Background The interplay between neurocognition, social cognition, and employment outcomes among the schizophrenic population has been extensively investigated, but there are disparities between the impairments that predict these outcomes. In this study, we aim to provide further insight by discriminating between factors that influence getting a job and sustaining employment. We hypothesized that neurocognitive factors would predict which individuals experienced challenges in ever getting a job, while interpersonal deficits, disruptive behavior, or psychosis would characterize individuals who were able to obtain a job but unable to keep it. Methods Patients (n=396) were between 18 and 70 years old and received a diagnosis of Schizophrenia, Schizoaffective Disorder or Schizophreniform Disorder. Performance-based assessments were conducted to measure neurocognition, social cognition and psychosis; and, clinical ratings provided information on psychosis, negative symptoms and disruptive behavior. Patients were divided into three clusters defined as: individuals who had never been employed (n=196), individuals who formerly had a job for at least 2 years but have been unemployed for at least 2 years (n=149), and individuals with current employment for at least 2 years (n=51). Results Patients who never had a job manifested the following characteristics compared to those who currently had a job: significantly fewer years of patient education (Self, p=.006), mother’s education (Mother, p=.028), and lower verbal working memory (LNS, p<.01). They also displayed significantly more PANSS social avoidance (p=.023), disturbance of volition (p=.037), and anxiety (p=.004). Compared to those who formerly had a job, these same patients manifested the following: significantly more total negative symptoms (p=.039), more severe poor rapport (p=.041) and more blunted affect (p=.002). Formerly employed patients reported significantly more depression (BDI, p=.01) and hostile cognitive bias (BLAME, p=.008), as well as worse emotional processing on the BLERT (p=.005) and ER-40 (p=.028) compared to the never employed group. Lastly, patients who formerly had a job manifested the following compared to those who currently had a job: less patient education (Self, p=.011), mother’s education (Mother, p=.015), premorbid intelligence (WRAT-3 Standard Score, p=.038), working memory (LNS, p<.01), and blunted affect (PANSS, p=.018). On the PANSS, they had more grandiosity (p=.031), suspiciousness (p=.008), anxiety (p=.001), active social avoidance (p=.003), and depression (p=.016). BDI total score, for depression, was also elevated [t(114)=3.58, p=001)]. Discussion Individuals who never had a job have evidence of less education and poorer working memory as well as negative and mood symptoms, when compared to those who were ever employed. Those who obtained a job but developed long-term unemployment had evidence of 1) social cognitive impairments, including hostile bias and emotion processing deficits, when compared to the never employed patients and 2) lower education, working memory, and PANSS ratings for negative symptoms, suspiciousness and grandiosity, when compared to the currently employed patients. Thus, the formerly employed patients manifested a constellation of symptoms that would seem to interfere with sustaining employment. Later research will be required to determine the time course of development that these predictors of unemployment have on patients who were previously able to work.
Background Vocational drift, or the suggestion that severe mental illness leads to reductions in occupational attainment, has been repeatedly observed in schizophrenia. Neurocognition, social functioning, education, environment, and previous work experience have been implicated in patients’ ability to acquire and maintain a job. Interestingly, some patients with successful prior work histories can develop chronic unemployment. In this study, we analyzed a sample of schizophrenic individuals with varying histories of obtaining and sustaining employment to examine vocational drift through the lens of vocational deterioration. We hypothesized that 1) social cognitive variables would be more impaired in patients with a long duration of unemployment and 2) neurocognitive deficits would be more prominent in patients who were never employed. Methods 396 patients between 18 and 70 years old with a diagnosis of Schizophrenia, Schizoaffective Disorder, or First Episode Spectrum Disorder were included in this analysis. Measures included comprehensive clinical, neurocognitive, social cognitive, and functional assessments. Samples were divided into groups based on their employment history. Although our original sample included currently employed patients, the following groups were examined as a function of vocational drift: a) Never (n=150), individuals who have never had a job and b) Formerly employed (n=138), individuals who had a job for at least two years in the past but are currently unemployed. Among unemployed patients, we identified those with Short (less than 2 years; n=65), Intermediate (2 to 5 years; n=87), and Extended (more than 5 years; n=136) unemployment. Results In the overall comparison of Formerly employed patients, those with Short and Intermediate duration of unemployment did not differ from each other on any variables and performed better than Extended duration unemployment patients on measures of premorbid intelligence (WRAT, p<.01), processing speed (Symbol coding, p<.01), emotion recognition (BLERT, p<.01 and ER-40, p<.01), theory of mind (Hinting test, p<.05) and hostile cognitive bias (AIHQ Blame, p<.01). Interestingly, patients with Extended unemployment had less depression (BDI total, p<.01) compared to patients who Never worked. The Extended unemployment patients performed worse than the Never employed patients on premorbid intelligence (WRAT, p<.01), processing speed (Symbol coding, p<.05), emotion recognition (BLERT, p<.01 and ER-40, p<.01), theory of mind (Hinting test, p<.05), social inference (TASIT, p<.01), hostile cognitive bias (AIHQ Blame, p<.01), and had higher clinical ratings on PANSS Blunted affect (P<.01) and Poor Rapport (p<.01). Discussion The development of long-term unemployment in patients with schizophrenia is associated with multiple neurocognitive and social cognitive deficits, particularly when compared to patients who have never been employed. These deficits were also notable when compared to patients with a shorter duration of unemployment. It is not possible to determine if these long-term unemployed patients always exhibited these deficits, suggesting additional support for vocational drift among patients with schizophrenia. The possible deterioration in neurocognitive and social cognitive performance over time may be driving the development of long-term unemployment in previously employed patients, who in many ways, underperformed compared to patients who had never worked.
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