Cognitive strengths-based assessment and intervention in first-episode psychosis: A complementary approach to addressing functional recovery?

Feasibility and Acceptability of Providing Cognitive Remediation in a Large USA System of Coordinated Specialty Care for Early Psychosis

INTRODUCTION

Multinational treatment guidelines support providing cognitive remediation to people recently diagnosed with schizophrenia, but the feasibility of implementing the treatment on a large scale is less well understood.

METHODS

This study took place between 2019 and 2023 at 14 clinics within a large network of programs providing early intervention services to people aged 16-30 experiencing nonaffective psychosis. Clinics were randomly assigned to deliver cognitive remediation as twice-weekly clinician-led groups (N = 5), cognitive remediation as once-weekly clinician-led groups with homework (N = 6), or treatment as usual (N = 3). All clinics screened for cognitive health need to guide treatment planning. Clinical teams (N = 11) received training to provide cognitive remediation. Program evaluation data were analysed for feasibility and acceptability.

RESULTS

Screening for cognitive health needs was completed on 77% of the 1193 participants enrolled at the 11 clinics offering cognitive remediation. Clinicians identified cognitive difficulties in 53.9% (n = 496) of screened participants and referred 27% (n = 134) of these participants to cognitive remediation. Of referred participants, 77.6% (n = 104) initiated treatment, and n = 41 completed the treatment. The rate of referral was nearly double, and treatment initiation was significantly higher at programs delivering once-weekly (84.3%) than twice-weekly (64.4%) treatment but the difference in the rate of treatment completion was statistically nonsignificant. Satisfaction among treatment completers was high.

CONCLUSIONS

Referrals to cognitive remediation required systemic support of a feasible cognitive health screening process. About a quarter of people with clinician-identified cognitive health needs were referred to cognitive remediation. Feasibility data suggest a flexible model of treatment delivery may facilitate implementation in this service setting.

Ormerod MB, Aukrust P, Melle I, Steen NE, Andreassen OA, Ueland T. Longitudinal course of inflammatory-cognitive subgroups across first treatment severe mental illness and healthy controls

BACKGROUND

While inflammation is associated with cognitive impairment in severe mental illnesses (SMI), there is substantial heterogeneity and evidence of transdiagnostic subgroups across schizophrenia (SZ) and bipolar (BD) spectrum disorders. There is however, limited knowledge about the longitudinal course of this relationship.

METHODS

Systemic inflammation (C-Reactive Protein, CRP) and cognition (nine cognitive domains) was measured from baseline to 1 year follow-up in first treatment SZ and BD (n = 221), and healthy controls (HC, n = 220). Linear mixed models were used to evaluate longitudinal changes separately in CRP and cognitive domains specific to diagnostic status (SZ, BD, HC). Hierarchical clustering was applied on the entire sample to investigate the longitudinal course of transdiagnostic inflammatory-cognitive subgroups.

RESULTS

There were no case-control differences or change in CRP from baseline to follow-up. We confirm previous observations of case-control differences in cognition at both time-points and domain specific stability/improvement over time regardless of diagnostic status. We identified transdiagnostic inflammatory-cognitive subgroups at baseline with differing demographics and clinical severity. Despite improvement in cognition, symptoms and functioning, the higher inflammation - lower cognition subgroup (75% SZ; 48% BD; 38% HC) had sustained inflammation and lower cognition, more symptoms, and lower functioning (SMI only) at follow-up. This was in comparison to a lower inflammation - higher cognition subgroup (25% SZ, 52% BD, 62% HC), where SMI participants showed cognitive functioning at HC level with a positive clinical course.

CONCLUSIONS

Our findings support heterogenous and transdiagnostic inflammatory-cognitive subgroups that are stable over time, and may benefit from targeted interventions.

Using Neuropsychological Profiling to Tailor Mental Health Care for Children and Youth: a Quality Improvement Project to Measure Feasibility

OBJECTIVE

Precision child and youth mental healthcare has great potential to improve treatment success by tailoring interventions to individual needs. An innovative care pathway in a pediatric mental health outpatient clinic was designed to allow for neuropsychology data to be integrated in psychotherapeutic care. This paper describes the feasibility of this new pathway, including implementation outcomes, acceptability, and potential for future integration.

METHOD

The target population was outpatients 6-17 years old referred for individual treatment to a tertiary outpatient mental health (OPMH) clinic. The new care pathway was co-developed by neuropsychologists and mental health practitioners. A logic model was created to guide the evaluation, which was informed by the Reach Effectiveness Adoption Implementation Maintenance framework. As part of the logic model, a stepped assessment protocol was implemented, and reports on neuropsychological function were shared with patients, caregivers, and care providers. Evaluation data were collected from phone surveys, questionnaires, a focus group, and administrative records.

RESULTS

Forty-two patients scheduled to receive therapy over a 6-month period were offered the opportunity to participate in the new care pathway and 39 (93%) agreed. Self-reported outcome data showed that 83% of patients and 94% of caregivers valued neuropsychology-informed care, with some describing it as transformative. Almost all practitioners (91%) reported that the project added value to their clinical care. There were no adverse effects on participants nor the flow of patients through the system.

CONCLUSIONS

Neuropsychology-informed pediatric OPMH care was feasible and well-received. Clinical effectiveness should be studied in an experimental trial.

Implementation of Cognitive Health Services in Large Systems of Care: Highlights From Coordinated Specialty Care for First Episode Psychosis

BACKGROUND AND HYPOTHESIS

With increasing recognition of the importance of cognitive health for recovery in people with psychosis, questions arise as to how to implement cognitive health services in large systems of care. This paper describes the implementation of cognitive health services in OnTrackNY (OTNY), a network of clinics delivering a Coordinated Specialty Care treatment model for early psychosis, with the goal of documenting the processes, challenges, and useful adaptations.

STUDY DESIGN

In 2018, OTNY piloted a Cognitive Health Toolkit for implementation across 18 affiliated clinics. The toolkit intended to identify the cognitive health needs of individuals early in the course of psychosis and to integrate cognitive health into the vocabulary of wellness and recovery. Implementation involved creating mechanisms for staff training and support to, in turn, help participants improve how they use cognitive skills in daily life.

STUDY RESULTS

The toolkit was disseminated to all 28 OTNY programs throughout New York state by 2023. When simple assessment and decision-making tools were embedded in routine care practices, the majority of participants identified that improving memory, attention, and critical thinking skills would be helpful. Consistently, about 70% of those asked wanted to learn more about how to better their cognitive health.

CONCLUSIONS

Cognitive health services can be implemented in large systems of care that provide a multi-level system of implementation supports. Organizational facilitators of implementation include a training program to educate about cognitive health and the delivery of cognitive health interventions, and embedded quality assurance monitoring and improvement activities.

Effects of Goal Management Training on self-efficacy, self-esteem, and quality of life for persons with schizophrenia spectrum disorders

Persons with schizophrenia often show executive dysfunction assessed with both subjective (self-report) and objective (neuropsychological tests) measures. In a recent randomized controlled trial (RCT), subjective executive functioning in everyday life was improved following Goal Management Training (GMT). The aim of the current study is to investigate the potential of GMT to improve secondary well-being outcomes from that RCT, including self-esteem, self-efficacy, and quality of life in persons with schizophrenia spectrum disorders. Since well-being is frequently lower in persons with schizophrenia compared to healthy individuals, further knowledge about well-being as an outcome after cognitive remediation may have implications for clinical treatment. Sixty-five participants were randomly assigned to GMT (n = 31) or a waiting list control condition (n = 34). Assessments were conducted at baseline (T1), immediately after the intervention (T2-5 weeks), and at six-month follow-up (T3). Measures included the Rosenberg Self-Esteem Scale, the Perceived Quality of Life Scale, and the General Self-Efficacy Scale. Results were analyzed using a linear mixed model analysis for repeated measures. There were no significant effects of GMT on self-esteem or quality of life. Only the GMT group showed a significant increase in self-efficacy that was most evident at six months follow-up, F(1, 34) = 10.71, p = 0.002, d = 0.71. Improved self-efficacy was found to correlate significantly with a reduction in perceived executive dysfunction in an exploratory post hoc analysis. Our findings demonstrate the potential of GMT in improving self-efficacy in schizophrenia Clinical trial registration:https://clinicaltrials.gov, NCT03048695.

Cognitive health treatment priorities and preferences among young people with mental illness: The your mind, your choice survey

AIM

Cognitive impairments negatively impact the everyday functioning of young people with mental illness. However, no previous study has asked young people (1) how much of a priority cognitive functioning is within mental health treatment, and (2) what types of cognition-focused treatments are most appealing. The current study aimed to address these questions.

METHODS

Your Mind, Your Choice was a survey-based study involving an Australian sample of young people who were receiving mental health treatment. The survey asked participants to (1) provide demographic and mental health history, (2) rate the importance of 20 recovery domains, including cognition, when receiving mental health treatment, (3) share their experiences of cognitive functioning, and (4) rate their likelihood of trying 14 different behavioural, biochemical, and physical treatments that may address cognitive functioning.

RESULTS

Two-hundred and forty-three participants (Mage  = 20.07, SD = 3.25, range = 15-25, 74% female) completed the survey. Participants reported that addressing cognitive functioning in mental health care was very important (M = 76.33, SD = 20.7, rated on a scale from 0 = not important to 100 = extremely important), ranking cognition among their top six treatment needs. Seventy percent of participants reported experiencing cognitive difficulties, but less than one-third had received treatment for these difficulties. Compensatory training, sleep interventions and psychoeducation were ranked as treatments that participants were most likely to try to support their cognitive functioning.

CONCLUSIONS

Young people with mental ill-health commonly experience cognitive difficulties and would like this to be a focus of treatment; however, this need is often unmet and should be a focus of research and implementation.

Delivery of Neuropsychological Interventions for Adult and Older Adult Clinical Populations: An Australian Expert Working Group Clinical Guidance Paper

Delivery of neuropsychological interventions addressing the cognitive, psychological, and behavioural consequences of brain conditions is increasingly recognised as an important, if not essential, skill set for clinical neuropsychologists. It has the potential to add substantial value and impact to our role across clinical settings. However, there are numerous approaches to neuropsychological intervention, requiring different sets of skills, and with varying levels of supporting evidence across different diagnostic groups. This clinical guidance paper provides an overview of considerations and recommendations to help guide selection, delivery, and implementation of neuropsychological interventions for adults and older adults. We aimed to provide a useful source of information and guidance for clinicians, health service managers, policy-makers, educators, and researchers regarding the value and impact of such interventions. Considerations and recommendations were developed by an expert working group of neuropsychologists in Australia, based on relevant evidence and consensus opinion in consultation with members of a national clinical neuropsychology body. While the considerations and recommendations sit within the Australian context, many have international relevance. We include (i) principles important for neuropsychological intervention delivery (e.g. being based on biopsychosocial case formulation and person-centred goals); (ii) a description of clinical competencies important for effective intervention delivery; (iii) a summary of relevant evidence in three key cohorts: acquired brain injury, psychiatric disorders, and older adults, focusing on interventions with sound evidence for improving activity and participation outcomes; (iv) an overview of considerations for sustainable implementation of neuropsychological interventions as 'core business'; and finally, (v) a call to action.

Prevalence of cognitive impairments and strengths in the early course of psychosis and depression

BACKGROUND

Studies investigating cognitive impairments in psychosis and depression have typically compared the average performance of the clinical group against healthy controls (HC), and do not report on the actual prevalence of cognitive impairments or strengths within these clinical groups. This information is essential so that clinical services can provide adequate resources to supporting cognitive functioning. Thus, we investigated this prevalence in individuals in the early course of psychosis or depression.

METHODS

A comprehensive cognitive test battery comprising 12 tests was completed by 1286 individuals aged 15-41 (mean age 25.07, s.d. 5.88) from the PRONIA study at baseline: HC (N = 454), clinical high risk for psychosis (CHR; N = 270), recent-onset depression (ROD; N = 267), and recent-onset psychosis (ROP; N = 295). Z-scores were calculated to estimate the prevalence of moderate or severe deficits or strengths (>2 s.d. or 1-2 s.d. below or above HC, respectively) for each cognitive test.

RESULTS

Impairment in at least two cognitive tests was as follows: ROP (88.3% moderately, 45.1% severely impaired), CHR (71.2% moderately, 22.4% severely impaired), ROD (61.6% moderately, 16.2% severely impaired). Across clinical groups, impairments were most prevalent in tests of working memory, processing speed, and verbal learning. Above average performance (>1 s.d.) in at least two tests was present for 40.5% ROD, 36.1% CHR, 16.1% ROP, and was >2 SDs in 1.8% ROD, 1.4% CHR, and 0% ROP.

CONCLUSIONS

These findings suggest that interventions should be tailored to the individual, with working memory, processing speed, and verbal learning likely to be important transdiagnostic targets.

Community-based models of care facilitating the recovery of people living with persistent and complex mental health needs: a systematic review and narrative synthesis

Objective

This study aims to assess the effectiveness of community-based models of care (MoCs) supporting the recovery of individuals who experience persistent and complex mental health needs.

Method

We conducted a systematic review and narrative synthesis of MoC studies reporting clinical, functional, or personal recovery from October 2016 to October 2021. Sources were Medline, EMBASE, PsycInfo, CINAHL, and Cochrane databases. Studies were grouped according to MoC features. The narrative synthesis was led by our researchers with lived experience.

Results

Beneficial MoCs ranged from well-established to novel and updated models and those explicitly addressing recovery goals and incorporating peer support: goal-focused; integrated community treatment; intensive case management; partners in recovery care coordination; rehabilitation and recovery-focused; social and community connection-focused; supported accommodation; and vocational support. None of our diverse group of MoCs supporting recovery warranted a rating of best practice. Established MoCs, such as intensive case management, are promising practices regarding clinical and functional recovery, with potential for enhancements to support personal recovery. Emerging practice models that support personal and functional recovery are those where consumer goals and priorities are central.

Conclusion

Evidence for established models of care shows that there is a need for inevitable evolution and adaptation. Considering the high importance of effective MoCs for people experiencing persistent and complex mental health needs, further attention to service innovation and research is required. Greater emphasis on the inclusion of lived and living experience in the design, delivery, implementation, and research of MoCs is needed, to enhance MOCs' relevance for achieving individual consumer recovery outcomes.

Moderators of metacognitive strategy training for executive functioning in early schizophrenia and psychosis risk

Goal Management Training (GMT) improved self-reported executive functioning in a recent randomized, controlled trial in early intervention for psychosis participants. Little is known about the mechanism for this benefit, so this study investigates objectively measured executive function, the difference between subjective and objective executive function, independent living and employment status as potential moderators of efficacy of GMT. Baseline scores from 81 participants (GMT n = 39 vs Treatment-as-usual; TAU n = 42) were analyzed in a linear mixed model analysis for repeated measures as predictors of improvement on the self-reported Behavior Rating Inventory of Executive Function-Adult version (BRIEF-A) immediately and 30 weeks after GMT. Potential moderators were scores from objective measures of executive functioning, discrepancy between subjective and objective measures, independent living and employment status. Discrepancy was assessed by comparing four clusters of participants with differing patterns of scores. The effect of GMT remained significant regardless of initial objective executive functioning at baseline. Those with higher subjective complaints at baseline in two clusters with (i) both objective and subjective executive dysfunction, and (ii) mostly subjective executive dysfunction experienced greater change after treatment. Living arrangements or participation in education or work did not significantly moderate the effects of GMT. Poor performance on neuropsychological tasks is not an obstacle to making use of GMT, but further knowledge is needed about the benefits of strategy training for individuals with a combination of poor performance with few subjective complaints.

Effects of empowerment-based illness management on the medication adherence and recovery of persons with schizophrenia: A systematic review and meta-analysis

Medication adherence and recovery rates are <50% among persons with schizophrenia; therefore, this health concern needs attention. Empowerment is a vital element for behavioural change, but previous studies have presented different results and lack specific connotations about empowerment. Therefore, this study systematically reviewed and meta-analysed the effects of empowerment-based illness management on the medication adherence and recovery of persons with schizophrenia. The databases searched included the PROSPERO registration network, Cochrane Library, PubMed, Embase, CINAHL, PsycAricle, and Airiti Library. The research steps were based on PRISMA. RoB 2.0 was used for article quality evaluation, the effect size was calculated using RevMan software, and the random-effect model and standardized mean differences (SMD) were established. Eight randomized controlled trials (RCTs) involving 859 participants were used to investigate the effect of empowerment on medication adherence. The trials involved the use of effective strategies as inducing medication motivation, promoting self-medication management, and providing support resources. A moderate effect was observed (SMD = 0.58, 95% CI 0.18-0.99). Ten RCTs involving 1473 participants were used to investigate the effect of empowerment on recovery. These trials involved the use of such effective strategies as using self-strength, connecting external forces, understanding personal needs, and overcoming self-stigma. A moderate effect was observed (SMD = 0.55, 95% CI 0.10-0.99). Empowerment in illness management can effectively promote the medication adherence and recovery of persons with schizophrenia. In the future, nurses can use self-strength care to promote medication motivation and connect internal and external forces to assist a person's medication adherence and recovery.

Arcuate Fasciculus Microstructure Predicts Alcohol Dependence Risk through Higher IQ

IQ has been found to correlate with alcohol consumption, with a higher IQ being a risk for alcohol misuse. Furthermore, recent research has shown that the microstructure of the arcuate fasciculus is associated with IQ. This study therefore aimed to examine the association between the arcuate fasciculus microstructure, IQ, and alcohol dependence risk. In this study, we performed probabilistic tractography between Wernicke's and Broca's areas in the left and right hemispheres to examine the association of the arcuate fasciculus's integrity with IQ and alcohol dependence risk, using DTI data from 344 individuals. Data regarding IQ were obtained from the Wechsler Abbreviated Scale of Intelligence (WASI-II). Alcohol substance involvement (SI) score was derived using the National Institute on Drug Abuse (NIDA) Quick Screen and was used as an index for alcohol dependence risk. Both the left arcuate fasciculus and IQ were found to have a significant association with alcohol dependence risk. A mediation analysis revealed that this association between the left arcuate fasciculus microstructure and an alcohol dependence risk was mediated by IQ. It is suggested that the left arcuate fasciculus microstructure is associated with IQ which is associated with alcohol dependence risk. While alcohol consumption is known to be robustly toxic to the brain, the left arcuate fasciculus shows exceptional characteristics in which its microstructure integrity is positively associated with an alcohol dependence risk through higher IQ. Clinical implications are discussed.

Enhancing functional recovery for young people recovering from first episode psychosis via sport-based life skills training: outcomes of a feasibility and pilot study

Early intervention within First Episode Psychosis (FEP) recovery efforts support functional recovery in several ways, including increasing levels of (1) physical activity (2) life skills, and (3) social connectivity. Sport has been proposed as an ideal platform to target these three goals simultaneously. The primary aims were to assess the feasibility of utilising sport-based life skills within FEP recovery efforts and test intervention components. The secondary aim was to evaluate the potential recovery benefits. Seven young people (aged 15-25 years) with FEP participated in a six-week sport programme alongside their support workers (community and peer workers) from the service, including peer workers with a lived experience of psychosis. The programme consisted of various sporting activities, which were designed to promote physical activity, maximise social connectivity, and teach life-skills (e.g. motivation, emotional regulation, and goal-setting) that are relevant and transferrable to other contexts (e.g. school, employment, independent living). The support participants engaged with the programme at the same level as the young people, with the role of providing support and normalising/modelling engagement. The young and support participants provided feedback during and after the programme via questionnaires and interviews. Young participants self-reported physical activity levels, psychological needs, recovery dimensions, and life skills pre- and post- intervention using established psychometric tools. We used thematic analysis to analyse the qualitative data and compared this information with other data collected (e.g. attendance, feedback, quantitative measurements). The study culminated with a process evaluation. The results indicated that, despite challenges with engagement for young people with FEP, sport-based life skills programming may be a feasible and useful recovery outlet. In addition, the results highlighted specific intervention components that were useful to promote engagement and recovery benefits. This study serves as a critical foundation for future sport-based work within FEP recovery.

Normal-range verbal memory in the first-episode of psychosis: Clinical and functional outcomes across 24 months and impact of estimated verbal memory decrement

Verbal memory (VM) dysfunction is prevalent in first-episode psychosis (FEP) and has major impacts on long-term functional and clinical outcomes. Nevertheless, a substantial proportion of FEP patients have VM performance in the norm, called normal-range (NR) VM, and only a few studies have explored its relation to outcomes. Moreover, probable decrements between estimated premorbid and current cognitive performance could confuse the relationship between VM and clinical or functional outcomes in FEP patients. These potential interactions have not yet been considered in FEP, thus, we examined 1) the longitudinal relationship between VM performance (NR vs. below NR (BNR)) in FEP and clinical and functional outcomes over 24 months following admission to treatment, and 2) compared the clinical and functional status of NR patients with and without cognitive decrement at baseline and 12 months. A total of 271 patients (BNR = 114, NR = 157; 81 out of 105 NR with decrement) completed measures of psychosocial functioning and clinical symptoms at baseline, month 12, and month 24. Generalized Estimating Equations and unpaired t-tests were used to address the first and second aim, respectively. NR demonstrated better functioning and fewer negative symptoms when compared to BNR. Interestingly, NR patients with decrement reported significantly more negative symptoms at baseline compared to their counterparts without decrement. These findings document that a large proportion (57.9 %) of FEP patients have NR VM that appear to be functionally advantageous but that NR VM is nuanced by the presence or absence of a potential decrement early in the developmental course of the disorder.

Digital technology for addressing cognitive impairment in recent-onset psychosis: A perspective

Cognitive impairments in psychosis negatively impact functional recovery and quality of life. Existing interventions for improving cognitive impairment in recent-onset psychosis show inconsistent treatment efficacy, small effects, suboptimal engagement and limited generalizability to daily life functioning. In this perspective we explore how digital technology has the potential to address these limitations in order to improve cognitive and functional outcomes in recent-onset psychosis. Computer programs can be used for standardized, automated delivery of cognitive remediation training. Virtual reality provides the opportunity for learning and practicing cognitive skills in real-world scenarios within a virtual environment. Smartphone apps could be used for notification reminders for everyday tasks to compensate for cognitive difficulties. Internet-based technologies can offer psychoeducation and training materials for enhancing cognitive skills. Early findings indicate some forms of digital interventions for cognitive enhancement can be effective, with well-established evidence for human-supported computer-based cognitive remediation in recent-onset psychosis. Emerging evidence regarding virtual reality is favorable for improving social cognition. Overall, blending digital interventions with human support improves engagement and effectiveness. Despite the potential of digital interventions for enhancing cognition in recent-onset psychosis, few studies have been conducted to date. Implementation challenges affecting application of digital technologies for cognitive impairment in recent-onset psychosis are sustained engagement, clinical integration, and lack of quality in the commercial marketplace. Future opportunities lie in including motivational frameworks and behavioral change interventions, increasing service engagement in young people and lived experience involvement in digital intervention development.

Cognitive strengths in first episode psychosis: a thematic analysis of clinicians' perspectives

BACKGROUND

Cognitive deficits are associated with poor functional outcomes in individuals recovering from a first episode of psychosis (FEP). Existing treatments that target cognitive deficits in FEP may enhance cognitive function, but improvements to real-world functioning are less consistent. Furthermore, these treatments may not adequately address the personal recovery goals of young people attending FEP services. A novel cognitive strengths-based approach may overcome these shortcomings.

METHODS

This qualitative study used semi-structured interviews to explore clinicians' (N = 12) perspectives toward the potential development of a cognitive strengths-based assessment or treatment in FEP. The interviews were analysed using thematic analysis.

RESULTS

Five higher-order themes emerged: (1) pro-strengths attitude despite unfamiliarity and minimal use, (2) default to a cognitive deficit lens, (3) potential benefits of a cognitive strengths approach, (4) potential risks and barriers, and (5) considerations for successful implementation. While clinicians acknowledged their current deficit approach, they supported implementing a cognitive strengths assessment or treatment and highlighted their potential benefits for the personal recovery needs of young people with FEP.

CONCLUSIONS

These findings suggest that a deficit-focused approach to cognitive function amongst clinicians may be common practice in FEP services. Nevertheless, a cognitive strengths approach was viewed favourably by clinicians and may represent a novel method of supporting personal recovery. Thus, the design and implementation of a cognitive strengths approach may be worthwhile. Future exploration of other stakeholder perspectives, such as young people with FEP, is essential.

Toolkit for assessing and addressing cognitive health in early psychosis: Evaluation of feasibility and utility in a coordinated specialty care setting

AIM

Methods to identify and harness individual cognitive strengths while addressing relative weaknesses have the potential to complement recovery services for first-episode psychosis but systematic implementation is needed. We developed a cognitive health toolkit, trained teams from OnTrackNY, a network of coordinated specialty care (CSC) programs and examined toolkit feasibility and clinical utility during the first year of roll-out.

METHODS

The toolkit includes a clinician manual, assessment and decision-making tools, and a menu of cognitive health service options. Assessment uses the WRAT5-Reading subtest and a new Self-Assessment of Cognitive Functioning which, together, determine participant- and clinician-perceived cognitive health need. Program-level data were analysed for rates of assessment, identification of cognitive health needs and cognitive health service provision.

RESULTS

Data from 18 OnTrackNY teams included 933 participants, including 310 new admissions. Across teams, 43.9% of newly admitted participants received a WRAT5-Reading and 41.3% received a self-assessment. Of all assessments completed in the study period, 50.7% were at or within 3-months of admission and 69.1% were within the first year of program participation. Cognitive health need was identified by self-report (57.6%) and clinician-report (69.9%) and led to provision of specific services, including psychoeducation, compensatory skills training and in some cases restorative cognitive training.

CONCLUSIONS

Preliminary feasibility data are encouraging but barriers to assessment need to be identified and addressed. Rates of identified cognitive health need warrant further study of the implementation process and outcomes so that cognitive health assessment and treatment practices may ultimately be disseminated to CSC programs more broadly.

Characterization and interrelationships of theory of mind, socially competitive emotions and affective empathy in bipolar disorder

OBJECTIVE

Evidence shows impaired theory of mind (ToM) in patients with bipolar disorder (BD), yet research examining its cognitive and affective components simultaneously is sparse. Moreover, recognition of socially competitive 'fortune of others' emotions (e.g. envy/gloat) may be related to ToM, but has not been assessed in BD. Finally, if and how ToM and 'fortune of others' emotions relate to affective empathy in BD is currently unclear. This study aimed to address these points.

METHODS

64 BD patients and 34 healthy controls completed the Yoni task, a visual task assessing first- and second-order cognitive and affective ToM as well as 'fortune of others' emotions. The Toronto Empathy Questionnaire was used to assess self-reported affective empathy.

RESULTS

Patients with BD showed no deficits in cognitive and affective ToM or recognition of 'fortune of others' emotions. The ability to infer 'fortune of others' emotions correlated with several ToM measures, indicating that these functions are part of the same system. Patients with BD reported similar levels of affective empathy to healthy controls, and this was not related to ToM or 'fortune of others' emotions, suggesting that affective empathy represents a separate social domain.

CONCLUSIONS

These findings highlight areas of spared social functioning in BD, which may be utilized in therapeutic strategies.

PRACTITIONER POINTS

Our results suggest theory of mind and empathy may represent areas of potentially spared cognitive functioning in BD. As many BD patients have experienced adversity during developmental periods in which theory of mind and empathy develop, our findings suggest that these abilities may be markers of resilience in the disorder. Our findings are important for the formulation of therapeutic interventions for BD, which may include considering practical ways that a patients' knowledge of intact ToM and empathy could be utilized to reduce self-stigma and promote self-efficacy, improved well-being and functioning.

Executive dysfunction in schizophrenia: Predictors of the discrepancy between subjective and objective measures

This study aimed to investigate what characterizes individuals with schizophrenia who experience more or less subjective executive dysfunction in everyday life compared to objective executive performance on neuropsychological tests. Sixty-six participants with broad schizophrenia spectrum disorders completed a comprehensive assessment of executive function. Discrepancies between performance on neuropsychological tests (objective) and an extensive self-report questionnaire (subjective) of central executive functions (inhibition, shifting and working memory) were calculated. Higher level of self-efficacy was the best predictor of experiencing fewer subjective cognitive complaints compared to objective performance, followed by higher levels of disorganized symptoms. Depressive symptoms did not predict discrepancy between subjective and objective executive function. Higher estimated IQ predicted greater subjective working memory difficulties in everyday life despite better objective performance. Results may aid clinicians in the assessment and remediation of cognitive impairment. Low self-efficacy may identify individuals who are not able to utilize their potential executive functions in daily life. Interventions aimed at fostering self-efficacy ought to be included in cognitive remediation for these individuals. Disorganized symptoms could prove useful in identifying individuals who are in need of cognitive remediation for executive dysfunction, despite that they overestimate their skills. These individuals may benefit from efforts to increase insight into cognitive dysfunction.

Are poor set-shifting and central coherence associated with everyday function in anorexia nervosa? A systematic review

BACKGROUND

There is increasing interest in associations between cognitive impairments and clinical symptoms in Anorexia Nervosa (AN), however, the relationship with everyday function is unclear. The current review synthesizes existing data regarding associations between scores on tests of set-shifting and central coherence and functional outcome measures for individuals with AN.

METHOD

A systematic electronic database search yielded 13 studies which included participants with current or lifetime AN where scores on a neuropsychological test of set-shifting or central coherence were directly or indirectly compared to a functional outcome measure.

RESULTS

Associations between set-shifting and central coherence performance measures and functional outcomes were limited in number and noted only in adult or mixed-age cohorts. Associations were noted at subscale level, suggesting they are specific in nature. In younger cohorts, assessments of executive functioning in everyday life appear sensitive to cognitive-behavioral flexibility issues.

CONCLUSIONS

Associations between cognitive performance and functional outcome have not been as systematically assessed in AN as in other psychiatric disorders. Key factors to address in future research include: (a) the use of function measures which are sensitive to both the level of impairment, and specific rather than general impairments (b) the ecological validity of measures, (c) the task impurity problem, especially in regard to cognitive flexibility assessment, and (d) the need to measure both cognitive deficits and strengths, because tests of specific cognitive processes may underestimate the ability to function in daily life due to compensatory strategies.