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How Schizophrenia Impacts Cognitive Function

Cognitive deficits in schizophrenia interfere with real-world functioning.

Schizophrenia is a disorder with readily observable symptoms including hallucinations, delusions, social withdrawal, apathy, and disorganized thinking and behavior. It is also associated with substantial cognitive deficits, which interfere dramatically with everyday functioning. Robert McCutcheon, Richard Keefe, and Philip McGuire recently published an excellent review in the journal Molecular Psychiatry that summarizes current knowledge about cognitive impairment in persons with schizophrenia.
Cognitive deficits associated with schizophrenia include difficulties with attention, working memory, learning, and processing speed. These deficits interfere with real-world functioning. They are associated with increased hospitalization, longer hospital stays, and decreased compliance with treatment.
Cognitive impairment is also a major contributor to illness-related disability, defined as an inability to work productively and/or live independently. Psychiatric illnesses, including schizophrenia, are among the leading causes of disability across the human lifespan.
Although, in general, persons with schizophrenia perform poorly on cognitive tasks and average in the lowest 5 to 10 percent of the population when compared to those without schizophrenia, the degree of deficit varies greatly among individuals. It is possible that some individuals have cognitive deficits in one area while others have deficits in other cognitive domains. Sorting out various patterns of cognitive deficits among individuals will require further research.

Natural History
Cognitive deficits typically precede the onset of behavioral symptoms in individuals who eventually develop schizophrenia. These cognitive deficits are often present during childhood and increase during adolescence. This differs from the time course of cognitive changes in bipolar disorder where such changes occur largely after the onset of mood symptoms.
The cognitive deficits that develop during childhood in those with schizophrenia remain relatively stable through middle adulthood. As individuals become elderly, they are at higher risk for cognitive decline. However, such late-in-life deterioration might result from a variety of health factors that are common in individuals with schizophrenia and that contribute to premature death in these individuals.

Various brain circuits and neurotransmitters play a role in the development of cognitive deficits. Elucidating which neurotransmitter systems are involved in which brain systems will require much more research.

It is well known that both older- and newer-generation antipsychotic drugs do not substantially alter the cognitive deficits associated with schizophrenia. Novel medications are being developed to treat schizophrenia, and increased attention is being directed toward developing drugs that help ameliorate cognitive deficits.
Knowing which specific cognitive deficits an individual with schizophrenia is experiencing can assist caregivers in tailoring psychosocial management. Neuropsychological testing can determine the type and degree of such deficits.
Advances in neuroscience will result in an improved understanding of the nature and causes of schizophrenia. This should lead to advances in novel drug development. Together with increased attention to psychosocial interventions, these advances should aid the development of integrated, personalized treatment approaches to improve the everyday functioning and life satisfaction of those suffering from this devastating psychiatric disorder.

psychology today

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Digital interventions can help relieve depressive symptoms

data from smartphones and wearable devices might be used to identify people with symptoms of depression and anxiety.

With a shortage of therapists, help with mental health problems is being sought from digital interventions, where elements of psychological treatment are offered via computer programs or mobile applications. According to a study, smart devices can help identify people with symptoms of depression and anxiety.

Every year, 400 million people worldwide are affected by depression or anxiety, and the coronavirus pandemic has only increased the prevalence of mental health problems. At the same time, there is a shortage of psychotherapists. Digital interventions, where elements of psychological treatment are offered via computer programs or mobile applications, have been proposed as a solution.

In his doctoral thesis in the field of psychology, researcher Isaac Moshe investigated the effectiveness of digital interventions in treating mental health problems, with depressive symptoms in particular focus.

Tracking depression and anxiety with smart devices
One sub-study in the doctoral thesis examined whether symptoms of depression or anxiety can be identified from data collected by smartphones or wearable devices. A total of 60 adults who used an iPhone or an Oura Ring took part in the sub-study.

Based on the study, smartphone GPS data was predicted the user's depressive symptoms. Subjects who visited the same locations repeatedly had more depressive symptoms than those whose location had more variability. The data collected by smart rings indicated that the longer the person slept or spent time in bed on average, the more depressive symptoms they had. The ring data also revealed that the more frequently people woke up at night, the more symptoms of anxiety they had.
Digital interventions alleviate depressive symptoms
The most extensive sub-study of the doctoral thesis was an international collaboration that assessed the effectiveness of digital interventions in treating depression by conducting a meta-analysis of all previous studies. Digital interventions typically include videos, interactive exercises or text to deliver the core components of psychotherapy, which are then packaged into an online program or smartphone app.

The dataset was composed of 83 randomized controlled trials conducted between 1990 and 2020 involving 15,530 participants.
The findings indicate that digital interventions brought relief from depressive symptoms when they were offered in public or private healthcare settings. Digital interventions alleviated symptoms in people of all ages, regardless of depression severity or physical comorbidity.

Moshe points out that there are important caveats: in children and adolescents, digital interventions were less effective than in adults. Having human support alongside the digital interventions was also critical to people completing the programs and therefore getting the maximum benefits. Furthermore, the researchers felt that it was unclear whether digital interventions were indeed as effective as face-to-face psychotherapy, as so few comparative studies on the topic have so far been conducted.

Moshe believes that, overall, digital interventions could provide a valuable way to help meet the growing global demand for mental healthcare.

"They lower the barrier to accessing treatment, enabling anyone with a computer an internet connection to benefit from psychotherapy at a time and place that is convenient to them. Digital interventions also require much less time from therapists than traditional therapy, making it possible to shorten waiting lists and treat more people."
Helsingin yliopisto (University of Helsinki)

Virtual reality app trial offers new hope for people suffering from phobias

There’s great potential for the use of VR and mobile phone apps as a means of self-guided treatment for people struggling with often-crippling phobias.

Results from a University of Otago, Christchurch trial suggest fresh hope for the estimated one-in-twelve people worldwide suffering from a fear of flying, needles, heights, spiders and dogs.

The trial, led by Associate Professor Cameron Lacey, from the Department of Psychological Medicine, studied phobia patients using a headset and a smartphone app treatment program – a combination of Virtual Reality (VR) 360-degree video exposure therapy and cognitive behavioral therapy (CBT).

Participants downloaded a fully self-guided smartphone app called "oVRcome", developed by Christchurch tech entrepreneur Adam Hutchinson, aimed at treating patients with phobia and anxiety.

The app was paired with a headset to immerse participants in virtual environments to help treat their phobia.

The results from the trial, just published in the Australian and New Zealand Journal of Psychiatry, showed a 75 per cent reduction in phobia symptoms after six weeks of the treatment programme.
"Participants demonstrated a strong acceptability of the app, highlighting its potential for delivering easily accessible, cost-effective treatment at scale, of particular use for those unable to access in-person exposure therapy to treat their phobias."

A total of 129 people took part in the six-week randomised, controlled trial, between May 2021 and December 2021, with a 12-week follow-up. Participants needed to be aged between 18-64 years, have a fear of either flying, heights, needles, spiders and dogs. They were emailed weekly questionnaires to record their progress. Those experiencing adverse events could request contact from a clinical psychologist at any stage.

"Participants experiencing all five types of phobia showed comparable improvements in the Severity Measures for Specific Phobia scale over the course of the trial. The average severity score decreased from 28/40 (moderate to severe symptoms) to 7/40 (minimal symptoms) after six weeks. There were no participant withdrawals due to intervention-related adverse events.

"The oVRcome app involves what's called "exposure therapy", a form of CBT exposing participants to their specific phobias in short bursts, to build up their tolerance to the phobia in a clinically-approved and controlled way," Associate Professor Lacey says.
"Some participants reported significant progress in overcoming their phobias after the trial period, with one feeling confident enough to now book an overseas family holiday, another lining up for a Covid vaccine and another reporting they now felt confident not only knowing there was a spider in the house but that they could possibly remove it themselves."

The app program consisted of standard CBT components including psychoeducation, relaxation, mindfulness, cognitive techniques, exposure through VR, and a relapse prevention model. Participants were able to select their own exposure levels to their particular phobia from a large library of VR videos.

"This means the levels of exposure therapy could be tailored to an individual's needs which is a particular strength. The more traditional in-person exposure treatment for specific phobias have a notoriously high dropout rate due to discomfort, inconvenience and a lack of motivation in people seeking out fears to expose themselves to. With this VR app treatment, triallists had increased control in exposure to their fears, as well as control over when and where exposure occurs," says Associate Professor Lacey.

The researchers say this trial was novel, due to the cost-effective availability of the app and headsets and the fact that multiple phobias were tested at once. They say most comparative VR studies to date have investigated high-end VR devices which are only available in research and limited clinical settings. One Dutch study examined a low-cost VR Dutch-language program using animated imagery that demonstrated improvement in fear-of-height symptoms, however this study only examined a single type of specific phobia.

Associate Professor Lacey says public demand to take part in the trial was unprecedented, demonstrating the increasing need and desire for phobia treatment in the community.

"An estimated ten per cent of New Zealanders have been hesitant to take part in the government's COVID-19 vaccination program due to needle phobia. This hasn't been helped by a significant shortage of psychologists. A petition to Parliament last year claimed New Zealand is 1,000 psychologists short, causing ballooning wait times nationwide, making it difficult for people to access help if needed. We need to further research and explore the use of more cost-effective, easily-accessible, home-based solutions such as this oVRcome app, to provide people with the treatment and support they need."

This study builds on the Department of Psychological Medicine's existing research into structured psychotherapy for mental distress.
Lacey, C., et al. (2022) oVRcome - Self-guided virtual reality for specific phobias: A randomised controlled trial. Australian & New Zealand Journal of Psychiatry. doi.org/10.1177/00048674221110779.
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Lifestyle interventions can help pediatricians meet the growing need for youth depression management

Psychological Intervention for Adolescent’s Depression

With rising prevalence of depression in adolescents, screening requirements are increasingly falling on pediatric primary care providers, who are encountering more at-risk patients. A new literature review in Harvard Review of Psychiatry underscores the evidence that non-traditional, so-called lifestyle interventions can help providers meet the growing need for youth depression management. The journal is published in the Lippincott portfolio by Wolters Kluwer.

The article reviews studies of lifestyle medicine interventions related to physical activity, sleep, nutrition, substance use, social connectedness, and stress management and provides clinical practice recommendations. "Having additional and more comprehensive details about such lifestyle recommendations could help clinicians integrate specific advice into anticipatory guidance, management, and treatment plans," suggest Talia S. Benheim, BA, and her colleagues at Massachusetts General Hospital, along with Michelle Dalal, MD, of the University of Massachusetts Chan Medical School and Daniel Hosker, MD, in the September/October issue of the Harvard Review of Psychiatry.

Lifestyle medicine interventions can mitigate lack of access to traditional mental health treatments
Adolescent depression is strongly associated with negative academic, employment, and health outcomes well into adulthood, and studies point to the importance of early and timely access to mental health interventions. Yet, inaccessibility of mental health services persists, especially among marginalized populations.

The utility, versatility, and cost-effectiveness of lifestyle interventions are well known. They can be used by both licensed and non-licensed providers; implemented in a standalone manner or as part of a larger treatment plan; administered in-person or virtually, with a single patient or in groups; and are often more cost-effective and accommodating to patients' unique cultural situations.

The article reviews evidence of lifestyle interventions in physical activity, sleep, nutrition, substance use, social connectedness, and stress, demonstrating efficacy or feasibility in reducing depressive symptoms in adolescents. Studies included clinical trials, quantitative studies, and qualitative studies, as well as the authors' own clinical experience.

Regardless of whether physical activity is considered light or rigorous, many studies demonstrate the efficacy of physical activity in reducing depression symptoms. For example, one revealed that a two-hour decrease in sedentary activity in patients between ages 12 and 16 reduced depression scores by 16%–22% by age 18.
Sleep problems in adolescents persist into adulthood and have been associated with lack of response to depressive treatment and are even a risk factor for suicide. Yet, one study demonstrated that simple and specific guidelines for healthy sleep habits improved depressive symptoms. Bedtime routines such as keeping a diary or maintaining wind-down activities, as well as cognitive-behavioral therapy for insomnia, are also important.

Nutritional studies demonstrate that healthy plant- and whole food–based diets can alleviate or reduce depressive symptoms. The authors suggest a number of simple interventional approaches, such as tip sheets or recipes, engaging professional nutritionists, and guidance on so-called mindful or intuitive eating.

Cannabis, alcohol, and nicotine are also associated with depression in adolescents and can hinder effective treatment of both. Studies show prompt intervention is paramount. An online program in Australia has shown that increased knowledge of substances, depression, and anxiety reduced likelihood of drinking.

In adolescents, loneliness is correlated with depression, and lack of social connectedness is a predictor of suicidal ideation. One study revealed that increases in connectedness over time had corresponding reductions in adolescents' suicidal ideation. Numerous forms of connectedness-;for example, via extracurricular activities such as clubs and sports-;have proven to reduce depressive symptoms and can overlap with other lifestyle interventions.

Finally, interventions to support patients in coping with and managing stress can favorably influence the onset, maintenance, and severity of depression. Successful interventions include deep breathing, meditation, muscle relaxation techniques, and mindfulness-based cognitive therapy.

The authors caution that interventions involving significant behavioral changes can be difficult, especially without social, financial, or cultural support. Despite the scarcity of randomized controlled trials of psychological and health behavior (e.g., physical activity) promoting interventions, Benheim, Dalal, and colleagues believe these interventions can help meet the increasing need for mental health services and give teens and families opportunities to empower themselves with the knowledge, skills, and habits to combat depression.

Benheim, T.S., et al. (2022) Back to Basics: Lifestyle Interventions for Adolescent Depression. Harvard Review of Psychiatry. doi.org/10.1097/HRP.0000000000000343.

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Timely treatment of depression could reduce the risk of dementia

Importance of Continuous Psychotherapy: Once again, the course of ineffectively treated depression carries significant medical risk.”

Depression has long been associated with an increased risk of dementia, and now a new study provides evidence that timely treatment of depression could lower the risk of dementia in specific groups of patients.

Over 55 million people worldwide live with dementia, a disabling neurocognitive condition that mainly affects older adults. No effective treatment for dementia exists but identifying ways to help minimize or prevent dementia would help to lessen the burden of the disease.

The study, led by Jin-Tai Yu, MD, PhD, Huashan Hospital, Shanghai Medical College, Fudan University, and Wei Cheng, PhD, Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China, appears in Biological Psychiatry, published by Elsevier.

Professor Yu and Professor Cheng used data collected by the UK Biobank, a population-based cohort of over 500,000 participants. The current study included more than 350,000 participants, including 46,280 participants with depression. During the course of the study, 725 of the depressed patients developed dementia.

Previous studies examining whether depression therapies such as pharmacotherapy and psychotherapy could lower the risk for dementia produced mixed results, leaving the question unresolved. "Older individuals appear to experience different depression patterns over time," said Professor Yu. "Therefore, intra-individual variability in symptoms might confer different risk of dementia as well as heterogeneity in effectiveness of depression treatment in relation to dementia prevention."

To address that heterogeneity, the researchers then categorized participants into one of four courses of depression: increasing course, in which mild initial symptoms steadily increase; decreasing course, starting with moderate- or high-severity symptoms but subsequently decreasing; chronically high course of ongoing severe depressive symptoms; and chronically low course, where mild or moderate depressive symptoms are consistently maintained.
As expected, the study found that depression elevated the risk of dementia – by a striking 51% compared to non-depressed participants. However, the degree of risk depended on the course of depression; those with increasing, chronically high, or chronically low course depression were more vulnerable to dementia, whereas those with decreasing course faced no greater risk than participants without depression.

The researchers most wanted to know whether the increased risk for dementia could be lowered by receiving depression treatment. Overall, depressed participants who received treatment had reduced risk of dementia compared to untreated participants by about 30%. When the researchers separated the participants by depression course, they saw that those with increasing and chronically low courses of depression saw lower risk of dementia with treatment, but those with a chronically high course saw no benefit of treatment in terms of dementia risk.
He notes that, "in this case, symptomatic depression increases dementia risk by 51%, whereas treatment was associated with a significant reduction in this risk."

"This indicates that timely treatment of depression is needed among those with late-life depression," added Professor Cheng. "Providing depression treatment for those with late-life depression might not only remit affective symptoms but also postpone the onset of dementia."

"The new findings shed some light on previous work as well," said Professor Cheng. "The differences of effectiveness across depression courses might explain the discrepancy between previous studies."
Yang, L., et al. (2022) Depression, Depression Treatments, and Risk of Incident Dementia: A Prospective Cohort Study of 354,313 Participants. Biological Psychiatry. doi.org/10.1016/j.biopsych.2022.08.026.