ORIGINAL ARTICLE

Correlates of Subjective Quality of Life in People With

Schizophrenia
Findings From the EuroSC Study
Steven Marwaha, MSc, MRCPsych,* Sonia Johnson, DM,* Paul Bebbington, PhD,*
Matthias C. Angermeyer, MD, Traolach Brugha, MD, Jean-Michel Azorin, MD,
Reinhold Kilian, PhD, Asa Kornfeld, MD, and Mondher Toumi, MD; on Behalf of the EuroSC Study Group

Abstract: Quality of life (QOL) is an important outcome for people

with schizophrenia, but most previous studies of its correlates have
had small sample sizes or explored a limited number of variables.
We conducted an analysis of the baseline data from the European
Schizophrenia Cohort (EuroSC) study, a naturalistic investigation of
people with schizophrenia living in France, Germany, and the
United Kingdom (N 1208). German participants had the highest
subjective QOL. Country of residence, depression, accommodation
status, and employment were the most important factors in explaining subjective QOL. Many correlates of subjective QOL in people
with schizophrenia were similar to those in the general population.
Many of the factors important in explaining subjective QOL in
people with schizophrenia are not readily amenable to change.
Differences in mental health service provision in the United Kingdom and Germany may in part explain variations in the QOL of
people with schizophrenia resident there.
Key Words: Schizophrenia, quality of life, correlates, employment.
(J Nerv Ment Dis 2008;196: 8794)

uality of life (QOL) has become one of the most important measures of outcome in schizophrenia research
(Meltzer, 1999). It is valuable because it attempts to measure
overall how satisfied individuals are with their lives, thus
encompassing many other outcomes. Facets of QOL such as
*Department of Mental Health Sciences, Royal Free and University College
London Medical School, University College London, London, United
Kingdom; Universitat Leipzig, Leipzig, Germany; University of Leicester, United Kingdom; Hospital Sainte Marguerite, Marseille, France;
Universitat Leipzig, University of Ulm, Germany; and Lundbeck S.A.,
France.
Supported by grants from Lundbeck A/S and from the German Federal
Ministry of Education and Research.
Send reprint requests to Dr. Steven Marwaha, MSc, MRCPsych, C/O M
Trott, Department of Mental Health Sciences, Royal Free and University
College London Medical School, University College London (Bloomsbury Campus), 48 Riding House Street, London, W1W 7EY. E-mail:
stevenmarwaha@yahoo.co.uk.
Copyright 2008 by Lippincott Williams & Wilkins
ISSN: 0022-3018/08/19602-0087
DOI: 10.1097/NMD.0b013e318162aa9c

employment are among the priorities of service users (Seebohm and Secker, 2005). Most definitions include the 3
dimensions of subjective wellbeing/satisfaction, functioning
in daily life, and external resources such as accommodation
(Naber et al., 2002), although the concept of QOL is still
developing (Lauer, 1999). Understanding the determinants of
QOL, including the subjective component, should enable us
to target areas for intervention.
Symptoms have been a major focus in previous explorations of QOL predictors. Correlational analyses have consistently shown that depression is important in explaining
subjective QOL in people with schizophrenia (BengtssonTops et al., 2005, Sim et al., 2004), even when potential
confounders are controlled for (Huppert et al., 2001). Numerous cross-sectional studies have assessed the effect of positive psychotic symptoms on QOL, but most find scant association (Carpiniello et al., 1997; Heslegrave et al., 1997;
Kasckow et al., 2001). The findings from cohort studies are
mixed, with some suggesting no relationship with positive
psychotic symptoms when confounders are controlled for
(Sota and Heinrichs, 2004), whereas in others positive psychotic symptoms and QOL are correlated in stable but not in
acutely psychotic groups (Bow-Thomas et al., 1999). A
relationship between more severe negative symptoms and
poorer QOL is much more commonly reported (Mueser et al.,
1991; Naber et al., 2002).
With regard to social factors, higher educational level
predicted lower general subjective well-being in a recent
prospective study of people with the full range of psychiatric
disorders living in Italy (Ruggeri et al., 2005). A similar
association has been reported in the United States (Caron et
al., 2005a), but the opposite has also been described (Swanson et al., 1998). The relationship between subjective QOL
and gender is likewise unclear in that men and women have
higher scores on different domains of satisfaction in a variety
of studies (Lehman et al., 1995; Vandiver, 1998). In the
general population and the mentally ill, increasing age is
associated with better overall life satisfaction (Caron et al.,
2005a; Mroczek and Spiro, 2005), whereas health-related
QOL worsens with age (Lubetkin et al., 2005).
Many studies encompass both objective and subjective
indicators of QOL, yet the relationship between them remains

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Marwaha et al.

unclear, partly because of the lack of consensus regarding the

most important components of objective QOL. Thus there is
little uniformity in which variables are studied and whether
they are distinguished from demographic characteristics. Objective factors covered in some QOL instruments include accommodation status, frequency of family contact, and whether a
person has been a victim of crime. Although some studies have
found little or no relationship between objective and subjective
QOL (Fakhoury et al., 2002; Warner, 1999), some have found
employed people have higher subjective QOL (Caron et al.,
2005b; Priebe et al., 1998) as do those housed in less restrictive
living conditions (Levitt et al., 1990).
Cross-national analyses of QOL based on large samples
are rare. To our knowledge the only relevant analysis to date
is the European Psychiatric Services: Inputs Linked to Outcome Domains and Needs study, which assessed the QOL of
people with schizophrenia in 5 European centers with a sample
size of 404 participants (Gaite et al., 2002). More frequent
contacts with family and having a reliable friend were independently associated with a better subjective QOL, whereas severity
of depressive symptoms predicted worse subjective QOL. Also
living in Amsterdam was associated with a worse QOL than
living in London.
There is a degree of inconsistency in the literature with
regards to the determinants of subjective QOL. The most
replicated findings seem to be that negative psychotic symptoms, depression, and demographic factors such as age may
be important in explaining subjective QOL. Studies to date
have tended to have small numbers, participants have often
been sampled from unrepresentative psychiatric services, and
most studies have used a limited number of potential determinants in the analyses. These limitations may account at
least in part for the lack of consistency in findings.
The aim of this study was to analyze cross-sectionally
the correlates of subjective QOL in a large sample of people
with schizophrenia, living in the United Kingdom, France,
and Germany and in contact with secondary mental health
care services. We considered the influence of a broad range of
objective measures including demographic factors, symptoms, and country of residence on subjective QOL.

METHODS
The European Schizophrenia Cohort (EuroSC) study is
a naturalistic 2-year follow-up of 1208 people aged 18 to 64
years suffering from schizophrenia and in contact with secondary psychiatric services (inpatient, outpatient, community
mental health team). A full explanation of the rationale and
methods of the study and a description of services in all 3
countries is presented by Bebbington et al. (2005). Data
collection lasted from 1998 to 2000.

Study Sites
The specific study sites were chosen because they were
socio-demographically distinct and had different styles of
service delivery. In France, participants were recruited from 3
centers: Lille (Northern France), Lyon and Clermont-Ferrand
(Central France), and Marseille and Toulon (Southern France).
In former East Germany, participants were recruited from
Leipzig and from the Altenburg area. In former West Germany,

88

recruitment was from the Hemer and Heilbronn districts. The

centers in the United Kingdom were the county of Leicestershire
(excluding the city of Leicester) and the inner London Borough
of Islington.

Sampling
The participants were selected to provide a representative sample of people with schizophrenia who were being
monitored and treated by secondary mental health services in
the 3 countries. People who had recently lost contact with
services were not approached for entry into the study except
in Islington, London. Sampling was achieved in London
(Islington) and in all the French centers by establishing a list
of all psychotic patients in the areas from information already
kept by the mental health services and taking a random
sample from all those identified. In Islington patients were
randomly sampled from the whole local list, whereas in
France 10 patients were randomly selected from each catchment area sector. In Germany and in Leicestershire, lists of all
potential participants in each catchment area were also compiled and all eligible people were included in the sample.
Participants were included if they had a diagnosis of
schizophrenia according to DSM-IV, were aged 18 to 64
years, and gave informed consent. Exclusion criteria were
continuous hospitalization for the previous 12 months, being
currently roofless, or planning to move out of the area.

Instruments Used
An extensive battery of instruments was used at interview, but only those relevant to this analysis will be presented
here. The instruments selected and used in the EuroSC study
depended on local requirements and interest. However all the
data collected for the current analysis were from the same
instruments regardless of the center. The short version of
Lehmans Quality of Life Interview (QOLI) (Lancon et al.,
2000) was used to assess QOL. The QOLI is intervieweradministered, has good psychometric properties (Dickerson
et al., 1997; Lehman, 1993) and has been used internationally. The version used in this study assesses subjective and
objective QOL and includes 78 items grouped in 8 dimensions (Lancon et al., 2000). These are living situation, daily
activities and functioning, family, social relations, finances,
work and school, legal and safety issues, and health. It also
provides a life-in-general subjective rating of QOL. Answers
to the subjective QOL questions are rated on a 7-point Likert
scale where 1 equates to terrible and 7 to delighted. Missing
values for single items were replaced by the mean score for
that section within the QOLI. For the purposes of this analysis the total scores for the 8 dimensions of subjective QOL
were added to the general life satisfaction score to produce a
total subjective QOL mean variable.
In all centers, a diagnosis of schizophrenia was confirmed after an interview using structured instruments by a
study investigator who applied the DSM-IV criteria (American Psychiatric Association, 1994). The Schedule for Clinical
Assessment in Neuropsychiatry (SCAN) (Wing et al., 1990;
World Health Organization (WHO), 1992) was used to establish the diagnosis in the United Kingdom and Germany,
whereas the French centers used the Structured Clinical
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The Journal of Nervous and Mental Disease Volume 196, Number 2, February 2008 Quality of Life in People With Schizophrenia

Interview for DSM-IV (First et al., 1997). Part of the alcohol

and substance misuse data available from the SCAN allowed
the coding of variables indicating lifetime history of alcohol
abuse and drug abuse. All centers completed the sections of
the SCAN related to alcohol and substance misuse. Psychiatric and social history was recorded using the Past History
and Socio-demographic Description Schedule (WHO, 1973).
Information on current symptom profile was collected
using the Positive and Negative Syndrome Scale (PANSS) (Kay
et al., 1987; Kay et al., 1989). The summary indicators from the
PANSS used in this analysis were the positive, negative, and
general psychopathology symptom subscores. Depression was
assessed using the Calgary Depression Scale for Schizophrenia
(Addington et al., 1990). The scores range from 0 to 27 and we
used a score of 6 or more to indicate depression, as suggested by
Addington et al. (1996). The overall functioning of participants
was measured using the Global Assessment of Functioning
(American Psychiatric Association, 1994).
Combined training was held involving interviewers from
all 3 sites to try and ensure instruments were used reliably. For
those instruments not already available in French and German,
translation followed the comprehensive procedures recommended by the WHO (Sartorius and Kuyken, 1994), including
back translation.

Analysis
This article presents analyses of the baseline QOL data.
It was carried out using SPSS (version 12). Using ANOVA or
chi square, we initially tested whether there were significant
differences in clinical and sociodemographic variables and in
the different domains of subjective QOL scores between
countries at the 5% significance level. Total subjective QOL
mean score was used as the primary variable for further
analyses. In an unadjusted analysis, we tested the association
with subjective QOL of a number of potential explanatory
variables derived from a literature review. These variables
were country of residence, marital status, number of years of
schooling, age, severity of positive, negative and general
psychopathology symptoms, depression, alcohol misuse, and
drug misuse. We also tested the association with subjective
QOL of the objective QOL measures from the QOLI apart
from in the domain of Health in which the QOLI instrument does not obtain objective information. To keep the
number of variables tested to a minimum and to make them
more meaningful to our sample we constructed summary
objective QOL variables. These were the following: living
situation, having enough money each month to cover basic
needs; whether someone had been a victim of crime in the last
6 months; employment status; whether a person had visited
someone who did not live with them in the last month;
frequency of talking to a member of their family in the last 6
months; and whether a person had performed at least 60% of
the activities of daily living listed in the QOLI.
To explore which variables were independently associated with QOL, we carried out multiple regression modeling
using the enter method, in which all independent variables of
interest are entered into the equation at the same time.
Subjective QOL total mean score was the dependent variable.
All candidate variables tested in the unadjusted analyses were
2008 Lippincott Williams & Wilkins

entered into the regression equation. The variables living

situation, marital status, whether someone talked to a member
of their family, and whether a participant visited someone
were dichotomized before entry into the regression equation.

RESULTS
In total, 1208 people with schizophrenia participated in
the study, 288 in France, 302 in the United Kingdom, and 618
in Germany.
Sociodemographic and clinical details of the sample are
shown in Table 1, and described in more detail by Bebbington et al. (2005). The mean age was approximately 40 years
in all 3 countries and employment status differed significantly, with the rate in Germany being approximately twice
that of the United Kingdom or France. Fewer participants in
Germany were in owner-occupied housing, and more French
respondents were in supported accommodation. Participants
in France were the most symptomatic with the highest mean
total PANSS scores (71.0) and CDDS scores (3.6).
Subjective QOL scores are shown in Table 2. Total mean
subjective QOL scores in all 3 countries were in the region of a
score of 5, indicating that participants were mostly satisfied with
their lives. Five of the 9 domains in the QOLI varied significantly between countries. Of these, German participants had the
highest subjective QOLI scores in the Living Situation, Family,
Health, and General Life Satisfaction domains. In the unadjusted
analyses (Table 3) nearly all variables were significantly associated with subjective QOL apart from gender and years of
schooling.
The correlates of baseline subjective QOL that remained
independent after regression are shown in Table 4. The coefficients indicate that living in the United Kingdom, being divorced, separated or widowed, having more severe general
psychopathology symptoms, being a victim of crime, and having
clinically significant depression were all associated with poorer
QOLI scores. Being employed, living in owner occupied or
supported accommodation, experiencing more negative symptoms, and being older were associated with higher QOLI scores.
Objective QOL measures, including participating in a number of
daily activities, frequency of talking to a member family, and
having enough money for basic needs were also significantly
associated with better subjective QOL.

DISCUSSION
This analysis is the largest international comparative
study of subjective QOL in people with schizophrenia and
investigates a comprehensive range of explanatory variables,
including country of residence.
Compared with people living in the United Kingdom and
France, German residents had the highest subjective QOLI
scores in the domains of living situation, family, health, and life
in general. Despite having the highest employment rate, it was
striking that people in Germany did not report significantly
higher satisfaction scores in the work and school domain of the
QOLI. This may be because the proportion of people working in
sheltered or voluntary work schemes was higher in Germany
than in the United Kingdom or France (Marwaha et al., 2007).

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Marwaha et al.

TABLE 1. Clinical and Sociodemographic Details of the Sample

Variable
Male
Living situation
Owner occupied
Rented
Supported accommodation
Hospital/homeless/other
Marital status
Single
Married/living as couple
Divorced/separated/Widowed
Employed (including sheltered)
Age
Total PANSS score
Depressed (CDDS)
GAF scores

France (N 288)

Germany (N 618)

UK (N 302)

All (N 1208)

Chi Square
Value

200 (69.7%)

348 (56.8%)

195 (64.6%)

743 (61.8%)

15.11

0.001

86 (29.9%)
179 (62.2%)
17 (5.9%)
6 (2.1%)

5 (0.8%)
461 (74.6%)
98 (15.9%)
54 (8.7%)

85 (28.1%)
160 (53%)
40 (13.2%)
17 (5.6%)

176 (14.6%)
800 (66.2%)
155 (12.8%)
77 (6.4%)

209.23

0.001

206 (71.8%)
44 (15.3%)
37 (12.9%)
33 (11.5%)

335 (54.2%)
157 (25.4%)
126 (20.4%)
187 (30.3%)

203 (67.2%)
53 (17.5%)
46 (15.2%)
39 (12.9%)

744 (61.6%)
254 (71.0%)
209 (17.3%)
259 (21.5%)

31.00

0.001

40.7 (10.3)
71.0 (21.3)
3.6 (4.1)
51.4 (14.8)

Mean (Standard Deviation)

43.0 (10.9)
42.1 (11.7)
55.7 (19.8)
48.1 (15.7)
2.8 (3.4)
2.4 (3.4)
50.0 (16.2)
54.0 (16.5)

42.3 (11.0)
57.4 (20.9)
2.9 (3.6)
51.3 (16)

58.84
F
F
F
F

Chi Square
Test p

0.001

F
4.54
108.95
8.69
6.52

ANOVA p
0.05
0.001
0.001
0.002

Chi square and ANOVA tests carried out at the 5% significance level.

TABLE 2. Subjective QOLI Scores

France Mean
(Standard Deviation)

Germany Mean
(Standard Deviation)

UK Mean
(Standard Deviation)

Total Mean
(Standard Deviation)

ANOVA Test p

4.9 (1.5)
4.8 (1.1)
4.5 (1.6)
4.9 (1.3)
4.2 (1.5)
5.0 (1.0)
4.9 (1.4)
4.4 (1.3)
4.5 (1.3)
4.6 (0.8)

5.2 (1.2)
4.8 (1.2)
5.0 (1.5)
5.0 (1.2)
4.2 (1.7)
5 (1.2)
5 (1.3)
4.6 (1.2)
4.7 (1.3)
4.8 (0.8)

4.8 (1.3)
4.5 (1.2)
4.8 (1.5)
4.7 (1.2)
4.2 (1.7)
4.9 (1.2)
4.8 (1.3)
4.3 (1.3)
4.4 (1.3)
4.6 (0.8)

5.0 (1.3)
4.7 (1.2)
4.8 (1.5)
4.9 (1.2)
4.2 (1.6)
5.0 (1.2)
4.9 (1.3)
4.5 (1.3)
4.6 (1.3)
4.7 (0.8)

0.001
0.004
0.001
0.16
0.978
0.843
0.152
0.012
0.001
0.001

Subjective QOL at baseline:

Living situation
Daily activities
Family
Social relations
Finances
Work and school
Legal and safety
Health
Life in general
Total subjective QOLI mean score
Tests carried out at the 5% significance level.

After controlling for clinical and socio-demographic

characteristics, living in the United Kingdom was independently associated with a poorer subjective QOL in the regression analysis. In the general population, the proportion of
people at least fairly satisfied with their life in France has
been reported as 83%, in Germany 86%, and in the United
Kingdom 90% (European Commission, 2004). This suggests
that the QOL of people with schizophrenia is disproportionately reduced in the United Kingdom, and that patients in
Germany have a better QOL than would be predicted from
national life satisfaction levels. It is thus likely that the
disparity found in our study results from differences in the
particular experiences of the mentally ill rather than those of
the population as a whole.
The nature of these differences in experience may be
related to social circumstances or social welfare policy. It
may also be related to the services and the treatment that

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people with schizophrenia receive. Using the European

Service Mapping Schedule (Johnson et al., 2000), differences between the United Kingdom and German mental
health system have been described (Angermeyer et al.,
2004; Becker et al., 2002). Comparing Leipzig with London shows that the United Kingdom center has much less
in the way of services providing daytime and structured
activities than Leipzig (42.6 vs. 71.7 users per 10,000
inhabitants per working day). Moreover, the number of
unmet needs was 2.3 in London compared with 1.0 in
Leipzig (Kilian et al., 2001). Finally if satisfaction with
mental health services is used as a proxy for the quality of
treatment, patients with schizophrenia from Leipzig are
more satisfied than their counterparts from London (Roick
et al., 2007). Thus there are indicators that United Kingdom patients receive a different quality of service compared with their German counterparts, and this may under 2008 Lippincott Williams & Wilkins

The Journal of Nervous and Mental Disease Volume 196, Number 2, February 2008 Quality of Life in People With Schizophrenia

TABLE 3. Unadjusted Associations With Total Subjective QOL Variable

Variable
Depression
No
Yes
Alcohol misuse
No
Yes
Drug misuse
No
Yes
Gender
Male
Female
Marital Status
Single
Married/living as a couple
Divorced/separated/widowed
Living in:
Owner occupied
Rented
Supported accommodation
Hospital/homeless/other
In employment
No
Yes
Victim of crime in last 6 mo
No
Yes
Daily activities and functioning (completed 60%
of activities or more)
No
Yes
Enough money for basic needs and activities
No
Yes
Age of patient
No. of years schooling
GAF scores
PANSS positive symptoms
PANSS negative symptoms
PANSS general psychopathology

Numbers (%)

Mean Total QOL

Score (SD)

960 (79.87)
242 (20.13)

4.86 (0.78)
4.08 (0.77)

13.87

0.001

972 (81.34)
223 (18.66)

4.75 (0.84)
4.53 (0.80)

3.46

0.001

1076 (90.80)
109 (9.20)

4.72 (0.84)
4.54 (0.76)

2.18

0.03

741(61.85)
457 (38.15)

4.68 (0.84)
4.73 (0.84)

1.02

0.307

742 (61.68)
252 (20.95)
209 (17.37)

4.70 (0.84)
4.80 (0.81)
4.57 (0.60)

F 4.25

0.014

174 (14.45)
799 (66.36)
154 (12.79)
77 (6.4)

4.80 (0.83)
4.69 (0.82)
4.80 (0.90)
4.41 (0.86)

F 4.81

0.002

944 (78.47)
259 (21.53)

4.62 (0.84)
5.00 (0.75)

6.95

0.001

1061(88.42)
139 (11.58)

4.75 (0.82)
4.33 (0.87)

5.67

0.001

524 (43.82)
672 (56.18)

4.57 (0.89)
4.81 (0.78)

4.96

0.001

590 (49.79)
595 (50.21)

4.44 (0.80)
4.97 (0.77)

11.46

0.001

Mean (SD)
40.8 (11.1)
10.1 (2.11)
51.3 (16.0)
12.4 (5.6)
15.8 (7.7)
29.3 (10.6)

T Value

Pearson (r)
p
0.06
0.039
0.01
0.679
0.17
0.001
0.22
0.001
0.09
0.003
0.25
0.001

Number (%)
How often do you talk to a member of the family
on telephone in the last 6 mo
Not at all
Once a month
At least once a month
At least once a week
At least once a day
Visit someone who does not live with you
Not at all
Less than once a month
At least once a month
At least once a week
At least once a day

210 (17.4)
124 (10.3)
185 (15.3)
445 (36.8)
201 (16.6)

0.09

0.004

278 (23.0)
149 (12.3)
178 (14.7)
418 (34.6)
175 (14.5)

0.14

0.001

SD indicates standard deviation.

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The Journal of Nervous and Mental Disease Volume 196, Number 2, February 2008

TABLE 4. Significant Correlates of Total Subjective QOL Score on Multiple Regression

Variable
Demographic
Living in UK
Age of patient
Divorced/separated or widowed
Symptoms
PANSS negative symptoms
PANSS general psychopathology
Presence of depression (from CDSS)
Objective measures
Employment
Daily activities and functioning
Frequency of talking to a member of family on
phone over the last month
Having enough money for basic needs each
month
Victim of crime in the last 6 mo
Owner occupied accommodation
Supported accommodation

Ba 95% Confidence Interval

Beta (standardized)

Significance

0.26 (0.38 to 0.14)

0.01 (0.003 to 0.011)
0.15 (0.28 to 0.03)

0.13
0.09
0.07

4.24
3.12
2.39

0.001
0.002
0.017

0.02 (0.01 to 0.03)

0.02 (0.03 to 0.01)
0.58 (0.69 to 0.46)

0.15
0.25
0.28

3.44
4.76
9.92

0.001
0.001
0.001

0.18 (0.07 to 0.28)

0.11 (0.02 to 0.20)
0.05 (0.02 to 0.08)

0.09
0.07
0.08

3.17
2.39
3.02

0.002
0.017
0.003

0.22 (0.15 to 0.29)

0.17

6.52

0.001

0.07
0.24
0.18

2.50
2.60
2.07

0.012
0.010
0.039

0.10 (0.18 to 0.02)

0.58 (0.14 to 1.02)
0.46 (0.02 to 0.90)

Adjusted R squared 0.269.

a
A positive B value indicates a correlation with a better QOL.

lie the finding that living in the United Kingdom is

associated with poorer QOL in the regression model.
Apart from country of residence correlates of subjective
QOL included demographic factors, objective measures, and
symptoms. As in a number of previous studies (Marwaha and
Johnson, 2004), we found employment status was moderately
associated with subjective QOL. Having lost a spouse was
associated with poorer QOL, whereas increasing age was
linked with improvements in QOL, both similar to findings in
the general population (Zahran et al., 2005). Living in owneroccupied or supported accommodation was also an important
correlate of better QOLI scores, presumably because of
housing security and better social support respectively. Likewise, in the general population having sufficient accommodation was rated as a necessity for a good life (European
Commission, 2004). Thus several of the social factors important in explaining variations in QOL among the mentally ill
simply reflect those in the general population.
Previous studies have suggested little relationship between objective and subjective QOL (Fitzgerald et al., 2001).
However, in this large sample we found that nearly all our
summary objective QOL measures were significantly related to
subjective QOL although some of the regression coefficients
indicate only a minor effect. Frequency of contact with family
was found to be an important predictor of QOL in another
international study (Gaite et al., 2002). We additionally found
that being capable of completing activities of daily living improved QOL, whereas being a victim of crime was understandably associated with poorer subjective QOLI scores.
Depression and the symptoms assessed by the general
psychopathology section of the PANSS were significantly
correlated with poorer QOL. However negative psychotic
symptoms were, surprisingly, associated with better QOLI
scores. Severe negative symptoms may result in a change in

92

the ability of individuals with schizophrenia to appraise their

situation, as greater acceptance of poor objective conditions
and loss of motivation may be reflected in diminished aspirations. Indeed previous authors have found that patients with
schizophrenia tend to rate their subjective QOL more highly
than they perhaps should, given their objective circumstances
(Franz et al., 2000; Katschnig and Angermeyer, 1997). One
plausible explanation for these findings, especially in our
analyses where older age was also associated with better
QOL, is that a process of adaptation to illness and its consequences occurs in people with schizophrenia. An important
finding about subjective QOL generally is that individuals have
a great capacity for adaptation, both to adversity and to positive
changes in their circumstances (Layard, 2005). Thus, in the
longer term, a schizophrenic illness may have a surprisingly
limited impact on ones self-reported happiness. This seemed to
be the case in this sample where the overall mean subjective
QOL score reported by people in all 3 countries indicated that
they were mostly satisfied with life.
There are a number of limitations to the analysis. Some
of the explanatory variables have relatively minor effects,
possibly being significant in our analysis only because of the
large sample size. Thus the effects on QOL of factors such as
telephone contact with family, although statistically significant may not be clinically important. We did not include
duration of illness as a potential explanatory variable of
subjective QOL, although it may be important, given our
finding that older age was associated with QOLI scores. The
study did not formally check the reliability of ratings between
centers, and country level comparisons of data from interviewer-rated instruments such as the Calgary Depression
Scale for Schizophrenia therefore warrant cautious interpretation. However, information such as patient-rated subjective
QOL is unlikely to be subject to problems of reliability.
2008 Lippincott Williams & Wilkins

The Journal of Nervous and Mental Disease Volume 196, Number 2, February 2008 Quality of Life in People With Schizophrenia

Although efforts were made to ensure consistent and comparable procedures in all centers, the service structures were
different and recruitment bias cannot be excluded. We are not
able to provide information on nonresponders.

CONCLUSIONS
Living in the United Kingdom was associated with a
poorer subjective QOL whereas people with schizophrenia
living in Germany had higher QOL overall. It is likely that in
part this is explained by the different organization of services
in the 2 countries. More detailed investigation of the relationship between QOL and national differences in the social
circumstances of patients and welfare systems is necessary in
future studies.
Our results indicate that a variety of separate domains
provide significant correlates of subjective QOL in people
with schizophrenia, suggesting that some of the inconsistency
in the literature is because of small sample sizes. Many of the
factors predictive of QOL are similar to those explaining
QOL in the general population. Some of these factors such as
being a victim of crime or not having enough money for basic
needs reflect the social exclusion that the mentally ill face and
are not under the direct influence of mental health services. Only
a minority seem to be amenable to change by specific treatment
interventions normally provided by psychiatrists. Better identification and treatment of depression and general psychopathology symptoms such as social anxiety and cognitive problems
(Penades et al., 2002) might potentially improve subjective QOL
in people with schizophrenia. Family contact was significantly
associated with higher subjective QOL and better family support
might improve family understanding and functioning and thus
the amount of contact after the onset of psychosis. Employment
opportunities for people with schizophrenia could also be improved through models such as individual placement and support (Crowther et al., 2001).
Despite these suggestions, people with schizophrenia in
our sample were mostly satisfied with their lives and, given
the moderate effects of many of the predictors, it is likely that
any further substantial improvement would be difficult.

ACKNOWLEDGMENTS
The authors thank all the patients and staff who helped
with the study, the Camden and Islington mental Health and
Social Care NHS Trust, and The Leicestershire Partnership
NHS Trust R & D Programme.
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