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

Characterizing Major Depressive Disorder (MDD) using alpha-band activity in resting-state electroencephalogram (EEG) combined with MATRICS Consensus Cognitive Battery (MCCB)

BACKGROUND

The diagnosis of major depressive disorder (MDD) is commonly based on the subjective evaluation by experienced psychiatrists using clinical scales. Hence, it is particularly important to find more objective biomarkers to aid in diagnosis and further treatment. Alpha-band activity (7-13 Hz) is the most prominent component in resting electroencephalogram (EEG), which is also thought to be a potential biomarker. Recent studies have shown the existence of multiple sub-oscillations within the alpha band, with distinct neural underpinnings. However, the specific contribution of these alpha sub-oscillations to the diagnosis and treatment of MDD remains unclear.

METHODS

In this study, we recorded the resting-state EEG from MDD and HC populations in both open and closed-eye state conditions. We also assessed cognitive processing using the MATRICS Consensus Cognitive Battery (MCCB).

RESULTS

We found that the MDD group showed significantly higher power in the high alpha range (10.5-11.5 Hz) and lower power in the low alpha range (7-8.5 Hz) compared to the HC group. Notably, high alpha power in the MDD group is negatively correlated with working memory performance in MCCB, whereas no such correlation was found in the HC group. Furthermore, using five established classification algorithms, we discovered that combining alpha oscillations with MCCB scores as features yielded the highest classification accuracy compared to using EEG or MCCB scores alone.

CONCLUSIONS

Our results demonstrate the potential of sub-oscillations within the alpha frequency band as a potential distinct biomarker. When combined with psychological scales, they may provide guidance relevant for the diagnosis and treatment of MDD.

Use of the Chinese version of the MATRICS Consensus Cognitive Battery to assess cognitive functioning in individuals with high risk for psychosis, first-episode schizophrenia and chronic schizophrenia: a systematic review and meta-analysis

More than one hundred studies have used the mainland Chinese version of the MATRICS Consensus Cognitive Battery (MCCB) to assess cognition in schizophrenia, but the results of these studies, the quality of the reports, and the strength of the evidence provided in the reports have not been systematically assessed. We identified 114 studies from English-language and Chinese-language databases that used the Chinese MCCB to assess cognition in combined samples of 7394 healthy controls (HC), 392 individuals with clinical high risk for psychosis (CHR-P), 4922 with first-episode schizophrenia (FES), 1549 with chronic schizophrenia (CS), and 2925 with schizophrenia of unspecified duration. The mean difference (MD) of the composite MCCB T-score (-13.72) and T-scores of each of the seven cognitive domains assessed by MCCB (-14.27 to -7.92) were significantly lower in individuals with schizophrenia than in controls. Meta-analysis identified significantly greater cognitive impairment in FES and CS than in CHR-P in six of the seven domains and significantly greater impairment in CS than FES in the reasoning and problem-solving domain (i.e., executive functioning). The only significant covariate of overall cognitive functioning in individuals with schizophrenia was a negative association with the severity of psychotic symptoms. These results confirm the construct validity of the mainland Chinese version of MCCB. However, there were significant limitations in the strength of the evidence provided about CHR-P (small pooled sample sizes) and the social cognition domain (inconsistency of results across studies), and the quality of many reports (particularly those published in Chinese) was rated 'poor' due to failure to report sample size calculations, matching procedures or methods of handling missing data. Moreover, almost all studies were cross-sectional studies limited to persons under 60 with at least nine years of education, so longitudinal studies of under-educated, older individuals with schizophrenia are needed.

The relationship between serum prolactin levels and cognitive function in drug-naïve schizophrenia patients: a cross-sectional study

This study aimed to investigate the association between serum prolactin levels and psychiatric symptoms and cognitive function in drug-naïve schizophrenia patients. The study recruited 91 drug-naïve schizophrenia patients and 67 healthy controls. Sociodemographic and clinical data were collected, and cognitive function was assessed using the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus Cognitive Battery (MCCB). Serum prolactin levels were measured, and statistical analyses were performed to examine the relationship between prolactin levels, clinical symptoms, and cognitive function. The study found that drug-naïve schizophrenia patients had severe cognitive deficits compared to healthy controls across all seven domains of the MCCB. However, no correlation was found between these patients' serum prolactin levels and clinical severity or cognitive function. The drug-naïve schizophrenia patients had significant cognitive deficits compared to healthy controls. However, there was no significant relationship between prolactin levels and symptomatology and cognition in drug-naïve schizophrenia patients.

Gender differences and clinical correlates in the age of the first hospitalization in patients with drug-naïve schizophrenia in China: a cross-sectional study

Gender differences in the onset age of schizophrenia have been reported in many studies, but differences in the age of the first hospitalization and associated factors have not been explored. The present study investigated gender differences and clinical correlates in the age of the first hospitalization in drug-naïve schizophrenia (DNS). A total of 144 DNS patients and 67 health controls were included. Demographic information, duration of untreated psychosis (DUP), Positive and Negative Symptom Scale (PANSS) scores, the Brief Psychiatric Rating Scale (BPRS) scores, Global Assessment of Functioning (GAF) scores, and MATRICS Consensus Cognitive Battery (MCCB) scores were collected and analyzed. The age of the first hospitalization was significantly earlier in males than in females (P < 0.01). In addition, there were significant differences in the age of the first hospitalization in terms of marital status, occupation, family ranking, suicide attempt, and place of residence (all P < 0.05). After Bonferroni correction, only DUP had a positive correlation with the age of the first hospitalization (PBonferroni < 0.05/6 = 0.0083). Multivariate linear regression analysis showed that gender (β = 0.141, t = 2.434, P = 0.016), marital status (β = 0.219, t = 3.463, P = 0.001), family ranking (β = 0.300, t = 4.918, P < 0.001), suicide attempt (β = 0.348, t = 5.549, P < 0.001), and DUP (β = 0.190, t = 2.969, P < 0.004) positively predicted the age of the first hospitalization. The age of the first hospitalization in male DNS was earlier than in females. In addition, gender, marital status, suicide attempt, DUP, and family rank were independent risk factors for the age of the first hospitalization.

Metformin improves cognitive impairment in patients with schizophrenia: associated with enhanced functional connectivity of dorsolateral prefrontal cortex

Cognitive impairment is a core feature of schizophrenia, which is aggravated by antipsychotics-induced metabolic disturbance and lacks effective pharmacologic treatments in clinical practice. Our previous study demonstrated the efficiency of metformin in alleviating metabolic disturbance following antipsychotic administration. Here we report that metformin could ameliorate cognitive impairment and improve functional connectivity (FC) in prefrontal regions. This is an open-labeled, evaluator-blinded study. Clinically stable patients with schizophrenia were randomly assigned to receive antipsychotics plus metformin (N = 48) or antipsychotics alone (N = 24) for 24 weeks. The improvement in cognition was assessed by the MATRICS Consensus Cognitive Battery (MCCB). Its association with metabolic measurements, and voxel-wise whole-brain FC with dorsolateral prefrontal cortex (DLPFC) subregions as seeds were evaluated. When compared to the antipsychotics alone group, the addition of metformin resulted in significantly greater improvements in the MCCB composite score, speed of processing, working memory, verbal learning, and visual learning. A significant time × group interaction effect of increased FC between DLPFC and the anterior cingulate cortex (ACC)/middle cingulate cortex (MCC), and between DLPFC subregions were observed after metformin treatment, which was positively correlated with MCCB cognitive performance. Furthermore, the FC between left DLPFC A9/46d to right ACC/MCC significantly mediated metformin-induced speed of processing improvement; the FC between left A46 to right ACC significantly mediated metformin-induced verbal learning improvement. Collectively, these findings demonstrate that metformin can improve cognitive impairments in schizophrenia patients and is partly related to the FC changes in the DLPFC. Trial Registration: The trial was registered with ClinicalTrials.gov (NCT03271866). The full trial protocol is provided in Supplementary Material.

Core of sensory gating deficits in first-episode schizophrenia: attention dysfunction

Background

Sensory gating deficits are a common feature of schizophrenia and may be indicative of higher-order psychopathological impairments. It has been proposed that incorporating subjective attention components into prepulse inhibition (PPI) measures may improve the accuracy of assessing these deficits. This study aimed to investigate the relationship between modified PPI and cognitive function, with a specific focus on subjective attention, to gain a better understanding of the underlying mechanisms of sensory processing deficits in schizophrenia.

Methods

Fifty-four unmedicated first-episode schizophrenia (UMFE) patients and 53 healthy controls participated in this study. The modified Prepulse Inhibition paradigm, including Perceived Spatial Separation PPI (PSSPPI) and Perceived Spatial Colocation PPI (PSCPPI), was used to evaluate sensorimotor gating deficits. Cognitive function was assessed in all participants using the Chinese version of the MATRICS Consensus Cognitive Suite Test (MCCB).

Results

UMFE patients had lower MCCB scores and deficient PSSPPI scores than healthy controls. PSSPPI was negatively correlated with total PANSS scores and positively correlated with the speed of processing, attention/ vigilance, and social cognition. Multiple linear regression analysis showed that the PSSPPI at 60 ms had a significant effect on attentional/ vigilance and social cognition, even after controlling for gender, age, years of education, and smoking.

Conclusion

The study revealed notable impairments in sensory gating and cognitive function in UMFE patients, best reflected by the PSSPPI measure. Specifically, PSSPPI at 60 ms was significantly associated with both clinical symptoms and cognitive performance, suggesting that PSSPPI at 60 ms may capture psychopathological symptoms related to psychosis.

Neurocognitive Deficits in First-Episode and Chronic Psychotic Disorders: A Systematic Review from 2009 to 2022

Cognitive impairment in patients suffering from schizophrenia spectrum disorders has been discussed as a strong predictor for multiple disease outcome variables, such as response to psychotherapy, stable relationships, employment, and longevity. However, the consistency and severity of cognitive deficits across multiple domains in individuals with first-episode and chronic psychotic disorders is still undetermined. We provide a comprehensive overview of primary research from the years 2009 to 2022. Based on a Cochrane risk assessment, a systematic synthesis of 51 out of 3669 original studies was performed. Impairment of cognitive functioning in patients diagnosed with first-episode psychotic disorders compared with healthy controls was predicted to occur in all assessed cognitive domains. Few overall changes were predicted for chronically affected patients relative to those in the first-episode stage, in line with previous longitudinal studies. Our research outcomes support the hypothesis of a global decrease in cognitive functioning in patients diagnosed with psychotic disorders, i.e., the occurrence of cognitive deficits in multiple cognitive domains including executive functioning, memory, working memory, psychomotor speed, and attention. Only mild increases in the frequency of cognitive impairment across studies were observed at the chronically affected stage relative to the first-episode stage. Our results confirm and extend the outcomes from prior reviews and meta-analyses. Recommendations for psychotherapeutic interventions are provided, considering the broad cognitive impairment already observed at the stage of the first episode. Based on the risk of bias assessment, we also make specific suggestions concerning the quality of future original studies.

The alternate-form reliability study of six variants of the Brief Visual-Spatial Memory Test-Revised and the Hopkins Verbal Learning Test-Revised

Introduction

The revised Hopkins Verbal Learning Test-Revised (HVLT-R) and the Brief Visual-Spatial Memory Test-Revised (BVMT-R) are two widely used test involving verbal and visual learning and memory. In the two tests, six different versions are assembled, respectively, to prevent learning effects. Currently, no researchers have compared the six versions of the two tests. Thus, their usefulness in clinical studies requiring multiple follow-ups is limited. In this work, we confirm the equivalence of six HVLT-R and BVMT-R versions.

Methods

20 people completed all six HVLT-R and BVMT-R versions, while 120 people were randomly assigned to complete one of the six versions of each test. The Intelligence Quotient (IQ) level is measured using the short version of the Wechsler Adult Intelligence test. R4.2.0 is used for statistical analysis. The K-Related sample test (a non-parametric test) is used to observe the differences in test scores among the 20 subjects. The one-way Analysis of Variance (ANOVA) test is utilized to analyze the differences in test scores among the 120 subjects. The scores on different versions are compared using two similar sample tests. The HVLT-R Total Learning, the HVLT-R Delayed Recall, the BVMT-R Total Learning, and the BVMT-R Delayed Recall are indexes for comparison. Version and test scores are used as research factors, while different versions are used as research levels.

Results

The results suggest that HVLT-R and BVMT-R versions 3, 5 and 6 are equally difficult, and relatively easy compared to versions 1, 2 and 4. HVLT-R versions 3, 5, and 6 show good reliability and can be used interchangeably when testing word learning ability or short-term memory; BVMT-R Versions 3, 5, and 6 show acceptable reliability and can be can be used interchangeably.

Discussion

In the study of multiple follow-ups, it is a must to avoid discrepant versions and choose other equivalent versions. The results from this study could be used as a guide for upcoming studies and clinical applications in China.

Elevated serum alkaline phosphatase correlates with postoperative cognitive dysfunction: A retrospective cohort study based on STROBE statement

Little is known about the association between serum alkaline phosphatase (ALP) levels and postoperative cognitive dysfunction (POCD) after general anesthesia. Thus, we investigated the association of serum ALP levels with POCD in patients who underwent surgery with general anesthesia in a retrospective cohort study. We retrospectively collected data from patients who underwent surgery with general anesthesia between May 2016 and June 2020. Serum ALP activity was detected using a p-nitrophenyl phosphate assay. Pre-and postoperative cognitive function were evaluated using the Chinese version of the Mini-Mental State Examination. Univariate and multivariate logistic regression were used to explore the effect of ALP on cognitive function. The incidence of POCD was 13.5%. Compared with the control group, the POCD group had higher ALP levels. The neuropsychological test results suggested that the scores of most items were lower in the POCD group than in the non-POCD group. Univariate logistic regression indicated that increased ALP levels were significantly associated with cognitive dysfunction (odds ratio = 1.15, 95% confidence interval: 1.13-1.18, P = .000). Multivariate regression showed that elevated ALP was still associated with POCD after adjusting for confounding factors (odds ratio = 1.16, 95% confidence interval: 1.13-1.18, P = .000). The spline regression model indicated the dose-response associations between ALP level and POCD risk (P for nonlinear trend < .001). Our study indicated that elevated serum ALP was an independent predictive factor of POCD at the 3-month follow-up. The occurrence of POCD could be associated with inflammatory status.

Altered regional homogeneity and cognitive impairments in first-episode schizophrenia: A resting-state fMRI study

BACKGROUND

Patients with schizophrenia consistently present pervasive cognitive deficits, but the neurobiological mechanism of cognitive impairments remains unclear. By analyzing regional homogeneity (ReHo) of resting-state functional Magnetic Resonance Imaging, this study aimed to explore the association between brain functional alterations and cognitive deficits in first-episode schizophrenia (FES) with a relatively large sample.

METHODS

A total of 187 patients with FES and 100 healthy controls from 3 independent cohorts underwent resting-state functional magnetic resonance scans. The MATRICS Consensus Cognitive Battery (MCCB) was used to assess cognitive function. Partial correlation analysis was performed between abnormal ReHo values and the severity of symptoms and cognitive deficits.

RESULTS

Compared with healthy controls, ReHo values increased in right superior frontal cortex and decreased in right anterior cingulate cortex (ACC), left middle occipital gyrus (MOG), left cuneus, right posterior cingulate cortex (PCC), and right superior occipital gyrus in schizophrenia patients. ReHo values in ACC, PCC and superior occipital gyrus were correlated with PANSS scores. In addition, ReHo values in ACC and MOG were negatively correlated with working memory; left cuneus was positively correlated with multiple cognitive domains (speed of processing, attention/vigilance and social cognition); PCC was positively correlated with verbal learning; right superior occipital gyrus was positively correlated with speed of processing and social cognition.

CONCLUSION

In conclusion, we found widespread ReHo alterations and cognitive dysfunction in FES. And the pathophysiology mechanism of a wide range of cognitive deficits may be related to abnormal spontaneous brain activity.

Correlation Between Resting Theta Power and Cognitive Performance in Patients With Schizophrenia

Objective

Schizophrenia is a mental disorder that is characterized by progressive cognitive impairment. Objective measures of cognitive function may provide reliable neurobiomarkers for patients with schizophrenia. The goal of the current work is to explore the correlation between resting theta power and cognitive performance in patients with schizophrenia.

Methods

Twenty-two patients with schizophrenia and 23 age-, sex-, and education-matched healthy controls were included in this study. The MATRICS Consensus Cognitive Battery (MCCB) was used for cognitive evaluation and the Positive and Negative Syndrome Scale (PANSS) for evaluation of clinical symptoms. EEGs were acquired in the resting state with closed and opened eyes. Between the two groups, we compared the relative theta power and examined their relationship with cognitive performance.

Results

Compared to healthy controls, patients with schizophrenia showed significantly higher theta power, both with eyes closed and open (P < 0.05). When the eyes were open, negative correlations were found in patients with schizophrenia between theta power in the central and parietal regions with processing speed scores, and between the theta power of the Pz electrode and verbal learning and reasoning and problem-solving scores (r ≥ −0.446). In the control group, theta power over the Fz electrode was negatively correlated with processing speed (r = −0.435).

Conclusions

Our findings showed that theta activity increased in certain brain regions during resting state in schizophrenia. Negative associations between resting theta power (increased) over the parietal-occipital regions with MCCB domains scores (decreased) suggest that altered theta activity can be used as a neurobiological indicator to predict cognitive performance.

Chinese patients with hereditary spastic paraplegias (HSPs): a protocol for a hospital-based cohort study

INTRODUCTION

Hereditary spastic paraplegias (HSPs) are uncommon but not rare neurodegenerative diseases. More than 100 pathogenic genes and loci related to spastic paraplegia symptoms have been reported. HSPs have the same core clinical features, including progressive spasticity in the lower limbs, though HSPs are heterogeneous (eg, clinical signs, MRI features, gene mutation). The age of onset varies greatly, from infant to adulthood. In addition, the slow and variable rates of disease progression in patients with HSP represent a substantial challenge for informative assessment of therapeutic efficacy. To address this, we are undertaking a prospective cohort study to investigate genetic-clinical characteristics, find surrogates for monitoring disease progress and identify clinical readouts for treatment.

METHODS AND ANALYSIS

In this case-control cohort study, we will enrol 200 patients with HSP and 200 healthy individuals in parallel. Participants will be continuously assessed for 3 years at 12-month intervals. Six aspects, including clinical signs, genetic spectrum, cognitive competence, MRI features, potential biochemical indicators and nerve electrophysiological factors, will be assessed in detail. This study will observe clinical manifestations and disease severity based on different molecular mechanisms, including oxidative stress, cholesterol metabolism and microtubule dynamics, all of which have been proposed as potential treatment targets or modalities. The analysis will also assess disease progression in different types of HSPs and cellular pathways with a longitudinal study using t tests and χ² tests.

ETHICS AND DISSEMINATION

The study was granted ethics committee approval by the first affiliated hospital of Fujian Medical University (MRCTA, ECFAH of FMU (2019)194) in 2019. Findings will be disseminated via presentations and peer-reviewed publications. Dissemination will target different audiences, including national stakeholders, researchers from different disciplines and the general public.

TRIAL REGISTRATION NUMBER

NCT04006418.

Assessing cognition in people with severe mental disorders in low- and middle-income countries: a systematic review of assessment measures

BACKGROUND

Cognitive difficulties are common in people with severe mental disorders (SMDs) and various measures of cognition are of proven validity. However, there is a lack of systematic evidence regarding the psychometric properties of these measures in low- and middle-income countries (LMICs).

OBJECTIVE

To systematically review the psychometric properties of cognitive measures validated in people with SMDs in LMICs.

METHODS

We conducted a systematic review of the literature by searching from four electronic databases. Two authors independently screened studies for their eligibility. Measurement properties of measures in all included studies were extracted. All eligible measures were assessed against criteria set for clinical and research recommendations. Results are summarized narratively and measures were grouped by measurement type and population.

RESULTS

We identified 23 unique measures from 28 studies. None of these was from low-income settings. Seventeen of the measures were performance-based. The majority (n = 16/23) of the measures were validated in people with schizophrenia. The most commonly reported measurement properties were: known group, convergent, and divergent validity (n = 25/28). For most psychometric property, studies of methodological qualities were found to be doubtful. Among measures evaluated in people with schizophrenia, Brief Assessment of Cognition in Schizophrenia, Cognitive Assessment Interview, MATRICS Consensus Cognitive Battery, and CogState Schizophrenia Battery were with the highest scores for clinical and research recommendation.

CONCLUSIONS

Studies included in our review provide only limited quality evidence and future studies should consider adapting and validating measures using stronger designs and methods. Nonetheless, validated assessments of cognition could help in the management and allocating therapy in people with SMDs in LMICs.

Transcranial direct current stimulation of the occipital lobes with adjunct lithium attenuates the progression of cognitive impairment in patients with first episode schizophrenia

BACKGROUND

There is no standard effective treatment for schizophrenia-associated cognitive impairment. Efforts to use non-invasive brain stimulation for this purpose have been focused mostly on the frontal cortex, with little attention being given to the occipital lobe.

MATERIALS AND METHODS

We compared the effects of nine intervention strategies on cognitive performance in psychometric measures and brain connectivity measured obtained from functional magnetic resonance imaging analyses. The strategies consisted of transcranial direct current stimulation (t-DCS) or repetitive transcranial magnetic stimulation (r-TMS) of the frontal lobe or of the occipital alone or with adjunct lithium, or lithium monotherapy. We measured global functional connectivity density (gFCD) voxel-wise.

RESULTS

Although all nine patient groups showed significant improvements in global disability scores (GDSs) following the intervention period (vs. before), the greatest improvement in GDS was observed for the group that received occipital lobe-targeted t-DCS with adjunct lithium therapy. tDCS of the occipital lobe improved gFCD throughout the brain, including in the frontal lobes, whereas stimulation of the frontal lobes had less far-reaching benefits on gFCD in the brain. Adverse secondary effects (ASEs) such as heading, dizziness, and nausea, were commonly experienced by patients treated with t-DCS and r-TMS, with or without lithium, whereas ASEs were rare with lithium alone.

CONCLUSION

The most effective treatment strategy for impacting cognitive impairment and brain communication was t-DCS stimulation of the occipital lobe with adjunct lithium therapy, though patients often experienced headache with dizziness and nausea after treatment sessions.

Baseline global brain structural and functional alterations at the time of symptom onset can predict subsequent cognitive deterioration in drug-naïve first-episode schizophrenia patients: Evidence from a follow-up study

Alterations in the global brain gray matter volume (gGMV) and global functional connectivity density (gFCD) play a pivotal role in the cognitive impairment and further deterioration in schizophrenia. This study aimed to assess the correlation between alterations in the gGMV and gFCD at baseline (ΔgGMV and ΔgFCD), and the subsequent alterations of cognitive function in schizophrenia patients after 2-year antipsychotic treatment. Global-brain magnetic resonance imaging scans were acquired from 877 drug-naïve, first-episode schizophrenia patients at baseline and after two years of antipsychotic treatment with adequate dosage and duration, and 200 healthy controls. According to ΔgGMV at baseline, schizophrenia patients were divided into mild, moderate, and severe alteration groups. The MATRICS consensus cognitive battery and Global Deficit Score (GDS) were used to assess cognitive impairment. We found that ΔgGMV and ΔgFCD at baseline were significantly correlated with the severity of the cognitive deterioration (ΔGDS). The correlation coefficient indicated a significant positive correlation between baseline ΔgFCD and subsequent cognitive deterioration, with a relatively stronger relation in the mild alteration group (r = 0.31). In addition, there was a significant positive correlation between baseline ΔgGMV and subsequent cognitive deterioration, with a stronger relation in the moderate and severe alteration groups (r = 0.303; r = 0.302, respectively). Our results showed that ΔgGMV and ΔgFCD are correlated with the severity of cognitive deterioration after completion of a 2-year antipsychotic treatment in schizophrenia patients. These findings suggest that baseline alterations in gGMV and gFCD hold potential for predicting subsequent cognitive decline in schizophrenia.

Sequential Multiple-Assignment Randomized Trials to Compare Antipsychotic Treatments (SMART-CAT) in first-episode schizophrenia patients: Rationale and trial design

Accumulated studies have investigated pharmacological interventions for first-episode schizophrenia (FES) patients. However, studies on subsequent treatment steps, which are essential to guide clinicians, are largely missing. This Sequential Multiple-Assignment Randomized Trials comparing Antipsychotic Treatments (SMART-CAT) program intends to evaluate the effectiveness of commonly used antipsychotic drugs in FES patients. The major goals of this study are to examine: 1) what would be the optimal subsequent sequential treatment if the first antipsychotic drug failed; 2) whether clozapine could be used in those first-trial failed and have superior efficacy compared to other atypical antipsychotics. In this article we will report the detail protocol of SMART-CAT. The SMART-CAT is a randomized controlled clinical multicenter trial in which 9 institutions in China will participate. A total of 720 FES patients will be enrolled and followed up for 12 months in this study. The trial includes three treatment phases (each phase lasting for 8 weeks) and a naturalistic follow-up phase; participants who do well on an assigned treatment will remain on that treatment for the duration of the 12-month treatment period, while non-responders will move to the next phase of the study to receive a new treatment. Phase 1 is a randomized controlled trial; patients will be randomly assigned to one of the treatments with oral olanzapine, risperidone, amisulpride, aripiprazole or perphenazine. Subjects who fail to respond after 8 weeks will enter the phase 2 randomization. Phase 2 is an equipoise-stratified randomization trial, and patients will be randomly assigned to oral olanzapine, amisulpride or clozapine for 8 weeks. Subjects who fail to respond after phase 2 will enter an open label trial (phase 3); patients who receive clozapine in phase 2 and fail to respond will be assigned to an extended clozapine treatment or modified electroconvulsive therapy add-on therapy (Phase 3A). Patients who were not assigned to clozapine in phase 2 will be assigned to treatment with clozapine or another SGAs not previously used in phase 1 and 2 (Phase 3B). The primary outcome for the treatment phase is the treatment efficacy rate, which is defined as at least 40% reduction in Positive and Negative Syndrome Scale (PANSS) total score. We hypothesize that clozapine is more therapeutically effective than any other SGAs to patients who failed to meet efficacy criteria in Phase 1, and earlier treatment with clozapine can improve the functional outcomes of schizophrenia patients. As for the naturalistic follow-up phase, time to all-cause treatment failure, marked by its discontinuation is selected as the primary outcome, since it reflects both efficacy and side effects. The all-cause discontinuation is defined as discontinuing for any reasons, including poor efficacy, intolerance of adverse reactions, poor compliance and other reasons. The results of the SMART-CAT trial will provide evidence for the selection of antipsychotics in FES patients who fail to respond to the first trial of an antipsychotic drug. It will also provide evidence for the efficacy and safety of using clozapine in the early phase of schizophrenia treatment by comparing with other SGAs. The study is based on the combination of sequential therapy and dynamic therapy, which can be more suitable to assess the effectiveness of treatment options in the real-world clinical setting. As a result, we hope that this study can provide guidance for an optimal treatment algorithm in first-episode schizophrenia patients. Trial registration: ID NCT03510325 in ClinicalTrials.gov.

The Association Between Metabolic Disturbance and Cognitive Impairments in Early-Stage Schizophrenia

Background: Cognitive impairment is one of the core symptoms of schizophrenia, which is considered to be significantly correlated to prognosis. In recent years, many studies have suggested that metabolic disorders could be related to a higher risk of cognitive defects in a general setting. However, there has been limited evidence on the association between metabolism and cognitive function in patients with early-stage schizophrenia.

Methods: In this study, we recruited 172 patients with early-stage schizophrenia. Relevant metabolic parameters were examined and cognitive function was evaluated by using the MATRICS Consensus Cognitive Battery (MCCB) to investigate the relationship between metabolic disorder and cognitive impairment.

Results: Generally, the prevalence of cognitive impairment among patients in our study was 84.7% (144/170), which was much higher than that in the general population. Compared with the general Chinese setting, the study population presented a higher proportion of metabolic disturbance. Patients who had metabolic disturbance showed no significant differences on cognitive function compared with the other patients. Correlation analysis showed that metabolic status was significantly correlated with cognitive function as assessed by the cognitive domain scores (p < 0.05), while such association was not found in further multiple regression analysis.

Conclusions: Therefore, there may be no association between metabolic disorder and cognitive impairment in patients with early-stage schizophrenia.

Trial Registration: Clinicaltrials.gov, NCT03451734. Registered March 2, 2018 (retrospectively registered).

Common and Distinct Alterations of Cognitive Function and Brain Structure in Schizophrenia and Major Depressive Disorder: A Pilot Study

Objective: Numerous studies indicate that schizophrenia (SCZ) and major depressive disorder (MDD) share pathophysiological characteristics. Investigating the neurobiological features of psychiatric-affective disorders may facilitate the diagnosis of psychiatric disorders. Hence, we aimed to explore whether patients with SCZ and patients with MDD had the similar or distinct cognitive impairments and GMV alterations to further understand their underlying pathophysiological mechanisms. Methods: We recruited a total of 52 MDD patients, 64 SCZ patients, and 65 healthy controls (HCs). The Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus Cognitive Battery was used to assess cognitive functions. In addition, voxel-based morphometry (VBM) analysis was used to evaluate the gray matter volume (GMV) by using MRI scanning. One-way ANOVA and post-hoc tests were used to find the differences among the MDD, SCZ, and HCs. Finally, we explored the correlation between structural alterations and cognitive functions. Results: Compared with that of HCs, processing speed was impaired in both patients with SCZ and patients with MDD (F = 49.505, p < 0.001). SCZ patients displayed impaired cognitive performance in all dimensions of cognitive functions compared with HCs (p < 0.001, except social cognition, p = 0.043, Bonferroni corrected). Whole-brain VBM analysis showed that both SCZ and MDD groups had reductions of GMV in the medial superior frontal cortex (cluster-level FWE p < 0.05). Patients with SCZ exhibited declining GMV in the anterior cingulate cortex and right middle frontal cortex (MFC) compared with HCs and MDD patients (cluster-level FWE p < 0.05). The mean values of GMV in the right MFC had a positive correlation with the attention/vigilance function in patients with MDD (p = 0.014, partial. r = 0.349, without Bonferroni correction). Conclusions: In total, our study found that MDD and SCZ groups had common cognitive impairments and brain structural alterations, but the SCZ group exhibited more severe impairment than the MDD group in both fields. The above findings may provide a potential support for recognizing the convergent and divergent brain neural pathophysiological mechanisms between MDD and SCZ.

The Association Between Cognitive Deficits and Clinical Characteristic in First-Episode Drug Naïve Patients With Schizophrenia

Background: Schizophrenia is a severe mental disease which characterized by positive symptom, negative symptom, general pathology syndrome and cognitive deficits. In recent years, many studies have investigated the relationship between cognitive deficits and clinical characteristics in schizophrenia, but relatively few studies have been performed on first-episode drug-naïve patients. Methods: Eighty seven first-episode drug-naïve schizophrenia patients were assessed for positive symptom, negative symptom, general pathology symptom and cognitive deficits from the Positive and Negative Symptom Scale and MATRICS Consensus Cognitive Battery. Psychotics depression were assessed using the Calgary depressing scale for schizophrenia. The relationship between clinical characteristics and cognitive deficits were assessed using correlation analysis and linear regression analysis. Results: The prevalence of cognitive deficits among the patients in our study was 85.1% (74/87) which was much higher than that in the general population. According to correlation analysis, negative symptom was negatively correlated with speed of processing and social cognition, and general pathology showed a negative correlation with attention/vigilance. In addition, a positive correlation was found between age and speed of processing. No correlation was found between cognitive deficits and positive symptom. Conclusions: This study confirmed that negative symptom is negatively related with some domains of cognitive function in first-episode drug naïve schizophrenia patients. Trail Registration: NCT03451734. Registered March 2, 2018 (retrospectively registered).

Does mindfulness improve inhibitory control in psychotic disorders? A randomized controlled clinical trial

Background/Objective: Impaired Inhibitory Control (IC) is a core feature of psychotic disorders and is related with impaired social functioning in people experiencing psychosis. Despite research showing the benefits of mindfulness over IC in the general population, no study has assessed its effects on IC in psychoses. The aim of our study was to assess the effectiveness of a mindfulness-based intervention combined with integrated rehabilitation treatment in a sample of people diagnosed of psychotic disorders. Method: Fifty-six patients diagnosed with psychotic disorder were recruited and randomly allocated either to integrated rehabilitation treatment or integrated rehabilitation treatment enhanced with 26 mindfulness group sessions. Measures comprised PANSS interview, MAAS scale, and Stroop Color Word Test (SCWT). The primary outcome variable was the performance in the non-congruent trials of the SCWT. Results: There were no differences between groups at baseline. At post-treatment patients allocated to mindfulness group increased their scores in non-congruent trials of SCWT and in MAAS. At post-treatment mindfulness group scored higher than integrated rehabilitation treatment in MAAS. Conclusions: Data suggest that mindfulness added to integrated rehabilitation treatment may improve IC in psychosis. Results are convergent with prior works about the effect of mindfulness over cognitive performance in general population.