Cognitive dysfunction at baseline predicts symptomatic 1-year outcome in first-episode schizophrenics

Could the severity of symptoms of schizophrenia affect ability of self-appraisal of cognitive deficits in patients with schizophrenia? Lack of insight as a mediator between the two domains

The relationship between subjective appraisal of cognitive deficits and symptom severity in schizophrenia is unclear. Insight reportedly affects both factors. Our aim is to further asses the relationship between subjective perception of cognitive deficits, symptom severity and lack of insight as a mediator variable. 109 subjects with schizophrenia were evaluated. Positive and Negative Syndrome Scale (PANSS) was modelled as independent variable, Subjective Scale to Investigate Cognition in Schizophrenia (SSTICS) as dependent and "Lack of Insight" (LoI) PANSS Item as mediator one. Mediation was assessed using bootstrap estimation approach. LoI acts as a suppressor variable (i.e., it enhances the relation between the independent and dependent variable) between Negative Symptoms and SSTICS, while showing a mediation effect between Depressive symptoms and SSTICS. LoI has a central role in mediating the relationship between negative and depressed symptoms on the one hand and self-appraisals of cognitive deficits (SACD) assessed with SSTICS on the other. Its suppressor role between negative symptoms and STICSS favour a direct effect of negative symptoms on SACD. On the other hand, its mediator role between depression and SSTICS is consistent with several reports of the 'insight paradox' of an enhanced severity of depression in patients with higher awareness of their disability.

Dissociating self-reported cognitive complaint from clinical insight in schizophrenia

Whereas new pharmacological treatments are developed for cognitive impairments in schizophrenia, self-assessment of cognitive dysfunctioning besides their objective validity could be of interest in evaluating patients' motivation to engage in rehabilitation program. Nevertheless insight into symptoms is severely impaired in schizophrenia and is negatively linked with poor compliance. But it is yet unknown if patients with poor insight into their symptoms could have some insight into their cognitive impairments. The aim of this study was to explore the relationships existing between the cognitive complaint and the level of awareness of the disease in patients with schizophrenia. A total of 101 patients with DSM-IV schizophrenia or schizoaffective disorder and 60 control participants were recruited. Insight was assessed using the Scale to assess Unawareness of Mental Disorder (SUMD) and cognitive complaint intensity was assessed with the Scale to Investigate Cognition in Schizophrenia (SSTICS). Participants with schizophrenia displayed the same level of cognitive complaint when compared to healthy controls. Strong correlations were observed between SSTICS total score and duration of illness, levels of depression and state anxiety. Patients with a good insight into the therapeutic effects achieved with medication expressed a more important cognitive complaint. No correlations were found between the four others SUMD insight dimensions and total SSTICS score. The partial overlap of insight into illness and cognitive complaint suggests that insight is modular in schizophrenia. Assessment of cognitive complaint and awareness of illness need to be assessed before engagement in rehabilitation program.

Self-Awareness of Psychopathology and Brain Volume in Patients With First Episode Psychosis

Memory impairment, excessive rumination, and increased interpersonal sensitivity are major characteristics of high psychosis risk or first episode psychosis (FEP). Herein, we investigated the relationship between brain volume and self-awareness of psychopathology in patients with FEP. All participants (FEP: 34 and HCs: 34) completed clinical assessments and the following self-reported psychopathology evaluations: prospective and retrospective memory questionnaire (PRMQ), ruminative response scale (RRS), and interpersonal sensitivity measure (IPSM). Structural magnetic resonance imaging was then conducted. The PRMQ, RRS, and IPSM scores were significantly higher in the FEP group than in the healthy controls (HCs). The volumes of the amygdala, hippocampus, and superior temporal gyrus (STG) were significantly lower in the FEP group than in the HCs. There was a significant group-dependent moderation effect between self-awareness of psychopathology (PRMQ, RRS, and IPSM scores) and right STG (rSTG) volume. In the FEP group, self-awareness of psychopathology was positively associated with rSTG volume, while in the HCs, this correlation was negative. Our results indicate that self-awareness of psychopathology impacts rSTG volume in the opposite direction between patients with FEP and HCs. In patients with FEP, awareness of impairment may induce increases in rSTG brain volume. However, HCs showed decreased rSTG volume when they were aware of impairment.

The Frankfurt Complaint Questionnaire for self-assessment of basic symptoms in the early detection of psychosis-Factor structure, reliability, and predictive validity

OBJECTIVES

Patients with schizophrenia often experience subtle disturbances in several domains of information processing-so-called basic symptoms (BS). BS are already present before onset of frank psychosis and can be assessed by interviews but also by the self-administered Frankfurt Complaint Questionnaire (FCQ). We investigated the factor structure, reliability, and predictive validity for transition to psychosis of the FCQ, comparing previously proposed factor solutions containing 1, 2, 4, and 10 factors.

METHODS

Confirmatory factor analysis was used in a sample of 117 at-risk mental state and 92 first-episode psychosis participants of the Basel FePsy (early detection of psychosis) study.

RESULTS

Although all factor models fitted to the data, the 2- or 4-factor solutions performed best among the models that used at least half of the FCQ items, suggesting the covariance between FCQ items is best explained by 2 to 4 underlying factors. No FCQ-scale predicted transition to psychosis.

CONCLUSION

We could confirm a 2- to 4-factor structure of the FCQ in a sample of at-risk mental state and first-episode psychosis patients using confirmatory factor analysis. Contrary to interview-assessed cognitive-perceptive BS, self-assessed BS do not seem to improve prediction of psychosis. This result reinforces reports of poor correspondence between interview- and questionnaire-assessed BS.

Effects of Group Cognitive-Behavioral Therapy in Young Patients in the Early Stage of Psychosis

OBJECTIVE

To develop a model of group cognitive-behavioral therapy (CBT) for Korean patients with early psychosis.

METHODS

The group CBT utilized in the present study consisted of metacognitive training, cognitive restructuring, and lifestyle managements. The Subjective Well-being Under Neuroleptics (SWN-K), Ambiguous Intentions Hostility Questionnaire (AIHQ), Drug Attitude Inventory (DAI), Beck Depression Inventory (BDI), Perceived Stress Scale (PSS), and Clinical Global Impression (CGI) were administered prior to and after CBT sessions. The participants were categorized into two groups according to the median duration of untreated psychosis (DUP; 4 months).

RESULTS

A total of 34 patients were included in this analysis. From pre- to post-therapy, there were significant increases in the SWN-K and DAI scores and significant decreases in the hostility subscale of the AIHQ, PSS, and CGI scores. Significant time × DUP interaction effects were observed for the SWN-K, DAI, and BDI scores, such that there were significant changes in patients with a short DUP but not in those with a long DUP.

CONCLUSION

The group CBT program had a positive effect on subjective wellbeing, attitude toward treatment, perceived stress, and suspiciousness of young Korean patients with early psychosis. These effects were particularly significant in patients with a short DUP.

The course of cognitive functioning after first-episode of psychosis: A six month follow-up study

Our aim with the present study was to evaluate rank-order and mean-level cognitive functioning stability among first-episode psychosis (FEP) patients, measured using the Cambridge Neuropsychological Test Automated Battery (CANTAB), over a six month period. We also aimed to examine longitudinal measurement invariance and identify factors-such as age, gender, educational level, treatment and psychopathological change scores-potentially linked to cognitive change among patients. In addition, correlations between objectively measured and subjectively evaluated cognitive functioning were estimated. Neuropsychological assessments were administered to 85 patients after the initial stabilisation of their psychosis; 82 of the patients were retested. Subjectively perceived cognitive functioning was measured using a subscale derived from the Estonian version of the Subjective Well-Being Under Neuroleptic Scale (SWN-K-E). On average, executive functioning and processing speed improved significantly, while memory test scores decreased significantly, over time. Very high rank-order stability (r=0.80 to 0.94, p<0.001) was observed with all measured ability scores. Confirmatory factor analysis revealed the loadings of a single (broad ability) factor model were equal across both measurement occasions, but the lack of intercept invariance suggested that mean-level comparisons are more appropriately carried out at a subtest level. On average psychopathology scores and antipsychotics doses declined over time, with the latter also significantly correlating with better executive functioning. Gender was a significant moderator of some domains of cognitive performance, and decline tended to be somewhat more pronounced for women. The results also indicated the lack of any relationship between objective and subjective measurements of cognitive functioning.

FDG-PET scans in patients with Kraepelinian and non-Kraepelinian schizophrenia

We recruited 14 unmedicated patients with Kraepelinian schizophrenia (12 men and 2 women; mean age = 47 years old), 27 non-Kraepelinian patients (21 men and 6 women; mean age = 36.4 years old) and a group of 56 age- and sex-matched healthy volunteers. FDG positron emission tomography and MRI scans were coregistered for both voxel-by-voxel statistical mapping and stereotaxic regions of interest analysis. While both Kraepelinian and non-Kraepelinian patients showed equally lower uptake than healthy volunteers in the frontal lobe, the temporal lobes (Brodmann areas 20 and 21) showed significantly greater decreases in Kraepelinian than in non-Kraepelinian patients. Kraepelinian patients had lower FDG uptake in parietal regions 39 and 40, especially in the right hemisphere, while non-Kraepelinian patients had similar reductions in the left. Only non-Kraepelinian patients had lower caudate FDG uptake than healthy volunteers. While both patient groups had lower uptake than healthy volunteers in the medial dorsal nucleus of the thalamus, Kraepelinian patients alone had higher uptake in the ventral nuclei of the thalamus. Kraepelinian patients also showed higher metabolic rates in white matter. Our results are consistent with other studies indicating that Kraepelinian schizophrenia is a subgroup of schizophrenia, characterized by temporal and right parietal deficits and normal rather than reduced caudate uptake. It suggests that Kraepelinian schizophrenia may be more primarily characterized by FDG uptake decreased in both the frontal and temporal lobes, while non-Kraepelinian schizophrenia may have deficits more limited to the frontal lobe. This is consistent with some neuropsychological and prognosis reports of disordered sensory information processing in Kraepelinian schizophrenia in addition to deficits in frontal lobe executive functions shared with the non-Kraepelinian subtype.

Self-perceived cognitive functioning and its relationship with objective performance in first-episode schizophrenia: the Subjective Cognitive Impairment Scale

BACKGROUND

Self-perceived cognitive dysfunction is under-recognized in clinical practice and under-studied in schizophrenia, particularly in the early illness stage. Findings on the relationship between subjective and objective cognitive measures were inconsistent. This study aimed to examine psychometric properties of a newly developed scale, Subjective Cognitive Impairment Scale (SCIS) and to investigate the relationship of self-reported ratings with objective test performance in first-episode schizophrenia.

METHODS

One hundred one Chinese patients aged 18 to 64years presenting with first episode schizophrenia-spectrum disorder were studied. A comprehensive set of assessments examining objective cognitive functioning, clinical and treatment characteristic were administered. Internal consistency, factor structure and construct validity of SCIS were evaluated. Correlations of scale score with objective cognitive measures, clinical and treatment variables were examined.

RESULTS

A single-factor underlying the structure of SCIS items was demonstrated by principal components analysis. Cronbach's alpha coefficient for the scale was 0.92. SCIS score was positively correlated with depression and anxiety symptom severity, and duration of untreated psychosis. SCIS score was not associated with other symptom dimensions, insight and chlorpromazine equivalents. No significant correlations were observed between SCIS score and objective cognitive measures with the exception of letter-number span test.

CONCLUSION

Our results provided preliminary evidence in support of reliability and validity of SCIS in evaluating patient's cognitive complaints. A lack of correspondence between subjective and objective cognitive functioning suggested that they may represent two distinct constructs with potentially differential therapeutic implications. Further research is warranted to examine ecological validity and clinical utility of the scale.

Association between subjective well-being and depressive symptoms in treatment-resistant schizophrenia before and after treatment with clozapine

BACKGROUND

We examined the relationship between subjective well-being and depressive symptoms in patients with treatment-resistant schizophrenia before and after treatment with clozapine to contribute to the growing body of research regarding the determinants of patients' perspective of their own well-being in schizophrenia.

METHODS

Forty patients with treatment-resistant schizophrenia were comprehensively evaluated for subjective well-being, schizophrenic symptoms, and depressive symptoms before and 8 weeks after the initiation of treatment with clozapine. Correlation analysis and Fisher's z-transformation statistics were performed.

RESULTS

There were significant improvements in all Positive and Negative Syndrome Scale (PANSS) factor scores and Beck Depression Inventory (BDI) score over the treatment period (P<.05). Before clozapine administration, the subjective well-being score had significant negative correlations with the PANSS depression factor score (P<.05) and the BDI score (P<.05). After clozapine treatment, the subjective well-being score still had significant negative correlations with the PANSS depression factor score (P<.05) and the BDI score (P<.05) and no new associations emerged with treatment. Fisher's z-transformation statistics revealed that the correlations between the subjective well-being score and the depression score were not significantly different before and after clozapine treatment.

CONCLUSIONS

These results indicate that depressive symptoms are significantly associated with low subjective well-being in patients with treatment-resistant schizophrenia. The association was equally significant before and after treatment with clozapine, suggesting that the relationship does not change with clozapine treatment, even when depressive symptoms improve significantly, and that there may be a common pathophysiological basis for depressive symptoms and the subjective appraisal of well-being in schizophrenia.

Cognitive remediation improves cognition and good cognitive performance increases time to relapse--results of a 5 year catamnestic study in schizophrenia patients

BACKGROUND

Cognitive deficits are stable features of schizophrenia that are linked to functional outcome. Cognitive remediation approaches have been proven successful in ameliorating these deficits, although effect sizes vary considerably. Whether cognitive deficits are serious predictors of clinical outcome is less clear.

METHODS

Sixty patients suffering from schizophrenia were included in our sample, thirty of them received computer-assisted cognitive training, and thirty received occupational therapy. For a subsample of 55 patients, who could be traced over a period of five years after the end of the cognitive remediation intervention, time until first relapse and time in psychosis were determined retrospectively from their medical records.

RESULTS

Cognitive remediation significantly improved problem solving, memory and attention with high effect sizes. Employment status, a post test verbal memory performance measure and a measure of executive functioning outperformed all other measures in the prediction of time to relapse, while allocation to treatment group outperformed all other variables in the prediction of both cognitive measures.

CONCLUSIONS

Cognitive remediation of neurocognitive deficits thus makes sense in a twofold fashion: It enhances cognition directly and positively acts on clinical course indirectly via improved neurocognition.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00004880.

The effect of paliperidone extended release on subjective well-being and responses in patients with schizophrenia

OBJECTIVE

This study aimed to evaluate the subjective well-being and attitudes toward antipsychotic medication of patients with schizophrenia who had switched to paliperidone extended release (ER).

METHODS

A total of 291 patients with schizophrenia treated with antipsychotics participated in this open-label, 24-week switching study. The primary outcome measures were the Subjective Well-Being under Neuroleptic Treatment Scale-short version (SWN-K) and the Drug Attitude Inventory (DAI). The Krawiecka scale, Clinical Global Impression-Schizophrenia (CGI-SCH), Personal and Social Performance scale (PSP) were used to evaluate psychopathology and psychosocial functioning, respectively.

RESULTS

Data from a total of 243 subjects who received the study medication and had at least one follow-up assessment without a major protocol violation were analyzed. Scores on the DAI and SWN-K showed significant improvement between baseline and end-point measurements beginning during the second week. Scores on the Krawiecka scale, all five subscales of the CGI-SCH scale, and the PSP scale were also significantly improved at the end point compared with the baseline. Significant predictors of improvements in the SWN-K and DAI after a switch to paliperidone ER were baseline scores, reductions in scores on the Krawiecka scale, and previous risperidone use. A clinically relevant increase in body weight (≥7% weight gain) occurred in one-fourth of the participants who completed the 24-week study.

CONCLUSION

Switching to paliperidone ER improved the subjective well-being and attitudes towards antipsychotic medication in patients with schizophrenia. Exploratory analyses revealed that these improvements were particularly pronounced in patients who had been treated with risperidone before treatment with paliperidone ER.

Self-perceived cognitive functioning does not correlate with objective measures of cognition in schizophrenia

BACKGROUND

Growing interest in the study of self-perceived cognitive deficits in schizophrenia has been recently observed. The authors validated in a previous study the Subjective Scale To Investigate Cognition into Schizophrenia Tunisian Arabic Version (SSTICS_tun_arab), a self-questionnaire established to collect cognitive complaints in patients with schizophrenia.

OBJECTIVE

The aim of the present study was to explore the relationship between the SSTICS_tun_arab scores and objective cognitive performances.

METHODS

One hundred four patients with schizophrenia spectrum disorders were administered measures of the Positive and Negative Syndrome Scale, the Global Assessment Functioning Scale, and the Calgary Depression Scale as well as measures of the SSTICS_tun_arab and a cognitive battery.

RESULTS

No correlations were found between objective neuropsychologic performances and scores of the SSTICS_tun_arab.

CONCLUSIONS

Our findings support the hypothesis of independence of self-perceived cognitive functioning from objective neuropsychologic deficits in schizophrenia. They also suggest that insight of mental illness seems to be not a unitary concept but more likely to be divided in different aspects including cognitive insight.

Comparison of the efficacy and impact on cognition of glycopyrrolate and biperiden for clozapine-induced sialorrhea in schizophrenic patients: a randomized, double-blind, crossover study

BACKGROUND

Clozapine-induced sialorrhea (CIS) is a subjective distressing adverse effect and occurs in 31%-57% of schizophrenic patients receiving clozapine therapy. Current pharmacotherapy on CIS has focused on anticholinergic agents, even though they may impair cognitive function. Previous case reports have suggested the benefit of glycopyrrolate or biperiden in treating this condition, but no randomized controlled trial has provided evidence. The objective of our study was to evaluate the efficacy and impact on cognition of glycopyrrolate and biperiden treatments for schizophrenic patients suffering from CIS.

METHODS

Patients who satisfied the inclusion criteria entered a 12-week, randomized, double-blind, crossover, fixed-dose trial. The study consisted of two 4-week crossover phases, which were separated by a 4-week washout period. Sialorrhea and global cognitive function were assessed by using a Drooling Rating Scale (DRS) and the Mini Mental State Examination (MMSE), respectively.

RESULTS

Throughout the study, patients treated with glycopyrrolate or biperiden had significantly reduced DRS scores. Moreover, the DRS scores were significantly lower with glycopyrrolate treatment than with biperiden. In other respects, there were no significant differences in MMSE scores in patients treated with glycopyrrolate. However, we found a significant reduction in MMSE scores in patients treated with biperiden.

CONCLUSION

We provide evidence, for the first time, of the efficacy of glycopyrrolate and biperiden in the treatment of CIS. Furthermore, glycopyrrolate displays less impact on cognitive function. Consequently, glycopyrrolate can become a valid option for treating CIS. Observations from our study serve as a springboard for additional large-scale prospective trials.

[Cognitive complaints in schizophrenia: relationship with insight and other cognitive measures]

INTRODUCTION

Individuals diagnosed with schizophrenia have significant cognitive deficits. However, the subjective perception of these deficits do not always coincide with the neuropsychological test and clinical ratings.

METHODOLOGY

This study evaluates the cognitive performance of 46 outpatients with schizophrenia, in a Psychosocial Rehabilitation Program, by three different measures: neuropsychological tests (objective assessment), cognitive factor of PANSS (clinical ratings), and subjective scale of cognition, SSTICS (patient self-report). Also studies the possible relationship between subjective assessment of cognitive symptoms and insight of the mental disorder (SUMD).

RESULTS

SSTICS total score correlated only with some neuropsychological subtest, but not with cognitive factor of PANSS. The clinical ratings is more consistent with neuropsychological test than the cognitive complaints. No relationship between SUMD and SSTICS.

CONCLUSIONS

Because of the lack of correspondence among several measures, it is possible to think that have been evaluated different cognitive areas. So, it is important to consider all options of assessment in order to create cognitive rehabilitation programs. Cognitive complaints seems to be an independent variable of insight.

The relationship between depressive symptoms and subjective well-being in newly admitted patients with schizophrenia

BACKGROUND

Depressive symptoms are common in schizophrenia and are considered core features of the disorder. The purpose of the present study was to examine the relationship between depressive symptoms and subjective well-being in newly admitted patients with schizophrenia.

METHODS

Eighty newly admitted patients were comprehensively evaluated for subjective well-being, schizophrenic symptoms, and depressive symptoms using the Subjective Well-Being Under Neuroleptics Scale (SWN), the Positive and Negative Syndrome Scale (PANSS), and the Beck Depression Inventory. Correlation coefficients were obtained between depressive symptoms and subjective well-being while controlling for the influence of the severity of psychotic symptoms, extrapyramidal side effect, and subjective attitude toward antipsychotics, as assessed by the PANSS, the Drug-Induced Extrapyramidal Symptoms Scale, and the Drug Attitude Inventory, respectively.

RESULTS

The SWN score had a significant negative correlation with the PANSS depression factor score (P < .001). Correlation analysis also revealed a significant negative correlation between the SWN score and the Beck Depression Inventory score (P < .001).

CONCLUSIONS

The results of our study suggest that depressive symptoms are significantly associated with a low subjective well-being in newly admitted patients with schizophrenia and that the relationship is significant even after controlling for the influence of potential confounding variables. Detection and appropriate management of depressive symptoms in schizophrenic patients may affect their perceptions of their own well-being.

Neuropsychological impairments predict the clinical course in schizophrenia

To add to the open question whether cognitive impairments predict clinical outcome in schizophrenia, a sample of 125 first episode patients was assessed at the onset and over one year of controlled long-term treatment within a study of the German Research Network on Schizophrenia. No relapse according to predefined criteria occurred within the first year, but a total of 29 patients fulfilled post-hoc criteria of "clinical deterioration". Impairments in cognitive functioning assessed by the Trail-Making Test B at the onset of long-term treatment differentiated between patients with vs. without later clinical deterioration and proved to be a significant predictor of the clinical course in a regression analysis outperforming initial clinical status as predictor. However, low sensitivity (72%) and specificity (51%) limit possibilities of a transfer to individual predictions. As a linear combination of neuropsychological and psychopathological variables obtained highest predictive validity, such a combination may improve the prediction of the course of schizophrenic disorders and may ultimately lead to a more efficient and comprehensive treatment planning.

Cognitive markers of short-term clinical outcome in first-episode psychosis

BACKGROUND

Outcome from psychotic disorders is heterogeneous with poorer outcomes frequently identified too late to be influenced. Symptomatic ratings at 1 or more years following initiation of treatment have been related to cognition in first-episode psychosis. However, the relationship between cognition and early outcome remains unclear.

AIMS

To determine whether specific cognitive domains could identify poor short-term outcome among individuals with first-episode psychosis.

METHOD

One hundred and fifty-one individuals with first-episode psychosis were divided into two groups based on 6-month clinical data after the initiation of treatment. Six cognitive domains were compared among 78 participants with poor outcomes, 73 with good outcomes and 31 healthy controls.

RESULTS

Lower performance on verbal memory (z-scores: poor outcome=-1.3 (s.d.=1.1); good outcome=-0.8 (s.d.=0.9); P=0.001) and working memory (poor outcome=-1.0 (s.d.=1.2); good outcome=-0.4 (s.d.=0.9); P=0.003) identified individuals with first-episode psychosis with a poor outcome after 6 months of treatment.

CONCLUSIONS

The early identification of those individuals with first-episode psychosis with a poor clinical outcome may encourage clinicians to pay special attention to them in the form of alternative pharmacological and psychological treatments for a more favourable outcome in the long term.

Executive functioning in schizophrenia and the relationship with symptom profile and chronicity

This study reports the executive function profile in people with schizophrenia, with a simultaneous comparison of chronicity and of those with predominately disorganization versus psychomotor poverty symptoms. The patients were split into one set defined according to symptoms (29 with disorganization, 29 with negative symptoms) and the other representing chronicity (22 first-episode, 35 chronic) and compared with 28 healthy controls on a broad range of executive process measures. Differences were investigated in both the severity and profile of impairments. Impairment patterns interacted with symptom groups, with disorganization and psychomotor poverty symptom groups showing different profiles of executive impairment. In contrast, across these same executive processes, impairment profiles were similar between first episode and chronic schizophrenia and became more similar, particularly for working memory, when controlling for disorganization symptoms. The executive profile, therefore, is related to symptom type rather than chronicity.

Objective measures of prospective memory do not correlate with subjective complaints in schizophrenia

While a number of studies have shown that individuals with schizophrenia are impaired on various types of prospective memory, few studies have examined the relationship between subjective and objective measures of this construct in this clinical group. The purpose of the current study was to explore the relationship between computer-based prospective memory tasks and the corresponding subjective complaints in patients with schizophrenia, individuals with schizotypal personality features, and healthy volunteers. The findings showed that patients with schizophrenia demonstrated significantly poorer performance in all domains of memory function except visual memory than individuals with schizotypal personality disorder and healthy controls. More importantly, there was a significant interaction effect of prospective memory type and group. Although patients with schizophrenia were found to show significantly poorer performance on computer-based measures of prospective memory than controls, their level of subjective complaint was not found to be significantly higher. While subjective complaints of prospective memory were found to associate significantly with self-reported executive dysfunctions, significant relationships were not found between these complaints and performance on a computer-based task of prospective memory and other objective measures of memory. Taken together, these findings suggest that subjective and objective measures of prospective memory are two distinct domains that might need to be assessed and addressed separately.

Pretreatment predictors of cognitive deficits in early psychosis

BACKGROUND

Predicting cognitive deficits in early psychosis may well be crucial to identify those individuals most in need of receiving intensive intervention. As yet, however, the identification of potential pretreatment predictors for cognitive performance has been hampered by inconsistent findings across studies. We aimed to examine the associations of functional and clinical pretreatment variables with cognitive functioning after a first psychotic episode.

METHOD

One hundred and thirty-one patients experiencing first-episode psychosis were assessed for psychopathology, pre-morbid functioning, duration of illness, age of onset, and family history of psychosis and neurocognitive functioning. Multiple regression analyses were conducted for six basic cognitive dimensions known to be affected in this population: verbal learning, verbal memory, verbal comprehensive abilities, executive functioning, motor dexterity and sustained attention.

RESULTS

Pre-morbid functioning was the main predictor for five out of the six basic cognitive domains. Pre-morbid social adjustment difficulties were associated with worse performance in executive functioning, motor dexterity and sustained attention. Academic functioning was associated with verbal comprehension, and verbal learning and memory. Gender, age of onset, duration of untreated psychosis, and family history of psychosis had no or limited value as predictors of neurocognitive outcome.

CONCLUSIONS

Poor pre-morbid functioning was related to a worse performance in the six basic cognitive dimensions evaluated; however, this accounted for only a small amount of the explained variance. Cognitive impairment is a prominent feature in patients with early psychosis regardless of favorable prognostic features such as short duration of illness, female gender, later age of onset, and non-family history of psychosis.

d-Serine and a glycine transporter inhibitor improve MK-801-induced cognitive deficits in a novel object recognition test in rats

Compounds enhancing N-methyl-d-aspartate (NMDA) glutamate receptor function have been reported to improve cognitive deficits. Since cognitive deficits are considered to be the core symptom of schizophrenia, enhancing NMDA receptor function represents a promising approach to treating schizophrenia. In the present study, we investigated whether d-serine or a glycine transporter inhibitor N-[3-(4'-fluorophenyl)-3-(4'-phenylphenoxy)propyl]sarcosine (NFPS), both of which enhance NMDA receptor function, could improve MK-801-induced cognitive deficits in rats, and compared their effects with those of the atypical antipsychotic clozapine and of the typical antipsychotic haloperidol. To assess cognitive function, we used a novel object recognition test in rats that measured spontaneous exploratory activity of a novel object when paired with a familiar object. We then evaluated the effects of the compounds on cognitive deficits induced by treatment with MK-801, the NMDA receptor antagonist. Pretreatment with clozapine (1, 5 mg/kg, i.p.) but not haloperidol (0.03, 0.1 mg/kg, i.p.) significantly improved MK-801-induced cognitive deficits. Pretreatment with D-serine at 800 mg/kg (i.p.) or NFPS (0.3, 1 mg/kg, i.p.) significantly improved MK-801-induced cognitive deficits under this test paradigm. These findings suggest that impaired preference for novel objects induced by MK-801 in the novel object recognition test could be a useful animal model for evaluating the efficacy of compounds targeting the cognitive deficits observed in schizophrenic patients. The results also suggest that enhancing NMDA receptor function is an effective way for treating the cognitive deficits associated with schizophrenia.

Cognitive functioning in the early course of first-episode schizophrenia spectrum disorders: timing and patterns

OBJECTIVE

The aim of this study was to examine possible cognitive changes throughout the early course of schizophrenia spectrum disorders.

METHOD

Forty-two patients, aged 15-50 years, admitted to a first episode psychosis program (PAFIP) serving to the community of Cantabria (Spain) and 43 healthy volunteers completed a brief battery of five neurocognitive tests at four time-points over 3 months. The cognitive testing comprise five domains: attention, visuomotor speed, declarative memory, working memory and executive function. Baseline assessment occurred within 72 hour after the initiation of standard pharmacological treatment, and after then parallel forms of the tests were applied at week-2, week-6, and month-3.

RESULTS

Patient scores showed a significant impairment compared to healthy volunteers in the five cognitive domains at baseline and week-2 assessments. After the first 3 months of antipsychotic treatment, the patient group performance reached healthy volunteers level on executive function (Stroop interference) and immediate verbal memory tests. In contrast, performance on working memory, sustained attention, visuomotor speed, and verbal memory delayed recall domains still remained below healthy volunteers, although visuomotor processing speed showed a significant improvement.

CONCLUSION

Schizophrenia spectrum patients show heterogeneous patterns and degrees of cognitive changes that contribute to stress the importance of when, what, and how neurocognitive functioning in the early phases of the illness is evaluated.

Subjective response to clozapine and risperidone treatment in outpatients with schizophrenia

The purpose of the present study was to compare the subjective response and attitude towards antipsychotic treatment between schizophrenic patients receiving clozapine and those receiving risperidone. Ninety-four outpatients who had been on a stable drug dosage were evaluated (clozapine group: n=57, mean dose=254.1 mg/day; risperidone group: n=37, mean dose=3.0 mg/day). Subjective response to antipsychotic treatment was assessed using the Drug Attitude Inventory (DAI). The two treatment groups had a positive total mean score, indicating that both groups had a positive subjective view of drug treatment. The proportion of subjects who had a positive total score was not different between the two groups. In subscale scores, multivariate analysis revealed that clozapine group tended to have a higher score on the subjective positive response subscale (P=0.06). The scores of subjective negative response or attitude to medication subscales were not different between groups. In conclusion, there was no marked difference between stabilized outpatients taking clozapine and risperidone in terms of subjective response and attitude towards antipsychotic treatment. Considering that subjects treated with clozapine were treatment resistant patients, equal DAI score might indicate a more favorable subjective experience of clozapine. Further prospective studies on subjective response to various atypical agents are required to obtain valuable insight into how best to use these drugs from the patient's perspective.

Neurocognitive impairment does not predict treatment outcome in obsessive-compulsive disorder

There is conflicting evidence pertaining to whether or not neurocognitive task performance at baseline predicts treatment response in obsessive-compulsive disorder (OCD). In the present study, we administered a set of executive neurocognitive tests with a putative sensitivity for treatment outcome to a sample of 138 OCD patients. Additionally, subjective neurocognitive dysfunction was determined via a questionnaire. All patients participated in a cognitive-behavioural treatment program (CBT). Results showed that responders (n = 73) did not differ from non-responders (n = 65) on any of the parameters except for decreased performance on the delayed alternation test (p < .1, effect size: .61). A subsidiary analysis revealed that slowing on the Trail-Making Test A and an enhanced rate of perserveration errors on the Wisconsin Card Sorting Test predicted poor outcome for the treatment of compulsions. It is concluded that neurocognitive impairment does not represent a reliable early warning sign for non-response to CBT.

Cognitive deficits caused by late gestational disruption of neurogenesis in rats: a preclinical model of schizophrenia

Late gestational disruption of neurogenesis in rats has been shown to induce behavioral abnormalities thought to mimic aspects of positive and negative symptoms of schizophrenia. Furthermore, it has been shown that the morphological changes produced by the perturbation are relevant to schizophrenia with reduced thickness of the hippocampus, thalamus, and cortical regions. In addition to the positive and negative symptoms, schizophrenia is associated with deficits in a wide variety of cognitive domains. In the present studies, we assessed whether the cognitive deficits are modeled by disruption of neurogenesis late during gestation (gestational day 17) in the rat. In the battery of tests utilized, we describe that rats in which neurogenesis was disrupted have deficits in a reversal-learning paradigm of the Morris water maze and in object recognition, and that they exhibit perseveration in the Porsolt forced swimming test. Additionally, we found deficient associative learning in an acquisition of an active avoidance paradigm and deficits in latent inhibition. No deficits were observed in the reference memory version of the Morris water maze and in a non-match-to position experiment, showing that the deficits are limited to certain aspects of cognition.

Current issues in schizophrenia: overview of patient acceptability, functioning capacity and quality of life

The increasing interest in the subjective wellbeing and quality of life (QoL) of patients with schizophrenia represents a conceptual extension of therapeutic outcome criteria. For a long time, the reduction of positive symptoms alone was the most important outcome parameter, but the development of atypical antipsychotic drugs in the early 1990s resulted in the adoption of more wide-reaching measures of therapeutic outcome. Patient satisfaction appears to be strongly related to their willingness to be or stay engaged in psychosocial and pharmacological treatment, and therefore to the symptomatic and functional outcome. Existing studies that deal with QoL and subjective wellbeing differ in their methodology and are difficult to compare because of varying underlying concepts of QoL or subjective wellbeing, different assessment scales or small sample sizes. Although QoL is a heterogeneous concept, it is clearly correlated with a number of factors, including illness, medication and stress process-related variables. Various protective factors have been identified; among these are personality traits, the degree of social support and treatment interventions. In clinical studies, atypical antipsychotic agents are associated with greater improvements in QoL and subjective wellbeing than are conventional agents. The reason for this is probably the ability of atypical agents to have a positive impact on factors most associated with QoL, such as negative and affective symptoms and drug tolerability. The most appropriate clinical approach to maximize QoL and subjective wellbeing for patients with schizophrenia is to use atypical antipsychotic drugs as a first-line treatment approach. Ideally, an atypical drug which is known not to have a negative effect on attention, affect or motivation should be chosen.

Memory and attention performance in psychiatric patients: lack of correspondence between clinician-rated and patient-rated functioning with neuropsychological test results

In the present study, the correspondence between clinician-assessed and self-reported neurocognitive performance was contrasted with scores obtained from psychometric neuropsychological tests in 148 psychiatric in-patients. Results revealed that self-reported cognitive functioning was strongly associated with depressive symptomatology but was only poorly related to psychometric neurocognitive performance, particularly in schizophrenia. After illness denial was controlled for, the overall association between subjective and objective test performance was slightly increased but still failed to reach significance in six out of eight analyses. In approximately 20% to 40% of all cases, clinicians judged memory performance to be normal despite substantial impairment revealed by neuropsychological test results (attention parameters: 7-51%). Since (ecological) validity and reliability have been demonstrated for many neurocognitive paradigms, the present results question the validity of non-psychometric neurocognitive assessment and call for a complementation of clinical judgment with neurocognitive assessment. Reasons for decreased sensitivity of self-reported and clinician-assessed neurocognitive functioning are discussed.

Reliable change indexes for memory performance in schizophrenia as a means to determine drug-induced cognitive decline

Some psychotropic medications frequently prescribed in schizophrenia, especially agents that contain anticholinergic properties, have adverse effects on learning and memory. Given the impact of memory on both functional and symptomatic outcome in schizophrenia, it is important to determine if patients suffer from medication-related memory impairment. This study provides a statistical methodology for identifying medication-related changes in memory functioning. Reliable change estimates were determined for Rey Auditory Verbal Learning Test performance in 38 inpatients with schizophrenia. When an 80% confidence criterion was applied, improvement or decline of 12 words in the total score (sum score: Trials 1-5) cannot be attributed to measurement error. These findings should help clinicians better understand cognitive side effects and facilitate decision making regarding changes to individual patient's psychopharmacotherapy.

Exploring cognitive complaints in schizophrenia: the subjective scale to investigate cognition in schizophrenia

While it has become commonplace to test the various components of memory in schizophrenia with paper-and-pencil or in-lab tasks, very little data exist on the subjective complaints of patients regarding their memory. Few instruments have been designed to collect systematically the complaints of patients with schizophrenia. We present a work in progress on the Subjective Scale to Investigate Cognition in Schizophrenia (SSTICS), a 21-item, Likert-type scale that is simple and easy to use. It allows a quantitative approach to the subjective and cognitive dimensions of schizophrenia. Stip constructed the scale based on a questionnaire covering several cognitive domains: memory (working memory, explicit long-term memory), attention (divided, distractibility, alertness, sustained), language, and praxia. We evaluated the psychometric properties of the SSTICS in a population of 114 French-speaking patients in Montreal. Patients were recruited in the community and assessed with the Structured Clinical Interview for DSM-III-R (SCID), the Positive and Negative Syndrome Scale (PANSS), and the Extrapyramidal Symptoms Rating Scale (ESRS). Cognition was measured using the Rey Auditory Verbal Learning Test (RAVLT) (long-term memory), Controlled Oral Word Association Test (verbal fluency), and Trails A and B. Preliminary analyses showed very good internal consistency for the global score (alpha=0.88), and alphas varying from 0.57 to 0.72 for the subscales. Stability over time was very good. The principal components analysis accounted for a multiple structure. Correlations between subjective scores and objective cognitive assessment were significant for several domains. Validation of the SSTICS needs to be completed through further exploration of the factorial structure and testing of the English version.

Dysexecutive syndrome and social adjustment in schizophrenia

OBJECTIVE

This paper reports on a study designed to (i) assess levels of executive functions among patients suffering from schizophrenia; (ii) investigate associations between measures of executive functions and psychosocial adjustment; and (iii) examine the influence of psychopathology on the relationship between executive functions and psychosocial adjustment. Clear knowledge of executive functions and of their impact on social adjustment in patients with schizophrenia may play a decisive role in preparing and structuring appropriate outpatient care.

METHOD

An extensive battery constituted of several tests developed for the assessment of executive functions was used in 38 inpatients with a DSM-IV diagnosis of schizophrenia. Psychosocial adjustment was assessed with a set of commonly used scales.

RESULTS

Performance on measures of executive functions was heterogeneous among the patient population, with a subgroup performing within normal scores. A similar pattern was found on measures of psychosocial adjustment. Most of the executive measures were not dependent on demographic or clinical variables. A factorial analysis on measures of psychosocial adjustment yielded a one-factor model which showed inconsistent, and at most, weak to moderate correlations with executive functions. Regression analysis revealed that symptom levels accounted for two-thirds of the variance of psychosocial adjustment, and together with measures of executive functions for 91% of the variance. General and negative symptoms showed strong correlations with psychosocial adjustment.

CONCLUSIONS

Our study supports the view that executive function is a heterogeneous construct with several subdimensions. Additionally, it suggests that symptom level has an important role as "rate limiting factor" on psychosocial adjustment and is partially mediated by executive dysfunction. Our results call for careful and detailed assessment in this patient population in order to establish appropriate treatment programmes such as cognitive remediation.

Pharmacotherapy of first-episode psychosis

Early intervention in psychosis has attracted more attention in the last few years. The treatment of this phase of the disorders requires a specific and adapted approach. The issue of engaging the patient is so critical that it influences not only the choice of medication, but also the context and the way in which it is administered. In the case of a first admission, patients should be observed for 24-48 h without any antipsychotic treatment, in order to clarify the diagnosis and exclude the possibility that symptoms are caused by acute intoxication with illicit substances, for example. The diagnosis is often difficult and unstable. A dimensional, rather than a categorical approach, is usually more likely to be adopted. In recent years, atypical antipsychotics have become the most frequently used first-line treatment. They are less likely to cause secondary negative symptoms, cognitive impairments and dysphoria. They also appear to influence the course of depression and hostility/aggression better than conventional neuroleptics, have possibly mood-stabilising properties and, subjectively, are often better accepted by patients. On the risk side, prevalence of acute extrapyramidal side effects and possibly tardive dyskinesia are lower, compared to the older neuroleptics. Although, the risk for short-term weight gain, cardiovascular, and especially hyperglycaemic complications are somewhat higher for some of these antipsychotics. Finally, the dose should be adapted as it has been shown that patients presenting a first psychotic episode respond to a lower dose of antipsychotic. This article focuses on the pharmacotherapy of first-episode psychosis, on the basis of a computerised and a manual search for articles dealing with antipsychotic treatment of these patients. Findings are discussed and combined in clinical guidelines for first-episode affective and non-affective psychosis, for patients with incomplete recovery or treatment resistance, for cases of emergency and for side effects associated with antipsychotic treatment.

Social and clinical consequences of cognitive deficits in early psychosis: a two-year follow-up study of first-admitted patients

OBJECTIVE

To explore whether baseline memory and executive deficits predicted poor social and clinical outcome over the 2 years following a first admission for psychosis, regardless of categorical diagnosis.

METHOD

Cognitive functioning was assessed in first-admitted subjects with psychosis (n=35) with a neuropsychological battery of tests measuring executive, language and memory functions. Social and clinical outcome were assessed at 6-monthly intervals over a two-year follow-up using multiple sources of information.

RESULTS

A dose-response relationship was found between visual and verbal memory performance at first admission and clinical outcome over the 2-year follow-up: the poorer the memory performance, the more likely the risk of presenting with psychotic symptoms and rehospitalization. Poor baseline performance on the WCST executive function predicted better medication adherence. No association was found between cognitive performance and occupational or residential outcome.

CONCLUSION

Cognitive performance was a better predictor of clinical than social outcome in this sample of first-episode patients. The association between cognitive deficits and poor social outcome may be more marked in subjects with chronic psychosis than in first-episode subjects. The finding that cognitive deficits predict better medication adherence is in need of further exploration.

Neuropsychological impairments in neuroleptic-responder vs. -nonresponder schizophrenic patients and healthy volunteers

To determine whether two groups of schizophrenic patients representing the two extremes of the neuroleptic response-spectrum (consistent responders vs. consistent nonresponders) differ with respect to their neuropsychological profile. Neuroleptic-responder (R; n=36) and -nonresponder (NR; n=39) schizophrenic patients were recruited according to a priori defined criteria of responsiveness to typical neuroleptics. Seven neuropsychological domains were assessed and compared between groups: attention-vigilance, abstraction-flexibility, spatial organization, visual-motor processing, visual memory, verbal abilities, and verbal memory and learning. All measures were standardized using the scores of 36 healthy volunteers. NR schizophrenic patients performed worse in all neuropsychological domains compared to normal controls and R schizophrenic patients. However, only performances on visual memory, verbal abilities, and verbal memory and learning were significantly poorer in NR compared to R patients. Only the latter domain significantly differentiated NR patients from the other two groups. R patients performed at an intermediate level in all domains. This report of differences in neuropsychological profile between neuroleptic-responder and -nonresponder schizophrenic patients adds to the growing evidence supporting the value of distinguishing schizophrenic patients on the basis of their therapeutic response to neuroleptics.

Relationship between neuroleptic dosage and subjective cognitive dysfunction in schizophrenic patients treated with either conventional or atypical neuroleptic medication

Previous research has suggested that high doses of conventional neuroleptics may induce neurocognitive deficits when assessed with standard tasks. However, little is known about the effects of high doses of neuroleptics (conventional or atypical) on subjective cognitive dysfunction. Recent research stresses the putative importance of self-reported cognitive deficits for both symptomatic outcome and medication compliance. The aim of the present study was to investigate the impact of neuroleptic medication on subjective cognition in patients treated with either conventional or atypical agents (clozapine, risperidone, olanzapine). Patients were asked to endorse the items of a questionnaire entitled 'Subjective Well-Being under Neuroleptic Treatment' prior to discharge. Subjective impairment, as assessed with the subscale 'mental functioning', was significantly correlated with greater conventional neuroleptic dosage after controlling for psychopathology (P<0.05). The difference between patients medicated with higher doses of conventional neuroleptics and those with lower doses was highly significant (P<0.001). In contrast, higher atypical neuroleptic doses were not associated with impairment.

Duration of untreated psychosis as a predictor of outcome in first-episode schizophrenia: a retrospective study

The aim of this study was to investigate possible clinical predictors of the outcome of first-episode schizophrenia. The clinical charts of the first episode of psychosis and the follow-up period over at least 4 years for 67 DSM-III-R schizophrenic patients were reviewed. According to the number of psychotic relapses observed during the follow-up period, patients were sub-divided into two groups: mono- and multi-episode patients. The main demographic and clinical variables recorded at the first episode were compared between the two groups. A logistic regression analysis was performed to test a model for the possible predictors of the two different patterns of outcome.Multi-episode patients had an earlier onset of the illness and a longer "duration of untreated psychosis" (DUP), defined as the interval between the onset of the first psychotic symptoms and the first antipsychotic treatment. The Brief Psychiatric Rating Scale (BPRS) total scores were lower and the "avolition/apathy" scores of the scale for the assessment of negative symptoms (SANS) were higher in multi-episode patients. The logistic regression analysis results confirmed the DUP and the pre-treatment BPRS scores to be significant predictors of the outcome. These findings confirm that the timing in recognizing and treating the early symptoms of schizophrenia, even when subtle, is a core issue for the clinical management of the disorder.

Duration of untreated psychosis and cognitive functioning in first-episode patients

BACKGROUND

The "toxicity" model of duration of untreated psychosis (DUP) suggests that longer DUP will be associated with poorer performance on cognitive tests in first-episode patients.

AIMS

To test this hypothesis on a sample of 113 patients in a community-based early intervention programme for psychosis.

METHOD

Information was collected concerning a number of possible predictors of cognitive functioning including DUP. These were examined for their relation to performance on an extensive battery of cognitive tests administered shortly after the patients' admission to the programme.

RESULTS

Although several variables such as gender, premorbid adjustment, education and handedness predicted cognitive functioning, no relation was found between DUP and performance on any component of the test battery.

CONCLUSIONS

Findings do not provide support for a toxic effect of DUP on cognitive functioning. Other mechanisms through which DUP might affect outcome such as psychological engulfment, social support and adherence to medication are discussed.

Improvement of schizophrenic patients' subjective well-being under atypical antipsychotic drugs

Recent research indicates that subjective well-being is a major determinant of medication compliance in schizophrenia. However, it is yet unresolved whether atypical neuroleptics differ regarding subjective side-effects. A self-report instrument has been constructed to evaluate 'subjective well-being under neuroleptics' (SWN). The primary aims of the present study were to develop a short form of the SWN and to investigate the extent to which the atypical antipsychotic improves the patient's subjective well-being. The short form of the SWN was constructed following an item analysis based on data from 212 schizophrenic patients medicated with either typical or atypical antipsychotics. The short form of the SWN showed sufficient internal consistency and good construct validity. The SWN was only moderately correlated with positive and negative syndrome scale (PANSS) scores or changes in psychopathology (r=-0.20 to -0.37). SWN-ratings in patients receiving olanzapine were superior compared to those of patients medicated with either clozapine or risperidone on three of five domains of well-being. Clozapine reduced global psychiatric symptoms significantly more than risperidone. It is concluded that the assessment of subjective well-being under antipsychotic treatment provides an independent outcome measure which is relevant to compliance.

An analysis of the specificity and the syndromal correlates of verbal memory impairments in schizophrenia

It was investigated whether schizophrenic and depressive patients show a distinguishable mnestic profile. A further aim was to explore the psychopathological correlates of memory malperfomance in schizophrenic patients. For the present study, schizophrenic, depressive and healthy samples (n=25 each) were compared regarding their performance in the Rey Auditory Verbal Learning Test. Subjects' sociodemographic background variables were comparable except for age (entered as a covariate). Depressive and schizophrenic patients performed significantly worse than healthy controls regarding both short-term and long-term free recall as well as recognition. No differences occurred for two parameters reflecting proneness to interference. Negative schizophrenic symptomatology was strongly correlated with memory dysfunction before and after controlling for distractibility. The study supports previous research suggesting that memory impairments in schizophrenia are not an epiphenomenon of deficits in verbal fluency or an attentional impairment. The major deficit in both schizophrenic and depressive patients is inferred to be the capability to learn.