Neurocognitive predictors of functional outcome two to 13 years after identification as ultra-high risk for psychosis

Background and aim

Little is known about the relationship between neurocognitive performance and functional outcome before the onset of frank psychosis. This longitudinal study aimed to investigate neurocognitive predictors of poor functional outcome in a group identified as ultra-high risk (UHR) for psychosis between two and 13 years prior.

Method

Individuals (N = 230) identified as UHR for psychosis at the PACE Clinic in Melbourne completed assessment of psychopathology, functioning and neurocognition at baseline and follow-up. The mean length of follow-up was 7.26 years (SD 3.05).

Results

Forty-one individuals with the poorest functional outcome were identified. Only 48.8% of this group had transitioned to psychosis. Poor functional outcome was associated with reduced performance at baseline in the specific neurocognitive domains of verbal learning and memory, processing speed and attention, and verbal fluency, but not global cognitive impairment. Reduced performance on a verbal story recall task, in combination with higher negative symptoms at baseline, was the best predictor of later poor outcome. Baseline positive psychotic symptoms and GAF scores were not associated with later poor outcome.

Discussion

To date, this is the longest follow-up study of an UHR sample. Poor functional outcome was associated with specific neurocognitive decrements, regardless of transition to psychosis. The detection of individuals with poor functioning at follow-up, against a background of previously identified risk factors for psychotic disorder, may yield a valid group in which to study biomarkers and treatment of schizophrenia.     

Cognitive predictors of psychosocial functioning outcome in schizophrenia: a follow-up study of subjects participating in a rehabilitation program

The aims of this prospective study were to explore in subjects with psychosis participating in a rehabilitation program whether cognitive performances at baseline predicted (i) psychosocial functioning over a 15-16 month follow-up; (ii) improvement in psychosocial functioning over the rehabilitation program. Visuo-spatial tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB) were administered to assess cognitive performance in 55 subjects with schizophrenia spectrum disorders who completed a rehabilitation program. The Multnomah Community Ability Scale (MCAS) was used to measure dimensions of community functioning. One subscale of the Client's Assessment of Strengths, Interests, and Goals (CASIG) provided a measure of subjective quality of life (QoL). Improvement was defined as a 15% or more increase in psychosocial scores between baseline and follow-up. Worse baseline sustained attention predicted better self-rated quality of life, and better baseline visual memory predicted better community functioning over the rehabilitation follow-up period, in particular, higher autonomy in activities of daily living, and less physical and psychiatric symptoms that could interfere with rehabilitation. Baseline cognitive performances predicted community functioning improvement during the follow-up period: visual memory predicted improvement in daily living autonomy and in social competence; sustained attention predicted improvement in behavioral problems (such as medication compliance, collaboration with treatment providers or impulse control) and social competence; planning performances predicted improvement in social competence. These cognitive functions could be specifically targeted in a rehabilitation program aimed at enhancing functioning in those particular dimensions.     

Social functioning and neurocognitive deficits in outpatients with schizophrenia: a 2-year follow-up

Neurocognitive deficits have been associated with the social functioning impairments of patients with schizophrenia. More information is needed about how cognitive status and other variables predict social functioning over defined periods of time. In this study, 72 relatively stable outpatients with schizophrenia were compared between baseline and a 2-year follow-up on measures of social functioning. Patients were also assessed with a battery of neurocognitive tests and the Positive and Negative Syndrome Scale. Results were compared by univariate and multivariate analyses. A total of four out of seven subscales of the Social Functioning Scale (SFS) and the total SFS score did not show a significant change over the 2-year period. On the three SFS subscales that did show a significant change, residual change scores were correlated with better neurocognitive performance at baseline, younger age, and shorter illness duration. For the Multnomah Community Ability Scale, 48.9% of the total score at follow-up was predicted by initial negative symptoms and scores on the Aphasia Screening Test. These results document the independent contribution of demographic variables, negative symptoms, and neurocognitive deficits to the social functioning impairments of individuals with schizophrenia.     

Effectiveness of integrated psychological therapy (IPT) for schizophrenia patients: a research update

Standardized recovery criteria go beyond symptom remission and put special emphasis on personal and social functioning in residence, work, and leisure. Against this background, evidence-based integrated approaches combining cognitive remediation with social skills therapy show promise for improving functional recovery of schizophrenia patients. Over the past 30 years, research groups in 12 countries have evaluated integrated psychological therapy (IPT) in 36 independent studies. IPT is a group therapy program for schizophrenia patients. It combines neurocognitive and social cognitive interventions with social skills and problem-solving approaches. The aim of the present study was to update and integrate the growing amount of research data on the effectiveness of IPT. We quantitatively reviewed the results of these 36 studies, including 1601 schizophrenia patients, by means of a meta-analytic procedure. Patients undergoing IPT showed significantly greater improvement in all outcome variables (neurocognition, social cognition, psychosocial functioning, and negative symptoms) than those in the control groups (placebo-attention conditions and standard care). IPT patients maintained their mean positive effects during an average follow-up period of 8.1 months. They showed better effects on distal outcome measures when all 5 subprograms were integrated. This analysis summarizes the broad empirical evidence indicating that IPT is an effective rehabilitation approach for schizophrenia patients and is robust across a wide range of sample characteristics as well as treatment conditions. Moreover, the cognitive and social subprograms of IPT may work in a synergistic manner, thereby enhancing the transfer of therapy effects over time and improving functional recovery.     

Gender differences in symptoms, functioning and social support in patients at ultra-high risk for developing a psychotic disorder

Gender differences have been widely observed in the clinical presentation, psychosocial functioning and course of illness in first-episode and chronic patients suffering from schizophrenia. However, little is known about gender differences in the psychosis prodrome. This study investigated gender differences in symptoms, functioning and social support in individuals at ultra-high-risk for developing a psychotic disorder. Sixty-eight ultra-high-risk patients were assessed at baseline, and twenty-seven returned for follow-up assessments approximately 6 and 12 months later. Clinical symptoms and functioning were assessed by clinical interview; social support was measured using a self-report questionnaire. There were no gender differences in demographic variables, symptoms or functioning at baseline. Males were found to have significantly higher levels of negative symptoms and marginally lower levels of functioning when baseline and follow-up time points were considered collectively. Additionally, females reported higher levels of social support at baseline. Differences in negative symptoms were found to mediate differences in functioning between male and female patients. This study suggests that gender based differences in symptom presentation and functional outcome may predate conversion to psychosis. Follow-up studies should examine the relationship between symptoms, functioning and social support in this population.     

Neurocognitive performance and functional disability in the psychosis prodrome

OBJECTIVE: This study evaluates the pattern of neuropsychological deficits and their association with clinical symptomatology and social functioning in individuals identified as ultra-high-risk (UHR) for psychosis. METHODS: A sample of 45 UHR individuals was identified using the Structured Interview for Prodromal Syndromes (SIPS) from consecutive referrals to the Staglin Music Festival Center for the Assessment and Prevention of Prodromal States (CAPPS) at UCLA. Participants were administered a neurocognitive test battery, as well as measures of global (Strauss-Carpenter Outcome Scale) and social functioning (UCLA Social Attainment Survey). RESULTS: Participants showed significant deficits in speed of processing, verbal learning and memory, and motor speed. Poorer verbal learning and memory performance was significantly associated with poorer social functioning, and there was a trend for poorer performance on reasoning and problem solving to be associated with poorer global functioning. Verbal memory independently predicted social functioning over and above severity of negative symptoms. Cognitive deficits were not associated with severity of clinical symptomatology. CONCLUSIONS: Despite the absence of fully psychotic symptoms, UHR individuals experience significant cognitive deficits, particularly on tasks requiring speeded information-processing and efficient recall from memory, and these deficits appear to be associated with functional disability in a manner parallel to that observed in patients with established psychotic illness.     

Attachment style predicts 6‐month improvement in psychoticism in persons with at‐risk mental states for psychosis

Aim: Insecure attachment may influence vulnerability to and outcome of psychotic symptomatology. The present study examined whether attachment style predicted symptoms and functioning of at‐risk mental state (ARMS) patients after 6 months of psychosocial intervention, over and above the effects of initial clinical severity and premorbid social adjustment (PSA). Methods: Symptoms and functioning were assessed at baseline and 6 months later in 31 ARMS patients (mean age = 15.7). No patient received antipsychotic medication, but all engaged in intense psychosocial needs‐adapted treatment. Clinicians (unaware of the aims of the study) rated attachment, PSA, symptoms, and functioning. Results: Attachment was not related to baseline clinical severity. However, improvement in psychoticism was predicted by attachment (in particular by secure, preoccupied and dismissing) beyond the effects of baseline clinical severity and PSA. Secure attachment also predicted improvements in disorganization and functioning. Poor PSA predicted less improvement in disorganization and negative symptoms but did not impact psychoticism. Conclusions: The three attachment prototypes that predicted improvement in psychoticism (secure, preoccupied and dismissing) share the existence of at least one positive psychological model (either about self or about others). It may be that the psychosocial intervention helped ARMS patients to disconfirm negative models and/or reinforce positive ones. Patients' attachment styles were not related to baseline clinical severity but impacted improvement of positive symptoms. These findings appear consistent with evidence that impaired self‐esteem and dysfunctional self and others schemas constitute risk factors for reality distortion.     

Individual prediction of long‐term outcome in adolescents at ultra‐high risk for psychosis: Applying machine learning techniques to brain imaging data

An important focus of studies of individuals at ultra‐high risk (UHR) for psychosis has been to identify biomarkers to predict which individuals will transition to psychosis. However, the majority of individuals will prove to be resilient and go on to experience remission of their symptoms and function well. The aim of this study was to investigate the possibility of using structural MRI measures collected in UHR adolescents at baseline to quantitatively predict their long‐term clinical outcome and level of functioning. We included 64 UHR individuals and 62 typically developing adolescents (12–18 years old at recruitment). At six‐year follow‐up, we determined resilience for 43 UHR individuals. Support Vector Regression analyses were performed to predict long‐term functional and clinical outcome from baseline MRI measures on a continuous scale, instead of the more typical binary classification. This led to predictive correlations of baseline MR measures with level of functioning, and negative and disorganization symptoms. The highest correlation (r = 0.42) was found between baseline subcortical volumes and long‐term level of functioning. In conclusion, our results show that structural MRI data can be used to quantitatively predict long‐term functional and clinical outcome in UHR individuals with medium effect size, suggesting that there may be scope for predicting outcome at the individual level. Moreover, we recommend classifying individual outcome on a continuous scale, enabling the assessment of different functional and clinical scales separately without the need to set a threshold. Hum Brain Mapp 38:704–714, 2017. © 2016 Wiley Periodicals, Inc.     

Treating young individuals at clinical high risk for psychosis

Background: Typically, studies investigating those at clinical high risk for psychosis have focused on predictors of conversion and treatments that might prevent conversion to full‐blown psychosis. Few studies have followed those who do not go on to develop a psychotic illness. Methods: Participants were 48 young people who were at risk for developing psychosis based on the Structured Interview for Prodromal Symptoms criteria and participated in a treatment programme where they were offered up to 6 months of psychosocial treatment and psychiatric management. Attenuated psychotic symptoms, negative symptoms, depression, anxiety, social functioning, alcohol and drug use, and meta‐cognitive beliefs were assessed at baseline, 6, 12 and 18 months. Personality characteristics were assessed at baseline. Medication use was tracked and psychiatric visits were logged over the 18‐month study period. Results: On average, participants attended 12 sessions of psychosocial treatment and had one meeting with the psychiatrist every 6 months. Only 24% were ever prescribed any psychotropic medications, and antipsychotics were not used. Significant improvements were found over time in attenuated positive symptoms, negative symptoms, depression, anxiety, meta‐cognitions and social functioning with most improvement occurring in the first 6 months. There was no change in the level of substance use. For personality assessment, participants generally scored high on neuroticism and openness and had low scores on extraversion, agreeableness and conscientiousness. Conclusion: With minimal treatment and no antipsychotics, young people who present as being at risk for developing a psychotic disorder demonstrate clinical improvement over time. However, a few continued to have the liability of ongoing attenuated psychotic symptoms.     

Cognitive remediation therapy for outpatients with chronic schizophrenia: a controlled and randomized study

Cognitive Remediation Therapy (CRT) is a novel rehabilitation approach designed to improve neurocognitive abilities such as attention, memory and executive functioning. The aim of the present study is to evaluate the effect of CRT on neurocognition, and secondarily on symptomatology and psychosocial functioning. Cognitive Behavioural Therapy (CBT) was used as a control condition because it aims to improve emotional problems and positive symptoms, focusing on modification of maladaptive beliefs and schemas, but neurocognition is not targeted. A total of 40 chronic patients with DSM-IV schizophrenia disorder were randomly assigned for 4 months to one of two treatment groups: CRT or CBT. Repeated assessments were conducted before and after the treatments and at the end of a follow-up period of 6 months. Additionally, a method to establish reliable change was calculated from a separate sample of 20 schizophrenic patients who were under standard medication without any kind of psychological treatment. Results showed that CRT produced an overall improvement on neurocognition (Mean effect size=0.5), particularly in verbal and nonverbal memory, and executive function. CBT showed the expected treatment effect on general psychopathology (anxiety and depression) but produced only a slight non-specific improvement in neurocognition (Working Memory). Furthermore, patients receiving CRT showed improvement in social functioning, demonstrating that cognitive improvements are clinically meaningful. These gains were still present at the 6 month follow-up.     

Théorie de l’esprit : un médiateur entre symptômes et fonctionnement dans la schizophrénie ?

This literature review aimed to summarize the scientific knowledge concerning the links between psychosocial functioning and social cognition. Social cognition, and particularly Theory of Mind, is strongly disturbed in patients with schizophrenia. There were strong arguments that psychosocial functioning was more strongly associated with Theory of Mind than with neurocognition (defined as nonsocial information processing in contrast to social cognition). The functional capacity mediated this influence. Moreover, longitudinal studies suggested a unidirectional causal pathway with primary neurocognitive disorders leading to secondary deficits in social cognition, which in turn led to disturbances in psychosocial functioning. Studies using structural equation modelling showed that positive, negative and disorganization symptoms were associated with disturbances in psychosocial functioning. Regarding negative symptoms and disorganization, the influences were mediated by social cognition. The influence of positive symptoms on psychosocial functioning was independent of social cognition. This literature review suggests that social cognitive remediation in patients with should improve the psychosocial functioning in patients with schizophrenia.     

Neuropsychological functioning and social anhedonia: three-year follow-up data from a longitudinal community high risk study

Social anhedonia is a promising vulnerability marker for schizophrenia-spectrum pathology. Prior research has demonstrated that individuals with psychometrically-defined social anhedonia show a range of “schizophrenia-like” neurocognitive abnormalities. However, this research is limited in that it is based largely on the study of college students. The present article reports findings from a longitudinal study of social anhedonia recruited from a community sample. As part of this study, a neurocognitive battery was administered at baseline and at three-year follow-up sessions to participants with (n = 78) versus without (n = 77) social anhedonia. Additional measures of global functioning and schizotypal, schizoid and paranoid schizophrenia-spectrum symptoms were also administered. Across groups, subjects showed significant improvement in neurocognitive functioning over time. Compared to controls, at follow-up, individuals with social anhedonia showed significantly poorer attentional vigilance and simple processing speed, but failed to evidence impairments in immediate or delayed verbal memory, immediate or delayed visual memory, visual or verbal working memory, olfaction or executive abilities. At follow-up, within the social anhedonia group, schizoid (and to a lesser extent, schizotypal) symptom severity was associated with a range of neurocognitive impairments. Neurocognitive impairments were generally not associated with paranoid symptoms or global functioning. Baseline neurocognitive performance was not significantly predictive of follow-up symptom severity or functioning. Collectively, these findings suggest that neurocognitive dysfunctions only characterize a subset of individuals with social anhedonia.     

Neurocognitive deficits in adolescents with schizophrenia: longitudinal stability and predictive utility for short-term functional outcome

OBJECTIVE: Previous cross-sectional studies in adolescents with early-onset schizophrenia (EOS; onset of psychotic symptoms by 18 years of age) have reported patterns of generalized neurocognitive deficits as compared to healthy comparison subjects (HCSs). Here, the authors examined the longitudinal stability of neuropsychological deficits in adolescents with EOS relative to HCS and the associations of these deficits with short-term functional outcome in patients. METHOD: Fifty-two subjects (26 EOS, 26 HCS) were evaluated using a comprehensive neuropsychological test battery a median of 13 months after baseline examination. The stability of scores and the relationship between baseline test performance and functional outcome in patients was explored. RESULTS: Adolescents with EOS were impaired across neurocognitive domains at baseline and follow-up compared to HCSs; these deficits remained relatively stable over time. Follow-up social/communication, personal living, and community living skills were significantly related to attention/vigilance, working memory and verbal memory at baseline; individual cognitive domains were more strongly related to functional outcome than a global measure of intelligence. CONCLUSIONS: Neuropsychological impairment in patients with EOS appears to remain relatively stable over time regardless of changes in clinical state. In addition, this report offers preliminary support for a longitudinal relationship between neurocognitive performance in specific domains and functional outcome.     

Impact of smoking Behavior on cognitive functioning in persons at risk for psychosis and healthy controls: A longitudinal study

BackgroundThe high prevalence of smoking in individuals who are at ultra-high risk (UHR) for psychosis is well known and moderate cognitive deficits have also been found in UHR. However, the association between smoking and cognition in UHR is unknown and longitudinal studies are lacking.MethodA cohort study with 330 UHR individuals and 66 controls was conducted, as part of the European network of national schizophrenia networks studying gene–environment interactions (EU-GEI). At baseline and after 6, 12, and 24 months, smoking behavior was assessed with the Composite International Diagnostic Interview and cognitive functioning with a comprehensive test battery. Linear mixed-effects analyses were used to examine the multicross-sectional and prospective associations between (change in) smoking behavior and cognitive functioning, accounting for confounding variables.ResultsAt baseline, 53% of UHR and 27% of controls smoked tobacco. Smoking UHR and controls did not significantly differ from nonsmoking counterparts on the tested cognitive domains (speed of processing, attention/vigilance, working memory, verbal learning, or reasoning/problem solving) across different assessment times. Neither smoking cessation nor initiation was associated with a significant change in cognitive functioning in UHR.ConclusionsNo associations were found between smoking and cognitive impairment in UHR nor in controls. However, the fact that one in every two UHR individuals report daily use of tobacco is alarming. Our data suggest that UHR have fewer cognitive impairments and higher smoking cessation rates compared to patients with first-episode psychosis found in literature. Implications to promote smoking cessation in the UHR stage need further investigation.     

Baseline neuropsychological profile and cognitive response to cerebrospinal fluid shunting for idiopathic normal pressure hydrocephalus

OBJECTIVE: To evaluate neurocognitive changes and predict neurocognitive outcome after ventriculoperitoneal shunting for idiopathic normal pressure hydrocephalus (INPH). BACKGROUND: Reports of neurocognitive response to shunting have been variable and studies that predict cognitive outcomes after shunting are limited. We reviewed our experience with cognitive outcomes for INPH patients who were selected for shunting based on abnormal cerebrospinal fluid (CSF) pressure monitoring and positive response in any of the NPH symptoms following large volume CSF drainage. METHODS: Forty-two INPH patients underwent neurocognitive testing and Folstein Mini-Mental State Examination (MMSE) prior to shunting. Neurocognitive testing or MMSEwere performed at least 3 months after shunt insertion. Significant improvement in a neurocognitive subtest was defined as improvement by one standard deviation (1 SD) for the patient's age, sex and education level. Significant improvement in overall neurocognitive outcome was defined as a 4-point improvement in MMSE or improvement by 1 SD in 50% of the administered neurocognitive subtests. Nonparametric tests were used to assess changes. Predictors of outcome were assessed via logistic regression analysis. RESULTS: Twenty-two patients (52.3%) showed overall neurocognitive improvement, and significant improvement was seen in tests of verbal memory and psychomotor speed. Predictive analysis showed that patients scoring more than 1 SD below mean at baseline on verbal memory immediate recall were fourfold less likely to show overall cognitive improvement, and sixfold less likely if also associated with visuoconstructional deficit or executive dysfunction. Verbal memory scores at baseline were higher in patients who showed overall cognitive improvement. CONCLUSIONS: Shunting INPH patients on the basis of CSF pressure monitoring and drainage response shows a significant rate of cognitive improvement, and baseline neurocognitive test scores may distinguish patients likely to respond to shunt surgery from those who will not.     

Social cognition deficits and the 'ultra high risk' for psychosis population: a review of literature

Aim: A number of risk factors for developing a psychotic disorder have been investigated in the ‘ultra high risk’ (UHR) population, including neurocognitive abilities, social functioning and, more recently, social cognition. We aimed to review the literature on social cognition in the UHR population. Methods: Literature was restricted to English articles and identified using Pubmed, Medline, PsychINFO and CINAHLplus, as well as the reference lists of published studies and reviews. Search terms included social cognition, theory of mind, emotion recognition, attributional style, social knowledge, social perception, ‘at risk mental state’, psychosis prodrome ‘clinical high risk’ and ‘ultra high risk’. Inclusion criteria were an outcome measure of a social cognition task and an UHR population defined by a structured validated instrument. Results: Seven original research articles met the inclusion criteria, one of which was a conference abstract. One of the two studies that assessed theory of mind, two of the four studies that assessed emotion recognition and both the two studies that assessed social perception/knowledge found significant deficits in UHR patients. The single study that assessed attributional bias also reported differences in UHR patients compared with healthy controls. Conclusions: There is limited published literature on social cognitive performance in the UHR population. Despite this, deficits in certain social cognitive abilities do appear to be present, but further research with more reliable cross‐cultural measures is needed. The characterization of social cognitive deficits in the UHR populations may aid in the identification of potential markers for development of a subsequent psychotic disorder, as well as targets for early intervention.     

RESEARCH: Cognitive Rehabilitation for Bipolar Disorder: An Open Trial for Employed Patients with Residual Depressive Symptoms

Bipolar disorder is characterized by recurrent episodes of depression and/or mania along with interepisodic mood symptoms that interfere with psychosocial functioning. Despite periods of symptomatic recovery, individuals with bipolar disorder often continue to experience impairments in psychosocial functioning, particularly occupational functioning. Two determinants of psychosocial functioning of euthymic (neither fully depressed nor manic) individuals with bipolar disorder are residual depressive symptoms and cognitive impairment (i.e., difficulties with executive functioning, attention, and memory). The present study explored whether a new cognitive remediation (CR) treatment designed to treat residual depressive symptoms and, for the first time to the best of our knowledge, address cognitive impairment would be associated with improvement in psychosocial functioning in individuals with bipolar disorder. Following a neuropsychological and clinical assessment 18 individuals with DSM‐IV bipolar disorder were treated with 14 individual sessions of CR. Results indicated that at the end of treatment, as well as at the 3‐months follow‐up, patients showed lower residual depressive symptoms, and increased occupational, as well as overall psychosocial functioning. Pretreatment neuropsychological impairment predicted treatment response. Improvements in executive functioning were associated with improvements in occupational functioning. These findings suggest that treating residual depressive symptoms and cognitive impairment may be an avenue to improving occupational and overall functioning in individuals with bipolar disorder.     

Psychosocial and neurocognitive functioning in unipolar and bipolar depression: a 12-month prospective study

Previous studies have revealed psychosocial and cognitive impairments in patients during unipolar and bipolar depression, which persist even in subsyndromal and euthymic states. Currently, little is known about the nature and the extent of psychosocial and cognitive deficits during depression. The aim of the present study was to characterize psychosocial and cognitive profiles among unipolar (MDD) and bipolar (BD) patients during a major depressive episode and to compare the profiles of the patient groups. Depressed patients with MDD (n=13) and BD (n=11) were followed over a period of 12 months. Clinical, psychosocial and neuropsychological assessments were conducted at baseline and at 6-week, 4-month, 8-month and 12-month follow-ups. In the case of severe mood disorders, psychosocial and neurocognitive functioning seem similar among MDD and BD patients during a depressive episode. All MDD and BD patients had global psychosocial dysfunction, characterized by occupational and relational impairments. Furthermore, the neurocognitive profile was heterogeneous with regard to the nature and extent of cognitive deficits but attentional processes were frequently compromised. After 1 year of treatment, occupational and relational impairments, as well as neurocognitive dysfunction, persisted sufficiently to alter daily functioning.     

Social and clinical consequences of cognitive deficits in early psychosis: a two-year follow-up study of first-admitted patients

OBJECTIVE: To explore whether baseline memory and executive deficits predicted poor social and clinical outcome over the 2 years following a first admission for psychosis, regardless of categorical diagnosis. METHOD: Cognitive functioning was assessed in first-admitted subjects with psychosis (n=35) with a neuropsychological battery of tests measuring executive, language and memory functions. Social and clinical outcome were assessed at 6-monthly intervals over a two-year follow-up using multiple sources of information. RESULTS: A dose-response relationship was found between visual and verbal memory performance at first admission and clinical outcome over the 2-year follow-up: the poorer the memory performance, the more likely the risk of presenting with psychotic symptoms and rehospitalization. Poor baseline performance on the WCST executive function predicted better medication adherence. No association was found between cognitive performance and occupational or residential outcome. CONCLUSION: Cognitive performance was a better predictor of clinical than social outcome in this sample of first-episode patients. The association between cognitive deficits and poor social outcome may be more marked in subjects with chronic psychosis than in first-episode subjects. The finding that cognitive deficits predict better medication adherence is in need of further exploration.     

Cognitive and clinical predictors of success in vocational rehabilitation in schizophrenia

Cognitive impairments in schizophrenia appear to be associated with social problem solving, social and vocational functioning, and psychosocial skill acquisition. The present study examined the relationship of cognitive functioning, as well as clinical symptoms, to vocational outcomes among individuals with schizophrenia. One hundred and twelve participants with DSM-IV schizophrenia spectrum diagnoses underwent a comprehensive neuropsychiatric evaluation after enrolling in one of several employment programs. The neuropsychological evaluation examined verbal learning and memory, attention, speed of information processing, and executive functioning. Clinical symptoms were evaluated with the Positive and Negative Syndrome Scale (PANSS). Vocational outcomes were assessed 4 months after baseline assessment and included both measures of employment outcome (e.g., earnings) and of work performance as assessed by the Work Behavior Inventory (WBI). Negative symptoms, learning and memory performance, processing speed, and executive functioning were related to hours, weeks, and wages earned on the job. Stepwise multiple regression analyses found that among baseline clinical and cognitive predictors, only verbal learning and memory and cognitive disorganization symptoms were significant predictors of work behaviors 4 months later. Learning and memory were the only significant predictors of integrated employment at 4 months. These results suggest specific aspects of cognition may be modestly predictive of vocational outcomes.