Associations of living arrangements with symptoms and functioning in schizophrenia.

BACKGROUND: Living arrangements and accommodation are closely related, but no study had concurrently investigated their associations with outcomes in schizophrenia. This study seeks to describe and compare socio-demographic, clinical and functioning profiles of people with schizophrenia in different living arrangements and accommodation, and to examine the associations of living arrangements and accommodation with symptomatic remission and functioning. METHODS: Community dwelling outpatients with schizophrenia (n = 276) were inquired on living arrangements, accommodation, socio-demographics and assessed on the Positive and Negative Syndrome Scale (PANSS) and the Social and Occupational Functioning Scale (SOFAS). Socio-demographics, symptoms and functioning of outpatients in different living arrangements and accommodation were compared. Symptomatic remission was investigated using logistic regression with living arrangements, socio-demographics and clinical variables as independent variables. Functioning was investigated using multiple regression with the same set of independent variables and the addition of PANSS factors. The same analyses were conducted with accommodation as independent variable. RESULTS: 185 (67.03%) participants lived with family and 195 (70.65%) participants lived in owned accommodation. People living with their spouses had significantly higher SOFAS, lower PANSS Total and PANSS Positive than people living with family, independently, or in rehabilitation centres. They also had lower PANSS Negative than people living with family and a higher likelihood to have achieved symptomatic remission. Types of accommodation was not associated with symptoms, symptomatic remission, and functioning. CONCLUSION: Living arrangements, but not types of accommodation, were associated with symptoms and functioning in schizophrenia. Family education and support is important to help maintain a conducive environment for people with schizophrenia. People living independently may need more support.

The effects of clinical illness severity and physical activity on health-related quality of life in schizophrenia.

BACKGROUND: Quality of life is an important clinical outcome in individuals with schizophrenia. Illness severity and physical activity (PA) were independently reported to influence health-related quality of life (HRQoL) in people with schizophrenia. This study attempts to examine the intensity and types of PA and their impact on HRQoL, as well as the relative contributions of illness severity, PA, and sedentary behavior (SB) to HRQoL in people with schizophrenia. METHODS: Demographic information was collected from 297 community-dwelling individuals with schizophrenia. Severity of illness was assessed on the Clinical Global Impression-Severity (CGI-S); PA and SB were assessed on the Global Physical Activity Questionnaire (GPAQ); HRQoL was assessed on the RAND-36. Regression analyses were conducted to examine the impact of different types and intensities of PA on HRQoL, and the relative impact of CGI-S, GPAQ-PA, and GPAQ-SB on HRQoL. RESULTS: Most participants had low PA level, and travel is the main type of PA adopted. Leisure time, travel-related, work-related, moderate-, and vigorous-intensity PA were all not associated with HRQoL. Lower severity of illness was significantly associated with better physical (PHC), mental (MHC) and global (GHC) health composites of the RAND-36 (GHC: t = - 5.628, p < 0.001, PHC: t = - 4.026, p < 0.001, MHC: t = - 5.534, p < 0.001). Both PA and SB were not significantly associated with PHC, MHC, and GHC. CONCLUSION: Severity of illness has a significant impact on HRQoL in people with schizophrenia. However, we found no evidence to support the association between physical activity and sedentary behavior with HRQoL.

The Impact of Medication Anticholinergic Burden on Cognitive Performance in People With Schizophrenia.

BACKGROUND: Cognitive deficits are prevalent in people with schizophrenia and associated with functional impairments. In addition to antipsychotics, pharmacotherapy in schizophrenia often includes other psychotropics, and some of these agents possess anticholinergic properties, which may impair cognition. The objective of this study was to explore the association between medication anticholinergic burden and cognition in schizophrenia. METHODS: Seven hundred five individuals with schizophrenia completed a neuropsychological battery comprising Judgment of Line Orientation Test, Wechsler Abbreviated Scale of Intelligence Matrix Reasoning, Continuous Performance Test-Identical Pairs Version, and the Brief Assessment of Cognition in Schizophrenia. Cognitive g and 3 cognitive factor scores that include executive function, memory/fluency, and speed of processing/vigilance, which were derived from a previously published analysis, were entered as cognitive variables. Anticholinergic burden was computed using 2 anticholinergic scales: Anticholinergic Burden Scale and Anticholinergic Drug Scale. Duration and severity of illness, antipsychotic dose, smoking status, age, and sex were included as covariates. RESULTS: Anticholinergic burden was associated with poorer cognitive performance in cognitive g, all 3 cognitive domains and most cognitive tasks in multivariate analyses. The associations were statistically significant, but the effect sizes were small (for Anticholinergic Burden Scale, Cohen f = 0.008; for Anticholinergic Drug Scale, Cohen f = 0.017). CONCLUSIONS: Although our results showed a statistically significant association between medications with anticholinergic properties and cognition in people with schizophrenia, the impact is of doubtful or minimal clinical significance.

Predictors of functioning in treatment-resistant schizophrenia: the role of negative symptoms and neurocognition.

Introduction: Predictors of functioning are well-studied in schizophrenia, but much less so in treatment-resistant schizophrenia (TRS). In this study, we aim to investigate contributions of schizophrenia symptom domains and neurocognition to predict functioning in a TRS population (n = 146). Methods: Participants were assessed on the Positive and Negative Syndrome Scale (PANSS), to calculate scores for five symptom factors (Positive, Negative, Cognitive, Depressive and Hostility) and two negative symptom constructs (Diminished Expressivity (DE), and Social Anhedonia (SA) as part of the Motivation and Pleasure-related dimension), based on a previously validated model, modified in accordance with EPA guidelines on negative symptoms assessment. Neurocognition was assessed with symbol coding and digit sequencing tasks from the Brief Assessment of Cognition in Schizophrenia (BACS). Functioning was assessed with the Social and Occupational Functioning Assessment Scale (SOFAS), employment status and World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Multiple regression analyses were performed on psychopathology scores and BACS scores against all three measures of functioning, controlling for age and sex. For WHODAS, regression with PANSS scores of significant symptom factors were also performed. Results: A lower severity of negative symptoms in the SA dimension was the strongest predictor of higher functioning across all three functioning measures. Neurocognition, in particular processing speed and attention assessed on the symbol coding task, predicted employment. A lower severity of somatic concerns and depressive symptoms was associated with lesser self-reported disability on WHODAS. Discussion: This study represents a first attempt at elucidating significant predictors of functioning in TRS. We highlight negative symptoms and neurocognition as important treatment targets to improve functioning in TRS, consistent with previous studies in general schizophrenia.

Impact of negative symptoms on health-related quality of life in schizophrenia.

Evidence regarding the association of Negative Symptoms (NS) dimensions with Health-related Quality of Life (HRQoL) is limited and no prior study has looked into contributions of NS domains on HRQoL. This study bridges the gap by examining the associations of NS, its two dimensions (Motivation and Pleasure, and Emotional Expressivity) and five domains (Anhedonia, Avolition, Asociality, Blunted affect and Alogia) with HRQoL in schizophrenia. 274 individuals with schizophrenia were assessed on the Positive and Negative Syndrome Scale (PANSS) and Brief Negative Symptom Scale (BNSS). PANSS scores were mapped to EuroQol five-dimensional (EQ-5D-5L) utility scores using an algorithm previously validated in Singapore, and the resulting EQ-5D-5L scores were used as a measure of HRQoL. Multiple linear regression analyses of the two NS dimensions and five NS domains against EQ-5D-5L showed that a lower severity of NS, specifically that of the Motivation and Pleasure (MAP) dimension and asociality domain was associated with higher HRQoL. Our findings highlight the importance of targeting NS, particularly MAP and asociality, in improving HRQoL in schizophrenia.

Defining negative symptoms remission in schizophrenia using the Brief Negative Symptom Scale.

INTRODUCTION: This study aimed to propose criteria for negative symptoms remission (NSR) in schizophrenia using the Brief Negative Symptom Scale (BNSS). MATERIAL AND METHODS: 274 participants were assessed on the Positive and Negative Syndrome Scale (PANSS), BNSS and Social and Occupational Functioning Assessment Scale (SOFAS). Two criteria for NSR on the BNSS were proposed - NSR based on the BNSS domains scores (NSRBNSS_DOMAINS) and NSR based on 5 key items of the BNSS (NSRBNSS_5ITEMS). A SOFAS score of 61 and above was considered as functional remission (FR). Logistic regressions were run to examine the association between FR and NSR. Receiver operating characteristic (ROC) curve analysis was performed for the NSR criteria on FR. Kappa agreement statistic was used to evaluate the agreement between the two NSR criteria. RESULTS: Eighty-nine (32.5%) participants fulfilled NSRBNSS_DOMAINS criterion whereas 70 (25.6%) participants fulfilled NSRBNSS_5ITEMS criterion. The two NSR criteria had substantial agreement (Kappa statistic=0.797) with each other. Sixty-one (25.3%) participants were in FR. FR was significantly associated with NSR, irrespective of the criterion used. To predict FR, the Area Under the Curve for NSRBNSS_DOMAINS and NSRBNSS_5ITEMS were 0.761 (CI: 0.696-0.826, p<0.001) and 0.723 (CI: 0.656-0.790, p<0.001), respectively. Hence, both NSR criteria demonstrated a fair ability to discriminate between functional remitters and non-remitters. CONCLUSIONS: Depending on the setting and needs, clinicians and researchers might employ either the full BNSS or an abbreviated 5-item BNSS scale to identify NSR in schizophrenia. More research is needed to further examine the validity of these criteria in schizophrenia.

Association between negative symptom domains and happiness in schizophrenia.

OBJECTIVE: The study aimed to examine the association between levels of self-reported happiness and different domains and subdomains of negative symptoms (NS), as well as symptomatic remission in schizophrenia. METHODS: 274 individuals with schizophrenia were assessed on the Subjective Happiness Scale (SHS), Positive and Negative Syndrome Scale and Clinical Assessment Interview for Negative Symptoms (CAINS). Multiple linear regressions were used to examine the association between levels of happiness and increasingly specific CAINS NS domains and subdomains, as well as symptomatic remission. RESULTS: 177 (64.6%) participants rated themselves as happy. NS, specifically motivation and pleasure related to social activities (MAP Social) (B=-0.402, t=-4.805, p<0.001), and depressive symptoms (B=-0.760, t=-7.102, p<0.001) were significantly associated with levels of happiness. Individuals in symptomatic remission rated themselves happier than those who were not in remission (mean composite SHS: 5.10 [SD=1.18] versus 4.61 [SD=1.16], p=0.002). CONCLUSIONS: In this largest study on happiness in schizophrenia, we found that the MAP domain of NS, MAP social subdomain and depressive symptoms were significantly associated with levels of happiness. Additionally, individuals in symptomatic remission rated themselves happier than those who were not in remission. Symptom management remains important in the holistic care plan for individuals with schizophrenia.

Defining negative symptoms remission in schizophrenia using the Brief Negative Symptom Scale.

INTRODUCTION: This study aimed to propose criteria for negative symptoms remission (NSR) in schizophrenia using the Brief Negative Symptom Scale (BNSS). MATERIAL AND METHODS: 274 participants were assessed on the Positive and Negative Syndrome Scale (PANSS), BNSS and Social and Occupational Functioning Assessment Scale (SOFAS). Two criteria for NSR on the BNSS were proposed - NSR based on the BNSS domains scores (NSRBNSS_DOMAINS) and NSR based on 5 key items of the BNSS (NSRBNSS_5ITEMS). A SOFAS score of 61 and above was considered as functional remission (FR). Logistic regressions were run to examine the association between FR and NSR. Receiver operating characteristic (ROC) curve analysis was performed for the NSR criteria on FR. Kappa agreement statistic was used to evaluate the agreement between the two NSR criteria. RESULTS: Eighty-nine (32.5%) participants fulfilled NSRBNSS_DOMAINS criterion whereas 70 (25.6%) participants fulfilled NSRBNSS_5ITEMS criterion. The two NSR criteria had substantial agreement (Kappa statistic=0.797) with each other. Sixty-one (25.3%) participants were in FR. FR was significantly associated with NSR, irrespective of the criterion used. To predict FR, the Area Under the Curve for NSRBNSS_DOMAINS and NSRBNSS_5ITEMS were 0.761 (CI: 0.696-0.826, p<0.001) and 0.723 (CI: 0.656-0.790, p<0.001), respectively. Hence, both NSR criteria demonstrated a fair ability to discriminate between functional remitters and non-remitters. CONCLUSIONS: Depending on the setting and needs, clinicians and researchers might employ either the full BNSS or an abbreviated 5-item BNSS scale to identify NSR in schizophrenia. More research is needed to further examine the validity of these criteria in schizophrenia.

Large-scale evaluation of the Positive and Negative Syndrome Scale (PANSS) symptom architecture in schizophrenia.

Although the Positive and Negative Syndrome Scale (PANSS) is widely utilized in schizophrenia research, variability in specific item loading exist, hindering reproducibility and generalizability of findings across schizophrenia samples. We aim to establish a common PANSS factor structure from a large multi-ethnic sample and validate it against a meta-analysis of existing PANSS models. Schizophrenia participants (N = 3511) included in the current study were part of the Singapore Translational and Clinical Research Program (STCRP) and the Clinical Antipsychotic Trials for Intervention Effectiveness (CATIE). Exploratory Factor Analysis (EFA) was conducted to identify the factor structure of PANSS and validated with a meta-analysis (N = 16,171) of existing PANSS models. Temporal stability of the PANSS model and generalizability to individuals at ultra-high risk (UHR) of psychosis were evaluated. A five-factor solution best fit the PANSS data. These were the i) Positive, ii) Negative, iii) Cognitive/disorganization, iv) Depression/anxiety and v) Hostility factors. Convergence of PANSS symptom architecture between EFA model and meta-analysis was observed. Modest longitudinal reliability was observed. The schizophrenia derived PANSS factor model fit the UHR population, but not vice versa. We found that two other domains, Social Amotivation (SA) and Diminished Expression (DE), were nested within the negative symptoms factor. Here, we report one of the largest transethnic factorial structures of PANSS symptom domains (N = 19,682). Evidence reported here serves as crucial consolidation of a common PANSS structure that could aid in furthering our understanding of schizophrenia.

Vocational Profile and Correlates of Employment in People With Schizophrenia: The Role of Avolition.

OBJECTIVE: Employment was associated with recovery in individuals with schizophrenia. Our study aimed to delineate the vocational profile and investigate factors associated with likelihood of employment in individuals with schizophrenia. MATERIALS AND METHODS: 276 community dwelling outpatients with schizophrenia were recruited; 274 completed the Positive and Negative Syndrome Scale (PANSS) and Brief Negative Symptom Scale (BNSS). Information on employment status, work outcomes and demographics were collected. Occupation was coded in accordance with the Singapore standard occupational classification. Either BNSS Motivation and Pleasure (MAP) and Emotional Expressivity (EE) or BNSS five-factor (Anhedonia, Asociality, Avolition, Blunted Affect, Alogia) were examined with PANSS factors and demographics in logistic regression with employment status and working full-time as outcome variables. RESULTS: One-hundred and twenty-seven (46.01%) participants were employed; 65 (51.18%) worked full-time. In the model with BNSS MAP-EE, MAP (OR=0.897, CI=0.854-0.941) and presence of physical comorbidity (OR=0.533, CI=0.304-0.937) were associated with reduced likelihood of employment; female sex (OR=0.286, CI=0.128 - 0.637) was associated with working part-time. In the model with BNSS five-factor, Avolition (OR=0.541, CI=0.440-0.666), and PANSS Positive (OR=0.924, CI=0.855-0.997) were associated with reduced likelihood of employment; female sex (OR=0.289, CI=0.126 - 0.662) and Avolition (OR=0.644, CI=0.475 - 0.872) were associated with working part-time. DISCUSSION: Our study described the vocational profile and correlates of employment in a developed urban Asian country. Negative symptoms, particularly MAP and Avolition, positive symptoms, and physical comorbidity reduced an individual's likelihood of employment, while female sex and Avolition were associated with working part-time. Efforts to identify and address these factors are necessary to encourage employment in individuals with schizophrenia.

Clinical determinants of social media use in individuals with schizophrenia.

This study aimed to examine the prevalence of social media use and its association with symptoms in individuals with schizophrenia. 265 individuals with schizophrenia were assessed. Symptoms were assessed on the Positive and Negative Syndrome Scale (PANSS) and the Clinical Assessment Interview for Negative Symptoms (CAINS). Information on social media use was collected. Logistic regressions were used to explore the association between social media use and socio-demographic and clinical characteristics of the participants. Of the 265 study participants, 139 (52.5%) used social media in the last week. Fifty-six (21.1%) of the study participants used more than one social media site in the last week. Facebook was the most popular social media site. Age, highest education level, monthly household income, PANSS negative and depression factor scores were significantly associated with social media use. Amongst negative symptoms, the CAINS motivation-pleasure (MAP) social factor scores were found to be significantly associated with social media use. Our study results suggested that the assessment of social interactions via social media should be considered in the clinical assessment of individuals with schizophrenia. Secondly, our results suggested that the development of treatment programs supported by social media platforms may be useful for certain groups of individuals with schizophrenia. Younger patients with above secondary level education, higher family income and lower symptom severity are likely to be avid users of social media and would be suitable candidates to receive illness related information or clinical interventions via social media.

Validation of the Brief Negative Symptom Scale and its association with functioning.

INTRODUCTION: The Brief Negative Symptom Scale (BNSS) includes five domains of negative symptoms suggested by the NIMH Consensus Development Conference (anhedonia, asociality, avolition, blunted affect, and alogia), which could be clustered into two factors - Motivation-Pleasure (MAP) and Emotional Expressivity (EE). Our study aims to examine the psychometric properties of BNSS, and its association with functioning. METHODS: 274 individuals with schizophrenia were assessed on the BNSS, Positive and Negative Syndrome Scale (PANSS), Scale for the Assessment of Negative Symptoms (SANS), Global Assessment of Functioning Scale (GAF), Calgary Depression Scale for Schizophrenia (CDSS), and Simpson-Angus Extrapyramidal Side Effects Scale (SAS). Internal consistency was examined using Cronbach's alpha. Concurrent, discriminant, and construct validity were examined. Factor structure of BNSS was explored using confirmatory factor analyses. Association between GAF and BNSS was examined with GAF as the dependent variable and BNSS Total, MAP and EE, and BNSS five domains as independent variables in three multiple regression models after controlling for covariates. RESULTS: BNSS showed good internal consistency (Cronbach's alpha = 0.880) and validity. The five-factor model fit the data better than the two-factor model; a second-order model was superior to both models. More severe symptoms on BNSS Total (B = -0.438, p < .001), MAP (B = -0.876, p < .001), Avolition (B = -2.503, p < .001) and Asociality (B = -0.950, p = .001) were associated with lower GAF. CONCLUSION: Our results lend support to the use of BNSS in clinical practice and in future research into negative symptoms. Composite scores could be computed using either the five-factor or second-order models. Negative symptoms, particularly MAP, avolition and asociality, were associated with functioning.

Clinical utility of the Negative Symptom Assessment-16 in individuals with schizophrenia.

This study examined the clinical utility of the Negative Symptom Assessment-16 (NSA-16) in schizophrenia. 274 individuals with schizophrenia were assessed on the NSA-16, Positive and Negative Syndrome Scale (PANSS), Clinical Assessment for Negative Symptoms (CAINS), Calgary Depression Scale for Schizophrenia (CDSS), Social and Occupational Functioning Assessment Scale (SOFAS) and the Simpson-Angus Extrapyramidal Side Effects Scale (SAS). Factor analyses were conducted and Cronbach's alpha was computed. Correlations were assessed using Spearman's correlation coefficient. The 5-factor model of the NSA-16 did not give good fit statistics from our sample. Exploratory factor analysis on a randomly selected split-half of the sample followed by confirmatory factor analysis on the remaining sample supported a 4-factor structure with 12 items. The factors were: Restricted speech, Poor quality of speech, Affective blunting and Amotivation. The NSA-16 with the 12 items was termed as the NSA-12. The NSA-12 showed good internal reliability. The NSA-12 total score and global negative symptom rating had strong correlations with CAINS total and PANSS negative factor scores, suggesting good convergent validity. Weak correlations of the NSA-12 total score and global negative symptom rating with PANSS positive, CDSS and SAS scores suggested good divergent validity. The NSA-12 total score and global negative symptom rating were strongly and inversely associated with SOFAS and positively associated with NSA-12 global level of functioning. In conclusion, the NSA-12 is useful to evaluate negative symptoms in clinical and research settings in individuals with schizophrenia. Our study results also support a 4-factor structure of the NSA-12 in outpatients with schizophrenia.

Assessing negative symptoms in schizophrenia: Validity of the clinical assessment interview for negative symptoms in Singapore.

This study aimed to examine the validity of the Clinical Assessment Interview for Negative Symptoms (CAINS) in Singapore. 274 participants with schizophrenia were assessed on the CAINS, Scale for the Assessment of Negative Symptoms (SANS), Positive and Negative Syndrome Scale (PANSS), Calgary Depression Scale for Schizophrenia (CDSS), Social and Occupational Functioning Assessment Scale (SOFAS) and the Simpson-Angus Extrapyramidal Side Effects Scale (SES). Factor analyses were conducted and Cronbach's coefficient alpha was calculated. Spearman's correlation coefficient was used to assess correlations. The 2-factor model of the CAINS failed to fit our data. Exploratory factor analysis of a randomly selected split-half of the sample yielded four factors: motivation-pleasure (MAP) social, MAP vocational, MAP recreational and expression (EXP), accounting for 73.94% of the total variance. Confirmatory factor analysis on the remaining sample supported this factor structure. Cronbach's alpha for the CAINS was 0.770. Significant correlations were observed between the CAINS total and the SANS total and PANSS negative subscale scores. Good divergent validity was shown by insignificant correlations with PANSS positive subscale score and CDSS total score. The MAP social and recreational factor scores had moderate correlations with the SANS anhedonia-asociality subscale scores, whereas the MAP vocational factor had the highest correlation with the avolition-apathy subscale of the SANS. EXP factor score correlated strongly with the SANS affective flattening and alogia subscales scores. In conclusion, the CAINS has good psychometric properties and can be used by clinicians to assess negative symptoms in individuals with schizophrenia in the local population.

The attitudinal consequences of thought suppression: a focus on thinness thoughts.

Four studies examined whether thought suppression could enhance attitude accessibility and whether behaviours that are consistent with the more accessible attitudes would follow. Thinness was examined as the attitude object. Experiments 1 and 2 showed that suppression of positive thoughts about thinness increased the accessibility of the positive attitudes associated with thinness. Experiments 3 and 4 showed that suppression of positive thinness thoughts also elicited more health-promoting behaviours. The implications of the findings for attitude accessibility and the practical consequences of thought suppression are discussed.