Predictors of real-life functioning in subjects with schizophrenia: A 4-year follow-up study

Network Analysis of the Brief ICF Core Set for Schizophrenia

Background

The International Classification of Functioning, Disability, and Health Core Sets (ICF-CSs) for schizophrenia are a set of categories for assessing functioning in persons with this health condition. This study aimed to: a) estimate the network structure of the Brief ICF-CS for schizophrenia, b) examine the community structure (categories strongly clustered together) underlying this network, and c) identify the most central categories within this network.

Methods

A total of 638 health professionals from different backgrounds and with a significant role in the treatment of individuals with schizophrenia participated in a series of Delphi studies. Based on their responses we used the Ising model to estimate the network structure of the 25-category Brief ICF-CS, and then estimated the degree of centrality for all categories. Finally, the community structure was detected using the walktrap algorithm.

Results

The resulting network revealed strong associations between individual categories within components of the ICF (i.e., Body functions, Activities and participation, and Environmental factors). The results also showed three distinct clusters of categories corresponding to the same three components. The categories e410 Individual attitudes of immediate family members, e450 Individual attitudes of health professionals, d910 Community life, and d175 Solving problems were among the most central categories in the Brief ICF-CS network.

Conclusion

These results demonstrate the utility of a network approach for estimating the structure of the ICF-CSs. Implications of these results for clinical interventions and development of new instruments are discussed.

Low-Dose Ziprasidone in Combination with Sertraline for First-Episode Drug-Naïve Patients with Schizophrenia: a Randomized Controlled Trial

Many patients with schizophrenia (SCZ) discontinue antipsychotics, frequently due to dose-related multiple and severe adverse effects. We hypothesized that a low-dose ziprasidone plus sertraline would reduce serious side effects without affecting treatment efficacy. Therefore, this clinical trial was designed to investigate the efficacy, safety, and tolerability of adding sertraline to ziprasidone in order to substantially reduce ziprasidone dose and potential side effects in first-episode and drug-naive (FEDN) patients with SCZ. This 24-week randomized, double-blinded, controlled clinical trial randomly allocated 452 FEDN SCZ patients to receive a usual dose of ziprasidone (control group) or half the dose of ziprasidone in combination with sertraline (ZS group). Treatment outcome included the Positive and Negative Syndrome Scale (PANSS), the Hamilton Depression Rating Scale (HAMD), CGI-Severity (CGI-S) and the Personal and Social Performance Scale (PSP) at baseline and weeks 2, 4, 8, 12, and 24. Repeated measures ANCOVA showed significant treatment by time interactions on the PANSS general psychopathology and total scores, as well as CGI-S, HAMD, and PSP scores (all p < 0.05). Furthermore, the ZS group had greater reductions in PANSS general psychopathology, total scores, HAMD, and CGI-S (all p < 0.05) and greater increases in the PSP total score (p < 0.01) than the control group. Importantly, adverse effects were lower in the ZS than control group. The reduction in PANSS, CGI-S, or HAMD scores was not correlated with the increase in PSP. Sex and duration of disease predicted PSP improvement from baseline to week 24 in the ZS group. Our FEDN patients with SCZ were effectively treated for their psychotic and depressive symptoms while experiencing significantly fewer adverse effects using half the usual ziprasidone dose when combined with sertraline. ClinicalTrials.gov, NCT04076371.

Factors influencing the outcome of integrated therapy approach in schizophrenia: A narrative review of the literature

The integration of pharmacotherapy with psychosocial interventions has an important role to play in the improvement of functional outcome of subjects with schizophrenia (SCZ), in all stages of the disorder. It is essential for the adequate management of unmet therapeutic needs, such as negative symptoms and cognitive dysfunctions which account for most of the functional impairment of subjects with SCZ and do not respond to available antipsychotics. Enhancing the knowledge on factors involved in the effectiveness of integrated treatment plans is an important step forward for SCZ care. This review aims to identify factors that might influence the impact of integrated treatments on functional outcome. Most studies on the impact of psychosocial treatments on functional outcome of subjects with SCZ did not control for the effect of prescribed antipsychotics or concomitant medications. However, several factors relevant to ongoing pharmacological treatment might influence the outcome of integrated therapy, with an impact on the adherence to treatment (e.g., therapeutic alliance and polypharmacotherapy) or on illness-related factors addressed by the psychosocial interventions (e.g., cognitive dysfunctions or motivational deficits). Indirect evidence suggests that treatment integration should consider the possible detrimental effects of different antipsychotics or concomitant medications on cognitive functions, as well as on secondary negative symptoms. Cognitive dysfunctions can interfere with participation to an integrated treatment plan and can be worsened by extrapyramidal or metabolic side effects of antipsychotics, or concomitant treatment with anticholinergics or benzodiazepines. Secondary negative symptoms, due to positive symptoms, sedation, extrapyramidal side effects or untreated depression, might cause early drop-out and poor adherence to treatment. Researchers and clinicians should examine all the above-mentioned factors and implement appropriate and personalized integrated treatments to improve the outcome of SCZ.

Efficacy of Integrated Social Cognitive Remediation vs. Neurocognitive Remediation in Improving Functional Outcome in Schizophrenia: Concept and Design of a Multicenter, Single-Blind RCT (The ISST Study)

BACKGROUND

Although clinically effective treatment is available for schizophrenia, recovery often is still hampered by persistent poor psychosocial functioning, which in turn is limited by impairments in neurocognition, social cognition, and social behavioral skills. Although cognitive remediation has shown general efficacy in improving cognition and social functioning, effects still need to be improved and replicated in appropriately powered, methodologically rigorous randomized controlled trials (RCTs). Existing evidence indicates that effects can most likely be optimized by combining treatment approaches to simultaneously address both social cognitive and social behavioral processes.

OBJECTIVES

To assess whether Integrated Social Cognitive and Behavioral Skill Therapy (ISST) is more efficacious in improving functional outcome in schizophrenia than the active control treatment Neurocognitive Remediation Therapy (NCRT).

METHODS

The present study is a multicenter, prospective, rater-blinded, two-arm RCT being conducted at six academic study sites in Germany. A sample of 180 at least partly remitted patients with schizophrenia are randomly assigned to either ISST or NCRT. ISST is a compensatory, strategy-based program that targets social cognitive processes and social behavioral skills. NCRT comprises mainly drill and practice-oriented neurocognitive training. Both treatments consist of 18 sessions over 6 months, and participants are subsequently followed up for another 6 months. The primary outcome is all-cause discontinuation over the 12-month study period; psychosocial functioning, quality of life, neurocognitive and social cognitive performance, and clinical symptoms are assessed as secondary outcomes at baseline before randomization (V1), at the end of the six-month treatment period (V6), and at the six-month follow-up (V12).

DISCUSSION

This RCT is part of the German Enhancing Schizophrenia Prevention and Recovery through Innovative Treatments (ESPRIT) research network, which aims at using innovative treatments to enhance prevention and recovery in patients with schizophrenia. Because this study is one of the largest and methodologically most rigorous RCTs on the efficacy of cognitive remediation approaches in schizophrenia, it will not only help to identify the optimal treatment options for improving psychosocial functioning and thus recovery in patients but also allow conclusions to be drawn about factors influencing and mediating the effects of cognitive remediation in these patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02678858, German Study Register DRKS 00010033.