Redefining real-life functioning in Schizophrenia, study highlights the role of neurocognition

Schizophrenia is no longer conceptualized as a progressive deteriorating illness. The clinical stability with persistent symptomatic remission is now considered a realistic outcome for most people. Hence, prospective identification of variables associated with real-life functioning domains is essential for personalized and integrated treatment programs. Mucci et al in their latest study published in JAMA Psychiatry, have shown that several variables associated with real-life functioning at follow-up are not routinely assessed and targeted by intervention programs.

The available evidence does not enable the drawing of solid conclusions regarding the variables associated with real-life functioning in people with schizophrenia across time owing to several methodological flaws:

(1) most studies have modest sample sizes (N ≤ 150);

(2) the assessment of is not always carried out using state-of-the-art instruments (eg, second-generation assessment instruments;

(3) social cognition impairment is not always evaluated;

(4) most studies explore global functioning or only 1 of the real-life functioning domains, which might have distinct determinants; and

(5) functional capacity is seldom included.

The present longitudinal study aimed to address some of these limitations and to assess whether baseline illness related variables, personal resources, and context-related factors were associated with work skills, interpersonal relationships, and everyday life skills at 4-year follow-up.

This 4-year cohort study, involving 618 clinically stable participants with schizophrenia, identified social and nonsocial cognition, avolition, and positive symptoms as the main baseline factors associated with real-life functioning at follow-up. Baseline everyday life skills were associated with changes in work skills at follow-up. 

In the latent change score model, higher neurocognitive abilities were associated with improvement of everyday life and work skills, social cognition and functional capacity; better baseline social cognition with improvement of work skills and interpersonal and better baseline everyday life skills with improvement of work skills. This is the first prospective study including a broad range of variables (ie, illness-related variables, personal resources, and context-related factors) that used state-of-the art assessment instruments to identify factors associated with functional outcome in a large sample of community-dwelling persons with schizophrenia.

Neurocognition was by far the variable with the strongest association with the everyday life skills domain of functioning, which is crucial for independent living and for reducing the burden on families and society.

"Findings of this large prospective study suggested that baseline variables associated with functional outcome at follow-up included domains not routinely assessed and targeted by intervention programs in community mental health services. The key roles of social and nonsocial cognition and of baseline everyday life skills support the adoption in routine mental health care of cognitive training programs combined with personalized psychosocial interventions aimed to promote independent living", concluded the authors.

Source: JAMA Psychiatry: doi: 10.1001/jamapsychiatry.2020.4614. Online ahead of print