Mechanisms of functional improvement through cognitive rehabilitation in schizophrenia.

Whereas the efficacy of cognitive rehabilitation in schizophrenia is widely known, studies examining mechanisms for functional improvement are still scarce. The aim of the study was to examine the mediational mechanisms through which cognitive rehabilitation improves functioning in schizophrenia. One hundred and eleven schizophrenia patients were randomly assigned to either a 4-month cognitive rehabilitation group or an active control group. Patients underwent a neurocognitive battery (including processing speed, verbal memory, working memory and executive functioning) and social cognition assessment (emotion perception, theory of mind and social perception). Functioning was assessed by the combined use of a performance-based instrument, the UCSD Performance-based Skills Assessment (UPSA) and an observer-rated instrument, the Global Assessment of Functioning (GAF). The trial was registered in clinicaltrials.gov (NCT02796417). Multiple mediational analyses revealed that the effect of cognitive rehabilitation on functional improvement was partially mediated by changes in processing speed and verbal memory, but not by the domains of social cognition and negative symptoms. More specifically, verbal memory partially mediated the treatment's effect on performance-based functioning (UPSA), whereas processing speed acted as a partial mediator for observer-rated functioning (GAF). The effect of rehabilitation on functioning did not take place through all the domains that showed significant improvement. Verbal memory and processing speed emerged as the most crucial factors. However, these complex interactions need further research.

Clinical (but not cognitive) recovery in schizophrenia through the experience of fictional cinema.

INTRODUCTION: One of the criticisms of rehabilitation techniques is their limited application to the patient's daily life. In the past, cinema has been used as a psychiatric rehabilitation tool, with the primary objective of facilitating training in social abilities and communication. In this study, we consider the use of film not only as a clinical recovery tool but also as a novel cognitive recovery tool for additional rehabilitation not only for communication and social abilities but also for all of the basic cognitive and social cognition processes. METHODS: In this randomized clinical trial, 48 patients with schizophrenia were assigned to an experimental or control group. Both of the groups received treatment sessions that included viewing episodes of the television series The Sopranos. Next, the experimental group participated in a structured cognitive training session that featured questions and exercises based on the episodes. The control group participated in an idea-sharing session (of the same duration and frequency) about what the group members saw in the episode. RESULTS: At the end of the treatment, both the positive and negative clinical symptoms of the experimental group improved significantly compared with the control group. However, this improvement was not observed in basic or social cognitive functions. DISCUSSION: A brief intervention based on transforming the activities of daily life can be an effective tool for psychiatric rehabilitation. However, the study's current characteristics and sample did not produce benefits in cognitive parameters.

Efficiency of cognitive rehabilitation with REHACOP in chronic treatment resistant Hispanic patients.

INTRODUCTION: Cognitive rehabilitation in schizophrenia has been proved to benefit cognition depending on the severity of the illness and the cognitive deficits. Nevertheless studies of efficiency with chronic patients, refractory to additional treatment interventions, have not yet been published. DESIGN: Ninety three patients with schizophrenia were recruited from the Treatment Resistant Schizophrenia Unit in Alava (Spain). All subjects underwent a baseline and a 3 months assessment including cognition, clinical symptoms and functional capacity. Patients were randomly assigned to receive either neuropsychological rehabilitation or occupational therapy for 3 months in addition to treatment as usual (TAU). RESULTS: Patients at the Rehacop group showed significantly greater improvements at 3 months in most areas of cognition evaluated including speed of processing, language, memory and executive functioning, compared to the occupational therapy group (group x time interactions p< 0.001). The Rehacop group also showed significant improvement in positive symptoms, functional and insight measures. Although data was not statistically significant, the Rehacop group showed a tendency to also improve negative symptoms compared to controls. CONCLUSIONS: Despite to their limited respond to TAU, our data suggest that chronic refractory patients can improve their cognitive performance after neuropsychological rehabilitation with the Rehacop. These findings support the feasibility of integrating neuropsychological rehabilitation into TAU programs for patients with lower responses to other treatment plans.

Hierarchical structure of the cognitive processes in schizophrenia: the fundamental role of processing speed.

OBJECTIVE: Decreased processing speed (PS) is a key feature of schizophrenia with respect to cognition, functional outcome and clinical symptoms. Our objective was to test whether PS slowing mediates other neuropsychological deficits among patients with chronic schizophrenia. METHOD: One hundred patients with schizophrenia and 53 healthy adults completed a series of neuropsychological measures that assess six cognitive domains. In addition to PS these included attention, verbal memory, visual memory, working memory, and executive functioning. Confirmatory factor analysis (CFA) was used to evaluate the fit of the 6-factor model. The cognitive performances of both groups were compared before and after controlling for the effect of PS, but also after controlling for the effect of each cognitive factor at a time. Finally, the PS-related variance was removed and the effect of the other cognitive factors was tested again. RESULTS: CFA supported the hypothesized 6-factor cognitive structure. As expected, the patients and controls differed on all cognitive measures. However, after controlling for the effects of PS, group differences on the other five cognitive factors decreased substantially. Controlling for other factors produced smaller attenuation of group differences, and these effects were also partially accounted for by decreased PS. CONCLUSIONS: PS deficits account for most of the differences in cognition between patients with schizophrenia and healthy controls. PS slowing appears to be a core feature of schizophrenia, one that underlies impairments of working memory, executive functioning, and other abilities.

Evolución de los síntomas cognitivos en la esquizofrenia: una revisión de la literatura / Course of cognitive symptoms in schizophrenia: a review of the literature

Los estudios longitudinales son los únicos capaces de dar respuesta a la cuestión de si los déficit cognitivos presentes en la esquizofrenia siguen un curso estable y establecer cuál es su relación evolutiva con otros síntomas clínicos de la enfermedad. Este artículo revisa un total de 30 estudios publicados en pacientes bien con un primer episodio psicótico, como crónicos o geriátricos con un período mínimo de seguimiento de 1 año. La disparidad de criterios y metodologías empleadas limita significativamente las conclusiones que pueden extraerse sobre esta materia. Sin embargo, la tendencia global a la que apuntan los resultados sugiere que ya en el inicio de la enfermedad están presentes síntomas cognitivos significativos y medibles que permanecen estables en el período posterior entre los 2 y los 5 años y cuyo deterioro se acentúa con la evolución de la enfermedad, especialmente en los pacientes institucionalizados, sin llegar a superar el nivel de deterioro que presentan otras patologías degenerativas. Los autores son conscientes de que la unificación de criterios de investigación y la superación de las limitaciones metodológicas pueden ofrecer en el futuro resultados que modifiquen las conclusiones aquí recogidas

Longitudinal studies are the only ones capable of responding to the question of whether cognitive deficits present in schizophrenia follow a stable course and establishing its evolutive relationship with other clinical symptoms of the disease. This article reviews a total of 30 studies published in patients with a first psychotic episode or chronic or geriatric patients, with a minimum follow-up period of 1 year. The diversity in criteria and methods used significantly limits the conclusions that can be drawn on this subject. However, the global tendency of the results suggests that significant and measurable cognitive symptoms are present at the onset of the disease and these remain stable in the subsequent period between 2 and 5 years. Their deterioration increases with the course of the disease, especially in hospitalized patients, it not exceeding the deterioration level presented in other degenerative diseases. The authors are aware that unifying research criteria and overcoming the methodological limitations may offer results that change the conclusions herein gathered in the future

Course of cognitive symptoms in schizophrenia: a review of the literature.

Longitudinal studies are the only ones capable of responding to the question of whether cognitive deficits present in schizophrenia follow a stable course and establishing its evolutive relationship with other clinical symptoms of the disease. This article reviews a total of 30 studies published in patients with a first psychotic episode or chronic or geriatric patients, with a minimum follow-up period of 1 year. The diversity in criteria and methods used significantly limits the conclusions that can be drawn on this subject. However, the global tendency of the results suggests that significant and measurable cognitive symptoms are present at the onset of the disease and these remain stable in the subsequent period between 2 and 5 years. Their deterioration increases with the course of the disease, especially in hospitalized patients, it not exceeding the deterioration level presented in other degenerative diseases. The authors are aware that unifying research criteria and overcoming the methodological limitations may offer results that change the conclusions herein gathered in the future.

Study of the influence of electroconvulsive therapy on the regional cerebral blood flow by HMPAO-SPECT.

STUDY OBJECTIVE: The aim of this preliminary study is to investigate the regional blood flow in response to ECT (electroconvulsive therapy) and to identify any responsive-pattern to the treatment. STUDY DESIGN: Single longitudinal prospective study of cohorts. SUBJECTS: For this preliminary study ten patients, female sex, mean age 70.8 years with major mood disorder (CID-10 investigation criteria) were studied after signature consent. INTERVENTIONS: The intervention consisted in the administration of bilateral brief pulse ECT three times a week, during 6 to 12 sessions according to the standards of the Psychiatric Department of the Santiago Hospital in Victoria. MEASUREMENT: Clinical evaluation of depression was evaluated by Hamilton Depression Scale, Montgomery and Asberg Scale, Newcastle Scale and regional cerebral blood flow (rCBF) using the HMPAO-SPECT. RESULTS: The pattern of distribution on the regional cerebral flow during the ECT showed changes from the basal pattern in all patients. All patients had a relative increased perfusion of the temporal lobes and basal ganglia. Other changes from the basal study were areas of decreased perfusion of the occipital lobe (6 patients) and parietal lobe (3 patients). CONCLUSIONS: Brain perfusion SPECT study of the patients with major depression shows changes during ECT. Further analysis are needed to understand the relationship between mechanisms of treatment and recovery in affective illness.

[Smoking in a psychiatric population]. / Tabaquismo en población psiquiátrica.

The relationship between tobacco consumption and psychiatric disorders is a widely discussed topic that is generating a considerable yet controversial bibliography, that can be approached from different points of view. The authors make a revision and critical evaluation about smoking prevalence on psychiatric population, in the different psychiatric disorders and discussing the theories implicated.

[Predictors of rehospitalization in schizophrenia]. / Predictores de rehospitalización en la esquizofrenia.

OBJECTIVES: The aim of this study is to determine the predictive value on rehospitalization of sociodemographic variables, positive/negative symptoms and thought disorders. The results are part of research project founded by the Basque Health Department. METHODS: A 18 month follow-up study of a cohort of 60 patients with acute exacerbation of schizophrenia was carried out. The assessment was performed with DSM III-R diagnostic criteria, PANSS and CGI rating scales, and SCID-P semistructured interview. All patients received antipsychotic treatment. The sociodemographic and disease data, the dimensional score of the PANSS subscales, the score of CGI scale, the items 2, 12, 13 and 14 of the PANSS as indicators of formal thought disorders; and the items 1, 5, 6, 17 and 23 of the PANSS as content thought disorders were established as predictors. The predictive value was determined by the Cox regression test (Lee 1992). RESULTS: We did not find predictive value either in the PANSS scores or in the 9 thought disorders evaluated (Wald and RR tests were not significative). Nevertheless, considering the values of standard error obtained in the Cox regression we were not in a position to assure that they did not have an incidence in the hospitalizations. The CGI was the only scale that showed prognostic value (Wald test = 1.9945; RR = 1.7499). Our results indicated that the lower number of previous hospitalizations (Wald test = 1.1437; RR = 1.1437) and the high level of studies (Wald test = 2.4258; RR = 1.8052) diminished the risk of rehospitalization. CONCLUSIONS: 1 o The predictive value on rehospitalization for the positive/negative symptoms and thought disorders was not confirmed. 2 o CGI is the only scale with predictive value. That fact makes us consider the importance of what German psychiatrists called "smelling the schizophrenia" or "The smell of schizophrenia". 3 o Our results indicate that the lower number of previous hospitalizations, and the high level of studies diminish the risk of rehospitalization.

[Serotonergic function in endogeneity of depression]. / Función serotoninérgica y endogeneidad en la depresión.

OBJECTIVE: This study employed an alternative method for assessing serotonergic function in depression. The neuroendocrine responses to acute intravenous administration of the serotonin (5-HT) reuptake inhibitor clomipramine were assessed in patients with Major Depression with Melancholia (DMM) and matched subjects with Major Depression (DM) (without Melancholia) and Dysthimic disorder (TD). METHOD: 10 patients who met DSM III-R criteria of DMM, 10 patients with DM and 10 with DD matched for age and sex received 12.5 mg of intravenously administered clomipramine. Prl, Cortisol and GH were measured during the next 135 minutes. We divided the samples using the Newcastle Scale. RESULTS: The DMM patients had significant blunting prolactin responses to clomipramine compared with the other patients. Most of the major depression patients without melancholia were neurotic depressions according to the Newcastle Scale. There was a negative correlation between endogeneity and prolactin response. CONCLUSIONS: These data support the hypothesis that DMM patients have abnormal neuroendocrine responses to the intravenous administration of the 5-HT reuptake inhibitor clomipramine, and that there is an association between endogeneity and prolactin response.

[Positive and negative symptoms in schizophrenia: standards of change during acute exacerbation]. / Síntomas positivos y negativos en la esquizofrenia: patrones de cambio durante la exacerbación aguda.

INTRODUCTION AND OBJECTIVES: The temporal stability of the positive and negative symptoms in schizophrenia deserves a special interest due to its consequences in the outcome and the treatment of the disease. This study determines the temporal stability of positive/negative subtypes in schizophrenia during the acute phase. MATERIAL AND METHODS: This is a clinical, observational and prospective study of a dynamic cohort of patients with acute exacerbation of schizophrenia defined by DSM III-R criteria. Patients with severe and unstable organic pathology, substance dependence, mental organic disorder, mental retardation, depression, or medicamentous parkinsonism were excluded. Clinical assessment was performed with the PANSS scale. Schizophrenic subtypes were established according to inclusive and restrictive criteria of PANSS. All patients were treated with new antipsycotics and biperiden if necessary. RESULTS: 51 patients were assessed for 8 weeks. In the baseline, the negative subtype (63.3% and 52.5% by inclusive and restrictive system respectively) and paranoid form (45.1%) were predominant. Three types of analysis were performed to determine the temporal stability: 1. Concordance (Kappa index). The concordance of the inclusive and restrictive System, regarding to the baseline assessment, indicated that both criteria had a low temporal stability. 2. Mc Nemar Ji Square. This test showed that these changes were bi-directional except for the first visit, which was significant through the restrictive system (higher change from the negative to other subtypes). 3. Transition analysis among groups by First Order Morkov Chains analysis indicated that this change was stationary (the change was the same in all phases). CONCLUSIONS: 1o The variable "time" has to be considered for the definition of subtypes in schizophrenia. 2o The restrictive system is more specific. It allows to identify a subgroup of patients with "Negative" schizophrenia with a high specificity and validity in clinical and epidemiological studies. 3o The use of the baseline visit as a reference (gold standard) is recommended because it exits a higher concordance among criteria and a more florid psychopathology.