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McGuire N, Gumley A, Hasson-Ohayon I, Allan S, Aunjitsakul W, Aydin O, Bo S, Bonfils KA, Bröcker AL, de Jong S, Dimaggio G, Inchausti F, Jansen JE, Lecomte T, Luther L, MacBeth A, Montag C, Pedersen MB, Pijnenborg GHM, Popolo R, Schwannauer M, Trauelsen AM, van Donkersgoed R, Wu W, Wang K, Lysaker PH, McLeod H. Investigating the relationship between specific negative symptoms and metacognitive functioning in psychosis: A systematic review. Psychol Psychother 2024; 97:191-214. [PMID: 37864383 DOI: 10.1111/papt.12505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/20/2023] [Accepted: 09/25/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Disrupted metacognition is implicated in development and maintenance of negative symptoms, but more fine-grained analyses would inform precise treatment targeting for individual negative symptoms. AIMS This systematic review identifies and examines datasets that test whether specific metacognitive capacities distinctly influence negative symptoms. MATERIALS & METHODS PsycINFO, EMBASE, Medline and Cochrane Library databases plus hand searching of relevant articles, journals and grey literature identified quantitative research investigating negative symptoms and metacognition in adults aged 16+ with psychosis. Authors of included articles were contacted to identify unique datasets and missing information. Data were extracted for a risk of bias assessment using the Quality in Prognostic Studies tool. RESULTS 85 published reports met criteria and are estimated to reflect 32 distinct datasets and 1623 unique participants. The data indicated uncertainty about the relationship between summed scores of negative symptoms and domains of metacognition, with significant findings indicating correlation coefficients from 0.88 to -0.23. Only eight studies investigated the relationship between metacognition and individual negative symptoms, with mixed findings. Studies were mostly moderate-to-low risk of bias. DISCUSSION The relationship between negative symptoms and metacognition is rarely the focus of studies reviewed here, and negative symptom scores are often summed. This approach may obscure relationships between metacognitive domains and individual negative symptoms which may be important for understanding how negative symptoms are developed and maintained. CONLCLUSION Methodological challenges around overlapping participants, variation in aggregation of negative symptom items and types of analyses used, make a strong case for use of Individual Participant Data Meta-Analysis to further elucidate these relationships.
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Affiliation(s)
| | | | | | | | | | - Orkun Aydin
- International University of Sarajevo, Sarajevo, Bosnia and Herzegovinia
| | - Sune Bo
- Psychiatric Research Unit, Region Zealand, Slagelse, Denmark
| | - Kelsey A Bonfils
- School of Psychology, University of Southern Mississippi, Hattiesburg, Mississippi, USA
| | | | - Steven de Jong
- Lentis Psychiatric Institute, Groningen, The Netherlands
| | | | - Felix Inchausti
- Department of Mental Health, Servicio Riojano de Salud, Logroño, Spain
| | - Jens Einar Jansen
- Mental Health Center Copenhagen, Capital Region, Copenhagen, Denmark
| | | | | | | | | | - Marlene Buch Pedersen
- Early Psychosis Intervention Centre, Psychiatry East, Region Zealand, Roskilde, Denmark
| | | | | | | | | | | | - Weiming Wu
- Anhui Medical University, Hefei City, China
| | - Kai Wang
- Anhui Medical University, Hefei City, China
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Fan L, Liang L, Wang Y, Ma X, Yuan L, Ouyang L, He Y, Li Z, Li C, Chen X, Palaniyappan L. Glutamatergic basis of antipsychotic response in first-episode psychosis: a dual voxel study of the anterior cingulate cortex. Neuropsychopharmacology 2024; 49:845-853. [PMID: 37752221 PMCID: PMC10948866 DOI: 10.1038/s41386-023-01741-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/31/2023] [Accepted: 09/11/2023] [Indexed: 09/28/2023]
Abstract
A subgroup of patients with schizophrenia is believed to have aberrant excess of glutamate in the frontal cortex; this subgroup is thought to show poor response to first-line antipsychotic treatments that focus on dopamine blockade. If we can identify this subgroup early in the course of illness, we can reduce the repeated use of first-line antipsychotics and potentially stratify first-episode patients to intervene early with second-line treatments such as clozapine. The use of proton magnetic resonance spectroscopy (1H-MRS) to measure glutamate and Glx (glutamate plus glutamine) may provide a means for such a stratification. We must first establish if there is robust evidence linking elevations in anterior cingulate cortex (ACC) glutamate metabolites to poor response, and determine if the use of antipsychotics worsens the glutamatergic excess in eventual nonresponders. In this study, we estimated glutamate levels at baseline in 42 drug-naive patients with schizophrenia. We then treated them all with risperidone at a standard dose range of 2-6 mg/day and followed them up for 3 months to categorize their response status. We expected to see baseline "hyperglutamatergia" in nonresponders, and expected this to worsen over time at the follow-up. In line with our predictions, nonresponders had higher glutamate than responders, but patients as a group did not differ in glutamate and Glx from the healthy control (HC) group before treatment-onset (F1,79 = 3.20, p = 0.046, partial η2 = 0.075). Glutamatergic metabolites did not change significantly over time in both nonresponders and responders over the 3 months of antipsychotic exposure (F1,31 = 1.26, p = 0.270, partial η2 = 0.039). We conclude that the use of antipsychotics without prior knowledge of later response delays symptom relief in a subgroup of first-episode patients, but does not worsen the glutamatergic excess seen at the baseline. Given the current practice of nonstratified use of antipsychotics, longer-time follow-up MRS studies are required to see if improvement in symptoms accompanies a dynamic shift in glutamate profile.
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Affiliation(s)
- Lejia Fan
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, China
- Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Liangbing Liang
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Yujue Wang
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xiaoqian Ma
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Liu Yuan
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Lijun Ouyang
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Ying He
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Zongchang Li
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Chunwang Li
- Department of Radiology, Hunan Children's Hospital, Changsha, China
| | - Xiaogang Chen
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, China.
| | - Lena Palaniyappan
- Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montreal, QC, Canada.
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
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3
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Pelizza L, Maestri D, Leuci E, Quattrone E, Azzali S, Paulillo G, Pellegrini P. Association between case management and longitudinal decrease in negative symptoms in patients with first episode psychosis: A 2-year follow-up. Early Interv Psychiatry 2022; 16:1185-1191. [PMID: 35086160 DOI: 10.1111/eip.13267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 10/19/2021] [Accepted: 01/18/2022] [Indexed: 01/21/2023]
Abstract
AIM Negative symptoms (NS) severely affect daily functioning already at the psychosis onset. However, most studies investigating beneficial effects of specific treatments for NS mainly included individuals with prolonged psychotic disorders. Furthermore, evidence on psychosocial rehabilitation for NS in early psychosis is still relatively poor. The aims of this study therefore were (A) to longitudinally examine NS stability in people with first episode psychosis (FEP) along a 2-year follow-up period, and (B) to overtime explore any relevant association of NS levels with the specific intervention components of an 'early intervention in psychosis' (EIP) protocol during the follow-up. METHODS At baseline, 266 FEP subjects (aged 12-35 years) completed the positive and negative syndrome scale (PANSS). Multiple linear regression analyses were then performed. RESULTS Along the follow-up, FEP participants had a relevant improvement in NS levels. This was specifically predicted by the total number of case management sessions offered within our 2-year EIP protocol, as well as by shorter duration of untreated psychosis at entry and by longitudinal reduction in PANSS depressive and positive symptom dimension levels. No association with antipsychotic medication was found. CONCLUSIONS NS are clinically relevant in FEP, already at the recruitment time in specialized EIP services. However, their severity appears to improve over time together with the delivery of patient-tailored, integrated EIP case management.
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Affiliation(s)
- Lorenzo Pelizza
- Department of Mental Health and Pathological Addiction, Azienda USL di Parma, Parma, Italy
| | - Davide Maestri
- Department of Mental Health and Pathological Addiction, Azienda USL di Parma, Parma, Italy
| | - Emanuela Leuci
- Department of Mental Health and Pathological Addiction, Azienda USL di Parma, Parma, Italy
| | - Emanuela Quattrone
- Department of Mental Health and Pathological Addiction, Azienda USL di Parma, Parma, Italy
| | - Silvia Azzali
- Department of Mental Health and Pathological Addiction, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Giuseppina Paulillo
- Department of Mental Health and Pathological Addiction, Azienda USL di Parma, Parma, Italy
| | - Pietro Pellegrini
- Department of Mental Health and Pathological Addiction, Azienda USL di Parma, Parma, Italy
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Hu HX, Lau WYS, Ma EPY, Hung KSY, Chen SY, Cheng KS, Cheung EFC, Lui SSY, Chan RCK. The Important Role of Motivation and Pleasure Deficits on Social Functioning in Patients With Schizophrenia: A Network Analysis. Schizophr Bull 2022; 48:860-870. [PMID: 35524755 PMCID: PMC9212088 DOI: 10.1093/schbul/sbac017] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Negative symptoms, particularly the motivation and pleasure (MAP) deficits, are associated with impaired social functioning in patients with schizophrenia (SCZ). However, previous studies seldom examined the role of the MAP on social functioning while accounting for the complex interplay between other psychopathology. This network analysis study examined the network structure and interrelationship between negative symptoms (at the "symptom-dimension" and "symptom-item" levels), other psychopathology and social functioning in a sample of 269 patients with SCZ. The psychopathological symptoms were assessed using the Clinical Assessment Interview for Negative Symptoms (CAINS) and the Positive and Negative Syndrome Scale (PANSS). Social functioning was evaluated using the Social and Occupational Functioning Assessment Scale (SOFAS). Centrality indices and relative importance of each node were estimated. The network structures between male and female participants were compared. Our resultant networks at both the "symptom-dimension" and the "symptom-item" levels suggested that the MAP factor/its individual items were closely related to social functioning in SCZ patients, after controlling for the complex interplay between other nodes. Relative importance analysis showed that MAP factor accounted for the largest proportion of variance of social functioning. This study is among the few which used network analysis and the CAINS to examine the interrelationship between negative symptoms and social functioning. Our findings supported the pivotal role of the MAP factor to determine SCZ patients' social functioning, and as a potential intervention target for improving functional outcomes of SCZ.
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Affiliation(s)
- Hui-Xin Hu
- Neuropsychology and Applied Cognitive Neuroscience Laboratory, CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China,Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Wilson Y S Lau
- Castle Peak Hospital, Hong Kong Special Administrative Region, China
| | - Eugenia P Y Ma
- Department of Adult Psychiatry, Kwai Chung Hospital, Hong Kong Special Administrative Region, China
| | - Karen S Y Hung
- Castle Peak Hospital, Hong Kong Special Administrative Region, China
| | - Si-Yu Chen
- Neuropsychology and Applied Cognitive Neuroscience Laboratory, CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China,Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Kin-Shing Cheng
- Department of Adult Psychiatry, Kwai Chung Hospital, Hong Kong Special Administrative Region, China
| | - Eric F C Cheung
- Castle Peak Hospital, Hong Kong Special Administrative Region, China
| | - Simon S Y Lui
- To whom correspondence should be addressed; Department of Psychiatry, The University of Hong Kong, Hong Kong Special Administrative Region, China; tel/fax: (852) 2831 5343, e-mail:
| | - Raymond C K Chan
- Neuropsychology and Applied Cognitive Neuroscience Laboratory, CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China,Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
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5
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Mustafa SS, Malla A, Joober R, Abadi S, Latimer E, Schmitz N, Jarvis GE, Margolese HC, Casacalenda N, Abdel-Baki A, Iyer SN. Unfinished business: Functional outcomes in a randomized controlled trial of a three-year extension of early intervention versus regular care following two years of early intervention for psychosis. Acta Psychiatr Scand 2022; 145:86-99. [PMID: 34599603 DOI: 10.1111/acps.13377] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 09/25/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To investigate whether first-episode psychosis patients receiving extended early intervention had better functional outcomes than those in regular care and to examine the predictors of functional outcomes. METHODS This is a randomized controlled single-blind trial of 220 patients randomized after 2 years of early intervention to receive early intervention or regular care for the subsequent 3 years. Outcomes included cumulative time in functional recovery during the 3-year trial assessed using the Social and Occupational Functioning Assessment Scale (SOFAS); and employment/education at last assessment which were, respectively, analyzed using multiple linear regression and logistic regression, accounting for well-known predictors. Linear mixed and generalized linear models were also used to examine the course of SOFAS and employment/education over the 3-year period. RESULTS The extended early intervention and regular care groups did not differ on time in functional recovery (mean = 50.17 weeks, SD = 46.62 vs. mean = 46.18 weeks, SD = 51.54); percent employed/in school (60.4% vs. 68.8%) or change in SOFAS or employment/education status over time. SOFAS scores were stable between years 2 and 5. Individuals with longer periods of total symptom remission experienced significantly longer periods of functional recovery and were likelier to be employed/in school. Those who had completed high school were nine times likelier to be employed/studying. CONCLUSION Most individuals maintained functional gains accrued from 2 years of early intervention with no further improvement whether in extended early intervention or regular care. There was a gap between symptomatic and functional recovery, and one-third were unemployed/not in school at year 5. The lack of additional progress even in extended early intervention suggests that specific interventions addressing functional roles need to be provided beyond the first 2 years of early intervention. Sustaining symptom remission and high-school completion may be additional avenues for targeting functional recovery.
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Affiliation(s)
- Sally S Mustafa
- Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Ashok Malla
- Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montreal, QC, Canada.,Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Ridha Joober
- Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montreal, QC, Canada.,Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Sherezad Abadi
- Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Eric Latimer
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Norbert Schmitz
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Douglas Mental Health University Institute, Montreal, QC, Canada.,Department of Population-Based Medicine, Institute of Health Sciences, University Hospital Tuebingen, Tuebingen, Germany
| | - G Eric Jarvis
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Jewish General Hospital, Montreal, QC, Canada
| | - Howard C Margolese
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,McGill University Health Centre, Montreal, QC, Canada
| | - Nicola Casacalenda
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Jewish General Hospital, Montreal, QC, Canada
| | | | - Srividya N Iyer
- Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montreal, QC, Canada.,Department of Psychiatry, McGill University, Montreal, QC, Canada
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6
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Breitborde NJK, Pine JG, Moe AM. Uncontrolled trial of specialized, multi-component care for individuals with first-episode psychosis: Effects on motivation orientations. Early Interv Psychiatry 2021; 15:41-46. [PMID: 31889415 PMCID: PMC9292764 DOI: 10.1111/eip.12907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/20/2019] [Accepted: 12/14/2019] [Indexed: 11/26/2022]
Abstract
AIM Deficits in motivation are present early in the course of psychotic disorders. However, growing data have highlighted important heterogeneity in motivation among individuals with psychosis, suggesting that this variable may not be a unitary concept. Outside of the psychosis literature, research on self-determination theory has identified three motivational orientations that guide the initiation and regulation of behaviour: autonomous, controlled and impersonal. Thus, our study goal is to investigate the longitudinal course of motivational orientations among individuals participating in a specialized clinical service for individuals with first-episode psychosis (ie, coordinated specialty care: CSC). METHODS Forty-one individuals with first-episode psychosis participating in CSC completed assessments of motivation orientations at enrolment and after 6 months of care. RESULTS Whereas there were no changes in controlled or impersonal orientations over the first 6-months of care, individuals with first-episode psychosis reported an increase in autonomous orientations. Moreover, while individuals with first-episode psychosis reported lower autonomous orientations at enrolment as compared to individuals without psychosis, after 6 months of care, ratings of autonomous orientations among individuals with first-episode psychosis were equivalent to those of individuals without psychosis. CONCLUSIONS Although the results should be interpreted cautiously given the uncontrolled study design, the results suggest that the benefits of participation in early intervention services for psychosis may extend to improvements in motivation.
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Affiliation(s)
- Nicholas J K Breitborde
- Department of Psychiatry & Behavioral Health, Early Psychosis Intervention Center (EPICENTER), Columbus, Ohio.,Department of Psychology, The Ohio State University, Columbus, Ohio
| | - Jacob G Pine
- Department of Psychiatry & Behavioral Health, Early Psychosis Intervention Center (EPICENTER), Columbus, Ohio
| | - Aubrey M Moe
- Department of Psychiatry & Behavioral Health, Early Psychosis Intervention Center (EPICENTER), Columbus, Ohio
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7
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Puntis S, Minichino A, De Crescenzo F, Cipriani A, Lennox B, Harrison R. Specialised early intervention teams (extended time) for recent-onset psychosis. Cochrane Database Syst Rev 2020; 11:CD013287. [PMID: 33135812 PMCID: PMC8094422 DOI: 10.1002/14651858.cd013287.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Psychosis is an illness characterised by the presence of hallucinations and delusions that can cause distress or a marked change in an individual's behaviour (e.g. social withdrawal, flat or blunted effect). A first episode of psychosis (FEP) is the first time someone experiences these symptoms that can occur at any age, but the condition is most common in late adolescence and early adulthood. This review is concerned with FEP and the early stages of a psychosis, referred to throughout this review as 'recent-onset psychosis.' Specialised early intervention (SEI) teams are community mental health teams that specifically treat people who are experiencing, or have experienced, a recent-onset psychosis. SEI teams provide a range of treatments including medication, psychotherapy, psychoeducation, educational and employment support, augmented by assertive contact with the service user and small caseloads. Treatment is time limited, usually offered for two to three years, after which service users are either discharged to primary care or transferred to a standard adult community mental health team. Evidence suggests that once SEI treatment ends, improvements may not be sustained, bringing uncertainty about the optimal duration of SEI to ensure the best long-term outcomes. Extending SEI has been proposed as a way of providing continued intensive treatment and continuity of care, of usually up to five years, in order to a) sustain the positive initial outcomes of SEI; and b) improve the long-term trajectory of the illness. OBJECTIVES To compare extended SEI teams with treatment as usual (TAU) for people with recent-onset psychosis. To compare extended SEI teams with standard SEI teams followed by TAU (standard SEI + TAU) for people with recent-onset psychosis. SEARCH METHODS On 3 October 2018 and 22 October 2019, we searched Cochrane Schizophrenia's study-based register of trials, including registries of clinical trials. SELECTION CRITERIA We selected all randomised controlled trials (RCTs) comparing extended SEI with TAU for people with recent-onset psychosis and all RCTs comparing extended SEI with standard SEI + TAU for people with recent-onset psychosis. We entered trials meeting these criteria and reporting usable data as included studies. DATA COLLECTION AND ANALYSIS We independently inspected citations, selected studies, extracted data and appraised study quality. For binary outcomes we calculated the risk ratios (RRs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and their 95% CIs, or if assessment measures differed for the same construct, we calculated the standardised mean difference (SMD) with 95% CIs. We assessed risk of bias for included studies and created a 'Summary of findings' table using the GRADE approach. MAIN RESULTS We included three RCTs, with a total 780 participants, aged 16 to 35 years. All participants met the criteria for schizophrenia spectrum disorders or affective psychoses. No trials compared extended SEI with TAU. All three trials randomly allocated people approximately two years into standard SEI to either extended SEI or standard SEI + TAU. The certainty of evidence for outcomes varied from low to very low. Our primary outcomes were recovery and disengagement from mental health services. No trials reported on recovery, and we used remission as a proxy. Three trials reported on remission, with the point estimate suggesting a 13% increase in remission in favour of extended SEI, but this included wide confidence intervals (CIs) and a very uncertain estimate of no benefit (RR 1.13, 95% CI 0.97 to 1.31; 3 trials, 780 participants; very low-certainty evidence). Two trials provided data on disengagement from services with evidence that extended SEI care may result in fewer disengagements from mental health treatment (15%) in comparison to standard SEI + TAU (34%) (RR 0.45, 95% CI 0.27 to 0.75; 2 trials, 380 participants; low-certainty evidence). There may be no evidence of a difference in rates of psychiatric hospital admission (RR 1.55, 95% CI 0.68 to 3.52; 1 trial, 160 participants; low-certainty evidence), or the number of days spent in a psychiatric hospital (MD -2.70, 95% CI -8.30 to 2.90; 1 trial, 400 participants; low-certainty evidence). One trial found uncertain evidence regarding lower global psychotic symptoms in extended SEI in comparison to standard SEI + TAU (MD -1.90, 95% CI -3.28 to -0.52; 1 trial, 156 participants; very low-certainty evidence). It was uncertain whether the use of extended SEI over standard SEI + TAU resulted in fewer deaths due to all-cause mortality, as so few deaths were recorded in trials (RR 0.38, 95% CI 0.09 to 1.64; 3 trials, 780 participants; low-certainty evidence). Very uncertain evidence suggests that using extended SEI instead of standard SEI + TAU may not improve global functioning (SMD 0.23, 95% CI -0.29 to 0.76; 2 trials, 560 participants; very low-certainty evidence). There was low risk of bias in all three trials for random sequence generation, allocation concealment and other biases. All three trials had high risk of bias for blinding of participants and personnel due to the nature of the intervention. For the risk of bias for blinding of outcome assessments and incomplete outcome data there was at least one trial with high or unclear risk of bias. AUTHORS' CONCLUSIONS There may be preliminary evidence of benefit from extending SEI team care for treating people experiencing psychosis, with fewer people disengaging from mental health services. Evidence regarding other outcomes was uncertain. The certainty of evidence for the measured outcomes was low or very low. Further, suitably powered studies that use a consistent approach to outcome selection are needed, but with only one further ongoing trial, there is unlikely to be any definitive conclusion for the effectiveness of extended SEI for at least the next few years.
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Affiliation(s)
- Stephen Puntis
- Department of Psychiatry, University of Oxford, Oxford, UK
| | | | | | | | - Belinda Lennox
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Rachael Harrison
- Oxford University Medical School, Medical Sciences Divisional Office, Oxford, UK
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8
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Chang WC, Westbrook A, Strauss GP, Chu AOK, Chong CSY, Siu CMW, Chan SKW, Lee EHM, Hui CLM, Suen YM, Lo TL, Chen EYH. Abnormal cognitive effort allocation and its association with amotivation in first-episode psychosis. Psychol Med 2020; 50:2599-2609. [PMID: 31576787 DOI: 10.1017/s0033291719002769] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Abnormal effort-based decision-making represents a potential mechanism underlying motivational deficits (amotivation) in psychotic disorders. Previous research identified effort allocation impairment in chronic schizophrenia and focused mostly on physical effort modality. No study has investigated cognitive effort allocation in first-episode psychosis (FEP). METHOD Cognitive effort allocation was examined in 40 FEP patients and 44 demographically-matched healthy controls, using Cognitive Effort-Discounting (COGED) paradigm which quantified participants' willingness to expend cognitive effort in terms of explicit, continuous discounting of monetary rewards based on parametrically-varied cognitive demands (levels N of N-back task). Relationship between reward-discounting and amotivation was investigated. Group differences in reward-magnitude and effort-cost sensitivity, and differential associations of these sensitivity indices with amotivation were explored. RESULTS Patients displayed significantly greater reward-discounting than controls. In particular, such discounting was most pronounced in patients with high levels of amotivation even when N-back performance and reward base amount were taken into consideration. Moreover, patients exhibited reduced reward-benefit sensitivity and effort-cost sensitivity relative to controls, and that decreased sensitivity to reward-benefit but not effort-cost was correlated with diminished motivation. Reward-discounting and sensitivity indices were generally unrelated to other symptom dimensions, antipsychotic dose and cognitive deficits. CONCLUSION This study provides the first evidence of cognitive effort-based decision-making impairment in FEP, and indicates that decreased effort expenditure is associated with amotivation. Our findings further suggest that abnormal effort allocation and amotivation might primarily be related to blunted reward valuation. Prospective research is required to clarify the utility of effort-based measures in predicting amotivation and functional outcome in FEP.
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Affiliation(s)
- W C Chang
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pok Fu Lam, Hong Kong
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong
| | - A Westbrook
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen 6525 EN, The Netherlands
- Department of Cognitive, Linguistics, and Psychological Sciences, Brown University, Providence, RI02906, USA
| | - G P Strauss
- Department of Psychology, University of Georgia, Athens, GA30602, USA
| | - A O K Chu
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - C S Y Chong
- Department of Psychiatry, Kwai Chung Hospital, Hong Kong
| | - C M W Siu
- Department of Psychiatry, Kwai Chung Hospital, Hong Kong
| | - S K W Chan
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pok Fu Lam, Hong Kong
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong
| | - E H M Lee
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - C L M Hui
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - Y M Suen
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - T L Lo
- Department of Psychiatry, Kwai Chung Hospital, Hong Kong
| | - E Y H Chen
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pok Fu Lam, Hong Kong
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong
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Chang WC, Wong CSM, Or PCF, Chu AOK, Hui CLM, Chan SKW, Lee EMH, Suen YN, Chen EYH. Inter-relationships among psychopathology, premorbid adjustment, cognition and psychosocial functioning in first-episode psychosis: a network analysis approach. Psychol Med 2020; 50:2019-2027. [PMID: 31451127 DOI: 10.1017/s0033291719002113] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Better understanding of interplay among symptoms, cognition and functioning in first-episode psychosis (FEP) is crucial to promoting functional recovery. Network analysis is a promising data-driven approach to elucidating complex interactions among psychopathological variables in psychosis, but has not been applied in FEP. METHOD This study employed network analysis to examine inter-relationships among a wide array of variables encompassing psychopathology, premorbid and onset characteristics, cognition, subjective quality-of-life and psychosocial functioning in 323 adult FEP patients in Hong Kong. Graphical Least Absolute Shrinkage and Selection Operator (LASSO) combined with extended Bayesian information criterion (BIC) model selection was used for network construction. Importance of individual nodes in a generated network was quantified by centrality analyses. RESULTS Our results showed that amotivation played the most central role and had the strongest associations with other variables in the network, as indexed by node strength. Amotivation and diminished expression displayed differential relationships with other nodes, supporting the validity of two-factor negative symptom structure. Psychosocial functioning was most strongly connected with amotivation and was weakly linked to several other variables. Within cognitive domain, digit span demonstrated the highest centrality and was connected with most of the other cognitive variables. Exploratory analysis revealed no significant gender differences in network structure and global strength. CONCLUSION Our results suggest the pivotal role of amotivation in psychopathology network of FEP and indicate its critical association with psychosocial functioning. Further research is required to verify the clinical significance of diminished motivation on functional outcome in the early course of psychotic illness.
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Affiliation(s)
- W C Chang
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, Hong Kong
| | - C S M Wong
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong
| | - P C F Or
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong
| | - A O K Chu
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong
| | - C L M Hui
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong
| | - S K W Chan
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, Hong Kong
| | - E M H Lee
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong
| | - Y N Suen
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong
| | - E Y H Chen
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, Hong Kong
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Makowski C, Lewis JD, Lepage C, Malla AK, Joober R, Evans AC, Lepage M. Intersection of verbal memory and expressivity on cortical contrast and thickness in first episode psychosis. Psychol Med 2020; 50:1923-1936. [PMID: 31456533 DOI: 10.1017/s0033291719002071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Longitudinal studies of first episode of psychosis (FEP) patients are critical to understanding the dynamic clinical factors influencing functional outcomes; negative symptoms and verbal memory (VM) deficits are two such factors that remain a therapeutic challenge. This study uses white-gray matter contrast at the inner edge of the cortex, in addition to cortical thickness, to probe changes in microstructure and their relation with negative symptoms and possible intersections with verbal memory. METHODS T1-weighted images and clinical data were collected longitudinally for patients (N = 88) over a two-year period. Cognitive data were also collected at baseline. Relationships between baseline VM (immediate/delayed recall) and rate of change in two negative symptom dimensions, amotivation and expressivity, were assessed at the behavioral level, as well as at the level of brain structure. RESULTS VM, particularly immediate recall, was significantly and positively associated with a steeper rate of expressivity symptom decline (r = 0.32, q = 0.012). Significant interaction effects between baseline delayed recall and change in expressivity were uncovered in somatomotor regions bilaterally for both white-gray matter contrast and cortical thickness. Furthermore, interaction effects between immediate recall and change in expressivity on cortical thickness rates were uncovered across higher-order regions of the language processing network. CONCLUSIONS This study shows common neural correlates of language-related brain areas underlying expressivity and VM in FEP, suggesting deficits in these domains may be more linked to speech production rather than general cognitive capacity. Together, white-gray matter contrast and cortical thickness may optimally inform clinical investigations aiming to capture peri-cortical microstructural changes.
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Affiliation(s)
- Carolina Makowski
- McGill Centre for Integrative Neuroscience, McGill University, Montreal, Canada
- McConnell Brain Imaging Centre, Montreal Neurological Institute, Montreal, Canada
- Ludmer Centre for Neuroinformatics and Mental Health, Montreal, Canada
- Department of Psychiatry, McGill University, Verdun, Canada
| | - John D Lewis
- McGill Centre for Integrative Neuroscience, McGill University, Montreal, Canada
- McConnell Brain Imaging Centre, Montreal Neurological Institute, Montreal, Canada
- Ludmer Centre for Neuroinformatics and Mental Health, Montreal, Canada
| | - Claude Lepage
- McGill Centre for Integrative Neuroscience, McGill University, Montreal, Canada
- McConnell Brain Imaging Centre, Montreal Neurological Institute, Montreal, Canada
- Ludmer Centre for Neuroinformatics and Mental Health, Montreal, Canada
| | - Ashok K Malla
- Department of Psychiatry, McGill University, Verdun, Canada
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Verdun, Canada
| | - Ridha Joober
- Department of Psychiatry, McGill University, Verdun, Canada
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Verdun, Canada
| | - Alan C Evans
- McGill Centre for Integrative Neuroscience, McGill University, Montreal, Canada
- McConnell Brain Imaging Centre, Montreal Neurological Institute, Montreal, Canada
- Ludmer Centre for Neuroinformatics and Mental Health, Montreal, Canada
| | - Martin Lepage
- Department of Psychiatry, McGill University, Verdun, Canada
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Verdun, Canada
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11
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Makowski C, Lewis JD, Khundrakpam B, Tardif CL, Palaniyappan L, Joober R, Malla A, Shah JL, Bodnar M, Chakravarty MM, Evans AC, Lepage M. Altered hippocampal centrality and dynamic anatomical covariance of intracortical microstructure in first episode psychosis. Hippocampus 2020; 30:1058-1072. [PMID: 32485018 DOI: 10.1002/hipo.23215] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 12/23/2022]
Abstract
Hippocampal circuitry has been posited to be fundamental to positive symptoms in psychosis, but its contributions to other factors important for outcome remains unclear. We hypothesized that longitudinal changes in the hippocampal circuit and concomitant changes of intracortical microstructure are altered in first episode psychosis (FEP) patients and that such changes are associated with negative symptoms and verbal memory. Longitudinal brain scans (2-4 visits over 3-15 months) were acquired for 27 FEP and 29 age- and sex-matched healthy controls. Quantitative T1 maps, sensitive to myelin content, were used to sample the microstructure of the hippocampal subfields and output circuitry (fimbria, alveus, fornix, mammillary bodies), and intracortical regions. Dynamic anatomical covariance in pair-wise regional trajectories were assessed for each subject, and graph theory was used to calculate a participation coefficient metric that quantifies the similarity/divergence between hippocampal and intracortical microstructure. The mean participation coefficient of the hippocampus was significantly reduced in FEP patients compared with controls, reflecting differences in output hippocampal regions. Importantly, lower participation coefficient of the hippocampal circuit was associated with worse negative symptoms, a relationship that was mediated by changes in verbal memory. This study provides evidence for reduced hippocampal centrality in FEP and concomitant changes in intracortical anatomy. Myelin-rich output regions of the hippocampus may be an important biological trigger in early psychosis, with cascading effects on broader cortical networks and resultant clinical profiles.
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Affiliation(s)
- Carolina Makowski
- Department of Psychiatry, Douglas Mental Health University Institute, Verdun, Quebec, Canada.,McGill Centre for Integrative Neuroscience, McGill University, Montreal, Quebec, Canada.,Department of Radiology, University of California San Diego, La Jolla, California, USA
| | - John D Lewis
- McGill Centre for Integrative Neuroscience, McGill University, Montreal, Quebec, Canada
| | | | - Christine L Tardif
- Department of Biological and Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Lena Palaniyappan
- Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Ridha Joober
- Department of Psychiatry, Douglas Mental Health University Institute, Verdun, Quebec, Canada.,Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Ashok Malla
- Department of Psychiatry, Douglas Mental Health University Institute, Verdun, Quebec, Canada.,Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Jai L Shah
- Department of Psychiatry, Douglas Mental Health University Institute, Verdun, Quebec, Canada.,Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Michael Bodnar
- Royal Ottawa Mental Health Centre, University of Ottawa, Ottawa, Ontario, Canada
| | - M Mallar Chakravarty
- Department of Psychiatry, Douglas Mental Health University Institute, Verdun, Quebec, Canada.,Department of Biological and Biomedical Engineering, McGill University, Montreal, Quebec, Canada.,Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Alan C Evans
- McGill Centre for Integrative Neuroscience, McGill University, Montreal, Quebec, Canada.,Department of Biological and Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Martin Lepage
- Department of Psychiatry, Douglas Mental Health University Institute, Verdun, Quebec, Canada.,Department of Psychiatry, McGill University, Montreal, Quebec, Canada
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12
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Dama M, Veru F, Schmitz N, Shah J, Iyer S, Joober R, Malla A. Sex Differences in Clinical and Functional Outcomes among Patients Treated in an Early Intervention Service for Psychotic Disorders: An Observational Study. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2019; 64:708-717. [PMID: 31189340 PMCID: PMC6783666 DOI: 10.1177/0706743719854069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE It has been shown that men with a longstanding psychotic disorder have worse clinical and functional outcomes than women. Our objectives were to examine whether these sex differences are also present among patients treated in an early intervention service (EIS) for psychosis and to determine if these differences are related to risk factors other than sex. METHOD Patients (N = 569) were assessed for demographic/clinical characteristics at entry and for symptoms/functioning over 2 years of treatment. Clinical outcomes included remission of positive, negative, and total symptoms. Functional outcomes included good functioning and functional remission. Logistic regression models examined the relationship between sex and outcomes after 1 and 2 years of treatment while controlling for the influence of other risk factors. RESULTS Men reported to be less educated and have a longer duration of untreated psychosis, poorer childhood and early adolescent premorbid functioning, higher rates of substance abuse/dependence disorders, greater severity of baseline negative symptoms, and poorer baseline social/occupational functioning than women. Women were more likely to achieve symptom remission than men after 2 years of treatment (negative odds ratio [OR], 1.69; 95% confidence interval [CI], 1.02 to 2.78; total OR, 1.79; 95% CI, 1.08 to 2.98). Women were also more likely than men to exhibit good functioning (OR, 1.61; 95% CI, 1.04 to 2.49) after 1 but not after 2 years of treatment. These results did not persist after controlling for other risk factors that could confound these associations (i.e., childhood premorbid functioning and age at onset of psychosis). CONCLUSIONS Sex differences seen in outcomes among patients treated in an EIS for psychosis may be largely influenced by the disparity of other risk factors that exist between the 2 sexes.
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Affiliation(s)
- Manish Dama
- Prevention and Early Intervention Program for Psychosis (PEPP-Montreal), Douglas Mental Health University Institute, Montreal, Quebec
| | - Franz Veru
- Department of Psychiatry, McGill University, Montreal, Quebec
| | - Norbert Schmitz
- Department of Psychiatry, McGill University, Montreal, Quebec
| | - Jai Shah
- Prevention and Early Intervention Program for Psychosis (PEPP-Montreal), Douglas Mental Health University Institute, Montreal, Quebec.,Department of Psychiatry, McGill University, Montreal, Quebec
| | - Srividya Iyer
- Prevention and Early Intervention Program for Psychosis (PEPP-Montreal), Douglas Mental Health University Institute, Montreal, Quebec.,Department of Psychiatry, McGill University, Montreal, Quebec
| | - Ridha Joober
- Prevention and Early Intervention Program for Psychosis (PEPP-Montreal), Douglas Mental Health University Institute, Montreal, Quebec.,Department of Psychiatry, McGill University, Montreal, Quebec
| | - Ashok Malla
- Prevention and Early Intervention Program for Psychosis (PEPP-Montreal), Douglas Mental Health University Institute, Montreal, Quebec.,Department of Psychiatry, McGill University, Montreal, Quebec
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