Cognitive impairment after recovery from COVID-19: Frequency, profile, and relationships with clinical and laboratory indices

Cognitive impairment (CI) is regarded as a remarkable burden in COVID-19 survivors. Its prevalence and profile, and relationships with the disease clinical and laboratory indices, remain unclear. The present study investigated, in a large sample of patients recovered from COVID-19, the frequency of CI with both a face-to-face screening tool and comprehensive test battery (MCCB). The study also evaluated the profile of CI and its relationships with COVID-19 clinical and laboratory indices and with psychopathological features. Out of 1344 subjects assessed for eligibility, 736 completed the screening phase 11 months after the COVID-19 infection; 402 participated in the baseline phase and completed an in depth cognitive, clinical and laboratory assessment about one month later. More than one third of the screened subjects presented a CI (COG+); it was associated to age, education, male gender, COVID-19 severity, and presence of anosmia, dyspnea at rest and exertional dyspnea during the acute phase. COG+ subjects showed a higher severity of depression, anxiety and post-traumatic distress, and worse global functioning, than subjects without CI. The MCCB showed that 45% of the subjects had a CI involving attention, working memory, verbal learning, visual learning, and reasoning and problem solving. Finally, neurocognitive functioning was inversely correlated with LDH blood levels, a potential biomarker of disease severity. According to our findings, cognitive functioning should be routinely and periodically assessed in COVID-19 patients, especially in older subjects, who experienced more severe COVID-19 symptoms. In case of persisting dysfunctions cognitive training programs should be considered as treatment strategies.

Negative symptoms and social cognition as mediators of the relationship between neurocognition and functional outcome in schizophrenia

Introduction

In this study we assessed the contribution of psychopathology, including the two domains of negative symptoms (motivational deficit and expressive deficit), processing speed as an index of neurocognition, and emotion recognition, as an index of social cognition, to poor functional outcomes in people with schizophrenia.

Methods

The Positive and Negative Syndrome Scale was used to evaluate positive symptoms and disorganization and the Brief Negative Symptom Scale to assess negative symptoms. The Symbol Coding and the Trail Making Test A and B were used to rate processing speed and the Facial Emotion Identification Test to assess emotion recognition. Functional outcome was assessed with the Personal and Social Performance Scale (PSP). Regression analyses were performed to identify predictors of functional outcome. Mediation analyses was used to investigate whether social cognition and negative symptom domains fully or partially mediated the impact of processing speed on functional outcome.

Results

One hundred and fifty subjects from 8 different European centers were recruited. Our data showed that the expressive deficit predicted global functioning and together with motivational deficit fully mediated the effects of neurocognition on it. Motivational deficit was a predictor of personal and social functioning and fully mediated neurocognitive impairment effects on the same outcome. Both motivational deficit and neurocognitive impairment predicted socially useful activities, and the emotion recognition domain of social cognition partially mediated the impact of neurocognitive deficits on this outcome.

Conclusions

Our results indicate that pathways to functional outcomes are specific for different domains of real-life functioning and that negative symptoms and social cognition mediate the impact of neurocognitive deficits on different domains of functioning. Our results suggest that both negative symptoms and social cognition should be targeted by psychosocial interventions to enhance the functional impact of neurocognitive remediation.

Advances in the understanding of the pathophysiology of schizophrenia and bipolar disorder through induced pluripotent stem cell models

The pathophysiology of schizophrenia and bipolar disorder involves a complex interaction between genetic and environmental factors that begins in the early stages of neurodevelopment. Recent advancements in the field of induced pluripotent stem cells (iPSCs) offer a promising tool for understanding the neurobiological alterations involved in these disorders and, potentially, for developing new treatment options. In this review, we summarize the results of iPSC-based research on schizophrenia and bipolar disorder, showing disturbances in neurodevelopmental processes, imbalance in glutamatergic-GABAergic transmission and neuromorphological alterations. The limitations of the reviewed literature are also highlighted, particularly the methodological heterogeneity of the studies, the limited number of studies developing iPSC models of both diseases simultaneously, and the lack of in-depth clinical characterization of the included samples. Further studies are needed to advance knowledge on the common and disease-specific pathophysiological features of schizophrenia and bipolar disorder and to promote the development of new treatment options.

External validation of the five domains of negative symptoms: Focus on cognition, functional capacity, and real-world functioning

BACKGROUND

The conceptualization of negative symptoms (NS) in schizophrenia is still controversial. Recent confirmatory factor-analytic studies suggested that the bi-dimensional model (motivational deficit [MAP] and expressive deficit [EXP]) may not capture the complexity of NS structure, which could be better defined by a five-factor (five NS domains) or a hierarchical model (five NS domains as first-order factors, and MAP and EXP, as second-order factors). A validation of these models is needed to define the structure of NS. To evaluate the validity and temporal stability of the five-factor or the hierarchical structure of the brief negative symptom scale (BNSS) in individuals with schizophrenia (SCZ), exploring associations between these models with cognition, social cognition, functional capacity, and functioning at baseline and at 4 years follow-up.

METHODS

Clinical variables were assessed using state-of-the-art tools in 612 SCZ at two-time points. The validity of the five-factor and the hierarchical models was analyzed through structural equation models.

RESULTS

The two models had both a good fit and showed a similar pattern of associations with external validators at the two-time points, with minor variations. The five-factor solution had a slightly better fit. The associations with external validators favored the five-factor structure.

CONCLUSIONS

Our findings suggest that both five-factor and hierarchical models provide a valid conceptualization of NS in relation to external variables and that five-factor solution provides the best balance between parsimony and granularity to summarize the BNSS structure. This finding has important implications for the study of pathophysiological mechanisms and the development of new treatments.

Correlations between Negative Symptoms and Cognitive Deficits in Individuals at First Psychotic Episode or at High Risk of Psychosis: A Systematic Review

The present review aims to identify correlations between negative symptoms (NS) and deficits in neurocognition and social cognition in subjects with first-episode psychosis (FEP) and at-high-risk populations (HR). A systematic search of the literature published between 1 January 2005 and 31 December 2022 was conducted on PubMed, Scopus, and PsycInfo. Out of the 4599 records identified, a total of 32 studies met our inclusion/exclusion criteria. Data on a total of 3086 FEP and 1732 HR were collected. The available evidence shows that NS correlate with executive functioning and theory of mind deficits in FEP subjects, and with deficits in the processing speed, attention and vigilance, and working memory in HR subjects. Visual learning and memory do not correlate with NS in either FEP or HR subjects. More inconsistent findings were retrieved in relation to other cognitive domains in both samples. The available evidence is limited by sample and methodological heterogeneity across studies and was rated as poor or average quality for the majority of included studies in both FEP and CHR populations. Further research based on shared definitions of first-episode psychosis and at-risk states, as well as on more recent conceptualizations of negative symptoms and cognitive impairment, is highly needed.

Clinical Assessment Interview for Negative Symptoms (CAINS): A Systematic Review of Measurement Properties

BACKGROUND AND HYPOTHESIS

Negative symptoms are very important for the overall loss of functioning observed in patients with schizophrenia. There is a need for valid tools to assess these symptoms.

STUDY DESIGN

We used the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) systematic review guideline to evaluate the quality of the clinical assessment interview for negative symptoms (CAINS) as a clinician-rated outcome measurement (ClinROM).

STUDY RESULTS

The search strategy resulted in the retrieval of 13 articles, 11 of which were included in this evaluation. In terms of risk of bias, most articles reported on measures of internal consistency and construct validity, which were overall of good quality. Structural validity, reliability, measurement error, and cross-cultural validity were reported with less than optimum quality. There was a risk of bias in ClinROM development. According to the updated criteria of good measurement properties, structural validity, internal consistency, and reliability showed good results. In contrast, hypothesis testing was somewhat poorer. Results for cross-cultural validity were indeterminate. According to the updated GRADE approach from the COSMIN group the scale received a moderate grade.

CONCLUSIONS

The COSMIN standard allows a judgment of the CAINS as an instrument with the potential to be recommended for use, but which requires further research to assess its quality, in particular in the domains of content validity, internal consistency, and cross-cultural validity.

Effect of anticholinergic burden on brain activity during Working Memory and real-world functioning in patients with schizophrenia

Cognitive impairment has been associated with poor real-world functioning in patients with Schizophrenia. Previous studies have shown that pharmacological treatment with anticholinergic properties may contribute to cognitive impairment in Schizophrenia. We investigated the effect of the anticholinergic burden (ACB) on brain activity, cognition, and real-world functioning in Schizophrenia. We hypothesized that greater ACB would be associated with altered brain activity along with poorer cognitive performance and lower real-world functioning. A sample of 100 patients with a diagnosis of schizophrenia or schizoaffective disorder was recruited in the naturalistic multicenter study of the Italian Network for Research on Psychoses (NIRP) across 7 centres. For each participant, ACB was evaluated using the Anticholinergic Cognitive Burden scale. The association of ACB with brain function was assessed using BOLD fMRI during the N-Back Working Memory (WM) task in a nested cohort (N = 31). Real-world functioning was assessed using the Specific Level of Functioning (SLOF) scale. Patients with high ACB scores (≥3) showed lower brain activity in the WM frontoparietal network (TFCE corrected alpha <0.05) and poorer cognitive performance (p = 0.05) than patients with low ACB scores (<3). Both effects were unaffected by demographic characteristics, clinical severity, and antipsychotic dosage. Moreover, patients with high ACB showed poorer real-world functioning than patients with lower ACB (p = 0.03). Our results suggest that ACB in Schizophrenia is associated with impaired WM and abnormal underlying brain function along with reduced real-world functioning. Clinical practice should consider the potential adverse cognitive effects of ACB in the treatment decision-making process.

The structure stability of negative symptoms: longitudinal network analysis of the Brief Negative Symptom Scale in people with schizophrenia

BACKGROUND

The structure of negative symptoms of schizophrenia is still a matter of controversy. Although a two-dimensional model (comprising the expressive deficit dimension and the motivation and pleasure dimension) has gained a large consensus, it has been questioned by recent investigations.

AIMS

To investigate the latent structure of negative symptoms and its stability over time in people with schizophrenia using network analysis.

METHOD

Negative symptoms were assessed in 612 people with schizophrenia using the Brief Negative Symptom Scale (BNSS) at baseline and at 4-year follow-up. A network invariance analysis was conducted to investigate changes in the network structure and strength of connections between the two time points.

RESULTS

The network analysis carried out at baseline and follow-up, supported by community detection analysis, indicated that the BNSS's items aggregate to form four or five distinct domains (avolition/asociality, anhedonia, blunted affect and alogia). The network invariance test indicated that the network structure remained unchanged over time (network invariance test score 0.13; P = 0.169), although its overall strength decreased (6.28 at baseline, 5.79 at follow-up; global strength invariance test score 0.48; P = 0.016).

CONCLUSIONS

The results lend support to a four- or five-factor model of negative symptoms and indicate overall stability over time. These data have implications for the study of pathophysiological mechanisms and the development of targeted treatments for negative symptoms.

The Brief negative Symptom Scale (BNSS): a systematic review of measurement properties

BACKGROUND

Negative symptoms of schizophrenia are linked with poor functioning and quality of life. Therefore, appropriate measurement tools to assess negative symptoms are needed. The NIMH-MATRICS Consensus defined five domains for negative symptoms, which The Brief Negative Symptom Scale (BNSS) covers.

METHODS

We used the COSMIN guidelines for systematic reviews to evaluate the quality of psychometric data of the BNSS scale as a Clinician-Rated Outcome Measure (ClinROM).

RESULTS

The search strategy resulted in the inclusion of 17 articles. When using the risk of bias checklist, there was a generally good quality in reporting of structural validity and hypothesis testing. Internal consistency, reliability and cross-cultural validity were of poorer quality. ClinROM development and content validity showed inadequate results. According to the updated criteria of good measurement properties, structural validity, internal consistency and interrater reliability showed good results, while hypothesis testing showed poorer results. Cross-cultural validity and test-retest reliability were indeterminate. The updated GRADE approach resulted in a moderate grade.

CONCLUSIONS

We can potentially recommend the use of the BNSS as a concise tool to rate negative symptoms. Due to weaknesses in certain domains further validations are warranted.

Electrophysiological Correlates of Reward Anticipation in Subjects with Schizophrenia: An ERP Microstate Study

The current study aimed to investigate alterations of event-related potentials (ERPs) microstate during reward anticipation in subjects with schizophrenia (SCZ), and their association with hedonic experience and negative symptoms. EEG data were recorded in thirty SCZ and twenty-three healthy controls (HC) during the monetary incentive delay task in which reward, loss and neutral cues were presented. Microstate analysis and standardized low-resolution electromagnetic tomography (sLORETA) were applied to EEG data. Furthermore, analyses correlating a topographic index (the ERPs score), calculated to quantify brain activation in relationship to the microstate maps, and scales assessing hedonic experience and negative symptoms were performed. Alterations in the first (125.0-187.5 ms) and second (261.7-414.1 ms) anticipatory cue-related microstate classes were observed. In SCZ, reward cues were associated to shorter duration and earlier offset of the first microstate class as compared to the neutral condition. In the second microstate class, the area under the curve was smaller for both reward and loss anticipation cues in SCZ as compared to HC. Furthermore, significant correlations between ERPs scores and the anticipation of pleasure scores were detected, while no significant association was found with negative symptoms. sLORETA analysis showed that hypo-activation of the cingulate cortex, insula, orbitofrontal and parietal cortex was detected in SCZ as compared to HC. Abnormalities in ERPs could be traced already during the early stages of reward processing and were associated with the anticipation of pleasure, suggesting that these dysfunctions might impair effective evaluation of incoming pleasant experiences. Negative symptoms and anhedonia are partially independent results.

A new era for the negative symptoms of schizophrenia

Negative symptoms remain one of the major unmet needs for people with schizophrenia, and the past decade has witnessed a surge in interest in negative symptoms. In this themed issue, we present new concepts of negative symptoms and recent findings on their epidemiology and pathophysiology and on therapeutic options for their management.

Insight in cognitive impairment assessed with the Cognitive Assessment Interview in a large sample of patients with schizophrenia

The Cognitive Assessment Interview (CAI) is an interview-based scale measuring cognitive impairment and its impact on functioning in subjects with schizophrenia (SCZ). The present study aimed at assessing, in a large sample of SCZ (n = 601), the agreement between patients and their informants on CAI ratings, to explore patients' insight in their cognitive deficits and its relationships with clinical and functional indices. Agreement between patient- and informant-based ratings was assessed by the Gwet's agreement coefficient. Predictors of insight in cognitive deficits were explored by stepwise multiple regression analyses. Patients reported lower severity of cognitive impairment vs. informants. A substantial to almost perfect agreement was observed between patients' and informants' ratings. Lower insight in cognitive deficits was associated to greater severity of neurocognitive impairment and positive symptoms, lower severity of depressive symptoms, and older age. Worse real-life functioning was associated to lower insight in cognitive deficit, worse neurocognitive performance, and worse functional capacity. Our findings indicate that the CAI is a valid co-primary measure with the interview to patients providing a reliable assessment of their cognitive deficits. In the absence of informants with good knowledge of the subject, the interview to the patient may represent a valid alternative.

The Autism Rating Scale for Schizophrenia - Revised English Version: An Instrument to Characterize Schizophrenia Spectrum Disorders Phenotype

Dis-sociality (DS) reflects the impairment of social experience in people with schizophrenia; it encompasses both negative features (disorder of attunement, inability to grasp the meaning of social contexts, the vanishing of social shared knowledge) and positive features (a peculiar set of values, ruminations not oriented to reality), reflecting the existential arrangement of people with schizophrenia. DS is grounded on the notion of schizophrenic autism as depicted by continental psychopathology. A rating scale has been developed, providing an experiential phenotype. Here we present the Autism Rating Scale for Schizophrenia - Revised English version (ARSS-Rev), developed on the Italian version of the scale. The scale is provided by a structured interview to facilitate the assessment of the phenomena investigated here. ARSS-Rev is composed of 16 distinctive items grouped into 6 categories: hypo-attunement, invasiveness, emotional flooding, algorithmic conception of sociality, antithetical attitude toward sociality, and idionomia. For each item and category, an accurate description is provided. Different intensities of phenomena are assessed through a Likert scale by rating each item according to its quantitative features (frequency, intensity, impairment, and need for coping). The ARSS-Rev has been able to discriminate patients with remitted schizophrenia from euthymic patients with psychotic bipolar disorder. This instrument may be useful in clinical/research settings to demarcate the boundaries of schizophrenia spectrum disorders from affective psychoses.

Negative symptoms in First-Episode Schizophrenia related to morphometric alterations in orbitofrontal and superior temporal cortex: the OPTiMiSE study

BACKGROUND

Negative symptoms are one of the most incapacitating features of Schizophrenia but their pathophysiology remains unclear. They have been linked to alterations in grey matter in several brain regions, but findings have been inconsistent. This may reflect the investigation of relatively small patient samples, and the confounding effects of chronic illness and exposure to antipsychotic medication. We sought to address these issues by investigating concurrently grey matter volumes (GMV) and cortical thickness (CTh) in a large sample of antipsychotic-naïve or minimally treated patients with First-Episode Schizophrenia (FES).

METHODS

T1-weighted structural MRI brain scans were acquired from 180 antipsychotic-naïve or minimally treated patients recruited as part of the OPTiMiSE study. The sample was stratified into subgroups with (N = 88) or without (N = 92) Prominent Negative Symptoms (PMN), based on PANSS ratings at presentation. Regional GMV and CTh in the two groups were compared using Voxel-Based Morphometry (VBM) and FreeSurfer (FS). Between-group differences were corrected for multiple comparisons via Family-Wise Error (FWE) and Monte Carlo z-field simulation respectively at p < 0.05 (2-tailed).

RESULTS

The presence of PMN symptoms was associated with larger left inferior orbitofrontal volume (p = 0.03) and greater CTh in the left lateral orbitofrontal gyrus (p = 0.007), but reduced CTh in the left superior temporal gyrus (p = 0.009).

CONCLUSIONS

The findings highlight the role of orbitofrontal and temporal cortices in the pathogenesis of negative symptoms of Schizophrenia. As they were evident in generally untreated FEP patients, the results are unlikely to be related to effects of previous treatment or illness chronicity.

Sex and gender differences in clinical and functional indices in subjects with schizophrenia and healthy controls: Data from the baseline and 4-year follow-up studies of the Italian Network for Research on Psychoses

Gender differences in clinical and psychosocial aspects of schizophrenia have been widely reported. Findings have not always been consistent, and some of them need further research. In a large sample of community dwelling persons with schizophrenia, we investigated gender differences in clinical, cognitive and functional indices, as well as their changes over a 4-year follow-up and their impact on real-life functioning. Gender differences in personal resources, cognitive and functional indices were explored also in a sample of healthy controls. Men with respect to women had an earlier age of illness onset, a worse premorbid adjustment in the academic domain, more severe avolition, expressive deficit and positive symptoms, lower prevalence of comorbidity for affective disorders, less frequent use of two coping strategies ('religion' and 'use of emotional support') and more frequent positive history of substance and alcohol abuse. In addition, men were more impaired in verbal learning, while women in reasoning/problem solving. Some patterns of gender differences observed in healthy controls were not confirmed in patients. Men's disadvantages in the clinical picture did not translate into a worse outcome. This finding may be related to the complex interplay of several factors acting as predictors or mediators of outcome.

Resting-State Brain Activity Dysfunctions in Schizophrenia and Their Associations with Negative Symptom Domains: An fMRI Study

The aim of the present study was to examine the neurobiological correlates of the two negative symptom domains of schizophrenia, the Motivational Deficit domain (including avolition, anhedonia, and asociality) and the Expressive Deficit domain (including blunted affect and alogia), focusing on brain areas that are most commonly found to be associated with negative symptoms in previous literature. Resting-state (rs) fMRI data were analyzed in 62 subjects affected by schizophrenia (SZs) and 46 healthy controls (HCs). The SZs, compared to the HCs, showed higher rs brain activity in the right inferior parietal lobule and the right temporoparietal junction, and lower rs brain activity in the right dorsolateral prefrontal cortex, the bilateral anterior dorsal cingulate cortex, and the ventral and dorsal caudate. Furthermore, in the SZs, the rs brain activity in the left orbitofrontal cortex correlated with negative symptoms (r = -0.436, p = 0.006), in particular with the Motivational Deficit domain (r = -0.424, p = 0.002), even after controlling for confounding factors. The left ventral caudate correlated with negative symptoms (r = -0.407, p = 0.003), especially with the Expressive Deficit domain (r = -0.401, p = 0.003); however, these results seemed to be affected by confounding factors. In line with the literature, our results demonstrated that the two negative symptom domains might be underpinned by different neurobiological mechanisms.

Thirty years of research on negative symptoms of schizophrenia: A scientometric analysis of hotspots, bursts, and research trends

Research on negative symptoms of schizophrenia has received renewed interest since the 1980s. A scientometric analysis that objectively maps scientific knowledge, with changes in recent trends, is currently lacking. We searched the Web of Science Core Collection (WOSCC) on December 17, 2021 using relevant keywords. R-bibliometrix and CiteSpace were used to perform the analysis. We retrieved 27,568 references published between 1966 and 2022. An exponential rise in scientific interest was observed, with an average annual growth rate in publications of 16.56% from 1990 to 2010. The co-cited reference network that was retrieved presented 24 different clusters with a well-structured network (Q=0.7921; S=0.9016). Two distinct major research trends were identified: research on the conceptualization and treatment of negative symptoms. The latest trends in research on negative symptoms include evidence synthesis, nonpharmacological treatments, and computational psychiatry. Scientometric analyses provide a useful summary of changes in negative symptom research across time by identifying intellectual turning point papers and emerging trends. These results will be informative for systematic reviews, meta-analyses, and generating novel hypotheses.

Cognitive Impairment after Post-Acute COVID-19 Infection: A Systematic Review of the Literature

The present study aims to provide a critical overview of the literature on the relationships between post-acute COVID-19 infection and cognitive impairment, highlighting the limitations and confounding factors. A systematic search of articles published from 1 January 2020 to 1 July 2022 was performed in PubMed/Medline. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only studies using validated instruments for the assessment of cognitive impairment were included. Out of 5515 screened records, 72 studies met the inclusion criteria. The available evidence revealed the presence of impairment in executive functions, speed of processing, attention and memory in subjects recovered from COVID-19. However, several limitations of the literature reviewed should be highlighted: most studies were performed on small samples, not stratified by severity of disease and age, used as a cross-sectional or a short-term longitudinal design and provided a limited assessment of the different cognitive domains. Few studies investigated the neurobiological correlates of cognitive deficits in individuals recovered from COVID-19. Further studies with an adequate methodological design are needed for an in-depth characterization of cognitive impairment in individuals recovered from COVID-19.

Unveiling the Associations between EEG Indices and Cognitive Deficits in Schizophrenia-Spectrum Disorders: A Systematic Review

Cognitive dysfunctions represent a core feature of schizophrenia-spectrum disorders due to their presence throughout different illness stages and their impact on functioning. Abnormalities in electrophysiology (EEG) measures are highly related to these impairments, but the use of EEG indices in clinical practice is still limited. A systematic review of articles using Pubmed, Scopus and PsychINFO was undertaken in November 2021 to provide an overview of the relationships between EEG indices and cognitive impairment in schizophrenia-spectrum disorders. Out of 2433 screened records, 135 studies were included in a qualitative review. Although the results were heterogeneous, some significant correlations were identified. In particular, abnormalities in alpha, theta and gamma activity, as well as in MMN and P300, were associated with impairments in cognitive domains such as attention, working memory, visual and verbal learning and executive functioning during at-risk mental states, early and chronic stages of schizophrenia-spectrum disorders. The review suggests that machine learning approaches together with a careful selection of validated EEG and cognitive indices and characterization of clinical phenotypes might contribute to increase the use of EEG-based measures in clinical settings.

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.

Network Analyses: Understanding the Pathways of Functional Improvement in Schizophrenia

Improving real-life functioning is the main goal of the most advanced integrated treatment programs in people with schizophrenia. The Italian Network for Research on Psychoses used network analysis in a four-year follow-up study to test whether the pattern of relationships among illness-related variables, personal resources and context-related factors differed between patients who were classified as recovered at follow-up versus those who did not recover. In a large sample (N=618) of clinically-stable, community-dwelling subjects with schizophrenia, the study demonstrated a considerable stability of the network structure. Functional capacity and everyday life skills had a high betweenness and closeness in the network at both baseline and follow-up, while psychopathological variables remained more peripheral. The network structure and connectivity of non-recovered patients were similar to those observed in the whole sample, but very different from those in recovered subjects, in which we found few connections only. These data strongly suggest that tightly coupled symptoms/dysfunctions tend to maintain each other’s activation, contributing to poor outcome in subjects with schizophrenia. The data suggest that early and integrated treatment plans, targeting variables with high centrality, might prevent the emergence of self-reinforcing networks of symptoms and dysfunctions in people with schizophrenia.

The Evidence Base For Psychiatric Support For Living Independently And Being Included In The Community

Functional recovery of subjects with schizophrenia remains an unmet need despite the availability of effective pharmacological and psychosocial treatments. The focus of recovery-oriented approaches is on fostering hope and resilience, fighting self-stigma, supporting self-determination and promoting social inclusion. The implementation of recovery-oriented plans requires an in depth understanding of key factors influencing real-life functioning, health status and quality of life. Recently published data from the Italian Network for Research on Psychoses have provided evidence that baseline variables associated with functional outcome at follow-up included domains not routinely assessed and targeted by intervention programs in community mental health services. As pointed out by experts in schizophrenia research and care, the management of subjects with schizophrenia has not significantly improved and only a minority of them receives integrated and personalized treatments. Shared decision-making and integrated pharmacological and psychosocial treatments, tailored on subjects’ needs, might significantly improve the outcome of subjects with schizophrenia, supporting independent living and inclusion in the community.

Disclosure

Honoraria, advisory board, or consulting fees from Angelini, Astra Zeneca, Bristol-Myers Squibb, Gedeon Richter Bulgaria, Innova-Pharma, Janssen Pharmaceuticals, Lundbeck, Otsuka, Pfizer, and Pierre Fabre, for services not related to this abstract

Recognition and Assessment of Cognitive Impairment in Schizophrenia

A renewal of interest in the cognitive assessment of people with schizophrenia was related to the increasing acknowledgement of the strong relationships of cognitive deficits with functional outcome. In the early 2000’s, research focused on those aspects of cognition that demonstrated a strong correlation with a variety of functional outcome measures (community functioning, functional capacity, social skills acquisition). Later on, social cognition, which was not included in neuropsychological batteries, became also a focus as it represents a mediator of the impact of neurocognition on functioning. The renewed interest and the association with functional outcome stimulated the development of batteries specifically devoted to the cognitive assessment of subjects with schizophrenia. The MATRICS Consensus Cognitive Battery (MCCB) is the instruments with the largest evidence of good psychometric properties and strong relationship with functional outcome. The MCCB has been proposed as the gold standard in assessing cognitive impairment in subjects with schizophrenia and has been translated into 24 languages and validated in many different countries. Different instruments are also available to assess emotional processing and theory of mind which should complement MCCB and similar batteries. The long administration time limits the use of batteries in everyday clinical routine and short-administered instruments were developed as screening tools. A brief, interview-based assessment of cognitive functioning, the Cognitive Assessment Interview, has also been developed and validated for use in clinical settings or as a co-primary measure in clinical trials. The development of a guidance paper might promote the routine assessment of cognition in subjects with schizophrenia.

Gender differences in clinical and psychosocial features in a large sample of Italian patients with schizophrenia

Introduction

An extensive literature regarding gender differences relevant to several aspects of schizophrenia is nowadays available. It includes some robust findings as well as some inconsistencies. The identification of gender differences and the understanding of their explanations may help to clarify the underlying etiopathogenetic mechanisms of specific aspects of the disorder.

Objectives

The present study aimed at investigating gender differences on premorbid, clinical, cognitive and outcome indices, as well as their impact on recovery, in a large sample of patients with schizophrenia recruited within the multicenter study of the Italian Network for Research on Psychoses.

Methods

State-of-the-art instruments were used to assess the investigated domains. Group comparisons between male and female patients were performed on all considered indices. The associations of premorbid, clinical and cognitive indices with recovery in the two patient groups were investigated by means of multiple regressions.

Results

Males with respect to females had a worse premorbid adjustment – limited to the academic dimension – an earlier age of onset, a higher frequency of history of substance and alcohol abuse, more severe negative symptoms (both avolition and expressive deficit), positive symptoms and impairment of social cognition. No gender difference was observed in neurocognition nor in the rates of recovery.

Conclusions

Although males showed some disadvantages in the clinical picture, this was not translated into a worse outcome. This finding may be related to the complex interplay of several factors acting as predictors or mediators of outcome.

Disclosure

No significant relationships.

The Cognitive Assessment Interview (CAI): Association with neuropsychological scores and real-life functioning in a large sample of Italian subjects with schizophrenia

INTRODUCTION

The Cognitive Assessment Interview (CAI) is an interview-based scale developed to measure cognitive impairment and its impact on functioning in subjects with schizophrenia (SCZ). Previous studies demonstrated good psychometric properties of the CAI. However, only relatively small samples of SCZ were investigated. This study aimed to determine in a large sample of SCZ (N = 580) the relationships of the Italian Version of the CAI with measures of cognitive performance and functional capacity and real-life functioning, using state-of-the-art instruments.

METHODS

Intraclass correlation coefficients (ICCs) and Cronbach's alpha were calculated to examine the CAI's inter-rater reliability and internal consistency. Pearson's correlation coefficients were used to evaluate relationships between CAI global and domain composite scores with neurocognition, social cognition, functional capacity, and functioning.

RESULTS

The inter-rater reliability and internal consistency were good to excellent. The CAI global composite score showed a strong correlation with the MATRICS Consensus Cognitive Battery (MCCB) composite score (r = -0.50) and moderate/strong associations with measures of functional capacity (-0.46 < r < -0.52) and real-life functioning (-0.30 < r < -0.51). Finally, CAI composite social cognition score correlated moderately with the Facial Emotion Identification Test (r = -0.31) and two subscales of the Awareness of Social Inference Test (-0.32 < r < -0.34).

CONCLUSIONS

The study suggests that CAI is a valid co-primary measure for clinical trials and a suitable instrument to screen impairment in neurocognitive and social cognitive domains and its impact on functioning in SCZ in everyday clinical practice.

Joint structural-functional magnetic resonance imaging features are associated with diagnosis and real-world functioning in patients with schizophrenia

OBJECTIVE

Earlier evidence suggested that structural-functional covariation in schizophrenia patients (SCZ) is associated with cognition, a predictor of functioning. Moreover, studies suggested that functional brain abnormalities of schizophrenia may be related with structural network features. However, only few studies have investigated the relationship between structural-functional covariation and both diagnosis and functioning in SCZ. We hypothesized that structural-functional covariation networks associated with diagnosis are related to real-world functioning in SCZ.

METHODS

We performed joint Independent Component Analysis on T1 images and resting-state fMRI-based Degree Centrality (DC) maps from 89 SCZ and 285 controls. Structural-functional covariation networks in which we found a main effect of diagnosis underwent correlation analysis to investigate their relationship with functioning. Covariation networks showing a significant association with both diagnosis and functioning underwent univariate analysis to better characterize group-level differences at the spatial level.

RESULTS

A structural-functional covariation network characterized by frontal, temporal, parietal and thalamic structural estimates significantly covaried with temporo-parietal resting-state DC. Compared with controls, SCZ had reduced structural-functional covariation within this network (p_FDR = 0.005). The same measure correlated positively with both social and occupational functioning (both p_FDR = 0.042). Univariate analyses revealed grey matter deviations in SCZ compared with controls within this structural-functional network in hippocampus, cerebellum, thalamus, orbito-frontal cortex, and insula. No group differences were found in DC.

CONCLUSIONS

Findings support the existence of a phenotypical association between group-level differences and inter-individual heterogeneity of functional deficits in SCZ. Given that only the joint structural/functional analysis revealed this association, structural-functional covariation may be a potentially relevant schizophrenia phenotype.

European Validation of the Self-Evaluation of Negative Symptoms (SNS): A Large Multinational and Multicenter Study

BACKGROUND

Negative symptoms are usually evaluated with scales based on observer ratings and up to now self-assessments have been overlooked. The aim of this paper was to validate the Self-evaluation of Negative Symptoms (SNS) in a large European sample coming from 12 countries. We wanted to demonstrate: (1) good convergent and divergent validities; (2) relationships between SNS scores and patients' functional outcome; (3) the capacity of the SNS compared to the Brief Negative Symptom Scale (BNSS) to detect negative symptoms; and (4) a five-domain construct in relation to the 5 consensus domains (social withdrawal, anhedonia, alogia, avolition, blunted affect) as the best latent structure of SNS.

METHODS

Two hundred forty-five subjects with a DSM-IV diagnosis of schizophrenia completed the SNS, the Positive and Negative Syndrome Scale (PANSS), the BNSS, the Calgary Depression Scale for Schizophrenia (CDSS), and the Personal and Social Performance (PSP) scale. Spearman's Rho correlations, confirmatory factor analysis investigating 4 models of the latent structure of SNS and stepwise multiple regression were performed.

RESULTS

Significant positive correlations were observed between the total score of the SNS and the total scores of the PANSS negative subscale (r = 0.37; P < 0.0001) and the BNSS (r = 0.43; p < 0.0001). SNS scores did not correlate with the level of insight, parkinsonism, or the total score of the PANSS positive subscale. A positive correlation was found between SNS and CDSS (r = 0.35; p < 0.0001). Among the 5 SNS subscores, only avolition subscores entered the regression equation explaining a lower functional outcome. The 1-factor and 2-factor models provided poor fit, while the 5-factor model and the hierarchical model provided the best fit, with a small advantage of the 5-factor model. The frequency of each negative dimension was systematically higher using the BNSS and the SNS vs. the PANSS and was higher for alogia and avolition using SNS vs. BNSS.

CONCLUSION

In a large European multicentric sample, this study demonstrated that the SNS has: (1) good psychometric properties with good convergent and divergent validities; (2) a five-factor latent structure; (3) an association with patients' functional outcome; and (4) the capacity to identify subjects with negative symptoms that is close to the BNSS and superior to the PANSS negative subscale.

European Psychiatric Association guidance on treatment of cognitive impairment in schizophrenia

Background

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

Methods

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

Results

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

Conclusions

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

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

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

European Psychiatric Association guidance on assessment of cognitive impairment in schizophrenia

Background

Impairment in a wide range of cognitive abilities has been consistently reported in individuals with schizophrenia. Both neurocognitive and social cognitive deficits are thought to underlie severe functional disabilities associated with schizophrenia. Despite the key role in schizophrenia outcome, cognition is still poorly assessed in both research and clinical settings.

Methods

In this guidance paper, we provide a systematic review of the scientific literature and elaborate several recommendations for the assessment of cognitive functions in schizophrenia both in research settings and in real-world clinical practice.

Results

Expert consensus and systematic reviews provided guidance for the optimal assessment of cognitive functions in schizophrenia. Based on the reviewed evidence, we recommend a comprehensive and systematic assessment of neurocognitive and social cognitive domains in schizophrenia, in all phases of the disorder, as well as in subjects at risk to develop psychosis. This European Psychiatric Association guidance recommends not only the use of observer reports but also self-reports and interview-based cognitive assessment tools. The guidance also provides a systematic review of the state of the art of assessment in the first episode of psychosis patients and in individuals at risk for psychosis.

Conclusion

The comprehensive review of the evidence and the recommendations might contribute to advance the field, allowing a better cognitive assessment, and avoiding overlaps with other psychopathological dimensions. The dissemination of this guidance paper may promote the development of shared guidelines concerning the assessment of cognitive functions in schizophrenia, with the purpose to improve the quality of care and to obtain recovery.

Investigating the Relationships of P3b with Negative Symptoms and Neurocognition in Subjects with Chronic Schizophrenia

Neurocognitive deficits and negative symptoms (NS) have a pivotal role in subjects with schizophrenia (SCZ) due to their impact on patients' functioning in everyday life and their influence on goal-directed behavior and decision-making. P3b is considered an optimal electrophysiological candidate biomarker of neurocognitive impairment for its association with the allocation of attentional resources to task-relevant stimuli, an important factor for efficient decision-making, as well as for motivation-related processes. Furthermore, associations between P3b deficits and NS have been reported. The current research aims to fill the lack of studies investigating, in the same subjects, the associations of P3b with multiple cognitive domains and the expressive and motivation-related domains of NS, evaluated with state-of-the-art instruments. One hundred and fourteen SCZ and 63 healthy controls (HCs) were included in the study. P3b amplitude was significantly reduced and P3b latency prolonged in SCZ as compared to HCs. In SCZ, a positive correlation was found between P3b latency and age and between P3b amplitude and the Attention-vigilance domain, while no significant correlations were found between P3b and the two NS domains. Our results indicate that the effortful allocation of attention to task-relevant stimuli, an important component of decision-making, is compromised in SCZ, independently of motivation deficits or other NS.

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

In a cross-sectional study, the Italian Network for Research on Psychoses (INReP) found that variables relevant to the disease, personal resources and social context explain 53.8% of real-life functioning variance in a large sample of community dwelling people with schizophrenia. In a longitudinal study, the INReP aimed to identify baseline predictors of main domains of real-life functioning, i.e. work skills, interpersonal relationships and everyday life skills, at 4-year follow-up. We assessed psychopathology, social and non-social cognition, functional capacity, personal resources, and context-related factors, as well as real-life functioning as the main outcome. We used structural equation modeling (SEM) and latent change score (LCS) model to identify predictors of real-life functioning domains at follow-up and changes from baseline in the same domains. Six-hundred-eighteen subjects took part in the study. Neurocognition predicted everyday life and work skills; avolition predicted interpersonal relationships; positive symptoms work skills, and social cognition work skills and interpersonal functioning. Higher neurocognitive abilities predicted the improvement of everyday life and work skills, as well as of social cognition and functional capacity; better baseline social cognition predicted the improvement of work skills and interpersonal functioning, and better baseline everyday life skills predicted the improvement of work skills. Several variables which predict important aspects of functional outcome of people with schizophrenia are not routinely assessed and are not systematically targeted by intervention programs in community mental health services. A larger dissemination of practices such as cognitive training and personalized psychosocial interventions should be promoted in mental health care.

Factors Associated With Real-Life Functioning in Persons With Schizophrenia in a 4-Year Follow-up Study of the Italian Network for Research on Psychoses

IMPORTANCE

The goal of schizophrenia treatment has shifted from symptom reduction and relapse prevention to functional recovery; however, recovery rates remain low. Prospective identification of variables associated with real-life functioning domains is essential for personalized and integrated treatment programs.

OBJECTIVE

To assess whether baseline illness-related variables, personal resources, and context-related factors are associated with work skills, interpersonal relationships, and everyday life skills at 4-year follow-up.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter prospective cohort study was conducted across 24 Italian university psychiatric clinics or mental health departments in which 921 patients enrolled in a cross-sectional study were contacted after 4 years for reassessment. Recruitment of community-dwelling, clinically stable persons with schizophrenia was conducted from March 2016 to December 2017, and data were analyzed from January to May 2020.

MAIN OUTCOMES AND MEASURES

Psychopathology, social and nonsocial cognition, functional capacity, personal resources, and context-related factors were assessed, with real-life functioning as the main outcome. Structural equation modeling, multiple regression analyses, and latent change score modeling were used to identify variables that were associated with real-life functioning domains at follow-up and with changes from baseline in these domains.

RESULTS

In total, 618 participants (427 male [69.1%]; mean [SD] age, 45.1 [10.5] years) were included. Five baseline variables were directly associated with real-life functioning at follow-up: neurocognition with everyday life (β, 0.274; 95% CI, 0.207-0.341; P < .001) and work (β, 0.101; 95% CI, 0.005-0.196; P = .04) skills; avolition with interpersonal relationships (β, -0.126; 95% CI, -0.190 to -0.062; P < .001); positive symptoms with work skills (β, -0.059; 95% CI, -0.112 to -0.006; P = .03); and social cognition with work skills (β, 0.185; 95% CI, 0.088-0.283; P < .001) and interpersonal functioning (β, 0.194; 95% CI, 0.121-0.268; P < .001). Multiple regression analyses indicated that these variables accounted for the variability of functioning at follow-up after controlling for baseline functioning. In the latent change score model, higher neurocognitive abilities were associated with improvement of everyday life (β, 0.370; 95% CI, 0.253-0.486; P < .001) and work (β, 0.102; 95% CI, 0.016-0.188; P = .02) skills, social cognition (β, 0.133; 95% CI, 0.015-0.250; P = .03), and functional capacity (β, 1.138; 95% CI, 0.807-1.469; P < .001); better baseline social cognition with improvement of work skills (β, 0.168; 95% CI, 0.075-0.261; P < .001) and interpersonal functioning (β, 0.140; 95% CI, 0.069-0.212; P < .001); and better baseline everyday life skills with improvement of work skills (β, 0.121; 95% CI, 0.077-0.166; P < .001).

CONCLUSIONS AND RELEVANCE

Findings of this large prospective study suggested that baseline variables associated with functional outcome at follow-up included domains not routinely assessed and targeted by intervention programs in community mental health services. The key roles of social and nonsocial cognition and of baseline everyday life skills support the adoption in routine mental health care of cognitive training programs combined with personalized psychosocial interventions aimed to promote independent living.

Investigation of electrophysiological markers to predict clinical and functional outcome of schizophrenia using sparse partial least square regression

Introduction

Despite innovative treatments, the impairment in real-life functioning in subjects with schizophrenia (SCZ) remains an unmet need in the care of these patients. Recently, real-life functioning in SCZ was associated with abnormalities in different electrophysiological indices. It is still not clear whether this relationship is mediated by other variables, and how the combination of different EEG abnormalities influences the complex outcome of schizophrenia.

Objectives

The purpose of the study was to find EEG patterns which can predict the outcome of schizophrenia and identify recovered patients.

Methods

Illness-related and functioning-related variables were measured in 61 SCZ at baseline and after four-years follow-up. EEGs were recorded at the baseline in resting-state condition and during two auditory tasks. We performed Sparse Partial Least Square (SPLS) Regression, using EEG features, age and illness duration to predict clinical and functional features at baseline and follow up. Through a Linear Support Vector Machine (Linear SVM) we used electrophysiological and clinical scores derived from SPLS regression, in order to classify recovered patients at follow-up.

Results

We found one significant latent variable (p<0.01) capturing correlations between independent and dependent variables at follow-up (RHO=0.56). Among individual predictors, age and illness-duration showed the highest scores; however, the score for the combination of the EEG features was higher than all other predictors. Within dependent variables, negative symptoms showed the strongest correlation with predictors. Scores resulting from SPLS Regression classified recovered patients with 90.1% of accuracy.

Conclusions

A combination of electrophysiological markers, age and illness-duration might predict clinical and functional outcome of schizophrenia after 4 years of follow-up.

Prediction of drop-out and functional impairment in recent-onset schizophrenia spectrum disorders

Persistent negative symptoms are associated with worse outcome in both first-episode and chronic subjects with schizophrenia. The identification of these symptoms in recent-onset subjects is still controversial as retrospective data are often unavailable. The prospective assessment of persistence of negative symptoms might represent a valid alternative but the length of the persistence is still to be established. The present study investigated the prevalence of negative symptoms of moderate severity, unconfounded by depression and extrapyramidal symptoms at baseline in a large cohort of patients in the early stage of a schizophrenia-spectrum disorder, recruited to the OPTiMiSE trial. Persistent unconfounded negative symptoms were assessed at 4, 10 and 22 weeks of treatment. Symptomatic remission, attrition rate and psychosocial functioning was evaluated in subjects with short-term (4 weeks) persistent negative symptoms (PNS) and in those with negative symptoms that did not persist at follow-up and/or were confounded at baseline (N-PNS). Negative symptoms of moderate severity were observed in 59% of subjects at baseline and were associated to worse global functioning. PNS were observed in 7.9% of the cohort, unconfounded at both baseline and end of 4-week treatment. PNS subjects showed lower remission and higher attrition rates at the end of all treatment phases. Fifty-six percent of subjects completing phase 3 (clozapine treatment) had PNS, and 60% of them were non-remitters at the end of this phase. The presence of short-term PNS during the first phases of psychosis was associated with poor clinical outcome and resistance to antipsychotic treatment, including clozapine.

Multivariate approach to identify electrophysiological markers for diagnosis and prognosis of schizophrenia

Introduction

Different electrophysiological indices have been investigated to identify diagnostic and prognostic markers of schizophrenia (SCZ). However, these indices have limited use in clinical practice, since both specificity and association with illness outcome remain unclear. In recent years, machine learning techniques, through the combination of multidimensional data, have been used to better characterize SCZ and to predict illness course.

Objectives

The aim of the present study is to identify multimodal electrophysiological biomarkers that could be used in clinical practice in order to improve precision in diagnosis and prognosis of SCZ.

Methods

Illness-related and functioning-related variables were measured at baseline in 113 subjects with SCZ and 57 healthy controls (HC), and after four-year follow-up in 61 SCZ. EEGs were recorded at baseline in resting-state condition and during two auditory tasks (MMN-P3a and N100-P3b). Through a Linear Support Vector Machine, using EEG data as predictors, four models were generated in order to classify SCZ and HC. Then, we combined unimodal classifiers’ scores through a stacking procedure. Pearson’s correlations between classifiers score with illness-related and functioning-related variables, at baseline and follow-up, were performed.

Results

Each EEG model produced significant classification (p < 0.05). Global classifier discriminated SCZ from HC with accuracy of 75.4% (p < 0.01). A significant correlation (r=0.40, p=0.002) between the global classifier scores with negative symptoms at follow-up was found. Within negative symptoms, blunted affect showed the strongest correlation.

Conclusions

Abnormalities in electrophysiological indices might be considered trait markers of schizophrenia. Our results suggest that multimodal electrophysiological markers might have prognostic value for negative symptoms.

Effectiveness of social skills training conducted in a group of subjects with first-episode psychosis

Introduction

Cognitive deficits are considered a key feature of schizophrenia due to their substantial influence on the psychosocial outcome of subjects affected by this disorder. Several studies showed that moderate to severe cognitive impairments, including dysfunctions of social cognition, are already present during the early phases of the illness, in subjects with first-episode psychosis (FEPs). Psychosocial interventions, such as social skill training (SST), could therefore be implemented already upon occurrence of the first episode of psychosis to improve the overall functional outcome of schizophrenia, which represents to date an unmet need in the care of these patients.

Objectives

The study aims to evaluate the use of SST to enhance social skills and real-life functioning in FEPs.

Methods

The sample included 7 FEPs (age between 15 and 40). The SST intervention included 30 sessions lasting 2 hours and delivered twice a week. Psychopathology, neurocognition, real life functioning, functional capacity and social cognition were assessed at baseline ad after training. Paired samples t-tests were performed to evaluate the effects of the intervention. All subjects were treated with second generation antipsychotics.

Results

Significant improvements were observed in negative symptoms, social cognition, problem solving skills, as well as in global functioning (all p<0.05). Within real-life functioning, the improvement was greater for the domain of interpersonal relationships.

Conclusions

These preliminary findings suggest that SST might complement pharmacological treatment in FEPs to improve functional outcome in these subjects. Further studies with a higher sample size and a longer follow-up are required in order to confirm the present results.

Apathy in schizophrenia: assessment in clinical settings and overlap with other dimensions of impairment

Negative symptoms are considered a core feature of schizophrenia. They are present since the prodromal phase and tend to persist more than other psychopathological dimensions in the chronic stages. The domain of apathy has attracted research efforts for the strong association with poor functional outcome. This negative symptom domain is observed in a number of neuropsychiatric disorders and might have both overlapping and distinct pathophysiological mechanisms. In schizophrenia it can be secondary to other aspects of the disorder, such as positive symptoms and depression, to drug side effects and/or social isolation, often observed in affected subjects. When primary to schizophrenia, apathy is conceptualized in terms of a reduction of the voluntary activity due to a lack of interest and motivation for goal-directed behavior initiation and persistence. In a percentage of subjects, apathy tend to persist and do not respond to available pharmacological and psychosocial treatments. The assessment of this domain in patients with schizophrenia using internationally recognized criteria for its definition, as were recently developed in other neuropsychiatric disorders, might help disentangle the different pathophysiological mechanisms. In the presentation, studies of apathy in schizophrenia will be illustrated to highlight the relationships with cognitive dysfunction, other psychopathological dimensions and functional outcome using state of the art instruments to assess the construct in schizophrenia.

Disclosure

Prof. Mucci has been a consultant and/or advisor to or has received honoraria from Gedeon Richter Bulgaria, Janssen Pharmaceuticals, Lundbeck, Otsuka, Pfizer and Pierre Fabre.

Resting-state functional connectivity of the ventral tegmental area and negative symptom domains in subjects with schizophrenia

Introduction

Negative symptoms (NS) represent a core aspect of schizophrenia with a huge impact on real life functioning. Dysfunctions within the dopaminergic cortico-striatal circuits have been documented in subjects with schizophrenia (SCZ) and hypothesized as possible neurobiological mechanisms underlying some domains of NS.

Objectives

We investigated relationships between the resting-state functional connectivity (RS-FC) of the ventro-tegmental area (VTA) and NS.

Methods

Resting-state fMRI data were recorded in 35 SCZ, recruited within the Italian Network for Research on Psychoses. We performed partial correlations between RS-FC and NS (evaluated with the Brief Negative Symptom Scale) controlling for possible sources of secondary negative symptoms.

Results

We found that the experiential domain correlated with the RS-FC of the VTA with the left ventro-lateral prefrontal cortex (lVLPFC) (r=0.372, p=0.039), while the Expressive deficit domain correlated with the RS-FC of the VTA with the left dorso-lateral prefrontal cortex (lDLPFC) (r= 0.470, p .008). Looking at subdomains, only the avolition (r= 0.418, p=0.019) and the blunted affect (r= 0.465, p=.008) showed the same correlations of the domains to which they belong.

Conclusions

According to our findings, separate dysfunctional neuronal circuits could underpin distinct negative symptom subdomains. A better understanding of neurobiological dysfunctions underlying NS could help to design new treatments, targeting different NS subdomains.

The efficacy of social skills training in the treatment of schizophrenia

Introduction

Social cognition and skill deficits have been largely documented in subjects with schizophrenia (SCZs), and have a strong influence on the functional outcome of these subjects. Different behavioural interventions have been developed to target and improve social skills in SCZs. For instance, the Social Skills Training (SST) focuses on improving communication skills and assertiveness to facilitate disease management, independent living and real-life functioning of SCZs. SST seems also to have an impact on negative symptoms and social cognition.

Objectives

The study aims to evaluate the effectiveness of SST in improving social cognition and negative symptoms in SCZs.

Methods

The sample included 8 chronic SCZs (age between 18 and 60), who completed 6 months of SST. The intervention consisted of two weekly group sessions of 2 hours each. We assessed psychopathology, neurocognition, real-life functioning, functional capacity and social cognition at baseline and after training. Paired samples t-tests were performed to evaluate the differences of the variables considered after completing the treatment.

Results

Significant improvements in negative symptoms (p<.05), social cognition (p<.05), functional capacity (p<.001), activities of daily living (p<.001) and interpersonal relationships (p<.011) were found.

Conclusions

The present findings suggest that SST might ameliorate social cognition and negative symptoms which are generally not influenced by antipsychotic treatment. The integration of pharmacological and SST interventions might have an impact on major determinants of poor real-life functioning in SCZs.

Recovery in schizophrenia: A network analysis of inter-relationships among disease-related variables, personal resources, context-related factors and real-life functioning

Abstract Body

Central to recovery-oriented approaches in schizophrenia are treatment integration and personalization, targeting key variables beyond symptom reduction. The Italian network for research on psychoses conducted a study demonstrating, using network analysis, the central role of community activities in bridging the effects of symptoms, cognition, functional capacity and service engagement on real-word functioning. A 4-year follow-up study was recently completed and the presentation will illustrate the findings. Network analysis was used to test whether relationships among all variables at baseline were similar at follow-up. In addition, the network structure was compared between subjects classified as recovered or non-recovered at follow-up. Six hundred eighteen subjects were assessed at both baseline and 4-year follow-up. Results showed that the network structure was stable from baseline to follow-up, and the overall strength of the connections among variables did not significantly change. Functional capacity and everyday life skills were the most central variables in the network at both baseline and follow-up, while psychopathological variables were more peripheral. The network structure of non-recovered patients was similar to the one observed in the whole sample, but very different from that of recovered subjects, showing few connections among the different nodes. These data strongly suggest that connections among symptoms/dysfunctions tend to maintain over time, contributing to poor outcome in schizophrenia. Early treatment plans, targeting variables with high centrality, might prevent the emergence of self-reinforcing networks of symptoms and dysfunctions in people with schizophrenia.

Disclosure

Armida Mucci has been a consultant and/or advisor to or has received honoraria from Gedeon Richter Bulgaria, Janssen Pharmaceuticals, Lundbeck, Otsuka, Pfizer and Pierre Fabre. None of these has any impact on this abstract and on the presented study.

EPA guidance on treatment of negative symptoms in schizophrenia

Negative symptoms of schizophrenia remain a major therapeutic challenge. The progress in the conceptualization and assessment is not yet fully reflected by treatment research. Nevertheless, there is a growing evidence base regarding the effects of biological and psychosocial interventions on negative symptoms. The importance of the distinction between primary and secondary negative symptoms for treatment selection might seem evident, but the currently available evidence remains limited. Good clinical practice is recommended for the treatment of secondary negative symptoms. Antipsychotic treatment should be optimized to avoid secondary negative symptoms due to side effects and due to positive symptoms. For most available interventions, further evidence is needed to formulate sound recommendations for primary, persistent, or predominant negative symptoms.

However, based on currently available evidence recommendations for the treatment of undifferentiated negative symptoms (including both primary and secondary negative symptoms) are provided. Although it has proven difficult to formulate an evidence-based recommendation for the choice of an antipsychotic, a switch to a second-generation antipsychotic should be considered for patients who are treated with a first-generation antipsychotic. Antidepressant add-on to antipsychotic treatment is an option. Social skills training is recommended as well as cognitive remediation for patients who also show cognitive impairment. Exercise interventions also have shown promise. Finally, access to treatment and to psychosocial rehabilitation should be ensured for patients with negative symptoms. Overall, there is definitive progress in the field, but further research is clearly needed to develop specific treatments for negative symptoms.

EPA guidance on assessment of negative symptoms in schizophrenia

Background

During the last decades, a renewed interest for negative symptoms (NS) was brought about by the increased awareness that they interfere severely with real-life functioning, particularly when they are primary and persistent.

Methods

In this guidance paper, we provide a systematic review of the evidence and elaborate several recommendations for the conceptualization and assessment of NS in clinical trials and practice.

Results

Expert consensus and systematic reviews have provided guidance for the optimal assessment of primary and persistent negative symptoms; second-generation rating scales, which provide a better assessment of the experiential domains, are available; however, NS are still poorly assessed both in research and clinical settings.

This European Psychiatric Association (EPA) guidance recommends the use of persistent negative symptoms (PNS) construct in the context of clinical trials and highlights the need for further efforts to make the definition of PNS consistent across studies in order to exclude as much as possible secondary negative symptoms. We also encourage clinicians to use second-generation scales, at least to complement first-generation ones.

The EPA guidance further recommends the evidence-based exclusion of several items included in first-generation scales from any NS summary or factor score to improve NS measurement in research and clinical settings. Self-rated instruments are suggested to further complement observer-rated scales in NS assessment.

Several recommendations are provided for the identification of secondary negative symptoms in clinical settings.

Conclusions

The dissemination of this guidance paper may promote the development of national guidelines on negative symptom assessment and ultimately improve the care of people with schizophrenia.

Exploring the role of age as a moderator of cognitive remediation for people with schizophrenia

BACKGROUND

While Cognitive Remediation (CR) is effective in reducing cognitive and functioning difficulties in people with schizophrenia, there is variability in treatment response. Previous research suggested that participants' age may be a significant moderator of CR response.

AIM

To examine the impact of participants' age on CR outcomes.

METHOD

Individual participant data were accessed from fourteen CR randomised controlled trials. We tested the moderating effect of participants' age on cognitive and functioning outcomes using multivariate linear models.

RESULTS

Data from 1084 people with a diagnosis of schizophrenia were considered. Participants had a mean age of 36.6 years (SD 11), with 11.6 years of education (SD 2.8), and an average duration of illness of 13.5 years (SD 10.7). Multivariate models showed that participants' age, when considered as a continuous variable, was not a significant moderator of treatment effect for cognitive and functioning outcomes. However, when participants were split by median age, younger participants showed higher gains in executive functions following CR compared to older participants (p=0.02).

CONCLUSION

These results suggest that participants' age does not moderate most CR outcomes. However, larger age differences may influence the effect of CR on executive function. This may suggest some adaptation of CR practice according to participants' age. These findings inform the CR personalisation agenda.