Schizophrenia is a complex and heterogeneous disorder, with a range of symptoms and effects on the lives of patients and their families 1 2 . It impacts to a significant and detrimental extent on patient functioning; indeed, this deficit in functioning is recognized as a diagnostic criterion of schizophrenia 3 . Several domains of functioning are affected, including occupational and social aspects and independent living 4 5 .

Social functioning, in particular, is widely recognized as an important factor when considering long-term outcomes in patients with schizophrenia 6 7 8 . In one study of patients in six European centres, impairments in social functioning were observed in over 78% of the population at assessment within 2 years of first-episode psychosis, and this persisted at subsequent 1-, 2- and 15-year follow-ups 9 . Up to two thirds of patients are unable to perform basic social roles, even when psychotic symptoms are in remission; only a minority marry, and less than one third are in regular employment 10 . There are regional differences in employment rates amongst patients with schizophrenia that may be linked in part to social or environmental influences such as local welfare or benefit systems, legislative and economic factors 11 . A US study found the number of patients with schizophrenia in regular, paid employment to be less than 15%. In addition, unemployed patients presented with lower quality of life scores, and an inverse relationship existed between the likelihood of employment and the receipt of disability payments 12 . Poor functioning therefore places a considerable burden (including an economic impact) on society 8 10 .

Improvement in functioning in patients with schizophrenia is now considered to be an important treatment goal 13 14 15 . As such, it is included in treatment guidelines 1 8 16 and has been recognized as a useful endpoint in the evaluation of treatment options by regulatory authorities 17 . A recent literature review highlighted an increase in the number of studies documenting symptomatic remission and an awareness of functioning and quality of life as outcome measures 18 . A number of studies have reported improved patient functioning following treatment with antipsychotics 19 20 21 22 23 24 or with non-pharmacological interventions such as social skills training, cognitive behavioural therapy, cognitive therapy, cognitive remediation and social cognition training 25 26 27 . Improved social and occupational functioning is also identified by patients and their families as an important treatment outcome 10 , as well as by groups representing patients 6 .

The remission of positive and negative symptoms does not always correspond with an improvement in functioning 6 15 28 29 , and improvements in symptoms do not always correlate with patient satisfaction or with performance in social relationships or performance of daily activities 30 . In one study, 3 years after beginning initial antipsychotic treatment, symptomatic remission rates were 60.3%, functional remission rates (defined by employment status, social relationships and independent living) were 45.4%, and 57% of patients achieved adequate subjective well-being. However, only 28.1% achieved remission in all three areas 31 . Social functioning may, therefore, represent an area that requires treatment beyond the resolution of overt symptoms of psychosis 32 . Conversely, early improvements in social functioning 33 or subjective well-being may be predictors of symptomatic remission 34 and of a good overall treatment outcome, supporting the importance of assessing social functioning in patients with schizophrenia 33 . Methods of gathering information in order to assess functioning are, however, known to vary and can include the perceptions or ratings of health care professionals, patients and family members 10 35 . While a number of assessment scales are used, including the Social and Occupational Functioning Assessment Scale (SOFAS) 36 , the Functional Remission Of General Schizophrenia (FROGS) scale 37 , the Global Assessment of Functioning (GAF) scale 38 and the Personal and Social Performance (PSP) scale 39 , there is a lack of standardization in methodology, as highlighted by several authors 6 7 10 13 40 .

Improved social functioning is an important treatment goal for patients with schizophrenia which does not necessarily correlate with improvement in disease symptoms. Despite the prevalence of impaired functioning, assessments of functional outcome are neither routinely conducted nor effectively standardized in clinical practice. As such, some authors recommend a change in current attitudes and perceptions with respect to the importance, evaluation and treatment of impairments in functioning 32 . Results from a survey previously conducted in Spain designed to assess the opinions and perceptions regarding functioning in patients with schizophrenia highlighted a need to obtain a broader understanding of the assessment of the measurement and treatment of patient functioning 41 . Results showed that psychiatrists considered the control of psychotic symptoms as the most important treatment objective, with outcomes such as functioning and relapse prevention regarded as secondary therapeutic objectives. Ninety-two percent of psychiatrists considered that functioning should be recorded in medical notes; only 17% of the psychiatrists surveyed used specific scales to assess their patients' functioning. Thirty-three percent of respondents thought that <20% of their patients had an adequate level of functioning, and 76% considered that patient functioning would be best improved by modifying pharmacological treatment. Overall, this survey showed that clinicians' perception of the level of functioning in their patients with schizophrenia was low and that there is a need to develop protocols to improve patient functioning 41 . How this type of perception applies in other countries (from Europe and elsewhere) is an important consideration in relation to improving the following: (1) the quality of assessment of patient functioning by psychiatrists, (2) the frequency of appropriate assessments of the patients' autonomy and (3) the knowledge and use of available therapeutic techniques that facilitate such processes.

The present survey was performed across countries in Europe, the Middle East and Africa, and aimed to determine psychiatrists' perceptions of the importance of social functioning in their patients, the ways in which deficits are assessed and managed and potential barriers to improving social functioning in patients with schizophrenia.

This study aimed to investigate psychiatrists' opinions and perceptions of functioning in their patients with schizophrenia. A paper-based survey was conducted amongst psychiatrists (and neurologists with a psychiatric background in Germany) treating patients with schizophrenia in 42 countries, between March and April 2011, to document the management of social functioning across Europe, the Middle East and Africa.

A scientific committee of international experts with a special interest in the functioning of patients with schizophrenia developed a survey specifically to conduct in Europe, the Middle East and Africa to understand further psychiatrists’ opinions and perceptions of functioning in patients with schizophrenia. The survey consisted of 17 questions, 4 relating to the demographic profile of respondents and the remaining 13 regarding the extent of impaired functioning seen in clinical practice, the role of personal and social functioning as a treatment goal, and approaches to the assessment and management of personal and social functioning in patients with schizophrenia. Finalization of the questions, their wording and the approach to analysis of the survey results took place during a series of steering committee meetings, funded by Janssen, and with input from an independent company with prior experience in conducting surveys of the perceptions of health care providers.

In order to maximize the reach of the survey and to capture any potential geographical variations regarding the perceptions and opinions of functioning in patients with schizophrenia, psychiatrists were identified using a database held by Janssen. Surveys were delivered by mail (in Belgium, The Netherlands, Germany, Serbia, Spain, France, UK and Switzerland) or by Janssen representatives (in other countries). Psychiatrists received a sealed pack containing the survey, a prepaid envelope and a signed letter from the steering committee explaining the aims of the survey. The survey was translated from English into local languages when required. The survey took approximately 10 min to complete. Surveys were completed anonymously, and no individual patient data were collected. Respondents to the survey provided informed consent for the use of the results for research purposes. A copy of the consent form is available for review by the Editor-in-Chief of this journal. Completed surveys were returned directly and blinded to an independent third party for data analysis. The survey was not designed to allow statistical analysis of the differences in responses. Interpretation of the results reported here is based on qualitative comparison of the responses obtained.

This survey gathered information on the perceptions and opinions of psychiatrists across Europe, the Middle East and Africa regarding the personal and social functioning of patients with schizophrenia. The survey demonstrated that a large proportion of patients with schizophrenia were considered by their clinician as having impaired personal and social functioning and that the vast majority of psychiatrists believed that it was important to assess functioning on a regular basis.

This survey found that while psychiatrists believe improving personal and social functioning to be an important treatment goal for patients and their families, they ranked this behind ‘alleviating psychotic symptoms’ and ‘reducing aggression and hostility’ when asked to rank the treatment goals for their patients with schizophrenia. While symptomatic remission has been cited as an important precursor to functional remission 18 42 , it does not, however, guarantee improvements in functioning. Rates of symptom remission normally exceed those of good functional outcome 15 . A recent study of outpatients with schizophrenia concluded that while almost half were in symptomatic remission, only 10% had attained adequate social and/or vocational functioning 29 . Similarly, an open-label antipsychotic trial found that remission status did not correlate with improvements in positive or negative symptoms or in cognitive functioning 43 . Considered alongside the growing body of evidence that alleviation of symptoms may not correlate with improvements in social functioning in patients with schizophrenia, the findings of this survey suggest that a change in psychiatrists' current awareness and perceptions is required regarding the importance of impairments in social functioning in patients with schizophrenia.

Psychiatrists concurred that the measurement and recording of social functioning on a regular basis is important, and most assess personal and social functioning at every visit. However, relatively few psychiatrists use specific scales for assessing functioning, with clinical interview being the method of preference, and many respondents also value the opinion of the patient's family. In this survey, the GAF scale 38 was reported as being used most often followed by the PSP scale 39 , although other scales (e.g. SOFAS 36 , FROGS 37 ) are also used in clinical practice. Non-standardized methods of assessment make cross-study comparison difficult, particularly as scales differ in terms of the types of domains assessed, the methods by which information is gathered and the level of complexity of the assessment. An additional complicating factor is the non-concordance between patients' and psychiatrists' assessments of functioning levels 44 . These are amongst several challenges facing psychiatrists when assessing functioning in their daily clinical practice. Others include difficulty in distinguishing functioning deficits from the effects of negative symptoms 7 45 and a frequent lack of distinction between quality of life and functioning measures 7 46 . In addition, only a relatively small number of randomized, controlled clinical trials of antipsychotic agents have assessed social functioning using a specific scale 7 . These aspects have been explored further in a recent research initiative 44 47 . In the current survey, improvements in functioning were normally found to be judged via personal and social relationships or by engagement in activities such as work and study. Although these measures can be considered to be objective and therefore valid and more straightforward to measure, they can also be influenced by external societal factors and individual values. Even when using these ‘objective’ assessment measures, the subjective opinions of the patient, family and psychiatrist will also inevitably form part of the evaluation process 6 . Most participants in this survey agreed that clinical guidelines on social functioning would prove useful to their practice, while opinions were more divided regarding the clinical need to differentiate the assessment of cognitive impairments and social functioning. This supports the suggestions that the current lack of a consensus in the assessment of functioning hinders the effective assessment of patient progress and subsequent improvement of outcomes 18 48 .

The results presented here suggest that the current method most commonly used as a primary measure to tackle functioning deficits in patients with schizophrenia is psychosocial intervention. Approximately one third of psychiatrists would reconsider the patient's pharmacological treatment as a first step. The pharmacological strategies most often used were changing the dose of the current antipsychotic or changing the antipsychotic. Respondents appeared to attach only low priority to switching antipsychotic formulation, including oral, oral extended release or long-acting injectable formulations.

In conclusion, psychiatrists recognize that a large proportion of their patients with schizophrenia have impaired personal and social functioning. Clinicians assess and record functioning on a regular basis, although there is no consensus on how these assessments should be conducted. There was agreement that guidelines on this topic would aid clinical practice. While the majority of psychiatrists would implement psychosocial strategies as an initial step in addressing functioning deficits, a considerable number would choose to alter the patient's pharmacological therapy (although few psychiatrists considered changing the antipsychotic formulation). Most psychiatrists identify improvements in social functioning as a key outcome for patients and their families. The majority also agreed that a distinction between symptom improvement and improvements in social functioning would be clinically useful. Despite this and the literature evidence suggesting a lack of correlation between improving symptoms and improving functioning, enhancing functioning was rated as a less important treatment goal than reducing psychotic symptoms. This may signify a need for increased awareness amongst psychiatrists of the uncertain correlation between improvements in symptoms and in social functioning. These results also highlight that addressing deficits in social and personal functioning in patients with schizophrenia is an important area for further development, where increased emphasis on functioning as a treatment goal may enhance outcomes for patients. It is hoped that the findings of this survey can contribute to the design of activities and tools applicable to everyday clinical practice to improve the assessment and management of social functioning in patients with schizophrenia.

LH is a full-time employee of Janssen-Cilag Medical and Scientific Affairs Europe, Middle East and Africa. AS is a full-time employee of Janssen-Cilag Medical and Scientific Affairs Europe, Middle East and Africa and a shareholder of Johnson & Johnson. PG, TB, GJ, AR and LS have been members of advisory boards, involved in designing and participating in clinical trials or received educational grants for research, honoraria and travel from Janssen as well as other pharmaceutical companies.

PG, TB, GJ, AR, LS, LH and AS approved the design and reviewed the results of the survey. All authors developed the draft of the manuscript, participated in subsequent revisions and read and approved the final manuscript.