Good morning, everyone, and good afternoon for those of you who are on the East Coast. We want to welcome you to today's webinar on how neurocognitive and social cognitive factors relate to daily functioning and first episode psychosis. I am Judith Doberman, the Program Manager for PEPNet at Stanford University School of Medicine. Also with us today is Dr. Steven Adelsheim, who is a clinical professor at the Stanford Department of Psychiatry and Behavioral Sciences. He is also the Associate Chair for Community Partnerships and the Director of the Stanford Center for Youth Mental Health and Well-Being. Dr. Adelsheim will be co-facilitating with our presenter today your questions. Today's webinar is brought to you as a partnership between PEPNet and SMI Advisor, and SMI Advisor is a funded initiative implemented by the American Psychiatric Association. And now I would like to introduce Dr. Joseph Ventura. Dr. Ventura is a Senior Research Psychologist and member of the faculty in the UCLA Department of Psychiatry and Biobehavioral Sciences. Dr. Ventura and his colleagues have developed and published a set of internationally recognized diagnostic and symptom assessment training and quality assurance procedures. He is responsible for all training and quality assurance functions, development, standardization, and refinement of the center's diagnostic and psychiatric symptom assessment procedures. Thank you. Thank you very much, Judith. And thank you, Dr. Adelsheim, for organizing this presentation and for inviting me to give this talk. I'm really very, very excited and very happy to have this opportunity to speak with you about a topic that I've been spending a lot of time thinking about and conducting research on and working with clinically. I am located at the moment at UCLA in the Department of Psychiatry. It's the Semmel Institute for Neuroscience and Human Behavior. And the program that I'm most affiliated with is the UCLA Aftercare Program, which is a joint clinical and research program that's studying the first episode of schizophrenia. So the first thing I want to say is that I don't have any relationships or conflicts of interest related to the subject matter of today's webinar. And here are some learning objectives. By the end of today's webinar, you should be able to identify domains of neurocognition and social cognition and how they're related to community functioning. You will also be able to describe brief neurocognitive and social cognitive assessment tools and list empirically based treatment approaches that have been used to improve neurocognitive and social cognitive skills. And the outline of the presentation calls for me to define neurocognitive domains. I'm really excited about the idea of sharing these domains to you and defining them a bit. I'm also going to share social cognitive domains and their relationship to functioning. I'm going to talk a bit about methods of assessing cognitive functioning, because I want the webinar to have some practical components to it and so that you could start using some of the information you're going to hear about today right away. I'm going to also, in both domains, talk about approaches to cognitive remediation. Sometimes I call it cognitive training, cognitive remediation, they mean about the same. So from the work that I've done here at UCLA in the aftercare program, we have found that many individuals who are in the early course of schizophrenia want to return to school of work. They've had a first or second episode of schizophrenia and they have been hospitalized. And so when they get out of the hospital and they're starting their recovery process, they would like to be able to go back to what activity they were doing prior to having an episode. So individuals in this situation with the first episode of schizophrenia, however, we feel are facing the challenge. And that is that in some cases, individuals have difficulty with cognition or put more simply thinking skills. We have found that neurocognitive functioning is related to daily functioning. So we think it's important to address this topic of cognitive functioning and how it relates to daily functioning, considering that many individuals want to return to school of work. And we believe that understanding neurocognition and social cognition is a part of a recovery oriented approach. Everything I'm going to be talking about today is really aimed at improving recovery, improving quality of life. That's why I'm very excited about being part of the field. We have really shifted to paying a lot of attention to quality of life and functioning as opposed to positive symptoms, mostly because the medications we have do help with symptoms but they don't necessarily address thinking skills or social cognition. So are cognitive difficulties central to schizophrenia? Well, there's a lot of research that shows that they are. It doesn't mean that everyone has these difficulties, but it means that we should pay attention to them and try to understand whether a given client or person that we're working with might have this as a difficulty. Now why are they considered important? It's because in many studies it's been shown that some of these cognitive difficulties or thinking difficulties may actually predate the onset of the psychotic symptoms. They also appear in individuals who have not yet been diagnosed but are considered at clinical high risk for developing a psychotic disorder or schizophrenia or bipolar disorder. They're also present in the children at risk for schizophrenia. If you have a parent or a couple of parents that have the condition or if you have a brother or sister, you're at increased risk compared to the general population. And so those individuals have some of these cognitive difficulties. They may not be as pronounced as they are in individuals who have the diagnosed condition, but they might still be present. They're also present in unaffected twins, meaning if a twin has schizophrenia, then the unaffected twin may also have some of the mild cognitive problems. They're certainly present in first episode individuals. There's been plenty of research to show that. They're relatively stable over time. Now why am I mentioning that? It's because given that they are stable over time, it means that they don't necessarily go away during periods of remission. So if they're there, if the clinical picture or the symptom picture improves, it doesn't necessarily mean that the cognitive thinking skills also improve. So it's important for us to track them and understand them and see how they change. And then you've heard me say, and you'll probably hear it a few times, these neurocognitive difficulties or challenges predict work and social outcome. But that's for everybody. That's not unique to any condition. If you're functioning really well at work and you're able to understand that your work tasks work quickly, you get good work performances, you're going to be able to advance or get promotions. Also, social situations, the ability to track what people are saying, understand what they're saying, be able to have discussions, is all related to improving social relations. Now neurocognition and symptoms are correlated, and I'll mention that along the way. But if we have a little time at the end, I can delve into that a little deeper. Here is a slide that demonstrates and shows you for the first time these neurocognitive domains that I'm going to be talking about and focusing on. There was a factor analysis conducted by my colleague, Keith Neckerlein, and through the factor analysis, he was able to identify, he and his colleagues, these domains of cognitive functioning. The work that he did indicates that these domains may be separable, which is very important because some individuals may have some challenges in these areas, but not all of them. Some individuals may have challenges in many of them, and some may not have any challenges in any of them. So I think it's important for us to understand that. And the first one is short-term memory, sometimes called working memory, attention and concentration, which is very important to all individuals, the ability to concentrate, verbal learning and memory, sometimes called long-term memory, visual learning and memory, reasoning and problem solving, and speed of processing. So I want you to start to think about the people that you're working with and think about whether they ever complain or mention any difficulties in these areas, and I'll provide you with a definition. And I want to encourage you right away to be able to discuss these topics and these domains with the people you're working with and see if, in fact, they do identify that they're having any difficulty. So the first one, short-term memory or working memory, that's taking information that you just learned and using that information a few moments later. The classic example is you're at a social situation, you meet two or three people, you learn their names, can you remember them in the next few moments if you want to address that person? Also, do you have the ability to remember a phone number long enough to dial it again if you can't write it down? So once again, most people will complain about some of these difficulties, but some individuals in the first episode of Schizophrenia or even with more established illness will say that even if they hear the name several times, they still have difficulty remembering them. Attention and concentration, that doesn't need much definition. It's the ability to be able to sustain one's focus and one's attention over an extended period of time. Verbal learning and memory, sometimes called long-term memory, involves the storage of information over a longer period of time. For example, listening to a lecture or a teacher give a lecture and then being able to use the information you learned later. This would be very key and critical for somebody who wants to return to school and is taking classes and who may be having difficulty in this area to be able to know that and then address those concerns. Visual learning and memory, it's learning information in a visual modality. For example, what you've seen. Reasoning and problem solving, a very interesting area of cognition. Sometimes people may have some deficits or difficulties with working memory or with attention, but they might be able to cope with them or compensate for them because they have good reasoning and problem solving ability. Reasoning and problem solving, sometimes you are stuck in a situation where you have to reason and problem solve quickly. If you have a flat tire on the freeway, you have to decide if you want to wait for the AAA tow truck driver to come, it's going to take 30 to 45 minutes, whether you should call a friend who lives nearby or a relative, or whether you have time to work on your cell phone and answer some texts while you're waiting for the tow truck driver. It all depends on where you have to be, how soon you have to be there, and being able to figure out and analyze problems and determine what the best course of action is. Data processing, a very important domain, because even if you have some good concentration and good working memory, in some situations, especially at work, I've heard this from many individuals that I've worked with who say that they're doing well on a job and their performance is fine, their boss likes what they're doing, but it's not being done fast enough. Now, in some situations, like being a cashier, you have to work very quickly, and in others, you have a little more time. So why are these domains so important, and why am I talking about them? Well, the ones that I just described to you are listed now on the left-hand side of the slide. Reasoning, problem solving, verbal memory, short-term memory, attention. And research that was done by my colleague, Michael Green, some years ago, but this work has been replicated again and again, indicates that there are direct links, if you look at the yellow arrows, direct links between these neurocognitive domains and all of the things we want to do in our lives. So I'm excited about the fact that we're interested in functioning, and here are the functions that we're interested in for the people we work with. Community functioning, daily activities, social problem solving, daily skills, and social skill learning. So these are all things that we want to do, they're all part of enjoying life. At the moment, some of them we're not permitted to do because of quarantine and social distancing, but there's certainly ways in which your quality of life improves and you can enjoy life. Well, let me now mention some of the work that we've done here at UCLA in the aftercare program, and it's all along the same lines that I've just been talking about. On the left-hand side of your screen, you could see that there are neurocognitive domains, just like the ones I've been talking about, working memory, verbal memory, attention. And these factors, it turns out, are very highly related to who returns to work or school. This was work done in our first episode, sample of individuals with schizophrenia. And what we found is that these neurocognitive factors accounted for 52% of the variance in who returns to work or school. Now you're saying, okay, Ventura, what do you mean 52% of the variance? That's a statistical term. Well, it's very easy to explain because there are 100% of reasons why people return to school or work. There might be a good economy. There might be some classes they're interested in. They're highly motivated. Somebody may help them find a job. So there's 100% of reasons. Well, these cognitive factors actually accounted for half of the reasons why somebody returns to school or work. So we've become pretty convinced that they're very important and that they should be addressed in anybody who might be having difficulty in these areas. So I mentioned that we want to talk about assessment of cognitive function. So I think it's very important to figure out a way of determining whether somebody has these difficulties. There are several ways of doing it. And so we've been talking about the underlying construct of cognition or neurocognition. That's the big circle here. That's the big construct, thinking skills or cognition. And there are two ways to assess cognition. One is through objective cognitive tests. And the other is through interview-based measures of cognition. And so I'm going to describe each one of these approaches because there have been some published methods that are available on the SMI Advisor that would allow individuals, clinicians, to use these approaches right away. The first one is called the Brief Cognitive Assessment Tool for Schizophrenia. Now, it has the word schizophrenia in the title, but it could be used for anybody with SMI, serious mental illness, any condition, to get an idea of an objective assessment of global cognition. It takes 10 minutes, and it was designed to be used by individuals who don't have a lot of neurocognitive training or not neurocognitive background. The BCATs, or this Brief Cognitive Assessment Tool, can be used as a screening instrument or to measure change. So if you are targeting cognition, you want to be able to repeat the assessment to see if the intervention you're using is working. That's part of measurement-based care approach, where if you are targeting, whether it's positive symptoms or cognition, you want to assess as much as you can whether or not your intervention is working. The BCATs correlates highly with longer neurocognitive test batteries that could take somewhere between 90 minutes to two hours to administer and are complicated to score. The BCATs, remember, takes 10 minutes to administer. The BCATs could be used to inform treatment planning, rehabilitation planning, and it could be used to measure the effectiveness of pharmacological, if you think that a particular medication might improve a person's thinking, or non-pharmacological treatments like cognitive training. And so the BCATs is made up of three tests. They each take a few minutes to administer. One is called the digit-symbol substitution test, the trail-making test. Some of these tests may be familiar to some of you in the audience, and animal fluency. Again, if you go to the SMI Advisor website, you'll be able to access the publications on this topic that were published by my colleague Irene Herford, and her work really was aimed at trying to provide tests that could be done quickly and done in clinical situations. Along those same lines, I have done some work with my colleagues here at UCLA, Robert Bilder, Richard Keefe at Duke, and we've developed what's called the Cognitive Assessment Interview, or the CAI. When I was coming up with the acronym for this, I tried to make it the CIA because I thought it would get a lot more attention, but no matter how I arranged the words, it still came out CAI. So that's the name of it, the CAI. The CAI takes 15 minutes to administer, and the reason I like the CAI is because it could be administered by trained clinicians, and it doesn't involve any knowledge of neurocognition or neurocognitive assessment. It could be easily scored, and it's interview-based, so it's user-friendly, and it's non-stigmatizing, because it's basically just talking to a person about their cognitive functions. And the domains that I just mentioned to you are assessed using the Cognitive Assessment Interview. It's similar to the BCATs in that it could be used to monitor treatment. It could be used as an initial screening to determine whether somebody has a difficulty in a particular area, and where their strengths are as well. So the Cognitive Assessment Interview has three components. You interview an individual, or basically just talk with them about their difficulties if they have them, and that takes about 15 minutes, as I mentioned. You can also interview an informant. These interviews are very, very useful, because if an individual isn't quite aware of the cognitive difficulties they may be experiencing, talking to an informant, which could be a psychiatrist, a friend, a parent, case manager, psychiatric nurse, anybody who knows about the cognitive functioning can help provide additional information that would add about another 10 minutes. A lot of information about the CHI is available on SMI Advisor. As part of my work with that group, I posted answer cards and information, including the publications on the CHI and some supplemental instructions. This is what it looks like. I've been talking quite a bit about working memory. You would first define the domain of working memory with the person you're working with, and then you would ask them some questions, just like the ones I mentioned. Do you forget the names of people you just met? Would you have trouble recalling telephone numbers? These are just opening questions. You could follow up with any other sorts of questions that might be relevant for the person, and then you could just start a dialogue with him or her about whether they have some of these difficulties. So working memory is one domain. There were two questions in that area. Also assessment of concentration and attention is possible with the CHI. There were two questions in the attention area. And again, most people, if you ask, do you have trouble concentrating? They'll say, yes. Some people have to have music on to concentrate. Some people have to have complete silence. But having a discussion about this and figuring out what works. And on question number four, you can talk about distractions. And there are specific techniques and approaches that could be used. And if somebody says, yes, I easily get, if they get distracted, there are some approaches that could be used to help with that. Well, I've talked a little bit about medication and I've said that medication has some limitations. Medication is good for controlling symptoms like positive symptoms of a condition like schizophrenia or any SMI condition, but they don't teach a person skills or how to function better at work. And again, that's exactly what we're interested in. Improving quality of life and paying attention to social relationships or skills of independent living and how cognition is related to that. So can exercising the brain make you smarter? In fact, we believe it can. And there's evidence to indicate that cognitive training, cognitive remediation does improve cognitive function. In this field of cognitive training and cognitive remediation, we have an ally on our side. It's called brain plasticity. You must likely have heard about it. It's, it defines the brain's infinite ability to adapt, to change and to be able to modify itself in relationship to a challenge or a task. So brain plasticity is sometimes called neuroplasticity. And there's some evidence to indicate that individuals who participate in cognitive training can actually increase the number of neuronal connections that they have or can grow new brain matter tissue. Like for example, in the hippocampus, which is responsible for memory. So there are MRI studies that have demonstrated this. However, research has limitations because it's all group data. It's not individual data. So it's either a limitation or a strength. So it shows on a group level that you can improve these domains, but whether it would work for any given individual, well, I think the best thing to do is try it and see if it works. I believe it does work, but it may not work in every single situation. So we have to be realistic about it. Now, the computer games that I'm gonna talk about and advocate are not these computer games. These computer games are very fun and have great graphics. Harry Potter, Mario Brothers, Star Wars, they're lots of fun. And these are the games that our clients and the people that we're working with are usually playing or enjoy. But when I talk about cognitive remediation or cognitive training to an individual I'm working with, I'm sure to tell them that it involves hard work. It's a bit of work. I don't emphasize that part of it, but it does involve work. So when it comes to improving your brain power, it turns out that you have to do it the old fashioned way. It involves some work. Just like losing weight involves exercise and dieting, which involves extra effort and work. In terms of cognitive remediation, most of the cognitive remediation programs we've worked with are computer assisted or computer based, and some of them are manualized. I'm gonna talk about two types of cognitive remediation because you can choose from either one of these two. And once again, the internet is my co-therapist. I use the internet quite a bit because all the information that I'm talking about is available on the internet. And I've worked with individuals side by side using my screen, which is used basically to surf the internet, look for helpful hints, look for approaches to be able to provide cognitive training to individuals. So here are the two types. The restorative type aims to restore cognitive functioning that may have been lost because of having an episode, being in the hospital, or in some cases, because of some of the sedating aspects of medication. Or they are used to establish cognitive skills that may be never formed for a person at the right time. There's another approach that's completely different in some ways, but overlapping. It's called the compensatory approach. The compensatory approach doesn't necessarily aim to restore brain function or change the brain so much as it is to compensate for difficulties by working around them. So these difficulties involve, or the compensatory approach to difficulties involve changing the person's environment. Some examples include putting up Post-it notes to remind individuals about a medication appointment or a job appointment. They also advocate the use of calendars and diaries and so scheduling things, writing things down so that you would remember them. And those kinds of environmental changes using an alarm clock. These approaches are available. If you're interested in the restorative approach, the one we've used is Brain HQ. The reason we've used it is because the early work done in this area in people with established illness was done using programs from Brain HQ. It's not an expensive program. It's about 90 or $95 for a one-year subscription. And it actually will self-pace the person through the exercises. Cogsmart.com, maybe some of you saw a webinar by my colleague, Beth Twombly, Elizabeth Twombly at UC San Diego. Cogsmart is the compensatory approach. She's developed an awesome program. It's available, it's free. She's willing to help anybody with the use of Cogsmart or the compensatory approach, as am I willing to help anybody who will email me. And this is a fully manualized approach. You can download the manual, you can read it. There are videos. You can share those videos with people you're working with. You can use them for yourself and then you can develop an approach. I advocate what we call cognitive coaches or the approach used by cognitive coaches. I don't call myself a therapist. We basically now think of the whole approach that we use as training, not necessarily therapy. We call the people who work with our individuals in our program, cognitive coaches, because what you're doing is you're coaching people and providing the structure that they need to remind them to stick with the program. There are other commercially available programs. I mentioned Positive Science of Brain HQ. Lumosity is one that's a very heavy advertising campaign. You might've heard of that one. There's another one, which is my favorite, Happy Neuron, which is, I think, exactly what we want. We want our neurons to be happy and then talking to each other and interacting with one another. But these cognitive training programs do promote that. So what I would recommend is use the internet. You could check out these programs using demo, the demos that are available on the internet. The person you're working with, you could decide whether he or she likes Happy Neuron, Lumosity, or Brain HQ, and then try it out. This is what Happy Neuron looks like. There's an attempt to make Happy Neuron look more fun, more like Harry Potter and Star Wars, but it doesn't involve work. Here's another attempt with this program to look more fun, to appeal to young people. And this program focuses more on speed of processing. And that's a very important domain. And many of the programs that I'm advocating are timed, and they do require individuals to work quickly, which is very good because it's challenging. And we have found that engagement and challenging the brain changes that I talked about. If it's easy and fun, you're not going to get as much of a change as if it's challenging and difficult. So we often remind our folks that it's not so important how well they perform, but how much effort is put into it. It's very, very similar to exercise, very similar. You're exercising the brain or you're exercising the muscle, and the brain has been referred to as a muscle. Here, I just want to mention that there were basic cognitive processes. I'm repeating these same domains again, so you can start getting familiar with them. Memory, attention, and processing. Those are some basic fundamental skills, cognitive skills that we all need to have, and we use them to be able to track information that's coming at us in this world full of information. And then there are higher order cognitive processes. And those are the ones I mentioned, such as decision-making and evaluating a situation, taking perspective, context appraisal, and flexibility. And sometimes if you have really good higher order cognitive processes, as I mentioned, you could use those to cope with some of the basic cognitive processes, but there's no substitute for being able to pay attention, have good working memory and long-term memory and processing speed. This is just some work I want to show you that puts research behind what I just described to you. This was a meta-analysis conducted by Till Weitz in 2011, basically that shows that using cognitive remediation programs does improve cognition, and you get an added bonus. It could also improve functioning, but this meta-analysis indicated that it didn't have much of an effect on symptoms. However, subsequent research has shown that it can improve symptoms. As a matter of fact, here at the bottom of the screen, you see another meta-analysis that indicates that people who participate in cognitive remediation actually had improvement in their negative symptoms. And we've also seen that here at UCLA. So this 0.3 would be a small to moderate impact, but any intervention, any program that improves negative symptoms, I think is worth celebrating. The effect here from the Weitz et al cognitive remediation programs and her meta-analysis, which is an average of many studies, a meta-analysis takes many studies, here the effect or the impact would be moderate on cognition and moderate on functioning. So we see somewhere from a small to moderate impact on cognition and on functioning from cognitive training. Now I wanna share with you specific data from our program here at UCLA and aftercare. This research was done with, again, with our first episode individuals. It's a second group of individuals compared to the first study that I showed you. And these are the findings. So I'll walk you through this. On the left-hand side is your score on cognition. This is your global cognition score. And then on the bottom, you see baseline and 12 months. The individuals who received the cognitive training are depicted here in yellow. So you can see there was an increase and individuals who received healthy behavior training, which is good, nutrition, stress management, independent living skills, very helpful material. It didn't focus on or target cognition. So what you see in the global score, which means all of the domains put together, you see an improvement over a one year period in cognitive function. I've mentioned now working memory several times. This is a specific domain. So this was a test of working memory within our battery of tests. And again, showing that the yellow line, individuals who received the cognitive training improved as compared to healthy behavior training, which again is also good, but didn't target cognition. We got the added bonus of increased role functioning. Individuals in the cognitive training here in yellow showed an increase in their role functioning. And we examined whether the cognitive gain, the amount of improvement in your cognition was related to your improvement in functioning. And here we see that that's the case. So people whose cognition improved were more likely to have their functioning improved. Here, again, I'm talking about work that was done at UCLA in our aftercare program. And this study aimed to determine whether adding exercise to cognitive training was helpful. And the answer is yes. There was an added benefit or an added impact. If you see again here in yellow, these are individuals who received cognitive training plus exercise. And in blue would be people who received cognitive training without the addition of the exercise. And you can see we got an added benefit. I wanna take this moment to make a super big plug for exercise. Cognitive training is one way to improve cognitive functioning, but so is exercise. And in the aftercare program now, we talked to everybody about wanting to improve their brain power so that when they go out into the world, they can function as well as possible. And exercise is one way to improve brain power. Cognitive training is another. So this just shows that adding exercise also helped with functioning. Now, I'm gonna switch gears a little bit, but not really. I'm gonna talk about the RAISE study, a study that Dr. Adelsheim was involved in where sites around the country were selected at random. The sites were selected to either provide standardized care or a newly developed approach to working with individuals with first episode psychosis. So now I'm switching to first episode psychosis because in the RAISE study, they didn't just include individuals whose first episode is schizophrenia. They included people with any kind of a first episode of a psychotic experience. So first, I'm gonna tell you that in this work that was done, it was a secondary analysis of the NIMH study RAISE, and you'll see what RAISE stands for here at the bottom. It's recovery after an initial schizophrenia episode. I think they picked the word schizophrenia because it fit in with RAISE, but they probably meant initial psychotic episode. But in any event, what I like about this study is that it compared black Americans to white Americans. Now, this is at baseline. So I'm gonna talk about two studies, but this is the baseline comparison. So these are the domains where there were no differences between black Americans and white Americans. So that's nice. There's the duration of untreated psychosis, prior hospitalizations, age of onset, symptoms, no differences. However, once again, at baseline, when you compare black Americans to white Americans, as they did in this study, here are the findings. Black Americans were more likely to lack permanent housing. They were less likely to have private insurance. They reported a poor quality of life. They had more severe symptoms of disorganization, a lower level of neurocognitive functioning, and they were less likely to abuse alcohol. So why is this important? It's because these are the factors, the ones that I just mentioned, that are predictive of or associated with improvement in a treatment program. So you wanna do this assessment early, and you wanna examine in your group of individuals coming into your clinic, whether there are any disparities according to RAISE at all. Now, there might be some reasons why there was lower level, for example, of neurocognitive functioning. It might have something to do with the test not being cultured fair, or the fact that individuals, like as we now know, as a topic in the news, might be experiencing long-term discrimination and stress and so forth. So there could be some real reasons for this that aren't pertaining to the individual him or herself. But if that's the case, that they have a lower level of neurocognitive functioning, you would wanna know that. And those instruments that I mentioned can be used or longer batteries can be used. So the recommendations from this study were that if the person is having trouble with housing, job one would be to use case management to improve the housing situation. Because frankly, you're not gonna be able to benefit from therapy if you don't know where you're gonna be sleeping tonight or the next day, or if you don't feel safe. The other recommendation was if you're having difficulties with cognitive functioning, to use cognitive remediation. I'm gonna talk about one more study regarding that they use data from the RAISE study. Again, you can see what RAISE stands for here at the bottom. And this is a separate study. Here, the researchers are looking at the researchers compared black Americans to white Americans who were participating either in the community-based care condition or NAVIGATE, a program that was developed specifically for the RAISE study that involved individual resiliency training, medication management, supported employment. It has some really neat features to it. So once again, agencies were selected randomly to either provide the community-based care or treatment as usual in some ways, you can describe it as that, versus this newer developed approach. And what was found was that over the two-year period, black Americans compared to white Americans had higher positive symptoms, higher levels of disability, and were less likely to use evidence-based care and less likely to recover in the community-based conditions. But this new approach, the NAVIGATE, with all those neat features, actually eliminated all of those trends. So the take-home message here is that providing good collaborative-based care, measurement-based care, supported employment, and all the things that we know help people is very, very important if you have individuals in your program that might be either of a minority group or black Americans. So it's very important for us to start paying attention to all of that as we're hearing now in the news as well. Well, let me switch now to social. I've talked a lot about neurocognitive. I'm going to talk about social cognition. And so I'm going to mention social. Joe, this is Steve. Just so you know, we have about a little over 15 minutes left and we've got at least 10 questions already lined up and waiting for you. Just so you're aware. Okay, good. Okay, thank you. Thank you very much. All right, so social interaction is very important for mental health and for physical health as well. There are, an easy definition of social cognition is thinking skills applied to social situations, just like the ones I mentioned. It's true that in first episode individuals, you also have these difficulties and not everybody has them, but some do. These are the areas, just like I showed you the neurocognitive domains. These are the areas of social cognition and facial recognition is very important. We get a wealth of information from a person's facial expressions, from their voice tone. These are some basic emotions that sometimes individuals have difficulty with being able to identify. This is some research that was shown that in fact individuals with schizophrenia with established illness and first episode individuals do have some difficulty with recognizing emotions, even if the emotions are exaggerated. There's a very important concept here that's called mirroring and mirroring enables us to be able to mimic behaviors that we see. Affective sharing has to do with being able to share those emotions. This is an example of mirroring, very important for newborns to be able to mirror the faces that their moms show them, smiling, happy faces. There's a concept called mentalizing, which is a higher order concept, which has to do with abstraction. Mentalizing is used to intuitively know how we get along with others. Once again, the research is very, very similar in social cognition as compared to neurocognition. There are clear and very consistent relationships shown in study after study between social cognition and social functioning. This slide has to do with attribution. Each of us has a self-referential attribution style. So if we see a coworker looking kind of angry, we might think, well, maybe it's something to do with me. But we know that individuals with schizophrenia tend to perceive more threat in the environment than the average person does. So understanding of whether there actually is threat can determine whether a person interacts with an individual. One approach to this person would be to say, did you have a bad weekend? Another would be to avoid him. So the CHI we use also to assess social cognition. There's an item on it. It's available on SMI Advisor with some special instructions from me. There are also social cognition training programs available that teach people facial recognition. You see, you're shown a few faces here, but then when you're asked to identify those faces, you don't see that same individual. You'll see a different person and still ask to identify, for example, you see the smiley face with the upturned mouth. And you see that in this individual here. And your goal is to select the same emotion that you just saw. This is training for improving your ability to follow conversations. You're given some information about Joy. She's a district attorney. And then later you're shown the picture of Joy and you have some choices and you have to remember that she's a district attorney and that her name is Joy. So in summary, I talked about neurocognitive and social cognitive difficulties. They're an important feature of first episode schizophrenia. They're also important features of individuals with established conditions. There are relatively brief methods for assessing cognition, which are available on SMI Advisor, the BCATs and the Cognitive Assessment Interview. And there are approaches to restoring these domains. And the internet is your friend. You can get a wealth of information and not necessarily involve yourself in Brain HQ or SocialVille, but there are even just some short term handouts and things you could do with individuals to improve their functioning. So I wanna thank you for your attention, your working memory, your speed of processing. I use speed of processing at the end here and social cognition. This is my email address. I'm happy to interact or talk with anybody or provide any additional materials. Thank you, Dr. Ventura. That was really wonderful presentation. And thank you for the time we have left. I think you generated quite a few questions. And I think one good place to start and maybe addressing some of them really was around some of the questions around the initial two cognitive assessments that you talked about. And one of the questions that came up was just maybe if you could clarify a little bit more some of the notable differences in terms of efficacy between the two assessments that were provided. That would just be helpful to a couple of people. So the BCATs is highly correlated. The correlation was somewhere in 0.7 or 0.8 range. It's highly correlated with longer neurocognitive batteries. And it's also correlated with functioning. So in terms of reliability, it's correlated with much longer neurocognitive batteries. And in terms of validity, it's also correlated with functioning. So it can be used as a screening instrument or to track change over time. The cognitive assessment interview is also, the correlation there between the CHI and objective neurocognitive testing is about 0.3. So I would say it's good, but I wouldn't say it's high. However, when you engage in a discussion with somebody about these cognitive domains, what you're learning is what's most important to the individual. So they're considered interviews that have relevance. You can administer neurocognitive batteries and you may get a score. However, that may or may not reflect what a person experiences who has schizophrenia or some other condition on a daily basis. The CHI gives you a chance to dialogue with people about that. So it's correlated with objective batteries, not as high as the BCATs because it is an objective cognitive test, but it's also correlated with functioning. And there, I would say the correlation is high. Thanks. Okay. Really, really helpful. One of the questions was around the CHI. Can you rely solely on the individual's report or do you really need the additional informant in order to be able to use it effectively? So that's a very, very important point. Not everyone who has cognitive difficulties is aware of them. So the CHI, the cognitive assessment interview really calls for an expert, calls for an expert evaluation of the person's cognitive function. So if you're talking to somebody about their cognition and they're giving you examples that indicate that they had trouble, for example, in school, or they had to quit a job because they couldn't remember the instructions from their supervisor. However, they say that their cognitive functioning is fine, then you can still determine that they are having difficulties in this area and have a more friendly discussion about improving performance. So the supplemental instructions on SMI Advisor really address the issues of how to get the information from an individual. In terms of an informant, yes, we've always found that informants provide additional helpful information. It's just that the informants are not always available. If they're not, then you use this more expert approach with the individual. If an informant's available, I highly recommend using the informant. You'll learn a tremendous amount of information, and I've done plenty of those interviews by telephone, and they've been very satisfying. So with an informant, you could maybe do it via telephone. And in general, when people are supportive of having an informant participate with their CHI questions, is there a lot of variation in the relationships between the individual client and the informant? Are they usually related to a family member or an employer? Or how flexible has that been generally? Well, the agreement is good, but it's not very high. So yes, the informant does provide additional information that's helpful. Yeah. Yeah, there's greater agreement between the raters rating and the informant than there is between the raters rating and the rating of the individual. So yes, there is agreement, but it's not as good as it could be. And it's exactly, I think, exactly what you're alluding to. A mom or a dad may be aware of some difficulties that the person, him or herself, is not aware of. So you're gonna get that extra information. We've tried to devise the cognitive assessment interview so that you can get the information from the individual, but that's a bit more challenging and involves understanding biases, like lack of awareness or depression biases. And the fact that if you have a cognitive difficulty, it may be difficult to talk about your cognitive difficulty. Right. There are some challenges, yes. One of the questions that also came up was, what are the long-term effects or benefits of cognitive remediation? And do we have a sense of how long the gains are potentially maintained post-participation? I guess, is there a maintenance component that needs to happen? What's your sense about that? Well, my sense about that is that it's very similar to weight loss or exercise. If you're exercising, you're gonna experience a tremendous number of benefits, cognitively and physical health-wise. If you stop, you'll probably lose some of those benefits. So the general consensus among colleagues is that you have to continue to maintain it. We're trying to study whether or not you could fade the intensity of it and still maintain the benefit, but our general impression is it has to be continued and it doesn't necessarily result in long-lasting benefits. However, some studies do show that it does last in a six-month or a one-year improvement even after the training has stopped, but we do advocate continuing with it. Thanks, okay. And one of the other related questions actually had to do with medication for people who might also benefit from doing cognitive remediation. Is there any evidence of any kind of dose-related detrimental effect of medication on cognition itself or on potential benefits from cognitive remediation? Well, it might be when you first start medication, I think as you well know, and I'm a clinical psychologist by training, not a psychiatrist just to clarify that, but as I think everyone knows, when you first start medication, you do have a tendency to experience perhaps some sedation as the body is getting accustomed to the medication. It may be that the sedation is gonna slow down your cognitive processes. So there may be some short-term, perhaps initial effects of the medication. I don't think that overall that the medication has detrimental effects on cognitive functioning, but in some individuals it might, and the mechanism by which this happens might be because of sedation. On the other hand, there are examples that I've seen in the early phase where medication actually improves a person's ability to think more clearly. So I think the combination of medication plus cognitive remediation has a benefit and is something to try. If a person is having a detriment, a decrement in cognitive function with a certain medication, well, the CHI is a really great instrument for a psychiatrist to use to pick up on that. And then I think Dr. Adelsheim, as you well know, you might consider then a different medication. And I think most psychiatrists will ask, well, how is this going with this medication? And if there are individuals reporting side effects, they'll try to switch to something else. Okay, thank you. So just as a time check, we have about three more minutes. We probably have five or six questions left that we probably won't be able to get to all of them. And then we have some closing slides we have to be sure we post so people can get their CU credit. So let's take one more for the moment, but I wonder if you would be open to maybe responding to some of the individuals that asked some of these other questions, maybe if we can follow up with them down the road after the presentation. Certainly. You know, one of the questions that I think probably will be of interest to large group really has to do with, you know, using this kind of a tool for people around who may have other kinds of individual challenges. One of the questions is around cognitive remediation, both restorative and compensatory for individuals with TBI or for autism. And do we have a sense for the benefits of that? And then also related to that, if, you know, people who might have a first episode of psychosis that may not have progressed to a schizophrenia per se, are there benefits for that higher risk population potentially in terms of using cognitive remediation almost in a preventative kind of way? So maybe we could speak to that, and then we'll have Judith put up our CU slide, and then we'll try to follow up and answer the other questions after we're done today. So for the first question, it has been used with individuals with TBI, and it should be as effective. It doesn't matter so much what the reason is or the underlying biological mechanism for the cognitive difficulty. It's more whether the individual is engaged, sticks with the program, and then tries to generalize the skills that are learned during cognitive training to daily life. So it has also been used in autism successfully in terms of research projects. So there's no reason to think that it should be restricted to any one condition. Really, it's more broadly applicable for individuals having any cognitive difficulties. In terms of, yes, I do believe, I believe that cognitive training can rewire the brain. And along those lines, I do believe that if somebody's had maybe a brief episode, not yet diagnosable as schizophrenia or something else, that rewiring of the brain could actually be preventative and prevent that further episodes or further symptoms. We never tell anybody who's having any positive symptoms in our program that they can't participate in cognitive remediation or cognitive training. Everyone gets the cognitive training no matter what symptoms they have. And I've seen examples where that is an organizing principle in and of itself. Just working on the computer tasks while having symptoms helps people to be able to structure and organize their thoughts. Thank you. Thank you, Dr. Ventura. Judith, do you want to take us through the last pieces of information? Great, yes. And thank you again, Dr. Ventura, for a very informative presentation this morning and Dr. Adelsheim for facilitating the Q&A. Thank you for participating in today's free course from SMI Advisor. We know that you may have additional questions on this topic and SMI Advisor is here to help. Education is only one of the free resources that SMI Advisor offers. Let's briefly review all SMI Advisor has to offer on this topic and many others. We'll start at the SMI Advisor website and show you how you can use our free and evidence-based resources. SMI Advisor's mission is to advance the use of a person-centered approach to care that ensures people who have serious mental illness find the treatment and support they need. We offer several services specifically for clinicians. This includes access to education, consultations, and more. These services help you make evidence-based treatment decisions. Click on consult request and submit questions to our national experts on bipolar disorder, major depression, and schizophrenia. Receive guidance within one business day. It only takes two minutes to submit a question and it is completely confidential and free to use. This service is available to all mental health clinicians, peer specialists, and mental health administrators. Ask us about psychopharmacology, recovery supports, patient and family engagement, comorbidities, and more. You can visit our online knowledge base to find hundreds of evidence-based answers and resources on serious mental illness. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Harvard, Emory, NAMI, University of Texas at Austin, and more. Browse by key topics or search for a specific keyword in the search bar. Access our free education catalog to find more than 100 free courses on topics related to serious mental illness. You can search the education catalog by topic, format, or credit type to find courses that fit your needs. SMI Advisor also offers live webinars each month that let you learn about evidence-based practices and participate in live Q&A with faculty. Check out our education catalog often to find new courses and earn continuing education credits. For individuals, families, friends, people who have questions, or people who care for someone with serious mental illness, SMI Advisor offers access to resources and answers from our national network of experts. The individuals and families section of our website contains an array of evidence-based resources on a variety of topics. This is a great place to refer individuals in your care for information about their conditions. They can choose from a list of important questions that individuals who have SMI typically ask. SMI Advisor worked with experts from the National Alliance on Mental Illness to develop these important questions and many of the resources in this section. Watch videos on important topics around SMI, such as what to know about a new diagnosis. They can also find dozens of fact sheets, infographics, and links to other important resources. To access even more evidence-based resources for individuals and families, visit our online knowledge base. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Mental Health America, and the American Psychiatric Association. For more information, visit our website at www.smi.org. To learn more about the National Alliance on Mental Illness, visit our website at www.smi.org. Browse by key topics and select View All to uncover a list of resources on each topic. SMI Advisor offers a smartphone app that lets you access all of the same features on our website in an easy-to-use, mobile-friendly format. You can download the app for both Apple and Android devices. Submit questions. Browse courses. And access clinical rating scales that you can use in your practice with individuals who have SMI. SMI Advisor also created My Mental Health Crisis Plan, a smartphone app that helps individuals in your care to create a crisis plan. 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neurocognitive

social cognitive

daily functioning

first episode psychosis

cognitive difficulties

early schizophrenia

work relationships

Brief Cognitive Assessment Tool for Schizophrenia

cognitive remediation

exercise