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European Psychiatry xx (2006) 1e7
4 http://france.elsevier.com/direct/EURPSY/
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6 Original article 63
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8 Social disability in different mental disorders 65
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J. Rymaszewska a,*, J. Jarosz-Nowak b, A. Kiejna a, T. Kallert c, M. Schützwohl c,
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S. Priebe d, D. Wright d, P. Nawka e, J. Raboch f

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13 a
Department of Psychiatry, Wroclaw Medical University, Wyb. L. Pasteura 10, 50-367 Wroclaw, Poland 70

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14 b
Institute of Mathematics and Information Technology, Wroclaw University of Technology, Wroclaw, Poland 71
c
15 Department of Psychiatry and Psychotherapy, Dresden University of Technology, Dresden, Germany 72
d
16 Unit for Social and Community Psychiatry, Newham Centre for Mental Health, London, UK 73
e
Michalovce Psychiatric Hospital, Michalovce, Slovakia
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Charles University of Prague, First Medical Faculty, Department of Psychiatry, Prague, Czech Republic
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19 Received 16 June 2006; received in revised form 21 November 2006; accepted 24 November 2006 76
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23 Abstract 80
24 81
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25 Objective. e To assess the social disability of people with different psychiatric disorders. 82
26 Methods. e Cross-site survey in five psychiatric hospitals (Dresden, Wroc1aw, London, Micha1owce and Prague). Working-aged patients 83
27 diagnosed (ICD-10) with schizophrenia and related disorders (F2), affective disorders (F3), anxiety disorders (F4), eating disorders (F5) and 84
28 personality disorders (F6), were assessed at admission (n ¼ 969) and 3 months after discharge (n ¼ 753) using the Brief Psychiatric Rating Scale 85
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and the Groningen Social Disability Schedule. The main outcome measure was Interviewer-rated social disability.
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Results. e During acute episodes patients with personality, eating and schizophrenic disorders functioned less effectively than those with
30 affective or anxiety disorders. After controlling for age and severity of psychopathology, there was no significant effect of the diagnosis (during
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31 remission), sex, education and history of disorder on disability. Site, employment and partnership were significant factors for the level of social 88
32 disability in both measure points. 89
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33 Conclusion. e Severity of psychopathological symptoms, not the diagnosis of a mental disorder, was the most significant factor in deter- 90
34 mining the level of social functioning, particularly during the remission period. Site, employment and partnership appeared as significant factors 91
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35 influencing the level of social disability. 92


36 Ó 2006 Published by Elsevier Masson SAS. 93
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Keywords: Functioning; Social disability; Mental disorders
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42 1. Introduction carried out amongst various groups: patients of general hospi- 99
43 tals with depressive disorders [1] and patients of health care 100
44 Interest in problems related to the social disability of peo- services [11], as well as the general population of a country 101
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45 ple with mental disorders is increasing. Such problems have [9,14]. The World Health Organization (WHO) has carried 102
46 often been considered in the literature: related to the disability out studies on the most commonly occurring psychiatric disor- 103
47 of people with schizophrenia [3], depressive disorders [5], ders in patients of health care services [12]. The large scale In- 104
48 anxiety and depressive disorders [12]. However, the issue ternational Study of Schizophrenia (ISoS) was carried out in 105
49 has rarely been studied in the case of persons with eating dis- 18 centers in 14 countries [22]. Cultural differences in the fre- 106
50 orders [2] and personality disorders [14]. Studies have been quency of disorders and their course were assessed. However, 107
51 no study has yet focused on an international comparison of the 108
52 social disability of persons with psychiatric disorders, or 109
53 aimed at comparing types of disorders at different stages of se- 110
* Corresponding author. Tel.: þ48(0)71 784 1600; fax: þ48(0)71 784 1602.
54 E-mail address: ankarym@psych.am.wroc.pl (J. Rymaszewska). verity. The aim of this study was to assess the social disability 111
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56 0924-9338/$ - see front matter Ó 2006 Published by Elsevier Masson SAS. 113
57 doi:10.1016/j.eurpsy.2006.11.006 114
Please cite this article in press as: Rymaszewska J et al., Social disability in different mental disorders, European Psychiatry (2006), doi:10.1016/
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115 of people with different, serious psychiatric disorders and to In the F2 diagnostic group a clear majority of patients had 172
116 evaluate the effect of sociodemographic and clinical variables schizophrenia or schizoaffective disorders (56.6% and 26.7%, 173
117 on the level of disability at two different time points. respectively). Among those with affective disorders (group 174
118 F3), the most common diagnoses were depressive episodes 175
119 2. Subjects and methods (42.6%), recurrent depressive disorders (35.7%) and bipolar 176
120 affective disorders (16%). In the group of patients with neu- 177
121 The study was based on data from the European Day Hos- rotic, stress-related and somatoform disorders (group F4), 178
122 pital Evaluation (EDEN) study [6,7], which was carried out in the most common diagnoses were anxiety disorders (30.1%), 179
123 five European centers: the Department of Psychiatry and Psy- acute stress reaction and adjustment disorders (29.6%), pho- 180
124 chotherapy of Dresden University of Technology, the Depart- bias (12.1%) and obsessive-compulsive disorders (10.7%). 181
125 ment of Psychiatry at Wroc1aw Medical University, the Unit The final group, which was inhomogeneous with respect to di- 182

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126 for Social and Community Psychiatry, Newham Centre for agnostic group (F5 þ F6, n ¼ 118), consisted of patients with 183
127 Mental Health, London, the psychiatric hospital in Micha1ovce personality disordersdF6 (75.4%, of these 86.5% were emo- 184

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128 and the Psychiatry Department at Charles University, Prague. tionally unstable; the rest had mixed personality disorders) or 185
129 Objectives and methods of the EDEN study were presented eating disordersdF5 (24.6%). 186
130 elsewhere [6,7]. 187
131 Working-aged (18e65 years) persons admitted voluntarily 2.1. Instruments 188
132 to psychiatric hospitals, who agreed to take part and were 189

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133 not excluded due to addictions, serious somatic diseases, de- The Client Sociodemographic and Clinical History Inven- 190
134 mentia were assessed in accordance with the EDEN protocol tory (CSCHI) [6], the expanded version 4.0 of the Brief Psy- 191
135 [6]. Participants with a psychiatric disorder of diagnostic class chiatric Rating Scale, (BPRS) [20] and the Groningen Social 192
136 F2, F3, F4, F5 and F6 (according to the ICD-10) were assessed Disability Schedule (GSDS-II) [21] were used. 193
137 just after the admission into hospital (time 1, n ¼ 969) and The 24-item Brief Psychiatric Rating Scale allows for the eval- 194
138 3 months after discharge (time 2, n ¼ 753). The mean age of 195
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uation of the severity of psychopathological symptoms ranged
139 the whole sample was 38.9 (SD ¼ 12.0). The majority of par- from ‘1’ (‘‘not present’’) to ‘7’ (‘‘extremely severe’’). The 196
140 ticipants were female (60.9%). The patients had on average intra-class correlation coefficient was good (ICC ¼ 0.78) [16]. 197
141 12.3 years of education (SD ¼ 2.8). 35.7% of the study group GSDS-II is a semi-structured interview for assessing the 198
142 lived in a permanent relationship. Less than a third (31.3%) functioning of a person in eight social roles over the previous 199
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143 were professionally active. After 3 months the mean age of month (in this study evaluating a month before hospitalization 200
144 the sample was 39.5 years (SD ¼ 12.1) with the majority and the third month after discharge). Within the GSDS-II, a so- 201
145 being women (63.1%) (see Table 1). cial role is defined as a complex of norms and expectations 202
146 203
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147 Table 1 204


148 Characteristics of the sample within diagnostic groups 205
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149 F2 F3 F4 F5 þ F6 206
150 n ¼ 258 n ¼ 387 n ¼ 206 n ¼ 118 207
151 208
Age (years, SD) 36.7 (11.3) 42.2 (11.4) 39.9 (11.8) 31.2 (11.1)
152 Gender (% females) 49.6 65.9 66.5 59.3 209
153 Education (years, SD) 12.38 (2.7) 12.44 (3.0) 11.75 (2.5) 12.26 (2.7) 210
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154 Family status (%) 211


155 Married 24.4 46.1 41 18.1 212
Single 21.7 18.9 15.6 19
156 213
Lived with family 53.9 35 43.4 62.9
157 Professional status (%) 214
158 Working 16 33.4 41.5 40.2 215
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159 Other activity (e.g. students) 10.5 15.9 13.7 20.5 216
160 Unemployed 25 29.5 30.7 31.6 217
Disability pensioned 48.4 21.1 14.1 7.7
161 218
Center (%)
162 Wroc1aw 36.8 23.8 16.5 5.1 219
163 Dresden 10.9 24.0 18.0 25.4 220
164 London 19.8 22.0 11.2 18.6 221
165 Micha1ovce 22.9 11.1 28.6 19.5 222
Prague 9.7 19.1 25.7 31.4
166 223
BPRS scores
167 Before hospitalization, Mean (SD) 2.12 (0.49) 1.99 (0.39) 1.82 (0.36) 1.95 (0.41) 224
168 3rd month after hospitalization, Mean (SD) 1.68 (0.5) 1.51 (0.39) 1.56 (0.39) 1.67 (0.45) 225
169 GSDS scores 226
170 Before hospitalization, Mean (SD) 1.37 (0.58) 1.20 (0.49) 1.09 (0.55) 1.35 (0.60) 227
3rd month after hospitalization, Mean (SD) 0.95 (0.57) 0.79 (0.59) 0.75 (0.54) 1.02 (0.61)
171 228
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229 prevailing within the so-called relevant reference group which (Rho ¼ 0.078; P ¼ 0.021). However, there was no such correla- 286
230 comprises people who in social or other respect are of great tion in the subsample of patients who had been previously 287
231 importance to the individual. The assessment is carried out treated (Rho ¼ 0.063; P ¼ 0.114). The duration of a disorder 288
232 by giving ratings for each of the eight roles (the Overall was not correlated with the overall GSDS score for the subsam- 289
233 Role Ratings), and for each of the dimensions of the role ple of patients who had previously been treated (Rho ¼ 0.061; 290
234 (the Dimensional Ratings). The rating scale self ranges from P ¼ 0.135). The overall BPRS score was correlated with the 291
235 ‘0’ (‘‘no disability’’) to ‘3’ (‘‘severe disability’’). Further overall GSDS score, both for the sample as a whole 292
236 guidelines for making ratings for each role are given in detail (Rho ¼ 0.443; P < 0.001) and those who had been previously 293
237 in the manual of the GSDS-II. A mean score based on all eight treated in a psychiatric unit (Rho ¼ 0.453; P < 0.001). 294
238 Overall Role Ratings were analyzed. Inter-rater reliability for Analysis of the data collected 3 months after discharge 295
239 the GSDS-II sum score of all overall role ratings was good from hospital indicated a significant association between the 296

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240 (ICC ¼ 0.77) [16]. overall GSDS score and both the overall BPRS score 297
241 (Rho ¼ 0.654; P ¼ 0.000) and the duration of the disorder 298

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242 2.2. Statistical analyses (Rho ¼ 0.154; P < 0.001). Age and education were not asso- 299
243 ciated with GSDS (Rho ¼ 0.009; P ¼ 0.822 and 300
244 The data collected were analyzed using version 10.3.1 of Rho ¼ 0.065; P ¼ 0.091, respectively). 301
245 Statistical Packages for the Social Sciences (SPSS). The Within one-way analysis of variance, it was found that 302
246 mean GSDS scores was taken to be the dependent variable. there was no significant association between the mean GSDS 303

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247 Socio-demographic features (age, sex, education, family scores and sex (F ¼ 3.2; df ¼ 1; P ¼ 0.073 before admission 304
248 status, professional status, center) and clinical features (diag- to hospital and F ¼ 2.0; df ¼ 1; P ¼ 0.161 3 months after dis- 305
249 nostic group, the overall BPRS score, history of disorder- charge). The other categoric variables analyzed were strongly 306
250 dpreviously treated or not, duration of the disorder, number associated with the overall GSDS score both on admssion to 307
251 of previous episodes and psychiatric hospitalizations) were and 3 months after discharge from hospital (see Table 2). 308
252 309
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taken to be the explanatory variables. The Spearman rank cor-
253 relation coefficient was used to assess the strength of associa- 310
254 tion between GSDS scores and quantitative variables, such as 3.1.1. Diagnostic group 311
255 age, years of education, duration of disorder. One-way analy- Significant differences in the overall GSDS score before 312
256 sis of variance was used to analyze the association between admission were found between diagnostic groups F2 and F3 313
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257 a quantitative variable and the overall result of GSDS. Models (P ¼ 0.006), F2 and F4 (P < 0.001), as well as F4 and 314
258 with interactions were not constructed due to small number of F5 þ F6 (P ¼ 0.002). Scheffe’s test determined classes which 315
259 observation for some cells. In order to distinguish diagnostic displayed similar mean GSDS scores (the lowest scores were 316
260 groups which are uniformly affected by a given independent in groups F4 and F3, there was no significant difference be- 317
tween F3 and F5 þ F6, F5 þ F6 together with F2 had the larg-
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261 variable, the Scheffe test was used, together with Dunnett’s 318
262 test when variance depended on diagnostic group. These re- est scores). Three months after discharge there were significant 319
differences between diagnostic groups F2 and F3 (P ¼ 0.045),
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263 sults were verified using the appropriate non-parametric test 320
264 (the KruskalleWallis test). One-way and multivariate analysis F2 and F4 (P ¼ 0.028), F3 and F5 þ F6 (P ¼ 0.022), as well 321
265 of covariance was used to analyze the influence of the inde- as F4 and F5 þ F6 (P ¼ 0.013). Again F4, F3 had the lowest 322
266 pendent variables on the overall level of social disability tak- GSDS scores and F2 and F5 þ F6 had the highest GSDS 323
267 ing into account the effect of two variables: the patients’ age scores Table 3. 324
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268 and the overall BPRS score. The choice of these two variables 325
269 is justified by the significant association of the mean age and 3.1.2. Center 326
270 mean BPRS score with the social functioning of a patient. The There were significant differences between the mean over- 327
271 post hoc multiple comparison procedure was used to verify the all GSDS scores on admission in Wroc1aw and both 328
272 classification of diagnostic groups made with respect to a given 329
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273 variable. All statistical tests were two-tailed and used a signif- Table 2 330
The association between the overall GSDS score and categorical variables
274 icance level of 5%. 331
275 Factor At admission 3 months after discharge 332
276 3. Results F df P F df P 333
277 Diagnosis 11.0 3 0.000 6.3 4 0.000 334
278 3.1. Associations between the parameters analyzed Center 6.7 4 0.000 3.6 4 0.007 335
279 Sex 3.2 1 0.073 2.0 1 0.161 336
Family status 10.3 2 0.000 4.3 2 0.013
280 On admission to hospital no significant association between 337
Professional status 10.9 3 0.000 14.1 3 0.000
281 the education of a patient and the overall GSDS score was found History of the disorder 11.2 2 0.000 7.4 2 0.001 338
282 (Rho ¼ 0.033, P ¼ 0.331 and Rho ¼ 0.073, P ¼ 0.066 for the No. of episodesa 2.1 2 0.118 7.2 3 0.000 339
283 subsample of patients who had previously been treated in a psy- No. of hospitalizationsa 4.2 3 0.006 6.2 3 0.000 340
284 chiatric unit). There was a significant correlation between the a
In the case of measurements made on admission only for the subsample of 341
285 overall GSDS score and age for the sample as a whole patients previously treated. 342
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343 Table 3 400


344 The association between the overall GSDS score and categorical variables adjusted by psychopathology and age in both time points with adjusted means of overall 401
GSDS scores (95% confidence interval)
345 402
346 Factor At admission 3 months after discharge 403
347 Diagnosis F ¼ 3.333; df ¼ 3; P ¼ 0.019 F ¼ 2.303; df ¼ 3; P ¼ 0.076 404
348 F2 1.286 (1.221e1.351) Not available 405
F3 1.212 (1.158e1.265) Not available
349 F4 1.181 (1.111e1.252) Not available
406
350 F5 þ F6 1.346 (1.251e1.441) Not available 407
351 Center F ¼ 6.950; df ¼ 4; P < 0.001 F ¼ 7.215; df ¼ 4; P < 0.001 408
352 Wroc1aw 1.333 (1.268e1.398) 0.851 (0.783e0.918) 409
353 Dresden 1.221 (1.150e1.292) 0.795 (0.724e0.867) 410

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London 1.088 (0.986e1.189) 0.835 (0.740e0.931)
354 Micha1ovce 1.150 (1.080e1.221) 0.733 (0.660e0.805)
411
355 Prague 1.315 (1.244e1.386) 0.994 (0.924e1.063) 412

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356 Sex F ¼ 2.168; df ¼ 1; P ¼ 0.141 F ¼ 0.089; df ¼ 1; P ¼ 0.766 413
357 Education F ¼ 0.307; df ¼ 2; P ¼ 0.736 F ¼ 2.246; df ¼ 2; P ¼ 0.107 414
358 Professional status F ¼ 6.168; df ¼ 3; P < 0.001 F ¼ 4.105; df ¼ 3; P ¼ 0.007 415
Professionally active 1.148 (1.090e1.205) 0.791 (0.733e0.849)
359 Otherwise active 1.213 (1.127e1.299) 0.761 (0.675e0.848)
416
360 Unemployed 1.278 (1.211e1.345) 0.891 (0.822e0.959) 417

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361 Pensioned 1.330 (1.266e1.394) 0.916 (0.850e0.981) 418
362 Family status F ¼ 6.114; df ¼ 2; P ¼ 0.002 F ¼ 3.613; df ¼ 2; P ¼ 0.027 419
363 Living with family 1.292 (1.240e1.344) 0.879 (0.825e0.933) 420
Living alone 1.281 (1.200e1.363) 0.894 (0.814e0.975)
364 Married 1.157 (1.100e1.214) 0.782 (0.723e0.840)
421
365 History of the disorder F ¼ 6.855; df ¼ 2; P ¼ 0.001 Not available 422
366 423
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Previously treated 1.279 (1.241e1.317) Not available
367 Previously not treated 1.139 (1.060e1.218) Not available 424
368 Lack of information 1.139 (1.032e1.246) Not available 425
No. of episodesa F ¼ 1.179; df ¼ 2; P ¼ 0.308 F ¼ 1.864; df ¼ 3; P ¼ 0.134
369 No. of hospitalizationsa F ¼ 3.223; df ¼ 3; P ¼ 0.022 F ¼ 1.719; df ¼ 3; P ¼ 0.162
426
370 0 1.318 (1.237e1.399) Not available 427
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371 1e3 1.297 (1.239e1.356) Not available 428


372 4þ 1.358 (1.274e1.442) Not available 429
373 Lack of information 1.163 (1.066e1.259) Not available 430
a
374 In the case of measurements made on admission only for the subsample of patients previously treated. 431
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375 432
376 Micha1owce (P < 0.001) and Prague (P ¼ 0.021), and mean GSDS score than those unemployed, receiving disability 433
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377 3 months after discharge in Wroc1aw and Micha1owce benefits or retired. 434
378 (P ¼ 0.017). 435
379 436
380 3.1.5. History of disorder 437
381 3.1.3. Family situation 438
Significant differences in the mean overall GSDS score
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382 Significant differences in the mean overall GSDS score on 439


were found between those who had not been previously treated
383 admission were found between married people and both peo- 440
in a psychiatric unit and those who had been treated earlier (a
384 ple living with their family (P ¼ 0.004) and people living on 441
higher mean score) both before admission and 3 months after
385 their own (P ¼ 0.013). Patients living on their own and living 442
discharge (P ¼ 0.001 and P ¼ 0.007, respectively).
386 with their families had similar mean overall GSDS scores, 443
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387 which were higher than the mean score of married people. 444
388 Three months after admission married people and people liv- 3.1.6. Number of episodes 445
389 ing on their own had similar mean overall GSDS scores, which In the subsample of patients who had been previously 446
390 were lower than the mean overall score of those living with treated in a psychiatric unit, there was no association between 447
391 their families, although there were no significant differences. the number of episodes and social functioning before admis- 448
392 sion. However, 3 months after discharge there was a significant 449
393 3.1.4. Professional status difference between the social functioning of patients who had 450
394 On admission professionally active patients had a signifi- one previous episode and both of patients who had previously 451
395 cantly lower mean overall GSDS score in comparison to had at least five previous episodes (P ¼ 0.001) and of patients 452
396 both those registered as unemployed (P < 0.001) and those re- for whom the number of previous episodes was not given 453
397 ceiving disability benefits or retired (P < 0.001). The results (P ¼ 0.001). Patients who had previously had at least five ep- 454
398 for the overall GSDS scores 3 months after discharge were isodes or for whom the number of episodes was not given, had 455
399 similar. Those professionally or otherwise active had a lower similar higher mean GSDS scores. 456
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457 3.1.7. Number of hospitalizations 514


458 In the subsample of patients who had previously been 515
459 treated in psychiatric units, the mean GSDS scores on admis- 516
460 sion of those patients who had been hospitalized at least four 517
461 times significantly differed from the mean GSDS scores of 518
462 those, for whom the number of hospitalizations was unknown 519
463 (P ¼ 0.007). Thus, no conclusion can be made from these re- 520
464 sults. Three months after discharge there were significant dif- 521
465 ferences in the mean GSDS scores of those who had been in 522
466 hospital just once and both those who had been hospitalized 523
467 between two and four times (P ¼ 0.001) and those who had 524

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468 been hospitalized at least five times (P ¼ 0.006). Patients 525
469 who had been hospitalized more than once had higher mean 526

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470 GSDS scores. Fig. 2. Mean overall GSDS scores on admission and 3 months after discharge 527
471 in the study centers (95% confidence interval). 528
472 529
473 3.2. Disability adjusted by psychopathology and age was associated with the overall GSDS score. However, the 530
474 only significant difference was found between the group of pa- 531

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475 3.2.1. At admission tients who had previously been hospitalized at least four times 532
476 The analysis taking into account the effect of age and the and the group of patients for whom the number of previous 533
477 overall BPRS score indicated a significant association between hospitalizations was unknown (P ¼ 0.018), which prevents 534
478 the GSDS score and diagnostic group, center, family status, any conclusions being drawn. 535
479 professional status, history of disorder and number of previous Regarding sex and education, no significant association was 536
480 hospitalizations. 537
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found between sex and social functioning before admission to
481 There was a significant difference between the mean GSDS hospital. Similarly, the level of a patient’s education did not 538
482 score in diagnostic group F4 and F5 hþ hF6 (P ¼ 0.04) have any effect on the overall GSDS score. Also, the number 539
483 (Fig. 1). Differences were also found between the social func- of previous episodes was not significantly associated with the 540
484 tioning of patients from Wroc1aw and London (P ¼ 0.001), overall GSDS score measured on admission. 541
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485 Wroc1aw and Micha1owce (P ¼ 0.002), as well as between 542


486 London and Prague (P ¼ 0.004) and London and Micha1owce 543
487 (P ¼ 0.012). (Fig. 2). Married patients had a significantly 3.2.2. Three months after discharge 544
488 lower mean GSDS score compared to those living with their Three months after discharge from hospital, adjusted by age 545
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489 family (P ¼ 0.004) and those living alone (P ¼ 0.038). Profes- and the overall BPRS score, a significant association between 546
490 sionally active patients had a significantly lower mean GSDS the overall GSDS score and three factors were observed: study 547
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491 score compared to those unemployed (P ¼ 0.025) and to those center, family status and professional status. The remaining in- 548
492 on disability allowance (P < 0.001). dependent variables (sex, education, diagnostic group (Fig. 1), 549
493 There was a significant difference between the mean GSDS number of previous episodes and psychiatric hospitalizations) 550
494 scores of those who had and had not previously been treated did not have any significant effect on GSDS score. 551
495 (P ¼ 0.005). Similarly, there was a significant difference be- There were significant differences between Prague and 552
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496 tween the mean GSDS scores of those who had previously Wroc1aw (P ¼ 0.045), Micha1owce (P < 0.001) and Dresden 553
497 been treated and of those for whom this information was not (P ¼ 0.001) (Fig. 2). The mean GSDS score among profes- 554
498 available (P ¼ 0.047). Number of previous hospitalizations sionally and otherwise active patients significantly differed 555
499 from the mean score of those receiving disability benefit 556
500 (P ¼ 0.036; P ¼ 0.039, respectively). A significant association 557
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501 was found between family status and the overall GSDS score. 558
502 However, pairwise comparison of the groups did not indicate 559
503 any significant differences between any two categories. 560
504 561
505 562
506 4. Discussion 563
507 564
508 Many studies have highlighted the significance of the pres- 565
509 ence and severity of psychopathological symptoms in relation 566
510 to social functioning [1,5,10e12]. Wohlfarth et al. [23] found 567
511 a moderate association between the severity of a psychopathol- 568
512 Fig. 1. Mean overall GSDS scores on admission and 3 months after discharge ogy and social functioning, such that level of disability was 569
513 in the diagnostic group (95% confidence interval). high in the case of acute disorders and depression. 570
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571 In the second stage of the analysis the effect of age and se- but the level of social disability varied from center to center. 628
572 verity of symptoms was taken into account when analyzing the Sanderson and Andrews [14] also carried out a multi-center 629
573 association between the social disability and the other factors study on the social functioning of patients. Based on a large 630
574 analyzed. The differences between the diagnostic groups was sample of psychiatric patients (n ¼ 1439) chosen from an orig- 631
575 less apparent and referred to patients with anxiety disorders, inal sample taken from the Australian population, he found 632
576 whose level of social functioning before admission was the that the place of residence (urban or rural) played a significant 633
577 best, and patients having personality and eating disorders, role, as well as migration (native English speakers compared 634
578 whose level of social functioning was the worst. Three months to immigrants from non-English speaking countries), in the 635
579 after discharge, controlling for age and the severity of a disor- level of social functioning. It appears that there are other sig- 636
580 der, there was no significant association between diagnosis nificant factors apart from those that have been considered in 637
581 group and social functioning. In their study carried out in Aus- multi-center studies on social functioning. 638

F
582 tralia (n ¼ 980) to assess the risk of psychosocial disability Controlling for age and severity of psychopathological 639
583 Gureje et al. [4] stated that this risk was comparable for pa- symptoms, there is no significant association of both sex and 640

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584 tients with affective disorders and for those with schizophre- education with social functioning either before admission or 641
585 nia. Diagnostic categories were not significantly associated after discharge. In their comprehensive study of the Australian 642
586 with the risk of social disability. This conclusion is not unan- population Sanderson and Andrews [14] also found that that 643
587 imously supported [1,14]. They both quote the results of the was no association between education and social functioning. 644
588 Dutch NEMESIS study, as well as the Australian National Many authors have found that male psychiatric patients show 645

PR
589 Survey of Mental Health and Wellbeing, carried out on the a higher level of social disability than female patients 646
590 general population. The severity of a disorder was assessed [13,14,17], which is not confirmed by this study. On the basis 647
591 according to CIDI (mild, moderate, severe). However, of studies carried out in Europe and North America it was es- 648
592 a more accurate scale was not used. In the studies of Bijl timated that 40% of males suffering from schizophrenia show 649
593 and Ravelli the level of social functioning varied according moderate or acute social disability compared with just 25% of 650
594 651
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to the psychiatric diagnosisdemotional disorders were associ- females [17]. The proportion of schizophrenic patients show-
595 ated with the lowest level of social functioning [1]. Sanderson ing social disability was lower in South America, India and 652
596 and Andrews [14] stated that the level of functioning varied Africa [8]. Salokangas et al. found that females suffering 653
597 according to diagnostic group, but in a different way to the from schizophrenia function better than males both socially 654
598 findings of Bijl and Ravelli [1]. The highest rate of social and professionally [13]. 655
CT

599 disability was associated with affective disorders (94%) and Moreover, it was found that the number of previous episodes 656
600 anxiety disorders (80%) in comparison to 70% of psychosis and hospitalizations did not have a significant effect on the so- 657
601 patients and 68% of personality disorders. It should be stressed cial functioning of patients. This seems to indicate that the sever- 658
602 that the Australian project was the only one in which patients ity of psychopathological symptoms is a more significant factor 659
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603 with personality disorders took part. in determining the level of social functioning of a patient than 660
604 It was also found that during acute episode patients from the history of a disorder or the type of disorder. 661
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605 Wroc1aw functioned at the lowest level and 3 months after Professional employment or other such activities (studying, 662
606 hospitalization patients from Prague functioned at the lowest running a household, voluntary work, working in sheltered 663
607 level. Patients from London functioned most effectively both employment) was associated with better social functioning, 664
608 prior to and after hospitalization. as did having a partner. Patients with a permanent partner 665
609 The WHO Collaborative Study on Psychological Problems showed a significantly higher level of social functioning than 666
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610 in General Health Care carried out in the first half of the 1990s people living on their own, or with their family (but not having 667
611 in 15 countries [12] was one of the few international studies a partner). Van Os et al. [19] also found that professional em- 668
612 comparing the social functioning of patients with various psy- ployment was a positive factor in determining the level of so- 669
613 chiatric disorders. The General Health Questionnaire (GHQ) cial functioning. Samderson and Andrews [14] found that lack 670
614 was used in choosing the sample, since the initial sample of professional employment in the past year was associated 671
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615 was taken from the population of patients from general health with social disability, which is in agreement with these results. 672
616 care. The Composite International Diagnostic Interview It is beyond the scope of this paper to discuss whether profes- 673
617 (CIDI) and GSDS were used in the study itself. On the basis sional status is a cause or a consequence of social disability. It 674
618 of the results from this study it was found that there was a is not easy to arrive at an unambiguous answer, which can be 675
619 significant difference in the level of professional disability of seen on the basis of other studies confirming the positive influ- 676
620 patients having affective disorders, anxiety disorders and ence of professional employment in counteracting the devel- 677
621 alcoholism, from 13% in Seattle (USA) to 59% in Groningen opment of psychiatric disorders [15,16]. This question also 678
622 (Holland). There were significant differences between the refers to the other factors considered and a solution to this 679
623 number of days taken in sick leave in the previous month problem may only be found by long-term prospective studies 680
624 from 1.0 day on average in Santiago (Chile) to 11.9 in Banga- with an assessment of the functioning of a person before he/ 681
625 lore (India) and Ibadan (Nigeria). Simon et al. [18] concluded she becomes ill. The fact that the sample was restricted to pa- 682
626 on the basis of these results that depressive disorders were tients requiring hospitalization is a significant limitation on the 683
627 associated with social disability regardless of the study center, interpretation of the results obtained. Almost all the studies 684
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685 cited were based on a sample of outpatients, patients of basic care systemsdobjectives of EDEN project. Psychiatr Pol 2002;36 740
686 healthcare services, or the general population. (suppl.):361e3 [in Polish]. 741
687 [8] Leff J, Sartorius N, Jablensky A, Korten A, Ernberg G. The International 742
688 Pilot Study of Schizophrenia: five-year follow-up findings. Psychol Med 743
689 5. Conclusions 1992;22:131e45. 744
690 [9] Melzer D, Fryers T, Jenkins R, Brugha T, McWilliams B. Social position 745
691 The severity of psychopathological symptoms, not the diag- and the common mental disorders with disability: estimates from the 746
692 nosis of a mental disorder, was the most significant factor in National Psychiatric Survey of Great Britain. Soc Psychiatry Psychiatr 747
693 Epidemiol 2003;38:238e43. 748
694
determining the level of social functioning, particularly during [10] Mueser KT, Becker DR, Torrey WC, et al. Work and nonvocational do- 749
695 remission periods. Site, employment and partnership appeared mains of functioning in persons with severe mental illness: a longitudinal 750
696 as significant factors influencing the level of social disability. analysis. J Nerv Ment Dis 1997;185:419e26. 751
697 The level of social disability should be monitoring during [11] Ormel J, Oldehinkel T, Brilman E, van den Brink W. Outcome of depres- 752

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698 standard psychiatric care. sion and anxiety in primary care. A three-wave 3 1/2-year study of psy- 753
699 chopathology and disability. Arch Gen Psychiatry 1993;50:759e66. 754
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701 Acknowledgments Common mental disorders and disability across cultures. JAMA 756
702 1994;272:1741e8. 757
703 EDEN (Psychiatric day hospital treatment: An alternative [13] Salokangas RK, Honkonen T, Stengard E, Koivisto AM. To be or not to 758
704 to inpatient treatment, being cost-effective and minimizing be married-that is the question of quality of life in men with schizophre- 759
705 nia. Soc Psychiatry Psychiatr Epidemiol 2001;36:381e90. 760
706
post-treatment needs for care? An evaluative study in Euro- [14] Sanderson K, Andrews G. Prevalence and severity of mental health- 761

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707 pean countries with different care systems) was funded by related disability and relationship to diagnosis. Psychiatr Serv 2002; 762
708 the European Commission (QLG4-CT-2000-01700). Addi- 531:80e6. 763
709 tional support was provided by Roland-Ernst-Stiftung für Ge- [15] Scheid T. An investigation of work and unemployment amongst psychi- 764
710 sundheitswesen and the Faculty of Medicine at the Dresden atric clients. International J Health Serv 1993;23:763e82. 765
711 [16] Schützwohl M, Jarosz-Nowak J, Briscoe J, Szajowski K, Kallert TW, 766
712
University of Technology, the National Health Service Execu- EDEN-study group. Inter-rater reliability of the Brief Psychiatric Rating 767
ED
713 tive Organization and Management Programme, the Polish Scale (BPRS 4.0) and the Groningen Social Disabilities Schedule 768
714 National Committee of Scientific Affairs, and the Slovak Min- (GSDS-II) in a European multi-site randomised controlled trial on the 769
715 istry of Education. Pfizer Pharmaceutical Company supported effectiveness of psychiatric day hospitals. Int J Methods Psych Res 770
716 travel and accommodation for EDEN project meetings. 2003;12:197e207. 771
717 [17] Shepherd M, Watt D, Falloon I, Smeeton N. The natural history of 772
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718 schizophrenia: a five-year follow-up study of outcome and prediction 773


719 References in a representative sample of schizophrenics. Psychol Med Monogr 774
720 Suppl. 1989;15:1e46. 775
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724 [2] Flament MF. Predictive factors of social disability in patients with eating [19] van Os J, Fahy TA, Jones P, et al. Psychopathological syndromes in the 779
725 disorders. Eat Weight Disord 2001;6:99e106. functional psychoses: associations with course and outcome. Psychol 780
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726 [3] Grant C, Addington J, Addington D, Konnert C. Social functioning in Med 1996;26:161e76. 781
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728 [4] Gureje O, Herrman H, Harvey C, Morgan V, Jablensky A. The Australian Symptom dimensions in recent-onset schizophrenia and mania: a princi- 783
729 National Survey of Psychotic Disorders: profile of psychosocial disability pal components analysis of the 24-item Brief Psychiatric Rating Scale. 784
730 and its risk factors. Psychol Med 2002;32:639e47. Psychiatr Res 2000;97:129e35. 785
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Please cite this article in press as: Rymaszewska J et al., Social disability in different mental disorders, European Psychiatry (2006), doi:10.1016/
j.eurpsy.2006.11.006