29 Mar Schizophrenia: Medications Reduce Psychotic Symptoms But Don’t Improve Real-Life Funtioning
MedicalResearch.com Interview with:
Silvana Galderisi MD
President of the European Psychiatric Association
Professor of Psychiatry
University of Campania “Luigi Vanvitelli”
MedicalResearch.com: What is the background for this study?
Response: The goal of schizophrenia treatment has gradually shifted from reduction of symptoms and prevention of relapse to improvement of real-life functioning. In fact, these outcomes not always coincide and, in spite of progress in treatments reducing symptoms and preventing relapses, people with schizophrenia live 15-20 years less than the general population, are often unemployed, and show severe disabilities.
Enhanced understanding of factors associated with real-life functioning is instrumental to design effective integrated and personalized treatment plans for persons with schizophrenia.
To this aim, the Italian Network for Research on Psychoses, including 26 twenty-six Italian university psychiatric clinics and/or mental health departments, has focused on the identification of variables influencing real-life functioning, in particular on the interrelationships among illness-related variables, personal resources, context-related variables and real-life functioning. The number of variables and subjects included in the study was larger than in any other study on this topic, and for the first time the network analysis was used to model the interplay among cognitive, psychopathological and psychosocial variables in a large sample of community dwelling subjects with schizophrenia. The network analysis is a data-driven approach; it does not rely on an a priori model of relationships among variables, provides quantitative measures of variable centrality within the network, thus indicating which variables play a key role in the network, and which ones are instead more peripheral. In addition, by inspecting the network, it is possible to understand the extent to which variables belonging to the same construct are connected, and how different constructs are mutually interacting and reinforcing each other.
MedicalResearch.com: What are the main findings?
Response: In 740 persons with a diagnosis of schizophrenia, living in the community, 27 study measures were used to build the network. The different domains of real-life functioning (vocational, interpersonal and every-day life skills) were interconnected, but showed different patterns of associations with the other variables of the network. The two variables with the highest centrality were “Functional capacity” and “Every-day life skills”.
Functional capacity is the ability to perform critical everyday life tasks in a controlled setting, similar to the one in which subjects perform neurocognitive tests. In such a setting, the task is proposed in a structured way, with clear instructions, in a relaxed and comfortable environment, that generally enables the person to perform at the best of her/his potential, with minimal influence of factors which make real-life performance of similar tasks much more challenging (e.g., noisy environment, difficult interaction with other people).
Every-day life skills is a measure of the abilities to perform common real-life tasks (e.g., shopping, handling personal finance, use of public transportation).
Functional capacity and Every-day life skills were strongly related to each other and associated with several other variables.
Functional capacity was associated with neurocognitive functions and social cognition.
Every-day life skills was linked to the other two domains of real-life functioning, i.e. interpersonal skills and vocational abilities, and with two aspects of psychopathology, i.e. conceptual disorganization and the expressive factor of the negative symptoms, including alogia (reduction in quantity of words spoken and in spontaneous elaboration of speech) and blunted affect (decrease of facial and vocal expression and expressive gestures).
Interpersonal functioning was associated with social competence and the avolition factor of the negative symptom dimension.
Vocational functioning was weakly associated with avolition and disorganization; poor vocational functioning was also associated with the availability of incentives and poor service engagement.
In addition, psychotic symptoms were peripheral, related to real-life functioning only through disorganization and, besides disorganization, associated with one other variables only, i.e. difficulty in engaging with mental health services.
MedicalResearch.com: What should readers take away from your report?
Response: Psychopharmacological treatments are important to reduce the burden of psychotic symptoms and disorganization, but not enough to improve the different domains of real-life functioning. Treatment plans including psychosocial interventions aimed at improving the ability to perform tasks relevant to everyday life is critical for any therapeutic intervention in people with schizophrenia.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: Longitudinal studies are needed to enable inferences on the direction of the observed associations. In fact, the cross-sectional nature of this study does not allow appropriate testing of the direction of the effects (what determines what). In addition, studies in large samples of first episode subjects are advisable, as our results might not generalize to this latter patient population, in which the impact of positive symptoms and disorganization on functioning might be more central than in chronic, stabilized patients.
MedicalResearch.com: Is there anything else you would like to add?
Response: Our study highlights the need for investments in research and care to improve the outcome of mental disorders. Many Countries are now moving from a hospital-based to a community-based treatment model for mental disorders, which is a highly promising development, provided that adequate human and financial resources are allocated to personnel training and organization of community-based services.
Galderisi S, Rucci P, Kirkpatrick B, et al. Interplay Among Psychopathologic Variables, Personal Resources, Context-Related Factors, and Real-life Functioning in Individuals With SchizophreniaA Network Analysis. JAMA Psychiatry. Published online February 14, 2018. doi:10.1001/jamapsychiatry.2017.4607
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Last Updated on March 29, 2018 by Marie Benz MD FAAD