Measuring psychosocial outcomes in schizophrenia patients

Cerebral, Psychosocial, Family Functioning and Disability of Persons with Schizophrenia

The human brain is the most cognitively capable of mammalian brains, endowed as it is with an overdeveloped cerebral cortex that, in parallel, renders it vulnerable to mental disorders. Schizophrenia is the expression of the dysregulation of the neuronal activity of cortical and subcortical regions due to modifications in the levels of the various neurotransmitters, especially of dopamine, with a reciprocal, intimate relationship among genes with environmental and psychosocial factors. If the dopaminergic system increases the function prefrontal cortex will be reduced: this is the main reason of social, occupational and familiar disruption. The present article describes the function of the brain in schizophrenia and its relation with anatomical, physiological, and genetic changes, in addition to identifying, psychosocial and family factors that can be determinant in the functionality of the patient. A review of national and international bibliography was conducted bearing in mind the following variables: functioning at the cerebral level; psychosocial functioning, familial functioning, disability, and functionality in persons with schizophrenia. Due to the variety of the issues included in this review, it can be concluded that schizophrenia is the product of a complex array of symptoms, deficits and disabilities. It was identified that there is a reciprocal confluence of diverse genetic, psychosocial, familial, environmental, educative, and social factors which affect the functionality of persons with this disorder. The latter makes it necessary to study the patient taking into consideration all of these components in an integral manner.

Quality versus quantity: Determining real-world social functioning deficits in schizophrenia

Social dysfunction is a hallmark of schizophrenia that is associated with emotional disturbances. Researchers have employed ecological momentary assessment (EMA) to measure social and emotional functioning in people with schizophrenia. Yet, few studies have evaluated quality of real-world social interactions, and it is unclear how interactions impact emotional experiences in this population. Using novel EMA that passively collects audio data, we examined daily social behavior and emotion in schizophrenia (n = 38) and control (n = 36) groups. Contrary to hypotheses, both groups interacted with others at the same rate and exhibited similar levels of positive emotion. However, as expected, the schizophrenia group exhibited significantly less high-quality interactions and reported more negative emotion than controls. Social versus non-social context did not influence experienced emotion in either group. This is the first real-world study to passively assess quality of social interactions in schizophrenia. Although those with schizophrenia did not differ in their number of interactions, they were less likely to engage in substantive, personal conversations. Because high-quality interactions are linked with better social outcomes, this finding has important potential treatment implications. Future research should investigate quality of interactions across different types of social activities to gain a more nuanced understanding of social dysfunction in schizophrenia.

Relationship between clinical outcomes measures and personal and social performance functioning in a prospective, interventional study in schizophrenia

OBJECTIVES

To explore clinical and demographic characteristics impacting patient functioning by determining extent of overlap in factors driving change in Personal and Social Performance (PSP) and other clinical outcomes.

METHODS

Post-hoc analysis from a single-arm trial of paliperidone extended release in adult patients with nonacute symptomatic schizophrenia. Psychosocial functioning measures: PSP, Clinical Global Impression-Severity (CGI-S), Positive and Negative Syndrome Scale (PANSS), Short-Form 36 (SF-36), treatment satisfaction, sleep quality/daytime drowsiness, and Extrapyramidal Symptoms Rating Scale.

RESULTS

Highest correlations with PSP total score change included PANSS total score change (Spearman's r = 0.607), PANSS general psychopathology change (r = 0.579), and CGI-S change (r = 0.569). A PSP score change of -32 predicted 90% probability of deterioration in CGI-S (score change of ≥1). The power of PSP change to predict PANSS total score change was lower. Linear stepwise regression demonstrated independent relationships for PSP change and: PANSS total change; CGI-S change; SF-36 Mental Component change; treatment satisfaction at endpoint; PSP at baseline; previous psychiatric hospitalizations. R ² = 0.55 meant that 45% of PSP variation could not be explained by other clinical outcome measures.

CONCLUSIONS

Psychosocial functioning improvement is important in schizophrenia. PSP may be valuable for assessing functioning; it encompasses psychosocial and clinical factors not measured by other established assessments.

A Random Forest Model for Predicting Social Functional Improvement in Chinese Patients with Schizophrenia After 3 Months of Atypical Antipsychotic Monopharmacy: A Cohort Study

PURPOSE

Impaired social functions contribute to the burden of schizophrenia patients and their families, but predictive tools of social functioning prognosis and specific factors are undefined in Chinese clinical practice. This article explores a machine learning tool to identify whether patients will achieve significant social functional improvement after 3 months of atypical antipsychotic monopharmacy and finds the defined risk factors using a multicenter clinical study.

PATIENTS AND METHODS

A multicenter study on atypical antipsychotic (AAP) treatment in Chinese patients with schizophrenia (SALT-C) was conducted from July 2011 to August 2018. Data from 550 patients with AAP monopharmacy from their baseline to their 3-month follow-up were used to establish machine learning tools after screening. The positive outcome was an increase in the Personal and Social Performance (PSP) scale score by ≥10 points. The predictors were a range of investigator-rated assessments on symptoms, functioning, the safety of AAPs and illness history. The Least Absolute Shrinkage and Selection Operator (LASSO) was used for the feature screening and ranking of the predicted variables. The random forest algorithm and five-fold cross-validation for optimizing the model were selected to ensure the generalizability and precision.

RESULTS

There were 137 patients (mean [SD] age, 41.1 [16.8] years; 77 [58.8%] female) who had a good social functional prognosis. A lower PSP score, taking a mood stabilizer, a high total Positive and Negative Symptom Scale (PANSS) and PANSS general subscale score, unemployment, a hepatic injury with medication, comorbid cardiovascular disease and being male predicted poor PSP outcomes. The generalizability of the PSP predictive tool was estimated with the precision-recall curve (accuracy of 79.5%, negative predictive value of 92.6% and positive predictive value of 57.1%) and receiver operating characteristic curve (ROC) (specificity of 81.8% and sensitivity of 78.7%).

CONCLUSION

The machine learning tool established using our current real-world data could assist in predicting PSP outcome by several clinical factors.

Social Cognition Training for People With a Psychotic Disorder: A Network Meta-analysis

Deficits in social cognition are common in people with psychotic disorders and negatively impact functioning. Social Cognition Training (SCT) has been found to improve social cognition and functioning, but it is unknown which interventions are most effective, how characteristics of treatments and participants moderate efficacy, and whether improvements are durable. This meta-analysis included 46 randomized studies. SCTs were categorized according to their focus (targeted/broad-based) and inclusion of cognitive remediation therapy (CRT). Network meta-analysis was conducted, using both direct (original) and indirect (inferred from the network of comparisons) evidence. All SCT types were compared to treatment as usual (TAU; the chosen reference group). Moderators of outcome were investigated with meta-regression and long-term efficacy with multivariate meta-analysis. Compared to TAU, emotion perception was improved by targeted SCT without CRT (d = 0.68) and broad-based SCT without CRT (d = 0.46). Individual treatments worked better for emotion perception. All treatments significantly improved social perception (active control, d = 0.98, targeted SCT with and without CRT, d = 1.38 and d = 1.36, broad-based SCT with and without CRT, d = 1.45 and d = 1.35). Only broad-based SCT (d = 0.42) improved ToM. Broad-based SCT (d = 0.82 without and d = 0.41 with CRT) improved functioning; group treatments worked significantly better. Male gender was negatively related to effects on social functioning and psychiatric symptoms. At follow-up, a moderate effect on social functioning (d = 0.66) was found. No effect was found on attribution, social cognition (miscellaneous), and psychiatric symptoms. While targeted SCT is the most effective for emotion perception and social perception, broad-based SCT produces the best overall outcomes. CRT did not enhance SCT effects.

The link between formal thought disorder and social functioning in schizophrenia: A meta-analysis

BACKGROUND

Formal thought disorder (FTD) and social functioning impairments are core symptoms of schizophrenia. Although both have been observed for over a century, the strength of the relationship between FTD and social functioning remains unclear. Furthermore, a variety of methodological approaches have been used to assess these constructs-which may contribute to inconsistency in reported associations. This meta-analysis aimed to: (a) systematically test the relationship between FTD and social functioning and (b) determine if the methodology used to assess FTD and/or social functioning moderates this relationship.

METHODS

Following Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines, a targeted literature search was conducted on studies examining the relationship between FTD and social functioning. Correlations were extracted and used to calculate weighted mean effect sizes using a random effects model.

RESULTS

A total of 1,478 participants across 13 unique studies were included in this meta-analysis. A small-medium inverse association (r = -0.23, p < 0.001) was observed between FTD and social functioning. Although heterogeneity analyses produced a significant Q-statistic (Q = 52.77, p = <0.001), the relationship between FTD and social functioning was not moderated by methodology, study quality, demographic variables, or clinical factors.

CONCLUSIONS

Findings illustrate a negative association between FTD and social functioning. Despite differences in the methodological approach used and type of information assessed, measurement type and clinical factors did not moderate the relationship between FTD and social functioning. Future studies should explore whether other variables, such as cognitive processes (e.g., social cognition), may account for variability in associations between these constructs.

Cognition and community functioning in schizophrenia: The nature of the relationship

Although cognition is one of the most important predictors of community functioning in schizophrenia, little is known about the causes of this correlation. To our knowledge, this study is the first to examine the extent to which this correlation is genetically mediated and whether the genetic correlation is specific to schizophrenia. Six hundred thirty-six participants from 43 multigenerational families with at least two relatives with schizophrenia and 135 unrelated controls underwent diagnostic interview and cognition and functioning assessment. Quantitative genetic analyses were conducted using maximum-likelihood variance decomposition methods implemented in SOLAR (Almasy & Blangero, 1998). Among patients with schizophrenia, cognition and community functioning were positively correlated and genetic effects shared between them were significant contributors to this relationship whereas environmental effects shared between them were not. In contrast, genetic effects were not shared significantly between cognition in depressed or nondiagnosed relatives and community functioning in schizophrenia. In all analyses, the contributions of social cognition to community functioning were accounted for by general cognition. These findings support heritable factors that contribute to the correlation between cognition and community functioning that are relatively specific to schizophrenia and are not significantly shared with depression or a lack of psychopathology. This suggests the possibility of identifying specific genetic variants that contribute to this correlation and to these important individual differences among schizophrenia patients. (PsycINFO Database Record

Development and Validation of the Health of the Nation Outcome Scales-Residential Facility (HoNOS-RF)

The Health of the Nation Outcome Scale (HoNOS) (Lora et al. Epidemiol Psichiatr Soc 10(3):198-212, 2001) is widely used. However, clinicians have expressed concerns about its ability to describe severe mentally ill patients, as it does not consider some relevant clinical aspects. This study aims to develop and validate the HoNOS-Residential Facility (HoNOS-RF) in order to pursue a thorough assessment of patients admitted to psychiatric residential facilities (RFs). The final version of the HoNOS-RF was administered to 409 patients admitted to four RFs. Exploratory factor analysis, Cronbach' alpha (α), Intraclass Correlation Coefficients (ICC) were used to assess construct validity, internal consistency and reliability, respectively. Concurrent criterion validity was assessed through correlations with the Brief Psychiatric Rating Scale-Expanded Version (BPRS-E) (Roncone et al. Acta Psychiatric Scand 100(3):229-36, 1999), Personal and Social Performance Scale (PSP) (Morosini et al. Acta Psychiatric Scand 101(4): 323-29, 2000), and comparisons across diagnostic groups. The final version of the HoNOS-RF consisted of 31 items, grouped into the following eight factors (overall explaining 55% of the total variability): personal and interpersonal functioning; environment; behavior and burden of care; cognitive function; somatic problems; anxiety-depression symptoms; psychotic symptoms; and other psychiatric symptoms. The scale showed high internal consistency (α = .807), and the correlations with PSP and BPRS-E ranged from adequate to moderate. The ICCs were in the excellent range for almost all items. These findings support the validity and the reliability of the HoNOS-RF, thus it may be a useful tool for the assessment of patients admitted to RFs, as it addresses clinical aspects that were mostly not included in the original version.

Functioning in patients with schizophrenia: a systematic review of the literature using the International Classification of Functioning, Disability and Health (ICF) as a reference

PURPOSE

To identify and quantify the main concepts included in published studies focusing on individuals with schizophrenia using the International Classification of Functioning, Disability and Health (ICF).

METHODS

Searches (limited to those published from 2008 to 2012) were performed in MEDLINE, PsycINFO and CINAHL. Included studies described participants with schizophrenia, were original articles and included only subjects who were at least 18 years of age at study entry. All concepts underlying the measures and the text of the articles were extracted, and they were linked to ICF categories using standardized rules.

RESULTS

From the 3584 abstracts retrieved, 348 were randomly selected, and of these, 206 studies met the inclusion criteria. A total of 17,141 concepts were extracted, 84.8% of which could be linked to 491 ICF categories: 222 (45.21%) of the categories referred to Body Functions, 29 (5.91%) to Body Structures, 186 (37.88%) to Activities and Participation and 54 (11%) to Environmental Factors. Seventy second-level categories were reported in at least 5% of all studies: 30 of these categories referred to Body Functions, 2 to Body Structures, 34 to Activities and Participation and 4 to Environmental Factors.

CONCLUSION

The study has allowed us to identify and quantify the main concepts included in studies focusing on people with schizophrenia using the ICF. The majority of the concepts refer to Body Functions and Activities and Participation, rather than to Body Structures and Environmental Factors.

Validation of the German Version of the Social Functioning Scale (SFS) for schizophrenia

Deficits in social functioning are a core symptom of schizophrenia and an important criterion for evaluating the success of treatment. However, there is little agreement regarding its measurement. A common, often cited instrument for assessing self-reported social functioning is the Social Functioning Scale (SFS). The study aimed to investigate the reliability and validity of the German translation. 101 patients suffering from schizophrenia (SZ) and 101 matched controls (C) (60 male / 41 female, 35.8 years in both groups) completed the German version. In addition, demographic, clinical, and functional data were collected. Internal consistency was investigated calculating Cronbach's alpha for SFS full scale (α: .81) and all subscales (α: .59-.88). Significant bivariate correlation coefficients were found between all subscales as well as between all subscales and full scale (p <.01). For the total sample, principal component analysis gave evidence to prefer a single-factor solution (eigenvalue ≥ 1) accounting for 48.5 % of the variance. For the subsamples, a two-component solution (SZ; 57.0 %) and a three-component solution (C; 65.6 %) fitted best, respectively. For SZ and C, significant associations were found between SFS and external criteria. The main factor "group" emerged as being significant. C showed higher values on both subscales and full scale. The sensitivity of the SFS was examined using discriminant analysis. 86.5% of the participants could be categorized correctly to their actual group. The German translation of the SFS turned out to be a reliable and valid questionnaire comparable to the original English version. This is in line with Spanish and Norwegian translations of the SFS. Concluding, the German version of the SFS is well suited to become a useful and practicable instrument for the assessment of social functioning in both clinical practice and research. It accomplishes commonly used external assessment scales.

Predicting functional remission in patients with schizophrenia: a cross-sectional study of symptomatic remission, psychosocial remission, functioning, and clinical outcome

BACKGROUND

New approaches to assess outcome in schizophrenia include multidimensional measures such as remission, cognition, psychosocial functioning, and quality of life. Clinical and psychosocial measures have been recently introduced to assess functional outcome.

OBJECTIVE

The study presented here was designed to examine the rates of symptomatic remission, psychosocial remission, global functioning, and clinical global impressions in a sample of schizophrenia outpatients in order to assess functional remission and to identify predictive factors for functional remission.

METHODS

A total of 168 consecutive Mexican outpatients receiving pharmacological treatment at the National Institute of Psychiatry in Mexico City were enrolled in a cross-sectional study. Symptomatic remission was assessed according to the definition and criteria proposed by the Remission in Schizophrenia Working Group using the Positive and Negative Symptom Scale. Psychosocial remission was assessed according to Barak criteria using the Psychosocial Remission in Schizophrenia scale. Functioning was measured with the Global Assessment of Functioning, and clinical outcome with the Clinical Global Impressions (CGI) Scale.

RESULTS

Findings showed that 45.2% of patients fulfilled the symptomatic remission criteria, 32.1% achieved psychosocial remission, and 53% reported adequate functioning. However, the combination of these three outcome criteria - symptomatic, psychosocial remission, and functioning - indicated that 14.9% of the patients achieved our predefined functional remission outcome. The logistic regression model included five predictive variables for functional remission: (1) being employed, (2) use of atypical antipsychotics, (3) lower number of medications, (4) lower negative symptom severity, and (5) lower excitement symptom severity.

CONCLUSION

The study demonstrated that symptomatic remission, psychosocial remission, and functioning could be achievable goals for a considerable number of patients. The outcome of functional remission was achieved by a minority of patients, less than 15%. New approaches should include multidimensional measures to assess functional outcome in schizophrenia research.

Impact of interpersonal trauma on the social functioning of adults with first-episode psychosis

BACKGROUND

Social functioning is an important treatment outcome for psychosis, and yet, we know little about its relationship to trauma despite high rates of trauma in people with psychosis. Childhood trauma is likely to disrupt the acquisition of interpersonal relatedness skills including the desire for affiliation and thus lead to impaired social functioning in adulthood.

AIMS

We hypothesized that childhood trauma would be a predictor of poor social functioning for adults with psychosis and that further trauma in adulthood would moderate this relationship.

METHOD

A first-episode psychosis sample aged 15-65 years (N = 233) completed measures of social functioning (Lehman's Quality of Life Interview and Strauss Carpenter Functioning Scale) and trauma (Brief Betrayal Trauma Survey), as well as clinical assessments.

RESULTS

Childhood trauma (any type) was associated with poorer premorbid functioning and was experienced by 61% of our sample. There were no associations with clinical symptoms. Interpersonal trauma in childhood was a significant predictor of social functioning satisfaction in adulthood, but this was not the case for interpersonal trauma in adulthood. However, 45% of adults who reported childhood interpersonal trauma also experienced adulthood interpersonal trauma.

CONCLUSION

Our results emphasize the importance of early relationship experience such as interpersonal trauma, on the social functioning of adults with psychosis. We recommend extending our research by examining the impact of interpersonal childhood trauma on occupational functioning in psychosis.

Collecting Information for Rating Global Assessment of Functioning (GAF): Sources of Information and Methods for Information Collection

INTRODUCTION

Global Assessment of Functioning (GAF) is an assessment instrument that is known worldwide. It is widely used for rating the severity of illness. Results from evaluations in psychiatry should characterize the patients. Rating of GAF is based on collected information. The aim of the study is to identify the factors involved in collecting information that is relevant for rating GAF, and gaps in knowledge where it is likely that further development would play a role for improved scoring.

METHODS

A literature search was conducted with a combination of thorough hand search and search in the bibliographic databases PubMed, PsycINFO, Google Scholar, and Campbell Collaboration Library of Systematic Reviews.

RESULTS

Collection of information for rating GAF depends on two fundamental factors: the sources of information and the methods for information collection. Sources of information are patients, informants, health personnel, medical records, letters of referral and police records about violence and substance abuse. Methods for information collection include the many different types of interview - unstructured, semi-structured, structured, interviews for Axis I and II disorders, semistructured interviews for rating GAF, and interviews of informants - as well as instruments for rating symptoms and functioning, and observation. The different sources of information, and methods for collection, frequently result in inconsistencies in the information collected. The variation in collected information, and lack of a generally accepted algorithm for combining collected information, is likely to be important for rated GAF values, but there is a fundamental lack of knowledge about the degree of importance.

CONCLUSIONS

Research to improve GAF has not reached a high level. Rated GAF values are likely to be influenced by both the sources of information used and the methods employed for information collection, but the lack of research-based information about these influences is fundamental. Further development of GAF is feasible and proposals for this are presented.

Towards a framework for treatment effectiveness in schizophrenia

INTRODUCTION

Prompt administration of antipsychotic treatment that is adhered to is essential for the optimal treatment of schizophrenia. Many patients have benefited from the advent of second-generation antipsychotics, which can offer good symptomatic control with reduced incidence of extrapyramidal symptoms, although with higher risk of metabolic side effects. It is unsurprising that accounts as to whether first- and second-generation antipsychotics differ in their efficacy vary, since treatment effectiveness is a broad notion and difficult to define.

OBJECTIVES

Numerous factors may be used to gauge treatment effectiveness and, while it has largely been defined in terms of improvements in four domains (symptoms of disease, treatment burden, disease burden, and health and wellness), the real-world clinical utility of this consensus is unclear. Therefore, this article aims to provide a framework that can aid psychiatrists in making assessments about treatment effectiveness.

METHODS AND RESULTS

A panel of 12 psychiatrists and psychopharmacologists convened to develop and propose an accessible and globally-applicable framework for assessing the effectiveness of antipsychotic treatments in patients with schizophrenia. Following presentation of a preliminary proposal to a wider group of psychiatrists from across Europe, it was refined into a framework comprising five domains: symptomatic remission and retention of treatment; affective symptoms; cognitive functioning; treatment satisfaction; and personal and social functioning - each of which is discussed in this article.

CONCLUSIONS

This article provides a framework that can aid psychiatrists in making assessments about treatment effectiveness. It is anticipated that the framework outlined here may contribute to improving clinical practice through the promotion of a patient-centered approach to the assessment of treatment effectiveness, using five specified domains, in patients with schizophrenia.

Recognition of emotion from body language among patients with unipolar depression

Major depression may be associated with abnormal perception of emotions and impairment in social adaptation. Emotion recognition from body language and its possible implications to social adjustment have not been examined in patients with depression. Three groups of participants (51 with depression; 68 with history of depression in remission; and 69 never depressed healthy volunteers) were compared on static and dynamic tasks of emotion recognition from body language. Psychosocial adjustment was assessed using the Social Adjustment Scale Self-Report (SAS-SR). Participants with current depression showed reduced recognition accuracy for happy stimuli across tasks relative to remission and comparison participants. Participants with depression tended to show poorer psychosocial adaptation relative to remission and comparison groups. Correlations between perception accuracy of happiness and scores on the SAS-SR were largely not significant. These results indicate that depression is associated with reduced ability to appraise positive stimuli of emotional body language but emotion recognition performance is not tied to social adjustment. These alterations do not appear to be present in participants in remission suggesting state-like qualities.

Psychiatrists' perceptions of the clinical importance, assessment and management of patient functioning in schizophrenia in Europe, the Middle East and Africa

BACKGROUND

It has been estimated that as many as two thirds of patients with schizophrenia are unable to perform basic personal and social roles or activities. Occupational functioning and social functioning, as well as independent living, are considered as core domains of patient functioning. Improvement in patient functioning has also been recognized as an important treatment goal in guidelines and an important outcome by regulatory agencies. Nevertheless, information is lacking on how these aspects are being considered by psychiatrists across the world and how they are being assessed and managed.

METHODS

The 'Europe, the Middle East and Africa functioning survey' was designed to canvas opinions of psychiatrists across these regions to ascertain their perceptions of the clinical importance, assessment and management of functioning amongst their patients with schizophrenia. The survey comprised 17 questions and was conducted from March to April 2011 in 42 countries. Data collected included the demographics of respondents and their opinions regarding personal and social functioning in patients with schizophrenia.

RESULTS

Results were obtained from 4,163 clinicians. Psychiatrists estimated that more than two thirds (70%) of their patients with schizophrenia showed impaired or very poor levels of functioning. The majority of psychiatrists (92%) believed that personal and social functioning was an important treatment goal for patients with schizophrenia, and 91% believed it was an important goal for patients' families. The majority of psychiatrists (55%) assess the personal and social functioning of their patient at each visit; however, 81% reported that they determine the level of functioning through clinical interview and not by using a specific assessment scale. To manage personal and social functioning in their patients, 26% of psychiatrists prefer pharmacological interventions, whereas 46% prefer psychosocial interventions.

CONCLUSION

Psychiatrists recognize that functioning is impaired/very poor in patients with schizophrenia, and there is still an important need to address functioning as a main treatment goal for patients with schizophrenia.

Tai-chi for residential patients with schizophrenia on movement coordination, negative symptoms, and functioning: a pilot randomized controlled trial

Objective. Patients with schizophrenia residing at institutions often suffer from negative symptoms, motor, and functional impairments more severe than their noninstitutionalized counterparts. Tai-chi emphasizes body relaxation, alertness, and movement coordination with benefits to balance, focus, and stress relief. This pilot study explored the efficacy of Tai-chi on movement coordination, negative symptoms, and functioning disabilities towards schizophrenia. Methods. A randomized waitlist control design was adopted, where participants were randomized to receive either the 6-week Tai-chi program and standard residential care or only the latter. 30 Chinese patients with schizophrenia were recruited from a rehabilitation residency. All were assessed on movement coordination, negative symptoms, and functional disabilities at baseline, following intervention and 6 weeks after intervention. Results. Tai-chi buffered from deteriorations in movement coordination and interpersonal functioning, the latter with sustained effectiveness 6 weeks after the class was ended. Controls showed marked deteriorations in those areas. The Tai-chi group also experienced fewer disruptions to life activities at the 6-week maintenance. There was no significant improvement in negative symptoms after Tai-chi. Conclusions. This study demonstrated encouraging benefits of Tai-chi in preventing deteriorations in movement coordination and interpersonal functioning for residential patients with schizophrenia. The ease of implementation facilitates promotion at institutional psychiatric services.

Disability and schizophrenia: a systematic review of experienced psychosocial difficulties

BACKGROUND

Schizophrenia is a significantly disabling disease that affects all major areas of life. There is a lack of comprehensive synthesis of research findings on the full extent of psychosocial difficulties (PSDs) experienced by people living with schizophrenia. This paper provides a systematic review of the literature concerning PSDs and their associated factors in schizophrenia. PSDs were conceptualized in accordance with the International Classification of Functioning, Disability and Health (ICF) as disabilities, in particular impairments of mental functions, activity limitations and participation restrictions.

METHODS

An electronic search using MEDLINE and PsychINFO plus a manual search of the literature was performed for qualitative and longitudinal studies published in English between 2005 and 2010 that examined PSDs in persons with schizophrenia. The ICF was used as a conceptual framework.

RESULTS

A total of 104 papers were included. The most frequent PSDs addressed in the literature were not specific ones, directly linkable to the ICF categories of mental functions, activity limitations or participation restrictions, but broad areas of psychosocial functioning, such as psychopathological symptoms (53% of papers) or global disability and functioning (37%). Among mental functions, the most extensively studied were cognitive functions (27%) and emotional functions (27%). Within the domain of activities and participation, the most widely investigated were difficulties in relationships with others (31%) and employment (20%). Of the factors associated with the intensity or course of PSDs, the most commonly identified were treatment modalities (56%), psychopathological symptoms (26%), and socio-demographic variables (24%). Medication tended to improve the most relevant PSD, but at the same time was the only consistently reported determinant of onset of PSDs (emerging as unwanted side-effects).

CONCLUSIONS

The present review illustrates the remarkably broad scope and diversity of psychosocial areas affected in schizophrenia and shows how these areas are interconnected and how they interact with contextual factors. The need for a shift in focus of schizophrenia research is suggested--from an excessive reliance on global measures of psychopathology and disability for defining outcomes to the creation of profiles of specific PSDs that have a more direct bearing on the disabling experience and real-world functioning of patients and can serve to guide interventions and monitoring over time.

The Portuguese version of the Personal and Social Performance Scale (PSP): reliability, validity, and relationship with cognitive measures in hospitalized and community schizophrenia patients

PURPOSE

Deficits in social functioning are a core feature of schizophrenia and are influenced by both symptomatic and neurocognitive variables. In the present study we aimed to determine the reliability and validity of the Portuguese version of the Personal and Social Performance (PSP) scale, and possible correlations with measures of cognitive functioning.

METHODS

One-hundred and four community and inpatients with schizophrenia were assessed using measures of social functioning and symptom severity alongside measures of executive function, processing speed, and verbal memory.

RESULTS

Convergent validity with the GAF in the four domains of the PSP varied from 0.357 to 0.899. Reliability was found to be satisfactory, with a Cronbach's alpha coefficient of 0.789. Inter-rater reliability in the four domains of the PSP varied from 0.430 to 0.954. Low-functioning patients (PSP < 70) were older, had longer duration of illness, were more symptomatic and had worse cognitive performances, as compared with high-functioning patients (PSP ≥ 70). In a regression model, deficits in social functioning were strongly predicted both by symptomatic and neurocognitive variables; these together accounted for up to 62% of the variance.

CONCLUSIONS

The present study supports the reliability and validity of the Portuguese language version of the PSP and further supports the original measure. The co-administration of brief cognitive assessments with measures of functioning may lead to more focused interventions, possibly improving outcomes in this group.

The importance of measuring psychosocial functioning in schizophrenia

BACKGROUND

Schizophrenia is among the most disabling of mental illnesses and frequently causes impaired functioning. We explore issues of definition and terminology, and the relationship between social functioning, cognition, and psychopathology considering relevant research findings.

METHODS

The present article describes measures of social functioning and outlines their psychometric properties. It considers their usefulness in research and clinical settings. Treatment aims and objectives are explored in the context of cognitive and social functioning. Finally, we identify areas for developing research and refining the measurement of social functioning.

RESULTS

The definition and measurement of social functioning in schizophrenia remains a complex and disputed area. The relationships between symptoms, cognitive functioning and social functioning are complex but we are beginning to understand them better. Scales for measuring functioning in clinical practice must be brief and sensitive to change and the Personal and Social Performance (PSP) scale may offer several advantages in these regards. Brief cognitive assessments focusing upon the domains most commonly affected in schizophrenia, such as verbal memory and executive functions, should be coadministered with measures of functioning.

CONCLUSIONS

The use of validated scales for schizophrenia that are sensitive to change over the course of the illness and its treatment, should allow for a better understanding of patients' functional disabilities, enabling better and more comprehensive monitoring and evaluation of both pharmacological and non-pharmacological treatment strategies.