Computerized cognitive training is associated with improved psychosocial treatment engagement in schizophrenia

Mismatch negativity predicts initial auditory-based targeted cognitive training performance in a heterogeneous population across psychiatric disorders

Auditory-based targeted cognitive training (ATCT) programs are emerging pro-cognitive therapeutic interventions which aim to improve auditory processing to attenuate cognitive impairment in a "bottom up" manner. Biomarkers of early auditory information processing (EAIP) like mismatch negativity (MMN) and P3a have been used successfully to predict gains from a full 40 h course of ATCT in schizophrenia (SZ). Here we investigated the ability of EAIP biomarkers to predict ATCT performance in a group of subjects (n = 26) across SZ, MDD, PTSD and GAD diagnoses. Cognition was assessed via the MATRICS Consensus Cognitive Battery (MCCB) and MMN/P3a were collected prior to completing 1 h of "Sound Sweeps," a representative ATCT exercise. Baseline and final performance over the first two levels of cognitive training served as the primary dependent variables. Groups had similar MMN, but the SZ group had attenuated P3a. MMN and MCCB cognitive domain t-scores, but not P3a, were strongly correlated with most ATCT performance measures, and explained up to 61% of variance in ATCT performance. Diagnosis was not a significant predictor for ATCT performance. These data suggest that MMN can predict ATCT performance in heterogeneous neuropsychiatric populations and should be considered in ATCT studies across diagnostically diverse cohorts.

Factors Impacting Access and Engagement of Cognitive Remediation Therapy for People with Schizophrenia: A Systematic Review

OBJECTIVES

Neurocognitive deficits are central in schizophrenia. Cognitive remediation has proven effective in alleviating these deficits, with medium effect sizes. However, sizeable attrition rates are reported, with the reasons still uncertain. Furthermore, cognitive remediation is not part of routine mental health care. We conducted a systematic review to investigate factors that influence access and engagement of cognitive remediation in schizophrenia.

METHODS

We systematically searched the PubMed, Web of Science, and PsycINFO databases for peer-reviewed articles including a cognitive remediation arm, access, and engagement data, and participants with schizophrenia spectrum disorders aged 17-65 years old. Duplicates and studies without a distinct cognitive remediation component, protocol papers, single case studies, case series, and reviews/meta-analyses were excluded.

RESULTS

We included 67 studies that reported data on access and engagement, and extracted quantitative and qualitative data. Access data were limited, with most interventions delivered on-site, to outpatients, and in middle- to high-income countries. We found a median dropout rate of 14.29%. Only a small number of studies explored differences between dropouts and completers (n = 5), and engagement factors (n = 13). Dropouts had higher negative symptomatology and baseline self-efficacy, and lower baseline neurocognitive functioning and intrinsic motivation compared to completers. The engagement was positively associated with intrinsic motivation, self-efficacy, perceived usefulness, educational level, premorbid intelligence quotient, baseline neurocognitive functioning, some neurocognitive outcomes, and therapeutic alliance; and negatively associated with subjective cognitive complaints. Qualitative results showed good acceptability of cognitive remediation, with some areas for improvement.

CONCLUSIONS

Overall, access and engagement results are scarce and heterogeneous. Further investigations of cognitive remediation for inpatients, as well as remote delivery, are needed. Future clinical trials should systematically explore attrition and related factors. Determining influential factors of access and engagement will help improve the implementation and efficacy of cognitive remediation, and thus the recovery of people with schizophrenia.

An examination of neurocognition and theory of mind as predictors of engagement with a tailored digital therapeutic in persons with serious mental illness

There is an increasing interest in the development and implementation of digital therapeutics (apps) in individuals with serious mental illness (SMI). However, there is limited understanding of the role of neurocognition and social cognition on engagement with apps. The present study is a secondary analysis of a pilot randomized controlled trial (N = 62) comparing a tailored digital intervention to treat tobacco use disorder in individuals with SMI to a standard of care digital intervention for the general population. The purpose of this study was to examine the impact of neurocognition, social cognition, and clinical characteristics on indices of app engagement in users of the tailored app compared to users of the standard of care app. Correlational analyses demonstrated that individuals with low levels of neurocognition and social cognition engaged more often and for longer duration with the tailored app compared to the standard of care app. In a series of multilevel zero-inflated negative binomial models, assignment to the tailored app remained the most robust predictor of app interactions (Risk Ratio [RR] = 1.72; p < .01), duration of app use (RR = 6.47; p < .01), and average length of interaction (RR = 2.70; p < .01), after adjusting for key demographic and clinical characteristics, and two measures of cognition. This is one of the first studies to demonstrate that digital therapeutics can be designed to mitigate the impact of neurocognition and social cognition on device engagement in SMI populations. Recommendations are made to advance the use of new analytic models to uncover patterns of engagement with digital therapeutics.

Evaluation of the frequency following response as a predictive biomarker of response to cognitive training in schizophrenia

Neurophysiological biomarkers of auditory processing show promise predicting outcomes following auditory-based targeted cognitive training (TCT) in schizophrenia, but the viability of the frequency following response (FFR) as a biomarker has yet to be examined, despite its ecological and face validity for auditory-based interventions. FFR is an event-related potential (ERP) that reflects early auditory processing. We predicted that schizophrenia patients would show acute- and longer-term FFR malleability in the context of TCT. Patients were randomized to either TCT (n = 30) or treatment as usual (TAU; n = 22), and electroencephalography was recorded during rapid presentation of an auditory speech stimulus before treatment, after one hour of training, and after 30 h of training. Whereas patients in the TCT group did not show changes in FFR after training, amplitude reductions were observed in the TAU. FFR was positively associated with performance on a measure of single word-in-noise perception in the TCT group, and with a measure of sentence-in-noise perception in both groups. Psychometric reliability analyses of FFR scores indicated high internal consistency but low one-hour and 12-week test-rest reliability. These findings support the dissociation between measures of speech discriminability along the hierarchy of cortical and subcortical early auditory information processing in schizophrenia.

Engagement with online psychosocial interventions for psychosis: A review and synthesis of relevant factors

BACKGROUND

Little is known about factors associated with engagement with online interventions for psychosis. This review aimed to synthesise existing data from relevant literature to develop a working model of potential variables that may impact on engagement with online interventions for psychosis.

METHODS

Online databases were searched for studies relevant to predictors of engagement with online interventions for psychosis; predictors of Internet use amongst individuals with psychosis; and predictors of engagement with traditional psychosocial treatments for psychosis. Data were synthesised into a conceptual model highlighting factors relevant to engagement with online interventions for psychosis.

RESULTS

Sixty-one studies were identified. Factors relevant to engagement related directly to the impact of psychosis, response to psychosis, integration of technology into daily lives and intervention aspects.

CONCLUSION

While several candidate predictors were identified, there is minimal research specifically investigated predictors of engagement with online interventions for psychosis. Further investigation examining both individual- and intervention-related factors is required to inform effective design and dissemination of online interventions for psychosis.

Oscillatory biomarkers of early auditory information processing predict cognitive gains following targeted cognitive training in schizophrenia patients

Auditory-based targeted cognitive training (TCT) is an effective and well-validated intervention for the treatment of cognitive impairment in schizophrenia patients. Improvements in higher-order cognition, reductions in symptom severity, and increases in psychosocial functioning secondary to TCT are thought to be driven by "bottom-up" enhancement of early auditory information processing (EAIP). Despite strong evidence of efficacy at the group level, there is significant variability in response to TCT, with few well-delineated biomarkers for predicting individual benefit. EEG biomarkers of EAIP are indicators of early-treatment sensitivity that predict full-course TCT outcome; however, further characterization is necessary for biomarker-guided clinical trials. The current study examined baseline and early-treatment sensitivity (i.e., change from baseline after 1 h) in theta band oscillatory activity to deviant stimuli as moderators of full course (30 h) TCT response in treatment-refractory schizophrenia patients randomly assigned to receive either treatment-as-usual (TAU; n = 22) or TAU augmented with TCT (n = 30). Theta evoked power and phase locking at baseline predicted patient improvements in global cognitive function after 30 h of TCT. Decrease in theta activity to deviant stimuli after 1 h of TCT predicted improvements in verbal learning after 30 h. Exploratory analyses using EEG composite scores had high levels of sensitivity and specificity for identifying patients most likely to benefit from TCT. The integrity of baseline neurophysiologic activity associated with EAIP, as well as the sensitivity of the underlying circuity to change, likely reflects an intermediate therapeutic process underlying the effectiveness of TCT that can be used to predict patient response to treatment.

Nicotine effects on cognitive remediation training outcome in people with schizophrenia: A pilot study

Cognitive remediation training can alleviate cognitive impairment associated with schizophrenia, but the impact is limited by small effect sizes. The present study aimed at augmenting training effects by administering nicotine prior to training sessions. Twenty-five people with schizophrenia were enrolled in a 10-week, 5 days/week, computerized cognitive training regimen. Participants were randomized to two treatment groups: nicotine or placebo. Every Monday and Thursday, the nicotine group received a nicotine lozenge before the training, and the placebo group a placebo lozenge. Outcome measurements were conducted on a no-lozenge day in weeks 0, 4, 7, and 10, and at 4-week follow-up. The MATRICS Consensus Cognitive Battery composite score improved over time, but there was no group difference in this effect. A significant group difference emerged over time in the reasoning/problem solving sub-domain: the placebo group improved but not the nicotine group, suggesting that nicotine exposure negatively impacted training benefits on executive control processes. There were no effects on psychiatric symptoms. However, significant improvements were seen across groups on the Quality of Life Scale and the Cognitive Assessment Interview, measuring real-life functional outcome. In conclusion, the present study failed to find evidence that nicotine exposure during cognitive remediation training may potentiate training benefits.

Divergence of subjective and performance-based cognitive gains following cognitive training in schizophrenia

BACKGROUND

Cognitive training is effective for improving cognitive performance among people with schizophrenia. An individual's perception of their own cognition is dissociable from performance on objective cognitive tests. Since subjective cognitive benefit may impact engagement, motivation, and satisfaction with time-intensive cognitive interventions, this study aimed to determine whether subjective cognitive difficulties improve in conjunction with cognitive gains following 30 h of cognitive training.

METHODS

Patients with schizophrenia or schizoaffective disorder (N = 46) were randomized to treatment as usual (TAU) or TAU augmented with auditory-targeted cognitive training (TCT). All participants completed assessment batteries at baseline and follow-up. As previously reported, the TCT group showed significant improvements in verbal learning and memory and reductions in auditory hallucinations relative to the TAU group.

RESULTS

Subjective cognitive difficulties did not significantly improve following TCT, even among TCT participants who showed improvements in cognitive performance (all ps > 0.05). Subjective cognitive difficulties were significantly associated with severity of depressive symptoms and hallucinations (r = 0.48 and r = 0.28, p < 0.001), but not global or specific domains of cognition (all rs < 0.1) at baseline. There were no significant relationships between change in subjective cognitive difficulties and change in cognitive or clinical variables (all ps > 0.05).

DISCUSSION

Patients with schizophrenia do not detect change in their cognition following cognitive training, even among those who showed robust gains in cognitive performance. Failure to detect improvement may undermine treatment engagement, motivation, and satisfaction. Translating score improvements on the cognitive exercises into tangible metrics, and providing ongoing, clinician-delivered feedback on performance may facilitate patient ability to detect improvements and improve motivation to engage with cognitive training interventions.

Mismatch negativity reveals plasticity in cortical dynamics after 1-hour of auditory training exercises

BACKGROUND

Impaired sensory processing contributes to deficits in cognitive and psychosocial functioning in individuals with schizophrenia (SZ). Mismatch Negativity (MMN), an event-related potential (ERP) index of sensory discrimination associated with cognitive and psychosocial functioning, is a candidate biomarker of auditory discrimination and thus possibly of changes following auditory-based Targeted Cognitive Training (TCT). Here we evaluated the acute effect of TCT on cortical processes supporting auditory discrimination.

METHODS

MMN was assessed in 28 SZ outpatients before and after a single 1-hour (hr) session of "Sound Sweeps," a pitch discrimination task that is a component of the TCT suite of exercises. Independent component (IC) analysis was applied to decompose 64-channel scalp-recorded electroencephalogram (EEG) activity into spatiotemporally stationary sources and their activities. ICs from all patients were pooled to find commonalities in their cortical locations. IC cluster-mean ERPs were evaluated to determine the clusters contributing to the (140-200 ms) MMN difference between responses to deviant and standard tone stimuli respectively.

RESULTS

Two frontal IC clusters centered in orbitofrontal cortex (OFC) and anterior cingulate cortex (ACC) accounted for >77% of MMN variance across all scalp channels. After 1-hr auditory training, significant suppression of ACC cluster contributions was detected, whereas the OFC cluster contribution was unchanged.

CONCLUSIONS

Prior to TCT, the MMN response was dominated by EEG effective sources in or near OFC and ACC. However, after 1-hr of auditory-based TCT, a significant attenuation of ACC was observed, whereas OFC contribution to MMN persisted. The present findings support further trials designed to test whether training-related MMN plasticity in the ACC after 1-hr may predict individual patient response to a full course of TCT.

Neurophysiologic measures of target engagement predict response to auditory-based cognitive training in treatment refractory schizophrenia

Cognitive impairment is a core feature of schizophrenia and a strong predictor of psychosocial disability. Auditory-based targeted cognitive training (TCT) aims to enhance verbal learning and other domains of cognitive functioning through "bottom-up" tuning of the neural systems underlying early auditory information processing (EAIP). Although TCT has demonstrated efficacy at the group level, individual response to TCT varies considerably, with nearly half of patients showing little-to-no benefit. EEG measures of EAIP, mismatch negativity (MMN) and P3a, are sensitive to the neural systems engaged by TCT exercises and might therefore predict clinical outcomes after a full course of treatment. This study aimed to determine whether initial malleability of MMN and P3a to 1-h of auditory-based TCT predicts improvements in verbal learning and clinical symptom reduction following a full (30-h) course of TCT. Treatment refractory patients diagnosed with schizophrenia were randomly assigned to receive treatment-as-usual (TAU; n = 22) or TAU augmented with TCT (n = 23). Results indicated that malleability (i.e., change from baseline after the initial 1-h dose of TCT) of MMN and P3a predicted improvements in verbal learning as well as decreases in the severity of positive symptoms. Examination of MMN and P3a malleability in patients after their first dose of TCT can be used to predict clinical response to a full course of treatment and shows promise for future biomarker-informed treatment assignment.

Targeted cognitive training improves auditory and verbal outcomes among treatment refractory schizophrenia patients mandated to residential care

Computerized targeted cognitive training (TCT) of auditory processing has been shown to improve verbal learning in several clinical trials of schizophrenia outpatients. Less is known, however, about the effectiveness of this promising intervention in more chronic, treatment-refractory patients who are treated in non-academic settings. This study aimed to determine whether TCT improves auditory processing, verbal learning, and clinical symptoms in SZ patients mandated to receive care at a locked residential rehabilitation center. Secondarily, potential factors that moderate TCT's effectiveness including age, symptom severity, antipsychotic medication load, and duration of illness were examined. Schizophrenia patients were randomized to treatment as usual (TAU; n = 22) or TAU augmented with TCT (TAU + TCT; n = 24). Outcomes included a measure of auditory perception (Word-In-Noise test, WIN), verbal learning domain scores from the MATRICS Consensus Cognitive Battery (MCCB), and clinical symptoms (Scale for the Assessment of Positive Symptoms, SAPS; Scale for the Assessment of Negative Symptoms, SANS). TCT produced significant improvements in auditory perception (d = 0.67) and verbal learning (d = 0.65); exploratory analyses revealed a statistically significant reduction in auditory hallucinations (d = -0.64). TCT's effects were only weakly, and mostly non-significantly, moderated by age, clinical symptoms, medication, and illness duration. These findings indicate that even highly symptomatic, functionally disabled patients with chronic illness benefit from this emerging treatment. Ongoing studies will examine the predictive utility of neurophysiological biomarkers and other characteristics assessed at baseline.