Psychometric properties of performance-based measurements of functional capacity: test-retest reliability, practice effects, and potential sensitivity to change

Adjunctive methylphenidate extended release in patients with schizophrenia: Protocol of a single-centre fixed dose cross-over open-label trial to improve functional and cognitive outcomes

Background

Cognitive symptoms, among the core symptoms of schizophrenia, are associated with poor functional outcome and burden of illness. To date, there is no effective pharmacological treatment for these symptom clusters. Augmentation with psychostimulants has been proposed as a potential treatment option.

Objectives

The present study aims to assess off-label use of adjunctive methylphenidate extended release (ER) in patients with schizophrenia who are stable on antipsychotic medications, and to assess its efficacy on functioning and cognitive outcome.

Methods

This is a single centre study at the Royal Ottawa Mental Health Centre. An open-label fixed dose controlled cross-over trial is planned. Eligible participants will be randomized into one of two arms of the study: 1) four weeks of add-on methylphenidate ER 36 mg, or 2) four weeks of treatment as usual. At 4 weeks, participants will switch arms. The duration of the study includes 8 weeks of treatment and a follow-up visit at 12 weeks. Primary outcome measures include tablet-based tests of functioning and cognition (VRFCAT and BAC) and will be administered at baseline and every 4 weeks. We are aiming to recruit a total of 24 participants.

Expected outcomes

The proposed project intends to assess a potential treatment option for cognitive deficits of schizophrenia, for which there are no recommendations by current treatment guidelines. The novelty and significance of the current study is that it investigates this intervention and assess applicability of it in a "real world setting" in a tertiary care hospital.

Social skills in neurodevelopmental disorders: a study using role-plays to assess adolescents and young adults with 22q11.2 deletion syndrome and autism spectrum disorders

BACKGROUNDS

Social skills are frequently impaired in neurodevelopmental disorders and genetic conditions, including 22q11.2 deletion syndrome (22q11DS) and autism spectrum disorders (ASD). Although often assessed with questionnaires, direct assessment provides a more valid estimate of the constructs. Role-plays (i.e., simulates situational settings) therefore appear to be an appropriate indicator of social skills in daily life.

METHODS

This co-registered study involved 53 individuals with 22q11DS, 34 individuals with ASD, and 64 typically developing (TD) peers aged 12-30 years. All participants were assessed with role-plays as well as parent-reported questionnaires and clinical interviews focusing on social skills, functioning and anxiety.

RESULTS

Both clinical groups showed impaired social skills compared to TD, but distinct social profiles emerged between the groups. Individuals with 22q11DS displayed higher social appropriateness and clarity of speech but weaker general argumentation and negotiation skills, with the opposite pattern observed in participants with ASD. No association was found between social skills measured by direct observation and caregiver reports. Social anxiety, although higher in clinical groups than in TD, was not associated with role-plays.

CONCLUSIONS

This study highlights the need to train social skills through tailored interventions to target the specific difficulties of each clinical population. It also highlights the importance of combining measures as they do not necessarily provide the same outcome.

A systematic review of social functioning outcome measures in schizophrenia with a focus on suitability for intervention research

Social functioning is an important part of recovery and a key treatment target in clinical research in schizophrenia. Evaluating and comparing interventions is challenged by the choice of many measures which focus on different aspects of functioning, with little to guide selection. This results in difficulties comparing outcomes of treatment where studies have used different measures. To improve the measurement of social functioning in intervention research, we aimed to provide practical information on suitability of measures. We conducted a systematic review of measures developed or psychometrically evaluated since 2007, and assessed and discussed the structure, content, quality, and the use of the measures in intervention research. Thirty-two measures of social functioning and 22 validation papers were identified. Measures included structured questionnaires, semi-structured interviews, and assessment of performance on specific tasks. The content of measures was organised into eight categories, which are in order of frequency with which they were covered by measures: activities of daily living, productive activity, relationships, leisure activities, cognition, anti-social behaviour, psychosis symptoms and self-esteem and empowerment. In terms of quality, most measures were rated as moderate, with the Personal and Social Performance Scale gaining the highest rating. However, there was little data on responsiveness of measures, or how they compare to objective or 'real-world' indicators of functioning. The Social Functioning Scale and Personal and Social Performance Scale have been most frequently used in intervention studies to date. Future research should aim to provide further data on psychometric properties relevant to intervention research.

Brain structural correlates of functional capacity in first-episode psychosis

Impaired functional capacity is a core feature of schizophrenia and presents even in first-episode psychosis (FEP) patients. Impairments in daily functioning tend to persist despite antipsychotic therapy but their neural basis is less clear. Previous studies suggest that volume loss in frontal cortex might be an important contributor, but findings are inconsistent. We aimed to comprehensively investigate the brain structural correlates of functional capacity in FEP using MRI and a reliable objective measure of functioning [University of California, San Diego Performance-Based Skills Assessment (UPSA)]. In a sample of FEP (n = 39) and a well-matched control group (n = 21), we measured cortical thickness, gray matter volume, and white matter tract integrity (fractional anisotropy, FA) within brain regions implicated by previous work. The FEP group had thinner cortex in various frontal regions and fusiform, and reduced FA in inferior longitudinal fasciculus (ILF). In FEP, poorer functional capacity correlated with reduced superior frontal volume and lower FA in left ILF. Importantly, frontal brain volumes and integrity of the ILF were identified as the structural correlates of functional capacity in FEP, controlling for other relevant factors. These findings enhance mechanistic understanding of functional capacity deficits in schizophrenia by specifying the underlying neural correlates. In future, this could help inform intervention strategies.

Development and Evaluation of a Visual Remediation Intervention for People with Schizophrenia

It is now well documented that schizophrenia is associated with impairments in visual processing at all levels of vision, and that these disturbances are related to deficits in multiple higher-level cognitive and social cognitive functions. Visual remediation methods have been slow to appear in the literature as a potential treatment strategy to target these impairments, however, in contrast to interventions that aim to improve auditory and higher cognitive functions in schizophrenia. In this report, we describe a National Institute of Mental Health (NIMH)-funded R61/R33 grant that uses a phased approach to optimize and evaluate a novel visual remediation intervention for people with schizophrenia. The goals of this project are: (1) in the R61 phase, to establish the optimal components and dose (number of sessions) of a visual remediation intervention from among two specific visual training strategies (and their combination) for improving low and mid-level visual functions in schizophrenia; and (2) in the R33 phase, to determine the extent to which the optimal intervention improves not only visual processing but also higher-level cognitive and role functions. Here we present the scientific background for and innovation of the study, along with our methods, hypotheses, and preliminary data. The results of this study will help determine the utility of this novel intervention approach for targeting visual perceptual, cognitive, and functional impairments in schizophrenia.

Predictive factors of functional capacity and real-world functioning in patients with schizophrenia

Purpose

This study was performed to identify the predictive factors of functional capacity assessed by the Spanish University of California Performance Skills Assessment (Sp-UPSA) and real-world functioning assessed by the Spanish Personal and Social Performance scale (PSP) in outpatients with schizophrenia.

Methods

Naturalistic, 6-month follow-up, multicentre, validation study. Here, we report data on 139 patients with schizophrenia at their baseline visit. Assessment: Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression-Severity (CGI-S), Sp-UPSA and PSP. Statistics: Pearson's correlation coefficient (r) was used to determine the relationships between variables, and multivariable stepwise linear regression analyses to identify predictive variables of Sp-UPSA and PSP total scores.

Results

Functional capacity: scores on the PSP and PANSS-GP entered first and second at P < 0.0001 and accounted for 21% of variance (R2 = 0.208, model df = 2, F = 15.724, P < 0.0001). Real-world functioning: scores on the CGI-S (B = −5.406), PANSS-N (B = −0.657) and Sp-UPSA (B = 0.230) entered first, second and third, and accounted for 51% of variance (model df = 3, F = 37.741, P < 0.0001).

Conclusion

In patients with schizophrenia, functional capacity and real-world functioning are two related but different constructs. Each one predicts the other along with other factors; general psychopathology for functional capacity, and severity of the illness and negative symptoms for real-world functioning. These findings have important clinical implications: (1) both types of functioning should be assessed in patients with schizophrenia and (2) strategies for improving them should be different.

Using self-reported vocational functioning measures to identify employed patients with impaired functional capacity in major depressive disorder

BACKGROUND

Patients with major depressive disorder (MDD) show impairments in cognitive functioning, including deficits on performance-based measures of functional capacity. A proportion of patients with MDD may achieve higher scores at baseline, and may not show a detectable response to treatment. How to identify these cases is the goal of this investigation.

METHODS

Retrospective analyses of data from the CONNECT study with vortioxetine were performed to determine whether the Work Limitations Questionnaire (WLQ) can be used to exclude very high-performing patients on the functional capacity outcome measure, University of California San Diego Performance-Based Skills Assessment (UPSA), in studies evaluating cognitive function impairment in MDD, to identify those with greater potential for treatment response. The post-hoc analyses included data on cognitive function assessed with a Digit Symbol Substitution Test (DSST) from vortioxetine-treated patients.

RESULTS

WLQ score >13 identified patients with greater impairments in UPSA-Brief (UPSA-B). Patients with WLQ scores >13, but not with scores ≤13, showed statistically significant improvements with vortioxetine treatment in UPSA-B and DSST compared with placebo.

LIMITATIONS

Study limitations include small sample size and use of post-hoc analyses. The generalizability of this analysis is limited to working patients with MDD.

CONCLUSIONS

The WLQ can be used to identify patients with MDD with high potential for treatment response in studies evaluating cognitive function impairment while excluding patients likely to achieve ceiling scores on UPSA. This approach helps identify higher performers on potential outcomes measures without biasing the study by requiring a specific UPSA cutoff score for eligible participants.

Long-acting atypical antipsychotics in schizophrenia: A systematic review and meta-analyses of effects on functional outcome

OBJECTIVE

Impairment in psychosocial function is common in schizophrenia. Long-acting injectable atypical antipsychotics are thought to enhance psychosocial function by boosting adherence. However, no systematic review has examined the effects of long-acting injectable atypical antipsychotics on psychosocial function in clinical trials.

METHODS

We searched major databases including Medline/PubMed, PsychINFO, EMBASE, CINAHL, Scopus, Web of Science, Cochrane Central Register of Controlled Trials and Clinical Trial Registries for randomised controlled trials that compared long-acting injectable atypical antipsychotics to placebo, oral antipsychotic medications or long-acting injectable atypical antipsychotics for all years till 2018, with no language limits. We performed a systematic review of findings on change in psychosocial function and its predictors in the included reports. Data on change in psychosocial functioning were meta-analysed using a random-effects model.

RESULTS

A total of 26 studies were included in systematic review, and 19 studies with 8616 adults, 68.1% males were meta-analysed. Long-acting injectable atypical antipsychotics were superior to placebo (standardised mean difference = 0.39; 95% confidence interval = [0.32, 0.47]; p < 0.001; I² = 0%; 9 studies) and oral antipsychotic medications (standardised mean difference = 0.16; 95% confidence interval = [0.01, 0.31]; p = 0.04; I² = 77%; 10 studies) for improved psychosocial function and superiority was maintained in short- and long trials. Poor psychosocial function was predicted by longer treatment duration, severe symptoms, poor cognition and poor insight. Functioning was assessed by either a single or a combination of measures, but was not the primary outcome in most studies. Other sources of bias include poor blinding and reporting of randomisation.

CONCLUSION

Long-acting injectable atypical antipsychotics are beneficial for recovery of psychosocial function in comparison with placebo, but the magnitude of superiority over oral antipsychotic treatment was small. Severe psychopathology at baseline predicted poor psychosocial function. Future effectiveness trials in which post-randomisation involvement is kept to a minimum, and psychosocial function is included as primary outcome a priori, are needed to capture the real-world impact of long-acting injectable atypical antipsychotics and to address methodological biases.

Temporal Stability of Cognitive Functioning and Functional Capacity in Women with Posttraumatic Stress Disorder

OBJECTIVE

In addition to clinical symptoms, patients with posttraumatic stress disorder (PTSD) often experience considerable disability and may evidence minor impairments in performance on measures of cognition and functional capacity (FC). The objective of the present study was to determine if cognitive and functional skills manifest temporal stability as observed in other neuropsychiatric conditions in the presence of greater fluctuations in clinical symptoms.

METHOD

Assessments of cognition, FC, and clinical symptoms were conducted over two time points as part of a pre- and post-treatment assessment in a placebo-controlled clinical trial in 96 women with PTSD. The goal of these analyses was to examine the relative stability of scores and intercorrelations of measures of cognition, FC, and clinical symptoms.

RESULTS

Cognitive and FC performance manifested considerably greater cross-temporal stability compared to clinical symptoms. FC performance did not change over time. Similar to previous findings in patients with schizophrenia and bipolar disorder measures of symptoms and self-reported disability did not correlate with measures of functional skills or cognitive performance.

CONCLUSIONS

Cognitive performance and functional capacity were temporally stable in women with PTSD. In contrast, clinical symptoms had much more cross-temporal fluctuation. Self-reported disability was correlated with current symptomatology but unrelated to objective measures of performance. Similar to other neuropsychiatric conditions, mood symptoms likely influence estimates of current level of functioning more than cognitive or functional skills.

Validation of the University of California San Diego Performance-based Skills Assessment (UPSA) in major depressive disorder: Replication and extension of initial findings

BACKGROUND

The University of California San Diego Performance-based Skills Assessment (UPSA) has been validated as a functional measure in patients with major depressive disorder (MDD). The study herein aims to both replicate and extend the initial validation incorporating data sets from two additional studies.

METHODS

NCT02279966 and NCT02272517 were multinational, double-blind, placebo-controlled studies in adult outpatients with moderate-to-severe MDD and a current major depressive episode of ≥3 months and less than 1 year, respectively. Subjects were randomized to vortioxetine (10 or 20 mg), placebo or active reference drug (paroxetine [20 mg], or escitalopram [10 or 20 mg]) for 8 weeks. Pearson correlation coefficients were estimated for baseline UPSA-Brief (UPSA-B), demographic/disease characteristics, Montgomery-Åsberg Depression Rating Scale (MADRS), Perceived Deficit Questionnaire-20 items (PDQ-20), and Digit Symbol Substitution Test (DSST), to examine construct validity. Distribution- and anchor-based methods examined clinically important difference (CID) threshold. A pooled analysis with data from NCT01564862 (initial validation study) was performed to increase the statistical power of the estimations.

RESULTS

In pooled analysis of the two new studies, UPSA-B score correlated with the DSST (r = 0.32, P < 0.0001), but not the MADRS (r = -0.07, p = 0.302) or the PDQ-20 (r = -0.10, p = 0.109), replicating initial validation results. Estimated CID range was 7.1-11.2 and 5.5-6.1 points for anchor- and distribution-based methods, respectively. In pooled analyses of all three studies, the CID was 7.0 and 6.4 for anchor- and distribution-based methods, respectively.

CONCLUSIONS

These results confirm the construct validity of UPSA for assessing functional capacity in patients with MDD. Estimated CID using UPSA is approximately 6-7 points.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01564862; NCT02272517; NCT02279966.

Social inclusion among mental health service users: A reliability test of the Mini-SCOPE Scale

AIM AND OBJECTIVES

To evaluate the reliability of the Mini-SCOPE scale through interitem consistency and test-retest consistency, as well as the initial correlation with outcome measures of recovery.

BACKGROUND

Adapted from a UK, Social and Communities Opportunities Profile (Mini-SCOPE) is a short version of an social inclusion measurement for English-speaking persons in recovery (PIR) in Singapore. Prior concept mapping sets the stage for this reliability study.

DESIGN

This study adopted a nonexperimental, pre- and postdesign to validate the psychosocial measurement tool for community services.

METHOD

Convenient sampling was conducted at the various designated clinics. A total of 170 voluntary participants from psychiatric outpatient clinics were recruited for this study. It evaluated the 4-week interval test-retest reliability of the Mini-SCOPE. "AGREE" equator checklist was completed to guide the reporting of clinical practice. "See Supporting Information File S1."

RESULT

Outcome demonstrated that the Mini-SCOPE scale has good strength of reliability.

CONCLUSION

This study showed that the Mini-SCOPE measurement has the potential to be used for programme evaluation in mental health settings.

RELEVANCE TO CLINICAL PRACTICE

Applicable to nurses and other mental health professionals to consider the social and wellness aspects of the patients in their care when planning appropriate services.

Clinical evaluation of functional capacity in treatment resistant schizophrenia patients: Comparison and differences with non-resistant schizophrenia patients

Treatment resistant schizophrenia (TRS) is defined by poor or non-response to conventional antipsychotic agents. Functional capacity is defined as the baseline potential of a patient to function in the community, irrespective of actual achievements gained, and has never been studied in TRS. Here, we screened 182 patients with psychotic symptoms and separated them in TRS (n = 28) and non-TRS (n = 32) ones, to evaluate whether they exhibited differential extents and predictive clinical variables of functional capacity. Functional capacity was measured by the UCSD Performance-Based Skills Assessment (UPSA). Psychotic symptoms by PANSS, social functioning by PSP and SLOF, clinical severity of the illness, cognitive functioning, and neurological soft signs (NSS) were assessed. TRS patients had non-significant lower UPSA scores compared to non-TRS (t-test: p > 0.05). In TRS, UPSA score correlated with multiple clinical variables. The highest effect sizes were observed for PANSS negative score (r = -0.67, p < 0.005); SLOF Area1 score (r = 0.66, p < 0.005); NSS severity (r = -0.61, p < 0.005). Multivariate analysis showed that main predictors of UPSA score in TRS patients were PANSS negative score, education years, NSS, Problem Solving performances, and PSP score (F = 11.12, R² = 0.75, p < 0.0005). These variables were not predictive of UPSA score in non-TRS patients. Hierarchical analysis found that variance in UPSA score mainly depended on negative symptoms, NSS, and problem solving (F = 15.21, R² = 0.65, p < 0.0005). Path analysis individuated two separate paths to UPSA score. These results delineate a limited and independent group of candidate predictors to be putatively accounted for therapeutic interventions to improve functional capacity, and possibly social functioning, in TRS patients.

A systematic review of a functional assessment Tool: UCSD Performance-based skill assessment (UPSA)

Performance based assessment instruments have been employed in functional capacity measurement of mental disorders. The aim of this systematic review was to identify the psychometric properties of the UCSD Performance-based Skill Assessment (UPSA). A search was conducted using the PRISMA protocol and 'UPSA' as key word term on electronic databases, with a date range for articles published from 2001-2017. Published studies involving community-dwelling adults were included. Pharmacological and/or clinical interventions involving clinical outcomes and/or institutionalized samples were excluded. Data related to construct validity, test-retest reliability and sensitivity/specificity were extracted, summarized and analyzed according to UPSA versions and psychiatric disorders. Fifty-eight studies including 8782 Community-dwelling adults met selection criteria. Data supporting the construct and known-groups validity were extracted from 41 studies involving Schizophrenia and schizoaffective disorders and 17 studies involving other metal illness. The UPSA was culturally adapted to 8 different languages and employed in 17 countries. Few studies reported sensitivity and specificity and the cut-off points could not be generalized. Moderate to strong evidence of construct validity and test-retest reliability was found. Few studies proposed cut-off points. The UPSA showed good psychometric properties in different versions including those culturally adapted.

Functional competence in major depressive disorder: Objective performance and subjective perceptions

BACKGROUND

Major depressive disorder (MDD) is increasingly recognized as a disorder of everyday functioning. Multi-level approaches to investigating functioning have been employed in other conditions whereby competence (ability to perform living skills) is distinguished from real-world functioning, but not yet in MDD. We used a multidimensional (adaptive and interpersonal), multi-level (competence and performance) approach to investigate differences between those with MDD and healthy comparisons (HC) on measures of competence, functional disability, and self-perceived competence.

METHODS

Between-group analysis of variance identified differences between MDD (n = 42) and HC (n = 24). Moderation analysis determined whether the strength of the relationship between competence accuracy and self-perception of performance was related to group membership.

RESULTS

In adaptive and interpersonal domains, the MDD group performed significantly lower on competence tasks, endorsed greater functional disability, and reported lower self-perception of competence. Group membership did not moderate the relationship between competence and self-perceived competence in the adaptive domain. Significant moderation was observed in the interpersonal domain such that competence and self-perception of abilities converged in the HC, but not MDD, group.

LIMITATIONS

A cross-sectional design precluded the ability to interpret causality of results. Functional disability was measured by interview, thereby susceptible to biases in self-report.

CONCLUSIONS

A multi-level approach to assessing functioning in MDD was supported. Performance-based measures of functional competence are sensitive to MDD and useful for research trials and clinical work to objectively track everyday living skills. Objective measurement is further supported, as those with depression are less likely to accurately evaluate their own abilities, even after demonstrating skills.

Vortioxetine improves symptomatic and functional outcomes in major depressive disorder: A novel dual outcome measure in depressive disorders

BACKGROUND

With symptomatic remission and functional recovery as the overarching therapeutic objectives of antidepressant therapy, composite endpoint measures that conjointly consider both aspects of treatment are needed. This analysis evaluated the combined effect of vortioxetine on depressive symptoms and functional capacity in adults with MDD.

METHODS

NCT01564862, a multinational, double-blind, placebo-controlled, duloxetine-referenced study, conducted between April 2012 and February 2014, in 602 adult outpatients (18-65 years) with moderate-to-severe MDD (Montgomery-Åsberg Depression Rating Scale (MADRS) ≥ 26), a major depressive episode of ≥ 3 months' duration, and self-reported cognitive symptoms were randomized to once-daily vortioxetine (10 or 20mg), duloxetine (60mg), or placebo for 8 weeks. Assessments included the University of California San Diego Performance-based Skills Assessment (UPSA) and the MADRS. Two versions of UPSA were utilized; UPSA ‒Validation of Intermediate Measures and UPSA Brief form. An aligned UPSA-B (communication and finance items) was examined for sensitivity analysis. Efficacy was analyzed versus placebo according to the dual response (change from baseline in UPSA ≥ 7 and ≥ 9 and reduction in MADRS total score from baseline ≥ 50%).

RESULTS

Significantly more vortioxetine-treated patients were classified as dual responders for change in MADRS total score and UPSA score of ≥ 7 (clinically important difference [CID]) (27.4% vs 14.5%; P = 0.004), and change above CID (≥ 9) (23.4% vs 13.9%; P = 0.025). Duloxetine did not differ significantly from placebo for these dual response criteria. Sensitivity analysis using the aligned UPSA-B confirmed these results for vortioxetine.

LIMITATIONS

An exploratory analysis of a new dual outcome measure in patients with MDD.

CONCLUSIONS

Vortioxetine, but not duloxetine, demonstrated a robust combined effect on depressive symptoms and functional capacity in patients with MDD.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01564862; European Clinical Trials Database [EudraCT] Number 2011-005298-22.

Exploratory analysis of normative performance on the UCSD Performance-Based Skills Assessment-Brief

The UCSD Performance-Based Skills Assessment (UPSA) is a performance-based measure of functional capacity. The brief, two-domain (finance and communication ability) version of the assessment (UPSA-B) is now widely used in both clinical research and treatment trials. To date, research has not examined possible demographic-UPSA-B relationships within a non-psychiatric population. We aimed to produce and describe preliminary normative scores for the UPSA-B over a full range of ages and educational attainment. The finance and communication subscales of the UPSA were administered to 190 healthy participants in the context of three separate studies. These data were combined to examine the effects of age, sex, and educational attainment on the UPSA-B domain and total scores. Fractional polynomial regression was used to compute demographically-corrected T-scores for the UPSA-B total score, and percentile rank conversion was used for the two subscales. Age and education both had significant non-linear effects on the UPSA-B total score. The finance subscale was significantly related to both gender and years of education, whereas the communication subscale was not significantly related to any of the demographic characteristics. Demographically corrected T-scores and percentile ranks for UPSA-B scores are now available for use in clinical research.

Predictors of current functioning and functional decline in schizophrenia

Positive, negative, and cognitive symptoms of schizophrenia may affect functional outcomes. However, these factors alone do not account for a large percentage of variance in outcomes. We investigated demographic, cognitive, symptom, and functional capacity predictors of current functional status in 280 outpatients with schizophrenia or schizoaffective disorder. Functional decline over the lifespan was also examined in a subset of participants. Stepwise regressions modeled predictors of current functional status and functional decline as measured by the Assessment of Lifespan Functioning Attainment (ALFA). ALFA functional domains included paid employment, independence in living situation, romantic relationships, close friendships, and recreational engagement. More severe depressive symptoms were consistently associated with worse current community integration (lower levels of close friendships and recreational engagement). Better working memory performance was associated with higher rates of current paid employment. There were no consistent modifiable predictors of decline in functioning, but women reported less functional decline in the domains of employment and close friendships than men. Better cognitive performance was associated with less decline in living independence and romantic relationships, but more decline in paid employment and recreational engagement. Increased assessment and treatment of comorbid depressive symptoms may improve functional outcomes in people with schizophrenia.

Everyday functional ability in HIV and methamphetamine dependence

BACKGROUND

Methamphetamine (METH) use is a risk factor for the transmission of HIV. Each is associated with neurocognitive impairment and subsequent problems in everyday functioning, yet additive effects of HIV and METH are not consistently observed. This study used the UCSD Performance-Based Skills Assessment (UPSA-2) to assess whether METH use disorder and HIV together resulted in poorer functional outcome than either condition alone.

METHOD

Participants in the Translational Methamphetamine AIDS Research Center (TMARC) cohort were stratified based upon HIV infection and METH use disorder: HIV-/METH- (n=49), HIV-/METH+ (n=48), HIV+/METH- (n=37), and HIV+/METH+ (n=38). They were administered the UPSA-2 which measures abilities in six domains of everyday functioning. Main effects and interactions of HIV and METH were examined, as were relationships between UPSA-2 scores and disease characteristics.

RESULTS

Significant HIV-by-METH interactions were observed for the UPSA-2 total score and Comprehension/Planning and Financial subscales such that METH was associated with lower scores in HIV- participants but not HIV+ participants. METH was associated with lower scores on the Communications subscale. All three risk groups had lower scores than HIV-/METH- participants. Recency and frequency of METH use were associated with lower scores. Lower Medication Management scores were related to lower nadir CD4 counts.

CONCLUSIONS

METH use disorder and HIV each impair functional performance, but there is no additive effect when the two conditions occur together. The neurocognitive sequelae of combined HIV infection and METH use are complex and warrant further study, as do the potential effects of compensatory strategies and other factors.

Determination of a clinically important difference and definition of a responder threshold for the UCSD performance-based skills assessment (UPSA) in patients with major depressive disorder

BACKGROUND

This article reports an evaluation of the psychometric properties and clinically important difference (CID) threshold of the UCSD Performance-Based Skills Assessment (UPSA) in major depressive disorder (MDD), using data from a large-scale study of the effects of vortioxetine on cognitive functioning and functional capacity in MDD patients.

METHODS

Adults with moderate-to-severe recurrent MDD and self-reported cognitive dysfunction were randomized to 8 weeks of double-blind treatment with vortioxetine 10/20mg QD (flexible), duloxetine 60mg QD, or placebo. Pearson correlation coefficients were calculated between UPSA composite score and demographic/disease characteristics at baseline to examine construct validity. Two methods (distribution-based and anchor-based) were used to establish a CID threshold.

RESULTS

A total of 602 patients were randomized; 528 comprised the full analysis set. For the entire sample mean UPSA composite scores were 77.8 at baseline and 83.9 at week 8 (mean change, +6.1). As hypothesized, at baseline, the UPSA composite score correlated with cognitive functioning (Digit Symbol Substitution Test: r=0.36, P<0.001) and workplace productivity (Work Limitations Questionnaire: r=-0.17, P=0.008), but not depressive symptoms (Montgomery-Åsberg Depression Rating Scale: r=0.02, P=0.707) or subjective cognitive dysfunction (Perceived Deficits Questionnaire: r=-0.02, P=0.698).

LIMITATIONS

Two versions of the UPSA were used and no inclusion/exclusion criteria were based on the UPSA.

CONCLUSIONS

These results support the construct validity of UPSA for assessing functional capacity independent of mood symptoms. The estimated CID for changes in UPSA scores was quite consistent at +6.4 points and +6.7 based on distribution-based and anchor-based methods, respectively.

Validation of the tablet-administered Brief Assessment of Cognition (BAC App)

Computerized tests benefit from automated scoring procedures and standardized administration instructions. These methods can reduce the potential for rater error. However, especially in patients with severe mental illnesses, the equivalency of traditional and tablet-based tests cannot be assumed. The Brief Assessment of Cognition in Schizophrenia (BACS) is a pen-and-paper cognitive assessment tool that has been used in hundreds of research studies and clinical trials, and has normative data available for generating age- and gender-corrected standardized scores. A tablet-based version of the BACS called the BAC App has been developed. This study compared performance on the BACS and the BAC App in patients with schizophrenia and healthy controls. Test equivalency was assessed, and the applicability of paper-based normative data was evaluated. Results demonstrated the distributions of standardized composite scores for the tablet-based BAC App and the pen-and-paper BACS were indistinguishable, and the between-methods mean differences were not statistically significant. The discrimination between patients and controls was similarly robust. The between-methods correlations for individual measures in patients were r>0.70 for most subtests. When data from the Token Motor Test was omitted, the between-methods correlation of composite scores was r=0.88 (df=48; p<0.001) in healthy controls and r=0.89 (df=46; p<0.001) in patients, consistent with the test-retest reliability of each measure. Taken together, results indicate that the tablet-based BAC App generates results consistent with the traditional pen-and-paper BACS, and support the notion that the BAC App is appropriate for use in clinical trials and clinical practice.

Improving Theory of Mind in Schizophrenia by Targeting Cognition and Metacognition with Computerized Cognitive Remediation: A Multiple Case Study

Schizophrenia is associated with deficits in theory of mind (ToM) (i.e., the ability to infer the mental states of others) and cognition. Associations have often been reported between cognition and ToM, and ToM mediates the relationship between impaired cognition and impaired functioning in schizophrenia. Given that cognitive deficits could act as a limiting factor for ToM, this study investigated whether a cognitive remediation therapy (CRT) that targets nonsocial cognition and metacognition could improve ToM in schizophrenia. Four men with schizophrenia received CRT. Assessments of ToM, cognition, and metacognition were conducted at baseline and posttreatment as well as three months and 1 year later. Two patients reached a significant improvement in ToM immediately after treatment whereas at three months after treatment all four cases reached a significant improvement, which was maintained through 1 year after treatment for all three cases that remained in the study. Improvements in ToM were accompanied by significant improvements in the most severely impaired cognitive functions at baseline or by improvements in metacognition. This study establishes that a CRT program that does not explicitly target social abilities can improve ToM.

Cognitive Function as a Transdiagnostic Treatment Target in Stimulant Use Disorders

Stimulant use disorder is an important public health problem, with an estimated 2.1 million current users in the United States alone. No pharmacological treatments are approved by the U.S. Food and Drug Administration for stimulant use disorder and behavioral treatments have variable efficacy and limited availability. Most individuals with stimulant use disorder have other comorbidities, most with overlapping symptoms and cognitive impairments. The goal of this article is to present a rationale for cognition as a treatment target in stimulant use disorder and to outline potential treatment approaches. Rates of lifetime comorbid psychiatric disorders among people with stimulant use disorders are estimated at 65% to 73%, with the most common being mood disorders (13% to 64%) and anxiety disorders (21% to 50%), as well as non-substance-induced psychotic disorders (<10%). There are several models of addictive behavior, but the dual process model particularly highlights the relevance of cognitive impairments and biases to the development and maintenance of addiction. This model explains addictive behavior as a balance between automatic processes and executive control, which in turn are related to individual (genetics, comorbid disorders, psychosocial factors) and other (craving, triggers, drug use) factors. Certain cognitive impairments, such as attentional bias and approach bias, are most relevant to automatic processes, while sustained attention, response inhibition, and working memory are primarily related to executive control. These cognitive impairments and biases are also common in disorders frequently comorbid with stimulant use disorder and predict poor treatment retention and clinical outcomes. As such, they may serve as feasible transdiagnostic treatment targets. There are promising pharmacological, cognitive, and behavioral approaches that aim to enhance cognitive function. Pharmacotherapies target cognitive impairments associated with executive control and include cholinesterase inhibitors (e.g., galantamine, rivastigmine) and monoamine transporter inhibitors (e.g., modafinil, methylphenidate). Cognitive behavioral therapy and cognitive rehabilitation also enhance executive control, while cognitive bias modification targets impairments associated with automatic processes. Cognitive enhancement to improve treatment outcomes is a novel and promising strategy, but its clinical value for the treatment of stimulant use disorder, with or without other psychiatric comorbidities, remains to be determined in future studies.

Report on ISCTM Consensus Meeting on Clinical Assessment of Response to Treatment of Cognitive Impairment in Schizophrenia

If treatments for cognitive impairment are to be utilized successfully, clinicians must be able to determine whether they are effective and which patients should receive them. In order to develop consensus on these issues, the International Society for CNS Clinical Trials and Methodology (ISCTM) held a meeting of experts on March 20, 2014, in Washington, DC. Consensus was reached on several important issues. Cognitive impairment and functional disability were viewed as equally important treatment targets. The group supported the notion that sufficient data are not available to exclude patients from available treatments on the basis of age, severity of cognitive impairment, severity of positive symptoms, or the potential to benefit functionally from treatment. The group reached consensus that cognitive remediation is likely to provide substantial benefits in combination with procognitive medications, although a substantial minority believed that medications can be administered without nonpharmacological therapy. There was little consensus on the best methods for assessing cognitive change in clinical practice. Some participants supported the view that performance-based measures are essential for measurement of cognitive change; others pointed to their cost and time requirements as evidence of impracticality. Interview-based measures of cognitive and functional change were viewed as more practical, but lacking validity without informant involvement or frequent contact from clinicians. The lack of consensus on assessment methods was viewed as attributable to differences in experience and education among key stakeholders and significant gaps in available empirical data. Research on the reliability, validity, sensitivity, and practicality of competing methods will facilitate consensus.

Assessment of Lifespan Functioning Attainment (ALFA) scale: A quantitative interview for self-reported current and functional decline in schizophrenia

Schizophrenia has been characterized as a disorder with poor outcomes across various functional domains, especially social and occupational functioning. Although these outcomes have been investigated based on patients' current functioning, few studies have considered the assessment of functional outcomes across the lifespan in schizophrenia. We developed a novel and brief scale of adulthood lifespan functioning, the Assessment of Lifespan Functioning Attainment (ALFA). We assessed current functioning and percentage of pre- and post-psychosis onset engagement for five functional domains including paid employment, living independently, romantic partnerships, close friendships, and recreational engagement with others. Pre-to post-psychosis functional decline was observed for all domains, with paid employment having the greatest decline (d = 2.68) and living independently having the least decline (d = .59). Our exploratory factor analysis suggests that a single factor accounted for the most variance in Pre-Psychosis Functioning in ALFA domains. Two factors explain the majority of variance in Post-Psychosis Functioning and Pre-to-Post Psychosis Decline: a sociability factor (close friendships and recreational engagement with others) and an independence factor (paid employment, living independently, romantic relationships). To our knowledge, this is the first study to report on a self-reported quantitative assessment of adult lifespan functioning in schizophrenia. The ALFA scale may be a useful tool for future research on functional outcomes in schizophrenia.

Dual-Task Performance Involving Hand Dexterity and Cognitive Tasks and Daily Functioning in People With Schizophrenia: A Pilot Study

OBJECTIVE. This study investigated separate and concurrent performance on cognitive and hand dexterity tasks and the relationship to daily functioning in 16 people with schizophrenia and 16 healthy control participants.

METHOD. Participants performed the Purdue Pegboard Test and the Serial Seven Subtraction Test under single- and dual-task conditions and completed two daily functioning evaluations.

RESULTS. The hand dexterity of all participants declined in the dual-task condition, but the discrepancy between single-task and dual-task hand dexterity was greater in the schizophrenia group than in the control group (p &lt; .03, d &gt; .70, for all). The extent of discrepancy in hand dexterity was negatively correlated with daily functioning in the schizophrenia group (rs = −.3 to −.5, ps = .04–.26).

CONCLUSION. Ability to perform dual tasks may be an indicator of daily functioning in people with schizophrenia. Use of dual-task training may be considered as a therapeutic activity with these clients.

The impact of aging, cognition, and symptoms on functional competence in individuals with schizophrenia across the lifespan

OBJECTIVE

Life expectancy in individuals with schizophrenia continues to increase. It is not clear whether cognitive deficits associated with schizophrenia remain as strong predictors of function in older and younger individuals. Thus, we assessed the relationship between cognition and functional competence in individuals with schizophrenia across 7 decades of life.

METHODS

We analyzed data obtained in 232 community-dwelling participants with schizophrenia (age range: 19-79 years). Cognition was assessed using the Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery. Functional competence was assessed using the UCSD Performance-based Skills Assessment, which includes measures of Comprehension and Planning of Recreational Activities Skills, Financial Skills, Communication Skills, Transportation Skills, and Household Management Skills. To assess the effects of Global Cognition on functional competence, we performed hierarchical multivariate linear or logistic regression analyses controlling for age, education, gender, and negative symptoms.

RESULTS

Participants' mean age was 49.1 (SD = 13.2, range = 19-79 years), 161 (69%) were male, and 55 (24%) were aged ≥60. Global Cognition was a predictor of Comprehension and Planning Skills (Exp(β) = 1.048), Financial Skills (Exp(β) = 1.104), Communication Skills (ΔR (2) = .31) and Transportation Skills (Exp(β) = 1.066), but not Household Management Skills after adjusting for age, education, gender, and negative symptoms of schizophrenia.

CONCLUSION

Cognition remains a strong predictor of functional competence across the lifespan. These findings suggest that treating cognitive impairment associated with schizophrenia could improve individuals' function independent of their age.

UCSD Performance-Based Skills Assessment (UPSA): validation of a Brazilian version in patients with schizophrenia

The UCSD Performance-based Skills Assessment (UPSA) is a measure of Functional Capacity and assesses skills involved in community tasks. It has good psychometrics properties, and is currently recommended as a co-primary assessment of cognition in the MATRICS Project. To our knowledge so far, there are no studies in western developing countries concerning Functional Capacity in Schizophrenia. The aims of this study were to translate, culturally adapt and validate the UPSA to assess Functional Capacity in community-dwelling patients with Schizophrenia living in Brazil. Eighty-two subjects (52 patients, 30 controls) were evaluated using: the Brazilian version of the UPSA (UPSA-1-BR), PANSS, Personal and Social Performance (PSP) and Global Assessment of Functioning (GAF). In the reliability test, UPSA-1-BR showed good Internal Consistency (Cronbach’s alpha of 0.88) and strong correlation between test and retest (4-month gap; r = 0.91; p < 0.01). Spearman’s rho values showed a moderate correlation between UPSA-1-BR and both PSP (0.50; p < 0.01) and GAF (0.46; p < 0.01) scores. UPSA-1-BR is capable of differentiating people with and without Schizophrenia. Patients scored lower than controls (58.9 versus 79.1), with an AUC of 0.79 (95%IC: 0.69–0.89). Sensitivity and specificity values of 0.71 and 0.70, respectively, were found in the cut-off point of 73.5, for separation of patients and controls, with predictive values of 80% (positive) and 58% (negative). UPSA-B-BR was also evaluated. UPSA-1-BR and its brief version presented adequate psychometric properties and proved to be valid and reliable instruments in the assessment of Functional Capacity in subjects with Schizophrenia.

Brief report: suitability of the Social Skills Performance Assessment (SSPA) for the assessment of social skills in adults with autism spectrum disorders

The present study aims at examining whether the 'Social Skills Performance Assessment' (SSPA; Patterson et al. in Schizophr Res 48(2-3):351-360, 2001) is a suitable performance-based measure to assess social skills in adults with autism spectrum disorders (ASD). For this purpose, social skills of individuals with ASD and non-ASD participants were assessed through the SSPA role plays. Results of this study suggest that the SSPA is suitable for the assessment of social skills in adults with ASD. The SSPA discriminates between individuals with ASD and non-ASD individuals, with the ASD group scoring significantly lower. Although no evidence was found for convergent validity of the SSPA in participants with ASD, divergent validity of the SSPA and interrater reliability among adults with ASD were good.

Utility of the UCSD Performance-based Skills Assessment-Brief Japanese version: discriminative ability and relation to neurocognition

The UCSD Performance-based Skills Assessment Brief (the UPSA-B) has been widely used for evaluating functional capacity in patients with schizophrenia. The utility of the battery in a wide range of cultural contexts has been of concern among developers. The current study investigated the validity of the Japanese version of the UPSA-B as a measure of functional capacity and as a co-primary for neurocognion. Sixty-four Japanese patients with schizophrenia and 83 healthy adults entered the study. The Japanese version of the UPSA-B (UPSA-B Japanese version) and the MATRICS Cognitive Consensus Battery Japanese version (MCCB Japanese version) were administered. Normal controls performed significantly better than patients, with large effect sizes for the Total and the subscale scores of the UPSA-B. Receiver Operating Characteristic (ROC) curve analysis revealed that the optimal cut-off point for the UPSA-B Total score was estimated at around 80. The UPSA-B Total score was significantly correlated with the MCCB Composite score and several domain scores, indicating the relationship between this co-primary measure and overall cognitive functioning in Japanese patients with schizophrenia. The results obtained here suggest that the UPSA-B Japanese version is an effective tool for evaluating disturbances of daily-living skills linked to cognitive functioning in schizophrenia, providing an identifiable cut-off point and relationships to neurocognition. Further research is warranted to evaluate the psychometrical properties and response to treatment of the Japanese version of the UPSA-B.

Testing trait depression as a potential clinical domain in schizophrenia

The DSM-5 includes depression as a dimension of psychosis. We tested whether persistent experience of depression, called 'trait depression', is a clinical feature separate from psychosis and several well-known, trait-like deficits of schizophrenia. 126 individuals with schizophrenia and 151 control participants completed the Maryland Trait and State Depression questionnaire, with a subset completing measures of cognition and functional capacity, and diffusion tensor imaging (n=73 patients and 102 controls for imaging analysis). Subjectively experienced, longitudinal trait depression is significantly higher in patients with schizophrenia compared with controls. Higher trait depression scores were associated with more severe psychosis. Surprisingly, individuals with higher trait depression manifested less cognitive and global functioning deficits. In addition, trait depression scores were positively associated with fractional anisotropy of white matter. Trait depression appears to be a highly relevant clinical domain in the care of patients with schizophrenia that also has distinct relationships with some other known traits of the disease. Trait depression may be an important contributor to the clinical heterogeneity of schizophrenia.

The effect of language on functional capacity assessment in middle-aged and older US Latinos with schizophrenia

The U.S. Latino population is steadily increasing, prompting a need for cross-cultural outcome measures in schizophrenia research. This study examined the contribution of language to functional assessment in middle-aged Latino patients with schizophrenia by comparing 29 monolingual Spanish-speakers, 29 Latino English-speakers, and 29 non-Latino English-speakers who were matched on relevant demographic variables and who completed cognitive and functional assessments in their native language. There were no statistically significant differences between groups on the four everyday functioning variables (UCSD Performance-Based Skills Assessment [UPSA], Social Skills Performance Assessment [SSPA], Medication Management Ability Assessment [MMAA], and the Global Assessment of Functioning [GAF]). The results support the cross-linguistic and cross-cultural acceptability of these functional assessment instruments. It appears that demographic variables other than language (e.g., age, education) better explain differences in functional assessment among ethnically diverse subpopulations. Considering the influence of these other factors in addition to language on functional assessments will help ensure that measures can be appropriately interpreted among the diverse residents of the United States.

The social cognition psychometric evaluation study: results of the expert survey and RAND panel

BACKGROUND

In schizophrenia, social cognition is strongly linked to functional outcome and is increasingly seen as a viable treatment target. The goal of the Social Cognition Psychometric Evaluation (SCOPE) study is to identify and improve the best existing measures of social cognition so they can be suitably applied in large-scale treatment studies. Initial phases of this project sought to (1) develop consensus on critical domains of social cognition and (2) identify the best existing measures of social cognition for use in treatment studies.

METHODS

Experts in social cognition were invited to nominate key domains of social cognition and the best measures of those domains. Nominations for measures were reduced according to set criteria, and all available psychometric information about these measures was summarized and provided to RAND panelists. Panelists rated the quality of each measure on multiple criteria, and diverging ratings were discussed at the in-person meeting to obtain consensus.

RESULTS

Expert surveys identified 4 core domains of social cognition-emotion processing, social perception, theory of mind/mental state attribution, and attributional style/bias. Using RAND panel consensus ratings, the following measures were selected for further evaluation: Ambiguous Intentions Hostility Questionnaire, Bell Lysaker Emotion Recognition Task, Penn Emotion Recognition Test, Relationships Across Domains, Reading the Mind in the Eyes Test, The Awareness of Social Inferences Test, Hinting Task, and Trustworthiness Task.

DISCUSSION

While it was possible to establish consensus, only a limited amount of psychometric information is currently available for the candidate measures, which underscores the need for well-validated and standardized measures in this area.

Depression, deficits in functional capacity, and impaired glycemic control in urban African Americans with type 2 diabetes

BACKGROUND

Effective depression treatment does not reliably reduce glycosylated hemoglobin (HbA1c) in depressed patients with type 2 diabetes, possibly in part due to deficits in functional capacity, i.e. performance of certain everyday living skills, essential for effective diabetes self-management. We sought to determine: a) the magnitude of deficits in functional capacity among urban, African American (AA) patients with type 2 diabetes, and b) whether these deficits were associated with poorer glycemic control.

METHODS

At their initial visit to an inner-city diabetes clinic, 172 AA patients with type 2 diabetes were assessed with a variety of instruments, including the Mini International Neuropsychiatric Interview (MINI) and the UCSD Performance Skills Assessment-Brief (UPSA-B). They then entered a comprehensive diabetes management intervention, whose success was indexed by HbA1c levels at up to four reassessments over a one-year period. A mixed-effects model repeated-measures method was used to predict HbA1c.

RESULTS

The prevalence of depression was 19%; the mean UPSA-B score was 81 ± 17. After multivariate adjustment, increased HbA1c levels over time were predicted by the presence of major depression (B = .911, p = .002) and decreasing (worse) scores on the UPSA-B (B = -.016, p = .027), respectively. Further adjustment for increasing the dosage of oral or insulin during the treatment eliminated the association between the UPSA score and HbA1c level (B = -.010, p = .115).

CONCLUSIONS

Depression, as well as deficits in functional capacity, predicted reduced effectiveness of a diabetes self-management intervention. Future studies will determine whether interventions targeted at both improve glycemic control.

Everyday functional ability across different phases of bipolar disorder

Bipolar Disorder (BD) is a chronic illness characterized by significant neurocognitive impairment and functional deficits. Functional status is typically assessed with self-report or observer ratings restricted by poor participant insight and subjective judgment, while application of performance-based measures has been limited. We assessed functional ability in manic, depressed, and euthymic BD individuals using the UCSD Performance-Based Skills Assessment (UPSA-2), which simulates real-world tasks such as medication management. UPSA-2 was administered to 17 manic or hypomanic BD, 14 depressed BD, 23 euthymic BD, and 28 healthy comparison (HC) participants matched for age, education, and IQ. Psychopathology was quantified with the Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HDRS), and the Positive and Negative Syndrome Scale (PANSS); executive functioning was assessed with the Wisconsin Card Sorting Task (WCST). All BD groups exhibited functional ability deficits on the UPSA-2 and impaired performance on the WCST compared to HC. UPSA-2 scores were lower in manic/hypomanic subjects relative to other BD participants and mania symptoms correlated with functional impairment. Poor WCST performance was also associated with worse UPSA-2 function. In summary, BD functional deficits occur across different phases of the disorder and may be impacted by symptom severity and associated with executive dysfunction.

Mismatch negativity: translating the potential

The mismatch negativity (MMN) component of the auditory event-related potential has become a valuable tool in cognitive neuroscience. Its reduced size in persons with schizophrenia is of unknown origin but theories proposed include links to problems in experience-dependent plasticity reliant on N-methyl-d-aspartate glutamate receptors. In this review we address the utility of this tool in revealing the nature and time course of problems in perceptual inference in this illness together with its potential for use in translational research testing animal models of schizophrenia-related phenotypes. Specifically, we review the reasons for interest in MMN in schizophrenia, issues pertaining to the measurement of MMN, its use as a vulnerability index for the development of schizophrenia, the pharmacological sensitivity of MMN and the progress in developing animal models of MMN. Within this process we highlight the challenges posed by knowledge gaps pertaining to the tool and the pharmacology of the underlying system.

Validation of a European Spanish-version of the University of California performance Skills Assessment (Sp-UPSA) in patients with schizophrenia and bipolar disorder

AIMS

To validate the Spanish version of the University of California Performance Skills Assessment (UPSA) in patients with severe mental disorders.

METHODS

Naturalistic, 6month follow-up, multicentre, validation study. 139 patients with schizophrenia, 57 bipolar patients and 31 controls were evaluated using the following scales: Spanish UPSA (Sp-UPSA), Clinical Global Impression, Severity (CGI-S), Global Assessment of Functioning (GAF), and Personal and Social Performance (PSP).

RESULTS

Reliability: Internal consistency (Cronbach's alpha) was 0.81 in schizophrenia and 0.58 in bipolar patients. Test-retest was 0.74 and 0.65 (p<0.0001) respectively. Construct validity: Pearson correlation coefficients between Sp-UPSA and PSP total scores were 0.42 (p<0.0001) for schizophrenia and 0.44 (p=0.001) for bipolar patients. For Sp-UPSA and GAF scores correlation coefficients were 0.43 and 0.52 (p<0.0001) respectively. Discriminant validity: The Sp-UPSA discriminated between patients and controls. In schizophrenia patients it also discriminated among different levels of illness severity according to CGI-S scores. In control versus patients with schizophrenia contrasts, the area under the curve was 0.89 and a cut-off point of 85 provided a sensitivity of 82.7% and a specificity of 77.4%. In bipolar patients, the area under the curve was 0.85 and a cut-off point of 90 provided a sensitivity of 82.5% and a specificity of 64.5%.

CONCLUSION

The Spanish UPSA is a reliable and valid instrument for assessing functional capacity in severe mentally ill patients. It seems to be appropriate for use in clinical trials and in everyday clinical practice as a means of monitoring functional outcomes.

The global cognitive impairment in schizophrenia: consistent over decades and around the world

OBJECTIVE

Schizophrenia results in cognitive impairments as well as positive, negative, and disorganized symptomatology. The present study examines the extent to which these cognitive deficits are generalized across domains, potential moderator variables, and whether the pattern of cognitive findings reported in schizophrenia has remained consistent over time and across cultural and geographic variation.

METHOD

Relevant publications from 2006 to 2011 were identified through keyword searches in PubMed and an examination of reference lists. Studies were included if they (1) compared the cognitive performance of adult schizophrenia patients and healthy controls, (2) based schizophrenia diagnoses on contemporary diagnostic criteria, (3) reported information sufficient to permit effect size calculation, (4) were reported in English, and (5) reported data for neuropsychological tests falling into at least 3 distinct cognitive domains. A set of 100 non-overlapping studies was identified, and effect sizes (Hedge's g) were calculated for each cognitive variable.

RESULTS

Consistent with earlier analyses, patients with schizophrenia scored significantly lower than controls across all cognitive tests and domains (grand mean effect size, g=-1.03). Patients showed somewhat larger impairments in the domains of processing speed (g=-1.25) and episodic memory (g=-1.23). Our results also showed few inconsistencies when grouped by geographic region.

CONCLUSIONS

The present study extends findings from 1980 to 2006 of a substantial, generalized cognitive impairment in schizophrenia, demonstrating that this finding has remained robust over time despite changes in assessment instruments and alterations in diagnostic criteria, and that it manifests similarly in different regions of the world despite linguistic and cultural differences.

Factor structure of neurocognition and functional capacity in schizophrenia: a multidimensional examination of temporal stability

Although neurocognition is commonly described in terms of different functional domains, some factor analytic studies have suggested a simpler dimensional structure for neuropsychological (NP) tests in patients with schizophrenia. Standardized tasks of everyday functioning, or tests of "functional capacity" (FC), are viewed differently from traditional NP tests, and are hence used as a co-primary measure in treatment studies. However, FC and NP tests have been found to be highly correlated. In fact, a recent study of ours suggested that performances on these different types of tasks constituted a single latent trait in a cross-sectional analysis. The current study examined the longitudinal factor structure of a combined set of NP and FC tests. Patients with schizophrenia (n = 195) were examined at two assessment occasions separated by periods ranging from 6 weeks to 6 months. Participants were assessed with the MATRICS Consensus Cognitive Battery (MCCB) and two performance-based assessments of FC. A single latent trait was extracted using full information maximum likelihood procedures, and its temporal stability was examined in terms of: stability of the latent trait scores, the inter-correlations of the three indicators of the latent trait, and the stability of loadings for the FC and NP items underlying the latent trait at the two measurement occasions. All indices of temporal stability were confirmed, with stability not related to follow-up duration. Variation in clinical symptoms and treatments across the measurement occasions was negligible. These findings raise the question of whether cognitive abilities measured by NP tests and FC instruments are tapping a single ability construct, which might have shared causal influences as well.

Hospitalization and psychosis: influences on the course of cognition and everyday functioning in people with schizophrenia

Long term institutional stay has decreased markedly in people with schizophrenia, although there are still many individuals with a history of long-term institutional stay residing in the community. In addition, although the average duration of acute admissions for schizophrenia is also decreasing, there are indications that psychotic episodes leading to acute admissions are associated with risk for cognitive and functional declines and changes in brain structure. In this paper we review the literature on cognitive changes with aging and institutionalization in schizophrenia, reaching to the conclusion that the reasons for current chronic institutionalization largely include severe psychosis and aggressive behavior. Thus, these factors may be the operative factor in the age-related declines in cognition and functioning reported in this population. We also present evidence to suggest that these changes may be similar to those seen in younger patients who experience repeated psychotic episodes leading to hospitalization. Our conclusion is that there is minimal evidence that hospitalization, long or short, leads to cognitive and functional changes, but rather that the reason for these hospitalizations may underlie cognitive and functional declines. Prevention of relapse and discovering treatments to assist patients with resistant symptoms may reduce the risk of cognitive and functional declines across the lifespan in people with schizophrenia.

The Canadian Objective Assessment of Life Skills (COALS): a new measure of functional competence in schizophrenia

This study examined the reliability and validity of a new performance-based measure of functional competence for individuals with serious mental illness, the Canadian Objective Assessment of Life Skills (COALS). The COALS assesses both routinized procedural knowledge routines (PKR) and executive operations (EXO) in order to capture functional outcome variance. The COALS was administered to 101 outpatients with schizophrenia and schizoaffective disorder and 80 non-psychiatric controls. One month later, 95 patients and 63 controls completed a follow-up assessment. Measures of psychopathology, neurocognition, functionality and community adjustment were also administered. Results indicated that the COALS summary scores had good test-retest reliability for patient data. Further, the COALS correlated with other measures of functionality and with negative symptoms, but was independent of positive symptoms, demonstrating concurrent and discriminant validity. The overall COALS summary score added incremental validity to the prediction of community independence over and above the contribution of symptoms, intellectual ability and neurocognitive performance. Inclusion of EXO scores provided incremental validity not available with PKR scores alone. The COALS increases the number of functional competence instruments and offers the advantage of specific validity while incorporating important distinctions in cognitive performance.

Cognitive impairments and cancer chemotherapy: translational research at a crossroads

Cancer chemotherapy is often associated with cognitive deficits which may remain after the treatment has ended. As more people survive cancer, concern is increasing about the impact of these problems with memory and executive function when they return to everyday life. When chemotherapeutic drugs are administered to healthy animals in dosing regimens modeling those used in humans, cognitive deficits also occur, and these preclinical studies can provide information about the biological mechanisms by which the cancer fighting drugs affect the brain. Evidence from animal studies points to damage to hippocampus, particularly a disruption of neurogenesis, whereas human studies emphasize cognitive deficits associated with impairments in frontal cortical function. This discrepancy may be due more to the tasks selected by researchers, and the choice of biochemical endpoints than inherently different effects of chemotherapy in humans and rodents. These differences in approach must be reconciled if common underlying mechanisms are to be identified, with the hope of leading to novel drug or non-pharmacological treatments. This may be achieved by broadening the scope of human and animal studies, and by looking outside the topic of chemotherapy-induced cancer deficits to learn from the advances being made by studying the effects of stress and somatic disease on brain function, and the cognitive impairments now recognized to result from a wide range of mental and physical illnesses.

Functional outcomes, functional capacity, and cognitive impairment in schizotypal personality disorder

BACKGROUND

Individuals with schizotypal personality disorder (SPD) exhibit impaired cognitive functioning in a pattern similar to that found in schizophrenia; less clear is the extent to which these individuals also share schizophrenia patients' impairments in functional capacity and real-world functioning.

METHOD

We evaluated 46 SPD patients, as well as 38 individuals with avoidant personality disorder (AvPD) and 55 healthy controls (HC) on: cognitive functioning, real-world functioning (employment and residential status), and functional capacity (indexed by the UPSA, a performance-based skills assessment).

RESULTS

We found that individuals with SPD exhibited worse performance on both the cognitive battery and the UPSA than the other groups; they were also less likely to be employed and to be living independently. Additionally, cognitive and UPSA performance in the SPD group was intercorrelated to a degree comparable to what has been found in schizophrenia, and this relationship was not present in the AvPD group. Finally, real-world functioning was related to UPSA performance for both patient groups.

CONCLUSIONS

SPD patients exhibit impaired real-world functioning suggesting that these deficits extend across the schizophrenia spectrum. In addition, there is supportive evidence for the validity and importance of performance-based measures such as the UPSA to predict everyday outcomes across the schizophrenia spectrum.

Initial validation of a computerized version of the UCSD Performance-Based Skills Assessment (C-UPSA) for assessing functioning in schizophrenia

OBJECTIVE

This study aimed to validate the Computerized UCSD Performance-Based Skills Assessment (C-UPSA), a newly developed scale for assessing functional capacity in patients with schizophrenia.

METHODS

The C-UPSA was administered to 21 middle-aged and older adults with schizophrenia and 20 healthy comparison (HC) subjects. Schizophrenia participants also completed the original UPSA and a symptom inventory (during a separate visit), and cognitive functioning was assessed in both groups using a brief neuropsychological screening battery.

RESULTS

The C-UPSA total score was significantly correlated with UPSA total scores, and the magnitude of the correlation was comparable to the test-retest reliability of the original UPSA. The C-UPSA was also significantly correlated with UPSA-Brief scores and neuropsychological status among schizophrenia participants. Furthermore, the schizophrenia group scored significantly lower than the HCs on the C-UPSA. ROC curves were generated to determine the optimal C-UPSA value for discriminating between the two groups, with results indicating an optimal cutoff of 75, which is consistent with the derived cutoff from the original UPSA. The C-UPSA identified persons with schizophrenia with 95% accuracy.

CONCLUSIONS

The C-UPSA appears to be highly related to the original UPSA. It has several advantages over the standard version, including increased portability, decreased administration time, and minimized examiner impact on participant performance. Future research would benefit from establishing this test as a clinical and research tool to effectively assess functional capacity.

Clinical applications of neuropsychological assessment

Neuropsychological assessment is a performance-based method to assess cognitive functioning. This method is used to examine the cognitive consequences of brain damage, brain disease, and severe mental illness. There are several specific uses of neuropsychological assessment, including collection of diagnostic information, differential diagnostic information, assessment of treatment response, and prediction of functional potential and functional recovery. We anticipate that clinical neuropsychological assessment will continue to be used, even in the face of advances in imaging technology, because it is already well known that the presence of significant brain changes can be associated with nearly normal cognitive functioning, while individuals with no lesions detectable on imaging can have substantial cognitive and functional limitations.

Cognitive and clinical predictors of functional capacity in patients with first episode schizophrenia

BACKGROUND

The predictors of functional capacity in first episode schizophrenia among seven separable cognitive domains and clinical variables are unknown.

AIM

To investigate predictors of functional capacity in first episode schizophrenia and the associations between functional capacity and measures of real-world functioning.

METHODS

Socio-demographic, clinical, and cognitive measures from a sample of patients with first episode schizophrenia spectrum disorders aged 18-34years (N=117) were examined at baseline, 4-month follow-up, and 10-month follow-up and used to predict concurrent and longitudinal functional capacity. Symptoms were assessed with the Positive and Negative Syndrome Scale, cognitive functioning with the MATRICS Cognitive Consensus Battery, and functional capacity with the brief version of the University of California San Diego Performance-based Skills Assessment. Linear and logistic regression analyses were adjusted for age, gender, and site.

RESULTS

Working memory, negative symptoms, and social cognition accounted for 41% of the variance in functional capacity at baseline. Longitudinally, verbal learning, working memory, and negative symptoms predicted 4-month functional capacity. Working memory and visual learning predicted 10-month functional capacity. Functional capacity was associated to global functioning in the univariate analysis, but in multivariable analyses global functioning, financial independence, and independent living were predicted by negative symptoms or general symptoms explaining 15-23% of the variance.

CONCLUSIONS

The strongest single predictor of functional capacity is working memory, followed by negative symptoms. Clinical symptoms, but not functional capacity, predicted real-world functioning. The usability of the UPSA-B in first episode schizophrenia is discussed. Neurocom, ClinicalTrials.gov Identifier: NCT00472862, http://clinicaltrials.gov/ct2/show/NCT00472862?term=neurocom&rank=1.

Impairment in functional capacity as an endophenotype candidate in severe mental illness

Impairment in everyday functioning (also referred to as "disability") is a central feature of schizophrenia (SZ) and bipolar disorder, as well as other neuropsychiatric conditions. There is a genetic contribution to both SZ and bipolar illness (BPI), and the primary putative determinant of impairments in everyday functioning across these 2 conditions, cognitive impairments, also show substantial heritability and in fact have been proposed to be endophenotypes for these disorders. In this article, we review data and make our case that impairments in functional capacity, the functional abilities that result in functional disability, may also be a heritable trait that is common across neuropsychiatric illnesses such BPI and SZ. While there has been little previous research on the heritability of these abilities, it is an area receiving substantial research attention. We consider advances in the measurement of cognitive functioning in SZ that may facilitate the discovery of genetic influences on functional capacity. Functional capacity measures are proximal to real-world impairments, measured with suitable psychometric precision to be used in heritability analyses, and appear to be minimally influenced by environmental factors that may cause disability such as environmental factors, symptoms, and disability compensation. Our conclusion is that these functional capacity measures have potential to be the target of genetic analyses and that these measures should be considered across neuropsychiatric conditions where impairments in everyday functioning are present.

Characterization of neurophysiologic and neurocognitive biomarkers for use in genomic and clinical outcome studies of schizophrenia

Background

Endophenotypes are quantitative, laboratory-based measures representing intermediate links in the pathways between genetic variation and the clinical expression of a disorder. Ideal endophenotypes exhibit deficits in patients, are stable over time and across shifts in psychopathology, and are suitable for repeat testing. Unfortunately, many leading candidate endophenotypes in schizophrenia have not been fully characterized simultaneously in large cohorts of patients and controls across these properties. The objectives of this study were to characterize the extent to which widely-used neurophysiological and neurocognitive endophenotypes are: 1) associated with schizophrenia, 2) stable over time, independent of state-related changes, and 3) free of potential practice/maturation or differential attrition effects in schizophrenia patients (SZ) and nonpsychiatric comparison subjects (NCS). Stability of clinical and functional measures was also assessed.

Methods

Participants (SZ n = 341; NCS n = 205) completed a battery of neurophysiological (MMN, P3a, P50 and N100 indices, PPI, startle habituation, antisaccade), neurocognitive (WRAT-3 Reading, LNS-forward, LNS-reorder, WCST-64, CVLT-II). In addition, patients were rated on clinical symptom severity as well as functional capacity and status measures (GAF, UPSA, SOF). 223 subjects (SZ n = 163; NCS n = 58) returned for retesting after 1 year.

Results

Most neurophysiological and neurocognitive measures exhibited medium-to-large deficits in schizophrenia, moderate-to-substantial stability across the retest interval, and were independent of fluctuations in clinical status. Clinical symptoms and functional measures also exhibited substantial stability. A Longitudinal Endophenotype Ranking System (LERS) was created to rank neurophysiological and neurocognitive biomarkers according to their effect sizes across endophenotype criteria.

Conclusions

The majority of neurophysiological and neurocognitive measures exhibited deficits in patients, stability over a 1-year interval and did not demonstrate practice or time effects supporting their use as endophenotypes in neural substrate and genomic studies. These measures hold promise for informing the “gene-to-phene gap” in schizophrenia research.