Personalised treatment for cognitive dysfunction in individuals with schizophrenia spectrum disorders

Personalized Cognitive Health in Psychiatry: Current State and the Promise of Computational Methods

BACKGROUND

Decades of research have firmly established that cognitive health and cognitive treatment services are a key need for people living with psychosis. However, many current clinical programs do not address this need, despite the essential role that an individual's cognitive and social cognitive capacities play in determining their real-world functioning. Preliminary practice-based research in the Early Psychosis Intervention Network early psychosis intervention network shows that it is possible to develop and implement tools that delineate an individuals' cognitive health profile and that help engage the client and the clinician in shared decision-making and treatment planning that includes cognitive treatments. These findings signify a promising shift toward personalized cognitive health.

STUDY DESIGN

Extending upon this early progress, we review the concept of interindividual variability in cognitive domains/processes in psychosis as the basis for offering personalized treatment plans. We present evidence from studies that have used traditional neuropsychological measures as well as findings from emerging computational studies that leverage trial-by-trial behavior data to illuminate the different latent strategies that individuals employ.

STUDY RESULT

We posit that these computational techniques, when combined with traditional cognitive assessments, can enrich our understanding of individual differences in treatment needs, which in turn can guide evermore personalized interventions.

CONCLUSION

As we find clinically relevant ways to decompose maladaptive behaviors into separate latent cognitive elements captured by model parameters, the ultimate goal is to develop and implement approaches that empower clients and their clinical providers to leverage individual's existing learning capacities to improve their cognitive health and well-being.

Effect of individualized occupational therapy on cognition among patients with schizophrenia: A randomized controlled trial

This study aimed to evaluate the feasibility and efficacy of individualized occupational therapy (IOT) plus group occupational therapy (GOT) as standard care for cognition compared to GOT alone, and to determine which IOT component has the greatest effect on cognitive outcome in patients with schizophrenia. This study was conducted at 14 clinical sites across Japan and enrolled recently hospitalized patients with schizophrenia. The IOT consisted of motivational interview, self-monitoring, individualized visits, craft activities, individualized psychoeducation, and discharge planning. Among the 68 patients who were randomized to the GOT + IOT group (n = 34) and GOT alone group (n = 34), 67 completed the trial (GOT + IOT group, n = 34; GOT alone group, n = 33). There were significant improvements in change from baseline to post-treatment between the groups in verbal memory, working memory, verbal fluency, attention, executive function domains, and the composite score of the Brief Assessment of Cognition in Schizophrenia (BACS). The BACS composite score was significantly associated with the number of craft activity sessions. The addition of IOT to GOT has a favorable feasibility profile and efficacy for cognition in schizophrenia. Craft activity is the most effective IOT component in improving cognition.

Moderators of functional improvement after integrative cognitive remediation in schizophrenia: Toward a personalized treatment approach

Cognitive remediation is an effective intervention for improving functional outcome in schizophrenia. However, the factors that moderate this improvement are still poorly understood. The study aimed to identify moderators of functional outcome improvement after integrative cognitive remediation (REHACOP) in schizophrenia. This was a secondary analysis of data from two randomized controlled trials, which included 182 patients (REHACOP group=94; active control group=88). Hierarchical regression analyses were conducted to identify moderators of functional outcome improvement. Two baseline level groups (low-level and high-level) were created to analyze the moderating role of this baseline level cluster using repeated measures ANCOVA. The REHACOP was effective regardless of participants' baseline level, but regression analyses indicated that the effectiveness on functional outcome was higher among those who were older, had fewer years in education, lower scores in baseline cognition and functional outcome, and more negative symptoms. Repeated measures ANOVA showed that the baseline level cluster influenced the improvement in functional outcome, with the low-level group showing greater improvements. The results reinforced the need to implement cognitive remediation programs more broadly as a treatment for schizophrenia in healthcare services. Furthermore, they provided evidence for the development of personalized cognitive remediation plans to improve benefits in different schizophrenia profiles.

Comparison of executive functions in individuals with high and low levels of schizotypal trait

The dimensional approach to Schizotypal Personality Disorder (SPD) indicates that SPD includes a constellation of maladaptive personality traits on a continuum with general personality functioning. This study aimed to compare executive functions (EFs) in low and high-level schizotypal individuals. Using a convenient sampling method, we recruited 120 individuals, from which 30 individuals with high schizotypal trait levels (fourth quartile) and 30 participants with lower schizotypal trait levels (first quartile) were selected based on their scores on the schizotypal personality disorder questionnaire. Then, participants from the two groups were administered the Corsi Block-Tapping Test (CBTT), Wisconsin Card Sorting Test (WCST), and Continuance Performance Test (CPT). The results indicated individuals with higher schizotypy trait levels performed significantly poorer in tasks measuring working-visual-spatial memory, cognitive flexibility, sustained attention, and response inhibition. This pattern of results indicated that EF dysfunctions in individuals with higher schizotypy trait levels would cause significant disturbances in multiple areas of life. The practical implications of the findings are further discussed.

Examining the association of life course neurocognitive ability with real-world functioning in schizophrenia-spectrum disorders

There is considerable variability in neurocognitive functioning within schizophrenia-spectrum disorders, and neurocognitive performance ranges from severe global impairment to normative performance. Few investigations of neurocognitive clusters have considered the degree to which deterioration relative to premorbid neurocognitive abilities is related to key illness characteristics. Moreover, while neurocognition and community functioning are strongly related, understanding of the sources of variability in the association between these two domains is also limited; it is unknown what proportion of participants would over-perform or under-perform the level of functioning expected based on current neurocognitive performance vs. lifelong attainment. This study examined data from 954 outpatients with schizophrenia-spectrum disorders across three previous studies. Neurocognition, community functioning, and symptoms were assessed. Neurocognitive subgroups were created based on current neurocognition, estimated premorbid IQ, and degree of deterioration from premorbid using z-score cut-offs; functional subgroups were created with cluster analysis based on the Specific Level of Functioning Scale and current neurocognition. The sample was neurocognitively heterogeneous; 65% displayed current neurocognitive impairment and 84% experienced some level of deterioration. Thirty percent of our sample was relatively higher functioning despite significant neurocognitive impairment. Individuals with better community functioning, regardless of neurocognitive performance, had lower symptom severity compared to those with worse functioning. These results highlight the variability in neurocognition and its role in functioning. Understanding individual differences in neurocognitive and functional profiles and the interaction between prior and current cognitive functioning can guide individualized treatment and selection of participants for clinical treatment studies.

An Update on Treatment of Cognitive Impairment Associated with Schizophrenia

Cognitive impairment associated with schizophrenia (CIAS) is widely regarded as a critically important treatment target for schizophrenia. Despite major efforts and a number of promising findings, we do not yet have an approved drug for CIAS. Similarly, promising cognitive remediation approaches are limited in their ability to help patients achieve real-world functional gains on a wide scale. This article provides an update and critical evaluation of recent treatment development activities for CIAS. First, we provide update on pharmacological approaches, which include a glutamatergic drug that is currently in Phase III trials for CIAS, and discuss factors that may have impacted past efforts to identify efficacious drugs. Second, we review positive findings, limitations, and current trends involving cognitive remediation approaches. Third, we consider newer transdiagnostic approaches aimed at looking beyond, or identifying more homogenous subgroups within, the diagnostic category schizophrenia to advance treatment development. Despite its many challenges, treatment development for CIAS remains a major public health issue and research continues to push forward on several encouraging fronts.

Cognitive remediation for people with bipolar disorder: The contribution of session attendance and therapy components to cognitive and functional outcomes

BACKGROUND

Cognitive remediation (CR) can reduce cognitive and functional difficulties in people with bipolar disorder (BD). To date, there is limited evidence on the contribution of session attendance and therapy components to treatment outcomes. This study explores whether attendance and core CR components contribute to treatment outcomes.

METHODS

This is a secondary analysis using data from a randomized controlled trial comparing CR plus treatment-as-usual (TAU; n = 40) to TAU only (n = 40) in euthymic people with BD. Session attendance was measured by number of sessions and by achieving therapy completion, pre-defined as attending ≥20 sessions. We used instrumental variable analysis to examine the effect of attendance on treatment outcomes. We then considered the association between core therapy components (i.e., massed practice, errorless learning, strategy use, therapist contact) and post-treatment outcome changes using correlation.

RESULTS

The CR group improved significantly in measure of global cognition, psychosocial functioning, and goal attainment. Therapy recipients attended 27.1 sessions on average, with 32 (80%) completing the minimum number of 20 sessions. Attending more sessions and achieving therapy completion were associated with improved treatment outcomes, but this relationship was not significant within the subgroup of CR completers. Improvement in psychosocial functioning was associated with therapist contact and goal attainment with selecting useful strategies during therapy.

CONCLUSIONS

Our findings highlight the relevance of session attendance, specifically the importance of achieving a minimum threshold of CR sessions, for outcome improvement. Strategy use and therapist contact might facilitate improvements in psychosocial functioning and personal recovery goals.

Multivariate pattern analysis of brain structure predicts functional outcome after auditory-based cognitive training interventions

Cognitive gains following cognitive training interventions are associated with improved functioning in people with schizophrenia (SCZ). However, considerable inter-individual variability is observed. Here, we evaluate the sensitivity of brain structural features to predict functional response to auditory-based cognitive training (ABCT) at a single-subject level. We employed whole-brain multivariate pattern analysis with support vector machine (SVM) modeling to identify gray matter (GM) patterns that predicted higher vs. lower functioning after 40 h of ABCT at the single-subject level in SCZ patients. The generalization capacity of the SVM model was evaluated by applying the original model through an out-of-sample cross-validation analysis to unseen SCZ patients from an independent validation sample who underwent 50 h of ABCT. The whole-brain GM volume-based pattern classification predicted higher vs. lower functioning at follow-up with a balanced accuracy (BAC) of 69.4% (sensitivity 72.2%, specificity 66.7%) as determined by nested cross-validation. The neuroanatomical model was generalizable to an independent cohort with a BAC of 62.1% (sensitivity 90.9%, specificity 33.3%). In particular, greater baseline GM volumes in regions within superior temporal gyrus, thalamus, anterior cingulate, and cerebellum predicted improved functioning at the single-subject level following ABCT in SCZ participants. The present findings provide a structural MRI fingerprint associated with preserved GM volumes at a single baseline timepoint, which predicted improved functioning following an ABCT intervention, and serve as a model for how to facilitate precision clinical therapies for SCZ based on imaging data, operating at the single-subject level.

Effectiveness, Core Elements, and Moderators of Response of Cognitive Remediation for Schizophrenia: A Systematic Review and Meta-analysis of Randomized Clinical Trials

Importance

Cognitive impairment is a core feature of schizophrenia, with negative consequences on functional outcomes. Although cognitive remediation (CR) is effective and mentioned in treatment guidance for schizophrenia, its active ingredients and ideal candidates are still debated.

Objective

To provide a comprehensive update on CR effectiveness for cognition and functioning in schizophrenia and analyze the core ingredients of efficacy and role of patient characteristics.

Data Sources

The reference list of the last comprehensive meta-analysis in 2011 was screened against eligibility criteria. Then, electronic databases (PubMed, Scopus, and PsycInfo) were systematically searched for articles published from January 2011 to February 2020. Reference lists of included articles and relevant reviews were hand searched, and Google Scholar was manually inspected.

Study Selection

Eligible studies were randomized clinical trials comparing CR with any other control condition in patients diagnosed with schizophrenia spectrum disorders (with an unrestricted clinical status). Screening was performed by at least 2 independent reviewers.

Data Extraction and Synthesis

The PRISMA guidelines were followed. Study data were independently extracted and pooled using random-effect models. Cohen d was used to measure outcomes. Trial methodological quality was evaluated with the Clinical Trials Assessment Measure.

Main Outcomes and Measures

Primary outcomes were changes in global cognition and overall functioning from baseline to after treatment, subsequently investigated through metaregressions, subgroup, and sensitivity analyses based on prespecified hypotheses, to identify potential moderators of response associated with treatment modality and patient characteristics.

Results

Of 1815 identified reports, 358 full texts were assessed and 194 reports on 130 studies were included. Based on 130 studies with 8851 participants, CR was effective on cognition (d, 0.29 [95% CI, 0.24-0.34]) and functioning (d, 0.22 [95% CI, 0.16-0.29]). An active and trained therapist (cognition: χ21, 4.14; P = .04; functioning: χ21, 4.26; P = .04), structured development of cognitive strategies (cognition: χ21, 9.34; P = .002; functioning: χ21, 8.12; P = .004), and integration with psychosocial rehabilitation (cognition: χ21, 5.66; functioning: χ21, 12.08) were crucial ingredients of efficacy. Patients with fewer years of education (global cognition: coefficient, -0.055 [95% CI, -0.103 to -0.006]; P = .03; global functioning: coefficient, -0.061 [95% CI, -0.112 to -0.011]; P = .02), lower premorbid IQ (global functioning: coefficient, -0.013 [-0.025 to -0.001]; P = .04), and higher baseline symptom severity (global cognition: coefficient, 0.006 [95% CI, 0.002 to 0.010]; P = .005) emerged as optimal candidates.

Conclusions and Relevance

These findings show that CR is an evidence-based intervention that should be included consistently into clinical guidelines for the treatment of individuals with schizophrenia and implemented more widely in clinical practice.

Achieving better outcomes for schizophrenia patients in Hong Kong: Strategies for improving treatment adherence

Recent research on second-generation long-acting injectable antipsychotics (LAI SGAs) has proven its effectiveness in minimizing medication nonadherence problem and reducing relapses. Administered by medical professionals, making quick detection of nonadherence possible, long-acting injectable antipsychotics (LAIs) facilitate immediate intervention and recovery process, and thus are favored by psychiatrists. Despite a higher initial cost with LAIs, the subsequent schizophrenia-related health costs for hospitalizations and outpatients are greatly reduced. With reference to guidelines published by psychiatric associations around the globe, this article looks at scenarios in Hong Kong on the management of severe mentally ill patients with regard to the use of a host of psychosocial interventions as well as LAI SGAs as a preferable treatment. In particular, it examines the benefits of using LAI SGAs for Hong Kong patients who demonstrated high nonadherence treatment rates due to their social environment. It assesses the rationale behind the early usages of LAI SGAs, which help to provide better recovery outcomes for patients.

Exploring the role of age as a moderator of cognitive remediation for people with schizophrenia

BACKGROUND

While Cognitive Remediation (CR) is effective in reducing cognitive and functioning difficulties in people with schizophrenia, there is variability in treatment response. Previous research suggested that participants' age may be a significant moderator of CR response.

AIM

To examine the impact of participants' age on CR outcomes.

METHOD

Individual participant data were accessed from fourteen CR randomised controlled trials. We tested the moderating effect of participants' age on cognitive and functioning outcomes using multivariate linear models.

RESULTS

Data from 1084 people with a diagnosis of schizophrenia were considered. Participants had a mean age of 36.6 years (SD 11), with 11.6 years of education (SD 2.8), and an average duration of illness of 13.5 years (SD 10.7). Multivariate models showed that participants' age, when considered as a continuous variable, was not a significant moderator of treatment effect for cognitive and functioning outcomes. However, when participants were split by median age, younger participants showed higher gains in executive functions following CR compared to older participants (p=0.02).

CONCLUSION

These results suggest that participants' age does not moderate most CR outcomes. However, larger age differences may influence the effect of CR on executive function. This may suggest some adaptation of CR practice according to participants' age. These findings inform the CR personalisation agenda.

The Implementation and Review of Cognitive Remediation Training for First Episode Psychosis in Singapore

Objective: Early intervention in patients with first episode psychosis (FEP) can improve cognitive abilities, with both short- and long-term benefits. In this paper, we describe the implementation and review of cognitive remediation training (CRT) in an Asian FEP population. The outcomes of the training are also evaluated and discussed. Methods: This naturalistic paper describes in detail the real-life implementation and conduct of CRT in an early psychosis intervention service. One hundred and nine patients with FEP underwent a 24-session CRT programme, using Cogpack and Neuropsychological Educational Approach to Remediation. The program is evaluated with pre- and post-CRT assessment scores which included Montreal Cognitive Assessment and Brief Assessment of Cognition in Schizophrenia. The rates of improvement on these cognitive assessments were evaluated using paired t-tests, with statistical significance set at p ≤ 0.05. Results: Of the 109 patients who underwent CRT, a total of 92 (84.4%) completed all 24 sessions. Paired t-tests between pre- and post-CRT assessments scores revealed that participants significantly improved on majority of the measures, including verbal memory, digit sequencing, and symbol coding. Conclusion: As with other cognitive remediation programmes, CRT has shown to improve cognitive functioning in patients with FEP. The results support the use of CRT in an Asian context and may serve as guidance for the implementation of similar training programmes in other Asian early psychosis intervention services.

Neuropsychological, clinical and environmental predictors of severe mental disorders in offspring of patients with schizophrenia

Offspring of individuals with schizophrenia (SZCOff) are at an increased risk for this disorder. Neuropsychological decline is a core feature of the disorder and researchers have reported increasing impairments in cognition during the prodromal phase in high-risk adolescents. Additionally, factors like the presence of prodromal symptoms or specific behavioral patterns could predict, together with neurocognitive functioning, the risk of conversion to severe mental disorders in SCZOff. This study aims to compare the neuropsychological functioning of a sample of 41 SCZOff children and adolescents and 105 community control offspring (CCOff) and to develop a prediction model to examine whether neuropsychological functioning, clinical and behavioral factors predict subsequent risk of severe mental disorders. We collected demographic, clinical and neuropsychological data. We found significant differences between groups in working memory, speed of processing, verbal memory and learning, visual memory and intelligence quotient (IQ). The socioeconomic status, verbal memory, working memory and positive prodromal symptoms predicted a significant proportion of the dependent variable variance. In conclusion, SCZOff showed neurocognitive impairments in several neuropsychological domains compared to CCOff. Neuropsychological functioning, environmental factors and positive prodromal symptoms could predict the risk of onset of severe mental disorders in SCZOff.

A meta-analysis of the associations between theory of mind and neurocognition in schizophrenia

Theory of mind (ToM) refers to the ability to infer the mental states of others. ToM is impaired in schizophrenia and these deficits seem to hinder functional recovery. ToM is thus an important, but complex treatment target, supported by several processes. A large number of studies report significant associations between ToM and neurocognition (e.g. memory, attention), but the neurocognitive domains that are most closely linked to ToM remain to be identified. A meta-analysis was conducted to estimate the magnitude of the associations between ToM and neurocognition in people with schizophrenia. Correlations were extracted from the relevant literature, transformed into effect sizes Zr and pooled as weighted means. Focused-tests were employed to test for differences between neurocognitive domains and for differences linked to the characteristics of ToM tasks. Ninety-one studies (N = 5462) were included. Moderate associations emerged between ToM and each neurocognitive domain (Zrs 0.27-0.43), with no significant difference between domains (χ2(8) = 11.89, p = 0.156). Within the domain of executive functions, abstraction showed a stronger association with ToM (χ2(4) = 18.93, p = 0.001). Several ToM tasks characteristics (e.g. modality of stimuli, type of mental state), were significantly related to the magnitude of the associations between ToM and executive functions, visuospatial/problem solving, attention and episodic memory. These results suggest that ToM is linked to a wide range of neurocognitive abilities in schizophrenia, and that ToM tasks are a significant moderator of these associations. The assessment and treatment of ToM should consider the neurocognitive profile of each patient to understand his difficulties and to tailor interventions.

Employment, Studies and Feelings: Two to Nine Years After a Personalized Program of Cognitive Remediation in Psychiatric Patients

Employment rate in psychiatry is around 10 to 30%. Cognitive remediation (CR) associated with psychosocial rehabilitation shows good functional outcomes, with a high level of satisfaction in participants provided by tailored CR. However, few studies looked at the long-term outcome in participants who experienced such a program. This retrospective survey examines the outcome of persons having psychiatric diseases 2 to 9 years after being treated with a personalized CR program. The survey included 12 domains with questions relevant to work, studies, before CR (T1) and at the moment of the survey (T2), questions about housing, relatedness, familiar relationships and daily activities at T2. Finally, a narrative interview was included to express feelings of the participants about CR. Sixty-six participants completed the survey, and were treated with neurocognitive or social cognition programs. Their diagnosis was: schizophrenia (80.3%), neurodevelopment disorder (autism as well as genetic or metabolic disease with psychiatric expression) (15.2%) and bipolar disorder (4.5%). The comparison between T1 and T2 showed significant difference for job employment (P < 0.001), even for competitive jobs (p < 0.007), for performing studies (p = 0.033), for practicing a physical activity (0.033) or reading (0.002). Outcome was also examined in reference to the delay from CR to highlight changes in patient characteristics and service delivery over the years. Hence, the total sample was split in two subgroups: CR delivered in 2009-2013 (n = 37); CR delivered in 2014-2016 (n = 29). While in the former group more participants were working (p = 0.037), in the latter group, which was younger (p = 0.04), more participants were studying (p = 0.02). At T2, a majority of persons experienced no relapse, three years (79.1%) to 8 years (56.8%) after CR, when referring to the anamnesis. Concerning subjective perception of CR, participants expressed feelings concerning positive impact on clarity of thought, on cognitive functions, self-confidence, perceiving CR as an efficient help for work and studies. To conclude, even long years after a personalized CR program, good benefits in terms of employment or studies emerge when compared to the status before CR, with good determinants for recovery in terms of leisure or physical activity practice.

Grant Report on d-Serine Augmentation of Neuroplasticity-Based Auditory Learning in Schizophrenia †

We report on the rationale and design of an ongoing NIMH sponsored R61-R33 project in schizophrenia/schizoaffective disorder. This project studies augmenting the efficacy of auditory neuroplasticity cognitive remediation (AudRem) with d-serine, an N-methyl-d-aspartate-type glutamate receptor (NMDAR) glycine-site agonist. We operationalize improved (smaller) thresholds in pitch (frequency) between successive auditory stimuli after AudRem as improved plasticity, and mismatch negativity (MMN) and auditory θ as measures of functional target engagement of both NMDAR agonism and plasticity. Previous studies showed that AudRem alone produces significant, but small cognitive improvements, while d-serine alone improves symptoms and MMN. However, the strongest results for plasticity outcomes (improved pitch thresholds, auditory MMN and θ) were found when combining d-serine and AudRem. AudRem improvements correlated with reading and other auditory cognitive tasks, suggesting plasticity improvements are predictive of functionally relevant outcomes. While d-serine appears to be efficacious for acute AudRem enhancement, the optimal dose remains an open question, as does the ability of combined d-serine + AudRem to produce sustained improvement. In the ongoing R61, 45 schizophrenia patients will be randomized to receive three placebo-controlled, double-blind d-serine + AudRem sessions across three separate 15 subject dose cohorts (80/100/120 mg/kg). Successful completion of the R61 is defined by ≥moderate effect size changes in target engagement and correlation with function, without safety issues. During the three-year R33, we will assess the sustained effects of d-serine + AudRem. In addition to testing a potentially viable treatment, this project will develop a methodology to assess the efficacy of novel NMDAR modulators, using d-serine as a "gold-standard".

A systematic review of moderators of cognitive remediation response for people with schizophrenia

Background

There is evidence that cognitive remediation (CR) is moderately effective in improving cognitive and functional difficulties in people with schizophrenia. However, there is still a limited understanding of what influence different treatment responses.

Aim

To identify moderators influencing CR response in people with schizophrenia.

Methods

This systematic review follows PRISMA guidelines. Searches were conducted up to January 2019 on PubMed and PsychInfo to identify randomized controlled trials of CR reporting analyses of moderators of treatment response. All papers were assessed for methodological quality and information on sample size, intervention and control condition, moderators, outcomes, effect of moderator on outcomes and demographic characteristics from each study was extracted and critically summarised.

Results

Thirty-six studies were included, considering 2737 participants. Study participants consisted on average of people in their late-thirties, mostly men, with over 10 years of illness. The review identified moderators that could be grouped into five categories: demographics, biological, cognitive and functional, psychological, and illness-related characteristics. The assessment of methodological quality showed that many studies had a high risk of bias.

Conclusions

There was no high-quality replicated evidence which identifies reliable moderators of CR response. Many moderators were not replicated or presented in single, underpowered studies. Studies also investigated moderators independently despite their potential to overlap (e.g. age and education). Future research should concentrate on evaluating, with sound studies, the role moderators may play in affecting CR treatment response. This information can inform who will benefit most from the therapy and help to improve the benefits of CR.

Motivation and engagement during cognitive training for schizophrenia spectrum disorders

Background

Motivation and engagement are important factors associated with therapeutic outcomes in cognitive training for schizophrenia. The goals of the present report were to examine relations between objective treatment engagement (number of sessions attended, amount of homework completed) and self-reported motivation (intrinsic motivation and perceived competence to complete cognitive training) with neurocognitive and functional outcomes from cognitive training.

Methods

Data from a clinical trial comparing two cognitive training approaches in schizophrenia-spectrum disorders were utilized in the current report (n = 38). Relations were examined between baseline intrinsic motivation, perceived competence, homework completion, and session attendance with improvements in neurocognition, functional competence, and community functioning.

Results

Number of sessions attended (r = 0.38) and time doing homework (r = 0.51) were significantly associated with improvements in neurocognition. Homework completion was associated with change in community functioning at a trend-level (r = 0.30). Older age was associated with greater treatment engagement (β = 0.37) and male biological sex was associated with greater self-reported motivation (β = 0.43). Homework completion significantly mediated the relationship between session attendance and neurocognitive treatment outcomes.

Conclusions

Objective measures of treatment engagement were better predictors of treatment outcomes than subjective measures of motivation. Homework completion was most strongly related to treatment outcomes and mediated the relationship between session attendance and treatment outcomes, suggesting continued engagement with cognitive stimulation may be an especially important component of cognitive remediation programs. Future research should examine methods to improve homework completion and session attendance to maximize therapeutic outcomes.

Validation of the MUSIC Model of Motivation Inventory for use with cognitive training for schizophrenia spectrum disorders: A multinational study

AIM

Low motivation is a core symptom of schizophrenia which significantly impacts successful engagement in and benefit from psychosocial treatments. Therefore, it is important for clinicians to design psychosocial treatments to effectively motivate and engage patients during the treatment. The MUSIC® Model of Academic Motivation Inventory (MMI) is an 18-item instrument with five scales that assess students' motivation during academic tasks. The objective of the current study was to validate the MMI for use with schizophrenia-spectrum patients undergoing cognitive training.

METHODS

Participants included 181 people with schizophrenia spectrum disorders enrolled in cognitive training in four countries. A confirmatory factor analysis (CFA) assessed construct validity. Quality of fit was determined using the Comparative Fit Index (CFI), the Standardized Root Mean Square Residual (SRMR), and the Root Mean Square Error of Approximation (RMSEA). Pearson's correlation coefficients assessed construct validity and Cronbach's alphas assessed reliability. Furthermore, we examined factor loadings for each inventory item and assessed predictive validity by analyzing MMI scales with attendance outcomes.

RESULTS

Consistent with the original MMI validation studies used in academic settings, we found CFI values indicated a good fit, as did the SRMR and RMSEA values. The scales were correlated yet distinct. Cronbach's alpha values ranged from good to excellent and factor loadings showed that all items loaded very well onto their intended factors. The MMI had a positive relationship to treatment intensity.

CONCLUSION

The MMI is a valid and reliable tool to use with individuals with schizophrenia spectrum disorders undergoing a cognitive training intervention.

Schizotypal traits, neurocognition, and paternal age in unaffected first degree relatives of patients with familial or sporadic schizophrenia

Studies comparing cognitive processes between familial and sporadic schizophrenia have yielded inconsistent findings. In this study we examined differences in neurocognition and schizotypal traits in unaffected relatives of schizophrenia-spectrum patients with either the familial (multiplex) or the sporadic (simplex) subtype of the disorder, taking paternal age at birth into consideration. Simplex (n = 65; SR), multiplex (n = 35; MR) relatives and controls (n = 114) were compared on several cognitive functions and schizotypal traits; between-group differences were evaluated with and without including paternal age in the analyses. SR and MR had higher negative and paranoid traits compared with controls, but paternal age abolished the differences between the SR and control groups. When taking into account schizotypal traits and participants' age, controls outperformed MR in strategy formation and set-shifting and SR in psychomotor speed, set-shifting and executive working memory. After including paternal age in the analyses, controls outperformed MR in strategy formation, working memory and executive working memory and both groups in psychomotor speed and set-shifting. These findings suggest that multiplex relatives present with a "riskier" personality and cognitive profile when considering the effects of paternal age. Nevertheless, simplex relatives are impaired in fundamental cognitive processes, thus highlighting the detrimental effects of paternal age on neurocognition.

An examination of the moderating effects of neurophysiology on treatment outcomes from cognitive training in schizophrenia-spectrum disorders

BACKGROUND

Impairments in neurocognition and community functioning are core features of schizophrenia and cognitive training techniques have been developed with the aim of improving these impairments. While cognitive training has produced reliable improvements in neurocognition and functioning, little is known about factors that moderate treatment response. Electroencephalographic (EEG) measures provide a neurophysiological indicator of cognitive functions that may moderate treatment outcomes from cognitive training.

METHODS

Data from a clinical trial comparing two cognitive training approaches in schizophrenia-spectrum disorders were utilized in the current report. Cluster analysis was conducted to identify participant clusters based on baseline P300, mismatch negativity (MMN), and theta power during an n-back task, and the EEG measures were also examined as continuous predictors of treatment response.

RESULTS

Three clusters were identified based on the baseline EEG variables; however, there were no significant differences in treatment response across the three clusters. Higher P300 amplitude and theta power during the n-back at baseline were significantly associated with greater improvements in a cognitive composite score post-treatment. None of the EEG measures were significantly associated with treatment outcomes in specific cognitive domains or community functioning. Change in EEG measures from baseline to post-treatment was not significantly associated with durability of cognitive or functional change at 12-week follow-up.

CONCLUSIONS

Clusters derived from the EEG measures were not significantly associated with either neurocognitive or functional outcomes. P300 and n-back theta power may be associated with learning-related processes, which are important for acquisition and retention of skills during cognitive training programs. Future research should aim to identify at an individual level who is likely to respond to specific forms of cognitive enhancement.

Factors Associated With Response and Resistance to Cognitive Remediation in Schizophrenia: A Critical Review

Cognitive impairment is a central feature of schizophrenia and has shown to play a crucial role in the psychosocial function of the disorder. Over the past few years, several cognitive remediation (CR) interventions have been developed for schizophrenia, whose effectiveness has also been widely demonstrated by systematic reviews and meta-analysis studies. Despite these evidences, many questions remain open. In particular, the identification of CR response predictors in patients with schizophrenia is still a topic with equivocal findings and only a few studies have looked for the relationship between CR response or resistance and the biological, socio-demographic, clinical and cognitive features in schizophrenia. The current knowledge on positive or negative response predictors to CR treatment in schizophrenia include: age, duration of illness, premorbid adjustment, baseline cognitive performance, intrinsic motivation, hostility, disorganized symptoms, neurobiological reserve, genetic polymorphisms, the amounts of antipsychotics, the type of CR, etc. The aim of this review is to identify neurobiological, psychopathological, cognitive, and functional predictors of CR response or resistance in schizophrenia, taking into account both cognitive and functional outcome measures. The information obtained could be very useful in planning integrated and personalized interventions, also with a better use of the available resources.

Auditory System Target Engagement During Plasticity-Based Interventions in Schizophrenia: A Focus on Modulation of N-Methyl-D-Aspartate-Type Glutamate Receptor Function

Cognitive deficits are predictive of long-term social and occupational functional deficits in schizophrenia but are currently without gold-standard treatments. In particular, augmentation of auditory cortical neuroplasticity may represent a rate-limiting first step before addressing higher-order cognitive deficits. We review the rationale for N-methyl-d-aspartate-type glutamate receptor (NMDAR) modulators as treatments for auditory plasticity deficits in schizophrenia, along with potential serum and electroencephalographic target engagement biomarkers for NMDAR function. Several recently published NMDAR-modulating treatment studies are covered, involving D-serine, memantine, and transcranial direct current stimulation. While all three interventions appear to modulate auditory plasticity, direct agonists (D-serine) appear to have the largest and most consistent effects on plasticity, at least acutely. We hypothesize that there may be synergistic effects of combining procognitive NMDAR-modulating approaches with auditory cortical neuroplasticity cognitive training interventions. Future studies should assess biomarkers for target engagement and patient stratification, along with head-to-head studies comparing putative interventions and potential long-term versus acute effects.

A review of cognitive remediation approaches for schizophrenia: from top-down to bottom-up, brain training to psychotherapy

INTRODUCTION

Individuals with psychotic disorders experience profound impairment in neurocognition, which is consistently found to be the best predictor of independent community functioning. Several diverse behavioural treatments designed to enhance neurocognitive abilities have been developed, with subtle to stark differences among them. Various approaches, to varying degrees, have demonstrated success across diffuse outcomes: improved brain structure and function, performance on neuropsychological tests, and community activities associated with daily living. Areas covered: This paper reviews the different approaches to cognitive remediation and the differential effects these approaches have on neurophysiological function, neurocognitive abilities, and real-world community functioning. Cognitive remediation approaches can be broadly classified along two dimensions: 1) treatment target, and 2) treatment modality. Some approaches target more basic perceptual skills, some target higher level executive processes, while some are non-targeted and seek to improve general cognitive ability. With regard to modality, approaches might have little/no therapist involvement and rely exclusively on computerized practice or they may include intensive therapist involvment to generalize neurocognitive change to community functioning. Expert commentary: Compared to other widely implemented treatments for schizophrenia, cognitive remediation produces better effects on outcome measures. It is time for cognitive remediation to be adopted as a best practice in the treatment of schizophrenia.

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

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