Neuropsychological impairments predict the clinical course in schizophrenia

To add to the open question whether cognitive impairments predict clinical outcome in schizophrenia, a sample of 125 first episode patients was assessed at the onset and over one year of controlled long-term treatment within a study of the German Research Network on Schizophrenia. No relapse according to predefined criteria occurred within the first year, but a total of 29 patients fulfilled post-hoc criteria of "clinical deterioration". Impairments in cognitive functioning assessed by the Trail-Making Test B at the onset of long-term treatment differentiated between patients with vs. without later clinical deterioration and proved to be a significant predictor of the clinical course in a regression analysis outperforming initial clinical status as predictor. However, low sensitivity (72%) and specificity (51%) limit possibilities of a transfer to individual predictions. As a linear combination of neuropsychological and psychopathological variables obtained highest predictive validity, such a combination may improve the prediction of the course of schizophrenic disorders and may ultimately lead to a more efficient and comprehensive treatment planning.

Further evidence for a functional role of the glutamate receptor gene GRM3 in schizophrenia

In recent years, evidence has been accumulating indicating a major role of glutamate in the pathogenesis and pathophysiology of schizophrenia. Of particular importance in this regard are the metabotropic glutamate receptors (GRM). Thus, a recently published trial of the amino acid analogue LY2140023, which exerts its effects through the activation of the glutamate receptors GRM3/GRM2, showed an improvement of positive and negative symptoms comparable to treatment with olanzapine. A functional variant of GRM3 has been described which modulates synaptic glutamate levels. We assessed whether this functional variant rs6465084 is related to schizophrenia in a large sample of patients and controls. We found an increased frequency of the A allele (p=0.027) and the AA genotype (p=0.024) in schizophrenia patients. Moreover, in an assessment of schizophrenia endophenotypes, patients of the AA genotype performed poorly in the digit symbol test, a measure of attention (p=0.008). Our results provide further evidence for the potential importance of the glutamate receptor GRM3 in schizophrenia, and indicate that the novel antipsychotic LY2140023 may actually be targeting a pathogenic pathway of schizophrenia.

Maintenance treatment with risperidone or low-dose haloperidol in first-episode schizophrenia: 1-year results of a randomized controlled trial within the German Research Network on Schizophrenia

OBJECTIVE

Second-generation antipsychotics (SGAs) have proven superior to first-generation antipsychotics regarding relapse prevention, mainly in multiple-episode patients. Practice guidelines recommend SGAs as first-line treatment particularly in first-episode patients, although evidence for this group is still limited. Accordingly, the hypothesis of whether 1-year relapse rate in first-episode schizophrenia under maintenance treatment with risperidone is lower compared to haloperidol in low dose was tested.

METHOD

Between November 2000 and May 2004, 1372 patients had been screened for eligibility in the inpatient facilities of 13 German psychiatric university hospitals. 159 remitted patients were enrolled after treatment of an acute first episode of schizophrenia according to ICD-10 F20 criteria. In the randomized controlled trial, double-blind antipsychotic treatment with risperidone or haloperidol was maintained in a targeted dose of 2 to 4 mg/day for 1 year. 151 patients were eligible for analysis. For 127 patients, this was a continuation trial after 8 weeks of randomized, double-blind, acute treatment with the same drugs; 24 patients were additionally randomly assigned after open acute treatment.

RESULTS

With both antipsychotics (risperidone, N = 77; haloperidol, N = 74), no relapse evolved. Additionally, according to 2 post hoc defined measures of "marked clinical deterioration," significant differences occurred neither in the 2 respective deterioration rates (risperidone = 9%/23%; haloperidol = 8%/22%) nor in time until deterioration. Both antipsychotics were equally effective regarding significant symptom reduction and improvement in quality of life. Extrapyramidal symptoms were slightly higher with haloperidol. The overall dropout rate of 68%, however, was not significantly different between the 2 drug groups.

CONCLUSION

Against the background of an overall favorable outcome, the hypothesized difference between risperidone and low-dose haloperidol regarding relapse prevention could not be supported for this sample of patients with first-episode schizophrenia. Possible design-related reasons for this finding are discussed. With regard to the high dropout rate, special programs are needed to keep schizophrenia patients who are in their early acute and postacute illness course in effective and safe treatment.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov identifier: NCT00159081.

The German Research Network on Schizophrenia--impact on the management of schizophrenia

The German Research Network On Schizophrenia (GRNS) is a nationwide network currently comprising 16 psychiatric university departments and 14 state and district hospitals, as well as six local networks of psychiatric practices and general practitioners collaborating on about 25 interrelated, multicenter projects on schizophrenia research. The GRNS aims to intensify collaboration and knowledge exchange betvi/een leading research institutions and qualified routine care facilities, both within (horizontal network) and between (vertical network) the two levels of research and care, in order to create the scientific preconditions for optimization of the management of schizophrenia. The concept and the first results of studies aiming at the investigation of(i) strategies for early detection and early intervention in the prodromal stage of psychosis; (ii) treatment in first-episode schizophrenia; (iii) quality management; and (iv) destigmatization, are described as examples of this effort.

The German Research Network on Schizophrenia--impact on the management of schizophrenia

The German Research Network On Schizophrenia (GRNS) is a nationwide network currently comprising 16 psychiatric university departments and 14 state and district hospitals, as well as six local networks of psychiatric practices and general practitioners collaborating on about 25 interrelated, multicenter projects on schizophrenia research. The GRNS aims to intensify collaboration and knowledge exchange between leading research institutions and qualified routine care facilities, both within (horizontal network) and between (vertical network) the two levels of research and care, in order to create the scientific preconditions for optimization of the management of schizophrenia. The concept and the first results of studies aiming at the investigation of (i) strategies for early detection and early intervention in the prodromal stage of psychosis; (ii) treatment in first-episode schizophrenia; (iii) quality management; and (iv) destigmatization, are described as examples of this effort.

Remediation of impairments in facial affect recognition in schizophrenia: efficacy and specificity of a new training program

OBJECTIVE

Schizophrenia patients often exhibit impairments in facial affect recognition which contribute to their poor social functioning. These impairments are stable in the course of the disorder and seem not to be affected by conventional treatment. The present study investigates the efficacy and specificity of a new training program for the remediation of such impairments.

METHOD

A newly developed training program tackling affect recognition (TAR) was compared with a cognitive remediation training program (CRT) and treatment as usual (TAU) within a randomized three group pre-post design in n=77 post-acute schizophrenia patients. The TAR is a computer-aided 12-session program focussing on facial affect recognition, whereas the CRT aims to improve attention, memory and executive functioning. Facial affect recognition, face recognition, and neurocognitive performance were assessed before (T0) and after (T1) the six week training phase. During the training period all patients received antipsychotic medication.

RESULTS

Patients under TAR significantly improved in facial affect recognition, with recognition performance after training approaching the level of healthy controls from former studies. Patients under CRT and those without special training (TAU) did not improve in affect recognition, though patients under CRT improved in verbal memory functions.

CONCLUSION

According to these results, remediation of disturbed facial affect recognition in schizophrenia patients is possible, but not achievable with a traditional cognitive rehabilitation program such as the CRT. Instead, functional specialized remediation programs such as the newly developed TAR are a more suitable option.

[A telephone hotline as an easily accessible service for questions on schizophrenia]

Public relations activities of the German Research Network on Schizophrenia (GRNS) have shown that there is a demand for more information about schizophrenia disorder. This confirms international research findings that relatives of schizophrenia patients are particularly in need of information and support. In response, the GRNS has maintained a telephone hotline since 2001. The hotline is manned by clinical experts, psychiatrists, or psychologists once a week. The telephone calls are documented in a systematic manner. From 2001 to 2003, 3,909 calls were registered. This volume exceeds the limit of the hotline's resources. The telephone hotline is mainly used by relatives of psychotic patients. Most questions relate to the symptoms of schizophrenia and pharmaceutical treatment. The need for emotional support is also a high motivational factor for dialing the hotline number. The telephone hotline seems to be a worthwhile addition to the already existing crisis telephones and should be maintained even after public funding of the network expires.

Facial expressivity in the course of schizophrenia and depression

This study investigates the nosological specificity and time stability of reduced facial expressivity in schizophrenia by means of objective measurement. Facial expression in an emotional interview was evaluated using the "Facial Action Coding System" in 33 acute schizophrenia patients and 23 acute depressive patients in comparison with 21 nonpatient controls, each assessed twice within 4 weeks, and in 36 partly remitted schizophrenia patients assessed twice within 3 months. Acute schizophrenia patients showed reduced facial activity especially in the upper face and in facial activity often used as communicative signs or as signs of positive emotions. As depressive patients showed a comparable pattern of facial activity, nosological specificity is questionable. This pattern remained stable in the acute illness course and was almost identical in remitted schizophrenia patients, indicating a marked time stability of attenuated facial expressivity in schizophrenia and--for the acute phase assessed--in depression.

Pharmacological long-term treatment strategies in first episode schizophrenia--study design and preliminary results of an ongoing RCT within the German Research Network on Schizophrenia

In first-episode schizophrenia the advantage of new atypical neuroleptics compared to low-dose haloperidol as well as the indicated duration of neuroleptic maintenance treatment has still to be based on empirical evidence. Accordingly, a multi-center study on the optimization of acute and long-term treatment in first-episode schizophrenia is currently being carried out as part of the German Research Network on Schizophrenia. This paper reports on the design, methods and preliminary results of the two-year randomized double-blind study comparing risperidone and low-dose haloperidol within the framework of psychological interventions. In the second treatment year, relapse rates under continued neuroleptic treatment are compared with those under stepwise drug withdrawal substituting instead prodrome-based early intervention (intermittent treatment). As to the results, by November 2003 142 first episode patients (ICD-10 F20) have been included in the long-term study. One-year relapse rates were very low (3.8 %). On average, symptoms as well as drug side-effects decreased steadily under maintenance treatment. Although compliance on average was high, about 60% of the patients dropped out during the first study year. More pronounced psychopathology, (neurological) side-effects, lower compliance at study entry and absence of psychological treatment seemed to enhance the risk for drop-out. In conclusion, treatment in first episode schizophrenia is effective under both (further on blinded) neuroleptics; however these patients are at high risk for treatment drop-out. This emphasizes the need for a special support program.

Early detection and secondary prevention of psychosis: facts and visions

As effective and practical approaches to primary and universal prevention of psychosis are lacking, intervention efforts are targeted at the early stages of schizophrenia to prevent (by way of secondary prevention) or postpone psychosis onset, reduce severity of illness or at least ameliorate the social consequences involved. Early intervention requires early detection and early recognition (diagnosis) of persons at risk and early prediction of psychosis. Within the German Research Network on Schizophrenia (GRNS) awareness programmes are being carried out in several German cities, and these efforts are already improving utilisation of early-recognition and early-prediction services by at risk persons. The empirical basis of developing a two-step early-recognition inventory and strategies of application will be discussed. This instrument is supplemented by a set of cognitive tests, prospectively validated in the GRNS. Results from preliminary analysis of data covering a two-year period demonstrate that the inventory and the cognitive tests are readily accepted. When used for screening in non-specialist settings and at the next level, i. e. at early-recognition centres, they seem to permit identification of at-risk persons. Early intervention is being tested 1) in a randomised controlled multi-centre trial consisting of a specially developed cognitive-behavioural therapy in the early (prepsychotic) prodromal state and 2) on additional treatment with appropriate doses of amisulpride in the late prodromal (early psychotic) state. Preliminary data from Study 1 covering 16.3 months show significantly fewer transitions to psychosis and from Study 2 reduced positive and negative symptoms and improved global functioning compared with controls who had received normal clinical treatment. As a result, both the early-recognition inventory plus cognitive tests and the two therapy strategies are feasible. We hope that the favourable trend indicated by the preliminary data will be confirmed in the final analysis planned for 2005 and the objective of implementing effective and practical secondary prevention of psychosis and its consequences will be attained.

German research network on schizophrenia-bridging the gap between research and care

The German Research Network on Schizophrenia (GRNS) is a nationwide network of presently 16 psychiatric university departments, 14 state and district hospitals, as well as six local networks of psychiatric practices and general practitioners, which are collaborating in about 25 interrelated, multicentre projects on schizophrenia research. The GRNS aims to intensify collaboration and knowledge exchange between leading research institutions and qualified routine care facilities, both within (horizontal network) and between (vertical network) the two levels of research and care, in order to create the scientific preconditions for optimization of care in patients with schizophrenia. With respect to illness development, the network is organized into two main "Project Networks" (PN). Whereas PN I targets the implementation of early detection and early intervention strategies, PN II aims at optimization of acute and long-term treatment, especially in first-episode patients. PN II also includes projects aiming at improvement of rehabilitation, particularly in patients with residual symptoms. Furthermore, there is a "Special Network" on molecular and pharmaco-genetics. Several more general projects address fighting stigma and discrimination, health care economy, continuing medical education, quality assurance, and methodology. The network is mainly funded by the German Ministry for Research spanning a period of 5 years.

Trait characteristic of impaired visuomotor integration during Trail-Making Test B performance in schizophrenia

Using concurrent recording of eye and hand movements during the performance of the Trail-Making Test B (TMT-B), Wölwer and Gaebel have recently reported impaired visuomotor integration in patients with acute schizophrenia, which mainly accounted for patients' poor test performance. In order to replicate these exploratory findings in an independent sample of patients and to further investigate their stability during different stages of the illness, the performance process during a computerized TMT-B was assessed in 22 remitted outpatients with schizophrenia, 12 unaffected first-degree relatives and 26 healthy controls. As an estimate of longitudinal stability, a partial sample of 12 patients and 19 controls was reassessed after a period of 3 months. Remitted schizophrenia patients showed exactly the same strategic problems during the performance process of TMT-B as previously found in acute patients. Compared with healthy controls, patients more often sequenced searching ('planning') and connecting targets instead of time-sparing parallel execution, and their planning periods contained more and longer planning fixations (i.e. fixations outside the cursor area), which was related to longer performance time. Unaffected relatives mostly scored between patients and healthy controls without statistically significant differences to either group. Thus, the abnormalities in the process of TMT-B performance proved to be reliable and stable trait characteristics in schizophrenia.

Impaired visuomotor integration in acute schizophrenia

Based on the interaction of eye and hand movements a comprehensive index summarizing schizophrenia patients' difficulties during the performance process in Trail-Making Test-B (TMT-B) was developed. The process of TMT-B performance was modelled as a sequence of planning, acting and resting periods in 23 inpatients with acute schizophrenia, 17 inpatients with acute depression and 21 non-psychiatric controls, each assessed at least twice within four weeks. Transition probabilities between these states were calculated and structured by factor analysis. Throughout their hospital stay schizophrenia patients scored significantly lower than non-patients on a derived "visuo-manumotor integration factor", characterized by high loadings of transitions between planning and acting periods. A significant negative correlation of this factor with performance time revealed frequent alternations between these two states and thus high factor scores to be a prerequisite for good TMT-B performance. No relationship of factor scores with psychopathology and medication could be found. Depressive patients differed neither from non-patients nor from schizophrenia patients during the acute phase of the illness, but scored significantly higher than schizophrenia patients shortly before discharge. Accordingly, poorer TMT-B performance in schizophrenia patients seems related to impaired planning strategies, which might be a nosologically specific, trait-like characteristic, probably related to neural dysfunctions involving the prefrontal cortex.

Time course of regional brain activations during facial emotion recognition in humans

Recognition of facial expressions of emotions is very important for communication and social cognition. Neuroimaging studies showed that numerous brain regions participate in this complex function. To study spatiotemporal aspects of the neural representation of facial emotion recognition we recorded neuromagnetic activity in 12 healthy individuals by means of a whole head magnetoencephalography system. Source reconstructions revealed that several cortical and subcortical brain regions produced strong neural activity in response to emotional faces at latencies between 100 and 360 ms that were much stronger than those to neutral as well as to blurred faces. Orbitofrontal cortex and amygdala showed affect-related activity at short latencies already within 180 ms after stimulus onset. Some of the emotion-responsive regions were repeatedly activated during the stimulus presentation period pointing to the assumption that these reactivations represent indicators of a distributed interacting circuitry.

Remediation of facial affect recognition impairments in patients with schizophrenia: a new training program

Impairments in facial affect recognition are trait-like characteristics in schizophrenia and might contribute to poor social functioning. A special Training of Affect Recognition program was developed, which shows a good feasibility and promising treatment effects. The specificity of these effects can now be demonstrated in a control group design.

Impaired Trail-Making Test-B performance in patients with acute schizophrenia is related to inefficient sequencing of planning and acting

In order to investigate the functional basis of the frequently described deficits of schizophrenia patients in Trail Making Test B (TMT-B) performance, the performance process was analyzed based on the interaction of eye and hand movements. In a longitudinal design, 23 acute schizophrenia patients, 17 acute depressive inpatients, and 21 healthy controls were assessed twice within 4 weeks. Computer versions of both TMT-A and TMT-B were used, which require to connect different targets with a cursor, with concurrent infrared oculography. In both TMT-versions, schizophrenia patients demonstrated poorer performance and longer "planning periods"--as defined by fixations outside the cursor area--containing more fixations, which were stable over time. However, these "planning fixations" were only also longer in duration during TMT-B and differed in time and context of their occurrence compared with healthy controls. Schizophrenia patients demonstrated more fixations while the cursor rested between targets. Significant correlations with performance time gave evidence that it is important for short planning periods to be performed parallel to ongoing connection of targets, to obtain a satisfactory result. No relationship between "planning variables" with psychopathology and medication could be found. Accordingly, poorer TMT-B performance in schizophrenia patients was found to be related to insufficient sequencing of planning and acting, which appears to be a trait-like characteristic. Though depressive patients also performed poorer in TMT-B, they did not differ from either of the other groups in the main process variables, which may hint to different underlying causes of the performance deficits in both groups of patients.

Out-patient behaviour therapy in alcoholism: treatment outcome after 2 years

OBJECTIVE

The main aim of the study was the evaluation of out-patient behavioural approaches in alcohol dependence. Additionally, the persistence of treatment effects and the impact of psychiatric comorbidity in long-term follow-up was examined.

METHOD

A total of 120 patients were randomly assigned to non-specific supportive therapy or to two different behavioural therapy programmes (coping skills training and cognitive therapy) each comprising 26 weekly sessions; the follow-up period lasted 2 years.

RESULTS

Patients undergoing behavioural therapy showed a consistent trend towards higher abstinence rates; significant differences between the two behavioural strategies could not be established. Moreover, the results indicate a reduced ability of cognitive impaired patients to cope with short-time abstinence violations and at a reduced benefit from behavioural techniques for patients with severe personality disorders.

CONCLUSION

Behavioural treatment yielded long-lasting effects and met high acceptance; yet, still in need of improvement is the development of specific programmes for high-risk patients.

[Outpatient behavioural treatment in alcoholism: alcohol consumption and sociodemographic factors]

In spite of the increasing interest in outpatient treatment programmes for alcohol dependents, there still exist only a few experimental studies on this issue. Moreover, the interaction between abstinence and sociodemographic factors has been only rarely explored. In this study, the efficiency of different behaviour therapy strategies was examined: 120 patients were randomly assigned to nonspecific supportive therapy or to 2 forms of behavioural therapy (coping skills training and cognitive therapy). Behavioural treatment comprised 26 weekly sessions; follow-up examinations took place every 6 months over 2 years. Patients undergoing behavioural therapy showed less drop outs and significantly higher rates of abstinence and also of reemployment and satisfaction with their job situation compared to those under supportive treatment. At the same time, the employment status proved to be a valid predictor of treatment success, whereas there was only a weak (negative) impact of an existing partnership on abstinence. Statistically significant differences between the 2 behavioural therapy strategies could be established in neither respect.

Disturbed facial affect recognition in patients with schizophrenia associated with hypoactivity in distributed brain regions: a magnetoencephalographic study

OBJECTIVE

The authors sought to identify brain mechanisms underlying the well-documented facial affect recognition deficit in patients with schizophrenia. Since this deficit is stable over the course of the illness and relatively specific for schizophrenic disorders, it was expected that knowledge about the related brain mechanisms would provide substantial information about the pathophysiology of the illness.

METHOD

Fifteen partly remitted schizophrenic inpatients and 12 healthy volunteers categorized facial expressions of emotion and performed two control tasks while magnetoencephalographic recordings were done by means of a 148-channel whole head system, which revealed foci of high cerebral activity and their evolution in time. Anatomical sites were defined through coregistrated magnetic resonance images.

RESULTS

The magnetoencephalography data recorded in response to facial expressions of emotion revealed that patients generated weaker activations (primary current density) in inferior prefrontal, temporal, occipital, and inferior parietal areas at circumscribed latencies. Group differences did not occur in basic visual areas during a first sensory-related activation between 60 and 120 msec. Behavioral performance was associated with strength of activation in inferior prefrontal areas, the right posterior fusiform gyrus region, right anterior temporal cortex, and the right inferior parietal cortex.

CONCLUSIONS

Disturbed facial affect recognition in schizophrenic patients might be a result of hypoactivity in distributed brain regions, some of them previously related to the pathophysiology of schizophrenic disorders. These regions are probably working within a spatially and temporally defined circuitry.

EEG-correlates of facial affect recognition and categorisation of blurred faces in schizophrenic patients and healthy volunteers

The ability to recognise emotional expressions of faces and the ability to categorise blurred and non-blurred faces and complex objects was tested in 16 schizophrenic in-patients and 16 healthy volunteers. EEGs were recorded during performance of the tasks and event-related potentials were compared between groups. Patients performed worse than healthy volunteers in recognition of facial affect but not in categorisation of blurred faces. Furthermore, within a 180-250ms latency range patients showed reduced amplitudes during affect recognition compared with controls but not during categorisation of blurred faces. Amplitudes recorded at frontal electrode sites were associated with performance in facial affect recognition. These results provide a first clue to the neurophysiological basis of the widely reported facial affect recognition deficit in schizophrenic patients.

Out-patient behaviour therapy in alcoholism: impact of personality disorders and cognitive impairments

OBJECTIVE

We investigated whether alcoholic patients with comorbid personality disorders and those with cognitive impairments would benefit in a different way from different behaviour therapy strategies.

METHOD

After detoxification, 120 alcoholics were assigned randomly to one of three out-patient treatment programmes comprising 'coping skills training', 'cognitive behaviour therapy' or unspecific supportive control therapy. Personality disorders and cognitive impairments were assessed at the beginning of the 6-month treatment period.

RESULTS

The impact of concomitant personality disorders or cognitive impairments was generally only moderate and mainly independent from treatment condition. However, alcoholic patients relapsing within 6 months after detoxification showed a higher rate of personality disorders (especially antisocial and borderline) and slightly more cognitive deficits (especially in verbal memory and visuomotor functions) than abstainers even before therapy.

CONCLUSION

The high amount of early relapses and drop-outs probably hindered larger differentiated treatment effects. Hypotheses will be retested in treatment completers using forthcoming follow-up data.