Longitudinal studies of cognition and functional outcome in schizophrenia: implications for MATRICS.

The impairments now called negative symptoms have long been noted as common features of schizophrenia, and the concept of negative symptoms itself has a long history.1,2 Patients who exhibit significant negative symptoms have particularly poor function and quality of life,3–8 and this aspect of schizophrenia has been proposed as a separate domain with distinctive pathophysiological and therapeutic implications since at least 1974.9 Despite the attention these problems receive, no drug has received Food and Drug Administration (FDA) approval for an indication of negative symptoms, and available data indicate that second-generation antipsychotic medications have not met early hopes for a highly effective treatment for alleviation of negative symptoms.10

Because of limited progress in the development of effective treatments for negative symptoms, under the auspices of the National Institute of Mental Health (NIMH), Drs. Steve Marder, Wayne Fenton, William T. Carpenter, Jr, and Brian Kirkpatrick initiated a process to examine issues that may interfere with treatment development. The NIMH had previously focused attention on impaired cognition as a therapeutic target with the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) project. The success of the MATRICS process suggested similar progress could be made in the area of negative symptoms and provided a possible model for proceeding in the area of negative symptoms.


Marder, Fenton, Carpenter, and Kirkpatrick organized a consensus development conference, which was held at the NIMH Neuroscience Center in Rockville, Maryland, on January 26–27, 2005. Those attending are listed in the appendix. The mission statement of the meeting was:


To review the data relating to the existence of separate domains within negative symptoms, as a prerequisite for choosing appropriate measures of these domains in clinical trials.


To initiate a process for developing or identifying widely acceptable, evidence-based measures and methodologies needed to establish the efficacy of treatments that target negative symptoms.





Prior to the meeting, the organizers asked experts to address a series of questions:


What are the separate components of negative symptoms?


Are they independent, or components of the same latent construct?


Which aspect of each domain belongs to the negative symptom construct?


Does this area need a separate assessment?


What is the best assessment method for clinical trials?





Since research has suggested that both negative symptoms and cognitive impairments were significant determinants of poor outcome in schizophrenia, an additional set of questions related to the relationship between these domains of psychopathology was also addressed at the conference:


Which aspects of cognition are part of the negative symptom construct?


Which are independent?


Which are uncertain?




Articles that more fully address the topics of these presentations can be found in this issue of Schizophrenia Bulletin. Those articles address regulatory issues and negative symptoms,11 negative symptoms as a therapeutic target,12 the factor structure of negative symptoms,13 restricted affect,14 anhedonia,15 and the relationship between negative symptoms and cognitive impairment.16 At the conference other presentations were also made: Wayne Fenton spoke on “Meeting Goals and Objectives: The NIMH Perspective,” Robert Buchanan on “Summary of the MATRICS Process,” William Carpenter, Jr, on “Study Design and the “Pseudospecificity' Problem,” Michael Green on “Social Cognition,” Nancy Andreasen on “Alogia,” and Jeffrey Cummings on “Apathy.”

The NIMH-MATRICS Consensus Statement on Negative Symptoms

Approaching a consensus cognitive battery for clinical trials in schizophrenia: The NIMH-MATRICS conference to select cognitive domains and test criteria

Approaching a Consensus Cognitive Battery for Clinical Trials in Schizophrenia: The NIMH-MATRICS Conference to Select Cognitive Domains and Test Criteria F. Green, Keith H. Nuechterlein, James M. Gold, Deanna M. Barch, Jonathan Cohen, Susan

Predicting Schizophrenia Patients’ Real-World Behavior with Specific Neuropsychological and Functional Capacity Measures

Objective: Reports suggesting that quality of life in schizophrenia is more highly related to negative rather than positive symptoms are largely based on use of the Quality of Life Scale which was devised to assess deficit symptoms and does not include an assessment of subjective general wellbeing In the current paper we examined symptoms, level of community functioning as well as living circumstances as correlates of Quality of Life Scale scores and scores on the General Well-Being Scale



Method: One hundred and twenty-eight patients completed the General Well-Being Scale and were rated on the Quality of Life Scale as well as scales assessing positive and negative symptoms



Results: While negative symptoms, level of functioning and positive symptoms all were related to the scores on the Quality of Life Scale, General Well-Being Scale scores were primarily related to positive symptoms, particularly reality distortion



Conclusion: The results highlight the importance of recognizing the complex nature of the concept of quality of life They demonstrate that varying indices of quality of life are likely to have different predictors

The relationship of symptoms and level of functioning in schizophrenia to general wellbeing and the Quality of Life Scale.

OBJECTIVE: It has been suggested that level of cognitive functioning as assessed by formal neurocognitive tests may be as important as, or even more important than, symptoms in predicting level of community functioning for patients with schizophrenia. The results of past prospective studies, when carefully examined, do not consistently support this hypothesis. In the current study, the authors used symptom and neurocognitive data to predict subsequent level of functioning in the community. METHOD: Neurocognitive and symptom data collected as part of an earlier study were used to predict the community functioning of 50 patients with a diagnosis of schizophrenia. Using the Life Skills Profile, staff of a community mental health program assessed community functioning while blind to the earlier symptom ratings and neurocognitive performance. RESULTS: Symptoms were more predictive of community functioning than were neurocognitive measures. Disorganization symptoms were generally more predictive of community fu...

https://ajp.psychiatryonline.org/doi/pdf/10.1176/ajp.156.3.400

Symptoms and cognition as predictors of community functioning: a prospective analysis.

PROBLEM. People with mental illness are twice as likely to smoke than people without a mental illness. METHODS. Data were collected through interviews with individuals who smoke and have been diagnosed with schizophrenia (N = 100). The research design included a descriptive, correlational design that described and examined the relationships among psychiatric symptoms, medication side effects, and reasons for smoking; and a qualitative analysis of the subjective experience of smoking. FINDINGS. A positive relationship was found between the age of onset of smoking and the onset of schizophrenia. Subjects reported they smoked primarily for sedative effects and control of negative symptoms of schizophrenia. Subjects also reported smoking related to addiction. Most indicated they would like to quit smoking or at least cut down on the number of cigarettes. CONCLUSIONS. Among people with schizophrenia, the motivation to smoke is related to their schizophrenia. Search terms: Motivation, qualitative research, quantitative research, schizophrenia, smoking ********** Lasser et al. (2000) found in a nationally representative U.S. sample that individuals with a mental illness are approximately twice as likely to smoke than are people without a mental illness. Individuals with schizophrenia tend to smoke. Studies over two decades have consistently found that between 74% and 90% of those with schizophrenia smoke (Benowitz, 1999; de Leon, 1996; Glynn & Sussman, 1990; Goff, Henderson, & Amico, 1992; Hughes, Hatsukami, Mitchell, & Dahlgren, 1986; Kramer, 2000; O'Farrell, Connors, & Upper, 1984). Smoking rates of individuals with schizophrenia are higher than for the general public (Glassman, 1993; Lasser et al.; Lyon, 1999), and higher than for other individuals with psychiatric problems (de Leon; Lyon). Although there has been some speculation about why this is so, very little is understood from the perspective of the person with schizophrenia who smokes. Understanding the issue of motivation is critical to assisting these people to quit smoking. De Leon reported that individuals with schizophrenia had great difficulty in quitting smoking, and only 8% were successful compared with 45% of the general U.S. population. The high incidence of smoking and difficulty in quitting smoking places a vulnerable population at high risk for other physical problems. Smoking as a Health Concern The single most important cause of cancer is smoking (Austoker, Sanders, & Fowler, 1994). Lung cancer alone remains the leading cause of cancer deaths (Statistics Canada, 2001). A much higher risk of cancer is associated with smoking cigarettes than with other forms of tobacco. Risk of developing lung cancer is associated with duration of smoking and number of cigarettes smoked. Therefore, the more cigarettes smoked over a longer period of time, the higher the risk an individual faces for developing lung cancer. Individuals who smoke 10 cigarettes a day reduce their life expectancy by an average of 2 to 3 years. Individuals who smoke 20 cigarettes a day reduce their life expectancy by 5 to 7 years, and those choosing to smoke 40 cigarettes a day are reducing their life expectancy by 8 to 10 years. Risk of cancer can be reduced by quitting smoking. After 10 years, a person who quit smoking may be at the same risk for cancer as someone who is a lifelong nonsmoker (Austoker et al., 1994). Smoking and Schizophrenia Previous authors have suggested that the reason for the high prevalence of smoking among people diagnosed with schizophrenia is that there may be unique motivators for smoking (Benowitz, 1999; Desai, Seabolt, & Jann, 2001; Farnam, 1999; Forchuk, Norman, Malla, Vos, & Martin, 1997; Glassman, 1993; Lohr & Flynn, 1992; McEvoy & Brown, 1999). Lohr and Flynn conducted a literature review related to schizophrenia and smoking. …

Schizophrenia and the motivation for smoking.

Objectifs : Donner un apercu d'un programme de gestion de cas complet et integre qui incorpore les principes du traitement communautaire dynamique et qui combine des interventions medicales et psychosociales efficaces, puis presenter les conclusions d'une evaluation de la methode et du resultat du programme, en soulignant sur les repercussions du programme sur l'utilisation du service et la satisfaction de la clientele. Methode : On a recueilli des donnees demographiques et cliniques ainsi que plusieurs indicateurs des resultats aupres de tous les patients qui ont recu des soins dans le cadre du programme pendant au moins six mois. Pour l'evaluation de la methode, nous avons determine le degre auquel le programme respecte ses objectifs et satisfait les patients. Les donnees d'evaluation du resultat sur le nombre et la duree des hospitalisations ont ete comparees, pour chaque sujet, avec les donnees historiques individuelles pour une periode equivalente au temps passe dans le programme. En outre, les rechutes de symptomes psychotiques qui ne se sont pas traduites par des hospitalisations ont ete calculees pour chaque patient admis au programme. Resultats : Les caracteristiques demographiques, cliniques et therapeutiques des clients demontrent que le programme a reussi a garder l'accent sur la prestation de services a des patients psychotiques relativement chroniques, sur une periode moyenne de trois ans. Les donnees d'evaluation de la methode indiquaient un degre eleve de satisfaction des patients, de leurs familles et d'autres organismes de service quant aux services recus. L'information sur les variables du resultat indiquait que le programme a depasse les predictions en reussissant a diminuer considerablement le nombre d'hospitalisations ainsi que le nombre de rechutes de la psychose. On a enregistre une diminution importante de l'utilisation des ressources allouees aux patients hospitalises chez les patients qui ont recu des soins dans le cadre du programme. Une grande partie de l'utilisation des services aux patients hospitalises a ete attribuee a des patients qui resistaient au traitement a l'aide d'agents antipsychotiques ou qui refusaient leur medication. Conclusions : Il est possible d'offrir une continuite de soins efficaces entre le traitement a l'hopital et l'adaptation communautaire a la plupart des personnes qui souffrent de troubles psychotiques de tout type, en combinant les ressources hospitalieres et communautaires dans un modele de gestion de cas integre.

Ann Rickwood

Papers

The relationship of symptoms and level of functioning in schizophrenia to general wellbeing and the Quality of Life Scale.

Symptoms and cognition as predictors of community functioning: a prospective analysis.

Schizophrenia and the motivation for smoking.

An integrated medical and psychosocial treatment program for psychotic disorders: patient characteristics and outcome.

Neuropsychological assessment as an aid to psychosocial rehabilitation in severe mental disorders.