Impact of avolition and cognitive impairment on functional outcome in first-episode schizophrenia-spectrum disorder: a prospective one-year follow-up study
Introduction
Negative symptoms and cognitive impairment are core features of schizophrenia and are critically associated with poor functional outcome (Green et al., 2000, Bowie et al., 2006). It is acknowledged that negative symptoms represent a multi-dimensional construct comprising two distinct symptom sub-domains, namely avolition and diminished expression (DE) (Messinger et al., 2011). Recent studies have shown that within the negative symptom construct, avolition is a much stronger predictor of functioning than is DE (Kiang et al., 2001, Foussias et al., 2009, Strauss et al., 2013, Fervaha et al., 2014). Accumulating evidence has further revealed that avolition independently predicts functional outcome above and beyond cognitive deficits and other symptom dimensions (Foussias et al., 2009, Foussias et al., 2011, Konstantakopoulos et al., 2011, Fervaha et al., 2013, Fervaha et al., 2015).
It should be noted that the majority of prior studies that examined the relationship between avolition and functioning were cross-sectional in design and focused mainly on patients with chronic illness. Few studies have been conducted in the early course of illness in this respect, particularly in a first episode of psychosis (FEP). However, it is recognized that research on FEP ensures a studied cohort to be more homogeneous regarding illness chronicity and treatment exposure, and allows the associations between symptoms, cognitive impairment and functioning to be better elucidated right from the onset of illness. Thus far, only four FEP studies (three from the same FEP cohort) investigating the relationship between avolition and functioning have been published (Evensen et al., 2012, Faerden et al., 2009, Faerden et al., 2010, Faerden et al., 2013). Among these four studies, only one has incorporated cognition in prediction model evaluation and examined the predictive value of avolition on longitudinal functional outcome (Faerden et al., 2013).
In this study, we aimed to examine the predictive capacity of avolition, cognitive functioning and other clinical variables assessed at baseline on 1-year functional outcome in a representative cohort of Chinese patients presenting with first-episode schizophrenia-spectrum disorder. Based on previous research (Foussias et al., 2009, Galderisi et al., 2014, Fervaha et al., 2015) which have shown that both avolition and cognitive dysfunction are the major determinants of functional impairment in schizophrenia, with recent evidence further suggesting that avolition predicts functional outcome over and above cognition and other symptom measures in chronic (Foussias et al., 2011, Konstantakopoulos et al., 2011) and early (albeit not necessarily FEP samples) (Faerden et al., 2013, Fervaha et al., 2015) stages of the illness, we hypothesized that avolition and cognitive deficits would independently predict functional outcome, with avolition demonstrating the strongest association with functioning at 1-year follow-up.
Section snippets
Subjects
One hundred forty-five consecutive patients aged 18–55 years presenting with first-episode DSM-IV (American Psychiatric Association, 1994) schizophrenia, schizophreniform disorder or schizoaffective disorder were recruited from both outpatient and inpatient psychiatric units that provide service for a catchment area (i.e., Hong Kong Island) in Hong Kong with a population of approximately 1.3 million. Patients with known neurological disorder, substance abuse or learning disability were excluded.
Results
Demographics, baseline clinical characteristics, functioning and cognition of 114 subjects are summarized in Table 1. As shown in Table 2, educational level, baseline PANSS disorganization score, baseline SANS AA and DE domain scores, average DAS score at entry, and cognitive composite score were correlated with functional outcome at 12 months. Multiple regression analysis revealed SANS AA domain and cognitive composite scores as independent predictors of functioning, accounting for 18.4% and
Discussion
The current study sought to identify baseline predictors of 1-year functional outcome in patients with first-episode schizophrenia-spectrum disorder. Our results showed that avolition and global cognitive function both independently predicted functioning at 1-year follow-up. Further, we found that avolition was the most robust predictor of functioning even when cognition, DE and other symptom dimensions were taken into consideration. Our findings thus concur with the results of those very few
Role of funding source
Not applicable.
Contributors
Author E.Y.H.C designed the study. Author W.C.C managed literature search and statistical analysis, and wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Conflicts of interest
Author E.Y.H.C. has participated in the paid advisory board for Otsuka, has received educational grant support from Janssen-Cilag, and has received research funding from Astra-Zeneca, Janssen-Cilag, Eli Lilly, Sanofi-Aventis and Otsuka. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Acknowledgments
We thank all the coordinating clinicians and staff from the psychiatric inpatient and outpatient units, as well as the medical records department for their kind assistance. We are also grateful to the individuals who participated in the study.
References (32)
- et al.
The factor structure for the Positive and Negative Syndrome Scale (PANSS) in recent-onset psychosis
Schizophr. Res.
(2003) - et al.
Apathy in first episode psychosis patients: a ten year longitudinal follow-up study
Schizophr. Res.
(2012) - et al.
Apathy in first episode psychosis patients: one year follow up
Schizophr. Res.
(2010) - et al.
Apathy, poor verbal memory and male gender predict lower psychosocial functioning one year after the first treatment of psychosis
Psychiatry Res.
(2013) - et al.
Amotivation and functional outcomes in early schizophrenia
Psychiatry Res.
(2013) - et al.
Motivational deficits in early schizophrenia: prevalent, persistent, and key determinants of functional outcome
Schizophr. Res.
(2015) - et al.
Motivational deficits as the central link to functioning in schizophrenia: a pilot study
Schizophr. Res.
(2009) - et al.
Prediction of longitudinal functional outcomes in schizophrenia: the impact of baseline motivational deficits
Schizophr. Res.
(2011) - et al.
IRAOS: an instrument for the assessment of onset and early course of schizophrenia
Schizophr. Res.
(1992) - et al.
Apathy, cognitive deficits and functional impairment in schizophrenia
Schizophr. Res.
(2011)
Reliability and validity of the Apathy Evaluation Scale
Psychiatry Res.
Avolition and expressive deficits capture negative symptom phenomenology: implications for DSM-5 and schizophrenia research
Clin. Psychol. Rev.
A modified card sorting test sensitive to frontal lobe defects
Cortex
Deconstructing negative symptoms of schizophrenia: avolition-apathy and diminished expression clusters predict clinical presentation and functional outcome
J. Psychiatr. Res.
Diagnostic and Statistical Manual of Mental Disorders
Negative symptoms in schizophrenia. Definitions and reliability
Arch. Gen. Psychiatry
Cited by (41)
Introducing an interview-based cognitive assessment tool for people with Schizophrenia in Ethiopia
2023, Psychiatry ResearchThe relationship between cognition and functioning in schizophrenia: A semi-systematic review
2022, Schizophrenia Research: CognitionCitation Excerpt :Across studies, baseline NC and SC predicted functioning at up to 5 years of follow-up. Predictors included NC, intelligence quotient and baseline cognitive reserve, in outpatients (Amoretti et al., 2016; Chang et al., 2016; Heinrichs et al., 2010; Norman et al., 2015) as well as in hospitalized patients (Lipskaya-Velikovsky et al., 2015). Robinson et al. (2004) reported that cognitive performance following stabilization of acute psychosis in a large sample of first episode patients was the best predictor of functional recovery 5 years later.
Clinical, behavioural and neural validation of the PANSS amotivation factor
2020, Schizophrenia ResearchCitation Excerpt :So far, a comprehensive model of diminished expression has not been established in the literature and empirical data are generally more limited (Kaiser et al., 2017). To date, several studies indicate that the amotivation factor is primarily related to functional outcomes (Chang et al., 2016; Fervaha et al., 2015), and therefore could be thought of as more relevant and a central target for the development of treatment interventions. However, previous work (Galderisi et al., 2013; Evensen et al., 2012), and most importantly, recent studies in large cohorts have found diminished expression to be linked to at least some aspects of community functioning (Liemburg et al., 2020).
Depressive symptoms during first episode psychosis and functional outcome: A systematic review and meta-analysis
2020, Schizophrenia Research