It is all in the factors: effects of cognitive remediation on symptom dimensions

[An effect of cholinesterase blockade on negative symptoms in schizophrenia]

Abstruct.

OBJECTIVE

To assess the possibilities of influencing the severity of negative disorders in schizophrenic patients with cholinesterase blockade.

MATERIAL AND METHODS

The study included stable 26 patients (13 of them women), average age 40.4 (SD 11.7) with paranoid schizophrenia, episodic form according to ICD-10). All patients received antipsychotic therapy, which was not changed at least for 2 months. We used psychometric scales (Positive and Negative Syndrome Assessment Scale (PANSS), Global Functioning Scale (GAF), neurocognitive techniques (Brief Assessment of Cognition in Schizophrenia-BACS), projective psychological techniques (Rorschach test).

RESULTS AND CONCLUSION

The results of the study showed that augmentation of maintenance antipsychotic therapy with a cholinesterase blocker (ipidacrine at a dose of 20 mg per day) had positive impact on negative symptoms, decreasing the severity of emotional deficiency. The positive changes of cognitive impairment, measured with BACS, occurred regardless of changes in the severity of negative disorders, measured with PANSS. The Rorschach test showed an improvement in the conventional orientation of the patients' thinking. No exacerbation of psychotic symptoms was registered.

The Implementation and Review of Cognitive Remediation Training for First Episode Psychosis in Singapore

Objective: Early intervention in patients with first episode psychosis (FEP) can improve cognitive abilities, with both short- and long-term benefits. In this paper, we describe the implementation and review of cognitive remediation training (CRT) in an Asian FEP population. The outcomes of the training are also evaluated and discussed. Methods: This naturalistic paper describes in detail the real-life implementation and conduct of CRT in an early psychosis intervention service. One hundred and nine patients with FEP underwent a 24-session CRT programme, using Cogpack and Neuropsychological Educational Approach to Remediation. The program is evaluated with pre- and post-CRT assessment scores which included Montreal Cognitive Assessment and Brief Assessment of Cognition in Schizophrenia. The rates of improvement on these cognitive assessments were evaluated using paired t-tests, with statistical significance set at p ≤ 0.05. Results: Of the 109 patients who underwent CRT, a total of 92 (84.4%) completed all 24 sessions. Paired t-tests between pre- and post-CRT assessments scores revealed that participants significantly improved on majority of the measures, including verbal memory, digit sequencing, and symbol coding. Conclusion: As with other cognitive remediation programmes, CRT has shown to improve cognitive functioning in patients with FEP. The results support the use of CRT in an Asian context and may serve as guidance for the implementation of similar training programmes in other Asian early psychosis intervention services.

Who will benefit from computerized cognitive remediation therapy? Evidence from a multisite randomized controlled study in schizophrenia

BACKGROUND

Computerized cognitive remediation therapy (CCRT) is generally effective for the cognitive deficits of schizophrenia. However, there is much uncertainty about what factors mediate or moderate effectiveness and are therefore important to personalize treatment and boost its effects.

METHOD

In total, 311 Chinese inpatients with Diagnostic and Statistical Manual of Mental Disorders-IV schizophrenia were randomized to receive CCRT or Active control for 12 weeks with four to five sessions per week. All participants were assessed at baseline, post-treatment and 3-month follow-up. The outcomes were cognition, clinical symptoms and functional outcomes.

RESULTS

There was a significant benefit in the MATRICS Consensus Cognitive Battery (MCCB) total score for CCRT (F1,258 = 5.62; p = 0.02; effect size was 0.27, 95% confidence interval 0.04-0.49). There were no specific moderators of CCRT improvements. However, across both groups, Wisconsin Card Sort Test improvement mediated a positive effect on functional capacity and Digit Span benefit mediated decreases in positive symptoms. In exploratory analyses younger and older participants showed cognitive improvements but on different tests (younger on Symbol Coding Test, while older on the Spatial Span Test). Only the older age group showed MSCEIT benefits at post-treatment. In addition, cognition at baseline negatively correlated with cognitive improvement and those whose MCCB baseline total score was around 31 seem to derive the most benefit.

CONCLUSIONS

CCRT can improve the cognitive function of patients with schizophrenia. Changes in cognitive outcomes also contributed to improvements in functional outcomes either directly or solely in the context of CCRT. Age and the basic cognitive level of the participants seem to affect the cognitive benefits from CCRT.

A randomized controlled trial of cognitive remediation for a national cohort of forensic patients with schizophrenia or schizoaffective disorder

BACKGROUND

Evidence is accumulating that Cognitive Remediation Training (CRT) is effective for ameliorating cognitive deficits experienced by patients with schizophrenia and accompanying functional impairment. There has been no randomized controlled trial of CRT using a nationally representative population of forensic patients, despite the significant cognitive deficits frequently present within this group.

METHODS

Sixty-five patients with schizophrenia or schizoaffective disorder were enrolled in a single blind randomized controlled trial of CRT versus treatment as usual (TAU); representing 94% of those eligible within a national forensic cohort. The primary outcome measure was the composite score of the MATRICS Consensus Cognitive Battery (MCCB). Secondary outcome measures included neurocognitive and social cognitive domains, symptoms, and 'real world' functioning. Patient satisfaction was examined using an exit interview. Participants were reassessed at 8 months follow up. All data were analyzed using an intention to treat design (ITT).

RESULTS

For the primary outcome measure, the MCCB composite score, there were significant differences between those who participated in CRT and those receiving TAU at both end of treatment and 8 months follow up (Cohen's d = 0.34. Significant improvements were observed in visual and working memory. Mediation analysis found that those who cognitively benefited from CRT had corresponding improved functioning, and more net positive therapeutic moves i.e. moves to units with lower security within the hospital. Ninety-six percent believed their cognitive gains positively affected their daily lives.

CONCLUSIONS

CRT may be an acceptable and efficacious intervention for forensic patients with schizophrenia or schizoaffective disorder.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02360813 . Trial registered Feb 4th 2015, last updated May 1st 2015.

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.

Cognitive behavioural therapy plus standard care versus standard care for people with schizophrenia

BACKGROUND

Cognitive behavioural therapy (CBT) is a psychosocial treatment that aims to re-mediate distressing emotional experiences or dysfunctional behaviour by changing the way in which a person interprets and evaluates the experience or cognates on its consequence and meaning. This approach helps to link the person's feelings and patterns of thinking which underpin distress. CBT is now recommended by the National Institute for Health and Care Excellence (NICE) as an add-on treatment for people with a diagnosis of schizophrenia. This review is also part of a family of Cochrane CBT reviews for people with schizophrenia.

OBJECTIVES

To assess the effects of cognitive behavioural therapy added to standard care compared with standard care alone for people with schizophrenia.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (up to March 6, 2017). This register is compiled by systematic searches of major resources (including AMED, BIOSIS CINAHL, Embase, MEDLINE, PsycINFO, PubMed, and registries of clinical trials) and their monthly updates, handsearches, grey literature, and conference proceedings, with no language, date, document type, or publication status limitations for inclusion of records into the register.

SELECTION CRITERIA

We selected all randomised controlled clinical trials (RCTs) involving people diagnosed with schizophrenia or related disorders, which compared adding CBT to standard care with standard care given alone. Outcomes of interest included relapse, rehospitalisation, mental state, adverse events, social functioning, quality of life, and satisfaction with treatment.We included studies fulfilling the predefined inclusion criteria and reporting useable data.

DATA COLLECTION AND ANALYSIS

We complied with the Cochrane recommended standard of conduct for data screening and collection. Where possible, we calculated relative risk (RR) and its 95% confidence interval (CI) for binary data and mean difference (MD) and its 95% confidence interval for continuous data. We assessed risk of bias for included studies and created a 'Summary of findings' table using GRADE.

MAIN RESULTS

This review now includes 60 trials with 5,992 participants, all comparing CBT added to standard care with standard care alone. Results for the main outcomes of interest (all long term) showed no clear difference between CBT and standard care for relapse (RR 0.78, 95% CI 0.61 to 1.00; participants = 1538; studies = 13, low-quality evidence). Two trials reported global state improvement. More participants in the CBT groups showed clinically important improvement in global state (RR 0.57, 95% CI 0.39 to 0.84; participants = 82; studies = 2 , very low-quality evidence). Five trials reported mental state improvement. No differences in mental state improvement were observed (RR 0.81, 95% CI 0.65 to 1.02; participants = 501; studies = 5, very low-quality evidence). In terms of safety, adding CBT to standard care may reduce the risk of having an adverse event (RR 0.44, 95% CI 0.27 to 0.72; participants = 146; studies = 2, very low-quality evidence) but appears to have no effect on long-term social functioning (MD 0.56, 95% CI -2.64 to 3.76; participants = 295; studies = 2, very low-quality evidence, nor on long-term quality of life (MD -3.60, 95% CI -11.32 to 4.12; participants = 71; study = 1, very low-quality evidence). It also has no effect on long-term satisfaction with treatment (measured as 'leaving the study early') (RR 0.93, 95% CI 0.77 to 1.12; participants = 1945; studies = 19, moderate-quality evidence).

AUTHORS' CONCLUSIONS

Relative to standard care alone, adding CBT to standard care appears to have no effect on long-term risk of relapse. A very small proportion of the available evidence indicated CBT plus standard care may improve long term global state and may reduce the risk of adverse events. Whether adding CBT to standard care leads to clinically important improvement in patients' long-term mental state, quality of life, and social function remains unclear. Satisfaction with care (measured as number of people leaving the study early) was no higher for participants receiving CBT compared to participants receiving standard care. It should be noted that although much research has been carried out in this area, the quality of evidence available is poor - mostly low or very low quality and we still cannot make firm conclusions until more high quality data are available.

Exploring the relationship between the anticipation and experience of pleasure in people with schizophrenia: An experience sampling study

BACKGROUND

It has been hypothesised that a reduction in anticipatory pleasure contributes to reduced levels of functioning in people with schizophrenia. Previous research on anticipatory pleasure, however, reports mixed findings and has not yet examined the link between anticipatory pleasure and activity. The aim of this study is to examine how pleasure anticipation is related to difficulties engaging in activity in people with schizophrenia.

METHOD

A healthy control group (n = 44) and a group of individuals with schizophrenia (n = 36) completed an experience sampling study using portable devices. Participants rated motivation, mood, functional, leisure and social activity levels; anticipatory and consummatory pleasure seven times a day for six consecutive days. Multi-level regression models were constructed to examine the role of anticipatory pleasure and/or motivation in predicting future activities.

RESULTS

The findings showed no evidence for a motivation or pleasure deficit in people with schizophrenia. Yet, people with schizophrenia did fewer functional activities and spent more time "resting" or "doing nothing". In the control group, expectation was the only significant predictor of future activity. In contrast, none of the parameters assessed could predict experiences occurring in people with schizophrenia.

CONCLUSIONS

In contrast with controls people with schizophrenia did not show a link between their predictions and the activities they engaged in. This appears to be an important process influencing functioning in people with psychosis. Future interventions targeting reduced functioning should focus on reinforcing the link between pleasure anticipation and goal-directed behaviour.

Using wearable technology to detect the autonomic signature of illness severity in schizophrenia

INTRODUCTION

Research suggests that people with schizophrenia have autonomic dysfunctions. These have been linked to functioning problems, symptoms and considered a risk factor for illness chronicity. The aim of this study is to introduce a new Mobile Health (mHealth) method using wearable technology to assessing autonomic activity in people's everyday life. We aim to evaluate the new method acceptability and characterise the association between schizophrenia illness features and autonomic abnormalities.

METHOD

Thirty participants with schizophrenia and 25 controls were asked to wear a mHealth device measuring autonomic activity and movements during their normal everyday life. Measures of device use acceptability were collected from all participants. Participants with schizophrenia were also assessed for symptoms and functioning levels. Measures of heart rate variability (HRV), electrodermal activity (EDA) and movement were collected by the device and groups were compared. Correlation between physiological measures, functioning, symptoms and medication levels were assessed in people with schizophrenia.

RESULTS

The mHealth device method proved to be acceptable and produced reliable measures of autonomic activity and behaviour. Compared to controls, people with schizophrenia showed lower levels of HRV, movement and functioning. In people with schizophrenia illness severity, particularly positive symptoms, was associated with parasympathetic deregulation.

CONCLUSIONS

Autonomic abnormalities can be detected using wearable technology from people's everyday life. These are in line with previous research and support the notion that autonomic deregulation are relevant illness features for mental and physical health in schizophrenia. This method may be developed as a monitoring system for well-being and relapse prevention.

Effects of cognitive remediation on negative symptoms dimensions: exploring the role of working memory

BACKGROUND

Recent theories suggest that poor working memory (WM) may be the cognitive underpinning of negative symptoms in people with schizophrenia. In this study, we first explore the effect of cognitive remediation (CR) on two clusters of negative symptoms (i.e. expressive and social amotivation), and then assess the relevance of WM gains as a possible mediator of symptom improvement.

METHOD

Data were accessed for 309 people with schizophrenia from the NIMH Database of Cognitive Training and Remediation Studies and a separate study. Approximately half the participants received CR and the rest were allocated to a control condition. All participants were assessed before and after therapy and at follow-up. Expressive negative symptoms and social amotivation symptoms scores were calculated from the Positive and Negative Syndrome Scale. WM was assessed with digit span and letter-number span tests.

RESULTS

Participants who received CR had a significant improvement in WM scores (d = 0.27) compared with those in the control condition. Improvements in social amotivation levels approached statistical significance (d = -0.19), but change in expressive negative symptoms did not differ between groups. WM change did not mediate the effect of CR on social amotivation.

CONCLUSIONS

The results suggest that a course of CR may benefit behavioural negative symptoms. Despite hypotheses linking memory problems with negative symptoms, the current findings do not support the role of this cognitive domain as a significant mediator. The results indicate that WM improves independently from negative symptoms reduction.

Psychological and psychosocial interventions for negative symptoms in psychosis: systematic review and meta-analysis

BackgroundNegative symptoms observed in patients with psychotic disorders undermine quality of life and functioning. Antipsychotic medications have a limited impact. Psychological and psychosocial interventions, with medication, are recommended. However, evidence for the effectiveness of specific non-biological interventions warrants detailed examination.AimsTo conduct a meta-analytic and systematic review of the literature on the effectiveness of non-biological treatments for negative symptoms in psychotic disorders.MethodWe searched for randomised controlled studies of psychological and psychosocial interventions in psychotic disorders that reported outcome on negative symptoms. Standardised mean differences (SMDs) in values of negative symptoms at the end of treatment were calculated across study domains as the main outcome measure.ResultsA total of 95 studies met our criteria and 72 had complete quantitative data. Compared with treatment as usual cognitive-behavioural therapy (pooled SMD -0.34, 95% CI -0.55 to -0.12), skills-based training (pooled SMD -0.44, 95% CI -0.77 to -0.10), exercise (pooled SMD -0.36, 95% CI -0.71 to -0.01), and music treatments (pooled SMD -0.58, 95% CI -0.82 to -0.33) provide significant benefit. Integrated treatment models are effective for early psychosis (SMD -0.38, 95% CI -0.53 to -0.22) as long as the patients remain in treatment. Overall quality of evidence was moderate with a high level of heterogeneity.ConclusionsSpecific psychological and psychosocial interventions have utility in ameliorating negative symptoms in psychosis and should be included in the treatment of negative symptoms. However, more effective treatments for negative symptoms need to be developed.

Effects of cognitive remediation therapy on neurocognition and negative symptoms in schizophrenia: an Italian naturalistic study

INTRODUCTION

Cognitive remediation therapy (CRT) has been reported to positively affect neurocognitive processes among patients with schizophrenia; however, the degree to which changes in cognition is linked to improved clinical symptoms, remains poorly understood. The current study aimed to investigate whether cognitive gains were associated to improvements in negative symptoms' severity in patients with schizophrenia living in two Italian psychiatric facilities.

METHODS

Patients with a diagnosis of schizophrenia were consecutively assigned to CRT (n = 33) and compared with an historical control group (n = 28). Assessments were performed at baseline and post-treatment using a neuropsychological battery (Trail Making Test A and B, Self-Ordered Pointing Task, California Verbal Learning Test), along with clinical and functioning measures.

RESULTS

Visual attention (TMT-A score change) was found as the only significant predictor of improvement in negative symptoms subscale of the Positive and Negative Syndrome Scale. Furthermore, a mediation path analysis confirmed that better performance in visual attention acts as mediator of the positive association between CRT intervention and lower post-treatment negative symptoms score.

CONCLUSIONS

CRT can have a positive impact on a measure of visual attention in patients with schizophrenia and on negative symptoms reduction that is mediated by this significant intervention effect.

Cognitive remediation for negative symptoms of schizophrenia: A network meta-analysis

Cognitive remediation (CR) is a treatment targeting cognitive difficulties in people with schizophrenia. Recent research suggested that CR may also have a positive effect on negative symptoms. This meta-analysis investigates the effect of CR on negative symptoms. A systematic search was used to identify all randomized-controlled trials of CR in people with schizophrenia reporting negative symptoms outcomes. Levels of negative symptoms at baseline, post-therapy and follow-up, sample demographics and treatment length were extracted. Study methodological quality and heterogeneity were addressed. Negative symptoms standardized mean change was calculated using Hedges's g and used as the main outcome. The search identified 45 studies reporting results for 2511 participants; 15 studies reported follow-up outcomes. CR was associated with a reduction of negative symptoms (most conservative model g=-0.30; 95% CI: -0.36, -0.22) at post-therapy compared with treatment as usual and this effect was larger at follow-up (g=-0.36; 95% CI: -0.51, -0.21). Drop-out rate was comparable between conditions. Network meta-analysis confirmed CR was superior to TAU and TAU plus active control or adjunctive treatment. No evidence of publication bias was found. Studies with more rigorous methodology were associated with larger negative symptom reduction (g=-0.40; 95% CI: -0.51 to -0.30). Although negative symptoms have not been considered a primary target for CR, this intervention can have small to moderate beneficial effects on this symptom cluster. Future research should explore in detail the active mechanisms responsible for negative symptom reduction and the relationship between cognitive and negative symptoms in schizophrenia.

The optimisation of experience sampling protocols in people with schizophrenia

Experience sampling methodology (ESM) involves completing questionnaires during daily life and has been used extensively in people with schizophrenia to assess symptoms and behaviours. Despite considerable advantages over interview measures, there is limited information about its external validity. Our aim is to investigate whether ESM protocol implementation is affected differentially in people with schizophrenia and healthy individuals by factors such as mood, medication and symptoms which would have implications for validity. Fifty-three people with schizophrenia and fifty-eight controls from the general population completed seven ESM questionnaires per day for six consecutive days. Compliance and acceptability, including overall experience, training and disruption of normal routines, were recorded. Overall questionnaire completion rate in people with schizophrenia was comparable to controls (i.e. over 70%). People with schizophrenia completed significantly fewer questionnaires in the morning but did not show fatigue effects over the experience sampling period. Excluding questionnaires in the morning did not significantly alter the findings. In the schizophrenia group medication level and symptoms did not influence adherence. However, higher disruption was associated with reduced questionnaire completion in this group. These findings suggest that minimising disruption may enhance validity and completion rates. ESM is a valid methodology to use with people with schizophrenia.

A question of time: A study of time use in people with schizophrenia

BACKGROUND

Loss of functioning is a core feature associated with the diagnosis of schizophrenia. Several measures are used to asses this domain including activity measures assessing time use which has been demonstrated to be a valuable indicator of recovery. However there is limited information on the magnitude and the domains where time use may differ between people with schizophrenia and the general population.

METHOD

One hundred and seventy people with a diagnosis of schizophrenia and 1124 people from the general population were assessed and compared on the Time Use Survey. This estimates the time spent in everyday activities in ten domains. The influence of symptom severity and clinical variables on time-use was examined in people with schizophrenia.

RESULTS

People with schizophrenia spent less time in functional but also in social and leisure activities and more time resting and "doing nothing" compared to the general population. When compared with unemployed individuals and people with a physical disability, people with schizophrenia spent comparable time in functional activities but significantly less in leisure, socialising activities and travelling. Negative symptom severity was associated with time spent in passive activities and negatively influenced time in social and leisure activities.

CONCLUSIONS

Alongside significant effects on functional economic activities schizophrenia has also a profound impact on activities that make life enjoyable. Mapping time use will be a useful additional tool to assess progress towards recovery.

A Two-Factor Model Better Explains Heterogeneity in Negative Symptoms: Evidence from the Positive and Negative Syndrome Scale

Acknowledging separable factors underlying negative symptoms may lead to better understanding and treatment of negative symptoms in individuals with schizophrenia. The current study aimed to test whether the negative symptoms factor (NSF) of the Positive and Negative Syndrome Scale (PANSS) would be better represented by expressive and experiential deficit factors, rather than by a single factor model, using confirmatory factor analysis (CFA). Two hundred and twenty individuals with schizophrenia spectrum disorders completed the PANSS; subsamples additionally completed the Brief Negative Symptom Scale (BNSS) and the Motivation and Pleasure Scale—Self-Report (MAP-SR). CFA results indicated that the two-factor model fit the data better than the one-factor model; however, latent variables were closely correlated. The two-factor model’s fit was significantly improved by accounting for correlated residuals between N2 (emotional withdrawal) and N6 (lack of spontaneity and flow of conversation), and between N4 (passive social withdrawal) and G16 (active social avoidance), possibly reflecting common method variance. The two NSF factors exhibited differential patterns of correlation with subdomains of the BNSS and MAP-SR. These results suggest that the PANSS NSF would be better represented by a two-factor model than by a single-factor one, and support the two-factor model’s adequate criterion-related validity. Common method variance among several items may be a potential source of measurement error under a two-factor model of the PANSS NSF.

Group cognitive remediation for schizophrenia: Exploring the role of therapist support and metacognition

OBJECTIVES

Cognitive remediation (CR) is a therapy targeting cognitive difficulties in psychiatric disorders. We recently develop a novel CR program for people with psychosis with a focus on metacognitive skills individually supported by a therapist. This study aims to assess the acceptability and feasibility of implementing CR in small groups where therapist support is shared amongst service users.

DESIGN

Control group design with non-randomized group allocation.

METHOD

Twenty-five service users with a diagnosis of schizophrenia participated. Ten received group CR and 15 individual CR (i.e., one therapist for each service user). Both therapy formats were supported by one therapist. Participants were assessed before and after therapy with neuropsychological tests assessing different cognitive domains, self-assessed cognitive complaints, and psychotic symptoms. Treatment satisfaction questionnaires and therapist's session ratings were also collected for group CR.

RESULTS

Dropout rate was 20% for both methods. Session attendance was 74% for group CR and 86% for individual CR. Service users evaluated positively group CR and considered it helpful; therapists rated this delivery format feasible. Exploratory analysis suggested that the two methods have similar effects on cognition. After therapy, service users showed improvements in recall memory, reduced negative symptoms, and reported fewer cognitive complains.

CONCLUSIONS

It is feasible and acceptable for people with schizophrenia to take part in small CR therapy groups. The reduced therapist contact compared to individual therapy was well tolerated and may help sustain independent work. The small group format allows therapists to spend sufficient time to support the use of metacognitive strategies.

PRACTITIONER POINTS

CR small groups are feasible and acceptable for service users and therapists. Therapist support can be shared. Metacognitive-based CR can improve cognition and may benefit awareness and negative symptoms.

Study protocol: a randomised controlled trial of cognitive remediation for a national cohort of forensic mental health patients with schizophrenia or schizoaffective disorder

BACKGROUND

Evidence is accumulating that cognitive remediation therapy (CRT) is an effective intervention for patients with schizophrenia or schizoaffective disorder. To date there has been no randomised controlled trial (RCT) cohort study of cognitive remediation within a forensic hospital. The goal of this study is to examine the effectiveness of a trial of cognitive remediation for forensic mental health patients with schizophrenia or schizoaffective disorder.

METHODS

An estimated sixty patients will be enrolled in the study. Participants will be randomised to one of two conditions: CRT with treatment as usual (TAU), or TAU. CRT will consist of 42 individual sessions and 14 group sessions. The primary outcome measure for this study is change in cognitive functioning using the MATRICS Consensus Cognitive Battery (MCCB). Secondary outcomes include change in social and occupational functioning, disorganised symptoms, negative symptoms, violence, participation in psychosocial treatment and recovery. In addition to these effectiveness measures, we will examine patient satisfaction.

DISCUSSION

Cognitive difficulties experienced by schizophrenia spectrum patients are associated with general functioning, ability to benefit from psychosocial interventions and quality of life. Research into the treatment of cognitive difficulties within a forensic setting is therefore an important priority. The results of the proposed study will help answer the question whether cognitive remediation improves functional outcomes in forensic mental health patients with schizophrenia or schizoaffective disorder. Forensic mental health patients are detained for the dual purpose of receiving treatment and for public protection. There can be conflict between these two roles perhaps causing forensic services to have an increased length of stay compared to general psychiatric admissions. Ultimately a focus on emphasising cognition and general functioning over symptoms may decrease tension between the core responsibilities of forensic mental health services.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02360813. Trial registered Feb 4th 2015 and last updated May 1(st) 2015.

Predicting the future in schizophrenia: The discrepancy between anticipatory and consummatory pleasure

When predicting future emotions we use inaccurate biases which rely on our most salient and recent experiences. In schizophrenia, there appears to be a specific deficit in this anticipatory process which is associated with reduced motivation and engagement. The nature of this deficit and how it differs to the general population is unclear. This study introduces a new task examining the discrepancy between anticipated and experienced pleasure and investigates its potential usefulness to characterise the pleasure deficit in people with schizophrenia. Forty-eight healthy controls and 50 individuals with schizophrenia completed the Components of Pleasure Task (COP) which uses a range of images to generate anticipatory and experiential ratings. Participants also completed measures of mood and symptoms. Individuals with schizophrenia had a larger anticipatory-consummatory discrepancy score. This was due to under-anticipating highly pleasant stimuli and over-anticipating low pleasantness stimuli. People with schizophrenia are blunted compared to controls when anticipating stimuli, considering highly and lowly rated stimuli alike. A greater discrepancy between anticipated and experienced pleasure may contribute to negative symptoms such as poor motivation and social withdrawal. Reducing the discrepancy between experienced and anticipated pleasure may be a target for interventions aiming to reduce negative symptoms.

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.