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Evidence-based treatments for binge eating disorder (BED), such as cognitive behavioral therapy (CBT) lead to successful outcomes only about half the time. Individuals with BED often have measurable deficits in executive function (EF) that may challenge adherence to or impact of cognitive behavioral intervention components. The aim of this study was to evaluate the impact of adding EF training to CBT by combining CBT with a compensatory cognitive training approach (EF-CBT). Participants were 32 adults with BED, overweight/obesity, and comorbid anxiety or depression who were randomly assigned to four months of group treatment in either standard CBT or EF-CBT. Outcomes were assessed at baseline, post-treatment, and at 2-month follow-up. Results showed that EF-CBT was feasible and acceptable, comparable to CBT. Both groups significantly decreased loss of control (LOC) days, clinical impairment, and depression at post-treatment and 2-month follow-up; though there were no differences between groups. Neither group significantly reduced anxiety or weight. Exploratory analyses found that participants with lower EF treated with EF-CBT were less likely to have LOC at post-treatment than those with lower EF treated with CBT. Higher self-monitoring rates during treatment were associated with lower LOC at post-treatment and participants with lower EF were more likely to self-monitor in the EF-CBT arm relative to the CBT arm. These findings suggest that EF-CBT is feasible, acceptable and efficacious, although larger scale research is needed. EF-CBT may be particularly suited for individuals with BED who have lower EF.

We investigated subjective cognitive complaints (SCCs), as well as physical and mental health factors, in adults and older adults. U.S. residents (N = 2,962) were recruited via the Amazon Mechanical Turk platform and completed a 90-item survey. Overall, 493/1930 (25.5%) of younger adults and 278/1032 (26.9%) of older adults endorsed SCCs. Analyses revealed worse physical and mental health characteristics in the SCC+ compared to the SCC- group, with primarily medium (Cohen's d = 0.50) to large (0.80) effect sizes. Age did not moderate relationships between SCCs and physical/mental health. Results suggest that SCCs are associated with a diverse set of negative health characteristics such as poor sleep and high body mass index, and lower levels of positive factors, including happiness and wisdom. Effect sizes of psychological correlates were at least as large as those of physical correlates, indicating that mental health is critical to consider when evaluating SCCs.

ObjectiveNegative symptoms and cognitive impairment in schizophrenia (SZ) remain unmet treatment needs as they are highly prevalent, associated with poor functional outcomes, and resistant to pharmacologic treatment. The current pilot randomized controlled trial examined the efficacy of an integrated Cognitive-Behavioral Social Skills Training and Compensatory Cognitive Training (CBSST-CCT) intervention compared to Goal-focused Supportive Contact (SC) on negative symptoms and cognitive performance.MethodsFifty-five adults with SZ or schizoaffective disorder with moderate-to-severe negative symptoms were randomized to receive 25 twice-weekly, 1-h manualized group sessions (12.5 weeks total duration) of either CBSST-CCT or SC delivered by master's level clinicians in five community settings. Assessments of negative symptom severity (primary outcomes) and neuropsychological performance, functional capacity, social skills performance, and self-reported functional ability/everyday functioning, psychiatric symptom severity, and motivation (secondary outcomes) were administered at baseline, mid-treatment, post-treatment, and 6-month follow-up.ResultsMixed-effects models using baseline, mid-treatment, and post-treatment data demonstrated significant CBSST-CCT-associated effects on negative symptom severity, as assessed by the Scale for the Assessment of Negative Symptoms (p = .049, r = 0.22), with improvements in diminished motivation driving this effect (p = .037, r = 0.24). The CBSST-CCT group also demonstrated improved verbal learning compared to SC participants (p = .026, r = 0.36). The effects of CBSST-CCT appeared to be durable at 6-month follow-up.ConclusionsCBSST-CCT improved negative symptom severity and verbal learning in high-negative-symptom individuals relative to SC. CBSST-CCT warrants larger investigations to examine its efficacy in treating negative symptoms, along with other symptoms, cognition, and, ultimately, real-world functional outcomes. Clinical Trial registration number NCT02170051.

ObjectiveRapid Eye Movement Sleep Behavior Disorder (RBD) is common in Parkinson's Disease (PD) and is associated with cognitive impairment; however, the majority of the evidence on the impact of RBD on multidomain cognitive batteries in PD is cross-sectional. This study evaluated the longitudinal impact of probable RBD (pRBD) on cognitive, psychiatric, and functional outcomes in people with PD.MethodCase-control study. A total of 65 people with PD completed the study protocol at baseline and 16-to-47-month follow-up. Participants were classified as pRBD+ (n = 25) or pRBD- (n = 40) based on an established cutoff of 6 on the RBD Sleep Questionnaire (RBDSQ). Participants also completed a) comprehensive cognitive testing, b) self-report measures of depression, anxiety, and apathy, and c) performance-based and other-report forms of instrumental activities of daily living.ResultsBaseline mean age was 67.8 (SD = 8.1; range = 45-86) and baseline mean years of education was 16.4 (SD = 2.1; range = 12-20). The two groups did not differ on measured demographic characteristics. Baseline mean T-scores for cognitive tests were in the average range (46-55). Hierarchical linear models tested group differences in cognitive and functional decline from baseline to follow-up, controlling for appropriate demographic and psychiatric variables. Compared to the pRBD- group, pRBD+ participants showed greater decline in attention/working memory (r = -0.31; p = 0.01) and UPSA financial skills (r = -0.31; p = 0.01). No other group differences approached significance.ConclusionsRBD may differentially affect attention/working memory and financial abilities in PD. Results underscore the importance of regular RBD screening in older adults with PD in order to triage symptomatic patients to appropriate cognitive and medical interventions.

ObjectiveThe current cross-sectional study examined cognition and performance-based functional abilities in a continuing care senior housing community (CCSHC) that is comparable to other CCSHCs in the US with respect to residents' demographic characteristics.MethodParticipants were 110 older adult residents of the independent living unit. We assessed sociodemographics, mental health, neurocognitive functioning, and functional capacity.ResultsCompared to normative samples, participants performed at or above expectations in terms of premorbid functioning, attention span and working memory, processing speed, timed set-shifting, inhibitory control, and confrontation naming. They performed below expectation in verbal fluency and verbal and visual learning and memory, with impairment rates [31.4% (>1 SD below the mean) and 18.49% (>1.5 SD below the mean)] well above the general population (16% and 7%, respectively). Within the cognitive test battery, two tests of delayed memory were most predictive of a global deficit score. Most cognitive test scores correlated with performance-based functional capacity.ConclusionsOverall, results suggest that a subset of older adults in the independent living sector of CCSHCs are cognitively and functionally impaired and are at risk for future dementia. Results also argue for the inclusion of memory tests in abbreviated screening batteries in this population. We suggest that CCSHCs implement regular cognitive screening procedures to identify and triage those older adults who could benefit from interventions and, potentially, a transition to a higher level of care.

BackgroundWith the aging of populations worldwide, early detection of cognitive impairments has become a research and clinical priority, particularly to enable preventive intervention for dementia. Automated analysis of the drawing process has been studied as a promising means for lightweight, self-administered cognitive assessment. However, this approach has not been sufficiently tested for its applicability across populations.ObjectiveThe aim of this study was to evaluate the applicability of automated analysis of the drawing process for estimating global cognition in community-dwelling older adults across populations in different nations.MethodsWe collected drawing data with a digital tablet, along with Montreal Cognitive Assessment (MoCA) scores for assessment of global cognition, from 92 community-dwelling older adults in the United States and Japan. We automatically extracted 6 drawing features that characterize the drawing process in terms of the drawing speed, pauses between drawings, pen pressure, and pen inclinations. We then investigated the association between the drawing features and MoCA scores through correlation and machine learning-based regression analyses.ResultsWe found that, with low MoCA scores, there tended to be higher variability in the drawing speed, a higher pause:drawing duration ratio, and lower variability in the pen's horizontal inclination in both the US and Japan data sets. A machine learning model that used drawing features to estimate MoCA scores demonstrated its capability to generalize from the US dataset to the Japan dataset (R2=0.35; permutation test, P

Obesity is associated with a multitude of negative health sequalae. Behavioral weight loss (BWL) is currently the recommended behavioral treatment for obesity; however, it is not effective for approximately half of the individuals who participate. BWL requires individuals to carry out many tasks requiring executive function (EF; i.e., higher order cognitive functions such as planning and problem solving) in order to be successful. Growing research supports that lower EF may be associated with attenuated weight loss following BWL, and targeting EF in treatment could improve outcomes. This paper aims to describe the rationale for the development of Novel Executive Function Training for Obesity (NEXT), which adapts Compensatory Cognitive Training to be delivered in conjunction with BWL. We summarize evidence relating EF to obesity and reduced weight loss following BWL, as well as the past success of cognitive training on EF. Then we describe the treatment model for NEXT followed by initial data suggesting that NEXT is feasible and acceptable and may impact EF and weight. Obesity treatments incorporating cognitive training, especially those that train compensatory strategies, may improve weight-loss outcomes and provide a more durable treatment than traditional interventions, but larger randomized control trials are necessary.

ObjectivesThe objective of this paper was to examine the implementation and effectiveness of a community-based intervention for hoarding disorder (HD) using Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST).DesignThis was a mixed-method, pre-post quasi-experimental study informed by the Practical, Robust Implementation and Sustainability Model for implementation science.SettingProgram activities took place in San Diego County, mainly within clients' homes or community, with some activities in-office.ParticipantsParticipants were aged 60 years or older, met eligibility for Medi-Cal or were uninsured, and met criteria for HD.InterventionA manualized, mobile protocol that incorporated CREST was utilized.MeasurementsThe Clutter Image Rating and Hoarding Rating Scale were used as effectiveness outcomes. An investigator-created staff questionnaire was used to evaluate implementation.ResultsThirty-seven clients were reached and enrolled in treatment and 15 completed treatment during the initial 2 years of the program. There were significant changes in hoarding severity and clutter volume. Based on the initial 2 years of the program, funding was provided for expansion to cover additional San Diego County regions and hire more staff clinicians in year three.ConclusionPreliminary data suggest that the CREST intervention can be successfully implemented in a community setting with positive results for older adults with HD.

We investigated subjective cognitive complaints (SCCs), as well as physical and mental health factors, in adults and older adults. U.S. residents (N = 2,962) were recruited via the Amazon Mechanical Turk platform and completed a 90-item survey. Overall, 493/1930 (25.5%) of younger adults and 278/1032 (26.9%) of older adults endorsed SCCs. Analyses revealed worse physical and mental health characteristics in the SCC+ compared to the SCC- group, with primarily medium (Cohen's d = 0.50) to large (0.80) effect sizes. Age did not moderate relationships between SCCs and physical/mental health. Results suggest that SCCs are associated with a diverse set of negative health characteristics such as poor sleep and high body mass index, and lower levels of positive factors, including happiness and wisdom. Effect sizes of psychological correlates were at least as large as those of physical correlates, indicating that mental health is critical to consider when evaluating SCCs.

ObjectiveThe current cross-sectional study examined cognition and performance-based functional abilities in a continuing care senior housing community (CCSHC) that is comparable to other CCSHCs in the US with respect to residents' demographic characteristics.MethodParticipants were 110 older adult residents of the independent living unit. We assessed sociodemographics, mental health, neurocognitive functioning, and functional capacity.ResultsCompared to normative samples, participants performed at or above expectations in terms of premorbid functioning, attention span and working memory, processing speed, timed set-shifting, inhibitory control, and confrontation naming. They performed below expectation in verbal fluency and verbal and visual learning and memory, with impairment rates [31.4% (>1 SD below the mean) and 18.49% (>1.5 SD below the mean)] well above the general population (16% and 7%, respectively). Within the cognitive test battery, two tests of delayed memory were most predictive of a global deficit score. Most cognitive test scores correlated with performance-based functional capacity.ConclusionsOverall, results suggest that a subset of older adults in the independent living sector of CCSHCs are cognitively and functionally impaired and are at risk for future dementia. Results also argue for the inclusion of memory tests in abbreviated screening batteries in this population. We suggest that CCSHCs implement regular cognitive screening procedures to identify and triage those older adults who could benefit from interventions and, potentially, a transition to a higher level of care.

ObjectiveThis study examined rates of objective cognitive and functional impairments and associations between cognitive performance and performance-based functional capacity in a well-characterized sample of adults experiencing homelessness.MethodsOne hundred participants completed a brief neuropsychological and functional capacity assessment and self-report questionnaires. Cognitive impairment rates were determined by comparing mean scores with published normative data, as well as by examining frequency of scores >1 SD below the mean. Pearson correlations were used to examine associations between cognitive and functional capacities.ResultsOverall, 65% of the study participants had scores in the cognitively impaired range on a brief cognitive screening test, 30% had impaired processing speed, and 11% met cognitive criteria for intellectual disability. Furthermore, 48% of the sample met functional impairment criteria, and poorer cognitive performance was strongly associated with poorer performance-based functional capacity (p

The current study examined the feasibility and acceptability of an integrated Cognitive-Behavioral Social Skills Training and Compensatory Cognitive Training (CBSST-CCT) intervention compared with Goal-Focused Supportive Contact (SC) in a pilot randomized controlled trial for people with schizophrenia with high negative symptom severity. The sample included 55 participants from five community settings; masters-level study clinicians delivered interventions on-site. Participants completed assessments of cognitive, functional, and psychiatric symptoms at baseline, mid-treatment, post-treatment (12.5 weeks), and 6-month follow-up. Enrollment goals were not initially met, necessitating the addition of a fifth site; however, all groups and assessments were completed on-site. Study procedures were acceptable, as evidenced by 100% enrollment and completion of baseline assessments following informed consent; however, over 1/3rd of participants dropped out. No modifications were necessary to the intervention procedures and CBSST-CCT fidelity ratings were acceptable. The intervention was deemed acceptable among participants who attended ≥1 session, as evidenced by similar attendance rates in CBSST-CCT compared to SC. Among CBSST-CCT participants, lower positive symptoms were significantly associated with better attendance. Overall, we found mixed evidence for the feasibility and acceptability of the CBSST-CCT protocol in people with schizophrenia with high negative symptoms. Challenges are highlighted and recommendations for future investigations are provided.

Many individuals demonstrate functionally relevant impairment in neurocognition as well as social cognition early on in the course of their psychotic disorder. There is robust evidence supporting cognitive remediation as an effective treatment of cognitive dysfunction in schizophrenia. Increasingly it is accepted that earlier treatment is associated with better outcome and that it is important to systematically assess and treat cognitive dysfunction before the cognitive and functional disabilities are fully realized. However, the clinical availability of these interventions remains sparse. As we move forward with implementing evidence-based interventions into multi-component treatment for early psychosis, it is important to reflect on experience as well as evidence. This case report aims to describe the implementation of an integrative cognitive remediation program in coordinated specialty care (CSC) for early psychosis in Iceland and investigate whether the intervention is sustainable in a CSC setting. Data on the number of patients treated, facilitators trained, groups conducted, and funding was used to assess the sustainability. The results show that since initial implementation in 2016, the intervention has been routinely available as part of standard care, with over 100 patients having received the treatment. The report discusses key factors in the successful implementation of the program.

Physical, emotional, and cognitive changes are well documented in aging populations. We administered a comprehensive battery of mental and physical health measures and the Montreal Cognitive Assessment (MoCA; a cognitive screening tool) to 93 independently living older adults (OAs) residing in a Continuing Care Senior Housing Community. Performance on the Timed Up-and-Go (TUG) test (a measure of functional mobility) correlated more strongly with the MoCA total score than did measures of aging, psychiatric symptoms, sleep, and both self-report and objective physical health. Furthermore, it was associated with MoCA Attention, Language, Memory, and Visuospatial/Executive subscales. The MoCA-TUG relationship remained significant after controlling for demographic and physical/mental health measures. Given that the TUG explained significantly more variance in broad cognitive performance than a comprehensive battery of additional physical and mental health tests, it may function as a multimodal measure of health in OAs, capturing physical changes and correlating with cognitive measures.

ObjectiveRapid eye movement sleep behavior disorder (RBD) affects 33-46% of patients with Parkinson's disease (PD) and may be a risk factor for neuropsychological and functional deficits. However, the role of RBD on neuropsychological functioning in PD has yet to be fully determined. We, therefore, examined differences in neurocognitive performance, functional capacity, and psychiatric symptoms among nondemented PD patients with probable RBD (PD/pRBD+) and without (PD/pRBD-), and healthy comparison participants (HC).MethodsTotally, 172 participants (58 PD/pRBD+; 65 PD/pRBD-; 49 HC) completed an RBD sleep questionnaire, psychiatric/clinical questionnaires, performance-based and self-reported functional capacity measures, and underwent a comprehensive neuropsychological battery assessing attention/working memory, language, visuospatial function, verbal and visual learning and memory, and executive function.ResultsControlling for psychiatric symptom severity, the PD/pRBD+ group had poorer executive functioning and learning performance than the PD/pRBD- group and poorer neuropsychological functioning across all individual cognitive domains than the HCs. In contrast, PD/pRBD- patients had significantly lower scores than HCs only in the language domain. Moreover, PD/pRBD+ patients demonstrated significantly poorer medication management skills compared to HCs. Both PD groups reported greater depressive and anxiety severity compared to HCs; PD/pRBD+ group also endorsed greater severity of apathy compared to HCs.ConclusionsThe presence of pRBD is associated with poorer neuropsychological functioning in PD such that PD patients with pRBD have poorer cognitive, functional, and emotional outcomes compared to HC participants and/or PD patients without pRBD. Our findings underscore the importance of RBD assessment for improved detection and treatment of neuropsychological deficits (e.g., targeted cognitive interventions).

AbstractSubjective cognitive decline (SCD), or internal feelings of reduced mental capacity, is of increasing interest in the scientific, clinical, and lay community. Much of the extant literature is focused on SCD as a risk factor for Alzheimer’s disease in older adults, while less attention has been paid to non-cognitive health correlates of SCD across adulthood. Consequently, we investigated physical and mental health correlates of SCD in younger, middle-aged, and older adults. We recruited 3,407 U.S. residents through Amazon’s Mechanical Turk, an online labor market. Participants completed a 90-item self-report survey questionnaire assessing sociodemographic characteristics, physical health, sleep, depression, anxiety, loneliness, wisdom, self-efficacy, and happiness. Overall, 493/1930 (25.5%) of younger adults (18-49) and 278/1032 (26.9%) of older adults (50 or older) endorsed the SCD item. Multivariate analysis of variance and follow-upt-tests revealed worse physical and mental health characteristics in people endorsing SCD compared to those who did not, with effect sizes primarily in the medium to large range. Additionally, age did not moderate relationships between SCD and physical and mental health. Results suggest that SCD is associated with a diverse set of negative health characteristics such as poor sleep and high body mass index, and lower levels of positive factors including happiness and wisdom. Effect sizes of psychological correlates of SCD were as large as (or larger than) those of physical correlates, indicating that mental health and affective symptoms may be critical to consider when evaluating SCD. Overall, findings from this large, national U.S. sample suggest the presence of relationships between SCD and multiple psychological and perceived health factors; our results also show that SCD may be highly prevalent in both younger and older adults, suggesting that it be assessed across the adult lifespan.

Preserving cognition and mental capacity is critical to aging with autonomy. Early detection of pathological cognitive decline facilitates the greatest impact of restorative or preventative treatments. Artificial Intelligence (AI) in healthcare is the use of computational algorithms that mimic human cognitive functions to analyze complex medical data. AI technologies like machine learning (ML) support the integration of biological, psychological, and social factors when approaching diagnosis, prognosis, and treatment of disease. This paper serves to acquaint clinicians and other stakeholders with the use, benefits, and limitations of AI for predicting, diagnosing, and classifying mild and major neurocognitive impairments, by providing a conceptual overview of this topic with emphasis on the features explored and AI techniques employed. We present studies that fell into six categories of features used for these purposes: (1) sociodemographics; (2) clinical and psychometric assessments; (3) neuroimaging and neurophysiology; (4) electronic health records and claims; (5) novel assessments (e.g., sensors for digital data); and (6) genomics/other omics. For each category we provide examples of AI approaches, including supervised and unsupervised ML, deep learning, and natural language processing. AI technology, still nascent in healthcare, has great potential to transform the way we diagnose and treat patients with neurocognitive disorders.

Adults who are homeless experience high rates of health conditions and psychological distress, including low IQ and functional status. Resources are available to help these individuals, but provision of support is often contingent upon the identification of a known disability. In this context, we examined case managers' (CMs') subjective estimates of IQ and functional status in 77 adult residents of an urban homeless shelter. Participants completed objective measures of IQ and functional capacity. CMs overestimated IQs of lower IQ (IQ < 90) participants, correctly estimated IQs of average IQ (IQ = 90-110) participants, and underestimated IQs of higher IQ (IQ > 110) participants. CMs correctly identified 2 out of 8 participants meeting criteria for intellectual disability and 4 out of 16 participants with impaired functional status. These findings suggest that subjective evaluations of IQ and functional status are prone to a central tendency bias, leading CMs to overlook clients who are in need of assistance. Consequently, the objective measurement of IQ and functional status in homeless shelters is highly recommended. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Promoting health and prolonging independence in the home is a priority for older adults, caregivers, clinicians, and society at large. Rapidly developing robotics technology provides a platform for interventions, with the fields of physically and socially assistive robots expanding in recent years. However, less attention has been paid to using robots to enhance the cognitive health of older adults. The goal of this review is to synthesize the current literature on home-based cognitively assistive robots (CAR) in older adults without dementia and to provide suggestions to improve the quality of the scientific evidence in this subfield. First, we set the stage for CAR by: a) introducing the field of robotics to improve health, b) summarizing evidence emphasizing the importance of home-based interventions for older adults, c) reviewing literature on robot acceptability in older adults, d) highlighting important ethical issues in healthcare robotics, and e) reviewing current findings on socially assistive robots, with a focus on translating findings to the CAR context. With this foundation in place, we then review the literature on CAR, identifying gaps and limitations of current evidence, and proposing future directions for research. We conclude that CAR is promising and feasible and that there is a need for more methodologically rigorous evaluations of CAR to promote prolonged home-based independence in older adults.

Many individuals demonstrate functionally relevant impairment in neurocognition as well as social cognition early on in the course of their psychotic disorder. There is robust evidence supporting cognitive remediation as an effective treatment of cognitive dysfunction in schizophrenia. Increasingly it is accepted that earlier treatment is associated with better outcome and that it is important to systematically assess and treat cognitive dysfunction before the cognitive and functional disabilities are fully realized. However, the clinical availability of these interventions remains sparse. As we move forward with implementing evidence-based interventions into multi-component treatment for early psychosis, it is important to reflect on experience as well as evidence. This case report aims to describe the implementation of an integrative cognitive remediation program in coordinated specialty care (CSC) for early psychosis in Iceland and investigate whether the intervention is sustainable in a CSC setting. Data on the number of patients treated, facilitators trained, groups conducted, and funding was used to assess the sustainability. The results show that since initial implementation in 2016, the intervention has been routinely available as part of standard care, with over 100 patients having received the treatment. The report discusses key factors in the successful implementation of the program.

ObjectiveAmong people with severe mental illnesses, neuropsychological abilities may contribute to vocational outcomes, such as job attainment, job tenure, and wages earned. The current study aimed to determine the strongest neuropsychological and other modifiable predictors of work outcomes in 153 people with severe mental illness (schizophrenia, 38%; bipolar disorder, 24%; and major depression, 38%) who participated in a 2-year supported employment study.MethodsAssessments of neuropsychological performance, functional capacity, social skills, and psychiatric symptom severity were administered at baseline; work outcomes (job attainment, weeks worked, and wages earned) were collected weekly for 2 years.ResultsIndependent of education, diagnosis, and estimated intellectual functioning, more recent work history and less severe negative symptoms significantly predicted job attainment during the 2-year study. Among the 47% who obtained jobs, better global neuropsychological performance (i.e., lower global deficit score) was a significant predictor of greater weeks worked. Both global neuropsychological performance and more recent work history predicted higher wages earned.ConclusionsModifiable predictors of supported employment outcomes included cognitive functioning and negative symptom severity; thus, interventions to improve these factors may improve work outcomes and decrease the loss of productivity associated with severe mental illness.

OBJECTIVE:Prospective memory (the ability to remember to do things) has clear implications for everyday functioning, including employment, in people with severe mental illnesses (SMI). This study aimed to evaluate prospective memory performance and its relationship to real-world functional variables in an employment-seeking sample of people with SMI (Clinical Trial registration number NCT00895258). METHOD:153 individuals with DSM-IV diagnosis of depression (n = 58), bipolar disorder (n = 37), or schizophrenia (n = 58) who were receiving outpatient psychiatric care at a university clinic enrolled in a trial of supported employment and completed a baseline assessment. Prospective memory was measured with the Memory for Intentions Test (MIST); real-world functional status included work history variables, clinical history variables, baseline functional capacity (UCSD Performance-based Skills Assessment-Brief), and work outcomes (weeks worked and wages earned during two years of supported employment). RESULTS:Participants with schizophrenia performed worse on the MIST than did those with affective disorders. Independent of diagnosis, education, and estimated intellectual functioning, prospective memory significantly predicted variance in measures of disability and illness burden (disability benefits, hospitalization history, current functional capacity), and work outcomes over two years of supported employment (weeks worked). CONCLUSIONS:Worse prospective memory appears to be associated with greater illness burden and functional disability in SMI. Mental health clinicians and employment specialists may counsel clients to use compensatory prospective memory strategies to improve work performance and decrease functional disability associated with SMI.

Research identifying the effects of cognitive training on negative symptoms of psychosis is limited. We examined the effects of Compensatory Cognitive Training (CCT) on expressive deficits and social amotivation in a randomized controlled trial comparing CCT to standard pharmacotherapy alone in 43 individuals with psychosis. ANCOVA analyses demonstrated significant CCT-associated effects on both expressive deficits and social amotivation. Moreover, improvements in both sub-domains were associated with improvements in global life satisfaction, with improvements in social amotivation also related to increased social contact. CCT appears to be a beneficial treatment approach for improving multiple aspects of negative symptoms.

Objective: This study examined the association of housing stability with neurocognitive outcomes of a well-characterized sample of homeless adults with mental illness over 18 months and sought to identify demographic and clinical variables associated with changes in neurocognitive functioning. Method: A total of 902 participants in the At Home/Chez Soi study completed neuropsychological measures 6 and 24 months after study enrollment to assess neurocognitive functioning, specifically verbal learning and memory, cognitive flexibility, and complex processing speed. Multivariable linear regression was performed to assess the association of housing stability with changes in neurocognitive functioning between 6 and 24 months and to examine the effect of demographic and clinical variables on changes in neurocognitive functioning. Results: Overall neurocognitive impairment remained high over the study period (70% at 6 months and 67% at 24 months) with a small but significant improvement in the proportion of those experiencing more severe impairment (54% vs. 49% p < 0.002). Housing stability was not associated with any of the neuropsychological measures or domains examined; improvement in neurocognitive functioning was associated with younger age, and bipolar affective disorder at baseline. Conclusions: The high prevalence and persistence of overall neurocognitive impairment in our sample suggests targeted approaches to improve neurocognitive functioning merit consideration as part of health interventions to improve everyday functioning and outcomes for this population. Further efforts are needed to identify potential modifiable factors that contribute to improvement in cognitive functioning in homeless adults with mental illness.

ObjectivesSuicidal ideation (SI) is highly prevalent in Iraq/Afghanistan-era veterans with a history of mild traumatic brain injury (mTBI), and multiple mTBIs impart even greater risk for poorer neuropsychological functioning and suicidality. However, little is known about the cognitive mechanisms that may confer increased risk of suicidality in this population. Thus, we examined relationships between neuropsychological functioning and suicidality and specifically whether lifetime mTBI burden would moderate relationships between cognitive functioning and suicidal ideation.MethodsIraq/Afghanistan-era Veterans with a history of mTBI seeking outpatient services (N = 282) completed a clinical neuropsychological assessment and psychiatric and postconcussive symptom questionnaires.ResultsIndividuals who endorsed SI reported more severe post-traumatic stress disorder (PTSD), depression, and postconcussive symptoms and exhibited significantly worse memory performance compared to those who denied SI. Furthermore, mTBI burden interacted with both attention/processing speed and memory, such that poorer performance in these domains was associated with greater likelihood of SI in individuals with a history of three or more mTBIs. The pattern of results remained consistent when controlling for PTSD, depression, and postconcussive symptoms.ConclusionsSlowed processing speed and/or memory difficulties may make it challenging to access and use past experiences to solve current problems and imagine future outcomes, leading to increases in hopelessness and SI in veterans with three or more mTBIs. Results have the potential to better inform treatment decisions for veterans with history of multiple mTBIs. (JINS, 2019, 25, 79-89).

Treatments for cognitive and functional impairments associated with severe mental illnesses are urgently needed. We tested a 12-week, manualized, Compensatory Cognitive Training (CCT) intervention targeting prospective memory, attention, learning/memory, and executive functioning in the context of supported employment for people with severe mental illnesses who were seeking work. 153 unemployed, work-seeking outpatients with schizophrenia/schizoaffective disorder (n=58), bipolar disorder (n=37), or major depression (n=58) were randomized to receive supported employment plus CCT or enhanced supported employment, a robust control group. Assessments of neuropsychological performance, functional capacity, psychiatric symptom severity, and self-reported functioning and quality of life were administered at baseline and multiple follow-up assessments over two years; work outcomes were collected for two years. Forty-seven percent of the participants obtained competitive work, but there were no differences in work attainment, weeks worked, or wages earned between the CCT and the enhanced supported employment group. ANCOVAs assessing immediate post-treatment effects demonstrated significant, medium to large, CCT-associated improvements on measures of working memory (p=0.038), depressive symptom severity (p=0.023), and quality of life (p=0.003). Longer-term results revealed no statistically significant CCT-associated improvements, but a trend (p=0.058) toward a small to medium CCT-associated improvement in learning. Diagnostic group (schizophrenia-spectrum vs. mood disorder) did not affect outcomes. We conclude that CCT has the potential to improve cognitive performance, psychiatric symptom severity, and quality of life in people with severe mental illnesses. Receiving CCT did not result in better work outcomes, suggesting that supported employment can result in competitive work regardless of cognitive status.

Background: Early psychosocial interventions targeting cognitive and functional outcomes in individuals at clinical high risk for psychosis are a research priority. An even greater need is the identification of effective interventions in underserved populations. Compensatory Cognitive Training (CCT) is a psychosocial intervention with demonstrated efficacy in chronic schizophrenia and first episode psychosis, but remains to be evaluated in pre-illness phases. The aim of this study was to describe the development and implementation of an ongoing pilot randomized controlled trial investigating the efficacy of group-based, manualized CCT, as compared to recreational therapy (RT), for Latino participants at clinical high risk for psychosis (CHR) in both the United States and Mexico. It is hypothesized that, in comparison to those receiving RT, participants receiving CCT will show significant improvements in neurocognitive performance and functional capacity (co-primary outcomes) and self-rated functioning and clinical symptoms (secondary outcomes). Methods: Latino CHR participants aged 12-30 years will be included in the study. Both CCT and RT will be delivered in either Spanish or English, depending on group preference. Additionally, all assessments will be administered in participants' preferred language. A comprehensive assessment of neurocognitive and functional performance and clinical symptomatology will be performed at baseline, mid-intervention (4 weeks, 8 weeks), post-intervention (12 weeks) and 3-month follow-up. The primary outcome measures are neurocognition and functional capacity, as assessed by the MATRICS (Measurement and Treatment Research in Cognition in Schizophrenia) Consensus Cognitive Battery and the University of California, San Diego Performance-Based Skills Assessment-Brief, respectively. Furthermore, secondary outcomes measures will be used to examine change in clinical symptoms and self-reported functioning in response to CCT versus RT. Discussion: The evaluation of a novel treatment such as CCT in CHR youth will provide empirical support for a low risk, comprehensive cognitive intervention that could have important implications for public health if it improves neurocognition and functioning.

Cognitive impairments, e.g., reward learning, are present in various psychiatric disorders and warrant treatment. Improving reward-related learning could synergistically enhance psychosocial treatments and cognition generally. A critical first step is to understand the mechanisms underlying reward learning. The dopamine system has been implicated in such learning, but less known is how indirect activation of this system may affect reward learning. We determined the role of alpha7 nicotinic acetylcholine receptors (nAChR) on a probabilistic reversal learning task (PRLT) in mice that includes reward and punishment. Male alpha7 knockout (KO), heterozygous (HT), and wildtype (WT) littermate mice (n = 84) were treated with vehicle, 0.03, or 0.3 mg/kg nicotine. Two cohorts of C57BL/6NJ male mice were treated with various alpha7 nAChR ligands, including the full agonists PNU282877 and AR-R-17779, the positive allosteric modulator CCMI, the partial agonist SSR180711, and the antagonist methyllycaconitine. All mice were then tested in the PRLT. Nicotine (0.3 mg/kg) significantly improved initial reward learning in alpha7 WT and HT mice but did not improve learning in KO mice, suggesting an involvement of the alpha7 nAChR in the pro-learning effects of nicotine. Neither alpha7 nAChR treatments (PNU282987, AR-R-17779, CCMI, SSR180711, nor methyllycaconitine) affected mouse PRLT performance however. Nicotine improved reward learning via a mechanism that may include alpha7 nAChRs. This improvement unlikely relied solely on alpha7 nAChRs however, since no alpha7 nAChR ligand improved reward learning in normal mice. Future assessments of the effects of other nAChR subtypes on reward learning are needed.

BackgroundBecause Veterans have higher rates of mental health conditions and both physical and mental health comorbidities are known to affect treatment outcomes, the purpose of this investigation was to compare the rates of risk factors for poor hoarding treatment outcomes between Veterans and non-Veterans with hoarding disorder (HD). This is the first study to investigate differences between Veterans and non-Veterans with HD.Material and methodsBaseline data were used from three different treatment studies of adults with hoarding disorder (n = 159). Demographic characteristics, baseline hoarding symptom severity, baseline medical and psychiatric comorbidities, and treatment attrition and response were compared between Veterans and non-Veterans.ResultsVeterans were significantly less likely to be employed than non-Veterans. Veterans did not report significantly more severe hoarding symptoms at baseline when compared to non-Veterans. Veterans reported having a greater mean number of overall medical and psychiatric comorbidities. Veterans were more likely than non-Veterans to meet criteria for major depressive disorder and post-traumatic stress disorder. There was no significant difference in the rate of attrition between Veterans and non-Veterans and Veterans were not significantly more likely to be classified as treatment responders.ConclusionMany similarities were observed between the two groups, including demographic characteristics, hoarding symptom severity, and rates of treatment response. Given that Veterans with HD may suffer from greater medical and psychiatric comorbidities, clinicians should ensure that their clients are receiving adequate medical care and that any other psychiatric comorbidities should be addressed in conjunction for treatment with HD.

Neuropsychological abilities may underlie successful performance of everyday functioning and social skills. We aimed to determine the strongest neuropsychological predictors of performance-based functional capacity and social skills performance across the spectrum of severe mental illness (SMI). Unemployed outpatients with SMI (schizophrenia, bipolar disorder, or major depression; n = 151) were administered neuropsychological (expanded MATRICS Consensus Cognitive Battery), functional capacity (UCSD Performance-Based Skills Assessment-Brief; UPSA-B), and social skills (Social Skills Performance Assessment; SSPA) assessments. Bivariate correlations between neuropsychological performance and UPSA-B and SSPA total scores showed that most neuropsychological tests were significantly associated with each performance-based measure. Forward entry stepwise regression analyses were conducted entering education, diagnosis, symptom severity, and neuropsychological performance as predictors of functional capacity and social skills. Diagnosis, working memory, sustained attention, and category and letter fluency emerged as significant predictors of functional capacity, in a model that explained 43% of the variance. Negative symptoms, sustained attention, and letter fluency were significant predictors of social skill performance, in a model explaining 35% of the variance. Functional capacity is positively associated with neuropsychological functioning, but diagnosis remains strongly influential, with mood disorder participants outperforming those with psychosis. Social skill performance appears to be positively associated with sustained attention and verbal fluency regardless of diagnosis; however, negative symptom severity strongly predicts social skills performance. Improving neuropsychological functioning may improve psychosocial functioning in people with SMI.

While cognitive-behavioral therapy for hoarding disorder (HD) has resulted in significant reductions in symptoms, most individuals continue to have significant hoarding symptoms following treatment. This investigation sought to extend the literature on the behavioral treatments for hoarding by examining (1) group cognitive rehabilitation and exposure/sorting therapy (CREST) and (2) group exposure therapy (ET) for hoarding. Participants in both studies reported significant decreases in hoarding symptom severity from baseline to post-treatment on all primary outcome measures using mixed-effects linear regression models with the intent to treat sample. Participants who received group CREST reported statistically significant reductions in anxiety, depression, and overall severity at post-treatment, while participants who received group ET did not. Results provide preliminary evidence for both group CREST and group ET as effective treatments for hoarding disorder.

ObjectiveTo compare the efficacy of Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST) with geriatric case management (CM) in a sample of older adults meeting DSM-5 diagnostic criteria for hoarding disorder (HD).MethodsFifty-eight older adults with HD were enrolled in a randomized controlled trial between December 2011 and March 2014. Thirty-one participants received CREST, and 27 participants received CM. Both interventions consisted of 26 individual sessions over a period of 6 months and included several home visits by the study therapists (CREST) or nurses (CM). The Saving Inventory-Revised (SI-R) and the UCLA Hoarding Severity Scale (UHSS) were the main outcome measures.ResultsParticipants in the CREST condition had significantly greater improvement on the SI-R than participants in the CM group (group × time interaction: β = 3.95, SE = 1.81, P = .029), with participants who completed the CREST condition averaging a 38% decrease in symptoms and participants who completed the CM condition averaging a 25% decrease in symptoms. In contrast, there was not a significant group × time interaction effect on the UHSS (β = 1.23, SE = 0.84, P = .144), although participants did report greater improvement in symptoms in the CREST condition (35%) than in the CM condition (24%). Treatment gains were maintained at 6-month follow-up.ConclusionsCREST appears to be an efficacious treatment compared to CM for older adults, but CM also showed meaningful benefits.Trial registrationClinicalTrials.gov identifier: NCT01227057​.

ObjectiveChildhood trauma is common and associated with both worse cognitive performance and disruption to the hypothalamic-pituitary-adrenal axis in younger adults. The extent to which these associations persist into older adulthood remains unknown. The aim of this study was to investigate self-reported childhood trauma in relation to cognitive performance, and the extent to which cortisol explained this association, in 2 independent samples of older adults.MethodsIn this cross-sectional study, participants in the discovery sample (N = 76) consisted of older adults with a DSM-IV diagnosis of generalized anxiety disorder (N = 57) and age-equated psychiatrically healthy comparison subjects (N = 19) who were referred largely through primary care clinics between 2004-2006. The replication sample (N = 48) consisted of older adults with DSM-IV anxiety or depressive disorders recruited between 2012-2013. Participants were administered the Early Trauma Inventory Self-Report-Short Form and a neuropsychological assessment (primary outcome).ResultsAcross both samples, childhood trauma was significantly associated with worse performance on measures of processing speed, attention, and executive functioning. The effect of trauma exposure was stronger when general, physical, and sexual traumatic events were examined specifically (all P < .05). Childhood trauma was not associated with cortisol levels, and cortisol did not explain the association between trauma and cognitive functioning.ConclusionsSelf-reported traumatic events experienced in childhood are associated with poorer cognitive performance in anxious and depressed older adults. Findings demonstrate a deleterious impact of childhood trauma on brain health in old age.

The population of adults on the autism spectrum continues to increase, and vocational outcomes are particularly poor. Longitudinal studies of adults with autism spectrum and without intellectual disability have shown consistent and persistent deficits across cognitive, social, and vocational domains, indicating a need for effective treatments of functional disabilities as each impact employment. This initial pilot study is an open trial investigation of the feasibility, acceptability, and initial estimates of outcomes for the newly developed Supported Employment, Comprehensive Cognitive Enhancement, and Social Skills intervention, a manualized "soft skills" curriculum, to enhance both cognitive and social development in adults with autism spectrum. A total of eight adults with autism spectrum, without intellectual disability (78% males), participated in the study. Results support the original hypothesis that adults with autism spectrum can improve both cognitive (i.e. executive functioning) and social cognitive (i.e. social thinking and social communication) abilities. Further Supported Employment, Comprehensive Cognitive Enhancement, and Social Skills was found to be feasible, acceptable, and highly satisfactory for participants and parents. Employment rates more than doubled post-intervention, with an increase from 22% to 56% of participants employed. Conclusion is that Supported Employment, Comprehensive Cognitive Enhancement, and Social Skills has promise as an intervention that can be easily embedded into exiting supported employment vocational training programs to improve cognitive, social, and vocational outcomes.

BackgroundA considerable proportion of patients with mild to moderate traumatic brain injury (TBI) experience long-lasting somatic, cognitive, and emotional symptoms that may hamper their capacity to return to work (RTW). Although several studies have described medical, psychological, and work-related factors that predict RTW after TBI, well-controlled intervention studies regarding RTW are scarce. Furthermore, there has traditionally been weak collaboration among health-related rehabilitation services, the labor and welfare sector, and workplaces.Methods/designThis study protocol describes an innovative randomized controlled trial in which we will explore the effect of combining manualized cognitive rehabilitation (Compensatory Cognitive Training [CCT]) and supported employment (SE) on RTW and related outcomes for patients with mild to moderate TBI in real-life competitive work settings. The study will be carried out in the southeastern region of Norway and thereby be performed within the Norwegian welfare system. Patients aged 18-60 years with mild to moderate TBI who are employed in a minimum 50% position at the time of injury and sick-listed 50% or more for postconcussive symptoms 2 months postinjury will be included in the study. A comprehensive assessment of neurocognitive function, self-reported symptoms, emotional distress, coping style, and quality of life will be performed at baseline, immediately after CCT (3 months after inclusion), following the end of SE (6 months after inclusion), and 12 months following study inclusion. The primary outcome measures are the proportion of participants who have returned to work at 12-month follow-up and length of time until RTW, in addition to work stability as well as work productivity over the first year following the intervention. Secondary outcomes include changes in self-reported symptoms, emotional and cognitive function, and quality of life. Additionally, a qualitative RTW process evaluation focused on organizational challenges at the workplace will be performed.DiscussionThe proposed study will combine cognitive and vocational rehabilitation and explore the efficacy of increased cross-sectoral collaboration between specialized health care services and the labor and welfare system. If the intervention proves effective, the project will describe the cost-effectiveness and utility of the program and thereby provide important information for policy makers. In addition, knowledge about the RTW process for persons with TBI and their workplaces will be provided.Trial registrationClinicalTrials.gov, NCT03092713 . Registered on 10 March 2017.

Positive, negative, and cognitive symptoms of schizophrenia may affect functional outcomes. However, these factors alone do not account for a large percentage of variance in outcomes. We investigated demographic, cognitive, symptom, and functional capacity predictors of current functional status in 280 outpatients with schizophrenia or schizoaffective disorder. Functional decline over the lifespan was also examined in a subset of participants. Stepwise regressions modeled predictors of current functional status and functional decline as measured by the Assessment of Lifespan Functioning Attainment (ALFA). ALFA functional domains included paid employment, independence in living situation, romantic relationships, close friendships, and recreational engagement. More severe depressive symptoms were consistently associated with worse current community integration (lower levels of close friendships and recreational engagement). Better working memory performance was associated with higher rates of current paid employment. There were no consistent modifiable predictors of decline in functioning, but women reported less functional decline in the domains of employment and close friendships than men. Better cognitive performance was associated with less decline in living independence and romantic relationships, but more decline in paid employment and recreational engagement. Increased assessment and treatment of comorbid depressive symptoms may improve functional outcomes in people with schizophrenia.

The UCSD Performance-Based Skills Assessment (UPSA) is a performance-based measure of functional capacity. The brief, two-domain (finance and communication ability) version of the assessment (UPSA-B) is now widely used in both clinical research and treatment trials. To date, research has not examined possible demographic-UPSA-B relationships within a non-psychiatric population. We aimed to produce and describe preliminary normative scores for the UPSA-B over a full range of ages and educational attainment. The finance and communication subscales of the UPSA were administered to 190 healthy participants in the context of three separate studies. These data were combined to examine the effects of age, sex, and educational attainment on the UPSA-B domain and total scores. Fractional polynomial regression was used to compute demographically-corrected T-scores for the UPSA-B total score, and percentile rank conversion was used for the two subscales. Age and education both had significant non-linear effects on the UPSA-B total score. The finance subscale was significantly related to both gender and years of education, whereas the communication subscale was not significantly related to any of the demographic characteristics. Demographically corrected T-scores and percentile ranks for UPSA-B scores are now available for use in clinical research.