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BackgroundCognitive remediation (CR) training has emerged as a promising approach to improving cognitive deficits in schizophrenia and related psychosis. The limited availability of psychological services for psychosis is a major barrier to accessing this intervention however. This study investigated the effectiveness of a low support, remotely accessible, computerised working memory (WM) training programme in patients with psychosis.MethodsNinety patients were enrolled into a single blind randomised controlled trial of CR. Effectiveness of the intervention was assessed in terms of neuropsychological performance, social and occupational function, and functional MRI 2 weeks post-intervention, with neuropsychological and social function again assessed 3–6 months post-treatment.ResultsPatients who completed the intervention showed significant gains in both neuropsychological function (measured using both untrained WM and episodic task performance, and a measure of performance IQ), and social function at both 2-week follow-up and 3–6-month follow-up timepoints. Furthermore, patients who completed MRI scanning showed improved resting state functional connectivity relative to patients in the placebo condition.ConclusionsCR training has already been shown to improve cognitive and social function in patient with psychosis. This study demonstrates that, at least for some chronic but stable outpatients, a low support treatment was associated with gains that were comparable with those reported for CR delivered entirely on a 1:1 basis. We conclude that CR has potential to be delivered even in services in which psychological supports for patients with psychosis are limited.

BackgroundRecent theories suggest that poor working memory (WM) may be the cognitive underpinning of negative symptoms in people with schizophrenia. In this study, we first explore the effect of cognitive remediation (CR) on two clusters of negative symptoms (i.e. expressive and social amotivation), and then assess the relevance of WM gains as a possible mediator of symptom improvement.MethodData were accessed for 309 people with schizophrenia from the NIMH Database of Cognitive Training and Remediation Studies and a separate study. Approximately half the participants received CR and the rest were allocated to a control condition. All participants were assessed before and after therapy and at follow-up. Expressive negative symptoms and social amotivation symptoms scores were calculated from the Positive and Negative Syndrome Scale. WM was assessed with digit span and letter-number span tests.ResultsParticipants who received CR had a significant improvement in WM scores (d = 0.27) compared with those in the control condition. Improvements in social amotivation levels approached statistical significance (d = −0.19), but change in expressive negative symptoms did not differ between groups. WM change did not mediate the effect of CR on social amotivation.ConclusionsThe results suggest that a course of CR may benefit behavioural negative symptoms. Despite hypotheses linking memory problems with negative symptoms, the current findings do not support the role of this cognitive domain as a significant mediator. The results indicate that WM improves independently from negative symptoms reduction.

BackgroundPeople with a diagnosis of schizophrenia have limited metacognitive awareness of their symptoms. This is also evident for cognitive difficulties when neuropsychological assessments and self-reports are compared. Unlike for delusions and hallucinations, little attention has been given to factors that may influence the mismatch between objective and subjectively reported cognitive problems. Symptom severity, and also self-esteem and social functioning, can have an impact on cognitive problem perception and help to explain the gap between objective and subjective cognitive assessments in psychosis.MethodOne-hundred participants with a diagnosis of schizophrenia were recruited and assessed with a comprehensive neuropsychological battery, a measure of awareness of cognitive problems and measures of psychotic symptoms, social and behavioural functioning and self-esteem. Regression was used to investigate the influence of symptoms, social functioning and self-esteem, and patients with different levels of cognitive problem awareness were contrasted.ResultsSimple correlation analysis replicated the lack of association between objective cognitive measures and metacognitive awareness of cognitive problems. However, the results of the regression analyses highlight that self-esteem and negative symptoms predict metacognitive awareness. When significant predictors were controlled, individuals with better awareness had more impaired working memory but higher IQ.ConclusionsPoor self-esteem and high negative symptoms are negatively associated with metacognitive awareness in people with schizophrenia. Interventions that aim to improve cognition should consider that cognitive problem reporting in people with schizophrenia correlates poorly with objective measures and is biased not only by symptoms but also by self-esteem. Future studies should explore the causal pathways using longitudinal designs.

BackgroundMoodscope is an entirely service-user-developed online mood-tracking and feedback tool with built-in social support, designed to stabilize and improve mood. Many free internet tools are available with no assessment of acceptability, validity or usefulness. This study provides an exemplar for future assessments.MethodA mixed-methods approach was used. Participants with mild to moderate low mood used the tool for 3 months. Correlations between weekly assessments using the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Assessment (GAD-7) with daily Moodscope scores were examined to provide validity data. After 3 months, focus groups and questionnaires assessed use and usability of the tool.ResultsMoodscope scores were correlated significantly with scores on the PHQ-9 and the GAD-7 for all weeks, suggesting a valid measure of mood. Low rates of use, particularly toward the end of the trial, demonstrate potential problems relating to ongoing motivation. Questionnaire data indicated that the tool was easy to learn and use, but there were concerns about the mood adjectives, site layout and the buddy system. Participants in the focus groups found the tool acceptable overall, but felt clarification of the role and target group was required.ConclusionsWith appropriate adjustments, Moodscope could be a useful tool for clinicians as a way of initially identifying patterns and influences on mood in individuals experiencing low mood. For those who benefit from ongoing mood tracking and the social support provided by the buddy system, Moodscope could be an ongoing adjunct to therapy.

BackgroundCognitive models suggest that auditory verbal hallucinations arise through defective self-monitoring and the external attribution of inner speech. We used a paradigm that engages verbal self-monitoring (VSM) to examine whether this process is impaired in people experiencing prodromal symptoms, who have a very high risk of developing psychosis.MethodWe tested 31 individuals with an At-Risk Mental State (ARMS) and 31 healthy volunteers. Participants read single adjectives aloud while the source and pitch of the online auditory verbal feedback was manipulated, then immediately identified the source of the speech they heard (Self/Other/Unsure). Response choice and reaction time were recorded.ResultsWhen reading aloud with distorted feedback of their own voice, ARMS participants made more errors than controls (misidentifications and unsure responses). ARMS participants misidentified the source of their speech as ‘Other’ when the level of acoustic distortion was severe, and misidentification errors were inversely related to reaction times.ConclusionsImpaired VSM is evident in people with an ARMS, although the deficit seems to be less marked than in patients with schizophrenia. Follow-up of these participants may clarify the extent to which the severity of this impairment predicts the subsequent onset of psychosis and development of positive symptoms.

BackgroundContinuity of care is considered by patients and clinicians an essential feature of good quality care in long-term disorders, yet there is general agreement that it is a complex concept. Most policies emphasize it and encourage systems to promote it. Despite this, there is no accepted definition or measure against which to test policies or interventions designed to improve continuity. We aimed to operationalize a multi-axial model of continuity of care and to use factor analysis to determine its validity for severe mental illness.MethodA multi-axial model of continuity of care comprising eight facets was operationalized for quantitative data collection from mental health service users using 32 variables. Of these variables, 22 were subsequently entered into a factor analysis as independent components, using data from a clinical population considered to require long-term consistent care.ResultsFactor analysis produced seven independent continuity factors accounting for 62.5% of the total variance. These factors,Experience and Relationship, Regularity,Meeting Needs,Consolidation,Managed Transitions,Care CoordinationandSupported Living, were close but not identical to the original theoretical model.ConclusionsWe confirmed that continuity of care is multi-factorial. Our seven factors are intuitively meaningful and appear to work in mental health. These factors should be used as a starting-point in research into the determinants and outcomes of continuity of care in long-term disorders.

Background. Complaints of poor memory and concentration are common in veterans of the 1991 Persian Gulf War as are other symptoms. Despite a large research effort, such symptoms remain largely unexplained.Method. A comprehensive battery of neuropsychological tests and rating scales was administered to 341 UK servicemen who were returnees from the Gulf War and peace keeping duties in Bosnia, plus non-deployed military controls. All were drawn from a large randomized survey. Most were selected on the basis of impaired physical functioning defined operationally.Results. Group comparisons revealed an association between physical functioning and symptoms of depression, post-traumatic stress reactions, increased anger and subjective cognitive failures. Poorer performance on some general cognitive measures, sequencing and attention was also seen in association with being ‘ill’ but virtually all differences disappeared after adjusting for depressed mood or multiple comparisons. Deployment was also associated with symptoms of post-traumatic stress and subjective cognitive failures, independently of health status, as well as minor general cognitive and constructional impairment. The latter remained significantly poorer in the Gulf group even after adjusting for depressed mood.Conclusions. Disturbances of mood are more prominent than quantifiable cognitive deficits in Gulf War veterans and probably lead to subjective underestimation of ability. Task performance deficits can themselves be explained by depressed mood although the direction of causality cannot be inferred confidently. Reduced constructional ability cannot be explained in this way and could be an effect of Gulf-specific exposures.

BackgroundCognitive remediation (CR) preceding cognitive–behavioural therapy for psychosis (CBTp) was trialled within routine clinical services, with the hypothesis that following first-episode non-affective psychosis CR would enhance CBTp efficacy by improving neuropsychological performance.MethodA total of 61 patients with DSM-IV non-affective psychoses waiting for routine CBTp were randomized to computerized CR over 12 weeks, supported by a trained support worker, or time-matched social contact (SC). Primary outcome was the blind-rated Psychotic Symptoms Rating Scale (PSYRATS). Secondary outcomes included measures of CBTp progress, cognition, symptoms, insight and self-esteem: all at baseline, after CR (12 weeks) and after CBTp (42 weeks). PSYRATS and global neuropsychological efficacy were tested using mixed-effects models with a group × time interaction term. Measures of CBTp progress and some neuropsychological measures were modelled by regression.ResultsThere was no significant difference between the CR and SC groups in PSYRATS (group × time coefficient 0.3, 95% confidence interval −0.4 to 1.1, p = 0.39). However, after CR CBTp was shorter [median 7 sessions, interquartile range (IQR) 2–12 after CR; median 13, IQR 4–18 after SC; model p = 0.011] and linked to better insight (p = 0.02). Global cognition did not improve significantly more after CR (p = 0.20) but executive function did (Wisconsin Card Sort, p = 0.012).ConclusionsCBTp courses preceded by CR were far shorter but achieved the same outcome as CBTp preceded by an active control, consistent with neuropsychological improvement enhancing CBTp. CR was delivered by staff with minimal training, offering the potential to reduce the costs of CBTp considerably.

SYNOPSISThis paper describes the second stage (years 4, 5 and 6) of a prospective follow-up of a sample of chronic patients which was designed to investigate the in service use. It also tested the relative predictive power of variables which included demographic, symptomatic and behavioural factors as well as a novel reaction time variable which reflects response processing time.During the six years of the study 91% of the patients in the sample changed either the degree of their day and/or night care. Many moved to more independence but, a number did also become more dependent on psychiatric services. There were no differences in outcome between a schizophrenic group and patients with other diagnoses. These results suggest a level of flexibility in outcome even in a severely disabled chronic group.The main predictor of future service use at each stage of the follow-up for the whole group was chronicity at entry to the study. But, when the group was divided into schizophrenic patients and ‘others’, the response processing measure was a significant predictor of service use in the schizophrenic group and accounted for between 17% and 30% of the variance. For the ‘other’ diagnostic group, the age of the patient seemed to be the major determinant of care.The reaction time variable seems to be an extra class correlate of a strict diagnosis of schizophrenia. It may also be a stable or episodic vulnerability factor, but as well as these promising hypotheses, which have yet to be justified, this measure does seem to have pragmatic value in predicting outcome in a rehabilitation network.

SynopsisSince 1977 there have been two major developments in the provision of services for the ‘new‘ long-stay in Camberwell – a hospital-hostel and an associated supervised group-home. This paper looks at the impact of these services over a 5-year period on a group of patients who fulfilled the ‘new’ long-stay criteria at the end of 1977. Both services appear to be extremely successful in containing such disabled patients. The results suggest that some improvements in patients' handicaps can be achieved and that some patients can be discharged with intensive psychiatric support. Excluding those patients in Special Hospitals, only one person was discharged to and has remained in unsupervised accommodation within the 5-year period.

Disturbances of speech are one of the most obvious signs, in an acute episode, of schizophrenia.Most psychopathologists have regarded these disturbances as an indication of an underlying dis-order of thought. It was hoped, therefore, that the study of schizophrenic language would notonly provide a measure of its deviance but would also throw some light on the construct 'schizo-phrenia' itself Unfortunately. , the progress of research has been very slow due, in part, to thefact that clinically relevant data, such as other symptoms, have not been taken into account inthe design of experiments. There have been several general reviews of the literature (Pavy, 1968;Maher, 1972), so the present essay will deal chiefly with very recent work.Is the schizophrenic speaker/listener, for the most part, an adequate user of language? A fewyears ago the answer was that schizophrenics differ markedly from normals in their ability toutilize the syntactic and semantic constraints of language (Maher, 1972). This view has oftenarisen from a lack of comparison with normal speech production. For instance, Chaika (1974)based her theory of schizophrenic language on the speech errors made by schizophrenics. Thesespeech errors are, however, not unique to schizophrenics; not only are they produced by normalspeakers (Fromkin, 1975), but they are also produced by the previous personnel of the WhiteHouse (Gold, 1974).The first study to suggest that schizophrenic listeners are aware of syntactic and semanticconstraints was carried out by Gerver (1967). He showed that both schizophrenics and normalswere better at recalling semantically and syntactically correct sentences than random strings ofwords. The increase was at least as large in his chronic schizophrenic sample as it was for thenormals. Recent studies have replicated this result and extended it further, using other paradigms(Truscott, 1970; Rochester et al. 1973; Carpenter, 1976).If the formal rules of language are used properly, why are conversations with acute schizophrenicsso difficult to follow? One suggestion has been that schizophrenic speech does not contain enoughredundancy. This hypothesis has led to much fruitless research using the cloze procedure, a techniquebased on guessing deleted words from the transcripts of speech. Some researchers have shownthat schizophrenic speech is less redundant than normal, i.e. it is more difficult to guess the missingwords (Salzinger et al. 1964; Silverman, 1972). Others, however, have not shown this difference(Rutter et al. 1975, 1977, 1978). There are many possible reasons for this discrepancy, the mostlikely being differences in the way patient samples are drawn. Recently, Manschrek et al. (1979)have shown that the speech of 'thought disordered' schizophrenics was significantly less predictablethan 'non-thought disordered' schizophrenics. A non-significant difference between schizophrenicand normal samples when using the cloze technique may simply mean that there were few thoughtdisordered patients in the schizophrenic sample. A tentative conclusion from all this research isthat a lack of redundancy is not a defining feature of schizophrenic language in general, but thatit may be characteristic of the speech of those schizophrenic patients who have marked thoughtdisorder.Other variables which might characterize schizophrenic speech, such as loose associations anddisruptive clauses, have also been investigated (e.g. Siegel et al. 1976; Rochester et al. 1977), butthese variables too cannot be considered as defining features of schizophrenic speech. Rochesterand her colleagues (1977) showed that, even in the most severely thought-disordered group, thespeech of 80 % of the patients contained very few clauses that could be defined as disruptive.If the deviancy of schizophrenic language does not lie in an inability to link words together, itmust lie elsewhere. One possibility is that the speaker is violating the rules of communication

SynopsisThe Social Behaviour Schedule (SBS) was examined as a measure of disability in a series of 66 chronic psychiatric patients, who were also assessed using the Social Role Performance Schedule (SRP) and the ninth edition of the Present State Examination (PSE). All three schedules have been used in previous studies in their present form. SBS and SRP measures were correlated with each other and neither showed any relationship with subjectively described current PSE symptoms. SBS deficit was associated with a clinical diagnosis of schizophrenia and with problems in supervised occupational activity. Long-term hospital residents showed greater SBS deficit than chronic patients in active rehabilitation programmes, although impaired SRP was the major correlate with the type of supervision provided. SRP measures can be compared with population norms, unlike measures derived from the SBS, which cover more severe ranges of disability.

SYNOPSISIn general, linguistic analyses have not proved useful to psychiatrists because of their complexity and their inability to differentiate between diagnostic groups. However, cohesion analyses of disordered speech seem to offer both a simple and potentially useful tool for clinical diagnosis. This study was designed to test whether psychiatrists can use the rudiments of this analysis in order to differentiate between two diagnostic groups, manics and schizophrenics.