Cognitive remediation and professional insertion of people with schizophrenia: RemedRehab, a randomized controlled trial.

BACKGROUND: People suffering from schizophrenia cannot easily access employment in European countries. Different types of vocational programs coexist in France: supported employment, sheltered employment (ShE), and hybrid vocational programs. It is now acknowledged that the frequent cognitive impairments constitute a major obstacle to employment for people with schizophrenia. However, cognitive remediation (CR) is an evidence-based nonpharmacological treatment for these neurocognitive deficits. METHODS: RemedRehab was a multicentric randomized comparative open trial in parallel groups conducted in eight centers in France between 2013 and 2018. Participants were recruited into ShE firms before their insertion in employment (preparation phase). They were randomly assigned to cognitive training Cognitive Remediation for Schizophrenia (RECOS) or Treatment As Usual (TAU). The aim of the study was to compare with the benefits of the RECOS program on access to employment and work attendance for people with schizophrenia, measured by the ratio: number of hours worked on number of hours stipulated in the contract. RESULTS: Seventy-nine patients were included in the study between October 2018 and September 2019. Fifty-three patients completed the study. Hours worked / planned hours equal to 1 or greater than 1 were significantly higher in the RECOS group than in the TAU group. CONCLUSIONS: Participants benefited from a RECOS individualized CR program allows a better rate of work attendance in ShE, compared to the ones benefited from TAU. Traditional vocational rehabilitation enhanced with individualized CR in a population of patients with schizophrenia is efficient on work attendance during the first months of work integration.

[MODen: Psychoeducationnal therapeutic group program for schizophrenic patients, based on nutritional balance and pleasure, using cognitive functions: A pilot study]. / MODen : programme d'éducation thérapeutique dans la schizophrénie centré sur l'équilibre alimentaire et le plaisir, sollicitant les fonctions cognitives : étude pilote.

INTRODUCTION: Schizophrenia causes psychological difficulties (with positive and/or negative symptoms) as well as cognitive disabilities (attention, memory, executive functions and social cognition). Moreover, 40 to 60% of patients suffer from an excess of weight or obesity (due to bad eating habits, eating disorders or medication). All these difficulties impair their autonomy and their insertion into the society. In this context, setting-up a therapeutic tool, which may have cognitive benefits seems relevant. Thus, MODen is a therapeutic educational tool whose aim is to improve cognitive functions and the symptoms by using "nutritional balance" as an aid. METHOD: In this treatment program, two therapists lead a group of 5 to 8 patients which group meets once a week during two to four hours for 16 weeks, divided in 4 cycles. The first three weeks of each cycle consists of theoretical instruction: patients talk about their eating habits, information is given about nutritional balance and preparation of meals. In the different cycles, flexibility, planning, memory and attention are trained. For instance, the work on categorisation of foods and nutritional balance allow enhancing flexibility abilities. Writing down the lists of different ingredients needed for one week's meals and preparation of meals train planning abilities. MODen also takes into account ecological issues such as the limited budget of patients to do their shopping (this budget is around 4 euros per meal in France). The budget is also linked to planning abilities and reasoning. Finally, during the last session of each cycle the group prepares a meal (from the shopping to cooking). This last session is all about sharing and social cognition abilities. By the end of the program, patients will have prepared four meals together. Also "homework" has to be done each week in order to facilitate memorisation of what has been learned during the last session and to prepare the beginning of the next session. RESULTS: In a pilot study with 8 patients with schizophrenia (DSM-IV), improvements in PANSS negative symptoms and disorganization (respectively P<0.02; P<0.02) were observed. An underlying improvement at BECS scores was also observed (P<0.08). Regarding those preliminary results as well as the ecological qualities of this program, this therapeutic tool could be relevant in the treatment of patients with schizophrenia.

In patients with schizophrenia, symptoms improvement can be uncorrelated with quality of life improvement.

OBJECTIVES: Quality of life has been found to be associated with symptoms in patients with schizophrenia. Nevertheless, the mechanism that underlies this association is still unclear. The objective of this paper is to prospectively evaluate the quality of life of patients with schizophrenia in relation to the concurrent evolution of their symptoms, their expectations and their perceived position in life. METHODS: Participants included 306 outpatients with schizophrenia who were interviewed at baseline, 6 and 12 months, about their quality of life (Outcome revealed by Preference in Schizophrenia, OPS) and symptoms (Positive and Negative Syndrome Scale, PANSS). RESULTS: Quality of life relative to subject expectations remained stable over time. A decrease in symptoms was correlated to an increase in both expectations and perceived position in life but did not correlate to quality of life. CONCLUSION: The level of expectations seems to play a major role in the subjective assessment of quality of life in patients with schizophrenia. Symptom improvement is not necessarily associated with quality of life improvement relative to subject expectations. Caregivers should be aware of this result so as to deal with possible disappointments in patients receiving a new efficient treatment.

[Interest of a new instrument to assess cognition in schizophrenia: The Brief Assessment of Cognition in Schizophrenia (BACS)]. / Intérêt d'un nouvel instrument dans l'évaluation cognitive dans la schizophrénie.

BACKGROUND: An increasing interest in the study of cognition in Schizophrenia has developed within the last few years although cognitive problems have been described in this disorder since the beginning of the 20th century. Presently, various data tend to assert that cognitive disorders are the core disturbance in schizophrenia and that their severity is predictive of the course of the disease. Indeed, studies have shown that the disturbances measured in cognitive tests are neither the consequences of positive or negative symptoms, nor related to motivation or global intellectual deficit, nor to anti-psychotic medication. It is also presently known that the severity of cognitive symptoms is a better indicator of social and functional outcome than the severity of the negative or positive symptoms. The patients who have the most severe cognitive deficits during the first episode of the disease are most likely to present a chronic and severe form later on. The aspects of cognition that are specifically impaired in schizophrenia are verbal memory, working memory, motor function, attention, executive functions, and verbal fluency. Cognitive disturbances are thus very important in several fields of research in schizophrenia such as: understanding the psychopathology, epidemiology (indicators of vulnerability), genetics (endophenotypes), neuro-imaging (including functional neuro-imaging), and psychopharmacology (they can be used as a parameter of evaluation in therapeutic trials with new molecules, or cognitive psychotherapy). LIMITS OF COGNITION ASSESSMENTS: However, there are some methodological limits to these cognitive evaluations. First, schizophrenia is a heterogeneous disease and there are no specificities of the different subgroups in terms of cognition. Secondly, the time chosen to evaluate the abilities of the patient is also a limiting factor. But most of all, the batteries of tests used in different studies are not standardized. BRIEF ASSESSMENT OF COGNITION IN SCHIZOPHRENIA: It is therefore of great interest to create an available and easily used battery of validated tests. This would enable one to measure the different cognitive deficits and to repeat the tests, and assess evolution through longitudinal follow up of the patients. The BACS is a new instrument developed by Keefe et al. in the Department of Psychiatry and Behavioural Sciences at the University of Duke Medical Centre. It evaluates the cognitive dimensions specifically altered in schizophrenia and correlated with the evolution of the disease. This test is simple to use, requiring only paper, pencils and a stopwatch. It can be administered by different carers. The duration of the test session is approximately 35min. This battery of tests was validated on a sample of 150 patients compared with a sample of 50 controls, matched for age, parent education and ethnic groups. This aim of this study is to create a French adaptation of the BACS (translation and back translation approved by the Department of Psychiatry and Behavioural Sciences at the University of Duke Medical Centre) and then to test its easiness of administration and its sensitivity, performing correlation analysis between the French Version of the BACS (version A) and a standard battery. Its adaptation and validation in French would at first be useful for the French-speaking areas and then would add some new data for the pertinence of using the BACS. METHODS: 35 French stabilized schizophrenic patients were recruited from the inpatient and outpatient facilities at the Clermont-de-L'Oise Mental Health Hospital (Picardie area, France) in Dr Boitard's Psychiatric Department (FJ 5.) Patients were required to meet DSM-IV criteria for schizophrenia or schizoaffective illness. The patients were tested on two separate days by two independent clinicians with less than two weeks between the two assessments. During the first test session, subjects received the French A version of the BACS and during the second session, they were administered the standard battery of cognitive tests including: the Rey Auditory-Verbal learning test, the Wechsler Adult Intelligence Scale, third edition, subtests (Digit inverse sequencing, Digit Symbol-Coding), the Trail-Making A, Verbal Fluency (Controlled Oral Word Association Test, Category Instances), and the Wisconsin Card Sort Test (128 card version). The factor structure of the French BACS A Version was determined by performing a principal components analysis with oblique rotation. The relationship between the French BACS sub-scores and the standard battery sub-scores was determined by calculating Pearson's correlations among the sub-scores, with a level of significance of alpha<0.05. RESULTS: All the 35 patients completed the standard battery and each subtest of the French BACS A Version without interruption and with good understanding of the instructions. The average duration of the BACS test sessions was 36.51min (S.D.=12.14.) compared to the standard battery in which the sessions lasted more than one hour with more difficulty during the Wisconsin tests. The factor analysis conducted on the data collected from patients suggests that there is a single dimension, a factor of general cognitive performance, which accounted for the greatest amount of variance. The BACS thus permits an assessment of overall cognitive function as a global score, more than some individual specific cognitive domains. The sub-scores from the French BACS A Version were strongly correlated with the standard battery corresponding sub-scores. We observed significant correlations for all the subtests evaluating: verbal memory (Pearson=0.83; p<0.001; IC [0.69; 0.91]), working memory (Pearson=0.67; p<0.001; IC[0.43; 0.80]), verbal fluency (semantic: Pearson=0.64; p<0.001; IC[0.40; 0.80]), alphabetical (Pearson=0.87; p<0.001;IC[0.77; 0.93]), attention and speed of information processing (Pearson=0.69; p<0.001; IC[0.47; 0.83]), executive function (Pearson=0.64; p<0.001; IC[0.39; 0.80]). We almost found a significant correlation for motor speed (Pearson=-0. 32; p=0.06; IC [-0.59; -0.014]). CONCLUSION: The French adaptation of the BACS scale is easier to use in schizophrenic patients with French as mother tongue, with a completion rate equal to 1, and also with less than 35min to complete and check. We obtained significant correlations for all domains except motor speed, which is almost significant. The BACS is as sensitive to cognitive impairment in patients with schizophrenia as a standard battery of tests that required over 2h to complete. Moreover, these results demonstrate that the BACS, the global score of which may be the most powerful indicator of functional outcome, can also be a good neuropsychological instrument for assessing global cognition in patients with schizophrenia.

[Cause of mortality in schizophrenic patients: prospective study of years of a cohort of 150 chronic schizophrenic patients]. / Causes de la mortalité chez les schizophrènes: étude prospective sur 8 ans d'une cohorte de 150 schizophrènes chroniques.

UNLABELLED: Overmortality in schizophrenic patients in comparison to the reference population has been found. At the present time this over mortality is mainly due to suicide or certain natural causes such as respiratory, cardio-vascular and cerebro-vascular diseases. In France there are not psychiatric cas registers that could allow us to study the mortality of psychiatric patients. The aim of the study was first to determine the standardized mortality ratio (SMR) in a group of 150 chronic schizophrenics followed during 8 years and secondly to detect the variables that could predict this mortality. METHOD: The subjects filled out the RDC criteria for definite chronic schizophrenia and were included from 1991 to 1995. The subjects were inpatients or outpatients and their evaluation was made by psychiatrist. The subjects were selected from the different departments of two psychiatric hospitals corresponding to two French geographic areas (the Somme and Oise, two French "département"). At the initial assessment socio-demographic, clinical and psychometrical variables were collected: sex, age, educative level, number of hospitalizations, mean duration of the illness, scores on the Physical Anhedonia Scale, Brief Psychiatric Rating Scale (BPRS), Positive and Negative Syndrome Scale (PANSS). For the BPRS and PANSS, negative, positive and general subscales were extracted. In May 1999 all the subjects were contacted in order to know if they are alive or not and if they are death to know the date and the causes of their death. For the subjects that were still alive we used either direct assessment by interview of their psychiatrist or general practioner or indirect assessment by interview of their family. For the deceased subjects, we obtained informations about the date and the causes of the death by their psychiatrist or general practioner. If the patients were lost sight of we send a letter to the city of their place of birth in order to know if they are alive or not and if they are dead to know the date of their death. Moreover demographic data concerning the French and the Somme populations as well as the corresponding data concerning the mortality according to age and gender were obtained. A comparison of global mortality between patients and the French general or the Somme populations was made by the SMR. Moreover the deceased subjects and the survivors were compared by unidimensional statistical tests (chi 2 analyses for qualitative variables or Student's t test for quantitative variables) for the sociodemographic, clinical or psychometric variables. For each significant difference at p level < or = 0.05, the corresponding variable was retained for a multivariate step by step discriminant analysis. RESULTS: We found 13 deaths (10 males, 3 females): 3 suicides, 3 cardiac diseases, 2 cancers, 1 respiratory disease, 1 car crash, 1 homicide, 1 infectious disease, 1 respiratory arrest. The mortality rate (without correction for age) were 1.08% for both sexes, 1.44% and 0.6% for males and females respectively. The mortality rates (corrected for age) were 2.47% in our cohort and 0.988% in the Somme population. The corresponding SMR was 2.5. (chi 2 = 3.15, df = 1, p < 0.01). The overmortality was found only for males (chi 2 = 2.57, df = 1, p < 0.01) and not for females (chi 2 = 0.034, df = 1, p > 0.05). Concerning the comparisons between the deceased subjects and the survivors, there were five significant differences: gender, age, duration of the illness, neuroleptic dosage, negative symptoms (BPRS negative subscale). The deceased subjects were older, there was more men, the duration of the illness and the neuroleptic dosage were higher and the BPRS negative subscale was lower. These five variables were introduced in the discriminant analysis to explore notably their respecting weight. The corresponding power of the five variables were in decreasing order: neuroleptic dosage, negative symptoms, age, gender, duration of the illness. DISCUSSION: Our study confirm the overmortality in schizophrenic patients, this overmortality was especially explained by natural and non natural causes of death. The overmortality concerned only schizophrenic males patients whereas schizophrenic females did not have an overmortality. This negative result could be explain by a bias selection, the males being overrepresented in our cohort. Among the variables that were linked to the overmortality, the low level of negative symptomatology confirmed previous studies that have shown a low suicide rate in deficit schizophrenic. Moreover a high level of positive symptomatology could lead to high risk behaviors (suicide attempts, sexual disinhibition...). The neuroleptic dosage was the variable whom discriminate power was the highest. At least two explanations can be proposed. (ABSTRACT TRUNCATED)