The effects of guided discontinuation of antipsychotics on neurocognition in first onset psychosis

Comparative analysis of anticholinergic burden scales to explain iatrogenic cognitive impairment in schizophrenia: results from the multicenter FACE-SZ cohort

Aim

The anticholinergic properties of medications are associated with poorer cognitive performance in schizophrenia. Numerous scales have been developed to assess anticholinergic burden and yet, there is no consensus indicating which anticholinergic burden scale is more relevant for patients with schizophrenia. We aimed to identify valid scales for estimating the risk of iatrogenic cognitive impairment in schizophrenia.

Methods

We identified 27 scales in a literature review. The responses to neuropsychological tests of 839 individuals with schizophrenia or schizoaffective disorder in the FACE-SZ database were collected between 2010 and 2021. We estimated the association between objective global cognitive performance and the 27 scales, the number of psychotropic drugs, and chlorpromazine and lorazepam equivalents in bivariable regressions in a cross-sectional design. We then adjusted the bivariable models with covariates: the predictors significantly associated with cognitive performance in multiple linear regressions were considered to have good concurrent validity to assess cognitive performance.

Results

Eight scales, the number of psychotropic drugs, and drug equivalents were significantly associated with cognitive impairment. The number of psychotropic drugs, the most convenient predictor to compute, was associated with worse executive function (Standardized β = -0.12, p = .004) and reasoning (Standardized β = -0.08, p = .037).

Conclusion

Anticholinergic burden, the number of psychotropic drugs, and drug equivalents were weakly associated with cognition, thus suggesting that cognitive impairment in schizophrenia and schizoaffective disorder is explained by factors other than medication. The number of psychotropic drugs was the most parsimonious method to assess the risk of iatrogenic cognitive impairment.

Cognitive functions following initiation of antipsychotic medication in adolescents and adults at clinical high risk for psychosis: a naturalistic sub group analysis using the MATRICS consensus cognitive battery

BACKGROUND

The effects of antipsychotic (AP) medications on cognitive functions in individuals at clinical high-risk (CHR) of psychosis are poorly understood. This study compared the effects of AP treatment on cognitive improvement in CHR adolescents and adults.

METHODS

A total of 327 CHR participants, with an age range of 13 to 45 years, who underwent baseline neuropsychological assessments and a 1-year clinical follow-up were included. Participants with CHR were categorized into four groups based on their age: adolescents (aged < 18) and adults (aged ≥ 18), as well as their antipsychotic medication status (AP+ or AP-). Therefore, the four groups were defined as Adolescent-AP-, Adolescent-AP+, Adult-AP-, and Adult-AP+.

RESULTS

During the follow-up, 231 CHR patients received AP treatment, 94 converted to psychosis, and 161 completed the 1-year follow-up. The Adolescent-AP+ group had more positive symptoms, lower general functions, and cognitive impairments than the Adolescent-AP- group at baseline, but no significant differences were observed among adults. The Adolescent-AP+ group showed a significant increase in the risk of conversion to psychosis (p < 0.001) compared to the Adolescent-AP- group. The Adult-AP+ group showed a decreasing trend in the risk of conversion (p = 0.088) compared to the Adult-AP- group. The Adolescent-AP- group had greater improvement in general functions (p < 0.001), neuropsychological assessment battery mazes (p = 0.025), and brief visuospatial memory test-revised (p = 0.020), as well as a greater decrease in positive symptoms (p < 0.001) at follow-up compared to the Adolescent-AP+ group. No significant differences were observed among adults.

CONCLUSIONS

Early use of AP was not associated with a positive effect on cognitive function in CHR adolescents. Instead, the absence of AP treatment was associated with better cognitive recovery, suggesting that AP exposure might not be the preferred choice for cognitive recovery in CHR adolescents, but may be more reasonable for use in adults.

Link between cognitive polygenic risk scores and clinical progression after a first-psychotic episode

BACKGROUND

Clinical intervention in early stages of psychotic disorders is crucial for the prevention of severe symptomatology trajectories and poor outcomes. Genetic variability is studied as a promising modulator of prognosis, thus novel approaches considering the polygenic nature of these complex phenotypes are required to unravel the mechanisms underlying the early progression of the disorder.

METHODS

The sample comprised of 233 first-episode psychosis (FEP) subjects with clinical and cognitive data assessed periodically for a 2-year period and 150 matched controls. Polygenic risk scores (PRSs) for schizophrenia, bipolar disorder, depression, education attainment and cognitive performance were used to assess the genetic risk of FEP and to characterize their association with premorbid, baseline and progression of clinical and cognitive status.

RESULTS

Schizophrenia, bipolar disorder and cognitive performance PRSs were associated with an increased risk of FEP [false discovery rate (FDR) ⩽ 0.027]. In FEP patients, increased cognitive PRSs were found for FEP patients with more cognitive reserve (FDR ⩽ 0.037). PRSs reflecting a genetic liability for improved cognition were associated with a better course of symptoms, functionality and working memory (FDR ⩽ 0.039). Moreover, the PRS of depression was associated with a worse trajectory of the executive function and the general cognitive status (FDR ⩽ 0.001).

CONCLUSIONS

Our study provides novel evidence of the polygenic bases of psychosis and its clinical manifestation in its first stage. The consistent effect of cognitive PRSs on the early clinical progression suggests that the mechanisms underlying the psychotic episode and its severity could be partially independent.

Effects of risperidone/paliperidone versus placebo on cognitive functioning over the first 6 months of treatment for psychotic disorder: secondary analysis of a triple-blind randomised clinical trial

The drivers of cognitive change following first-episode psychosis remain poorly understood. Evidence regarding the role of antipsychotic medication is primarily based on naturalistic studies or clinical trials without a placebo arm, making it difficult to disentangle illness from medication effects. A secondary analysis of a randomised, triple-blind, placebo-controlled trial, where antipsychotic-naive patients with first-episode psychotic disorder were allocated to receive risperidone/paliperidone or matched placebo plus intensive psychosocial therapy for 6 months was conducted. A healthy control group was also recruited. A cognitive battery was administered at baseline and 6 months. Intention-to-treat analysis involved 76 patients (antipsychotic medication group: 37; 18.6_Mage [2.9] years; 21 women; placebo group: 39; 18.3_Mage [2.7]; 22 women); and 42 healthy controls (19.2_Mage [3.0] years; 28 women). Cognitive performance predominantly remained stable (working memory, verbal fluency) or improved (attention, processing speed, cognitive control), with no group-by-time interaction evident. However, a significant group-by-time interaction was observed for immediate recall (p = 0.023), verbal learning (p = 0.024) and delayed recall (p = 0.005). The medication group declined whereas the placebo group improved on each measure (immediate recall: p = 0.024; η_p² = 0.062; verbal learning: p = 0.015; η_p² = 0.072 both medium effects; delayed recall: p = 0.001; η_p² = 0.123 large effect). The rate of change for the placebo and healthy control groups was similar. Per protocol analysis (placebo n = 16, medication n = 11) produced similar findings. Risperidone/paliperidone may worsen verbal learning and memory in the early months of psychosis treatment. Replication of this finding and examination of various antipsychotic agents are needed in confirmatory trials. Antipsychotic effects should be considered in longitudinal studies of cognition in psychosis.Trial registration: Australian New Zealand Clinical Trials Registry ( http://www.anzctr.org.au/ ; ACTRN12607000608460).

Non-affective psychotic disorders and risk of dementia: a systematic review and meta-analysis

Non-affective psychotic disorders have been associated with an increased risk of developing dementia. However, research in this area remains limited, highlighting the need for an up-to-date systematic review and meta-analysis of the evidence. We aimed to systematically review and quantify the risk of dementia associated with psychotic disorders. We searched four electronic databases for longitudinal studies investigating non-affective psychotic disorders and subsequent dementia. We used random-effects meta-analyses to pool estimates across studies and assessed risk of bias for each study. Non-affective psychotic disorders were associated with increased risk of all-cause dementia; pooled risk ratio (RR) = 2.52, 95% confidence interval (CI) (1.67-3.80), I2 = 99.7%, n = 12,997,101; 11 studies, with high heterogeneity between studies. Subgroup analyses indicated stronger associations in studies with shorter follow-up periods, conducted in non-European countries, published after 2020, and where ≥60% of the sample were female. The risk was higher in people aged <60 years at baseline, in typical and late-onset psychotic disorders versus very late-onset psychosis, in broader psychotic disorders vs schizophrenia, and in prospective vs retrospective studies. Associations remained after excluding low quality studies (pooled RR = 2.50, 95% CI (1.71-3.68), I2 = 99.0%). Our review finds a substantial association between psychotic disorders and subsequent dementia. Our findings indicate that psychotic disorders are a potentially modifiable risk factor for dementia and suggest that individuals with psychotic disorders need to be closely monitored for cognitive decline in later life. Further research is needed to investigate the mechanisms underlying the association between psychotic disorders and dementia.

Psychiatrization in mental health care: The emergency department

BACKGROUND

In the light of high incidences of diagnosed mental disorders and the growing utilization of mental healthcare services, a progressing psychiatrization of society has been hypothesized as the underlying dynamic of these developments. Mental healthcare institutions, such as psychiatric hospitals, may play a decisive role in this. However, there is a scarcity of research into how psychiatrization emerges in hospital settings. This paper explores whether the emergency department (ED) can be considered as a site where psychiatrization happens, becomes observable, and which factors in the context of the ED may be its potential drivers.

METHODS

Two cases as encountered in an interdisciplinary ED will be presented in the following in an anonymized way. Although the cases originate from individual consultations, they can be considered as prototypical. The cases were collected and discussed using the method of interactive interviewing. The results will be analyzed against the backdrop of current theoretic concepts of psychiatrization.

FINDINGS

The ED can be seen as an important area of contact between society and psychiatry. Decisions whether to label a certain condition as a "mental disorder" and to therefore initiate psychiatric treatment, or not, can be highly difficult, especially in cases where the (health) concerns are rather moderate, and clearly associated with common life problems. Psychiatrists' decisions may be largely influenced in favor of psychiatrization by a wide array of disciplinary, institutional, interpersonal, personal, cultural, and social factors.

CONCLUSIONS

The ED appears to be a promising field for research into the mechanisms and motives through which psychiatrization may emerge in mental healthcare settings. Psychiatrists in the ED work within a complex sphere of top-down and bottom-up drivers of psychiatrization. Encounters in the ED can be an important step toward adequate support for many individuals, but they also risk becoming the starting point of psychiatrization by interpreting certain problems through the psychiatric gaze, which may induce diagnoses of questionable validity and treatment of little use.

An observational study of antipsychotic medication discontinuation in first-episode psychosis: clinical and functional outcomes

PURPOSE

To study the impact of supervised antipsychotic medication discontinuation on clinical and functional outcomes in first-episode psychosis (FEP) in two different cultural environments.

METHOD

FEP patients(N = 253), treated in two early intervention services (Montreal, Canada and Chennai, India) for 2 years, were assessed for medication use, positive and negative symptom remission and social-occupational functioning at regular intervals.

RESULTS

Between months 4 and 24 of treatment, 107 patients discontinued medication ('Off'group) as compared to 146 who stayed on medication ('On'group). Medication discontinuation was higher in Chennai as compared to Montreal (n = 80, 49.07% vs n = 27, 16.87%; χ² 37.80, p < 0.001), with no difference in time to discontinuation [Means(SDs) = 10.64(6.82) and 10.04(5.43), respectively, p = 0.71). At month 24 (N = 235), there were no differences in the rate of positive symptom remission between the on and Off groups (81.5 vs 88.0%, respectively) at both sites. The rate of negative symptom remission was lower among patients in the On compared to the Off group (63.2 vs 87.9%, respectively, χ² = 17.91, p < 0.001), but only in Montreal (55.4% vs 80.0%, respectively, χ² = 4.12, p < 0.05). Social and Occupational Functioning Assessment Scale scores were equally high in both Off and On medication groups in Chennai [Means (SDs) = 79.43(12.95) and 73.59(17.63), respectively] but higher in the Off compared to the On group in Montreal Means (SDs) = 77.47(14.97) and 64.94(19.02), respectively; Time × site interaction F = 3.96(1,217), p < 0.05]. Medication status (On-Off) had no impact on the outcomes, independent of other variables known to influence outcomes.

CONCLUSION

Certain cultural environments and patient characteristics may facilitate supervised discontinuation of antipsychotic medication following treatment of an FEP without negative consequences.

Effect of antipsychotic dose reduction on cognitive function in schizophrenia

Cognitive deficits are predictors of social functioning but remain an unmet therapeutic challenge. While lowering the antipsychotics carries a risk of relapse, it possibly has a beneficial effect on cognitive function. However, this has not been examined in a real-world setting. A prospective naturalistic 6-month follow-up study (n = 71) was conducted with patients between 18 and 45 years in their first five years of illness and the maintenance phase of the treatment. Brief Assessment of Cognition in Schizophrenia (BACS) was administered to assess cognitive functions. Patients were divided into three groups based on the change in dose of antipsychotics. The data were analyzed using linear mixed-effects modeling (LMEM) to examine the group differences. At the end of six months, those with decreased antipsychotic dose had significant improvement in BACS total score, token test, and symbol coding compared to those with no change in the dose of antipsychotic. Reducing the dose of antipsychotics during the maintenance phase was associated with improved cognitive functions without an increased risk of relapse. Antipsychotic dose reduction may be better than discontinuation as the relapse risk is higher with the discontinuation strategy. Clinicians must balance the improvements in cognitive functions and relapse risk.

The relationship between TLR4/NF-κB/IL-1β signaling, cognitive impairment, and white-matter integrity in patients with stable chronic schizophrenia

OBJECTIVE

Previous studies have implicated intricate interactions between innate immunity and the brain in schizophrenia. Monocytic Toll-like receptor (TLR) 4 signaling, a crucial "sensor" of innate immunity, was reported to be over-activated in link with cognitive impairment in schizophrenia. As TLR4 is predominantly expressed on gliocytes prior to expression in neurons, we hypothesized that higher TLR4 levels may contribute to cognitive deterioration by affecting white matter microstructure.

METHODS

Forty-four patients with stable chronic schizophrenia (SCS) and 59 healthy controls (HCs) were recruited in this study. The monocytic function was detected with lipopolysaccharide (LPS) stimulation to simulate bacterial infection. Basal and LPS- stimulated levels of TLR4, nuclear factor-kappa B (NF-κB), and interleukin (IL)-1β were quantified with flow cytometry. Cognitive function was assessed by the MATRICS Consensus Cognitive Battery (MCCB) and psychopathological symptoms were evaluated by the Positive and Negative Syndrome Scale (PANSS). We employed diffusion tensor imaging with a 3-T scanner and evaluated white-matter integrity with fractional anisotropy (FA). Subcortical volume and cortical thickness were also assessed.

RESULTS

The TLR4/NF-κB/IL-1β signaling pathway was activated in patients with SCS, but responded sluggishly to LPS stimulation when compared with HCs. Furthermore, monocytic TLR4 expressions were inversely correlated with cognitive function and white matter FA, but not with cortical thickness or subcortical gray matter volume in schizophrenia.

CONCLUSION

Our findings support altered TLR4 signaling pathway activity in association with deficits in cognition and white matter integrity in schizophrenia.

Tapered discontinuation vs. maintenance therapy of antipsychotic medication in patients with first-episode schizophrenia: Obstacles, findings, and lessons learned in the terminated randomized clinical trial TAILOR

AIM

Evidence is insufficient regarding the consequences of discontinuing vs. maintaining antipsychotic medication in patients with first-episode schizophrenia. Our aim was to examine tapered discontinuation vs. maintenance treatment regarding remission of psychotic symptoms and impact on other areas.

METHODS

Patients included had a diagnosis of schizophrenia, were treated with antipsychotic medication, and were in remission of psychotic symptoms. Participants were randomized to tapered discontinuation or maintenance treatment with antipsychotic medication. Assessments were undertaken at baseline and after 1-year. The primary outcome was remission of psychotic symptoms without antipsychotic medication.

RESULTS

The trial was terminated due to insufficient recruitment. In total, 29 participants were included: 14 in the tapering/discontinuation group and 15 in the maintenance group. Adherence to maintenance treatment was poor. At 1-year follow-up, remission of psychotic symptoms without antipsychotic medication for 3 months was observed in five participants in the tapering/discontinuation group and two in the maintenance group.

CONCLUSION

Due to insufficient recruitment this study does not provide a conclusion on whether unfavorable outcomes or advantages follow tapering of antipsychotic medication. Recruitment and adherence to maintenance treatment encountered obstacles. Based on experiences from this trial, we discussed alternative study designs as consistent evidence is still needed on whether to continue or discontinue antipsychotic medication in remitted patients with first-episode schizophrenia.

CLINICAL TRIAL REGISTRATION

https://www.clinicaltrialsregister.eu/ctr-search/trial/2016-000565-23/DK, EU Clinical Trials Register-EudraCT no. 2016-000565-23.

A systematic review of the effects of psychiatric medications on social cognition

INTRODUCTION

Social cognition is an important area of mental functioning relevant to psychiatric disorders and social functioning, that may be affected by psychiatric drug treatments. The aim of this review was to investigate the effects of medications with sedative properties, on social cognition.

METHOD

This systematic review included experimental and neuroimaging studies investigating drug effects on social cognition. Data quality was assessed using a modified Downs and Black checklist (Trac et al. CMAJ 188: E120-E129, 2016). The review used narrative synthesis to analyse the data.

RESULTS

40 papers were identified for inclusion, 11 papers investigating benzodiazepine effects, and 29 investigating antipsychotic effects, on social cognition. Narrative synthesis showed that diazepam impairs healthy volunteer's emotion recognition, with supporting neuroimaging studies showing benzodiazepines attenuate amygdala activity. Studies of antipsychotic effects on social cognition gave variable results. However, many of these studies were in patients already taking medication, and potential practice effects were identified due to short-term follow-ups.

CONCLUSION

Healthy volunteer studies suggest that diazepam reduces emotional processing ability. The effects of benzodiazepines on other aspects of social cognition, as well as the effects of antipsychotics, remain unclear. Interpretations of the papers in this review were limited by variability in measures, small sample sizes, and lack of randomisation. More robust studies are necessary to evaluate the impact of these medications on social cognition.

The longitudinal effect of antipsychotic burden on psychosocial functioning in first-episode psychosis patients: the role of verbal memory

BACKGROUND

Previous literature supports antipsychotics' (AP) efficacy in acute first-episode psychosis (FEP) in terms of symptomatology and functioning but also a cognitive detrimental effect. However, regarding functional recovery in stabilised patients, these effects are not clear. Therefore, the main aim of this study is to investigate dopaminergic/anticholinergic burden of (AP) on psychosocial functioning in FEP. We also examined whether cognitive impairment may mediate these effects on functioning.

METHODS

A total of 157 FEP participants were assessed at study entry, and at 2 months and 2 years after remission of the acute episode. The primary outcomes were social functioning as measured by the functioning assessment short test (FAST). Cognitive domains were assessed as potential mediators. Dopaminergic and anticholinergic AP burden on 2-year psychosocial functioning [measured with chlorpromazine (CPZ) and drug burden index] were independent variables. Secondary outcomes were clinical and socio-demographic variables.

RESULTS

Mediation analysis found a statistical but not meaningful contribution of dopaminergic receptor blockade burden to worse functioning mediated by cognition (for every 600 CPZ equivalent points, 2-year FAST score increased 1.38 points). Regarding verbal memory and attention, there was an indirect effect of CPZ burden on FAST (b = 0.0045, 95% CI 0.0011-0.0091) and (b = 0.0026, 95% CI 0.0001-0.0006) respectively. However, only verbal memory post hoc analyses showed a significant indirect effect (b = 0.009, 95% CI 0.033-0.0151) adding premorbid IQ as covariate. We did not find significant results for anticholinergic burden.

CONCLUSION

CPZ dose effect over functioning is mediated by verbal memory but this association appears barely relevant.

Different neurocognitive profiles of risperidone and aripiprazole in the FIRST episode of psychosis: A 3-year follow-up comparison

Cognitive deficits have been recognized as a central feature of schizophrenia spectrum disorders. These deficits are often related to more severe negative symptoms, as well as a poorer adjustment in social functioning. Therefore, it is important to improve cognitive performance from the onset of the disease. In this study, we compared the effects of two atypical antipsychotics, risperidone and aripiprazole, on cognition. The data used in the present investigation were obtained from a large epidemiological cohort of patients with a first episode of psychosis who were treated in a longitudinal intervention programme. The patients included in the program were randomized to treatment with risperidone or aripiprazole and were assessed for cognitive function at baseline and 3 years later. The final sample consisted of 115 patients, 55 of whom were initially assigned to risperidone and 60 to aripiprazole. The groups did not show significant differences in their sociodemographic or clinical characteristics at intake. Longitudinal analyses showed that risperidone-treated patients improved in the processing speed domain at the 3-year follow-up, while the aripiprazole group showed better scores for the executive function domain. Our study shows slight differences between the effects of risperidone and aripiprazole on cognition, suggesting different patterns of efficacy on cognitive function that may warrant more thorough research to determine the beneficial effects of these drugs on cognition. Future studies should evaluate the effects of these treatments over longer follow-up periods using standardized tools for the assessment of cognitive function.

Psychiatrization of Society: A Conceptual Framework and Call for Transdisciplinary Research

Purpose: Worldwide, there have been consistently high or even rising incidences of diagnosed mental disorders and increasing mental healthcare service utilization over the last decades, causing a growing burden for healthcare systems and societies. While more individuals than ever are being diagnosed and treated as mentally ill, psychiatric knowledge, and practices affect the lives of a rising number of people, gain importance in society as a whole and shape more and more areas of life. This process can be described as the progressing psychiatrization of society. Methods: This article is a conceptual paper, focusing on theoretical considerations and theory development. As a starting point for further research, we suggest a basic model of psychiatrization, taking into account its main sub-processes as well as its major top-down and bottom-up drivers. Results: Psychiatrization is highly complex, diverse, and global. It involves various protagonists and its effects are potentially harmful to individuals, to societies and to public healthcare. To better understand, prevent or manage its negative aspects, there is a need for transdisciplinary research, that empirically assesses causes, mechanisms, and effects of psychiatrization. Conclusion: Although psychiatrization has highly ambivalent effects, its relevance mainly derives from its risks: While individuals with minor disturbances of well-being might be subjected to overdiagnosis and overtreatment, psychiatrization could also result in undermining mental healthcare provision for the most severely ill by promoting the adaption of services to the needs and desires of the rather mild cases. On a societal level, psychiatrization might boost medical interventions which incite individual coping with social problems, instead of encouraging long-term political solutions.

Cognitive heterogeneity in first-episode psychosis and its relationship with premorbid developmental adjustment

BACKGROUND

Patients with schizophrenia spectrum disorders have been increasingly recognised to form cognitive subgroups with differential levels of impairment. Using cluster analytical techniques, this study sought to identify cognitive clusters in a sample of first-episode psychosis (FEP) patients and examine clinical and developmental differences across the resultant groups.

METHODS

In total, 105 FEP patients in the University of California Los Angeles Aftercare Research Program were assessed for cognition, symptoms and premorbid developmental adjustment. Hierarchical cluster analysis with Ward's method and squared Euclidean distance was conducted, confirmed by discriminant function analysis and optimised with k-means clustering. The stability of the solution was evaluated through split-sample (random, 80 and 70% samples) and alternate method (average linkage method) replication via Cohen's κ analysis. Controlling for multiple comparisons, one-way analysis of variances examined group differences in symptom severity and premorbid adjustment.

RESULTS

Three groups were identified: severely impaired (n = 27), moderately impaired (n = 41) and relatively intact (n = 37). There were no significant differences in symptom severity across the groups. Significant differences were observed for scholastic performance at three different developmental stages: childhood, early adolescence and late adolescence, with the relatively intact group demonstrating significantly better scholastic performance at all three stages than both the moderately impaired and severely impaired groups (who did not significantly differ from each other).

CONCLUSIONS

The findings add to growing evidence that cognitive clusters in FEP mirror that of later-stage schizophrenia. They also suggest that premorbid scholastic performance may not just be a risk factor for developing schizophrenia, but is also related to cognitive impairment severity and potentially to prognosis.

Dose-dependent effects of antipsychotics on efficacy and adverse effects in schizophrenia

BACKGROUND

Antipsychotics are a cornerstone of pharmacological treatment of schizophrenia. Improved understanding of the dose-response relationship of antipsychotics in terms of efficacy, adverse effects, and mortality can help to optimize the pharmacological treatment of schizophrenia.

METHODS

This narrative literature review summarizes current evidence on the relationship of antipsychotic dose with efficacy, adverse effects, and mortality in patients with schizophrenia.

RESULTS

The efficacy of antipsychotics generally appeared to be highly dose-dependent in the acute phase of schizophrenia, with each antipsychotic having a specific dose-response curve. The presence or absence of dose-dependency and its extent varied according to the type of adverse effect. Parkinsonism, hyperprolactinemia, weight gain, and neurocognitive impairment appeared to be dose-related. The following adverse effects might be at least somewhat dose-dependent: akathisia, tardive dyskinesia, osteoporosis, sexual dysfunction, diabetes mellitus, myocardial infarction, stroke, thromboembolism, QT interval prolongation, anticholinergic adverse effects, somnolence, pneumonia, hip fracture, and neuroleptic malignant syndrome. In contrast, the relationships of antipsychotic dose with dyslipidemia, hypotension, seizure, sialorrhea, and neutropenia and agranulocytosis remained unclear due to mixed findings and/or limited data. Although a higher lifetime cumulative antipsychotic dose might contribute to higher mortality, it is still difficult to conclude whether mortality increases in a dose-dependent manner.

CONCLUSION

These findings could help clinicians to optimize antipsychotic treatment in patients with schizophrenia by balancing risks and benefits in clinical practice. However, further investigations with larger sample sizes and more robust study designs that focus on each antipsychotic agent are needed.

Maintenance treatment with antipsychotic drugs for schizophrenia

BACKGROUND

The symptoms and signs of schizophrenia have been linked to high levels of dopamine in specific areas of the brain (limbic system). Antipsychotic drugs block the transmission of dopamine in the brain and reduce the acute symptoms of the disorder. An original version of the current review, published in 2012, examined whether antipsychotic drugs are also effective for relapse prevention. This is the updated version of the aforesaid review.

OBJECTIVES

To review the effects of maintaining antipsychotic drugs for people with schizophrenia compared to withdrawing these agents.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials including the registries of clinical trials (12 November 2008, 10 October 2017, 3 July 2018, 11 September 2019).

SELECTION CRITERIA

We included all randomised trials comparing maintenance treatment with antipsychotic drugs and placebo for people with schizophrenia or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated risk ratios (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis based on a random-effects model. For continuous data, we calculated mean differences (MD) or standardised mean differences (SMD), again based on a random-effects model.

MAIN RESULTS

The review currently includes 75 randomised controlled trials (RCTs) involving 9145 participants comparing antipsychotic medication with placebo. The trials were published from 1959 to 2017 and their size ranged between 14 and 420 participants. In many studies the methods of randomisation, allocation and blinding were poorly reported. However, restricting the analysis to studies at low risk of bias gave similar results. Although this and other potential sources of bias limited the overall quality, the efficacy of antipsychotic drugs for maintenance treatment in schizophrenia was clear. Antipsychotic drugs were more effective than placebo in preventing relapse at seven to 12 months (primary outcome; drug 24% versus placebo 61%, 30 RCTs, n = 4249, RR 0.38, 95% CI 0.32 to 0.45, number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 2 to 3; high-certainty evidence). Hospitalisation was also reduced, however, the baseline risk was lower (drug 7% versus placebo 18%, 21 RCTs, n = 3558, RR 0.43, 95% CI 0.32 to 0.57, NNTB 8, 95% CI 6 to 14; high-certainty evidence). More participants in the placebo group than in the antipsychotic drug group left the studies early due to any reason (at seven to 12 months: drug 36% versus placebo 62%, 24 RCTs, n = 3951, RR 0.56, 95% CI 0.48 to 0.65, NNTB 4, 95% CI 3 to 5; high-certainty evidence) and due to inefficacy of treatment (at seven to 12 months: drug 18% versus placebo 46%, 24 RCTs, n = 3951, RR 0.37, 95% CI 0.31 to 0.44, NNTB 3, 95% CI 3 to 4). Quality of life might be better in drug-treated participants (7 RCTs, n = 1573 SMD -0.32, 95% CI to -0.57 to -0.07; low-certainty evidence); probably the same for social functioning (15 RCTs, n = 3588, SMD -0.43, 95% CI -0.53 to -0.34; moderate-certainty evidence). Underpowered data revealed no evidence of a difference between groups for the outcome 'Death due to suicide' (drug 0.04% versus placebo 0.1%, 19 RCTs, n = 4634, RR 0.60, 95% CI 0.12 to 2.97,low-certainty evidence) and for the number of participants in employment (at 9 to 15 months, drug 39% versus placebo 34%, 3 RCTs, n = 593, RR 1.08, 95% CI 0.82 to 1.41, low certainty evidence). Antipsychotic drugs (as a group and irrespective of duration) were associated with more participants experiencing movement disorders (e.g. at least one movement disorder: drug 14% versus placebo 8%, 29 RCTs, n = 5276, RR 1.52, 95% CI 1.25 to 1.85, number needed to treat for an additional harmful outcome (NNTH) 20, 95% CI 14 to 50), sedation (drug 8% versus placebo 5%, 18 RCTs, n = 4078, RR 1.52, 95% CI 1.24 to 1.86, NNTH 50, 95% CI not significant), and weight gain (drug 9% versus placebo 6%, 19 RCTs, n = 4767, RR 1.69, 95% CI 1.21 to 2.35, NNTH 25, 95% CI 20 to 50).

AUTHORS' CONCLUSIONS

For people with schizophrenia, the evidence suggests that maintenance on antipsychotic drugs prevents relapse to a much greater extent than placebo for approximately up to two years of follow-up. This effect must be weighed against the adverse effects of antipsychotic drugs. Future studies should better clarify the long-term morbidity and mortality associated with these drugs.

To continue or not to continue? Antipsychotic medication maintenance versus dose-reduction/discontinuation in first episode psychosis: HAMLETT, a pragmatic multicenter single-blind randomized controlled trial

BACKGROUND

Antipsychotic medication is effective for symptomatic treatment in schizophrenia-spectrum disorders. After symptom remission, continuation of antipsychotic treatment is associated with lower relapse rates and lower symptom severity compared to dose reduction/discontinuation. Therefore, most guidelines recommend continuation of treatment with antipsychotic medication for at least 1 year. Recently, however, these guidelines have been questioned as one study has shown that more patients achieved long-term functional remission in an early discontinuation condition-a finding that was not replicated in another recently published long-term study.

METHODS/DESIGN

The HAMLETT (Handling Antipsychotic Medication Long-term Evaluation of Targeted Treatment) study is a multicenter pragmatic single-blind randomized controlled trial in two parallel conditions (1:1) investigating the effects of continuation versus dose-reduction/discontinuation of antipsychotic medication after remission of a first episode of psychosis (FEP) on personal and social functioning, psychotic symptom severity, and health-related quality of life. In total 512 participants will be included, aged between 16 and 60 years, in symptomatic remission from a FEP for 3-6 months, and for whom psychosis was not associated with severe or life-threatening self-harm or violence. Recruitment will take place at 24 Dutch sites. Patients are randomized (1:1) to: continuation of antipsychotic medication until at least 1 year after remission (original dose allowing a maximum reduction of 25%, or another antipsychotic drug in similar dose range); or gradual dose reduction till eventual discontinuation of antipsychotics according to a tapering schedule. If signs of relapse occur in this arm, medication dose can be increased again. Measurements are conducted at baseline, at 3, and 6 months post-baseline, and yearly during a follow-up period of 4 years.

DISCUSSION

The HAMLETT study will offer evidence to guide patients and clinicians regarding questions concerning optimal treatment duration and when to taper off medication after remission of a FEP. Moreover, it may provide patient characteristics associated with safe dose reduction with a minimal risk of relapse.

TRIAL STATUS

Protocol version 1.3, October 2018. The study is active and currently recruiting patients (since September 2017), with the first 200 participants by the end of 2019. We anticipate completing recruitment in 2022 and final assessments (including follow-up 3.5 years after phase one) in 2026.

TRIAL REGISTRATION

European Clinical Trials Database, EudraCT number 2017-002406-12. Registered 7 June 2017.

Hippocampus and cognitive domain deficits in treatment-resistant schizophrenia: A comparison with matched treatment-responsive patients and healthy controls✰,✰✰,★,★★

Some patients with schizophrenia do not respond to pharmacotherapy. More severe cognitive dysfunctions have been associated with treatment-resistant schizophrenia (TRS). This study examines cognitive functions and hippocampal volumes in 43 patients with TRS and compared them to 43 treatment-responsive patients (NTRS), matched on age, sex and education, as well as 53 healthy controls (HC). The results showed that there were significant deficits in all domains of cognition and hippocampal volumes in TRS as compared to HC group. However, TRS specific deficits, as indicated by comparisons with matched NTRS, were limited to poorer performance in working memory (p = 0.003) and smaller total hippocampal volume (p = 0.01). Logistic regression analysis showed that working memory deficits [OR 0.94 (95% CI 0.89-0.98), p = 0.005] and smaller hippocampal volume [OR 0.89 (95% CI 0.81-0.97), p = 0.01], but not their interactions (p = 0.68), contributed to higher risk of treatment resistance. The findings suggest that treatment-resistance to currently available antipsychotic medications may not be due to global cognitive deficits in these patients, but be associated with specific deficits in working memory and hippocampus deficits in the subgroup of schizophrenia.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

Can neuropsychological testing facilitate differential diagnosis between at-risk mental state (ARMS) for psychosis and adult attention-deficit/hyperactivity disorder (ADHD)?

Background:

Patients with an at-risk mental state (ARMS) for psychosis and patients with attention-deficit/hyperactivity disorder (ADHD) have many overlapping signs and symptoms and hence can be difficult to differentiate clinically. The aim of this study was to investigate whether the differential diagnosis between ARMS and adult ADHD could be improved by neuropsychological testing.

Methods:

168 ARMS patients, 123 adult ADHD patients and 109 healthy controls (HC) were recruited via specialized clinics of the University of Basel Psychiatric Hospital. Sustained attention and impulsivity were tested with the Continuous Performance Test, verbal learning and memory with the California Verbal Learning Test, and problem solving abilities with the Tower of Hanoi Task. Group differences in neuropsychological performance were analyzed using generalized linear models. Furthermore, to investigate whether adult ADHD and ARMS can be correctly classified based on the pattern of cognitive deficits, machine learning (i.e. random forests) was applied.

Results:

Compared to HC, both patient groups showed deficits in attention and impulsivity and verbal learning and memory. However, in adult ADHD patients the deficits were comparatively larger. Accordingly, a machine learning model predicted group membership based on the individual neurocognitive performance profile with good accuracy (AUC = 0.82).

Conclusions:

Our results are in line with current meta-analyses reporting that impairments in the domains of attention and verbal learning are of medium effect size in adult ADHD and of small effect size in ARMS patients and suggest that measures of these domains can be exploited to improve the differential diagnosis between adult ADHD and ARMS patients.

Can antipsychotic dose reduction lead to better functional recovery in first-episode psychosis? A randomized controlled-trial of antipsychotic dose reduction. The reduce trial: Study protocol

Antipsychotic medication has been the mainstay of treatment for psychotic illnesses for over 60 years. This has been associated with improvements in positive psychotic symptoms and a reduction in relapse rates. However, there has been little improvement in functional outcomes for people with psychosis. At the same time there is increasing evidence that medications contribute to life shortening metabolic and cardiovascular illnesses. There is also uncertainty as to the role played by antipsychotic medication in brain volume changes.

AIM

The primary aim of the study is, in a population of young people with first-episode psychosis, to compare functional outcomes between an antipsychotic dose reduction strategy with evidence-based intensive recovery treatment (EBIRT) group (DRS+) and an antipsychotic maintenance treatment with EBIRT group (AMTx+) at 24-months follow-up.

METHODS

Our single-blind randomized controlled trial, within a specialist early psychosis treatment setting, will test the whether the DRS+ group leads to better vocational and social recovery than, the AMTx+ group over a 2-year period in 180 remitted first-episode psychosis patients. Additionally, we will examine the effect of DRS+ vs AMTx+ on physical health, brain volume and cognitive functioning. This study will also determine whether the group receiving DRS+ will be no worse off in terms of psychotic relapses over 2 years follow-up.

RESULTS

This paper presents the protocol, rationale and hypotheses for this study which commenced recruitment in July 2017.

CONCLUSION

This study will provide evidence as to whether an antipsychotic dose-reduction recovery treatment leads to improved functioning and safer outcomes in first-episode psychosis patients. In addition, it will be the first-controlled experiment of the effect of exposure to antipsychotic maintenance treatment on brain volume changes in this population.

Making decisions about antipsychotics: a qualitative study of patient experience and the development of a decision aid

BACKGROUND

Shared decision making is a widely accepted standard of patient-centred care that leads to improved clinical outcomes, yet it is commonly underutilised in the field of mental health. Furthermore, little is known regarding patient decision making around antipsychotic medication, which is often poorly adhered to. We aim to explore psychiatric patients' experiences of antipsychotic medication decision making in order to develop a patient decision aid to promote shared decision making.

METHODS

Focus groups were conducted with patients with chronic psychotic illnesses (n = 20) who had previously made a decision about taking or changing antipsychotic medication. Transcripts were coded and analysed for thematic content and continued until thematic saturation. These themes subsequently informed the development of a decision aid with the help of expert guidance. Further patient input was sought using the think aloud method (n = 3).

RESULTS

Twenty-three patients participated in the study. Thematic analysis revealed that 'adverse effects' was the most common theme identified by patients surrounding antipsychotic medication decision-making followed by 'mode and time of administration', 'symptom control' and 'autonomy'. The final decision aid is included to provoke further discussion and development of such aids.

CONCLUSIONS

Patients commonly report negative experiences of antipsychotic medication, in particular side-effects, which remain critical to future decision making around antipsychotic medication. Clinical encounters that increase patient knowledge and maximise autonomy in order to prevent early negative experiences with antipsychotic medication are likely to be beneficial.

Should people with psychosis be supported in choosing cognitive therapy as an alternative to antipsychotic medication: A commentary on current evidence

Evidence from randomised controlled trials suggest that both antipsychotic medication and cognitive behaviour therapy (CBT) can be helpful to people with a diagnosis of a schizophrenia spectrum disorder. On this basis, many clinical guidelines recommend that people with psychosis should be offered both antipsychotic medication and CBT and that they should be collaboratively involved in the decisions about which treatment options they choose. The reality of service provision is often very different, with data regarding the availability of such treatment options and the extent of user involvement in decision making suggesting that medication is much more widely available and that service users are often not involved in these decisions, despite retaining decision making capacity. Many patients choose not to take antipsychotic medication, often due to inefficacy or side effects, but there is little evidence regarding whether CBT can be effective as an alternative to antipsychotic medication. However, several recent trials suggest that CBT without medication may be a safe and acceptable option for people with psychosis. The implications for clinical practice and future research are considered and it is recommended that informed choices that include the option to try CBT without antipsychotic medication are supported.

Is cognitive impairment associated with antipsychotic dose and anticholinergic equivalent loads in first-episode psychosis?

BACKGROUND

Cognitive deficits are a core feature of early stages in schizophrenia. However, the extent to which antipsychotic (AP) have a deleterious effect on cognitive performance remains under debate. We aim to investigate whether anticholinergic loadings and dose of AP drugs in first episode of psychosis (FEP) in advanced phase of remission are associated with cognitive impairment and the differences between premorbid intellectual quotient (IQ) subgroups.

METHODS

Two hundred and sixty-six patients participated. The primary outcomes were cognitive dimensions, dopaminergic/anticholinergic load of AP [in chlorpromazine equivalents (Eq-CPZ) and the Anticholinergic Risk Scale (ARS), respectively].

RESULTS

Impairments in processing speed, verbal memory and global cognition were significantly associated with high Eq-CPZ and verbal impairment with high ARS score. Moreover, this effect was higher in the low IQ subgroup.

CONCLUSIONS

Clinicians should be aware of the potential cognitive impairment associated with AP in advanced remission FEP, particularly in lower premorbid IQ patients.

Monocausal attribution and its relationship with reasoning biases in schizophrenia

BACKGROUND

Aberrant attributional styles are counted to a set of circumscribed cognitive biases that are implicated in the pathogenesis of (paranoid) psychosis. However, evidence for a specific profile (e.g., an exaggerated self-serving bias, other-blaming bias) has become equivocal over the years. More recently, one-sided (monocausal) attributions have been reported in patients with psychosis.

METHODS

We compared a large sample of patients with diagnosed schizophrenia (n=145) to nonclinical controls (n=30) on a revised version of the Internal, Personal and Situational Attributions Questionnaire (IPSAQ-R). In this task, participants have to assign probability estimates to each of three potential causes (i.e., myself, others, circumstances) for a specific (negative or positive) event.

RESULTS

Participants with schizophrenia displayed an abolished self-serving bias and showed a significant preference for one-sided/monocausal attributions, which was neither correlated with jumping to conclusions nor overconfidence in errors. School education correlated with less monocausal attributions. We did not find any congruence between attributional styles with core delusional ideas.

CONCLUSIONS

Our study corroborates earlier investigations showing that monocausal attributions may play a role in the pathogenesis of psychosis; this bias unlikely represents an epiphenomenon of established biases. Unexpectedly, attributional styles (e.g., external-blaming) did not shape delusional contents. The true prevalence of monocausal attributions in psychosis is perhaps underestimated in the study, as groups were equated on school education, which was correlated with monocausal attributions.

Dose Reduction/Discontinuation of Antipsychotic Drugs in Psychosis; Effect on Cognition and Functional Outcomes

Backgrounds: There is a debate regarding the optimal timing of discontinuation of antipsychotic drugs in patients with first episode psychosis (FEP) or schizophrenia. We aimed to provide a review of the literature on which strategy (medication maintenance vs. dose reduction/discontinuation) is more likely to maximize outcomes, such as cognition and social function. Methods: Using PubMed, the Cochrane Library and systematic reviews, articles published between 2007 and 2018 were reviewed, which investigated the effect of dose reduction/discontinuation vs. maintenance treatment on measures of cognition and/or social function in FEP and schizophrenia. Results: Six studies were identified; 2 studies reported on cognition while 4 studies concern social function. All studies except one reported that improvement of functional outcomes in remitted patients with FEP or schizophrenia allocated to a dose reduction/discontinuation arm was equal to or better than that in patients for whom medication doses were maintained. One trial of social function with a 1-year follow-up period found a greater improvement in the medication maintenance group, while no group difference was observed with 3-year and 10-year follow-up periods. On the other hand, a 7-year follow-up study found a superiority for the dose reduction/discontinuation regimen in terms of social outcome. Two studies on cognition with a short follow-up period reported a greater improvement for the dose reduction/discontinuation group. Conclusions: Information on cognition and social function has been relatively sparse. These measures of functional outcome should be considered in deciding which strategy of antipsychotic treatments is beneficial in individual cases with FEP or schizophrenia.

Predicting trauma-focused treatment outcome in psychosis

OBJECTIVE

Although TF treatments are effective in patients with psychosis, it is unknown whether specific psychosis-related obstacles limit the effects, and what determines good outcome.

METHODS

Baseline posttraumatic stress disorder (PTSD) symptom severity and seven psychosis-specific variables were tested as predictors in patients with a psychotic disorder and PTSD (n=108), who received eight sessions of TF treatment (Prolonged Exposure, or Eye Movement Desensitization and Reprocessing therapy) in a single-blind randomized controlled trial. Multiple regression analyses were performed.

RESULTS

Baseline PTSD symptom severity was significantly associated with posttreatment PTSD symptom severity, explaining 11.4% of the variance. Additionally, more severe PTSD at baseline was also significantly associated with greater PTSD symptom improvement during treatment. After correction for baseline PTSD symptom severity, the model with the seven baseline variables did not significantly explain the variance in posttreatment PTSD outcome. Within this non-significant model, the presence of auditory verbal hallucinations contributed uniquely to posttreatment outcome but explained little variance (5.4%). Treatment completers and dropouts showed no significant difference on any of the psychosis-related variables.

CONCLUSIONS

Given the low predictive utility of baseline psychosis-related factors, we conclude that there is no evidence-based reason to exclude patients with psychotic disorders from TF treatments. Also, we speculate that patients with psychosis and severe baseline PTSD might derive more benefit if given more than eight sessions. Trial registration current controlled-trials.com | Identifier: ISRCTN79584912 | http://www.isrctn.com/ISRCTN79584912.

Executive dysfunction and cognitive subgroups in a large sample of euthymic patients with bipolar disorder

Bipolar disorder (BP), at the group level, is associated with significant but modest cognitive deficits, including executive dysfunction. Among executive functions, response inhibition deficits have been suggested to be particularly relevant to BP. However, BP is associated with significant heterogeneity in neurocognitive performance and level of functioning. Very few studies have investigated neurocognitive subgroups in BP with data-driven methods rather than arbitrarily defined criteria. Other than having relatively small sample sizes, previous studies have not taken into consideration the neurocognitive variability in healthy subjects. Five-hundred-fifty-six euthymic patients with BP and 416 healthy controls were assessed using a battery of cognitive tests and clinical measures. Neurocognitive subgroups were investigated using latent class analysis, based on executive functions. Four neurocognitive subgroups, including a good performance cluster, two moderately low-performance groups, which differ in response inhibition and reasoning abilities, and a severe impairment cluster were found. In comparison to healthy controls, BP patients were overrepresented in severe impairment cluster (27% vs 5.3%) and underrepresented in good performance cluster. BP patients with lower educational attainment and older age were significantly more likely to be members of cognitively impaired subgroups. Antipsychotic use was less common in good performance cluster. These results suggest that there is a considerable overlap of cognitive functions between BP and healthy controls. Neurocognitive differences between BP and healthy controls are driven by a subgroup of patients who have severe and global, rather than selective, cognitive deficits.

Psychopathology, psychopharmacological properties, decision-making capacity to consent to clinical research and the willingness to participate among long-term hospitalized patients with schizophrenia

Many studies discuss factors related to the decision-making capacity to consent to clinical research (DMC) of patients with schizophrenia. However, these studies rarely approached willingness to participate and the association between psychopharmacological properties (e.g., antipsychotic-induced side effects) and DMC. This study aimed to explore factors related to DMC and willingness to participate in patients with schizophrenia. All 139 patients with schizophrenia were assessed with the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) and other measures. A linear regression model was used to find the predictors of MacCAT-CR scores. A logistic regression model was used for exploring the predictors of willingness to participate. Patients with more severe negative symptoms performed poorly in DMC outcomes. In addition, females, those with fewer years of education and reduced cognitive function are more likely to experience difficulties in decision-making. Forty-three subjects (30.4%) chose to participate. Patients with higher level of positive symptoms, longer length of stay, higher burden of anticholinergics and users of atypical antipsychotics were more likely to participate in a clinical study which aimed to "enhance cognition". These finding suggest that research investigators should consider many variables for patients who require more intensive screening for impaired DMC.

The optimization of treatment and management of schizophrenia in Europe (OPTiMiSE) trial: rationale for its methodology and a review of the effectiveness of switching antipsychotics

BACKGROUND

Most of the 13 542 trials contained in the Cochrane Schizophrenia Group's register just tested the general efficacy of pharmacological or psychosocial interventions. Studies on the subsequent treatment steps, which are essential to guide clinicians, are largely missing. This knowledge gap leaves important questions unanswered. For example, when a first antipsychotic failed, is switching to another drug effective? And when should we use clozapine? The aim of this article is to review the efficacy of switching antipsychotics in case of nonresponse. We also present the European Commission sponsored "Optimization of Treatment and Management of Schizophrenia in Europe" (OPTiMiSE) trial which aims to provide a treatment algorithm for patients with a first episode of schizophrenia.

METHODS

We searched Pubmed (October 29, 2014) for randomized controlled trials (RCTs) that examined switching the drug in nonresponders to another antipsychotic. We described important methodological choices of the OPTiMiSE trial.

RESULTS

We found 10 RCTs on switching antipsychotic drugs. No trial was conclusive and none was concerned with first-episode schizophrenia. In OPTiMiSE, 500 first episode patients are treated with amisulpride for 4 weeks, followed by a 6-week double-blind RCT comparing continuation of amisulpride with switching to olanzapine and ultimately a 12-week clozapine treatment in nonremitters. A subsequent 1-year RCT validates psychosocial interventions to enhance adherence.

DISCUSSION

Current literature fails to provide basic guidance for the pharmacological treatment of schizophrenia. The OPTiMiSE trial is expected to provide a basis for clinical guidelines to treat patients with a first episode of schizophrenia.

The trajectory of neuropsychological dysfunctions in bipolar disorders: a critical examination of a hypothesis

OBJECTIVE

The hypothesis of a progressive nature of neuropsychological deficits in bipolar disorders is often accepted as an axiom by many clinicians and researchers in the field. However, contradictory pieces of data and a number of methodological concerns put it under debate.

METHOD

We reviewed findings from three different approaches to the study of the trajectory of cognitive features in bipolar disorders: longitudinal evaluation of cognition in affected subjects, cross-sectional neuropsychological assessment of patients belonging to different age groups, and exploration of the risk of dementia in bipolar subjects.

RESULTS

An increased risk of developing dementia was found in bipolar subjects. However, evidence from cross-sectional studies did not show more severe cognitive deficits in patients with longer illness duration. Furthermore, longitudinal studies revealed that bipolar subjects׳ cognitive performance did not change between different points in time.

CONCLUSIONS

After a thorough discussion of these findings and the limitations of the different approaches, we argue that, at present, there is no consistent evidence supporting that bipolar disorders, as a group, have a progressively deteriorating course of cognitive functions. Furthermore, we highlight the possible influence of psychotropic agents and metabolic factors on neuropsychological outcomes. Finally, we discuss the clinical implications of these findings and propose targets for forthcoming research.

Neurodevelopmental origin of cognitive impairment in schizophrenia

Cognitive impairment is a common feature of schizophrenia; however, its origin remains controversial. Neurodevelopmental abnormalities clearly play a role in pre-morbid cognitive dysfunction in schizophrenia, yet many authors believe that schizophrenia is characterized by illness-related cognitive decline before and after onset of the psychosis that can be the result of neurodegenerative changes. The main reasons behinds such arguments include, first, the evidence showing that effect sizes of the cognitive deficits in subjects who develop adult schizophrenia gradually increase in the first two decades of life and, second, the fact that there is functional decline in many patients with schizophrenia over the years. In this Editorial, I argue that current evidence suggests that illness-related cognitive impairment is neurodevelopmental in origin and characterized by slower gain (developmental lag) but not cognitive decline continuing throughout the first two decades of life. I introduce a model suggesting that neurodevelopmental abnormality can in fact explain the course of cognitive dysfunction and variations in the trajectory of functional decline throughout the life in individuals with schizophrenia. In this model, the severity of underlying neurodevelopmental abnormality determines the age that cognitive deficits first become apparent and contributes to the cognitive reserve of the individual. Interaction of neurodevelopmental abnormality with clinical symptoms, especially negative symptoms and aging, vascular changes, psychological and iatrogenic factors contributes to the heterogeneity of the functional trajectory observed in this disorder.

12-month longitudinal cognitive functioning in patients recently diagnosed with bipolar disorder

OBJECTIVES

Although cognitive deficits are observed in the early stages of bipolar disorder, the longitudinal course of neuropsychological functioning during this period is unknown. Such knowledge could provide etiologic clues into the cognitive deficits associated with the illness, and could inform early treatment interventions. The purpose of the present study was to evaluate cognitive change in bipolar disorder in the first year after the initial manic episode.

METHODS

From an initial pool of 65 newly diagnosed patients with bipolar disorder (within three months of the end of the first manic or mixed episode) and 36 demographically similar healthy participants, 42 patients [mean age 22.9 years, standard deviation (SD) = 4.0] and 23 healthy participants [mean age 22.9 years (SD = 4.9)] completed baseline, six-month, and one-year neuropsychological assessments of multiple domains including processing speed, attention, verbal and nonverbal memory, working memory, and executive function. Patients also received clinical assessments, including mood ratings.

RESULTS

Although patients showed consistently poorer cognitive performance than healthy individuals in most cognitive domains, patients showed a linear improvement over time in processing speed (p = 0.008) and executive function (p = 0.004) relative to the comparison group. Among patients, those without a history of alcohol/substance abuse or who were taken off an antipsychotic treatment during the study showed better improvement.

CONCLUSIONS

The early course of cognitive functioning in bipolar disorder is likely influenced by multiple factors. Nevertheless, patients with bipolar disorder showed select cognitive improvements in the first year after resolution of their initial manic episode. Several clinical variables were associated with better recovery, including absence of substance abuse and discontinuation of antipsychotic treatment during the study. These and other factors require further investigation to better understand their contributions to longitudinal cognitive functioning in early bipolar disorder.

Cognitive behavioural therapy for psychosis prevention: a systematic review and meta-analysis

BACKGROUND

Clinical equipoise regarding preventative treatments for psychosis has encouraged the development and evaluation of psychosocial treatments, such as cognitive behavioural therapy (CBT).

METHOD

A systematic review and meta-analysis was conducted, examining the evidence for the effectiveness of CBT-informed treatment for preventing psychosis in people who are not taking antipsychotic medication, when compared to usual or non-specific control treatment. Included studies had to meet basic quality criteria, such as concealed and random allocation to treatment groups.

RESULTS

Our search produced 1940 titles, out of which we found seven completed trials (six published). The relative risk (RR) of developing psychosis was reduced by more than 50% for those receiving CBT at every time point [RR at 6 months 0.47, 95% confidence interval (CI) 0.27-0.82, p = 0.008 (fixed-effects only: six randomized controlled trials (RCTs), n = 800); RR at 12 months 0.45, 95% CI 0.28-0.73, p = 0.001 (six RCTs, n = 800); RR at 18-24 months 0.41, 95% CI 0.23-0.72, p = 0.002 (four RCTs, n = 452)]. Heterogeneity was low in every analysis and the results were largely robust to the risk of an unpublished 12-month study having unfavourable results. CBT was also associated with reduced subthreshold symptoms at 12 months, but not at 6 or 18-24 months. No effects on functioning, symptom-related distress or quality of life were observed. CBT was not associated with increased rates of clinical depression or social anxiety (two studies).

CONCLUSIONS

CBT-informed treatment is associated with a reduced risk of transition to psychosis at 6, 12 and 18-24 months, and reduced symptoms at 12 months. Methodological limitations and recommendations for trial reporting are discussed.