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Original Investigation |

Motivational Deficits and Cognitive Test Performance in Schizophrenia

Gagan Fervaha, BSc1,2; Konstantine K. Zakzanis, PhD3; George Foussias, MD, PhD1,2,4; Ariel Graff-Guerrero, MD, PhD1,2,4; Ofer Agid, MD1,2,4; Gary Remington, MD, PhD1,2,4
[+] Author Affiliations
1Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
2Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
3Department of Psychology, University of Toronto Scarborough, Scarborough, Ontario, Canada
4Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
JAMA Psychiatry. 2014;71(9):1058-1065. doi:10.1001/jamapsychiatry.2014.1105.
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Importance  Motivational and cognitive deficits are core features of schizophrenia, both closely linked with functional outcomes. Although poor effort and decreased motivation are known to affect performance on cognitive tests, the extent of this relationship is unclear in patients with schizophrenia.

Objective  To evaluate the association between intrinsic motivation and cognitive test performance in patients with schizophrenia.

Design, Setting, and Participants  Cross-sectional and 6-month prospective follow-up study performed at 57 sites in the United States, including academic and community medical treatment centers, participating in the Clinical Antipsychotic Trials of Intervention Effectiveness study. The primary sample included 431 stable patients with a DSM-IV diagnosis of schizophrenia currently receiving a stable medication regimen.

Interventions  Cognitive performance and intrinsic motivation were evaluated using a comprehensive neuropsychological test battery and a derived measure from the Heinrichs-Carpenter Quality of Life Scale, respectively. Symptom severity and functional status were also assessed.

Main Outcomes and Measures  The primary outcome variable was global neurocognition. Individual domains of cognition were also evaluated for their association with motivation.

Results  Level of intrinsic motivation was significantly and positively correlated with global cognitive test performance, a relationship that held for each domain of cognition evaluated (correlation range, 0.20-0.34; P < .001). This association was found to be reliable after statistically accounting for positive, negative, depressive, and overall symptom severity (P < .05) and after accounting for community functioning (P < .001). The relationship between motivation and cognitive performance also remained significant after controlling for antipsychotic dose (P < .05). Prospective increase in motivation during the 6-month follow-up was also found to be significantly related to improvement in global cognitive performance (P < .05).

Conclusions and Relevance  The present findings provide strong support for a robust and reliable relationship between motivation and cognitive performance and suggest that test performance is not purely a measure of ability. Future studies assessing cognition in patients with schizophrenia should consider potential moderating variables such as effort and motivation. Implications for the assessment and interpretation of cognitive impairment based on neuropsychological test measures in schizophrenia are discussed, especially in the case of clinical trials for cognition-enhancing treatments.

Trial Registration  clinicaltrials.gov Identifier: NCT00014001

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Figure 1.
Illustration of the Components of Cognitive Test Performance

The largest influence is hypothesized to be cognitive (ie, information processing) ability. Level of intrinsic motivation and/or deployment of mental effort influence the link between ability and performance. Other factors (eg, familiarity with tests, anxiety) may also affect performance through an influence on motivation or independently. In addition, test performance can be interpreted as an observed variable, whereas the other factors such as cognitive ability are latent constructs.

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Figure 2.
Graphical Depiction of the Strength of the Bivariate Relationship Between Intrinsic Motivation Level and Each Cognitive Domain Score

Data are reported from 431 patients with schizophrenia. Level of motivation was correlated with the cognitive composite score (r = 0.33; P < .001; 95% bias-corrected accelerated CI, 0.25-0.40), verbal memory (r = 0.27; P < .001; 95% bias-corrected accelerated CI, 0.18-0.34), vigilance (r = 0.22; P < .001; 95% bias-corrected accelerated CI, 0.13-0.31), processing speed (r = 0.34; P < .001; 95% bias-corrected accelerated CI, 0.26-0.42), reasoning (r = 0.20; P < .001; 95% bias-corrected accelerated CI, 0.11-0.29), and working memory (r = 0.25; P < .001; 95% bias-corrected accelerated CI, 0.17-0.33).

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