Samir Sabbag

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.

Functional milestones and clinician ratings of everyday functioning in people with schizophrenia: Overlap between milestones and specificity of ratings

Everyday functioning is known to be impaired in people with schizophrenia, across multiple functional domains. It is not clear, however, how impairments across social, vocational, and residential domains overlap with each other, Further, although there are multiple ratings scales available to rate everyday functioning, it is also not clear how scores on these scales, particularly total scores, relate to milestone achievement. This is important, because efforts to reduce disability with pharmacological or rehabilitative interventions are ultimately evaluated in terms of their impact on everyday functioning, which is often indexed with total scores on rating scales. In this paper from the VALERO study, we report on 195 people with schizophrenia who were rated with a comprehensive process on 6 different functional status rating scales. Milestone achievements in social (ever married or equivalent), vocational (ever employed, currently employed), and residential (living independently, financially responsible) domains were examined for their overlap with each other and with ratings on the rating scales. Total scores on the 6 rating scales were minimally related to milestone achievements and milestone achievements were quite independent of each other. Subscales from two of the rating scales, specifically examining vocational and residential functioning, were specifically related to milestone achievements in their functional domains, but not other milestones. These data suggest that global scores on everyday functioning measures may not capture functional milestones and highlight the fact that functional milestones have multiple determinants other then the ability variables that these rating scales attempt to capture.

Self Assessment in Schizophrenia: Accuracy of Evaluation of Cognition and Everyday Functioning

OBJECTIVE Self-assessment deficits, often referred to as impaired insight or unawareness of illness, are well established in people with schizophrenia. There are multiple levels of awareness, including awareness of symptoms, functional deficits, cognitive impairments, and the ability to monitor cognitive and functional performance in an ongoing manner. The present study aimed to evaluate the comparative predictive value of each aspect of awareness on the levels of everyday functioning in people with schizophrenia. METHOD We examined multiple aspects of self-assessment of functioning in 214 people with schizophrenia. We also collected information on everyday functioning rated by high contact clinicians and examined the importance of self-assessment for the prediction of real-world functional outcomes. The relative impact of performance-based measures of cognition, functional capacity, and metacognitive performance on everyday functioning was also examined. RESULTS Misestimation of ability emerged as the strongest predictor of real-world functioning and exceeded the influences of cognitive performance, functional capacity performance, and performance-based assessment of metacognitive monitoring. The relative contribution of the factors other than self-assessment varied according to which domain of everyday functioning was being examined, but, in all cases, accounted for less predictive variance. CONCLUSION These results underscore the functional impact of misestimating ones current functioning and relative level of ability. These findings are consistent with the use of insight-focused treatments and compensatory strategies designed to increase self-awareness in multiple functional domains.

Self-assessment of functional ability in schizophrenia: milestone achievement and its relationship to accuracy of self-evaluation.

Between 50% and 80% of patients with schizophrenia do not believe they have any illness, and their self-assessment of cognitive impairments and functional abilities is also impaired compared to other information, including informant reports and scores on performance-based ability measures. The present article explores self-assessment accuracy in reference to real world functioning as measured by milestone achievement such as employment and independent living. Our sample included 195 people with schizophrenia examined with a performance-based assessment of neurocognitive abilities and functional capacity. We compared patient self-assessments across achievement of milestones, using patient performance on cognitive and functional capacity measures as a reference point. Performance on measures of functional capacity and cognition was better in people who had achieved employment and residential milestones. Patients with current employment and independence in residence rated themselves as more capable than those who were currently unemployed or not independent. However, individuals who had never had a job rated themselves at least as capable as those who had been previously employed. These data suggest that lifetime failure to achieve functional milestones is associated with overestimation of abilities. As many patients with schizophrenia never achieve milestones, their self-assessment may be overly optimistic as a result.

The course of vocational functioning in patients with schizophrenia: Re-examining social drift

Vocational functioning is markedly impaired in people with schizophrenia. In addition to low rates of employment, people with schizophrenia have been reported to be underachieved compared to other family members. Among the causes of this vocational impairment may be cognitive deficits and other skills deficits, as well as social factors impacting on opportunities for employment. In this study, we examined two separate samples of people with schizophrenia who differed in their educational and social backgrounds. We compared personal and maternal education in people with schizophrenia attending an outpatient rehabilitation facility (n = 57) or receiving outpatient services at a VA medical center (n = 39). The sample as a whole showed evidence of decline in vocational status from their best job to their most recent job. Patients attending a rehabilitation facility had completed less education than their mothers, while the VA patients completed more. Differences between personal and maternal education predicted the difference in status between best and latest jobs in the sample as a whole. VA patients were more likely to be living independently and performed better on a measure of functional capacity than the rehabilitation sample. These data implicate vocational decline in schizophrenia and also suggest that this decline may originate prior to the formal onset of the illness. At the same time, vocational outcomes appear to be related to social opportunities.

Concerns about aging and caregiving among middle-aged and older lesbian and gay adults

Objectives: Despite the increasing number of lesbian and gay older adults, research geared towards health and well-being of this population is limited. Many lesbian and gay seniors experience health disparities and are at risk for poor health outcomes. The aims of this study were to gather in-depth information on the concerns of lesbian and gay elders with respect to aging and care needs. Method: The sample included 124 gay men and lesbian women aged 50+ years. Data were gathered via focus groups and questionnaires. The focus groups addressed: (1) concerns about aging in the LGBT community, (2) barriers to needed support and services, (3) concerns about caregiving and (4) needed programs for lesbian and gay seniors. Results: Concerns expressed about aging included: lack of financial security, lack of family or social support, fears about the lack of someone to provide needed care, and discrimination in healthcare or service communities. Participants also indicated concerns about being alone and vulnerable and a need for resources and support programs, specifically for lesbian and gay older adults and for lesbian and gay caregivers. Conclusions: These findings suggest needed areas of support and programs for older gay men and lesbian women. They also suggest that healthcare professionals might need more training regarding the particular needs and concerns of this community.

A Novel Method for Direct Assessment of Everyday Competence Among Older Adults

BACKGROUND Recent findings indicate that impairments in functional performance do occur among individuals diagnosed with mild cognitive impairment (MCI). Most assessment strategies for everyday competence are associated with challenges with reliability, are typically in paper and pencil format, or require in-person administration by a trained professional. OBJECTIVE This paper reports on a novel technology-based assessment battery of everyday competence that includes ecologically valid simulations of daily activities important to independence. METHODS The sample included 85 non-cognitively impaired older adults aged 65+ and 62 older adults diagnosed with amnestic MCI (aMCI). Participants completed standard measures of cognitive abilities and the computerized battery of everyday tasks, which included simulations of a doctors visit; and medication and financial management tasks. RESULTS The older adults with aMCI performed significantly poorer on all three tasks in the everyday task battery. Performance on these measures were also moderately correlated with standard measures of cognitive abilities and showed good test-retest reliability. CONCLUSIONS The results show that it is feasible to use a technology-based assessment battery of everyday tasks with both non-cognitively impaired older adults and older adults with MCI. The use of this type of battery can overcome many of the logistic constraints associated with current functional assessment protocols.