Which levels of cognitive impairments and negative symptoms are related to functional deficits in schizophrenia?

Reexamination of the relationships among neurocognition, self-defeatist beliefs, experiential negative symptoms, and social functioning in a sample of patients diagnosed with chronic schizophrenia and schizoaffective disorder

PURPOSE

This study proposed and evaluated a theoretical model for exploring the relationships between neurocognition, self-defeatist beliefs, experiential negative symptoms, and social functioning in individuals with chronic schizophrenia.

METHOD

The study recruited 229 individuals given a diagnosis of schizophrenia and schizoaffective disorders from outpatient clinics and the day ward of a mental health hospital. After informed consent was obtained, the participants underwent assessments using the backward digit span, the digit symbol, and measures of self-defeatist beliefs, experiential negative symptoms, and social functioning. A structural equation model was applied to assess the fitness of the hypothesized model, with indices such as the goodness-of-fit index, comparative fit index, root mean square error of approximation, and standardized root mean square residual being used for model evaluation.

RESULTS

The hypothesized model had an adequate fit. The study findings indicated that neurocognition might indirectly influence self-defeatist beliefs through its effect on experiential negative symptoms. Contrary to expectations, the study did not observe a direct influence of neurocognition, self-defeatist beliefs, or negative symptoms on social functioning. The revised model revealed the role of experiential negative symptoms in mediating the association between neurocognition and social functioning. However, self-defeatist beliefs did not significantly affect social functioning.

DISCUSSION

Before modifying negative thoughts, enhancement of self-awareness ability can help improve negative symptoms and thereby improve the performance of social functions. Future research should develop a hierarchical program of negative symptoms, from cognition rehabilitation to enhancement of self-awareness, and end with modifying maladaptive beliefs.

Conceptualization and characterization of "primary" and "secondary" cognitive impairment in schizophrenia

Cognitive impairment represents one of the core features of schizophrenia, involves both neurocognition and social cognition domains, and has a significant negative impact on real-world functioning. The present review provides a framework for the conceptualization and characterization of "primary" and "secondary" cognitive impairment in schizophrenia. In this conceptualization, primary cognitive impairment can be defined as a consequence of the neurobiological alterations that underlie psychopathological manifestations of the disorder, while secondary cognitive impairment can be defined as the results of a source issue that has a negative impact on cognitive performance. Sources of secondary cognitive impairment are frequent in people with schizophrenia and include several different factors, such as positive and negative symptoms, depressive symptoms, autistic symptoms, pharmacotherapy, substance abuse, metabolic syndrome, social deprivation, and sleep disorders. It can be hypothesized that secondary cognitive impairment may be improved by effectively resolving the source issue, while primary cognitive impairment may benefit from dedicated treatment. Further research is required to confirm this hypothesis, to better characterize the distinction between primary and secondary cognitive impairment in a clinical and in a neurobiological perspective, and to evaluate the impact of systematically assessing and treating secondary cognitive impairment.

Investigating the relationship between specific negative symptoms and metacognitive functioning in psychosis: A systematic review

BACKGROUND

Disrupted metacognition is implicated in development and maintenance of negative symptoms, but more fine-grained analyses would inform precise treatment targeting for individual negative symptoms.

AIMS

This systematic review identifies and examines datasets that test whether specific metacognitive capacities distinctly influence negative symptoms.

MATERIALS & METHODS

PsycINFO, EMBASE, Medline and Cochrane Library databases plus hand searching of relevant articles, journals and grey literature identified quantitative research investigating negative symptoms and metacognition in adults aged 16+ with psychosis. Authors of included articles were contacted to identify unique datasets and missing information. Data were extracted for a risk of bias assessment using the Quality in Prognostic Studies tool.

RESULTS

85 published reports met criteria and are estimated to reflect 32 distinct datasets and 1623 unique participants. The data indicated uncertainty about the relationship between summed scores of negative symptoms and domains of metacognition, with significant findings indicating correlation coefficients from 0.88 to -0.23. Only eight studies investigated the relationship between metacognition and individual negative symptoms, with mixed findings. Studies were mostly moderate-to-low risk of bias.

DISCUSSION

The relationship between negative symptoms and metacognition is rarely the focus of studies reviewed here, and negative symptom scores are often summed. This approach may obscure relationships between metacognitive domains and individual negative symptoms which may be important for understanding how negative symptoms are developed and maintained.

CONLCLUSION

Methodological challenges around overlapping participants, variation in aggregation of negative symptom items and types of analyses used, make a strong case for use of Individual Participant Data Meta-Analysis to further elucidate these relationships.

Two and five-factor models of negative symptoms in schizophrenia are differentially associated with trait affect, defeatist performance beliefs, and psychosocial functioning

Recent factor analytic evidence supports both two-factor (motivation and pleasure, MAP; diminished expression, EXP) and five-factor (anhedonia, asociality, avolition, blunted affect, alogia) conceptualizations of negative symptoms. However, it is unclear whether these two conceptualizations of the latent structure of negative symptoms have differential associations with external correlates. The current study evaluated external correlates of the two- and five-factor structures by examining associations with variables known to have critical relations with negative symptoms: trait affect, defeatist performance beliefs, neurocognition, and community-based psychosocial functioning. Participants included a total of 245 outpatients diagnosed with schizophrenia who were rated on the Brief Negative Symptom Scale and completed a battery of additional measures during periods of clinical stability. These additional measures included the Positive and Negative Affect Schedule, Defeatist Performance Beliefs scale, MATRICS Consensus Cognitive Battery, and Level of Function Scale. Pearson correlations indicated differential patterns of associations between the BNSS scores and the external correlates. Support for the two-factor model was indicated by a stronger association of MAP with positive affect and psychosocial functioning, compared to EXP with neurocognition. Significance tests examining a differential magnitude of associations showed that the two-dimension negative symptom structure masked unique correlational relationships among the five negative symptom domains with neurocognition and social/vocational community functioning and captured unique patterns of correlation with trait affect. Support for the five-factor model was shown by a stronger association between Blunted Affect with Attention/Vigilance, and stronger associations between Avolition, Anhedonia, and Asociality with psychosocial functioning. Results offer support for both the two-dimension and five-domain model of negative symptoms as well as a hierarchical two-dimensions-five-domains model of negative symptoms. Findings may have implications for diagnostic criteria and descriptions of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5), as well as possible treatment targets of negative symptoms.

Sex difference in association between cognitive and P50 deficits in patients with chronic schizophrenia

A large number of studies have reported that sensory gating disorders represented by P50 inhibition may be involved in the pathophysiological process of schizophrenia. However, few studies have explored the relationship between sensory gating disorders and cognitive dysfunction in patients with schizophrenia. This study aimed to explore sex differences in the relationship between cognitive and P50 deficits in patients with chronic schizophrenia, which has not been reported. A total of 183 chronic schizophrenia patients (128 males and 55 females) and 166 healthy controls (76 males and 90 females) participated in this study. The MATRICS Consensus Cognitive Battery (MCCB) was measured for cognitive function and P50 components for the sensory gating in all participants. The Positive and Negative Syndrome Scales (PANSS) was used to assess the psychopathological symptoms in patients. Female patients performed significantly better than male patients in several cognitive domains of MCCB (all p < 0.01). There were no significant differences in P50 components between male and female patients (all p > 0.05). Further analysis showed that in female patients, latency of S2 was negatively correlated with reasoning and problem-solving domain of MCCB (p < 0.05), and P50 ratio was negatively correlated with social cognition domain of MCCB (p < 0.05). In male patients, there was no any correlation between P50 and cognitive domains of MCCB. Our results suggest that there is a sex difference in the association between P50 deficiency and cognitive impairment in Chinese Han patients with schizophrenia.

Transdiagnostic Predictors of Everyday Functioning: Examining the Relationships of Depression and Reinforcement Learning

BACKGROUND AND HYPOTHESIS

Impairments in function (ie, the ability to independently accomplish daily tasks) have been established in psychotic disorders. Identifying factors that contribute to these deficits is essential to developing effective interventions. The current study had several goals: examine potential differential relationships across domains of neurocognition, assess whether reinforcement learning is related to function, identify if predictors of function are transdiagnostic, determine whether depression and positive symptoms contribute to function, and to explore whether the modality of assessment impacts observed relationships.

STUDY DESIGN

Data from 274 participants were examined with schizophrenia/schizoaffective disorder (SZ; n = 195) and bipolar disorder (BD; n = 79). To reduce dimensionality, a PCA was completed on neurocognitive tasks which resulted in 3 components. These components and clinical interview data were used to investigate predictors of functional domains across measures of function (self- and informant-report SLOF and UPSA).

RESULTS

Two components, working memory/processing speed/episodic memory (βs = 0.18-0.42), and negative/positive reinforcement learning (β = -0.04), predicted different functional domains. Predictors of function were largely transdiagnostic with two exceptions: reinforcement learning had a positive association with self-reported interpersonal relationships for SZ and a negative association for BD (β = 0.34), and the negative association between positive symptoms and self-reported social acceptability was stronger for BD than for SZ (β = 0.93). Depression robustly predicted self-reported but not informant-reported function, and anhedonia predicted all domains of informant-reported function.

CONCLUSIONS

These findings imply that reinforcement learning may differentially relate to function across disorders, traditional domains of neurocognition can be effective transdiagnostic targets for interventions, and positive symptoms and depression play a critical role in self-perceived functional impairments.

Impact of cognitive performance and negative symptoms on psychosocial functioning in Czech schizophrenia patients

Schizophrenia has a profound influence on the real-life functioning of patients. There are several factors inherent to the disease course affecting the level of psychosocial functioning. Our study focused on the impact of cognitive deficit and severity of negative symptoms (i.e., the experiential domain (avolition, asociality, and anhedonia) and the expressive domain (blunted affect and alogia)) to explore psychosocial functioning in schizophrenia. Schizophrenia patients (n = 211) were tested for the presence of cognitive impairment using the NIMH-MATRICS: Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Cattery (MCCB; MATRICS Consensus Cognitive Battery) and the extent of negative symptoms using the PANSS (PANSS; Positive and Negative Syndrome Scale-selected items). The level of psychosocial functioning was measured with the Personal and Social Performance Scale (PSP). The path analysis using three regression models was used to analyse variables influencing psychosocial functioning (PSP). One of these models analyzed influence of cognitive functioning (MCCB) and negative schizophrenia symptoms (PANSS selected items reflecting expressive and experiential deficits) as predictors and NART/CRT and disease length as confounders. R² was 0.54. The direct effect of the MCCB (β = 0.09) on the PSP was suppressed by the strong effect of the negative symptoms (β = -0.64). The presence of cognitive deficits and negative symptoms in our sample of schizophrenia patients significantly influences the level of their psychosocial functioning, a key factor in remission and recovery.

Patterns of Impaired Neurocognitive Performance on the Global Neuropsychological Assessment, and Their Brain Structural Correlates in Recent-onset and Chronic Schizophrenia

Objective

Schizophrenia is associated with impairment in multiple cognitive domains. There is a paucity of research on the effect of prolonged illness duration (≥ 15 years) on cognitive performance along multiple domains. In this pilot study, we used the Global Neuropsychological Assessment (GNA), a brief cognitive battery, to explore the patterns of cognitive impairment in recent-onset (≤ 2 years) compared to chronic schizophrenia (≥ 15 years), and correlate cognitive performance with brain morphometry in patients and healthy adults.

Methods

We assessed cognitive performance in patients with recent-onset (n = 17, illness duration ≤ 2 years) and chronic schizophrenia (n = 14, duration ≥ 15 years), and healthy adults (n = 16) using the GNA and examined correlations between cognitive scores and gray matter volumes computed from T1-weighted magnetic resonance imaging images.

Results

We observed cognitive deficits affecting multiple domains in the schizophrenia samples. Selectively greater impairment of perceptual comparison speed was found in adults with chronic schizophrenia (p = 0.009, η2partial = 0.25). In the full sample (n = 47), perceptual comparison speed correlated significantly with gray matter volumes in the anterior and medial temporal lobes (TFCE, FWE p < 0.01).

Conclusion

Along with generalized deficit across multiple cognitive domains, selectively greater impairment of perceptual comparison speed appears to characterize chronic schizophrenia. This pattern might indicate an accelerated or premature cognitive aging. Anterior-medial temporal gray matter volumes especially of the left hemisphere might underlie the impairment noted in this domain in schizophrenia.

Paeonol, the active component of Cynanchum paniculatum, ameliorated schizophrenia-like behaviors by regulating the PI3K-Akt-GSK3β-NF-κB signalling pathway in MK-801-treated mice

ETHNOPHARMACOLOGICAL RELEVANCE

Cynanchum paniculatum (Bunge) Kitag. ex H. Hara (Asclepiadaceae) have been traditionally used in East Asia as analgesic or antiviral agents. Interestingly, some Chinese and Korean traditional medicinal books reported that the use of C. paniculatum in the treatment of psychotic symptoms, such as hallucinations and delusions.

AIM OF THE STUDY

In this study, we aimed to investigate whether C. paniculatum could improve sensorimotor gating disruption in mice with MK-801-induced schizophrenia-like behaviors. We also aimed to identify the active component of C. paniculatum that could potentially serve as a treatment for schizophrenia and found that paeonol, the major constituent compound of C. paniculatum, showed potential as a treatment for schizophrenia.

MATERIALS AND METHODS

To assess the effect of paeonol on mice with MK-801-induced schizophrenia-like behaviors, we carried out a series of behavioral tests related with symptoms of schizophrenia. In addition, we utilized Western blotting and ELISA techniques to investigate the antipsychotic actions of paeonol.

RESULT

C. paniculatum extract (100 or 300 mg/kg) and paenol (10 or 30 mg/kg) significantly reversed MK-801-induced prepulse deficits in acoustic startle response test. In addition, paeonol (10 or 30 mg/kg) attenuated social novelty preference and novel object recognition memory on MK-801-induced schizophrenia-like behaviour in mice. Furthermore, the phosphorylation levels of PI3K, Akt, GSK3β and NF-κB, as well as related pro-inflammatory cytokine, such as IL-1β and TNF-α, were significantly reversed by the administration of paeonol (10 or 30 mg/kg) in the prefrontal cortex of MK-801-treated mice.

CONCLUSIONS

Collectively, these data show that paeonol can potentially be used as an agent for treating sensorimotor gating deficits, negative symptoms, and cognitive deficits, such as those observed in schizophrenia with few adverse effects.

Diminished Auditory Cortex Dynamic Range and its Clinical Correlates in First Episode Psychosis

BACKGROUND AND HYPOTHESIS

There is growing appreciation for the contribution of sensory disruptions to disease morbidity in psychosis. The present study examined auditory cortex (AC) dynamic range: the scaling of neurophysiological responses to stimulus intensity, among individuals with a schizophrenia spectrum illness (FESz) and its relationship to clinical outcomes at disease onset.

STUDY DESIGN

Magnetoencephalography (MEG) was recorded from 35 FESz and 40 healthy controls (HC) during binaural presentation of tones at three intensities (75 dB, 80 dB, and 85 dB). MRIs were obtained to enhance cortical localization of MEG sensor-level activity. All participants completed the MATRICS cognitive battery (MCCB) and Global Functioning: Role and Social scales (GFR/GFS). Patients were administered the Positive and Negative Syndrome Scale (PANSS).

STUDY RESULTS

FESz exhibited reduced AC response relative to HC. Enhancement of AC activity to tones of increasing intensity was blunted in FESz relative to HC. Reduced dynamic range (85-75 dB AC response) was associated with lower GFS (r = .58) and GFR (r = .45) scores, worse MCCB performance (r = .45), and increased PANSS Negative symptom subscale scores (r = -.55) among FESz, relationships not observed with AC responses to individual tones.

CONCLUSION

Beyond an impaired AC response to pure tones, FESz exhibit reduced dynamic range relative to HC. This impairment was correlated with markers of disease morbidity including poorer community functioning as well as cognitive and negative symptoms. The relationship with impaired social functioning may reflect the role of AC dynamic range in decoding the emotional content of language and highlights its importance to future therapeutic sensory remediation protocols.

A new era for schizophrenia drug development - Lessons for the future

For many patients and their treating clinicians, the pharmacological management of psychotic symptoms centres on trying to find a regime that balances efficacy and quality of life, impairing side effects associated with dopamine antagonism. Recent reports of a positive Phase III study from Karuna Therapeutics indicate that the first primarily non-dopamine-based treatment for schizophrenia may come to market soon with the potential for substantially reduced or differentiated side effects. Against a background of repeated failures, Karuna's success promises a desperately needed new treatment option for patients. It also reflects some hard-won lessons about the methodology for schizophrenia drug development. Teaser A positive Phase II study and positive media report from a Phase III study with xanomeline/trospium may herald the first truly new treatment option for schizophrenia patients in decades. This drug's journey to this point reflects some hard-won lessons about the methodology for schizophrenia drug development.

Longitudinal clinical and functional outcome in distinct cognitive subgroups of first-episode psychosis: a cluster analysis

BACKGROUND

Cognitive deficits may be characteristic for only a subgroup of first-episode psychosis (FEP) and the link with clinical and functional outcomes is less profound than previously thought. This study aimed to identify cognitive subgroups in a large sample of FEP using a clustering approach with healthy controls as a reference group, subsequently linking cognitive subgroups to clinical and functional outcomes.

METHODS

204 FEP patients were included. Hierarchical cluster analysis was performed using baseline brief assessment of cognition in schizophrenia (BACS). Cognitive subgroups were compared to 40 controls and linked to longitudinal clinical and functional outcomes (PANSS, GAF, self-reported WHODAS 2.0) up to 12-month follow-up.

RESULTS

Three distinct cognitive clusters emerged: relative to controls, we found one cluster with preserved cognition (n = 76), one moderately impaired cluster (n = 74) and one severely impaired cluster (n = 54). Patients with severely impaired cognition had more severe clinical symptoms at baseline, 6- and 12-month follow-up as compared to patients with preserved cognition. General functioning (GAF) in the severely impaired cluster was significantly lower than in those with preserved cognition at baseline and showed trend-level effects at 6- and 12-month follow-up. No significant differences in self-reported functional outcome (WHODAS 2.0) were present.

CONCLUSIONS

Current results demonstrate the existence of three distinct cognitive subgroups, corresponding with clinical outcome at baseline, 6- and 12-month follow-up. Importantly, the cognitively preserved subgroup was larger than the severely impaired group. Early identification of discrete cognitive profiles can offer valuable information about the clinical outcome but may not be relevant in predicting self-reported functional outcomes.

Community-based multi-site randomized controlled trial of behavioral activation for patients with negative symptoms of schizophrenia

BACKGROUND

Negative symptoms are closely related to the poor prognosis of schizophrenia, for which there is no effective treatment to date. Behavioral activation (BA), which is an effective treatment for depression, is a behavioral approach that targets low levels of response-contingent positive reinforcement. This study aimed to explore BA as an effective intervention for relieving the negative symptoms of schizophrenia.

METHODS

This was a randomized single-blind controlled trial. Eighty-four patients with schizophrenia were enrolled in community mental health settings. Excluding 14 patients who opted out of the study, 70 were randomly assigned to receive BA in addition to treatment-as-usual (BA + TAU) or treatment-as-usual (TAU) only. Negative symptoms were assessed using the Clinical Assessment Interview for Negative Symptoms (CAINS) and Brief Negative Symptom Scale (BNSS) at baseline, post-treatment, and 6-months follow-up.

RESULTS

Significant differences between the BA + TAU and TAU only groups were observed in the measures of negative symptoms post-treatment. The total score of CAINS was significantly decreased after BA treatment (η² = 0.13). The tendency of the BA + TAU treatment effect was also observed for the BNSS total score and PANSS negative symptom subscale (η² = 0.10 and η² = 0.11, respectively). However, the difference between the two groups was not sustained at the six-month follow-up.

CONCLUSIONS

Our findings suggest that BA could be a promising time-limited and structured psychosocial intervention for schizophrenia-associated negative symptoms with the merit of easy dissemination. Further studies are needed to examine the factors involved in sustaining improvement.

Is change over time in psychotic symptoms related to social functioning?

OBJECTIVE

In psychosis, treatment often focuses on symptom reduction whereas social functioning is also essential. In this study, we investigate positive psychotic symptoms and medication use in relation to social functioning over a 3-year time-period in 531 patients diagnosed with psychosis. Furthermore, relations of positive symptoms with needs for care and quality of life were also investigated.

METHOD

Using repeated measures analysis, changes were measured over time. Hereafter, mixed model analyses were performed to determine the associations of social functioning, needs for care, and quality of life with psychotic symptoms and patient characteristics. Finally, we assessed differences in symptoms and medication dose between those with an increase and those with a decrease in social functioning.

RESULTS

Patients significantly improved in social functioning, while psychotic symptoms increased. Improvement in social functioning was associated with younger age, higher IQ, and lower social functioning at T1, but not with positive symptoms. Also, improvement in social functioning was found to be related to a decrease in the dose of clozapine. Improvement in social functioning occurs despite worsening of positive symptoms.

CONCLUSIONS

The findings suggest the need to further explore the relation between symptomatology, social functioning, and medication use. In the treatment of psychotic disorders, one should reconsider the strong focus on reducing psychotic symptoms. The current focus needs to shift much more toward improving functional outcome, especially when the patient expresses a desire for change in this respect.

Effectiveness of KarXT (xanomeline-trospium) for cognitive impairment in schizophrenia: post hoc analyses from a randomised, double-blind, placebo-controlled phase 2 study

The muscarinic receptor agonist xanomeline improved cognition in phase 2 trials in Alzheimer's disease and schizophrenia. We present data on the effect of KarXT (xanomeline-trospium) on cognition in schizophrenia from the 5-week, randomised, double-blind, placebo-controlled EMERGENT-1 trial (NCT03697252). Analyses included 125 patients with computerised Cogstate Brief Battery (CBB) subtest scores at baseline and endpoint. A post hoc subgroup analysis evaluated the effects of KarXT on cognitive performance in patients with or without clinically meaningful cognitive impairment at baseline, and a separate outlier analysis excluded patients with excessive intraindividual variability (IIV) across cognitive subdomains. ANCOVA models assessed treatment effects for completers and impairment subgroups, with or without removal of outliers. Sample-wide, cognitive improvement was numerically but not statistically greater with KarXT (n = 60) than placebo (n = 65), p = 0.16. However, post hoc analyses showed 65 patients did not exhibit clinically meaningful cognitive impairment at baseline, while eight patients had implausibly high IIV at one or both timepoints. Significant treatment effects were observed after removing outliers (KarXT n = 54, placebo n = 63; p = 0.04). Despite the small sample size, a robust (d = 0.50) and significant effect was observed among patients with cognitive impairment (KarXT n = 23, placebo n = 37; p = 0.03). These effects did not appear to be related to improvement in PANSS total scores (linear regression, R²= 0.03). Collectively, these findings suggest that KarXT may have a separable and meaningful impact on cognition, particularly among patients with cognitive impairment.

Violence in relation to cognitive deficits and symptom severity in a sample of Egyptian patients with schizophrenia

BACKGROUND

Patient with schizophrenia are significantly more likely to be violent than general population; and the consequences of this violence risk are often very serious for the patients, their caregivers, and the entire community.

AIM

To assess the risk of violence in patients with schizophrenia and its correlation with severity of symptoms and cognitive functions.

METHODS

A cross-sectional comparative study conducted in Okasha institute of psychiatry including 50 patients with schizophrenia compared to 50 healthy control group regarding violence risk as assessed by Historical, Clinical, and Risk Management-20 (HCR-20), case group was assessed using Structured Clinical Interview for DSM-IV (SCID-I), Positive and Negative Syndrome Scale (PANSS), cognitive functions were assessed by Wechsler Adult Intelligence Scale (WAIS), Trail Making Test (TMT) Part A and B, the Wisconsin Card Sorting Test (WCST), and the Wechsler Memory Scale (WMS).

RESULTS

There was a statistically significant difference between case and control groups regarding risk of violence where 58% of the case group were found to have risk of violence compared to only 18% in the control group. There was a significant correlation between this risk of violence and period of untreated psychosis, no of episodes, and history of substance use; also was significantly correlated with PANSS and Wisconsin card sorting test subscales. Regarding logistic regression analysis for factors affecting violence risk; total PANSS score and history of substance use were significant independent factors that increase violence risk.

CONCLUSION

Violence risk in patient with schizophrenia is a cardinal factor that may affect life of the patients, their family, and society; this risk can be affected by different factors including severity of symptoms, no of episodes, history of substance use, and cognitive function of the patients.

The design and process of a family and community-based intervention for relapse prevention in people living with schizophrenia in Iran

BACKGROUND

People living with schizophrenia (PLS) suffer frequent relapse accompanied by emergency room visits, premature mortality, lower quality of life and a substantial social and economic burden on families and health systems. There is a dearth of community-based relapse prevention interventions (RPIs) in Iran.

AIMS

To determine an ideal model for a community-based RPIs for PLS.

METHODS

A qualitative study with 27 experts in Iran was carried out to understand the ideal RPIs for PLS and the key components of such interventions.

RESULTS

In 16 semi-structured interviews and 8 group-discussions, the participants identified six major stages of family and community-based RPIs including preparation, social mobilization, local team formation, design an RPI, implementing the RPI, participatory monitoring, and evaluation of the RPI.

CONCLUSIONS

Given the suboptimal healthcare systems and lack of professionals and services, PLS in Iran may benefit from family and community-based RPIs. Our findings warrant pilot testing of such initiatives across developing communities like Iran to improve health outcomes of PLS.

Increased NLRP3 inflammasome expression in peripheral blood mononuclear cells of patients with schizophrenia: a case-control study

OBJECTIVE

This study aimed to evaluate the gene expression of the P2X purinoceptor 7 (P2X7R)- nod-like receptor pyrin domain-containing protein 3 (NLRP3) signal pathway in peripheral blood mononuclear cells (PBMCs) between schizophrenia (SCZ) patients and healthy controls (HC) to reveal its relationship with clinical variables.

METHODS

Thirty-two SCZ patients and 41 healthy controls were included in this study. The Scale for the Assessment of Positive Symptoms (SAPS) and the Scale for the Assessment of Negative Symptoms (SANS), The Global Assessment of Functioning (GAF) scale and the Functioning Assessment Short Test (FAST) scales were applied. P2X7R, NLRP3, IL-1β and IL-18 gene expression levels were evaluated by real-time polymerase chain reaction in PBMCs.

RESULTS

NLRP3, P2RX7, IL-1β and IL-18 expression levels were significantly higher in PBMCs of SCZ patients than in HC subjects. Negative correlations were found between NLRP3 gene expression levels and GAF and FAST scales scores. There was a negative correlation between IL-18 expression levels and the GAF and FAST scales scores and a positive correlation with the SAPS scale scores.

CONCLUSIONS

Systemic inflammation is implicated in SCZ pathogenesis, according to our findings, which suggest that the NLRP3 pathway may be involved. The NLRP3 inflammasome may serve as a biomarker for SCZ, and its pharmacological regulation may be a promising treatment approach.Key pointsWe hypothesised that the NLRP3 pathway may contribute to the etiopathogenesis of schizophrenia.NLRP3, IL-1β and IL-18 mRNA levels were higher in patients with schizophrenia compared to healthy controls.Negative correlations were found between NLRP3 gene expression levels and GAF and FAST scales scores.There was a negative correlation between IL-18 expression levels and the GAF and FAST scales scores.The SAPS scale scores and IL-18 expression levels had a positive correlation.Given all these findings, it can be stated that NLRP3 inflammasome may play a role in the pathogenesis and symptoms of schizophrenia.

The prevalence and characteristics of MCCB cognitive impairment in unmedicated patients with bipolar II depression and major depressive disorder

BACKGROUND

Cognitive impairment has been acknowledged as a core clinical manifestation of bipolar disorder (BD) as well as major depressive disorder (MDD). Determining the prevalence and characteristics of cognitive impairment is important for clinical interventions. This study investigated the prevalence and characteristics of cognitive impairment based on the Measurement and Treatment Research to Improve Cognition Schizophrenia Consensus Cognitive Battery (MCCB) in both BD and MDD.

METHOD

One hundred and forty-nine BD II depression, 147 MDD, and 124 demographically matched healthy controls (HC) underwent MCCB cognitive assessment. The prevalence of MCCB cognitive impairment and group difference comparisons were performed. Additionally, association analysis was performed to investigate the relationship between cognitive performance and clinical variables.

RESULTS

Compared to the HC group, both BD II depression and MDD groups had a significantly reduced performance for all MCCB cognitive domains (all p < 0.05). The numerical scores for visual learning were lower in the BD II depression group compared to the MDD group. 32.89% of the BD II depression patients had clinically significant impairment (>1.5 SD below the normal mean) in two or more MCCB domains compared to 23.13% for MDD patients.

CONCLUSIONS

A high percent of patients in the BD II depression and MDD group exhibited MCCB cognitive impairments with clinical significance. Cognitive impairments were more common in BD II depression patients compared to MDD patients, particularly for visual learning. These findings suggest that clinicians should be aware of the severe cognitive impairment in mood disorders and establish effective cognitive screening and intervention strategies.

Lifespan evolution of neurocognitive impairment in schizophrenia - A narrative review

Cognitive impairment is a well-recognized key feature of schizophrenia. Here we review the evidence on (1) the onset and sensitive periods of change in cognitive impairment before and after the first psychotic episode, and (2) heterogeneity in neurocognitive presentations across cognitive domains between and within individuals. Overall, studies suggest that mild cognitive impairment in individuals who develop schizophrenia or related disorders is already present during early childhood. Cross-sectional studies further suggest increasing cognitive impairments from pre- to post-psychosis onset, with the greatest declines between adolescence, the prodrome, and the first psychotic episode and with some variability between domains. Longitudinal studies with more than 10 years of observation time are scarce but support mild cognitive declines after psychosis onset until late adulthood. Whether and how much this cognitive decline exceeds normal aging, proceeds further in older patients, and is specific to certain cognitive domains and subpopulations of patients remains to be investigated. Finally, studies show substantial heterogeneity in cognitive performance in schizophrenia and suggest a variety of impairment profiles.

This review highlights a clear need for long-term studies that include a control group and individuals from adolescence to old age to better understand critical windows of cognitive change and their predictors. The available evidence stresses the importance of interventions that aim to counter cognitive decline during the prodromal years, as well as careful assessment of cognition in order to determine who will profit most from which cognitive training.

Determinants of Recreational Outcomes in Schizophrenia: An Exploratory Study Focusing on Gender Differences

While recreation is impactful for recovery in schizophrenia, no study has examined the effects of schizophrenic symptoms on recreational outcomes. This study examined the determinants of recreational outcomes based on gender. We investigated the relationship between recreational outcomes, positive and negative symptoms, cognitive function, and factors such as negative self-evaluation and evaluation by others. Motivation had a significant impact on both men and women. However, participation in recreational activities was impacted by negative self-assessment for men and evaluations from others for women. The importance of matching strategies based on gender when using recreation therapeutically was emphasized.

Gender Differences in Psychiatric Symptoms and the Social Functioning of 610 Patients with Schizophrenia in Urban China: A 10-Year Follow-Up Study

PURPOSE

To explore the different outcomes between male and female patients with schizophrenia after long-term follow-up.

PATIENTS AND METHODS

Schizophrenia patients were participants in our study. First, two senior psychiatrists collected data on the demographic characteristics and clinical symptoms of patients from the Hospital Information System between February 2009 and January 2010. Second, two other senior psychiatrists called the patients and their guardians between February 2019 and January 2020 to get general information on the patients and assess their psychiatric symptoms and social functioning using the Positive and Negative Syndrome Scale (PANSS) and the Personal and Social Performance (PSP) scale.

RESULTS

Of the 610 participants, the 306 female participants were younger (48.32 ± 12.99 vs 49.84 ± 12.60) and had received more education (8.08 ± 3.76 vs 7.94 ±3 0.73). After 10 years, women were found to have more outpatient visits than men (20.86 ± 22.21 vs 16.11 ± 16.87, P < 0.05). However, there was no significant gender difference in number of hospitalizations (3.12 ± 5.34 vs 2.77 ± 5.84, P > 0.05). The PANSS scores were lower for both groups at the 10-year follow-up. Women had significantly lower scores than men after the 10-year period (P < 0.05). With regard to social functioning, there was a significant difference in social functioning between baseline scores and 10-year follow-up scores indicating an improvement in social functioning. PSP scores had significantly increased in women (P < 0.01) but not in men (P > 0.05).

CONCLUSION

Female patients had significantly lower levels of psychiatric symptoms and higher levels of social functioning at 10-year follow-up than male patients. They also reported more outpatient visits, which may have contributed to the gender differences in outcomes. Family members and doctors of patients should urge patients to make regular outpatient visits for better outcomes after hospitalization.

Negative symptom dimensions and social functioning in Chinese patients with schizophrenia

OBJECTIVE

Negative symptoms can seriously affect social functioning in patients with schizophrenia. However, the role of various components of negative symptoms in social functioning remains unclear. This study aimed to explore the associations among three different dimensions of negative symptoms (i.e., communication, emotion, and motivation) and social functioning to identify potential therapeutic targets.

METHODS

This cross-sectional study enrolled 202 Chinese participants with schizophrenia. Negative symptoms were evaluated using the Negative Symptom Assessment (NSA). Social functioning was represented by the Personal and Social Performance Scale (PSP) total score and employment status. Correlation analysis was conducted to clarify the relationship between negative symptoms and the PSP total score. Regression analysis was performed to explore the determinants of the PSP total score and employment status, considering negative symptoms and possible confounders, such as demographic features, positive symptoms, cognitive symptoms, depressive symptoms, and extrapyramidal side effects.

RESULTS

The PSP total score was correlated with all three dimensions of negative symptoms (i.e., emotion, motivation, and communication; rs = -0.509, -0.662, and -0.657, respectively). Motivation, instead of emotion or communication, predicted both low PSP total scores and unemployment.

CONCLUSION

Social functioning in patients with schizophrenia was significantly related to motivation. Further studies should focus on motivation and consider it as a therapeutic target to improve patients' social functioning.

European Psychiatric Association guidance on assessment of cognitive impairment in schizophrenia

Background

Impairment in a wide range of cognitive abilities has been consistently reported in individuals with schizophrenia. Both neurocognitive and social cognitive deficits are thought to underlie severe functional disabilities associated with schizophrenia. Despite the key role in schizophrenia outcome, cognition is still poorly assessed in both research and clinical settings.

Methods

In this guidance paper, we provide a systematic review of the scientific literature and elaborate several recommendations for the assessment of cognitive functions in schizophrenia both in research settings and in real-world clinical practice.

Results

Expert consensus and systematic reviews provided guidance for the optimal assessment of cognitive functions in schizophrenia. Based on the reviewed evidence, we recommend a comprehensive and systematic assessment of neurocognitive and social cognitive domains in schizophrenia, in all phases of the disorder, as well as in subjects at risk to develop psychosis. This European Psychiatric Association guidance recommends not only the use of observer reports but also self-reports and interview-based cognitive assessment tools. The guidance also provides a systematic review of the state of the art of assessment in the first episode of psychosis patients and in individuals at risk for psychosis.

Conclusion

The comprehensive review of the evidence and the recommendations might contribute to advance the field, allowing a better cognitive assessment, and avoiding overlaps with other psychopathological dimensions. The dissemination of this guidance paper may promote the development of shared guidelines concerning the assessment of cognitive functions in schizophrenia, with the purpose to improve the quality of care and to obtain recovery.

Dynamic contextual influences on social motivation and behavior in schizophrenia: a case-control network analysis

Contextual influences on social behavior and affective dynamics are not well understood in schizophrenia. We examined the role of social context on emotions, and the motivation to interact in the future, using dynamic network analysis of ecological momentary assessment (EMA) data. Participants included 105 outpatients with schizophrenia or schizoaffective disorder (SZ) and 76 healthy comparators (HC) who completed 7 days, 7 times a day of EMA. Dynamic networks were constructed using EMA data to visualize causal interactions between emotional states, motivation, and context (e.g., location, social interactions). Models were extended to include the type and frequency of interactions and the motivation to interact in the near future. Results indicated SZ networks were generally similar to HC but that contextual influences on emotion and social motivation were more evident in SZ. Further, feedback loops in HC were likely adaptive (e.g., positive emotions leading to social motivation), but most were likely maladaptive in SZ (e.g., sadness leading to reduced happiness leading to increased sadness). Overall, these findings indicate that network analyses may be useful in specifying emotion regulation problems in SZ and that instability related to contextual influences may be a central aspect of aberrant regulation.

Daily Ecological Momentary Assessments of happy and sad moods in people with schizophrenia and bipolar disorders: What do participants who are never sad think about their activities and abilities?

OBJECTIVES

People with schizophrenia have challenges in their self-assessments of everyday functioning and those who report no sadness also tend to overestimate their everyday functional abilities. While previous studies were cross-sectional, this study related longitudinal assessments of sadness to self-reports of abilities in domains of everyday functioning and cognitive abilities.

METHODS

71 people with bipolar illness (BPI) were compared to 102 people with schizophrenia (SCZ). Participants were sampled 3 times per day for 30 days with a smartphone-based Ecological Momentary Assessment (EMA) survey. Each survey asked where they were, with whom they were, what they were doing, and if they were sad. Performance based assessments of executive functioning, social competence, and everyday activities were collected after the EMA period, at which time the participants and observers were asked to provide ratings of three different domains of everyday functioning and neurocognitive ability.

RESULTS

18% of participants with SCZ reported that they were never sad on any one of the 90 EMA surveys. Reports of never being sad were associated with overestimated functioning compared to observers and SCZ participants who reported that they were never sad were more commonly home and alone than both SCZ participants who reported occasional sadness and participants with BPI. These participants reported being significantly happier than all people in the study.

IMPLICATIONS

Reporting that you were never sad was associated with overestimation of everyday functioning and cognitive abilities. Although participants who were never sad did not perform more poorly on objective measures than those were occasionally sad, their self-assessed functioning was significantly elevated. These data suggest that negative symptoms constructs such as reduced emotional experience need to consider reduced ability to subjectively evaluate emotional experience as a feature of negative symptoms.

Characterising Demographic, Clinical and Functional Features of Cognitive Subgroups in Schizophrenia Spectrum Disorders: A Systematic Review

Considerable cognitive heterogeneity is present within the schizophrenia spectrum disorder (SSD) population. Several subgroups characterised by more homogenous cognitive profiles have been identified. It is not yet clear however, whether these subgroups represent different points along a continuum of cognitive symptom severity, or whether they reflect unique profiles of the disorder. One way to determine this is by comparing subgroups on their non-cognitive characteristics. The aim of the present review was to systematically summarise our current understanding of the non-cognitive features of the cognitive subgroups of schizophrenia spectrum disorder (SSD). Thirty-five relevant studies were identified from January 1980 to March 2020. Cognitive subgroups were consistently compared on age, sex, education, age of illness onset, illness duration, positive, negative and disorganised symptoms, depression and psychosocial functioning. It was revealed that subgroups were consistently distinguished by education, negative symptom severity and degree of functional impairment; with subgroups characterised by worse cognitive functioning performing/rated worse on these characteristics. The lack of consistent subgroup differences for the majority of the non-cognitive characteristics provides partial support for the notion that cognitive subgrouping in SSD is not simply reflecting a rehash of previously identified clinical subtypes. However, as subgroups were consistently distinguished by three characteristics known to be associated with cognition, our understanding of the extent to which the cognitive subgrouping approach is representing separate subtypes versus subdivisions along a continuum of symptom severity is still not definitive.

The relationship between cognition and functioning in schizophrenia: A semi-systematic review

In schizophrenia, impairments in neurocognition (NC) and social cognition (SC) are associated with reduced functional capacity (FC) and poor real-world functioning (RWF).

In this semi-systematic review, we examined this association across a range of research questions.

We conducted a systematic search in Embase and MEDLINE from 2005 to 2019, and conducted additional pragmatic searches. After screening of titles, abstracts and full-texts, we included 564 citations, of which 44 (26 primary studies, 15 systematic reviews and 3 narrative reviews) were prioritized for reporting.

Both NC and SC were significantly associated with functioning, with slightly stronger association for SC. Effect sizes were generally larger for FC than for RWF. NC showed stronger associations with occupational functioning and independent living, and SC with social functioning. Baseline cognition predicted long-term RWF up to 20 years of follow-up, though long-term data were limited for SC. Cognitive remediation improved RWF functioning, especially when it was combined with psychosocial rehabilitation.

SC mediated the relationship of NC with functioning. Negative symptoms appeared to mediate and moderate the association of cognition with functioning. Other factors involved included severity of cognitive dysfunction, metacognition, depression and choice of RWF instrument.

We discuss potential implications for studies of pharmacological cognitive interventions in schizophrenia – the relevance of both NC and SC, the advantage of adjunctive psychosocial rehabilitation, the role of relevant moderating and mediating variables, and the challenges with RWF instrument selection. Successful cognitive interventions could allow patients with schizophrenia to improve their potential for community functioning.

The Relationship between Negative Symptoms and Both Emotion Management and Non-social Cognition in Schizophrenia Spectrum Disorders

OBJECTIVE

There is ongoing debate regarding the relationship between clinical symptoms and cognition in schizophrenia spectrum disorders (SSD). The present study aimed to explore the potential relationships between symptoms, with an emphasis on negative symptoms, and social and non-social cognition.

METHOD

Hierarchical cluster analysis with k-means optimisation was conducted to characterise clinical subgroups using the Scale for the Assessment of Negative Symptoms and Scale for the Assessment of Positive Symptoms in n = 130 SSD participants. Emergent clusters were compared on the MATRICS Consensus Cognitive Battery, which measures non-social cognition and emotion management as well as demographic and clinical variables. Spearman's correlations were then used to investigate potential relationships between specific negative symptoms and emotion management and non-social cognition.

RESULTS

Four distinct clinical subgroups were identified: 1. high hallucinations, 2. mixed symptoms, 3. high negative symptoms, and 4. relatively asymptomatic. The high negative symptom subgroup was found to have significantly poorer emotion management than the high hallucination and relatively asymptomatic subgroups. No further differences between subgroups were observed. Correlation analyses revealed avolition-apathy and anhedonia-asociality were negatively correlated with emotion management, but not non-social cognition. Affective flattening and alogia were not associated with either emotion management or non-social cognition.

CONCLUSIONS

The present study identified associations between negative symptoms and emotion management within social cognition, but no domains of non-social cognition. This relationship may be specific to motivation, anhedonia and apathy, but not expressive deficits. This suggests that targeted interventions for social cognition may also result in parallel improvement in some specific negative symptoms.

Anomalous self-experiences in cognition are negatively associated with neurocognitive functioning in schizophrenia

INTRODUCTION

Anomalous self-experiences (ASEs) are disturbances in the subjective experience of the self and are common in people with schizophrenia. Theorists have suggested that ASEs may underlie the neurocognitive deficits that are also common in people with schizophrenia; however, few studies have empirically investigated the relationship between these variables. Thus, the current study aimed to determine whether self-reported ASEs, particularly disturbances in cognitive or mental experiences, are meaningfully related to neurocognitive performance in individuals with schizophrenia.

METHODS

48 individuals with schizophrenia and 34 healthy comparison participants completed the Inventory of Psychotic-Like Anomalous Experiences (IPASE), which is composed of five subscales including disturbances in cognition, and the MATRICS Consensus Cognitive Battery (MCCB).

RESULTS

Participants with schizophrenia performed worse than controls on each MCCB domain and had higher ASE scores on the total IPASE and all five subscales. Only the IPASE-Cognition subscale was associated with cognitive performance. Specifically, IPASE-Cognition was negatively correlated with scores in attention, visual learning, reasoning, and working memory.

CONCLUSIONS

These results suggest that self-reported subjective disturbances in cognition may be meaningfully associated with several objectively-measured domains of neurocognition. Severity of ASEs may therefore be an important consideration when analysing the extent of cognitive deficits in schizophrenia.

Real-World Functioning in Patients With Schizophrenia: Beyond Negative and Cognitive Symptoms

Introduction: Interest in the idea of recovery for certain patients with schizophrenia has been growing over the last decade. Improving symptomatology and functioning is crucial for achieving this. Our study aims to identify those factors that substantially contribute to real-world functioning in these patients. Methods: We carried out a cross-sectional study in stable outpatients with schizophrenia on maintenance antipsychotic monotherapy. Patients: We studied 144 outpatients with schizophrenia (DSM-IV-TR criteria) meeting the following criteria: (1) 18-65 years of age; (2) being clinically stable for at least the previous three months; (3) on maintenance antipsychotic monotherapy (prescriptions ≤ 10 mg olanzapine, ≤200 mg quetiapine, or ≤100 mg levomepromazine as hypnotics were also allowed); and (4) written informed consent. Assessment: We collected information on demographic and clinical variables by using an ad hoc questionnaire. For psychopathology, we employed the Spanish versions of the following psychometric instruments: the Positive and Negative Syndrome Scale (PANSS), the Brief Negative Symptom Scale (BNSS-Sp), and the Calgary Depression Scale (CDS). In addition, cognitive domains were assessed using the Verbal Fluency Test (VFT), the Digit Symbol Substitution Test (DSST), and the Trail Making Test, parts A and B (TMT-A and TMT-B). Finally, we employed the Spanish versions of the University of California San Diego Performance-based Skills Assessment (Sp-UPSA) and the Personal and Social Performance (PSP) for assessing functional capacity and real-world functioning, respectively. Statistical analysis: A forward stepwise regression was conducted by entering those variables significantly associated with PSP total score into the univariate analyses (Student's t-test, ANOVA with Duncan's post-hoc test, or bivariate Pearson correlation). Results: A total of 144 patients; mean age 40 years, 64% males, mean length of illness 12.4 years, PSP total score 54.3. The final model was a significant predictor of real-world functioning [F (7, 131) = 36.371, p < 0.001] and explained 66.0% of the variance. Variables retained in the model: BNSS-Sp abulia, asociality, and blunted affect, PANSS general psychopathology, Sp-UPSA transportation, TMT-B, and heart rate. Conclusion: Our model will contribute to a more efficient and personalized daily clinical practice by assigning specific interventions to each patient based on specific impaired factors in order to improve functioning.

Using a Meta-cognitive Wisconsin Card Sorting Test to measure introspective accuracy and biases in schizophrenia and bipolar disorder

People with schizophrenia (SCZ) and bipolar disorder (BD) have challenges in self-evaluation of their cognitive and functional performance (introspective accuracy). They also manifest response biases, with tendencies toward overestimation. This study aimed to examine objective test performance, momentary judgments of performance, momentary confidence, and subsequent global judgments of performance on a metacognitive version of the Wisconsin Card Sorting Test (WCST). This sample included 99 participants with SCZ and 67 with BD. After each of the 64 WCST trials, participants reported whether they believed their sort was correct and how confident they were in that judgment, they then received performance feedback. After completion of the entire task, participants generated a global performance judgment. On average, the SCZ group got 31 sorts correct, reporting being correct on 49 whereas the BD group got 37 trials correct but reported being correct on 53. For participants with BD, sorting performance correlated with trial x trial accuracy judgments, confidence, and predicted global judgments. For SCZ participants, performance minimally correlated with trial x trial accuracy judgments, confidence, and global judgments, while trial x trial confidence was strongly associated with trial x trial accuracy judgments (r = 0.58). Our findings suggest that confidence in participants with BD is correlated with task performance, whereas in SCZ confidence was entirely associated with self-generated performance judgments. SCZ participants manifested challenges with utilization of feedback. Global judgments of performance were predicted by task performance and confidence for BD participants, with performance and confidence judgments occurring prior to generation of the global performance judgments.

Negative Symptoms and Behavioral Alterations Associated with Dorsolateral Prefrontal Syndrome in Patients with Schizophrenia

The present study had three main aims: (1) to explore the possible relationships between the two dimensions of negative symptoms (NS) with the three frontal behavioral syndromes (dorsolateral, orbitofrontal and the anterior or mesial cingulate circuit) in patients with schizophrenia; (2) to determine the influence of sociodemographic and clinical variables on the severity of the two dimensions of NS (expressive deficits and disordered relationships/avolition); and (3) to explore the possible relationships between the two dimensions of NS and social functioning. We evaluated a group of 33 patients with schizophrenia with a predominance of NS using the self-reported version of the Frontal System Behavior scale. To quantify the severity of NS, the Assessment of Negative Symptoms (SANS) scale was used. The results revealed that the two dimensions of NS correlate positively with the behavioral syndrome of dorsolateral prefrontal origin. Regarding the influence of sociodemographic and clinical variables, in patients with a long evolution the NS of the expressive deficits dimension were less severe than in patients with a short evolution. A negative correlation was found between the severity of NS of the disordered relationships/avolition dimension and perceived social functioning. Our results show the importance of differentiating between the two dimensions of NS to characterize better their possible frontal etiology and impact on clinical course and social functioning.

Glutathione Deficiency during Early Postnatal Development Causes Schizophrenia-Like Symptoms and a Reduction in BDNF Levels in the Cortex and Hippocampus of Adult Sprague-Dawley Rats

Growing body of evidence points to dysregulation of redox status in the brain as an important factor in the pathogenesis of schizophrenia. The aim of our study was to evaluate the effects of l-buthionine-(S,R)-sulfoximine (BSO), a glutathione (GSH) synthesis inhibitor, and 1-[2-Bis(4-fluorophenyl)methoxy]ethyl]-4-(3-phenylpropyl)piperazine dihydrochloride (GBR 12909), a dopamine reuptake inhibitor, given alone or in combination, to Sprague–Dawley pups during early postnatal development (p5–p16), on the time course of the onset of schizophrenia-like behaviors, and on the expression of brain-derived neurotrophic factor (BDNF) mRNA and its protein in the prefrontal cortex (PFC) and hippocampus (HIP) during adulthood. BSO administered alone decreased the levels of BDNF mRNA and its protein both in the PFC and HIP. Treatment with the combination of BSO + GBR 12909 also decreased BDNF mRNA and its protein in the PFC, but in the HIP, only the level of BDNF protein was decreased. Schizophrenia-like behaviors in rats were assessed at three time points of adolescence (p30, p42–p44, p60–p62) and in early adulthood (p90–p92) using the social interaction test, novel object recognition test, and open field test. Social and cognitive deficits first appeared in the middle adolescence stage and continued to occur into adulthood, both in rats treated with BSO alone or with the BSO + GBR 12909 combination. Behavior corresponding to positive symptoms in humans occurred in the middle adolescence period, only in rats treated with BSO + GBR 12909. Only in the latter group, amphetamine exacerbated the existing positive symptoms in adulthood. Our data show that rats receiving the BSO + GBR 12909 combination in the early postnatal life reproduced virtually all symptoms observed in patients with schizophrenia and, therefore, can be considered a valuable neurodevelopmental model of this disease.

Evidence for avolition in bipolar disorder? A 30-day ecological momentary assessment comparison of daily activities in bipolar disorder and schizophrenia

OBJECTIVES

Disability is common in bipolar disorder (BD) and predicted by persistent sadness. We used ecological momentary assessment (EMA) to examine daily activities in people with BD and schizophrenia. We classified activities as productive, unproductive, or passive recreation, relating them to momentary sadness, location, and social context.

METHODS

71 people with BD and 102 people with schizophrenia were sampled 3 times/day for 30 days with an EMA survey. Each survey asked where they were, with whom, what they were doing, and if they were sad.

RESULTS

People with BD were home more than 50% of the time. There were no differences in prevalence of activity types across diagnoses. People with BD were less likely to report only one activity since the prior survey, but the most surveys still reported only one. For both groups, sadness and being home and alone since the last survey was associated with less productive activity and more passive recreation.

CONCLUSIONS

Participants with BD and schizophrenia manifested high levels of unproductive and passive activities, predicted by momentary sadness. These activity patterns are consistent with descriptions of avolition and they minimally differentiated people with BD and schizophrenia. Previous reports of negative symptoms in BD may have been identifying these behaviors.

Computational methods for integrative evaluation of confidence, accuracy, and reaction time in facial affect recognition in schizophrenia

People with schizophrenia (SZ) process emotions less accurately than do healthy comparators (HC), and emotion recognition have expanded beyond accuracy to performance variables like reaction time (RT) and confidence. These domains are typically evaluated independently, but complex inter-relationships can be evaluated through machine learning at an item-by-item level. Using a mix of ranking and machine learning tools, we investigated item-by-item discrimination of facial affect with two emotion recognition tests (BLERT and ER-40) between SZ and HC. The best performing multi-domain model for ER40 had a large effect size in differentiating SZ and HC (d = 1.24) compared to a standard comparison of accuracy alone (d = 0.48); smaller increments in effect sizes were evident for the BLERT (d = 0.87 vs. d = 0.58). Almost half of the selected items were confidence ratings. Within SZ, machine learning models with ER40 (generally accuracy and reaction time) items predicted severity of depression and overconfidence in social cognitive ability, but not psychotic symptoms. Pending independent replication, the results support machine learning, and the inclusion of confidence ratings, in characterizing the social cognitive deficits in SZ. This moderate-sized study (n = 372) included subjects with schizophrenia (SZ, n = 218) and healthy controls (HC, n = 154).

•

This paper explores the value of integrative evaluation of confidence, accuracy, and reaction time by way of machine learning in understanding the unique aspects of facial affect recognition in schizophrenia.

•

Machine learning models better separated schizophrenia from healthy comparators that standard statistical comparison, confidence ratings contributed to this separation in a disproportionate manner.

•

Machine learning approaches provide a novel way to analyze item-by-item associations with social cognition measures, or potentially other tests, where multiple overlapping dimensions exist.

•

Aberrant confidence ratings interact with performance variables in complex ways to contribute to social cognitive deficits in schizophrenia.

Single versus dual pathways to functional outcomes in schizophrenia: Role of negative symptoms and cognitive function

Background

The functional outcomes for many patients with schizophrenia remain poor, and the specific determinants for and pathways to functional outcomes are not well understood to date. It is unknown whether major determinants of outcomes are achieved via a motivated single pathway or by the motivation and capacity defined in dual pathways. This study investigated whether different aspects of functional outcomes, such as residential, social, and vocational outcomes, are the main determinants of the experience factors for negative symptoms or whether the experience factors and cognitive function are the determinants.

Method

We enrolled 107 patients with schizophrenia. The Social Functioning Scale domains were used to examine whether a single or dual pathway is appropriate for each domain based on the model fit using structural equation modeling.

Results

The model goodness of fit criterion showed a dual pathway for residential and vocational outcomes. In contrast, social and recreational outcomes showed a single pathway.

Conclusion

The major determinants were clearly different for each outcome. Therefore, we emphasize the importance of using different treatment strategies for each outcome. Irrespective of the factors approached, social and recreational outcomes should ultimately focus on motivation. The findings also suggest that interventions should be combined for vulnerable cognitive functions and motivational interventions for residential and vocational outcomes.

Long-Term Benzodiazepine Prescription During Maintenance Therapy of Individuals With Psychosis Spectrum Disorders-Associations With Cognition and Global Functioning

BACKGROUND

Cognitive difficulties have a significant impact on life functioning and overall well-being in patients with psychosis spectrum disorders (PSDs). There are indications that continuous use of benzodiazepines (BZDs) in various patient groups has a detrimental effect on cognition. Our aim was to explore the association between long-term BZD prescription, global functioning, and cognitive functioning in persons with PSD.

METHODS

This exploratory study included 55 PSD patients, recruited from 2 outpatient services in Serbia. Patients were grouped into BZD long-term prescription group and BZD-other group. Brief Psychiatric Rating Scale was used for symptom assessment, functioning was measured by Global Assessment and Functioning Scale, and cognition was assessed by the Global Assessment of Functioning-Cognition in Schizophrenia Scale.

RESULTS

The sample comprised 52.7% patients who were prescribed with BZD for 6 months or more continually (29/55), with a mean daily dose of 3.16 ± 0.66 mg lorazepam equivalents. There were no differences between study groups in any of the sociodemographic characteristics, duration of illness, or antipsychotic daily dosages. The BZD long-term prescription group had lower global (P < 0.01) and cognitive functioning (P < 0.01), higher Brief Psychiatric Rating Scale scores (1.86 vs 1.58, respectively, P < 0.01), and more psychotropic drugs prescribed on a daily basis than the other group (median: 4 vs 2, respectively, P < 0.01).

CONCLUSIONS

The study explored a topic that continues to be underresearched, especially in the Balkans. Prospective studies and comprehensive cognitive batteries are needed to further elucidate the associations between polypharmacy, long-term BZD use, cognitive functioning, and global functioning during maintenance therapy of individuals with PSD.

Impact of Negative Symptom Domains and Other Clinical Characteristics on Functional Outcomes in Patients with Schizophrenia

Negative symptoms of schizophrenia have generally been defined using five factors; however, few studies have examined the relationship between these five factors and functional outcomes. In addition, there is no definitive conclusion regarding the association between negative symptoms and various aspects of functional outcomes (daily living, social, and vocational). This study is aimed at examining the relationship between these five domains of negative symptoms and different functional outcomes. Patients diagnosed with chronic schizophrenia (n = 100) were selected for the evaluation. We used the Brief Negative Symptom Scale to assess negative symptoms, the Brief Psychiatric Rating Scale to assess positive symptoms, the Schizophrenia Cognition Rating Scale to assess cognition, and the Evaluative Beliefs Scale (negative self-assessment) to assess psychological factors. We analyzed their relative impact on Social Functioning Scale domains using hierarchical multiple regression analysis. Concerning the relationship between daily living and negative symptoms, cognitive function showed the highest association with residential outcomes, such as self-care and shopping, while avolition appeared to show an additional contribution; however, for recreational outcomes, avolition showed the main association, whereas cognitive function showed no additional contribution. For social outcomes, asociality and negative self-assessment showed the main associations, while vocational outcomes were determined by both cognitive function and multiple negative symptoms, such as avolition, anhedonia, asociality, and alogia. Since negative symptom domains appear to differentially impact each outcome, specifically daily living outcome, it is important to evaluate the residential outcomes and recreational outcomes separately. Overall, the present study points to the importance of formulating psychosocial treatment strategies specific for each type of preferred outcome in patients with schizophrenia.

Emotional determinants of life-space through GPS and ecological momentary assessment in schizophrenia: What gets people out of the house?

BACKGROUND

Previous research employing global positioning satellite (GPS) data and ecological momentary assessment (EMA) has shown a smaller life-space (distance traveled from home) was associated with poorer community functioning and more severe negative symptoms in people with schizophrenia. Momentary emotional experiences may influence how much time is spent outside of the home. We evaluated the associations between emotional experiences in relation to life-space among people with schizophrenia compared to healthy controls (HCs).

METHODS

105 participants with schizophrenia and 76 HCs completed in-lab assessments of symptoms, cognition, and functioning. Participants completed EMA assessments of location and emotions seven times daily for seven days at stratified random intervals. GPS coordinates were collected 24 h a day over the 7-day study period. Analyses were performed at the momentary, day, and full week level using mixed effects models and Spearman correlations.

RESULTS

For HCs, greater happiness was associated with greater concurrent distance traveled away from home as measured by GPS. For participants with schizophrenia, greater anxiety was associated with greater distance traveled away from home and being outside of the home. Less happiness, but not anxiety, was also associated with greater negative symptoms, especially outside the home.

DISCUSSION

These findings suggest diminished positive emotion is associated with the experience of leaving the home in schizophrenia, but also suggest that anxiety may contribute to avoidance of out of home mobility. Interventions targeting both positive emotions and social anxiety may improve social functioning, and life-space may provide a useful outcome for functional rehabilitation interventions in schizophrenia.

Emerging 5-HT receptor antagonists for the treatment of Schizophrenia

INTRODUCTION

While antipsychotics have been generally successful in treating psychosis in schizophrenia, there is a major treatment gap for negative symptoms and cognitive deficits. Given that these aspects of the disease contribute to poor functional outcomes independently of positive symptoms, treatments would have profound implications for quality of life. The 5-HT_2A- receptor has been considered a potential target for interventions aimed at negative and cognitive symptoms and multiple antagonists and inverse agonists of this receptor have been tested.

AREAS COVERED

Ritanserin and volinanserin, are historically important compounds in this area, while pimavanserin, roluperidone, and lumateperone are either newly approved, in late stages of development, or currently being tested for efficacy in schizophrenia-related features. The focus will be on their efficacy in the treatment of negative symptoms, with a limited secondary discussion of cognition.

EXPERT OPINION

In addition to their efficacy in treating negative symptoms and cognition, these compounds may also have a role in modulating antipsychotic-induced dopamine super-sensitivity and preventing relapse. They may also show efficacy in treating patients with milder symptoms such as patients with schizotypal personality disorder and attenuated psychosis syndrome. Their utility may also expand outside the spectrum of schizophrenia to encompass Parkinson's Disease psychosis, major depression, bipolar depression, and dementia-associated apathy.

Pharmacological treatment of violence in schizophrenia

Chronic aggression and violence in schizophrenia are rare, but receive disproportionate negative media coverage. This contributes to the stigma of mental illness and reduces accessibility to mental health services. Substance Use Disorders (SUD), antisocial behavior, non-adherence and recidivism are known risk factors for violence. Treatment with antipsychotic medication can reduce violence. Aside from clozapine, long-acting injectable antipsychotics (LAI) appear to be superior to oral antipsychotics for preventing violence, addressing adherence and recidivism. LAI also facilitate the implementation of functional skills training. For the high-risk recidivist target population with schizophrenia, better life skills have the potential to also reduce the risk for contact with the legal system, including an improved ability to live independently in supported environments and interact appropriately with others. High-risk patients who are resistant to treatment with other antipsychotics should receive treatment with clozapine due to its direct positive effects on impulsive violence, along with a reduction in comorbid risk factors such as SUDs.

The Role of Cytokines in Predicting the Efficacy of Acute Stage Treatment in Patients with Schizophrenia

PURPOSE

Inflammatory response in schizophrenia (SCz) is related to its underlying pathological mechanism and might be significant in deciding a patient's prognosis. The current study aims to investigate the differences in the serum inflammation level between schizophrenic patients and healthy controls and identify inflammatory markers that can predict clinical therapeutic effects in early-stage SCz patients at the 6-month follow-up.

PATIENTS AND METHODS

In total, 71 subjects were recruited in this study, including 35 patients with Scz and 36 healthy controls. The 35 Scz patients, who were in the first-episode or acute relapse state at admission, had completed the 6-month follow-up. The Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impression (CGI) assessment results, demographic details, and blood samples were collected at the baseline and at follow-up. Data were analyzed using the Spearman correlation and multiple linear regression.

RESULTS

Serum interleukin (IL-1β, IL-4, IL-6, and IL-8) levels were significantly elevated in SCz patients at baseline compared with healthy controls, with a reduced IL-8 level at the follow-up. Furthermore, a higher IL-6 level and lower IL-8 level was found to predict better improvement in negative symptoms. The higher IL-6 level also predicted lesser improvement in depressive symptoms. Finally, a higher interferon (IFN)-γ level predicted a lower therapeutic effect for excitatory symptoms.

CONCLUSION

The serum levels of inflammatory markers were higher in patients with SCz than in healthy controls. These markers can be considered accurate predictors of therapeutic effects in patients with SCz.

Autistic Symptoms and Social Cognition Predict Real-World Outcomes in Patients With Schizophrenia

OBJECTIVE

Real-world functioning is a complex construct influenced by different factors. The impact of social cognition and autism spectrum disorder (ASD) symptoms on different aspects of the life of people with schizophrenia has been demonstrated independently, but it is unclear how these factors are related to functioning when considered concurrently. We hypothesized that ASD symptoms could play a major role in predicting real-world functioning in schizophrenia.

METHODS

Existent databases from two studies (SCOPE Phase 3 and SCOPE Phase 5), in which a total of 361 patients (mean age 41.7 years; 117 females) were assessed with measures of symptom severity, neuro- and socio-cognitive abilities, functional capacity, social skills, and informant-reported real-world functioning outcomes, were analyzed.

RESULTS

Active social avoidance, social skills, ASD symptoms, and emotion processing emerged as predictors of real-world interpersonal relationships. Cognitive performance, positive symptoms, and functional capacity emerged as predictors of real-world participation in daily activities. Cognitive performance, emotion processing, positive symptoms severity, and social skills emerged as predictors of real-world work outcomes.

CONCLUSION

Among other demographic, clinical, and functional capacity variables, increased ASD symptoms emerged as a significant predictor of poorer social relationships and may therefore represent a key factor in predicting real-world social functioning in schizophrenia.

Effects of Roluperidone (MIN-101) on two dimensions of the negative symptoms factor score: Reduced emotional experience and reduced emotional expression

BACKGROUND

Recent research has suggested that negative symptoms (NS) can be considered in terms of two different dimensions: reduced expression (expressive deficit) and reduced experience (experiential deficit). Roluperidone, a compound with high affinities for 5 HT2A and sigma2 receptors, has previously shown superiority over placebo on improving NS in a prospective study in patients with schizophrenia. The objective here is to explore the effect of roluperidone compared to placebo, on the 2 domains of the Negative Symptoms.

METHODS

This was a multi-national Phase 2b trial that enrolled 244 symptomatically stable patients with schizophrenia who had baseline scores ≥20 on the NS subscale of the PANSS. Patients were randomized to daily monotherapy with roluperidone 32 mg, roluperidone 64 mg, or placebo in a 1:1:1 ratio. All enrolled patients were Caucasian, and 137 (56%) were male. The 3 treatment groups were balanced on all demographic and illness-related baseline characteristics.

RESULTS

Both doses of roluperidone were superior to placebo on both domains: Reduced Experience (p ≤ .006 for the 32 mg; p ≤ .001 for the 64 mg) with persistent superiority from Week 2 for the 64 mg dose and Week 8 for the 32 mg dose; Reduced Expression (p ≤ .003 for 32 mg; p ≤ .001 for 64 mg) with similar persistence.

IMPLICATIONS

Both doses of roluperidone previously improved PANSS negative symptoms in general and demonstrated tolerability in stable schizophrenia patients. The post hoc analysis reported here found the drug to work on both the reduced emotional experience and reduced emotional expression sub-scales empirically derived from the PANSS.

Deviation from expected cognitive ability is a core cognitive feature of schizophrenia related to neurophysiologic, clinical and psychosocial functioning

Cognitive functioning in schizophrenia is characterized by a generalized impairment in current cognitive ability based on traditional population-based norms. However, these norms assume a normal cognitive trajectory and do not directly account for illness-related declines from expected cognitive potential. Indeed, schizophrenia patients exhibit even greater deviation between their observed and expected cognitive functioning based on expanded norms that leverage premorbid variables resistant to illness-related features. The current study further quantified the extent to which illness-related features account for this deviation from expectation and assessed its relationship to neurophysiologic (mismatch negativity, P3a, theta oscillations), clinical, and psychosocial functioning in schizophrenia patients. Expected cognitive ability (PENN-CNB global cognition) in patients (n = 684) was calculated using healthy comparison subject (n = 660) weighted regression based on premorbid variables resistant to illness-related decline (demographics, single-word reading, parental education). The magnitude of any deviation between current (observed) and regression-predicted (expected) cognitive ability was calculated. Results indicated that 24% (n = 164) of the total patient population exhibited significant (≥-1.96 SD) deviation between observed and expected global cognitive ability. Interestingly, 20% of the total patient population (n = 136) had "normal" range cognitive performance when using traditional population-based norms, but also had significant deviation from expected cognitive ability. The magnitude of this deviation was associated with more severe neurophysiologic abnormalities, longer illness duration, higher levels of negative symptoms, and worse psychosocial functioning. Assessment of cognitive deviation is thus a complementary metric for characterizing the severity of illness-related cognitive declines in patients, while also reflecting the expression and severity of key endophenotypes of schizophrenia.

Predicting real-world functioning in outpatients with schizophrenia: Role of inflammation and psychopathology

Several studies indicate that negative and cognitive symptoms are determining factors of functioning in patients with schizophrenia. However, they do not usually include biological aspects, such as inflammatory markers. The current prospective study aims to identify clinical and biological factors predicting real-world functioning, at baseline and at one-year follow-up, of outpatients in an early stage of schizophrenia. Sample consist of 73 clinically stable patients with schizophrenia, of which 57 completed the one-year follow-up. Accurate psychopathology, functioning, and cognitive assessments were performed at baseline and follow-up (Positive and Negative Syndrome, Brief Negative Symptom, Calgary Depression, Personal and Social Performance Scales, and MATRICS Cognitive Consensus Battery). Biological biomarkers including anthropometric data and blood parameters were collected. Pearson correlation and multiple regression analyses including potential confounding factors were performed. Negative symptoms (especially asociality and avolition), along with the inflammatory biomarker interleukin-2, are the most important determining factors of poor real-world functioning in early-stage schizophrenia. The previous functioning, along with baseline cognitive performance in attention and vigilance, predicts functioning at one-year follow-up in these patients. Strategies aimed at improving negative and cognitive symptoms, as well as modifying certain inflammatory pathways, should be the targets to achieve functional recovery in the first years of schizophrenia.

A large European, multicenter, multinational validation study of the Brief Negative Symptom Scale

Negative symptoms represent an unmet need of treatment in schizophrenia. Although a consensus exists on negative symptom construct, and second generation assessment instruments reflecting the consensus are available, studies still rely upon old assessment instruments, that do not reflect recent conceptualizations and might limit progress in the search for effective treatments. This is often the case in the European context, where one of the challenges encountered in designing large studies is the availability of validated instruments in the many languages of the continent. To address this challenge and promote sound research on negative symptoms in Europe, the ECNP Schizophrenia Network coordinated a large multicenter, multinational validation study of the Brief Negative Symptom Scale (BNSS). Clinically-stable subjects with schizophrenia (SCZ, N = 249) were recruited from 10 European Countries. Apart from BNSS, subjects were administered the Positive and Negative Syndrome Scale (PANSS) and standardized instruments for depression, extrapyramidal symptoms and psychosocial functioning. Results showed an excellent internal consistency, convergent and discriminant validity of BNSS and replicated a 5 factor-model. A larger number of subjects with predominant negative symptoms, i.e. the target population for clinical trials, was identified by using the BNSS compared to the PANSS. Regression analysis showed that BNSS-avolition, a key negative symptom poorly assessed by PANSS, explained 23.9% of psychosocial functioning, while no combination of the PANSS core negative symptoms showed the same impact on functioning. The study demonstrated that BNSS has substantial advantages with respect to PANSS for the identification of the avolition domain and subjects with predominant negative symptoms.