PANSS-6: a brief rating scale for the measurement of severity in schizophrenia

Distinct global brain connectivity alterations in depressed adolescents with subthreshold mania and the relationship with processing speed: Evidence from sBEAD Cohort

BACKGROUND

Bipolar disorder (BD) is a progressive condition. Investigating the neuroimaging mechanisms in depressed adolescents with subthreshold mania (SubMD) facilitates the early identification of BD. However, the global brain connectivity (GBC) patterns in SubMD patients, as well as the relationship with processing speed before the onset of full-blown BD, remain unclear.

METHODS

The study involved 72 SubMD, 77 depressed adolescents without subthreshold mania (nSubMD), and 69 gender- and age-matched healthy adolescents (HCs). All patients underwent a clinical follow-up ranging from six to twelve months. We calculated the voxel-based graph theory analysis of the GBC map and conducted the TMT-A test to measure the processing speed.

RESULTS

Compared to HCs and nSubMD, SubMD patients displayed distinctive GBC index patterns: GBC index decreased in the right Medial Superior Frontal Gyrus (SFGmed.R)/Superior Frontal Gyrus (SFG) while increased in the right Precuneus and left Postcentral Gyrus. Both patient groups showed increased GBC index in the right Inferior Temporal Gyrus. An increased GBC value in the right Supplementary Motor Area was exclusively observed in the nSubMD-group. There were opposite changes in the GBC index in SFGmed.R/SFG between two patient groups, with an AUC of 0.727. Additionally, GBC values in SFGmed.R/SFG exhibited a positive correlation with TMT-A scores in SubMD-group.

LIMITATIONS

Relatively shorter follow-up duration, medications confounding, and modest sample size.

CONCLUSION

These findings suggest that adolescents with subthreshold BD have specific impairments patterns at the whole brain connectivity level associated with processing speed impairments, providing insights into early identification and intervention strategies for BD.

The contribution of prosody to machine classification of schizophrenia

We show how acoustic prosodic features, such as pitch and gaps, can be used computationally for detecting symptoms of schizophrenia from a single spoken response. We compare the individual contributions of acoustic and previously-employed text modalities to the algorithmic determination whether the speaker has schizophrenia. Our classification results clearly show that we can extract relevant acoustic features better than those textual ones. We find that, when combined with those acoustic features, textual features improve classification only slightly.

Overcoming the barriers to identifying and managing treatment-resistant schizophrenia and to improving access to clozapine: A narrative review and recommendation for clinical practice

Clozapine is the only approved antipsychotic for treatment-resistant schizophrenia (TRS). Although a large body of evidence supports its efficacy and favorable risk-benefit ratio in individuals who have failed two or more antipsychotics, clozapine remains underused. However, variations in clozapine utilization across geographic and clinical settings suggest that it could be possible to improve its use. In this narrative review and expert opinion, we summarized information available in the literature on the mechanisms of action, effectiveness, and potential adverse events of clozapine. We identified barriers leading to discouragement in clozapine prescription internationally, and we proposed practical solutions to overcome each barrier. One of the main obstacles identified to the use of clozapine is the lack of appropriate training for physicians: we highlighted the need to develop specific professional programs to train clinicians, both practicing and in residency, on the relevance and efficacy of clozapine in TRS treatment, initiation, maintenance, and management of potential adverse events. This approach would facilitate physicians to identify eligible patients and offer clozapine as a treatment option in the early stage of the disease. We also noted that increasing awareness of the benefits of clozapine among healthcare professionals, people with TRS, and their caregivers can help promote the use of clozapine. Educational material, such as leaflets or videos, could be developed and distributed to achieve this goal. The information provided in this article may be useful to improve disease burden and support healthcare professionals, patients, and caregivers navigating the complex pathways to TRS management.

Screening for psychotic experiences and psychotic disorders in general psychiatric settings: a systematic review and meta-analysis

Background

The absence of systematic screening for psychosis within general psychiatric services contribute to substantial treatment delays and poor long-term outcomes. We conducted a meta-analysis to estimate rates of psychotic experiences, clinical high-risk for psychosis syndrome (CHR-P), and psychotic disorders identified by screening treatment-seeking individuals to inform implementation recommendations for routine psychosis screening in general psychiatric settings.

Methods

PubMed and Web of Science databases were searched to identify empirical studies that contained information on the point prevalence of psychotic experiences, CHR-P, or psychotic disorders identified by screening inpatient and outpatient samples aged 12-64 receiving general psychiatric care. Psychotic experiences were identified by meeting threshold scores on validated self-reported questionnaires, and psychotic disorders and CHR-P by gold-standard structured interview assessments. A meta-analysis of each outcome was conducted using the Restricted Maximum Likelihood Estimator method of estimating effect sizes in a random effects model.

Results

41 independent samples (k=36 outpatient) involving n=25,751 patients (58% female, mean age: 24.1 years) were included. Among a general psychiatric population, prevalence of psychotic experiences was 44.3% (95% CI: 35.8-52.8%; 28 samples, n=21,957); CHR-P was 26.4% (95% CI: 20.0-32.7%; 28 samples, n=14,395); and psychotic disorders was 6.6% (95% CI: 3.3-9.8%; 32 samples, n=20,371).

Conclusions

High rates of psychotic spectrum illness in general psychiatric settings underscore need for secondary prevention with psychosis screening. These base rates can be used to plan training and resources required to conduct assessments for early detection, as well as build capacity in interventions for CHR-P and early psychosis in non-specialty mental health settings.

Developing a machine learning-based short form of the positive and negative syndrome scale

BACKGROUND AND HYPOTHESIS

The Positive and Negative Syndrome Scale (PANSS) consists of 30 items and takes up to 50 minutes to administer and score. Therefore, this study aimed to develop and validate a machine learning-based short form of the PANSS (PANSS-MLSF) that reproduces the PANSS scores. Moreover, the PANSS-MLSF estimated the removed-item scores.

STUDY DESIGN

The PANSS-MLSF was developed using an artificial neural network, and the removed-item scores were estimated using the eXtreme Gradient Boosting classifier algorithm. The reliability of the PANSS-MLSF was examined using Cronbach's alpha. The concurrent validity was examined by the association (Pearson's r) between the PANSS-MLSF and the PANSS. The convergent validity was examined by the association (Pearson's r) between the PANSS-MLSF and the Clinical Global Impression-Severity, Mini-Mental State Examination, and Lawton Instrumental Activities of Daily Living Scale. The agreement of the estimated removed-item scores with their original scores was examined using Cohen's kappa.

STUDY RESULTS

Our analysis included data from 573 patients with moderate severity. The two versions of the PANSS-MLSF comprised 15 items and 9 items were proposed. The PANSS-MLSF scores were similar to the PANSS scores (mean squared error=2.6-24.4 points). The reliability, concurrent validity, and convergent validity of the PANSS-MLSF were good. Moderate to good agreement between the estimated removed-item scores and the original item scores was found in 60% of the removed items.

CONCLUSION

The PANSS-MLSF offers a viable way to reduce PANSS administration time, maintain score comparability, uphold reliability and validity, and even estimate scores for the removed items.

Improvement of social functioning in patients with first-episode schizophrenia using blonanserin treatment: a prospective, multi-centre, single-arm clinical trial

Objectives

This clinical trial primarily aimed to investigate the effects of blonanserin on social functioning in patients with first-episode schizophrenia.

Methods

In this prospective, multi-centre, single-arm clinical trial study, blonanserin (flexible oral dose ranging from 8mg to 24mg per day) was given 26 weeks. Outcome measures included the Personal and Social Performance (PSP) scale for evaluating social functioning, the Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery (MCCB) for measuring neurocognitive performance, and the Positive and Negative Syndrome Scale (PANSS) for assessing symptom severity. The primary endpoint was social function improvement evaluated by PSP scale at the end of blonanserin treatment. And the secondary endpoint was to validate the efficacy and neurocognitive effects of blonanserin. Adverse drug reactions (ADRs) were also recorded and analysed.

Results

A total of 96 patients with first-episode schizophrenia were recruited and proceeded to analysis. Fifty-one participants (53.1%) completed the PSP scale measurements at baseline and week 26. Following 26 weeks of blonanserin treatment, all outcome measurements demonstrated significant improvement during the follow-up period. Notably, PSP scores exhibited a continuous increase up to 68.1% ± 103.7% at the end of the treatment (46.6 ± 14.6 at baseline, 69.4 ± 17.4 at week 26, p<0.001), indicating positive effects on social functioning that were already noticeable by week 8.

Conclusion

Blonanserin treatment exhibited favourable effects on social functioning in individuals with first-episode schizophrenia. The results suggest that blonanserin was effective treatment options for patients with schizophrenia encountering functional impairments.

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.

Proxy measures for the assessment of psychotic and affective symptoms in studies using electronic health records

BACKGROUND

There is a lack of standardised psychometric data in electronic health record (EHR)-based research. Proxy measures of symptom severity based on patients' clinical records may be useful surrogates in mental health EHR research.

AIMS

This study aimed to validate proxy tools for the short versions of the Positive and Negative Syndrome Scale (PANSS-6), Young Mania Rating Scale (YMRS-6) and Montgomery-Åsberg Depression Rating Scale (MADRS-6).

METHOD

A cross-sectional, multicentre study was conducted in a sample of 116 patients with first-episode psychosis from 12 public hospitals in Spain. Concordance between PANSS-6, YMRS-6 and MADRS-6 scores and their respective proxies was evaluated based on information from EHR clinical notes, using a variety of statistical procedures, including multivariate tests to adjust for potential confounders. Bootstrapping techniques were used for internal validation, and an independent cohort from the Treatment and Early Intervention in Psychosis Program (TIPP-Lausanne, Switzerland) for external validation.

RESULTS

The proxy versions correlated strongly with their respective standardised scales (partial correlations ranged from 0.75 to 0.84) and had good accuracy and discriminatory power in distinguishing between patients in and not in remission (percentage of patients correctly classified ranged from 83.9 to 91.4% and bootstrapped optimism-corrected area under the receiver operating characteristic curve ranged from 0.76 to 0.89), with high interrater reliability (intraclass correlation coefficient of 0.81). The findings remained robust in the external validation data-set.

CONCLUSIONS

The proxy instruments proposed for assessing psychotic and affective symptoms by reviewing EHR provide a feasible and reliable alternative to traditional structured psychometric procedures, and a promising methodology for real-world practice settings.

Randomized, double-blind, sham-controlled trial to evaluate the efficacy and tolerability of electroconvulsive therapy in patients with clozapine-resistant schizophrenia

There is no established treatment for patients with clozapine-resistant schizophrenia (CRS). Clozapine augmentation strategies with antipsychotics or others substances are effective in comparison with placebo while and Electroconvulsive therapy (ECT) showed to be effective in comparison with treatment as usual (TAU) but not with placebo (sham-ECT). In the present double- blind randomized controlled trial, we compared 40 outpatients who received 20 sessions of ECT (n = 21) or sham-ECT (n = 19) (age = 37.40 ± 9.62, males = 77.5 %, illness duration = 14.95 ± 8.32 years, mean total Positive and Negative Syndrome Scale (PANSS) = 101.10 ± 24.91) who fulfilled well-defined CRS criteria including baseline clozapine plasma levels ≥350 ng/mL. The primary outcome was the ≥50 % PANSS Total Score reduction; secondary outcomes were the scores of the PANSS subscales, PANSS five-factor dimensions, PANSS-6 and the Calgary Depression Rating Scale (CDRS). Treatment response was analyzed by percentage reduction, Linear Mixed Models and effect sizes. At baseline both groups showed no differences except for years of school education (included as a covariate). At endpoint, only 1/19 of the completers (5.26 %) in the ECT group and 0/17 in the sham-ECT group showed a ≥50 % total PANSS score reduction. Both groups showed no significant differences of the total PANSS score (F = 0.12; p = 0.73), Positive (F = 0.27, p = 0.61), Negative (F = 0.25, p = 0.62), and General Psychopathology scores (F = 0.01, p = 0.94) as well for all PANSS five factors, the PANSS-6 and CDRS. Thus, the present study found no evidence that ECT is better than Sham-ECT in patients with CRS. Future sham-ECT controlled studies with larger sample sizes are warranted to test the efficacy of ECT for patients with CRS.

Evaluation of a Cannabis Harm Reduction Intervention for People With First-Episode Psychosis: Protocol for a Pilot Multicentric Randomized Trial

BACKGROUND

Cannabis use is highly prevalent in young people with first-episode psychosis (FEP). Most report cannabis use and are often diagnosed with a cannabis use disorder upon admission to specialized services for psychosis. Cannabis use in this population is associated with worse clinical and psychosocial outcomes, rendering it an important clinical target. Despite this, few cannabis-specific interventions have been developed for FEP and empirically evaluated through randomized controlled trials. Most evaluated interventions have targeted cannabis abstinence, with limited efficacy, but none have centered on harm reduction outcomes for people with FEP who use cannabis. Early intervention services (EIS), the standard of care for FEP, have not successfully addressed problematic cannabis use in people with FEP either. Clinical trials are needed to explore the potential of harm reduction strategies, although these should be preceded by robust pilot studies to establish optimal design and approaches.

OBJECTIVE

Recognizing the need for harm reduction strategies for individuals with FEP who use cannabis and based on research on patients' preferences supporting harm reduction interventions, we developed a mobile app-based cannabis harm reduction intervention for this population. This intervention is called Cannabis Harm-reducing Application to Manage Practices Safely (CHAMPS). Here, we describe the protocol for a multicenter, 2-arm, parallel group, randomized pilot trial evaluating the acceptability of CHAMPS for people with FEP who use cannabis and the feasibility of conducting a full-scale trial in this population using CHAMPS. The impact on key clinical outcomes will also be explored.

METHODS

This pilot trial aims to recruit 100 young people with FEP using cannabis from 6 Canadian EIS clinics. Participants will be randomized in a 1:1 ratio to CHAMPS+EIS or EIS-only. CHAMPS acceptability will be assessed using completion rates for the intervention arm. Trial feasibility will be assessed using a retention rate for randomized participants. Secondary outcomes will explore tendencies of change in the use of protective behavioral strategies and in motivation to change strategies. Exploratory outcomes include cannabis use-related problems, other substance use, the severity of dependence, psychotic symptoms, and health care service use.

RESULTS

Recruitment began in December 2021. Data collection and analysis are expected to be completed in early 2024. Study results describing CHAMPS acceptability and trial feasibility will then be submitted for publication in a peer-reviewed journal.

CONCLUSIONS

CHAMPS uniquely combines evidence-based approaches, patient perspectives, and mobile health technology to support harm reduction in people with FEP who use cannabis. Attaining adequate acceptability and feasibility through this trial may justify further exploration of harm reduction tools, particularly within the context of conducting a larger-scale randomized controlled trial. This pilot trial has the potential to advance knowledge for researchers and clinicians regarding a feasible and user-acceptable research design in the cannabis and early psychosis fields.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04968275, https://clinicaltrials.gov/ct2/show/NCT04968275.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53094.

Treatment of schizophrenia evaluated via the pharmacopsychometric triangle-An integrative approach with emphasis on well-being and functioning

Quantification of treatment response is crucial to optimize outcomes for patients with schizophrenia. In this study, we evaluated the relationship between quantitative measures of clinician-rated symptom severity and self-rated side effects, well-being, and functioning among inpatients with schizophrenia using the six-item version of the Positive and Negative Syndrome Scale (PANSS-6), the Glasgow Antipsychotic Side-effect Scale (GASS), the WHO-Five Well-being Index (WHO-5), and the Sheehan Disability Scale (SDS). All measurements were conducted as close to admission and discharge as possible. Well-being and functioning were found to be most strongly associated with the additive effect of symptoms and side effects, while changes in side effects, well-being, and functioning appeared to be relatively independent from changes in symptom severity. The use of both symptom and side effect measures should inform clinical decision-making in the treatment of schizophrenia, as it has the potential to optimize functioning and well-being.

A Cross-sectional Conceptual Replication and Longitudinal Evaluation of the PANSS-Autism-Severity-Score Measure Suggests it Does Not Capture Autistic Traits in Individuals With Psychosis

BACKGROUND

Autism and psychosis co-occur at elevated rates, with implications for clinical outcomes, functioning, and suicidality. The PANSS-Autism-Severity-Score (PAUSS) is a measure of autism trait severity which has not yet been validated externally or longitudinally.

STUDY DESIGN

Participants were derived from the GROUP and SCOPE datasets. Participants included 1448 adults with schizophrenia spectrum disorder (SSD), 800 SSD-siblings, 103 adults diagnosed with an autistic spectrum condition (ASC), and 409 typically-developing controls (TC). Analyses from the original validation study were conducted with SSD participants, and extended into ASC, SSD-sibling, and TC participants. Test-retest reliability of the PAUSS at 2-weeks and long-term stability 3 and 6-years was also examined.

STUDY RESULTS

Results differed in important ways from the original validation. SSD participants reported higher PAUSS scores than other groups, with only a fraction of ASC participants scoring as "PAUSS-Autistic." Cronbach's alpha was acceptable for the SSD cohort only. Two-week stability of the PAUSS was fair to good for all PAUSS scores. Long-term stability was poor for most PAUSS items but fair for total PAUSS score.

CONCLUSIONS

Results suggest that the PAUSS does not appear appropriate for assessing autism, with the low rate of PAUSS-Autistic in the ASC population suggesting the PAUSS may not accurately reflect characteristics of autism. The relative lack of long-term stability is cause for concern and suggestive that the PAUSS is capturing features of psychosis rather than autism traits.

An umbrella review of candidate predictors of response, remission, recovery, and relapse across mental disorders

We aimed to identify diagnosis-specific/transdiagnostic/transoutcome multivariable candidate predictors (MCPs) of key outcomes in mental disorders. We conducted an umbrella review (protocol  link ), searching MEDLINE/Embase (19/07/2022), including systematic reviews of studies reporting on MCPs of response, remission, recovery, or relapse, in DSM/ICD-defined mental disorders. From published predictors, we filtered MCPs, validating MCP criteria. AMSTAR2/PROBAST measured quality/risk of bias of systematic reviews/individual studies. We included 117 systematic reviews, 403 studies, 299,888 individuals with mental disorders, testing 796 prediction models. Only 4.3%/1.2% of the systematic reviews/individual studies were at low risk of bias. The most frequently targeted outcome was remission (36.9%), the least frequent was recovery (2.5%). Studies mainly focused on depressive (39.4%), substance-use (17.9%), and schizophrenia-spectrum (11.9%) disorders. We identified numerous MCPs within disorders for response, remission and relapse, but none for recovery. Transdiagnostic MCPs of remission included lower disease-specific symptoms (disorders = 5), female sex/higher education (disorders = 3), and quality of life/functioning (disorders = 2). Transdiagnostic MCPs of relapse included higher disease-specific symptoms (disorders = 5), higher depressive symptoms (disorders = 3), and younger age/higher anxiety symptoms/global illness severity/ number of previous episodes/negative life events (disorders = 2). Finally, positive trans-outcome MCPs for depression included less negative life events/depressive symptoms (response, remission, less relapse), female sex (response, remission) and better functioning (response, less relapse); for schizophrenia, less positive symptoms/higher depressive symptoms (remission, less relapse); for substance use disorder, marital status/higher education (remission, less relapse). Male sex, younger age, more clinical symptoms and comorbid mental/physical symptoms/disorders were poor prognostic factors, while positive factors included social contacts and employment, absent negative life events, higher education, early access/intervention, lower disease-specific and comorbid mental and physical symptoms/conditions, across mental disorders. Current data limitations include high risk of bias of studies and extraction of single predictors from multivariable models. Identified MCPs can inform future development, validation or refinement of prediction models of key outcomes in mental disorders.

Are informants required to obtain valid ratings on the Positive and Negative Syndrome Scale (PANSS)?

Ratings on the Positive and Negative Syndrome Scale (PANSS) are ideally based on both a patient interview and an informant questionnaire. In research and clinical settings, however, the informant questionnaire is often omitted. This study investigated the consequences of omitting informant information by comparing PANSS ratings of patients with schizophrenia (n = 49 patients, 77 ratings) conducted with and without informant information, respectively. Additionally, changes in symptom severity over time based on ratings with and without informant information were also compared for the full PANSS and the six-item version of the PANSS (PANSS-6). PANSS ratings including informant information were higher than those without, both at the total score and individual item level. Additionally, the full PANSS appeared less "responsive" to baseline-to-endpoint changes for ratings without informant information compared to ratings including informant information, while no differences were found for the PANSS-6.

Initial severity of the Positive and Negative Syndrome Scale (PANSS)-30, its main subscales plus the PANSS-6, and the relationship to subsequent improvement and trial dropout: a pooled participant-level analysis of 18 placebo-controlled risperidone and paliperidone trials

Greater initial severity on the 30-item Positive and Negative Syndrome Scale (PANSS-30) correlates positively with antipsychotic-placebo separation and trial dropout, but it is unknown whether these associations are present also on PANSS-derived subscales. We assessed the relationship between initial severity and antipsychotic-placebo separation as measured by PANSS-30 and four PANSS symptom subscales: the positive (PANSS-POS), negative (PANSS-NEG), general (PANSS-GEN) and 6-item (PANSS-6) subscales, using patient-level data from 18 placebo-controlled risperidone and paliperidone trials. Analysis of covariance in the intention-to-treat population (last-observation-carried-forward) was used to assess antipsychotic-placebo separation and trial dropout. Across 6685 participants (90% schizophrenia, 10% schizoaffective disorder), the initial severity-by-treatment interaction was statistically significant for PANSS-30 (beta: -0.155; p < 0.001) and all PANSS subscales (beta range: -0.097 to -0.135; p-value range: < 0.001 to 0.002). In all cases, antipsychotic-placebo differences increased with initial severity. Judging by the distribution of relative outcomes (percent remaining symptoms), the interaction was partly explained by an increased chance of responding, but also by larger numerical responses in those who did respond, as initial severity increased. Except for PANSS-NEG, high initial severity on all PANSS scales predicted increased trial dropout, although not statistically significantly so for PANSS-6. In summary, we thus replicate previous findings showing greater initial severity to predict larger antipsychotic-placebo separation and extend these results to four PANSS subscales. For PANSS-POS and PANSS-GEN, but not for PANSS-NEG and PANSS-6, we also replicate the association between initial severity and trial dropout. Patients with low initial negative symptom severity were identified as a group of particular interest for further study since their results diverged most from the average both with regard to antipsychotic-placebo separation (low separation measured by PANSS-NEG) and trial dropout (high level).

A smoking cessation intervention for people with severe mental illness treated in ambulatory mental health care (KISMET): study protocol of a randomised controlled trial

BACKGROUND

Smoking among people with severe mental illness (SMI) is highly prevalent and strongly associated with poor physical health. Currently, evidence-based smoking cessation interventions are scarce and need to be integrated into current mental health care treatment guidelines and clinical practice. Therefore, the present study aims to evaluate the implementation and effectiveness of a smoking cessation intervention in comparison with usual care in people with SMI treated by Flexible Assertive Community Treatment (FACT) teams in the Netherlands.

METHODS

A pragmatic, cluster-randomised controlled trial with embedded process evaluation will be conducted. Randomisation will be performed at the level of FACT teams, which will be assigned to the KISMET intervention or a control group (care as usual). The intervention will include pharmacological treatment combined with behavioural counselling and peer support provided by trained mental health care professionals. The intervention was developed using a Delphi study, through which a consensus was reached on the core elements of the intervention. We aim to include a total of 318 people with SMI (aged 18-65 years) who smoke and desire to quit smoking. The primary outcome is smoking status, as verified by carbon monoxide measurements and self-report. The secondary outcomes are depression and anxiety, psychotic symptoms, physical fitness, cardiovascular risks, substance use, quality of life, and health-related self-efficacy at 12 months. Alongside the trial, a qualitative process evaluation will be conducted to evaluate the barriers to and facilitators of its implementation as well as the satisfaction and experiences of both patients and mental health care professionals.

DISCUSSION

The results of the KISMET trial will contribute to the evidence gap of effective smoking cessation interventions for people treated by FACT teams. Moreover, insights will be obtained regarding the implementation process of the intervention in current mental health care. The outcomes should advance the understanding of the interdependence of physical and mental health and the gradual integration of both within the mental health care system.

TRIAL REGISTRATION

Netherlands Trial Register, NTR9783. Registered on 18 October 2021.

Effect of the GLP-1 receptor agonist semaglutide on metabolic disturbances in clozapine-treated or olanzapine-treated patients with a schizophrenia spectrum disorder: study protocol of a placebo-controlled, randomised clinical trial (SemaPsychiatry)

INTRODUCTION

Clozapine and olanzapine are some of the most effective antipsychotics, but both are associated with weight gain and relevant metabolic disturbances, including pre-diabetes and diabetes. Non-pharmacological/behavioural interventions have had limited effects counteracting these adverse effects. Semaglutide, a glucagon-like peptide 1 receptor agonist, is approved for the treatment of type 2 diabetes and obesity. We will investigate the long-term effects of add-on treatment with semaglutide once a week versus placebo once a week on the metabolic status in pre-diabetic (glycated haemoglobin A1c (HbA1c) 35-47 mmol/mol (5.4%-6.4%) and diabetic (HbA1c 48-57 mmol/mol (6.5%-7.4%)) patients diagnosed with a schizophrenia spectrum disorder who initiated clozapine or olanzapine treatment within the last 60 months.

METHODS AND ANALYSIS

This is a 26-week, double-blinded, randomised, placebo-controlled trial. Altogether, 104 patients diagnosed with a schizophrenia spectrum disorder, aged 18-65 years, with pre-diabetes or diabetes will be randomised to injections of 1.0 mg semaglutide once a week or placebo for 26 weeks. The primary endpoint is change from baseline in HbA1c. Secondary endpoints include changes in body weight, hip and waist circumference and plasma levels of insulin, glucagon, glucose, and C-peptide, insulin sensitivity, beta cell function, hepatic function, fibrosis-4 score, lipid profile, incretin hormones, bone markers, body composition, bone density, proteomic analyses and oxidative stress markers. Together with alcohol, tobacco and drug use, potential effects on the reward value of a sweet-fat stimulus, psychopathology, level of activity and quality of life will also be assessed.

ETHICS AND DISSEMINATION

This study is approved by the Danish Medicines Agency and the regional scientific ethics committee of the Capital Region of Denmark (committee C, #H-20019008) and will be carried out in accordance with International Council for Harmonisation Good Clinical Practice guidelines and the Helsinki Declaration. The results will be disseminated through peer-review publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04892199.

Response of Polish Psychiatric Patients to the Russian Invasion of Ukraine in February 2022-Predictive Role of Risk Perception and Temperamental Traits

This study examined the impact of the Russian invasion of Ukraine in February 2022 on Polish patients with depression and schizophrenia. It has been hypothesized that possible changes in symptoms may be predicted by the subjective risk perception related with the Russo-Ukraine War (RUW) as well as by temperamental traits. The study was conducted with 80 patients with schizophrenia or depression. A questionnaire measuring sociodemographic characteristics, perception of risk, temperamental characteristics, and symptoms of depression and schizophrenia were used as research tools. Symptom intensity was compared with the average symptom intensity calculated on the basis of archival symptom measurements from the three consecutive months preceding the outbreak of the RUW. Predictors of change in symptoms were also analyzed, taking into account sociodemographic variables, the level of risk perception, and temperamental traits. The results indicate the specific patterns of reactions to war danger for patients with different types of psychiatric diagnosis. Depressed patients reacted with an increase in seven symptoms related to unworthiness and/or guilt, lack of interest, and/or pleasure and pessimism. The response of schizophrenic patients was related only with an increase in positive symptoms. This study highlights the need to provide more support to psychiatric patients in acute emergencies.

Reducing Cannabis Use in Young Adults With Psychosis Using iCanChange, a Mobile Health App: Protocol for a Pilot Randomized Controlled Trial (ReCAP-iCC)

BACKGROUND

Cannabis use is the most prevalent among adolescents and young adults; frequent consumption is associated with cannabis use disorder (CUD) and psychosis, with a high prevalence (up to 50%) of CUD in individuals with first-episode psychosis (FEP). Early Intervention Services (EIS) for psychosis include face-to-face psychosocial interventions for CUD, because reducing or discontinuing cannabis use improves clinical and health care service use outcomes. However, multiple barriers (eg, staff availability and limited access to treatment) can hinder the implementation of these interventions. Mobile health (mHealth) interventions may help circumvent some of these barriers; however, to date, no study has evaluated the effects of mHealth psychological interventions for CUD in individuals with FEP.

OBJECTIVE

This study describes the protocol for a pilot randomized controlled trial using a novel mHealth psychological intervention (iCanChange [iCC]) to address CUD in young adults with FEP. iCC was developed based on clinical evidence showing that in individuals without psychosis, integrating the principles of cognitive behavioral therapy, motivational interviewing, and behavioral self-management approaches are effective in improving cannabis use-related outcomes.

METHODS

Consenting individuals (n=100) meeting the inclusion criteria (eg, aged 18-35 years with FEP and CUD) will be randomly allocated in a 1:1 ratio to the intervention (iCC+modified EIS) or control (EIS) group. The iCC is fully automatized and contains 21 modules that are completed over a 12-week period and 3 booster modules available during the 3-month follow-up period. Validated self-report measures will be taken via in-person assessments at baseline and at 6, 12 (end point), and 24 weeks (end of trial); iCC use data will be collected directly from the mobile app. Primary outcomes are intervention completion and trial retention rates, and secondary outcomes are cannabis use quantity, participant satisfaction, app use, and trial recruiting parameters. Exploratory outcomes include severity of psychotic symptoms and CUD severity. For primary outcomes, we will use the chi-square test using data collected at week 12. We will consider participation in iCC acceptable if ≥50% of the participants complete at least 11 out of 21 intervention modules and the trial feasible if attrition does not reach 50%. We will use analysis of covariance and mixed-effects models for secondary outcomes and generalized estimating equation multivariable analyses for exploratory outcomes.

RESULTS

Recruitment began in July 2022, and data collection is anticipated to be completed in July 2024. The main results are expected to be submitted for publication in 2024. We will engage patient partners and other stakeholders in creating a multifaceted knowledge translation plan to reach a diverse audience.

CONCLUSIONS

If feasible, this study will provide essential data for a larger-scale efficacy trial of iCC on cannabis use outcomes in individuals with FEP and CUD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05310981; https://www.clinicaltrials.gov/ct2/show/NCT05310981.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/40817.

Validation of ratings on the six-item Positive and Negative Syndrome Scale obtained via the Simplified Negative and Positive Symptoms Interview among outpatients with schizophrenia

BACKGROUND

The six-item Positive and Negative Syndrome Scale (PANSS-6) is a measure of the severity of core symptoms of schizophrenia, which can be administered via the brief Simplified Negative and Positive Symptoms Interview (SNAPSI). A recent study has confirmed the validity of PANSS-6 ratings as derived by SNAPSI (PANSS-6_SNAPSI) among inpatients with schizophrenia.

AIMS

We aimed to test the validity of PANSS-6_SNAPSI among outpatients with schizophrenia using PANSS-6 ratings extracted from the 30-item PANSS-30 as derived by the Structured Clinical Interview for the Positive and Negative Syndrome Scale (PANSS-6_SCI-PANSS) as a gold standard reference.

METHODS

PANSS-6_SNAPSI and PANSS-6_SCI-PANSS ratings were obtained at two time points by independent raters with established inter-rater reliability. Agreement between PANSS-6_SNAPSI and PANSS-6_SCI-PANSS ratings was estimated via intra-class coefficients (ICCs) and responsiveness over time was quantified using Spearman's rank correlation coefficients. Post hoc "leave-one-out" analyses were carried out, in which each rater in turn was excluded from the ICC calculations.

RESULTS

Seventy-three outpatients with schizophrenia participated in the study (mean age: 38.3 years; 56% males). The ICC for PANSS-6_SNAPSI versus PANSS-6_SCI-PANSS was 0.67 [95%CI = 0.56-0.76] and the Spearman's rank correlation coefficient for responsiveness was 0.40 (p = 0.004). When data from a specific outlying rater were excluded, the ICC for PANSS-6_SNAPSI versus PANSS-6_SCI-PANSS was 0.75 [95% CI = 0.63-0.83] and the Spearman's rank correlation coefficient for responsiveness was 0.55 (p = 0.018).

CONCLUSIONS

We found PANSS-6_SNAPSI ratings to have acceptable clinical validity, suggesting that PANSS-6_SNAPSI can be used for both inpatients and outpatients with schizophrenia.

The animated assessment of theory of mind for people with schizophrenia (AToMS): development and psychometric evaluation

Theory of mind (ToM) deficits in people with schizophrenia have been reported and associated with impaired social interactions. Thus, ToM deficits may negatively impact social functioning and warrant consideration in treatment development. However, extant ToM measures may place excessive cognitive demands on people with schizophrenia. Therefore, the study aimed to develop a comprehensible Assessment of ToM for people with Schizophrenia (AToMS) and evaluate its psychometric properties. The AToMs was developed in 5 stages, including item formation, expert review, content validity evaluation, animation production, and cognitive interviews of 25 people with schizophrenia. The psychometric properties of the 16-item AToMS (including reliability and validity) were then tested on 59 people with schizophrenia. The newly developed animated AToMS assesses 8 ToM concepts in the cognitive and affective dimensions while placing minimal neurocognitive demands on people with schizophrenia. The AToMS presented satisfactory psychometric properties, with adequate content validity (content validity index = 0.91); mostly moderate item difficulty (item difficulty index = 0.339-0.966); good discrimination (coefficients = 0.379-0.786), internal consistency (Cronbach's α = 0.850), and reliability (intraclass correlation coefficient = 0.901 for test-retest, 0.997 for inter-rater); and satisfactory convergent and divergent validity. The AToMS is reliable and valid for evaluating ToM characteristics in people with schizophrenia. Future studies are warranted to examine the AToMS in other populations (e.g., people with affective disorders) to cross-validate and extend its utility and psychometric evidence.

Clinical high at-risk mental state in young subjects accessing a mental disorder prevention service in Italy

We aim to assess how functioning, depressive symptoms, and psychotic symptoms are associated with different numbers of Clinical High At-Risk Mental State (CHARMS) categories. In this cross-sectional study, we assessed 62 help-seeking subjects aged 15-24 with a drop in functioning, with Structured Clinical Interview for DSM-5, Social and Occupational Functioning Assessment Scale (SOFAS), Comprehensive Assessment of At-Risk Mental State to define risk for psychosis, Hamilton Depression Rating scale (HAM-D), Positive and Negative Symptoms Scale, 6 items (PANSS-6). CHARMS criteria were assessed via retrospective chart review. Overall, 30.6% did not meet any CHARMS component criteria at baseline (CHARMS-), 27.4%, 33.9% and 8.1% met one, two, and three or more CHARMS groups. Overall, 48.8% met criteria for ultra-high risk for psychosis (17.7% without other CHARMS categories), 25.8% risk of borderline personality disorder (3.2% alone), 35.5% mild depression (8.1% alone), 11.3% risk of bipolar disorder (1.6% alone). SOFAS score and HAM-D score worsened from CHARMS- to three or more CHARMS categories, whilst PANSS-6 score did not. In a multivariate regression only PANSS-6 (beta=-1.105, p<0.001) was associated with SOFAS (R²=0.385). Help-seeking youth with poor functioning present symptoms meeting CHARMS criteria. Meeting criteria for multiple CHARMS categories is associated with increased depressive, but not psychotic symptoms, while psychotic symptoms play a prominent role in determining functional impairment. Results should be interpreted within the limitations of the study including the small sample size and the cross-sectional design, and need further replications.

Early Antipsychotic Nonresponse as a Predictor of Nonresponse and Nonremission in Adolescents With Psychosis Treated With Aripiprazole or Quetiapine: Results From the TEA Trial

OBJECTIVE

To evaluate 1) whether early nonresponse to antipsychotics predicts nonresponse and nonremission, 2) patient and illness characteristics as outcome predictors, and 3) response prediction of 30-item Positive and Negative Syndrome Scale (PANSS-30) compared with 6-item PANSS (PANSS-6) and Clinical Global Impressions-Improvement Scale (CGI-I) in youths with first-episode psychosis.

METHOD

Post hoc analysis from a 12-week, double-blinded, randomized trial of aripiprazole vs extended-release quetiapine in adolescents (age 12-17 years) with first-episode psychosis was performed. Early nonresponse (week 2 or week 4) was defined as <20% symptom reduction (PANSS-30) (or <20% symptom reduction [PANSS-6] or CGI-I score 4-7 [less than "minimally improved"]). Nonresponse (week 12) was defined as <50% symptom reduction (PANSS-30). Nonremission (week 12) was defined as a score of >3 on 8 selected PANSS-items. Positive/negative predictive values (PPV/NPV) and receiver operating characteristics, binary logistic regression models, and PPV/NPV using PANSS-6 and CGI-I were analyzed.

RESULTS

Of 113 randomized patients, 84 were included in post hoc analysis (mean [SD] age = 15.7 [1.3] years; 28.6% male). The 12-week symptom decrease was 31.9% [27.9%], most pronounced within the first 2 weeks (61.1% of total PANSS reduction). Response (27.4%) and remission (22.6%) rates were low. Results indicated that early nonresponse reliably predicted 12-week nonresponse (PPV: week 2, 82.2%; week 4, 90.0%) and nonremission (PPV: week 2, 80.0%; week 4, 90.0%); early nonresponse at week 4 was a statistically significant baseline predictor for 12-week nonresponse; and PANSS-6 had similar predictive significance as PANSS-30. However, outcomes were heterogeneous using CGI-I.

CONCLUSION

In youths with first-episode psychosis showing early nonresponse to aripiprazole or extended-release quetiapine, switching antipsychotic drug should be considered. PANSS-6 is a feasible and clinically relevant alternative to PANSS-30 to predict 12-week nonresponse/nonremission.

CLINICAL TRIAL REGISTRATION INFORMATION

Tolerance and Effect of Antipsychotics in Children and Adolescents With Psychosis; https://www.

CLINICALTRIALS

gov/; NCT01119014.

Editorial: Assessing the Predictive Characteristics of Second-Generation Antipsychotic Early Nonresponse in Youth With First-Episode Psychosis

Identifying early predictors of response or nonresponse to medications in youth with first-episode psychosis is essential to optimize outcome. Specifically, longer duration of untreated psychosis is associated with less long-term improvement in youth.¹ Therefore, identifying early predictors of nonresponse to medications is particularly important in patients with first-episode psychosis to minimize duration of untreated psychosis and avoid lengthy trials of ineffective and poorly tolerated medications. Additionally, medication response is associated with better adherence. A recent study of youth with first-episode psychosis reported that medication efficacy promotes adherence if it produces sustained remission of positive symptoms.² Thus, early identification of effective medications is associated with better adherence and ultimately improves outcome. Conversely, characterizing early predictors of nonresponse to specific antipsychotics in patients with first-episode psychosis is also important because it might trigger a clinician to consider pharmacological options that are not typically considered early in the illness course (eg, clozapine).³.

A cohort study of adolescents with depression in China: tracking multidimensional outcomes and early biomarkers for intervention

Background

Depression in adolescents is recognised as a global public health concern, but little is known about the trajectory of its clinical symptoms and pathogenesis. Understanding the nature of adolescents with depression and identifying early biomarkers can facilitate personalised intervention and reduce disease burden.

Aims

To track multidimensional outcomes of adolescents with depression and develop objective biomarkers for diagnosis, as well as response to treatment, prognosis and guidance for early identification and intervention.

Methods

This is a multidimensional cohort study on the Symptomatic trajectory and Biomarkers of Early Adolescent Depression (sBEAD). We planned to recruit more than 1000 adolescents with depression and 300 healthy controls within 5 years. Multidimensional clinical presentations and objective indicators are collected at baseline, weeks 4, 8, 12 and 24, and years 1, 2, 3, 4 and 5.

Conclusions

To the best of our knowledge, this is the first longitudinal cohort study that examines multidimensional clinical manifestations and multilevel objective markers in Chinese adolescents with depression. This study aims at providing early individualised interventions for young, depressed patients to reduce the burden of disease.

Trial registration number

Chinese Clinical Trial Registry ID ChiCTR2100049066.

A Guideline and Checklist for Initiating and Managing Clozapine Treatment in Patients with Treatment-Resistant Schizophrenia

Treatment-resistant schizophrenia (TRS) will affect about one in three patients with schizophrenia. Clozapine is the only treatment approved for TRS, and patients should be treated as soon as possible to improve their chances of achieving remission. Despite its effectiveness, concern over side effects, monitoring requirements, and inexperience with prescribing often result in long delays that can expose patients to unnecessary risks and compromise their chances of achieving favorable long-term outcomes. We critically reviewed the literature on clozapine use in TRS, focusing on guidelines, systematic reviews, and algorithms to identify strategies for improving clozapine safety and tolerability. Based on this, we have provided an overview of strategies to support early initiation of clozapine in patients with TRS based on the latest evidence and our clinical experience, and have summarized the key elements in a practical, evidence-based checklist for identifying and managing patients with TRS, with the aim of increasing confidence in prescribing and monitoring clozapine therapy.

Scalability of the Positive and Negative Syndrome Scale in first-episode schizophrenia assessed by Rasch models

OBJECTIVE

Historically, assessment of the psychometric properties of the Positive and Negative Syndrome Scale (PANSS) has had several foci: (1) calculation of reliability indexes, (2) extraction of subdimensions from the scale, and (3) assessment of the validity of the total score. In this study, we aimed to examine the scalability and to assess the clinical performance of the 30-item PANSS total score as well as the scalability of a shorter version (PANSS-6) of the scale.

METHODS

A composite data set of 1073 patients with first-episode schizophrenia or schizophrenia spectrum disorder was subjected to Rasch analysis of PANSS data from baseline and 4-6 weeks follow-up.

RESULTS

The central tests of fit of the Rasch model failed to satisfy the statistical requirements behind item homogeneity for the PANSS-30 as well as the PANSS-6 total score. For the PANSS-30, Differential Item Functioning was pronounced both for the 7-point Likert scale rating categories and when dichotomizing the rating categories. Subsequently, the Rasch structure analysis in the context of dichotomized items was used to isolate and estimate a systematic error because of item inhomogeneity, as well as a random error. The size of the combined sources of error for the PANSS-30 total score approximated 20% which is often regarded as clinical cut-off between response versus no-response.

CONCLUSION

The results demonstrate the operational consequences of a lack of statistical fit of the Rasch model and suggest that the calculated measure of uncertainty needs to be considered when using the PANSS-30 total score.

Evidence-based Shared-Decision-Making Assistant (SDM-assistant) for choosing antipsychotics: protocol of a cluster-randomized trial in hospitalized patients with schizophrenia

BACKGROUND

Choosing an antipsychotic medication is an important medical decision in the treatment of schizophrenia. This decision requires risk-benefit assessments of antipsychotics, and thus, shared-decision making between physician and patients is strongly encouraged. Although the efficacy and side-effect profiles of antipsychotics are well-established, there is no clear framework for the communication of the evidence between physicians and patients. For this reason, we developed an evidence-based shared-decision making assistant (SDM-assistant) that presents high-quality evidence from network meta-analysis on the efficacy and side-effect profile of antipsychotics and can be used as a basis for shared-decision making between physicians and patients when selecting antipsychotic medications.

METHODS

The planned matched-pair cluster-randomised trial will be conducted in acute psychiatric wards (n = 14 wards planned) and will include adult inpatients with schizophrenia or schizophrenia-like disorders (N = 252 participants planned). On the intervention wards, patients and their treating physicians will use the SDM-assistant, whenever a decision on choosing an antipsychotic is warranted. On the control wards, antipsychotics will be chosen according to treatment-as-usual. The primary outcome will be patients' perceived involvement in the decision-making during the inpatient stay as measured with the SDM-Q-9. We will also assess therapeutic alliance, symptom severity, side-effects, treatment satisfaction, adherence, quality of life, functioning and rehospitalizations as secondary outcomes. Outcomes could be analysed at discharge and at follow-up after three months from discharge. The analysis will be conducted per-protocol using mixed-effects linear regression models for continuous outcomes and logistic regression models using generalised estimating equations for dichotomous outcomes. Barriers and facilitators in the implementation of the intervention will also be examined using a qualitative content analysis.

DISCUSSION

This is the first trial to examine a decision assistant specifically designed to facilitate shared-decision making for choosing antipsychotic medications, i.e., SDM-assistant, in acutely ill inpatients with schizophrenia. If the intervention can be successfully implemented, SDM-assistant could advance evidence-based medicine in schizophrenia by putting medical evidence on antipsychotics into the context of patient preferences and values. This could subsequently lead to a higher involvement of the patients in decision-making and better therapy decisions.

TRIAL REGISTRATION

German Clinical Trials Register (ID: DRKS00027316 , registration date 26.01.2022).

Remote group therapies for cognitive health in schizophrenia-spectrum disorders: Feasible, acceptable, engaging

Severe cognitive impairments and cognitive distortions are core to schizophrenia-spectrum disorders (SSDs) and are associated with deteriorated social functioning. Despite well-established efficacy of group psychosocial therapies targeting cognitive health in SSDs, dissemination of these programs remains limited. Remote delivery offers a promising strategy for increasing the programs' accessibility. Yet, little research has evaluated group therapies for cognitive health delivered in this way. Thus, we aimed to assess, from participants' and therapists' perspectives, the feasibility, acceptability, as well as levels and process of engagement in a videoconference delivery of group psychosocial therapies for SSD patients' cognitive health. Participants, outpatients, attended Action Based Cognitive Remediation or Metacognitive Training, both adapted for videoconference. Then, participants and therapists completed post-therapy questionnaires. Of the 28 participants attending at least one session, 75% completed more than half of sessions and seven dropped out. Technology did not appear to significantly hinder participation in the programs. All completing participants reported a positive experience with therapy, 67% were not bothered by the distance from the therapist, and 77% trusted that the information shared was kept confidential. Therapist-rated levels of attention M = 7.5/9 (SD = 1.04), participation M = 6.91/9 (SD = 1.32), and social interactions M = 5.31/9 (SD = 1.96) were satisfactory. Nonetheless, participants indicated that they would have appreciated more social interactions with group members. These positive results validate the earliest stage in the implementation process for remote group therapies targeting cognitive health in SSDs. Remote delivery promises to improve access to therapies targeting cognitive health and, ultimately, facilitate functional recovery for SSD patients.

Pragmatic implementation of the Clinical Global Impression Scale of Severity as a tool for measurement-based care in a first-episode psychosis program

INTRODUCTION

Measurement-based care (MBC) is an evidence-based practice wherein clinical decisions are informed by patient data collected throughout treatment. MBC has yielded superior patient outcomes compared to standard care. However, the implementation of MBC in the day-to-day practice, particularly in psychotic disorders, poses several challenges. This study evaluates the clinician-rated Clinical Global Impressions Scale of Severity (CGI-S), for MBC implementation at a first-episode psychosis program.

METHODS

The CGI-S was evaluated in the context of routine care on fidelity to practice, inter-rater reliability among psychiatrists and concurrent validity with scales measuring different domains of psychopathology (SAPS, SANS, GAF, BPRS, PANSS-6).

RESULTS

A high fidelity to practice (67%) and inter-rater reliability was found (r_wg = 0.92). CGI-S correlations were significant and strongest with BPRS (r = 0.55; p < 0.01), GAF (r = 0.53; p < 0.01), SAPS (r = 0.52, p < 0.01), and PANSS-6 (r = 0.41; p < 0.05) scores. However, correlations with SANS and PANSS-6 Negative sub-scale were weak.

CONCLUSION

Findings suggest the CGI may be used to overcome important barriers towards MBC implementation within the context of first episode psychosis. However, as suggested by data, further improvements in capturing negative symptoms by rating clinicians are needed.

TWITTER

A novel strategy for measurement-based care to optimize treatment for individuals with first episode psychosis and related psychotic disorders.

Clozapine augmentation with cariprazine for negative symptoms: a case series and literature review

Only about 50% of patients with treatment-resistant schizophrenia respond to clozapine, and many more patients continue to experience ongoing and prominent negative symptoms. These negative symptoms, for which there are limited pharmacological options, may represent the greatest barrier to functional recovery. Cariprazine is a novel antipsychotic drug that is a partial agonist at dopamine D₂ and D₃ receptors with preferential binding to the D₃ receptor, antagonism of 5HT_2B receptors, and partial agonism at 5HT_1A receptors. Cariprazine is currently licenced for the treatment of schizophrenia in Europe and the United States and has also been approved for bipolar disorder in the United States. There is a limited body of evidence to suggest clinical effectiveness as an augmentation strategy for negative symptoms in those treated with clozapine. In this case series, we present five cases of successful treatment of negative symptoms by clozapine combined with cariprazine in treatment-resistant psychosis.

Morphological characteristics of spoken language in schizophrenia patients - an exploratory study

Psychosis is diagnosed based on disruptions in the structure and use of language, including reduced syntactic complexity, derailment, and tangentiality. With the development of computational analysis, natural language processing (NLP) techniques are used in many areas of life to make evaluations and inferences regarding people's thoughts, feelings and behavior. The present study explores morphological characteristic of schizophrenia inpatients using NLP. Transcripts of recorded stories by 49 male subjects (24 inpatients diagnosed with schizophrenia and 25 controls) about 14 Thematic Apperception Test (TAT) pictures were morphologically analyzed. Relative to the control group, the schizophrenic inpatients employed: (1) a similar ratio of nouns, but fewer verbs, adjectives and adverbs; (2) a higher ratio of lemmas to token (LTR) and type to token (TTR); (3) a smaller gap between LTR and TTR; and (4) greater use of the first person. The results were cross-verified using three well-known fitting classifier algorithms (Random Forest, XGBoost and a support vector machine). Tests of prediction accuracy, precision and recall found correct attribution of patients to the schizophrenia group at a rate of between 80 and 90%. Overall, the results suggest that the language of schizophrenic inpatients is significantly different from that of healthy controls, being morphologically less complex, more associative and more focused on the self. The findings support NLP analysis as a complementary addition to the traditional clinical psychosis evaluation for schizophrenia.

The Relational Trip Task, a novel ecological measure of relational memory: data from a schizophrenia sample

INTRODUCTION

Relational memory (RM) is severely impaired in schizophrenia. Unitisation can circumvent RM impairments in clinical populations as measured by the transverse-patterning (TP) task, a well-established measure of RM capacity. We compared memory performance on a new ecological RM measure, the Relational Trip Task (RTT), to that of TP at baseline and examined the effects of a unitisation intervention in RTT performance. RTT involves learning relational information of real-life stimuli, such as the relationship between people and places or objects.

METHODS

TP and RTT performances were examined in 45 individuals with schizophrenia. TP-impaired participants (n = 22) were randomised to either the intervention or an active control group. TP and RTT were administered again after unitisation training. Task validity and reliability were assessed. Intervention group's pre- and post-RTT accuracies were compared and contrasted to that in the control group.

RESULTS

RTT and TP were moderately correlated. TP non-learners had inferior performance in RTT at baseline. Improvement in RTT performance after unitisation training was observed in the intervention group; no pre-post improvement was observed in the control group.

CONCLUSION

RTT has an acceptable criterion validity and excellent alternate-form reliability. Unitisation seemed to be successfully generalized to support associations of real-life stimuli.

Prediction of Self-Report Cognitive Function for the Symptomatic Remission in Schizophrenia Treated with Amisulpride: a Multicenter, 8-Week Case-Control Study

This study aimed to determine whether self-report cognitive function is a predictor of symptomatic remission in amisulpride-treated schizophrenia. Patients with DSM-IV schizophrenia diagnoses who received amisulpride treatment, were recruited. Each patient received amisulpride with a flexible-dose strategy of 400-800 mg daily for eight weeks. Remission was defined by a shorter version of the Positive and Negative Symptom Scale(PANSS)criteria, which includes six items (PANSS-6) with scores of less than three in each item(criteria A) or total six scores of less than fourteen(criteria B). Three hundred and three patients completed the study in 15 hospitals in China. By criteria A, 244 (80.5%) achieved symptomatic remission at endpoint, and 258 (85.1%) by criteria B. Duration of illness (DOI) (criteria A: t = 2.31, P = 0.025,criteria B:t = 2.24,p = 0.026) and perceived deficits questionnaire at baseline (PDQ20 Day0) (criteria A: t = 3.32, P = 0.001,criteria B:t = 2.76,p = 0.006) in remission groups were less than that in non-remission groups. Logistic regression analysis took into account sex, age, age-onset, DOI, and PDQ20(Day0), and showed that PDQ20(Day0) was a predictor for symptomatic remission in criteria A (B = - 0.02, P = 0.014) and criteria B (B = - 0.03, P = 0.005). The odds ratio (OR) of achieving remission will be reduced by 2% in criteria A and 3% in criteria B. There were no significant differences in gender composition, age, BMI, education level, age-onset, a daily dose of amisulpride and the percentage of PDQ20 Improvement between remission and nonremission in criteria A or criteria B. Receiver operating characteristic(ROC) curves were found for PDQ20(Day0) to define the precise scores to predict remission of schizophrenia (criteria A:AUC = 0.614, S.E. = 0.041, 95% CI = 0.535-0.694, p = 0.007; criteria B:AUC = 0.633, S.E. = 0.045, 95% CI = 0.545-0.721, p = 0.005). Our data suggest that an early self-report cognitive function in amisulpride-treated schizophrenia is important in predicting for symptomatic remission, the fewer scores of PDQ20 at baseline mean the patients have less daily cognitive difficulty, the more likely the patient is to achieve symptomatic remission.

Clinical validation of ratings on the six-item Positive and Negative Syndrome Scale obtained via the Simplified Negative and Positive Symptoms Interview

BACKGROUND

The six-item version of the Positive and Negative Syndrome Scale (PANSS-6) has shown promise as a brief measure of the severity of core symptoms of schizophrenia. However, since all prior analyses of the PANSS-6 were based on data extracted from studies using the full 30-item PANSS (PANSS-30), it remains unknown whether it is possible to obtain valid information for the PANSS-6 ratings via a brief interview, such as the Simplified Negative and Positive Symptoms Interview (SNAPSI).

AIMS

We aimed to validate the PANSS-6 ratings obtained via the SNAPSI using the PANSS-6 scores extracted from the PANSS-30 ratings obtained via the comprehensive Structured Clinical Interview for PANSS (SCI-PANSS) as the gold-standard reference.

METHODS

The PANSS-6 ratings based on the SNAPSI and the PANSS-30 ratings based on the SCI-PANSS were conducted by independent raters with established inter-rater reliability.

RESULTS

Seventy-seven inpatients with schizophrenia (M_age = 35.1 ± 11.7 years; males = 57%; paranoid schizophrenia = 75%) participated in the study. The intraclass correlation coefficient (ICC) of the PANSS-6 total scores obtained using the SNAPSI and the PANSS-30-derived PANSS-6 total scores via the SCI-PANSS was 0.77 (p < 0.001). The ICC for the PANSS-6 total score and the PANSS-30-derived PANSS-8 (Andreasen's remission criteria) was 0.75 (p < 0.001). Spearman's rank correlation coefficient for changes in PANSS-6 total scores via the SNAPSI and changes in PANSS-30-derived PANSS-6 total scores was 0.70 (p < 0.001).

CONCLUSIONS

Using the SNAPSI to rate the PANSS-6 enables a focused and brief assessment of the severity of core symptoms of schizophrenia, which facilitates measurement-based care and clinical decision making in the treatment of schizophrenia.

Antipsychotic-placebo separation on the PANSS-6 subscale as compared to the PANSS-30: a pooled participant-level analysis

In order for measurement-based care to be implemented, there is a need for brief rating instruments that can be administered in a short amount of time, but that are still sufficiently informative. Here, we assessed the drug-placebo sensitivity of the six-item subscale (PANSS-6) of the 30-item Positive and Negative Syndrome Scale (PANSS-30) using a large collection of patient-level data (n = 6685) from randomized controlled trials of risperidone and paliperidone. When analyzing the data by study, we found no material difference in mean effect sizes (ES) between the two measures (PANSS-30 ES = 0.45, PANSS-6 ES = 0.44; p = 0.642). Stratifying the pooled population according to several putative effect moderators (e.g., age, formulation, dose, or diagnosis) generally yielded no meaningful ES differences between the two measures. Similarly, early improvement (≥20% improvement at week 1) on the PANSS-6 predicted subsequent response (≥40% improvement at endpoint) as well as the analog prediction using PANSS-30. Finally, cross-sectional symptom remission assessed via the PANSS-6 showed very good agreement (sensitivity = 100%, specificity = 98%) with cross-sectional symptom remission defined by the Remission in Schizophrenia Working Group.

Factor analysis of the relationship between PANSS score and family burden of patients with schizophrenia

This study aims to investigate the burden of family caregivers of patients with schizophrenia, and its influencing factors METHODS: A total of 105 patients with schizophrenia and their caregivers were investigated using the positive and negative symptom scale (PANSS) and family burden scale of disease (FBS) RESULTS: There was a strong correlation between the patient's recovery and family burden, especially between positive and negative symptoms and family financial burden, family daily activities, family recreational activities, and family relationship CONCLUSION: There is a strong correlation between the patient's recovery and family burden, and this is especially correlated to family economic burden, family daily activities, family recreational activities, and family relationship. Medical staff should pay attention to the psychological characteristics of patients and fully understand and avoid the adverse effects of family burden on the rehabilitation of patients.

Clinical validation of the Symptom Self-rating Scale for Schizophrenia (4S) among inpatients

PURPOSE

Self-reports of psychosis-related symptoms may be a valuable supplement to clinician-ratings, but more validation studies are required. The aim of this study was to conduct clinical validation for the Symptom Self-rating Scale for Schizophrenia (4S) in an inpatient setting.

MATERIALS AND METHODS

Inpatients diagnosed with schizophrenia were invited to participate in the study. The participants completed the 4S, the 5-item World Health Organization Wellbeing Index (WHO-5) and the Sheehan Disability Scale (SDS) at two time points. Trained raters assessed participants using the 6-item Positive And Negative Syndrome Scale (PANSS-6). The relationship between the 4S and PANSS-6, self-reported side effects, functioning and wellbeing was assessed using Spearman's correlation coefficient (rho).

RESULTS

Sixty-one participants completed the 4S at least once (yielding a total of 91 completed 4S questionnaires). The 4S total score was weakly correlated with the PANSS-6 total score (rho = 0.37, p < 0.001). The rho's for individual 4S and PANSS-6 subscales and item comparisons ranged from -0.24 (thought disorder) to 0.69 (hallucinations). Finally, the 4S hallucination subscale was also sensitive to change. The 4S was strongly inversely correlated with wellbeing (WHO-5) and moderately inversely correlated with functioning (SDS total score).

CONCLUSION

The 4S holds promise as a valid self-report of core schizophrenia symptoms among inpatients. While the hallucination subscale seems superior to existing scales, the thought disorder subscale needs to be re-developed.

Long-Acting Injectable Antipsychotics in the Treatment of Schizophrenia: Practical Considerations

The positive symptoms of schizophrenia are usually treated with oral antipsychotics despite high rates of nonadherence leading to relapse and rehospitalization. Seven long-acting injectable (LAI) antipsychotics are currently approved by the U.S. Food and Drug Administration for maintenance treatment of schizophrenia. These medications reduce the risk for nonadherence and relapse, yet relatively few clinicians prescribe them. All LAI anti-psychotics are equally effective in treating the positive symptoms of schizophrenia. Dosing requirements, dosing frequencies, and what clinicians should consider in choosing a LAI antipsychotic for a specific patient are discussed. Communication strategies that help patients and families understand what they need to know about schizophrenia and its treatment to share in the decision-making process are also provided. [Journal of Psychosocial Nursing and Mental Health Services, 59(7), 7-12.].

Development and Validation of a Computerized Adaptive Assessment Tool for Discrimination and Measurement of Psychotic Symptoms

OBJECTIVE

Time constraints limit the use of measurement-based approaches in research and routine clinical management of psychosis. Computerized adaptive testing (CAT) can reduce administration time, thus increasing measurement efficiency. This study aimed to develop and test the capacity of the CAT-Psychosis battery, both self-administered and rater-administered, to measure the severity of psychotic symptoms and discriminate psychosis from healthy controls.

METHODS

An item bank was developed and calibrated. Two raters administered CAT-Psychosis for inter-rater reliability (IRR). Subjects rated themselves and were retested within 7 days for test-retest reliability. The Brief Psychiatric Rating Scale (BPRS) was administered for convergent validity and chart diagnosis, and the Structured Clinical Interview (SCID) was used to test psychosis discriminant validity.

RESULTS

Development and calibration study included 649 psychotic patients. Simulations revealed a correlation of r = .92 with the total 73-item bank score, using an average of 12 items. Validation study included 160 additional patients and 40 healthy controls. CAT-Psychosis showed convergent validity (clinician: r = 0.690; 95% confidence interval [95% CI]: 0.610-0.757; self-report: r = .690; 95% CI: 0.609-0.756), IRR (intraclass correlation coefficient [ICC] = 0.733; 95% CI: 0.611-0.828), and test-retest reliability (clinician ICC = 0.862; 95% CI: 0.767-0.922; self-report ICC = 0.815; 95%CI: 0.741-0.871). CAT-Psychosis could discriminate psychosis from healthy controls (clinician: area under the receiver operating characteristic curve [AUC] = 0.965, 95% CI: 0.945-0.984; self-report AUC = 0.850, 95% CI: 0.807-0.894). The median length of the clinician-administered assessment was 5 minutes (interquartile range [IQR]: 3:23-8:29 min) and 1 minute, 20 seconds (IQR: 0:57-2:09 min) for the self-report.

CONCLUSION

CAT-Psychosis can quickly and reliably assess the severity of psychosis and discriminate psychotic patients from healthy controls, creating an opportunity for frequent remote assessment and patient/population-level follow-up.

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

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

Standardized training in the rating of the six-item Positive And Negative Syndrome Scale (PANSS-6)

The six-item Positive And Negative Syndrome Scale (PANSS-6) allows for a brief assessment of the severity of core symptoms of schizophrenia. However, implementing the PANSS-6 in clinical practice requires that staff members' ratings are accurate and reliable. We aimed to investigate whether such accuracy and reliability can be obtained via a brief video-based training program. One-hundred-and-four staff members from a psychiatric hospital in Denmark participated in the training. Participants performed a baseline PANSS-6 rating based on a video of a patient being interviewed using the Simplified positive And Negative Symptoms interview (SNAPSI). Subsequently, a theoretical introduction video was displayed followed by five successive videotaped SNAPSI patient interviews. After each SNAPSI video, individual ratings were conducted before a video providing the gold standard rating was displayed. The accuracy of ratings was estimated by calculating the proportion of participants not deviating from the gold standard rating with >2 points on individual items or >6 points on the PANSS-6 total score. Reliability was tested after each step in the training by means of Gwet's Agreement Coefficient (Gwet). By the end of the training, 72% of the participants rated within the acceptable deviations of the gold standard, ranging from 60% (nurses) to 91% (medical doctors & psychologists). The reliability improved (Gwet baseline vs. endpoint) for all PANSS-6 items, except for Blunted affect. In conclusion, the majority of the staff members conducted accurate PANSS-6 ratings after a brief standardized training program, supporting the implementation of PANSS-6 in clinical settings to facilitate measurement-based care.

Assessment of the Minimum Clinically Important Difference in Symptoms and Functions of Patients With Acute Schizophrenia: A Post hoc Analysis of an Open-Label, Single-Arm Multicenter Study

The purpose of this study was to evaluate the application of the minimum clinically important difference (MCID) concept to clinical results in Chinese patients with acutely exacerbated schizophrenia. The original study was an 8-week, open-label, single-arm, multicenter study of flexible doses of paliperidone-extended release (pali-ER) in Chinese patients with acutely exacerbated schizophrenia. This is a post hoc analysis to determine the MCID value of PANSS, PSP and evaluate the responsiveness of each outcome measurements in the acute phase of schizophrenia. The responsiveness of the four measurements (PANSS, PANSS reduction rate, PSP, CGI-S) was analyzed. Four hundred ninety nine patients completed the 8-week follow-up and were finally used for this post hoc analysis. The MCID calculated by different approaches varied from 14.02 to 31.50 for PANSS, 15.14 to 42.79% for PANSS reduction rate, and 7.62 to 13.13% for PSP. In addition, the improvement of the CGI-S owned the highest responsiveness of the four outcome measurements. The threshold value of MCID for schizophrenia patients was determined by choice of the assessment method to an extent. In addition, the CGI-S score appeared to be the most valid and responsive measure of effectiveness for the acute phase of schizophrenia when take the treatment satisfaction of patients as anchor.

Online Survey of Clinical Practice in Patients with Schizophrenia Treated with Long-Acting Injectable Aripiprazole or Paliperidone Palmitate

BACKGROUND

To obtain real-world evidence of functional improvements during atypical long-acting injectable (aLAI) therapy in recent-onset schizophrenia, an online survey was conducted to assess the impact of aripiprazole once-monthly injectable 400 mg (AOM 400; partial D₂ receptor agonist) and paliperidone palmitate once-monthly (PP1M; injectable, full D₂ receptor antagonist).

METHODS

Psychiatrists provided data for their 2 most recent AOM 400 patients, 2 most recent PP1M patients. Survey included 2000 patient cases (1000 AOM 400; 1000 PP1M). Eligible patients were aged 18-35 years, had been diagnosed with schizophrenia within 5 years, received AOM 400 or PP1M continuously for ≥6 months according to approved labels (mean durations: 1.6 and 1.7 years with AOM 400 and PP1M, respectively). Assessments included Global Assessment of Functioning (GAF) Scale, Personal and Social Performance Scale, Positive and Negative Syndrome Scale, and Quality of Life Scale. GAF assessments were done retrospectively and also at the time of survey.

RESULTS

Baseline mean GAF scores were 43.3 and 43.8 for AOM 400 and PP1M, respectively, indicating serious symptoms/functional impairment in both groups. Mean improvements following AOM 400 and PP1M therapy were 19.7 and 16.3 points, respectively (final scores in mild functional impairment category). Other measures assessing symptoms/functionality/quality of life demonstrated the benefits of long-term aLAI therapy.

CONCLUSION

Schizophrenia patients with serious functional impairment prior to current aLAI treatment showed improvements in functional outcome after AOM 400 or PP1M therapy. These results suggest functional improvements with aLAIs are apparent not only in research but also real-world settings.

Does Adding Social Cognitive Remediation Therapy to Neurocognitive Remediation Therapy Improve Outcomes in Young People With a Severe Mental Illness?-The Advantage Trial

INTRODUCTION

Cognitive impairments are a common and significant issue for young people with a severe mental illness. Young people with schizophrenia, bipolar disorder and major depression all experience significant cognitive problems that impede their ability to return to work or study. These neurocognitive problems are frequently exacerbated by social cognitive deficits that interfere with their ability to integrate into the community and understand the social and emotional nuances about them. This study aimed to assess if the addition of a social cognitive remediation treatment to a neurocognitive remediation therapy improved functional outcome.

METHODS

Five youth mental health services were trained in both the Neuropsychological Educational Approach to Remediation (NEAR) and the Social Cognition and Interaction Training (SCIT) treatments. Participants were randomised between receiving either NEAR + SCIT or NEAR + treatment as usual (TAU) over a 20-week period, with all participants receiving the NEAR treatment first. Symptoms, neurocognition, social cognition and functioning were examined at baseline, end of treatment and at 3 months follow-up and compared between the two arms of the study. The primary outcome was function.

RESULTS

Thirty-nine participants were randomised to treatment (Schizophrenia spectrum = 28, Bipolar disorder = 7, Major Depression = 2). The trial was curtailed by Covid-related service restrictions. There was an overall significant improvement in function over time with a trend towards a greater improvement in the NEAR + SCIT arm. No changes in symptoms, neurocognitive or social cognitive measures were seen. While 74% completed treatment only 49% agreed to follow up at 3 months affecting our ability to interpret the findings. Attrition did not differ by arm.

CONCLUSIONS

In a pragmatic, service-based research project, treatment aimed at improving cognition enhanced functional outcome in young people with a range of severe mental illnesses. There was a trend towards improved function in young people who had a combined NEAR + SCIT approach.

CLINICAL TRIAL REGISTRATION

Identifier: ACTRN12622000192785.

Different response patterns in hallucinations and delusions to antipsychotic treatment

Introduction: Psychosis is a multifaceted clinical phenomenon in which the various symptoms may show a differential response to treatment. Important information may be lost when heterogeneous symptoms are grouped together in global sum scores when studying treatment effects.Aims: The aim of this study was to compare the level and rate of change in the two separate symptoms hallucinations and delusions during the acute psychotic phase, and to explore whether potential temporal differences depend on diagnosis or patients being previously medicated with antipsychotics or not.Method: Patients admitted with active symptoms of schizophrenia or related psychotic disorders were included in the Bergen Psychosis Project (BPP) (N = 226), a prospective, pragmatic, study of four second-generation antipsychotics. The Positive and Negative Syndrome Scale were assessed at baseline, one, three and six months.Results: Over the total follow-up period, latent growth curve models showed greater reductions in delusions than in hallucinations. However, the percentage of the total reduction was found to be larger in hallucinations than that of delusions in the first interval (91% vs. 64%). The levels and changes in these variables were dependent on diagnosis and whether or not patients had a life-time history of antipsychotic use.Conclusion: Focusing on separate symptoms rather than general symptom clusters could offer clinicians a useful approach when evaluating the early response of antipsychotics.ClinicalTrials.gov ID: NCT00932529; URL: http://www.clinicaltrials.gov/.

Morita therapy for schizophrenia: An updated meta-analysis

Morita therapy was developed for common mental problems, and our aim was to evaluate the clinical effect of Morita therapy on schizophrenia. The literature was searched in 10 databases, namely, PubMed, Chinese National Knowledge Infrastructure (CNKI), Sinomed, Wanfang, Cochrane Library, UpToDate, Web of Science, Medline, PsycINFO and Embase, from inception to September 4, 2019. Random-effects models were used. For continuous results, the standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated to synthesize the effects. Thirty studies were included, with a total of 2651 patients with schizophrenia. Compared to pharmacotherapy alone and standard care alone, Morita therapy plus pharmacotherapy and Morita therapy plus standard care both had significant effects on mental state (pooled effect size = -1.09, 95% CI: -0.35, -0.83), social functioning (pooled effect size = -0.61, 95% CI: -2.30, -0.92) and behavior (pooled effect size = 1.13, 95% CI: 0.75, 1.51). Significant heterogeneity between studies was found for mental state (I² = 89%, p < 0.05) and social functioning (I² = 95%, p < 0.05), but no heterogeneity was found for behavior (I² = 0%, p = 0.84). Morita therapy has positive effects on mental state and social functioning among patients with schizophrenia, but it leads to some problems with behavior among these patients. Most included studies have unclear bias, and the forest plots show high heterogeneity among the results. Thus, Morita therapy cannot be implemented in clinical practice as a feasible strategy, the conclusion has yet to be confirmed, and new trials and future studies are desired.

Association between Serum Essential Metal Elements and the Risk of Schizophrenia in China

Numerous essential metal elements (EMEs) are necessary to maintain the proper function of human body. In this case-control study, we investigated the associations of 11 EMEs [Calcium (Ca), potassium (K), magnesium (Mg), sodium (Na), manganese (Mn), selenium (Se), cobalt (Co), Molybdenum (Mo), copper (Cu), zinc (Zn), and iron (Fe)] in serum with the risk of schizophrenia. We recruited first-episode and drug-naïve schizophrenic patients (cases = 99) and age-sex-matched normal subjects (controls = 99) from Tangshan, Hebei Province, China. The 11 EMEs in serum from cases and controls were quantified by inductively coupled plasma atomic emission spectrometry and inductively coupled plasma mass spectrometry. We observed that a higher level of Mn (OR = 2.390; 95%CI: 1.504–3.796) and lower levels of Ca (OR = 0.939; 95%CI: 0.890–0.990), Mg (OR = 0.806; 95%CI: 0.669–0.972), Na (OR = 0.995; 95%CI: 0.993–0.998), and Se (OR = 0.954; 95%CI: 0.937–0.972) were associated with an elevated risk of schizophrenia. Dose–response relationships between serum EME concentrations and the risk of schizophrenia were observed in most of the schizophrenia-associated EMEs. Moreover, the serum concentrations of these schizophrenia-associated EMEs in patients were correlated with the severity of their clinical symptoms. Significant correlations were found between EMEs and biomarkers associated with schizophrenia related to metabolic and oxidative stress. This study suggested that the concentration and profile of EMEs were different between schizophrenic patients and normal controls and revealed potential metabolisms associated with EMEs and schizophrenia, suggesting EMEs might act as biomarkers of schizophrenia to improve the current situation of diagnosis and treatment.

Rasch analysis of the PANSS negative subscale and exploration of negative symptom trajectories in first-episode schizophrenia - data from the OPTiMiSE trial

The observed heterogeneity in negative symptom treatment response may be partly attributable to inadequate measurement tools or limitations in methods of analysis. Previous Item Response Theory models of the Positive and Negative Syndrome Scale (PANSS) have only examined samples of chronic patients and with mixed results. We examined the scalability of the negative subscale embedded in the PANSS and subsequently explored negative symptom trajectories across four weeks of amisulpride treatment. Data were derived from the OPTiMiSE trial comprising 446 patients with first-episode schizophrenia or schizophreniform disorder. Using the Rasch Model to examine psychometric properties of the PANSS negative subscale, we found that the composite score across items was not an adequate measure of negative symptom severity. Consequently, we chose an exploratory statistical approach involving Principal Component Analysis which yielded one significant component clustering into two significant symptom trajectories: 1) Subtle but constant decrease in negative symptom severity (N = 323; 72%), and 2) symptom instability across visits (N = 19; 4%). Explorative analytic methods as presented here may pave the way for more efficient and sensitive methods of analyzing negative symptom response in research and in clinical practice.

Effects of Transcranial Direct Current Stimulation (tDCS) and Approach Bias Modification (ABM) training on food cravings in people taking antipsychotic medication

BACKGROUND

Antipsychotic drug-induced weight gain puts individuals with schizophrenia at increased cardiometabolic risk. As a potential intervention for this problem, we describe the theoretical background and a protocol for a feasibility randomised controlled trial (RCT) of approach bias modification (ABM) training combined with real versus sham (placebo) transcranial direct current stimulation (tDCS). The primary aim of this trial is to obtain information that will guide decision making and protocol development in relation to a future large-scale RCT of ABM and tDCS in this group of participants. Second, the study will assess the preliminary efficacy of ABM + tDCS in reducing food cravings in people who take antipsychotic medication.

METHODS

Thirty adults with a DSM-V diagnosis of schizophrenia or schizoaffective disorder treated with anti-psychotic medication will be randomly allocated to receive five sessions that will combine ABM and real or sham tDCS, in a parallel group design. In this feasibility study, a broad range of outcome variables will be examined. Measures will include food craving, psychopathology (e.g. symptoms of schizophrenia and depression), neuropsychological processes (such as attentional bias and impulsiveness), and the tolerability and acceptability of tDCS. The feasibility of conducting a large-scale RCT of ABM + tDCS and appropriateness of tDCS as a treatment for antipsychotic drug-induced weight gain will be evaluated by assessment of recruitment and retention rates, acceptability of random allocation, blinding success (allocation concealment), completion of treatment sessions and research assessments (baseline, post-treatment and follow-up).

DISCUSSION

The effect sizes generated and other findings from this trial will inform a future large-scale RCT with respect to decisions on primary outcome measures and other aspects of protocol development. In addition, results from this study will provide a preliminary indication of the efficacy of ABM + tDCS treatment for antipsychotic drug-induced weight gain.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN13280178. Registered on 16 October 2018.