Determinants of different aspects of everyday outcome in schizophrenia: The roles of negative symptoms, cognition, and functional capacity

Cognition, negative symptoms, and depression are potential predictors of disability in schizophrenia. We present analyses of pooled data from four separate studies (all n>169; total n=821) that assessed differential aspects of disability and their potential determinants. We hypothesized that negative symptoms would predict social outcomes, but not vocational functioning or everyday activities and that cognition and functional capacity would predict vocational functioning and everyday activities but not social outcomes. The samples were rated by clinician informants for their everyday functioning in domains of social and vocational outcomes, and everyday activities, examined with assessments of cognition and functional capacity, rated clinically with the Positive and Negative Syndrome Scale (PANSS) and self-reporting depression. We computed a model that tested the hypotheses described above and compared it to a model that predicted that negative symptoms, depression, cognition, and functional capacity had equivalent influences on all aspects of everyday functioning. The former, specific relationship model fit the data adequately and we subsequently confirmed a similar fit within all four samples. Analyses of the relative goodness of fit suggested that this specific model fit the data better than the more general, equivalent influence predictor model. We suggest that treatments aimed at cognition may not affect social functioning as much as other aspects of disability, a finding consistent with earlier research on the treatment of cognitive deficits in schizophrenia, while negative symptoms predicted social functioning. These relationships are central features of schizophrenia and treatment efforts should be aimed accordingly

Prediction of disability in schizophrenia: Symptoms, cognition, and self-assessment

Schizophrenia is associated with wide-ranging disability across multiple functional domains. There are several determinants of disability that have been identified to date, including cognitive and social cognitive impairments, impairments in everyday functional skills and social skills, difficulties in self-assessment of abilities, and negative symptoms. These impairments are related to different elements of disability, and disability and its predictors are not a single global dimension. Further, although psychotic symptoms have limited cross-sectional correlations with everyday functioning, emerging evidence suggests that long-term clinical stability, often induced through treatment with long-acting antipsychotic medications, is also associated with improvements in everyday functioning. This review addresses the characteristics and origins of disability, with treatment implications noted in each disability domains

Emerging 5-HT receptor antagonists for the treatment of Schizophrenia

While antipsychotics have been generally successful in treating psychosis in schizophrenia, there is a major treatment gap for negative symptoms and cognitive deficits. Given that these aspects of the disease contribute to poor functional outcomes independently of positive symptoms, treatments would have profound implications for quality of life. The 5-HT 2A - receptor has been considered a potential target for interventions aimed at negative and cognitive symptoms and multiple antagonists and inverse agonists of this receptor have been tested. Ritanserin and volinanserin, are historically important compounds in this area, while pimavanserin, roluperidone, and lumateperone are either newly approved, in late stages of development, or currently being tested for efficacy in schizophrenia-related features. The focus will be on their efficacy in the treatment of negative symptoms, with a limited secondary discussion of cognition. In addition to their efficacy in treating negative symptoms and cognition, these compounds may also have a role in modulating antipsychotic-induced dopamine super-sensitivity and preventing relapse. They may also show efficacy in treating patients with milder symptoms such as patients with schizotypal personality disorder and attenuated psychosis syndrome. Their utility may also expand outside the spectrum of schizophrenia to encompass Parkinson's Disease psychosis, major depression, bipolar depression, and dementia-associated apathy

Pharmacological treatment of violence in schizophrenia

Chronic aggression and violence in schizophrenia are rare, but receive disproportionate negative media coverage. This contributes to the stigma of mental illness and reduces accessibility to mental health services. Substance Use Disorders (SUD), antisocial behavior, non-adherence and recidivism are known risk factors for violence. Treatment with antipsychotic medication can reduce violence. Aside from clozapine, long-acting injectable antipsychotics (LAI) appear to be superior to oral antipsychotics for preventing violence, addressing adherence and recidivism. LAI also facilitate the implementation of functional skills training. For the high-risk recidivist target population with schizophrenia, better life skills have the potential to also reduce the risk for contact with the legal system, including an improved ability to live independently in supported environments and interact appropriately with others. High-risk patients who are resistant to treatment with other antipsychotics should receive treatment with clozapine due to its direct positive effects on impulsive violence, along with a reduction in comorbid risk factors such as SUDs

Real world sedentary behavior and activity levels in patients with schizophrenia and controls: An ecological momentary assessment study

People with schizophrenia often experience poor health, leading to shortened lifespans. The health of people with schizophrenia may be further exacerbated by increased sedentary behavior, which independently predicts health risk in the general population. However, the prevalence and patterns of objectively measured sedentary behavior in schizophrenia have not been studied extensively on a momentary basis. Activity of 100 patients with schizophrenia was compared to that of healthy controls (HC; n = 71) using ecological momentary assessment (EMA). EMA provides real-time, real-world monitoring of behavior. We sampled behavior seven times per day for seven days, quantifying active versus inactive behaviors and four different movement patterns (recumbent, seated, standing, and moving). Due to different employment rates between samples, we focused on surveys completed at home. Four of the five most commonly reported activities for participants with schizophrenia involved sitting or lying down. When considering activity during the last hour, participants with schizophrenia were more likely to be sitting or pacing and less likely to be standing than HC. If participants with schizophrenia only did one thing in the last hour, it was more likely to involve sitting and less likely to involve standing compared to HC. People with schizophrenia were significantly more likely to be seated and less likely to be standing or active during the past hour than HC, despite high frequencies of seated behaviors in the HC as well. The adverse health consequences of sitting for extended periods may be especially relevant for people with schizophrenia and likely contribute to premature mortality in this population. •Activity levels of schizophrenia patients and healthy controls were monitored for seven days, repeated after four weeks, with ecological momentary assessment (EMA), a smartphone-based technology.•Four of the five most commonly reported activities of patients with schizophrenia involved sitting (43% of activity) or lying down during the daytime hours (19% of activity).•Patients with schizophrenia were more likely to be sitting and less likely to be standing than healthy controls.•Activity levels were quite stable at a 4-week follow-up assessment.•Adverse health consequences of sitting may contribute to premature mortality in schizophrenia

Evidence for avolition in bipolar disorder? A 30-day ecological momentary assessment comparison of daily activities in bipolar disorder and schizophrenia

•People with bipolar disorder typically have better functional outcomes than people with schizophrenia, but disability is quite common.•People with bipolar disorder were no more likely to engage in productive activities than people with schizophrenia and momentary sadness was correlated with unproductivity in both samples.•People with bipolar disorders were more likely to have done more than one activity in the recent past than people with schizophrenia, but most of their ecological momentary assessment surveys also only indicated one activity.•Negative symptoms such as avolition have been reported previously in people with bipolar disorder and it seems as though avolition occurs in the context of momentary experiences of sadness. Disability is common in bipolar disorder (BD) and predicted by persistent sadness. We used ecological momentary assessment (EMA) to examine daily activities in people with BD and schizophrenia. We classified activities as productive, unproductive, or passive recreation, relating them to momentary sadness, location, and social context. 71 people with BD and 102 people with schizophrenia were sampled 3 times/day for 30 days with an EMA survey. Each survey asked where they were, with whom, what they were doing, and if they were sad. People with BD were home more than 50% of the time. There were no differences in prevalence of activity types across diagnoses. People with BD were less likely to report only one activity since the prior survey, but the most surveys still reported only one. For both groups, sadness and being home and alone since the last survey was associated with less productive activity and more passive recreation. Participants with BD and schizophrenia manifested high levels of unproductive and passive activities, predicted by momentary sadness. These activity patterns are consistent with descriptions of avolition and they minimally differentiated people with BD and schizophrenia. Previous reports of negative symptoms in BD may have been identifying these behaviors