UCSD Performance-Based Skills Assessment: development of a new measure of everyday functioning for severely mentally ill adults

Effect of Action-Based Cognitive Remediation on cognitive impairment in patients with remitted bipolar disorder: A randomized controlled trial

OBJECTIVES

Cognitive impairment affects many patients with bipolar disorder (BD), and treatments with replicated pro-cognitive effects are lacking. This study aimed to assess the effect of Action-Based Cognitive Remediation (ABCR) vs control treatment on cognitive impairment in patients with BD.

METHODS

Patients with remitted BD with objective cognitive impairment were randomized to 10 weeks of ABCR vs control treatment, and assessed at baseline, after 2 weeks of treatment, at treatment completion and at 6 months follow-up. The primary outcome was a cognitive composite score. Secondary outcomes were executive function and observer-rated functional capacity. Tertiary measures included additional neuropsychological tests, performance-based functional capacity and quality of life. Data were analysed with linear mixed effects models.

RESULTS

In total, 64 participants were randomized; given three dropouts before the baseline assessments, data were analysed for 61 participants (ABCR: n = 32, control: n = 29). There was no effect on ABCR vs control on the primary cognitive composite score (P-values ≥.60). At treatment completion, there was a large effect of ABCR vs control on the secondary executive function measure (treatment effect= -0.16, 95% CI [-0.27, -0.05], P ≤ .01, d = 0.65), and on subjective cognitive functioning (treatment effect = -5.38, 95% CI [-8.13, -2.67], P ≤ .001, d = 0.80), which disappeared at follow-up. There was no treatment-effect on functioning, and no association between cognitive and functional change.

CONCLUSIONS

There was no effect of ABCR on the cognitive composite score. However, there was an effect on executive function and subjective cognitive functioning suggesting that ABCR may be relevant for patients with executive dysfunction.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03295305.

Virtual Reality Functional Capacity Assessment Tool (VRFCAT-SL) in Parkinson's Disease

Background:

Cognitive impairment is common in Parkinson’s disease (PD) and highly associated with loss of independence, caregiver burden, and assisted living placement. The need for cognitive functional capacity tools validated for use in PD clinical and research applications has thus been emphasized in the literature. The Virtual Reality Functional Capacity Assessment Tool (VRFCAT-SL) is a tablet-based instrument that assesses proficiency for performing real world tasks in a highly realistic environment.

Objective:

The present study explored application of the VRFCAT-SL in clinical assessments of patients with PD. Specifically, we examined associations between VRFCAT-SL performance and measures of cognition, motor severity, and self-reported cognitive functioning.

Methods:

The VRFCAT-SL was completed by a sample of 29 PD patients seen in clinic for a comprehensive neuropsychological evaluation. Fifteen patients met Movement Disorders Society Task Force criteria for mild cognitive impairment (PD-MCI); no patients were diagnosed with dementia. Non-parametric correlations between VRFCAT-SL performance and standardized neuropsychological tests and clinical measures were examined.

Results:

VRFCAT-SL performance was moderately associated with global rank on neuropsychological testing and discriminated PD-MCI. Follow-up analyses found completion time was associated with visual memory, sustained attention, and set-switching, while errors were associated with psychomotor inhibition. No clinical or motor measures were associated with VRFCAT-SL performance. Self-report was not associated with VRFCAT-SL or neuropsychological test performance.

Conclusion:

The VRFCAT-SL appears to provide a useful measure of cognitive functional capacity that is not confounded by PD motor symptoms. Future studies will examine utility in PD dementia.

Development of novel measures for Alzheimer's disease prevention trials (NoMAD)

INTRODUCTION

Assessment of cognition and everyday function is essential in clinical trials for Alzheimer's disease (AD). Two novel measures of cognition (No Practice Effects (NPE) cognitive battery and Miami Computerized Functional Assessment Scale (CFAS)) were designed to have robust psychometric properties and reduced practice and ceiling effects. This study aims to evaluate if the NPE and CFAS demonstrate stronger psychometric properties and reduced practice effects compared with established measures, including the Preclinical Alzheimer Cognitive Composite (PACC), Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), and Functional Activities Questionnaire (FAQ).

METHODS

This parallel group, four-site study will randomize 320 cognitively intact adults aged 60 to 85 years to novel or well-established measures of cognition and function. All participants will receive assessments at baseline (week 0), 3-months, and 12-months, as well as a brain MRI scan and Apolipoprotein E genetic test at study entry. Analyses will determine psychometric properties of the NPE and CFAS, compare the sensitivity of measures to AD risk markers, and identify cognitive domains within the NPE.

DISCUSSION

Practice effects have been a major limitation of Alzheimer's disease clinical trials that typically assess cognitive changes over serial assessments. Detection of functional impairment in cognitively normal individuals with biomarkers for Alzheimer's disease requires instruments sensitive to very subtle functional changes. This study is intended to support the validation of two new composite measures, the NPE battery and the CFAS, which may advance clinical testing of interventions for individuals across the spectrum of early stage Alzheimer's disease.

TRIAL REGISTRATION

NCT03900273.

Drug development for Autism Spectrum Disorder (ASD): Progress, challenges, and future directions

In 2017, facing lack of progress and failures encountered in targeted drug development for Autism Spectrum Disorder (ASD) and related neurodevelopmental disorders, the ISCTM with the ECNP created the ASD Working Group charged to identify barriers to progress and recommending research strategies for the field to gain traction. Working Group international academic, regulatory and industry representatives held multiple in-person meetings, teleconferences, and subgroup communications to gather a wide range of perspectives on lessons learned from extant studies, current challenges, and paths for fundamental advances in ASD therapeutics. This overview delineates the barriers identified, and outlines major goals for next generation biomedical intervention development in ASD. Current challenges for ASD research are many: heterogeneity, lack of validated biomarkers, need for improved endpoints, prioritizing molecular targets, comorbidities, and more. The Working Group emphasized cautious but unwavering optimism for therapeutic progress for ASD core features given advances in the basic neuroscience of ASD and related disorders. Leveraging genetic data, intermediate phenotypes, digital phenotyping, big database discovery, refined endpoints, and earlier intervention, the prospects for breakthrough treatments are substantial. Recommendations include new priorities for expanded research funding to overcome challenges in translational clinical ASD therapeutic research.

Building clinically relevant outcomes across the Alzheimer's disease spectrum

Demonstrating that treatments are clinically meaningful across the Alzheimer's disease (AD) continuum is critical for meeting our goals of accelerating a cure by 2025. While this topic has been a focus of several Alzheimer's Association Research Roundtable (AARR) meetings, there remains no consensus as to what constitutes a "clinically meaningful outcome" in the eyes of patients, clinicians, care partners, policymakers, payers, and regulatory bodies. Furthermore, the field has not come to agreement as to what constitutes a clinically meaningful treatment effect at each stage of disease severity. The AARR meeting on November 19-20, 2019, reviewed current approaches to defining clinical meaningfulness from various perspectives including those of patients and care partners, clinicians, regulators, health economists, and public policymakers. Participants discussed approaches that may confer clinical relevance at each stage of the disease continuum and fostered discussion about what should guide us in the future.

Evidence for avolition in bipolar disorder? A 30-day ecological momentary assessment comparison of daily activities in bipolar disorder and schizophrenia

OBJECTIVES

Disability is common in bipolar disorder (BD) and predicted by persistent sadness. We used ecological momentary assessment (EMA) to examine daily activities in people with BD and schizophrenia. We classified activities as productive, unproductive, or passive recreation, relating them to momentary sadness, location, and social context.

METHODS

71 people with BD and 102 people with schizophrenia were sampled 3 times/day for 30 days with an EMA survey. Each survey asked where they were, with whom, what they were doing, and if they were sad.

RESULTS

People with BD were home more than 50% of the time. There were no differences in prevalence of activity types across diagnoses. People with BD were less likely to report only one activity since the prior survey, but the most surveys still reported only one. For both groups, sadness and being home and alone since the last survey was associated with less productive activity and more passive recreation.

CONCLUSIONS

Participants with BD and schizophrenia manifested high levels of unproductive and passive activities, predicted by momentary sadness. These activity patterns are consistent with descriptions of avolition and they minimally differentiated people with BD and schizophrenia. Previous reports of negative symptoms in BD may have been identifying these behaviors.

How well do people living with neurodegenerative diseases manage their finances? A meta-analysis and systematic review on the capacity to make financial decisions in people living with neurodegenerative diseases

Self and proxy reported questionnaires indicate that people living with a neurodegenerative disease (NDD) have more difficulties with financial decision-making (FDM) than healthy controls. Self-reports, however, rely on adequate insight into everyday functioning and might, therefore, be less reliable. The present study provides a comprehensive overview and meta-analysis of studies evaluating FDM in people living with an NDD. For this, the reliability of performance-based tests to consistently identify FDM difficulties in people living with an NDD compared to healthy controls is evaluated. Furthermore, the associations between FDM and disease severity, performances on standard measures of cognition and demographics are evaluated. All 47 included articles, consistently reported lower performances on performance-based FDM tests of people living with an NDD (including Alzheimer's disease, mild cognitive impairment, frontotemporal dementia, Parkinson's disease, multiple sclerosis or Huntington's disease) compared to healthy controls. The majority of studies, however, focused on Alzheimer's disease and mild cognitive impairment (k = 38). FDM performance appears to be related to cognitive decline, specifically in working memory, processing speed and numeracy.

REM Sleep Behavior Disorder in Parkinson's Disease: Change in Cognitive, Psychiatric, and Functional Outcomes from Baseline to 16-47-Month Follow-Up

OBJECTIVE

Rapid Eye Movement Sleep Behavior Disorder (RBD) is common in Parkinson's Disease (PD) and is associated with cognitive impairment; however, the majority of the evidence on the impact of RBD on multidomain cognitive batteries in PD is cross-sectional. This study evaluated the longitudinal impact of probable RBD (pRBD) on cognitive, psychiatric, and functional outcomes in people with PD.

METHOD

Case-control study. A total of 65 people with PD completed the study protocol at baseline and 16-to-47-month follow-up. Participants were classified as pRBD+ (n = 25) or pRBD- (n = 40) based on an established cutoff of 6 on the RBD Sleep Questionnaire (RBDSQ). Participants also completed a) comprehensive cognitive testing, b) self-report measures of depression, anxiety, and apathy, and c) performance-based and other-report forms of instrumental activities of daily living.

RESULTS

Baseline mean age was 67.8 (SD = 8.1; range = 45-86) and baseline mean years of education was 16.4 (SD = 2.1; range = 12-20). The two groups did not differ on measured demographic characteristics. Baseline mean T-scores for cognitive tests were in the average range (46-55). Hierarchical linear models tested group differences in cognitive and functional decline from baseline to follow-up, controlling for appropriate demographic and psychiatric variables. Compared to the pRBD- group, pRBD+ participants showed greater decline in attention/working memory (r = -0.31; p = 0.01) and UPSA financial skills (r = -0.31; p = 0.01). No other group differences approached significance.

CONCLUSIONS

RBD may differentially affect attention/working memory and financial abilities in PD. Results underscore the importance of regular RBD screening in older adults with PD in order to triage symptomatic patients to appropriate cognitive and medical interventions.

Neural correlates of daily function: A pilot study of the white matter retrogenesis hypothesis and three separate performance-based functional assessments

OBJECTIVE

Increasing evidence points to mild alterations in everyday functioning early in the course of Alzheimer's disease and related dementias (ADRD), despite prior research suggesting functional declines occur primarily in later stages. However, daily function assessment is typically accomplished with subjective self- or informant-report, which can be prone to error due to various factors. Performance-based functional assessments (PBFAs) allow for objective evaluation of daily function abilities, but little is known on their sensitivity to the earliest ADRD-related brain alterations. We aimed to determine the neural correlates of three different PBFAs in a pilot study.

METHOD

A total of 40 older participants (age = 70.9 ± 6.5 years; education = 17.0 ± 2.6 years; 51.5% female; 10.0% non-White; 67.5% cognitively normal) completed standardized PBFAs related to medication management (MM), finances (FIN), and communication abilities (COM). Participants underwent diffusion tensor imaging (DTI) scans, from which mean fractional anisotropy (FA) composite scores of late- (LMF) and early myelinated (EMF) fibers were calculated. Linear regression analyses controlling for age and global cognition were used to assess the relationship of PBFAs with FA.

RESULTS

Better performance on MM was associated with higher mean FA on LMF composite (t38 = 2.231, p = .032), while FIN and COM were not (ps > .05). PBFAs were not associated with EMF (p > .05).

CONCLUSIONS

Our preliminary findings demonstrate better performance on a PBFA of medication management is associated with higher FA in late-myelinated white matter tracts. Despite a small sample size, these results are consistent with growing evidence that performance-based functional assessments may be a useful tool in identifying early changes related to ADRD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The functional significance of cognitive empathy and theory of mind in early and chronic schizophrenia

Theoretical models suggest that it is the interplay between social cognitive processes that result in adaptive social functioning in schizophrenia. This study explored the relative contributions of, and interplay between, cognitive empathy, affective theory of mind (ToM), neurocognition, and severity of clinical symptoms, in predicting the social functioning of individuals with schizophrenia. Clinical participants (early schizophrenia n = 26, chronic schizophrenia n = 32) were administered an ecologically valid measure of ToM (viz., the Virtual Assessment of Mentalising Ability or VAMA) and the Empathy Quotient (EQ) as part of a larger neuropsychological and social functioning assessment battery. Results indicated that individuals with early schizophrenia reported significantly better cognitive empathy than individuals with chronic schizophrenia. ToM was found to have added value in predicting both community functioning and functional capacity that was beyond that accounted for by cognitive empathy, clinical symptoms, and neurocognition for both clinical groups. Further, our results indicated that the capacity to demonstrate empathic understanding of another's situation (i.e., cognitive empathy) mediates the relationship between ToM and social functioning. Together, our findings highlight the intricate and compounding nature of social cognition constructs, and their effect on social functioning for individuals with schizophrenia.

Predicting response to cognitive training for schizophrenia using results from two studies with different outcomes

BACKGROUND

Collaborative data sharing between research groups provides an opportunity to explore the basis for the heterogeneity in cognitive training outcomes reported in the schizophrenia literature. The current analyses focused on the contribution of site and participant characteristics to these heterogeneous outcomes.

METHODS

Data from two independent studies, from New York (NY) and Los Angeles (LA), were combined to yield a sample of 132 outpatient adults with schizophrenia/schizoaffective disorder. While similar treatment doses, cognitive exercises and outcome measures were used, sites differed in use of coaching, group discussion and compensation. Between-site differences in participant demographic and baseline clinical characteristics were tested. Regression examined predictors of change in cognition (MCCB) and functional capacity (UPSA) which could explain site differences in treatment effects.

RESULTS

Medium to large treatment effect size differences in MCCB and UPSA favored the NY site over LA. When the studies were combined, the effect of site was significant for both outcomes with a medium effect size difference. After controlling for background characteristics, the effect of site was reduced for both outcomes, but remained significant for cognition. Improvement in UPSA was associated with better baseline MCCB (p < 0.001), lower baseline UPSA (p < 0.001) and younger age (p = 0.019). The overall model with site, baseline scores, and participant background characteristics explained about 30% to 40% of the variance in outcomes.

DISCUSSION

Participant and treatment characteristics are both predictive of outcomes, but treatment characteristics may be more consequential to cognitive gain, while participant characteristics may be more consequential to change in functional capacity.

The Computerized Functional Skills Assessment and Training Program: Sensitivity to Global Cognitive Impairment, Correlations With Cognitive Abilities, and Factor Structure

OBJECTIVES

We evaluated a novel computer-based functional skills assessment and training (CFSAT) program, which includes ecologically valid simulations of six everyday technology-related tasks. In this report, we describe the psychometric properties of the assessment in terms of sensitivity to impairment, factor structure and correlations with cognitive performance.

DESIGN

Cross-sectional baseline assessment prior to a treatment study.

PARTICIPANTS

Noncognitively impaired older adults (n = 62) and cognitively impaired older adults (n = 55), that ranged in age from 60 to 86 years (M = 73.12), was primarily female (90%), and ethnically diverse (21% Hispanic, 52% African American). Participants were divided at baseline on the basis of MOCA scores and cognitive complaints.

MEASUREMENTS

The Brief Assessment of Cognition (BAC), app version, was used to measure cognitive performance and completion times on the six subtasks of the CFAST constituted the functional capacity measures.

RESULTS

Performance on the CFSAT and BAC discriminated the two cognitive status groups. All of the cognitive domains on the BAC correlated significantly with all six CFSAT subtasks (all p < .01). Factor analyses suggested that the CFSAT and the BAC loaded on separate factors and regression analyses indicated that executive functioning and processing speed had the largest independent association with performance on the CFSAT.

CONCLUSION

The CFSAT is sensitive to functional impairments seen in cognitively impaired older adults. Cognitive performance and CFSAT scores were related but nonredundant. Thus, the CFSAT appears to identify functional deficits that could be targeted with skills training interventions, likely augmented by pharmacological or computerized cognitive training interventions.

Cognitive remediation therapy for patients with bipolar disorder: A randomised proof-of-concept trial

OBJECTIVES

Cognitive remediation therapy (CRT) may benefit people with bipolar disorder type I and II for whom cognitive impairment is a major contributor to disability. Extensive research has demonstrated CRT to improve cognition and psychosocial functioning in people with different diagnoses, but randomised trials of evidenced therapy programmes are lacking for bipolar disorders. The Cognitive Remediation in Bipolar (CRiB) study aimed to determine whether an established CRT programme is feasible and acceptable for people with bipolar disorders.

METHODS

This proof-of-concept, single-blind randomised trial recruited participants aged 18-65 with bipolar disorder, not currently experiencing an episode. They were 1:1 block randomised to treatment-as-usual (TAU) with or without individual CRT for 12 weeks. The partly computerised CRT programme ("CIRCuiTS") was therapist-led and is evidence-based from trials in those with psychotic illnesses. Data were collected and analysed by investigators blinded to group allocation. The main outcomes (week 13 and 25) examined participant retention, intervention feasibility and putative effects of CRT on cognitive and psychosocial functioning via intention-to-treat analyses.

TRIAL REGISTRATION

ISRCTN ID32290525.

RESULTS

Sixty participants were recruited (02/2016-06/2018) and randomised to CRT (n = 29) or TAU (n = 31). Trial withdrawals were equivalent (CRT n = 2/29; TAU n = 5/31). CRT satisfaction indicated high acceptability. Intention-to-treat analyses (N = 60) demonstrated greater improvements for CRT- than TAU-randomised participants: at both week 13 and 25, CIRCuiTS participants showed larger improvements in the following domains (week 25 effect sizes reported here): IQ (SES = 0.71, 95% CI [0.29,1.13]), working memory (SES = 0.70, 95% CI [0.31,1.10]), executive function (SES = 0.93, 95% CI [0.33,1.54]), psychosocial functioning (SES = 0.49, 95% CI [0.18,0.80]) and goal attainment (SES = 2.02, 95% CI [0.89,3.14]). No serious adverse events were reported.

CONCLUSIONS

CRT is feasible for individuals with bipolar disorders and may enhance cognition and functioning. The reported effect sizes from this proof-of-concept trial encourage further investigation in a definitive trial.

Aerobic endurance training to improve cognition and enhance recovery in schizophrenia: design and methodology of a multicenter randomized controlled trial

Even today, patients with schizophrenia often have an unfavorable outcome. Negative symptoms and cognitive deficits are common features in many patients and prevent recovery. In recent years, aerobic endurance training has emerged as a therapeutic approach with positive effects on several domains of patients' health. However, appropriately sized, multicenter randomized controlled trials that would allow better generalization of results are lacking. The exercise study presented here is a multicenter, rater-blind, two-armed, parallel-group randomized clinical trial in patients with clinically stable schizophrenia being conducted at five German tertiary hospitals. The intervention group performs aerobic endurance training on bicycle ergometers three times per week for 40-50 min/session (depending on the intervention week) for a total of 26 weeks, and the control group performs balance and tone training for the same amount of time. Participants are subsequently followed up for 26 weeks. The primary endpoint is all-cause discontinuation; secondary endpoints include psychopathology, cognition, daily functioning, cardiovascular risk factors, and explorative biological measures regarding the underlying mechanisms of exercise. A total of 180 patients will be randomized. With currently 162 randomized participants, our study is the largest trial to date to investigate endurance training in patients with schizophrenia. We hypothesize that aerobic endurance training has beneficial effects on patients' mental and physical health, leading to lower treatment discontinuation rates and improving disease outcomes. The study results will provide a basis for recommending exercise interventions as an add-on therapy in patients with schizophrenia.The study is registered in the International Clinical Trials Database (ClinicalTrials.gov identifier [NCT number]: NCT03466112) and in the German Clinical Trials Register (DRKS-ID: DRKS00009804).

Video games for people with schizophrenia

BACKGROUND

Commercial video games are a vastly popular form of recreational activity. Whilst concerns persist regarding possible negative effects of video games, they have been suggested to provide cognitive benefits to users. They are also frequently employed as control interventions in comparisons of more complex cognitive or psychological interventions. If independently effective, video games - being both engaging and relatively inexpensive - could provide a much more cost-effective add-on intervention to standard treatment when compared to costly, cognitive interventions.

OBJECTIVES

To review the effects of video games (alone or as an additional intervention) compared to standard care alone or other interventions including, but not limited to, cognitive remediation or cognitive behavioural therapy for people with schizophrenia or schizophrenia-like illnesses.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (March 2017, August 2018, August 2019).

SELECTION CRITERIA

Randomised controlled trials focusing on video games for people with schizophrenia or schizophrenia-like illnesses.

DATA COLLECTION AND ANALYSIS

Review authors extracted data independently. For binary outcomes we calculated risk ratio (RR) with its 95% confidence interval (CI) on an intention-to-treat basis. For continuous data we calculated the mean difference (MD) between groups and its CI. We employed a fixed-effect model for analyses. We assessed risk of bias for the included studies and created a 'Summary of findings' table using GRADE.

MAIN RESULTS

This review includes seven trials conducted between 2009 and 2018 (total = 468 participants, range 32 to 121). Study duration varied from six weeks to twelve weeks. All interventions in the included trials were given in addition to standard care, including prescribed medication. In trials video games tend to be the control for testing efficacy of complex, cognitive therapies; only two small trials evaluated commercial video games as the intervention. We categorised video game interventions into 'non-exergame' (played statically) and 'exergame' (the players use bodily movements to control the game). Our main outcomes of interest were clinically important changes in: general functioning, cognitive functioning, social functioning, mental state, quality of life, and physical fitness as well as clinically important adverse effects. We found no clear difference between non-exergames and cognitive remediation in general functioning scores (Strauss Carpenter Outcome Scale) (MD 0.42, 95% CI -0.62 to 1.46; participants = 86; studies = 1, very low-quality evidence) or social functioning scores (Specific Levels of Functioning Scale) (MD -3.13, 95% CI -40.17 to 33.91; participants = 53; studies = 1, very low-quality evidence). There was a clear difference favouring cognitive remediation for cognitive functioning (improved on at least one domain of MATRICS Consensus Cognitive Battery Test) (RR 0.58, 95% CI 0.34 to 0.99; participants = 42; studies = 1, low-quality evidence). For mental state, Positive and Negative Syndrome Scale (PANSS) overall scores showed no clear difference between treatment groups (MD 0.20, 95% CI -3.89 to 4.28; participants = 269; studies = 4, low-quality evidence). Quality of life ratings (Quality of Life Scale) similarly showed no clear intergroup difference (MD 0.01, 95% CI -0.40 to 0.42; participants = 87; studies = 1, very low-quality evidence). Adverse effects were not reported; we chose leaving the study early as a proxy measure. The attrition rate by end of treatment was similar between treatment groups (RR 0.96, 95% CI 0.87 to 1.06; participants = 395; studies = 5, low-quality evidence). One small trial compared exergames with standard care, but few outcomes were reported. No clear difference between interventions was seen for cognitive functioning (measured by MATRICS Consensus Cognitive Battery Test) (MD 2.90, 95% CI -1.27 to 7.07; participants = 33; studies = 1, low-quality evidence), however a benefit in favour of exergames was found for average change in physical fitness (aerobic fitness) (MD 3.82, 95% CI 1.75 to 5.89; participants = 33; studies = 1, low-quality evidence). Adverse effects were not reported; we chose leaving the study early as a proxy measure. The attrition rate by end of treatment was similar between treatment groups (RR 1.06, 95% CI 0.75 to 1.51; participants = 33; studies = 1). Another small trial compared exergames with non-exergames. Only one of our main outcomes was reported - physical fitness, which was measured by average time taken to walk 3 metres. No clear intergroup difference was identified at six-week follow-up (MD -0.50, 95% CI -1.17 to 0.17; participants = 28; studies = 1, very low-quality evidence). No trials reported adverse effects. We chose leaving the study early as a proxy outcome.

AUTHORS' CONCLUSIONS

Our results suggest that non-exergames may have a less beneficial effect on cognitive functioning than cognitive remediation, but have comparable effects for all other outcomes. These data are from a small number of trials, and the evidence is graded as of low or very low quality and is very likely to change with more data. It is difficult to currently establish if the more sophisticated cognitive approaches do any more good - or harm - than 'static' video games for people with schizophrenia. Where players use bodily movements to control the game (exergames), there is very limited evidence suggesting a possible benefit of exergames compared to standard care in terms of cognitive functioning and aerobic fitness. However, this finding must be replicated in trials with a larger sample size and that are conducted over a longer time frame. We cannot draw any firm conclusions regarding the effects of video games until more high-quality evidence is available. There are ongoing studies that may provide helpful data in the near future.

The Impact of Anticholinergic Burden on Functional Capacity in Persons With Schizophrenia Across the Adult Life Span

Anticholinergic burden (ACB) from medications impairs cognition in schizophrenia. Cognition is a predictor of functional capacity; however, little is known about ACB effect on functional capacity in this population. This study assesses the relationship between ACB and functional capacity across the life span in individuals with schizophrenia after controlling for ACB effect on cognition. A cross-sectional analysis was performed with data collected from 6 academic tertiary health centers. Two hundred and twenty-three community-dwelling participants with schizophrenia or schizoaffective disorder were included in this study. Main variables were ACB, antipsychotic olanzapine equivalents, functional capacity, cognition, and negative symptoms. Simultaneous linear regression analyses were performed to assess the association between ACB, functional capacity, and cognition and then between ACB and cognition. A mediation analysis was then performed to examine whether cognition mediated ACB effect on functional capacity if there was an association between ACB and cognition. Mean age of participants was 49.0 years (SD = 13.1, range 19-79), and 63.7% of participants had severe ACB, ie, a total score of 3 or above. Regression analyses revealed that ACB, age, education, and cognition independently predicted functional capacity and that ACB predicted cognition among those aged 55 years and older. Mediation analysis showed that cognition did partially mediate the effect of ACB on functional capacity in this older cohort. In conclusion, people with schizophrenia are exposed to severe ACB that can have a direct negative impact on functional capacity after controlling for its impact on cognition. Reducing ACB could improve functional capacity and potentially real-world function in schizophrenia.

Multimodal Neuroimaging Study of Visual Plasticity in Schizophrenia

Schizophrenia is a severe mental illness with visual learning and memory deficits, and reduced long term potentiation (LTP) may underlie these impairments. Recent human fMRI and EEG studies have assessed visual plasticity that was induced with high frequency visual stimulation, which is thought to mimic an LTP-like phenomenon. This study investigated the differences in visual plasticity in participants with schizophrenia and healthy controls. An fMRI visual plasticity paradigm was implemented, and proton magnetic resonance spectroscopy data were acquired to determine whether baseline resting levels of glutamatergic and GABA metabolites were related to visual plasticity response. Adults with schizophrenia did not demonstrate visual plasticity after family-wise error correction; whereas, the healthy control group did. There was a significant regional difference in visual plasticity in the left visual cortical area V2 when assessing group differences, and baseline GABA levels were associated with this specific ROI in the SZ group only. Overall, this study suggests that visual plasticity is altered in schizophrenia and related to basal GABA levels.

Empathy and Its Relationship With Social Functioning in Individuals at Ultra-High Risk for Psychosis

Introduction: Social functioning is often impaired in the ultra-high-risk (UHR) phase of psychosis. There is some evidence that empathy is also impaired in this phase and that these impairments may underlie difficulties in social functioning. The main aim of this study was to investigate whether cognitive and affective empathy are lower in people in the UHR phase of psychosis in comparison to healthy controls, and whether possible impairments have the same magnitude as in people with schizophrenia. A second aim was to examine whether there is a relationship between empathy and social functioning in individuals in the UHR phase. Method: Forty-three individuals at UHR for psychosis, 92 people with a schizophrenia spectrum disorder, and 49 persons without a psychiatric disorder completed the Interpersonal Reactivity Index (IRI), Questionnaire of Cognitive and Affective Empathy (QCAE), and Faux Pas as instruments to measure empathy. The Time Use survey was used to measure social functioning. MAN(C)OVA was used to analyse differences between groups on empathy and social functioning, and correlations were calculated between empathy measures and social functioning for each group. Results: The UHR group presented significantly lower levels of self-reported cognitive empathy than the healthy controls, but not compared to patients with SSD, while performance-based cognitive empathy was unimpaired in the UHR group. On the affective measures, we found that people with UHR and patients with SSD had significantly higher levels of self-reported distress in interpersonal settings compared to healthy controls. In the UHR group, perspective-taking was negatively associated with time spent on structured social activities. In the SSD group, we found that structured social activities were positively associated with perspective-taking and negatively associated with personal distress in interactions with others. Lastly, in people without mental illness, social activities were positively associated with performance-based perspective-taking. Conclusion: Impairments in subjective cognitive empathy appear to be present in the UHR phase, suggesting that difficulties in interpreting the thoughts and feelings of others precede the onset of psychotic disorders. This can inform future interventions in the UHR phase.

Development and validation of Vellore Inventory of Life Skills among people with severe mental illness

BACKGROUND AND AIM

Rehabilitation for people with severe mental illness is incomplete without life skills assessment and intervention. The aim of the study was develop a culturally specific performance-based measure assessing life skills of patients with severe mental illness.

MATERIALS AND METHODS

The items for the Vellore Inventory of Life Skills (VILS) were drawn after consultation with a reference group and from existing standardized scales. The items were categorized into two sections with six components each, which was further hierarchically arranged into activities at either basic, intermediate, or advanced level. One hundred consecutive clients between 18 and 60 years of age who provided written informed consent were assessed on the Comprehensive Evaluation of Basic Living Skills (CEBLS) and the VILS to evaluate convergent validity and inter-rater reliability. The General Health Questionnaire (GHQ-12) was used to evaluate divergent validity. The assessments were repeated after a week to evaluate test-retest reliability.

RESULTS

The scale had good inter-rater reliability 0.938 (95% confidence interval [CI] 0.887-0.967) and test-retest reliability 0.907 (95% CI 0.865-0.937). The correlation between total score of VILS and CEBLS (Pearson's correlation coefficient [PCC] = 0.611; P = 0.001) suggested moderate convergent validity. The correlation between total score of VILS and GHQ-12 (PCC = -0.260; P = 0.105) implied good divergent validity.

CONCLUSION

Preliminary data suggest that the VILS is clinically useful for the Indian population.

Predicting Real-World Functioning in Schizophrenia: The Relative Contributions of Neurocognition, Functional Capacity, and Negative Symptoms

Neurocognition and functional capacity are commonly reported predictors of real-world functioning in schizophrenia. However, the additional impact of negative symptoms, specifically its subdomains, i.e., diminished expression (DE) and avolition-apathy (AA), on real-world functioning remains unclear. The current study assessed 58 individuals with schizophrenia. Neurocognition was assessed with the Brief Assessment of Cognition in Schizophrenia, functional capacity with the UCSD Performance-based Skills Assessment (UPSA-B), and negative symptoms with the Negative Symptom Assessment-16. Real-world functioning was assessed with the Multnomah Community Ability Scale (MCAS) with employment status as an additional objective outcome. Hierarchical regressions and sequential logistic regressions were used to examine the associations between the variables of interest. The results show that global negative symptoms contribute substantial additional variance in predicting MCAS and employment status above and beyond the variance accounted for by neurocognition and functional capacity. In addition, both AA and DE predict the MCAS after controlling for cognition and functional capacity. Only AA accounts for additional variance in employment status beyond that by UPSA-B. In summary, negative symptoms contribute substantial additional variance in predicting both real-world functioning and employment outcomes after accounting for neurocognition and functional capacity. Our findings emphasize both DE and AA as important treatment targets in functional recovery for people with schizophrenia.

Metabolite Alterations in Adults With Schizophrenia, First Degree Relatives, and Healthy Controls: A Multi-Region 7T MRS Study

Proton magnetic resonance spectroscopy (MRS) studies in schizophrenia have shown altered GABAergic, glutamatergic, and bioenergetic pathways, but if these abnormalities are brain region or illness-stage specific is largely unknown. MRS at 7T MR enables reliable quantification of multiple metabolites, including GABA, glutamate (Glu) and glutamine (Gln), from multiple brain regions within the time constraints of a clinical examination. In this study, GABA, Glu, Gln, the ratio Gln/Glu, and lactate (Lac) were quantified using 7T MRS in five brain regions in adults with schizophrenia (N = 40), first-degree relatives (N = 11), and healthy controls (N = 38). Metabolites were analyzed for differences between groups, as well as between subjects with schizophrenia with either short (<5 years, N = 19 or long (>5 years, N = 21) illness duration. For analyses between the three groups, there were significant glutamatergic and GABAergic differences observed in the anterior cingulate, centrum semiovale, and dorsolateral prefrontal cortex. There were also significant relationships between anterior cingulate cortex, centrum semiovale, and dorsolateral prefrontal cortex and cognitive measures. There were also significant glutamatergic, GABAergic, and lactate differences between subjects with long and short illness duration in the anterior cingulate, centrum semiovale, dorsolateral prefrontal cortex, and hippocampus. Finally, negative symptom severity ratings were significantly correlated with both anterior cingulate and centrum semiovale metabolite levels. In summary, 7T MRS shows multi-region differences in GABAergic and glutamatergic metabolites between subjects with schizophrenia, first-degree relatives and healthy controls, suggesting relatively diffuse involvement that evolves with illness duration. Unmedicated first-degree relatives share some of the same metabolic characteristics as patients with a diagnosis of schizophrenia, suggesting that these differences may reflect a genetic vulnerability and are not solely due to the effects of antipsychotic interventions.

Effects of Repetitive Transcranial Magnetic Stimulation on Working Memory Performance and Brain Structure in People With Schizophrenia Spectrum Disorders: A Double-Blind, Randomized, Sham-Controlled Trial

BACKGROUND

There are currently no approved treatments for working memory deficits in schizophrenia spectrum disorders (SSDs). The objective of the present study was to assess whether repetitive transcranial magnetic stimulation (rTMS) to the bilateral dorsolateral prefrontal cortex (DLPFC) in people with SSDs 1) improves working memory deficits and 2) changes brain structure.

METHODS

We conducted a double-blind, parallel, randomized, sham-controlled study at the Centre for Addiction and Mental Health in Toronto, Canada. We randomized 83 participants with SSDs to receive either active 20 Hz rTMS applied to the bilateral DLPFC or sham rTMS for 4 weeks. The participants also completed pre/posttreatment magnetic resonance imaging. Clinical and cognitive assessments were performed at baseline, treatment end, and 1 month later. The primary outcome was change in verbal n-back working memory performance accuracy (d-prime). The secondary outcome measures were change in DLPFC thickness and fractional anisotropy of white matter tracts connecting to the DLPFC. Prespecified exploratory outcome measures were changes in general cognition; positive, negative, and depressive symptoms.

RESULTS

Compared with sham treatment, active rTMS did not lead to significant change in working memory performance; it was associated with an increase in right DLPFC thickness but not fractional anisotropy. Prespecified exploratory analysis showed a significant decrease in depressive symptoms in the active group; the decrease in depressive symptoms was correlated with an increase in right DLPFC thickness.

CONCLUSIONS

Although rTMS applied to the bilateral DLPFC was not efficacious in treating working memory deficits in SSDs, it did increase right DLPFC thickness and decrease depressive symptoms. These findings deserve further study given the lack of efficacy of antidepressant medications in SSDs.

Modernizing Daily Function Assessment in Parkinson's Disease Using Capacity, Perception, and Performance Measures

Many disease symptoms restrict the quality of life of the affected. This usually occurs indirectly, at least in most neurological diseases. Here, impaired daily function is interposed between the symptoms and the reduced quality of life. This is reflected in the International Classification of Function, Disability and Health model published by the World Health Organization in 2001. This correlation between symptom, daily function, and quality of life makes it clear that to evaluate the success of a therapy and develop new therapies, daily function must also be evaluated as accurately as possible. However, daily function is a complex construct and therefore difficult to quantify. To date, daily function has been measured primarily by capacity (clinical assessments) and perception (surveys and patient-reported outcomes) assessment approaches. Now, daily function can be captured in a new dimension, that is, performance, through new digital technologies that can be used in the home environment of patients. This viewpoint discusses the differences and interdependencies of capacity, perception, and performance assessment types using the example of Parkinson's disease. Options regarding how future study protocols should be designed to get the most comprehensive and validated picture of daily function in patients are presented. © 2020 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

The influence of stage of illness on functional outcomes after psychological treatment in bipolar disorder: A systematic review

OBJECTIVES

The aim of this study was to advance understanding of stage of illness in bipolar disorder (BD), by interrogating the literature for evidence of an influence of stage of illness on functional (ie non-symptom) outcomes following psychosocial intervention.

METHODS

A systematic literature search following PRISMA guidelines was conducted to identify empirical studies of psychosocial interventions for established BD. To investigate stage as a predictor of three functional outcomes (general/social functioning, cognitive functioning and quality of life [QoL]), study samples were dichotomised into earlier and later stage using proxy measures identified in existing staging models. Findings were integrated using data-based convergent synthesis.

RESULTS

A total of 88 analyses from 62 studies were identified. Synthesis across studies suggested that psychosocial intervention was more likely to be effective for general functioning outcomes earlier in the course of established BD. No stage-related differences were found for cognitive or QoL outcomes. Exploratory investigations found some evidence of an interaction between specific intervention type and stage of illness in predicting outcomes.

CONCLUSIONS

A novel systematic review provided preliminary evidence that benefits general/social functioning may be more pronounced in earlier versus later stages of established BD. The review also generated hypotheses about a potential three-way interaction, whereby specific psychosocial interventions may be best placed to target functional outcomes in earlier versus later stage BD. The strength of conclusions is limited by the overall low-quality and significant heterogeneity of studies. Further research is urgently required to understand the impact of illness stage on the effectiveness of psychosocial interventions.

Cognitive predictors of a performance-based measure of instrumental activities of daily living following stroke

BACKGROUND

To inform cognitive interventions that target functional capacity for individuals who have survived stroke, an evaluation of predictors of daily functioning is necessary. The current literature is limited regarding identifying the associations between objective cognitive functioning and objective performance of Instrumental Activities of Daily Living (IADLs).

OBJECTIVES

To investigate the relationship between objectively measured cognitive domains/executive functions and performance on an objective measure of IADLs following a stroke.

METHODS

Cross-sectional examination of 52 participants who have survived strokes and completed assessments of immediate memory, visuospatial/constructional skills, language, attention, delayed memory, executive functions (i.e., inhibition and flexibility, concept-formation and problem-solving, abstract thinking, deductive thinking, and verbal abstraction), and a performance-based measure of IADLs (UCSD Performance-based Skills Assessment; UPSA).

RESULTS

Results indicated significant correlations between the UPSA and immediate memory, visuospatial/constructional skills, language, delayed memory, and executive functions (i.e., concept formation and problem-solving, flexibility of thinking, and verbal abstraction). A hierarchical multiple regression, controlling for age, severity of stroke, side of stroke, and depressive symptoms and including the cognitive measures individually significantly associated with the UPSA, explained approximately 62% of the variance in overall UPSA performance. This regression demonstrated that only language significantly predicted UPSA total score, in the context of multiple variables.

CONCLUSIONS

Cognitive functioning is significantly associated with IADL functioning post-stroke, and considering multiple domains of cognitive functioning together largely explains the performance of IADLs.

Brain structural correlates of functional capacity in first-episode psychosis

Impaired functional capacity is a core feature of schizophrenia and presents even in first-episode psychosis (FEP) patients. Impairments in daily functioning tend to persist despite antipsychotic therapy but their neural basis is less clear. Previous studies suggest that volume loss in frontal cortex might be an important contributor, but findings are inconsistent. We aimed to comprehensively investigate the brain structural correlates of functional capacity in FEP using MRI and a reliable objective measure of functioning [University of California, San Diego Performance-Based Skills Assessment (UPSA)]. In a sample of FEP (n = 39) and a well-matched control group (n = 21), we measured cortical thickness, gray matter volume, and white matter tract integrity (fractional anisotropy, FA) within brain regions implicated by previous work. The FEP group had thinner cortex in various frontal regions and fusiform, and reduced FA in inferior longitudinal fasciculus (ILF). In FEP, poorer functional capacity correlated with reduced superior frontal volume and lower FA in left ILF. Importantly, frontal brain volumes and integrity of the ILF were identified as the structural correlates of functional capacity in FEP, controlling for other relevant factors. These findings enhance mechanistic understanding of functional capacity deficits in schizophrenia by specifying the underlying neural correlates. In future, this could help inform intervention strategies.

REM Sleep Behavior Disorder in Parkinson's Disease: Effects on Cognitive, Psychiatric, and Functional outcomes

OBJECTIVE

Rapid eye movement sleep behavior disorder (RBD) affects 33-46% of patients with Parkinson's disease (PD) and may be a risk factor for neuropsychological and functional deficits. However, the role of RBD on neuropsychological functioning in PD has yet to be fully determined. We, therefore, examined differences in neurocognitive performance, functional capacity, and psychiatric symptoms among nondemented PD patients with probable RBD (PD/pRBD+) and without (PD/pRBD-), and healthy comparison participants (HC).

METHODS

Totally, 172 participants (58 PD/pRBD+; 65 PD/pRBD-; 49 HC) completed an RBD sleep questionnaire, psychiatric/clinical questionnaires, performance-based and self-reported functional capacity measures, and underwent a comprehensive neuropsychological battery assessing attention/working memory, language, visuospatial function, verbal and visual learning and memory, and executive function.

RESULTS

Controlling for psychiatric symptom severity, the PD/pRBD+ group had poorer executive functioning and learning performance than the PD/pRBD- group and poorer neuropsychological functioning across all individual cognitive domains than the HCs. In contrast, PD/pRBD- patients had significantly lower scores than HCs only in the language domain. Moreover, PD/pRBD+ patients demonstrated significantly poorer medication management skills compared to HCs. Both PD groups reported greater depressive and anxiety severity compared to HCs; PD/pRBD+ group also endorsed greater severity of apathy compared to HCs.

CONCLUSIONS

The presence of pRBD is associated with poorer neuropsychological functioning in PD such that PD patients with pRBD have poorer cognitive, functional, and emotional outcomes compared to HC participants and/or PD patients without pRBD. Our findings underscore the importance of RBD assessment for improved detection and treatment of neuropsychological deficits (e.g., targeted cognitive interventions).

The Effect of Aerobic Exercise on Physical and Cognitive Outcomes in a Small Cohort of Outpatients with Schizophrenia

Background:

Schizophrenia (SCZ) is a severe, chronic illness characterized by psychotic symptoms and impairments in many cognitive domains. Dysregulation of brain derived neurotrophic factor (BDNF) is associated with the cognitive impairments seen in patients with SCZ. Given the growing literature supporting a positive effect of aerobic exercise on cognition in other populations, we hypothesized that a structured aerobic exercise program would improve cognitive and functional outcomes in subjects with SCZ, potentially mediated by increases in BDNF.

Methods:

The study was a small randomized parallel group clinical trial of subjects with SCZ comparing 12 weeks of aerobic exercise (AE) against control (CON) stretching and balance training. At Baseline, Week 12, and Week 20 we collected serum samples for analysis of brain derived neurotrophic factor (BDNF), and assessed functional, physical, and cognitive outcomes. Linear regression models were used to compare change scores between timepoints.

Results:

We randomized 21 subjects to AE and 17 to CON; however, only 9 AE and 6 CON completed their programs. Subjects in both groups were slower at the 400 m walk in Week 12 compared to Baseline, but the AE group had significantly less slowing than the CON group (B = –28.32, p = 0.011). Between Week 12 and Week 20, the AE group had a significantly greater change score on the Composite and Visual Learning Domain of the MATRICS Consensus Cognitive Battery (B = 5.11, p = 0.03; B = 13.96, p = 0.006).

Conclusion:

These results indicate that participation in a structured aerobic exercise paradigm may modestly blunt physical function decline and enhance cognitive function in individuals with SCZ.

Assessing instrumental activities of daily living (iADL) with a game-based assessment for individuals with schizophrenia

BACKGROUND

The Virtual Reality Functional Capacity Assessment Tool (VRFCAT) is an "applied" game-based assessment that uses a multi-level functional task to assess instrumental activities of daily living (iADL). This study examines the feasibility, convergent validity, and predictive ability of the VRFCAT in a sample of inpatients with chronic schizophrenia.

METHODS

Inpatients with a DSM-5 diagnosis of schizophrenia or schizoaffective disorder, completed the VRFCAT prior to discharge. The UPSA-B, SLOF, and PSP were administered, both at baseline and after four-weeks in the community. VRFCAT performance scores were compared to published data from the VRFCAT validation study.

RESULTS

All 62 participants completed the VRFCAT. Compared to the performance of stable outpatients, participants performed 1.50 SDs below the VRFCAT mean adjusted total time (ATT) (Validation study: Mean T Score = 32.5, SD = 16.59) with more errors. The VRFCAT ATT T-score was significantly correlated with baseline UPSA-B total score (p = 0.005) and PSP Global score (p = 0.010). 34 participants completed the follow-up period (55%), and 28 were lost to follow-up. There were no statistically significant differences in VRFCAT scores between these two groups (all p > 0.29). The VRFCAT composite score at baseline was significantly associated with the UPSA-B total score (p = 0.010) and the PSP total score (p = 0.008) at four-weeks, as was the PSP Socially Useful Activities subscale score (p = 0.006).

CONCLUSION

The VRFCAT is a valid measure of iADLs in inpatients with chronic schizophrenia. The VRFCAT predicted instrumental functioning four-weeks post-discharge. Future studies should examine other moderators of measures of functional capacity pre-discharge, predicting function later in the community.

Factor structure of cognitive performance and functional capacity in schizophrenia: Evidence for differences across functional capacity measures

BACKGROUND

Cognition and functional capacity predict functional outcomes in mental illness. Traditional approaches conceptualize cognition as comprised of domains, but many studies support a unifactorial structure. Some functional capacity measures may share a single-factor structure with cognition. In this study, we examined the factor structure of two measures of functional capacity, a conventional assessment and a newer computerized assessment, testing for a shared factor structure with cognition.

METHODS

Patients with schizophrenia and healthy controls were examined with the MATRICS Consensus Cognitive Battery (MCCB), the UCSD Performance Based Skills Assessment (UPSA), and the Virtual Reality Functional Capacity Assessment Tool (VRFCAT). Models of the factor structures of the MCCB, UPSA, and VRFCAT were calculated, as were correlations between MCCB scores and individual VRFCAT objectives.

RESULTS

The MCCB, VRFCAT, and UPSA all had unifactorial structures. The best fitting model of the correlations between MCCB and UPSA was a shared single factor, while the best fit for the relationship between MCCB and VRFCAT had two factors. Correlations between the MCCB domain and composite scores and the VRFCAT objectives suggested global rather than specific patterns of correlation.

DISCUSSION

The relationship between cognitive performance and functional capacity was found to vary across functional capacity assessments. The UPSA and MCCB were not differentiated into separate factors, suggesting that the UPSA may overlap with neurocognitive performance. However, the VRFCAT appears to measure functional abilities that are separable from, yet correlated with, neurocognitive performance. It may provide a more distinctive assessment of the functional capacity construct.

The University of California San Diego performance-based skills assessment: a useful tool to detect mild everyday functioning difficulties in HIV-infected patients with very good immunological condition

Everyday functioning (EF) impairment is frequent in people living with HIV (PLWH). Our aim was to better explore EF and its association with PLWH cognition, by administering both the IADL scale, the most common functional scale, and a new and ecologic multi-domain (communication and financial skills) tool to measure EF as the University of California San Diego (UCSD) Performance-Based Skills Assessment-Brief Version (UPSA-B). Eighty-five PLWH on cART with very good immunological condition and 23 age- and education-matched healthy controls (HC) were enrolled. PLWH underwent a standardized neuropsychological battery plus IADL, and cognitive impairment was defined according to Frascati criteria. Both groups underwent the UPSA-B. Only 6 subjects (7%) were affected by cognitive impairment (asymptomatic profile). While IADL score was at ceiling for all patients, the UPSA-B total score was significantly worse in PLWH when compared with HC [mean 82.1 (SD 9.3) vs 89.2 (SD 6.2); p < 0.001]. At communication subtest, PLWH group and HC were significantly different (p = 0.002), while no difference emerged at financial skills (p = 0.096). Higher score at UPSA-B was independently associated with better global cognitive performance (composite Z-score) (β 7.79; p < 0.001). Also considering each single cognitive domain, UPSA-B performance (both total and at subtests) confirmed the association with neurocognitive performance. In conclusion, UPSA-B seems to better discriminate EF impairment than IADL in PLWH, and it was associated with cognitive functions, also in the absence of symptomatic cognitive impairment. Thus, it appears a promising tool in the context of HIV infection to avoid misdiagnosis and to better detect also mild EF.

Development and Evaluation of a Visual Remediation Intervention for People with Schizophrenia

It is now well documented that schizophrenia is associated with impairments in visual processing at all levels of vision, and that these disturbances are related to deficits in multiple higher-level cognitive and social cognitive functions. Visual remediation methods have been slow to appear in the literature as a potential treatment strategy to target these impairments, however, in contrast to interventions that aim to improve auditory and higher cognitive functions in schizophrenia. In this report, we describe a National Institute of Mental Health (NIMH)-funded R61/R33 grant that uses a phased approach to optimize and evaluate a novel visual remediation intervention for people with schizophrenia. The goals of this project are: (1) in the R61 phase, to establish the optimal components and dose (number of sessions) of a visual remediation intervention from among two specific visual training strategies (and their combination) for improving low and mid-level visual functions in schizophrenia; and (2) in the R33 phase, to determine the extent to which the optimal intervention improves not only visual processing but also higher-level cognitive and role functions. Here we present the scientific background for and innovation of the study, along with our methods, hypotheses, and preliminary data. The results of this study will help determine the utility of this novel intervention approach for targeting visual perceptual, cognitive, and functional impairments in schizophrenia.

Minimum clinically important differences for the Functioning Assessment Short Test and a battery of neuropsychological tests in bipolar disorders: results from the FACE-BD cohort

AIMS

Establishing the minimum clinically important difference (MCID) in functioning and cognition is essential to the interpretation of the research and clinical work conducted in bipolar disorders (BD). The present study aimed to estimate the MCID for the Functioning Assessment Short Test (FAST) and a battery of neuropsychological tests in BD.

METHODS

Anchor-based and distributive methods were used to estimate the MCID for the FAST and cognition using data from a large, multicentre, observational cohort of individuals with BD. The FAST and cognition were linked with the Clinical Global Impressions Scale-Severity (CGI-S) and Global Assessment of Functioning (GAF) using an equipercentile method. The magnitude of the standard error measurement (s.e.m.) provided another estimate of the MCID.

RESULTS

In total, 570 participants were followed for 2 years. Cross-sectional CGI-S and GAF scores were linked to a threshold ⩽7 on the FAST for functional remission. The MCID for the FAST equalled 8- or 9-points change from baseline using the CGI-S and GAF. One s.e.m. on the FAST corresponded to 7.6-points change from baseline. Cognitive variables insufficiently correlated with anchor variables (all ρ <0.3). One s.e.m. for cognitive variables corresponded to a range of 0.45 to 0.93-s.d. change from baseline.

CONCLUSIONS

These findings support the value of the estimated MCID for the FAST and cognition and may be a useful tool to evaluate cognitive and functional remediation effects and improve patient functional outcomes in BD. The CGI-S and GAF were inappropriate anchors for cognition. Further studies may use performance-based measures of functioning instead.

Online Social Cognition Training in Schizophrenia: A Double-Blind, Randomized, Controlled Multi-Site Clinical Trial

Social cognition (SC), the mental operations underlying social functioning, are impaired in schizophrenia. Their direct link to functional outcome and illness status have made them an important therapeutic target. However, no effective treatment for these deficits is currently applied as a standard of care. To address this need, we have developed SocialVille-an online, plasticity-based training program that targets SC deficits in schizophrenia. Here we report the outcomes of a double-blind, controlled, randomized, multi-site clinical trial of SocialVille. Outpatients with schizophrenia were randomized to complete 40 sessions of either SocialVille (N = 55 completers) or active control (computer games; N = 53 completers) from home. The a priori co-primary outcome measures were a social cognitive composite and a functional capacity outcome (UCSD Performance-based Skills Assessment [UPSA-2]). Secondary outcomes included a virtual functional capacity measure (VRFCAT), social functioning, quality of life, and motivation. Linear mixed models revealed a group × time interaction favoring the treatment group for the social cognitive composite (b = 2.81; P < .001) but not for the UPSA-2 measure. Analysis of secondary outcome measures showed significant group × time effects favoring the treatment group on SC and social functioning, on the virtual functional capacity measure and a motivation subscale, although these latter findings were nonsignificant with FDR correction. These results provide support for the efficacy of a remote, plasticity-based social cognitive training program in improving SC and social functioning in schizophrenia. Such treatments may serve as a cost-effective adjunct to existing psychosocial treatments. Trial Registration: NCT02246426.

Construct validity, sensitivity and specificity of the USCD Performance-based Skill Assessment 2 in a mixed Portuguese sample

Assessment batteries of functional capacity provide robust indicators of real-world functioning in major psychiatric illnesses and important information on an individual's ability to live autonomously and pursue relevant psychosocial goals.

OBJECTIVES

This study explores the psychometric properties of the Portuguese USCD Performance-based Skill Assessment 2 (UPSA-2-PT) in a mixed sample of Portuguese participants.

METHOD

A sample of 110 participants, 37 patients diagnosed with schizophrenia, 27 first-degree relatives of patients and 46 controls were administered the UPSA-2-PT and self-report questionnaires. The UPSA-2-PT reliability was assessed through inter-rater reliability and internal consistency, convergent validity with community integration and a receiver operating curve analysis was conducted to establish scores' sensitivity and specificity. Youden's Index was used to determine an optimal UPSA-2-PT cutoff score.

RESULTS

Findings show an excellent inter-rater reliability, good internal consistency and construct validity, consistent with previous studies in Western countries. The UPSA-2-PT also showed a good discriminant ability between patients and controls, and an overall percentage of correct classification of 86.7% based on the 81.59 cutoff.

DISCUSSION

Findings are congruous with previous versions, strengthening the body of evidence supporting the construct validity and providing a useful tool for research and clinical purposes to practitioners.

Effects of an extrinsic motivator on the evaluation of cognitive and daily living functions in patients with schizophrenia

We investigated the effect of an extrinsic motivator on the MATRICS Consensus Cognitive Battery (MCCB) and UCSD Performance-Based Skills Assessment (UPSA) scores, which assess cognitive and daily living functions, in patients with schizophrenia. We enrolled 60 clinically stable patients with schizophrenia and allocated them to the motivator or control group. We conducted baseline assessments of cognitive function using the MCCB, daily living function using the UPSA, clinical symptoms, and psychosocial characteristics in both groups. In the retrial, we initially evaluated clinical symptoms. Next, we assigned an extrinsic motivator to the motivator group and again assessed cognitive function and daily living function using the MCCB and UPSA. Statistical analyses were performed using t-tests, Chi-square tests, Fisher's exact test, repeated measures analysis of variance, and logistic regression analysis. We found significant time × group interactions in processing speed, verbal learning, visual learning, and composite scores of MCCB. There were no significant interactions in UPSA scores. The meaningful change rates of social cognition and composite scores in MCCB were significantly higher in the motivator group than in the control group. After adjusting for additional variables, the extrinsic motivator had a significant effect on the meaningful MCCB composite score change. Conclusively, our findings suggest beneficial effects of extrinsic motivator on the MCCB score in patients with schizophrenia. In the future, the implementation and interpretation of the MCCB considering the motivation is necessary.

A systematic review of the effects of psychosocial interventions on social functioning for middle-aged and older-aged adults with severe mental illness

OBJECTIVES

The number of older adults with severe mental health problems such as schizophrenia is likely to double in the next 20 years. The needs of this patient group change across the life course, but difficulties with social functioning persist into older age. Poorer social functioning is associated with poorer outcomes and has been identified as a priority for intervention by patients themselves. This paper systematically reviews studies examining the effectiveness of psychosocial interventions on social functioning for people with severe mental health problems in later life.

METHODS

A systematic review of peer-reviewed journal articles was conducted and databases were searched from inception to December 2017. The review was limited to psychosocial interventions, for mid to older aged adults (≥40 years of age) with severe mental illness that included a validated measure of social functioning.

RESULTS

Fifteen studies (17 papers) met inclusion criteria. There was evidence to support skills training interventions that primarily focused on social skills training or integrated mental and physical health interventions. There was not sufficient evidence to recommend any other interventions.

CONCLUSIONS

The results highlight the limited nature of interventions designed specifically for older people with severe mental health problems that target social functioning and the need for more robust, large-scale studies in the area. Current evidence suggests that cognitive behaviour therapy can be effective in targeting social functioning in younger age groups, but, as yet, there is insufficient evidence to recommend this intervention for an older population.

Improving social functioning in community-dwelling patients with schizophrenia: a randomized controlled computer cognitive remediation therapy trial with six months follow-up

Computerized cognitive remediation therapy (CCRT) has been found to generally improve cognition among patients with schizophrenia, but its effect on functioning has not been extensively studied. This study addressed this gap in the literature by investigating the effect of CCRT and its long-term efficacy among community-dwelling patients with schizophrenia. 157 Chinese patients with schizophrenia were recruited from communities and randomized to CCRT (n = 78) or treatment as usual (TAU; n = 79) groups for 12 weeks with 4-5 sessions per week. Neurocognition, functioning, and symptoms of participants were assessed at baseline, after treatment, and at the 6 month follow-up. The CCRT group showed significantly greater improvements than the TAU group regarding the MATRICS Consensus Cognitive Battery (MCCB) total score and social cognition score. Significant cognitive benefits for functioning were observed (Personal and Social Performance scale, PSP). Moreover, improvement of the MCCB total score mediated a positive effect on functional capacity (UCSD Performance-based Skills Assessment, UPSA), and mediated decreases in negative symptoms across both groups. CCRT improved social functioning and general cognitive functioning among community-dwelling patients with schizophrenia. These improvements persisted for 6 months after treatment. CCRT also led to improvements in functioning and symptom severity by modulating cognitive functioning.

Predictive factors of functional capacity and real-world functioning in patients with schizophrenia

Purpose

This study was performed to identify the predictive factors of functional capacity assessed by the Spanish University of California Performance Skills Assessment (Sp-UPSA) and real-world functioning assessed by the Spanish Personal and Social Performance scale (PSP) in outpatients with schizophrenia.

Methods

Naturalistic, 6-month follow-up, multicentre, validation study. Here, we report data on 139 patients with schizophrenia at their baseline visit. Assessment: Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression-Severity (CGI-S), Sp-UPSA and PSP. Statistics: Pearson's correlation coefficient (r) was used to determine the relationships between variables, and multivariable stepwise linear regression analyses to identify predictive variables of Sp-UPSA and PSP total scores.

Results

Functional capacity: scores on the PSP and PANSS-GP entered first and second at P < 0.0001 and accounted for 21% of variance (R2 = 0.208, model df = 2, F = 15.724, P < 0.0001). Real-world functioning: scores on the CGI-S (B = −5.406), PANSS-N (B = −0.657) and Sp-UPSA (B = 0.230) entered first, second and third, and accounted for 51% of variance (model df = 3, F = 37.741, P < 0.0001).

Conclusion

In patients with schizophrenia, functional capacity and real-world functioning are two related but different constructs. Each one predicts the other along with other factors; general psychopathology for functional capacity, and severity of the illness and negative symptoms for real-world functioning. These findings have important clinical implications: (1) both types of functioning should be assessed in patients with schizophrenia and (2) strategies for improving them should be different.

People with schizophrenia show enhanced cognitive costs of maintaining a single item in working memory

BACKGROUND

Working memory (WM) deficits are seen as a core deficit in schizophrenia, implicated in the broad cognitive impairment seen in the illness. Here we examine the impact of WM storage of a single item on the operation of other cognitive systems.

METHODS

We studied 37 healthy controls (HCS) and 43 people with schizophrenia (PSZ). Each trial consisted of a sequence of two potential target stimuli, T1 and T2. T1 was a letter presented for 100 ms. After delays of 100-800 ms, T2 was presented. T2 was a 1 or a 2 and required a speeded response. In one condition, subjects were instructed to ignore T1 but respond to T2. In another condition, they were required to report T1 after making their speeded response to T2 (i.e. to make a speeded T2 response while holding T1 in WM).

RESULTS

PSZ were dramatically slowed at responding to T2 when T1 was held in WM. A repeated measures ANOVA yielded main effects of group, delay, and condition with a group by condition interaction (p's < 0.001). Across delays, the slowing of the T2 response when required to hold T1 in memory, relative to ignoring T1, was nearly 3 times higher in PSZ than HCS (633 v. 219 ms).

CONCLUSIONS

Whereas previous studies have focused on reduced storage capacity, the present study found that PSZ are impaired at performing tasks while they are successfully maintaining a single item in WM. This may play a role in the broad cognitive impairment seen in PSZ.

Emotional processing subtypes in bipolar disorder: A cluster analysis

BACKGROUND

Evidence regarding the performance of Bipolar Disorder patients (BD) on Emotional Processing (EP) is conflicting, suggesting that heterogeneity within this population may exist. It is not completely understood if this impacts on clinical presentation and functional outcomes.

METHODS

A total of 212 BD patients were recruited. Patients underwent MATRICS Consensus Cognitive Battery as well as a clinical evaluation to detect premorbid traits, comorbidities and clinical features. Performance on each basic emotion on the Emotional Recognition Task (ERT) and Reading the Mind in the Eyes Test were entered into hierarchical cluster analyses in order to determine the number of clusters and to assign subjects to specific clusters. We then compared subgroups on clinical factors and real-world community functioning.

RESULTS

No differences between BD patients as a group and controls were found in EP performance. Two clusters of BD patients were found, one with "intact" performance (71.2%) that performed as healthy controls (HC) and other with "impaired" performance (28.8%) performing worse than HC and schizophrenic patients on basic emotion recognition. Patients in the "impaired group" presented higher rates of childhood trauma, schizotypal traits, lower premorbid IQ and education, poor psychosocial functioning and cognitive performance.

LIMITATIONS

Cross-sectional data which limits our ability to infer directionality of our findings.

CONCLUSION

These results suggest the presence of two subgroups regarding EP performance with unique clinical and neurodevelopmental profiles associated. Next steps will include using these data to identify a homogeneous group of patients to target these disabling symptoms with treatment.

Cognitive and metacognitive factors predict engagement in employment in individuals with first episode psychosis

BACKGROUND

Research has demonstrated that cognitive abilities predict work outcomes in people with psychosis. Cognitive Remediation Programs go some way in improving work outcomes, but individuals still experience difficulty maintaining employment. Metacognition has been demonstrated to predict work performance in individuals with schizophrenia, but this has not yet been applied to First Episode Psychosis (FEP). This study assessed whether metacognition, intellectual aptitude and functional capacity can predict engagement in work and number of hours of work within FEP.

METHODS

Fifty-two individuals with psychosis, from an Early Intervention in Psychosis service, completed measures of IQ, metacognition (Metacognitive Assessment Interview), functional capacity (UPSA), and functional outcome (hours spent in structured activity per week, including employment).

RESULTS

Twenty-six participants (22 males, 4 females) were employed and twenty-six (22 males, 4 females) were not employed. IQ and metacognition were significantly associated with whether the individual was engaged in employment [IQ (p = .02) and metacognition (p = 006)]. When controlling for IQ, metacognition (differentiation subscale) remained significant (p = .04). Next, including only those employed, no cognitive nor metacognitive factors predicted number of hours in employment.

DISCUSSION

This is the first study to directly assess metacognition as a predictor of work hours for individuals with FEP. This study highlights the importance of enhancing metacognitive ability in order to improve likelihood of, and engagement in, employment for those with FEP.

A longitudinal comparison of two neurocognitive test batteries in patients with schizophrenia and healthy volunteers: Time effects on neuropsychological performance and their relation to functional outcome

Cognitive impairment is a major unmet need in the treatment of schizophrenia. Over the last decade, the MATRICS Consensus Cognitive Battery (MCCB) has been used to assess the effects of novel treatments for cognitive impairment in schizophrenia. However, other cognitive-neuroscience-based cognitive batteries, such as the Cambridge Neuropsychological Test Automated Battery (CANTAB) have been suggested as an alternative to the MCCB. Although both batteries purport to assess cognitive function in psychosis, no previous study has attempted to examine their validity longitudinally and the potential overlap between the two batteries over time. The aim of the current study was to assess the relationship between the MCCB and the CANTAB in the longitudinal assessment of cognitive impairment in schizophrenia. A sample of 39 stable schizophrenia outpatients and 18 controls completed the MCCB and the CANTAB battery at baseline, and at 2, 4 and 8-weeks follow-up. Correlation analyses and a mixed-model repeated measures approach were used. We found no significant effect of time in the MCCB. In contrast, for the CANTAB a significant effect of time consistent with practice effects for the attention domain in the control group and for the visual learning, reasoning and problem-solving, and social cognition domains in patients, with subjects performing better at follow-up. In particular, a significant time ∗ battery interaction was found for those cognitive domains. These findings suggest there are specific differences across cognitive tests to assess cognitive impairments in schizophrenia and that measures derived from the CANTAB appear to be more prone to practice effects in these patients.

Virtual reality assessment of functional capacity in the early course of schizophrenia: Associations with cognitive performance and daily functioning

AIM

Computer-based virtual reality assessments of functional capacity have shown promise as a reliable and valid way to assess individuals with multi-episode schizophrenia. However, there has been little research utilizing this innovative approach with young patients who are in the early phase of schizophrenia.

METHODS

Outpatients in the early course of schizophrenia (n = 42) were compared to controls (n = 13) at cross-sectional study points. Patients were within 2 years of their first psychotic episode, were an average of 22.2 years old and had an average of 12.3 years of education. We used the Virtual Reality Functional Capacity Assessment Tool (VRFCAT) and the University of California, San Diego (UCSD) Performance-Based Skills Assessment-2 (UPSA-2) to assess functional capacity. The MATRICS Consensus Cognitive Battery (MCCB) and the Cognitive Assessment Interview (CAI) were the measures of cognitive functioning. The Global Functioning Scale: Role (GFS-R) and Social (GFS-S), and the Role Functioning Scale (RFS) were the measures of daily functioning.

RESULTS

Early course patients vs controls were slower (patient M = 830.41 seconds vs control M = 716.84 seconds; t = 3.0, P < .01) and committed more errors (patient M = 3.2 vs control M = 1.7 seconds, t = 2.9, P < .01) on the VRFCAT. Total time was significantly correlated with the UPSA (r = -0.66, P < .01), MCCB (r = -0.70, P < .01), CAI (r = -0.51, P < .01), and GFS role (r = -0.52, P <. 01) and social functioning (r = -0.43, P = .03).

CONCLUSIONS

We extend previous findings to patients with first-episode schizophrenia. Virtual-reality-based performance was correlated with a standard test of functional capacity, indicating VRFCAT validity. Furthermore, correlations with cognitive functioning and occupational/school and social functioning indicate promise as a co-primary measure to track changes in response to treatment.

Defining cognitive and functional profiles in schizophrenia and affective disorders

BACKGROUND

Neurocognitive dysfunction is a common symptom of various major psychiatric disorders, including schizophrenia, major depressive disorder (MDD), and bipolar I disorder (BD). In this study, we investigated whether cognitive profiles and daily skill functioning could effectively differentiate between patients with schizophrenia, MDD, and BD.

METHOD

In this cross-sectional study, we recruited a total of 63 patients with schizophrenia, 55 patients with MDD, 43 patients with BD, and 92 healthy control subjects. We evaluated participants' cognitive functions and functional capacity using the Brief Assessment of Cognition in Schizophrenia (BACS) and the UCSD Performance-based Skills Assessment, Brief Version (UPSA-B), respectively. Multivariate analysis of covariance was then adopted to determine inter-group differences in BACS and UPSA-B performance.

RESULTS

The BACS was capable of differentiating patients with a major psychiatric disorder (schizophrenia, MDD, and BD) from healthy subjects. Furthermore, schizophrenia patients had poorer motor speed performance than patients with affective disorders. The UPSA-B, particularly the financial portion, was able to distinguish schizophrenia patients from other groups. However, we did not observe any differences in UPSA-B performance between patients with mood disorders and the healthy controls. No significant difference between patients with BD and those with MDD were observed in either cognitive function or in functional capacity. The performances of the BACS and the UPSA-B were positively correlated, particularly in the MDD group.

CONCLUSION

Considering overall performance, the BACS and the UPSA-B characterize different endophenotyping profiles in the aforementioned four participant groups. Therefore, the results support the need for comprehensive assessments that target both cognitive function and functional capacity for patients with major psychiatric disorders.

Developing clinical cut-off scores for the university of California San Diego performance-based skills assessment in patients with schizophrenia

This study aimed to obtain University of California San Diego Performance-based Skill Assessment (UPSA) cut-off scores for the purpose of severity classification and to expand the clinical utility of the UPSA for the evaluation of cognitive function in patients with schizophrenia. In total, 191 patients with schizophrenia were recruited. The UPSA, Positive and Negative Symptom Scale (PANSS), Clinical Global Impression-Schizophrenia Scale (CGI-SCH), and Global Assessment Functioning Scale (GAF) were used for the evaluation. The cognitive symptoms item of the CGI-SCH was used as a reference and the subjects were divided into three groups: mild, moderate, and severe. The sensitivity and specificity of the UPSA were analyzed by receiver operating characteristic curves. There were significant differences in the UPSA, CGI-SCH, PANSS, and GAF scores among the groups. In the mild and moderate groups, a UPSA score of 59 was identified as the optimal cut-off score, and a score of 41 was identified as the optimal cut-off score in the moderate and severe groups. Severity can be classified using the UPSA score as follows: ≥ 60 for mild, 41-59 for moderate, and ≤ 40 for severe. The UPSA could be used to assess the degree of daily living dysfunction in patients with schizophrenia.