Social functioning is often defined as a person’s ability to engage effectively in social interactions, to maintain interpersonal relationships, to engage in work, and conduct everyday activities independently (Brissos S et al, 2011 ).
Social functioning deficits are thought to be a defining marker of Schizophrenia Spectrum Disorders (SSD) and research findings indicate that in young people (15–25 years) at high risk of psychosis, poorer social functioning may be predictive of a transition to SSD (Brissos S et al, 2011).
Moreover, research findings also indicate that around 10–22% of young individuals at ultra high risk for psychosis develop a psychotic disorder after one year, and 29% after two years (Fusar-Poli P et al, 2012). This is of concern because psychotic disorders are associated with marked impairment and disability. It is therefore imperative that effective means of early intervention are identified in order to mitigate this risk and produce greater functional recovery outcomes for affected individuals (Alvarez-Jimenez M et al, 2018).
Published in Early Intervention in Psychiatry, this systematic review and meta-analysis conducted by Devoe, Farris, Townes and Addington (2018) aimed to synthesise, summarise and evaluate the impact of all available biopsychosocial treatment interventions on social functioning outcomes in young individuals at clinical high risk (CHR) for psychosis.
- 5 databases were used to search relevant literature from 1957-2018
- Literature examined biopsychosocial treatment interventions aimed to improve social functioning in CHR populations (measured outcomes at follow-up)
- Inclusion criteria:
- Mean reported age of 12-30,
- At risk of psychosis (CHR, at risk-mental state [ARMS], attenuated psychosis syndrome [APS], and ultra-high risk populations [UHR])
- Experimental or observational treatment
- Social functioning scales:
- Global Functioning Social (GFS)
- Social and Occupational Functioning Assessment Scale (SOFAS)
- Social Functioning Scale (SFS)
- Social Adjustment Scale (SAS).
The systematic review and meta-analysis were conducted in accordance with the Preferred Reporting for Systematic Review and Meta-Analysis (PRISMA) and Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. The studies were also independently evaluated for quality by two reviewers using the Cochrane risk of bias assessment tool for randomised control trials (RCT) and the Newcastle Ottawa Scale (NOS) for non-randomised studies.
- 19 papers were included in the review (a total of 1,513 participants)
- Sample sizes ranged from 6 to 304 participants
- Overall mean age= 21 years (53% female)
- Majority of studies were conducted in North America (n =11), Europe (n =4), Asia (n=2) and Australia (n=1)
- Social functioning treatment interventions:
- Cognitive remediation studies (n=5),
- Antipsychotics (n=4),
- Cognitive-behavioural therapy (n=4),
- Family-based therapy (n=3),
- Omega-3 (n=2) and
- Heart rate variability feedback (n=1).
- Frequency of intervention measures:
- GFS (n=8),
- SOFAS (n=5),
- SFS (n=4) and
- SAS (n=2).
- Of the 11 RCTs, seven studies were identified as high risk of bias. The NOS, used to assess the quality of the observational studies (n=8) uses an overall star system and the highest quality studies are awarded up to nine stars. One study (family intervention, McFarlene) was rated seven stars, four of the studies were rated five stars, and three of the studies were rated four stars.
- Due to variability in assessment and follow-up times, meta-analysis was only feasible for assessing cognitive-behavioural therapy, omega-3 and cognitive remediation studies.
The authors found no treatment modality was effective in improving social functioning outcomes at any of the follow-up times. The authors noted that in relation to the 19 included studies, only one cognitive remediation-based study reported a statistically significant improvement in social functioning within this population compared to a control group. The authors also argued that these results are in stark contrast to first-episode psychosis and schizophrenia studies that have demonstrated significant improvements compared to controls.
Strengths and limitations
The systematic review and meta-analysis has several strengths. First, the authors should be commended on their adherence to best-practice guidelines in relation to registering their review prospectively on the PROSPERO database and adhering to both PRISMA and MOOSE reporting guidelines. The authors also utilised two well-validated risk of bias tools to assess the quality of the included studies and provided a rationale for the suitability of each that was dependent on the specific study’s research design. However, it was not apparent why they had explicitly included search terms for two assessment measures not included in their inclusion criteria and omitted search terms for two measures that were included in their inclusion criteria.
Another strength of the study was the authors’ acknowledgment that conceptual differences in the social functioning measures may mean that the measures themselves are tapping into different aspects of the construct (e.g. some included a specific focus on occupational functioning), making it difficult to compare the studies’ outcomes in a synthesised manner. This is an important point, more broadly speaking, as it begs the question of to how social functioning (a broad, multifaceted concept) is best operationalised for use within this particular population. Future research focus would benefit from a more nuanced examination of what particular social functioning deficits constitute a greater risk for youth at CHR for psychosis to transition to a frank psychotic disorder. This would also provide researchers with an understanding of how to tailor therapeutic targets in future interventions.
Another limitation of the study was that the variability in the assessment measures used to determine criteria for CHR, ARMS and UHR for psychosis. This is important given the heterogeneity in this given population. Greater clarity could have been achieved if information on how CHR, ARMS and UHR for psychosis measures may differ conceptually was provided (as the authors did for the social functioning measures). This would have allowed readers the opportunity to gain a greater understanding of how the individual studies determined that individuals met these specific criteria and, in doing so, assess whether variability across these measures may have contributed to the study’s findings.
Implications for practice
The findings of this systematic review and meta-analysis did not provide any evidence to support the efficacy for a wide range of examined biopsychosocial treatment interventions to improve social functioning in young people at CHR of psychosis; highlighting a need for further research in this area.
Broadly speaking and admittedly, beyond the scope of this review, it is not clear as to what particular social functioning deficits may be of greater significance in relation to risk of a transition from CHR to psychotic disorder. Social functioning is a broad concept and as such, captures a wide range of functions.
From a practice perspective, it would be helpful for clinicians to have an understanding of what particular social functioning deficits may be of most benefit to target therapeutically. This is particularly important to identify because clinicians will be working from a preventative perspective, to best assist vulnerable individuals at clinical risk of psychosis.
Devoe D, Farris M, Townes P, Addington, L. (2018) Interventions and social functioning in youth at risk of psychosis: A systematic review and meta-analysis (PDF). Early Intervention in Psychiatry 1-12. [PubMed abstract]
Alvarez-Jimenez M, Gleeson J, Bendall S, Penn SL, Yung AR, Ryan RM et al. (2018) Enhancing social functioning in young people at Ultra High Risk (UHR) for psychosis: A pilot study of a novel strengths and mindfulness-based online social therapy. Schizophr Res 2018 202 369-377 [PubMed abstract]
Brissos S, Molodynski A., Dias VV, Figueira ML. (2011) The importance of measuring psychosocial functioning in schizophrenia. Annals of General Psychiatry 2011 10, 18 [PubMed abstract]
Fusar-Poli P, Bonoldi I, Yung AR, Borgwardt S, Kempton MJ, Valmaggia L, et al. (2012) Predicting psychosis: meta-analysis of transition outcomes in individuals at high clinical risk. Archives of General Psychiatry 2012 69(3) 220-9. [PubMed abstract]