Physical comorbidity, insight, quality of life and global functioning in first episode schizophrenia: A 24-month, longitudinal outcome study

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Abstract

This prospective study sought to determine the clinical impact of physical comorbidity on patients with first episode schizophrenia (FES) and we tested the hypothesis that patients with physical comorbidity were associated with poorer clinical and functional outcomes. The severity of psychopathology, insight, social/occupational functioning and quality of life were evaluated using Positive And Negative Syndrome Scale (PANSS), Scale to assess Unawareness of Mental Disorder, Global Assessment of Functioning Scale (GAF), and World Health Organisation Quality of Life-Bref Scale (WHOQOL-Bref) respectively at baseline and at 6, 12, 18 and 24 months. Out of 142 patients, physical comorbidity was present in 21.8% (n = 31) of the patients, and they were mainly related to the cardiovascular, respiratory and endocrine systems. Compared to baseline measurements, patients with physical comorbidity had greater awareness into the consequences of their psychiatric illness at 12 months, the need for treatment at 12 and 18 months, and better improvement of PANSS total and general psychopathology subscale scores at 24 months. FES patients with physical comorbidity also had less reduction in their WHOQOL-Bref scores in the physical health domain at 12 and 18 months and greater increase in the GAF scores at 18 and 24 months, indicating better subjective rating of quality of life and objective measure of their global functioning prospectively. Clinicians need to be aware of the substantial rates of physical comorbidity in FES patients which may not be necessarily associated with worse longitudinal outcomes and the findings should encourage even greater efforts at early identification and management of these physical conditions.

Introduction

Previous reports have highlighted the presence of physical illnesses in patients with psychotic disorders such as schizophrenia, with prevalence rates ranging from 19% to 57% (Koran et al., 1989, Koranyi, 1979, Hall et al., 1981) which included infective conditions (such as HIV/AIDS) (Cournos et al., 1994, Stefan and Catalan, 1995) and conditions affecting the cardiovascular system (such as hypertension, dyslipidaemias) (Kendrick, 1996, Davidson, 2002), endocrine system (such as diabetes, hyperprolactinaemia) (Dixon et al., 2000, Sernyak et al., 2002) and gastrointestinal system (such as irritable bowel syndrome, hepatitis C, H. pylori infection) (De Hert et al., 1997, Gupta et al., 1997, Davidson et al., 2001). Despite this, several studies have suggested that the detection rates of these medical conditions in patients with serious mental illnesses remained poor. Koran et al. (1989) estimated that up to 45% of patients in the Californian public mental health system had physical illness and about half of them were undiagnosed. Koranyi (1979), similarly found that up to 43% of their patients in an outpatient clinic had physical illnesses and 46% were not detected in the course of treatment and follow up. Furthermore, these physical illnesses can potentially impact negatively on the symptoms of mental illness (Dixon et al., 1999), and result in greater healthcare burden, and affect attitudes towards treatment as well as the quality of life in these individuals (Hofer et al., 2004). This can, in turn, affect the subsequent management of these medical illnesses in individuals with serious mental illnesses (Sokal et al., 2004).

Most studies of physical comorbidity in psychotic disorders such as schizophrenia were conducted in patients with chronic illnesses and to the best of our knowledge to date, there is a lack of longitudinal data on the impact of physical comorbidity on the outcomes of these psychotic illnesses. Furthermore, studies of chronic patients are confounded by the prevailing effects of psychotropic medications and their interactions with the disease process (Meltzer et al., 2002). In this study, we seek to (1) examine the prevalence of reported physical comorbidity in a cohort of patients with first episode schizophrenia (FES) within a National Early Psychosis Intervention Program and (2) systematically evaluate the longitudinal outcomes of these individuals with respect to the clinical (psychopathology, insight, number of hospitalisation and duration of hospitalisation) as well as functional domains (psychosocial functioning as measured by the Global Assessment of Functioning Scale, quality of life as measured by World Health Organisation Quality of Life-Bref Scale). Based on extant data, we hypothesised that patients with physical comorbidity were associated with poorer clinical and functional outcomes.

Section snippets

Participants and study design

This longitudinal study report is part of a larger research project evaluating the impact of psychiatric and physical comorbidities in patients with first episode psychotic disorders (Early Psychosis and Comorbidity Project). The study population consisted of 142 consecutive subjects enrolled in the Early Psychosis Intervention Program at the Institute of Mental Health/Woodbridge Hospital in Singapore from March 2001 to March 2003 fulfilling the following criteria: 1) age between 18 and

Demographic and clinical characteristics

Table 1 compares the basic demographic and clinical characteristics of FES patients with and without medical comorbidity. Of the 142 patients, physical comorbidity was present in 21.8% (n = 31) of the patients: 16.9% (n = 24) had co-existing medical illnesses, 4.2% (n = 6) had co-existing surgical illnesses and 0.7% (n = 1) had both at baseline. The medical or surgical conditions were related to the respiratory, cardiovascular, endocrine and other bodily systems (Table 2). There were no significant

Discussion

This study highlighted that physical comorbidity was not uncommon amongst patients admitted with FES. Over time, patients with physical comorbidity showed significant improvements in their level of awareness of the consequences of their mental illness, effects of treatment as well as psychopathology, observer rated global functioning and self rated QOL, thus disproving our hypothesis that patients with physical comorbidity had poorer symptomatic and functional outcomes. This is, to the best of

Acknowledgements

This study was supported by a National Healthcare Group Research Grant (K.S.) (STP/02003).

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