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People with schizophrenia-spectrum and bipolar disorders have difficulty accurately estimating their abilities and skills (impaired introspective accuracy [IA]) and tend to over- or underestimate their performance. This discrepancy between self-reported and objective task performance has been identified as a significant predictor of functional impairment. Yet, the factors driving this discrepancy are currently unclear. To date, the relationships between sleep quality and IA have not been examined. The current study aimed to explore the relationships between sleep quality and IA in participants diagnosed with schizophrenia (SCZ; n = 36), schizoaffective disorder (SCZ-A; n = 55), and bipolar disorder with psychotic features (BP; n = 87). Participants completed tasks of emotion recognition, estimated their performance on the tasks (used to calculate IA), and provided confidence ratings for their accuracy judgments. Participants also self-reported their sleep quality. These results suggest significantly greater discrepancies between self-reported and actual task scores for those with SCZ and SCZ-A compared to participants with BP. For those with SCZ, lower confidence on the tasks and underestimation of abilities were associated with lower sleep quality, while for those with SCZ-A, lower sleep quality was associated with higher confidence and overestimation of performance. Results suggest differential relationships between diagnostic groups. Future research is needed to further explore the factors driving these differing relationships, particularly the contrasting relationships between SCZ and SCZ-A.

BackgroundThe outbreak of coronavirus disease 2019 (COVID-19) has caused significant stress and mental health problems among the general public. However, persons at greatest risk for poor mental health outcomes, such as people with serious mental illness, have been largely overlooked. ObjectiveThis paper presents the protocol for a study that aims to examine the mental health impact of COVID-19 and social distancing behaviors in people with serious mental illness and the behaviors undertaken to prevent COVID-19 infection in this group. MethodsParticipants will include individuals with serious mental illness (eg, schizophrenia, bipolar disorder) and nonpsychiatric control participants who are currently participating in or have previously participated in several ongoing parent observational studies. Data will be collected from April 2020 through August 2020. Participants will complete phone interviews at 2 time points to assess their current emotional functioning and discuss the measures they have taken to prevent COVID-19 infection. Baseline (pre-COVID-19) mental health, sampled by ecological momentary assessment over an extended period, will be compared with current mental health, also sampled by ecological momentary assessment over an extended period. Demographic, cognitive, and psychosocial factors at baseline will be used to examine risk and resilience to current mental health and coping. ResultsThe inclusion of participants for the first round of telephone assessments started on April 3, 2020 and will be completed by May 31, 2020. As of April 30, 2020, 101 individuals had completed these first-round assessments. The second round of telephone assessments will likely occur between June 1, 2020, and August 31, 2020. Study results will be published in peer-reviewed scientific journals. ConclusionsOur findings will have broad implications for understanding the psychological consequences of COVID-19 among vulnerable persons with serious mental illness and will provide the opportunity to identify targets to reduce negative outcomes in the future. We also hope our efforts will provide a roadmap and resources for other researchers who would like to implement a similar approach. International Registered Report Identifier (IRRID)DERR1-10.2196/19203

OBJECTIVE: Suicidal behavior is heritable and is a major cause of death worldwide. Two large-scale genome-wide association studies (GWASs) recently discovered and cross-validated genome-wide significant (GWS) loci for suicide attempt (SA). The present study leveraged the genetic cohorts from both studies to conduct the largest GWAS meta-analysis of SA to date. Multi-ancestry and admixture-specific meta-analyses were conducted within groups of significant African, East Asian, and European ancestry admixtures. METHODS: This study comprised 22 cohorts, including 43,871 SA cases and 915,025 ancestry-matched controls. Analytical methods across multi-ancestry and individual ancestry admixtures included inverse variance-weighted fixed-effects meta-analyses, followed by gene, gene-set, tissue-set, and drug-target enrichment, as well as summary-data-based Mendelian randomization with brain expression quantitative trait loci data, phenome-wide genetic correlation, and genetic causal proportion analyses. RESULTS: Multi-ancestry and European ancestry admixture GWAS meta-analyses identified 12 risk loci at p values

BACKGROUND: Social determinants of health (SDoHs) are receiving growing attention and are particularly relevant to persons with schizophrenia-spectrum psychotic disorders (SSPDs), considering their heightened risk of comorbidities, cognitive and functional decline, and early mortality. Yet, we did not find any comprehensive review of multiple SDoHs in SSPD. STUDY DESIGN: We conducted a scoping review of meta-analyses and systematic reviews of nine major SDoHs in SSPD. STUDY RESULTS: Childhood abuse, parental psychopathology, parental communication problems, bullying, and urban settings with lower socioeconomic status were major risk factors for the greater incidence of SSPD and/or worse health. Social network size was inversely associated with overall psychopathology and negative symptoms. Experiences of racial/ethnic discrimination correlated with the prevalence of psychotic symptoms and experiences. Compared to native populations, the risk of psychosis was higher in immigrants, refugees, and asylees. Social fragmentation was associated with an increased prevalence of schizophrenia. Homeless populations had a 30-fold higher prevalence of schizophrenia than the general population. Seriously mentally ill people were 2.7 times more likely to report food insecurity than controls. The prevalence of non-affective psychosis in prisoners was 2.0%-6.5%, compared to 0.3% in the general population. Certain potentially positive factors like family and community resilience remain poorly studied. CONCLUSIONS: SDoHs are associated with higher rates of and worse outcomes in SSPD. Well-designed longitudinal studies are needed to understand SDoHs contribution to health in persons with SSPD, to develop interventions, and to implement changes in clinical care and public health policies that would reduce adverse health impacts of SDoHs. Positive SDoHs deserve greater attention.

BackgroundThere are a few ecologically valid measurements of Daily Living Skills (DLS)-a critical component of adaptive functioning (AF)-for autistic adolescents and young adults. This is particularly important given that DLS predict outcomes as autistic adolescents transition to adulthood.MethodsWe pilot-tested the assessment section of two modules of the Computerized Functional Skills Assessment and Training program (CFSAT) in 25 autistic (n = 4 female) and 25 non-autistic (n = 6 female) adolescents and young adults to evaluate preliminary feasibility in an autistic sample. Tasks involved using an ATM and ticket-buying machine. We also assessed AF and DLS with a well-validated self-report questionnaire. We examined group differences in performance and relationships between performance on CFSAT and an existing measure of AF and DLS. We also conducted regression analyses to investigate the associations between age, IQ, executive functioning (EF), and CFSAT task performance.ResultsAll but one autistic participant were able to complete the CFSAT tasks. Autistic participants made more errors, but did not take longer to complete the task, than non-autistic participants. Performance correlated strongly with self-reported AF generally and DLS specifically. The regression analyses revealed that task performance was associated with EF in the autistic group, but not the non-autistic group.ConclusionsThese results provide preliminary support for the use of a new performance-based ecologically valid assessment of DLS in an autistic population. Two CFSAT modules were well-tolerated and detected differences in DLS ability. Strong correlations with an existing measure of AF suggest evidence of construct validity. The EF was associated with CFSAT task performance in autistic individuals. Such a tool could help identify individuals who would benefit from a DLS intervention.

INTRODUCTION: Mood states have been reported to manifest a cross-sectional correlation with self-assessment accuracy across functional domains and psychiatric conditions. Ecological momentary assessment (EMA) provides a strategy to examine the momentary course and correlates of mood states. This study tested the association of moods assessed longitudinally with accuracy of immediate self-assessments of cognitive test performance in participants with schizophrenia and bipolar disorder. METHODS: 240 well-diagnosed participants with schizophrenia and bipolar disorder completed a subset of tests from the MATRICS Consensus Cognitive Battery and an immediate self-assessment of cognitive performance. Differences between actual and self-reported performance were used to index the accuracy of self-assessment. Daily smartphone EMA, 3× per day for 30 days, sampled participants´ momentary moods (sad, happy, relaxed, anxious), aggregated into positive affect and negative affect (NA). RESULTS: Bipolar participants had better cognitive performance, but both samples had equivalent mis-estimation. Repeated-measures analyses found that NA did not manifest significant variability over time either between or within participants in the two diagnostic groups. Within-group analyses found that higher average NA was associated with greater mis-estimation and poorer cognitive performance in participants with bipolar disorder, but not in those with schizophrenia. CONCLUSION: Negative moods had a significant association with impairments in self-assessment of cognitive performance in participants with bipolar disorder. Our study did not confirm previous cross-sectional findings of more accurate self-assessment associated with greater NA in schizophrenia. These findings suggest that cross-sectional assessments, particularly self-reports, may lead to different results than aggregated data from longitudinal evaluations.

Participants with schizophrenia (SCZ) and bipolar disorder (BD) have challenges in self-evaluation of their cognitive and functional abilities, referred to as introspective accuracy (IA). Although psychotic symptoms are commonly found to be uncorrelated with cognitive performance, many models of the development of delusions focus on failures in self-assessment and responses biases during momentary monitoring. We performed a single 4-test cognitive assessment on 240 participants (schizophrenia n = 126; bipolar disorder n = 114) and asked them to make a judgment about their performance immediately after completion of each task. We related performance and these judgments to results of Ecological Momentary Assessments (EMA) of the momentary occurrence of psychotic symptoms (Voices, paranoid ideas, other delusions) collected over up to 90 surveys over a 30 days prior to the single cognitive assessment. We examined test performance and the accuracy of self-assessment at that assessment, looking at diagnostic differences in performance and mis-estimation of performance. Participants with bipolar disorder had better cognitive performance, but there were no differences in mis-estimation. Analyses of the correlation between cognitive performance and self-assessment were all significant and better cognitive performance predicted reduced errors in self-assessment. Examination of the 30-day course of psychotic symptoms and IA could only be performed in participants with schizophrenia, revealing correlations between more common occurrences of all three psychotic symptoms and increased absolute values for IA errors. These data are consistent with theories of cognitive response biases and the formation of delusions.

BACKGROUND: Avolition is associated cross-diagnostically with extensive functional impairment. Participants with schizophrenia and bipolar disorder (BD) engage in fewer productive activities than healthy controls, with more sedentary activities such as sitting. We examined the temporal variability in activities of participants with schizophrenia and bipolar disorder, focusing on persistence of activities and the likelihood of performing more than one activity at a time. METHODS: 101 participants with schizophrenia and 76 participants with BD were sampled 3 times per day for 30 days utilizing Ecological Momentary Assessment surveys. Each survey queried current activities along with questions about who they were with and if they were home or away and moods. We separated activities into productive, unproductive, or passive recreational categories. RESULTS: Participants with schizophrenia and bipolar disorder reported one activity on most surveys, with that activity commonly being passive or unproductive. No participant reported engaging in more than one productive activity. Productive activities were more likely to occur away from home, with 17 % of surveys from home reporting productive activities. All three activities were persistent, but passive and unproductive activities were more likely than productive activities to be persistent at home. Negative mood states predicted unproductive and passive activities in BD participants only. DISCUSSION: The low numbers of activities, combined with persistence of unproductive and passive activities highlights the impact of avolition. Most persistent activities reflected sedentary behavior. People with schizophrenia or bipolar disorder may benefit from interventions targeting leaving home more often to improve their general levels of functioning and overall health.

BACKGROUND: Cognitive tasks delivered during ecological momentary assessment (EMA) may elucidate the short-term dynamics and contextual influences on cognition and judgements of performance. This paper provides initial validation of a smartphone task of facial emotion recognition in serious mental illness. METHODS: A total of 86 participants with psychotic disorders (non-affective and affective psychosis), aged 19-65, were administered in-lab gold standard affect recognition, neurocognition, and symptom assessments. They subsequently completed 10 days of the mobile facial emotion recognition task, assessing both accuracy and self-assessed performance, along with concurrent EMA of psychotic symptoms and mood. Validation focused on task adherence and predictors of adherence, gold standard convergent validity, and symptom and diagnostic group variation. RESULTS: The mean rate of adherence to the task was 79%; no demographic or clinical variables predicted adherence. Convergent validity was observed with in-lab measures of facial emotion recognition, and no practice effects were observed on the mobile facial emotion recognition task. EMA reports of more severe voices, sadness, and paranoia were associated with worse performance, whereas mood more strongly associated with self-assessed performance. CONCLUSION: The mobile facial emotion recognition task was tolerated and demonstrated convergent validity with in-lab measures of the same construct. Social cognitive performance, and biased judgements previously shown to predict function, can be evaluated in real-time in naturalistic environments.

BACKGROUND: Emotion recognition deficits are linked with social dysfunction in psychosis, as is inaccurate self-assessment of emotion recognition abilities. However, little is known about the link between ER and real-time social appraisals and behavior. METHODS: In 136 people with psychotic disorders or affective disorder with psychosis we administered a novel ecological momentary cognitive test of emotion recognition which both assesses emotion recognition ability and self-assessed performance in conjunction with ecological momentary assessment of social appraisals, motivation, and time spent alone. Hybrid mixed effects models evaluated emotion recognitions associations with social experiences. RESULTS: Better recognition ability was associated with greater pleasure and more positive appraisals of others during interactions, whereas accuracy of self-assessment of emotion recognition ability was associated with more positive appraisals of interactions and social motivation. Overestimation of emotion recognition was linked with concurrent higher social motivation yet greater desire to avoid others. Time alone was unrelated to emotion recognition ability or self-assessment of ability. DISCUSSION: Mobile emotion recognition performance was associated with appraisals of recent interactions but not behavior. Self-assessment of social cognitive performance was associated with more positive appraisals and social motivation, and may be a novel target for interventions aimed at social dysfunction.

Milestone achievements are reduced in people with schizophrenia and are lower in comparison to people with bipolar disorder. However, it is not clear what the implications are for engagement in momentary activities based on milestone achievements. Further, some recent research has suggested that psychotic symptoms are associated with challenges in self-assessment of activities, but there is less information about the correlations of milestone achievements and ongoing psychotic symptoms. We examined momentary activities and symptoms as a function of lifetime milestone achievement in 102 individuals with schizophrenia and 71 with bipolar disorder. Ecological Momentary Assessment (EMA) was used to sample daily activities and concurrent symptoms 3 times per day for 30 days. Each survey asked the participant where they were, who they were with, and what they were doing, as well as sampling the concurrent presence of psychotic symptoms. Not being financially responsible for their residence was associated with engaging in fewer productive activities. Participants who never had a relationship were more commonly home and alone and engaged in fewer social interactions. A lifetime history of employment was correlated with engaging in more productive activities, including at home. More common momentary psychosis was seen in participants who failed to achieve each of the functional milestones. Lifetime milestone achievements were associated with greater frequencies of productive behaviors and with fewer momentary experiences of psychosis, suggesting that psychotic symptoms may have importance for sustaining disability that would be challenging to detect without momentary information.

Childhood trauma (CT) is associated with suicidal ideation and behaviors (SI/SB) in people with psychosis. The interpersonal psychological theory of suicide (IPTS) suggests that there are four factors that increase suicide risk: thwarted belongingness, perceived burdensomeness, acquired capacity for suicide, and hopelessness. The IPTS constructs and social cognitive biases are associated with SI/SB in psychotic disorders. However, the role of CT in IPTS constructs and social cognitive biases has not been examined in psychosis. In an outpatient community sample of persons with psychotic disorders (N = 96) assessed with the Childhood Trauma Questionnaire, the aims of this study were to a) evaluate rates of CT in this sample, b) determine the relationship between CT types and lifetime SI/SB, and c) explore the relationship between CT types, IPTS constructs, and social cognitive biases. All participants reported experiencing CT. Emotional abuse was associated with greater SI severity and higher rates of lifetime suicide attempts, as well as with greater perceived burdensomeness and more severe negative social cognitive biases. Other CT types were minimally associated with SI/SB or IPST constructs; hopelessness was not associated. Overall, negative interpersonal beliefs and social cognitive biases may explain how CT increases suicide risk in psychosis.

OBJECTIVES: Schizophrenia participants generate self-reports of their competencies that differ from objective information. They may base their reports on momentary moods or experiences rather than objective data. Theories of delusion formation implicate overconfidence during self-assessment as a cause. METHODS: Ecological momentary assessment (EMA) was used to sample activities and experiences in 101 participants with schizophrenia up to 3 times a day for 30 days. Each survey asked where and with whom they were, what they were doing, and moods and psychotic symptoms they were experiencing. Self-reports and observer ratings of competence in work and everyday activities were collected. RESULTS: Being home was associated with self-reports of better functioning in activities and work skills (p

The MATRICS Consensus Cognitive Battery (MCCB) is a gold-standard tool for assessing cognitive functioning in individuals with severe mental illness. This study is an initial examination of the validity of remote administration of 4 MCCB tests measuring processing speed (Trail Making Test: Part A, Animal Fluency), working memory (Letter-Number Span), and verbal learning and memory (Hopkins Verbal Learning Test-Revised). We conducted analyses on individuals with bipolar disorder (BD) and schizophrenia-spectrum disorders (SCZ), as well as healthy volunteers, who were assessed in-person (BD = 80, SCZ = 116, HV = 14) vs. remotely (BD = 93, SCZ = 43, HV = 30) to determine if there were significant differences in performance based on administration format. Additional analyses tested whether remote and in-person assessment performance was similarly correlated with symptom severity, cognitive and social cognitive performance, and functional outcomes. Individuals with BD performed significantly better than those with SCZ on all MCCB subtests across administration format. Animal Fluency did not differ by administration format, but remote participants performed significantly worse on Trail Making and HVLT-R. On the Letter-Number Span task, individuals with bipolar disorder performed significantly better when participating remotely. Finally, patterns of correlations with related constructs were largely similar between administration formats. Thus, results suggest that remote administration of some of the MCCB subtests may be a valid alternative to in-person testing, but more research is necessary to determine why some tasks were affected by administration format.

It is critical to intervene early in the mild cognitive impairment (MCI) stage of the Alzheimers disease trajectory, but traditional cognitive testing methods are costly, burdensome, and difficult to access. We examined adherence and validity data to a 30-day self-administered ecological momentary cognitive testing protocol among a sample of older adults with MCI and cognitively normal controls to evaluate feasibility, tolerability, and initial validity in comparison to standard neuropsychological tests. Participants included 48 participants with MCI (Mean age = 72 years, SD = 7 years) and 46 demographically-matched cognitively normal (NC) control participants (Mean age = 70 years, SD = 7 years). Participants completed traditional neuropsychological testing to determine MCI status, followed by 30 days of remote ecological momentary cognitive testing. Ecological momentary assessment (EMA) surveys were administered 3 times per day for 30 days (possible total = 90), and mobile cognitive tests were administered every other day (for a total of 15 administrations). Mobile cognitive tests included the Variable Difficulty List Memory Test (VLMT; measure of learning and memory), Memory Matrix (measure of visual working memory), and the Color Trick Test (measure of executive function). EMA and mobile cognitive test adherence, fatigue effects, mobile cognitive test performance and group differences, and psychometrics (reliability, convergent validity, ceiling effects, and practice effects) were examined. Overall mean-level adherence to the mobile cognitive tests was 85% and did not differ by MCI status. The reliability of stable between-person individual differences for the VLMT and Memory Matrix were very high. Moreover, although the reliability of within-person change for Memory Matrix was adequate, the corresponding reliability for VLMT was somewhat low. Averaged performance on the mobile cognitive tests was correlated with lab-based tests measuring the same construct. Participants with MCI performed worse than NCs on the VLMT and Color Trick Test, and there was no evidence of fatigue effects for these two tests. These findings support the feasibility and potential for ecological momentary cognitive testing to support clinical trials and for measuring cognitive changes over time in persons with increased risk for Alzheimers disease such as those with MCI.

The Research Domain Criteria (RDoC) initiative aims to organize research according to domains of brain function. Dysfunction within these domains leads to psychopathology that is classically measured with rating scales. Examining the correspondence between the specific measures assessed within rating scales and RDoC domains is necessary to assess the needs for new RDoC-focused scales. Such RDoC-focused scales have the potential of allowing translation of this work into the clinical domain of measuring psychopathology and designing treatment. Here, we describe an initial qualitative assessment by a group of 10 clinician-scientists of the alignment between RDoC domains and the items within five commonly used rating scales. In this commentary, we report limited correspondence and make recommendations for future work needed to address these limitations.

OBJECTIVES: People with schizophrenia have challenges in their self-assessments of everyday functioning and those who report no sadness also tend to overestimate their everyday functional abilities. While previous studies were cross-sectional, this study related longitudinal assessments of sadness to self-reports of abilities in domains of everyday functioning and cognitive abilities. METHODS: 71 people with bipolar illness (BPI) were compared to 102 people with schizophrenia (SCZ). Participants were sampled 3 times per day for 30 days with a smartphone-based Ecological Momentary Assessment (EMA) survey. Each survey asked where they were, with whom they were, what they were doing, and if they were sad. Performance based assessments of executive functioning, social competence, and everyday activities were collected after the EMA period, at which time the participants and observers were asked to provide ratings of three different domains of everyday functioning and neurocognitive ability. RESULTS: 18% of participants with SCZ reported that they were never sad on any one of the 90 EMA surveys. Reports of never being sad were associated with overestimated functioning compared to observers and SCZ participants who reported that they were never sad were more commonly home and alone than both SCZ participants who reported occasional sadness and participants with BPI. These participants reported being significantly happier than all people in the study. IMPLICATIONS: Reporting that you were never sad was associated with overestimation of everyday functioning and cognitive abilities. Although participants who were never sad did not perform more poorly on objective measures than those were occasionally sad, their self-assessed functioning was significantly elevated. These data suggest that negative symptoms constructs such as reduced emotional experience need to consider reduced ability to subjectively evaluate emotional experience as a feature of negative symptoms.

INTRODUCTION: Performance-based assessments of social skills have detected impairments in people with severe mental illness and are correlated with functional outcomes in people with schizophrenia and bipolar disorder. The most common of these assessments, the Social Skills Performance Assessment (SSPA), has two communication scenarios and items measuring both social competence and appropriateness. As real-world competence and appropriateness appear to have different correlates, we hypothesized that SSPA Items measuring competence and appropriateness would be distinct and have different correlations with other outcomes. METHODS: We aggregated data from 557 people with schizophrenia, 106 with bipolar disorder, and 378 well controls from 4 separate research studies. All participants were assessed with both SSPA scenarios and other performance based and clinician-rated measures. A single expert rated the SSPA interactions for competence and appropriateness while blind to participant diagnoses. RESULTS: Participants with bipolar disorder and schizophrenia performed more poorly on every item of the SSPA than healthy controls. Items measuring social competence and appropriateness in communication were intercorrelated across scenarios, as were elements of socially competent communication, although the items measuring competence did not correlate substantially with appropriateness. Items assessing social competence, but not social appropriateness, correlated with better cognitive and functional performance and residential and financial independence. DISCUSSION: Social competence and social appropriateness were distinct elements of performance-based social skills with potential differences in their functional correlates. As both social competence and appropriateness impact functional outcomes, improvement in the measurement and treatment of appropriate communication seems to be an important goal.

BACKGROUND: Performance monitoring entails rapid error detection to maintain task performance. Impaired performance monitoring is a candidate pathophysiological process in psychotic disorders, which may explain the broader deficit in executive function and its known associations with negative symptoms and poor functioning. The current study models cross-sectional pathways bridging neurophysiological measures of performance monitoring with executive function, symptoms, and functioning. METHODS: Data were from the 20-year assessment of the Suffolk County Mental Health Project. Individuals with psychotic disorders (N = 181) were originally recruited from inpatient psychiatric facilities. Data were also collected from a geographically and demographically matched group with no psychosis history (N = 242). Neural measures were the error-related negativity (ERN) and error positivity (Pe). Structural equation modeling tested mediation pathways. RESULTS: Blunted ERN and Pe in the clinical cohort related to impaired executive function (r = 0.26-0.35), negative symptom severity (r = 0.17-0.25), and poor real-world functioning (r = 0.17-0.19). Associations with executive function were consistent across groups. Multiple potential pathways were identified in the clinical cohort: reduced ERN to inexpressivity was mediated by executive function (β = 0.10); reduced Pe to global functioning was mediated by executive function and avolition (β = 0.10). CONCLUSIONS: This supports a transdiagnostic model of psychotic disorders by which poor performance monitoring contributes to impaired executive function, which contributes to negative symptoms and poor real-world functioning. If supported by future longitudinal research, these pathways could inform the development of targeted interventions to address cognitive and functional deficits that are central to psychotic disorders.

BACKGROUND: People with psychotic disorders are at an increased risk of suicide, but there is little understanding of suicidal ideation (SI) in this population. The Interpersonal Psychological Theory of Suicide posits that perceived burdensomeness (PB) and thwarted belonginess (TB) contribute to SI. To our knowledge there are no studies using ecological momentary assessment (EMA) to assess these interpersonal risk factors in a sample of individuals with psychotic disorders. This study investigated the validity and variability of PB and TB, and whether SI, EMA-measured psychotic symptoms, mood, and social context relate to PB and TB. METHOD: Ninety-six participants with a psychotic disorder, including mood disorders with psychosis completed in-lab assessments of current SI, and then EMA surveys on a smartphone 3×/day for 10 days, answering questions about burdensomeness, belongingness, symptoms (i.e., hearing voices, experiencing suspiciousness), mood (i.e., happy, sad), and social context. RESULTS: Burdensomeness varied within-participants less than belongingness (t (95) = -3.74, p=< .001). Participants with SI had higher mean burdensomeness ratings (t (94) = -2.70, p < .01) and lower mean belongingness ratings (t (94) = 3.68, p < .001) than did participants without SI. Being with others, greater psychotic experiences, less happiness, and greater sadness related to greater burdensomeness. SI status, being alone, greater psychotic experiences, less happiness, and greater sadness related to less belongingness. CONCLUSIONS: This study examined the real-time influences of SI and psychotic symptoms on burdensomeness and belongingness. Hearing voices, suspiciousness, mood, and SI are related to interpersonal suicide-related risk factors. In this sample, social context had a differential effect on burdensomeness and belongingness.

People with schizophrenia (SCZ) and bipolar disorder (BD) have challenges in self-evaluation of their cognitive and functional performance (introspective accuracy). They also manifest response biases, with tendencies toward overestimation. This study aimed to examine objective test performance, momentary judgments of performance, momentary confidence, and subsequent global judgments of performance on a metacognitive version of the Wisconsin Card Sorting Test (WCST). This sample included 99 participants with SCZ and 67 with BD. After each of the 64 WCST trials, participants reported whether they believed their sort was correct and how confident they were in that judgment, they then received performance feedback. After completion of the entire task, participants generated a global performance judgment. On average, the SCZ group got 31 sorts correct, reporting being correct on 49 whereas the BD group got 37 trials correct but reported being correct on 53. For participants with BD, sorting performance correlated with trial x trial accuracy judgments, confidence, and predicted global judgments. For SCZ participants, performance minimally correlated with trial x trial accuracy judgments, confidence, and global judgments, while trial x trial confidence was strongly associated with trial x trial accuracy judgments (r = 0.58). Our findings suggest that confidence in participants with BD is correlated with task performance, whereas in SCZ confidence was entirely associated with self-generated performance judgments. SCZ participants manifested challenges with utilization of feedback. Global judgments of performance were predicted by task performance and confidence for BD participants, with performance and confidence judgments occurring prior to generation of the global performance judgments.

OBJECTIVES: Disability is common in bipolar disorder (BD) and predicted by persistent sadness. We used ecological momentary assessment (EMA) to examine daily activities in people with BD and schizophrenia. We classified activities as productive, unproductive, or passive recreation, relating them to momentary sadness, location, and social context. METHODS: 71 people with BD and 102 people with schizophrenia were sampled 3 times/day for 30 days with an EMA survey. Each survey asked where they were, with whom, what they were doing, and if they were sad. RESULTS: People with BD were home more than 50% of the time. There were no differences in prevalence of activity types across diagnoses. People with BD were less likely to report only one activity since the prior survey, but the most surveys still reported only one. For both groups, sadness and being home and alone since the last survey was associated with less productive activity and more passive recreation. CONCLUSIONS: Participants with BD and schizophrenia manifested high levels of unproductive and passive activities, predicted by momentary sadness. These activity patterns are consistent with descriptions of avolition and they minimally differentiated people with BD and schizophrenia. Previous reports of negative symptoms in BD may have been identifying these behaviors.

Smartphone-based ecological mobile cognitive tests (EMCTs) can measure cognitive abilities in the real world, complementing traditional neuropsychological assessments. We evaluated the validity of an EMCT of recognition memory designed for use with people with serious mental illness, as well as relevant contextual influences on performance. Participants with schizophrenia (SZ), schizoaffective disorder, and bipolar disorder (BD) completed in-lab assessments of memory (Hopkins Verbal Learning Test, HVLT), other cognitive abilities, functional capacity, and symptoms, followed by 30 days of EMCTs during which they completed our Mobile Variable Difficulty List Memory Test (VLMT) once every other day (3 trials per session). List length on the VLMT altered between 6, 12, and 18 items. On average, participants completed 75.3% of EMCTs. Overall performance on VLMT 12 and 18 items was positively correlated with HVLT (ρ = 0.52, P < .001). People with BD performed better on the VLMT than people with SZ. Intraindividual variability on the VLMT was more specifically associated with HVLT than nonmemory tests and not associated with symptoms. Performance during experienced distraction, low effort, and out of the home location was reduced yet still correlated with the in-lab HVLT. The VLMT converged with in-lab memory assessment, demonstrating variability within person and by different contexts. Ambulatory cognitive testing on participants personal mobile devices offers more a cost-effective and ecologically valid measurement of real-world cognitive performance.

OBJECTIVES: People with schizophrenia (SCZ) and bipolar illness (BPI) generate self-reports of their functioning that diverge from objective information. It has been suggested that these participants do not base such reports on daily experiences, relying on other information. We used ecological momentary assessment (EMA) to sample socially relevant daily activities in SCZ and BPI and related them to self-reported and observer-rated social functioning and social cognitive ability. METHODS: 71 people with (BPI) were compared to 102 people with SCZ. Participants were sampled 3 times per day for 30 days with a smartphone-based survey. Each survey asked where they were, with whom they were, what they were doing, and if they were sad. Participants and observers were asked to provide ratings on social functioning and social cognitive abilities at the end of the EMA period. RESULTS: There was no association between being home or alone and self-reports of everyday social functioning. In contrast observer ratings were highly correlated with the momentary survey results. Reports of very low levels of sadness were associated with overestimated functioning and participants who were commonly home and alone rated their social functioning as better than participants who were commonly away in the presence of others. IMPLICATIONS: Both SCZ and BPI were marked by a disconnect between momentary experiences and self-reports. The largest effect was overestimation of functioning by participants who reported no sadness. Experience appears important, as participants who were routinely home and alone reported better social functioning than participants who spent more time others.

Individuals with severe mental illnesses (SMIs) may be disproportionately vulnerable to COVID-19 infection and psychological distress. This study investigated the prevalence of engagement in COVID-19 preventative behaviors, predictors of these behaviors, and COVID-19-related psychological distress. One hundred and sixty-three individuals with SMIs (94 with schizophrenia spectrum illnesses and 69 with affective disorders) and 27 psychiatrically healthy comparison participants were recruited from ongoing studies across 3 sites, to complete a phone survey querying implementation of 8 specific COVID-19 preventative behaviors that participants engaged in at least once in the past month as well as standard assessments of depression, anxiety, perceived stress, loneliness, and coping. Data were collected between 3 April 2020 and 4 June 2020. The large majority of our SMI sample, which consisted of outpatients with relatively mild symptom severity, endorsed engaging in multiple preventative behaviors. Relatively few differences were found between groups; however, individuals with SMI were less likely to work remotely than healthy individuals and individuals with schizophrenia spectrum illness were less likely to stay home as a preventative measure, wear face masks, and work remotely than individuals with affective disorders. Differences in staying home remained after controlling for potential confounds. Although individuals with SMI reported more psychological distress related to COVID-19, this distress was largely unrelated to engagement in preventative behaviors. The large majority of individuals with SMI in this outpatient sample, regardless of broad diagnostic category, reported performing multiple behaviors intended to prevent COVID-19 infection at least once a month and reported distress associated with the pandemic. These findings suggest a good level of awareness of COVID-19 among stable outpatients with SMI. The degree to which more acutely ill persons with SMI engage in such preventative behaviors, however, remains to be examined.

The current management of patients with primary psychosis worldwide is often remarkably stereotyped. In almost all cases an antipsychotic medica-tion is prescribed, with second-generation antipsychotics usually preferred to first-generation ones. Cognitive behavioral therapy is rarely used in the vast majority of countries, although there is evidence to support its efficacy. Psychosocial interventions are often provided, especially in chronic cases, but those applied are frequently not validated by research. Evidence-based family interventions and supported employment programs are seldom implemented in ordinary practice. Although the notion that patients with primary psychosis are at increased risk for cardiovascular diseases and diabetes mellitus is widely shared, it is not frequent that appropriate measures be implemented to address this problem. The view that the management of the patient with primary psychosis should be personalized is endorsed by the vast majority of clinicians, but this personalization is lacking or inadequate in most clinical contexts. Although many mental health services would declare themselves recovery-oriented, it is not common that a focus on empowerment, identity, meaning and resilience is ensured in ordinary practice. The present paper aims to address this situation. It describes systematically the salient domains that should be considered in the characterization of the individual patient with primary psychosis aimed at personalization of management. These include positive and negative symptom dimensions, other psychopathological components, onset and course, neurocognition and social cognition, neurodevelopmental indicators; social functioning, quality of life and unmet needs; clinical staging, antecedent and concomitant psychiatric conditions, physical comorbidities, family history, history of obstetric complications, early and recent environmental exposures, protective factors and resilience, and internalized stigma. For each domain, simple assessment instruments are identified that could be considered for use in clinical practice and included in standardized decision tools. A management of primary psychosis is encouraged which takes into account all the available treatment modalities whose efficacy is supported by research evidence, selects and modulates them in the individual patient on the basis of the clinical characterization, addresses the patients needs in terms of employment, housing, self-care, social relationships and education, and offers a focus on identity, meaning and resilience.

BACKGROUND: Ecological momentary assessment (EMA) offers a highly valid strategy to assess everyday functioning in people with severe mental illness. Adherence is generally good, but several questions regarding the impact of study length, daily density of sampling, and symptom severity on adherence remain. METHODS: EMA adherence in two separate studies was examined. One sampled participants with schizophrenia (n=106) and healthy controls (n=76) 7 times per day for 7 days and the other sampled participants with schizophrenia (n=104) and participants with bipolar illness (n=76) 3 times per day for 30 days. Participants were asked where they were, who they were with, what they were doing and how they were feeling in both studies. The impact of rates of very early adherence on eventual adherence was investigated across the samples, and adherence rates were examined for associations with mood state and most common location when answering surveys. RESULTS: Median levels of adherence were over 80% across the samples, and the 10th percentile for adherence was approximately 45% of surveys answered. Early adherence predicted study-long adherence quite substantially in every sample. Mood states did not correlate with adherence in the patient samples and being home correlated with adherence in only the bipolar sample. IMPLICATIONS: Adherence was quite high and was not correlated with the length of the study or the density of sampling per study day. There was a tendency for bipolar participants who were more commonly away from home to answer fewer surveys but overall adherence for the bipolar patients was quite high. These data suggest that early nonadherence is a potential predictor of eventual nonadherence and study noncompletion.

Objective: The development and deployment of technology-based assessments of clinical symptoms are increasing. This study used ecological momentary assessment (EMA) to examine clinical symptoms and relates these sampling results to structured clinical ratings. Methods: Three times a day for 30 days, participants with bipolar disorder (n=71; BPI) or schizophrenia (n=102; SCZ) completed surveys assessing five psychosis-related and five mood symptoms, in addition to reporting their location and who they were with at the time of survey completion. Participants also completed Positive and Negative Syndrome Scale (PANSS) interviews with trained raters. Mixed-model repeated-measures (MMRM) analyses examined diagnostic effects and the convergence between clinical ratings and EMA sampling. Results: In total, 12,406 EMA samples were collected, with 80-percent adherence to prompts. EMA-reported psychotic symptoms manifested substantial convergence with equivalent endpoint PANSS items. Patients with SCZ had more severe PANSS and EMA psychotic symptoms. There were no changes in symptom severity scores as a function of the number of previous assessments. Conclusions: EMA surveyed clinical symptoms converged substantially with commonly used clinical rating scales in a large sample, with high adherence. This suggested that remote assessment of clinical symptoms is valid and practical and was not associated with alterations in symptoms as a function of reassessment, with additional benefits of in the moment sampling, such as eliminating recall bias and the need for informant reports.

ObjectiveIndividuals with severe mental illnesses (SMI), including schizophrenia spectrum illnesses and affective disorders, may be at increased risk for negative mental health outcomes related to the COVID-19 pandemic. This study compared the severity of pre-pandemic symptoms and affective experiences to current symptoms to evaluate this possibility.Methods148 individuals with SMI (92 with schizophrenia spectrum illnesses and 56 with affective disorders) were recruited from ongoing ecological momentary assessment studies that sampled day-to-day experiences and symptom severity prior to the pandemic. Participants completed a one-time phone survey that queried these same experiences/symptoms between April and June of 2020.ResultsSeverity of affective experiences and psychotic symptoms remained stable across time, as did sleep duration. Well-being and the number of substances used increased during the early months of the pandemic. Increases in well-being were associated with being female and spending less time alone pre-pandemic. Patterns of stability/change did not differ according to diagnostic category.ConclusionsAt this relatively early stage, individuals with SMI are not reporting a worsening of symptoms or affective experiences and instead appear to be resilient in the face of the pandemic. Continued assessment is needed to determine whether this resilience will persist as the pandemic progresses.