A randomized controlled trial comparing a "bottom-up" and "top-down" approach to cognitive training in schizophrenia

Efficacy of technology-based interventions in psychosis: a systematic review and network meta-analysis

BACKGROUND

Technology-based interventions (TBIs) are a useful approach when attempting to provide therapy to more patients with psychosis.

METHODS

Randomized controlled trials of outcomes of TBIs v. face-to-face interventions in psychosis were identified in a systematic search conducted in PubMed/Ovid MEDLINE. Data were extracted independently by two researchers, and standardized mean changes were pooled using a three-level model and network meta-analysis.

RESULTS

Fifty-eight studies were included. TBIs complementing treatment as usual (TAU) were generally superior to face-to-face interventions (g = 0.16, p ≤ 0.0001) and to specific outcomes, namely, neurocognition (g = 0.13, p ≤ 0.0001), functioning (g = 0.25, p = 0.006), and social cognition (g = 0.32, p ≤ 0.05). Based on the network meta-analysis, the effect of two TBIs differed significantly from zero; these were the TBIs cognitive training for the neurocognitive outcome [g = 0.16; 95% confidence interval (CI) 0.09-0.23] and cognitive behavioral therapy for quality of life (g = 1.27; 95% CI 0.46-2.08). The variables educational level, type of medication, frequency of the intervention, and contact during the intervention moderated the effectiveness of TBIs over face-to-face interventions in neurocognition and symptomatology.

CONCLUSIONS

TBIs are effective for the management of neurocognition, symptomatology, functioning, social cognition, and quality of life outcomes in patients with psychosis. The results of the network meta-analysis showed the efficacy of some TBIs for neurocognition, symptomatology, and quality of life. Therefore, TBIs should be considered a complement to TAU in patients with psychosis.

Exploring the Effectiveness of Group Cognitive Stimulation Training in People With Schizophrenia: A Randomized Controlled Trial

BACKGROUND

Schizophrenia is a chronic degenerative brain disease. Cognitive impairment, the core symptom of this disease, affects the mood and social functioning of patients severely. Nonpharmacological therapies that both improve cognitive function and are suitable for patients with schizophrenia remain underdeveloped.

PURPOSE

This article was designed to explore the effects of group cognitive stimulation training (GCST) on cognitive function and social function in people with schizophrenia.

METHODS

A randomized controlled trial was conducted. The 76 participants were allocated into either the experimental or control group using blocked randomization. The participants were all patients with chronic schizophrenia recruited from seven rehabilitation units in northern Taiwan who were 20-65 years old and scored 10-25 on the Montreal Cognitive Assessment Taiwan Version. The experimental group received the 60-minute GCST twice a week for 7 weeks, whereas the control group received standard treatment. All outcome indicators were analyzed at baseline and after intervention using generalized estimating equations. The primary outcome indicators included cognitive function assessed using the Taiwan version of the Montreal Cognitive Assessment, working memory assessed using the Wechsler Memory Scale-Third Edition, and executive function assessed using the Taiwanese version of the Frontal Assessment Battery. The secondary outcome indicator was social function assessed using the Social Function Scale-Taiwan short version.

RESULTS

Generalized estimating equation modeling revealed the experimental group exhibited significant improvement in Montreal Cognitive Assessment total score ( B = 1.33, SE = 0.65, p = .040) and Social Function Scale-Taiwan short version ( B = 9.55, SE = 2.38, p < .001) after adjusting for nine covariates. No significant differences between the two groups in terms of working memory ( B = 4.79, SE = 2.66, p = .071) or executive function ( B = 0.53, SE = 0.63, p = .399) were found.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The results indicate that GCST positively impacts overall cognitive and social functions but not higher-order cognitive function (working memory and executive function). In clinical settings, GCST may be applied to improve cognitive function in people with schizophrenia. The findings of this study may inform the practice of mental health nurses to improve cognitive function in patients in clinical care.

Factors Impacting Access and Engagement of Cognitive Remediation Therapy for People with Schizophrenia: A Systematic Review

OBJECTIVES

Neurocognitive deficits are central in schizophrenia. Cognitive remediation has proven effective in alleviating these deficits, with medium effect sizes. However, sizeable attrition rates are reported, with the reasons still uncertain. Furthermore, cognitive remediation is not part of routine mental health care. We conducted a systematic review to investigate factors that influence access and engagement of cognitive remediation in schizophrenia.

METHODS

We systematically searched the PubMed, Web of Science, and PsycINFO databases for peer-reviewed articles including a cognitive remediation arm, access, and engagement data, and participants with schizophrenia spectrum disorders aged 17-65 years old. Duplicates and studies without a distinct cognitive remediation component, protocol papers, single case studies, case series, and reviews/meta-analyses were excluded.

RESULTS

We included 67 studies that reported data on access and engagement, and extracted quantitative and qualitative data. Access data were limited, with most interventions delivered on-site, to outpatients, and in middle- to high-income countries. We found a median dropout rate of 14.29%. Only a small number of studies explored differences between dropouts and completers (n = 5), and engagement factors (n = 13). Dropouts had higher negative symptomatology and baseline self-efficacy, and lower baseline neurocognitive functioning and intrinsic motivation compared to completers. The engagement was positively associated with intrinsic motivation, self-efficacy, perceived usefulness, educational level, premorbid intelligence quotient, baseline neurocognitive functioning, some neurocognitive outcomes, and therapeutic alliance; and negatively associated with subjective cognitive complaints. Qualitative results showed good acceptability of cognitive remediation, with some areas for improvement.

CONCLUSIONS

Overall, access and engagement results are scarce and heterogeneous. Further investigations of cognitive remediation for inpatients, as well as remote delivery, are needed. Future clinical trials should systematically explore attrition and related factors. Determining influential factors of access and engagement will help improve the implementation and efficacy of cognitive remediation, and thus the recovery of people with schizophrenia.

Artificial Cognitive Systems Applied in Executive Function Stimulation and Rehabilitation Programs: A Systematic Review

This article presents a systematic review of studies on cognitive training programs based on artificial cognitive systems and digital technologies and their effect on executive functions. The aim has been to identify which populations have been studied, the characteristics of the implemented programs, the types of implemented cognitive systems and digital technologies, the evaluated executive functions, and the key findings of these studies. The review has been carried out following the PRISMA protocol; five databases have been selected from which 1889 records were extracted. The articles were filtered following established criteria, to give a final selection of 264 articles that have been used for the purposes of this study in the analysis phase. The findings showed that the most studied populations were school-age children and the elderly. The most studied executive functions were working memory and attentional processes, followed by inhibitory control and processing speed. Many programs were commercial, customizable, gamified, and based on classic tasks. Some more recent initiatives have begun to incorporate user-machine interfaces, robotics, and virtual reality, although studies on their effects remain scarce. The studies recognize multiple benefits of computerized neuropsychological stimulation and rehabilitation programs for executive functions in different age groups, but there is a lack of studies in specific population sectors and with more rigorous research designs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13369-022-07292-5.

Unveiling the Associations between EEG Indices and Cognitive Deficits in Schizophrenia-Spectrum Disorders: A Systematic Review

Cognitive dysfunctions represent a core feature of schizophrenia-spectrum disorders due to their presence throughout different illness stages and their impact on functioning. Abnormalities in electrophysiology (EEG) measures are highly related to these impairments, but the use of EEG indices in clinical practice is still limited. A systematic review of articles using Pubmed, Scopus and PsychINFO was undertaken in November 2021 to provide an overview of the relationships between EEG indices and cognitive impairment in schizophrenia-spectrum disorders. Out of 2433 screened records, 135 studies were included in a qualitative review. Although the results were heterogeneous, some significant correlations were identified. In particular, abnormalities in alpha, theta and gamma activity, as well as in MMN and P300, were associated with impairments in cognitive domains such as attention, working memory, visual and verbal learning and executive functioning during at-risk mental states, early and chronic stages of schizophrenia-spectrum disorders. The review suggests that machine learning approaches together with a careful selection of validated EEG and cognitive indices and characterization of clinical phenotypes might contribute to increase the use of EEG-based measures in clinical settings.

Advances in Cognitive Remediation Training in Schizophrenia: A Review

Cognitive Remediation Training (CRT) in schizophrenia has made great strides since its introduction in the 1990s. CRT was developed with the aim of improving the everyday functioning of individuals living with cognitive impairment. MEDLINE, PsychINFO, and Google Scholar were searched to extract peer-reviewed randomized controlled trials to produce the current review article. The aim of the present review is to summarize CRT effects on addressing cognitive changes in patients undergoing CRT as defined by the Cognitive Remediation Experts Workshop and to describe the areas of greatest impact in specific cognitive domains. Another area of this review aims to summarize the modalities of intervention (paper and pencil; computerized; home bound), the persistence of improvements, and their generalization to other domains of functioning. Finally, this review delineates barriers for wider dissemination of CRT, such as the transfer of research findings into clinical everyday practice and future developments of CRT.

The effects of neuroplasticity-based auditory information processing remediation in adults with chronic traumatic brain injury

BACKGROUND

Adults with chronic traumatic brain injury (TBI) may experience long-term deficits in multiple cognitive domains. Higher-order functions, such as verbal memory, are impacted by deficits in the ability to acquire verbal information.

OBJECTIVE

This study investigated the effects of a neuroplasticity-based computerized cognitive remediation program for auditory information processing in adults with a chronic TBI.

METHODS

Forty-eight adults with TBI were randomly assigned to an intervention or control group. Both groups underwent a neuropsychological assessment at baseline and post-training. The Intervention group received 40 one-hour cognitive training sessions with the Brain Fitness Program.

RESULTS

The intervention group improved in performance on measures of the Woodcock-Johnson-III Understanding Directions subtest and Trail Making Test Part-A. They also reported improvement on the cognitive domain of the Cognitive Self-Report Questionnaire.

CONCLUSIONS

The present study demonstrated that a neuroplasticity-based computerized cognitive remediation program may improve objective and subjective cognitive function in adults with TBI several years post-injury.

Effectiveness, Core Elements, and Moderators of Response of Cognitive Remediation for Schizophrenia: A Systematic Review and Meta-analysis of Randomized Clinical Trials

Importance

Cognitive impairment is a core feature of schizophrenia, with negative consequences on functional outcomes. Although cognitive remediation (CR) is effective and mentioned in treatment guidance for schizophrenia, its active ingredients and ideal candidates are still debated.

Objective

To provide a comprehensive update on CR effectiveness for cognition and functioning in schizophrenia and analyze the core ingredients of efficacy and role of patient characteristics.

Data Sources

The reference list of the last comprehensive meta-analysis in 2011 was screened against eligibility criteria. Then, electronic databases (PubMed, Scopus, and PsycInfo) were systematically searched for articles published from January 2011 to February 2020. Reference lists of included articles and relevant reviews were hand searched, and Google Scholar was manually inspected.

Study Selection

Eligible studies were randomized clinical trials comparing CR with any other control condition in patients diagnosed with schizophrenia spectrum disorders (with an unrestricted clinical status). Screening was performed by at least 2 independent reviewers.

Data Extraction and Synthesis

The PRISMA guidelines were followed. Study data were independently extracted and pooled using random-effect models. Cohen d was used to measure outcomes. Trial methodological quality was evaluated with the Clinical Trials Assessment Measure.

Main Outcomes and Measures

Primary outcomes were changes in global cognition and overall functioning from baseline to after treatment, subsequently investigated through metaregressions, subgroup, and sensitivity analyses based on prespecified hypotheses, to identify potential moderators of response associated with treatment modality and patient characteristics.

Results

Of 1815 identified reports, 358 full texts were assessed and 194 reports on 130 studies were included. Based on 130 studies with 8851 participants, CR was effective on cognition (d, 0.29 [95% CI, 0.24-0.34]) and functioning (d, 0.22 [95% CI, 0.16-0.29]). An active and trained therapist (cognition: χ21, 4.14; P = .04; functioning: χ21, 4.26; P = .04), structured development of cognitive strategies (cognition: χ21, 9.34; P = .002; functioning: χ21, 8.12; P = .004), and integration with psychosocial rehabilitation (cognition: χ21, 5.66; functioning: χ21, 12.08) were crucial ingredients of efficacy. Patients with fewer years of education (global cognition: coefficient, -0.055 [95% CI, -0.103 to -0.006]; P = .03; global functioning: coefficient, -0.061 [95% CI, -0.112 to -0.011]; P = .02), lower premorbid IQ (global functioning: coefficient, -0.013 [-0.025 to -0.001]; P = .04), and higher baseline symptom severity (global cognition: coefficient, 0.006 [95% CI, 0.002 to 0.010]; P = .005) emerged as optimal candidates.

Conclusions and Relevance

These findings show that CR is an evidence-based intervention that should be included consistently into clinical guidelines for the treatment of individuals with schizophrenia and implemented more widely in clinical practice.

Predicting response to cognitive training for schizophrenia using results from two studies with different outcomes

BACKGROUND

Collaborative data sharing between research groups provides an opportunity to explore the basis for the heterogeneity in cognitive training outcomes reported in the schizophrenia literature. The current analyses focused on the contribution of site and participant characteristics to these heterogeneous outcomes.

METHODS

Data from two independent studies, from New York (NY) and Los Angeles (LA), were combined to yield a sample of 132 outpatient adults with schizophrenia/schizoaffective disorder. While similar treatment doses, cognitive exercises and outcome measures were used, sites differed in use of coaching, group discussion and compensation. Between-site differences in participant demographic and baseline clinical characteristics were tested. Regression examined predictors of change in cognition (MCCB) and functional capacity (UPSA) which could explain site differences in treatment effects.

RESULTS

Medium to large treatment effect size differences in MCCB and UPSA favored the NY site over LA. When the studies were combined, the effect of site was significant for both outcomes with a medium effect size difference. After controlling for background characteristics, the effect of site was reduced for both outcomes, but remained significant for cognition. Improvement in UPSA was associated with better baseline MCCB (p < 0.001), lower baseline UPSA (p < 0.001) and younger age (p = 0.019). The overall model with site, baseline scores, and participant background characteristics explained about 30% to 40% of the variance in outcomes.

DISCUSSION

Participant and treatment characteristics are both predictive of outcomes, but treatment characteristics may be more consequential to cognitive gain, while participant characteristics may be more consequential to change in functional capacity.

Gamma oscillations predict pro-cognitive and clinical response to auditory-based cognitive training in schizophrenia

Cognitive impairments are pervasive and disabling features of schizophrenia. Targeted cognitive training (TCT) is a "bottom-up" cognitive remediation intervention with efficacy for neurocognitive outcomes in schizophrenia, yet individual responses are variable. Gamma oscillatory measures are leading candidate biomarkers in the development of biologically informed pro-cognitive therapeutics. Forty-two schizophrenia patients were recruited from a long-term residential treatment facility. Participants were randomized to receive either 1 h of cognitive training (TCT, n = 21) or computer games (TAU, n = 21). All participants received standard-of-care treatment; the TCT group additionally completed 30 h of cognitive training. The auditory steady-state response paradigm was used to elicit gamma oscillatory power and synchrony during electroencephalogram recordings. Detailed clinical and cognitive assessments were collected at baseline and after completion of the study. Baseline gamma power predicted cognitive gains after a full course of TCT (MCCB, R² = 0.31). A change in gamma power after 1-h TCT exposure predicted improvement in both positive (SAPS, R² = 0.40) and negative (SANS, R² = 0.30) symptoms. These relationships were not observed in the TAU group (MCCB, SAPS, and SANS, all R² < 0.06). The results indicate that the capacity to support gamma oscillations, as well as the plasticity of the underlying ASSR circuitry after acute exposure to 1 h of TCT, reflect neural mechanisms underlying the efficacy of TCT, and may be used to predict individualized treatment outcomes. These findings suggest that gamma oscillatory biomarkers applied within the context of experimental medicine designs can be used to personalize individual treatment options for pro-cognitive interventions in patients with schizophrenia.

Performance in Practice: Practice Assessment Tool for the Care of Patients With Schizophrenia

Schizophrenia is associated with significant health, social, occupational, and economic burdens, including increased mortality. Despite extensive and robust research on the treatment of individuals with schizophrenia, many individuals with the illness do not currently receive evidence-based pharmacological and nonpharmacological treatments. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia, Third Edition, aims to enhance knowledge and increase the appropriate use of interventions for schizophrenia, thereby improving the quality of care and treatment outcomes. To this end, this evidence-based Performance in Practice tool can facilitate the implementation of a systematic approach to practice improvement for the care of individuals with schizophrenia. This practice assessment activity can also be used in partial fulfillment of Continuing Medical Education and Maintenance of Certification, part IV, requirements, which can also satisfy requirements for the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System program.

Testing Psychosis Phenotypes From Bipolar-Schizophrenia Network for Intermediate Phenotypes for Clinical Application: Biotype Characteristics and Targets

BACKGROUND

Psychiatry aspires to the molecular understanding of its disorders and, with that knowledge, to precision medicine. Research supporting such goals in the dimension of psychosis has been compromised, in part, by using phenomenology alone to estimate disease entities. To this end, we are proponents of a deep phenotyping approach in psychosis, using computational strategies to discover the most informative phenotypic fingerprint as a promising strategy to uncover mechanisms in psychosis.

METHODS

Doing this, the Bipolar-Schizophrenia Network for Intermediate Phenotypes (B-SNIP) has used biomarkers to identify distinct subtypes of psychosis with replicable biomarker characteristics. While we have presented these entities as relevant, their potential utility in clinical practice has not yet been demonstrated.

RESULTS

Here we carried out an analysis of clinical features that characterize biotypes. We found that biotypes have unique and defining clinical characteristics that could be used as initial screens in the clinical and research settings. Differences in these clinical features appear to be consistent with biotype biomarker profiles, indicating a link between biological features and clinical presentation. Clinical features associated with biotypes differ from those associated with DSM diagnoses, indicating that biotypes and DSM syndromes are not redundant and are likely to yield different treatment predictions. We highlight 3 predictions based on biotype that are derived from individual biomarker features and cannot be obtained from DSM psychosis syndromes.

CONCLUSIONS

In the future, biotypes may prove to be useful for targeting distinct molecular, circuit, cognitive, and psychosocial therapies for improved functional outcomes.

Protein intake is associated with cognitive functioning in individuals with psychiatric disorders

Schizophrenia and bipolar disorder are associated with reduced cognitive functioning which contributes to problems in day-to-day functioning and social outcomes. A paucity of research exists relating dietary factors to cognitive functioning in serious mental illnesses, and results are inconsistent. The study aims to describe the nutritional intake of persons with schizophrenia and those with a recent episode of acute mania and to determine relationships between the intake of protein and other nutrients on cognitive functioning in the psychiatric sample. Persons with schizophrenia and those with acute mania were assessed using a 24-h dietary recall tool to determine their intakes of protein and other nutrients. They were also assessed with a test battery measuring different domains of cognitive functioning. Results indicate that lower amounts of dietary protein intake were associated with reduced cognitive functioning independent of demographic and clinical factors. The association was particularly evident in measures of immediate memory and language. There were not associations between cognitive functioning and other nutritional variables, including total energy, gluten, casein, saturated fat, or sugar intakes. The impact of dietary interventions, including protein intake, on improving cognitive functioning in individuals with psychiatric disorders warrants further investigation.

Oscillatory biomarkers of early auditory information processing predict cognitive gains following targeted cognitive training in schizophrenia patients

Auditory-based targeted cognitive training (TCT) is an effective and well-validated intervention for the treatment of cognitive impairment in schizophrenia patients. Improvements in higher-order cognition, reductions in symptom severity, and increases in psychosocial functioning secondary to TCT are thought to be driven by "bottom-up" enhancement of early auditory information processing (EAIP). Despite strong evidence of efficacy at the group level, there is significant variability in response to TCT, with few well-delineated biomarkers for predicting individual benefit. EEG biomarkers of EAIP are indicators of early-treatment sensitivity that predict full-course TCT outcome; however, further characterization is necessary for biomarker-guided clinical trials. The current study examined baseline and early-treatment sensitivity (i.e., change from baseline after 1 h) in theta band oscillatory activity to deviant stimuli as moderators of full course (30 h) TCT response in treatment-refractory schizophrenia patients randomly assigned to receive either treatment-as-usual (TAU; n = 22) or TAU augmented with TCT (n = 30). Theta evoked power and phase locking at baseline predicted patient improvements in global cognitive function after 30 h of TCT. Decrease in theta activity to deviant stimuli after 1 h of TCT predicted improvements in verbal learning after 30 h. Exploratory analyses using EEG composite scores had high levels of sensitivity and specificity for identifying patients most likely to benefit from TCT. The integrity of baseline neurophysiologic activity associated with EAIP, as well as the sensitivity of the underlying circuity to change, likely reflects an intermediate therapeutic process underlying the effectiveness of TCT that can be used to predict patient response to treatment.

Nicotine effects on cognitive remediation training outcome in people with schizophrenia: A pilot study

Cognitive remediation training can alleviate cognitive impairment associated with schizophrenia, but the impact is limited by small effect sizes. The present study aimed at augmenting training effects by administering nicotine prior to training sessions. Twenty-five people with schizophrenia were enrolled in a 10-week, 5 days/week, computerized cognitive training regimen. Participants were randomized to two treatment groups: nicotine or placebo. Every Monday and Thursday, the nicotine group received a nicotine lozenge before the training, and the placebo group a placebo lozenge. Outcome measurements were conducted on a no-lozenge day in weeks 0, 4, 7, and 10, and at 4-week follow-up. The MATRICS Consensus Cognitive Battery composite score improved over time, but there was no group difference in this effect. A significant group difference emerged over time in the reasoning/problem solving sub-domain: the placebo group improved but not the nicotine group, suggesting that nicotine exposure negatively impacted training benefits on executive control processes. There were no effects on psychiatric symptoms. However, significant improvements were seen across groups on the Quality of Life Scale and the Cognitive Assessment Interview, measuring real-life functional outcome. In conclusion, the present study failed to find evidence that nicotine exposure during cognitive remediation training may potentiate training benefits.

Cognitive impairment in psychotic illness: prevalence, profile of impairment, developmental course, and treatment considerations

Despite effective pharmacological treatments for psychotic symptoms (eg, hallucinations, delusions), functional outcomes for people with psychotic disorders are often disappointing. Although it is not included in the diagnostic criteria for psychotic disorders, cognitive impairment is one of the strongest determinants of community functioning in this clinical population, and thus it is an important target for intervention. In this review, we discuss the major areas of research regarding impaired cognition in psychotic illness. The specific topics covered include: (i) the prevalence of cognitive impairment in psychotic disorders; (ii) the profile and magnitude of cognitive impairment in psychotic disorders; (iii) the developmental course of cognitive impairment; (iv) the longitudinal stability of cognitive impairment; and (v) treatment approaches to improve cognitive performance in people with psychotic disorders.
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