1997 - Does Quality Of Life Differ In Schizophrenic Women And Men - An Empirical Study

Intemdtio&l Jotmol aI Social PrJchidt l (1997) Vat.43 No.2 t29-113.

DOES QUALITY OF LIFE DIFFER IN SCHZOPHREMC WOMEN AND MEN? AN EMPIRICAL STUDY UTE ULRIKE RODER-WANNER, JOSEPHP. J. OLIVER& STEFANPRIEBE SUMMARY ln our sludyof 617schizophrenic patients, we tesledthe hypothesis lhat women have a betterobjectiveand subiectivequatityot tife than men. Bettersocial rntegration ol womenwas confinned.Objeciiveconditions had a signiticanl but quantilativey smallimpacton satistaclion withspeciticlifedomajns.Benersociat inleg€tiondid not, however,tead to more satistactiofamongschizophrenic women.Satislaction with lite in generatwas bette.predictedby satisfaction in prcdictorsot satisfacljon differentlile domainsthanby objectivecircumslances. with lile were not equal fof bolh sexes. Batherthan continningquantltalive ditlerences in subjective quatityof life,our datasupporllhe existence ot genderspeciticprocesses andconle)ds oi subjective vatuation.

INTRODUCTION To naintain or improve quality of tifc of the mentaly ilt is one of the naior ains of p \ ) L b a r n c c a r e . D e s p , r er s l o " t ) g ' o w i n g t r r e r a t u r er.h e r e 1 5 n o g e n e r J l i ) a c c e p r c d operationaldefininon of qualiry of life of the mentally i . Nevenheless.lhere is broad agreemenltbal subjeclile indicarors should be assesseda.swel as objecrive indicarors. Objective measurescover sociodemognphicirems.indicarorsof healthand tiving condirions and rolc fu.ctioning o. performance.Subjecriveindicalorsaremeasuredby gtobal wel_being or salisfactionwith life in generaland wirhjn diiTerenrtife donains. As for fie ..obiective; p . ) c h o l o p i c aal n d \ o c i r l s u a l i u no f . c h i / u p n r e n j cp r e n r r .d u r i n gr h e l J , r t 0 r o i 5 )cu\ empncal studieshaveshown imponar! genderdifferences.Wamer and decnolamo (1995) slate lhat gender differencesin schizophrenia !!may prove to be a producrive area of Schizophrenic women premo.bidty seem to be betrer artapted. Even early i! adotescence they are less isolated,have more relationshipswith their peersand more sociosexuallies. more rnt€reslsjand more funciioning oulside rhe ouclear family rhan men (Chi1de6 & Harding, 1990;Foerstereral. 1991;Haas& Sweeney,1992:ciuetrnan Kte'n & Ktein. 1969: Shmseler dl 1992b).In adulrhood,women a.e morefrequenrlymaried the rime of onserof lhe disease(Angenneyer?| al. 1989,Bromer et at. t992; Haas?r dl 1990;Hatuer et aI. tggg. 1993a:Huber G. er .1. I 979). Women have a higberprecentageof adequa!€role pertbrmuce in pannership, occupaiion, income and livmg condnions and fewer breaks in the pc.formance u f \ o c r J lr o l e sp r i u rr o n r j r d d m i s r o or h d m e n ( H a f n e tc r d t t o e 2 . t q q l a r c o t d s t e i n .r 9 U 8 :

110

QUALTTY OF LIFE IN SCTMOPHRENIA

Goldsteinet al. 1990).cender differenceshavealso beenshownin rhe ctinjcal fealuresof rhe disorde.: in ils onser,ils cours€ and its outcome.Age at onset of the diseaseis higher in w o m e nL h l n i n m e n .T l u \ h u l d r r r u e f o r $ e n , : r n o n c p e c i f isLl m p r o m , o f m e n l J ti ; e $ r , well as for the iirsr psycholic signs and lhe first hospiraladmission.tn contrasrio mat€s a secondpeakofincidenceof the disorde!is seenberweenihe ageof 40 and 50 (Angermeyerer al. 1989. 1990; Eifner er at 199t; L€win€, 1980, l98tj Mccl:$han & S,raenitein. iqSO: S h r r \ e l ? rd / l o o 2 b , A n 8 e m e l e r & K L i h n t t { r 8 8 l r n b n o \ e r v i e w orth el i r e n r d r e . I o u n d lhe S e n d ( 'd i t l e r e o c .i n a g e d r h r s ra d m i \ \ i o nr ' l 0 r m e di n < 0 n u r o i 5 1 s t u d r e sS. . n i z o o t f e n , c $ o m e n m r ) h a \ e d i t f e r e n r. ) m p r o m , : ! h e ) e \ p e f l e n r eJ r f e ( f i r e a n d p a r a n o r d\ ! m p r o m r more rrequently,and negarivesynptoms less frequerrly rhan men (Gebhardt& pietzcker. 1985jGoldstein,1986;coldsrein el.rl 1990;Mcctashan & Bardensrein.1990:Shhsel e, al r a o 2 b , .s c h i z o p h r e t umc e ns h o wa h ; g h e rf r e q u e n c o ) f r o . r a ) n c 8 c r r v eb e h a v i o u rs,u c ha \ aggressivebehaviour,rrouble wirh the law, self-neglecr,social witbdruwal and alcohol and d.ug abuse(Diebold & Engel. 1977;cebh dr & pietzcker, 1985;Haas"ral t990r Hiifner?, dl. 1992i Mccl.shan & Bardenstein, 1990). Some studies have shown superior clinical responseof woncn to neurolepticrealmerl (Seernan,1983;young & Meltzer, t9S0) as well as to socrothenpy and to family inrervenrion rearment (Haas er al t990; Ho]afty et at. 1974).The cou$e of rhe schizophrenicdisord€ris perhapsmore benign in women, with a smaller .isk of rehospiralizarion,a smaler average number of hospiraliz,rions. shoner avenge length ofhospital stay and of overall iime spen!in hospirlt, and berterpsychopaiho logical slatus at lbllow up (Angemeyer e, at 1989, 1990: Childers & H;rdins. 1990r C o l J . t e j n .l 0 8 8 :M c c l a \ h $ & B ! ' J r n s r e r n t. v o 0 :U J ? r 1 1 .t a 8 1 r .I n a n o v c n r e q ; f m o , e than 100 studieson the courseof the diseaseAngermeyereral.(1990)found that abourhatfof them confnn the more favourabteclinicat course in women. whereasonlv four Droduce c o n c l u s i ! e l yb e r l . r o u r L o n , eF \ u t r s r n m ( 1 . l J h t e n \ k yc r a l . ( t q q 2 ) c o n c t u d cI n r h ; W H O _ study that genderis a predicto. of rhe courseof the disorder. Not only the clinical bur also rhe sociat siuarion seemsto be relativelv advantaseousfor I h c r e m J l eD J r i e n !d5u n n : r h ec o u r \ eo l r h ed r \ e a \ ( .T h e ) J r e b e e r o f f i n r h c i rg t o ; a t \ o c i a l adaptanon,more often bave regular employment, less often have negaiive proibssional developmeni,less often retirc early. have superiorfamily and occuparionatrole iunctioning, more often live wiih a pafiner oi rhe opposile sex and more of rhem are hererosexua v active. b-e more independenr.To be iemJle predi . befter ,orrat fLncrronrns in scn.,,oohrenir r ( h i l d e r s& H r r d i n 8 . 1 9 , r 0 .D e r l r e r& M J m e r o . . t o q . ' i H d d sp , a / . l q a - 0 J: a o L e n s tev M L l a o 2 :M c G l a . h . n& B r r e n s r e i n .I a 9 0 :p r e r z c k e?rr d t . l 0 8 2 :S c h J h u nc / a t . t 9 8 t , iT i r . r a / . l q a O , .I n a n o ! . N r e s o r l ? n u d r r j . r e d t i n gw r ! hs o c i J t: d a p u r r o n A . n g e r m e y e?, ; d / ( l c a 0 l found halfshowing bederoutcomein women,oniy lwo showingbefter@cup;bonal statusin Not a[€ited genderditTerences areconclusiveiyprolen. Themost consislentfndins is rhe d i f e R n c e I n a g e a r o n \ c t o l L n ed i n { d e r . S o r n eg c n , l e rd r l l e r e n r e .o i m j n i . h o r h a v ed s . appearedin studies with very iong-rerm observarion periods (Angenneyer er al I 990t Bteuie., 1972; Ciompi, 1980; coldsrein, 1988i Huber C. et at. t9j9J. So, desDitesome methodol o g i c a ld i i f r c u l u e b r n dd i f f e r e n c e cl h. e r eL s u b s. n u a t e m p i n . r t e v i d e l . e I n a ts . h ; T o D h r e m c $ o m e n a n d m e n o , i r e rr n p . i c h . , l o g r ( aa r . w c t r a , s o c i a lL h d r c r e n . r i c s h . r , r m o o n a n tl o l n o s s h e r h c rr h e \ ed r f l e r e n c e dr e r e f l e c r e di n r h e . u b i e c u v ep e r . e p u o n "o i u r i w o m e n themselves.Are schizophrenicwomen happieror more satis6edwitb rheir liv€s than men?

U RODER,WA}i'}IER ET AI-.

1-r1

In a national survey of the generd popularionin the United States(Andrews & Withey, 1976i Campbell, I 981) no (or only ninor) differencesin qualily of life were found berween women and men; for instanceglobal well being is aboui the same in men and woncn. Andrews and Withey aiso failed to find any scnder difference in satisfaction with different life donains bul nevertheless describedthe subgroupwith the lowes!qualiry of lif€ as mainty fbmale, with children and wilhout partDe.ship.Campbell (1981) found America. women tendedto be lesssatisliedthan men: they were lesssatisfiedwirh mmiage. wilh then heahh, hemselves,with their saferywhengoing outin rhe evening.Women weremore pronero state tha! they had had less luck in $eL life rhan they expecredand hld more experiencesof negativeaffect in the recentp:rst. Brithh surveys,in the specificdonain of healrh, have indicaled some sex differencesin satisfaction.On average,women appeu slightly more dissalisficdthan men wiih their owt heahh, alihough a ereaterpropo(ion of wonen atso rare themselves,.s complet€tysarisfied (Abrams & Hall, 1972: Hall & Ring, 1974). At 6rsi sight contradicrory,this coutd be explaj.ed by womenis strongerrendency!o mle themselvesat bo& rhe exrreme ends of satisfaction dissadsfactionscales.Brisco€(1982) evduared UK surveydaraand dala from a generalpractitionersample with a high jncidenceof minor psychologicaldisturbance.She concludedthat women are more likely rhan men to report feeling slilles,both pleasantand In a surveyof thc generalpopulalionofthe Fcde.alRepublicofcermany, clatzer and Zapf 1 4 8 4 ,r o u n d$ o m e nI e ' " s a n \ h c dl n J n m e ni n o ' . i 2 h l i i e d o m a r n \i:n o n l , o r e , c h u r r h ,u e i e they more satjs{ied.Wornen expcnenced less satisfacrionnot only in educarionatand Fofessionll domainsbur also in public and private ones. Claizer and Zapf even declared r h e mI u b e r h e d F s d t i \ f i e dg e n d e r . I n f u n n e rr e p r e s . n u l i \ er r u a r e sr n F R C r s r r r r . r i s c h e . Bundesatu, I 985, 1989,I 992 and 1994)genderdiftbrencesin rhe generalCennanpopulalion seem!o oecreGeoler llme. Despilethe known genderdifferencesin rhe objectiveconditionsof schizopkenic patienLr, shtdi€s explicitly dedicaled to quality ol life give only scant inforrnarion on sender d . l f e ' c n c c s S e \ e r a la L r h o r , 5 r a r e$ ! r g e n d e rd o € r n o r p t d ) a n r m p o n d n rr u l e r o r ; t o b i l qualit) of lile or giobal well being (Baker & lntagliata. i982t Huber ?. a/. 1988; Lehnan, 1983,1988;Levift el al. 1990:Mettze' et ol. 1990).Heinrichsar al (1984) assessed quaiiry ot' life within four caegories: intrapsychicfoundation", ,,inrerpersonairetations,', ..instrumental role" and conmo. objects and acriviti€s". A factor analysisrevealed different loadingsof threeitems of the subscate"inrapsychic foundation" (senseofpurpose, ainless inactivity and cudosrty) for schizophrenicwomen and men on rhe qualiiy of life facton "inrcrpersonal reladons", "instrumentat rote' and ..inbaps)rchicfacror,,. They exptain these findings to be due ro societaldifferencesbetween women dd men. This. it seenN. indicates implicitly that equal d€iicits in schizophreniamigit disrurb quality of tife in a genderspe.ific way. Shtaselet al. (19922,1992b)appliedrhe sane qudity of liie scaleand identilied by faclor analysisrhreefactors.One facto. sociatfuncrionine.. covers inrimate r e l d r o l " h i p . .a . u v e a c q L a i n r a n r e . . . o c jrrttu r i a r i ! e . , u c i J$t r l n d r a w a ts. ; i u " e \ u a l r e t d u r n . and annedonia.Schizophrenicwomen bad belrerraringsin rhjs qualiry oftife factor thanmen. They also had beuer funcrioningon rhe eDgagemenf,factor. which coveredreladonships with family, a senseof purpose,molivarion, cunosity. possessionof commonptaceobjecrs, engagenentm commoDplaceactivities, empatby.dd e.gagementwith intervjewer.There

t32

QUALITY OF LTFEIN SCXZOPHRENL{

was no gender difference in the third faclor, the ..vocationatfunctioning,, Shraseler at concludethat in a''sense of life involvenent,' (measuredby the ..engagemena,) eOL facto; and in socialrole functio ng. qualily of lite is rclatively lessimpairedin worn* trr* in **. Holever, ihe qualiiy of tife scaleused in thesc studiesis an i;shment desjgneilto assess deficir sympbns and role funcrioning rated by rhe jnteraieweri and ir conrains no subjecrive indicalorsofquality of life. Studieswitb data on objectivelife condidonsand generaiwelt_ -of being, satishction wirh Ufe and wirh diffe.enr life domains.assessthe impacr senderon q c l l . b e i n e o\erall or rJristacrion w h t r f e r \ a w h u t e .r a l h e -r r r a ng e n j e r d u r e - r e n c er n . specificLife domains. thes€srudieson genderdifferencesin schizophrenicparientsand on quality -h-conclusion of life in the mentaly itl sugges!fie byporhesisrhat (in contrastro iile gener"rpopui,t;onl subjectivequaliry of life shouldbe betrerin schizoptrenicwomen rhanin men becauserheir objective sociai siuarion is less impaired, and gender specific pe.sonni and behaviourat characterisiicsshouldailow schizophrcnicwonen ro have a beudsubjecrive qualily ofiife. The presemstudy examinesihe impact of genderon the subjectivers;ects ofihe quality of life of schizophrenicpatienls.

METHODS Subjects and measures 617 psychiatricpatients.270 women and 347 men, werequesltunedin 1993and 1994on rhejr actualobjectire and subjecdle quatiiy oflife in Berlin (407 parjenls),and in the Nonh_Wesr ofEngimd (210patients).All ofthem had a diagnosisofschizoptueda or schizophrenialike disorderaccordingto ICD-10 (F20 and 23), and aI of rhemhad ;crual contactwit'hsome kind or comnmrty cde service.z!42parientsLivedjn the conmunity. Most of them (352) were out patientsin a psychiarriccollnnunirycaresystemand of these.85 lived in singteanjg,nup protectedliving aparnnenls,hosrelsor boardinghouses.Ninety of lhe parienrsIiving in tle c o n n r u n i r )w e r ee x t u n i n edou r i n et n e r n r s rp \ y c t u d L r ihco s p i r a i : r r y t r 5 p a r , e n r . * " i e r o n e l e r m m ( n l a l l yi l l r n d l u n g - l e m h o \ p r r a t r z c,d_ o t o | ' t m o n r h \u p r o r s o y e a r . .o o p u u . n - n for nore than two yearsl. The gend€r dislribution was aboul equal in patienrstiving in the ( u m m u n i r va n d i n r h u s et r v r n g i n r h e h u \ p i r a t Ouatir) of iife uar n,e*ed Jirh ue L a n c a s t u rQ e d a l r r )o i L i f . P r o h l e .d e v e t o p r db y O t j \ e r i n B r i r a r nr O L ! e r . I i r o t , r n d j 1 5 u c m d r v e h r o n .r h e B e r l i n e rL e b e n \ q u a t r t a r s p , or pt ir' i e b e" r a / . t q o ) , . T h i " q u e s r i u n n r i r e w a s a e v e t o p e ud n d e rl h e d s r u m p l i o nr h . l q u d . i r y, . f h f e r s I m u l U d j m e n s r o n d t c o n , t r u c ld n d that objective |o be consideredas we as subjecrivemeasures.Ir bas been appliedin severalcounrriesand translatedinto severaltanguagesinctuding Chinese, Dutch, Italiar, Nosesian and Poush (oliver er dl- 1996). Ninc Uftdomains -! in"rua"a in ti," pJofile: halth, !ork, 6ndces. personat safety, sociat retanons. family. leisure, ljving srtuanonand religion. ln this study religion has bcen omired due to the tacl of variarce in L h e B e r l r n , - m p l e . S d I | J a c r i o ni s \ c o r e d ^ n a 7 . p u n l s c a t er a n r i n e f r o m c o m o i e L e l r d i s . a u , f i e d, | ' r o c o m D l e r e ls) a r r 5 f i e,d- , . q i r h 4 , J t r e m a , c t.)d L i , f r e ;a ; d o 6 . a r : , n e o , as: midpoinl. A subjectiveglob,l quatiiy of life measure,satisfacrionwith life in gene;!I, is scoredin the samewav.

U. RODER.WANNER ET AL,

RESULTS The importanceof gender for fie qualiry of life of schizophrenicpntientswas assessedin L Do the obj@rlve and subjectiye indicarors of quality of life differ for mate and femate sctuzoplr€nia suffere.sl Il. ls salisf:clion with a given life domain der,eminedby th€ conesponding objecrive srtuahon and how is it inltuenced by gender after removat of this eft.eci? IIL Is global wel-being or satistactionwirh tife in generalin schizophenlc women and ruen predictedby the sameobjectiveand subjectiveindicators? I. Objective and subjective indicators ofquality oftife in schizophrenicwom€n rnd men L Objectire indnabn The objectiw situalion of rhe schizophrenic women differs ctearly from th,r of the schrzophrenicmen (Table t). The wonen are older and were al€ady older at fie time of Table1 Dcmographic daraand objecrivetivi.s condiri,rn!

Ase or fiN adnt$jon (yc6) Mon.y nt dispos.l per nonrh (DM) Numberof leisureaciivitics

29.3

26.9

.'

2.9

3.0

{*)

35.3 In rbe connuniry u.sheheEd h be comunny shelkd Longrm hosplal {ay

59.9 50.8 9.2 13.5 t0.9 30.? '11.6 123

Connic(wirhla*. past).d Beinga vicrim,psr yeu

16.7 15.0

Spouseo. liie conpanlon

231

Fregu.nct of contud rnh pnmrt fonib

t2.l

35.3 16.5 60.7 615 393 33.5 62.2 6t.2

Cora.r with frisnd. pst *eek c o n u c * $ r e d ' c . . . 8 * . F m . o r p n \ ! . . J t r . t n e $p J . r j ( c Lo0ract$ru p\y(hi.ric crre syskm,pan y.r ror nalents hqnB 'f, rhe l(munjrj

onty

50.0 53.0

i

QIJALITY O! LIFE IN SCHIZOPHREN]-A

Th€ generalpopulllion in Germany

t3% 29v.

'Daterepon 94 ! altensb.cher derDenoskopie t 934-1992 Jatuouch their first admissionto hospiral;ihey are more ofteo jn employmen(,and ihis holds true even if shelteredwork is excluded; have more monel per moDtb a1 then disposal; live less frequently in sheltercdenvironmentsand more frequently with their families; more oflen have (or had) a spouseor life companion;visited a doctor or a hospiralmo.e o{tenbecauseof physic,l illness in the past yea.: ue less olten accusedof a crime, and have a Endency 10 participlte in fewer leisureactivitics tban the men. There Jre only two variableswhere fi€ exmined wom€n ard men do nol differ: Equal nunbers had been assaultedor beatenin the past year and, surprisingly,no difference is observedin their social life (such as having a close friendship,having a reliable fhend, having rccendy seena hiend and having rnore or less ftequem conlactsto the pnrnary family). Compatible with other findings reviewed lbove, the schizopkenic women in thjs study (althoughprobably worseotf thar lhe generalpopulationar one can seefrom Table 2) have better obiective conditionsin severallife domainstban the schizophrenicnenAs already indicated, these differences might be explained in several ways. Gender differencesin occupatioDairole, mar;tal statusand Living sinradon could not only be due to gender differencesin the disease,but mighi be explained by lhe diffe.eDt age at first admission. which lrappens in men in an earlier and even 'nore sensitive pe.iod (of professionalintegration and helerosexualrel.ttionships).Gender specinc roles nay well accountfor the wom€n s tendencyto have less leisureaciivity and fewer conffictswith law, which is also seenin the generalpopulatron. 2. Subjectire indicators af qualitJ of life Table 3 shows the padents' averagesatisfactionwith life in general and with severallife domains. Table 4 shows the percentages of patienls who are either rather satisii€d or rather dissatislied(mther than those who are undecidedand alemately satisiiedand dissatislied). For comparativepurposes.daia on the generalpopulalion in Gemany de also shown. a) The averagesltisfactun of schizophrenicpatientsseemsto be less for all life domains and global well-being |han in the generalpopnlrtion (Table 3). The percenrageof padents saosliedwith theirliles, with work. finances.Iiving,pannershipand healtbis smaller,and the percentag€of dissaiisfiedpatientsiarger (Table 4). At the sme rime, schizophrenicpatients

t35

U RODER.WANNERET AI-. Tabte3 rilh life in general and flirh lile donains

Average stisfuctioo'

Gen€ru| populstn'nh wonen Men

Schi,ophenjc patienrs Wom€n Men

SltisLction with Enployed Un.npldt.d Al,o6ehd Eamings Pdne6hip orhntuhily FEquencyofco acr Altogerher Friends Ceninson rid oihen LennE aclivities LiviDgsitution Pe6onrlsalct] lin$ces

5.1 4.2 4.5 4.1

5.0 ,1.1 4.1 4.2

4.9 5.0 4.? 4.9 4.8 4.9 48 41 4.7 4.3

54 5.1 43 51 41 4.9 4.3 1.9 (.')' 5.0 1** 4.2

5.9 6.0

59 58

5.4 5.9

5.3 5.8

5.2

5.0

4.5 4.1 5.0 5.0 In geneFl McnLJ 1.4 4.6 1.5 5.7 5.6 Life in sfl€ral 43 "Selen loint srle of srtklacdon1l =complerelyd^satishedl ed 7=.omplerel)sarsnedi4 = midpoi.r llremablt sarisliod blnftrcst (HealthSuwey) c rg.ificmt diffeEncs: (!) p <.l; ***p =.0o1 Tablc4 Pcr.€nlla€olsrlisf€d and dis.lislied won€n lnd mcn

Sllt|lction

vith

Work (€nployell Finrnces lrsure activitiG Pft*hip Livi.g nt!{ion Hqtn b genenl Mentalhealth Life in gederar

(icner.l

\.htophrrnic p.rienB' Wooen Men

69.2 52.1 63.2 58.8 62.3 56.7 52.8 45.1

66.7 49.3 71.3 ?6.6 63.3 63.3 58.6 53 3

Dupuhliunh

*' (r) (i)

88 73 85 91 a1 ?6

*

92

SchiTuphrrni. ltlienB' Won€n M€n

12.I a4.l 19.9 2n.0 25.1 28.7 29.6 24.1

17.3 37.1 11.2 12.8 1J.3 t* 22.3 e) 2,1.0 (*) 23.2

Ceneral plpulllion"

5 ll 5 2 s 13 l

" lx'irfied: scoEr oi 5 uDto ?. dissatisfre{ scorcsor I up to 3 on rhesevenpoinr salisfrtion 'Darenepon 94j sarislied: scoEsof 6 roi di$aiisfied:scoEsof 0-4 on lhe 1l rFiot "sisnificrnlditreEncd (i) p s.li *p <.05; '*p <.01

136

QUAI-ITY OF LIFE b- SCI{I2,OPHREMA

are more often undecided in lhen subjecrive evatuarion. One mighr say that worse objective conditionsfor schizophrenicpatientsseemto be reflecledin their tower satisfaciionwiih both their Livesin gene.aland severaltife domains. b) Asjudged by mean sarisfactionvatues(Table 3) rbe nost satisfying life donains are work (obviously only for rhose who are working), inle{personal do;airs and teisure activities. Both women and men are tea* sansfied with their health in eenerat. their m e n u l h e a l r h .l i i e r n g e n e r u l f. i n . n c e sd n d i f r l l e ) d o n o r s o r * _ b e i n 8 u n e m p t o y e d . Compding global weil-being and sarisfaclioDwith the tife domains vielded sisnificant dilltrencer only in one damain: rhe lctuzophrcnic women are tes, , rsfiea t^irtr Llerr personalsafety.They also rend !o be lesssatisfiedwith th€ir tiving siluarion.Compdjng the percentageofsatisfied or dissatisfiedrnalesand fenates, more differencesappearimoonant. F e $ e r o l $ e e t J r u n e d s o m c n d e . a l r h e d $ i f i t r t er n g c n e m ta n d u i r h p a n n e n h r pa. n d i r seemsthat fbwer are satisfiedwirhthejrliving siruadonand with rhen he th in sener;I.Morc o f r h e { c h i z o p h r e n 'sco m e n J r e d j - h r j s h e dq i r h l h e i r t r r r n gs i r u a l o na n d m o r er e n dr o b e dissatisliedwiih their healrhin generaland rheir nenlal heallh. This minor differenc€in rhe resuhs (when comparing averagesatisfacrionand percentagesof sdtislied and dissalisEed female and male patients)is due to rhe ldger proponjon of wornen being uodecided_ We crn conchde rhat despile a tot of difierencesjn ihe objcctive circumstancesof life. geDderdifferencesin sarisfacrionwirh ljfe in generaland with thc differenl life dornainsa.e suprisingly small od thar we have to reject rhis pdr ofour hypothesis.The schizophrenic women, althoughsocially better adapledthan the mcn. haye no better subjectivequalitv of l i t e r h . n m e n .u . r h F g a r d r o p e F o n a l\ a i e r ) a n i j r h e i rl i ! i n g s i r u d r i o nr.h ; y f e t ; v e n i e . Since w€ combined data from England and Gerlllany in our anatysis, differences between the English and the Germansubsampleare wotth considering.As far !5 objecrivevariables aretorcerned, a sjgnificandy larger percentage of cennan parients are long_term hospilalized (45/4).live alone(50/35).havea spouseor rif€ cumpanion1:Vrry. a.. "mployed (34/12) and have beenvictim of a c.ime in the past year (19/10).They havefewer coniactswirh their primary family (569, daily or weekly vs. 719.) and a betler income (1027DM vs. 652DM). R ( g d J r n g t h e \ u n j e c r i l e d a l a . C r n a n p a r : e n r sr r e m o r e s J l i s n c dq i t h l h e i r f r n a n c . d l srtualron(4.4 vs.3.9). the;r fdends (4.9 vs.4.7) and wilh teisule acrivities (4.9 vs.4.6). Other differences in global welt,being and satisfrction with the Life rtornains fail to reacir statisticalsigaificance.However, atl differencesberweenwomen and men that are idenlified in this paper occur in rhe E.gtish as well as in $e cerman subsamplein a simihr wav a l r h o u S bs i r h v a D i n g d e g r e e ,o f s r d r i \ r i c ast j g t u f i c J n coer - i n s o m e { , e s _ w r d r o ; slalisticalsignificancein one of the two subsarnples. D're ro tbe lack of gender-difference in gtobal well,being and sarisfacrion wirh life domains. we examined whether the objective conditjon of our patienls i. a given life domain was rcflectedin iheir sarisfactionand if so, ro what degreejt is possibly ;ituenced by gender. II. Effect ofgender and an objecrive domain-sp€cificcircumstance on satisfacrionwith a Iif€ domain Analysis of variancewas undertakenwith genderand a domain-speci6cobiecrivevdiable as i n d e p e n d < nv ra n a b l e sr n d s d r i s i o c t r owni r h t h e c o n e , p " n d i n gt i i e d o m a , na . r h ed e p e n d e n r variable.Resultsare shown in Table 5.

t3?

U. RODER WANNER ET AL. labl€ 5 Th€ eflEt ofg€ndcrand of lh€ objetir€ circunslrnceon the $lisficlion eilh a life domrir Independent obj€clive rariable

Ell€cl of ob.ielive '*irble'

Erecr ot Fx'

Efted of inl..a(tion'

i. rhdcohnunity and unsheltc€d

c)

Psychirtic cm systemfreluented psych.bd otn€r cm synen fEquenrcd noney pernondl (spdaredar nedian) hon-psychahc cft sysGmfrequented

r ( ) p < t . p < . 0 5 i ' i p < . 0 t* ' t < . o 0 l ' + r t p < m o a) Satisfaciionwith a given lile domain dependssigniGcantlyon the obiective circum stancesrclated to it with the exception of one case.Satisfacdonwith the living situation is depcndent on this siruatio!: parients living in rh€ conmunity, especiatly those Living rlnploiected, are more satisJied than those living long-term in a hospilal. For these patienrs in the communiry, satisfaction th living conditions is also related to whether they iive with the family or not; hving with the family rcnders people more salisfied. Salisfaction with personalsafetyis influencednegativelyby having beena victim ofau offenseduring the past year. Satisfactionwith leisure activities is increased*ith the increding number of leisure activities-Satisfactionwith financesdependson disposableincotrte.Patientswho work are more satisfied with their occup:uional situirion than those who do not work. More frequent contacts to the primary family are accompanied by more satisfaction with the p.inary fanily. Satisfaction with f.iends depends on the exjslence of a close and/or reliable friendship. Patie.rswho have seena doclor or were in hospitalfor somephysicalillness during tbe past ycd de less satisfiedwith tbeir heallh in generalrhan thosewithout contactto the medical syslem.There is one exceptionto this regular panem: salisfactionwilh mcntrl heallh is not Ielaled to conlact with the psychiat.ic care systemduring the pasi year. b) with the objective conditioD kept constant,gender has a signiiicant influence on sarisfaciionin two life domainsi Living situation and personal safety. The schizopbrenic worien, even in the sameobjective circunstances,feel less satisficdthan the schizoph.enic c) Age asa covrriate h6 a signiGcantinfl uenceon sltisfirctionwithliving situaiion(only iD tbosepatientsliving in the conDunity), finaDces,menlal bealth and occupauonalsituatio.The signiEcantinltuenceof the objectivesituarionand of gender.emainsunaffected(oreven increases)by cont.olling for age. d) An int€raclion between gende. and some objective neasures is of some inponance for satisfaction with leisure rime and mental he!]th. The inltuence of fie nurnber of leisure

tl8

QUAUTY O! LIFE IN SCHZOPMENIA

activities on satisfactionis pronouncedin schizophrenjcwomen. As for sarisfacdonwith rnental h€atth, women and men reacr in opposite ways. Whereas wom€n who had frequenred the psychiatric care sysrem during the pasr year are rnore satisfied wiih rheir.ment: heakh, rnen are less satisfied_ We cltn conclude rhai i! seve.al life domajns sucb as occuDationalsituarion. {inances. l e r s u r ea r d u r r e , . n d c o n r o f l w r r h r n e m e d i c J l. u e l s r e m n o i o r l y a r h e r e0 d i f e r e n c e belween the objective circumslancesof schizophenic men and women. but also that satisfaciionwith these domains dependson rhesecircurnstances. Nevertheiess.no sender diFferencein \arisfacrion wirh rhese Iite domr:nr sar ,oLnd. The ,ote of rhe diilennp o b j e c l i \ ec o n r i r i o n st.h o u g hs i 8 n i n c . n l t yd e r e c r J b t \ee. e m rq u a n t i r r \ e l ) r o o . m a l l r 2 I U d explanatjonofvariance) ro be reflecredin differins srtisfaction. T h e o b j m t i v es i r u r i o n a l \ o . f e c r e d p e A o n " te i a t u a d o no i t r v . n t s i t u r o n d n J p e r , n n a j saftfy. With the objectivecircumstancekept constdt, gerder l]tso has a sig.ificant i;fluence on sat'sfiction wirh thes€domains.To be a schizophenic woman neans tess satisfactionin We therefore conclud€ rhar rhe size of rhe impact of better sociat adaprarion js smal. and schuuphrenrl \^omen are nor. d: r consequence.Tore \ari,fied Neirher do pcnonal capacjtiesor fewer dencirshelp rhem ro be more srrisfiedunder equai conditions. lII. Obj€ctive and subjectiv€ d€t€rminants ofgtobat we -b€ing in schizophrenic women Three multiple s€pwise regressionanntyseswe.e carried out. The fiIst was conductedwilh vaoablesindjcatingobjectiveljfe cicumsknc€s, the secondwirh the subjectiveindicatorsi.e. saLr\facr,'n $ i l h d i f t e r c n rl i f e d o m a r n . .u d r h e r t u r ds , r h b o r h o b i e ; r i v ed d \ u b i e c o \ e ' n d r c a r o ro, f q u a [ r y o i h l t . O b j e c l r \ ei n d r c a r u hc n \ e r e de a c ho f L n er n r e r e s r i nI g iie domarn, ! n d u e r e .a t s cn. u m b c ro t l e b u r er c r i v i u e sm . o n e \ r r d i s p o \ : p e rm o n r h :r h et o o w i n g w e r e enteredas dunmy variables:having work. trving unshelteredin the communjty. tiving with the fnmily, having beenvicrim of 3n assaultduring the pastyear,having beenchuged;rh m ofience, having a spouse or life companion, having frequ"nt contaci *;tt pri,nu.y tamity, haung a close friendship, recem coniact wirh a friend, having used the psychiarric care systemin the past year. The following subjecrivemeasureswere enteredin rhe resression a n a l ) . r s s: a r i \ l a c r i o "n i l h t e i \ u r ea c ! v , e s .\ a l r , t ] (r i o n $ r r ht h e t i n a n c i dst l | u a r r o ni a. r i s t a c _ tror wiah the living siluation, sarisfactionwith personalsafety, satisfaclionwirb getting on with othe.s,sarisfacrion\aitb fnends, tamily and with n€nial health.The resuttsare strowntn Table 6. Significantpredicrorsof the subjectiveglobal quatiq, of life are shown in the mnt order of their importance for the exDtanarion oj vulnce. a) The obhined predictive power js moderatefo. tbe schizophrenicwomen as wel 6 for th€ men. Subjecriveindicators alone predicr satisfactionwirh life i, qeneral be!€r thr o b i e c r i v eI n d r c l r o r . C o m b i n a u u nu f b o r h , e d d , u n l ) r o a . m J r n c r e a r ei n r l e a m o u n r" i varianceexpiainedin borh groups. b) More variancewas explainedusing subjecuveindicalorsof qualiry of Life for selected g r o u p ,o f p J r i e n l s d. . f o r L n , r : r n l e t b r L n e, u L ' c o r e g o r . e".o r t r n g r n o rs o r k r n g .u r t r v i n g , n u t living with family. c) Subjectiveglobat q'rality of life, i.e. satisfacrionwirh life in generat,is detenninedby difibrent objectiv€ indicarors for &e schizoptuenic woncn and for rhe schizophrenic men.

U. RODER WANNER ET AL. T.ble 6 or s.tisfacti"tr *ith lif€ in gene.ll Dd$ninanls {multipl€slep*i* regr6sion $mlysis) t objrctre Women

deteminonc Rsenl.o

Men ad wilh a incnd

Nunber ol leisu€ dtivities

I stujectuedekninui

ltl Obje.tiv

att subtectie deteminon6

Living Recent conract vilh I hend

The subjectivedeterminantsofglobal subjectivequaliry oflife arealso differenl.For women, the most important predictor is sltisfaction with menial health, a subjectivelyunsatisfying domlin in our schizophrcnics.The most imponnnt predictorfor the men is iheir saltslaction with getting on wilh others,a ralher sarisryingdomain in schizophrenics.Consideringboth sisnificant objectile lnd all subjectiveind;caiorsof quality of Lifb,satisfactionwith leisure becomesthe most importantpredictorin thc men, a satisryingdomainas well The predicttve power of the firsl prediclor was twjce rs irnportanl $ rhat of the second prediclor in both wome! md men. Subjeclive predictors seen only in the nale schizophrenicsde then saiisfactionwith financesand with then getti.S on with others Subjectiveptediclors seen only in the lemale padenls are then satisfaction with personal salety and wilh friends Wben subjeciive and ob.jectiveindicatorsboth enter regression.rnalysis.the objective indicators. age fbr women, recentcontactwith a friend for Inen. also make modestconidbirtions we concludethal schizophreniclnen and women in pan have differem predictorsofrheir satisfactionwith lile in gene.al.Beyondthis. women detenrxnetheirsubjeciiveglobalqualitv of lif€ accordingto a life domainwith low satisfadionratingssuchas mental healtt\ whereas men nther choosea positivelynled ljfe domain.ln spiteof similarities,the processof global evaluatioD of their condiiions of life apPears to be differert in schizophrenic women dnd

QUAI-ITY OF LIF€ IN SCHZO?IRENIA

DISCUSSION ln ourstudy we exami.ed the importanceof genderfor subjecriveand objectivequatiry oftife 'n scbrzophrenicpalients.Our hlpoihesis war: schizophenic wome, should have a betrer subJectrve quality ol life thanthe male patienrs,becauseottheir betre.obiecriveconditionsof tife. which are minored in more ldri.rJcrion on Lheone hand dn.t bec;use sende, sDecrhc p e r ' o n J lr n d b c h a \ r o u r ! cl h . r . . r e r i s u ( , a t s o f a r o u r v r i . t u c r i o no f , c m . t e ; a r i e n r \ o n r h e other hand. This hypothesis includes four assumprions.F;sr, thar ihc objective social .iruauon i. bener iur "clu,,uph.enicwomen rh!n .clurophJenic men. Ou, ;,utr. confinn the bercr socialinlegrationof the female palientsin the domainsof working, living siiuadon, financesand partnership,as alreadydescribedin previousstudi€s.Social conlacts(existence of and frequencyot. in corrrasl werenor different in o!!r nale and female schizophrenics. A secondassumptionincludedin the hyporhesiswas thar objecriveci.cumsiancesco_determine sansfacrion.This supposirionwas also confinned.Objective condirionsplay a significantly detectable,bur quantitativelyftther srnall, role for the sarisfacrionwirh a liven life domain rnd $ irh LIe in general.The hLrd r::Lmprjon. har lhe \chirophretuc$ume;. becau\eof lheir betterconditionsoflifc. are mor€ sarisfiedthan the schizophrenicnen. coutd nor be Droven. f t e q o m e n r n r h b \ r u o ) , w h o d i d n o r r s n i r , r a n r t ) d , i f e a f ' o mm e n , n B P R S , , l n " ; " r . , " , subscores,which were assessed in two thijds of th€ sample)were neirhermore satisfiedwirh lrle rn genFnl nor $irn anl ut rhe lxe dom:rins, nor iren in t}ose domains where lhcn objective situationwas b€trer.Neither the influence of the bener socjal conditions.nor the influence of age. which shoutd also have favoured the (older) ibmale patients of ou. studvg r u u p . $ a s s u l f i c r e nr o p r n d u c eh i B h c r , . u . t a c u o n .O u r f o u n n a . s u m p r i o no t a e e n o i r ' p c c i h ce l d l J d r i o no f e q u r , s o c r act i ' c u m s , J n c ews a r p m \ c o n t i r m e , lB. u r ,c o n , , - r r o o u . d ' { u m t r ' o n . , a r i s r a c J i ooni r h e w o m ! n w . \ i n f l u e n c e d n c g r r i v e . )j n r h e d o m a i n j u i t i v r n g si ation and personal safety. tn these two domains lhe gender specific view had a quantitativeeffecl and led, eveDwhen rhe objeciive situationwrx better, as for instancein the living domain, to iess satisfactionot the schizophrenicwomen. An underlying qualitatively differentprocessofevalualion. iied ro genderrote, may accountfor this In conirastto men, the schizophrenicwonen choosea negarivetyraredlife domain as rhe most imporranl delenninantoftheir subjectiveglobal qualjry of life, they also use satisfactionwinhpenonal s a f e t ] r \ a d e r e m r n a r td n J n e g , e c ,r J r b r r c l i o n $ i l h L h e i rg e i n g o n u i r h o r h e r si n , t w r r h extemal resourcessuchas fiDances. Quantilativelysimilar resuhsin schizophrenicwoner and men thus se€mro obscureson€ underlying diilerencesin rhe fomaiion of subjecrjveviews. For a betrercomprehensionof t h e \ ep r o c e \ , e \a n d c o n r e { \ o f . u b j e c t i ! e v a l u a r r o n r n m e n t a l } i p d r i e n t sL, h F e\ c i e n u n c s n a r e g i essn o u l db e h e l p f u lI n r h e t u t u r c :t i m i r a t r o n o l . l u d , e ,r o m o r eh o m o g e n e o uBsr o u t . : syslemrlic inclusion of rhe examinationof mer and unmet needsiand tonsitudinat studics. l n d r v r d L d"lf l r 5 l d c r i o cna nr e , L l rt r o mI u t h t m e nol t n e e d \ ,t i o m F d u c r i o no i r h e l e \ e i o r n e e J and./or from realistic adapration ro limjted possibilities. Tl€ practical consequeoces of each could be conplelely differenr.Schizophrenicmen in ourstudy. althoughibwer ofthem reach currentsocialnormsfor men. ar€ nevenhclessnot more dissatisliedrhanthe wornen.and lhis could indeedbe viewed ss resignedor realistic adaptalionto their situation. ln interpretatlonofthe resulls ir shoutdbe raken inro accountrhat we examineda samDle w l u c h w a s h e r e r o s e n e o au n: d \ e l e c r i ! er n m a n y r e \ p e ( r \ A s e p a r a ka , a l y s i so f . u b g o u p s

U. RODER-WANNERET AL

l4l

according!o criterh suchastredmenr seuingmight haveyieldeddifferenl resutrs.SubslouDs h o w e \ e r .. r e n e . e \ s d i l ) . m a u e r r h r h e s h o t e \ a m p t e .I n r m J e r s a m p t e ." r a r r s i i c a t i y g n i f i c l l n rL l i l f e r e n c eb.r r w e e ns o m e n a n d m e nu e p r o b a b t ]m o r ed i i c u t r r o r l i , c o v e r ari the non-findinsof a significanrdilTerenceand resutrsof mutrivariateanalysisare tessretiable. In tuture subjeclivequaliry of life should be used sysrematicaltyas an ourcomecriterion and in the planning of therapiesand psychialriccare systemsas well. Today we can use it as an outcome and evaluationcriterion of defined intervenrionsor care syslems,as it gives fudher and different info.marion than objective measures aione. But in order io use ir for Ine planningofnew therapiesor psychiarriccareslsremswe needfunher insigh! inro rhe process, and context,of rhe subjecrivevaluarionof condilions of life in rneniaily ilt oarienrs.

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QUAL]'I'Y OF LTFE[\] SCTIZOPT{R€]\'LA GoLDSTEIN, J.M. ( 1988)c.nder difr€.erccs in rhe couM or clx zophrc$a.Ah./i.tu

torrul

oI ps!chjo,r^. t45,

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fii.

STATISTTSCHESBUNDESAMI l.d.) 11992)Dde^repon 1992. Bonn. Schrifteucihe dct Bundeszenfrle 6jr STATIS-|ISCHES BIjNDESAMT (ed.) (l99a) D,t.rr.pon

1994 B.m

Schnfkn.eihc d.r Bund€szenhlc tu.

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Dr Ute Uhte RadeFwdner.Depadmedof Scial Psychi*ry,FEie Unire6iiit Berlin,PlaEnenallec 19. 1a050, DrJosephP.J Ol,v.r. NonnW.:tRegiaoHealthAutho.ity. NarionilH€rld Sewic.Erecutive,910932Bircbwood Boulev,rd.MellctuumPrL Birche@d-waninsbn wA3 ?QN.U.K. DrSter&Prieb€,DiplonPsycholosis!DepdncntofScialPsychiary,FreieUnire^nriBerlin.PlaFnenallecl9. Cdftspondcncc to Dr Ritder-Wnnner