Effects of cognitive remediation therapies on psychotic symptoms and cognitive complaints in patients with schizophrenia and related disorders: a randomized study

Investigating subjective cognitive complaints in psychosis: Introducing the brief scale to Investigate cognition in schizophrenia (SSTICS-Brief)

Background: Cognitive difficulties are a core deficit for people with schizophrenia and are generally assessed with neuropsychological tests. Self-report assessments are also useful in understanding difficulties from the service user's perspective. This study aims to introduce and test the shorter version of the Subjective Scale to Investigate Cognition in Schizophrenia (SSTICS) to improve its acceptability and comprehensibility.Methods: In consultation with service users and clinicians, we identified items from the original 21-item SSTICS that were found difficult and these were excluded. The reduced scale was explored with Confirmatory Factor Analysis (CFA) in two independent samples in the UK and Canada. Convergent validity with symptoms and IQ was assessed and compared between the original and the reduced scale.Results: Six-hundred and seven people with schizophrenia and first-episode psychosis took part in this study. Seven items were removed to produce the SSTICS-Brief. This had good reliability and the CFA confirmed a unidimensional structure. Convergent validity with symptoms and IQ were optimal between the long and short versions.Conclusions: The SSTICS-B has better acceptability than its longer form and could be administered in less time. The resulting measure is likely to be a valuable short self-assessment of cognitive complaints for people with schizophrenia.

How does awareness of cognitive impairment impact motivation and treatment outcomes during cognitive remediation for schizophrenia?

BACKGROUND

There is concern that awareness of cognitive deficit among people with schizophrenia receiving Cognitive Remediation (CR) might undermine motivation, engagement, and CR outcomes. We therefore examined the relationship of subjective awareness of cognitive deficit to aspects of motivation and cognitive learning during an efficacious CR program.

METHODS

Individuals with schizophrenia/schizoaffective disorder who completed 30 sessions of CR (N = 67) were evaluated on cognitive performance, self-reported cognitive difficulties, intrinsic motivation and perceived competency for cognitive training tasks at the beginning and end of treatment.

RESULTS

We found no relationship between actual and perceived cognitive functioning when measured cross-sectionally or as difference scores, pre/post treatment. Greater awareness of cognitive problems was associated with lower perceived competency for cognitive tasks at treatment beginning and end-point (p-values < .05). The significant relationship between awareness of cognitive problems and perceived value of the treatment at end-point was fully mediated by perceived competency. While greater perceived competency was associated with shorter time to treatment completion (p = .0025), it was intrinsic motivation measured at end-point that was associated with cognitive change (p = .02).

DISCUSSION

While awareness of cognitive problems may not be a prerequisite for cognitive improvement during CR, it could impact engagement in, and how one values treatment via its effect on perceived competency. Results also highlighted the importance of intrinsic motivation for doing cognitive learning activities, given its relationship to cognitive gain. Further study is needed to understand how best to assess and address awareness of cognitive abilities within the CR setting.

Effects of peer social interaction on performance during computerized cognitive remediation therapy in patients with early course schizophrenia: A pilot study

BACKGROUND

Recent studies show that computer-based training enhances cognition in schizophrenia; furthermore, socialization has also been found to improve cognitive functions. It is generally believed that non-social cognitive remediation using computer exercises would be a pre-requisite for therapeutic benefits from social cognitive training. However, it is also possible that social interaction by itself enhances non-social cognitive functions; this possibility has scarcely been explored in schizophrenia patients. This pilot study examined the effects of computer-based neurocognitive training, along with social interaction either with a peer (PSI) or without one (N-PSI). We hypothesized that PSI will enhance cognitive performance during computerized exercises in schizophrenia, as compared with N-PSI.

METHODS

Sixteen adult participants diagnosed with schizophrenia or schizoaffective disorder participating in an ongoing trial of Cognitive Enhancement Therapy completed several computerized neurocognitive remediation training sessions (the Orientation Remedial Module©, or ORM), either with a peer or without a peer.

RESULTS

We observed a significant interaction between the effect of PSI and performance on the different cognitive exercises (p<0.05). More precisely, when patients performed the session with PSI, they demonstrated better cognitive performances than with N-PSI in the ORM exercise that provides training in processing speed, alertness, and reaction time (the standard Attention Reaction Conditioner, or ARC) (p<0.01, corrected). PSI did not significantly affect other cognitive domains such as target detection and spatial attention.

CONCLUSION

Our findings suggest that PSI could improve cognitive performance, such as processing speed, during computerized cognitive training in schizophrenia. Additional studies investigating the effect of PSI during cognitive remediation are needed to further evaluate this hypothesis.

Room to move: Plasticity in early auditory information processing and auditory learning in schizophrenia revealed by acute pharmacological challenge

Many patients with chronic psychotic disorders including schizophrenia (SZ) maintain meaningful levels of plasticity (i.e., capacity for change) within neurocognition-relevant brain mechanisms, as evidenced by gains in neurocognition and function after interventions such as targeted cognitive training. However, like many clinical features of these disorders, therapeutic responses in SZ are heterogeneous, and prospectively identifying treatment-sensitive individuals and individualized treatment modalities remains an unmet challenge. We propose that available plasticity in neurocognition-relevant brain mechanisms in individual SZ patients can be detected by gains in laboratory measures of early auditory information processing (EAIP) and auditory learning after a single challenge-dose of a pharmacologic agent; here, we present supportive data for this strategy with the non-competitive NMDA antagonist, memantine, and the psychostimulant, amphetamine. We describe a novel therapeutic model where this "challenge dose" strategy is used to prospectively identify a sensitive cohort of patients, and in these patients, a therapeutic response is elicited by pairing drug-enhanced EAIP and auditory learning with auditory-based targeted cognitive training.

Feasibility and acceptability of brief cognitive remediation targeting metacognition in acute inpatients with psychosis: a case series

Cognitive remediation (CR) is an intensive intervention targeting cognitive impairment with the aim of improving functioning in people with psychotic disorders. Shorter forms of CR based on metacognition and targeting awareness of cognitive problems may be more appropriate for acute inpatient settings where time is limited. The objective of the study was to evaluate the feasibility and acceptability of a new brief course of CR targeting cognitive and metacognitive difficulties within an acute inpatient psychiatric setting. Thirteen male service users with psychosis received a three-week course of CR. Participants were assessed at baseline and post-treatment on cognitive measures, subjective cognitive complaints, functional impairment, and symptom severity. Feasibility was assessed based on engagement, attendance, and attrition. Acceptability was evaluated through treatment satisfaction. Eight participants completed therapy, with 81% session attendance. Therapy was considered acceptable, with the majority of participants considering it satisfactory. Potential benefit analysis showed a significant post-treatment improvement in global cognition and memory. Subjective cognitive complaints did not change over time. It was concluded that it is feasible to deliver brief CR in an acute inpatient setting. Context of delivery and engagement are challenges for optimal therapy implementation. CR protocol adaptations made to promote metacognitive competencies may compensate for lack of intensive practice.

A survey of eMedia-delivered interventions for schizophrenia used in randomized controlled trials

BACKGROUND

Randomized trials evaluating electronic Media (eMedia) delivery of interventions are increasingly frequent in mental health. Although a number of reviews have reported efficacy of these interventions, none has reviewed the type of eMedia interventions and quality of their description. We therefore decided to conduct a survey of eMedia-delivered interventions for schizophrenia.

METHODS

We surveyed all relevant trials reliably identified in the Cochrane Schizophrenia Group's comprehensive register of trials by authors working independently. Data were extracted regarding the size of the trial, interventions, outcomes and how well the intervention was described.

RESULTS

eMedia delivery of interventions is increasingly frequent in trials relevant to the care of people with schizophrenia. The trials varied considerably in sample sizes (mean =123, median =87, range =20-507), and interventions were diverse, rarely evaluating the same approaches and were poorly reported. This makes replication impossible. Outcomes in these studies are limited, have not been noted to be chosen by end users and seem unlikely to be easy to apply in routine care. No study reported on potential adverse effects or cost, end users satisfaction or ease of use. None of the papers mentioned the use of CONSORT eHealth guidelines.

CONCLUSION

There is a need to improve reporting and testing of psychosocial interventions delivered by eMedia. New trials should comply with CONSORT eHealth guidance on design, conduct and reporting, and existing CONSORT should be updated regularly, as the field is constantly evolving.

Are Group Psychotherapeutic Treatments Effective for Patients with Schizophrenia? A Systematic Review and Meta-Analysis

BACKGROUND

Different psychotherapeutic treatments for schizophrenia are delivered in groups. However, little is known about the effectiveness of these group therapies for people with schizophrenia across different treatments with varying therapeutic orientations. This review aimed to (1) estimate the effect of different group psychotherapeutic treatments for schizophrenia and (2) explore whether any overall 'group effect' is moderated by treatment intensity, diagnostic homogeneity and therapeutic orientation.

METHODS

A systematic search of randomised controlled trials exploring the effectiveness of group psychotherapeutic treatments for people with schizophrenia was conducted. Random-effect meta-analyses on endpoint symptom scores compared group psychotherapeutic treatments with treatment as usual and active sham groups. Findings on social functioning were described narratively, and meta-regression analyses on group characteristics were carried out.

RESULTS

Thirty-four eligible trials were included. A weak-to-moderate significant between-group difference in favour of group psychotherapeutic treatments was found for negative symptom scores (standard mean difference = -0.37, 95% confidence interval -0.60, -0.14; p < 0.01, I(2) = 59.8%) only when compared to treatment as usual and not to active sham groups. Improved social functioning was reported as a treatment outcome in the majority of studies compared to treatment as usual. The 'group effect' on negative symptoms was positively related to 'treatment intensity' (β = 0.32, standard error = 0.121; p < 0.05).

CONCLUSION

Group psychotherapeutic treatments can improve negative symptoms and social functioning deficits in the treatment of schizophrenia. The effect occurs across different treatments and appears to be non-specific. Future research should identify the underlying mechanisms for the positive effect of participating in groups and explore how they can be maximised to increase the therapeutic benefit.

A randomized study of cognitive remediation for forensic and mental health patients with schizophrenia

Cognitive remediation has proven efficacy for improving neurocognition in people with schizophrenia. The current study evaluated the benefits of cognitive remediation on neurocognition, functioning, psychotic symptoms, and aggression in a sample of forensic and mental health patients. Care recipients with schizophrenia or schizoaffective disorder (N = 78) receiving services in the forensic and mental health units of a state hospital were randomized to participate in cognitive remediation versus computer games control activities. Participants' neurocognition, functional capacity, experiential recovery, psychotic symptoms, and aggression incidents were assessed at baseline and posttreatment. Cognitive remediation was associated with improvements in several neurocognitive domains and circumscribed domains of functional capacity. People assigned to cognitive remediation experiences greater reductions in negative symptoms, agitation/excitement, and verbal and physical aggression. In addition to improving neurocognition in long-term hospitalized forensic and mental health patients, cognitive remediation may enhance efforts at reducing negative symptoms, emotion dysregulation, and aggression incidents. Forensic settings may represent a new frontier for the clinical dissemination of cognitive remediation.

Neurocognitive insight, treatment utilization, and cognitive training outcomes in schizophrenia

BACKGROUND

The degree to which people with schizophrenia show awareness of cognitive dysfunction and whether this neurocognitive insight affects treatment use or outcome is understudied. We aimed to examine neurocognitive insight among a treatment-seeking sample of patients with psychotic disorders, and whether neurocognitive insight affected treatment utilization or outcome.

METHOD

69 individuals with schizophrenia-spectrum disorders enrolled in a trial comparing Compensatory Cognitive Training (CCT) to standard pharmacotherapy. Participants with objective cognitive impairment were identified and grouped into "intact" vs. "impaired" neurocognitive insight groups. These groups were then compared via ANCOVA on three treatment utilization variables and six post-treatment cognitive/functional variables.

RESULTS

43 participants demonstrated objective cognitive impairment. Among those individuals, 31 were considered to have intact neurocognitive insight and 12 showed impaired neurocognitive insight. These two groups did not differ on CCT attendance, satisfaction with the intervention, or self-reported cognitive strategy use at post-treatment. There were significant treatment group by neurocognitive insight group interactions for verbal memory and functional capacity outcomes, such that individuals with impaired neurocognitive insight who received treatment performed better than those who did not receive treatment.

CONCLUSIONS

Even among individuals who self-select into a cognitive treatment study, many show minimal awareness of cognitive dysfunction. Impaired neurocognitive insight, however, was not associated with decreased treatment utilization, and was associated with positive treatment outcomes in some cognitive domains as well as functional capacity. As cognitive training treatments become increasingly available, impaired neurocognitive insight need not be a barrier to participation.

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.

Emotional facial expression processing in depression: data from behavioral and event-related potential studies

Behavioral literature investigating emotional processes in depressive populations (i.e., unipolar and bipolar depression) states that, compared to healthy controls, depressive subjects exhibit disrupted emotional processing, indexed by lower performance and/or delayed response latencies. The development of brain imaging techniques, such as functional magnetic resonance imaging (fMRI), provided the possibility to visualize the brain regions engaged in emotional processes and how they fail to interact in psychiatric diseases. However, fMRI suffers from poor temporal resolution and cognitive function involves various steps and cognitive stages (serially or in parallel) to give rise to a normal performance. Thus, the origin of a behavioral deficit may result from the alteration of a cognitive stage differently situated along the information-processing stream, outlining the importance of access to this dynamic "temporal" information. In this paper, we will illustrate, through depression, the role that should be attributed to cognitive event-related potentials (ERPs). Indeed, owing to their optimal temporal resolution, ERPs can monitor the neural processes engaged in disrupted cognitive function and provide crucial information for its treatment, training of the impaired cognitive functions and guidelines for clinicians in the choice and monitoring of appropriate medication for the patient.

A composite scale applied to evaluate anxiety in schizophrenic patients (SAES)

Anxiety in schizophrenia possesses specific features and is difficult to assess because no specific evaluating tool is currently available. The aim of this study was to develop and validate a hetero-assessment-based scale to specifically measure anxiety in schizophrenia. A literature review and a survey among psychiatrists allowed the selection of 29 items from 4 previous scales evaluating anxiety. Factor analysis allowed building up a final 22-item composite scale of anxiety evaluation in schizophrenia (SAES), which was then validated in 147 schizophrenic patients. One hundred and forty-seven (147) schizophrenic patients (70.8 % male, mean age = 36.9 years) were included in the study. Principal component analysis of the SAES revealed three factors, namely "expressed and perceived anxiety," "somatic anxiety," and "anxiety and environment". All total and factor scores of the SAES were significantly correlated (p < .001) with total and factor scores of the original scales. Finally, the SAES showed good inter-rater reliability [intra-class correlation coefficient (ICC) = .82]. In conclusion, a specific tool for evaluating anxiety in schizophrenia (SAES) was developed and validated in a sample of schizophrenic patients. The SAES can be useful to investigate clinical, psychopathological, and therapeutic aspects of anxiety in schizophrenia.

[Cognitive deficits in first episode psychosis patients and people at risk for psychosis: from diagnosis to treatment]

BACKGROUND

Up to now, studies have not demonstrated significant efficacy of antipsychotics on cognitive impairments in patients with psychotic disorders. These cognitive deficits are of particular interest since they traditionally start early before the diagnosis of psychosis. They are observed during premorbid and prodromal stages, and during the first episode of psychosis. Moreover, cognitive impairments may be detected without any psychotic symptoms (such as positive symptoms) suggesting their development independently of the psychotic symptoms. Cognitive disturbances consist of impairments of episodic and working memories, intellectual functioning, executive functions (planning, inhibition, and cognitive flexibility), selective and sustained attentions and social cognition (emotion, recognition, theory of mind). The altered cognitive functions observed in schizophrenia are the same as in earlier stages but at a lower level of severity.

LITERATURE FINDINGS

Data suggest that cognitive deficits can be considered as vulnerability markers of psychosis since they have been described in healthy relatives of psychotic patients with high genetic risk. Cognitive deficits might also be considered as predictive of the occurrence of the disease after the first episode of psychosis. Indeed, retrospective studies suggest cognitive impairments in patients with schizophrenia during premorbid and prodromal phases but not in bipolar patients. Cognitive assessment might be of particular interest in people at risk for psychosis, in order to differentiate diagnostic outcomes. Cognitive functioning impairs until the diagnosis of first episode psychosis, even though cognitive profiles are quite heterogeneous in these patients. Once the diagnosis of schizophrenia is considered, cognitive deficits may be stable, although the literature is still controversial. Several factors such as symptoms and gender can contribute in diversifying the cognitive profiles. Moreover, age of onset might worsen the prognosis because of a disruption of the cognitive development and the disturbance of scholarship in young individuals.

DISCUSSION

Considering these results, the treatment of cognitive deficits should be initiated as soon as possible, e.g. in people at risk for psychosis in order to reinforce the normal cognitive development, prevent cognitive decline and to preserve the educational, professional and social status. Since antipsychotic medications do not impact on cognitive functioning, alternative therapeutics should be developed such as cognitive remediation. Several studies and meta-analyses have shown that cognitive remediation programs are particularly efficient in patients with schizophrenia or bipolar disorders. Contrary to antipsychotics, these techniques should be used in patients with a first psychotic episode, but also in individuals with subpsychotic symptoms, subthreshold to the diagnosis of schizophrenia.

Working memory training in patients with chronic schizophrenia: a pilot study

Background. There is evidence that patients with schizophrenia suffer from decline in working memory performance with consequences for psychosocial outcome. Objective. To evaluate the efficacy of a computerized working memory training program (BrainStim) in patients with chronic schizophrenia. Methods. Twenty-nine inpatients with chronic schizophrenia were assigned to either the intervention group receiving working memory training (N = 15) or the control group without intervention (N = 14). Training was performed four times a week for 45 minutes during four weeks under neuropsychological supervision. At baseline and followup all participants underwent neuropsychological testing. Results. Pre-post comparisons of neuropsychological measures showed improvements in visual and verbal working memories and visual short-term memory with small and large effect sizes in the intervention group. In contrast, the control group showed decreased performance in verbal working memory and only slight changes in visual working memory and visual and verbal short-term memories after 4 weeks. Analyses of training profiles during application of BrainStim revealed increased performance over the 4-week training period. Conclusions. The applied training tool BrainStim improved working memory and short-term memory in patients with chronic schizophrenia. The present study implies that chronic schizophrenic patients can benefit from computerized cognitive remediation training of working memory in a clinical setting.

An Overview of Cognitive Remediation Therapy for People with Severe Mental Illness

Cognitive remediation refers to nonpharmacological methods of improving cognitive function in people with severe mental disorders. Cognitive remediation therapy (CRT) can be delivered via computerised programs, of varying length and complexity, or can be undertaken one-on-one by a trained clinician. There has been a considerable interest in cognitive remediation, driven by recognition that cognitive deficits are a major determinant of outcome in people with severe, chronic mental illnesses. CRT has been shown to be effective, especially if combined with vocational rehabilitation.

Why it is time to develop the use of cognitive event-related potentials in the treatment of psychiatric diseases

The relapse rate for many psychiatric disorders is staggeringly high, indicating that treatment methods combining psychotherapy with neuropharmacological interventions are not entirely effective. Therefore, in psychiatry, there is a current push to develop alternatives to psychotherapy and medication-based approaches. Cognitive deficits have gained considerable importance in the field as critical features of mental illness, and it is now believed that they might represent valid therapeutic targets. Indeed, an increase in cognitive skills has been shown to have a long-lasting, positive impact on the patients' quality of life and their clinical symptoms. We hereby present four principal arguments supporting the use of event-related potentials (ERP) that are derived from electroencephalography, which allow the identification of specific neurocognitive deficiencies in patients. These arguments could assist psychiatrists in the development of individualized, targeted therapy, as well as a follow-up and rehabilitation plan specific to each patient's deficit. Furthermore, they can be used as a tool to assess the possible benefits of combination therapy, consisting of medication, psychotherapy, and "ERP-oriented cognitive rehabilitation". Using this strategy, specific cognitive interventions could be planned based on each patient's needs, for an "individualized" or "personalized" therapy, which may have the potential to reduce relapse rates for many psychiatric disorders. The implementation of such a combined approach would require intense collaboration between psychiatry departments, clinical neurophysiology laboratories, and neuropsychological rehabilitation centers.

Theory of mind and context processing in schizophrenia: the role of cognitive flexibility

The present study sought to identify whether cognitive flexibility and context processing may impact theory of mind (ToM) ability in schizophrenia. Thirty two patients with schizophrenia and 29 matched healthy participants were tested individually on their ToM ability using a task involving attribution and comprehension of a speaker's ironic intent. This task made it possible to determine whether the degree of incongruity between contextual information and a target sentence has an impact on the attribution of ironic intent to the protagonists of a story. Participants were also assessed on their cognitive flexibility and working memory. The main results revealed that participants with schizophrenia correctly perceived contextual information cueing attribution of ironic intent to the protagonist of the stimulus, but they showed difficulty to correctly integrate this information, performing significantly worse than healthy participants when they attributed mental states. However, some participants with schizophrenia performed like healthy control participants on the ToM task while others did not. A lack of flexibility seems to differentiate the two schizophrenia subgroups thereby obtained, suggesting that cognitive flexibility has an impact on ToM performances in schizophrenia. These difficulties were not associated with clinical symptoms. Such results will have an impact on cognitive remediation.

A systematic review of cognitive remediation for schizo-affective and affective disorders

BACKGROUND

Cognitive remediation is accepted as an important therapeutic intervention in schizophrenia, but few studies provide data on whether the benefits extend to affective disorders.

OBJECTIVES

To review quantitatively studies of cognitive remediation with samples that included cases of schizoaffective disorder, affective psychosis, unipolar and/or bipolar disorders.

METHODS

Twenty one studies met preliminary inclusion criteria, comprising a total of 940 participants of which 35% had an affective or schizoaffective disorder. Effect sizes (ES) for pre- to post-intervention change in cognitive performance were estimated.

RESULTS

A meta-analysis of 16 studies gave a pooled ES for change in cognitive function of 0.32 (95% Confidence Intervals 0.20 to 0.43) and produced statistical homogeneity. Overall, ES were significantly positively correlated with higher proportion of schizo-affective and affective cases (r=0.61; p=0.007), even when age, gender and duration of therapy were included as covariates in the analysis (r=.59, p=0.017).

LIMITATIONS

The quality of and small number of affective disorder only studies mean the findings must be treated with caution.

CONCLUSIONS

The estimated ES reflect those reported in the literature on cognitive remediation for schizophrenia. As such a conservative interpretation is that cognitive remediation has at least equivalent benefits in affective and schizo-affective disorder as demonstrated in schizophrenia. Further studies are urgently required to examine the durability of any gains with cognitive remediation in affective populations and to determine if any changes in cognitive deficits lead to improvements in symptoms or functioning and/or whether post-intervention cognitive changes differ in character or magnitude from those reported in schizophrenia.

Effects of cognitive remediation on neurocognitive functions and psychiatric symptoms in schizophrenia inpatients

OBJECTIVE

Many individuals diagnosed with schizophrenia have significant neurocognitive deficits, especially in the areas of attention, memory, and executive function. These deficits may exacerbate patients' psychiatric symptoms. Cognitive remediation has shown efficacy in improving neurocognitive functioning and may lead to amelioration of psychiatric symptoms in persons with schizophrenia.

METHOD

Forty-two schizophrenic inpatients were randomly assigned to either a cognitive remediation group (n=21) or a control group (n=21) and were assessed using a neuropsychological battery and symptom scales for depression, anxiety, and positive and negative symptoms of schizophrenia at baseline and after two months of participation in a cognitive remediation program.

RESULTS

The intervention group showed significant improvements in neuropsychological functioning, depression and negative symptoms of schizophrenia after the intervention compared to the control group.

CONCLUSION

Results of the study provide support for cognitive remediation as an efficacious intervention to improve neurocognitive functioning and decrease psychiatric symptoms of schizophrenia.

Cognitive remediation: a new generation of psychosocial interventions for people with schizophrenia

Schizophrenia is a mental health condition characterized by broad impairments in cognition that place profound limitations on functional recovery. Social work has an enduring legacy in pioneering the development of novel psychosocial interventions for people with schizophrenia, and in this article the author introduces cognitive remediation, the latest advance in psychosocial treatments for the disorder designed to improve cognition. First, the author presents an overview of the nature of cognitive impairments and their functional consequences in schizophrenia, followed by a description of the theoretical basis and key practice principles of cognitive remediation. Next, the author reviews the latest biopsychosocial evidence for the efficacy of cognitive remediation in schizophrenia. Finally, the author presents a model cognitive remediation program, cognitive enhancement therapy, which was developed and evaluated by a social work-led multidisciplinary team. Cognitive enhancement therapy is a significant advance in cognitive remediation for schizophrenia and uses a unique holistic approach that extends beyond traditional neurocognitive training to facilitate the achievement of adult social-cognitive milestones and broader functional recovery. Cognitive remediation is an effective next-generation psychosocial intervention that social workers can use to help improve the lives of many people who live with schizophrenia.

Can genetics inform the management of cognitive deficits in schizophrenia?

There is no doubt that schizophrenia has a significant genetic component and a number of candidate genes have been identified for this debilitating disorder. Of note, several of these are implicated in cognition. Cognitive deficits constitute core symptoms of schizophrenia, and while current antipsychotic treatment strategies aim to help psychosis-related symptomatology, the cognitive symptom domain is largely inadequately treated. A number of other pharmacological approaches (e.g. using drugs that target specific neurotransmitter systems) have also been attempted for the amelioration of cognitive deficits in this population; however, these too have had limited success so far. Psychological interventions appear promising, though there has been speculation regarding whether or not these produce long-term functional improvements. Pharmacogenetic studies of the cognitive effects of currently available antipsychotics, although in relatively early stages, suggest that the treatment of cognitive deficits in schizophrenia may be advanced by focusing on genetic variants associated with specific cognitive dysfunctions in the general population and using this to match the most relevant pharmacological and/or psychological interventions with the genetic and cognitive profiles of the target population. Such a strategy would encourage bottom-up advances in drug development and provide a platform for individualised treatment of cognitive deficits in schizophrenia.

The Effectiveness of the Attention Training Technique in Reducing Intrusive Thoughts in Schizophrenia

The aim of this study was to investigate the effectiveness of the attention training technique (ATT) on the frequency of intrusive thoughts experienced by a person with schizophrenia in her daily life. The attentional procedure was designed to attenuate self-focused attention and to reinforce attentional control and consisted of auditory external exercises. Homework practice was included to promote transfer to everyday life. The efficacy and specificity of the ATT were assessed with cognitive, functional, and control measures. The impact of ATT on symptomatology, work functioning, and self-esteem was also measured. Postrehabilitation results showed that, after nine training sessions, there was a reduction in intrusive thoughts for the cognitive and ecological outcome measures. Selective attention, attention switching, and resistance to distractive interference specifically improved. The person reported a reduction in intrusive thoughts in her daily life. In addition, positive symptoms decreased. Finally, a 6-month follow-up assessment revealed the maintenance of most of the beneficial effects in daily life.

Effectiveness of different modalities of cognitive remediation on symptomatological, neuropsychological, and functional outcome domains in schizophrenia: a prospective study in a real-world setting

OBJECTIVES

The efficacy of cognitive remediation interventions in schizophrenia has been demonstrated in several experimental studies. However, the effectiveness of such treatments in the usual setting of care of schizophrenia and a direct comparison of different modalities of interventions have not been systematically analyzed. The aim of the study was to assess the effectiveness of the cognitive subprograms of Integrated Psychological Therapy (IPT-cog) and of a computer-assisted cognitive remediation (CACR) method on symptomatological, neuropsychological and functional outcome measures in schizophrenia.

METHODS

Ninety patients with schizophrenia were assigned to IPT-cog, CACR or usual rehabilitative interventions (REHAB) in a naturalistic setting of care. Clinical, neuropsychological, and functional outcome variables were assessed at baseline and after 24 weeks of treatment.

RESULTS

Both the IPT-cog and CACR groups improved more than the comparison group with respect to all outcome variables. The more responsive cognitive domains were speed of processing and working memory. The effectiveness of the 2 remediation methods on the outcome dimensions considered was comparable. However, IPT-cog, but not CACR, was more effective than REHAB on speed of processing, and the CACR group had better outcome than both the REHAB and the IPT-cog groups when the Health of the Nation Outcome Scale was considered. Few correlations between neurocognitive and functional outcome changes were found.

CONCLUSIONS

The study demonstrates the effectiveness, although nongeneralized, of IPT-cog and CACR in schizophrenia when applied within a psychiatric and psychosocial treatment regimen representative of the usual setting and modality of care, with no evident superiority of any of the methods, and indicates that the changes in functional outcome during treatment are modestly mediated by improvement in specific cognitive domains.

Integrative circuit models and their implications for the pathophysiologies and treatments of the schizophrenias

A preponderance of evidence indicates that the heterogeneous group of schizophrenias is accompanied by disturbances in neural elements distributed throughout multiple levels of interconnected cortico-striato-pallido-thalamic circuitry. These disturbances include a substantial loss of, or failure to develop, both cells and/or appropriate cellular connections in regions that include at least portions of the hippocampus, parahippocampal gyrus, entorhinal cortex, amygdala, prefrontal and anterior cingulate cortex, superior and transverse temporal gyri, and mediodorsal, anterior, and pulvinar nuclei of the thalamus; they appear to reflect failures of early brain maturation, that become codified into dysfunctional circuit properties, that in the opinion of this author cannot be "undone" or even predictably remediated in any physiological manner by existing pharmacotherapies. These circuit disturbances are variable across individuals with schizophrenia, perhaps reflecting the interaction of multiple different risk genes and multiple different epigenetic events. Evidence for these complex circuit disturbances has significant implications for many areas of schizophrenia research, and for future efforts toward developing more effective therapeutic approaches for this group of disorders. The conclusion of this chapter is that such future efforts should focus on further developing and refining medications that target nodal or convergent circuit points within the limbic-motor interface, with the goal of constraining the scope and severity of psychotic exacerbations, to be used in concert with systematic rehabilitative psychotherapies designed to engage healthy neural systems to compensate for and replace dysfunctional higher circuit elements. This strategy should be applied in both preventative and treatment settings, and disseminated for community delivery via an evidence-based manualized format. In contrast to alternative treatment strategies that range from complex polypharmacy to gene therapies to psychosurgical interventions, the use of combined medication plus targeted cognitive and behavioral psychotherapy has both common sense and time-tested documented efficacy with numerous other neuropsychiatric disorders.

Vocational, social, and cognitive rehabilitation for individuals diagnosed with schizophrenia: a review of recent research and trends

A growing body of evidence suggests that social and vocational interventions effectively enhance social and vocational functioning for individuals with schizophrenia. In this review, we first consider recent advances in vocational and social rehabilitation, then examine current findings on neurocognition, social cognition, and motivation with regard to the impact these elements have on rehabilitation interventions and outcomes. A critical evaluation of recent studies examining standalone treatment approaches and hybrid approaches that integrate components such as cognitive remediation and skills training reveals several ongoing challenges within the field. Greater understanding of the differential impact of various approaches, methods that may increase the magnitude of treatment effects, and the generalization of treatment effects to community functioning are among crucial areas for future research. Overall, these treatments hold promise in improving psychosocial functioning and helping individuals with schizophrenia acquire important life skills.