Who will benefit from computerized cognitive remediation therapy? Evidence from a multisite randomized controlled study in schizophrenia.

BACKGROUND: Computerized cognitive remediation therapy (CCRT) is generally effective for the cognitive deficits of schizophrenia. However, there is much uncertainty about what factors mediate or moderate effectiveness and are therefore important to personalize treatment and boost its effects. METHOD: In total, 311 Chinese inpatients with Diagnostic and Statistical Manual of Mental Disorders-IV schizophrenia were randomized to receive CCRT or Active control for 12 weeks with four to five sessions per week. All participants were assessed at baseline, post-treatment and 3-month follow-up. The outcomes were cognition, clinical symptoms and functional outcomes. RESULTS: There was a significant benefit in the MATRICS Consensus Cognitive Battery (MCCB) total score for CCRT (F1,258 = 5.62; p = 0.02; effect size was 0.27, 95% confidence interval 0.04-0.49). There were no specific moderators of CCRT improvements. However, across both groups, Wisconsin Card Sort Test improvement mediated a positive effect on functional capacity and Digit Span benefit mediated decreases in positive symptoms. In exploratory analyses younger and older participants showed cognitive improvements but on different tests (younger on Symbol Coding Test, while older on the Spatial Span Test). Only the older age group showed MSCEIT benefits at post-treatment. In addition, cognition at baseline negatively correlated with cognitive improvement and those whose MCCB baseline total score was around 31 seem to derive the most benefit. CONCLUSIONS: CCRT can improve the cognitive function of patients with schizophrenia. Changes in cognitive outcomes also contributed to improvements in functional outcomes either directly or solely in the context of CCRT. Age and the basic cognitive level of the participants seem to affect the cognitive benefits from CCRT.

Association of functional COMT Val108/Met polymorphism with smoking cessation in a nicotine replacement therapy.

Nicotine replacement treatment (NRT) can be efficacious for smoking cessation, but used by only a minority of smokers in China. Pharmacogenetic matching may improve treatment outcomes for NRT in subgroups of smokers. We evaluated the efficacy and safety of sublingual nicotine tablets (SNT) for smoking cessation and the association of catechol-O-methyltransferase (COMT) genotype with efficacy in this smoking cessation trial among Chinese smokers. We conducted a double-blind, placebo-controlled, 8-week trial of SNT with a follow-up at week 12 among 250 Chinese smokers. Efficacy and safety were evaluated at day 4 and weeks 2, 4, 6, 8, and 12. Abstinence was biochemically verified by exhaled carbon monoxide (CO) and urine cotinine. The COMT Val108Met genotype was determined as a restriction fragment length polymorphism. Our results showed that the success rates for complete abstinence were greater for active versus placebo treatments at 8 weeks (48 vs. 17 %) and 12 weeks (52 vs. 19 %) (both p < 0.0001). Craving was significantly reduced from week 2 on active treatment compared to placebo. Adverse events were mild and tolerable. We found a genotype by treatment interaction at 12 weeks with greater abstinence rates in the COMT Val/Val (50 vs. 15 %) than the Met/Val + Met/Met genotypes (46 vs. 25 %). We found that SNT significantly increased smoking abstinence, reduced craving and was well tolerated, and the COMT Val/Val genotype was associated with a greater improvement in smoking cessation.

Computerized or manual? Long term effects of cognitive remediation on schizophrenia.

BACKGROUND: Cognitive remediation therapy (CRT) and Computerized CRT (CCRT) improve cognition and functioning, but there is no direct evidence of whether there is an advantage of using a computer. This study fills this gap and extends research evidence to the long-term effect of these two treatments in a large sample of Chinese inpatients with a diagnosis of schizophrenia. METHOD: We conducted a randomized single-blind, follow-up study with participants randomized to receive CCRT (n = 144), CRT (n = 72) or Active control (n = 54) for 12 weeks with 4-5 sessions per week. The main outcome was cognition (MATRICS Consensus Cognitive Battery total score, MCCB), and secondary outcomes were cognitive domains, symptoms and functioning assessed at baseline (0 month), post-treatment (3 months) and follow-up (6, 12 and 18 months). RESULTS: The primary outcome (MCCB total score) improved in both treatment groups which was maintained at 18 months but did not differ between treatment groups. Post hoc analysis demonstrated that the CRT group had an advantage over CCRT for the Trail Making and Symbol Coding Tests (all p < 0.05), which lasted for almost 18 months. CONCLUSIONS: Both CCRT and CRT contribute to general cognitive improvements in schizophrenia and the overall efficacy was similar. The effects were maintained for 18th months. Exploratory analyses revealed few differences except that CRT had a processing speed advantage.

Improving social functioning in community-dwelling patients with schizophrenia: a randomized controlled computer cognitive remediation therapy trial with six months follow-up.

Computerized cognitive remediation therapy (CCRT) has been found to generally improve cognition among patients with schizophrenia, but its effect on functioning has not been extensively studied. This study addressed this gap in the literature by investigating the effect of CCRT and its long-term efficacy among community-dwelling patients with schizophrenia. 157 Chinese patients with schizophrenia were recruited from communities and randomized to CCRT (n = 78) or treatment as usual (TAU; n = 79) groups for 12 weeks with 4-5 sessions per week. Neurocognition, functioning, and symptoms of participants were assessed at baseline, after treatment, and at the 6 month follow-up. The CCRT group showed significantly greater improvements than the TAU group regarding the MATRICS Consensus Cognitive Battery (MCCB) total score and social cognition score. Significant cognitive benefits for functioning were observed (Personal and Social Performance scale, PSP). Moreover, improvement of the MCCB total score mediated a positive effect on functional capacity (UCSD Performance-based Skills Assessment, UPSA), and mediated decreases in negative symptoms across both groups. CCRT improved social functioning and general cognitive functioning among community-dwelling patients with schizophrenia. These improvements persisted for 6 months after treatment. CCRT also led to improvements in functioning and symptom severity by modulating cognitive functioning.

Four-Subtest Index-based Short Form of WAIS-IV: Psychometric Properties and Clinical Utility.

Short form of the Wechsler Adult Intelligence Scale is often needed to quickly estimate intelligence for time-saving or screening in clinical practice. The present study aims to examine the psychometric properties of Chinese version of the four-subtest index-based short form (SF4) of WAIS-IV (FS) and to confirm its clinical application. 1,757 adults from the WAIS-IV Chinese version standardization sample and 239 mixed clinical samples including patients with schizophrenia or schizoaffective disorder (SCH), obsessive-compulsive disorder (OCD), and mild or moderate intellectual disability (ID) were used. Demographic data were collected and intelligence was assessed with WAIS-IV. The SF4 split-half reliability, test-retest stability coefficients and corrected SF4-FS correlations were good to excellent. The result of the Bland-Altman plot showed that the difference fell within 2SD was 95% and indicated a random error. The sensitivity, specificity positive predictive value (PPV), and negative predictive value (NPV) of the stepwise screening were good. There was an interaction (p < .001) between the IQ level (≥111) and gender on the accuracy of SF4, SF4 might get underestimated on females with the IQ level (≥111) than on males. In conclusion, SF4 is a valid and reliable instrument for use in the clinic, and its clinical application, stepwise screening and influencing factors in clinical use are discussed herein.

Asian models of excellence in psychiatric care and rehabilitation.

In Asia, like other regions, the circumstances for psychiatric care and rehabilitation impose various limitations on us. However, committed professionals have been creating innovative models of excellence, which are culturally appropriate and clinically effective. In this paper, seven innovative models of psychiatric care and rehabilitation are presented. The Nitte project in India provides a comprehensive free rural psychiatric service, while transforming the 'brain drain' problem to 'brain circulation' cooperation. Through Social Enterprises in Hong Kong recovered clients are trained and employed. Senior Peer Counselling in Singapore emphasizes the relief of emotional distress by psychological methods and the primacy of communication in the healing or therapeutic relationship. Seoul Mental Health 2020, an epoch-making project in Korea, has increased the coverage rate of community mental health centres remarkably. Yuli Psychiatric Rehabilitation Model in Taiwan helps long-term inpatients to get reintegrated into the community. In Japan, models of excellence for community-based psychiatry have been developed at local government, hospital and community/NGO levels. Chinese Psychiatry Online, an excellent website, provides public education, resource searching, self-testing and consultation services for the public along with various contents for professionals. We must disseminate information about models of excellence which provide great benefit to the people who suffer from psychiatric illness without high expenses.

Computerized cognitive remediation therapy effects on resting state brain activity and cognition in schizophrenia.

This study aimed to test how an 8-week training using computerized cognitive remediation therapy (CCRT) would modify resting brain functional activity and improve cognitive function in patients with schizophrenia. Twenty-seven patients with schizophrenia were recruited and randomized into two groups: CCRT or treatment-as-usual (TAU). The CCRT group received 40 sessions of computerized cognitive training over an eight-week period. There was a significant treatment group × time interaction on the processing speed (trail making test: F = 8.14, P = 0.01) and a trend in problem solving (mazes test: P = 0.06). Post-hoc tests showed that CCRT but not TAU significantly improved scores from baseline to end-of-treatment on these two cognitive assessments. For the resting brain functional activity, significant group × time interaction effect was found in the medial prefrontal cortex (mPFC)/anterior cingulate cortex (ACC) and brainstem pons region. Post-hoc tests showed that there was significant increased activity in the mPFC/ACC in CCRT but not TAU group. In this small sample study, computerized cognitive remediation therapy is shown to enhance mPFC/ACC activity even at resting state and improve cognitive function in patients with schizophrenia. If replicated, this community and clinic accessible therapy may assist cognitive remediation effort for people with schizophrenia.

Changing needs and new perspectives in Chinese psychiatry and mental health services.

As a populated developing country, China may have needs and perspectives similar to some countries from which she could learn, but there are always some differences and China has to create her own way to fit the service. In summary, short of budget, short of professionals and low recognition are the three main obstacles for mental health. The family resource and the traditional Chinese medicine may play valuable role in mental health. It is important to use the rich World heritage and experience of psychiatry to make the right choice for China and provide scientific, equitable and efficient mental health service for one fifth of world population.

Group cognitive remediation therapy for chronic schizophrenia: A randomized controlled trial.

Individual-level cognitive remediation therapy (CRT) has been shown to be effective for cognitive improvement and social function amelioration. Here, we aimed to test the efficacy of group-based CRT in Chinese subjects with schizophrenia. One-hundred and four inpatients were randomly assigned to either 40 sessions of small-group CRT therapy or therapeutic contact-matched Musical and Dancing Therapy (MDT). Cognitive and social functioning, as well as clinical symptoms, were evaluated over the course of treatment. Specifically, cognitive function was evaluated using a battery of cognitive measurements, clinical symptoms were evaluated using the Positive and Negative Syndrome Scale, and social function was evaluated using the Nurse's Observation Scale for Inpatient Evaluation-30. All patients were evaluated pre- and post-treatment. Forty-four individuals in the CRT group and 46 in the MDT group completed all of the planned treatments and analyses. Cognitive functions, especially cognitive flexibility and memory, showed significant improvement in the CRT group over the course of the study. The MDT group also showed improvement in several cognitive flexibility assessments, but the degree of improvement was significantly greater in the CRT group. Several social-function factors exhibited a significant improvement in the CRT group, but not in the MDT group. Cognitive function improvement correlated positively with social function without predicting social function change. We conclude that group-based CRT is an effective and promising therapy.

[Psychological and physical presentations of severe acute respiratory syndrome].

OBJECTIVE: To study the relation between psychological symptoms and physical parameters in patients with severe acute respiratory syndrome (SARS) at different stages of the disease. METHODS: Physical parameters such as SCL-90, chest CT, T lymphocytes and subset and SaO2 were studied in 29 SARS patients at three different stages (initial stage, serious stage, rehabilitating stage). RESULTS: Patients with SARS showing severe psychological symptoms constituted about 41% (group I) and patients with SARS showing mild psychological symptoms (group II) constituted about 59%. There were no change of the psychological symptoms at the three stages in group I and II (P > 0.05). Statistical differences were found between physical parameters of group I and II in rehabilitating stage. CONCLUSIONS: Severe psychological symptoms such as obsession, depression and anxiety were found in a minority of patients with SARS and the psychological symptoms were not related with the change of physical parameters. The majority of the patients with SARS did not have severe psychological symptoms. Whether or not psychological symptoms were related to their personality needs further study.

Brain Correlates of Self-Evaluation Deficits in Schizophrenia: A Combined Functional and Structural MRI Study.

Self-evaluation plays an important role in adaptive functioning and is a process that is typically impaired in patients with schizophrenia. Underlying neural mechanisms for this dysfunction may be associated with manifested psychosis. However, the brain substrates underlying this deficit are not well known. The present study used brain blood oxygen level dependent (BOLD) functional magnetic resonance imaging (fMRI) and gray matter voxel-based morphometry to explore the functional and structural brain correlates of self-evaluation deficits in schizophrenia. Eighteen patients with schizophrenia and 17 healthy controls were recruited and asked to judge whether a set of personality-trait adjectives were appropriate for describing themselves, a familiar other, or whether the adjectives were of positive or negative valence. Patients had slower response times for negative trait attributions than controls did; responses to positive trait attributions were faster than those for negative traits among the patient group, while no differences were observed in the control group. Control subjects showed greater activation within the dorsal medial prefrontal cortex (dMPFC) and the anterior cingulate cortex (ACC) than the patient group during the self-evaluation > semantic positivity-evaluation contrast. Patients showed greater activation mainly within the posterior cingulate gyrus (PCC) as compared to controls for the other-evaluation > semantic positivity-evaluation contrast. Furthermore, gray matter volume was reduced in the MPFC, temporal lobe, cuneus, and the dorsal lateral prefrontal cortex (DLPFC) among the patient group when compared to controls. The present study adds to previous findings regarding self- and other-referential processing in schizophrenia, providing support for neurobiological models of self-reflection impairment.

Smoking, MATRICS consensus cognitive battery and P50 sensory gating in a Han Chinese population.

BACKGROUND: The effects of smoking on cognitive performance have long been studied, with mixed results. P50 sensory gating has been used as endophenotype for studying nicotinic systems genetics, and P50 gating deficits have been reported to be a sensitive biomarker for cognitive impairment in schizophrenia. This study examined the inter-relationship between P50 suppression, cognitive function, and smoking in a healthy Han Chinese population, which has not been reported before. METHODS: We recruited 82 healthy male subjects, including 48 smokers and 34 non-smokers who were matched for age and education. The authors measured P50 sensory gating and administered the Chinese-language version of the MATRICS consensus cognitive battery (MCCB) and Stroop tests. RESULTS: The results showed that the smokers scored lower than nonsmokers on the MCCB brief visuospatial memory test (BVMT) index and the STROOP test. Furthermore, the MCCB total score was negatively associated with number of cigarettes smoked per day in the smoker group. However, P50 sensory gating was not associated with either smoking status or any cognitive performance. CONCLUSIONS: Our results show that smoking is associated with cognitive impairment, but not with P50 sensory gating.

Impaired prepulse inhibition of acoustic startle in Chinese patients with first-episode, medication-naïve schizophrenia.

BACKGROUND: Patients with schizophrenia have prominent abnormality in information processing that can be observed by measures of prepulse inhibition (PPI) of acoustic startle reflex and PPI deficits have been considered as a candidate endophenotypic marker of schizophrenia. However, there has been little information on PPI and related measures in Chinese patients with schizophrenia. The research was to explore the deficits of acoustic startle reflex that might exist in Chinese patients with schizophrenia. METHODS: Startle response to acoustic stimuli, habituation, and PPI were examined in 31 Chinese patients with first-episode, medication-naïve schizophrenia and 30 age- and sex-matched healthy Chinese controls. At the same day of startle testing, psychopathological symptoms of the patients were assessed with the Positive and Negative Syndrome Scale (PANSS). RESULTS: Compared with healthy controls, patients exhibited the significant reduction in startle response and PPI deficits at 60 milliseconds (ms) intervals (PPI60, P < 0.05) but not at 30 or 120 ms intervals. Furthermore, there was a relatively strong correlation between PPI60 (P < 0.05) and scores of positive scale of PANSS in patients with schizophrenia. CONCLUSION: Our findings confirmed impaired PPI in Chinese patients with schizophrenia and suggested that a relationship between sensorimotor gating deficits and clinical symptoms of patients with schizophrenia might exist.

Ventral medial prefrontal functional connectivity and emotion regulation in chronic schizophrenia: a pilot study.

People with schizophrenia exhibit impaired social cognitive functions, particularly emotion regulation. Abnormal activations of the ventral medial prefrontal cortex (vMPFC) during emotional tasks have been demonstrated in schizophrenia, suggesting its important role in emotion processing in patients. We used the resting-state functional connectivity approach, setting a functionally relevant region, the vMPFC, as a seed region to examine the intrinsic functional interactions and communication between the vMPFC and other brain regions in schizophrenic patients. We found hypo-connectivity between the vMPFC and the medial frontal cortex, right middle temporal lobe (MTL), right hippocampus, parahippocampal cortex (PHC) and amygdala. Further, there was a decreased strength of the negative connectivity (or anticorrelation) between the vMPFC and the bilateral dorsal lateral prefrontal cortex (DLPFC) and pre-supplementary motor areas. Among these connectivity alterations, reduced vMPFC-DLPFC connectivity was positively correlated with positive symptoms on the Positive and Negative Syndrome Scale, while vMPFC-right MTL/PHC/amygdala functional connectivity was positively correlated with the performance of emotional regulation in patients. These findings imply that communication and coordination throughout the brain networks are disrupted in schizophrenia. The emotional correlates of vMPFC connectivity suggest a role of the hypo-connectivity between these regions in the neuropathology of abnormal social cognition in chronic schizophrenia.

The study of acoustic startle reflex in male patients with chronic schizophrenia.

OBJECTIVE: To explore the deficits of acoustic startle reflex (ASR) that might exist in Chinese patients with schizophrenia and the effects of antipsychotics on ASR. METHODS: Participants included 25 male patients with chronic schizophrenia treated with typical antipsychotics (typical group), 25 who were treated with atypical antipsychotic clozapine (clozapine group) and 25 healthy male subjects (control group) matched for age and years of education. Startle reflex to acoustic stimuli were examined in all subjects from the three groups. At the same day of startle testing, psychopathological symptoms of the patients were assessed with the Positive and Negative Syndrome Scale (PANSS). RESULTS: (1) Startle response (SR) was significantly reduced in typical group as compared to control group [(553.6±516.9)mV vs. (942.0±447.3)mV, P=0.009]. SR of clozapine group [(755.9±439.4)mV] was greater than that of typical group and less than that of control group, but there was no significant difference between the clozapine group and the other two. (2) Habituation (HAB) of startle reflex in typical group was significantly lower than in control group [(17.8±35.8)% vs. (44.9±28.9)%, P=0.027]. HAB of clozapine group [(22.9±34.1)%] was higher than that of typical group and less than that of control group, but there was no significant difference between clozapine group and the other groups. (3) Compared with healthy controls, patients of typical group exhibited the significant reduction in prepulse inhibition (PPI) of startle reflex (P=0.024) when prepulse interval (LI) was 120ms. PPI of clozapine group was higher than typical group and less than control group, but no significant differences in PPI were found between clozapine group and the other groups. While LI was 30- or 120-ms, PPI among the three groups showed not significantly different (P>0.05). (4) No significant relationship was found between PPI of different LIs and symptom scores assessed with PANSS in patients with schizophrenia (P>0.05). CONCLUSION: Our findings suggest impaired PPI in Chinese patients with schizophrenia; Atypical antipsychotic clozapine might partly improve disinhibition of startle reflex in schizophrenic patients.

Comparison of psychiatrists' views on classification of mental disorders in four East Asian countries/area.

OBJECTIVE: Authors of this study collaborated with psychiatrists in East Asia to undertake the international survey with the following objectives: (1) to identify the psychiatric classification systems currently used in East Asia, (2) to describe the views of psychiatrists on the classificatory systems of mental disorders in Japan, Korea, China and Taiwan, (3) to analyze their similarities and differences among the four countries/area, and (4) to discuss factors which influence the usages of the classificatory systems in East Asia. METHOD: Views of psychiatrists in four East Asian countries/area were collected by a minimum of 100 psychiatrists in each country/area using the same questionnaire. Psychiatrists from East Asian countries/area completed the questionnaire developed originally by a New Zealand psychiatrist and translated into Japanese, Korean and Chinese. The questionnaire was designed to determine the views of psychiatrists in the utilization, preference, and opinion about the current classificatory systems represented by the DSM and ICD. RESULTS: The study revealed variations in the utilization, preference and opinion for further revision of the DSM and the ICD classificatory systems in East Asia. Psychiatrists in China and Japan routinely use the ICD, while psychiatrists in Korea and Taiwan favor using the DSM. The majority of Asian psychiatrists expressed the view that it was sometimes difficult to apply the system transculturally. CONCLUSIONS: Views on psychiatric classification in a country/area are strongly influenced by several factors including mental health service systems, psychiatric resources and historical background.

Chinese psychiatrists views on global features of CCMD-III, ICD-10 and DSM-IV.

OBJECTIVE: To survey psychiatrists' opinions about psychiatric classification in China, and provide information and suggestions for developing a new version of classificatory system. METHOD: The questionnaire about psychiatry classification written by Professor Graham Mellsop, New Zealand, was translated and modified into Chinese. An anonymous field survey of 380 psychiatry professionals was undertaken in Beijing. RESULTS: A total of 181 questionnaires were eligible for analysis. The Chinese Classification of Mental Disorders version 3 (CCMD-III) is the most commonly used in China (63.8%), then ICD-10 (28.5%) and DSM-IV (7.7%). Half of the respondents (53.0%) agreed that the most important diagnostic classification is for communication among physicians, and then for communication between physician and patient (21.0%). Most professionals (90.0%) agree that classification should include less than 100 diagnostic options. Disagreement presents on cross-culture application of the ICD-10 and DSM-III: 75.1% professionals agreed that they are "useful and reliable regardless of patient ethnicity and culture", while 46.8% found "sometimes difficult to apply across cultures", and 35.8% thought classification is "over-embedded in European cultural concepts and values". CONCLUSION: There is a strong trend of convergence and unification of China's diagnostic standards with international standards inevitable. A classification that is less complicated and confused, easy-to-communicate and understand and cross-cultural/nation applicable is expected by most Chinese psychiatrists. Such classification should also be reflective of the advances in understanding of aetiology of disorders and helpful in clinical management.

[Psychiatric and central nervous system involvement in Sjogren's syndrome].

OBJECTIVE: To study psychiatric features and the manifestations of central nervous system involvement in Chinese patients with primary Sjogren's syndrome (PSS). METHODS: The Minnesota Multiphasic Personality Inventory (MMPI) was used to study 27 PSS female patients and 57 healthy women. The results from two groups were compared. Ten SS patients were evaluated by electroencephalography (EEG), transcranial doppler ultrasound (TCD) and magnetic resonance imaging (MRI). RESULTS: Of 27 patients tested, the three highest clinical mean scales included Hypochondriasis (Hs), Hysteria (Hy), Psychasthenia (Pt) were found. When PSS group was compared with normal control, T scores of SS patients were significantly higher than the healthy women in Hs, Hy. Abnormal EEG was found in 3 of 9 PSS patients. TCD was abnormal in 5 of 9 patients. MRI in 1 patient showed abnormality. CONCLUSIONS: This study shows that the personality of PSS patients is abnormal, the features are neuroticism. Central nervous system was markedly involved in Chinese patients with PSS, including abnormal EEG and TCD. The changes of central nervous system may be related to abnormalities of psychiatric changes.