Neuropsychological screening in the psychiatric emergency room

Neurocognitive Endophenotypes of Schizophrenia and Bipolar Disorder and Possible Associations with FKBP Variant rs3800373

Introduction

Schizophrenia(SCZ) and Bipolar disorder (BD) are frequently occurring and impairing disorders that affect around 1% of the population. Important endophenotypes in the genetic research of SCZ and BD are cognitive functions. Core symptoms for SCZ and BD are impairments in working memory, declarative memory and attention, all of which fulfill the criteria for an endophenotype. The FK506 Binding Protein 5 (FKBP5) gene codes for a co-chaperone of the glucocorticoid receptor and has been reported to be associated with cognition.

Aim

The aims of our research were to determine the degree of cognitive impairment in patients suffering from SCZ and BD and to explore the association of the FKBP5 variant rs3800373 genotype with the cognitive endophenotypes.

Material and Methods

Patients and healthy controls were recruited over a period of two years from the Psychiatric Clinic, Clinical Center University of Sarajevo. Genotyping and neuropsychological assessments were performed for 263 subjects (129 SCZ, 53 BD, and 81 healthy controls [HC]). Neuropsychological assessments were performed for all patients with the Trail Making Test-A&B (TMT-A&B) and Digit-span forward&backwards tasks. The single nucleotide polymorphism (SNP) rs3800373 in the FKBP5 gene was genotyped using Infinium PsychArray Bead Chips.

Results and Conclusion

SCZ and BD patients performed lower than HC in the TMT-A&B and in the Digit-span backwards task, while no differences were observed between SCZ and BD patients. While SCZ patients performed lower than HC in the Digit-span forwards task, there were no differences between BD and HC or between BD and SCZ. Rs 3800373 was not associated with performance in the TMT-A&B or Digit-span forwards&backwards tasks. SCZ and BD share largely overlapping neurocognitive characteristics. Rs3800373 was not associated with performance in the neuropsychological tests. However, given the limited sample size, the results do not exclude an association with the rs3800373 variant in a larger sample. Furthermore, as the analysis was limited to one SNP, the results cannot be generalized to other genetic variants in FKBP5.

Clinical neuropsychology within adolescent and young-adult psychiatry: conceptualizing theory and practice

Historically, clinical neuropsychology has made significant contributions to the understanding of brain-behavior relationships, particularly in neurological conditions. During the past several decades, neuropsychology has also become established as an important discipline in psychiatric settings. Cognition is increasingly recognized as being core to psychiatric illnesses and predictive of functional outcomes, augmenting theories regarding symptomatology and illness progression. Adult-type psychiatric disorders (including schizophrenia and other psychotic, mood, anxiety, eating, substance-related, and personality disorders) typically emerge during adolescence or young adulthood, a critical neurodevelopmental period. Clinical neuropsychological assessment in adolescent psychiatric patients is particularly valuable in informing clinical formulation and intervention and can be therapeutic across a number of levels. This article articulates the theoretical considerations and practical challenges and applications of clinical neuropsychology within adolescent and young-adult psychiatry. The importance of considering the neurodevelopmental context and its relationship to current theoretical models underpinning clinical practice are discussed.

Diagnostic accuracy of a new instrument for detecting cognitive dysfunction in an emergent psychiatric population: the Brief Cognitive Screen

OBJECTIVES

In certain clinical contexts, the sensitivity of the Mini-Mental State Examination (MMSE) is limited. The authors developed a new cognitive screening instrument, the Brief Cognitive Screen (BCS), with the aim of improving diagnostic accuracy for cognitive dysfunction in the psychiatric emergency department (ED) in a quick and convenient format.

METHODS

The BCS, consisting of the Oral Trail Making Test (OTMT), animal fluency, the Clock Drawing Test (CDT), and the MMSE, was administered to 32 patients presenting with emergent psychiatric conditions. Comprehensive neuropsychological evaluation served as the criterion standard for determining cognitive dysfunction. Diagnostic accuracy of the MMSE was determined using the traditional clinical cutoff and receiver operating characteristic (ROC) curve analyses. Diagnostic accuracy of individual BCS components and BCS Summary Scores was determined by ROC analyses.

RESULTS

At the traditional clinical cutoff, MMSE sensitivity (46.4%) and total diagnostic accuracy (53.1%) were inadequate. Under ROC analyses, the diagnostic accuracy of the full BCS Summary Score (area under the curve [AUC]=0.857) was comparable to the MMSE (AUC=0.828). However, a reduced BCS Summary Score consisting of OTMT Part B (OTMT-B), animal fluency, and the CDT yielded classification accuracy (AUC=0.946) that was superior to the MMSE.

CONCLUSIONS

Preliminary findings suggest the BCS is an effective, convenient alternative cognitive screening instrument for use in emergent psychiatric populations.

A comparison of two mental status examinations in an inpatient psychiatric sample

This study compares the psychometric properties and clinical use of the Mini-Mental Status Exam (MMSE) and the Modified MMSE (3MS) in patients admitted to an acute medical-psychiatric inpatient unit. Internal consistencies were .56 for the estimated MMSE and .72 for the 3MS. Regression analyses revealed that the 3MS was a significant predictor of both length of hospital stay (LOS) and the need for additional services postdischarge. Regressions were also used to evaluate the contribution of the four new items contained in the 3MS: Word Generation, Similarities, Second Recall, and Date and Place of Birth. The 3MS was a significant predictor of LOS and the need for discharge services, whereas the MMSE did not contribute to any regression model. Word Generation was found to be a significant predictor of patients' needing posthospital services. Results support prior findings of the 3MS's superiority over the (estimated) MMSE and help to demonstrate the continued importance of cognitive screening in psychiatric samples.

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

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

Cognitive impairment in psychiatric patients and length of hospital stay

The purpose of this study was to determine whether brief neuropsychologic screening at the time of admission to an acute-care psychiatric unit predicts the length of inpatient hospital stay (LOS). Over a 4-month period, 41 consecutively admitted patients on a general psychiatric inpatient unit were administered the Mini-Mental State Examination (MMSE), the Trails A and B subtests from the Halstead-Reitan Neuropsychological Battery, and the Visual Reproduction subtest (VR) of the Wechsler Memory Scale within 72 hours of admission. A setwise, hierarchic multiple regression model examined the contributions of demographic factors, clinical features, and the four neuropsychologic tests to LOS variance. VR and Trails A were the best predictors of LOS, responsible for 21.6% and 16.3% of outcome variance, respectively. The independent variables (IVs) comprising the best-fitting model include Trails A, VR, MMSE, and patient diagnosis. These variables collectively accounted for 48.8% of the variance in LOS, and predicted 70.4% of patients with LOS < 21 days and 82.4% of patients with LOS > 21 days. The results of this study support the hypothesis that LOS is related to cognitive impairment associated with psychiatric illness, and suggest that neuropsychologic testing upon admission to an inpatient unit can be useful in predicting LOS.