Effectiveness of cognitive remediation in depression: a meta-analysis

Considering Theory-Based Gamification in the Co-Design and Development of a Virtual Reality Cognitive Remediation Intervention for Depression (bWell-D): Mixed Methods Study

BACKGROUND

In collaboration with clinical domain experts, we developed a prototype of immersive virtual reality (VR) cognitive remediation for major depressive disorder (bWell-D). In the development of a new digital intervention, there is a need to determine the effective components and clinical relevance using systematic methodologies. From an implementation perspective, the effectiveness of digital intervention delivery is challenged by low uptake and high noncompliance rates. Gamification may play a role in addressing this as it can boost adherence. However, careful consideration is required in its application to promote user motivation intrinsically.

OBJECTIVE

We aimed to address these challenges through an iterative process for development that involves co-design for developing content as well as in the application of gamification while also taking into consideration behavior change theories. This effort followed the methodological framework guidelines outlined by an international working group for development of VR therapies.

METHODS

In previously reported work, we collected qualitative data from patients and care providers to understand end-user perceptions on the use of VR technologies for cognitive remediation, reveal insights on the drivers for behavior change, and obtain suggestions for changes specific to the VR program. In this study, we translated these findings into concrete representative software functionalities or features and evaluated them against behavioral theories to characterize gamification elements in terms of factors that drive behavior change and intrinsic engagement, which is of particular importance in the context of cognitive remediation. The implemented changes were formally evaluated through user trials.

RESULTS

The results indicated that feedback from end users centered on using gamification to add artificial challenges, personalization and customization options, and artificial assistance while focusing on capability as the behavior change driver. It was also found that, in terms of promoting intrinsic engagement, the need to meet competence was most frequently raised. In user trials, bWell-D was well tolerated, and preliminary results suggested an increase in user experience ratings with high engagement reported throughout a 4-week training program.

CONCLUSIONS

In this paper, we present a process for the application of gamification that includes characterizing what was applied in a standardized way and identifying the underlying mechanisms that are targeted. Typical gamification elements such as points and scoring and rewards and prizes target motivation in an extrinsic fashion. In this work, it was found that modifications suggested by end users resulted in the inclusion of gamification elements less commonly observed and that tend to focus more on individual ability. It was found that the incorporation of end-user feedback can lead to the application of gamification in broader ways, with the identification of elements that are potentially better suited for mental health domains.

Change in Cognitive Function over the Course of Major Depressive Disorder: A Systematic Review and Meta-analysis

Major depressive disorder (MDD) is associated with significant cognitive deficits during the acute and remitted stages. The aim of this systematic review and meta-analysis was to examine the course of cognitive function whilst considering demographic, treatment, or clinical features of MDD that could moderate the extent of cognitive change. Databases were searched to identify studies that reported on cognitive function in MDD with a ≥12-week test-retest interval. Relevant studies were pooled using random effects modelling to generate an inverse-variance, weighted, mean effect size estimate (Hedges' g) of cognitive change for each cognitive variable and for an overall composite cognitive domain. Of 6898 records, 99 eligible studies were identified from which 69 were meta-analysed, consisting of 4639 MDD patients (agemean = 40.25 years, female% = 64.62%) across 44 cognitive variables. In over 95% of cognitive variables, improvements were either of non-significant, negligible, or of a small magnitude, and when compared to matched healthy controls, the possibility of practice effects could not be precluded. Depressive symptom improvement and the number of previous depressive episodes moderated the extent of cognitive change, demonstrating state- and scar-like features for one-quarter of the cognitive domains. Further longitudinal studies are required to elucidate the MDD cognitive trajectory from initial onset. Findings nonetheless suggest that following pharmacological and non-pharmacological treatment, cognitive change in MDD is typically small, but the capacity for change may be less with episode recurrence. Targeting cognition early in the course of illness may facilitate better prognosis and support a more complete functional recovery.

Cognitive Training for Emotion-Related Impulsivity and Rumination: Protocol for a Pilot Randomized Waitlist-Controlled Trial

BACKGROUND

Inhibitory deficits are common in psychopathology. Emotion-related impulsivity (ERI) and rumination are general risk factors for psychiatric distress that are similarly associated with dysfunctional inhibition-particularly in affective contexts. A number of cognitive remediation procedures have been developed to improve inhibitory control; however, most remediation programs focus on "cold" cognition independent of affective processing. This pilot trial will gather preliminary evidence for a new cognitive training intervention targeting "hot" affective control (ie, inhibitory functions during elevated emotional arousal) in a transdiagnostic sample of adults who report heightened emotion dysregulation.

OBJECTIVE

This manuscript describes a protocol for a pilot randomized waitlist-controlled trial to assess changes in ERI and rumination after neurobehavioral affective control training (N-ACT), an 8-week cognitive training intervention designed to improve emotional response inhibition and emotional working memory. Our primary aim is to evaluate the efficacy, feasibility, and acceptability of N-ACT in reducing rumination and ERI, which we respectively conceptualize as complementary cognitive and behavioral consequences of emotion dysregulation. Secondarily, we will examine whether N-ACT leads to improvements in inhibitory control and, more distally, psychopathology symptoms.

METHODS

The final sample will comprise 80 adults who report high ERI or rumination. Participants will be randomized to (1) begin the N-ACT program without delay or (2) join a waitlist condition and then complete N-ACT. Exclusion criteria include active alcohol or substance use disorders, psychosis, and suicide risk. At the baseline and postintervention time points, participants will complete measures of emotion dysregulation and psychiatric symptoms, as well as a neuropsychological assessment of inhibitory control. Individuals assigned to the control group will undergo an identical assessment before joining the waitlist, followed by parallel assessments before and after N-ACT.

RESULTS

This trial is funded by support from the University of California Board of Regents and the Peder Sather Foundation (funding period: October 2022-September 2025). Recruitment is scheduled to begin in spring 2025. We will begin data analysis once data collection is complete, which is planned to occur in fall 2025.

CONCLUSIONS

This pilot randomized waitlist-controlled trial is designed to assess the initial efficacy, feasibility, and acceptability of N-ACT, a novel cognitive remediation approach developed to address 2 key contributors to psychopathology: ERI and rumination. The N-ACT program uses computerized adaptive behavioral tasks to strengthen the affective control processes theoretically and empirically linked to ERI and rumination. We hope this work will help inform future studies with sufficient statistical power to ascertain whether enhancing affective control through cognitive training (N-ACT) produces downstream reductions in psychiatric symptoms via improved emotion regulation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06226467; https://www.clinicaltrials.gov/study/NCT06226467; Open Science Framework Registry rak5z; https://osf.io/rak5z.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/54221.

Home-based transcranial direct current stimulation paired with cognitive training to reduce fatigue in multiple sclerosis

Fatigue is a common and often debilitating feature of multiple sclerosis (MS) that lacks reliably effective treatment options for most patients. Transcranial direct current stimulation (tDCS), a safe and well-tolerated type of noninvasive brain stimulation, is a low-cost and home-based approach with the potential to reduce fatigue in MS. We conducted a double-blind, sham-controlled, randomized clinical trial to compare active vs. low-dose (sham) tDCS paired with computer-based cognitive training, delivered as a home-based intervention, to reduce MS-related fatigue. Participants with MS-related fatigue, but without depression, were stratified by neurologic disability using the Extended Disability Status Scale (EDSS) and randomized to complete 30 daily sessions over six weeks of either active or sham tDCS paired with online cognitive training (BrainHQ). The primary outcome was the change in PROMIS Fatigue score from baseline to the end of the intervention. A total of 117 participants were randomized, with 92% completing all treatment sessions. Both groups showed significant reductions in fatigue, with no significant difference between them. This suggests that tDCS does not provide any additional benefit over cognitive training alone in reducing fatigue, but confirms the feasibility and tolerance of this home-based intervention.

Efficacy and safety of Neurocognitive Adaptive Training for Depression combined with SSRIs for treating cognitive impairment among patients with late-life depression: a 12-week, randomized controlled study

BACKGROUND

This randomized, open-label study examined the therapeutic effects of Neurocognitive Adaptive Training for Depression (NCAT-D) combined with selective serotonin reuptake inhibitors (SSRIs) on cognitive impairment among patients with late-life depression (LLD).

METHOD

Study data were collected from May 5, 2021, to April 21, 2023. Outpatients who met the diagnostic criteria for major depressive disorder according to the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (i.e., a total score on the 17-item Hamilton Depression Rating Scale (HAMD-17) ≥ 18 and a total score on the Montreal Cognitive Assessment scale (MOCA) < 26) were recruited at Beijing Anding Hospital. These participants were randomly assigned to receive up to 12 weeks of NCAT-D and SSRIs treatment (n = 57) or SSRIs with a control treatment (n = 61). Primary outcomes included changes in Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) scores from baseline to week 12 between the two groups. Assessments were conducted at baseline, after 2 weeks, 4 weeks, 8 weeks, and at 12 weeks. Mixed model repeated measures (MMRM) analysis was performed on modified intention-to-treat (mITT) and completer populations.

RESULTS

The full analysis set (FAS) included 118 patients (NCAT-D and SSRIs group, n = 57; SSRIs and Control group, n = 61). During the 12-week study period, MMRM analysis revealed a significantly greater reduction in cognitive function (as indicated by ADAS-cog total scores) from baseline to post-treatment in the NCAT-D and SSRIs group compared to the SSRIs and Control groups [(F (1,115) = 13.65, least-squares mean difference [95% CI]: -2.77 [- 3.73, - 1.81], p < 0.001)]. The intervention group showed a significantly greater reduction in HAMD-17 scores compared to the control group [MMRM, estimated mean difference (SE) between groups: -3.59 [- 5.02, - 2.15], p < 0.001]. There was no significant difference in the incidence of adverse events between the two groups.

CONCLUSIONS

NCAT-D combined with SSRIs was efficacious and well tolerated in LLD patients with cognitive impairment.

TRIAL REGISTRATION

Registered on October 18, 2022, at ClinicalTrials.gov Identifier: (#NCT05588102).

Efficacy of an internet-delivered cognitive enhancement intervention for subjective residual cognitive deficits in remitted major depressive disorder: A randomized crossover trial

BACKGROUND

Cognitive deficits such as difficulties with attention, memory, and executive functions are frequently reported during remission from depression and relates to adverse functioning in daily life and risk of relapse. There is therefore a need for interventions targeting cognitive deficits after depression. However, few randomized controlled trials have investigated the efficacy of interventions targeting subjective residual cognitive deficits in adults remitted from depression.

METHODS

This randomized crossover trial aimed to investigate the efficacy of an internet-delivered cognitive enhancement intervention on subjective residual cognitive deficits. Forty-four formerly depressed adults (89 % female;mean age = 39 years) were included. Twenty-three participants received the intervention, and 21 participants were assigned to a waitlist control group. The waitlist control group received the intervention after seven weeks. Analyses of follow-up assessment after six months were conducted for the combined sample.

RESULTS

Significant differences were found between the intervention and waitlist control group in subjective cognitive functioning (d = 1.83) and rumination (d = 1.65). There was a difference in symptoms of depression between the groups (d = 1.22), whereas symptoms of depression increased in the waitlist control, but not in the intervention group. Fewer participants in the waitlist control group (43 %), compared to the intervention group (78 %) showed reliable improvement in self-reported cognitive deficits after receiving the intervention.

LIMITATIONS

Findings should be interpreted with caution due to the small sample, and lack of an active control group.

CONCLUSIONS

Internet-delivered cognitive enhancement interventions may improve subjective cognitive deficits. Waiting time to receive cognitive enhancement interventions may worsen symptoms and treatment response.

Conceptualization and characterization of "primary" and "secondary" cognitive impairment in schizophrenia

Cognitive impairment represents one of the core features of schizophrenia, involves both neurocognition and social cognition domains, and has a significant negative impact on real-world functioning. The present review provides a framework for the conceptualization and characterization of "primary" and "secondary" cognitive impairment in schizophrenia. In this conceptualization, primary cognitive impairment can be defined as a consequence of the neurobiological alterations that underlie psychopathological manifestations of the disorder, while secondary cognitive impairment can be defined as the results of a source issue that has a negative impact on cognitive performance. Sources of secondary cognitive impairment are frequent in people with schizophrenia and include several different factors, such as positive and negative symptoms, depressive symptoms, autistic symptoms, pharmacotherapy, substance abuse, metabolic syndrome, social deprivation, and sleep disorders. It can be hypothesized that secondary cognitive impairment may be improved by effectively resolving the source issue, while primary cognitive impairment may benefit from dedicated treatment. Further research is required to confirm this hypothesis, to better characterize the distinction between primary and secondary cognitive impairment in a clinical and in a neurobiological perspective, and to evaluate the impact of systematically assessing and treating secondary cognitive impairment.

Effects of aerobic exercise on cognitive function in adults with major depressive disorder: A systematic review and meta-analysis

Background

Major Depressive Disorder (MDD) is a highly prevalent psychiatric disorder that impairs the cognitive function of individuals. Aerobic exercise stands out as a promising non-pharmacological intervention for enhancing cognitive function and promoting brain health.While positive impacts of aerobic exercise on executive function in adults with depression have been documented, a comprehensive understanding of its benefits on overall cognitive function, including memory, attention, and processing speed, along with key moderating factors in adults with MDD, remains unexplored. The purpose of the systematic review and meta-analysis was to investigate the effects of aerobic exercise on overall cognitive function in adults with MDD, and to explore whether cognitive sub-domains, aerobic exercise characteristics, and study and sample variables modify the effects of aerobic exercise on cognition.

Methods

Six English electronic databases (Embase, Cochrane Central, Scopus, APA PsycInfo, PubMed, Web of Science) were searched from inception to 2 April 2023. Randomized trials, including adults aged 18 years or above with a diagnosis of clinical depression, of the effects of aerobic exercise on cognitive function in adults with MDD compared to non-aerobic exercise groups were included. A three-level meta-analysis was conducted utilizing a random-effects model in R. The quality of the studies was evaluated using the Physiotherapy Evidence Database (PEDro) scale. The PROSPERO registration number is CRD42022367350.

Results

Twelve randomized trials including 945 adults with MDD were included. Results indicated that aerobic exercise significantly improved overall cognitive function (g = 0.21; 95 % confidence intervals [CI] = 0.07, 0.34), and the sub-domains of memory (g = 0.25; 95 % CI = 0.06, 0.44) and executive function (g = 0.12; 95 % CI = 0.04, 0.20). Significant benefits in cognitive function were found from moderate-to-vigorous (mixed) intensity (g = 0.19; 95 % CI = 0.02, 0.37), aerobic exercise conducted 3 times per week (g = 0.23; 95 % CI = 0.10, 0.38), in sessions < 45 min (g = 0.59; 95 % CI = 0.28, 0.90), and 45-60 min (g = 0.16; 95 % CI = 0.07, 0.26), in aerobic exercise intervention ≤ 12 weeks (g = 0. 26; 95 % CI = 0.08, 0.44).

Limitations

This review only included peer-reviewed English-language studies, which may lead to a language bias. The results of the Egger's test suggested a potential publication bias.

Conclusions

Aerobic exercise is efficacious in improving overall cognitive function and the sub-domains of memory and executive function in adults with major depressive disorder.

Effect of immersive virtual reality-based cognitive remediation in patients with mood or psychosis spectrum disorders: study protocol for a randomized, controlled, double-blinded trial

BACKGROUND

Cognitive impairments are prevalent across mood disorders and psychosis spectrum disorders, but there is a lack of real-life-like cognitive training programmes. Fully immersive virtual reality has the potential to ensure motivating and engaging cognitive training directly relevant to patients' daily lives. We will examine the effect of a 4-week, intensive virtual reality-based cognitive remediation programme involving daily life challenges on cognition and daily life functioning in patients with mood disorders or psychosis spectrum disorders and explore the neuronal underpinnings of potential treatment efficacy.

METHODS

The trial has a randomized, controlled, double-blinded, parallel-group design. We will include 66 symptomatically stable outpatients with mood disorders or psychosis spectrum disorders aged 18-55 years with objective and subjective cognitive impairment. Assessments encompassing a virtual reality test of daily life cognitive skills, neuropsychological testing, measures of daily life functioning, symptom ratings, questionnaires on subjective cognitive complaints, and quality of life are carried out at baseline, after the end of 4 weeks of treatment and at a 3-month follow-up after treatment completion. Functional magnetic resonance imaging scans are performed at baseline and at the end of treatment. The primary outcome is a broad cognitive composite score comprising five subtasks on a novel ecologically valid virtual reality test of daily life cognitive functions. Two complete data sets for 54 patients will provide a power of 80% to detect a clinically relevant between-group difference in the primary outcome. Behavioural data will be analysed using linear mixed models in SPSS, while MRI data will be analysed with the FMRIB Expert Analysis Tool (FEAT). Treatment-related changes in neural activity from baseline to end of treatment will be investigated for the dorsal prefrontal cortex and hippocampus as the regions of interest.

DISCUSSION

The results will provide insight into whether virtual reality-based cognitive remediation has beneficial effects on cognition and functioning in symptomatically stable patients with mood disorders or psychosis spectrum disorders, which can aid future treatment development.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06038955. Registered on September 15, 2023.

The longitudinal change pattern of cognitive subtypes in medication-free patients with major depressive disorder: a cluster analysis

This study aimed to investigate whether there are different cognitive subtypes in patients with major depressive disorder (MDD) and the change pattern of cognitive clusters across the course of MDD. A battery of comprehensive cognitive tests was used to assess the executive function, processing speed, attention, and memory of 153 medication-free patients and 142 healthy controls (HCs). After 6 months of treatment with antidepressants, 87 patients completed cognitive tests again. K-means cluster analysis was performed to determine the cognitive subtypes. A preserved cognition cluster and an impaired cognition cluster were identified in the acute episode phase and the 6-month follow-up phase. 80.5% of the patients remained in their original subgroup after 6 months of treatment. The impaired cognition cluster during the 6-month follow-up period could be predicted by impaired cognition during the episode phase, disease state (remission or non-remission), current illness duration, and education level. This study supporting the heterogeneity of cognitive performance across the course of disease in patients with MDD using cluster analysis. It was found that cognitive impairment during depressive episodes was predictive of poorer cognitive performance even after treatment with antidepressants. Therefore, interventions targeting cognitive function from the early stages of MDD is essential.

Long-term outcomes of an internet-delivered cognitive enhancement intervention targeting residual cognitive deficits after major depressive disorder: a 2-year follow-up of an open trial

Background

Cognitive deficits are common and disabling residual symptoms following major depressive disorder (MDD) and are related to increased risk of relapse. Residual cognitive deficits should thus be considered an important target for treatment. However, few have reported long-term outcomes of interventions targeting residual cognitive deficits.

Objective

This study aimed to (1) investigate change between pre-treatment and 2-year follow-up assessments in cognitive deficits, rumination, and symptoms of MDD after an internet-delivered intervention targeting residual cognitive deficits; (2) to investigate stability in outcomes between 6-month and 2-year follow-up assessments; (3) to report the number of participants' experiencing a new episode of MDD in the follow-up period; and (4) to investigate differences in outcomes between those who experienced a new episode of MDD and those who did not.

Methods

A total of 43 partly remitted adults were included to test a guided internet-delivered intervention, which consisted of 10 modules involving psychoeducation, cognitive strategies, and attention training. Participants were assessed at pre-treatment, post-treatment, after 6-months, and after 2-years, with measures assessing self-reported residual cognitive deficits, rumination, symptoms of MDD and relapse. Overall, 32 participants completed the 2-year follow-up assessment.

Results

Between the pre-treatment and 2-year follow-up assessments, there was a reduction in cognitive deficits and rumination, while there was an increase in symptoms of MDD. Cognitive deficits were stable between the 6-month and the 2-year follow-up, while there was an increase in rumination and symptoms of MDD. Thirteen of 32 participants reported a new episode of MDD during the follow-up period. The relapse group reported longer duration of MDD at pre-treatment and showed a difference in all outcomes after 2 years compared to the no-relapse group. The no-relapse group showed improvement in MDD symptoms at post-treatment, while the relapse group did not.

Conclusion

Delivering cognitive enhancement interventions over the internet is potentially related to stable improvements in residual cognitive deficits. The effects on rumination and symptoms of MDD are less certain. Lack of improvement in MDD symptoms after the intervention period should be investigated as an indicator of relapse. Results should be interpreted with caution due to the lack of control group and sample size.

Improvement in self-reported cognitive functioning but not in rumination following online working memory training in a two-year follow-up study of remitted major depressive disorder

Self-reported subjective cognitive difficulties (subjective deficits) and rumination are central residual cognitive symptoms following major depressive disorder (MDD). These are risk factors for more a severe course of illness, and despite the considerable relapse risk of MDD, few interventions target the remitted phase, a high-risk period for developing new episodes. Online distribution of interventions could help close this gap. Computerized working memory training (CWMT) shows promising results, but findings are inconclusive regarding which symptoms improve following this intervention, and its long-term effects. This study reports results from a longitudinal open-label two-year follow-up pilot-study of self-reported cognitive residual symptoms following 25 sessions (40 min), five times a week of a digitally delivered CWMT intervention. Ten of 29 patients remitted from MDD completed two-year follow-up assessment. Significant large improvements in self-reported cognitive functioning on the behavior rating inventory of executive function-adult version appeared after two-years (d = 0.98), but no significant improvements were found in rumination (d < 0.308) measured by the ruminative responses scale. The former showed moderate non-significant associations to improvement in CWMT both post-intervention (r = 0.575) and at two-year follow-up (r = 0.308). Strengths in the study included a comprehensive intervention and long follow-up time. Limitations were small sample and no control group. No significant differences between completers and drop-outs were found, however, attrition effects cannot be ruled out and demand characteristics could influence findings. Results suggested lasting improvements in self-reported cognitive functioning following online CWMT. Controlled studies with larger samples should replicate these promising preliminary findings.

Co-design of a Virtual Reality Cognitive Remediation Program for Depression (bWell-D) With Patient End Users and Clinicians: Qualitative Interview Study Among Patients and Clinicians

BACKGROUND

Major depressive disorder (MDD) is the leading cause of global disability; however, the existing treatments do not always address cognitive dysfunction-a core feature of MDD. Immersive virtual reality (VR) has emerged as a promising modality to enhance the real-world effectiveness of cognitive remediation.

OBJECTIVE

This study aimed to develop the first prototype VR cognitive remediation program for MDD ("bWell-D"). This study gathered qualitative data from end users early in the design process to enhance its efficacy and feasibility in clinical settings.

METHODS

Semistructured end-user interviews were conducted remotely (n=15 patients and n=12 clinicians), assessing the participants' perceptions and goals for a VR cognitive remediation program. Video samples of bWell-D were also shared to obtain feedback regarding the program. The interviews were transcribed, coded, and analyzed via thematic analysis.

RESULTS

End users showed an optimistic outlook toward VR as a treatment modality, and perceived it as a novel approach with the potential of having multiple applications. The participants expressed a need for an engaging VR treatment that included realistic and multisensorial settings and activities, as well as customizable features. Some skepticism regarding its effectiveness was also reported, especially when the real-world applications of the practiced skills were not made explicit, as well as some concerns regarding equipment accessibility. A home-based or hybrid (ie, home and clinic) treatment modality was preferred.

CONCLUSIONS

Patients and clinicians considered bWell-D interesting, acceptable, and potentially feasible, and provided suggestions to enhance its real-world applicability. The inclusion of end-user feedback is encouraged when developing future VR programs for clinical purposes.

Immersive virtual reality for improving cognitive deficits in children with ADHD: a systematic review and meta-analysis

Virtual reality (VR) shows great potential in treating and managing various mental health conditions. This includes using VR for training or rehabilitation purposes. For example, VR is being used to improve cognitive functioning (e.g. attention) among children with attention/deficit-hyperactivity disorder (ADHD). The aim of the current review and meta-analysis is to evaluate the effectiveness of immersive VR-based interventions for improving cognitive deficits in children with ADHD, to investigate potential moderators of the effect size and assess treatment adherence and safety. The meta-analysis included seven randomised controlled trials (RCTs) of children with ADHD comparing immersive VR-based interventions with controls (e.g. waiting list, medication, psychotherapy, cognitive training, neurofeedback and hemoencephalographic biofeedback) on measures of cognition. Results indicated large effect sizes in favour of VR-based interventions on outcomes of global cognitive functioning, attention, and memory. Neither intervention length nor participant age moderated the effect size of global cognitive functioning. Control group type (active vs passive control group), ADHD diagnostic status (formal vs. informal) and novelty of VR technology were not significant moderators of the effect size of global cognitive functioning. Treatment adherence was similar across groups and there were no adverse effects. Results should be cautiously interpreted given the poor quality of included studies and small sample.

Is suboptimal effort an issue? A systematic review on neuropsychological performance validity in major depressive disorder

BACKGROUND

In Major Depressive Disorder (MDD), emotion- and motivation related symptoms may affect effort during neuropsychological testing. Performance Validity Tests (PVT's) are therefore essential, but are rarely mentioned in research on cognitive functioning in MDD. We aimed to assess the proportion of MDD patients with demonstrated valid performance and determine cognitive functioning in patients with valid performance. This is the first systematic review on neuropsychological performance validity in MDD.

METHODS

Databases PubMed, PsycINFO, Embase, and Cochrane Library were searched for studies reporting on PVT results of adult MDD patients. We meta-analyzed the proportion of MDD patients with PVT scores indicative of valid performance.

RESULTS

Seven studies with a total of 409 MDD patients fulfilled inclusion criteria. Six studies reported the exact proportion of patients with PVT scores indicative of valid performance, which ranged from 60 to 100 % with a proportion estimate of 94 %. Four studies reported on cognitive functioning in MDD patients with valid performance. Two out of these studies found memory impairment in a minority of MDD patients and two out of these studies found no cognitive impairment.

LIMITATIONS

Small number of studies and small sample sizes.

CONCLUSIONS

A surprisingly small number of studies reported on PVT in MDD. About 94 % of MDD patients in studies using PVT's had valid neuropsychological test performance. Concessive information regarding cognitive functioning in MDD patients with valid performance was lacking. Neuropsychological performance validity should be taken into account since this may alter conclusions regarding cognitive functioning.

Examining the synergistic effects of a cognitive control video game and a home-based, self-administered non-invasive brain stimulation on alleviating depression: the DiSCoVeR trial protocol

Enhanced behavioral interventions are gaining increasing interest as innovative treatment strategies for major depressive disorder (MDD). In this study protocol, we propose to examine the synergistic effects of a self-administered home-treatment, encompassing transcranial direct current stimulation (tDCS) along with a video game based training of attentional control. The study is designed as a two-arm, double-blind, randomized and placebo-controlled multi-center trial (ClinicalTrials.gov: NCT04953208). At three study sites (Israel, Latvia, and Germany), 114 patients with a primary diagnosis of MDD undergo 6 weeks of intervention (30 × 30 min sessions). Patients assigned to the intervention group receive active tDCS (anode F3 and cathode F4; 2 mA intensity) and an action-like video game, while those assigned to the control group receive sham tDCS along with a control video game. An electrode-positioning algorithm is used to standardize tDCS electrode positioning. Participants perform their designated treatment at the clinical center (sessions 1-5) and continue treatment at home under remote supervision (sessions 6-30). The endpoints are feasibility (primary) and safety, treatment efficacy (secondary, i.e., change of Montgomery-Åsberg Depression Rating Scale (MADRS) scores at week six from baseline, clinical response and remission, measures of social, occupational, and psychological functioning, quality of life, and cognitive control (tertiary). Demonstrating the feasibility, safety, and efficacy of this novel combined intervention could expand the range of available treatments for MDD to neuromodulation enhanced interventions providing cost-effective, easily accessible, and low-risk treatment options.ClinicalTrials.gov: NCT04953208.

Gamification improves antidepressant effects of cognitive control training-A pilot trial

OBJECTIVE

Computerised cognitive trainings have been put forward to improve control over negatively biased information processing and associated depressive symptomatology. Yet, disease-related impairments of motivation and endurance, as well as insufficient accessibility hinder use of this promising therapeutic opportunity. Here, we developed an app (de:)press^© ) that utilizes a cognitive control training (paced auditory serial addition task) enriched with gamification and information elements. We compared a six-week training with de:)press^© to a non-gamified version (active control group).

METHODS

Thirty-two depressed participants were included. Each received either de:)press^© or the non-gamified version and was instructed to train three times per week for two weeks. Afterwards (four weeks) they were free to train at their own discretion. Depression severity was assessed during training and two follow-up sessions. Primary endpoint was defined as difference between groups [change of Montgomery-Åsberg Depression Rating Scale (MADRS)] four weeks after end of training.

RESULTS

Depression severity decreased in both groups. At primary endpoint, MADRS scores were significantly lower in the de:)press^© -group compared to the control group. No differences were observed at three months' follow-up. Intervention usability was consistently rated positively. Participants who had trained with de:)press^© maintained the recommended training frequency without further prompting. Besides transient fatigue or frustration, no adverse effects were observed.

CONCLUSION

This pilot demonstrates that gamification and information elements can substantially increase cognitive control training efficacy in alleviating depressive symptoms. Moreover, it provides first evidence for the feasibility and efficacy of de:)press^© as an add-on intervention to treat depression.

CLINICAL TRIAL REGISTRATION

The study is registered under ClinicalTrials.gov, identifier: NCT04400162.

What role for cognitive remediation in the treatment of depressive symptoms? A superiority and noninferiority meta-analysis for clinicians

BACKGROUND

Cognitive remediation (CR) is a promising technique in the treatment of the cognitive dimension of depression. The present study evaluated the potential of CR in treating depressive symptoms and provides practical information about its usefulness in clinical settings.

METHODS

We performed two meta-analyses of published randomized (and nonrandomized) clinical trials, comparing CR to control conditions in subjects with current depressive symptomatology. The superiority meta-analysis aimed to determine the superiority of CR when compared with placebo/waiting list interventions and its efficacy when used as an augmentation therapy. The noninferiority meta-analysis determined whether CR had noninferior efficacy compared with standard antidepressant interventions.

RESULTS

CR was found to significantly improve depressive symptomatology in the superiority meta-analysis (CR: n = 466, control n = 478). Moreover, CR seemed to be noninferior to standard antidepressant interventions (CR: n = 230, control n = 235). CR was more effective when addressing hot (vs. cold) cognition, when involving younger patients (i.e., <30 years), and in the case of mild-moderate (vs. severe) depression.

CONCLUSIONS

CR should be considered an augmentation treatment to improve treatment outcomes in depressed subjects, especially among young individuals. Interventions addressing hot cognition seem to be the most promising.

Computerized Working Memory Training in Remission From Major Depressive Disorder: Effects on Emotional Working Memory, Processing Speed, Executive Functions, and Associations With Symptoms

Introduction

Remission from major depressive disorder (MDD) is associated with residual symptoms related to reduced functioning, quality of life, and relapse risk. Previous studies have raised questions about mechanisms involved-in and affected by cognitive training. This study investigated the associations and changes among depressive symptoms, rumination, processing speed (PS), executive functioning (EF), and emotional working memory (e-WM) pre- post computerized working memory training (CWMT).

Method

Twenty-nine remitted participants were included in a pre- post pilot study of within-subject effects of online CWMT. A total of 20 participants completed the intervention and pre- post tests of EF and PS, e-WM, in addition to symptom and rumination measures. Associations between changes in symptoms and cognition were investigated pre- post. Associations between improvements in CWMT, depression history, and changes in cognition were explored. Hypotheses and statistics were preregistered before data were analyzed.

Results

Manipulation of negatively valanced stimuli in e-WM showed an inverse association with rumination pre-intervention, but the association disappeared post-intervention. Cognitive functioning improved in most conditions with largest effects in EF. Symptoms did not change in the remitted sample. CWMT improvements were related to improvements in some aspects of EF and PS, but also to worse self-reported attention. Depression history was related to less improvement in EF.

Limitations

Sample size was small and there was dropout from the study. There was no control group, thus precluding practice and placebo effects and causal relationships.

Conclusions

Computerized WM training improves cognitive functions and could influence associations between e-WM and rumination. This could counteract functional impairment following MDD.

Augmenting neurocognitive remediation therapy to Preventive Cognitive Therapy for partially remitted depressed patients: protocol of a pragmatic multicentre randomised controlled trial

INTRODUCTION

Major depressive disorder (MDD) affects 163 million people globally every year. Individuals who experience subsyndromal depressive symptoms during remission (ie, partial remission of MDD) are especially at risk for a return to a depressive episode within an average of 4 months. Simultaneously, partial remission of MDD is associated with work and (psycho)social impairment and a lower quality of life. Brief psychological interventions such as preventive cognitive therapy (PCT) can reduce depressive symptoms or relapse for patients in partial remission, although achieving full remission with treatment is still a clinical challenge. Treatment might be more effective if cognitive functioning of patients is targeted as well since cognitive problems are the most persisting symptom in partial remission and predict poor treatment response and worse functioning. Studies show that cognitive functioning of patients with (remitted) MDD can be improved by online neurocognitive remediation therapy (oNCRT). Augmenting oNCRT to PCT might improve treatment effects for these patients by strengthening their cognitive functioning alongside a psychological intervention.

METHODS AND ANALYSIS

This study will examine the effectiveness of augmenting oNCRT to PCT in a pragmatic national multicentre superiority randomised controlled trial. We will include 115 adults partially remitted from MDD with subsyndromal depressive symptoms defined as a Hamilton Depression Rating Scale score between 8 and 15. Participants will be randomly allocated to PCT with oNCRT, or PCT only. Primary outcome measure is the effect on depressive symptomatology over 1 year. Secondary outcomes include time to relapse, cognitive functioning, quality of life and healthcare costs. This first dual approach study of augmenting oNCRT to PCT might facilitate full remission in partially remitted individuals as well as prevent relapse over time.

ETHICS AND DISSEMINATION

Ethical approval was obtained by Academic Medical Center, Amsterdam. Outcomes will be made publicly available.

TRIAL REGISTRATION NUMBER

NL9582.

Cognitive Remediation in Psychiatric Disorders: State of the Evidence, Future Perspectives, and Some Bold Ideas

Many people with psychiatric disorders experience impairments in cognition. These deficits have a significant impact on daily functioning and sometimes even on the further course of their disease. Cognitive remediation (CR) is used as an umbrella term for behavioral training interventions to ameliorate these deficits. In most but not all studies, CR has proven effective in improving cognition and enhancing everyday functional outcomes. In this paper, after quickly summarizing the empirical evidence, practical advice to optimize the effects of CR interventions is provided. We advocate that CR interventions should be as fun and motivating as possible, and therapists should at least consider using positively toned emotional stimuli instead of neutral stimuli. Participants should be screened for basic processing deficits, which should be trained before CR of higher-order cognitive domains. CR should stimulate metacognition and utilize natural settings to invoke social cognition. Wherever possible, CR tasks should link to tasks that participants face in their everyday life. Therapists should consider that participants might also benefit from positive side effects on symptomatology. Finally, the CR approach might even be utilized in settings where the treatment of cognitive impairments is not a primary target.

Effect of Vagus Nerve Stimulation on Attention and Working Memory in Neuropsychiatric Disorders: A Systematic Review

BACKGROUND

It has been suggested that vagus nerve stimulation (VNS) may enhance attention and working memory. The neuromodulator effects of VNS are thought to activate the release of neurotransmitters involving cognition and to promote neuronal plasticity. Therefore, VNS has been studied for its effects on attention and working memory impairment in neuropsychiatric disorders.

OBJECTIVES

This study aimed to assess the effects of VNS on attention and working memory among patients with neuropsychiatric disorders, examine stimulation parameters, provide mechanistic hypotheses, and propose future studies using VNS.

MATERIALS AND METHODS

We conducted a systematic review using electronic databases MEDLINE (Ovid), Embase (Ovid), Cochrane library, and PsycINFO (Ovid). Narrative analysis was used to describe the therapeutic effects of VNS on attention and working memory, describe stimulation parameters, and propose explanatory mechanisms.

RESULTS

We identified 20 studies reporting VNS effects on attention and working memory in patients with epilepsy or mood disorders. For epilepsy, there was one randomized controlled trial from all 18 studies. It demonstrated no statistically significant differences in the cognitive tasks between active and control VNS. From a within-subject experimental design, significant improvement of working memory after VNS was demonstrated. One of three nonrandomized controlled trials found significantly improved attentional performance after VNS. The cohort studies compared VNS and surgery and found attentional improvement in both groups. Nine of 12 pretest-posttest studies showed improvement of attention or working memory after VNS. For mood disorders, although one study showed significant improvement of attention following VNS, the other did not.

CONCLUSIONS

This review suggests that, although we identified some positive results from eligible studies, there is insufficient good-quality evidence to establish VNS as an effective intervention to enhance attention and working memory in persons with neuropsychiatric disorders. Further studies assessing the efficacy of such intervention are needed.

Influence of pre-treatment structural brain measures on effects of action-based cognitive remediation on executive function in partially or fully remitted patients with bipolar disorder

Cognitive impairment is an emerging treatment target in patients with bipolar disorder (BD) but so far, no evidence-based treatment options are available. Recent studies indicate promising effects of Cognitive Remediation (CR) interventions, but it is unclear who responds most to these interventions. This report aimed to investigate whether pre-treatment dorsal prefrontal cortex (dPFC) thickness predicts improvement of executive function in response to Action-Based Cognitive Remediation (ABCR) in patients with BD. Complete baseline magnetic resonance imaging (MRI) data were available from 45 partially or fully remitted patients with BD from our randomized controlled ABCR trial (ABCR: n = 25, control group: n = 20). We performed cortical reconstruction and volumetric segmentation using FreeSurfer. Multiple linear regression analysis was conducted to assess the influence of dPFC thickness on ABCR-related executive function improvement, reflected by change in the One Touch Stocking of Cambridge performance from baseline to post-treatment. We also conducted whole brain vertex wise analysis for exploratory purposes. Groups were well-matched for demographic and clinical variables. Less pre-treatment dPFC thickness was associated with greater effect of ABCR on executive function (p = 0.02). Further, whole-brain vertex analysis revealed an association between smaller pre-treatment superior temporal gyrus volume and greater ABCR-related executive function improvement. The observed associations suggest that structural abnormalities in dPFC and superior temporal gyrus are key neurocircuitry treatment targets for CR interventions that target impaired executive function in BD.

A randomised controlled trial of psychotherapy and cognitive remediation to target cognition in mood disorders

OBJECTIVE

To examine the impact of a treatment package combining Interpersonal and Social Rhythm Therapy (IPSRT) and cognitive remediation (CR), vs IPSRT alone, on cognition, functioning, and mood disturbance outcomes in mood disorders.

METHODS

A pragmatic randomised controlled trial in adults with bipolar disorder (BD) or major depressive disorder (MDD), recently discharged from mental health services in Christchurch, New Zealand, with subjective cognitive difficulties. Individuals were randomised to a 12-month course of IPSRT with CR (IPSRT-CR), or without CR (IPSRT). In IPSRT-CR, CR was incorporated into therapy sessions from approximately session 5 and continued for 12 sessions. The primary outcome was change in Global Cognition (baseline to 12 months).

RESULTS

Sixty-eight individuals (BD n = 26, MDD n = 42; full/partial remission n = 39) were randomised to receive IPSRT-CR or IPSRT (both n = 34). Across treatment arms, individuals received an average of 23 IPSRT sessions. Change in Global Cognition did not differ between arms from baseline to treatment-end (12 months). Psychosocial functioning and longitudinal depression symptoms improved significantly more in the IPSRT compared with IPSRT-CR arm over 12 months, and all measures of functioning and mood symptoms showed moderate effect size differences favouring IPSRT (0.41-0.60). At 18 months, small to moderate, non-significant benefits (0.26-0.47) of IPSRT vs IPSRT-CR were found on functioning and mood outcomes.

CONCLUSIONS

Combining two psychological therapies to target symptomatic and cognitive/functional recovery may reduce the effect of IPSRT, which has implications for treatment planning in clinical practice and for CR trials in mood disorders.

Randomised controlled trial of Interpersonal and Social Rhythm Therapy and group-based Cognitive Remediation versus Interpersonal and Social Rhythm Therapy alone for mood disorders: study protocol

BACKGROUND

Individuals with mood disorders frequently experience cognitive impairment, which impacts on the long-term trajectory of the disorders, including being associated with persisting difficulties in occupational and psychosocial functioning, residual mood symptoms, and relapse. Current first-line treatments for mood disorders do little to improve cognitive function. Targeting cognition in clinical research is thus considered a priority. This protocol outlines a prospectively-registered randomised controlled trial (RCT) which examines the impact of adding group-based Cognitive Remediation (CR) to Interpersonal and Social Rhythm Therapy (IPSRT-CR) for individuals with mood disorders.

METHODS

This is a pragmatic, two-arm, single-blinded RCT comparing IPSRT-CR with IPSRT alone for adults (n = 100) with mood disorders (Major Depressive Disorder or Bipolar Disorder) with subjective cognitive difficulties, on discharge from Specialist Mental Health Services in Christchurch, New Zealand. Both treatment arms will receive a 12-month course of individual IPSRT (full dose = 24 sessions). At 6 months, randomisation to receive, or not, an 8-week group-based CR programme (Action-based Cognitive Remediation - New Zealand) will occur. The primary outcome will be change in Global Cognition between 6 and 12 months (treatment-end) in IPSRT-CR versus IPSRT alone. Secondary outcomes will be change in cognitive, functional, and mood outcomes at 6, 12, 18, and 24 months from baseline and exploratory outcomes include change in quality of life, medication adherence, rumination, and inflammatory markers between treatment arms. Outcome analyses will use an intention-to-treat approach. Sub-group analyses will assess the impact of baseline features on CR treatment response. Participants' experiences of their mood disorder, including treatment, will be examined using qualitative analysis.

DISCUSSION

This will be the first RCT to combine group-based CR with an evidence-based psychotherapy for adults with mood disorders. The trial may provide valuable information regarding how we can help promote long-term recovery from mood disorders. Many issues have been considered in developing this protocol, including: recruitment of the spectrum of mood disorders, screening for cognitive impairment, dose and timing of the CR intervention, choice of comparator treatment, and choice of outcome measures.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry, ACTRN12619001080112 . Registered on 6 August 2019.

Efficacy of cognitive therapy and behavior therapy for menopausal symptoms: a systematic review and meta-analysis

BACKGROUND

T long-term effects of cognitive therapy and behavior therapy (CTBT) for menopausal symptoms are unknown, and whether the effects are different between natural menopause and treatment-induced menopause are currently unclear. Therefore, we sought to conduct an accurate estimate of the efficacy of CTBT for menopausal symptoms.

METHODS

We conducted searches of Cochrane Library, EMBASE, PsycINFO, PubMed, and Web of Science databases for studies from 1 January 1977 to 1 November 2021. Randomized controlled trials (RCTs) comparing intervention groups to control groups for menopausal symptoms were included. Hedge's g was used as the standardized between-group effect size with a random-effects model.

RESULTS

We included 14 RCTs comprising 1618 patients with a mean sample size of 116. CTBT significantly outperformed control groups in terms of reducing hot flushes [g = 0.39, 95% confidence interval (CI) 0.23-0.55, I2 = 45], night sweats, depression (g = 0.50, 95% CI 0.34-0.66, I2 = 51), anxiety (g = 0.38, 95% CI 0.23-0.54, I2 = 49), fatigue, and quality of life. Egger's test indicated no publication bias.

CONCLUSIONS

CTBT is an effective psychological treatment for menopausal symptoms, with predominantly small to moderate effects. The efficacy is sustained long-term, although it declines somewhat over time. The efficacy was stronger for natural menopause symptoms, such as vasomotor symptoms, than for treatment-induced menopause symptoms. These findings provide support for treatment guidelines recommending CTBT as a treatment option for menopausal symptoms.

Computerized cognitive training in people with depression: a protocol for a systematic review and meta-analysis

BACKGROUND

People with depression often present with concurrent cognitive impairment. Computerized cognitive training (CCT) is a safe and efficacious strategy to maintain or enhance cognitive performance in a range of clinical populations. However, its efficacy in people with depression and how it varies across populations and design factors are currently unclear.

METHODS

We searched MEDLINE, EMBASE, and PsycINFO from inception to 13 July 2021 for randomised controlled trials examining the efficacy of CCT vs any control condition on cognitive, mood, psychiatric symptoms, psychosocial, and daily functioning in adults with depression. Eligible samples include studies specifically targeting people with major depressive disorder as well as those with other diagnoses where at least 50% of the sample meets the clinical criteria for depression, with the exception of major psychiatric disorders or dementia. The primary outcome is change in the overall cognitive performance. Multivariate analyses will be used to examine the effect sizes on each outcome category as well as possible effect modifiers and correlations between categories. The risk of bias will be assessed using the Cochrane risk of bias tool version 2.

DISCUSSION

To the best of our knowledge, this will be the first systematic review and meta-analysis of narrowly defined CCT across clinical populations with depression. We aim to investigate not only whether CCT is efficacious for cognition, but also how such effects vary across design factors, what other clinically relevant outcomes might respond to CCT, and the extent to which they differ across populations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020204209.

Cognitive Impairment and Neurocognitive Profiles in Major Depression-A Clinical Perspective

Increasingly, studies have investigated cognitive functioning from the perspective of acute state- to remitted phases of Major Depressive Disorder (MDD). Some cognitive deficits observed in the symptomatic phase persist in remission as traits or scars. The etiological origin and clinical consequences of the neurocognitive profiles reported in the literature are still unclear and may vary across populations. Deficits are suspected to influence the association between MDD and neurodegenerative disorders and could thus be of particular clinical consequence. The aim of this review is to describe the clinical neuropsychological profile in MDD and how it is related to research during the past decade on cognitive deficits in MDD from a state, trait, and scar perspective. This review, with a clinical perspective, investigates research from the past decade regarding cognitive functioning in MDD in a long-term perspective. We focus on the clinical manifestation of deficits, and the potential neurodegenerative consequences of the neurocognitive profile in MDD. Searches in Medline, PsycINFO and Embase were conducted targeting articles published between 2010 and 2020. Examination of the evidence for long-lasting neurocognitive deficits in major depression within the cognitive domains of Memory, Executive Functions, Attention, and Processing Speed was conducted and was interpreted in the context of the State, Scar and Trait hypotheses. Defining the neurocognitive profiles in MDD will have consequences for personalized evaluation and treatment of residual cognitive symptoms, and etiological understanding of mood disorders, and treatments could potentially reduce or delay the development of neurodegenerative disorders.

Defining Autonomy in Psychiatry

Mental illness undermines a patient's personal autonomy: the capacities of a person that enables them to live a meaningful life of their own making. So far there has been very little attention given to personal autonomy within psychiatry. This is unfortunate as personal autonomy is disturbed in different ways in psychiatric disorders, and understanding how autonomy is affected by mental illness is crucial for differential diagnosis and treatment, and also for understanding personal recovery. We will argue that disturbance of personal autonomy is related to patient's diminished quality of life and suffering that motivates seeking treatment. We hypothesize that (1) personal autonomy is generally reduced by mental illness but (2) the effects on autonomy are expressed differently according to the underlying psychopathology, and also vary according to the (3) context, and perspective of the individual patient. We provide a discussion of how autonomy can be affected in five prototypical mental disorders; Major Depressive Disorder, Substance-use Disorders, Obsessive Compulsive Disorder, Anorexia Nervosa and Schizophrenia. We take these disorders to be illustrative of how diminished autonomy is a central but overlooked dimension of mental illness. We will use our discussion of these disorders as the basis for identifying key dimensions of autonomy that could be relevant to innovate treatment of psychiatric disorders.

A randomized controlled trial of cognitive control training (CCT) as an add-on treatment for late-life depression: a study protocol

BACKGROUND

Already a major health concern, late-life depression (LLD) is expected to form an increasing problem in the aging population. Moreover, despite current treatments, LLD is associated with a poor long-term prognosis and high rate of chronicity. Treatment provision and treatment accordingly warrant improvement, where add-on treatments might contribute to the efficacy of conventional therapies. Although it is known that impaired cognitive control contributes to LDD, it is not targeted sufficiently by current interventions. Research on cognitive control training (CCT) shows promising results on depressive symptoms, cognitive performance, and overall functioning. However, further research is needed to determine the long-term effects of CCT on LLD, its cost-effectiveness, and mechanisms of change.

METHODS

In the current multicenter randomized controlled trial (RCT) with a between-subjects design participants aged 60 years and over with a current LLD receiving treatment as usual (TAU) are randomized to add-on CCT or placebo training. Randomization is stratified by depression severity. Participants will receive eight online CCT or placebo sessions spread across four consecutive weeks. They will complete a post-training assessment after 1 month and three follow-up assessments scheduled three, six and 12 months after completing the training. We expect CCT and TAU to be more (cost-)effective in reducing depressive symptoms than placebo training and TAU. Additionally, we will be looking at secondary clinical, cognitive and global functioning outcomes and likely mechanisms of change (e.g., improved cognitive functioning, reduced rumination, and improved inhibition of negative stimuli).

DISCUSSION

The proposed RCT aims to contribute to the clinical and scientific knowledge on the long-term effects of CCT as an add-on treatment for LLD. Cost-effectiveness is particularly relevant considering the expected volume of the target demographic. The study will be a pragmatic trial with few inclusion restrictions, providing information on feasibility of web-based trainings in clinical settings. The outcomes are potentially generalizable to guidelines for treatment of LLD.

TRIAL REGISTRATION

This trial is registered in the Netherlands Trial Register (code: NL7639 ). Registered 3 april 2019.

Goal Management Training and Computerized Cognitive Training in Depression-a 2-Year Follow-Up of a Randomized Controlled Trial

Objective: Information on the long-term effects of cognitive remediation (CR) in major depressive disorder (MDD) is lacking. The present study reports 2-year follow-up data from a previously published randomized controlled trial (RCT) from our research group, comparing Goal Management Training (GMT), a strategy-based CR intervention, to drill-and-practice computerized cognitive training (CCT). In previous work, we found comparable improvements in executive function (EF), in addition to reductions in depressive symptoms, following both GMT and CCT at 6-month follow-up. Methods: Forty-two participants of the RCT, all diagnosed with MDD, were invited to complete rating-scales pertaining daily-life EF, rumination, and depressive symptoms. Explorative analyses compared the 2-year follow-up with previously published baseline and 6-month follow-up data, using non-parametric statistics. Similarly, GMT and CCT were compared at the 2-year follow-up, and completers were compared with non-completers. Results: Twenty participants completed the study. Overall, completers (n = 20) and non-completers (n = 22) were similar. There were no significant differences between GMT (n = 11) and CCT (n = 9) for any outcome 2 years post-treatment. Reduction compared to baseline in depressive symptoms and rumination, but not in daily-life EFs, emerged for GMT only. Conclusions: Findings suggest long-term improvements in mental health following GMT, while improvements in everyday EFs might require additional treatment or maintenance to sustain. Caution is warranted in the interpretation due to the small sample size and high attrition rates.