European Neuropsychopharmacology (2014) 24, 133–141

www.elsevier.com/locate/euroneuro

Routine clinical assessment of cognitive functioning in schizophrenia, major depressive disorder, and bipolar disorder Wael Belgaieda, Jennifer Sampb, Alexandre Vimonta, Cécile Rémuzata, Samuel Aballéaa, Emna El Hammia, Amna Koolia, Mondher Toumia,c,n, Kasem Akhrasb a

Creativ-Ceutical, 500 Lake Cook Road #350, Deerfield, IL, USA Takeda Pharmaceuticals International, Inc. Deerfield, IL, USA c University of Lyon, University Claude Bernard Lyon I, UFR d’Odontologie, 11 rue Guillaume Paradin, 69372 Lyon, Cedex 08, France b

Received 15 July 2013; received in revised form 31 October 2013; accepted 1 November 2013

KEYWORDS

Abstract

Cognitive dysfunction; Schizophrenia; Major depressive disorder; Bipolar disorder; Cognitive instruments; Survey

As more evidence points to the association of cognitive dysfunction with mental health disorders, the assessment of cognitive function in routine clinical care of these disorders is increasingly important. Despite this, it remains unknown how cognitive function is measured in routine clinical practice. The objective of this study was to assess psychiatrists' awareness of cognitive dysfunction in mental health disorders and their methods of cognitive assessment. An online survey was disseminated to psychiatrists in Europe, Asia, Australia and the United States. The survey asked about their perceptions of cognitive dysfunction in several mental health disorders, knowledge of cognitive assessment, method of cognitive assessment, and instruments used to measure cognitive function. Among the 61 respondents, most perceived that schizophrenia was associated with the greatest cognitive dysfunction. Many were unaware whether guidelines were available on cognitive assessment. In schizophrenia, 59% of psychiatrists reportedly used cognitive instruments, while the remainder relied solely on patient history interviews. The use of instruments to assess cognition in major depressive disorder (MDD) and bipolar disorder (BPD) was lower, 38% and 37% respectively. Of the reported instruments used, only a few were actually appropriate for use in the diseases of interest (12% in schizophrenia, 3% in MDD and 0% in BPD). Other instruments reported were clinical measures that did not assess cognition. These findings reveal some inconsistencies in psychiatrists' routine

n

Corresponding author at: University of Lyon, University Claude Bernard Lyon I, UFR d’Odontologie, 11 rue Guillaume Paradin 69372 Lyon, Cedex 08, France. Tel.: +33 4 78 77 10 52; fax: +33 1 53 75 49 24. E-mail address: [email protected] (M. Toumi). 0924-977X/$ - see front matter & 2013 Elsevier B.V. and ECNP. All rights reserved. http://dx.doi.org/10.1016/j.euroneuro.2013.11.001

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W. Belgaied et al. clinical evaluation of cognitive function. There appeared to be low use of true cognitive assessment instruments in clinical practice and confusion regarding what constituted a cognitive assessment instrument. & 2013 Elsevier B.V. and ECNP. All rights reserved.

1.

Introduction

Cognitive deficits have increasingly become recognized as a symptom in certain mental health disorders. Patients with schizophrenia (Bora et al., 2010; Heinrichs and Zakzanis, 1998), major depressive disorder (MDD) (Maalouf et al., 2011; Porter et al., 2003) and bipolar disorder (BPD) (Green, 2006; Lopes and Fernandes, 2012; Sanchez-Morla et al., 2009) often present with neuropsychological deficits that affect functioning of different cognitive domains. However, the extent to which cognition and different cognitive domains are impacted can differ from one disease to another. Patients with schizophrenia have characteristic deficits across cognitive domains which are distinct from the cognitive deficit patterns in MDD and BPD. The key impacted cognitive domains in schizophrenia are speed of processing, attention/ vigilance, working memory, verbal learning, visual learning, problem solving and social cognition (Green, 2006). Although patients with MDD and BPD show deficits in many of these domains, the deficits are generally less severe and largely related to the severity of the disease (Buchanan et al., 2005). Individuals with cognitive problems may struggle with simple activities of daily living and functioning. This can add to the burden of mental health disorders and can negatively impact quality of life, functioning and employment. As a result, assessment of cognitive dysfunction in these three mental disorders is important for overall disease management. The first effort to reach consensus around cognitive function assessment arose with the expert group of the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS). This program was initiated by the National Institute of Mental Health (NIMH) and established the MATRICS Consensus Cognitive Battery (MCCB). This battery is considered the gold standard for cognitive assessment in schizophrenia and is now mandated by the Food and Drug Administration (FDA) for the development of cognition enhancing compounds in schizophrenia (Buchanan et al., 2011). A similar initiative has been undertaken lately to design a standard cognitive battery for measuring cognition in BPD or measuring change in cognition following an intervention. The International Society for Bipolar Disorders (ISBD) proposed the ISBD Battery for Assessment of Neurocognition (ISBD-BANC). Based on the finding that cognitive deficits in BPD are similar in pattern but less severe than in schizophrenia, the ISBD-BANC was designed taking the MCCB for model. However unlike the MCCB, the ISBD-BANC is not yet validated by the FDA and should only be considered as a preliminary step toward a standard cognitive battery for BPD (Yatham et al., 2010). A considerable body of literature exists regarding the instruments for assessing cognitive dysfunction, although not all are appropriate for use in every mental disorder

(Cullen et al., 2007). Despite this, little is known on how psychiatrists routinely evaluate and manage cognitive deficits in patients. The aim of this study was to determine the perceptions of psychiatrists regarding cognitive dysfunction in schizophrenia, MDD, and BPD, and to understand the routine assessment of cognitive dysfunction in patients with these mental health disorders.

2. 2.1.

Experimental procedures Study design

A cross-sectional, web-based survey was administered to practicing psychiatrists in the United States (US), France, Germany, Spain, Australia, and Hong Kong in March of 2012. Seven hundred eighty six practicing psychiatrists from a proprietary list were randomly selected and invited via email to participate. Psychiatrists were eligible to participate if they saw at least 50 patients per month with schizophrenia, MDD, and bipolar disorder and stated that they regularly assess cognition in their patients. Psychiatrists were ineligible to participate if they practiced psychoanalysis, did not prescribe drug therapy, saw fewer than 50 patients per month with schizophrenia, MDD and BPD, or obtained their Medical Degree before 1977 or after 2009.

2.2.

Survey description

The survey was developed by Creativ-Ceutical based on a literature review of information on cognitive evaluation in mental health disorders and was approved by Takeda Pharmaceuticals International. The survey consisted of 3 sections, each with multiple subsections. The first section of the questionnaire contained eligibility questions. The survey was terminated if any previously mentioned exclusion criteria were met. The second section contained socio-demographic questions regarding gender, country of residence, practice setting (rural or urban), work environment (public, private or both) and year of medical degree. The last section contained questions on knowledge, attitude and insights on the following: (1) the cognitive status of their schizophrenic, MDD, and BPD patients; (2) the availability of guidelines for cognitive function evaluation; (3) the methods for routine assessment of cognitive function and frequency of reassessments; and (4) perception of cognitive instruments' robustness and sensitivity in cognitive evaluation. Survey responses on method of cognitive assessment were captured by three options: use of patient history interview, use of cognitive function instruments, and use of both methods. The patient history interview method comprised gathering qualitative information about patients' ability to act in a socially apt manner and to organize and communicate information effectively. Cognitive assessment instruments were defined as the use of standardized tools to obtain a score relative to the norm. Responses were given in yes/no, ranking, multiple choice and open-ended formats. No identifiable physician information was collected. The survey was developed in English and translated into French, German, and Spanish for administration. Psychiatrists answered the questionnaire in their native language except in Hong Kong where

Surveying cognitive evaluation in schizophrenia, MDD, and BPD psychiatrists completed the survey in English. Responses were translated back to English for analysis.

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3.

Results

3.1. 2.3.

A link to the survey was provided in the invitation email and the entire survey was completed online. All psychiatrists received the same set of questions. When the desired number of participants from a country completed the survey, the link was disabled. The survey took approximately 45 min to complete, and participating psychiatrists were compensated between €70 and €177 for their time, depending on the country.

2.4.

Socio-demographic profile of respondents

Sampling and recruitment of psychiatrists

Data collection and analysis

An initial, qualitative analysis of answers was performed to evaluate psychiatrists' understanding of the questionnaire and to identify inconsistency in answers. Psychiatrists were re-contacted for clarifications, if needed, to ensure that results were not misinterpreted. Data from all countries were pooled into histograms and tables and analyzed by country and disease state.

2.5. Determination of appropriate use of reported cognitive instruments The cognitive instruments reported in the survey were assessed and validated for appropriateness in schizophrenic, MDD, and BPD patients by an expert group and in-house statisticians, and discrepancies were resolved by consensus. Appropriate instruments were defined as (1) those that have been tested for use in the disease of interest, and (2) those which met 5 recommendations proposed by the MATRICS initiative. These recommendations include test–retest reliability, utility as a repeated measure, relationship to functional outcome, potential changeability in response to pharmacological agents, and tolerability and practicality for a clinical setting. Instruments were not evaluated against the 6th recommendation (inclusion of 8 different cognitive domains) as this recommendation related to the compilation of instruments for a cognitive consensus battery, rather than an evaluation of a single instrument (http:// www.matrics.ucla.edu/matrics-ct/home.html). Though the MATRICS criteria are intended for use in schizophrenia, the criteria are being tested for use in MDD (Green et al., 2004; Nuechterlein et al., 2008) and the ISBD-BANC was lately designed for BPD based on the MCCB (Yatham et al., 2010).

Table 1

Sixty-one psychiatrists from six countries (United States [US, N= 15], France [N= 12], Germany [N= 10], Spain [N = 10], Australia [N = 8], and Hong Kong [N= 6]) completed the survey. Respondents had an average of 19 years of clinical practice experience. The respondents were 64% men and 36% women. Spain was the only country with more women participating in the survey than men. In Hong Kong, only men participated in the survey (Table 1). Six psychiatrists were re-contacted after completing the survey for clarification on their responses. The majority of respondents worked in an urban practice setting (87%), the remainder in rural settings (13%). Between 10% and 20% of US and European respondents worked in a rural setting, while all respondents from Hong Kong and Australia worked in an urban setting. Data revealed differences in the distribution of public and private work environments between countries. With the exception of the US and Hong Kong, most respondents worked in a public environment (Table 1); all 10 psychiatrists in Spain worked in public hospitals while all those in Hong Kong worked in the private sector. In the US and Australia, 7% and 37% of respondents, respectively, practiced in both environments (private and public) (Table 1). The average number of patients seen per month across countries was 61 with schizophrenia, 70 with MDD and 40 with BPD. German psychiatrists reported the highest number of patients seen per month (N= 239) and Australian respondents reported the lowest number (N= 96). In Germany, Australia and Hong Kong, psychiatrists saw more schizophrenic patients than MDD and BPD patients. In the US, France and Spain, psychiatrists saw more MDD patients (Figure 1). When psychiatrists were asked to estimate the severity of cognitive dysfunction in schizophrenia, MDD, and BPD patients, most patients were viewed to have some level of cognitive dysfunction. Schizophrenic patients were believed to display the greatest deficits of the 3 mental diseases (no cognitive dysfunction [17%], mild [37%], moderate [28%] and severe [18%]) (Figure 2). MDD and BPD patients were viewed

Sociodemographic profile of survey's respondents. Total

US

France

Germany

Spain

Australia

Hong Kong

Number of psychiatrists

61

15

12

10

10

8

6

Gender Male (%) Female (%)

64 36

73 27

58 42

70 30

40 60

50 50

100 0

Practice setting Urban (%) Rural (%)

87 13

80 20

83 17

80 20

90 10

100 0

100 0

Working environment Private (%) Public (%) Both (%)

35 58 7

73 20 7

17 83 0

20 80 0

0 100 0

0 63 37

100 0 0

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W. Belgaied et al.

100%

Schizophrenia

100

90%

MDD 80

BPD

60 40 20 0 USA

France

Germany

Spain

Australia

Hong Kong

Figure 1 Average number of patients seen monthly by psychiatrists in each country.

% of cognitive function assessment

Average number of patients seen/month

120

80% 70% 60%

Patient history solely

50% Instruments 40% 30% 20% 10% 0% Schizophrenia

35%

Schizophrenia

30%

MDD

25%

BPD

20% 15% 10% 5% 0% No cognitive dysfunction

MDD

BPD

90%

Mild cognitive Moderate cognitive Severe cognitive dysfunction dysfunction dysfunction

Figure 2 Distribution of patients seen by psychiatrists according to cognitive impairment state across countries.

% of use of instruments in cognitive function assessment

Overall percentage of patients seen/month

40%

80% 70% 60% 50% 40%

30% 20% 10% 0% Schizophrenia

No

Yes United States

13%

USA

I don't know 60%

27%

Germany

100%

France

17%

Spain

20%

Australia

58%

25%

30%

50%

13%

50%

37%

Hong Kong

100%

0%

20%

40%

60%

80%

100%

% of psychiatrists aware about existence of guidelines for cognitive function assessment

Figure 3 Psychiatrists' knowledge of existence and availability of guidelines for cognitive function assessment.

as having less cognitive dysfunction, yet 67% and 61% of patients, respectively, were still reported to have some cognitive dysfunction. Seventeen percent of MDD patients and 13% of BPD patients were viewed as severely impaired.

3.2. Local guidelines in the management of cognitive dysfunction in schizophrenia, MDD and BPD Despite the existence and the availability of several guidelines for disease management of schizophrenia, MDD and BPD, there are no guidelines for assessment of cognitive function in these diseases (Hirschfeld et al., 2002;Lehman et al., 2004). Nevertheless, 11% of psychiatrists believed that their country had standard guidelines on cognitive assessment in these diseases. (2 psychiatrists from the US, 2 from France, 2 from Spain and

MDD

BPD

France

Germany

Australia

Hong Kong

Spain

Figure 4 Methods of cognitive function evaluation in clinical practice. (A) Assessment of cognitive function with instruments and patient history interview in schizophrenia, MDD and BPD. (B) Percentage of use of cognitive instruments by country in schizophrenia, MDD and BPD. Data include respondents who reported using both patient history and instruments to assess cognition in their patients.

1 from Australia). When asked to report the name of the guideline, some respondents cited clinical measurement tools (e.g., Mini Mental State Examination [MMSE]) rather than standard clinical guidelines. One US respondent reported the American Psychiatric Association (APA) guidelines; while these guidelines encourage evaluating cognitive function, there are no specific details on methodology or frequency of the cognitive assessment. The remainder of respondents did not know if there were guidelines (48%) or stated that there were no guidelines (41%) in these mental diseases (Figure 3).

3.3. Cognitive function evaluation in routine clinical practice The rate of use of cognitive instruments was different across diseases. Fifty-nine percent of psychiatrists relied completely or partly on instruments to assess cognitive function in schizophrenia. In MDD and BPD, psychiatrists relied more often on the patient history interview (62% and 63% respectively) (Figure 4A). Respondents who reportedly did not assess

Surveying cognitive evaluation in schizophrenia, MDD, and BPD

been used to screen for Alzheimer's disease and dementia, they have not been tested for use in schizophrenia, MDD, or BPD. Other reported instruments, such as the HAM-D and MADRS, were not actual measures of cognitive function but measures of clinical disease severity.

Psychiatrists relying on a cut off score

25

20

Yes No

15

3.5. Administration of cognitive function instruments

10

5

0 Schizophrenia

Psychiatrists considering the instrument robust and sensitive

137

MDD

BPD

100% 90% 80%

Yes

70% No

60% 50% 40%

Fewer than half of all respondents (43% in schizophrenia, 42% in MDD and 44% in BPD) reported that they evaluated cognitive function themselves (Figure 7). Most cognitive assessments were performed by other healthcare professionals including nurses, physicians, and psychologists. There were differences between countries in this regard. In European countries, most psychiatrists relied on other health professionals to assess cognitive function in their patients. US and Australian psychiatrists were more likely to assess cognition themselves. In Hong Kong, psychiatrists and other health professionals assessed cognitive function to the same extent (Figure 7).

30%

3.6. Re-assessment of cognitive function in clinical practice

20% 10% 0% Schizophrenia

MDD

BPD

Figure 5 Psychiatrists' interpretation of cognitive function results. (A) Number of psychiatrists relying on a cut-off score when using instruments to diagnose cognitive dysfunction. (B) Psychiatrists' perceptions of robustness and sensitivity of cognitive instruments.

cognition in one of these diseases stated that they believed cognitive assessment was irrelevant to the disease. This was particularly true of assessment in MDD. The use of instruments for cognitive assessment varied by country. Spain had the highest use (60–80%). Hong Kong used cognitive instruments to a much lesser extent in all 3 diseases. French psychiatrists had the lowest use of cognitive instruments, with 50% of psychiatrists using instruments in schizophrenia, 17% in MDD, and 8% in BPD (Figure 4B). Among respondents who reported using instruments for cognitive assessment, none reportedly relied on normative data for results interpretation. Only 16 psychiatrists in schizophrenia, 8 in MDD and 10 in BPD relied on a cut-off score (Figure 5A). Despite this, most percieved these instruments to be robust and sensitive (67% in schizophrenia, 65% in MDD and 68% in BPD) (Figure 5B).

3.4. Appropriateness of reported cognitive function instruments Of the wide range of cognitive instruments reported, only 12% of those used in schizophrenia and 3% in MDD were indeed appropriate based on the MATRICS criteria. None of the instruments reportedly used in BPD were appropriate based on these criteria (Figure 6A–D). Many psychiatrists named instruments such as the clock drawing test and the MMSE. While these measures have

When psychiatrists were asked to report the time before reassessment following a diagnosis of cognitive dysfunction, the average time to reassessment in the acute phase was 23 weeks in schizophrenia, 19 in MDD and 17 in BPD. For patients in the chronic phase, time to reassessment was longer: 49 weeks in schizophrenia, 45 in MDD, and 43 in BPD (Table 2). In all countries, the time to reassessment was equal for MDD and BPD patients. German respondents took 3 times as long (123–125 weeks) to reassess their patients' cognitive function in the chronic phase than respondents in other countries (about 46 weeks). Hong Kong psychiatrists were the only ones to report a time to reassessment in the acute phase (4 weeks) consistent with practice in clinical trials.

4.

Discussion

The aim of this survey was to examine practicing psychiatrists' knowledge and assessment of cognitive function in patients with schizophrenia, MDD, and BPD. The study is limited by within country sample sizes which seem too small to draw a definitive conclusion and therefore cannot be assumed to be representative of the entire population of psychiatrists in that country. In future, a larger survey should be conducted on a larger sample size to capture the opinion of the majority of these practitioners and develop guidelines in accordance. Additionally, because participants were selected from a proprietary list of psychiatrists, these psychiatrists may not be representative of the general population of psychiatrists among other unmeasured variables. Psychiatrists who chose to participate in the survey may be inherently different from those who chose not to participate. However, our sample provides a certain level of representativeness as the sample of 61 psychiatrists was diverse in country of practice, years of experience, practice setting,

100%

% of instruments used

90% 80% 70% 60% 50% Non appropriate

40%

appropriate

30% 20% 10%

Number of psychiatrists using instruments

0%

7

MDD 6 5 4 Non appropriate 3 apropriate 2 1 0

Number of psychiatrists using instruments

W. Belgaied et al.

8

Number of psychiatrists using instruments

138

9

Schizophrenia

7 6 5 4

Non appropriate

3

appropriate

2 1 0

BPD

8 7 6 5

Non appropriate

4 3

appropriate

2 1 0

Figure 6 Classification of instruments' appropriateness based on the MATRICS criteria and history of use in disease. (A) Percentage of appropriate instruments used per disease for all countries. Number of psychiatrists using appropriate and inappropriate instruments in (B) schizophrenia (C) MDD and (D) BPD. All respondents were allowed to name up to 10 instruments.

and work environment, and because of the stringent eligible criteria that allow to accurately assessing the level of knowledge of psychiatrists who are more likely to be aware of these instruments. The overall distribution of patients seen per month in all 6 countries was reflective of data by World Health Organization (WHO) and NIMH statistics (Kessler et al., 2012). The distribution of patients according to their cognitive status was also consistent with previous literature (Kremen et al., 2000; Palmer et al., 1997). Their responses should therefore reflect the views of a large population of psychiatrists. Psychiatrists who regularly assess cognitive function in 1of the 3 disorders of interest were purposely selected. Therefore, we anticipated that this sample would be more familiar than psychiatrists in general with cognitive assessment. In fact, a previous survey addressing psychiatrists' opinions on cognition in schizophrenia revealed that only 12% routinely assessed cognitive function for every patient diagnosed with schizophrenia (Green et al., 2005). Overall,

the findings of this study were surprising, particularly the sense of confusion around terms associated with cognitive assessment. Most psychiatrists were not aware whether specific guidelines for cognitive assessment in schizophrenia, MDD, and BPD were available. Some falsely believed that such guidelines existed. In fact, national guidelines generally encourage practitioners to evaluate cognitive function but do not expressly state how to do so (Hirschfeld et al., 2002). This lack of guidance hinders the growing efforts to acknowledge the impact of cognitive dysfunction on these diseases. A wide range of instruments have been developed to aid clinicians in cognitive assessment (Burleigh et al., 2002). The use of such instruments is necessary to determine patients' condition and to recognize changes over time (Green et al., 2005). Nevertheless, many respondents in our study relied solely on the patient history interview to assess cognitive deficits. Limitations of this method include the lack of a scoring system for interpreting results and the potential for subjective bias. Additionally, subtle cognitive

Surveying cognitive evaluation in schizophrenia, MDD, and BPD

139

Other health professionals

30% 20% 10%

Psychiatrist 40%

80% 70% 60% 50%

Psychiatrist

40%

Other health professionals

30%

Other health professionals

30% 20% 10% 0% USA

90%

20% 10%

100% 90% 80% 70% 60% 50%

Psychiatrist

40% 30%

Other health professionals

20% 10% 0%

Hong Kong

0%

Professionals assessing cognitive function

Spain

50%

Australia Hong…

Germany

USA

BPD

100%

USA

Professionals assessing cognitive function

France

0%

60%

Hong Kong

Psychiatrist

40%

70%

Spain

50%

80%

Australia

60%

90%

Germany

70%

MDD

100%

France

80%

Professionals assessing cognitive function

90%

France Germany Spain Australia

Professionals assessing cognitive function

Schizophrenia 100%

Figure 7 Administration of cognitive function assessment by health professionals and psychiatrists. Only respondents reportedly using instruments were included. Those who reported assessing cognitive function along with health professionals were accounted in both categories.

changes that signal the emergence of clinical deterioration or improvement may not be detectable by a patient history interview (Harwood et al., 1997). These study results also showed that psychiatrists relied more on instruments than the patient history interview for assessing schizophrenic patients; in MDD and BPD, most relied on patient history interview. This may suggest that practitioners appreciate the impact of cognitive dysfunction in schizophrenia more than in MDD and BPD. Moreover, survey results revealed that psychiatrists follow similar approaches to assess cognitive function in MDD and BPD. In fact, nearly all psychiatrists relied on the patient history interview to similar extents in MDD and BPD and waited about as long before reassessment. This implies that psychiatrists perceive both disorders as similar; however,

the extent of cognitive deficits and impacted domains are different for these 2 diseases (Godard et al., 2011; Murphy and Sahakian, 2001). Cullen et al. and others have recently reported that not all cognitive function instruments are appropriate for use in all diseases (Brodaty et al., 1998; Cullen et al., 2007). Therefore careful selection is advised when choosing an instrument. In our study, most reported instruments were inappropriate for use in the diseases of interest. However, in the absence of consensus about what specific instruments should be used with these mental disorders in routine practise, selection by authors of appropriate instruments to be used, although based on MATRICS criteria and literature review, may be questioned. Nevertheless impact of this study limitation is weak as many psychiatrists reported

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Table 2 Cognitive function re-assessment following diagnosis of cognitive dysfunction in acute and chronic phase of the disease state. US France Germany Spain Australia Hong Kong Schizophrenia Acute 11 38 Chronic 27 46

36 123

21 28

19 46

4 16

MDD Acute 9 16 Chronic 27 28

38 125

37 35

16 43

4 18

BPD Acute 9 16 Chronic 27 28

38 125

37 35

16 43

4 18

Average number of weeks before reassessment of cognitive function in schizophrenia, MDD and BPD is reported for each country.

instruments that were not appropriate for measuring cognitive dysfunction at all, such as HAM-D and MADRS, suggesting a lack of awareness about proper cognitive instruments. Moreover the MMSE was the most frequent instrument reported by psychiatrists, as described in other studies dealing with cognitive impairment (Boustani et al., 2003; Mair and Starr, 2011). However, its use has been debated due to limitations such as age, education biases, and ceiling effects (Woodford and George, 2007). While the MMSE is simple and easy to administer, the results may not provide a comprehensive assessment of true cognitive function. In addition to selecting appropriate instruments, discriminating between cognitively healthy and impaired individuals is based on the proper interpretation of obtained results with respect to cut-off scores and normative data (O'Connor, 1990; Woodford and George, 2007). In our study, most psychiatrists did not use cut-off scores or normative data. Surprisingly, all participants were unfamiliar with these terms as even those who replied positively suggested erroneous cut-off scores and normative data. Yet, instruments were considered robust and sensitive in detecting cognitive deficits. These findings are consistent with a previous study that revealed a lack of knowledge among psychiatrists regarding interpretation of cognitive assessment test results (Green et al., 2005). This study revealed that not all psychiatrists perform cognitive function evaluation themselves. Indeed, many rely on other health professionals to administer these assessments. Reasons for this are unclear; future research may examine whether test complexity and administration time prevents more psychiatrists from administering these assessments. A sustained rate of cognitive function reassessment (e.g., monthly assessments) is suitable to capture change in cognitive state over time (Buchanan et al., 2005). Yet only Hong Kong psychiatrists appear to reassess on such a schedule. Most psychiatrists wait much longer before reassessing their patients.

5.

Conclusions

Despite most psychiatrists' interest in treating cognitive dysfunction as part of mental health disease management, many lack proper training on the appropriate methodology for cognitive function assessment. Moreover survey's answers revealed a gap between diseases and practices through the countries. This should further be addressed to increase awareness among psychiatrists and standardize cognitive function assessment.

Role of funding source The study was sponsored and funded by the Takeda Pharmaceuticals, Inc. Creativ-Ceutical was contracted by Takeda to conduct the study and to provide medical writing assistance.

Contributors All authors believe the manuscript represents honest and original work. The authors bear full responsibility for the accuracy and recency of the factual content of their contributions. The authors attest that the article has not been published or is not being presented for publication elsewhere. Author CR designed the study. Authors WB and AK managed the literature searches and analyses. Author AV undertook the statistical analysis, and authors WB and JS wrote the manuscript. All authors contributed to results interpretation and have approved the final manuscript.

Conflict of interest Kasem Akhras was an employee of Takeda Pharmaceuticals. Jennifer Samp was supported by a fellowship funded by Takeda Pharmaceuticals. Wael Belgaied, Alexandre Vimont, Cecile Remuzat, Samuel Alballea, Emna El Hammi, Amna Kooli, and Mondher Toumi are employees of Creativ-Ceutical.

Acknowledgments The study was sponsored and funded by the Takeda Pharmaceutical Company.

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Routine clinical assessment of cognitive functioning in schizophrenia, major depressive disorder, and bipolar disorder.

As more evidence points to the association of cognitive dysfunction with mental health disorders, the assessment of cognitive function in routine clin...
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