The concept of subjective well-being (SW) in people with schizophrenia has come to the attention of clinical researchers in recent years. SW has been defined as satisfaction with the subjective aspects of one’s quality of life. Naber and colleagues (1995) argue that its importance lies in its representation of the patient’s perspective on psychiatric treatment. These authors viewed SW as mainly a state phenomenon strongly influenced by antipsychotic drug treatment and devised a research measure to quantify SW while receiving antipsychotic drugs. This was called the SWN (Subjective Well-being under Neuroleptics). Research by Naber and colleagues (e.g. Naber, 1995) suggested that treatment with oral second-generation antipsychotics (SGA) improves the patient’s subjective well-being (SWN) compared to treatment with first generation antipsychotics (FGA) due to the better subjective tolerability of the former medications. However, recent research has called into question some of the apparent advantages of SGA with respect to subjective wellbeing in general and SWN in particular. Furthermore, there is evidence that SWN tends to be relatively stable over time and might therefore have a trait-like quality. The present study aimed to compare SWN in patients with persistent psychotic disorders treated with either long-acting injectable (LAI) FGA or SGA medications. The study examined a number of variables that could influence reports of SWN, including personality traits, comorbid depression, anxiety and, stress, neurocognitive function and self-assessed global health. The stability of the SWN score over time was also investigated. Finally, the factor structure of the SWN was examined.
77 patients, 56 with schizophrenia, 19 with schizoaffective disorder, and two with bipolar disorder, taking LAI medication were assessed on a battery of questionnaires. These included SWN, personality traits, negative affect, side-effects, attitudes to adherence, insight, cognitive functioning, and psychopathology symptoms. 30 of these patients received an LAI SGA medication (predominantly risperidone), the rest received a variety of LAI FGA medications. 61 patients were additionally taking oral antipsychotic medications.
Differences in SWN associated with type of LAI medication were small and inconsistent. There were strong effects from personality traits, so that patients who were higher on extraversion, agreeableness, conscientiousness, and openness to experience and lower on neuroticism, reported higher levels of SWN. Depression, anxiety, stress, cognitive/disorganised symptoms, and side-effect severity were associated with lower SWN. Exploratory factor analysis revealed two SWN factors, one named negative SWN, strongly associated with neuroticism and depression, and to a lesser extent medication side-effects; the other named positive SWN, strongly associated with health, agreeableness, and extraversion. Regression analysis suggested that extraversion, agreeableness, depression, disorganised symptoms, and self-assessed health were independent predictors of total SWN. Performance on neurocognitive tests had modest positive associations with SWN, but these mostly became non-significant when controlling for openness to experience. Attitudes to adherence were strongly associated with insight but had little association with SWN.
With respect to stability, 21 patients completed a follow up assessment after three or more months. Changes in SWN were strongly related to changes in depression, anxiety, and to some extent side-effect severity. Most patients showed high levels of stability in their SWN scores and in depression between baseline and follow up. Improvements in some aspects of cognitive functioning, such as memory, were also evident, but these were weakly and inconsistently related to changes in SWN.
With respect to SWN, SGA medications lacked advantages over FGA in patients in long-term maintenance therapy. There were non-significant trends suggesting that long acting injectable monotherapy may be associated with better SWN than antipsychotic polypharmacy.
Patients’ SWN and hence perceived quality of life seemed to be most strongly related to depression, self-assessed global health and stable features of personality. Current psychopathology (cognitive/disorganised symptoms) was related to SWN to a lesser extent. Subjective well-being may have both a stable trait-like character due to its relationship with personality features as well as a relationship to state related factors in this population.