LAUSR

Abstract Background Family environment plays a key role in the development of psychotic symptoms (Pitschel-Walz et al., 2001; Tienari et al., 2004) and negative family environmental factors are linked to poor prognosis in psychosis (Geller et al., 2000). By contrast, a positive family environment is associated with greater improvements in negative and disorganized symptoms among individuals at imminent risk of becoming psychotic (O’Brien et al., 2006). Nonetheless, little is known about the implication of family environment on longitudinal functioning in patients that presented a first psychotic episode. Methods This study is part of the “Phenotype-genotype and environmental interaction. Application of a predictive model in first psychotic episodes” (PEPS) study, a multicentric, longitudinal, naturalistic follow-up study (Bernardo et al., 2013). The Functional Assessment Short Test (FAST) was used to assess functional outcome. The Family Environment Scale (FES) evaluated family emotional climate in different categories: COHESION (C) for mutual reliance; EXPRESSIVITY (EX), the extent to which family members express their feelings directly; CONFLICTS (CON) for open expression of anger, aggressiveness and conflict; INDEPENDENCE (IND), the extent to which family members are independent in their decisions; ACHIEVEMENT ORIENTATION (AO) for an achievement-orientated environment; INTELLECTUAL–CULTURAL ORIENTATION (ICO) for political, intellectual, cultural interests; ACTIVE–RECREATIONAL ORIENTATION (ARO) for participation in social activities; MORAL–RELIGIOUS EMPHASIS (MRE) for the importance given to ethical and religious practices and values; ORGANIZATION (ORG) for the organization in activities and responsibilities; and CONTROL (CTL), the extent to which the family considers rules and established procedures. Patients with a first psychotic episode (FEPs) and healthy controls (HCs) have been evaluated baseline and after two years of follow-up. Diagnoses at 2 years have been established according to the Structured Clinical Interview for DSM-IV. Linear regression models have been conducted in order to assess the effect that different family environments exert on functioning at baseline but also at 2 years of follow-up, when the group of FEPs has been divided in patients diagnosed with psychotic disorders (PSYC) versus bipolar disorder (BD). All data were analyzed with the Statistic Package for Social Sciences (SPSS v.23 for Windows). All the analyses were two-tailed with alpha set at p < 0.05. Results At baseline, the total sample included 335 FEPs (mean FAST=27.8±16.1) and 253 HCs (mean FAST 3.5±8.1). At baseline the linear model was not significant neither for FEPs nor for HCs and no family environment was associated with functioning. At 2 years (mean FAST BD=13.8±15.1, mean FAST PSYC =20.98±15.4), in the BD group (F(10,14)=2.6, p=.05) worse functioning was associated with CON (β=.741, p=.004) whilst in the PSYC group (F(10,108)=3.509, p=<.001) it was negatively associated with ARO (β=- .305, p=.006) and AO (β=- .204, p=.039) and positively associated with MRE (β=.268, p=.003). Discussion At baseline, no specific family environment was associated with functioning. At 2 years, in BD worse functioning was associated with higher rates of open expression of conflict in the family whilst in PSYC it was associated with lower rates of participation in social activities and achievement-orientated family environment as well as with higher rates of religious practices and values. Family environment exerts an important role in the functioning of FEPs mainly in the long-term, with important implications for early interventions for both patients and caregivers.