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Original Investigation |

Developmental Trajectories of Impaired Community Functioning in Schizophrenia

Eva Velthorst, PhD1,2,3; Abraham Reichenberg, PhD1,2; Ori Kapara, BA4; Shira Goldberg, MSc4; Menachem Fromer, PhD1,5; Eyal Fruchter, MD4; Karen Ginat, MD4; Lieuwe de Haan, MD, PhD3; Michael Davidson, MD4; Mark Weiser, MD4
[+] Author Affiliations
1Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
2Department of Preventive Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
3Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
4Department of Psychiatry, Sheba Medical Center, Tel-Hashomer, Israel
5Department of Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
JAMA Psychiatry. 2016;73(1):48-55. doi:10.1001/jamapsychiatry.2015.2253.
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Importance  Community functioning is a core component of the functional deficits in schizophrenia, yet little systematic research on the origins of these functional deficits has been performed.

Objectives  To examine 3 key domains of community functioning—social activity, independent behavior, and functioning in school or work—before first hospitalization for schizophrenia and to determine whether these domains are familial.

Design, Setting, and Participants  In this population-based, prospective study that included a sibling-control comparison, data from the Israeli National Draft Board Registry were linked with data from the Israeli Psychiatric Hospitalization Case Registry. The merged file included data for all male adolescents who visited the draft board and were followed up for as much as 25.4 years from draft board assessment (through the end of 2010). The 3 functional domains for cases, their unaffected siblings, and controls were compared by time between assessment and time to hospitalization. Analyses were conducted from March 13, 2014, to October 19, 2014.

Main Outcomes and Measures  The trajectories and familiality of 3 key components of community functioning—social activity, independent behavior, and functioning in school or work—in the years preceding hospitalization for schizophrenia.

Results  Participants included 723 316 Israeli male adolescents who underwent a mandatory behavioral assessment to determine eligibility for military service. Linkage identified 3929 individuals hospitalized for schizophrenia. Data for 338 550 sibling pairs, 1659 hospitalized with schizophrenia, were similarly ascertained. Among those with schizophrenia, impairments in social activity (effect size [d], 0.55) and functioning in school or work (d = 0.37) were recognizable up to 15 years before hospitalization. Independent behavior seemed preserved until the few years before first admission. For social activity, differences between cases and controls were progressively greater for patients admitted closer to time of testing (F = 115.33, P < .001). Unaffected siblings had small impairments compared with controls in social activity (F = 28.25, P < .001) and functioning in school or work scales (F = 14.77, P < .001). Group familial (sibling) correlations were relatively high for social activity (r = 0.40; 95% CI, 0.39-0.41) and functioning in school or work (r = 0.50; 95% CI, 0.49-0.51) but nil for independent behavior (r = 0; 95% CI, −0.01 to −0.01). Impairments in siblings had no progressive increase and were unrelated to their affected sibling’s time of illness onset (time trend: social activity: F = 5.463, P = .02; independent behavior: F = 0.908, P = .34; and functioning in school or work: F = 1.386, P = .24).

Conclusions and Relevance  Various components of impaired community functioning in schizophrenia followed different developmental trajectories. Our results indicate that impairments in social activity and functioning in school or work are familial.

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Figure 1.
Overall Mean Level of Impairments in Community Functioning in Individuals Later Hospitalized for Schizophrenia Compared With the General Population

aSignificant difference at the P = .001 level.

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Figure 2.
Impairments in Community Functioning of Affected and Randomly Selected Unaffected Siblings in the Years Before and After First Admission of the Proband

−1 Indicates before onset; 0, onset within a year; and 1, after onset.

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