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Searle A, Allen L, Lowther M, Cotter J, Barnett JH. Measuring functional outcomes in schizophrenia in an increasingly digital world. Schizophr Res Cogn 2022; 29:100248. [PMID: 35444930 PMCID: PMC9014442 DOI: 10.1016/j.scog.2022.100248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/15/2022] [Accepted: 03/15/2022] [Indexed: 12/01/2022] Open
Abstract
With an unmet clinical need for effective interventions for cognitive and negative symptoms in patients with schizophrenia, measures of functional status (often a co-primary endpoint) remain key clinical trial outcomes. This review aims to give an overview of the different types of functional assessments commonly used in clinical trials and research involving patients with schizophrenia and highlight pertinent challenges surrounding the use of these as reliable, sensitive, and specific assessments in intervention trials. We provide examples of commonly used functional measures and highlight emerging real-time digital assessment tools. Informant- and clinician-rated functional outcome measures and functional capacity assessments are valid, commonly used measures of functional status that try to overcome the need for often overly ambitious and insensitive ‘real world’ milestones. The wide range of scientific and practical challenges associated with these different tools leave room for the development of improved functional outcome measures for use in clinical trials. In particular, many existing measures fail to capture small, but meaningful, functional changes that may occur over the course of typically short intervention trials. Adding passive digital data collection and short active real-time digital assessments whilst patients go about their day offers the opportunity to build a more fine-grained picture of functional improvements that, if thoughtfully developed and carefully applied, could provide the sensitivity needed to accurately evaluate functional status in intervention studies, aiding the development of desperately needed treatments. Functional outcome measures are important for evaluating the efficacy of treatments. A variety of these are available, each with their own strengths and limitations. However, consensus on the optimal functional outcome measure(s) is lacking. Digital measures may enhance the assessment of associated functional constructs.
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Affiliation(s)
- Anja Searle
- Cambridge Cognition, Tunbridge Court, Bottisham, Cambridge CB25 9TU, UK
| | - Luke Allen
- Cambridge Cognition, Tunbridge Court, Bottisham, Cambridge CB25 9TU, UK
| | - Millie Lowther
- Cambridge Cognition, Tunbridge Court, Bottisham, Cambridge CB25 9TU, UK.,Anxiety Lab, Neuroscience and Mental Health Group, University College London Institute of Cognitive Neuroscience, Alexandra House, 17-19 Queen Square, Bloomsbury, London WC1N 3AZ, UK
| | - Jack Cotter
- Cambridge Cognition, Tunbridge Court, Bottisham, Cambridge CB25 9TU, UK.,Medical and Scientific Affairs, Nutrition, Reckitt, Slough, UK
| | - Jennifer H Barnett
- Cambridge Cognition, Tunbridge Court, Bottisham, Cambridge CB25 9TU, UK.,University of Cambridge Department of Psychiatry, Cambridge CB2 0SZ, UK
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Mucci A, Vignapiano A, Bitter I, Austin SF, Delouche C, Dollfus S, Erfurth A, Fleischhacker WW, Giordano GM, Gladyshev I, Glenthøj B, Gütter K, Hofer A, Hubeňák J, Kaiser S, Libiger J, Melle I, Nielsen MØ, Papsuev O, Rybakowski JK, Sachs G, Üçok A, Wojciak P, Galderisi S. A large European, multicenter, multinational validation study of the Brief Negative Symptom Scale. Eur Neuropsychopharmacol 2019; 29:947-959. [PMID: 31255394 DOI: 10.1016/j.euroneuro.2019.05.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/11/2019] [Accepted: 05/29/2019] [Indexed: 12/18/2022]
Abstract
Negative symptoms represent an unmet need of treatment in schizophrenia. Although a consensus exists on negative symptom construct, and second generation assessment instruments reflecting the consensus are available, studies still rely upon old assessment instruments, that do not reflect recent conceptualizations and might limit progress in the search for effective treatments. This is often the case in the European context, where one of the challenges encountered in designing large studies is the availability of validated instruments in the many languages of the continent. To address this challenge and promote sound research on negative symptoms in Europe, the ECNP Schizophrenia Network coordinated a large multicenter, multinational validation study of the Brief Negative Symptom Scale (BNSS). Clinically-stable subjects with schizophrenia (SCZ, N = 249) were recruited from 10 European Countries. Apart from BNSS, subjects were administered the Positive and Negative Syndrome Scale (PANSS) and standardized instruments for depression, extrapyramidal symptoms and psychosocial functioning. Results showed an excellent internal consistency, convergent and discriminant validity of BNSS and replicated a 5 factor-model. A larger number of subjects with predominant negative symptoms, i.e. the target population for clinical trials, was identified by using the BNSS compared to the PANSS. Regression analysis showed that BNSS-avolition, a key negative symptom poorly assessed by PANSS, explained 23.9% of psychosocial functioning, while no combination of the PANSS core negative symptoms showed the same impact on functioning. The study demonstrated that BNSS has substantial advantages with respect to PANSS for the identification of the avolition domain and subjects with predominant negative symptoms.
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Affiliation(s)
- Armida Mucci
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie, 80138 Naples, Italy.
| | - Annarita Vignapiano
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie, 80138 Naples, Italy
| | - István Bitter
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
| | - Stephen F Austin
- Psychiatric Research Unit, Psychiatry Region Zealand, Hillerød, Denmark
| | - Camille Delouche
- Service de Psychiatrie, CHU de Caen, Caen, France; UFR de Médecine, UNICAEN, Normandie Université, Caen, France; ISTS, UNICAEN, Normandie Université, Caen, France
| | - Sonia Dollfus
- Service de Psychiatrie, CHU de Caen, Caen, France; UFR de Médecine, UNICAEN, Normandie Université, Caen, France; ISTS, UNICAEN, Normandie Université, Caen, France
| | - Andreas Erfurth
- 6th Psychiatric Department, Otto-Wagner-Spital, Vienna, Austria
| | - W Wolfgang Fleischhacker
- Department of Psychiatry, Psychotherapy and Psychosomatics, Division of Psychiatry I, Medical University Innsbruck, Innsbruck, Austria
| | - Giulia M Giordano
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie, 80138 Naples, Italy
| | - Igor Gladyshev
- Department of Socio-clinical and Biological Research of Psychotic spectrum disorders, Moscow Research Institute of Psychiatry, Moscow, Russia
| | - Birte Glenthøj
- Center for Neuropsychiatric Schizophrenia Research (CNSR) and Center for Clinical Intervention and Neuropsychiatric Schizophrenia Research (CINS), Mental Health Center Glostrup, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Karoline Gütter
- Department of Psychiatry and Psychotherapy, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Alex Hofer
- Department of Psychiatry, Psychotherapy and Psychosomatics, Division of Psychiatry I, Medical University Innsbruck, Innsbruck, Austria
| | - Jan Hubeňák
- Psychiatric Department, Charles University Medical School and Faculty Hospital Hradec Králové, Hradec Králové, Czechia
| | - Stefan Kaiser
- Adult Psychiatry Division, Department of Psychiatry, University of Geneva Hospitals, Geneva, Switzerland
| | - Jan Libiger
- Psychiatric Department, Charles University Medical School and Faculty Hospital Hradec Králové, Hradec Králové, Czechia
| | - Ingrid Melle
- NORMENT Centre, Institute of Clinical Psychiatry, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Mette Ø Nielsen
- Center for Neuropsychiatric Schizophrenia Research (CNSR) and Center for Clinical Intervention and Neuropsychiatric Schizophrenia Research (CINS), Mental Health Center Glostrup, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Oleg Papsuev
- Department of Socio-clinical and Biological Research of Psychotic spectrum disorders, Moscow Research Institute of Psychiatry, Moscow, Russia
| | - Janusz K Rybakowski
- Department of Adult Psychiatry, Poznan University of Medical Sciences, Poznan, Poland
| | - Gabriele Sachs
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Alp Üçok
- Istanbul Faculty of Medicine, Psychotic Disorders Research Program, Istanbul University, Istanbul, Turkey
| | - Pawel Wojciak
- Department of Adult Psychiatry, Poznan University of Medical Sciences, Poznan, Poland
| | - Silvana Galderisi
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie, 80138 Naples, Italy
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Cotter J, Barnett JH, Granger K. The Use of Cognitive Screening in Pharmacotherapy Trials for Cognitive Impairment Associated With Schizophrenia. Front Psychiatry 2019; 10:648. [PMID: 31551837 PMCID: PMC6743013 DOI: 10.3389/fpsyt.2019.00648] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/12/2019] [Indexed: 11/13/2022] Open
Abstract
There are currently no regulatory approved pharmacological treatments for cognitive impairment associated with schizophrenia (CIAS). One possibility is that trial methodology itself is hindering their development. Emerging evidence suggests that patients with schizophrenia may show limited benefit from pro-cognitive interventions if they already exhibit intact cognitive performance, relative to normative thresholds. The aim of this report was to examine the extent to which objectively assessed cognitive performance has been used as an eligibility and/or stratification criterion in CIAS pharmacotherapy trials. On 16th January 2019, we conducted a systematic search of studies listed on ClinicalTrials.gov to identify randomized, double-blind, placebo-controlled, add-on pharmacotherapy trials conducted in patients with a diagnosis of schizophrenia, in which a paper-and-pencil or computerized cognitive task (or battery) was specified as a primary outcome measure. Of the 87 trials that met our inclusion criteria, 10 (11.5%) required the presence of an objectively assessed cognitive deficit as part of their patient eligibility criteria. No studies reported stratifying patients according to the presence or degree of cognitive impairment they exhibited. These results suggest that the vast majority of CIAS trials may have been underpowered due to the inclusion of cognitively "normal" patients. Purposive screening for cognitive impairment could increase CIAS trial success.
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Affiliation(s)
- Jack Cotter
- Cambridge Cognition, Cambridge, United Kingdom
| | - Jennifer H Barnett
- Cambridge Cognition, Cambridge, United Kingdom.,Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
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Strassnig M, Bowie C, Pinkham AE, Penn D, Twamley EW, Patterson TL, Harvey PD. Which levels of cognitive impairments and negative symptoms are related to functional deficits in schizophrenia? J Psychiatr Res 2018; 104:124-129. [PMID: 30029051 DOI: 10.1016/j.jpsychires.2018.06.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/17/2018] [Accepted: 06/28/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Negative symptoms and cognitive impairments predict difficulties in aspects of everyday functioning in schizophrenia, with little research to date attempting to determine if there are threshold levels of impairment required to predict the severity of functional deficits. METHODS People diagnosed with chronic schizophrenia (n = 821) were assessed with the MCCB and PANSS, and rated by high contact informants with SLOF. Negative symptoms of reduced emotional experience were specifically targeted for analysis because of their previously identified relationships with social outcomes. We identified patients with moderate negative symptoms (at least one PANSS item ≥4) versus less severe symptoms (PANSS items ≤3) and divided patients on the basis of a single latent-trait global cognition score (neuropsychologically normal vs neuropsychologically impaired; performance at or below 1.0 SD from the normative population mean, T = 40), then examined correlations between cognition, negative symptoms and everyday functioning in the groups with lower and higher negative symptoms and those with/without cognitive impairment. RESULTS Even low levels of negative symptoms were correlated with ratings of social functioning. Cognitive performance in the neuropsychologically normal range, in contrast, was not correlated with any aspects of everyday functioning while more impaired performance predicted greater functional impairments. CONCLUSIONS Even minimal symptoms may be a target for clinical attention in the domains of negative symptoms, consistent with previous findings regarding social deficits in populations with modest negative symptoms (e.g., schizotypal personality disorder). Cognitive rehabilitation treatments might not improve social functioning if even low levels of negative symptoms (social amotivation) are present.
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Affiliation(s)
- M Strassnig
- Department of Integrated Medical Science, Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Road Boca Raton, FL, 33431, USA.
| | - C Bowie
- Department of Psychology, Queen's University, Kingston, ON, USA
| | - A E Pinkham
- School of Behavior and Brain Science, University of Texas at Dallas, Dallas, TX, USA
| | - D Penn
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC, USA
| | - Elizabeth W Twamley
- Department of Psychiatry, University of California at San Diego, San Diego, CA, USA
| | - Thomas L Patterson
- Department of Psychiatry, University of California at San Diego, San Diego, CA, USA
| | - P D Harvey
- Department of Psychiatry and Behavioral Sciences, University of Miami, Miami, FL, USA; Research Services, Bruce V. Carter VA, Miami, FL, USA
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Bailey SJ, Neill JC, Moran PM. Pharmacology of cognition: a panacea for neuropsychiatric disease? Br J Pharmacol 2018; 174:3133-3135. [PMID: 28901012 DOI: 10.1111/bph.13956] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
LINKED ARTICLES This article is part of a themed section on Pharmacology of Cognition: a Panacea for Neuropsychiatric Disease? To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.19/issuetoc.
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Affiliation(s)
- Sarah J Bailey
- Drug and Target Discovery, Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Joanna C Neill
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
| | - Paula M Moran
- School of Psychology, University of Nottingham, Nottingham, UK
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Joshi YB, Light GA. Using EEG-Guided Basket and Umbrella Trials in Psychiatry: A Precision Medicine Approach for Cognitive Impairment in Schizophrenia. Front Psychiatry 2018; 9:554. [PMID: 30510520 PMCID: PMC6252381 DOI: 10.3389/fpsyt.2018.00554] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/15/2018] [Indexed: 12/21/2022] Open
Abstract
Due to advances over the last several decades, many fields of medicine are moving toward a precision medicine approach where treatments are tailored to nuanced patient factors. While in some disciplines these innovations are commonplace leading to unique biomarker-guided experimental medicine trials, there are no such analogs in psychiatry. In this brief review, we will overview two unique biomarker-guided trial designs for future use in psychiatry: basket and umbrella trials. We will illustrate how such trials could be useful in psychiatry using schizophrenia as a candidate illness, the EEG measure mismatch negativity as the candidate biomarker, and cognitive impairment as the target disease dimension.
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Affiliation(s)
- Yash B Joshi
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, United States
| | - Gregory A Light
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, United States.,VISN-22 Mental Illness, Research, Education and Clinical Center (MIRECC), VA San Diego Health Care System, San Diego, CA, United States
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