Introduction

The outcome studies of schizophrenic patients treated with anti-

psychotic drugs (APs) have traditionally been focused on the eval-
uation of positive and/or negative symptoms through the admin-
istration of classical rating scales such as BPRS, PANSS, and CGI,
while symptoms such as the subjective experience toward the
illness and its drug treatment have been considerably neglected.
Subjective experience can be described as an inner feeling that
a patient perceives of his or her body, mind, relationships toward
others, disease, and medication. In a comprehensive evaluation
of the drug treatment of schizophrenia, the assessment of the
subjective experience of the patient toward the drug adminis-
tered should be considered an important tool to measure the
quality of treatment [4, 8].
A number of studies indicate that a patient's subjective experi-
ence to APs and the adherence to treatment are key factors in en-
suring a smooth recovery from illness [26], as it has been docu-
mented that an increase in a patient's adherence may improve
the outcome of schizophrenia [3].
Although there has been interest in the study of the subjective
experience of schizophrenic patients since the 1950 s, it was not
until the 1980 s that the majority of studies on the assessment of
subjective experience were published [22]. In addition, a number
of studies comparing first-generation antipsychotics (FGAs) and
second-generation antipsychotics (SGAs) found a more favorable
subjective experience in those who were taking SGAs [13,15].
Nowadays the following scales measuring subjective experien-
ces and attitudes toward treatments are available:
Performance of the Italian Version of the Subjective
Well-being Under Neuroleptic (SWN) Scale in
Schizophrenic Outpatients
M. Balestrieri
1
G. Giaroli
2
M. Mazzi
2
C. Bellantuono
2
Affiliation
1
Centro InterUniversitario di Neuroscienze Comportamentali, Dipartimento di Patologia e Medicina Clinica e
Sperimentale, University of Udine
2
Sezione di Psichiatria e Psicologia Clinica, Dipartimento di Medicina e Sanit Pubblica, University of Verona
Correspondence
Prof. Cesario Bellantuono Sezione di Psichiatria e Psicologia Clinica Dipartimento di Medicina e Sanit
Pubblica Universit di Verona Policlinico G. Rossi Piazza L. Scuro 37134 VERONA Italy
Phone: +39.045.8074.442 Fax: +39.3387004577 E-Mail: cesario.bellantuono@univr.it
Received 13.6.2005 Revised 15.10.2005 Accepted 1.11.2005
Bibliography
Pharmacopsychiatry 2006; 39: 14 Georg Thieme Verlag KG Stuttgart New York
DOI n
ISSN 0176-3679
Background: Several studies indicate that subjective experience
toward antipsychotic drugs (APs) in schizophrenic patients is a
key factor in ensuring a smooth recovery fromthe illness. Objec-
tive: The principal aim of this study was to establish the psycho-
metric performance of the Subjective Well-being Under Neuro-
leptic (SWN) scale in its Italian version and to assess, through
the SWN scale, the subjective experience of stabilized psychotic
outpatients in maintenance with APs. Methods: The original
short version of SWN, consisting of 20 items, was back translat-
ed, and a focus group was also conducted to better improve the
comprehension of the scale. Results: The results showed a good
performance of the Italian version of the SWN as documented by
the internal consistency (Cronbach's alpha; 0.85). A satisfactory
subjective experience was reported in the sample of schizophre-
nic outpatients interviewed (SWN mean total score: 84.95, SD:
17.5). Conclusions: The performance of the SWN scale in the
present study was very similar to that reported by Naber et al.
[18] in the original validation study. Large multi-center studies
are needed to better establish differences in the subjective ex-
perience of schizophrenic patients treated with first- and sec-
ond-generation APs.
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the Neuroleptic Dysphoria Scale (NDS) [25];
the Drug Attitude Inventory, available in a long and a short ver-
sion (DAI 30 items, DAI 10 items) [9,10];
the Rating of Medication Influence (ROMI) [27];
the Attitude Toward Medication Treatment (ANT) [11];
the Personal Evaluation of Transitions in Treatment (PETiT)
[26]; and
the Subjective Well Being Under Neuroleptics, available in a
long and a short version (SWN 38 items, SWN 20 items)
[16,18].
Of these instruments, only the DAI-30, in its Italian version, has
been validated and used in an outpatient setting [23].
The first aim of this study was to assess, in a sample of schizo-
phrenic outpatients, the psychometric performance of the Italian
version of the SWN scale (20 items). In previous validation stud-
ies, this scale has shown a good performance in terms of reliabil-
ity and sensitivity [12,16].
Secondary aims of the study were to evaluate the subjective ex-
perience of schizophrenic patients and to establish whether
there were differences between patients treated with FGAs ver-
sus SGAs.
Methods
The SWN scale
The SWN scale was originally designed by Naber [14] in a 38-
itemversion, with the aimof exploring the subjective experience
of psychotic patients towards their illness and medication; a
short version of 20 items was further validated in 2001 [18].
The SWN scale contains five subscales consisting of four items
each:
1. mental functioning (MF),
2. self-control (SC),
3. emotional regulation (ER),
4. social integration (SI), and
5. physical functioning (PF).
Items have to be endorsed on a six-point Likert scale [18]. The to-
tal score ranges from a minimum of 20 (poor subjective experi-
ence) to a maximum of 120 (excellent subjective experience). To
be able to calculate the total score and the sub-scores, some
items have to be reversed [18].
Translation and focus group on the SWN
In this study, the SWN scale was translated into Italian from the
English version by an Italian trainee in psychiatry (G.G.) and was
translated back to English [22] by an English-speaking benefit
counselor (A.C.). The two versions have been compared and cor-
rected to be as faithful as possible to the original English version.
Then a focus group [14] consisting of two trainees in psychiatry
(P.C. and S.T., conductor of the group), two psychiatric nurses (R.L
and R.C.), one psychologist (C.P.), two parents of psychotic pa-
tients (B.C. and F. F.), and two fully remitted schizophrenic pa-
tients (T.B. and M.P.) was carried out. Only a few difficulties
were observed in the comprehension of items 2, 5, 8, 15, 17, 18,
and 19. However, these problems were overcome after minor
changes to the Italian translation.
Recruitment and inclusion criteria
The Italian version of the SWB was administrated to consecutive
schizophrenic outpatients attending two Community Psychiatric
Services (CPS) located in the Friuli-Venezia-Giulia and Veneto re-
gions, run by the Academic Departments of Psychiatry of Udine
and Verona, respectively.
Inclusion criteria for patients enrolled in the study were (1)
being 1865 years old and (2) being on a stabilized antipsychotic
drug treatment (with a first- or second-generation AP) during
the last month; the combination of AP monotherapy with other
psychotropic drugs (antidepressants, benzodiazepines, and a
mood stabilizers) was allowed. Patients were adequately in-
formed about the aims of the study and all gave their written
consent to participate to the survey.
Statistical Analysis
Cronbach's alpha was utilized to analyze the internal consisten-
cy. To investigate differences in SWN scores by gender and by
type of Aps, a t-Student test for independent analysis was used.
A nonparametric statistic was used to compare SWN scores by
age groups. ANOVA analysis was also performed for investigating
the co-therapy. All statistical analysis was performed using SPSS
11.5.
Results
The sample consisted of 98 patients, 52 recruited in the Verona
CPS and 46 in the Udine CPS. The diagnoses of the patients
were, according to DSM IV-TR [1], schizophrenia for 86 patients,
schizoaffective disorder for 9 patients, and delusional disorder
for 3 patients. The mean age of the patients was 42.7 (11 DS),
and the gender distribution showed a significant majority of
males over females (54.1% vs. 45.9%, respectively).
On the whole, 55% of the total sample were taking a monother-
apy (22 patients with a FGA, 32 with a SGA), while 45% were
treated with a psychotropic drug combination.
About 40% of the sample were in treatment with a FGA; of this,
22% were receiving a long-acting medication (as fluphenazine or
haloperidol long-acting). About 60% of patients were on SGA: 21
with olanzapine, 12 with clozapine, 18 with risperidone, and 8
with quetiapine.
The psychometric performance of the SWN
Table 1 shows the performance of the SWN scale. The mean total
score was 84.95 (SD 17.5), which can be interpreted, according to
the scoring, as a satisfactory level of subjective well-being. The
mean scores for the subscales were as follows: MF = 16.96 (SD
4.52), SC = 16.87 (SD 3.91), ER = 17.54 (SD 3.76), SI = 16.78 (SD
3.98), and PF = 16.81 (SD 4.39).
The internal consistency, as measured with the Cronbach's alpha,
for the whole scale was 0.85, while for the subscales the coeffi-
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cients were as follows: MF = 0.76, SC = 0.53, ER = 0.54,
SI = 0.50, and PF = 0.67.
The SWN according to age, sex, and drug treatment
Treatment with FGA and SGA by age and gender was evenly dis-
tributed. No differences were evident in SWN total score by gen-
der (t = 0.27, df = 96, P = 0.97) or age group (1829, 3039, 40
49, 5065) (F = 0.41 P = 0.626).
Table 2 shows that there were no differences in SWN total scores
(as well as single sub-scores; not shown) between patients treat-
ed with FGAs versus SGAs (t = 1.6, df = 96, P = 0.12). Even when
we performed the same exercise on selected samples of patients
in monotherapy, we could not find any significant statistical dif-
ferences in SWN total scores between patients taking FGAs ver-
sus SGAs (t = 0.5, df = 52, P = 0.65).
Discussion
This is the first study carried out with the aim to establish the
psychometric performance of the SWN scale in an Italian sample
of stabilized schizophrenic patients taking AP drugs.
The study presents the following limitations: (1) we did not per-
form a testretest reliability, and (2) the Italian version was
translated and back translated from the English 20-item version
published by Naber et al. [18] and not from the original German
version.
It is of interest to note that our study presents some differences
as compared with Naber's original study [16].
1. Our patients were recruited among those in contact with out-
patient services, while Naber's original sample included only
inpatients. Even taking into account that in the Italian mental
health system the use of hospital admissions is quite infre-
quent, it is probable that the psychopathology of our sample
was less severe than that observed in the original sample.
2. Our study included older patients (mean age 42.7) as compar-
ed with Naber's sample (mean age 36.6).
Notwithstanding these differences, it is remarkable that the per-
formance of the SWN scale was so similar in the two samples. In
both studies neither age nor gender distribution were signifi-
cantly associated with the SWN scores. At discharge, the patients
studied by Naber reported a positive subjective experience, which
was similar to that observed in the patients of our CPS.
However, even if the mean scores were quite similar, in our sam-
ple the SWN showed a worse internal consistency in all the
measures, and in particular in the subscales of self-control, emo-
tional regulation, and social integration. Although it is difficult to
understand the reasons for such differences, we must underline
that even in the original sample these measures showed a lower
performance. Despite this outcome, our results emphasize the
impression that the measures of emotional regulation, self-con-
trol, and social integration may require a better assessment. We
suggest considering conservatively the general measure of SWN
as an excellent measure of the subjective well-being during
treatment with APs, without considering the single subscales.
Even though in our sample we were unable to find any statisti-
cally significant difference between FGAs and SGAs, it should be
noted that this could have been determined by the fact that we
did not assess the psychopathology of the patients treated with
different APs.
Table 1 Psychometric characteristics of the Italian version of the SWN compared with the Naber study [16]
Our sample (n = 98) Naber study (n = 212)
Mean (SD) Internal consistency
(Cronbach's alpha)
Mean (SD) at discharge Internal consistency
(Cronbach's alpha)
SWN total score 84.95 (17.5) 0.89 84.79 (16.5) 0.92
Mental functioning 16.96 (4.5) 0.76 16.24 (4.3) 0.80
Self-control 16.87 (3.9) 0.53 16.44 (3.9) 0.63
Emotional regulation 17.54 (3.7) 0.54 17.94 (3.9) 0.73
Social integration 16.78 (4.0) 0.50 16.90 (4.4) 0.74
Physical functioning 16.81 (4.4) 0.67 17.28 (3.4) 0.82
Table 2 Mean score of the SWN total score and use of antipsychotic drugs
Mean SD t-Student P
SWN total score for individuals treated with FGAs (n = 39) 88.31 15.04 1.6 0.12
SWN total score for individuals treated with SGAs (n = 59) 82.73 18.69
SWN total score for individuals treated with FGAs in monotherapy (n = 22) 85.86 15.86 0.5 0.65
SWN total score for individuals treated with SGAs in monotherapy (n = 32) 83.59 19.35
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Moreover, our sample was too small to allowthe detection of any
significant difference in the subjective well-being of patients
treated with each SGA. However, it is reasonable to think that,
because of the different pharmacological profiles of these drugs,
such differences may exist. It has been documented that negative
subjective response to APs could be caused by the inhibition of
the dopaminergic system of reward [2, 5, 6]. Recently, De Haan
et al. [7] studied, through single-photon emission tomography,
D2 receptor occupancy in the striatum of patients affected by
schizophrenia and treated with APs. They found that receptor oc-
cupancy between 60% and 70% was correlated with a good sub-
jective experience as measured with the SWN scale [18]. Given
this evidence, one may expect that pharmacological agents act-
ing with a different degree on D2 receptors would determine dif-
ferent experiences of well-being. Previous research demonstrat-
ed that under this profile clozapine was superior to FGAs [16],
olanzapine was superior to both risperidone and clozapine [18],
and olanzapine was not inferior to clozapine [20].
A large multi-center study is currently in progress in five Italian
psychiatric community services (SubWeb Study) to better define
this important issue.
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