At the time of attendance to treatment, patients with FEP, CHR-P or CHR-N did not differ in their sociodemographic background, childhood adverse experiences and premorbid adjustment. In terms of premorbid functioning, CHR-P subjects did not differ from patients with first-episode psychosis or multi-episode schizophrenia [49].
At the baseline, functioning of patients with FEP was poorer than in CHR-P and CHR-N patients, but during the follow-up, this difference became equalised; functioning in FEP and CHR-P patients improved but not in CHR-N patients. In FEP patients, resolving of psychotic symptoms associating with reduced functioning at acute phase (Supplementary Table 2) possibly explained their good functional recovery. In CHR-P patients, recovery of functioning was slower and possibly correlated with improving in negative and disorganised symptoms (Supplementary Table 2). The interventions possibly focused on reduction of positive psychotic symptoms could not considerably improve functioning in the CHR-N patients.
At the eighteen months follow-up, 43.4% of FEP patients were functioning well, 29.5% moderately and 27.1% poorly. The proportion of patients with a good functioning was a little higher than in previous studies [81, 82]. It was remarkable that sociodemographic background, SIPS symptoms, neurocognitive deficits and premorbid adjustment associated extensively with functioning. However, in multivariate modelling, only basic education (high), work situation (good), disorganised symptoms (few), perceptual disturbances (few) and late adolescence premorbid adjustment (good) predicted significantly good functional outcome. However, constructions of predictive factors for functional outcome varied considerably between FEP, CHR-P and CHR-N patients.
In patients with FEP, marital status (single), poor basic education and poor work situation associated strongly with poor functional outcome. Marital status, education and work situation, central components of the social competence [83, 84] represent an endpoint of psychosocial development at the beginning of the first attendance to treatment. Interestingly, these three sociodemographic factors were still powerful predictors, although the effect of adolescence development [64] had been taken into account. Possibly, since adolescence occurring psychiatric symptomatology and neuropsychological deficits with difficulties in schooling, deviate both socio-sexual and work performance development to the low competence trajectory with further worsening after onset of psychosis. In chronic schizophrenia, extremely low competence was seen in single men whose quality of life was exceptionally low [85].
In patients with CHR-P and CHR-N, the role of education and work situation varied, being significant predictor in the latter and non-significant in the former. In our previous studies on CHR-P patients [60, 86] work situation and education predicted short-term follow-up functioning. In the present study, low number of CHR-P patients may explain the difference; in a combined sample both education and work situation were significant predictors (analyses available by request) indicating that they both are important predictors for functioning also in patients with sub-clinical psychotic symptoms.
From baseline symptoms, only SIPS disorganised symptoms had an independent predictive power on functional outcome both in FEP and CHR-P patients. The effect of negative symptoms on functioning, found in several studies on schizophrenia [15, 17, 18, 20, 22] and in bivariate analyses of the present study, was replaced by the effects of work situation and disorganised symptoms. Positive symptoms correlated with baseline functioning, but in modelling, they did not significantly predict follow-up functioning. In a follow-up study of FEP patients, remission of negative symptoms was found to be critical in the prediction of future functioning [81] In line with earlier studies [20, 22, 60, 87] among patients with clinical psychosis, major psychotic symptoms, delusions and hallucinations, their prevention hardly has a great effect on their functional outcome. In CHR-P patients, the role of positive symptoms is similar. Like in our previous studies [60, 86] in CHR-P patients, positive symptoms and transition to psychosis did not associate with functional outcome. Positive psychotic symptoms (like delusions and hallucinations) are specific predictors for new or incident psychotic disorders88-90 but they hardly play any role in predicting functional outcome in patients with CHR-P.
In bivariate analyses, various neurocognitive deficit indicators associated with functional outcome, but in multivariate modelling, only perceptual disturbances, assessed by the Rorschach Exner (RCS) test, had, specifically in FEP patients, an independent association with poor functional outcome. This kind of disturbances in visual form perceptions differ from sense disturbances, like hallucinations. Interestingly, deficits in visual learning (BVMT-R) associated also with poor functional outcome, but in modelling lost their predictive power when premorbid adjustment entered into the model. Anyway, perceptual disturbances, possibly caused by incoherent structure and function of CNS neuronal network, seem to play an important role in functional outcome among psychotic patients. In CHR-P and CHR-N patients, neurocognitive deficits played minor role in prediction of functional outcome. Thus, it seems that although, neurocognitive deficits are common in patients with FEP [23–28] and CHR-P [47–54] and correlate with actual functioning, their value in predicting function outcome is not great.
In accordance with earlier studies [14–22, 60] premorbid adjustment, assessed by the PAS scale64, associated strongly with functional outcome in the patients with FEP and CHR-P. In both patient groups, the late adolescence PAS had the strongest association with follow-up functioning. It is generally known that first signs of schizophrenia often occur in adolescence. While PAS assessment represents a global assessment of individuals’ early psychosocial development, it also includes effects of genetic and environmental factors, like childhood adversities.
It was remarkable that although childhood adversities associate with onset of psychotic and sub-psychotic disorders, like CHR [30–33, 56, 57] and with transition to psychosis in patients with CHR,91 in multivariate modelling of the present study, they did not predict follow-up functioning.
Like in other studies on CHR-P [45, 92] affective disorders, both depression and anxiety, were very common at the time of help seeking. During follow-up, transition to psychosis did not associate with functioning, and the association of positive psychotic symptoms was slight, while depressive and anxiety symptoms associated strongly with poorer functioning and increased the model’s predictive power greatly. These findings indicate that affective, not positive psychotic symptomatology, is the major psychiatric symptomatology worsening functional outcome in CHR-P patients. Also, in other CHR-P studies, non-psychotic comorbidity has been associated with poor functional outcome [93, 94].
Comparison of short-term functional outcome between FEP and CHR-P patients suggests that they may represent qualitatively different groups of help-seekers. Individuals with FEP form a heterogenic group of psychotic patients among whom, together with previous psychosocial and educational development, disorganised symptoms are decisive clinical factors predicting functional outcome. CHR-P help-seekers represent individuals suffering from long-term affective disorders with mostly temporary, distress increasing psychotic/-like symptoms. In both groups of patients, resolving of positive symptoms correlates with functional improving, while continuation of affective (depression and anxiety) symptoms seem to prevent further improving of functioning. In patients with CHR-N, sub-clinical positive symptoms are mild and functional recovery minor. In all three patient groups, ability to work at the time of the first attendance to treatment is considerably reduced and greatly predict their further functioning.