Social Cognition Training for People With a Psychotic Disorder: A Network Meta-analysis

Social cognitive training among individuals with schizophrenia: Identifying responders to treatment

In this follow-up study of a previous randomized controlled trial of targeted facial affect recognition training among individuals with schizophrenia, reliable change indices (RCIs) were employed to identify responders to treatment. The original study found improved theory of mind at 3-month follow-up. The current study included 15 participants who received the intervention and who completed all three assessment points in the original study. Six of them had RCIs over the cutoff (≥+1.64), indicating that they had a clinically meaningful and statistically reliable improvement in ToM. The responders had significantly higher psychotic symptom level at baseline, but no other group differences between responders and nonresponders were identified. The study found no support for suggested moderators of treatment effect of social cognitive training (sex, education). As no consistently replicated barriers to treatment gains have been identified, we suggest that social cognitive training, where available, should be offered to interested clients.

Predicting emotions across schizotypy levels

Successfully navigating the social world requires making accurate predictions about others. Individual differences in emotion prediction-the ability to predict someone's subsequent emotion given their current emotional state-can lead to variability in social success. In this study (N = 1024) we found evidence that individuals with heightened schizotypy displayed worse emotion prediction accuracy. This difficulty with emotion prediction was associated with increased loneliness, diminished social support, and smaller social networks, partially mediating some of the social difficulties in individuals with heightened schizotypy. Individuals with heightened schizotypy showed disruptions to key sources of affective information, meaning they had less reliable information about how emotions work when making emotion predictions. Specifically, their own emotion experiences were less typical, and their perception of others' emotions was less accurate. These findings highlight emotion prediction as a key social cognitive construct that should be considered in future research for individuals across the schizophrenia spectrum.

Efficacy of integrated social cognitive remediation vs neurocognitive remediation in schizophrenia: Results from the multicenter randomized controlled ISST (Integrated Social Cognition And Social Skills Therapy) study

INTRODUCTION

Persistent poor psychosocial functioning, which is associated with impairments in cognition, is one of the main barriers to recovery in schizophrenia. Although cognitive remediation therapy (CRT) has shown general efficacy in improving cognition and functioning, simultaneously focusing on social cognition and social behavioural processes may increase its efficacy.

METHODS

In a multicenter, rater-blinded, randomized controlled trial, schizophrenia patients (N = 177) were assigned to six months of either Integrated Social Cognitive and Behavioral Skills Therapy (ISST) or, as an active control intervention, Neurocognitive Remediation Therapy (NCRT). The primary endpoint was all-cause discontinuation (ACD) over the 12-month study period. Secondary endpoints were cognition, psychosocial functioning and quality of life, and clinical symptoms.

RESULTS

ACD was not significantly different between the ISST and NCRT groups (43.3 % vs 34.5 %, respectively). More improvement was seen in social cognition (Pictures of Facial Affect; d = 0.83) in the ISST group and in neurocognition (subscores of the Auditory Verbal Learning Test; d = 0.29-0.40) in the NCRT group. Level of functioning, quality of life, and clinical symptoms significantly improved in both groups, with no significant between-group differences.

DISCUSSION

Both therapies differentially improved measures of the cognitive domains they were designed for. Moreover, they both improved social functioning with high effect sizes (d = 0.8-1.0), underlining the important role of CRT in recovery-oriented schizophrenia treatment. However, the absence of a third group without an active intervention limits the interpretability of the results.

Interpersonal synchronization: An overlooked factor in development, social cognition, and psychopathology

Intact social functioning relies on a combination of explicit and implicit behavioral, attentional, and interpersonal processes referred to as "social cognition". Characterizing these interpersonal processes forms a critical underpinning to understanding and treating psychopathology, particularly in disorders where deficits in social functioning do not emerge as a secondary symptom but rather as an essential feature of the disorder. Two of such disorders are autism spectrum disorders (ASD) and schizophrenia spectrum disorders (SZ). However, despite the substantial overlap in the features of social dysfunction between ASD and SZ, including social cognitive deficits in theory of mind, perspective-taking, and empathy, there is a limited understanding of the mechanisms underlying those shared deficits, and how to treat them. We suggest that disruptions of interpersonal functioning emerge over the course of development, and that interpersonal synchronization, a phenomenon in which behavioral and physiological cues align between interacting partners, forms a critical component of social cognition that underlies the disruption in social functioning in ASD and SZ. We present a conceptual review of typical and atypical development of social processes and highlight the role of interpersonal synchronization across the course of development. Then, we review the existing evidence suggesting impairments in both the intentional and spontaneous synchronization of interpersonal processes in ASD and SZ, as well as studies suggesting that interpersonal synchronization and clinical symptoms may be improved through body-oriented interventions within these disorders. Finally, we suggest potential mechanisms that may underpin typical and atypical development of interpersonal synchronization.

International perspective on social cognition in schizophrenia: current stage and the next steps

In the last decades, research from cognitive science, clinical psychology, psychiatry, and social neuroscience has provided mounting evidence that several social cognitive abilities are impaired in people with schizophrenia and contribute to functional difficulties and poor clinical outcomes. Social dysfunction is a hallmark of the illness, and yet, social cognition is seldom assessed in clinical practice or targeted for treatment. In this article, 17 international experts, from three different continents and six countries with expertise in social cognition and social neuroscience in schizophrenia, convened several meetings to provide clinicians with a summary of the most recent international research on social cognition evaluation and treatment in schizophrenia, and to lay out primary recommendations and procedures that can be integrated into their practice. Given that many extant measures used to assess social cognition have been developed in North America or Western Europe, this article is also a call for researchers and clinicians to validate instruments internationally and we provide preliminary guidance for the adaptation and use of social cognitive measures in clinical and research evaluations internationally. This effort will assist promoting scientific rigor, enhanced clinical practice, and will help propel international scientific research and collaboration and patient care.

Examining the impact of a group treatment using cognitive and social cognition remediation for young offenders: The justice health NSW school-link advantage pilot study

AIM

Young offenders experience higher rates of neurodevelopmental and mental health disorders than the general population, and significant access barriers to health treatment. Treatment combining Cognitive Remediation Therapy (CRT) and Social Cognition Remediation Therapy (SCRT) has demonstrated benefits for functional improvements and social development. However, there is limited information regarding group treatment programs in custodial settings for young offenders. This pilot study explores the effectiveness and feasibility of a group treatment program for youth offenders with cognitive deficits and mental health concerns in youth detention.

METHODS

The School-Link Advantage pilot study designed and tested a 10-week group treatment program combining CRT and SCRT for young offenders in custody. The closed groups incorporated interactive activities focussed on emotional recognition and regulation skills, optimizing executive functioning, understanding values, exploring belief systems, improving relationships, and safety planning.

RESULTS

Of the 22 male participants recruited in an Australian Youth Justice Centre, 12 completed all aspects of the treatment program, reflecting a 54.5% completion rate in a typically challenging to engage population cohort. Results demonstrated significant improvements in the ability to store and retrieve information, recognize information, and control emotions. Planning and organizing skills also showed considerable development.

CONCLUSIONS

This pilot study suggests that a combined CRT and SCRT group treatment program has the potential to effectively target cognitive challenges associated with mental health disorders in young offenders in custody. These promising outcomes suggest exploring randomized controlled trials with increased cultural sensitivity for diverse populations.

Autism-spectrum quotient mediates the relationship between clinical symptoms and quality of life in schizophrenia

BACKGROUND

Social dysfunctions can affect the quality of life (QOL) of patients with schizophrenia. The autism-spectrum quotient (AQ) is a widely used measure of innate autistic traits. However, in patients with schizophrenia, the score may represent the severity of autism-like social dysfunctions as a consequence of symptoms. We tested the hypothesis that AQ would mediate the relationship between clinical symptoms and QOL in patients with schizophrenia, based on the assumption that the AQ measures autism-like social dysfunctions rather than autistic traits in this population.

METHODS

We analyzed data from 108 outpatients with schizophrenia. The relationships among the scores on the Positive and Negative Syndrome Scale (PANSS), the Schizophrenia Quality of Life Scale (SQLS), and the AQ were examined using structural equation modeling (SEM).

RESULTS

Path analyses of the total scale scores revealed partial mediation, but not full mediation or independent effects. However, both the AQ and PANSS scores could be mediators. SEM including the three domain scores of PANSS, the two factors of the AQ, and the three subscale scores of the SQLS showed a good fit of the AQ mediation model, but not the symptom mediation model, supporting our hypothesis. In this final model, the relationship between negative symptoms and QOL was mediated by autism-like social dysfunctions, whereas positive symptoms directly affected QOL.

CONCLUSIONS

Our findings advance our understanding of what the AQ measures when applied to patients with schizophrenia and suggest that autism-like social dysfunctions are important treatment targets for improving QOL in this population.

Effectiveness of a social cognition remediation intervention for patients with schizophrenia: a randomized-controlled study

This randomized-controlled study evaluates the effectiveness of a newly developed social cognition rehabilitation intervention, the modified Social Cognition Individualized Activity Lab (mSoCIAL), in improving social cognition and clinical and functional outcomes of persons with schizophrenia recruited in two Italian sites: University of Campania "Luigi Vanvitelli" in Naples and ASST Fatebenefratelli-Sacco in Milan. mSoCIAL consists of a social cognitive training module focusing on different domains of social cognition and of a narrative enhancement module. We assessed changes in social cognition, clinical characteristics and functional variables in patients with schizophrenia who participated in 10 weekly sessions of mSoCIAL or received treatment as usual (TAU). A paired-sample t test and a repeated-measures MANOVA were used to investigate respectively within and between-group differences. Twenty people with schizophrenia were blindly assigned to mSoCIAL and 20 to TAU. After 10 weeks, mSoCIAL significantly improved disorganization, emotion recognition, functional capacity and real-life functioning. As compared to TAU, the mSoCIAL group showed a significant improvement in minimal and enriched social inference domain of theory of mind, and in key domains of real-life functioning (interpersonal relationships, everyday life skills, and work skills). mSoCIAL improved social cognition and real-life functioning of people with schizophrenia. These results highlight the importance of social cognition deficit treatment in schizophrenia and the necessity for these interventions to be multifaced and personalized. Such an approach ensures that improvements in social cognition translate into enhanced functional outcomes.Trial registration NCT05130853, registered on 24 November 2021.

Delivery of Neuropsychological Interventions for Adult and Older Adult Clinical Populations: An Australian Expert Working Group Clinical Guidance Paper

Delivery of neuropsychological interventions addressing the cognitive, psychological, and behavioural consequences of brain conditions is increasingly recognised as an important, if not essential, skill set for clinical neuropsychologists. It has the potential to add substantial value and impact to our role across clinical settings. However, there are numerous approaches to neuropsychological intervention, requiring different sets of skills, and with varying levels of supporting evidence across different diagnostic groups. This clinical guidance paper provides an overview of considerations and recommendations to help guide selection, delivery, and implementation of neuropsychological interventions for adults and older adults. We aimed to provide a useful source of information and guidance for clinicians, health service managers, policy-makers, educators, and researchers regarding the value and impact of such interventions. Considerations and recommendations were developed by an expert working group of neuropsychologists in Australia, based on relevant evidence and consensus opinion in consultation with members of a national clinical neuropsychology body. While the considerations and recommendations sit within the Australian context, many have international relevance. We include (i) principles important for neuropsychological intervention delivery (e.g. being based on biopsychosocial case formulation and person-centred goals); (ii) a description of clinical competencies important for effective intervention delivery; (iii) a summary of relevant evidence in three key cohorts: acquired brain injury, psychiatric disorders, and older adults, focusing on interventions with sound evidence for improving activity and participation outcomes; (iv) an overview of considerations for sustainable implementation of neuropsychological interventions as 'core business'; and finally, (v) a call to action.

Is It Possible to Combine Non-Invasive Brain Stimulation and Evidence-Based Psychosocial Interventions in Schizophrenia? A Critical Review

In schizophrenia, it was suggested that an integrated and multimodal approach, combining pharmacological and non-pharmacological interventions, could improve functional outcomes and clinical features in patients living with schizophrenia (PLWS). Among these alternatives, evidence-based psychosocial interventions (EBPIs) and Non-Invasive Brain Stimulation (NIBS) represent feasible treatment options targeting the clinical features that are unmet needs of PLWS (especially negative and cognitive symptoms). As no clear evidence is available on the combination of these non-pharmacological approaches, this review aimed to collect the available literature on the combination of EBPIs and NIBS in the treatment of PLWS. We demonstrated that the field of combining EBPIs and NIBS in schizophrenia is in its infancy, as only 11 studies were reviewed. In fact, only a few trials, with divergent results, combined these non-pharmacological modalities; while emerging evidence is available on the combination of cognitive remediation and rTMS/iTBS, inconclusive results were obtained. Conversely, albeit preliminary, more solid findings are available on the combination of HF-rTMS and family intervention. Moreover, despite the fact that cognitive activation could not be considered an EBPI, promising results are available in combination with tDCS to improve the working memory domain. To overcome these limitations, we considered several methodological issues to promote research in this field.

Efficacy of a Culturally Adapted Emotion Recognition Training Program in Improving Facial Emotion Recognition in Persons with Schizophrenia

Background

Facial emotion recognition (FER) deficits are being considered as core features of social cognitive deficits in schizophrenia, associated with socio-occupational dysfunction. Social cognition intervention programs have been shown to improve these deficits; however, there are no such intervention strategies in India. In this study, we aim to examine the efficacy of Training of Affect Recognition - Indian Version (TAR-IV) to enhance the FER abilities of people with schizophrenia.

Methods

In an open-label experimental design, 36 participants with schizophrenia underwent 12 sessions of TAR-IV as an add-on to treatment as usual (TAU), while 29 participants with schizophrenia continued TAU (pharmacological treatment with or without occupational therapy and vocational rehabilitation services). Clinical and functional assessments were done using the positive and negative syndrome scale (PANSS) and socio-occupational functioning scale. Emotion recognition abilities were assessed on the tool for recognition of emotions in neuropsychiatric disorders at baseline, post-intervention, and follow-up (two to three months post-intervention).

Results

The intervention group showed significant improvements in FER (P = .001) and socio-occupational functioning (P = .008) after receiving the TAR-IV, which remained significant at two months follow-up. A lower age of onset and poorer neurocognitive function at baseline predicted greater changes in emotion recognition ability following the intervention.

Conclusions

This study demonstrated the efficacy of TAR-IV, the Indian adaptation of social cognition intervention, in improving emotion recognition abilities and socio-occupational functioning in patients with schizophrenia. These findings need to be replicated in randomized controlled trials.

Emotion Processing and Its Relationship to Social Functioning and Symptoms in Psychotic Disorder: A Systematic Review and Meta-analysis

BACKGROUND

Emotion processing (EP) is impaired in individuals with psychosis and associated with social functioning; however, it is unclear how symptoms fit into this relationship. The aim of this systematic review and meta-analysis was to examine interrelationships between EP, symptoms, and social functioning, test whether different symptom domains mediate the relationship between EP and social functioning, and examine the moderating effects of illness stage and EP task type.

STUDY DESIGN

MEDLINE, Embase, and PsycINFO databases were searched for studies that included individuals with psychosis and reported correlations between EP, symptom domains (positive, negative, depressive, and disorganization), and social functioning. Random effects meta-analyses determined the strength of correlations, and subgroup analyses included illness stage and EP task type (lower- vs higher-level processing). Meta-analytic structural equation models tested whether symptom domains mediated the relationship between EP and social functioning.

RESULTS

There was a small relationship (r = .18) between EP and social functioning. Positive, negative, and disorganization symptoms mediated this relationship, although indirect effects were small. Higher-level EP tasks were more strongly associated with negative symptoms than lower-level tasks. Relationships between EP and both social functioning and positive symptoms were smaller in the first episode of psychosis than in established illness.

CONCLUSIONS

The mediating relationship suggests that EP not only influences social dysfunction directly but contributes to negative and disorganization symptoms, which in turn impair social functioning. This pathway suggests that targeting negative and disorganization symptoms may ultimately improve social outcomes for individuals with psychosis. Future research, particularly in early psychosis, is needed to determine other factors impacting these interrelationships.

Stable neural underpinnings of emotional cognition subgroups in patients newly diagnosed with bipolar disorder: A prospective fMRI study

OBJECTIVES

This study aimed to investigate the neural underpinnings of emotional cognition subgroups in recently diagnosed patients with bipolar disorder (BD) and change over time over a 15-month follow-up period.

METHODS

Patients and healthy controls (HC) underwent emotional and nonemotional cognitive assessments and functional magnetic resonance imaging (fMRI) at the baseline (BD n = 87; HC n = 65) and at 15-month follow-up (BD n = 44; HC n = 38). Neural activity during emotion reactivity and regulation in response to aversive pictures was assessed during fMRI. Patients were clustered into subgroups based on their emotional cognition and, with HC, were compared longitudinally on cognition and neural activity during emotion reactivity and regulation.

RESULTS

Patients were optimally clustered into two subgroups: Subgroup 1 (n = 40, 46%) was characterized by heightened emotional reactivity in negative social scenarios, which persisted over time, but were otherwise cognitively intact. This subgroup exhibited stable left amygdala hyper-activity over time during emotion reactivity compared to subgroup 2. Subgroup 2 (n = 47, 54%) was characterized by global emotional cognitive impairments, including stable difficulties with emotion regulation over time. During emotion regulation across both time points, this group exhibited hypo-activity in the left dorsolateral prefrontal cortex. Additionally, patients in subgroup 2 had poorer nonemotional cognition, had more psychiatric hospital admissions and history of psychotic episodes than those in subgroup 1.

CONCLUSIONS

Broad impairments in emotional cognition in approximately half of BD patients and associated nonemotional cognitive deficits may originate from insufficient recruitment of prefrontal resources, contributing to poorer clinical outcomes.

Personalized Cognitive Health in Psychiatry: Current State and the Promise of Computational Methods

BACKGROUND

Decades of research have firmly established that cognitive health and cognitive treatment services are a key need for people living with psychosis. However, many current clinical programs do not address this need, despite the essential role that an individual's cognitive and social cognitive capacities play in determining their real-world functioning. Preliminary practice-based research in the Early Psychosis Intervention Network early psychosis intervention network shows that it is possible to develop and implement tools that delineate an individuals' cognitive health profile and that help engage the client and the clinician in shared decision-making and treatment planning that includes cognitive treatments. These findings signify a promising shift toward personalized cognitive health.

STUDY DESIGN

Extending upon this early progress, we review the concept of interindividual variability in cognitive domains/processes in psychosis as the basis for offering personalized treatment plans. We present evidence from studies that have used traditional neuropsychological measures as well as findings from emerging computational studies that leverage trial-by-trial behavior data to illuminate the different latent strategies that individuals employ.

STUDY RESULT

We posit that these computational techniques, when combined with traditional cognitive assessments, can enrich our understanding of individual differences in treatment needs, which in turn can guide evermore personalized interventions.

CONCLUSION

As we find clinically relevant ways to decompose maladaptive behaviors into separate latent cognitive elements captured by model parameters, the ultimate goal is to develop and implement approaches that empower clients and their clinical providers to leverage individual's existing learning capacities to improve their cognitive health and well-being.

Durability of Effects of Cognitive Remediation on Cognition and Psychosocial Functioning in Schizophrenia: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

OBJECTIVE

Cognitive remediation provides substantial improvements in cognitive performance and real-world functioning for people living with schizophrenia, but the durability of these benefits needs to be reassessed and better defined. The aims of this study were to provide a comprehensive assessment of the durability of the benefits of cognitive remediation for cognition and functioning in people living with schizophrenia and evaluating potential moderators of effects.

METHODS

A systematic search was conducted in PubMed, Scopus, and PsycINFO, and reference lists of included articles and Google Scholar were inspected. Eligible studies were randomized clinical trials of cognitive remediation in patients diagnosed with schizophrenia spectrum disorders in which follow-up assessments were included. Screening and data extraction were performed by at least two independent reviewers. Cohen's d was used to measure outcomes. Primary outcomes were changes in cognition and functioning from baseline to conclusion of follow-up. Moderators of the durability of effects were assessed.

RESULTS

Of 2,840 identified reports, 281 full texts were assessed and 130 reports on 67 studies with 5,334 participants were included. Cognitive remediation produced statistically significant positive effects that persisted at the end of follow-up in global cognition (d=0.23) and in global functioning (d=0.26). Smaller study samples and single-center studies were associated with better cognitive outcomes; longer treatment and follow-up duration, techniques for transferring cognitive gains to the real world, integration with psychiatric rehabilitation, group format of delivery, and more female participants in the sample were associated with better functional outcomes.

CONCLUSIONS

Cognitive remediation provides durable improvements in cognition and functioning in schizophrenia. This finding corroborates the notion that cognitive remediation should be implemented more widely in clinical and rehabilitation practice.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54251.

Combining transcranial magnetic stimulation with training to improve social cognition impairment in schizophrenia: a pilot randomized controlled trial

Schizophrenia is a severe, chronic mental disorder that profoundly impacts patients' everyday lives. The illness's core features include positive and negative symptoms and cognitive impairments. In particular, deficits in the social cognition domain showed a tighter connection to patients' everyday functioning than the other symptoms. Social remediation interventions have been developed, providing heterogeneous results considering the possibility of generalizing the acquired improvements in patients' daily activities. In this pilot randomized controlled trial, we investigated the feasibility of combining fifteen daily cognitive and social training sessions with non-invasive brain stimulation to boost the effectiveness of the two interventions. We delivered intermittent theta burst stimulation (iTBS) over the left dorsolateral prefrontal cortex (DLPFC). Twenty-one patients were randomized into four groups, varying for the assigned stimulation condition (real vs. sham iTBS) and the type of cognitive intervention (training vs. no training). Clinical symptoms and social cognition tests were administered at five time points, i.e., before and after the treatment, and at three follow-ups at one, three, and six months after the treatments' end. Preliminary data show a trend in improving the competence in managing emotion in participants performing the training. Conversely, no differences were found in pre and post-treatment scores for emotion recognition, theory of mind, and attribution of intentions scores. The iTBS intervention did not induce additional effects on individuals' performance. The methodological approach's novelty and limitations of the present study are discussed.

The schizophrenia syndrome, circa 2024: What we know and how that informs its nature

With new data about different aspects of schizophrenia being continually generated, it becomes necessary to periodically revisit exactly what we know. Along with a need to review what we currently know about schizophrenia, there is an equal imperative to evaluate the construct itself. With these objectives, we undertook an iterative, multi-phase process involving fifty international experts in the field, with each step building on learnings from the prior one. This review assembles currently established findings about schizophrenia (construct, etiology, pathophysiology, clinical expression, treatment) and posits what they reveal about its nature. Schizophrenia is a heritable, complex, multi-dimensional syndrome with varying degrees of psychotic, negative, cognitive, mood, and motor manifestations. The illness exhibits a remitting and relapsing course, with varying degrees of recovery among affected individuals with most experiencing significant social and functional impairment. Genetic risk factors likely include thousands of common genetic variants that each have a small impact on an individual's risk and a plethora of rare gene variants that have a larger individual impact on risk. Their biological effects are concentrated in the brain and many of the same variants also increase the risk of other psychiatric disorders such as bipolar disorder, autism, and other neurodevelopmental conditions. Environmental risk factors include but are not limited to urban residence in childhood, migration, older paternal age at birth, cannabis use, childhood trauma, antenatal maternal infection, and perinatal hypoxia. Structural, functional, and neurochemical brain alterations implicate multiple regions and functional circuits. Dopamine D-2 receptor antagonists and partial agonists improve psychotic symptoms and reduce risk of relapse. Certain psychological and psychosocial interventions are beneficial. Early intervention can reduce treatment delay and improve outcomes. Schizophrenia is increasingly considered to be a heterogeneous syndrome and not a singular disease entity. There is no necessary or sufficient etiology, pathology, set of clinical features, or treatment that fully circumscribes this syndrome. A single, common pathophysiological pathway appears unlikely. The boundaries of schizophrenia remain fuzzy, suggesting the absence of a categorical fit and need to reconceptualize it as a broader, multi-dimensional and/or spectrum construct.

Utilizing Technology to Enhance the Ecological Validity of Cognitive and Functional Assessments in Schizophrenia: An Overview of the State-of-the-Art

Cognitive impairment is a core feature of schizophrenia and a key determinant of functional outcome. Although conventional paper-and-pencil based cognitive assessments used in schizophrenia remained relatively static during most of the 20th century, this century has witnessed the emergence of innovative digital technologies that aim to enhance the ecological validity of performance-based assessments. This narrative review provides an overview of new technologies that show promise for enhancing the ecological validity of cognitive and functional assessments. We focus on 2 approaches that are particularly relevant for schizophrenia research: (1) digital functional capacity tasks, which use simulations to measure performance of important daily life activities (e.g., virtual shopping tasks), delivered both in-person and remotely, and (2) remote device-based assessments, which include self-administered cognitive tasks (e.g., processing speed test) or functionally-focused surveys regarding momentary activities and experiences (e.g., location, social context), as well as passive sensor-based metrics (e.g., actigraphy measures of activity), during daily life. For each approach, we describe the potential for enhancing ecological validity, provide examples of select measures that have been used in schizophrenia research, summarize available data on their feasibility and validity, and consider remaining challenges. Rapidly growing evidence indicates that digital technologies have the potential to enhance the ecological validity of cognitive and functional outcome assessments, and thereby advance research into the causes of, and treatments for, functional disability in schizophrenia.

Social cognition and psychosocial functioning in schizophrenia and bipolar disorder: Theory of mind as a key to understand schizophrenia dysfunction

Functional impairment is a common symptom in schizophrenia (SZ) and bipolar disorder (BD). Pharmacological treatments have limited functional recovery in both disorders. Social cognition, a cognitive process, has been associated with functioning in mental disorders. Theory of mind (ToM) is considered a key factor in understanding the social cognitive deficits in SZ and BD. Our study aimed to investigate the relationship between ToM and functioning in SZ, BD, and healthy controls (HC) and compare ToM and functioning impairments between groups. A total of 208 participants (HC n = 69; BD n = 89; SZ n = 50) were evaluated with the Functioning Assessment Short Test (FAST), Reading the Mind in the Eyes Test (RMET), the Vocabulary subtest of the Wechsler Abbreviated Scale for Intelligence (WASI) and the Hopkins Verbal Learning Test - Revised (HVLT-R). Comparisons of RMET between low- and high-functioning individuals and multiple linear regression analyses were conducted for each group. Multiple regression analysis revealed that the association between ToM and psychosocial functioning was observed only in SZ (β = -1.352, p = 0.008). Low-functioning SZ participants showed a lower ToM performance compared to participants with high-functioning SZ (t = 1.80, p = 0.039, Cohen's d = 0.938). No significant associations were found in the other groups. ToM is essential to understand the functional impairment in SZ, more than in BD. Furthermore, ToM may be a primary target for intervention strategies in improving functioning in SZ.

Electrode montage for transcranial direct current stimulation governs its effect on symptoms and functionality in schizophrenia

Backgrounds

Patients with schizophrenia suffer from cognitive impairment that worsens real-world functional outcomes. We previously reported that multi-session transcranial direct current stimulation (tDCS) delivered to the left dorsolateral prefrontal cortex (DLPFC) improved daily living skills, while stimulation on the left superior temporal sulcus (STS) enhanced performance on a test of social cognition in these patients. To examine the region-dependent influence of tDCS on daily-living skills, neurocognition, and psychotic symptoms, this study compared effects of anodal stimulation targeting either of these two brain areas in patients with schizophrenia.

Methods

Data were collected from open-label, single-arm trials with anodal electrodes placed over the left DLPFC (N = 28) or STS (N = 15). Daily-living skills, neurocognition, and psychotic symptoms were measured with the UCSD performance-based skills assessment-brief (UPSA-B), Brief Assessment of Cognition in Schizophrenia (BACS), and Positive and Negative Syndrome Scale (PANSS), respectively. After baseline evaluation, tDCS (2 mA × 20 min) were delivered two times per day for 5 consecutive days. One month after the final stimulation, clinical assessments were repeated.

Results

Performance on the UPSA-B was significantly improved in patients who received anodal tDCS at the left DLPFC (d = 0.70, p < 0.001), while this effect was absent in patients with anodal electrodes placed on the left STS (d = 0.02, p = 0.939). Significant improvement was also observed for scores on the BACS with anodal tDCS delivered to the DLPFC (d = 0.49, p < 0.001); however, such neurocognitive enhancement was absent when the STS was stimulated (d = 0.05, p = 0.646). Both methods of anodal stimulation showed a significant improvement of General Psychopathology scores on the PANSS (DLPFC, d = 0.50, p = 0.027; STS, d = 0.44, p = 0.001).

Conclusion

These results indicate the importance of selecting brain regions as a target for tDCS according to clinical features of individual patients. Anodal stimulation of the left DLPFC may be advantageous in improving higher level functional outcomes in patients with schizophrenia.

Trial registration

These studies were registered within the University hospital Medical Information Network Clinical Trials Registry [(24), UMIN000015953], and the Japan Registry of Clinical Trials [(28), jRCTs032180026].

The use of implementation science to close the research-to-treatment gap for cognitive impairment in psychosis

For people living with psychosis, cognitive impairment is common and can have significant impacts for functional recovery, impacting engagement with treatment and quality of life more broadly. There is now strong evidence for the effectiveness of cognition-focused treatments, such as cognitive remediation to improve clinical and functional outcomes for people with psychosis. However, engagement with treatment has been a long-standing issue in mental health care, including for people with psychosis, who often experience difficulties with motivation. While research on clinical effectiveness of cognition-focused treatment is growing, to date there has been little research focused on the implementation of such treatments and it is not clear how best to support uptake and engagement across diverse mental health settings. Implementation science is the study of methods and strategies to promote the adoption, application, and maintenance of evidence-based practices in routine care. To integrate cognition-focused treatments into routine practice, and improve engagement with treatment and the quality and effectiveness of care for people with psychosis, researchers need to embrace implementation science and research. This paper provides a succinct overview of the field of implementation science, current evidence for implementation of cognition-focused treatments for psychosis and practical guidance for using implementation science in clinical research. The future of psychosis research includes multidisciplinary teams of clinical researchers and implementation scientists, working together with providers and consumers to build the evidence that can improve the implementation of cognition-focused treatments.

Training volitional control of the theory of mind network with real-time fMRI neurofeedback

Is there a way improve our ability to understand the minds of others? Towards addressing this question, here, we conducted a single-arm, proof-of-concept study to evaluate whether real-time fMRI neurofeedback (rtfMRI-NF) from the temporo-parietal junction (TPJ) leads to volitional control of the neural network subserving theory of mind (ToM; the process by which we attribute and reason about the mental states of others). As additional aims, we evaluated the strategies used to self-regulate the network and whether volitional control of the ToM network was moderated by participant characteristics and associated with improved performance on behavioral measures. Sixteen participants underwent fMRI while completing a task designed to individually-localize the TPJ, and then three separate rtfMRI-NF scans during which they completed multiple runs of a training task while receiving intermittent, activation-based feedback from the TPJ, and one run of a transfer task in which no neurofeedback was provided. Region-of-interest analyses demonstrated volitional control in most regions during the training tasks and during the transfer task, although the effects were smaller in magnitude and not observed in one of the neurofeedback targets for the transfer task. Text analysis demonstrated that volitional control was most strongly associated with thinking about prior social experiences when up-regulating the neural signal. Analysis of behavioral performance and brain-behavior associations largely did not reveal behavior changes except for a positive association between volitional control in RTPJ and changes in performance on one ToM task. Exploratory analysis suggested neurofeedback-related learning occurred, although some degree of volitional control appeared to be conferred with the initial self-regulation strategy provided to participants (i.e., without the neurofeedback signal). Critical study limitations include the lack of a control group and pre-rtfMRI transfer scan, which prevents a more direct assessment of neurofeedback-induced volitional control, and a small sample size, which may have led to an overestimate and/or unreliable estimate of study effects. Nonetheless, together, this study demonstrates the feasibility of training volitional control of a social cognitive brain network, which may have important clinical applications. Given the study's limitations, findings from this study should be replicated with more robust experimental designs.

Effect of cognitive behavioral group therapy on rehabilitation of community patients with schizophrenia: A short-term randomized control trial

BACKGROUND

The efficacy of cognitive behavioral group therapy (CBGT) for cognitive dys-function and negative symptoms of schizophrenia is established, but more evidence is required.

AIM

To assess the effectiveness of CBGT combined with mental health education as a treatment for schizophrenia compared with mental health education alone.

METHODS

In all, 120 schizophrenia out-patients were randomized into CBGT combined with mental health education or single mental health education. The primary outcomes were positive and negative symptoms, cognitive function, excitatory factor, anxiety and depression symptom improvements on the positive and negative syndrome scale score. Secondary outcome measures included social function and drug compliance.

RESULTS

There were significant differences between CBGT combined with mental health education and single mental health education on measures of positive and negative symptoms, cognitive functions, excitatory factor, anxiety and depression symptoms, and social functions. No other significant difference in outcomes was observed.

CONCLUSION

CBGT combined with mental health education may be relevant beneficial treatment method in reducing symptoms, cognitive and social functions of patients with schizophrenia.

Efficacy of social cognition and interaction training in outpatients with schizophrenia spectrum disorders: randomized controlled trial

Given the relationship between social cognition and functional outcome in schizophrenia, a number of social cognitive interventions have been developed, including Social Cognition Interaction Training (SCIT), a group-based, comprehensive, manualized intervention. In the current trial, we examined SCIT efficacy as well as potential moderators of treatment effects. Fifty-one outpatients were randomized to SCIT or a wait-list-control (WLC), with assessments of social cognition, neurocognition, self-report, symptoms, and functioning conducted at baseline and end of the active phase. Relative to WLC, we did not find significant improvements for SCIT on neurocognition, social cognition, self-report, or symptoms, though there was a trend-level, medium effect favoring the SCIT condition on interpersonal and instrumental role function. Post-hoc analyses indicated that baseline neurocognition did not impact degree of social cognitive or functional change. Shorter duration of illness was significantly associated with better post-training neurocognition and self-esteem and, at trend-level with better symptoms and social functioning. We discuss the importance of outcome measure selection and the need for continued evaluation of potential treatment moderators in order to better match people to existing treatments. Clinical trial registration: Clinicaltrials.gov, Identifier NCT00587561.

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.

Dynamic Interactive Social Cognition Training in Virtual Reality (DiSCoVR) versus Virtual Reality Relaxation (VRelax) for People With a Psychotic Disorder: A Single-Blind Multicenter Randomized Controlled Trial

BACKGROUND AND HYPOTHESIS

Social cognition training (SCT), an intervention for social cognition and social functioning, might be improved by using virtual reality (VR), because VR may offer better opportunities to practice in a potentially more realistic environment. To date, no controlled studies have investigated VR-SCT. This study investigated a VR-SCT, "DiSCoVR". We hypothesized that DiSCoVR would improve social cognition and social functioning.

STUDY DESIGN

Participants were randomized to DiSCoVR (n = 41) or VR relaxation ('VRelax', n = 40), an active control condition, and completed 16 twice-weekly sessions. Three assessments (baseline, posttreatment, and 3-month follow-up) were performed by blinded assessors. The primary outcome was social cognition (emotion perception and theory of mind). Secondary outcomes included social functioning (measured with an interview and experience sampling), psychiatric symptoms, information processing, and self-esteem. Data were analyzed using mixed-models regression analysis. Treatment effects were evaluated by the time by condition interaction terms.

STUDY RESULTS

No significant time by condition interactions were found for any of the outcome variables, indicating an absence of treatment effects. Between-group effect sizes ranged from negligible to moderate (Cohen's d < |0.53|). Main effects of time were found for several outcomes.

CONCLUSIONS

These results suggest that DiSCoVR was not effective, possibly because of inadequate simulation of emotional expressions in VR. This lack of efficacy may indicate that current SCT protocols are relatively unsuitable for improving social functioning. Previous studies showed small to moderate effects on higher order social cognition, but the SCT approach may need critical reevaluation, as it may not sufficiently lead to functional improvement.

Feasibility and Effect of Increasing Clozapine Plasma Levels in Long-Stay Patients With Treatment-Resistant Schizophrenia

BACKGROUND

It is unknown whether increasing the clozapine plasma level to 400, 750, or even 1000 ng/mL is a feasible and effective strategy in patients with treatment-resistant schizophrenia (TRS). We investigated this in long-stay patients with TRS.

METHODS

In long-stay TRS patients, doses of clozapine were increased gradually to reach target plasma levels of 400, 750, or 1000 ng/mL, depending on the clinical response and tolerability. After an effective or tolerated level was reached, positive and negative syndrome scale scores were evaluated after 3 months and 1 year.

RESULTS

Twenty-eight patients were included. Overall, 54% of the patients, and especially patients 60 years and older, could not achieve one of the clozapine target levels because of adverse effects. Three physically vulnerable patients died, probably not directly related to clozapine use. Although only 21% of patients achieved a more than 20% reduction in total symptoms at the 1-year follow-up, the mean severity of positive symptoms decreased from 18.18 to 15.10 ( P < 0.01). The largest decrease in positive symptoms was seen in TRS patients who achieved a plasma level of 750 ng/mL of clozapine.

CONCLUSIONS

Most TRS patients older than 60 years could not tolerate high clozapine levels and so this should not be attempted in older or otherwise physically vulnerable patients. Increasing clozapine levels to approximately 750 ng/mL in middle-aged patients with longstanding TRS may modestly reduce the severity of positive symptoms and improve the response rate.

Efficacy and acceptability of psychosocial interventions in schizophrenia: systematic overview and quality appraisal of the meta-analytic evidence

Psychosocial interventions are recommended in schizophrenia and first-episode psychosis/early psychosis (EP). Nevertheless, literature is heterogeneous and often contradictory. We conducted an umbrella review of (network) meta-analyses of randomized controlled trials (RCTs) comparing psychosocial interventions vs treatment as usual (TAU)/active interventions(ACTIVE)/MIXED controls. Primary outcome was total symptoms (TS); secondary outcomes were positive/negative/depressive symptoms (PS/NS/DS), cognition, functioning, relapse, hospitalization, quality of life (QoL), treatment discontinuation. Standardized mean difference (SMD)/odds ratio (OR)/risk ratio (RR) vs TAU/ACTIVE/MIXED were summarized at end-of-treatment (EoT)/follow-up (FU). Quality was rated as high/medium/low (AMSTAR-PLUS). Eighty-three meta-analyses were included (RCTs = 1246; n = 84,925). Against TAU, regarding TS, Early Intervention Services (EIS) were superior EoT/FU in EP (SMD = -0.32/-0.21), cognitive behavioral therapy (CBT) in schizophrenia EoT/FU (SMD = -0.38/-0.19). Regarding secondary outcomes, in EP, EIS were superior for all outcomes EoT except cognition, and at FU for PS/NS/QoL, specific family interventions (FI-s) prevented relapse EoT; in schizophrenia, superiority emerged EoT for CBT for PS/NS/relapse/functioning/QoL; psychoeducation (EDU)/any FI for relapse; cognitive remediation therapy (CRT) for cognition/functioning; and hallucination-focused integrative treatment for PS. Against ACTIVE, in EP, mixed family interventions (FI-m) were superior at FU regarding TS (SMD = -0.61) and for functioning/relapse among secondary outcomes. In schizophrenia, regarding TS, mindfulness and social skills training (SST) were superior EoT, CBT at FU; regarding secondary outcomes superiority emerged at EoT for computerized cognitive drill-and-practice training for PS/DS, CRT for cognition/functioning, EDU for relapse, individual placement and support (IPS) for employment; and at FU CBT for PS/NS. Against MIXED, in schizophrenia, CRT/EDU were superior for TS EoT (d = -0.14/SMD = -0.33), CRT regarding secondary outcomes EoT for DS/social functioning, both EoT/FU for NS/cognition/global functioning; compensatory cognitive interventions for PS/functioning EoT/FU and NS EoT; CBT for PS at FU, and EDU/SST for relapse EoT. In conclusion, mental health services should consider prioritizing EIS/any FI in EP and CBT/CRT/any FI/IPS for schizophrenia, but other interventions may be helpful for specific outcomes.

Social cognition training improves recognition of distinct facial emotions and decreases misattribution errors in healthy individuals

Facial emotion recognition is a key component of social cognition. Impaired facial emotion recognition is tied to poor psychological wellbeing and deficient social functioning. While previous research has demonstrated the potential for social cognition training to improve overall facial emotion recognition, questions remain regarding what aspects of emotion recognition improve. We report results from a randomized controlled trial that evaluates whether computerized social cognition training can improve recognition of distinct facial emotions in healthy participants. This investigation was designed to better understand the therapeutic potential of social cognition training for individuals with neuropsychiatric disorders. Fifty-five healthy adult participants were randomly assigned to an internet-based intervention during which they either completed social cognition training (SCT) or played control computer games (CON) for 10.5 h over 2-3 weeks. Facial emotion recognition was measured with the Penn ER-40, which was conducted before and after training. The following variables were collected and analyzed: facial emotion recognition accuracy for each emotion (i.e., anger, fear, happy, neutral (no emotional expression), and sad), reaction times for each emotion, and response error types (i.e., frequency of an emotion being chosen incorrectly, frequency of an emotion being missed, and frequency of an emotion being confused for another particular emotion). ANOVAs and t-tests were used to elucidate intervention effects both within and between groups. Results showed that the SCT group improved their accuracy for angry and neutral faces. They also improved their reaction times for neutral, fearful, and sad faces. Compared to the CON group, the SCT group had significantly faster reaction times to neutral faces after training. Lastly, the SCT group decreased their tendency to confuse angry faces for no emotional expression and to confuse no emotional expression for sad faces. In contrast, the CON group did not significantly improve their accuracy or reaction times on any emotional expression, and they did not improve their response error types. We conclude that social cognition training can improve recognition of distinct emotions in healthy participants and decrease response error patterns, suggesting it has the potential to improve impaired emotion recognition and social functioning in individuals with facial emotion recognition deficits.

Mentalizing abilities mediate the impact of the basic social perception on negative symptoms in patients with schizophrenia

Social cognitive deficits are currently considered as one of the main predictors of clinical symptoms and functional outcome in patients with schizophrenia. Multiple studies have suggested that a two-factor solution (low-level vs. high-level) best describes the structure of social cognitive processes in patients. While higher-order processes have been repeatedly linked to negative symptoms, no such association was found for lower-level processes. Thus, the aim of the current study is to examine whether the association between basic social perception processes and symptoms in patients with schizophrenia is mediated by mentalizing abilities. One hundred thirty-nine patients have completed basic social perception (Communicative Interactions Database task CID-12) and mentalizing (Reading the Mind in the Eyes task) tasks. In line with our hypothesis, we have observed full mediation of the effects of basic social perception abilities on negative symptoms via mentalizing abilities in patients. This effect suggests that, similarly as in the case of positive symptoms, a hierarchical nature of social cognitive processes should be considered while investigating negative symptoms of schizophrenia.

Perceptions of and subjective difficulties with social cognition in schizophrenia from an internet survey: Knowledge, clinical experiences, and awareness of association with social functioning

AIM

Social cognition impacts social functioning in schizophrenia; however, little is known about how patients with schizophrenia themselves perceive social cognition. This study, using an internet survey, aimed to investigate their knowledge of social cognition, clinical experiences related to social cognition, awareness of social cognition's role in one's social life, and the relationships between subjective difficulties with social cognition and social functioning.

METHODS

Data from 232 outpatients with schizophrenia (SZ) and 494 healthy controls (HC) were obtained through an internet survey and were weighted according to the demographics of the national population. A newly developed survey questionnaire on knowledge, experience, and awareness of social cognition was administered. Subjective difficulties were evaluated using the Self-Assessment of Social Cognition Impairments and the Observable Social Cognition Rating Scale.

RESULTS

Less than a quarter of both groups were familiar with the term or concept of social cognition. Less than 5% of both groups had experienced being assessed or treated for social cognition. More than half of both groups were aware of the relationship between social cognition and social functioning. The SZ group had higher levels of subjective difficulties than the HC group across all social cognitive domains. The attributional bias domain of subjective difficulties was negatively associated with social functioning.

CONCLUSION

Patients with schizophrenia had substantial subjective difficulties in social cognition, which they perceived as being related to social functioning. However, their knowledge of social cognition was limited, and the assessment and treatment might not be widespread in regular clinical practice.

Pharmacological interventions for social cognitive impairments in schizophrenia: A protocol for a systematic review and network meta-analysis

Background

Social cognitive impairments adversely affect social functioning (e.g., employment status) in patients with schizophrenia. Although pharmacological interventions have been suggested to provide some benefits on social cognition, little information is available on the comparative efficacy of pharmacotherapy. Thus, the aim of this planned systematic review and network meta-analysis is to perform a quantitative comparison of the effects of various psychotropic drugs, including supplements, on social cognition disturbances of schizophrenia.

Methods

The literature search will be carried out using the PubMed, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, ClinicalTrials.gov, and International Clinical Trials Registry Platform databases from inception onward. Randomized controlled trials that examined the efficacy of drugs in social cognitive disturbances will be included, based on the most recent studies and the broader literature than previously searched. This protocol defines a priori the methods that will be used for study selection, data collection, quality assessment, and statistical syntheses.

Discussion

The findings this work are expected to help promote the development of better therapeutics of social cognitive impairments in schizophrenia and related psychiatric conditions.

Systematic Review Registration

[www.crd.york.ac.uk/prospero], identifier [CRD42021293224].

Do cognitive impairments limit treatment gains in a standalone digital intervention for psychosis? A test of the digital divide

Digital mental health interventions, such as those provided by smartphone applications (apps), show promise as cost-effective approaches to increasing access to evidence-based psychosocial interventions for psychosis. Although it is well known that limited financial resources can reduce the benefits of digital approaches to mental healthcare, the extent to which cognitive functioning in this population could impact capacity to engage in and benefit from these interventions is less studied. In the current study we examined the extent to which cognitive functioning (premorbid cognitive abilities and social cognition) were related to treatment engagement and outcome in a standalone digital intervention for social functioning. Premorbid cognitive abilities generally showed no association with aggregated treatment engagement markers, including proportion of notifications responded to and degree of interest in working on app content, though there was a small positive association with improvements in social functioning. Social cognition, as measured using facial affect recognition ability, was unrelated to treatment engagement or outcome. These preliminary findings suggest that cognitive functioning is generally not associated with engagement or outcomes in a standalone digital intervention designed for and with people with schizophrenia spectrum disorders.

Voices 2: Improving Prosodic Recognition in Schizophrenia With an Online Rehabilitation Program

Introduction: Emotion recognition of voices may play an important role in interpersonal communication and patients with schizophrenia present alterations in this regard. Several on-line rehabilitation tools have been developed for treatment in this area. Voices is an on-line prosodic recognition program consisting of identifying different emotional tones in neutral phrases, in different sessions of gradually increasing difficulty. This training tool has previously reported benefits, and a new version has been created called Voices 2. The main aim of this study is to test the capacity of the Voices 2 program to improve emotion recognition through prosody for adults with schizophrenia. Secondly, it seeks to observe durability effects 1 month after intervention.

Method: A randomized, single-blind, multicenter clinical trial was conducted with 44 outpatients diagnosed with schizophrenia or schizoaffective disorder. The intervention group (also called Voices) was treated with Voices 2, whereas the control group was treated with auditory training that was not related to emotions. Sociodemographic and clinical data, clinical state (PANSS), Intelligence Quotient and prosodic recognition (RMV-SV) were measured at baseline. After intervention, RMV-SV and PANSS were assessed. One month later, the RMV-SV measure was repeated.

Results: The control group (n = 19) and the Voices group (n = 22) did not differ on χ², t or U tests in sociodemographic, clinical and psychometric variables at baseline or post-intervention (all p-values > 0.05). In the Voices group, statistically significant differences were observed in the RMV-SV scale applied post-intervention vs. that applied pre-intervention (Z = 2.47, p = 0.013). Similar results were observed in the 1-month follow-up RMV-SV vs. the pre-intervention RMV-SV (Z = 1.97, p = 0.049). PANSS scale was also assessed with no significant differences between pre vs. post measures in both groups. Lastly, Voices 2 was rated relatively higher, based on its ease of understanding, entertainment value, usefulness and the appropriateness of use of its emotional glossary.

Discussion: Improvements were observed in prosodic recognition following intervention with Voices 2 in the Voices group. Although these results are similar to other clinical trial rehabilitation programs, specific research on the matter remains scarce. Certain aspects, such as the durability of effects or adherence should be thoroughly studied and clarified.

Clinical Trial Registration: [https://doi.org/10.17605/OSF.IO/G95C4].

Virtual-reality-based social cognition and interaction training for patients with schizophrenia: A preliminary efficacy study

BACKGROUND

Social cognition and interaction training (SCIT) is a psychosocial intervention program for patients with psychosis, designed to improve their social functioning by improving social cognition. Although the feasibility and efficacy of SCIT have been verified, patients with schizophrenia tend to suffer from motivational deficits and low treatment adherence. It has been suggested that using virtual reality (VR) technology might be effective in addressing these issues. In this study, we aimed to develop a VR-based SCIT and compare its efficacy with that of traditional SCIT.

MATERIALS AND METHODS

We developed a novel VR-based social cognition and interaction training (VR-SCIT) that combines traditional SCIT (TR-SCIT) intervention with VR technology. Participants were randomly assigned in a 1:1:1 ratio to the VR-SCIT (n = 28), TR-SCIT (n = 30), or waiting-list groups (n = 29). All treatments were combined with treatment-as-usual. Assessments of social cognition (i.e., Chinese version of Face-Affective Identification Task, Chinese version of Social Cognition Screening Questionnaire) and social functioning (i.e., Chinese version of Personal and Social Performance Scale) were administered from baseline to post-intervention.

RESULTS

Patients receiving VR-SCIT and TR-SCIT showed a significantly greater improvement on the assessments of emotion perception (Cohen's d was 1.66, 0.55, and 0.10 for VR-SCIT, TR-SCIT, and Waiting-list, respectively), hostile attributional bias (Cohen's d was 0.48, 0.44, and 0.05 for VR-SCIT, TR-SCIT, and Waiting-list, respectively), metacognition (Cohen's d was 1.66, 0.76, and 0.06 for VR-SCIT, TR-SCIT, and waiting-list, respectively), and social functioning (Cohen's d was 1.09, 0.90, and 0.20 for VR-SCIT, TR-SCIT, and waiting-list, respectively) from baseline to post-intervention, compared to those in waiting-list group. Additionally, VR-SCIT showed an advantage over TR-SCIT in improving emotion perception and metacognition with higher treatment compliance.

CONCLUSION

These preliminary findings indicate that VR-SCIT is a feasible and promising method for improving social cognition and social functioning in patients with schizophrenia.

European Psychiatric Association guidance on treatment of cognitive impairment in schizophrenia

Background

Although cognitive impairment is a core symptom of schizophrenia related to poorer outcomes in different functional domains, it still remains a major therapeutic challenge. To date, no comprehensive treatment guidelines for cognitive impairment in schizophrenia are implemented.

Methods

The aim of the present guidance paper is to provide a comprehensive meta-review of the current available evidence-based treatments for cognitive impairment in schizophrenia. The guidance is structured into three sections: pharmacological treatment, psychosocial interventions, and somatic treatments.

Results

Based on the reviewed evidence, this European Psychiatric Association guidance recommends an appropriate pharmacological management as a fundamental starting point in the treatment of cognitive impairment in schizophrenia. In particular, second-generation antipsychotics are recommended for their favorable cognitive profile compared to first-generation antipsychotics, although no clear superiority of a single second-generation antipsychotic has currently been found. Anticholinergic and benzodiazepine burdens should be kept to a minimum, considering the negative impact on cognitive functioning. Among psychosocial interventions, cognitive remediation and physical exercise are recommended for the treatment of cognitive impairment in schizophrenia. Noninvasive brain stimulation techniques could be taken into account as add-on therapy.

Conclusions

Overall, there is definitive progress in the field, but further research is needed to develop specific treatments for cognitive impairment in schizophrenia. The dissemination of this guidance paper may promote the development of shared guidelines concerning the treatment of cognitive functions in schizophrenia, with the purpose to improve the quality of care and to achieve recovery in this population.

Transcranial Direct Current Stimulation on the Left Superior Temporal Sulcus Improves Social Cognition in Schizophrenia: An Open-Label Study

BACKGROUND

Patients with schizophrenia show impairments of social cognition, which cause poor real-world functional outcomes. Transcranial direct current stimulation (tDCS) delivered to frontal brain areas has been shown to partially alleviate disturbances of social cognition. In this study, we aimed to determine whether multisession tDCS targeting the superior temporal sulcus (STS), a brain region closely related to social cognition, would improve social cognitive performance in patients with schizophrenia.

METHODS

This was an open-label, single-arm trial to investigate the benefits and safety of multisession tDCS over the left STS. Fifteen patients received tDCS (2 mA × 20 min) two times per day for 5 consecutive days. Anodal and cathodal electrodes were placed over the left STS and right supraorbital regions, respectively. Assessments with the Social Cognition Screening Questionnaire (SCSQ), the Hinting Task (HT), the Brief Assessment of Cognition in Schizophrenia (BACS), and the Positive and Negative Syndrome Scale (PANSS) were conducted at baseline and 1 month after the final stimulation.

RESULTS

Significant improvements were found on theory of mind, as measured using the SCSQ (d = 0.53) and the HT (d = 0.49). These changes on social cognition were not correlated with those of neurocognition, as measured using the BACS or psychotic symptoms, as measured using the PANSS. There were no adverse events of serious/moderate levels attributable to tDCS.

CONCLUSION

These results suggest that administration of multisession tDCS with anode stimulation targeting the left STS provides a novel strategy to improve functional outcomes in patients with schizophrenia.

ETHICS STATEMENT

The National Center of Neurology and Psychiatry Clinical Research Review Board (CRB3180006) approved this study.

TRIAL REGISTRATION

This study was registered within the Japan Registry of Clinical Trials (jRCTs032180026).

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

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

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.

Developments in Biological Mechanisms and Treatments for Negative Symptoms and Cognitive Dysfunction of Schizophrenia

The causal mechanisms and treatment for the negative symptoms and cognitive dysfunction in schizophrenia are the main issues attracting the attention of psychiatrists over the last decade. The first part of this review summarizes the pathogenesis of schizophrenia, especially the negative symptoms and cognitive dysfunction from the perspectives of genetics and epigenetics. The second part describes the novel medications and several advanced physical therapies (e.g., transcranial magnetic stimulation and transcranial direct current stimulation) for the negative symptoms and cognitive dysfunction that will optimize the therapeutic strategy for patients with schizophrenia in future.

A meta-analysis of the effects of social-cognitive training in schizophrenia: The role of treatment characteristics and study quality

OBJECTIVES

This meta-analysis was designed to assess the effects of social-cognitive training (SCT) and whether study quality, treatment approach, treatment context, and sample characteristics influence these effects.

METHODS

Electronic databases were searched up to 5 August 2020 using variants of keywords: 'social cognition', 'training', 'rehabilitation', 'remediation', and 'schizophrenia'. Methodological moderators were extracted through the Clinical Trials Assessment Measure and verified by authors. This study was pre-registered on PROSPERO (CRD42020154026).

RESULTS

Forty-two controlled trials with 1,868 participants were identified. The meta-analysis revealed moderate effects on emotion recognition, mental state attribution, and social perception. No significant effects were evident on psychiatric symptoms or social functioning. A small signal was evident for the generalization of treatment gains to executive function. Moderator analyses revealed that studies of lower methodological quality reported larger effects, and samples with lower mean years of education were associated with larger effects of SCT on mental state attribution. Treatment effects did not differ by other moderator variables such as treatment context and intervention types.

CONCLUSIONS

SCT benefits people with schizophrenia on a variety of social-cognitive outcomes. Differences in baseline symptoms, gender distribution, antipsychotic medication dose, IQ, and other sample features did not create barriers to treatment benefits. Future studies should aim to enhance the generalization of training effects on broader clinical outcomes.

Exploring the Interplay Between Adversity, Neurocognition, Social Cognition, and Functional Outcome in People With Psychosis: A Narrative Review

History of adversity is associated with subsequent psychosis, and with a spectrum of cognitive alterations in individuals with psychosis. These cognitive features go from neurocognitive aspects as working memory and attention, to complex social cognitive processes as theory of mind and emotional perception. Difficulties in these domains impact patients' social and occupational functioning, which has been shown to be more impaired in those previously exposed to childhood trauma. However, the interplay between adversity, neurocognition, and functioning is yet poorly understood. This narrative review aims to explore the evidence on whether deficits in neurocognitive and social cognitive domains may act as possible putative mechanism linking adversity with functioning in people with psychosis. We show available evidence supporting the link between adversity and poorer functioning in psychosis, especially in chronic stages; and replicated evidence suggesting associations of social cognition and, to a lesser extent, neurocognition with impairment in functioning in patients; although there is still an important gap in the literature testing particularly deficits in social cognition as mediator of the link between adversity and functional decline in psychosis. Targeting interventions focusing on neurocognition and social cognition in individuals with adversity and psychosis seems important, given the severe deterioration of these patients in these domains, although more research is needed to test whether such treatments can specifically improve functioning in individuals with psychosis and adversity. Literature aiming to understand the determinants of functional outcome should consider the pervasive impact of childhood adversity, and its related effects on cognition.

Effects of an Audiovisual Emotion Perception Training for Schizophrenia: A Preliminary Study

Individuals with schizophrenia show a reduced ability to integrate facial and vocal information in emotion perception. Although emotion perception has been a target for treatment, no study has yet examined the effect of multimodal training on emotion perception in schizophrenia. In the present study, we developed an audiovisual emotion perception training and test in which a voice and a face were simultaneously presented, and subjects were asked to judge whether the emotions of the voice and the face matched. The voices were either angry or happy, and the faces were morphed on a continuum ranging from angry to happy. Sixteen patients with schizophrenia participated in six training sessions and three test sessions (i.e., pre-training, post-training, and generalization). Eighteen healthy controls participated only in pre-training test session. Prior to training, the patients with schizophrenia performed significantly worse than did the controls in the recognition of anger; however, following the training, the patients showed a significant improvement in recognizing anger, which was maintained and generalized to a new set of stimuli. The patients also improved the recognition of happiness following the training, but this effect was not maintained or generalized. These results provide preliminary evidence that a multimodal, audiovisual training may yield improvements in anger perception for patients with schizophrenia.

Benefits of social cognitive skills training within routine community mental health services: Evidence from a non-randomized parallel controlled study

Although social cognitive impairments are evident in patients with schizophrenia across many cultures, psychosocial interventions are less used in Eastern countries. Despite a growing emphasis on community care in mental health services in Eastern countries, the synergistic effects of social cognitive intervention strategies on routine community mental health services are not well documented. This study aimed to adapt a group-based social cognitive skills training (SCST) program for use in a Korean context and evaluate its feasibility and preliminary effects among community-dwelling individuals with schizophrenia. Forty-seven patients were assigned to either the SCST + treatment as usual (TAU) group (n = 21) or the TAU only group (n = 24). Participants completed tasks to assess social cognition, social functioning, neurocognition, and psychiatric symptoms before and after treatment. Over a period of approximately 12 weeks, drop-out rates were comparably low in both groups, and the attendance rates for the SCST program were high (85.7 %, mean sessions attended = 20.56/24 sessions). The SCST + TAU group demonstrated significant improvements in facial affect recognition, social functioning, and psychiatric symptoms compared to the TAU only group. A non-significant trend in theory of mind was observed, along with no improvements in social perception and neurocognition. The adapted version of the SCST program is feasible for implementation and demonstrates promise for enhancing social cognition and functioning in Korean outpatients with schizophrenia.

Dynamic Interactive Social Cognition Training in Virtual Reality (DiSCoVR) for People With a Psychotic Disorder: Single-Group Feasibility and Acceptability Study

BACKGROUND

People with a psychotic disorder commonly experience problems in social cognition and functioning. Social cognition training (SCT) improves social cognition, but may inadequately simulate real-life social interactions. Virtual reality (VR) provides a realistic, interactive, customizable, and controllable training environment, which could facilitate the application of skills in daily life.

OBJECTIVE

We developed a 16-session immersive VR SCT (Dynamic Interactive Social Cognition Training in Virtual Reality [DiSCoVR]) and conducted a single-group feasibility pilot study.

METHODS

A total of 22 people with a psychotic disorder and reported problems in social cognition participated. Feasibility and acceptability were assessed using a survey for participants and therapists, and by examining relevant parameters (eg, dropouts). We analyzed preliminary treatment effects on social cognition, neurocognition, and psychiatric symptoms.

RESULTS

A total of 17 participants completed the study. Participants enjoyed DiSCoVR (mean 7.25, SD 2.05; range 3-10), thought it was useful for daily social activities (mean 7.00, SD 2.05; range 3-10), and enjoyed the combination of VR and a therapist (mean 7.85, SD 2.11; range 3-10). The most frequently mentioned strength of DiSCoVR was the opportunity to practice with personalized social situations (14/20, 70%). A significant improvement of emotion perception was observed (Ekman 60 Faces; t₁₆=-4.79, P<.001, d=-0.67), but no significant change was found in other measures of social cognition, neurocognition, psychiatric symptoms, or self-esteem.

CONCLUSIONS

DiSCoVR was feasible and acceptable to participants and therapists, and may improve emotion perception.