A randomized controlled trial of cognitive remediation and long-acting injectable risperidone after a first episode of schizophrenia: improving cognition and work/school functioning

Assessment of functional recovery in patients with schizophrenia, with a focus on early-phase disease: results from a Delphi consensus and narrative review

BACKGROUND

Treatment of schizophrenia has traditionally aimed for symptomatic remission without addressing many daily problems patients face. Although no standard definition of functional recovery in patients with first-episode psychosis (FEP) and early-phase (EP) schizophrenia exists in the literature, most clinicians consider it a useful concept in daily practice. We conducted a Delphi panel to develop expert consensus on assessing functional recovery in FEP and EP schizophrenia patients and defining its domains, which we compared with currently available patient- and clinician-reported outcome measures (PROMs, CROMs).

METHODS

The three-stage modified Delphi panel consisted of a 1:1 interview round and two online survey rounds involving five expert steering committee and 16 panel members. We conducted a narrative review of the literature in PubMed to identify instruments assessing functioning in people with schizophrenia.

RESULTS

Panelists were presented with 38 statements about functional recovery (definition, domains, and assessment) and approaches to achieving it. Panelists defined functional recovery for FEP and EP schizophrenia patients as a multidimensional state closely related to quality of life. When evaluating functional recovery, panelists agreed that assessing (1) depression, (2) aggressive behavior, (3) social interaction, (4) family functioning, (5) education and/or employment, (6) leisure activities, (7) self-care, and (8) sexual functioning was important. Panelists also agreed that asking patients about self-care and sexual functioning was less critical at every encounter. It was agreed that patients may be said to have reached partial functional recovery if they recovered in some but not all domains. There was consensus that long-acting injectable antipsychotics can facilitate functional recovery by increasing treatment adherence, lessening disease and treatment burden, and reducing functional decline. The literature review identified eight PROMs and CROMs that assess functioning in schizophrenia. However, none evaluated all eight domains of functional recovery.

CONCLUSIONS

Functional recovery is an important treatment goal in FEP and EP patients. PROMs and CROMs do not evaluate all eight domains of functional recovery agreed by the Delphi panel. Further research is needed to better understand and improve how functional recovery is assessed in clinical practice.

An analysis of the clinical application of paliperidone palmitate injection based on real-world

Objective

To analyze the clinical application, adherence and relapse of paliperidone palmitate (PP) injection.

Method

The information of patients treated with PP 1-month (PP1M), patients switching from PP1M to paliperidone palmitate 3-month (PP3M), and the relapse of patients after discharge from 1 January 2021 to 31 December 2023 was retrieved from the electronic medical record system. Descriptive statistics, two-tailed t-test and Chi-Squared test are used to process data.

Results

189 patients were administered with PP1M in this study accounted for 0.88% of all inpatients. 5 (9.09%) patients were switched from risperidone long-acting injection (RLAI) to PP1M. 45 (∼23.81%) patients were switched into PP3M. The patients without relapses were twice than relapsed patients after discharge of 1 year. Patients with initial episodes administered with PP1M showed fewer relapses than patients with non-initial episodes (11.11% vs. 34.72%; a P < 0.05). 75 (39.68%) patients adhering to PP1M or PP3M after discharge showed fewer relapses than patients discontinuing injection (20.00% vs. 35.09%; b P >0.05). Besides, our results showed that the instability of disease and the non-adherence were the main factors contributing to relapse.

Conclusion

The current utilization of PP1M and conversion from PP1M to PP3M is low. Patients with initial episodes with and adhering to PP injection were at lower risk of relapse. Thus, the patients' adherence and the education about PP injections should be improved.

Considerations for Streamlining the Pathway Toward Approval of a Cognition Enhancer for Schizophrenia

Given the difficulties of developing cognitive enhancers for schizophrenia and demonstrating their efficacy, we welcome a review of the measurement procedures and the clinical trial design recommendations developed through the collaboration of academics, industry, National Institute of Mental Health (NIMH), and U.S.A. Food and Drug Administration (FDA) representatives during the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) process. We provide a perspective from investigators who helped to lead the MATRICS initiative. We acknowledge some of the practical challenges in the use of the MATRICS Consensus Cognitive Battery (MCCB) while pointing out that others are overstated. We suggest that a brief MCCB might be used in phase III trials when phase II results had shown no negative impact on any MCCB cognitive domain. The complexities of requiring a functional co-primary measure are discussed. For clinical trial research design to evaluate monotherapies that might have both antipsychotic and cognition-enhancing properties, we agree that the original MATRICS design recommendations may need to be revised, as those recommendations focused on the evaluation of potential adjunctive cognitive enhancers. Horan et al provide a thoughtful summary of the current challenges in obtaining approval for a new drug designed to enhance cognition in schizophrenia.

Barriers and Facilitators to Motivation for Work and School in First Episode Psychosis: A Qualitative Exploration

AIM

Decreased motivation has been found to be the strongest predictor of poor work or school functioning among individuals with psychosis. Since motivation decreases immediately following onset of psychosis, it may be an ideal potential target for intervention. The aim of this study was to explore the specific barriers and facilitators to motivation through experiences of those living with first episode psychosis.

METHOD

A total of 40 individuals recently diagnosed with psychosis and receiving treatment within a coordinated specialty care program completed a semi-structured qualitative interview. Audio recordings were transcribed and independently coded by three reviewers.

RESULTS

Themes emerged regarding barriers to work and school motivation, such as challenging mental health symptoms, discouragement resulting from negative perceptions/experiences, mental health treatment/side effects, uncertainty about the future, pressure of expectations from others, financial and legal concerns, and fear of symptom recurrence. Similarly, participants described several motivational facilitators for work and school including the opinions of others, financial needs and desires, career aspirations, beneficial mental health treatment, positive attitudes about mental illness, desire for autonomy and desire for meaning in daily life.

DISCUSSION

Better understanding of the factors that drive motivation for work and school among those with first episode psychosis may facilitate identification of ways to optimise existing treatments and/or develop more targeted approaches.

Lost and found: dynamics of relationship and employment status over time in people with affective and psychotic spectrum disorders

BACKGROUND

Employment and relationship are crucial for social integration. However, individuals with major psychiatric disorders often face challenges in these domains.

AIMS

We investigated employment and relationship status changes among patients across the affective and psychotic spectrum - in comparison with healthy controls, examining whether diagnostic groups or functional levels influence these transitions.

METHOD

The sample from the longitudinal multicentric PsyCourse Study comprised 1260 patients with affective and psychotic spectrum disorders and 441 controls (mean age ± s.d., 39.91 ± 12.65 years; 48.9% female). Multistate models (Markov) were used to analyse transitions in employment and relationship status, focusing on transition intensities. Analyses contained multiple multistate models adjusted for age, gender, job or partner, diagnostic group and Global Assessment of Functioning (GAF) in different combinations to analyse the impact of the covariates on the hazard ratio of changing employment or relationship status.

RESULTS

The clinical group had a higher hazard ratio of losing partner (hazard ratio 1.46, P < 0.001) and job (hazard ratio 4.18, P < 0.001) than the control group (corrected for age/gender). Compared with controls, clinical groups had a higher hazard of losing partner (affective group, hazard ratio 2.69, P = 0.003; psychotic group, hazard ratio 3.06, P = 0.001) and job (affective group, hazard ratio 3.43, P < 0.001; psychotic group, hazard ratio 4.11, P < 0.001). Adjusting for GAF, the hazard ratio of losing partner and job decreased in both clinical groups compared with controls.

CONCLUSION

Patients face an increased hazard of job loss and relationship dissolution compared with healthy controls, and this is partially conditioned by the diagnosis and functional level. These findings underscore a high demand for destigmatisation and support for individuals in managing their functional limitations.

Cognitive improvements linked to lysophosphatidylethanolamine after olanzapine treatment in drug-naïve first-episode schizophrenia

BACKGROUND

Cognitive impairments are a hallmark symptom of schizophrenia (SCZ). Phosphatidylethanolamine (PE) is the second most abundant phospholipid in mammalian cells, yet its role in cognitive deficits remains unexplored. The aim of this study was to investigate the association between plasma LysoPE and cognitive improvements following olanzapine monotherapy in drug-naïve first-episode (DNFE) SCZ patients.

METHODS

Twenty-five female DNFE SCZ patients were treated with olanzapine for four weeks, and cognitive function was assessed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) at baseline and after the 4-week follow-up. Utilizing an untargeted ultra-performance liquid chromatography-mass spectrometry (UPLC-MS)-based metabolomics approach, we measured LysoPE concentrations.

RESULTS

Significant improvements in immediate and delayed memory domains were observed post-treatment. We identified nine differential LysoPE species after olanzapine monotherapy, with increased concentrations for all LysoPE except LysoPE (22:6). Elevated LysoPE (22:1) concentration positively correlated with cognitive improvement in patients. Baseline LysoPE (16:1) emerged as a predictive factor for cognitive improvement following olanzapine monotherapy.

CONCLUSIONS

This study offers preliminary evidence for the involvement of LysoPE in cognitive improvements observed in drug-naïve first-episode SCZ patients after olanzapine treatment.

Defeatist performance beliefs in individuals with recent-onset schizophrenia: Relationships with cognition and negative symptoms

BACKGROUND

The cognitive model of negative symptoms of schizophrenia suggests that defeatist performance beliefs (DPB), or overgeneralized negative beliefs about one's performance, are an intermediary variable along the pathway from impaired neurocognitive performance to negative symptoms and functioning in daily life. Although reliable associations between these variables have been established in chronic schizophrenia, less is known about the nature of these relationships in recent-onset schizophrenia (ROSz). This current study tested the associations between DPB and variables in the cognitive model (neurocognitive performance, negative symptoms, functioning) as well as mediation by DPB of the association between neurocognitive performance and negative symptoms in ROSz.

METHODS

A total of 52 participants (32 adults with ROSz and 20 non-psychiatric healthy comparators; HC) completed in-lab measures of neurocognitive performance, self-reported defeatist performance beliefs, and clinician administered measures of negative symptoms and functional outcome. Bivariate relationships among these variables were tested with Pearson correlations. Bootstrapped regression analyses were conducted to test the strength of the indirect effect of neurocognitive performance on negative symptoms through DPB.

RESULTS

Defeatist performance beliefs were significantly elevated in ROSz, and were associated with neurocognitive performance, negative symptoms, and functional outcome as predicted by the cognitive model. There was a significant indirect effect of neurocognition on experiential negative symptoms through DPB, indicating DPB are a partial mediator of the relationship between neurocognitive performance and negative symptoms.

CONCLUSION

These findings are consistent with the cognitive model of negative symptoms and extend previous findings in both ROSz and established schizophrenia. Specifically, these data demonstrate that DPB are elevated among ROSz and the associations with neurocognition and clinical outcomes (e.g., negative symptoms and functioning) are of similar magnitude to those reported in chronic schizophrenia. DPB may therefore be a viable treatment target in the early course of illness.

In-Hospital Use of Long-Acting Injectable Antipsychotics and Readmission Risk in Patients With First-Admission Schizophrenia in Taiwan

Importance

Long-acting injectable antipsychotics (LAIs) can help decrease the rate of nonadherence to medications in patients with schizophrenia, but these drugs are underutilized in clinical practice, especially in Asian countries. One strategy for the early prescription of LAIs is to administer the drugs during patients' first admission, when they have more time to absorb medication-related knowledge.

Objective

To estimate the prevalence of and risk factors for in-hospital use of LAIs among first-admission patients with schizophrenia in Taiwan and to examine the association of early discontinuation with readmission risk among patients receiving LAIs.

Design, Setting, and Participants

This cohort study included data from a claims database for patients with a first admission for schizophrenia at psychiatric wards in Taiwan from 2004 to 2017. Eligible patients were diagnosed with schizophrenia or schizoaffective disorder at discharge and aged between 15 and 64 years. Data analysis was performed from April to September 2022.

Exposure

In-hospital use of LAIs with or without early discontinuation.

Main Outcome and Measures

Readmission for any psychotic disorder following discharge from first admission, with risk estimated via multivariable survival regression analysis, including the Cox proportional hazards (CPH) model and accelerated failure time (AFT) model.

Results

Of the 56 211 patients with a first admission for schizophrenia (mean [SD] age, 38.1 [12.1] years; 29 387 men [52.3%]), 46 875 (83.4%) did not receive any LAIs during admission, 5665 (10.1%) received LAIs with early discontinuation, and 3671 (6.5%) received LAIs without early discontinuation. The prevalence of receiving LAIs increased by 4%, from 15.3% (3863 of 25 251 patients) to 19.3% (3013 of 15 608 patients) between 2004-2008 and 2013-2017. After controlling for sex, year, prior antipsychotic use, age at first admission, and length of stay, the CPH regression analysis revealed that the readmission risk increased among patients receiving LAIs with early discontinuation (adjusted hazard ratio [aHR], 1.25; 95% CI, 1.21-1.30) but decreased among patients receiving LAIs without early discontinuation (aHR, 0.88; 95% CI, 0.84-0.92) compared with patients not receiving LAIs. Results remained similar for the AFT model.

Conclusions and Relevance

The incidence of in-hospital use of LAIs among patients with a first admission for schizophrenia has remained low. In this study, early discontinuation of LAIs was associated with readmission risk-specifically, early discontinuation with a higher risk while the lack of early discontinuation with a lower risk compared with treatment with oral antipsychotics alone-which suggests our results have implications for improving the efficacy of LAI administration among patients with a first admission for schizophrenia.

Adherence, health care utilization, and costs between long-acting injectable and oral antipsychotic medications in South Carolina Medicaid beneficiaries with schizophrenia

BACKGROUND

Schizophrenia and schizoaffective disorder require long-term antipsychotic treatment with antipsychotic medications, but poor medication adherence can lead to increased health care utilization and costs. Long-acting injectable antipsychotics (LAIs) offer potential therapeutic advantages in that they require less frequent dosing and improved medication adherence. South Carolina has the highest adoption of LAIs among US states, making it an ideal population for comparing the effectiveness of LAIs vs oral antipsychotics (OAPs) in treating schizophrenia or schizoaffective disorder.

OBJECTIVE

To evaluate the effect of LAIs compared with OAPs on medication adherence, health care resource utilization, and costs among South Carolina Medicaid beneficiaries with schizophrenia or schizoaffective disorder.

METHODS

South Carolina Medicaid beneficiaries with at least 1 claim for an LAI or OAP between January 1, 2015, and December 31, 2018, aged 18 to 65, with at least 2 claims with diagnoses of schizophrenia or schizoaffective disorder were included. Propensity scores (PSs) were calculated using logistic regression adjusting for confounders and predictors of the outcome. We estimated the "average treatment effect on the treated" by employing PS-weighted t-tests and chi-square tests.

RESULTS

A total of 3,531 patients met the inclusion criteria, with 1,537 (44.5%) treated with LAIs and 1,994 (56.5%) treated with OAPs. In PS-weighted analyses, the LAI cohort had a greater proportion of days covered than the OAP cohort with a 365-day fixed denominator (69% vs 64%; P < 0.0001), higher medication possession ratio with a variable denominator while on therapy (85% vs 80%; P < 0.0001), and higher persistence (82% vs 64%; P < 0.0001). The average number of inpatient visits and emergency department visits did not significantly differ between cohorts (0.28 hospitalizations, P = 0.90; 3.68 vs 2.96 emergency department visits, P = 0.19). The number of outpatient visits, including visits for medication administration, were greater in the LAI cohort (23.1 [SD 24.2]) vs OAP (16.9 [SD 21.2]; P < 0.0001); however, including the costs for medication administration visits, outpatient costs (per member) were approximately $2,500 lower in the LAI cohort (P < 0.0001). The number of pharmacy visits was greater in the OAP cohort (LAI 21.0 [SD 17.0] vs OAP 23.0 [SD 15.0]; P = 0.006). All-cause total costs were greater in the LAI cohort ($26,025 [SD $29,909]) vs the OAP cohort ($17,291 [SD $25,261]; P < 0.0001) and were driven by the difference in pharmaceutical costs (LAI $15,273 [SD $16,183] vs OAP $4,696 [SD $10,371]; P < 0.0001).

CONCLUSIONS

Among South Carolina Medicaid beneficiaries, treatment with LAIs for schizophrenia or schizoaffective disorder was associated with greater medication adherence rates. Patients using LAIs had higher drug costs and total costs, but lower outpatient and total nondrug costs compared with those using OAPs.

Intrinsic motivation predicts cognitive and functional gains during coordinated specialty care for first-episode schizophrenia

Coordinated Specialty Care (CSC) and embedded group therapeutic interventions have been effective in improving outcomes for individuals experiencing recent first-episode schizophrenia, including cognitive performance and functioning. Treatment response varies substantially, with some patients experiencing limited or no improvement. Motivation has emerged as a key determinant of treatment engagement and efficacy. However, the impact of intrinsic and extrinsic aspects of motivation has not been directly examined with treatment outcomes in first-episode schizophrenia. This study investigated whether baseline levels of intrinsic and extrinsic motivation predicted cognitive and functional gains over 6 and 12 months in CSC. Forty participants with first-episode schizophrenia completed a 12-month CSC treatment period. Baseline measures of intrinsic and extrinsic motivation were obtained for group therapeutic interventions and work/school, as well as measures of cognition and functioning (role and social) at baseline, 6 months, and 12 months. Results revealed that higher baseline scores of intrinsic motivation for group therapeutic interventions were significantly predictive of greater cognitive gains at 12 months, and a similar tendency was observed at 6 months. Additionally, baseline scores of intrinsic motivation for work/school predicted role gains at 6 months, with a similar tendency observed at 12 months. Extrinsic motivation did not consistently impact treatment outcomes, except for work/school-related extrinsic motivation, which was linked to greater social functioning gains at 12 months. These findings provide insight into the factors influencing treatment outcomes for individuals with first-episode schizophrenia and highlight the importance of intrinsic motivation as a modifiable personal variable that can enhance response to CSC.

Developmental trajectories of premorbid functioning predict cognitive remediation treatment response in first-episode schizophrenia

BACKGROUND

Cognitive development after schizophrenia onset can be shaped by interventions such as cognitive remediation, yet no study to date has investigated whether patterns of early behavioral development may predict later cognitive changes following intervention. We therefore investigated the extent to which premorbid adjustment trajectories predict cognitive remediation gains in schizophrenia.

METHODS

In a total sample of 215 participants (170 first-episode schizophrenia participants and 45 controls), we classified premorbid functioning trajectories from childhood through late adolescence using the Cannon-Spoor Premorbid Adjustment Scale. For the 62 schizophrenia participants who underwent 6 months of computer-assisted, bottom-up cognitive remediation interventions, we identified MATRICS Consensus Cognitive Battery scores for which participants demonstrated mean changes after intervention, then evaluated whether developmental trajectories predicted these changes.

RESULTS

Growth mixture models supported three premorbid functioning trajectories: stable-good, deteriorating, and stable-poor adjustment. Schizophrenia participants demonstrated significant cognitive remediation gains in processing speed, verbal learning, and overall cognition. Notably, participants with stable-poor trajectories demonstrated significantly greater improvements in processing speed compared to participants with deteriorating trajectories.

CONCLUSIONS

This is the first study to our knowledge to characterize the associations between premorbid functioning trajectories and cognitive remediation gains after schizophrenia onset, indicating that 6 months of bottom-up cognitive remediation appears to be sufficient to yield a full standard deviation gain in processing speed for individuals with early, enduring functioning difficulties. Our findings highlight the connection between trajectories of premorbid and postmorbid functioning in schizophrenia and emphasize the utility of considering the lifespan developmental course in personalizing therapeutic interventions.

The relationship between sex and functional outcome in first-episode schizophrenia: the role of premorbid adjustment and insight

BACKGROUND

Studies that examined sex differences in first-episode patients consistently show that males compared to females have poor premorbid adjustment, earlier age of onset, worse clinical characteristics, and poorer outcomes. However, little is known about potential mediators that could explain these sex differences.

METHODS

Our sample consisted of 137 individuals with first episode schizophrenia (males, n = 105; 77%) with a mean age of 22.1(s.d. = 4.1) years and mean education of 12.5(s.d. = 1.7) years. At entry, patients were within 2 years of their first psychotic episode onset. Baseline assessments were conducted for premorbid adjustment, symptoms, cognitive functioning, insight, and at 6-months for role and social functioning.

RESULTS

Males as compared to females had poorer premorbid adjustment across several key developmental periods (p < 0.01), an earlier age of onset [M = 20.3(3.3) v. 22.8(5.6), p = 0.002], more negative symptoms (p = 0.044), poorer insight (p = 0.031), and poorer baseline and 6-month role (p = 0.002) and social functioning (p = 0.034). Several of these variables in which males showed impairment were significant predictors of 6-month role and social functioning. Premorbid adjustment and insight mediated the relationship between sex and role and social functioning at 6-months, but not negative symptoms.

DISCUSSION

Males compared to females were at lower levels across several key premorbid and clinical domains which are strongly associated with functional outcome supporting the hypothesis that males might have a more disabling form of schizophrenia. The relationship between sex with role and social functioning was mediated through premorbid adjustment and insight suggesting pathways for understanding why females might have a less disabling form of schizophrenia.

Aerobic exercise enhances cognitive training effects in first-episode schizophrenia: randomized clinical trial demonstrates cognitive and functional gains

BACKGROUND

Cognitive training (CT) and aerobic exercise both show promising moderate impact on cognition and everyday functioning in schizophrenia. Aerobic exercise is hypothesized to increase brain-derived neurotrophic factor (BDNF) and thereby synaptic plasticity, leading to increased learning capacity. Systematic CT should take advantage of increased learning capacity and be more effective when combined with aerobic exercise.

METHODS

We examined the impact of a 6-month program of cognitive training & exercise (CT&E) compared to cognitive training alone (CT) in 47 first-episode schizophrenia outpatients. All participants were provided the same Posit Science computerized CT, 4 h/week, using BrainHQ and SocialVille programs. The CT&E group also participated in total body circuit training exercises to enhance aerobic conditioning. Clinic and home-based exercise were combined for a target of 150 min per week.

RESULTS

The MATRICS Consensus Cognitive Battery Overall Composite improved significantly more with CT&E than with CT alone (p = 0.04), particularly in the first 3 months (6.5 v. 2.2 T-score points, p < 0.02). Work/school functioning improved substantially more with CT&E than with CT alone by 6 months (p < 0.001). BDNF gain tended to predict the amount of cognitive gain but did not reach significance. The cognitive gain by 3 months predicted the amount of work/school functioning improvement at 6 months. The amount of exercise completed was strongly associated with the degree of cognitive and work/school functioning improvement.

CONCLUSIONS

Aerobic exercise significantly enhances the impact of CT on cognition and functional outcome in first-episode schizophrenia, apparently driven by the amount of exercise completed.

Acceptability of cognitive remediation for schizophrenia: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Acceptability is an important factor for predicting intervention use and potential treatment outcomes in psychosocial interventions. Cognitive remediation (CR) improves cognition and functioning in people with a diagnosis of schizophrenia, but its acceptability, and the impact of participants and treatment characteristics, remain to be investigated. Few studies provide a direct measure of acceptability, but treatment drop-out rates are often available and represent a valid surrogate.

METHOD

The systematic search conducted for the most comprehensive CR outcomes database for schizophrenia was updated in December 2020. Eligible studies were randomized clinical trials comparing CR with any other control condition in patients diagnosed with schizophrenia spectrum disorders and that also reported drop-out in treatment and control arms separately. Acceptability was measured as odd-ratios (OR) of drop-out.

RESULTS

Of 2119 identified reports, 151 studies, reporting 169 comparisons between CR and control interventions with 10 477 participants were included in the analyses. The overall rate of drop-out was 16.58% for CR programs and 15.21% for control conditions. In the meta-analysis, no difference emerged between CR interventions and controls [OR 1.10, 95% confidence interval (CI) 0.96-1.25, p = 0.177]. Factors improving acceptability were: inpatient only recruitment, participants with fewer years of education and lower premorbid IQ, the presence of all CR core elements, and the presence of techniques to transfer cognitive gains into real-world functioning.

CONCLUSIONS

CR for people diagnosed with schizophrenia is effective and has a good acceptability profile, similar to that of other evidence-based psychosocial interventions.

A meta-analysis of cognitive interventions for patients with recent onset psychosis: are they effective for improving functioning?

The increasing popularity of cognitive interventions for patients with psychosis calls for further exploration on how these interventions may benefit functional outcomes. We conducted a meta-analysis of randomized controlled trials (RCTs) to examine the effectiveness of cognitive interventions (i.e. Cognitive Remediation, Cognitive Training, Social Cognition, and their combination) on functioning of patients with recent onset psychosis, established as the period within the first five years from the first episode. The following databases were searched: Proquest, PUBMED/MEDLINE, PsycINFO, WOS, Scopus for research published until January 2022. In total, 12 studies were eligible. The total number of participants was 759, of which 32.2% in the intervention and 30.8% in the control group were female. We extracted data to calculate the standardized mean change from pre-test to post-test comparing the intervention with the control conditions. Overall, there was no effect of any of the cognitive intervention types on functioning. None of the examined factors (intervention type, length, and modality; control condition, follow-up time; cognitive functions; medication; symptoms) seemed to moderate these findings. Our results indicate that cognitive interventions as standalone interventions do not appear to improve functioning in patients with recent onset psychosis. Given the small number of eligible studies, further RCTs with larger and more refined samples are needed to test whether these interventions should be applied as single interventions with these patients.

Cognitive Remediation Works But How Should We Provide It? An Adaptive Randomized Controlled Trial of Delivery Methods Using a Patient Nominated Recovery Outcome in First-Episode Participants

BACKGROUND AND HYPOTHESIS

Cognitive remediation (CR) benefits cognition and functioning in psychosis but we do not know the optimal level of therapist contact, so we evaluated the potential benefits of different CR modes.

STUDY DESIGN

A multi-arm, multi-center, single-blinded, adaptive trial of therapist-supported CR. Participants from 11 NHS early intervention psychosis services were independently randomized to Independent, Group, One-to-One, or Treatment-as-usual (TAU). The primary outcome was functional recovery (Goal Attainment Scale [GAS]) at 15-weeks post randomization. Independent and TAU arms were closed after an interim analysis, and three informative contrasts tested (Group vs One-to-One, Independent vs TAU, Group + One-to-One vs TAU). Health economic analyses considered the cost per Quality Adjusted Life Year (QALY). All analyses used intention-to-treat principles.

STUDY RESULTS

We analyzed 377 participants (65 Independent, 134 Group, 112 One-to-One, 66 TAU). GAS did not differ for Group vs One-to-One: Cohen's d: 0.07, -0.25 to 0.40 95% CI, P = .655; Independent vs TAU: Cohen's d: 0.07, -0.41 to 0.55 95% CI, P = .777. GAS and the cognitive score improved for Group + One-to-One vs TAU favoring CR (GAS: Cohen's d: 0.57, 0.19-0.96 95% CI, P = .003; Cognitive score: Cohens d: 0.28, 0.07-0.48 95% CI, P = .008). The QALY costs were £4306 for Group vs TAU and £3170 for One-to-One vs TAU. Adverse events did not differ between treatment methods and no serious adverse events were related to treatment.

CONCLUSIONS

Both active therapist methods provided cost-effective treatment benefiting functional recovery in early psychosis and should be adopted within services. Some individuals benefited more than others so needs further investigation.

TRIAL REGISTRATION

ISRCTN14678860 https://doi.org/10.1186/ISRCTN14678860Now closed.

Efficacy and safety of prophylactic use of benzhexol after risperidone treatment

To test the effect of prophylactic use of benzhexol in schizophrenia patients after risperidone treatment. Sixty-nine drug naïve schizophrenia patients were recruited. All patients were administered risperidone. Patients in the benzhexol group were given a benzhexol tablet of 2 mg bid daily. The controls received a placebo tablet of 2 mg bid daily. The primary outcome measured using the Extrapyramidal Symptoms Rating Scale (ESRS). The Positive and Negative Syndrome Scale (PANSS) and the Brief Psychiatric Rating Scale (BPRS) measured secondary outcome. There were significant time and group effects on the ESRS scores of the two groups. The post hoc analysis yielded significant differences at 1, 2, 4, and 8 weeks between the two groups. There was a significant time effect on the PANSS scores of the two groups. No significant group and interaction effects on the PANSS scores of the two groups. There was a significant time effect on the BPRS scores of the two groups. No serious adverse events were found in this study. Prophylactic use of benzhexol reduced extrapyramidal symptom in schizophrenia patients after risperidone treatment and did not affect the antipsychotic action of risperidone.

Technology and Mental Health: State of the Art for Assessment and Treatment

Technology is ubiquitous in society and is now being extensively used in mental health applications. Both assessment and treatment strategies are being developed and deployed at a rapid pace. The authors review the current domains of technology utilization, describe standards for quality evaluation, and forecast future developments. This review examines technology-based assessments of cognition, emotion, functional capacity and everyday functioning, virtual reality approaches to assessment and treatment, ecological momentary assessment, passive measurement strategies including geolocation, movement, and physiological parameters, and technology-based cognitive and functional skills training. There are many technology-based approaches that are evidence based and are supported through the results of systematic reviews and meta-analyses. Other strategies are less well supported by high-quality evidence at present, but there are evaluation standards that are well articulated at this time. There are some clear challenges in selection of applications for specific conditions, but in several areas, including cognitive training, randomized clinical trials are available to support these interventions. Some of these technology-based interventions have been approved by the U.S. Food and Drug administration, which has clear standards for which types of applications, and which claims about them, need to be reviewed by the agency and which are exempt.

The MATRICS Consensus Cognitive Battery: An Update

Through a series of NIMH-supported consensus-building meetings of experts and empirical comparisons of candidate tests, the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative developed a battery of standardized cognitive measures to allow reliable evaluation of results from clinical trials of promising interventions for core cognitive deficits in this disorder. Ten tests in seven cognitive domains were selected for the MATRICS Consensus Cognitive Battery (MCCB). The MCCB has now been translated into 39 languages/dialects and has been employed in more than 145 clinical trials. It has become the standard cognitive change measure for studies of both pharmacological and training-based interventions seeking to improve cognitive deficits in schizophrenia. We summarize its applications and its relationship to the subsequent development of the NIMH RDoC Matrix.

Cognitive Remediation in Psychiatric Disorders: State of the Evidence, Future Perspectives, and Some Bold Ideas

Many people with psychiatric disorders experience impairments in cognition. These deficits have a significant impact on daily functioning and sometimes even on the further course of their disease. Cognitive remediation (CR) is used as an umbrella term for behavioral training interventions to ameliorate these deficits. In most but not all studies, CR has proven effective in improving cognition and enhancing everyday functional outcomes. In this paper, after quickly summarizing the empirical evidence, practical advice to optimize the effects of CR interventions is provided. We advocate that CR interventions should be as fun and motivating as possible, and therapists should at least consider using positively toned emotional stimuli instead of neutral stimuli. Participants should be screened for basic processing deficits, which should be trained before CR of higher-order cognitive domains. CR should stimulate metacognition and utilize natural settings to invoke social cognition. Wherever possible, CR tasks should link to tasks that participants face in their everyday life. Therapists should consider that participants might also benefit from positive side effects on symptomatology. Finally, the CR approach might even be utilized in settings where the treatment of cognitive impairments is not a primary target.

Population Pharmacokinetic Modeling and Simulation of TV-46000: A Long-Acting Injectable Formulation of Risperidone

TV‐46000 is a long‐acting subcutaneous antipsychotic that uses a novel copolymer drug delivery technology in combination with a well‐characterized molecule, risperidone, that is in clinical development as a treatment for schizophrenia. A population pharmacokinetic (PPK) modeling and simulation approach was implemented to identify TV‐46000 doses and dosing schedules for clinical development that would provide the best balance between clinical efficacy and safety. The PPK model was created by applying pharmacokinetic data from a phase 1 study of 97 patients with a diagnosis of schizophrenia or schizoaffective disorder who received either single or repeated doses of TV‐46000. The PPK model was used to characterize the complex release profile of the total active moiety (TAM; the sum of the risperidone and 9‐OH risperidone concentrations) concentration following subcutaneous injections of TV‐46000. The PK profile was best described by a double Weibull function of the in vivo release rate and by a 2‐compartment disposition and elimination model. Simulations were performed to determine TV‐46000 doses and dosing schedules that maintained a median profile of TAM concentrations similar to published TAM exposure following oral risperidone doses that have been correlated to a 40% to 80% dopamine‐D2 receptor occupancy therapeutic window. The simulations showed that therapeutic dose ranges for TV‐46000 are 50 to 125 mg for once‐monthly and 100 to 250 mg for the once every 2 months regimens. This PPK model provided a basis for prediction of patient‐specific exposure and dopamine‐D2 receptor occupancy estimates to support further clinical development and dose selection for the phase 3 studies.

Evidence-Based Expert Consensus Regarding Long-Acting Injectable Antipsychotics for Schizophrenia from the Taiwanese Society of Biological Psychiatry and Neuropsychopharmacology (TSBPN)

OBJECTIVE

Schizophrenia is a chronic, debilitating psychiatric disorder with a high risk of relapse. Nonadherence to medication is a significant contributor to poor outcomes. Although long-acting injectable (LAI) antipsychotics prevent the relapse of schizophrenia, several factors present obstacles to the use of LAI antipsychotics, and clinical guidelines for LAI antipsychotics remain limited. To provide clinical recommendations, the Taiwanese Society of Biological Psychiatry and Neuropsychopharmacology (TSBPN) developed consensus statements for the effectiveness, target populations, initiation timing, and particular clinical situations for the use of LAI antipsychotics in patients with schizophrenia.

METHODS

After a systematic literature review, a working group drafted consensus statements for the selected clinical topics and determined the levels of evidence-based recommendation based on the latest World Federation of Societies of Biological Psychiatry grading system. A scientific committee evaluated the draft statements and decided the final recommendations regarding the grades by anonymous voting after incorporating clinical experience and practice into the evidence from research.

RESULTS

The TSBPN proposed ten consensus statements for the application of LAI antipsychotics. The current evidence supported that LAI antipsychotics could be a treatment option for all schizophrenia patients, including first-episode patients. LAI antipsychotics could be initiated both during an acute psychotic episode and when patients are stable. The consensus also gave recommendations for particular clinical situations with insufficient scientific data, such as for use in elderly or adolescent patients, patients with treatment-resistant schizophrenia, and breakthrough psychosis, and strategies to assist patients/caregivers with decision making.

CONCLUSIONS

The consensus statements developed by the TSBPN provide evidence-based clinical recommendations and could give clinicians more confidence when prescribing LAI antipsychotics to treat schizophrenia, thereby improving treatment outcomes.

Cognitive heterogeneity in first-episode psychosis and its relationship with premorbid developmental adjustment

BACKGROUND

Patients with schizophrenia spectrum disorders have been increasingly recognised to form cognitive subgroups with differential levels of impairment. Using cluster analytical techniques, this study sought to identify cognitive clusters in a sample of first-episode psychosis (FEP) patients and examine clinical and developmental differences across the resultant groups.

METHODS

In total, 105 FEP patients in the University of California Los Angeles Aftercare Research Program were assessed for cognition, symptoms and premorbid developmental adjustment. Hierarchical cluster analysis with Ward's method and squared Euclidean distance was conducted, confirmed by discriminant function analysis and optimised with k-means clustering. The stability of the solution was evaluated through split-sample (random, 80 and 70% samples) and alternate method (average linkage method) replication via Cohen's κ analysis. Controlling for multiple comparisons, one-way analysis of variances examined group differences in symptom severity and premorbid adjustment.

RESULTS

Three groups were identified: severely impaired (n = 27), moderately impaired (n = 41) and relatively intact (n = 37). There were no significant differences in symptom severity across the groups. Significant differences were observed for scholastic performance at three different developmental stages: childhood, early adolescence and late adolescence, with the relatively intact group demonstrating significantly better scholastic performance at all three stages than both the moderately impaired and severely impaired groups (who did not significantly differ from each other).

CONCLUSIONS

The findings add to growing evidence that cognitive clusters in FEP mirror that of later-stage schizophrenia. They also suggest that premorbid scholastic performance may not just be a risk factor for developing schizophrenia, but is also related to cognitive impairment severity and potentially to prognosis.

Shaping therapeutic trajectories in mental health: Instructive vs. permissive causality

We are currently facing the challenge of improving treatments for psychiatric disorders such as major depression. Notably, antidepressants have an incomplete efficacy, mostly due to our limited knowledge of their action. Here we present a theoretical framework that considers the distinction between instructive and permissive causality, which allows formalizing and disentangling the effects exerted by different therapeutic strategies commonly used in psychiatry. Instructive causality implies that an action determines a specific effect while permissive causality allows an action to take effect or not. We posit that therapeutic strategies able to improve the quality of the living environment or the ability to face it, including changes in lifestyle and psychotherapeutic interventions, rely mainly on instructive causality and thus shape the individual's ability to face the psychopathology and build resilience. By contrast, pharmacological treatments, such as selective serotonin reuptake inhibitors, act primarily through a permissive causality: they boost neural plasticity, i.e. the ability of the brain to change itself, and therefore allow for instructive interventions to produce beneficial effects or not. The combination of an instructive and a permissive action represents the most promising approach since the quality of the living environment can shape the path leading to mental health while drug treatment can increase the likelihood of achieving such a goal.