Negative Symptom Trajectories in Individuals at Clinical High Risk for Psychosis: Differences Based on Deficit Syndrome, Persistence, and Transition Status.

Background and Hypothesis: Negative symptom trajectory in clinical high risk (CHR) for psychosis is ill defined. This study aimed to better characterize longitudinal patterns of change in negative symptoms, moderators of change, and differences in trajectories according to clinical subgroups. We hypothesized that negative symptom course will be nonlinear in CHR. Clinical subgroups known to be more severe variants of psychotic illness-deficit syndrome (DS), persistent negative syndrome (PNS), and acute psychosis onset-were expected to show more severe baseline symptoms, slower rates of change, and less stable rates of symptom resolution. Study Design: Linear, curvilinear, and stepwise growth curve models, with and without moderators, were fitted to negative symptom ratings from the NAPLS-3 CHR dataset (N = 699) and within clinical subgroups. Study Results: Negative symptoms followed a downward curvilinear trend, with marked improvement 0-6 months that subsequently stabilized (6-24 months), particularly among those with lower IQ and functioning. Clinical subgroups had higher baseline ratings, but distinct symptom courses; DS vs non-DS: more rapid initial improvement, similar stability of improvements; PNS vs non-PNS: similar rates of initial improvement and stability; transition vs no transition: slower rate of initial improvement, with greater stability of this rate. Conclusions: Continuous, frequent monitoring of negative symptoms in CHR is justified by 2 important study implications: (1) The initial 6 months of CHR program enrollment may be a key window for improving negative symptoms as less improvement is likely afterwards, (2) Early identification of clinical subgroups may inform distinct negative symptom trajectories and treatment needs.

Neurocognition and Depressive Symptoms have Unique Pathways to Predicting Different Domains of Functioning in Major Depressive Disorder.

BACKGROUND: Research has established the independent relationships between depressive symptoms to cognition and functioning in depression; however, little is known about the role of mediators in this relationship. We explored the role of neurocognitive abilities, depressive symptom severity, dysfunctional attitudes, and functional capacity in predicting two dimensions of daily functioning in individuals with major depressive disorder (MDD). METHODS: One hundred and twenty-four participants (mean age = 46.26, SD = 12.27; 56% female) with a diagnosis of MDD were assessed on a standard neurocognitive battery, self-reported depressive symptoms, dysfunctional attitudes, and clinician-rated functional impairment. They completed a performance-based assessment of functional competence. RESULTS: Confirmatory path analyses were used to model the independent and mediated effects of variables on two domains of functioning: social (relationships and social engagement) and productive (household and community activities). Cognition and depressive symptoms both predicted productive functioning, and dysfunctional attitudes mediated each of these relationships. Functional competence was a significant mediator in the relationship between neurocognition and productive functioning. Depressive symptoms and cognition were direct predictors of social functioning with no significant mediators. CONCLUSIONS: There are divergent pathways to different dimensions of daily functioning in MDD. Measurement implications include the consideration of multiple levels of predicting productive activities and more direct relationships with social outcomes. Treatments that directly target depressive symptoms and cognition might not generalize to improvements in everyday functioning if additional pathways to functioning are not addressed.

Implicit cognitive effort monitoring impairments are associated with expressive negative symptoms in schizophrenia.

Negative symptoms are a strong predictor of functional impairment in schizophrenia (SZ). Unfortunately, mechanisms underlying negative symptoms are poorly understood and available treatments are minimally effective. The current study evaluated the novel hypothesis that negative symptoms are associated with an implicit cognitive effort monitoring impairment that manifests during tasks requiring sustained allocation of cognitive control. Outpatients with SZ (n = 33) and healthy controls (CN; n = 29) completed an adapted Demand Selection Task (DST) in which subjects made choices between pairs of cognitive tasks that were implicitly and then explicitly made discrepant in effort demands. The SZ group demonstrated a reduced probability of avoiding the high effort cognitive task in the implicit choice condition but were able to become effort avoidant when the demands of the task were made explicit. Implicit cognitive effort monitoring deficits were associated with greater severity of the expressivity dimension of negative symptoms, but not the motivation and pleasure dimension. The association between diminished expressivity and implicit cognitive effort monitoring deficits is interpreted in light of a novel cognitive resource depletion theory, whereby individuals with SZ may become less expressive due to difficulty implicitly monitoring ongoing cognitive effort exertion and dynamically adjusting effort expenditure as task demands fluctuate.

What is normal cognition in depression? Prevalence and functional correlates of normative versus idiographic cognitive impairment.

OBJECTIVE: Traditional neuropsychological assessment methods identify a subpopulation of individuals with Major Depressive Disorder (MDD) who demonstrate cognitive functioning below population norms. An even larger proportion of those with MDD self-report problems with cognition that interfere with daily roles and responsibilities. We aim to test whether an intraindividual deviation of cognitive functioning relative to premorbid estimates (idiographic impairment) may better characterize challenges for functional recovery in MDD. METHOD: Adult participants with MDD (N = 111) who completed a baseline neuropsychological assessment battery for a cognitive remediation trial were used in analyses. We compared the frequency of cognitive impairment using the normative and idiographic approaches and examined how these indexes related to observed functioning, perceived functioning, and depression severity. RESULTS: While only 25% of the sample would be classified as cognitively impaired on a composite measure according to normative comparison standards, 62.2% of this group were classified as idiographically impaired using a conservative cut-off of at least 1 SD deviation below premorbid estimates. Idiographic cognitive impairment shared a stronger inverse relationship with perceived functional competence than normative cognitive impairment. Depressive symptoms did not significantly correlate with both normative and idiographic impairment. CONCLUSIONS: In MDD, reliance on assessment of contemporary cognitive functioning might underestimate rates of those who could be considered cognitively impaired. Consideration of idiographic impairment may help explain gaps between normatively defined cognitive ability with subjective complaints and disability in MDD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The THINC-it Tool for Cognitive Assessment and Measurement in Major Depressive Disorder: Sensitivity to Change.

BACKGROUND: Herein, we sought to determine the sensitivity to change in cognitive function, as measured by the THINC-it tool, in a sample of adults with major depressive disorder (MDD) receiving standardized antidepressant therapy. METHODS: Adults meeting the DSM-5 criteria for MDD with at least moderate depressive symptom severity [i.e., Montgomery Åsberg Depression Rating Scale (MADRS) total score ≥ 20] were treated with open-label vortioxetine (10-20 mg/day, flexibly-dosed) for 8 weeks. The previously validated THINC-it tool was the primary dependent measure. The THINC-it tool was validated against the paper and pencil version of the Digit Symbol Substitution Test (DSST) and the Trails Making Test B (TMTB). RESULTS: After 8 weeks of treatment, adults with MDD exhibited improvement in cognitive function relative to healthy controls (e.g., processing speed) (p = 0.031). A subdomain measure of working memory (i.e., symbol check; SC) exhibited significant improvement at Weeks 2 and 8 in latency (p = 0.032), SC accuracy (p = 0.046), and objective z-score (p = 0.001) independent of depressive symptoms. A linear regression analysis determined that the THINC-it tool measures of processing speed, as well as executive function were significantly associated with changes observed on the pencil and paper version the Digit Symbol Substitution Test (DSST) (p = 0.002) and in Trails Making Test B (TMTB) (p = 0.003), respectively. CONCLUSION: The THINC-it tool demonstrates sensitivity to change in adults with MDD and is highly correlated with improvements on pencil and paper versions of DSST and TMTB. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, identifier NCT03053362.

"What has been is what will be"? Autobiographical memory and prediction of future events in depression.

Depression is associated with negative autobiographical thinking regarding the past and the future. The association between the two temporal dimensions, however, has not been examined. In the present study, 32 participants diagnosed with Major Depressive Disorder (MDD) and 32 controls completed a cued-recall task. Participants rated memories for positivity, frequency of occurrence to themselves/others, and expected recurrence, and listed planned social events and expected participation and enjoyment of these events. Memories of individuals diagnosed with MDD (vs. controls) were rated as more negative by both participants and objective coders. Individuals diagnosed with MDD were more negative in their evaluation of past events and in future expectations compared to controls. For both groups, expected recurrence of positive past events was associated with the frequency of these events occurring to oneself. For individuals diagnosed with MDD, however, expected recurrence of negative past events was associated exclusively with the frequency of these events occurring to self and not to others. Expectations for past events' recurrence predicted increased expected participation and enjoyment from social events in both groups. These results suggest that memory in MDD is associated with more negative future expectations, which may affect mood and motivation.

Motivation and engagement during cognitive training for schizophrenia spectrum disorders.

BACKGROUND: Motivation and engagement are important factors associated with therapeutic outcomes in cognitive training for schizophrenia. The goals of the present report were to examine relations between objective treatment engagement (number of sessions attended, amount of homework completed) and self-reported motivation (intrinsic motivation and perceived competence to complete cognitive training) with neurocognitive and functional outcomes from cognitive training. METHODS: Data from a clinical trial comparing two cognitive training approaches in schizophrenia-spectrum disorders were utilized in the current report (n = 38). Relations were examined between baseline intrinsic motivation, perceived competence, homework completion, and session attendance with improvements in neurocognition, functional competence, and community functioning. RESULTS: Number of sessions attended (r = 0.38) and time doing homework (r = 0.51) were significantly associated with improvements in neurocognition. Homework completion was associated with change in community functioning at a trend-level (r = 0.30). Older age was associated with greater treatment engagement (ß = 0.37) and male biological sex was associated with greater self-reported motivation (ß = 0.43). Homework completion significantly mediated the relationship between session attendance and neurocognitive treatment outcomes. CONCLUSIONS: Objective measures of treatment engagement were better predictors of treatment outcomes than subjective measures of motivation. Homework completion was most strongly related to treatment outcomes and mediated the relationship between session attendance and treatment outcomes, suggesting continued engagement with cognitive stimulation may be an especially important component of cognitive remediation programs. Future research should examine methods to improve homework completion and session attendance to maximize therapeutic outcomes.

Brief executive function training for individuals with severe mental illness: Effects on EEG synchronization and executive functioning.

BACKGROUND: Executive Functioning (EF) is an important factor for community functioning for people with severe mental illness. Cognitive remediation programs often improve EF, but do so by using multiple therapeutic techniques. Little is known regarding how individual treatment elements promote cognitive improvement. Oscillatory brain activity is a potential neurophysiological mechanism that may change as a result of targeted training on computerized exercises. The current study aimed to examine the effects of a brief EF training program on EEG and neurocognitive measures. METHODS: 25 people with severe mental illness were randomized to either 2weeks of computerized EF training or control training. Training consisted of 1h training sessions 3 times per week and 40min of daily home training. Assessments examined EEG theta and alpha band oscillatory power during EF tasks and neurocognitive measures of EF. RESULTS: EF training resulted in greater frontal theta power and reduced posterior alpha power during computerized EF tasks than control training. Power in the alpha frequency band over frontal electrode sites did not significantly differ between the two groups as a result of training. Additionally, participants in the EF training experienced significantly greater improvement in EF ability as measured by neurocognitive tests than the control condition. CONCLUSIONS: Two weeks of EF training is sufficient to produce neurophysiological and neurocognitive change. Frontal theta power and posterior alpha power may be important neurophysiological markers to consider in cognitive remediation studies, and the addition of a brief executive function training procedure to other psychosocial interventions is worth examining.

Developing a tailored substance use intervention for youth exiting foster care.

Youth who are aging out of the foster care system face significant barriers to accessing substance use treatment. Mobile interventions have shown efficacy for several mental and physical health issues and may be helpful in overcoming barriers facing foster youth with substance use problems. A program (iHeLP) for substance use reduction was developed that used a computerized screening and brief intervention (SBI) followed by six months of dynamically-tailored text messages. The program was shown to focus groups of youth (N = 24) ages 18-19 who recently left foster care and had moderate to severe substance use risk. Focus group feedback was used to modify iHeLP prior to delivery in an open trial (N = 16). Both study phases included assessments of feasibility and acceptability; the open trial also included assessments of substance use outcomes at 3 and 6 months. Focus groups indicated a high level of acceptability for the proposed intervention components. Of those screened for the open trial, 43% were eligible and 74% of those eligible enrolled, indicating good feasibility. Retention through the final follow-up was 59%, and drop out was associated with involvement in the criminal justice system. Participant ratings for liking, ease of working with, interest in and respectfulness of the SBI were high. Satisfaction ratings for the texting component were also high. A computerized brief screening intervention for substance use risk reduction together with tailored text messaging is both feasible and highly acceptable among youth who have recently aged-out of foster care.

Feeling Heard and Not Judged: Perspectives on Substance Use Services Among Youth Formerly in Foster Care.

Youth in foster care have limited access to substance use services for a variety of reasons. Attempts to unpack this health disparity have focused on foster care systems, administrators, providers, and foster parents. This study seeks to understand the perspectives of youth themselves, with the hope of understanding their experiences with and preferences for such services. Analyses of focus groups with youth who had recently left foster care suggested concrete and perceptual facilitators/barriers to treatment. Concrete facilitators/barriers included the need for expanding social support, access to multiple service options, and tailored intervention approaches. Perceptual concerns revolved around understanding each individual's readiness to change, feeling judged by authority figures, and desiring help from people with lived experience. Participants also described novel intervention ideas, including a focus on technology-based approaches. By relying on youth voices, we can improve upon the current state of substance use interventions within foster care.

Developing a Tailored Texting Preventive Intervention: A Card Sort Methodology.

PURPOSE: Intervention content written by adults for youth can result in miscommunication due to generational and cultural differences. Inviting at-risk youth to participate in the creation of intervention material can augment acceptability for their peers. METHODS: To improve intervention messaging, the present study examines the utility of a card sort technique when creating cellular phone text messages to be used in a preventive substance use intervention. During focus groups with 24 youth who are exiting the foster care system - a population with distinct cultural attributes - participants were asked to rate stage of change-specific health messages rooted in Motivational Interviewing and the Transtheoretical Model. RESULTS: Participants unanimously favored content that encouraged autonomy and choice. Statements that invited a "look to the future" were also rated favorably. Messages that referenced the past were not rated well, as were suggestions for professional assistance. Finally, encouragement to receive social support for change was met with ambivalence. While some participants regarded support as helpful, many others felt a severe lack of support in their lives, possibly prompting further substance use. CONCLUSIONS: Youth exiting foster care constitute a unique population whose voice is paramount in the development of interventions. The content present in traditional approaches to substance use prevention (e.g., increasing social support) may not apply to this group of vulnerable youth. The card sort technique has strong potential to evoke youth-specific intervention content that is more readily understood and accepted by target audiences.

Disengagement from tasks as a function of cognitive load and depressive symptom severity.

INTRODUCTION: Depression is associated with impairment in cognition and everyday functioning. Mechanisms of cognitive dysfunction in depression and the factors that influence strategic deployment of cognitive abilities in complex environments remain elusive. In this study we investigated whether depression symptom severity is associated with disengagement from a working memory task (Paced Auditory Serial Addition Task; PASAT) with parametric adjustment of task difficulty. METHODS: 235 participants completed the Beck Depression Inventory, low and high cognitive load conditions of the PASAT, and quality of life. Cognitive disengagement was the sum of consecutive items in which participants did not proffer a response to the trial. RESULTS: Individuals with higher depression severity showed more cognitive disengagement on the high but not low cognitive load trial of the PASAT; they did not differ in number of correct responses. Increased disengagement from the low to high cognitive load was associated with more impaired quality of life. CONCLUSIONS: Depression severity is associated with increased disengagement from tasks as difficulty increases. These findings suggest the importance of measuring how cognitive skills are avoided in complex environments in addition to considering performance accuracy. Individuals with depressive symptoms might preferentially avoid cognitive tasks that are perceived as more complex in spite of intact ability.

Canadian Physicians' Attitudes towards Accessing Mental Health Resources.

Despite their rigorous training, studies have shown that physicians experience higher rates of mental illness, substance abuse, and suicide compared to the general population. An online questionnaire was sent to a random sample of physicians across Canada to assess physicians' knowledge of the incidence of mental illness among physicians and their attitudes towards disclosure and treatment in a hypothetical situation where one developed a mental illness. We received 139 responses reflecting mostly primary care physicians and nonsurgical specialists. The majority of respondents underestimated the incidence of mental illness in physicians. The most important factors influencing respondent's will to disclose their illness included career implications, professional integrity, and social stigma. Preference for selecting mental health treatment services, as either outpatients or inpatients, was mostly influenced by quality of care and confidentiality, with lower importance of convenience and social stigma. Results from this study suggest that the attitudes of physicians towards becoming mentally ill are complex and may be affected by the individual's previous diagnosis of mental illness and the presence of a family member with a history of mental illness. Other factors include the individual's medical specialty and level of experience. As mental illness is common among physicians, one must be conscious of these when offering treatment options.

Attitudes of Canadian psychiatry residents if mentally ill: awareness, barriers to disclosure, and help-seeking preferences.

BACKGROUND: The medical culture is defined by mental illness stigma, non-disclosure, and avoidance of professional treatment. Little research has explored attitudes and help-seeking behaviors of psychiatry trainees if they were to become mentally ill. METHOD: Psychiatry residents (n = 106) from training centres across Ontario, Canada completed a postal survey on their attitudes, barriers to disclosure, and help-seeking preferences in the context of hypothetically becoming mentally ill. RESULTS: Thirty-three percent of respondents reported personal history of mental illness and the frequency of mental illness by year of training did not significantly differ. The most popular first contact for disclosure of mental illness was family and friends (n = 61, 57.5%). Frequent barriers to disclosure included career implications (n = 39, 36.8%), stigma (n = 11, 10.4%), and professional standing (n = 15, 14.2%). Personal history of mental illness was the only factor associated with in-patient treatment choice, with those with history opting for more formal advice versus informal advice. CONCLUSIONS: At the level of residency training, psychiatrists are reporting barriers to disclosure and help-seeking if they were to experience mental illness. A majority of psychiatry residents would only disclose to informal supports. Those with a history of mental illness would prefer formal treatment services over informal services.

Implicit interpretation biases affect emotional vulnerability: a training study.

Cognitive theories of emotion propose that the interpretation of emotion-eliciting situations crucially shapes affective responses. Implicit or automatic biases in these interpretations may hinder emotion regulation and thereby increase risk for the onset and maintenance of psychological disorders. In this study, participants were randomly assigned to a positive or negative interpretation bias training using ambiguous social scenarios. After the completion of the training, a stress task was administered and changes in positive and negative affect and self-esteem were assessed. The results demonstrate that the interpretation bias training was successful in that participants exhibited a tendency to interpret novel scenarios in accordance with their training condition. Importantly, the positive training condition also had a protective effect on self-esteem. Participants in this condition did not exhibit a decrease in self-esteem after the stress task, whereas participants in the negative condition did. These results demonstrate that implicit cognitive biases can be trained and that this training affects self-esteem. Implications of these findings for research on psychopathology and emotion regulation are discussed.

Cognitive bias modification: induced interpretive biases affect memory.

Previous research has shown that it is possible to experimentally induce interpretive biases using ambiguous scenarios. This study extends past findings by examining the effects of cognitive bias modification for interpretation on subsequent scenario recall. Participants were trained to interpret emotionally ambiguous passages in either a positive or negative direction. Transfer of the training to novel scenarios was tested. After training, participants were also asked to recall details from these novel scenarios. The results indicate that the training was effective in inducing the intended group differences in interpretive bias. Importantly, participants exhibited memory biases that corresponded to their training condition. These results suggest that manipulating interpretive biases can result in corresponding changes in memory. Findings from this study highlight the importance of future research on the relation among cognitive biases and on the possibility of modifying cognitive biases in emotional disorders.

Cognitive behavioral therapy for rapid-cycling bipolar disorder: a pilot study.

Bipolar disorder is characterized by depressive and/or manic episodes that interfere with daily functioning. Between 10%-24% of bipolar patients experience a rapid-cycling course, with 4 or more mood episodes occurring per year. Characterized by nonresponse to standard mood stabilizing medications, patients with rapid-cycling bipolar disorder are particularly in need of effective, adjunctive treatments. Adjunctive cognitive-behavioral therapy (CBT) has been shown to improve adherence to medication and reduce relapse rates in patients with bipolar disorder. However, no published trials to date have examined the application of CBT to the treatment of patients with a rapid-cycling course of illness, with only a single case study published in the literature. We recently developed a CBT protocol that addresses the specific needs of bipolar patients with rapid cycling. The present study was designed to investigate outcomes with this CBT protocol. Study participants were 10 patients with rapid-cycling bipolar disorder, 6 of whom completed the study. Completers showed significant decreases in depressive mood, and improvements remained stable during the 2-month follow-up. This suggests that CBT for rapid cycling may have beneficial effects.

Bipolar disorder: what can psychotherapists learn from the cognitive research?

Randomized controlled trials of psychological treatment, principally cognitive therapy, for bipolar disorder have yielded inconsistent results. Given the status of this evidentiary base, we provide a more fine-grained analysis of the cognitive profiles associated with bipolar disorder to inform clinical practice. In this practice-friendly review, we consider evidence that both negative and positive cognitive styles are related to bipolar disorder. Cross-sectional and prospective evidence suggest that negative cognitive styles are related to depression within bipolar disorder, but there also is evidence that bipolar disorder is related to an elevated focus on goals as well as to increases in confidence during manic states. With such findings as backdrop, we consider the outcomes of psychological treatments for bipolar disorder and advance several suggestions for clinical practice.

The relationship between smoking and suicidal behavior, comorbidity, and course of illness in bipolar disorder.

OBJECTIVES: The rate of smoking in people with bipolar disorder is much greater than in the general population, but the implications of smoking for the course of bipolar disorder have not been well studied. The purpose of this retrospective study was to examine the relationship between smoking, severity of bipolar disorder, suicidal behavior, and psychiatric and substance use disorder comorbidity. METHOD: We evaluated 399 outpatients with bipolar disorder who were treated in a bipolar specialty clinic from December 1999 to October 2004. Diagnosis, mood state, course of illness, functioning, and psychiatric comorbidities were assessed using the Affective Disorders Evaluation and the Mini-International Neuropsychiatric Interview. RESULTS: Of the 399 patients evaluated, 155 (38.8%) had a history of daily smoking. Having ever smoked was associated with earlier age at onset of first depressive or manic episode, lower Global Assessment of Functioning scores, higher Clinical Global Impressions-Bipolar Disorder scale scores, lifetime history of a suicide attempt (47% for smokers vs. 25% for those who had never smoked), and lifetime comorbid disorders: anxiety disorders, alcohol abuse and dependence, and substance abuse and dependence. In a logistic regression model including these factors, suicide attempts and substance dependence were significantly associated with smoking in patients with bipolar disorder. CONCLUSIONS: Bipolar patients with lifetime smoking were more likely to have earlier age at onset of mood disorder, greater severity of symptoms, poorer functioning, history of a suicide attempt, and a lifetime history of comorbid anxiety and substance use disorders. Smoking may be independently associated with suicidal behavior in bipolar disorder.