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Enhancing Functional Outcomes in Schizophrenia:
Pharmacologic and Nonpharmacologic Strategies
A CME-Certified Initiative

CME Monograph
June 2008

Sponsorship and Support
Sponsored by Veritas Institute for Medical Education, Inc. Supported by an educational grant from Janssen, administered by Ortho-McNeil Janssen Scientific Affairs, LLC.

Method of Participation
Read this monograph, complete the CME Activity Evaluation and Request for Credits Form online, and receive your statement of credits immediately. Print your statement of credits. This activity is provided free of charge to participants.

Intended Audience
Psychiatrists

Effective Dates
June 2008 to June 30, 2009 - Extend to October 31, 2009

Accreditation
Veritas Institute for Medical Education, Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Designation of Credit Statement
Veritas Institute for Medical Education, Inc. designates this educational activity for a maximum of 2.0 AMA PRA Category 1 Credits^TM. Physicians should only claim credits commensurate with the extent of their participation in the activity.

Financial Disclosure Summary
In accordance with the ACCME’s Standards for Commercial Support, all CME providers are required to disclose to the activity audience the relevant financial relationships of the planners, teachers, and authors involved in the development of CME content. An individual has a relevant financial relationship if he or she has a financial relationship in any amount occurring in the last 12 months with a commercial interest whose products or services are discussed in the CME activity content over which the individual has control. Disclosures are as follows:

John M. Kane, MD: Bristol-Myers Squibb Company, GlaxoSmithKline, Eli Lilly and Company, Lundbeck Research USA, Inc., Ortho-McNeil Janssen Scientific Affairs, LLC, Otsuka Pharmaceutical Co., Ltd., Pfizer Inc, PGxHealth, Proteus Applied Technologies, Vanda Pharmaceuticals, Inc., Wyeth Pharmaceuticals (consultant); AstraZeneca, Bristol-Myers Squibb Company, Eli Lilly and Company, Ortho-McNeil Janssen Scientific Affairs, LLC (speakers bureau).

Richard S. E. Keefe, PhD: AstraZeneca, Johnson and Johnson, Eli Lilly and Company, Pfizer Inc, Schering-Plough Corporation, (grant/research support); Abbott Laboratories, ACADIA Pharmaceuticals Inc., BioLineRx, Ltd., Bristol-Myers Squibb Company, Cephalon, Inc., Cortex Pharmaceuticals, Inc., Johnson and Johnson, Merck and Company, Inc., Orexigen Therapeutics. Inc., Otsuka America Pharmaceutical, Inc., Pfizer Inc, sanofi-aventis, Schering-Plough Corporation, XenoPort, Inc. (consultant); Brief Assessment of Cognition [BACS] MATRICS Battery [BACS Symbol Coding] (royalties).

The staff of Veritas Institute for Medical Education, Inc. has nothing to disclose.

Off-Label/Investigational Uses of Drugs
Participants are advised that this CME activity will contain references to the unlabeled/unapproved/investigational uses of drugs to treat patients with schizophrenia.

Disclaimer
The opinions expressed in this activity are those of the faculty and do not necessarily reflect those of Veritas Institute for Medical Education, Inc. or Ortho-McNeil Janssen Scientific Affairs, LLC. Please consult the appropriate package insert for full prescribing information on all drug therapies discussed. Editorial Board

Editor
John M. Kane, MD
Professor, Psychiatry, Neurology, and Neuroscience
Albert Einstein College of Medicine
Bronx, New York
Chairman, Psychiatry
The Zucker Hillside Hospital
Glen Oaks, New York

Faculty Reviewer
Richard S. E. Keefe, PhD
Professor, Psychiatry and Behavioral Sciences
Duke University Medical Center
Durham, North Carolina

Learning Objectives

You will be better able to recognize the presence of cognitive impairments in patients with schizophrenia.
You will have a greater awareness of the role of measurement tools in assessing cognitive impairment.
You will be able to identify types of cognitive impairment and their role in functional outcomes in patients with schizophrenia.
You will be better able to select and sequence appropriate pharmacologic therapies to address cognitive impairments and maximize functional outcomes in patients with schizophrenia.
You will be better able to utilize nonpharmacologic interventions, such as cognitive and neuropsychiatric rehabilitative techniques and psychoeducation, to address cognitive impairment in patients with schizophrenia.

WELCOME FROM FACULTY CHAIR
Schizophrenia is a severe, disabling mental illness that affects approximately 2.4 million US adults and is associated with substantial disability and functional impairment. It is estimated that people with untreated psychiatric conditions (including schizophrenia) comprise one-third of the 744,000 US homeless population. Homelessness compromises not only quality of life but also physical safety; the mortality risk among homeless individuals is 3 times higher than in the general population.

In 2002, schizophrenia costs to society in the United States were estimated at about $63 billion, with a trend toward declining inpatient cost versus increased outpatient and medication costs. Schizophrenia is associated with lifelong functional impairment in social, occupational, and independent living activities, with recurring problems involving adherence, quality of life, and risk for psychotic relapse and rehospitalization. Indeed, functional impairment is now considered a core diagnostic feature of schizophrenia. However, despite the well-established centrality of functional impairment in schizophrenia, patient function has been neglected as a focus and target in both research and treatment.

The understanding of functional impairment in schizophrenia has evolved from a focus on delusions and hallucinations to a focus on a more central role for cognition. Among patients with schizophrenia, 85% score from 1.3 to 2 standard deviations below the mean, compared with samples drawn from the mentally healthy population. There is a correlation between neuropsychological impairment and several domains of functional impairment. Cognitive impairment is strongly associated with the ability of a patient to function in an employment, residential, and social situation. Nevertheless, cognitive impairment is still not included in the DSM-IV-TR’s formal criteria for the diagnosis of schizophrenia. Cognition is only now being recognized as a critical target for new drug research and treatment.

This monograph seeks to enhance understanding of the role of cognition and functional impairment in schizophrenia. You will be introduced to Mr J, a composite patient with schizophrenia. As you follow his case, you will learn how to recognize, assess, and address cognitive dysfunction and maximize functionality in the real-world setting. You will learn about assessment tools to measure cognitive impairment, and, in the “Clinical Tools” section of this Web site, you can access printable copies for your immediate use.

This monograph is a component of a broader educational initiative that includes 3 live regional workshops, to be held in Huntington Beach, California; Chicago, Illinois; and New York, New York. The workshops will build upon the content of this monograph and allow you to personally interact with key faculty in further fine-tuning your understanding and practice.

Sincerely,
John M. Kane, MD
Editor

Please indicate your level of agreement with these statements:

Disordered thinking is the same as cognitive impairment in patients with schizophrenia.

A patient with schizophrenia, who occasionally “hears voices,” presents to your office stating that he would like to “find a job and make some money.” However, he has been dismissed from 3 jobs due to tardiness, disorganization, distractibility, and forgetfulness. His most likely primary obstacle to successful employment is (select one):

I use an assessment tool to measure cognition in patients with schizophrenia.