Decision-making capacity for research participation among individuals in the CATIE schizophrenia trial

OBJECTIVE: Uncertainty regarding the degree to which persons with schizophrenia may lack decision-making capacity, and what the predictors of capacity may be led us to examine the relationship between psychopathology, neurocognitive functioning, and decision-making capacity in a large sample of persons with schizophrenia at entry into a clinical trial. METHOD: In the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial, a clinical trial sponsored by the National Institute of Mental Health designed to compare the effectiveness of antipsychotic drugs, subjects were administered the MacArthur Competence Assessment Tool-Clinical Research (MacCAT-CR) and had to demonstrate adequate decision-making capacity before randomization. The MacCAT-CR, the Positive and Negative Syndrome Scale (PANSS), and an extensive neurocognitive battery were completed for 1447 study participants. RESULTS: The neurocognitive composite score and all 5 neurocognitive subscores (verbal memory, vigilance, processing speed, reasoning, and working memory) were positive correlates of the MacCAT-CR understanding, appreciation, and reasoning scales at baseline. Higher levels of negative symptoms, but not positive symptoms, were inversely correlated with these three MacCAT-CR scales. Linear regression models of all three MacCAT-CR scales identified working memory as a predictor; negative symptoms made a small contribution to the understanding and appreciation scores. CONCLUSIONS: Negative symptoms and aspects of neurocognitive functioning were correlated with decision-making capacity in this large sample of moderately ill subjects with schizophrenia. In multiple regression models predicting performance on the MacCAT-CR scales, working memory was the only consistent predictor of the components of decision-making capacity. Individuals with schizophrenia who have prominent cognitive dysfunction, especially memory impairment, may warrant particular attention when participating in research.     

Validation of Chinese version of the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) in patients with schizophrenia spectrum disorders

There is a lack of validated instruments assessing the decision-making capacity to consent to clinical research of patients with schizophrenia spectrum disorders who speak Chinese. This study aimed to determine the validity and reliability of the Chinese version of MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR). The MacCAT-CR using a hypothetical study, the Positive and Negative Syndrome Scale (PANSS), the Mini-Mental State Examination (MMSE) assessed 139 patients with schizophrenia or schizoaffective disorder. The Cronbach's alpha coefficient was 0.74. The intra-class coefficients for understanding, appreciation, and reasoning scores ranged from 0.53 to 0.81. Regarding validity, the understanding, appreciation and reasoning scores were negatively correlated with the PANSS (r ranged from −0.27 to −0.33), and the negative subscale score (r ranged from −0.31 to −0.37) as well as positively correlated with the MMSE (r ranged from 0.26 to 0.43). All pvalues were less than 0.01. The factor analysis explained 57.6 % of the total variance; specifically, Components 1 and 2 contributed 44.5% and 13.1 % of the variance respectively. These findings indicate that the Chinese version of the MacCAT-CR is a reliable and valid instrument to assess the decision-making capacity to consent to clinical research of patients with schizophrenia spectrum disorders.     

Prevalence and correlates of adequate performance on a measure of abilities related to decisional capacity: differences among three standards for the MacCAT-CR in patients with schizophrenia

Despite the availability of structured decision-making capacity assessment tools, insufficient guidance exists for applying their results. Investigators often use cutpoints on these instruments to identify potential subjects in need of further assessment or education. Yet, information is lacking regarding the effects of different cutpoints on the proportion and characteristics of individuals categorized as possessing adequate or impaired decisional abilities for consent to research. To demonstrate the potential impact of different standards, we informed 91 individuals, aged 50 or older with a diagnosis of schizophrenia or schizoaffective disorder, about a hypothetical clinical trial, and assessed their decisional abilities with the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR). Three published MacCAT-CR-based standards were applied to participants' scores to examine the rates and correlates of categorical determinations of adequate performance. The three standards ranged in stringency: the most stringent incorporated cutpoints on all three of the major MacCAT-CR subscales (Understanding, Appreciation, and Reasoning); the other two standards required threshold performance only on the Understanding subscale. The most stringent standard resulted in a 57% rate of impaired performance; the intermediate standard, 19%; and the least stringent standard, 8%. Nearly half of the participants (n=45) were classified as having performed adequately by the least stringent standard yet inadequately by the most stringent. The majority of these 45 were impaired on the Appreciation subscale (n=9), Reasoning (n=15), or both (n=18). Cognitive functioning was correlated with performance status for the more stringent standards. These findings underscore the need for refinement of capacity assessment procedures and for improvements in the use of capacity assessment tools for screening purposes and to assist in categorical capacity determinations.     

Congruence of diagnoses 2 years after a first-admission diagnosis of psychosis

BACKGROUND: Diagnostic changes may reflect evolution of an illness, emergence of newly disclosed information, or unreliability of assessment. This study evaluates the stability of research diagnoses in a heterogeneous first-admission sample with psychosis. METHODS: A group of 547 subjects initially diagnosed with a psychosis were reassessed 6 and 24 months after enrollment. The DSM-IV consensus diagnoses were formulated by psychiatrists blind to previous research diagnoses. The analysis focuses on agreement over time and the effects of demographic, family history, and clinical variables on the shift from a nonschizophrenia diagnosis to schizophrenia. RESULTS: Seventy-two percent of 6- and 24-month diagnoses were congruent. The most temporally consistent 6-month categories were schizophrenia (92%), bipolar disorder (83%), and major depression (74%); the least stable were psychosis not otherwise specified (44%), schizoaffective disorder (36%), and brief psychosis (27%). The most frequent shift in diagnosis at 24 months was to schizophrenia spectrum (n=45). These 45 subjects had a similar illness course after 6 months as the 171 subjects in this category at both assessments, but their prior clinical functioning was better. Risk factors predicting change to a schizophrenia spectrum diagnosis include facility variables (schizophrenia diagnosis, longer stays, and given antipsychotic medication on hospital discharge); prehospital features (psychotic > or =3 months before admission, poorer adolescent adjustment, lifetime substance disorder); and negative symptoms. CONCLUSIONS: Changes in diagnosis, particularly to schizophrenia, are mostly attributable to the evolution of the illness. Rigid adherence to DSM-IV requirements may have led to underdiagnosis of schizophrenia. The findings support the need for a longitudinally based diagnostic process in incidence samples.     

Multimedia consent for research in people with schizophrenia and normal subjects: a randomized controlled trial

Limitations of printed, text-based, consent forms have long been documented and may be particularly problematic for persons at risk for impaired decision-making capacity, such as those with schizophrenia. We conducted a randomized controlled comparison of the effectiveness of a multimedia vs routine consent procedure (augmented with a 10-minute control video presentation) as a means of enhancing comprehension among 128 middle-aged and older persons with schizophrenia and 60 healthy comparison subjects. The primary outcome measure was manifest decisional capacity (understanding, appreciation, reasoning, and expression of choice) for participation in a (hypothetical) clinical drug trial, as measured with the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) and the University of California San Diego (UCSD) Brief Assessment for Capacity to Consent (UBACC). The MacCAT-CR and UBACC were administered by research assistants kept blind to consent condition. Additional assessments included standardized measures of psychopathology and cognitive functioning. Relative to patients in the routine consent condition, schizophrenia patients receiving multimedia consent had significantly better scores on the UBACC and on the MacCAT-CR understanding and expression of choice subscales and were significantly more likely to be categorized as being capable to consent than those in the routine consent condition (as categorized with several previously established criteria). Among the healthy subjects, there were few significant effects of consent condition. These findings suggest that multimedia consent procedures may be a valuable consent aid that should be considered for use when enrolling participants at risk for impaired decisional capacity, particularly for complex and/or high-risk research protocols.     

A population-based cohort study of premorbid intellectual,language, and behavioral functioning in patients with schizophrenia,schizoaffective disorder,and nonpsychotic bipolar disorder

OBJECTIVE: The premorbid intellectual, language, and behavioral functioning of patients hospitalized for schizophrenia, schizoaffective disorder, or nonpsychotic bipolar disorder was compared with that of healthy comparison subjects. METHOD: The Israeli Draft Board Registry, which contains measures of intellectual, language, and behavioral functioning for the unselected population of 16- to 17-year-olds, was merged with the National Psychiatric Hospitalization Case Registry, which contains diagnoses for all patients with psychiatric hospitalizations in Israel. The database was used to identify adolescents with no evidence of illness at their draft board assessment who were later hospitalized for nonpsychotic bipolar disorder (N=68), schizoaffective disorder (N=31), or schizophrenia (N=536). The premorbid functioning of these subjects was compared to that of nonhospitalized individuals matched for age, gender, and school attended at the time of the draft board assessment. The diagnostic groups of hospitalized subjects were also compared. RESULTS: Relative to the comparison subjects, subjects with schizophrenia showed significant premorbid deficits on all intellectual and behavioral measures and on measures of reading and reading comprehension. Subjects with schizophrenia performed significantly worse on these measures than those with a nonpsychotic bipolar disorder, who did not differ significantly from the comparison subjects on any measure. Subjects with schizoaffective disorder performed significantly worse than the comparison subjects only on the measure of nonverbal abstract reasoning and visual-spatial problem solving and performed significantly worse than subjects with nonpsychotic bipolar disorder on three of the four intellectual measures and on the reading and reading comprehension tests. CONCLUSIONS: The results support a nosologic distinction between nonpsychotic bipolar disease and schizophrenia in hospitalized patients.     

Magnitude of impairment in decisional capacity in people with schizophrenia compared to normal subjects: an overview

The capacity of individuals with schizophrenia to make decisions related to research participation or clinical treatment has received increasing empirical attention. A number of studies have compared patients with schizophrenia to nonpsychiatric comparison subjects (NPCs) on structured measures of decision-making capacity. In this review, we evaluated the magnitude of the difference between schizophrenia and NPC groups reported across these studies, as well as the influence of sample characteristics on observed effect sizes. We also computed the effect sizes of group differences in psychopathology and cognitive deficits. Twelve studies met the search criteria; a majority of them reported data using the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) or for Treatment (MacCAT-T). The mean effect size (evaluated in terms of Cohen's d) for group differences on the Understanding subscale of the MacCAT instruments was 0.88 (SD = 0.40); it was twice as high among inpatient samples as among outpatients. Similar differences were observed in terms of Appreciation and Reasoning subscales, but the effect sizes for Expression of Choice were small (mean d = 0.29, SD = 0.24). Notably, these observed effect sizes were generally smaller than those for differences between schizophrenia and NPC groups in psychopathology (mean d = 2.06, SD = 1.03) and cognition (mean d = 1.01, SD = 0.61). The published studies demonstrate a substantial heterogeneity in decision-making capacity among people with schizophrenia, as well as among NPCs, suggesting that the presence of schizophrenia does not necessarily mean the patient has impairment in capacity.     

Diagnostic specificity of poor premorbid adjustment: Comparison of schizophrenia, schizoaffective disorder, and mood disorder with psychotic features

Individuals with schizophrenia have significant deficits in premorbid social and academic adjustment compared to individuals with non-psychotic diagnoses. However, it is unclear how severity and developmental trajectory of premorbid maladjustment compare across psychotic disorders. This study examined the association between premorbid functioning (in childhood, early adolescence, and late adolescence) and psychotic disorder diagnosis in a first-episode sample of 105 individuals: schizophrenia (n=68), schizoaffective disorder (n=22), and mood disorder with psychotic features (n=15). Social and academic maladjustment was assessed using the Cannon-Spoor Premorbid Adjustment Scale. Worse social functioning in late adolescence was associated with higher odds of schizophrenia compared to odds of either schizoaffective disorder or mood disorder with psychotic features, independently of child and early adolescent maladjustment. Greater social dysfunction in childhood was associated with higher odds of schizoaffective disorder compared to odds of schizophrenia. Premorbid decline in academic adjustment was observed for all groups, but did not predict diagnosis at any stage of development. Results suggest that social functioning is disrupted in the premorbid phase of both schizophrenia and schizoaffective disorder, but remains fairly stable in mood disorders with psychotic features. Disparities in the onset and time course of social dysfunction suggest important developmental differences between schizophrenia and schizoaffective disorder.     

Neurocognition and suicidal behaviour in an Irish population with major psychotic disorders

OBJECTIVES: Although neurocognitive deficits are seen as core to schizophrenia the association between suicidality and neurocognition has received little attention. Our aim was to examine the relationship between neurocognitive variables and suicidal behaviour in patients with schizophrenia and schizoaffective disorder. METHODS: Seventy-eight patients with DSM-IV diagnoses of schizophrenia or schizoaffective disorder were categorised as either having attempted suicide or not having attempted suicide based on clinical interview and chart review. Attempters and non-attempters were compared on an extensive neuropsychological battery examining pre-morbid and current general cognitive functioning, episodic memory, and executive functioning. RESULTS: Suicide attempters tended to out perform non-attempters across all areas of executive functioning, and showed significantly better performances on measures of attention and verbal fluency. After controlling for relevant clinical and demographic variables, the differences between attempters and non-attempters remained significant for measures of attention (F = 4.97, p = 0.03) and verbal fluency (F = 4.28, p = 0.04). CONCLUSION: This study adds to existing data that suicide attempters with schizophrenia or schizoaffective disorder may have higher cognitive functioning than non-attempters. In particular, the preservation of higher executive function may influence the ability to initiate and plan suicidal behaviour.     

Global assessment of functioning following assertive community treatment in Edmonton, Alberta: a longitudinal study.

OBJECTIVE: To examine longitudinally the effects of Assertive Community Treatment (ACT) on Global Assessment of Functioning (GAF) scores in Edmonton, Alberta. METHODS: We acquired GAF scores for all clients at initial registration in the ACT program and at subsequent 18- and 36-month time points while in ACT. We analyzed both the entire ACT cohort and separate diagnostic groups. RESULTS: We obtained baseline and follow-up GAF scores for 411 clients, of whom the largest diagnostic group suffered from schizophrenia (n = 189), followed by bipolar disorder (n = 98). Collapsed across all groups, GAF scores significantly improved at both 18 (P < 0.0001) and 36 months (P < 0.0001). By group, at 18-month follow-up, significant improvements were seen in patients with delusional disorder (P < 0.05), dysthymia (P < 0.05), schizoaffective disorder (P < 0.05), and schizophrenia (P < 0.001). This was also seen at 36-month follow-up, with the addition of significant improvements in those with bipolar disorder (P < 0.05). Those patients with major affective disorder or psychosis not otherwise specified (NOS) did not show significant improvements over time. Regardless of diagnosis, those clients with baseline GAF scores of < or = 40 significantly improved at both 18-month (P < 0.0001) and 36-month (P < 0.0001) follow-up, while those with baseline GAF scores above 40 did not show significant improvement. CONCLUSIONS: GAF scores improved at 18- and 36-month follow-up from enrolment in an ACT program. Groups with different diagnoses and levels of functioning at time of enrolment may not benefit to the same degree.     

The effects of an indigenous muscarinic drug, Betel nut (Areca catechu), on the symptoms of schizophrenia: a longitudinal study in Palau, Micronesia

OBJECTIVE: This study tested the findings of a prior study indicating a therapeutic relationship between consumption of betel nut and symptoms of schizophrenia. METHOD: The subjects were 65 outpatients with diagnoses of schizophrenia or schizoaffective disorder. Symptoms rated with the Positive and Negative Syndrome Scale were compared between high- and low-consumption betel chewers in a repeated-measures design. Movement disorders were assessed with the Abnormal Involuntary Movement Scale and Simpson-Angus Rating Scale. Global health and social functioning were assessed with the Medical Outcomes Study 12-item and 36-item Short-Form Health Surveys, respectively. RESULTS: Male high-consumption betel chewers had significantly milder positive symptoms than low-consumption chewers over 1 year. Betel chewing was not associated with global health, social functioning, or movement disorders. Betel chewing was associated with tobacco use but not with cannabis or alcohol. CONCLUSIONS: These findings have clinical significance in betel-chewing regions and broader implications for theory of muscarinic neurophysiology in schizophrenia.     

A family study of DSM-III-R schizoaffective disorder, depressive type, compared with schizophrenia and psychotic and nonpsychotic major depression

OBJECTIVE: To assess the validity of DSM-III-R schizoaffective disorder, the authors explored the morbid risks for schizophrenia and major affective disorders in the first-degree relatives of patients with schizoaffective disorder and relevant other diagnoses. METHOD: In addition to patients with DSM-III-R schizoaffective disorder, depressive type (N = 21), the probands included patients with mood-incongruent psychotic depression (N = 22), mood-congruent psychotic depression (N = 19), nonpsychotic depression (N = 27), or schizophrenia (N = 28) and normal subjects (N = 18). The patients were consecutively recruited from the outpatient facilities of a university psychiatry department; the normal subjects were students and nurses. All probands were directly interviewed, with the Schedule for Affective Disorders and Schizophrenia--Lifetime Version (SADS-L), by a psychiatrist blind to information about relatives. Consenting relatives were directly interviewed, with the SADS-L, by two psychiatrists blind to the probands' diagnoses. The direct interview was supplemented--or replaced, when an interview was not possible (24%)--by family history data from all available sources. Morbid risks in relatives were calculated according to the Weinberg method. RESULTS: The relatives of the schizoaffective patients had almost the same risk for schizophrenia as the relatives of the schizophrenic patients. In the relatives of the patients mood-incongruent psychotic depression, the morbid risk for major affective disorders was about one-half that of the relatives of the patients with mood-congruent psychotic depression and one-third that of the relatives of the patients with nonpsychotic depression, but these differences did not reach statistical significance. CONCLUSIONS: These results suggest that DSM-III-R schizoaffective disorder is close to schizophrenia and largely corresponds to mainly schizophrenic schizoaffective disorder in the Research Diagnostic Criteria, whereas DSM-III-R mood-incongruent psychotic depression is probably quite heterogeneous and should be studied further.     

The impact of insight on functioning in patients with schizophrenia or schizoaffective disorder receiving risperidone long-acting injectable

This post hoc analysis explored the role of insight as a mediator of functioning in a 52-week, double-blind, international trial of 323 patients with schizophrenia or schizoaffective disorder receiving risperidone long-acting injectable. Measures included the Positive and Negative Syndrome Scale (PANSS) insight item, PANSS factors, Clinical Global Impressions-Severity (CGI-S), Strauss-Carpenter Levels of Functioning (LOF), Personal and Social Performance (PSP) scale, and a cognitive test battery. Correlation/regression analyses examined associations between demographic and clinical characteristics, including insight, and functional measures. Insight scores correlated significantly with CGI-S, PANSS subscales, PSP, LOF, and several cognitive measures. Regression models demonstrated that changes in insight, changes in negative symptoms, and study duration were significantly associated with PSP and LOF total change scores. Findings identified important variables to consider for intervention to improve functioning in schizophrenia.     

Sexual functioning, psychopathology and quality of life in patients with schizophrenia

OBJECTIVE: The present study was to characterize relationships among sexual functioning, schizophrenia symptoms and quality of life measures. In addition, sexual functioning was compared among patients treated with different antipsychotic agents. METHODS: Outpatient subjects were assessed using the Positive and Negative Symptom Scale (PANSS), the Changes in Sexual Functioning Questionnaire (CSFQ) and the Hamilton Rating Scale for Depression (HAMD). Quality of life was assessed using two different instruments: observer-rated Heinrich's Quality of Life Scale (QLS) and self-rated The Behavior and Symptom Identification Scale (BASIS). RESULTS: One hundred twenty-four patients with schizophrenia or schizoaffective disorder were enrolled in the study. Eight-six patients (69%) completed at least part of the CSFQ assessment, which generated at least one valid subscale score. High rates of sexual impairment were found in both male and female patients (65%-94% across different subscales). For males, higher scores on the PANSS-positive subscale were associated with a lower frequency of sexual activity (p=0.04). For females, higher scores on the PANSS-positive subscale and PANSS-general psychopathology subscale were significantly associated with more difficulty in both sexual arousal and orgasm (p's<0.05). For both males and females, there were no significant relationships between any CSFQ subscale measures and the quality of life measures (p's>0.05). No significant differences were found among three antipsychotic treatment groups (clozapine, olanzapine or typical agents) on any CSFQ subscale measures or quality of life measures after controlling for PANSS total scores (p's>0.05). CONCLUSIONS: Effective treatment strategies still need to be developed to address sexual dysfunction and quality of life in patients with schizophrenia.     

Potential sampling and recruitment source impacts in schizophrenia research

Most schizophrenia research is undertaken on clinical samples in current contact with mental health services. It is not clear to what extent such samples are representative of the population of people with schizophrenia or whether they differ significantly, for example, from those who are being treated predominantly in primary care settings or who are recruited from non-clinical sources. Data from a volunteer schizophrenia research register and two recent Australian studies are reported, the Low Prevalence (psychotic) Disorders Study and an associated study of schizophrenia in general practice, in which all participants completed the same clinical assessment interview. Participants meeting criteria for schizophrenia or schizoaffective disorder were classified according to their source of recruitment: volunteer research register (n=128), general practice (n=123), community (n=236) or public inpatient (n=178) mental health services. Hierarchical discriminant function analyses revealed significant differences between these recruitment sources with respect to illness-onset factors, relationship and support factors, current functioning and course of illness. A severity/functioning gradient was observed across the four recruitment sources, possibly reflecting a spectrum of neurobiological impairment from good to poor prognosis. The implications of these findings for sampling strategies in schizophrenia research are discussed.     

Differential cognitive performances between schizophrenic responders and non-responders to antipsychotics: Correlation with course of the illness,psychopathology, attitude to the treatment and antipsychotics doses

Multiple lines of evidence demonstrate that schizophrenia patients may perform worse than normal controls in several cognitive tasks. However, little is known on putative differences in cognitive functioning between schizophrenia patients responding to antipsychotics and those resistant to the treatment. In this cross-sectional study, 63 subjects (41 schizophrenia and schizoaffective patients and 22 age and sex-matched controls) were enrolled. Patients were divided in resistant (TRS, n=19) and non-resistant to pharmacological treatment (non-TRS, n=22) according to the American Psychiatric Association (APA) criteria for treatment resistance. The Brief Assessment of Cognition in Schizophrenia (BACS) was administered to patients and controls. The following rating scales were administered to schizophrenia patients: the Positive and Negative Syndrome Scale (PANSS), the Drug Attitude Inventory (DAI) and the Subjective Well-being under Neuroleptics (SWN). Statistically significant differences among non-TRS patients, TRS ones, and controls were detected at the BACS. TRS patients performed significantly worse than non-TRS ones on Verbal Memory task, exhibited higher PANSS total and subscales scores and were prescribed higher antipsychotic doses. Poorer performances at the BACS significantly correlated with more severe negative symptoms in TRS but not in non-TRS patients. These results may suggest that TRS patients suffer from a form of the disease with prominent cognitive impairment possibly related to negative symptoms.     

Health-related quality of life and functioning of middle-aged and elderly adults with bipolar disorder

OBJECTIVE: Data characterizing bipolar disorder in older people are scarce, particularly on functional status. We evaluated health-related quality of life and functioning (HRQoLF) among older outpatients with bipolar disorder as well as the relationship of HRQoLF to bipolar illness characteristics. METHOD: We compared community-dwelling middle-aged and older adults (age range, 45 to 85 years) with bipolar disorder (N=54; mean age=57.6 years), schizophrenia (N=55; mean age=58.5 years), or no psychiatric illnesses (N=38; mean age=64.7 years) on indicators of objective functioning (e.g., education, occupational attainment, medical comorbidity) and health status (e.g., Quality of Well-Being scale [QWB] and the Medical Outcomes Study-Short Form Health Survey [SF-36]). Within the group with bipolar disorder, we examined the relationship between HRQoLF and clinical variables (e.g., phase and duration of illness, psychotic symptoms, cognitive functioning). RESULTS: Patients with bipolar disorder were similar in educational and occupational attainment to the normal comparison group, but they obtained lower scores on the QWB and SF-36 (with large effect sizes). Compared with schizophrenia, bipolar disorder was associated with better educational and work histories but similar QWB and SF-36 scores and more medical comorbidity. Patients in remission from bipolar disorder had QWB scores that were worse than those of normal comparison subjects. Greater severity of psychotic and depressive symptoms and cognitive impairment were associated with lower HRQoLF. CONCLUSIONS: Bipolar disorder was associated with substantial disability in this sample of older adults, similar in severity to schizophrenia. Remission of bipolar disorder was associated with significant but incomplete improvement in functioning, whereas psychotic and depressive symptoms and cognitive impairment seemed to contribute to lower HRQoLF.     

Association between psychopathology and problems of psychosocial functioning in the long-term outcome of patients diagnosed with schizophrenic, schizoaffective and affective disorders

Mental health problems do significantly impact on a person’s functioning. In the past, problems with psychosocial functioning were mainly associated with the diagnoses of schizophrenia. However, nowadays it is clear that impaired psychosocial functioning is also a common phenomenon in people suffering from affective disorders. Only few studies have investigated psychosocial functioning in patients with affective, schizoaffective and schizophrenic disorders in the long-term and in a comparative approach. In the present study, we analysed the association between psychopathology and psychosocial functioning. This question is relevant as symptom remission and sufficient levels of functioning are considered as important indicators of patients’ recovery from their mental health problems. The here reported findings refer to the data of a sample of 177 patients with life-time diagnoses belonging to the schizophrenic, schizoaffective or affective spectrum according to the ICD-10 criteria. Psychopathological, socio-demographic and other illness-related variables were assessed at the index hospitalisation and at the 15-year follow-up evaluation. In the present study, psychopathology is focused on data assessed with the PANSS (Positive and Negative Syndrome Scale). Information about patients’ psychosocial functioning was assessed by using a modified and extended version of the WHO disability assessment scale (WHO-DAS-M). The association between psychosocial functioning and psychopathology was analysed by correlation analyses with the total sample and diagnostic subsamples. The consistency of correlations across the diagnostic groups and domains of psychosocial functioning was calculated. Findings revealed for all diagnostic groups that higher levels of psychopathology were associated with higher levels of problems in psychosocial functioning in various domains. Though there seem to be some differences between psychopathological dimensions and their effects on different aspects of psychosocial functioning, findings across the three diagnostic categories were fairly consistent. The present findings do highlight the importance of symptom remission in achieving social recovery and preventing impairment in psychosocial functioning in all major psychiatric disorders.     

Early-onset psychotic disorders: course and outcome over a 2-year period

OBJECTIVE: To examine the course and outcome of early-onset psychotic disorders. METHOD: These are data from a longitudinal, prospective study of youths with psychotic disorders. Standardized diagnostic and symptom rating measures were used. RESULTS: Fifty-five subjects with the following disorders have been recruited: schizophrenia (n = 18), bipolar disorder (n = 15), psychosis not otherwise specified (n = 15), schizoaffective disorder (n = 6), and organic psychosis (n = 1). Follow-up assessments were obtained on 42 subjects at year 1 and 31 subjects at year 2. Youths with schizophrenia had more chronic global dysfunction, whereas subjects with bipolar disorder overall had better functioning, with a cyclical course of illness. However, according to results of a regression model, premorbid functioning and ratings of negative symptoms, but not diagnosis, significantly predicted the highest level of functioning over years 1 and 2. CONCLUSIONS: Course and level of functioning differentiated bipolar disorder from schizophrenia. However, premorbid functioning and ratings of negative symptoms were the best predictors of functioning over the follow-up period. These findings are consistent with the adult literature, and they further support that psychotic illnesses in young people are continuous with the adult-onset forms.     

Outcome on quality of life in a Canadian national sample of patients with schizophrenia and related psychotic disorders

OBJECTIVE: To examine changes in subjective and objective dimensions of quality of life (QoL) in a large Canadian sample of patients with diagnosis of schizophrenia or schizoaffective disorder treated in academic and non-academic settings over a 2-year period. METHOD: Patients recruited in the study across the country were assessed for QoL and functioning using the Client and Provider versions of the Wisconsin Quality of Life Questionnaire (WQoL) and the Short Form-36 (SF-36) at baseline (n = 448), 1 year (n = 308-353) and 2 years (188-297). Data were analyzed to examine change across time using multivariate analyses controlling for potential influence of variables such as age, regional variation, gender, duration of illness, type of treatment taken and baseline measures of symptoms and QoL. RESULTS: The weighted quality of life index (W-QoL-I) showed a significant change on both the client and the provider versions of the WQoL while the physical and mental composites of the SF-36 showed change only at 2 years. These changes were influenced significantly by baseline scores on W-QoL-I and in the case of provider version of the WQoL by baseline Brief Psychiatric Rating Scale (BPRS) scores. Regional variation or type of medication had no impact on improvement in QoL. CONCLUSION: Within a naturalistic sample of schizophrenia patients treated and followed in routine care the overall QoL showed an improvement over time but this improvement was not influenced by the type of medication prescribed.