Next Article in Journal
Efficacy and Blood Levels of Lacosamide in Patients with Focal Epilepsy
Previous Article in Journal
Myeloproliferative Neoplasms: Challenging Dogma
Previous Article in Special Issue
Tact Training with Augmentative Gestural Support for Language Disorder and Challenging Behaviors: A Case Study in an Italian Community-Based Setting
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
JCM
Volume 13
Issue 22
10.3390/jcm13226959
jcm-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Internalised Stigma, Self-Esteem and Perceived Social Support as Psychosocial Predictors of Quality of Life in Adult Patients with Schizophrenia

by
Corina Gagiu
1,2,
Vlad Dionisie
1,2,*,
Mihnea Costin Manea
1,2,
Doina Carmen Mazilu
3 and
Mirela Manea
1,2
1
Department of Psychiatry and Psychology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
2
“Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania
3
Department of Nursing, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
*
Author to whom correspondence should be addressed.
J. Clin. Med. 2024, 13(22), 6959; https://doi.org/10.3390/jcm13226959
Submission received: 15 October 2024 / Revised: 3 November 2024 / Accepted: 17 November 2024 / Published: 19 November 2024
(This article belongs to the Special Issue Diagnosis, Treatment, and Prognosis of Neuropsychiatric Disorders)
Versions Notes

Abstract

:
Background: Schizophrenia is a chronic and severe mental illness that ultimately leads to reduced quality of life (QoL). Over the years, QoL has emerged as an important outcome in the treatment of schizophrenia patients, but the role of psychosocial variables in determining QoL is still ambiguous. Therefore, in the present research, demographic, clinical and psychosocial variables were examined for their influence on QoL. Methods: We conducted a prospective and cross-sectional study on a sample of 139 patients with schizophrenia (72.7% females, age 48.17 ± 10.22) attending an outpatient service. QoL was measured using Schizophrenia Quality of Life Revision-4 (SQLR4) and internalised stigma, self-esteem, perceived social support, resilience and coping mechanisms were assessed using a battery of standardized self-report scales. Results: Female patients and those less adherent to treatment had reduced cognition and vitality QoL. The worst QoL in all domains was observed in patients with a younger age at illness onset and with six or more hospitalizations. Regression analysis indicated that reduced self-esteem, perceived social support, a larger number of hospitalization and increased internalised stigma predicted poorer overall QoL and accounted for 44.9% in the variance in SQLSR4 global score (adjusted R2 = 0.449, p = 0.046). Conclusions: Routine assessment of internalised stigma, self-esteem and perceived social support, in addition to demographic and clinical variables and addressing possible deficits in these areas through personalized intervention, could improve QoL in schizophrenia patients.

1. Introduction

Schizophrenia is a severe and complex mental illness characterized by distortions in thinking, perception, affect and behaviour, as well as cognitive impairments [1]. It affects approximately 1 in 300 persons worldwide and is ranked among top 10 causes of disability [2,3]. Despite its low lifetime prevalence, schizophrenia imposes a substantial health, social and economic burden on patients, their families, caregivers and society as a whole [4]. Patients encounter varying degrees of disability across multiple functional areas [5] and have a poorer quality of life (QoL) compared to the general population, as shown by meta-analytic evidence [6].
QoL is a broad concept that can be defined from a two-faceted perspective. From a subjective point of view, the World Health Organization defines QoL as “an individual’s perception of his or her position in life in the context of the culture and value systems in which he or she lives, and in relation to his or her goals, expectations, standards, and concerns” [7]. Objectively, QoL is measured through various living, financial and social indicators [8]. Ritsner M. (2007) argues that impairments in health-related QoL in schizophrenia form a distinct syndrome that is influenced by multiple factors. These factors may have a protective or distressing effect [9]. A wealth of research on factors affecting QoL has been focused on the role of symptomatology. In this context, although a meta-analysis revealed a small negative association between QoL and psychiatric symptoms [10], a systematic review found that positive or depressive symptoms may not influence QoL [11]. Also, some studies have reported different demographic and clinical factors (i.e., marital status, monthly household income, employment, living arrangement, level of education, number of hospitalizations, age, illness duration, adherence to medication, body mass index—BMI, etc.) as predictors of QoL [12,13,14,15,16,17,18,19,20,21,22]. Furthermore, while these studies show inconsistent results, other research has failed to identify any demographic or clinical characteristics as potential predictors of QoL in schizophrenia [23]. Therefore, clinical and demographic variables seem to have a small influence on QoL among schizophrenia patients. For this reason, researchers recommend exploring factors beyond the medical model to gain a better understanding of health-related QoL [24,25]. In addition, these inconsistent results regarding clinical and demographic factors call for future research to deepen our understanding of their actual contribution in determining QoL.
Psychosocial factors associated with emotional regulation, such as social support, feelings of self-esteem, resilience, internalised stigma and coping mechanisms to stressful situations, are presumed to be involved in predicting QoL, as they may serve as protective factors, according to the Ritsner’s distress/protection vulnerability model of QoL outcome [9]. Moreover, The Substance and Mental Health Service Administration National Consensus Statement on Mental Health Recovery proposed 10 recovery components that include the above-mentioned self-factors. Numerous researchers have recognised that the term recovery is similar to the concept of QoL [26]. Broadly speaking, stigma is regarded as one of the most significant challenges encountered by people with psychosis. A recent meta-analysis revealed that high levels of internalised stigma have been linked to lower subjective QoL [27]. Similar results were reported concerning self-esteem [28]. Also, studies showed that self-esteem mediates the relationship between different clinical and psychological outcomes (i.e., depression, stigma, and medication compliance) and QoL [29,30,31], further emphasizing the important role of self-esteem in determining QoL in schizophrenia. Social support is thought to be a crucial factor in the course of many mental health illnesses by attenuating stress or increasing self-esteem [32]. In schizophrenia, it was revealed that social support is associated not only with symptom improvement or even remission, as well as fewer hospitalizations, but also with a better overall QoL [16,33,34,35,36,37,38,39,40]. Unfortunately, there are limited data on this topic.
Schizophrenia patients encounter considerable challenges and stress due to positive symptoms, cognitive deficits and decreased functionality [41]. Resilience is the ability to adapt in the face of adversity, and it is considered that it may have an important role in achieving and sustaining full recovery in schizophrenia [42]. Current evidence from a systematic review shows that higher resilience in patients with schizophrenia was associated with better quality of life [41]. Another important aspect related to an individual’s stress response is the coping mechanisms they use. “Coping” refers to the conscious and unconscious psychic mechanisms that people employ to adaptively manage stress. Individuals use a variety of coping mechanisms to manage or overcome stressful situations, including dealing with the wider impact of mental illness [43]. As noted by Kao et al. (2017) and Montemagni et al. (2014), people with schizophrenia have difficulties in coping with life stresses and generally use less effective coping strategies than healthy individuals [44,45]. Regarding QoL, Yanos and Moos (2007) proposed coping as a major determinant [46].
However, as previously noted, limited research has explored all these factors simultaneously to assess their impact on QoL. Therefore, it is imperative to deepen our comprehension of their intricate relationships and contributions to defining QoL. Thus, this study aimed to investigate the influence of various demographic and clinical factors as well as internalised stigma, social support, self-esteem, coping strategies and resilience on predicting QoL in patients with schizophrenia. Understanding the factors that affect QoL in patients with schizophrenia could aid in creating targeted interventions to improve their QoL.

2. Materials and Methods

2.1. Study Design, Procedures and Population

We conducted a prospective, cross-sectional and observational research study from 1 July 2022 to 31 December 2023, on a sample of 139 patients with schizophrenia. Patients were recruited from the outpatient units and the Mental Health Centre of the “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry in Bucharest, Romania. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki for Medical Research involving human subjects and was approved by the Institutional Ethics Committee (approval no. 90/07.06.2022). All patients provided written informed consent before entering the study.
Participants were recruited during regular appointments to their treating psychiatrist. Patients were included in this study if they met the following criteria: (1) age between 18 and 65 years old; (2) have a diagnosis of schizophrenia according to the 10th revision of the International Classification of Diseases criteria confirmed by their treating psychiatrist based on a semi-structured interview and the patient’s history; (3) clinically stable and with adequate symptom control; the patient is not in an acute episode and has more than 3 months after the last hospitalization or major change in treatment regimen; (4) the patient agreed to participate in the study and signed the informed consent. We applied the following exclusion criteria: (1) presence of a serious medical illness; (2) patients with first-episode schizophrenia; (3) presence of a neurological or organic cerebral pathology; (4) mental retardation; (5) psychiatric comorbidities (including addition to alcohol or other psychoactive substances, except nicotine); (6) uncorrected visual or hearing impairments that may influence understanding of the information presented or performance in completing a self-administered scale; (7) pregnancy or lactation; (8) inability to follow the instructions; (9) the patient did not give his consent to participate in the study and/or did not sign the informed consent form.
Each patient was asked to provide socio-demographic and clinical data and to complete self-administered scales assessing quality of life, internalised stigma, perceived social support, coping mechanisms, resilience, self-esteem and adherence to treatment.

2.2. Measures

2.2.1. Socio-Demographic and Clinical Variables

We recorded the following socio-demographic and clinical data for each patient using a semi-structured questionnaire especially designed for this research: age (years), gender (male or female), residence (urban or rural), marital status (with partner or single), years of formal education (≤8, 9–12, >12 years), residential status (lives alone or lives with other—family, friends, partner), professional status (unemployed, disability pension, retirement pension, employed), income source (personal income, family support, personal income and family support), duration since last hospitalization (months), age at illness onset (years), duration of illness (years), number of hospital admissions (none, 1, 2–5, ≥6), height (cm), weight (kg), type of antipsychotic administration (oral, long-acting injectable—LAI, oral and LAI), type of antipsychotic (typical, atypical, combination of typical and atypical), presence of somatic comorbidities.

2.2.2. Instruments

After collecting socio-demographic and clinical data, each participant was given a set of self-administered psychometric scales that contained the following: Schizophrenia Quality of Life Revision 4 (SQLR4), Internalised Stigma of Mental Illness (ISMI), Multidimensional Scale of Perceived Social Support (MSPSS), Coping Orientation to Problems Experience (COPE) Questionnaire, Brief Resilience Scale (BRS), Rosenberg Self-Esteem Scale and Medication Adherence Rating Scale (MARS).
The SQLSR4 was used to evaluate patient’s quality of life. This disease-specific self-administered instrument includes 33 items and was specifically designed to measure quality of life from the patient’s perspective. All items, except for four, are scored on a 5-point Likert scale from 0 to 4. The scale comprises 2 domains, specifically “psychosocial feelings” (20 items) and “cognition and vitality” (13 items). The global score and the two subscale scores are transformed to have a range from 0 to 100, and a lower score represents a better quality of life [47]. The SQLR4 has been extensively used in studies assessing QoL of schizophrenia patients [48,49,50] and has proven, good psychometric proprieties [51,52,53,54]. In our study, the Romanian version of the SQLSR4 demonstrated good internal consistency (Cronbach’s alpha = 0.93).
The ISMI is one of the most-used measures of subjective experience of stigma and assesses five thematic areas (i.e., alienation, stereotype endorsement, perceived discrimination, social withdrawal and stigma resistance). It comprises 29 items rated on a 4-point Likert scale (from “strongly disagree” to “strongly agree”). A higher score is indicative of a more severe self-stigma [55]. Although originally designed for a broad spectrum of mental illnesses, the scale was applied to samples of patients with schizophrenia, including those from Romania [56]. The Romanian version is available and was produced within the GAMIAN-Europe study [57,58]. In this research, the Romanian version of ISMI had good internal consistency, with a reliability coefficient alpha of 0.87.
The COPE Questionnaire was developed by Carver et al. (1989) to evaluate how people respond to challenging or stressful situations in their lives [59]. The original instrument comprises 53 items that encompass 14 strategies [59], which can be further categorised as either adaptive or maladaptive [44]. The following domains are considered adaptive: positive reinterpretation, venting of emotions, use of instrumental social support, active coping, religious coping, restraint, use of emotional social support, acceptance, suppression of competing activities and planning. Mental disengagement, denial, behavioural disengagement and alcohol–drug use are viewed as maladaptive coping mechanisms [44]. The scale was translated into Romanian and underwent psychometric validation [60,61]. The COPE has been also used in clinical samples, specifically those with schizophrenia-spectrum disorders [62,63]. Internal consistency in our study was satisfactory for the 14 subscales (Cronbach’s alpha ranging from 0.70 to 0.79), as well as for the two coping domains (Cronbach’s alpha of 0.88 for adaptive coping and Cronbach’s alpha of 0.73 for maladaptive coping).
Developed by Zimet et al. (1988), the MSPSS aims to capture the self-perceptions of the support received from friends, family and significant others. The instrument is short and consists of 12 statements, divided into four for each source of support. Respondents are asked to rate each statement on a scale ranging from 1 (strongly disagree) to 7 (strongly agree) [64,65]. The scale has been previously translated into Romanian and proved to be valid and reliable [66,67]. Although initially developed on undergraduate students [64], the MSPSS has been shown to be suitable for assessing perceived social support among patients with schizophrenia [68]. In the current study, all three subscales and the total scale demonstrated excellent internal reliability (Cronbach’s alpha = 0.874, 0.940, 0.921 and 0.859, respectively).
The Rosenberg Self-Esteem scale is regarded as the benchmark for measuring self-esteem. It is a 10-item questionnaire, and responses are rated on a 4-point Likert scale. Higher scores correspond to increased self-esteem levels [69]. The instrument has been utilized in several studies involving patients with schizophrenia [70,71], and its validity and reliability have been confirmed for the Romanian version [60].
The BRS is a 6-item measure that assesses an individual’s capacity to bounce back or recover from stress. The BRS total score ranges from 6 to 30, where higher scores reflect greater resilience [72]. The BRS was validated to be used in people with serious mental illnesses (including schizophrenia) [73]. The scale was translated and adapted for the Romanian population, and it showed good internal consistency across several studies [74,75,76]. In the current study, the BRS yielded a Cronbach’s alpha of 0.74.
The MARS is intended to measure the level of psychoactive medication compliance and was developed by Thompson et al. (2000) [77]. Respondents are instructed to rate each statement with a score of 0 or 1. The total score is calculated by summing the scores of all items, with a higher total score indicating better compliance [29,77]. In the current study, the internal consistency of the instrument, as measured by Cronbach’s alpha, was 0.77.

2.3. Statistical Analysis

The statistical analysis was computed with IBM Statistical Package for Social Sciences (SPSS) version 26.0. software for Windows (IBM, Armonk, NY, USA). Sample size calculation was based on the primary outcome: identification of independent predictors associated with SQLSR4 in patients with schizophrenia. The parameters taken into consideration for sample size calculation were an alpha error of 0.05, a beta error of 0.8 (study power), an effect size (F) of 0.39 (medium effect) and a number of 15 possible predictors identified in the literature. Thus, a number of 137 subjects should be included in the entire regression model in order to have a statistical power of 0.8015. Categorial variables were expressed as absolute (number) and relative (percentage) frequency, and continuous variables were expressed as mean and standard deviation (mean ± standard deviation). Continuous data from two independent groups were compared using the independent t-test, and for three or more groups, ANOVA (analysis of variance) was employed. Bivariate correlations between continuous variables were performed using Pearson’s correlation coefficients. A stepwise forward method was used to build multivariate regression models. Factors were kept in the model if probability of F to enter was ≤0.05 and removed if probability of F to remove was ≥0.1. Separate models were built taking the following as the dependent variable: SQLS-R4 psychosocial score, SQLS-R4 cognition and vitality score, and SQLS-R4 global score. The sociodemographic, clinical and psychosocial variables were tested for independent predictive value. Effect size was expressed as adjusted R square. p values less than an alpha level of 0.05 were considered to be statistically significant.

3. Results

One hundred and eighty-four patients were invited to participate in the study, and one hundred and fifty agreed to participate and signed the informed consent. A total of 11 patients were excluded based on the inclusion and exclusion criteria (age >65 years old). One hundred and thirty-nine schizophrenia patients were included in the final analysis in this research. The mean (±SD) age of the participants was 48.17 (±10.22), and 72.7% of them were female. Most of the patients lived in urban areas (79.9%) with someone (family, friends or partner) (80.6%). The mean (±SD) duration of illness was 23.95 (±9.06), and more than half of the participants had six or more hospital admissions (53.2%). All sociodemographic and clinical data are presented in Table 1.
Only the SQLS cognition and vitality score was associated with gender (female vs. male: 38.78 ± 10.88 vs. 34.36 ± 13.32, p = 0.048). SQLS total, SQLS psychosocial and SQLS cognition and vitality were associated with age at illness onset (R = −0.206, p = 0.015; R = −0.177, p = 0.037; and R = −0.226, p = 0.007, respectively) and number of hospital admissions (2–5 admissions vs. >6 admissions: 32.33 ± 12.07 vs. 39.58 ± 10.73, p = 0.000; 31.71 ± 13.47 vs. 38.46 ± 11.98, p = 0.000; and 33.28 ± 11.38 vs. 41.32 ± 10.74, p = 0.000, respectively). The MARS score was negatively associated with the SQLS cognition and vitality score (R = −0.167, p = 0.049). The other socio-demographic and clinical characteristics of the study sample were not associated with any of the SQLS scores (p > 0.05) (Table 1).
Patients had a mean (±SD) SQLS total score of 36.19 (±11.90). The means (±SD) for the psychosocial and cognition and vitality subscales were 35.30 (±13.10) and 37.56 (±11.72), respectively. Regarding stigma, the sample had a mean (±SD) for the global ISMI score of 2.41 ± 0.23, which indicates mild internalised stigma. For the MSPSS, the mean (±SD) score was 4.35 ± 0.70. The group had normal resilience levels (3.00 ± 0.20), and the mean (±SD) of the self-esteem score was 27.44 ± 3.16. Table 2 presents all results regarding psychometric scales scores.
Bivariate analyses found that the ISMI showed significant positive correlations with the overall QoL score and both domains (p < 0.01). The MSPSS and Rosenberg Self-Esteem negatively correlated with all SQLS scores (p < 0.01) (Table 3).
For global QoL and for each QoL domain a distinct predictive model was found using stepwise multiple regression analysis (Table 4). The Rosenberg Self-Esteem score, internalised stigma, social support and number of hospitalizations explained 44.9% of the variance (adjusted R2) in the SQLS global score. More precisely, higher self-esteem, fewer hospital admissions, lower internalised stigma and greater perceived social support predicted a better overall QoL. The psychosocial domain score was predicted by the Rosenberg Self-Esteem score, MSPSS score and number of hospitalizations. This model explained 38.9% of the variance. Also, the model including the Rosenberg Self-Esteem score, ISMI score and the number of hospitalizations explained 42.5% of the variance in the SQLS cognition and vitality score (Table 4).

4. Discussion

The current study sought to identify demographic, clinical, and psychosocial determinants of QoL in a sample of outpatients with schizophrenia. Therefore, it was demonstrated that increased self-esteem and perceived social support, lower internalised stigma and fewer hospital admissions independently predicted better global QoL. These factors explain up to 44.9% of the variance in overall QoL. Higher self-esteem and fewer hospitalizations continued to be significant predictors for both QoL domains. Greater perceived social support and reduced self-stigma, specifically, predicted the psychosocial and cognition and vitality domains of QoL, respectively.
SQLS scores in our sample are comparable to those found in other studies involving schizophrenia outpatients, inpatients, or both [47,49,51,52,54,78,79], even though the mean SQLS global score in our study is lower than it was estimated by a recent meta-analysis (40.66, 95% CI: 37.66–43.66) [80]. Moreover, based on experts’ opinions on the range of SQLS-R4 scores (very good: 0–20, good: 21–40, moderate: 41–60, poor: 61–80, very poor: 81–100), the global QoL in our sample (36.19 ± 11.90) can be categorised as good to moderate [80].

4.1. Demographic and Clinical Variables and Quality of Life

Findings on the relationship between socio-demographic variables and QoL measured using SQLS-R4 have been inconsistent and conflicting. In the present study, among all demographic variables, only gender was found to have a relationship with QoL; specifically, women had poorer QoL in the cognition and vitality domain compared to men. Similar results were reported by Domenech et al. (2019) for the global score of SQLS—original version [81] and by other researchers using a generic QoL scale [82], but results at difference with these are reported in the current literature [83,84]. The large female representation in our sample (72.7%) may be a contributing reason for this association. Moreover, individuals with an older age at schizophrenia onset and those with fewer hospitalizations had a better QoL than the other patients in our study, regarding all components of SQLS-R4. In addition, a lower number of hospital admissions predicted a better QoL. Zhou et al. (2024) reported findings consistent with ours concerning age at illness onset but not number of hospitalizations [85]. Age at illness onset is of outmost importance in understanding the course of schizophrenia. It significantly influences the course of the illness, with early onset being associated with a more severe prognosis, including more negative symptoms, lower educational attainment, reduced employability, impaired social functioning and a poorer global outcome [86]. These observations might explain our results where a younger age at onset was related to worse QoL even though other studies provide different results [87]. The number of hospitalizations is viewed as a proxy of clinical and functional outcomes, which intersects with concepts such as quality of life and recovery [88]. Using SQLS-R4, Taha et al. (2024) and Kuo et al. (2009) observed that patients with a higher level of education had a poorer global QoL [89,90], and Arraras et al. (2018) found that unemployment was associated with lower QoL in the vitality and cognition domain [49]. We might have not obtained similar results due to the high proportion of patients in our research receiving a disability pension (80.6%) and having 9–12 years of education (81.3%). Other studies failed to show an association between socio-demographic or clinical variables and SQLS-R4 global and/or sub-domain scores [48,50].

4.2. Psychosocial Variables and Quality of Life

In the present research, internalised stigma was observed to be correlated with QoL in all domains and, furthermore, to be a predictor of QoL. More precisely, high levels of internalised stigma predicted a poorer global and cognition and vitality QoL. This association aligns with a prior, very limited, body of research utilizing SQLS-R4 to assess QoL, which documented an inverse relationship between QoL and internalised stigma as well as internalised stigma as a predictor of QoL [29,31,50]. These findings were confirmed by a meta-analysis which included studies carried out using SQLS-R4 or SQLS [27]. The explanation for our results derives from data showing that self-stigma affects one’s sense of self (self-esteem and self-efficacy) [91]. Morgades-Bamba et al. (2019) and Kim et al. (2019) showed that internalised stigma decreases QoL through lowering the positive self-concept (i.e., self-esteem) [31,92]. Moreover, self-prejudice and self-discrimination lead not only to a negative emotional reaction (i.e., lower self-esteem) but also to a negative behavioural response (e.g., neglecting to seek employment or housing opportunities and becoming socially isolated) that interferes with QoL [93]. These observations also align with our findings on the influence of self-esteem on quality of life. Specifically, our study demonstrated that lower self-esteem is associated with poorer quality of life in all aspects and identified self-esteem as an independent predictor of life satisfaction. Studies by Morgades-Bamba et al. (2019), Kim et al. (2019) and Lien et al. (2018) using SQLS-R4 or SQLS have demonstrated similar results [31,92,94]. In addition, a recent meta-analysis showed that there is a strong negative correlation between self-esteem and QoL in individuals with schizophrenia spectrum disorders [28]. However, one possible explanation for our results could be the overlap between the construct of the SQLSR4 psychosocial domain and Rosenberg Self-Esteem scale [79].
Current theories suggest that coping with life stress strategies employed by persons with schizophrenia influence their QoL [46,95]. Patients with schizophrenia have been observed to be more likely to adopt maladaptive or negative coping strategies, exhibit a lower use of adaptive coping, or perceive their coping strategies as less effective than healthy controls [43,96,97,98,99]. Holubova et al. (2015) identified a correlation between negative coping strategies and poorer overall quality of life in patients with schizophrenia, as well as specific quality of life subdomains, including physical health, emotional well-being, work and social activities [43]. Ritsner et al. (2003b) and Montemagni et al. (2014) showed that a social diversion coping strategy (i.e., strategy based on seeking social support) positively influenced QoL [45,100], with coping accounting for up to 25% in the variance of QoL [100]. Navarro et al. (2018) revealed that problem-focused coping (i.e., planning, active coping and suppression of competing activities, which are considered adaptive), but not avoidance coping (i.e., behavioural disengagement, denial, substance use and mental disengagement, which are considered maladaptive), predicted QoL (i.e., physical, psychological and environmental QoL domains) [101]. In contrast, Bechdolf et al. (2003) showed that negative coping (i.e., social withdrawal, resignation and self-pity) was a predictor of poorer QoL [40]. Our results are in agreement with previous data and show that use of maladaptive coping strategies (i.e., mental disengagement, denial, behavioural disengagement and alcohol–drug use) was associated with poorer global and psychosocial QoL. Future studies assessing coping strategies in persons with schizophrenia could shed more light on the relationship between coping and QoL.
The social support of schizophrenia patients became of great interest after the deinstitutionalization process, being instrumental to the successful adaptation of patients in the community and rehabilitation [102]. Additionally, social support is believed to act as a buffer between the patient and various stressors, playing a significant role in the vulnerability–stress model of disease [37]. Unfortunately, perceived social support is not well studied in schizophrenia patients. Munikanan et al. (2017) researched the impact of perceived social support measured using the MSPSS on QoL. It was reported that perceived social support predicted better QoL in all domains (i.e., physical, psychological, social and environmental) [38]. Similar results were observed by other researchers [16,39,40,103]. In addition, Ritsner et al. (2012) showed that an increase in the perceived support from a significant other or friends predicted better QoL over a 10-year follow-up period [34]. Our findings provide evidence in line with previous research and show that perceived social support was associated with all domains of quality of life and demonstrated predictive ability for overall QoL and, of course, the psychosocial domain. Specifically, higher levels of perceived social support were linked to improved quality of life.
Adherence to antipsychotic medication is a challenging issue in schizophrenia and has an important impact on the course of illness. Non-adherence leads to relapse and frequent hospitalizations, which corresponds to worse functional outcomes and delayed recovery [104,105,106,107]. Yu et al. (2021) found that both the psychosocial and cognition and vitality domains were influenced by treatment adherence, measured using MARS [108]. Other researchers found that adherence to medication was a predictor of better QoL [13,106], but results at difference with this are reported in the current literature [109]. Moreover, improvement in QoL over the course of one year was predicted by improvement in treatment adherence [14]. In our study, the MARS score was not a predictor of QoL, but we found a significant negative relationship between the SQLS vitality and cognition score and MARS score, meaning that better adherence to treatment is associated with better QoL. An explanation for our results comes from the inclusion of chronic community dwelling schizophrenia patients, who demonstrated strong adherence to the prescribed treatment.

4.3. Implications for Future Practice and Study Limitations

Our findings have important implications for outpatient care in schizophrenia. Our results support the need for tailored psychosocial interventions alongside antipsychotic therapy in order to improve QoL, which is increasingly recognized as a key treatment outcome in outpatients with schizophrenia. The majority of psychosocial interventions have been primarily focused on symptom reduction or functioning and overshadowed the importance of QoL and well-being [110,111]. Improving QoL in people with schizophrenia by incorporating psychological interventions successfully proven to reduce self-stigma and improve treatment adherence is recommended [112]. In this regard, Sibitz et al. (2013) showed that a recovery-oriented programme that covered self-stigma and compliance to treatment aspects had a positive impact on QoL as well [113].
Even though our study contributes to the current understanding of predictors of QoL in patients with schizophrenia, it has several limitations that should be acknowledged. Firstly, the number of patients included is relatively low, and studies with larger samples are warranted in order to confirm our results. Also, our study included stable outpatients, thus the results lack generalizability to patients treated in other settings. Another limitation is that symptom severity, which may affect QoL, was not evaluated; however, our study focused on exploring demographic and psychosocial aspects involved in shaping QoL. Fourthly, this researched was carried out using a cross-sectional design, thus it prevented us from establishing causal relationships between variables. Also, SQLSR4 had moderate to good correlations with the Rosenberg Self-Esteem scale, which indicates several construct similarities despite their distinctive purposes; therefore, this might be another limitation of this study. Finally, we used a subjective assessment of QoL, thus objective measures could lead to different results.

5. Conclusions

Our study acknowledges self-esteem, perceived social support and internalised stigma as the most important psychosocial variables that affect subjective QoL in patients with schizophrenia. More precisely, 44.9% in the variance in QoL was predicted by these factors, alongside the number of previous hospitalizations. Since psychosocial interventions have been found to be superior in improving QoL in comparison to antipsychotic treatment alone [114], comprehensive assessment of patients suffering from schizophrenia and then addressing these aspects through integrated and tailored psychosocial therapies seems the most promising measure to improve patients’ QoL.

Author Contributions

Conceptualization, C.G., V.D.; methodology, V.D.; validation, C.G., V.D.; formal analysis, V.D.; investigation, C.G.; resources, C.G., M.C.M., and V.D.; data curation, V.D.; writing—original draft preparation, C.G., V.D.; writing—review and editing, V.D., M.C.M., D.C.M. and M.M.; visualization, C.G.; supervision, M.M.; project administration, C.G. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee of “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry (approval no.90/07.06.2022).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data presented in this study are available on reasonable request from the corresponding author. The data are not publicly available due to ethical and institutional reasons.

Acknowledgments

Publication of this paper was supported by the University of Medicine and Pharmacy Carol Davila, through the institutional program Publish not Perish. We would like to express our gratitude to Mapi Research Trust, Lyon, France for granting permission to use the Romanian version of Schizophrenia Quality of Life Scale Revision 4. Also, the research team acknowledges Katherine Thompson for allowing the use of Medication Adherence Rating Scale.

Conflicts of Interest

The authors declare no conflicts of interest.

References

  1. Lungu, P.F.; Lungu, C.-M.; Ciobîcă, A.; Balmus, I.M.; Boloș, A.; Dobrin, R.; Luca, A.C. Metacognition in Schizophrenia Spectrum Disorders—Current Methods and Approaches. Brain Sci. 2023, 13, 1004. [Google Scholar] [CrossRef] [PubMed]
  2. Marder, S.R.; Cannon, T.D. Schizophrenia. N. Engl. J. Med. 2019, 381, 1753–1761. [Google Scholar] [CrossRef] [PubMed]
  3. Oprea, D.C.; Mawas, I.; Moroșan, C.A.; Iacob, V.T.; Cămănaru, E.M.; Cristofor, A.C.; Dobrin, R.P.; Gireadă, B.; Petrariu, F.D.; Chiriță, R. A Systematic Review of the Effects of EEG Neurofeedback on Patients with Schizophrenia. J. Pers. Med. 2024, 14, 763. [Google Scholar] [CrossRef] [PubMed]
  4. Chaiyakunapruk, N.; Chong, H.Y.; Teoh, S.L.; Wu, D.B.-C.; Kotirum, S.; Chiou, C.-F. Global Economic Burden of Schizophrenia: A Systematic Review. Neuropsychiatr. Dis. Treat. 2016, 2016, 357–373. [Google Scholar] [CrossRef]
  5. Harvey, P.D.; Strassnig, M.T.; Silberstein, J. Prediction of Disability in Schizophrenia: Symptoms, Cognition, and Self-Assessment. J. Exp. Psychopathol. 2019, 10, 1–20. [Google Scholar] [CrossRef]
  6. Dong, M.; Lu, L.; Zhang, L.; Zhang, Y.-S.; Ng, C.H.; Ungvari, G.S.; Li, G.; Meng, X.; Wang, G.; Xiang, Y.-T. Quality of Life in Schizophrenia: A Meta-Analysis of Comparative Studies. Psychiatr. Q. 2019, 90, 519–532. [Google Scholar] [CrossRef]
  7. THE WHOQOL GROUP. Development of the World Health Organization WHOQOL-BREF Quality of Life Assessment. Psychol. Med. 1998, 28, 551–558. [Google Scholar] [CrossRef]
  8. Ritsner, M.S. The Distress/Protection Vulnerability Model of Quality of Life Impairment Syndrome. In Quality of Life Impairment in Schizophrenia, Mood and Anxiety Disorders New Perspectives on Research and Treatment; Ritsner, M.S., Awad, G.A., Eds.; Springer: Dordrecht, The Netherlands, 2007; pp. 3–20. [Google Scholar]
  9. Ritsner, M.A.; Gibel, A. Quality of Life Impairment Syndrome in Schizophrenia. In Quality of Life Impairment in Schizophrenia, Mood and Anxiety Disorders New Perspectives on Research and Treatment; Ritsner, M.A., Awad, G.A., Eds.; Springer: Dordrecht, The Netherlands, 2007; pp. 173–226. [Google Scholar]
  10. Eack, S.M.; Newhill, C.E. Psychiatric Symptoms and Quality of Life in Schizophrenia: A Meta-Analysis. Schizophr. Bull. 2007, 33, 1225–1237. [Google Scholar] [CrossRef]
  11. de Pinho, L.M.G.; Pereira, A.M.S.; Chaves, C.M.C.B.; Batista, P. Quality of Life Scale and Symptomatology of Schizophrenic Patients—A Systematic Review. Eur. J. Psychiatry 2018, 32, 1–10. [Google Scholar] [CrossRef]
  12. Faulkner, G.; Cohn, T.; Remington, G.; Irving, H. Body Mass Index, Waist Circumference and Quality of Life in Individuals with Schizophrenia. Schizophr. Res. 2007, 90, 174–178. [Google Scholar] [CrossRef]
  13. Caqueo-Urízar, A.; Urzúa, A.; Mena-Chamorro, P.; Fond, G.; Boyer, L. Adherence to Antipsychotic Medication and Quality of Life in Latin-American Patients Diagnosed with Schizophrenia. Patient Prefer. Adherence 2020, 14, 1595–1604. [Google Scholar] [CrossRef] [PubMed]
  14. Hayhurst, K.P.; Drake, R.J.; Massie, J.A.; Dunn, G.; Barnes, T.R.E.; Jones, P.B.; Lewis, S.W. Improved Quality of Life over One Year Is Associated with Improved Adherence in Patients with Schizophrenia. Eur. Psychiatry 2014, 29, 191–196. [Google Scholar] [CrossRef]
  15. Desalegn, D.; Girma, S.; Abdeta, T. Quality of Life and Its Association with Psychiatric Symptoms and Socio-Demographic Characteristics among People with Schizophrenia: A Hospital-Based Cross-Sectional Study. PLoS ONE 2020, 15, e0229514. [Google Scholar] [CrossRef] [PubMed]
  16. Choo, C.C.; Chew, P.K.H.; Ho, C.S.; Ho, R.C. Prediction of Quality of Life in Asian Patients with Schizophrenia: A Cross-Sectional Pilot Study. Front. Psychiatry 2017, 8, 198. [Google Scholar] [CrossRef] [PubMed]
  17. Chou, C.-Y.; Ma, M.-C.; Yang, T.-T. Determinants of Subjective Health-Related Quality of Life (HRQoL) for Patients with Schizophrenia. Schizophr. Res. 2014, 154, 83–88. [Google Scholar] [CrossRef] [PubMed]
  18. Fujimaki, K.; Morinobu, S.; Yamashita, H.; Takahashi, T.; Yamawaki, S. Predictors of Quality of Life in Inpatients with Schizophrenia. Psychiatry Res. 2012, 197, 199–205. [Google Scholar] [CrossRef]
  19. Boyer, L.; Aghababian, V.; Richieri, R.; Loundou, A.; Padovani, R.; Simeoni, M.C.; Auquier, P.; Lançon, C. Insight into Illness, Neurocognition and Quality of Life in Schizophrenia. Prog. Neuropsychopharmacol. Biol. Psychiatry 2012, 36, 271–276. [Google Scholar] [CrossRef]
  20. Xiang, Y.-T.; Wang, C.-Y.; Wang, Y.; Chiu, H.F.K.; Zhao, J.-P.; Chen, Q.; Chan, S.S.M.; Lee, E.H.M.; Ungvari, G.S. Socio-Demographic and Clinical Determinants of Quality of Life in Chinese Patients with Schizophrenia: A Prospective Study. Qual. Life Res. 2010, 19, 317–322. [Google Scholar] [CrossRef]
  21. Hasan, A.A.; Tumah, H. Determinants of Quality of Life among People Diagnosed with Schizophrenia at Outpatient Clinics. Perspect. Psychiatr. Care 2019, 55, 30–39. [Google Scholar] [CrossRef]
  22. Caron, J.; Mercier, C.; Diaz, P.; Martin, A. Socio-Demographic and Clinical Predictors of Quality of Life in Patients with Schizophrenia or Schizo-Affective Disorder. Psychiatry Res. 2005, 137, 203–213. [Google Scholar] [CrossRef]
  23. Narvaez, J.M.; Twamley, E.W.; McKibbin, C.L.; Heaton, R.K.; Patterson, T.L. Subjective and Objective Quality of Life in Schizophrenia. Schizophr. Res. 2008, 98, 201–208. [Google Scholar] [CrossRef] [PubMed]
  24. Lim, M.W.Z.; Lee, J. Determinants of Health-Related Quality of Life in Schizophrenia: Beyond the Medical Model. Front. Psychiatry 2018, 9, 712. [Google Scholar] [CrossRef] [PubMed]
  25. Fervaha, G.; Agid, O.; Takeuchi, H.; Foussias, G.; Remington, G. Clinical Determinants of Life Satisfaction in Chronic Schizophrenia: Data from the CATIE Study. Schizophr. Res. 2013, 151, 203–208. [Google Scholar] [CrossRef] [PubMed]
  26. Ho, W.W.; Chiu, M.Y.; Lo, W.T.; Yiu, M.G. Recovery Components as Determinants of the Health-Related Quality of Life Among Patients with Schizophrenia: Structural Equation Modelling Analysis. Aust. N. Z. J. Psychiatry 2010, 44, 71–84. [Google Scholar] [CrossRef] [PubMed]
  27. Degnan, A.; Berry, K.; Humphrey, C.; Bucci, S. The Relationship between Stigma and Subjective Quality of Life in Psychosis: A Systematic Review and Meta-Analysis. Clin. Psychol. Rev. 2021, 85, 102003. [Google Scholar] [CrossRef]
  28. Sarraf, L.; Lepage, M.; Sauvé, G. The Clinical and Psychosocial Correlates of Self-Stigma among People with Schizophrenia Spectrum Disorders across Cultures: A Systematic Review and Meta-Analysis. Schizophr. Res. 2022, 248, 64–78. [Google Scholar] [CrossRef]
  29. Lien, Y.-J.; Chang, H.-A.; Kao, Y.-C.; Tzeng, N.-S.; Lu, C.-W.; Loh, C.-H. The Impact of Cognitive Insight, Self-Stigma, and Medication Compliance on the Quality of Life in Patients with Schizophrenia. Eur. Arch. Psychiatry Clin. Neurosci. 2018, 268, 27–38. [Google Scholar] [CrossRef]
  30. Kunikata, H.; Mino, Y.; Nakajima, K. Quality of Life of Schizophrenic Patients Living in the Community: The Relationships with Personal Characteristics, Objective Indicators and Self-esteem. Psychiatry Clin. Neurosci. 2005, 59, 163–169. [Google Scholar] [CrossRef]
  31. Kim, E.Y.; Jang, M.H. The Mediating Effects of Self-Esteem and Resilience on the Relationship Between Internalized Stigma and Quality of Life in People with Schizophrenia. Asian Nurs. Res. (Korean Soc. Nurs. Sci.) 2019, 13, 257–263. [Google Scholar] [CrossRef]
  32. Degnan, A.; Berry, K.; Sweet, D.; Abel, K.; Crossley, N.; Edge, D. Social Networks and Symptomatic and Functional Outcomes in Schizophrenia: A Systematic Review and Meta-Analysis. Soc. Psychiatry Psychiatr. Epidemiol. 2018, 53, 873–888. [Google Scholar] [CrossRef]
  33. Ritsner, M. Predicting Changes in Domain-Specific Quality of Life of Schizophrenia Patients. J. Nerv. Ment. Dis. 2003, 191, 287–294. [Google Scholar] [CrossRef] [PubMed]
  34. Ritsner, M.S.; Arbitman, M.; Lisker, A.; Ponizovsky, A.M. Ten-Year Quality of Life Outcomes among Patients with Schizophrenia and Schizoaffective Disorder II. Predictive Value of Psychosocial Factors. Qual. Life Res. 2012, 21, 1075–1084. [Google Scholar] [CrossRef] [PubMed]
  35. Fan, C.-H.; Hsu, S.-C.; Hsiao, F.-H.; Chang, C.-M.; Liu, C.-Y.; Lai, Y.-M.; Chen, Y.-T. The Association of Social Support and Symptomatic Remission among Community-Dwelling Schizophrenia Patients: A Cross-Sectional Study. Int. J. Env. Res. Public Health 2021, 18, 3977. [Google Scholar] [CrossRef] [PubMed]
  36. Norman, R.M.G.; Malla, A.K.; Manchanda, R.; Harricharan, R.; Takhar, J.; Northcott, S. Social Support and Three-Year Symptom and Admission Outcomes for First Episode Psychosis. Schizophr. Res. 2005, 80, 227–234. [Google Scholar] [CrossRef]
  37. Vázquez Morejón, A.J.; León Rubio, J.M.; Vázquez-Morejón, R. Social Support and Clinical and Functional Outcome in People with Schizophrenia. Int. J. Soc. Psychiatry 2018, 64, 488–496. [Google Scholar] [CrossRef]
  38. Munikanan, T.; Midin, M.; Daud, T.I.M.; Rahim, R.A.; Bakar, A.K.A.; Jaafar, N.R.N.; Sidi, H.; Baharuddin, N. Association of Social Support and Quality of Life among People with Schizophrenia Receiving Community Psychiatric Service: A Cross-Sectional Study. Compr. Psychiatry 2017, 75, 94–102. [Google Scholar] [CrossRef]
  39. Chen, J.; Song, H.; Li, S.; Teng, Z.; Su, Y.; Chen, J.; Huang, J. Social Support and Quality of Life among Chronically Homeless Patients with Schizophrenia. Front. Psychiatry 2022, 13, 928960. [Google Scholar] [CrossRef]
  40. Bechdolf, A.; Klosterkötter, J.; Hambrecht, M.; Knost, B.; Kuntermann, C.; Schiller, S.; Pukrop, R. Determinants of Subjective Quality of Life in Post Acute Patients with Schizophrenia. Eur. Arch. Psychiatry Clin. Neurosci. 2003, 253, 228–235. [Google Scholar] [CrossRef]
  41. Yeo, J.J.; Chew, Q.H.; Sim, K. Resilience and Its Inter-relationship with Symptomatology, Illness Course, Psychosocial Functioning, and Mediational Roles in Schizophrenia: A Systematic Review. Asia-Pac. Psychiatry 2022, 14, e12486. [Google Scholar] [CrossRef]
  42. Wambua, G.N.; Kilian, S.; Ntlantsana, V.; Chiliza, B. The Association between Resilience and Psychosocial Functioning in Schizophrenia: A Systematic Review and Meta-Analysis. Psychiatry Res. 2020, 293, 113374. [Google Scholar] [CrossRef]
  43. Holubova, M.; Prasko, J.; Hruby, R.; Kamaradova, D.; Ociskova, M.; Latalova, K.; Grambal, A. Coping Strategies and Quality of Life in Schizophrenia: Cross-Sectional Study. Neuropsychiatr. Dis. Treat. 2015, 11, 3041–3048. [Google Scholar] [CrossRef]
  44. Kao, Y.-C.; Lien, Y.-J.; Chang, H.-A.; Tzeng, N.-S.; Yeh, C.-B.; Loh, C.-H. Stigma Resistance in Stable Schizophrenia: The Relative Contributions of Stereotype Endorsement, Self-Reflection, Self-Esteem, and Coping Styles. Can. J. Psychiatry 2017, 62, 735–744. [Google Scholar] [CrossRef] [PubMed]
  45. Montemagni, C.; Castagna, F.; Crivelli, B.; De Marzi, G.; Frieri, T.; Macrì, A.; Rocca, P. Relative Contributions of Negative Symptoms, Insight, and Coping Strategies to Quality of Life in Stable Schizophrenia. Psychiatry Res. 2014, 220, 102–111. [Google Scholar] [CrossRef] [PubMed]
  46. Yanos, P.T.; Moos, R.H. Determinants of Functioning and Well-Being among Individuals with Schizophrenia: An Integrated Model. Clin. Psychol. Rev. 2007, 27, 58–77. [Google Scholar] [CrossRef] [PubMed]
  47. Martin, C.R.; Allan, R. Factor Structure of the Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4). Psychol. Health Med. 2007, 12, 126–134. [Google Scholar] [CrossRef] [PubMed]
  48. Kim, J.-H.; Lee, S.; Han, A.-Y.; Kim, K.; Lee, J. Relationship between Cognitive Insight and Subjective Quality of Life in Outpatients with Schizophrenia. Neuropsychiatr. Dis. Treat. 2015, 2015, 2041–2048. [Google Scholar] [CrossRef]
  49. Arraras, J.I.; Ibañez, B.; Basterra, I.; Pereda, N.; Martin, M.; Iribarren, S. Determinants of Quality of Life in Spanish Outpatients with Schizophrenia Spectrum Disorders. Eur. J. Psychiatry 2018, 32, 113–121. [Google Scholar] [CrossRef]
  50. Shin, Y.-J.; Joo, Y.-H.; Kim, J.-H. Self-Perceived Cognitive Deficits and Their Relationship with Internalized Stigma and Quality of Life in Patients with Schizophrenia. Neuropsychiatr. Dis. Treat. 2016, 12, 1411–1417. [Google Scholar] [CrossRef]
  51. Isjanovski, V.; Naumovska, A.; Bonevski, D.; Novotni, A. Validation of the Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4) Among Patients with Schizophrenia. Open Access Maced. J. Med. Sci. 2016, 4, 65–69. [Google Scholar] [CrossRef]
  52. Arraras, J.; Basterra, I.; Pereda, N.; Ibañez, B.; Iribarren, S.; Cabases, J. The Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4) Questionnaire. A Validation Study with Spanish Schizophrenia Spectrum Outpatients. Actas Españolas Psiquiatr. 2019, 47, 97–109. [Google Scholar]
  53. Kuo, P.-J.; Chen-Sea, M.-J.; Lu, R.-B.; Chung, M.-S.; Kuo, C.-C.; Huang, W.-C.; Ma, H.-I. Validation of the Chinese Version of the Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4) in Taiwanese Patients with Schizophrenia. Qual. Life Res. 2007, 16, 1533–1538. [Google Scholar] [CrossRef] [PubMed]
  54. Taha, N.A.; Ibrahim, M.I.; Rahman, A.F.; Shafie, A.A.; Rahman, A.H. Validation of the Schizophrenia Quality of Life Scale Revision 4 among Chronic Schizophrenia Patients in Malaysia. Value Health Reg. Issues 2012, 1, 82–86. [Google Scholar] [CrossRef] [PubMed]
  55. Boyd Ritsher, J.; Otilingam, P.G.; Grajales, M. Internalized Stigma of Mental Illness: Psychometric Properties of a New Measure. Psychiatry Res. 2003, 121, 31–49. [Google Scholar] [CrossRef] [PubMed]
  56. Căpățână, O.; Micluția, I. Internalized Stigma as a Predictor of Quality of Life in Schizophrenia. J. Evid. Based Psychother. 2018, 18, 35–53. [Google Scholar] [CrossRef]
  57. Boyd, J.E.; Adler, E.P.; Otilingam, P.G.; Peters, T. Internalized Stigma of Mental Illness (ISMI) Scale: A Multinational Review. Compr. Psychiatry 2014, 55, 221–231. [Google Scholar] [CrossRef]
  58. Brohan, E.; Gauci, D.; Sartorius, N.; Thornicroft, G. Self-Stigma, Empowerment and Perceived Discrimination among People with Bipolar Disorder or Depression in 13 European Countries: The GAMIAN–Europe Study. J. Affect. Disord. 2011, 129, 56–63. [Google Scholar] [CrossRef]
  59. Carver, C.S.; Scheier, M.F.; Weintraub, J.K. Assessing Coping Strategies: A Theoretically Based Approach. J. Pers. Soc. Psychol. 1989, 56, 267–283. [Google Scholar] [CrossRef] [PubMed]
  60. Băban, A. Stres Și Personalitate; Presa Universitara Clujeană: Cluj-Napoca, Romania, 1998. [Google Scholar]
  61. Crașovan, D.I.; Sava, F.A. Translation, Adaptation, and Validation on Romanian Population of Cope Questionnaire for Coping Mechanisms Analysis. Cogn. Brain Behav. 2013, XVII, 61–76. [Google Scholar]
  62. Premkumar, P.; Peters, E.R.; Fannon, D.; Anilkumar, A.P.; Kuipers, E.; Kumari, V. Coping Styles Predict Responsiveness to Cognitive Behaviour Therapy in Psychosis. Psychiatry Res. 2011, 187, 354–362. [Google Scholar] [CrossRef]
  63. Cooke, M.; Peters, E.; Fannon, D.; Anilkumar, A.P.P.; Aasen, I.; Kuipers, E.; Kumari, V. Insight, Distress and Coping Styles in Schizophrenia. Schizophr. Res. 2007, 94, 12–22. [Google Scholar] [CrossRef]
  64. Zimet, G.D.; Dahlem, N.W.; Zimet, S.G.; Farley, G.K. The Multidimensional Scale of Perceived Social Support. J. Pers. Assess. 1988, 52, 30–41. [Google Scholar] [CrossRef]
  65. Zimet, G.D.; Powell, S.S.; Farley, G.K.; Werkman, S.; Berkoff, K.A. Psychometric Characteristics of the Multidimensional Scale of Perceived Social Support. J. Pers. Assess. 1990, 55, 610–617. [Google Scholar] [CrossRef] [PubMed]
  66. Robu, V.; Sandovici, A.; Ciudin, M. Measuring Perceived Social Support in Romanian Adolescents: Psychometric Properties of the Multidimensional Scale of Perceived Social Support. J. Innov. Psychol. Educ. Didact. 2020, 24, 65–90. [Google Scholar]
  67. Alexe, D.I.; Sandovici, A.; Robu, V.; Burgueño, R.; Tohănean, D.I.; Larion, A.C.; Alexe, C.I. Measuring Perceived Social Support in Elite Athletes: Psychometric Properties of the Romanian Version of the Multidimensional Scale of Perceived Social Support. Percept. Mot. Ski. 2021, 128, 1197–1214. [Google Scholar] [CrossRef] [PubMed]
  68. Vaingankar, J.A.; Abdin, E.; Chong, S.A. Exploratory and Confirmatory Factor Analyses of the Multidimensional Scale of Perceived Social Support in Patients with Schizophrenia. Compr. Psychiatry 2012, 53, 286–291. [Google Scholar] [CrossRef]
  69. Rosenberg, M. Conceiving the Self; Basic Books: New York, NY, USA, 1979. [Google Scholar]
  70. Moritz, S.; Veckenstedt, R.; Randjbar, S.; Vitzthum, F.; Karow, A.; Lincoln, T.M. Course and Determinants of Self-esteem in People Diagnosed with Schizophrenia during Psychiatric Treatment. Psychosis 2010, 2, 144–153. [Google Scholar] [CrossRef]
  71. Haug, E.; Øie, M.G.; Andreassen, O.A.; Bratlien, U.; Romm, K.L.; Møller, P.; Melle, I. The Association between Anomalous Self-Experiences, Self-Esteem and Depressive Symptoms in First Episode Schizophrenia. Front. Hum. Neurosci. 2016, 10, 557. [Google Scholar] [CrossRef]
  72. Smith, B.W.; Dalen, J.; Wiggins, K.; Tooley, E.; Christopher, P.; Bernard, J. The Brief Resilience Scale: Assessing the Ability to Bounce Back. Int. J. Behav. Med. 2008, 15, 194–200. [Google Scholar] [CrossRef]
  73. Sánchez, J.; Estrada-Hernández, N.; Booth, J.; Pan, D. Factor Structure, Internal Reliability, and Construct Validity of the Brief Resilience Scale (BRS): A Study on Persons with Serious Mental Illness Living in the Community. Psychol. Psychother. Theory Res. Pract. 2021, 94, 620–645. [Google Scholar] [CrossRef]
  74. Macovei, C. The Brief Resilience Scale-a Romanian-Language Adaptation. Agora Psycho-Pragmatica 2015, 9, 70–87. [Google Scholar]
  75. Stănculescu, E. Fear of COVID-19 in Romania: Validation of the Romanian Version of the Fear of COVID-19 Scale Using Graded Response Model Analysis. Int. J. Ment. Health Addict. 2022, 20, 1094–1109. [Google Scholar] [CrossRef] [PubMed]
  76. Stănculescu, E.; Roskam, I.; Mikolajczak, M.; Muntean, A.; Gurza, A. Parental Burnout in Romania: Validity of the Romanian Version of the Parental Burnout Assessment (PBA-RO). New Dir. Child. Adolesc. Dev. 2020, 2020, 119–136. [Google Scholar] [CrossRef]
  77. Thompson, K.; Kulkarni, J.; Sergejew, A.A. Reliability and Validity of a New Medication Adherence Rating Scale (MARS) for the Psychoses. Schizophr. Res. 2000, 42, 241–247. [Google Scholar] [CrossRef] [PubMed]
  78. Rofail, D.; Regnault, A.; le Scouiller, S.; Berardo, C.G.; Umbricht, D.; Fitzpatrick, R. Health-Related Quality of Life in Patients with Prominent Negative Symptoms: Results from a Multicenter Randomized Phase II Trial on Bitopertin. Qual. Life Res. 2016, 25, 201–211. [Google Scholar] [CrossRef] [PubMed]
  79. Chou, C.-Y.; Yang, T.-T.; Ma, M.-C.; Teng, P.-R.; Cheng, T.-C. Psychometric Validations and Comparisons of Schizophrenia-Specific Health-Related Quality of Life Measures. Psychiatry Res. 2015, 226, 257–263. [Google Scholar] [CrossRef] [PubMed]
  80. Hoseinipalangi, Z.; Golmohammadi, Z.; Rafiei, S.; Pashazadeh Kan, F.; Hosseinifard, H.; Rezaei, S.; Ahmadi, S.; Ahmadi, N.; Raoofi, S.; Aghajani, F.; et al. Global Health-Related Quality of Life in Schizophrenia: Systematic Review and Meta-Analysis. BMJ Support. Palliat. Care 2022, 12, 123–131. [Google Scholar] [CrossRef]
  81. Domenech, C.; Pastore, A.; Altamura, A.C.; Bernasconi, C.; Corral, R.; Elkis, H.; Evans, J.; Malla, A.; Margari, F.; Krebs, M.-O.; et al. Correlation of Health-Related Quality of Life in Clinically Stable Outpatients with Schizophrenia. Neuropsychiatr. Dis. Treat. 2019, 15, 3475–3486. [Google Scholar] [CrossRef]
  82. Xiang, Y.-T.; Weng, Y.-Z.; Leung, C.-M.; Tang, W.-K.; Chan, S.S.M.; Wang, C.-Y.; Han, B.; Ungvari, G.S. Gender Differences in Sociodemographic and Clinical Characteristic and the Quality of Life of Chinese Schizophrenia Patients. Aust. N. Z. J. Psychiatry 2010, 44, 450–455. [Google Scholar] [CrossRef]
  83. Shafie, S.; Samari, E.; Jeyagurunathan, A.; Abdin, E.; Chang, S.; Chong, S.A.; Subramaniam, M. Gender Difference in Quality of Life (QoL) among Outpatients with Schizophrenia in a Tertiary Care Setting. BMC Psychiatry 2021, 21, 61. [Google Scholar] [CrossRef]
  84. Zeng, Y.; Zhou, Y.; Lin, J.; Zhou, Y.; Yu, J. Generic and Disease-Specific Quality of Life and Its Predictors among Chinese Inpatients with Schizophrenia. Psychiatry Res. 2015, 228, 724–728. [Google Scholar] [CrossRef]
  85. Zhou, D.; Yang, X.; Wang, W.; Jin, W.; Tang, Y.; Zheng, Z.; Ren, Y. Exploring the Interplay of Psychiatric Symptoms, Antipsychotic Medications, Side Effects, Employment Status, and Quality of Life in Chronic Schizophrenia. BMC Psychiatry 2024, 24, 484. [Google Scholar] [CrossRef] [PubMed]
  86. Immonen, J.; Jääskeläinen, E.; Korpela, H.; Miettunen, J. Age at Onset and the Outcomes of Schizophrenia: A Systematic Review and Meta-analysis. Early Interv. Psychiatry 2017, 11, 453–460. [Google Scholar] [CrossRef] [PubMed]
  87. Rotstein, A.; Roe, D.; Gelkopf, M.; Levine, S.Z. Age of Onset and Quality of Life among Males and Females with Schizophrenia: A National Study. Eur. Psychiatry 2018, 53, 100–106. [Google Scholar] [CrossRef] [PubMed]
  88. Seeman, M.V. Does Gender Influence Outcome in Schizophrenia? Psychiatr. Q. 2019, 90, 173–184. [Google Scholar] [CrossRef] [PubMed]
  89. Kuo, P.-J.; Ma, H.-I.; Kuo, C.-C.; Huang, W.-C.; Chung, M.-S. Factor Analysis of the Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4) Chinese Version and Related Factors. Int. J. Psychiatry Clin. Pr. 2009, 13, 278–284. [Google Scholar] [CrossRef]
  90. Taha, S.M.; Abdelraof, A.I.; El-Monshed, A.H.; Amr, M.; Elhay, E.S.A. Insight and Empathy in Schizophrenia: Impact on Quality of Life and Symptom Severity. Arch. Psychiatr. Nurs. 2024, 52, 60–68. [Google Scholar] [CrossRef]
  91. Corrigan, P. How Stigma Interferes with Mental Health Care. Am. Psychol. 2004, 59, 614–625. [Google Scholar] [CrossRef]
  92. Morgades-Bamba, C.I.; Fuster-Ruizdeapodaca, M.J.; Molero, F. Internalized Stigma and Its Impact on Schizophrenia Quality of Life. Psychol. Health Med. 2019, 24, 992–1004. [Google Scholar] [CrossRef]
  93. Tang, I.-C.; Wu, H.-C. Quality of Life and Self-Stigma in Individuals with Schizophrenia. Psychiatr. Q. 2012, 83, 497–507. [Google Scholar] [CrossRef]
  94. Lien, Y.-J.; Chang, H.-A.; Kao, Y.-C.; Tzeng, N.-S.; Lu, C.-W.; Loh, C.-H. Insight, Self-Stigma and Psychosocial Outcomes in Schizophrenia: A Structural Equation Modelling Approach. Epidemiol. Psychiatr. Sci. 2018, 27, 176–185. [Google Scholar] [CrossRef]
  95. Ritsner, M.; Kurs, R. Quality of Life Outcomes in Mental Illness: Schizophrenia, Mood and Anxiety Disorders. Expert. Rev. Pharmacoecon Outcomes Res. 2003, 3, 189–199. [Google Scholar] [CrossRef] [PubMed]
  96. Martins, J.; Rudnick, A. A Re-analysis of the Relationship among Coping, Symptom Severity and Quality of Life in Schizophrenia. Schizophr. Res. 2007, 89, 355–356. [Google Scholar] [CrossRef] [PubMed]
  97. Moritz, S.; Lüdtke, T.; Westermann, S.; Hermeneit, J.; Watroba, J.; Lincoln, T.M. Dysfunctional Coping with Stress in Psychosis. An Investigation with the Maladaptive and Adaptive Coping Styles (MAX) Questionnaire. Schizophr. Res. 2016, 175, 129–135. [Google Scholar] [CrossRef] [PubMed]
  98. Phillips, L.J.; Francey, S.M.; Edwards, J.; McMurray, N. Strategies Used by Psychotic Individuals to Cope with Life Stress and Symptoms of Illness: A Systematic Review. Anxiety Stress Coping 2009, 22, 371–410. [Google Scholar] [CrossRef] [PubMed]
  99. Kommescher, M.; Wagner, M.; Pützfeld, V.; Berning, J.; Janssen, B.; Decker, P.; Bottlender, R.; Möller, H.; Gaebel, W.; Maier, W.; et al. Coping as a Predictor of Treatment Outcome in People at Clinical High Risk of Psychosis. Early Interv. Psychiatry 2016, 10, 17–27. [Google Scholar] [CrossRef]
  100. Ritsner, M.; Ben-Avi, I.; Ponizovsky, A.; Timinsky, I.; Bistrov, E.; Modai, I. Quality of Life and Coping with Schizophrenia Symptoms. Qual. Life Res. 2003, 12, 1–9. [Google Scholar] [CrossRef]
  101. López-Navarro, E.; del Canto, C.; Mayol, A.; Fernández-Alonso, O.; Munar, E. Psychotic Symptoms and Quality of Life: A Mediation Analysis of Daily-Life Coping. Psychiatry Res. 2018, 262, 505–509. [Google Scholar] [CrossRef]
  102. Clinton, M.; Lunney, P.; Edwards, H.; Weir, D.; Barr, J. Perceived Social Support and Community Adaptation in Schizophrenia. J. Adv. Nurs. 1998, 27, 955–965. [Google Scholar] [CrossRef]
  103. Xiang, Y.-T.; Hou, Y.-Z.; Yan, F.; Dixon, L.B.; Ungvari, G.S.; Dickerson, F.; Li, W.-Y.; Li, W.-X.; Zhu, Y.-L.; Chan, S.S.M.; et al. Quality of Life in Community-Dwelling Patients With Schizophrenia in China. J. Nerv. Ment. Dis. 2012, 200, 584–587. [Google Scholar] [CrossRef]
  104. Cañas, F.; Alptekin, K.; Azorin, J.M.; Dubois, V.; Emsley, R.; García, A.G.; Gorwood, P.; Haddad, P.M.; Naber, D.; Olivares, J.M.; et al. Improving Treatment Adherence in Your Patients with Schizophrenia. Clin. Drug Investig. 2013, 33, 97–107. [Google Scholar] [CrossRef]
  105. Loots, E.; Goossens, E.; Vanwesemael, T.; Morrens, M.; Van Rompaey, B.; Dilles, T. Interventions to Improve Medication Adherence in Patients with Schizophrenia or Bipolar Disorders: A Systematic Review and Meta-Analysis. Int. J. Env. Res. Public Health 2021, 18, 10213. [Google Scholar] [CrossRef]
  106. Endriyani, L.; Chien, C.; Huang, X.; Chieh-Yu, L. The Influence of Adherence to Antipsychotics Medication on the Quality of Life among Patients with Schizophrenia in Indonesia. Perspect. Psychiatr. Care 2019, 55, 147–152. [Google Scholar] [CrossRef] [PubMed]
  107. Caqueo-Urízar, A.; Urzúa, A.; Mena-Chamorro, P.; Bravo de la Fuente, J. Effects of Adherence to Pharmacological Treatment on the Recovery of Patients with Schizophrenia. Healthcare 2021, 9, 1230. [Google Scholar] [CrossRef] [PubMed]
  108. Yu, W.; Tong, J.; Sun, X.; Chen, F.; Zhang, J.; Pei, Y.; Zhang, T.; Zhang, J.; Zhu, B. Analysis of Medication Adherence and Its Influencing Factors in Patients with Schizophrenia in the Chinese Institutional Environment. Int. J. Env. Res. Public. Health 2021, 18, 4746. [Google Scholar] [CrossRef] [PubMed]
  109. Wang, X.Q.; Petrini, M.A.; Morisky, D.E. Predictors of Quality of Life among Chinese People with Schizophrenia. Nurs. Health Sci. 2017, 19, 142–148. [Google Scholar] [CrossRef] [PubMed]
  110. Puolakka, K.; Pitkänen, A. Effectiveness of Psychosocial Interventions on Quality of Life of Patients with Schizophrenia and Related Disorders: A Systematic Review. Arch. Psychiatr. Nurs. 2019, 33, 73–82. [Google Scholar] [CrossRef] [PubMed]
  111. Valiente, C.; Espinosa, R.; Trucharte, A.; Nieto, J.; Martínez-Prado, L. The Challenge of Well-Being and Quality of Life: A Meta-Analysis of Psychological Interventions in Schizophrenia. Schizophr. Res. 2019, 208, 16–24. [Google Scholar] [CrossRef]
  112. Jagan, S.; Mohd Daud, T.I.; Chia, L.C.; Saini, S.M.; Midin, M.; Eng-Teng, N.; Ratnasingam, S. Evidence for the Effectiveness of Psychological Interventions for Internalized Stigma among Adults with Schizophrenia Spectrum Disorders: A Systematic Review and Meta-Analyses. Int. J. Env. Res. Public. Health 2023, 20, 5570. [Google Scholar] [CrossRef]
  113. Sibitz, I.; Provaznikova, K.; Lipp, M.; Lakeman, R.; Amering, M. The Impact of Recovery-Oriented Day Clinic Treatment on Internalized Stigma: Preliminary Report. Psychiatry Res. 2013, 209, 326–332. [Google Scholar] [CrossRef]
  114. Guo, X.; Zhai, J.; Liu, Z.; Fang, M.; Wang, B.; Wang, C.; Hu, B.; Sun, X.; Lv, L.; Lu, Z.; et al. Effect of Antipsychotic Medication Alone vs Combined With Psychosocial Intervention on Outcomes of Early-Stage Schizophrenia. Arch. Gen. Psychiatry 2010, 67, 895. [Google Scholar] [CrossRef]
Table 1. Socio-demographic and clinical characteristics of the analysed sample and their correlations with SQLS-R4 scores.
Table 1. Socio-demographic and clinical characteristics of the analysed sample and their correlations with SQLS-R4 scores.
Patient CharacteristicsMean ± SD or N (%)SQLS-R4 GlobalSQLS-R4 PsychosocialSQLS-R4 Cognition and Vitality
Mean ± SDp
(R)		Mean ± SDp
(R)		Mean ± SDp
(R)
Age48.17 ± 10.22 0.12
(−0.132)		 0.09
(−0.145)		 0.28
(−0.091)
Gender
Female 101 (72.7%)37.39 ± 11.640.0536.50 ± 13.100.0738.76 ± 10.880.048
Male38 (27.3%)32.99 ± 12.13 32.10 ± 12.69 34.36 ± 13.32
Residence
Urban111 (79.9%)36.84 ± 12.15 0.1935.81 ± 13.560.3638.44 ± 11.480.07
Rural 2833.60 ± 10.68 33.30 ± 11.04 34.06 ± 12.19
Marital status
Single 66 (47.5%)35.81 ± 11.850.7235.49 ± 13.490.8536.91 ± 12.360.53
With partner 73 (52.5%)36.54 ±12.01 35.09 ±12.74 38.14 ± 11.15
Level of education
≤8 years20 (14.4%)35.90 ± 10.140.8735.43 ± 11.900.8036.63 ± 8.380.91
9–12 years113 (81.3%)36.11 ± 12.32 35.09 ± 13.46 37.67 ± 12.30
>12 years 6 (4.3%)38.63 ± 10.56 38.75 ± 11.06 38.46 ± 11.40
Living situation
Alone27 (19.4%)35.32 ± 11.39 0.6735.23 ± 12.670.9735.47 ± 11.160.30
With others (family, friends, partner)112 (80.6%)36.40 ± 12.06 35.32 ±13.25 38.06 ± 11.84
Professional status
Unemployed10 (7.2%)40.22 ± 6.800.4140.50 ± 7.970.4239.80 ± 7.90 0.34
Disability pension112 (80.6%)35.36 ± 12.45 34.44 ± 13.69 36.77 ± 12.05
Retirement pension 6 (4.3%)39.89 ± 11.81 36.87 ± 11.08 44.55 ± 14.25
Employed11 (7.9%)38.98 ± 9.04 38.52 ± 10.95 39.68 ± 8.90
Source of income
Personal income77 (55.4%)36.65 ± 10.960.5035.61 ± 12.610.6938.26 ± 10.08 0.29
Family support15 (10.8)38.43 ± 8.91 37.25 ± 10.66 40.25 ± 8.94
Family support and personal income 47 (33.8%)34.71 ± 14.07 37.17 ± 14.64 35.55 ± 14.57
Age at illness onset (years)24.22 ± 5.15 0.01
(−0.206)		 0.03
(−0.177)		 0.007
(−0.226)
Illness duration (years)23.95 ± 9.06 0.71
(−0.031)		 0.46
(−0.062)		 0.76 (0.026)
Time since last hospital admission (months)15.34 ± 27.12 0.778 (0.24) 0.827 (0.019) 0.727 (0.030)
Number of hospital admissions
2–565 (46.8%)32.33 ± 12.070.00031.71 ± 13.47 0.00033.28 ± 11.38 0.000
≥674 (53.2%)39.58 ± 10.73 38.46 ± 11.98 41.32 ± 10.74
BMI26.89 ± 5.95 0.70 (0.032) 0.70 (0.032) 0.75 (0.026)
Type of antipsychotic administration
Oral82 (59%)36.98 ± 11.930.6335.77 ± 13.040.8738.83 ± 11.670.24
LAI35 (25.2%)35.34 ± 10.89 34.53 ± 11.95 36.59 ± 10.74
Oral and LAI 22 (15.8%)34.60 ± 13.54 34.77 ± 15.41 34.35 ± 13.08
Type of antipsychotic
Typical 12 (8.6%)36.61 ± 10.530.9735.20 ± 12.24 0.9938.78 ± 8.78 0.78
Atypical 118 (84.9%)36.20 ± 11.53 35.28 ± 13.02 37.61 ± 11.85
Typical and atypical 9 (6.5%)35.53 ± 14.13 35.69 ± 16.50 35.25 ± 14.16
Adherence to treatment (MARS score)9.01 ± 1.13 0.18
(−0.112)		 0.40
(−0.071)		 0.049
(−0.167)
Presence of somatic comorbidities (no)
No135 (97.1%)36.18 ± 11.970.9535.33 ± 13.130.8837.49 ± 11.830.68
Yes4 (2.9%)36.55 ± 10.57 34.37 ± 13.71 39.90 ± 7.75
N, number of patients; SD, standard deviation; LAI, long-acting antipsychotic; BMI, body mass index; SQLS-R4, Schizophrenia Quality of Life Scale—Revision 4; MARS, Medication Adherence Rating Scale.
Table 2. Psychometric scales scores.
Table 2. Psychometric scales scores.
MeasureScore (Mean ± SD)
SQLS global 36.19 ± 11.90
SQLS Psychosocial35.30 ± 13.10
SQLS Cognition and Vitality37.56 ± 11.72
ISMI total 2.41 ± 0.23
MSPSS total 4.35 ± 0.70
COPE Adaptative coping2.47 ± 0.30
COPE Maladaptive coping2.07 ± 0.38
Brief Resilience Scale3.00 ± 0.20
Rosenberg Self-Esteem27.44 ± 3.16
SD, standard deviation; SQLS, Schizophrenia Quality of Life; ISMI, Internalised Stigma of Mental Illness; MSPSS, Multidimensional Scale of Perceived Social Support; COPE, Coping Orientation to Problems Experience.
Table 3. Correlations coefficients between SQLS scores and internalised stigma, social support, coping strategies, resilience and self-esteem scores.
Table 3. Correlations coefficients between SQLS scores and internalised stigma, social support, coping strategies, resilience and self-esteem scores.
SQLS Total SQLS Psychosocial SQLS Cognition and Vitality
ISMI 0.331 **0.285 **0.362 **
MSPSS−0.403 **−0.401 **−0.348 **
COPE Adaptative coping0.1040.173 *−0.028
COPE Maladaptive coping0.226 **0.276 **0.108
Brief Resilience Scale0.0300.068−0.040
Rosenberg Self-Esteem−0.615 **−0.587 **−0.575 **
SQLS, Schizophrenia Quality of Life; ISMI, Internalised Stigma of Mental Illness; MSPSS, Multidimensional Scale of Perceived Social Support; COPE, Coping Orientation to Problems Experience; *, p < 0.05; **, p < 0.01.
Table 4. Summary of models predicting quality of life: findings from the stepwise multiple linear regressions.
Table 4. Summary of models predicting quality of life: findings from the stepwise multiple linear regressions.
Independent VariableBStandard Errorβtp-ValueModel’s Proprieties
SQLS global score (dependent variable)
Rosenberg Self-Esteem−18280.265−0.486−6.8910.000adj. R2 = 0.449
p = 0.046
Number of hospital admissions4.7961.5250.2023.1460.002
ISMI6.9863.3560.1402.0810.039
MSPSS −2.4271.205−0.143−2.0130.046
SQLS psychosocial score (dependent variable)
Rosenberg Self-Esteem−2.0070.303−0.485−6.6240.000adj. R2 = 0.389
p = 0.02
MSPSS −3.5541.360−0.190−2.6130.010
Number of hospital admissions4.1641.7660.1592.3580.020
SQLS cognition and vitality score (dependent variable)
Rosenberg Self-Esteem−1.7590.251−0.047−7.0070.000adj. R2 = 0.425
p = 0.002
Number of hospital admissions5.8921.5310.2523.8480.000
ISMI 10.5633.2860.2163.2140.002
SQLS, Schizophrenia Quality of Life Scale; ISMI, Internalised Stigma of Mental Illness; MSPSS, Multidimensional Scale of Perceived Social Support; adj., adjusted.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Gagiu, C.; Dionisie, V.; Manea, M.C.; Mazilu, D.C.; Manea, M. Internalised Stigma, Self-Esteem and Perceived Social Support as Psychosocial Predictors of Quality of Life in Adult Patients with Schizophrenia. J. Clin. Med. 2024, 13, 6959. https://doi.org/10.3390/jcm13226959

AMA Style

Gagiu C, Dionisie V, Manea MC, Mazilu DC, Manea M. Internalised Stigma, Self-Esteem and Perceived Social Support as Psychosocial Predictors of Quality of Life in Adult Patients with Schizophrenia. Journal of Clinical Medicine. 2024; 13(22):6959. https://doi.org/10.3390/jcm13226959

Chicago/Turabian Style

Gagiu, Corina, Vlad Dionisie, Mihnea Costin Manea, Doina Carmen Mazilu, and Mirela Manea. 2024. "Internalised Stigma, Self-Esteem and Perceived Social Support as Psychosocial Predictors of Quality of Life in Adult Patients with Schizophrenia" Journal of Clinical Medicine 13, no. 22: 6959. https://doi.org/10.3390/jcm13226959

APA Style

Gagiu, C., Dionisie, V., Manea, M. C., Mazilu, D. C., & Manea, M. (2024). Internalised Stigma, Self-Esteem and Perceived Social Support as Psychosocial Predictors of Quality of Life in Adult Patients with Schizophrenia. Journal of Clinical Medicine, 13(22), 6959. https://doi.org/10.3390/jcm13226959

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop