Impact of avolition and cognitive impairment on functional outcome in first-episode schizophrenia-spectrum disorder: a prospective one-year follow-up study

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Abstract

Previous research investigating the relationships between avolition, cognition and functioning in schizophrenia mostly focused on chronic samples and were cross-sectional in design. Impacts of avolition and cognition on longitudinal functional outcome in first-episode patients are under-studied. We assessed 114 Chinese aged 18–55 years presenting with first-episode schizophrenia-spectrum disorder aiming to identify baseline predictors of 1-year functional outcome. Results showed that both avolition and global cognition independently predicted functioning, with avolition being the strongest predictor above and beyond cognition and other symptom dimensions. Our findings indicate the central role of in determining longitudinal functional status in the early illness stage.

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.

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