|Year : 2022 | Volume
| Issue : 1 | Page : 23-29
Assessment of social functioning, quality of life, and social support in persons with schizophrenia: A gender difference
Shrishti Dahuja1, Upendra Singh2, Ram Pratap Beniwal3
1 Junior Research Fellow, Department of Psychiatry and Drug De-addiction, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
2 Senior Lecturer, Department of Psychiatric Social Work, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
3 Professor, Department of Psychiatry and Drug De-addiction, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
|Date of Submission||18-Jun-2021|
|Date of Acceptance||05-Sep-2021|
|Date of Web Publication||23-Nov-2021|
Dr. Ram Pratap Beniwal
Room No. 5, Department of Psychiatry and Drug De-addiction, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Context: The outcome of schizophrenia (SZ) is impaired psychosocial functioning and poor quality of life (QOL) which is associated with burdens and societal expenditure to the caregivers.
Aims: This study was aimed to access the difference in social occupational functioning, QOL, and social support between male and female patients with SZ.
Settings and Design: This is a cross-sectional observational study conducted on persons with SZ visiting the psychiatry outpatient department in a tertiary care teaching institute.
Materials and Methods: The sample consisted of N = 200 persons with SZ (International Classification of Diseases-10) aged 21–45 years of both genders. The assessment of socio-occupational functioning, QOL, and social support with administering the Social Occupational Functioning Scale (SOFS), World Health Organization Quality of Life-BREF Scale, and PGI Social Support questionnaire.
Statistical Analysis: A Chi-square test was applied for discrete variables and a t-test for continuous variables. An independent sample t-test was used to assess differences between the males and females.
Results: Overall, males were more educated than females. Occupationally, there was a significant difference between males and females (P = 0.000). A significant difference (P = 0.000) was found between males and females on total socio-occupational functioning and social support (P = 0.000). The difference between males and females on QOL was observed on perceived physical health (P = 0.000) and psychological health (P = 0.039).
Conclusions: This study confirms that there is a definite gender difference in SZ on psychosocial and QOL. Males were physically, psychologically healthier and had better socio-occupational functions as well as strong social support compared to females.
Keywords: Gender difference, males and females, quality of life, schizophrenia, social occupational functioning, social support
|How to cite this article:|
Dahuja S, Singh U, Beniwal RP. Assessment of social functioning, quality of life, and social support in persons with schizophrenia: A gender difference. Arch Ment Health 2022;23:23-9
|How to cite this URL:|
Dahuja S, Singh U, Beniwal RP. Assessment of social functioning, quality of life, and social support in persons with schizophrenia: A gender difference. Arch Ment Health [serial online] 2022 [cited 2023 Jan 30];23:23-9. Available from: https://www.amhonline.org/text.asp?2022/23/1/23/330928
| Introduction|| |
Schizophrenia (SZ) is a disabling, chronic mental health disorder. Its early onset and chronic course make it a debilitating disorder for the patients and their families. SZ is one of the most burdensome mental disorders in terms of human suffering and societal expenditure. SZ is associated with significant functional impairment, challenges in community living, the burden of disability, and affects many other spheres of living, such as interpersonal and socio-occupational domains.
The National Mental Health Survey of India reported a lifetime prevalence of 1.4% and a current prevalence of 0.5% for SZ. The sex-specific incidence rates in SZ had consistently been reported higher in males rather than females. Although suicides seem to be more in women with SZ, there is no significant gender difference in the incidence and prevalence. Studies have shown better premorbid functioning and social adjustment for women compared with men. Females have better clinical outcomes compared to males in short term, whereas these gender differences tend to disappear in the long term.
Social functioning is “the inability of individuals to meet societal defined roles such as homemaker, worker, student, spouse, family member or friend”. The definition also takes account of an individual's satisfaction with their ability to meet these roles, to take care of themselves, and the extent of their leisure and recreational activities. In terms of their social, sexual, and marital adjustment, females are better in functioning at the premorbid level, but after the illness, women are having severe issues with their level of functioning and in their interpersonal relations. Contrary to this, the males are having better long-term outcomes. A study showed that the females had a superior social working than men, and the prescient factors for social working have a bigger number of similitudes than contrasts among men and women. Persons with chronic SZ experience various levels of dysfunctions in different areas according to different sociocultural backgrounds. Swain et al. reported that there are definite and substantial psychosocial dysfunctions in personal, familial, social, vocational, and cognitive spheres with the advancement of the duration of illness in chronic SZ patients.
Quality of life (QoL) was recognized as a crucial factor that helps to understand the outcome of the patient suffering from SZ and is much better in those who are in remission. There was a significant relationship between the QoL and global functioning of the individual with SZ. The concept QoL applies to those chronic illness required long-term treatment and now understood to be a multidimensional construct that encompasses both subjective and objective measures. The World Health Organization (WHO) definition of QoL includes a person's physical health, psychological state, level of independence, social relationships, personal beliefs, and environment, all of which are shaped by culture and value systems. The information from caregivers has been used as a proxy and surrogate marker of the QoL of patients. Persons with SZ who did not identify themselves as having an illness have been reported to have a higher QoL. Symptoms of depression and cognition may also influence the QoL in patients with SZ.
Social support from the family and friends had a lower score than other kinds of social support with the patients suffering from SZ. A similar study found that social support directly affects the overall functioning of the individual. For youngsters with the first episode of psychosis, the outcomes depend on the significance of timely intervention.
SZ is a severe psychiatric illness that affects the individual's normal life and impaired psychosocial, occupational, and personal life. There are limited studies related to gender differences in SZ. As women face a lot of problems, there is a need to plan for gender-sensitive mental health services in India. In this background, we, therefore, examined the socio-occupational functioning, QOL, and social support in males and females with SZ.
| Materials and Methods|| |
Study setting and design
This study was carried out at the department of psychiatry in tertiary care, a government teaching hospital. This was a cross-sectional observational study. Consecutive patients (n = 200) attending outpatient and inpatient facilities and diagnosed with SZ were recruited. A convenient sampling method was followed for selecting the patient for this study. The data were collected over a period of 6 months from November 2018 to April 2019. The descriptive and comparative research design was adopted for the study. Permission from the Institutional Ethics Committee was obtained.
Persons with SZ along with the primary caregiver who visited for treatment and follow-up were approached. Individuals willing to participate in the study were referred by the treating psychiatrist from outdoor and indoor to the researcher for recruitment. These patients were administered International Classification of Diseases-10 diagnostic criteria under supervision to confirm the diagnosis. Written informed consent was obtained from those who fulfilled the inclusion and exclusion criteria of the study.
Male and female participants aged 21–45 years and able to read and write in Hindi were included. Participants with any chronic physical illness, organic brain disorder, or substance dependence except nicotine and with any other comorbid psychiatric illness were excluded. Initially, a total of 230 patients were screened, but finally, 200 patients (n = 200, 100 male and 100 female) were recruited. Thirty patients (n = 30) were dropped due to unwillingness to participate for one or other reasons. Subsequently, the following assessment tools were administered [Figure 1].
Sociodemographic and clinical datasheet
This includes age, gender, education, marital status, religion, socioeconomic status, occupation, residence, type of family, age at onset of illness, duration of illness, duration of the marriage, and history of previous treatment.
Social Occupational Functioning Scale
The Social Occupational Functioning Scale (SOFS) is a new scale that differs from the Global Assessment of Functioning (GAF) scale and demonstrates adequate internal consistency and test–retest reliability.
World Health Organization Quality of Life Scale-BREF
Hindi version of the WHOQOL-BREF (26 items) has been derived from the original WHO QoL Scale (100 items) by Saxena et al.(1998).
PGI Social Support
It is constructed and standardized by Nehra et al., 1998.
Data collected were analyzed using Statistical Package for Social Sciences ((SPSS v 21 IBM Corp New York). To assess sociodemographic profile, a t-test was used for continuous variables and Chi-square for discrete variables. Descriptive (i.e. mean, median, percentage, range, and standard deviation [SD]) and inferential (χ2) statistics were used. The level of significance was set as P < 0.05.
| Results|| |
In the total sample (N = 200), males and females were equal in numbers (n = 100 each). The majority of participants (55%) were educated up to secondary level, and males were more educated than females. In contrast to these, males were less educated than females at higher secondary and above. A statistically significant difference was seen in the distribution of occupation (P = 0.000) and domicile (P = 0.001) between males and females. The majority of females were homemakers, and on the other hand, the majority of males were unemployed. About 55% of males and 71% of females belong to urban areas, while 40% of males and 18% of females belong to rural. The majority of males (60%) and females (63%) were living in the nuclear family. The majority of the participants were married (57%), and the marital distribution was comparable based on gender. The first contact to treatment was a psychiatrist for females (65%) than males (56%), differing to this faith healer was the first contact for males (42%) than females (28%). A majority (80%) of the participants were continuing their treatment (83 males and 77 females), whereas 93% were adherent to the treatment (97 males and 90 females) [Table 1].
|Table 1: Frequency distribution of sociodemographic for the male and female participants of schizophrenia (n=200)|
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Age, age of onset of illness, and monthly income were slightly higher in females as compared to males though statistically nonsignificant. Contrarily, the duration of illness was longer in males (P = 0.004) even though the duration of marriage was longer in females (P = 0.008) compared to their statistically significant counterparts [Table 2].
|Table 2: Discrete variable of sociodemographic data in male and female participants of schizophrenia|
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Between males and females, mean and SDs scores were statistically significant on all variables of SOFS except on four domains of bathing and grooming, recreation and leisure, respect for property, and independence/responsibility on which it was nonsignificant. The mean and SDs of the remaining ten domains as well as on total SOFS score were statistically significant at (P < 0.05 and P < 0.001) level [Table 3].
|Table 3: Social occupational functions between male and female participants of schizophrenia|
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The mean and SDs of QoL were compared between males and females. Finding suggests that out of four domains, the difference was statistically significant in two domains, whereas on “social relationship” and “environment,”' it was nonsignificant. The mean and SDs between male and females in respect of physical health were highly significant (P = 0.000), whereas in psychological health, it was comparatively significant (P = 0.039). Moreover, the mean and SDs between male and female in social support questionnaire were also highly significant (P = 0.000) [Table 4].
|Table 4: Distribution of quality of life and social support questionnaire between male and female participants of schizophrenia|
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| Discussion|| |
The current study found that the mean age of the male (34.17 ± 7.10 years) and female participants (34.24 ± 7.24 years) was comparable and females were older than males. Similar findings were reported that the women were older than the men.,, A study reported that no significant gender differences were found regarding the duration of illness in male and female participants. The comparable age between males and females shows that both genders are being equally reported for the treatment and workup for the illness of SZ. In the present study, males were more educated up to the primary level compared to females. Similarly, studies also reported that mean education obtained by males was higher than females., In another study, mean years of education were significantly different in male and female patients (P = 0.02).
In this study, a statistically significant difference (P = 0.000) was seen in the distribution of occupation between males and females. In the present sample, 50% of males were employed by one or other means, 10% were students, and the rest, 40%, were unemployed, whereas 45% of females were homemaker, 11% were students, 9% was employed, and 15% were unemployed. Likewise, Galuppi et al. reported that 30.7% of the subjects were employed, 3.8% were unemployed, 5.7% were retired, and 59.6% had a disability pension. In a similar study, 47% of males and 37% of females were employed, the difference being not statistically significant. In the present study, the numbers married males (52) was less than married females (63), but contrary to this, unmarried males (42) were more than unmarried females (32%), yet the majority of participants were married (57.5%) in both the groups and were comparable. Similarly, Usall et al. reported that 23% of women were married compared to 9.4% of men, (P < 0.01). Contrarily, another study finds out that men were significantly less likely to have ever been married. Almost 96% of males and 71% of females never married. This could be because marriages are done at a later age in western countries as compared to India. Since SZ began in the twenties in the current study, thus it was more seen in the married population as compared to other western studies.
In the present study, at the time of recruitment, majority of males and females (83 vs. 77) continued their antipsychotic treatment. Moreover, 93% of males and females (97 vs. 90) were adherents to the treatment. A similar trend was reported by Willhite et al. that there were no differences in the number of males and females taking antipsychotics at baseline, or in the average number of medications being taken by males and females at baseline. Likewise, Pérez-Garza et al. reported that males adhered more than females (P < 0.05). In the current sample, age at onset was slightly higher in females (24.820 ± 7.671) as compared to males (23.424 ± 5.719) but was statistically nonsignificant. Similarly, a study reported that the women had a higher age of onset (mean age 25.3 for women vs. 23.4 years for men) (P < 0.05). Another study revealed the same trend that the mean age of onset in males was (13.69 ± 2.11 years) compared to females (14.01 ± 1.63).
The social functioning of persons with SZ contributes to their overall functional outcome and ability to live in the community. In this study, SOFS was used to assess socio-occupational functioning, whereas, in other studies, the GAF and Disability Assessment Scale (WHO's DAS-sv) scale were used. Findings of the extant study revealed that there was a highly significant difference between males and females on all domains of SOFS except four, as well as on total SOFS (P = 0.000), whereas on clothing and dressing, orientation and mobility, and work, it was significant (P < 0.05).
Usall et al. reported that mean scores on the GAF scale were significantly higher in women, whereas men were more disabled as assessed by the DAS scale in occupational functioning and total disability. The study concluded that gender was a significant predictor for GAF, total DAS, and occupational functioning DAS. Willhite et al. found that there were no significant differences in psychosocial functioning between male and female participants at baseline. Males had lower functioning than females and the mean GAF score at baseline was 44.2 and 46.7, respectively. The extant study noticed a similar pattern where SOFS skills (total SOFS) were better in males (28.110 ± 8.599) compared to females (22.100 ± 8.180) (P = 0.000).
In the contemporary study, QoL measures were compared in males and females. The mean score between males and females on physical health (P = 0.000) and on psychological health was significant (P = 0.039), whereas on social relationship and environment, it was nonsignificant. Similarly, Galuppi et al. reported that males show a higher level of satisfaction than females in all domains of QoL except in social relationships. Thus, it is seen that there is a reduction in QoL in persons with SZ; however, different parameters such as perceived physical health and psychological state were better in males compared to females in the present study. This may be due to a different built of males, giving them an edge over females in physical health. The concerns about gender differences with physical health and metabolic complications in psychosis have also been addressed. Moreover, the current study finds that males (44.47 ± 7.86) had strong social support than females (39.38 ± 6.12), (P = 0.000). This reflects that males have a strong outside social network as they work out of home, having an opportunity to mix with people through sports activity, shopping, and attending various social functions, whereas females are mostly confined to the home as homemakers (45% in the current sample) or their workplace.
| Conclusions|| |
The study concludes that there was a significant gender difference detected in various measures used. Males were physically and psychologically healthier than females as far as their QoL is concerned. Moreover, males had better social occupational functions and had strong perceived social support compared to females.
Being a single-center hospital-based study and purposive sampling, its results may not be generalizable. Patients who were using a substance (except nicotine) were not included. Since the study was cross-sectional, the longitudinal effect of the variables could not be measured.
Psychosocial functioning, quality of life, and social support are important factors for the patients of schizophrenia as well as their caregivers. The overall difference in the three variables between the males and females was highly significant; nonetheless, the difference is more with females rather than males; hence; intervention strategies should be focused more on women for a better outcome. Further multicentric and community-based studies are vital to replicate the findings.
We thank all our participants who took part in this study. Dr Triptish Bhatia supported statical analysis whenever needed, also special thanks to Dr Smita N Deshpande who encouraged us to conduct the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Patel KR, Cherian J, Gohil K, Atkinson D. Schizophrenia: Overview and treatment options. P T 2014;39:638-45.
Chong HY, Teoh SL, Wu DB, Kotirum S, Chiou CF, Chaiyakunapruk N. Global economic burden of schizophrenia: a systematic review. Neuropsychiatr Dis Treat 2016;12:357-7.
Świtaj P, Anczewska M, Chrostek A, Sabariego C, Cieza A, Bickenbach J, et al.
Disability and schizophrenia: A systematic review of experienced psychosocial difficulties. BMC Psychiatry 2012;12:193.
Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK. National Mental Health Survey of India, 2015-16: Prevalence, Patterns and Outcomes. Bengaluru: National Institute of Mental Health and Neuro Sciences, NIMHANS Publication; 2016.
Kühl JO, Laursen TM, Thorup A, Nordentoft M. The incidence of schizophrenia and schizophrenia spectrum disorders in Denmark in the period 2000-2012. A register-based study. Schizophr Res 2016;176:533-9.
Thara R, Kamath S. Women and schizophrenia. Indian J Psychiatry 2015;57:S246-51.
] [Full text]
Mueser KT, Tarrier NE. Handbook of Social Functioning in Schizophrenia. Allyn and Bacon; (Eds.) 1998.
Stefanopoulou E, Lafuente AR, Fonseca AS, Keegan S, Vishnick C, Huxley A. Global assessment of psychosocial functioning and predictors of outcome in schizophrenia. Int J Psychiatry Clin Pract 2011;15:62-8.
McGlashan TH, Bardenstein KK. Gender differences in affective, schizoaffective, and schizophrenic disorders. Schizophr Bull 1990;16:319-29.
Usall J, Haro JM, Araya S, Moreno B, Munoz PE, Martínez A, et al
. Social functioning in schizophrenia: What is the influence of gender? Eur J Psychiatry 2007;21:199-205.
Chowdur R, Dharitri R, Kalyanasundaram S, Suryanarayana RN. Efficacy of psychosocial rehabilitation program: The RFS experience. Indian J Psychiatry 2011;53:45-8.
] [Full text]
Swain SP, Behura SS, Dash MK, Nayak AK, Pati SS. The influence of psychosocial dysfunctions in chronic schizophrenia patients in remission: A hospital-based study. Indian J Psychol Med 2017;39:157-39:
Lambert M, Karow A, Leucht S, Schimmelmann BG, Naber D. Remission in schizophrenia: Validity, frequency, predictors, and patients' perspective 5 years later. Dialogues Clin Neurosci 2010;12:393-407.
Wartelsteiner F, Mizuno Y, Apor FB, Kemmler G, Pardeller S, Sondermann C, et al.
Quality of life in stabilized patients with schizophrenia is mainly associated with resilience and self-esteem. Acta Psychiatr Scand 2016;134:360-7.
Chaturvedi SK, Muliyala KP. The meaning in quality of life. J Psychosoc Rehabil Ment Health 2016;3:47-9.
Lobana A, Mattoo SK, Basu D, Gupta N. Quality of life in schizophrenia in India: Comparison of three approaches. Acta Psychiatr Scand 2001;104:51-5.
Jacob JA, Kuruvilla A. Quality of life and explanatory models of illness in patients with schizophrenia. Indian J Psychol Med 2018;40:328-34.
] [Full text]
Kurtz MM, Gopal S, John S, Thara R. Objective psychosocial function vs. subjective quality-of-life in schizophrenia within 5-years after diagnosis: A study from southern India. Psychiatry Res 2019;272:419-24.
Munikanan T, Midin M, Daud TI, Rahim RA, Bakar AK, Jaafar NR, et al.
Association of social support and quality of life among people with schizophrenia receiving community psychiatric service: A cross-sectional study. Compr Psychiatry 2017;75:94-102.
Bag B, Yilmaz S, Kirpinar I. Factors influencing social distance from people with schizophrenia. Int J Clin Pract 2006;60:289-94.
World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1992.
Saraswat N, Rao K, Subbakrishna DK, Gangadhar BN. The social occupational functioning scale (SOFS): A brief measure of functional status in persons with schizophrenia. Schizophr Res 2006;81:301-9.
Saxena S, Chandiramani K, Bhargava R. WHOQOL-Hindi: A questionnaire for assessing quality of life in health care settings in India. Natl Med J India 1998;11:160-5.
Nehra R, Kulhara P, Verma SK. Adaptation of social support questionnaire in Hindi. Indian Journal of Clinical Psychology 1998; 23:33-39.
IBM Corp. BM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.; 2012.
Galuppi A, Turola MC, Nanni MG, Mazzoni P, Grassi L. Schizophrenia and quality of life: How important are symptoms and functioning? Int J Ment Health Syst 2010;4:31.
Sajatovic M, Jenkins JH, Strauss ME, Butt ZA, Carpenter E. Gender identity and implications for recovery among men and women with schizophrenia. Psychiatr Serv 2005;56:96-8.
Willhite RK, Niendam TA, Bearden CE, Zinberg J, O'Brien MP, Cannon TD. Gender differences in symptoms, functioning and social support in patients at ultra-high risk for developing a psychotic disorder. Schizophr Res 2008;104:237-45.
Ran MS, Mao WJ, Chan CL, Chen EY, Conwell Y. Gender differences in outcomes in people with schizophrenia in rural China: 14-year follow-up study. Br J Psychiatry 2015;206:283-8.
Pérez-Garza R, Victoria-Figueroa G, Ulloa-Flores RE. Sex differences in severity, social functioning, adherence to treatment, and cognition of adolescents with schizophrenia. Schizophr Res Treatment 2016;2016:1928747.
Ochoa S, Usall J, Cobo J, Labad X, Kulkarni J. Gender differences in schizophrenia and first-episode psychosis: A comprehensive literature review. Schizophr Res Treatment 2012;2012:916198.
[Table 1], [Table 2], [Table 3], [Table 4]