The impact of intrinsic motivation on session attendance and reliable cognitive improvement in cognitive remediation in schizophrenia

Efficacy of cognitive training on cognition, symptoms and functioning: Impact of motivation and attendance

While cognitive remediation therapy (CRT) and compensatory strategy training both have large literature bases supporting their efficacy on both proximal and distal outcomes, the research base on stand-alone cognitive training (CT) is smaller and less consistent, with little information about factors associated with better outcomes. In this study, we examined the efficacy of CT on training task, cognitive, symptom, and functional ability measures as well as the impact of motivational interviewing (MI), motivation level, and session attendance on treatment outcomes. Adults with psychotic spectrum disorders (n = 114) were randomized to MI or a sham control interview (CI), followed by 4 months of computerized CT. In whole sample analyses, participants improved on training tasks, cognitive performance, and psychiatric symptoms, but self-reported cognition, self-reported depression, and functional ability did not change. Compared to CI, MI was associated with greater reductions in self-reported depressive symptoms. Motivation level and session attendance did not significantly influence outcomes. Findings support the efficacy of CT on several key outcomes, and its simplicity may be advantageous in uptake in community clinics with limited staffing. The lack of functional gains underscores the need to incorporate treatment ingredients that promote generalization and real-world implementation of learned skills. We also speculate that engagement during course of training may be a better predictor of training success than baseline task-specific motivation.

Intrinsic motivation predicts cognitive and functional gains during coordinated specialty care for first-episode schizophrenia

Coordinated Specialty Care (CSC) and embedded group therapeutic interventions have been effective in improving outcomes for individuals experiencing recent first-episode schizophrenia, including cognitive performance and functioning. Treatment response varies substantially, with some patients experiencing limited or no improvement. Motivation has emerged as a key determinant of treatment engagement and efficacy. However, the impact of intrinsic and extrinsic aspects of motivation has not been directly examined with treatment outcomes in first-episode schizophrenia. This study investigated whether baseline levels of intrinsic and extrinsic motivation predicted cognitive and functional gains over 6 and 12 months in CSC. Forty participants with first-episode schizophrenia completed a 12-month CSC treatment period. Baseline measures of intrinsic and extrinsic motivation were obtained for group therapeutic interventions and work/school, as well as measures of cognition and functioning (role and social) at baseline, 6 months, and 12 months. Results revealed that higher baseline scores of intrinsic motivation for group therapeutic interventions were significantly predictive of greater cognitive gains at 12 months, and a similar tendency was observed at 6 months. Additionally, baseline scores of intrinsic motivation for work/school predicted role gains at 6 months, with a similar tendency observed at 12 months. Extrinsic motivation did not consistently impact treatment outcomes, except for work/school-related extrinsic motivation, which was linked to greater social functioning gains at 12 months. These findings provide insight into the factors influencing treatment outcomes for individuals with first-episode schizophrenia and highlight the importance of intrinsic motivation as a modifiable personal variable that can enhance response to CSC.

A randomized controlled pilot trial of brief online mindfulness training in young drivers

OBJECTIVE

Driver distraction contributes to fatal and injury crashes in young drivers. Mind wandering (MW) is a covert form of distraction involving task-unrelated thoughts. Brief online mindfulness training (MT) may reduce unsafe driving by enhancing recognition (meta-awareness) of MW and reducing its occurrence. This pilot trial tested these proposed mechanisms of MT and explored its specificity of action, effects on driving behaviour in simulation, as well as intervention adherence and acceptability in young drivers.

METHODS

A pre-post (T1, T2), randomized, active placebo-controlled, double-blinded design was used. Twenty-six drivers, aged 21-25, received either brief online MT (experimental) or progressive muscle relaxation (PMR, control) over 4-6 days. A custom website blindly conducted randomization, delivered interventions, administered questionnaires, and tracked adherence. At T1 and T2, a simulator measured driving behaviour while participants indicated MW whenever they recognized it, to assess meta-awareness, and when prompted by a thought-probe, to assess overall MW.

RESULTS

MT reduced MW while driving in simulation. The MT group reported higher state mindfulness following sessions. Motivation did not account for MW or mindfulness results. MT and meta-awareness were associated with more focus-related steering behaviour. Intervention groups did not significantly differ in adherence or attrition. No severe adverse effects were reported, but MT participants reported more difficulty following intervention instructions.

CONCLUSION

Results support a plausible mechanism of MT for reducing MW-related crash risk (i.e., reduction of MW) in young drivers. This preliminary evidence, alongside promising online adherence and acceptability results, warrants definitive efficacy and effectiveness trials of online MT.

Evaluation of a new intrinsic and extrinsic motivation scale in youth with psychosis spectrum symptoms

BACKGROUND

Impairment in intrinsic motivation (IM), the drive to satisfy internal desires like mastery, may play a key role in disability in psychosis. However, we have limited knowledge regarding relative impairments in IM compared to extrinsic motivation (EM) or general motivation (GM), in part due to limitations in existing measures.

METHODS

Here we address this gap using a novel Trait Intrinsic and Extrinsic Motivation self-report scale in a sample of n = 243 participants including those with schizophrenia, psychosis-risk, and healthy controls. Each of the 7 IM and 6 EM items used a 7-point Likert scale assessing endorsement of dispositional statements. Bifactor analyses of these items yielded distinct IM, EM, and GM factor scores. Convergent and discriminant validity were examined in relation to General Causality Orientation Scale (GCOS-CP) and Quality of Life 3-item IM measure (QLS-IM). Utility was assessed in relation to psychosis-spectrum (PS) status and CAINS clinical amotivation.

RESULTS

IM and EM showed acceptable inter-item consistency (IM: α = 0.88; EM: α = 0.66); the bifactor model exhibited fit that varied from good to borderline to inadequate depending on the specific fit metric (SRMR = 0.038, CFI = 0.94, RMSEA = 0.106 ± 0.014). IM scores correlated with established IM measures: GCOS-CP Autonomy (rho = 0.38, p < 0.01) and QLS-IM (rho = 0.29, p < 0.01). Supporting discriminant validity, IM did not correlate with GCOS-CP Control (rho = -0.14, p > 0.05). Two-year stability in an available longitudinal subset (n = 35) was strong (IM: rho = 0.64, p < 0.01; EM: rho = 0.55, p < 0.01). Trait IM was lower in PS youth (t = 4.24, p < 0.01), and correlated with clinical amotivation (rho = -0.36, p < 0.01); EM did not show significant clinical associations.

CONCLUSIONS

These results demonstrate the clinical relevance of IM in psychosis risk. They also provide preliminary support for the reliability, validity and utility of this new Trait IM-EM scale, which addresses a measurement gap and can facilitate identification of neurobehavioral and clinical correlates of IM deficits.

Learning without contingencies: A loss of synergy between memory and reward circuits in schizophrenia

Motivational deficits in schizophrenia may interact with foundational cognitive processes including learning and memory to induce impaired cognitive proficiency. If such a loss of synergy exists, it is likely to be underpinned by a loss of synchrony between the brains learning and reward sub-networks. Moreover, this loss should be observed even during tasks devoid of explicit reward contingencies given that such tasks are better models of real world performance than those with artificial contingencies. Here we applied undirected functional connectivity (uFC) analyses to fMRI data acquired while participants engaged in an associative learning task without contingencies or feedback. uFC was estimated and inter-group differences (between schizophrenia patients and controls, n = 54 total, n = 28 patients) were assessed within and between reward (VTA and NAcc) and learning/memory (Basal Ganglia, DPFC, Hippocampus, Parahippocampus, Occipital Lobe) sub-networks. The task paradigm itself alternated between Encoding, Consolidation, and Retrieval conditions, and uFC differences were quantified for each of the conditions. Significantly reduced uFC dominated the connectivity profiles of patients across all conditions. More pertinent to our motivations, these reductions were observed within and across classes of sub-networks (reward-related and learning/memory related). We suggest that disrupted functional connectivity between reward and learning sub-networks may drive many of the performance deficits that characterize schizophrenia. Thus, cognitive deficits in schizophrenia may in fact be underpinned by a loss of synergy between reward-sensitivity and cognitive processes.

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.

Treatment engagement in first-episode schizophrenia: Associations between intrinsic motivation and attendance during cognitive training and an aerobic exercise program

Systematic cognitive training and aerobic exercise programs have emerged as promising interventions to improve cognitive deficits in first-episode schizophrenia, with successful outcomes closely linked with greater treatment engagement (e.g., higher attendance and homework completion rates). Unfortunately, treatment disengagement from these services remains a persistent issue. Intrinsic motivation, or the willingness to exert effort because a task is inherently interesting or meaningful, has emerged as a promising malleable personal factor to enhance treatment engagement. This study investigated whether early task-specific intrinsic motivation and its domains (e.g., interest, perceived competence, and value) predicted treatment engagement within the context of intensive cognitive training and aerobic exercise interventions over a 6-month period. Thirty-nine participants with first-episode schizophrenia were administered baseline measures of task-specific intrinsic motivation inventories, one for cognitive training and one for exercise, and completed a 6-month randomized clinical trial comparing a neuroplasticity-based cognitive training plus aerobic exercise program against the same cognitive training alone. Results indicated that higher baseline scores of intrinsic motivation for cognitive training, specifically early perceptions of task interest and value, were predictive of greater cognitive training and exercise group attendance. Scores for exercise-specific intrinsic motivation were generally unrelated to indices of exercise participation, with the exception that the gain over time in perceived choice for exercise was linked with greater exercise homework completion and a similar directional tendency for greater in-clinic exercise attendance. This study provides support for monitoring and enhancing motivation early during service delivery to maximize engagement and the likelihood of successful treatment outcomes.

Therapeutic alliance in a cognitive rehabilitation programme for people with serious mental illness: A qualitative analysis

OBJECTIVE

Therapeutic alliance is an important element of evidence-based treatments for people diagnosed with a serious mental illness. Cognitive enhancement therapy (CET) is an efficacious cognitive rehabilitation programme that emphasizes coach-participant relationships. The purpose of this study was to examine experiences of therapeutic alliance among CET participants.

DESIGN

We used an exploratory qualitative approach.

METHODS

Semi-structured interviews were conducted with 24 participants diagnosed with a serious mental illness. Interview transcripts were analysed by three independent coders using thematic analysis.

RESULTS

Four themes related to therapeutic alliance emerged: (1) positive regard; (2) collaboration; (3) authenticity; (4) negative alliance.

CONCLUSIONS

Findings suggest that therapeutic alliance is an important component of CET that bolsters the learning environment and ensures a positive group experience. Our qualitative analyses contribute greater understanding of how strong therapeutic relationships impact people with serious mental illnesses participating in evidence-based treatments beyond psychotherapy context.

Minds@Work: A New Manualized Intervention to Improve Job Tenure in Psychosis Based on Scoping Review and Logic Model

Introduction A significant proportion of people experiencing psychosis are unemployed, despite a strong desire to work. Current supported employment programs appear effective in helping them obtain employment, yet job tenure remains an arduous challenge. The objective of this study was to review the literature and model the results to inform the development of a new manualized group psychosocial intervention-'Minds@Work'-aimed specifically at improving job tenure in psychosis. Methods The study was registered on the Open Science Framework platform ( https://osf.io/he68z ). The literature was searched in Medline, Embase, PsycInfo and Cochrane Library databases for studies examining predictors of job tenure in psychosis and existing occupational psychosocial interventions. Data were extracted using a pre-established form and synthesized using logic models. Results A total of 94 studies were included and their findings were modeled using different categories: intervention typologies, mechanisms of action, predictors of job tenure, outcomes and contextual factors. The 'Minds@Work' program was built based on these modeled findings and aimed to target specific predictors of job tenure while addressing some of the limitations of existing interventions. The program uses evidence-based techniques and is divided into 9 modules covering 4 themes: positive psychology (motivation, character strengths, self-compassion), neurocognitive remediation (attention, memory, problem-solving), cognitive biases training (jumping to conclusions, defeatists beliefs, theory of mind, attributional styles) and socioemotional coping skills (emotion regulation, communication). Conclusions Once validated, this new program is meant to be used either as a stand-alone intervention or integrated in supported employment initiatives, by employment specialists or healthcare workers.

Aerobic exercise and cognitive functioning in schizophrenia: An updated systematic review and meta-analysis

This study serves as an update to a recent systematic review and meta-analysis to summarize the effect of aerobic exercise on cognition in schizophrenia and determine the most effective method of aerobic exercise. We searched for controlled studies investigating the effect of aerobic exercise on cognition in schizophrenia published until January 2021. Fifteen studies were included. A random-effects model was used to estimate the standardized mean differences (SMDs) between cognitive outcomes of aerobic exercises and controls. Compared with controls, aerobic exercises resulted in significant improvements in global cognition (SMD = 0.21), attention/vigilance (SMD = 0.32), working memory (SMD = 0.27), and verbal learning (SMD = 0.30). Significant improvements in global cognition were observed with group exercise (SMD = 0.28), exercise supervised by exercise professionals (SMD = 0.27), as well as with ≥ 90 min/week (SMD = 0.26) and ≥ 12 weeks duration (SMD = 0.22). Our findings provide information beneficial for determining the most effective aerobic exercise method to improve cognition in schizophrenia.

Motivational interviewing to enhance psychosocial treatment attendance in people with SMI

BACKGROUND

While there is increasing support for the efficacy of psychosocial interventions for people with SMI, the real-world effectiveness of such treatments is diminished by lack of motivation for treatment, leading to poor treatment engagement/dropout. We sought to evaluate the efficacy of motivational interviewing (MI) in improving attendance in a full course of cognitive training, examine motivation level as a potential mechanism of action, and examine variables associated with initial engagement in the training.

METHODS

One hundred fourteen participants with SMI were randomized to MI or sham control interview (CI), both of which were followed by a 4-month active phase during which participants could attend up to 50 unpaid cognitive training sessions.

RESULTS

Fidelity to the MI intervention was high, and MI condition was associated with increases in perceived value of training tasks and, to a lesser extent, how enjoyable/interesting they were rated. Twenty-nine percent of the full sample did not attend any training sessions. In ITT analyses, there was no significant between-group impact of MI on treatment attendance, though one emerged when participants who did not attend any sessions were excluded. Treatment attendance was predicted by the level of motivation achieved after the MI/CI intervention. Those who attended at least one training session (regardless of randomization) were more likely to believe they had cognitive impairments, had higher IQ and had less severe general psychiatric symptoms.

CONCLUSIONS

MI showed some promise and may be a worthwhile addition to more comprehensive, robust efforts to promote initial treatment engagement and subsequent adherence.

The Contribution of a Music and Arts Rehabilitation Program to the Creative Identity, Well-Being, and Community Integration of People With Mental Health Conditions

The United Nations highlighted the importance of promoting the rights of people with mental health conditions (MHC) to education, employment, and citizenship. One related initiative in Israel is the Garage pre-academic music and arts school for individuals with musical and artistic abilities coping with MHC. This process–outcome study examined whether and how the Garage contributes to participants’ creative self-concept, mental health, alleviates loneliness, and promotes postsecondary education and work integration. It also probed the participants’ initial expectations and the extent to which these were fulfilled. Using a single-group pretest–posttest design, quantitative data on the outcome variables were collected, along with mid-test data on process variables from the Garage students ( N = 44). Supplementary qualitative data were collected at pretest on the students’ expectations. The results suggest a significant increase in creative personal identity and mental health, a decrease in loneliness, and promotion of postsecondary education and work integration. These findings were associated with persistent attendance, basic psychological needs satisfaction, and expectation fulfillment. A merged analysis indicated that the students’ qualitative expectations were generally congruent with the quantitative results. Overall, the findings show how the program corresponds to humanistic values, targets service users’ needs and rights, and promotes personal recovery and community integration.

On what motivates us: a detailed review of intrinsic v. extrinsic motivation

Motivational processes underlie behaviors that enrich the human experience, and impairments in motivation are commonly observed in psychiatric illness. While motivated behavior is often examined with respect to extrinsic reinforcers, not all actions are driven by reactions to external stimuli; some are driven by 'intrinsic' motivation. Intrinsically motivated behaviors are computationally similar to extrinsically motivated behaviors, in that they strive to maximize reward value and minimize punishment. However, our understanding of the neurocognitive mechanisms that underlie intrinsically motivated behavior remains limited. Dysfunction in intrinsic motivation represents an important trans-diagnostic facet of psychiatric symptomology, but due to a lack of clear consensus, the contribution of intrinsic motivation to psychopathology remains poorly understood. This review aims to provide an overview of the conceptualization, measurement, and neurobiology of intrinsic motivation, providing a framework for understanding its potential contributions to psychopathology and its treatment. Distinctions between intrinsic and extrinsic motivation are discussed, including divergence in the types of associated rewards or outcomes that drive behavioral action and choice. A useful framework for understanding intrinsic motivation, and thus separating it from extrinsic motivation, is developed and suggestions for optimization of paradigms to measure intrinsic motivation are proposed.

Video Games as a Complementary Therapy for Schizophrenia: A Systematic Review

BACKGROUND

Schizophrenia is a prevalent and serious disorder. Video games have shown potential as an aid in health care for people who suffer from schizophrenia. Although video games may contribute benefit in the treatment of schizophrenia, reviews on this topic are scarce. In this article, we systematically review the evidence concerning video game-based therapeutic interventions for people diagnosed with schizophrenia.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review protocol was registered in the PROSPERO database. We searched 4 databases-PubMed, Web of Science, EMBASE, and clinicaltrials.gov-to identify original studies exploring video game-based therapeutic interventions for people with schizophrenia.

RESULTS

After initial screening, full-text review, and study selection, 11 articles were included in the review. Most studies used video consoles as the platform, with a minority using a personal computer. Video game-based therapeutic interventions were well accepted and generally effective in improving cognitive areas.

CONCLUSIONS

Cognitive training could be one of the main mechanisms underlying the usefulness and effectiveness of video game-based therapeutic interventions. Software optimization and greater collaboration between developers and health care professionals are some of the priorities for future research in this area.

An Open Trial of Metacognitive Remediation Therapy and Pharmacotherapy to Promote Smoking Cessation among Individuals with Psychotic-Spectrum Disorders

Introduction

Individuals with psychotic-spectrum disorders may smoke due to the ameliorating effect of nicotine on the cognitive deficits that accompany these illnesses. Metacognitive remediation therapy (MCR) has been shown to produce improvements in cognitive functioning among individuals with psychotic-spectrum disorders and provides a foundation for a novel smoking cessation intervention for this population.

Aims

To complete an open investigation of pharmacotherapy and a modified version of MCR [MCR to Quit (MCR-Q)] in promoting smoking cessation among individuals with psychotic-spectrum disorders.

Methods

Forty-nine individuals with a psychotic-spectrum disorder and who currently smoke cigarettes participated in MCR-Q while also receiving evidence-based smoking cessation pharmacotherapy. Tobacco use was assessed as follows: (i) prior to MCR-Q, (ii) immediately after completing MCR-Q, and (iii) six weeks after completion of MCR-Q.

Results

/Findings. During participation in MCR-Q, nearly 80% of participants made a 24-hour quit attempt. Following the completion of MCR-Q, participants experienced reductions in level of nicotine dependency and exhaled carbon monoxide, with reductions in nicotine dependency sustained six weeks after completion of MCR-Q. Over the course of their participation in MCR-Q, participants reported strong therapeutic alliance with their MCR-Q therapist and high levels of intrinsic motivation with regard to completing MCR-Q exercises.

Conclusions

The results from the current study suggest cautious optimism with regard to the use of MCR-Q in combination with medication for individuals with psychotic-spectrum disorders who want to quit smoking.

Strategies for Psychiatric Rehabilitation and their Cognitive Outcomes in Schizophrenia: Review of Last Five-year Studies

BACKGROUND

Cognitive deficits are core features of Schizophrenia, showing poor response to antipsychotic treatment, therefore non-pharmacological rehabilitative approaches to such a symptom domain need to be identified. However, since not all patients with Schizophrenia exhibit the same cognitive impairment profile, individualized rehabilitative approaches should be set up.

OBJECTIVES

We explored the last five-year literature addressing the issue of cognitive dysfunction response to rehabilitative methodologies in Schizophrenia to identify possible predictors of response and individualized strategies to treat such a dysfunction.

CONCLUSION

A total of 76 studies were reviewed. Possible predictors of cognitive rehabilitation outcome were identified among patient-specific and approach-specific variables and a general overview of rehabilitative strategies used in the last five years has been depicted. Studies suggest the existence of multifaced and multi-domain variables that could significantly predict pro-cognitive effects of cognitive rehabilitation, which could also be useful for identifying individual-specific rehabilitation trajectories over time.An individualized rehabilitative approach to cognitive impairment in Schizophrenia is possible if taking into account both patient and approach specific predictors of outcomes.

Perspectives on paid work among men and women with schizophrenia: The results of a two study comparison in Ireland

BACKGROUND

While research indicates that people with serious mental health conditions want to work, few studies have examined motivation and concerns associated with employment.

OBJECTIVES

This study examined the work attitudes among two samples of Irish people with psychotic conditions, primarily schizophrenia.

METHODS

Data gathered through two work related research projects was used. A self-report instrument, the work motivation scale (WMS), gathered data in two separate studies. It was possible to examine participants' motives and concerns due to the two factor structure, positive and negative, of this scale. Descriptive statistical analysis was conducted for each of the two samples individually. A sub-analysis by gender was also conducted.

RESULTS

Across the two samples, analysis showed the consistent motivators were increased coping ability, improved self-identity, and enhanced self-worth. Men particularly wanted others to see them as good workers. On the other hand, women regarded a job as a means to forget about having a mental illness. A sizeable minority in both samples expressed apprehensions such as work being boring and an expectation from others that they should work rather than them being personally motivated to do so.

CONCLUSIONS

While caution must be exercised in interpreting the results due to the small sample size, this study has extended our understanding in this under-researched but important topic.

Predictors of attendance in health and wellness treatment groups for people with serious mental illness

OBJECTIVE

People with serious mental illness have dramatically reduced life expectancy that is largely attributed to elevated rates of chronic medical conditions. Several group interventions have been developed and implemented in recent years to improve health and wellness among people with mental health conditions. Unfortunately, attendance in these interventions is often low, and there is limited understanding of factors that influence patient engagement in this treatment modality.

METHOD

Participants (N = 242) were enrolled in 1 of 2 group-based health and wellness treatment programs. Using descriptive statistics and regression, we assessed treatment attendance and a range of potential predictors of attendance.

RESULTS

We found lower attendance among people who were younger, people with more medical conditions, and people with more emergency room visits in the 6 months prior to the beginning of treatment. Younger age was a particularly strong predictor of low attendance and was the only variable significantly associated with attending zero treatment sessions.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

These results highlight the need for strategies to improve engagement of patients with poorer objective indicators of medical health and patients with younger age. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

How does awareness of cognitive impairment impact motivation and treatment outcomes during cognitive remediation for schizophrenia?

BACKGROUND

There is concern that awareness of cognitive deficit among people with schizophrenia receiving Cognitive Remediation (CR) might undermine motivation, engagement, and CR outcomes. We therefore examined the relationship of subjective awareness of cognitive deficit to aspects of motivation and cognitive learning during an efficacious CR program.

METHODS

Individuals with schizophrenia/schizoaffective disorder who completed 30 sessions of CR (N = 67) were evaluated on cognitive performance, self-reported cognitive difficulties, intrinsic motivation and perceived competency for cognitive training tasks at the beginning and end of treatment.

RESULTS

We found no relationship between actual and perceived cognitive functioning when measured cross-sectionally or as difference scores, pre/post treatment. Greater awareness of cognitive problems was associated with lower perceived competency for cognitive tasks at treatment beginning and end-point (p-values < .05). The significant relationship between awareness of cognitive problems and perceived value of the treatment at end-point was fully mediated by perceived competency. While greater perceived competency was associated with shorter time to treatment completion (p = .0025), it was intrinsic motivation measured at end-point that was associated with cognitive change (p = .02).

DISCUSSION

While awareness of cognitive problems may not be a prerequisite for cognitive improvement during CR, it could impact engagement in, and how one values treatment via its effect on perceived competency. Results also highlighted the importance of intrinsic motivation for doing cognitive learning activities, given its relationship to cognitive gain. Further study is needed to understand how best to assess and address awareness of cognitive abilities within the CR setting.

Aerobic exercise and cognitive functioning in schizophrenia: Results of a 1-year follow-up from a randomized controlled trial

We previously reported that adding combined, individual, and group aerobic exercise (AE) interventions to the treatment as usual (TAU) for schizophrenia showed significant improvements in cognition and other outcomes compared to those with TAU alone in a randomized controlled trial. Following the promising results of our previous study, this 1-year follow-up study evaluated the improvements in cognition and other outcomes with TAU + AE compared to those with TAU alone. Of 41 randomized patients, 40 were included in the intent-to-treat population-20 in the TAU + AE and 20 in the TAU alone; all patients completed the 1-year follow-up. Mixed models were applied to assess changes in outcome measures over time from baseline to 1-year follow-up. At 1-year follow-up, the TAU + AE demonstrated significant group by time interaction effects in several cognitive domains, intrinsic motivation, negative symptom, interpersonal relations, and functional outcome compared with the TAU alone. Our results demonstrate that the improvements in cognition and other outcomes with TAU + AE were maintained and that functional outcome improved over 1-year follow-up. These findings show that the improvements sustained for each outcome over 1 year have the potential to offer opportunities for greater transitions to improvement of functional outcome.

Divergence of subjective and performance-based cognitive gains following cognitive training in schizophrenia

BACKGROUND

Cognitive training is effective for improving cognitive performance among people with schizophrenia. An individual's perception of their own cognition is dissociable from performance on objective cognitive tests. Since subjective cognitive benefit may impact engagement, motivation, and satisfaction with time-intensive cognitive interventions, this study aimed to determine whether subjective cognitive difficulties improve in conjunction with cognitive gains following 30 h of cognitive training.

METHODS

Patients with schizophrenia or schizoaffective disorder (N = 46) were randomized to treatment as usual (TAU) or TAU augmented with auditory-targeted cognitive training (TCT). All participants completed assessment batteries at baseline and follow-up. As previously reported, the TCT group showed significant improvements in verbal learning and memory and reductions in auditory hallucinations relative to the TAU group.

RESULTS

Subjective cognitive difficulties did not significantly improve following TCT, even among TCT participants who showed improvements in cognitive performance (all ps > 0.05). Subjective cognitive difficulties were significantly associated with severity of depressive symptoms and hallucinations (r = 0.48 and r = 0.28, p < 0.001), but not global or specific domains of cognition (all rs < 0.1) at baseline. There were no significant relationships between change in subjective cognitive difficulties and change in cognitive or clinical variables (all ps > 0.05).

DISCUSSION

Patients with schizophrenia do not detect change in their cognition following cognitive training, even among those who showed robust gains in cognitive performance. Failure to detect improvement may undermine treatment engagement, motivation, and satisfaction. Translating score improvements on the cognitive exercises into tangible metrics, and providing ongoing, clinician-delivered feedback on performance may facilitate patient ability to detect improvements and improve motivation to engage with cognitive training interventions.