PRINCIPAL INVESTIGATOR:
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
by Dr. Adesanmi Akinsulore as a requirement for his part II West African College of
Head of Department
2
TABLE OF CONTENT
1. NAME OF CANDIDATE 6
2. FACULTY OF CANDIDATE 6
3. TRAINING INSTITUTION 6
5. NAME OF SUPERVISOR 6
6. ADDRESS OF SUPERVISOR 6
13.1 SUBJECTS 9
13.4 PROCEDURE 10
13.5 MEASURES 10
14 LITERATURE REVIEW 15
14.1 PREAMBLE 15
14.2 DEFINITION 16
3
14.3 METHODOLOGICAL ISSUES 16
COURSE OF SCHIZOPHRENIA 19
18. REFERENCES 31
19. APPENDIX 43
4
19.31 SIDE EFFECT CHECKLIST 44
INTERVIEW (MINI) 45
SCALE (PANSS) 48
5
WEST AFRICAN COLLEGE OF PHYSICIANS
OF PART II CANDIDATES
Schizophrenia.
6
12. AIMS AND OBJECTIVES OF THE STUDY:
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
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
symptoms from deficit states (Negative Symptoms) and manage them appropriately in
The overall aim of this study is to assess the relationship between depression and
7
The specific objectives of this study are as follows:
experience.
psychopathological symptoms.
schizophrenia.
Hypothesis
schizophrenia
8
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:
diagnosis plan sheet available for research purposes and also submitted for
(Sheehan et al 1998).
3. The patients should have been diagnosed and receiving treatment for at
4. The last hospital admission must be at least 6 months or more before the
9
5. There must be no evidence of organic disease or mental retardation and
13.3 SAMPLE SIZE: The required sample size for the study group will be calculated
[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
Qc = 1 - Pc
N = 69.06
A sample size of 100 will be chosen in order to increase the statistical power.
13.4 PROCEDURE
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
10
1. The Clinical Interview: The diagnosis of schizophrenia will be ascertained with
(Sheehan et al 1998). The MINI was designed as a brief structured interview for
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)
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
2.1 Age, sex, marital status, religion, ethnicity, highest level of formal education,
2.2 Earnings/income per month, amount spent on treatment per month, residential
relationship with same and opposite gender and level of social support from
11
2.3 Duration of the illness, age of onset of active symptoms of schizophrenia, past
2.4 Psychopathological symptoms: These will be assessed with the Positive and
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).
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
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
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,
2.6 Level of Functioning: This will be assessed with the Global Assessment of
100 point scale, where 100 indicates not only the absence of pathology but also
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
12
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:
These will be assessed with the aid of a clinician-rated structured check list
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
WHO QOL – 100 scale (the WHO QOL Group, 1998). The WHO QOL – BREF
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.
Either the English version or the back-translated Yoruba version of the instrument
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.
13
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
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
14
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,
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
15
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,
mental and social well being and not merely the absence of disease or infirmity”.
warranted.
In accordance with the definition of health by the WHO, SQOL covers physical,
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
(Atkinson et al, 1996; Yamauchi et al, 2008) and objective QOL has been
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.
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
syndrome of depression (Siris, 2000). This has been a source of confusion and has
subjective experience spectrum from happiness to sadness as he or she interacts with his
symptom of depression but also includes cognitive and vegetative features such as
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
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
precursor of relapse (Herz and Melville, 1980; Becker 1988), may increase the risk for
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
schizophrenia is vital.
differentials have to be kept in mind. These include medical or organic causes, negative
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
19
14.51 Medical or Organic Factors
depression as a side effect. Depression can also accompany the discontinuation of other
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).
et al, 1985; Siris et al, 1988; Bermanzohn and Siris, 1992). Diminished interest, pleasure,
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
1982; Harrow et al, 1994). Therefore, dopamine blockade by a neuroleptic drug could
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
neuroleptic induced dysphoria have been reported. (Browne et al, 1998). Nevertheless,
the majority of controlled studies tend to refute the proposition that neuroleptic
(1975; 1978) and Vanputten & May (1978) were able to describe a more subtle but
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
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.
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
event or exacerbation of schizophrenia (Birch wood et al, 1993; Liddle et al, 1993;
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
22
14.58 Schizoaffective Depression
The term schizoaffective disorder was first used in the early 1930s to describe
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
disorder refers to episodic disorder in which both affective and schizophrenic symptoms
The term quality of life was described by Katschnig (1997) as a “loosely related
status, functional performance, life satisfaction, social support, and standard of living,
whereby normative, objective and subjective indicators of physical, social and emotional
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
expectations, aspirations and comparison standards. Similar findings had been reported
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
In Nigeria, Gureje and Bamidele (1999) assessed the social, occupational and
marital relationship whereas women had a more impaired outcome in the domain of
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
disablements.
Sokoya (1999) assessed the quality of life (using the WHO QOL instruments) of
Nigeria. The result revealed that most patients were satisfied with their QOL and socio
demographic variables like age, occupational states were significantly associated with
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
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
concluded that the subjective QOL ratings, realistically reflect the strengths and
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
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.
The relationship between the quality of life of patients with schizophrenia and
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
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,
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
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-
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
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
patients on conventional antipsychotics (Awad et al, 1997; Hamilton et al, 1999; Stallard
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,
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;
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
28
16. APPLICATION SUPPORTED BY
29
17. FOR OFFICIAL USE ONLY
30
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APPENDIX
THE RELATIONSHIP BETWEEN DEPRESSION AND SUBJECTIVE QUALITY OF LIFE IN
NIGERIAN OUTPATIENTS WITH SCHIZOPHRENIA QUESTIONNAIRE
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 )
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(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) ____________________
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.
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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.
SECTION E: MINI
SECTION F:
1) PANSS
2) ZUNGS’ SELF RATING DEPRESSION SCALE
SECTION G: WHOQOL
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