Thinking clearly with schizophrenia

The impact of cognitive impairment associated with schizophrenia (CIAS) is wide reaching, affecting the quality of life of patients, caregivers and family members. It is also a major obstacle on the way to recovery. This symposium from ECNP 2021 explored the important benefits that improving cognitive function could have, current management strategies and future treatment options.

Benefits of improving cognitive impairment

Martine Frager Berlet (member of UNAFAM, France) opened the session by describing first-hand, the reality of living with CIAS.  She is a member of a French organisation, supporting family and friends of those living with mental illness.

Martine’s desire is that improving cognitive function will improve the lives of individual patients by:

  • Adapted behaviour – improved understanding of attempts by family/friends to help, expression of their feelings, and anticipation and planification
  • Accepting help
  • Completing tasks
  • Better insight

Improving cognitive skills can increase the likelihood of restoring social functioning

Her experience is that improving cognitive skills can increases patients’ self-confidence and their control over their emotions. It reduces stigma, promotes societal inclusion, and increases the likelihood of restoring social functioning. Martine stressed the importance of strengthening the therapeutic alliance between patients, caregivers and health care professionals (HCPs), to achieve these goals.

 

Managing cognitive impairment in clinical practice

Dr Nagore Penades (NHS Greater Glasgow and Clyde, UK) gave her perspective, as a consultant psychiatrist, into how best to approach CIAS in clinical practice. This includes assessment of functional impact, and identification and management of symptoms.

85% of people with schizophrenia have specific cognitive deficits

 Negative symptoms in schizophrenia contribute more to impaired quality of life and poor functioning than positive symptoms1. Negative symptoms are present in at least one-fifth of people with schizophrenia1, and up to 85% of people with schizophrenia have specific cognitive deficits2. So, it is insufficient to only treat positive symptoms.

Most typical and antitypical antipsychotic drugs show modest efficacy in managing negative and cognitive symptoms3. Dr Penades suggested that there will not be a single magic treatment, but different therapeutic elements will need to be combined, and non-pharmacological approaches should not be forgotten4.

Social functioning is a person’s ability to adapt to their social environment and its requirements5. A well-functioning individual requires good cognition, including attention, working memory and executive functions6, as well as opportunities to practice. She encouraged HCPs to ensure they assess cognition and functioning, at baseline and return visits. The range of tools include the SCoRS (Schizophrenia Cognition Rating Scale)7.

Different pharmacological treatments impact on different aspects of cognition and functioning, and safety profile should be considered for the particular patient

 Different pharmacological treatments impact on different aspects of cognition and functioning, and the safety profile should be considered for the particular patient8. Dr Penades’ proposed strategy involves understanding the root problem; targeting each issue individually, while not forgetting the patient as a whole; and rating the baseline, as each person’s ability, potential and wishes are different.

 

Current and future treatment options

Prof Philip Harvey (University of Miami Miller School of Medicine, USA) concluded with current and novel therapeutic options. The pharmacological approach has tested multiple strategies and mechanisms, including nicotinic agonists9,10, AMPA‑kines10 and cholinesterase inhibitors10, but many failed after Phase II. Results using a novel glycine transporter inhibitor show promise11, but there is still much to be done in the quest for an effective pharmacological treatment for those living with CIAS.

Pharmacologically Augmented Cognitive Training has shown benefit by using pharmacological agents in combination with cognitive training

Prof Harvey described how meta-analyses of cognitive and skills training have found clear evidence of efficacy12,13. Functional changes need targeted functioning training to be added to cognitive training13. Pharmacologically Augmented Cognitive Training (PACT) has shown benefit by using pharmacological agents in combination with cognitive training14,15. This may augment activity or facilitate plasticity15, and long acting injectables show greater benefit than oral medications16.

A future challenge is that self-reports of cognitive and functional ability do not correlate well with observer ratings17. He suggested that technology-related solutions may be helpful in getting better outcomes data. Capturing ‘in the moment’ clinical symptoms, using ecological momentary assessment, has potential benefits over clinic visit assessments, including eliminating recall bias18.

 

Educational financial support for this Satellite symposium was provided by Boehringer Ingelheim.

 

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Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

References
  1. Tsapakis EM, et al. Clinical management of negative symptoms of schizophrenia: An update. Pharmacol Ther 2015;153:135-47.
  2. Sheffield JM, et al. Cognitive Deficits in Psychotic Disorders: A Lifespan Perspective. Neuropsychol Rev 2018;28(4):509-33.
  3. Sinkeviciute I, et al. Efficacy of different types of cognitive enhancers for patients with schizophrenia: a meta-analysis. NPJ Schizophr 2018;4(1):22.
  4. Stevović LI, et al. Non-pharmacological treatments for schizophrenia in Southeast Europe: An expert survey. Int J Soc Psychiatry 2021;207640211023072. doi: 10.1177/00207640211023072. Online ahead of print.
  5. Javed A, Charles A. The Importance of Social Cognition in Improving Functional Outcomes in Schizophrenia. Front Psychiatry 2018;9:157.
  6. Bowie CR, Harvey PD. Cognitive deficits and functional outcome in schizophrenia. Neuropsychiatr Dis Treat 2006;2(4):531-6.
  7. Keefe RSE, et al. Reliability, validity and treatment sensitivity of the Schizophrenia Cognition Rating Scale. Eur Neuropsychopharmacol 2015;25(2):176-84.
  8. Baldez DP, et al. The effect of antipsychotics on the cognitive performance of individuals with psychotic disorders: Network meta-analyses of randomized controlled trials. Neurosci Biobehav Rev 2021;126:265-75.
  9. Recio-Barbero M, et al. Cognitive Enhancers in Schizophrenia: A Systematic Review and Meta-Analysis of Alpha-7 Nicotinic Acetylcholine Receptor Agonists for Cognitive Deficits and Negative Symptoms. Front Psychiatry 2021;12:631589.
  10. Sinkeviciute I, et al. Efficacy of different types of cognitive enhancers for patients with schizophrenia: a meta-analysis. NPJ Schizophr 2018;4(1):22.
  11. Fleischhacker WW, et al. Efficacy and safety of the novel glycine transporter inhibitor BI 425809 once daily in patients with schizophrenia: a double-blind, randomised, placebo-controlled phase 2 study. Lancet Psychiatry 2021;8(3):191-201.
  12. Turner DT, et al. A Meta-Analysis of Social Skills Training and Related Interventions for Psychosis. Schizophr Bull 2018;44(3):475-91.
  13. Harvey PD, et al. Evaluation of the Efficacy of BI 425809 Pharmacotherapy in Patients with Schizophrenia Receiving Computerized Cognitive Training: Methodology for a Double-blind, Randomized, Parallel-group Trial. Clin Drug Investig 2020;40(4):377-85.
  14. Swerdlow NR, et al. Amphetamine Enhances Gains in Auditory Discrimination Training in Adult Schizophrenia Patients. Schizophr Bull 2017;43(4):872-80.
  15. Harvey PD, Sand M. Pharmacological Augmentation of Psychosocial and Remediation Training Efforts in Schizophrenia. Front Psychiatry 2017;8:177.
  16. Zhornitsky S, Stip E. Oral versus Long-Acting Injectable Antipsychotics in the Treatment of Schizophrenia and Special Populations at Risk for Treatment Nonadherence: A Systematic Review. Schizophr Res Treatment 2012;2012:407171.
  17. Gould F, et al. Self-assessment in schizophrenia: Accuracy of evaluation of cognition and everyday functioning. Neuropsychology 2015;29(5):675-82.
  18. Harvey PD, et al. Capturing Clinical Symptoms with Ecological Momentary Assessment: Convergence of Momentary Reports of Psychotic and Mood Symptoms with Diagnoses and Standard Clinical Assessments. Innov Clin Neurosci 2021;18(1-3):24-30.
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