Department of Psychiatry, University of Campania "Luigi Vanvitelli," Naples, Italy.
Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.
JAMA Psychiatry. 2021 May 1;78(5):550-559. doi: 10.1001/jamapsychiatry.2020.4614.
The goal of schizophrenia treatment has shifted from symptom reduction and relapse prevention to functional recovery; however, recovery rates remain low. Prospective identification of variables associated with real-life functioning domains is essential for personalized and integrated treatment programs.
To assess whether baseline illness-related variables, personal resources, and context-related factors are associated with work skills, interpersonal relationships, and everyday life skills at 4-year follow-up.
DESIGN, SETTING, AND PARTICIPANTS: This multicenter prospective cohort study was conducted across 24 Italian university psychiatric clinics or mental health departments in which 921 patients enrolled in a cross-sectional study were contacted after 4 years for reassessment. Recruitment of community-dwelling, clinically stable persons with schizophrenia was conducted from March 2016 to December 2017, and data were analyzed from January to May 2020.
Psychopathology, social and nonsocial cognition, functional capacity, personal resources, and context-related factors were assessed, with real-life functioning as the main outcome. Structural equation modeling, multiple regression analyses, and latent change score modeling were used to identify variables that were associated with real-life functioning domains at follow-up and with changes from baseline in these domains.
In total, 618 participants (427 male [69.1%]; mean [SD] age, 45.1 [10.5] years) were included. Five baseline variables were directly associated with real-life functioning at follow-up: neurocognition with everyday life (β, 0.274; 95% CI, 0.207-0.341; P < .001) and work (β, 0.101; 95% CI, 0.005-0.196; P = .04) skills; avolition with interpersonal relationships (β, -0.126; 95% CI, -0.190 to -0.062; P < .001); positive symptoms with work skills (β, -0.059; 95% CI, -0.112 to -0.006; P = .03); and social cognition with work skills (β, 0.185; 95% CI, 0.088-0.283; P < .001) and interpersonal functioning (β, 0.194; 95% CI, 0.121-0.268; P < .001). Multiple regression analyses indicated that these variables accounted for the variability of functioning at follow-up after controlling for baseline functioning. In the latent change score model, higher neurocognitive abilities were associated with improvement of everyday life (β, 0.370; 95% CI, 0.253-0.486; P < .001) and work (β, 0.102; 95% CI, 0.016-0.188; P = .02) skills, social cognition (β, 0.133; 95% CI, 0.015-0.250; P = .03), and functional capacity (β, 1.138; 95% CI, 0.807-1.469; P < .001); better baseline social cognition with improvement of work skills (β, 0.168; 95% CI, 0.075-0.261; P < .001) and interpersonal functioning (β, 0.140; 95% CI, 0.069-0.212; P < .001); and better baseline everyday life skills with improvement of work skills (β, 0.121; 95% CI, 0.077-0.166; P < .001).
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.
精神分裂症治疗的目标已经从减少症状和预防复发转移到功能恢复上；然而，康复率仍然很低。前瞻性地确定与现实生活功能领域相关的变量对于个性化和综合治疗方案至关重要。
评估基线疾病相关变量、个人资源和环境相关因素是否与 4 年后的工作技能、人际关系和日常生活技能相关。
设计、地点和参与者：这是一项多中心前瞻性队列研究，在意大利 24 所大学精神病诊所或心理健康部门进行，在 4 年后对 921 名参加横断面研究的患者进行了重新评估。从 2016 年 3 月到 2017 年 12 月招募社区居住、临床稳定的精神分裂症患者，数据分析于 2020 年 1 月至 5 月进行。
评估了精神病理学、社会和非社会认知、功能能力、个人资源和环境相关因素，以现实生活功能为主要结果。结构方程模型、多元回归分析和潜在变化评分模型用于识别与随访时现实生活功能领域相关的变量，以及这些领域从基线开始的变化。
共有 618 名参与者（427 名男性[69.1%]；平均[标准差]年龄为 45.1[10.5]岁）被纳入。5 个基线变量直接与随访时的现实生活功能相关：神经认知与日常生活（β，0.274；95%置信区间，0.207-0.341；P<0.001）和工作（β，0.101；95%置信区间，0.005-0.196；P=0.04）技能；意志减退与人际关系（β，-0.126；95%置信区间，-0.190 至-0.062；P<0.001）；阳性症状与工作技能（β，-0.059；95%置信区间，-0.112 至-0.006；P=0.03）；社会认知与工作技能（β，0.185；95%置信区间，0.088-0.283；P<0.001）和人际关系（β，0.194；95%置信区间，0.121-0.268；P<0.001）。多元回归分析表明，在控制基线功能后，这些变量可以解释功能在随访时的变化。在潜在变化评分模型中，较高的神经认知能力与日常生活（β，0.370；95%置信区间，0.253-0.486；P<0.001）和工作（β，0.102；95%置信区间，0.016-0.188；P=0.02）技能、社会认知（β，0.133；95%置信区间，0.015-0.250；P=0.03）和功能能力（β，1.138；95%置信区间，0.807-1.469；P<0.001）的改善相关；更好的基线社会认知与工作技能（β，0.168；95%置信区间，0.075-0.261；P<0.001）和人际关系（β，0.140；95%置信区间，0.069-0.212；P<0.001）的改善相关；以及更好的基线日常生活技能与工作技能（β，0.121；95%置信区间，0.077-0.166；P<0.001）的改善相关。
这项大型前瞻性研究的结果表明，与随访时功能结果相关的基线变量包括社区心理健康服务中常规评估和目标干预方案未涉及的领域。社会和非社会认知以及基线日常生活技能的关键作用支持在常规精神保健中采用认知训练方案，并结合个性化心理社会干预措施，以促进独立生活。
