ECNP consensus meeting. Negative, depressive and cognitive symptoms of schizophrenia. Nice, March 2004

Reliability and validity of the self-report version of the apathy evaluation scale in first-episode Psychosis: Concordance with the clinical version at baseline and 12 months follow-up

Negative symptoms have traditionally been assessed based on clinicians' observations. The subjective experience of negative symptoms in people with psychosis may bring new insight. The Apathy Evaluation Scale (AES) is commonly used to study apathy in psychosis and has corresponding self-rated (AES-S) and clinician-rated (AES-C) versions. The aim of the present study was to determine the validity and reliability of the AES-S by investigating its concordance with the AES-C. Eighty-four first-episode (FEP) patients completed the shortened 12-item AES-S and AES-C at baseline (T1) and 12 months (T2). Concordance was studied by degree of correlation, comparison of mean scores, and change and difference between diagnostic groups. The Positive and Negative Symptom Scale (PANSS) was used to study convergent and discriminative properties. High concordance was found between AES-S and AES-C at both T1 and T2 regarding mean values, change from T1 to T2, and the proportion with high levels of apathy. Both versions indicated high levels of apathy in FEP, while associations with PANSS negative symptoms were weaker for AES-S than AES-C. Controlling for depression did not significantly alter results. We concluded that self-rated apathy in FEP patients is in concordance with clinician ratings, but in need of further study.

Cariprazine specificity profile in the treatment of acute schizophrenia: a meta-analysis and meta-regression of randomized-controlled trials

Cariprazine is a new dopamine D2 and D3 receptor partial agonist antipsychotic. Meta-analytic evidence of efficacy in acute schizophrenia and specific groups of patients is lacking. We carried out a meta-analysis in patients with acute schizophrenia to evaluate the efficacy of cariprazine over placebo and active comparators in overall symptoms, positive and negative symptoms and quality of life. Low and high (≥6 mg/day) doses were tested separately. The possible effect of clinical-demographic modulators was also tested. Four studies (2144 patients) were included. Both high and low cariprazine doses proved superior to placebo in all symptom domains. The standardized mean difference (SMD) to placebo showed a modest impact on overall symptoms compared with meta-analytic results for other antipsychotics (SMD was similar to lurasidone, asenapine, ziprasidone and aripiprazole, but lower than risperidone, quetiapine and olanzapine). The SMD to placebo on negative symptoms was superior to many antipsychotics including aripiprazole, with a slightly more relevant effect of cariprazine low doses. This effect was probably on secondary negative symptoms since the short-term follow-up of the studies included. Meta-regression data further refined the compound clinical profile, suggesting that cariprazine may be particularly useful in young patients with a relatively short duration of disease.

EPICOG-SCH: A brief battery to screen cognitive impact of schizophrenia in stable outpatients

Brief batteries in schizophrenia, are needed to screen for the cognitive impact of schizophrenia. We aimed to validate and co-norm the Epidemiological Study of Cognitive Impairment in Schizophrenia (EPICOG-SCH) derived brief cognitive battery. A cross-sectional outpatient evaluation was conducted of six-hundred-seventy-two patients recruited from 234 centers. The brief battery included well-known subtests available worldwide that cover cognitive domains related to functional outcomes: WAIS-III-Letter-Number-Sequencing-LNS, Category Fluency Test-CFT, Logical-Memory Immediate Recall-LM, and Digit-Symbol-Coding-DSC. CGI-SCH Severity and WHO-DAS-S were used to assess clinical severity and functional impairment, respectively. Unit Composite Score (UCS) and functional regression-weighted Composite Scores (FWCS) were obtained; discriminant properties of FWCS to identify patients with different levels of functional disability were analyzed using receiver-operating characteristic (ROC) technique. The battery showed good internal consistency, Cronbach's alpha = 0.78. The differences between cognitive performance across CGI-SCH severity level subscales ranged from 0.5 to 1 SD. Discriminant capacity of the battery in identifying patients with up to moderate disability levels showed fair discriminant accuracy with areas under the curve (AUC) > 0.70, p < 0.0001. An FWCS mean cut-off score ≥ 100 showed likelihood ratios (LR) up to 4.7, with an LR + of 2.3 and a LR - of 0.5. An FWCS cut-off ≥ 96 provided the best balance between sensitivity (0.74) and specificity (0.62). The EPICOG-SCH proved to be a useful brief tool to screen for the cognitive impact of schizophrenia, and its regression-weighted Composite Score was an efficient complement to clinical interviews for confirming patients' potential functional outcomes and can be useful for monitoring cognition during routine outpatient follow-up visits.

Validation of the Korean-Version of the Clinical Assessment Interview for Negative Symptoms of Schizophrenia (CAINS)

The Clinical Assessment Interview for Negative Symptoms (CAINS) was developed to overcome the limitations of existing instruments and reflect the current view of negative symptoms. The aim of the present study was to evaluate the reliability and validity of the Korean version of the Clinical Assessment Interview for Negative Symptoms (K-CAINS). Inpatients (n = 49) and outpatients (n = 70) with schizophrenia were recruited from three institutions. The confirmative factor analysis, test-retest reliability, inter-rater reliability, convergent validity, and discriminant validity were assessed. The study group consisted of 71 males (59.7%) and 48 females (40.3%). Their mean age was 42.15 years (SD = 12.2). The K-CAINS was confirmed to be divided into two subscales of 9 items related to "motivation/pleasure" and 4 items related to "expression" in concordance with the original version of the CAINS. The results showed that the K-CAINS had a good inter-rater reliability (ICC = 0.84-0.94), test-retest reliability (r = 0.90, P < 0.001). Convergent validity was proven by demonstrating a significant correlation with the Positive and Negative Syndrome Scale (PANSS) negative subscale, and the Scale for the Assessment of Negative Symptoms (SANS). Discriminant validity was proven by the lack of a significant correlation with the PANSS positive subscale, the Korean version of the Beck depression inventory (BDI), the Korean version of the Calgary depression scale for schizophrenia (K-CDSS), and the Modified Simpson Angus scale (MSAS). The K-CAINS could be a reliable and valid tool to assess the negative symptoms of Korean schizophrenia patients.

Cognitive Performance associated to functional outcomes in stable outpatients with schizophrenia

Background–objective

Prevalence data of cognitive impairment in Schizophrenia based on large population samples are scarce. Our goal is to relate cognition and functional outcomes, and estimate prevalence of cognitive impairment in a large sample of schizophrenia outpatients treated with second-generation antipsychotics.

Method

A cross-sectional outpatient evaluation conducted during follow-up visits. Selection criteria included six-months stable treatment. The brief battery, EPICOG-SCH, covered four cognitive domains related to functional outcomes: working memory (WAIS-III-Letter-Number-Sequencing), executive function (Category Fluency Test; CFT), verbal memory (WMS-III-Logical-Memory), and information processing speed (Digit-Symbol-Coding and CFT). Clinical severity and functional impairment were assessed with CGI-SCH and WHO DAS-S. Impairment prevalence was calculated at ≤ 1.5 SD.

Results

Among patients recruited (n = 848) in 234 participating centers, 672 were under 6-month treatment. 61.5% (n = 413) reported cognitive impairment according to CGI-SCH Cognitive Subscale. Estimated prevalences were 85.9% (95% CI 85.6–86.2%) CFT-Fruits; 68.3% (95% CI 67.8–68.8%) CFT-Animals; 38.1% (95% CI 37.5–38.3%) Digit-Symbol-Coding; 24.8% (95% CI 24.1–25.5%) Verbal Memory-Units; 20.9% (95% CI 20.2–21.6%) Letter-Number Sequencing; 11.7% (95% CI 11.0–12.4%) Verbal Memory-Items. Negative and Depressive symptoms, Deficit Syndrome, and functional disability were related to poor performance. Functional disability was predicted by CGI-SCH-Overall severity (OR = 1.34635, p < 0.0001), CGI-SCH-Negative Symptoms (OR = 0.75540, p < 0.0001), working memory (Letter-Number-Sequencing) (OR = − 0.16442, p = 0.0004) and the time-course (OR = 0.05083, p = 0.0094), explaining 47% of the observed variability.

Conclusion

Most prevalent impairments were on executive function and processing speed domains; however, working memory showed the strongest relationship to functional disability. Monitoring cognitive function during follow up is critical to understand patient’s everyday functional capacity.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, part 2: update 2012 on the long-term treatment of schizophrenia and management of antipsychotic-induced side effects

Abstract These updated guidelines are based on a first edition of the World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia published in 2006. For this 2012 revision, all available publications pertaining to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations that are clinically and scientifically meaningful. They are intended to be used by all physicians diagnosing and treating people suffering from schizophrenia. Based on the first version of these guidelines, a systematic review of the MEDLINE/PUBMED database and the Cochrane Library, in addition to data extraction from national treatment guidelines, has been performed for this update. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into six levels of evidence (A-F) and five levels of recommendation (1-5) ( Bandelow et al. 2008a ,b, World J Biol Psychiatry 9:242, see Table 1 ). This second part of the updated guidelines covers long-term treatment as well as the management of relevant side effects. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication and other pharmacological treatment options) of adults suffering from schizophrenia.

BCL9 and C9orf5 are associated with negative symptoms in schizophrenia: meta-analysis of two genome-wide association studies

Schizophrenia is a chronic and debilitating psychiatric condition affecting slightly more than 1% of the population worldwide and it is a multifactorial disorder with a high degree of heritability (80%) based on family and twin studies. Increasing lines of evidence suggest intermediate phenotypes/endophenotypes are more associated with causes of the disease and are less genetically complex than the broader disease spectrum. Negative symptoms in schizophrenia are attractive intermediate phenotypes based on their clinical and treatment response features. Therefore, our objective was to identify genetic variants underlying the negative symptoms of schizophrenia by analyzing two genome-wide association (GWA) data sets consisting of a total of 1,774 European-American patients and 2,726 controls. Logistic regression analysis of negative symptoms as a binary trait (adjusted for age and sex) was performed using PLINK. For meta-analysis of two datasets, the fixed-effect model in PLINK was applied. Through meta-analysis we identified 25 single nucleotide polymorphisms (SNPs) associated with negative symptoms with p<5×10(-5). Especially we detected five SNPs in the first two genes/loci strongly associated with negative symptoms of schizophrenia (P(meta-analysis)<6.22×10(-6)), which included three SNPs in the BCL9 gene: rs583583 showed the strongest association at a P(meta-analysis) of 6.00×10(-7) and two SNPs in the C9orf5 (the top SNP is rs643410 with a p = 1.29 ×10(-6)). Through meta-analysis, we identified several additional negative symptoms associated genes (ST3GAL1, RNF144, CTNNA3 and ZNF385D). This is the first report of the common variants influencing negative symptoms of schizophrenia. These results provide direct evidence of using of negative symptoms as an intermediate phenotype to dissect the complex genetics of schizophrenia. However, additional studies are warranted to examine the underlying mechanisms of these disease-associated SNPs in these genes.

Development and psychometric validation of the Clinical Assessment Interview for Negative Symptoms (CAINS)

Progress in the development of new pharmacological and psychosocial treatments for the negative symptoms of schizophrenia is impeded by limitations of available assessment instruments. The multi-site Collaboration to Advance Negative Symptom Assessment in Schizophrenia (CANSAS) was established to develop and validate a new clinical rating scale using a transparent, iterative, and data-driven process. The Clinical Assessment Interview for Negative Symptoms (CAINS) was designed to address limitations of existing measures and assess consensus-based sub-domains, including asociality, avolition, anhedonia, affective blunting, and alogia. The structure and psychometric properties of the CAINS were evaluated in a sample of 281 schizophrenia and schizoaffective outpatients at four sites. Converging structural analyses indicated that the scale was comprised of two moderately correlated factors - one reflecting experiential impairments (diminished motivation and enjoyment of social, vocational, and recreational activities) and one reflecting expressive impairments (diminished non-verbal and verbal communication). Item-level analyses revealed generally good distributional properties, inter-rater agreement, discriminating anchor points, and preliminary convergent and discriminant validity. Results indicate that the CAINS is a promising new measure for quantifying negative symptoms in clinical neuroscience and treatment studies. Results guided item modification or deletion, and the reliability and validity of the revised, shorter version of the CAINS is in the final phase of development within the CANSAS project.

Toward the next generation of negative symptom assessments: the collaboration to advance negative symptom assessment in schizophrenia

Negative symptoms in schizophrenia are related to poor functional outcome, persistent over time, a source of burden for caregivers, and only minimally responsive to currently available medications. A major challenge to developing efficacious interventions concerns the valid and reliable assessment of negative symptoms. In a recent consensus statement on negative symptoms, a central recommendation was the need to develop new assessment approaches that address the limitations of existing instruments. In the current report, we summarize the background and rationale for the Collaboration to Advance Negative Symptom Assessment in Schizophrenia (CANSAS). The CANSAS project is an National Institute of Mental Health-funded multisite study that is constructing a next-generation negative symptom scale, the Clinical Assessment Interview for Negative Symptoms (CAINS). The CAINS is being developed within a data-driven iterative process that seeks to ensure the measure's reliability, validity, and utility for both basic psychopathology and treatment development research.

Initial development and preliminary validation of a new negative symptom measure: the Clinical Assessment Interview for Negative Symptoms (CAINS)

As part of an ongoing scale development process, this study provides an initial examination of the psychometric properties and validity of a new interview-based negative symptom instrument, the Clinical Assessment Interview for Negative Symptoms (CAINS), in outpatients with schizophrenia or schizoaffective disorder (N = 37). The scale was designed to address limitations of existing measures and to comprehensively assess five consensus-based negative symptoms: asociality, avolition, anhedonia (consummatory and anticipatory), affective flattening, and alogia. Results indicated satisfactory internal consistency reliability for the total CAINS scale score and promising inter-rater agreement, with clear areas identified in need of improvement. Convergent validity was evident in general agreement between the CAINS and alternative negative symptom measures. Further, CAINS subscales significantly correlated with relevant self-report emotional experience measures as well as with social functioning. Discriminant validity of the CAINS was strongly supported by its small, non-significant relations with positive symptoms, general psychiatric symptoms, and depression. These preliminary data on an early beta-version of the CAINS provide initial support for this new assessment approach to negative symptoms and suggest directions for further scale development.

Emotional response deficits in schizophrenia: insights from affective science

Our understanding of the emotional features of schizophrenia has benefited greatly from the adoption of methods and theory from the field of affective science. This article covers basic concepts and methods from affective science on the psychological and neural mechanisms contributing to emotions and reviews the ways in which this research has advanced our understanding of emotional response deficits in schizophrenia. We review naturalistic studies and elicitation studies that evoke emotion responses among participants, including emotion expression, experience, and autonomic physiology. We also consider how these emotion response measures correspond to schizophrenia symptoms, and we focus particular attention on the issue of sex differences in emotional responding and how this may influence our understanding emotional functioning among individuals with schizophrenia.

An update on the role of the 5-hydroxytryptamine6 receptor in cognitive function

As the 5-hydroxytryptamine(6) (5-HT(6)) receptor is almost exclusively expressed in the CNS, particularly in areas associated with learning and memory, many studies have examined its role in cognitive function in the rodent, as reviewed herein. Most studies, in healthy adult rats, report that 5-HT(6) receptor antagonists enhance retention of spatial learning in the Morris water maze, improve consolidation in autoshaping tasks and reverse natural forgetting in object recognition. Antagonists appear to facilitate both cholinergic and glutamatergic neurotransmission, reversing scopolamine- and NMDA receptor antagonist-induced memory impairments. Recent reports show that the 5-HT(6) receptor antagonist, PRX-07034, restores the impairment of novel object recognition produced in rats reared in social isolation, a neurodevelopmental model producing behavioural changes similar to several core symptoms seen in schizophrenia. The 5-HT(6) receptor antagonist, Ro 04-6790, modestly improved reversal learning in isolation reared but not group-housed controls in the water maze. Ro 04-6790 also improved novel object discrimination both in adult rats that received chronic intermittent phencyclidine and drug-naïve 18-month-old rats. However, more information on their effect in animal models of schizophrenia and Alzheimer's disease is required. Several selective high-affinity 5-HT(6) receptor agonists developed recently also improve object discrimination and extra-dimensional set-shifting behaviour. Thus both 5-HT(6) receptor agonist and antagonist compounds show promise as pro-cognitive agents in pre-clinical studies but the explanation for their paradoxical analogous effect is currently unclear, and is discussed in this article.

Refinement of diagnosis and disease classification in psychiatry

Knowledge concerning the classification of mental disorders progressed substantially with the use of DSM III-IV and IDCD 10 because it was based on observed data, with precise definitions. These classifications a priori avoided to generate definitions related to etiology or treatment response. They are based on a categorical approach where diagnostic entities share common phenomenological features. Modifications proposed or discussed are related to the weak validity of the classification strategy described above. (a) Disorders are supposed to be independent but the current coexistence of two or more disorders is the rule; (b) They also are supposed to have stability, however anxiety disorders most of the time precede major depression. For GAD age at onset, family history, biology and symptomatology are close to those of depression. As a consequence broader entities such as depression-GAD spectrum, panic-phobias spectrum and OCD spectrum including eating disorders and pathological gambling are taken into consideration; (c) Diagnostic categories use thresholds to delimitate a border with normals. This creates "subthreshold" conditions. The relevance of such conditions is well documented. Measuring the presence and severity of different dimensions, independent from a threshold, will improve the relevance of the description of patients pathology. In addition, this dimensional approach will improve the problems posed by the mutually exclusive diagnoses (depression and GAD, schizophrenia and depression); (d) Some disorders are based on the coexistence of different dimensions. Patients may present only one set of symptoms and have different characteristics, evolution and response to treatment. An example would be negative symptoms in Schizophrenia; (e) Because no etiological model is available and most measures are subjective, objective measures (cognitive, biological) and genetics progresses created important hopes. None of these measures is pathognomonic and most appear to be related to risk factors especially at certain periods when associated with environmental events. One of the major aims for a classification of patients is to identify groups to whom a best possible therapeutic strategy can be proposed. Drugs may improve fear extinction while the genetic and/or acquired avoidance may be called phobia. The basic mechanism and or the corresponding phenotype should appear in the classification. Progresses in early identification of disturbances by taking into account all the information available (prodromal symptoms, cognitive, biological, imaging, genetic, family information) are crucial for the future therapeutic strategy: prevention.

Abnormal prediction error is associated with negative and depressive symptoms in schizophrenia

Prediction error in learning is where learning occurs to the degree to which an outcome consequent to a stimulus is surprising. It has been suggested that abnormal use of prediction error in schizophrenia may underlie the formation of inappropriate associations giving rise to psychotic symptoms. Kamin blocking is a phenomenon that demonstrates prediction error. Kamin blocking is shown where prior learning about a stimulus A paired with an outcome retards learning about a stimulus B when presented subsequently as part of a stimulus compound AB paired with the same outcome. Prior studies have indicated reduced Kamin blocking in schizophrenia specifically in non-paranoid patients. It is however unclear how reduced Kamin blocking is associated with specific symptoms in schizophrenia. The present study examined Kamin blocking performance in a high functioning community-based sample of 34 people with schizophrenia and 48 controls closely matched for pre-morbid IQ. In these patients we measured Kamin blocking and symptoms using positive and negative symptom scales (PANSS) and Scale for the Assessment of Negative Symptoms (SANS) and Scale for the Assessment of Positive Symptoms (SAPS). Results confirmed that people with schizophrenia had significantly reduced Kamin blocking. Kamin blocking performance was associated with negative and depressive symptoms. These associations with symptoms were crucially not found with baseline associative learning or unblocking measures, confirming specificity to the Kamin blocking effect. These data demonstrate first that abnormal prediction error as assessed in the Kamin blocking task is associated with negative and depressive symptoms rather than positive symptoms in high functioning schizophrenia patients. Second this strongly suggests that reduced Kamin blocking may be useful as an animal model of specific relevance to negative and depressive symptoms in schizophrenia.