Boyer et al.

BMC Psychiatry 2013, 13:15

http://www.biomedcentral.com/1471-244X/13/15

RESEARCH ARTICLE Open Access

Quality of life is predictive of relapse in

schizophrenia
Laurent Boyer1*, Aurelie Millier2, Emeline Perthame2, Samuel Aballea2, Pascal Auquier1 and Mondher Toumi3

Abstract
Background: The objective of this study was to evaluate whether quality of life (QoL), as measured by the SF36
and the Quality of Life Interview (QoLI), is predictive of relapse for patients with schizophrenia.
Methods: Using data from a multicenter cohort study conducted in France, Germany, and the United-Kingdom
(EuroSC), we performed Cox proportional-hazards models to estimate the associations between QoL at baseline
and the occurrence of relapse over a 24-month period, with adjustment for age; gender; positive, negative and
general psychopathology PANSS factors; functioning (GAF); medication; side-effects; and compliance measures.
Results: Our sample consisted of 1,024 patients; 540 (53%) had at least one period of relapse, and 484 (47%) had
no relapse. QoL levels were the most important features predicting relapse. We found that a higher level of QoL
predicts a lower rate of relapse at 24 months: HR = 0.82 (0.74; 0.91), p < 0.001 for the SF36-Physical Composite Score;
and HR = 0.88 (0.81; 0.96), p = 0.002 for the SF36-Mental Composite Score. These results were not confirmed using
the QoLI: HR = 0.91 (0.81; 1.01), p = 0.083. To a lesser extent, older age, better functioning, and a higher compliance
score also predict a lower rate of relapse at 24 months (HRs from 0.97 to 0.98; p < 0.05).
Conclusions: QoL, as assessed by the SF36, is an independent predictor of relapse at a 24-month follow-up in
schizophrenia. This finding may have implications for future use of the QoL in psychiatry. Moreover, our findings
may support the development and monitoring of complementary therapeutic approaches, such as ‘recovery-
oriented’ combined with traditional mental health cares to prevent relapse.
Keywords: Schizophrenia, Quality of life, Relapse, Compliance, Functioning, Recovery

Background these factors imperfectly predict relapse, and the relapse

Schizophrenia is a severe and chronic mental illness that rate still remains high. Other factors, such as social and
is characterized by recurrent relapses [1,2]. Relapse is environmental factors known to influence the course of
disabling and distressing for the individual with schizo- schizophrenia [10,11], have received scant attention. A
phrenia and is associated with a progressive functional more thorough and comprehensive understanding of
deterioration as well as worsening treatment response and these factors is necessary. On the other hand, Quality of
clinical prognosis [3]. Moreover, relapse increases care- Life (QoL), which is defined as a subjective evaluation em-
giver burden [4] and represents a significant economic bedded in a cultural, social, and environmental context
burden on families and society [5,6]. Because the preven- [12], has gained increasing acceptance in psychiatric re-
tion of relapse is a major challenge in the care of patients search along with the traditional assessments of clinical
with schizophrenia, numerous studies have investigated outcomes. Recent studies have shown QoL to be an inde-
the value of socio-demographic, clinical, and medication pendent prognostic factor associated with clinical out-
factors in the prediction of relapse [1,2,5,7-9]. However, come in various chronic diseases including oncology,
although these reports have provided a better understand- often predicting survival or occurrence of hospitalization
ing of factors that influence the course of schizophrenia, [13-17]. However, two studies have shown that QoL scores
added relatively little to socio-demographic, clinical, and
medication factors in the prediction of relapse in schizo-
* Correspondence: laurent.boyer@ap-hm.fr
1
Aix-Marseille Univ, EA 3279 Research Unit, Marseille 13284, France phrenia [1,5]. Because the median time to relapse
Full list of author information is available at the end of the article

© 2013 Boyer et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
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following a previous remission in schizophrenia has been participant at initial assessment and after every 6 months
estimated to occur at the end of the first year [18,19], the for the subsequent 2 years. Sample attrition resulted in
relatively short follow-up period of these two studies (6 and 1024 (84.8%) participants taking part in the second inter-
12 months) may have underestimated the rate of relapse. view, 914 (75.7%) in the third, 777 (64.3%) in the fourth,
To date, no study has assessed whether QoL provides prog- and 684 (56.7%) in the final interview.
nostic information in addition to conventional socio-demo-
graphic, clinical, and medication factors for patients with Data collection
schizophrenia after a sufficient follow-up. The objective of The following data were collected at baseline:
this study was to evaluate whether baseline QoL, as mea-
sured by the SF36 and the QoLI, is predictive of relapse for 1. Socio-demographic information: gender, age, living
patients with schizophrenia over a 24-month follow-up. conditions, and employment status.
2. Clinical characteristics: psychotic symptoms based on
Methods the Positive and Negative Syndrome Scale (PANSS),
Study design and sampling which includes three different subscales (positive,
The data are from the European Schizophrenia Cohort negative and general psychopathology) [22]; and
(EuroSC) conducted in France, Germany, and the United functioning based on the Global Assessment of
Kingdom (UK). A detailed description of the EuroSC has Functioning (GAF) scale [23].
been published previously [20]. It is a naturalistic 2-year 3. Drug information: Antipsychotic medication
follow-up, from 1998 to 2000, of a cohort of patients (first-generation antipsychotics - FGAs,
suffering from schizophrenia. The study was observa- second-generation antipsychotics – SGAs); the
tional, as no intervention was made either by or at the Simpson and Angus Scale (SAS) [24], the Barnes
behest of the research team. The main objective of the Akathisia Scale (BAS) [25], and the Abnormal
EuroSC was to identify and describe the types of treat- Involuntary Movement Scale (AIMS) [26] were used to
ment and methods of care for individuals with schizo- assess side-effects; the Rating of Medication Influences
phrenia and to correlate these with clinical outcomes, (ROMI) Scale was used to evaluate adherence to
states of health, and quality of life. This study was con- treatment [27]. We only examined the responses to
ducted in accordance with the Declaration of Helsinki Part I of the ROMI, which assesses the reasons for
and the French Good Clinical Practices. The protocol of taking the medication. In our analysis, however, we did
this study was approved by the Institutional Review Board not include Part 2 of the ROMI, which assesses the
or the Ethics Committee responsible for the participating reasons why people might not take their medication.
hospital or institution: The Amden & Islington Commu- According to Weiden et al. [27], the non-compliance
nity Mental Health NHS Trust Ethics Committee and The items in the ROMI apply only to patients who have not
Leicester University Committee for Research Ethics for taken their medication for at least one week for any
all UK sites, The Ethics Committee of the University of part of the past month; otherwise, only the compliance
Leipzig for Germany, and The Ethics Committee of the items are administered. The latter situation applied to
University of Aix-Marseille 2 for France. Written informed all participants in this study.
consent was obtained from each participant after the study 4. QoL was assessed using 2 types of questionnaires: a
details had been fully explained. generic measure usable regardless the health status of
In France, participants were recruited from 4 areas: the individual (either healthy or with different health
Lille (Northern France), Lyon, Clermont-Ferrand (Central conditions) - the SF36 [28]; and a measurement
France), Marseille and Toulon (Southern France). In specific to people with chronic mental illnesses,
Germany, the study took place in 4 areas: Leipzig and tailored to a broad range of mental illnesses - the
Altenburg in the former East Germany, and the districts of Quality of Life Interview (QoLI) [29].
Hemer and Heilbronn in the former West Germany. In the
UK, the two centers of Islington, an inner-city area of The SF36 is a generic, self-administered QoL question-
London, and the county of Leicestershire (excluding the naire consisting of 36 items describing 8 dimensions:
city of Leicester) were chosen. In each center, patients were Physical Functioning (PF); Social Functioning (SF); Role—
identified according to the following criteria: diagnosis of Physical Problems (RPP); Role—Emotional Problems
schizophrenia according to the DSM-IV criteria [21], ages (REP); Mental Health (MH); Vitality (VIT); Bodily Pain
18 to 64 years, and absence of relapse for the previous (BP); and General Health (GH). Two composite scores
12 months. Random sampling from these patients was used can be calculated: the physical composite score (SF36-
to generate a representative sample. The sample included PCS) and the mental composite score (SF36-MCS). Each
1,208 patients: 287 from France, 619 from Germany, and dimension is scored within a range from 0 (low QoL level)
302 from the UK. Five interviews were completed with each to 100 (high QoL level).
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The QoLI is an instrument specifically designed to score, medication, side-effects based on the BAS score,
assess QoL in patients with severe mental illnesses. It compliance ROMI score). An additional variable was in-
consists of 74 items describing 8 domains: Living Situation cluded in the models owing to its socio-demographic inter-
(LS), Daily Activities and functioning (DA), Family Rela- est (gender). The proportional hazards assumption was
tionships (FR), Social Relationships (SR), Finances (F), investigated by testing the constancy of the log hazard ratio
Work and School (WS), Legal and Safety Issues (LSI), and over time by means of log-minus-log survival plots; accor-
Mental and Physical Health (MPH). Each domain is rated ding to the test, the proportional hazard assumption was
objectively by an interviewer and subjectively by the pa- not violated. The statistical significance level was set at
tient reporting his/her satisfaction through an individual p < 0.05 in a two-sided test. The SAS statistical package
structured interview. Subscale scores and an overall life (SAS System for Windows, version 9.1) was used to
satisfaction (OLS) score are calculated, ranging from 1 to perform all analyses.
7. Higher scores indicate a better QoL.
For the purpose of the study, only the SF36-PCS, Results
SF36-MCS, and QoLI-OLS were included in the analyses. Of the 1,208 patients in the EuroSC, 184 patients were
excluded from the analysis because they did not have any
Study outcomes follow-up data (15%). A total of 1,024 patients (85%) were
Our primary measure was the time to first relapse during a then included in the present analysis. There were no stat-
24-month period. Relapse was defined according to a istical differences between the 1,024 patients in the study
common, clinically reproducible and validated definition group and those 184 who were excluded in terms of age,
[30,31]: (1) hospitalization due to worsening of psychotic gender, living condition, functioning (GAF score), anti-
symptoms or an unequivocal worsening of psychotic symp- psychotic medication, SAS, BAS AIMS, and QoL scores at
toms of such magnitude that hospitalization appeared baseline (all p-values > 0.05). On the contrary, in compari-
imminent, or (2) a re-emergence of florid psychotic symp- son to included patients, excluded patients had a slightly
toms such as delusions, hallucinations, or bizarre behavior, higher severity of symptoms (respectively 56.5 (20.2) vs.
or (3) a thought disorder lasting seven days or more. This 64.3 (24.9), p = 0.001 for the total PANSS score) and lower
information was obtained by a structured clinical interview, compliance scores (respectively 11.0 (3.3) vs. 11.5 (3.1),
centred on a checklist of criteria, conducted by a psych- p = 0.043 for the ROMI compliance score).
iatrist every six months. Relapse was defined relative to the
baseline characteristics of the patient. Additional rele- Baseline characteristics of patients with relapse
vant information was obtained from medical records and and no relapse
through staff interviews. This process was intended to The baseline characteristics of the patients with relapse
standardise the collection of information about relapse. and no relapse are reported in Table 1. Five hundred and
forty patients (53%) had at least one period of relapse, and
Statistical analysis 484 (47%) had no relapse. Patients with relapse were sig-
Descriptive statistics, reported as means (SD) or percen- nificantly younger than patients with no relapse, but no
tages, summarized baseline characteristics by relapse significant difference was found for gender and living
status. Characteristics of patients were compared using conditions. Patients with relapse also had higher levels of
Chi-squared or Fisher exact tests for categorical vari- severity (positive, negative, and general psychopathology
ables and the Student or Wilcoxon rank sum test for PANSS factors) and a lower level of functioning. The pro-
continuous variables. Cox proportional hazards models portion of patients receiving SGAs was significantly higher
were also used for the univariate analyses to predict the in patients with relapse than in patients with no relapse.
interval time to relapse. Subjects were censored from Side effects as assessed with the AIMS, BAS, and SAS and
the survival analysis at the time they discontinued the compliance as assessed with the ROMI did not differ sig-
study, i.e. at the time of last interview. nificantly between the two groups. Concerning QoL scores,
Multivariate Cox proportional-hazards models were per- patients with relapse reported lower QoL levels than
formed to estimate the Hazard Ratio (HR) and its corre- patients with no relapse for the SF36-PCS, SF36-MCS, and
sponding 95% confidence interval (CI) for associations QoLI-OLS.
between QoL scores and the occurrence of relapse, with ad-
justment for baseline characteristics, one model including Predictors of relapse in the Cox’s proportional hazard
the SF36 questionnaire (SF36 model), and one model models
including the QoLI (QoLI model). The adjustment variables In the univariate Cox’s proportional hazard models ana-
relevant to the models were selected from the univariate lysis (Table 1), relapse was significantly predicted by
analysis, based on a threshold p-value ≤0.20 (age, positive, older age, higher level of severity, lower level of func-
negative and general psychopathology PANSS scores, GAF tioning, SGAs, lower compliance and lower QoL level.
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Table 1 Characteristics of the patients according to relapse status and univariate Cox proportional-hazards
models: Crude Hazard Ratio (HR) and its corresponding 95% confidence interval (95% CI)
Relapse
Yes (N = 540) No (N = 484)
1
M (SD) M (SD) p-value Crude HR 95% CI p-value
Socio-demographic characteristics
Age 40.3 (10.1) 42. 0 (11.6) p = 0.013 0.99 (0.98;0.99) p = 0.004
Gender (Male), N (%)2 62.1 61.2 p = 0.773 0.97 (0.82;1.16) p = 0.762
Living alone, N (%) 33.5 34.5 p = 0.740 0.97 (0.81;1.16) p = 0.754
Unemployed, N (%) 56.9 35.7 P = 0.240 0.79 (0.53;1.15) p = 0.237
Severity of symptoms: PANSS3
Positive PANSS score 12.7 (5.7) 11.7 (5.1) p = 0.003 1.03 (1.01;1.04) p = 0.001
Negative PANSS score 16.1 (7.3) 14.6 (7.5) p = 0.002 1.02 (1.01;1.03) p = 0.001
General Psychopathology PANSS score 29.7 (10.2) 27.7 (10.1) P = 0.001 1.02 (1.01;1.02) p < 0.001
Functioning
GAF4 48.5 (15.6) 55.0 (15.9) p < 0.001 0.98 (0.98;0.99) p < 0.001
Side Effects
BAS5 1.3 (3.0) 1.1 (2.7) p = 0.192 1.02 (0.99;1.04) p = 0.147
AIMS6 3.0 (6.9) 2.5 (5.6) p = 0.228 1.01 (0.99;1.02) p = 0.328
7
SAS 3.5 (8.2) 3.5 (7.7) p = 0.963 1.00 (0.99;1.011) p = 0.990
Medication
Second-generation antipsychotics (Yes), N (%) 45.6 38.9 p = 0.034 1.26 (1.06;1.49) p = 0.009
Attitude towards medication: ROMI8
ROMI compliance score 10.8 (3.5) 11.1 (3.1) p = 0.223 0.97 (0.95;0.99) p = 0.035
Quality of life
SF36 - Physical Composite Score * 47.2 (9.8) 49.1 (8.7) p = 0.001 0.83 (0.76;0.91) p < 0.001
SF36 - Mental Composite Score ** 40.3 (11.8) 43.7 (11.0) p < 0.001 0.84 (0.78;0.91) p < 0.001
QoLI - OLS score*** 4.7 (0.9) 4.8 (0.8) p = 0.006 0.86 (0.78;0.95) p = 0.003
1
Mean (Standard Deviation); 2 Effective (Percentage); 3 Positive and Negative Syndrome Scale; 4Global Assessment Functioning; 5Barnes Akathisia score;
6
Abnormal Involuntary Movement Score; 7Simpson-Angus score; 8Rating of Medication Influences Scale.
* HR for the SF36 - Physical Composite Score should be interpreted this way, “an increase of 10 points on the Physical Composite Score multiplied by 0.83 the
instantaneous risk of relapse at 24 months”;
** HR for the SF36 - Mental Composite Score should be interpreted this way, “an increase of 10 points on the Mental Composite Score multiplied by 0.84 the
instantaneous risk of relapse at 24 months”;
*** HR for the QoLI - OLS score should be interpreted this way, “an increase of 1 point on the QoLI score multiplied by 0.86 the instantaneous risk of relapse at 24 months”.

Factors that were independently associated with re- relapse. Our study examined 1,024 patients with schizo-
lapse during the 24 months of follow-up on the basis of phrenia; controlled for important socio-demographic,
the multivariate Cox analyses are reported in Table 2. In clinical, and medication factors; and has attempted to
the SF36 model, QoL levels were the most important overcome the limitations of past studies by using a large
features predicting relapse. A higher level of QoL pre- sample size and a 24-month follow-up, which enables a
dicts a lower rate of relapse at 24 months for both the more complete analysis of full relapse. The findings pro-
SF36-PCS and -MCS. To a lesser extent, older age, better vide evidence in support of a relationship between QoL
functioning, and higher compliance score also predict a scores and relapse in this patient population.
lower rate of relapse at 24 months. On the contrary, the QoL, as assessed by a generic instrument (SF36), is an
severity of symptoms and second-generation antipsychotics independent predictor of relapse in schizophrenia. This
did not significantly predict relapse. In the QoLI model, finding is consistent with a 12-month follow-up study
only older age and better functioning predict a lower rate using the SF36, in which a higher level of QoL predicted
of relapse. a moderately lower rate of relapse at 12 months (OR =
0.98 for both the Physical and Mental Composite Scores)
Discussion [1]. Surprisingly, this relationship was not confirmed in
Using data from the observational EuroSC cohort, we our study using the QoLI, which only presented a trend
examined the predictive value of QoL with respect to (p = 0.083). Again, this finding is consistent with a
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Table 2 Factors associated with relapse during the 24 months of follow-up in the multivariate Cox proportional-
hazards models: Adjusted Hazard Ratio (HR) and its corresponding 95% confidence interval (95% CI)
SF-36 Model QoLI Model
HR 95% IC p-value HR 95% IC p-value
Quality of life
SF36 - Physical Composite Score * 0.82 (0.74;0.91) p < 0.001 - - -
SF36 - Mental Composite Score ** 0.88 (0.81;0.96) p = 0.002 - - -
QoLI - OLS score*** - - - 0.91 (0.81;1.01) p = 0.083
Socio-demographic characteristics
Age 0.98 (0.98;0.99) p = 0.001 0.98 (0.98;0.99) p < 0.001
Gender (Male) 1.06 (0.88;1.30) p = 0.532 1.12 (0.93;1.34) p = 0.249
Severity of symptoms: PANSS1
Positive PANSS score 0.99 (0.97;1.02) p = 0.514 0.99 (0.97;1.02) p = 0.560
Negative PANSS score 1.01 (0.99;1.03) p = 0.248 1.00 (0.98;1.02) p = 0.969
General Psychopathology PANSS score 0.99 (0.97;1.01) p = 0.419 1.00 (0.98;1.02) p = 0.937
Functioning
GAF2 0.98 (0.97;0.99) p < 0.001 0.98 (0.97;0.99) p < 0.001
Side Effects
BAS3 0.99 (0.95;1.02) p = 0.497 1.00 (0.97;1.03) p = 0.844
Medication
Second-generation antipsychotics (Yes) 1.07 (0.88;1.29) p = 0.508 1.13 (0.94;1.36) p = 0.195
Attitude towards medication: ROMI4
ROMI compliance score 0.97 (0.94;0.99) p = 0.041 0.97 (0.95;1.00) p = 0.063
1
Positive and Negative Syndrome Scale; 2Global Assessment Functioning; 5Barnes Akathisia score; 4Rating of Medication Influences Scale.
* HR for the SF36 - Physical Composite Score should be interpreted this way, “an increase of 10 points on the Physical Composite Score multiplied by 0.82 the
instantaneous risk of relapse at 24 months”;
** HR for the SF36 - Mental Composite Score should be interpreted this way, “an increase of 10 points on the Mental Composite Score multiplied by 0.88 the
instantaneous risk of relapse at 24 months”;
*** HR for the QoLI - OLS score should be interpreted this way, “an increase of 1 point on the QoLI score multiplied by 0.91 the instantaneous risk of relapse at 24 months”.

6-month follow-up study using the QoLi, in which health of patients with schizophrenia [34]. Although
relapsed patients appeared to experience a lower QoL most patients view their physical health as a high prior-
than non-relapsed patients at baseline, but the differ- ity, many clinicians consider their primary function to
ences were not statistically significant [5]. The fact that a be the management of mental and psychological health
generic instrument like the SF36 better predicts relapse [35]. The subjective physical well-being of patients with
than a specific instrument like QoLI may appear para- schizophrenia should thus be considered by clinicians as
doxical. The use of QoL-specific instruments is generally an important predictor of relapse, in the same way that
recommended in schizophrenia because they identify the psychological aspects are considered.
specific needs of patients and are more sensitive to In our study, unlike previous studies [5,7,19,36], a
change and treatment/intervention effects than are gen- more severe symptomatology was not associated with
eric instruments [32]. However, the QoLI is designed to relapse, and other factors such as functioning or compli-
encompass a broad range of mental illnesses, not specif- ance were only moderately associated with relapse. One
ically schizophrenia. According to Cramer et al. [32], the possible explanation for this discrepancy might be that
QoLI showed less sensitivity to change and treatment QoL, which was not taken into account as a potential
effect than did schizophrenia specific QoL instruments. predictor in previous studies, may have a confounding
A previous study has also shown that a better agreement influence on the relationship between traditional predic-
was observed between the SF36 and schizophrenia spe- tors and relapse. On the other hand, the exclusion of
cific QoL instruments than with the QoLI and that the more severe and less compliant patients (15% of the
SF-36 was more strongly correlated with clinical status cohort) may have also attenuated the predictor strength
than the QoLI [33]. of symptomatology and compliance. Beyond these ex-
An important finding in our study concerns the SF36- planations, it is interesting to note that, although the
PCS, which was a stronger relapse predictor compared predictive value of the different factors was moderate in
to the SF36-MCS. This finding confirms the need for our study, QoL was a stronger predictor than clinical
clinicians to increase their attention on the physical information.
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Finally, our findings can also be interpreted in terms of relapses were globally detected. Finally, attrition and
the recovery process. The concept of recovery is broadly relapse rates were globally within the range of other
organised into 2 types: clinical objective (i.e. clinical symp- schizophrenia cohorts [1,5,6,43].
toms and functioning) and personal subjective including Fourth, the SF36 is a generic measure and may not
in particular QoL among other domains such as personal adequately capture all areas of functioning and well-being
confidence and hope, willingness to ask for help [37,38]. that are relevant to people with schizophrenia [44]. More-
Our findings suggest that personal subjective recovery over, a recent review raised question about metrological
(i.e. QoL in our study) is more predictive of relapse than properties of the SF36 in schizophrenia [45]. Future inves-
objective recovery. These findings should however be con- tigators should attempt to replicate our findings using
firmed on other domains of subjective recovery. On the disease-specific instruments.
other hand, these results should be considered to improve Fifth, compliance is not easy to detect and quantify, and
the characterisation and treatment of patients with schizo- all methods of detection have some drawbacks. As such,
phrenia. Our findings may support the development and the use of the ROMI may be criticised. This scale is a
monitoring of complementary therapeutic approaches, subjective method of assessing compliance in comparison
such as ‘recovery-oriented’ combined with traditional with objective methods such as pill counts, pharmacy
mental health cares to prevent relapse. Interestingly, QoL records, electronic monitor and plasma concentrations.
has been linked to metacognitive capacities in recent stud- However, as suggested by Velligan et al., even the use of
ies [39,40], suggesting that interventions targeting meta- more objective measures can result in significant errors
cognition, such as psychotherapy, may play a key role in [46]. Moreover, the ROMI has several advantages. It has
preventing relapse [41]. good psychometric properties and predicts compliance
satisfactorily [27].
Limitations Sixth, although our models account for a large set of
Some limitations of this study have to be carefully potentially relevant variables, other factors might have
considered. increased their explanatory power. For example, having
First, a problem remains with the definition of relapse a history of previous relapse or hospitalisation was not a
for schizophrenic patients. There are no consensual cri- variable that we examined in our study, although it has
teria for relapse [30]. Admission to a psychiatric hospital previously been identified as an important predictor of
unit, increase in medication, worsening of florid symp- relapse [1]. However, in the present study, patients did
toms of schizophrenia, worsening of any psychiatric symp- not have any relapse or hospitalisation for the 12 months
toms, and threatened clinical exacerbations have all been prior to the baseline evaluation in accordance with the
variables used to indicate relapse [42]. However, in this inclusion criteria. Lastly, despite our large sample, this
study, we have chosen the most commonly used definition study only included 3 European countries. Given the im-
in the recent scientific literature. portant influence of cultural, social, and environmental
Second, the representativeness of our sample should context on QoL, it would be necessary to know whether
be discussed. Although the sampling procedure for the our findings can be replicated in other countries.
EuroSC aimed to provide a representative sample of the
patients treated, this cohort of patients had mostly para- Conclusion
noid schizophrenia and was characterized by long-term This study shows that QoL measures can be considered as
illness [20]. Moreover, excluded patients presented with an independent predictor of relapse in schizophrenia. This
a higher clinical severity than included patients. Replica- finding may have implications for the future use of QoL in
tion is therefore needed, using larger and more diverse psychiatry. To date, QoL remains largely under-utilized in
groups of patients. clinical practice [47]. Several studies have reported that
Third, 43% is a moderately high attrition rate in our clinicians believe that QoL measures lack clinical rele-
study at 24 months, and this can lead to biased esti- vance for their patients [48,49]. More work must be done
mates, especially if patients who did not follow up failed to convince clinicians of the clinical relevance of QoL
to do so because they suffered a higher relapse rate due instruments in order to enhance the use of QoL measures
to higher clinical severity. However, three facts suggest in clinical decision-making [50]. Our findings, similar to
minimal bias due to attrition. First, among patients lost those in other studies, especially in oncology, provide
to follow up, 40.3% had a relapse before their last visit strong support for the integration of QoL into clinical
and were thus included in the analysis. Second, patients practice along with other standard assessments in
lost to follow up did not differ significantly in age, gen- psychiatry.
der, or PANSS scores at baseline from those patients
Competing interests
who did follow up (p > 0.05; data not shown). Third, the The authors have declared that there are no conflicts of interest in relation
relapse rate was relatively high (53%), suggesting that to the subject of this study.
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Authors’ contributions 15. Sehlen S, Lenk M, Hollenhorst H, Schymura B, Aydemir U, Herschbach P,

LB, AM, PA and MT wrote the manuscript. All authors designed the study Duhmke E: Quality of life (QoL) as predictive mediator variable for
and wrote the protocol. LB, AM, EP, and SA conducted the literature search survival in patients with intracerebral neoplasma during radiotherapy.
and analyses. AM and EP conducted the statistical analyses. All authors Onkologie 2003, 26:38–43.
contributed to and approved the final manuscript. 16. Sprenkle MD, Niewoehner DE, Nelson DB, Nichol KL: The Veterans Short
Form 36 questionnaire is predictive of mortality and health-care
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doi:10.1186/1471-244X-13-15
Cite this article as: Boyer et al.: Quality of life is predictive of relapse in
schizophrenia. BMC Psychiatry 2013 13:15.

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