Study protocol: A randomised controlled trial of cognitive remediation for a national cohort of forensic mental health patients with schizophrenia or schizoaffective disorder.

By O’Reilly, Ken; Donohoe, Gary; O’Sullivan, Danny; Coyle, Ciaran; Mullaney, Ronan; O’Connell, Paul; Maddock, Catherine; Nulty, Andrea; O’Flynn, Padraic; O’Connell, Carina; Kennedy, Harry G

BMC Psychiatry, Vol 16, Dec 2016, Article 5.

Background: Evidence is accumulating that cognitive remediation therapy (CRT) is an effective intervention for patients with schizophrenia or schizoaffective disorder. To date there has been no randomised controlled trial (RCT) cohort study of cognitive remediation within a forensic hospital. The goal of this study is to examine the effectiveness of a trial of cognitive remediation for forensic mental health patients with schizophrenia or schizoaffective disorder. Methods: An estimated sixty patients will be enrolled in the study. Participants will be randomised to one of two conditions: CRT with treatment as usual (TAU), or TAU. CRT will consist of 42 individual sessions and 14 group sessions. The primary outcome measure for this study is change in cognitive functioning using the MATRICS Consensus Cognitive Battery (MCCB). Secondary outcomes include change in social and occupational functioning, disorganised symptoms, negative symptoms, violence, participation in psychosocial treatment and recovery. In addition to these effectiveness measures, we will examine patient satisfaction. Discussion: Cognitive difficulties experienced by schizophrenia spectrum patients are associated with general functioning, ability to benefit from psychosocial interventions and quality of life. Research into the treatment of cognitive difficulties within a forensic setting is therefore an important priority. The results of the proposed study will help answer the question whether cognitive remediation improves functional outcomes in forensic mental health patients with schizophrenia or schizoaffective disorder. Forensic mental health patients are detained for the dual purpose of receiving treatment and for public protection. There can be conflict between these two roles perhaps causing forensic services to have an increased length of stay compared to general psychiatric admissions. Ultimately a focus on emphasising cognition and general functioning over symptoms may decrease tension between the core responsibilities of forensic mental health services. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Treatment patterns and antipsychotic medication adherence among commercially insured patients with schizoaffective disorder in the United States.

doi: http://dx.doi.org/10.1097/JCP.0000000000000549

By Joshi, Kruti; Lin, Jay; Lingohr-Smith, Melissa; Fu, Dong-Jing; Muser, Erik

Journal of Clinical Psychopharmacology, Vol 36(5), Oct 2016, 429-435.

This study assessed real-world treatment patterns and antipsychotic (AP) medication adherence among commercially insured US patients with schizoaffective disorder (SCA). Continuously insured adults aged 18 years or older with a diagnosis of SCA from January 1, 2009, to December 31, 2012, were identified from the Clinformatics Data Mart database. Patients were categorized into 2 cohorts: incident or prevalent SCA. Demographics and clinical characteristics were evaluated during the baseline period. Use of psychiatric medications and adherence to AP medications were evaluated during a 12-month follow-up period after index diagnosis of SCA. Of the overall study population (N = 2713; mean age, 40.2 y; 52.7% female), 1961 patients (72.3%) (mean age, 38.7 y; 51.3% female) had incident SCA, and 752 patients (27.7%) (mean age, 43.9 y; 56.5% female) had prevalent SCA. Antipsychotics were used by 74.8% of patients in the overall study population during the follow-up period. The most commonly prescribed oral AP was risperidone (23.9%), followed by quetiapine (21.4%) and aripiprazole (20.4%). Use of any long-acting injectable APs in the overall study population during the follow-up period was less than 3%. A total of 49.0% and 38.0% of the overall study population had medication possession ratios and proportion of days covered for APs of 80% or greater, respectively. Overall use of long-acting injectable APs for the treatment of SCA is low, and adherence to AP medications, measured by both medication possession ratio and proportion of days covered, is suboptimal among patients with SCA in the real-world setting. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Neurocognitive functioning and outcome of the Illness Management and Recovery Program for clients with schizophrenia and schizoaffective disorder.

doi: http://dx.doi.org/10.3109/08039488.2016.1146797

By Färdig, Rickard; Fredriksson, Anders; Lewander, Tommy; Melin, Lennart; Mueser, Kim T.

Nordic Journal of Psychiatry, Vol 70(6), Aug 2016, 430-435.

The relationship between psychosocial programming and neurocognition has been established in previous research, but has not been explored in the context of the Illness Management and Recovery Program (IMR). This study examined associations between neurocognition and illness self-management skills acquisition, based on two previous trials of IMR. Neurocognitive functioning was assessed at baseline and post-treatment in 53 participants with schizophrenia or schizoaffective disorder who completed the IMR. Illness self-management was measured by the client and clinician versions of the Illness Management and Recovery Scale. Statistical analyses investigated improvements in neurocognitive functioning and possible association between illness self-management skills acquisition and neurocognitive functioning. Speed of processing as measured by the Trail Making Test A, was related to client-reported acquisition of illness self-management skills, before and after controlling for psychiatric symptoms and medication, but did not predict improvement in clinician ratings of client illness self-management skills. However, when controlling for client session attendance rates, the association between speed of processing and client-reported illness self-management skills acquisition ceased to be statistically significant, which suggests that compromised neurocognitive functioning does not reduce response to training in illness self-management in itself. The association between the frequency of attended IMR sessions and outcome of the IMR seems to decrease the negative impact of compromised neurocognition on illness self-management skills acquisition. Also, clients with slower speed of processing may experience less benefit from the IMR and may attend fewer sessions. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Paliperidone palmitate once-monthly injectable treatment for acute exacerbations of schizoaffective disorder.

doi: http://dx.doi.org/10.1097/JCP.0000000000000535

By Fu, Dong-Jing; Turkoz, Ibrahim; Simonson, R. Bruce; Walling, David; Schooler, Nina; Lindenmayer, Jean-Pierre; Canuso, Carla; Alphs, Larry

Journal of Clinical Psychopharmacology, Vol 36(4), Aug 2016, 372-376.

The optimal treatment for schizoaffective disorder (SCA) is not well established. In this initial 6-month open-label treatment period of a large, multiphase, relapse-prevention study, the efficacy and safety of paliperidone palmitate once-monthly (PP1M) injectable were evaluated in subjects with symptomatic SCA. Subjects with acute exacerbation of SCA (ie, with psychotic and either depressive and/or manic symptoms) were enrolled and treated with PP1Meither as monotherapy or in combination with antidepressants or mood stabilizers (combination therapy group). After flexible-dose treatment with PP1M for 13 weeks, stabilized subjects continued into a 12-week fixed-dose PP1M treatment period. A total of 667 subjects were enrolled; 320 received monotherapy and 347 received PP1M as combination therapy; 334 subjects completed the entire 25-week treatment. Statistically significant and clinically meaningful improvements from baseline were observed for all efficacy measures in psychosis (per Positive and Negative Syndrome Scale), mood symptoms (per Young Mania Rating Scale and Hamilton Depression Rating Scale—21 items), and functioning (per Personal and Social Performance Scale) from week 1 to all time points during the 25-week treatment period (P < 0.001). Similar improvements in efficacy measures were observed between subjects receiving monotherapy or combination therapy. Efficacy benefits persisted throughout the 25-week period. The most common adverse events were akathisia (11.1%), injection-site pain (10.6%), and insomnia (10.0%). Paliperidone palmitate once-monthly administered as monotherapy or in combination with mood stabilizers or antidepressants in patients with an acute exacerbation of SCA provided rapid, broad, and persistent reduction in psychotic, depressive, and manic symptoms, as well as improved functioning. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Stephen, thank you for this honest and instructive personal disclosure. I appreciate that you point to the important role of motivation, and of maintaining and regaining goal-directedness. The latter is, I think, a key to understanding schizophrenia, as I argued once in a comment on an article at the subject:

https://www.researchgate.net/publication/264583388_Schizophrenia_as_a_consequence_of_an_extremely_impaired_goal-_directedness_Comment_on_Hirjak_D_Breyer_T_Thomann_PA_Fuchs_T_2013_Disturbance_of_intentionality_A_phenomenological_study_of_body-affecting

Article Schizophrenia as a consequence of an extremely impaired goal...

Stephen, no I am not talking of movement disorders, but of losing one's active involvment and emotional engagement with whatever in the world. Once, goals are lacking in your life, including short-sighted goals as in addiction, you are at a loss. Perception and action disintegrate. Such a thing affects everything, including one's movement and the perception of one's own movement. Fortunately, that did not happen to be the case with you in such an extreme degree. Study completion could still motivate you. Indeed, it was rather anhedonia you suffered from, and indeed this had much to do with the failed med attempts.