Professional Documents
Culture Documents
CONTROLS
OF
BY
1
DATE STARTED PART 2 POSTING: JUNE 2008
PROPOSED TITLE:
1st SUPERVISOR
2nd SUPERVISOR
HEAD OF DEPARTMENT
CHAPTER ONE
1.1 INTRODUCTION
Since antiquity, society has recognized disabilities among its member arising out of
(Banerjee, 2001). These disabilities prevent the affected persons from participating in the main
2
stream of social life. Due to the recent spurt in the growth of scientific knowledge in this area,
the concept disability has become an important issue for re-examination and redefinition.
In 1993, the United Nations declared that the term “disability” summarized a great
number of different functional limitations occurring in any population in any country of the
conditions or mental illness. The United Nations has thereby broadened the scope of the concept
of disability and specifically included mental illness in addition to mental retardation as a cause
of disability
Furthermore, the notion of disability itself has undergone a sea change from being viewed
international effort of the World Health Organization (WHO) to have a re-look at the concept,
International Classification of Impairment, Disability and Handicap (ICIDH). The new version,
disability and describes the dimensions of disability as body function/structure, activities and
participation in a societal context. This also led to the development of the World Health
Psychiatric disorders account for nearly 31% of the world’s disability and schizophrenia
is one of the ten leading causes of disability worldwide (Mohan et al, 2005). Schizophrenia,
which is a chronic mental illness, may cause functional disability across a wide array of domains
(McClure and Harvey, 2007; Hofer et al, 2006). Schizophrenic patients experience impairments
in their social competence, vocational aptitude, everyday living skills and self-care abilities. In
3
the majority of patients, these impairments are severe enough to prevent the return to
independent living, even after hallmark symptoms such as hallucinations and delusions are
remitted. Schizophrenia also impacts negatively on the academic, occupational, social and family
functioning of the patients (Mohan et al., 2005). Therefore, investigating psychiatric disability as
an important area of research is essential because of its role in understanding the nature of the
illness, especially its chronicity, and planning intervention programme for the chronically
mentally ill.
in the context of schizophrenia in Nigeria. Gureje and Bamidele (1999) examined the thirteen
year social outcome among Nigerian out-patients with Schizophrenia. Also, Gureje (2002)
examined the association of psychological disorders and symptoms with disability and service
use after 12 months among primary care attenders. Gureje et al. (2006) evaluated functional
disability in elderly Nigerians living in the community. Also Uwakwe and Modebe (2007)
described the pattern of disability and care for older community residents in a selected Nigerian
location. Of recent, Gureje et al. (2008) compared the effects of depression and chronic physical
conditions on disability in elderly persons. Also Ogundele (2009) evaluated the risk factors for
disability among depressed elderly people living in a Nigerian community. These studies were
4
LITERATURE REVIEW
2.1 PREAMBLE
Traditionally, disabilities have been associated with conditions, physical and mental,
where a handicap or impairment has been tangible and obvious such as physical and sensory
handicap or mental retardation. In the recent past, however, certain chronic illnesses are being
arthritis and chronic mental illness are among the most prominent. (Thara and Menon, 1991)
interaction between a person’s health condition (e.g. illness, trauma, injury) and the context in
which that person lives. Being multifaceted, it comprises a number of different aspects that
further inter-relate in a complex manner (WHO, 2001). These aspects include the health
condition, functioning and level of independence of the person, the external physical, social, and
attitudinal environment, the person’s quality of and satisfaction with life, and the level of
disadvantage and social exclusion experienced by the person (Schneider et al, 2003).
Defining disability is not an easy task, and it is becoming clear that no single definition
can cover all aspects of disabilities. According to the International Classification of Impairment,
Disability and Handicap (ICIDH, 1980), disability is “interference with activities of the whole
person in relation to the immediate environment”. Disability may also be defined as “disturbance
of social roles that would normally be expected of an individual in his habitual milieu, arising in
5
WHO (1980) defined the consequences of disease at the level of impairment (any loss or
restriction of ability to perform an activity in the manner or range considered normal) and
handicap (a disadvantage for a given individual resulting from an impairment or disability that
limits or prevents the fulfillment of a role). The Institution of Medicine (IOM, 1991) further
defined disability as a limitation in performing certain roles and tasks that society expects of an
individual. Expected roles and tasks are defined by cultural norms, and when these roles cannot
disabled.
The WHO developed a revised working disability model, (Fig 1) that was designed to increase
conceptual clarity and operationalize functioning across 3 levels (Wood, 1980; Pope and Tarlov,
1991; Verbrungge and Jette, 1994; Whiteneck et al, 1997). The levels are the body, the person as
a whole and the person in social context. Disability involves dysfunction at one or more of these
levels. In schizophrenia, impairments i.e. body level (problems in body function or structure)
may be reflected by micro or macro deviations in brain structure (e.g. ventricle size, neuronal
disarray) as well as cognitive function (e.g. working memory, verbal reasoning) and psychiatric
deficits (e.g. hallucinations, delusions). Activity limitations i.e. the person as a whole (difficulty
in executing activities) may be evidenced by difficulty with mental calculation such as counting
change or difficulty producing logical, fluent and goal-directed speech. Participation restrictions
i.e. person in social context (problems experienced in real life situations) refer to the total life
context of the individual and may occur when a person cannot participate in meaningful work
6
Health conditions
(Disease/disorder)
↕
Impairment ↔ Activity limitation ↔ Participation restriction
↑____________________↕____________________↑
_____________↓_____________
↓ ↓
Personal factors Environmental factors
As an essential ingredient of any chronic mental disorder, disability has lent itself to
measurement (Thara et al, 1988). Clinicians use measurement as a guide to clinical practice
when quantifying the severity of an illness or subsequent disability. Disability measurement can
when a person’s health status is deteriorating unexpectedly. The standardized numerical scores
can be used to administer services and to ensure that the rights of the disabled are met. An
aggregated numerical score of disablement can be used to estimate the burden of a disease and
the resources that should be applied to the amelioration of the consequence of the disease.
- Clinician ratings
- Performance-based measures.
7
Each method has its unique advantages and disadvantages. Self reports are widely used
and have been constructed to reflect any of the 3 levels of dysfunction identified in the WHO
model (e.g. impairment, activity limitation, participation restriction). Some instruments address
more than one level of dysfunction while others address only one primary domain. The
information obtained reflects issues of importance from the patient’s perspective (Wilkinson et
functioning (Atkinson et al, 1997), the patient’s insight, personal values and situational events
(Williams, 1994). The 12 item and 36 item self-administered versions of WHODAS II are
Proxy reports are collateral or caregivers’ reports. They measure any level of dysfunction
in the disability model and may increase the reliability of self-report measurement. However, this
modality is limited by the lack of persons available to report on patients’ everyday functioning
(Wilkinson et al, 2000) and by caregivers’ own psychiatric, emotional and cognitive functioning
(Mckibbin et al, 2004a). Example of proxy reports are the WHODAS II - 6 item self-
influences, but is limited in that a small sample of observed behaviours may lead to an
underestimate of patient capacity (Patterson et al., 2001a). Observer rating is the best way to
assess real world functioning through direct observation in naturalistic settings, thereby
assessment appears ideal, observers would be required to shadow patients throughout their daily
8
routine or during selected observational periods in which the targeted behaviour is likely to
environment designed to mirror the real world, thus measuring activity limitations and inferring
participation restrictions. Patients may be asked to perform basic instrumental activities such as
combing their hair, or more complex tasks such as engaging in social interactions or paying bills.
evaluations, which may create assessment demands that differ from those in the real world
thereby threatening external validity. They also ignore environmental factors that may facilitate
or inhibit participation in life situations. Examples are the Bay Area Functional Performance
Assessment (William and Bloomer, 1987), the Maryland Assessment of Social Competence
(MASC, Bellack et al, 1994; Sayers et al, 1995), Medication Management Ability Assessment
The measurement of disability as a construct has been fraught with difficulties. This is
measurement modalities (Patterson et al, 2001b). Also, the lack of conceptual clarity between
the construct disability and other related constructs at any given point and over time (e.g.
functional limitation, handicap, disability; Bruce 2001; Lehman et al, 2002), and disagreements
among disciplines about what constitutes disability makes measurement of disability a difficult
task. Assessment of disability in persons with serious mental illness such as schizophrenia is
9
further complicated by impairments of insight and cognition associated with the disorder that
may interfere with patients’ ability to report their own experiences accurately (Atkinson et al,
The WHO with collaboration among researchers from several countries developed an
instrument to evaluate psychiatric disability. This instrument, the WHO Psychiatric Disability
Assessment Schedule (WHODAS; WHO, 1988), was designed to assess disturbances in social
adjustment and behaviour in persons with mental illness and to identify factors that may
influence these dysfunctions. Thereafter, the WHO modified and clarified the conceptualization
of disability and developed a research instrument called the World Health Organization
Disability Assessment Schedule-second version (WHODAS II). This instrument differs from the
WHODAS in that it applies more broadly to the impact of any disorder (not just psychiatric
disorder) on everyday functioning and treats all disorders (physical and mental) equally when
The WHODAS II distinguishes itself from other measures of health status, disability and
different countries including Nigeria. It is also conceptually compatible with the WHO’s
10
The WHODAS II has been developed to assess the limitations in activity and
2. Getting around
3. Self care
5. Life activities
6. Participation in society
A set of questions were written to operationalize these concepts. Ninety-two items were
selected from this large item pool and subjected to field trials in 19 countries. The WHODAS II
is available in 16 languages and several versions are available. These include interviewer-
administered versions, self-administered versions, and proxy versions. The 36 item, interviewer-
respondents. Other versions are the interviewer-administered 12 item version and the 12+24
screener version; self-administered 36 item version and 12 item version;proxy versions 6 item
proxy. WHODAS has been used by researchers in Nigeria (Ogundele, 2009; Bella and
11
The chronic course and debilitating effects of schizophrenia combine to create a disease
which imposes very considerable clinical, social and economic consequences on societies
throughout the world, resulting in it being a leading contributor to global and regional levels of
disability and the overall disease burden (WHO, 2001). Comparison of studies on disability is
often hampered by differences in methodology, outcome assessment and the studied population.
In spite of the above, studies have shown that patients with schizophrenia reported greater
severity of disability than normal comparison subjects (Ertugrul and Ulug, 2002; McKibbin et
al., 2004b). When patients with schizophrenia and obsessive-compulsive disorder (OCD) were
compared with matched duration of illness using the Indian Disability Evaluation Assessment
Scale (IDEAS), significantly greater disability was seen in the patients with schizophrenia in the
areas of self care, interpersonal activities, communication and understanding, work and global
disability score ( Mohan et al., 2005). Comparison of disability in the different mental disorders
using IDEAS indicated that schizophrenia is by far the most disabling of the mental disorders,
followed by Dementia. Depression, OCD, Bipolar affective disorders and Alcohol use disorders
are the next four disability causing disorders in order of the severity of disability associated with
Marneros et al. (1990) reported that schizophrenia caused persistent alterations in social life,
including social and occupational drift, premature retirement and inability to achieve the
expected level of social development. In one study, it was emphasized that disability in
schizophrenia starts primarily in social and occupational roles and interpersonal relations, and in
more severe situations self care begins to be affected (De Jong et al., 1985). Ertugrul and Ulug
(2002), using WHODAS II, demonstrated that life activities, participation in society,
understanding and communicating with the world, and getting along with people were the
12
domains where differences in disability level compared with the controls were more apparent,
whereas self care seemed to be relatively less affected. These results are consistent with the view
that disability has a hierarchic progression from high level roles to low level roles (Cooper,
1980).
social or vocational skills training (Patterson et al., 2006) as well as supported employment
(Drake et al., 1999) and housing interventions. These interventions have been empirically
demonstrated to have benefits for people with schizophrenia (Bell et al., 1996; Bond et al., 2001)
but these are also costly interventions. Several recent studies have shown that cognitive
remediation interventions both improve cognition and improve work outcomes in employment-
seeking individuals with schizophrenia (Hogarty et al., 2004; McGurk et al., 2005; Wexler and
Bell, 2005). Thus, treatments aimed at the origins of disability have demonstrated some potential
for reducing impairments. However, it is possible that other interventions could have a beneficial
effect as well. Cross-sectional studies have found that patients remaining untreated in the
(Padmavathi et al., 1998; Thirthalli et al., 2006). Also, studies have shown that disability tends to
be stable over a period of 3 years and seems to be independent of fluctuations in clinical course
(1994) in their study concluded that antipsychotic treatment have not been proven to be
particularly beneficial for the treatment of disability, several recent studies have reported
(such as sex, marital status and socio-economic status), illness characteristics (such as age of
onset, duration of untreated psychoses), clinical factors (presence and severity of positive or
negative symptoms) and cognitive deterioration (Alptekin et al., 2005; Ertugrul and Ulug, 2002;
Krapow et al., 1997; Lysaker et al., 1995). The relationship between disability and sex remains
controversial; while some studies reported higher a prevalence of disability among females
(Ganesh et al., 2008; Alptekine et al., 2005), Gupta and Chadda (2008) reported that males
showed higher social disability than females. Marital status has been shown to be an independent
predictor of outcome in schizophrenia (Jablensky et al., 1992; Padmavathi et al., 1998). While
some studies found no association between marital status and functional outcomes (Kebede et
al., 2005; Kua et al., 2003), Gupta and Chadda (2008) reported that the unmarried patients
suffered higher disability in personal area than the married patients. Being married may be an
indicator of increased family support and enhanced treatment compliance. . The prevalence of
mental disability has been reported to be lower among persons with high socio-economic status
(Kumar et al., 2008). Early –onset schizophrenia is said to predict more disability (Carpiniello
and Carta, 2002; Lay et al., 2003). Also studies have linked early-onset schizophrenia to poor
prognosis (Hafner et al., 1998; Moriarty et al., 2001; Sobin et al., 2001; Lenior et al., 2001;
Concerning duration of untreated psychoses (DUP), a study from Turkey found that DUP
was significantly associated with social disability as measured by the Brief Disability
Questionnaire (Alptekine et al., 2005) and a study from rural China reported that 35% of patients
with a DUP of less than a year had a complete symptomatic and social remission (Ran et al.,
14
2003). Also, a study from Mexico reported that patients with a DUP of less than 27 months were
significantly more likely to make a good social and occupational recovery (Apiquian et al., 2006)
and another study from India found a trend towards an improved social and occupational
outcome in patients with a shorter DUP (Tirupati et al., 2004). Farooq et al. (2009), using a
pooled estimate of diverse outcome measures found a significant association between longer
DUP and a greater level of disability. Some previous studies found no relationship between
neuro-cognitive functions and disability (Ertugrul & Ulug, 2002; Hertegrave et al, 1997;
Johnstone et al, 1990), but in others, a relationship was found (Velligan et al, 1997; Breier et al,
1991). One possibility why neuro-cognitive deficits are not related to disability is that the deficits
in attention, visual memory and executive functions or degree of disability of patients may not be
high enough to show the relationship between them. Another explanation is that patients adapt to
deficits by developing protective mechanisms that compensate for the deficits and lessen their
effect on their functional status. Decreasing the expectations and choosing simpler jobs may be
Disability in patients with schizophrenia has been reported to be related to the negative syndrome
(Lysaker et al., 1995; Klapow et al., 1997; Gupta and Chadda, 2008) and positive symptoms
(Alptekin et al., 2005). Ertugrul and Ulug (2002) using WHODAS to assess disability found that
both positive and negative symptoms are significantly related to disability but the highest
relation is with the general psychopathology score of PANSS. When symptoms severity
increases, patients have more difficulty in interpersonal relations. The researcher also noted the
orthopedically disabled patient may not be able to move, but a patient with schizophrenia can
also have difficulty in moving and getting around just because of his delusions. Negative
15
symptoms and duration of untreated psychoses were reported to be a significant predictor of
reported to be associated with worse functioning and with poorer quality of well-being (Gaynes
et al., 2002; Jin et al., 2001). Researchers have found that the WHODAS II appeared to be
sensitive to severity of depressive symptoms (pyne et al., 2003; Mckibbin et al., 2004). Patients
with greater severity of depressive symptoms reported greater levels of disability. However, the
direction of causality is not clear, because depression may both cause and result from the
Comparison of results from disability studies are limited by the differing methods used in
the evaluation of disability, outcome assessment and the population studied, as well as the
environment in which the patients were identified. Another limitation is the use of different terms
to refer to specific subsets of activities measured by these instruments. There are few studies on
Diagnostic Criteria (RDC) for schizophrenia that spanned a range of 7 to 26 years. Outcome was
consistent over the 7 years of follow-up, with a good outcome achieved by 50.7% and a
moderate outcome achieved by 23.9%. The most typical course was acute onset followed by an
episodic course with rapid remission in response to treatment. Negative symptoms were rarely
noted. Women had an older age of onset and, a rare finding, poorer outcome than men. The
16
researcher noted that many of the male patients, even those in moderate to poor-outcome
categories, were able to complete education and /or work in order to become self sustaining.
Gureje and Bamidele (1999) examined the social, occupational and residential outcomes
of 120 clinically stable outpatients with schizophrenia after 13 years. A substantial proportion of
patients showed a moderate to severe degree of disability in areas of occupation and social
contacts. Four percent were homeless or of unstable abode while men were particularly
Women had a more impaired outcome in the domain of frequency and quality of social contact.
Poor response to initial treatment and indices of impaired premorbid adjustment were associated
In another study, Gureje (2002) assessed psychological symptoms that do not reach the
threshold for formal diagnosis and its association with disability and service use after 12 months
among 2379 consecutive primary care attenders. Using the 12 item General Health Questionnaire
(GHQ12) and a stratified random sample (n=704) completed baseline structured diagnostic
interview, disability assessment and the 28 item version of the GHQ (GHQ28). At baseline
caseness on either the GHQ or ICD-10 was associated with poor self rated overall health,
interviewer-rated occupational disability and with more disability days in prior month. At 12
months follow-up, being a case on the GHQ but not on ICD-10 at baseline was associated with
disability, poor health perception and high health service utilization. The researcher concluded
that psychological symptoms that may not reach diagnostic threshold are associated with
17
Gureje and others (2006) studied functioning disability among 2,152 Yoruba, elderly
people using Katz index of independence to assess activities of daily living (ADLS), the Nagi
Physical Performance Scale and the Health Assessment Questionnaire to assess instrumental
activities of daily living (IADLs). They found that 3% had ADL disability and 9.1% had IADL
disability. Women were more disabled, significantly so in the performance of IADLs and overall.
In all, disability increased with age and persons who were currently married had lower rates of
disability than those who were separated, divorced or widowed. Also, elderly persons living in
rural areas had the lowest rates and those living in urban areas had the highest. Self reported
chronic medical illness did not significantly increase the risk of disability. Persons with disability
were more likely to have had major depression in the prior 12 months, but the association was
significant only with regard to ADLs. Also, persons reporting persistent pain were four times as
likely to be disabled as those with no persistent pain. Poor self perception of health was also a
significant predictor of functional disability, with those reporting that their health was poor or
very poor having about five times the risk of disability as those who rated their health as
excellent, good or fair. Furthermore, the observation that 19% of elderly persons with disability
and therefore in need of assistance were unable to access such help was striking. In addition, the
study demonstrated the urgent need for developing countries to become more aware of the
consequences of the growth in the population of older people. Policies aimed at supporting
family members to fulfill such roles remain most viable and possibly more likely to be culturally
Uwakwe and Modebe (2002) described the pattern of disability and care for 102 elderly
Nigerians living in a selected community. Disability was assessed with the modified World
Health Organization Disability Assessment Schedule- Short Version (WHODAS-S). 47% of the
18
elderly people had some form of disability. Help with self care was the greatest problem reported
by the carers, and care-giving was regarded as a very heavy burden associated with high
emotional distress. The researcher concluded that disability is high in elderly subjects living in
the community. Care-giving is proving a great challenge in the face of children deserting their
parents in an increasingly harsh economy. There is need for a systematic, realistic plan to
Gureje et al. (2008) compared the effects of depression and chronic physical conditions
on disability among 2152 community dwelling elderly persons. Disorder-specific disability was
evaluated using the Sheehan Disability Scale (SDS). A higher proportion of persons with major
depressive disorder (MDD, 47.2%) were rated severely disabled globally than those with arthritis
(20.6%), chronic spinal pain (24.2%) or high blood pressure (25.0%). Subjects with MDD had
worse disability ratings on the SDS and were more likely to be severely disabled globally and
with regard to work, home and social roles than those with arthritis, chronic spinal pain, high
blood pressure, asthma, or diabetes mellitus. In pair-wise comparisons, persons with MDD had
significantly higher levels of disability than those with any of the other disorders, with
differences in mean scores ranging between -3.74 and -27.50. The researchers concluded that to
reduce the public health burden of depression, its prevention and treatment require more clinical
and research attention than was currently being given by developing countries.
Of recent, Ogundele (2009) examined the risk factors for disability among 236 elderly
persons living in a rural community of Oyo State, Nigeria. Disability was assessed using the
World Health Organization Disability Assessment Schedule (WHODAS II). Disability was
significantly higher in subjects with depression than in the non-depressed subjects with the
of the WHODAS except the life activity domain which assesses functioning in household
maintenance and in caring for people close to the respondent, and includes activities such as
cooking, cleaning, shopping, and caring for others and for one’s belongings and work related
activities. The researchers found that the severity of depression was not associated with
disability, which was not consistent with most existing information on disability in geriatric
depression. A possible explanation for this may be that most of the studies that reported
associations between disability and increased severity of depression used instruments that
assessed only a limited range of physical activities which are usually compromised in severe
depression, leading to bias towards higher disability rates in the severely depressed.
20
CHAPTER 3
The aim of this study is to assess disability among schizophrenic patients attending the outpatient
schizophrenia
2. To compare severity of disability among patients with schizophrenia, with healthy control
subjects
3. To evaluate and compare the relationship between disability in schizophrenia and socio-
3.1 HYPOTHESIS
1. Patients with schizophrenia will not report greater level of severity of disability on the
21
CHAPTER FOUR
4.1.1 SUBJECTS: The subjects will be recruited from the outpatients’ psychiatric clinic of
Wesley Guild Hospital, Ilesa, a unit of the Obafemi Awolowo University Teaching Hospitals
Complex (OAUTHC), Ile-Ife, Osun State. Healthy control subjects will be selected from among
the hospital staff. Patients will be consecutively recruited over a period of six months. The
the diagnostic nosology used by the department. All patients presenting in the unit
are interviewed based on the ICD – 10 diagnostic criteria and the final diagnosis
research purposes and also submitted for input into the hospital’s computerized
3. The patients should have been diagnosed and receiving treatment for at least 1
4. The last hospital admission must be at least 6 months or more before the date of
assessment and
22
4.1.2 STUDY DESIGN: A cross-sectional descriptive survey.
4.1.3 SAMPLE SIZE: The required sample size for the study group will be calculated using
[2 ( Pc) + Qc ]
+
2
+ 2
N = C
d2 d
Where
C is a constant that depends on the values for alpha (significance level) and beta (power)
Qc = 1 - Pc
N = 69.06
A sample size of 100 will be chosen in order to increase the statistical power. Thus, each of
the two study groups will comprise 100 sample subjects, including Yoruba or
patients and healthy controls will be matched for age, sex and educational
status
23
4.1.4 PROCEDURE:
Approval of the research protocol by the Ethics and Research Committee of Obafemi Awolowo
University Teaching Hospitals Complex will be obtained and written informed consent will be
obtained from the subjects after the aims of the study have been explained to them.
4.1.5 MEASURES
4.1.51 The Clinical Interview: The diagnosis of schizophrenia will be ascertained with the
al 1998). The MINI was designed as a brief structured interview for the major AXIS I
Validation and reliability studies done comparing the MINI to other similar structured
interviews such as the Structured Clinical Interview for the DSM-IV Patient version
(SCID – P, First et al, 1994) and the Composite International Diagnostic Interview (CIDI;
Smeets and Dingemans, 1993) have shown high validity and reliability scores. The MINI
has a current (for present symptoms) and a lifetime version (for retrospective diagnosis).
The lifetime diagnosis version will be used in this study. The instrument has been used in
variables of the subjects. The information that will include: Age, sex, marital status,
status, earnings/income per month, amount spent on treatment per month, and level of
social support from family members, friends and others. Also information about duration
of the illness, age of onset of active symptoms of schizophrenia, past history of hospital
24
admissions and number of hospital admissions will be obtained either from patient or the
case file.
Negative Syndrome Scale (PANSS; Kay et al, 1987) which includes a structured
symptoms. For each item, ratings are made on a 1 – 7 scale of symptom severity. The
scale has been used in Nigeria (Mccreadie and Ohaeri, 1994; Lawal et al, 2003).
4.1.54 Depression: This will be assessed using the Zung’s self-rating depression scale (SDS;
Zung, 1965) which is a 20- item self administered questionnaire graded with a 4 point
likert’s scale (Never, occasionally, sometimes, mostly) for each question. The sum of
scores (raw scores) for each respondent will be converted to a 100 point scale (SDS Index
Score) with a score of less than 50 points classified as normal, 50-59 points classified as
mild depression, 60-69 points classified as moderate depression and 70 points and above
classified as severe depression. The instrument and its back translated Yoruba version has
been used in Nigeria (Jegede, 1979; Fatoye et al, 2004; Mosaku et al, 2008).
4.1.55 Insight into Illness: A semi structured questionnaire based on the Present State
Examination (Wing et al., 1974) will be used to enquire about patients’ awareness of their
4.1.56 Medication Related Variables: These will be assessed with the use of a questionnaire
and a review of the patient’s case file. It will include the type and dose of current
medication will be assessed with the aid of a clinician-rated structured check list detailing
25
common side-effect symptoms. Each symptom is scored on as present or absent. This
check list has been standardized and used in the unit (Adewuya, 2007).
This is a scale developed by the World Health Organization (W.H.O) to measure disability
Classification of Functioning, Disability, and Health at bodily, personal, and social levels.
The 36-item interviewer-administered version of WHODAS II will be used for the study.
It measures the difficulty the individual has had with performing particular daily activities
over a period of 30 days. It consists of 36 Likert formatted questions, divided into six
domains: understanding and communicating (six items); getting around (five items); self-
care (four items); getting along with others (five items); life activities (eight items); and
participation in society (eight items). The final score is calculated using a standardized
SPSS algorithm. There are two syntax versions which may be administered according to a
respondent’s occupational status: a 36-item version for those currently working, and a 32-
item version for those not working. The final scores derived from both versions range
from 0 to 100 with higher scores indicating greater disability. It has been validated for use
The healthy control group will complete the socio-demographic questionnaire along with
4.1.6 Data analysis: The Statistical Package for Social Sciences (SPSS) software (version 11)
will be used for analysis. The Student t- test and Chi-square statistics will be used to
study the differences between the two groups. Correlations between psychiatric disability
26
and various socio-demographic and clinical characteristics will be studied using
27
REFERENCES
Adewuya AO, Afolabi MO, Ola BO, Ogundele OA, et al. (2008). Relationshis between
depression and quality of life in persons with HIV infection in Nigeria. The International Journal
of Psychiatry and Medicine 38 (1): 43- 51
Alptekin K, Erkoc S, Gogus AK, Kultur S, Mete L, Ucok A, Yazici KM (2005). Disability in
schizophrenia: Clinical correlates and prediction over 1-year follow-up. Psychiatry Research
135: 103-111.
Apiquián R, Fresán-Orellana A, García-Anaya M, et al., (2006). Impacto de la duración de la
psicosis no tratada en pacientes con primer episodio psicótico. Gac. Méd. Méx. 142: 113–120.
Atkinson, M., Zibin, S., Chuang, H., (1997). Characterizing quality of life among patients with
chronic mental illness: a critical examination of the self-report methodology. Am. J. Psychiatry
154, 99–105.
Banerjee, G. (2001). The concept of disability and mental illness. Mental Health
Reviews, Accessed from <http://www.psyplexus.com/excl/cdmi.html> on August 31, 2009.
28
Bruce JL (2001). Depression and disability in late-life: Directions for future research. Am. J.
Geriatr. Psychiatry. 9:102–112.
Carpiniello B, Carta MG (2002). Disability in Schizophrenia. Intrinsic factors and predictor of
psychosocial outcome. An analysis of literature. Epidemiol. Psichiatr. Soc.11(1):45-58.
Chaudhury P C, Deka K, Chetia D (2006). Disability associated with mental illness. Indian
Journal of Psychiatry 48:95-101.
Cooper J (1980). The description and classification of social disability by means of a taxonomic
hierarchy. Acta Psychiatr. Scand. 62 (Suppl. 285):140-146.
De Jong A, Giel R, Slooff Cj, Wiersma D (1985). Social disability and outcome in schizophrenic
patients. Br. J. Psychiatry 147:631-636.
Doyle M, Flanagan S, Browne S (1999) Subjective and external assessments of quality of life in
schizophrenia: Relationship to insight. Acta Psychiatr. Scand. 99:466–472.
Drake R E, McHugo G J, Bebout R R, Becker D R, Harris M, Bond G R, Quimby E (1999). A
randomized clinical trial of supported employment for inner-city patients with severe mental
illness. Arch. Gen. Psychiatry 56:627–633.
Ertugrul A, Ulug B (2002). The influence of neurocognitive deficits and symptoms on disability
in schizophrenia. Acta Psychiatr Scand. 105:196–201.
Farooq S, Large M, Nielssen O, Waheed W (2009). The relationship between the duration of
untreated psychosis and outcome in low-and-middle income countries: A systematic review and
meta-analysis. Schizophrenia Research 109: 15–23.
Fatoye FO, Adeyemi AB & Oladimeji BY (2004) Emotional distress and its correlates among
Nigerian Women in late pregnancy. Journal of Obstetrics and Gynaecology, 24:5:504-509.
First MB, Spitzer RL, Gibbon M et al. (1994). Structured Clinical Interview for the DSM IV
AXIS I Disorders, Patient-Edition (SCID-P), Version 2, New York State Psychiatric Institute,
Biometrics Research, New York.
Fleiss JL (1981). Statistical methods for rates and proportions. 2nd Ed. New York: Wiley.
Gaynes BN, Burns BJ, Tweed DL, Erikson P (2002). Depression and health-related quality of
life. J Nerv Ment Dis. 190:799–806.
29
Giel R, Wiersman D, DeJong A, Sloof C (1984). Prognosis and outcome in a cohort of patients
with non-affective functional psychosis.European Archives of Psychiatry and Neurological
sciences 234: 97-101.
Gupta A, Chadda RK (2008). Disability in Schizophrenia: Do Short Hospitalizations have a role.
International Journal of Psychosocial Rehabilitation. 13(1): 91-96.
Gureje O, Bamidele R (1999). Thirteen-year social outcome among Nigerian out-patients with
Schizophrenia. Soc Psychiatry epidemiol. 34:147-151.
Gureje O. (2002). Psychological disorders and symptoms in primary care. Association with
disability and service use after 12 months. Soc. Psychiatry Psychiatr Epidemiol. 37(5): 220-4.
Gureje O., Ademola A., Olley B.O.(2008). Depression and disability: comparisons with common
physical conditions in the Ibadan study of aging. J Am Geriatr Soc 56:2033-2038.
Gureje O., Ogunniyi A., Kola L., Afolabi E. (2006). Functional disability in elderly Nigerians:
results from the Ibadan study of aging. J Am Geriatr Soc 54:1784-1789.
30
Hofer A, Rettenbacher M.A, Widschwendter C.G, Kemmler G, Hummer M, Fleischhacker W.W
(2006). Correlates of subjective and functional outcomes in outpatient clinic attendees with
schizophrenia and schizoaffective disorder. Eur Arch psychiatry clin neurosci 256: 246-255.
Hogarty G E, Flesher S, Ulrich R F, Carter M, Greenwald D, Pogue-Geile M, Kechavan M,
Cooley S, DiBarry A L, Garrett A, Parepally H, Zoretich R (2004). Cognitive enhancement
therapy for schizophrenia: effects of a 2-year randomized trial on cognition and behavior. Arch.
Gen. Psychiatry 61: 866–876.
Institution of Medicine (1991). Disability in America. Washington, DC: National Academy Press.
Jablensky A, Satorius N, Emberg G, Anker M, Korten A, Cooper JE, Day R, Bertelsen A (1992).
Schizophrenia: manifestations, incidence and course in different cultures. A World Health
Organization ten-country study. Psychol. Med. Monogr. Suppl. 20: 1-97.
Jablensky A., Schwarz R., Tomov T. (1980). WHO collaborative study on Impairments and
Disability in Schizophrenic patients. A preliminary communication: objective and methods. Acta
Psychiatrica Scandinavica supplement 285:62
Jin H, Zisook S, Palmer BW, Patterson TL, Heaton RK, Jeste DV (2001). Association of
depressive symptoms and functioning in schizophrenia: A study in older outpatients. J. Clin.
Psychiatry. 62:797–803.
Johnstone EC, Macmillan JF, Frith CD, Benn DK, Crow TJ (1990). Further investigation of the
predictors of outcome following first schizophrenic episodes. Br J Psychiatry. 157:182-189.
Kay SR., Fiszbeins & Opler LA (1987). The Positive and Negative Syndrome scale (PANSS) for
Schizophrenia. Schizophrenia Bulletin 13: 262-273
31
Klapow J C, Evans J, Patterson T L, Heaton RK , Koch W, Jeste, D V (1997) Direct assessment
of functional status in older patients with schizophrenia. Am. J. Psychiatry, 154: 1022-1024.
Lay B, Blanz B, Hartmann M, Schmidt MH (2000). The psychosocial outcome of adolescent-
onset schizophrenia: a 12-year follow-up. Schizophrenia Bulletin 26: 801– 816.
Lenior ME, Dingemans PMA, Linszen DH, De Haan L, Schene AH (2001). Social functioning
and the course of early-onset schizophrenia. British Journal of Psychiatry 179:53–58.
Lysaker P H, Bell M D, Zito W S, Bioty S M (1995). Social skills at work – Deficits and
predictors of improvement in schizophrenia. J Nerv Ment Dis 183: 688-692.
Kua J, Wong KE, Kua EH, Tsoi WF (2003). A 20-year follow-up study on schizophrenia in
singapore. Acta Psychiatr. Scand. 108(2): 118-125.
Kumar SG, Das A, Bhandary PV, Soans SJ, Kumar HNH, Kotian MS (2008). Prevalence and
pattern of mental disability evaluation assessment scale in a rural community of Karnataka.
Indian J. Psychiatry 50:21-23.
Lawal R.A., Suleiman GT, & Onyeze B. (2003). Risperidone in the treatment of chronic
Schizophrenia. Nigerian Medical Practitioner, 44:12-18.
Lehman AF, Alexopoulos GS, Goldman H, Jeste D, Ustan B (2002). Mental disorders and
disability: Time to reevaluate the relationship? In DJ Kupfer, MB First, DA Regier (Eds.), A
Research Agenda for DSM-V (pp 201–218).
Marneros A, Deister A, Rohde A (1990). Psychopathological and social status of patients with
affective, schizophrenic and schizoaffective disorders after long-term course. Acta Psychiatric
Scand 82: 352-8.
McClure M.M., Harvey P.D. (2007).Critical issues in the assessment of disability in
schizophrenia. Clinical Schizophrenia & related psychoses.1 (2): 147-153.
McCreadie RG & Ohaeri JU (1994). Movement Disorder in Never and Minimally Treated
Nigerian Schizophrenic patients. British Journal of Psychiatry, 164, 184-189.
McGurk S R, Mueser K T, Pascaris A (2005). Cognitive training and supported employment for
persons with severe mental illness: oneyear results from a randomized controlled trial. Schizophr.
Bull. 31: 898–909.
32
McKibbin C, Patterson T L, Jeste D V(2004b). Assessing Disability in Older Patients With
Schizophrenia: Results From the WHODAS-II. J. Nerv. Ment. Dis. 192: 405–413.
Mckibbin C.L., Brekke J.S., Sires D., Jeste D.V., Patterson T.L. (2004a). Direct assessment of
functional abilities: relevance to persons with schizophrenia. Schizophr. Res. 72: 53-67.
Mohan I, Tandon R, Kalra H, Trivedi J.K. (2005). Disability assessment in mental illnesses using
Indian Disability Evaluation Assessment Scale (IDEAS). Indian J Med Res 121: 759-763.
Moriarty PJ, Lieber D, Bennett A, White L, Parrella M, Harvey PD, Davis KL (2001). Gender
differences in poor outcome patients with lifelong schizophrenia. Schizophrenia Bulletin 27:
103– 113.
Mosaku S, Kolawole B, Mume C & Ikem R. (2008) Psychological symptoms and quality of life
among diabetic patients: a comparative study. Endocrine Abstracts 16:244.
Ogundele A.T. (2009). Risk factors for disability among depressed elderly people living in a
Nigerian community. Dissertation submitted to the West African College of Physicians.
33
Patterson, T.L., Moscona, S., McKibbin, C.L., Davidson, K., Jeste, D.V., (2001a). Social skills
performance assessment among older patients with schizophrenia. Schizophr. Res. 48: 351– 360.
Pope A M, Tarlov A R (1991). Disability in America: Toward a National Agenda for Prevention.
National Academy Press, Washington, D.C.
Promise of Outcomes Research. Brookes Pub. Co., Baltimore, pp. 91– 102.
Pyne JM, Sullivan G, Kaplan R, Williams DK (2003). Comparing thesensitivity of generic
effectiveness measures with symptom improvement in persons with schizophrenia. Med. Care.
41:208–217.
Ran M S, Xiang M Z, Li S X (2003). Prevalence and course of schizophrenia in a Chinese rural
area. Aust. N.Z.J. Psychiatry 37: 452–457.
Sayers, M.D., Bellack, A.S., Wade, J.H., Bennett, M.E., Fong, P., (1995). An empirical method
for assessing social problem solving in schizophrenia. Behav. Modif. 19: 267– 289.
Schneider M., Hurst R., Miller J., Ustun B. (2003). The role of environment in the International
Classification of Functioning, Disability and Health (ICF). Disability and Rehabilitation 25(11-
12): 588-595
Smeets, RMW, Dingmans PMA (1993). Composite International Diagnostic Interview (CIDI),
Verse 1.1. WHO Amsterdam.
Sobin C, Blundell ML, Conry A, Weiller F, Gavigan C, Haiman C, Karayiorgou M (2001). Early,
non-psychotic deviant behavior in schizophrenia: a possible endophenotypic marker for genetic
studies. Psychiatry Research 101: 101–113.
Srinivasa Murthy R, Kishore Kumar KV, Chisholm D et al. (2005). Community outreach for
untreated schizophrenia in rural India: a follow-up study of symptoms, disability, family burden
and costs. Psychol. Med. 35:341–351.
Srinivasan TN, Rajkumar S, Padmavathi R.(2001). Initiating care for untreated schizophrenia
patients and results of one year follow-up. Int. J. Soc. Psychiatry 47:73–80.
34
Thara R and Rajkumar S (1993). Nature and course of disability in schizophrenia Indian J.
Psychiat. 35(1): 33-35.
Thara R, Rajkumar S, Valecha V. (1988). Schedule for the assessment of psychiatric disability - a
modification of DAS II. Indian J. Psychiatr. 30: 47-53.
Thara R., Menon M.S., (1991). A new perspective of disability – Chronic Mental Illness. Indian
Journal of Disability and rehabilitation, jan-june, 33-36.
Uwakwe R., Modebe I. (2007). Disability and care-giving in old age in a Nigerian community.
Niger J Clin Pract. 10(1): 58-65.
Velligan DI, Mahurin RK, Diamond PL, Hazleton BC, Eckert SL, Mièller AL (1997). The
functional significance of symptomatology and cognitive function in schizophrenia. Schizoph.
Res. 25: 21-31.
Verbrungge L.M., Jette, A.M., (1994). The disablement process. Soc. Sci. Med. 38: 1 – 14.
Wexler B E, Bell M D (2005). Cognitive remediation and vocational rehabilitation for
schizophrenia. Schizophr. Bull. 31: 931–941.
Whiteneck, G.G., Fougeyrollas, P., Gerhart, K.A., (1997). Elaborating the model of disablement.
In: Fuhrer, M.J., Brookes, Paul H. (Eds.), Assessing Medical Rehabilitation Practices: The
35
Wilkinson, G., Hedson, B., Wild, D., Cookson, R., Farina, C., Sharma, V., Fitzpatrick, R.,
Jenkinson, C., (2000). Self-report quality of life measure for people with schizophrenia: the
SQLS. Br. J. Psychiatry 177: 42– 46.
Williams, B., (1994). Patient satisfaction: a valid concept? Soc. Sci. Med. 38, 509–516.
Williams, S.L., Bloomer, J.S., (1987). Bay Area Functional Performance Evaluation, 2nd ed.
Consulting Psychologists, Palo Alto,CA.
Wing JK, Cooper JE, Sartorious N (1974). Measurement and classification of psychiatric
symptoms. London: Cambridge University Press.
Wood PH, (1980). Measuring the consequences of illness. World Health Stat. Q. 42: 115– 121.
World Health Organization (1980). International classifications of impairments, disabilities and
handicaps. Geneva: WHO.
Zung WWK (1965). A Self rating depression scale. Arch Gen Psy, 12:63-70.
APPENDIX 1
-CONSULTATION: _______________________________________
(6). If presently mentally stable, when was the last episode of mental illness (in months) _____
1.)
2.)
3.)
37
4.)
1.)
2.)
3.)
4.)
2 Dystonia 15 Constipation
5 Menstrual 18 Photosensitivity
dysfunction
7 Dizziness 20 NMS
10 Sedation 23 Gynaecomastia
13 Blood dyscrasia
0 = Full insight (in intelligent subject, able to appreciate the issues involved).
1 = As much insight into the nature of the condition as social background and intelligence
allow.
38
2 = Agrees to a nervous condition but examiner feels that subject does not really accept the
explanation in terms of a nervous illness (e.g. gives delusional explanation, the result of
persecution, or rays, etc.)
SECTION E: MINI
SECTION F:
1) PANSS
2) ZUNGS’ SELF RATING DEPRESSION SCALE
SECTION G: WHODAS II
APPENDIX 2 (CONTROL)
39
1. AGE: (in years) ____________________
2. SEX: Male ( 1 ) Female ( 2 )
3. MARITAL STATUS: Single ( 1 ) Married (2 ) Divorced ( 3 ) Separated ( 4 ) Widowed ( 5 ) Others
(specify) ______________________________
4. RELIGION: Christianity ( 1 ) Islam ( 2 ) Traditional religion ( 3) Others (specify)
_____________
5. ETHNICITY: Yoruba (1 ) Igbo ( 2 ) Hausa ( 3 ) Others ( please state) ___________________
6. OCCUPATION:_________________________________
7. HIGHEST EDUCATIONAL LEVEL: None ( 0 ) Primary ( 1 ) Secondary ( 2 ) Post Secondary ( not
University) (3 ) University ( 4 )
8. EMPLOYMENT STATUS: Working full time ( 1) Working part time ( 2) Unemployed (3 ) Never
Unemployed ( 4) Retired (5 ) In School (6 ) Keeping house ( 7) Others (specify)
______________________
9. INCOME/EARNING PER MONTH (in Naira) _______________________________
10. ANY CONCOMITANT MEDICAL/PHYSICAL ILLNESS/PROBLEMS
________________________________________________________________________
SECTION B
- ZUNG’S SELF RATING DEPRESSION SCALE
SECTION C
- WHODAS II
40