DISABILITY IN TURKEY
DISABILITY IN TURKEY
DIS-QOL Project Natioanl Review of Disability and Quality of Life and its determinants
This report has been prepared as one of the initial workpages of the Project titled : Quality of Care and Quality of Life For People with Intellectual and Physical Disabilities: Integrated Living, Social Inclusion and Service User Participation (Acronym: DIS-QOL) supported by EU FP 6 program.
Prof. Dr. Erhan Eser
Turkish Society of HRQOL (SAYKAD) and Department of Public Health, Celal Bayar University Fac. of Medicine, Manisa
Prof. Dr. Ömer Aydemir
Turkish Society of HRQOL (SAYKAD) and Department of Psychiatry, Celal Bayar University Hospital , Manisa
Since there is currently no registration system of disabled population in Turkey , there is lack of quantitative and qualitative information about disabled population (Turkish Prime Ministry Presidency of Administration on Disabled People 1999, Türkiye Sakatlar Dernegi 2002). One of the data sources on disabled people is population cencus. Information about disabled population has been taken from General Population Cencus of 1927, 1945, 1955, 1965, 1975, 1985 and 2000 in our country. 1985census can be regarded as the first one to determine the number of disabled in the country. Yet, it has been observed that information in population cencus is insufficient. A recent country-wide representative 2002 Turkey Disability Survey - you will see the details below- aimed to fill-in the information gap of the disabled population in Turkey can be regarded as the most important baseline information about disability in Turkey (Turkish Prime Ministry Presidency of Administration on Disabled People 2002).
The Prevalance of Disability in Turkey
The main problem in regard to the prevalance of disability arises from the definition and classification of disability used in the methodology of disability studies in Turkey as many other countries. Although many attempts have been proposed for the definition and classification of disability such as Nagi's Disability Model and International Classification of Functioning, Disability and Health (WHO 2001) which was based on the work of Philli H. Wood in 1980 (Fougeyrollos 1998), there is stil a debate on the classification of disability and handicapped.
As mentioned above, the first i nformation about disabled population has been taken from General Population Cencus of 1927, 1945, 1955, 1965, 1975, 1985 and 2000 in Turkey. In each of the population census the definition of disability and handicapped has been changed. Until 2000, these census information reported the disability prevalence as around 1.0 - 1.4% in Turkey (Öz 1976) , but the prevalence rate can be seen to be underestimated during the course of census when compared with the rate estimated for Turkey by World Health Organization. In 2000 census a more detailed set of questions were asked (e.g. do you have any physical or mental disability? ; if yes please state the type of it) and diasbility prevalance was found as 1.8%. Here we must state that the presence any chronic disorder was excluded in the classification of disability in 2000 census.
The population based studies have also generated some important figures on the prevalance of disability in different population groups in Turkey. But the range of prevalance was quite wide (such as 0.73 to 11.3%) in there studies due to the variability on classification of disability and methodology. For instance, the prevalance was 0.73% in two health center districts of Ankara (Karamemetoglu 1995). The prevalance was 4.1% in the 1957 birth cohort of young (20 years of age) men who went to compulsory military services in 1982 (Özyurda 1982). A rural orthopedic disability prevalance based of 5068 inhabitants of 17 villages of Sivas province of Turkey was reported as 3.1% (Ünsaldi 1990) . In an urban study conducted in Edirne ( a western developed) province with a sample size of 12 072, the prevalance of disability was found as 2.28% in 1989 (Saltik 1990) On the other hand a recent study that was carried out in an underdeveloped region of Turkey based on a large sanple of 38 600 population found orthopedic disability prevalance as 2.66% in 1999 (Nas 1999). A series of six surveys conducted in 1990 by using World Health Organization Disability Forms developed in 1981 are as follows: Ankara (n=1904) 9.98 % ; Bornova-Izmir (n=34) 11.31%; Bezirganbahçe-Istanbul (n= 3540) 11.3%;Eskibaglar-Istanbul (n= 3680) 10.4%; Ikitelli-Istanbul (n= 3755) 10.7% and Karaaslan-Konya (n=3518) 6.9% (Yazgan 1990,Yöndemli 1990, Becer 1991, Serdaroglu 1990, Müslümanoglu 1990). In addition to these studies, two recent urban population studies revealed the disablity prevalances as 5.0% in Aydin city (n=2700) (Beser 2004 ) and 5.3% in Isparta city (n=3500) (Kisioglu 2003 )
Working Life of Disabled persons:
A shift from the decision social state has restricted the disabled people to participate work-life more deeply. According to a survey of International Labor Organization (ILO), the employment status has favored disabled people in the countries with a developed social security system such as Germany, France, Netherlands and Sweden, whereas in those countries with liberal administration system such as US, UK and New Zealand the employment of disabled people has been sacrificed to the benefits of the companies (ILO 1998). Its not very easy to estimate figures on the employment of disabled population in Turkey . Very scarce information can be obtained from different sources, generated with a variety of purposes. In addition, these data are supporting each other. Nevertheless it is estimated that about 55% of the disabled population is intergrated to the work life in Turkey . (Turkish Prime Ministry Presidency of Administration on Disabled People 1999). A survey conducted in 197 institutions in 1993 had found that the disabled persons composed of only 0.98% of the total working population and 60.3 of the disabled have orthopedic disorders and only 1.0% have learning disability (Sakatlari Koruma Milli Koordinasyon Kurulu 1996).
When we focus of the obstacles of the employment of the disabled people we can classify them into two main categories: Objective and Subjective reasons.
Objective reasons might have two categories such as Economic and Organizational obstacles. Economic obstacles can be briefly defined as high unemployment rates (Öz 1976, SEMO 2002), and the special interest of high productivity in recent decades. This means that according to the current job-ethic, “disability or handicapped” can be regarded as an economic term rather than a medical term (Roussel 2000). So the very high unemployment rate of Turkey makes the likelihood of employment of disabled people more difficult. On the other hand, high technology used in the workplaces have caused the need of strict standardization which would create difficulties in work on the disabled workers (Bazier 2002).
The main subjective obstacles on the employment of disabled people are “prejudice” (Özmen 1997, Fucks 1999) of employers and “perception of disability” of the disabled people, other workers and the trade unions.
2002 Turkey Disability Survey:
2002 Turkey Disability Survey is the only cross-sectional representatitve nationwide survey, carried out by The State Institute of Statistics for the first time in cooperation with The State Planning Organization and Disabled People. This survey was aimed to eliminate information deficiency problem on disabled people.
The aim of this survey was to collect data on
• Number of disabled people,
• The proportion of disability,
• The type of disability(orthopedical, seeing, hearing, speaking and mental disability),
• The cause of disability,
• The socio-economic characteristics of disabled population,
• The family and social life status of disabled population,
• The problems of disabled population in their working lives and daily lives,
• Their expectations from institutions
• The another aim of the survey is to collect data on population having chronic illnesses.
This survey was applied on a sample size of 97 433 households in whole country. The results of survey was evaluated on the basis of 7 geographical regions and urban-rural areas. Information was obtained on all disabled individuals determined in household questionnaire. In the first part, it was obtained information on disabled individuals characteristics, their expectations from Institutions. In the second part, it was obtained detailed information on disabled persons for each type of disability.
Results of the 2002 Turkey Disability Survey:
Total disability proportion in the overall population is 12.29%. The proportion of orthopedically, seeing, hearing, speaking and mentally disabled people is 2.58% and proportion of people having chronic illnesses is 9.70 %. When the proportion of these disabilities is examimined by age groups, it is observed that proportion of disabled people increase in older ages. This is especially observed in people having chronic illnesses. While the proportion of orthopedically, seeing, hearing, speaking and mentally disabled people is 1.54% in 0-9 age group, this proportion is 2.60% for people having chronic illnesses in 0-9 age group. The proportion of these disabilities is almost doubled in 20-29 age interval.
The median age for orthopedically, seeing, hearing, speaking and mentally disabled people is 33.87 and the median age for people having chronic illnesses is 48.86. In disabled population, median age of females is higher than that of males. But, the difference among sexes is higher in orthopedically, seeing, hearing, speaking and mentally disabled people.
When the proportions are examined by sex, it is observed that while the proportion of orthopedically, seeing, hearing, speaking and mentally disabled people is higher in males, the proportion of people having chronic illnesses is higher in females.
While the proportion of orthopedically, seeing, hearing, speaking and mentally disabled people is higher in rural, the proportion of people having chronic illnesses is higher in urban. When the proportion of disability is examined by regions, it is observed that while Black Sea Region has the highest proportion with 3.22%, Marmara Region has the lowest proportion with 2.23% for orthopedically, seeing, hearing, speaking and mentally disabled people. On the other hand, it is observed that while the proportion of people having chronic illnesses is the highest in Marmara Region with 10.90%, this proportion is the lowest in Southeast Anatolia Region with 7.18%.
The illiteracy rate of orthopedicaly, seeing, hearing, speaking and mentally disabled people six years of age and over is 36.33%, this rate for people having chronic illnesses is 24.81%. Compared to the normal population rate of illiteracy (e.g. 12.94%) these rates can be regarded as significantly higher in disabled population. In total population while approximately one person from ten persons is illiterate, this number increase to two persons in people having chronic illnesses and four persons in orthopedically, seeing, hearing, speaking and mentally disabled people. When the illiteracy rate is examined by urban-rural, it is observed that while illiteracy rate of orthopedically, seeing, hearing, speaking and mentally disabled people in rural is 43.44%, this rate is 29.58% in urban. On the other hand, it is observed that while the illiteracy rate of people having chronic illnesses is 32.85% in rural, this rate is 20.49% in urban. This rate for total population is 10.04% in urban and 17.37% in rural. The illiteracy rate of orthopedicaly, seeing, hearing, speaking and mentally disabled people is higher than that of people having chronic illnesses in both urban and rural. While illiteracy rate of orthopedically, seeing, hearing, speaking, mentally disabled people is 28.14% for males and 48.01% for females, illiteracy rate of people having chronic illnesses is 9.78% for males and 35.04% for females. In total population, illiteracy rate is 6.89% for males and 18.83% for females. In every three population groups, the illiteracy rate of females is higher than that of males.
Marital status of disabled population is examined, it is observed that the proportion of never- married in orthopedically, seeing, hearing, speaking and mentally disabled people is 34.41%. This proportion is 7.43% for people having chronic illnesses and 26.28% for total population, as well. The proportion of never-married in orthopedically, seeing, hearing, speaking and mentally disabled people is higher than that of both in people having chronic illnesses and total population. In orthopedically, seeing, hearing, speaking, and mentally disabled people, the proportion of married-living separately and divorced people(2.14%) is higher than that of people having chronic illnesses (1.92%). The proportion of widowed in people having chronic illnesses (13.95%) is higher than that of orthopedically, seeing, hearing, speaking and mentally disabled people (9.31%).
Labor force status, labor force participation: (The information on labor force is evaluated for disabled population of 15 years of age an over) In orthopedically, seeing, hearing, speaking and mentally disabled population, while the labor force participation rate is 21.71%, on population rate not in labor force is 78.29%. on the other hand, in people having chronic illnesses, the labor force participation rate is 22.87%, population rate not in labor force is 77.13%. in other word, one of every five disabled persons participates labor force. While it is seen an important difference in labor force participation rate for orthopedically, seeing, hearing, speaking and mentally disabled people with 25.61% in urban and 17.76 in rural, it is not observed and important difference between urban (23.08%) and rural (22.48%) for people having chronic illnesses. Labor force participation rate by sex shows and important difference for disabled people. While labor force participation rate for orthopedically, seeing, hearing, speaking and mentally disabled people is 32.22% for males and 6.71% for females, this rate is 46.58% for males and 7.21% for females in people having chronic illnesses.
Unemployment rate is 15.46% for orthopedically, seeing, hearing, speaking and mentally disabled people and 10.77% for people having chronic illnesses. While unemployment rate in orthopedically, seeing, hearing, speaking and mentally disabled people
is 17.43% in urban and 12.58% in rural, this rate in people having chronic illness is 12.72% in urban and 7.08% in rural. Unemployment rate is higher in urban than rural. But, this difference is much more higher in people having chronic illnesses. While labor force participation rate in both orthopedically, seeing, hearing, speaking and mentally disabled people and people having chronic illnesses is higher for males, unemployment rate is higher for females. While unemployment rate in orthopedically, seeing, hearing, speaking and mentally disabled people is 14.57% for males and 21.54% for females, this rate is 10.28% for males and 12.84% for females in people having chronic illnesses. For both males and females, unemployment rate of orthopedically, seeing, hearing, speaking and mentally disabled people
is higher than that of people having chronic illnesses.
Social security status: 47.55% of orthopedically, seeing, hearing, speaking and mentally disabled people and 63.67% of people having chronic illnesses have social security. The proportion of disabled people having social security is higher in urban. While the proportion of having social security in orthopedically, seeing, hearing, speaking and mentally disabled people is 59.27% in urban and 35.15% in rural, this proportion in people having chronic illnesses is 70.80% in urban and 50.28% in rural. While the proportion of people having social security is 51.41% for females and 44.84% for males in orthopedically, seeing, hearing, speaking and mentally disabled people, this proportion is 64.56% for females and 62.40% for males in people having chronic illnesses. The proportion of people having social security is higher for females in both orthopedically, seeing, hearing, speaking and mentally disabled people and people chronic illnesses. 44.21% of orthopedically, seeing, hearing, speaking and mentally disabled people and %44.36 of people having chronic illnesses have social securities on behalf of them. The proportion of disabled people having social securities on behalf of them does not show a significant difference between urban and rural. While the proportion of having social security on behalf of them in orthopedically, seeing, hearing, speaking and mentally disabled people is 67.96% for males and 17.04% for females, this proportion is 86.42% for males and 15.89% for females in people having chronic illnesses.
The appearance time of disability: The proportion of subsequent disability in orthopedical (73.30%), seeing (76.32%) and hearing (67.10%) disabled people is higher. But, it is not observed that there is no important difference between the proportion of congenital and subsequent disability in speaking and mentally disabled people. Among these two types of disabilities, the congenital disability proportions are 46.63% and 47.92% respectively. When the appearance time of disability is examined by urban and rural, it is observed that in all types of disability, while the proportion of congenital disabled people is higher in rural, the proportion of subsequently disabled people is higher in urban. Whwn the appearance time of disability is examined by sex, it is observed that there is no significant difference among sexes in seeing and hearing disabled people. In orthopedically, speaking and mentally disabled people, the proportion of congenital disabled people is higher in females.
The cause of disability:
The cause of disability of people with speaking disabilities: Among speaking disabled people, illness is the most important disability reasons with 23.88%. the second important reason is the genetic and hereditary deformity causes with 15.90%, the third important reason is mental disability and hearing disability with 10.49% and 10.31% respectively. While the proportion of speaking disabled people because of hearing disability and genetic and hereditary deformity is higher in rural, this proportion in other causes of speaking disability is higher in urban. While the proportion of speaking disabled people because of mental disability, emotional problems, accident and illness are higher in males, this proportion in other causes of speaking disability is higher in females.
The cause of congenital disability: The proportion of disabled people who do not know the cause of disability from congenital in all the types of disability is approximately 50%. It shows that disabled people from congenital do not know the cause of their disabilities. This proportion in all types of disabilities is higher in rural. In orthopedical and hearing disabled people, this proportion for females is higher than males. Among all causes, these genetical reasons are the highest proportion. The second reason is to have problems during delivery, in all types of disabilities. In these two causes, it is observed that the proportion in urban is higher than rural. At the same time, it is seen that the proportion in females is higher than males.
The cause of subsequent(acquired) disability: When the causes of subsequent disability are examined, it is seen that the proportion of accidents and illnesses is higher in all the types of disabilities. While the proportion of orthopedically disabled people because of accident and illness is almost same, the proportion of disabled people because of illnesses is higher in other types of disabilities (seeing, hearing and mentally disabled people). In both of causes of disability (accident and illness), it is observed that there is no significant differences between urban and rural. When the causes of accident and illness are examined by sex, it is observed that in all types of disabilities, while the proportion of disabled people because of accident is higher in males, the proportion of disabled people because of illness is higher in females.
The degree of disability: It is observed that disfigurement is seen in orthopedically disabled people mostly. Organ deficiency is 11.81%. While the proportion of disfigurement and organ deficiency in males is higher than in females, function loss is higher in females. The proportion of total seeing loss in one eye is the highest proportion in seeing disabled people. The proportion of total blindness is 11.75%. the proportion of total seeing loss in one eye and blindness is higher in rural. In hearing disabled people, the proportion of deaf is highest proportion with 32.45%. The mild loss in both ears follows the deaf. The proportion of deaf is higher in rural and also females. In speaking disabled people, it is observed that the proportion of speechless is the highest proportion with 45.93%. 47.03% of mentally disabled people have the level of being educated or tought. The proportion of disabled people having a higher idiocy is 19.66%.
The status of being treated: When the status of being treated of disabled people is examined by the type of disability, the proportion of being treated of disabled people is above 50% in orthopedical, seeing and hearing disability. In these disabilities, the proportions of being treated of disabled people are 56.66%, 57.31% and 52.04% respectively. The proportion of being treated of speaking and mentally disabled people is 32.92% and 42.95% respectively. While the proportion of being treated is the highest in seeing disabled people, this proportion is the lowest in speaking disabled people. In all types of disabilities, the proportion of being treated is higher in urban. Nevertheless, in all types of disabilities, the proportion of males being treated is higher than females.
The status of using apparatus: The proportion of using apparatus is 19.65% in orthopedically disabled people and 20.84% in hearing disabled people. This proportion is 30.81% in seeing disabled people and also 2.46% in speaking disabled people. In all types of disabilities, the proportion of using apparatus is higher in urban. While the proportion of using apparatus in orthopedically and hearing disabled males is higher than females, in other disabilities (seeing and speaking), this proportion is higher in females.
The expectations of disabled people from organizations: It is collected information on the most important expectations from organizations of disabled people duruing survey. According to this survey, the most important expectation of disabled people is financial support assistance is 68.03% in rural, this proportion is 55.28% in urban. 59.34% of disabled males and 63.76% of disabled females want to get financial support assistance from organizations. The proportion of disabled people expecting working assistance is 9.55%. This expectation is higher in urban areas and for males. This proportion is 12.33% for males and 5.78% for females. The proportion of disabled people requiring the assistance of finding job, the assistance of education and defense of legal rights is higher in males and in urban.
Quality of life in Mental Disorders with learning disabilities in Turkey
In this part of the review, first, some correlates of learning disorders in childhood such as mental retardation, attention deficit-hyperactivity disorder, and in geriatrics such as Alzheimer's disease will be reviewed. In the second part, the studies on the quality of life in the major psychiatric disorders such as schizophrenia, bipolar disorder, and obsessive-compulsive disorder, and in some neuropsychiatric disorders such as stroke, epilepsy, and cerebral palsy, carried out in Turkey will be reviewed.
Correlates of Learning Disorders in Childhood
Mentally retarded children between 8-16 years of age in the special schools were assessed and 73.7% of them had mild mental retardation and 26.3% of them had moderate mental retardation. The most frequent comorbid psychiatric diagnoses were enuresis, encopresis, stereotypic behaviors, autistic symptoms, tics, aggression, attention deficit, and speech disorder (Kaya et al., 1997).
When the relationship between mentally retarded children and their mothers were evaluated, even though there was no difference between interactional behaviors, time mothers of mentally retarded children spent more amount of teaching, controlling and goal settings behaviors. Also, the types of play, compliance and no interaction/no response behaviors also differed (Sucuoglu 2001).
The parents of the mentally retarded children were from low socio-economic and cultural levels, they realized their children's condition below the age of six years, they had many problems of adaptation to social environments and making friends; and their children had problems such as telling lies, biting nails, enuresis nocturna, impatience, nervousness and conciliatory, but they liked sports, repairing things and handcrafts (Ozer and Mangir 1997).
ADHD (attention-deficit/hyperactivity disorder) is the most common childhood psychiatric disorder. With the aim to evaluate the sociodemographic and clinical features of children and adolescents with attention deficit hyperactivity disorder (ADHD), 93 children and adolescents were included. The ratio of boys/girls was 3.65/1. The most common type of ADHD among girls was inattentive type (Toros and Tataroglu 2002).
The comorbid conditions in ADHD (attention-deficit/hyperactivity disorder) is evaluated and 29.9% of the subjects did not have any comoborbid psychiatric disorder. 35% of the subjects ad one comorbid disorder, 25.5% of the subjects had two comorbid disorders, and 8% of them had three comorbid disorders. The most common comorbid diagnosis in male patients was oppositional defiant disorder (ODD) (62.3%), the other comorbid disorders observed were conduct disorder (22.6%), communication disorders (11.3%), mood disorders (7.5%), and anxiety disorders (6.6%). In female subjects the most common five comorbid disorders were classified as ODD (54.8%), conduct disorder (22.6%), mood disorders (12.9%), communication disorders (9.7%), and anxiety disorders (6.5%). No significant difference of prevalence rate of comorbid disorders was found between male and female subjects (Erman et al. 1999).
The family functioning in attention deficit-hyperactiviy disorder was examined. It was found that family functioning of chidren with ADHD (aged 9-14 years) were in normal range. But family interactions with older children with ADHD (aged 9-14 years) were problematic in control and communication including message sent is not clear, direct, and sufficient (Pekcanlar et al., 1999).
Epidemiology of Alzheimer's Disease in Turkey
In Turkey , in the population above 65 years of age, the prevalence rate of dementia is 7.3%. Mild cognitive impairment was diagnosed in 26% of the population. When gender was taken into consideration, the prevalence rate is 5.9% in men, and 9.0% in women. Alzheimer's Disease is the most prevalent, and vascular dementia is the second most prevalent in this population (Bulut et al., 2002).
In order to study risk factors for Alzheimer's disease (AD) in Turkey , people over age 70 in the community were screened for cognitive impairment. The results suggest that having a higher education is protective from AD and that electromagnetic field exposure at work or at home (i. e. use of electricity for residential heating) is a significant risk factor (Harmanci et al., 2003).
Psychiatric Disorders in General
Since psychopathology may affect the physical, psychological, social, economical and occupational areas in life, patients with chronic psychiatric disorders were evaluated with WHOQOL-BREF, compared to the patients with diabetes mellitus and healthy subjects. In the psychiatric patient group, 119 patients with chronic alcoholism, 24 patients with schizophrenia, 28 patients with bipolar disorder, and 23 patients with obsessive-compulsive disorder were included. In the physical domain, all patients groups scored significantly lower when compared to the healthy control group. In the psychological domain, patients with schizophrenia and with obsessive-compulsive had the lowest scores. In the social domain, while patients with schizophrenia and with chronic alcoholism scored the lowest; diabetic patients and healthy subjects had the highest scores. Schizophrenic patients scored the lowest in the environment domain (Akvardar et al., 2004).
Schizophrenia
In a study to investigate the sensitivity of WHOQOL-100 in schizophrenia, 54 stabilized outpatients with schizophrenia and 49 age-, sex-, and occupation-matched healthy control subjects were recruited. Significant negative correlations were obtained especially between subscales of the BPRS, SANS, SAPS, and QOL domains. Stepwise multiple regression analysis also revealed that the BPRS anxiety/depression and SANS anhedonia subcales were the predictor variables in five of six QOL domains in the schizophrenia group. It is concluded that the WHOQOL-100 scale is reliable in schizophrenia and the clinical sensitivity should be assessed in large follow-up studies (Orsel et al., 2004).
In a group of 40 (16 women and 24 men)schizophrenic patients without any physical or neurological diseases, using WHOQOL-BREF, the mean scores of the physical, the psychological, and the social domains were statistically lower than that of the healthy subjects; even though the cognitive functions were not different (Akvardar et al., 2003).
However in another study, 38 patients with schizophrenia (15 women and 23 men) and 31 healthy individuals (18 women and 13 men) were administered WHOQOL-BREF to assess their quality of life, and Digit Span Test (DST) and Controlled Oral Word Association Test (COWAT) for cognitive functions. The patients with schizophrenia demonstrated lower scores in physical, psychological and social domains compared to control group. The patients with schizophrenia showed significantly lower scores on COWAT compared to healthy subjects. The patients with lower level of cognitive functioning had lower scores on social domain of WHOQOL-BREF. These results confirm that the cognitive deficits in executive function and workingmemory appear to have direct impact on the patients perceived quality of life especially in social domain which can either be a cause or a consequence of social isolation of patients with schizophrenia (Alptekin et al., 2005).
With the aim of comparing quality of life in schizophrenic patients and their household relatives, 30 patients with schizophrenia (16 women, 14 men), diagnosed using DSM-IV criteria, 31 of their relatives (15 women, 16 men), and 34 control subjects (21 women, 13 men) were included in the study. Quality of life was worse for the patient group than for their relatives and control subjects, but relatives of the patients and control subjects were not significantly different on Quality of life. Quality of life was negatively correlated with the severity of psychopathology and extrapyramidal side effects induced by antipsychotic drugs in the patients (Alptekin et al., 2004).
Similarly, in another study concerning the schizophrenic patients and their relatives, WHOQOL-BREF with specific scales for psychopathology were used in the assessment. The worse quality of life was significantly affected by depression, lack of insight, low self-esteem, and household conflict. Quality of life was positively correlated to the perception of the household as good. The perception of the household by the relatives as good and regular increased quality of life, but high expressed emotion decreased (Tuzer et al, 2004).
There are also intervention studies carried out in schizophrenia using quality of life probe.
In a study on schizophrenic patients subjected to Social and Psychological Skills Training, 15 patients in the training group and 15 patients in the waiting group were compared. The training was once a week in two sessions for 8 months. The assessments were made with Quality of Life Scale for Schizophrenia, Social Functioning Scale and Positive and Negative Scale for Schizophrenia. In the training group, both the mean score of QOL and social functioning decreased when compared to the waiting group (Yildiz et al. 2004).
In a naturalistic study with two groups of schizophrenic patients (302 patients on olanzapine and 283 patients on other antipsychotic drugs), the olanzapine group showed significant improvement both in VAS for quality of life and EQ-5D. In both groups, improvement in social ineractions and occupational functioning was evident, but in the 3rd and 6th months, the olanzapine group was separated from the other antipsychotics group (Saylan et al., 2003).
After the discharge from the hospital, 23 patients with schizophrenia received psychosocial approaches six times in their homes once per two weeks. At the end of the third month, improvements in social interactions and in family relationships were observed. Also WHOQOL-BREF, Specific Level of Functioning Scale (SLFS) and Multidimensional Scale of Perceived Social Support (MSPSS) mean scores were found to be significantly higher at the end (Dogan et al., 2004).
Bipolar Disorder
In four groups of 28 patients with bipolar patients, 20 household relatives, 30 patients with diabetes mellitus and 35 healthy control subjects, WHOQOL-100 was used for the assessment of quality of life. In the social domain, bipolar and diabetic patients scored significantly lower than the healthy subjects. In the cultural domain, the bipolar and household relatives groups had lower scores than the control group. In the environment domain, the bipolar and household relatives groups had also lower scores than the control group (Ozerdem et al., 2004).
With the aim of assessing outcome measures in interepisode bipolar patients, the Brief Disability Questionnaire (BDQ), the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) and the Global Assessment Scale (GAS) were administered to 100 patients with bipolar disorder. The results can be summarized as follows: (1) quality of life was predicted by current subthreshold depressive symptoms; (2) the number of previous depressive episodes, current subthreshold depressive and manic symptoms predicted
disability; and (3) the number of previous depressive episodes and the duration of hospitalisation as well as current subthreshold depressive and manic symptoms predicted overall functioning (Ozer et al., 2002).
Obsessive-Compulsive Disorder
To compare quality of life in patients with obsessive-compulsive disorder with that in healthy subjects and to relate quality of life to cognitive functions and the severity of clinical symptoms, 23 patients with obsessive compulsive disorder and 22 healthy subjects were assessed with WHOQOL-BREF. The comparison of quality of life between the patient and control groups showed a significant difference. The significant differences between the two groups in psychological and social scores were responsible for the overall significant difference. The scores of quality of life were correlated with the scores of the cognitive tests and the severity of obsessive-compulsive symptoms (Kivircik-Akdede et al., 2005).
To identify the predictors of health care seeking behavior in obsessive-
compulsive disorder, 25 health care-seekers (HCS) with OCD were compared with 23 non–health careseekers (NHCS) with OCD. The NHCS group reported significantly worse levels of QOL in psychological health and level of independence domains. The social domain which is primarily affected by OCD was not different in the two HCS and NHCS groups (Besiroglu et al., 2004).
Neuropsychiatric Disorders
In multiple sclerosis, 100 patients evaluated in terms of functioning and health-related quality of life. The impairment in functioning was negatively correlated with hrqol; but hrqol was not correlated with the occupational functioning (Oksuz et al., 2004).
In another study on multiple sclerosis, 62 patients with MS and 34 healthy control subjects were compared in terms of quality of life assessed with WHOQOL-BREF and disability assessed with Brief Disability Questionnaire. All domains were lower in the MS group, and all domain scores were significantly correlated with anxiety and depression. There was a negative correlation between disability and quality of life; however no correlation was found between the physician's assessment of physical disability and quality of life (Kaya et al., 2003).
With the objective of comparing health-related quality of life (HRQOL) between stroke patients 6 months after rehabilitation and a control group who did not have any major illness, sixty consecutive stroke patients and 58 healthy control participants were assessed with Nottingham Health Profile. The scores of NHP domains (energy level, emotional reactions, sleep, social isolation and physical mobility) of the stroke patients were higher than those of the healthy group. Being a woman, lower educational status, tendency to depression and the presence of several comorbidities were significantly correlated with the NHP scores (Gokkaya et al., 2005).
To evaluate changes in intractable epilepsy patients in terms of quality of life, depression, anxiety, stigma, and impact of epilepsy before and after surgery, 20 patients with intractable temporal lobe epilepsy who were waiting for surgery (pre-SAH group) and 21 patients who had already undergone surgery (post-SAH group) were studied. Post-SAH group scored higher on all subscales of SF-36, with only role-emotional scores being significantly better. Results also revealed that seizure frequency, comorbidity, and anti-epileptic medication affected health related QOL negatively (Aydemir et al., 2004).
To evaluate the quality of life of mothers with children suffering from cerebral palsy compared with those who have children with minor health problems, 40 mothers with a child suffering from cerebral palsy and 44 mothers with a child suffering from minor health problems were assessed with SF-36. With the exception of the SF-36 physical functioning subscale, the mean scores on the SF-36 subscales were significantly lower in mothers of children with CP than those of the comparison group. The quality of life scores of mothers were significantly correlated with the severity of a child's motor disability (except physical functioning subscale) (Eker and Tüzün 2004).
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