Correcting National Proposal 2009

ASSESSMENT OF DISABILITY AMONG NIGERIAN OUTPATIENTS WITH SCHIZOPHRENIA: COMPARISON WITH MATCHED HEALTHY CONTROLS OBAFEMI AWOLOWO UNIVERSITY TEACHING HOSPITALS COMPLEX, ILE-IFE.

A RESEARCH PROPOSAL PRESENTED TO FACULTY OF PSYCHIATRY OF THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA BY DR. AKINSULORE, ADESANMI MBChB (2002), OAU, ILE-IFE

APPLICATION FOR APPROVAL OF PROPOSAL FOR DISSERTATION NAME OF CANDIDATE: DR AKINSULORE, ADESANMI FACULTY OF CANDIDATE: PSYCHIATRY DATE PASSED PART 1: MAY 2008 1

DATE STARTED PART 2 POSTING: JUNE 2008 APPROVED TRAINING CENTER: OBAFEMI AWOLOWO UNIVERSITY TEACHING HOSPITALS COMPLEX. ADDRESS OF TRAINING CENTER: O.A.U.T.H.C. ILE-IFE, OSUN STATE. PROPOSED TITLE: ASSESSMENT OF DISABILITY AMONG NIGERIAN OUTPATIENTS WITH SCHIZOPHRENIA: COMPARISON WITH MATCHED HEALTHY CONTROLS 1st SUPERVISOR Signature_______________________

Date ____________________

DR F.O. FATOYE, MB ChB, FMCPsych. 2nd SUPERVISOR Signature________________________

Date _____________________

PROF. R.O.A. MAKANJUOLA, MB BS, PhD, MRCPsych, FWACP, FMCPsych. HEAD OF DEPARTMENT Signature ____________________

Date _____________________

Dr S.K MOSAKU, MB BS, FMCPsych. CHAPTER ONE 1.1

INTRODUCTION Since antiquity, society has recognized disabilities among its member arising out of

obvious deficits in anatomical structures, sensory functions and intellectual development (Banerjee, 2001). These disabilities prevent the affected persons from participating in the main 2

stream of social life. Due to the recent spurt in the growth of scientific knowledge in this area, the concept disability has become an important issue for re-examination and redefinition. In 1993, the United Nations declared that the term “disability” summarized a great number of different functional limitations occurring in any population in any country of the world. People may be disabled by physical, intellectual or sensory impairment, medical conditions or mental illness. The United Nations has thereby broadened the scope of the concept of disability and specifically included mental illness in addition to mental retardation as a cause of disability Furthermore, the notion of disability itself has undergone a sea change from being viewed as just a handicap to a concept incorporating personal, social, and environmental dimensions. An international effort of the World Health Organization (WHO) to have a re-look at the concept, definition, classification, and measurement of disability resulted in the revision of the International Classification of Impairment, Disability and Handicap (ICIDH). The new version, renamed as International classification of Functioning (ICF), adopts the universal model of disability and describes the dimensions of disability as body function/structure, activities and participation in a societal context. This also led to the development of the World Health Organization Disability Assessment Schedule II (WHODAS II) to measure disability. Psychiatric disorders account for nearly 31% of the world’s disability and schizophrenia is one of the ten leading causes of disability worldwide (Mohan et al, 2005). Schizophrenia, which is a chronic mental illness, may cause functional disability across a wide array of domains (McClure and Harvey, 2007; Hofer et al, 2006). Schizophrenic patients experience impairments in their social competence, vocational aptitude, everyday living skills and self-care abilities. In 3

the majority of patients, these impairments are severe enough to prevent the return to independent living, even after hallmark symptoms such as hallucinations and delusions are remitted. Schizophrenia also impacts negatively on the academic, occupational, social and family functioning of the patients (Mohan et al., 2005). Therefore, investigating psychiatric disability as an important area of research is essential because of its role in understanding the nature of the illness, especially its chronicity, and planning intervention programme for the chronically mentally ill. A search of the literature revealed a dearth of published research on disability occurring in the context of schizophrenia in Nigeria. Gureje and Bamidele (1999) examined the thirteen year social outcome among Nigerian out-patients with Schizophrenia. Also, Gureje (2002) examined the association of psychological disorders and symptoms with disability and service use after 12 months among primary care attenders. Gureje et al. (2006) evaluated functional disability in elderly Nigerians living in the community. Also Uwakwe and Modebe (2007) described the pattern of disability and care for older community residents in a selected Nigerian location. Of recent, Gureje et al. (2008) compared the effects of depression and chronic physical conditions on disability in elderly persons. Also Ogundele (2009) evaluated the risk factors for disability among depressed elderly people living in a Nigerian community. These studies were mainly among elderly people with associated depression. Therefore it is worth-while to investigate disability among schizophrenic patients in our community.

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LITERATURE REVIEW 2.1

PREAMBLE Traditionally, disabilities have been associated with conditions, physical and mental,

where a handicap or impairment has been tangible and obvious such as physical and sensory handicap or mental retardation. In the recent past, however, certain chronic illnesses are being increasingly recognized as a source of great disability in the community. Cardiac diseases, arthritis and chronic mental illness are among the most prominent. (Thara and Menon, 1991) Disability is a complex and multifaceted phenomenon, and is an outcome of an interaction between a person’s health condition (e.g. illness, trauma, injury) and the context in which that person lives. Being multifaceted, it comprises a number of different aspects that further inter-relate in a complex manner (WHO, 2001). These aspects include the health condition, functioning and level of independence of the person, the external physical, social, and attitudinal environment, the person’s quality of and satisfaction with life, and the level of disadvantage and social exclusion experienced by the person (Schneider et al, 2003). 2.2

DEFINITIONS OF DISABILITY Defining disability is not an easy task, and it is becoming clear that no single definition

can cover all aspects of disabilities. According to the International Classification of Impairment, Disability and Handicap (ICIDH, 1980), disability is “interference with activities of the whole person in relation to the immediate environment”. Disability may also be defined as “disturbance of social roles that would normally be expected of an individual in his habitual milieu, arising in association with diagnosable mental disorder” (Jablensky et al., 1980).

5

WHO (1980) defined the consequences of disease at the level of impairment (any loss or abnormality of physiological, psychological or anatomical structure or function), disability (any restriction of ability to perform an activity in the manner or range considered normal) and handicap (a disadvantage for a given individual resulting from an impairment or disability that limits or prevents the fulfillment of a role). The Institution of Medicine (IOM, 1991) further defined disability as a limitation in performing certain roles and tasks that society expects of an individual. Expected roles and tasks are defined by cultural norms, and when these roles cannot be performed because of physical or psychiatric limitations, the individual is considered as disabled. The WHO developed a revised working disability model, (Fig 1) that was designed to increase conceptual clarity and operationalize functioning across 3 levels (Wood, 1980; Pope and Tarlov, 1991; Verbrungge and Jette, 1994; Whiteneck et al, 1997). The levels are the body, the person as a whole and the person in social context. Disability involves dysfunction at one or more of these levels. In schizophrenia, impairments i.e. body level (problems in body function or structure) may be reflected by micro or macro deviations in brain structure (e.g. ventricle size, neuronal disarray) as well as cognitive function (e.g. working memory, verbal reasoning) and psychiatric deficits (e.g. hallucinations, delusions). Activity limitations i.e. the person as a whole (difficulty in executing activities) may be evidenced by difficulty with mental calculation such as counting change or difficulty producing logical, fluent and goal-directed speech. Participation restrictions i.e. person in social context (problems experienced in real life situations) refer to the total life context of the individual and may occur when a person cannot participate in meaningful work activities or join community activities.

6

Health conditions (Disease/disorder) ↕ Impairment ↔ Activity limitation ↔ Participation restriction ↑____________________↕____________________↑ _____________↓_____________ ↓ ↓ Personal factors Environmental factors Fig. 1 Conceptualization of disablement presented by the World Health Organization: Interaction between the components of ICF

2.3

MEASUREMENT OF DISABILITY

As an essential ingredient of any chronic mental disorder, disability has lent itself to measurement (Thara et al, 1988). Clinicians use measurement as a guide to clinical practice when quantifying the severity of an illness or subsequent disability. Disability measurement can be used to measure the effectiveness of a treatment or rehabilitation program and as an alert when a person’s health status is deteriorating unexpectedly. The standardized numerical scores can be used to administer services and to ensure that the rights of the disabled are met. An aggregated numerical score of disablement can be used to estimate the burden of a disease and the resources that should be applied to the amelioration of the consequence of the disease. Functional assessment methods of assessing disability are as follows: - Self report method - Through proxy (e.g. caregiver) - Clinician ratings - Observer ratings and - Performance-based measures. 7

Each method has its unique advantages and disadvantages. Self reports are widely used and have been constructed to reflect any of the 3 levels of dysfunction identified in the WHO model (e.g. impairment, activity limitation, participation restriction). Some instruments address more than one level of dysfunction while others address only one primary domain. The information obtained reflects issues of importance from the patient’s perspective (Wilkinson et al, 2000), self-report may be influenced by psychopathology, emotional and cognitive functioning (Atkinson et al, 1997), the patient’s insight, personal values and situational events (Williams, 1994). The 12 item and 36 item self-administered versions of WHODAS II are examples of a self report instrument. Proxy reports are collateral or caregivers’ reports. They measure any level of dysfunction in the disability model and may increase the reliability of self-report measurement. However, this modality is limited by the lack of persons available to report on patients’ everyday functioning (Wilkinson et al, 2000) and by caregivers’ own psychiatric, emotional and cognitive functioning (Mckibbin et al, 2004a). Example of proxy reports are the WHODAS II - 6 item selfadministered proxy, 6 item self-administered clinician, 36 item self-administered proxy and 36 item interviewer-administered proxy Clinical rating typically measures impairment and activity limitation. It provides information regarding specific behaviours observed and is less vulnerable to psychosocial influences, but is limited in that a small sample of observed behaviours may lead to an underestimate of patient capacity (Patterson et al., 2001a). Observer rating is the best way to assess real world functioning through direct observation in naturalistic settings, thereby addressing activity limitation and/or participation restriction. Although this method of assessment appears ideal, observers would be required to shadow patients throughout their daily 8

routine or during selected observational periods in which the targeted behaviour is likely to occur. Such a task could be time consuming. Performance-based measures require participants to perform a skill in a contrived testing environment designed to mirror the real world, thus measuring activity limitations and inferring participation restrictions. Patients may be asked to perform basic instrumental activities such as combing their hair, or more complex tasks such as engaging in social interactions or paying bills. Skills may be demonstrated directly or by interacting with the examiner in a role-play. Limitations of these measures include their reliance on contrived environments to conduct evaluations, which may create assessment demands that differ from those in the real world thereby threatening external validity. They also ignore environmental factors that may facilitate or inhibit participation in life situations. Examples are the Bay Area Functional Performance Assessment (William and Bloomer, 1987), the Maryland Assessment of Social Competence (MASC, Bellack et al, 1994; Sayers et al, 1995), Medication Management Ability Assessment (MMAA, Patterson et al, 2002) 2.4

MEASUREMENT ISSUES The measurement of disability as a construct has been fraught with difficulties. This is

complicated by several factors, including weaknesses inherent in each of the several measurement modalities (Patterson et al, 2001b). Also, the lack of conceptual clarity between the construct disability and other related constructs at any given point and over time (e.g. functional limitation, handicap, disability; Bruce 2001; Lehman et al, 2002), and disagreements among disciplines about what constitutes disability makes measurement of disability a difficult task. Assessment of disability in persons with serious mental illness such as schizophrenia is 9

further complicated by impairments of insight and cognition associated with the disorder that may interfere with patients’ ability to report their own experiences accurately (Atkinson et al, 1997; Doyle et al, 1999). The WHO with collaboration among researchers from several countries developed an instrument to evaluate psychiatric disability. This instrument, the WHO Psychiatric Disability Assessment Schedule (WHODAS; WHO, 1988), was designed to assess disturbances in social adjustment and behaviour in persons with mental illness and to identify factors that may influence these dysfunctions. Thereafter, the WHO modified and clarified the conceptualization of disability and developed a research instrument called the World Health Organization Disability Assessment Schedule-second version (WHODAS II). This instrument differs from the WHODAS in that it applies more broadly to the impact of any disorder (not just psychiatric disorder) on everyday functioning and treats all disorders (physical and mental) equally when determining the level of functioning (WHO, 2000). The WHODAS II distinguishes itself from other measures of health status, disability and functioning in that it has been cross-culturally developed and field-tested in 16 languages in 19 different countries including Nigeria. It is also conceptually compatible with the WHO’s revisions to the International Classification of Functioning and Disability now known as International Classification of Functioning, Disability and Health (ICF)

2.5

THE WHODAS II

10

The WHODAS II has been developed to assess the limitations in activity and participation experienced by an individual irrespective of medical diagnosis. The domains included in the instrument are: 1. Understanding and communication 2. Getting around 3. Self care 4. Getting along with people 5. Life activities 6. Participation in society A set of questions were written to operationalize these concepts. Ninety-two items were selected from this large item pool and subjected to field trials in 19 countries. The WHODAS II is available in 16 languages and several versions are available. These include intervieweradministered versions, self-administered versions, and proxy versions. The 36 item, intervieweradministered version is recommended because it provides the most complete profiling of respondents. Other versions are the interviewer-administered 12 item version and the 12+24 screener version; self-administered 36 item version and 12 item version;proxy versions 6 item self administered clinician, 36 item self – administered proxy; 36 item interviewer-administered proxy. WHODAS has been used by researchers in Nigeria (Ogundele, 2009; Bella and Omigbodun, 2009; Gureje et al., 2007) 2.6

DISABILITY IN SCHIZOPHRENIA 11

The chronic course and debilitating effects of schizophrenia combine to create a disease which imposes very considerable clinical, social and economic consequences on societies throughout the world, resulting in it being a leading contributor to global and regional levels of disability and the overall disease burden (WHO, 2001). Comparison of studies on disability is often hampered by differences in methodology, outcome assessment and the studied population. In spite of the above, studies have shown that patients with schizophrenia reported greater severity of disability than normal comparison subjects (Ertugrul and Ulug, 2002; McKibbin et al., 2004b). When patients with schizophrenia and obsessive-compulsive disorder (OCD) were compared with matched duration of illness using the Indian Disability Evaluation Assessment Scale (IDEAS), significantly greater disability was seen in the patients with schizophrenia in the areas of self care, interpersonal activities, communication and understanding, work and global disability score ( Mohan et al., 2005). Comparison of disability in the different mental disorders using IDEAS indicated that schizophrenia is by far the most disabling of the mental disorders, followed by Dementia. Depression, OCD, Bipolar affective disorders and Alcohol use disorders are the next four disability causing disorders in order of the severity of disability associated with them ( Chaudhury et al., 2006) Marneros et al. (1990) reported that schizophrenia caused persistent alterations in social life, including social and occupational drift, premature retirement and inability to achieve the expected level of social development. In one study, it was emphasized that disability in schizophrenia starts primarily in social and occupational roles and interpersonal relations, and in more severe situations self care begins to be affected (De Jong et al., 1985). Ertugrul and Ulug (2002), using WHODAS II, demonstrated that life activities, participation in society, understanding and communicating with the world, and getting along with people were the 12

domains where differences in disability level compared with the controls were more apparent, whereas self care seemed to be relatively less affected. These results are consistent with the view that disability has a hierarchic progression from high level roles to low level roles (Cooper, 1980). Treatment of disability in schizophrenia has focused on behavioural interventions such as social or vocational skills training (Patterson et al., 2006) as well as supported employment (Drake et al., 1999) and housing interventions. These interventions have been empirically demonstrated to have benefits for people with schizophrenia (Bell et al., 1996; Bond et al., 2001) but these are also costly interventions. Several recent studies have shown that cognitive remediation interventions both improve cognition and improve work outcomes in employmentseeking individuals with schizophrenia (Hogarty et al., 2004; McGurk et al., 2005; Wexler and Bell, 2005). Thus, treatments aimed at the origins of disability have demonstrated some potential for reducing impairments. However, it is possible that other interventions could have a beneficial effect as well. Cross-sectional studies have found that patients remaining untreated in the community experience greater disability than those on treatment with antipsychotics (Padmavathi et al., 1998; Thirthalli et al., 2006). Also, studies have shown that disability tends to be stable over a period of 3 years and seems to be independent of fluctuations in clinical course (Giel et al 1984; Thara & Rajkumar 1993). Regarding the usefulness of antipsychotics in reducing disability, while Hegarty et al. (1994) in their study concluded that antipsychotic treatment have not been proven to be particularly beneficial for the treatment of disability, several recent studies have reported improvement in disability in schizophrenic patients following atypical antipsychotic treatment (Srinivasan 2001;2005; Thirtnalli et al.,2009; Harvey et al. 2009). 13

2.7

FACTORS ASSOCIATED WITH DISABILITY IN SCHIZOPHRENIA

Disability in schizophrenia has been found to be affected by socio-demographic characteristics (such as sex, marital status and socio-economic status), illness characteristics (such as age of onset, duration of untreated psychoses), clinical factors (presence and severity of positive or negative symptoms) and cognitive deterioration (Alptekin et al., 2005; Ertugrul and Ulug, 2002; Krapow et al., 1997; Lysaker et al., 1995). The relationship between disability and sex remains controversial; while some studies reported higher a prevalence of disability among females (Ganesh et al., 2008; Alptekine et al., 2005), Gupta and Chadda (2008) reported that males showed higher social disability than females. Marital status has been shown to be an independent predictor of outcome in schizophrenia (Jablensky et al., 1992; Padmavathi et al., 1998). While some studies found no association between marital status and functional outcomes (Kebede et al., 2005; Kua et al., 2003), Gupta and Chadda (2008) reported that the unmarried patients suffered higher disability in personal area than the married patients. Being married may be an indicator of increased family support and enhanced treatment compliance. . The prevalence of mental disability has been reported to be lower among persons with high socio-economic status (Kumar et al., 2008). Early –onset schizophrenia is said to predict more disability (Carpiniello and Carta, 2002; Lay et al., 2003). Also studies have linked early-onset schizophrenia to poor prognosis (Hafner et al., 1998; Moriarty et al., 2001; Sobin et al., 2001; Lenior et al., 2001; Harrison et al., 2001). Concerning duration of untreated psychoses (DUP), a study from Turkey found that DUP was significantly associated with social disability as measured by the Brief Disability Questionnaire (Alptekine et al., 2005) and a study from rural China reported that 35% of patients with a DUP of less than a year had a complete symptomatic and social remission (Ran et al., 14

2003). Also, a study from Mexico reported that patients with a DUP of less than 27 months were significantly more likely to make a good social and occupational recovery (Apiquian et al., 2006) and another study from India found a trend towards an improved social and occupational outcome in patients with a shorter DUP (Tirupati et al., 2004). Farooq et al. (2009), using a pooled estimate of diverse outcome measures found a significant association between longer DUP and a greater level of disability. Some previous studies found no relationship between neuro-cognitive functions and disability (Ertugrul & Ulug, 2002; Hertegrave et al, 1997; Johnstone et al, 1990), but in others, a relationship was found (Velligan et al, 1997; Breier et al, 1991). One possibility why neuro-cognitive deficits are not related to disability is that the deficits in attention, visual memory and executive functions or degree of disability of patients may not be high enough to show the relationship between them. Another explanation is that patients adapt to deficits by developing protective mechanisms that compensate for the deficits and lessen their effect on their functional status. Decreasing the expectations and choosing simpler jobs may be some examples of these protective mechanisms. Disability in patients with schizophrenia has been reported to be related to the negative syndrome (Lysaker et al., 1995; Klapow et al., 1997; Gupta and Chadda, 2008) and positive symptoms (Alptekin et al., 2005). Ertugrul and Ulug (2002) using WHODAS to assess disability found that both positive and negative symptoms are significantly related to disability but the highest relation is with the general psychopathology score of PANSS. When symptoms severity increases, patients have more difficulty in interpersonal relations. The researcher also noted the relationship of disability in “moving and getting around” to positive symptoms. An orthopedically disabled patient may not be able to move, but a patient with schizophrenia can also have difficulty in moving and getting around just because of his delusions. Negative 15

symptoms and duration of untreated psychoses were reported to be a significant predictor of disability after 1 year (Alptekin et al., 2005) Depressive symptoms, commonly experienced by people with schizophrenia, have been reported to be associated with worse functioning and with poorer quality of well-being (Gaynes et al., 2002; Jin et al., 2001). Researchers have found that the WHODAS II appeared to be sensitive to severity of depressive symptoms (pyne et al., 2003; Mckibbin et al., 2004). Patients with greater severity of depressive symptoms reported greater levels of disability. However, the direction of causality is not clear, because depression may both cause and result from the experience of disability (Bruce, 2001) 2.8

DISABILITY STUDIES IN NIGERIA Comparison of results from disability studies are limited by the differing methods used in

the evaluation of disability, outcome assessment and the population studied, as well as the environment in which the patients were identified. Another limitation is the use of different terms to refer to specific subsets of activities measured by these instruments. There are few studies on the assessment of disability among schizophrenia patients in Nigeria. Ohaeri (1993) conducted a retrospective follow up of 142 patients meeting Research Diagnostic Criteria (RDC) for schizophrenia that spanned a range of 7 to 26 years. Outcome was consistent over the 7 years of follow-up, with a good outcome achieved by 50.7% and a moderate outcome achieved by 23.9%. The most typical course was acute onset followed by an episodic course with rapid remission in response to treatment. Negative symptoms were rarely noted. Women had an older age of onset and, a rare finding, poorer outcome than men. The

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researcher noted that many of the male patients, even those in moderate to poor-outcome categories, were able to complete education and /or work in order to become self sustaining. Gureje and Bamidele (1999) examined the social, occupational and residential outcomes of 120 clinically stable outpatients with schizophrenia after 13 years. A substantial proportion of patients showed a moderate to severe degree of disability in areas of occupation and social contacts. Four percent were homeless or of unstable abode while men were particularly disadvantaged in establishing a marital relationship and also evidenced impaired fecundity. Women had a more impaired outcome in the domain of frequency and quality of social contact. Poor response to initial treatment and indices of impaired premorbid adjustment were associated with poor outcome 13 years after illness onset. In another study, Gureje (2002) assessed psychological symptoms that do not reach the threshold for formal diagnosis and its association with disability and service use after 12 months among 2379 consecutive primary care attenders. Using the 12 item General Health Questionnaire (GHQ12) and a stratified random sample (n=704) completed baseline structured diagnostic interview, disability assessment and the 28 item version of the GHQ (GHQ28). At baseline caseness on either the GHQ or ICD-10 was associated with poor self rated overall health, interviewer-rated occupational disability and with more disability days in prior month. At 12 months follow-up, being a case on the GHQ but not on ICD-10 at baseline was associated with disability, poor health perception and high health service utilization. The researcher concluded that psychological symptoms that may not reach diagnostic threshold are associated with impaired functioning over 12 months.

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Gureje and others (2006) studied functioning disability among 2,152 Yoruba, elderly people using Katz index of independence to assess activities of daily living (ADLS), the Nagi Physical Performance Scale and the Health Assessment Questionnaire to assess instrumental activities of daily living (IADLs). They found that 3% had ADL disability and 9.1% had IADL disability. Women were more disabled, significantly so in the performance of IADLs and overall. In all, disability increased with age and persons who were currently married had lower rates of disability than those who were separated, divorced or widowed. Also, elderly persons living in rural areas had the lowest rates and those living in urban areas had the highest. Self reported chronic medical illness did not significantly increase the risk of disability. Persons with disability were more likely to have had major depression in the prior 12 months, but the association was significant only with regard to ADLs. Also, persons reporting persistent pain were four times as likely to be disabled as those with no persistent pain. Poor self perception of health was also a significant predictor of functional disability, with those reporting that their health was poor or very poor having about five times the risk of disability as those who rated their health as excellent, good or fair. Furthermore, the observation that 19% of elderly persons with disability and therefore in need of assistance were unable to access such help was striking. In addition, the study demonstrated the urgent need for developing countries to become more aware of the consequences of the growth in the population of older people. Policies aimed at supporting family members to fulfill such roles remain most viable and possibly more likely to be culturally acceptable than those centered on institutional or formal care. Uwakwe and Modebe (2002) described the pattern of disability and care for 102 elderly Nigerians living in a selected community. Disability was assessed with the modified World Health Organization Disability Assessment Schedule- Short Version (WHODAS-S). 47% of the 18

elderly people had some form of disability. Help with self care was the greatest problem reported by the carers, and care-giving was regarded as a very heavy burden associated with high emotional distress. The researcher concluded that disability is high in elderly subjects living in the community. Care-giving is proving a great challenge in the face of children deserting their parents in an increasingly harsh economy. There is need for a systematic, realistic plan to implement qualitative care policy for older Nigerians. Gureje et al. (2008) compared the effects of depression and chronic physical conditions on disability among 2152 community dwelling elderly persons. Disorder-specific disability was evaluated using the Sheehan Disability Scale (SDS). A higher proportion of persons with major depressive disorder (MDD, 47.2%) were rated severely disabled globally than those with arthritis (20.6%), chronic spinal pain (24.2%) or high blood pressure (25.0%). Subjects with MDD had worse disability ratings on the SDS and were more likely to be severely disabled globally and with regard to work, home and social roles than those with arthritis, chronic spinal pain, high blood pressure, asthma, or diabetes mellitus. In pair-wise comparisons, persons with MDD had significantly higher levels of disability than those with any of the other disorders, with differences in mean scores ranging between -3.74 and -27.50. The researchers concluded that to reduce the public health burden of depression, its prevention and treatment require more clinical and research attention than was currently being given by developing countries. Of recent, Ogundele (2009) examined the risk factors for disability among 236 elderly persons living in a rural community of Oyo State, Nigeria. Disability was assessed using the World Health Organization Disability Assessment Schedule (WHODAS II). Disability was significantly higher in subjects with depression than in the non-depressed subjects with the WHODAS score and standard deviation of 41.06+/-19.97 (median51.9) and 23.88+/-16.38 19

(median25.5) respectively. Depression was also associated with disability across all the domains of the WHODAS except the life activity domain which assesses functioning in household maintenance and in caring for people close to the respondent, and includes activities such as cooking, cleaning, shopping, and caring for others and for one’s belongings and work related activities. The researchers found that the severity of depression was not associated with disability, which was not consistent with most existing information on disability in geriatric depression. A possible explanation for this may be that most of the studies that reported associations between disability and increased severity of depression used instruments that assessed only a limited range of physical activities which are usually compromised in severe depression, leading to bias towards higher disability rates in the severely depressed.

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CHAPTER 3 3.0 AIM AND OBJECTIVES The aim of this study is to assess disability among schizophrenic patients attending the outpatient unit of the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) The specific objectives of the study are as follows: 1. To assess the severity of disability on the WHODAS II among patients with

schizophrenia 2. To compare severity of disability among patients with schizophrenia, with healthy control

subjects 3. To evaluate and compare the relationship between disability in schizophrenia and socio-

demographic and clinical variables. 3.1

HYPOTHESIS 1.

Patients with schizophrenia will not report greater level of severity of disability on the WHODAS II compared with healthy subjects

2.

There will be no significant association between socio-demographic and clinical variables and level of severity of disability on the WHODAS II

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CHAPTER FOUR 4.1 MATERIALS AND METHODS 4.1.1 SUBJECTS: The subjects will be recruited from the outpatients’ psychiatric clinic of

Wesley Guild Hospital, Ilesa, a unit of the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Osun State. Healthy control subjects will be selected from among the hospital staff. Patients will be consecutively recruited over a period of six months. The inclusion criteria into the study will be: 1.

Adults aged 18 years and above.

2.

Having been diagnosed as having schizophrenia using ICD – 10 criteria which is the diagnostic nosology used by the department. All patients presenting in the unit are interviewed based on the ICD – 10 diagnostic criteria and the final diagnosis recorded in a departmentally structured diagnosis plan sheet that is available for research purposes and also submitted for input into the hospital’s computerized diagnostic register. The diagnosis of schizophrenia will be confirmed by the researcher using the Mini International Neuropsychiatric Interview (MINI) English Version 5.0.0 (Sheehan et al 1998).

3.

The patients should have been diagnosed and receiving treatment for at least 1 year before inclusion in the study.

4.

The last hospital admission must be at least 6 months or more before the date of assessment and

5.

There must be no evidence of organic disease or mental retardation and significant physical illness such as hypertension. 22

4.1.2 STUDY DESIGN: A cross-sectional descriptive survey. 4.1.3 SAMPLE SIZE: The required sample size for the study group will be calculated using the formula according to Fleiss (1981).

N

=

C

[2

( Pc) + Qc ] d2

+

2 + 2 d

Where C is a constant that depends on the values for alpha (significance level) and beta (power) with alpha set at 0.05 and beta at 90% then C = 10.51 Pc:

the estimate of the proportion of outcome set at 50% (0.5)

Qc = 1 - Pc d =

differences in the outcome ( 1 - 0.5) = 0.5

N =

10.51 [2 (0.5) + 0.5] 0.5 X 0.5

+

2 0.5

+ 2

N = 69.06 Adding 10% attrition rate = 6.906 + 69.06 = 75.97 A sample size of 100 will be chosen in order to increase the statistical power. Thus, each of the two study groups will comprise 100 sample subjects, including Yoruba or English speaking adults, making a total sample population of 200. The patients and healthy controls will be matched for age, sex and educational status 23

4.1.4

PROCEDURE:

Approval of the research protocol by the Ethics and Research Committee of Obafemi Awolowo University Teaching Hospitals Complex will be obtained and written informed consent will be obtained from the subjects after the aims of the study have been explained to them. 4.1.5

MEASURES

4.1.51 The Clinical Interview: The diagnosis of schizophrenia will be ascertained with the Mini International Neuropsychiatric Interview (MINI), English Version 5.0.0 (Sheehan et al 1998). The MINI was designed as a brief structured interview for the major AXIS I psychiatric diagnoses in the DSM IV and ICD-10. Validation and reliability studies done comparing the MINI to other similar structured interviews such as the Structured Clinical Interview for the DSM-IV Patient version (SCID – P, First et al, 1994) and the Composite International Diagnostic Interview (CIDI; Smeets and Dingemans, 1993) have shown high validity and reliability scores. The MINI has a current (for present symptoms) and a lifetime version (for retrospective diagnosis). The lifetime diagnosis version will be used in this study. The instrument has been used in Nigeria (Adewuya et al., 2008) 4.1.52. A semi–structured questionnaire inquiring about socio-demographic and illness related variables of the subjects. The information that will include:

Age, sex, marital status,

religion, ethnicity, highest level of formal education, occupation, current employment status, earnings/income per month, amount spent on treatment per month, and level of social support from family members, friends and others. Also information about duration of the illness, age of onset of active symptoms of schizophrenia, past history of hospital 24

admissions and number of hospital admissions will be obtained either from patient or the case file. 4.1.53Psychopathological symptoms: These will be assessed with the Positive and

Negative Syndrome Scale (PANSS; Kay et al, 1987) which includes a structured interview to assess patients on 30 items covering positive, negative and general symptoms. For each item, ratings are made on a 1 – 7 scale of symptom severity. The scale has been used in Nigeria (Mccreadie and Ohaeri, 1994; Lawal et al, 2003). 4.1.54 Depression: This will be assessed using the Zung’s self-rating depression scale (SDS;

Zung, 1965) which is a 20- item self administered questionnaire graded with a 4 point likert’s scale (Never, occasionally, sometimes, mostly) for each question. The sum of scores (raw scores) for each respondent will be converted to a 100 point scale (SDS Index Score) with a score of less than 50 points classified as normal, 50-59 points classified as mild depression, 60-69 points classified as moderate depression and 70 points and above classified as severe depression. The instrument and its back translated Yoruba version has been used in Nigeria (Jegede, 1979; Fatoye et al, 2004; Mosaku et al, 2008). 4.1.55 Insight into Illness: A semi structured questionnaire based on the Present State Examination (Wing et al., 1974) will be used to enquire about patients’ awareness of their own mental state. 4.1.56 Medication Related Variables: These will be assessed with the use of a questionnaire and a review of the patient’s case file. It will include the type and dose of current antipsychotic and other psychotropic medications. Side effects of antipsychotic medication will be assessed with the aid of a clinician-rated structured check list detailing

25

common side-effect symptoms. Each symptom is scored on as present or absent. This check list has been standardized and used in the unit (Adewuya, 2007). 4.1.57 World Health Organization Disability Assessment Schedule (WHODAS-II): This is a scale developed by the World Health Organization (W.H.O) to measure disability in concordance with the bio-psycho-social model of the WHO’s International Classification of Functioning, Disability, and Health at bodily, personal, and social levels. The 36-item interviewer-administered version of WHODAS II will be used for the study. It measures the difficulty the individual has had with performing particular daily activities over a period of 30 days. It consists of 36 Likert formatted questions, divided into six domains: understanding and communicating (six items); getting around (five items); selfcare (four items); getting along with others (five items); life activities (eight items); and participation in society (eight items). The final score is calculated using a standardized SPSS algorithm. There are two syntax versions which may be administered according to a respondent’s occupational status: a 36-item version for those currently working, and a 32item version for those not working. The final scores derived from both versions range from 0 to 100 with higher scores indicating greater disability. It has been validated for use in this environment (WHODAS II, 2000).

The healthy control group will complete the socio-demographic questionnaire along with the Zung’s SDS and WHODAS II. 4.1.6

Data analysis: The Statistical Package for Social Sciences (SPSS) software (version 11) will be used for analysis. The Student t- test and Chi-square statistics will be used to study the differences between the two groups. Correlations between psychiatric disability 26

and various socio-demographic and clinical characteristics will be studied using Pearson’s product moment correlation co-efficient. Multivariate analysis may also be used to eliminate the effect of confounding factors.

27

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APPENDIX 1 ASSESSMENT OF DISABILITY AMONG NIGERIAN OUTPATIENTS WITH SCHIZOPHRENIA: COMPARISON WITH MATCHED HEALTHY CONTROLS QUESTIONNAIRE SECTION A – SOCIODEMOGRAPHIC SECTION 1. AGE: (in years) ____________________

Serial No/ Date: ______________ HOSPITAL No: ______________________ 36

2. SEX: Male ( 1 ) Female ( 2 ) 3. MARITAL STATUS: Single ( 1 ) Married (2 ) Divorced ( 3 ) Separated ( 4 ) Widowed ( 5 ) Others (specify) ______________________________ 4. RELIGION: Christianity ( 1 ) Islam ( 2 ) Traditional religion ( 3) Others (specify) _____________ 5. ETHNICITY: Yoruba (1 ) Igbo ( 2 ) Hausa ( 3 ) Others ( please state) ___________________ 6. OCCUPATION: _____________________________ 7. HIGHEST EDUCATIONAL LEVEL: None ( 0 ) Primary ( 1 ) Secondary ( 2 ) Post Secondary ( not University) (3 ) University ( 4 ) 8. EMPLOYMENT STATUS: Working full time ( 1) Working part time ( 2) Unemployed (3 ) Never Unemployed ( 4) Retired (5 ) In School (6 ) Keeping house ( 7) Others (specify) ______________________ 9. INCOME/EARNING PER MONTH (in Naira) _______________________________ 10.COST OF TREATMEANT PER MONTH: ( in Naira) -DRUGS: _______________________________________ -TRANSPORTATION: ______________________________ -CONSULTATION: _______________________________________ 11. (a) (b) (c) (d) (e)

WHAT LEVEL OF SOCIAL SUPPORT DO YOU GET FROM : Family members............ ( Good, Fair ,Poor , None ) Friends.................... ( Good, Fair ,Poor , None ) Government............................ ( Good, Fair ,Poor , None ) Non-governmental organization ( Good, Fair ,Poor , None ) Others (specify).......... ( Good, Fair ,Poor , None )

SECTION B – ILLNESS RELATED DETAILS (1) Duration of illness (in years)___________________________ (2). Age at onset of illness (in years) ________________ (3). Number of episodes of illness ____________________ (4). Number of hospital admissions due to illness_______________________ (5) Is the patient currently mentally ill (symptomatic?)____Duration of symptoms ______________ (6). If presently mentally stable, when was the last episode of mental illness (in months) _____ (7). Concomitant medical/physical illness/problems___________________ SECTION C: MEDICATION RELATED DETAILS Type and dose of antipsychotics (mg/day) 1.) 2.) 3.) 37

4.) Other relevant psychotropic medications and doses (mg/day). 1.) 2.) 3.) 4.) SIDE EFFECT CHECKLIST – within the last 2 weeks No

Side effects

Present

Absent No Side effects

1

Akathisia

14

Dry mouth

2

Dystonia

15

Constipation

3

Parkinsonism

16

Urinary hesitancy

4

Tardive dyskinesia

17

Blurred vision

5

Menstrual dysfunction

18

Photosensitivity

6

Sexual dysfunction

19

Weight gain

7

Dizziness

20

NMS

8

Postural hypotension

21

Skin discoloration

9

Reflex tachycardia

22

Galactorrhea

10

Sedation

23

Gynaecomastia

11.

Seizures

24

Rashes

12

Excessive salivation

25

Fever

13

Blood dyscrasia

present

Absent

NMS = Neuroleptic malignant syndrome

SECTION D: INSIGHT INTO ILLNESS. (PSE – SECTION 17. BOX 104) 0 = Full insight (in intelligent subject, able to appreciate the issues involved). 1 = As much insight into the nature of the condition as social background and intelligence allow. 38

2 = Agrees to a nervous condition but examiner feels that subject does not really accept the explanation in terms of a nervous illness (e.g. gives delusional explanation, the result of persecution, or rays, etc.) 3 = Denies nervous condition entirely. Rating :

(0- full insight, 1&2= partial insight, 3=Nil insight)

SECTION E: MINI SECTION F: 1) PANSS 2) ZUNGS’ SELF RATING DEPRESSION SCALE SECTION G: WHODAS II

APPENDIX 2 (CONTROL) ASSESSMENT OF DISABILITY AMONG NIGERIAN OUTPATIENTS WITH SCHIZOPHRENIA: COMPARISON WITH MATCHED HEALTHY CONTROLS QUESTIONNAIRE SECTION A – SOCIODEMOGRAPHIC SECTION

Serial No/ Date: ___________ 39

1. AGE: (in years) ____________________ 2. SEX: Male ( 1 ) Female ( 2 ) 3. MARITAL STATUS: Single ( 1 ) Married (2 ) Divorced ( 3 ) Separated ( 4 ) Widowed ( 5 ) Others (specify) ______________________________ 4. RELIGION: Christianity ( 1 ) Islam ( 2 ) Traditional religion ( 3) Others (specify) _____________ 5. ETHNICITY: Yoruba (1 ) Igbo ( 2 ) Hausa ( 3 ) Others ( please state) ___________________ 6. OCCUPATION:_________________________________ 7. HIGHEST EDUCATIONAL LEVEL: None ( 0 ) Primary ( 1 ) Secondary ( 2 ) Post Secondary ( not University) (3 ) University ( 4 ) 8. EMPLOYMENT STATUS: Working full time ( 1) Working part time ( 2) Unemployed (3 ) Never Unemployed ( 4) Retired (5 ) In School (6 ) Keeping house ( 7) Others (specify) ______________________ 9. INCOME/EARNING PER MONTH (in Naira) _______________________________ 10. ANY CONCOMITANT MEDICAL/PHYSICAL ILLNESS/PROBLEMS ________________________________________________________________________

SECTION B - ZUNG’S SELF RATING DEPRESSION SCALE SECTION C WHODAS II

40