Social class of origin, lost potential, and hopelessness in schizophrenia

A Scoping and Systematic Review of Employment Processes and Outcomes for Young Adults Experiencing Psychosis

Young adults who experience psychosis want to work but are less likely to be employed than their peers. Sixty two studies relating to young adults with psychosis and employment were reviewed following a systematic search of five databases: CINAHL, PsycINFO, MEDLINE, SCOPUS and EMBASE. Publication date ranged from 1973 to 2019 with > 70% between 2010 and 2019. Intervention was considered in 29 papers; critical appraisal revealed 90% of these had moderate to good methodological quality with only three RCTs. Of 11 intervention types "Early Intervention" and "Individual Placement and Support" were most common; both demonstrating positive impact on obtaining employment. The review identified minimal participant perspectives and great variability in: terminology used; the reporting of participant attributes; intervention characteristics and ways employment outcomes were measured. Employment processes identified were preparing for, seeking, obtaining, keeping and re-obtaining employment, with current research efforts focused on obtaining work. More focus is required on keeping and re-obtaining employment.

Painful insight vs. usable insight in schizophrenia. Do they have different influences on suicidal behavior?

BACKGROUND

Suicidal behavior is highly prevalent in schizophrenia. Among the risk factors, insight has been little studied and has yielded contradictory results. In addition, it has been studied neglecting relevant psychological aspects, such as beliefs about illness and coping styles.

METHOD

We assessed 133 outpatients diagnosed with schizophrenia according to ICD-10 criteria. Evaluation included sociodemographic, general clinical, psychopathological, psychological and suicidal behavior variables.

RESULTS

Neither insight nor insight coupled with negative beliefs and/or coping styles were associated with suicidal behavior. Nevertheless, insight coupled with negative beliefs and/or coping styles was associated with greater hopelessness and depression, internalized stigma, worse control over illness and greater global severity as compared to insight coupled with positive beliefs and coping styles. Suicide attempt and suicidal ideation groups showed greater depression and hopelessness, worse global beliefs and worse control over illness, higher socio-economic level, and greater number of previous psychiatric admissions compared to the non-suicidal group.

CONCLUSIONS

Insight coupled with negative beliefs and/or coping style was not associated with suicidal behavior. Nevertheless, it was associated with greater depression and hopelessness, both of which are firmly established risk factors for suicide in schizophrenia. Prospective studies with long-term follow-up and large samples are needed to clarify this issue. Clinicians should assess these psychological features associated with insight, both in patients with insight and in those with poor insight when promoting it.

The economic burden of schizophrenia in Germany: A population-based retrospective cohort study using genetic matching

Objective

Prior studies to determine the economic consequences of schizophrenia have largely been undertaken in clinical settings with a small number of cases and have been unable to analyze effects across different age cohorts. The aim of this study is to investigate the burden of schizophrenia in Germany.

Methods

Costs, service utilization, and premature mortality attributable to schizophrenia were estimated for the year 2008 using a retrospective matched cohort design. Therefore, 26,977 control subjects as well as 9411 individuals with a confirmed diagnosis of schizophrenia were drawn from a sickness fund claims database. To reduce conditional bias, the non-parametric genetic matching method was employed.

Results

The final study population comprised 8224 matched pairs. The annual cost attributable to schizophrenia was €11,304 per patient from the payers’ perspective and €20,609 from the societal perspective with substantial variations among age groups: direct medical expenses were highest among patients aged > 65 years, whereas younger individuals (< 25 years) incurred the greatest non-medical costs. The annual burden of schizophrenia from the perspective of German society ranges between €9.63 billion and €13.52 billion.

Conclusion

There are considerable differences in the distribution of costs and service utilization for schizophrenia. Because schizophrenia is characterized by an early age of onset and a long duration, research efforts should be targeted at particular populations to obtain the most beneficial outcomes, both clinically and economically.

Social Status and Suicidal Activity Among Psychiatric Patients: Moderating Effects of Gender, Race and Psychiatric Diagnosis

The relationship between suicide and social class has proved to be complex. Durkheim predicted suicide rates would increase with social status, while others thought the opposite. Results have been mixed. In some studies, suicidality has increased with increasing social status, and in other studies, the two variables have had an inverse relationship. These studies have been primarily conducted on general non-psychiatric populations The present study, in contrast, examines this relationship on a 20-year prospective longitudinal sample of 400 psychiatric patients (differentiated by psychiatric diagnosis) after index hospitalization. Of these, 160 patients show some sign of suicide risk (87 cases of suicidal ideation, 41 of suicide attempts, and 32 suicide completions). A complicated pattern emerges across psychiatric diagnosis, gender, and race. The great majority of patients show no statistically significant relationship between social status and suicide risk. At the maximally different extremes, however, a dramatic difference does emerge. White women diagnosed with nonpsychotic depression show a positive relationship between social status and suicide risk (p < .01) while black men diagnosed with schizophrenia show a negative relationship between these 2 variables (p < .02). The relationship between social status and suicidality among psychiatric patients varies across race, gender, and psychiatric diagnosis. More research needs to be done on this complex and important topic, especially with regard to samples of psychiatric patients. The role of anomie should be studied.

Correlates and moderators of stigma resistance among people with severe mental illness

Research on factors associated with stigma resistance among people with severe mental illness remains relatively scant. This study aimed to (1) replicate previous findings linking stigma resistance with variables associated with recovery; (2) explore associations between stigma resistance and coping strategies and psychiatric symptoms; (3) compare these associations among individuals with different levels of self-stigma; and (4) examine whether race, age and education moderate these relationships. Analyses of a sample (n = 353) and sub-sample (n = 177) of persons with severe mental illness examined associations between stigma resistance and self-stigma, functional and clinical outcomes, and the moderating impact of age, race, and education on these relationships. Stigma resistance was significantly negatively associated with self-stigma and positively associated with social functioning, self-esteem, problem-centered coping, and symptoms of hostility-excitement, but not other types of symptoms. Race significantly moderated the relationship between stigma resistance and self-stigma, age significantly moderated the relationships between hopelessness and both stigma resistance and self-stigma, and education significantly moderated the relationship between stigma resistance and social functioning. Findings suggest that social circumstances impact the benefit of stigma resistance in complex ways; future work should aim to understand how these experiences impact stigma resistance to inform intervention development.

Psychosis as a risk factor for suicidal thoughts and behaviors: a meta-analysis of longitudinal studies

BACKGROUND

Research has long noted higher prevalence rates of suicidal thoughts and behaviors among individuals with psychotic symptoms. Major theories have proposed several explanations to account for this association. Given the differences in the literature regarding the operationalization of psychosis and sample characteristics, a quantitative review is needed to determine to what extent and how psychosis confers risk for suicidality.

METHODS

We searched PsycInfo, PubMed, and GoogleScholar for studies published before 1 January 2016. To be included in the analysis, studies must have used at least one psychosis-related factor to longitudinally predict suicide ideation, attempt, or death. The initial search yielded 2541 studies. Fifty studies were retained for analysis, yielding 128 statistical tests.

RESULTS

Suicide death was the most commonly studied outcome (43.0%), followed by attempt (39.1%) and ideation (18.0%). The median follow-up length was 7.5 years. Overall, psychosis significantly conferred risk across three outcomes, with weighted mean ORs of 1.70 (1.39-2.08) for ideation, 1.36 (1.25-1.48) for attempt, and 1.40 (1.14-1.72) for death. Detailed analyses indicated that positive symptoms consistently conferred risk across outcomes; negative symptoms were not significantly associated with ideation, and were protective against death. Some small moderator effects were detected for sample characteristics.

CONCLUSIONS

Psychosis is a significant risk factor for suicide ideation, attempt, and death. The finding that positive symptoms increased suicide risk and negative symptoms seemed to decrease risk sheds light on the potential mechanisms for the association between psychosis and suicidality. We note several limitations of the literature and offer suggestions for future directions.

The Role of Educational Attainment in Supported Employment

Rehabilitation counselors provide vocational services to consumers living with serious mental illness (SMI) who have an estimated rate of workforce participation from 10% to 30%. Services, such as supported employment (SE), have strived to overcome these figures. Yet, people living with SMI are often only qualified for employment within the secondary labor market. Human capital theory offers a useful theoretical framework for employment for persons living with SMI. The Brief Symptom Inventory Global Severity Index (GSI) and educational level were used to predict employment outcomes in a sample which consists of 105 individuals with SMI recruited from five SE programs in the mid-Atlantic region. Logistic regression with the predictors of time in SE, GSI, and educational level achieved was used to predict whether someone became employed within the next 6 months. The variable educational level was a significant predictor of successful employment outcome at the 6-month follow-up, Wald χ2 = 7.6, p = .003. The other two variables were not statistically significant. The current study suggests that it is difficult to ignore an individual’s education when considering his or her future achievement in employment. Furthermore, the findings of this study support utilizing human capital theory.

Overcome by or Overcoming Loss: A Call for the Development of Therapy for Individuals Mourning Vocational Loss in Schizophrenia

People with schizophrenia are often unable to realize vocational expectations because of schizophrenia-related functional impairments. This is particularly acute in those individuals from advantaged sociocultural backgrounds of whom much is expected. We present the case history of an acclaimed woman artist who lost artistic productivity with the advent of severe and persistent psychotic symptoms. We suggest that “loss of vocational potential” is a major loss worthy of grief work. Introduction and rationale are presented, followed by a case presentation that aims to illustrate the psychological effects of intangible loss for individuals suffering from serious mental illness. Three approaches to grief work are reviewed. The notion of incorporating grief work into the treatment of persons with schizophrenia is introduced. The authors call for increased attention to and study of the symbolic and emotional impact of the interpersonal and vocational losses that accompany schizophrenia. A carefully structured grief work intervention needs to be developed that maximizes adaptation and minimizes risk for suicide and that should be coupled with clinical indicators and validated outcome measures.

The impact of neuropsychological functioning and coping style on perceived stress in individuals with first-episode psychosis and healthy controls

Stress is implicated in the development and course of psychotic illness, but the factors that influence stress levels are not well understood. The aim of this study was to examine the impact of neuropsychological functioning and coping styles on perceived stress in people with first-episode psychosis (FEP) and healthy controls (HC). Thirty-four minimally treated FEP patients from the Early Psychosis Prevention and Intervention Centre, Melbourne, Australia, and 26 HC participants from a similar demographic area participated in the study. Participants completed a comprehensive neuropsychological test battery as well as the Coping Inventory for Stressful Situations (task-, emotion- and avoidance-focussed coping styles) and Perceived Stress Scale (PSS). Linear regressions were used to determine the contribution of neuropsychological functioning and coping style to perceived stress in the two groups. In the FEP group, higher levels of emotion-focussed and lower levels of task-focussed coping were associated with elevated stress. Higher premorbid IQ and working memory were also associated with higher subjective stress. In the HC group, higher levels of emotion-focussed coping, and contrary to the FEP group, lower premorbid IQ, working memory and executive functioning, were associated with increased stress. Lower intellectual functioning may provide some protection against perceived stress in FEP.

Social class mobility in first episode psychosis and the association with depression, hopelessness and suicidality

BACKGROUND

Psychotic disorders are associated with a significant impairment in occupational functioning that can begin in the prodromal phase of the disorder. As a result, individuals with a psychotic disorder may not maintain their social class at birth. The aim of this study was to examine the distribution of the social classes of individuals presenting with a first episode of psychosis (FEP) compared to the general population and to their family of origin. We evaluated whether social drift was associated with depression, hopelessness and suicidality at first presentation.

METHODS

All individuals with a FEP presenting to a community mental health service between 1995 and 1999 and to an early intervention service between 2005 and 2011were included. Diagnosis was established using the Structured Clinical Interview for DSM IV diagnoses and clinical evaluations included the Calgary Depression Scale for Schizophrenia, Beck Hopelessness Scale and the Suicidal Intent Scale.

RESULTS

330 individuals were included in the study and by the time of presentation, individuals with a FEP were more likely to be represented in the lower social classes compared to the general population. 43% experienced a social drift and this was associated with a diagnosis of a non-affective disorder, co-morbid cannabis abuse and a longer DUP. Individuals who did not experience a social drift had a higher risk of hopelessness.

CONCLUSIONS

Social drift is common in psychotic disorders; however, individuals who either maintain their social class or experience upward social class mobility are more susceptible to hopelessness.

Relationships between subjective or objective symptoms and mortality in schizophrenia: a prospective study on 310 schizophrenic patients with a median follow-up of 8.4 years

The aim of the study was to explore the relationships between subjective or objective symptoms and mortality in schizophrenia. 310 subjects meeting the ICD-10 criteria for schizophrenia were included in the study between 1998 and 2000. At the initial assessment the following variables were respectively assessed to evaluate subjective and objective symptoms: the Frankfurt Complaints Questionnaire (FCQ) and the Positive and Negative Syndrome Scale (PANSS). In May 2008, information about the subjects were collected in order to know if they are alive or not and if they are deceased to know the date and the causes of their death. Survival analysis was conducted using the Kaplan-Meier product-limit estimator and standardized mortality ratio (SMR) was calculated. A multivariate Cox regression was done to detect predictive factors associated with mortality. Absolute mortality rates were 10.01%, 4.46% and 5.42% for overall mortality, unnatural causes and natural causes, respectively. SMR for overall mortality was 4.73. Cox regression analyses showed that elevated scores of FCQ was significant predictor of deaths from unnatural causes. High levels of subjective symptoms, as rated by the FCQ were independent predictor of mortality by unnatural causes in schizophrenic subjects. There were several limitations: The causes of death were not determined by autopsy and secondly, the duration of the study could be insufficient to detect significant associations between clinical variables and mortality.

First episode psychosis and employment: a review

Despite considerable growth in treatments, interventions, services and research of young people with a first episode of psychosis, little attention has been given to the priorities of these young people, in particular, gaining employment. A literature review was undertaken with the aim of investigating: 1) whether young people with a first episode of psychosis want to work, 2) what challenges they experience regarding work, 3) what is understood about employment outcomes, 4) what the most effective interventions to enable them to gain employment may be, and 5) what the associated costs may be. The review found that these young people appear to want to work yet face a range of psychological and social challenges to achieving this. Typically by the time they first come into contact with mental health services a proportion are already falling out of education and employment, and this decline continues with contact with services. However, there are specific interventions that can support them to gain employment. The Individual Placement and Support approach, adapted to include support to fulfil educational goals, has demonstrated that a mean of 69% of young people with a first episode of psychosis can gain education and employment compared to 35% of controls.

Antecedents and patterns of suicide behavior in first-admission psychosis

BACKGROUND

Persons with psychotic illnesses have an increased risk for suicide, especially early in the illness. Sufficient knowledge allowing for early recognition is lacking.

OBJECTIVES

To describe suicide behaviors before and during the 4 years following first psychiatric hospitalization, examine associations of demographic and psychiatric risk factors, and develop a suicide risk index.

METHOD

Data came from the Suffolk County Mental Health Project, a first-admission cohort (n = 529). Cox regression was used to study associations of risk factors to suicide behaviors; a summary suicide behavior risk index was also tested.

RESULTS

Prior to first admission, 28.0% (n = 148) of the cohort had attempted suicide. During the 4-year follow-up, 13.6% (n = 72) of the cohort attempted suicide (29.7% of those with previous attempts and 7.3% making their first attempt) and 3 respondents died of suicide. The significant predictors at index admission of subsequent attempts were prior attempts or ideation, severity of depressive symptoms and thought disorder, lifetime substance abuse, and younger age. Suicide ideation was predicted by the same variables with the addition of insight into illness and with the exception of age at admission. A 3-category risk index was created; 61.1% of those who made a suicide attempt were in the highest risk group (n = 44/72).

CONCLUSION

The current study confirms and extends previous research showing that risk factors early in the course of illness are predictive of subsequent ideation and attempts. The risk index may be a useful adjunct in identifying individuals likely to benefit from preventive interventions.

Implementation of the thinking skills for work program in a psychosocial clubhouse

OBJECTIVE

Cognitive remediation programs aimed at improving role functioning have been implemented in a variety of different mental health treatment settings, but not in psychosocial clubhouses. This study sought to determine the feasibility and preliminary outcomes of providing a cognitive remediation program (the Thinking Skills for Work program), developed and previously implemented in supported employment programs at mental health agencies, in a psychosocial club-house.

METHODS

Twenty-three members with a history of difficulties getting or keeping jobs, who were participating in a supported employment program at a psychosocial clubhouse, were enrolled in the Thinking Skills for Work program. A neurocognitive battery was administered at baseline and 3 months later after completion of the computer cognitive training component of the program. Hours of competitive work were tracked for the 2 years before enrollment and 2 years following enrollment. Other work-related activities (school, volunteer) were also tracked for 2 years following enrollment.

RESULTS

Twenty-one members (91%) completed 6 or more computer cognitive training sessions. Participants demonstrated significant improvements on neurocognitive measures of processing speed, verbal learning and memory, and executive functions. Sixty percent of the members obtained a competitive job during the 2-year follow-up, and 74% were involved in some type of work-related activity. Participants worked significantly more competitive hours over the 2 years after joining the Thinking Skills for Work program than before.

CONCLUSIONS

The findings support the feasibility and promise of implementing the Thinking Skills for Work program in the context of supported employment provided at psychosocial clubhouses.

Work expectations, cultural sensitivity, schizophrenia, and suicide risk in male patients

This study examines the relationship between "vocational lost potential" and suicide risk in a mixed sample of severely and persistently mentally ill psychiatric patients. We hypothesized that increased lost potential would be associated with increased suicide risk indicator ratings and that this relationship would be moderated by patients' social class of origin. One hundred sixty-seven psychiatric patients rated a range of clinical symptoms and vocational expectations, as well as providing sociodemographic information including their parents' years of education (used as a proxy for social class of origin). Contrary to our prediction, the results suggest that individuals from higher social class who experience minimal lost potential may be at a higher risk for suicide than their counterparts with maximal lost potential; this is especially true when based on fathers' educational level. In discussing the clinical implications of our findings, we suggest that a subgroup of individuals' vocational success may depend on first addressing the cognitive conflict inherent in the phenomenon of lost potential.

Outcomes of public concern in schizophrenia

BACKGROUND

Schizophrenia is known to be associated with a range of adverse outcomes, which have an impact atthe societal level and are therefore of public concern.

AIMS

To examine the epidemiology and methods for measuring six adverse outcomes in schizophrenia: violence, victimisation, suicide/self-harm, substance use, homelessness and unemployment.

METHOD

A review ofthe literature was carried out for each adverse outcome, with attention to critical appraisal of existing measurement tools.

RESULTS

Schizophrenia is associated strongly with all six outcomes, although research has mainly focused on violence. Each outcome acts as a risk factor for at least some of the other outcomes. There are few standardised or validated measures for these 'hard' outcomes. Each measure has inherent biases but a growing trend is for these to be minimised by using multiple measures.

CONCLUSIONS

A single instrument which systematically measures multiple societal outcomes of schizophrenia would be extremely useful for both clinical and research purposes.

High social class and suicide in persons at risk for schizophrenia

OBJECTIVE

The relationship between suicide and social class has been equivocal. While some authors have reported that higher social class is related to higher rates of suicide, most other studies report that lower social class is associated with higher rates of suicide. Our study attempted to resolve these inconsistencies by using a High Risk for schizophrenia method.

METHOD

Children of women with severe schizophrenia were assessed in 1962. In 2005, when subjects were a mean age of 58 years, we identified those who had committed suicide.

RESULTS

A higher rate of suicide was associated with risk for schizophrenia in the High-Risk sample. Higher social class origin was associated with suicide in persons at risk for mental illness.

CONCLUSION

Higher social class origin was associated with suicide in subjects at genetic risk for schizophrenia (but not those without risk).

Suicide risk in schizophrenia: explanatory models and clinical implications, The Schematic Appraisal Model of Suicide (SAMS)

PURPOSE

The objective of this paper was to evaluate the Cry of Pain model of suicide behaviour as applied to psychosis and to derive theoretically driven guidelines for prevention. Suicide risk in psychotic patients is a serious but poorly understood clinical and social problem. There is a dearth of psychological models to explain suicidal behaviour and to guide effective preventative clinical interventions. Understanding suicidal behaviour in psychosis may be facilitated by utilizing models from depression. The 'Cry of Pain' model of suicide is founded on an evolutionary approach to understanding suicidal behaviour in depression.

METHODS

The model was critically evaluated and relevant literature reviewed.

RESULTS

Although strengths of the model were identified, lack of clarity regarding the concepts of defeat, entrapment, and lack of rescue appeared to limit its theoretical and clinical utility. We suggest a modification to this model which replaces concepts of defeat, entrapment, and lack of rescue with a four-stage appraisal process in conjunction with information-processing biases and suicidal schema.

CONCLUSIONS

Methods of testing this model are suggested and guidelines for a clinical intervention (Cognitive Behavioural Suicide Prevention for Psychosis; CBSPp) are outlined.

Developing psychological perspectives of suicidal behaviour and risk in people with a diagnosis of schizophrenia: We know they kill themselves but do we understand why?

People with a diagnosis of schizophrenia are at increased risk of suicidal behaviour yet little is understood of the psychological underpinnings of this vulnerability. The biopsychosocial 'Cry of Pain' model [Williams, J.M.G. (1997). Cry of pain. Harmondsworth: Penguin.] provides a broad framework from which to understand suicidal behaviour. However, the utility of the model in relation to suicide in schizophrenia has not yet been explored. This was the primary goal of this paper. Six components of the 'Cry of Pain' model were identified and evaluated with respect to whether they contributed to i. common transdiagnostic factors underlying suicide, ii. factors relating to co-morbid depression which account for suicidal behaviour, or iii. factors which are specific to schizophrenia and underlie suicide risk. The potential for applying the model to clinical management of suicide in schizophrenia is illustrated.

Socioeconomic status of origin and the clinical expression of Schizophrenia

The concentrated focus on biology during the "decade of the brain" has resulted in decreased attention to the indisputable influence of psychosocial and sociocultural factors in the expression of schizophrenia. The aim of this study was to evaluate the relationship between the socioeconomic background of the origin and the clinical manifestation of schizophrenia. Parent socioeconomic information and clinical symptom data from 120 (84 men and 36 women) schizophrenia and schizoaffective patients were analyzed. Results suggested that higher parental SES (socioeconomic status) is associated with decreased symptom severity in female patients, but with increased symptom severity and decreased global functioning in male patients. Possible interactions between socioeconomic status and sex of patient are discussed, as well as suggestions for further study.