Open Journal of Psychiatry, 2011, 1, 88-97
doi:10.4236/ojpsych.2011.13013 Published Online October 2011 (http://www.SciRP.org/journal/OJPsych/ OJPsych ).
Published Online October 2011 in SciRes. http://www.scirp.org/journal/OJP sych
Consumer satisfaction, quality of life and distress with regard
to social function and gender in severe mental illness*
Bo Ivarsson1,4# , Leif Lindström2, Ulf Malm3, Torsten Norlander4
1Psychiatric Services, Borås Hospital, Borås, Sweden;
2Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden;
3Institution for Clinical Neuropsychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden;
4Department of Psychology, Karlstad University, Karlstad, Sweden.
Received 5 July 2011; revised 10 August 2011; accepted 17 August 2011.
ABSTRACT
OBJECTIVE: The relationships between subjective
satisfaction, distress and quality of life for severely
mental ill patients with different functional levels and
gender was investigated in a multi-center cohort,
using a balanced mix of subjective and clinician rat-
ings in an outcome-informed model for a clinical
management based on shared decision making, “The
Quality Star”. METHODS: Naturalistic data for 2552
pe rso ns , mainly with s chizophrenia diagnoses, in lo ng-
term treatment and rehabilitation, were analyzed in a
cross-sectional study. RESULTS: With increasing
Social Function, rated with the split-GAF Disability/
Functioning scale, the better were patients’ Satis-
faction, subjective Quality of life and Perceived Glo-
bal Distress. Women were more satisfied with the
care but a lso more distres sed. CONCLUSION: Main
findings were in line with other studies. However, the
gender differences are in line with some, but not with
other, studies. This poses questions how patient fac-
tors, instrument constructs, and treatment, especially
shared decision making, influence subjective reports.
Keywords: Consumer Satisfaction; Quality of Life; Per-
ceived Distress; Schizophrenia; Social Function
1. INTRODUCTION
In addition to the continuous refinement of instruments
for diagnosis and measurement of change in terms of
psychopathology, development of instruments for mea-
suring social functioning and patient subjective aspects
has become increasingly important, as emphasized in a
recent review of instruments for social functioning in
serious mental illnesses with the title “Functioning is the
cornerstone of life” [1]. Specifically regarding schizo-
phrenia it was noted in another review that social func-
tion is re-emerging as an important outcome measure,
though psychometrics and direct comparisons between
differing social function instruments, and their relation to
quality of life is unclear [2]. The increasing importance of
functioning in the treatment, rehabilitation and recovery is
also mirrored in the ongoing revision of the DSM and
ICD classifications ,as well as in the introduction of the
WHO International Classification of Functioning (ICF)
[ex. 3-5] .
There is also broad recogn ition of findings that impro-
vement, as a rule, is related to services being given in a
way that is perceiv ed with satisfact i o n by the users [6- 9] .
A topic with relation to patient satisfaction is the im-
portance of open and respectful dialogue with patients,
keeping in focus the pu rely patient subjective perception
of distress and quality of life as a sound basis for ach-
ieving treatment alliance, shared decision making and
user empowerment [10-12].
There are numerous constructs within these general
areas, and for instance, McCabe et al. address different
patient-related outcomes in the context of schizophrenia,
their relevant constructs, associated scales and key emp-
irical findings within outcomes relating to a) illness and
treatment, with emphasis in the areas: needs for care, tr-
eatment satisfaction, therapeutic relationship, clinical
communication, self-rated symptoms, insight, and b)
psychological well-being and resilien ce of self, with spe-
cial mention to empowerment, self-esteem, sense of coh-
erence and recovery [12].
*Author’s notes: The research plan has been evaluated and approved by
the Regional Ethical Vetting Board in Uppsala and the study followed
the ethical standards of the World Medical Association declaration o
f
Helsinki concerning Ethical Principles of Medical Research Involving
Human Subjects. The authors declare that they have no competing
interests. It is also noteworthy that findings regarding the influ-

B. Ivarsson et al. / Open Journal of Psychiatry 1 (2011) 88-97 89
ence of gender differences and functioning on subjective
perceptions have varied between different studies. [13].
This raises questions if well adapted service models may
stand a better chance to help, for instance if gender
specific issue are targeted [14].
In research regarding the abovementioned complex
relationships a great number of instruments have been
used. However, from the clinical perspective, this mul-
titude of alternatives may be one of the reasons why
there is seldom wide-spread agreement on what instru-
ments to use for practical monitoring in such an holistic
perspective. In Sweden, a concept was developed, nam-
ed “The Quality Star” [15,16], aimed to be a minimal
platform for follow-up of psychiatric care in a multi-
dimensional, holistic perspective using simple, global
measures of generic nature. Instruments were chosen to
be handy in clinical praxis, and fill the function to be a
point of departure for a dialogue with users within the
areas mentioned with an under-l y i ng questio n “ Where do
we stand now?—How do we improve ?”
With this perspective the choice of global instruments
was made, illustrated in Figure 1.
A thorough research program at the Department of
Psychology of Karlstad University has been launched
with the purpose of (a) assessing the psychometric pro-
perties of the Quality Star and (b) investigating group
differences within the cohort between patients with
different background characteristics and with different
intervention pattern s, especially the Integrated Care Pro-
gram (ICP), which during the last years has made great
advancements in Sweden [10,17,18], and been tested in
a number of different countries with various types of
Figure 1. Graphic representation of global instruments in “The
Quality Star” concept. Measures used for each dimension in
parentheses. In addition to chosen quality dimensions, a repre-
sentation of resource use is included in the bottom of the “star”
by number of “days in care”, later to be specified by national
treatment content codes. (Adapted from Ivarsson, Malm, Lind-
ström & Norlander, 2010).
systems regarding health care and welfare [19]. Regard-
ing psychometric properties of the Quality Star instru-
ments basic works have been done by others regarding
the split-GAF symptom severity and functional level
scales [20], as well as the scale Burden for important
other [21]. As part of the ongoing studies validation
work has been published regarding the global, patient
subjective instruments: Consumer satisfaction [22],
Quality of life [23], and Subjectiv e distress [24 ]. Further,
a study dedicated to investigate group differences within
the cohort [25] reported as one of the main findings that
women were more satisfied with the health care and had
better functioning compared to men.
The aim of the present study was to further investigate
the relationships between th e patient subjective measures
of consumer satisfaction, perceived distress and quality
of life for severely mental ill p atients with regard to dif-
ferent functional levels and gender. The following ques-
tions are of special interest: “Are there differences re-
garding the patient subjective measures at different psy-
chosocial functional levels?” “Are there gender differ-
ences in this respect?”
2. MATERIALS AND METHODS
2.1. Participants
Participants in this study were 2552 patients, 1340 men
and 1212 women (52.5 and 47.5 percents respectively),
where the Quality Star have been used at one or more
occasions during a ten year period at psychiatric centers
in 13 areas in Sweden, and where data were complete
regarding professional and patient instruments. Patients
were, by large, severely ill patients (SMI) in long-term
treatment and support and rehabilitation schemes. Dura-
tion of illness mean was in the order of 17 years (SD
about 12), based on data available from 77.9% of the
cases. At first recording, which is used in this study, their
mean age was 44.23 years (SD = 13.21), men somewhat
younger than women (43.60 years of age and 44.93 re-
spectively). The majority, 83.23%, had schizophrenia
spectrum disorders (ICD codes F20-F29). Remaining
patients had representations in particular from affective
disorders (F3 chapter, 5.21%), anxiety states (F4, 2.70%),
eating disorders (F5, 3.17%), and Personality disorders
(F6, 2.12%).
2.2. Instruments
Consumer Satisfaction Rating Scale-self-rating version
(ConSat-P). The original ConSat-P scale has been shown
to have acceptable psychometric properties including
acceptable internal consistency. Its use has been vali-
dated for schizophrenia spectrum disorders as well as for
affective, anxiety and substance abuse syndromes [22].
The slightly changed version used by the Quality Star
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B. Ivarsson et al. / Open Journal of Psychiatry 1 (2011) 88-97 90
network scale has 11 items in following domains: avail-
ability, atmosphere, continuity, information and parti-
cipation, drug treatment, psychological and psycho-
social interventions, result of treatment/care and trust in
future well-being. All items are rated on a seven point
scale with the format in principle +3 full satisfaction, +2
satisfied but with minor dissatisfaction, +1 More satis-
faction than dissatisfaction, 0 equally satisfaction/diss-
atisfaction or indecisive, –1 to –3 formulated in a reci-
procal fashion. Total score raw data are transformed to
percentages where 0% is extreme dissatisfaction and
100% complete satisfaction.
Global Quality of Life scale (GQL). The instrument is
a visual analogue scale [26]. The introductory question
has the wording “How do you find your life situation
right now?" and the anchor-points of the visual analogue
scale (VAS) line are marked “Best possible life situ-
ation” and “Worst possible life situation”. The scale is a
10 cm line, thus giving a scale 0 - 100 mm, where 0
signifies the worst situation and 100 the best possible
[27]. The GQL have been found valid for serious mental
ill persons with acceptable psychometric properties [23].
Test-retest reliability was found satisfactory. Concurrent
validity with the initial item of life satisfaction scale of
MANSA, “Life as a whole”, was good (r = 0.85 and rho
= 0.86). Content validity was clarified by associations
with a number of validating measures. Healthy adults'
ratings on the GQL, was found to be mean 76.0 (SD =
17.00).
Perceived Global Distress scale (PGD). The instru-
ment is a visual analogue scale [26]. The introductory
question has the wording “How much have you been
bothered by your psychiatric problems during the last
month?” and the anchor-points of the VAS line are
marked “I have not experienced any psychiatric pro-
blems at all” and “My psychiatric problems have trou-
bled me extremely much”. The scale is a 10 cm line,
thus giving a scale 0 - 100 mm, where 0 signifies the
worst situation and 100 the best possible [27]. The PGD
scale has been found valid for serious mental ill persons
with acceptable psychometric properties [24]. Test-retest
reliability properties were found satisfactory. Concurrent
validity with the last item of life satisfaction scale of
MANSA, “Mental health” was (rho = 0.59). Conten t va-
lidity was clarified by associations with a number of
validating measures. Correlation with depression index
of Symptom Check List –90 (SCL90) was rho = –0.64.
Healthy adults rated mean 89.55 (SD = 19.18).
Global Assessment of Functioning (GAF). With this
instrument professionals rate global mental health from
the perspective of psychic, social, and functional ability
[28]. The scale has ten vignettes exemplifying symptom
severity and psychosocial functioning to be used as ref-
erence in rating, each vignette representing successive
10-point intervals in the semi-quantifying in the total
scale range 1 - 100. Rating 1 represents the maximum
dysfunction and 100 best possible. In each vignette the
first part exemplifies syndrome severity and the last part
psychosocial functioning. GAF is a widely used scale
and its psychometric properties are documented in sever al
studies [e.g. 29-31]. The reliable use of GAF requires a
conscious strategy for its use due to pit-falls in the basic
instructions and guidelines [31-33]. The Quality Star net-
work uses the split-GAF version, with separate ratings of
symptom severity (GAF-S) and psychosocial function-
ing (GAF-F) [20]. The main measures taken by the net-
work to obtain reliable results include basic education,
monitoring of the datab ase and calibration by participat-
ing centers against a set of video cases.
2.3. Design
The study was designed to clarify the importance of
level of psychosocial functioning and gender for SMI
patients’ subjective experience in the three patient sub-
jective dimensions regularly monitored according to the
Quality Star method. Thus, the dependent variables used
were the scales for satisfaction with treatment and
service (ConSat-P), the subjective global quality of life
scale (GQL) and the perceived global mental distress
scale (PGD) scales. The independent variables were
gender (man/woman) and the Global functioning scale
(GAF-F) according to the Split-GAF method. Four
GAF-F categories were constructed based on the fre-
quency distribution of data, considering that GAF-F-
scores 61 and above has been suggested as a level where
recovery for serious mentally ill persons is well in pro-
gress, whereas GAF-F values below 30 is often seen as
indicative of need for intensive treatment. As partici-
pants with GAF-F values 30 and below were judged too
small in numbers, it was decided to include also the
31-40 GAF-F ratings in the most severe group.
Thus, the following four groups were created: GAF-F
40 and below, GAF-F 41-50, GAF-F 51-60, GAF-F 60
and above, named “Very low”, “Low”, “Intermediate”,
and “Higher”.
2.4. Statistics
Descriptive statistics for model variables. The model was
tested with Pillai’s MANOVA regarding psychosocial
function and gender. Univariate F-test and Post hoc tests,
and subsequently trend tests (Difference Custom Hy-
pothesis Tests) were conducted.
2.5. Procedure
Decision to participate in the Quality Star network by
the psychiatric departments include ethical conside-

B. Ivarsson et al. / Open Journal of Psychiatry 1 (2011) 88-97 91
OJPsych
rations regarding clinical follow up by using data from
routine care and quality systems. The data software was
not delivered to any site unless such declaration was
given. The personal were trained in use of the instru-
ments following the manual [27]. Instructions include
that subjective instruments, should be used in an as
neutral situation as possible, for instance not directly
after focus on topics that may influence rating. Sub-
jective instruments should not be used immediately foll-
owing each other, for the same reason.
Participants were introduced to the Quality Star at
routine visits by their case manager (CM) and given wri-
tten information. Right to withdraw without further mo-
tivation, and right to get extracts from the data-base was
part of the information. If they chose to participate, this
is noted in the clinical case notes. CM present the
instruments to the patient at one or two ordinary appoin-
tments with prime purpose to review the situation and
further to document findings in the p atient record and in
the Quality Star data-base. CM prepares the first con tact
by reviewing notes to enter background data regarding
history and socio-demographic questions. Recommen-
ded order to use the instrument is to start with GQL and
then ConSat-P. Next the CM turn to the question if the
participant would be willing to let a next of kin or
important other tell if he/she is troubled by burden in
order to—if so—discuss how the situation might be im-
proved. Written information of the Quality Star method
and the instrument PGB is presented. The next instru-
ment presented is the PGD, followed by the Health scr-
eening using the UKU-Side Effect Rating Scale (SERS).
Finally the CM presents her/his rating of the GAF.
Additional instruments used locally to further pene-
trate the areas covered by the global measures mentioned
above are presented after the basic measures. Conclu-
ding, a summar y presentation (Figure 1) of all ratings is
done and it is established what needs to be taken care of
in the following client-directed outcome informed [34]
review of the personal treatment plan. Entries to the lo-
cal Quality Star software are transferred to the national
data-base at intervals where participant identification is
replaced by random identification.
3. RESULTS
The mean values for participants’ ratings on the subjec-
tive measures were: For ConSat-P to tal, mean 75.21 (SD
= 14.67), for GQL 60.14 (SD = 25.34), and for PGD
61.46 (SD = 28. 59). The mean values for GAF-S was
49.89 (SD = 11.92) and for GAF-F 50.10 (SD = 11.92).
The total GAF score mean, based on lowest GAF-S or
GAF-F value, was 47.27 (SD = 11.26). For mean values
of the subjective measures divided by functional level
and gender, see Table 1.
A Pillai’s MANOVA (4 × 2 factorial design) was con-
ducted with Social Function (very low, low, intermediate,
higher) and Gender (men, women) as independent vari-
ables, and consumers satisfaction (ConSat), global qual-
ity of life (GQL), and perceived global distress (PGD) as
dependent variables. The analysis revealed significant
effects for Social Function (p < 0.001, Eta2 = 0.027,
power > 0.99) and for Gender (p < 0.001, Eta2 = 0.008,
power = 0.98). However, the analysis did not show a
significant main effect for the interaction Social Func-
tion × Gender (p = 0.273, Eta2 = 0.001, power = 0.62).
Results from univariate F-tests regarding Social Func-
tion and Gender are shown below. For means and stan-
dard deviati ons see Table 1.
Table 1. Means and (standard deviations) for social function (very low, low, intermediate, higher) and gender (men, women) in re-
gard to consumer’s satisfaction (ConSat), global quality of lif e (G QL), and perceived global distress (PGD).
Very low Low Intermediate Higher
Men Women Men Women Men Women Men Women
ConSat 70.78
(15.87)
70.03
(17.48)
73.35
(13.85)
75.53
(14.11)
75.96
(14.32)
78.05
(13.73)
78.90
(11.68)
81.63
(12.33)
GQL 56.59
(27.90)
51.50
(30.27)
59.45
(24.91)
57.32
(25.43)
62.16
(21.95)
60.62
(24.59)
68.40
(20.66)
69.55
(21.11)
PGD 57.79
(29.36)
50.65
(32.69)
60.45
(27.64)
55.89
(28.40)
67.29
(25.42)
62.08
(27.56)
70.80
(24.64)
72.53
(27.08)

B. Ivarsson et al. / Open Journal of Psychiatry 1 (2011) 88-97 92
3.1. Social Function
Univariate F-tests showed significant effects for ConSat
[F (3, 2544) = 42.19, p < 0.001], GQL [F (3, 2544) =
30.59, p < 0.001], and PDG [F (3, 2544) = 38.03, p <
0.001]. Post hoc testing (Tukey-HSD, 5% level) showed
concerning ConSat significant effects between all the
four groups according to a trend where the group with
the higher function was the most satisfied with the care
while the group with very low function was the least
satisfied group. Similar pattern was found for GQL,
where those with the best function scored more posi-
tively while those with the worst function score more
negatively (even though there were no significant effects
in regard to the low and intermediate groups) and for
PGD (even though there was no significant difference
between the very low function group and the low func-
tion group). Subsequently trend tests (Difference Cus-
tom Hypothesis Tests, 5% level) confirmed significant
trends for all dependent variables indicating that the hi-
gher the social function, the higher would participants
score on dependent variables.
3.2. Gender
Univariate F-tests showed significant effects for ConSat
[F (1, 2544) = 7.02, p = 0.008] and PGD [F (1, 2544) =
10.79, p = 0.001]. Descriptive analysis (Table 1) showed
that women were more satisfied with the care but also
more distressed as compared to men.
4. DISCUSSION
The present study had two main results: (a) With in-
creasing Social Function, as rated by professionals with
the split-GAF-F scale, the better were patients’ Con-
sumer Satisfaction, as well as their subjective Qu ality of
Lif e an d P ercei v ed G lob a l D ist re ss ; (b ) Women, as a gr oup,
were more satisfied with the care but also more dis-
tressed as compared to men.
4.1. Differences in Subjective Dimensions
According to Level of Social Functioning
In this study si gnificant effects were found between all the
four groups of Social function according to a trend where
the group with the higher function was the most satisfied
with the care while the group with very low function was
the least satisfied group as measured with ConSat. We
found no other studies describing associations between
consumers satisfaction in relation to GAF-F apart from
previous work from our group, where an Assertive Com-
munity Treatment (ACT) based CM program was com-
pared with best usual praxis showing improved ConSat
and GAF-F scores (whereas GAF-S, symptoms severity,
and split-GAF total did not improve) [10].
Studies using the original GAF together with other
satisfaction scales targeting similar conceptual domains
as ConSat provide some support to our findings, judged
with caution considering the complexity of satisfaction
construct [12]. For instance, in a study with schizoph-
renia in a Swedish city an association between psychoso-
cial functioning as measured by GAF and satisfaction
with care was found, and its relationship with subjectiv e
quality of life, sense of coheren ce, satisfaction with daily
occupations, self-directedness, interviewer-rated quality
of life, psychopathology, and psychosocial functioning
[35]. A study in Japan found patients with higher satis-
faction amongst generally-insured, mainly other then
schizophrenia patients with higher GAF, whereas no
correlation was found for the less satisfied mainly schi-
zophrenia patients [36]. An evaluation of the Lambeth
Early Onset team, found GAF associated with consumer
satisfaction, attributable to satisfaction with staff man-
ners, perceived competence, willingness to listen, type of
service offered, and belief that the treatment “is right for
me” [37].
In the present study a significant trend was found for
Quality of Life indicating that the higher the social func-
tion, based on GAF-F grouping, the higher would par-
ticipants score on subjective quality of life, even though
there were no significant effects in regard to the low and
intermediate functioning groups in univariate F-tests. In
a previous study in part of the cohort modest correlation
between GAF-F and GQL was found (rho = 0.18) [23].
This is in line with previous research suggesting that
these dimensions might be independent and should be
assessed separately [38].
The only other study found concerning mainly schizo-
phrenia patients using GAF-F and a quality of life meas-
ure (Lehman Quality of Life scale), was a First-Episode
Schizophrenia Scandinavian study, but no associative
results were presented allowing comparison [39]. Stud-
ies that described changes with other quality of life
measures together with GAF-F changes, but in other
patient groups, also give some support to the use of
GAF-F for categorizing social functioning [40,41].
As mentioned in the instruments section, the GQL was
developed from the corresponding item in MANSA and
LQOLP, and GQL correlation with the initial item of
MANSA, “Life as a whole” was rho = 0.86, with the
MANSA-total sum rho = 0.66. With this in mind, find-
ings in a study with schizophrenia patients at six sites
within the UK that found a correlatio n between MANSA
and GAF-F of r = 0.36 seems in line with the present
study [42]. This fairly low correlation in the two studies
can be assumed to indicate a relatively weak association
and be a reason why there was no significant effects on
GQL in regard to the low and intermediate functioning
groups in univariate F-tests in the present study. This is
not disappointin g. A modest association between qu ality

B. Ivarsson et al. / Open Journal of Psychiatry 1 (2011) 88-97 93
of life and social functioning on group level is precisely
a reason why the Quality star network in cluded the GQL
in its follow-up system, to be a remainder that in indi-
vidual cases subjective quality of life may often be per-
ceived as low though other measures are good, or vice
versa.
Thus, it should not be assumed that GAF-F social
function ratings, as a rule, are strongly associated with
subjective experience outcomes measures such as self-
esteem or satisfaction with life [43].
In this study a significant trend for the perceived menta l
distress, using the Perceived Global Distress scale, was
found, indicating that the higher the social function,
based on GAF-F grouping, the better would participants
score on PGD, even though there was no significant ef-
fects in regard to the “Very low” function group and the
“Low” function group in univariate F-tests. In previous
work it was shown that correlations between PGD and
different subjective and objective measures varied but
depressive features seemed to play an important role in
patients’ construct of PGD [24].
The reliable use of GAF-F groupings for describing
associations with distress also seems supported by re-
ports by others in distress associated areas. Such reports
are available regarding “Apathy” correlation with GAF-
F [44,45]. SCL90R and GAF-F both improved following
care at milieu therapeutic wards [41], a psychotherapeu-
tic program with mainly borderline patients showed im-
provements in GAF-F, and ratings on Target Complaint
(TC), a measure to provide information about the three
major complaints that led to seek treatment [40 ]. Reports
of distress related measures between patient groups with
parallel use of GAF-F and are also supportive. Such re-
ports include a reports regarding “self-certainty” for bi-
polar and schizophrenia patients [46], using the Beck
Depression Inventory (BDI) and the Beck Anxiety In-
ventory (BAI) for schizophrenia and mood disorder pa-
tient groups [47], narcissism using the Narcissistic Per-
sonality Inventory (NPI-21), self-esteem and “self-be-
liefs about ability to cope” using the Rosenberg Self-
Esteem Scale (RSES) in acute ward patients [48], and
results with The Generalized Self-Efficacy Scale in a
milieu therap eutic wards study [41].
4.2. Differences in Subjective Dimensions
According to Gender
A main result in this study was that women, as a group,
were found more satisfied with the care but also more
distressed as compared to men, whereas no difference
was found regarding quality of life. The finding that
women are more satisfied with the care than men is in
line with other studies, for instance reported from Nor-
wegian outpatient clinics within 33 health trusts [49],
and from a psychiatric catchment area in south Rome,
Italy [50]. However, yet other studies found no gender
differences regarding satisfaction with care and service,
for instance in the EPSILON project regarding schizo-
phrenia in five European countries [ 51], an d a study with
a community mental health team in North Yorkshire,
England [52]. A pilot study by Nysam (A Swedish net-
work for development of Key Figures) using the Quality
Star instruments, report a ConSat mean of 75 with small
variations between diagnoses but no significant differ-
ences between men and women [53] .
In a previous work in part of the present cohort it was
found that women were significantly more satisfied than
men with the provided care, according to scores on
ConSat, during an entire six year period studied, than
men, though both show ed increasing tendencies [2 5]. As
no major differences in patient characteristics between
genders were evident, it was hypothesized that service
factors may be part of an explanation. The service deliv-
ery model of most services participating in the Quality
Start cooperation are devoted to case-management and
ACT principles and several centers practices a developed
form of shared decision making, in which the Quality
Star method is integrated. The question was raised, if
this program and service form may attract women more.
The finding in this study that women, as a group, were
more distressed, according to scores on the PGD scale,
as compared to men, (whereas the opposite was the case
for consumer satisfaction) is in line with finding in the
mentioned Nysam study [53]. PGD self-ratings in the
present study was 61.46, whereas the total mean in the
Nysam study was in the range of 63 - 67 for psychosis
patients (with women slightly more distressed than men),
in contrast to means 57 - 32 in other diagnostic groups,
where women were particularly more distressed in the
affective disorder groups then men.
In view of previously mentioned opinion that subject-
tive measures tend to be largely influenced by mood [12]
and that much of the feelings of being ill seems to be
channeled via affective symptoms [54], the question
could be raised if affective aspects of perceived distress
are particularly detected with the PDG, as its construct
was found strongly associated to depressive features [24].
Possibly women express more perceived distress am-
ongst psychosis SMI patients through a depressive com-
ponent. To clarify this further, it would be fit to, in the
first place, explore this using MANSA, reported on item
level, together with relevant variables, as PGD is derived
from the last MANSA item “How satisfied are you with
your mental health” for stand-alone use. Our literature
search failed at this time to find such studies.
A final finding in this study was that there was no dif-
ference between men and women regarding perceived
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B. Ivarsson et al. / Open Journal of Psychiatry 1 (2011) 88-97 94
quality of life, measured by the GQL scale. Similarly,
the previously mentioned Nysam study found no sig-
nificant difference in this regard [53]. This finding is in
line with, for instance, a pooled analysis of 16 studies
(using MANSA or LQOLP) to study factors influencing
subjective quality of life in patients with schizophrenia
and other mental disorders, where it was found that
gender did not have an effect [55]. Likewise, using the
LQOLP instrument, it was found in a study with schizo-
phrenia patients in the Netherlands that gender was not
related to general quality of life [5 6]. The referred works
and others have elaborated on what other factors have
major effect on quality of life. To clarify this further, it
would, again, be fit to explore this using MANSA or
LQOLP, reported on item level, together with relevant
independent variables, as PGD is derived from the first
MANSA item regarding satisfaction with “Life as a
whole” for stand-alone use.
4.3. Limitations of the Study
Although the fo ur groups of functiona l levels were suffi-
cient to show variations in subjective measures in the
cohort of serious mentally ill, it might have been of cer-
tain interest to add subjective evaluations from patients
below GAF-F 30 (where intensive care and service is
often needed) and to add a separate analysis of the main
diagnostic group of sch izophrenia in the material.
4.4. Final Remarks
A secondary result comes out of the use in this study of
the fairly new split-GAF Social Function subscale, GAF-
F and its use for categorizing functioning into “Very
Low” to “Higher” Social Function groups. Literature re-
garding split-GAF use is still limited. A search for re-
ports using this instrument revealed 32 articles citing the
main methods article [20]. Summarizing, none of the
studies were found with a patient groups similar to the
cohort in the present work allowing direct comparisons.
However, the descriptions found of GAF-F differences
between patient groups, and, in some cases, changes
over time are judged supportive to GAF-F reliability
allowing its use to discriminate between group levels
and justify our GAF-F based subdivision into “Very
Low” to “Higher” Social Function groups.
In the present study, there was a trend for all three
subjective areas in our study, i.e. consumer satisfaction,
subjective quality of life and perceived distress, to have
higher ratings with increased levels of observed social
function. It may intuitively seem plausible that the three
subjective dimensions travel together in the same direc-
tion. The first study question regarding differences in
subjective measures depending on functional levels, thus
got a positive answer, and, it may be added, this was
possible to demonstrate with the global generic measures
used. The second question, regarding the influence of
gender differences was also verified. The combined ef-
fect of functional level and gender on the patient subject-
tive measures was however not shown on significant
level. Bearing in mind that the study was carried out as a
cross-sectional study and our familiarity with case-mix
differences between centers and also reminding that, as
exemplified from the literature in the preceding discus-
sion, variations in levels of effects of gender and func-
tional levels on different subjective measures has been
noted by several researches, this result underline the
importance of scrutinizing case-mix details before com-
paring between p atien t groups or serv ices. As th e presen t
cohort can be expected to be fairly representative for
schizophrenia dominated SMI specialized psychiatric
care in Sweden, it might be suggested to standardize
materials regarding gender and functional levels before
at all comparing centers regarding patient subjective out-
comes.
The questions must also be raised to what extent
variations shown might be explained also by the con-
structs of the measures used. For instance, the PGD may
possibly be sensitive to “mood” elements, and it merits
further studies to ascertain such aspects in comparison
with other constructs. Other possible explanatory factors
to the variations are for instance duration of illness, syn-
drome severity, as well as service delivery elements,
both in form and in contents. Further studies in the series
of investigations with the Quality star cohort should ad-
dress this, by adding such factors in group analyses.
For the basic aim of the Quality Star, to be a tool to
support dialogue with the individual patient, the result
support the importance of talking though the situation in
a multi-dimensional perspective as it is obvious that the
general tendency that though subj ective meas ur es tend to
“travel together” there is important individual variations
in this sence. Thus, we do agree with for instance Prieb e
et al. [57] in their suggestion that: “If one is to make use
of subjective assessments for the planning and delivery
of care and treatment one has to use different instru-
ments.” In this sense The Quality star, with a balanced
mix of user perceived and clinician ratings, is an out-
come-informed model for a clinical management based
on shared decision making.
5. CONCLUSIONS
The main findings, that subj ective reports of satisfactio n,
quality of life, and distress are more positive the better
rated functioning, were in line with other studies. How-
ever, the gender differences in these respects are in line
with some, but not with other, studies. This poses ques-
tions how patient factors, instrument constructs, and

B. Ivarsson et al. / Open Journal of Psychiatry 1 (2011) 88-97 95
treatment, especially shared decision making, influence
subjective reports. Basic common variables in all these
respects are needed in routine care to facilitate service
comparisons. The Swedish “Quality star” initiative is an
attempt to support development in this direction. The
present study indicated that the used global measures
could be sufficient for overview group comparisons, and
supports that further efforts should be made to develop
the model regarding routine reporting of needed vari-
ables.
6. ACKNOWLEDGEMENTS
Authors acknowledge the excellent technical assistance of Göran
Eiman, RN, Ass. Head Psychiatric dept., Kungälv Hospital, Kungäl v in
preparing the data base used. Our gratitude is also expressed to all
users of the Quality Star method and their willingness to make their
data available for this study.
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