Integrated psychological therapy (IPT) for schizophrenia: is it effective?

Navigating Social Cognitive Impairments in Schizophrenia Spectrum Disorders: Protocol for a Pilot Pre-Post Quasi-Experimental Study for Remote Avatar-Assisted Cognitive Remediation Therapy

BACKGROUND

Social cognitive impairments are prevalent in schizophrenia spectrum disorder (SSD) and have detrimental effects on functioning. Cognitive remediation (CR) has shown its efficacy in improving social cognitive impairments, although the transfer of these skills to daily life and the personalization of these interventions remain challenging. RC2S (Remédiation Cognitive de la Cognition Sociale dans la Schizophrénie; Cognitive remediation of social cognition in Schizophrenia) is a French CR that combines the learning of strategies and practice using paper-and-pencil exercises and digital relational simulations. This French program was designed as an in-person intervention.

OBJECTIVE

This project aims to culturally adapt the RC2S program, in French-Canadian and North American English and to assess the feasibility, acceptability, safety, and implementation of a remote version in people with SSD. An exploratory objective is to assess the preliminary effect of remote RC2S on goal attainment, social cognition, and psychosocial outcomes.

METHODS

We will use a pre-post quasi-experimental design. First, the translation and cultural adaptation in North American English and French-Canadian of RC2S is presented. Then, 20 participants aged ≥18 years with a diagnosis of SSD, presenting with a subjective or an objective impairment in social cognition, will be included to receive RC2S. In addition, 5 therapists will be included as research participants to assess their perspective on RC2S. Participants with SSD will undergo a baseline remote assessment of their social cognition, clinical symptoms, and functioning. They will then start remote RC2S for 24 biweekly individual 1-hour sessions with a therapist. Following the case formulation and goal setting, participants will complete personalized paper-and-pencil exercises to develop strategies and integrative digital relational simulations, during which they will help an avatar navigate through a variety of social contexts and relationships. The last 2 sessions are dedicated to the transfer to daily life. All participants will complete in-session questionnaires assessing therapeutic alliance, motivation, acceptability, feasibility, and implementation. Following RC2S, the participants with SSD will repeat the same assessment as the baseline. Descriptive statistics will be used to summarize the data about acceptability, feasibility, safety, and implementation. To assess the preliminary effect of RC2S, an intention-to-treat approach will be used with linear mixed models for repeated measures with fixed effects of time.

RESULTS

So far, 45% (9/20) of participants with SSD (mean age 37.9, SD 9.3 years) have completed the project. They received a mean of 20.5 out of 24 (SD 3.5) sessions of RC2S. A total of 5 therapists also completed the project.

CONCLUSIONS

Improving social cognitive impairments is an important target in SSD to promote functional recovery. Using digital technologies to address these impairments and deliver the intervention is a promising approach to increase the ecological validity of CR and access to the intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05017532; https://classic.clinicaltrials.gov/ct2/show/NCT05017532.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54251.

Effects of Exercise on Positive Symptoms, Negative Symptoms, and Depression in Patients with Schizophrenia: A Systematic Review and Meta-Analysis

This study was performed to evaluate the effects of exercise on positive and negative symptoms and depression in patients with schizophrenia through a systematic review and meta-analysis focusing on randomized controlled trials (RCTs). PubMed, Embase, CINAHL, MEDLINE, Cochrane Library, PsycINFO, and Web of Science were searched from their inception to 31 October 2022. We also conducted a manual search using Google Scholar. This meta-analysis was conducted according to the PRISMA guidelines. The methodological quality of the studies was assessed using the Cochrane risk-of-bias tool for randomized trials. To identify the cause of heterogeneity, subgroup analysis, meta-ANOVA, and meta-regression analyses were performed as moderator analyses. Fifteen studies were included. The meta-analysis (random-effects model) for overall exercise showed a medium significant effect (standardized mean difference [SMD] = -0.51, 95% confidence interval [CI]: -0.72 to -0.31) on negative symptoms, a small significant effect (SMD = -0.24, 95% CI: -0.43 to -0.04) on positive symptoms, and a nonsignificant effect (SMD = -0.87, 95% CI: -1.84 to 0.10) on depression. Our findings demonstrate that exercise can relieve the negative and positive symptoms of schizophrenia. However, the quality of some included studies was low, limiting our results for clear recommendations.

Cognitive Enhancement Therapy vs social skills training in schizophrenia: a cluster randomized comparative effectiveness evaluation

BACKGROUND

Schizophrenia and related disorders are highly disabling and create substantial burdens for families, communities, and health care systems. Although pharmacological treatments can often lessen the psychotic symptoms that are a hallmark of schizophrenia, they do not lessen the social and cognitive deficits that create the greatest impediments to community engagement and functional recovery. This study builds on prior research on psychosocial rehabilitation by comparing the effectiveness of two treatments demonstrated as efficacious in improving social and community functioning, Cognitive Enhancement Therapy (CET) and a version of Social Skills Training (HOPES/SST).

METHODS

The study uses a randomized cluster design in which a pair of clinicians at community- and hospital-based mental service centers deliver either CET or HOPES to at least one group of 6-8 eligible clients for 12 months. Clinicians are trained and then supervised weekly, with ongoing process measurement of treatment fidelity, attendance, satisfaction, and retention, and use of other services. Measures administered at baseline and at 6 and 12 months while in treatment, and then at 18 and 24 months after treatment include social adjustment, quality of life, social skills, positive and negative symptoms, and neuro- and social cognition. We hypothesize that CET will be associated with greater improvements than SST in both the primary outcome of community functioning and the secondary outcomes of neuro- and social cognition and social skills. Secondarily, we hypothesize that more cognitive impairment at baseline and younger age will predict more benefit from CET compared to HOPES.

DISCUSSION

Resource shortages endemic in mental health services and exacerbated by the pandemic highlight the importance of identifying the most effective approach to improving social and community functioning. We aim to improve understanding of the impact of two efficacious psychosocial treatments and to improve clinicians' ability to refer to both treatments the individuals who are most likely to benefit from them. We expect the result to be programmatic improvements that improve the magnitude and durability of gains in community functioning.

TRIAL REGISTRATION

ClinicalTrial.gov NCT04321759 , registered March 25, 2020.

Predictors of competitive employment in individuals with severe mental illness: results from an observational, cross-sectional study in Germany

BACKGROUND

Employment is of great importance as it is associated with various positive effects. Individuals with severe mental illness (SMI) are often excluded from competitive employment. Current data on employment of individuals with mental illness are rare, and influencing factors are under-researched. The present study examines possible predictors of competitive employment among individuals with SMI.

METHODS

This was a cross-sectional and multicentered study of 300 individuals with SMI aged 18 to 65 years. The following inclusion criteria were used: (I) diagnosis of schizophrenia, schizotypal and delusional disorders (ICD-10 F2x), or affective disorders (ICD-10 F3x), (II) duration of psychiatric illness ≥ 2 years, and (III) substantial impact of illness on social functioning. Participants were interviewed by trained staff using standardised instruments. The relationship between potential predictors (age, sex, education, marital status, living situation, migration background, psychosocial functioning, age at first mental problem, physical illness, work ability) and employment was analysed using a hierarchic binary logistic regression model.

RESULTS

Only one-third (34%) of participants were competitively employed. Almost one-third were unemployed (30%), and 28% reported early retirement due to mental illness. Psychosocial functioning was positively associated with competitive employment (OR = 1.09, 95% CI: 1.05 - 1.13, p < 0.001); concurrent chronic physical illness was negatively associated with competitive employment (OR = 0.38, 95% CI: 0.21 - 0.71, p = 0.002).

CONCLUSIONS

Findings confirm a high risk of exclusion from competitive employment among individuals with SMI. Nonetheless, a substantial proportion of individuals are employed. Findings call for efforts to maintain or enhance workforce participation among individuals with SMI. A special focus should be placed on improving physical health and strengthening psychosocial functioning.

TRIAL REGISTRATION

The study was registered in the German Clinical Trials Register (DRKS) under the registration number DRKS00015801 before the start of recruitment (Registration date: 21.02.2019).

The relation of integrated psychological therapy to resting state functional brain connectivity networks in patients with schizophrenia

Functional brain dysconnectivity measured with resting state functional magnetic resonance imaging (rsfMRI) has been linked to cognitive impairment in schizophrenia. This study investigated the effects on functional brain connectivity of Integrated Psychological Therapy (IPT), a cognitive behavioral oriented group intervention program, in 31 patients with schizophrenia. Patients received IPT or an equal intensity non-specific psychological treatment in a non-randomized design. Evidence of improvement in executive and social functions, psychopathology and overall level of functioning was observed after treatment completion at six months only in the IPT treatment group and was partially sustained at one-year follow up. Independent Component Analysis and Isometric Mapping (ISOMAP), a non-linear manifold learning algorithm, were used to construct functional connectivity networks from the rsfMRI data. Functional brain dysconnectivity was observed in patients compared to a group of 17 healthy controls, both globally and specifically including the default mode (DMN) and frontoparietal network (FPN). DMN and FPN connectivity were reversed towards healthy control patterns only in the IPT treatment group and these effects were sustained at follow up for DMN but not FPN. These data suggest the use of rsfMRI as a biomarker for accessing and monitoring the therapeutic effects of cognitive remediation therapy in schizophrenia.

Late 'Early Intervention in Psychosis': A Family School for Learning How to Live with Schizophrenia

The paper describes a family school for learning how to live with schizophrenia, which was founded in 1986 in Vienna, Austria, and is still running today. It was established in cooperation between professionals and the Austrian self-help association HPE of the relatives of persons with mental disorders. It addresses the needs of 10 families at a time, in cases where a son or a daughter was diagnosed with schizophrenia and had already experienced one or several episodes of the illness. The course lasts one and a half years and is organized according to the model of a weekly boarding school, where 10 children, the "residents", stay in the school overnight from Sunday evening to Friday and take part in a structured program on cognitive, social and practical life skills. Ambulatory psychiatric treatment is taking place concurrently outside the school through local routine services. On weekends residents stay with their parents since the school is closed. Parents visit the school regularly to take part in joint activities with the residents. They also undertake night shifts in the school and attend a weekly parents' group. In the regular encounters during everyday activities in the school, "learning by doing" occurs - parents get to know the daughters and sons of other families and can learn to distinguish between disease-related and personality-related behavior. Residents can have similar learning experiences in relation to the parents of other residents. The main aim of the school is that parents learn to provide "protected autonomy" for the daughters or sons in question, in order to assist them after the end of the course in leading a life characterized by as much autonomy as possible after the end of the school.

Predictors of social and role outcomes in first episode psychosis: A prospective 12-month study of social cognition, neurocognition and symptoms

BACKGROUND

Poor functioning is common in psychosis, with predictors of poor outcome including negative symptoms and deficits in neurocognition (NC) and social cognition (SC). The extent to which these variables contribute unique variance in social and role trajectories remains inconclusive. Identifying robust predictors of outcome will inform targeted interventions in early psychosis, where functional trajectories are being set.

METHOD

Prospective 12-month follow-up study investigating the predictive values of NC and SC on social and role functioning in individuals with first-episode psychosis (FEP), within the context of clinical variables. 98 individuals with FEP (mean age = 24; male = 77) were assessed within the first year of diagnosis on functioning (social and role), cognition (SC and NC) and psychosis symptoms.

RESULTS

Negative symptoms were the only significant predictor of 12-month social (χ²  = 9.59, P = .002, OR = 1.12) and role (χ²  = 10.86, P < .001, OR = 1.16) functioning in FEP. In exploratory analyses, negative symptoms mediated the relationship between baseline social knowledge and social functioning (Z = 1.92, P = .05; d = 0.56), and between baseline logical memory and role functioning (Z = 2.40, P = .02; d = 0.80) at 12-month follow-up.

CONCLUSION

Although social and role trajectories in early psychosis appear somewhat distinct, negative symptoms were the best prognostic marker of social and role outcome in FEP, and mediated the relationship between SC and social outcome, and NC and role outcome; these relationships may be important when considering interventions to improve functional outcome in early psychosis.

Pharmacological Treatment for Social Cognition: Current Evidence

Cognitive impairment is currently considered a core feature of schizophrenia (SZ) and is gaining attention as a fundamental therapeutic target. Standard treatment for SZ involves the use of antipsychotics that are successfully used to control positive symptoms and disorganized behaviour. However, it is still unclear whether they are effective on social cognition (SC) impairment. Furthermore, different medications are currently being studied to improve SC in patients with SZ. A literature search on this topic was conducted using the PubMed database. All kinds of publications (i.e., reviews, original contributions and case reports) written in English and published in the last 15 years were included. The aim of our literature review is to draw a picture of the current state of the pharmacological treatment of SC impairment in SZ.

Improved social functioning following social recovery therapy in first episode psychosis: Do social cognition and neurocognition change following therapy, and do they predict treatment response?

There is a need to develop and refine psychosocial interventions to improve functioning in First Episode Psychosis (FEP). Social cognition and neurocognition are closely linked to functioning in psychosis; examinations of cognition pre- and post- psychosocial intervention may provide insights into the mechanisms of these interventions, and identify which individuals are most likely to benefit.

METHOD

Cognition was assessed within a multi-site trial of Social Recovery Therapy (SRT) for individuals with FEP experiencing poor functioning (<30 h weekly structured activity). Fifty-nine participants were randomly allocated to the therapy group (SRT + Early intervention), and 64 were allocated to treatment as usual group (TAU - early intervention care). Social cognition and neurocognition were assessed at baseline and 9 months; assessors were blind to group allocation. It was hypothesized that social cognition would improve following therapy, and those with better social cognition prior to therapy would benefit the most from SRT.

RESULTS

There was no significant impact of SRT on individual neurocognitive or social cognitive variables, however, joint models addressing patterns of missingness demonstrate improvement across a number of cognitive outcomes following SRT. Further, regression analyses showed those who had better social cognition at baseline were most likely to benefit from the therapy (ß = 0.350; 95% CI = 0.830 to 8.891; p = .019).

CONCLUSION

It is not clear if SRT impacts on social cognitive or neurocognitive function, however, SRT may be beneficial in those with better social cognition at baseline.

Feasibility and Efficacy of a Psychological Therapy for Patients With a Schizophrenic Psychosis in an Inpatient Setting: Study Protocol of a Randomized Switch Controlled Trial

Background: Schizophrenic psychoses are severe mental disorders. Despite advances in treatment, outcomes are still unsatisfactory. Pharmacological treatments are still limited, in particular regarding improvements in psychosocial functioning and neuro-cognitive impairment. In recent years new psychological therapies have been developed, demonstrating promising results. However, most of these interventions have been designed for and studied in outpatients; their efficacy and feasibility for patients requiring hospitalization is still unknown. Therefore, we have designed a clinical trial to compare a neuro-cognitive (Integrated Neuro-cognitive Treatment INT); a cognitive-behavioral (Integrated Psychological Therapy IPT); and a control (Cogpack CGP) intervention for patients with a schizophrenic psychosis hospitalized for treatment.

Methods: In a three-parallel-arm, single-blind, randomized, controlled study, we compare INT, IPT, and CGP. Participants will take part in two weekly sessions of one intervention for at least 16 sessions. If due to randomization, participants are allocated to a treatment arm not suitable for them, they are allowed to switch intervention after four sessions. Based on a sample size calculation, recruitment will continue until 30 participants have completed the intervention for each treatment arm.

Outcome Measurement: Primary outcomes are: change in symptom as measured by the Positive and Negative Syndrome Scale (PANSS), change in psychosocial functioning as assessed by the mini ICF-APP and neuro-cognitive performance, assessed by the Matrics Cognitive Consensus Battery (MCCB). Other outcomes of interest are the Brief Symptom Inventory (BSI) and the Health of the Nation Outcome Scales (HoNOS); together with prescribed medication, treatment retention and completion rates. Outcomes will be measured at baseline, 2 weeks into treatment (prior to a potential switch of intervention arm), post-treatment and at 6 and 12-month post-treatment follow-ups.

Expected Outcomes: We expect an overall improvement; however, with differences in specific domains for each treatment arm, with those completing INT showing better outcomes than IPT and CGP, respectively. We anticipate that lower functioning participants will drift to CGP and higher functioning participants to INT.

Conclusion: Due to the complexity of treatment for patients with a schizophrenic psychosis, we consider it crucial to compare different treatment options for those more severely affected, therefore, requiring inpatient treatment.

Trial registration:www.clinicaltrials.gov (ID: NCT03316664; 17.10.2017).

Social cognition in epilepsy: State of the art and perspectives

INTRODUCTION

The neuropsychology of epilepsy has been a major area of study for almost a century and cognitive impairments are an integral part of the new definition of epilepsy. Among such impairments, social cognition (SC) dysfunctions are of relatively recent interest. SC abilities refer to the body of knowledge and processes involved in establishing satisfying and appropriate social interactions. In particular, they allow the recognition of emotions in others, emotional experiences which are suitably adapted to social situations, and the ability to infer mental states in oneself and others.

METHODS

An overeview was conducted of the available data within the literature, with the objective of presenting the SC disorders associated with certain types of epilepsy and the possible risk factors already explored i.e., localisation of epileptic focus, age of onset/duration of the disease, and effects of treatments including surgery. Studies investigating the potential repercussions of these disorders on patients' daily life have also been included.

RESULTS

Social cognition disorders are an integral part of the cognitive disorders traditionally described in epilepsy. Indeed, a growing number of studies highlight the increased prevalence of SC disorders in various domains, and some patients appear to be more at risk than others. These disorders could be a major determining factor in the deterioration of patients' quality of life (QOL), particularly patients' support and social integration. This highlights the importance of assessing and managing these disorders in patients with epilepsy (PWE). Perspectives in the field of research and clinical practice are also evoked, such as exploring the links between disruptions in SC abilities and treatments, or developing specific tools for assessment and rehabilitation within the context of epilepsy.

Do community mental health teams caring for severely mentally ill patients adjust treatments and services based on patients’ antisocial or criminal behaviours?

Background

Antisocial behaviour is common among patients with severe mental illness (SMI) requiring hospitalisation.

Aim

To determine whether differential treatments and services are provided to patients with SMI who engage in antisocial behaviour.

Method

A random sample of 161 inpatients with SMI were recruited from general adult wards and assessed at baseline and two years later. Information on symptoms, aggressive behaviour, substance misuse, and service use was obtained from patients and clinical files.

Results

Past antisocial behaviours were not associated with type or intensity of treatments and services. Severity of positive symptoms, aggressive behaviour, and illicit drug use were positively associated with the frequency of CMHT contact, but not with the type of CMHT, type of medication, or other treatments and benefits.

Conclusions

While the frequency of meetings with CMHTs increased with the severity of antisocial behaviours, no specific treatments were provided to patients with SMI engaging in antisocial behaviours.

Effectiveness of integrated psychological therapy on cognitive function among Lebanese patients with schizophrenia: a pilot study

Background: The integrated term emphasises the need for cognitive therapy to always be embedded into an extended treatment concept adapted to cognitive resources and deficits and to patient rehabilitation. One of the first approaches is integrated psychological therapy (IPT).Aim: To assess the effect of the IPT Programme compared to the Treatment as Usual (TaU) in terms of cognitive performance and social skills among a group of schizophrenic patients.Methods: This randomised controlled study enrolled 20 patients in each group. Patients attended 60-min sessions, 3 days/week.Results: When considering the TaU group, the bivariate results showed that significantly higher means of attention scores, lower means in social dysfunction and aggression, social adaptation scores were found after IPT compared to before. The effect size for all tests was found to be weak. When considering the IPT group, significantly higher means attention score, lower means cognitive disorders, social dysfunction, aggression and social adaptation scores were found after IPT compared to before. The effect size for all tests was found to be high.Conclusion: The therapeutic combination of the IPT programme with medical treatment has shown additional beneficial effects on the schizophrenic patients' treatment, enabling them, as far as possible, to reintegrate into the community.KEY POINTSIn cases, a significantly higher GZ-F and KL scores and a lower SDAS-9 and SDAS-6 scores were found post-IPT respectively.In controls, a significant increase in the GZ-F and KL subscales and a decrease in all other scales was found post-IPT respectively.This therapeutic combination of the integrative programme with medical treatment has shown additive beneficial effects in patients with schizophreniaThe treatment approach would allow them, as far as possible, to reintegrate within the community.

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

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

Improving clinical symptoms, functioning, and quality of life in chronic schizophrenia with an integrated psychological therapy (IPT) plus emotional management training (EMT): A controlled clinical trial

Objective: This paper describes the results of testing a multi-component psychological therapy that includes integrated psychological therapy (IPT), together with an adaptation of emotional management therapy (EMT), versus treatment as usual (TAU), delivered in a community mental health setting for individual with chronic schizophrenia. We investigated the effectiveness of a psychological intervention on clinical symptoms, cognitive and social functioning, as well as the feasibility of treatment and its acceptance. Method: 77 outpatients were recruited, 42 in the experimental group, who were treated with IPT + EMT, and 35 participants in control condition (TAU), both during 8 months. The subjects of both groups were assessed pre and postreatment. Results: Treatment attendance was 98% in experimental group and none of patients required hospital admission during therapy, meanwhile 11 patients from the TAU group withdrew and 3 were hospitalized during therapy. After therapy, patients in the experimental group compared to TAU, reduced clinical symptoms and improved cognitive functioning and quality of life. Conclusion: Psychological therapy seems to be a feasible intervention even in the chronic stages of the disease.

Treatment of social cognition in schizophrenia: Current status and future directions

Efforts to develop psychosocial interventions that specifically target social cognition in schizophrenia spectrum disorders began nearly two decades ago. The field has matured considerably since then and has engendered a great deal of optimism about this treatment approach. Indeed, the efficacy of social cognitive interventions, especially those that address multiple domains of social cognition, has received substantial support. This article critically evaluates the current evidence for social cognitive interventions, identifies limitations and open questions, and suggests priorities and directions for further research. Limitations of available studies include a frequent lack of methodological rigor, suboptimal selection of endpoints, and sparse evidence for generalization to functional improvements. We highlight several emerging psychosocial and non-psychosocial approaches that may enhance the efficacy of social cognitive interventions and promote generalization to improvements in real world functioning. We conclude that cautious optimism is warranted as the field moves forward into the next wave of social cognitive treatment studies.

Effectiveness of integrated psychological therapy on clinical, neuropsychological, emotional and functional outcome in schizophrenia: a RCT study

Background: Cognitive impairment is considered a central feature of schizophrenia (SZ) and several rehabilitation treatments have been developed to try to improve cognitive deficits.Aims: The aim of the present study was to analyze the effectiveness of integrated psychological therapy (IPT) compared with a standard treatment (TAU) in two groups of patients with SZ, using a comprehensive testing battery of clinical, cognitive, social cognition and functional outcome domains.Methods: Forty-one patients with SZ were assigned to IPT or TAU groups in a randomized controlled trial (RCT). Psychopathological, neuropsychological, emotional and functional outcome variables were assessed at baseline and after 36 weeks of treatment.Results: The IPT group showed significant improvements than the TAU group regarding clinical and functional outcome variables. Moreover, the IPT group improved significantly in the cognitive domains and emotional functioning. Finally, linear regression has highlighted that the improvement of cognitive variables depends on having done the IPT treatment.Conclusions: IPT seems to be effective in improving clinical, neuropsychological, emotional and functional outcome in chronic SZ inpatients. Further studies would be desirable to deepen the effectiveness of IPT in the field of the psychiatric rehabilitation pointing to the possibility of recovery from mental illness.

Social cognitive interventions for people with schizophrenia: A systematic review

Social cognition is the mental process which underpins social interactions. Increasingly, it has been recognized to be impaired in people with schizophrenia, resulting in functional problems. Correspondingly, the past ten years have seen huge developments in the study of interventions to ameliorate social cognitive deficits among people with schizophrenia. In the present review, we systematically reviewed published studies on social cognitive interventions from 2005 to 2015. Of the 61 studies included in this review, 20 were on broad-based social cognitive interventions, which incorporated neurocognitive training, specialized learning technique or virtual reality social skills training. On the other hand, 31 studies on targeted interventions either focused on specific social cognitive domains, or a range of domains. Improvements in emotion processing and theory of mind were often reported, while social perception and attributional style were less frequently measured. Both broad-based and targeted interventions achieved gains in social functioning, albeit inconsistently. Lastly, nine studies on the use of oxytocin and one study on transcranial direct current stimulation reported positive preliminary results in higher-order cognition and facial affect recognition respectively. This review revealed that a wide range of social cognitive interventions is currently available and most have shown some promise in improving social cognition outcomes. However, there is a need to use a common battery of measurements for better comparisons across interventions. Future research should examine combination therapies and the sustainability of gains beyond the intervention period.

Psychological interventions for positive symptoms in schizophrenia: protocol for a network meta-analysis of randomised controlled trials

INTRODUCTION

There is rising awareness that we need multidisciplinary approaches integrating psychological treatments for schizophrenia, but a comprehensive evidence based on their relative efficacy is lacking. We will conduct a network meta-analysis (NMA), integrating direct and indirect comparisons from randomised controlled trials (RCTs) to rank psychological treatments for schizophrenia according to their efficacy, acceptability and tolerability.

METHODS AND ANALYSIS

We will include all RCTs comparing a psychological treatment aimed at positive symptoms of schizophrenia with another psychological intervention or with a no treatment condition (waiting-list and treatment as usual). We will include studies on adult patients with schizophrenia, excluding specific subpopulations (eg, first-episode patients or patients with psychiatric comorbidities). Primary outcome will be the change in positive symptoms on a published rating scale. Secondary outcomes will be acceptability (dropout), change in overall and negative symptoms of schizophrenia, response, relapse, adherence, depression, quality of life, functioning and adverse events. Published and unpublished studies will be sought through database searches, trial registries and websites. Study selection and data extraction will be conducted by at least two independent reviewers. We will conduct random-effects NMA to synthesise all evidences for each outcome and obtain a comprehensive ranking of all treatments. NMA will be conducted in Stata and R within a frequentist framework. The risk of bias in studies will be evaluated using the Cochrane Risk of Bias tool and the credibility of the evidence will be evaluated using an adaptation of the Grading of Recommendations Assessment, Development and Evaluation framework to NMA, recommended by the Cochrane guidance. Subgroup and sensitivity analyses will be conducted to assess the robustness of the findings.

ETHICS AND DISSEMINATION

No ethical issues are foreseen. Results from this study will be published in peer-reviewed journals and presented at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42017067795.

Using Functional Analysis as a Framework to Guide Individualized Treatment for Negative Symptoms

Although numerous interventions are available for negative symptoms, outcomes have been unsatisfactory with pharmacological and psychological interventions producing changes of only limited clinical significance. Here, we argue that because negative symptoms occur as a complex syndrome caused and maintained by numerous factors that vary between individuals they are unlikely to be treated effectively by the present "one size fits all" approaches. Instead, a well-founded selection of those interventions relevant to each individual is needed to optimize both the efficiency and the efficacy of existing approaches. The concept of functional analysis (FA) can be used to structure existing knowledge so that it can guide individualized treatment planning. FA is based on stimulus-response learning mechanisms taking into account the characteristics of the organism that contribute to the responses, their consequences and the contingency with which consequences are tied to the response. FA can thus be flexibly applied to the level of individual patients to understand the factors causing and maintaining negative symptoms and derive suitable interventions. In this article we will briefly introduce the concept of FA and demonstrate-exemplarily-how known psychological and biological correlates of negative symptoms can be incorporated into its framework. We then outline the framework's implications for individual assessment and treatment. Following the logic of FA, we argue that a detailed assessment is needed to identify the key factors causing or maintaining negative symptoms for each individual patient. Interventions can then be selected according to their likelihood of changing these key factors and need to take interactions between different factors into account. Supplementary case vignettes exemplify the usefulness of functional analysis for individual treatment planning. Finally, we discuss and point to avenues for future research guided by this model.

Does Integrated Neurocognitive Therapy (INT) reduce severe negative symptoms in schizophrenia outpatients?

Negative symptoms often inhibit the social integration of people suffering from schizophrenia. Reducing severe negative symptoms (SNS) in a clinically relevant way is a major unmet need. The aim of this study was to investigate whether Integrated Neurocognitive Therapy (INT), a group cognitive remediation therapy (CRT), reduces SNS in schizophrenia outpatients. INT was compared with Treatment As Usual (TAU) in a randomized-controlled trial (RCT). A total of 61 SNS outpatients participated in the study, 28 were allocated to the INT group and 33 to the TAU group. A test-battery was used at baseline, post-treatment at 15weeks, and 1-year-follow-up. Remission rates of SNS after therapy were significantly higher for INT compared to TAU. A trend favoring INT was obtained at follow-up. Furthermore, INT showed significantly higher functional outcome during follow-up compared to TAU. Regarding cognition, the strongest significant effect was found in attention post-treatment. No effects between groups on more complex neurocognition and social cognition were evident. SNS outpatients seem to accept INT group intervention as suggested by the high attendance rate.

Treatment of negative symptoms: Where do we stand, and where do we go?

Negative symptoms, e.g. social withdrawal, reduced initiative, anhedonia and affective flattening, are notoriously difficult to treat. In this review, we take stock of recent research into treatment of negative symptoms by summarizing psychosocial as well as pharmacological and other biological treatment strategies. Major psychosocial approaches concern social skills training, cognitive behavior therapy for psychosis, cognitive remediation and family intervention. Some positive findings have been reported, with the most robust improvements observed for social skills training. Although cognitive behavior therapy shows significant effects for negative symptoms as a secondary outcome measure, there is a lack of data to allow for definite conclusions of its effectiveness for patients with predominant negative symptoms. With regard to pharmacological interventions, antipsychotics have been shown to improve negative symptoms, but this seems to be limited to secondary negative symptoms in acute patients. It has also been suggested that antipsychotics may aggravate negative symptoms. Recent studies have investigated glutamatergic compounds, e.g. glycine receptor inhibitors and drugs that target the NMDA receptor or metabotropic glutamate 2/3 (mGlu2/3) receptor, but no consistent evidence of improvement of negative symptoms was found. Finally, some small studies have suggested improvement of negative symptoms after non-invasive electromagnetic neurostimulation, but this has only been partly replicated and it is still unclear whether these are robust improvements. We address methodological issues, in particular the heterogeneity of negative symptoms and treatment response, and suggest avenues for future research. There is a need for more detailed studies that focus on different dimensions of negative symptoms.

Adapting cognitive remediation to a group home: A brief report

OBJECTIVE

This pilot project was designed to develop procedures for and test the feasibility of implementing Cognitive Enhancement Therapy (CET) in a group home environment, with a goal of maximizing treatment efficacy by augmenting social engagement in group CET sessions with ongoing social interaction.

METHODS

Six participants who met criteria including chronic schizophrenia were recruited in a group home with 30 residents. After two months of CET, pre-and posttest measures, including cognitive tests, were administered and qualitative interviews were conducted periodically. Interaction was observed in the house and staff members were interviewed in a focus group.

RESULTS

Five of the initial six participants completed the intervention-which continued for a total of 45 weeks-engaging in weekly group CET sessions and computer exercises outside of the formal sessions. All participants liked the computer exercises, and all but one participated in and reported enjoying the group exercises. Observations and staff comments indicated increased social interaction and sustained impact for some residents. Some aspects of cognitive functioning improved for some participants during the initial two months.

CONCLUSIONS

CET now needs to be tested more formally to determine if it can be delivered successfully in other group homes with a manualized procedure. The idea should be tested that feedback effects due to the sustained social contact may enhance the effectiveness of CET in group homes and lead to larger, sustained gains in community functioning. Clinicians who provide cognitive interventions should focus attention on the social context in which treatment is delivered and consider providing treatment to patient groups whose daily, ongoing social interaction can enhance its effects.

Rehabilitation Interventions to Promote Recovery from Schizophrenia: A Systematic Review

Only one out of seven patients recovers after a first episode of psychosis despite psychiatric care. Rehabilitation interventions have been developed to improve functional outcomes and to promote recovery. We conducted a systematic review of the effectiveness of the main psychiatric rehabilitation interventions following a search of the electronic databases Pubmed, ScienceDirect, and Google Scholar using combinations of terms relating to cognitive remediation, psychoeducation, cognitive-behavioral therapies, and schizophrenia. Eighty articles relevant to the topic of interest were found. According to results, cognitive remediation has been found to be effective in reducing the impact of cognitive impairment, social skills in the learning a variety of skills and to a lesser extent in reducing negative symptoms, psychoeducation in improving compliance and reducing relapses, and cognitive therapy in reducing the intensity of or distress related to positive symptoms. All psychosocial rehabilitation interventions should be considered as evidence-based practices for schizophrenia and need to become a major part of the standard treatment of the disease.

Creating Live Interactions to Mitigate Barriers (CLIMB): A Mobile Intervention to Improve Social Functioning in People With Chronic Psychotic Disorders

BACKGROUND

Numerous psychosocial interventions for individuals with chronic psychotic disorders (CPD) have shown positive effects on social cognitive and functional outcome measures. However, access to and engagement with these interventions remains limited. This is partly because these interventions require specially trained therapists, are not available in all clinical settings, and have a high scheduling burden for participants, usually requiring a commitment of several weeks. Delivering interventions remotely via mobile devices may facilitate access, improve scheduling flexibility, and decrease participant burden, thus improving adherence to intervention requirements. To address these needs, we designed the Creating Live Interactions to Mitigate Barriers (CLIMB) digital intervention, which aims to enhance social functioning in people with CPD. CLIMB consists of two treatment components: a computerized social cognition training (SCT) program and optimized remote group therapy (ORGT). ORGT is an innovative treatment that combines remote group therapy with group texting (short message service, SMS).

OBJECTIVES

The objectives of this single-arm study were to investigate the feasibility of delivering 6 weeks of CLIMB to people with CPD and explore the initial effects on outcomes.

METHODS

Participants were recruited, screened and enrolled via the Internet, and delivered assessments and interventions remotely using provided tablets (iPads). Participants were asked to complete 18 hours of SCT and to attend 6 remote group therapy sessions. To assess feasibility, adherence to study procedures, attrition rates, engagement metrics, and acceptability of the intervention were evaluated. Changes on measures of social cognition, quality of life, and symptoms were also explored.

RESULTS

In total, 27 participants were enrolled over 12 months. Remote assessments were completed successfully on 96% (26/27) of the enrolled participants. Retention in the 6-week trial was 78% (21/27). Of all the iPads used, 95% (22/23) were returned undamaged at the end of the intervention. Participants on average attended 84% of the group therapy sessions, completed a median of 9.5 hours of SCT, and posted a median of 5.2 messages per week on the group text chat. Participants rated CLIMB in the medium range in usability, acceptability, enjoyment, and perceived benefit. Participants showed significant improvements in emotion identification abilities for prosodic happiness (P=.001), prosodic happiness intensity (P=.04), and facial anger (P=.04), with large within-group effect sizes (d=.60 to d=.86). Trend-level improvements were observed on aspects of quality of life (P values less than .09). No improvements were observed for symptoms.

CONCLUSIONS

It is feasible and acceptable to remotely deliver an intervention aimed at enhancing social functioning in people with CPD using mobile devices. This approach may represent a scalable method to increase treatment access and adherence. Our pilot data also demonstrate within-group gains in some aspects of social cognition after 6 weeks of CLIMB. Future randomized controlled studies in larger samples should evaluate the extent to which CLIMB significantly improves social cognition, symptoms, and quality of life in CPD.

Restricted attention to social cues in schizophrenia patients

Deficits of psychosocial functioning are a robust finding in schizophrenia. Research on social cognition may open a new avenue for the development of effective interventions. As a correlate of social perceptive information processing deficits, schizophrenia patients (SZP) show deviant gaze behavior (GB) while viewing emotional faces. As understanding of a social environment requires gathering complex social information, our study aimed at investigating the gaze behavior of SZP related to social interactions and its impact on the level of social and role functioning. GB of 32 SZP and 37 healthy control individuals (HCI) was investigated with a high-resolution eye tracker during an unguided viewing of 12 complex pictures of social interaction scenes. Regarding whole pictures, SZP showed a shorter scanpath length, fewer fixations and a shorter mean distance between fixations. Furthermore, SZP exhibited fewer and shorter fixations on faces, but not on the socially informative bodies nor on the background, suggesting a cue-specific abnormality. Logistic regression with bootstrapping yielded a model including two GB parameters; a subsequent ROC curve analysis indicated an excellent ability of group discrimination (AUC .85). Face-related GB aberrations correlated with lower social and role functioning and with delusional thinking, but not with negative symptoms. Training of spontaneous integration of face-related social information seems promising to enable a holistic perception of social information, which may in turn improve social and role functioning. The observed ability to discriminate SZP from HCI warrants further research on the predictive validity of GB in psychosis risk prediction.

Cognitive behavioral therapy in 22q11.2 microdeletion with psychotic symptoms: What do we learn from schizophrenia?

The 22q11.2 deletion syndrome (22q11.2DS) is one of the most common microdeletion syndromes, with a widely underestimated prevalence between 1 per 2000 and 1 per 6000. Since childhood, patients with 22q11.2DS are described as having difficulties to initiate and maintain peer relationships. This lack of social skills has been linked to attention deficits/hyperactivity disorder, anxiety and depression. A high incidence of psychosis and positive symptoms is observed in patients with 22q11.2DS and remains correlated with poor social functioning, anxiety and depressive symptoms. Because 22q11.2DS and schizophrenia share several major clinical features, 22q11.2DS is sometimes considered as a genetic model for schizophrenia. Surprisingly, almost no study suggests the use of cognitive and behavioral therapy (CBT) in this indication. We reviewed what should be learned from schizophrenia to develop specific intervention for 22q11.2DS. In our opinion, the first step of CBT approach in 22q11.2DS with psychotic symptoms is to identify precisely which tools can be used among the already available ones. Cognitive behavioral therapy (CBT) targets integrated disorders, i.e. reasoning biases and behavior disorders. In 22q11.2DS, CBT-targeted behavior disorders may take the form of social avoidance and withdrawal or, in the contrary, a more unusual disinhibition and aggressiveness. In our experience, other negative symptoms observed in 22q11.2DS, such as motivation deficit or anhedonia, may also be reduced by CBT. Controlled trials have been studying the benefits of CBT in schizophrenia and several meta-analyses proved its effectiveness. Therefore, it is legitimate to propose this tool in 22q11.2DS, considering symptoms similarities. Overall, CBT is the most effective psychosocial intervention on psychotic symptoms and remains a relevant complement to pharmacological treatments such as antipsychotics.

Efficacy and feasibility of the Integrated Psychological Therapy for outpatients with schizophrenia in Greece: Final results of a RCT

The goal of this study was to evaluate the efficacy and the feasibility of cognitive remediation group therapy in patients with schizophrenia in Greece. For this purpose, the cognitive part of the Integrated Psychological Therapy (IPT), focusing on neuro- and social cognition, was compared in a randomized controlled trial (RCT) with treatment as usual (TAU). 48 outpatients took part in the study. IPT groups received 20 biweekly 1-h-therapy sessions. A test-battery was assessed at baseline, after therapy, and at a 3-month follow-up. Regarding cognitive functioning, significant effects favouring IPT were found in working memory and social perception during therapy and at follow-up. No effects could be found in verbal memory and vigilance. Significant effects favoring IPT were found in negative symptoms, in insight and in general symptoms during therapy and at follow-up using the Positive and Negative Syndrome Scale (PANSS). No effects were evident in positive symptoms and in psychosocial functioning. Significant effects favoring TAU were found in the quality of life assessment at follow-up. The study supports evidence for the feasibility and efficacy of IPT in psychiatric care in Greece and it hopefully will initiate the broader use of evidenced-based treatments like IPT in Greek Psychiatry.

Neuroplastic Changes Following Social Cognition Training in Schizophrenia: A Systematic Review

Social cognitive impairment is a key feature of schizophrenia and social cognition training (SCT) is a promising tool to address these deficits. Neurobiological dysfunction in schizophrenia has been widely researched, but neuronal changes induced by SCT have been scarcely explored. This review aims to assess the neuroplastic effects of SCT in patients with schizophrenia spectrum disorders. PubMed and Web of Science databases were searched for clinical trials testing the effects of SCT in functional and structural brain measurements of adult patients with schizophrenia or schizoaffective disorders. A total of 11 studies were included: five used fMRI, two used EEG and ERP, one used ERP only, two used MEG and one study used MRI. Data extracting and processing regarding sociodemographic and clinical variables, intervention characteristics, neuroimaging procedures, neuroplastic findings, effect sizes and study quality criteria was completed by two raters. Results indicate a wide range of structural and functional changes in numerous regions and circuits of the social brain, including early perceptual areas, the limbic system and prefrontal regions. Despite the small number of trials currently available, evidence suggests that SCT is associated with neuroplastic changes in the social brain and concomitant improvements in social cognitive performance. There is a lack of extensive knowledge about the neural mechanisms that underlie social cognitive enhancement after treatment, but the reported findings may shed light on the neural substrates of social cognitive impairment in schizophrenia and how improved treatment procedures can be developed and applied.

Cognitive remediation in schizophrenia: A methodological appraisal of systematic reviews and meta-analyses

OBJECTIVE

Systematic reviews and meta-analyses are a primary source of evidence when evaluating the benefit(s) of cognitive remediation (CR) in schizophrenia. These studies are designed to rigorously synthesize scientific literature; however, cannot be assumed to be of high methodological quality. The aims of this report were to: 1) review the use of systematic reviews and meta-analyses regarding CR in schizophrenia; 2) conduct a systematic methodological appraisal of published reports examining the benefits of this intervention on core outcome domains; and 3) compare the correspondence between methodological and reporting quality.

METHOD

Electronic databases were searched for relevant articles. Twenty-one reviews met inclusion criteria and were scored according to the AMSTAR checklist-a validated scale of methodological quality. Five meta-analyses were also scored according to PRISMA statement to compare 'quality of conduct' with 'quality of reporting'.

RESULTS

Most systematic reviews and meta-analyses shared strengths and fell within a 'medium' level of methodological quality. Nevertheless, there were consistent areas of potential weakness that were not addressed by most reviews. These included the lack of protocol registration, uncertainty regarding independent data extraction and consensus procedures, and the minimal assessment of publication bias. Moreover, quality of conduct may not necessarily parallel quality of reporting, suggesting that consideration of these methods independently may be important.

CONCLUSIONS

Reviews concerning CR for schizophrenia are a valuable source of evidence. However, the methodological quality of these reports may require additional consideration. Enhancing quality of conduct is essential for enabling research literature to be interpreted with confidence.

Nonverbal Synchrony in Social Interactions of Patients with Schizophrenia Indicates Socio-Communicative Deficits

BACKGROUND

Disordered interpersonal communication can be a serious problem in schizophrenia. Recent advances in computer-based measures allow reliable and objective quantification of nonverbal behavior. Research using these novel measures has shown that objective amounts of body and head movement in patients with schizophrenia during social interactions are closely related to the symptom profiles of these patients. In addition to and above mere amounts of movement, the degree of synchrony, or imitation, between patients and normal interactants may be indicative of core deficits underlying various problems in domains related to interpersonal communication, such as symptoms, social competence, and social functioning.

METHODS

Nonverbal synchrony was assessed objectively using Motion Energy Analysis (MEA) in 378 brief, videotaped role-play scenes involving 27 stabilized outpatients diagnosed with paranoid-type schizophrenia.

RESULTS

Low nonverbal synchrony was indicative of symptoms, low social competence, impaired social functioning, and low self-evaluation of competence. These relationships remained largely significant when correcting for the amounts of patients' movement. When patients showed reduced imitation of their interactants' movements, negative symptoms were likely to be prominent. Conversely, positive symptoms were more prominent in patients when their interaction partners' imitation of their movements was reduced.

CONCLUSIONS

Nonverbal synchrony can be an objective and sensitive indicator of the severity of patients' problems. Furthermore, quantitative analysis of nonverbal synchrony may provide novel insights into specific relationships between symptoms, cognition, and core communicative problems in schizophrenia.

Comprehensive treatments for social cognitive deficits in schizophrenia: A critical review and effect-size analysis of controlled studies

Recent advances in psychosocial treatments for schizophrenia have targeted social cognitive deficits. A critical literature review and effect-size (ES) analysis was conducted to investigate the efficacy of comprehensive programs of social cognitive training in schizophrenia. Results revealed 16 controlled studies consisting of seven models of comprehensive treatment with only three of these treatment models investigated in more than one study. The effects of social cognitive training were reported in 11/15 studies that included facial affect recognition skills (ES=.84) and 10/13 studies that included theory-of-mind (ES=.70) as outcomes. Less than half (4/9) of studies that measured attributional style as an outcome reported effects of treatment, but effect sizes across studies were significant (ESs=.30-.52). The effect sizes for symptoms were modest, but, with the exception of positive symptoms, significant (ESs=.32-.40). The majority of trials were randomized (13/16), selected active control conditions (11/16) and included at least 30 participants (12/16). Concerns for this area of research include the absence of blinded outcome raters in more than 50% of trials and low rates of utilization of procedures for maintaining treatment fidelity. These findings provide preliminary support for the broader use of comprehensive social cognitive training procedures as a psychosocial intervention for schizophrenia.

Randomized controlled trial of computer-based treatment of social cognition in schizophrenia: the TRuSST trial protocol

BACKGROUND

Schizophrenia is a severe and chronic medical condition, characterized by positive and negative symptoms, as well as pervasive social cognitive deficits. Despite the functional significance of the social cognition deficits affecting many aspects of daily living, such as social relationships, occupational status, and independent living, there is still no effective treatment option for these deficits, which is applied as standard of care. To address this need, we developed a novel, internet-based training program that targets social cognition deficits in schizophrenia (SocialVille). Preliminary studies demonstrate the feasibility and initial efficacy of Socialville in schizophrenia patients (Nahum et al., 2014). The purpose of the current trial (referred to as the TReatment of Social cognition in Schizophrenia Trial or TRuSST) is to compare SocialVille to an active control training condition, include a larger sample of patients, and assess both social cognitive functioning, and functional outcomes.

METHODS/DESIGN

We will employ a multi-site, longitudinal, blinded, randomized controlled trial (RCT) design with a target sample of 128 patients with schizophrenia. Patients will perform, at their home or in clinic, 40 sessions of either the SocialVille training program or an active control computer game condition. Each session will last for 40-45 minutes/day, performed 3-5 days a week, over 10-12 weeks, totaling to 30 hours of training. Patients will be assessed on a battery of social cognitive, social functioning and functional outcomes immediately before training, mid-way through training (after 20 training sessions) and at the completion of the 40 training sessions.

DISCUSSION

The strengths of this protocol are that it tests an innovative, internet-based treatment that targets fundamental social cognitive deficits in schizophrenia, employs a highly sensitive and extensive battery of functional outcome measures, and incorporates a large sample size in an RCT design.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02246426 Registered 16 September 2014.

One-year randomized controlled trial and follow-up of integrated neurocognitive therapy for schizophrenia outpatients

OBJECTIVE

Cognitive remediation (CR) approaches have demonstrated to be effective in improving cognitive functions in schizophrenia. However, there is a lack of integrated CR approaches that target multiple neuro- and social-cognitive domains with a special focus on the generalization of therapy effects to functional outcome.

METHOD

This 8-site randomized controlled trial evaluated the efficacy of a novel CR group therapy approach called integrated neurocognitive therapy (INT). INT includes well-defined exercises to improve all neuro- and social-cognitive domains as defined by the Measurement And Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative by compensation and restitution. One hundred and fifty-six outpatients with a diagnosis of schizophrenia or schizoaffective disorder according to DSM-IV-TR or ICD-10 were randomly assigned to receive 15 weeks of INT or treatment as usual (TAU). INT patients received 30 bi-weekly therapy sessions. Each session lasted 90min. Mixed models were applied to assess changes in neurocognition, social cognition, symptoms, and functional outcome at post-treatment and at 9-month follow-up.

RESULTS

In comparison to TAU, INT patients showed significant improvements in several neuro- and social-cognitive domains, negative symptoms, and functional outcome after therapy and at 9-month follow-up. Number-needed-to-treat analyses indicate that only 5 INT patients are necessary to produce durable and meaningful improvements in functional outcome.

CONCLUSIONS

Integrated interventions on neurocognition and social cognition have the potential to improve not only cognitive performance but also functional outcome. These findings are important as treatment guidelines for schizophrenia have criticized CR for its poor generalization effects.

The HELPER programme: HEalthy Living and Prevention of Early Relapse – three exploratory randomised controlled trials of phase-specific interventions in first-episode psychosis

Background

Schizophrenia represents a substantial cost to the NHS and society because it is common (lifetime prevalence around 0.5–1%); it begins in adolescence or early adulthood and often causes lifelong impairment. The first 3 years are a ‘critical period’ in which the course of the illness is determined. Hence under the NHS Plan, specialist early intervention in psychosis services were established to care for people who develop psychosis between the ages of 14 and 35 years for the first 3 years of their illness. However, there has been a lack of evidence-based treatments specifically designed for the early years. This is important because emerging evidence has shown that in the critical period it is vital to avoid relapse and prevent deterioration in physical health, as both can drastically reduce the chances of a full recovery.

Objectives

To develop and evaluate three phase-specific interventions to prevent relapse and/or deterioration in physical health in people with first-episode psychosis. The interventions were (1) cognitive remediation (CR) to improve meta-cognition and insight and enhance engagement in cognitive therapy [evaluated in the IMproving PArticipation in Cognitive Therapy (IMPACT) trial]; (2) a healthy-living intervention to control weight in people taking antipsychotic medication after a first episode of psychosis [evaluated in the INTERvention to Encourage ACTivity, Improve Diet, and Reduce Weight Gain (InterACT trial)]; and (3) integrated motivational interviewing and cognitive–behavioural therapy (MiCBT) to reduce cannabis use [evaluated in the Rethinking Choices After Psychosis (ReCAP) trial]. The trials were conducted to explore the case for larger definitive trials with relapse as a primary outcome measure. However, as small trials do not have sufficient power to detect significant reductions in relapse, each was focused on a relevant primary outcome for which there was sufficient power to detect a significant difference. In all three trials relapse was a secondary outcome in the hope of detecting trends towards lower relapse rates in the presence of effective interventions or a general trend across all three studies towards lower relapse rates.

Design

Three exploratory randomised controlled trials (RCTs) accompanied by qualitative work employing grounded theory and framework analysis to inform the interventions and determine acceptability (InterACT and ReCAP trials).

Setting

Five early-intervention services in the north-west of England.

Participants

Early-intervention service users aged 16–35 years who had recently experienced a first episode of psychosis. Participants in the IMPACT trial were drawn from a waiting list of people referred for routine CBT; those in the InterACT trial were required to have a body mass index (BMI) of ≥ 25 kg/m2(or ≥ 24 kg/m2for service users from the South Asian community); and those in the ReCAP trial metDiagnostic and Statistical Manual of Mental Disorders– Fourth Edition (DSM-IV) criteria for cannabis abuse or dependence.

Interventions

The IMPACT trial involved 13 sessions of CR over 12 weeks; the InterACT trial involved eight face-to-face sessions plus optional group activities over 12 months; and the ReCAP trial involved MiCBT in brief (12 sessions over 4.5 months) and long (24 sessions over 9 months) forms.

Main outcome measures

The primary outcome in the IMPACT trial was psychotic symptoms assessed by the Psychotic Symptom Rating Scales (PSYRATS). BMI was the primary outcome in the InterACT trial and cannabis use (measured by timeline follow-back) was the primary outcome in the ReCAP trial. Relapse was a secondary outcome across all three trials.

Results

In the IMPACT trial there was no beneficial effect of CR on psychotic symptoms; however, the amount of CBT required was significantly less after CR. In the InterACT trial a small reduction in BMI in the intervention group was not statistically significant. For participants taking olanzapine or clozapine the effect size was larger although not significant. Outcome data from the ReCAP trial are not yet available. Retention in all three trials was good, indicating that the interventions were acceptable.

Conclusions

Early-intervention services provided a good setting to conduct trials. The IMPACT trial found that CR delivered by relatively unskilled workers improved the efficiency of subsequent CBT. Across the three trials there was little evidence that any intervention reduced relapse.

Trial registration

Current Controlled Trials ISRCTN17160673 (IMPACT); Current Controlled Trials ISRCTN22581937 (InterACT); Current Controlled Trials ISRCTN88275061 (ReCAP).

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 3, No. 2. See the NIHR Journals Library website for further project information.

S3 guideline on psychosocial therapies in severe mental illness: evidence and recommendations

The burden of severe and persistent mental illness is high. Beside somatic treatment and psychotherapeutic interventions, treatment options for patients with severe mental illness also include psychosocial interventions. This paper summarizes the results of a number of systematic literature searches on psychosocial interventions for people with severe mental illness. Based on this evidence appraisal, recommendations for the treatment of people with severe mental illness were formulated and published in the evidence-based guideline series of the German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) as an evidence-based consensus guideline ("S3 guideline"). Recommendations were strongly based on study results, but used consensus processes to consider external validity and transferability of the recommended practices to the German mental healthcare system. A distinction is made between system-level interventions (multidisciplinary team-based psychiatric community care, case management, vocational rehabilitation and participation in work life and residential care interventions) and single psychosocial interventions (psychoeducation, social skills training, arts therapies, occupational therapy and exercise therapy). There is good evidence for the efficacy of the majority of psychosocial interventions in the target group. The best available evidence exists for multidisciplinary team-based psychiatric community care, family psychoeducation, social skills training and supported employment. The present guideline offers an important opportunity to further improve health services for people with severe mental illness in Germany. Moreover, the guideline highlights areas for further research.

[Improving functional outcome of schizophrenia with cognitive remediation]

The functional outcome of schizophrenia is partly conditioned by cognitive disorders associated with this disease. The functional outcome of schizophrenia depends not only on psychotropic medications, but also on non-pharmacological measures and in particular on cognitive remediation. All patients suffering from schizophrenia should benefit from a multidisciplinary functional evaluation including neuropsychological assessment. The restitution of the functional evaluation's results values preserved skills rather than deficits. Cognitive remediation should be considered when cognitive disorders have a functional impact. It reduces the impact of the patient's cognitive disorders and improves the success of his/her concrete projects.

Merging evidence-based psychosocial interventions in schizophrenia

Psychosocial interventions are an essential part of the treatment for people with severe mental illness such as schizophrenia. The criteria regarding what makes an intervention “evidence-based” along with a current list of evidence-based interventions are presented. Although many evidence-based interventions exist, implementation studies reveal that few, if any, are ever implemented in a given setting. Various theories and approaches have been developed to better understand and overcome implementation obstacles. Among these, merging two evidence-based interventions, or offering an evidence-based intervention within an evidence-based service, are increasingly being reported and studied in the literature. Five such merges are presented, along with their empirical support: cognitive behavior therapy (CBT) with skills training; CBT and family psychoeducation; supported employment (SE) and skills training; SE and cognitive remediation; and SE and CBT.

A naturalistic, randomized, controlled trial combining cognitive remediation with cognitive-behavioural therapy after first-episode non-affective psychosis

BACKGROUND

Cognitive remediation (CR) preceding cognitive-behavioural therapy for psychosis (CBTp) was trialled within routine clinical services, with the hypothesis that following first-episode non-affective psychosis CR would enhance CBTp efficacy by improving neuropsychological performance.

METHOD

A total of 61 patients with DSM-IV non-affective psychoses waiting for routine CBTp were randomized to computerized CR over 12 weeks, supported by a trained support worker, or time-matched social contact (SC). Primary outcome was the blind-rated Psychotic Symptoms Rating Scale (PSYRATS). Secondary outcomes included measures of CBTp progress, cognition, symptoms, insight and self-esteem: all at baseline, after CR (12 weeks) and after CBTp (42 weeks). PSYRATS and global neuropsychological efficacy were tested using mixed-effects models with a group × time interaction term. Measures of CBTp progress and some neuropsychological measures were modelled by regression.

RESULTS

There was no significant difference between the CR and SC groups in PSYRATS (group × time coefficient 0.3, 95% confidence interval -0.4 to 1.1, p = 0.39). However, after CR CBTp was shorter [median 7 sessions, interquartile range (IQR) 2-12 after CR; median 13, IQR 4-18 after SC; model p = 0.011] and linked to better insight (p = 0.02). Global cognition did not improve significantly more after CR (p = 0.20) but executive function did (Wisconsin Card Sort, p = 0.012).

CONCLUSIONS

CBTp courses preceded by CR were far shorter but achieved the same outcome as CBTp preceded by an active control, consistent with neuropsychological improvement enhancing CBTp. CR was delivered by staff with minimal training, offering the potential to reduce the costs of CBTp considerably.

RC2S: A Cognitive Remediation Program to Improve Social Cognition in Schizophrenia and Related Disorders

In people with psychiatric disorders, particularly those suffering from schizophrenia and related illnesses, pronounced difficulties in social interactions are a key manifestation. These difficulties can be partly explained by impairments in social cognition, defined as the ability to understand oneself and others in the social world, which includes abilities such as emotion recognition, theory of mind (ToM), attributional style, and social perception and knowledge. The impact of several kinds of interventions on social cognition has been studied recently. The best outcomes in the area of social cognition in schizophrenia are those obtained by way of cognitive remediation programs. New strategies and programs in this line are currently being developed, such as RC2S (cognitive remediation of social cognition) in Lyon, France. Considering that the social cognitive deficits experienced by patients with schizophrenia are very diverse, and that the main objective of social cognitive remediation programs is to improve patients' functioning in their daily social life, RC2S was developed as an individualized and flexible program that allows patients to practice social interaction in a realistic environment through the use of virtual reality techniques. In the RC2S program, the patient's goal is to assist a character named Tom in various social situations. The underlying idea for the patient is to acquire cognitive strategies for analyzing social context and emotional information in order to understand other characters' mental states and to help Tom manage his social interactions. In this paper, we begin by presenting some data regarding the social cognitive impairments found in schizophrenia and related disorders, and we describe how these deficits are targeted by social cognitive remediation. Then we present the RC2S program and discuss the advantages of computer-based simulation to improve social cognition and social functioning in people with psychiatric disorders.

[Cognitive remediation and work outcome in schizophrenia]

Recovery is partly defined by the patients' capacity to work, since doing well in a job favors hope and responsibilities' taking. Diminished job placement or tenure is linked with cognitive disorders, which impact directly and indirectly (through negative symptoms) functional outcomes. Attention, executive functions and working memory disorders can result in an alteration of the ability to manage the tasks required in the workplace. Executive function, working memory and social cognition disorders may also have an impact on behavior in relationships. Cognitive disorders do not automatically directly contribute to vocational outcome, yet their effects may be mediated by other variables such as symptoms, metacognition, social skills and intrinsic motivation. Then, since all these dimensions have to be taken into account, reducing the impact of cognitive troubles becomes a major challenge for the care of schizophrenia. Cognitive remediation is the more effective therapeutic tool to reduce cognitive dysfunctions. It rests in particular on the development of new strategies that allow taking concrete situations into account more efficiently. Cognitive remediation reduces the detrimental consequences of cognitive disorders and permits their compensation. It has emerged as an effective treatment, that improves not only cognitive abilities but also functioning, as it has been shown by numerous randomized controlled studies and several meta-analyses. The present article considers the effects on cognitive remediation on work function in schizophrenia. Several randomized controlled trials that compared supported employment alone versus supported employment associated with cognitive remediation showed significant improvement of employment rates in the latter condition. These results favor the use of cognitive remediation before job placement. The specific needs of the occupation that will be provided and the cognitive profile of the user should be taken into account.

A patient with medication-resistant epilepsy featuring psychosensorial and psychotic symptoms presenting with significant functional improvement on psychotherapeutic treatment: a case report

Background

Partial complex epilepsy with psychosensorial and psychotic symptoms remains a relatively rare condition that can sometimes be mistaken for an axis I psychiatric disorder. There is no specific treatment for this particular type of epilepsy, anti-epileptic medication being the cornerstone of therapeutic intervention with the occasional addition of neuroleptics. Lack of response to anti-epileptic agents is often a sign of poor prognosis and requires risky and sometimes invasive interventions with high morbidity for patients.

Case presentation

We report the case of a 21-year-old right-handed Caucasian man of French-Canadian descent who was living with his mother immediately before being hospitalized in a psychiatric setting for the first time. He seemed obsessed with developing new concepts to reach a more ‘perfect’ existence. He also claimed feeling odd sensations in his mind and in his body that could be linked to some sort of ‘evolutionary’ process resulting from spiritual uplift. He reported non-specific visual hallucinations and what sounded like auditory hallucinations and telepathic powers. The first diagnosis was a possible schizophreniform disorder and our patient was hospitalized. Shortly afterwards, an electroencephalogram showed an important subcortical epileptic activity, compatible with partial complex epilepsy with psychosensorial and psychotic symptoms. Despite a negative response to medication, symptoms proper to this type of epilepsy were substantially alleviated using a psychotherapeutical treatment intended for patients with psychotic disorders, namely integrated psychological therapy (IPT). Significant functional improvement in our patient has been achieved since then.

Conclusions

This case report illustrates that despite a negative response to medication, symptoms proper to this type of epilepsy could be substantially alleviated using psychotherapeutical treatment modalities. To the best of our knowledge, this is the first time such a finding has been reported in the scientific literature. This could open the way for new research themes and therapeutic interventions for such patients.

Metakognitive und sozial-kognitive Defizite bei Schizophrenien. Funktionelle Bedeutung und Behandlungsstrategien

Die Gruppe der Schizophrenien umfasst heterogene psychopathologische Syndrome, die oft mit neurokognitiven Störungen und niedrigem psychosozialen Funktionsniveau assoziiert sind. Empirische Studien legen nahe, dass viele mit Schizophrenie assoziierte Symptome auf Störungen der sozialen Kognition bzw. metakognitive Störungen zurückgeführt werden können. Diese Konzepte beziehen sich auf die Fähigkeit, soziale Signale wahrnehmen und interpretieren, eigene und psychische Zustände Anderer reflektieren und dieses Wissen flexibel in sozialen Interaktionen und zur Problemlösung einsetzen zu können. Der vorliegende Artikel gibt eine Übersicht über sozial-kognitive und metakognitive Defizite bei Schizophrenien und wie über das Training dieser Kernkompetenzen das psychosoziale Funktionsniveau von Patienten mit Schizophrenie verbessert werden kann. Bei Schizophrenien sind soziale Kognition und Metakognition eng mit dem psychosozialen Funktionsniveau verbunden, zum Teil jedoch auch abhängig von neurokognitiven Fähigkeiten. Sozial-kognitives bzw. metakognitives Training kann zur Verbesserung des psychosozialen Funktionsniveaus beitragen, möglicherweise aber in Abhängigkeit vom Lernpotential und der Motivation der Patienten. Zukünftige Studien sollten untersuchen, welche Subtypen innerhalb des Schizophrenie-Spektrums am ehesten von sozial-kognitivem und metakognitivem Training profitieren können und welche Gruppen ggf. zusätzlich neurokognitives Training benötigen, um das psychosoziale Funktionsniveau zu verbessern.

Longitudinal relationships between neurocognition, theory of mind, and community functioning in outpatients with serious mental illness

The purpose of this study was to examine relationships between neurocognition, theory of mind, and community functioning in a sample of 43 outpatients with serious mental illness (SMI). Relationships between baseline values and changes over time were analyzed using multilevel modeling. The results showed that a) neurocognition and theory of mind were each associated with community functioning at baseline, b) community functioning improved during approximately 12 months of treatment, c) greater improvement in neurocognition over time predicted higher rates of improvement in community functioning, d) theory of mind did not predict change in community functioning after controlling for neurocognition, and e) the effect of change in neurocognition on community functioning did not depend on the effect of baseline neurocognition. This study provides empirical support that individuals with SMI may experience improvement in community functioning, especially when they also experience improvement in neurocognition. Limitations and recommendations for future research are discussed.