The Role of Motivation in Cognitive Remediation for People with Schizophrenia

Integrative Neuro-social cognitive Strategy Programme for Instilling REcovery (INSPIRE): a community-based cognitive remediation trial-study procotol

BACKGROUND

Adults with schizophrenia experience a range of neurocognitive problems that affect their daily functioning. Evidence for the efficacy of cognitive remediation in schizophrenia has been established, but its implementation in under-resourced community-based settings is less well-studied. In recent years, interventions have also focused on the strategy-learning approach in favor of drill-and-practice. Moreover, there is an increasing recognition to address social cognition and negative symptoms alongside neurocognition. This study attempts to carry out cognitive remediation in a community mental health setting. The Neuropsychological and Educational Approach to Remediation (NEAR) is used as the cognitive remediation intervention. Neurocognitive and social cognitive games will be introduced during the computer-assisted cognitive exercises sessions. In addition, the instructional technique will foster the use of metacognition and cognitive strategies. Moreover, metamotivation training will be the focus of some bridging sessions to enhance motivation to engage in goal-directed learning behaviors. The aims of the study are to 1) investigate the effects of cognitive remediation on neurocognition, social cognition and functional outcomes of participants with schizophrenia/schizoaffective disorders in community mental health settings; and 2) explore the mediators for change (eg: metamotivation, metacognition and negative symptoms) in cognitive performance and functional outcomes.

METHODS

This randomized controlled trial will be conducted in three Singapore Anglican Community Services (SACS) centers, where standard psychiatric rehabilitation is delivered. Participants who are randomized to the experimental arm will receive cognitive remediation and psychiatric rehabilitation, while those randomized to the control arm will receive standard psychiatric rehabilitation only. Cognitive remediation is carried out three times a week for 12 weeks. It consists of computer-assisted cognitive exercises, as well as bridging groups to aid transfer of learning to daily living. Baseline, post-intervention and eight-week follow-up measurements will be collected. Group by time differences in cognitive performance, negative symptoms, metamotivation, metacognition, functioning and recovery will be analyzed across the three time points. Mediators for improvement in cognitive performance and functioning will also be explored.

DISCUSSION

Findings of this research will add to the body of knowledge about the key therapeutic ingredients within a strategy-based cognitive remediation program and improve its implementation within under-resourced community settings.

TRIAL REGISTRATION

This study has been registered with ClinicalTrials.gov (ID: NCT06286202). Date of registration: 29 February 2024. Date of last update: 21 May 2024.

Personalized Cognitive Health in Psychiatry: Current State and the Promise of Computational Methods

BACKGROUND

Decades of research have firmly established that cognitive health and cognitive treatment services are a key need for people living with psychosis. However, many current clinical programs do not address this need, despite the essential role that an individual's cognitive and social cognitive capacities play in determining their real-world functioning. Preliminary practice-based research in the Early Psychosis Intervention Network early psychosis intervention network shows that it is possible to develop and implement tools that delineate an individuals' cognitive health profile and that help engage the client and the clinician in shared decision-making and treatment planning that includes cognitive treatments. These findings signify a promising shift toward personalized cognitive health.

STUDY DESIGN

Extending upon this early progress, we review the concept of interindividual variability in cognitive domains/processes in psychosis as the basis for offering personalized treatment plans. We present evidence from studies that have used traditional neuropsychological measures as well as findings from emerging computational studies that leverage trial-by-trial behavior data to illuminate the different latent strategies that individuals employ.

STUDY RESULT

We posit that these computational techniques, when combined with traditional cognitive assessments, can enrich our understanding of individual differences in treatment needs, which in turn can guide evermore personalized interventions.

CONCLUSION

As we find clinically relevant ways to decompose maladaptive behaviors into separate latent cognitive elements captured by model parameters, the ultimate goal is to develop and implement approaches that empower clients and their clinical providers to leverage individual's existing learning capacities to improve their cognitive health and well-being.

Measuring Cognitive Impairments Associated With Schizophrenia in Clinical Practice: Overview of Current Challenges and Future Opportunities

BACKGROUND

Cognitive impairment associated with schizophrenia (CIAS) negatively impacts daily functioning, quality of life, and recovery, yet effective pharmacotherapies and practical assessments for clinical practice are lacking. Despite the pivotal progress made with establishment of the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus Cognitive Battery (MCCB) for clinical research, implementation of the full MCCB is too time-consuming and cost-ineffective for most clinicians in clinical practice.

STUDY DESIGN

Here we discuss current assessments in relation to delivery format (interview-based and performance-based), validity, ease of use for clinicians and patients, reliability/reproducibility, cost-effectiveness, and suitability for clinical implementation. Key challenges and future opportunities for improving cognitive assessments are also presented.

STUDY RESULTS

Current assessments that require 30 min to complete would have value in clinical settings, but the associated staff training and time required might preclude their application in most clinical settings. Initial profiling of cognitive deficits may require about 30 min to assist in the selection of evidence-based treatments; follow-up monitoring with brief assessments (10-15 min in duration) to detect treatment-related effects on global cognition may complement this approach. Guidance on validated brief cognitive tests for the strategic monitoring of treatment effects on CIAS is necessary.

CONCLUSIONS

With increased advancements in technology-based and remote assessments, development of validated formats of remote and in-person assessment, and the necessary training models and infrastructure required for implementation, are likely to be of increasing clinical relevance for future clinical practice.

Effect of Computer-Assisted Cognitive Remediation Therapy on Cognition among Patients with Schizophrenia: A Pilot Randomized Controlled Trial

In schizophrenia, cognition is closely linked to social competence and influences long-term prognosis. Thus, treatment should target cognitive improvement to enhance the patient's societal adaptation. This study evaluated the effects of computer-assisted cognitive remediation therapy (CR) using RehaCom® on cognition in patients with schizophrenia. Thirty patients were randomized, with 15 assigned to the CR and treatment as usual (TAU) group and 15 to the TAU-alone group. Over 12 weeks, patients received CR twice weekly, including two computer sessions and one verbal session. The outcomes measured were cognition using the Brief Assessment of Cognition in Schizophrenia and Schizophrenia Cognition Rating Scale, intrinsic motivation using the Quality of Life Scale and Intrinsic Motivation Inventory, psychiatric symptoms using the Positive and Negative Syndrome Scale, negative symptoms using the Scale for the Assessment of Negative Symptoms, and functional level using the modified Global Assessment of Functioning scale for Functioning. The CR + TAU group demonstrated considerable improvements in cognition, intrinsic motivation, and functional level compared to the TAU-alone group. These findings indicate that the CR using RehaCom® enhances cognition and other outcomes in schizophrenia.

Effect of individualized occupational therapy on cognition among patients with schizophrenia: A randomized controlled trial

This study aimed to evaluate the feasibility and efficacy of individualized occupational therapy (IOT) plus group occupational therapy (GOT) as standard care for cognition compared to GOT alone, and to determine which IOT component has the greatest effect on cognitive outcome in patients with schizophrenia. This study was conducted at 14 clinical sites across Japan and enrolled recently hospitalized patients with schizophrenia. The IOT consisted of motivational interview, self-monitoring, individualized visits, craft activities, individualized psychoeducation, and discharge planning. Among the 68 patients who were randomized to the GOT + IOT group (n = 34) and GOT alone group (n = 34), 67 completed the trial (GOT + IOT group, n = 34; GOT alone group, n = 33). There were significant improvements in change from baseline to post-treatment between the groups in verbal memory, working memory, verbal fluency, attention, executive function domains, and the composite score of the Brief Assessment of Cognition in Schizophrenia (BACS). The BACS composite score was significantly associated with the number of craft activity sessions. The addition of IOT to GOT has a favorable feasibility profile and efficacy for cognition in schizophrenia. Craft activity is the most effective IOT component in improving cognition.

Intrinsic motivation predicts cognitive and functional gains during coordinated specialty care for first-episode schizophrenia

Coordinated Specialty Care (CSC) and embedded group therapeutic interventions have been effective in improving outcomes for individuals experiencing recent first-episode schizophrenia, including cognitive performance and functioning. Treatment response varies substantially, with some patients experiencing limited or no improvement. Motivation has emerged as a key determinant of treatment engagement and efficacy. However, the impact of intrinsic and extrinsic aspects of motivation has not been directly examined with treatment outcomes in first-episode schizophrenia. This study investigated whether baseline levels of intrinsic and extrinsic motivation predicted cognitive and functional gains over 6 and 12 months in CSC. Forty participants with first-episode schizophrenia completed a 12-month CSC treatment period. Baseline measures of intrinsic and extrinsic motivation were obtained for group therapeutic interventions and work/school, as well as measures of cognition and functioning (role and social) at baseline, 6 months, and 12 months. Results revealed that higher baseline scores of intrinsic motivation for group therapeutic interventions were significantly predictive of greater cognitive gains at 12 months, and a similar tendency was observed at 6 months. Additionally, baseline scores of intrinsic motivation for work/school predicted role gains at 6 months, with a similar tendency observed at 12 months. Extrinsic motivation did not consistently impact treatment outcomes, except for work/school-related extrinsic motivation, which was linked to greater social functioning gains at 12 months. These findings provide insight into the factors influencing treatment outcomes for individuals with first-episode schizophrenia and highlight the importance of intrinsic motivation as a modifiable personal variable that can enhance response to CSC.

Five Challenges in Implementing Cognitive Remediation for Patients with Substance Use Disorders in Clinical Settings

Many patients with substance use disorders (SUDs) present cognitive deficits, which are associated with clinical outcomes. Neuropsychological remediation might help rehabilitate cognitive functions in these populations, hence improving treatment effectiveness. Nardo and colleagues (Neuropsychology Review, 32, 161-191, 2022) reviewed 32 studies applying cognitive remediation for patients with SUDs. They underlined the heterogeneity and lack of quality of studies in this research field but concluded that cognitive remediation remains a promising tool for addictive disorders. We capitalize on the insights of this review to identify the key barriers that currently hinder the practical implementation of cognitive remediation in clinical settings. We outline five issues to be addressed, namely, (1) the integration of cognitive remediation in clinical practices; (2) the selection criteria and individual factors to consider; (3) the timing to be followed; (4) the priority across trained cognitive functions; and (5) the generalization of the improvements obtained. We finally propose that cognitive remediation should not be limited to classical cognitive functions but should also be extended toward substance-related biases and social cognition, two categories of processes that are also involved in the emergence and persistence of SUDs.

Perceptions of and subjective difficulties with social cognition in schizophrenia from an internet survey: Knowledge, clinical experiences, and awareness of association with social functioning

AIM

Social cognition impacts social functioning in schizophrenia; however, little is known about how patients with schizophrenia themselves perceive social cognition. This study, using an internet survey, aimed to investigate their knowledge of social cognition, clinical experiences related to social cognition, awareness of social cognition's role in one's social life, and the relationships between subjective difficulties with social cognition and social functioning.

METHODS

Data from 232 outpatients with schizophrenia (SZ) and 494 healthy controls (HC) were obtained through an internet survey and were weighted according to the demographics of the national population. A newly developed survey questionnaire on knowledge, experience, and awareness of social cognition was administered. Subjective difficulties were evaluated using the Self-Assessment of Social Cognition Impairments and the Observable Social Cognition Rating Scale.

RESULTS

Less than a quarter of both groups were familiar with the term or concept of social cognition. Less than 5% of both groups had experienced being assessed or treated for social cognition. More than half of both groups were aware of the relationship between social cognition and social functioning. The SZ group had higher levels of subjective difficulties than the HC group across all social cognitive domains. The attributional bias domain of subjective difficulties was negatively associated with social functioning.

CONCLUSION

Patients with schizophrenia had substantial subjective difficulties in social cognition, which they perceived as being related to social functioning. However, their knowledge of social cognition was limited, and the assessment and treatment might not be widespread in regular clinical practice.

Aerobic exercise and cognitive functioning in schizophrenia: An updated systematic review and meta-analysis

This study serves as an update to a recent systematic review and meta-analysis to summarize the effect of aerobic exercise on cognition in schizophrenia and determine the most effective method of aerobic exercise. We searched for controlled studies investigating the effect of aerobic exercise on cognition in schizophrenia published until January 2021. Fifteen studies were included. A random-effects model was used to estimate the standardized mean differences (SMDs) between cognitive outcomes of aerobic exercises and controls. Compared with controls, aerobic exercises resulted in significant improvements in global cognition (SMD = 0.21), attention/vigilance (SMD = 0.32), working memory (SMD = 0.27), and verbal learning (SMD = 0.30). Significant improvements in global cognition were observed with group exercise (SMD = 0.28), exercise supervised by exercise professionals (SMD = 0.27), as well as with ≥ 90 min/week (SMD = 0.26) and ≥ 12 weeks duration (SMD = 0.22). Our findings provide information beneficial for determining the most effective aerobic exercise method to improve cognition in schizophrenia.

Combining compensatory cognitive training and medication self-management skills training, in inpatients with schizophrenia: A three-arm parallel, single-blind, randomized controlled trial

OBJECTIVE

Cognitive impairment has a critical impact on functional outcomes in patients with schizophrenia. Compensatory cognitive training (CCT) has shown promise as a cognitive rehabilitation tool but little is known about its effectiveness when combined with medication self-management skills training (MSST) in patients with schizophrenia. Thus, this study compared the effects of a combined CCT and MSST with CCT and treatment as usual (TAU) on cognitive function, symptoms, and medication adherence.

METHOD

Eighty-seven inpatients with schizophrenia were randomly assigned to the TAU, CCT, or CCT + MSST groups. Assessments of cognitive function using the Brief Assessment of Cognition in Schizophrenia, symptoms using the Positive and Negative Syndrome Scale, and medication adherence using the Medication Adherence Questionnaire, were administered to all participants at baseline and at post-intervention.

RESULTS

Compared with the TAU group, the CCT group had significant improvements in verbal fluency, total cognitive function and medication adherence, and the CCT + MSST group had significant improvements in verbal fluency, total cognitive function, positive symptoms, and medication adherence. Compared with the CCT group, the CCT + MSST group had significant improvements in total cognitive function.

CONCLUSIONS

These results indicate that the integrated intervention may be more advantageous than CCT alone in improving total cognitive function and positive symptoms. Future research should seek to further explore the long-term effects of such a joint intervention.

Effects of motivation domains on social functioning in schizophrenia with consideration of the factor structure and confounding influences

In patients with schizophrenia, motivation has been assumed to act as an intervening factor between cognitive function and social functioning. Motivation is thought to comprise three domains defined by their orientations: intrinsic motivation, extrinsic motivation, and amotivation. Although these orientations can confound each other, the effects of motivation domains on social functioning remain obscure. We investigated these relationships after confirming the factor structure of social functioning using the Social Functioning Scale (SFS). A total of 97 stable outpatients with schizophrenia were recruited. In addition to the SFS, the General Causality Orientations Scale (GCOS) was used to measure the motivation domains. First, we examined the factor structure of the SFS using exploratory and confirmatory factor analyses. Next, we conducted structural equation modeling to examine the effects of motivation domains on social functioning. The SFS showed a two-factor structure: interpersonal and intrapersonal functioning. The structural equation model revealed that (1) amotivation was negatively related to both intrapersonal and interpersonal functioning, (2) intrinsic motivation was positively related only to intrapersonal functioning, and (3) extrinsic motivation was positively related only to interpersonal functioning. Each motivation domain was associated with different factors of social functioning. Future interventions aimed at improving social functioning should consider these motivation domains based on their orientations. Cognitive remediation accompanied by considerations for and approaches to each of the domains may maximize recovery in patients with schizophrenia.

Targeting Cognitive Control Deficits With Neuroplasticity-Based Computerized Cognitive Remediation in Patients With Geriatric Major Depression: A Randomized, Double-Blind, Controlled Trial

Late life major depression (LLD) is often accompanied by cognitive deficits. When patients have specific deficits in cognitive control functions (CCD), they are not only distressing and debilitating, they often predict poor clinical outcomes such as reduced response to SSRI/SNRI antidepressants, increased disability, suicide and all-cause mortality. We recently reported that in an open label trial, our treatment designed to target these specific CCD with neuroplasticity-based computerized cognitive remediation (nCCR) improved depression and CCD in patients who failed to remit with conventional antidepressant treatment. This study tested the hypothesis that in patients with LLD who have failed at least one trial of an SSRI/SNRI antidepressant at an adequate dose for at least 8 weeks, nCCR will improve both depressive symptoms and the CCD associated with poor antidepressant response (i.e. semantic strategy, inhibition of prepotent responses) more than an active control group. Participants were randomized (1:1) to receive either 30 hours/ 4 weeks of neuroplasticity based computerized cognitive remediation (nCCR) designed to target CCD, or the active control condition matched for duration, engagement, reward, computer presentation, and contact with study staff. All participants and raters were blinded. Mixed effects model analysis the time effect (week) (F(1,71.22)=25.2, p<0.0001) and treatment group X time interaction (F(1,61.8)=11.37, p=.002) reached significance indicating that the slope of decline in MADRS was steeper in the nCCR-GD group. Further, the nCCR group improved their semantic clustering strategy(t(28)=9.5; p=.006), as well as performance on the Stroop interference condition, and cognitive flexibility (Trails B). Further, results transferred to memory performance, which was not a function trained by nCCR. clinicaltrials.gov.

Aerobic exercise and cognitive functioning in schizophrenia: Results of a 1-year follow-up from a randomized controlled trial

We previously reported that adding combined, individual, and group aerobic exercise (AE) interventions to the treatment as usual (TAU) for schizophrenia showed significant improvements in cognition and other outcomes compared to those with TAU alone in a randomized controlled trial. Following the promising results of our previous study, this 1-year follow-up study evaluated the improvements in cognition and other outcomes with TAU + AE compared to those with TAU alone. Of 41 randomized patients, 40 were included in the intent-to-treat population-20 in the TAU + AE and 20 in the TAU alone; all patients completed the 1-year follow-up. Mixed models were applied to assess changes in outcome measures over time from baseline to 1-year follow-up. At 1-year follow-up, the TAU + AE demonstrated significant group by time interaction effects in several cognitive domains, intrinsic motivation, negative symptom, interpersonal relations, and functional outcome compared with the TAU alone. Our results demonstrate that the improvements in cognition and other outcomes with TAU + AE were maintained and that functional outcome improved over 1-year follow-up. These findings show that the improvements sustained for each outcome over 1 year have the potential to offer opportunities for greater transitions to improvement of functional outcome.

The cognitive training version of the MUSIC® model of motivation inventory: A follow-up validity study

Further validation of the MUSIC® Model of Motivation Inventory (MMI) for use in Cognitive Remediation (CR) for schizophrenia is needed. The MMI was compared to the Intrinsic Motivation Inventory - Schizophrenia Research and Perceived Competency Scale following early treatment exposure in a CR clinical trial. MMI Usefulness, Success, and Interest scales were significantly correlated with corresponding comparison scales. The MMI was not correlated with pre-morbid cognitive ability. Higher expectancy for success and perceived usefulness were significantly associated with greater intensity of session attendance. Results support the convergent, divergent, and predictive validity of the MMI for CR research and clinical use.

Evaluation of a plasticity-based cognitive training program in schizophrenia: Results from the eCaesar trial

OBJECTIVE

Cognitive impairment in schizophrenia is a core feature of the disorder. Computerized cognitive training has shown promise in pilot studies. A 26-week randomized blinded placebo-controlled trial was conducted to investigate the effect of a novel computerized cognitive training program on cognitive and functional capacity outcomes.

METHOD

The study followed MATRICS guidelines for the evaluation of interventions designed to improve cognitive function in schizophrenia. Participants (N = 150) were randomized to experimental (computerized cognitive training in a game-like format) or active control (computer games) groups. Training was conducted in-clinic, with an intended training schedule of 5 days per week, 1 h per day, for 26 weeks. Co-primary outcome measures were the MATRICS Consensus Cognitive Battery (MCCB) composite score and the UCSD Performance-Based Skills Assessment (UPSA-2) total score, secondary outcome measures included the Cognitive Assessment Interview (CAI) and the Short-Form-12 Mental Composite Score (SF-12 MCS). Target engagement was assessed with task-learning based assessment.

RESULTS

At baseline, the groups were well matched. No significant effect of the experimental treatment was seen on the primary or secondary outcome measures compared to the active control. Review of the task learning/target engagement data suggested inadequate target engagement.

CONCLUSIONS

Results do not support a cognitive or functional capacity benefit from this implementation of a computerized cognitive training program in people with schizophrenia. In future trials, careful consideration is merited of the assessment of task learning/target engagement, the effects of making the cognitive training game-like on motivation, and the implicit effects of trial requirements on participant selection.

Motivation and engagement during cognitive training for schizophrenia spectrum disorders

Background

Motivation and engagement are important factors associated with therapeutic outcomes in cognitive training for schizophrenia. The goals of the present report were to examine relations between objective treatment engagement (number of sessions attended, amount of homework completed) and self-reported motivation (intrinsic motivation and perceived competence to complete cognitive training) with neurocognitive and functional outcomes from cognitive training.

Methods

Data from a clinical trial comparing two cognitive training approaches in schizophrenia-spectrum disorders were utilized in the current report (n = 38). Relations were examined between baseline intrinsic motivation, perceived competence, homework completion, and session attendance with improvements in neurocognition, functional competence, and community functioning.

Results

Number of sessions attended (r = 0.38) and time doing homework (r = 0.51) were significantly associated with improvements in neurocognition. Homework completion was associated with change in community functioning at a trend-level (r = 0.30). Older age was associated with greater treatment engagement (β = 0.37) and male biological sex was associated with greater self-reported motivation (β = 0.43). Homework completion significantly mediated the relationship between session attendance and neurocognitive treatment outcomes.

Conclusions

Objective measures of treatment engagement were better predictors of treatment outcomes than subjective measures of motivation. Homework completion was most strongly related to treatment outcomes and mediated the relationship between session attendance and treatment outcomes, suggesting continued engagement with cognitive stimulation may be an especially important component of cognitive remediation programs. Future research should examine methods to improve homework completion and session attendance to maximize therapeutic outcomes.

Training engagement, baseline cognitive functioning, and cognitive gains with computerized cognitive training: A cross-diagnostic study

Computerized cognitive training (CCT) interventions are increasing in their use in outpatient mental health settings. These interventions have demonstrated efficacy for improving functional outcomes when combined with rehabilitation interventions. It has recently been suggested that patients with more cognitive impairment have a greater therapeutic response and that reduced engagement in training can identify cases who manifest low levels of benefit from treatment. Participants were psychiatric rehabilitation clients, with diagnoses of major depression, bipolar disorder and schizophrenia. Newly admitted cases received CCT, delivered via Brain HQ, with cognitive functioning divided into groups on the basis of a BACS t-score of 40 or less vs. more. Training engagement was indexed by the number of training levels achieved per day trained. Forty-nine cases trained on average for 17 days and completed a mean of 150 levels. Overall, patients improved by an average of 4.4 points (0.44 SD) in BACS t-scores (p < .001). Improvements were positively correlated with training engagement (r = 0.30, p < .05), but not with days trained (r = 0.09) or levels earned (r = 0.03) alone. Patients with higher levels of baseline cognitive performance had reduced cognitive gains (p < .003), but did not have less training engagement (p = .97). Diagnoses did not predict cognitive gains (p = .93) or target engagement (p = .74). Poorer performance at baseline and higher levels of training engagement accounted for >10% in independent variance in cognitive gains. The mean level of cognitive improvement far exceeded practice effects. The index of engagement, levels achieved per training day, is easily extracted from the training records of patients, which would allow for early and continuous monitoring of treatment engagement in CCT activities and therapist intervention as needed to improve engagement.

Cognitive remediation in large systems of psychiatric care

IntroductionWith the increasing enthusiasm to provide cognitive remediation (CR) as an evidence-based practice, questions arise as to what is involved in implementing CR in a large system of care. This article describes the first statewide implementation of CR in the USA, with the goal of documenting the implementation issues that care providers are likely to face when bringing CR services to their patients.

METHODS

In 2014, the New York State Office of Mental Health set up a Cognitive Health Service that could be implemented throughout the state-operated system of care. This service was intended to broadly address cognitive health, to assure that the cognitive deficits commonly associated with psychiatric illnesses are recognized and addressed, and that cognitive health is embedded in the vocabulary of wellness. It involved creating a mechanism to train staff to recognize how cognitive health could be prioritized in treatment planning as well as implementing CR in state-operated adult outpatient psychiatry clinics.

RESULTS

By 2017, CR was available at clinics serving people with serious mental illness in 13 of 16 adult Psychiatric Centers, located in rural and urban settings throughout New York state. The embedded quality assurance program evaluation tools indicated that CR was acceptable, sustainable, and effective.

CONCLUSIONS

Cognitive remediation can be feasibly implemented in large systems of care that provide a multilevel system of supports, a training program that educates broadly about cognitive health and specifically about the delivery of CR, and embedded, ongoing program evaluation that is linked to staff supervision.

Factors Associated With Response and Resistance to Cognitive Remediation in Schizophrenia: A Critical Review

Cognitive impairment is a central feature of schizophrenia and has shown to play a crucial role in the psychosocial function of the disorder. Over the past few years, several cognitive remediation (CR) interventions have been developed for schizophrenia, whose effectiveness has also been widely demonstrated by systematic reviews and meta-analysis studies. Despite these evidences, many questions remain open. In particular, the identification of CR response predictors in patients with schizophrenia is still a topic with equivocal findings and only a few studies have looked for the relationship between CR response or resistance and the biological, socio-demographic, clinical and cognitive features in schizophrenia. The current knowledge on positive or negative response predictors to CR treatment in schizophrenia include: age, duration of illness, premorbid adjustment, baseline cognitive performance, intrinsic motivation, hostility, disorganized symptoms, neurobiological reserve, genetic polymorphisms, the amounts of antipsychotics, the type of CR, etc. The aim of this review is to identify neurobiological, psychopathological, cognitive, and functional predictors of CR response or resistance in schizophrenia, taking into account both cognitive and functional outcome measures. The information obtained could be very useful in planning integrated and personalized interventions, also with a better use of the available resources.

Effectiveness of Cognitive Remediation in Early Versus Chronic Schizophrenia: A Preliminary Report

Background: Many evidences have demonstrated the effectiveness of cognitive remediation on cognition and functioning in patients with schizophrenia. Some researchers speculate that cognitive deficits are more amenable to remediation during earlier phases of illness than in chronicity. Therefore, cognitive rehabilitation should be used as an early intervention, seeking to produce durable functional changes in the early course of schizophrenia. Although there is strong evidence that cognitive remediation is effective in adult schizophrenia, there is little evidence about its efficacy and long-term generalized effectiveness in the early course of the disease. In this paper, we intended to investigate the possibility that cognitive remediation may produce more beneficial effects when applied in the early phase of the illness compared to chronic patients. Materials and methods: Data were gathered from a database used for a previous study performed by our group, in which 56 patients with schizophrenia received a cognitive remediation intervention. In a post hoc analysis, patients with a duration of illness shorter than 5 years were defined as "early course" patients, while patients with a duration of illness longer than 5 years were defined as "chronic." Clinical, neuropsychological, and functional outcome variables were assessed at baseline and after treatment. Result: Of the 56 patients included in the study, 11 were "early course" and 45 were "chronic." Both the early course group and the chronic group showed significant improvements in all the clinical, neurocognitive, and functional parameters analyzed. A significantly greater improvement in early course patients compared with chronic patients emerged in clinical and functional measures. No differential change was observed between early course patients and chronic patients in the cognitive composite score. Conclusion: Our study confirms the effectiveness of cognitive remediation in improving clinical, cognitive, and functional parameters in patients with schizophrenia, both in patients in the early course and in chronic patients. However, patients in the early course showed a differential, greater change in clinical and functional parameters compared to chronic patients. Although this study has some limitations, it confirms the effectiveness of cognitive remediation interventions, particularly if applied in the early course of the illness.

The Efficacy, Feasibility And Acceptability Of A Remotely Accessible Use Of CIRCuiTS, A Computerized Cognitive Remediation Therapy Program For Schizophrenia: A Pilot Study

INTRODUCTION

The Computerized Interactive Remediation of Cognition - Training for Schizophrenia (CIRCuiTS) is a form of cognitive remediation therapy developed to target neurocognitive and metacognitive deficits of people with schizophrenia, which have a detrimental impact on real-life functioning. The English version of CIRCuiTS demonstrated good acceptability and feasibility. A recent randomized controlled trial provided evidence that the program improves memory and functioning, and that the impact on functional outcome is mediated by metacognition. The next steps in the development of CIRCuiTS include both: 1) the translation and adaptation of the program in different cultural settings; and 2) the demonstration of feasibility, acceptability and effectiveness of a standardized method to administer CIRCuiTS remotely.

PURPOSE

To implement the CIRCuiTS Italian version and to assess acceptability, feasibility and efficacy of a standardized method to administer CIRCuiTS remotely.

METHODS

Participants were assessed at baseline and received up to 40 CIRCuiTS therapy sessions, three times a week, for about 1 hr over a three-month period. Participants were reassessed post-treatment.

RESULTS

The program demonstrated good feasibility and high acceptability when assessed by the number of dropouts and evaluation of patients' satisfaction. Participants improved in learning, speed of processing, working memory and executive control. They showed a reduction in disorganization and improvement in self-esteem, functional capacity, and real-life functioning.

CONCLUSION

In this study, a standardized protocol for using CIRCuiTS from home was implemented. The first set of data showed in the paper is encouraging. The proposed procedure could lead to a dropout reduction while maintaining the efficacy of the program.

The nuts and bolts of Cognitive Remediation: Exploring how different training components relate to cognitive and functional gains

BACKGROUND

Cognitive Remediation (CR) is an evidence based treatment targeting cognitive and functional difficulties in people with psychosis. Despite the large number of effectiveness studies, only limited evidence exists for the active ingredients of this therapy. This study begins to fill this gap by exploring the relationship between CR ingredients, including alliance with a therapist, and therapy outcomes.

METHOD

This is a secondary analysis based on data from a published randomised controlled trial comparing CR+treatment-as-usual (TAU) to TAU alone. We considered the association between CR active ingredients including errorless learning, massed practice, strategy use and therapeutic alliance on the cognitive, functioning and symptom outcomes that significantly improved following therapy.

RESULTS

Forty-six of the 96 participants were randomised to CR. After therapy the CR group showed significant improvement in non-verbal memory, functioning and approaching significance, improvements in executive functions. All therapy ingredients were inter-related but strategy use alone was associated therapeutic alliance. Cognitive improvements were associated with massed practice, number of useful strategies and therapeutic alliance, but improvements in functioning were associated only with therapeutic alliance.

CONCLUSIONS

These findings build the evidence base for the usefulness of specific therapy components. As for other psychological therapies it appears that therapeutic alliance may be an important factor in driving change for key CR outcomes, particularly functioning, in people with psychosis.

The impact of intrinsic motivation on session attendance and reliable cognitive improvement in cognitive remediation in schizophrenia

OBJECTIVE

Cognitive remediation (CR) is considered a potentially effective method of improving cognitive function in people with schizophrenia. Few studies, however, have explored the role of intrinsic motivation on treatment utilization or training outcomes in CR in this population. This study explored the impact of task-specific intrinsic motivation on attendance and reliable cognitive improvement in a controlled trial comparing CR with a computer game (CG) playing control.

METHODS

Forty-nine participants with schizophrenia or schizoaffective disorder, allocated to 10 weeks of group-based CR (n = 25) or CG control (n = 24), provided complete outcome data at baseline. Forty-three participants completed their assigned intervention. Cognition, psychopathology and intrinsic motivation were measured at baseline and end-treatment. Regression analyses explored the relative contribution of baseline motivation and other clinical factors to session attendance as well as the association of baseline and change in intrinsic motivation with the odds of reliable cognitive improvement (calculated using reliable change indices).

RESULTS

Baseline reports of perceived program value were the only significant multivariable predictor of session attendance when including global cognition and psychiatric symptomatology. The odds of reliable cognitive improvement significantly increased with greater improvements in program interest and value from baseline to end-treatment. Motivational changes over time were highly variable between participants.

CONCLUSION

Task-specific intrinsic motivation in schizophrenia may represent an important patient-related factor that contributes to session attendance and cognitive improvements in CR. Regular evaluation and enhancement of intrinsic motivation in cognitively enhancing interventions may optimize treatment engagement and the likelihood of meaningful training outcomes.

Objective investigation of activity preference in schizophrenia: A pilot study

Amotivation and reduced goal-directed activity engagement are prominent features of schizophrenia. Previous investigations of patients' activities have relied on accounts of daily living activities, rather than objective measures. This study used wireless motion capture to objectively evaluate activity preference when individuals are provided an explicit choice between an active versus passive engagement option. Twenty outpatients with schizophrenia and twenty matched healthy controls completed the Activity Preference Task, in which participants play a motion-based game (active) or watch a film (passive), and were administered clinical and cognitive assessments. Schizophrenia participants' duration, intensity, and persistence of active engagement were associated with apathy and community functioning. No group differences emerged from comparisons of task measures; however, exploratory cluster analysis identified a distinct subgroup of schizophrenia patients with reduced engagement and increased apathy compared to other patients and controls. The Task provides a means of quantifying activity engagement, which may be particularly valuable given the lack of objective measures for intrinsically motivated behaviours. Our initial findings suggest that schizophrenia patients as a group are equally inclined as healthy individuals towards actively engaging activities when presented an explicit choice, but such provision may be insufficient for initiation and maintenance of functional behaviours among amotivated patients.

Computer-assisted cognitive remediation therapy in schizophrenia: Durability of the effects and cost-utility analysis

The durability of computer-assisted cognitive remediation (CACR) therapy over time and the cost-effectiveness of treatment remains unclear. The aim of the current study is to investigate the effectiveness of CACR and to examine the use and cost of acute psychiatric admissions before and after of CACR. Sixty-seven participants were initially recruited. For the follow-up study a total of 33 participants were enrolled, 20 to the CACR condition group and 13 to the active control condition group. All participants were assessed at baseline, post-therapy and 12 months post-therapy on neuropsychology, QoL and self-esteem measurements. The use and cost of acute psychiatric admissions were collected retrospectively at four assessment points: baseline, 12 months post-therapy, 24 months post-therapy, and 36 months post-therapy. The results indicated that treatment effectiveness persisted in the CACR group one year post-therapy on neuropsychological and well-being outcomes. The CACR group showed a clear decrease in the use of acute psychiatric admissions at 12, 24 and 36 months post-therapy, which lowered the global costs the acute psychiatric admissions at 12, 24 and 36 months post-therapy. The CACR is durable over at least a 12-month period, and CACR may be helping to reduce health care costs for schizophrenia patients.

Pharmacological Augmentation of Psychosocial and Remediation Training Efforts in Schizophrenia

Pharmacological approaches to cognitive enhancement have received considerable attention but have not had considerable success in improving their cognitive and functional targets. Other intervention strategies, such as cognitive remediation therapy (CRT), have been shown to enhance cognitive performance but have not been found to improve functional outcomes without additional psychosocial interventions. Recently, several studies have attempted to enhance the effects of CRT by adding pharmacological interventions to the CRT treatments. In addition, as CRT has been shown to synergistically improve the effects of psychosocial interventions, the combination of pharmacological therapies aimed at cognition and psychosocial interventions may itself provide a promising strategy for improving functional outcomes. This review and commentary examines the current state of interventions combining CRT and psychosocial treatments with pharmacological augmentation. Our focus is on the specific level of effect of the pharmacological intervention, which could be enhancing motivation, training efficiency, or the consolidation of therapeutic gains. Different pharmacological strategies (e.g., stimulants, plasticity-inducing agents, or attentional or alertness enhancers) may have the potential to lead to different types of gains when combined with CRT or psychosocial interventions. The relative potential of these different mechanisms for immediate and durable effects is considered.

Insights About Striatal Circuit Function and Schizophrenia From a Mouse Model of Dopamine D2 Receptor Upregulation

The dopamine hypothesis of schizophrenia is supported by a large number of imaging studies that have identified an increase in dopamine binding at the D₂ receptor selectively in the striatum. We review a decade of work using a regionally restricted and temporally regulated transgenic mouse model to investigate the behavioral, molecular, electrophysiological, and anatomical consequences of selective D₂ receptor upregulation in the striatum. These studies have identified new and potentially important biomarkers at the circuit and molecular level that can now be explored in patients with schizophrenia. They provide an example of how animal models and their detailed level of neurobiological analysis allow a deepening of our understanding of the relationship between neuronal circuit function and symptoms of schizophrenia, and as a consequence generate new hypotheses that are testable in patients.

Cognitive remediation therapy (CRT) as a treatment enhancer of eating disorders and obsessive compulsive disorders: study protocol for a randomized controlled trial

BACKGROUND

Anorexia nervosa (AN) and Obsessive Compulsive Disorder (OCD) are among the most incapacitating and costly of mental disorders. Cognitive Behaviour Therapy (CBT), medication, and combination regimens, to which in AN personalised guidance on weight control is added, are moderately successful, leaving room for more effective treatment algorithms. An underlying deficit which the two disorders share is cognitive inflexibility, a trait that is likely to impede treatment engagement and reduce patients' ability to benefit from treatment. Cognitive remediation therapy (CRT) is an easy-to-use intervention aimed at reducing cognitive inflexibility and thereby enhancing treatment outcome, which we aim to test in a controled study.

METHODS

In a randomized-controlled multicenter clinical trial 64 adult patients with AN and 64 with OCD are randomized to 10 bi-weekly sessions with either CRT or a control condition, after which Treatment As Usual (TAU) is started. All patients are evaluated during single-blind assessments at baseline, post-CRT/control intervention, and after 6 months. Indices of treatment effect are disorder-specific symptom severity, quality of life, and cost-effectivity. Also, moderators and mediators of treatment effects will be studied.

DISCUSSION

To our knowledge, this is the first randomized controlled trial using an control condition evaluating the efficacy and effectiveness of CRT as a treatment enhancer preceding TAU for AN, and the first study to investigate CRT in OCD, moreover taking cost-effectiveness of CRT in AN and OCD into account.

TRIAL REGISTRATION

The Netherlands Trial Register NTR3865 . Registered 20 february 2013.

Personalised treatment for cognitive dysfunction in individuals with schizophrenia spectrum disorders

Cognitive deficits are a well-recognised issue for individuals diagnosed with schizophrenia spectrum disorders. Despite positive group findings for the use of cognitive remediation (CR) interventions, there are substantial individual differences in response to treatment. In addition, the aggregate CR literature reports low moderate effect sizes for cognitive and functional outcomes. Based on personalised medicine theory, this paper uses extant CR literature to examine the individual characteristics determined to predict treatment response. These characteristics, which fall into the broad categories of cognitive, psychological, and biological can be used as tailoring variables to personalise CR to an individual's unique profile. Personalisation through the use of these tailoring variables has the potential to improve the delivery of CR to maximise treatment outcomes.

Benefits of group cognitive remediation therapy in anorexia nervosa: case series

Background

Cognitive remediation therapy (CRT) is a treatment targeting cognitive difficulties in psychiatric disorders. CRT has been used with patients with severe anorexia nervosa (AN) in individual and group formats. Research of group CRT in AN is limited.

Methods

Evaluation of a series of CRT groups delivered in inpatient and intensive daycare services was performed. Participants’ self-reported cognitive flexibility and central coherence, as well as motivation to change were assessed pre- and post-group. Additionally, patients’ evaluative feedback was collected after completion of the group.

Results

There was a significant improvement in the patients’ self-reported cognitive flexibility and bigger picture thinking, as well as in their self-efficacy to change. The feedback questionnaires highlighted that patients found the sessions useful and reported confidence in using some of the skills and strategies they learnt in the group.

Conclusion

In line with evidence from small-scale reports, this larger scale case series study indicates that group CRT leads to increased flexibility and bigger picture thinking, as well as improved confidence in the ability to change for participants. CRT in a group format seems to be a practical and helpful intervention for patients with AN in intensive treatment programmes.