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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

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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

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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

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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).

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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.

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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.

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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 self-

administered 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
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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

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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

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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 interviewer-

administered versions, self-administered versions, and proxy versions. The 36 item, interviewer-

administered 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

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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

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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 employment-

seeking 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).


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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.,

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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

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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

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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


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(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).

[2 ( Pc) + Qc ]
+
2
+ 2
N = C
d2 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

10.51 [2 (0.5) + 0.5] 2


N = + + 2
0.5 X 0.5 0.5

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); self-

care (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 32-

item 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 Serial No/ Date: ______________

1. AGE: (in years) ____________________ 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. WHAT LEVEL OF SOCIAL SUPPORT DO YOU GET FROM :


(a) Family members............ ( Good, Fair ,Poor , None )
(b) Friends.................... ( Good, Fair ,Poor , None )
(c) Government............................ ( Good, Fair ,Poor , None )
(d) Non-governmental organization ( Good, Fair ,Poor , None )
(e) 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 present Absent

1 Akathisia 14 Dry mouth

2 Dystonia 15 Constipation

3 Parkinsonism 16 Urinary hesitancy

4 Tardive dyskinesia 17 Blurred vision

5 Menstrual 18 Photosensitivity
dysfunction

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

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.

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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: ___________

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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

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