Using Tools of Neuroscience to Make Personalized Care a ... · “Experimental Medicine” Trial...
Transcript of Using Tools of Neuroscience to Make Personalized Care a ... · “Experimental Medicine” Trial...
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Using Tools of Neuroscience to Make Personalized Care a Reality in Schizophrenia
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Cognitive impairment underlies functional outcome in SZ
Cognition Clinical Symptoms
Daily Functioning
MODEST IMPROVEMENTS IN COGNITION
CLINICALLY RELEVANT IMPROVEMENTS IN OUTCOMES
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Testing the Information Processing Cascade Model
Early Auditory
Information Processing
(MMN)
Cognition Clinical Symptoms
Daily Functioning
Thomas et al. (2017)
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Disentangling Multivariate Relationships:Testing the Information Processing Cascade Model
Thomas ML, Green MF, Hellemann G, Sugar CA, Tarasenko M, Calkins ME, Greenwood TA, Gur RE, Gur RC, Lazzeroni LC, Nuechterlein KH, RadantAD, Seidman LJ, Siever LJ, Silverman JM, Sprock J, Stone WS, Swerdlow NR, Tsuang DW, Tsuang MT, Turetsky BI, Braff DL, Light GA. JAMA Psychiatry. 2017 Jan 1;74(1):37-46. doi: 10.1001/jamapsychiatry.2016.2980.
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Single-dose (1 pill) Malleability
0 100 200 300 400-3
-2
-1
0
1
2
Time (ms)
Amplitude (µV)
SZ PlaceboSZ Memantine 20mg
MMN is Sensitive to Initial Exposure to Memantine: 1 pill
Swerdlow NR, Bhakta SG, Chou HH, Talledo JA, Balvaneda B, Light GA (2015), Neuropsychopharmacology
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Thomas et al. (2017), JAMA Psychiatry.
Testing the Information Processing Cascade Model
Early Auditory
Information Processing
(MMN)
Cognition Clinical Symptoms
Daily Functioning
a 1- uVchange
Supports d>0.78 change
Time-course & requirements for change? Cognitive Training?
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“Experimental Medicine” Trial with a Nonpharmacologic Intervention:An Example using Auditory Targeted Cognitive Training (TCT)
• Computerized approach to cognitive remediation
• Aims to improve the accuracy and fidelity of auditory sensory information
processing
• Capitalizes on “neuroplasticity based” learning mechanisms via exercises
that are: intensive, adaptive, rewarding
• Place progressive demands on higher-order cognitive domains
• Efficacious for improving cognition in psychosis patients at the group level
Tarasenko M, Perez VB, Pianka ST, Vinogradov S, Braff DL, Swerdlow NR, Light GA.(2016), Schizophrenia Research
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• TCT improves verbal learning and memory in adult SZ outpatients. Fisher M, et al. Am J Psychiatry. 2009
• TCT improves verbal learning/memory in recent onset SZ outpatients. Fisher M, et al. Schizophrenia Bulletin. 2015|
• TCT improves verbal learning/memory in adolescents and young adults at clinical high riskfor psychosis.Loewy R, et al. Schizophrenia Bulletin. 2016
• TCT improves verbal learning/memory and auditory hallucinations in treatment refractory schizophrenia inpatients.*Thomas ML, Bismark AW, Joshi YB, Tarasenko M, Treichler EBH, Hochberger WC, Zhang W, Nungaray J, Sprock J, Cardoso L, Tiernan K, Attarha M, Braff DL, Vinogradov S, SwerdlowN, Light GA. Schizophrenia Research. 2018
Previous Studies have Demonstrated Efficacy of TCT in Sz
* Top Research Finding of 2018, Brain & Behavior Research Foundation
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Challenges to overcome
TCT has largely been tested in academic labsTCT is time-intensive and requires resources
TCT does not help all patients
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Are EEG measures acutely sensitive to the neural systems engaged by 1h of TCT exercises?
Does 30h of cognitive training “work” in treatment refractory schizophrenia Inpatients?
Do EEG changes following initial exposure to TCT predict future therapeutic benefit?
Testing the Effectiveness of TCT & Predictive Utility of EEG Biomarkers
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Sound Sweeps
Memory Grid
To-do List Training
Fine Tuning
Syllable Stacks
Rhythm Recall
Auditory Targeted Cognitive Training: Brain Fitness Auditory Exercises
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Auditory Targeted Cognitive Training
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Auditory Targeted Cognitive Training
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Are EEG measures acutely sensitive to the neural systems engaged by 1h of TCT exercises?
Does 30h of cognitive training “work” in treatment refractory schizophrenia Inpatients?
Do EEG changes following initial exposure to TCT predict future therapeutic benefit?
Testing the Effectiveness of TCT & Predictive Utility of EEG Biomarkers
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Changes in Source Contributions after 1h of Cognitive Training
Perez VB et al (2019), Int J PsychophysiologyPerez VB et al (2017), Neuropsychopharmacology
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Are EEG measures acutely sensitive to the neural systems engaged by 1h of TCT exercises?
Does 30h of cognitive training “work” in treatment refractory schizophrenia Inpatients?
Do EEG changes following initial exposure to TCT predict future therapeutic benefit?
Testing the Effectiveness of TCT & Predictive Utility of EEG Biomarkers
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Thomas et al, (2018)
SZ Inpatients Matched on at Randomization to TAU vs. TCT
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d = 0.82p < 0.01
*
Verbal Learning
TAUTCT
PostBaseline
TCT Enhances Verbal Learning in Severely Disabled SZ inpatients
Thomas et al, (2018)
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TAUTCT
TCT Reduces Hallucinations in Severely Disabled SZ inpatients
Auditory Hallucinations Thomas et al, (2018)
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TAUTCT
TCT Improves Engagement in SZ inpatients
~1 extra total week of
rehabilitation
+ 1.34 groups activities/wk+ 0.58 ADLs/wk
+ 0.84 rehabilitation activities/wk
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Are EEG measures acutely sensitive to the neural systems engaged by 1h of TCT exercises?
Does 30h of cognitive training “work” in treatment refractory schizophrenia Inpatients?
Do EEG changes following initial exposure to TCT predict future therapeutic benefit?
Testing the Effectiveness of TCT & Predictive Utility of EEG Biomarkers
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Amplitude Changes After 1h Predicts Improvements in Verbal Learning After 30h
Hochberger et al (2019), Neuropsychopharmacology
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Amplitude Changes After 1h Predicts Reductions in Auditory Hallucinations After 30h
Hochberger et al (2019), Neuropsychopharmacology
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EEG Biomarkers Predict Individual Benefits
Hochberger et al (in press)
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Swerdlow NR, Bhakta SG, Light GA (2018), Schizophrenia Research
Revised Neuroscience-Informed Experimental Medicine Approach
“IMPRECISE MEDICINE”
Intervention
Clinical Phenotype
12.5%“Responders”
87.5%“Non-Responders”
TREATMENT FAILURE
Intervention
“PRECISION MEDICINE”
SCREEN FOR “BIOMARKER”
Clinical Phenotype Clinical Phenotype+
“BIOMARKER”
100% “Responders”
TREATMENT SUCCESS
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Lessons Learned and Caveats• This particular form of cognitive training is effective for improving cognitive, clinical, and psychosocial
functioning of patients, even those with long-standing illness. • Patients with greater severity of deficits benefited the most• Biomarkers measured
• The exercises are not that much fun• Our sample size was small, others demonstrating similar effectiveness larger• Not all patients benefited • Complaints of daily cognitive problems were not improved, even among those with larger gains• Specific cognitive exercises and dose probably matters• Context of delivery and who administers it probably matters• Clinical stabilization first• Get the context right first – embedded within enriched psychosocial experiences.
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Ongoing Studies and Future Directions– Accelerating drug development via translational neuroscience– Predicting development of illness in at risk individuals– Tracking progression of deficits across course of illness– Novel Analytics: Neural mechanisms, temporal dynamics, multivariate
composite indices
• Biomarker-guided assignment to treatments?
• Biomarker in early and later phase clinical trials
• Assessing early response to pharmacologic interventions: PACT
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Using Tools of Neuroscience to Make Personalized Care a Reality in Schizophrenia