Ten-year follow-up of social functioning and behaviour problems in people with schizophrenia and related disorders

Abstract

Background:

In recent years, several variables in the course of schizophrenia and related psychotic disorders have been studied. However, an instrumental analysis of the evolution of social functioning and behaviour problems has scarcely been explored.

Aim:

To analyse the evolution of social functioning and behaviour problems and find any diagnosis or gender differences.

Method:

The Social Functioning Scale (SFS) and the Behaviour Problems Inventory (BPI) were administered in Stages I (2003–2007) and II (2014–2017) to 100 close relatives of patients under treatment at a Community Mental Health Unit. A related samples t-test, analysis of variance and multivariate analysis of variance were performed to study the evolution and differences in social functioning and behaviour problems. Then a stepwise multiple linear regression analysis was done to predict the evolution of social functioning.

Results:

No deterioration in the evolution of social functioning or behaviour problems was observed, and schizophrenia patient scores were lower. Women scored higher in withdrawal/social engagement, interpersonal behaviour, independence-performance, independence-competence and total social functioning, with no significant differences in behaviour problems. Previous social functioning, underactivity/social withdrawal and education are predictive factors in the evolution of social functioning. Conclusion: The results show the need for implementing psychosocial intervention programs that promote functional recovery and keep problems from becoming chronic.

Keywords

schizophrenia psychotic disorders bipolar disorders social functioning behaviour problems gender

Introduction

Schizophrenia and related psychotic disorders, which make up most of the severe mental disorders and are a public health problem, have been associated with significant deterioration in social functioning (Grove et al., 2016), an increase in disability (World Health Organization [WHO], 2011) and considerable socioeconomic cost (Chong et al., 2016; Knapp et al., 2004).

Having surpassed the classic view of progressive deterioration and poor course, and reductionist attention to clinical symptoms (Bleuler, 1950; Kraeplin, 1919), the functional area emerges as a core dimension of recovery (Best et al., 2020; Correll, 2020). Studies have emphasized achievement in psychosocial domains as indicators of favourable evolution (Buonocore, 2018; Liberman et al., 2002; Morin & Franck, 2017). Thus, social functioning has become a strategic area in the study of severe mental disorders, and there is agreement on its consideration as a robust marker of treatment success ahead of clinical symptoms (Burns & Patrick, 2007; Liberman et al., 2002; Peer et al., 2007), making it an essential factor for community adaptation (Johnstone et al., 1990) and evolution of the illness (Rajkumar & Thara, 1989).

Social functioning is a multidimensional construct referring to personal skills for everyday social tasks and an adequate social life (Birchwood et al., 1990; Hirschfeld et al., 2000). It can be analysed on three levels: (1) social achievements, with global measures such as education, marital status or occupation (Hambrecht et al., 1992), (2) social roles, referring to the execution of certain roles and (3) instrumental behaviour, which involves specific analysis of functioning in different areas and dimensions (Mueser & Tarrier, 1998). Nevertheless, most studies have analysed global aspects or social achievements, ignoring instrumental analysis of social functioning and impeding identification of specific patient needs.

Among other factors, behaviour problems, understood as the behavioural manifestation of underlying psychopathology (Wykes & Sturt, 1986), are closely linked to adaptation and social adjustment (Brewin et al., 1987). However, even though there are studies relating behaviour problems with autonomy (Vázquez-Morejón & Jiménez-García-Bóveda, 1994; Wykes, 1982), family burden (Bellido-Zanin et al., 2017b; Othman & Salleh, 2008) or family coping (Vázquez-Morejón et al., 2013), they are limited to analysing their course and possible relationship between behaviour problems and social functioning.

In addition to behaviour problems, diagnosis is a variable related to differences in the evolution of social functioning. Despite studies having found stability and even recovery during the course of schizophrenia (Liberman et al., 2002; Liberman & Kopelowicz, 2002; Strauss et al., 2010), there is a consensus that social functioning is more deteriorated in it than in other psychotic disorders or bipolar disorder that have a more favourable prognosis (Gee et al., 2016; Harrow et al., 2005; Robinson et al., 2004). However, studies have focused mainly on analysis of global social functioning, impeding identification of specific dimensions that are more affected, and therefore, need more clinical attention.

Gender is also a factor related to heterogeneity in premorbid social functioning as well as during the course of the illness (Andia et al., 1995). Some studies have found better results in women, both premorbid and during the course of illness (Haas & Sweeney, 1992; Leung & Chue, 2000; Thorup et al., 2007). In this sense, the best social adjustment during the course of the illness has been associated with more premorbid social functioning, better cognitive functioning and late age of onset (Castle et al., 2000; Liberman et al., 2002). However, again, most gender studies do not analyse the social functioning dimensions, so it cannot be known whether better social functioning in women is due to higher performance in all areas or in some of them, or whether there are specific gender needs (Haas et al., 1990; Jiménez-García-Bóveda et al., 2000).

Our objective was to study the evolution of social functioning and behaviour problems, and find any diagnosis or gender differences during a ten-year follow-up in patients with schizophrenia and related psychotic disorders.

Method

Participants

The study sample consisted of 100 patients diagnosed with schizophrenia and related psychotic disorders: schizophrenia (ICD-10 F.20, n = 55), other psychotic disorders (ICD-10 F.21–F.29, n = 28) and bipolar type I disorder (ICD-10 F.31, n = 17). All of them were in treatment at a Community Mental Health Unit (CMHU, Virgen del Rocío University Hospital, Seville, Spain) in two different periods: 2003–2007 (Stage I) and 2014–2017 (Stage II).

Evaluation tests were completed by close relatives who had frequent contact with the patient. Of the original number of participants, 15 would not let their close relative fill in the evaluation, 14 had no close relative available and 44 had been transferred to another healthcare district, leaving a total of 100 patients who completed the follow-up period (Figure 1). Of these, 64 were men (64%) and 36 women (36%). The mean age of participants in Stage I was 38.26 (SD = 10.65; range = 18–65), while in Stage II it was 51.42 (SD = 10.51; range = 30–77). The distribution by marital status was 77 single (77%), 13 married (13%), 9 separated (9%) and 1 widow (1%) in Stage I, while in Stage II 77 were single (77%), 12 married (12%), 10 separated (10%) and 1 widow (1%).

Figure 1.

Flow chart for selection of participants in the study.

Close relatives in Stage I were: 60 mothers (60%), 16 fathers (16%), 8 spouses (8%), 12 siblings (12%), 4 other family members (4%). Of these, 74 (74%) were women and 26 (26%) were men. In Stage II, 48 (48%) were mothers, 5 fathers (5%), 10 spouses (10%), 29 siblings (29%) and 8 other family members (8%). Of the total, 71 (71%) were women and 29 (29%) men.

The inclusion criteria were: (1) be of legal age, (2) have been diagnosed with schizophrenia or related psychotic disorders, (3) agree to participate in the study. Inclusion criteria for close relatives were voluntary participation in the study and have been selected by the patient as the person knowing most about their condition. The exclusion criteria were having a severe organic disease or abuse or dependence on toxic substances.

Instruments and measures

Social Functioning Scale (SFS, Birchwood et al., 1990): This scale evaluates the most significant facets of social functioning in schizophrenia patients. It has 77 items divided in seven dimensions: withdrawal/social engagement scored from 0 to 15, interpersonal behaviour scored from 0 to 9, prosocial activities scored from 0 to 66, recreation scored from 0 to 45, independence-performance scored from 0 to 39, independence-competence scored from 13 to 39 and employment/occupation scored from 0 to 10. Higher scores show higher level functioning in each dimension. A total score classifies the social functioning level as low (<96 points), medium (96–106) or high (>106).

The scale has a self-report version (SFS-SR) to be filled out by the patient and an informant-report (SFS-IR) filled in by a relative who knows the patient well. For this study, we used the SFS-IR because it has demonstrated more sensitivity in evaluating social functioning than the SFS-SR, which has a higher tendency to self-evaluation bias (Jiménez-García-Bóveda et al., 2000).

Studies of the psychometric properties of both the English version of this instrument (Birchwood et al., 1990) and its Spanish adaptation (Vázquez-Morejón & Jiménez-García-Bóveda, 2000) have supported its validity and reliability, and internal consistency (Cronbach’s alpha) of α = .85, and three-month temporal reliability α = .84. The internal consistency in our sample for Stage I was: withdrawal/social engagement α = .55, interpersonal behaviour α = .58, prosocial activities α = .84, recreation α = .70, independence-performance α = .83, independence-competence α = .87, employment/occupation α = .37 and total α = .91. In Stage II it was: withdrawal/social engagement α = .57, interpersonal behaviour α = .68, prosocial activities α = .86, recreation α = .79, independence-performance α = .87, independence-competence α = .89, employment/occupation α = .31 and total α = .93. We selected this instrument because it can evaluate specific areas of social functioning, and furthermore, its items refer to observable quantifiable behaviours, reducing possible evaluation bias.

The Behaviour Problem Inventory (BPI, Vázquez-Morejón et al., 2005, 2018): Was designed to evaluate behaviour problems in patients with psychotic disorders. It has 14 items and three dimensions: underactivity/social withdrawal (scored from 0 to 15), active problems (scored from 0 to 15) and lack of impulse control (scored from 0 to 12). Two more indices can be found: moderate behaviour problems (MBP, number of items with scores equal to or over 2, scored from 0 to 14) and severe behaviour problems (SBP, number of items with score equal to 3, scored from 0 to 14). Higher scores indicate worse behaviour problems. The answers refer to observable behaviour during the three last months on a Likert-type scale: 0 = never, 1 = a few times, 2 = sometimes and 3 = often.

Internal consistency in our sample in Stage I was: underactivity/social withdrawal α = .75, active problems α = .84, lack of impulse control α = .70, total α = .87; and in Stage II: underactivity/social withdrawal α = .78, active problems α = .82, lack of impulse control α = .64, total α = .88.

Procedure

The 173 patients were selected from a census of patients with schizophrenia and related psychotic disorders as diagnosed by a clinical psychologist or psychiatrist based on psychopathological exploration and clinical history at a Virgen del Rocío University Hospital CMHU. As shown in Figure 1, 100 patients were selected; all of them were in treatment in 2003–2007 (Stage I) and 2014–2017 (Stage II).

In Stage I of psychological evaluation, during the programmed checkups at the centre, a member of the team (who had the most contact with and/or knew the family) requested the participation of close relatives and informed them that it was voluntary, and if they agreed, gave them the evaluation instruments to be filled out.

At the end of Stage I evaluation and the ten-year follow-up, Stage II of the psychometric evaluation began. Contextualized within the follow-up checkups and as a normal part of the psychological evaluation, a member of the team again asked the close relatives of each patient for their voluntary participation in the study, and if they wanted to participate, they were given the evaluation scales to be filled out. In this second evaluation period, the close relative might not have been the same one who participated in Stage I, because that person either had an organic disease, was deceased or not available for exceptional reasons. However, those who were different from Stage I were a minority and met the criterion of knowing the current state of the patient well.

Statistical analysis

The analyses were done using SPSS v.24. First, multiple analyses of variance were done to measure the influence of two independent factors (each one with two levels: Stage [Stage I and Stage II] and gender [men and women]) on social functioning and behaviour problems in severe mental disorders. The evolution and differences in social functioning and behaviour problems were also studied by diagnosis (related samples t-test and analysis of variance). Data had previously been tested with the Kolmogorov–Smirnov test and found to follow a normal distribution, and the Levene test checked that the homoscedasticity criterion was met. The effect size was calculated with Cohen’s d, interpreted as: d < 0.20 = null; d ⩾ 0.20 < 0.50 = small; d ⩾ 0.50 < 0.80 = medium; d ⩾ 0.80 = large (Cohen, 1988).

Finally, a stepwise linear regression analysis was done to predict the evolution of total social functioning in Stage II (criterion or dependent variable) through the following predictor or independent variables: total social functioning in Stage I, behaviour problems (underactivity/social withdrawal, active problems and lack of impulse control), education, age and diagnosis, all measured in Stage II. It was previously confirmed that statistical assumptions for multiple linear regression analysis had been met (linearity, residual independence, homoscedasticity and non-multicollinearity).

Results

Descriptive analysis

Table 1 shows the mean, median, Q1 and Q3, and the minimum and maximum scores on the social functioning dimensions and behaviour problems in Stages I and II. Table 2 shows the mean and standard deviation in both stages by diagnosis and gender.

Table 1.

Descriptive analysis of social functioning and behaviour problems (N = 100).

	Stage I (n = 100)						Stage II (n = 100)
	Minimum	Q1	Median	Mean	Q3	Maximum	Minimum	Q1	Median	Mean	Q3	Maximum
Withdrawal/social engagement	0	8	10	9.47	11	14	3	7	10	9.43	11	15
Interpersonal behaviour	0	4	6	5.80	8	9	0	4	6	5.82	8	9
Prosocial activities	3	19	24	23.97	29	39	5	20	24	25.03	33.75	39
Recreation	3	11	15	15.07	19	32	2	10	15	15.12	20	36
Independence-performance	0	8	13	15.22	22	42	0	6	12	14.85	22	46
Independence-competence	13	30	34	32.94	37	39	16	29	34	32.92	37	39
Employment/occupation	0	2	4	5.02	9	10	0	2	5	4.77	8	10
Total SF	33	87.25	109.50	107.49	129	170	31	88.25	105.50	107.94	132.75	182
Underactivity/social withdrawal	0	3	6	6.02	9	14	0	2	6	5.85	9	14
Active problems	0	1	3	3.96	7	15	0	1	3	3.90	5.25	15
Lack of impulse control	0	0	0	0.93	1	12	0	0	0	0.84	1	9
MBP	0	1	3	3.78	6	14	0	1	3	3.46	5	12
SBP	0	0	0	1.15	1	10	0	0	0	1.20	1.25	12

Total SF = total social functioning; MBP = moderate behaviour problems; SBP = severe behaviour problems.

Social Functioning, Behaviour Problems and diagnosis

Patients with other psychotic disorders showed a significant increase in the evolution of their social functioning in independence-performance (p = .035, d = −0.314, small effect size), while there were no significant differences in schizophrenia or bipolar disorder patients. Moderate behaviour problems also diminished significantly in the group with other psychotic disorders (p = .031, d = 0.542, moderate effect size), but no significant differences were found in schizophrenia or bipolar disorder patients either (Table 3).

Table 2.

Total social functioning, moderate and severe behaviour problems.

	Schizophrenia (n = 55)		Other psychotic disorders (n = 28)		BAD (n = 17)		Men (n = 64)		Women (n = 36)
	M	SD	M	SD	M	SD	M	SD	M	SD
Stage I
Total SF	99.65	26.53	115.25	29.12	120.06	24.91	100.42	27.71	120.06	24.68
MBP	3.73	2.68	4.63	3.52	2.38	3.07	3.97	3.03	3.44	3.14
SBP	1.18	1.69	1.52	2.49	.44	1.03	1.38	2.04	0.74	1.48
Stage II
Total SF	97.98	27.44	122.82	33.12	115.65	28.30	102.91	32.92	116.89	25.62
MBP	4.14	2.85	2.93	2.69	2.19	1.47	3.56	2.75	3.26	2.77
SBP	1.24	1.79	1.33	2.76	.69	1.01	1.31	2.16	1.00	1.67

BAD = bipolar affective disorder; SD = standard deviation; Total SF = total social functioning; MBP = moderate behaviour problems; SBP = severe behaviour problems.

Table 3.

Evolution of social functioning and behaviour problems by diagnosis.

	Schizophrenia (n = 55)						Other psychotic disorders (n = 28)						BAD (n = 17)
	M I	SD I	M II	SD II	p	d	M I	SD I	M II	SD II	p	d	M I	SD I	M II	SD II	p	d
Withdrawal/social engagement	9.05	2.84	9.31	3.02	.575	−0.089 N	10.00	2.82	9.68	2.96	.739	0.111 N	9.94	2.05	9.41	3.12	.275	0.201 S
Interpersonal behaviour	5.27	2.26	5.16	2.28	.747	0.048 N	5.93	2.68	6.07	2.93	.433	−0.050 N	7.29	1.79	7.53	1.77	1.000	−0.135 N
Prosocial activities	13.45	9.57	12.44	8.81	.438	0.110 N	16.96	10.53	18.93	12.18	.269	−0.173 N	18.06	7.89	15.94	10.84	.331	0.224 S
Recreation	13.62	5.62	13.16	6.54	.616	0.075 N	16.64	6.09	18.68	7.51	.180	−0.298 S	17.18	6.91	15.59	6.65	.382	0.234 S
Independence-performance	22.15	7.40	23.09	8.78	.432	−0.116 N	25.82	8.44	28.54	8.87	.035	−0.314 S	26.82	8.46	25.53	7.54	.424	0.161 N
Independence-competence	32.20	4.72	31.42	5.81	.326	0.147 N	33.64	5.90	34.71	5.19	.468	−0.193 N	34.18	6.45	34.82	4.35	.480	−0.116 N
Employment/occupation	3.91	3.28	3.40	3.03	.280	0.162 N	6.25	3.10	6.21	3.20	1.000	0.013 N	6.59	3.47	6.82	3.05	.526	−0.070 N
Total SF	99.65	26.53	97.98	27.44	.652	0.062 N	115.25	29.12	122.82	33.12	.138	−0.243 S	120.06	24.91	115.65	28.30	.526	0.165 N
Underactivity/social withdrawal	6.20	3.40	6.63	3.71	.494	−0.121 N	6.26	3.68	4.96	3.78	.113	0.349 S	4.88	3.95	5.00	3.58	.905	−0.032 N
Active problems	4.14	3.35	4.67	3.73	.358	−0.150 N	4.74	4.50	3.48	3.74	.186	0.305 S	1.81	2.88	2.00	1.63	.819	−0.081 N
Lack of impulse control	.82	1.37	1.02	1.71	.446	−0.129 N	1.30	2.55	.74	1.83	.253	0.252 S	.62	1.54	.38	.89	.609	0.191 N
MBP	3.73	2.68	4.14	2.85	.365	−0.148 N	4.63	3.52	2.93	2.69	.031	0.542 M	2.38	3.07	2.19	1.47	.814	0.079 N
SBP	1.18	1.69	1.24	1.63	.866	−0.036 N	1.52	2.49	1.33	2.76	.742	0.072 N	.44	1.03	.69	1.01	.534	−0.245 S

BAD = bipolar affective disorder; M I = mean stage I; M II = mean stage II; SD I = standard deviation stage I; SD II = standard deviation stage II; N = null effect size; S = small effect size; M = medium effect size; L = large effect size; Total SF = total social functioning; MBP = moderate behaviour problems; SBP = severe behaviour problems.

With regard to differences between diagnostic categories, in Stage I patients with schizophrenia had significantly lower scores than patients with bipolar disorder in interpersonal behaviour (p = .007, d = −0.991, large effect size). They also had a lower score in employment/occupation than other psychotic disorders (p = .008, d = −0.733, moderate effect size) or bipolar disorder (p = .012, d = −0.794, moderate effect size), and social functioning compared to psychotic disorders (p = .044, d = −0.560, moderate effect size) and bipolar disorder (p = .023, d = −0.793, moderate effect size). Patients with other psychotic disorders had a higher score than patients with bipolar disorder in active problems (p = .038, d = 0.775, moderate effect size). Furthermore, schizophrenia patients scored lower than those with psychotic disorders in recreation with important effect sizes (d = −0.515, moderate effect size) and those with bipolar disorder in prosocial activities (d = −0.526, moderate effect size), recreation (d = −0.565, moderate effect size) and independence-performance (d = −0.588, moderate effect size), while they had higher scores than those with bipolar disorder in active problems (d = 0.767, moderate effect size) and severe behaviour problems (d = 0.507, moderate effect size). Patients with other psychotic disorders scored lower than those with bipolar disorder in interpersonal behaviour (d = −0.597, moderate effect size) and higher in moderate behaviour problems (d = 0.681, moderate effect size) and in severe behaviour problems (d = 0.557, moderate effect size) (Table 4).

Table 4.

Differences in social functioning and behaviour problems by diagnosis.

			Stage I				Stage II
			Mean difference	Error	p	Cohen’s d	Mean difference	Error	p	Cohen’s d
Withdrawal/social engagement	Schizophrenia	Other psychotic	–.95	.63	.413	–0.336 S	–.37	.70	1.000	–0.120 N
	Schizophrenia	BAD	–.89	.75	.729	–0.359 S	–.10	.84	1.000	–0.033 N
	Other psychotic	BAD	.06	.63	.413	0.024 N	.27	.93	1.000	0.085 N
Interpersonal behaviour	Schizophrenia	Other psychotic	–.66	.54	.679	–0.265 S	–.91	.56	.322	–0.347 S
	Schizophrenia	BAD	–2.02	.64	.007	–0.991 L	–2.37	.67	.002	–1.162 L
	Other psychotic	BAD	–1.37	.71	.176	–0.597 M	–1.46	.74	.155	–0.603 M
Prosocial activities	Schizophrenia	Other psychotic	–3.51	2.23	.355	–0.346 S	–6.49	2.37	.022	–0.611 M
	Schizophrenia	BAD	–4.60	2.66	.261	–0.526 M	–3.50	2.83	.655	–0.354 S
	Other psychotic	BAD	–1.09	2.95	1.000	–0.118 N	2.99	3.13	1.000	0.259 S
Recreation	Schizophrenia	Other psychotic	–3.02	1.39	.096	–0.515 M	–5.14	1.59	.002	–0.783 M
	Schizophrenia	BAD	–3.56	1.66	.104	–0.565 M	–2.42	1.90	.613	–0.368 S
	Other psychotic	BAD	–.53	1.84	1.000	–0.082 N	3.09	2.10	.435	0.436 S
Independence-performance	Schizophrenia	Other psychotic	–3.68	1.83	.142	–0.462 S	–5.44	2.00	.023	–0.618 M
	Schizophrenia	BAD	–4.68	2.19	.105	–0.588 M	–2.43	2.39	.931	–0.298 S
	Other psychotic	BAD	–1.01	2.42	1.000	–0.118 N	3.01	2.65	.778	0.366 S
Independence-competence	Schizophrenia	Other psychotic	–1.44	1.25	.753	–0.270 S	–3.30	1.26	.031	–0.597 S
	Schizophrenia	BAD	–4.60	2.66	.261	–0.350 S	–3.41	1.51	.078	–0.662 S
	Other psychotic	BAD	–1.09	2.95	1.000	–0.087 N	–.11	1.67	1.000	–0.023 N
Employment/occupation	Schizophrenia	Other psychotic	–2.34	.76	.008	–0.733 S	–2.81	.72	.000	–0.902 L
	Schizophrenia	BAD	–2.68	.91	.012	–0.794 S	–3.42	.86	.000	–1.125 L
	Other psychotic	BAD	–.34	1.01	1.000	–0.103 N	–.61	.95	1.000	–0.195 N
Total SF	Schizophrenia	Other psychotic	–15.60	6.27	.044	–0.560 M	–24.84	6.79	.001	–0.817 L
	Schizophrenia	BAD	–20.40	7.50	.023	–0.793 M	–17.66	8.12	.096	–0.634 M
	Other psychotic	BAD	–4.81	8.31	1.000	–0.177 N	7.17	8.99	1.000	0.233 S
Underactivity/social withdrawal	Schizophrenia	Other psychotic	–0.01	.85	1.000	–0.002 N	1.91	.87	.089	0.507 M
	Schizophrenia	BAD	1.38	1.02	.543	0.372 S	1.76	1.03	.277	0.489 S
	Other psychotic	BAD	1.38	1.13	.666	0.362 S	–.155	1.14	1.000	–0.041 N
Active problems	Schizophrenia	Other psychotic	–.53	.87	1.000	–0.133 N	1.47	.82	.232	0.388 S
	Schizophrenia	BAD	2.40	1.04	.072	0.767 M	2.95	.98	.010	1.000 L
	Other psychotic	BAD	2.93	1.15	.038	0.775 M	1.47	.824	.232	0.513 M
Lack of impulse control	Schizophrenia	Other psychotic	–.47	.43	.825	–0.230 S	.34	.37	1.000	0.200 S
	Schizophrenia	BAD	.20	.52	1.000	0.138 N	.70	.45	.370	0.527 M
	Other psychotic	BAD	.67	.57	.722	0.318 S	.36	.50	1.000	0.255 S
MBP	Schizophrenia	Other psychotic	–.86	.71	.690	–0.275 S	1.40	.62	.074	0.506 M
	Schizophrenia	BAD	1.39	.86	.323	0.482 S	2.11	.73	.015	0.928 L
	Other psychotic	BAD	2.25	.95	.058	0.681 M	.70	.81	1.000	0.323 S
SBP	Schizophrenia	Other psychotic	–.35	.44	1.000	–0.164 N	.05	.47	1.000	0.022 N
	Schizophrenia	BAD	.74	.53	.513	0.507 M	.69	.56	.654	0.477 S
	Other psychotic	BAD	1.08	.58	.208	0.557 M	.64	.62	.908	0.313 S

BAD = bipolar affective disorder; Total SF = total social functioning; MBP = moderate behaviour problems; SBP = severe behaviour problems; N = null effect size; S = small effect size; M = medium effect size; L = large effect size.

In Stage II, schizophrenia patients scored lower than those with other psychotic disorders in prosocial activities (p = .022, d = −0.611, moderate effect size), recreation (p = .002, d = −0.783, moderate effect size), independence-performance (p = .023, d = −0.618, moderate effect size), independence-competence (p = .031, d = −0.597, moderate effect size), employment/occupation (p = .000, d = −0.902, large effect size), and total social functioning (p = .001, d = −0.817, large effect size). Differences between schizophrenia patients and those with bipolar disorder were also unfavourable to schizophrenia in interpersonal behaviour (p = .002, d = −1.162, large effect size), employment/occupation (p = .000, d = −1.125, large effect size), active problems (p = .010, d = 1.000, large effect size) and moderate behaviour problems (p = .015, d = 0.928, large effect size). In addition, schizophrenia patient scores were higher than those of psychotic disorder patients, also with important effect sizes, in underactivity/social withdrawal (d = 0.507, moderate effect size) and in moderate behaviour problems (d = 0.506, moderate effect size), while they had lower scores than bipolar disorder patients in independence-competence (d = −0.662, moderate effect size) and in total social functioning (d = −0.634, moderate effect size), and higher scores in lack of impulse control (d = 0.527, moderate effect size). Lastly, other psychotic disorders scored lower than bipolar disorder patients in interpersonal behaviour (d = −0.603, moderate effect size) and higher in active problems (d = 0.513, moderate effect size) (Table 4).

Social functioning, behaviour problems, gender and stage

Tables 5 and 6 show the results of multivariate analysis of variance and associated effect sizes. No statistically significant interaction effects were found in the social functioning variables or behaviour problems. The only statistically significant main effect was the influence of gender on social functioning, where women had higher scores regardless of stage in the withdrawal/social engagement (p = .009, d = 0.472, small effect size), interpersonal behaviour (p = .017, d = 0.452, small effect size), independence-performance (p = .000, d = 0.837, large effect size), independence-competence (p = .003, d = 0.550, moderate effect size) and total social functioning (p = .002, d = 0.603, moderate effect size) dimensions.

Table 5.

Evolution of social functioning by gender and stage.

Psychosocial variables	Means		SD		Main effects		Cohen`s d		Interaction effects
	Gender	Stage	Gender	Stage	Gender	Stage	Gender	Stage	F _(1,98) (p)
	Men	I	Men	I	F _(1,98) (p)	F _(1,98) (p)
	Women	II	Women	II	F _(1,98) (p)	F _(1,98) (p)
Withdrawal/social engagement	8.99	9.47	3.03	2.73	7.036 (.009)	0.132 (.717)	0.472 S	0.014 N	0.765 (.384)
Withdrawal/social engagement	10.27	9.43	2.35	2.99	7.036 (.009)	0.132 (.717)	0.472 S	0.014 N	0.765 (.384)
Interpersonal behaviour	5.43	5.80	2.56	2.41	5.863 (.017)	0.027 (.869)	0.452 S	−0.008 N	0.087 (.769)
Interpersonal behaviour	6.50	5.82	2.16	2.54	5.863 (.017)	0.027 (.869)	0.452 S	−0.008 N	0.087 (.769)
Prosocial activities	14.19	15.22	9.99	9.70	2.147 (.146)	0.000 (.997)	0.234 S	0.036 N	0.046 (.831)
Prosocial activities	16.55	14.85	10.21	10.49	2.147 (.146)	0.000 (.997)	0.234 S	0.036 N	0.046 (.831)
Recreation	14.50	15.07	6.81	6.14	1.662 (.200)	0.244 (.622)	0.254 S	−0.007 N	0.244 (.622)
Recreation	16.17	15.12	6.32	7.18	1.662 (.200)	0.244 (.622)	0.254 S	−0.007 N	0.244 (.622)
Independence-performance	22.19	23.97	8.29	8.07	22.325 (.000)	0.489 (.486)	0.837 L	−0.125 N	2.564 (.113)
Independence-performance	28.61	25.03	6.98	8.85	22.325 (.000)	0.489 (.486)	0.837 L	−0.125 N	2.564 (.113)
Independence-competence	31.90	32.94	5.63	5.39	9.540 (.003)	0.045 (.833)	0.550 M	0.004 N	0.409 (.524)
Independence-competence	34.77	32.92	4.77	4.32	9.540 (.003)	0.045 (.833)	0.550 M	0.004 N	0.409 (.524)
Employment/occupation	4.49	5.02	3.49	3.46	3.54 (.063)	0.497 (.482)	0.313 S	0.073 N	0.014 (.907)
Employment/occupation	5.63	4.77	3.77	3.42	3.54 (.063)	0.497 (.482)	0.313 S	0.073 N	0.014 (.907)
Total SF	101.67	107.49	30.32	28.18	10.45 (.002)	0.014 (.905)	0.603 M	−0.015 N	0.990 (.322)
Total SF	118.48	107.94	25.16	31.10	10.45 (.002)	0.014 (.905)	0.603 M	−0.015 N	0.990 (.322)

SD = standard deviation; Total SF = total social functioning; N = null effect size; S = small effect size; M = medium effect size; L = large effect size.

Table 6.

Evolution of behaviour problems by gender and stage.

Psychosocial variables	Means		SD		Main effects		Cohen’s d		Interaction effects
	Gender	Stage	Gender	Stage	Gender	Stage	Gender	Stage	F _(1,98) (p)
	Men	I	Men	I	F_(1,98) (p)	F _(1,98) (p)
	Women	II	Women	II	F_(1,98) (p)	F _(1,98) (p)
Underactivity/social withdrawal	6.35	5.99	3.58	3.57	3.620 (.060)	0.006 (.940)	0.328 S	0.033 N	1.190 (.278)
Underactivity/social withdrawal	5.15	5.87	3.73	3.76	3.620 (.060)	0.006 (.940)	0.328 S	0.033 N	1.190 (.278)
Active problems	3.90	3.91	3.75	3.75	0.001 (.972)	0.037 (.847)	0.005 N	0.011 N	0.114 (.737)
Active problems	3.88	3.87	3.56	3.58	0.001 (.972)	0.037 (.847)	0.005 N	0.011 N	0.114 (.737)
Lack of impulse control	0.95	0.93	1.83	1.81	.376 (.541)	0.155 (.694)	0.112 N	0.058 N	1.035 (.312)
Lack of impulse control	0.76	0.83	1.53	1.64	.376 (.541)	0.155 (.694)	0.112 N	0.058 N	1.035 (.312)
MBP	3.74	3.76	2.87	3.07	.560 (.456)	.366 (.547)	0.131 N	0.222 S	.366 (.547)
MBP	3.36	3.46	2.95	2.71	.560 (.456)	.366 (.547)	0.131 N	0.222 S	.366 (.547)
SBP	1.32	1.15	2.06	1.89	1.876 (.174)	.104 (.748)	0.239 S	−0.010 N	.663 (.417)
SBP	0.88	1.17	1.60	1.94	1.876 (.174)	.104 (.748)	0.239 S	−0.010 N	.663 (.417)

SD = standard deviation; MBP = moderate behaviour problems; SBP = severe behaviour problems; N = null effect size; S = small effect size; M = medium effect size; L = large effect size.

Predictors of social functioning

The results of multiple linear regression analysis with total social functioning in Stage II as the dependent variable and as independent variables, total social functioning in Stage I, behaviour problems (underactivity/social withdrawal, active problems and lack of impulse control) education, age and diagnosis (measured in Stage II), are shown in Table 7. The final model [F_(3,99) = 34.85, p = .000] identified three predictor variables: Stage I social functioning (p = .000), underactivity/social withdrawal (p = .000) and education (p = .016). On the contrary, active problems, lack of impulse control, age and diagnosis were not significant and were eliminated by the model. This model explained 51.2% (R² = 0.512) of the variance observed in total social functioning in Stage II.

Table 7.

Prediction of total social functioning in stage II.

Predictor variables	B	SE	β	t (p)	R²	ΔR
Step 1					.337	.330
Social functioning stage I	.641	.092	.580	6.982 (p = .000)
Step 2					.496	.486
Social functioning stage I	.538	.083	.488	6.523 (p = .000)
Underactivity/social withdrawal	−3.391	.618	−.410	−5.484 (p = .000)
Step 3					.527	.512
Social functioning stage I	.465	.086	.422	5.433 (p = .000)
Underactivity/social withdrawal	−3.295	.604	−.398	−5.459 (p = .000)
Education level	4.704	1.909	.188	2.465 (p = .016)

Discussion

Overall, our results reinforce studies on schizophrenia and related psychotic disorders that emphasize stability and functional recovery during its course, surpassing the classical view of progressive functional deterioration.

In agreement with previous research (Häfner et al., 1995; Liberman et al., 2002; Strauss et al., 2010), our findings on the evolution of the social functioning dimensions and behaviour problems show a period of stability in patients with schizophrenia. This stability seems to reflect the efficacy of intervention applied to contain possible functional deterioration, but insufficient to stimulate recovery, so a need emerges to develop psychosocial treatments that strengthen the functional area (Liberman & Kopelowicz, 2002; Ventriglio et al., 2020). Major studies with at least 20 years of follow-up of chronic schizophrenia patients in rehabilitation programs have found social recovery of 50% to 68% of the participants (Harding et al., 1987a, 1987b, 1992). Therefore, our results demonstrate the need for developing and ensuring access to psychosocial intervention based on evidence in the early stages that promote recovery through training in social skills, supporting employment, prosocial community training or family intervention, to facilitate community adaptation and integration and avoid chronicity (Armijo et al., 2013; Leopold et al., 2020; Norman et al., 2017; Rummel-Kluge & Kissling, 2008).

The results for other psychotic disorders coincide with previous studies which have shown recovery of social functioning (Gee et al., 2016; Harrow et al., 2005; Robinson et al., 2004), significantly increasing skills related to independence-performance and their consequent community adaptation. In agreement with Tohen et al. (2000), there were no differences from bipolar disorder patients after follow-up. However, even though schizophrenia evolved favourably, it would be important to include these patients in psychosocial treatment programs that stimulate overall functional recovery.

Gender differences, supporting previous studies, showed that women had better total social functioning throughout the course of the illness (Leung & Chue, 2000; Morgan et al., 2008; Thorup et al., 2007). An instrumental analysis identified differences favourable to women in four dimensions: withdrawal/social engagement, interpersonal behaviour, independence-performance and independence-competence. Coinciding with the results found by Jiménez-García-Bóveda et al. (2000), the differences in independence-performance and independence-competence may be motivated by cultural discrepancies in gender roles (Goldstein & Tsuang, 1990; Mayston et al., 2020), since the items refer to tasks related to performance in the home, which are mostly associated with women. Withdrawal/social engagement and interpersonal behaviour are both dimensions reflecting a deficit in social skills that could impede community integration of men, also therefore justifying from a gender perspective the need to develop psychosocial rehabilitation programs based on evidence and adapted to individual needs. With regard to behaviour problems, contrary to previous studies that show higher intensity and persistence of psychopathology in men (Chang et al., 2011; Hui et al., 2014; Segarra et al., 2012), the results did not show any significant gender differences in behaviour problems.

In line with earlier studies, previous social functioning and underactivity/social withdrawal problems are powerful variables for explaining the evolution of social functioning (Castle et al., 2000; Liberman et al., 2002). Thus, deterioration in social functioning and presence of underactivity/social withdrawal problems are related to a poor course and heavier use of healthcare resources (Bellido-Zanín et al., 2017a; Raudino et al., 2014), and both factors become priority targets of treatment to avoid evolution toward chronicity. Of the sociodemographic variables, social isolation has been associated as a factor in poor prognosis (Harvey et al., 2007), so it was expected for a higher level of education to exert a protective role, probably explained by greater social and cognitive skills required in higher education.

Among the limitations, it should be mentioned that social functioning and behaviour problem evaluation was done by a single family member who had frequent contact with the patient, and this person could have been different in Stages I and II, so it would be recommendable to include other sources of evaluation (other clinical psychology, psychiatry or nursing professionals) who could provide the psychometric assessment with greater objectivity and avoid any bias (Sabbag et al., 2011). Moreover, the participants were selected from a single CMHU, and inclusion of patients from other healthcare centres would have been more representative.

Future research could study what psychotherapeutic intervention and what associated characteristics (intensity, frequency, group or individual, and so forth) contribute to promoting recovery of social functioning and behaviour problems. It would also be of interest to study what other factors are involved in recovery of social functioning beyond behaviour problems and education, and which contribute to explaining gender differences.

In conclusion, our study reinforces the need for attention to the functional area in schizophrenia and related disorders. The results confirm the importance of previous social functioning and problems related to underactivity/social withdrawal during the course of social functioning. Therefore, there is a need to include psychosocial treatment programs in the early stages that contribute to improving the course and favour recovery.

Footnotes

Acknowledgements

We thank all the professionals at the Guadalquivir Community Mental Health Unit for their work.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Antonio Vázquez-Reyes

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