Cognitive Remediation In Schizophrenia Research Articles

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

The cognitive problems experienced by people with schizophrenia not only impede recovery but also interfere with treatments designed to improve overall functioning. Hence there has been a proliferation of new therapies to treat cognitive problems with the hope that improvements will benefit future intervention and recovery outcomes. Cognitive remediation therapy (CR) that relies on intensive task practice can support basic cognitive functioning but there is little evidence on how these therapies lead to transfer to real life skills. However, there is increasing evidence that CR including elements of transfer training (e.g., strategy use and problem solving schemas) produce higher functional outcomes. It is hypothesized that these therapies achieve higher transfer by improving metacognition. People with schizophrenia have metacognitive problems; these include poor self-awareness and difficulties in planning for complex tasks. This paper reviews this evidence as well as research on why metacognition needs to be explicitly taught as part of cognitive treatments. The evidence is based on research on learning spanning from neuroscience to the field of education. Learning programmes, and CRT, may be able to achieve better outcomes if they explicitly teach metacognition including metacognitive knowledge (i.e., awareness of the cognitive requirements and approaches to tasks) and metacognitive regulation (i.e., cognitive control over the different task relevant cognitive requirements). These types of metacognition are essential for successful task performance, in particular, for controlling effort, accuracy and efficient strategy use. We consider metacognition vital for the transfer of therapeutic gains to everyday life tasks making it a therapy target that may yield greater gains compared to cognition alone for recovery interventions.

COMT genotype and response to cognitive remediation in schizophrenia

BackgroundA functional polymorphism of the catechol-O-methyltransferase (COMT) gene (Val158Met) partially appears to influence cognitive performance in schizophrenia subjects and healthy controls by modulating prefrontal dopaminergic activity. This study evaluated the association of the COMT Val108/158 Met genotype with response to computerized neurocognitive remediation (CRT). Method145 subjects with DSM-IV-TR schizophrenia or schizoaffective disorder were genotyped via saliva sampling. Subjects were evaluated on neurocognitive assessments (MATRICS) and clinical symptoms (PANSS) at baseline and endpoint after 12weeks of CRT. “Improvement” was defined as ≥67% of cognitive domains (≥4) showing performance increases. If ≤67% (≤2) of domains improved, the change was defined as “minimal improvement.” A general linear model was conducted for change of each cognitive domain. ResultsOf 145 subjects, data from 138 subjects were usable. Distribution of COMT genotype: Met/Met: 28 (20.29%), Val/Met: 61 (44.20%), and Val/Val: 49 (35.51%). No significant differences were seen among genotype groups at baseline or across genotype group for “Improvement” vs. “Minimal Improvement.” GLM analysis showed significant differences in Verbal Learning (p=0.003), Visual Learning (p=0.014) and Attention/Vigilance (p=0.011) favoring Met/Met and Val/Met groups. ConclusionsThe low activity Met allele (Met/Met; Val/Met) was associated with significantly greater improvements in the MATRICS domains of Verbal Learning, Visual Learning and Attention/Vigilance after CRT.

Brain Correlates of Cognitive Remediation in Schizophrenia: Activation Likelihood Analysis Shows Preliminary Evidence of Neural Target Engagement.

Cognitive remediation training (CRT) for schizophrenia has been found to improve cognitive functioning and influence neural plasticity. However, with various training approaches and mixed findings, the mechanisms driving generalization of cognitive skills from CRT are unclear. In this meta-analysis of extant imaging studies examining CRT's effects, we sought to clarify whether varying approaches to CRT suggest common neural changes and whether such mechanisms are restorative or compensatory. We conducted a literature search to identify studies appropriate for inclusion in an activation likelihood estimation (ALE) meta-analysis. Our criteria required studies to consist of training-based interventions designed to improve patients' cognitive or social functioning, including generalization to untrained circumstances. Studies were also required to examine changes in pre- vs posttraining functional activation using functional magnetic resonance imaging or positron emission tomography. The literature search identified 162 articles, 9 of which were appropriate for inclusion. ALE analyses comparing pre- and posttraining brain activation showed increased activity in the lateral and medial prefrontal cortex (PFC), parietal cortex, insula, and the caudate and thalamus. Notably, activation associated with CRT in the left PFC and thalamus partially overlapped with previous meta-analytically identified areas associated with deficits in working memory, executive control, and facial emotion processing in schizophrenia. We conclude that CRT interventions from varying theoretic modalities elicit plasticity in areas that support cognitive and socioemotional processes in this early set of studies. While preliminary, these changes appear to be both restorative and compensatory, though thalamocortical areas previously associated with dysfunction may be common sources of plasticity for cognitive remediation in schizophrenia.

Social skills training and computer-assisted cognitive remediation in schizophrenia

A growing body of research shows that cognitive remediation (COG REM), consisting of drill-and-practice and/or strategy training in neurocognitive functions, produces moderate improvements in neurocognition. These improvements generalize to functioning when COG REM is provided with other rehabilitation interventions (Wykes et al., 2011). The number of studies using COG REM as an adjunct to other behavioral-based rehabilitation interventions however remains small and consists of widely varying interventions with few active control conditions. This study compared the effects of an extended (6-month), standardized, computer-assisted cognitive remediation intervention, administered along with a standardized program of social skills-training (SST), with those of an active control condition that included participation in the same SST program and a computer skills training program (Computer Skills). Sixty-four individuals with schizophrenia recruited from two treatment sites were randomly assigned to one of two conditions and were assessed by blinded raters on neurocognitive measures, performance-based measures of social skill, and ratings of psychosocial function before and after treatment. Results revealed that the COG REM group improved significantly more in attention, working memory, and empathy than the Computer Skills group, but there were no differences between groups on other measures of psychosocial functioning or skills. Taken together, these findings suggest that COG REM used in the context of other evidence-based psychosocial interventions (SST) improves working memory in schizophrenia and suggests that this effect may generalize to improved empathy.

Top-down computerized cognitive remediation in schizophrenia: a case study of an individual with impairment in verbal fluency.

The objective of this case study was to assess the specific effect of cognitive remediation for schizophrenia on the pattern of cognitive impairments. Case A is a 33-year-old man with a schizophrenia diagnosis and impairments in visual memory, inhibition, problem solving, and verbal fluency. He was provided with a therapist delivered cognitive remediation program involving practice and strategy which was designed to train attention, memory, executive functioning, visual-perceptual processing, and metacognitive skills. Neuropsychological and clinical assessments were administered at baseline and after three months of treatment. At posttest assessment, Case A had improved significantly on targeted (visual memory and problem solving) and nontargeted (verbal fluency) cognitive processes. The results of the current case study suggest that (1) it is possible to improve specific cognitive processes with targeted exercises, as seen by the improvement in visual memory due to training exercises targeting this cognitive domain; (2) cognitive remediation can produce improvements in cognitive processes not targeted during remediation since verbal fluency was improved while there was no training exercise on this specific cognitive process; and (3) including learning strategies in cognitive remediation increases the value of the approach and enhances participant improvement, possibly because strategies using verbalization can lead to improvement in verbal fluency even if it was not practiced.

The Role of Motivation in Cognitive Remediation for People with Schizophrenia.

Motivation impairment is an often prominent component of schizophrenia symptomatology that impacts treatment engagement and reduces the functional benefit from psychosocial interventions. Intrinsic motivation in particular has been shown to be impaired in schizophrenia. Nowhere is the role of intrinsic motivation impairment more evident than in cognitive remediation for schizophrenia. This chapter describes the theoretical determinants of motivation to learn and illustrates how those determinants have been translated into therapeutic techniques that enhance intrinsic motivation in a clinical context. We review the extant research that indicates how motivation enhancing techniques yield treatment-related improvements within cognitive remediation therapy and, more broadly, in other behavioral skills-based interventions for schizophrenia.

Efficacy of Cognitive Remediation in Schizophrenia: A Short Review of Its Variable Effects According to Cognitive Domain

Cognitive impairment is a symptom of schizophrenia and strongly associated with impaired social function. In recent years, cognitive interventions (cognitive remediation therapies) have been implemented and their results have also been reported. Intervention studies have been conducted using a variety of methods that differ in terms of terminology, approach, and targeted cognitive domains. In this study, we examined trends in recent cognitive remediation research conducted subsequent to the meta-analyses of McGurk et al. (2007) and Wykes et al. (2011). We identified studies conducted between 2009 and 2013 to examine computer-assisted cognitive remediation and collated and analyzed the literature describing their major results and trends. Our results indicated improved cognitive performance subsequent to cognitive remediation therapy using computer programs. We found promising outcomes, particularly in reasoning and problem solving, verbal learning and memory, verbal working memory, and attention and vigilance, which replicated the findings of Wykes et al. (2011).

Persistence of effectiveness of cognitive remediation interventions in schizophrenia: A 1-year follow-up study

ObjectivesCognitive remediation interventions are effective in patients with schizophrenia, but the durability of their effects is still under debate. This study aimed to investigate the 1-year persistence of the effectiveness of cognitive remediation. MethodsPatients with schizophrenia treated with cognitive remediation or usual rehabilitation were reassessed with clinical, neuropsychological and functional measures 1year after cognitive remediation. ResultsAt the 1-year follow-up, the advantages of cognitive remediation remained significant for clinical variables and specific cognitive domains. Functional measures showed increasing improvement at follow-up. ConclusionsThe study suggests that the effectiveness of cognitive remediation in schizophrenia persists after 1year.

Amusia and protolanguage impairments in schizophrenia.

Both language and music are thought to have evolved from a musical protolanguage that communicated social information, including emotion. Individuals with perceptual music disorders (amusia) show deficits in auditory emotion recognition (AER). Although auditory perceptual deficits have been studied in schizophrenia, their relationship with musical/protolinguistic competence has not previously been assessed. Musical ability was assessed in 31 schizophrenia/schizo-affective patients and 44 healthy controls using the Montreal Battery for Evaluation of Amusia (MBEA). AER was assessed using a novel battery in which actors provided portrayals of five separate emotions. The Disorganization factor of the Positive and Negative Syndrome Scale (PANSS) was used as a proxy for language/thought disorder and the MATRICS Consensus Cognitive Battery (MCCB) was used to assess cognition. Highly significant deficits were seen between patients and controls across auditory tasks (p < 0.001). Moreover, significant differences were seen in AER between the amusia and intact music-perceiving groups, which remained significant after controlling for group status and education. Correlations with AER were specific to the melody domain, and correlations between protolanguage (melody domain) and language were independent of overall cognition. This is the first study to document a specific relationship between amusia, AER and thought disorder, suggesting a shared linguistic/protolinguistic impairment. Once amusia was considered, other cognitive factors were no longer significant predictors of AER, suggesting that musical ability in general and melodic discrimination ability in particular may be crucial targets for treatment development and cognitive remediation in schizophrenia.

Cognitive Remediation for Schizophrenia: A Review of Recent Findings

Schizophrenia and related psychotic disorders are characterized by deficits in neurocognition. Deficits in domains such as attention, memory, executive functions, and speed of processing, as well as early perceptual processes, typically appear early in the course of the disorder and remain stable over time. Cognitive deficits can cause serious impairments in community functioning (i.e., work, independent living, and social relationships). For this reason, cognitive remediation (CR) is increasingly utilized to improve neurocognition. The empirical support for CR for adults with chronic schizophrenia is encouraging and growing. CR approaches are suitable for widespread dissemination and have been the focus of the majority of recent empirical research in psychoses. There are two broad categories of computerized CR approaches: those that target higher-level cognitive processes, and those that target neuroplasticity using basic auditory and visual processing. Research currently supports the efficacy of both higher-level and neuroplasticity-based CR for improving targeted cognitive domains; however, there is more consistent support for higher-level approaches in terms of generalization to untrained cognitive domains and functional outcomes. To achieve functional outcomes, CR combined with skills training or other psychosocial rehabilitation approaches is likely the most effective approach. The majority of CR interventions allow difficulty to be individually adjusted, which is an important therapeutic feature, and some provide an array of modules to allow personalized interventions. Several CR interventions appear to have durable treatment benefits, but more research is needed to clarify whether booster sessions, pharmacological augmentation, or other treatments should routinely be incorporated into treatment plans.

D-Cycloserine augmentation of cognitive remediation in schizophrenia

d-Cycloserine (DCS) has been shown to enhance memory and, in a previous trial, once-weekly DCS improved negative symptoms in schizophrenia subjects. We hypothesized that DCS combined with a cognitive remediation (CR) program would improve memory of a practiced auditory discrimination task and that gains would generalize to performance on unpracticed cognitive tasks. Stable, medicated adult schizophrenia outpatients participated in the Brain Fitness CR program 3–5 times per week for 8weeks. Subjects were randomly assigned to once-weekly adjunctive treatment with DCS (50mg) or placebo administered before the first session each week. Primary outcomes were performance on an auditory discrimination task, the MATRICS cognitive battery composite score and the Scale for the Assessment of Negative Symptoms (SANS) total score. 36 subjects received study drug and 32 completed the trial (average number of CR sessions=26.1). Performance on the practiced auditory discrimination task significantly improved in the DCS group compared to the placebo group. DCS was also associated with significantly greater negative symptom improvement for subjects symptomatic at baseline (SANS score ≥20). However, improvement on the MATRICS battery was observed only in the placebo group. Considered with previous results, these findings suggest that DCS augments CR and alleviates negative symptoms in schizophrenia patients. However, further work is needed to evaluate whether CR gains achieved with DCS can generalize to other unpracticed cognitive tasks.

Increased activation in Broca's area after cognitive remediation in schizophrenia

Functional magnetic resonance imaging (fMRI) was used to measure changes in cerebral activity in patients with schizophrenia after participation in the Cognitive Remediation Program for Schizophrenia and other related disorders (RECOS). As RECOS therapists make use of problem-solving and verbal mediation techniques, known to be beneficial in the rehabilitation of dysexecutive syndromes, we expected an increased activation of frontal areas after remediation. Executive functioning and cerebral activation during a covert verbal fluency task were measured in eight patients with schizophrenia before (T1) and after (T2) 14 weeks of RECOS therapy. The same measures were recorded in eight patients with schizophrenia who did not participate in RECOS at the same intervals of time (TAU group). Increased activation in Broca's area, as well as improvements in performance of executive/frontal tasks, was observed after cognitive training. Metacognitive techniques of verbalization are hypothesized to be the main factor underlying the brain changes observed in the present study.

COMT and 5-HT1A-receptor genotypes potentially affect executive functions improvement after cognitive remediation in schizophrenia

Cognitive remediation therapy (CRT) has been proved to improve cognitive deficits in schizophrenia and to enhance functional outcomes of classical rehabilitation. However, CRT outcomes are heterogeneous and predictors of response are still unknown. Genetic variability, especially in the dopaminergic system, has been hypothesized to affect CRT. We previously reported that rs4680 of the catechol-O-methyltrasferase (COMT) influences improvements in executive functions in patients treated with CRT, but this result was not confirmed by other studies. Such inconsistent findings may depend, other than on clinical variables, also on other genes involved in cognition. Recent studies proved that serotonin 1A receptor (5-HT1A-R) regulates dopamine in the prefrontal cortex (PFC), and clinical works suggested a 5-HT1A-R role in cognition. We then analysed possible effects of COMT rs4680 and 5-HT1A-R rs6295 on CRT outcomes, taking into account also clinical and demographic factors. Eighty-six clinically stabilized schizophrenia patients treated with three months CRT were assessed with the Wisconsin Card Sorting Test, as a measure of executive functions, at enrolment and after CRT treatment, and underwent COMT and 5-HT1A-R genotyping. We found a significant main effect of COMT genotype and an interaction with 5-HT1A-R on executive function improvement after CRT. The results suggest that these two polymorphisms may have an additive effect on individual capacity to recover from cognitive deficit, probably through their role on PFC dopaminergic transmission modulation, known to be critical for modulating cognitive functions.

Cognitive remediation in schizophrenia: background, techniques, evidence of efficacy and perspectives

Impairment of cognitive functions is a core feature of schizophrenia with relevant consequences on patients' psychosocial functioning. Cognitive remediation techniques have been recently developed with the aim to restore or compensate for such impairments and improve the functional outcome of the disease. There is now convincing evidence of the efficacy of many of these techniques, especially when delivered in the context of a comprehensive treatment programme. Whether the application of these techniques in the early phases of the disease could modify the disease course and outcome and how they could affect brain plasticity and the trajectory of brain disease of schizophrenia is still under scrutiny.

The need for an individualized, everyday life and integrative approach to cognitive remediation in schizophrenia.

The main goal of any rehabilitation program is to improve everyday functioning, and cognitive remediation for schizophrenia is no exception. Recent meta-analyses show that cognitive remediation provides beneficial effects for persons with schizophrenia on both a cognitive and functional level. However, these effects are limited, particularly in their ability to improve functional outcome. Reasons for this are threefold. The vast heterogeneity in schizophrenia has not been taken into account, and, consequently, an individualized approach is called for. Second, specific difficulties in everyday life should be the focus of rehabilitation programs, but these difficulties have not been given the importance they deserve when designing and proposing cognitive (and otherwise) rehabilitation programs. Finally, cognitive functioning is not the only factor involved in predicting functional outcome in schizophrenia, and thus an integrative approach is needed that comprises the various other factors that also play a significant role in functional outcome. It is argued that taking these three issues into account will result in more effective intervention programs in their ability to provide improvements in functional outcome. To conclude, an individualized, everyday life and integrative approach is described. Furthermore, preliminary examples of such an approach are given, in addition to various methods that can be used in order to test the efficacy of this approach in future studies.

Cognitive remediation as a treatment for major depression: A rationale, review of evidence and recommendations for future research

There is considerable literature regarding the effectiveness of cognitive remediation (CR) in schizophrenia and in conditions such as stroke and traumatic brain injury. Patients with major depressive disorder (MDD) present with significant cognitive impairment which in many cases may not resolve with treatment. Neurobiological data suggest that this may relate to underlying dysfunction of pre-frontal cortical areas of the brain and their connections with limbic structures. There has been limited research into specific CR to activate these areas and target impaired cognitive function in MDD. We therefore review current evidence, examine the theoretical basis for and present a rationale for research into CR in MDD. In addition, we will examine important methodological issues in developing such an approach. Based on preliminary studies using CR-based techniques, data from CR in schizophrenia, data regarding baseline and residual cognitive impairment in depression, and knowledge of the neurobiology of MDD, we examine the possible utility of CR strategies in the treatment of MDD and make recommendations for research in this area. A small number of previous studies have examined specific CR in MDD. The studies are small and inconclusive. However, data on the neuropsychological function and neurobiology of MDD suggest that this is an approach that deserves further attention and research. Further research is required in carefully selected populations, using well-defined CR techniques and some form of comparator treatment.

Does practice make perfect? Results from a Chinese feasibility study of cognitive remediation in schizophrenia

Patients with schizophrenia often receive little by way of non-pharmacological interventions. Despite this, promising outcomes in programmes targeting cognitive deficits have been reported, suggesting that this is an area worthy of further investigation. The aim of the study was to implement and evaluate a brief computerised cognitive remediation programme designed to improve memory and attention in a male Chinese sample with chronic schizophrenia. Pre-testing was completed on a number of clinical and cognitive measures for intervention (n = 14) and treatment as usual (n = 17) participants. The intervention group then completed six weeks ( x no. of sessions = 12.78) of the computer-based cognitive remediation programme. Post-test measures for both groups were then collected again. Following the six week intervention, we found, contrary to our expectations, the intervention group improved on several of the clinical variables. The intervention group also performed better than the control group on the post-test measure of attention, but not verbal memory. These findings suggest that it is feasible to improve some aspects of cognitive abilities with a simple computerised training programme for people with serious mental illness.

Cognitive remediation in schizophrenia: efficacy and effectiveness in patients with early versus long‐term course of illness

We examined the efficacy and effectiveness (transfer to functional competence and everyday functioning) of cognitive remediation in early-course (within 5 years of first episode) and long-term (more than 15 years of illness) schizophrenia. Treatment lasted 12 weeks and included computerized exercises, strategic monitoring and methods to transfer cognition to behaviour. Assessments included a standard battery of neurocognition, performance-based measures of social and adaptive competence, and case manager ratings of real-world functional behaviour. Changes from baseline to post-treatment were examined with repeated measures analysis of variance and estimated premorbid intelligence and total months in hospital as covariates. The early-course group had larger improvements in measures of processing speed and executive functions, as well as larger improvements in adaptive competence and real-world work skills. Duration of illness was inversely associated with improvement in neurocognition and real-world work skills. Treatment of cognitive impairments is feasible in both early-course and chronic schizophrenia, but the clinical meaningfulness and generalization to functioning appear to be more substantial when delivered early. Cognitive remediation should be considered a tool for early intervention in schizophrenia.

Cognitive Remediation in Schizophrenia: Current Status and Future Perspectives

Objectives. This study is aimed to review the current scientific literature on cognitive remediation in schizophrenia. In particular, the main structured protocols of cognitive remediation developed for schizophrenia are presented and the main results reported in recent meta-analyses are summarized. Possible benefits of cognitive remediation in the early course of schizophrenia and in subjects at risk for psychosis are also discussed. Methods. Electronic search of the relevant studies which appeared in the PubMed database until April 2013 has been performed and all the meta-analyses and review articles on cognitive remediation in schizophrenia have been also taken into account. Results. Numerous intervention programs have been designed, applied, and evaluated, with the objective of improving cognition and social functioning in schizophrenia. Several quantitative reviews have established that cognitive remediation is effective in reducing cognitive deficits and in improving functional outcome of the disorder. Furthermore, the studies available support the usefulness of cognitive remediation when applied in the early course of schizophrenia and even in subjects at risk of the disease. Conclusions. Cognitive remediation is a promising approach to improve real-world functioning in schizophrenia and should be considered a key strategy for early intervention in the psychoses.

Adverse Effects of Cognitive Behavioral Therapy and Cognitive Remediation in Schizophrenia: Results of the Treatment of Negative Symptoms Study

Adverse Effects of Cognitive Behavioral Therapy and Cognitive Remediation in Schizophrenia: Results of the Treatment of Negative Symptoms Study