Sources of social support and clinical and functional evolution of people with schizophrenia

Antonio J. Vázquez Morejón. Hospital Universitario Virgen del Rocío. Sevilla Jose Mª León Rubio. Grupo de investigación Cármides. Universidad de Sevilla Raquel Vázquez-Morejón. Grupo de investigación Cármides. Universidad de Sevilla Correspondence to: Raquel Vázquez-Morejón. Departamento de Psicología Social. Facultad de Psicología. Universidad de Sevilla. C/Camilo José Cela s/n. Sevilla 41018. España E-mail address: vazq[email protected] 3 Abstract Purpose: The impact of social support on comprehensive measures of results (clinical and functional) of the course of schizophrenia was studied, understood and evaluated as a multidimensional construct differentiating sources of support (family vs. nonfamily). Methods: 152 patients diagnosed with schizophrenia were assessed with the Mannheim Interview on Social Support (MISS) and the Social Functioning Scale (SFS). The hypotheses were explored in a prospective longitudinal design, using a causal correlational analysis for their evaluation by applying structural equation models. Results: The only explanatory factor of social functioning was nonfamily social support, while the only explanatory factor of clinical result measurements was family social support, observing a clearly differentiated impact of the different sources of support on the schizophrenia result measurements. It was also found that while family social support explained 6.8% of the variance in the clinical result measurements, nonfamily social support explained 13.7% of the variance in social functioning. Conclusion: The results confirmed the differential importance of social support variables (family vs. nonfamily) in the clinical and functional result measurements of people with schizophrenia. Keywords: Schizophrenia; family social support; nonfamily social support; clinical evolution; functional evolution 4 Introduction In the theoretical framework of the vulnerability/stress models of schizophrenia, social support has been an important protective factor favoring modulation of the negative effects of social and environmental stressors (Anthony & Liberman, 1986; Nuechterlein, 1987; Nuechterlein & Dawson, 1984; Vázquez Morejón et al., 2018). Historically, there have been three basic lines of research on SS in schizophrenia (Hammer, 1986): 1) Comparing the social support characteristics of people with schizophrenia with those observed in people with other pathologies or with no psychopathological disorder, 2) Comparing social support of schizophrenia patients with different characteristics, usually chronic vs acute, with positive symptoms vs negative or patients with a first vs multiple hospitalizations, and 3) Analyzing the relationship between social support and results measured related to the evolution of schizophrenia: psychopathology, relapse, type of course, readmissions and social functioning. Along the same line, prospective studies that have examined the relationship between social support and evolution of the disease are of special importance for their methodological interest. Although several studies have undertaken this relationship (Calsyn & Winter, 2002; Harvey et al., 2007; Lo & Lo, 1977; Salokangas,1997; Siegrist et al., 2015; Strauss & Carpenter ,1977), very few have approached the relationship between social support and the evolution of schizophrenia with validated instruments in a prospective longitudinal design (Bengtsson-Top & Hansson, 2001; Clinton et al., 1998; Erickson et al., 1998; Erickson et al., 1989; Hultman et al., 1996; Hultman et al., 1997), and even fewer 5 simultaneaously including both clinical and functional measures of results, as postulated by the vulnerability/stress model. Authors such as Erickson et al. (1998), Erickson et al. (1989), Hultman et al. (1996), Hultman et al. (1997) and Bengtsson-Top & Hansson (2001) explored these relationships including multidimensional measures of social support, but including simple measures of results in evaluating social functioning, usually based on overall scores from the Global Assessment of Functioning (GAF) scale. Only the study by Clinton et al. (1998) meets these requirements, and even so, with the limitation of a very short follow-up period (12 months), and more importantly, it lacks replication that can confirm its conclusions. It is worth mentioning the absence of specific research on one aspect, which although identified collaterally in some of the studies (Becker et al., 1997; Corrigan & Phelan, 2004; Erickson et al., 1998; Erickson et al., 1989; Nguyen et al., 2016; Salokangas,1997), has not been explicitly approached in the field of schizophrenia: The differential impact of social support sources in the various measures of results. Some social support components may have implications in different processes, and therefore, impact very differently on the main measures of results of schizophrenia. This complexity makes it indispensable to conceptualize and measure social support from a multidimensional perspective that allows the specific aspects of social support that come into play in a certain process or relationship to be determined. Weiss (1974), who identified six basic needs that are satisfied in social relationships, already mentioned that each of them requires “specialized” relationships. Different sources of support (family and nonfamily) could cover different needs, and also constitute critical variables for 6 very differentiated processes with consequences in different measures of results. From this perspective, it might be proposed that nonfamily relationships are the most closely related to social functioning measures and entail less impact on stress levels, and therefore, on clinical measures. On the contrary, family relationships, due to their characteristics, have a closer relatlionship with stress levels, and the quality of these relationships are particularly important, as demonstrated in studies of expressed emotion (Leff & Vaughn, 1985). In any case, the differences observed led Erickson et al. (1989) to mention that support by family or friends is differentially related to result measurements, which may reflect different relational processes. While Erickson et al. (1998) examined the relationship between social support and functional evolution (albeit, with a very basic unidimentional measure, the GAF), Norman et al. (2005) explored the relationship between social support and clinical evolution (symptoms and rehospitalizations). However, neither of the two explored the two measures of results, symptomatology and social functioning, together from the theoretical framework of the vulnerability/stress model. Neither did they simultaneously explore the differential influence of different social support sources on each of the measures of results. The importance of these measures is obvious considering that many areas in schizophrenia could be affected, that recovery occurs at different rhythms in different domains of results (Carpenter & Strauss, 1991; Harvey et al., 2007), and that the symptomatic and social results could be independent of each other (Öhman et al., 1989). 7 Therefore, we studied the impact of social support, understood and evaluated as a multidimensional construct differentiating sources of support, on comprehensive measures of results (clinical and functional) of the course of schizophrenia. This study posed the following hypotheses: Different sources of social support impact differentially on the evolution of schizophrenia: 1) social support of family members impacts on the clinical evolution of people with schizophrenia, so more social support from family members would correspond to a lower number of admissions, a shorter total hospitalization time and a longer survival time to admission; and 2) social support by people outside of the family impacts on the evolution of social functioning of people with schizophrenia, such that more social support from people outside of the family in a satisfactory network could correspond to a higher level of social functioning. Methodology Subjects The sample consisted of 152 participants in treatment at a community mental health unit (Virgen del Rocío University Hospital in the Andalusian Health Service, Spain) who met the following inclusion criteria: 1) Diagnosed with schizophrenia according to ICD 10 (WHO, 1992) criteria; 2) aged 18 to 45; 3) no cognitive and/or psychopathological decline that would impede following instructions and answering interview questions coherently, and 4) agree to participate after being informed about the purpose of the study and that they were under no obligation to do so. 8 At first, 177 participants were identified including all the patients under treatment at the community mental health unit, although the study was finally done with only 152 since 25 of them had to be discarded (11 because the decline and/or severity of symptoms prevented their participating, 6 did not want to participate, 6 more because their data were incomplete as they only attended some of the interviews agreed upon for their evaluation, and 2 were discarded as their professionals advised against participating in the study). No differences were observed between patients included and excluded insofar as age, sex, living situation or marital status. However, significant differences were found in age at onset (22.75 in those included vs 18.70 in those excluded) and in number of admissions (1.46 of those included vs 2.91 of those excluded). These differences could be indicating that those excluded were more clinically severe, which was to be expected considering that 11 of the patients were excluded because of their decline and/or severity. The mean age of the 152 participants was 30.9 years (S.D.= 6.97 and range 1845), 105 were men (69.1%) and 47 were women (30.9%). Their clinical characteristics were: mean age at onset 22.7 (S.D. = 5.78, range = 15-44), and 8.1 years of evolution (S.D.= 5.83, range = 0-25) from onset of the disorder and 1.46 mean hospital admissions (S.D.= 2, range=0-9) at the start of the study. Sixty-two participants (40.8%) had not been admitted previously to hospital, while 12 participants (7.9%) had been admitted more than five times. Age of onset of 36% of the participants was 20, while on the contrary, only 10% were over 30 at onset. Table 1 presents other sociodemographic characteristics. 9 _____________ Table 1 _____________ It should be mentioned that during the three-year follow-up, 16 participants were lost ( 12 men and four women) for various reasons (quitting, change of residence, death, etc.), and therefore, the final analyses could only be done with a total of 136 participants. However, no significant differences were observed between the two groups in any of the variables in the study. Instruments Mannheim Interview on Social Support (MISS; Veiel, 1990). This instrument attempts to combine the advantages of social support questionnaires and network-analytical approaches. The interview structure is based on a multidimensional concept of support, systematically distinguishing between a) Everyday support and crisis support; b) psychological-emotional and instrumental-material support; c) different sources of support and d) different descriptive (e.g., contact frequency, number of friends) and evaluative (evaluation of support received, satisfaction with the relationship) evaluation focal points (Veiel, 1985). The four general categories of support evaluated in the interview arise from the combination of these two basic distinctions in support functions (psychological vs instrumental, daily vs crisis): 1) Psychological Everyday Support (PES), 2) 10 Instrumental Everyday Support (IES), 3) Psychological Crisis Support (PCS) 4) Instrumental Crisis Support (ICS). This way scores may be found for size of network, each of the four support functions (PES, IES, PCS, ICS), and the multiplicity and frequency of contact. Evaluation focused on the satisfactory social support network, understood as support from members of the family the patients themselves think they have a satisfactory relationship with, that is, higher quality. The original version has satisfactory psychometric characteristics, very similar to those found in the Spanish adaptation used in this study (Vázquez Morejón & Jiménez García-Bóveda, 1997). The temporal reliability for a six-week period varies from .60 to .84 for the family and .68 to .97 for nonfamily. Social Functioning Scale (SFS; Birchwood, Smith, Cochrane, Wetton & Copestake, 1990). This scale was specifically designed to evaluate those areas of social functioning most crucial to keeping people with schizophrenia in the community. The scale covers seven areas: Social Engagement/Withdrawal, Interpersonal Behavior, Prosocial Activities, Recreation, Autonomy-Execution, Independence-Competence, Employment/Occuption. It provides a total social functioning score and a score for each of the seven areas. Higher scores always indicate a higher level of social funtioning. There are two versions, depending on the source of information: the patient (self-reported) or key informant (otherreported). The psychometric characteristics have been explored in both the English (Birchwood et al., 1990), and Spanish (Vázquez Morejón & Jiménez García-Bóveda, 2000) versions, with results that support its validity and reliability. 17 which comprises the critical element in the clinical evolution of people with schizophrenia. As observed by Dozier et al. (1987), enlargement of the network beyond a certain mínimum does not seem to reflect more support. Rather it would be the intensity and quality of family relations that would ensure protective support. These results are consistent with those of Norman et al. (2005), who in an exploratory study, found that the quality of family relations correlated significantly with the number of hospitalizations, while relationships with friends did not. These results also seemed to be related to these people’s high sensitivity to stress and would be in agreement with reports of studies on the Expressed Emotion construct (Brown, Monck, Carstairs & Wing, 1962; Leff & Vaughn, 1985; Vaughn & Leff, 1976), which identified family relational dimensions as critical to the clinical evolution of people with schizophrenia. First, only Nonfamily social support in the satisfactory network showed a significant relationship with the total Social Functioning Scale score, which partly explained the variability in total social functioning, while none of the Family social support variables appeared to be involved in this measure of results. This is in agreement with Erickson et al. (1989) and Erickson et al. (1998), who found that Nonfamily social support predicted adaptive functioning, showing this relationship to be specific to people with schizophrenia, as it is not observed in those with affective psychosis. Although these authors also found that the number of family relationships in the social network predicted poorer results in social functioning at 18 months, results that would contradict those found in this study, in their second study (Erickson et al, 1998), with a longer follow-up period of five years, 18 they found that the number of family members did not predict the results in the mid-term, which is consistent with the mid-term follow-up of three years in our study. Nonfamily social support in the satisfactory network was particulary important in the Social Functioning dimensions, where the variables in five of the seven social support dimensions showed a significant relationship explaining from 11.8% in Isolation to 21.6% in Communication. Concerning the importance of social support quantity vs quality, Becker et al. (1998) already reported that the quality of social relations is especially important, and that focus on the number of contacts may lead to erroneous conclusions. The results of our study also show that it is not quantity, but quality, of social support that is especially associated with better evolution. Thus, it may be observed how the satisfactory network constitutes the most explanatory factor of variance in the result measurements. Barrera (1986) pointed out that social integration measurements (structural measurments) captured the extent of the connection by evaluating the number of persons recognized as support providers and the frequency of social participation, while social support measurements (functional measurements) are more sensitive to the basic mechanisms of the connection, that is, the adequacy of support to the person’s needs. All these results confirm the importance of support perceived by patients, and not so much real availability, which is crucial to favorable evolution, as already mentioned by various authors (Clinton et al.,1998; Turner, 1981; Hengartner et al., 2017; El-Monshed & Amr, 2020). As mentioned by Cohen et al. (1984), relationships between social support, life eperiences and results represent a 19 continuous, dynamic process more than cause-effect. It is even possible that there are different causal models depending on the dimensions of social support measured and the processes studied (Trumbetta et al., 1999). Calsyn and Winter (2002), in their study of people with severe mental disorders using structural equation models, found that a reciprocal model explained the relationship between social support and psychiatric symptoms better, while a social causation model would better explain the relationship between social support and the type of residence where these people lived. Among the limitations of the study that should be mentioned is the number of quitters. However, the percentage of 7.2% observed differed only slightly from the 10.3% found by Ericson et al. (1989) at 18-month follow-up and is much lower than the 22% referred to by both Bengtsson-Top and Hansson (2001) and Hultman et al. (1997) in their 18-month and four-year follow-ups, respectively. With regard to diagnostic criteria, a structured interview could confirm the diagnoses, which would have made them more reliable. This is important in view of the observations made by various authors on the specific relationship between social support and different diagnoses (Beels, 1981; Erickson et al., 1989). Although strict compliance with ICD-10 diagnostic criteria was confirmed, for practical reasons, it was not possible to include any of the structured interviews for diagnostic confirmation in the study. In another vein, it could certainly be suggested that only the direct effect of social support was considered, since to evaluate the buffer effect, it would be necessary to evaluate the life events each of the participants was exposed to during the follow-up period. More so, the advisability of studying the adequacy of available 20 social support to the type of life event experienced has even been mentioned (Thoits, 1986). Even recognizing the great interest of this type of study, it should be considered that, in view of the results of Hultman et al. (1997), in which 72% of the patients with schizophrenia had experienced some life experience during the nine-month follow-up, during our three-year follow-up period, most of the participants would have been exposed to some life event, so that the buffer effect of their social support would have, although very partial, some type of impact on the measurements of results. In this sense, it should also be recalled that some types of support could be useful in coping with most stressors (Cohen & Wills, 1985) and that in view of the omnipresence of stressors throughout life, both direct and interactive effects could be considered in terms of buffering (Antonovsky, 1979). It should also be mentioned that, although all the subjects included in the study were on medication with antipsychotics, the dose and adherence to them may have varied considerably, a point not evaluated here, and which should be taken into account in other studies, since it could influence some of the results presented. In the future, it would be of interest to explore the impact of different sources of social support, especially in the early stages of psychotic disorders (GayerAnderson & Morgan, 2013), with more complex models that incorporate coping mechanisms as possible mediators (Davis & Brekke, 2014) and include variables not undertaken in this study, in particular, formal support by professionals and peer support. The impact of other specific support categories in line with those identified from the perspective of family members could also be explored 21 (Chronister et al., 2020). Moreover, it would be of interest to analyze the data by gender due to the importance of gender roles in social support, and include results more focused on positive points such as recovery (Corrigan & Phelan, 2004; Cullen et al., 2017) and quality of life (Prabhakaran et al., 2021). It would also be of interest to identify specific subgroups in which intervention in family and nonfamily networks could exert a stronger effect on clinical and functional evolution (Beckers et al., 2022). In conclusion, it is worthy of mention that in the scope of schizophrenia, our results confirm the proposal that social support has a direct significant relationship with clinical and functional evolution, at the same time that, coherent with Weiss (1974), they show that support provided should be developed in various relationships and involves different processes and consequences. The sources of support and quality of relationships entail various consequences, showing the complexity of the relationship between social support and the evolution of schizophrenia. In any case, the limited intensity of relationships between social support and results measurements is foreseeable, since, as the vulnerability/stress model argues, in schizophrenia, the result is the fruit of interaction of a wide diversity of factors: genetic predisposition, psychopathologic severity, stress levels, personal skills and competencies, social support, and others (Nuechterlein et al., 1992). As mentioned by Hammer (1981), there is no reason to suppose that social processes are less complex than biological. Major focus on the process of social support resources in line with therapeutic models directed at resources, as an alternative or complement to deficit-oriented 22 models (Priebe et al., 2014) could promote pragmatic intervention strategies focused on strengthening people with schizophrenia and their recovery (Terzian et al., 2013). 23 References Anthony, W. A., & Liberman, R. P. (1986). 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