Search

BACKGROUND: Physical exercise (PE) is a safe, non-stigmatizing, and side-effect free intervention that has the potential to mitigate neurocognitive dysfunction in psychosis, as well as reduce anxiety and paranoia. Developing and promoting PE programs for people with SMI in the community where participants cannot be paid to participate requires an interdisciplinary approach to activate motivation for exercise. We report the initial development and pilot results of a PE community program developed to enhance motivation and engagement in adults with schizophrenia, merging expertise from the fields of exercise physiology, recreational therapy, virtual reality (VR) gaming technology, and neuropsychiatric rehabilitation. METHODS: Adult outpatients diagnosed with schizophrenia (N=29) were enrolled in 18 hours (40 min session, 3x/week for 3 months) of exergaming. Exergaming uses interactive exercise equipment connected to a computer and monitor so the patient is engaged in a virtual game while exercising. For example, while pedaling on an exergaming stationary bike, the can have the experience of racing or biking through the countryside, either using a virtual reality headset or simply looking at the monitor. The PE regimen was tailored for each participant based on input from a (1) exercise physiologist about optimal methods to achieve volitional exhaustion and reduce the risk for injury, (b) recreational therapist who set up the overall exercise milieu to promote enjoyment, (c) expert in VR technology who calibrated and tailored the virtual experience to each participant (d) psychiatrist who monitored medical risk for strenuous exercise, and (d) psychologist who collected outcome data. Cognition and symptoms were assessed at baseline and post (3 mo.) while motivation and treatment engagement were recorded biweekly. RESULTS: Large effects were seen in working memory from baseline to post (WASI WMI; ES=.53), with medium effects in overall symptoms (PANSS; ES=.30). Importantly, participants reported a high degree of motivation for PE throughout the treatment period (Intrinsic Motivation Inventory total score>35), and 27 out of 29 completed the entire PE regimen of 18 hours although they were not paid to attend. CONCLUSIONS: This study highlights the potential benefits of a PE program developed by an interdisciplinary team combing expertise in exercise, technology, recreation, and neuropsychiatry. Drawing from experience in other fields may help develop new treatments in psychiatric rehabilitation to maximize overall outcome. Funded by a Hartford Hospital Auxiliary Special Projects Grant to JC

BACKGROUND: A growing body of research shows that cognitive remediation (CR) consisting of drill-and-practice and/or strategy training targeted at neurocognitive functions produces small-to-moderate improvements in neurocognition that are durable and generalize to psychosocial function when CR is provided with other rehabilitation interventions (Wykes et al., 2011; Prikken et al., 2018). Despite these positive group findings, results to date reveal substantial individual differences in response to CR interventions. For example, one summary of three CR trials found improvement rates for a mixed group of psychiatric patients that ranged between 40 and 69% for individuals (Medalia and Richardson, 2005). This finding emphasizes the need of determining factors that predict a strong response to CR to effectively match patients to efficacious treatments. METHODS: The current study is a secondary data analysis from two separate, randomized, controlled trials (Kurtz et al., 2007; 2015) that revealed improvements in working memory in response to an extended (6-month), standardized, computer-assisted cognitive remediation intervention when compared to an active, computer-skills control condition. We investigated the relationship between demographic factors (age, education, duration of illness), hours of CR treatment, cognitive skills (crystallized verbal ability, visual sustained attention, verbal learning and memory, and problem-solving), and symptoms (total positive and negative symptoms and general symptoms) measured at study entry, to improvements in working memory skills across these two RCTs. RESULTS: Results from 58 people with chronic schizophrenia randomly assigned to the CR condition in these two studies (mean age=34.1 years, SD=12.0; mean duration of illness=10.2 years, SD=10.3) revealed that baseline visual sustained attention (partial r=-.30, p=.05) and number of hours of training (partial r=.27 p=.05) predicted end of trial working memory scores with baseline working memory scores held constant. CONCLUSIONS: These findings will be evaluated with respect to other studies of prediction of response to CR.

Given the high rates of treatment disengagement and medication nonadherence in individuals with schizophrenia spectrum disorders and early psychosis, fostering a strong alliance in treatment is critical. Moreover, the role of the therapeutic alliance extends beyond that in traditional psychotherapy because of the multifaceted nature of treatment. Thus, this review provides a comprehensive discussion of the relationship between the alliance and client variables across various provider types and individual treatments. This review summarizes existing research on (a) client correlates/predictors of the therapeutic alliance and on (b) the relationship between the alliance and client treatment outcomes in individual treatment for schizophrenia spectrum disorders and early psychosis. Parallel literature searches were conducted using PubMed and PsycINFO databases, which yielded 1202 potential studies with 84 studies meeting inclusion criteria. With regard to correlates/predictors, the existing evidence suggests that better insight, medication adherence, social support, and recovery variables were related to better client-rated alliance. Better medication adherence and recovery variables as well as less severe symptoms were related to better provider-rated alliance. In terms of alliance-outcome relationships, evidence suggests that a strong provider-rated alliance was predictive of improved functioning and medication and treatment adherence. There was some limited evidence that better client-rated alliance was related to improved recovery outcomes. Despite mixed results and heterogeneity among studies, this review suggests that a strong alliance can be beneficial in individual schizophrenia treatment. Thus, training and supervision of providers should emphasize developing a positive alliance, particularly with clients for whom developing an alliance may be difficult.

We sought to determine whether the exposure to the sub-concussive blows that occur during division III collegiate collision sports affect later life neurobehavioral quality-of-life measures. We conducted a cross-sectional study of alumni from four division III colleges, targeting those between the ages of 40-70 years, using several well-validated quality-of-life measures for executive function, general concerns, anxiety, depression, emotional and behavior dyscontrol, fatigue, positive affect, sleep disturbance, and negative consequences of alcohol use. We used multivariable linear regression to assess for associations between collision sport participation and quality-of-life measures while adjusting for covariates including age, gender, race, annual income, highest educational degree, college grades, exercise frequency, and common medical conditions. We obtained data from 3702 alumni, more than half of whom (2132) had participated in collegiate sports, 23% in collision sports, 23% in non-contact sports. Respondents with a history of concussion had worse self-reported health on several measures. When subjects with a history of concussion were removed from the analyses in order to assess for any potential effect of sub-concussive blows alone, negative consequences of alcohol use remained higher among collision sport athletes (β-coefficient 1.957, 95% CI 0.827-3.086). There were, however, no other significant associations between exposure to collision sports during college and any other quality-of-life measures. Our results suggest that, in the absence of a history of concussions, participation in collision sports at the Division III collegiate level is not a risk factor for worse long-term neurobehavioral outcomes, despite exposure to repeated sub-concussive blows.

Recent advances in psychosocial treatments for schizophrenia have targeted social cognitive deficits. A critical literature review and effect-size (ES) analysis was conducted to investigate the efficacy of comprehensive programs of social cognitive training in schizophrenia. Results revealed 16 controlled studies consisting of seven models of comprehensive treatment with only three of these treatment models investigated in more than one study. The effects of social cognitive training were reported in 11/15 studies that included facial affect recognition skills (ES = .84) and 10/13 studies that included theory-of-mind (ES = .70) as outcomes. Less than half (4/9) of studies that measured attributional style as an outcome reported effects of treatment, but effect sizes across studies were significant (ESs = .30–.52). The effect sizes for symptoms were modest, but, with the exception of positive symptoms, significant (ESs = .32–.40). The majority of trials were randomized (13/16), selected active control conditions (11/16) and included at least 30 participants (12/16). Concerns for this area of research include the absence of blinded outcome raters in more than 50% of trials and low rates of utilization of procedures for maintaining treatment fidelity. These findings provide preliminary support for the broader use of comprehensive social cognitive training procedures as a psychosocial intervention for schizophrenia.

BackgroundA growing number of studies have investigated the efficacy of novel, adjunctive pharmacotherapies for treatment of cognitive deficits in schizophrenia with conflicting results.AimsTo investigate the comparative efficacy of these agents on cognition and symptoms in schizophrenia, and to identify promising cognitive domains and candidate medications that can be incorporated in treatment trials combined with cognitive remediation to maximise treatment effects.MethodA total of 26 double-blind, placebo-controlled studies investigating medications targeted at cholinergic, glutamatergic or serotonergic receptor classes and with participants with schizophrenia or schizoaffective disorder were identified.ResultsMedications targeted at the cholinergic receptor class produced marginal improvements in verbal learning and memory (d = 0.23, P = 0.06), and donepezil, a specific type of cholinergic agonist, produced a moderate effect (d = 0.58) on spatial learning and memory. Cholinergic and glutamatergic agents produced moderate effect-size improvements on negative symptoms (d = 0.54 and d = 0.62 respectively), and small effect-size improvements on general symptoms (d = 0.46 and d = 0.41 respectively). Serotonergic agents produced small effect-size improvements in positive symptoms (d = 0.33).ConclusionsCholinergic medications produced marginal improvement in verbal learning and memory and moderate improvements on spatial learning and memory, although there was no evidence to support the use of glutamatergic or serotonergic medications as a stand-alone treatment for improving cognitive function. Cholinergic and glutamatergic agents improved negative and general symptoms, whereas serotenergic medications improved positive symptoms.

Social-skill deficits are pervasive in schizophrenia and negatively impact many key aspects of functioning. Prior studies have found that measures of elementary neurocognition and social cognition are related to social-skills. In the present study we selected a range of neurocognitive measures and examined their relationship with identification of happy and sad faces and performance-based social-skills. Fifty-three patients with schizophrenia or schizoaffective disorder participated. Results revealed that: 1) visual vigilance, problem-solving and affect recognition were related to social-skill; 2) links between problem-solving and social-skill, but not visual vigilance and social-skill, remained significant when estimates of verbal intelligence were controlled; 3) affect recognition deficits explained unique variance in social-skill after neurocognitive variables were controlled; and 4) affect recognition deficits partially mediated the relationship of visual vigilance and social-skill. These results support the conclusion that facial affect recognition deficits are a crucial domain of impairment in schizophrenia that both contribute unique variance to social-skill deficits and may also mediate the relationship between some aspects of neurocognition and social-skill. These findings may help guide the development and refinement of cognitive and social-cognitive remediation methods for social-skill impairment.

A growing body of literature has shown that neurocognitive deficits in schizophrenia account for 20-60% of the variance in measures of outcome, and in many studies are more closely related to outcome than symptoms [Green, M.F., Kern, R.S., Braff, D.L., Mintz, J., 2000. Neurocognitive deficits and functional outcome in schizophrenia: are we measuring the "right stuff"? Schizophr. Bull. 26(1), 119-136; Green, M.F., Kern, R.S., Heaton, R.K., 2004. Longitudinal studies of cognition and functional outcome in schizophrenia: implications for MATRICS. Schizophr. Res. 72(1), 41-51]. Most of these studies have been cross-sectional, few longitudinal studies have investigated the degree to which neurocognition and symptoms predict ability to benefit from outpatient rehabilitation, and no longitudinal studies use measures of everyday life skills that are performance-based. In the current study we investigated the relationship between five measures of neurocognitive function, crystallized verbal ability, visual sustained vigilance, verbal learning, problem-solving, and processing speed, and two measures of symptoms, total positive and negative symptoms, and change on a performance-based measure of everyday life skills after a year of outpatient rehabilitation. Rehabilitation consisted of both psychosocial and cognitive interventions. Forty-six patients with schizophrenia or schizoaffective disorder were studied. Results of a linear regression model revealed that verbal learning predicted a significant amount of the variance in change in performance-based measures of everyday life skills after outpatient rehabilitation, even when variance for all other variables in the model was accounted for. Measures of crystallized verbal ability, sustained visual vigilance, problem-solving, processing speed and symptoms were not linked to functional status change. These findings emphasize the importance of verbal learning for benefiting from psychosocial and cognitive rehabilitation interventions, and suggest the development of alternative rehabilitation strategies for those who do not benefit.

Performance on a novel, virtual reality (VR) assessment of medication management skills, the Virtual Reality Apartment Medication Management Assessment (VRAMMA), was investigated in 25 patients with schizophrenia and 18 matched healthy controls. The VRAMMA is a virtual 4-room apartment consisting of a living room with an interactive clock and TV, a bedroom, a kitchen, and a bathroom with an interactive medicine cabinet. After an exploratory phase, participants were given a mock prescription regimen to be taken 15 minutes later from pill bottles located in the medicine cabinet in the bathroom of the virtual environment. The VRAMMA was administered with a validated measure of medication management skills, several neurocognitive tests, and a symptom scale. Results revealed that (1) schizophrenic patients made significantly more quantitative errors in the number of pills taken, were less accurate at taking the prescribed medications at the designated time, and checked the interactive clock less frequently than healthy controls; (2) in patients with schizophrenia, there was significant agreement in classification of adherence vs nonadherence between a validated measure of medication management skills and the VRAMMA; and (3) in patients with schizophrenia, years of education and a measure of verbal learning and memory were linked to quantitative errors on the VRAMMA, while positive symptoms, specifically delusional symptoms, were inversely linked to distance traveled within the VRAMMA. This is the first study, to our knowledge, to provide evidence for the utility of VR technology in the assessment of instrumental role functioning in patients with schizophrenia.