Schizophrenia remains among the top 10 disabling conditions worldwide for young adults. Including care expenditures and disability, the costs of serious mental illnesses are more than $317 billion annually in the United States, or more than $1000 per year for every man, woman, and child.1,2 In the US, the cost of treatment and loss in productivity associated with schizophrenia are estimated to be above $60 billion annually.2,3 More than three-quarters of this amount is associated with loss in productivity.
Patients with schizophrenia struggle with many functional impairments, including performance of independent living skills, social functioning, and occupational/educational performance and attainment. Most patients require some public assistance for support, and only 10% to 20% of patients are able to sustain full- or part-time competitive employment.4,5 Improving functional outcomes for these individuals is a significant mental health priority.
It may be that the negative symptoms of schizophrenia, including problems with motivation, social interactions, affective experience and responsiveness, prosody and clarity of speech, and slowed movement, contribute more to poor functional outcomes and quality of life for individuals with schizophrenia than do positive symptoms. Caregivers report high levels of burden secondary to negative symptoms.
Negative symptoms tend to persist longer than positive symptoms and are more difficult to treat. Improvements in negative symptoms were associated with a variety of improved functional outcomes, including independent living skills, social functioning, and role functioning.6 Moreover, such improvements predicted future improvements in global functional outcomes for patients with schizophrenia. Thus, targeting negative symptoms in the treatment of schizophrenia may have significant functional benefits.
Current antipsychotic agents are most effective for treating the positive symptoms of schizophrenia. During brief medication visits, physicians typically focus on considerations related to delusions, hallucinations, disorganized and aggressive behavior, and hostility. These common symptoms may increase during relapse, resulting in hospitalization, emergency department visits, and crisis center services, or in incarceration in the criminal justice system.
Physicians may not be aware of the impact of negative symptoms on the patient’s and caregiver’s lives, may not know how to assess these symptoms, and may be unfamiliar with treatment strategies that favorably impact negative symptoms. In this article, we describe the signs generally regarded as negative symptoms, some of the etiological factors that contribute to a negative symptom presentation, and ways of treating these symptoms.
Recognizing negative symptoms
Negative symptoms represent a reduction of emotional responsiveness, motivation, socialization, speech, and movement. Analytic studies of multiple instruments indicate that these domains load onto 2 primary factors: avolition-apathy and diminished expressiveness. Primary negative symptoms are thought to be etiologically related to the core pathophysiology of schizophrenia, whereas secondary negative symptoms are derivative of other symptoms of schizophrenia, other disease processes, medications, or the environment. For example, antipsychotic medications variably produce both akinesia and blunted affect. Depression can cause anhedonia, lack of motivation, and social withdrawal. Lack of stimulation in impoverished institutional environments can lead to complacency and problems with motivation and initiation of productive activities.
Dr Velligan is Professor and Director of the Division of Schizophrenia and Related Disorders in the department of psychiatry at the University of Texas Health Science Center at San Antonio. Dr Alphs is Therapeutic Area Leader in Psychiatry, Medical and Scientific Affairs, for Janssen, LP, Ortho-McNeil Janssen Scientific Affairs, LLC, Titusville, NJ. Dr Velligan reports that she has the following relationships: Lundbeck-Otsuka: consultant, travel expenses, honoraria, speakers’ bureau, and advisory board; Bristol-Myers Squibb: consultant, honoraria; Janssen: consultant, honoraria advisory board; Genentech-Roche, consultant, honoraria, travel expenses, advisory board, research grant. Dr Alphs reports that he is employed by Ortho-McNeil Janssen.
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