Remediation of memory disorders in schizophrenia

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.

The MATRICS Consensus Cognitive Battery: An Update

Through a series of NIMH-supported consensus-building meetings of experts and empirical comparisons of candidate tests, the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative developed a battery of standardized cognitive measures to allow reliable evaluation of results from clinical trials of promising interventions for core cognitive deficits in this disorder. Ten tests in seven cognitive domains were selected for the MATRICS Consensus Cognitive Battery (MCCB). The MCCB has now been translated into 39 languages/dialects and has been employed in more than 145 clinical trials. It has become the standard cognitive change measure for studies of both pharmacological and training-based interventions seeking to improve cognitive deficits in schizophrenia. We summarize its applications and its relationship to the subsequent development of the NIMH RDoC Matrix.

The characteristics of cognitive neuroscience tests in a schizophrenia cognition clinical trial: Psychometric properties and correlations with standard measures

In comparison to batteries of standard neuropsychological tests, cognitive neuroscience tests may offer a more specific assessment of discrete neurobiological processes that may be aberrant in schizophrenia. However, more information regarding psychometric properties and correlations with standard neuropsychological tests and functional measures is warranted to establish their validity as treatment outcome measures. The N-back and AX-Continuous Performance Task (AX-CPT) are two promising cognitive neuroscience tests designed to measure specific components of working memory and contextual processing respectively. In the current study, we report the psychometric properties of multiple outcome measures from these two tests as well as their correlations with standard neuropsychological measures and functional capacity measures. The results suggest that while the AX-CPT and N-back display favorable psychometric properties, they do not exhibit greater sensitivity or specificity with functional measures than standard neurocognitive tests.

A randomized controlled trial of working memory and processing speed training in schizophrenia

BACKGROUND

Although prior research has shown that cognitive training may improve cognition for schizophrenia patients, it is currently unclear which domains of cognition should be targeted in training. One suggestion is to target low- or mid-level cognitive processes. In particular, working memory (WM) and processing speed (PS) have been named as two key areas of impairment in schizophrenia, and two domains of cognition that are linked to higher-order cognition and daily functioning. This study aimed to investigate the near-transfer (transfer of gains to related contexts), far-transfer (transfer of gains to unrelated contexts), and real-world gains associated with WM and PS training in schizophrenia.

METHODS

Eighty-three participants with schizophrenia were recruited and randomly assigned to computerized WM training, PS training, or a no-training control group. Outcome measures included WM, PS, fluid intelligence, executive functioning, social cognition, and daily functioning and symptoms.

RESULTS

PS training led to significant gains in untrained PS tasks, as well as gains in far-transfer tasks that required speed of processing. WM training did not lead to gains in untrained WM tasks and showed inconsistent effects on some far-transfer tasks.

CONCLUSIONS

These results suggest some benefit of domain-specific cognitive training, specifically PS training, in schizophrenia. Far-transfer of gains to other cognitive domains and to real-world functioning may not occur after targeted WM or PS training, though non-specific effects (e.g. through behavioral activation, increased motivation) may lead to improvements in some tasks. Future studies should continue to investigate the mechanisms by which cognitive training may enhance cognition and functioning in schizophrenia.

A systematic review of factors that influence the efficacy of cognitive remediation therapy in schizophrenia

OBJECTIVE

Cognitive remediation therapy is a moderately effective intervention for ameliorating cognitive deficits in individuals with schizophrenia-related disorders. With reports of considerable variability in individual response to cognitive remediation therapy, we need to better understand factors that influence cognitive remediation therapy efficacy to realise its potential. A systematic review was conducted to identify and evaluate predictors of cognitive outcome.

METHODS

An electronic database search was conducted identifying peer-reviewed articles examining predictors of cognitive response to cognitive remediation therapy.

RESULTS

A total of 40 articles accounting for 1681 cognitive remediation therapy participants were included; 81 distinct predictors of cognitive response were identified. Data synthesis and discussion focused on 20 predictors examined a minimum three times in different studies. Few of the examined predictors of cognitive outcome following cognitive remediation therapy were significant when examined through systematic review. A strong trend was found for baseline cognition, with reasoning and problem solving and working memory being strongly predictive of within-domain improvement. Training task progress was the most notable cross-domain predictor of cognitive outcome.

CONCLUSION

It remains unclear why a large proportion of participants fail to realise cognitive benefit from cognitive remediation therapy. However, when considering only those variables where a majority of articles reported a statistically significant association with cognitive response to cognitive remediation therapy, three stand out: premorbid IQ, baseline cognition and training task progress. Each of these relates in some way to an individual's capacity or potential for change. There is a need to consolidate investigation of potential predictors of response to cognitive remediation therapy, strengthening the evidence base through replication and collaboration.

Effects of cognitive remediation therapy versus other interventions on cognitive functioning in schizophrenia inpatients

Computerised cognitive remediation therapy (CCRT) has been shown to improve cognitive function in individuals with schizophrenia beyond effects of other forms of therapy. However, results vary between studies, and most are aimed at individuals who are living in the community. Very few studies have investigated its efficacy in psychiatric wards in order to assess whether or not this is a suitable site to start the therapy. This study evaluated CCRT efficacy among schizophrenia inpatients who received a broad range of therapeutic interventions in a psychiatric ward. A randomised controlled trial of CCRT versus an active control in 66 young inpatients with a diagnosis of schizophrenia was conducted. The intervention lasted for 6 weeks and its efficacy was assessed with the composite score of the MATRICS Consensus Cognitive Battery. Both groups improved similarly in cognitive function and psychopathological symptoms. However, the CCRT group improved more than the controls in negative symptoms. This result shows that providing a drill and practice cognitive remediation to inpatients does not produce benefits for cognitive functioning substantially greater than other forms of therapy provided in a ward, but it is more efficient in reduction of negative symptoms. Our results suggest that CRT might be considered as a promising intervention for reducing negative symptoms in schizophrenia individuals.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cognitive Remediation in Middle-Aged or Older Inpatients with Chronic Schizophrenia: A Randomized Controlled Trial in Korea

Background: Accumulating evidence indicates that cognitive remediation (CR) is effective for improving various cognitive deficits in adult patients with schizophrenia. Although reports of brain plasticity in older adults and the service needs for chronic patients with schizophrenia are increasing, very few randomized controlled trials of CR have been conducted in middle-aged or older inpatients with chronic schizophrenia. We investigated the efficacy of individualized CR on the cognitive impairments of middle-aged or older inpatients with chronic schizophrenia within the context of comprehensive psychiatric rehabilitation (PR) by comparing the results obtained with PR only and treatment as usual (TAU). Method: Fifty-seven middle-aged and older individuals with chronic schizophrenia and mild to moderate cognitive deficits were enrolled. Thirty-eight who were undergoing PR were randomly assigned to CR + PR (N = 19) or PR-only (N = 19) groups. Nineteen participants who were undergoing TAU without CR or PR were evaluated pre- and post-treatment. Results: CR was easily provided and well received (drop-out rates = 5.3%) by middle-aged or older psychiatric inpatients. Compared to the PR-Only or TAU patients, patients in the CR + PR group showed greater improvement in executive functioning. Compared to TAU patients, CR + PR and PR-only patients showed greater improvement in logical memory. More patients in the CR + PR group improved clinically significantly in executive functioning and logical memory, compared with the PR-only and TAU patients. Conclusions: These results suggested that CR improved some cognitive deficits in middle-aged or older inpatients with chronic schizophrenia and that it was effective as an adjunctive treatment to the usual PR services provided in inpatient settings. Clinical Registration: KCT0002609.

Verbal Learning and Memory Enhancement Strategies in Schizophrenia: A Randomized, Controlled Investigation

OBJECTIVES

Verbal episodic memory is a key domain of impairment in people with schizophrenia with close ties to a variety of aspects of functioning and therapeutic treatment response. A randomized, blinded trial of two mnemonic strategies for verbal episodic memory deficits for people with schizophrenia was conducted.

METHODS

Sixty-one people with schizophrenia were assigned to one of three experimental conditions: training in a mnemonic strategy that included both visualization and narrative structure (Story Method), a condition in which participants were trained to visualize words interacting with one another (Imagery), or a non-trained control condition in which participants received equivalent exposure to training word lists and other verbal memory assessments administered in the other two conditions, but without provision of any compensatory mnemonic strategy. Participants were assessed on improvements in recall of the word list used as part of training, as well as two, standardized verbal memory assessments which included stimuli not used as part of strategy training.

RESULTS

The Story Method produced improvements on a trained word list that generalized to a non-trained, prose memory task at a 1-week follow-up. In contrast, provision of a mnemonic strategy of simple visualization of words produced little improvement on word recall of trained words or on measures of generalization relative to the performance of participants in the control condition.

CONCLUSIONS

These findings support the inclusion of enriched mnemonic strategies consisting of both visualization and narrative structure in sustained and comprehensive programs of CR for enhancement of verbal episodic memory in schizophrenia. (JINS, 2017, 23, 352-357).

Pharmacological Augmentation of Psychosocial and Remediation Training Efforts in Schizophrenia

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

The effect of cognitive training on evoked potentials in schizophrenia

Electrophysiological indices are sensitive to cognitive dysfunction in schizophrenia but have rarely been used to assess benefits of cognitive remediation. Our aim was to evaluate the effect of specific cognitive training approaches on event-related potentials.

Forty-six patients with schizophrenia underwent either auditory (AUD) or visuo-spatial (VIS) cognitive training or treatment-as-usual (TAU). Cognitive training was computer-assisted and administered for 10 sessions within two weeks. Event-related potentials during an active odd-ball paradigm together with clinical and neuropsychological variables were assessed before and after training and again at a two-month follow-up.

Compared to the TAU group both the AUD and VIS training groups showed decreased P2 latency following training. At follow-up, the P2-latency reduction was stable in the VIS group but the AUD group experienced a relapse. Training resulted in improved digit-span backward among neuropsychological variables. Increased P2 amplitude was related to more positive symptoms and lower social-occupational functioning and longer P2 latency was associated with greater severity of stereotyped thinking.

The more general visuo-spatial training appears to have a longer-lasting effect on P2 latency than the specific auditory training. Alternatively, there may be specific auditory discrimination deficits in schizophrenia requiring more extensive training for a stable change.

Developing a Cognitive Training Strategy for First-Episode Schizophrenia: Integrating Bottom-Up and Top-Down Approaches

It is clear that people with schizophrenia typically have cognitive problems in multiple domains as part of their illness. The cognitive deficits are among the main contributors to limitations in their everyday functioning, including their work recovery. Cognitive remediation has been applied successfully to help people with long-term, persistent schizophrenia to improve their cognitive functioning, but it is only beginning to be applied with individuals who have recently had a first episode of psychosis. Several different approaches to cognitive training have been developed. Some approaches emphasize extensive systematic practice with lower-level cognitive processes and building toward higher-level processes ("bottom-up"), while others emphasize greater focus on high-level cognitive processes that normally integrate and organize lower-level processes ("top-down"). Each approach has advantages and disadvantages for a disorder like schizophrenia, with its multiple levels of cognitive dysfunction. In addition, approaches to cognitive remediation differ in the extent to which they systematically facilitate transfer of learning to everyday functioning. We describe in this article the cognitive training approach that was developed for a UCLA study of people with a recent first episode of schizophrenia, a group that may benefit greatly from early intervention that focuses on cognition and recovery of work functioning. This approach integrated bottom-up and top-down computerized cognitive training and incorporated an additional weekly group session to bridge between computerized training and application to everyday work and school functioning.

A systematic review on improving cognition in schizophrenia: which is the more commonly used type of training, practice or strategy learning?

BACKGROUND

The purpose of this article was to conduct a review of the types of training offered to people with schizophrenia in order to help them develop strategies to cope with or compensate for neurocognitive or sociocognitive deficits.

METHODS

We conducted a search of the literature using keywords such as "schizophrenia", "training", and "cognition" with the most popular databases of peer-reviewed journals.

RESULTS

We reviewed 99 controlled studies in total (though nine did not have a control condition). We found that drill and practice training is used more often to retrain neurocognitive deficits while drill and strategy training is used more frequently in the context of sociocognitive remediation.

CONCLUSIONS

Hypotheses are suggested to better understand those results and future research is recommended to compare drill and strategy with drill and practice training for both social and neurocognitive deficits in schizophrenia.

Comparison of remedial and compensatory approaches in memory dysfunction: a comprehensive literature review

ABSTRACT Memory is a cognitive process of information storage and retrieval that is essential to performing daily functional activities efficiently. Occupational therapists regularly help individuals with memory impairment to manage their memory deficits. The purpose of this paper was to review the main memory strategies and instructional methods used to improve or manage memory. Studies were identified by searching for the relevant literature published between 1980 and 2007 through the use of several databases with the inclusion criteria that the study must identify at least one specific memory rehabilitation method with an outcome measure representative of the specific method. The reviewed studies included three reviews, 10 randomized control trials, 17 quasi-experimental studies, and five single subjects' designs. The results suggest that there is empirical evidence to support the effectiveness of certain remedial and compensatory memory rehabilitation methods with healthy populations, but weaker evidence can be identified for the memory-impaired populations. In general, remedial methods are effective in lab settings with primarily healthy populations, yet effectiveness in daily activities is less clear. Compensatory methods are generally more efficient than remedial ones and more easily generalized to daily activities, even with memory-impaired populations.

Computer-assisted cognitive remediation in adolescents with psychosis or at risk for psychosis: a 6-month follow-up

Urben S, Pihet S, Jaugey L, Halfon O, Holzer L. Computer-assisted cognitive remediation in adolescents with psychosis or at risk for psychosis: a 6-month follow-up.

Objective: To investigate short-term outcomes of a computer-assisted cognitive remediation (CACR) for adolescents with psychotic disorders or at high risk for psychosis.

Method: Cognitive abilities and clinical status were assessed at baseline (N = 32) and at 6-month follow-up (N = 22) after enrolment in either a CACR (treatment group) or a computer games (control group) program (8 weeks).

Results: With regard to the cognitive abilities, no amelioration was found in the control group while, in the CACR group, significant improvements in inhibition (p = 0.040) and reasoning (p = 0.005) were observed. Furthermore, symptom severity decreased significantly in the control group (p = 0.046) and marginally in the CACR group (p = 0.088). Improvements in cognitive abilities were not associated with symptoms' amelioration. Finally, increase in reasoning abilities was related to the median effective work time in sessions of CACR (R = 0.64, p = 0.024).

Conclusion: At follow-up, enhanced cognitive abilities (reasoning and inhibition), which are necessary for executing higher-order goals or adapting behaviour to the ever-changing environment, were reported in adolescents participants of the CACR. Thus, further studies are needed to confirm and extend these interesting results.

Early cognitive experience prevents adult deficits in a neurodevelopmental schizophrenia model

Brain abnormalities acquired early in life may cause schizophrenia, characterized by adulthood onset of psychosis, affective flattening, and cognitive impairments. Cognitive symptoms, like impaired cognitive control, are now recognized to be important treatment targets but cognition-promoting treatments are ineffective. We hypothesized that cognitive training during the adolescent period of neuroplastic development can tune compromised neural circuits to develop in the service of adult cognition and attenuate schizophrenia-related cognitive impairments that manifest in adulthood. We report, using neonatal ventral hippocampus lesion rats (NVHL), an established neurodevelopmental model of schizophrenia, that adolescent cognitive training prevented the adult cognitive control impairment in NVHL rats. The early intervention also normalized brain function, enhancing cognition-associated synchrony of neural oscillations between the hippocampi, a measure of brain function that indexed cognitive ability. Adolescence appears to be a critical window during which prophylactic cognitive therapy may benefit people at risk of schizophrenia.

Predicting the severity of everyday functional disability in people with schizophrenia: cognitive deficits, functional capacity, symptoms, and health status

Disability is pervasive in schizophrenia and is refractory to current medication treatments. Inability to function in everyday settings is responsible for the huge indirect costs of schizophrenia, which may be as much as three times larger than direct treatment costs for psychotic symptoms. Treatments for disability are therefore urgently needed. In order to effectively treat disability, its causes must be isolated and targeted; it seems likely that there are multiple causes with modest overlap. In this paper, we review the evidence regarding the prediction of everyday disability in schizophrenia. We suggest that cognition, deficits in functional capacity, certain clinical symptoms, and various environmental and societal factors are implicated. Further, we suggest that health status variables, recently recognized as pervasive in severe mental illness, may also contribute to disability in a manner independent from these other better-studied causes. We suggest that health status be considered in the overall prediction of real-world functioning and that interventions aimed at disability reduction targeting health status may be needed, in addition to cognitive enhancement, skills training, and public advocacy for better services.

Is there any impact of cognitive remediation on an ecological test in schizophrenia?

INTRODUCTION

Cognitive deficits are commonly reported in schizophrenia and have a significant impact on the daily life of patients and on their social and work inclusion. Cognitive remediation therapies (CRT) may enhance the capabilities of schizophrenia patients. Although social and work integration is the ultimate goal of CRT, previous studies have failed to carry out a detailed assessment of the effects on everyday life.

METHODS

Fifty-nine schizophrenia patients were randomised into two groups (remediation or usual treatment) to test the effects of a new remediation programme, which included both rehearsal and strategy learning, on cognitive functions. An ecological test was used to evaluate its transfer to daily living skills.

RESULTS

Cognitive improvements are revealed in CRT patients, mainly in memory and executive functions. Patients showing some deficiencies to perform the ecological test had better scores after the CRT. Moreover, they significantly improve their social activity scores.

CONCLUSIONS

CRT would facilitate mental load monitoring by enhancing or reallocating cognitive resources, facilitating the patient's organisation and autonomy. The rehearsal learning approach improves the ability to carry out automatic operations that are less demanding in terms of cognitive resources, thereby increasing the resources available for acquisition and efficient use of strategies provided during the strategy learning approach.

Can genetics inform the management of cognitive deficits in schizophrenia?

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

Negative symptoms of schizophrenia as primary target of cognitive behavioral therapy: results of the randomized clinical TONES study

Clinical studies on cognitive behavioral therapy (CBT) that include schizophrenia patients primarily on the basis of negative symptoms are uncommon. However, those studies are necessary to assess the efficacy of CBT on negative symptoms. This article first gives an overview of CBT on negative symptoms and discusses the methodological problems of selecting an adequate control group. Furthermore, the article describes a clinical study (the TONES-Study, ISRCTN 25455020), which aims to investigate whether CBT is specifically efficacious for the reduction of negative symptoms. This multicenter randomized clinical trial comparing CBT with cognitive remediation (CR) for control of nonspecific effects is depicted in detail. In our trial, schizophrenia patients (n = 198) participated in manualized individual outpatient treatments. Primary outcome is the negative syndrome assessed with the positive and negative syndrome scale, analyzed with multilevel linear mixed models. Patients in both groups moderately improved regarding the primary endpoint. However, against expectation, there was no difference between the groups after treatment in the intention to treat as well as in the per-protocol analysis. In conclusion, psychotherapeutic intervention may be useful for the reduction of negative symptoms. However, there is no indication for specific effects of CBT compared with CR.

Planning and problem-solving training for patients with schizophrenia: a randomized controlled trial

BACKGROUND

The purpose of this study was to assess whether planning and problem-solving training is more effective in improving functional capacity in patients with schizophrenia than a training program addressing basic cognitive functions.

METHODS

Eighty-nine patients with schizophrenia were randomly assigned either to a computer assisted training of planning and problem-solving or a training of basic cognition. Outcome variables included planning and problem-solving ability as well as functional capacity, which represents a proxy measure for functional outcome.

RESULTS

Planning and problem-solving training improved one measure of planning and problem-solving more strongly than basic cognition training, while two other measures of planning did not show a differential effect. Participants in both groups improved over time in functional capacity. There was no differential effect of the interventions on functional capacity.

CONCLUSION

A differential effect of targeting specific cognitive functions on functional capacity could not be established. Small differences on cognitive outcome variables indicate a potential for differential effects. This will have to be addressed in further research including longer treatment programs and other settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00507988.

Efficacy and specificity of computer-assisted cognitive remediation in schizophrenia: a meta-analytical study

BACKGROUND

Cognitive remediation is frequently based on computerized training methods that target different cognitive deficits. The aim of this article was to assess the efficacy of computer-assisted cognitive remediation (CACR) in schizophrenia and to determine whether CACR enables selective treatment of specific cognitive domains.

METHOD

A meta-analysis was performed on 16 randomized controlled trials evaluating CACR. The effect sizes of differences between CACR and control groups were computed and classified according to the cognitive domain assessed. The possible influences of four potential moderator variables were examined: participants' age, treatment duration, weekly frequency, and control condition type. To test the domain-specific effect, the intended goal of each study was determined and the effect sizes were sorted accordingly. The effect sizes of the cognitive domains explicitly targeted by the interventions were then compared with those that were not.

RESULTS

CACR enhanced general cognition with a mean effect size of 0.38 [confidence interval (CI) 0.20-0.55]. A significant medium effect size of 0.64 (CI 0.29-0.99) was found for Social Cognition. Improvements were also significant in Verbal Memory, Working Memory, Attention/Vigilance and Speed of Processing with small effect sizes. Cognitive domains that were specifically targeted by the interventions did not yield higher effects than those that were not.

CONCLUSIONS

The results lend support to the efficacy of CACR with particular emphasis on Social Cognition. The difficulty in targeting specific domains suggests a 'non-specific' effect of CACR. These results are discussed in the light of the possible bias in remediation tasks due to computer interface design paradigms.

Intrinsic motivation inventory: an adapted measure for schizophrenia research

This article describes the psychometric validation of a scale designed to measure intrinsic motivation (IM) in schizophrenia. Recent studies have highlighted the relationship between motivation and functional outcome in schizophrenia and identified IM as an important mediating factor between neurocognition and psychosocial outcome. It therefore becomes imperative to have validated measures of IM for empirical use. To that end, we validated a self-report IM scale that gauges the central motivational structures identified by Self-determinism Theory as pertinent to cognitive task engagement, skill acquisition, treatment compliance, and remediation outcome. Participants were schizophrenia outpatients involved in a cognitive remediation study (n = 58), a convenience subsample of clinically stable schizophrenia outpatients (n = 15), and a group of healthy normals (n = 22). The Intrinsic Motivation Inventory for Schizophrenia Research (IMI-SR) is a concise instrument, possessing good internal consistency (alpha = .92) and test-retest reliability (intraclass correlation = .77). Data were analyzed to abridge the original 54 items into a final 21-item questionnaire comprised of 3 domains relevant to motivation for treatments (interest/enjoyment, perceived choice, value/usefulness). The scale was highly associated with germane constructs of motivation for health-related behaviors, including perceived competency for attempting challenging tasks and autonomous treatment engagement. Importantly, the scale was able to distinguish improvers and nonimprovers on a cognitive task and actual learning exercises, delineate high vs low treatment attendance, and demonstrate sensitivity to motivational changes due to intervention variation. The IMI-SR is a viable instrument to measure IM in schizophrenia as part of a cognitive remediation protocol or psychosocial rehabilitation program.

Social skills and neurocognitive individualized training in schizophrenia: comparison with structured leisure activities

Cognitive impairment and deficits in social skills have been largely documented in patients with schizophrenia and are increasingly recognized as rate-limiting factors for recovery. Evidence has been provided that cognitive training and social skills training (SST) are effective to treat cognitive and social skills impairment in schizophrenia; however, the translation of improved performance on cognitive or social skills tasks into improved functional outcome is controversial. According to recent reviews, interventions providing cognitive training in conjunction with psychosocial rehabilitation have a greater impact on functional outcome than either intervention alone suggesting that the two treatment approaches may work together in a synergistic fashion. The present pilot study was designed to test the hypothesis that an integrated rehabilitation program, including individualized cognitive and SST, is more effective than the structured leisure activities (SLA) carried out in many Italian Mental Health Departments. The primary outcome measure was subjects' personal and social functioning as assessed by the Interview for the assessment of disability. The study is based on a controlled design including randomization to treatment groups, blind assessments and stable pharmacological treatment. Subjects were recruited among patients attending three psychiatric facilities located in the Italian region Campania. Thirty patients were randomized to the experimental program "social skills and neurocognitive individualized training" (SSANIT), and 30 to SLA. The two programs were matched for the overall duration as well as frequency and duration of the sessions. The two groups of patients did not differ at baseline on psychopathology, neurocognitive and personal/social functioning. After 6 months of treatment, personal and social functioning was significantly better in patients assigned to SSANIT than in those assigned to usual rehabilitation activities practiced in Mental Health Departments. No advantage was observed for either program on psychopathological and cognitive outcome indices. As for other integrated programs, also for SSANIT further studies are needed to verify generalization and persistence of the observed gains, and to clarify most adequate length and doses of the therapeutic intervention as well as the relative contribution of each program component to its impact on subjects' disability.

A randomized controlled trial of cognitive remediation in schizophrenia

Individuals with schizophrenia have consistently been found to exhibit cognitive deficits, which have been identified as critical mediators of psychosocial functional outcomes. Recent reviews of cognitive remediation (CRT) have concluded that these deficits respond to training. This multi-site community study examined 40 individuals with schizophrenia who underwent cognitive remediation using the Neuropsychological Educational Approach to Remediation(1) (NEAR). Assessments using the same neuropsychological tests and measures of psychosocial outcome were made at four time points: baseline, before start of active intervention, end of active intervention and 4 months after end of active intervention. Dose of antipsychotic medication remained constant throughout the study period. After participating in NEAR, individuals showed significant improvements in verbal and visual memory, sustained attention and executive functioning. This effect persisted 4 months after the treatment ceased. The average effect size was mild to moderate. Social and occupational outcomes also improved from baseline to post-treatment, which persisted 4 months later. Our findings replicate those of previous studies that suggest that NEAR is effective in improving cognition in individuals with schizophrenia in a naturalistic and ecologically valid setting. Further it extends such findings to show a generalisation of effects to social/occupational outcomes and persistence of effects in the short term.

Psychosocial treatments to promote functional recovery in schizophrenia

A number of psychosocial treatments are available for persons with schizophrenia that include social skills training, cognitive behavioral therapy, cognitive remediation, and social cognition training. These treatments are reviewed and discussed in terms of how they address key components of functional recovery such as symptom stability, independent living, work functioning, and social functioning. We also review findings on the interaction between pharmacological and psychosocial treatments and discuss future directions in pharmacological treatment of schizophrenia. Overall, these treatments provide a range of promising approaches to helping patients achieve better outcomes far beyond symptom stabilization.

The use of individually tailored environmental supports to improve medication adherence and outcomes in schizophrenia

Cognitive adaptation training (CAT) is a psychosocial treatment that uses environmental supports such as signs, checklists, alarms, and the organization of belongings to cue and sequence adaptive behaviors in the home. Ninety-five outpatients with schizophrenia (structured clinical interview for diagnosis, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) were randomly assigned to (1) Full-CAT (CAT focused on many aspects of community adaptation including grooming, care of living quarters, leisure skills, social and role performance, and medication adherence), (2) Pharm-CAT (CAT focused only on medication and appointment adherence), or (3) treatment as usual (TAU). Treatment lasted for 9 months, and patients were followed for 6 months after the withdrawal of home visits. Medication adherence (assessed during unannounced, in-home pill counts) and functional outcomes were assessed at 3-month intervals. Results of mixed-effects regression models indicated that both CAT and Pharm-CAT treatments were superior to TAU for improving adherence to prescribed medication (P < .0001). Effects on medication adherence remained significant when home visits were withdrawn. Full-CAT treatment improved functional outcome relative to Pharm-CAT and TAU (P < .0001). However, differences for functional outcome across groups decreased following the withdrawal of home visits and were no longer statistically significant at the 6-month follow-up. Survival time to relapse or significant exacerbation was significantly longer in both CAT and Pharm-CAT in comparison to TAU (.004). Findings indicate that supports targeting medication adherence can improve and maintain this behavior. Comprehensive supports targeting multiple domains of functioning are necessary to improve functional outcomes. Maintenance of gains in functional outcome may require some form of continued intervention.

Preserved memory monitoring but impaired memory control during episodic encoding in patients with schizophrenia

Metamemory awareness refers to the ability to monitor and control how well information is processed depending on the loads and needs of the task at hand. There is some evidence that metamemory functions are impaired in schizophrenia at the time of memory retrieval. This study investigated whether patients with schizophrenia exhibit metamemory abnormalities during the encoding of new information. The frequency of item presentation was varied. Both memory control and memory monitoring were assessed using study-time allocation and Judgments of Learning (JOL), respectively. Repeated items were recalled better by both groups, but memory performance was lower in patients than controls. Patients' behavior patterns were abnormal in terms of the study-time allocated for each item according to presentation frequency. Patients' JOLs were lower than those of controls but remained sensitive to item repetition. Patients' predictive values on memory accuracy were no different to those measured in controls. In addition, none of the patients reported using efficient strategies to help memorize target items. The results show a dissociation between memory control, which was impaired, and memory monitoring, which was spared, in patients with schizophrenia during encoding of new information.

Computer-assisted cognitive remediation in schizophrenia: what is the active ingredient?

An emerging body of research has shown that computer-assisted cognitive remediation, consisting of training in attention, memory, language and/or problem-solving, produces improvement in neurocognitive function that generalizes to untrained neurocognitive tests and may also impact symptoms and work functioning in patients with schizophrenia. The active ingredient of these interventions, however, remains unknown as control groups in these studies have typically included few, if any, of the elements of these complex behavioral treatments. This study compared the effects of an extended (12-month), standardized, computer-assisted cognitive remediation intervention with those of a computer-skills training control condition that consisted of many of the elements of the experimental intervention, including hours spent on a computer, interaction with a clinician and non-specific cognitive stimulation. Forty-two patients with schizophrenia were randomly assigned to one of two conditions and were assessed with a comprehensive neuropsychological test battery before and after treatment. Results revealed that cognitive-remediation training produced a significant improvement in working memory, relative to the computers-skills training control condition, but that there was overall improvement in both groups on measures of working memory, reasoning/executive-function, verbal and spatial episodic memory, and processing speed. Taken together, these findings suggest that specific practice in neurocognitive exercises targeted at attention, memory and language, produce improvements in neurocognitive function that are not solely attributable to non-specific stimulation associated with working with a computer, interacting with a clinician or cognitive challenge, but that non-specific stimulation has a salutary effect on neurocognition as well.

Learning proficiency on the Wisconsin Card Sorting Test in people with serious mental illness: what are the cognitive characteristics of good learners?

Although it is widely accepted that schizophrenia and other serious mental illnesses (SMI) are associated with neurocognitive difficulties, there is great variability in neurocognitive functioning across individuals. In recent years, a growing number of schizophrenia studies have utilized the concept of learning potential to explore individual variation in cognition. Learning potential refers to the ability to benefit from instruction and is measured by assessing test performance before and after training. The present study was intended to explore the cognitive characteristics associated with learning potential in people with serious mental illness. Sixty individuals with schizophrenia, bipolar or major (unipolar) depression completed a learning potential assessment using the Wisconsin Card Sorting Test (WCST) and a battery of standard cognitive measures. Based on established criteria for WCST learner subgroups, participants were categorized as high achievers, learners or non-retainers. There were several significant cognitive differences among the three learner subgroups. Most notably, individuals who were categorized as learners on the WCST showed significantly better verbal and working memory compared to non-retainers. Secondary analyses revealed that the three SMI diagnostic groups (depression, bipolar, schizophrenia) were similar in learning potential and did not differ on any of the standard cognitive measures. This study provides support for learning potential classification in schizophrenia as well as other serious mental illnesses, and indicates that learning potential may specifically be related to verbal and working memory abilities.

Cognitive remediation therapy for outpatients with chronic schizophrenia: a controlled and randomized study

Cognitive Remediation Therapy (CRT) is a novel rehabilitation approach designed to improve neurocognitive abilities such as attention, memory and executive functioning. The aim of the present study is to evaluate the effect of CRT on neurocognition, and secondarily on symptomatology and psychosocial functioning. Cognitive Behavioural Therapy (CBT) was used as a control condition because it aims to improve emotional problems and positive symptoms, focusing on modification of maladaptive beliefs and schemas, but neurocognition is not targeted. A total of 40 chronic patients with DSM-IV schizophrenia disorder were randomly assigned for 4 months to one of two treatment groups: CRT or CBT. Repeated assessments were conducted before and after the treatments and at the end of a follow-up period of 6 months. Additionally, a method to establish reliable change was calculated from a separate sample of 20 schizophrenic patients who were under standard medication without any kind of psychological treatment. Results showed that CRT produced an overall improvement on neurocognition (Mean effect size=0.5), particularly in verbal and nonverbal memory, and executive function. CBT showed the expected treatment effect on general psychopathology (anxiety and depression) but produced only a slight non-specific improvement in neurocognition (Working Memory). Furthermore, patients receiving CRT showed improvement in social functioning, demonstrating that cognitive improvements are clinically meaningful. These gains were still present at the 6 month follow-up.

Efficacy of psychological therapy in schizophrenia: conclusions from meta-analyses

Over the past years, evidence for the efficacy of psychological therapies in schizophrenia has been summarized in a series of meta-analyses. The present contribution aims to provide a descriptive survey of the evidence for the efficacy of psychological therapies as derived from these meta-analyses and to supplement them by selected findings from an own recent meta-analysis. Relevant meta-analyses and randomized controlled trials were identified by searching several electronic databases and by hand searching of reference lists. In order to compare the findings of the existing meta-analyses, the reported effect sizes were extracted and transformed into a uniform effect size measure where possible. For the own meta-analysis, weighted mean effect size differences between comparison groups regarding various types of outcomes were estimated. Their significance was tested by confidence intervals, and heterogeneity tests were applied to examine the consistency of the effects. From the available meta-analyses, social skills training, cognitive remediation, psychoeducational coping-oriented interventions with families and relatives, as well as cognitive behavioral therapy of persistent positive symptoms emerge as effective adjuncts to pharmacotherapy. Social skills training consistently effectuates the acquisition of social skills, cognitive remediation leads to short-term improvements in cognitive functioning, family interventions decrease relapse and hospitalization rates, and cognitive behavioral therapy results in a reduction of positive symptoms. These benefits seem to be accompanied by slight improvements in social functioning. However, open questions remain as to the specific therapeutic ingredients, to the synergistic effects, to the indication, as well as to the generalizability of the findings to routine care.

Does cognition predict community function only in schizophrenia?: a study of schizophrenia patients, bipolar affective disorder patients, and community control subjects

Cognitive deficits predict functioning in schizophrenia; however, little is known as to whether the association is present in other mental disorders. If specific cognitive deficits uniquely predict functional impairment in schizophrenia the association of select aspects of brain dysfunction with daily living would suggest an intervention target and perhaps a means by which to improve the functioning of schizophrenia patients. The relationship of cognition and functioning was investigated in schizophrenia (n=39), bipolar affective disorder (n=27), and nonpsychiatric control (n=38) participants to determine whether the associations varied across groups. We examined verbal memory, verbal learning, verbal fluency, vigilance, executive functioning, symptomatology, and generalized cognitive functioning for associations with social function. Correlational analyses revealed particular cognitive domains (e.g., verbal memory) to be associated with social functioning in schizophrenia, bipolar, and control subjects; however generalized cognitive function and symptomatology were also associated with social functioning in patients. Multiple regression analyses revealed that in schizophrenia poor verbal memory predicted worse social functioning even after the effects of generalized cognitive dysfunction were considered. Verbal memory indices failed to account for variance in social function in bipolar patients and control subjects after consideration of generalized cognitive function. Bipolar patients with worse planning and problem solving tended to have worse social functioning. Therefore, unlike schizophrenia patients who may fail to process verbally mediated material, bipolar patients' difficulty with logical approaches to problems in daily living may have the greatest impact on their community function.

[Cognitive remediation and work therapy in the outpatient treatment of patients with schizophrenia]

In the present paper, we describe a behavioral rehabilitation program for patients with schizophrenia. The program combines vocational rehabilitation with cognitive training, thereby addressing two of the hallmark impairments of this chronic disorder. In addition to targeting these two types of impairments, we also wished to investigate the impact of one on the other. Specifically, previous research has suggested that cognitive impairments may serve as rate-limiters in the psychosocial rehabilitation of patients with schizophrenia. Our intent was to investigate whether specifically addressing and remediating these cognitive deficits would in turn lead to superior outcomes in vocational rehabilitation. Following a detailed description of our program, we offer initial support for the efficacy of this type of approach in both improving cognitive function as well as leading to better functional outcomes.

Cognitive training of verbal memory using a dichotic listening paradigm: impact on symptoms and cognition

OBJECTIVE

The objective was to investigate the impact of a verbal memory training task on psychiatric symptoms and cognition in schizophrenia.

METHOD

As part of a larger, 6-month cognitive remediation program, 57 patients with schizophrenia were randomly assigned to receive performance-based, hierarchical training on a verbal memory task based on a dichotic listening (DL) with distracter paradigm. These patients were compared with 68 patients who had been randomly assigned to a control condition.

RESULTS

Training on the DL task was not associated with changes in general psychopathology or auditory hallucinations (AH) specifically. Training was associated with improvements in verbal memory, but not attention.

CONCLUSION

The current investigation adds to the growing literature on the effectiveness of cognitive remediation training and indicates that training on the DL task enhances verbal episodic memory. The results do not support the use of DL training as a method for reducing AH.

Computerized cognitive remediation improves verbal learning and processing speed in schizophrenia

Computerized cognitive remediation has resulted in improved executive function in schizophrenia, whereas results with regard to verbal memory were inconsistent. In the present study, 42 inpatients with schizophrenia were randomly assigned to a computerized cognitive remediation group or to a treatment-as-usual (TAU) control group. The remediation group received 15 sessions of computerized cognitive training (Cogpack) over a 3-week period. Neurocognitive functions were assessed at the beginning and end of this period. Compared to the control condition, remediation training resulted in improvements in verbal learning, processing speed and executive function (verbal fluency). The results indicate that cognitive remediation may lead to improvements beyond those of executive function.

Treatment of cognitive dysfunction in schizophrenia

BACKGROUND

Cognitive impairment has always been regarded as an important characteristic of schizophrenia. Many domains of cognition are disrupted with varying degrees of deficit: attention, executive functions, verbal and visuospatial working memory, learning, and memory. However, it is only recently that cognitive dysfunction has been recognized as a primary and enduring core deficit in schizophrenia (rather than the previous focus on positive and negative symptoms).

OBJECTIVE

This article discusses cognitive impairment and the therapeutic effects of newer antipsychotic agents on cognitive functioning in patients with schizophrenia.

CONCLUSIONS

Cognitive dysfunction occurs before the first psychotic episode and persists throughout the course of the illness. It involves every aspect of cognitive functioning and has an important impact on long-term social and occupational outcomes. Improvement of cognitive functioning by antipsychotic treatment can be due indirectly to the improvement of therapeutic profiles of the newer antipsychotic agents (eg, higher efficacy on positive and negative symptoms, fewer side effects, less anticholinergic effects) or directly to effects on cerebral functioning (eg, by restoring dopamine prefrontal activity). However, further research is needed regarding the therapeutic effects of the newer antipsychotic drugs on cognitive functioning and their impact on psychosocial outcome. Although newer medications may improve cognitive functioning, they do not normalize neurocognitive deficits in schizophrenia. In addition, various nonpharmacologic, psychological interventions have been used in the rehabilitation of patients with cognitive deficits.

Effects of neurocognitive enhancement therapy in schizophrenia: normalisation of memory performance

INTRODUCTION

A preponderance of research indicates that cognitive function in schizophrenia can be improved through cognitive remediation. However, few studies have attempted to characterise the extent of improvement relative to nonpsychiatric controls.

METHOD

Cognitive performance on reaction time, digit recall, and word recall of 58 schizophrenia patients at baseline and after 6 months of cognitive remediation was compared to the performance on these tasks of 39 community controls. Schizophrenia patients participated in Neurocognitive Enhancement Therapy (NET) and received hierarchical training on the memory tasks, but not on the reaction time task, which was only administered at intake and follow-up.

RESULTS

The schizophrenia sample showed significantly poorer performances than the community control sample on all three tasks at baseline. NET led to significant improvements in performance on trained memory tasks, but not the untrained reaction time task. There was a significant increase in the proportion of schizophrenia patients who achieved normal range performance on the memory tasks.

CONCLUSIONS

52% of schizophrenia patients who were impaired on at least one of the memory tasks normalised their performance on at least one of those tasks as a result of cognitive training. Results suggest that clinically meaningful improvement may be possible using cognitive remediation.

Durability of cognitive remediation training in schizophrenia: performance on two memory tasks at 6-month and 12-month follow-up

Patients with schizophrenia have consistently been found to exhibit cognitive deficits, particularly in memory, which have been suggested to mediate functional outcomes. Several recent reviews of cognitive retraining have concluded that these deficits respond to training, although the sustainability of cognitive improvement following completion of training has not been adequately evaluated. Most studies had small samples and very short follow-up periods. As part of a larger study, we examined performance on two memory tasks in two groups of participants: those who received computerized cognitive remediation training in addition to work therapy (n=45), vs. those who only received work therapy (n=49). Computerized cognitive remediation included hierarchical training on a computerized digit span task and a computerized words serial position task. Assessments using the same computerized tasks were made at three time points: baseline, end of active intervention, and 6-month follow-up. Compared to the active control condition (work therapy only), the group receiving computerized cognitive remediation in addition to work therapy showed significantly greater improvements on the trained digit span task following training. These improvements were maintained at the 6-month follow-up. There were no significant group differences on the word serial position task at any time point. Results indicate that computerized training can lead to sustained improvements on some, but not all, training tasks.

Treatment of cognitive dysfunction in psychiatric disorders

Most people with severe and persistent psychiatric disorders have significant cognitive deficits. Both schizophrenia and affective disorders with psychosis are associated with problems in attention, memory, and executive functioning. These deficits are predictive of lower work status, impairments in social skills, and poorer response to psychosocial skills training. Cognitive impairment makes it difficult for individuals to benefit from focused skills interventions that they are offered. This article describes behavioral treatments available to address cognitive dysfunction in individuals with psychiatric disorders. The evidence for efficacy is reviewed and recommendations are made for ways to begin addressing cognitive impairment in mainstream psychiatric practice.

Skills training for people with severe mental illness

There is a growing empirical literature on psychosocial rehabilitation strategies for schizophrenia and other severe mental illnesses. Three of the best-supported and most promising approaches were reviewed: social skills training (SST), cognitive behavior therapy (CBT), and cognitive remediation (CR). Of the three, SST has the strongest empirical support and can be considered an evidence-based treatment. However, it is appropriate as a targeted treatment for social impairment, not as a broad based treatment for schizophrenia. CBT has only recently been applied to patients with psychotic disorders and the preliminary results are promising for reducing distress associated with residual psychotic symptoms. All but a handful of trials have been carried out in the context of the public health system in the UK with specially selected patients. Consequently, it is not yet clear if it would be effective in public health systems in the US, with highly impaired patients, or for patients with comorbid substance abuse. There is an extensive literature documenting that a variety of training techniques can improve performance on neuropsychological tests, and there is a growing literature of more clinically relevant CR trials that have produced small to medium effect sizes. No studies have yet demonstrated a clinically significant effect on community functioning. This is a promising area for further research, but CR, like CBT, does not have a sufficient evidentiary base for widespread dissemination to the public mental health system at this time.

The impact of cognitive remediation on psychiatric symptoms of schizophrenia

OBJECTIVE

The relationship between psychopathology and cognitive functioning in schizophrenia is of interest, both for an understanding of the nature of the disease, and for comprehensive treatment planning. The aim of this study was to investigate how psychiatric symptoms affect, and are affected by, cognitive remediation.

METHOD

Fifty-four psychiatric inpatients received either cognitive remediation exercises (remediation group) or no cognitive intervention (control group). The subjects' scores on tests of cognition and on the Positive and Negative Symptoms Scale (PANSS) were measured before, after the 10 session treatment, and again 4 weeks post treatment.

RESULTS

Only the remediation group showed significant and persistent improvement on all three PANSS Subscales as well as on the Positive Symptoms and Depression Factors. There were no significant between-group differences on any PANSS pre/posttreatment change scores. Baseline measures of psychopathology did not correlate meaningfully with amount of change made on cognitive measures after rehabilitation.

CONCLUSIONS

A brief 10-session course of cognitive remediation is sufficient to benefit cognition and has some positive effects on psychopathology as measured by the PANSS, but does not add significantly to the effects of standard psychiatric treatment on psychopathology. Furthermore, psychiatric symptom profile is not predictive of the degree to which cognitive symptoms respond to cognitive remediation. The differential impact of cognitive remediation on cognition and psychopathology may imply that psychopathology and cognitive functioning follow fairly independent treatment courses.

Cognitive rehabilitation in schizophrenia: a quantitative analysis of controlled studies

RATIONALE

Cognitive rehabilitation is now recognized as an important tool in the treatment of schizophrenia, and findings in this area are emerging rapidly. There is a need for a systematic review of the effects of the different training programs.

OBJECTIVES

To review quantitatively the controlled studies on cognitive rehabilitation in schizophrenia for the effect of training on performance on tasks other than those practiced in the training procedure.

METHODS

A meta-analysis was conducted on 12 controlled studies of cognitive rehabilitation in schizophrenia taking into account the effects of type of rehabilitation approach (rehearsal or strategy learning) and duration of training.

RESULTS

The mean weighted effect size was 0.45, with a 95% confidence interval from 0.26 to 0.64. Effect sizes differed slightly, depending on rehabilitation approach, in favor of strategy learning, but this difference did not reach statistical significance. Duration of training did not influence effect size.

CONCLUSIONS

Cognitive rehabilitation can improve task performance in patients with schizophrenia and this effect is apparent on tasks outside those practiced during the training procedure. Future studies should include more real-world outcomes and perform longitudinal evaluations.

Cognitive remediation of working memory deficits: durability of training effects in severely impaired and less severely impaired schizophrenia

OBJECTIVE

To determine whether augmenting work therapy (WT) with neurocognitive enhancement therapy (NET) yields greater improvement in working memory performance than WT alone and whether there is an interaction with severity of impairment.

METHOD

A total of 102 participants with schizophrenia or schizoaffective disorder were categorized as severely or less severely cognitively impaired and randomly assigned to receive NET + WT or WT alone. NET consisted of cognitive training exercises in attention, memory, executive function, and social information processing, and WT was a 6-month work program.

RESULTS

Comparison on Digits Backwards from intake to follow-up revealed significantly greater improvement for participants receiving NET + WT, but there was no interaction with severity group. Follow-up 6 months after training showed that training effects endured.

CONCLUSION

NET + WT improved working memory for most participants regardless of impairment severity. Intensity and duration of training may have contributed to duration of effects. Findings support continued exploration of cognitive remediation.

Neurocognitive rehabilitation for schizophrenia

A critical review of randomized, controlled trials of extended programs of neurocognitive rehabilitation for the cognitive deficits characteristic of schizophrenia conducted between the years 2000 to 2002 was completed. Over the past several years, two models of cognitive rehabilitation have emerged. In one model, labeled "cognitive remediation," cognitive deficits are treated directly through repeated practice and acquisition of compensatory strategies on cognitive exercises designed to engage underfunctioning brain systems. In a second model, labeled "cognitive adaptation," neurocognitive deficits are addressed through modification of the patients' environment to allow patients to bypass their deficits. Results revealed that a range of cognitive remediation strategies varying widely along dimensions of duration, intensity, method, target of behavioral intervention, and clinical status of participants produced improvements on measures of working memory, emotion perception, and executive function distinct from those trained during remediation. No effects were evident in secondary verbal or nonverbal memory. Results of two pilot studies using functional magnetic resonance imaging to assess changes in task-evoked brain activation have revealed that these interventions may produce changes in several functionally relevant neural systems in a subset of patients. Results from studies of standardized cognitive adaptation interventions have indicated that these treatments can produce improvements in symptoms, psychosocial status, and relapse rates. A variety of approaches for future research are also discussed.

Remediation of problem-solving skills in schizophrenia: evidence of a persistent effect

Neuropsychological deficits in problem solving are commonly found in patients with schizophrenia. We have previously presented the results of a study examining the feasibility of utilizing problem-solving teaching techniques developed within educational psychology, for remediating the problem-solving deficits of inpatients with schizophrenia spectrum disorders. These techniques emphasize the importance of intrinsic motivation on therapeutic outcome and promote this through contextualization, personalization and control of learning activities. We present here the results of the follow-up assessment, which found that the gains made by the problem-solving group persisted for 4 weeks after cessation of problem-solving remediation ended. These results provide more evidence of the therapeutic benefit of problem-solving training techniques that promote intrinsic motivation and generic problem-solving strategies.

Is it time to develop a new cognitive therapy for psychosis--cognitive remediation therapy (CRT)?

The cognitive difficulties associated with the disorder of schizophrenia seem to be predictive of future dependence on psychiatric services and predict social functioning. Cognitive remediation therapy (CRT) was designed to rehabilitate these cognitive functions, and the interest in it has grown dramatically over the past ten years. However, the programmes are rarely based on clear theoretical principles and sometimes rely heavily on practice rather than guided learning. The evidence for their efficacy is variable and seems to be dependent on the use of specific components of training. The current review tries to put this evidence into context and sets out a programme of research, which is essential in this area if future progress is to be made.