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Yoon G, Sofuoglu M, Petrakis IL, Pittman B, Bell MD. The combination of donepezil and cognitive training for improving treatment outcomes for alcohol use disorder: Design of a randomized controlled trial. Contemp Clin Trials 2024; 145:107657. [PMID: 39111388 PMCID: PMC11423257 DOI: 10.1016/j.cct.2024.107657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 07/13/2024] [Accepted: 08/03/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND The development of alcohol use disorder (AUD) is a major concern in public health, and cognitive impairments caused by alcohol are involved in this process. Emerging neurobiological evidence suggests that donepezil, an anticholinesterase agent, may improve AUD treatment outcomes by enhancing neurocognitive functioning. Previous research has also suggested that cognitive remediation therapy (CRT) could potentially improve cognitive function and AUD treatment outcomes. We present the rationale and design of a trial to evaluate the combination of donepezil and cognitive remediation therapy (donepezil + CRT) as an intervention for AUD. METHODS We propose a 13-week, randomized, double-blind, placebo-controlled, between-subjects trial comparing 4 groups (donepezil + CRT vs. donepezil alone vs. CRT alone vs. placebos) as an intervention for AUD. The main goal of the study is to evaluate if donepezil + CRT is superior to placebo in reducing heavy drinking days and improving neurocognitive functioning. A total of 160 patients (4 groups, 40 per each group) with AUD between the ages of 18-80 years will be recruited at Yale University and the VA Connecticut Healthcare System. Primary outcome measures include 1) heavy drinking by Timeline Follow Back (TLFB) over 13 weeks and 2) global neurocognitive functioning by a global index of neurocognitive function score at 7 and 13 weeks. DISCUSSION This protocol paper describes the rationale and proposed methods for the randomized controlled trial for improving AUD treatment outcomes. This project has significant clinical potential to help patients suffering from AUD by improving their cognition and reducing alcohol consumption. TRIAL REGISTRATION NCT05042102.
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Affiliation(s)
- Gihyun Yoon
- VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
| | - Mehmet Sofuoglu
- VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Ismene L Petrakis
- VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Brian Pittman
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Morris D Bell
- VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
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2
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Peshkovskaya A. Cognitive Alterations Associated with Remission and Alcohol Dependence Severity in Ethnically Diverse Patients of Siberia. Clin Pract Epidemiol Ment Health 2024; 20:e17450179297171. [PMID: 39130186 PMCID: PMC11311726 DOI: 10.2174/0117450179297171240522051748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 04/11/2024] [Accepted: 05/07/2024] [Indexed: 08/13/2024]
Abstract
Background Impaired cognition in individuals with alcohol dependence may be associated with increased relapse risk. It has been recorded in more than half of patients during six months after treatment. In certain ethnic groups, for example, Tuvinians, the indigenous people of Siberia, relapses occur in extremely short periods of one to three months after treatment. An approach currently used to alcohol dependence treatment may be less effective for these patients. Objective The study aimed to investigate cognitive sequelae in indigenous Tuvinian patients with alcohol dependence. Methods The sample included 166 patients, 74 of indigenous ethnicity (Tuvinians) and 92 non-indigenous white patients. Data on inhibitory control, cognitive flexibility, attention, and working memory were collected from all the patients and processed using cluster analysis. The clustering data were then complemented by indicators of disorder dynamics, impulsivity, and emotion regulation. Results The clustering procedure revealed groups with severe cognitive sequelae. More than four-fold attention decrease was found in 43.5% of non-indigenous patients, and more impaired cognitive flexibility was revealed among 60.8% of indigenous patients. Groups with severe cognitive sequelae had higher impulsivity, maladaptive emotion regulation, more hospitalizations, faster disease progression, and shorter remissions. The latter was significantly reduced to 90 days on average in the severe group of indigenous patients versus 135 days of remission in the non-indigenous severe group. Conclusion Results obtained may advance tailored intervention in alcohol-dependent patients of the indigenous Tuvinian ethnicity. While little is still known about the alcohol dependence course and consequences in the indigenous Tuvinians of Siberia, this study contributes to the global mental health data on alcohol abuse and dependence in indigenous communities.
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Affiliation(s)
- Anastasia Peshkovskaya
- Tomsk State University, Tomsk, Russia
- Mental Health Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
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Ferreira S, Virgolino A, Ribeiro C, Pombo S, Bacelar-Nicolau L. Effectiveness of Neuropsychological Rehabilitation in the Recovery of Executive Deficits in Patients with Alcohol Use Disorder: A Systematic Review Protocol. ACTA MEDICA PORT 2024; 37:262-266. [PMID: 37668530 DOI: 10.20344/amp.19804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 06/29/2023] [Indexed: 09/06/2023]
Abstract
INTRODUCTION Changes in executive functions associated with alcohol consumption are frequently found in alcohol use disorder. Neuropsychological rehabilitation can play an essential role as an effective treatment in the recovery from these deficits, leading to the maintenance of abstinence. However, there are still some uncertainties regarding its impact on the recovery of deficits in executive functions. Our purpose is to present a protocol for a systematic review aiming to assess which neuropsychological rehabilitation programs are effective in the recovery of executive deficits in patients with alcohol use disorder. METHODS We will search the following databases: PubMed, Cochrane Library (CENTRAL), Web of Science, and Scopus, as well as the list of references of the identified studies. Screening, data extraction, and synthesis, as well as evaluation of the risk of bias, will be carried out by two reviewers independently, using ROBINS-I and RoB 2. Disagreements will be resolved using a third additional reviewer. Primary outcomes will correspond to changes in executive functions, following a neuropsychological rehabilitation program in patients with alcohol use disorder. The evidence will be synthesized using a narrative description of neuropsychological rehabilitation programs and the indicators of their effectiveness will be identified. The neuropsychological rehabilitation programs for executive functions will be assessed considering their different components and their impact on the recovery of these functions. The review described in this protocol will allow the development of guidelines for the design of more effective rehabilitation programs for clinical populations with alcohol use disorder.
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Affiliation(s)
- Sónia Ferreira
- Unidade de Tratamento e Reabilitação de Alcoólicos. Centro Hospitalar Psiquiátrico de Lisboa. Lisboa; Faculdade de Medicina. Universidade de Lisboa. Lisboa. Portugal
| | - Ana Virgolino
- Instituto de Saúde Ambiental. Faculdade de Medicina. Universidade de Lisboa. Lisboa; Laboratório Associado TERRA. Faculdade de Medicina. Universidade de Lisboa. Lisboa. Portugal
| | - Cristina Ribeiro
- Faculdade de Medicina. Universidade de Lisboa. Lisboa; Instituto de Medicina Preventiva e Saúde Pública. Clínica Universitária de Medicina Geral e Familiar. Faculdade de Medicina. Universidade de Lisboa. Lisboa. Portugal
| | - Samuel Pombo
- Faculdade de Medicina. Universidade de Lisboa. Lisboa. Portugal
| | - Leonor Bacelar-Nicolau
- Instituto de Saúde Ambiental. Faculdade de Medicina. Universidade de Lisboa. Lisboa; Laboratório Associado TERRA. Faculdade de Medicina. Universidade de Lisboa. Lisboa; Instituto de Medicina Preventiva e Saúde Pública & Área Disciplinar Autónoma de Bioestatística (Laboratório de Biomatemática). Faculdade de Medicina. Universidade de Lisboa. Lisboa. Portugal
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Maurage P, Rolland B, Pitel AL, D'Hondt F. Five Challenges in Implementing Cognitive Remediation for Patients with Substance Use Disorders in Clinical Settings. Neuropsychol Rev 2023:10.1007/s11065-023-09623-1. [PMID: 37843739 DOI: 10.1007/s11065-023-09623-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 10/02/2023] [Indexed: 10/17/2023]
Abstract
Many patients with substance use disorders (SUDs) present cognitive deficits, which are associated with clinical outcomes. Neuropsychological remediation might help rehabilitate cognitive functions in these populations, hence improving treatment effectiveness. Nardo and colleagues (Neuropsychology Review, 32, 161-191, 2022) reviewed 32 studies applying cognitive remediation for patients with SUDs. They underlined the heterogeneity and lack of quality of studies in this research field but concluded that cognitive remediation remains a promising tool for addictive disorders. We capitalize on the insights of this review to identify the key barriers that currently hinder the practical implementation of cognitive remediation in clinical settings. We outline five issues to be addressed, namely, (1) the integration of cognitive remediation in clinical practices; (2) the selection criteria and individual factors to consider; (3) the timing to be followed; (4) the priority across trained cognitive functions; and (5) the generalization of the improvements obtained. We finally propose that cognitive remediation should not be limited to classical cognitive functions but should also be extended toward substance-related biases and social cognition, two categories of processes that are also involved in the emergence and persistence of SUDs.
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Affiliation(s)
- Pierre Maurage
- Louvain Experimental Psychopathology Research Group (LEP), Psychological Science Research Institute, UCLouvain, Louvain-La-Neuve, Belgium.
- Faculté de Psychologie, Place du Cardinal Mercier, 10, B-1348, Louvain-La-Neuve, Belgium.
| | - Benjamin Rolland
- Service Universitaire d'Addictologie de Lyon (SUAL), Hospices Civils de Lyon, CH Le Vinatier, Lyon, France & PSYR, CRNL, INSERM U1028, CNRS UMR5292, UCBL1, Lyon, France
| | - Anne-Lise Pitel
- Normandie Univ, UNICAEN, INSERM, U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Institut Blood and Brain @ Caen-Normandie, Cyceron, France
| | - Fabien D'Hondt
- Univ. Lille, Inserm, CHU Lille, U1172-LilNCog-Lille Neuroscience & Cognition, Lille, France
- Centre National de Ressources Et de Résilience Lille-Paris (CN2R), Lille, France
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Draheim C, Pak R, Draheim AA, Engle RW. The role of attention control in complex real-world tasks. Psychon Bull Rev 2022; 29:1143-1197. [PMID: 35167106 PMCID: PMC8853083 DOI: 10.3758/s13423-021-02052-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2021] [Indexed: 11/15/2022]
Abstract
Working memory capacity is an important psychological construct, and many real-world phenomena are strongly associated with individual differences in working memory functioning. Although working memory and attention are intertwined, several studies have recently shown that individual differences in the general ability to control attention is more strongly predictive of human behavior than working memory capacity. In this review, we argue that researchers would therefore generally be better suited to studying the role of attention control rather than memory-based abilities in explaining real-world behavior and performance in humans. The review begins with a discussion of relevant literature on the nature and measurement of both working memory capacity and attention control, including recent developments in the study of individual differences of attention control. We then selectively review existing literature on the role of both working memory and attention in various applied settings and explain, in each case, why a switch in emphasis to attention control is warranted. Topics covered include psychological testing, cognitive training, education, sports, police decision-making, human factors, and disorders within clinical psychology. The review concludes with general recommendations and best practices for researchers interested in conducting studies of individual differences in attention control.
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Affiliation(s)
- Christopher Draheim
- Department of Psychology, Lawrence University, Appleton, WI, USA.
- School of Psychology, Georgia Institute of Technology, Atlanta, GA, USA.
| | - Richard Pak
- Department of Psychology, Clemson University, Clemson, SC, USA
| | - Amanda A Draheim
- Department of Psychology, Lawrence University, Appleton, WI, USA
| | - Randall W Engle
- School of Psychology, Georgia Institute of Technology, Atlanta, GA, USA
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Caetano T, Pinho MS, Ramadas E, Clara C, Areosa T, Dixe MDA. Cognitive Training Effectiveness on Memory, Executive Functioning, and Processing Speed in Individuals With Substance Use Disorders: A Systematic Review. Front Psychol 2021; 12:730165. [PMID: 34489833 PMCID: PMC8418081 DOI: 10.3389/fpsyg.2021.730165] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/20/2021] [Indexed: 12/20/2022] Open
Abstract
Background: Cerebral neuroplasticity is compromised due to substance abuse. There is damage to neuronal areas that are involved in memory and executive functioning. Treatments with worse outcomes are often associated with cognitive deficits that have resulted from substance dependence. However, there is evidence that cognitive training can lead to improvements in cognitive functions and can be useful when treating addictions. This systematic review aims to synthesize evidence on the effectiveness of cognitive training in memory, executive functioning, and processing speed in individuals with substance use disorder (SUD). Methods: The Joanna Briggs Institute's PICO strategy was used to develop this systematic literature review. Four databases were searched (PubMed, the Cochrane Library, Web of Science, and PsycINFO) to identify controlled randomized clinical studies and quasi-experimental studies, in English, Portuguese, and Spanish, from 1985 to 2019. The literature found was examined by two independent reviewers, who assessed the quality of studies that met the inclusion criteria. The Cochrane risk-of-bias tool for the randomized controlled trials and the ROBINS-I tool for non-randomized studies were used to assess the risk of bias. In data extraction, the Cochrane Handbook for Systematic Reviews was considered. Results: From a total of 470 studies, 319 were selected for analysis after the elimination of duplicates. According to the inclusion criteria defined, 26 studies were eligible and evaluated. An evaluation was performed considering the participant characteristics, countries, substance type, study and intervention details, and key findings. Of the 26 selected studies, 14 considered only alcoholics, six included participants with various SUD (alcohol and other substances), three exclusively looked into methamphetamine-consuming users and another three into opioid/methadone users. Moreover, 18 studies found some kind of cognitive improvement, with two of these reporting only marginally significant effects. One study found improvements only in measures similar to the training tasks, and two others had ambiguous results. Conclusions: The included studies revealed the benefits of cognitive training with regard to improving cognitive functions in individuals with SUD. Memory was the most scrutinized cognitive function in this type of intervention, and it is also one of the areas most affected by substance use. Systematic Review Registration: [PROSPERO], identifier [CRD42020161039].
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Affiliation(s)
- Tânia Caetano
- Center for Research in Neuropsychology and Cognitive and Behavioral Intervention, Faculty of Psychology and Educational Sciences, University of Coimbra, Coimbra, Portugal.,Center for Innovative Care and Health Technology (ciTechcare), Polytechnic of Leiria, Leiria, Portugal.,VillaRamadas International Treatment Centre, Research and Innovation Department, Leiria, Portugal
| | - Maria Salomé Pinho
- Center for Research in Neuropsychology and Cognitive and Behavioral Intervention, Faculty of Psychology and Educational Sciences, University of Coimbra, Coimbra, Portugal
| | - Eduardo Ramadas
- Center for Innovative Care and Health Technology (ciTechcare), Polytechnic of Leiria, Leiria, Portugal.,VillaRamadas International Treatment Centre, Research and Innovation Department, Leiria, Portugal
| | - Cátia Clara
- VillaRamadas International Treatment Centre, Research and Innovation Department, Leiria, Portugal
| | - Timóteo Areosa
- Center for Innovative Care and Health Technology (ciTechcare), Polytechnic of Leiria, Leiria, Portugal
| | - Maria Dos Anjos Dixe
- Center for Innovative Care and Health Technology (ciTechcare), Polytechnic of Leiria, Leiria, Portugal
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Ekhtiari H, Rezapour T, Sawyer B, Yeh HW, Kuplicki R, Tarrasch M, Paulus MP, Aupperle R. Neurocognitive Empowerment for Addiction Treatment (NEAT): study protocol for a randomized controlled trial. Trials 2021; 22:330. [PMID: 33962675 PMCID: PMC8106153 DOI: 10.1186/s13063-021-05268-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 04/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neurocognitive deficits (NCDs) and associated meta-cognition difficulties associated with chronic substance use often delay the learning and change process necessary for addiction recovery and relapse prevention. However, very few cognitive remediation programs have been developed to target NCDs and meta-cognition for substance users. The study described herein aims to investigate the efficacy of a multi-component neurocognitive rehabilitation and awareness program termed "Neurocognitive Empowerment for Addiction Treatment" (NEAT). NEAT is a fully manualized, cartoon-based intervention involving psychoeducation, cognitive practice, and compensatory strategies relevant across 10 major cognitive domains, including aspects of attention, memory, executive functions, and decision-making. METHOD/DESIGN In a single-blind randomized controlled trial (RCT), 80 female opioid and/or methamphetamine users will be recruited from an addiction recovery program providing an alternative to incarceration for women with substance use-related offenses. Eight groups of 9-12 participants will be randomized into NEAT or treatment-as-usual (TAU). NEAT involves 14 90-min sessions, delivered twice weekly. The primary outcome is change in self-reported drug craving from before to after intervention using Obsessive Compulsive Drug Use Scale. Secondary and exploratory outcomes include additional psychological, neurocognitive, and structural and functional neuroimaging measures. Clinical measures will be performed at five time points (pre- and post-intervention, 3-, 6-, and 12-month follow-up); neuroimaging measures will be completed at pre- and post-intervention. DISCUSSION The present RCT is the first study to examine the efficacy of an adjunctive neurocognitive rehabilitation and awareness program for addiction. Results from this study will provide initial information concerning potential clinical efficacy of the treatment, as well as delineate neural mechanisms potentially targeted by this novel intervention. TRIAL REGISTRATION ClinicalTrials.gov NCT03922646 . Registered on 22 April 2019.
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Affiliation(s)
- Hamed Ekhtiari
- Laureate Institute for Brain Research, 6655 South Yale Ave., Tulsa, OK, 74136, USA.
| | - Tara Rezapour
- Institute for Cognitive Science Studies, Tehran, Iran
| | - Brionne Sawyer
- Laureate Institute for Brain Research, 6655 South Yale Ave., Tulsa, OK, 74136, USA
| | | | - Rayus Kuplicki
- Laureate Institute for Brain Research, 6655 South Yale Ave., Tulsa, OK, 74136, USA
| | | | - Martin P Paulus
- Laureate Institute for Brain Research, 6655 South Yale Ave., Tulsa, OK, 74136, USA
| | - Robin Aupperle
- Laureate Institute for Brain Research, 6655 South Yale Ave., Tulsa, OK, 74136, USA
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8
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Nardo T, Batchelor J, Berry J, Francis H, Jafar D, Borchard T. Cognitive Remediation as an Adjunct Treatment for Substance Use Disorders: A Systematic Review. Neuropsychol Rev 2021; 32:161-191. [PMID: 33871785 DOI: 10.1007/s11065-021-09506-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 04/06/2021] [Indexed: 11/28/2022]
Abstract
Substance use disorders are associated with diverse neuropsychological impairments, with deficits in memory and executive functioning commonly observed. Cognitive remediation has been shown to be effective in other populations with cognitive impairments in these domains, including those with psychiatric disorders and acquired brain injuries, and it has been hypothesised to be similarly effective for those in treatment for substance use disorders. We aimed to systematically review the evidence for cognitive remediation interventions administered as an adjunct treatment to substance use rehabilitation. Studies were included if participants were receiving substance use treatment, if improving cognitive functioning was the main focus of the intervention and if they used an experimental design with a control condition receiving treatment-as-usual or an active control intervention. Two independent reviewers agreed on the final selection of 32 studies, encompassing cognitive remediation for working memory, memory, executive functioning and general cognition. Significant differences between intervention and control groups for cognitive test results and treatment outcomes were extracted and compared across treatment approaches. The review found considerable heterogeneity across studies, including in the types of interventions, the nature of participants and the outcome measures used. Further, a lack of quality studies with sufficient power meant that limited conclusions could be drawn, highlighting a need for further replication and research. However, findings indicate that cognitive remediation remains a promising potential avenue for improving cognition and treatment outcomes for those in treatment for substance use disorders. Protocol submitted prospectively to PROSPERO 30.09.2019, CRD42020150978.
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Affiliation(s)
- Talia Nardo
- Macquarie University, North Ryde, NSW, 2109, Australia.
| | | | - Jamie Berry
- Macquarie University, North Ryde, NSW, 2109, Australia.,Advanced Neuropsychological Treatment Services, Strathfield South, NSW, 2136, Australia
| | | | - Deyyan Jafar
- Macquarie University, North Ryde, NSW, 2109, Australia
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Bell MD, Pittman B, Petrakis I, Yoon G. Donepezil and cognitive remediation therapy to augment treatment of alcohol use disorder related mild cognitive impairment (AUD-MCI): An open label pilot study with historical controls. Subst Abus 2020; 42:412-416. [PMID: 33284058 DOI: 10.1080/08897077.2020.1844847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Pharmacological and psychosocial interventions have only modest efficacy for Alcohol Use Disorder (AUD), and continued alcohol use has brain effects on neurocognition, which place heavy drinkers at increased risk of early onset dementia. The most common neurocognitive deficits are in the domains of executive function and memory, and these deficits may impact AUD treatment outcomes. AUD related Mild Cognitive Impairment (AUD-MCI) is a diagnosis in DSM-V and ICD-10. Donepezil, a cholinesterase inhibitor, is currently FDA approved for treatment of dementia, and recent preclinical research suggests anticholinesterase agents may treat alcoholism. Another approach to cognitive recovery is Cognitive Remediation Therapy (CRT). Recent research supports CRT efficacy in schizophrenia and related disorders, and some research suggests that CRT could improve neurocognition in substance abuse disorders (SUDs). This is the first report of an open-label clinical trial that combined donepezil with CRT to improve neurocognitive and clinical outcomes in the early phase of AUD recovery. Methods: Eleven older male US Veterans with AUD-MCI as determined by Level II neurocognitive criteria and who had recently relapsed participated in an open-label trial of 13 weeks of donepezil combined with CRT. They were compared with matched historical control samples on neurocognitive and clinical outcomes. Results: Participants had excellent adherence to donepezil and CRT. Neurocognitive improvements were highly significant on a composite score of learning and memory and executive function measures (p < .0001) and was significantly better than historical matched controls (p < .001). On a Clinical Global Impression scale, 90.9% of participants had a good clinical recovery compared with 59.5% of historical matched controls (p <.052). Conclusions: AUD-MCI has not received much research attention but is of considerable public health importance. Findings in this open-label trial of donepezil + CRT should encourage further investigation into the clinical benefit of this combined treatment for AUD-MCI.
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Affiliation(s)
- Morris D Bell
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA.,Psychiatry Service, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Brian Pittman
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ismene Petrakis
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA.,Psychiatry Service, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Gihyun Yoon
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA.,Psychiatry Service, VA Connecticut Healthcare System, West Haven, Connecticut, USA
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Bell MD, Muppala B, Weinstein AJ, Ciosek D, Pittman B, Petrakis I, Fiszdon JM. Randomized clinical trial of Cognitive Remediation Therapy with Work Therapy in the early phase of substance use disorder recovery for older Veterans: 12-Month follow-up. J Subst Abuse Treat 2020; 112:17-22. [PMID: 32199541 DOI: 10.1016/j.jsat.2020.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/29/2020] [Accepted: 01/29/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE In a previous report on a randomized clinical trial of a 3-month program of Cognitive Remediation Therapy (CRT) augmented by Work Therapy (WT) compared with WT alone for older veterans with substance use disorder (SUD), we reported significantly greater improvements at six-month follow-up on neurocognitive outcomes of working memory and executive functions for the CRT + WT condition. However, no difference was found between conditions on SUD outcomes, with both groups showing unusually high levels of abstinence. In this study, we extended follow-up to 12 months to test whether there was an SUD outcome "sleeper effect" from CRT + WT. To better understand the effects of WT, we added a treatment-as-usual (TAU) comparison sample. METHOD Forty-eight veterans with SUD receiving standard outpatient VA care were randomized into CRT + WT or WT. Clinical Global Impression (CGI) ratings were performed on 43/48 participants with up-to-date medical records. A TAU comparison group (n = 44) with similar demographic and illness characteristics was added to the analysis. RESULTS Treatment groups did not differ significantly at 12 months on CGI (p = 0.27), with 77% receiving CRT + WT showing favorable SUD outcomes compared to 62% in WT. Both groups had better CGI outcomes (p < 0.01) compared to the TAU comparison group (27%). Hours of WT participation (r = -0.49, p = 0.001) and hours of CRT (r = -0.45, p = 0.048) were associated with better CGI scores. CONCLUSION While no sleeper effect was found for CRT, a robust effect was strongly supported for WT on SUD outcomes.
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Affiliation(s)
- Morris D Bell
- Department of Psychiatry, Yale University, VA Connecticut Healthcare System, United States of America.
| | - Bharath Muppala
- Department of Psychiatry, Yale University, United States of America
| | | | - David Ciosek
- VA Connecticut Healthcare System, United States of America
| | - Brian Pittman
- Department of Psychiatry, Yale University, United States of America
| | - Ismene Petrakis
- Department of Psychiatry, Yale University, VA Connecticut Healthcare System, United States of America
| | - Joanna M Fiszdon
- Department of Psychiatry, Yale University, VA Connecticut Healthcare System, United States of America
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The development of adaptive risk taking and the role of executive functions in a large sample of school-age boys and girls. Trends Neurosci Educ 2019; 17:100120. [DOI: 10.1016/j.tine.2019.100120] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 09/09/2019] [Accepted: 10/09/2019] [Indexed: 11/20/2022]
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12
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Sampedro-Piquero P, Ladrón de Guevara-Miranda D, Pavón FJ, Serrano A, Suárez J, Rodríguez de Fonseca F, Santín LJ, Castilla-Ortega E. Neuroplastic and cognitive impairment in substance use disorders: a therapeutic potential of cognitive stimulation. Neurosci Biobehav Rev 2019; 106:23-48. [DOI: 10.1016/j.neubiorev.2018.11.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 10/15/2018] [Accepted: 11/23/2018] [Indexed: 01/08/2023]
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13
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Verdejo-Garcia A, Lorenzetti V, Manning V, Piercy H, Bruno R, Hester R, Pennington D, Tolomeo S, Arunogiri S, Bates ME, Bowden-Jones H, Campanella S, Daughters SB, Kouimtsidis C, Lubman DI, Meyerhoff DJ, Ralph A, Rezapour T, Tavakoli H, Zare-Bidoky M, Zilverstand A, Steele D, Moeller SJ, Paulus M, Baldacchino A, Ekhtiari H. A Roadmap for Integrating Neuroscience Into Addiction Treatment: A Consensus of the Neuroscience Interest Group of the International Society of Addiction Medicine. Front Psychiatry 2019; 10:877. [PMID: 31920740 PMCID: PMC6935942 DOI: 10.3389/fpsyt.2019.00877] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 11/06/2019] [Indexed: 01/01/2023] Open
Abstract
Although there is general consensus that altered brain structure and function underpins addictive disorders, clinicians working in addiction treatment rarely incorporate neuroscience-informed approaches into their practice. We recently launched the Neuroscience Interest Group within the International Society of Addiction Medicine (ISAM-NIG) to promote initiatives to bridge this gap. This article summarizes the ISAM-NIG key priorities and strategies to achieve implementation of addiction neuroscience knowledge and tools for the assessment and treatment of substance use disorders. We cover two assessment areas: cognitive assessment and neuroimaging, and two interventional areas: cognitive training/remediation and neuromodulation, where we identify key challenges and proposed solutions. We reason that incorporating cognitive assessment into clinical settings requires the identification of constructs that predict meaningful clinical outcomes. Other requirements are the development of measures that are easily-administered, reliable, and ecologically-valid. Translation of neuroimaging techniques requires the development of diagnostic and prognostic biomarkers and testing the cost-effectiveness of these biomarkers in individualized prediction algorithms for relapse prevention and treatment selection. Integration of cognitive assessments with neuroimaging can provide multilevel targets including neural, cognitive, and behavioral outcomes for neuroscience-informed interventions. Application of neuroscience-informed interventions including cognitive training/remediation and neuromodulation requires clear pathways to design treatments based on multilevel targets, additional evidence from randomized trials and subsequent clinical implementation, including evaluation of cost-effectiveness. We propose to address these challenges by promoting international collaboration between researchers and clinicians, developing harmonized protocols and data management systems, and prioritizing multi-site research that focuses on improving clinical outcomes.
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Affiliation(s)
- Antonio Verdejo-Garcia
- Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
| | - Valentina Lorenzetti
- School of Psychology, Faculty of Health Sciences, Australian Catholic University, Canberra, ACT, Australia
| | - Victoria Manning
- Eastern Health Clinical School Turning Point, Eastern Health, Richmond, VIC, Australia.,Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Hugh Piercy
- Eastern Health Clinical School Turning Point, Eastern Health, Richmond, VIC, Australia.,Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Raimondo Bruno
- School of Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Rob Hester
- School of Psychological Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - David Pennington
- San Francisco Veterans Affairs Health Care System (SFVAHCS), San Francisco, CA, United States.,Department of Psychiatry, University of California, San Francisco, San Francisco, CA, United States
| | - Serenella Tolomeo
- School of Medicine, University of St Andrews, Medical and Biological Science Building, North Haugh, St Andrews, United Kingdom.,Department of Psychology, National University of Singapore, Singapore, Singapore
| | - Shalini Arunogiri
- Eastern Health Clinical School Turning Point, Eastern Health, Richmond, VIC, Australia.,Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Marsha E Bates
- Department of Kinesiology and Health, Rutgers University, New Brunswick, NJ, United States
| | | | - Salvatore Campanella
- Laboratoire de Psychologie Médicale et d'Addictologie, ULB Neuroscience Institute (UNI), CHU Brugmann-Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - Stacey B Daughters
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Christos Kouimtsidis
- Department of Psychiatry, Surrey and Borders Partnership NHS Foundation Trust, Leatherhead, United Kingdom
| | - Dan I Lubman
- Eastern Health Clinical School Turning Point, Eastern Health, Richmond, VIC, Australia
| | - Dieter J Meyerhoff
- DVA Medical Center and Department of Radiology and Biomedical Imaging, University of California San Francisco, School of Medicine, San Francisco, CA, United States
| | - Annaketurah Ralph
- School of Psychology, University of Queensland, Brisbane, QLD, Australia
| | - Tara Rezapour
- Department of Cognitive Psychology, Institute for Cognitive Sciences Studies, Tehran, Iran
| | - Hosna Tavakoli
- Department of Cognitive Psychology, Institute for Cognitive Sciences Studies, Tehran, Iran.,Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehran Zare-Bidoky
- Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran.,School of Medicine, Shahid-Sadoughi University of Medical Sciences, Yazd, Iran
| | - Anna Zilverstand
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, United States
| | - Douglas Steele
- Medical School, University of Dundee, Ninewells Hospital, Scotland, United Kingdom
| | - Scott J Moeller
- Department of Psychiatry, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | - Martin Paulus
- Laureate Institute for Brain Research, University of Tulsa, Tulsa, OK, United States
| | - Alex Baldacchino
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, United States
| | - Hamed Ekhtiari
- Laureate Institute for Brain Research, University of Tulsa, Tulsa, OK, United States
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14
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McKowen JW, Isenberg BM, Carrellas NW, Zulauf CA, Ward NE, Fried RS, Wilens TE. Neuropsychological changes in patients with substance use disorder after completion of a one month intensive outpatient treatment program. Am J Addict 2018; 27:632-638. [PMID: 30387896 PMCID: PMC11006117 DOI: 10.1111/ajad.12824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/01/2018] [Accepted: 10/06/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Data suggest individuals with substance use disorders (SUD) exhibit high rates of executive functioning (EF) impairment, and that EF level can predict treatment retention. The primary aim of the present study was to investigate if patients who completed a 1 month intensive outpatient program (IOP) for SUD demonstrated recovered EF. METHODS Baseline and follow-up neurocognitive functioning was assessed by the Cambridge Neuropsychological Test Automated Battery (CANTAB) and the self-reported Behavior Rating Inventory of Executive Functioning (BRIEF-A) questionnaire. RESULTS The final sample included 15 patients who completed the one month IOP and for whom data were available (53% male, aged 36 years ± 13.4). Despite exhibiting general improvements in EF and significant improvements in organization, subjects continued to manifest significant executive dysfunction as evaluated by self-report and computerized assessment. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Patients with SUD often manifest high levels of executive dysfunction upon entry into SUD treatment that, while improving minimally, appears to persist despite intensive outpatient treatment at 1 month. These persistent EF deficits may affect patient engagement and participation in treatment, thus necessitating SUD programs to assess and accommodate EF issues throughout treatment. (Am J Addict 2018;XX:1-7).
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Affiliation(s)
- James W McKowen
- Addiction Recovery Management Service and West End Clinic, Massachusetts General Hospital, Boston, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Benjamin M Isenberg
- Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, Boston, Massachusetts
| | - Nicholas W Carrellas
- Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, Boston, Massachusetts
| | - Courtney A Zulauf
- Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, Boston, Massachusetts
| | - Nalan E Ward
- Addiction Recovery Management Service and West End Clinic, Massachusetts General Hospital, Boston, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Ronna S Fried
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
- Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, Boston, Massachusetts
| | - Timothy E Wilens
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
- Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, Boston, Massachusetts
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15
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Aharonovich E, Hasin DS, Nunes EV, Stohl M, Cannizzaro D, Sarvet A, Bolla K, Carroll KM, Genece KG. Modified cognitive behavioral therapy (M-CBT) for cocaine dependence: Development of treatment for cognitively impaired users and results from a Stage 1 trial. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2018; 32:800-811. [PMID: 30346186 DOI: 10.1037/adb0000398] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Cognitive impairments are associated with poor outcomes when treating cocaine dependent patients, but behavioral interventions to mitigate this impact have not been developed. In this Stage 1A/1B treatment development study, several compensatory strategies (e.g., content repetition, daily logs, diaries, visual presentation) were combined to create a modified cognitive behavioral therapy (M-CBT) for treating cocaine dependence. Initially, a select group of therapists, neuropsychology experts, and patients were asked to provide input on early drafts of the treatment manual and companion patient workbook. After an uncontrolled small trial (N = 15) and two rounds of manual development (Stage 1A), a pilot randomized clinical trial (N = 102) of cocaine dependent outpatients with and without cognitive impairments was conducted (Stage 1B). Participants were randomized to M-CBT (N = 52) or CBT (N = 50). Both treatments were individually delivered over 12 weeks with assessments conducted at baseline, end-of-treatment, and 3-month follow-up. The primary outcome was frequency of cocaine use, measured by number of days used in the prior 7 days. Participants in the two treatment groups did not differ significantly on drug use reduction or retention in treatment. However, among participants who completed at least 9 weeks of treatment, those in M-CBT showed a trend toward greater reduction in cocaine use compared to those in the CBT group. M-CBT is feasible for impaired and nonimpaired cocaine dependent participants. However, M-CBT treatment did not show significant superiority over standard CBT in the present sample. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
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Affiliation(s)
| | | | | | | | | | | | - Karen Bolla
- Department of Neurology, Bayview Medical Center, Johns Hopkins University
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16
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Kim EJ, Bahk YC, Oh H, Lee WH, Lee JS, Choi KH. Current Status of Cognitive Remediation for Psychiatric Disorders: A Review. Front Psychiatry 2018; 9:461. [PMID: 30337888 PMCID: PMC6178894 DOI: 10.3389/fpsyt.2018.00461] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/05/2018] [Indexed: 12/22/2022] Open
Abstract
Cognition is an important factor that affects daily functioning and quality of life. Impairment in cognitive function is a common symptom present in various psychological disorders, which hinders patients from functioning normally. Given that cognitive impairment has devastating effects, enhancing this in patients should lead to improvements in compromised quality of life and functioning, including vocational functioning. Over the past 50 years, several attempts have been made to improve impaired cognition, and empirical evidence for cognitive remediation (CR) has accumulated that supports its efficacy for treating schizophrenia. More recently, CR has been successfully applied in the treatment of depressive disorders, bipolar disorders, attention deficit/hyperactivity disorder, and anorexia nervosa. This study critically reviews recent CR studies and suggests their future direction. This study aimed to provide a modern definition of CR, and examine the current status of empirical evidence and representative CR programs that are widely used around the world.
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Affiliation(s)
- Eun Jin Kim
- Department of Psychology, Korea University, Seoul, South Korea
| | - Yong-Chun Bahk
- Department of Psychology, Korea University, Seoul, South Korea
| | - Hyeonju Oh
- Department of Psychology, Korea University, Seoul, South Korea
| | - Won-Hye Lee
- Department of Clinical Psychology, National Center for Mental Health, Seoul, South Korea
| | - Jong-Sun Lee
- Department of Psychology, Kangwon National University, Chuncheon, South Korea
| | - Kee-Hong Choi
- Department of Psychology, Korea University, Seoul, South Korea
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17
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Rezapour T, Hatami J, Farhoudian A, Sofuoglu M, Noroozi A, Daneshmand R, Samiei A, Ekhtiari H. Cognitive rehabilitation for individuals with opioid use disorder: A randomized controlled trial . Neuropsychol Rehabil 2017; 29:1273-1289. [PMID: 29161998 DOI: 10.1080/09602011.2017.1391103] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Aim: To examine the efficacy of cognitive rehabilitation treatment (CRT) for people with opioid use disorder who were recruited into a methadone maintenance treatment (MMT) programme. Method: 120 male subjects were randomly assigned to (1) MMT plus CRT in two months or (2) MMT plus a control intervention. Subjects were assessed at the beginning, mid-point and post-intervention as well as at 1-, 3- and 6-month follow-up time points. Results: Analysis with repeated measure ANOVA showed that the CRT group performed significantly better in tests of learning, switching, processing speed, working memory and memory span. Moreover, the CRT group had significantly lower opiate use over the control group during 3-months follow-up. Analysis including only those with a history of methamphetamine use showed that the CRT group had significantly lower amphetamine use. No group differences were observed for treatment retention. Conclusions: Our findings provide evidence that adding CRT as an adjunct intervention to MMT can improve cognitive performance as well as abstinence from both opiates and stimulants.
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Affiliation(s)
- Tara Rezapour
- a Department of Cognitive Psychology , Institute for Cognitive Science Studies , Tehran , Iran
| | - Javad Hatami
- a Department of Cognitive Psychology , Institute for Cognitive Science Studies , Tehran , Iran.,b Department of Psychology, Faculty of Psychology and Education , University of Tehran , Tehran , Iran
| | - Ali Farhoudian
- c Substance Abuse and Dependence Research Center , University of Social Welfare and Rehabilitation Sciences , Tehran , Iran
| | - Mehmet Sofuoglu
- d Department of Psychiatry, School of Medicine , Yale University , CT , USA.,e VA Connecticut Healthcare System , West Haven , CT , USA
| | - Alireza Noroozi
- f Neurocognitive Laboratory, Iranian National Center for Addiction Studies (INCAS) , Tehran University of Medical Sciences (TUMS) , Tehran , Iran.,g Neuroscience and Addiction Studies Department, School of Advanced Technologies in Medicine (SATiM) , Tehran University of Medical Sciences (TUMS) , Tehran , Iran
| | - Reza Daneshmand
- c Substance Abuse and Dependence Research Center , University of Social Welfare and Rehabilitation Sciences , Tehran , Iran
| | - Ahmadreza Samiei
- h Clinical Department, School of Medicine , Arak University of Medical Sciences , Arak , Iran
| | - Hamed Ekhtiari
- f Neurocognitive Laboratory, Iranian National Center for Addiction Studies (INCAS) , Tehran University of Medical Sciences (TUMS) , Tehran , Iran.,i Translational Neuroscience Program , Institute for Cognitive Science Studies , Tehran , Iran.,j Research Center for Molecular and Cellular Imaging , Tehran University of Medical Sciences , Tehran , Iran
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18
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Brooks SJ, Funk SG, Young SY, Schiöth HB. The Role of Working Memory for Cognitive Control in Anorexia Nervosa versus Substance Use Disorder. Front Psychol 2017; 8:1651. [PMID: 29018381 PMCID: PMC5615794 DOI: 10.3389/fpsyg.2017.01651] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 09/07/2017] [Indexed: 01/20/2023] Open
Abstract
Prefrontal cortex executive functions, such as working memory (WM) interact with limbic processes to foster impulse control. Such an interaction is referred to in a growing body of publications by terms such as cognitive control, cognitive inhibition, affect regulation, self-regulation, top-down control, and cognitive–emotion interaction. The rising trend of research into cognitive control of impulsivity, using various related terms reflects the importance of research into impulse control, as failure to employ cognitions optimally may eventually result in mental disorder. Against this background, we take a novel approach using an impulse control spectrum model – where anorexia nervosa (AN) and substance use disorder (SUD) are at opposite extremes – to examine the role of WM for cognitive control. With this aim, we first summarize WM processes in the healthy brain in order to frame a systematic review of the neuropsychological, neural and genetic findings of AN and SUD. In our systematic review of WM/cognitive control, we found n = 15 studies of AN with a total of n = 582 AN and n = 365 HC participants; and n = 93 studies of SUD with n = 9106 SUD and n = 3028 HC participants. In particular, we consider how WM load/capacity may support the neural process of excessive epistemic foraging (cognitive sampling of the environment to test predictions about the world) in AN that reduces distraction from salient stimuli. We also consider the link between WM and cognitive control in people with SUD who are prone to ‘jumping to conclusions’ and reduced epistemic foraging. Finally, in light of our review, we consider WM training as a novel research tool and an adjunct to enhance treatment that improves cognitive control of impulsivity.
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Affiliation(s)
- Samantha J Brooks
- Functional Pharmacology, Department of Neuroscience, Uppsala UniversityUppsala, Sweden.,Department of Psychiatry and Mental Health, University of Cape TownCape Town, South Africa
| | - Sabina G Funk
- Department of Psychiatry and Mental Health, University of Cape TownCape Town, South Africa
| | - Susanne Y Young
- Department of Psychiatry, Stellenbosch UniversityBellville, South Africa
| | - Helgi B Schiöth
- Functional Pharmacology, Department of Neuroscience, Uppsala UniversityUppsala, Sweden
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