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Original Investigation
April 2018

Interplay Among Psychopathologic Variables, Personal Resources, Context-Related Factors, and Real-life Functioning in Individuals With SchizophreniaA Network Analysis

Author Affiliations
  • 1Department of Psychiatry, Campania University “Luigi Vanvitelli,” Naples, Italy
  • 2Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
  • 3Department of Psychiatry and Behavioral Sciences, University of Nevada, Reno School of Medicine, Reno
  • 4Department of Neuroscience, Section of Psychiatry, University of Turin, Turin, Italy
  • 5Section of Psychiatry, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
  • 6Department of Neurological and Psychiatric Sciences, University of Bari, Bari, Italy
  • 7Department of Psychology, University of Georgia, Athens
  • 8Department of Clinical and Molecular Biomedicine, Psychiatry Unit, University of Catania, Catania, Italy
  • 9Psychiatry Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
  • 10Section of Psychiatry, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health, University of Genoa, Genoa, Italy
  • 11Section of Psychiatry, Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Cagliari, Italy
  • 12Department of Neurosciences, Mental Health and Sensory Organs, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
  • 13Department of Molecular Medicine and Clinical Department of Mental Health, University of Siena, Siena, Italy
  • 14Department of Neuroscience and Imaging, G. D’Annunzio University, Chieti, Italy
  • 15Section of Psychiatry, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
  • 16Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
  • 17Department of Neuroscience, Psychiatry Unit, University of Parma, Parma, Italy
  • 18Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana,” Section of Neuroscience, University of Salerno, Salerno, Italy
  • 19Department of Psychiatry, University of Milan, Milan, Italy
  • 20Unit of Psychiatry, Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
  • 21Psychiatric Clinic, Department of Neurosciences, University of Padua, Padua, Italy
  • 22Department of Systems Medicine, Psychiatry and Clinical Psychology Unit, Tor Vergata University of Rome, Rome, Italy
  • 23Psychiatric Unit, School of Medicine, University of Brescia, Brescia, Italy
  • 24Department of Mental Health, Spedali Civili Hospital, Brescia, Italy
  • 25Department of Translational Medicine, Psychiatric Unit, University of Eastern Piedmont, Novara, Italy
JAMA Psychiatry. 2018;75(4):396-404. doi:10.1001/jamapsychiatry.2017.4607
Key Points

Question  How are real-life functioning, psychopathologic variables, cognition, personal resources, and sociodemographic variables connected to each other in community-dwelling individuals with schizophrenia?

Findings  In this network analysis of 740 individuals with schizophrenia, functional capacity and everyday life skills were the most central and interconnected nodes, while positive symptoms were the least interconnected nodes. Real-life functioning was connected with several variables belonging to different domains.

Meaning  The high centrality of functional capacity and everyday life skills suggests that improving the ability to perform tasks relevant to everyday life is critical for any therapeutic intervention in schizophrenia, and the pattern of network node connections supports the implementation of personalized interventions for individuals with schizophrenia.

Abstract

Importance  Enhanced understanding of factors associated with symptomatic and functional recovery is instrumental to designing personalized treatment plans for people with schizophrenia. To date, this is the first study using network analysis to investigate the associations among cognitive, psychopathologic, and psychosocial variables in a large sample of community-dwelling individuals with schizophrenia.

Objective  To assess the interplay among psychopathologic variables, cognitive dysfunctions, functional capacity, personal resources, perceived stigma, and real-life functioning in individuals with schizophrenia, using a data-driven approach.

Design, Setting, and Participants  This multicenter, cross-sectional study involved 26 university psychiatric clinics and/or mental health departments. A total of 921 community-dwelling individuals with a DSM-IV diagnosis of schizophrenia who were stabilized on antipsychotic treatment were recruited from those consecutively presenting to the outpatient units of the sites between March 1, 2012, and September 30, 2013. Statistical analysis was conducted between July 1 and September 30, 2017.

Main Outcomes and Measures  Measures covered psychopathologic variables, neurocognition, social cognition, functional capacity, real-life functioning, resilience, perceived stigma, incentives, and service engagement.

Results  Of 740 patients (221 women and 519 men; mean [SD] age, 40.0 [10.9] years) with complete data on the 27 study measures, 163 (22.0%) were remitted (with a score of mild or better on 8 core symptoms). The network analysis showed that functional capacity and everyday life skills were the most central and highly interconnected nodes in the network. Psychopathologic variables split in 2 domains, with positive symptoms being one of the most peripheral and least connected nodes. Functional capacity bridged cognition with everyday life skills; the everyday life skills node was connected to disorganization and expressive deficits. Interpersonal relationships and work skills were connected to avolition; the interpersonal relationships node was also linked to social competence, and the work skills node was linked to social incentives and engagement with mental health services. A case-dropping bootstrap procedure showed centrality indices correlations of 0.75 or greater between the original and randomly defined samples up to 481 of 740 case-dropping (65.0%). No difference in the network structure was found between men and women.

Conclusions and Relevance  The high centrality of functional capacity and everyday life skills in the network suggests that improving the ability to perform tasks relevant to everyday life is critical for any therapeutic intervention in schizophrenia. The pattern of network node connections supports the implementation of personalized interventions.

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