Effects of metacognitive training (MCT) on social cognition for schizophrenia spectrum and related psychotic disorders: a systematic review and meta-analysis.

BACKGROUND: Individuals with schizophrenia spectrum and related psychotic disorders (SSD) experience significant impairments in social cognition that impede functioning. Social cognition is a multidimensional construct consisting of four domains: 1. theory of mind, 2. emotion processing, 3. attributional style and 4. social perception. Metacognitive training (MCT) is an intervention designed to target cognitive biases in psychosis containing two modules addressing social cognition. METHODS: A systematic review and meta-analysis was conducted to investigate the effects of MCT on social cognition and two of its domains: theory of mind and emotion processing. Ten electronic databases were scoured from 2007 to 1 February 2022 for MCT studies reporting social cognition outcomes for people with SSD (1050 identified, 282 assessed). Effect sizes were calculated using Cohen's d in R. RESULTS: Nine studies were included in the meta-analysis (nMCT = 212, ncontrol = 194). MCT had a small but positive effect on global social cognition (d = 0.28 [95% CI 0.07-0.49]) and theory of mind (d = 0.27 [95% CI 0.01-0.52]). MCT showed no evidence of an effect on emotion processing (d = 0.03 [95% CI -0.26 to 0.32]). CONCLUSION: MCT has a small but significant effect on social cognition for people with SSD. Our results add to other recent meta-analyses showing significant effects of MCT on clinically relevant outcomes such as positive symptoms, cognitive biases and cognitive insight. We recommend that future studies on MCT report outcomes on all four domains of social cognition. TRIAL REGISTRATION: PROSPERO (in the process of registration) available at https://www.crd.york.ac.uk/prospero/#recordDetails.

The neural correlates of referential communication: Taking advantage of sparse-sampling fMRI to study verbal communication with a real interaction partner.

This paper introduces an innovative functional magnetic resonance imaging (fMRI) protocol to study real verbal interactions while limiting the impact of speech-related movement artefacts. This protocol is based on a sparse sampling acquisition technique and allowed participants to complete a referential communication task with a real interaction partner. During verbal interactions, speakers adjust their verbal productions depending on their interlocutors' knowledge of the referents being mentioned. These adjustments have been linked to theory of mind (ToM), the ability to infer other's mental states. We thus sought to determine if the brain regions supporting ToM would also be activated during a referential communication task in which participants have to present movie characters that vary in their likelihood of being known by their interlocutor. This pilot study establishes that the sparse sampling strategy is a viable option to study the neural correlates of referential communication while minimizing movement artefacts. In addition, the brain regions supporting ToM were recruited during the task, though specifically for the conditions where participants could adjust their verbal productions to the interlocutor's likely knowledge of the referent. This study therefore demonstrates the feasibility and relevance of a sparse-sampling approach to study verbal interactions with fMRI, including referential communication.

Personalized cognitive remediation therapy to facilitate return to work or to school in recent-onset psychosis.

Cognitive deficits are barriers to job acquisition or return to school, and can be reduced through Cognitive remediation therapy (CRT). The main goal of this multiple case study was to investigate the effect of personalized CRT on occupational status in three participants with a recent-onset psychosis. Two cases improved their occupational status at post-treatment, and showed improvements in cognitive, psychological, and/or clinical variables. This study suggests that personalized CRT may facilitate job acquisition or return to school. However, the different pathways showed by our cases indicate that personalized CRT may influence occupational status through multiple mechanisms, underlining the relevance of treatment personalization.

Navigating Social Cognitive Impairments in Schizophrenia Spectrum Disorders: Protocol for a Pilot Pre-Post Quasi-Experimental Study for Remote Avatar-Assisted Cognitive Remediation Therapy.

BACKGROUND: Social cognitive impairments are prevalent in schizophrenia spectrum disorder (SSD) and have detrimental effects on functioning. Cognitive remediation (CR) has shown its efficacy in improving social cognitive impairments, although the transfer of these skills to daily life and the personalization of these interventions remain challenging. RC2S (Remédiation Cognitive de la Cognition Sociale dans la Schizophrénie; Cognitive remediation of social cognition in Schizophrenia) is a French CR that combines the learning of strategies and practice using paper-and-pencil exercises and digital relational simulations. This French program was designed as an in-person intervention. OBJECTIVE: This project aims to culturally adapt the RC2S program, in French-Canadian and North American English and to assess the feasibility, acceptability, safety, and implementation of a remote version in people with SSD. An exploratory objective is to assess the preliminary effect of remote RC2S on goal attainment, social cognition, and psychosocial outcomes. METHODS: We will use a pre-post quasi-experimental design. First, the translation and cultural adaptation in North American English and French-Canadian of RC2S is presented. Then, 20 participants aged ≥18 years with a diagnosis of SSD, presenting with a subjective or an objective impairment in social cognition, will be included to receive RC2S. In addition, 5 therapists will be included as research participants to assess their perspective on RC2S. Participants with SSD will undergo a baseline remote assessment of their social cognition, clinical symptoms, and functioning. They will then start remote RC2S for 24 biweekly individual 1-hour sessions with a therapist. Following the case formulation and goal setting, participants will complete personalized paper-and-pencil exercises to develop strategies and integrative digital relational simulations, during which they will help an avatar navigate through a variety of social contexts and relationships. The last 2 sessions are dedicated to the transfer to daily life. All participants will complete in-session questionnaires assessing therapeutic alliance, motivation, acceptability, feasibility, and implementation. Following RC2S, the participants with SSD will repeat the same assessment as the baseline. Descriptive statistics will be used to summarize the data about acceptability, feasibility, safety, and implementation. To assess the preliminary effect of RC2S, an intention-to-treat approach will be used with linear mixed models for repeated measures with fixed effects of time. RESULTS: So far, 45% (9/20) of participants with SSD (mean age 37.9, SD 9.3 years) have completed the project. They received a mean of 20.5 out of 24 (SD 3.5) sessions of RC2S. A total of 5 therapists also completed the project. CONCLUSIONS: Improving social cognitive impairments is an important target in SSD to promote functional recovery. Using digital technologies to address these impairments and deliver the intervention is a promising approach to increase the ecological validity of CR and access to the intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT05017532; https://classic.clinicaltrials.gov/ct2/show/NCT05017532. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/54251.

Assessing the fidelity of supported education programs for first-episode psychosis to the supported employment guidelines adapted for education.

INTRODUCTION: Psychotic disorders are associated with academic difficulties. Supported Employment Program (SEP) guidelines have become the gold standard to improve occupational functioning in psychotic disorders. More recently, these guidelines have been adapted to education. In Canada, several community organizations and hospital programs offer supported education to young people with psychotic disorders. However, SEP guidelines are not systematically used. The objective of this study was to assess the fidelity of 6 Canadian (Quebec) organizations offering supported education services to young people with psychotic disorders to the SEP guidelines adapted to education. METHODS: Six sites offering educational services to young people with psychotic disorders were recruited. Semi-structured interviews were conducted with one supported education professional and one manager of each site, using the Quality of Supported Education Implementation Scale (QSEDIS). This new scale has been developed from the Quality of Supported Employment Implementation Scale. The QSEDIS assesses the fidelity of the quality of the implementation of supported education programs, using three subscales (Employees, Organization and Services). RESULTS: Acceptable fidelity scores were observed in the three QSEDIS subscales for all six sites combined. The Services subscale received the highest score of fidelity (4.4/5), followed by the Supported Education Employee (4.1/5) and the Organization (3.7/5). CONCLUSION: The results suggest that supported education services offered to young people with psychotic disorders in the six sites are generally consistent with SEP guidelines adapted to education. Further research is warranted to validate whether acceptable SEP guidelines fidelity according to the QSEDIS translates into educational outcomes.

Acceptability, engagement, and efficacy of cognitive remediation for cognitive outcomes in young adults with first-episode psychosis and social anxiety: A randomized-controlled trial.

Social anxiety disorder (SAD) is a frequent comorbidity in first-episode psychosis (FEP) and may increase cognitive impairments. Cognitive remediation (CR) is an effective treatment for cognition, particularly in a group format. This study aims to assess the efficacy, acceptability and engagement of group CR on cognitive outcomes in FEP+SAD compared to group cognitive-behavioral therapy (CBT). Participants with FEP+SAD were randomized to group CR (n = 45) or CBT-SAD (n = 51). They were assessed for cognition at baseline, post-therapy and 3- and 6-month follow-up. The CR group additionally completed scale to assess perceived competency and enjoyment in CR. Linear mixed models for repeated measures were used for cognitive scores. Descriptive statistics and t-tests were used to summarize acceptability, perceived competency, and enjoyment, for CR completers and non-completers. The CR group performed significantly better than CBT on executive functions and visual memory at post-therapy compared to baseline. Twenty participants completed CR (44 %; mean 5.5 sessions). At week 1, CR non-completers presented higher levels of perceived competency. Completers reported higher enjoyment scores at the last session compared to the first session. Group CR is effective for cognitive outcomes in FEP+SAD, but acceptability and engagement present a challenge. Future studies are necessary to explore approaches promoting engagement.

Associations between theory of mind and clinical symptoms in recent onset schizophrenia spectrum disorders.

Introduction: People with schizophrenia often present with Theory of mind (ToM) deficits, and the link between these deficits and clinical symptoms remains to be refined, for instance through the use of more recent assessment methods. The objective of this study was to examine the associations between a psychometrically sound ToM task and the clinical symptoms of schizophrenia as measured with the five dimensions of the Positive and Negative Syndrome Scale (PANSS) namely positive, negative, cognitive/disorganization, depression/anxiety and excitability/hostility, while controlling for non-social cognitive abilities. Methods: Seventy participants with recent-onset schizophrenia spectrum disorders (SSD) were assessed for ToM using the Combined stories task (COST) and for clinical symptoms using the PANSS. Results: The results revealed significant correlations between ToM and the positive (r = -0.292, p = 0.015) and cognitive/disorganization (r = -0.480, p < 0.001) dimensions when controlling for non-social cognitive abilities. In contrast, the negative symptoms dimension was only significantly correlated with ToM when non-social cognitive abilities were not controlled for (r = -0.278, p = 0.020). Discussion: Very few prior studies used the five-dimensions of the PANSS to examine the link with ToM and this study is the first to rely on the COST, which includes a non-social control condition. This study highlights the importance of taking non-social cognitive abilities into account when considering the relationship between ToM and symptoms.

What areas of everyday functioning are affected by theory of mind deficits in recent-onset schizophrenia spectrum disorders?

AIM: Functional recovery is now a recognized treatment goal for schizophrenia. It is therefore important to better understand the cognitive and psychological factors that influence functioning. Theory of mind (ToM) deficits are common in schizophrenia and have been linked to greater impairments in functioning. The current study aimed to identify which specific areas of functioning are linked to ToM in a group of 54 patients with a recent-onset of a schizophrenia spectrum disorder. METHODS: ToM was assessed with the Combined Stories Test (COST). Several areas of functioning were rated based on an extensive semi-structured interviews. RESULTS: Among the different areas of functioning that were examined, ToM showed a significant, positive relationship with ratings for productive activities (e.g. work or school) as well as with collaboration to psychiatric care. CONCLUSION: These results suggest that ToM can impair functioning especially in situations in which patients need to collaborate with others, including the interactions with the clinical team.

Disentangling the Relationships Between the Clinical Symptoms of Schizophrenia Spectrum Disorders and Theory of Mind: A Meta-analysis.

BACKGROUND AND HYPOTHESIS: Previous studies have suggested links between clinical symptoms and theory of mind (ToM) impairments in schizophrenia spectrum disorders (SSD), but it remains unclear whether some symptoms are more strongly linked to ToM than others. STUDY DESIGN: A meta-analysis (Prospero; CRD42021259723) was conducted to quantify and compare the strength of the associations between ToM and the clinical symptoms of SSD (Positive, Negative, Cognitive/Disorganization, Depression/Anxiety, Excitability/Hostility). Studies (N = 130, 137 samples) including people with SSD and reporting a correlation between clinical symptoms and ToM were retrieved from Pubmed, PsycNet, Embase, Cochrane Library, Science Direct, Proquest, WorldCat, and Open Gray. Correlations for each dimension and each symptom were entered into a random-effect model using a Fisher's r-to-z transformation and were compared using focused-tests. Publication bias was assessed with the Rosenthal failsafe and by inspecting the funnel plot and the standardized residual histogram. STUDY RESULTS: The Cognitive/Disorganization (Zr = 0.28) and Negative (Zr = 0.24) dimensions revealed a small to moderate association with ToM, which was significantly stronger than the other dimensions. Within the Cognitive/Disorganization dimension, Difficulty in abstract thinking (Zr = 0.36) and Conceptual disorganization (Zr = 0.39) showed the strongest associations with ToM. The association with the Positive dimension (Zr = 0.16) was small and significantly stronger than the relationship with Depression/Anxiety (Zr = 0.09). Stronger associations were observed between ToM and clinical symptoms in younger patients, those with an earlier age at onset of illness and for tasks assessing a combination of different mental states. CONCLUSIONS: The relationships between Cognitive/Disorganization, Negative symptoms, and ToM should be considered in treating individuals with SSD.

Sociodemographic and clinical risk factors associated with suicidal ideation and attempt during a 2-year early intervention program for first-episode psychosis.

BACKGROUND: Identifying risk factors for suicidal ideation and attempt among first-episode psychosis patients is essential to prevent suicide in this high-risk population. We investigated risk factors at admission for suicidal ideation and attempt during a 2-year early intervention program. METHODS: Our sample included patients aged 18-35 years who were consecutively admitted to an early intervention program (2003-2017). Sociodemographic and clinical variables were obtained from a longitudinal study, while data on suicidal ideation and attempt were collected via systematic file review. Univariable and multivariable logistic regressions assessed the association of these variables with suicide ideation and attempt. RESULTS: Of 446 participants, 35 (7.8 %) attempted suicide during the 2-year follow up, including two resulting in death (0.45 %), and 168 (37.7 %) reported solely suicidal ideation. Multivariable analyses indicated living alone (OR = 4.01, CI = 2.11-7.63), affective psychosis (OR = 1.95, CI = 1.22-3.14) and depressive symptomatology (OR = 1.45, CI = 1.13-1.86) were associated with increased risk for suicidal ideation. Attempting suicide close to admission (OR = 10.29, CI = 3.63-29.22), living alone (OR = 4.17, CI = 1.40-12.35), and depressive (OR = 1.67, CI = 1.06-2.63) and positive symptomatology (OR = 1.60, CI = 1.02-2.50) were associated with increased risk for suicide attempt. Attempting suicide close to admission (OR = 11.65, CI = 4.08-33.30), being part of an ethnic minority (OR = 3.71, CI = 1.59-8.63), and presenting lower anxiety (OR = 0.58, CI = 0.36-0.94) were the only factors specifically associated with suicide attempt compared to ideation. CONCLUSION: Close monitoring of patients who recently attempted suicide, live alone, are part of an ethnic minority, and present with affective and positive symptomatology may help reduce the risk of suicide-related outcomes during early intervention programs.

Immediate and Sustained Outcomes and Moderators Associated With Metacognitive Training for Psychosis: A Systematic Review and Meta-analysis.

Importance: A substantial increase in the number of trials examining metacognitive training (MCT) for psychosis necessitates an updated examination of the outcomes associated with MCT. Objectives: To review the immediate and sustained associations of MCT with proximal (directly targeted) and distal (indirectly influenced) outcomes and assess treatment- and participant-related moderators to identify the potential factors associated with the expected heterogeneity of effect sizes. Data Sources: Eleven electronic databases were searched from 2007 to June 3, 2021 (alert until September 10, 2021). Reference lists of earlier meta-analyses and included reports were screened. Study Selection: Reports examined MCT and included participants with schizophrenia spectrum and related psychotic disorders (1045 reports identified; 281 assessed). There were no age, sex, gender, race and ethnicity, language, or study design restrictions. Two reviewers performed the selection of studies to be analyzed. Data Extraction and Synthesis: The Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline was followed. Data were extracted by 3 reviewers and pooled using random effects models. Hedges g effect sizes were computed. The Mixed-Methods Appraisal tool was used to assess study quality. Main Outcomes and Measures: Proximal outcomes were global positive symptoms, delusions, hallucinations, and cognitive biases. Distal outcomes were self-esteem, negative symptoms, quality of life, well-being, and functioning. Immediate and sustained outcomes were examined. Meta-regressions, subgroup, and sensitivity analyses assessed moderators. Results: This systematic review and meta-analysis included 43 studies (46 reports). Forty reports were synthesized in meta-analysis (N=1816 participants) and 6 reports were included in narrative review. In the studies examined, MCT was associated with positive symptoms (g = 0.50; 95% CI, 0.34-0.67), delusions (g = 0.69; 95% CI, 0.45-0.93), hallucinations (g = 0.26; 95% CI, 0.11-0.40), cognitive biases (g = 0.16; 95% CI, 0.03-0.29), self-esteem (g = 0.17; 95% CI, 0.03-0.31), negative symptoms (g = 0.23; 95% CI, 0.10-0.37), and functioning (g = 0.41; 95% CI, 0.12-0.69). These associations were maintained up to 1 year. The quality of life effect size was nonsignificant (g = 0.20; 95% CI, -0.07 to 0.47); only 1 study assessed well-being. Publication year was associated with moderated hallucinations (ß = 0.04; 95% CI, 0.00-0.07). Overall, narrative review results corroborated meta-analytic findings. Conclusions and Relevance: In this meta-analysis, MCT for psychosis was associated with benefits up to 1 year postintervention in several treatment contexts. These findings suggest that MCT may merit integration in treatment guidelines for schizophrenia.

Remote group therapies for cognitive health in schizophrenia-spectrum disorders: Feasible, acceptable, engaging.

Severe cognitive impairments and cognitive distortions are core to schizophrenia-spectrum disorders (SSDs) and are associated with deteriorated social functioning. Despite well-established efficacy of group psychosocial therapies targeting cognitive health in SSDs, dissemination of these programs remains limited. Remote delivery offers a promising strategy for increasing the programs' accessibility. Yet, little research has evaluated group therapies for cognitive health delivered in this way. Thus, we aimed to assess, from participants' and therapists' perspectives, the feasibility, acceptability, as well as levels and process of engagement in a videoconference delivery of group psychosocial therapies for SSD patients' cognitive health. Participants, outpatients, attended Action Based Cognitive Remediation or Metacognitive Training, both adapted for videoconference. Then, participants and therapists completed post-therapy questionnaires. Of the 28 participants attending at least one session, 75% completed more than half of sessions and seven dropped out. Technology did not appear to significantly hinder participation in the programs. All completing participants reported a positive experience with therapy, 67% were not bothered by the distance from the therapist, and 77% trusted that the information shared was kept confidential. Therapist-rated levels of attention M = 7.5/9 (SD = 1.04), participation M = 6.91/9 (SD = 1.32), and social interactions M = 5.31/9 (SD = 1.96) were satisfactory. Nonetheless, participants indicated that they would have appreciated more social interactions with group members. These positive results validate the earliest stage in the implementation process for remote group therapies targeting cognitive health in SSDs. Remote delivery promises to improve access to therapies targeting cognitive health and, ultimately, facilitate functional recovery for SSD patients.

Functional Impairments and Theory of Mind Deficits in Schizophrenia: A Meta-analysis of the Associations.

Schizophrenia is associated with major functioning difficulties. Theory of mind (ToM), the ability to infer the mental states of others, is an important determinant of functioning. However, the contribution of ToM to each specific domain of functioning remains to be better understood. The objectives of this meta-analysis were to document and compare the magnitude of the associations between ToM and (1) different domains of functioning (social functioning, productive activities, and instrumental activities of daily living), each assessed separately for functional performance and functional outcome and (2) different aspects of functioning (functional performance and functional outcome) in schizophrenia. Fifty-nine studies (N = 4369) published between 1980 and May 2019 targeting patients with schizophrenia or schizoaffective disorder aged between 18 and 65 years old were included. Studies were retrieved from seven databases. Correlations were extracted from the articles, transformed into effect sizes Zr and combined as weighted and unweighted means. The strength of the associations between the domains and aspects of functioning were compared using focused tests. A moderate association was observed between ToM and all domains of functioning, with a stronger association between ToM and productive activities compared with social functioning (only for functional outcome [χ2(2) = 6.43, P = 0.040]). Regarding the different aspects of functioning, a stronger association was observed between ToM and functional performance, compared with functional outcome, for overall functioning (χ2(1) = 13.77, P < 0.001) and social functioning (χ2(1) = 18.21, P < 0.001). The results highlight a stronger association of ToM with productive activities and with functional performance, which should be considered in future studies to improve functional recovery in schizophrenia.

[Psychosocial Interventions for People with a First-Episode Psychosis: A Narrative and Critical Review]. / Les interventions psychosociales destinées aux personnes composant avec un premier épisode psychotique : une revue narrative et critique.

Objective Treatment guidelines for the treatment of psychotic disorders suggest evidence-based interventions. These interventions target several domains such as self-management of clinical symptoms, social, familial and love relationships as well as cognitive functioning. However, these general guidelines do not provide specific evidence for people with a first-episode psychosis (FEP). The objective of this narrative and critical review is to present evidence supporting the interventions suggested by the treatment guidelines that were validated in people with a FEP, particularly those interventions validated in French. Method Based on the international and national treatment guidelines, a narrative and critical review of the scientific literature conducted in people with FEP and focusing on two recommended interventions for psychotic disorders, cognitive-behavioral therapy for psychosis (CBTp) and cognitive remediation (CR), was performed. Administration modalities adapted to the participant's profile are important to consider in this type of intervention. We thus explored two promising modalities in people with FEP, the group format and the use of digital technologies. Results Several studies support the use of CBTp in people with FEP, including one Quebec study. The effects of CR are less promising in people with FEP compared to those with a chronic evolution of their psychotic illness (e.g. schizophrenia). However, some limitations of the included studies are identified and the specific improvements in people with FEP are presented. Regarding the group format and the digital technologies, most interventions currently available need to be systematically validated, and the results need to be replicated by other groups of researchers to obtain evidence-based results. Conclusion This narrative and critical review of the literature highlights the evidence available for CBTp and CR in people with FEP. The group format used in several interventions with this population reveals encouraging results, while interventions using digital technologies have shown their acceptability and feasibility, but the efficacy remains to be assessed. In addition to contributing to symptomatic recovery, psychosocial interventions also support functional and personal recovery in people with FEP. Nonetheless, some limitations are observed regarding the accessibility of such interventions. While some interventions are currently not available in French, other available evidence-based interventions are not currently systematically used in clinical settings. These limitations call for the importance of developing an implementation science for these interventions to improve the transfer of results from research to clinical settings as well as a service organization model that promote or facilitate access to such interventions.

Understanding others as a mediator between verbal memory and negative symptoms in schizophrenia-spectrum disorder.

From the onset of schizophrenia, verbal memory (VM) deficits and negative symptoms are strongly associated, and both additively predict functional outcomes. Emotion recognition (ER) and theory of mind (ToM; the ability to infer others' mental states), two components of social cognition, are also particularly affected in schizophrenia. Explanatory models of negative symptoms have integrated these cognitive impairments as potential precursors and previous studies revealed relationships between ER and/or ToM and VM, as well as with negative symptoms, but the organization of these associations remains unclear. We aimed to determine whether impairments in VM and social cognition sequentially pave the way for negative symptoms in schizophrenia. To this end, we used mediation analyses. One hundred and forty participants with a diagnosis of schizophrenia or schizoaffective disorder were recruited. First, correlational analyses were conducted between our variables of interest. The mediating effect of social cognition between VM and negative symptoms was then examined using the PROCESS macro. Variables of interest were significantly correlated (r = |0.166| to |0.391|), except for ER and negative symptoms. Only the serial multiple mediation model with 2 mediators (ER followed by ToM) revealed a significant indirect effect of VM on negative symptoms (ß = - 0.160, 95% CI = -.370 to -.004). This relationship was selective for expressive negative symptoms (e.g., blunted affect and alogia). This study illustrates the richness of the relationship between cognitive deficits and negative symptoms and provides additional information for the involvement of social cognition in negative symptoms' etiology.

A meta-analysis of the associations between theory of mind and neurocognition in schizophrenia.

Theory of mind (ToM) refers to the ability to infer the mental states of others. ToM is impaired in schizophrenia and these deficits seem to hinder functional recovery. ToM is thus an important, but complex treatment target, supported by several processes. A large number of studies report significant associations between ToM and neurocognition (e.g. memory, attention), but the neurocognitive domains that are most closely linked to ToM remain to be identified. A meta-analysis was conducted to estimate the magnitude of the associations between ToM and neurocognition in people with schizophrenia. Correlations were extracted from the relevant literature, transformed into effect sizes Zr and pooled as weighted means. Focused-tests were employed to test for differences between neurocognitive domains and for differences linked to the characteristics of ToM tasks. Ninety-one studies (N = 5462) were included. Moderate associations emerged between ToM and each neurocognitive domain (Zrs 0.27-0.43), with no significant difference between domains (χ2(8) = 11.89, p = 0.156). Within the domain of executive functions, abstraction showed a stronger association with ToM (χ2(4) = 18.93, p = 0.001). Several ToM tasks characteristics (e.g. modality of stimuli, type of mental state), were significantly related to the magnitude of the associations between ToM and executive functions, visuospatial/problem solving, attention and episodic memory. These results suggest that ToM is linked to a wide range of neurocognitive abilities in schizophrenia, and that ToM tasks are a significant moderator of these associations. The assessment and treatment of ToM should consider the neurocognitive profile of each patient to understand his difficulties and to tailor interventions.

Reliability of two social cognition tests: The combined stories test and the social knowledge test.

Deficits in social cognition are common in psychiatric disorders. Validated social cognition measures with good psychometric properties are necessary to assess and target social cognitive deficits. Two recent social cognition tests, the Combined Stories Test (COST) and the Social Knowledge Test (SKT), respectively assess theory of mind and social knowledge. Previous studies have shown good psychometric properties for these tests, but the test-retest reliability has never been documented. The aim of this study was to evaluate the test-retest reliability and the inter-rater reliability of the COST and the SKT. The COST and the SKT were administered twice to a group of forty-two healthy adults, with a delay of approximately four weeks between the assessments. Excellent test-retest reliability was observed for the COST, and a good test-retest reliability was observed for the SKT. There was no evidence of practice effect. Furthermore, an excellent inter-rater reliability was observed for both tests. This study shows a good reliability of the COST and the SKT that adds to the good validity previously reported for these two tests. These good psychometrics properties thus support that the COST and the SKT are adequate measures for the assessment of social cognition.

Improving Theory of Mind in Schizophrenia by Targeting Cognition and Metacognition with Computerized Cognitive Remediation: A Multiple Case Study.

Schizophrenia is associated with deficits in theory of mind (ToM) (i.e., the ability to infer the mental states of others) and cognition. Associations have often been reported between cognition and ToM, and ToM mediates the relationship between impaired cognition and impaired functioning in schizophrenia. Given that cognitive deficits could act as a limiting factor for ToM, this study investigated whether a cognitive remediation therapy (CRT) that targets nonsocial cognition and metacognition could improve ToM in schizophrenia. Four men with schizophrenia received CRT. Assessments of ToM, cognition, and metacognition were conducted at baseline and posttreatment as well as three months and 1 year later. Two patients reached a significant improvement in ToM immediately after treatment whereas at three months after treatment all four cases reached a significant improvement, which was maintained through 1 year after treatment for all three cases that remained in the study. Improvements in ToM were accompanied by significant improvements in the most severely impaired cognitive functions at baseline or by improvements in metacognition. This study establishes that a CRT program that does not explicitly target social abilities can improve ToM.