,
Marvin Swartz, Diana Perkins, Scott Stroup, John K. Hsiao, Jeffrey Lieberman,
CATIE Study Investigators Group. Barriers to Employment for People With
Schizophrenia. [Barriers to Employment for People With Schizophrenia.]. The
American Journal of Psychiatry 2006;163(March):411-417.
Slade E.
et al
{published data only}
*
Slade E, Salkever D. Effects on Employment in a Structural Model of Mental
Illness and Treatment: Analysis of Patients with Schizophrenia. [Effects on
Employment in a Structural Model of Mental Illness and Treatment: Analysis of
Patients with Schizophrenia.]. The Journal of Mental Health Policy and
Economics 2001;(4):25-34.
References to
excluded studies
Haefner H. et al. {published data only}
*
Haefner Heinz, Maurer Kurt, Löffler
Walter, Van der Heiden
Wolfram, Hambrecht Martin, Schultze Lutter Frauke. Modelling the early course of schizophrenia. [Modelling the early course of schizophrenia.]. Schizophrenia
Bulletin 2003;29(2):325-340.
* indicates the primary reference for the study
Additional
references
Allen H
Allen
H. Cognitive processing and its relationship to symptoms and social functioning
in schizophrenia.. Br J Psychiatry 1990;156:201-203.
Bassett
J, Lloyd C, Bassett H. Work issues for young people with psychosis: barriers to
employment.. Br J Occup Ther
2001;64(2):66-72.
Bigelow
NO, Paradiso S, Adolphs R,
Moser DJ, Arndt S, Heberlein A, Nopoulos
P, Andreasen NC.. Perception of socially relevant
stimuli in schizophrenia.. Schizophr Res. 2006;83:257-267.
Blank
RM, Dabady M, Citro CF.
Measuring Racial Discrimination..
Bond
GR, Becker DR, Drake RE, Rapp CA, Meisler N, Lehman
AF, Bell MD, Blyler CR. Implementing supported
employment as an evidence-based practice.. Psychiatr Serv 2001;52:313-322.
Carpenter
WT, Strauss JS. The prediction of outcome in schizophrenia: IV. Eleven-year
follow-up of the Washington IPSS cohort.. J Nerv Ment Dis 1991;179:517-525.
Duke
PJ, Pantelis C, Barnes TRE.
Freeman,
H., & Alpert, M.. Prevalence of schizophrenia in an urban environment..
British Journal of Psychiatry 1986;149:603-611.
Goeree
R; Farahati F; Burke N; Blackhouse
G; D. O'Reilly; J. Pyne; J.-E. Tarride..
The Economic Burden of Schizophrenia in
Jeffreys S,
Johnstone EC. Disabilities and circumstances of
schizophrenic patients: A follow-up study.. Br J Psychiatry (Supplement 3)
1991;159.
Marwaha
S, Johnson S.. Schizophrenia and employment. A review.. Soc Psychiatry Psychiatr Epidemiol 2004;39:337-
349.
McCreadie
RG. The Nithsdale schizophrenia survey: I. Psychiatric
and social handicaps.. Br J Psychiatry 1982;140:582-586.
Mechanic
D, Blider S, McAlpine DD.
Employing persons with serious mental illness.. Health Aff
(Millwood) 2002;21(5):242-253.
Schmiedebach HP, Beddies
T, Schulz J, Priebe S.. Housing and work as criteria of the ''social
integration'' of the mentally ill-development in
Additional
tables
01 Personal Data from the studies
included in the review.
|
Study |
Sample Size, N |
Age, years |
Gender, N of male |
Completed a high sch |
|
Kelly
C et al (1998) for 1981 |
133 |
48
(15) |
69 |
|
|
Kelly
C et al (1998) for 1996 |
168 |
50
(17) |
87 |
|
|
McCreadie
RG (2002) |
316
|
45
(14) |
197
|
|
|
Rosenheck
R, et al (2006) |
1,438 |
40.4
(11.6) |
1,086 |
1,064 |
|
|
1208 |
40.8
(11.1) |
743 |
|
|
Hansson
L et al (2002) |
418 |
39
(9) |
271 |
|
|
Hansson
L et al (2001) |
300 |
38
(9) |
194 |
|
|
Slade
E & Salkever D (2001) |
1,643 |
42 |
1035 |
1150 |
02 Marital status and Living
circumstances from the studies included in the review
|
Study |
Sample Size, N |
Single/ Separated/ W |
Married/With partner |
Living family/relati |
Living alone |
Other Living circums |
|
Kelly
C et al (1998) for 1981 |
133 |
104 |
29 |
73 |
36 |
24 |
|
Kelly
C et al (1998) for 1996 |
168 |
138 |
30
|
62 |
49 |
57 |
|
McCreadie
RG (2002) |
316
|
269 |
47 |
99 |
141 |
76 |
|
Rosenheck
R, et al (2006) |
1,438 |
1,272 |
166 |
|
|
|
|
|
1,208 |
954 |
254 |
563 |
417 |
228 |
|
Hansson
L et al (2002) |
418 |
390 |
28 |
|
251 |
|
|
Hansson
L et al (2001) |
300 |
278 |
22 |
|
167 |
|
03 Accommodation for participants
from the studies included in the review.
|
Study |
Sample Size, N |