1. MethodIntroductionResults Discussion Factors Affecting Psychosocial Functioning in Serious Mental Illness and Implications for Treatment Jason E. Vogler, Jason E. Peer, Srividya N. Iyer, Thea L. Rothmann, Myla Browne, A. Jocelyn Ritchie, and William D. Spaulding University of Nebraska-Lincoln For More Information on the Serious Mental Illness Research Group at the University of Nebraska-Lincoln: http://www.unl.edu/psypage/smi/ Increasingly, serious mental illness (SMI) is understood through an examination of impairments in varying levels of functioning (e.g., neurocognition, psychosocial, etc.) as well as intrasystemically (Spaulding, 1997). Previous research has indicated that psychosocial functioning (e.g., social competence, social interest, and irritability) in SMI is a product of complex relationships between factors such as neurocognitive functioning (Brekke, Kohrt, & Green, 2001) and sociocognitive variables, such as insight and locus of control. A greater understanding of the interrelationships between these factors may aid not only in improving psychosocial functioning but also treatment outcomes (Hoffmann & Kupper, 2002; Kupper & Hoffman, 2000; Smith, et al., 1999). Hoffmann and Kupper (2002) found that adherence to psychosocial treatment programs facilitated positive treatment outcomes. Research exploring the relationship between insight and neurocognitive functioning has shown a negative association such that lower levels of neurocognitive impairment is associated with lower levels of insight (Mohamed, Fleming, Penn, & Spaulding, 1999). Hoffmann and Kupper (2002) indicate that locus of control, particularly attribution to powerful others and chance, has important implications for level of psychosocial functioning and treatment outcomes. Further research may help us to understand the complex interrelationships of these factors and help us to identify more efficacious forms of treatment in SMI. The current study provides an analysis of the individual and relative contributions of neurocognitive functioning (e.g., executive functioning and attention), insight, and locus of control to level of psychosocial functioning. The participants were 35 inpatients engaged in a comprehensive psychosocial rehabilitation program for individuals with SMI. The Inventory for Self-Efficacy and Externality (I-SEE) (Krampen, 1991) was used to assess a more global attributional style (locus of control). The Internal, Personal, Situational Attribution Questionnaire (IPSAQ) (Kinderman and Bentall, 1997) assesses a more interpersonal attributional style based on participants explanations of positive and negative social scenarios. Insight was assessed based on the total score on the Insight Scale (IS) (Birchwood et al., 1993), an eight item self-report measure of insight into mental disorder. To estimate neurocognitive functioning, the five subscales of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Randolph, et al., 1998), the Trail Making A and B tests (Army Individual Test Battery, 1944), and the Mazes subtest (Wechsler Intelligence Scale for Children) were used. The Nurses’ Observation Scale for Inpatient Evaluation (NOSIE-30; Honigfeld, Roderick, & Klett, 1966) was used to measure general psychosocial functioning and outcomes. The mean monthly total NOSIE scores were calculated for the first six months of rehabilitation and used in the subsequent analyses. Attribution, insight, and neurocognitive measures were administered within the first month of admission. Participants’ scores on the NOSIE-30 were provided separately by two psychiatric technicians at the end of the first month of admission. All data were collected as part of routine clinical assessment and were screened for outliers and normalized (windsorized). Any outliers identified among the data examined and subsequently normalized using a windsorizing procedure. A series of correlation and regression analyses were conducted to examine the relationships between NOSIE-30 ratings for people with serious mental illness, scores of attributional style (I-SEE self-efficacy and externality scales; IPSAQ personalizing bias and externalizing bias scales), insight, and neurocognitive variables (RBANS, Trail Making A and B, and Mazes). Table 1 shows the univariate statistics, correlations of each variable with NOSIE-30 scores, and the regression weights for the model. Of the 17 predictors in the model, only the Immediate Memory Index of the RBANS, Trail Making B (standardized score and number of errors), and I-SEE externality scores were significantly correlated with the criterion (NOSIE-30 scores). The RBANS Immediate Memory Index was positively correlated with NOSIE-30 (r =.41, p =.007) as was Trail Making B (standardized score; r =.32, p =.033 and errors; r = -.62, p <.001) indicating that those participants with less impaired cognitive functioning and fewer processing errors have higher psychosocial outcomes. The I-SEE externality scale was also negatively correlated with NOSIE-30 (r = -.40, p =.009) indicating that those participants who make fewer externalizing attributions have more positive psychosocial outcomes. The full model containing all 17 predictors had an R² =.72, F(17, 17) = 2.54, p =.031. Given the high collinearity within the model, it is not surprising that only one variable (Trail Making B errors) was a significant predictor. The results indicate that psychosocial outcomes can be predicted when considering a combination of neurocognitive functioning, insight, and social cognition in SMI. As expected, those participants who have less impaired neurocognitive functioning have better psychosocial outcomes, in that they are able to make cognitive decisions more quickly and with less error. According to this model, locus-of-control also plays a role in the prediction of psychosocial outcomes in that those participants who make fewer externalizing attributions have more positive outcomes. This finding represents a replication of earlier research which used the I-SEE and found that an external locus-of-control was associated with poorer outcomes for SMI (Kupper & Hoffman, 2000). Despite this finding, there were no significant correlations between negative attribution style as measured by the IPSAQ externalizing bias score and the criterion variable (NOSIE-30 scores). The results of this study were expected to support previous research identifying locus of control as a mediating factor between insight and psychosocial functioning; however there was no significant relationship between insight and psychosocial outcomes. It was hypothesized that there would be a positive relationship between levels of insight and psychosocial functioning such that greater insight is associated with higher levels of psychosocial functioning for those with relatively less impaired neurocognitive functioning and an external locus of control. Because there was no relationship between insight and outcomes, this analysis was not possible. Although several correlations approached significance, the results were not powerful enough to make this distinction clear. For this, a larger sample size is needed to find the effect. While more research is needed, these results have important implications for the course of treatment for those people with SMI. Drawing upon the abundance of prior research indicating that those people with less impaired cognitive functioning have more positive treatment outcome and research findings indicating the positive correlation between insight and neurocognitive functioning; more information is needed about the role of locus of control and attributional style in shaping the ways people with SMI use insight-oriented information. Table 1. Summary statistics, correlations, and results from the regression analyses. _____________________________________________________________________________________________________________ VariableMeanSDCorrelation with NOSIERegression weightsBeta Weights _____________________________________________________________________________________________________________ NOSIE-30 Ratings165.0420.77 RBANS Immediate Memory Index75.8917.64.41*.31.26 Visuospatial/Constructional Index79.6618.53.27.23.21 Language Index87.7115.79.26-.19-.14 Attention Index73.2916.25.26.08.06 Delayed Memory Index80.2918.49.15-.08-.08 Mazes (standardized)-.791.42.18-2.93-.20 TRAIL MAKING Form A (standardized)-1.992.72.11-.58-.08 Form A Errors.26.51-.22-11.02-.27 Form B (standardized)-1.952.49.32*.73.09 Form B Errors.69.96-.62*-9.59*-.45* INSIGHT Relabel Symptoms2.141.33-.10-6.99-.45 Awareness of Illness2.431.69.143.06.25 Need for Treatment2.511.56.275.56.42 I-SEE Self-Efficacy68.208.91-.04.21.09 Externality50.8612.45-.40**-.18-.11 IPSAQ Personalizing Bias.55.27.2613.98.18 Externalizing Bias2.113.53.15-.36-.06 _____________________________________________________________________________________________________________ *p <.05, **p <.001