Neurocognitive enhancement therapy with vocational services: work outcomes at two-year follow-up

Effects of integrated supported employment plus cognitive remediation training for people with schizophrenia and schizoaffective disorders

OBJECTIVES

The present study aims to investigate the synergistic effects of cognitive remediation training (CRT) on Integrated Supported Employment (ISE). ISE blends individual placement support service with work-related social skills training for Chinese people suffering from schizophrenia or schizoaffective disorder.

METHOD

Ninety participants with schizophrenia or schizoaffective disorders were recruited from two psychiatric outpatient services in Hong Kong. They were randomly assigned into the ISE+CRT (n=45) and ISE (n=45) conditions. Blinded assessments on vocational, clinical, psychological, and neurocognitive outcomes were conducted by independent assessors. The two groups were followed up at 7 and 11months.

RESULTS

Both groups yielded similar improvements across several outcome domains assessed immediately after the interventions and at 7 and 11month follow-ups, but no significant group differences were found. Significant positive trends over time in vocational, clinical and cognitive outcomes consistently favored the ISE+CRT condition.

CONCLUSION

While both the ISE+CRT and ISE groups demonstrated improvement in vocational, clinical, psychological, and neurocognitive outcomes, there was no evidence to show that cognitive remediation facilitated further improvement in these domains beyond gains associated with ISE alone. Further investigation is needed to fully exploit the synergistic potential of ISE combined with CRT, and to better understand which individuals experience a maximal benefit from the specific rehabilitation program components.

Randomized controlled trial of computer-based treatment of social cognition in schizophrenia: the TRuSST trial protocol

BACKGROUND

Schizophrenia is a severe and chronic medical condition, characterized by positive and negative symptoms, as well as pervasive social cognitive deficits. Despite the functional significance of the social cognition deficits affecting many aspects of daily living, such as social relationships, occupational status, and independent living, there is still no effective treatment option for these deficits, which is applied as standard of care. To address this need, we developed a novel, internet-based training program that targets social cognition deficits in schizophrenia (SocialVille). Preliminary studies demonstrate the feasibility and initial efficacy of Socialville in schizophrenia patients (Nahum et al., 2014). The purpose of the current trial (referred to as the TReatment of Social cognition in Schizophrenia Trial or TRuSST) is to compare SocialVille to an active control training condition, include a larger sample of patients, and assess both social cognitive functioning, and functional outcomes.

METHODS/DESIGN

We will employ a multi-site, longitudinal, blinded, randomized controlled trial (RCT) design with a target sample of 128 patients with schizophrenia. Patients will perform, at their home or in clinic, 40 sessions of either the SocialVille training program or an active control computer game condition. Each session will last for 40-45 minutes/day, performed 3-5 days a week, over 10-12 weeks, totaling to 30 hours of training. Patients will be assessed on a battery of social cognitive, social functioning and functional outcomes immediately before training, mid-way through training (after 20 training sessions) and at the completion of the 40 training sessions.

DISCUSSION

The strengths of this protocol are that it tests an innovative, internet-based treatment that targets fundamental social cognitive deficits in schizophrenia, employs a highly sensitive and extensive battery of functional outcome measures, and incorporates a large sample size in an RCT design.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02246426 Registered 16 September 2014.

Cognitive remediation combined with an early intervention service in first episode psychosis

OBJECTIVE

This randomised clinical trial assessed the effects of a 16-week cognitive remediation programme (NEUROCOM) combined with an early intervention service (EIS) vs. EIS alone.

METHOD

One hundred and seventeen patients with first episode psychosis were randomly assigned to 4 months cognitive remediation combined with EIS vs. EIS alone. Statistical analysis of effect was based on intention to treat.

RESULTS

A total of 98 patients (83.8%) participated in post-training assessments at 4 months and 92 (78.6%) in 12-month follow-up assessments. No effects were found on the primary outcome measure functional capacity. At the post-training assessment, the intervention group had improved significantly on Rosenberg Self-Esteem Scale (Cohen's d=0.54, P=0.01), Positive and Negative Symptoms Scale (PANSS), General Psychopathology Scale (Cohen's d=0.51, P=0.05) and the verbal learning domain (Cohen's d=0.46, P=0.02). At follow-up assessment, the intervention group retained the significant improvements on the verbal learning domain (Cohen's d=0.58, P<0.05). Furthermore, significant improvements were observed on the working memory domain (Cohen's d=0.56, P=0.01) and PANSS positive symptoms (Cohen's d=0.44, P=0.04), while improvement on the composite score was marginally significant (Cohen's d=0.34, P=0.05).

CONCLUSION

In accordance with other cognitive remediation programmes, this programme demonstrates some immediate and long-term effect on cognitive functioning, symptoms and self-esteem.

Virtual reality job interview training for individuals with psychiatric disabilities

Services are available to help support existing employment for individuals with psychiatric disabilities; however, there is a gap in services targeting job interview skills that can help obtain employment. We assessed the feasibility and efficacy of Virtual Reality Job Interview Training (VR-JIT) in a randomized controlled trial. Participants were randomized to VR-JIT (n = 25) or treatment-as-usual (TAU) (n = 12) groups. VR-JIT consisted of 10 hours of simulated job interviews with a virtual character and didactic online training. The participants attended 95% of laboratory-based training sessions and found VR-JIT easy to use and felt prepared for future interviews. The VR-JIT group improved their job interview role-play performance (p ≤ 0.05) and self-confidence (p ≤ 0.05) between baseline and follow-up as compared with the TAU group. VR-JIT performance scores increased over time (R = 0.65). VR-JIT demonstrated initial feasibility and efficacy at improving job interview skills and self-confidence. Future research may help clarify whether this intervention is efficacious in community-based settings.

Alexithymia in schizophrenia: associations with neurocognition and emotional distress

While alexithymia, or difficulties identifying and describing affect, has been commonly observed in schizophrenia, little is known about its causes and correlates. To test the hypothesis that deficits in emotion identification and expression result from, or are at least related to, deficits in neurocognition and affective symptoms, we assessed alexithymia using the Toronto Alexithymia Scale (TAS-20), symptoms using the Positive and Negative Syndrome Scale (PANSS), and neurocognition using the MATRICS battery among 65 adults with schizophrenia spectrum disorders in a non-acute phase of illness. Partial correlations controlling for the effects of social desirability revealed that difficulty identifying feelings and externally oriented thinking were linked with greater levels of neurocognitive deficits, while difficulty describing feelings was related to heightened levels of emotional distress. To explore whether neurocognition and affective symptoms were uniquely related to alexithymia, a multiple regression was conducted in which neurocognitive scores and affective symptoms were allowed to enter to predict overall levels of alexithymia after controlling for social desirability. Results revealed both processing speed and anxiety uniquely contributed to the prediction of the total score on the TAS-20. Results suggest that dysfunctions in both cognitive and affective processes may be related to alexithymia in schizophrenia independently of one another.

Multi-domain computerized cognitive training program improves performance of bookkeeping tasks: a matched-sampling active-controlled trial

Cognitive skills are important predictors of job performance, but the extent to which computerized cognitive training (CCT) can improve job performance in healthy adults is unclear. We report, for the first time, that a CCT program aimed at attention, memory, reasoning and visuo-spatial abilities can enhance productivity in healthy younger adults on bookkeeping tasks with high relevance to real-world job performance. 44 business students (77.3% female, mean age 21.4 ± 2.6 years) were assigned to either (a) 20 h of CCT, or (b) 20 h of computerized arithmetic training (active control) by a matched sampling procedure. Both interventions were conducted over a period of 6 weeks, 3-4 1-h sessions per week. Transfer of skills to performance on a 60-min paper-based bookkeeping task was measured at three time points-baseline, after 10 h and after 20 h of training. Repeated measures ANOVA found a significant Group X Time effect on productivity (F = 7.033, df = 1.745; 73.273, p = 0.003) with a significant interaction at both the 10-h (Relative Cohen's effect size = 0.38, p = 0.014) and 20-h time points (Relative Cohen's effect size = 0.40, p = 0.003). No significant effects were found on accuracy or on Conners' Continuous Performance Test, a measure of sustained attention. The results are discussed in reference to previous findings on the relationship between brain plasticity and job performance. Generalization of results requires further study.

[Cognitive remediation and work outcome in schizophrenia]

Recovery is partly defined by the patients' capacity to work, since doing well in a job favors hope and responsibilities' taking. Diminished job placement or tenure is linked with cognitive disorders, which impact directly and indirectly (through negative symptoms) functional outcomes. Attention, executive functions and working memory disorders can result in an alteration of the ability to manage the tasks required in the workplace. Executive function, working memory and social cognition disorders may also have an impact on behavior in relationships. Cognitive disorders do not automatically directly contribute to vocational outcome, yet their effects may be mediated by other variables such as symptoms, metacognition, social skills and intrinsic motivation. Then, since all these dimensions have to be taken into account, reducing the impact of cognitive troubles becomes a major challenge for the care of schizophrenia. Cognitive remediation is the more effective therapeutic tool to reduce cognitive dysfunctions. It rests in particular on the development of new strategies that allow taking concrete situations into account more efficiently. Cognitive remediation reduces the detrimental consequences of cognitive disorders and permits their compensation. It has emerged as an effective treatment, that improves not only cognitive abilities but also functioning, as it has been shown by numerous randomized controlled studies and several meta-analyses. The present article considers the effects on cognitive remediation on work function in schizophrenia. Several randomized controlled trials that compared supported employment alone versus supported employment associated with cognitive remediation showed significant improvement of employment rates in the latter condition. These results favor the use of cognitive remediation before job placement. The specific needs of the occupation that will be provided and the cognitive profile of the user should be taken into account.

Trauma-informed cognitive remediation group therapy

This brief report presents the rationale for the importance of integrating trauma therapy with cognitive remediation in order to enhance both component interventions in the treatment of serious mental illness. It describes a general format that allows the above integration and suggests that future studies should investigate the efficacy of the proposed group design.

A systematic review on improving cognition in schizophrenia: which is the more commonly used type of training, practice or strategy learning?

BACKGROUND

The purpose of this article was to conduct a review of the types of training offered to people with schizophrenia in order to help them develop strategies to cope with or compensate for neurocognitive or sociocognitive deficits.

METHODS

We conducted a search of the literature using keywords such as "schizophrenia", "training", and "cognition" with the most popular databases of peer-reviewed journals.

RESULTS

We reviewed 99 controlled studies in total (though nine did not have a control condition). We found that drill and practice training is used more often to retrain neurocognitive deficits while drill and strategy training is used more frequently in the context of sociocognitive remediation.

CONCLUSIONS

Hypotheses are suggested to better understand those results and future research is recommended to compare drill and strategy with drill and practice training for both social and neurocognitive deficits in schizophrenia.

Improvements in negative symptoms and functional outcome after a new generation cognitive remediation program: a randomized controlled trial

Cognitive remediation improves cognition in patients with schizophrenia, but its effect on other relevant factors such as negative symptoms and functional outcome has not been extensively studied. In this hospital-based study, 84 inpatients with chronic schizophrenia were recruited from Alava Hospital (Spain). All of the subjects underwent a baseline and a 3-month assessment that examined neurocognition, clinical symptoms, insight, and functional outcome according to the Global Assessment of Functioning (GAF) scale and Disability Assessment Schedule from World Health Organization (DAS-WHO). In addition to receiving standard treatment, patients were randomly assigned either to receive neuropsychological rehabilitation (REHACOP) or to a control group. REHACOP is an integrative program that taps all basic cognitive functions. The program included experts' latest suggestions about positive feedback and activities of daily living in the patients' environment. The REHACOP group showed significantly greater improvements at 3 months in the areas of neurocognition, negative symptoms, disorganization, and emotional distress compared with the control group (Cohen's effect size for these changes ranged from d = 0.47 for emotional distress to d = 0.58 for disorganization symptoms). The REHACOP group also improved significantly in both the GAF (d = 0.61) and DAS-WHO total scores (d = 0.57). Specifically, the patients showed significant improvement in vocational outcomes (d = 0.47), family contact (d = 0.50), and social competence (d = 0.56). In conclusion, neuropsychological rehabilitation may be useful for the reduction of negative symptoms and functional disability in schizophrenia. These findings support the integration of neuropsychological rehabilitation into standard treatment programs for patients with schizophrenia.

Cognition in schizophrenia: Past, present, and future

Schizophrenia Research: Cognition will serve an important function - a place where interests converge and investigators can learn about the recent developments in this area. This new journal will provide rapid dissemination of information to people who will make good use of it. In this initial article, we comment globally on the study of cognition in schizophrenia: how we got here, where we are, and where we are going. The goal of this first article is to place the study of cognition in schizophrenia within a historical and scientific context. In a field as richly textured as ours it is impossible to hit all the important areas, and we hope the reader will forgive our omissions. Phrased in cognitive terms, our limited presentation of the past is a matter of selective memory, the present is a matter of selective attention, and the future is a matter of selective prospection. This broad introduction emphasizes that cognition in schizophrenia provides clues to pathophysiology, treatment, and outcome. In fact, the study of cognitive impairment in schizophrenia has become wholly intertwined with the study of schizophrenia itself.

The effects of the combination of cognitive training and supported employment on improving clinical and working outcomes for people with schizophrenia in Japan

Background: In Japan, Job assistance for SMI have been not active. Compared with mental retardation, employment rate of SMI was low. The needs of the effective job assistance for SMI are growing. The purpose of this study was to determine the effectiveness of the combination approach of Cognitive Remediation (CR) and Supported Employment (SE) in clinical outcomes, including cognitive functioning and psychiatric symptoms besides vocational outcomes. Methods: The participants diagnosed with schizophrenia or schizoaffective disorder were assigned to CR+SE group (n=52) and SE group (n=57). CR comprised computer based trainings using COGPACK and group works. SE was individualized vocational support provided by employment specialists. Outcome measures included cognitive functioning, psychiatric symptoms, social functioning, performance of tasks as clinical outcomes, employment rate, duration of employment, and earned wage as vocational outcome. Results: CR+SE group displayed significantly better psychiatric symptoms (F=3.490, p<.10), interpersonal relations (F=11.695, p<.01), and social and cognitive functioning including verbal memory (F=9.439, p<.01), digit sequencing (F=5.544, p<.05), token motor tasks (F=6.685, p<.05), and overall cognitive functioning (F=8.136, p<.01). We did not find any significant difference between two groups in terms of employment rate and earned wage. Discussions: This is the first controlled study to determine the effectiveness of CR on vocational outcomes in Japan. The results showed that CR and SE programs were feasible in Japan and that CR using COGPACK had favorable effects on cognitive functioning, psychiatric symptoms, and social functioning, which is consistent with previous researches.

Social cognition training as an intervention for improving functional outcome in first-episode psychosis: a feasibility study

BACKGROUND

Social cognitive deficits have a detrimental effect on social and role functioning at both early and late stages of psychotic illness.

AIM

To assess the feasibility of social cognition and interaction training (SCIT) in first-episode psychosis (FEP).

METHODS

A total of 12 FEP participants were sequentially allocated to one of two SCIT groups, each of which met once per week for 10 consecutive weeks. Social cognition and functioning was assessed at baseline and post-intervention.

RESULTS

SCIT was well-tolerated and retention was good. FEP participants improved significantly on measures of emotion recognition and social and occupational functioning.

CONCLUSIONS

This study extends previous research by applying SCIT early in the course of illness, with the rationale that there is greater brain plasticity in this developmental phase of life, and greater scope to reduce or prevent disability. Results suggest SCIT is acceptable to and potentially helpful for this young population, thus a large randomized controlled trial is warranted.

Metakognitive und sozial-kognitive Defizite bei Schizophrenien. Funktionelle Bedeutung und Behandlungsstrategien

Die Gruppe der Schizophrenien umfasst heterogene psychopathologische Syndrome, die oft mit neurokognitiven Störungen und niedrigem psychosozialen Funktionsniveau assoziiert sind. Empirische Studien legen nahe, dass viele mit Schizophrenie assoziierte Symptome auf Störungen der sozialen Kognition bzw. metakognitive Störungen zurückgeführt werden können. Diese Konzepte beziehen sich auf die Fähigkeit, soziale Signale wahrnehmen und interpretieren, eigene und psychische Zustände Anderer reflektieren und dieses Wissen flexibel in sozialen Interaktionen und zur Problemlösung einsetzen zu können. Der vorliegende Artikel gibt eine Übersicht über sozial-kognitive und metakognitive Defizite bei Schizophrenien und wie über das Training dieser Kernkompetenzen das psychosoziale Funktionsniveau von Patienten mit Schizophrenie verbessert werden kann. Bei Schizophrenien sind soziale Kognition und Metakognition eng mit dem psychosozialen Funktionsniveau verbunden, zum Teil jedoch auch abhängig von neurokognitiven Fähigkeiten. Sozial-kognitives bzw. metakognitives Training kann zur Verbesserung des psychosozialen Funktionsniveaus beitragen, möglicherweise aber in Abhängigkeit vom Lernpotential und der Motivation der Patienten. Zukünftige Studien sollten untersuchen, welche Subtypen innerhalb des Schizophrenie-Spektrums am ehesten von sozial-kognitivem und metakognitivem Training profitieren können und welche Gruppen ggf. zusätzlich neurokognitives Training benötigen, um das psychosoziale Funktionsniveau zu verbessern.

Community rehabilitation and psychosocial interventions for psychotic disorders in youth

During recovery, young people with psychosis need attention paid not only to their psychotic symptoms but also to the areas of functioning that restrict their capacity to live a fulfilled life in the community. Despite improvements in medications and psychological therapies, people with psychosis still have poor outcomes in functional domains such as vocation, physical health, housing, and imprisonment. This article reviews 2 of these areas: vocational functioning and physical health. It examines the extent of each of these issues, provides guidance as to what evidence there exists on which to base interventions, and describes such evidence.

Creative writing in recovery from severe mental illness

There is evidence that creative writing forms an important part of the recovery experience of people affected by severe mental illness. In this paper, we consider theoretical models that explain how creative writing might contribute to recovery, and we discuss the potential for creative writing in psychosocial rehabilitation. We argue that the rehabilitation benefits of creative writing might be optimized through focus on process and technique in writing, rather than content, and that consequently, the involvement of professional writers might be important. We describe a pilot workshop that deployed these principles and was well-received by participants. Finally, we make recommendations regarding the role of creative writing in psychosocial rehabilitation for people recovering from severe mental illness and suggest that the development of an evidence base regarding the effectiveness of creative writing is a priority.

The relative contribution of neurocognition and social cognition to 6-month vocational outcomes following Individual Placement and Support in first-episode psychosis

AIMS

To examine whether baseline neurocognition and social cognition predict vocational outcomes over 6 months in patients with first-episode psychosis (FEP) enrolled in a randomised controlled trial of Individual Placement and Support (IPS) versus treatment as usual (TAU).

METHODS

135 FEP participants (IPS n=69; TAU n=66) completed a comprehensive neurocognitive and social cognitive battery. Principal axis factor analysis using PROMAX rotation was used to determine the underlying cognitive structure of the battery. Setwise (hierarchical) logistic and multivariate linear regressions were used to examine predictors of: (a) enrolment in education and employment; and (b) hours of employment over 6 months. Neurocognition and social cognition factors were entered into the models after accounting for premorbid IQ, baseline functioning and treatment group.

RESULTS

Six cognitive factors were extracted: (i) social cognition; (ii) information processing speed; (iii) verbal learning and memory; (iv) attention and working memory; (v) visual organisation and memory; and (vi) verbal comprehension. Enrolment in education over 6 months was predicted by enrolment in education at baseline (p=.002) and poorer visual organisation and memory (p=.024). Employment over 6 months was predicted by employment at baseline (p=.041) and receiving IPS (p=.020). Better visual organisation and memory predicted total hours of paid work over 6 months (p<.001).

CONCLUSIONS

Visual organisation and memory predicted the enrolment in education and duration of employment, after accounting for premorbid IQ, baseline functioning and treatment. Social cognition did not contribute to the prediction of vocational outcomes. Neurocognitive interventions may enhance employment duration in FEP.

Supported employment for adults with severe mental illness

BACKGROUND

People who suffer from severe mental disorder experience high rates of unemployment. Supported employment is an approach to vocational rehabilitation that involves trying to place clients in competitive jobs without any extended preparation. The Individual placement and support (IPS) model is a carefully specified form of supported employment.

OBJECTIVES

1. To review the effectiveness of supported employment compared with other approaches to vocational rehabilitation or treatment as usual.2. Secondary objectives were to establish how far:(a) fidelity to the IPS model affects the effectiveness of supported employment,(b) the effectiveness of supported employment can be augmented by the addition of other interventions.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (February 2010), which is compiled by systematic searches of major databases, handsearches and conference proceedings.

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, of working age (normally 16 to 70 years), where supported employment was compared with other vocational approaches or treatment as usual. Outcomes such as days in employment, job stability, global state, social functioning, mental state, quality of life, satisfaction and costs were sought.

DATA COLLECTION AND ANALYSIS

Two review authors (YK and KK) independently extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated mean difference (MD) between groups and its 95% (CI). We employed a fixed-effect model for analyses. A random-effects model was also employed where heterogeneity was present.

MAIN RESULTS

A total of 14 randomised controlled trials were included in this review (total 2265 people). In terms of our primary outcome (employment: days in competitive employment, over one year follow-up), supported employment seems to significantly increase levels of any employment obtained during the course of studies (7 RCTs, n = 951, RR 3.24 CI 2.17 to 4.82, very low quality of evidence). Supported employment also seems to increase length of competitive employment when compared with other vocational approaches (1 RCT, n = 204, MD 70.63 CI 43.22 to 94.04, very low quality evidence). Supported employment also showed some advantages in other secondary outcomes. It appears to increase length (in days) of any form of paid employment (2 RCTs, n = 510, MD 84.94 CI 51.99 to 117.89, very low quality evidence) and job tenure (weeks) for competitive employment (1 RCT, n = 204, MD 9.86 CI 5.36 to 14.36, very low quality evidence) and any paid employment (3 RCTs, n = 735, MD 3.86 CI -2.94 to 22.17, very low quality evidence). Furthermore, one study indicated a decreased time to first competitive employment in the long term for people in supported employment (1 RCT, n = 204, MD -161.60 CI -225.73 to -97.47, very low quality evidence). A large amount of data were considerably skewed, and therefore not included in meta-analysis, which makes any meaningful interpretation of the vast amount of data very difficult.

AUTHORS' CONCLUSIONS

The limited available evidence suggests that supported employment is effective in improving a number of vocational outcomes relevant to people with severe mental illness, though there appears to exist some overall risk of bias in terms of the quality of individual studies. All studies should report a standard set of vocational and non-vocational outcomes that are relevant to the consumers and policy-makers. Studies with longer follow-up should be conducted to answer or address the critical question about durability of effects.

Evaluation of a computer-assisted errorless learning-based memory training program for patients with early Alzheimer's disease in Hong Kong: a pilot study

BACKGROUND

Improving the situation in older adults with cognitive decline and evidence of cognitive rehabilitation is considered crucial in long-term care of the elderly. The objective of this study was to implement a computerized errorless learning-based memory training program (CELP) for persons with early Alzheimer's disease, and to compare the training outcomes of a CELP group with those of a therapist-led errorless learning program (TELP) group and a waiting-list control group.

METHODS

A randomized controlled trial with a single-blind research design was used in the study. Chinese patients with early Alzheimer's disease screened by the Clinical Dementia Rating (score of 1) were recruited. The subjects were randomly assigned to CELP (n = 6), TELP (n = 6), and waiting-list control (n = 7) groups. Evaluation of subjects before and after testing, and at three-month follow-up was achieved using primary outcomes on the Chinese Mini-Mental State Examination, Chinese Dementia Rating Scale, Hong Kong List Learning Test, and the Brief Assessment of Prospective Memory-Short Form. Secondary outcomes were the Modified Barthel Index, Hong Kong Lawton Instrumental Activities of Daily Living Scale, and Geriatric Depression Scale-Short Form. The data were analyzed using Friedman's test for time effect and the Kruskal-Wallis test for treatment effect.

RESULTS

Positive treatment effects on cognition were found in two errorless learning-based memory groups (ie, computer-assisted and therapist-led). Remarkable changes were shown in cognitive function for subjects receiving CELP and emotional/daily functions in those receiving TELP.

CONCLUSION

Positive changes in the cognitive function of Chinese patients with early Alzheimer's disease were initially found after errorless training through CELP. Further enhancement of the training program is recommended.

Effects of age and cognitive reserve on cognitive remediation therapy outcome in patients with schizophrenia

OBJECTIVE

Older people with a diagnosis of schizophrenia seem to show fewer benefits following cognitive remediation therapy (CRT). It is not clear whether cognitive reserve modifies the relationship with age.

METHODS

A total of 134 individuals with schizophrenia were pooled from one randomized control trial and one observational trial. Eighty-five participants received more than 20 sessions of CRT and 49 participants received fewer than 20 sessions of CRT or treatment as usual. Participants were divided into two groups according to their age (younger than 40 years: younger, N = 77; and 40 years or older: older, N = 57). Cognition (working memory, cognitive flexibility, and planning) was assessed at baseline and posttreatment. Premorbid IQ and vocabulary at baseline were used as cognitive reserve proxies.

RESULTS

There was a significant effect of CRT on working memory in younger but not older participants. Better premorbid IQ was associated with better working memory performance in younger participants irrespective of treatment. No significant effects of treatment or cognitive reserve were revealed in older participants. Cognitive reserve proxies did not modify CRT treatment effect.

CONCLUSION

In conclusion, the effects of CRT were limited in older people with schizophrenia. Cognitive reserve could not be shown to influence the relationship of age with CRT efficacy. Better premorbid IQ was associated with increased practice effects on working memory in younger but not older individuals.

Relationships among neurocognition, symptoms, and functioning in treatment-resistant depression

Treatment-resistant depression (TRD) refers to a condition where individuals with major depressive disorder have inadequate or no response to treatment. Although functional disability is a prominent and costly feature of treatment resistance, very little is known about the factors that contribute to and maintain functional impairment in TRD. This is the first study to report the neurocognitive profile of TRD and the relationships among neurocognition, symptoms, and functioning in this syndrome. Results indicated that patients with TRD (N = 33) exhibit mildly reduced performance across all neurocognitive domains with a superimposed moderate impairment in verbal working memory. Neurocognition was associated with functional competence (what one can do), whereas depressive symptoms were associated with functional performance (what one actually does). Understanding the psychological mechanisms related to functioning may help us move toward recovery in this chronically ill group.

Cognitive Education: Constructivist Perspectives on Schooling, Assessment, and Clinical Applications

Our responses to the five questions concerning cognitive education that Robert Sternberg raised focus on the school, the learner, and applications to clinical settings.

Considering the school and the learner, we emphasize constructivist theory and applications of learner-centered instructional and assessment approaches. Considering applications to clinical settings, we focus on cognitive remediation and dynamic assessment (DA) approaches that address the impaired balance of cognitive level and task requirement for people with psychoses and other cognitive or developmental disorders. Emphasis is on the goal of including these persons into communities of learners that will be able to benefit from cognitive education.

Computerized cognitive training targeting brain plasticity in schizophrenia

Two important paradigm shifts have occurred recently in the field of schizophrenia research. First, we now understand schizophrenia to be a neurodevelopmental disorder, one that is characterized by aberrant patterns of activation and connectivity in cortical and subcortical neural networks that are present before illness onset and that worsen as an individual progresses into later stages of the disease. Second, we now understand that these abnormalities are not immutable and fixed, but instead can respond to interventions targeting brain plasticity, particularly when delivered in the prodromal and early phases of schizophrenia. In this chapter, we will first describe some of the neurocognitive impairments that characterize schizophrenia, highlighting the developmental course of the illness. We will then briefly review salient features of currently available computerized cognitive training programs that target these impairments. Next, we will present an overview of current research findings regarding neurobiological effects of computerized cognitive training in schizophrenia and how these results shed light on the critical neuroplasticity mechanisms that support successful training. Finally, we will present recommendations for future research to optimize computerized cognitive training programs, with an aim to promoting functional recovery.

Compensatory cognitive training for psychosis: effects in a randomized controlled trial

OBJECTIVE

Treatments for the cognitive impairments of schizophrenia are urgently needed. We developed and tested a 12-week, group-based, manualized, compensatory cognitive training intervention targeting prospective memory, attention, learning/memory, and executive functioning. The intervention focused on compensatory strategies, such as calendar use, self-talk, note taking, and a 6-step problem-solving method, and did not require computers.

METHOD

In a randomized controlled trial, 69 outpatients with DSM-IV primary psychotic disorders were assigned to receive standard pharmacotherapy alone or compensatory cognitive training + standard pharmacotherapy for 12 weeks. Assessments of neuropsychological performance and functional capacity (primary outcomes) and psychiatric symptom severity, quality of life, social skills performance, cognitive insight, and self-reported everyday functioning (secondary outcomes) were administered at baseline, posttreatment, and 3-month follow-up. Data were collected between September 2003 and August 2009.

RESULTS

Hierarchical linear modeling analyses demonstrated significant compensatory cognitive training-associated effects on attention at follow-up (P = .049), verbal memory at posttreatment and follow-up (P values ≤ .039), and functional capacity (University of California, San Diego Performance-based Skills Assessment) at follow-up (P = .004). The compensatory cognitive training group also differentially improved in negative symptom severity at posttreatment and follow-up (P values ≤ .025) and subjective quality of life at follow-up (P = .002).

CONCLUSIONS

Compensatory cognitive training, a low-tech, brief intervention, has the potential to improve not only cognitive performance but also functional skills, negative symptoms, and self-rated quality of life in people with psychosis.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01521026.

Cognitive enhancement in schizophrenia: pharmacological and cognitive remediation approaches

This article discusses the measurement of cognition in schizophrenia, its role as a determinant of disability, and treatment efforts to date, including pharmacological and behavioral interventions as well as effective treatments that lead to improved outcomes. The measurement of functioning when patients with schizophrenia receive treatment in the office is addressed. The review focuses on new developments in the creation and adoption of a consensus method for the assessment of cognitive functioning in treatment studies, on the increased appreciation for assessment of functional skills in the prediction of everyday outcomes, and on developments in the basic neuroscience of cognition.

Cognitive remediation for schizophrenia: current status, biological correlates and predictors of response

Cognitive remediation (CR) is an increasingly studied behavioral intervention for improving illness-linked cognitive deficits in schizophrenia, with considerable promise for improving the disease outcome when offered in concert with other therapies. We present findings from a comprehensive, critical review of the extant literature on CR for schizophrenia. Conclusions from six meta-analyses presented to date are summarized, and existing CR interventions are categorized into three major classes: restorative, strategy-based and hybrid approaches. The crucial elements and empirical support for each class are presented. Studies of predictors of treatment response suggest that attention, motivation and clinician expertise, along with the measures of 'brain reserve', are key features of a positive treatment response. Lastly, findings from studies of neuroimaging indicate that CR is accompanied by structural and functional neural changes in key frontal and temporal brain regions.

Can Social Functioning in Schizophrenia Be Improved through Targeted Social Cognitive Intervention?

Efforts to use cognitive remediation in psychosocial intervention for schizophrenia have increasingly incorporated social cognition as a treatment target. A distinction can be made in this work between “broad-based” interventions, which integrate social cognitive training within a multicomponent suite of intervention techniques and “targeted” interventions; which aim to enhance social cognition alone. Targeted interventions have the potential advantage of being more efficient than broad-based interventions; however, they also face difficult challenges. In particular, targeted interventions may be less likely to achieve maintenance and generalization of gains made in treatment. A novel potential solution to this problem is described which draws on the social psychological literature on social cognition.

Additional interventions to enhance the effectiveness of individual placement and support: a rapid evidence assessment

Topic. Additional interventions used to enhance the effectiveness of individual placement and support (IPS). Aim. To establish whether additional interventions improve the vocational outcomes of IPS alone for people with severe mental illness. Method. A rapid evidence assessment of the literature was conducted for studies where behavioural or psychological interventions have been used to supplement standard IPS. Published and unpublished empirical studies of IPS with additional interventions were considered for inclusion. Conclusions. Six published studies were found which compared IPS alone to IPS plus a supplementary intervention. Of these, three used skills training and three used cognitive remediation. The contribution of each discrete intervention is difficult to establish. Some evidence suggests that work-related social skills and cognitive training are effective adjuncts, but this is an area where large RCTs are required to yield conclusive evidence.

The cultural adaptability of intermediate measures of functional outcome in schizophrenia

The Measurement and Treatment Research to Improve Cognition in Schizophrenia initiative was designed to encourage the development of cognitive enhancing agents for schizophrenia. For a medication to receive this indication, regulatory agencies require evidence of improvement in both cognition and functional outcome. Because medication trials are conducted across multiple countries, we examined ratings of the cross-cultural adaptability of 4 intermediate measures of functional outcome (Independent Living Scales, UCSD Performance-based Skills Assessment, Test of Adaptive Behavior in Schizophrenia, Cognitive Assessment Interview [CAI]) made by experienced clinical researchers at 31 sites in 8 countries. English-speaking research staff familiar with conducting medication trials rated the extent to which each subscale of each intermediate measure could be applied to their culture and to subgroups within their culture based on gender, geographic region, ethnicity, and socioeconomic status on the Cultural Adaptation Rating Scale. Ratings suggested that the CAI would be easiest to adapt across cultures. However, in a recent study, the CAI was found to have weaker psychometric properties than some of the other measures. Problems were identified for specific subscales on all the performance-based assessments across multiple countries. India, China, and Mexico presented the greatest challenges in adaptation. For international clinical trials, it would be important to use the measures that are most adaptable, to adapt subscales that are problematic for specific countries or regions, or to develop a battery composed of the subscales from different instruments that may be most acceptable across multiple cultures with minimal adaptation.

The efficacy of supported employment for middle-aged and older people with schizophrenia

OBJECTIVE

Supported employment is the evidence-based treatment of choice for assisting individuals with severe mental illness to achieve competitive employment, but few supported employment programs specifically target older clients with psychiatric illness. The purpose of this study was to evaluate the efficacy of supported employment for middle-aged or older people with schizophrenia.

METHOD

Participants included 58 outpatients with schizophrenia or schizoaffective disorder aged 45 or older who were recruited from a community mental health clinic. Participants were randomly assigned to receive Individual Placement and Support (IPS; the manualized version of supported employment) or conventional vocational rehabilitation (CVR) for one year, and completed assessments at baseline, six months, and twelve months.

RESULTS

IPS was superior to CVR on nearly all work outcome measures, including attainment of competitive employment, weeks worked, and wages earned. Fifty-seven percent of IPS participants worked competitively, compared with 29% of CVR participants; 70% of IPS participants obtained any paid work, compared with 36% of CVR participants. Within the IPS group, better baseline functional capacity (as measured by the UCSD Performance Based Skills Assessment) and more recent employment were modestly associated with better work outcomes.

CONCLUSIONS

Middle-aged and older adults with schizophrenia are good candidates for supported employment services.

Relationship of neurocognitive deficits to diagnosis and symptoms across affective and non-affective psychoses

INTRODUCTION

Neurocognitive dysfunction is believed to be a core feature of schizophrenia and is increasingly recognized as a common symptom dimension in bipolar disorder. Despite a copious literature on neurocognition in these disorders, the relationship amongst neurocognition, symptoms, and diagnosis remains unclear. We examined neurocognitive functioning in a cross-diagnostic sample of patients with psychotic disorders. Based on previous findings, it was hypothesized that neurocognitive functioning would be impaired in all three patient groups, and that groups would be similarly impaired on all neuropsychological measures. Additionally, we predicted that negative symptoms but not positive, general, or mood symptoms, would be associated with neurocognitive functioning.

METHOD

Neurocognitive functioning and symptoms were assessed in participants with schizophrenia (n=25), schizoaffective disorder (n=29), or bipolar disorder with psychosis (n=31), and in healthy controls (n=20).

RESULTS

Neurocognitive functioning was significantly impaired in all patient groups, and groups did not differ by diagnosis on most measures. A series of linear regressions revealed that negative symptoms (but no other clinical symptom) predicted poorer executive functioning across groups. Diagnosis was not a significant predictor of any neurocognitive variable.

DISCUSSION

Neurocognitive deficits were pronounced in this cross-diagnostic sample of patients with psychotic disorders, and did not differ by diagnosis. Neurocognitive dysfunction may represent a symptom dimension that spans diagnostic categories, and may reflect shared pathogenic processes. As neurocognitive dysfunction is among the strongest predictors of outcome in patients, efforts to treat these deficits, which have shown promise in schizophrenia, should be extended to all patients with psychosis.

Cognitive remediation therapy for schizophrenia: what is it and does it work?

Impaired cognition is a core feature of schizophrenia (SZ) that precedes, accompanies, and often outlasts a patient's clinical symptoms. The success of new generation antipsychotics, as well as their failure to ameliorate the persistent disabilities associated with the disorder are well documented. Consequently, a number of psychosocial and cognitive interventions have been developed to address specific aspects of disability not adequately alleviated by medication. Among these, interventions adapted from the acquired brain literature that target cognitively based disability (cognitive remediation therapy; CRT) have received significant empirical support both for ameliorating specific deficits in memory, attention and executive function, and improving real world outcome. CRT strategies have focused either on providing drill-based training aimed at increasing capacity or providing behavioural strategies for compensating for cognitive deficits, or a mixture of both. Nonetheless, these interventions have varied widely and several questions remain. This review provides a brief overview of cognitive remediation therapies in psychosis, discusses evidence for its success, and outlines a number of questions that remain about its implementation. Given the current unavailability of cognitive remediation as part of standard care in Irish mental health services, we conclude by describing one such intervention developed within our clinical research group and the questions we hope to address in making this programme more widely available to Irish patients.

fMRI working memory hypo-activations in schizophrenia come with a coupling deficit between arousal and cognition

Cognition has become a target for therapeutic intervention and favoring arousal could be a way to help patients. Working memory is an arousal dependent cognitive function. This study used functional MRI (fMRI) as a surrogate marker of working memory to evaluate the sensitivity of patients' hypoactive regions to arousal in a subpopulation of rehabilitated patients. Are hypoactive regions sensitive to arousal? Does the deficit result from arousal deficit or improper coupling with cognitive activity? Eighteen patients and matched controls were recruited. Participants performed a working memory task during combined electroencephalographic (EEG) and fMRI measurements. Cortical regions sensitive to arousal were defined as those which were inversely correlated with low EEG frequencies. Overlap between the arousal-sensitive and hypoactive regions was assessed by mutual information. Arousal-cognitive coupling was evaluated by the correlation between the arousal effect and the task effect. In the patient group, most hypoactive voxels were sensitive to arousal and corresponded to the prefronto-parietal network. But patients had no arousal deficit. Although arousal seems to improve cognitive activity in most of the patients' cortical areas, this coupling appears to be specifically disturbed in their hypoactive regions. In conclusion, although increasing arousal may help cognition, it may do so in an unspecific way.

Intrinsic motivation as a predictor of work outcome after vocational rehabilitation in schizophrenia

Intrinsic motivation is a construct commonly used in explaining goal-directed behavior. In people with schizophrenia, intrinsic motivation is usually subsumed as a feature of negative symptoms or underlying neurocognitive dysfunction. A growing literature reflects an interest in defining and measuring motivational impairment in schizophrenia and in delineating the specific role of intrinsic motivation as both an independent predictor and a mediator of psychosocial functioning. This cross-sectional study examined intrinsic motivation as a predictor of vocational outcomes for 145 individuals with schizophrenia and schizoaffective disorder participating in a 6-month work rehabilitation trial. Correlation and mediation analyses examined baseline intrinsic motivation and negative symptoms in relation to work hours and work performance. Data support a significant relationship between intrinsic motivation and negative symptoms and significant correlations with outcome variables, such that lower negative symptoms and greater intrinsic motivation were associated with better work functioning. Moreover, in this sample, intrinsic motivation fully mediated the relationships between negative symptoms, work productivity, and work performance. These results have significant implications on the design of work rehabilitation interventions for people with schizophrenia and support a role for targeting intrinsic motivation directly to influence vocational functioning. Future directions for research and intervention are discussed.

Compensatory cognitive training for psychosis: who benefits? Who stays in treatment?

Enhancing cognitive performance to improve functioning in schizophrenia is a fundamental research priority. Previous investigations have demonstrated that various types of cognitive training (CT) can improve neuropsychological performance, psychosocial functioning, and psychiatric symptom severity. However, there is limited information about individual differences that may predict CT response and adherence to treatment. The purpose of this study was to identify who is likely to drop out of this type of study as well as this type of intervention and to explore individual factors predicting treatment outcome. Participants included 89 outpatients diagnosed with a primary psychotic disorder who enrolled in a randomized controlled trial of compensatory CT and were assessed at baseline, 3 months (posttest), and 6 months (follow-up). Study completers had more formal education and lower daily doses of antipsychotic medications than did dropouts with no CT exposure, but the groups did not otherwise differ. There were no significant differences between participants who completed CT and those who began CT but later dropped out. CT-associated improvement was correlated with worse baseline scores on measures of cognitive performance, symptom severity, functional capacity, and self-rated quality of life, cognitive problems, and strategy use. These results suggest that those with lower baseline functioning may have more room to improve following CT. The pattern of correlations in this sample indicated that many types of individuals can improve with CT treatment, including older patients.

Simulated job interview skill training for people with psychiatric disability: feasibility and tolerability of virtual reality training

The job interview is an important step toward successful employment and often a significant challenge for people with psychiatric disability. Vocational rehabilitation specialists can benefit from a systematic approach to training job interview skills. The investigators teamed up with a company that specializes in creating simulated job interview training to create software that provides a virtual reality experience with which learners can systematically improve their job interview skills, reduce their fears, and increase their confidence about going on job interviews. The development of this software is described and results are presented from a feasibility and tolerability trial with 10 participants with psychiatric disability referred from their vocational service programs. Results indicate that this representative sample had a strongly positive response to the prototype job interview simulation. They found it easy to use, enjoyed the experience, and thought it realistic and helpful. Almost all described the interview as anxiety provoking but that the anxiety lessened as they became more skilled. They saw the benefit of its special features such as ongoing feedback from a "coach in the corner" and from being able to review a transcript of the interview. They believed that they could learn the skills being taught through these methods. Participants were enthusiastic about wanting to use the final product when it becomes available. The advantages of virtual reality technology for training important skills for rehabilitation are discussed.

Neurocognition and occupational functioning in patients with first-episode psychosis: a 2-year follow-up study

Neurocognitive deficits are a core feature of schizophrenia that is associated with poor occupational functioning. Few studies have investigated this relationship in patients with first-episode psychosis. The current study examined the characteristics of employed and unemployed patients with first-episode psychosis at baseline and 2-year follow-up, and the predictive value of neurocognition on employment status. One-hundred and twenty-two first-episode psychosis patients were assessed with clinical and neurocognitive measures at baseline. Occupational status was assessed at baseline and 2-year follow-up. Those unemployed at baseline were rated lower on global functioning and were more likely to have a schizophrenia spectrum disorder. Total employment rates were 41% at baseline and 38% at 2-year follow-up. Four employment paths emerged at follow-up, defined as persistently employed, becoming unemployed, entering employment and persistently unemployed. The persistently employed group had the highest global functioning score. For the total sample, baseline employment status and sustained attention predicted employment status at follow-up. For those employed at baseline, better sustained attention, higher global functioning, more positive symptoms and less alcohol use predicted persistent employment at follow-up. For those unemployed at baseline, none of the variables predicted change in employment status. Implications of these results are discussed.

Efficacy and specificity of social cognitive skills training for outpatients with psychotic disorders

Psychosocial interventions that target social cognition show promise for enhancing the functional outcomes of people with psychotic disorders. This randomized controlled trial evaluated the efficacy and treatment-outcome specificity of a 24-session Social Cognitive Skills Training (SCST) that targets emotional processing, social perception, attributional bias, and mentalizing (or Theory of Mind). Sixty-eight stable outpatients with primary psychotic disorders were randomly assigned to one of four time- and group format-matched treatment conditions: (1) SCST, (2) computerized neurocognitive remediation, (3) standard illness management skills training, or (4) a Hybrid treatment that combined elements of SCST and neurocognitive remediation. The SCST group demonstrated greater improvements over time than comparison groups in the social cognitive domain of emotional processing, including improvement on measures of facial affect perception and emotion management. There were no differential benefits among treatment conditions on neurocognitive or clinical symptom changes over time. Results indicate that a targeted social cognitive intervention led to improvements in social cognition among outpatients with psychosis. Findings provide guidance for continued efforts to maximize the benefits of social cognitive interventions.

Test-performance after cognitive training in persons at risk mental state of schizophrenia and patients with schizophrenia

This exploratory study aims to examine the differential effects of a computer-based cognitive training in 'prodromal' patients (mean age 27.20 years, S.D. 5.31 years) compared with patients with full-blown schizophrenia (mean age 30.13 years, S.D. 7.77 years). Ten patients at risk for schizophrenia and 16 patients suffering from schizophrenia underwent a computerized cognitive training program (Cogpack). Cognitive functioning before and after a total of 10 training sessions was assessed by different tests controlling for memory, attention, and logical thinking. Prodromal patients turned out to be able to significantly improve their long-term memory functions and their attention after cognitive training with the Cogpack software package whereas in the group of patients with schizophrenia no improvement occurred (e.g. continuous performance test, identical pairs-subtest 'shapes': improvement from 0.73 to 0.88 in persons at risk of schizophrenia vs. no improvement in patients with schizophrenia (0.55 to 0.53). Cognitive training using Cogpack is helpful for the improvement of cognitive functioning in persons at risk of schizophrenia. Thus, the application of cognitive training should be provided as early as possible in the prodromal phases of schizophrenia in order to use the full rehabilitative potential of the patients. These results should be confirmed by further investigations including larger sample sizes.

Prospective memory deficits are associated with unemployment in persons living with HIV infection

OBJECTIVE

To determine whether deficits in prospective memory (i.e., "remembering to remember") confer an increased risk of unemployment in individuals living with chronic HIV infection.

METHODS

Fifty-nine Unemployed and 49 Employed individuals with HIV infection underwent comprehensive neuropsychological and medical evaluations, including measures of prospective memory.

RESULTS

The Unemployed participants demonstrated significantly lower performance on time- and event-based prospective memory, which was primarily characterized by errors of omission. Importantly, prospective memory impairment was an independent predictor of unemployment when considered alongside other neurocognitive abilities, mood disturbance, and HIV disease severity.

CONCLUSIONS

Prospective memory impairment is a salient predictor of unemployment in persons living with HIV infection and might be considered in screening for unemployment risk and developing vocational rehabilitation plans.

Efficacy and specificity of computer-assisted cognitive remediation in schizophrenia: a meta-analytical study

BACKGROUND

Cognitive remediation is frequently based on computerized training methods that target different cognitive deficits. The aim of this article was to assess the efficacy of computer-assisted cognitive remediation (CACR) in schizophrenia and to determine whether CACR enables selective treatment of specific cognitive domains.

METHOD

A meta-analysis was performed on 16 randomized controlled trials evaluating CACR. The effect sizes of differences between CACR and control groups were computed and classified according to the cognitive domain assessed. The possible influences of four potential moderator variables were examined: participants' age, treatment duration, weekly frequency, and control condition type. To test the domain-specific effect, the intended goal of each study was determined and the effect sizes were sorted accordingly. The effect sizes of the cognitive domains explicitly targeted by the interventions were then compared with those that were not.

RESULTS

CACR enhanced general cognition with a mean effect size of 0.38 [confidence interval (CI) 0.20-0.55]. A significant medium effect size of 0.64 (CI 0.29-0.99) was found for Social Cognition. Improvements were also significant in Verbal Memory, Working Memory, Attention/Vigilance and Speed of Processing with small effect sizes. Cognitive domains that were specifically targeted by the interventions did not yield higher effects than those that were not.

CONCLUSIONS

The results lend support to the efficacy of CACR with particular emphasis on Social Cognition. The difficulty in targeting specific domains suggests a 'non-specific' effect of CACR. These results are discussed in the light of the possible bias in remediation tasks due to computer interface design paradigms.

Rethinking schizophrenia

How will we view schizophrenia in 2030? Schizophrenia today is a chronic, frequently disabling mental disorder that affects about one per cent of the world's population. After a century of studying schizophrenia, the cause of the disorder remains unknown. Treatments, especially pharmacological treatments, have been in wide use for nearly half a century, yet there is little evidence that these treatments have substantially improved outcomes for most people with schizophrenia. These current unsatisfactory outcomes may change as we approach schizophrenia as a neurodevelopmental disorder with psychosis as a late, potentially preventable stage of the illness. This 'rethinking' of schizophrenia as a neurodevelopmental disorder, which is profoundly different from the way we have seen this illness for the past century, yields new hope for prevention and cure over the next two decades.

Cognitive training in schizophrenia: a neuroscience-based approach

Meta-analytic data from over a decade of research in cognitive remediation, when combined with recent findings from basic and clinical neuroscience, have resulted in a new understanding of the critical elements that can contribute to successful cognitive training approaches for schizophrenia. Some of these elements include: the use of computerized repetitive practice methods, high dosing schedules, a focus on sensory processing, and carefully constrained and individually adapted learning trials. In a preliminary randomized controlled trial of cognitive training exercises based on these principles, we demonstrated significant improvements in working memory, verbal learning and memory, and global cognition in patients with schizophrenia. These cognitive improvements were accompanied by neurobiological findings suggestive of learning-induced cortical plasticity. Future directions for research and essential remaining questions are discussed.