Another major issue in the functional remission domain is intrinsic and extrinsic motivations for real-world functional achievement. One of the most substantial predictors of unemployment in schizophrenia in the United States is the receipt of disability compensation.25
Regardless of the willingness of an individual to work (ie, exert effort), there is minimal motivation or even disincentives to do so. In many circumstances in the United States, because of the rules associated with insurance and disability payments, seeking employment at levels above the minimal level can compromise both financial compensation and health insurance. Thus, an individual without developed work skills or a meaningful work history, who receives compensation for a disability, may find that seeking entry-level employment would be an irrational choice. In a related vein, real-world functional performance is also affected by societal factors, including stigma. Thus, a patient who is motivated and able to work may find himself shut out of the job market by negative attitudes among employers or a weak economy that favors those with good work histories.
Environmental factors that preclude performance of real-world activities should be considered in the determination of the presence of remission. If an individual is capable of full-time work, but receives more compensation than they would earn, then their compensation status needs to be considered as a factor in their current employment. Similarly, if an individual could live independently but prefers to spend the money that it would cost to live along on other productive activities, such as education, then this extraneous factor needs to be considered as well. Directly relevant to this issue, we recently examined the correlation in a sample of older people with schizophrenia between normal performance on neuropsychological tests and functioning in 3 different real-world outcomes areas: independence in residential status, martial status, and employment status.10
The relationship between neuropsychological normality and residential outcomes was clear and statistically significant: normal-performing patients were more likely to be living independently and to be financially responsible for their dwelling than patients who were performing in the impaired range. The impaired patients were significantly more likely to be living in a fully supported residence than normal performers as well. Interestingly, marital status and employment were both unassociated with cognitive status. Societal influences may impact on employment, while the lack of opportunities during critical developmental periods may have an adverse impact on social and marital outcomes.
These issues clearly indicate that the development of meaningful criteria for functional remission will require understanding premorbid abilities and likely outcomes if schizophrenia had never developed, as well as cultural and familial expectations for achievement and social outcomes, and opportunities and disincentives present in the immediate environment. Defining functional remission with too high a bar may mean that functional remission in schizophrenia requires “supernormal” functioning. Requiring that all individuals have equivalent performance across functional domains may disadvantage those from cultures where certain activities are not performed by members of one sex or the other. Excessive reliance on personal/subjective definitions of functional remission could define as remitted a seriously ill group who lack awareness of limitations and who report satisfaction with levels of functioning that are truly impoverished and have long-term adverse effects.
Another major issue to be considered is that of whether elements of functional disability can be more reasonably accounted for by other symptoms, such as negative symptoms. If an individual has both the cognitive abilities and the skills required to perform functional acts but does not do so because they experience anhedonia then their functional disability may be due entirely to symptoms. The inability to anticipate a pleasurable experience may remove motivation to perform the acts.26
Similarly, high levels of anergic symptoms may lead an individual to simply not engage in enough behavior to achieve functional outcomes.27
Most directly, and as discussed before, symptoms of amotivation are a potent interfering factor for functional outcomes. What will need to be determined in the end result is if remission is a purely behavioral criteria, ie, what does the person do in the real world regardless of the reasons for it, or if other contributors need to be considered as well. This element of the disability picture strongly suggests that functional abilities (ie, functional capacity) need to be examined when attempting to determine if a person with schizophrenia is in functional remission or not.28
Measuring the ability to behave in a manner consistent with remission is likely to be a critical step in the assessment process and to determine the causes for lack of functional remission when it is seen.
Subjective reaction to illness and current subjective illness burden are important factors. First, the willingness of a patient to participate in, contribute to, and sustain involvement in their functionally relevant aspects of treatment is likely linked to their subjective impression of current illness burden and likely future treatment benefit. Patients who are “objectively” doing well (symptomatic remission and partial functional remission) but do not share this positive view are likely to be at high risk for a variety of adverse outcomes. Conversely, patients who see themselves as unimpaired or not ill, despite disability and symptoms, should clearly not be considered to be in functional remission simply because they do not consider themselves disabled. While it has been known for years that unawareness of illness in the realm of lack of insight into psychotic symptoms is common in schizophrenia,29
it has become quite apparent in recent years that many patients manifest discrepancies compared with observer reports in evaluating their cognitive, social, and functional abilities and their level of success in the achievement of real-world outcomes.30
While subjective reports of illness burden and perceived disability have been found to have a substantial correlation in schizophrenia, these self-reports are often found not to correlate with observer ratings or direct measurements of functional skills performance.31
This applies as well to self-estimated cognitive impairment, where subjective appraisals of cognitive functioning are often correlated close to 0 with performance on NP tests, while observer and clinician ratings of impairment were found to be more highly associated with patient performance.32
The implication of these issues is that the global concept of recovery needs to consider patient impression, but functional remission cannot be entirely dependent on subjective response. We argue that it is critical to consider both real-world functioning, objectively measured, and subjective response to life situations (including treatment) as separate components of the recovery process. Satisfaction with one’s life can arise from many sources, and there is no clear definition of some threshold level of everyday functioning above which satisfaction from achievement, in social, financial, or residential domains, would intrinsically accrue in either patient or healthy populations.