511791

research-article2013

ISP60710.1177/0020764013511791International Journal of Social PsychiatryYildirim et al.

E CAMDEN SCHIZOPH

Article

The relationship between working status and symptoms, quality of life and self-esteem in patients with schizophrenia in Turkey

International Journal of Social Psychiatry 2014, Vol. 60(7) 646­–655 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764013511791 isp.sagepub.com

Munevver Hacioglu Yildirim,1 Zeynep Alantar,1 and Ejder A Yildirim2

Abstract Background: Schizophrenia is a severe mental disorder with substantial socioeconomic burden associated with poorer psychosocial functioning during the course of illness. In schizophrenia patients, multiple factors play a role in occupational functioning. Aim: It was aimed to investigate the relationship between different working conditions and quality of life and self-esteem on patients with schizophrenia in Turkey. Methods: A total of 100 patients diagnosed as schizophrenic were divided into three groups: competitive working, supported working and unemployed. Results: The groups did not differ significantly with regard to psychotic symptoms, self-esteem and illness history. Working was associated with higher scores on quality of life subscales especially in supported working group, whereas unemployed patients had more depressive symptoms and autonomic drug side effects. Conclusion: Structured working programs which may improve social life of patients with schizophrenia in many aspects is warranted in Turkey. Keywords Schizophrenia, occupational functioning, self-esteem, quality of life, employment

Introduction Work functioning has a major role in one’s life and it is associated with improved psychological and physiological well-being (Chan, Reid, Roldan, Rahimi, & Pmofu, 1997). On the other hand, patients with severe mental disorders often suffer from loss of professional skills such as job seeking, selecting a job and maintaining work (Brekke, Kohrt, & Green, 2001; Massel et al., 1990). Schizophrenia is a severe mental disorder with substantial socioeconomic burden associated with poorer psychosocial functioning during the course of illness (Brekke et al., 2001; Cancro & Meyerson, 1999; Carpenter, 2006). Age of onset is usually in a period of high productivity further affecting the patients’ work functioning partially or completely and leading to increased need for care and protection (Brekke et al., 2001). In patients diagnosed as having schizophrenia, multiple factors play a role in occupational functioning (Mechanic, Bilder, & McAlpine, 2002). Previous work history is one of the most important predictors of employment outcome in people with schizophrenia (Catty et al., 2008; Marwaha & Johnson, 2004).

Some clinical features such as multiple hospitalizations and severity of negative symptoms might affect work performance negatively (Mowbray, Bybee, Harris, & McCrohan, 1995). Negative psychotic symptoms were reported to worsen patients’ ability to work by interfering with social skills, thus making adjustment to work environment even more difficult (Bond & Meyer, 1999; Lysaker, Bell, & Beam-Goulet, 1995). It has also been put 1Department

of Psychiatry, Psychotic Disorders Inpatient Clinic, Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey 2Department of Psychiatry, Psychotherapy Outpatient Clinic, Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey Corresponding author: Munevver Hacioglu Yildirim, Psychotic Disorders Inpatient Clinic, Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery [Bakırköy Ruh ve Sinir Hastalıkları Hastanesi], Bakırköy, Istanbul 34147, Turkey. Email: [email protected]

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Yildirim et al. forward that unemployment also increased abstaining from job seeking which might end up in a vicious circle further leading to aggravation of negative symptoms (Bond & Meyer, 1999; Hayes & Halford, 1996). It has been reported that depression comorbidity in schizophrenia plays a devastating role in the long-term course of disease and causes significant losses in social and professional functioning of some patients (Aydemir, Danaci, & Pırıldar, 2002; Siris et al., 2001). Self-esteem, defined as evaluations across salient attributes of one’s self or personality (Blascovich & Tomaka, 1991), is another important factor affecting the work status of patients with schizophrenia. Degree of self-esteem is associated with degree of life satisfaction of the individual (Oliver, Huxley, Bridges, & Mohamad, 1996). Bowins and Shugar (1998) suggested that self-esteem plays an important role in persistence of symptoms. It is reported that self-esteem increases with duration of work (Chandler, Meisel, Hu, McGowen, & Madison, 1997; Van Dongen, 1996). Working had a positive effect on self-esteem independently from qualification of the job performed (Van Dongen, 1996). Working status is also one of the characteristics that could determine quality of life of an individual. It has been suggested that the level of quality of life of people with schizophrenia which is already lower than that of the general population would decrease even more in the case of unemployment (Caron, Diaz, & Martin, 2005; Nordt, Müller, Rössler, & Lauber, 2007). Negative symptoms and general psychopathology measures are generally predictive for quality of life of patients with schizophrenia (Caqueo-Urízar, Gutiérrez-Maldonado, Morales, & Fernández-Dávila, 2013). Employment of the patients also depends on picking suitable working environments and determination of proper type of jobs. Work environment and work style are important variables in work adjustment of patients with mental disorders (Marwaha et al., 2009; R. A. Rosenheck & Mares, 2007). After the onset of the disease, patients with schizophrenia work in various statuses including supported work, protected work or competitive work (Catty et al., 2008). Supported employment is a welldefined approach aiming that people with disabilities could participate as much as possible in the competitive labor market, working in jobs they prefer with the level of professional help they need (Gaston & Phyllis, 2000). However, Becker (2008) defined the competitive working as part-time or full-time jobs in the community that are open to anyone and pay is at least minimum wage. The wage should be equivalent to the wage and level of benefits paid for the same work performed by other workers. Recently, interest in returning patients diagnosed with schizophrenia to the workforce by enabling them to work in competitive jobs is gradually increasing (Becker & Drake, 2001; Marwaha & Johnson, 2004; Wehman, Rewel, & Broke, 2003). Positive effects of competitive work have been discussed elsewhere with regard to disease symptoms

and quality of life (R. Rosenheck et al., 2006). On the other hand, supported work might be more useful in some conditions such as coping with drug side effects (Slade & Salkever, 2001). It has been suggested that supported employment is more effective than vocational services (Burns et al., 2007). Supported work programs are widely used for patients with schizophrenia and those with other severe mental disorders in developed countries (Drake et al., 1999; R. A. Rosenheck & Mares, 2007; Wehman & Bricout, 1999). However, in developing countries, there is limited knowledge about the relationship between symptoms, quality of life of the patients and self-esteem affecting the work life and work style in either competitive or supported work. Although the transition toward community-based mental health models is planned, mental health services are still hospital-based in Turkey. There are no systematic rehabilitation programs for patients with schizophrenia (Alatas, Karaoglan, Arslan, & Yanık, 2009). In addition to that, protected workplaces or structured supported working programs for these patients are not available. On the other hand, many persons with severe mental illnesses are already actively working in Turkey. Some of these patients work in competitive work settings and some of them work in jobs which could be classified as supported work. In Turkey as well as in other developing countries, there is a clear need for research looking into the parameters that could affect the work style and the illness, especially in working environments. The question of how work style affects patients’ signs and symptoms, course of the illness and social lives of patients still remains to be answered. Proper information related to work style and the illness will be useful to determine the characteristics of working environments and to develop programs which response the patient’s needs and abilities. In this study, we aimed to investigate the effects of such working conditions as competitive work and supported work on patients with schizophrenia who had worked before disease onset, and also to investigate the relationship between employment and positive, negative and depressive symptoms, and quality of life and self-esteem of these patients.

Method Sample Patients included in the study were aged 20–65 years and were followed up in the outpatient psychiatry units of Bakırköy Research and Training Hospital for Psychiatry and Neurology. They had presented for 1 year follow-up and had been diagnosed as having schizophrenia by at least two clinicians according to the current edition of Diagnostic and Statistical Manual of Mental Disorders (4th ed.; text rev.; DSM-IV-TR) classification (American

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Psychiatric Association (APA), 2000). Those patients who had had a work life before disease onset and patients having at least primary school education were included into the study. A total of 110 consecutive patients who met the inclusion criteria were invited to the study. Five patients who did not agree to participate in the study and five patients that did not complete the scales were excluded from the study. The patients who had mental retardation, dementia, delirium and any other amnestic disorders and those who were illiterate were not included into the study. As a result, 100 patients were enrolled. This study was approved by the institutional review board for studies on human subject. The aim and scope of the study were explained in detail and written informed consent was received from the patients who agreed to participate in the study. A working background was defined as at least 1 year work before the disease onset. Since no structured supported working programs were available in Turkey (Alatas et al., 2009), criteria for supported work in this study were constituted as follows: to be working at least 1 year under the control of a family member, a social worker or an acquaintance; demands of the patient and his or her doctor have been taken into consideration when determining the working hours; working in an area of work appropriate for work skills and functioning; working with job security and working less than 40 hours in a week. It is reported that functioning before disease onset is one of the important factors determining functioning after the disease (R. A. Rosenheck & Mares, 2007). In our sample, the common feature in unemployed patients and currently working patients was to have a positive history of work before disease onset. Patients completed the interview and questionnaires in an isolated, silent room and same order of scales applied for each patient.

Assessment tools Form including demographic and clinical features. Clinic interview form developed by the authors for this study including information related to age, gender, marital status, education, work, earning sources (handicapped salary, invalidation, retirement pay) and illness history. Positive and Negative Syndrome Scale.  This scale is developed by Kay, Fiszbein, and Opler (1987), and it is composed of total 30 items including a 7-point range severity evaluation which is applied to assess general psychopathology and to measure the levels of positive and negative symptoms. Seven items assess positive symptoms, another seven address negative symptoms and 16 items include general psychopathology symptoms; adaptation into Turkish was performed by Kostakoğlu, Batur, Tiryaki, and Gögüş (1999). The examination of internal consistency

reveals considerably high total Cronbach’s alpha values for positive syndrome, negative syndrome and general psychopathology subscales (.75, .77 and .71, respectively). In structural validity, the partial correlation quotient between positive and negative syndrome subscales was found to be inverse when controlled for the general psychopathology variable (r = −.41, p < .001). This finding indicates that the two subscales measure different symptoms clusters. The intraclass correlation quotients determined for inter-rater reliability were found to be high for positive and negative syndrome subscales and general psychopathology subscale (.97, p < .0001; .96, p < .0001; .91, p < .0001, respectively) and for the entire scale. These findings indicate that the Turkish adaptation of Positive and Negative Syndrome Scale (PANSS) can be used validly and reliably in the assessment of positive and negative syndromes and general psychopathology in Turkish schizophrenia samples. Udvalg for Kliniske Undersogelser Adverse Events Evaluation Scale.  Udvalg for Kliniske Undersogelser Adverse Events Evaluation Scale (UKU) is a 52-item scale to assess adverse events occurring due to psychotropic drug use by establishing causal relation. It has four subscales including psychological, neurological, autonomic and other adverse effects. Severity score ranges between 0 and 3 for each adverse event. This scale (UKU) was developed by Lingjaerde, Ahlfors, Bech, Dencker, and Elgen (1987). Turkish translation was used but validity and reliability study has not been performed in Turkish yet. Calgary Depression Scale in Schizophrenia.  This scale is used to evaluate patients with schizophrenia for depression and, if present, to measure the levels and change of severity in depressive symptoms (Addington, Addington, & MatickaTyndale, 1994; Addington, Addington, Maticka-Tyndale, & Joyce, 1992). It comprises total 9 items with a severity range between 0 and 3 and total point changes between 0 and 27. The cutoff score is considered to be 11/12. Turkish adaptation of the scale was performed by Aydemir, EsenDanacı, Deveci, and İçelli (2000). In the reliability study of the Turkish form, Cronbach’s alpha quotient was found to be .89, and item-total score correlation quotients were found to be between .85 and .88. Inter-rater reliability quotient was r = .96 (p < .0001). In the validity study, correlation with Hamilton Rating Scale for Depression was checked for criterion-related validity, and it was found to be significant (r = .89, p < .0001). World Health Organization Quality of Life Scale–Brief Form (WHOQOL-BREF).  WHOQOL-BREF is an assessment tool that was initially developed by WHO, for the subjective evaluation of quality of life. It comprises 26 questions in four domains including physical health, psychological health, social relationships and environment. It measures

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NCSS 2007© (NCSS-Statistical Data Analysis and Graphics Software, Kaysville, Utah, A.B.D.) program was used for statistical analysis of this study. Cronbach’s alpha coefficients were calculated to demonstrate the internal consistency of the scales at the statistical reliability analysis and all of them were found to be greater than .70. During evaluation of the data, one-way analysis of variance (ANOVA) was used in the comparison of descriptive statistical methods (mean and standard deviation) in addition to intergroup comparisons; Tukey’s multiple comparison tests were used for subgroup comparisons and chi-square test was used for comparison of quantitative data. Bonferroni correction was used for post hoc testing. Group differences among the patients were investigated with ANOVA. The statistical significance level was considered to be p < .05.

Comparison of groups in relation to demographic features was presented in Table 1. Items showing significance were further evaluated by chi-square test between two groups for these items. When the marital statuses of the patients were compared, rate of single status in unemployed group was significantly higher than in competitive working group, and married status in competitive working group was significantly higher than in unemployed group (p = .019, χ2 = 7.88). Rate of high-school education in competitive working group was significantly higher than in supported working group, and rates of primary school and university education in supported working group were significantly higher than in competitive working group (p = .049, χ2= 8.573). Patients who were seeking job were significantly higher in unemployed group and supportive working group compared to competitive working group (p = .001, χ2 = 13.05; p = .010; χ2 = 9.152). Patients’ income level in competitive working group was significantly higher than in unemployed group (p = .006, χ2 = 12.29). Rate of patients with low income level (2 Alone Family Wife and children Relatives Primary school High school Academy Absent Worker Officer Tradesmen Office staff Self-employed No Part-time Full-time 1,000 TL No Yes No Yes Typical antipsychotic Atypical antipsychotic Typical and atypical antipsychotic

Unemployed

Supported working

Competitive working

 

N

(%)

N

(%)

N

(%)

 

25 10 29 2 4

71.4% 28.6% 82.9% 5.7% 11.4%

25 5 24 5 1

83.3% 16.7% 80.0% 16.7% 3.3%

29 6 20 11 4

82.9% 17.1% 57.1% 31.4% 11.4%

χ2 = 1.86, p = .394

31 2 2 0 3 30 1 1 19 10 6 0 21 2 5 4 3 24 3 8 10 14 9 2 31 4 27 8 5

88.6% 5.7% 5.7% 0.0% 8.6% 85.7% 2.9% 2.9% 54.3% 28.6% 17.1% 0.0% 60.0% 5.7% 14.3% 11.4% 8.6% 68.6% 8.6% 22.9% 28.6% 40.0% 25.7% 5.7% 88.6% 11.4% 77.1% 22.9% 14.3%

24 3 3 0 2 23 4 1 20 5 5 0 23 2 1 3 1 23 2 5 6 17 7 0 28 2 26 4 4

80.0% 10.0% 10.0% 0.0% 6.7% 76.7% 13.3% 3.3% 66.7% 16.7% 16.7% 0.0% 76.7% 6.7% 3.3% 10.0% 3.3% 76.7% 6.7% 16.7% 20.0% 56.7% 23.3% 0.0% 93.3% 6.7% 86.7% 13.3% 13.3%

25 3 6 1 1 23 11 14 18 3 1 24 5 3 1 1 35 0 0 0 16 16 3 34 1 33 2 5

71.4% 8.6% 17.1% 2.9% 2.9% 65.7% 31.4% 0.0% 40.0% 51.4% 8.6% 2.9% 68.6% 14.3% 8.6% 2.9% 2.9% 100.0% 0.0% 0.0% 0.0% 45.7% 45.7% 8.6% 97.1% 2.9% 94.3% 5.7% 14.3%

27

77.1%

24

80.0%

29

82.9%

3

8.6%

2

6.7%

1

2.9%

χ2 = 9.87, p = .043

χ2 = 5.01, p = .543

χ2 = 12.1, p = .059

χ2 = 9.55, p = .049

χ2 = 9.57, p = .479

χ2 = 12.5, p = .014

χ2 = 15.9, p = .013

χ2 = 1.98, p = .371 χ2 = 4.28, p = .117 χ2 = 1.06, p = .899

N: number of subjects; TL: Turkish Lira.

self-esteem and quality of life. No difference was observed in terms of age, sex, age at hospitalization and number and length of hospitalization. On the other hand, we found differences in few demographic features including education, looking for a job, income level and marital status among groups. Competitive working group had higher rates of married patients than the unemployed group. This finding

is consistent with the literature. Association between being married and having a job has been reported in patients with psychotic disorders (Evert, Harvey, Trauer, & Herrman, 2003) and replicated in cross-cultural settings (Marwaha & Johnson, 2004). Although no difference was found between working groups and unemployed group in terms of education level, education levels of patients in

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Yildirim et al. Table 2.  One-way analysis of clinical characteristic and scales’ result of groups.

Age Duration of marriage Year of the disease Age at hospitalization Number of hospitalizations Duration of hospitalizations PANSS negative-total PANSS positive-total PANSS general-total PANSS total Calgary-total UKU psychological UKU neurological UKU autonomic UKU other RSES-total WHOQOL-BREF physical health WHOQOL-BREF psychological health WHOQOL-BREF social relationships WHOQOL-BREF environmental field WHOQOL-BREF environmental field–TR

Unemployed

Supported working

Competitive working

F

p

37.17 ± 9.55 1.97 ± 5.04 21.97 ± 5.37 23.09 ± 7.09 5.57 ± 5.21 145.57 ± 165.8 15.29 ± 4.45 13.4 ± 4.29 26.57 ± 7.47 56 ± 11.34 4.86 ± 4.37 4.11 ± 2.45 0.23 ± 0.65 4 ± 2.73 5 ± 3.23 17.6 ± 4.12 46.96 ± 14.47 46.17 ± 14.77 44 ± 16.79 49.75 ± 10.31 50.19 ± 10.22

33.27 ± 7.83 3.2 ± 7.35 21.07 ± 4.65 21 ± 8.69 4.3 ± 4.64 165.73 ± 196.94 14.07 ± 4.04 12.7 ± 4.03 25.63 ± 5.19 52.4 ± 10.7 2.47 ± 2 3.3 ± 2.07 0.47 ± 1.28 3.73 ± 3.36 4.17 ± 3.17 17.87 ± 4.13 56.55 ± 15.27 59.67 ± 14.69 53.39 ± 20.04 58.54 ± 14.26 58.24 ± 13.58

32.89 ± 7.88 5.6 ± 8.9 22.91 ± 5.82 21.14 ± 9.62 3.17 ± 4.87 141.23 ± 296.58 14.31 ± 3.75 12.31 ± 4.51 24.26 ± 6.22 50.89 ± 13.07 3.23 ± 3.24 3.86 ± 3.02 0.4 ± 1.06 2.4 ± 2.28 4.51 ± 2.54 17.49 ± 3.18 58.57 ± 10.18 55.6 ± 13.21 42.86 ± 16.81 53.3 ± 12.86 54.05 ± 12.68

2.68 2.25 0.97 0.63 2.08 0.10 0.83 0.57 1.15 1.73 4.27 0.84 0.49 3.25 0.64 0.08 7.41 7.86 3.31 4.02 3.54

.073 .111 .382 .533 .13 .902 .439 .565 .321 .183 .017 .435 .617 .043 .528 .92 .001 .001 .041 .021 .033

TR: Turkish Form; PANSS: Positive and Negative Syndrome Scale; UKU: Udvalg for Kliniske Undersogelser Adverse Events Evaluation Scale; WHOQOL-BREF: World Health Organization Quality of Life Scale–Brief Form; RSES: Rosenberg Self-Esteem Scale; SD: standard deviation. Values are expressed as mean ± SD.

Table 3.  Tukey’s multiple comparison test of scales’ results of groups. p values of Tukey’s Calgary-total UKU WHOQOL- WHOQOLmultiple comparison test autonomic BREF physical BREF health psychological health

WHOQOLBREF social relationships

WHOQOLBREF environmental field

WHOQOLBREF environmental field–TR

Unemployed/supported 0.016 working Unemployed/competitive 0.116 working Supported working/ 0.641 competitive working

0.922

0.014

0.001

0.092

0.015

0.025

0.048

0.001

0.018

0.961

0.461

0.384

0.139

0.817

0.485

0.05

0.216

0.353

UKU: Udvalg for Kliniske Undersogelser Adverse Events Evaluation Scale; WHOQOL-BREF: World Health Organization Quality of Life Scale–Brief Form 0–100; TR: Turkish Form. Values are expressed as p value.

competitive working and supportive working were significantly different. Most of the patients in competitive working group had high-school education, but rates of university graduates and primary school graduates were higher in supported working group. Previous studies in patients with schizophrenia reported a strong relationship between higher levels of education and being employed in competitive work (Rosenheck et al., 2006). In contrast, few studies showed that there was no correlation between education level and having a work, but personal skills were more strong predictors for having a work (Marwaha & Johnson, 2004).

As expected, being employed in competitive work enables patients to have higher income levels compared to patients in supported work or unemployed patients. In our sample, patients in competitive work group did not need to look for a job, whereas 23.3% of patients in supported work group and 31.5% of unemployed patients stated that they would be looking for a job. This finding is important as it indicated patients’ will to work. It was reported that patients diagnosed as having schizophrenia could not find a job even though they wanted to work (Crowther, Marshall, Bond, & Huxley, 2001; Mechanic et al., 2002). Approximately one-third of unemployed patients in our

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sample wanted to work. In a multicenter study from Turkey, unemployment rate among patients with schizophrenia was reported as 56% (Yıldız, Yazıcı, & Böke, 2010). Rate of unemployment in schizophrenia is also high in European countries (R. A. Rosenheck & Mares, 2007). Our findings also manifest the crucial demand of patients diagnosed as having schizophrenia towards work in Turkey. While there were no new job demands among those patients in competitive work group, declaring new job demands among those patients in supported work group may be associated with stigmatization. However, in this study we did not investigate level of stigmatization that patients felt. High rates of job seeking in supported work group may also be related to low income levels. On the other hand, not declaring demand for a job does not necessarily mean that the patients were actually abstaining from job seeking. Many studies have shown that patients with schizophrenia who do not want to work seem to be engaged in active job seeking (Marwaha & Johnson, 2004). They suggested that there is a contradiction between attitudes and behavior in this area. We did not find any significant difference between groups in PANSS negative, positive or general psychopathology scores. In general, negative symptoms have been reported to have an adverse effect on work status of the patients (Bond & Meyer, 1999; Lysaker & Bell, 1995). Slade and Salkever (2001) found lower PANSS total scores in working patients compared to others. Effects of negative symptoms on work status were highly prominent while effects of positive symptoms on work status were also negative, but not statistically significant. In addition, the relationship between severity of psychotic symptoms and employment status is still debatable (Marwaha & Johnson, 2004). In our study, these findings in PANSS scores may be due to type of antipsychotics used. A total of 11% of patients in our sample used typical antipsychotics, 74% used atypical antipsychotics and 15% used combination of typical and atypical antipsychotics. Moreover, the type of drug used was comparable among groups. Atypical antipsychotics are relatively more effective for negative symptoms than typical antipsychotics (Bond & Meyer, 1999), and patients might have benefited from treatment resulting in less negative symptoms. This interpretation needs to be confirmed by further studies in similar samples addressing effects of type of drug on symptom severity and work functioning. There was no significant difference among three groups in terms of psychiatric, neurological and other side effects of drugs. However, unemployed patients reported more autonomic side effects than patients in competitive work. It was previously shown that adverse effects of antipsychotic drugs might have negative effects on work status. Particularly, extrapyramidal adverse effects had negative effects for patients in competitive work, but these adverse effects were not pronounced for patients in supported work (Slade & Salkever, 2001). We may suggest that autonomic

side effects might negatively affect patients’ work capacity and might be a factor in abstaining from work. Unemployed patients had more depressive symptoms than those who work in a supported job. Our findings were compatible with previous studies. Depression in patients with schizophrenia was associated with higher rates of unemployment (Sands & Harrow, 1999). It was reported that depressive symptoms may negatively affect patients in competitive work as well as patients in supported work (Slade & Salkever, 2001). Having difficulties in the business environment and risk of losing a job may contribute to depressive mood. Diagnosis of depression in patients with schizophrenia has become increasingly important in psychiatric treatment (Tarrier, 2006). Depressive symptoms occurring in working patients should be evaluated by the clinician carefully (Salkever et al., 2007). In our sample, depressive symptoms might be a factor related with unemployment. We suggest that treating depressive symptoms may increase the ability to work for patients who have worked before disease onset. Average self-esteem scores of patients were intermediate for all three groups and there was no difference among groups in terms of self-esteem scores. In unemployed patients with schizophrenia, lower self-esteem scores were reported previously (R. A. Rosenheck & Mares, 2007). Similarly, it was emphasized that self-esteem scores of working patients were higher (Chandler et al., 1997; Van Dongen, 1996). Given the higher rates of looking for a job (R. A. Rosenheck & Mares, 2007) in supported working group and unemployed group in our sample, it can be suggested that self-esteem might not be a variable in finding a job. Besides, all patients in our sample had a work experience before disease onset and none had been included in a special rehabilitation program, suggesting a relative similarity between groups. Cultural reasons might also contribute to comparable self-esteem scores. We observed that working was associated with increase in some quality-of-life parameters. Physical health and psychological health subscale scores of competitive working and supported working groups were higher than unemployed group. This finding is consistent with the literature (Caron et al., 2005; Pattani, Constantinovici, & Williams, 2004; Van Dongen, 1996; Wu, 2008). On the other hand, it was determined that patients in supported work had higher social relationship subscale scores than those in competitive work. Moreover, environmental field subscale scores in supported work group were higher than unemployed group. In R. Rosenheck et al.’s (2006) study, three similar groups were also investigated for quality of life, and it was reported that competitive work group had higher scores than supported work group, and supported work group had higher scores than unemployed patients. According to our findings, we may suggest that supported work seems to be partially advantageous to quality of life compared to competitive work, especially regarding social relationships.

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Yildirim et al. Differences between the findings of R. Rosenheck et al.’s (2006) multicenter study and ours might be due to different characteristics of the samples, cultural differences or standards related to work environments. In this study, specific criteria for supported work were identified by the authors because there is not any structured system related with supported employment in Turkey. In general, supported employment is defined by regulatory authorities in many developed countries. However, procedure and applications of supported work programs in different countries may vary (Burns et al., 2007; Wehman & Bricout, 1999). Wehman and Bricout (1999) have identified supported working models in four categories. These categories included agency-mediated, business-mediated, government-mediated and family- or community-mediated. In Turkey, a remarkable number of patients with severe mental illness have still worked in jobs which could not be classified as competitive work but are similar to supported employment in many ways. In our study, evaluation criteria used to define supported working (Table 1) are not only similar to family- and communitymediated support but also informally similar to agencymediated and business-mediated support in terms of having a job coach assistance, effect of the decision of the patient’s physicians or support by business owners. On the other hand, regulatory structure for supportive employment is lacking in Turkey and the aim of support for our patients in supported work group was not enough for the preparation of the patient for competitive work environment as it is the case in some models. According to the results of our study, both supported work and competitive work have positive associations with the quality of life compared to unemployment. Especially, the patients working in a supported environment have higher quality-of-life scores in multiple parameters compared to patients not working. Rates of being married and high income levels were increased for competitive working patients in comparison to supported working patients. Moreover, almost one-third of unemployed and supported working patients were looking for a new work environment. This might be associated with many factors (e.g. demand for a more qualified job that can provide higher income or less stigmatization) which should be investigated in further studies. Since the Mental Health Act is not available in Turkey, legal arrangements for social rights of patients with psychiatric disorders like schizophrenia are insufficient (Alatas et al., 2009; Kurt, 2008). Rates in job demands of the patients are especially striking. In the current situation, supported work seems partially more advantageous for patients in Turkey. Structured supported working programs may be useful to prepare patients for competitive work environment. Patients who do not work should be evaluated in detail for depressive symptoms and side effects of drugs. Social needs of competitive working patients should be

taken into account and proper legal arrangements are required. Increasing structured supported work possibilities in countries like Turkey where community-based psychiatric system is not established and rehabilitation programs are limited will facilitate the lives of patients diagnosed as having schizophrenia from various aspects. Having worked before disease onset also affects the working ability in course of schizophrenia (R. A. Rosenheck & Mares, 2007). Furthermore, age at disease onset and the number of disease attacks are also factors interfering psychosocial functioning and therefore affecting the work of al., 2007; patients with schizophrenia (Marwaha et  Mechanic et al., 2002). Our sample might be regarded as a relatively homogeneous one in terms of multiple variables which could affect the work status of patients. All patients had work experiences before disease onset, and demographic characteristic, age at disease onset, age at initial hospitalization, number of hospitalizations and total hospitalization days were comparable between the groups, which minimizes the inferring effects of these variables. There have been few limitations to this study. During sampling, patients from similar settings were enrolled. Other limitations were the absence of standardized work environments in Turkey, limited number of patients, lack of measures addressing neurocognitive functions and questioning behavior of the health-care providers and stigmatization. Another limitation of this study is that the data were not compared to data obtained from a healthy control group. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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