Lessons learnt? The importance of metacognition and its implications for Cognitive Remediation in schizophrenia

Does cognitive improvement translate into functional changes? Exploring the transfer mechanisms of cognitive remediation therapy for euthymic people with bipolar disorder

BACKGROUND

Bipolar disorder (BD) is associated with cognitive and functional difficulties, persistent beyond mood episodes. Cognitive remediation (CR) is a psychological therapy targeting cognitive and functioning difficulties. Recent evidence suggests that CR may enhance long-term functioning but transfer mechanisms on functional outcomes have not been explored. We aim to investigate whether and how cognitive gains after CR transfer to functional improvement.

METHODS

We considered data from a randomized controlled trial comparing CR (n = 40) to treatment-as-usual (TAU; n = 40) in euthymic people with BD. Treatment outcomes included individual cognitive domains and global cognition, psychosocial functioning, and goal attainment. Regression-based mediation and moderation modelling were used to assess whether and how post-treatment cognitive changes translate into functional improvement at follow-up, three months after treatment end.

RESULTS

Cognitive gains after CR transferred to functional changes three months later: improvement in post-treatment global cognition partially mediated the effect of CR on psychosocial functioning (standardized indirect effect: -0.23, 95% CI -0.51 to -0.04). Goal attainment was not significantly mediated by changes in cognition, but post-treatment cognitive performance moderated the effect of CR on the GAS at follow-up (interaction effect: 0.78, 95% CI 0.08-1.55).

CONCLUSIONS

Our findings suggest that cognitive improvements contribute to functional improvement but transfer mechanisms differ between psychosocial functioning and idiosyncratic recovery goals. Cognition accounted for only a proportion of the total CR effect on functional outcomes. Future studies should consider other variables, such as metacognition, that may drive the transfer of CR effects to functional outcomes.

Evaluating the mechanisms of social cognition intervention in schizophrenia: A proof-of-concept trial

BACKGROUND

Social cognition interventions have shown promise for improving social functioning in people with schizophrenia. However, it is unclear how changes in social cognition affect social functioning. This study evaluates the impact of a social cognition intervention (GRASP - GRoup trAining for Social skills in Psychosis) on social cognition and social functioning outcomes and explores how two mechanisms, affect and physiological arousal, may drive changes.

METHOD

A two-arm single blind (assessor) randomized pilot trial comparing GRASP plus treatment-as-usual (TAU) with TAU alone in people with a diagnosis of schizophrenia. Participants were assessed with measures of social cognition, social functioning, and symptoms. All participants undertook a week-long mobile health assessment (experience sampling method) measuring social behavior and affect and used a wearable device recording autonomic activity. Assessments were performed at baseline and at week 10.

RESULTS

Forty-eight participants were randomly allocated to the treatment or control condition. Individuals randomized to GRASP did not show improvements on experience sampled social behavior and social cognition measures compared to controls. However, participants in the GRASP group enjoyed social contact more and had lower levels of negative affect and higher levels of positive affect compared to controls. There was no evidence of autonomic changes (i.e., electrodermal activity) associated with social behavior resulting from the therapy.

CONCLUSION

Social cognition interventions may be helpful in improving the quality of social contacts in people with schizophrenia by decreasing negative affect. Increase in social behavior may require longer periods to be evident. Future studies should consider how social cognition interventions may alter qualitative aspects associated with social behavior.

What areas of everyday functioning are affected by theory of mind deficits in recent-onset schizophrenia spectrum disorders?

AIM

Functional recovery is now a recognized treatment goal for schizophrenia. It is therefore important to better understand the cognitive and psychological factors that influence functioning. Theory of mind (ToM) deficits are common in schizophrenia and have been linked to greater impairments in functioning. The current study aimed to identify which specific areas of functioning are linked to ToM in a group of 54 patients with a recent-onset of a schizophrenia spectrum disorder.

METHODS

ToM was assessed with the Combined Stories Test (COST). Several areas of functioning were rated based on an extensive semi-structured interviews.

RESULTS

Among the different areas of functioning that were examined, ToM showed a significant, positive relationship with ratings for productive activities (e.g. work or school) as well as with collaboration to psychiatric care.

CONCLUSION

These results suggest that ToM can impair functioning especially in situations in which patients need to collaborate with others, including the interactions with the clinical team.

Virtual Reality Therapy for the Negative Symptoms of Schizophrenia (V-NeST): A pilot randomised feasibility trial

BACKGROUND

Negative symptoms are typically observed in people with schizophrenia and indicate a loss or reduction of normal function (e.g. reduced motivation and affect display). Despite obstructing people's recovery, intervention development has received limited attention. This study tests the feasibility and acceptability of a novel Virtual Reality Supported Therapy for the Negative Symptoms of Schizophrenia (V-NeST).

METHOD

A single (rater) blind randomised study with two conditions; V-NeST plus treatment as-usual (TAU) vs. TAU alone, recruiting people with schizophrenia experiencing debilitating negative symptoms. Assessment was at baseline and 3-month post-randomisation. The pre-specified primary outcome was participants' goal attainment, secondary outcomes were negative symptoms and functioning. The study assessed feasibility and acceptability parameters including recruitment, eligibility, treatment adherence and retention. Acceptability was also evaluated qualitatively using a post-therapy feedback interview. Explorative therapy effect on outcomes was estimated.

RESULTS

The study recruited to its pre-specified target of 30 participants (15 randomised to V-Nest). Two participants in each trial arm disengaged and did not complete the study. Therapy engagement for those randomised to V-NeST was appropriate and research procedures were feasible. The experience with therapy and VR was described as positive and useful. Preliminary analysis suggested the therapy may have a large effect on participants goals and a possible effect on negative symptoms.

CONCLUSION

V-NeST is a feasible and acceptable intervention. This therapy has the potential to support people with schizophrenia achieving their recovery goals and may reduce negative symptoms. The efficacy results need to be evaluated in an appropriately powered efficacy study.

Effects of chess-based cognitive remediation training as therapy add-on in alcohol and tobacco use disorders: protocol of a randomised, controlled clinical fMRI trial

BACKGROUND

Alcohol and tobacco use disorders (AUD, TUD) are frequent, both worldwide and in the German population, and cognitive impairments are known to facilitate instances of relapse. Cognitive training has been proposed for enhancing cognitive functioning and possibly improving treatment outcome in mental disorders. However, these effects and underlying neurobiological mechanisms are not yet fully understood regarding AUD and TUD. Examining the effect of chess-based cognitive remediation training (CB-CRT) on neurobiological, neuropsychological and psychosocial aspects as well as treatment outcomes will provide insights into mechanisms underlying relapse and abstinence and might help to improve health behaviour in affected individuals if used as therapy add-on.

METHODS AND ANALYSIS

N=96 individuals with either AUD (N=48) or TUD (N=48) between 18 and 65 years of age will participate in a randomised, controlled clinical functional MRI (fMRI) trial. Two control groups will receive treatment as usual, that is, AUD treatment in a clinic, TUD outpatient treatment. Two therapy add-on groups will receive a 6-week CB-CRT as a therapy add-on. FMRI tasks, neurocognitive tests will be administered before and afterwards. All individuals will be followed up on monthly for 3 months. Endpoints include alterations in neural activation and neuropsychological task performance, psychosocial functioning, and relapse or substance intake. Regarding fMRI analyses, a general linear model will be applied, and t-tests, full factorial models and regression analyses will be conducted on the second level. Behavioural and psychometric data will be analysed using t-tests, regression analyses, repeated measures and one-way analyses of variance.

ETHICS AND DISSEMINATION

This study has been approved by the ethics committee of the medical faculty Mannheim of the University of Heidelberg (2017-647N-MA). The findings of this study will be presented at conferences and published in peer-reviewed journals.

TRIAL REGISTRATION

The study was registered in the Clinical Trials Register (trial identifier: NCT04057534 at clinicaltrials.gov).

Cognitive remediation for people with bipolar disorder: The contribution of session attendance and therapy components to cognitive and functional outcomes

BACKGROUND

Cognitive remediation (CR) can reduce cognitive and functional difficulties in people with bipolar disorder (BD). To date, there is limited evidence on the contribution of session attendance and therapy components to treatment outcomes. This study explores whether attendance and core CR components contribute to treatment outcomes.

METHODS

This is a secondary analysis using data from a randomized controlled trial comparing CR plus treatment-as-usual (TAU; n = 40) to TAU only (n = 40) in euthymic people with BD. Session attendance was measured by number of sessions and by achieving therapy completion, pre-defined as attending ≥20 sessions. We used instrumental variable analysis to examine the effect of attendance on treatment outcomes. We then considered the association between core therapy components (i.e., massed practice, errorless learning, strategy use, therapist contact) and post-treatment outcome changes using correlation.

RESULTS

The CR group improved significantly in measure of global cognition, psychosocial functioning, and goal attainment. Therapy recipients attended 27.1 sessions on average, with 32 (80%) completing the minimum number of 20 sessions. Attending more sessions and achieving therapy completion were associated with improved treatment outcomes, but this relationship was not significant within the subgroup of CR completers. Improvement in psychosocial functioning was associated with therapist contact and goal attainment with selecting useful strategies during therapy.

CONCLUSIONS

Our findings highlight the relevance of session attendance, specifically the importance of achieving a minimum threshold of CR sessions, for outcome improvement. Strategy use and therapist contact might facilitate improvements in psychosocial functioning and personal recovery goals.

Metacognitive mastery moderates the relationship between positive symptoms and distress in adults with serious mental illness

BACKGROUND

Research supports the possibility that a person's metacognitive ability may influence the impact of positive symptoms. This connection is important because understanding how metacognitive capacity relates to positive symptoms and distress can guide treatment and bolster recovery.

AIMS

To explore this, we assessed the moderating role of Metacognitive Mastery on the relationship of positive symptoms to affective symptoms, or markers of distress, measured both concurrently and at a later time point (to assess durability of metacognition) with persons with serious mental illness. To rule out the possibility that any findings were the result of cognitive impairments or general psychopathology we included measures of neurocognition and symptoms as potential covariates.

METHODS

Participants were 67 individuals with the majority diagnosed with either schizophrenia spectrum disorder, major depressive disorder, or bipolar disorder. Metacognition was measured with the Metacognitive Assessment Scale-Abbreviated, symptoms were measured using the Brief Psychiatric Rating Scale and verbal memory was measured using the California Verbal Learning Test.

RESULTS

Metacognitive Mastery moderated the relationship between positive symptoms and affective symptoms at both time points with differential patterns at each point.

CONCLUSIONS

Metacognitive Mastery may exert a complex influence upon the effects of positive symptoms on distress.

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

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

The use of virtual reality and augmented reality in psychosocial rehabilitation for adults with neurodevelopmental disorders: A systematic review

OBJECTIVES

Virtual reality and augmented reality have been used in psychosocial rehabilitation for adults with neurodevelopmental disorders in recent years, to provide functional training in a scaffolded and appealing manner. This systematic review attempted to evaluate (1) how virtual reality or augmented reality technology was deployed, when used as an intervention for adults with neurodevelopmental disorders; and (2) how virtual or augmented reality-assisted psychosocial rehabilitation programs impacted on the functional domains of community living, employment and social participation.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was adopted and a search of publications between June 2012 and June 2022 was carried out. The target groups were adults with schizophrenia/schizoaffective disorders, autism spectrum disorder, intellectual disabilities and attention deficit hyperactivity disorder. Interventions that targeted at least one functional domain were included.

RESULTS

The database search generated 1,267 records and 38 studies met the inclusion criteria. Three studies utilized augmented reality while the rest utilized virtual reality. The virtual scenarios were displayed in various ways, such as head-mounted displays, computer screens, mobile devices and cave rooms. A few studies also used features such as speech recognition, eye tracking and motion-capture device to provide real-time feedback to participants during rehabilitation. Eleven studies reported interventions that addressed community living, 15 studies addressed vocational skills and nine studies trained participants in social skills or social cognition. Three studies sought to improve quality of life using virtual scenarios to expose participants to various situations. Majority of these studies reported preliminary promising results, with improvement in the functional domains addressed. However, several studies had small sample sizes and many single-arm pretest-posttest studies were assessed to be of serious or critical risk of bias.

CONCLUSION

Virtual reality and augmented reality are deployed in various ways to augment psychosocial rehabilitation for adults with neurodevelopmental disorders. Most interventions target skills training or strategy learning in the areas of community living, work and social participation. Preliminary positive findings of their effects on functional performance were reported. Larger and robust studies using ecologically valid outcome measures will be needed to establish their effects on real-world functional outcomes.

SYSTEMATIC REVIEW REGISTRATION

identifier: CRD42022335443.

Social Dysfunction in Psychosis Is More Than a Matter of Misperception: Advances From the Study of Metacognition

Many with psychosis experience substantial difficulties forming and maintaining social bonds leading to persistent social alienation and a lack of a sense of membership in a larger community. While it is clear that social impairments in psychosis cannot be fully explained by symptoms or other traditional features of psychosis, the antecedents of disturbances in social function remain poorly understood. One recent model has proposed that deficits in social cognition may be a root cause of social dysfunction. In this model social relationships become untenable among persons diagnosed with psychosis when deficits in social cognition result in inaccurate ideas of what others feel, think or desire. While there is evidence to support the influence of social cognition upon social function, there are substantial limitations to this point of view. Many with psychosis have social impairments but not significant deficits in social cognition. First person and clinical accounts of the phenomenology of psychosis also do not suggest that persons with psychosis commonly experience making mistakes when trying to understand others. They report instead that intersubjectivity, or the formation of an intimate shared understanding of thoughts and emotions with others, has become extraordinarily difficult. In this paper we explore how research in metacognition in psychosis can transcend these limitations and address some of the ways in which intersubjectivity and more broadly social function is compromised in psychosis. Specifically, research will be reviewed on the relationship between social cognitive abilities and social function in psychosis, including measurement strategies and limits to its explanatory power, in particular with regard to challenges to intersubjectivity. Next, we present research on the integrated model of metacognition in psychosis and its relation to social function. We then discuss how this model might go beyond social cognitive models of social dysfunction in psychosis by describing how compromises in intersubjectivity occur as metacognitive deficits leave persons without an integrated sense of others' purposes, relative positions in the world, possibilities and personal complexities. We suggest that while social cognitive deficits may leave persons with inaccurate ideas about others, metacognitive deficits leave persons ill equipped to make broader sense of the situations in which people interact and this is what leaves them without a holistic sense of the other and what makes it difficult to know others, share experiences, and sustain relationships. The potential of developing clinical interventions focused on metacognition for promoting social recovery will finally be explored.

Metacognition, social cognition, and mentalizing in psychosis: are these distinct constructs when it comes to subjective experience or are we just splitting hairs?

Research using the integrated model of metacognition has suggested that the construct of metacognition could quantify the spectrum of activities that, if impaired, might cause many of the subjective disturbances found in psychosis. Research on social cognition and mentalizing in psychosis, however, has also pointed to underlying deficits in how persons make sense of their experience of themselves and others. To explore the question of whether metacognitive research in psychosis offers unique insight in the midst of these other two emerging fields, we have offered a review of the constructs and research from each field. Following that summary, we discuss ways in which research on metacognition may be distinguished from research on social cognition and mentalizing in three broad categories: (1) experimental procedures, (2) theoretical advances, and (3) clinical applications or indicated interventions. In terms of its research methods, we will describe how metacognition makes a unique contribution to understanding disturbances in how persons make sense of and interpret their own experiences within the flow of life. We will next discuss how metacognitive research in psychosis uniquely describes an architecture which when compromised - as often occurs in psychosis - results in the loss of persons' sense of purpose, possibilities, place in the world and cohesiveness of self. Turning to clinical issues, we explore how metacognitive research offers an operational model of the architecture which if repaired or restored should promote the recovery of a coherent sense of self and others in psychosis. Finally, we discuss the concrete implications of this for recovery-oriented treatment for psychosis as well as the need for further research on the commonalities of these approaches.

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.

Who will benefit from computerized cognitive remediation therapy? Evidence from a multisite randomized controlled study in schizophrenia

BACKGROUND

Computerized cognitive remediation therapy (CCRT) is generally effective for the cognitive deficits of schizophrenia. However, there is much uncertainty about what factors mediate or moderate effectiveness and are therefore important to personalize treatment and boost its effects.

METHOD

In total, 311 Chinese inpatients with Diagnostic and Statistical Manual of Mental Disorders-IV schizophrenia were randomized to receive CCRT or Active control for 12 weeks with four to five sessions per week. All participants were assessed at baseline, post-treatment and 3-month follow-up. The outcomes were cognition, clinical symptoms and functional outcomes.

RESULTS

There was a significant benefit in the MATRICS Consensus Cognitive Battery (MCCB) total score for CCRT (F1,258 = 5.62; p = 0.02; effect size was 0.27, 95% confidence interval 0.04-0.49). There were no specific moderators of CCRT improvements. However, across both groups, Wisconsin Card Sort Test improvement mediated a positive effect on functional capacity and Digit Span benefit mediated decreases in positive symptoms. In exploratory analyses younger and older participants showed cognitive improvements but on different tests (younger on Symbol Coding Test, while older on the Spatial Span Test). Only the older age group showed MSCEIT benefits at post-treatment. In addition, cognition at baseline negatively correlated with cognitive improvement and those whose MCCB baseline total score was around 31 seem to derive the most benefit.

CONCLUSIONS

CCRT can improve the cognitive function of patients with schizophrenia. Changes in cognitive outcomes also contributed to improvements in functional outcomes either directly or solely in the context of CCRT. Age and the basic cognitive level of the participants seem to affect the cognitive benefits from CCRT.

Brain Structural Correlates of Metacognition in First-Episode Psychosis

Metacognition is impaired in schizophrenia and is an important predictor of functional outcome, but the underlying neuropathology is not clear. Studies have implicated frontal regions and there is also some evidence that the hippocampus might play a pivotal role, but findings are inconsistent. We set out to more comprehensively investigate the neural underpinnings of insight in first-episode psychosis (FEP) using 2 metacognitive measures (the Beck Cognitive Insight Scale [BCIS]) and a perceptual metacognitive accuracy task alongside structural magnetic resonance imaging (MRI). We measured cortical thickness in insula and frontal regions, hippocampal (including subfield) volumes, hippocampal microstructure (using neurite orientation dispersion and density imaging [NODDI]), and fractional anisotropy in fornix. Relative to controls, FEP showed poorer metacognitive accuracy, thinner cortex in frontal regions and lower fornix integrity. In healthy controls (but not FEP), metacognitive accuracy correlated with cortical thickness in frontal cortex and insula. Conversely, in FEP (but not controls), metacognitive accuracy correlated with hippocampal volume and microstructural indices. Subicular hippocampal subregions were particularly implicated. No structural correlates of BCIS were found. These findings suggest that the neural bases of metacognition might differ in FEP: hippocampal (rather than frontal) integrity seems to be critical. Further, the use of objectively measured metacognitive indices seems to be a more powerful method for understanding the neurocircuitry of metacognition in FEP, which has the potential to inform therapeutic strategies and improve outcome in these patients.

Schizophrenia, recovery and the self: An introduction to the special issue on metacognition

In this special issue, work is presented linking metacognition among persons with schizophrenia with a range of psychosocial outcomes including vocational functioning, empathy, motivation, self-evaluation, and other cognitive functions. This overview will highlight how these works allow for the quantitative study of processes which underpin alterations in self-experience in schizophrenia, which in turn allows self-experience to be studied as part of a larger set of brain-based and social phenomena whose interaction influences the trajectory of one's life and illness. We explore the hypothesis that metacognitive capacity, as a node in a larger biopsychosocial network, may be accessible by psychosocial treatment and, if successfully targeted, may disrupt the processes which perpetuate disability. Limitations and directions for future research are also discussed.

Cognitive remediation for schizophrenia: An expert working group white paper on core techniques

Cognitive remediation is now widely recognized as an effective treatment for cognitive deficits in schizophrenia. Its effects are meaningful, durable, and related to improvements in everyday functional outcomes. As with many therapies, the evolution of cognitive remediation has resulted in treatment programs that use a variety of specific techniques, yet share common core principles. This paper is the product of a cognitive remediation expert working group consensus meeting to identify core features of the treatment and produce recommendations for its design, conduct, reporting, and implementation. Four techniques were identified as core features of cognitive remediation: facilitation by a therapist, cognitive exercise, procedures to develop problem-solving strategies, and procedures to facilitate transfer to real world functioning. Treatment techniques within each of these core features are presented to facilitate decisions for clinical trials and implementation in clinical settings.

Self-defining Memories Predict Engagement in Structured Activity in First Episode Psychosis, Independent of Neurocognition and Metacognition

BACKGROUND

Self-defining memories (SDMs) are vivid personal memories, related to narrative identity. Individuals with schizophrenia report less specific, more negative, and extract less meaning from these memories compared to control groups. SDMs have been shown to be predicted by neurocognition, associated with metacognition, and linked to goal outcomes in healthy controls. As neurocognition and metacognition are known predictors of poor functioning in psychosis, SDMs may also be a predictor. No study has assessed the relationship to functioning or pattern of SDMs in first episode psychosis (FEP).

METHODS

This was a cross-sectional study involving 71 individuals with FEP and 57 healthy controls who completed an SDM questionnaire. FEP participants completed measures of neurocognition, metacognition (Metacognitive Assessment Interview), functional capacity (The University of California, San Diego [UCSD] Performance-Based Skills Assessment), and functional outcome (Time-Use Survey).

RESULTS

SDMs reported by individuals with FEP were less integrated compared to healthy controls. Within the FEP sample, holding less specific memories was associated with engagement in significantly fewer hours of structured activity per week and specificity of SDMs mediated the relationship between neurocognition and functional outcome, independent of metacognition.

CONCLUSION

This is the first study to assess SDMs in FEP and to explore the important role of SDMs on clinical outcomes, compared to healthy controls. This study suggests that elaborating on specific SDMs is a valid therapeutic target and may be considered a tool to improve daily functioning in FEP.

Metacognitive functioning in bipolar disorder versus controls and its correlations with neurocognitive functioning in a cross-sectional design

INTRODUCTION

Metacognition is an important factor in the development and persistence of bipolar disorder. One of the most striking examples of impairment in metacognitive functioning in bipolar disorder is the lack of insight these patients have in their disorder. Despite its importance, research regarding metacognition in bipolar disorder is scarce. Furthermore, the neurocognitive basis of metacognitive functioning is unknown.

METHODS

The current study included 29 patients with bipolar disorder and 29 age, educational level and gender matched healthy controls. All the participants filled in a metacognition questionnaire that examined their metacognitive beliefs. In addition, it was tested how well they estimated their performance on a neurocognitive test-battery beforehand (metacognitive knowledge) and afterwards (metacognitive experience).

RESULTS

Bipolar disorder patients showed maladaptive metacognitive beliefs in comparison with the healthy controls. They also showed impaired metacognitive knowledge and experience. That is, they overestimated their own cognitive performance. However, the latter result was also true for the healthy controls. In addition, metacognition had neurocognitive correlates. However, for the bipolar patients, depressive symptomatology had an important effect on this relationship and on metacognition in general.

CONCLUSION

Maladaptive metacognitive skills are related to depression in bipolar disorder. A more healthy metacognitive thinking should be promoted. An effective training for this could be a therapy that includes various elements, from basic cognitive- to higher order metacognitive training.

Three-Year Follow-Up Study Exploring Metacognition and Function in Individuals With First Episode Psychosis

Introduction: Research has demonstrated that functional outcome in psychosis is predicted by factors such as neurocognition, functional capacity, symptoms and, more recently, metacognition. Metacognitive ability has been demonstrated to mediate between neurocognition and functional outcome in First Episode Psychosis (FEP). Whether metacognition also predicts longer-term recovery in first episode psychosis is unknown. This study assessed whether neurocognition, functional capacity and metacognitive ability in FEP predicted functional outcome three years later. Methods: Eighty individuals with First Episode Psychosis were re-contacted after an average 3 years (range: 26-45 month follow-up) from baseline. Twenty-six participants (33%) completed completed measures of neurocognition, metacognition, functional capacity, functional outcome (hours spent in structured activity per week) and psychopathology at baseline and at follow-up. Results: Individual regression analyses demonstrated neurocognition, functional capacity, and metacognitive ability at baseline significantly predicted functional outcome at three years. However, when baseline functional outcome was controlled, only metacognitive ability was a significant predictor of change in functional outcome from baseline to follow-up, p < 0.001. This model explained 72% (adjusted r ² = 0.69) of the variance in functional outcome at follow-up. Negative symptoms did not change the model. Discussion: This study demonstrated that better metacognitive ability significantly predicted improvement in functioning in FEP across a 3-year period. This highlights the potential value of clinical interventions that focus on improving metacognitive ability at first point of illness to maximize recovery.

The Efficacy, Feasibility And Acceptability Of A Remotely Accessible Use Of CIRCuiTS, A Computerized Cognitive Remediation Therapy Program For Schizophrenia: A Pilot Study

INTRODUCTION

The Computerized Interactive Remediation of Cognition - Training for Schizophrenia (CIRCuiTS) is a form of cognitive remediation therapy developed to target neurocognitive and metacognitive deficits of people with schizophrenia, which have a detrimental impact on real-life functioning. The English version of CIRCuiTS demonstrated good acceptability and feasibility. A recent randomized controlled trial provided evidence that the program improves memory and functioning, and that the impact on functional outcome is mediated by metacognition. The next steps in the development of CIRCuiTS include both: 1) the translation and adaptation of the program in different cultural settings; and 2) the demonstration of feasibility, acceptability and effectiveness of a standardized method to administer CIRCuiTS remotely.

PURPOSE

To implement the CIRCuiTS Italian version and to assess acceptability, feasibility and efficacy of a standardized method to administer CIRCuiTS remotely.

METHODS

Participants were assessed at baseline and received up to 40 CIRCuiTS therapy sessions, three times a week, for about 1 hr over a three-month period. Participants were reassessed post-treatment.

RESULTS

The program demonstrated good feasibility and high acceptability when assessed by the number of dropouts and evaluation of patients' satisfaction. Participants improved in learning, speed of processing, working memory and executive control. They showed a reduction in disorganization and improvement in self-esteem, functional capacity, and real-life functioning.

CONCLUSION

In this study, a standardized protocol for using CIRCuiTS from home was implemented. The first set of data showed in the paper is encouraging. The proposed procedure could lead to a dropout reduction while maintaining the efficacy of the program.

The nuts and bolts of Cognitive Remediation: Exploring how different training components relate to cognitive and functional gains

BACKGROUND

Cognitive Remediation (CR) is an evidence based treatment targeting cognitive and functional difficulties in people with psychosis. Despite the large number of effectiveness studies, only limited evidence exists for the active ingredients of this therapy. This study begins to fill this gap by exploring the relationship between CR ingredients, including alliance with a therapist, and therapy outcomes.

METHOD

This is a secondary analysis based on data from a published randomised controlled trial comparing CR+treatment-as-usual (TAU) to TAU alone. We considered the association between CR active ingredients including errorless learning, massed practice, strategy use and therapeutic alliance on the cognitive, functioning and symptom outcomes that significantly improved following therapy.

RESULTS

Forty-six of the 96 participants were randomised to CR. After therapy the CR group showed significant improvement in non-verbal memory, functioning and approaching significance, improvements in executive functions. All therapy ingredients were inter-related but strategy use alone was associated therapeutic alliance. Cognitive improvements were associated with massed practice, number of useful strategies and therapeutic alliance, but improvements in functioning were associated only with therapeutic alliance.

CONCLUSIONS

These findings build the evidence base for the usefulness of specific therapy components. As for other psychological therapies it appears that therapeutic alliance may be an important factor in driving change for key CR outcomes, particularly functioning, in people with psychosis.

Decision-making ability in psychosis: a systematic review and meta-analysis of the magnitude, specificity and correlates of impaired performance on the Iowa and Cambridge Gambling Tasks

To identify factors which may help or hinder decision-making ability in people with psychosis, we did a systematic review and meta-analysis of their performance on the Iowa and Cambridge Gambling Tasks. Analysis of 47 samples found they had moderately poorer performance than healthy individuals (N = 4264, g = -0.57, 95% confidence interval (CI) -0.66 to -0.48). Few studies (k = 8) used non-psychotic clinical comparator groups, although very low-quality evidence (k = 3) found people with bipolar disorder may perform better. Negative symptoms (k = 13, N = 648, r = -0.17, 95% CI -0.26 to -0.07) and lower IQ (k = 11, N = 525, r = 0.20, 95% CI 0.29-0.10), but not positive symptoms (k = 10, N = 512, r = -0.01, 95% CI -0.11 to 0.08), each had small-moderate associations with poorer decision-making. Lower quality evidence suggested general symptoms, working memory, social functioning, awareness of emotional responses to information, and attentional bias towards gain are associated with decision-making, but not education, executive functioning or overall symptoms. Meta-regression suggested an inverse association between decision-making and depression severity (k = 6, Q = 6.41, R2 100%, p = 0.01). Those taking first-generation (k = 6, N = 305, g = -0.17, 95% CI -0.40 to 0.06, p = 0.147) or low-dose antipsychotics (k = 5, N = 442, g = -0.19, 95% CI -0.44 to 0.06, p = 0.139) had unimpaired decision-making. Although meta-regression found no linear association between dose and performance, non-reporting of the dose was common and associated with larger impairments (k = 46, Q = 4.71, R2 14%, p = 0.03). Those supporting people with psychosis to make decisions, including treatment decisions, should consider the potential effect of these factors. Interventionist-causal trials are required to test whether reducing antipsychotic dose and treating anxiety and depression can improve decision-making in this group.

Metacognition - What did James H. Flavell really say and the implications for the conceptualization and design of metacognitive interventions

In the last two decades years, several interventions have been designed for people with major psychological disorders that all have "metacognitive" in their name: Metacognitive Therapy (MCT), Metacognitive Training (e.g., for people with psychosis) and Metacognitive Reflection and Insight Therapy (MERIT). Two of these interventions are primarily targeted at patients with schizophrenia. Prompted by a recent discussion about what constitutes "true" metacognitive treatment, we will first explore the original concept of metacognition as defined by James H. Flavell. Then, we will describe each approach in detail before highlighting how each intervention picks up on slightly different aspects of Flavell's original metacognitive construct. We will also discuss inherent problems with the label "metacognition."

Systematic review and meta-analysis of factors that help or hinder treatment decision-making capacity in psychosis

BackgroundThe evidence on factors that may influence treatment decisional capacity ('capacity') in psychosis has yet to be comprehensively synthesised, which limits the development of effective strategies to improve or support it.AimsTo determine the direction, magnitude and reliability of the relationship between capacity in psychosis and a range of clinical, demographic and treatment-related factors, thus providing a thorough synthesis of current knowledge.MethodWe conducted a systematic review, meta-analytical and narrative synthesis of factors that help or hinder treatment decision-making capacity in psychosis, assessing the direction, magnitude, significance and reliability of reported associations.ResultsWe identified 23 relevant studies (n = l823). Psychotic symptoms had small, moderate and strong associations with appreciation, understanding and reasoning respectively. Both verbal cognitive functioning and duration of education had small to moderate correlations with understanding and reasoning. Better capacity was also associated with better insight, better metacognitive ability, higher anxiety and lower perceived coercion. No linear relationship with depression was observed. Interventions linked to improved capacity over time were in-patient care, information simplification, shared decision-making and metacognitive training.ConclusionsAlthough much is known about the role of symptoms and other clinical variables, effective and acceptable psychological interventions to support capacity in this group are lacking.

Social cognition interventions for people with schizophrenia: a systematic review focussing on methodological quality and intervention modality

BACKGROUND

People with a diagnosis of schizophrenia have significant social and functional difficulties. Social cognition was found to influences these outcomes and in recent years interventions targeting this domain were developed. This paper reviews the existing literature on social cognition interventions for people with a diagnosis of schizophrenia focussing on: i) comparing focussed (i.e. targeting only one social cognitive domain) and global interventions and ii) studies methodological quality.

METHOD

Systematic search was conducted on PubMed and PsycInfo. Studies were included if they were randomised control trials, participants had a diagnosis of schizophrenia or schizoaffective disorder, and the intervention targeted at least one out of four social cognition domains (i.e. theory of mind, affect recognition, social perception and attribution bias). All papers were assessed for methodological quality. Information on the intervention, control condition, study methodology and the main findings from each study were extracted and critically summarised.

RESULTS

Data from 32 studies fulfilled the inclusion criteria, considering a total of 1440 participants. Taking part in social cognition interventions produced significant improvements in theory of mind and affect recognition compared to both passive and active control conditions. Results were less clear for social perception and attributional bias. Focussed and global interventions had similar results on outcomes. Overall study methodological quality was modest. There was very limited evidence showing that social cognitive intervention result in functional outcome improvement.

CONCLUSIONS

The evidence considered suggests that social cognition interventions may be a valuable approach for people with a diagnosis of schizophrenia. However, evidence quality is limited by measure heterogeneity, modest study methodology and short follow-up periods. The findings point to a number of recommendations for future research, including measurement standardisation, appropriately powered studies and investigation of the impact of social cognition improvements on functioning problems.

Effectiveness of metacognitive interventions for mental disorders in adults: a systematic review protocol (METACOG)

INTRODUCTION

Whereas the efficacy of cognitive-behavioural therapy has been demonstrated for a variety of mental disorders, there is still need for improvement, especially regarding less prevalent or more severe disorders. Recently, metacognitive interventions have been developed and are now available for a variety of diagnoses. Still, a systematic review investigating the effectiveness of different metacognitive interventions for various mental disorders is missing.

METHODS AND ANALYSIS

Randomised controlled trials (RCTs), cross-over and cluster RCTs and non-randomised controlled trials on metacognitive interventions (ie, metacognitive therapy, metacognitive training, others) in adults with any mental disorder will be included. As comparators, another psychological or pharmacological treatment, a combined psychological and pharmacological treatment, treatment as usual or no active treatment are eligible. Outcomes refer to efficacy and acceptability of metacognitive interventions.

ETHICS AND DISSEMINATION

In light of the popularity of metacognitive interventions, the systematic review will provide researchers, clinicians and patients with substantial information on the intervention's effectiveness across different mental disorders. Results will be published in peer-reviewed journals and disseminated through a patient workshop.

Feasibility and acceptability of brief cognitive remediation targeting metacognition in acute inpatients with psychosis: a case series

Cognitive remediation (CR) is an intensive intervention targeting cognitive impairment with the aim of improving functioning in people with psychotic disorders. Shorter forms of CR based on metacognition and targeting awareness of cognitive problems may be more appropriate for acute inpatient settings where time is limited. The objective of the study was to evaluate the feasibility and acceptability of a new brief course of CR targeting cognitive and metacognitive difficulties within an acute inpatient psychiatric setting. Thirteen male service users with psychosis received a three-week course of CR. Participants were assessed at baseline and post-treatment on cognitive measures, subjective cognitive complaints, functional impairment, and symptom severity. Feasibility was assessed based on engagement, attendance, and attrition. Acceptability was evaluated through treatment satisfaction. Eight participants completed therapy, with 81% session attendance. Therapy was considered acceptable, with the majority of participants considering it satisfactory. Potential benefit analysis showed a significant post-treatment improvement in global cognition and memory. Subjective cognitive complaints did not change over time. It was concluded that it is feasible to deliver brief CR in an acute inpatient setting. Context of delivery and engagement are challenges for optimal therapy implementation. CR protocol adaptations made to promote metacognitive competencies may compensate for lack of intensive practice.

Improving Theory of Mind in Schizophrenia by Targeting Cognition and Metacognition with Computerized Cognitive Remediation: A Multiple Case Study

Schizophrenia is associated with deficits in theory of mind (ToM) (i.e., the ability to infer the mental states of others) and cognition. Associations have often been reported between cognition and ToM, and ToM mediates the relationship between impaired cognition and impaired functioning in schizophrenia. Given that cognitive deficits could act as a limiting factor for ToM, this study investigated whether a cognitive remediation therapy (CRT) that targets nonsocial cognition and metacognition could improve ToM in schizophrenia. Four men with schizophrenia received CRT. Assessments of ToM, cognition, and metacognition were conducted at baseline and posttreatment as well as three months and 1 year later. Two patients reached a significant improvement in ToM immediately after treatment whereas at three months after treatment all four cases reached a significant improvement, which was maintained through 1 year after treatment for all three cases that remained in the study. Improvements in ToM were accompanied by significant improvements in the most severely impaired cognitive functions at baseline or by improvements in metacognition. This study establishes that a CRT program that does not explicitly target social abilities can improve ToM.

The Cognitive Remediation in Bipolar (CRiB) pilot study: study protocol for a randomised controlled trial

Background

People with bipolar disorder often show difficulties with cognitive functioning, and though these difficulties are identified as important targets for intervention, few treatment options are available. Preliminary evidence suggests that cognitive remediation therapy (a psychological treatment proven beneficial for people diagnosed as having schizophrenia) is helpful for people with bipolar disorders. We are conducting a pilot trial to determine whether individual, computerised, cognitive remediation therapy (CRT) for people with bipolar disorder 1) increases cognitive function; 2) improves global functioning, goal attainment and mood symptoms; 3) is acceptable and feasible for participants; and 4) can be addressed in a comprehensive, larger, randomised, controlled trial.

Methods/design

The study is designed as a two-arm, randomised, controlled trial comparing cognitive remediation therapy with treatment-as-usual (TAU) for euthymic bipolar patients. Participants are eligible to take part if aged between 18 and 65 with a diagnosis of bipolar disorder (type I) and currently in euthymic state, and no neurological, substance or personality disorder diagnoses. Sixty participants will be recruited (mainly through secondary and tertiary care) and will be block-randomised to receive either treatment-as-usual alone or in addition to a 12-week course of cognitive remediation therapy totalling 20–40 therapy hours. The intervention will comprise regular sessions with a therapist and computer-based training. Research assessments will take place before and after the intervention period and at a 12-week follow-up, and will include evaluation of neuropsychological, symptom-related, demographic and social factors, as well as collecting qualitative data regarding CRT expectations and satisfaction. Intention-to-treat analyses will examine the efficacy of cognitive remediation therapy primarily on cognition and additionally on functioning, quality of life and mood symptoms. Furthermore, we will examine the acceptability of CRT and undertake a preliminary health economics analysis to ascertain the cost of delivering the intervention.

Discussion

The results of this trial will provide valuable information about whether cognitive remediation therapy may be beneficial for people diagnosed with bipolar disorder in a euthymic state.

Trial Registration

ISRCTN registry, ISRCTN32290525. Registered on 2 March 2016

Study protocol: a randomised controlled trial of cognitive remediation for a national cohort of forensic mental health patients with schizophrenia or schizoaffective disorder

BACKGROUND

Evidence is accumulating that cognitive remediation therapy (CRT) is an effective intervention for patients with schizophrenia or schizoaffective disorder. To date there has been no randomised controlled trial (RCT) cohort study of cognitive remediation within a forensic hospital. The goal of this study is to examine the effectiveness of a trial of cognitive remediation for forensic mental health patients with schizophrenia or schizoaffective disorder.

METHODS

An estimated sixty patients will be enrolled in the study. Participants will be randomised to one of two conditions: CRT with treatment as usual (TAU), or TAU. CRT will consist of 42 individual sessions and 14 group sessions. The primary outcome measure for this study is change in cognitive functioning using the MATRICS Consensus Cognitive Battery (MCCB). Secondary outcomes include change in social and occupational functioning, disorganised symptoms, negative symptoms, violence, participation in psychosocial treatment and recovery. In addition to these effectiveness measures, we will examine patient satisfaction.

DISCUSSION

Cognitive difficulties experienced by schizophrenia spectrum patients are associated with general functioning, ability to benefit from psychosocial interventions and quality of life. Research into the treatment of cognitive difficulties within a forensic setting is therefore an important priority. The results of the proposed study will help answer the question whether cognitive remediation improves functional outcomes in forensic mental health patients with schizophrenia or schizoaffective disorder. Forensic mental health patients are detained for the dual purpose of receiving treatment and for public protection. There can be conflict between these two roles perhaps causing forensic services to have an increased length of stay compared to general psychiatric admissions. Ultimately a focus on emphasising cognition and general functioning over symptoms may decrease tension between the core responsibilities of forensic mental health services.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02360813. Trial registered Feb 4th 2015 and last updated May 1(st) 2015.