CLINICAL HANDBOOK OF SCHIZOPHRENIA

57. Quality of Life 583different concepts of quality of life (Lehman, Ward, & Linn, 1982). International comparisonsindicated that differences in subjective quality-of-life domains did not correspondwith differences in the objective data. However, this is not always the case, andsubstantial differences in objective living situations were found to be related to differencesin subjective quality of life. Evidence exists of congruence at a group level betweenunemployment and homelessness, and their corresponding subjective domains, wherebythose employed and those with housing stability were found to have higher satisfactionscores in the subjective quality-of-life domains of employment (Priebe, Warner, Hubschmid,& Eckle, 1998) and accommodation (Lehman, Kernan, Deforge, & Dixon,1995), leading to higher general satisfaction with life. Also, dramatic changes in the livingsituation, such as discharge into community care after long-term hospitalization, canhave a positive effect on patients’ subjective quality of life (Priebe, Hoffmann, Isermann,& Kaiser, 2002).From an anthropological perspective, Warner (1999) suggested that the subjective–objective distinction in quality-of-life research is similar to the difference between Pike’s(1967) emic and etic units of data. For Pike, an anthropological linguist, an emic unit ofdata is something that insiders in a culture regard as being the same entity regardless ofvariation, whereas an etic unit of data is one that an outsider can objectively observe andverify. It has been postulated that “emic statements are those referring to logical systemswhose discriminations are real and significant to the actors themselves, while etic statementsdepend on distinctions judged appropriate by scientific observers” (Harris, 1968).Therefore, based on this, there is a difference between what the patient perceives is his orher quality of life (subjective indicators) and what researchers can objectively measure toassess what they believe is that patient’s quality of life (objective indicators). Researchershave indicated that whereas objective data are of immense importance for the predictionof change over time, psychological adaptation, or “response shift,” can happen in chronicillnesses such as schizophrenia, resulting in a shift in the patient’s appraisal of his or hercurrent state; thus, the patient’s responses to subjective well-being questions can changesignificantly, reducing the strength of the association between subjective assessment andobjective conditions. Psychological adaptation can also occur in the general population,for quality of life tends to be relatively stable over time and not greatly affected in thelong term by dramatic changes in life conditions. Some have argued that the most practicalinformation for portraying outcomes of mental health services may indeed be etic(e.g., does the person have accommodation?); however, to understand such data and developan intervention to change the outcome, emic data are needed (e.g., does the personwish to spend his or her income on rent?). In research, subjective indicators have becomedominant, but in clinical practice, data on both objective and subjective indicators ofquality of life are important, because they are used to provide services tailored to patients’specific needs.ASSESSMENT INSTRUMENTSA spectrum of scales, checklists, and structured and semistructured interviews assessquality of life among psychiatric patients. Measures can be classified into two groups: (1)proxy and (2) specifically designed.Proxy measures of quality of life are established psychiatric rating scales used to assessthe patient’s symptom levels, particularly symptoms of depression. Such scales havebeen used in the screening and surveillance of psychiatric disorders, particularly in studiesmapping psychiatric disorders in the community (e.g., the General Health Questionnaire;