Investigating the Contribution of Decision-Making, Cognitive Insight, and Theory of Mind in Insight in Schizophrenia: A Cross-Sectional Study

INTRODUCTION: Insight in schizophrenia spectrum disorders (SSD) is associated with outcomes. Although the neurocognitive basis of insight is widely accepted, the specific contribution of decision-making (Jumping to Conclusions [JTC]), Cognitive Insight (CI), and Theory of Mind (ToM) to insight remains unclear. METHODS: The sample included N = 77 SSD outpatients aged 18–64 years from a randomized controlled trial of metacognitive training. Assessments included JTC-Beads Task, CI-Beck Cognitive Insight Scale, ToM-Hinting Task, and the Emotions Recognition Test Faces. STATISTICS: hierarchical multivariable linear regression models tested their contribution to total insight (TI) and three insight dimensions – illness recognition (IR), symptom relabelling (SR), and treatment compliance (TC) – measured with the Schedule for the Assessment of Insight – Expanded version, whilst adjusting for potential confounders. RESULTS: Bivariate analyses showed that CI was associated with TI (R2 change = 0.214; p < 0.001), IR (R2 change = 0.154; p = 0.003), and SR (R2 change = 0.168; p = 0.003), while JTC predicted IR (R2 change = 0.790; p = 0.020). Multivariable regression models showed that CI predicted TI (R2 change = 0.116; p = 0.036) and SR (R2 change = 0.166, p = 0.011), whereas JTC was linked with IR (R2 change = 0.710; p = 0.026). ToM was not linked with any insight score. No cognitive variable was associated with treatment compliance. DISCUSSION: Results supported the (meta)cognitive model of insight in SSD. JTC and CI emerged as the main (meta)cognitive processes underlying insight. Metacognitive interventions may therefore improve insight in SSD, although these therapies alone may fail to address treatment compliance

Study protocol of a randomised clinical trial testing whether metacognitive training can improve insight and clinical outcomes in schizophrenia

Background: Although insight in schizophrenia spectrum disorders (SSD) has been associated with positive outcomes, the effect size of previous treatments on insight has been relatively small to date. The metacognitive basis of insight suggests that metacognitive training (MCT) may improve insight and clinical outcomes in SSD, although this remains to be established. Methods: This single-center, assessor-blind, parallel-group, randomised clinical trial (RCT) aims to investigate the efficacy of MCT for improving insight (primary outcome), including clinical and cognitive insight, which will be measured by the Schedule for Assessment of Insight (Expanded version) (SAI-E) and the Beck Cognitive Scale (BCIS), respectively, in (at least) n = 126 outpatients with SSD at three points in time: i) at baseline (T0); ii) after treatment (T1) and iii) at 1-year follow-up (T2). SSD patients receiving MCT and controls attending a non-intervention support group will be compared on insight level changes and several clinical and cognitive secondary outcomes at T1 and T2, whilst adjusting for baseline data. Ecological momentary assessment (EMA) will be piloted to assess functioning in a subsample of participants. Discussion: To the best of our knowledge, this will be the first RCT testing the effect of group MCT on multiple insight dimensions (as primary outcome) in a sample of unselected patients with SSD, including several secondary outcomes of clinical relevance, namely symptom severity, functioning, which will also be evaluated with EMA, hospitalizations and suicidal behaviour.This study was supported by the Universidad Autónoma de Madrid and European Union via the Intertalentum Project Grant-Marie Skłodowska Curie Actions (GA 713366) to JDLM who is the Princiapl Investigator. This grant therefore funds both JDLM’s salary and the consumable expenses related to the study. JDLM, VGRR, ASEM, MLBE, LMI, LML, SSA, AAR and EBG’s salaries come from the Hospital Universitario Fundación Jiménez Díaz, where this study is currently being carried out, which therefore provides the necessary institutional/departmental support for its development. Additional departmental support concerning the use of Ecological Momentary Assessment (see Methods section, page 11 -last paragraph- and page 12 –first paragraph-, for details) is provided by the Instituto de Salud Carlos III (Madrid, Spain) (ISCIII PI16/01852) and the Madrid Regional Government (Madrid, Spain) (B2017/BMD-3740 AGES-CM 2CM; Y2018/TCS-4705 PRACTICO-CM). ASD acknowledges funding supports from University College London, which covers his salar

Investigating the Role of Insight, Decision-Making and Mentalizing in Functional Outcome in Schizophrenia: A Cross-Sectional Study

Background: Recovery has become a priority in schizophrenia spectrum disorders (SSDs). This study aimed to investigate predictors of objective—general functioning and disability—and subjective—quality of life (QoL)—measures of functional outcomes in SSD. Methods: Sample: n = 77 SSD outpatients (age 18–64, IQ > 70) participating in a randomised controlled trial. Baseline data were used to build three multivariable linear regression models on: (i) general functioning—General Assessment of Functioning (GAF); (ii) disability—the World Health Organization Disability Assessment Schedule (WHODAS-2.0); and (iii) QoL—Satisfaction Life Domains Scale (SLDS). Results: Young age and being employed (R2 change = 0.211; p = 0.001), late adolescence premorbid adjustment (R2 change = 0.049; p = 0.0050), negative symptoms and disorganization (R2 change = 0.087; p = 0.025) and Theory of Mind (R2 change = 0.066, p = 0.053) predicted general functioning. Previous suicidal behaviour (R2 change = 0.068; p = 0.023) and negative and depressive symptoms (R2 change = 0.167; p = 0.001) were linked with disability. Previous suicidal behaviour (R2 change = 0.070, p = 0.026), depressive symptoms (R2 change = 0.157; p < 0.001) and illness recognition (R2 change = 0.046, p = 0.044) predicted QoL. Conclusions: Negative, disorganization and depressive symptoms, older age, unemployment, poor premorbid adjustment, previous suicide attempts and illness awareness appear to underlie a poor global functional outcome in SSD. Achieving recovery in SSD appears to require both symptomatic remission (e.g., through antipsychotics) and measures to improve mastery and relieve low mood

Can metacognitive interventions improve insight in schizophrenia spectrum disorders? A systematic review and meta-analysis

Background: Patients with schizophrenia spectrum disorders (SSD) tend to lack insight, which is linked to poor outcomes. The effect size of previous treatments on insight changes in SSD has been small. Metacognitive interventions may improve insight in SSD, although this remains unproved. Methods: We carried out a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine the effects of metacognitive interventions designed for SSD, namely Metacognitive Training (MCT) and Metacognitive Reflection and Insight Therapy (MERIT), on changes in cognitive and clinical insight at post-treatment and at follow-up. Results: Twelve RCTs, including 10 MCT RCTs (n = 717 participants) and two MERIT trials (n = 90), were selected, totalling N = 807 participants. Regarding cognitive insight six RCTs (n = 443) highlighted a medium effect of MCT on self-reflectiveness at post-treatment, d = 0.46, p < 0.01, and at follow-up, d = 0.30, p < 0.01. There was a small effect of MCT on self-certainty at post-treatment, d = −0.23, p = 0.03, but not at follow-up. MCT was superior to controls on an overall Composite Index of cognitive insight at post-treatment, d = 1.11, p < 0.01, and at follow-up, d = 0.86, p = 0.03, although we found evidence of heterogeneity. Of five MCT trials on clinical insight (n = 244 participants), which could not be meta-analysed, four of them favoured MCT compared v. control. The two MERIT trials reported conflicting results. Conclusions: Metacognitive interventions, particularly Metacognitive Training, appear to improve insight in patients with SSD, especially cognitive insight shortly after treatment. Further long-term RCTs are needed to establish whether these metacognitive interventions-related insight changes are sustained over a longer time period and result in better outcomes

Use of ecological momentary assessment through a passive smartphone-based app (eB2) by patients with schizophrenia: Acceptability study

Background: Ecological momentary assessment (EMA) tools appear to be useful interventions for collecting real-time data on patients behavior and functioning. However, concerns have been voiced regarding the acceptability of EMA among patients with schizophrenia and the factors influencing EMA acceptability. Objective: The aim of this study was to investigate the acceptability of a passive smartphone-based EMA app, evidence-based behavior (eB2), among patients with schizophrenia spectrum disorders and the putative variables underlying their acceptance. Methods: The participants in this study were from an ongoing randomized controlled trial (RCT) of metacognitive training, consisting of outpatients with schizophrenia spectrum disorders (F20-29 of 10th revision of the International Statistical Classification of Diseases and Related Health Problems), aged 18-64 years, none of whom received any financial compensation. Those who consented to installation of the eB2 app (users) were compared with those who did not (nonusers) in sociodemographic, clinical, premorbid adjustment, neurocognitive, psychopathological, insight, and metacognitive variables. A multivariable binary logistic regression tested the influence of the above (independent) variables on being user versus nonuser (acceptability), which was the main outcome measure. Results: Out of the 77 RCT participants, 24 (31%) consented to installing eB2, which remained installed till the end of the study (median follow-up 14.50 weeks) in 14 participants (70%). Users were younger and had a higher education level, better premorbid adjustment, better executive function (according to the Trail Making Test), and higher cognitive insight levels (measured with the Beck Cognitive Insight Scale) than nonusers (univariate analyses) although only age (OR 0.93, 95% CI 0.86-0.99; P=048) and early adolescence premorbid adjustment (OR 0.75, 95% CI 0.61-0.93; P=01) survived the multivariable regression model, thus predicting eB2 acceptability. Conclusions: Acceptability of a passive smartphone-based EMA app among participants with schizophrenia spectrum disorders in this RCT where no participant received financial compensation was, as expected, relatively low, and linked with being young and good premorbid adjustment. Further research should examine how to increase EMA acceptability in patients with schizophrenia spectrum disorders, in particular, older participants and those with poor premorbid adjustment.This study was supported by the Universidad Autónoma de Madrid and European Union via the Intertalentum Project Grant-Marie Skodowska Curie Actions (GA 713366) to JDLM who is the principal investigator. This grant, therefore, funds both JDLM's salary and the consumable expenses related to the study. MLB, VGRR, ASEM, PJEA, SSA, LMI, LML, and EBG's salaries come from the Hospital Universitario Fundación Jiménez Díaz, where this study is currently being carried out, which therefore provides the necessary institutional/departmental support for its development. Additional departmental support concerning the use of EMA is provided by the Instituto de Salud Carlos III (Madrid, Spain) (ISCIII PI16/01852), the Madrid Regional Government (Madrid, Spain) (B2017/BMD-3740 AGES-CM 2CM; Y2018/TCS-4705 PRACTICO-CM), and the Spanish Ministerio de Ciencia, Innovación y Universidades (TEC2017-92552-EXP). ASD acknowledges funding support from University College London, which covers his salary. The funders had no role in hypothesis generation, study design, decision to publish, or the manuscript writing. No funder has a conflict of interest in relation to the study's results and findings. The funding bodies supported the peer review for this manuscript

Onset of Mental Disorders Following Hospitalization for COVID-19: A 6-Month Follow-Up Study

(1) Background: The present study aimed to investigate the onset of mental disorders in the six months following hospitalization for COVID-19 in people without a previous psychiatric history. (2) Methods: This was a longitudinal study carried out among adults who had been hospitalized due to COVID-19 infection. Six months after discharge, a series of questionnaires were administered (the World Health Organization Well-being Index (WHO-5), the Patient Health Questionnaire-9, the General Anxiety Disorder Questionnaire-7, and the Drug Abuse Screen Test, among others). Based on these scores, a compound Yes/No variable that indicated the presence of common mental disorders was calculated. A multivariate logistic regression was built to explore the factors associated with the presence of common mental disorders. (3) Results: One hundred and sixty-eight patients (57.34%) developed a common mental disorder in the 6 months following hospital discharge after COVID-19 infection. Three variables were independently associated with the presence of common mental disorders after hospitalization for COVID-19, and the WHO-5 duration of hospitalization), and severity of illness. (4) Conclusions: Among people with no previous psychiatric history, we observed a high incidence of mental disorders after COVID-19 hospitalization. A moderate (1–2 weeks) duration of hospitalization may pose a higher risk of post-COVID-19 onset of a mental health condition than longer or shorter durations of medical hospitalization. Further research is needed to better understand the mechanisms underlying the psychopathological consequences of COVID-19 and their predictors