|Year : 2019 | Volume
| Issue : 3 | Page : 201-206
Certifiable disability in schizophrenia and its correlates: A cross-sectional study
Rakesh Byra Reddy, Kailash Sureshkumar, Srinivasan Balasubramania, OT Sabari Sridhar, Shabeeba Z Kailash
Department of Psychiatry, Chettinad Hospital and Research Institute, Kelambakkam, Tamil Nadu, India
|Date of Submission||18-Feb-2019|
|Date of Decision||08-Apr-2019|
|Date of Acceptance||26-Apr-2019|
|Date of Web Publication||30-Sep-2019|
Dr. Kailash Sureshkumar
Department of Psychiatry, Chettinad Hospital and Research Institute, Kelambakkam - 603 103, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Disability associated with schizophrenia has an impact on various domains of life. Patients with >40% disability are entitled for getting benefits from the government. The study aimed at assessing the certifiable disability, severity of the disability, and its correlates in patients with schizophrenia. Materials and Methods: Tertiary hospital-based cross-sectional study comprised of 63 patients with schizophrenia fulfilling the selection criteria. The data included sociodemographic and illness variables. Positive and Negative Syndrome Scale, Medication Adherence Rating Scale, and Glasgow Antipsychotic Side-effects Scale were used to assess the symptom severity, treatment adherence, and side effects, respectively. The Indian Disability Evaluation Assessment Scale (IDEAS) was used to evaluate the disability. Data were analyzed using the Statistical Package for Social Sciences software. Results: Majority of the patients (53.7%) had certifiable disability. About 46% of patients had mild level of disability, while 39.7% had moderate level of disability, 1.6% had severe level of disability, and 12.7% had profound disability. The disability was observed to be more in the work, social relationships, and communication domain of IDEAS. There was a strong positive correlation between symptom severity, antipsychotic side effects, and disability. The disability was greater in patients who had a poor medication adherence. Conclusion: Patients with schizophrenia have a significant certifiable disability in all domains of life. Symptomatology, antipsychotic side effects, and medication adherence are important predictors of disability. Preventive and rehabilitative measures should be taken for controlling these modifiable factors which would help in limiting disability. Suitable guidance should be given to avail the disability benefits.
Keywords: Antipsychotic side effects, certifiable disability, Indian Disability Evaluation Assessment Scale, medication adherence, schizophrenia
|How to cite this article:|
Reddy RB, Sureshkumar K, Balasubramania S, Sabari Sridhar O T, Kailash SZ. Certifiable disability in schizophrenia and its correlates: A cross-sectional study. Indian J Soc Psychiatry 2019;35:201-6
|How to cite this URL:|
Reddy RB, Sureshkumar K, Balasubramania S, Sabari Sridhar O T, Kailash SZ. Certifiable disability in schizophrenia and its correlates: A cross-sectional study. Indian J Soc Psychiatry [serial online] 2019 [cited 2020 Jan 22];35:201-6. Available from: http://www.indjsp.org/text.asp?2019/35/3/201/268335
| Introduction|| |
Disability is a multifarious concept which includes impairments, activity limitations, or participation restrictions. It has evolved to encompass the sociooccupational well-being. Hence, public policies have emerged worldwide to create a better situation by offering monetary benefits and job-related provisions to aid individuals with disabilities. In India, people with more than 40% disability are entitled to avail welfare assistance from the government.
Schizophrenia is a chronic illness affecting various spheres of life. It generally results in social isolation and poor occupational functioning. Therefore, it is one of the significant causes of disability. Typically, 14.5 years of possible life is lost in affected people. The number of disability-adjusted life years lost due to schizophrenia in India is 156.8/100,000 individuals. Hence, just treating the symptoms is not the only purpose, rather the enhancement of social functioning is of utmost importance.
Studies in India have used various instruments and scales for the assessment of the disability. Hence, the data are varied with reference to the factors influencing it. Mohan et al. in their study found that schizophrenia had a significant disability in all domains of the Indian Disability Evaluation Assessment Scale (IDEAS). It has been suggested that factors such as negative symptoms, prolonged period of illness, male sex, poor insight, adherence to treatment, and cognitive deficits have an effect on disability in schizophrenia.,,, In a study done in Hong Kong, it was seen that extrapyramidal symptoms due to antipsychotic side effects correlated greatly with disability in schizophrenia.
With the evidence available, it is apparent that disability in schizophrenia is influenced by a multitude of factors, such as illness variables and social support. In many instances, people do not have adequate knowledge and information about the available disability benefits. As far as we know, not many studies on certifiable disability in schizophrenia have been done in the past. In view of this background, this study aimed to detect the frequency of certifiable disability in schizophrenia and identify the factors affecting it. The study also intended to assess the severity of the disability and its correlates in patients with schizophrenia.
| Materials and Methods|| |
Study design and selection criteria
This cross-sectional study was conducted in the Department of Psychiatry at a tertiary care teaching hospital in South India. It is located in a semi-urban area which has seen recent development and urbanization. Sixty-three patients diagnosed with schizophrenia fulfilling the 10th revision of the International Statistical Classification of Diseases and Related Health Problem criteria coming for follow-up with a minimum illness duration of at least 2 years aged more than 18 years were selected for the study. Patients having a chief diagnosis of substance use disorder, affective disorder, organic mental disorder, aggression, major physical illness, and patients unable to give informed consent were excluded. The study was conducted after obtaining ethical clearance from Institutional Human Ethics Committee. All patients were given necessary treatment irrespective of their participation in the study. All patients selected signed a written informed consent to participate in the study.
- Questionnaire: Predesigned sociodemographic and clinical questionnaire were used to elicit variables such as age, sex, marital status, occupation, educational level, religion, family structure, age at onset of illness, duration of illness, duration of untreated psychosis, and family history of psychiatric illness
- The Positive and Negative Syndrome Scale (PANSS) was used to rate the severity of symptoms in the patients. The patient was scored from 0 to 6 on 30 symptom clusters 
- IDEAS was used to assess the disability in the domains of Self Care, Interpersonal Activities (Social Relationships), Communication and Understanding, and Work. Those with global score of >8 were considered as having certifiable disability 
- Medication Adherence Rating Scale (MARS) was used to assess the treatment compliance. It is a 10-item questionnaire with total scores ranging from 0 to 10 indicating low-to-high likelihood of adherence. A score of 6 and above indicates adherence 
- Glasgow Antipsychotic Side-effect Scale (GASS) which is a 22-item questionnaire to screen for the level of metabolic and neuromuscular side effects was used. They are characterized as mild, moderate, and severe.
The above-mentioned questionnaires and tools were administered to the individuals by the same person. The researcher had adequate training for the administration of all instruments and scales by qualified psychiatrists.
Data analysis was done using the IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. The disability was considered as the primary outcome variable. The sociodemographic and clinical variables and the assessment scores were summarized as mean ± standard deviation and percentages as applicable. The sample was divided into those with and without certifiable disability. Association and comparison of the above variables to test for statistical significance were done by independent sample t-test and Chi-square test, respectively. In addition, the relationship between global disability and clinical symptoms, medication adherence, and side effects was done using the Pearson correlation. P < 0.05 was considered statistically significant for all these tests.
| Results|| |
The mean age of the sample was 40.43 ± 11.76 years. Among the study population, 34 (54%) were male while the remaining 29 (46%) were female. 44 (69.8%) were married, out of which 2 individuals were separated. The majority of the individuals were literate with 70% of them having completed secondary education. More than three-fourths (75.4%) were Hindu by religion. Large percentage (66.7%) was unemployed. Most of them came from an urban 21 (33.3%) and 17 (27.0%) semiurban background. Four-fifths came from a lower and middle (49%) social class and belonged to a nuclear family (79.4%).
The mean age of onset of illness was 29.08 ± 7.74 years. The average duration of illness was 11.3 ± 8.9 years, and the mean duration of untreated psychosis was 12.14 ± 11.32 months. About 38.1% of the individuals had a family history of psychiatric illness. The mean PANSS positive, negative, and general symptom score was 16.68 ± 7.08, 20.11 ± 8.58, and 24.05 ± 9.27, respectively. The mean PANSS total score was 60.65 ± 19.85. Majority of the participants (68.3%) had mild antipsychotic side effects and 38 (60.3%) of the respondents had poor compliance to medications.
Among the individuals, most of them 29 (46.0%) had mild disability, followed by 25 (39.7%) moderate disability, 8 (12.7%) severe disability, and 1 (1.6%) profound disability. A little more than half of the study population (53.9%) had certifiable disability [Figure 1].
Factors affecting certifiable disability
For the purpose of comparison, individuals were divided into those who had certifiable disability and those who are not certifiable disabled. There was no statistically significant differences in most of the sociodemographics variables between the groups. Unemployment was higher in the certifiable disabled group compared to the other group which was statistically significant (P = 0.02) [Table 1].
It was also seen that there was no significant differences in the age of onset, duration of illness, duration of untreated psychosis, and family history between the two groups. There were significantly higher scores in all domains of PANSS and GASS in the certifiable disabled group compared to the nondisabled group. Medication adherence was significantly poor in the certifiable disabled group [Table 2].
|Table 2: Comparison of clinical variables, medication adherence, and side effects between the groups|
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The disability was observed to be more in the work, interpersonal relationships and communication domain of IDEAS. The mean scores in each domain were significantly higher in the certifiable disabled group [Figure 2].
|Figure 2: Mean scores of the Indian Disability Evaluation Assessment Scale domains|
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Correlations between disability and symptoms, medication adherence, and side effects
Correlation analysis revealed that there was only a weak positive correlation between disability and age of onset (r = 0.076, P = 0.55) and duration of illness (r = 0.053, P = 0.078). However, there was a significant positive correlation between disability and all the areas of the PANSS scale. The association was greater for the positive symptoms, followed by the negative symptoms and general psychopathology [Table 3].
|Table 3: Pearson correlation between global disability and symptom severity|
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A strong positive correlation between disability and antipsychotic side effects GASS (r = 0.533, P < 0.001) was observed. There was a negative relationship between disability and the MARS score (r = −0.617, P < 0.001), signifying that poorer the medication compliance, greater the disability [Figure 3] and [Figure 4].
|Figure 3: Scatter plot for correlation between global disability and antipsychotic side effects|
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|Figure 4: Scatter plot for correlation between global disability and medication adherence|
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| Discussion|| |
The general goal in the management of any illness is symptom remission. On the other hand, in psychiatric illnesses, especially schizophrenia, improving the overall functioning is paramount as the disability is very common. In India, many are not aware of the disability benefits available for mental illness. Taking this aspect into account, this study reports some key findings related to the certifiable disability such as frequency and other correlates.
In this study, majority of the individuals were male. However, 55% of females had certifiable disability compared to 44% males. This is comparable to other studies where women were more disabled compared to men., Majority of the individuals were married, and in those who were separated, influence of illness, and poor functioning was evident. Unemployment was a major factor in the group, where many of them were unable to continue the job or were deemed unfit by the employers. This aspect of functional impairment was also found in previous studies.,
Mild disability was most common followed by moderate disability. Various studies have reported similar nature of the severity of the disability.,, However, some other studies have reported a moderate disability as more common. More than half of the individuals had certifiable disability implying moderate-to-severe disability. This finding was comparable to two other Indian studies., We report that work, interpersonal activities and communication, and understanding domains are the most affected. This mirrors other studies that have described the disability in the work domain being the most incapacitating., This could be attributed due to higher negative symptoms and poor treatment compliance.
Evidence from past studies has shown that the sociodemographic and clinical variables such as gender, age of onset, mode of onset, duration of illness, and duration of untreated psychosis are linked to the outcome of schizophrenia and in turn resulting in disability.,, This study, however, did not find any such correlation. It could be due to the cross-sectional nature of the study design. The severity of symptoms in all domains are interlinked with disability.,,, In a similar trend, a strong positive correlation was seen between disability and all components of the PANSS. The association was strongest for positive and negative symptoms. However, another Indian study showed only negative symptoms associated with disability. This explains the importance of symptom remission in schizophrenia.
Poor medication adherence is another important factor to be considered, as it results in the persistence of symptoms and hence poor functioning. Thirthalli et al. evaluated disability in a community setting using IDEAS and compared disability in patients with and without treatment compliance. They observed that patients on antipsychotics had considerably less disability. Our study also found that poor medication adherence had a strong positive association with global disability. It was also seen that in patients who had certifiable disability, significantly large number had poor compliance to medications. Hofer et al. found that antipsychotic side effects such as Parkinsonism More Details and psychic symptoms have an impact on psychosocial functioning. Our study findings were similar in nature. However, being on antipsychotic treatment should help in limiting disability. The disability arising could be due to irregular treatment as a result of side effects.
Certain limitations identified may have affected the findings in the study. This study being a hospital-centered, with small sample size and being cross-sectional in nature cannot be generalized to represent all the patients. Cross-sectional studies with a larger sample size considering subtype of schizophrenia, changes in severity, type of treatment and influence of social support could be undertaken. Notwithstanding, the above-mentioned limitations, the strength of this study is that it looks at both correlates of overall disability and factors predicting the disability in those who have certifiable disability.
| Conclusion|| |
The results suggest that disability in all domains of life is seen in schizophrenia. Nature of symptoms and its severity was found to significantly correlate with disability. Medication adherence and antipsychotic side effects are also important predictors of disability. Symptom reduction is the primary aim. Furthermore, it is prudent to focus on modifiable factors such as treatment compliance and side effects, which would help patients in improved sociooccupational functioning. The goal is to reduce the incapacity, and in those who have certifiable disability, it is also important to guide them in obtaining government schemes which will be an immense means of support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. International Classification of Functioning, Disability and Health. World Health Organization; 2018. Available from: https://www.who.int/classifications/icf/en/
. [Last accessed on 2019 Feb 17].
Hjorthøj C, Stürup AE, McGrath J, Nordentoft M. SA57. Life expectancy and years of potential life lost in schizophrenia: A systematic review and meta-analysis. Schizophr Bull 2017;43 Suppl 1:133-4.
Global Burden of Disease Study 2016 Data Resources. GBD Results Tool | GHDx. Global Burden of Disease; 2016. Available from: http://ghdx.healthdata.org/gbd-2016
. [Last accessed on 2019 Feb 17].
Galuppi A, Turola MC, Nanni MG, Mazzoni P, Grassi L. Schizophrenia and quality of life: How important are symptoms and functioning? Int J Ment Health Syst 2010;4:31.
Mohan I, Tandon R, Kalra H, Trivedi JK. Disability assessment in mental illnesses using Indian disability evaluation assessment scale (IDEAS). Indian J Med Res 2005;121:759-63.
Thirthalli J, Kumar CN. Stigma and disability in schizophrenia: Developing countries' perspective. Int Rev Psychiatry 2012;24:423-40.
Harvey PD. Disability in schizophrenia: Contributing factors and validated assessments. J Clin Psychiatry 2014;75 Suppl 1:15-20.
García-Cabeza I, Díaz-Caneja CM, Ovejero M, de Portugal E. Adherence, insight and disability in paranoid schizophrenia. Psychiatry Res 2018;270:274-80.
Chen R, Liou TH, Chang KH, Yen CF, Liao HF, Chi WC, et al.
Assessment of functioning and disability in patients with schizophrenia using the WHO disability assessment schedule 2.0 in a large-scale database. Eur Arch Psychiatry Clin Neurosci 2018;268:65-75.
Xiang YT, Weng YZ, Leung CM, Tang WK, Ungvari GS. Quality of life of Chinese schizophrenia outpatients in Hong Kong: Relationship to sociodemographic factors and symptomatology. Aust N
Z J Psychiatry 2007;41:442-9.
Kay SR, Fiszbein A, Opler LA. The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophr Bull 1987;13:261-76.
The Rehabilitation Committee of the Indian Psychiatric Society. IDEAS (Indian Disability Evaluation and Assessment Scale) – A Scale for Measuring and Quantifying Disability in Mental Disorders. Gurgaon, India: Indian Psychiatric Society; 2002.
Thompson K, Kulkarni J, Sergejew AA. Reliability and validity of a new Medication Adherence Rating Scale (MARS) for the psychoses. Schizophr Res 2000;42:241-7.
Waddell L, Taylor M. A new self-rating scale for detecting atypical or second-generation antipsychotic side effects. J Psychopharmacol 2008;22:238-43.
Kumar SG, Das A, Bhandary PV, Soans SJ, Harsha Kumar HN, Kotian MS, et al.
Prevalence and pattern of mental disability using Indian disability evaluation assessment scale in a rural community of Karnataka. Indian J Psychiatry 2008;50:21-3.
] [Full text]
Shankar R, Kamath S, Joseph AA. Gender differences in disability: A comparison of married patients with schizophrenia. Schizophr Res 1995;16:17-23.
Olagunju AT, Adegbaju DA, Uwakwe R. Disability among attendees with schizophrenia in a Nigerian hospital: Further evidence for integrated rehabilitative treatment designs. Ment Illn 2016;8:6647.
Lyngdoth L, Ali A. Disability in person with schizophrenia: A study from North East India. Int J Psychosoc Rehabil 2016;20:3.
Shihabuddeen I, Chandran M, Moosabba. Disability in persons with schizophrenia correlated to family burden and family distress among their caregivers. Delhi Psychiatry J 2012;15:332-7.
Chowdhury TR, Sahu KK, Biswas P. Disability and rehabilitation needs of persons with schizophrenia. Indian J Psychiatr Soc Work 2018;9:38-46.
Parker G, Hadzi-Pavlovic D. The capacity of a measure of disability (the LSP) to predict hospital readmission in those with schizophrenia. Psychol Med 1995;25:157-63.
Balhara YP, Verma R, Deshpande SN. A study of profile of disability certificate seeking patients with schizophrenia over a 5 year period. Indian J Psychol Med 2013;35:127-34.
] [Full text]
Thara R, Rajkumar S. Nature and course of disability in schizophrenia. Indian J Psychiatry 1993;35:33-5.
] [Full text]
Alptekin K, Erkoç S, Göǧüş AK, Kültür S, Mete L, Uçok A, et al.
Disability in schizophrenia: Clinical correlates and prediction over 1-year follow-up. Psychiatry Res 2005;135:103-11.
Thara R, Joseph A. Gender difference in symptoms and course of schizophrenia. Indian J Psychiatry 1995;37:124-8.
] [Full text]
Ali A. Disability in schizophrenia and its relationship with duration of illness and age of onset. Int J Psychosoc Rehabil 2009;14:37-41.
Chaudhury PK, Deka K, Chetia D. Disability associated with mental disorders. Indian J Psychiatry 2006;48:95-101.
] [Full text]
Grover S, Shah R, Kulhara P, Malhotra R. Internal consistency & validity of Indian disability evaluation and assessment scale (IDEAS) in patients with schizophrenia. Indian J Med Res 2014;140:637-43.
] [Full text]
Ertuǧrul A, Uluǧ B. The influence of neurocognitive deficits and symptoms on disability in schizophrenia. Acta Psychiatr Scand 2002;105:196-201.
Galderisi S, Rossi A, Rocca P, Bertolino A, Mucci A, Bucci P, et al.
The influence of illness-related variables, personal resources and context-related factors on real-life functioning of people with schizophrenia. World Psychiatry 2014;13:275-87.
Kumar CN, Thirthalli J, Yadav M, Gangadhar BN, Varghese M, Cottler LB. Certifiable disability in first episode schizophrenia: the role of adherence to antipsychotic treatment. J Psychosoc Rehabil Ment Health 2014;1:55-9.
Thirthalli J, Venkatesh BK, Naveen MN, Venkatasubramanian G, Arunachala U, Kishore Kumar KV, et al.
Do antipsychotics limit disability in schizophrenia? A naturalistic comparative study in the community. Indian J Psychiatry 2010;52:37-41.
] [Full text]
Hofer A, Baumgartner S, Edlinger M, Hummer M, Kemmler G, Rettenbacher MA, et al.
Patient outcomes in schizophrenia I: Correlates with sociodemographic variables, psychopathology, and side effects. Eur Psychiatry 2005;20:386-94.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]