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

For Peer Review Ten-year follow-up of social functioning and behavior problems in people with schizophrenia and related disorders Journal: International Journal of Social Psychiatry Manuscript ID Draft Manuscript Type: Original Research Article Date Submitted by the Author: n/a Complete List of Authors: Vázquez-Reyes, Antonio; Virgen del Rocio University Hospital, Keywords: schizophrenia, psychotic disorders, bipolar disorders, social functioning, behavior problems, gender 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 behavior problems has scarcely been explored. Aim: To analyze the evolution of social functioning and behavior problems and find any diagnosis or gender differences. Method: The Social Functioning Scale (SFS) and the Behavior 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 behavior 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 behavior problems was observed, and schizophrenia patient scores were lower. Women scored higher in withdrawal/social engagement, interpersonal behavior, independence-performance, independencecompetence and total social functioning, with no significant differences in behavior 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. https://mc.manuscriptcentral.com/ijspsych International Journal of Social Psychiatry This is the accepted manuscript of the following article: Vázquez-Reyes, A., Ángeles Pérez-San-Gregorio, M., Martín-Rodríguez, A., & Vázquez-Morejón, A. J. (2021). Ten-year follow-up of social functioning and behaviour problems in people with schizophrenia and related disorders. International Journal of Social Psychiatry, 68(7), 1324–1335. https://doi.org/10.1177/00207640211023083. ©2021The Author(s) For Peer Review * Correspondence to: Unidad de Salud Mental Comunitaria Guadalquivir. Hospital Universitario Virgen del Rocío, Calle Manuel Siurot s/n. E-mail address: [email protected] (A. Vázquez-Reyes) Ten-year follow-up of social functioning and behavior problems in people with schizophrenia and related disorders Antonio Vázquez-Reyes1, Maria Ángeles Pérez-San-Gregorio2, Agustín Martín-Rodríguez2, and Antonio J. Vázquez-Morejón1,2 1 University Hospital Virgen del Rocío, Mental Health Service, Seville, Spain 2 Faculty of Psychology, Department of Personality, Assessment, and Psychological Treatment. University of Seville, Seville, Spain Page 1 of 32 https://mc.manuscriptcentral.com/ijspsych International Journal of Social Psychiatry 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 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, 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 favorable 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 analyzed on three levels: 1) social achievements, with global measures such as education, marital status or occupation (Hambrecht et al., 1990), 2) social roles, referring to the execution of certain roles, and 3) instrumental behavior, which involves specific analysis of functioning in different areas and dimensions (Mueser & Tarrier, 1998). Nevertheless, most studies have analyzed global aspects or social achievements, ignoring instrumental analysis of social functioning and impeding identification of specific patient needs. Among other factors, behavior problems, understood as the behavioral manifestation of underlying psychopathology (Wykes & Sturt, 1986), are closely linked to adaptation and social Page 2 of 32 https://mc.manuscriptcentral.com/ijspsych International Journal of Social Psychiatry 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review adjustment (Brewin et al., 1987). However, even though there are studies relating behavior problems with autonomy (Vázquez-Morejón & Jiménez-García-Bóveda, 1994; Wykes, 1982), family burden (Bellido-Zanin, Vázquez-Morejón, Pérez-San-Gregorio & Martín-Rodríguez, 2017; Othman & Salleh, 2008) or family coping (Vázquez-Morejón et al., 2013), they are limited to analyzing their course and possible relationship between behavior problems and social functioning. In addition to behavior 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 & Kopelowicz, 2002; Liberman et al., 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 favorable 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 analyze 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 (Jiménez-García-Bóveda et al., 2000; Haas et al., 1990). Our objective was to study the evolution of social functioning and behavior problems, and Page 3 of 32 https://mc.manuscriptcentral.com/ijspsych International Journal of Social Psychiatry 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 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 one widow (1%) in Stage I, while in Stage II 77 were single (77%), 12 married (12%), 10 separated (10%) and one widow (1%). 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 eight 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 Page 4 of 32 https://mc.manuscriptcentral.com/ijspsych International Journal of Social Psychiatry 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 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 behavior 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 informantreport (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 behavior α=.58, prosocial activities α=.84, recreation α=.70, independence-performance α=.83, independencecompetence α=.87, employment/occupation α=.37, and total α=.91. In Stage II it was: withdrawal/social engagement α=.57, interpersonal behavior α=.68, prosocial activities α=.86, Page 5 of 32 https://mc.manuscriptcentral.com/ijspsych International Journal of Social Psychiatry 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 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 behaviors, reducing possible evaluation bias. The Behavior Problem Inventory (BPI, Vázquez-Morejón et al., 2005; Vázquez-Morejón et al., 2018): Was designed to evaluate behavior 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 behavior problems (MBP, number of items with scores equal to or over 2, scored from 0 to 14) and severe behavior problems (SBP, number of items with score equal to 3, scored from 0 to 14). Higher scores indicate worse behavior problems. The answers refer to observable behavior 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 center, a member of the team (who had the most contact with and/or knew the family) requested the Page 6 of 32 https://mc.manuscriptcentral.com/ijspsych International Journal of Social Psychiatry 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 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 behavior problems in severe mental disorders. The evolution and differences in social functioning and behavior 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, behavior problems (underactivity/social withdrawal, active problems and lack of impulse control), education, age Page 7 of 32 https://mc.manuscriptcentral.com/ijspsych International Journal of Social Psychiatry 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review and diagnosis, and Stage II means. 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 behavior problems in Stages I and II. Social Functioning, Behavior 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 behavior 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). With regard to differences between diagnostic categories, in Stage I patients with schizophrenia had significantly lower scores than patients with bipolar disorder in interpersonal behavior (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 Page 8 of 32 https://mc.manuscriptcentral.com/ijspsych International Journal of Social Psychiatry 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Bleuler, E. (1950). 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Assessing everyday functioning in schizophrenia: Not all informants seem equally informative. Schizophrenia Research, 131, 250-255. https://doi:10.1016/j.schres.2011.05.003 Page 20 of 32 https://mc.manuscriptcentral.com/ijspsych International Journal of Social Psychiatry 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Segarra, R., Ojeda, N., Zabala, A., García, J., Catalan, A., & Eguiluz, J. I., & Gutiérrez, M. (2012). Similarities in early course among men and women with a first episode of schizophrenia and schizophreniform disorder. European Archives of Psychiatry and Clinical Neuroscience, 262(2), 95-105. https://doi:10.1007/s00406-11-0218-2 Strauss, G., Harrow, M., Grossman, L. S., & Rosen, C. (2010). Periods of recovery in deficit syndrome schizophrenia: a 20-year multi-follow-up longitudinal study. Schizophrenia bulletin, 36 (4), 788-799. https://doi:10.1093/schbul/sbn167 Thorup, A., Petersen, L., Jeppesen, P., Ohlenschloeger, J., Christensen, T., Krarup, G., Jorgensen, P., & Nordentoft, M. (2007). Gender differences in young adults with firstepisode schizophrenia spectrum disorders at baseline in the Danish OPUS study. The Journal of Nervous and Mental Disease, 195, 396-405. https://doi:10.1097/01.nmd.0000253784.59708.dd Tohen, M., Strakowski, S. M., Zarate Jr, C., Hennen, J., Stoll, A. L., Suppes, T., Faedda, G. L., Cohen, B. M., Gebre-Medhin, P., & Baldessarini, R. J. (2000). The McLean-Harvard first-episode project: 6-month symptomatic and functional outcome in affective and nonaffective psychosis. Biological Psychiatry, 48, 467-476. https://doi:10.1016/s006- 3223(00)00915-x Vázquez-Morejón, A. J., & Jiménez-García-Bóveda, R. (1994). 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Problemas de conducta y Psicosis: Datos preliminares en un estudio llevado a cabo en el Hospital Universitario Virgen del Rocío [Behavioral Problems and Psychosis: Preliminary datain a study carried out in the Virgen del Rocio University Hospital]. Paper presented at the I Congreso Andaluz de Salud Mental Comunitaria, Granada, Spain. Vázquez-Morejón, A. J., Segura-Chaves, I., & Bellido-Zanin, G. (2013). Problemas de conducta en personas con trastorno bipolar. Datos preliminares de un estudio en el área Virgen del Rocío de Sevilla. In: The 13th International Review of Bipolar Disorders, Sevilla. Spain. Vázquez-Morejón, A. J., Vázquez-Morejón, R., & Bellido-Zanin, G. (2018). Behavior Problems Inventory (BPI): Psychometric characteristics of an instrument for routine assessment of persons with psychoses and related disorders. Psychiatry Research, 270, 1027-1032. https://doi:10.1016/j.psychres.2018.03.051 Ventriglio, A., Ricci, F., Magnifico, G., Chumakov, E., Torales, J., Watson, C., Castaldelli- Maia, J. M., Petito, A., & Bellomo, A. (2020). Psychosocial interventions in schizophrenia: Focus on guidelines. International Journal of Social Psychiatry, 66 (8), 735-747. https://doi:10.1177/0020764020934827 World Health Organization (2011). World Report on Disability. Geneva: World Health Organization. Wykes, T. (1982). A hostel ward for new long-stay patients: an evaluative study of a “ward in a house” in a long-term community care: Experience in a London borough. Psychological Medicine, 2, 59-97. https://doi:10.1017/S026418010000165X Page 22 of 32 https://mc.manuscriptcentral.com/ijspsych International Journal of Social Psychiatry 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Wykes, T., & Sturt, E. (1986). The measurement of social behaviour in psychiatric patients: an assessment of the reliability and validity of the SBS schedule. British Journal of Psychiatry, 148, 1-11. https://doi:10.1192/bjp.148.1.1 Page 23 of 32 https://mc.manuscriptcentral.com/ijspsych International Journal of Social Psychiatry 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Table 1. Descriptive Analysis of Social Functioning and Behavior Problems (N=100). Total SF: Total social functioning; MBP: Moderate behavior problems; SBP: Severe behavior problems. 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 behavior 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 Total SF 0 33 2 87.25 4 109.50 5.02 107.49 9 129 10 170 0 31 2 88.25 5 105.50 4.77 107.94 8 132.75 10 182 Underactivity/social withdrawal Active problems Lack of impulse control MBP SBP 0 0 0 0 0 3 1 0 1 0 6 3 0 3 0 6.02 3.96 0.93 3.78 1.15 9 7 1 6 1 14 15 12 14 10 0 0 0 0 0 2 1 0 1 0 6 3 0 3 0 5.85 3.90 0.84 3.46 1.20 9 5.25 1 5 1.25 14 15 9 12 12 Page 24 of 32 https://mc.manuscriptcentral.com/ijspsych International Journal of Social Psychiatry 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Table 7. Prediction of Total Social Functioning in Stage II. Predictor Variables B SE β t (p) R² ΔR Step 1 Social Functioning Stage I .641 .092 .580 6.982 (p=.000) .337 .330 Step 2 Social Functioning Stage I Underactivity/social withdrawal .538 -3.391 .083 .618 .488 -.410 6.523 (p=.000) -5.484 (p=.000) .496 .486 Step 3 Social Functioning Stage I Underactivity/social withdrawal Education level .465 -3.295 4.704 .086 .604 1.909 .422 -.398 .188 5.433 (p=.000) -5.459 (p=.000) 2.465 (p=.016) .527 .512 Page 31 of 32 https://mc.manuscriptcentral.com/ijspsych International Journal of Social Psychiatry 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Figure 1. Flow chart for selection of participants in the study. 173 patients met inclusion criteria 73 patients were excluded: -15 rejected participation of a relative -14 had no relative available -44 had been transferred to other healthcare districts 100 patients were included Stage I (2003-2007) Stage II (2014-2017) Close relatives -60 mothers -16 fathers -8 spouses -12 siblings -4 other relatives Close relatives: -48 mothers -5 fathers -10 spouses -29 siblings -8 other relatives Page 32 of 32 https://mc.manuscriptcentral.com/ijspsych International Journal of Social Psychiatry 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60