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

Treatment of social cognition in schizophrenia: Current status and future directions

Efforts to develop psychosocial interventions that specifically target social cognition in schizophrenia spectrum disorders began nearly two decades ago. The field has matured considerably since then and has engendered a great deal of optimism about this treatment approach. Indeed, the efficacy of social cognitive interventions, especially those that address multiple domains of social cognition, has received substantial support. This article critically evaluates the current evidence for social cognitive interventions, identifies limitations and open questions, and suggests priorities and directions for further research. Limitations of available studies include a frequent lack of methodological rigor, suboptimal selection of endpoints, and sparse evidence for generalization to functional improvements. We highlight several emerging psychosocial and non-psychosocial approaches that may enhance the efficacy of social cognitive interventions and promote generalization to improvements in real world functioning. We conclude that cautious optimism is warranted as the field moves forward into the next wave of social cognitive treatment studies.

Cognitive behavioural therapy plus standard care versus standard care for people with schizophrenia

BACKGROUND

Cognitive behavioural therapy (CBT) is a psychosocial treatment that aims to re-mediate distressing emotional experiences or dysfunctional behaviour by changing the way in which a person interprets and evaluates the experience or cognates on its consequence and meaning. This approach helps to link the person's feelings and patterns of thinking which underpin distress. CBT is now recommended by the National Institute for Health and Care Excellence (NICE) as an add-on treatment for people with a diagnosis of schizophrenia. This review is also part of a family of Cochrane CBT reviews for people with schizophrenia.

OBJECTIVES

To assess the effects of cognitive behavioural therapy added to standard care compared with standard care alone for people with schizophrenia.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (up to March 6, 2017). This register is compiled by systematic searches of major resources (including AMED, BIOSIS CINAHL, Embase, MEDLINE, PsycINFO, PubMed, and registries of clinical trials) and their monthly updates, handsearches, grey literature, and conference proceedings, with no language, date, document type, or publication status limitations for inclusion of records into the register.

SELECTION CRITERIA

We selected all randomised controlled clinical trials (RCTs) involving people diagnosed with schizophrenia or related disorders, which compared adding CBT to standard care with standard care given alone. Outcomes of interest included relapse, rehospitalisation, mental state, adverse events, social functioning, quality of life, and satisfaction with treatment.We included studies fulfilling the predefined inclusion criteria and reporting useable data.

DATA COLLECTION AND ANALYSIS

We complied with the Cochrane recommended standard of conduct for data screening and collection. Where possible, we calculated relative risk (RR) and its 95% confidence interval (CI) for binary data and mean difference (MD) and its 95% confidence interval for continuous data. We assessed risk of bias for included studies and created a 'Summary of findings' table using GRADE.

MAIN RESULTS

This review now includes 60 trials with 5,992 participants, all comparing CBT added to standard care with standard care alone. Results for the main outcomes of interest (all long term) showed no clear difference between CBT and standard care for relapse (RR 0.78, 95% CI 0.61 to 1.00; participants = 1538; studies = 13, low-quality evidence). Two trials reported global state improvement. More participants in the CBT groups showed clinically important improvement in global state (RR 0.57, 95% CI 0.39 to 0.84; participants = 82; studies = 2 , very low-quality evidence). Five trials reported mental state improvement. No differences in mental state improvement were observed (RR 0.81, 95% CI 0.65 to 1.02; participants = 501; studies = 5, very low-quality evidence). In terms of safety, adding CBT to standard care may reduce the risk of having an adverse event (RR 0.44, 95% CI 0.27 to 0.72; participants = 146; studies = 2, very low-quality evidence) but appears to have no effect on long-term social functioning (MD 0.56, 95% CI -2.64 to 3.76; participants = 295; studies = 2, very low-quality evidence, nor on long-term quality of life (MD -3.60, 95% CI -11.32 to 4.12; participants = 71; study = 1, very low-quality evidence). It also has no effect on long-term satisfaction with treatment (measured as 'leaving the study early') (RR 0.93, 95% CI 0.77 to 1.12; participants = 1945; studies = 19, moderate-quality evidence).

AUTHORS' CONCLUSIONS

Relative to standard care alone, adding CBT to standard care appears to have no effect on long-term risk of relapse. A very small proportion of the available evidence indicated CBT plus standard care may improve long term global state and may reduce the risk of adverse events. Whether adding CBT to standard care leads to clinically important improvement in patients' long-term mental state, quality of life, and social function remains unclear. Satisfaction with care (measured as number of people leaving the study early) was no higher for participants receiving CBT compared to participants receiving standard care. It should be noted that although much research has been carried out in this area, the quality of evidence available is poor - mostly low or very low quality and we still cannot make firm conclusions until more high quality data are available.

Relationships among functional capacity, cognition, and naturalistic skill performance in people with serious mental illness

There has been increasing interest in understanding real-world outcomes for individuals with serious mental illnesses (SMI). This study examined domain-specific skill knowledge, functional capacity, and neurocognition as predictors of naturalistic grocery shopping skill performance in forty-eight individuals with SMI. Participants completed measures of skill knowledge and general functional capacity (UCSD Performance-Based Skill Assessment - brief) as well as measures of neurocognition and symptoms. The Test of Grocery-Shopping Skills (TOGSS) assessed naturalistic shopping. TOGSS was significantly correlated with functional capacity, shopping skill knowledge, and neurocognition, but not symptoms. Multiple regression analysis was conducted with variables entered in 2 blocks. Skill knowledge and functional capacity were entered in block 1. Neurocognitive measures were entered in block 2 using forward entry. Skill knowledge was not a significant predictor of TOGSS when accounting for functional capacity and neurocognition. Functional capacity predicted TOGSS over and above skill knowledge and remained significant after accounting for the effects of neurocognition. Our findings indicate that functional capacity was associated with skill assessment under naturalistic conditions. Further, there was some, but not complete, overlap between neurocognitive and functional capacity predictors of naturalistic skill performance. Further development of naturalistic assessments may hold promise for interventions targeting real-world function.

Relationship of Interferon-γ to Cognitive Function in Midlife Women with Schizophrenia

Recent literature suggests that schizophrenia is linked to an abnormal response of the immune system. Interferon-γ is a cytokine that acts as a mediator between immune stimulation and the kynurenine pathway and may be related to cognitive abilities. The objectives of the present study are to determine if serum cytokines are correlated with cognitive function differently in patients with schizophrenia compared to controls. Fourteen midlife (30-70 year-old) females with DSM-IV diagnosis of schizophrenia or schizoaffective disorder and 13 midlife control females were analyzed. Cytokines were collected from serum blood draws and analyzed at the Cytokine Core Lab at the University of Maryland, Baltimore. The RBANS, HVLT-R, and UPSA were performed to measure cognition and social performance. The results demonstrate a non-significant difference between interferon-γ levels in women with schizophrenia compared to controls, but this cytokine appears to correlate to cognitive abilities differently in these groups. There were several significant negative correlations between interferon-γ and cognition in midlife patients with schizophrenia, but only one in the midlife control group. The negative correlations between interferon-γ and cognition in patients with schizophrenia suggest the hypothesis that inflammation and the kynurenine pathway have important roles in this disorder.

Potential Role of Antipsychotic-Galantamine-Memantine Combination in the Treatment of Positive, Cognitive, and Negative Symptoms of Schizophrenia

Schizophrenia is, in part, a cognitive illness. There are no approved medications for cognitive impairments associated with schizophrenia (CIAS) and primary negative symptoms. Cholinergic and glutamatergic systems, alpha-7 nicotinic acetylcholine (α-7nACh) and N-methyl-D-aspartate (NMDA) receptors, kynurenic acid (KYNA), and mismatch negativity have been implicated in the pathophysiology of CIAS and negative symptoms. Galantamine is an acetylcholinesterase inhibitor that is also a positive allosteric modulator at the α4β2 and α7nACh receptors. Memantine is a noncompetitive NMDA receptor antagonist. Galantamine and memantine alone and in combination were effective for cognition in animals and people with Alzheimer's disease. The objective of this article is to critically dissect the published randomized controlled trials with galantamine and memantine for CIAS to highlight the efficacy signal. These studies may have failed to detect a clinically meaningful efficacy signal due to limitations, methodological issues, and possible medication nonadherence. There is evidence from a small open-label study that the galantamine-memantine combination may be effective for CIAS with kynurenine pathway metabolites as biomarkers to detect the severity of cognitive impairments. Given that there are no available treatments for cognitive impairments and primary negative symptoms in schizophrenia, testing of this "five-pronged strategy" (quintuple hypotheses: dopamine, nicotinic-cholinergic, glutamatergic/NMDA, GABA, and KYNA) is a "low-risk high-gain" approach that could be a major breakthrough in the field. The galantamine-memantine combination has the potential to treat positive, cognitive, and negative symptoms, and targeting the quintuple hypotheses concurrently may lead to a major scientific advancement - from antipsychotic treatment to antischizophrenia treatment.

Role of frontal white matter and corpus callosum on social function in schizophrenia

Patients with schizophrenia show severe impairment in social function and have difficulty in their daily social life. Although a recent large-scale multicenter study revealed alterations in white matter microstructures, the association between these anatomical changes and social dysfunction in schizophrenia remains unknown. Therefore, we investigated the association between the white matter integrity of regions of interest and social function in schizophrenia. A total of 149 patients with schizophrenia and 602 healthy comparison subjects (HCS) underwent DTI and completed the Picture Arrangement subtest of the Wechsler Adult Intelligence Scale-Third Edition and the Finance subscale of the University of California, San Diego, Performance-Based Skills Assessment Brief, as social indices of interest. The fractional anisotropy (FA) in the anterior corona radiata and corpus callosum was significantly lower in patients than in HCS, and the radial diffusivity (RD) in the anterior corona radiata and corpus callosum was significantly higher in patients. The Picture Arrangement and Finance scores were both significantly impaired in patients. The effect of the FA of the right anterior corona radiata on the Finance score and the Picture Arrangement score, of the RD of the right anterior corona radiata on the Picture Arrangement score, and of the RD of the corpus callosum on the Picture Arrangement score were significant. In conclusion, our results confirmed the association between structural connectivity in the right frontal white matter and corpus callosum and social function in schizophrenia. These findings may provide a foundation for developing an intervention for functional recovery in schizophrenia.

Clinical evaluation of functional capacity in treatment resistant schizophrenia patients: Comparison and differences with non-resistant schizophrenia patients

Treatment resistant schizophrenia (TRS) is defined by poor or non-response to conventional antipsychotic agents. Functional capacity is defined as the baseline potential of a patient to function in the community, irrespective of actual achievements gained, and has never been studied in TRS. Here, we screened 182 patients with psychotic symptoms and separated them in TRS (n = 28) and non-TRS (n = 32) ones, to evaluate whether they exhibited differential extents and predictive clinical variables of functional capacity. Functional capacity was measured by the UCSD Performance-Based Skills Assessment (UPSA). Psychotic symptoms by PANSS, social functioning by PSP and SLOF, clinical severity of the illness, cognitive functioning, and neurological soft signs (NSS) were assessed. TRS patients had non-significant lower UPSA scores compared to non-TRS (t-test: p > 0.05). In TRS, UPSA score correlated with multiple clinical variables. The highest effect sizes were observed for PANSS negative score (r = -0.67, p < 0.005); SLOF Area1 score (r = 0.66, p < 0.005); NSS severity (r = -0.61, p < 0.005). Multivariate analysis showed that main predictors of UPSA score in TRS patients were PANSS negative score, education years, NSS, Problem Solving performances, and PSP score (F = 11.12, R² = 0.75, p < 0.0005). These variables were not predictive of UPSA score in non-TRS patients. Hierarchical analysis found that variance in UPSA score mainly depended on negative symptoms, NSS, and problem solving (F = 15.21, R² = 0.65, p < 0.0005). Path analysis individuated two separate paths to UPSA score. These results delineate a limited and independent group of candidate predictors to be putatively accounted for therapeutic interventions to improve functional capacity, and possibly social functioning, in TRS patients.

A Novel hAPP/htau Mouse Model of Alzheimer's Disease: Inclusion of APP With Tau Exacerbates Behavioral Deficits and Zinc Administration Heightens Tangle Pathology

The brains of those with Alzheimer's disease have amyloid and tau pathology; thus, mice modeling AD should have both markers. In this study, we characterize offspring from the cross of the J20 (hAPP) and rTg4510 (htau) strains (referred to as dual Tg). Behavior was assessed at both 3.5 and 7 months, and biochemical differences were assessed at 8 months. Additionally, mice were placed on zinc (Zn) water or standard lab water in order to determine the role of this essential biometal. Behavioral measures examined cognition, emotion, and aspects of daily living. Transgenic mice (dual Tg and htau) showed significant deficits in spatial memory in the Barnes Maze at both 3.5 and 7 months compared to controls. At 7 months, dual Tg mice performed significantly worse than htau mice (p < 0.01). Open field and elevated zero maze (EZM) data indicated that dual Tg and htau mice displayed behavioral disinhibition compared to control mice at both 3.5 and 7 months (p < 0.001). Transgenic mice showed significant deficits in activities of daily living, including burrowing and nesting, at both 3.5 and 7 months compared to control mice (p < 0.01). Dual Tg mice built very poor nests, indicating that non-cognitive tasks are also impacted by AD. Overall, dual Tg mice demonstrated behavioral deficits earlier than those shown by the htau mice. In the brain, dual Tg mice had significantly less free Zn compared to control mice in both the dentate gyrus and the CA3 of the hippocampus (p < 0.01). Dual Tg mice had increased tangles and plaques in the hippocampus compared to htau mice and the dual Tg mice given Zn water displayed increased tangle pathology in the hippocampus compared to htau mice on Zn water (p < 0.05). The dual Tg mouse described here displays pathology reminiscent of the human AD condition and is impaired early on in both cognitive and non-cognitive behaviors. This new mouse model allows researchers to assess how both amyloid and tau in combination impact behavior and brain pathology.

Resistance is not futile: treatment-refractory schizophrenia - overview, evaluation and treatment

INTRODUCTION

Schizophrenia is a debilitating condition with three main symptom domains: positive, negative, and cognitive. Approximately one-third of persons with schizophrenia will fail to respond to treatment. Growing evidence suggests that treatment-resistant (refractory) schizophrenia (TRS) may be a distinct condition from treatment-respondent schizophrenia. There is limited evidence on effective treatments for TRS, and a lack of standardized diagnostic criteria for TRS has hampered research. Areas covered: A literature search was conducted using Pubmed.gov and the EMBASE literature database. The authors discuss the pragmatic definitions of TRS and review treatments consisting of antipsychotic monotherapy and augmentation strategies. Expert opinion: Currently available first-line antipsychotic medications are generally effective at treating the positive symptoms of schizophrenia, leaving residual negative and cognitive symptoms. Before diagnosing TRS, rule out any pharmacodynamic or pharmacokinetic failures. Most evidence supports clozapine as having the most efficacy for TRS. If clozapine is used, it should be optimized, and serum levels should be at least 350-420 ng/ml. If clozapine is unable to be tolerated, some evidence suggests olanzapine at dosages up to 40mg/day can be useful. Augmentation strategies have weak evidence. Tailoring treatment to the specific domain is the preferred approach, and the use of a structured assessment/outcome measure is encouraged.

Effects of recombinant human erythropoietin on cognition and neural activity in remitted patients with mood disorders and first-degree relatives of patients with psychiatric disorders: a study protocol for a randomized controlled trial

Background

Bipolar disorder (BD) and unipolar disorder (UD) are associated with cognitive deficits and abnormal neural activity in a “cognitive control network.” There is an increased prevalence of cognitive dysfunction in psychiatric patients’ first-degree relatives, which constitutes a risk factor for psychiatric illness onset. However, there is no treatment with enduring pro-cognitive efficacy. We found preliminary evidence for beneficial effects of eight weekly doses of recombinant human erythropoietin (EPO) on cognition in BD in a recent randomized controlled trial (RCT). The present RCT consists of two sub-studies that extend our previous work by investigating important novel aspects: (1) the effects of 12 weekly doses of EPO on cognition in first-degree relatives of patients with BD, UD, or schizophrenia; and (2) the effects of extending the treatment schedule from 8 to 12 weeks in remitted patients with BD or UD; and (3) assessment of early treatment-associated neural activity changes that may predict cognitive improvement.

Methods

The trial comprises two parallel sub-studies with randomized, controlled, double-blinded, parallel group designs. First-degree relatives (sub-study 1; n = 52) and partially or fully remitted patients with BD or UD (sub-study 2; n = 52) with objectively verified cognitive dysfunction are randomized to receive weekly high-dose EPO (40,000 IU/mL) or placebo (saline) infusions for 12 weeks. Assessments of cognition and mood are conducted at baseline, after two weeks of treatment, after treatment completion, and at six-month follow-up. Functional magnetic resonance imaging (fMRI) is conducted at baseline and after two weeks of treatment. Psychosocial function is assessed at baseline, after treatment completion and six-month follow-up. The primary outcome is change in a cognitive composite score of attention, verbal memory, and executive functions. Statistical power of ≥ 80% is reached to detect a clinically relevant between-group difference by including 52 first-degree relatives and 52 patients with BD or UD, respectively. Behavioral data are analyzed with an intention-to-treat approach using mixed models. fMRI data are analyzed with the FMRIB Software Library.

Discussion

If this trial reveals pro-cognitive effects of EPO, this may influence future treatment of mood disorders and/or preventive strategies in at-risk populations. The fMRI analyses may unravel key neurobiological targets for pro-cognitive treatment.

Trial registration

ClinicalTrials.gov, NCT03315897. Registered on 20 October 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2995-7) contains supplementary material, which is available to authorized users.

Developing a dynamic model of anomalous experiences and function in young people with or without psychosis: a cross-sectional and longitudinal study protocol

INTRODUCTION

Anomalous experiences are common within the general population, but the frequency and intensity is increased in young people with psychosis. Studies have demonstrated that perceptual biases towards noticing these phenomena plays a role, but the way one thinks about one's experience (metacognition) may also be relevant. While poor metacognitive function has been theoretically associated with anomalous experiences, this relationship is currently unclear. However, metacognition may work along a continuum with various metacognitive levels, many of which have been demonstrated as impaired in psychosis. These metacognitive components may interact via processes that maintain poor metacognition across levels, and that potentially impact both what people do in their everyday lives (functional outcome) and how people feel about their everyday lives (subjective recovery outcome) in young people with psychosis compared with healthy control participants.

METHODS AND ANALYSIS

This study will investigate the association and contribution of metacognition to anomalous experiences and outcome measures cross-sectionally and longitudinally in a 36-month follow-up. First, young people with psychosis will be compared with healthy control participants on selected measures of anomalous experience, metacognition, and function, using analysis of covariance to identify group differences. Next, the relationship between metacognitive components and processes will be explored, including processes connecting the different components, using regression analyses. Finally, mediation analyses will be used to assess the predictive value of metacognitive measures on outcome measures, both cross-sectionally and longitudinally at 36 months, while controlling for symptoms and cognition.

ETHICS AND DISSEMINATION

Ethical and Health Research Authority approval has been obtained through Camberwell St. Giles Research Ethics Committee (reference number: 17/LO/0055). This research project will be reported within a PhD thesis and submitted for journal publication. Once key predictive components of poor outcome in psychosis are identified, this study will develop a series of dynamic models to understand influences on outcome for young people with psychosis.

Cognitive and functional deficits in bipolar disorder and schizophrenia as a function of the presence and history of psychosis

OBJECTIVES

Schizophrenia and bipolar disorder overlap considerably. Schizophrenia is a primary psychotic disorder, whereas approximately half of people with bipolar disorder will experience psychosis. In this study, we examined the extent to which cognitive and functional impairments are related to the presence and history of psychosis across the two disorders.

METHOD

A total of 633 participants with bipolar disorder I, schizophrenia, and schizoaffective disorder were recruited for a study on the genetics of cognition and functioning in bipolar disorder and schizophrenia. Participants were classified into five groups: bipolar disorder with current psychosis (N = 30), bipolar disorder with a history of psychosis (N = 162), bipolar disorder with no history of psychosis (N = 92), schizophrenia with current psychosis (N = 245), and schizophrenia with past psychosis (N = 104).

RESULTS

Cognitive profiles of all groups were similar in pattern; however, both current psychosis (P < .02) and a diagnosis of schizophrenia (P < .03) were associated with greater impairment. Schizophrenia with current psychosis was also associated with a superimposed severe impairment in processing speed. Both psychosis (P < .03) and schizophrenia diagnosis (P < .01) were associated with poorer functional competence. Individuals with bipolar disorder and schizophrenia experienced similar impairments in real-world functioning if they were experiencing current psychosis (P = .32).

CONCLUSION

The presence of active psychosis is an important cross-diagnostic factor in cognition and functioning in both schizophrenia and bipolar disorder. Characterization and treatment of cognition and functional deficits in bipolar disorder should consider the effects of both current and history of psychosis.

Impaired Midline Theta Power and Connectivity During Proactive Cognitive Control in Schizophrenia

BACKGROUND

Disrupted proactive cognitive control, a form of early selection and active goal maintenance, is hypothesized to underlie the broad cognitive deficits observed in patients with schizophrenia (SPs). Current research suggests that the disrupted activation within and connectivity between regions of the cognitive control network contribute to disrupted proactive cognitive control; however, no study has examined these mechanisms using an AX Continuous Performance Test task in schizophrenia.

METHODS

Twenty-six SPs (17 male subjects; mean age 34.46 ± 8.77 years) and 28 healthy control participants (HCs; 16 male subjects; mean age 31.43 ± 7.23 years) underwent an electroencephalogram while performing the AX Continuous Performance Test. To examine the extent of activation and level of connectivity within the cognitive control network, power, intertrial phase clustering, and intersite phase clustering metrics were calculated and analyzed.

RESULTS

SPs exhibited expected general decrements in behavioral performance relative to HCs and a more selective deficit in conditions requiring proactive cognitive control. Additionally, SPs exhibited deficits in midline theta power and connectivity during proactive cognitive control trials. Specifically, HCs exhibited significantly greater theta power for B cues relative to A cues, whereas SPs exhibited no significant differences between A- and B-cue theta power. Additionally, differential theta connectivity patterns were observed in SPs and HCs. Behavioral measures of proactive cognitive control predicted functional outcomes in SPs.

CONCLUSIONS

This study suggests that low-frequency midline theta activity is selectively disrupted during proactive cognitive control in SPs. The disrupted midline theta activity may reflect a failure of SPs to proactively recruit cognitive control processes.

Evaluation of a few discrete clinical markers may predict categorization of actively symptomatic non-acute schizophrenia patients as treatment resistant or responders: A study by ROC curve analysis and multivariate analyses

Here, we used Receiver Operating Characteristic (ROC) curve analysis to determine whether clinical factors may aid predicting the categorization of schizophrenia patients as Treatment Resistant (TRS) or antipsychotic responsive schizophrenia (ARS). Patients with an established condition of TRS or ARS were assessed for: clinical presentation and course; neurological soft signs (NES); psychopathology by PANSS; cognitive performances; quality of life scale (QLS); functional capacity; social functioning (PSP and SLOF scales). In ROC curve analysis, significance indicated that the Area under curve (AUC) allowed distinguishing between TRS and ARS. Multivariate analyses were additionally used to provide independent predictive analysis. Multiple clinical variables showed significant AUCs. The largest significant AUCs were found for: NES total score; SLOF Area2; QLS subscale; antipsychotic doses. The highest sensitivity was found for NES total score, the highest specificity for previous hospitalizations. The highest Odds Ratio of being included within the TRS category were found for: NES total score (7.5); QLS total score (5.49); and previous hospitalizations (4.76). This same circumscribed group of variables was also found to be predictive of TRS when adopting stepwise logistic regression or discriminant analysis. We concluded that the evaluation of few clinical factors may provide reliable and accurate predictions on whether one schizophrenia patient may be categorized as a TRS.

Validation of a performance-based assessment of cognitive functional ability in Parkinson's disease

BACKGROUND

Outcome measures that capture functional abilities related to cognition offer the potential to demonstrate real-world effectiveness of cognitive-enhancing treatments. However, distinguishing functional disability related to cognition from that attributed to motor symptoms can be difficult in PD. A performance-based functional assessment allows for direct observation of activity of daily living skills and separation of cognitive from motoric disabilities.

OBJECTIVES

Validate the University of California San Diego Performance-Based Skills Assessment in PD.

METHODS

One hundred PD participants, ranging from normal cognition to dementia, completed the University of California San Diego Performance-Based Skills Assessment, a performance-based measure of cognitively demanding activities of daily living, as well as a neuropsychological battery and motor examination. Cognitive classification was determined by consensus conference, blinded to University of California San Diego Performance-Based Skills Assessment scores. Psychometric properties of the University of California San Diego Performance-Based Skills Assessment, including internal consistency, test-retest and inter-rater reliability, and discriminant validity for dementia, were examined.

RESULTS

The University of California San Diego Performance-Based Skills Assessment demonstrated strong internal consistency (Cronbach's α = 0.82) and test-retest reliability (r = 0.89) and correlated strongly with global cognition (Mattis Dementia Rating Scale: r = 0.80; P < 0.001). University of California San Diego Performance-Based Skills Assessment regression models indicated greater contribution from cognitive explanatory variables (marginal partial: R2  = 0.33) than motor variables (marginal partial: R2  = 0.05), controlling for age, education, disease duration, and l-dopa equivalent dose. Additionally, the University of California San Diego Performance-Based Skills Assessment exhibited strong discriminant validity for dementia (area under the curve = 0.91).

CONCLUSIONS

The University of California San Diego Performance-Based Skills Assessment is a valid measure of functional abilities related to cognition rather than motor symptoms in PD. Furthermore, it reliably distinguishes demented from nondemented participants. The University of California San Diego Performance-Based Skills Assessment may be considered as an outcome measure that combines cognitive and functional abilities in treatment trials for cognitive impairment in PD. © 2018 International Parkinson and Movement Disorder Society.

An approach to directly link ICA and seed-based functional connectivity: Application to schizophrenia

Independent component analysis (ICA) and seed-based analyses are widely used techniques for studying intrinsic neuronal activity in task-based or resting scans. In this work, we show there is a direct link between the two, and show that there are some important differences between the two approaches in terms of what information they capture. We developed an enhanced connectivity-matrix independent component analysis (cmICA) for calculating whole brain voxel maps of functional connectivity, which reduces the computational complexity of voxel-based connectivity analysis on performing many temporal correlations. We also show there is a mathematical equivalency between parcellations on voxel-to-voxel functional connectivity and simplified cmICA. Next, we used this cost-efficient data-driven method to examine the resting state fMRI connectivity in schizophrenia patients (SZ) and healthy controls (HC) on a whole brain scale and further quantified the relationship between brain functional connectivity and cognitive performances measured by the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) battery. Current results suggest that SZ exhibit a wide-range abnormality, primarily a decrease, in functional connectivity both between networks and within different network hubs. Specific functional connectivity decreases were associated with MATRICS performance deficits. In addition, we found that resting state functional connectivity decreases was extensively associated with aging regardless of groups. In contrast, there was no relationship between positive and negative symptoms in the patients and functional connectivity. In sum, we have developed a novel mathematical relationship between ICA and seed-based connectivity that reduces computational complexity, which has broad applicability, and showed a specific application of this approach to characterize connectivity changes associated with cognitive scores in SZ.

Predictors of residency status in chronically institutionalized and community dwelling schizophrenia patients

BACKGROUND

This cross-sectional study contrasted chronically hospitalized schizophrenia (SZ) spectrum disorder inpatients to SZ community dwelling patients on measures of psychopathology, social competence, neuropsychological performance and real-world functioning in order to discern factors predictive of patients' residency status and to characterize the contrasting ends of the SZ outcome continuum.

METHOD

Subjects included 26 chronic SZ patients hospitalized continuously on average for 12.8 years, and 26 SZ patients with a history of at least 18 months tenure in community placement.

RESULTS

A series of multivariate analyses revealed both chronically hospitalized and community dwelling patients were similar in terms of their real world functioning abilities such as work skills, interpersonal skills, self-care skills and community engagement. Chronic SZ inpatients' manifested more severe functional competency and neurocognitive deficits relative to outpatients. Additionally, chronic inpatients were discriminated from community dwelling outpatients by their symptom severity and commitment of more socially undesirable/antisocial type behaviors.

CONCLUSIONS

Factors associated with chronic institutionalization are, in part, related to commission of antisocial type behaviors, as well as poor social and neurocognitive competences, and total symptom severity rather than deficits in everyday functional abilities.

Social Cognitive Skills Training for Psychosis With Community-Based Training Exercises: A Randomized Controlled Trial

Impairments in social cognition are key determinants of poor functioning in psychosis and an important new target for treatment development. Initial studies support the feasibility and efficacy of training interventions for social cognition, but have been small and have had substantial methodological limitations. This report describes the largest rigorously controlled study of a social cognitive treatment to date. We evaluated the efficacy of a refined version of the 24-session Social Cognitive Skills Training (SCST) program, and whether adding in vivo training sessions in community settings would enhance generalization to functional improvements. One hundred thirty-nine outpatients with psychotic disorders were randomly assigned to one of 3 time- and format-matched conditions: (1) SCST plus in vivo community-based training, (2) SCST plus clinic-based training, or (3) Illness management control condition. SCST targeted the domains of emotion processing, social perception, attributional bias, empathy, and mentalizing. Assessments of social cognition, nonsocial cognition, symptoms, and functioning were completed at baseline, mid-treatment, posttreatment, and 3-month follow-up. On the primary social cognitive outcome measures, there was significant, durable SCST-related improvement in facial emotion identification. There was also a significant SCST benefit for emotional intelligence and an in vivo training effect for empathy, though these improvements were not durable. Further, there were no overall or in vivo-related changes in functioning. This study bolsters and extends support for the efficacy of SCST in a relatively large and rigorously controlled trial, although our effort to enhance generalization to functional improvements through in vivo community-based training was not successful.

The Relationship of Motivation and Neurocognition with Functionality in Schizophrenia: A Meta-analytic Review

The role that neurocognition plays in functionality in schizophrenia has been widely examined, although in recent years increasing attention has been paid to the influence of motivation instead. This study provides a review of the relationship of neurocognition and motivation with functionality in schizophrenia, taking into account objective/subjective functionality assessment, demographic variables, and the different terms used when referring to motivation. A search of electronic databases identified 34 studies that met the inclusion criteria for review. Correlation coefficients between motivation and functionality and between neurocognition and functionality were extracted. For a better understanding, potential moderator variables were also extracted. Meta-analysis showed that both motivation and neurocognition assessments were strongly associated with functioning, with correlations between motivation and functional outcomes being stronger. However, more than three-quarters of the variance in outcome remained unexplained by the moderating factors examined. The paper concludes with recommendations for clinical practice and future research.

Effect of action-based cognitive remediation on cognition and neural activity in bipolar disorder: study protocol for a randomized controlled trial

BACKGROUND

Cognitive impairment is present in bipolar disorder (BD) during the acute and remitted phases and hampers functional recovery. However, there is currently no clinically available treatment with direct and lasting effects on cognitive impairment in BD. We will examine the effect of a novel form of cognitive remediation, action-based cognitive remediation (ABCR), on cognitive impairment in patients with BD, and explore the neural substrates of potential treatment efficacy on cognition.

METHODS/DESIGN

The trial has a randomized, controlled, parallel-group design. In total, 58 patients with BD in full or partial remission aged 18-55 years with objective cognitive impairment will be recruited. Participants are randomized to 10 weeks of ABCR or a control group. Assessments encompassing neuropsychological testing and mood ratings, and questionnaires on subjective cognitive complaints, psychosocial functioning, and quality of life are carried out at baseline, after 2 weeks of treatment, after the end of treatment, and at a six-month-follow-up after treatment completion. Functional magnetic resonance imaging scans are performed at baseline and 2 weeks into treatment. The primary outcome is a cognitive composite score spanning verbal memory, attention, and executive function. Two complete data sets for 52 patients will provide a power of 80% to detect a clinically relevant between-group difference on the primary outcome. Behavioral data will be analyzed using mixed models in SPSS while MRI data will be analyzed with the FMRIB Expert Analysis Tool (FEAT). Early treatment-related changes in neural activity from baseline to week 2 will be investigated for the dorsal prefrontal cortex and hippocampus as the regions of interest and with an exploratory whole-brain analysis.

DISCUSSION

The results will provide insight into whether ABCR has beneficial effects on cognition and functioning in remitted patients with BD. The results will also provide insight into early changes in neural activity associated with improvement of cognition, which can aid future treatment development.

TRIAL REGISTRATION

Clinicaltrials.gov , NCT03295305 . Registered on 26 September 2017.

Transcranial magnetic stimulation intervention in Alzheimer's disease: a research proposal for a randomized controlled trial

Objective

Alzheimer’s disease is a major health problem in our society. To date, pharmacological treatments have obtained poor results and there is a growing interest in finding non-pharmacological interventions for this disease. Transcranial magnetic stimulation (TMS) is a non-invasive technique that is able to induce changes in brain activity and long-term modifications in impaired neural networks, becoming a promising clinical intervention. Our goal is to study the benefit of individualized TMS targeting based on the patient’s functional connectivity (personalized targeting), and short duration TMS protocol, instead of current non-individualized and longer session approaches. A double blind randomized controlled trial will be conducted to assess the effects of TMS treatment immediately, 1 month, 3 months and 6 months after the end of the intervention. Fifty-four patients with a diagnosis of Alzheimer’s disease will be randomly allocated into experimental (active TMS), sham control, or conventional intervention control group. We will quantify changes in cognitive, functional, and emotional deficits in Alzheimer patients, as well as the functional connectivity changes induced by the TMS treatment.

Results

We expect to demonstrate that personalized TMS intervention has a measurable positive impact in cognition, emotion, daily living activities and brain connectivity, thus representing a potential treatment for Alzheimer’s disease.

Trial registration The trial has been prospectively registered at ClinicalTrials.gov, identifier NCT03121066. Date of registration: 04/19/2017

Social cognitive impairments in individuals with schizophrenia vary in severity

Social cognitive deficits are a hallmark feature of schizophrenia and have been confirmed by several meta-analyses; however, the uniformity of these impairments across individuals remains unknown. The present study evaluated the heterogeneity of social cognitive impairment. A secondary aim was to identify a subset of measures to quickly identify those individuals who are most in need of remediation. Two independent samples of people with schizophrenia (n = 176; n = 178) and their respective healthy control groups (n = 104; n = 154) were selected from two phases of the Social Cognition Psychometric Evaluation (SCOPE) project, which assessed multiple domains of social cognition. Latent profile analysis was utilized to identify sub-clusters of performance within each patient sample. Receiver operator curve and discriminant analysis were implemented to identify tasks suitable as screening tools. Three clusters were identified in each sample that differed primarily in severity of impairment. The first showed no social cognitive impairment (∼25% of patients). The second consisted of patients with mild impairment (∼40% of each sample), and the third showed severe SC impairment (∼32%). Patients in the severe cluster were older, less educated, more neurocognitively impaired, and lower functioning. Using the Bell Lysaker Emotion Recognition Task (BLERT) for screening provided sensitivity of 80.15% and specificity 89.13%. Combining BLERT with the Reading the Mind in the Eyes task yielded sensitivity of 91.60% and specificity 75.00% for identifying impaired individuals. These results illustrate the existence of distinct degrees of social cognitive impairment in schizophrenia and indicate that remediation efforts may not be necessary for all individuals.

A systematic review of a functional assessment Tool: UCSD Performance-based skill assessment (UPSA)

Performance based assessment instruments have been employed in functional capacity measurement of mental disorders. The aim of this systematic review was to identify the psychometric properties of the UCSD Performance-based Skill Assessment (UPSA). A search was conducted using the PRISMA protocol and 'UPSA' as key word term on electronic databases, with a date range for articles published from 2001-2017. Published studies involving community-dwelling adults were included. Pharmacological and/or clinical interventions involving clinical outcomes and/or institutionalized samples were excluded. Data related to construct validity, test-retest reliability and sensitivity/specificity were extracted, summarized and analyzed according to UPSA versions and psychiatric disorders. Fifty-eight studies including 8782 Community-dwelling adults met selection criteria. Data supporting the construct and known-groups validity were extracted from 41 studies involving Schizophrenia and schizoaffective disorders and 17 studies involving other metal illness. The UPSA was culturally adapted to 8 different languages and employed in 17 countries. Few studies reported sensitivity and specificity and the cut-off points could not be generalized. Moderate to strong evidence of construct validity and test-retest reliability was found. Few studies proposed cut-off points. The UPSA showed good psychometric properties in different versions including those culturally adapted.

Comparison of performance-based assessment and real world skill in people with serious mental illness: Ecological validity of the Test of Grocery Shopping Skills

Valid functional measures are essential for clinical and research efforts that address recovery and community functioning in people with serious mental illness. Although there is a great deal of interest in functional assessment, there is limited research supporting how well current evaluation methods provide a true assessment of real world functioning or naturalistic behavior. To address this gap in the literature, the present study examined the performance of individuals with serious mental illness (i.e., diagnosis of schizophrenia-spectrum, bipolar disorder, or other depression/anxiety diagnoses and accompanying functional disability) on the Test of Grocery Shopping Skills (TOGSS), a performance-based naturalistic task. We compared TOGSS performance to two dimensions of real world functioning: directly observed real world grocery shopping and ratings of community functioning. Results indicated that the TOGSS was significantly associated with real life grocery shopping, in terms of both shopping accuracy (r = 0.424) and time (r = 0.491). Further, self-report and observer-rated methods of assessing real world shopping behaviors were significantly correlated (r = 0.455). To our knowledge, this is one of the first studies to directly compare a performance-based naturalistic skill assessment with carefully observed real world performance of that skill in people with serious mental illness. These findings support the feasibility and ecological validity of performance-based naturalistic assessment with the TOGSS.

Overview of measurement-based positive psychiatry

BACKGROUND

Psychiatry has traditionally focused on studying psychopathology and treating mental illnesses to relieve symptoms and prevent relapse. Positive psychiatry seeks to expand the scope of psychiatry to broader aspects of mental health and well-being among individuals with or without mental illnesses. Positive psychosocial factors such as well-being, resilience, optimism, wisdom, and social support are central to positive psychiatry.

AIM

To summarize the emerging science of positive psychiatry, emphasizing the use of measures of positive characteristics and outcomes relevant to mental health.

METHODS

Overview of recent research in positive psychiatry, focusing on measurements.

RESULTS

Positive psychosocial factors are associated with better mental and physical health in diverse populations. Among individuals with serious mental illnesses, levels of these factors vary considerably, but positive psychiatry interventions can improve well-being and rates of recovery in at least subsets of the patients. A number of measures of positive factors and outcomes are available; most of them are based on self-reports, which have advantages as well as limitations.

CONCLUSIONS

Positive psychiatry has the potential to improve the health and well-being of individuals with or without mental illnesses. Further research is needed to provide clinicians and investigators with a full tool-box of validated measures for positive psychosocial factors and outcomes. These measures should be subjected to rigorous psychometric evaluation across populations to help clarify mechanisms underlying positive factors, evaluate their longitudinal trajectories, and examine the impact of interventions on health and well-being over the lifespan in different clinical groups.

Clinical Utility of Select Neuropsychological Assessment Battery Tests in Predicting Functional Abilities in Dementia

OBJECTIVE

Neuropsychological test performance can provide insight into functional abilities in patients with dementia, particularly in the absence of an informant. The relationship between neuropsychological measures and instrumental activities of daily living (IADLs) is unclear due to hetereogeneity in cognitive domains assessed and neuropsychological tests administered. Practical and ecologically valid performance-based measures of IADLs are also limited. The Neuropsychological Assessment Battery (NAB) is uniquely positioned to provide a dual-purpose assessment of cognitive and IADL function, as it includes Daily Living tests that simulate real-world functional tasks. We examined the utility of select NAB tests in predicting informant-reported IADLs in mild cognitive impairment and dementia.

METHODS

The sample of 327 participants included 128 normal controls, 97 individuals with mild cognitive impairment, and 102 individuals with Alzheimer's disease dementia from the Boston University Alzheimer's Disease Center research registry. Informants completed the Lawton Brody Instrumental Activities of Daily Living Scale, and study participants were administered selected NAB tests that were complementary to the existing protocol.

RESULTS

ROC curves showed strongest prediction of IADL (AUC > 0.90) for memory measures (List Learning delayed recall and Daily Living Memory delayed recall) and Daily Living Driving Scenes. At a predetermined level of specificity (95%), List Learning delayed recall (71%) and Daily Living Memory delayed recall (88%) were the most sensitive. The Daily Living Memory and Driving Scenes tests strongly predicted IADL status, and the other Daily Living tests contributed unique variance.

CONCLUSIONS

NAB memory measures and Daily Living Tests may have clinical utility in detecting informant-rated functional impairment in dementia.

Functional competence in major depressive disorder: Objective performance and subjective perceptions

BACKGROUND

Major depressive disorder (MDD) is increasingly recognized as a disorder of everyday functioning. Multi-level approaches to investigating functioning have been employed in other conditions whereby competence (ability to perform living skills) is distinguished from real-world functioning, but not yet in MDD. We used a multidimensional (adaptive and interpersonal), multi-level (competence and performance) approach to investigate differences between those with MDD and healthy comparisons (HC) on measures of competence, functional disability, and self-perceived competence.

METHODS

Between-group analysis of variance identified differences between MDD (n = 42) and HC (n = 24). Moderation analysis determined whether the strength of the relationship between competence accuracy and self-perception of performance was related to group membership.

RESULTS

In adaptive and interpersonal domains, the MDD group performed significantly lower on competence tasks, endorsed greater functional disability, and reported lower self-perception of competence. Group membership did not moderate the relationship between competence and self-perceived competence in the adaptive domain. Significant moderation was observed in the interpersonal domain such that competence and self-perception of abilities converged in the HC, but not MDD, group.

LIMITATIONS

A cross-sectional design precluded the ability to interpret causality of results. Functional disability was measured by interview, thereby susceptible to biases in self-report.

CONCLUSIONS

A multi-level approach to assessing functioning in MDD was supported. Performance-based measures of functional competence are sensitive to MDD and useful for research trials and clinical work to objectively track everyday living skills. Objective measurement is further supported, as those with depression are less likely to accurately evaluate their own abilities, even after demonstrating skills.

Multimodal Neuroimaging in Schizophrenia: Description and Dissemination

In this paper we describe an open-access collection of multimodal neuroimaging data in schizophrenia for release to the community. Data were acquired from approximately 100 patients with schizophrenia and 100 age-matched controls during rest as well as several task activation paradigms targeting a hierarchy of cognitive constructs. Neuroimaging data include structural MRI, functional MRI, diffusion MRI, MR spectroscopic imaging, and magnetoencephalography. For three of the hypothesis-driven projects, task activation paradigms were acquired on subsets of ~200 volunteers which examined a range of sensory and cognitive processes (e.g., auditory sensory gating, auditory/visual multisensory integration, visual transverse patterning). Neuropsychological data were also acquired and genetic material via saliva samples were collected from most of the participants and have been typed for both genome-wide polymorphism data as well as genome-wide methylation data. Some results are also presented from the individual studies as well as from our data-driven multimodal analyses (e.g., multimodal examinations of network structure and network dynamics and multitask fMRI data analysis across projects). All data will be released through the Mind Research Network's collaborative informatics and neuroimaging suite (COINS).

Cognitive and functional deficits in people with schizophrenia: Evidence for accelerated or exaggerated aging?

Cognitive and functional deficits are commonly seen in people with schizophrenia. The profile of these impairments has a resemblance to the cognitive changes seen in healthy aging. In specific, many of the cognitive ability domains that change the most with aging in healthy people are the most salient of these deficits seen in people with schizophrenia, including prominent deficits in processing speed, working memory, and episodic memory. Functional deficits seen in schizophrenia are also similar to those seen in healthy aging. There is a relationship between multiple psychotic relapses and treatment resistance and longitudinal cognitive and functional changes in schizophrenia, with this relationship starting early in the course of illness. Cognitive performance in people with schizophrenia may be consistent with accelerated or premature aging. People with schizophrenia perform similarly to healthy people who are 3 or more decades older on indices of both cognition and their everyday functional skills. Some people with schizophrenia show exaggerated cognitive changes as well. Cognitive and functional performance worsens at the outset of the illness in schizophrenia compared to premorbid functioning, meaning that these deficits are not due to development disabilities. There are multiple medical and substance abuse comorbidities in schizophrenia and although these comorbidities affect cognitive functioning, they are not completely responsible for age-related changes.

Mechanisms of functional improvement through cognitive rehabilitation in schizophrenia

Whereas the efficacy of cognitive rehabilitation in schizophrenia is widely known, studies examining mechanisms for functional improvement are still scarce. The aim of the study was to examine the mediational mechanisms through which cognitive rehabilitation improves functioning in schizophrenia. One hundred and eleven schizophrenia patients were randomly assigned to either a 4-month cognitive rehabilitation group or an active control group. Patients underwent a neurocognitive battery (including processing speed, verbal memory, working memory and executive functioning) and social cognition assessment (emotion perception, theory of mind and social perception). Functioning was assessed by the combined use of a performance-based instrument, the UCSD Performance-based Skills Assessment (UPSA) and an observer-rated instrument, the Global Assessment of Functioning (GAF). The trial was registered in clinicaltrials.gov (NCT02796417). Multiple mediational analyses revealed that the effect of cognitive rehabilitation on functional improvement was partially mediated by changes in processing speed and verbal memory, but not by the domains of social cognition and negative symptoms. More specifically, verbal memory partially mediated the treatment's effect on performance-based functioning (UPSA), whereas processing speed acted as a partial mediator for observer-rated functioning (GAF). The effect of rehabilitation on functioning did not take place through all the domains that showed significant improvement. Verbal memory and processing speed emerged as the most crucial factors. However, these complex interactions need further research.

Thought, language, and communication deficits and association with everyday functional outcomes among community-dwelling middle-aged and older adults with schizophrenia

Older adults with schizophrenia experience poorer community integration and social functioning compared to same-age peers with no mental health disorders; these individuals are at elevated risk for functional decline and early institutionalization in long-term care facilities. Deficits in thought, language, and communication (TLC; that is, thought disorder and alogia) are core features of schizophrenia and may worsen with age; however, little research focuses on the functional sequelae of these impairments among older adults with schizophrenia. The present study aimed to examine the relationships among age, TLC deficits, and functional outcomes in a sample of community-dwelling middle-aged and older adults with schizophrenia (N = 245; ages 40-85). Participants completed assessments of symptoms, neurocognition, TLC deficits, and functional outcomes. Two different categories of TLC deficits were examined: verbal underproductivity (i.e., alogia) and disconnected speech. Regression analyses, controlling for gender, age, Veteran status, smoking status, cognitive impairment, and symptom severity, found that disconnected speech predicted occupational functioning, while verbal underproductivity predicted capacity to communicate skillfully in semi-structured social situations, as well as community functioning across interpersonal, occupational, and everyday living domains. Exploratory mediation analyses found significant indirect effects of age, through TLC deficits, on certain functional outcomes. Targeted training to improve TLC deficits, especially verbal underproductivity, among older adults with schizophrenia could have downstream effects on community functioning, improving outcomes for a vulnerable group.

Self Efficacy in Depression: Bridging the Gap Between Competence and Real World Functioning

We investigated the discrepancy between competence and real-world performance in major depressive disorder (MDD) for adaptive and interpersonal behaviors, determining whether self-efficacy significantly predicts this discrepancy, after considering depressive symptoms. Forty-two participants (Mage = 37.64, 66.67% female) with MDD were recruited from mental health clinics. Competence, self-efficacy, and real-world functioning were evaluated in adaptive and interpersonal domains; depressive symptoms were assessed with the Beck Depression Inventory II. Hierarchical regression analysis identified predictors of functional disability and the discrepancy between competence and real-world functioning. Self-efficacy significantly predicted functioning in the adaptive and interpersonal domains over and above depressive symptoms. Interpersonal self-efficacy accounted for significant variance in the discrepancy between interpersonal competence and functioning beyond symptoms. Using a multilevel, multidimensional approach, we provide the first data regarding relationships among competence, functioning, and self-efficacy in MDD. Self-efficacy plays an important role in deployment of functional skills in everyday life for individuals with MDD.

A Pilot Randomized Controlled Trial of the ACCESS Program: A Group Intervention to Improve Social, Adaptive Functioning, Stress Coping, and Self-Determination Outcomes in Young Adults with Autism Spectrum Disorder

The purpose of this pilot randomized controlled trial was to investigate the acceptability and efficacy of the Acquiring Career, Coping, Executive control, Social Skills (ACCESS) Program, a group intervention tailored for young adults with autism spectrum disorder (ASD) to enhance critical skills and beliefs that promote adult functioning, including social and adaptive skills, self-determination skills, and coping self-efficacy. Forty-four adults with ASD (ages 18-38; 13 females) and their caregivers were randomly assigned to treatment or waitlist control. Compared to controls, adults in treatment significantly improved in adaptive and self-determination skills, per caregiver report, and self-reported greater belief in their ability to access social support to cope with stressors. Results provide evidence for the acceptability and efficacy of the ACCESS Program.

A 10-minute measure of global cognition: Validation of the Brief Cognitive Assessment Tool for Schizophrenia (B-CATS)

INTRODUCTION

Schizophrenia is marked by a global cognitive impairment that contributes significantly to chronic disability and unemployment. As new treatments are developed for cognition in schizophrenia, clinicians require easily administered instruments to assess cognition. We previously developed a very brief cognitive battery (Bell et al., 2005). The Brief Cognitive Assessment Tool for Schizophrenia (B-CATS) was developed specifically to provide clinicians with a way to assess cognition in their patients with schizophrenia. Here, we report the results of a validity study comparing B-CATS to a larger neurocognitive battery, the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) battery.

METHODS

Outpatients with schizophrenia (N=91) were administered the B-CATS and the non-overlapping tests of the MATRICS battery at two time points separated by 1month. They were also administered the UCSD Performance-based Skills Assessment-Brief (UPSA-B), a measure of functional capacity.

RESULT

The B-CATS has an administration time of approximately 10min. It demonstrates good test-retest reliability and internal consistency. It correlates 0.76 (p<0.01) with the MATRICS battery. The shorter B-CATS and the MATRICS battery correlate with the UPSA-B at 0.50 and 0.58 respectively.

CONCLUSION

A 10-minute version of the B-CATS correlates highly with the "gold standard" neurocognitive battery that has an administration time of over 60min. Both measures correlate moderately with a measure of functional capacity. This brief battery was designed to allow clinicians to monitor cognitive change and better inform treatment decisions.

A Subgroup Analysis of the Impact of Vortioxetine on Functional Capacity, as Measured by UPSA, in Patients with Major Depressive Disorder and Subjective Cognitive Dysfunction

BACKGROUND

We evaluated vortioxetine's effects on functional capacity in demographic and clinical subgroups of patients with major depressive disorder.

METHODS

This was an exploratory analysis of the CONNECT study (NCT01564862) that evaluated changes in functional capacity using University of California San Diego Performance-based Skills Assessment data, categorized by sex, age, education, employment status, and baseline disease severity (Montgomery-Åsberg Depression Rating Scale, Clinical Global Impressions-Severity of Illness).

RESULTS

Greater changes in University of California San Diego Performance-based Skills Assessment composite scores were observed with vortioxetine vs placebo in specific subgroups: males (∆+3.2), females (∆+2.9), 45-54 or ≥55 years (∆+5.6, ∆+3.4), working (∆+2.8), high school or greater education (∆+2.7, ∆+2.8), disease severity (Montgomery-Åsberg Depression Rating Scale, <30, ∆+3.5; ≥30, ∆+2.5; Clinical Global Impressions-Severity of Illness ≤4, ∆+2.8; >4, ∆+3.0), major depressive episodes (≤2, >2 [∆+2.7,+3.3]), and episode duration (≤22, >22 weeks [∆+3.7,+2.4]).

CONCLUSIONS

Our findings support the need for additional studies to assess whether vortioxetine improves functional capacity within specific patient subgroups.

CLINICAL TRIAL REGISTRY

clinicaltrials.gov: NCT01564862.

Loneliness in psychosis: a systematic review

PURPOSE

The aim of the review is to understand the relationships between loneliness and related psychological and social factors in individuals with psychosis. Loneliness is poorly understood in people with psychosis. Given the myriad of social challenges facing individuals with psychosis, these findings can inform psychosocial interventions that specifically target loneliness in this vulnerable group.

METHODS

We adhered to the PRISMA guidelines and systematically reviewed empirical studies that measured loneliness either as a main outcome or as an associated variable in individuals with psychosis.

RESULTS

A total of ten studies examining loneliness in people diagnosed with a psychotic disorder were examined. Heterogeneity in the assessment of loneliness was found, and there were contradictory findings on the relationship between loneliness and psychotic symptomatology. In individuals with psychosis, loneliness may be influenced by psychological and social factors such as increased depression, psychosis, and anxiety, poor social support, poor quality of life, more severe internalised stigma and perceived discrimination, and low self-esteem.

CONCLUSIONS

The relationship between loneliness and psychosis remains poorly understood due to a lack of rigorous studies. Although having strong social relationships is crucial to facilitate recovery from serious mental illness, psychosocial interventions that specifically target loneliness in individuals with psychosis are lacking and sorely needed. Interventions targeting loneliness in those with psychosis will also need to account for additional barriers associated with psychosis (e.g., social skill deficits, impoverished social networks, and negative symptoms).

Deficient Emotion Processing is Associated with Everyday Functioning Capacity in HIV-associated Neurocognitive Disorder

OBJECTIVE

Emotion processing has received little research focus in HIV, but emerging evidence suggests that abilities such as facial affect discrimination may be features of HIV-associated neurocognitive disorder (HAND). The present study hypothesized that individuals with HAND would evidence an emotion processing deficit relative to cognitively unimpaired individuals with HIV and seronegative comparison participants on a task assessing these abilities. Moreover, it was expected that this deficit would be significantly associated with social aspects of everyday functioning.

METHOD

To explore these hypotheses, 37 HIV+ individuals with HAND, 46 HIV+ without HAND, and 38 HIV-seronegative comparison participants were administered the CogState Social Emotional Cognition Task (SECT) and the UCSD Performance-based Skills Assessment-Brief (UPSA-B).

RESULTS

Results revealed that the HAND group was more likely to have impaired accuracy and slower reaction time relative to the comparison groups on the SECT task. In fact, individuals with HAND were almost 10 times more likely to be impaired on emotion processing accuracy than HIV+ without HAND. Among individuals with HIV, accuracy (but not reaction time) was independently related to a functional capacity measure tapping social ability, but not to a similar measure without a social component (UPSA-B Communication and Finances subscales, respectively).

CONCLUSIONS

These results suggest that disruption of emotion processing may be an important feature of HAND that has clinical value as an independent predictor of real-world activities that involve social components. Future research should prospectively investigate this relationship, which may inform of intervention strategies for improving everyday functioning.

A Novel Method for Direct Assessment of Everyday Competence Among Older Adults

BACKGROUND

Recent findings indicate that impairments in functional performance do occur among individuals diagnosed with mild cognitive impairment (MCI). Most assessment strategies for everyday competence are associated with challenges with reliability, are typically in paper and pencil format, or require in-person administration by a trained professional.

OBJECTIVE

This paper reports on a novel technology-based assessment battery of everyday competence that includes ecologically valid simulations of daily activities important to independence.

METHODS

The sample included 85 non-cognitively impaired older adults aged 65+ and 62 older adults diagnosed with amnestic MCI (aMCI). Participants completed standard measures of cognitive abilities and the computerized battery of everyday tasks, which included simulations of a doctor's visit; and medication and financial management tasks.

RESULTS

The older adults with aMCI performed significantly poorer on all three tasks in the everyday task battery. Performance on these measures were also moderately correlated with standard measures of cognitive abilities and showed good test-retest reliability.

CONCLUSIONS

The results show that it is feasible to use a technology-based assessment battery of everyday tasks with both non-cognitively impaired older adults and older adults with MCI. The use of this type of battery can overcome many of the logistic constraints associated with current functional assessment protocols.

Deficit of supramodal executive control of attention in schizophrenia

Although a deficit in executive control of attention is one of the hallmarks in schizophrenia that has significant impact on everyday functioning due to its relationship with thought processing, whether this deficit occurs across modalities, i.e., is supramodal, remains unclear. To investigate the supramodal mechanism in SZ, we examined cross-modal correlations between visual and auditory executive control of attention in a group of patients with schizophrenia (SZ, n = 55) compared to neurotypical controls (NC, n = 55). While the executive control effects were significantly correlated between the two modalities in the NC group, these effects were not correlated in the SZ group, with a significant group difference in the correlation. Further, the inconsistency and magnitude of the cross-modal executive control effects were significantly larger in the SZ group compared to the NC group. Together, these results suggest that there is a disruption of a common supramodal executive control mechanism in patients with schizophrenia, which may be related to the thought processing disorder characterizing the disorder.

Utility of functioning measures in the prediction of independent living status in older adults with serious mental illness

OBJECTIVE

The objective of the study was to compare the predictive utility of three commonly used functioning measures for people with serious mental illness in the prediction of independent living status.

METHODS

We conducted a secondary data analysis from the Helping Older People Experience Success study with adults aged 50 years and older with a diagnosis of bipolar disorder, schizoaffective disorder, schizophrenia, or major depressive disorder (N = 183).

RESULTS

Total scores for the Independent Living Skills Survey, Multnomah Community Ability Scale, and UCSD Performance-Based Skills Assessment were modestly inter-correlated. For the overall sample, greater independent living status at baseline and 1-year follow-up was predicted by higher baseline functioning scores on both the self-reported Independent Living Skills Survey and the UCSD Performance-Based Skills Assessment. However, by diagnostic subgroup, independent living status at 1-year follow-up was only predicted by the Independent Living Skills Survey for affective disorders and by the UCSD Performance-Based Skills Assessment for schizophrenia-spectrum disorders. For the total sample, the Independent Living Skills Survey was associated with self-efficacy and employment status. Neither the Independent Living Skills Survey nor UCSD Performance-Based Skills Assessment was associated with medical or psychiatric hospitalizations or with subjective physical or mental health status.

CONCLUSIONS

These commonly used functioning measures for people with serious mental illness examine different aspects of functioning. The choice of functional measurement should be based on the population under study and intervention goals. Copyright © 2017 John Wiley & Sons, Ltd.

Integrated cognitive remediation and standard rehabilitation therapy in patients of schizophrenia: persistence after 5years

Cognitive remediation, often used in combination with standard rehabilitation programs, represents the best available tool to treat cognitive impairments in patients with schizophrenia. However, there are still open questions about durability of effects and generalization of cognitive improvements to functional outcome. This study aims to investigate the persistence of both cognitive and functional effects of combined cognitive remediation plus standard rehabilitation interventions, 5years after completion of the intervention, also comparing different durations of the standard rehabilitation. Sixty patients diagnosed with schizophrenia and previously treated with a 6months intervention, consisting of standard rehabilitation plus 3-months of cognitive remediation, either followed by another year of standard rehabilitation or routine psychiatric treatment, were reassessed with neuropsychological and functional measures 5years after the intervention. Results show that cognitive abilities remained stable after 5years in both groups, while functional performance significantly decreased in patients treated with the 6months intervention only. Data thus suggest that cognitive effects persist even after 5years, while a longer standard rehabilitation following the cognitive remediation program may be needed to achieve a stable functional gain.

Vortioxetine improves symptomatic and functional outcomes in major depressive disorder: A novel dual outcome measure in depressive disorders

BACKGROUND

With symptomatic remission and functional recovery as the overarching therapeutic objectives of antidepressant therapy, composite endpoint measures that conjointly consider both aspects of treatment are needed. This analysis evaluated the combined effect of vortioxetine on depressive symptoms and functional capacity in adults with MDD.

METHODS

NCT01564862, a multinational, double-blind, placebo-controlled, duloxetine-referenced study, conducted between April 2012 and February 2014, in 602 adult outpatients (18-65 years) with moderate-to-severe MDD (Montgomery-Åsberg Depression Rating Scale (MADRS) ≥ 26), a major depressive episode of ≥ 3 months' duration, and self-reported cognitive symptoms were randomized to once-daily vortioxetine (10 or 20mg), duloxetine (60mg), or placebo for 8 weeks. Assessments included the University of California San Diego Performance-based Skills Assessment (UPSA) and the MADRS. Two versions of UPSA were utilized; UPSA ‒Validation of Intermediate Measures and UPSA Brief form. An aligned UPSA-B (communication and finance items) was examined for sensitivity analysis. Efficacy was analyzed versus placebo according to the dual response (change from baseline in UPSA ≥ 7 and ≥ 9 and reduction in MADRS total score from baseline ≥ 50%).

RESULTS

Significantly more vortioxetine-treated patients were classified as dual responders for change in MADRS total score and UPSA score of ≥ 7 (clinically important difference [CID]) (27.4% vs 14.5%; P = 0.004), and change above CID (≥ 9) (23.4% vs 13.9%; P = 0.025). Duloxetine did not differ significantly from placebo for these dual response criteria. Sensitivity analysis using the aligned UPSA-B confirmed these results for vortioxetine.

LIMITATIONS

An exploratory analysis of a new dual outcome measure in patients with MDD.

CONCLUSIONS

Vortioxetine, but not duloxetine, demonstrated a robust combined effect on depressive symptoms and functional capacity in patients with MDD.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01564862; European Clinical Trials Database [EudraCT] Number 2011-005298-22.

Role of subcortical structures on cognitive and social function in schizophrenia

Subcortical regions have a pivotal role in cognitive, affective, and social functions in humans, and the structural and functional abnormalities of the regions have been associated with various psychiatric disorders. Although previous studies focused on the neurocognitive and socio-functional consequences of prefrontal and tempolo-limbic abnormalities in psychiatric disorders, those of subcortical structures remain largely unknown. Recently, MRI volume alterations in subcortical structures in patients with schizophrenia have been replicated in large-scale meta-analytic studies. Here we investigated the relationship between volumes of subcortical structures and neurocognitive and socio-functional indices in a large sample of patients with schizophrenia. First, we replicated the results of meta-analyses: the regional volumes of the bilateral hippocampus, amygdala, thalamus and nucleus accumbens were significantly smaller for patients (N = 163) than for healthy controls (HCs, N = 620). Second, in the patient group, the right nucleus accumbens volume was significantly correlated with the Digit Symbol Coding score, which is known as a distinctively characteristic index of cognitive deficits in schizophrenia. Furthermore, the right thalamic volume was significantly correlated with social function scores. In HCs, no significant correlation was found. The results from this large-scale investigation shed light upon the role of specific subcortical nuclei on cognitive and social functioning in schizophrenia.

Assessing the Relationship between Performance on the University of California Performance Skills Assessment (UPSA) and Outcomes in Schizophrenia: A Systematic Review and Evidence Synthesis

OBJECTIVE

To perform a systematic review of the published literature to evaluate how functional capacity, as measured by the University of California at San Diego (UCSD) Performance-based Skills Assessment (UPSA), relates to other functional measures and real-world outcomes among individuals with schizophrenia.

METHODS

The MEDLINE® and Embase® databases were searched to identify joint evaluations with UPSA and key functional outcomes (functional scale measures; generic or disease-specific, health-related quality of life [HRQoL]; or real-world outcomes [residential status; employment status]) in patients with schizophrenia. Pearson correlations were estimated between UPSA scores, HRQoL, other functional scale measures, and real-world outcomes, for outcomes described in at least six studies.

RESULTS

The synthesis included 76 studies that provided 73 unique data sets. Quantitative assessment between the Specific Level of Function (SLOF) (n=18) scores and UPSA scores demonstrated a moderate borderline-significant correlation (0.45, p=0.06). Quantitative analysis of the relationship between the Global Assessment of Functioning (GAF) (n=11) and the Multidimensional Scale of Independent Functioning (MSIF) (n=6) scales revealed moderate and small nonsignificant Pearson correlations of -0.34 (p=0.31) and 0.12 (p=0.83), respectively. There was a small borderline-significant correlation between UPSA score and residential status (n=36; 0.31; p=0.08), while no correlation was found between UPSA score and employment status (n=19; 0.04; p=0.88).

CONCLUSION

The SLOF was the most often used functional measure and had the strongest observed correlation with the UPSA. Although knowledge gaps remain, evidence from this review indicates that there is a quantitative relationship between functional capacity and real-world outcomes in individuals with schizophrenia.

A Brief Assessment of Intelligence Decline in Schizophrenia As Represented by the Difference between Current and Premorbid Intellectual Quotient

Patients with schizophrenia elicit several clinical features, such as psychotic symptoms, cognitive impairment, and subtle decline of intelligence. The latter two features become evident around the onset of the illness, although they may exist even before the disease onset in a substantial proportion of cases. Here, we review the literature concerning intelligence decline (ID) during the progression of schizophrenia. ID can be estimated by comparing premorbid and current intellectual quotient (IQ) by means of the Adult Reading Test and Wechsler Adult Intelligence Scale (WAIS), respectively. For the purpose of brief assessment, we have recently developed the WAIS-Short Form, which consists of Similarities and Symbol Search and well reflects functional outcomes. According to the degree of ID, patients were classified into three distinct subgroups; deteriorated, preserved, and compromised groups. Patients who show deteriorated IQ (deteriorated group) elicit ID from a premorbid level (≥10-point difference between current and premorbid IQ), while patients who show preserved or compromised IQ do not show such decline (<10-point difference). Furthermore, the latter patients were divided into patients with preserved and compromised IQ based on an estimated premorbid IQ score >90 or below 90, respectively. We have recently shown the distribution of ID in a large cohort of schizophrenia patients. Consistent with previous studies, approximately 30% of schizophrenia patients had a decline of less than 10 points, i.e., normal intellectual performance. In contrast, approximately 70% of patients showed deterioration of IQ. These results indicate that there is a subgroup of schizophrenia patients who have mild or minimal intellectual deficits, following the onset of the disorder. Therefore, a careful assessment of ID is important in identifying appropriate interventions, including medications, cognitive remediation, and social/community services.

Methodological recommendations for cognition trials in bipolar disorder by the International Society for Bipolar Disorders Targeting Cognition Task Force

OBJECTIVES

To aid the development of treatment for cognitive impairment in bipolar disorder, the International Society for Bipolar Disorders (ISBD) convened a task force to create a consensus-based guidance paper for the methodology and design of cognition trials in bipolar disorder.

METHODS

The task force was launched in September 2016, consisting of 18 international experts from nine countries. A series of methodological issues were identified based on literature review and expert opinion. The issues were discussed and expanded upon in an initial face-to-face meeting, telephone conference call and email exchanges. Based upon these exchanges, recommendations were achieved.

RESULTS

Key methodological challenges are: lack of consensus on how to screen for entry into cognitive treatment trials, define cognitive impairment, track efficacy, assess functional implications, and manage mood symptoms and concomitant medication. Task force recommendations are to: (i) enrich trials with objectively measured cognitively impaired patients; (ii) generally select a broad cognitive composite score as the primary outcome and a functional measure as a key secondary outcome; and (iii) include remitted or partly remitted patients. It is strongly encouraged that trials exclude patients with current substance or alcohol use disorders, neurological disease or unstable medical illness, and keep non-study medications stable. Additional methodological considerations include neuroimaging assessments, targeting of treatments to illness stage and using a multimodal approach.

CONCLUSIONS

This ISBD task force guidance paper provides the first consensus-based recommendations for cognition trials in bipolar disorder. Adherence to these recommendations will likely improve the sensitivity in detecting treatment efficacy in future trials and increase comparability between studies.

One size doesn't fit all: A trial of individually tailored skills training

OBJECTIVES

This article describes a pilot test of an individually tailored program to improve community living and health self-management skills in older adults with serious mental illness.

METHOD

This study provided the Helping Older People Experience Success-Individually Tailored (HOPES-I) intervention, an adaptation of an empirically supported, manualized, group-based skills training program shown to improve community functioning, psychiatric symptoms, self-efficacy, and receipt of preventive health. HOPES-I targets 5 skill areas: leisure time, communication, independent living, friendships, and health self-management. We enrolled 47 adults age 50 and older (mean age = 62) with serious mental illness (38% schizophrenia spectrum, 62% mood disorders). Trained HOPES-I coaches evaluated participants' skills and functioning and engaged them in shared decision-making to select which curricular areas to receive. Participants received 1 HOPES-I session per week for 9-12 months, with assessments of overall psychosocial functioning and the 5 skill areas targeted by the program at baseline, postintervention, and at 3 and 6 months.

RESULTS

Participants with baseline impairments in overall functioning and in each of the skill areas targeted by the program demonstrated significant improvements on related outcome measures. Selection of specific HOPES-I curriculum was not associated with level of impairment in associated skill areas at baseline, but participants with more impairment overall chose and completed more curriculum modules.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The results of this study support the feasibility and potential benefits of an individually tailored skills training program for the rapidly growing and vulnerable group of older people with serious mental illness. (PsycINFO Database Record

Cognitive correlates of visual neural plasticity in schizophrenia

Neuroplasticity may be an important treatment target to improve the cognitive deficits in schizophrenia (SZ). Yet, it is poorly understood and difficult to assess. Recently, a visual high-frequency stimulation (HFS) paradigm that potentiates electroencephalography (EEG)-based visual evoked potentials (VEP) has been developed to assess neural plasticity in the visual cortex. Using this paradigm, we examined visual plasticity in SZ patients (N=64) and its correlations with clinical symptoms, neurocognition, functional capacity, and community functioning. VEPs were assessed prior to (baseline), and 2-, 4-, and 20-min after (Post-1, Post-2, and Post-3, respectively) 2min of visual HFS. Cluster-based permutation tests were conducted to identify time points and electrodes at which VEP amplitudes were significantly different after HFS. Compared to baseline, there was increased negativity between 140 and 227ms for the early post-HFS block (average of Post-1 and Post-2), and increased positivity between 180 and 281ms for the late post-HFS block (Post-3), at parieto-occipital and occipital electrodes. The increased negativity in the early post-HFS block did not correlate with any of the measures, whereas increased positivity in the late post-HFS block correlated with better neurocognitive performance. Results suggest that SZ patients exhibit both short- and long-term plasticity. The long-term plasticity effect, which was present 22min after HFS, was evident relatively late in the VEP, suggesting that neuroplastic changes in higher-order visual association areas, rather than earlier short-term changes in primary and secondary visual cortex, may be particularly important for the maintenance of neurocognitive function in SZ.