A brief cognitive assessment tool for schizophrenia: construction of a tool for clinicians

Montreal Cognitive Assessment (MoCA) as a screening tool for cognitive impairment in early stages of psychosis

Background

Cognitive alterations have been reported in early stages of psychosis including people with First Episode Psychosis (FEP), Clinical High-Risk Mental State (CHR), and Psychotic-Like Experience (PLE). This study aimed to compare the cognitive function in early stages of psychosis using the Montreal Cognitive Assessment (MoCA), a low-cost and brief assessment tool of cognitive functions.

Methods

A total of 154 individuals, including 35 with FEP, 38 CHR, 44 PLE, and 37 healthy controls (HC), were evaluated with the MoCA in Santiago, Chile. We calculated the mean total score of the MoCA and the standard deviation of the mean. Groups were assessed for a trend to lower scores in a pre-determined sequence (HC > PLE > CHR > FEP) using the Jonckheere-Terpstra test (TJT).

Results

The mean total MoCA scores were 24.8 ± 3.3 in FEP, 26.4 ± 2.4 in CHR, 26.4 ± 2.3 in PLE, and 27.2 ± 1.8 in HC. The analyses revealed a significant trend (p < 0.05) toward lower MoCA individual domain scores and MoCA total scores in the following order: HC > PLE > CHR > FEP. The mean total scores of all groups were above the cut-off for cognitive impairment (22 points).

Conclusions

The MoCA describes lower scores in cognition across early stages of psychosis and may be a useful low-cost assessment instrument in early intervention centers of poorly resourced settings.

Deciphering the interplay between psychopathological symptoms, sensorimotor, cognitive and global functioning: a transdiagnostic network analysis

BACKGROUND

Understanding the relationship between psychopathology and major domains of human neurobehavioral functioning may identify new transdiagnostic treatment targets. However, studies examining the interrelationship between psychopathological symptoms, sensorimotor, cognitive, and global functioning in a transdiagnostic sample are lacking. We hypothesized a close relationship between sensorimotor and cognitive functioning in a transdiagnostic patient sample.

METHODS

We applied network analysis and community detection methods to examine the interplay and centrality [expected influence (EI) and strength] between psychopathological symptoms, sensorimotor, cognitive, and global functioning in a transdiagnostic sample consisting of 174 schizophrenia spectrum (SSD) and 38 mood disorder (MOD) patients. All patients (n = 212) were examined with the Positive and Negative Syndrome Scale (PANSS), the Heidelberg Neurological Soft Signs Scale (NSS), the Global Assessment of Functioning (GAF), and the Brief Cognitive Assessment Tool for Schizophrenia consisted of trail making test B (TMT-B), category fluency (CF) and digit symbol substitution test (DSST).

RESULTS

NSS showed closer connections with TMT-B, CF, and DSST than with GAF and PANSS. DSST, PANSS general, and NSS motor coordination scores showed the highest EI. Sensory integration, DSST, and CF showed the highest strength.

CONCLUSIONS

The close connection between sensorimotor and cognitive impairment as well as the high centrality of sensorimotor symptoms suggests that both domains share aspects of SSD and MOD pathophysiology. But, because the majority of the study population was diagnosed with SSD, the question as to whether sensorimotor symptoms are really a transdiagnostic therapeutic target needs to be examined in future studies including more balanced diagnostic groups.

An SMS text messaging intervention to improve clinical engagement in early psychosis: A pilot randomized-controlled trial

Disengagement of youth with psychosis from Early Psychosis Intervention (EPI) services continues to be a significant barrier to recovery, with approximately one-third prematurely discontinuing treatment despite the ongoing need. The current pilot trial sought to evaluate the preliminary efficacy and feasibility of a weekly short message service (SMS) intervention to improve engagement in EPI services. This was a longitudinal single-blinded randomized control trial in which participants were assigned to receive either an active or sham SMS intervention over nine months. Sixty-one participants with early psychosis between the ages of 16 and 29 were enrolled, randomized, and received at least part of the intervention. Primary outcomes consisted of participant clinic attendance rates over the course of the intervention and clinician-rated engagement. Secondary measures included patient-rated therapeutic rapport, attitude toward medication, psychopathology, cognition, functioning, and intervention feedback from participants. Compared to the sham group, participants receiving the active intervention did not show improved appointment attendance rates; however, did exhibit some improvements in aspects of engagement, including improved clinician-rated availability, attitude toward medication, positive symptoms, avolition-apathy and social functioning. Thus, contrary to our hypotheses, digitally augmented care did not result in enhanced engagement in EPI services, as measured by clinic attendance, although with some indication that it may contribute to improved attitude toward medication and, potentially, medication adherence. Weekly SMS text messaging appeared to result in a pattern of engagement whereby individuals who were improving clinically attended appointments less often, possibly due to inadvertent use of the intervention to check in with clinicians. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04379349).

Microstructural white matter biomarkers of symptom severity and therapy outcome in catatonia: Rationale, study design and preliminary clinical data of the whiteCAT study

The number of magnetic resonance imaging (MRI) studies on neuronal correlates of catatonia has dramatically increased in the last 10 years, but conclusive findings on white matter (WM) tracts alterations underlying catatonic symptoms are still lacking. Therefore, we conduct an interdisciplinary longitudinal MRI study (whiteCAT) with two main objectives: First, we aim to enroll 100 psychiatric patients with and 50 psychiatric patients without catatonia according to ICD-11 who will undergo a deep phenotyping approach with an extensive battery of demographic, psychopathological, psychometric, neuropsychological, instrumental and diffusion MRI assessments at baseline and 12 weeks follow-up. So far, 28 catatonia patients and 40 patients with schizophrenia or other primary psychotic disorders or mood disorders without catatonia have been studied cross-sectionally. 49 out of 68 patients have completed longitudinal assessment, so far. Second, we seek to develop and implement a new method for semi-automatic fiber tract delineation using active learning. By training supportive machine learning algorithms on the fly that are custom tailored to the respective analysis pipeline used to obtain the tractogram as well as the WM tract of interest, we plan to streamline and speed up this tedious and error-prone task while at the same time increasing reproducibility and robustness of the extraction process. The goal is to develop robust neuroimaging biomarkers of symptom severity and therapy outcome based on WM tracts underlying catatonia. If our MRI study is successful, it will be the largest longitudinal study to date that has investigated WM tracts in catatonia patients.

Structure/function interrelationships and illness insight in patients with schizophrenia: a multimodal MRI data fusion study

Illness insight in schizophrenia (SZ) has an important impact on treatment outcome, integration into society and can vary over the course of the disorder. To deal with and treat reduced or absent illness insight, we need to better understand its functional and structural correlates. Previous studies showed regionally abnormal brain volume in brain areas related to cognitive control and self-reference. However, little is known about associations between illness insight and structural and functional network strength in patients with SZ. This study employed a cross-sectional design to examine structural and functional differences between patients with SZ (n = 74) and healthy controls (n = 47) using structural and resting-state functional magnetic resonance imaging (MRI). Voxel-based morphometry was performed on structural data, and the amplitude of low frequency fluctuations (ALFF) was calculated for functional data. To investigate abnormal structure/function interrelationships and their association with illness insight, we used parallel independent component analysis (pICA). Significant group (SZ vs. HC) differences were detected in distinct structural and functional networks, predominantly comprising frontoparietal, temporal and cerebellar regions. Significant associations were found between illness insight and two distinct structural networks comprising frontoparietal (pre- and postcentral gyrus, inferior parietal lobule, thalamus, and precuneus) and posterior cortical regions (cuneus, precuneus, lingual, posterior cingulate, and middle occipital gyrus). Finally, we found a significant relationship between illness insight and functional network comprising temporal regions (superior temporal gyrus). This study suggests that aberrant structural and functional integrity of neural systems subserving cognitive control, memory and self-reference are tightly coupled to illness insight in SZ.

Disrupted functional connectivity associated with cognitive impairment in generalized anxiety disorder (GAD) and comorbid GAD and depression: a follow-up fMRI study

BACKGROUND

Impaired functional connectivity between the bilateral hemispheres may serve as the neural substrate for anxiety and depressive disorders, yet its role in comorbid generalized anxiety disorder (GAD) and depression, as well as the effect of treatment on this connectivity, remains unclear. We sought to examine functional connectivity between homotopic regions of the 2 hemispheres (voxel-mirrored homotopic connectivity [VMHC]) among people with GAD with and without comorbid depression at baseline and after a 4-week paroxetine treatment.

METHODS

Drug-naïve patients with GAD, with or without comorbid depression and healthy controls underwent functional magnetic resonance imaging and clinical assessments at baseline and after treatment. We compared VMHC and seed-based functional connectivity across the 3 groups. We performed correlation analysis and support vector regression (SVR) to examine the intrinsic relationships between VMHC and symptoms.

RESULTS

Both patient groups (n = 40 with GAD only, n = 58 with GAD and depression) showed decreased VMHC in the precuneus, posterior cingulate cortex and lingual gyrus compared with healthy controls (n = 54). Moreover, they showed decreased VMHC in different brain regions compared with healthy controls. However, we did not observe any significant differences between the 2 patient groups. Seeds from abnormal VMHC clusters in patient groups had decreased functional connectivity. Voxel-mirrored homotopic connectivity in the precuneus, posterior cingulate cortex and lingual gyrus was negatively correlated with cognitive impairment among patients with GAD only and among all patients. The SVR analysis based on abnormal VMHC showed significant positive correlations (p < 0.0001) between predicted and actual treatment responses. However, we did not observe significant differences in VMHC or functional connectivity after treatment.

LIMITATIONS

A notable dropout rate and intergroup somatic symptom variations may have biased the results.

CONCLUSION

Patients with GAD with or without comorbid depression exhibited shared and distinct abnormal VMHC patterns, which might be linked to their cognitive deficits. These patterns have the potential to serve as prognostic biomarkers for GAD.Clinical trial registration: ClinicalTrials.gov NCT03894085.

Breaking the Fear Barrier: Aberrant Activity of Fear Networks as a Prognostic Biomarker in Patients with Panic Disorder Normalized by Pharmacotherapy

Panic disorder (PD) is a prevalent type of anxiety disorder. Previous studies have reported abnormal brain activity in the fear network of patients with PD. Nonetheless, it remains uncertain whether pharmacotherapy can effectively normalize these abnormalities. This longitudinal resting-state functional magnetic resonance imaging study aimed to investigate the spontaneous neural activity in patients with PD and its changes after pharmacotherapy, with a focus on determining whether it could predict treatment response. The study included 54 drug-naive patients with PD and 54 healthy controls (HCs). Spontaneous neural activity was measured using regional homogeneity (ReHo). Additionally, support vector regression (SVR) was employed to predict treatment response from ReHo. At baseline, PD patients had aberrant ReHo in the fear network compared to HCs. After 4 weeks of paroxetine treatment (20 mg/day), a significant increase in ReHo was observed in the left fusiform gyrus, which had shown reduced ReHo before treatment. The SVR analysis showed significantly positive correlations (p < 0.0001) between the predicted and actual reduction rates of the severity of anxiety and depressive symptoms. Here, we show patients with PD had abnormal spontaneous neural activities in the fear networks. Furthermore, these abnormal spontaneous neural activities can be partially normalized by pharmacotherapy and serve as candidate predictors of treatment response. Gaining insight into the trajectories of brain activity normalization following treatment holds the potential to provide vital insights for managing PD.

Emotion regulation relates to clinical characteristics and quality of life but not daily functioning in psychosis spectrum outpatients

Difficulties in emotion regulation (ER) can negatively impact the clinical course and outcomes of a range of psychiatric conditions, including psychosis spectrum disorders. Individuals with psychosis may exhibit poorer ER abilities, which have been associated with increased severity and distress of psychotic symptoms. A paucity of research has investigated the clinical correlates of ER in psychosis and the influence of these difficulties on indices of recovery, such as daily functioning and quality of life. In the present study, 59 outpatients presenting for Cognitive Behaviour Therapy for psychosis (CBTp) in a large psychiatric hospital completed an intake assessment of clinician-rated and self-reported measures prior to treatment. Poor ER abilities were positively correlated with positive symptoms (overall and delusions), social anxiety, depression, and self-reflectiveness and negatively correlated with quality of life and personal recovery. Multiple regression analyses showed ER was a significant predictor of quality of life but not daily functioning, which was predicted most by cognition and psychiatric symptoms. Overall, findings support the clinical utility of assessing emotion dysregulation in psychosis and provide a more nuanced understanding of how such challenges differentially influence recovery in psychosis, which can further inform treatment planning and intervention.

Automatic Detection of Cognitive Impairment with Virtual Reality

Cognitive impairment features in neuropsychiatric conditions and when undiagnosed can have a severe impact on the affected individual's safety and ability to perform daily tasks. Virtual Reality (VR) systems are increasingly being explored for the recognition, diagnosis and treatment of cognitive impairment. In this paper, we describe novel VR-derived measures of cognitive performance and show their correspondence with clinically-validated cognitive performance measures. We use an immersive VR environment called VStore where participants complete a simulated supermarket shopping task. People with psychosis (k=26) and non-patient controls (k=128) participated in the study, spanning ages 20-79 years. The individuals were split into two cohorts, a homogeneous non-patient cohort (k=99 non-patient participants) and a heterogeneous cohort (k=26 patients, k=29 non-patient participants). Participants' spatio-temporal behaviour in VStore is used to extract four features, namely, route optimality score, proportional distance score, execution error score, and hesitation score using the Traveling Salesman Problem and explore-exploit decision mathematics. These extracted features are mapped to seven validated cognitive performance scores, via linear regression models. The most statistically important feature is found to be the hesitation score. When combined with the remaining extracted features, the multiple linear regression model resulted in statistically significant results with R2 = 0.369, F-Stat = 7.158, p(F-Stat) = 0.000128.

Associations between aerobic fitness, negative symptoms, cognitive deficits and brain structure in schizophrenia—a cross-sectional study

Negative symptoms and cognitive deficits are common in individuals with schizophrenia, greatly affect their outcome, and have been associated with alterations in cerebral gray and white matter volume (GMV, WMV). In the last decade, aerobic endurance training has emerged as a promising intervention to alleviate these symptoms and improved aerobic fitness has been suggested as a key moderator variable. In the present study, we investigated, whether aerobic fitness is associated with fewer cognitive deficits and negative symptoms and with GMVs and WMVs in individuals with schizophrenia in a cross-sectional design. In the largest study to date on the implications of fitness in individuals with schizophrenia, 111 participants at two centers underwent assessments of negative symptoms, cognitive functioning, and aerobic fitness and 69 underwent additional structural magnetic resonance imaging. Multilevel Bayesian partial correlations were computed to quantify relationships between the variables of interest. The main finding was a positive association of aerobic fitness with right hippocampal GMV and WMVs in parahippocampal and several cerebellar regions. We found limited evidence for an association of aerobic fitness with cognitive functioning and negative symptoms. In summary, our results strengthen the notion that aerobic fitness and hippocampal plasticity are interrelated which holds implications for the design of exercise interventions in individuals with schizophrenia.

Cognitive function and treatment response trajectories in first-episode schizophrenia: evidence from a prospective cohort study

OBJECTIVES

This prospective cohort study tested for associations between baseline cognitive performance in individuals early within their first episode and antipsychotic treatment of psychosis. We hypothesised that poorer cognitive functioning at the initial assessment would be associated with poorer antipsychotic response following the subsequent 6 weeks.

DESIGN

Prospective cohort .

SETTING

National Health Service users with a first-episode schizophrenia diagnosis, recently starting antipsychotic medication, recruited from two UK sites (King's College London, UK and University of Manchester, UK). Participants attended three study visits following screening.

PARTICIPANTS

Eighty-nine participants were recruited, with 46 included in the main analysis. Participants required to be within the first 2 years of illness onset, had received minimal antipsychotic treatment, have the capacity to provide consent, and be able to read and write in English. Participants were excluded if they met remission criteria or showed mild to no symptoms.

PRIMARY AND SECONDARY OUTCOME MEASURES

Antipsychotic response was determined at 6 weeks using the Positive and Negative Syndrome Scale (PANSS), with cognitive performance assessed at each visit using the Brief Assessment of Cognition in Schizophrenia (BACS). The groups identified (responders and non-responders) from trajectory analyses, as well as from >20% PANSS criteria, were compared on baseline BACS performance.

RESULTS

Trajectory analyses identified 84.78% of the sample as treatment responsive, and the remaining 15.22% as treatment non-responsive. Unadjusted and adjusted logistic regressions observed no significant relationship between baseline BACS on subscale and total performance (BACS t-score: OR=0.98, p=0.620, Cohen's d=0.218) and antipsychotic response at 6 weeks.

CONCLUSIONS

This investigation identified two clear trajectories of treatment response in the first 6 weeks of antipsychotic treatment. Responder and non-responder groups did not significantly differ on performance on the BACS, suggesting that larger samples may be required or that an association between cognitive performance and antipsychotic response is not observable in the first 2 years of illness onset.

TRIAL REGISTRATION NUMBER

REC: 17/NI/0209.

The role of glutamate and GABA in cognitive dysfunction in schizophrenia and mood disorders - A systematic review of magnetic resonance spectroscopy studies

Epidemiologic, genetic, and neurobiological studies suggest considerable overlap between schizophrenia and mood disorders. Importantly, both disorders are associated with a broad range of cognitive deficits as well as altered glutamatergic and GABAergic neurometabolism. We conducted a systematic review of magnetic resonance spectroscopy (MRS) studies investigating the relationship between glutamatergic and GABAergic neurometabolites and cognition in schizophrenia spectrum disorders and mood disorders. A literature search in Pubmed of studies published before April 15, 2019 was conducted and 37 studies were deemed eligible for systematic review. We found that alterations in glutamatergic and GABAergic neurotransmission have been identified relatively consistently in both schizophrenia and mood disorders. However, because of the vast heterogeneity of published studies in terms of illness stage, medication exposure, MRS acquisition parameters and data post-processing strategies, we still do not understand the relationship between those neurotransmitters and cognitive dysfunction in mental illness, which is a critical initial step for rational drug development. Our findings emphasize the need for coordinated multi-center studies that characterize cognitive function and its biological substrates in large and well-defined clinical populations, using harmonized imaging sequences and analytical methods with the goal to elucidate the underlying pathophysiological mechanisms and to inform future clinical trials.

Montreal Cognitive Assessment (MoCA) and Digit Symbol Substitution Test (DSST) as a screening tool for evaluation of cognitive deficits in schizophrenia

Cognitive deficit is one of the core features of schizophrenia and is associated with poor functional outcomes. There is a lack of validated criteria to screen and monitor cognitive deficits in schizophrenia. This study aimed to evaluate the concurrent validity and sensitivity of MoCA (Montreal Cognitive Assessment) and DSST (Digit Symbol Substitution Test) in identifying cognitive deficits in Schizophrenia comparing with a comprehensive MCCB [MATRICS (Measurement And Treatment Research to Improve Cognition in Schizophrenia) Consensus Cognitive Battery] equivalent battery. We did clinical and cognitive assessments on 30 patients with schizophrenia and 30 age and gender-matched healthy controls. The Cronbach's Alpha of MoCA was 0.839, and on adding the DSST, it increased to 0.859. In stepwise binary logistic regression, adding DSST to MoCA improved the prediction of cognitive impairment as defined by a comprehensive battery with 86.7% classification accuracy. Receiver operating characteristic curve analysis suggested a score of 25 of MoCA and 59 of DSST as an optimal cut-off in identifying severe cognitive deficits with an additional MoCA cut-off of 27 for identifying mild cognitive deficits. Combined MoCA and DSST is a sensitive and quick method to screen for neurocognitive deficits in schizophrenia.

The use of the Montreal Cognitive Assessment (MoCA) screening tool to evaluate cognitive deficits in Lebanese in-patients with schizophrenia

BACKGROUND

The Montreal Cognitive Assessment (MoCA) is a brief cognitive impairment screening tool suitable for a rapid diagnosis of cognitive functioning. The primary objective was to examine the ability of the MoCA to detect cognitive impairment and functioning (autonomy and social cognition) among Lebanese patients with schizophrenia. The secondary objective was to evaluate factors related to cognition.

METHODS

A cross-sectional study conducted between July 2019 and Mars 2020 that enrolled 120 in-patients diagnosed with schizophrenia. The MoCA tool and the BACS were used to evaluate the patients' cognitive functioning.

RESULTS

The MoCA adjusted total score was significantly correlated with the BACS total score (r = .72, p < .001). The cut-off value of the MoCA for detecting mild cognitive impairment was 21, moderate cognitive impairment was 20.50 and severe cognitive impairment was 19.5. The multivariable analysis showed that the MoCA total score and the BACS score resulted in a non-significant association with autonomy. Also, higher cognition (higher BACS) (B =.10, p < 0.001) was significantly associated with a higher MoCA total score. However, higher depression (B=-.18, p = .02) and higher psychosis (B=-.04, p = .01) were significantly associated with lower MoCA.

CONCLUSION

The Arabic version of the MoCA can be a useful tool for screening cognitive impairment in patients with schizophrenia.

Characterizing the sensorimotor domain in schizophrenia spectrum disorders

The rapidly evolving field of sensorimotor neuroscience reflects the scientific and clinical relevance of sensorimotor abnormalities as an intrinsic component of the disease process, e.g., in patients with schizophrenia spectrum disorders (SSD). Despite previous efforts, however, prevalence rates and relationships between different categories of sensorimotor abnormalities in SSD patients are still subject of ongoing debate. In this study, we examined five different categories of the sensorimotor domain (Neurological soft signs (NSS), parkinsonism, catatonia, akathisia, and tardive dyskinesia) according to well-established clinical ratings scales and the respective cut-off criteria in a sample of 131 SSD patients. We used a collection of statistical methods to better understand prevalence, overlap and heterogeneity, as well as psychopathological and cognitive correlates of sensorimotor abnormalities. 97.7% of the SSD patients considered by this study exhibited at least one categorically defined sensorimotor abnormality that tended to co-vary within three different sensorimotor subgroups (moderate, hyperkinetic and hypokinetic). Finally, hyperkinetic and hypokinetic groups differed significantly in their neurocognitive performance compared with the moderate group. The results suggest different patterns of clinical overlap, highlight the relationship between sensorimotor and cognitive domain and provide clues for further neurobiological studies.

Association between aerobic fitness and the functional connectome in patients with schizophrenia

BACKGROUND

Schizophrenia is accompanied by widespread alterations in static functional connectivity associated with symptom severity and cognitive deficits. Improvements in aerobic fitness have been demonstrated to ameliorate symptomatology and cognition in people with schizophrenia, but the intermediary role of macroscale connectivity patterns remains unknown.

OBJECTIVE

Therefore, we aim to explore the relation between aerobic fitness and the functional connectome in individuals with schizophrenia. Further, we investigate clinical and cognitive relevance of the identified fitness-connectivity links.

METHODS

Patients diagnosed with schizophrenia were included in this cross-sectional resting-state fMRI analysis. Multilevel Bayesian partial correlations between aerobic fitness and functional connections across the whole brain as well as between static functional connectivity patterns and clinical and cognitive outcome were performed. Preliminary causal inferences were enabled based on mediation analyses.

RESULTS

Static functional connectivity between the subcortical nuclei and the cerebellum as well as between temporal seeds mediated the attenuating relation between aerobic fitness and total symptom severity. Functional connections between cerebellar seeds affected the positive link between aerobic fitness and global cognition, while the functional interplay between central and limbic seeds drove the beneficial association between aerobic fitness and emotion recognition.

CONCLUSION

The current study provides first insights into the interactions between aerobic fitness, the functional connectome and clinical and cognitive outcome in people with schizophrenia, but causal interpretations are preliminary. Further interventional aerobic exercise studies are needed to replicate the current findings and to enable conclusive causal inferences.

TRIAL REGISTRATION

The study which the manuscript is based on is registered in the International Clinical Trials Database (ClinicalTrials.gov identifier [NCT number]: NCT03466112) and in the German Clinical Trials Register (DRKS-ID: DRKS00009804).

European Psychiatric Association guidance on assessment of cognitive impairment in schizophrenia

Background

Impairment in a wide range of cognitive abilities has been consistently reported in individuals with schizophrenia. Both neurocognitive and social cognitive deficits are thought to underlie severe functional disabilities associated with schizophrenia. Despite the key role in schizophrenia outcome, cognition is still poorly assessed in both research and clinical settings.

Methods

In this guidance paper, we provide a systematic review of the scientific literature and elaborate several recommendations for the assessment of cognitive functions in schizophrenia both in research settings and in real-world clinical practice.

Results

Expert consensus and systematic reviews provided guidance for the optimal assessment of cognitive functions in schizophrenia. Based on the reviewed evidence, we recommend a comprehensive and systematic assessment of neurocognitive and social cognitive domains in schizophrenia, in all phases of the disorder, as well as in subjects at risk to develop psychosis. This European Psychiatric Association guidance recommends not only the use of observer reports but also self-reports and interview-based cognitive assessment tools. The guidance also provides a systematic review of the state of the art of assessment in the first episode of psychosis patients and in individuals at risk for psychosis.

Conclusion

The comprehensive review of the evidence and the recommendations might contribute to advance the field, allowing a better cognitive assessment, and avoiding overlaps with other psychopathological dimensions. The dissemination of this guidance paper may promote the development of shared guidelines concerning the assessment of cognitive functions in schizophrenia, with the purpose to improve the quality of care and to obtain recovery.

Patient, family and provider views of measurement-based care in an early-psychosis intervention programme

Background

Measurement-based care (MBC) in mental health improves patient outcomes and is a component of many national guidelines for mental healthcare delivery. Nevertheless, MBC is not routinely integrated into clinical practice. Several known reasons for the lack of integration exist but one lesser explored variable is the subjective perspectives of providers and patients about MBC. Such perspectives are critical to understand facilitators and barriers to improve the integration of MBC into routine clinical practice.

Aims

This study aimed to uncover the perspectives of various stakeholders towards MBC within a single treatment centre.

Method

Researchers conducted qualitative semi-structured interviews with patients (n = 15), family members (n = 7), case managers (n = 8) and psychiatrists (n = 6) engaged in an early-psychosis intervention programme. Data were analysed using thematic analysis, informed by critical realist theory.

Results

Analysis converged on several themes. These include (a) implicit negative assumptions; (b) relevance and utility to practice; (c) equity versus flexibility; and (d) shared decision-making. Providers assumed patients’ perspectives of MBC were negative. Patients’ perspectives of MBC were actually favourable, particularly if MBC was used as an instrument to engage patients in shared decision-making and communication rather than as a dogmatic and rigid clinical decision tool.

Conclusions

This qualitative study presents the views of various stakeholders towards MBC, providing an in-depth examination of the barriers and facilitators to MBC through qualitative investigation. The findings from this study should be used to address the challenges organisations have experienced in implementing MBC.

[Differential diagnostic distinction between substance-induced and primary psychoses: : Recommendations for general psychiatric and forensic practice]

Substanzinduzierte psychotische Störungen (SIPS) sind häufig und für ca. 25 % der ersten Einweisungen in eine psychiatrische Klinik verantwortlich. Aus klinischer Sicht ist aufgrund ähnlicher psychopathologischer Phänomene die diagnostische Unterscheidung zwischen SIPS und primären (genuinen oder kryptogenen) psychotischen Störungen oft eine Herausforderung. Dieser Umstand wird dadurch erschwert, dass SIPS im Zusammenhang mit Cannabis, Halluzinogenen und Amphetaminen ein erhebliches Risiko des Übergangs in eine primäre psychotische Störung (z. B. Schizophrenie) haben. Im ersten Abschnitt dieser Arbeit werden zunächst zwei exemplarische Fallvignetten aus der allgemeinpsychiatrischen und forensischen Praxis vorgestellt. Danach wird im Sinne einer selektiven Literaturübersicht die Relevanz der differenzialdiagnostischen Unterscheidung beider Störungsbilder aus der Sicht der allgemeinen und forensischen Psychiatrie in Bezug auf Therapie, Prognose und richterliche Entscheidung bezüglich der Unterbringung im Maßregelvollzug (§ 63 vs. § 64 StGB) beleuchtet. Der letzte Abschnitt hat das Ziel, ein strukturiertes Vorgehen zur differenzialdiagnostischen Unterscheidung zwischen SIPS und primären psychotischen Störungen zu erarbeiten. Die in dieser Arbeit dargestellten und diskutierten Konzepte und Befunde sollen klinisch tätigen Psychiatern und Psychologen die Diagnosestellung im allgemeinen und forensischen Kontext erleichtern.

Aerobic endurance training to improve cognition and enhance recovery in schizophrenia: design and methodology of a multicenter randomized controlled trial

Even today, patients with schizophrenia often have an unfavorable outcome. Negative symptoms and cognitive deficits are common features in many patients and prevent recovery. In recent years, aerobic endurance training has emerged as a therapeutic approach with positive effects on several domains of patients' health. However, appropriately sized, multicenter randomized controlled trials that would allow better generalization of results are lacking. The exercise study presented here is a multicenter, rater-blind, two-armed, parallel-group randomized clinical trial in patients with clinically stable schizophrenia being conducted at five German tertiary hospitals. The intervention group performs aerobic endurance training on bicycle ergometers three times per week for 40-50 min/session (depending on the intervention week) for a total of 26 weeks, and the control group performs balance and tone training for the same amount of time. Participants are subsequently followed up for 26 weeks. The primary endpoint is all-cause discontinuation; secondary endpoints include psychopathology, cognition, daily functioning, cardiovascular risk factors, and explorative biological measures regarding the underlying mechanisms of exercise. A total of 180 patients will be randomized. With currently 162 randomized participants, our study is the largest trial to date to investigate endurance training in patients with schizophrenia. We hypothesize that aerobic endurance training has beneficial effects on patients' mental and physical health, leading to lower treatment discontinuation rates and improving disease outcomes. The study results will provide a basis for recommending exercise interventions as an add-on therapy in patients with schizophrenia.The study is registered in the International Clinical Trials Database (ClinicalTrials.gov identifier [NCT number]: NCT03466112) and in the German Clinical Trials Register (DRKS-ID: DRKS00009804).

Different diagnostic strategies for different settings

Diagnostic strategies should always take into consideration the setting in which they are administered. The predictive value, positive or negative of a clinical sign or diagnostic test has a different weight in family medicine than in the hospital setting. Many tests have not been formally evaluated in primary care; unfortunately, very often low prevalence settings are used to conduct screening in these populations, and often result in unrealistically high prevalence estimates for chronic disease and these results are then used to conclude that General Practitioners are not good at detecting diseases. In primary care, the prevalence and incidence of disease differs from what appears in the hospital setting, and severe disease occurs less frequently in general practice than in hospital because there is no preventive selection. This requires a specific probability-based decision-making process, based by the knowledge of patients and the community. In primary care, the diagnostic strategy should begin with complaints and symptoms and address uncertainty and complexity, using step-by-step strategies, including watchful waiting, presumptive symptomatic treatment, and focusing on low-tech strategies.

The clinical characterization of the patient with primary psychosis aimed at personalization of management

The current management of patients with primary psychosis worldwide is often remarkably stereotyped. In almost all cases an antipsychotic medica-tion is prescribed, with second-generation antipsychotics usually preferred to first-generation ones. Cognitive behavioral therapy is rarely used in the vast majority of countries, although there is evidence to support its efficacy. Psychosocial interventions are often provided, especially in chronic cases, but those applied are frequently not validated by research. Evidence-based family interventions and supported employment programs are seldom implemented in ordinary practice. Although the notion that patients with primary psychosis are at increased risk for cardiovascular diseases and diabetes mellitus is widely shared, it is not frequent that appropriate measures be implemented to address this problem. The view that the management of the patient with primary psychosis should be personalized is endorsed by the vast majority of clinicians, but this personalization is lacking or inadequate in most clinical contexts. Although many mental health services would declare themselves "recovery-oriented", it is not common that a focus on empowerment, identity, meaning and resilience is ensured in ordinary practice. The present paper aims to address this situation. It describes systematically the salient domains that should be considered in the characterization of the individual patient with primary psychosis aimed at personalization of management. These include positive and negative symptom dimensions, other psychopathological components, onset and course, neurocognition and social cognition, neurodevelopmental indicators; social functioning, quality of life and unmet needs; clinical staging, antecedent and concomitant psychiatric conditions, physical comorbidities, family history, history of obstetric complications, early and recent environmental exposures, protective factors and resilience, and internalized stigma. For each domain, simple assessment instruments are identified that could be considered for use in clinical practice and included in standardized decision tools. A management of primary psychosis is encouraged which takes into account all the available treatment modalities whose efficacy is supported by research evidence, selects and modulates them in the individual patient on the basis of the clinical characterization, addresses the patient's needs in terms of employment, housing, self-care, social relationships and education, and offers a focus on identity, meaning and resilience.

A systematic review of research on neuropsychological measures in psychotic disorders from low and middle-income countries: The question of clinical utility

INTRODUCTION

Several studies of neuropsychological measures have been undertaken in patients with psychotic disorders from low- and middle-income countries (LMICs). It is, however, unclear if the measures used in these studies are appropriate for cognitive screening in clinical settings. We undertook a systematic review to determine if measures investigated in research on psychotic disorders in LMICs meet the clinical utility criteria proposed by The Working Group on Screening and Assessment.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses were employed. We determined if tests had been validated against a comprehensive test battery, the duration and scope of the tests, the personnel administering the tests, and the means of administration.

RESULTS

A total of 31 articles were included in the review, of which 11 were from Africa. The studies included 3254 participants with psychosis and 1331 controls. 3 studies reported on the validation of the test against a comprehensive cognitive battery. Assessments took 1 h or less to administer in 6/31 studies. The average number of cognitive domains assessed was four. Nonspecialized staff were used in only 3/31 studies, and most studies used pen and paper tests (17/31).

CONCLUSION

Neuropsychological measures used in research on psychotic disorders in LMICs typically do not meet the Working Group on Screening and Assessment clinical utility criteria for cognitive screening. Measures that have been validated in high-income countries but not in LMICs that do meet these criteria, such as the Brief Assessment of Cognition in Schizophrenia, therefore deserve further study in LMIC settings.

Italian Validation of the Screen for Cognitive Impairment in Psychiatry

Cognitive impairments have profound implications for the management of severe mental disorders; however, they are rarely assessed in everyday clinical practice due to constraints in time, resource and expertise. Novel and short instruments, such as the Screen for Cognitive Impairment in Psychiatry (SCIP), which overcome such limitations are greatly needed. The study aims to assess the validity and reliability, among healthy subjects, of the Italian translation of the SCIP, a brief, accessible tool to detect cognitive impairments among individuals suffering from mental disorders, as the first step to validate the instrument in clinical settings. One-hundred and twenty healthy subjects completed two of the three alternative forms of the SCIP. Cronbach Alpha (0.70) supported the reliability of the SCIP scores. Correlation coefficients supported the test-retest reliability of the tool. Learning effects were observed despite the use of alternative forms. Factor analysis indicated a two-factor solution explaining 55.4% of the total variance: the first factor ("memory") loading for VLT-I and VLT-D and less for WMT; the second factor ("executive function") loading for VFT and PST and less for WMT. The study proved the validity and reliability of the Italian version of the SCIP as a reliable and simple instrument to screen for cognitive impairment in the general population.

Montreal Cognitive Assessment for evaluating the cognitive impairment in patients with schizophrenia: A systematic review

OBJECTIVE

This study aims to systematically review the evidence on the accuracy of the Montreal Cognitive Assessment (MoCA) test for evaluating the presence of cognitive impairment in patients with schizophrenia and to outline the quality and quantity of research evidence available about the accuracy of MoCA in this population.

METHODS

We conducted a systematic literature review, searching four databases from inception until April 2020.

RESULTS

We identified only three cross-sectional studies, two case - control studies, three studies comparing MoCA with Mini-Mental State Examination (MMSE) and four prevalence studies that met the inclusion criteria. Publication period ranged from 2012 to 2020.

CONCLUSIONS

In patients with schizophrenia, the MoCA test provides information about general cognitive functioning disturbances. A lower threshold than the original cut-off of 26 is probably more useful for optimal screening, as it lowers false positive rates and improves diagnostic accuracy. Nonetheless, more studies are necessary in this direction.

Moving forward: distinct sensorimotor abnormalities predict clinical outcome after 6 months in patients with schizophrenia

Despite substantial efforts in the last decades, objective measures that can predict clinical outcome in patients with schizophrenia (SZ) after an acute psychotic episode are still lacking. Here, we introduced a comprehensive assessment of sensorimotor function to predict mid-term clinical outcome following an acute psychotic episode. This naturalistic follow-up of 43 patients with DSM-IV-TR diagnosis of SZ examined sensorimotor abnormalities (i.e. Neurological Soft Signs (NSS), parkinsonism, akathisia, catatonia and acute dyskinesia), psychopathology, cognition and psychosocial functioning using well-established instruments. A collection of statistical methods was used to examine the relationship between sensorimotor domain, psychopathology, cognition and psychosocial functioning. We also tested the clinical feasibility of this relationship when predicting clinical outcome after an acute psychotic episode. Longitudinal data were collected on 43 individuals after a follow-up period of >6 months. At follow-up, patients showed significantly reduced general symptom severity, as well as decreased levels of NSS, parkinsonism and catatonia. Further, NSS scores at baseline predicted PANSS negative scores and cognitive functioning at baseline. Finally, NSS scores at baseline predicted symptom change (reduction of PANSS positive and negative scores) at follow-up. In conclusion, our results suggest that NSS are significant predictors of poor clinical outcome in SZ at baseline and >6 months after an acute psychotic episode. These findings propose sensorimotor domain as state biomarker of SZ and support its predictive power with respect to treatment outcome.

Measurement based care in schizophrenia-Feasibility in routine clinical practice

Measurement based care (MBC) implies the utilization of structured objective scales/batteries in the assessment and monitoring of an illness. Patients with schizophrenia with heterogeneous presentation would potentially benefit better through MBC. Time constraints and additional work burden are frequently cited as barriers in implementing objective assessments. In this selective review, the authors discuss the available standard scales for assessment in schizophrenia, the advantages and disadvantages in implementing MBC and a feasible approach to overcome the barriers by adapting shorter versions of structured scales.

Utility of the MoCA for cognitive impairment screening in long-term psychosis patients

Cognitive impairment is a key feature in patients with psychotic disorders. The Montreal Cognitive Assessment (MoCA) is a brief tool that has been shown to be effective in identifying mild cognitive impairment and early dementia. This study explores the usefulness of this instrument to detect cognitive impairment in long-term psychotic disorders. One hundred-forty stabilized patients were re-evaluated more than 15 years after a First Episode of Psychosis (FEP). Patients were psychopathologically assessed, and the MoCA test and MATRICS Consensus Cognitive Battery (MCCB) were administered. Two cut-off scores for cognitive impairment using the MCCB were applied (T score <40 and < 30). Concurrent validation was found between the total scores of the MoCA and MCCB. We also found significant associations between 5 out of 7 MoCA subtests (visuospatial-executive, attention, language, abstraction and delayed recall) and MCCB subtests but not for the naming and orientation MoCA subtests. Receiver operating characteristic (ROC) analysis suggested a <25 cut-off for cognitive impairment instead of the original <26. Our results suggest that the MoCA test is a useful screening instrument for assessing cognitive impairment in psychotic patients and has some advantages over other available instruments, such as its ease-of-use and short administration time.

Development and testing of a web-based battery to remotely assess cognitive health in individuals with schizophrenia

Cognitive impairment in schizophrenia is often severe, enduring, and contributes significantly to chronic disability. A standardized platform for identifying cognitive impairments and measuring treatment effects in cognition is a critical aspect of comprehensive evaluation and treatment for individuals with schizophrenia. In this project, we developed and tested a suite of ten web-based, neuroscience-informed cognitive assessments that are designed to enable the interpretation of specific deficits that could signal that an individual is experiencing cognitive difficulties. The assessment suite assays speed of processing, sustained attention, executive functioning, learning and socio-affective processing in the auditory and visual modalities. We have obtained data from 283 healthy individuals who were recruited online and 104 individuals with schizophrenia who also completed formal neuropsychological testing. Our data show that the assessments 1) are acceptable and tolerable to users, with successful completion in an average of under 40 min; 2) reliably measure the distinct theoretical cognitive constructs they were designed to assess; 3) can discriminate schizophrenia patients from healthy controls with a fair degree of accuracy (AUROC > 0.70); and 4) have promising construct, convergent, and external validity. Further optimization and validation work is in progress to finalize the evaluation process prior to promoting the dissemination of these assessments in real-world settings.

The Relationship of Motivation and Neurocognition with Functionality in Schizophrenia: A Meta-analytic Review

The role that neurocognition plays in functionality in schizophrenia has been widely examined, although in recent years increasing attention has been paid to the influence of motivation instead. This study provides a review of the relationship of neurocognition and motivation with functionality in schizophrenia, taking into account objective/subjective functionality assessment, demographic variables, and the different terms used when referring to motivation. A search of electronic databases identified 34 studies that met the inclusion criteria for review. Correlation coefficients between motivation and functionality and between neurocognition and functionality were extracted. For a better understanding, potential moderator variables were also extracted. Meta-analysis showed that both motivation and neurocognition assessments were strongly associated with functioning, with correlations between motivation and functional outcomes being stronger. However, more than three-quarters of the variance in outcome remained unexplained by the moderating factors examined. The paper concludes with recommendations for clinical practice and future research.

The Screen for Cognitive Impairment in Psychiatry: Proposal for a polytomous scoring system

The Screen for Cognitive Impairment in Psychiatry is a simple, fast, and easy to administer scale that has been validated in clinical and community samples. The aim of this study was to propose a polytomous scoring system for the Screen for Cognitive Impairment in Psychiatry and to demonstrate its functioning, thus providing new and complementary information regarding the utility and precision of this screening tool. Three hundred seventy-six Spanish patients diagnosed with schizophrenia spectrum disorder were evaluated. A polytomous scoring system was generated and analyzed by means of the partial credit model. Category assessment revealed optimal functioning after collapsing the 7-category system to 1 with either 5 or 4 categories, depending on the item. The proposed polytomous scoring system shows good psychometric properties and an adequate fit to the partial credit model. These results provide further confirmation of the test's utility in clinical settings and of its suitability for detecting cognitive impairment.

A 10-minute measure of global cognition: Validation of the Brief Cognitive Assessment Tool for Schizophrenia (B-CATS)

INTRODUCTION

Schizophrenia is marked by a global cognitive impairment that contributes significantly to chronic disability and unemployment. As new treatments are developed for cognition in schizophrenia, clinicians require easily administered instruments to assess cognition. We previously developed a very brief cognitive battery (Bell et al., 2005). The Brief Cognitive Assessment Tool for Schizophrenia (B-CATS) was developed specifically to provide clinicians with a way to assess cognition in their patients with schizophrenia. Here, we report the results of a validity study comparing B-CATS to a larger neurocognitive battery, the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) battery.

METHODS

Outpatients with schizophrenia (N=91) were administered the B-CATS and the non-overlapping tests of the MATRICS battery at two time points separated by 1month. They were also administered the UCSD Performance-based Skills Assessment-Brief (UPSA-B), a measure of functional capacity.

RESULT

The B-CATS has an administration time of approximately 10min. It demonstrates good test-retest reliability and internal consistency. It correlates 0.76 (p<0.01) with the MATRICS battery. The shorter B-CATS and the MATRICS battery correlate with the UPSA-B at 0.50 and 0.58 respectively.

CONCLUSION

A 10-minute version of the B-CATS correlates highly with the "gold standard" neurocognitive battery that has an administration time of over 60min. Both measures correlate moderately with a measure of functional capacity. This brief battery was designed to allow clinicians to monitor cognitive change and better inform treatment decisions.

Establishing the Brief Assessment of Cognition - Short form

The study aims to identify and validate a parsimonious subset of tests in the commonly used Brief Assessment of Cognition in Schizophrenia (BACS) that allows the evaluation of global cognitive ability. Several permutations of subtests from the BACS were examined to identify the best subset of tests to compose the short form measure. The Brief Assessment of Cognition-Short Form (BAC-SF) was evaluated for convergent validity in healthy and psychiatric samples (N = 3718). Verbal Memory, Digit Sequencing, and Symbol Coding subtests were found to best summarize the variance of composite scores in both Asian and US Norming samples (r = 0.91) indicating that BAC-SF is an appropriate approximation of cognitive deficits. Test re-test reliability of the BAC-SF was adequate (Intraclass Correlation Coefficient (ICC) = 0.73) and showed sufficient separation between healthy controls and schizophrenia (Average Predictive Accuracy = 79.9%; replication = 76.5%). Findings indicate that the BAC-SF an could be used as a cognitive screener for large-scale clinical and epidemiological studies. The short form does not replace the need for comprehensive neuropsychological batteries purposed for detailed neuropsychological and clinical investigation of cognitive function. Further replication of the construct might be necessary in other clinical populations.

EPICOG-SCH: A brief battery to screen cognitive impact of schizophrenia in stable outpatients

Brief batteries in schizophrenia, are needed to screen for the cognitive impact of schizophrenia. We aimed to validate and co-norm the Epidemiological Study of Cognitive Impairment in Schizophrenia (EPICOG-SCH) derived brief cognitive battery. A cross-sectional outpatient evaluation was conducted of six-hundred-seventy-two patients recruited from 234 centers. The brief battery included well-known subtests available worldwide that cover cognitive domains related to functional outcomes: WAIS-III-Letter-Number-Sequencing-LNS, Category Fluency Test-CFT, Logical-Memory Immediate Recall-LM, and Digit-Symbol-Coding-DSC. CGI-SCH Severity and WHO-DAS-S were used to assess clinical severity and functional impairment, respectively. Unit Composite Score (UCS) and functional regression-weighted Composite Scores (FWCS) were obtained; discriminant properties of FWCS to identify patients with different levels of functional disability were analyzed using receiver-operating characteristic (ROC) technique. The battery showed good internal consistency, Cronbach's alpha = 0.78. The differences between cognitive performance across CGI-SCH severity level subscales ranged from 0.5 to 1 SD. Discriminant capacity of the battery in identifying patients with up to moderate disability levels showed fair discriminant accuracy with areas under the curve (AUC) > 0.70, p < 0.0001. An FWCS mean cut-off score ≥ 100 showed likelihood ratios (LR) up to 4.7, with an LR + of 2.3 and a LR - of 0.5. An FWCS cut-off ≥ 96 provided the best balance between sensitivity (0.74) and specificity (0.62). The EPICOG-SCH proved to be a useful brief tool to screen for the cognitive impact of schizophrenia, and its regression-weighted Composite Score was an efficient complement to clinical interviews for confirming patients' potential functional outcomes and can be useful for monitoring cognition during routine outpatient follow-up visits.

Successful evaluation of cognitive function and the nature of cognitive deficits among people with schizophrenia in clinical rehabilitation settings

OBJECTIVES

Despite possessing considerable relevance for planning and delivery of effective rehabilitation interventions, systematic evaluation of cognitive function is often ignored in clinical practice. This paper describes a successful method for measuring cognitive function and the nature of cognitive deficits (CD) in people with schizophrenia admitted to psychiatric rehabilitation services.

METHODS

Data on the cognitive functioning of consecutive patients with schizophrenia / schizoaffective disorder admitted during a 5-year period to a public in-patient rehabilitation facility was collated retrospectively and analysed. The Brief Assessment of Cognition in Schizophrenia (BACS) was used to evaluate cognitive function.

RESULTS

It was possible to administer the BACS to 122 of 135 consecutive admissions. The mean composite score on the BACS was 1.8 standard deviations below the norm, and 43% had moderate or severe CD. The BACS sub-tests of list learning and symbol coding revealed more severe deficits.

CONCLUSIONS

The study indicates that evaluation of cognitive function using brief instruments is feasible in psychiatric rehabilitation settings. Global and domain-specific CD were prevalent among people with schizophrenia. In view of the strong association of cognitive functioning with community functioning and rehabilitation outcomes, further studies exploring the feasibility and utility of routinely evaluating cognitive function are warranted.

A comparison between the Mini-Mental State Examination and the Montreal Cognitive Assessment Test in schizophrenia

BACKGROUND

Cognitive impairment is a core feature of schizophrenia that also has strong prognostic significance. In most clinical settings comprehensive neuropsychological testing to detect cognitive impairment in schizophrenia patients is not readily available, but because cognitive deficits in schizophrenia are clinically important it would be useful to detect or at least screen for them in a clinical setting. Unfortunately there are no validated, brief screening instruments for the detection of cognitive impairment in schizophrenia. Nevertheless, the Montreal Cognitive Assessment Test (MoCA) and the Mini-Mental State Examination (MMSE) show promise in this regard. The objective of this study was to compare the results of the MMSE and MoCA in a group of outpatient schizophrenia sufferers to contribute to research into the instruments' potential usefulness as screening tools for cognitive impairment in schizophrenia.

METHOD

The Afrikaans versions of the MMSE and MoCA were administered to Afrikaans-speaking adult outpatients. Participants had at least seven years of formal education and had been in partial or full remission for at least 3 months. The MMSE and MoCA scores for each participant were matched and compared using the non-parametric Wilcoxon matched pairs test.

RESULTS

The sample consisted of 30 Afrikaans-speaking outpatients with schizophrenia. The mean MMSE score was 27.17 ± 2.64, and the mean MoCA score was 22.53 ± 3.91. There was a statistically significant difference between participants' performance on the MMSE and MoCA tests (p = 0.000008).

CONCLUSION

Compared to the MMSE, the MoCA may be a more useful instrument to detect cognitive impairment in patients with schizophrenia. Further studies are required.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders

OBJECTIVES

This guideline provides recommendations for the clinical management of schizophrenia and related disorders for health professionals working in Australia and New Zealand. It aims to encourage all clinicians to adopt best practice principles. The recommendations represent the consensus of a group of Australian and New Zealand experts in the management of schizophrenia and related disorders. This guideline includes the management of ultra-high risk syndromes, first-episode psychoses and prolonged psychoses, including psychoses associated with substance use. It takes a holistic approach, addressing all aspects of the care of people with schizophrenia and related disorders, not only correct diagnosis and symptom relief but also optimal recovery of social function.

METHODS

The writing group planned the scope and individual members drafted sections according to their area of interest and expertise, with reference to existing systematic reviews and informal literature reviews undertaken for this guideline. In addition, experts in specific areas contributed to the relevant sections. All members of the writing group reviewed the entire document. The writing group also considered relevant international clinical practice guidelines. Evidence-based recommendations were formulated when the writing group judged that there was sufficient evidence on a topic. Where evidence was weak or lacking, consensus-based recommendations were formulated. Consensus-based recommendations are based on the consensus of a group of experts in the field and are informed by their agreement as a group, according to their collective clinical and research knowledge and experience. Key considerations were selected and reviewed by the writing group. To encourage wide community participation, the Royal Australian and New Zealand College of Psychiatrists invited review by its committees and members, an expert advisory committee and key stakeholders including professional bodies and special interest groups.

RESULTS

The clinical practice guideline for the management of schizophrenia and related disorders reflects an increasing emphasis on early intervention, physical health, psychosocial treatments, cultural considerations and improving vocational outcomes. The guideline uses a clinical staging model as a framework for recommendations regarding assessment, treatment and ongoing care. This guideline also refers its readers to selected published guidelines or statements directly relevant to Australian and New Zealand practice.

CONCLUSIONS

This clinical practice guideline for the management of schizophrenia and related disorders aims to improve care for people with these disorders living in Australia and New Zealand. It advocates a respectful, collaborative approach; optimal evidence-based treatment; and consideration of the specific needs of those in adverse circumstances or facing additional challenges.

A Case Study on Promoting Neuroplasticity in a Patient With Schizophrenia

PURPOSE

The purpose of this study is to introduce the concept of neuroplasticity, explore strategies that psychiatric nurse practitioners can use to improve cognitive functioning, and apply these strategies to a case study of a patient diagnosed with schizophrenia.

DESIGN AND METHODS

This study used an explanatory descriptive approach with a single-case study to describe cognitive functioning in people with schizophrenia and to illustrate practical implications.

FINDINGS

Schizophrenia is a severe mental illness with typical onset in late adolescence and young adulthood. Cognitive impairment often accompanies schizophrenia and may lead to significant functional impairment. Research demonstrates that the brain is able to change (neuroplasticity) in response to environmental stimuli either negatively or positively. Evidence suggests intervention, including cognitive remediation, physical activity, and sleep, can positively modify neuroplasticity in schizophrenia and improve cognitive function, which may lead to improved quality of life.

PRACTICE IMPLICATIONS

Psychiatric mental health nurses need to offer cognitive enhancing strategies to take advantage of neuroplasticity. Ongoing nursing education regarding therapeutic neurocognitive approaches from basic research should be emphasized.

Implementing the Use of a Brief Cognitive Assessment on Individuals Diagnosed With Schizophrenia in an Acute Psychiatric Facility

Cognitive impairments are prevalent in schizophrenia. The use of a brief cognitive assessment allows for early detection and improves functional outcomes. The purpose of this quality improvement study was to implement the Montreal Cognitive Assessment (MoCA) into the nursing admission assessment for patients who are diagnosed with schizophrenia or related disorders. Nurses administered the MoCA in 67.3% of eligible patients. The high acuity and uncooperative states were the major barriers to screening. The majority of nurses reported confidence in their ability to perform the screening and believed that the results triggered clinical actions to address psychosocial or cognitive deficits.

Inefficient effort allocation and negative symptoms in individuals with schizophrenia

Negative symptoms like avolition and anhedonia are thought to involve difficulties with reward processing and motivation. The current study aimed to replicate and extend prior findings that individuals with schizophrenia display reduced willingness to expend effort for rewards and that such reduced effort is associated with negative symptoms, poor functioning, and cognitive impairment. The present study compared the effortful decision making of individuals with schizophrenia (n=48) and healthy controls (n=27) on the Effort Expenditure for Rewards Task (EEfRT). Individuals with schizophrenia chose a smaller proportion of hard tasks than healthy controls across all probability and reward levels with the exception of trials with a 12% probability and low or medium reward magnitude wherein both groups chose similarly few hard tasks. Contrary to expectations, in individuals with schizophrenia, greater negative symptoms were associated with making more effortful choices. Effortful decision making was unrelated to positive symptoms, depression, cognition, and functioning in individuals with schizophrenia. Our results are consistent with prior findings that revealed a pattern of inefficient decision making in individuals with schizophrenia relative to healthy controls. However the results did not support the hypothesized association of negative symptoms and reduced effort in schizophrenia and highlight prior inconsistencies in this literature. Future research is needed to understand what factors may be related to diminished effortful decision making in schizophrenia and the clinical significance of such performance deficits.

Report on ISCTM Consensus Meeting on Clinical Assessment of Response to Treatment of Cognitive Impairment in Schizophrenia

If treatments for cognitive impairment are to be utilized successfully, clinicians must be able to determine whether they are effective and which patients should receive them. In order to develop consensus on these issues, the International Society for CNS Clinical Trials and Methodology (ISCTM) held a meeting of experts on March 20, 2014, in Washington, DC. Consensus was reached on several important issues. Cognitive impairment and functional disability were viewed as equally important treatment targets. The group supported the notion that sufficient data are not available to exclude patients from available treatments on the basis of age, severity of cognitive impairment, severity of positive symptoms, or the potential to benefit functionally from treatment. The group reached consensus that cognitive remediation is likely to provide substantial benefits in combination with procognitive medications, although a substantial minority believed that medications can be administered without nonpharmacological therapy. There was little consensus on the best methods for assessing cognitive change in clinical practice. Some participants supported the view that performance-based measures are essential for measurement of cognitive change; others pointed to their cost and time requirements as evidence of impracticality. Interview-based measures of cognitive and functional change were viewed as more practical, but lacking validity without informant involvement or frequent contact from clinicians. The lack of consensus on assessment methods was viewed as attributable to differences in experience and education among key stakeholders and significant gaps in available empirical data. Research on the reliability, validity, sensitivity, and practicality of competing methods will facilitate consensus.

Duration of Untreated Psychosis and Brain Function during Verbal Fluency Testing in First-Episode Schizophrenia: A Near-Infrared Spectroscopy Study

A longer duration of untreated psychosis (DUP) has been associated with poor clinical outcomes in patients with schizophrenia (SZ); however, it remains unclear whether this is due to neurotoxic effects of psychosis. The purpose of this study was to use near-infrared spectroscopy (NIRS) to investigate the influence of DUP on brain function using two verbal fluency tests (VFTs) in patients with first-episode SZ (FES). A total of 28 FES patients and 29 healthy controls (HC) underwent NIRS during VFTs. Group comparisons of cortical activity were made using two-tailed t-tests and the false discovery rate method. We then examined the associations between DUP and hemodynamic changes in each channel to identify any effects of DUP on brain cortical activity. During the letter VFT, the HC group exhibited significantly greater cortical activations over bilateral frontotemporal regions compared to FES patients. However, this distinction was not observed while performing a category version of the VFT. In addition, no associations between DUP and brain cortical activity were observed in the FES group during either VFT. In conclusion, we did not find an association between DUP and frontotemporal cortical activities. This might be because neurodevelopmental disturbances result in neurocognitive deficits long before psychotic symptoms onset.

Brain Structure in Neuropsychologically Defined Subgroups of Schizophrenia and Psychotic Bipolar Disorder

BACKGROUND

Neuropsychological impairment is heterogeneous in psychosis. The association of intracranial volume (ICV) and total brain volume (TBV) with cognition suggests brain structure abnormalities in psychosis will covary with the severity of cognitive impairment. We tested the following hypotheses: (1) brain structure abnormalities will be more extensive in neuropsychologically impaired psychosis patients; (2) psychosis patients with premorbid cognitive limitations will show evidence of hypoplasia (ie, smaller ICV); and (3) psychosis patients with evidence of cognitive decline will demonstrate atrophy (ie, smaller TBV, but normal ICV).

METHODS

One hundred thirty-one individuals with psychosis and 97 healthy subjects underwent structural magnetic resonance imaging and neuropsychological testing. Patients were divided into neuropsychologically normal and impaired groups. Impaired patients were further subdivided into deteriorated and compromised groups if estimated premorbid intellect was average or below average, respectively. ICV and TBV were compared across groups. Localized brain volumes were qualitatively examined using voxel-based morphometry.

RESULTS

Compared to healthy subjects, neuropsychologically impaired patients exhibited smaller TBV, reduced grey matter volume in frontal, temporal, and subcortical brain regions, and widespread white matter volume loss. Neuropsychologically compromised patients had smaller ICV relative to healthy subjects, and neuropsychologically normal and deteriorated patient groups, but relatively normal TBV. Deteriorated patients exhibited smaller TBV compared to healthy subjects, but relatively normal ICV. Unexpectedly, TBV, adjusted for ICV, was reduced in neuropsychologically normal patients.

CONCLUSIONS

Patients with long-standing cognitive limitations exhibit evidence of early cerebral hypoplasia, whereas neuropsychologically normal and deteriorated patients show evidence of brain tissue loss consistent with progression or later cerebral dysmaturation.

The Montreal Cognitive Assessment as a preliminary assessment tool in general psychiatry: Validity of MoCA in psychiatric patients

OBJECTIVE

The aim of the presented research was to obtain the initial data regarding the validity of Montreal Cognitive Assessment (MoCA) in diagnosing cognitive impairment in psychiatrically hospitalized patients.

METHOD

The results in MoCA obtained from 221 patients were analyzed in terms of proportional participation of patients with particular diagnosis in three result ranges. In 67 patients, additional version of the scale was also used. Comparative analysis of average results in particular diagnostic groups (organically based disorders, disorders due to psychoactive substance use, psychotic disorders, neurotic disorders and personality disorders) was also carried out, as well as an analysis of the scale's accuracy as a diagnostic test in detecting organic disorders.

RESULTS

The reliability of the test measured with between tests correlation coefficient rho=0.92 (P=.000). Significant differences between particular diagnoses groups were detected (J-T=13736; P=.000). The cutoff points of 23 turned out to have a satisfactory sensitivity and specificity (0.82 and 0.70, respectively) in diagnosing organically based disorders. The area below the receiver operating characteristic curve (AUC=0.854; P=.000) suggests that MoCA has a satisfactory value as a classifier.

CONCLUSION

The initial data suggest MoCA's high value in prediction of future diagnosis of organically based disorders. The initial results obtained in particular group of diagnoses support construct validity of the method.