UCSD Performance-Based Skills Assessment: development of a new measure of everyday functioning for severely mentally ill adults

The relationship of neurocognitive and social cognitive performance to social competence and appropriateness on a performance-based social skills assessment in individuals with psychosis and unaffected controls

Social deficits are common in psychosis. The Social Skills Performance Assessment (SSPA) is a performance-based measure used to approximate an individual's social skills. Those with psychosis perform worse than do unaffected controls. Prior work has examined two social skills domains derived from the SSPA: social competence and social appropriateness. Social competence and appropriateness are associated with neurocognition and functioning outcomes. However, no study to date has examined the relationship of social cognition to social competence and appropriateness. We aimed to examine the relationships among different aspects of social cognition and performance-based social functioning and hypothesized that social cognitive performance would be related to social competence and appropriateness. We also hypothesized that after controlling for neurocognition, social cognition would account for unique variance in social competence and appropriateness in separate regression models. Forty-one participants who had experienced psychosis and 42 unaffected controls completed a comprehensive battery of neurocognitive, social cognitive, and social functioning measures. Social competence was associated with neurocognition and some aspects of social cognition, while social appropriateness was only marginally associated with neurocognition. Regression models revealed that social cognition did not account for additional and unique variance in social competence or appropriateness, after adjusting for demographic covariates and neurocognition. Findings suggest that aspects of social functioning performance are differentially related to neurocognitive and social cognitive skills. Social skill interventions may be most effective when targeting both neurocognitive and social cognitive skills in treatment.

Cognitive training for schizophrenia: Do race and ethnicity matter?

Racial disparities in diagnosis, treatment, and outcome have been well-established for people with schizophrenia. While cognitive remediation treatments have been shown to produce mild to moderate improvements in cognition for people with schizophrenia, few studies have examined racial/ethnic differences in treatment response. This study employed a secondary analysis of data from two randomized, single-blind controlled trials (N = 119) investigating the efficacy of two forms of cognitive training, to explore potential racial/ethnic differences in targeted outcomes. Given the extant literature, we predicted that racial/ethnic minorities would (1) drop out of the study at higher rates, (2) display greater levels of functional and cognitive impairment prior to treatment, and (3) display lower levels of improvement in cognitive and functioning outcomes following treatment. Our study revealed largely negative findings: white vs. non-white groups showed similar treatment drop-out rates, similar levels of cognitive impairment and symptom severity at study baseline and showed similar responses to cognitive training, with the exception of working memory in which participants' racial/ethnic minority status predicted significantly greater improvement in response to cognitive training. These findings suggest that cognitive remediation treatments are effective at addressing cognitive deficits in racial/ethnic minorities and supports cognitive remediation as a treatment which may help address racial/ethnic disparities in cognition. Given the scant research literature, future analyses should look at race as a potential mediator of treatment in a variety of evidence-based psychosocial treatments.

Everyday function in schizophrenia: The impact of aerobic endurance and skeletal muscle strength

BACKGROUND

Patients with schizophrenia suffer from physical health conditions, culminating in reduced physical functioning with enormous costs for patients and society. Although aerobic endurance and skeletal muscle strength, typically reduced in this population, relate to cognition and function, no study has explored their respective contributions to performance of functional skills and everyday tasks.

METHODS

In a cross-sectional study, 48 outpatients (28/20 men/women; 35 ± 11(SD) years) with schizophrenia spectrum disorders (ICD-10; F20-25) were administered the UCSD Performance-based Skills Assessment-Brief (UPSA-B; functional skills), Specific Level of Functioning (SLOF; functional performance) and the Positive and Negative Syndrome (PANSS) scale. Peak oxygen uptake (V̇O2peak) was assessed along with leg press maximal muscle strength (1RM) and mechanical power.

RESULTS

UPSA-B performance was associated with V̇O2peak (r = 0.28,p < 0.05), accounting for 8 % (p < 0.05) of shared variance, but was unrelated to 1RM and mechanical power. The SLOF physical functioning domain was associated with V̇O2peak (r = 0.30,p < 0.05) and 1RM (r = 0.24,p < 0.05), while SLOF personal care (r = 0.27,p < 0.05) and activities (r = 0.30,p < 0.05) were related only to V̇O2peak. Hierarchical regression analyses revealed that while V̇O2peak and age combined to account for 20 % (p < 0.05) of the variance in physical functioning, the contribution of 1RM was eliminated after adjusting for age. V̇O2peak and negative symptoms combined predicted 24 % and 35 % of the variance in personal care and activities, respectively. UPSA-B scores did not add to the prediction of SLOF scores.

CONCLUSIONS

Although V̇O2peak and 1RM both relate to functional outcomes, the combination of V̇O2peak, age, and negative symptoms exert the greatest detrimental influence on functional performance beyond skills deficits.

Daily life participation in PTSD: pilot study on patterns and correlators

Introduction

Participation in daily life activities with both the personal and community meaning is an important component of health and well-being. Even though there are mounting reports on the challenges in various aspects of daily-life functioning among individuals with post-traumatic stress disorder (PTSD), to date little research has been conducted on their comprehensive patterns of participation. The study aimed to describe objective and subjective participation dimensions in PTSD compared to healthy controls and investigate the association between personal and environmental factors and participation.

Methods

Sixty-one individuals were enrolled in two groups: PTSD (N=31; age: M=34.3; women:77.4%) and healthy controls matched by age and gender. The PTSD group completed standard assessments for symptom severity, general cognition, executive function (EF), sensory processing, self-efficacy, functional capacity, and environmental properties. Both groups completed a participation questionnaire.

Results

Individuals with PTSD participated with low intensity and diversity, more occupations were abandoned (-4.73

Discussion

The study demonstrates profound restrictions in participation in PTSD raising serious concerns. There are unique patterns of association between objective participation dimensions, subjective cognitive indices, sensory modulation, and environmental factors, suggesting a need for PTSD feature-specific intervention approaches to advance the participation of those with PTSD as a means of promoting health and well-being.

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Key Words

• environmental impacts
• functional capacity
• neurocognition
• objective participation
• subjective participation

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MESH Headings Collapse

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Affiliation(s)

Ruth Shapira Day care ward, School of Occupational Therapy, Faculty of Medicine, the Hebrew University, Jerusalem, Israel The Jerusalem Mental Health Center, Jerusalem, Israel
Yisca Jessica Baris Ginat The Jerusalem Mental Health Center, Jerusalem, Israel
Lena Lipskaya-Velikovsky Day care ward, School of Occupational Therapy, Faculty of Medicine, the Hebrew University, Jerusalem, Israel

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The relationship between obsessive-compulsive symptoms and real-life functioning in schizophrenia: New insights from the multicenter study of the Italian Network for Research on Psychoses

BACKGROUND

Although obsessive-compulsive disorder (OCD) is highly prevalent in schizophrenia, its relationship with patients' real-life functioning is still controversial.

METHODS

The present study aims at investigating the prevalence of OCD in a large cohort of non-preselected schizophrenia patients living in the community and verifying the relationship of OCD, as well as of other psychopathological symptoms, with real-life functioning along a continuum of OCD severity and after controlling for demographic variables.

RESULTS

A sample of 327 outpatients with schizophrenia was enrolled in the study and collapsed into three subgroups according to OCD severity (subclinical, mild-moderate, severe). A series of structural equation modeling (SEM) was performed to analyze in each subgroup the association of obsessive-compulsive symptoms with real-life functioning, assessed through the Specific Levels of Functioning Scale and the UCSD Performance-Based Skills Assessment. Moreover, latent profile analysis (LPA) was performed to infer latent subpopulations. In the subclinical OCD group, obsessive-compulsive symptoms (OCS) were not associated with functioning, whereas in the mild-moderate OCD group, they showed a positive relationship, particularly in the domains of work and everyday life skills. The paucity of patients with severe OCD did not allow performing SEM analysis in this group. Finally, LPA confirmed a subgroup with mild-moderate OCS and more preserved levels of functioning.

CONCLUSIONS

These findings hint at a positive association between mild-moderate OCD and real-life functioning in individuals with schizophrenia and encourage a careful assessment of OCD in personalized programs to sustain daily life activities.

Trajectories and predictors of response to social cognition training in people with schizophrenia: A proof-of-concept machine learning study

BACKGROUND

Social cognition training (SCT) can improve social cognition deficits in schizophrenia. However, little is known about patterns of response to SCT or individual characteristics that predict response.

METHODS

76 adults with schizophrenia randomized to receive 8-12 weeks of remotely-delivered SCT were included in this analysis. Social cognition was measured with a composite of six assessments. Latent class growth analyses identified trajectories of social cognitive response to SCT. Random forest and logistic regression models were trained to predict membership in the trajectory group that showed improvement from baseline measures including symptoms, functioning, motivation, and cognition.

RESULTS

Five trajectory groups were identified: Group 1 (29 %) began with slightly above average social cognition, and this ability significantly improved with SCT. Group 2 (9 %) had baseline social cognition approximately one standard deviation above the sample mean and did not improve with training. Groups 3 (18 %) and 4 (36 %) began with average to slightly below-average social cognition and showed non-significant trends toward improvement. Group 5 (8 %) began with social cognition approximately one standard deviation below the sample mean, and experienced significant deterioration in social cognition. The random forest model had the best performance, predicting Group 1 membership with an area under the curve of 0.73 (SD 0.24; 95 % CI [0.51-0.87]).

CONCLUSIONS

Findings suggest that there are distinct patterns of response to SCT in schizophrenia and that those with slightly above average social cognition at baseline may be most likely to experience gains. Results may inform future research seeking to individualize SCT treatment for schizophrenia.

Effects of erythropoietin on cognitive impairment and prefrontal cortex activity across affective disorders: A randomized, double-blinded, placebo-controlled trial

BACKGROUND

Persistent cognitive impairment is frequent across bipolar disorder (BD) and major depressive disorder (MDD), highlighting an urgent need for pro-cognitive treatments.

AIM

This study investigated effects of erythropoietin (EPO) on cognitive impairment and dorsal prefrontal cortex (dPFC) activity in affective disorders.

METHODS

In this randomized, double-blinded, placebo-controlled trial, cognitively impaired patients with remitted BD or MDD received 1 weekly recombinant human EPO (40,000 IU/mL) or saline infusion for a 12-week period. Assessments were conducted at baseline, after 2 weeks of treatment (week 3), immediately after treatment (week 13) and at 6-months follow-up. Participants underwent functional MRI during performance on a n-back working memory (WM) task at baseline and week 3, and for a subgroup 6 weeks post-treatment (week 18). The primary outcome was a cognitive composite score at week 13, whereas secondary outcomes comprised sustained attention and functioning. WM-related dPFC activity was a tertiary outcome.

RESULTS

Data were analysed for 101 of the 103 included patients (EPO, n = 58; saline, n = 43). There were no effects of EPO over saline on any cognitive or functional outcomes or on WM-related dPFC activity.

CONCLUSIONS

The absence of treatment-related changes in cognition and neural activity was unexpected and contrasts with multiple previous preclinical and clinical studies. It is possible that the lack of effects resulted from a recent change in the manufacturing process for EPO. Nevertheless, the findings support the validity of dPFC target engagement as a biomarker model for pro-cognitive effects, according to which treatments that do not improve cognition should not modulate dPFC activity.

TRIAL REGISTRATIONS

EudraCT no.: 2016-004023-24; ClinicalTrials.gov identifier: NCT03315897.

Measures of Social and Occupational Function in Early Psychosis: A Systematic Review and Meta-analysis

Deficits in social and occupational function are widely reported in psychosis, yet no one measure of function is currently agreed upon as a gold standard in psychosis research. The aim of this study was to carry out a systematic review and meta-analysis of functioning measures to determine what measures were associated with largest effect sizes when measuring between-group differences, changes over time, or response to treatment. Literature searches were conducted based on PsycINFO and PubMed to identify studies for inclusion. Cross-sectional and longitudinal observational and intervention studies of early psychosis (≤5 years since diagnosis) that included social and occupational functioning as an outcome measure were considered. A series of meta-analyses were conducted to determine effect size differences for between-group differences, changes over time, or response to treatment. Subgroup analyses and meta-regression were carried out to account for variability in study and participant characteristics. One hundred and sixteen studies were included, 46 studies provided data (N = 13 261) relevant to our meta-analysis. Smallest effect sizes for changes in function over time and in response to treatment were observed for global measures, while more specific measures of social and occupational function showed the largest effect sizes. Differences in effect sizes between functioning measures remained significant after variability in study and participant characteristics were accounted for. Findings suggest that more specific measures of social function are better able to detect changes in function over time and in response to treatment.

Financial dissatisfaction in people with psychotic disorders - A short report on its prevalence and correlates in a large naturalistic psychosis cohort

Psychotic disorders have a strong negative impact on multiple aspects of daily life, including people's financial situation. This exploratory study examines the level of financial dissatisfaction and its correlates in a large cohort of people with psychotic disorders. Data from the first assessments of people with psychotic disorders (n = 5271) who were included in the Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS; 2006-2020), which is conducted in the northern Netherlands, were used. The Manchester Short Assessment of Quality of Life (MANSA) was used to measure financial dissatisfaction. In addition, sociodemographic and psychiatric characteristics, substance use and global and social functioning were assessed. One-fifth to one-third of people with psychotic disorders report financial dissatisfaction, fluctuating over the year in which they were assessed. These proportions are considerably higher than in the general population. Cannabis and other substance use were associated with higher levels of financial dissatisfaction (small to medium effect). The other significant associations showed (very) small effect sizes. Therefore, we conclude that financial dissatisfaction in people with psychotic disorders appears to be relatively independent of other demographic and psychiatric characteristics, and global and social functioning. These findings are an important first step for increasing knowledge on financial dissatisfaction among people with psychotic disorders. The findings can also contribute to raising awareness about the topic for healthcare professionals working in this field.

A Clinic-Based Measure of Everyday Planning Ability: The Overnight Trip Task

OBJECTIVE

Traditional measures of cognitive abilities most used by neuropsychologists are generally low in ecological validity and only capture a small proportion of the variance of a person's true functional capacity. This study evaluates the association between clinic-based performance and parallel real-world completion of an everyday planning test, the Overnight Trip Task (OTT).

METHOD

A cross-sectional cohort of 65 community-dwelling older adults completed a battery of cognitive assessments and two formats of the OTT: the paper-and-pencil clinic OTT, which was completed remotely through video conferencing (Zoom), and the parallel real-world OTT (RW-OTT), which was completed at home between sessions. Both formats required participants to plan for what they would pack and prepare for a hypothetical overnight trip based on a provided story that included rules and embedded contingencies.

RESULTS

The clinic OTT demonstrated a small-to-moderate relationship with the RW-OTT (r = 0.35) and no relationship with measures of learning, long delay recall, an executive function composite, and a measure of everyday planning. Hierarchical regressions indicated that the clinic OTT demonstrated incremental validity above an executive function composite measure and global cognition when predicting self-reported everyday functioning and RW-OTT performance.

CONCLUSIONS

The clinic OTT showed only modest association with the RW-OTT and discriminate but not convergent validity was demonstrated. The clinic OTT showed incremental validity when predicting self-reported everyday functioning and RW-OTT performance above more traditional measures. Before the clinic OTT could be considered a reliable and valid clinic-based measure for predicting real-world behavior, additional research would be needed.

Aberrant Effective Connectivity During Eye Gaze Processing Is Linked to Social Functioning and Symptoms in Schizophrenia

BACKGROUND

Patients with schizophrenia show abnormal gaze processing, which is associated with social dysfunction. These abnormalities are related to aberrant connectivity among brain regions that are associated with visual processing, social cognition, and cognitive control. In this study, we investigated 1) how effective connectivity during gaze processing is disrupted in schizophrenia and 2) how this may contribute to social dysfunction and clinical symptoms.

METHODS

Thirty-nine patients with schizophrenia/schizoaffective disorder (SZ) and 33 healthy control participants completed an eye gaze processing task during functional magnetic resonance imaging. Participants viewed faces with different gaze angles and performed explicit and implicit gaze processing. Four brain regions-the secondary visual cortex, posterior superior temporal sulcus, inferior parietal lobule, and posterior medial frontal cortex-were identified as nodes for dynamic causal modeling analysis.

RESULTS

Both the SZ and healthy control groups showed similar model structures for general gaze processing. Explicit gaze discrimination led to changes in effective connectivity, including stronger excitatory, bottom-up connections from the secondary visual cortex to the posterior superior temporal sulcus and inferior parietal lobule and inhibitory, top-down connections from the posterior medial frontal cortex to the secondary visual cortex. Group differences in top-down modulation from the posterior medial frontal cortex to the posterior superior temporal sulcus and inferior parietal lobule were noted, such that these inhibitory connections were attenuated in the healthy control group but further strengthened in the SZ group. Connectivity was associated with social dysfunction and symptom severity.

CONCLUSIONS

The SZ group showed notably stronger top-down inhibition during explicit gaze discrimination, which was associated with more social dysfunction but less severe symptoms among patients. These findings help pinpoint neural mechanisms of aberrant gaze processing and may serve as future targets for interventions that combine neuromodulation with social cognitive training.

Self-report versus performance based executive functioning in people with psychotic disorders

Background

Although executive functioning is often measured using performance-based measures, these measures have their limits, and self-report measures may provide added value. Especially since these two types of measures often do not correlate with one another. It thus has been proposed they might measure different aspects of the same construct. To explore the differences between a performance-based measure of executive functioning and a self-report measure, we examined their associations in patients with a psychotic disorder with the following: other neurocognitive measures; psychotic symptoms; anxiety and depression symptoms, and daily-life outcome measures.

Method

This cross-sectional study consisted of baseline measures collected as part of a cohort study of people with a psychotic disorder (the UP'S study; n = 301). The Behavioral Rating Inventory of Executive Functioning Adult version (BRIEF-A) was used to assess self-rated executive functioning, and the Tower of London (TOL) to assess performance-based executive functioning. Generalized linear models (GLM) were used with the appropriate distribution and link function to study the associations between TOL and BRIEF-A, and the other variables, including the Brief Assessment of Cognition in Schizophrenia (BACS), the Positive and Negative Symptoms Scale-Remission (PANSS-R), the General Anxiety Disorder - 7 (GAD-7), the Patient Health Questionnaire - 9 (PHQ-9) and the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0). Model selection was based on the Wald test.

Results

The TOL was associated with other neurocognitive measures, such as verbal list learning (β = 0.24), digit sequencing (β = 0.35); token motor task (β = 0.20); verbal fluency (β = 0.24); symbol coding (β = 0.43); and a screener for intelligence (β = 2.02). It was not associated with PANNS-R or WHO-DAS scores. In contrast, the BRIEF-A was associated not with other neurocognitive measures, but with the PANSS-R (β = 0.32); PHQ-9 (β = 0.52); and GAD-7 (β = 0.55); and with all the WHODAS domains: cognition domain (β = 0.54), mobility domain (β = 0.30) and selfcare domain (β = 0.22).

Conclusion

Performance-based and self-report measures of executive functioning measure different aspects of executive functioning. Both have different associations with neurocognition, symptomatology and daily functioning measures. The difference between the two instruments is probably due to differences in the underlying construct assessed.

Brief instrument for direct complex functionality assessment: a new ecological tool

Background

The Direct Assessment of Functional Status (DAFS) is the only instrument validated in Brazil that assesses functionality directly with the patient. However, this clinical tool takes a long time to be administered. This limits its use in hospitals and outpatient clinics that require brief assessment instruments. Additionally, we need to count with a direct assessment because the number of older adults living alone is increasing and we thus lack reliable informants.

Objective

This study aimed to present the development and content validity evidence of a direct complex functionality test for older adults, the Brief Instrument for Direct Functionality Assessment (BIDFA).

Method

A total sample of 30 older adults and eight expert judges took part in the study stages. The BIDFA construction stages were: (1) literature review of functionality instruments; (2) development of seven ecological tasks to evaluate the performance of daily complex activities with the older adults; (3) content analysis by eight expert judges; (4) pilot study with 30 older adults; (5) the ecological analysis of items; (6) focus group analysis; and (7) final version of the BIDFA.

Results

The BIDFA had evidence of content validity with an agreement index of 96.5%. The final version of BIDFA was left with six domains of complex functionality divided into semantic memory and time orientation; shopping skills; executive attention, math and finance skills; organization; planning and procedural memory; and problem-solving. The complex functionality score by BIDFA ranges from 0 to 100 points.

Conclusion

The BIDFA was found to have good content validity by the expert judges and by the ecological analysis of the items by the older adults. The new instrument is expected to help assess the functional status of older adults, in an abbreviated context including complex functionality demands, with a wider range of total and subdomain scores.

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.

Continuous Assessment of Function and Disability via Mobile Sensing: Real-World Data-Driven Feasibility Study

BACKGROUND

Functional limitations are associated with poor clinical outcomes, higher mortality, and disability rates, especially in older adults. Continuous assessment of patients' functionality is important for clinical practice; however, traditional questionnaire-based assessment methods are very time-consuming and infrequently used. Mobile sensing offers a great range of sources that can assess function and disability daily.

OBJECTIVE

This work aims to prove the feasibility of an interpretable machine learning pipeline for predicting function and disability based on the World Health Organization Disability Assessment Schedule (WHODAS) 2.0 outcomes of clinical outpatients, using passively collected digital biomarkers.

METHODS

One-month-long behavioral time-series data consisting of physical and digital activity descriptor variables were summarized using statistical measures (minimum, maximum, mean, median, SD, and IQR), creating 64 features that were used for prediction. We then applied a sequential feature selection to each WHODAS 2.0 domain (cognition, mobility, self-care, getting along, life activities, and participation) in order to find the most descriptive features for each domain. Finally, we predicted the WHODAS 2.0 functional domain scores using linear regression using the best feature subsets. We reported the mean absolute errors and the mean absolute percentage errors over 4 folds as goodness-of-fit statistics to evaluate the model and allow for between-domain performance comparison.

RESULTS

Our machine learning-based models for predicting patients' WHODAS functionality scores per domain achieved an average (across the 6 domains) mean absolute percentage error of 19.5%, varying between 14.86% (self-care domain) and 27.21% (life activities domain). We found that 5-19 features were sufficient for each domain, and the most relevant being the distance traveled, time spent at home, time spent walking, exercise time, and vehicle time.

CONCLUSIONS

Our findings show the feasibility of using machine learning-based methods to assess functional health solely from passively sensed mobile data. The feature selection step provides a set of interpretable features for each domain, ensuring better explainability to the models' decisions-an important aspect in clinical practice.

Cognition in Bipolar Disorder: An Update for Clinicians

Bipolar disorder is associated with cognitive deficits, which persist across mood states and affect functional outcomes. This article provides an overview of recent progress in measuring cognition in bipolar disorder and its implications for both research and clinical practice. The authors summarize work conducted over the past decade that has helped guide researchers and clinicians in the appropriate measurement of cognitive functioning in bipolar disorder, the design of research studies targeting this domain for treatment, and the implementation of screening and psychoeducational tools in the clinic. Much of this work was conducted by the International Society for Bipolar Disorders Targeting Cognition Task Force. Here, the authors also highlight the need for clinicians to be informed about this aspect of illness and to be equipped with the necessary information to assess, track, and intervene on cognitive problems when appropriate. Finally, the article identifies gaps in the literature and suggests potential future directions for research in this area.

Functioning in older adults with bipolar disorder: A report on recommendations by the International Society of bipolar disorder (ISBD) older adults with bipolar disorder (OABD) task force

OBJECTIVES

Despite the importance of psychosocial functioning impairment in Bipolar Disorder (BD), its role among Older Adults with BD (OABD) is not well known. The development of guidelines for the assessment of psychosocial functioning helps to facilitate a better understanding of OABD and can lead to better tailored interventions to improve the clinical outcomes of this population.

METHODS

Through a series of virtual meetings, experts from eight countries in the International Society of Bipolar Disorder (ISBD) on OABD task force developed recommendations for the assessment of psychosocial functioning.

RESULTS

We present (1) a conceptualization of functioning in OABD and differences compared with younger patients; (2) factors related to functioning in OABD; (3) current measures of functioning in OABD and their strengths and limitations; and, (4) other potential sources of information to assess functioning.

CONCLUSIONS

The task force created recommendations for assessing functioning in OABD. Current instruments are limited, so measures specifically designed for OABD, such as the validated FAST-O scale, should be more widely adopted. Following the proposed recommendations for assessment can improve research and clinical care in OABD and potentially lead to better treatment outcomes.

Original research: longitudinal evaluation of cognitively demanding daily function using performance-based functional assessment highlights heterogeneous trajectories in cognitive and functional abilities in people with Parkinson's disease

Background

Longitudinal assessment of functional abilities in Parkinson's disease (PD) is needed to determine the efficacy of cognitive interventions in providing meaningful improvements in daily life. Additionally, subtle changes in instrumental activities of daily living may precede a clinical diagnosis of dementia and could aid earlier detection of and intervention for cognitive decline.

Objective

The primary goal was to validate the longitudinal application of the University of California San Diego Performance-Based Skills Assessment (UPSA). An exploratory secondary goal was to determine whether UPSA may identify individuals at higher risk of cognitive decline in PD.

Methods

Seventy participants with PD completed the UPSA with at least one follow-up visit. Linear mixed effects modeling was used to identify associations between baseline UPSA score and cognitive composite score (CCS) over time. Descriptive analysis of four heterogeneous cognitive and functional trajectory groups and individual case examples was performed.

Results

Baseline UPSA score predicted CCS at each timepoint for functionally impaired and unimpaired groups (p < 0.01) but did not predict the rate change in CCS over time (p = 0.83). Participants displayed heterogenous trajectories in both UPSA and CCS during the follow-up period. Most participants maintained both cognitive and functional performance (n = 54), though some displayed cognitive and functional decline (n = 4), cognitive decline with functional maintenance (n = 4), and functional decline with cognitive maintenance (n = 8).

Conclusion

The UPSA is a valid measure of cognitive functional abilities over time in PD. Given the heterogeneity of functional and cognitive trajectories, this performance-based assessment did not predict cognitive decline with this relatively short follow-up. Further work is needed to understand longitudinal functional assessments in PD-associated cognitive impairment.

Executively-mediated language skills are related to performance-based social functioning in the early psychosis spectrum

Social impairment is a core deficit in psychotic spectrum disorders (PSDs). Prior work shows that language abnormalities can predict psychosis onset and are related to social outcomes in PSDs. Few studies have investigated nuanced relationships between language/verbal abilities and social functioning in the early psychosis spectrum, including at-risk (schizotypy) and first episode of psychosis (FEP) individuals. This study aimed to examine the relationship to between language/verbal performance and performance-based and examiner-rated social functioning. We also aimed to replicate prior models that demonstrate neurocognition is related to social functioning through negative symptoms and social cognition. Low schizotypy (n = 42), high schizotypy (n = 44), and FEP (n = 15) participants completed a battery of language/verbal, social cognition, and social functioning measures. Regression analyses revealed that Proverb Test performance was uniquely and significantly associated with performance-based but not examiner-rated social functioning. Other language/verbal measures were not significantly related to social functioning. In mediational analyses, language/verbal performance was indirectly related to social functioning through negative traits, and also through social cognition. Findings extend support for negative symptom and social cognitive intervention in the early psychosis spectrum, and uniquely suggest that executively-mediated language skills may be an additional target to improve social functioning.

Neurocognition and Depressive Symptoms have Unique Pathways to Predicting Different Domains of Functioning in Major Depressive Disorder

BACKGROUND

Research has established the independent relationships between depressive symptoms to cognition and functioning in depression; however, little is known about the role of mediators in this relationship. We explored the role of neurocognitive abilities, depressive symptom severity, dysfunctional attitudes, and functional capacity in predicting two dimensions of daily functioning in individuals with major depressive disorder (MDD).

METHODS

One hundred and twenty-four participants (mean age  =  46.26, SD  =  12.27; 56% female) with a diagnosis of MDD were assessed on a standard neurocognitive battery, self-reported depressive symptoms, dysfunctional attitudes, and clinician-rated functional impairment. They completed a performance-based assessment of functional competence.

RESULTS

Confirmatory path analyses were used to model the independent and mediated effects of variables on two domains of functioning: social (relationships and social engagement) and productive (household and community activities). Cognition and depressive symptoms both predicted productive functioning, and dysfunctional attitudes mediated each of these relationships. Functional competence was a significant mediator in the relationship between neurocognition and productive functioning. Depressive symptoms and cognition were direct predictors of social functioning with no significant mediators.

CONCLUSIONS

There are divergent pathways to different dimensions of daily functioning in MDD. Measurement implications include the consideration of multiple levels of predicting productive activities and more direct relationships with social outcomes. Treatments that directly target depressive symptoms and cognition might not generalize to improvements in everyday functioning if additional pathways to functioning are not addressed.

Correlates of real-world goal-directed behavior in schizophrenia

BACKGROUND

Deficits in goal-directed behavior (i.e. behavior conducted to achieve a specific goal or outcome) are core to schizophrenia, difficult to treat, and associated with poor functional outcomes. Factors such as negative symptoms, effort-cost decision-making, cognition, and functional skills have all been associated with goal-directed behavior in schizophrenia as indexed by clinical interviews or laboratory-based tasks. However, little work has examined whether these factors relate to the real-world pursuit of goal-directed activities in this population.

METHODS

This study aimed to fill this gap by using Ecological Momentary Assessment (four survey prompts per day for 1 week) to test hypotheses about symptom, effort allocation, cognitive, and functional measures associated with planned and completed goal-directed behavior in the daily lives of 63 individuals with schizophrenia.

RESULTS

Individuals with schizophrenia completed more goal-directed activities than they planned [t(62) = -4.01, p < 0.001]. Motivation and pleasure (i.e. experiential) negative symptoms, controlling for depressive symptoms, negatively related to planned goal-directed behavior [odds ratio (OR) 0.92, p = 0.005]. Increased effort expenditure for high probability rewards (planned: OR 1.01, p = 0.034, completed: OR 1.01, p = 0.034) along with performance on a daily functional skills task (planned: OR 1.04, p = 0.002, completed: OR 1.03, p = 0.047) negatively related to both planned and completed goal-directed activity.

CONCLUSIONS

Our results present correlates of real-world goal-directed behavior that largely align with impaired ability to make future estimations in schizophrenia. This insight could help identify targeted treatments for the elusive motivated behavior deficits in this population.

Comparable repetition blindness effect in patients with schizophrenia

BACKGROUND AND OBJECTIVES

Repetition blindness (RB) refers to the difficulty to report repetitions of stimuli visually presented in a rapid list. To date only two studies have examined RB in patients with schizophrenia and the results are not clear-cut. The current study was designed to employ a task with reduced memory load, more trials in each experimental condition, and more participants to obtain a more reliable RB effect.

METHODS

A 2x2x3x2 mixed factor repeated measure design was used, with stimulus repetition, lag, and presentation rate as within-subject factors, and group (patient or control) as a between-subject factor. A rapid serial visual presentation (RSVP) procedure was used. Twenty eight inpatients with schizophrenia and 28 healthy controls participated in the experiment.

RESULTS

The patient group showed significantly impaired performance when compared tothe control group in every experimental condition. Nevertheless, the patient group demonstrated similar RB effect as the control group. Furthermore, the overall RB effect observed in patients did not relate to their illness severity or psychotic symptoms. Neither was it related to their age or education.

LIMITATIONS

It was difficult to match the age and education of the control group to that of the inpatient group.

CONCLUSIONS

Patients with schizophrenia performed worse than healthy controls in each experimental condition. Both the control and patient group showed robust RB effect in the short lag with faster rates. In addition, RB effect seemed to be irrelevant to patients' illness severity and clinical symptoms.

Piloting a Novel Daily Living Skills Assessment in Autistic Adolescents and Young Adults

Background

There are a few ecologically valid measurements of Daily Living Skills (DLS)-a critical component of adaptive functioning (AF)-for autistic adolescents and young adults. This is particularly important given that DLS predict outcomes as autistic adolescents transition to adulthood.

Methods

We pilot-tested the assessment section of two modules of the Computerized Functional Skills Assessment and Training program (CFSAT) in 25 autistic (n = 4 female) and 25 non-autistic (n = 6 female) adolescents and young adults to evaluate preliminary feasibility in an autistic sample. Tasks involved using an ATM and ticket-buying machine. We also assessed AF and DLS with a well-validated self-report questionnaire. We examined group differences in performance and relationships between performance on CFSAT and an existing measure of AF and DLS. We also conducted regression analyses to investigate the associations between age, IQ, executive functioning (EF), and CFSAT task performance.

Results

All but one autistic participant were able to complete the CFSAT tasks. Autistic participants made more errors, but did not take longer to complete the task, than non-autistic participants. Performance correlated strongly with self-reported AF generally and DLS specifically. The regression analyses revealed that task performance was associated with EF in the autistic group, but not the non-autistic group.

Conclusions

These results provide preliminary support for the use of a new performance-based ecologically valid assessment of DLS in an autistic population. Two CFSAT modules were well-tolerated and detected differences in DLS ability. Strong correlations with an existing measure of AF suggest evidence of construct validity. The EF was associated with CFSAT task performance in autistic individuals. Such a tool could help identify individuals who would benefit from a DLS intervention.

Qualitative Analysis of the Content Validity of the Virtual Reality Functional Capacity Assessment Tool (VRFCAT) in Schizophrenia: A Multi-Stakeholder Perspective

The US Food and Drug Agency (FDA) requires clinical trials targeting cognitive impairment associated with schizophrenia (CIAS) to demonstrate the functional relevance of cognitive improvements by employing a functional co-primary measure. Although quantitative evidence supports the suitability of the Virtual Reality Functional Capacity Assessment Tool (VRFCAT) for this purpose, FDA guidelines for qualification of clinical outcome assessments require evidence of content validity, defined as qualitative evidence that key stakeholders view the measure as relevant and important. To collect this important qualitative data, semi-structured interviews were conducted with outpatients with schizophrenia (n = 24), caregivers (n = 12), and professional peer support specialists (n = 12) to elicit their views about the definition and importance of functional independence, the importance of the functional domains assessed by the VRFCAT (meal planning, using transportation, handling money, shopping), and the relevance of the VRFCAT tasks to these domains. Qualitative thematic analyses revealed consistent themes across groups in defining functional independence, including performing instrumental self-care, financial, and social tasks; making decisions autonomously; and not depending on others to carry out daily activities. There were, however, notable differences in their views regarding the importance of and barriers to functional independence. All groups viewed the VRFCAT as assessing skill domains that are central to independent functioning and, with some minor differences, the VRFCAT tasks were viewed as relevant and meaningful examples of the domains. These qualitative results provide converging evidence that key stakeholders view the VRFCAT as a content-valid measure.

Feasibility, acceptability and evaluation of meditation to augment yoga practice among persons diagnosed with schizophrenia

OBJECTIVE

To design a meditation protocol and test its feasibility, acceptability and efficacy in conjunction with yoga training (YT) for persons with schizophrenia (SZ).

METHODS

The meditation protocol consisted of Anapana (observing normal respiration) and Yoga Nidra (supine, restful awareness). In a single-blind randomised controlled trial, medicated and clinically stable outpatients diagnosed with SZ were randomised to receive treatment as usual (TAU), TAU augmented with YT or TAU augmented with meditation and yoga training (MYT) for 3 weeks (N = 145). Acceptability, clinical, social and cognitive functions were assessed after 3-week and 3-month post-randomisation using within-group and between-group analyses with repeated measures multivariate tests.

RESULTS

No group-wise differences in compliance, study discontinuation, major/serious side effects or adverse events were noted. For six assessed clinical variables, the direction of changes were in the desired direction and the effect sizes were greater in the MYT group compared with the TAU group at both time points. Changes in social function variables were greater at 3 months than at 3 weeks. Nominally significant improvement in individual cognitive domains were noted in all groups at both time points. All effect sizes were in the small to medium range.

CONCLUSION

MYT is feasible and acceptable and shows modest benefits for persons with SZ. MYT can also improve quality of life and clinical symptoms. Larger studies of longer duration are warranted.

Measuring functional outcomes in schizophrenia in an increasingly digital world

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

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

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

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

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Digital measures may enhance the assessment of associated functional constructs.

A randomized controlled trial of Goal Management Training for executive functioning in schizophrenia spectrum disorders or psychosis risk syndromes

BACKGROUND

Executive functioning is essential to daily life and severely impaired in schizophrenia and psychosis risk syndromes. Goal Management Training (GMT) is a theoretically founded, empirically supported, metacognitive strategy training program designed to improve executive functioning.

METHODS

A randomized controlled parallel group trial compared GMT with treatment as usual among 81 participants (GMT, n = 39 versus Wait List Controls, n = 42) recruited from an early intervention for psychosis setting. Computer generated random allocation was performed by someone independent from the study team and raters post-intervention were unaware of allocation. The primary objective was to assess the impact of GMT administered in small groups for 5 weeks on executive functioning. The secondary objective was to explore the potential of the intervention in influencing daily life functioning and clinical symptoms.

RESULTS

GMT improved self-reported executive functioning, measured with the Behavior Rating Inventory of Executive Function - Adult version (BRIEF-A), significantly more than treatment as usual. A linear mixed model for repeated measures, including all partial data according to the principle of intention to treat, showed a significant group x time interaction effect assessed immediately after intervention (post-test) and 6 months after intervention (follow-up), F = 8.40, p .005, r .37. Improvement occurred in both groups in objective executive functioning as measured by neuropsychological tests, functional capacity, daily life functioning and symptoms of psychosis rated by clinicians. Self-reported clinical symptoms measured with the Symptoms Check List (SCL-10) improved significantly more after GMT than after treatment as usual, F = 5.78, p .019, r .29. Two participants withdrew due to strenuous testing and one due to adverse effects.

CONCLUSIONS

GMT had clinically reliable and lasting effects on subjective executive function. The intervention is a valuable addition to available treatment with considerable gains at low cost.

TRIAL REGISTRATION

Registered at clinicaltrials.gov NCT03048695 09/02/2017.

Evidence for the reliability and validity of a Spanish translation of the Medication Management Ability Assessment administered via tele-assessment

We translated the Medication Management Ability Assessment (MMAA) from English to Spanish for use via tele-assessment and examined its reliability and validity. Following International Test Commission Guidelines for Translating and Adapting Tests, we used translation/back-translation and a small focus group (n = 6) to adapt a Spanish version of the MMAA. Eighty-six Spanish-speaking adults completed the adapted MMAA via tele-assessment at baseline and at a two-week follow-up visit. Participants also completed several self-report and performance-based cognitive and functional measures. The internal consistency of the MMAA was excellent (standardized Cronbach's α = 0.90). Performance-based functional assessments (PBFAs) and objective cognition were positively associated with the MMAA at small to medium effect sizes. Self-report measures of daily function and cognition, measures of health literacy, and estimates of premorbid intellectual functioning were not significantly associated with MMAA performance. The test-retest reliability of the MMAA was good (CCC = 0.73, 95% CI [0.62, 0.81]; rs = 0.37, p < 0.001) and demonstrated a small practice effect (Cohen's d = 0.36, p = 0.001). Preliminary evidence for the construct validity of a Spanish-language MMAA administered via tele-assessment further expands the potential clinical utility of PBFAs in culturally diverse, Spanish-speaking populations.

Modifiable predictors of self-reported and performance-based functioning in individuals with schizophrenia-spectrum disorders and high levels of negative symptoms

Individuals with schizophrenia who have high negative symptoms are at high risk for poor functional outcomes. However, the determinants of psychosocial functioning in this group are not well understood. We aimed to examine modifiable predictors of both objective, performance-based functional capacity and social skills, and self-reported functioning in individuals with schizophrenia and schizoaffective disorder and high negative symptoms. Fifty-five adults with moderate-to-severe negative symptoms were administered measures of neuropsychological performance, performance-based functional capacity and social competence, self-reported functioning, psychiatric symptom severity, defeatist/asocial beliefs, and intrinsic motivation. In the context of multiple significant predictor variables identified through bivariate correlations, multiple regression models showed that neuropsychological performance was the only significant predictor of performance-based functional capacity; neuropsychological performance and motivation/pleasure negative symptoms were significant predictors of performance-based social competence. For two different measures of self-reported functioning, intrinsic motivation, asocial beliefs, and diminished expression emerged as significant predictors. Neurocognitive ability was a better predictor of performance-based functional skills whereas motivation and beliefs more strongly predicted self-reported real-world functioning. The findings of this study suggest a complex picture of predictors of performance-based functional capacity (objective neuropsychological functioning) and self-reported functioning (motivation and beliefs), underscoring the clinical and scientific utility of including both self-reported and objective measures of functioning to identify treatment approach. Individuals with high negative symptoms and a cognitive/functional skills deficit may benefit from interventions such as cognitive remediation or skills training, whereas individuals with motivational difficulties may benefit from treatments such as cognitive behavioral therapy.

Validation of the Chinese Version of the Schizophrenia Cognition Rating Scale

OBJECTIVE

The Schizophrenia Cognition Rating Scale (SCoRS) is an interview-based assessment tool for evaluating the cognitive deficit and daily functioning of patients with schizophrenia.

METHODS

Sixty-eight patients with schizophrenia and 68 age- and sex-matched healthy individuals were recruited to validate the Chinese version of SCoRS in this study. All participants underwent cognitive assessment using the SCoRS, which was verified by the Brief Assessment of Cognition in Schizophrenia (BACS), and the UCSD Performance-based Skills Assessment, Brief Version (UPSA-B). Patients with schizophrenia were additionally assessed using the Positive and Negative Syndrome Scale (PANSS).

RESULTS

SCoRS ratings reported by patients (SCoRS-S), those reported by the interviewer (SCoRS-I), and SCoRS global scores (SCoRS-G) showed significant correlation with all subscales of the BACS and the UPSA-B. On receiver operating characteristic curve analysis, SCoRS-S, SCoRS-I, and SCoRS-G significantly differentiated patients with schizophrenia from healthy controls. Moreover, SCoRS-S and SCoRS-I ratings showed positive correlation with the negative symptoms and general symptoms of PANSS.

CONCLUSION

The Chinese version of SCoRS showed good discriminant, concurrent, and external validity, suggesting that it is a useful and convenient tool for assessment of cognitive function among Mandarin-speaking patients with schizophrenia in clinical practice.

Validation of the Brazilian version of the Hinting Task and Facial Emotion Recognition Test (FERT-100) in patients with schizophrenia

Social cognition is an especially relevant domain in schizophrenia due to its association with functional impairment. However, we still do not have studies that have validated instruments with internationally established psychometric qualities for the Brazilian population.

Objectives

This study aimed to present psychometric qualities and contribute to the validation of the Brazilian version of the Hinting Task and Facial Emotion Recognition Test (FERT-100).

Methods

A total of 104 stabilized patients living in the community diagnosed with schizophrenia and 89 controls were evaluated. We assess the psychometric properties of Hinting Task and FERT-100 for discriminant construct validity, divergent construct validity, convergent construct validity, concurrent criterion validity, and reliability.

Results

There is a statistically significant difference between patients and controls regarding social cognition (Hinting Task: Z=6.85, p<0.001; FERT-100: t=4.88, p<0.001). The main predictors of variation in social cognition were the neurocognitive domains. The associations between social cognition tests and other studied variables are similar to what is found in the literature. Social cognition maintains correlation with functional capacity even when neurocognition is taken into account.

Conclusions

The validity of the Brazilian version of Hinting Task and FERT-100 can be determined, since the relationship of these tests with other clinical variables is similar to that observed in the literature.

Developing a profile of activities of daily living for bipolar disorder: a systematic review protocol and meta-analysis

INTRODUCTION

Bipolar disorder (BD) is a severe mental health disorder that affects 2% of the adult population. Individuals with this disorder are at a higher risk for morbidity and functional difficulties. They may also experience significant challenges in their activities of daily living (ADLs). This systematic review will identify all available studies that examine subsets of ADLs that impact individuals with BD.

METHODS AND ANALYSIS

MEDLINE, Embase, CINAHL and APA PsycINFO will be searched to identify observational studies that examined functioning, independence or performance across a variety of ADLs. Title and abstract, full-text screening and a risk of bias assessment will be conducted in duplicate. An overarching table that summarises the level of functioning across different ADLs or an 'ADL profile' will be developed, and if there are sufficient data, these will be separated based on the phases of BD, such as manic/hypomanic, depressed and euthymic.

ETHICS AND DISSEMINATION

As this systematic review uses information from previous literature, this review does not require ethics approval. This review will help identify the trends in daily activities that individuals struggle with and can help healthcare practitioners identify specific areas of need for support. We plan to disseminate the results in a peer-reviewed journal and conferences targeting occupational therapists and mental health clinicians.

PROSPERO REGISTRATION NUMBER

CRD42021255089.

The relations between executive functions and occupational functioning in individuals with bipolar disorder: a scoping review

Background

Patients with bipolar disorder experience impairments in their occupational functioning, despite remission of symptoms. Previous research has shown that neurocognitive deficits, especially deficits in executive functions, may persist during euthymia and are associated with diminished occupational functioning.

Objectives

The aim of this scoping review was to identify published studies that report on the relationships between executive functions and occupational functioning in BD to review current knowledge and identify knowledge gaps. In addition to traditional neuropsychological approaches, we aimed to describe executive functioning from a self-regulation perspective, including emotion regulation.

Methods

We applied the methodological framework as described by Arksey and O’Malley (Int J Soc Res Methodol Theory Pract 8:19–32, 2005) and Levac et al. (Implement Sci 5:1–9, 2010). We searched PubMed and psycINFO for literature up to November 2021, after which we screened papers based on inclusion criteria. Two reviewers independently performed the screening process, data charting process, and synthesis of results.

Results

The search yielded 1202 references after deduplication, of which 222 remained after initial screening. The screening and inclusion process yielded 82 eligible papers in which relationships between executive functions and occupational functioning are examined.

Conclusion

Neurocognitive deficits, including in executive functions and self-regulation, are associated with and predictive of diminished occupational functioning. Definitions and measurements for neurocognitive functions and occupational functioning differ greatly between studies, which complicates comparisons. Studies on functional remediation show promising results for improving occupational functioning in patients with BD. In research and clinical practice more attention is needed towards the quality of work functioning and the various contexts in which patients with BD experience deficits.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00255-7.

The Puzzle of Functional Recovery in Schizophrenia-Spectrum Disorders-Replicating a Network Analysis Study

BACKGROUND AND HYPOTHESIS

Recovery from psychosis is a complex phenomenon determined by an array of variables mutually impacting each other in a manner that is not fully understood. The aim of this study is to perform an approximated replication of a previous network analysis study investigating how different clinical aspects-covering psychopathology, cognition, personal resources, functional capacity, and real-life functioning-are interrelated in the context of schizophrenia-spectrum disorders.

STUDY DESIGN

A sample of 843 subjects from a multisite cohort study, with the diagnosis of a schizophrenia-spectrum disorder, was used to estimate a network comprising 27 variables. The connectivity and relative importance of the variables was examined through network analysis. We used a quantitative and qualitative approach to infer replication quality.

STUDY RESULTS

Functional capacity and real-life functioning were central and bridged different domains of the network, in line with the replicated study. Neurocognition, interpersonal relationships, and avolition were also key elements of the network, in close relation to aspects of functioning. Despite significant methodological differences, the current study could substantially replicate previous findings.

CONCLUSIONS

Results solidify the network analysis approach in the context of mental disorders and further inform future studies about key variables in the context of recovery from psychotic disorders.

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

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

The Impact of Poor Nonverbal Social Perception on Functional Capacity in Schizophrenia

Background

Nonverbal social perception is the ability to interpret the intentions and dispositions of others by evaluating cues such as facial expressions, body movements, and emotional prosody. Nonverbal social perception plays a key role in social cognition and is fundamental for successful social interactions. Patients with schizophrenia have severe impairments in nonverbal social perception leading to social isolation and withdrawal. Collectively, these aforementioned deficits affect patients' quality of life. Here, we compare nonverbal social perception in patients with schizophrenia and controls and examine how nonverbal social perception relates to daily functioning.

Methods

We compared nonverbal social perception in 41 stable outpatients with schizophrenia and 30 healthy controls using the Mini Profile of Nonverbal Sensitivity (Mini-PONS). The participants evaluated 64 video clips showing a female actor demonstrating various nonverbal social cues. Participants were asked to choose one of two options that best described the observed scenario. We correlated clinical ratings (Positive and Negative Syndrome Scale, Brief Negative Syndrome Scale), Self-report of Negative Symptoms, and functional assessments (functional capacity and functional outcome) with Mini-PONS scores.

Results

Patients performed significantly poorer in the Mini-PONS compared to controls, suggesting deficits in nonverbal social perception. These deficits were not associated with either positive symptoms or negative symptoms (including self-report). However, impaired nonverbal social perception correlated with distinctive domains of BNSS (mainly avolition and blunted affect), as well as functional capacity and functional outcome in patients.

Conclusion

We demonstrate that nonverbal social perception is impaired in stable outpatients with schizophrenia. Nonverbal social perception is directly related to specific negative symptom domains, functional capacity and functional outcome. These findings underline the importance of nonverbal social perception for patients' everyday life and call for novel therapeutic approaches to alleviate nonverbal social perception deficits.

A Novel Virtual Reality Assessment of Functional Cognition: Validation Study

Background

Cognitive deficits are present in several neuropsychiatric disorders, including Alzheimer disease, schizophrenia, and depression. Assessments used to measure cognition in these disorders are time-consuming, burdensome, and have low ecological validity. To address these limitations, we developed a novel virtual reality shopping task—VStore.

Objective

This study aims to establish the construct validity of VStore in relation to the established computerized cognitive battery, Cogstate, and explore its sensitivity to age-related cognitive decline.

Methods

A total of 142 healthy volunteers aged 20-79 years participated in the study. The main VStore outcomes included verbal recall of 12 grocery items, time to collect items, time to select items on a self-checkout machine, time to make the payment, time to order coffee, and total completion time. Construct validity was examined through a series of backward elimination regression models to establish which Cogstate tasks, measuring attention, processing speed, verbal and visual learning, working memory, executive function, and paired associate learning, in addition to age and technological familiarity, best predicted VStore performance. In addition, 2 ridge regression and 2 logistic regression models supplemented with receiver operating characteristic curves were built, with VStore outcomes in the first model and Cogstate outcomes in the second model entered as predictors of age and age cohorts, respectively.

Results

Overall VStore performance, as indexed by the total time spent completing the task, was best explained by Cogstate tasks measuring attention, working memory, paired associate learning, and age and technological familiarity, accounting for 47% of the variance. In addition, with λ=5.16, the ridge regression model selected 5 parameters for VStore when predicting age (mean squared error 185.80, SE 19.34), and with λ=9.49 for Cogstate, the model selected all 8 tasks (mean squared error 226.80, SE 23.48). Finally, VStore was found to be highly sensitive (87%) and specific (91.7%) to age cohorts, with 94.6% of the area under the receiver operating characteristic curve.

Conclusions

Our findings suggest that VStore is a promising assessment that engages standard cognitive domains and is sensitive to age-related cognitive decline.

Cognitive-Behavioral Social Skills Training for patients with late-life schizophrenia and the moderating effect of executive dysfunction

The objectives of this study are to test the efficacy of Cognitive-Behavioral Social Skills Training (CBSST) in enhancing social function in a sample of older patients with schizophrenia, and to assess whether baseline cognition moderates response to CBSST. To address these objectives, we conducted a randomized controlled trial of 63 participants, randomized 1:1 into CBSST or Treatment-As-Usual (TAU). The setting was a community-based geriatric mental health outpatient clinic in Toronto, Ontario, Canada. Data were collected at baseline, and week 18, 36 and 52, between June 2008 and May 2014. Participants were outpatients, aged 60 or older, with a diagnosis of schizophrenia or schizoaffective disorder and no evidence of dementia or other conditions associated with cognitive or functional impairment. The intervention was a weekly group CBSST for 36 weeks. Cognition, including executive function, was assessed at baseline. Modified total score on the Independent Living Skills Survey (ILSS) at 18, 36, and 52 weeks was the primary outcome measure. In a linear mixed model analysis, the ILSS trajectory was better in the CBSST group than the TAU group, with significantly better function at 36 (Cohen's d = 0.75) and 52 weeks (Cohen's d = 0.92). Baseline executive dysfunction moderated CBSST response, whereby participants with more severe executive dysfunction experienced the most improvement in ILSS. CBSST was efficacious in patients with late-life schizophrenia and prevented decline in social function over a one-year period. CBSST was most beneficial for patients with more severe executive dysfunction, i.e., those who needed skills training the most.

Rates of Cognitive and Functional Impairments in Older Adults Residing in a Continuing Care Senior Housing Community

OBJECTIVE

The current cross-sectional study examined cognition and performance-based functional abilities in a continuing care senior housing community (CCSHC) that is comparable to other CCSHCs in the US with respect to residents' demographic characteristics.

METHOD

Participants were 110 older adult residents of the independent living unit. We assessed sociodemographics, mental health, neurocognitive functioning, and functional capacity.

RESULTS

Compared to normative samples, participants performed at or above expectations in terms of premorbid functioning, attention span and working memory, processing speed, timed set-shifting, inhibitory control, and confrontation naming. They performed below expectation in verbal fluency and verbal and visual learning and memory, with impairment rates [31.4% (>1 SD below the mean) and 18.49% (>1.5 SD below the mean)] well above the general population (16% and 7%, respectively). Within the cognitive test battery, two tests of delayed memory were most predictive of a global deficit score. Most cognitive test scores correlated with performance-based functional capacity.

CONCLUSIONS

Overall, results suggest that a subset of older adults in the independent living sector of CCSHCs are cognitively and functionally impaired and are at risk for future dementia. Results also argue for the inclusion of memory tests in abbreviated screening batteries in this population. We suggest that CCSHCs implement regular cognitive screening procedures to identify and triage those older adults who could benefit from interventions and, potentially, a transition to a higher level of care.

Social Cognition Individualized Activities Lab for Social Cognition Training and Narrative Enhancement in Patients With Schizophrenia: A Randomized Controlled Study to Assess Efficacy and Generalization to Real-Life Functioning (Prot. n°: NCT05130853)

Subjects affected by schizophrenia present significant deficits in various aspects of social cognition, such as emotion processing, social perception and theory of mind (ToM). These deficits have a greater impact than symptoms on occupational and social functioning. Therefore, social cognition represents an important therapeutic target in people with schizophrenia. Recent meta-analyses showed that social cognition training (SCT) is effective in improving social cognition in subjects with schizophrenia; however, real-life functioning is not always ameliorated. Integration of SCT with an intervention targeting metacognitive abilities might improve the integration of social cognitive skills to daily life functioning. Our research group has implemented a new individualized rehabilitation program: the Social Cognition Individualized Activities Lab, SoCIAL, which integrates SCT with a module for narrative enhancement, an intervention targeting metacognitive abilities. The present multi-center randomized controlled study will compare the efficacy of SoCIAL and treatment as usual (TAU) in subjects diagnosed with a schizophrenia-spectrum disorder. The primary outcome will be the improvement of social cognition and real-life functioning; while the secondary outcome will be the improvement of symptoms, functional capacity and neurocognition. The results of this study will add empirical evidence to the benefits and feasibility of SCT and narrative enhancement in people with schizophrenia-spectrum disorders.

The effect of sex on social cognition and functioning in schizophrenia

Social cognitive impairment is a core feature of schizophrenia and plays a critical role in poor community functioning in the disorder. However, our understanding of the relationship between key biological variables and social cognitive impairment in schizophrenia is limited. This study examined the effect of sex on the levels of social cognitive impairment and the relationship between social cognitive impairment and social functioning in schizophrenia. Two hundred forty-eight patients with schizophrenia (61 female) and 87 healthy controls (31 female) completed five objective measures and one subjective measure of social cognition. The objective measures included the Facial Affect Identification, Emotion in Biological Motion, Self-Referential Memory, MSCEIT Branch 4, and Empathic Accuracy tasks. The subjective measure was the Interpersonal Reactivity Index (IRI), which includes four subscales. Patients completed measures of social and non-social functional capacity and community functioning. For objective social cognitive tasks, we found a significant sex difference only on one measure, the MSCEIT Branch 4, which in both patient and control groups, females performed better than males. Regarding the IRI, females endorsed higher empathy-related items on one subscale. The moderating role of sex was found only for the association between objective social cognition and non-social functional capacity. The relationship was stronger in male patients than female patients. In this study, we found minimal evidence of a sex effect on social cognition in schizophrenia across subjective and objective measures. Sex does not appear to moderate the association between social cognition and functioning in schizophrenia.

Cognitive function mediates the relationship between visual contrast sensitivity and functional outcome in schizophrenia

BACKGROUND

Individuals with schizophrenia exhibit deficits in visual contrast processing, though less is known about how these deficits impact neurocognition and functional outcomes. This study investigated effects of contrast sensitivity (CS) on cognition and capacity for independent living in schizophrenia.

METHODS

Participants were 58 patients with schizophrenia (n = 49) and schizoaffective disorder (n = 9). Patients completed a psychophysical paradigm to obtain CS with stimuli consisting of grating patterns of low (0.5 and 1 cycles/degree) and high spatial frequencies (4, 7, 21 cycles/degree). Patients completed the MATRICS Consensus Cognitive Battery and Wechsler Adult Intelligence Scales, Third Edition to assess cognition, and the problem-solving factor of the Independent Living Scales to assess functional capacity. We computed bivariate correlation coefficients for all pairs of variables and tested mediation models with CS to low (CS-LSF) and high spatial frequencies (CS-HSF) as predictors, cognitive measures as mediators, and capacity for independent living as an outcome.

RESULTS

Cognition mediated the relationship between CS and independent living with CS-LSF a stronger predictor than CS-HSF. Mediation effects were strongest for perceptual organization and memory-related domains. In an expanded moderated mediation model, CS-HSF was found to be a significant predictor of independent living through perceptual organization as a mediator and CS-LSF as a moderator of this relationship.

CONCLUSION

CS relates to functional capacity in schizophrenia through neurocognition. These relationships may inform novel visual remediation interventions.

Cognitive behavioural social skills training: Methods of a randomized controlled trial for youth at risk of psychosis

AIM

Poor functioning has become a hallmark of many youth at clinical high-risk (CHR) of psychosis. Even for those who do not make the transition to psychosis remain troubled by functional deficits and a decline in functioning increases the odds of transitioning to psychosis. There are very few treatment studies that have attempted to improve social and role functioning. The aim of this paper is to describe the methods of a treatment study to address social and role functioning in CHR.

METHODS

This was a randomized controlled trial of cognitive-behavioural social skills training (CBSST) versus a supportive therapy. CBSST combines elements of cognitive behaviour therapy (CBT) and social skills training (SST), two evidence-based treatments for schizophrenia. By adding CBT to SST to target functioning outcomes, SST can be used to train new social skills, and thoughts that interfere with skilled performance in the real world can be addressed using CBT. We developed an adapted version of CBSST, more appropriate for the age range and illness severity of typical CHR individuals, to attempt to show improvements in social and role functioning for these young people.

RESULTS

Two hundred and three participants were recruited for this study. Results include initial baseline data.

CONCLUSION

This article describes the baseline methodology of a CHR youth who have difficulties in social and/or role functioning. It is one of the first clinical trials to address this significant problem.

Computer-Delivered Cognitive Training and Transcranial Direct Current Stimulation in Patients With HIV-Associated Neurocognitive Disorder: A Randomized Trial

Objective: HIV infection is associated with impaired cognition, and as individuals grow older, they may also experience age-related changes in mental abilities. Previous studies have shown that computer-based cognitive training (CCT) and transcranial direct current stimulation (tDCS) may be useful in improving cognition in older persons. This study evaluated the acceptability of CCT and tDCS to older adults with HIV-associated neurocognitive disorder, and assessed their impact on reaction time, attention, and psychomotor speed. Methods: In a single-blind randomized study, 46 individuals with HIV-associated mild neurocognitive disorder completed neuropsychological assessments and six 20-min training sessions to which they had been randomly assigned to one of the following conditions: (1) CCT with active tDCS; (2) CCT with sham tDCS, or (3) watching educational videos with sham tDCS. Immediately after training and again 1 month later, participants completed follow-up assessments. Outcomes were evaluated via repeated measures mixed effects models. Results: Participant ratings of the intervention were positive. Effects on reaction time were not significant, but measures of attention and psychomotor speed suggested positive effects of the intervention. Conclusion: Both CCT and tDCS were highly acceptable to older persons with HIV infection. CCT and tDCS may improve cognitive in affected individuals. Clinical Trial Registration: [www.ClinicalTrials.gov], identifier [NCT03440840].

Cognitive impairment in euthymic patients with bipolar disorder: Prevalence estimation and model selection for predictors of cognitive performance

Objectives Although cognitive dysfunction is a prominent feature of bipolar disorder (BD), previous research presents limitations in estimating the proportion of euthymic patients experiencing clinically relevant deficits and identifying predictors of cognitive difficulties. We explored the relevance of recommended definitions of clinically significant cognitive impairment for functional outcomes, estimated its prevalence, and identified patient characteristics associated with cognition. Methods We assessed cognitive performance across four domains in 80 euthymic participants with BD. Participants were categorized based on two criteria for clinically significant cognitive impairment and we assessed the ability of these criteria to differentiate participant performance on established functional outcomes. Variable selection with elastic net regression was used to identify sociodemographic and clinical factors associated with cognitive performance. Selected variables were examined as predictors of clinically significant cognitive impairment with logistic regression. Results According to the selected criterion, 34% presented with clinically significant cognitive impairment. Poorer current cognitive performance was associated with older age, lower estimated premorbid IQ, more currently prescribed psychotropic medications, fewer previous psychological therapies, and current use of antipsychotics. A model with premorbid IQ, psychotropic medications and previous psychological therapies as predictors of cognitive impairment correctly classified 75% of the participants. Conclusions This is one of the first studies to use a model selection approach to identify factors associated with cognitive difficulties in BD. Our findings offer the initial steps towards a predictive model for cognitive impairment. This could improve treatment decisions and prioritization for euthymic patients with BD, particularly the implementation of cognitive interventions.

Patterns of instrumental activities of daily living between community-dwelling older adults

The ability to perform instrumental activities of daily living (IADLs) is an important marker within the aging process, as it reflects the level of independence to perform in the real world. However, there is a scarcity of studies that investigate the different performance profiles among older adults.

Objective

To investigate the heterogeneity present in the community of elderly people, grouping them based on characteristics and patterns observed through an objective performance-based assessment.

Methods

Participants were selected according to the following inclusion criteria: fluency in Portuguese, ³60 years, regular participation in a social program offered by the government of Rio de Janeiro, and absence of a caregiver. The evaluation of IADLs was determined by the total and brief version of the University of California, San Diego Performance-Based Skills Assessment (UPSA) and the Lawton and Brody IADL scale. The Brief Cognitive Screening Battery and the Mini-Mental State Examination were used to characterize the sample, in addition to the Geriatric Depression Scale. A total of 61 elderly people with an average age of 72.5 years, predominantly females (85.2%), and average education of 11.2 were evaluated and grouped according to their performance at UPSA through clustering analysis.

Results

The analysis revealed three grouping patterns, subdividing the sample into subgroups that differed significantly in terms of age, education, global cognition, and all instrumental activities assessed by UPSA - planning, finance, communication, transportation, and household chores.

Conclusions

This study was able to identify the heterogeneity present between the elderly people in the different factors that compose the IADLs through a performance-based assessment.

The neurocognitive and functional profile of schizophrenia in a genetically homogenous European sample

Schizophrenia is a complex heritable brain disorder that entails significant social, neurocognitive, and functional deficits, and significant psychosocial challenges to affected and unaffected family members. In this cross-sectional study, we explore impairments in specific neurocognitive and social cognition processes in patients affected with schizophrenia, unaffected relatives, and in controls to provide a characterization of a genetically homogenous European sample from an endophenotypic and functional standpoint. A sample of 38 affected patients, 28 first-degree relatives, and 97 controls performed a series of computerized and skills-based assessments. Samples were compared across several neurocognitive, social, and functional domains. Significant impairments in episodic memory, executive function, social cognition, complex cognition, sensorimotor domains were found in patients and first-degree relatives. Findings also showed increased processing speed in memory and other complex cognitive processes relevant to autonomous living. A discriminant function analysis yielded 2 functions allowing 79% of correct group classifications based on social cognition and functional skills, neurocognition, and age. The study highlights the importance of resourcing to wide-ranging assessment methodologies, of developing research efforts to further understand the decline of social and neurocognitive processes, and the need for designing more targeted intervention strategies to be implemented both with affected patients and families.

Real-World Functioning in Patients With Schizophrenia: Beyond Negative and Cognitive Symptoms

Introduction: Interest in the idea of recovery for certain patients with schizophrenia has been growing over the last decade. Improving symptomatology and functioning is crucial for achieving this. Our study aims to identify those factors that substantially contribute to real-world functioning in these patients. Methods: We carried out a cross-sectional study in stable outpatients with schizophrenia on maintenance antipsychotic monotherapy. Patients: We studied 144 outpatients with schizophrenia (DSM-IV-TR criteria) meeting the following criteria: (1) 18-65 years of age; (2) being clinically stable for at least the previous three months; (3) on maintenance antipsychotic monotherapy (prescriptions ≤ 10 mg olanzapine, ≤200 mg quetiapine, or ≤100 mg levomepromazine as hypnotics were also allowed); and (4) written informed consent. Assessment: We collected information on demographic and clinical variables by using an ad hoc questionnaire. For psychopathology, we employed the Spanish versions of the following psychometric instruments: the Positive and Negative Syndrome Scale (PANSS), the Brief Negative Symptom Scale (BNSS-Sp), and the Calgary Depression Scale (CDS). In addition, cognitive domains were assessed using the Verbal Fluency Test (VFT), the Digit Symbol Substitution Test (DSST), and the Trail Making Test, parts A and B (TMT-A and TMT-B). Finally, we employed the Spanish versions of the University of California San Diego Performance-based Skills Assessment (Sp-UPSA) and the Personal and Social Performance (PSP) for assessing functional capacity and real-world functioning, respectively. Statistical analysis: A forward stepwise regression was conducted by entering those variables significantly associated with PSP total score into the univariate analyses (Student's t-test, ANOVA with Duncan's post-hoc test, or bivariate Pearson correlation). Results: A total of 144 patients; mean age 40 years, 64% males, mean length of illness 12.4 years, PSP total score 54.3. The final model was a significant predictor of real-world functioning [F (7, 131) = 36.371, p < 0.001] and explained 66.0% of the variance. Variables retained in the model: BNSS-Sp abulia, asociality, and blunted affect, PANSS general psychopathology, Sp-UPSA transportation, TMT-B, and heart rate. Conclusion: Our model will contribute to a more efficient and personalized daily clinical practice by assigning specific interventions to each patient based on specific impaired factors in order to improve functioning.

Effect of Action-Based Cognitive Remediation on cognitive impairment in patients with remitted bipolar disorder: A randomized controlled trial

OBJECTIVES

Cognitive impairment affects many patients with bipolar disorder (BD), and treatments with replicated pro-cognitive effects are lacking. This study aimed to assess the effect of Action-Based Cognitive Remediation (ABCR) vs control treatment on cognitive impairment in patients with BD.

METHODS

Patients with remitted BD with objective cognitive impairment were randomized to 10 weeks of ABCR vs control treatment, and assessed at baseline, after 2 weeks of treatment, at treatment completion and at 6 months follow-up. The primary outcome was a cognitive composite score. Secondary outcomes were executive function and observer-rated functional capacity. Tertiary measures included additional neuropsychological tests, performance-based functional capacity and quality of life. Data were analysed with linear mixed effects models.

RESULTS

In total, 64 participants were randomized; given three dropouts before the baseline assessments, data were analysed for 61 participants (ABCR: n = 32, control: n = 29). There was no effect on ABCR vs control on the primary cognitive composite score (P-values ≥.60). At treatment completion, there was a large effect of ABCR vs control on the secondary executive function measure (treatment effect= -0.16, 95% CI [-0.27, -0.05], P ≤ .01, d = 0.65), and on subjective cognitive functioning (treatment effect = -5.38, 95% CI [-8.13, -2.67], P ≤ .001, d = 0.80), which disappeared at follow-up. There was no treatment-effect on functioning, and no association between cognitive and functional change.

CONCLUSIONS

There was no effect of ABCR on the cognitive composite score. However, there was an effect on executive function and subjective cognitive functioning suggesting that ABCR may be relevant for patients with executive dysfunction.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03295305.