John S. Brekke

Biosocial pathways to functional outcome in schizophrenia.

UNLABELLED Biosocial models are preeminent in the study of schizophrenia, yet there has been little empirical testing of these models. OBJECTIVE This study provided the first test of a biosocial causal model of functional outcome in schizophrenia, using neurocognition, social cognition, social competence and social support as predictors of both global and specific domains of functional outcome. METHOD The design used baseline variables to predict both concurrent functional status and prospective 12-month functional outcome. Subjects were recruited upon admission to outpatient community-based psychosocial rehabilitation programs shown in previous studies to be effective in improving functional outcomes. 139 individuals diagnosed with schizophrenia or schizoaffective disorder participated in the study; 100 participants completed the 12-month assessments. Face-to-face interviews assessed neurocognitive functioning (with five neuropsychological measures), social cognition (as perception of emotion), social competence, social support, and functional outcome which consisted of items covering the domains of social, independent living, and work functioning. RESULTS Path analysis modeling showed that the proposed biosocial models had strong fit with the data, for both concurrent and 12-month global functional outcomes, with fit indices ranging from .95 to .98. The model explained 21% of the variance in concurrent global functional outcome, and 14% of the variance in 12-month prospective outcome. CONCLUSIONS The support for this model was strong, and it has implications for understanding the causal factors related to functional outcome, as well as for intervention strategies for improving functional outcomes in schizophrenia.

Intrinsic motivation, neurocognition and psychosocial functioning in schizophrenia: testing mediator and moderator effects.

BACKGROUND This study examined the nature of the relationships among neurocognition, intrinsic motivation, and psychosocial functioning for persons with schizophrenia. Hypotheses concerning both mediator and moderator mechanisms were tested. METHOD 120 individuals diagnosed with schizophrenia were recruited as they entered outpatient psychosocial rehabilitation programs. Measures of psychosocial functioning and intrinsic motivation were administered at baseline. Measures of neurocognition were administered at baseline by testers blind to scores on other study variables. Data were analyzed using latent construct modeling to test for mediator and moderator effects. RESULTS There were strong bivariate relationships between neurocognition, intrinsic motivation, and psychosocial functioning. The results demonstrated that intrinsic motivation strongly mediated the relationship between neurocognition and psychosocial functioning. This mediation was evidenced by: (i) the direct path from neurocognition to functional outcome no longer being statistically significant after the introduction of motivation into the model, (ii) the statistical significance of the indirect path from neurocognition through motivation to functional outcome. There was no support for the two moderation hypotheses: the level of neurocognition did not influence the relationship between intrinsic motivation and psychosocial functioning, nor did the level of intrinsic motivation influence the relationship between neurocognition and psychosocial functioning. CONCLUSIONS Neurocognition influences psychosocial functioning through its relationship with intrinsic motivation. Intrinsic motivation is a critical mechanism for explaining the relationship between neurocognition and psychosocial functioning. Implications for the theoretical understanding and psychosocial treatment of intrinsic motivation in schizophrenia are discussed.

Translational Science at the National Institute of Mental Health: Can Social Work Take Its Rightful Place?

Several recent national reports have noted that there is a 20-year gap between knowledge generated from our best clinical research and the utilization of that knowledge in our health and mental health care sectors. One solution to this dilemma has been the emergence of translational science. Translational science has become a top priority of the National Institute of Mental Health. The goal of translational science in mental health is to speed the use of findings from our best science into usual-care settings and to build partnerships between research and practice constituencies. The purpose of this article is to define translational science for social work, to provide a framework for translational research, and to outline an agenda of activity that will allow social work to become a significant driver in the translational research agenda in mental health services.

Direct assessment of functional abilities: relevance to persons with schizophrenia

OBJECTIVE To review functional outcome assessment strategies specifically focusing on performance-based measures used in patients with schizophrenia. METHOD In order to identify relevant performance-based measures of functioning we conducted a literature search using key words: functioning, disability, performance, situation, assessment, skills, scale, measurement, instrument, psychosis, and schizophrenia. RESULTS A description of each of eight measures was provided including assessment protocol, domains of functioning assessed, scoring, basic psychometric properties, appropriateness for clinical trials and likely sensitivity to pharmacologic interventions. Methods for assessment of functioning in patients with schizophrenia are reviewed. CONCLUSIONS The measurement of functional capacity, through performance-based activities, provides a critical benchmark by which to evaluate the efficacy and effectiveness of medications in clinical trials to improve both cognition and capacity for everyday functioning in seriously mentally ill persons with schizophrenia. In order to comprehensively evaluate functional outcome, a combination of performance-based and other assessment modalities may be required.

Shaping a Science of Social Work

Social workers provide more social services to populations across the life span than any other human service profession, including psychiatry, nursing, and psychology. The scientific methodologies and the scientific knowledge relevant to social services have expanded dramatically in the last 30 years. Using the two indicators of the total number of journals and the impact factors of those journals, it would appear that social work’s contribution to that expanding scientific knowledge base has been relatively limited. The purpose of this article is to examine the relationship between social work and science and to propose the outlines of a science of social work that intends to serve as a catalyst for shaping social work into a scientific discipline.

The Prospective Relationships Among Intrinsic Motivation, Neurocognition, and Psychosocial Functioning in Schizophrenia

To address significant gaps in our understanding about how neurocognition, intrinsic motivation (IM), and psychosocial functioning are interrelated in schizophrenia, this study investigated the following questions: Is IM stable or dynamic over time? Does neurocognition predict change in IM over time? What is the association between change in neurocognition, change in IM, and change in psychosocial functioning? Finally, what is the causal structure of the relationships among neurocognition, IM, and psychosocial functioning over time? One hundred and thirty individuals diagnosed with schizophrenia or schizoaffective disorder were recruited from 4 community-based psychosocial rehabilitation programs in urban Los Angeles. Measures of neurocognition were taken at baseline and 12 months. Measures of IM, psychosocial functioning, and symptoms were taken at baseline, 6, and 12 months. Results of latent growth curve modeling analyses demonstrated that IM is dynamic over time. Baseline neurocognition was associated with the initial level of IM but did not predict the rate of change in motivation. However, baseline levels of IM predicted rates of subsequent improvement in neurocognition. Change in IM was strongly associated with change in psychosocial functioning, and change in neurocognition was associated with change in psychosocial functioning, but change in IM was not associated with change in neurocognition. Latent difference score analyses revealed that neurocognition caused changes in psychosocial functioning, and psychosocial functioning caused changes in IM. These findings improve our fundamental understanding of the relationships among these variables and contribute to intervention development for improving outcomes in schizophrenia.

A model for measuring the implementation of community support programs: Results from three sites

We present and test a model for measuring the implementation of Community Support Programs (CSPs) for persons with severe mental illnesses. The model is intended to facilitate the description and replication of these programs and the future study of their critical ingredients. The model defines important implementation variables in seven areas of program functioning; we then suggest instruments to measure each of these variables. Results of a study examining the application of the model and measures forthree conceptually distinct CSPs illustrate the utility of the model and measures for implementation analysis of CSPs. Importantly, findings revealed thata priori hypotheses about how the programs were expected to differ on the implementation variables were largely supported.

The causal relationships between neurocognition, social cognition and functional outcome over time in schizophrenia: a latent difference score approach.

BACKGROUND Social cognition has been identified as a significant construct for schizophrenia research with relevance to diagnosis, assessment, treatment and functional outcome. However, social cognition has not been clearly understood in terms of its relationships with neurocognition and functional outcomes. The present study sought to examine the empirical independence of social cognition and neurocognition; to investigate the possible causal structure among social cognition, neurocognition and psychosocial functioning. METHOD The sample consists of 130 individuals diagnosed with schizophrenia. All participants were recruited as they were admitted to four community-based psychosocial rehabilitation programs. Social cognition, neurocognition and psychosocial functioning were measured at baseline and 12 months. The empirical independence of social cognition and neurocognition was tested using confirmatory factor analysis (CFA) and the possible causal structure among social cognition, neurocognition and psychosocial functioning was investigated using latent difference score (LDS) analysis. RESULTS A two-factor model of social cognition and neurocognition fit the data very well, indicating the empirical independence of social cognition, whereas the longitudinal CFA results show that the empirical independence of neurocognition and social cognition is maintained over time. The results of the LDS analysis support a causal model that indicates that neurocognition underlies and is causally primary to social cognition, and that neurocognition and social cognition are causally primary to functional outcome. CONCLUSIONS Social cognition and neurocognition could have independent and distinct upward causal effects on functional outcome. It is also suggested that the approaches for remediation of neurocognition and social cognition might need to be distinct.

In Search of a Theoretical Structure for Understanding Motivation in Schizophrenia

This themed issue considers different ways to conceptualize the motivational impairment that is a core negative symptom of schizophrenia. Motivational impairment has been linked to poor functional outcome, thus it is important to understand the nature and causes of motivational impairment in order to develop better treatment strategies to enhance motivation and engage patients in the process of recovery. Motivation refers to the processes whereby goal-directed activities are instigated and sustained and can be thought of as the product of a complex interaction of physiological processes and social contextual variables. In this issue, the physiological processes of motivation are the focus of Barch and Dowd, who highlight the role of prefrontal and subcortical mesolimbic dopamine systems in incentive-based learning and the difficulties people with schizophrenia have using internal representations of relevant experiences and goals to drive the behavior that should allow them to obtain desired outcomes. The articles in this issue by Choi et al., Nakagami et al., and Silverstein, focus on social contextual or environmental variables that can shape behavior and motivation. Together, these articles highlight the impact of external cues and goal properties on the expectations and values attached to goal outcomes. Expectancy-value and Self-Determination theories provide an overarching framework to accommodate the perspectives and data provided in all these articles. In the following introduction we show how the articles in this themed issue both support the role of expectancies and value in motivation in schizophrenia and elucidate possible deficiencies in the way expectations and value get assigned.

A latent structure analysis of the positive and negative symptoms in schizophrenia

Although previous studies have suggested the inadequacy of the two-factor models of positive and negative symptoms in schizophrenia, confirmatory testing of the putative three-factor models is needed. Using a sample of 193 individuals diagnosed with schizophrenia, this study tested the relative goodness-of-fit of one-, two-, and three-factor models of the positive and negative symptoms. Using confirmatory factor analysis (CFA), the three-factor model of Addington et al., Arndt et al., and Liddle and Barnes that specifies positive, negative, and disorganized factors had the best fit with the data. Allowing the factors to co-vary and specifying dimensionality to the negative symptoms substantially improved the fit of the model. The study addressed several other issues. First, whereas the correlation between positive and negative symptoms was modest, the disorganized symptoms were significantly and more strongly related to both the positive and negative symptoms. Second, depression was not correlated with negative symptoms, but was significantly related to both the positive and disorganized symptoms. Third, the relationships between the three factors and levels of global, social, and work functioning in the sample supported the criterion-related validity of the three-factor model.