Cognitive and symptomatic predictors of functional disability in schizophrenia

Therapeutic potential of D-amino acid oxidase inhibitors for cognitive impairment associated with schizophrenia: learnings from luvadaxistat

Hypofunction of the N-methyl-D-aspartate receptor (NMDAR) has been proposed to underlie the pathophysiology of schizophrenia, suggesting that promoting NMDAR activity may alleviate the negative or cognitive symptoms associated with schizophrenia. To circumvent excitotoxicity that may accompany direct agonism of the glutamate binding site on the NMDAR, therapeutic trials have focused on targeting the glycine binding site on the NMDAR. Direct administration of either glycine or D-serine, both of which are endogenous coagonists at the NMDAR glycine site, has yielded mixed outcomes across an array of clinical trials investigating different doses or patient populations. Furthermore, directly administering D-serine and glycine is challenging, and thus attention has turned to alternative, indirect methods that increase endogenous D-serine and glycine levels in the brain, such as D-amino acid oxidase (DAAO) inhibitors and glycine transporter 1 inhibitors, respectively. In this review, we provide an overview of the evidence supporting the potential of NMDAR modulators in general, and DAAO inhibitors in particular, as potential adjunctive treatments for schizophrenia. We also discuss the preclinical and clinical data related to luvadaxistat, an investigational highly selective and potent DAAO inhibitor that was under development for the treatment of the cognitive impairment associated with schizophrenia.

Working memory processes and the histamine-3 receptor in schizophrenia: a [11C]MK-8278 PET-fMRI study

RATIONALE

Working memory impairment is a prominent feature of schizophrenia which predicts clinical and functional outcomes. Preclinical data suggest histamine-3 receptor (H3R) expression in cortical pyramidal neurons may have a role in working memory, and post-mortem data has found disruptions of H3R expression in schizophrenia.

OBJECTIVES

We examined the role of H3R in vivo to elucidate its role on working memory impairment in schizophrenia.

METHODS

We used positron emission tomography (PET) with the selective H3R radioligand [11C]MK-8278 to measure H3R availability, and employed a task during functional magnetic resonance imaging (fMRI) to assess working memory-evoked brain activation and cognitive task performance, in patients with schizophrenia (n = 12) and matched healthy volunteers (n = 12). We assessed the relationship between H3R availability and both task performance and working memory-evoked brain activation in regions of interest (ROIs), including the anterior cingulate cortex (ACC) and dorsolateral prefrontal cortex (DLPFC).

RESULTS

Patients with schizophrenia showed a strong positive correlation, after corrections for multiple comparisons, between ACC H3R availability and task performance (rho = 0.73, p = 0.007), which was absent in the control group (rho = 0.03, p = 0.94). Further ROI analysis did not find a significant relationship between H3R availability and working memory-evoked brain activation.

CONCLUSIONS

These results provide support for the role of H3R on working memory processes in patients with schizophrenia.

Predictors of Psychosocial Functioning Among Long-stay Schizophrenia Patients in a Malaysian Mental Institution

Background

A considerable number of schizophrenia patients still require long-term hospital care despite psychiatric deinstitutionalisation, especially in developing nations. Prolonged hospitalisation is associated with greater impairment in psychosocial functioning. This study aimed to determine the level of psychosocial functioning and its predictors among long-stay schizophrenia patients in a Malaysian mental institution.

Methods

This cross-sectional study included 138 patients selected through universal sampling. Data on socio-demographics, illness characteristics such as psychopathology and illness severity [measured using the Brief Psychiatric Rating Scale (BPRS)], and cognitive function [assessed using the Montreal Cognitive Assessment (MoCA)] were collected. The Personal and Social Performance (PSP) scale was used to evaluate psychosocial functioning. Pearson correlation coefficients and multiple linear regression analyses were applied to identify the correlates and predictors of psychosocial functioning.

Results

This study found that 47.8% and 16.7% of the patients had moderate and severe cognitive impairments, respectively. The mean PSP score was 69.68 (standard deviation (SD) = 15.48). Female gender, previous unemployment and more severe cognitive impairments were significantly associated with poorer psychosocial functioning. Meanwhile, negative symptoms and age of onset were negatively correlated with psychosocial functioning. By contrast, the duration of illness was positively correlated with psychosocial functioning. The regression model indicated that being female (β = -7.32, p < 0.001), previously unemployed (β = -3.67, p < 0.047), having negative symptoms (β = -4.18, p < 0.001), experiencing a longer illness duration (β = -0.60, p = 0.004), and the presence of severe cognitive impairment (β = -9.80, p < 0.001) significantly predicted poorer psychosocial functioning.

Conclusion

Long-stay schizophrenia patients experience substantial difficulties in psychosocial functioning. Factors such as gender, last employment status, negative symptoms, illness duration, and cognitive function affect psychosocial functioning.

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.

ℛSCZ: A Riemannian schizophrenia diagnosis framework based on the multiplexity of EEG-based dynamic functional connectivity patterns

Abnormal electrophysiological (EEG) activity has been largely reported in schizophrenia (SCZ). In the last decade, research has focused to the automatic diagnosis of SCZ via the investigation of an EEG aberrant activity and connectivity linked to this mental disorder. These studies followed various preprocessing steps of EEG activity focusing on frequency-dependent functional connectivity brain network (FCBN) construction disregarding the topological dependency among edges. FCBN belongs to a family of symmetric positive definite (SPD) matrices forming the Riemannian manifold. Due to its unique geometric properties, the whole analysis of FCBN can be performed on the Riemannian geometry of the SPD space. The advantage of the analysis of FCBN on the SPD space is that it takes into account all the pairwise interdependencies as a whole. However, only a few studies have adopted a FCBN analysis on the SPD manifold, while no study exists on the analysis of dynamic FCBN (dFCBN) tailored to SCZ. In the present study, I analyzed two open EEG-SCZ datasets under a Riemannian geometry of SPD matrices for the dFCBN analysis proposing also a multiplexity index that quantifies the associations of multi-frequency brainwave patterns. I adopted a machine learning procedure employing a leave-one-subject-out cross-validation (LOSO-CV) using snapshots of dFCBN from (N-1) subjects to train a battery of classifiers. Each classifier operated in the inter-subject dFCBN distances of sample covariance matrices (SCMs) following a rhythm-dependent decision and a multiplex-dependent one. The proposed ℛSCZ decoder supported both the Riemannian geometry of SPD and the multiplexity index DC reaching an absolute accuracy (100 %) in both datasets in the virtual default mode network (DMN) source space.

Effects of transcranial direct current stimulation in children and young people with psychiatric disorders: a systematic review

Transcranial direct current stimulation (tDCS) has demonstrated benefits in adults with various psychiatric disorders, but its clinical utility in children and young people (CYP) remains unclear. This PRISMA systematic review used published and ongoing studies to examine the effects of tDCS on disorder-specific symptoms, mood and neurocognition in CYP with psychiatric disorders. We searched Medline via PubMed, Embase, PsychINFO via OVID, and Clinicaltrials.gov up to December 2022. Eligible studies involved multiple session (i.e., treatment) tDCS in CYP (≤ 25 years old) with psychiatric disorders. Two independent raters assessed the eligibility of studies and extracted data using a custom-built form. Of 33 eligible studies (participant N = 517), the majority (n = 27) reported an improvement in at least one outcome measure of disorder-specific symptoms. Few studies (n = 13) examined tDCS effects on mood and/or neurocognition, but findings were mainly positive. Overall, tDCS was well tolerated with minimal side effects. Of 11 eligible ongoing studies, many are sham-controlled RCTs (n = 9) with better blinding techniques and a larger estimated participant enrolment (M = 79.7; range 15-172) than published studies. Although encouraging, the evidence to date is insufficient to firmly conclude that tDCS can improve clinical symptoms, mood, or cognition in CYP with psychiatric disorders. Ongoing studies appear of improved methodological quality; however, future studies should broaden outcome measures to more comprehensively assess the effects of tDCS and develop dosage guidance (i.e., treatment regimens).

Linking social motivation, general motivation, and social cognition to interpersonal functioning in schizophrenia: insights from exploratory graph analysis

Motivation in general, and social motivation in particular are important for interpersonal functioning in individuals with schizophrenia. Still, their roles after accounting for social cognition, are not well understood. The sample consisted of 147 patients with schizophrenia. General motivation was measured using the Behavioral inhibition/activation scale (BIS/BAS). Social motivation was measured by Passive social withdrawal and Active social avoidance items from PANSS. Interpersonal functioning was evaluated with Birchwood's Social Functioning Scale (SFS). We used Exploratory Graph Analysis for network estimation and community detection. Active social avoidance, passive social withdrawal, and social withdrawal/engagement (from SFS) were the most important nodes. In addition, three distinct communities were identified: Social cognition, Social motivation, and Interpersonal functioning. Notably, the BIS and BAS measures of general motivation were not part of any community. BAS showed stronger links to functioning than BIS. Passive social withdrawal was more strongly linked to interpersonal functioning than social cognitive abilities. Results suggest that social motivation, especially social approach, is more closely related to interpersonal functioning in schizophrenia than general motivation. In contrast, we found that general motivation was largely unrelated to social motivation. This pattern highlights the importance of type of motivation for understanding variability in interpersonal difficulties in schizophrenia.

Predictors of functioning in treatment-resistant schizophrenia: the role of negative symptoms and neurocognition

Introduction

Predictors of functioning are well-studied in schizophrenia, but much less so in treatment-resistant schizophrenia (TRS). In this study, we aim to investigate contributions of schizophrenia symptom domains and neurocognition to predict functioning in a TRS population (n = 146).

Methods

Participants were assessed on the Positive and Negative Syndrome Scale (PANSS), to calculate scores for five symptom factors (Positive, Negative, Cognitive, Depressive and Hostility) and two negative symptom constructs (Diminished Expressivity (DE), and Social Anhedonia (SA) as part of the Motivation and Pleasure-related dimension), based on a previously validated model, modified in accordance with EPA guidelines on negative symptoms assessment. Neurocognition was assessed with symbol coding and digit sequencing tasks from the Brief Assessment of Cognition in Schizophrenia (BACS). Functioning was assessed with the Social and Occupational Functioning Assessment Scale (SOFAS), employment status and World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Multiple regression analyses were performed on psychopathology scores and BACS scores against all three measures of functioning, controlling for age and sex. For WHODAS, regression with PANSS scores of significant symptom factors were also performed.

Results

A lower severity of negative symptoms in the SA dimension was the strongest predictor of higher functioning across all three functioning measures. Neurocognition, in particular processing speed and attention assessed on the symbol coding task, predicted employment. A lower severity of somatic concerns and depressive symptoms was associated with lesser self-reported disability on WHODAS.

Discussion

This study represents a first attempt at elucidating significant predictors of functioning in TRS. We highlight negative symptoms and neurocognition as important treatment targets to improve functioning in TRS, consistent with previous studies in general schizophrenia.

Functional phenotypes in schizophrenia spectrum disorders: defining the constructs and identifying biopsychosocial correlates using data-driven methods

Functional impairments contribute to poor quality of life in schizophrenia spectrum disorders (SSD). We sought to (Objective I) define the main functional phenotypes in SSD, then (Objective II) identify key biopsychosocial correlates, emphasizing interpretable data-driven methods. Objective I was tested on independent samples: Dataset I (N = 282) and Dataset II (N = 317), with SSD participants who underwent assessment of multiple functioning areas. Participants were clustered based on functioning. Objective II was evaluated in Dataset I by identifying key features for classifying functional phenotype clusters from among 65 sociodemographic, psychological, clinical, cognitive, and brain volume measures. Findings were replicated across latent discriminant analyses (LDA) and one-vs.-rest binomial regularized regressions to identify key predictors. We identified three clusters of participants in each dataset, demonstrating replicable functional phenotypes: Cluster 1-poor functioning across domains; Cluster 2-impaired Role Functioning, but partially preserved Independent and Social Functioning; Cluster 3-good functioning across domains. Key correlates were Avolition, anhedonia, left hippocampal volume, and measures of emotional intelligence and subjective social experience. Avolition appeared more closely tied to role functioning, and anhedonia to independent and social functioning. Thus, we found three replicable functional phenotypes with evidence that recovery may not be uniform across domains. Avolition and anhedonia were both critical but played different roles for different functional domains. It may be important to identify critical functional areas for individual patients and target interventions accordingly.

The management of patients with predominant negative symptoms in Slovakia: A 1-year longitudinal, prospective, multicentric cohort study

BACKGROUND

Predominant negative symptoms (PNSs) in schizophrenia can affect the patients' psychosocial functioning immensely and are less responsive to treatment than positive symptoms.

AIMS

The aim of the study was to observe negative symptoms and psychosocial functioning in PNS schizophrenia patients and to understand whether PNS can be improved and with what treatment strategies.

METHODS

This was a 1-year, prospective, multicentric cohort study conducted in Slovakia. Adult outpatients with diagnosis of schizophrenia according to ICD-10 and PNS evaluated using the criteria by the European Psychiatric Association's (EPA) guidance were included. Change in negative symptoms, functionality, and treatment patterns were observed. Treatment effectiveness was evaluated using the modified Short Assessment of Negative Domain (m-SAND), the Self-evaluation of Negative Symptoms (SNS) scale, the Personal and Social Performance (PSP) scale, and the Clinical Global Impression - Severity (CGI-S) and the Clinical Global Impression - Improvement (CGI-I) scales. Least-squares (LS) means were calculated for the change from baseline to final visit for the outcomes.

RESULTS

The study included 188 patients. Functionality improved as, by the end of the study, fewer patients were unemployed (53%) and more worked occasionally (21%). PNS improved significantly according to both physicians and patients (LS mean change from baseline in m-SAND total score: -10.0 (p-value <0.0001)). Most patients received polytherapy throughout the study. Cariprazine was utilized most (20% monotherapy and 76% polytherapy). Only a few patients discontinued treatment due to adverse drug reactions.

CONCLUSIONS

With the right treatment strategy, it is possible to achieve improvement in PNS and everyday functioning in schizophrenia outpatients.

Effects of physical exercise on executive functions of individuals with schizophrenia spectrum disorders: Protocol for a systematic review and meta-analysis

INTRODUCTION

Executive functions are commonly impaired in individuals with schizophrenia spectrum disorders. Physical exercise has the potential for improving executive functions and can be easily implemented as a therapeutic method. However, there are only few systematic reviews of exercise effects in schizophrenia including cognitive outcomes, and no meta-analytical syntheses of effects on "cool" and "hot" executive functions. The purpose of this systematic review and meta-analysis will be to determine the effects of physical exercise on "cool" and "hot" executive functions of adults with schizophrenia spectrum disorders.

METHODS AND ANALYSIS

This protocol was guided by PRISMA-P guidelines. Studies will be searched using combinations of keywords and medical terms in the Web of Science, PubMed, Scopus, and EBSCO databases. Inclusion criteria will be determined as per PICOS approach. The risk of bias will be assessed using the Cochrane RoB2 tool. The certainty of evidence (per outcome) will be assessed using the GRADE method. The meta-analyses will be performed using the DerSimonian and Laird random effects model. Effect sizes (Hedges' g) with 95% confidence intervals will be calculated for each main outcome.

CONCLUSIONS

The results of this review may be useful for mental health professionals to design treatment plans for adults with schizophrenia spectrum disorders, offering potential benefits related to the quality of life and cognitive abilities of this population.

PROSPERO REGISTRATION NUMBER

CRD42023392295.

Cognitive deficits profiles in the first-episode of schizophrenia, clinical high risk of psychosis, and genetically high-risk of psychosis

Background

Cognitive deficits are core characteristics of schizophrenia, presenting before the emergence of psychotic symptoms. Individuals with a clinical high-risk for psychosis (CHR) and those with genetically high-risk of psychosis (GHR) also exhibit cognitive impairments. Nonetheless, it remains uncertain in which domains of cognitive impairments in these two groups were more similar to those of schizophrenia patients. Moreover, it is unclear which domains of impairment are caused by quality factors and which are more related to the state of disease. This research initiative aimed to extensively examine the distinct cognitive impairment profiles among the CHR, GHR, and first-episode schizophrenia (FES) cohorts.

Methods

We compared the cognitive functions of the three groups and a healthy control group (HCs) using the MATRICS Consensus Cognitive Battery (MCCB). The participants for this study were recruited from the Beijing Anding Hospital of Capital Medical University. Our sample consisted of 56 patients with FES, 42 with CHR, 26 with GHR, and 62 HCs. The participants across all groups were matched in terms of gender, age, and level of education.

Results

Individuals with FES, GHR, and CHR showed significant impairment across the majority of MCCB domains, with the exception of visual learning, in comparison to HCs. None of the MCCB domains demonstrated a discerning ability to accurately differentiate between individuals with CHR and those with GHR. In the speed of processing and attention/vigilance domains, individuals with GHR and CHR exhibited scores between those of FES and HCs, with all group differences reaching statistical significance. This pattern of results indicates an intermediate level of cognitive function in individuals with GHR and CHR. Conversely, the levels of impairment observed in working memory and verbal learning were relatively consistent across all three groups: FES, CHR, and GHR. Notably, individuals in the CHR group exhibited performance akin to that of the HCs in the reasoning/problem-solving domain, while showing significant differences from the FES group, with the CHR individuals demonstrating better performance. Additionally, individuals with GHR displayed performance in social cognition similar to that of the HCs, while also demonstrating significant distinctions from the FES group, with the GHR individuals demonstrating better performance.

Conclusion

Significant cognitive deficits exist in individuals with CHR, GHR, and FES, and these deficits vary across domains. Processing speed and attention/vigilance could potentially serve as robust biomarkers for identifying individuals at a risk of psychosis. The impairment observed in reasoning/problem-solving abilities might signify a qualitative trait, whereas deficits in social recognition could indicate a state characteristic specific to schizophrenia.

Characterization and prediction of individual functional outcome trajectories in schizophrenia spectrum disorders (PREDICTS study): Study protocol

Schizophrenia spectrum disorders (SSDs) are associated with significant functional impairments, disability, and low rates of personal recovery, along with tremendous economic costs linked primarily to lost productivity and premature mortality. Efforts to delineate the contributors to disability in SSDs have highlighted prominent roles for a diverse range of symptoms, physical health conditions, substance use disorders, neurobiological changes, and social factors. These findings have provided valuable advances in knowledge and helped define broad patterns of illness and outcomes across SSDs. Unsurprisingly, there have also been conflicting findings for many of these determinants that reflect the heterogeneous population of individuals with SSDs and the challenges of conceptualizing and treating SSDs as a unitary categorical construct. Presently it is not possible to identify the functional course on an individual level that would enable a personalized approach to treatment to alter the individual's functional trajectory and mitigate the ensuing disability they would otherwise experience. To address this ongoing challenge, this study aims to conduct a longitudinal multimodal investigation of a large cohort of individuals with SSDs in order to establish discrete trajectories of personal recovery, disability, and community functioning, as well as the antecedents and predictors of these trajectories. This investigation will also provide the foundation for the co-design and testing of personalized interventions that alter these functional trajectories and improve outcomes for people with SSDs.

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.

Effectiveness and optimal duration of early intervention treatment in adult-onset psychosis: a randomized clinical trial

BACKGROUND

Contrasting the well-described effects of early intervention (EI) services for youth-onset psychosis, the potential benefits of the intervention for adult-onset psychosis are uncertain. This paper aims to examine the effectiveness of EI on functioning and symptomatic improvement in adult-onset psychosis, and the optimal duration of the intervention.

METHODS

360 psychosis patients aged 26-55 years were randomized to receive either standard care (SC, n = 120), or case management for two (2-year EI, n = 120) or 4 years (4-year EI, n = 120) in a 4-year rater-masked, parallel-group, superiority, randomized controlled trial of treatment effectiveness (Clinicaltrials.gov: NCT00919620). Primary (i.e. social and occupational functioning) and secondary outcomes (i.e. positive and negative symptoms, and quality of life) were assessed at baseline, 6-month, and yearly for 4 years.

RESULTS

Compared with SC, patients with 4-year EI had better Role Functioning Scale (RFS) immediate [interaction estimate = 0.008, 95% confidence interval (CI) = 0.001-0.014, p = 0.02] and extended social network (interaction estimate = 0.011, 95% CI = 0.004-0.018, p = 0.003) scores. Specifically, these improvements were observed in the first 2 years. Compared with the 2-year EI group, the 4-year EI group had better RFS total (p = 0.01), immediate (p = 0.01), and extended social network (p = 0.05) scores at the fourth year. Meanwhile, the 4-year (p = 0.02) and 2-year EI (p = 0.004) group had less severe symptoms than the SC group at the first year.

CONCLUSIONS

Specialized EI treatment for psychosis patients aged 26-55 should be provided for at least the initial 2 years of illness. Further treatment up to 4 years confers little benefits in this age range over the course of the study.

Racial disparities and predictors of functioning in schizophrenia

Black Americans are diagnosed with schizophrenia spectrum disorders at more than twice the rate of White individuals and experience significantly worse outcomes following diagnosis. Little research has examined specific factors that may contribute to worse functional outcomes among Black Americans diagnosed with schizophrenia. One approach to understanding why racial disparities emerge is to examine established predictors of functioning in this population: neurocognition, social cognition, and symptom severity. The present study aims to broaden existing literature on racial differences within these domains by (a) examining racial differences in functioning and these established predictors of functioning (i.e., neurocognition, social, and symptom severity) and (b) investigating whether cognition and symptom domains similarly predict functioning between Black and White Americans with schizophrenia. Sixty-six participants' baseline neurocognition, social cognition, symptom severity, and functioning were assessed. Black participants demonstrated lower neurocognition scores and higher levels of disorganized symptoms relative to White participants. No racial differences in functioning or social cognition were observed. Further, race did not moderate the relationship between any of these established predictors and functioning outcomes. The largely nonsignificant differences in known predictors of functioning highlight the need to explore further domains that may be more relevant for understanding racial disparities in schizophrenia. Considering that psychosocial treatments for schizophrenia spectrum disorders often focus on cognition, these results underscore the importance of identifying whether these domains or other treatment targets may be better in addressing racial disparities in functioning. Possible areas of exploration for future work (e.g., structural factors, racism-related stress) are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Fully Immersive Virtual Reality-Based Cognitive Remediation for Adults with Psychosocial Disabilities: A Systematic Scoping Review of Methods Intervention Gaps and Meta-Analysis of Published Effectiveness Studies

BACKGROUND

Cognitive Remediation (CR) programs are effective for the treatment of mental diseases; in recent years, Virtual Reality (VR) rehabilitation tools are increasingly used. This study aimed to systematically review and meta-analyze the published randomized controlled trials that used fully immersive VR tools for CR programs in psychiatric rehabilitation. We also wanted to map currently published CR/VR interventions, their methods components, and their evidence base, including the framework of the development intervention of CR in fully immersive VR.

METHODS

Level 1 of evidence. This study followed the PRISMA extension for Scoping Reviews and Systematic Review. Three electronic databases (Pubmed, Cochrane Library, Embase) were systematically searched, and studies were included if they met the eligibility criteria: only randomized clinical trials, only studies with fully immersive VR, and only CR for the adult population with mental disorders.

RESULTS

We found 4905 (database) plus 7 (manual/citation searching articles) eligible studies. According to inclusion criteria, 11 studies were finally reviewed. Of these, nine included patients with mild cognitive impairment, one with schizophrenia, and one with mild dementia. Most studies used an ecological scenario, with improvement across all cognitive domains. Although eight studies showed significant efficacy of CR/VR, the interventions' development was poorly described, and few details were given on the interventions' components.

CONCLUSIONS

Although CR/VR seems to be effective in clinical and feasibility outcomes, the interventions and their components are not clearly described. This limits the understanding of the effectiveness and undermines their real-world implementation and the establishment of a gold standard for fully immersive VR/CR.

The relationship between cognitive functioning and psychopathology in patients with psychiatric disorders: a transdiagnostic network analysis

BACKGROUND

Patients with psychiatric disorders often experience cognitive dysfunction, but the precise relationship between cognitive deficits and psychopathology remains unclear. We investigated the relationships between domains of cognitive functioning and psychopathology in a transdiagnostic sample using a data-driven approach.

METHODS

Cross-sectional network analyses were conducted to investigate the relationships between domains of psychopathology and cognitive functioning and detect clusters in the network. This naturalistic transdiagnostic sample consists of 1016 psychiatric patients who have a variety of psychiatric diagnoses, such as depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, and schizophrenia spectrum and other psychotic disorders. Psychopathology symptoms were assessed using various questionnaires. Core cognitive domains were assessed with a battery of automated tests.

RESULTS

Network analysis detected three clusters that we labelled: general psychopathology, substance use, and cognition. Depressive and anxiety symptoms, verbal memory, and visual attention were the most central nodes in the network. Most associations between cognitive functioning and symptoms were negative, i.e. increased symptom severity was associated with worse cognitive functioning. Cannabis use, (subclinical) psychotic experiences, and anhedonia had the strongest total negative relationships with cognitive variables.

CONCLUSIONS

Cognitive functioning and psychopathology are independent but related dimensions, which interact in a transdiagnostic manner. Depression, anxiety, verbal memory, and visual attention are especially relevant in this network and can be considered independent transdiagnostic targets for research and treatment in psychiatry. Moreover, future research on cognitive functioning in psychopathology should take a transdiagnostic approach, focusing on symptom-specific interactions with cognitive domains rather than investigating cognitive functioning within diagnostic categories.

Magnocellular and parvocellular contributions to brain network dysfunction during learning and memory: Implications for schizophrenia

Memory deficits are core features of schizophrenia, and a central aim in biological psychiatry is to identify the etiology of these deficits. Scrutiny is naturally focused on the dorsolateral prefrontal cortex and the hippocampal cortices, given these structures' roles in memory and learning. The fronto-hippocampal framework is valuable but restrictive. Network-based underpinnings of learning and memory are substantially diverse and include interactions between hetero-modal and early sensory networks. Thus, a loss of fidelity in sensory information may impact memorial and cognitive processing in higher-order brain sub-networks, becoming a sensory source for learning and memory deficits. In this overview, we suggest that impairments in magno- and parvo-cellular visual pathways result in degraded inputs to core learning and memory networks. The ascending cascade of aberrant neural events significantly contributes to learning and memory deficits in schizophrenia. We outline the network bases of these effects, and suggest that any network perspectives of dysfunction in schizophrenia must assess the impact of impaired perceptual contributions. Finally, we speculate on how this framework enriches the space of biomarkers and expands intervention strategies to ameliorate this prototypical disconnection syndrome.

Clinical symptoms and social functioning in schizophrenia

INTRODUCTION

The aim of the present study was to assess the relationship between social functioning and clinical symptoms in people with schizophrenia, analyzing the influence of both global social functioning and the specific aspects of social functioning, assertiveness and communication skills in the explanation of type of symptoms.

MATERIAL AND METHODS

A cross-sectional descriptive study composed of 125 people diagnosed with schizophrenia was performed. Patients were assessed with the Communication Skills Questionnaire (CSQ), the Gambrill and Richey Assertiveness Inventory (GR), the Global Assessment of Functioning Scale (GAF) and the Global Assessment of Social Functioning Scale (SOFAS), Social Functioning Scale (SFS), Life Skills Profile (LSP) scale and the Clinical Global Impression scale for Schizophrenia (CGI-S).

RESULTS

SOFAS, LSP and GR are related to each of the subscales and total scores of symptoms (p<0.05-0.001). The multiple regressions show that SOFAS and GR explained 59% of the total symptoms. SOFAS and GR, accounting for 65% of the variance, explain positive symptoms. GR and SOFAS explained 34% of the variance of negative symptoms. SOFAS, CSQ and LSP, accounting for 20% of the variance, explain depressive symptoms. SOFAS explained 46% of the variance of cognitive symptoms.

CONCLUSIONS

Our findings suggest the usefulness of social functioning assessment in the explanation of clinical symptoms in people with schizophrenia. Moreover, our results point out that not only negative and cognitive symptoms, but also positive and depressive symptoms, should be taken into account in the rehabilitation process in order to improve patient adaptation in the community.

Measuring functional outcomes in schizophrenia in an increasingly digital world

With an unmet clinical need for effective interventions for cognitive and negative symptoms in patients with schizophrenia, measures of functional status (often a co-primary endpoint) remain key clinical trial outcomes. This review aims to give an overview of the different types of functional assessments commonly used in clinical trials and research involving patients with schizophrenia and highlight pertinent challenges surrounding the use of these as reliable, sensitive, and specific assessments in intervention trials. We provide examples of commonly used functional measures and highlight emerging real-time digital assessment tools. Informant- and clinician-rated functional outcome measures and functional capacity assessments are valid, commonly used measures of functional status that try to overcome the need for often overly ambitious and insensitive ‘real world’ milestones. The wide range of scientific and practical challenges associated with these different tools leave room for the development of improved functional outcome measures for use in clinical trials. In particular, many existing measures fail to capture small, but meaningful, functional changes that may occur over the course of typically short intervention trials. Adding passive digital data collection and short active real-time digital assessments whilst patients go about their day offers the opportunity to build a more fine-grained picture of functional improvements that, if thoughtfully developed and carefully applied, could provide the sensitivity needed to accurately evaluate functional status in intervention studies, aiding the development of desperately needed treatments.

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Functional outcome measures are important for evaluating the efficacy of treatments.

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A variety of these are available, each with their own strengths and limitations.

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However, consensus on the optimal functional outcome measure(s) is lacking.

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Digital measures may enhance the assessment of associated functional constructs.

Context-specific abnormalities of the central executive network in first-episode psychosis: relationship with cognition

BACKGROUND

Cognitive impairments, which contribute to the profound functional deficits observed in psychotic disorders, have found to be associated with abnormalities in trial-level cognitive control. However, neural tasks operate within the context of sustained cognitive states, which can be assessed with 'background connectivity' following the removal of task effects. To date, little is known about the integrity of brain processes supporting the maintenance of a cognitive state in individuals with psychotic disorders. Thus, here we examine background connectivity during executive processing in a cohort of participants with first-episode psychosis (FEP).

METHODS

The following fMRI study examined background connectivity of the dorsolateral prefrontal cortex (DLPFC), during working memory engagement in a group of 43 patients with FEP, relative to 35 healthy controls (HC). Findings were also examined in relation to measures of executive function.

RESULTS

The FEP group relative to HC showed significantly lower background DLPFC connectivity with bilateral superior parietal lobule (SPL) and left inferior parietal lobule. Background connectivity between DLPFC and SPL was also positively associated with overall cognition across all subjects and in our FEP group. In comparison, resting-state frontoparietal connectivity did not differ between groups and was not significantly associated with overall cognition, suggesting that psychosis-related alterations in executive networks only emerged during states of goal-oriented behavior.

CONCLUSIONS

These results provide novel evidence indicating while frontoparietal connectivity at rest appears intact in psychosis, when engaged during a cognitive state, it is impaired possibly undermining cognitive control capacities in FEP.

Healthcare resource utilization and quality of life by cognitive impairment in patients with schizophrenia

OBJECTIVE

The objective was to investigate the association between cognitive impairment and healthcare resource utilization (HCRU) and quality of life (QoL) among patients with schizophrenia.

METHODS

Data from the Adelphi Schizophrenia Disease Specific Programme™, a point-in-time survey of physicians and their patients, were collected in the United States between July-October 2019. Psychiatrists reported on patient cognitive function, HCRU, housing circumstances and employment status for their next 10 consulting adult patients with schizophrenia. Patients were classified as having no/mild or moderate/severe cognitive impairment and asked to complete a QoL questionnaire voluntarily. Multiple regression analysis estimated the association between severity of cognitive impairment and patient outcomes adjusting for patient demographics and clinical characteristics.

RESULTS

Psychiatrists (n=124) reported on 651 and 484 patients with no/mild and moderate/severe cognitive impairment, respectively. Moderate/severe vs. no/mild cognitive impairment was associated with greater odds of hospitalization related to schizophrenia relapse within the last 12 months (adjusted odds ratio [aOR] [95% CI] = 2.23 [1.53-3.24]) and being unemployed due to disability (aOR = 2.39 [1.65-3.45]). Patients with moderate/severe vs. no/mild cognitive impairment had worse average QoL (EuroQoL 5-dimension [EQ-5D] Health Index: difference = -0.09 [-0.13 to -0.04]; EQ-5D Visual Analogue Scale: difference = -7.0 [-13.0 to -1.0]) and overall life satisfaction (Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form: difference = -8.4 [-14.1 to -2.8]).

CONCLUSIONS

Moderate/severe cognitive impairment among patients with schizophrenia was associated with worse patient outcomes including greater risk of hospitalizations related to schizophrenia relapse. Treatment to improve cognitive function could benefit the large proportion of patients with schizophrenia who suffer from cognitive impairment.

Beyond antipsychotics: a twenty-first century update for preclinical development of schizophrenia therapeutics

Despite 50+ years of drug discovery, current antipsychotics have limited efficacy against negative and cognitive symptoms of schizophrenia, and are ineffective-with the exception of clozapine-against any symptom domain for patients who are treatment resistant. Novel therapeutics with diverse non-dopamine D2 receptor targets have been explored extensively in clinical trials, yet often fail due to a lack of efficacy despite showing promise in preclinical development. This lack of translation between preclinical and clinical efficacy suggests a systematic failure in current methods that determine efficacy in preclinical rodent models. In this review, we critically evaluate rodent models and behavioural tests used to determine preclinical efficacy, and look to clinical research to provide a roadmap for developing improved translational measures. We highlight the dependence of preclinical models and tests on dopamine-centric theories of dysfunction and how this has contributed towards a self-reinforcing loop away from clinically meaningful predictions of efficacy. We review recent clinical findings of distinct dopamine-mediated dysfunction of corticostriatal circuits in patients with treatment-resistant vs. non-treatment-resistant schizophrenia and suggest criteria for establishing rodent models to reflect such differences, with a focus on objective, translational measures. Finally, we review current schizophrenia drug discovery and propose a framework where preclinical models are validated against objective, clinically informed measures and preclinical tests of efficacy map onto those used clinically.

Impact of cognitive remediation on the prediction of employment outcomes in severe mental illness

OBJECTIVE

Cognitive functioning is a potent predictor of work in people with a severe mental illness, including those receiving vocational services. Cognitive remediation has been shown to improve cognitive functioning and work outcomes in people receiving vocational services. However, it is unknown whether it reduces the strength of cognitive functioning as a predictor of work outcomes compared to people receiving vocational services alone.

METHOD

Data were pooled from five randomized controlled trials evaluating the effects of adding cognitive remediation to vocational rehabilitation vs. vocational services alone. A battery of baseline cognitive functioning measures was examined to identify predictors of competitive work outcomes over the following two years. Study condition (i.e., receipt of cognitive remediation) was included in the analyses to evaluate whether cognitive functioning was a weaker predictor of work outcomes in people receiving cognitive remediation compared to those receiving vocational services alone.

RESULTS

Cognitive functioning was a stronger predictor of wages earned and weeks worked in participants receiving vocational services alone than those who also received cognitive remediation. Cognitive functioning did not predict job acquisition in either study condition.

CONCLUSION

Cognitive remediation may improve employment outcomes in people receiving vocational services in part by reducing the adverse effects of impaired cognitive functioning on work performance.

Applying machine learning to smartphone based cognitive and sleep assessments in schizophrenia

Background

Methods

Results

Discussion

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.

Occupational Goal Intervention Method for the Management of Executive Dysfunction in People With Treatment-Resistant Schizophrenia: A Randomized Controlled Trial

IMPORTANCE

The occupational goal intervention (OGI) method has been proven effective in improving executive function (EF) in people with schizophrenia, but it has not yet been tested with those with treatment-resistant schizophrenia (TRS).

OBJECTIVE

To test the efficacy of the OGI in people with TRS.

DESIGN

Single-blind randomized controlled trial.

SETTING

The Schizophrenia Program, Institute of Psychiatry, University of São Paulo General Hospital, Brazil.

PARTICIPANTS

People with TRS according to Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria, ages 18 to 55. Outcomes and Measures: Primary outcome: improvement in EF as measured by the Behavioural Assessment of the Dysexecutive Syndrome (BADS).

SECONDARY OUTCOMES

improvement of functionality, as measured by the Direct Assessment of Functional Status-Revised (DAFS-BR), and improvement in autonomy in activities of daily living (ADLs), as measured by the Independent Living Skills Survey (ILSS-BR), administered to caregivers. The outcomes were measured at baseline, posttreatment, and follow-up.

INTERVENTION

Participants were divided into two groups: OGI and craft activities (control). Each group participated in 30 sessions during 15 wk, with follow-up at 6 mo postintervention.

RESULTS

The OGI group improved significantly compared with the control group, with medium to large effect sizes in posttreatment scores on the BADS and DAFS-BR. The ILSS-BR showed the highest effect sizes at posttreatment and follow-up.

CONCLUSIONS AND RELEVANCE

The OGI method is effective for improving EF, occupational performance and ADLs in people with TRS. What This Article Adds: The OGI method is an important therapeutic tool for use in the occupational therapy clinic.

Cognitive ability and metabolic physical health in first-episode psychosis

Cognitive impairments are a core feature of first-episode psychosis (FEP), arising before illness onset and antipsychotic exposure. Individuals with chronic psychosis experience poorer physical health while taking antipsychotic medication, but health disparities may be evident at FEP onset, prior to antipsychotic exposure. Given the links between cognition and physical health in healthy populations, the aim was to explore whether cognition and physical health are associated in FEP, which could inform early physical health interventions for cognition in FEP. Participants were aged 15 to 25 and included 86 individuals experiencing FEP with limited antipsychotic exposure and duration of untreated psychosis of ≤six months, and 43 age- and sex-matched controls. Individuals with FEP performed significantly poorer than controls in most cognitive domains (Cohen's d = 0.38 to 1.59). Groups were similar in metabolic health measures, excluding a significantly faster heart rate in FEP (d = 0.68). Through hierarchical regression analyses, we found that in the overall sample, BMI was negatively related to current IQ after controlling for education and group (FEP/control). Relationships between BMI and cognition were consistent across the FEP and healthy control groups. In FEP, current IQ and working memory were negatively correlated with lipid profiles. Findings suggest that in FEP, impaired cognition is exhibited earlier than physical health problems, and that compared to controls, similar relationships with cognition are demonstrated. Causal pathways and trajectories of relationships between health and cognition in FEP require investigation, especially as antipsychotic medications are introduced. The findings have implications for cognitive and health interventions.

Translation-Focused Approaches to GPCR Drug Discovery for Cognitive Impairments Associated with Schizophrenia

There are no effective therapeutics for cognitive impairments associated with schizophrenia (CIAS), which includes deficits in executive functions (working memory and cognitive flexibility) and episodic memory. Compounds that have entered clinical trials are inadequate in terms of efficacy and/or tolerability, highlighting a clear translational bottleneck and a need for a cohesive preclinical drug development strategy. In this review we propose hippocampal-prefrontal-cortical (HPC-PFC) circuitry underlying CIAS-relevant cognitive processes across mammalian species as a target source to guide the translation-focused discovery and development of novel, procognitive agents. We highlight several G protein-coupled receptors (GPCRs) enriched within HPC-PFC circuitry as therapeutic targets of interest, including noncanonical approaches (biased agonism and allosteric modulation) to conventional clinical targets, such as dopamine and muscarinic acetylcholine receptors, along with prospective novel targets, including the orphan receptors GPR52 and GPR139. We also describe the translational limitations of popular preclinical cognition tests and suggest touchscreen-based assays that probe cognitive functions reliant on HPC-PFC circuitry and reflect tests used in the clinic, as tests of greater translational relevance. Combining pharmacological and behavioral testing strategies based in HPC-PFC circuit function creates a cohesive, translation-focused approach to preclinical drug development that may improve the translational bottleneck currently hindering the development of treatments for CIAS.

Latent Clinical-Anatomical Dimensions of Schizophrenia

Widespread structural brain abnormalities have been consistently reported in schizophrenia, but their relation to the heterogeneous clinical manifestations remains unknown. In particular, it is unclear whether anatomical abnormalities in discrete regions give rise to discrete symptoms or whether distributed abnormalities give rise to the broad clinical profile associated with schizophrenia. Here, we apply a multivariate data-driven approach to investigate covariance patterns between multiple-symptom domains and distributed brain abnormalities in schizophrenia. Structural magnetic resonance imaging and clinical data were derived from one discovery sample (133 patients and 113 controls) and one independent validation sample (108 patients and 69 controls). Disease-related voxel-wise brain abnormalities were estimated using deformation-based morphometry. Partial least-squares analysis was used to comprehensively map clinical, neuropsychological, and demographic data onto distributed deformation in a single multivariate model. The analysis identified 3 latent clinical-anatomical dimensions that collectively accounted for 55% of the covariance between clinical data and brain deformation. The first latent clinical-anatomical dimension was replicated in an independent sample, encompassing cognitive impairments, negative symptom severity, and brain abnormalities within the default mode and visual networks. This cognitive-negative dimension was associated with low socioeconomic status and was represented across multiple races. Altogether, we identified a continuous cognitive-negative dimension of schizophrenia, centered on 2 intrinsic networks. By simultaneously taking into account both clinical manifestations and neuroanatomical abnormalities, the present results open new avenues for multi-omic stratification and biotyping of individuals with schizophrenia.

Clinical symptoms and social functioning in schizophrenia

INTRODUCTION

The aim of the present study was to assess the relationship between social functioning and clinical symptoms in people with schizophrenia, analyzing the influence of both global social functioning and the specific aspects of social functioning, assertiveness and communication skills in the explanation of type of symptoms.

MATERIAL AND METHODS

A cross-sectional descriptive study composed of 125 people diagnosed with schizophrenia was performed. Patients were assessed with the Communication Skills Questionnaire (CSQ), the Gambrill and Richey Assertiveness Inventory (GR), the Global Assessment of Functioning Scale (GAF) and the Global Assessment of Social Functioning Scale (SOFAS), Social Functioning Scale (SFS), Life Skills Profile (LSP) scale and the Clinical Global Impression scale for Schizophrenia (CGI-S).

RESULTS

SOFAS, LSP and GR are related to each of the subscales and total scores of symptoms (p<0.05-0.001). The multiple regressions show that SOFAS and GR explained 59% of the total symptoms. SOFAS and GR, accounting for 65% of the variance, explain positive symptoms. GR and SOFAS explained 34% of the variance of negative symptoms. SOFAS, CSQ and LSP, accounting for 20% of the variance, explain depressive symptoms. SOFAS explained 46% of the variance of cognitive symptoms.

CONCLUSIONS

Our findings suggest the usefulness of social functioning assessment in the explanation of clinical symptoms in people with schizophrenia. Moreover, our results point out that not only negative and cognitive symptoms, but also positive and depressive symptoms, should be taken into account in the rehabilitation process in order to improve patient adaptation in the community.

Comparison of the touch-screen and traditional versions of the Corsi block-tapping test in patients with psychosis and healthy controls

BACKGROUND

Working memory (WM) refers to the capacity system for temporary storage and processing of information, which is known to depend on the integrity of the prefrontal cortex. Impairment in working memory is a core cognitive deficit among individuals with psychotic disorders. The Corsi block-tapping test is a widely-used instrument to assess visuospatial working memory. The traditional version is composed of 9 square blocks positioned on a physical board. In recent years, the number of digital instruments has increased significantly; several advantages might derive from the use of a digital version of the Corsi test.

METHODS

This study aimed to compare the digital and traditional versions of the Corsi test in 45 patients with psychotic disorders and 45 healthy controls. Both groups completed a neuropsychological assessment involving attention and working memory divided into the two conditions.

RESULTS

Results were consistent between the traditional and digital versions of the Corsi test. The digital version, as well as the traditional version, can discriminate between patients with psychosis and healthy controls. Overall, patients performed worse with respect to the healthy comparison group. The traditional Corsi test was positively related to intelligence and verbal working memory, probably due to a more significant effort to execute the test.

CONCLUSIONS

The digital Corsi might be used to enhance clinical practice diagnosis and treatment.The digital version can be administered in a natural environment in real-time. Further, it is easy to administer while ensuring a standard procedure.

Clarifying the direction of impact of negative symptoms and neurocognition on prospective work functioning in psychosis: A 20-year longitudinal study

Both neurocognition and negative symptoms have demonstrated strong links to functional outcomes, such as work functioning, among those with severe mental illness (SMI). Prior models have suggested that reduced neurocognition 1) precedes or predicts greater negative symptoms and 2) indirectly influences functional outcomes via its impact on negative symptoms. The current study sought to also test a divergent model: whether greater negative symptoms predict reduced neurocognition and indirectly influence work functioning through their impact on neurocognition. Both models were tested using cross-sectional and prospective data spanning 20-years in a sample of 277 people with a SMI with psychotic features. Results showed that both models were supported in cross-sectional analyses. However, in prospective models predicting work functioning, only the models examining the indirect influence of negative symptoms on work functioning (7.5 to up to 20-years later) through neurocognition demonstrated significant mediation (i.e., a significant indirect effect); further, higher negative symptoms significantly predicted lower prospective neurocognition, while lower neurocognition did not significantly predict greater prospective negative symptoms. Although cross-sectional data were consistent with prior models, our prospective models offered greater support for a putative causal pathway running from negative symptoms to neurocognition-rather than the reverse-to work functioning. Findings have implications for mechanisms contributing to longitudinal work functioning and suggest that targeting negative symptoms prior to neurocognition could be more beneficial for long-term work outcomes.

Symptomatic remission affects employment outcomes in schizophrenia patients

BACKGROUND

Remission criteria were proposed by Andreasen et al. for classifying patients with schizophrenia according to the severity of psychopathology. Up to the present time, there have been no cohort studies exploring the association between remission status and employment outcomes in patients with schizophrenia. The study explored whether symptomatic remission is significantly associated with employment outcomes in a two-year longitudinal study.

METHODS

All 525 stable patients with schizophrenia in the therapeutic community of a public mental hospital in Taiwan were recruited between 2013 and 2015. Employment outcomes, defined as the cumulative on-the-job duration (months/per year) and income (new Taiwan dollars, NT$/per year), were investigated at the end of 1- and 2-year follow-up periods after enrollment. For repeated measurements, linear mixed models were constructed to examine the association between symptomatic remission and employment outcomes after controlling for potential confounding variables including age, sex, education, type and daily dose of antipsychotics, cognitive function, psychosocial functioning and initial employment type.

RESULTS

The average age of patients was 51.8 years, and 65.3% were males. Among them, 124 patients (23.6%, 124/525) met the remission criteria at baseline. The linear mixed-model analysis showed that patients who had symptomatic remission were employed 0.8 of a month longer (p = 0.029) and earned NT$3250 more (p = 0.001) within 1 year than those who did not show symptomatic remission.

CONCLUSION

Our study suggests that assessing symptomatic remission is a useful part of monitoring treatment effectiveness for schizophrenia, and all strategies targeting the bio-psycho-social domains to attain symptomatic remission are paramount to maintaining favorable employment outcomes.

Protocol Across study: longitudinal transdiagnostic cognitive functioning, psychiatric symptoms, and biological parameters in patients with a psychiatric disorder

BACKGROUND

Patients with psychiatric disorders, such as major depressive disorder, schizophrenia or obsessive-compulsive disorder, often suffer from cognitive dysfunction. The nature of these dysfunctions and their relation with clinical symptoms and biological parameters is not yet clear. Traditionally, cognitive dysfunction is studied in patients with specific psychiatric disorders, disregarding the fact that cognitive deficits are shared across disorders. The Across study aims to investigate cognitive functioning and its relation with psychiatric symptoms and biological parameters transdiagnostically and longitudinally.

METHODS

The study recruits patients diagnosed with a variety of psychiatric disorders and has a longitudinal cohort design with an assessment at baseline and at one-year follow-up. The primary outcome measure is cognitive functioning. The secondary outcome measures include clinical symptoms, electroencephalographic, genetic and blood markers (e.g., fatty acids), and hair cortisol concentration levels.

DISCUSSION

The Across study provides an opportunity for a transdiagnostic, bottom-up, data-driven approach of investigating cognition in relation to symptoms and biological parameters longitudinally in patients with psychiatric disorders. The study may help to find new clusters of symptoms, biological markers, and cognitive dysfunctions that have better prognostic value than the current diagnostic categories. Furthermore, increased insight into the relationship among cognitive deficits, biological parameters, and psychiatric symptoms can lead to new treatment possibilities.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NL8170.

Predictors of life skills in people with schizophrenia

Objective : The purpose of the present study is to examine clinical factors related to life skills in people with schizophrenia. Method : The participants were 51 stabilized outpatients with schizophrenia. Their mean age was 38.91 (SD = 10.73) years. Life skills were assessed using the Life skills profile (LSP). Cognitive function was evaluated with the Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery (MCCB). Clinical symptoms were assessed using the Positive and Negative Syndrome scale (PANSS), the Calgary Depression Scale for Schizophrenia (CDSS) and the Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS). Results : Cognitive function was not correlated with the LSP scores at all. Among clinical symptoms, scores of the PANSS positive and negative syndrome scales, the CDSS, and the DIEPSS had negative correlations with the LSP total score and the subscales. Stepwise regression analyses showed that the CDSS and PANSS negative syndrome scale scores were independent predictors of the LSP total score and two of the subscales. Conclusions : These results indicate that cognitive function is not associated with life skills but clinical symptoms such as depressive and negative symptoms have considerable impacts on life skills in people with schizophrenia. J. Med. Invest. 67 : 75-82, February, 2020.

Excitatory amino acid transporter (EAAT)1 and EAAT2 mRNA levels are altered in the prefrontal cortex of subjects with schizophrenia

Excitatory amino acid transporter (EAAT)1 and EAAT2 mediate glutamatergic neurotransmission and prevent excitotoxicity through binding and transportation of glutamate into glia. These EAATs may be regulated by metabotropic glutamate receptor 5 (mGluR5), which is also expressed by glia. Whilst we have data from an Affymetrix™ Human Exon 1.0 ST Array showing higher levels of EAAT1 mRNA (+36%) in Brodmann's are (BA)9 of subjects with schizophrenia, there is evidence that EAAT1 and EAAT2, as well as mGluR5 levels, are altered in the cortex of subjects with the disorder. Hence, we measured mRNA levels of these genes in other cortical regions in subjects with that disorder. EAAT1, EAAT2 and mGluR5 mRNA were measured, in triplicate, using Quantitative PCR in BA10 and BA46 from subjects with schizophrenia (n = 20) and age and sex matched controls (n = 18). Levels of mRNA were normalised to the geometric mean of two reference genes, transcription factor B1, mitochondrial (TFB1M) and S-phase kinase-associated protein 1A (SKP1A), for which mRNA did not vary between diagnostic groups in either region. Normalised levels of EAAT1 and EAAT2 mRNA were significantly higher in BA10 (EAAT1: U = 58, p = 0.0002; EAAT2 U = 70, p = 0.0009), but not BA46 (EAAT1: U = 122, p = 0.09; EAAT2: U = 136, p = 0.21), from subjects with schizophrenia compared to controls. mGluR5 levels in BA10 (U = 173, p=0.85) and BA46 (U = 178, p = 0.96) did not vary by cohort. Our data suggests that region-specific increases in cortical EAAT1 and EAAT2 mRNA are involved in schizophrenia pathophysiology and that disrupted glutamate uptake in schizophrenia may be of particular significance in BA10.

Emotion Recognition, Emotion Awareness, Metacognition, and Social Functioning in Persons with Schizophrenia

BACKGROUND

Emotion processing has received significant research attention in persons with schizophrenia. However, some aspects of this construct, such as emotion awareness, are less researched. In addition, there is limited work on metacognitive awareness and social functioning in persons with schizophrenia.

METHODS

Our sample comprised of 27 participants with schizophrenia- and 26 nonclinical controls. The clinical group was assessed on Scale for Assessment of Positive Symptoms, Scale for Assessment of Negative Symptoms, Tool for Recognition of Emotions in Neuropsychiatric Disorders, Toronto Alexithymia Scale, Metacognitive Assessment Scale, self-reflectiveness subscale of Beck's Cognitive Insight Scale, Scale S and Scale U subscales of the Metacognitive Assessment Scale, and Groningen's Social Dysfunction Scale.

RESULTS AND CONCLUSION

Participants with schizophrenia had greater deficits in emotion recognition than nonclinical controls (P = 0.05, df = 51). There was no significant correlation between emotion recognition and metacognition in the clinical group. The presence of negative symptoms was significantly associated with social functioning in persons with schizophrenia.

KEY MESSAGES

Clinical symptoms, in particular negative symptoms, play an important role in social functioning in persons with schizophrenia and it is necessary to address these along with social cognition in order to improve functioning.

Individual Alpha Peak Frequency Moderates Transfer of Learning in Cognitive Remediation of Schizophrenia

OBJECTIVE

Meta-analyses report moderate effects across cognitive remediation (CR) trials in schizophrenia. However, individual responses are variable, with some participants showing no appreciable gain in cognitive performance. Furthermore, reasons for heterogeneous outcome are undetermined. We examine the extent to which CR outcome is attributable to near learning-direct gains in trained cognitive tasks-while also exploring factors influencing far transfer of gains during training to external cognitive measures.

METHOD

Thirty-seven schizophrenia outpatients were classified as CR responders and non-responders according to change in MATRICS Consensus Cognitive Battery composite score following 20 sessions of computer-based training. Metrics of near learning during training, as well as baseline demographic, clinical, cognitive, and electroencephalographic (EEG) measures, were examined as predictors of responder status.

RESULTS

Significant post-training improvement in cognitive composite score (Cohen's d = .41) was observed across the sample, with n = 21 and n = 16 classified as responders and non-responders, respectively. Near learning was evidenced by significant improvement on each training exercise with practice; however, learning did not directly predict responder status. Group-wise comparison of responders and non-responders identified two factors favoring responders: higher EEG individual alpha frequency (IAF) and lower antipsychotic dosing. Tested in moderation analyses, IAF interacted with learning to predict improvement in cognitive outcome.

CONCLUSION

CR outcome in schizophrenia is not directly explained by learning during training and appears to depend on latent factors influencing far transfer of trained abilities. Further understanding of factors influencing transfer of learning is needed to optimize CR efficacy.

Disability in clinically stable patients of schizophrenia

PURPOSE

Disability associated with schizophrenia affects every aspect of life. In India, persons with schizophrenia are eligible for disability benefits. Only a handful of patients are aware and able to avail the benefits. We intended to assess disability in clinically stable patients of schizophrenia as even though they are stable but are disabled and may benefit from disability benefits and rehabilitation.

METHODS

Sixty-two clinically stable patients of schizophrenia were assessed on the Mini-International Neuropsychiatric Interview, Positive and Negative Syndrome Scale (PANSS), and Schizophrenia Cognition Rating Scale. Disability was assessed on the Indian Disability Evaluation and Assessment Scale (IDEAS).

RESULTS

Nearly one-fourth of the "stable patients" had moderate-to-severe disability (22.6% - moderate and 1.6% - severe), i.e., certifiable disability as per IDEAS. Disability had a significant correlation with all three domains of PANSS as well as total PANSS score. The correlation was stronger with negative than with positive symptom scores. Disability also strongly correlated with cognitive impairment. "Work," "communication and understanding," and "interpersonal relationship" domains of IDEAS had a strong correlation with cognitive impairment.

CONCLUSION

Nearly 25% of the stable patients had certifiable disability. The "work" domain of IDEAS was most affected. It demonstrates that the rehabilitation of this population may contribute to reducing disability.

Sleep Problems and Social Impairment in Psychosis: A Transdiagnostic Study Examining Multiple Social Domains

Psychotic disorders are characterized by profound social impairment. An accumulation of research has explored the contribution of symptoms, cognitive functioning, and behavioral skills deficits to this social dysfunction. Recent research indicates that sleep disturbance has significant social implications in nonclinical populations-this research suggests that sleep problems may also be relevant to understanding social impairment in psychosis. This study adopted a symptom-oriented dimensional approach to examine how sleep disturbance and sleep-related impairment are related to multiple social domains within a transdiagnostic sample (N = 90). This sample included individuals with a variety of psychotic disorders (n = 75) along with healthy non-clinical participants (n = 15) to ensure sampling across the full range of sleep problems and social functioning. Social domains spanned self-reported perceptions of social relationships, social functioning in the community, and behavioral assessments of social competence. We hypothesized that greater sleep disturbance and sleep-related impairment would be associated with more negative or problematic perceptions of social relationships (i.e., less social support, less companionship, and greater distress), poorer social functioning in the community, smaller social networks, and poorer behavioral ratings of social competency. Results supported these hypotheses indicating that sleep disturbance and sleep-related impairment have widespread deleterious impacts on perceptions of social relationships, social functioning, and competence. Sleep disturbance retained associations with perceptions of social relationships, social functioning, and social competence even after controlling for total symptoms or cognitive functioning. These findings indicate that sleep problems may have important implications for fully understanding the causes of social impairment in psychosis.

Challenges of Psychiatry Drug Development and the Role of Human Pharmacology Models in Early Development-A Drug Developer's Perspective

Psychiatric diseases have the lowest probability of success in clinical drug development. This presents not only an issue to address the unmet medical needs of patients, but also a hurdle for pharmaceutical and biotech industry to continue R&D in this disease area. Fundamental pharmacokinetic and pharmacodynamic principles provide an understanding of the drug exposure, target binding and pharmacological activity at the target site of action for a new drug candidate. Collectively, these principles determine the likelihood of testing the mechanism of action and enhancing the likelihood of candidate survival in Phase 2 clinical development, therefore, they are termed as the "three pillars of survival." Human Phase 1 pharmacokinetic and pharmacodynamic studies provide evidence of the three pillars. Electroencephalogram (EEG) assessments and cognitive function tests in schizophrenia patients can provide proof of pharmacology and ensure that a pharmacological active regimen will be tested in Phase 2 proof of concept (POC) studies for the treatment of cognitive impairment associated with schizophrenia (CIAS).

Relationships Between Working Alliance and Outcomes in Group Therapy for People Diagnosed with Schizophrenia

Working alliance (WA) is an important predictor of treatment outcomes in therapy. Forming a strong WA can be challenging with people diagnosed with schizophrenia, and differences between client-rated and clinician-rated WA have been found in this population. This project examined WA in people diagnosed with schizophrenia who completed a skills training and attention shaping group intervention. Paired samples t-tests revealed differences between client and clinician ratings on the Working Alliance Inventory Short Form (WAI-S). Clinician-rated WAI-S scores were related to symptom severity, cognitive functioning, and attention during group sessions. Yet, the primary hypothesis was not supported as WAI-S scores were unrelated to clients' treatment response. Clinician-rated WAI-S was found to partially mediate the relationship between negative symptoms and overall attention. Client-rated WAI-S scores were associated with client measures of self-efficacy and mastery. Results reinforce the importance of working alliance in the treatment of those diagnosed with schizophrenia and indicate clinical and functional factors that may influence the quality of WA.

Improvement in verbal learning over the first year of antipsychotic treatment is associated with serum HDL levels in a cohort of first episode psychosis patients

To investigate whether changes in serum lipids are associated with cognitive performance in first episode psychosis (FEP) patients during their first year of antipsychotic drug treatment. One hundred and thirty-two antipsychotic-treated FEP patients were included through the TOP study along with 83 age- and gender-matched healthy controls (HC). Information regarding cognitive performance, psychotic symptoms, lifestyle, body mass index, serum lipids [total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein cholesterol, and triglycerides] and antipsychotic treatment was obtained at baseline and after 1 year. The cognitive test battery is comprised of assessments for verbal learning, processing speed, working memory, verbal fluency, and inhibition. Mixed-effects models were used to study the relationship between changes over time in serum lipids and cognitive domains, controlling for potential confounders. There was a significant group by HDL interaction effect for verbal learning (F = 11.12, p = 0.001), where an increase in HDL levels was associated with improvement in verbal learning in FEP patients but not in HC. Practice effects, lifestyle, and psychotic symptoms did not significantly affect this relationship. Antipsychotic-treated FEP patients who increased in HDL levels during the first year of follow-up exhibited better verbal learning capacity. Further investigations are needed to clarify the underlying mechanisms.

Neuropsychological function at first episode in treatment-resistant psychosis: findings from the ÆSOP-10 study

BACKGROUND

Neuropsychological investigations can help untangle the aetiological and phenomenological heterogeneity of schizophrenia but have scarcely been employed in the context of treatment-resistant (TR) schizophrenia. No population-based study has examined neuropsychological function in the first-episode of TR psychosis.

METHODS

We report baseline neuropsychological findings from a longitudinal, population-based study of first-episode psychosis, which followed up cases from index admission to 10 years. At the 10-year follow up patients were classified as treatment responsive or TR after reconstructing their entire case histories. Of 145 cases with neuropsychological data at baseline, 113 were classified as treatment responsive, and 32 as TR at the 10-year follow-up.

RESULTS

Compared with 257 community controls, both case groups showed baseline deficits in three composite neuropsychological scores, derived from principal component analysis: verbal intelligence and fluency, visuospatial ability and executive function, and verbal memory and learning (p values⩽0.001). Compared with treatment responders, TR cases showed deficits in verbal intelligence and fluency, both in the extended psychosis sample (t = -2.32; p = 0.022) and in the schizophrenia diagnostic subgroup (t = -2.49; p = 0.017). Similar relative deficits in the TR cases emerged in sub-/sensitivity analyses excluding patients with delayed-onset treatment resistance (p values<0.01-0.001) and those born outside the UK (p values<0.05).

CONCLUSIONS

Verbal intelligence and fluency are impaired in patients with TR psychosis compared with those who respond to treatment. This differential is already detectable - at a group level - at the first illness episode, supporting the conceptualisation of TR psychosis as a severe, pathogenically distinct variant, embedded in aberrant neurodevelopmental processes.

What is the optimal neuropsychological test battery for schizophrenia in China?

BACKGROUND

The MATRICS consensus cognitive battery (MCCB) has been widely used to evaluate cognitive deficits in schizophrenia (SCZ), however, no study has formally examined the validity of the MCCB in Chinese SCZ. This study compared Chinese SCZ patients with healthy Chinese controls on the MCCB and some additional neurocognitive tests to determine if the Chinese MCCB is an optimal battery to assess the cognitive deficits in Chinese SCZ patients.

METHOD

The study enrolled and examined 230 patients met DSM-IV criteria for SCZ and 656 healthy controls matched for gender, age and education. Besides the MCCB, we also included some additional neurocognitive tests that have been widely used in patients with schizophrenia. We selected MCCB and non-MCCB tests with large effect size, to assemble a new "optimal battery" and compared its performance with that of the standard MCCB.

RESULTS

Comparing the putative "optimal" battery with the original MCCB, more patients with SCZ were identified as cognitively impaired according to the criteria of GDS ≥ 0.50 for the optimal battery (166 vs 135, or 72.2% vs 58.7%). The rate of cognitive impairment according to MCCB GDS in patients with SCZ who were currently working, ever worked and never worked are 45.5%, 61.6% and 70.8% (p = 0.051), whereas the optimal battery GDS showed 56.4%, 74.8%, 91.7% (p = 0.003), respectively.

CONCLUSIONS

Our study needs validation with independent samples but suggests that the current "optimal" cognitive battery could be more sensitive than the widely used MCCB in detecting SCZ related cognitive impairment in China.

Validation of the Brief Negative Symptom Scale and its association with functioning

INTRODUCTION

The Brief Negative Symptom Scale (BNSS) includes five domains of negative symptoms suggested by the NIMH Consensus Development Conference (anhedonia, asociality, avolition, blunted affect, and alogia), which could be clustered into two factors - Motivation-Pleasure (MAP) and Emotional Expressivity (EE). Our study aims to examine the psychometric properties of BNSS, and its association with functioning.

METHODS

274 individuals with schizophrenia were assessed on the BNSS, Positive and Negative Syndrome Scale (PANSS), Scale for the Assessment of Negative Symptoms (SANS), Global Assessment of Functioning Scale (GAF), Calgary Depression Scale for Schizophrenia (CDSS), and Simpson-Angus Extrapyramidal Side Effects Scale (SAS). Internal consistency was examined using Cronbach's alpha. Concurrent, discriminant, and construct validity were examined. Factor structure of BNSS was explored using confirmatory factor analyses. Association between GAF and BNSS was examined with GAF as the dependent variable and BNSS Total, MAP and EE, and BNSS five domains as independent variables in three multiple regression models after controlling for covariates.

RESULTS

BNSS showed good internal consistency (Cronbach's alpha = 0.880) and validity. The five-factor model fit the data better than the two-factor model; a second-order model was superior to both models. More severe symptoms on BNSS Total (B = -0.438, p < .001), MAP (B = -0.876, p < .001), Avolition (B = -2.503, p < .001) and Asociality (B = -0.950, p = .001) were associated with lower GAF.

CONCLUSION

Our results lend support to the use of BNSS in clinical practice and in future research into negative symptoms. Composite scores could be computed using either the five-factor or second-order models. Negative symptoms, particularly MAP, avolition and asociality, were associated with functioning.

Clinical relevance of paliperidone palmitate 3-monthly in treating schizophrenia

Antipsychotics are the mainstay in schizophrenia management, and long-acting injectable (LAI) antipsychotics contribute to the successful maintenance of treatment by improving non-adherence and preventing relapses. Paliperidone palmitate 3-monthly (PP3M) formulation is the only available LAI antipsychotic that offers an extended 3-month window of stable plasma drug concentration, enabling only four injections per year. This paper summarizes clinically relevant endpoints from available evidence for PP3M to bridge translational research gaps and provide measurable outcomes that can be interpreted in clinical practice. Low number-needed-to-treat (NNT) for relapse prevention (NNT [95% CI] 6-month estimate: 4.8 [3.2; 10.0]; 12-month estimate: 3.4 [2.2; 7.0]), and high number-needed-to-harm (NNH [95% CI] akathisia, 27.1 [12.3; -667.1]; tremor, 80.0 [22.5; 67.3]; dyskinesia, -132.6 [44.5; -23.2]; parkinsonism, 160.0 [28.9; -49.8]) quantify the relative benefits and low propensity for adverse events with PP3M. Symptom remission and reductions in positive and negative symptoms indicate treatment stability. Additionally, meaningful functional remission, reduced dosing frequency, and freedom from daily negotiations favorably impact patient preference and attenuate burdensome aspects of caregiving, representing important healthcare determinants that enhance prospects of treatment continuity in schizophrenia. This information can potentially improve clinicians' judgment of treatment choices, clinical response, and patient selection in routine care. Taken together, PP3M is a valuable antipsychotic treatment option, meriting consideration for a broader role in the long-term management of schizophrenia; its utility should not be limited to patients with poor adherence or when oral antipsychotics have failed.