original papers - Advances in Clinical and Experimental Medicine

original papers
Adv Clin Exp Med 2012, 21, 2, 215–223
ISSN 1899–5276
© Copyright by Wroclaw Medical University
Joanna Rymaszewska1, Justyna Mazurek2
The Social and Occupational Functioning of Outpatients
from Mental Health Services*
Funkcjonowanie społeczne i zawodowe pacjentów
ambulatoryjnej opieki psychiatrycznej
1
2
Department of Psychiatry, Wroclaw Medical University, Poland
Academic Hospital, Wroclaw, Poland
Abstract
Background. Many authors stress the important correlation between disorders and social disability.
Objectives. The aim of the project was the assessment of the occupational and relational social functioning of
persons who suffer from different mental disorders.
Material and Methods. During the 15 months of the project, enrollment was conducted among patients calling in
to three outpatient psychiatric clinics in the Lower Silesia region in Poland. The study included persons (n = 185)
at the age of 18–54 from five diagnostic groups, according to ICD-10: psychotic disorders (F2), affective disorders
(F3), anxiety disorders (F4), eating disorders (F5) and personality disorders (F6). Functioning was evaluated using
the Groningen Social Disabilities Schedule (GSDS II), the Social and Occupational Functioning Assessment Scale
(SOFAS) and the Global Assessment of Relational Functioning (GARF).
Results. The group which had the highest level of functioning with a disability consisted of persons with the F2
diagnosis (1.42, SD = 0.63), whereas persons with anxiety disorders had the lowest disability (0.72, SD = 0.59).
The severity of psychopathological symptoms was indeed related to social functioning. There was a significant
correlation between general social functioning (the overall GSDS score) and the number of episodes (cor = 0.289;
p = 0.001), hospitalizations (cor = 0.352; p < 0.001) and days on leave (cor = 0.393; p < 0.001) for the sample as
a whole.
Conclusions. The functional disabilities indicated within the majority of patients give strong arguments for introducing the diagnosis and therapy of these disabilities and implementation of them to the standards of psychiatric
treatment (Adv Clin Exp Med 2012, 21, 2, 215–223).
Key words: social disability, functioning, mental disorders, outpatient clinics.
Streszczenie
Wprowadzenie. Wielu autorów podkreśla istotną korelację między zaburzeniem psychicznym a niesprawnością
społeczną.
Cel pracy. Ocena poziomu niesprawności społecznej i zawodowej wśród osób z różnymi rozpoznaniami psychiatrycznymi.
Materiał i metody. Badanie przeprowadzono w ciągu 15 miesięcy wśród pacjentów zgłaszających się do trzech
poradni zdrowia psychicznego na Dolnym Śląsku w Polsce. Do badania zostały włączone osoby (n = 185) w wieku
18–54 lat z pięciu grup diagnostycznych według ICD-10: zaburzeń schizofrenicznych (F2), zaburzeń afektywnych (F3), zaburzeń nerwicowych, związanych ze stresem i pod postacią somatyczną (F4), zaburzeń odżywiania
(F5) i zaburzeń osobowości (F6). Funkcjonowanie oceniano za pomocą Formularza Niesprawności Społecznej
Groningen (GSDS II), Skali Oceny Funkcjonowania Społeczno-Zawodowego (SOFAS) oraz Skali Globalnej Oceny
Funkcjonowania w Związkach (GARF).
Wyniki. Osoby z zaburzeniami schizofrenicznymi (F2) odznaczały się najwyższym poziomem niesprawności społecznej (1,42, SD = 0,63), a pacjenci z zaburzeniami nerwicowymi, związanymi ze stresem i pod postacią somatyczną – najniższym (0,72; SD = 0,59). Nasilenie objawów psychopatologicznych w sposób istotny było związane
z funkcjonowaniem społecznym. Stwierdzono istotną korelację między ogólnym poziomem niesprawności spo*The study was funded by the Research Committee No. 40406931/3103.
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J. Rymaszewska, J. Mazurek
łecznej oraz liczbą epizodów (cor = 0,289; p = 0,001), hospitalizacji (cor = 0,352; p < 0,001) oraz dni na urlopie (cor
= 0,393; p < 0,001) dla całej grupy pacjentów.
Wnioski. Stwierdzone u większości badanych zaburzenia funkcjonowania społecznego uzasadniają wprowadzenie
terapii tych zaburzeń do standardów leczenia psychiatrycznego (Adv Clin Exp Med 2012, 21, 2, 215–223).
Słowa kluczowe: niesprawność społeczna, funkcjonowanie, zaburzenia psychiczne, pacjenci leczeni ambulatoryjnie.
Research results confirm that in social disability, the mental factor often plays a much larger
role than the somatic factor. Disability caused by
mental disorders is considered equal to or even
larger than in chronic, serious physical illnesses [4,
13]. The occurrence of a mental disorder, even at
a subliminal level, is connected to an aggravation
of social life [29]. Furthermore, unemployed persons suffer from mental disorders twice as often as
those employed [11]. It is believed that work, for
many of the mentally ill, constitutes an important
mechanism for coping and enables them to maintain social contacts [18]. Experience from practice
proves beyond doubt the need for assessment and
the taking into account of changes in the patients’
functioning during the therapy.
The problem of social disability has been undertaken using cases of patients that had different
mental diagnoses, e.g. schizophrenia or with anxiety, mood, personality or eating disorders [6, 22,
28]. Studies have been conducted on patients with
depression [2, 4, 20], persons with depression and
a chronic somatic illness [28] and with subdepressive symptoms [12]. There are also studies on the
disability of persons with personality and eating
disorders [8, 22, 27], who, before having treatment
in a hospital, function worse than persons suffering from anxiety disorders [26]. The influence of
socio-demographic parameters (e.g. age, gender,
family situation, occupational status and marital
status) on the severity of disorders in social functioning were also verified [1, 27]. Many authors
stress the important correlation between disorders
and social disability [2, 21]. Also, the connection
between social malfunction and the general number of requirements of patients with mental diagnoses has been examined [15, 23].
The aim of the project was the assessment of
the occupational and relational social functioning
of persons who have different mental disorders
and its predictors.
Material and Methods
During the first 15 months of the project,
enrollment was conducted within patients calling in to the outpatient psychiatric clinic of the
Academic Specialist Health Center and the mental hospitals in Wroclaw, Swidnica and Zabkowice
Slaskie in the Lower Silesia region of Poland. The
study included persons at the age of 18–54 from
five diagnostic groups according to ICD-10: psychotic disorders, incl. schizophrenia (F2), affective disorders (F3), neurotic, stress-related and
somatoform disorders (F4), eating disorders (F5)
and personality disorders (F6). The inclusion criteria was the lack of a stated inability to work and
written consent.
The criteria for exclusion from the study were:
addiction to alcohol or other psychoactive substances, dementia, serious, chronic somatic diseases and the inability to give conscious agreement
to participate in the study.
Instruments
Social disability was assessed using the Groningen Social Disabilities Schedule (GSDS II),
which is a semi-structuralized interview used for
evaluation of disorders in social functioning in
several social roles (self-care, family, kinship, partner, citizen, social and occupational) both in nonpsychiatric and psychiatric patients, irrespectively
of the total of their psychopathological symptomatology. The sum score was based on overall role
ratings. The higher score in GSDS II, the worse the
social functioning.
Occupational functioning was evaluated by the
Social and Occupational Functioning Assessment
Scale (SOFAS), that focuses exclusively on the individual’s level of occupational functioning and is
not directly influenced by the overall severity of
the individual’s psychological symptoms.
The Global Assessment of Relational Functioning (GARF) was used to indicate an overall
judgment of the functioning of a family or other
ongoing relationship. SOFAS and GARF are onedimensional scales (0–100 points) which are based
on DSM-IV. They are helpful in the assessment of
social, occupational and relational (family, partner) functioning irrespectively of the patient’s diagnosis.
The Brief Psychiatric Rating Scale was used
for the assessment of the presence and severity
of psychopathological symptoms (BPRS 24-item
version 4.0; Schützwohl et al. 2003; Ventura et
al, 2003). The rating scale of this instrument for
each symptom ranged from “1” (“not present”)
to “7” (“extremely severe”). This is an inventory
217
Social Functioning and Mental Disorders
of psychopathological symptoms, which consists
of 24 positions and enables a quick assessment of
the main symptoms of mental illnesses (depression, anxiety, hallucinations, delusions, activity,
suicidality, hostility, guilt, elevated mood, bizarre
behavior, self-neglect, etc.) and also the dynamics
of their changes over time.
The study was approved by the Commission
of Bioethics at Wroclaw Medical University. All
participants provided written informed consent to
participate in the study.
Results
Group Description
Statistical Methods
The research material gathered was analyzed,
taking into account its diversity, using the program R package 2.4.1. The data was divided into
the following parameters: dependent variables,
which included the overall scores of the GSDS
II, SOFAS and GARF scales, and independent
variables such as socio-demographic and clinical
parameters (age, gender, education, occupational
category, marital status and diagnostic group),
clinic diagnosis in accordance to ICD-10 and the
overall score of the BPRS scale. A Pearson’s test
was used to compare qualitative attributes between diagnosis groups and within these groups
due to other factors. This was verified with the
Monte Carlo method. A Spearman’s rank correlation coefficient was used to define the strength
of the connection between continuous variables.
A basic comparison of two tests was conducted
using a Student’s t-test and its non-parametric
equivalent, the Mann-Whitney test. Test statistics were verified using a two-tailed test, at the
significance level of 0.05. The overall scores of the
scales and subscales for all patients and diagnosis groups were counted as an arithmetic mean.
Missing observations and cases in which patients
refused to answer the question were not taken
into account in stating the arithmetic means.
Regression analysis, including stepwise multiple
block regression and two step multiple regression, was constructed to examine the relation of
a dependent variable to specified independent
variables.
The average age (n = 185) was 34.8 (SD = 11.3),
Table 1. The examined patients were grouped into
diagnostic categories in accordance with the main
psychiatric diagnosis according to ICD-10 classification. Among all patients, the majority were persons
whose main diagnosis was recognized as neurotic,
stress-related and somatoform disorders (F4, n =
58). The subsequent groups, in respect to quantity,
consisted of persons with affective disorders (F3, n
= 44), personality disorders (F6, n = 36), and schizophrenic disorders (F2, n = 32). The smallest group
consisted of patients with diagnosed eating disorders (F5, n = 16). Essential statistical differences between diagnosis groups (p < 0.001) were indicated.
Patients from group F5, with eating disorders, have
the lowest age average (23.7) comparing to the rest
of the patients, and the highest ages correspond to
patients from group F4, with neurotic, stress-related and somatoform disorders (38.8), and F3, with
affective disorders (38.7). In all the tested groups
there were more women (n = 132, 71%) than men,
Table 2. The exception was eating disorders, from
which only women suffered (n = 16). Among the
patients described, the most had secondary education (n = 96, 51.9%) and the least had only completed their education at a primary level (n = 16,
8.6%). Particular diagnostic groups did not differ
significantly with respect to the level of education.
Nearly two thirds of those tested were workers (n
= 116, 63%). 74 persons (40%) remained in a formal relationship, the least of the patients were in the
group widow/widower (n = 6, 3.3%) and only a few
lived alone (n = 13, 7%).
Table 1. Mean age in the diagnostic groups
Tabela 1. Średnia wieku w grupach diagnostycznych
Min.
1st Qu.
Median.
Mean
3rd Qu.
Max
Std
NA’s
F2
19.00
23.00
29.00
30.26
32.50
54.00
10.15
1.00
F3
19.00
30.00
36.00
37.36
47.00
55.00
11.27
2.00
F4
20.00
29.50
41.00
38.03
48.00
57.00
10.64
1.00
F5
19.00
20.00
23.00
24.54
27.00
32.00
4.72
1.00
F6
21.00
24.00
27.00
32.17
44.00
53.00
10.68
1.00
218
J. Rymaszewska, J. Mazurek
Table 2. Gender in the diagnostic groups
Tabela 2. Płeć w grupach diagnostycznych
F2
F3
F4
F5
F6
Female (Żeńska)
15
26
30
13
16
Male (Męska)
 8
 8
 9
 0
13
The Severity of Psychopathological Symptoms (BPRS)
The studied group of patients obtained an
overall score of approximately 1.61 (SD = 0.38).
For half of the patients, the results were in the
range of 1.38–1.7 5. The differences between diagnostic groups were statistically significant (p =
0.001). Persons with schizophrenic disorders had
the highest average BPRS result (1.80, SD = 0.48),
and patients with neurotic, stress-related and somatoform disorders had the lowest results (1.45,
SD = 0.29), Figure 1.
Relational Functioning (GARF)
On the Global Assessment of Relational Functioning Scale the examined patients obtained
a mean result of 61.67 (SD = 16.32). Significant
statistical differences between the diagnostic
groups were observed (p < 0.001). Persons from
diagnostic group F2 (53.59, SD = 13.93) obtained
the lowest result in the scale, and persons from
group F4 (68.71, SD = 14.16) the highest. A negative, directly proportional correlation between
overall scores of the GSDS II and GARF scales (r =
Fig. 1. The results of BPRS in diagnostic groups
Ryc. 1. Wyniki BPRS w grupach diagnostycznych
Fig. 2. Overall score of GSDS II in respect to overall
GARF score
Ryc. 2. Ogólny wynik GSDS II w odniesieniu do ogólnego wyniku GARF
-0.695; p < 0.001) was observed. According to statistics, patients with higher social disability in fact
also functioned worse in relations, Figure 2.
Social and Occupational
Functioning Assessment Scale
(SOFAS)
The examined patients obtained an average result of 63.92 (SD = 17.43). Significant differences between diagnostic groups (p < 0.01) were noted. As
in the case of the GARF scale, the largest disproportions concerned patients with a main diagnosis F4
or F2 (p = 0.0013). Indeed, patients with neurotic,
219
Social Functioning and Mental Disorders
Fig. 3. Overall score of SOFAS in respect to overall score of BPRS
Ryc. 3. Ogólny wynik SOFAS w odniesieniu do ogólnego wyniku BPRS
Fig. 4. Overall score of GSDS II in respect to overall
SOFAS score
Ryc. 4. Ogólny wynik GSDS II w odniesieniu do ogólnego wyniku SOFAS
stress-related and somatoform disorders (67.81, SD
= 16.28) had the highest average results and persons
with schizophrenic disorders – the lowest (53.44, SD
= 14.39), which is presented in Figure 3. Similarly, as
in the relation between GSDS II and GARF, here also
a negative, directly proportional correlation between
overall scores of GSDS II and SOFAS (r = -0.759; p
< 0.001) was observed. The lower the GSDS II result,
the higher the SOFAS result, Figure 4.
Social Functioning (GSDS II)
The studied group obtained an average result
of 1.06 (SD = 0.66), which corresponds to a functioning disorder at a low rate. Half of the examined
obtained results from 0.57 to 1.50. Results significantly varied between patients from different diagnostic groups (p < 0.001). The group which had
the highest level of functioning disorder consisted
of persons with the F2 diagnosis (1.42, SD = 0.63).
Patients from groups F5 (1.09, SD = 0.56) and F3
(1.09, SD = 0.73) functioned at a similar level as
persons from group F3 (1.03, SD = 0.55), whereas
persons diagnosed as F4 showed disability of social functioning at the level 0.72 (SD = 0.59). The
particular statistical parameters are presented in
Table 1.
The analyses showed significantly statistical
differences in the overall scores of GSDS II between persons in a formal relationship and single
persons (p = 0.0086) and between people in informal relationships and single persons (p = 0.0012).
Patients with a marital status defined as single had
significantly higher GSDS II results (worse social
functioning) than patients remaining in a formal
or informal relationship.
A significant difference between persons living
alone and people living with others were indicated
(p < 0.01). Persons living alone had a significantly
lower overall GSDS II scale score (better social
functioning).
The overall GSDS II score for persons with
higher education was considerably lower than for
persons with primary education (p < 0.01).
No correlation between the overall GSDS II
score and age (p < 0.05), gender (p < 0.05) or occupation category (p < 0.05) was noted.
There was a significant correlation between
the overall GSDS score and the number of: previous episodes (r = 0.289; p = 0.001), psychiatric
hospitalizations (r = 0.352; p < 0.001) and days
220
J. Rymaszewska, J. Mazurek
Table 3. The results of GSDS II in diagnostic groups
Tabela 3. Wyniki GSDS II w grupach diagnostycznych
Min.
1st Qu.
Median
Mean
3rd Qu.
Max.
SD
Missing
F2
0.43
1.09
1.29
1.42
1.78
2.71
0.63
0.00
F3
0.00
0.57
1.00
1.09
1.57
2.57
0.72
0.00
F4
0.00
0.26
0.62
0.72
0.97
2.50
0.59
0.00
F5
0.29
0.82
1.00
1.09
1.31
2.29
0.56
0.00
F6
0.00
0.71
1.00
1.03
1.43
2.12
0.55
0.00
Fig. 5. Overall score of GSDS II in respect to the overall BPRS score
Ryc. 5. Ogólny wynik GSDS II w odniesieniu do ogólnego wyniku BPRS
on leave (r = 0.393; p < 0.001) for the sample as
a whole.
A positive, directly proportional correlation
between overall scores of the GSDS II and BPRS
scales (r = -0.684; p < 0.001) was observed. Indeed,
patients with larger social disability had more severe psychopathological symptoms, Figure 5.
Considering regression analyses, a high level of
negative symptoms appeared as the strongest predictor of social disability. Depressive symptoms,
main diagnosis, education and gender were other
important predictors which all together explained
66% of the variance, Figure 6.
Discussion
The social functioning of persons from four
different diagnostic groups was compared taking
into account the connections of different factors.
On the basis of comparison of the overall GSDS II
score between diagnostic groups, it was stated that
patients with neurotic, stress-related and somatoform disorders had statistically the lowest level
of social disability in comparison to the examined
patients with affective, schizophrenic, personality
and eating disorders. In this study, the social disability differences between persons with affective,
eating and personality disorders have not been indicated. These results partially confirm the results
obtained in previous research conducted in several
European centers (n = 969) [26], where during the
period of severity of symptoms, persons with eating, personality and schizophrenic disorders functioned worse than persons with affective and neurotic disorders. In population studies conducted
in Belgium, France, Germany, Italy, Holland and
Spain (n > 21,000) which assessed the correlation
between mental and physical disorders and different areas of functioning, Biust-Bouwman and
co-authors stated that the largest connection with
disability is among anxiety disorders, which are
followed by mood disorders and those related to
alcohol [4]. Other authors confirm a direct connection between the level of disability and diagnostic category. Sanderson and Andrews showed
that the greatest disability is found among patients
with affective and anxiety disorders [27] and Rie
and co-authors have proven that social disability is higher among persons with personality and
eating disorders than among persons with fear
or mood symptoms [22]. In Bij and Ravelli’s research, the level of social disability was different
depending on the main psychiatric diagnosis, and
the highest degree of disability was found among
persons with affective disorders [2]. Simon stated
that functioning got worse in the case of persons
with affective disorders [28], whereas in Bilder’s
and Mechanic’s research, patients with the same
diagnosis functioned worse in all the areas of the
Functional Status Questionaire, in comparison to
general population [3]. According to Judd and coauthors, it is the subdepressive state that can be
linked with psycho-social disability [12]. However,
the conclusion of a significant correlation between
Social Functioning and Mental Disorders
221
Fig. 6. Predictors of social
disability
Ryc. 6. Czynniki prognostyczne dla niesprawności
społecznej
psychiatric diagnosis and functioning hasn’t been
confirmed unanimously. Some authors have proven a lack of direct connection between the level of
occupational skills and diagnostic category [1, 10].
Detailed comparisons are impossible due to methodological differences.
The severity of psychopathological symptoms
was indeed related to social functioning: patients
with more intensified mental disorder functioned
much worse. This conclusion has been confirmed
in many studies [2, 19] and some authors have
stressed that the severity of psychopathological
symptoms has more importance for the level of social disability than the type of diagnosis [24, 25].
Neither the age nor gender nor occupational
category have any significant influence on social
functioning within the examined group. Among
researchers, there is lack of agreement whether
there is an influence of gender on social functioning within patients with different diagnostic categories. Sanderson and Andrews obtained different
results, in which functioning was different between
men and women suffering from mental illnesses,
finding it advantageous to women [27]. Melle and
co-authors proved that, among those suffering from
schizophrenia, the male gender and higher education were connected to better functioning [16],
whereas Wiersma and co-authors confirmed the
lack of influence of gender on disability amongst
patients with the same diagnosis [30].
Górna and Rybakowski proved the lack of essential significance of marital status with social
functioning among persons receiving outpatient
treatment [9]. However in the present study, persons with a marital status defined as single functioned much worse than persons remaining in
formal or informal relationships.
The comparison of the level of social disability among persons from different diagnostic categories made it possible to come to the following
conclusions.
Among patients from outpatient psychiatric
clinics, persons with schizophrenic disorders (F2)
functioned relatively the worst and patients with
neurotic, stress-related and somatoform disorders
(F4) the best. A similar level of disability was characteristic for patients with eating, affective and
personality disorders.
Among the rest of the independent variables,
severity of psychopathological symptoms, marital
status, residence and education were significant
for the level of social disability. The higher the
social disability, the worse the social-occupational
and relational functioning. The more intensified
the psychopathological symptoms, the higher the
social disability.
The level of social efficiency didn’t differ
among patients based on age, gender and occupational category.
Negative symptoms, depressive symptoms,
main diagnosis, education and gender were significant predictors of social disability.
The social functioning disabilities indicated
within the majority of patients give reason to introduce the diagnosis and therapy of these disabilities to the standards of psychiatric treatment.
222
J. Rymaszewska, J. Mazurek
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Address for correspondence:
Justyna Mazurek
Faculty of Physiotherapy
Wroclaw University of Physical Education
Łęczycka 11/4
53-632 Wrocław
Poland
Tel.: +48 695 18 09 84
E-mail: [email protected]
Conflict of interest: None declared
Received: 14.07.2011
Revised: 9.09.2011
Accepted: 29.03.2012