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Quality of life in a 20-year follow-up study of people suffering from schizophrenia
Comprehensive Psychiatry, pages 133 - 140
1. To assess the changes in quality of life indicators in schizophrenia sufferers at three measurement points: 7, 12 and 20 years after the first hospitalization. 2. To assess changes in the level of functioning and psychopathological state. 3. To assess the relationships between quality of life, the level of functioning and the severity of symptoms.
A sample group of fifty-two people diagnosed with schizophrenia was investigated using the Lehman's QOLQ, the GAF scale and BPRS.
A deterioration was noted in the subjective and objective areas of family life and health, subjectively assessed social relationships and objectively assessed finances. The better functioning sub-group returned better scores for the following objective quality of life indicators: free time, family life, health, social relationships and financial situation. The sub-group in remission obtained better results for general, subjective quality of life and for subjectively assessed health, as well as better scores for objectively assessed free time, social relationships, financial situation and health. An improvement in general, subjective quality of life was seen in the sub-group whose symptoms had grown more severe.
The decline in subjective and objective quality of life in the areas of health and family life, in the subjective evaluation of social relationships and in the objective assessment of financial situation was associated with a deterioration in functioning and an absence of symptom remission. The improvement in general, subjective quality of life in the sub-group with severe symptoms may be evidence of the formation of adaptive mechanisms.
In recent decades quality of life has been recognized as a significant indicator in the treatment outcomes of people with serious mental disorders, including those who have been diagnosed with schizophrenia, , and . Among the reasons for this has been the transition in the model of psychiatric treatment in Western countries, which begun at the end of the 1950s and has seen a move from an asylum-based model to a community-based one. In Poland these changes were delayed by approximately two decades due to political factors. They therefore began only in the late 1980s and early 1990s. Our research initiative, whose aim was to observe the fate of eighty people diagnosed with schizophrenia over a period of 20 years and to evaluate their treatment outcomes, their social functioning and the changes in their quality of life, also began towards the end of the 1980s.
It has been demonstrated in the existing body of research that quality of life depends not only on the severity of the psychopathological symptoms  but also on a series of other factors  . A relationship has been established between quality of life and the following: the neuro-cognitive functions  , theory of mind  , cognitive functions and social cognition and , unmet need, , , and , insight into the symptoms of the disorder  and the social network  . Research into patients diagnosed as schizophrenic and into improvement in their quality of life is also important because, as a number of research initiatives have indicated, the diagnosis is associated with the risk of recurrence of psychotic symptoms  . There have, however, been few prospective studies of quality of life.
The present work is the result of the observation of changes in quality of life in people diagnosed as schizophrenic according toDSM IVin a prospective, 20-year follow-up study. In addition to the long-term observation of a diagnostically homogeneous group, the important features of this study are the stable, community-based therapeutic environment and the search for—besides psychopathology—a relationship with the overall level of functioning. This is a continuation of earlier studies completed in Kraków, which concerned shorter time intervals, , and . It also fills a certain gap in the geographical distribution of quality of life research  .
2.1. Study design and sample
Quality of life was investigated at three measurement points: 7 (n = 66), 12 (n = 71) and 20 (n = 61) years after the first hospitalization. The analyses were restricted to fifty-two people who were examined at all three measurement points.
General functioning was evaluated with the aid of the Global Assessment of Functioning (GAF) scale. GAF forms a part of theDSMmulti-axial system for assessment, which is intended as a reflection of the evaluating clinician's judgement concerning the patient's ability to function in daily life. The 100-point scale measures psychological, social and occupational functioning. Patients with scores of up to 59 points on the GAF scale were assigned to the sub-group with worse general functioning, while those with scores of 60 and above—the threshold value established by researchers as indicating recovery  —to the sub-group with better general functioning. The Brief Psychiatric Rating Scale (BPRS), a tool constructed in 1960 by Overall and Gorham  , was employed to determine the severity of the psychopathological symptoms. In our study we used the extended version by Lukoff et al.  , which is composed of twenty-four symptoms, each assessed on a seven-degree scale from 1 to 7. The sub-groups were obtained by assigning those with results on the BPRS scale of ≤2 to the group with less severe symptoms and assigning those with results on that scale of >2 to the group with more severe symptoms. At the symptomatic level, then, we adopted more demanding remission criteria than did, for example, Andreasen et al.  .
The Polish version of Anthony Lehman's Quality of Life Questionnaire  was used to assess quality of life. First, information was collected on the objective indicators, which refer to a variety of aspects of quality of life, and then on the subjective attitude of the respondents to them. The resulting objective and subjective quality of life indicators for the areas studied formed the base for the quality of life assessment model. The objective indicators concern the assessment of functioning, such as the frequency of social contacts or activity during the course of the day, access to resources, such as financial means and types of care, and the extent to which the respondent is able to take advantage of them. All of the subjective quality of life indicators were evaluated by the sample based on a seven-point ‘satisfaction scale’. General satisfaction with life was measured as the average of the assessments at the beginning and at the end of the questionnaire.
All subjects' data were collected in ambulatory setting, with wholly voluntary participation. At each assessment an informed consent was sought from the patients and their family members. They were informed of the objective, methods and the course of the assessment. The study has been approved by the Bioethical Committee of the Collegium Medicum, Jagiellonian University, Cracow.
2.3. Statistical analyses
The difference between the demographic indicators at the three measurement points was assessed using the McNemar and Wilcoxon tests. The dynamics of the changes in psychopathological state, general functioning and quality of life, as well as the relationships between them, were evaluated with the aid of analysis of variance with repeated measures and one between-group factor.
3.1. Sample demographics
During the research period, across all time intervals, there were statistically significant changes in the sample regarding the number drawing incapacity benefit and regarding life context. After 20 years of being ill, 79% of the sample were drawing incapacity benefit and the risk of disability and incapacity to work was higher the longer the illness had lasted. The number of people living with their family of origin fell markedly from 48 to 27%, the number of people living independently rose from 8 to 19% and the number living with a procreational family rose from 44 to 52% ( Table 1 .).
|Description of the sample N = 52||7 years||12 years||20 years||p-Level 7 vs.12 years||p-Level 7 vs. 20 years||p-Level 12 vs. 20 years|
|Age||34 ± 6||39 ± 6||47 ± 6||na||na||na|
|Married||40%||46%||44%||ns a||ns a||ns a|
|In employment||35%||39%||33%||ns a||ns a||ns a|
|Drawing incapacity benefit||65%||77%||79%||0.014 a||0.001 a||0.001 a|
|With family of origin||48%||29%||27%||0.012 b||0.001 b||0.004 b|
|With procreational family||44%||60%||52%|
a McNemar test.
b Wilcoxon test.
3.2. Changes in clinical indicators
In the first time interval between 7 and 12 years from the first hospitalization the GAF indicator of general functioning showed statistically significant growth (p < 0.001) before, in the second interval between 12 and 20 years, returning a statistically significant decline (p = 0.035). An increase in the intensity of symptoms throughout the successive time intervals was observed in all of the psychopathological syndromes assessed on the BPRS scale: in the general assessment between 7 and 12 years (p = 0.029), 7 and 20 years (p < 0.001) and 12 and 20 years (p = 0.001) from the first hospitalization; in the positive syndrome between 7 and 20 years (p = 0.025) from the first hospitalization; in the negative syndrome between 7 and 20 years (p < 0.001) and between 12 and 20 years (p = 0.002) from the first hospitalization; in the depressive domain between 7 and 20 years (p = 0.001) and between 12 and 20 years (p = 0.016) from the first hospitalization ( Table 2 .).
|Clinical feature||Time impact||Mean, standard deviation||LSD tests p-level|
|7 years||12 years||20 years||7–12 years||7–20 years||12–20 years|
|GAF scale||F(2.102) = 9.54, p = 0.001||56.1 ± 13.3||64.0 ± 15.2||60.5 ± 19.2||0.001||0.045||0.042|
|General BPRS scale||F(2.102) = 13.61, p = 0.001||1.36 ± 0.39||1.48 ± 0.41||1.71 ± 0.60||0.030||0.001||0.001|
|Positive symptoms according to BPRS||F(2.102) = 3.46, p = 0.035||1.40 ± 0.70||1.49 ± 0.56||1.69 ± 0.84||n.s.||0.025||0.060|
|Negative symptoms according to BPRS||F(2.102) = 13.00, p = 0.001||1.39 ± 0.53||1.53 ± 0.71||1.85 ± 0.92||0.096||0.001||0.001|
|Depressive symptoms according to BPRS||F(2.102) = 8.62, p = 0.001||1.51 ± 0.65||1.67 ± 0.63||1.93 ± 0.91||0.068||0.001||0.011|
|Number of rehospitalizations per year||F(2.102) = 13.46, p = 0001||0.25 ± 0.30||0.21 ± 0.25||0.15 ± 0.17||0.033||0.001||0.001|
|Combined duration of hospitalizations per year||F(2.102) = 13.39, p = 0.001||2.05 ± 2.44||1.71 ± 2.03||1.34 ± 1.61||0.007||0.001||0.001|
All comparisons produced by ANOVA tests.
The data concerning the number of people from the sample that met the criteria we adopted for symptom remission and recovery within the context of general functioning are presented in Table 3 .
|Recovery||K7||K12||K20||K7, K12 and K20|
|GAF ≥ 60||38.5%||59.6%||55.8%||20.3%|
|BPRS ≤ 2||53.8%||42.3%||21.2%||11.4%|
3.2.1. Changes in objective and subjective quality of life assessments
The general, subjective quality of life assessment was stable for the entire group over the study period. No statistically significant differences were detected between the different measurement points. In the majority of the specific areas of quality of life there were no statistically significant changes other than with regard to family life (p = 0.02), social relationships (p = 0.021) and health (p = 0.001). There was significant worsening in all three of these areas between the twelfth and twentieth years of the follow-up study ( Table 4 .).
|Subjective quality of life||Time impact||Mean||LSD tests p-level|
|Year 7||Year 12||Year 20||7–12 years||7–20 years||12–20 years|
|A General||F(2.98) = 2.80, p = 0.066||4.02 ± 1.56||4.36 ± 1.23||4.34 ± 1.43||0.052||0.072||n.s.|
|B1 Housing and living conditions||F(2.74) = 0.63, p = 0.537||5.10 ± 0.89||5.27 ± 0.77||5.09 ± 1.18||n.s.||n.s.||n.s.|
|B2 Neighbours||F(2.96) = 2.21, p = 0.116||4.85 ± 1.02||4.71 ± 1.05||5.06 ± 1.13||n.s.||n.s.||0.046|
|C Free time||F(2.100) = 2.11, p = 0.127||4.27 ± 1.02||4.55 ± 0.90||4.34 ± 1.11||0.032||n.s.||n.s.|
|D Family||F(2.100) = 3.27, p = 0.042||4.62 ± 1.19||5.00 ± 1,16||4.55 ± 1.23||0.057||n.s.||0.020|
|E Social relationships||F(2.48) = 3.22, p = 0.049||4.72 ± 0.70||4.98 ± 0.52||4.50 ± 0.93||0.057||n.s.||0.021|
|F Finances||F(2.86) = 0.07, p = 0.930||3.66 ± 1.31||3.74 ± 1.15||3.74 ± 1.37||n.s.||n.s.||n.s.|
|G1 In employment||Too few instances|
|G2 In education||Too few instances|
|H Sense of security||F(2.90) = 0.15, p = 0.862||4.47 ± 1.21||4.46 ± 0.97||4.54 ± 1,27||n.s.||n.s.||n.s.|
|I Health||F(2.92) = 4.65, p = 0.012||4.70 ± 0.93||4.77 ± 0.73||4.41 ± 0.92||n.s.||0.054||0.001|
|J Religion||F(2.92) = 0.15, p = 0.860||5.07 ± 1.08||5.01 ± 1.06||5.09 ± 1.27||n.s.||n.s.||n.s.|
All comparisons produced by ANOVA tests.
In the objective assessment of the quality of life indicators, across all of the time intervals, a significant improvement in the area of housing and living conditions was observed alongside a decline in the areas of family life, finances and health. The decline was recorded both between years 7 and 20 and years 12 and 20 of the study. The remaining objective quality of life indicators (free time, relationships, employment, sense of security and religion) showed no significant statistical change ( Table 5 .).
|Objective quality of life||Time impact||Mean||LSD tests p-level|
|B Housing and living conditions||F(2.96) = 12.57, p = 0.001||9.16 ± 1.20||9.57 ± 0.96||9.98 ± 0.14||0.024||0.001||0.005|
|C Free time||F(2.102) = 1.49, p = 0.231||8.19 ± 2.28||8.52 ± 2.02||7.90 ± 2.69||n.s.||n.s.||0.056|
|D Family||F(2.102) = 8.33, p = 0.001||5.15 ± 1.04||5.38 ± 1.27||4.44 ± 1.64||n.s.||0.004||0.001|
|E Social relationships||F(2.100) = 1.76, p = 0.177||4.65 ± 3.46||4.82 ± 3.30||3.92 ± 3.37||n.s.||n.s.||0.082|
|F Objective finances||F(2.96) = 4.26, p = 0.017||0.65 ± 0.36||0.68 ± 0.73||0.48 ± 0.31||n.s.||0.001||0.022|
|G In employment||F(2.100) = 2.24, p = 0.112||14.0 ± 19.2||15.5 ± 18.6||10.1 ± 17.7||n.s.||n.s.||0.060|
|H Sense of security||F(2.100) = 1.58, p = 0.212||3.80 ± 0.45||3.84 ± 0.42||3.94 ± 0.31||n.s.||0.090||n.s.|
|I Health||F(2.100) = 5.80, p = 0.004||32.0 ± 4.92||32.5 ± 4.39||30.0 ± 6.31||n.s.||0.032||0.003|
|J Religion||F(2.92) = 0.65, p = 0.525||2.70 ± 1.44||2.77 ± 1.54||2.96 ± 1.81||n.s.||n.s.||n.s.|
All comparisons produced by ANOVA tests.
The worsening of the objective results in the areas of family and health was consistent with the subjective assessment of the sample. The subjective lack of change in the area of social relationships was, however, associated with their objective decline. The objective improvement in housing and living conditions was not reflected in greater subjective well-being. Likewise, the objective decline in finances prompted no worsening in its subjective assessment. The indicators connected with ways of spending free time, employment, sense of security and religion remained stable and consistent in their subjective and objective assessments.
3.2.2. Relationships between quality of life, general functioning and the severity of psychopathological symptoms
The relationships between subjective and objective quality of life were analyzed by reference to the dichotomous division of the sample into sub-groups of better and worse general functioning and less and more severe symptoms.
3.3. The relationships between subjective quality of life and general functioning
Neither the general, subjective quality of life, nor the majority of the specific indicators, was found to be associated with better or worse general functioning as measured by the GAF scale. It was only in the assessment following 7 years of illness (p = 0.006) that the subjective indicator of housing and living conditions was better in the sub-group with worse functioning than it was in that with better functioning. The difference between the sub-groups had disappeared at the later measurement points.
3.4. The relationships between objective quality of life and general functioning
The objective quality of life indicators differed between the groups with low and high GAF in the assessment of free time, family life, social relationships, financial situation and state of health. Hence the objective assessment of free time was more favorable in members of the sample with a higher level of general functioning (p = 0.003). In the area of family life in the sub-group with better functioning the results remained at a consistent level, while in the group with poorer functioning there was a decline in the time intervals between years 7 and 20 (p = 0.001) and years 12 and 20 (p = 0.001). As a result of these changes a statistically significant difference between the groups in favor of the group with better functioning (p = 0.033) was recorded at the third measurement point (after twenty years). In the area of social relationships the group with high GAF scores had better (p = 0.006) results than the group with poorer general functioning according to GAF. The objective financial situation in the group with high GAF scores was better (p = 0.001). These differences were noticeable at all measurement points: after 7 years (p = 0.002) after 12 years (p = 0.001) and after 20 years (p = 0.005). Initially, between years 7 and 12, the objective financial situation in the sub-group with better functioning improved (p = 0.046). This was followed, though, by a worsening assessment of the financial situation after both 12 (p = 0.001) and 7 (p = 0.004) years in the same group. In the poorer functioning group there was a decline in the assessment of the financial situation throughout the 7 to 20 year time interval (p = 0.008). Those people who had functioned better in the earlier period coped better and for longer in the financial area and, after 20 years of illness and despite the objective worsening, still had better results. The objective health situation in the better functioning group was significantly better than in the sub-group characterized by poorer functioning (p = 0.002).
3.5. The relationships between subjective quality of life indicators and the severity of symptoms
There was a statistically significant difference (p = 0.048) in the general, subjective quality of life assessment between the sub-groups with less and more severe psychopathological symptoms across all of the measurement points. A higher level of general, subjective quality-of-life was recorded for patients with mild symptoms. This difference was particularly striking at point one of the study after 7 years of illness (p = 0.017). During the course of the study, subjective quality of life recorded for patients with greater symptom severity rose between years 7 and 12 (p = 0.001) and between years 7 and 20 (p = 0.025). This is illustrated by Fig. 1 .
In the specific areas of subjectively-assessed quality of life 7 years after first hospitalization a difference between the groups was noted in the area of health (p = 0.006), for which a higher subjective quality of life assessment was recorded for those in the sample with less severe symptoms. There was a statistically significant reduction in the quality of life assessment results for health in the sub-group with less severe symptoms after 20 years when compared with those obtained after 7 (p = 0.001) and 12 years (p = 0.001). The results for health remained stable in the sub-group with high initial symptom severity.
3.6. The relationships between objective quality of life and the severity of psychopathological symptoms
The objective assessment of the quality of the organization of free time was better (p = 0.004) in those in the sample with less severe symptoms. With regard to family life in those with less severe symptoms there was a worsening between 7 and 20 years of illness (p = 0.041). In the sub-group with more severe symptoms there was a significant improvement between 7 and 12 years (p = 0.014). This was followed by a decline between 12 and 20 years (p = 0.001), as well as over the entire study period between 7 and 20 years (p = 0.037). In the area of social relationships the sub-group with less severe symptoms had better results than the sub-group with more severe symptoms (p = 0.02). These differences were particularly evident after year 20 (p = 0.001), which was also a result of the statistically significant decline (p = 0.001) recorded for the latter group in the year 12 to year 20 interval.
The objective financial situation of the sub-group with less severe symptoms worsened (7–20,p = 0.003; 12–20,p = 0.002). There was also a decline between years 7 and 20 in the group with more severe symptoms (p = 0.017). At the study's second measurement point, after 12 years, a significant difference (p = 0028) in favor of the sub-group with less severe symptoms was noted ( Table 6 .).
|Quality of life dimensions||Result of interaction of time and the between-group factor (BPRS, GAF)||Factor||Mean||LSD tests p-level|
|7 years||12 years||20 years||7 years||12 years||20 years||7–12 years||7–20 years||12–20 years|
|Subjective general quality of life vs. BPRS||F(2.48) = 3.23, p = .049||Low||4.50||4.44||4.59||0.017||n.s.||n.s.||n.s.||n.s.||n.s.|
|Subjective health vs. BPRS||F(2.90) = 4.64, p = .012||Low||5.05||4.90||4.40||0.006||n.s.||n.s.||n.s.||0.001||0.001|
|Objective family vs. BPRS||F(2.100) = 4.06, p = .020||Low||5.36||5.07||4.68||n.s.||n.s.||n.s.||n.s.||0.041||n.s.|
|Objective social relationships vs. BPRS||F(2.98) = 5.27, p = .007||Low||5.44||4.81||5.41||n.s.||n.s.||0.001||n.s.||n.s.||n.s.|
|Objective finances vs. BPRS||F(2.94) = 3.79, p = .026||Low||0.71||0.89||0.52||n.s.||0.028||n.s.||n.s.||0.003||0.002|
|Subjective housing and living conditions vs. GAF||F(2.72) = 3.43, p = .038||Low||5.35||5.43||5.03||0.014||n.s.||n.s.||n.s.||n.s.||n.s.|
|Objective family vs. GAF||F(2.100) = 3.59, p = .031||Low||5.06||5.50||4.06||n.s.||n.s.||0.033||n.s.||0.001||0.001|
|Objective finances vs. GAF||F(2.94) = 5.90, p = .004||Low||0.53||0.41||0.39||0.002||0.001||0.005||n.s.||0.008||n.s.|
All comparisons produced by ANOVA tests.
The results for employment were not calculated because too few people (n = 6) were working at all three measurement points. The objective position with regard to health, which takes into account both physical and mental health, was better in the group with lower scores on the BPRS scale (p = 0.030).
In attempting to situate the results of our study in a wider research context we were faced with the difficulty that there have been few long-term quality-of-life studies conducted in a stable therapeutic environment with a group of patients with a non-specific age profile. Of the papers that have investigated changes in quality of life in schizophrenia sufferers only a few, , , , , , , , and have presented research whose observation period was 5 years or longer. Researchers have concentrated on specific contexts, such as changes in the therapeutic environment  , the age of patients  or the issue of employment  . The works done by Tempier et al.  , Cechnicki  ; Cechnicki et al.  , Górna et. al.  , Ritsner and Grinshpoon  and Ritsner et al. and , however, have applied a research model similar to that of the present study.
Tempier et al.  investigated subjective quality of life in sixty people with chronic psychotic disorders who were receiving treatment in a non-hospital setting in two towns in the province of Quebec. No statistically significant changes in the subjective quality of life as assessed by patients and measured with the SLDS scale were detected over the study's 7-year duration. The authors offered the stability of the living conditions and the broad range of health and social benefits the patients obtained, which allowed them to maintain their quality of life, as explanations for this result. It is also worth pointing out that there lies concealed beneath this opinion the expectation that the natural progression of schizophrenia worsens quality of life. Górna et al.  described the results of an observation of a group of seventy-four people diagnosed with schizophrenia who were studied three times: 1 month, 1 year and 4 to 6 years after their first hospitalization. It emerged from the results that an initial low, objective quality of life improved in three areas (independence–performance, recreation–pastimes, interpersonal behaviour), worsened in one (employment–occupation) and did not change in a further three (social engagement–withdrawal, prosocial activities, independence–competence). The subjective assessment of quality of life showed no significant change over the course of the observation. In two articles Ritsner et al. and set out the results of an observation of changes in quality of life over 10 years in one-hundred-and-eight people diagnosed with schizophrenia and schizo-affective disorders. He demonstrated that quality of life remained at a low level (64%) or worsened (12%) in the majority (76%) of those studied, while quality of life improved in 16% of those examined and in 8% it remained at a stable, high level.
In earlier studies, Cechnicki et al.  compared changes in quality of life in a sample of sixty-four people between 7 and 12 years after first hospitalization. The results they obtained allowed them to confirm a growth in subjective quality of life in the area of social relationships and a fall in objective quality of life in the areas of social relationships, finances, health and religion. In research addressing relationships between quality of life and the social network  , the same team of researchers detected a dependency between the extent of the social network and level of support and the general, subjective quality of life assessment. The larger the network and the higher the level of support, the higher was the general, subjective quality of life assessment. Among those studied, a more extensive network was positively correlated with a greater number of free-time activities, with a greater number of social contacts, with higher monthly income and with less victimization. Cechnicki demonstrated in a further work  that—7 years after becoming ill—positive results both for objective and subjective quality of life predominated in the group of patients in the community treatment program when compared with those receiving individual care—especially in the areas of family life and religion.
Our results confirm earlier observations, , and that indicated the occurrence of changes in quality of life. In such areas of subjective quality of life as family, social relationships or health a statistically significant worsening took place. This should be understood in terms of the ageing of the patients. The age of around 50 is a time when parents pass away and when health—including somatic health due to accelerated ageing in the mentally ill—declines. The objective financial situation of the whole sample declined markedly—especially between years 12 and 20 of illness (p = 0.001). This is probably because of the death, disability or retirement of the parents of those in the sample. Notwithstanding this, there was an improvement in objective housing and living conditions. In our view, this was largely the result of the improved housing and living conditions of Polish society as a whole during the years in which the study was being conducted. It is noticeable that in two areas of assessment—family situation and health—the results of the entire sample declined in both objective and subjective terms. The conformity of this assessment lends credence to the results of the observation and underlines the importance of the changes taking place.
What is striking when analyzing the results concerning the relationships between general functioning measured on the GAF scale and the objective quality of life indicators is the stable assessment of functioning in the sub-group with good earlier results and the worsening of results in the sub-group with poorer functioning at the beginning of the study. Clear differences between the sub-groups are also visible with regard to free time, family life, health, social relationships and financial situation. The results paint a picture of a distinct stratification of the sample that distinguishes a sub-group of better and stable functioning in a variety of the areas researched from one whose functioning is poorer or declining. In showing that earlier positive results influence later positive results that are evaluated years after, and that it is hardest to help the chronically ill and , our study was consistent with a series of other studies, such as Marchesi et al. or Schennach-Wolff et al. and . Studies of the relationship between the severity of symptoms and the quality of life have produced divergent results. Wilson-d'Almeida et al.  concluded that the psychopathological condition of the sample improved while quality of life did not. On the other hand, there have been investigations that have shown a dependency between quality of life and psychopathological state. The meta-analysis produced by Eack et al.  , which was based on a review of fifty-six studies from the period 1966–2005, found that the majority pointed to a relationship between the severity of psychopathological symptoms and quality of life. That being said, the strongest relationship detected was that between quality of life and general psychopathology.
In our study we confirmed a relationship between severity of symptoms and quality of life at the borderline of statistical significance (p = 0.048); the sub-group with more severe symptoms had poorer quality of life. On the other hand, even though over the course of the follow-up study there was a significant intensification of symptoms in both sub-groups, the quality of life in the sub-group with less severe symptoms did not vary, while in the sub-group with more severe symptoms it even improved. We can attempt to understand this result as an expression of adaptation: of learning to live with symptoms and ameliorating the suffering and sense of discomfort associated with them. This phenomenon may also be associated with the withdrawal after some years from being an active member of society and, therefore, less exposure to stress.
What is conspicuous in the different categories of subjective quality of life is the significant decline in the area of health in the intervals between 7 and 20 years and between 12 and 20 years from the first hospitalization. This result was present in the entire sample, but was particularly strong in the sub-group with less severe symptoms. From one perspective this may reflect the earlier onset of the somatic ageing process in mentally ill people, while from another it may be an expression of deteriorating mental health. It is intriguing that—despite the worsening of psychopathological state (less or more severe symptoms) to a similar extent in both sub-groups—it was only among patients with less severe symptoms that subjective quality of life in the area of health declined. This could perhaps be a sign of better insight or criticism in this sub-group. If so, it confirms the results obtained in research by Aghababian et al.  and van Baars et al.  into the relationship between insight and quality of life.
The relationships between objective quality of life and the severity of symptoms are different in the area of family life than they are in that of social relationships beyond the family. A worsening of the family situation was found in both sub-groups (more/less severe symptoms) and, because of the absence of significant differences between the sub-groups with regard to marital status, the results can be at least partially explained by the age of those in the sample. After 20 years of illness their parents began to suffer ill health and die. Differences were revealed between the sub-groups in the area of social relationships in favor of the group with symptom remission. Unlike those whose illness is less severe, those who are seriously ill thus lose not only their family relationships, but also their social relationships. These results are consistent with those from earlier research conducted by Cechnicki et al.  , which concerned relationships between quality of life and the social network.
There may be at least two reasons for the differences noted between the sub-groups in the objective assessment of health. Firstly, in the objective assessment of the overall health situation it is mental health that is taken into account first of all. In this way, those in remission automatically obtain a better assessment. What is more, the presence of symptoms increases the risk of poorer physical health in the form of self-neglect, not following doctors' directions, cigarette smoking and a poor diet, which has also been demonstrated in other studies and .
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a Department of Community Psychiatry, Chair of Psychiatry, Collegium Medicum, Jagiellonian University, Cracow, Poland
b Association for the Development of Community Psychiatry and Care, Cracow, Poland
The study was conducted by the Cracow Schizophrenia Research Group.
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