Computer-aided neurocognitive remediation in schizophrenia: Durability of rehabilitation outcomes in a follow-up study

Cognitive remediation in schizophrenia: What happens after 10 years?

Cognitive Remediation Therapy (CRT) represents the gold standard treatment for cognitive impairment in schizophrenia, but the permanence of its effects over time have been poorly investigated. Our study aims to evaluate long lasting cognitive and functional effects of CRT together with standard rehabilitation interventions (SRT) in a group of patients diagnosed with schizophrenia, 10 years after the end of the treatment. Forty patients, previously included in a 5-year follow-up study evaluating the effects of CRT combined with SRT, were revalued 10 years after the complete of the intervention. Results revealed that cognitive and functional improvements of combined CRT/SRT interventions are still preserved 10 years after the end of the treatments, with the only exception of psychomotor speed and coordination cognitive subdomain. Moreover, investigating persistence of the influence of SRT, patients that underwent a shorter SRT following CRT (six months vs one year) showed worsened processing speed abilities. This is the first study confirming that cognitive and functional improvements of joint CRT/SRT interventions are still conserved 10 years after the end of the treatments. Preliminary datas suggest that a longer SRT following CRT may lead to significant benefits, in terms of cognitive gains, in patients affected by schizophrenia.

Cognitive dysfunction in schizophrenia: An expert group paper on the current state of the art

Cognitive impairment in schizophrenia represents one of the main obstacles to clinical and functional recovery. This expert group paper brings together experts in schizophrenia treatment to discuss scientific progress in the domain of cognitive impairment to address cognitive impairments and their consequences in the most effective way. We report on the onset and course of cognitive deficits, linking them to the alterations in brain function and structure in schizophrenia and discussing their role in predicting the transition to psychosis in people at risk. We then address the assessment tools with reference to functioning and social cognition, examining the role of subjective measures and addressing new methods for measuring functional outcomes including technology based approaches. Finally, we briefly review treatment options for cognitive deficits, focusing on cognitive remediation programs, highlighting their effects on brain activity and conclude with the potential benefit of individualized integrated interventions combing cognitive remediation with other approaches.

Functional benefits of co-occurring autistic symptoms in schizophrenia is delimited by symptom severity

BACKGROUND

Impairments in daily functioning characterize both autism spectrum disorder and schizophrenia. Research has shown that a subsample of schizophrenia patients presents autistic symptoms, leading to the hypothesis that their co-occurrence would be associated with a 'double dose' of deficit. A growing body of research examined this hypothesis by looking at the joint effect of autistic and positive psychotic symptoms, and yielded contrasting results, ranging from benefits to adverse effects. We hypothesized that the interactive effect of autistic and positive symptoms on functioning in schizophrenia might depend on the patients' symptom severity.

METHOD

In 170 schizophrenia patients, a two-step cluster analysis identified two groups of patients with different levels of autistic and positive symptom severity. Using general linear models, we examined the interactions of groups, autistic and positive symptoms on functioning.

RESULTS

Autistic and positive symptoms were interactively associated with better functioning, but only in the symptomatically less severe patients. In contrast, autistic and positive symptoms were independently associated with worse functioning in the symptomatically more severe patients. These associations were observed above and beyond the effects of I.Q. and illness duration.

CONCLUSIONS

The findings highlight the complex role played by co-occurring autistic symptoms in schizophrenia, whose beneficial effects on functioning appear to depend on patients' psychopathological severity. Our findings may help to reconcile the seemingly contrasting results from previous studies, and to understand the heterogeneity of behavior and functional outcomes in schizophrenia. This study underscores the potential utility of routinely assessing autism in schizophrenia, in order to better formulate individualized rehabilitative programs.

The Recovery Process for Individuals With Schizophrenia in the Context of Evidence-Based Psychotherapy and Rehabilitation

Abstract. This systematic review aimed to evaluate the efficacy of Cognitive Behavioral Therapy (CBT), META Cognitive Therapy (MCT), Metacognitive Training (MCTR), Metacognitive Reflection and Insight Therapy (MERIT), of various rehabilitation programs and of recovery programs in schizophrenia. Medline/Pubmed was searched for studies published in English from January 2010 to August 2018, which were screened against inclusion criteria by two reviewers. The methodological quality of the included studies was evaluated by two independent raters, which are the Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies and the fidelity criteria. The study included 41 RCTs and 12 case studies with n = 3,059 persons with schizophrenia. Cognitive Behavioral Therapy (CBT) proved to be superior in terms of the improvement of primary and secondary outcomes. MCT decreased positive symptoms and improved metacognitive capacity and insight. MCTR reduced positive symptoms and socially disruptive behavior. MERIT improved metacognitive capacity and insight. Rehabilitation programs were efficacious in the improvement of cognition, symptoms, and functional outcome. The recovery programs enhanced illness-management knowledge, attitudes toward medication and insights related to negative symptoms. It is recommended to combine the above evidence based psychotherapeutic interventions. Limitations of this systematic review are discussed toward the end of the essay. Some important factors have to be considered in the future have been mentioned.

Cognitive Remediation for Inpatients With Schizophrenia: Effects of a Brief and Intensive Training

Computer-assisted cognitive remediation (CACR) is a computer-based rehabilitation treatment aimed at improving cognition and at developing strategies that can be applied to various functional areas. Different protocols are currently used with great variability over the intensity and duration of treatments. In this study, we evaluated the effects of a brief and intensive CACR training (i.e., 15 sessions for 3 weeks) on cognitive domains, as well as the durability of cognitive gains and their generalization to functional areas, 3 months after CACR training. Thirty-eight patients with schizophrenia were recruited and assessed for psychopathology, cognitive performance, and functioning before the rehabilitative intervention. Patients were reassessed for cognition after CACR rehabilitation. Moreover, a subsample of 13 patients was evaluated for cognition and functioning 3 months after CACR completion. Results show significant improvements in multiple cognitive domains after CACR. Furthermore, 3 months after CACR completion, significant improvements were also detected in executive functions and daily functioning. This study suggests that a brief and intense CACR training is effective on cognitive and functional domains and that it could be feasible and affordable for health care services, thus offering patients the best options for fulfilling recovery goals.

A leopard cannot change its spots: A novel pragmatic account of concretism in schizophrenia

Concretism is a well-known feature of schizophrenia, tracing back to the early descriptions of the disease and commonly associated with the literal interpretation of figurative expressions such as proverbs, metaphors, and idioms. However, figurative expressions are not all alike in terms of linguistic and pragmatic processes. Determining if some figurative types are more impaired than others and if the type of task affects the performance constitutes an open issue with implications for the description of the clinical profile and for treatment. We run a fine-grained assessment of figurative language comprehension by comparing 47 patients with schizophrenia and 39 controls in three figurative types (idioms, metaphors, proverbs) presented in two response formats (multiple-choice, verbal-explanation), considering also the role of cognitive and clinical variables and the impact on quality of life. Mixed-effects models analysis revealed that: i) patients performed worse than controls across figurative types and response formats, indicating a diffuse impairment; ii) there is an interplay of figurative type and response format, which makes verbal-explanation of proverbs especially challenging; iii) in patients, problems in figurative language are largely connected with formal thought disorder and global IQ. Moreover, multiple-choice of metaphors was associated with patients' quality of life. This study offers a novel account of concretism, framed in pragmatics and figurative language processing. Adopting this perspective allowed us to describe the nuances of concretism, which areas in the figurative domain are especially challenging for patients and which ones capture differences in functioning, in order to guide intervention programs and integration in society.

The efficacy of computer-based cognitive training for executive dysfunction in schizophrenia

The purpose of this study was to assess the effect of computer-based cognitive training on executive dysfunction in patients with schizophrenia. Sixty-five patients with schizophrenia were randomly assigned to a training group (n = 33) or a non-training group (n = 32), and compared in terms of executive performance to a healthy control group (n = 33). Executive function was assessed using the Trail Making Test, the Stroop Color and Word Test, and the Wisconsin Card Sorting Test (computer version). Cognitive training was performed using RehaCom software over a course of 16 individual sessions. Primary outcomes were training (performance at three different timepoints) and neuropsychological components (flexibility and cognitive inhibition, high executive processing, and processing speed). In both clinical groups, all aspects of executive function were found to be deficient. In the patient training group, the use of computer-based training alongside pharmacological treatment was more effective in terms of cognitive improvement than pharmacological treatment alone. However, there was no significant effect of cognitive training on processing speed. Cognitive training in schizophrenia patients was effective at improving several aspects of executive function, but did not improve processing speed.

Evidence for Interventions to Improve and Maintain Occupational Performance and Participation for People With Serious Mental Illness: A Systematic Review

OBJECTIVE

This systematic review evaluates the evidence for the effectiveness of interventions within the scope of occupational therapy to improve and maintain performance and participation for people with serious mental illness. Areas included in this review are activities of daily living, instrumental activities of daily living, leisure, social participation, and rest and sleep.

METHOD

Databases searched included MEDLINE, PsycINFO, CINAHL, OTseeker, and the Cochrane Database of Systematic Reviews. Reviewers read and assessed citations, abstracts, and full-text articles for inclusion and analysis.

RESULTS

Sixty-one articles were selected for inclusion. The review yielded strong evidence for psychoeducation and occupation- and cognitive-based interventions, moderate evidence for skills-based interventions, and limited evidence for technology-supported interventions.

CONCLUSION

Results of this review support use of evidence-based practice within the scope of occupational therapy, inclusion of occupational therapy practitioners as mental health service providers, and continued research.

Integrated cognitive remediation and standard rehabilitation therapy in patients of schizophrenia: persistence after 5years

Cognitive remediation, often used in combination with standard rehabilitation programs, represents the best available tool to treat cognitive impairments in patients with schizophrenia. However, there are still open questions about durability of effects and generalization of cognitive improvements to functional outcome. This study aims to investigate the persistence of both cognitive and functional effects of combined cognitive remediation plus standard rehabilitation interventions, 5years after completion of the intervention, also comparing different durations of the standard rehabilitation. Sixty patients diagnosed with schizophrenia and previously treated with a 6months intervention, consisting of standard rehabilitation plus 3-months of cognitive remediation, either followed by another year of standard rehabilitation or routine psychiatric treatment, were reassessed with neuropsychological and functional measures 5years after the intervention. Results show that cognitive abilities remained stable after 5years in both groups, while functional performance significantly decreased in patients treated with the 6months intervention only. Data thus suggest that cognitive effects persist even after 5years, while a longer standard rehabilitation following the cognitive remediation program may be needed to achieve a stable functional gain.

Improving Cognition to Increase Treatment Efficacy in Schizophrenia: Effects of Metabolic Syndrome on Cognitive Remediation's Outcome

Cognitive impairment, typically more severe in treatment resistant patients, is considered a hallmark of schizophrenia and the prime driver of functional disability. Recent evidence suggests that metabolic syndrome may contribute to cognitive deficits in schizophrenia, possibly through shared underlying mechanisms. However, results are still contradictory and no study has so far examined the influence of metabolic syndrome on cognitive outcome after cognitive remediation therapy (CRT). Based on these premises, this study aims to investigate the relationship between metabolic syndrome and cognition, specifically considering cognitive outcome after treatment. Secondary objectives include the analysis of the association between cognitive impairment and psychopathological status and, in a subgroup of patients, the evaluation of the effect of Sterol Regulatory Element Binding Transcription Factor 1 (SREBF-1) rs11868035 genetic polymorphism, previously associated with metabolic alterations, on both cognition and metabolic syndrome. One-hundred seventy-two outpatients with schizophrenia were assessed for metabolic parameters and neurocognitive measures and 138 patients, who completed CRT, were re-evaluated for cognition. A subsample of 51 patients was also genotyped for rs11868035 from peripheral blood sample. Results show a negative impact of metabolic syndrome on executive functions and global cognitive outcome after CRT. Data also revealed a significant effect of SREBF-1 polymorphism, with a higher prevalence of metabolic syndrome and worse processing speed performance among G/G homozygous subjects, compared the A allele carriers. Overall these findings support the hypothesis that metabolic alterations may hamper the capacity to restore cognitive deficits, as well as they highlight the need to further explore possible converging mechanisms underlying both cognitive and metabolic dysfunction. At the clinical level, results point to the importance of a comprehensive assessment including the metabolic status of patients and of individualized strategies addressing metabolic dysfunction in order to potentiate treatment outcome in schizophrenia.

Achieving recovery in patients with schizophrenia through psychosocial interventions: A retrospective study

AIM

Recovery, or functional remission, represents the ultimate treatment goal in schizophrenia. Despite its importance, a standardized definition of remission is still lacking, thus reported rates significantly vary across studies. Moreover, the effects of rehabilitative interventions on recovery have not been thoroughly investigated. This study aimed to evaluate recovery in a sample of patients with chronic schizophrenia engaged in rehabilitation programs and to explore contributing factors, with a focus on sociocognitive rehabilitative interventions.

METHODS

Data from 104 patients with schizophrenia treated either with a standard rehabilitation program, including cognitive remediation (n = 46), or the latter plus a specific sociocognitive intervention (n = 58), and assessed for psychopathology, cognition, social cognition, and Quality of Life Scale, were retrospectively analyzed for this study.

RESULTS

Recovery, evaluated with the Quality of Life Scale, was achieved by 56.76% of patients in our sample. While no effects were observed for clinical, cognitive, or sociocognitive variables, participation in the sociocognitive rehabilitative interventions was positively associated with recovery.

CONCLUSION

Our results indicate that high rates of recovery can be achieved in patients treated with psychosocial interventions and suggest that rehabilitative programs targeting social cognition may further facilitate the process of recovery. If confirmed, these results may have relevant implications for daily clinical practice and service provision, allowing clinicians to develop and optimize specific rehabilitation programs in order to promote recovery.

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]

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.

Computer-assisted cognitive remediation therapy in schizophrenia: Durability of the effects and cost-utility analysis

The durability of computer-assisted cognitive remediation (CACR) therapy over time and the cost-effectiveness of treatment remains unclear. The aim of the current study is to investigate the effectiveness of CACR and to examine the use and cost of acute psychiatric admissions before and after of CACR. Sixty-seven participants were initially recruited. For the follow-up study a total of 33 participants were enrolled, 20 to the CACR condition group and 13 to the active control condition group. All participants were assessed at baseline, post-therapy and 12 months post-therapy on neuropsychology, QoL and self-esteem measurements. The use and cost of acute psychiatric admissions were collected retrospectively at four assessment points: baseline, 12 months post-therapy, 24 months post-therapy, and 36 months post-therapy. The results indicated that treatment effectiveness persisted in the CACR group one year post-therapy on neuropsychological and well-being outcomes. The CACR group showed a clear decrease in the use of acute psychiatric admissions at 12, 24 and 36 months post-therapy, which lowered the global costs the acute psychiatric admissions at 12, 24 and 36 months post-therapy. The CACR is durable over at least a 12-month period, and CACR may be helping to reduce health care costs for schizophrenia patients.

Targeting anxiety to improve quality of life in patients with schizophrenia

BACKGROUND

Several studies suggested that anxiety can significantly affect the outcome of schizophrenia. Despite this evidence, non-pharmacological interventions targeting anxiety are still heterogenous. This study aims to test the efficacy of a novel training specifically designed to target anxiety in patients with schizophrenia. Innovatively, this training, beyond psychoeducation and problem solving, also targets Theory of Mind, as it provides coping strategies.

METHOD

Twenty-seven outpatients with schizophrenia received a novel rehabilitative training targeting anxiety (Anxiety Management Group [AMG]) combined with a Computer-Assisted Cognitive Remediation (CACR), and twenty received CACR plus a control intervention (Control Newspaper discussion Group [CNG]). All patients were assessed at baseline and after treatment for quality of life, neurocognition and anxiety.

RESULTS

After training, patients treated with AMG+CACR showed significantly greater improvements on anxiety. A significant increase in quality of life was observed only for AMG+CACR group. Moreover, the participants' appraisal showed a significant difference between treatment groups with higher ratings among patients who received the AMG+CACR.

CONCLUSIONS

This study thus suggests feasibility and efficacy of the proposed intervention, that could be implemented in rehabilitative programs for patients with schizophrenia with potential benefits also on disease course and outcome.

Neuroscience-informed computer-assisted cognitive training in schizophrenia

Schizophrenia is a heterogeneous psychiatric syndrome characterized by psychosis. It is also a neurodevelopmental disorder. In the earliest phases of the illness, at-risk individuals exhibit subtle, nonspecific symptoms, including cognitive dysfunction and progressive brain volumetric loss. Generally, schizophrenia is characterized by abnormal/inefficient neural system operations and neural oscillatory activity, as well as functional disconnectivity across frontal-temporo parietal and frontal-subcortical networks; it thus may best be described as a widespread neural oscillatory connectomopathy. Despite earlier views of schizophrenia as an inevitably progressive neurodegenerative disease, emerging evidence indicates that endogenous neuroplastic capacity is retained. An active area of research is directed at understanding how best to harness this learning-induced neuroplasticity to enhance neural system functioning, improve cognition, and prevent-and possibly even reverse-disease progression. In this review, we present an overview of results from the most widely used computer-assisted cognitive-training programs in schizophrenia, contrasting a broad neuropsychological rehabilitation approach with a targeted cognitive-training approach. We then review studies on the neurobiological effects of these two training methods. Finally, we discuss future directions with a focus on the "oscillatory connectome" as a key area of investigation for developing the most precise and scientifically informed treatment approaches for this illness.

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.

A survey of eMedia-delivered interventions for schizophrenia used in randomized controlled trials

BACKGROUND

Randomized trials evaluating electronic Media (eMedia) delivery of interventions are increasingly frequent in mental health. Although a number of reviews have reported efficacy of these interventions, none has reviewed the type of eMedia interventions and quality of their description. We therefore decided to conduct a survey of eMedia-delivered interventions for schizophrenia.

METHODS

We surveyed all relevant trials reliably identified in the Cochrane Schizophrenia Group's comprehensive register of trials by authors working independently. Data were extracted regarding the size of the trial, interventions, outcomes and how well the intervention was described.

RESULTS

eMedia delivery of interventions is increasingly frequent in trials relevant to the care of people with schizophrenia. The trials varied considerably in sample sizes (mean =123, median =87, range =20-507), and interventions were diverse, rarely evaluating the same approaches and were poorly reported. This makes replication impossible. Outcomes in these studies are limited, have not been noted to be chosen by end users and seem unlikely to be easy to apply in routine care. No study reported on potential adverse effects or cost, end users satisfaction or ease of use. None of the papers mentioned the use of CONSORT eHealth guidelines.

CONCLUSION

There is a need to improve reporting and testing of psychosocial interventions delivered by eMedia. New trials should comply with CONSORT eHealth guidance on design, conduct and reporting, and existing CONSORT should be updated regularly, as the field is constantly evolving.

Cognitive Remediation and Functional Improvement in Schizophrenia: is it a Matter of Size?

Background

Cognitive Remediation represents the best available tool to treat cognitive deficits in schizophrenia and evidence suggests an effect also on global functioning. However, the relationship between cognitive and functional improvement is not yet fully elucidated: do cognitive changes need to be of a definite size and/or encompass a certain number of domains in order to impact on daily functioning? This study aims to explore the role of cognitive improvement, evaluated both quantitatively and qualitatively through the use of Italian equivalent scores, on the daily functioning of patients. As secondary goal, the influence of demographic, clinical and neuropsychological variables on functional outcome was also systematically investigated.

Methods

One hundred subjects with a diagnosis of schizophrenia underwent 36 sessions of Cognitive Remediation and were evaluated at baseline and after the training with the Brief Assessment of Cognition in Schizophrenia and the Quality of Life Scale.

Results

A total of 70% of patients improved in at least one cognitive domain and over 50% obtained a normalized score. Among the clinical and neurocognitive factors examined, the only significant predictor of quality of life’s improvement was the proportion of cognitive functions that reached an equivalent score of “normal”.

Conclusions

This study suggests that improvements in daily functioning depend on the achievement of a cognitive profile as much as possible “normal”, harmonious and balanced, supporting the idea that a qualitative leap in cognition is needed in order to gain an advantage in real life activities.

Treatment of adult patients with schizophrenia and complex mental health needs - A national clinical guideline

BACKGROUND AND AIM

The Danish Health and Medicines Authority assembled a group of experts to develop a national clinical guideline for patients with schizophrenia and complex mental health needs. Within this context, ten explicit review questions were formulated, covering several identified key issues.

METHODS

Systematic literature searches were performed stepwise for each review question to identify relevant guidelines, systematic reviews/meta-analyses, and randomized controlled trials. The quality of the body of evidence for each review question was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Clinical recommendations were developed on the basis of the evidence, assessment of the risk-benefit ratio, and perceived patient preferences.

RESULTS

Based on the identified evidence, a guideline development group (GDG) recommended that the following interventions should be offered routinely: antipsychotic maintenance therapy, family intervention and assertive community treatment. The following interventions should be considered: long-acting injectable antipsychotics, neurocognitive training, social cognitive training, cognitive behavioural therapy for persistent positive and/or negative symptoms, and the combination of cognitive behavioural therapy and motivational interviewing for cannabis and/or central stimulant abuse. SSRI or SNRI add-on treatment for persistent negative symptoms should be used only cautiously. Where no evidence was available, the GDG agreed on a good practice recommendation.

CONCLUSIONS

The implementation of this guideline in daily clinical practice can facilitate good treatment outcomes within the population of patients with schizophrenia and complex mental health needs. The guideline does not cover all available interventions and should be used in conjunction with other relevant guidelines.

Combined social cognitive and neurocognitive rehabilitation strategies in schizophrenia: neuropsychological and psychopathological influences on Theory of Mind improvement

BACKGROUND

Neurocognitive and social cognitive impairments represent important treatment targets in schizophrenia, as they are significant predictors of functional outcome. Different rehabilitative interventions have recently been developed, addressing both cognitive and psychosocial domains. Although promising, results are still heterogeneous and predictors of treatment outcome are not yet identified. In this study we evaluated the efficacy of two newly developed social cognitive interventions, respectively based on the use of videotaped material and comic strips, combined with domain-specific Cognitive Remediation Therapy (CRT). We also analysed possible predictors of training outcome, including basal neurocognitive performance, the degree of cognitive improvement after CRT and psychopathological variables.

METHOD

Seventy-five patients with schizophrenia treated with CRT, were randomly assigned to: social cognitive training (SCT) group, Theory of Mind Intervention (ToMI) group, and active control group (ACG).

RESULTS

ANOVAs showed that SCT and ToMI groups improved significantly in ToM measures, whereas the ACG did not. We reported no influences of neuropsychological measures and improvement after CRT on changes in ToM. Both paranoid and non-paranoid subjects improved significantly after ToMI and SCT, without differences between groups, despite the better performance in basal ToM found among paranoid patients. In the ACG only non-paranoid patients showed an improvement in non-verbal ToM.

CONCLUSION

Results showed that both ToMI and SCT are effective in improving ToM in schizophrenia with no influence of neuropsychological domains. Our data also suggest that paranoid symptoms may discriminate between different types of ToM difficulties in schizophrenia.

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.

Computerized cognitive training targeting brain plasticity in schizophrenia

Two important paradigm shifts have occurred recently in the field of schizophrenia research. First, we now understand schizophrenia to be a neurodevelopmental disorder, one that is characterized by aberrant patterns of activation and connectivity in cortical and subcortical neural networks that are present before illness onset and that worsen as an individual progresses into later stages of the disease. Second, we now understand that these abnormalities are not immutable and fixed, but instead can respond to interventions targeting brain plasticity, particularly when delivered in the prodromal and early phases of schizophrenia. In this chapter, we will first describe some of the neurocognitive impairments that characterize schizophrenia, highlighting the developmental course of the illness. We will then briefly review salient features of currently available computerized cognitive training programs that target these impairments. Next, we will present an overview of current research findings regarding neurobiological effects of computerized cognitive training in schizophrenia and how these results shed light on the critical neuroplasticity mechanisms that support successful training. Finally, we will present recommendations for future research to optimize computerized cognitive training programs, with an aim to promoting functional recovery.

Executive functions rehabilitation for schizophrenia: a critical systematic review

BACKGROUND

Consistent evidences suggest that poor functional outcomes in schizophrenia are associated with deficits in executive functions (EF). As result cognitive training, remediation and/or rehabilitation (CR) programs have been developed and many theories, methods and approaches have emerged in support of them. This article presents a systematic review of randomized controlled trials (RCT), including EF rehabilitation interventions, with a focus on methodological issues and evidences of EF improvements.

METHOD

Electronic databases (Medline, Web of Science, PsycINFO and Embase) were searched for articles on schizophrenia, EF and cognitive rehabilitation terms. The methodological quality of each article was measured by 5-point JADAD scale.

RESULTS

A total of 184 articles were initially identified, but after exclusion criteria, 30 RCT remained in this review. A proportion of 23% of studies scored higher than 4 points in JADAD scale, 40% scored 3 points, 33% scored 2 points and one study scored only 1 point. The average length of interventions was approximately 80 h distributed around 3.42 h/week.

CONCLUSION

The reviewed articles corroborate the literature pointing that CR could be a promising therapeutic option for cognitive deficits in schizophrenia. In general, CR could improve cognitive domains and social adjustment either using computerized or paper-and-pencil programs. Additionally, CR combined with cognitive behavioral therapy and/or group sessions is particularly effective. In this paper, we also speculated and discussed optimal doses of treatment and the differences regarding modalities and approaches.

Cognition, behaviour and academic skills after cognitive rehabilitation in Ugandan children surviving severe malaria: a randomised trial

Background

Infection with severe malaria in African children is associated with not only a high mortality but also a high risk of cognitive deficits. There is evidence that interventions done a few years after the illness are effective but nothing is known about those done immediately after the illness. We designed a study in which children who had suffered from severe malaria three months earlier were enrolled into a cognitive intervention program and assessed for the immediate benefit in cognitive, academic and behavioral outcomes.

Methods

This parallel group randomised study was carried out in Kampala City, Uganda between February 2008 and October 2010. Sixty-one Ugandan children aged 5 to 12 years with severe malaria were assessed for cognition (using the Kaufman Assessment Battery for Children, second edition and the Test of Variables of Attention), academic skills (Wide Range Achievement Test, third edition) and psychopathologic behaviour (Child Behaviour Checklist) three months after an episode of severe malaria. Twenty-eight were randomised to sixteen sessions of computerised cognitive rehabilitation training lasting eight weeks and 33 to a non-treatment group. Post-intervention assessments were done a month after conclusion of the intervention. Analysis of covariance was used to detect any differences between the two groups after post-intervention assessment, adjusting for age, sex, weight for age z score, quality of the home environment, time between admission and post-intervention testing and pre-intervention score. The primary outcome was improvement in attention scores for the intervention group. This trial is registered with Current Controlled Trials, number ISRCTN53183087.

Results

Significant intervention effects were observed in the intervention group for learning mean score (SE), [93.89 (4.00) vs 106.38 (4.32), P = 0.04] but for working memory the intervention group performed poorly [27.42 (0.66) vs 25.34 (0.73), P = 0.04]. No effect was observed in the other cognitive outcomes or in any of the academic or behavioural measures.

Conclusions

In this pilot study, our computerised cognitive training program three months after severe malaria had an immediate effect on cognitive outcomes but did not affect academic skills or behaviour. Larger trials with follow-up after a few years are needed to investigate whether the observed benefits are sustained.

Trial registration

ISRCTN: ISRCTN53183087