Objectives
To aid the development of treatment for cognitive impairment in bipolar disorder, the International Society for Bipolar Disorders (ISBD) convened a task force to create a consensus‐based ...guidance paper for the methodology and design of cognition trials in bipolar disorder.
Methods
The task force was launched in September 2016, consisting of 18 international experts from nine countries. A series of methodological issues were identified based on literature review and expert opinion. The issues were discussed and expanded upon in an initial face‐to‐face meeting, telephone conference call and email exchanges. Based upon these exchanges, recommendations were achieved.
Results
Key methodological challenges are: lack of consensus on how to screen for entry into cognitive treatment trials, define cognitive impairment, track efficacy, assess functional implications, and manage mood symptoms and concomitant medication. Task force recommendations are to: (i) enrich trials with objectively measured cognitively impaired patients; (ii) generally select a broad cognitive composite score as the primary outcome and a functional measure as a key secondary outcome; and (iii) include remitted or partly remitted patients. It is strongly encouraged that trials exclude patients with current substance or alcohol use disorders, neurological disease or unstable medical illness, and keep non‐study medications stable. Additional methodological considerations include neuroimaging assessments, targeting of treatments to illness stage and using a multimodal approach.
Conclusions
This ISBD task force guidance paper provides the first consensus‐based recommendations for cognition trials in bipolar disorder. Adherence to these recommendations will likely improve the sensitivity in detecting treatment efficacy in future trials and increase comparability between studies.
Objectives
Cognition is a new treatment target to aid functional recovery and enhance quality of life for patients with bipolar disorder. The International Society for Bipolar Disorders (ISBD) ...Targeting Cognition Task Force aimed to develop consensus‐based clinical recommendations on whether, when and how to assess and address cognitive impairment.
Methods
The task force, consisting of 19 international experts from nine countries, discussed the challenges and recommendations in a face‐to‐face meeting, telephone conference call and email exchanges. Consensus‐based recommendations were achieved through these exchanges with no need for formal consensus methods.
Results
The identified questions were: (I) Should cognitive screening assessments be routinely conducted in clinical settings? (II) What are the most feasible screening tools? (III) What are the implications if cognitive impairment is detected? (IV) What are the treatment perspectives? Key recommendations are that clinicians: (I) formally screen cognition in partially or fully remitted patients whenever possible, (II) use brief, easy‐to‐administer tools such as the Screen for Cognitive Impairment in Psychiatry and Cognitive Complaints in Bipolar Disorder Rating Assessment, and (III) evaluate the impact of medication and comorbidity, refer patients for comprehensive neuropsychological evaluation when clinically indicated, and encourage patients to build cognitive reserve. Regarding question (IV), there is limited evidence for current evidence‐based treatments but intense research efforts are underway to identify new pharmacological and/or psychological cognition treatments.
Conclusions
This task force paper provides the first consensus‐based recommendations for clinicians on whether, when, and how to assess and address cognition, which may aid patients’ functional recovery and improve their quality of life.
OBJECTIVE: Impairments in adaptive life skills are a major source of disability in patients with schizophrenia. The relationship between adaptive life skills in real-world settings and performance on ...neuropsychological tests may be complicated by other factors that interfere with deployment of skills. Assessment of the ability to perform life skills under optimal conditions (i.e., assessment of functional capacity) has been proposed as a means to clarify these relationships. METHOD: The authors examined cross-sectional data from a study of the course of neuropsychological and adaptive life skills of older (age 50-85) schizophrenia patients (N=78). Functional capacity was examined with a performance-based measure (UCSD Performance-Based Skills Assessment), and case managers rated real-world adaptive functions (i.e., interpersonal skills, work skills, and community activities). Neuropsychological performance was assessed with a comprehensive battery, while symptoms were assessed with patient self-report and clinical ratings. RESULTS: Confirmatory path analyses were used to evaluate the effects of neuropsychological performance, functional capacity, and symptoms on the various domains of real-world functioning. Neuropsychological performance predicted functional capacity, which predicted all three domains of real-world functioning. Depression predicted interpersonal and work skills, while negative symptoms affected interpersonal skills independently of other predictors. CONCLUSIONS: Real-world adaptive life skills are predicted by neuropsychological performance, symptoms, and functional capacity. Neuropsychological performance contributes little to the prediction of real-world performance after accounting for functional capacity. In some domains, negative and depressive symptoms influenced real-world performance while not relating to functional capacity or neuropsychological performance.
Recent findings support and add to earlier findings of cognitive dysfunction in schizophrenia. Deficits across neurocognitive domains such as attention, working memory, language skills, and executive ...functioning tend to be moderate, with the most pronounced deficits found in verbal learning and memory. All these neurocognitive domains are related to adaptive and social skills, with executive functions and verbal learning and memory showing more variance across more domains than other neuro-cognitive variables. Negative symptoms and neurocognitive domains, although correlated, are distinct and have differential pathways of change with treatment. General psychopathology symptoms, such as depression and anxiety, may become important treatment targets as strategies are developed for translating cognitive enhancement to real-world functional performance.
Sleep, both overnight and daytime naps, can facilitate the consolidation of declarative memories in healthy humans. However, it is unclear whether such beneficial effects of sleep occur in special ...populations, such as individuals with elevated neuropsychiatric symptoms, and if they apply to clinically relevant material that may have personal significance to those populations.
We examined memory retention over a 60-minute interval of wakefulness or nap opportunity in participants with low or elevated scores (≤13 and ≥21, respectively) on the Beck Depression Inventory-II (BDI-II). Memory for depression-related information was assessed by (a) free-recall of a video depicting a personal experience narrative of the impact of depression on cognition and workplace performance; and (b) a paired-associates task linking depression-related cognitive symptoms to appropriate coping strategies.
The results showed no overall difference in recall between the nap and waking condition. However, across the full sample of participants, there were significant positive correlations between total sleep time and paired associates recall, and slow wave sleep (SWS) percentage and story free recall performance. Unexpectedly, participants with elevated BDI-II scores exhibited better free-recall performance compared to those with low scores.
These results suggest that sleep, specifically SWS, may stabilize memories for clinically relevant information in populations with low and elevated depressive symptoms. The superior recall in participants with elevated-BDI scores may be related to the personal significance and stronger encoding of depression-related information. These observations raise the possibility that mnemonic deficits in depressed patients may be, at least in part, related to the type of information used to assess memory performance.
Deficits in neurocognitive functioning are common to both schizophrenia and alcoholism. Recent studies suggest that neurocognitive functioning is the most significant predictor of social-adaptive ...functioning in schizophrenia. Cognitive impairment induced by alcoholism may result in more impaired functional outcome for comorbid patients. Past research examining alcohol-abusing schizophrenia patients has not examined correlates with functional outcome and has generally been limited to relatively younger patients. This study examined neurocognitive functioning and its correlates in alcohol-abusing schizophrenia patients between the ages of 40 and 80. Outpatients with schizophrenia (SZ; n = 17) or both schizophrenia and alcohol abuse or dependence (SZ + ETOH; n = 18) were tested on a neurocognitive battery, rated for symptomatology, and assessed for functional abilities. The results suggest that alcohol abuse in schizophrenia is associated with more impaired functioning across many domains, including memory impairment, negative and general psychopathology symptoms, and adaptive functions. The only significant predictor of impaired functional status in the overall sample and the SZ + ETOH group was neurocognitive functioning.
OBJECTIVE: This study longitudinally assessed previously validated dimensions of thought disorder-verbal underproductivity and disconnection-in geriatric schizophrenia and replicated previous ...cross-sectional differences in communication disorders. METHOD: Two hundred twenty patients with chronic schizophrenia were assessed with the Thought, Language, and Communication Scale over a mean follow-up period of 2.3 years. RESULTS: Patients had increases in verbal underproductivity but stable scores on disconnection over the follow-up period. Worsening in verbal underproductivity was associated with concurrent worsening in Mini-Mental State Examination scores and older age at baseline. CONCLUSIONS: Verbal underproductivity worsens with aging and is associated with cognitive worsening, although disconnected speech is relatively stable. Some geriatric patients with schizophrenia may lose the skills necessary to report symptoms, leading to the impression that their clinical status is improving.
To determine the frequency of depressed mood in institutionalized schizophrenia patients and its association with illness-related and functional variables.
Out of 657 institutionalized schizophrenia ...patients, patients with depressed mood were identified and compared to non-depressed patients, matching for potential confounders.
Forty-eight (7.3%) patients had moderate to severe depressed mood. They were younger, more educated and had fewer years since their first hospitalization than non-depressed patients. After matching for these variables, depressed patients showed more positive symptoms and exhibited better social and cognitive functioning. When controlling for negative symptoms, the differences in social and cognitive functioning between the depressed and non-depressed patients disappeared, and depressed patients showed more positive symptoms and more impaired impulse control.
Unlike the negative impact of depressed mood in other populations, this study shows that symptoms of depressed mood may identify a subgroup of institutionalized schizophrenia patients who show better functioning across a variety of indicators. Future studies should determine differential treatment responses and long-term outcomes of these patients.
Cognitive deficits are a core feature of schizophrenia and are a major contributor to functional disability. These impairments persist even when patients are in remission of psychotic symptoms and ...have, to date, eluded treatment. While some improvement is noted with existing medications, current trends in this field include studying and searching for adjunctive treatments to truly remediate cognitive dysfunction in schizophrenia. Psychosocial treatments have demonstrated some success, but the use of existing cognitive enhancers in schizophrenia treatment has provided little cognitive improvement. This paper reviews the current status of cognitive deficit treatment in schizophrenia and offers suggestions for future work.
Deficits in verbal fluency are common in schizophrenia and may provide keys to some of the abnormalities in the semantic system in schizophrenia. While a number of studies have outlined the severity ...and implications of verbal fluency deficits in younger schizophrenia patients, these findings have not yet been extended to older patients with schizophrenia. In this study, 392 older (age≥50) patients with schizophrenia were administered phonological and semantic (i.e., category) fluency examinations, as well as tests of learning, memory, language, and praxic skills, and rated for clinical symptoms and functional status. When compared to normative standards, 82% of the patients were impaired in semantic fluency and 83% were impaired in phonological fluency. Both semantic and phonological fluency impairment were significantly correlated with other cognitive variables, total scores on the functional status measure, and with the social and self-care subscales. Scores were uncorrelated with the severity of psychosis, but were correlated with the severity of negative symptoms. Furthermore, the severity of poverty of speech (a clinical measure of verbal underproductivity) was moderate in magnitude and failed to enter as a predictor of verbal fluency, indicating that impaired fluency scores are not simply an artifact of general underproductivity or mutism. The findings support conclusions from studies with younger schizophrenia patients that suggest that verbal fluency impairment is a consequence of a disorganized semantic system. Verbal fluency impairment remains common and functionally relevant in schizophrenia patients in late life.
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