Investigation of the Montreal Cognitive Assessment (MoCA) as a cognitive screener in severe mental illness
Introduction
There is a large body of the literature documenting cognitive deficits in patients across the severe mental illness (SMI) spectrum, including schizophrenia (Heinrichs and Zakzanis, 1998) and unipolar (McDermott and Ebmeier, 2009) and bipolar mood disorders (Kurtz and Gerraty, 2009). In schizophrenia, for example, evidence suggests that cognitive deficits reflect a core feature of illness (Goldberg and Green, 2002, Nuechterlein et al., 1994), with moderate to large effect sizes across neurocognitive domains (ds>0.60, Heinrichs and Zakzanis, 1998). Performance on standard neuropsychological tests is reliably one of the most robust predictors of functional abilities in patients with schizophrenia (Green, 1996). Accordingly, improvement of cognitive functioning has become a target for clinical trials research (Green and Nuechterlein, 1999, Green et al., 2004). The National Institute of Mental Heath established the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative in 2002 to establish standards, including neuropsychological battery recommendations, for evaluating outcomes in the treatment of schizophrenia (Green et al., 2004). Other neuropsychological batteries, for example, the Brief Assessment of Cognition in Schizophrenia (BACS; Keefe et al., 2004), have also been developed for this purpose. In the last decade or so, a relatively large literature supporting the use of these cognitive batteries has emerged.
While much of the research on neurocognition and severe mental illness has focused on schizophrenia, cognitive impairment has been noted in other Axis I disorders. For example, a meta-analysis of 14 studies reported small but significant effect sizes for deficits in episodic memory, executive function, and processing speed in major depression (McDermott and Ebmeier, 2009). In addition, a recent meta-analysis found moderate to large effect sizes for associations between bipolar disorder and deficits in attention, working memory, verbal memory, nonverbal memory, language, psychomotor speed, and executive functioning (Kurtz and Gerraty, 2009). In this meta-analysis, the largest effect sizes were for verbal learning (d=0.81) and verbal and nonverbal memory (d=0.80–0.92). Two meta-analyses suggest cognitive deficits persisted even during euthymic episodes (Robinson et al., 2006, Kurtz and Gerraty, 2009). Similar to what is seen in schizophrenia, neurocognitive impairment has also been associated with poorer psychosocial functioning in bipolar disorder (Wingo et al., 2009).
Extensive neuropsychological testing provided by current batteries has many benefits; however, elaborate testing of all psychiatric patients is not practical in some settings, such as medical settings, where sessions are time-limited, resource-limited, and neuropsychologists or trained psychometricians may be unavailable. The MATRICS battery requires approximately 60–90 min for administration. Even shorter batteries such as the BACS require over 30 min for administration. Patients with severe mental illness may have difficulty withstanding the duration and frustration of such batteries. There is a need for brief screening measures that can be quickly and easily administered and that provide important information about cognitive and functional status to inform health care providers about the need for further neuropsychological assessment.
There is a paucity of research regarding the use of brief screening measures in outpatients with severe mental illness. Importantly, some studies have reported that brief cognitive screening measures may be useful in predicting functional outcomes in patients with major depression (Withall et al., 2009). The Mini-Mental State Examination (MMSE), widely considered the most oft-used measure of mental status, has been associated with poorer ability to perform Instrumental Activities of Daily Living as measured by self-report on the Personal Self-Maintenance Scale (Lawton and Brody, 1969) in patients with severe depression (McCall and Dunn, 2003). However, a number of studies that examined the utility of the MMSE in community-dwelling patients with schizophrenia noted poor sensitivity to subtle cognitive deficits, as few patients scored below the impaired range (Ganjuli et al., 1998, Moore et al., 2004, Manning et al., 2007). The Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005) is a more recently developed, 30-item, screener designed for use by health professionals that shows promise in SMI populations. Compared with the MMSE, it places greater emphasis on the domains of attention and executive functioning. Two recent studies from the University of Sarajevo examined the utility of the MoCA in schizophrenia and found the MoCA appears to be more sensitive to mild cognitive impairment in schizophrenia compared to the MMSE (Fisekovic et al., 2012b, Fisekovic et al., 2012a). Despite this promise, the MoCA has largely gone unexamined in studies of cognition in SMI.
This was an experimental study designed to examine the utility and psychometric properties of the MoCA in a group of outpatients with SMI. This study also compared the MoCA to the BACS, a validated but lengthier and more extensive neuropsychological battery commonly employed in SMI research. We tested the following hypotheses: (1) SMI patients would obtain significantly lower scores on the MoCA compared to healthy controls, and the MoCA would offer acceptable sensitivity to subtle cognitive deficits in the SMI group. (2) Poorer MoCA performance would be associated with functional deficits measured by both a performance-based measure of functional abilities (the UPSA-2) and clinician ratings on the Global Assessment of Functioning (GAF). (3) In exploratory analyses, the MoCA would be significantly associated with functional deficits to a similar degree in comparison with the BACS.
Section snippets
Patients
Twenty-eight participants with severe mental illness were recruited from outpatient treatment programs located in Louisiana (see Table 1 for demographic information). At the time of testing, all participants were under the supervision of a multi-disciplinary team within a community mental health clinic. All participants met criteria for past or present psychotic or mood disorders. All patients were prescribed psychotropic medications at the time of testing, and there was substantial variability
Demographics and descriptive statistics
Within the SMI group, 10 participants were diagnosed with mood disorders and 18 were diagnosed with schizophrenia. BACS data was missing for one patient, and two patients were missing data for the UPSA-2 and GAF. There were no significant differences between the schizophrenia and mood disorders group for age, t(26)=0.97, p=0.34, or education, t(26)=0.93, p=0.37. In addition, the groups did not differ in MoCA scores, t(26)=0.56, p=0.58, BACS z-scores, t(25)=0.46, p=0.65, UPSA-2 z-score, t
Discussion
The purpose of the present study was to examine the utility of the MoCA, a brief cognitive screening instrument, in a sample of outpatients diagnosed with SMI. Overall, the results support the use of the MoCA for understanding neurocognitive deficits in patients with SMI. There were four important findings from this study. First, replicating prior research, patients obtained significantly lower scores on the cognitive measures (MoCA and BACS) and functional measures (GAF and UPSA-2) compared to
Acknowledgments
The authors acknowledge the efforts of Gina Najolia, Kyle Minor, Laura Brown, and Rebecca MacAulay for their help with data collection. They also thank the subjects for their participation and MMO Behavioral Health Systems for the assistance in subject outreach.
This study received no specific grant from any funding agency, commercial or not-for-profit sectors. There are no conflicts of interest.
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