Obiettivo del trattamento della schizofrenia: RECOVERY FUNZIONALE

Transcription

1 Obiettivo del trattamento della schizofrenia: RECOVERY FUNZIONALE Autonomia abitativa Relazioni interpersonali Attività del tempo libero Lavoro/scuola Symptom remission alone is inadequate for a definition of recovery... Dimensions of improved psychosocial functioning must also be integral to a definition of recovery... these dimensions include work, school, family life, friends, recreation, and independent living. Liberman & Kopelowicz, Psychiatr Serv 2005

2 Schizofrenia e Recovery Meta-analisi di 50 studi Recovery: La persona deve mostrare un recupero sia sul piano clinico che su quello psicosociale. In almeno uno di questi piani il recupero deve avere una durata di almeno 2 anni. A proportion of schizophrenia patients have a favourable prognosis and have a good clinical and functional outcomes Systematic review of available data showed that 13.5% of patients met recovery criteria Jääskeläinen et al. Schizophr Bull 2013

3 NEUROCOGNITIVE FUNCTIONING IN SCHIZOPHRENIA Summary of results from meta-analytic studies presented in effect-size units Reichenberg, Dialogues Clin Neurosci 2010

4 Meta-analysis of cognitive performance in drug-naïve patients with schizophrenia Verbal Memory Attention Speed of Processing Working Memory Verbal memory, speed of processing and working memory were three of the domains with the greatest impairments The pattern of results is in line with previous meta-analytic findings in antipsychotic treated patients The present meta-analysis confirms the existence of significant cognitive impairments at the early stage of the illness in the absence of antipsychotic medication Fatouros-Bergman et al, Schizophr Res 2014

5 The Italian Network for Research on Psychoses Study Degree of cognitive impairment in individual subjects with schizophrenia (N=921) SD below norms SD below norms in at least 2 domains SD below norms in at least 2 domains SD below norms in at least 2 domains Mucci et al, 2017

6

7 Baseline Follow-Up 7 anni VELOCITÀ DI PROCESSAZIONE ATTENZIONE MEMORIA VERBALE FUNZIONAMENTO GLOBALE PSICOSOCIALE SINTOMI NEGATIVI (Milev et al., Am J Psychiatry, 2005)

8 Neurocognitive constructs and functional outcome Neuropsychopharmacology: The Fifth Generation of Progress 2002

9 Negative Symptoms, Cognitive Impairment and Real-Life Functioning Mediating Variables Functional Outcome Domains Neuro- Cognition Social Cognition Negative symptoms Social Occupational Independent Living Rehabilitation Success Green and Horan, Current Directions 2010

10 Negative symptoms of schizophrenia: Clinical characteristics, pathophysiological substrates, experimental models and prospects for improved treatment NS may, to a certain extent, channel the deleterious influence of other symptoms into poor functional outcome with which NS are strongly correlated

11

12

13

14 SEM - Modello Finale

15 The Italian Network for Research in Psychoses VARIABLES SHOWING SIGNIFICANT ASSOCIATION WITH FUNCTIONING TOTAL (direct+indirect) NEUROCOGNITIVE FUNCTIONING 0.30 PANSS DISORGANIZATION BNSS AVOLITION FUNCTIONAL CAPACITY 0.24 ENGAGEMENT WITH MENTAL HEALTH SERVICES SOCIAL COGNITION 0.17 PANSS POSITIVE INCENTIVES RESILIENCE 0.11 INTERNALIZED STIGMA Galderisi et al, World Psychiatry 2014

16

17 Is cognitive remediation effective? 0,5 0,4 0,3 0,2 0, participants 0 Effect size 0.45 Wykes et al., 2011

18

19 What differences really matter? Strategic approach produced a higher functional effect DP=0.34 (95% CI -0.11, 0.78); SC+=0.47 (95% CI 0.22, 0.73) Adjunctive psychiatric rehabilitation increases functional gains Rehab=0.59 (95% CI 0.30, 0.88); CRT only=0.28(95% CI -0.02, 0.58) 1 0,9 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0,1 0 SC+ Rehab DP+ Rehab Effect sizes when rehab provided

20

21

22 Continuous treatment Design CRT/SRT for 6 months CRT/SRT + post-therapy SRT Schizophrenia Research, 2017 Follow-up after 5 years Cognition stable over time in both groups BUT CRT/SRT + only produced stable functional improvement (Time by treatment effect F=11.48, p<0.001)

23

24

25 USE OF PSYCHIATRIC SERVICES BEFORE AND AFTER TREATMENT IN THE CR GROUP Variable Number of hospitalizations in acute unit per month (mean±sd) Days of hospitalizations in acute units per month (mean±sd) Number of admissions in rehabilitative facilities per month (mean±sd) Days of stay in rehabilitative facilities per month (mean±sd) Number of total outpatient interventions per month (mean±sd) Number of total rehabilitation interventions per month (mean±sd) Before treatment 12 months after treatment 36 months after treatment 60 months after treatment 0.070± ±0.064* 0.020±0.037** 0.012±0.022** 1.855± ±1.431** 0.456±0.881** 0.486±1.165** 0.048± ±0.047* 0.013±0.023** 0.030± ± ± ±3.708* 5.140± ± ±26.568** ±27.907* ± ± ±19.367** ± ± * p<0.05 (Wilcoxon Signed Rank test, comparisons performed versus parameters before treatment) * * p<0.01 (Wilcoxon Signed Rank test, comparisons performed versus parameters before treatment)

26

27 Addestramento alle abilità sociali Rimedio cognitivo Interventi psicosociali Inserimento lavorativo Psicoeducazione Motivazione estrinseca e intrinseca Benessere soggettivo Sintomi, funzioni cognitive, social cognition Funzionamento Relazioni interpersonali Cura di sé sociale Lavoro/ Scuola Qualità della vita Recovery funzionale Autonomia Farmacoterapia (efficace, tollerata, continuativa) MODELLO DI INTERVENTO INTEGRATO NELLA SCHIZOFRENIA

28 DEPRESSION AND COGNITION Vita et al., 2016

29 Cognitive domain Meta-analysis of cognitive deficits in 1st-episode MDD: pooled effect sizes by cognitive domain Std mean difference IV, random, 95% CI Std mean difference IV, random, 95% CI Cognitive flexibility 0.53 [0.23, 0.83] Verbal fluency 0.59 [0.10, 1.07] Attentional switching 0.22 [0.00, 0.44] Visual learning and memory 0.53 [-0.05, 1.11] Verbal learning and memory 0.13 [-0.18, 0.45] Working memory Attention Psychomotor speed 0.16 [-0.20, 0.51] 0.36 [0.13, 0.59] 0.48 [0.21, 0.75] MDD, major depressive disorder; CI, confidence interval Controls performing worse Patients performing worse Lee RS et al. J Affect Disord 2012;140:113-24

30 Cognitive symptoms are common in depression Cognitive symptoms during depressive episodes Proportion of time spent without cognitive symptoms Residual cognitive symptoms in between depressive episodes Proportion of time spent without cognitive symptoms 94% Proportion of time spent with cognitive symptoms a 44% Proportion of time spent with cognitive symptoms a a According to Diagnostic and Statistical Manual of Mental Disorders 4th Edition: diminished ability to think or concentrate, or indecisiveness Prospective study (n=267) assessed 12 times over 3 years Conradi HJ et al. Psychol Med 2011;41:

31

32