Quality of life in community-dwelling patients with schizophrenia in China

The aim of this study was to assess Chinese schizophrenia patients' quality of life (QOL) and identify its demographic and clinical correlates. A random sample of 540 community-dwelling schizophrenia patients was interviewed using standardized assessment instruments. The patients' basic sociodemographic and clinical data and QOL were collected. Compared with the general population, patients had significantly lower scores in the physical and psychological QOL domains. Multivariate analyses showed that better social support independently predicted higher QOL in all domains, whereas more severe positive symptoms predicted worse psychological and environmental domains. Overall psychopathology predicted both worse physical and psychological domains; depressive symptoms and being married predicted worse physical and social QOL, respectively. Our results suggest that therapeutic and psychosocial interventions alleviating positive and depressive symptoms and improving poor social support and marriage-related problems in Chinese patients with schizophrenia might be of considerable benefit in improving their QOL.     

Quality of life of Chinese schizophrenia outpatients in Hong Kong: relationship to sociodemographic factors and symptomatology

OBJECTIVE: To explore the relationships between sociodemographic and clinical factors and quality of life (QOL) in a cohort of Chinese schizophrenia outpatients. METHOD: Two hundred subjects with a diagnosis of DSM-IV schizophrenia aged 18-60 years were randomly selected, and their sociodemographic and clinical characteristics including psychotic and depressive symptoms, extrapyramidal symptoms (EPS), and quality of life were assessed. Correlation and multiple regression analyses were used to evaluate the relationships of sociodemographic, clinical data and QOL. RESULTS: Compared to normative data obtained for the general population in Hong Kong, significantly lower scores in physical, psychological, and social QOL domains were found in the patient group. History of suicidal attempts and the presence of positive, negative, depressive, anxiety and EPS symptoms were all significantly correlated with QOL in schizophrenia patients. After controlling for the effects of variables that were significantly correlated with QOL in the correlation analysis, however, only depressive symptoms were still significantly correlated with each QOL domain. Multiple regression analysis showed that depressive symptoms predicted all QOL domains, while positive symptoms predicted overall and physical QOL domains. CONCLUSIONS: Chinese outpatients with schizophrenia had poorer QOL than the general population. In this patient population, QOL was more strongly related to the severity of depressive symptoms and was independent of sociodemographic factors.     

Cognitive functioning related to quality of life in schizophrenia

The present study compared the cognitive function of patients with schizophrenia to that of healthy subjects, and investigated the relationships between cognitive function and quality of life (QOL). Participants consisted of 53 patients meeting DSM-IV criteria for schizophrenia and 31 normal controls. All participants completed a neuropsychological test battery assessing executive function, verbal memory, and social knowledge. QOL was rated using the Schizophrenia Quality of Life Scale. Patients with schizophrenia showed lower performance across various cognitive measures of memory, including the Sentence Memory Test, the Verbal Learning Test, and the Script Test, as well as the Rule Shift Cards Test of executive function. Multiple regression analyses were used to evaluate the neuropsychological measures and clinical symptoms to predict QOL. The QOL total score, the social initiative score or the empathy score were significantly predicted by the Script or/and the Sentence Memory. Neuropsychological functioning was unrelated to most QOL scores in the presence of clinical symptoms, while ability of empathy in the QOL was predicted by performance of the Sentence Memory Test. These results demonstrated patients with schizophrenia have deficits in executive function, memory and learning, and social knowledge, and that social knowledge and memory are related to QOL. Thus, in patients with schizophrenia, deficits in social knowledge appear to be associated with current QOL in general, and specifically with the capacity for empathy and social initiative.     

Social cognition and quality of life in schizophrenia

Schizophrenia is associated with poor quality of life (QOL). Whereas the effects of neurocognitive deficits and psychopathology on QOL of schizophrenia patients have recently been elucidated, little is known about social cognitive deficits in this regard. This study investigated the influence of social cognition on QOL in schizophrenia. A sample of 1032 patients, 1011 of their siblings, and 552 healthy controls was recruited from the Dutch Genetic Risk and Outcome in Psychosis (GROUP) study. Participants completed a battery of cognitive tests, including social cognitive tests on theory of mind and emotion perception. To assess QOL the World Health Organization QOL Assessment-BREF (WHOQOL-BREF) was used. Schizophrenia symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Social cognitive performance was significantly worse in patients compared to siblings and healthy controls. Patients had the poorest QOL, while QOL in healthy controls was better than in siblings. Theory of mind but not emotion perception or neurocognition was associated with QOL in patients, whereas neurocognition was the only significant predictor of QOL in siblings and healthy controls. There was a significant interaction between theory of mind and symptom severity with respect to QOL. Our study indicates that social cognition is associated with QOL in schizophrenia. Theory of mind rather than emotion perception is associated with QOL, and this association is moderated by schizophrenia symptoms. In particular, patients with relatively unimpaired theory of mind and more severe schizophrenia symptoms have poor QOL and could therefore benefit from therapeutic intervention.     

A longitudinal study of patient- and observer-rated quality of life in schizophrenia

Patient-rated life satisfaction and observer-rated quality of life (ORQOL) appear to have different determinants in patients with schizophrenia, although most studies conducted to date have used cross-sectional methods or related clinical dimensions at one time point with quality of life (QOL) measured at another. The aim of this study was to investigate the relationship between changes in patient-rated QOL (PRQOL) and ORQOL over time and changes in clinical variables. Two hundred and thirty-one patients taking part in the Schizophrenia Care Assessment Program (SCAP) study at Dandenong in Australia were included in this analysis. Subjective ratings of several domains of social functioning and life satisfaction were taken from the SCAP instrument and comparisons made with data from the QOL Scale rated by research staff, as well as several psychopathology measures. Changes in these scores over 1 year were correlated to investigate relationships between measures. Weak correlations were seen between changes in PRQOL and ORQOL domains. Patient-rated domains related most closely to depressive symptoms (Montgomery-Asberg Depression Rating Scale scores) whereas observer-rated domains related to both negative symptoms and depressive symptoms. Positive psychotic symptoms had little effect on either domain. Longitudinal data appear to confirm that PRQOL and ORQOL are not closely related and may have differing determinants in patients with schizophrenia. They should be considered as separate and complementary outcome variables and utilized accordingly.     

Quality of life and its correlates in patients with bipolar disorder stabilized on lithium prophylaxis

The quality of life (QOL) of 50 bipolar disorder patients in remission (stabilized on lithium prophylaxis) was assessed and compared with that of clinically stable patients with schizophrenia (n = 20) and healthy subjects (n = 20). World Health Organization Quality of Life-Bref (WHOQOL-BREF) and Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) were used to assess QOL in the three groups of subjects. The factors that contribute or influence QOL (i.e. stressful life events, social support, daily hassles) were also studied using standardized instruments in the study group. It was found that, compared to schizophrenia group, the bipolar group had significantly better QOL in all the domains of Q-LES-Q and the domains of general well-being, physical health and psychological health of the WHOQOL-Bref. The bipolar group had similar QOL scores in all other domains and higher scores in leisure time activity domain of Q-LES-Q, in comparison to the healthy group. The QOL in the bipolar group was better in patients who were younger and had a lesser severity of daily hassle. The present findings suggest that euthymic patients with bipolar disorder have a QOL that is comparable to that of healthy subjects. In contrast, patients with clinically stable schizophrenia have a poorer QOL. Occurrence of daily hassles contributes significantly to QOL in patients with bipolar disorder. However, the relatively limited variance explained by the independent variables included in the study, suggests the need to examine other (perhaps non-clinical) factors that may affect QOL.     

The dilemma of insight into illness in schizophrenia: self- and expert-rated insight and quality of life

Introduction A major subgroup of patients with acute schizophrenia lacks awareness of having a mental disorder. The aim of this study was to investigate the association of self- and expert-rated insight into illness with subjective quality of life (QOL). It was hypothesised that patients with greater self- and expert-rated insight into illness report lower QOL compared to patients with poor insight. Method For the present study, patients with schizophrenia or schizoaffective disorders were investigated during in-patient treatment. Insight into illness was measured by the scale to assess unawareness of a mental disorder (SUMD), the insight scale and the PANSS. QOL was assessed with the modular system of quality of life (MSQoL). Results Fifty-nine patients entered the study. Self- and expert-rated illness insight were associated with poor QOL. Patients with good insight into illness reported significantly lower physical health (p < 0.05), vitality (p < 0.01), psychosocial (p < 0.01), affective (p < 0.01) and general QOL (p < 0.001) compared to patients with poor insight. Good insight was significantly associated with other parameters of clinical and social functioning and depressive symptoms. Discussion The results indicate that patients with acute schizophrenia and greater insight realise their restrictions more clearly, which contribute to poor QOL, but were stronger integrated in social networks. The inclusion of modules focussing on QOL related aspects of treatment from the beginning as well as a greater awareness of the physician for these questions and a strengthening of the therapeutic alliance might help improving insight without the risk of deteriorating mood and QOL.     

Predictors of Quality of Lifein Schizophrenia

The objective of this study was to clarify the relationships between socio-demographics, clinical characteristics, stressors, coping strategies, social support and quality of life (QOL) in 143 patients with a diagnosis of either schizophrenia or schizoaffective disorders. The research design is cross-sectional with repeated measures on the same subjects after a 6-month interval. A regression analysis generated a model that accounts for 50% of the variance in QOL at Time 1 and 43% at Time 2. The best predictors of QOL were two components of social support: attachment and reassurance of worth. Severity of daily hassles, the coping strategy of changing the situation, level of education and life-time hospitalization length were also related to QOL.This study received financial support from the Fonds de recherche en Santé du Québec (FRSQ). Grant No. 980673.     

The well-being of chronic mental patients

The concept, "quality of life" (QOL), offers a broad perspective for assessing the needs and outcomes of chronic mental patients. In this survey of Los Angeles board-and-care homes, 278 randomly selected, mentally disabled residents evaluated their QOL in structured interviews based on a general QOL model. Life areas studied included living situation, family, social relations, leisure, work, safety, finances, and health. The model performed as well among these residents as among the general population, explaining 48% to 58% of the variance in global well-being. Adding patients' subjective QOL evaluations doubled the explanatory power of a model based only on personal characteristics and objective life conditions. Global well-being was most consistently associated with personal safety, social relations, finances, leisure, and health care variables. The study identifies methodological and service issues in need of further examination.     

Impact of the priority follow-up system on quality of life in Chinese schizophrenia patients

OBJECTIVE: Priority follow up (PFU) is a particular aspect of mental health care in Hong Kong whereby psychiatric patients with a history of violence or suspected proclivity to violence are identified and their management is closely monitored. The aim of the present study was to determine the impact of a PFU system on quality of life (QOL) in schizophrenia patients. METHODS: Two hundred and sixty-seven clinically stable outpatients with schizophrenia were randomly selected and interviewed in Hong Kong using standardized assessment instruments that covered their clinical condition and QOL. RESULTS: Patients with PFU status constituted 8.2% of the sample. PFU patients were more likely to be men, have a history of violence, and were poorer in the physical, psychological, social and environmental QOL domains than their non-PFU counterparts even after controlling for the effects of potential confounding variables. CONCLUSIONS: More effective measures should be taken to improve QOL in PFU schizophrenia patients who are prone to violent behavior.     

Schizophrenia in Malaysian families: A study on factors associated with quality of life of primary family caregivers

Background

Schizophrenia is a chronic illness which brings detrimental effects in the caregivers' health. This study was aimed at highlighting the socio-demographic, clinical and psychosocial factors associated with the subjective Quality of Life (QOL) of Malaysian of primary family caregivers of subjects with schizophrenia attending an urban tertiary care outpatient clinic in Malaysia.

Methods

A cross-sectional study was performed to study patient, caregiver and illness factors associated with the QOL among 117 individuals involved with caregiving for schizophrenia patients. The study used WHOQOL-BREF to assess caregivers' QOL and Brief Psychiatric Rating Scale (BPRS) to assess the severity of patients' symptoms. Social Readjustment Rating Scale (SRRS) assessed the stress level due to life events.

Results

The mean scores of WHOQOL-BREF in physical, psychological, social and environmental domains were 66.62 (14.36), 61.32 (15.52), 62.77 (17.33), 64.02 (14.86) consecutively. From multiple regression analysis, factors found to be significantly associated with higher QOL were higher educational level among caregivers in social and environmental domains; caregivers not having medical problem/s in physical and psychological domains; later onset and longer illness duration of illness in social domains; patients not attending day care program in environmental domain; lower BPRS score in physical and environmental domains. SRRS score of caregivers was also found to have a significant negative correlation with QOL in environmental and psychological domains. Other factors were not significantly associated with QOL.

Conclusion

Caregivers with more social advantages such as higher educational level and physically healthier and dealing with less severe illness had significantly higher QOL in various aspects. Supporting the caregivers in some of these modifiable factors in clinical practice is important to achieve their higher level QOL.     

Quality of life and its association with insight, adverse effects of medication and use of atypical antipsychotics in patients with bipolar disorder and schizophrenia in remission

Objective: The present study aimed: (i) to compare the level of quality of life (QOL) among subjects with bipolar disorder (BD) and schizophrenia who were in remission and healthy control subjects and (ii) to examine the association of QOL with insight, adverse effects of medication and use of atypical antipsychotics among subjects with BD and schizophrenia who were in remission by controlling other confounding factors. Methods: The QOL on the four domains of the World Health Organization Questionnaire on Quality of Life: Short Form – Taiwan version (WHOQOL-BREF) were compared between 96 subjects with BD in remission, 96 subjects with schizophrenia in remission and 106 healthy control subjects. The association between the four QOL domains and subjects’ insight, adverse effects of medication and use of atypical antipsychotics were examined using multiple regression analyses in the subjects with BD and schizophrenia in remission. Results: The results demonstrated that the subjects with BD in remission had similarly poor levels of QOL in all four domains as those subjects with schizophrenia in remission, and both subjects with BD and schizophrenia had poorer QOL than those in the control group. For both subjects with BD and schizophrenia in remission, insight was negatively associated with QOL on the physical domain, and adverse effects of medication were negatively associated with QOL on the physical and environment domains. Use of atypical antipsychotics was not associated with QOL, but subjects with BD receiving olanzapine perceived better psychological QOL than those receiving risperidone and better psychological and social relationship QOL than those receiving no atypical antipsychotic. Conclusions: The results of the present study indicate that subjects with BD are dissatisfied with their QOL, even when they are in a remitted state. Clinicians must consider the negative influences of insight and adverse effects of medication on QOL of patients with BD and schizophrenia in remission.     

PANSS syndromes and quality of life in schizophrenia

BACKGROUND: Results from factor analysis studies have suggested that a five-dimensional structure appears to be a better representation of the psychopathological data of the PANSS. The purpose of this study was the detailed investigation of the association of schizophrenia syndromes and single symptoms with quality of life (QOL) in acute and remitted patients. The leading hypotheses were: (1) affective symptoms, especially depression and anxiety, are mostly associated with QOL longitudinally and (2) in the acute phase, QOL is also associated with positive schizophrenia symptoms. METHODS: For the present study, schizophrenia and schizophreniform patients were studied on admission, at the end of the acute phase and 6 months after hospitalization. Psychopathology was measured using the PANSS syndromes, QOL was assessed using disease-specific (SWN) and generic (MLDL, EDLQ) scales. RESULTS: Eighty-four patients entered the study and were assessed during the acute phase taking into account their history and actual treatment. Results revealed anxiety as the most important symptom and depression as the most important syndrome associated with different areas of QOL during and after hospitalization. Also cognitive and negative symptoms were associated with different QOL domains, but both positive symptom clusters showed no substantial association with QOL. CONCLUSIONS: Results of this longitudinal study investigating psychopathology and QOL in schizophrenia provide further support for the need to consider the psychopathological state and treatment setting when measuring QOL in schizophrenia and the need for a differential analysis of schizophrenia symptoms and QOL in the acute, mid-term and long-term phase. Anxiety reduction should be a critical goal of treatment in order to prevent further QOL impairment.     

Emotional expressiveness and the quality of life of patients with schizophrenia

BACKGROUND: The present research aims to study the association between emotional expressiveness of primary care-givers and quality of life of patients with schizophrenia. METHOD: The data for the present study were collected from 174 purposively selected patients with schizophrenia and their primary care-givers. The Quality of Life Interview (QOLI) (Lehman 1988) was used to collect information related to the quality of life of patients. The care-givers' emotional expressiveness was assessed using three questions on home environment from Disability Assessment Schedule (WHO/DAS) (WHO 1988). RESULTS: Three components of emotional expressiveness were included in the present research, namely, emotional involvement, control and attitude of rejection. Among these three components, emotional involvement of key care-givers was found to have a significant association with quality of life of schizophrenia patients. CONCLUSION: Based on this result, the present study argues that emotional involvement of key care-givers needs careful attention while planning psychosocial rehabilitation programmes aimed at enhancing the quality of life of schizophrenia patients.     

Contribution of spirituality to quality of life in patients with residual schizophrenia

There is increasing recognition that a person's spiritual or religious experiences contribute to quality of life (QOL). However, research exploring the relation between spirituality and QOL has mainly been in the context of chronic and life-threatening illnesses, and studies examining this important correlate of QOL in chronically mentally ill subjects are sparse. This study aimed to explore the relationship between spirituality and QOL, and to investigate if spirituality contributes to other domains of QOL (both physical and psycho-social) in subjects with residual schizophrenia. In a study with a cross-sectional design, 103 patients with residual schizophrenia were assessed with the Positive and Negative Syndrome scale, and their quality of life, spirituality and religiousness were assessed with the WHO Quality of Life-Spirituality, Religiousness and Personal Beliefs (WHOQOL-SRPB) scale. The SRPB domain and all its facets other than spiritual connection correlated significantly with all other domains of QOL and overall QOL. On regression analysis, the inner peace domain of spirituality explained 21.6 to 37.6% of variance of all QOL domains except the domain of level of independence. The spirituality domain explained 33.8% of the variance of the 'level of independence domain of QOL. Taken together, inner peace and spirituality facets explained 23 to 40% of the variance of the social relationships domain, the psychological domain and the level of independence domain of QOL. This study suggests that spirituality and religiosity have an important influence on overall QOL of patients with schizophrenia. Hence, besides pharmacological and non-pharmacological management for schizophrenia, clinicians should focus on this aspect and encourage their patients to follow their religious practices and spiritual beliefs.     

Satisfaction with quality of life varies with temperament types of patients with schizophrenia

We sought to explore the relationships of three temperament factors with domain-specific subjective quality of life (QOL) of patients with schizophrenia. Ninety patients with schizophrenia were evaluated using the Quality of Life Enjoyment and Life Satisfaction Questionnaire, the Tridimensional Personality Questionnaire, the Positive and Negative Syndromes Scale, the Distress Scale for Adverse Symptoms, the Insight and Treatment Attitudes Questionnaire, the Insight Self-Report Scale, and standardized questionnaires for self-reported emotional distress and stress process-related variables. Predictors of domain-specific QOL were identified using multiple regression techniques. Temperament factors explain 6% to 16% of variability in QOL domain scores among patients with schizophrenia after controlling for the remaining variables (emotional distress, social support, self-esteem, avoidance coping, age, side effects, and depression). We found that higher levels of novelty seeking are associated with better general QOL, physical health, and more positive subjective feelings, whereas higher levels of reward dependence are related to better satisfaction from social relationships. Higher levels of harm avoidance are associated with poorer satisfaction with general activities, and medication. Thus, temperament factors, as assessed by the Tridimensional Personality Questionnaire, substantially influence satisfaction with life quality in schizophrenia. Novelty seeking, reward dependence, and harm avoidance are associated with different domains of QOL.     

Relationship between depressive symptoms and quality of life in Nigerian patients with schizophrenia

Purpose

Quality of life (QOL) in patients with schizophrenia is influenced by various factors such as depressive symptoms. This study assessed the relationship between depressive symptoms and QOL in outpatients with schizophrenia in Nigeria and evaluated the associated socio-demographic and clinical factors.

Methods

One hundred patients with 10th edition of the International Classification of Diseases diagnosis of schizophrenia participated in this study. Socio-demographic and clinical factors such as depression were assessed with Zung Self-rating Depression Scale and symptoms of schizophrenia with the Positive and Negative Syndrome Scale of schizophrenia (PANSS). The level of functioning was assessed with the Global Assessment of Functioning Scale. QOL was assessed using the brief version of the World Health Organisation Quality of Life Scale.

Results

There were 27 (27.0 %) patients with depression. The depressed patients reported significant lower scores in all QOL domains when compared with the non-depressed group. All QOL domains were significantly negatively correlated with the total PANSS and all its subscales (except for psychological domain with total PANSS and social relationship and environmental domains with PANSS positive). Severity of depressive symptoms was significantly negatively correlated with all QOL domains. Functioning was significantly positively correlated with all QOL domains except in the environmental domain. Multiple regression analysis showed that depressive symptoms predicted all QOL domains except the social relationship domain while negative symptoms predicted social relationship and environmental domains.

Conclusion

Depression is a common occurrence during the course of schizophrenia. Depressive and negative symptoms have a significant impact on the QOL of patients with schizophrenia.     

社区康复期精神分裂症患者生活质量及其影响因素分析

目的 探讨社区康复期精神分裂症患者的生活质量及其影响因素.方法 采用SF-36、SSRS、BPRS、TESS、SAS、SDS等量表对120例社区康复期精神分裂症患者(社区患者组)进行评定,并与100例住院精神分裂症患者(住院患者组)及100例正常健康人群(健康对照组)进行对照.结果 (1)社区患者组QOL评分各因子分均显著低于健康对照组(P<0.05);与住院患者组比较,社区患者组在躯体功能,躯体健康所致的角色限制因子分高于住院患者组,而总体健康感和心理健康因子分则低于住院患者组(P<0.05);(2)社区患者组的生活质量总评分(SF-36总分)影响因素分析显示,社会支持少、病程短、年龄轻、无业,独居的患者生活质量差;多因素逐步回归分析显示影响患者生活质量的主要因素依次为BPRS、SSRS、工作、婚姻.结论 社区康复期精神分裂症患者的生活质量全面低下,影响因素是多方面的,在社区康复过程中应予以重视.     

Differences in quality of life domains and psychopathologic and psychosocial factors in psychiatric patients

BACKGROUND: Although treatment of severe mental disorders should strive to optimize quality of life (QOL) for the individual patient, little is known about variations in QOL domains and related psychopathologic and psychosocial factors in patients suffering from schizophrenia, schizoaffective disorder, and/or mood disorders. We hypothesized that QOL in severe mental disorder patients would have a more substantial relationship with psychosocial factors than with illness-associated factors. METHOD: A case-control, cross-sectional design was used to examine QOL of 210 inpatients who met DSM-IV criteria for a severe mental disorder and who were consecutively admitted to closed, open, and rehabilitation wards. Following psychiatric examination, 210 inpatients were assessed using standardized self-report measures of QOL, insight, medication side effects, psychological distress, self-esteem, self-efficacy, coping, expressed emotion, and social support. QOL ratings for patients and a matched control group (175 nonpatients) were compared. Regression and factor analyses were used to compare multidimensional variables between patients with schizophrenia and schizoaffective and mood disorders. RESULTS: In all QOL domains, patients were less satisfied than nonpatient controls. Patients with schizophrenia reported less satisfaction with social relationships and medication when compared with patients with schizoaffective and/or mood disorders. Regression analysis established differential clusters of predictors for each group of patients and for various domains of QOL. On the basis of the results of factor analysis, we propose a distress protection model to enhance life satisfaction for severe mental disorder patients. CONCLUSION: Psychosocial factors rather than psychopathologic symptoms affect subjective QOL of hospitalized patients with severe mental disorders. The findings enable better understanding of the combining effects of psychopathology and psychosocial factors on subjective life satisfaction and highlight targets for more effective intervention and rehabilitation.     

Insight, quality of life, and functional capacity in middle-aged and older adults with schizophrenia

OBJECTIVE: The quality of life (QOL) for individuals with schizophrenia is determined by a number of factors, not limited to symptomatology. The current study examined lack of insight as one such factor that may influence subjective QOL or functional capacity. It was hypothesized that insight would significantly interact with symptom severity to influence subjective QOL. Insight was not expected to influence the relation between symptom severity and functional capacity. METHODS: Participants were middle-aged and older outpatients who met diagnostic criteria for schizophrenia or schizoaffective disorder, and subsyndromal depression. Insight, psychopathology, and subjective QOL were assessed via semi-structured interviews and functional capacity was assessed via performance-based measures. RESULTS: Insight interacts with negative symptom severity to predict subjective QOL. Severity of negative symptoms and insight contribute directly to functional capacity. CONCLUSIONS: Individuals with intact insight may be better able to manage their symptoms, resulting in improved QOL. Treatment implications for improving the QOL of middle age and older adults with schizophrenia are discussed.