CLINICAL HANDBOOK OF SCHIZOPHRENIA - PART 10 pps

covering patient with schizophrenia: medical care, human relationships, material quality of life, communication and transport services, work and work conditions, safety, knowl - edge, education, leisure and recreation, and inner experience (May, 1986). Competency models, on the other hand, view people as active agents who govern their own lives. The core variables of competency models are personal autonomy (Mercier & King, 1994), and self-esteem and self-efficacy (Arns & Linney, 1993). At least two further concepts of quality of life found in the psychiatric literature can be summarized as the “combined approach” and “adaptive functioning models.” In the combined approach, both social and psychological indicators are taken into account. The best-known combined approach model was designed by Lehman (1983) and considered quality of life a subjective matter, reflected in a sense of global well-being. In this model, quality-of-life experience is reflected by personal characteristics (e.g., age and sex), objec - tive indicators in various domains of life, and subjective quality of life in the same life do - mains. The objective indicators are external life conditions, such as income, housing, and access to the community; whereas subjective quality of life represents the individual’s ap - praisal of these conditions and uses mostly satisfaction constructs. The domains included in the combined approach are living situation, family, social relations, leisure, work, law, safety, finances, and health. In adaptive functioning models, importance is given to individual satisfaction in rela - tion to social expectations; a reasonable or high quality of life is dependent on the degree to which patients can meet the demands of life and achieve fulfillment of needs and find satisfaction. An example of an adaptive functioning model is that of Baker and Intagliata (1982), in which quality of life is a measure of the environmental system (social indica- tors), the experienced environment (psychological indicators), the biopsychological sys- tem (health, well-being, and needs), and behavior (self-management and adaptation). Both the experienced environment and the biopsychological system are within the person, and comparisons (against standards/levels of adaptation) are made between both these foci. Different concepts of quality of life exist, and no universally accepted unitary con- cept has emerged in the last two decades of extensive research in psychiatry. This helps keep the construct of quality of life open, with lively debate on the issue. The consensus, however, is that quality of life is multidimensional, and that it encompasses objective and subjective indicators, as well as health- and non-health-related domains. It is this combi - nation of indicators and domains that makes quality of life a measure both useful and challenging as a specific health outcome. OBJECTIVE AND SUBJECTIVE INDICATORS Over the last two decades, the trend has moved from more objectively defined quality-of- life concepts toward understanding quality of life as largely determined by the patient’s subjective experiences of life and life conditions. Patients’ subjective perceptions of their quality of life appear linked to their personal subjective evaluation of life events and cir - cumstances, and to the inevitable psychological burden imposed by the often-debilitating consequences of schizophrenia. An understanding of the relationship between the objec - tive and subjective indicators may, however, be required to make an informed decision, when necessary, on which quality-of-life measure to choose. Although objective and subjective indicators reflect aspects of quality of life, the association between the objective and subjective indicators is reported to be weak to moderate at best, with correlations ranging from .04 to .57, suggesting that they measure 582 VIII. SPECIAL TOPICS different concepts of quality of life (Lehman, Ward, & Linn, 1982). International com - parisons indicated that differences in subjective quality-of-life domains did not corre - spond with differences in the objective data. However, this is not always the case, and substantial differences in objective living situations were found to be related to differ - ences in subjective quality of life. Evidence exists of congruence at a group level between unemployment and homelessness, and their corresponding subjective domains, whereby those employed and those with housing stability were found to have higher satisfaction scores in the subjective quality-of-life domains of employment (Priebe, Warner, Hub - schmid, & Eckle, 1998) and accommodation (Lehman, Kernan, Deforge, & Dixon, 1995), leading to higher general satisfaction with life. Also, dramatic changes in the living situation, such as discharge into community care after long-term hospitalization, can have a positive effect on patients’ subjective quality of life (Priebe, Hoffmann, Isermann, & Kaiser, 2002). From an anthropological perspective, Warner (1999) suggested that the subjective– objective distinction in quality-of-life research is similar to the difference between Pike’s (1967) emic and etic units of data. For Pike, an anthropological linguist, an emic unit of data is something that insiders in a culture regard as being the same entity regardless of variation, whereas an etic unit of data is one that an outsider can objectively observe and verify. It has been postulated that “emic statements are those referring to logical systems whose discriminations are real and significant to the actors themselves, while etic state- ments depend on distinctions judged appropriate by scientific observers” (Harris, 1968). Therefore, based on this, there is a difference between what the patient perceives is his or her quality of life (subjective indicators) and what researchers can objectively measure to assess what they believe is that patient’s quality of life (objective indicators). Researchers have indicated that whereas objective data are of immense importance for the prediction of change over time, psychological adaptation, or “response shift,” can happen in chronic illnesses such as schizophrenia, resulting in a shift in the patient’s appraisal of his or her current state; thus, the patient’s responses to subjective well-being questions can change significantly, reducing the strength of the association between subjective assessment and objective conditions. Psychological adaptation can also occur in the general population, for quality of life tends to be relatively stable over time and not greatly affected in the long term by dramatic changes in life conditions. Some have argued that the most practi - cal information for portraying outcomes of mental health services may indeed be etic (e.g., does the person have accommodation?); however, to understand such data and de - velop an intervention to change the outcome, emic data are needed (e.g., does the person wish to spend his or her income on rent?). In research, subjective indicators have become dominant, but in clinical practice, data on both objective and subjective indicators of quality of life are important, because they are used to provide services tailored to pa - tients’ specific needs. ASSESSMENT INSTRUMENTS A spectrum of scales, checklists, and structured and semistructured interviews assess quality of life among psychiatric patients. Measures can be classified into two groups: (1) proxy and (2) specifically designed. Proxy measures of quality of life are established psychiatric rating scales used to as - sess the patient’s symptom levels, particularly symptoms of depression. Such scales have been used in the screening and surveillance of psychiatric disorders, particularly in studies mapping psychiatric disorders in the community (e.g., the General Health Questionnaire; 57. Quality of Life 583 Goldberg, 1972) and in the evaluation of various interventions in clinical samples. Al - though scores on these scales have frequently been taken as indicators of quality of life, these scales are not specific to quality of life and do not capture its objective and subjec - tive indicators. Specifically designed health-related quality-of-life instruments are developed with the multidimensionality concept of the quality of life in mind. Table 57.1 summarizes some of the established instruments. Measures such as the Quality of Life Scale (QLS), the Quality of Life Interview (QLI), and the Oregon Quality of Life Scale (OQLS) are popu - lar in the United States, whereas instruments such as the Lancashire Quality of Life Pro - file (LQOLP), the Manchester Short Assessment of Quality of Life Scale (MANSA), and the European Quality of Life 5-Dimensional Format (EuroQol-5D) are more widely used in Europe. However, despite differences in their geographical use, some of these instru - ments are related (e.g., the MANSA was based on the LQOLP, which in turn was based on the QLI). 584 VIII. SPECIAL TOPICS TABLE 57.1. Specifically Designed Quality-of-Life Instruments Title Author(s) Number of items Number of domains Estimated completion time Client Quality of Life Interview Mulkern et al. (1986) 65 8 30 min EuroQol-5D EuroQol group (1990) 15 5 5 min Index of Health-Related Quality of Life Rosser et al. (1992) 107, 225 3 Not known Lancashire Quality of Life Profile (LQOLP) Oliver (1991) 100 11 30–50 min Manchester Short Assessment of Quality of Life (MANSA) Priebe et al. (1999) 25 12 10–15 min Munich Quality of Life Dimensions List Heinisch et al. (1991) 20 4 10 min Oregon Quality of Life Scale (OQS) Bigelow et al. (1991) 146 14 45 min Quality of Life Checklist Malm et al. (1981) 93 11 60 min Quality of Life Interview (QLI) Lehman (1988) 143 8 45 min Quality of Life Scale (QLS) Heinrichs et al. (1984) 21 21 45 min Satisfaction with Life Domains Scale Baker and Intagliata (1982) 15 15 10 min Schizophrenia Quality of Life Scale (SQLS) Wilkinson et al., 2000 30 3 5–10 min SmithKline Beacham Quality of Life Dunbar et al. (1992) 78 23 Not known Subjective Well-Being Under Neuroleptics Scale (SWN) Naber (1995) 38 5 Not known Well-Being Project Client Interview Campbell et al. (1989) 151, 76, and 77 60 Not known World Health Organization Quality of Life Instrument— Brief (WHOQOL) World Health Organization (1996) 26 4 5–10 min Specifically designed quality-of-life measures can be generic, health-related, or disease- specific. Generic scales are not specific to illness, treatment types, or patient characteristics, and they contain health-related quality-of-life concepts pertaining to both patients and the general population. These scales allow comparison of quality-of-life results across interven - tions, diagnostic conditions, and groups of the population. Examples are the Sickness Im - pact Profile (SIP), the Nottingham Health Profile, QLI, LQOLP, and MANSA. Health-related quality-of-life measures are designed to describe the health problems of populations across several dimensions of health, but not specifically mental health. They are classified under generic scales, with the term generic referring to all nondisease- specific measures. Examples are the Medical Outcome Study (MOS) questionnaire (which was modified to the 36-item Short-Form General Health Survey (SF-36; Ware & Sherbourne, 1992) and the EuroQol-5D. Generic scales are, however, not specific enough to capture the quality-of-life problems of patients with specific illnesses; hence, there is a need for disease-specific quality-of-life scales. Disease-specific measures may have greater clinical appeal due to the specificity of content and an associated increased responsiveness to specific change in condition. Per - haps the best-known disease-specific quality-of-life measure is the QLS, a clinician-rating scale that was designed to assess patients’ symptoms and functional status in the course and treatment of schizophrenia, and that has acceptable psychometric properties. The scale items reflect the manifestations of the deficit syndrome in schizophrenia, and are classified into four subscales: Intrapsychic Foundations, Interpersonal Relations, Instru- mental Roles, and Common Object and Activities. Other, newer disease-specific quality- of-life scales exist but have not been as widely used as the QLS, such as the Subjective Well-Being Under Neuroleptics Scale (SWN) and the Schizophrenia Quality of Life Scale (SQLS). However, whereas disease-specific quality-of-life scales may be useful to explain symptoms directly and the experience of medication side effects, quality-of-life constructs may become blurred and overlap with other constructs, most notably symptomatology, a problem that some of the disease-specific scales share with proxy measures. Selection of Measures Specifically designed quality-of-life measures are multi-item scales. Some of these scales, such as the OQLS and the LQOLP, are lengthy and time-consuming to complete. Lengthy scales covering the different domains of subjective quality of life may be preferable to short ones, which may be less sensitive. However, length may become a problem if the scale is used as a part of a battery of instruments (too many long scales to complete) and/ or yields various scores for which there is no clear method of analysis. Regarding the use of self-administered or interviewer-administered quality-of-life scales, it has been argued that self-administered scales (e.g., the Quality of Life Index for Mental Health; Becker, Diamond, & Sainfort, 1993) should not be administered to people with severe mental ill - ness, because these patients’ negative symptoms, such as apathy and withdrawal, might make completion of the questionnaires difficult, and various aspects of thought disorder and auditory hallucinations can diminish patients’ ability to concentrate and may affect the reliability of their answers. As far as psychometric properties are concerned, quality- of-life instruments have to be reliable, valid, and sensitive to changes in patients’ condi - tions over time. Several measures have been used with acute patients (e.g., after admis - sion to the hospital), and there is no evidence that the findings lack validity, although such concerns have repeatedly been expressed. Thus, quality-of-life instruments may also be administered in acute states of schizophrenia, as long as it is feasible and not too bur - densome for the patient. There is a symptom level above which a reasonable response to 57. Quality of Life 585 the quality-of-life scale questions becomes increasingly unlikely. However, research has not yet established the maximum symptom level to gain valid responses to quality-of-life questions, and the exact level may vary among individuals. The decision on which measure to use therefore depends on striking a balance among factors such as clinical time spent administering the instrument, practicalities re - lated to ways of collecting the information (e.g., whether through face-to-face interviews, postal questionnaires, etc.), and psychometric properties of the instrument. The purpose of data collection should also be considered. If the measure is used to help clinicians in in - dividual patient care, a detailed measure may be needed to provide comprehensive infor - mation on areas of dissatisfaction in the patient’s life that need to be addressed. On the other hand, if it is used to evaluate a service at a group level, then a shorter measure with good psychometric properties may be more appropriate. A further criterion for selecting an instrument may be the availability of data to compare results. With respect to patients with schizophrenia, various studies providing such data have been published using the QLS, QLI, LQOLP, MANSA and WHO Quality of Life Instrument—Brief (WHOQOL), and these scales have become established in schizophrenia research. ASSOCIATION WITH OTHER CONSTRUCTS There is a tendency in psychiatry to use several instruments to describe the subjective experience of patients with schizophrenia. While subjective quality of life reflects the patient’s appraisal of the current life, self-ratings of needs and symptoms, as well as treat- ment satisfaction, are also used as research criteria to assess the outcomes of interven- tions, and are intended to assess distinct constructs. Is subjective quality-of-life independ- ent of other constructs reflecting subjective experience, and should it be measured along with other constructs in the same study? Evidence indicates moderate to strong correla- tions between subjective quality of life and ratings of symptoms, needs, and treatment satisfaction, with correlations ranging from .5 to .7 (Fakhoury, Kaiser, Röder-Wanner, & Priebe, 2002; Priebe, Kaiser, Huxley, Röder-Wanner, & Rudolph, 1998). A single subjec - tive appraisal factor—reflecting negative subjective quality of life, more symptoms, and more needs—explained 48–69% of the variance of all these patient-rated outcomes (Fakhoury et al., 2002; Priebe, Kaiser, et al., 1998). All this indicates that subjective crite - ria are all interrelated and do not really capture distinct constructs. Thus, scales to assess several of these constructs should not be used as outcome criteria, unless a specific hy - pothesis justifies the use of separate scales to assess patient-rated outcomes. Research also suggests a significant association between subjective quality of life and the Antonovsky’s Sense of Coherence instrument. Sense of Coherence measures the per - sonal orientation toward life that determines one’s health experience. Individuals with a strong sense of coherence believe that the world around them is structured, explicable, and predictable; that the resources needed to meet the demands of the world are available to them; and that these demands are worthy of investment. There are three domains within the construct: comprehensibility, manageability, and meaningfulness. In a sample of patients with schizophrenia it was found to be significantly associated with quality of life. Increased Sense of Coherence score over time was found to be significantly associ - ated with improvements in overall subjective quality of life (Bengtsson-Tops & Hansson, 2001). Finally, a significant positive association between psychosocial functioning and subjective quality of life in patients with schizophrenia has also been reported. This asso - ciation was moderated by the executive functioning of the patient, independent of patient psychopathology, suggesting the need to incorporate executive capacity in models of quality of life (Brekke, Kohrt, & Green, 2001). 586 VIII. SPECIAL TOPICS FACTORS INFLUENCING QUALITY OF LIFE Studies have shown that patients with schizophrenia are frequently more satisfied with their lives than clinicians would objectively expect them to be given their poor living situ - ation, and that they are also no more dissatisfied than members of other groups with physical illnesses or social disadvantages. Schizophrenia often is a persistent condition that lasts for several decades. A high subjective quality of life despite poor living condi - tions may be explained by the relatively long duration of illness, which has given the pa - tients time to accept their chronic condition; to adjust their expectations of life, their state of health, and their available resources; and to compare themselves to other patients rather than to people from preillness peer groups. Yet, in addition to the length of illness, a number of other factors associated with subjective quality-of-life scores may be grouped into sociodemographic and clinical domains. Sociodemographic Factors Lower quality of life is more likely to be reported by male patients with schizophrenia who are younger, have a high level of education, live alone, live in a less restrictive envi - ronment, and are not employed. However, these characteristics are not strong predictors of subjective quality of life in clinical populations. Clinical Factors Symptom level is the most important factor influencing subjective quality of life of patients with schizophrenia. The higher symptom level is consistently associated with lower subjec- tive quality of life, explaining up to 30% of the variance (Kaiser et al., 1997). The associa- tion is dominated mostly by mood, especially anxiety and depression symptoms. Indeed, de- pression is the strongest variable associated with life satisfaction in psychiatric patients. On the individual-patient level, changes over time in subjective quality of life were found to cor- relate with changes in anxiety and depression, suggesting that changes in depressive symp- toms need to be considered when interpreting changes in satisfaction with life (Fakhoury et al., 2002). The significant impact of mood on subjective quality of life suggests that any in - tervention to improve psychopathology may need to consider patients’ affective state, which is significantly related to their subjective quality of life. However, the direction of the influence can be questioned: Does depression influence the appraisal of life and lead to less favorable subjective quality-of-life scores? Or does the reverse occur,with a negative view of life leading to more depressive symptoms? Or is the association more complex, so that both depression and subjective quality of life are determined by similar underlying cognitive and emotional processes? Research has not yet answered these questions. Clinical characteris - tics such as subclass of schizophrenia (e.g., paranoid schizophrenia), early onset of symp - toms, previous hospitalization, and age at first hospitalization are negatively associated with subjective quality of life of patients with schizophrenia. QUALITY OF LIFE AS AN OUTCOME CRITERION The current prominence of quality of life stems from its frequent use as an outcome in clinical trials. However, it is a rather “distal” outcome, because the effect of most thera - peutic interventions on quality of life is likely to be indirect and evidenced at a later time. This is in contrast to “proximal” outcomes, such as symptoms, whose effect is likely to be direct and immediate. Thus, the time it takes for an intervention to impact on quality- 57. Quality of Life 587 of-life measures needs to be considered by the clinician using the concept as an outcome criterion. Another issue is the sensitivity of these measures in capturing changes over time. Some measures reported significant changes in objective, but not subjective, indica - tors over time, whereas others reported congruent changes in objective indicators and their corresponding subjective domains. This mixed picture highlights the importance of examining the different effects of well-defined interventions on the objective and subjec - tive indicators of quality of life. Use in Pharmacological Interventions The questions of whether neuroleptics—directly or indirectly—improve patients’ quality of life, and whether the impact varies between typical and atypical neuroleptics, are of obvious clinical relevance and, subsequently, of marketing interest to pharmaceutical companies sponsoring major drug trials. Quality-of-life measures have therefore been used frequently to assess the outcome of antipsychotic medication. Pioneering conceptual work in this area has been provided by Awad, Vorauganti, and Heselgrave (1997), who developed the integrative conceptual model for quality of life of patients with schizophrenia on neuroleptics. In this model, quality of life is defined as the patient’s own perception of the outcome of an interaction among psychotic symp - tom severity, medication side effects, and the level of psychosocial performance. Personal- ity characteristics, premorbid adjustment, values and attitudes toward health and illness, and resources and their availability are all sets of variables that may modulate the interac- tion and are therefore considered in the model. The model also specifies requirements that the measure must meet to assess properly the quality of life of patients on neuroleptics. Based on these variables, the 136-item SIP was identified as the most suit- able scale to discriminate the effects of medication. However, although this model is inno- vative, it ignores the objective indicators of quality of life, and requires more validation in research and practice. With respect to the potential effect of different neuroleptics on quality-of-life mea- sures, empirical evidence from 31 published randomized clinical trials involving more than 12,000 individuals indicates that, compared to typical neuroleptics, the effect of atypicals on patients’ quality of life is not consistently more favorable; only about half of the studies reported significant improvements (Corrigan, Reinke, Landsberger, Charat, & Tombs, 2003). Some evidence suggests that patients on olanzapine may have more posi - tive quality-of-life scores than patients on other atypical (Taylor et al., 2005) or typical (Silva De Lima et al., 2005) neuroleptics. Use in Psychosocial and Other Interventions Psychosocial interventions have a documented positive impact on the clinical outcomes of patients with schizophrenia. However, their influence on quality of life has not always been measured, and in studies that assessed quality of life as an outcome, a nonsignificant effect has often been found. Interventions such as art therapy, standard case management, and client-focused case management have not been found to have a significant effect on patients’ quality of life. However, intensive case management, hallucination-focused inte - grative treatment—which incorporates an element of cognitive-behavioral therapy (CBT), and discharge into community after long-term hospitalizations have all been associated with significant improvements in quality of life. More evidence is required to establish which psychosocial interventions impact on quality of life, their mediating processes, and expected effect sizes. 588 VIII. SPECIAL TOPICS Use in Treatment Since 2000, quality-of-life measures have increasingly been used to improve individual treatment processes in mental health services, mostly in forms of outcome management in which data are assessed regularly and individually—and later possibly aggregated on the levels of groups and services. The results are fed back to clinicians, managers, and pa - tients to inform their decisions on care and service management (McCabe & Priebe, 2002). There have been attempts to implement outcomes management in routine prac - tice, with a view toward improving quality and outcome of treatment, although there is no consistent evidence for its effectiveness in mental health care. An example of outcome management is the Quality of Life Profiling Project that was developed around the LQOLP. The project used a computerized system to assess quality of life with results fed back to patients through graphs. In a randomized controlled trial (Slade et al., 2006), researchers assessed patients’ quality of life and other outcome crite - ria, and reported the results to clinicians in community mental health care teams. The in - tervention was associated with lower care costs but did not lead to an improvement of patients’ quality of life. Another trial conducted in six European countries incorporated quality-of-life assessments in the routine sessions between patients and clinicians in com - munity mental health care teams. Computer-mediated procedures were used to display results, including comparisons with previous ratings, and results were expected to feed into the therapeutic dialogue between clinicians and patients (Priebe, McCabe, et al., 2002). Compared with a control group receiving treatment as usual, patients in the inter- vention group showed a small but significant improvement in subjective quality of life af- ter 1 year. KEY POINTS • There is no universally agreed-upon concept of quality of life. • In clinical practice, data on both objective and subjective indicators of quality of life are used, and the importance of subjective indicators reflecting the views of patients has in - creased over time. • Quality of life in patients with schizophrenia is measured by generic and disease-specific scales; whereas the former have concepts pertaining to both patients and the general popu - lation, the latter have greater clinical appeal due to the specificity of content. • The selection of a quality-of-life scale depends on its psychometric properties, the clinical time to administer it, and practicalities related to collecting the data. • Symptom level, particularly depression, is the most important factor negatively influencing subjective quality of life of patients with schizophrenia. • Quality of life is a distal outcome criterion to evaluate the effects of all types of therapeutic interventions, particularly long-term treatment. • Quality-of-life measures are used to improve individual treatment processes in mental health services in the form of outcomes management. 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Quality of Life 591 [...]... set of communication skills These so-called “go/no-go” signals include the subtle and not so subtle cues that people use to indicate interest in a two-way conversation or an exchange of information Go/no-go signals are used by the partners to communicate a lack of interest in pursuing sexual activity or to reinforce a partner’s sexual advances Acquiring the skill to accurately read a partner’s go/no-go... occurs despite the use of structured interview instruments The development of DSM-III has certainly improved validity and diagnosis of psychiatric disorders However, consistent use of DSM-III and now DSM-IV often does not prevent the misdiagnosing of African Americans Strakowski and colleagues (2003) showed that the misdiagnosis was not the consequence of the misapplication of diagnostic criteria (i.e.,... rates of schizophrenia for African Americans in inpatient and outpatient settings The higher rates were often associated with correspondingly lower rates of affective disorders The findings have generally been assumed to reflect affective disorders misdiagnosed as schizophrenia These differences often disappeared with the use of structured interviews, which presumably minimize bias Large-scale, door-to-door... sense of wholeness and self-acceptance Religious communities can also reinforce this more expansive sense of self, going far beyond illness-based identity to that of valued member of a caring community Taking on a meaningful role in a faith community is one means of cementing more positive self-understanding The third theme is somewhat more concrete and often closer to the immediate experiences of people... professional training in this area SEXUAL ACTIVITY OF INDIVIDUALS WITH SCHIZOPHRENIA Although limited data are available on sexuality in persons with schizophrenia, a few studies have been published in the past decade For instance, in comparison with representative samples of non-mentally-ill persons in the United States, men with schizophrenia and mood disorders had approximately the same number of. .. of lifetime sexual partners Both non-mentally-ill and seriously mentally ill males reported three to four times as many sexual partners as women In terms of sexual precocity, there were no differences between the mentally ill and non-mentally-ill cohorts The average age of first reported sexual intercourse was 16–18 for men and women It is interesting to note that similar surveys of physically disabled... young persons with schizophrenia, active verbal participation had to be specifically elicited during the group meetings The exercises were an excellent means of “warming up” the group to facilitate the sharing of experiences and exploration of attitudes None of the participants objected to participating, and none avoided answering relevant questions about their sexuality Over the course of the seminar,... with schizophrenia First, people in recovery from the often devastating reality of, and profound stigma associated with, schizophrenia need to construct and reconstruct a sense of meaning and purpose in their lives Severe mental disorders, and the social isolation and conflict that often accompany them, frequently raise “ultimate” questions—about the nature of reality, about the trustworthiness of other... understanding the complexity of spirituality as it may be expressed at a specific time by a particular individual By approaching spirituality in the same kind of collaborative, conversational exploration that characterizes other topics of interest, clinicians create a space for meaningful discussion of the important and often minimized place of spirituality in the lives of people diagnosed with schizophrenia KEY... disenfranchising thousands of individuals with schizophrenia from the potentialities of recovery The lack of substantive and systematic interest in the sexuality of their patients should not be surprising given the stigma and prevailing views of schizophrenia as a disorder of despair, deficit syndrome, neurodevelopmental abnormalities, and enduring cognitive impairments For most providers of mental health services, . contain health-related quality -of- life concepts pertaining to both patients and the general population. These scales allow comparison of quality -of- life results across interven - tions, diagnostic. clear method of analysis. Regarding the use of self-administered or interviewer-administered quality -of- life scales, it has been argued that self-administered scales (e.g., the Quality of Life Index. the 36-item Short-Form General Health Survey (SF-36; Ware & Sherbourne, 1992) and the EuroQol-5D. Generic scales are, however, not specific enough to capture the quality -of- life problems of