Validating cognitive screening in young people with first-episode psychosis: The CogScreen protocol.

AIM: Cognitive impairments are a core feature of first-episode psychosis (FEP) and one of the strongest predictors of long-term psychosocial functioning. Cognition should be assessed and treated as part of routine clinical care for FEP. Cognitive screening offers the opportunity to rapidly identify and triage those in most need of cognitive support. However, there are currently no validated screening measures for young people with FEP. CogScreen is a hybrid effectiveness-implementation study which aims to evaluate the classification accuracy (relative to a neuropsychological assessment as a reference standard), test-retest reliability and acceptability of two cognitive screening tools in young people with FEP. METHODS: Participants will be 350 young people (aged 12-25) attending primary and specialist FEP treatment centres in three large metropolitan cities (Adelaide, Sydney, and Melbourne) in Australia. All participants will complete a cross-sectional assessment over two sessions including two cognitive screening tools (Screen for Cognitive Impairment in Psychiatry and Montreal Cognitive Assessment), a comprehensive neuropsychological assessment battery, psychiatric and neurodevelopmental assessments, and other supplementary clinical measures. To determine the test-retest reliability of the cognitive screening tools, a subset of 120 participants will repeat the screening measures two weeks later. RESULTS: The protocol, rationale, and hypotheses for CogScreen are presented. CONCLUSIONS: CogScreen will provide empirical evidence for the validity and reliability of two cognitive screening tools when compared to a comprehensive neuropsychological assessment. The screening measures may later be incorporated into clinical practice to assist with rapid identification and treatment of cognitive deficits commonly experienced by young people with FEP.

Cognitive health treatment priorities and preferences among young people with mental illness: The your mind, your choice survey.

AIM: Cognitive impairments negatively impact the everyday functioning of young people with mental illness. However, no previous study has asked young people (1) how much of a priority cognitive functioning is within mental health treatment, and (2) what types of cognition-focused treatments are most appealing. The current study aimed to address these questions. METHODS: Your Mind, Your Choice was a survey-based study involving an Australian sample of young people who were receiving mental health treatment. The survey asked participants to (1) provide demographic and mental health history, (2) rate the importance of 20 recovery domains, including cognition, when receiving mental health treatment, (3) share their experiences of cognitive functioning, and (4) rate their likelihood of trying 14 different behavioural, biochemical, and physical treatments that may address cognitive functioning. RESULTS: Two-hundred and forty-three participants (Mage = 20.07, SD = 3.25, range = 15-25, 74% female) completed the survey. Participants reported that addressing cognitive functioning in mental health care was very important (M = 76.33, SD = 20.7, rated on a scale from 0 = not important to 100 = extremely important), ranking cognition among their top six treatment needs. Seventy percent of participants reported experiencing cognitive difficulties, but less than one-third had received treatment for these difficulties. Compensatory training, sleep interventions and psychoeducation were ranked as treatments that participants were most likely to try to support their cognitive functioning. CONCLUSIONS: Young people with mental ill-health commonly experience cognitive difficulties and would like this to be a focus of treatment; however, this need is often unmet and should be a focus of research and implementation.

The use of implementation science to close the research-to-treatment gap for cognitive impairment in psychosis.

For people living with psychosis, cognitive impairment is common and can have significant impacts for functional recovery, impacting engagement with treatment and quality of life more broadly. There is now strong evidence for the effectiveness of cognition-focused treatments, such as cognitive remediation to improve clinical and functional outcomes for people with psychosis. However, engagement with treatment has been a long-standing issue in mental health care, including for people with psychosis, who often experience difficulties with motivation. While research on clinical effectiveness of cognition-focused treatment is growing, to date there has been little research focused on the implementation of such treatments and it is not clear how best to support uptake and engagement across diverse mental health settings. Implementation science is the study of methods and strategies to promote the adoption, application, and maintenance of evidence-based practices in routine care. To integrate cognition-focused treatments into routine practice, and improve engagement with treatment and the quality and effectiveness of care for people with psychosis, researchers need to embrace implementation science and research. This paper provides a succinct overview of the field of implementation science, current evidence for implementation of cognition-focused treatments for psychosis and practical guidance for using implementation science in clinical research. The future of psychosis research includes multidisciplinary teams of clinical researchers and implementation scientists, working together with providers and consumers to build the evidence that can improve the implementation of cognition-focused treatments.

Digital technology for addressing cognitive impairment in recent-onset psychosis: A perspective.

Cognitive impairments in psychosis negatively impact functional recovery and quality of life. Existing interventions for improving cognitive impairment in recent-onset psychosis show inconsistent treatment efficacy, small effects, suboptimal engagement and limited generalizability to daily life functioning. In this perspective we explore how digital technology has the potential to address these limitations in order to improve cognitive and functional outcomes in recent-onset psychosis. Computer programs can be used for standardized, automated delivery of cognitive remediation training. Virtual reality provides the opportunity for learning and practicing cognitive skills in real-world scenarios within a virtual environment. Smartphone apps could be used for notification reminders for everyday tasks to compensate for cognitive difficulties. Internet-based technologies can offer psychoeducation and training materials for enhancing cognitive skills. Early findings indicate some forms of digital interventions for cognitive enhancement can be effective, with well-established evidence for human-supported computer-based cognitive remediation in recent-onset psychosis. Emerging evidence regarding virtual reality is favorable for improving social cognition. Overall, blending digital interventions with human support improves engagement and effectiveness. Despite the potential of digital interventions for enhancing cognition in recent-onset psychosis, few studies have been conducted to date. Implementation challenges affecting application of digital technologies for cognitive impairment in recent-onset psychosis are sustained engagement, clinical integration, and lack of quality in the commercial marketplace. Future opportunities lie in including motivational frameworks and behavioral change interventions, increasing service engagement in young people and lived experience involvement in digital intervention development.

Screening Tools for Cognitive Impairment in Adults with Substance Use Disorders: A Systematic Review.

OBJECTIVES: Cognitive impairment is common in individuals with substance use disorders (SUDs), yet no evidence-based guidelines exist regarding the most appropriate screening measure for use in this population. This systematic review aimed to (1) describe different cognitive screening measures used in adults with SUDs, (2) identify substance use populations and contexts these tools are utilised in, (3) review diagnostic accuracy of these screening measures versus an accepted objective reference standard, and (4) evaluate methodology of included studies for risk of bias. METHODS: Online databases (PsycINFO, MEDLINE, Embase, and CINAHL) were searched for relevant studies according to pre-determined criteria, and risk of bias and applicability was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). At each review phase, dual screening, extraction, and quality ratings were performed. RESULTS: Fourteen studies met inclusion, identifying 10 unique cognitive screening tools. The Montreal Cognitive Assessment (MoCA) was the most common, and two novel screening tools (Brief Evaluation of Alcohol-Related Neuropsychological Impairments [BEARNI] and Brief Executive Function Assessment Tool [BEAT]) were specifically developed for use within SUD populations. Twelve studies reported on classification accuracy and relevant psychometric parameters (e.g., sensitivity and specificity). While several tools yielded acceptable to outstanding classification accuracy, there was poor adherence to the Standards for Reporting Diagnostic Accuracy Studies (STARD) across all studies, with high or unclear risk of methodological bias. CONCLUSIONS: While some screening tools exhibit promise for use within SUD populations, further evaluation with stronger methodological design and reporting is required. Clinical recommendations and future directions for research are discussed.

Treatments for objective and subjective cognitive functioning in young people with depression: Systematic review of current evidence.

AIM: Cognitive deficits are recognized features of depressive disorders in youth aged 12-25. These deficits are distressing, predict functional impairment and limit the effectiveness of psychological therapies. Cognitive enhancement using behavioural, biochemical or physical treatments may be useful in young people with depression, but studies have not been synthesized. The aim was to systematically review the evidence for treatments for objective and subjective cognitive functioning, and their acceptability and functional outcomes in people aged 12-25 with depression. METHOD: Three electronic databases were searched for articles using pre-specified criteria. Pharmacological treatments were not eligible. Risk of bias was rated using the Cochrane Collaboration's revised risk-of-bias tool. Dual full-text article screening, data extraction and quality ratings were completed. RESULTS: Twelve studies were included for review (median participant age: 20.39 years), five of which were randomized-controlled trials (RCTs). Sample sizes were generally small (median = 23; range: 9-46). Eight studies investigated behavioural treatments including aerobic exercise, cognitive training and education or strategy-based methods. Four studies examined repetitive transcranial magnetic brain stimulation (rTMS). Most behavioural treatments revealed preliminary evidence of improved cognitive function in youth depression. Consent rates were greatest for exercise- and education-based approaches, which may indicate higher acceptability levels. Findings from rTMS trials were mixed, with only half showing cognitive improvement. Functional outcomes were reported by three behavioural treatment trials and one rTMS trial, with functional improvement reported only in the former. Some concern of risk of bias was found in each RCT. CONCLUSION: Behavioural treatments, such as exercise, cognitive training and education/strategy-focused techniques, show encouraging results and appear to be acceptable methods of addressing cognitive deficits in youth depression based on participation rates. Brain stimulation and biochemical treatments (e.g., nutrient-based treatment) require further investigation.

Cognitive strengths in first episode psychosis: a thematic analysis of clinicians' perspectives.

BACKGROUND: Cognitive deficits are associated with poor functional outcomes in individuals recovering from a first episode of psychosis (FEP). Existing treatments that target cognitive deficits in FEP may enhance cognitive function, but improvements to real-world functioning are less consistent. Furthermore, these treatments may not adequately address the personal recovery goals of young people attending FEP services. A novel cognitive strengths-based approach may overcome these shortcomings. METHODS: This qualitative study used semi-structured interviews to explore clinicians' (N = 12) perspectives toward the potential development of a cognitive strengths-based assessment or treatment in FEP. The interviews were analysed using thematic analysis. RESULTS: Five higher-order themes emerged: (1) pro-strengths attitude despite unfamiliarity and minimal use, (2) default to a cognitive deficit lens, (3) potential benefits of a cognitive strengths approach, (4) potential risks and barriers, and (5) considerations for successful implementation. While clinicians acknowledged their current deficit approach, they supported implementing a cognitive strengths assessment or treatment and highlighted their potential benefits for the personal recovery needs of young people with FEP. CONCLUSIONS: These findings suggest that a deficit-focused approach to cognitive function amongst clinicians may be common practice in FEP services. Nevertheless, a cognitive strengths approach was viewed favourably by clinicians and may represent a novel method of supporting personal recovery. Thus, the design and implementation of a cognitive strengths approach may be worthwhile. Future exploration of other stakeholder perspectives, such as young people with FEP, is essential.

Brief, Performance-Based Cognitive Screening in Youth Aged 12-25: A Systematic Review.

OBJECTIVE: Cognitive screening is an efficient method of detecting cognitive impairment in adults and may signal need for comprehensive assessment. Cognitive screening is not, however, routinely used in youth aged 12-25, limiting clinical recommendations. The aims of this review were to describe performance-based cognitive screening tools used in people aged 12-25 and the contexts of use, review screening accuracy in detecting cognitive impairment relative to an objective reference standard, and evaluate the risk of bias of included studies. METHOD: Electronic databases (Scopus, Medline, PsychINFO, and ERIC) were searched for relevant studies according to pre-determined criteria. Risk of bias was rated using the Quality Assessment of Diagnostic Accuracy Studies-2. Dual screening, extraction, and quality ratings occurred at each review phase. RESULTS: Twenty studies met the review inclusion criteria. A diverse range of screening tools (length, format) were used in youth aged 12-25 with or without health conditions. Six studies investigating cognitive screening were conducted as primary accuracy studies and reported some relevant psychometric parameters (e.g., sensitivity and specificity). Fourteen studies presented correlational data to investigate the cognitive measure utility. Studies generally presented limited data on classification accuracy, which impacted full screening tool appraisal. Risk of bias was high (or unclear) in most studies with poor adherence to the Standards for Reporting Diagnostic Accuracy Studies (STARD) criteria. CONCLUSIONS: Few, high quality studies have investigated the utility of cognitive screening in youth aged 12-25, with no screening measure emerging as superior at detecting cognitive impairment in this age group.

Emotional discomfort mediates the relationship between self-efficacy and subjective quality of life in people with schizophrenia.

BACKGROUND: In people with schizophrenia, self-efficacy (i.e. the belief in one's capability to perform particular tasks/skills) is associated with and motivates performance of social, health and independent living behaviours. Less well known is whether self-efficacy is associated with subjective quality of life (sQoL) or whether psychopathology impacts this relationship. AIMS: Measure whether greater self-efficacy is associated with greater community functioning and sQoL and whether emotional discomfort mediates this relationship. METHOD: Fifty-two community living people with schizophrenia completed measures of self-efficacy for everyday living and social situations, clinical symptoms, sQoL and community functioning. RESULTS: Greater everyday living and social self-efficacy was significantly correlated with greater sQoL and community functioning and lower emotional discomfort (p < 0.05). Only social self-efficacy was correlated with negative symptoms. The relationship between both aspects of self-efficacy and sQoL was, however, mediated by emotional discomfort. Greater confidence in performing social and everyday living behaviours therefore indirectly impacted sQoL through reducing emotional distress. CONCLUSIONS: Holding negative capability self-beliefs may contribute to poorer outcome for people with schizophrenia. Intervention aimed at facilitating recovery should therefore provide opportunities to develop knowledge and skills required for success in desired life roles and the belief that tasks required for success can be performed.

Perceived need for neuropsychological assessment according to geographic location: A survey of Australian youth mental health clinicians.

Recent studies have shown that neuropsychological assessment is a scarce resource in youth mental health settings. The need for neuropsychological assessment might differ in metropolitan and nonmetropolitan areas due to characteristics inherent to these different regions. However, no formal studies have investigated this question. The aim of this research was to investigate whether need for neuropsychological assessment in youth mental health settings varies by geographic location. A cross-sectional online survey was completed by clinicians (N = 532) treating or assessing adolescents and young adults attending Australian primary care mental health (headspace) centers. Results indicated a similar need for neuropsychological assessment across the geographic areas. However, neuropsychological assessment was significantly less available to clients in outer regional, remote and very remote areas compared to major cities. Exploratory analyses further revealed that there were significantly fewer clinicians with a postgraduate degree and more clinicians with a bachelor degree in outer regional, remote and very remote areas than in major cities. Given the negative impact of cognitive impairments in youth with a mental illness, these findings reveal a necessity to enhance the availability and access to neuropsychological assessment in rural settings. Several plausible avenues to achieving increased access include increasing the funding available for this resource; providing nonmetropolitan clinicians with sufficient neuropsychological consultation, including rural training and rotations in neuropsychologists' postgraduate training; and exploring the use of tele-health in the provision of neuropsychological assessments in nonmetropolitan settings.

Acceptability, safety and perceived impact of providing a fact sheet to young people about cognitive symptoms in depression.

AIM: Cognitive deficits are common in young people, aged 15-25, with depression. Nevertheless, these symptoms are not routinely addressed in clinical care. This study examined the acceptability, safety, and reported impact on cognitive knowledge and strategy use, of a newly developed fact sheet (Thinking about Thinking Skills in Depression) for young people with depression. METHOD: Twenty-three participants, aged 15-25 years old (M = 19.6, SD = 3.2), receiving community-based treatment for a depressive disorder were delivered the fact sheet by their case manager and completed pre- and post-assessments conducted 3 weeks apart. Primary outcomes included: acceptability, safety, subjective distress, knowledge of cognition and use of, and confidence in using, cognitive strategies. Exploratory outcomes included depression symptoms, perceived cognitive difficulties, self-efficacy and self-esteem. Case manager perspectives were obtained using an anonymous online survey. RESULTS: Participant experiences of the fact sheet were favourable. Most reported that the amount of content provided was appropriate (91%), looked at the fact sheet again after receiving it (83%), and tried at least one strategy (57%). Participants reported significant improvements in their knowledge of cognitive difficulties and a greater use of, and confidence in using, cognitive strategies. Distress did not change following fact sheet delivery, supporting safety. Perceived improvements in depression symptoms and cognitive deficits, but not self-esteem or self-efficacy, were revealed. Case manager perspectives were also positive. CONCLUSION: Written fact sheet resources are an acceptable, safe and pragmatic method of delivering information about cognitive difficulties to young people with depression.

Cognitive strengths-based assessment and intervention in first-episode psychosis: A complementary approach to addressing functional recovery?

People who have experienced psychosis describe functional and personal recovery as a key goal of treatment. To date, the early, pervasive and influential role of cognitive impairments in functional recovery in psychosis has been predominantly addressed using approaches aiming to remediate clinically-defined cognitive deficits. Despite acceptance of the recovery and strengths-based model of care for first-episode psychosis (FEP), there has been minimal attention paid to the potential for strengths-based approaches to be extended to cognitive function. The purpose of this review is to present the case for supplementary strengths-based approaches to addressing cognition and functioning in FEP. In this review we appraise current approaches to addressing cognition in FEP that have primarily focused on remediating cognitive impairment, showing evidence for inconsistent engagement and generally small treatment effects. We describe the important role of psychological factors such as motivation and self-efficacy in mediating the relationship between cognitive performance and functional outcome, and draw on positive psychology and self-determination theory as models for potential application in relation to a cognitive-strengths paradigm. Our review supports the argument for complementing approaches for remediating cognitive deficits by applying strengths-based or positive psychology approaches to the domain of cognition as a promising avenue for further enhancing personal and functional recovery from FEP.

Compensatory Interventions for Cognitive Impairments in Psychosis: A Systematic Review and Meta-Analysis.

OBJECTIVE: Cognitive compensatory interventions aim to alleviate psychosocial disability by targeting functioning directly using aids and strategies, thereby minimizing the impact of cognitive impairment. The aim was to conduct a systematic review and meta-analysis of cognitive compensatory interventions for psychosis by examining the effects on functioning and symptoms, and exploring whether intervention factors, study design, and age influenced effect sizes. METHODS: Electronic databases (Ovid Medline, PsychINFO) were searched up to October 2018. Records obtained through electronic and manual searches were screened independently by two reviewers according to selection criteria. Data were extracted to calculate estimated effects (Hedge's g) of treatment on functioning and symptoms at post-intervention and follow-up. Study quality was assessed using Cochrane Collaboration's risk of bias tool. RESULTS: Twenty-six studies, from 25 independent randomized controlled trials (RCTs) were included in the meta-analysis (1654 participants, mean age = 38.9 years, 64% male). Meta-analysis revealed a medium effect of compensatory interventions on functioning compared to control conditions (Hedge's g = 0.46, 95% CI = 0.33, 0.60, P < .001), with evidence of relative durability at follow-up (Hedge's g = 0.36, 95% CI = 0.19, 0.54, P < .001). Analysis also revealed small significant effects of cognitive compensatory treatment on negative, positive, and general psychiatric symptoms, but not depressive symptoms. Estimated effects did not significantly vary according to treatment factors (ie, compensatory approach, dosage), delivery method (ie, individual/group), age, or risk of bias. Longer treatment length was associated with larger effect sizes for functioning outcomes. No evidence of publication bias was identified. CONCLUSION: Cognitive compensatory interventions are associated with robust, durable improvements in functioning in people with psychotic illnesses.

Thematic analysis of youth mental health providers' perceptions of neuropsychological assessment services.

AIM: A growing number of quantitative studies have investigated the utility of neuropsychological assessment in mental health settings. However, to the best of our knowledge, no previous study has qualitatively explored youth mental health providers' perceptions of neuropsychological assessment services. A more in-depth understanding of the perceived advantages and barriers associated with neuropsychological assessment in youth mental health settings is critical to better inform policy, practice and service uptake. Thus, the aim of this study was to qualitatively explore clinicians' views about neuropsychological assessments for youth with mental health concerns. METHODS: A single open-ended qualitative question, included as part of an anonymous cross-sectional online survey, was completed by clinicians (N = 206) treating or assessing adolescents and young adults within Australian primary care mental health centres (headspace). Responses were analysed using an inductive approach to thematic analysis. RESULTS: Five main themes were identified. Clinicians (a) identified barriers to accessing neuropsychological assessments (53%), (b) indicated a range of mixed outcomes following neuropsychological assessment (39%), (c) highlighted a need for neuropsychological assessments (22%), (d) reported a lack of awareness about this resource (10%) and (e) described practice issues associated with neuropsychological services (4%). CONCLUSION: This study uncovered perceived factors contributing to reduced access to neuropsychological assessment in Australian youth mental health settings. Given potential adverse outcomes resulting from this clinical service gap, efforts should be made to address factors contributing to poorer access, thereby mitigating the impact of poor access on the management of mental illness in youth. Several strategies, including funding neuropsychological assessments, are discussed.

Subjective experiences of neurocognitive functioning in young people with major depression.

BACKGROUND: Research suggests that young people with major depressive disorder (MDD) experience neurocognitive deficits and that these are associated with poorer functional and clinical outcomes. However, we are yet to understand how young people experience such difficulties. The aim of the current study was to explore the subjective experiences of neurocognitive functioning among young people with MDD. METHODS: Semi-structured qualitative interviews were conducted with 11 young people (aged 17-24 years) attending a specialist clinic for youth experiencing moderate-severe depression. Interview transcripts were analysed via Thematic Analysis to identify patterns and themes representing how young people with MDD subjectively experience neurocognitive deficits. RESULTS: Five main themes were identified: (1) experience of neurocognitive complaints; (2) relationship between neurocognitive complaints and depression; (3) impact on functioning; (4) strategies and supports; and (5) neurocognitive complaints and treatment. Overall, young people with MDD commonly experienced a range of subjective neurocognitive complaints. These appeared to have a bidirectional relationship with depressive symptomatology and significantly disrupted vocational, social and independent functioning, and aspects of psychological well-being including self-esteem. Neurocognitive difficulties represented an experiential barrier to psychological therapeutic engagement and were perceived as variably responsive to psychotropic medications, highlighting the need for targeted intervention. DISCUSSION: Neurocognitive difficulties are a common and pervasive experience for young people with MDD, with perceived impacts on depressive symptoms, attitudinal beliefs, everyday functioning and therapeutic engagement. Subjective neurocognitive complaints may therefore contribute to or exacerbate personal challenges faced by young people with MDD and thus, require early identification, consideration in psychological formulation, and treatment. Further research into the mechanisms of neurocognitive impairment in MDD is also needed.

Vocational engagement among young people entering mental health treatment compared with their general population peers.

AIM: To compare rates of vocational engagement for youth entering specialist mental health treatment with the general population. METHODS: A file audit retrieved vocational data for 145 youth aged 15 to 25 entering treatment. Clinical and population data were stratified by age and sex and compared between cohorts. RESULTS: Compared to the population, young people entering mental health treatment were less likely to have completed at least Year 11 in school (77% vs 42%, P < 0.001); and demonstrated higher rates of "Not in Education, Employment or Training" (9% vs 33%, P < 0.001). Individuals aged 15 to 18 years entering treatment experienced greater rates of educational disengagement than the population (30% vs 11%, P < 0.001), whereas people aged 19 to 25 years showed higher unemployment rates (52% vs 35%, P = 0.003). CONCLUSIONS: Youth entering specialist mental health treatment have marked levels of vocational disengagement compared to demographically-matched peers. Early vocational intervention for these young people is essential.