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Original Investigation
February 10, 2021

Factors Associated With Real-Life Functioning in Persons With Schizophrenia in a 4-Year Follow-up Study of the Italian Network for Research on Psychoses

Author Affiliations
  • 1Department of Psychiatry, University of Campania “Luigi Vanvitelli,” Naples, Italy
  • 2Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
  • 3Section of Psychiatry, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
  • 4Department of Neuroscience, Section of Psychiatry, University of Turin, Turin, Italy
  • 5Department of Neurological and Psychiatric Sciences, University of Bari, Bari, Italy
  • 6Department of Clinical and Molecular Biomedicine, Psychiatry Unit, University of Catania, Catania, Italy
  • 7Section of Psychiatry, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health, University of Genoa, Genoa, Italy
  • 8Psychiatry Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
  • 9Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
  • 10Section of Psychiatry, Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Cagliari, Italy
  • 11Department of Molecular Medicine and Clinical Department of Mental Health, University of Siena, Siena, Italy
  • 12Section of Psychiatry, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
  • 13Department of Neuroscience, Psychiatry Unit, University of Parma, Parma, Italy
  • 14Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana,” Section of Neuroscience, University of Salerno, Salerno, Italy
  • 15Department of Systems Medicine, Psychiatry and Clinical Psychology Unit, Tor Vergata University of Rome, Rome, Italy
  • 16Department of Psychiatry, State University of Milan, Milan, Italy
  • 17Department of Neuroscience and Imaging, G. D’Annunzio University, Chieti, Italy
  • 18Department of Neurosciences, Mental Health and Sensory Organs, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
  • 19Unit of Psychiatry, Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
  • 20Psychiatric Clinic, Department of Neurosciences, University of Padua, Padua, Italy
  • 21Psychiatric Unit, School of Medicine, University of Brescia, Brescia, Italy
  • 22Department of Mental Health, Spedali Civili Hospital, Brescia, Italy
  • 23Department of Translational Medicine, Psychiatric Unit, University of Eastern Piedmont, Novara, Italy
JAMA Psychiatry. Published online February 10, 2021. doi:10.1001/jamapsychiatry.2020.4614
Key Points

Question  What factors are associated with real-life functioning in people with schizophrenia, and what are the implications for the implementation of management plans?

Findings  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.

Meaning  Findings suggest that several variables associated with real-life functioning at follow-up are not routinely assessed and targeted by intervention programs and that personalized interventions aimed at promoting cognition and independent living should be an integral part of management programs for schizophrenia.


Importance  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.

Objective  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.

Main Outcomes and Measures  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.

Results  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).

Conclusions and Relevance  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.

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