THE RELATIONSHIP BETWEEN DEPRESSION AND SUBJECTIVE

QUALITY OF LIFE IN NIGERIAN OUTPATIENTS WITH

SCHIZOPHRENIA
OBAFEMI AWOLOWO UNIVERSITY TEACHING HOSPITALS
COMPLEX, ILE-IFE

PRINCIPAL INVESTIGATOR:

DR. AKINSULORE ADESANMI

DEPARTMENT OF MENTAL HEALTH

OBAFEMI AWOLOWO UNIVERSITY TEACHING HOSPITALS
COMPLEX

PROPOSAL SUBMITTED IN PARTIAL FULFILLMENT OF THE

PART II FELLOWSHIP EXAMINATION OF THE WEST AFRICAN
COLLEGE OF PHYSICIANS
FACULTY OF PSYCHIATRY

SUPERVISORS:

PROF R O A MAKANJUOLA
DR F O FATOYE

1
CERTIFICATE OF SUPERVISION

This is to certify that I am supervising the project titled “The relationship between

depression and subjective quality of life in Nigerian outpatients with Schizophrenia”

by Dr. Adesanmi Akinsulore as a requirement for his part II West African College of

Physicians, Faculty of psychiatry qualification.

Signature ……………………………………… Date ……………………….

Prof. R.O.A Makanjuola, FWACP, FMCPsych

Head of Department

Signature ……………………………………… Date ……………………….

Dr D.I Ukpong, FMCPsych

2
 TABLE OF CONTENT

1. NAME OF CANDIDATE 6

2. FACULTY OF CANDIDATE 6

3. TRAINING INSTITUTION 6

4. ADDRESS OF TRAINING INSTITUTION 6

5. NAME OF SUPERVISOR 6

6. ADDRESS OF SUPERVISOR 6

7. NAME OF SECONDARY SUPERVISOR 6

8. ADDRESS OF SECONDARY SUPERVISOR 6

9. MONTH AND YEAR PART I PASSED 6

10. PROPOSED EXAMINATION DATE 6

11. PROPOSED TITLE OF PROJECT 6

12. AIMS AND OBJECTIVES OF THE STUDY 7

13. PROPOSED METHODOLOGY 9

13.1 SUBJECTS 9

13.2 STUDY DESIGN 9

13.3 SAMPLE SIZE 10

13.4 PROCEDURE 10

13.5 MEASURES 10

13.6 STATISTICAL ANALYSIS 14

14 LITERATURE REVIEW 15

14.1 PREAMBLE 15

14.2 DEFINITION 16

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 14.3 METHODOLOGICAL ISSUES 16

14.4 DEPRESSION IN SCHIZOPHRENIA 18

14.5 DIFFERENTIAL DIAGNOSIS OF DEPRESSION IN THE

COURSE OF SCHIZOPHRENIA 19

14.51 MEDICAL OR ORGANIC FACTORS 20

14.52 NEGATIVE SYMPTOMS OF SCHIZOPHRENIA 20

14.53 NEUROLEPTIC INDUCED DYSPHORIA 21

14.54 NEUROLEPTIC INDUCED AKINESIA 21

14.55 NEUROLEPTIC INDUCED AKATHISIA 22

14.56 REACTIONS TO DISAPPOINTMENT OR STRESS 22

14.57 POST PSYCHOTIC DEPRESSION 22

14.58 SCHIZOAFFECTIVE DEPRESSION 23

14.6 QUALITY OF LIFE IN SCHIZOPHRENIA 23

14.7 FACTORS AFFECTING QUALITY OF LIFE 26

15. RELEVANCE OF THE PROPOSED PROJECT TO

THE PRACTICE OF PSYCHIATRY 28

16. APPLICATION SUPPORT 29

17. FOR OFFICIAL USE 30

18. REFERENCES 31

19. APPENDIX 43

19.1 SOCIO-DEMOGRAPHIC QUESTIONNAIRE 43

19.2 ILLNESS RELATED DETAILS 43

19.3 MEDICATION RELATED DETAILS 44

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 19.31 SIDE EFFECT CHECKLIST 44

19.32 SIMPSON ANGUS SCALE 44

19.4 INSIGHT INTO ILLNESS 44

19.5 MINI INTERNATIONAL NEUROPSYCHIATRIC

INTERVIEW (MINI) 45

19.6 POSITIVE AND NEGATIVE SYNDROME

SCALE (PANSS) 48

19.7 ZUNG’S SELF-RATING DEPRESSION SCALE 50

19.8 WORLD HEALTH ORGANIZATION QUALITY OF

LIFE SCALE – BRIEF VERSION (WHOQOL-BREF) 51

19.9 INFORMED CONSENT FORM 55

5
WEST AFRICAN COLLEGE OF PHYSICIANS

RESEARCH PROPOSAL AND TITLE REGISTRATION ASSESSMENTS FORM

OF PART II CANDIDATES

1. NAME OF CANDIDATE: AKINSULORE, Adesanmi

2. FACULTY OF CANDIDATE: Psychiatry

3. TRAINING INSTITUTION: Obafemi Awolowo University Teaching

Hospital Complex (OAUTHC), Ile-Ife.

4. ADDRESS OF TRAINING INSTITUTION: Obafemi Awolowo University

Teaching Hospitals Complex (OAUTHC), Ile-Ife, Osun State, Nigeria.

5. NAME OF SUPERVISOR: Prof. R.O.A. Makanjuola

6. ADDRESS OF SUPERVISOR: Department of Mental Health Obafemi

Awolowo University, Ile-Ife, Osun State, Nigeria.

7. NAME OF SECONDARY SUPERVISOR: Dr. F.O. Fatoye

8. ADDRESS OF SECONDARY SUPERVISOR: Department of Mental

Health, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria.

9. MONTH AND YEAR PART I PASSED: OCTOBER 2008

10. PROPOSED EXAMINATION DATE: OCTOBER 2010

11. PROPOSED TITLE OF PROJECT: The Relationship between

Depression and Subjective Quality of Life in Nigerian Outpatients with

Schizophrenia.

6
12. AIMS AND OBJECTIVES OF THE STUDY:

Schizophrenic disorders afflict approximately 1% of the population during their

lifetime. These disorders impose severe hardships on patients and their families and

challenge society in the development of public policies that both preserve the public

welfare and afford patients a decent quality of life (QOL) (Lehman, 1996). QOL refers to

the health-related aspect of personal well-being or, when expanded to encompass the

psychosocial aspects, a subjective perception of health (Bohmer and Ravenssieberer,

2005). Psychiatric research employs QOL as a discriminating, predictive and evaluating

indicator of well-being (Pukrop, 2003).

Several variables have been studied in relation to subjective QOL. Depression has

been found to be inversely related to subjective QOL among outpatients with serious

mental illness (Fitzgerald et al, 2001; Huppert et al, 2001; Reine et al, 2003; Tomotake et

al, 2006; Aki et al, 2008; Yamauchi et al, 2008). Depressive symptoms play an important

role in schizophrenia as these contribute to a further worsening of any already existing

deficit state, i.e., negative symptoms (Murali & Kumar, 2008).

Therefore, it becomes important and essential to clearly delineate depressive

symptoms from deficit states (Negative Symptoms) and manage them appropriately in

order to improve the clinical outcome.

A search of the literature revealed a dearth of published research on the

relationship of depression on the subjective quality of life of patients presenting with

schizophrenia in the West African environment.

The overall aim of this study is to assess the relationship between depression and

subjective quality of life in outpatients with schizophrenia.

7
The specific objectives of this study are as follows:

1. To examine the perception of patients with schizophrenia on their

overall QOL as well as their level of satisfaction with the physical,

psychological, social and environmental domains of their living

experience.

2. To identify and compare depressed and non-depressed

schizophrenic patients in terms of subjective QOL and

psychopathological symptoms.

3. To evaluate the socio-demographic and clinical variables that may

be associated with the subjective QOL in patients with

schizophrenia.

4. To compare the relationship between subjective quality of life and

positive and negative symptoms of schizophrenia

Hypothesis

The hypotheses of this study are as follows:

1. There will be no significant difference in the subjective quality of

life of depressed and non-depressed Schizophrenic outpatients.

2. There will be no significant association between socio-

demographic and clinical characteristics of depressed and non-

depressed Schizophrenic outpatients

3. There will be no significant association between the subjective

quality of life and positive and negative symptoms of

schizophrenia

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13. PROPOSED METHODOLOGY

13.1 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. They will be consecutively

recruited over a period of six months. The inclusion criteria into the study will be:

1. Adults aged 18 years and above.

2. Having been diagnosed as having schizophrenia using ICD – 10 criteria

which is 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 recorded in a departmentally structured

diagnosis plan sheet available for research purposes and also submitted for

input into the hospital’s computerized diagnostic register. The diagnosis of

schizophrenia will be confirmed by the researcher using the Mini

International Neuropsychiatric Interview (MINI) English Version 5.0.0

(Sheehan et al 1998).

3. The patients should have been diagnosed and receiving treatment for at

least 1 year before inclusion in the study.

4. The last hospital admission must be at least 6 months or more before the

date of assessment and

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 5. There must be no evidence of organic disease or mental retardation and

significant physical illness such as hypertension.

13.2 STUDY DESIGN: A cross-sectional descriptive survey.

13.3 SAMPLE SIZE: The required sample size for the study group will be calculated

using the formula according to Fleiss (1981).

[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) with alpha set at 0.05 and beta at 90% then C = 10.51

Pc : the estimate of the proportion of outcome set at 50% (0.5)

Qc = 1 - Pc

d = differences in the outcome ( 1 - 0.5) = 0.5

10.51 [2 (0.5) + 0.5] 2

N = + + 2
0.5 X 0.5 0.5

N = 69.06

Adding 10% attrition rate = 6.906 + 69.06 = 75.97

A sample size of 100 will be chosen in order to increase the statistical power.

13.4 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 taken from the subjects after the aims of the study have been

explained to them.

13.5 MEASURES

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1. The Clinical Interview: The diagnosis of schizophrenia will be ascertained with

the Mini International Neuropsychiatric Interview (MINI), English Version 5.0.0

(Sheehan et al 1998). The MINI was designed as a brief structured interview for

the major AXIS I psychiatric diagnoses in the DSM IV and ICD-10.

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 Nigeria (Adewuya et al,

2008)

2. A semi–structured questionnaire inquiring about socio-demographic and illness

related variables of the subjects. The illness-related variables will also be obtained

with the use of specific instruments and a review of the patient’s case file. The

information obtained will include:

2.1 Age, sex, marital status, religion, ethnicity, highest level of formal education,

occupation, current employment status.

2.2 Earnings/income per month, amount spent on treatment per month, residential

type, housing condition, mode of transport, domestic situation, leisure activities,

relationship with same and opposite gender and level of social support from

family members, friends and others..

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2.3 Duration of the illness, age of onset of active symptoms of schizophrenia, past

history of hospital admissions, number of hospital admissions

2.4 Psychopathological symptoms: These will be assessed with the Positive and

Negative Syndrome Scale (PANSS; Kay et al, 1987) which includes a structured

interview to assess patients on 30 items covering positive, negative and general

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).

2.5 Depression: This will be assessed using the Zung’s self-rating depression scale

(SDS; Zung WWK, 1965) which is a 20- item self administered questionnaire with 4

fold likert’s scale (Never, occasionally, sometimes, mostly) in answering 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 and above points 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).

2.6 Level of Functioning: This will be assessed with the Global Assessment of

Functioning scale (GAF; APA, 1994). This is an observer-rated single rating on a

100 point scale, where 100 indicates not only the absence of pathology but also

positive mental health.

2.7 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 own mental state.

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3. 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 following:

3.1 Type and dose of current antipsychotic and anticholinergic medications.

3.2 Side effects of antipsychotic medication –

These will be assessed with the aid of a clinician-rated structured check list

detailing 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).

4. The Subjective Quality of Life: This will be measured using the World Health

Organization Quality of Life Scale – Brief version (WHO QOL – BREF) which is

a 26-item self-administered generic questionnaire. It is a short version of the

WHO QOL – 100 scale (the WHO QOL Group, 1998). The WHO QOL – BREF

is an international quality of life instrument which produces a profile with four

domain scores: physical health (7 items), psychological health (6 items), social

relationships (3 items), environmental domain (8 items) as well as two separately

scored items about the individuals’ perception of their quality of life (QI) and

health (Q2). Each item is scored in a Likert format from 1 to 5. The WHO QOL –

BREF has been validated across a wide variety of cultures, including Nigeria.

(Olusina and Ohaeri, 2003).

Either the English version or the back-translated Yoruba version of the instrument

(Sokoya, 1999; Adeponle, 2003) will be administered on the patients. Literate

subjects will be given the instrument to fill and for the non-literate subjects the

researcher will read the questions out to the patients and tick the answers.

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13.6 STATISTICAL ANALYSIS

The Statistical Package for the Social Sciences 11 (SPSS 11) program will be

used for statistical analysis. The domain scores of the WHO QOL – BREF will be

calculated according to the instructors’ manual. Descriptive statistics will be used

for all variables while inferential statistics such as chi-square test, independent t-

test, and Pearson’s correlations will be used to identify the relationships between

QOL and the variables assessed.

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14 LITERATURE REVIEW

14.1 Preamble

In recent years, great attention has been given to quality of life (QOL) in

schizophrenia and factors related to patients’ QOL (Yamauchi et al, 2008). Among the

various clinical factors related to levels of QOL, depression has been suggested to be the

most important determinant for subjective QOL (Fitzgerald et al, 2001; Huppert et al,

2001; Reine et al, 2003; Tomotake et al, 2006; Aki et al, 2008; Yamauchi et al, 2008).

From the literature, the rate of depression among schizophrenic patients ranges

from 6% - 75% in the course of psychosis in general (Gorna et al, 2007). In first

psychotic episodes and psychotic relapses the prevalence of depression varies from 65 –

80% and in the psychosis free intervals from 4-20% (Hafner et al, 2005). It has also been

reported that a large proportion (30 – 40%) of schizophrenic patients present with full

depressive syndromes and that this was associated with poor overall outcome,

characterized by significant work impairment, lower activity, dissatisfaction, less

employment, suicidal tendencies, more rehospitalization and more psychosis than the

patients with primary major depression (Sands and Harrow, 1999; Wassink et al, 1999;

Gorna et al, 2007). The variations in the prevalence rates may be due to methodological

and sampling differences as well as differences in the definition of both schizophrenia

and depression that were employed in the various studies.

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14.2 Definition

QOL is a highly complex concept and difficult to define. The World Health

Organization Quality of life Group (WHO QOL Group) defined QOL as the

“individuals’ perception of their position in life in the context of the culture and

value system in which they live and in relation to their goals, expectations,

standards and concerns” (Harper and Power, 1998). It is a broad-ranging concept,

affected in a complex way by the person’s physical health, psychological state,

level of independence, social relationships and their relationship to salient

features of their environment.

According to the WHO (1944) health is a “state of complete physical,

mental and social well being and not merely the absence of disease or infirmity”.

Only partially in keeping with this definition, psychiatric interventions have

focused mostly on the treatment of symptoms. Expanding the outcome measures

in psychiatry, for example by using subjective quality of life (SQOL), is thus

warranted.

In accordance with the definition of health by the WHO, SQOL covers physical,

emotional, mental, social and behavioural components of well-being and

functions as perceived by each individual.

14.3 Methodological Issues

The methodological requirements for a useful quality of life instrument are that it

be reliable, valid, sensitive to change and relatively brief (assuming that it will be

part of a larger battery of assessments). The ideal instrument is one that is suitable

for different patient groups, yet specific enough to be sensitive to the effects of

16
 particular treatments. At this time, no single instrument has been tested across

diverse patient samples. QOL has been measured from two different viewpoints.

One is subjective QOL, rated by patients themselves, and the other is objective

QOL, rated by observers. Patients with schizophrenia were thought to be unable

to assess their QOL themselves because of their cognitive deficit function

(Atkinson et al, 1996; Yamauchi et al, 2008) and objective QOL has been

frequently used in many studies.

However, now there is general agreement that symptomatically stabilized patients

are able to evaluate their QOL themselves (Voruganti et al, 1998). More importantly,

Hunt (1988) asserts that quality of life ‘refers essentially to a subjective assessment of the

situation by the patient - the only person with sufficient relevant knowledge to make that

assessment’.

While a host of studies have examined quality of life or subjective well being using

schizophrenia – specific scales (Heinrichs S et al, 1984; Naber et al, 2001; Wilkinson et

al, 2000) these scales have not been validated among West African schizophrenic

patients.

Another methodological issue is that evaluation of depression in schizophrenia is

subject to several difficulties. The contamination of depressive symptoms by negative or

extra pyramidal symptoms constitutes a frequent bias. The Zung’s self-Rating depression

scale is a measure which has been found useful in the assessment of depression among

schizophrenic patients (Kaneda, 1999). Also, the instrument has been used by several

researchers in Nigeria (Jegede, 1979; Fatoye et al, 2004; Mosaku et al, 2008).

17
14.4 Depression in Schizophrenia

A number of systematic studies of persons suffering from schizophrenia have

observed that there is often a significant co-occurrence of depression (Siris, 1995).

The term “depression” in schizophrenia could be considered from three different

viewpoints; whether it is the affect of depression, the symptom of depression or the

syndrome of depression (Siris, 2000). This has been a source of confusion and has

confounded the schizophrenia literature.

Depression as an affect reflects an individual’s momentary mood state on the

subjective experience spectrum from happiness to sadness as he or she interacts with his

or her internal and external environment. It is not, in itself, pathological as long as it is

situationally appropriate. Depression as a symptom is a sad mood state that causes a

person distress. It is an unwanted painful feeling and can be a source of complaint.

However, it is not necessarily enduring or accompanied by other features that are

required for the diagnosis of the syndrome of depression (Siris, 2000).

The depression syndrome is a complex feature that typically involves the

symptom of depression but also includes cognitive and vegetative features such as

pessimism, guilt, impaired concentration, lack of confidence, loss of interest or pleasure

and disturbance of sleep, appetite and energy level. Differences in the definition of

depression may account for some of the discrepancies in the reported occurrence rates

and treatment responses of depression in schizophrenia (Siris, 2000).

Depression in patients with schizophrenia has been shown to be associated with a

family history of depression, early parental loss, and higher doses of depot neuroleptics;

no significant gender difference has been found (Subotnik et al, 1997; Addington et al,

18
1996; King et al, 1995). The association of depressive symptoms with attentional

difficulties suggests frontal lobe dysfunction and volume changes in temporal lobes

(Kholer et al, 1988; Kholer et al, 1998) and some neurobiological similarities between

schizophrenia and depressive illness.

Vaillant (1964) reported that the presence of depression confers a favourable

prognosis in schizophrenia. However, other studies have suggested that depression is a

precursor of relapse (Herz and Melville, 1980; Becker 1988), may increase the risk for

rehospitalization (Herz and Melville, 1980) and is likely to be associated with

demoralization, hopelessness (Drake and Cotton, 1986) and impaired psychosocial skills

(Glazer et al, 1981). Most importantly, the presence of depression may put the patient

with schizophrenia at risk for suicidal thoughts and, ultimately, completion of a suicide

attempt (Addington and Addington, 1992).

Therefore, accurate identification of depression among patients with

schizophrenia is vital.

14.5 Differential Diagnosis of Depression in the Course of Schizophrenia

While considering the possibility of depression in schizophrenia, a number of

differentials have to be kept in mind. These include medical or organic causes, negative

symptoms of schizophrenia, neuroleptic induced negative symptoms and schizoaffective

disorder (Bartels and Drake, 1988; Kirkpatrick and Fischer, 2006). Depressive symptoms

may also be a psychological reaction to the illness or it might be one of the core features

of schizophrenia (Mulholland and Cooper, 2000).

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14.51 Medical or Organic Factors

A number of medical or organic factors can present as depression in patients with

schizophrenia (Bartels and Drake, 1988). These include cardiovascular disorders,

pulmonary infections, autoimmune diseases, anaemia, cancer, metabolic, neurological

and endocrine disorders.

Various pharmaceuticals used in medical treatment such as B – Blockers, other

antihypertensive agents, sedative hypnotics, antineoplastics and sulphonamides can cause

depression as a side effect. Depression can also accompany the discontinuation of other

prescribed drugs such as corticosteroids and psycho-stimulants. Used or abused

substances such as alcohol, cannabis, cocaine or narcotics can contribute to depression

either on the basis of acute use, chronic use or discontinuation. It is also important to note

that the discontinuation of nicotine and caffeine can lead to withdrawal states that

potentially mimic depression (Dalack et al, 1998; Griffitus and Mumford, 1995).

14.52 Negative Symptoms of Schizophrenia

The negative symptoms syndrome of schizophrenia overlaps with the syndrome

of depression in a number of important respects (Andreason and Olsen, 1982; Carpenter

et al, 1985; Siris et al, 1988; Bermanzohn and Siris, 1992). Diminished interest, pleasure,

energy, or motivation along with psychomotor retardation and impaired ability to

concentrate are relevant overlapping features. However, certain other symptoms may be

more distinguishing (Lindenmayer et al, 1991; Kuck et al, 1992; Kibel et al, 1993).

Blunted affect, for example, suggests negative symptoms whereas distinct blue mood or

cognitive features, such as guilt or suicidal thoughts suggest depression. However, these

20
two states can sometimes be difficult to differentiate if patients lack the interpersonal

communication skills to articulate their internal subjective states well.

14.53 Neuroleptic Induced Dysphoria

Dopamine synapses are involved in brain pathways mediating “reward” (Wise,

1982; Harrow et al, 1994). Therefore, dopamine blockade by a neuroleptic drug could

theoretically lead to anhedonia and perhaps, depression. The relationship between

neuroleptic use and depression remain controversial. A number of older anecdotal reports

have suggested a link between neuroleptic use and depression (De Alarcon and Carney,

1969; Floru et al, 1975; Johnson, 1981; Galdi, 1983) and one study found more

anhedonia and depression in maintenance phase schizophrenic patients who were taking

neuroleptics than in others who were not (Harrow et al, 1994). Another study found a

positive relationship between haloperidol plasma levels and depressive symptoms in the

context of a positive association between extra pyramidal symptoms and depressive

symptoms (Krakowsi et al, 1997). Also, impairments of quality of life related to

neuroleptic induced dysphoria have been reported. (Browne et al, 1998). Nevertheless,

the majority of controlled studies tend to refute the proposition that neuroleptic

medication is regularly responsible for the development of depressive state in

schizophrenia (Knights and Hirsch, 1981; Siris, 1991).

14.54 Neuroleptic Induced Akinesia

Akinesia is usually defined as “large muscle stiffness”. However Rifkin et al,

(1975; 1978) and Vanputten & May (1978) were able to describe a more subtle but

equally debilitating extrapyramidal side effect of neuroleptic treatment involving

impaired ability to initiate and sustain motor behaviour. Patients with this form of

21
akinesia may or may not have the classical parkinsonian features of decreased accessory

motor movements. Patients themselves may attribute this effect to “Laziness”,

experiencing guilt or shame. Blue mood can also accompany this condition, possibly as a

primary issue (Van Putten & May, 1978), making it virtually indistinguishable clinically

from depression.

14.55 Neuroleptic Induced Akathisia

Akathisia is another extrapyramidal side effect of neuroleptic treatment that, in

subtle presentation, can easily be confounded with depression (Van Putten, 1975).

Patients experience this state as substantially dysphoric (Van Putten, 1975; Halstead et al,

1994). Also akathisia has been associated with both suicidal ideation and suicidal

behaviour (Shear et al, 1983; Drake and Ehrlich, 1985).

14.56 Reactions to Disappointment or Stress

Reactions to disappointments, a sense of loss or powerlessness over psychotic

symptoms or psychological deficits can present as or follows closely after a stressful

event or exacerbation of schizophrenia (Birch wood et al, 1993; Liddle et al, 1993;

Lysaker et al, 1995)

14.57 Post Psychotic Depression

This term was earlier used to describe a dysphoric state that immediately followed

a psychotic episode (Mcglashan and Carpenter, 1976). DSM-IV now suggests that the

term “post psychotic depression” be used to describe depression that occurs at any time

after a psychotic episode in schizophrenia

22
14.58 Schizoaffective Depression

The term schizoaffective disorder was first used in the early 1930s to describe

patients showing an overlap of features of schizophrenia and affective illness (Kasanin,

1933). In DSM IV, schizoaffective disorder refers to patients in whom a full affective

syndrome coincides with the florid psychotic syndrome but who also have substantial

periods of psychosis in the absence of an affective syndrome. In ICD 10, schizoaffective

disorder refers to episodic disorder in which both affective and schizophrenic symptoms

are prominent within the same episode of illness.

14.6 Quality Of Life in Schizophrenia

The term quality of life was described by Katschnig (1997) as a “loosely related

body of work on psychological well-being, social and emotional functioning, health

status, functional performance, life satisfaction, social support, and standard of living,

whereby normative, objective and subjective indicators of physical, social and emotional

functioning are all used”

Schizophrenic patients, over the course of illness, experience increases in their

subjective dissatisfaction in the overall quality of life and general health domain, and the

psychological domain (Makanjuola et al, 2005). This is in keeping with the “mediational

role” hypothesis, which is a quality of life construct theory proposed by Zissi et al (1998).

It proposes that in severe mental illness, an appraisal process exists between a patient’s

external life condition and other subjective evaluation, and that in making the subjective

evaluation, the appraisal process is influenced by cognitive mechanisms such as

expectations, aspirations and comparison standards. Similar findings had been reported

by Ritsner et al (2000).They observed that respondents who experienced stress, feeling of

23
low esteem and self efficacy had worse subjective quality of life than other respondents

who had no similar feeling. Furthermore, a host of studies reported that schizophrenic

patients rate their quality of life lower in comparison with the general population (Bobes

and Gonzalez, 1997; Skantze et al, 1992)

In Nigeria, Gureje and Bamidele (1999) assessed the social, occupational and

residential outcomes of schizophrenic patients after thirteen years. A substantial

proportion of patients showed a moderate to severe degree of disability in the area of

occupation and social contact. Men were particularly disadvantaged in establishing a

marital relationship whereas women had a more impaired outcome in the domain of

frequency and quality of social contacts.

A majority of these patients came from the low social (and occupational) groups but still

manifested downward drift on the social ladder. The researchers concluded that the

medium to long term traditional family networks may be inadequate to prevent patients

with schizophrenia in developing societies from acquiring significant and multiple

disablements.

Sokoya (1999) assessed the quality of life (using the WHO QOL instruments) of

patients consecutively admitted to an in-patient psychiatric unit ward in South western

Nigeria. The result revealed that most patients were satisfied with their QOL and socio

demographic variables like age, occupational states were significantly associated with

QOL of the patients.

Adeponle (2003) studied the QOL of 135 patients (100 patients with

schizophrenia and 35 with affective disorders) and observed that persons with major

mental illness have a good objective QOL and good social outcome in all life areas

24
except for the social relationships domain (Marital status and occupational status). They

experienced increased subjective dissatisfaction on the entire QOL domains over the

course of the illness. Sex and occupational status were found to correlate with the

subjective QOL domain of physical health and psychological health respectively.

Olusina and Ohaeri (2003) examined the perceptions of recently recovered

psychiatric patients on their feelings of well being, their satisfaction with the domain of

living experience and the correlates of subjective quality of life. They found that items of

highest satisfaction included overall sense of well being and satisfaction with self.

Satisfaction with personal relationships and ability to work were moderate. There was

dissatisfaction with adequacy of money to meet needs, dependence on treatment and sex

life. At least two-thirds of the subjects were categorized as having average QOL in each

of the six domains of living experience. They observed no significant association between

psychiatric diagnoses, socio-demographic characteristics and QOL. The authors

concluded that the subjective QOL ratings, realistically reflect the strengths and

weaknesses of socio-cultural circumstances and patients perceived personal qualities

Makanjuola et al (2005) studied a hundred subjects with schizophrenia and found

that they had an appreciably good objective QOL and social outcome in all areas of life

except for the social relations domain. However, they had experienced increased

subjective dissatisfaction in all QOL domains over the course of their illness. A poor

correlation was found between respondents’ objective life circumstances and subjective

satisfaction. This study showed a significant association between the male gender and

performance on overall QOL and general health. Marital status was significantly

associated with performance on domain III (Level of independence) on one hand and also

25
between domain III and occupational status on the other hand. Married people and those

who were employed tended to have a better score. They implied that marriage and

employment are predictors of good QOL in the mentally ill.

Of recent, Adewuya (2007) studied 99 patients with Schizophrenia and concluded

that despite the problems encountered by the patients and other poor conditions of living,

their level of satisfaction with the items of subjective QOL was generally high with self,

overall QOL enjoyment, meaningfulness of life and overall health. The least satisfying

items were availability of money for everyday needs, sexual life, need for medical

treatment, transport and leisure facilities. There was a low to moderate correlation

between the patients reported living situations and their satisfaction with their life.

14.7 Factors Affecting Quality Of Life

The relationship between the quality of life of patients with schizophrenia and

clinical, socio-demographic, environmental and treatment factors have been explored in

many cross-sectional studies. Summary of these studies of general as well as clinical

populations have been published (Pinikahana et al, 2002; Sota & Heinrichs, 2004). The

relationship between subjective QOL and socio demographic and clinical factors remains

controversial.

Meltzer et al (1990) reported that negative symptoms may be more important than

positive symptoms in determining the quality of life of treatment resistant schizophrenic

patients. In addition, quality of life was found to be inversely related to the number of

previous hospitalizations, but unrelated to the patients’ age, age of onset of schizophrenia,

duration of illness or gender.

26
 In contrast, Shtasel et al (1992) found that female subjects had a better quality of

life than men. Furthermore, they reported that although female subjects did not differ

from males in terms of occupational functioning, they were less impaired with regard to

social role functioning and their sense of life involvement.

Skantze et al (1992) reported that quality of life was independent of gender,

marital status and standard of living but employed patients were found to have a better

quality of life. In Nigeria, while Sokoya (1999) and Adeponle (2003) found an

association between socio demographic variables and subjective QOL, Olusina and

Ohaeri (2003) found no significant association between subjective QOL and socio-

demographic variables. The adverse influences of extrapyramidal side-effects on

subjective QOL have been documented by several authors (Browne et al, 1996; Awad et

al, 2003; Risner et al, 2002). However, others did not find such an association (Gerlach

and Larsen, 1999; Reine et al, 2003).

Several authors have reported a negative correlation between depression and

subjective QOL (Reine et al, 2003; Gorna et al, 2007). Regarding the type of medication

used, some studies have suggested that patients on atypical antipsychotics have better

subjective QOL than those on conventional antipsychotics (Franz et al, 1997; Awad &

Voruganti, 1999; Voruganti et al, 2002; Cook et al, 2002). Some other studies found no

difference in the quality of life of patients on atypical antipsychotics compared with

patients on conventional antipsychotics (Awad et al, 1997; Hamilton et al, 1999; Stallard

& Joyce, 2001; Ritsner et al, 2000).

The role of insight in subjective QOL is controversial. While some studies have

noted a significant association between insight into illness and subjective QOL (Hofer et

27
al, 2004), others studies have found no association (Browne et al, 1998; Doyle et al,

1999; Holloway and Carson, 1999).

15. Relevance of the Proposed Project to the Practice of Psychiatry

Schizophrenia is a worldwide public health problem and a serious concern for

mental health professionals. A number of systematic studies of persons suffering from

schizophrenia have observed that there is often a significant co-occurrence of depression

in schizophrenia (Siris, 1995). The occurrence of depression in schizophrenia has often

been associated with worse outcome, impaired functioning, personal suffering, higher

rates of relapse or rehospitalization and even suicide – a tragic event that terminates the

lives of an estimated 10% of patients with schizophrenia (Caldwell and Gottesman, 1990;

Fenton et al, 1997).

The proposed research is relevant to the field of psychiatry in that the knowledge

derived from this study will help in defining the relationship between depression and

subjective quality of life among schizophrenic patients in our environment. This will

assist in the formulation of treatment plans that are aimed at minimising the impact of the

disorder and improving the clinical outcome.

28
16. APPLICATION SUPPORTED BY

(a) Head of Department: Name: ……………………………………………………

If a Fellow, year of fellowship: …………………………………………………

Signature and Date: ……………………………………………..

(b) Supervisor: Name: ……………………………………………………………

If a Fellow, year of fellowship: …………………………………………….

Signature and Date: ……………………………………………..

(c) Second Supervisor: Name: ……………………………………………………

If a Fellow, year of fellowship: …………………………………………….

Signature and Date: ……………………………………………..

29
17. FOR OFFICIAL USE ONLY

a) Date of Receipt of proposal ……………………………………

b) Date Forwarded to Chief Examiner or designated assessor ……………….

c) Date returned by Chief Examiner or designated assessor …………………..

d) Approved by Chief Examiner (Yes/ No) ………………

e) If not approved, objections must be communicated to the candidate.

Date approval/objections communicated. ……………………………………

30
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APPENDIX
THE RELATIONSHIP BETWEEN DEPRESSION AND SUBJECTIVE QUALITY OF LIFE IN
NIGERIAN OUTPATIENTS WITH SCHIZOPHRENIA QUESTIONNAIRE

SECTION A – SOCIODEMOGRAPHIC SECTION DATE: ___________

1. AGE: (in years) ____________________ HOSPITAL No: ______________________

41
2. SEX: Male ( ) Female ( )
3. MARITAL STATUS: Single ( ) Married ( ) Divorced ( ) Separated ( ) Widowed ( )
Others (specify) ______________________________
4. RELIGION: Christianity ( ) Islam ( ) Traditional religion ( ) Others (specify)
_____________
5. ETHNICITY: Yoruba ( ) Igbo ( ) Hausa ( ) Others ( please state) ___________________
6. OCCUPATION:
7. HIGHEST EDUCATIONAL LEVEL: None ( ) Primary ( ) Secondary ( ) Post Secondary
( not University) ( ) University ( )
8. EMPLOYMENT STATUS: Working full time ( ) Working part time ( ) Unemployed ( )
Retired ( ) In School ( ) Keeping house ( ) Others (specify) ______________________
9. INCOME/EARNING PER MONTH (in Naira) _______________________________
10. COST OF TREATMEANT PER MONTH: ( in Naira)
-DRUGS: _______________________________________
-TRANSPORTATION: ______________________________
-CONSULTATION: _______________________________________
11. DOMESTIC SITUATION OF PATIENT
a) Living in own flat/room
b) Living with relatives / friends
c) Living in hostel
d) Others (specify) ________________________
12. HOUSING CONDITION/ FACILITIES
a) Electricity: Present / Absent
b) Pipe borne water: Present / Absent
c) Toilet facilities: Present / Absent
d) Telephone: Present / Absent
13. MODE OF TRANSPORT TO HOSPITAL
a) Public transport b) Own a car c) Own a motorcycle d) Own a bicycle e) Walking
14. LEISURE ACTIVITY
(a) Radio/ Television (b) Indoor games (c) Outdoor games
15. RELATIONSHIP WITH SAME GENDER
(b) Easy (b) Difficult (c) None
16. RELATIONSHIP WITH OPPOSITE GENDER
(c) Easy (b) Difficult (c) None
17. WHAT LEVEL OF SOCIAL SUPPORT DO YOU GET FROM :
(a) Family members............ ( Good, Fair ,Poor , None )
(b) Friends.................... ( Good, Fair ,Poor , None )
(c) Government............................ ( Good, Fair ,Poor , None )
(d) Non-governmental organization ( Good, Fair ,Poor , None )
(e) Others (specify).......... ( Good, Fair ,Poor , None )

SECTION B – ILLNESS RELATED DETAILS

(1) Duration of illness (in years)___________________________
(2). Age at onset of illness (in years) ________________
(3). Number of episodes of illness ____________________
(4). Number of hospital admissions due to illness_______________________

42
(5) Is the patient currently mentally ill (symptomatic?)____Duration of symptoms
______________
(6). If presently mentally stable, when was the last episode of mental illness (in months) _____
(7). Concomitant medical/physical illness/problems___________________
(8) Global Assessment of Functioning (GAF SCORE) ____________________

SECTION C: MEDICATION RELATED DETAILS

Type and dose of antipsychotics (mg/day)

1.)
2.)
3.)
4.)
5.)
Other relevant drugs and doses (mg/day) (e.g. Anticholinergic, Antidepressant etc.)
1.)
2.)
3.)
4.)
5.)

SIDE EFFECT CHECKLIST – within the last 2 weeks

No Side effects Present Absent No Side effects present Absent

1 Akathisia 14 Dry mouth
2 Dystonia 15 Constipation
3 Parkinsonism 16 Urinary hesitancy
4 Tardive dyskinesia 17 Blurred vision
5 Menstrual 18 Photosensitivity
dysfunction
6 Sexual dysfunction 19 Weight gain
7 Dizziness 20 NMS
8 Postural hypotension 21 Skin discoloration
9 Reflex tachycardia 22 Galactorrhea
10 Sedation 23 Gynaecomastia
11. Seizures 24 Rashes
12 Excessive salivation 25 Fever
13 Blood dyscrasia
NMS = Neuroleptic malignant syndrome

SECTION D: INSIGHT INTO ILLNESS. (PSE – SECTION 17. BOX 104)

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.

43
 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.)
3 = Denies nervous condition entirely.

Rating : (0- full insight, 1&2= partial insight, 3=Nil insight)

SECTION E: MINI

SECTION F:
1) PANSS
2) ZUNGS’ SELF RATING DEPRESSION SCALE

SECTION G: WHOQOL

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