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

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.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Kirkpatrick reported receiving licensing royalties from ProPhase LLC for use of the Brief Negative Symptom Scale (BNSS) by for-profit groups (these fees are donated to the Brain and Behavior Research Foundation); receiving honoraria and travel support from ProPhase LLC for training pharmaceutical company raters on the BNSS, consulting fees and/or travel support from Genentech/Roche, Minerva Neurosciences, ProPhase LLC, and Allergan, consulting fees from anonymized pharmaceutical companies through Decision Resources Inc and from an anonymized investment capital company through Guideposts; working with Allergan to prepare a manuscript without receiving a fee; receiving fees from Walsh Medical Media and from Physicians Postgraduate Press Inc for editorial services. No other conflicts were reported.

Figures

Figure 1.. Adaptive Least Absolute Shrinkage and Selection Operator Network of the Overall Study Population

The thickness of an edge reflects the magnitude of the correlation (the thickest edge representing a value of 0.61, which is the correlation between Positive and Negative Syndrome Scale [PANSS] positive [Pos] and PANSS disorganization [Dis]). Green lines represent positive correlations, whereas red lines represent negative correlations. Nodes with the same color belong to the same domain. Att indicates attention; Avl, Brief Negative Symptom Scale (BNSS) avolition; Dep, Calgary Depression Scale for Schizophrenia total score for depression; Dis, PANSS disorganization; ELS, everyday life skills; EnS, service engagement; ExD, BNSS expressive deficit domain; FC, functional capacity; FCo, family cohesion; FEI, Facial Emotion Identification Test; Inc, incentives; Int, interpersonal relationships; MSC, Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery Mayer-Salovey-Caruso Emotional Intelligence Test managing emotion section; PFu, perception of future; Pos, PANSS positive factor; PrS, problem solving; PSe, perception of self; PSp, processing speed; SCo, social competence; SLe, visuospatial learning; Stg, stigma; Ta1, The Awareness of Social Inference Test (TASIT) section 1 (see footnote a in Table 1 for a description of the sections); Ta2, TASIT section 2; Ta3, TASIT section 3; VLe, verbal learning; WMe, working memory; and Wrk, Specific Level of Functioning Scale work skills.

Figure 2.. Centrality Plots for Adaptive Least Absolute Shrinkage and Selection Operator Network of the Overall Study Population Depicting the Betweenness, Closeness, and Strength of Each Node

A, Betweenness indicates the number of times a node lies on the shortest path length between any 2 other nodes. B, Closeness indicates the average distance of a node from all other nodes in the network. C, Strength quantifies the extent to which a certain node influences other nodes in the network. For each index, higher values reflect greater centrality in the network. Att indicates attention; Avl, Brief Negative Symptom Scale (BNSS) avolition; Dep, Calgary Depression Scale for Schizophrenia total score for depression; Dis, Positive and Negative Syndrome Scale (PANSS) disorganization; ELS, everyday life skills; EnS, service engagement; ExD, BNSS expressive deficit domain; FC, functional capacity; FCo, family cohesion; FEI, Facial Emotion Identification Test; Inc, incentives; Int, interpersonal relationships; MSC, Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery Mayer-Salovey-Caruso Emotional Intelligence Test managing emotion section; PFu, perception of future; Pos, PANSS positive factor; PrS, problem solving; PSe, perception of self; PSp, processing speed; SCo, social competence; SLe, visuospatial learning; Stg, stigma; Ta1, The Awareness of Social Inference Test (TASIT) section 1 (see footnote a in Table 1 for a description of the sections); Ta2, TASIT section 2; Ta3, TASIT section 3; VLe, verbal learning; WMe, working memory; and Wrk, Specific Level of Functioning Scale work skills.