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Individuals with schizophrenia (SCZs) demonstrate social cognitive (SC) deficits across a variety of social cognitive tasks: affect recognition, social perception, Theory-of-Mind (ToM), and attributional style. These tasks all use socially-relevant words, social scenarios, clothing, faces and voices that may make their application to different cultural contexts problematic. However a paucity of research has investigated the cross-cultural validity of SC measures. We meta-analyzed the literature investigating differences in social cognitive skills SCZs and matched healthy controls (NCs) across different regions of the world using a group of expert-selected, standardized measures of social cognition. Studies of SC in SCZ using these measures published between January 1980 and August 2020 were evaluated. Data were extracted independently by 3 reviewers with excellent reliability; 156 unique studies of 10,235 SCZs and 9924 NCs across 34 countries were identified. Random effects models revealed SCZs demonstrated poorer performance in all domains of SC including emotion processing (g = -0.770), social perception (g = -0.880), ToM (g = -1.090), attributional style (hostility: g = -0.715, aggression: g = -0.209, blame: g = -0.322), as well as a measure of emotion regulation (g = -0.867). Hostile attributional style was more pronounced in European and North American samples (g = 1.054 and g = -0.605, respectively) compared to Asian samples (g = -0.284). Our results revealed that SCZs performed mildly-severely worse than HCs in all domains of SC. With the exception of hostile attributional style, the magnitude of deficits in social cognition was consistent across the globe.

OBJECTIVES This meta-analysis was designed to assess the effects of social-cognitive training (SCT) and whether study quality, treatment approach, treatment context, and sample characteristics influence these effects. METHODS Electronic databases were searched up to 5 August 2020 using variants of keywords: 'social cognition', 'training', 'rehabilitation', 'remediation', and 'schizophrenia'. Methodological moderators were extracted through the Clinical Trials Assessment Measure and verified by authors. This study was pre-registered on PROSPERO (CRD42020154026). RESULTS Forty-two controlled trials with 1,868 participants were identified. The meta-analysis revealed moderate effects on emotion recognition, mental state attribution, and social perception. No significant effects were evident on psychiatric symptoms or social functioning. A small signal was evident for the generalization of treatment gains to executive function. Moderator analyses revealed that studies of lower methodological quality reported larger effects, and samples with lower mean years of education were associated with larger effects of SCT on mental state attribution. Treatment effects did not differ by other moderator variables such as treatment context and intervention types. CONCLUSIONS SCT benefits people with schizophrenia on a variety of social-cognitive outcomes. Differences in baseline symptoms, gender distribution, antipsychotic medication dose, IQ, and other sample features did not create barriers to treatment benefits. Future studies should aim to enhance the generalization of training effects on broader clinical outcomes.

There is increasing interest from treaters and patients alike in subjective quality-of-life (sQOL) and objective psychosocial function as indices of treatment outcome in studies of schizophrenia. With the emergence of evidence-based treatment protocols (e.g., NIMH-funded Recovery after Initial Schizophrenia Episode Initiative) these outcomes are of particular significance in treatment studies of samples early in the course of their illness. Few studies have investigated demographic, clinical and cognitive factors associated with sQOL in samples early in the course of their illness and compared these factors to objective measures. We administered measures of sQOL or satisfaction with life, and objective psychosocial function to 59 people with schizophrenia within 5-years of diagnosis, along with standardized measures of symptoms and cognition. Results revealed that symptoms, rather than cognitive or demographic variables, were the best independent predictors of both subjective QOL and objective functioning. Positive symptoms were independent predictors of sQOL, while positive and negative symptoms were independent predictors of objective psychosocial status. Depression and cognition were also linked to sQOL. These findings point to the importance of attending to residual positive symptoms early in the treatment of schizophrenia as a means of possibly enhancing both subjective and objective outcome in early course schizophrenia.

The number of randomized, controlled studies of cognitive remediation (CR) for schizophrenia, a therapeutic approach designed to improve cognitive skills and function, has grown substantially over the past 20 years. Active elements of CR treatment, however, remain unknown. The current meta-analysis investigated treatment, study, and participant factors in the size of observed treatment effects. Electronic databases were searched up to May 2020 using variants of the key words “cognitive remediation,” “clinical trials,” and “schizophrenia.” This search produced 73 unique, randomized, controlled trials. Data were independently extracted by 3 reviewers with excellent reliability. Random-effects models were used to assess primary cognitive and secondary symptom and functional outcomes. Moderator analyses investigated the role of a variety of treatment, study, and participant factors. The meta-analysis (4594 participants) revealed that CR produced significant small-to-moderate size improvements in all domains of cognition studied (Hedge’s gs = .19–.33). and a significant small improvement in function (Hedge’s g = .21). CR programs that included a discussion (“bridging”) group to help apply acquired cognitive skills to everyday life produced larger effects on global cognition and verbal memory. CR programs with strategy-coaching produced larger effects on episodic memory. Sample age, gender, positive, negative, and overall symptoms, and medication dose did not serve as barriers to treatment gains. CR produces small-to-moderate improvements in cognition and function in schizophrenia. Programs of CR that utilize bridging groups and strategy-coaching are more cognitively potent. Future research should focus on ways to modify CR to bolster generalization of cognitive improvements to function.

The therapeutic alliance, or client-provider relationship, has been associated with better treatment engagement and outcomes for persons with schizophrenia-spectrum disorders (SSDs) and early psychosis in some studies, but not others. We conducted a meta-analysis of the research on alliance in SSDs and early psychosis across a range of interventions and outcomes. Parallel literature searches were conducted in PubMed and PsycINFO databases for articles between inception and 6/11/2020. English-language studies were included if they evaluated the relationship between alliance and a prospective outcome (treatment engagement, medication adherence, functioning, or total, positive, negative, or depressive symptoms) in an individual clinical treatment for SSDs/early psychosis and contained analyzable data. Correlations and partial correlations were meta-analyzed with random effects models to calculate mean across-study correlations and to carry out subsequent homogeneity and moderator variable analyses. Fourteen studies consisting of 2968 participants that assessed six outcomes across six psychosocial treatments were included. Results indicated that better client-rated (r = 0.20) and other-rated (i.e., provider- or observer-rated; r = 0.25) alliance were associated with better treatment engagement. Treatment type and sample race/ethnicity, but not age, gender, or timing of alliance rating moderated the association between other-rated alliance and engagement. Further, better other-rated alliance was related to improvements in positive (r = -0.14) and negative (r = -0.22) symptoms. A strong therapeutic alliance is important for both engaging clients with SSDs and early psychosis in treatment and facilitating improvements in positive and negative symptoms. Delivery and monitoring of treatments for this population should include assessment of the therapeutic alliance from multiple perspectives.

Mounting evidence has indicated that early intervention leads to improved clinical and functional outcomes for young persons experiencing recent onset psychosis. As part of a large early detection campaign, the present study aimed to investigate subjective experiences during the duration of untreated psychosis (DUP), or time between psychosis onset and treatment contact. Participants were 10 young adults participating in early intervention services for psychosis. After DUP was estimated during standardized baseline assessment, participants engaged in qualitative interviews focused on their life experiences prior to treatment and leading up to the present. Mixed methods data analyses compared standardized DUP estimates with participants’ subjective narratives. Findings revealed that participants experienced and conceptualized a longer trajectory of subjective difficulties (TSD) beginning before and extending beyond standardized DUP estimates. Participants emphasized striving for independence and social belonging. The majority of participants reported benefiting from their current services and believed that earlier support of some kind would have been beneficial. These findings support previous research on subjective barriers to early detection and treatment seeking in young adults experiencing psychosis. Implications and future research directions include further efforts to differentiate the struggles unique to early psychosis from psychosocial risk factors and other challenges of young adulthood.

In high-income countries a wealth of studies has revealed cognitive and social cognitive deficits in schizophrenia and a close relationship of these deficits to psychosocial functioning. Studies examining these illness features in middle and low-income countries are rare, particularly in early-stage samples. Sixty adult participants within 5 years of diagnosis with schizophrenia and 53 matched, healthy control were assessed with the MATRICS Consensus Cognitive Battery and the PEAT emotion identification task at study entry, and the WHODAS functioning scale one year later. Deficits on cognitive instruments ranged from d = 0.64–1.04 and were consistent with those reported in Western samples. Negative symptoms were linked to function longitudinally. Deficits in social cognitive skills and longitudinal links between cognition and functioning were not evident. These findings suggest a highly consistent magnitude of neurocognitive deficits in people with schizophrenia across widely varying cultures, but with limited evidence of social cognitive skill deficits using Western-based instruments. There was little evidence of a relationship between cognition and psychosocial disability in people with early-stage schizophrenia in this sample.

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.

Background and aims Deficits in cognitive function are observed during nicotine withdrawal and present a challenge to successful smoking cessation. This clinical trial evaluated a cognitive exercise training (CT) program to improve smoking cessation rates. Methods Adult treatment-seeking smokers (n = 213) were randomized to receive nicotine patch therapy and 12 weeks of either computerized CT or computerized relaxation (control) training. Smoking status was biochemically verified at the end of treatment and 6-month follow-up. Results Quit rates did not differ by treatment arm at either time-point, nor were there effects on withdrawal symptoms or smoking urges. Reaction time for emotion recognition and verbal interference tasks showed improvement in the CT group. When including only successful quitters, improvements in recognition memory, verbal interference accuracy, and attention switching error rate were also observed in the CT group, while commission errors on the continuous performance task decreased in the control group. Conclusions Despite modest changes in cognitive performance, these results do not support the efficacy of computerized cognitive training as an adjunctive therapy for smoking cessation.

While a wealth of studies have evaluated cross-sectional links between cognition and functioning in schizophrenia, few have investigated the relationship between change in cognition and change in functioning in the context of treatment trials targeted at cognition. Identifying cognitive skills that, when improved, predict improvement in functioning will guide the development of more targeted rehabilitation for this population. The present study identifies the relationship between change in specific cognitive skills and change in functional ability during one year of cognitive rehabilitation. Ninety-six individuals with schizophrenia were assessed with a battery of cognitive measures and a measure of performance-based functioning before and after cognitive training consisting of either drill-and-practice cognitive remediation or computer skills training. Results revealed that while working and episodic memory, problem-solving, and processing speed skills all improved during the trial, only improved working memory and processing speed skills predicted improvement in functional ability. Secondary analyses revealed these relationships were driven by individuals who showed a moderate level (SD≥0.5) of cognitive improvement during the trial. These findings suggest that while a variety of cognitive skills may improve during training targeted at cognition, only improvements in a subset of cognitive functions may translate into functional gains.

Aim Schizophrenia and 22q11.2 deletion syndrome (22q11DS) share similar patterns of cognitive deficits. Up to 30% of those with 22q11DS develop schizophrenia during early adulthood. As cognitive decline has recently been found to predict onset of psychosis in adolescents with 22q11DS, early interventions such as cognitive remediation (CR) during adolescence are warranted. This paper investigates the durability of a remote, computerized, CR programme for youth with 22q11DS. Our aim was to determine if the positive effects of CR persisted 6 months beyond intervention completion. Methods A longitudinal design with 21 participants serving as their own controls was used. Youth were seen for neurocognitive assessments at pre-treatment, after the targeted 8-month intervention, at post-treatment, and 6 months after for follow-up. During the intervention, cognitive coaches met remotely with participants for CR via video conferencing three times a week, and offered task-specific strategies. To determine if intervention improvements held across the 6-month follow-up period, neurocognitive measures were statistically examined with repeated measures analysis of variances from pre-treatment through follow-up. Results Our CR intervention proved durable. Post-treatment improvements comprising cognitive flexibility, executive function, reaction time and working memory were maintained over the follow-up period. Conclusions Results confirm previous research regarding the durability of CR treatment and extend these findings to youth with 22q11DS. The present study may serve to inform early intervention efforts focused on cognitive and functionally relevant rehabilitation goals for youth with 22q11DS and suggests that 22q11DS can potentially serve as a suitable model for examining the trajectory preceding psychosis.

Conceptually, motivation can be separated into two types, intrinsic and extrinsic. Intrinsic motivation involves goal-directed behaviors that meet internal psychological needs, while extrinsic motivation involves behaviors executed to obtain external reward or avoid punishment. Both these types of motivation are diminished in psychosis and are linked to amotivation and anhedonia, two of the negative symptoms seen in schizophrenia. In the last several years, the field of motivation research has advanced by (a) developing better instruments to quantify intrinsic motivation, (b) studying the role of effort in evaluating the importance of rewards, (c) examining the neurobiological and behavioral correlates of deficits in learning from feedback, and (d) honing neurophysiologic and behavioral interventions to directly target motivation impairments. In this review, we examine each of the above topics and comment on how our current understanding of motivation may inform the development and testing of new interventions to optimize psychiatric recovery.

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.

On average, cognitive remediation (CR) is effective in improving cognitive function in individuals with psychosis, though there is considerable variability in treatment response. No consensus has emerged to date about the potential influence of patient and illness characteristics on CR efficacy. In the current analyses, we examined baseline demographic, cognitive, clinical, and functional ability variables as potential moderators of cognitive improvements during a randomized, controlled trial of a hybrid drill-and-practice plus strategy training CR intervention.In an attempt to disentangle non-specific vs. CR specific treatment effects, we separately examined potential predictors of cognitive improvement in individuals who received CR versus those in the control condition. Cognitive gains were predicted by a large array of demographic, symptom and cognitive variables, however this was true both in the CR and the control condition. CR-specific cognitive improvement was associated with more severe course of illness as indexed by higher number of hospitalizations, with poorer baseline cognition, and with less severe baseline negative symptoms. Keywords: Psychosis, Schizophrenia, Cognitive remediation, Moderators, Treatment outcome

Cognitive impairment affects more than half of persons with multiple sclerosis (PwMS), and it is associated with difficulties in multiple aspects of daily functioning. There is a growing body of literature that has explored the use of cognitive-focused interventions in PwMS, which aim to improve cognition-related function through drill and practice exercises, training in compensatory strategies, or a combination of the two. The current study aimed to expand upon previously published meta-analyses in this area, exploring the effects of cognitive-focused interventions on objective and subjective functioning in PwMS, as well as determining demographic and treatment-related factors that may influence intervention efficacy. Thirty-three studies, with a total of 1890 participants, were included in the meta-analysis. Outcome measures were categorised based on the domain they presumably assessed. For objective cognitive functioning, weighted effect-size analysis revealed small effects of cognitive-focused interventions on working memory (

Adherence to treatment in psychiatric populations is notoriously low. In this randomized, controlled, proof-of-concept study, we sought to examine whether motivational interviewing (MI) could be used to enhance motivation for, adherence to, and benefit obtained from cognitive rehabilitation. Dual diagnosis MI, developed specifically for individuals with psychotic symptoms and disorganization, was further adapted to focus on cognitive impairments and their impact. Sixty-four outpatients diagnosed with schizophrenia spectrum disorders completed baseline assessments and were randomized to receive either the 2-session MI focused on cognitive functioning or a 2-session sham control interview focused on assessment and feedback about preferred learning styles. Next, all participants were given 4 weeks during which they could attend up to 10 sessions of a computer-based math training program, which served as a brief analog for a full course of cognitive rehabilitation. As hypothesized, MI condition was associated with greater increases in task-specific motivation along with greater training program session attendance. Moreover, postinterview motivation level predicted session attendance. There were no significant differences in improvement on a measure of cognitive training content, which may have been due to the abbreviated nature of the training. While the literature on the efficacy of MI for individuals with psychosis has been mixed, we speculate that our positive findings may have been influenced by the adaptations made to MI as well as the focus on a nonpharmacological intervention.

Background 22q11DS is a multiple anomaly syndrome involving intellectual and behavioral deficits, and increased risk for schizophrenia. As cognitive remediation (CR) has recently been found to improve cognition in younger patients with schizophrenia, we investigated the efficacy, feasibility, and fidelity of a remote, hybrid strategy, computerized CR program in youth with 22q11DS. Methods A longitudinal design was implemented in which 21 participants served as their own controls. Following an eight month baseline period in which no interventions were provided, cognitive coaches met with participants remotely for CR via video conferencing three times a week over a targeted 8 month timeframe and facilitated their progress through the intervention, offering task-specific strategies. A subset of strategies were examined for fidelity. Outcomes were evaluated using a neurocognitive test battery at baseline, pre-treatment and post-treatment. Results All participants adhered to the intervention. The mean length of the treatment phase was 7.96 months. A moderately high correlation (intraclass correlation coefficient, 0.73) was found for amount and type of strategies offered by coaches. Participants exhibited significant improvements (ES = .36–.55, p ≤ .009) in working memory, shifting attention and cognitive flexibility. All significant models were driven by improvements in pre to post-treatment scores. Conclusions Based on our preliminary investigation, a remote, hybrid strategy, computerized CR program can be implemented with 22q11DS youth despite geographic location, health, and cognitive deficits. It appears effective in enhancing cognitive skills during the developmental period of adolescence, making this type of CR delivery useful for youth with 22q11DS transitioning into post-school environments.

A growing body of research shows that cognitive remediation (Cog Rem), consisting of drill- and-practice and/or strategy training in neurocognitive functions, produces moderate improvements in neurocognition. These improvements generalize to functioning when Cog Rem is provided with other rehabilitation interventions (Wykes et al., 2011) The number of studies using Cog Rem as an adjunct to other behavioral-based rehabilitation interventions however remains small and consists of widely varying interventions with few active control conditions. This study compared the effects of an extended (6-month), standardized, computer-assisted cognitive remediation intervention, administered along with a standardized program of social skills-training (SST), with those of an active control condition that included participation in the same SST program and a computer skills training program (Computer Skills). Sixty-four individuals with schizophrenia recruited from two treatment sites were randomly assigned to one of two conditions and were assessed by blinded raters on neurocognitive measures, performance-based measures of social skill, and ratings of psychosocial function before and after treatment. Results revealed that the Cog Rem group improved significantly more in attention, working memory, and empathy than the Computer Skills group, but there were no differences between groups on other measures of psychosocial functioning or skills. Taken together, these findings suggest that Cog Rem used in the context of other evidence-based psychosocial interventions (SST) improves working memory in schizophrenia and suggests that this effect may generalize to improved empathy.

Objectives: Verbal episodic memory is a key domain of impairment in people with schizophrenia with close ties to a variety of aspects of functioning and therapeutic treatment response. A randomized, blinded trial of two mnemonic strategies for verbal episodic memory deficits for people with schizophrenia was conducted. Methods: Sixty-one people with schizophrenia were assigned to one of three experimental conditions: training in a mnemonic strategy that included both visualization and narrative structure (Story Method), a condition in which participants were trained to visualize words interacting with one another (Imagery), or a non-trained control condition in which participants received equivalent exposure to training word lists and other verbal memory assessments administered in the other two conditions, but without provision of any compensatory mnemonic strategy. Participants were assessed on improvements in recall of the word list used as part of training, as well as two, standardized verbal memory assessments which included stimuli not used as part of strategy training. Results: The Story Method produced improvements on a trained word list that generalized to a non-trained, prose memory task at a 1-week follow-up. In contrast, provision of a mnemonic strategy of simple visualization of words produced little improvement on word recall of trained words or on measures of generalization relative to the performance of participants in the control condition. Conclusions: These findings support the inclusion of enriched mnemonic strategies consisting of both visualization and narrative structure in sustained and comprehensive programs of CR for enhancement of verbal episodic memory in schizophrenia. (JINS, 2017, 23, 352–357)

Objective: Impaired adherence to medication regimens is a serious concern for individuals with schizophrenia linked to relapse and poorer outcomes. One possible reason for poor adherence to medication is poor ability to remember future intentions, labeled prospective memory skills. It has been demonstrated in several studies that individuals with schizophrenia have impairments in prospective memory that are linked to everyday life skills. However, there have been no studies, to our knowledge, examining the relationship of a clinical measure of prospective memory to medication management skills, a key element of successful adherence. Methods: In this Study 41 individuals with schizophrenia and 25 healthy adults were administered a standardized test battery that included measures of prospective memory, medication management skills, neurocognition, and symptoms. Results: Individuals with schizophrenia demonstrated impairments in prospective memory (both time and event-based) relative to healthy controls. Performance on the test of prospective memory was correlated with the standardized measure of medication management in individuals with schizophrenia. Moreover, the test of prospective memory predicted skills in medication adherence even after measures of neurocognition were accounted for. Conclusions: This suggests that prospective memory may play a key role in medication management skills and thus should be a target of cognitive remediation programs.

The aim of this pilot randomized controlled trial was to investigate whether an extended, standardized program of computer-assisted cognitive remediation (CR; a behavioral intervention designed to improve cognitive function through repeated task practice and strategy acquisition) improves disordered attention and related cognitive functions in patients with hoarding disorder (HD) as compared to patients with HD assigned to a relaxation control condition. Seventeen participants with primary HD were randomized to receive 8 weeks and 24 sessions of either CR or relaxation control treatment, and blinded assessments of cognitive functioning and hoarding severity were conducted before and after treatment. Results revealed that cognitive remediation produced improvements in attention relative to the relaxation control condition; the two conditions did not differentially influence memory or executive functioning, or hoarding severity. Future research should confirm these findings in larger sample studies and investigate the utility of cognitive remediation for attentional impairment as an adjunct to cognitive-behavioral therapy for hoarding disorder.

Self-efficacy, defined as the confidence one has in the ability to perform a behavior or specific task, has been introduced as a crucial motivational factor for successfully carrying out social and everyday living skills (Bandura, 1977, 1997). Few studies have assessed its role in functioning in schizophrenia. The current study was designed to investigate whether degree of illness insight determined whether self-efficacy was a mediator of the relationship between two key illness features, negative symptoms and cognition, and functional skills. Sixty-nine individuals with schizophrenia were administered measures of self-efficacy, cognition, symptoms, insight and performance-based measure of everyday living and social skill. Results revealed that self-efficacy was only linked to measures of functional skills when illness insight was intact. There was evidence of moderation of confounding effects such that when self-efficacy was controlled, the relationship between negative symptoms and measures of everyday life skills became non-significant, but only when illness insight was intact. These findings emphasize the importance of including illness insight in models of the role of self-efficacy in functioning in schizophrenia.

Treating the less well-recognized social aspects of schizophrenia could help patients lead fuller, more productive lives

Cognitive remediation (CR), a novel behavioral intervention designed to improve cognitive deficits through repeated task practice and/or strategy acquisition has gained increasing empirical support in people with schizophrenia, but substantial individual differences in treatment response remain (Wykes et al., 2011). The role of age on response to CR in schizophrenia remains understudied. We evaluated the role of three age ranges in treatment response to CR relative to a closely-matched computer skills control intervention in a blinded, randomized control trial (RCT) with 112 adults with schizophrenia divided into three groups: an early-stage group (ES; 25 years or younger, mean=3.4 years of illness; n=45), an early-chronic group (EC; 26-39, mean=7.6 years of illness; n=31) and a late-chronic group (LC; 40 and over, mean=18.2 years of illness; n=36). With respect to cognitive outcomes, early-stage and early-chronic individuals with schizophrenia showed greater improvement in response to CR on a working memory measure at a trend level, relative to late-chronic clients. These findings were confirmed in analyses of a subsample of clients who received an adequate dose of treatment. These findings emphasize the need for adaptations of currently-existing CR programs to more effectively address the needs of older client populations.

A small but growing body of work has studied the role of cognitive skills in predicting response to integrated programs of rehabilitation in schizophrenia. No studies however, have directly compared the roles and interrelationships of cognition, social cognition and other disease factors in predicting improvements in the separate domains of objective quality-of-life (QOL) and subjective satisfaction with life (SWL) in response to rehabilitation in schizophrenia,. Forty-four outpatients with schizophrenia were administered measures of cognition, social cognition, and symptoms at entry to a psychosocial and cognitive rehabilitation program. Change in objective QOL and subjective SWL before and after treatment were measured as outcome variables. Cognitive measures of verbal memory and social cognitive measures of facial affect recognition were linked to improvements in objective QOL, while verbal memory and crystallized verbal skill was linked to improvements in SWL. Facial affect recognition partially mediated the relationship between verbal memory and improvements in objective QOL. The implications of these findings for understanding interrelationships between cognition and social cognition and their role in predicting change in different domains of outcome as a function of behavioral treatment are discussed.

This study investigated demographic, clinical and neurocognitive factors predicting drop-out from an intensive, community outpatient psychosocial rehabilitation program for people with schizophrenia or schizoaffective disorder. One-hundred and twenty-seven outpatients with DSM-IV schizophrenia or schizoaffective disorder participated. Demographic variables of age, sex, education and race/ethnicity were recorded and formal symptom measures and a neurocognitive assessment consisting of measures of crystallized verbal ability, sustained visual vigilance, verbal learning, verbal fluency and problem-solving were administered at study entry. Thirty-seven percent of the sample dropped-out of the program. In a final multivariate model, younger age, and lower verbal fluency scores in clients with a history of a high number of hospitalizations predicted a greater likelihood of drop-out. The implications of these findings are discussed.

Quality of life (QOL) has been recognized as a crucial domain of outcome in schizophrenia treatment, and yet its determinants are not well understood. Recent meta-analyses suggest that symptoms have only a modest relationship to QOL (Eack SM, Newhill CE. Psychiatric symptoms and quality of life in schizophrenia: a meta-analysis. Schizophr Bull. 2007;33:1225-1237). Individuals with schizophrenia show 1-2 SD deficits on measures of elementary neurocognition, and links between these deficits and objective measures of community functioning (eg, employment and independent living) are well established. While objective measures of community functioning and measures of QOL would appear to be closely related, studies investigating the ability of neurocognitive variables to predict QOL in individuals with schizophrenia have yielded conflicting results. One potential explanation for opposing findings in the schizophrenia literature is the interchangeable use of objective and subjective indices of QOL. This study used quantitative methods of meta-analysis to clarify the relationship between neurocognitive determinants of objective QOL (ie, observable, clinician-rated) and subjective QOL (ie, patient satisfaction) separately in individuals with schizophrenia. A total of 20 studies (10 objective and 10 subjective) consisting of 1615 clients were aggregated from relevant databases. Weighted effect size analysis revealed that there were small-moderate relationships (d ≤ 0.55) between crystallized verbal ability, working memory verbal list learning, processing speed, and executive function and objective indices of QOL. In contrast, results revealed either nonsignificant or inverse relationships for the vast majority of neurocognitive measures and measures of subjective QOL. Moderating variables and implications for future research and treatment development are discussed.

Few studies have investigated the relationships between static, elementary neurocognitive functions, dynamic measures of learning potential and functional status in schizophrenia, despite the putative role of learning potential in models of the relationship between static neurocognitive function and functional status (e.g., Green et al., 2000). The current study sought to clarify these relationships. One-hundred and twenty-five outpatients with schizophrenia were administered the California Verbal Learning Test-II (CVLT-II), as an index of learning potential, along with measures of sustained attention, verbal prose recall, working memory, problem-solving and processing speed, and a capacity measure of everyday life skills (Study 1). A subset of 48 outpatients with schizophrenia who were impaired on the Wisconsin Card Sorting Test (WCST) were also administered a test-train-test version of the WCST as a second measure of learning potential (Study 2). As expected, several static, elementary neurocognitive measures were linked to measures of everyday life skills in both samples. There was no evidence, however, that either measure of learning potential contributed unique variance beyond that explained by elementary cognitive skill to measures of everyday life skills. Learning potential was also tested as a mediator and moderator of the relationship between static neurocognitive function and measures of everyday life skills. Neither learning potential measure mediated the relationship between static measures of neurocognition and everyday life skills. Learning potential, as measured by the CVLT-II, was found to moderate the relationship of processing speed and everyday life skills. Taken together, these findings raise questions as to the explanatory value of measures of learning potential as predictors of functional status in schizophrenia.

A meta-analysis of neuropsychological studies of patients with bipolar disorder in euthymic, manic/mixed or depressed phases of illness was conducted. Measures of attention, working memory, verbal and non-verbal memory, visuospatial function, psychomotor speed, language, and executive-function were evaluated in 42 studies of 1197 patients in euthymia, 13 studies consisting of 314 patients in a manic/mixed phase of illness, and 5 studies of 96 patients in a depressed state. Cohen d-values were calculated for each study as the mean difference between patient and control group score on each neuropsychological measure, expressed in pooled standard deviation units. Results for patients in euthymic, depressed and manic/mixed phases were evaluated separately and then a subset of measures on which patients in all three phases were tested were compared. For euthymia, results revealed impairment across all neuropsychological domains, with d-values in the moderate-large range (d=.5–.8) for the vast majority of measures. There was evidence of large effect-size impairment on measures of verbal learning (d=.81), and delayed verbal and non-verbal memory (d=.80-.92), while effect-size impairment on measures of visuospatial function was small-to-moderate (d≤.55). Patients tested during a manic/mixed or depressed phase of illness showed exaggerated impairment on measures of verbal learning, while patients tested during a depressed phase showed greater decrement on measures of phonemic fluency. Consistent with previous meta-analyses (Arts et al, 2007; Bora et al., 2009; Robinson et al., 2007), these results suggest that bipolar illness during euthymia is characterized by generalized moderate level impairment across an array of neurocognitive domains, with particular marked impairment in verbal learning and memory. These results also show that a subset of these deficits moderately worsen during acute disease states.

A meta-analysis of randomized, controlled trials of social skills training for schizophrenia was conducted. Outcome measures from 22 studies including 1,521 clients were categorized according to a proximal-distal continuum in relation to the presumed site of action of skills training interventions, with content mastery tests and performance-based measures of skills assumed to be most proximal, community functioning and negative symptoms intermediate, and general symptoms and relapse most distal. Results reveal a large weighted mean effect size for content-mastery exams (d = 1.20), a moderate mean effect size for performance-based measures of social and daily living skills (d = 0.52), moderate mean effect sizes for community functioning (d = 0.52) and negative symptoms (d = 0.40), and small mean effect sizes for other symptoms (d = 0.15) and relapse (d = 0.23). These results support the efficacy of social skills training for improving psychosocial functioning in schizophrenia.

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.

Social cognitive impairment is a key feature of schizophrenia and social cognition training (SCT) is a promising tool to address these deficits. Neurobiological dysfunction in schizophrenia has been widely researched, but neuronal changes induced by SCT have been scarcely explored. This review aims to assess the neuroplastic effects of SCT in patients with schizophrenia spectrum disorders. PubMed and Web of Science databases were searched for clinical trials testing the effects of SCT in functional and structural brain measurements of adult patients with schizophrenia or schizoaffective disorders. A total of 11 studies were included: five used fMRI, two used EEG and ERP, one used ERP only, two used MEG and one study used MRI. Data extracting and processing regarding sociodemographic and clinical variables, intervention characteristics, neuroimaging procedures, neuroplastic findings, effect sizes and study quality criteria was completed by two raters. Results indicate a wide range of structural and functional changes in numerous regions and circuits of the social brain, including early perceptual areas, the limbic system and prefrontal regions. Despite the small number of trials currently available, evidence suggests that SCT is associated with neuroplastic changes in the social brain and concomitant improvements in social cognitive performance. There is a lack of extensive knowledge about the neural mechanisms that underlie social cognitive enhancement after treatment, but the reported findings may shed light on the neural substrates of social cognitive impairment in schizophrenia and how improved treatment procedures can be developed and applied.