Comparing Life Experiences of College Students with Differing Courses of Schizophrenia in Korea: Case Studies

Perspectives in Psychiatric Care, May 2006 by Sung, Kyung-Mi, Kim, Soyaja, Puskar, Kathryn R, Kim, Euisook

PURPOSE. The objective of this study was to identify how daily experiences of college students with schizophrenia reflected the course of their disease.

METHODS. The sample included 8 college students with schizophrenia. Comparisons of life experiences were made across disease courses using themes established in a prior study.

FINDINGS. Subjects had different themes according to the following three disease courses: recovering, deteriorating, and fluctuating.

CONCLUSIONS. This finding provides support for developing intervention strategies for college students in each disease course, such as the unique ways that psychiatric nurses can help college students with difficulties due to serious mental illness.

Search terms: Schizophrenia, college students, life experience, recovering course, deteriorating course, fluctuating course

The course of schizophrenia has been the subject of extensive investigations. Many researchers have reported a poor outcome in schizophrenia (Harrow, Grossman, Jobe, & Herbener, 2005; Lay, Blanz, Hartmann, & Schmidt, 2000; Fencer, Addington, & Addington, 2005). Only about 20 to 25% of patients with schizophrenia achieve complete recovery (Heiden & Hafner, 2000; Unger, 1990), and less than half of patients diagnosed with schizophrenia show substantial clinical improvement (Hegarty, Baldessarini, Tohen, Waternaux, & Oepen, 1994). Furthermore, several studies about schizophrenia have reported the highly variable nature of the illness and the difficulty in predicting outcome, particularly at the individual level. Sources of course variability, independent of schizophrenic pathology per se, have received extra focus in the current literature (Rakfeldt & McGlanshan, 1996; Walker, Kestler, Bollini, & Hochman, 2004).

Recently, researchers have focused on recovery in schizophrenia. Recognition and intervention at the earliest stage of schizophrenia and related disorders may contribute to good outcomes, such as earlier symptom remission, delay of psychotic relapse, and prevention of psychosocial deterioration (Buckley, Dayem, Parker, & Weisser, 2001; Larsen et al., 2001; McGlashan, 1996; Robinson, Woerner, McMeniman, Mendelowitz, & Bilder, 2004). On the contrary, a long duration of untreated psychosis has been found to predict more severe forms of schizophrenic illness-for example, more psychotic relapses and delays in symptom remission (Kohn et al., 2004). Evidence in support of these findings have been described in young people with early onset psychosis (Loebel et al., 1992; McGorry, Edward, Mihalopoulos, Harrigan, & Jackson, 1996). By using qualitative data, some researchers have been describing recovery experiences and courses of illness in schizophrenia (Sells, Stayner, & Davidson, 2004; Spaniol, Wewiorski, Gagne, & Anthony, 2002).

The criteria for recovery from schizophrenia have also been investigated from various perspectives. Noordsy and colleagues (2002) proposed an operational definition of recovery that consists of three components: hope, taking personal responsibility for illness management and wellness, and getting on with life beyond illness. Whitehorn, Brown, Richard, Rui, and Kopala (2002) have defined three key dimensions in the process of recovery from a first episode of a psychotic disorder: symptom control, autonomous daily living, and return to the social and occupational life line. Recently some researchers have proposed resilience as a new concept related to recovery from living with schizophrenia (Geanellos, 2005). According to Andresen, Oades, and Caputi (2003), a resilient person has faith in his or her own ability to maintain a positive outlook, lives a meaningful life, and looks forward to the future. Early mental health screening, assessment, and treatment as a common practice is one of goals suggested by the President's Commission (New Freedom Commission on Mental Health, 2003). Early intervention in psychosis is an especially important challenge related to recovery for psychiatric health services. The purpose of this study was to address the practical guidance that is specific to the phases of illness in early schizophrenia. We studied how daily experiences of college students with schizophrenia reflected the courses of the disease.

Methods

This study was an in-depth analysis of eight case studies designed to describe the experiences of college students with schizophrenia. This study was an extended study based on the findings of a previous qualitative study (Sung & Puskar, 2006). The aim of this study was to identify the students' subjective experiences according to their disease progression. We used operational definitions of recovery for determining disease courses: symptoms remission, successful school attendance, maintaining social activity, and having peer relationships (Liberman, Kopelowicz, Ventura, & Gutking, 2002). To establish the historical progression of their experiences, we ordered themes by time and sequence, preserving the personal historical flow (Miles & Huberman, 1994). The sample consisted of 8 of 21 participants from a prior study (Sung & Puskar, 2006) by selection criteria for this study. First, we excluded three participants who transferred to other local hospitals or who were admitted to a hospital at the time of the study; two respondents who refused to participate; and five informants who had insufficient medical records. The remaining 11 participants had good medical progress notes, including symptoms, treatments, and general histories, as outpatients of the two university hospitals participating in the study, and each of whom volunteered to participate in additional interview sessions after the prior study. Three respondents were unable to complete their interviews because of absence and attention problems. Informants had been diagnosed with schizophrenia of more than 2 years' duration and were college students within the last year of college at the point of data gathering. There were 3 females and 5 males; 3 sophomores, 3 juniors and 2 seniors; 3 attending school and 5 absent from school (Table 1). Data were collected by in-depth interviews in the context of the previous study; two more interviews with each of the eight participants were conducted in attempts to determine precisely when the students were experiencing themes related to disease progression as revealed by reviews of their medical records. Interviews with each of the eight study respondents were held privately by the researcher (K. M. Sung) over the period spanning October to December 2002 at two university hospitals in Korea. The questions for the interviews were informed by the themes established in the prior study: experiences of family interactions, interactions with friends, school life, everyday life, social role performance and mental illness. These themes were developed through qualitative content analysis and validated through extensive review together with a senior psychiatric nursing educator with experience in qualitative research. Each interview lasted 40 to 60 min for a total of 16 interviews. Data were analyzed by analysis of content (Holsti, 1969), and were matched with each theme conducted from prior study. The study protocol was approved by the institutional review board (IRB) of the two participating university hospitals. All participants gave informed consent; their confidentiality and anonymity were protected.