The remediation of problem-solving skills in schizophrenia

Computerized social cognitive training in the subacute phase after traumatic brain injury: A quasi-randomized controlled trial

OBJECTIVES

To assess the usefulness of a computerized tasks module designed for the rehabilitation of social cognition (SC) in acquired brain injury.

METHODS

Quasi-randomized controlled trial (ClinicalTrials.gov:NCT03479970) involving 45 patients with moderate-severe traumatic brain injury (TBI) in a subacute inpatient rehabilitation hospital. The experimental group (n = 28) received treatment with a computerized SC module in combination with a non-SC module. The control group (n = 26) only received a treatment with non-SC module.

RESULTS

Intragroup comparisons showed that the experimental group had better results for all SC measures, except for International Affective Picture System (IAPS). The control group improved for Facial Expressions of cEmotion-Stimuli and Tests (FEEST) and Moving Shapes Paradigm (MSP), showing no changes with respect to pretreatment in IAPS, MSP and Reading the Mind in the Eyes Test (RMET). Intergroup comparisons did not present differences between the two groups for pretreatment measures. Post-treatment comparison showed that the experimental group obtained better results for RMET than the control group.

CONCLUSION

The computerized SC module was useful for the rehabilitation of SC in patients with moderate-severe TBI in the subacute phase. The group that received combined rehabilitative treatment (SC + non-SC) obtained better results for SC than the group that received treatment intended only for non-SC.

Predictors of treatment discontinuation during an 18-month multi-site randomized trial of Cognitive Enhancement Therapy for early course schizophrenia

Treatment discontinuation during clinical trials in schizophrenia is a critical challenge, especially for longer-term interventions in the early course. This research explored predictors of treatment discontinuation in an outpatient early course schizophrenia sample (N = 102) during an 18-month multi-site trial of Cognitive Enhancement Therapy (n = 58) and Enriched Supportive Therapy (n = 44). Fifty-three (52%) participants discontinued, with no significant difference between the treatment groups in discontinuation rate. Univariate and multivariate binary logistic regression models explored differences in key demographic and cognitive and behavioral outcomes between participants who completed and discontinued treatment. Significant multivariate predictors of discontinuation included IQ (linear) and problem solving (curvilinear). The concave shape of the problem solving prediction demonstrated that initially as scores were increasing the probability of non-completion was increasing. However, after a score of 41 (below average problem solving), the probability of being a non-completer decreased as performance increased. Non-completers had significantly lower IQ scores compared to completers. Post-hoc analyses indicated that participants who discontinued prior to mid-treatment exhibited the greatest intellectual challenges, with comparisons moderate-to-large in strength. IQ and problem solving are likely important factors to assess at pre-treatment in early course schizophrenia trials to identify those most vulnerable to discontinuation.

Effect of combining motivational interviewing with cognitive remediation on personal recovery in patients with schizophrenia

Background/objective

We have been practising the Neuropsychological and Educational Approach to Remediation (NEAR) as cognitive remediation (CR) in a psychiatric hospital and have implemented it in combination with regular interviews based on Motivational Interviewing (MI) approximately 2 years after launching NEAR. In this study, we investigated whether combining MI with CR affected completion of the programme, cognitive functions, global functioning, and personal recovery of patients with schizophrenia by analysing medical records.

Methods

In this retrospective observational study, 14 participants were assigned to the NEAR group and 12 participants were assigned to the NEAR + MI group. Fifteen participants in the NEAR group (n = 6) and NEAR + MI group (n = 9) completed the programme. First, the difference in the completion rate between the groups was examined using the chi-squared test. Second, measures of cognitive functions, global functioning, and personal recovery pre-and post-intervention were examined using the Wilcoxon signed-rank tests for those in each group who completed the programme. Third, therapeutic responses for each group were compared using the Mann-Whitney U tests.

Results

There were no statistically significant differences in completion rates between the groups. In the NEAR group, verbal memory and overall cognition improved after the intervention. On the other hand, not only cognitive functions but also global functioning and personal recovery improved in the NEAR + MI group. Moreover, changes in global functioning and personal recovery were significantly higher in the NEAR + MI group.

Conclusion

Study findings indicated that combining MI with CR improves cognitive functions, global functioning, and personal recovery in patients with schizophrenia.

"Goals in Focus"-a targeted CBT approach for motivational negative symptoms of psychosis: study protocol for a randomized-controlled feasibility trial

BACKGROUND

The reduction of goal-directed behavior is the main characteristic in motivational negative symptoms of psychosis as it accounts for the long-term decline in psychological well-being and psychosocial functioning. However, the available treatment options are largely unspecific and show only small effects on motivational negative symptoms. Interventions that directly target the relevant psychological mechanisms are likely to be more effective. For "Goals in Focus", we translated findings from basic clinical research on mechanisms underlying motivational negative symptoms into a tailored and comprehensive novel psychological outpatient treatment program. With this study, we will test the feasibility of the therapy manual and the trial procedures. We also aim to examine first estimates of the effect size that can be expected from "Goals in Focus" to inform the sample size calculation of a subsequent fully powered trial.

METHODS

Thirty participants diagnosed with a schizophrenia spectrum disorder and at least moderate motivational negative symptoms will be randomly assigned to either 24 sessions of "Goals in Focus" over the course of 6 months (n = 15) or to a 6-month wait-list control group (n = 15). Single-blind assessments will be conducted at baseline (t₀) and 6 months after baseline completion (t₁). Feasibility outcomes include patient recruitment, retention, and attendance rates. Acceptability will be rated by trial therapists and by participants at end of treatment. Primary outcome for effect size estimation is the motivational negative symptom subscale sum score of the Brief Negative Symptom Scale at t₁ corrected for baseline values. Secondary outcomes include psychosocial functioning, psychological well-being, depressive symptoms, expressive negative symptoms, negative symptom factor scores, and goal pursuit in everyday life.

DISCUSSION

The feasibility and acceptability data will be used to improve trial procedures and the "Goals in Focus" intervention where necessary. The treatment effect on the primary outcome will provide the basis for the sample size calculation for a fully powered RCT.

TRIAL REGISTRATION

1) ClinicalTrials.gov, NCT05252039 . Registered on 23 February 2022. 2) Deutsches Register Klinischer Studien, DRKS00018083 . Registered on 28 August 2019.

Factors Affecting Employability of Patients with Schizophrenia who had First Participated in Vocational Training: A Pilot Study

While vocational training may offer financial and health benefits for patients with schizophrenia (PwS), further empirical research is required to investigate the effectiveness of this intervention for PwS, as well as the factors influencing their employability. This study aimed to (i) identify the factors affecting the employability of PwS who had participated in vocational training and (ii) examine the effectiveness of vocational training. This prospective cohort study was conducted in a community rehabilitation center attached to a psychiatric hospital in southern Taiwan that provides vocational training. The participants completed two questionnaires: (i) a pre-test that served as the study's baseline; (ii) a post-test during a follow-up 12 months later. The questionnaire was divided into three parts: (i) participants' basic information, (ii) the work performance scale, and (iii) the mental state measure. The participants included 35 males and 30 females, with the average age being 45.85 years. The significant factors affecting their employability were social support, work behavior, thinking disorder, and cognitive impairment. In other words, participants with better social support, work behavior, and fewer thought disorders and cognitive impairment were more employable. Their work attitude and ability were found to have significantly improved after having participated in vocational training for 12 months. In conclusion, when conducting vocational training in the future, it is necessary to pay attention to individual participants' social support and work behavior and reduce thinking disorders and cognitive impairments. This may help improve the employability of PwS.

Effects of exercise on cognitive functioning in adults with serious mental illness: A meta analytic review

Cognitive performance is usually impaired in those with serious mental illness (SMI). Exercise may improve cognitive functioning, but studies examining the effects of exercise in SMI indicate heterogenous findings. To estimate the effects of exercise on cognitive outcomes in people with SMI. Randomized controlled trials evaluating the acute or chronic effects of exercise on cognitive functioning in SMI were searched from inception to December 26th, 2022 on major electronic databases. Random effect meta-analyses were conducted to assess the effects of exercise on over the cognitive domains and Standardized Mean Differences (SMD) and 95% confidence intervals (CIs) were used as the effect size measure. Funnel plots and Egger's test of effect size and the Trim and Fill procedure applied if evidence of publication bias was noted. Methodological quality was assessed using RoB 2. A total of 15 chronic (1 acute), 936 participants (46.7% women). Exercise showed large effects on reasoning and problem solving; small effects on executive functioning. Per diagnosis, exercise showed moderate positive effects on executive functioning and large effects on processing speed in people with depression; large effects on reasoning and problem solving in people with schizophrenia. The present study indicates a large beneficial effect of chronic physical exercise on reasoning and problem solving and small effects on executive functioning in people with SMI.

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.

The MATRICS Consensus Cognitive Battery: An Update

Through a series of NIMH-supported consensus-building meetings of experts and empirical comparisons of candidate tests, the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative developed a battery of standardized cognitive measures to allow reliable evaluation of results from clinical trials of promising interventions for core cognitive deficits in this disorder. Ten tests in seven cognitive domains were selected for the MATRICS Consensus Cognitive Battery (MCCB). The MCCB has now been translated into 39 languages/dialects and has been employed in more than 145 clinical trials. It has become the standard cognitive change measure for studies of both pharmacological and training-based interventions seeking to improve cognitive deficits in schizophrenia. We summarize its applications and its relationship to the subsequent development of the NIMH RDoC Matrix.

Does the virtual shopping training improve executive function and instrumental activities of daily living of patients with mild cognitive impairment?

To date, ecological validity of virtual shopping training for patients with mild cognitive impairment (MCI) has not been confirmed yet. Main objective of this study was to investigate effects of virtual shopping training on executive function and instrumental activities of daily living (IADL) in patients with MCI. 32 patients with MCI were randomly assigned to the experimental group that received virtual shopping training or the waitlist control group for a total of 16 sessions. To examine effects of virtual shopping training on executive function and IADL, Korean version of the Executive Function Performance Test (EFPT-K) and Korean Instrumental Activities of Daily living (K-IADL) were conducted. After the 16 sessions, the experimental group showed greater improvement in the EFPT-K (p < 0.001) and the K-IADL (p < 0.001) compared to the control group. These results suggest that virtual shopping training might be clinically beneficial to enhance executive function and IADL in patients with MCI.

Executive Function Skills Are Linked to Restricted and Repetitive Behaviors: Three Correlational Meta Analyses

There is a consensus on the centrality of restricted and repetitive behaviors (RRBs) in the diagnosis of Autism Spectrum Disorder (ASD), yet the origins of these behaviors are still debated. We reconsider whether executive function (EF) accounts of RRBs should be revisited. EF deficits and high levels of RRBs are often pronounced in individuals with ASD and are also prevalent in young typically developing children. Despite this, the evidence is mixed, and there has been no systematic attempt to evaluate the relationship across studies and between task batteries. We examine recent evidence, and in three highly powered random-effects analyses (N = 2964), examine the strength of the association between RRB levels and performance on set shifting, inhibitory control, and parental-report based EF batteries. The analyses confirm significant associations between high levels of the behaviors and poor EF skills. Moreover, the associations remained stable across typical development and in individuals with ASD and across different types of EF measures. These meta-analyses consolidate recent evidence identifying that cognitive mechanisms correlate with high RRBs that are seen in individuals with ASD, as well as in typical development. We propose that the EF account may be critical for guiding future interventions in ASD research. LAY SUMMARY: Restricted and repetitive behaviors (RRBs) are diagnostic criteria for Autism yet also common in typical development, and if they persist over time some can have a negative impact on learning and social acceptance. The present meta-analyses found that high levels of RRBs related to poor performance on set-shifting and inhibitory control tasks, as well as high ratings on parental report scales. Future studies should create interventions that aim to improve these skills as they may help manage challenging RRBs.

Recovery in Supported Accommodations: A Scoping Review and Synthesis of Interventions for People with Severe Mental Illness

Research on the recovery domains beside clinical recovery of people with severe mental illness in need of supported accommodations is limited. The aim of this study was (1) to investigate which recovery interventions exist for this group of people and (2) to explore the scientific evidence. We conducted a scoping review, including studies with different designs, evaluating the effectiveness the recovery interventions available. The search resulted in 53 eligible articles of which 22 focused on societal recovery, six on personal recovery, five on functional recovery, 13 on lifestyle-interventions, and seven on creative and spiritual interventions. About a quarter of these interventions showed added value and half of them initial promising results. The research in this area is still limited, but a number of recovery promoting interventions on other areas than clinical recovery have been developed and evaluated. Further innovation and research to strengthen and repeat the evidence are needed.

Cognitive remediation for inpatients with psychosis: a systematic review and meta-analysis

Cognitive difficulties are common in people with psychosis and associated with considerable disability. Cognitive remediation (CR) can reduce the burden of cognitive difficulties and improve functioning. While mental health care has predominantly shifted to the community, people with greater illness severity and complexity, and those with poor response to treatment and concomitant greater cognitive difficulties, continue to receive inpatient care. The aim of this study is to review and evaluate the acceptability and efficacy of CR for inpatients with psychosis. A systematic search was used to identify randomized controlled trials of CR for inpatients with psychosis. Demographic and clinical information was extracted by independent raters together with therapy outcomes. Study quality was assessed using the Cochrane Collaboration Risk of Bias Assessment tool. Standardized mean change for cognitive and functional outcomes was calculated using Hedges's g and used to infer therapy effects with meta-analysis. Twenty studies were identified considering 1509 participants. Results from random-effect models suggested that CR was effective in improving processing speed (g = 0.48), memory (g = 0.48) and working memory (g = 0.56). While there was an indication of improvements in the levels of vocational, social and global functioning, these were less reliable. On average, 7% of participants dropped-out of treatment. Studies methodological quality was moderate. CR is an acceptable intervention for inpatients with psychosis and can lead to significant cognitive improvements. Evidence for improvement in functioning requires more robust and converging evidence. Future research should extend the evaluation of inpatient CR to subsequent post-discharge community functioning and further need for care.

Is a program to improve grocery-shopping skills clinically effective in improving executive function and instrumental activities of daily living of patients with schizophrenia?

To date, cognitive intervention to improve executive function for patients with schizophrenia has not been ecologically validated. Our main objective was to investigate the effectiveness of grocery shopping skill program on executive function and instrumental activities of daily living (IADL) of patients with schizophrenia. Among 20 patients with schizophrenia who received conventional rehabilitation, 10 patients were allocated to an experimental group and they additionally performed the program to improve grocery shopping skill in a real situation for eight sessions. The rest of participants were assigned to the wait-list group. To identify the effects on executive function, the Korean version of the Executive Function Performance Test (EFPT-K) was used. IADL was evaluated using the Korean Instrumental Activities of Daily Living (K-IADL). After the sessions, the EFPT-K (p < .001) and K-IADL (p < .05) were significantly improved in the experimental group. These results indicate that the program to improve grocery shopping skills might be clinically beneficial to enhance executive function and IADL of patients with schizophrenia.

A systematic review of factors that influence the efficacy of cognitive remediation therapy in schizophrenia

OBJECTIVE

Cognitive remediation therapy is a moderately effective intervention for ameliorating cognitive deficits in individuals with schizophrenia-related disorders. With reports of considerable variability in individual response to cognitive remediation therapy, we need to better understand factors that influence cognitive remediation therapy efficacy to realise its potential. A systematic review was conducted to identify and evaluate predictors of cognitive outcome.

METHODS

An electronic database search was conducted identifying peer-reviewed articles examining predictors of cognitive response to cognitive remediation therapy.

RESULTS

A total of 40 articles accounting for 1681 cognitive remediation therapy participants were included; 81 distinct predictors of cognitive response were identified. Data synthesis and discussion focused on 20 predictors examined a minimum three times in different studies. Few of the examined predictors of cognitive outcome following cognitive remediation therapy were significant when examined through systematic review. A strong trend was found for baseline cognition, with reasoning and problem solving and working memory being strongly predictive of within-domain improvement. Training task progress was the most notable cross-domain predictor of cognitive outcome.

CONCLUSION

It remains unclear why a large proportion of participants fail to realise cognitive benefit from cognitive remediation therapy. However, when considering only those variables where a majority of articles reported a statistically significant association with cognitive response to cognitive remediation therapy, three stand out: premorbid IQ, baseline cognition and training task progress. Each of these relates in some way to an individual's capacity or potential for change. There is a need to consolidate investigation of potential predictors of response to cognitive remediation therapy, strengthening the evidence base through replication and collaboration.

Effects of cognitive remediation therapy versus other interventions on cognitive functioning in schizophrenia inpatients

Computerised cognitive remediation therapy (CCRT) has been shown to improve cognitive function in individuals with schizophrenia beyond effects of other forms of therapy. However, results vary between studies, and most are aimed at individuals who are living in the community. Very few studies have investigated its efficacy in psychiatric wards in order to assess whether or not this is a suitable site to start the therapy. This study evaluated CCRT efficacy among schizophrenia inpatients who received a broad range of therapeutic interventions in a psychiatric ward. A randomised controlled trial of CCRT versus an active control in 66 young inpatients with a diagnosis of schizophrenia was conducted. The intervention lasted for 6 weeks and its efficacy was assessed with the composite score of the MATRICS Consensus Cognitive Battery. Both groups improved similarly in cognitive function and psychopathological symptoms. However, the CCRT group improved more than the controls in negative symptoms. This result shows that providing a drill and practice cognitive remediation to inpatients does not produce benefits for cognitive functioning substantially greater than other forms of therapy provided in a ward, but it is more efficient in reduction of negative symptoms. Our results suggest that CRT might be considered as a promising intervention for reducing negative symptoms in schizophrenia individuals.

The efficacy of computerized cognitive drill and practice training for patients with a schizophrenia-spectrum disorder: A meta-analysis

BACKGROUND

Computerized methods for improving cognitive functioning in schizophrenia have gained popularity during the past decades. Therefore, this study evaluates the available evidence for the efficacy of computerized cognitive drill and practice training for patients with schizophrenia-spectrum disorders.

METHODS

A systematic search was carried out using PubMed, Embase, Cochrane Database of Systematic Reviews, and PsycINFO. A meta-analysis was performed to compare cognitive drill and practice training in patients with a schizophrenia-spectrum disorder with non-cognitively oriented control conditions. The primary outcome was cognitive functioning. Secondary outcome measures included psychotic symptoms, depressive symptoms, and functional outcomes. Effect sizes (ES) for all included studies were calculated as Hedges' g.

RESULTS

24 studies were included with 1262 patients in total. Compared to a control condition, patients receiving computerized cognitive drill and practice training showed significantly more improvement on attention (ES = 0.31, p = 0.001), working memory (ES = 0.38, p < 0.001), positive symptoms (ES = 0.31, p = 0.003), and depressive symptoms (ES = 0.37, p = 0.002). Small, marginally significant effect sizes were found for processing speed, verbal and visual learning and memory, and verbal fluency. However, significant effects on functional outcomes and social cognition were absent.

DISCUSSION

The current study showed evidence for the efficacy of computerized cognitive drill and practice training in patients with schizophrenia-spectrum disorders. However, the absence of effects on social cognition and functional outcomes questions the generalization of treatment effects. Together, these results stimulate further development of computerized training programs for schizophrenia that not only improve cognitive functioning, but also generalize cognitive improvement to functional outcomes.

Cognitive Remediation in Middle-Aged or Older Inpatients with Chronic Schizophrenia: A Randomized Controlled Trial in Korea

Background: Accumulating evidence indicates that cognitive remediation (CR) is effective for improving various cognitive deficits in adult patients with schizophrenia. Although reports of brain plasticity in older adults and the service needs for chronic patients with schizophrenia are increasing, very few randomized controlled trials of CR have been conducted in middle-aged or older inpatients with chronic schizophrenia. We investigated the efficacy of individualized CR on the cognitive impairments of middle-aged or older inpatients with chronic schizophrenia within the context of comprehensive psychiatric rehabilitation (PR) by comparing the results obtained with PR only and treatment as usual (TAU). Method: Fifty-seven middle-aged and older individuals with chronic schizophrenia and mild to moderate cognitive deficits were enrolled. Thirty-eight who were undergoing PR were randomly assigned to CR + PR (N = 19) or PR-only (N = 19) groups. Nineteen participants who were undergoing TAU without CR or PR were evaluated pre- and post-treatment. Results: CR was easily provided and well received (drop-out rates = 5.3%) by middle-aged or older psychiatric inpatients. Compared to the PR-Only or TAU patients, patients in the CR + PR group showed greater improvement in executive functioning. Compared to TAU patients, CR + PR and PR-only patients showed greater improvement in logical memory. More patients in the CR + PR group improved clinically significantly in executive functioning and logical memory, compared with the PR-only and TAU patients. Conclusions: These results suggested that CR improved some cognitive deficits in middle-aged or older inpatients with chronic schizophrenia and that it was effective as an adjunctive treatment to the usual PR services provided in inpatient settings. Clinical Registration: KCT0002609.

Effects of cognitive remediation on cognitive and social functions in individuals with schizophrenia

Individuals with schizophrenia exhibit cognitive impairments, which are related to impairments in social functions. This study investigated the effects of cognitive remediation on cognitive, social, and daily living impairment. Participants were individuals with schizophrenia between 20 and 60 years old (N = 44). Participants were randomly assigned to two groups: a cognitive remediation intervention group and a non-intervention control group. The control group was provided with conventional drug therapy and either day care or occupational therapy. The intervention group was provided with the "neuropsychological educational approach to cognitive remediation" developed by Medalia and co-workers. We assessed cognitive functions using the brief assessment of cognition in schizophrenia (BACS), and evaluated social and daily living functions using the global assessment of functioning (GAF) scale. Significant group by time interaction effects indicated that verbal memory, working memory, attention, and executive function showed significantly greater improvement at post-intervention for the intervention group than the control group. Social and daily living function also improved in the intervention group and improvements were maintained one year after intervention. These preliminary findings indicate that the combination of cognitive remediation and psychiatric rehabilitation is effective for facilitating improvements in cognitive function and social and daily living functions in individuals with schizophrenia.

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

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

Targeting anxiety to improve quality of life in patients with schizophrenia

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Neuroscience-informed computer-assisted cognitive training in schizophrenia

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

A review of cognitive remediation approaches for schizophrenia: from top-down to bottom-up, brain training to psychotherapy

INTRODUCTION

Individuals with psychotic disorders experience profound impairment in neurocognition, which is consistently found to be the best predictor of independent community functioning. Several diverse behavioural treatments designed to enhance neurocognitive abilities have been developed, with subtle to stark differences among them. Various approaches, to varying degrees, have demonstrated success across diffuse outcomes: improved brain structure and function, performance on neuropsychological tests, and community activities associated with daily living. Areas covered: This paper reviews the different approaches to cognitive remediation and the differential effects these approaches have on neurophysiological function, neurocognitive abilities, and real-world community functioning. Cognitive remediation approaches can be broadly classified along two dimensions: 1) treatment target, and 2) treatment modality. Some approaches target more basic perceptual skills, some target higher level executive processes, while some are non-targeted and seek to improve general cognitive ability. With regard to modality, approaches might have little/no therapist involvement and rely exclusively on computerized practice or they may include intensive therapist involvment to generalize neurocognitive change to community functioning. Expert commentary: Compared to other widely implemented treatments for schizophrenia, cognitive remediation produces better effects on outcome measures. It is time for cognitive remediation to be adopted as a best practice in the treatment of schizophrenia.

Adherence to a Low-Support Cognitive Remediation Training Program for Psychosis

Cognitive remediation (CR) has emerged as the treatment of choice for impaired cognition in psychosis. However, little is known about adherence rates and factors predicting adherence to CR, particularly in clinical settings where high-level therapist support is unavailable. This study aimed to establish adherence rates and examine variables predicting adherence to a computerized CR program for psychosis (with minimal support). Patients with psychosis (n = 61) participated in an 8-week CR program. Results showed 46% completed a meaningful amount of CR training. The fully adherent (>80% of the prescribed amount) and nonadherent groups differed where adherent participants had poorer working-memory and higher negative symptom scores. These findings suggest that approximately half of the sample were adherent to treatment despite minimal therapist support. Furthermore, higher cognitive deficits and negative symptoms did not impede adherence, and may have contributed to patients' motivation to complete the program.

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.

Computerized Exercises to Promote Transfer of Cognitive Skills to Everyday Life

In recent years, computerized and non-computerized cognitive remediation programs have been designed for both individual and group settings. We believe, however, that a common misconception lies in considering the efficiency of a cognitive remediation therapy as resulting from the sole use of a computer. This omits that metacognitive skills need also to be trained throughout the remediation phase. RECOS is a theory-based therapeutic approach designed to promote the transfer of cognitive skills to functional improvements. It involves working with one person at a time using both paper/pencil tasks and a set of interactive computer exercises. Paper/pencil exercises are used to promote problem-solving techniques and to help patients to find appropriate suitable strategies. During the following computerized 1-h session, therapists guide participants to the procedural dimension of the action, which refers to knowledge about doing things and relies on retrospective introspection. We assume that each patient has a rich and underestimated procedural knowledge he/she is not aware of. By providing complex and interactive environments, computerized exercises are recommended to bring this knowledge to light. When strategies used by the participant become conscious, conditional knowledge determines when and why to use them in real-life situations.

Computerised working-memory focused cognitive remediation therapy for psychosis--A preliminary study

BACKGROUND

Cognitive deficits are a core feature of schizophrenia and related psychotic disorders and are associated with decreased levels of functioning. Behavioural interventions have shown success in remediating these deficits; determining how best to maximise this benefit while minimising the cost is an important next step in optimising this intervention for clinical use.

AIMS

To examine the effects of a novel working-memory focused cognitive remediation (CR) training on cognitive difficulties based on internet delivery of training and weekly telephone support.

METHOD

Participants with a diagnosis of psychosis (n=56) underwent either 8 weeks of CR (approximately 20 h) or 8 weeks of treatment as usual (TAU). General cognitive ability, working memory and episodic memory were measured both pre and post intervention for all participants.

RESULTS

In addition to improvements on trained working memory tasks, CR training was associated with significant improvements in two tests of verbal episodic memory. No association between CR and changes in general cognitive ability was observed. Effect sizes for statistically significant changes in memory were comparable to those reported in the literature based primarily on 1:1 training.

CONCLUSIONS

The cognitive benefits observed in this non-randomised preliminary study indicate that internet-based working memory training can be an effective cognitive remediation therapy. The successes and challenges of an internet-based treatment are discussed.

Social skills programmes for schizophrenia

BACKGROUND

Social skills programmes (SSP) are treatment strategies aimed at enhancing the social performance and reducing the distress and difficulty experienced by people with a diagnosis of schizophrenia and can be incorporated as part of the rehabilitation package for people with schizophrenia.

OBJECTIVES

The primary objective is to investigate the effects of social skills training programmes, compared to standard care, for people with schizophrenia.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (November 2006 and December 2011) which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. We inspected references of all identified studies for further trials.A further search for studies has been conducted by the Cochrane Schizophrenia Group in 2015, 37 citations have been found and are currently being assessed by review authors.

SELECTION CRITERIA

We included all relevant randomised controlled trials for social skills programmes versus standard care involving people with serious mental illnesses.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated risk ratios (RRs) and their 95% confidence intervals (CI) on an intention-to-treat basis. For continuous data, we calculated mean differences (MD) and 95% CIs.

MAIN RESULTS

We included 13 randomised trials (975 participants). These evaluated social skills programmes versus standard care, or discussion group. We found evidence in favour of social skills programmes compared to standard care on all measures of social functioning. We also found that rates of relapse and rehospitalisation were lower for social skills compared to standard care (relapse: 2 RCTs, n = 263, RR 0.52 CI 0.34 to 0.79, very low quality evidence), (rehospitalisation: 1 RCT, n = 143, RR 0.53 CI 0.30 to 0.93, very low quality evidence) and participants' mental state results (1 RCT, n = 91, MD -4.01 CI -7.52 to -0.50, very low quality evidence) were better in the group receiving social skill programmes. Global state was measured in one trial by numbers not experiencing a clinical improvement, results favoured social skills (1 RCT, n = 67, RR 0.29 CI 0.12 to 0.68, very low quality evidence). Quality of life was also improved in the social skills programme compared to standard care (1 RCT, n = 112, MD -7.60 CI -12.18 to -3.02, very low quality evidence). However, when social skills programmes were compared to a discussion group control, we found no significant differences in the participants social functioning, relapse rates, mental state or quality of life, again the quality of evidence for these outcomes was very low.

AUTHORS' CONCLUSIONS

Compared to standard care, social skills training may improve the social skills of people with schizophrenia and reduce relapse rates, but at present, the evidence is very limited with data rated as very low quality. When social skills training was compared to discussion there was no difference on patients outcomes. Cultural differences might limit the applicability of the current results, as most reported studies were conducted in China. Whether social skills training can improve social functioning of people with schizophrenia in different settings remains unclear and should be investigated in a large multi-centre randomised controlled trial.

The effect of cognitive training on evoked potentials in schizophrenia

Electrophysiological indices are sensitive to cognitive dysfunction in schizophrenia but have rarely been used to assess benefits of cognitive remediation. Our aim was to evaluate the effect of specific cognitive training approaches on event-related potentials.

Forty-six patients with schizophrenia underwent either auditory (AUD) or visuo-spatial (VIS) cognitive training or treatment-as-usual (TAU). Cognitive training was computer-assisted and administered for 10 sessions within two weeks. Event-related potentials during an active odd-ball paradigm together with clinical and neuropsychological variables were assessed before and after training and again at a two-month follow-up.

Compared to the TAU group both the AUD and VIS training groups showed decreased P2 latency following training. At follow-up, the P2-latency reduction was stable in the VIS group but the AUD group experienced a relapse. Training resulted in improved digit-span backward among neuropsychological variables. Increased P2 amplitude was related to more positive symptoms and lower social-occupational functioning and longer P2 latency was associated with greater severity of stereotyped thinking.

The more general visuo-spatial training appears to have a longer-lasting effect on P2 latency than the specific auditory training. Alternatively, there may be specific auditory discrimination deficits in schizophrenia requiring more extensive training for a stable change.

Developing a Cognitive Training Strategy for First-Episode Schizophrenia: Integrating Bottom-Up and Top-Down Approaches

It is clear that people with schizophrenia typically have cognitive problems in multiple domains as part of their illness. The cognitive deficits are among the main contributors to limitations in their everyday functioning, including their work recovery. Cognitive remediation has been applied successfully to help people with long-term, persistent schizophrenia to improve their cognitive functioning, but it is only beginning to be applied with individuals who have recently had a first episode of psychosis. Several different approaches to cognitive training have been developed. Some approaches emphasize extensive systematic practice with lower-level cognitive processes and building toward higher-level processes ("bottom-up"), while others emphasize greater focus on high-level cognitive processes that normally integrate and organize lower-level processes ("top-down"). Each approach has advantages and disadvantages for a disorder like schizophrenia, with its multiple levels of cognitive dysfunction. In addition, approaches to cognitive remediation differ in the extent to which they systematically facilitate transfer of learning to everyday functioning. We describe in this article the cognitive training approach that was developed for a UCLA study of people with a recent first episode of schizophrenia, a group that may benefit greatly from early intervention that focuses on cognition and recovery of work functioning. This approach integrated bottom-up and top-down computerized cognitive training and incorporated an additional weekly group session to bridge between computerized training and application to everyday work and school functioning.

A systematic review on improving cognition in schizophrenia: which is the more commonly used type of training, practice or strategy learning?

BACKGROUND

The purpose of this article was to conduct a review of the types of training offered to people with schizophrenia in order to help them develop strategies to cope with or compensate for neurocognitive or sociocognitive deficits.

METHODS

We conducted a search of the literature using keywords such as "schizophrenia", "training", and "cognition" with the most popular databases of peer-reviewed journals.

RESULTS

We reviewed 99 controlled studies in total (though nine did not have a control condition). We found that drill and practice training is used more often to retrain neurocognitive deficits while drill and strategy training is used more frequently in the context of sociocognitive remediation.

CONCLUSIONS

Hypotheses are suggested to better understand those results and future research is recommended to compare drill and strategy with drill and practice training for both social and neurocognitive deficits in schizophrenia.

The feasibility of cognitive adaptation training for outpatients with schizophrenia in integrated treatment

Cognitive adaptation training (CAT) has been tested as a psychosocial treatment, showing promising results. To date there are no reported tests of CAT treatment outside the United States. Thus, we decided to adjust CAT treatment and apply it to an Integrated Treatment setting in Denmark. In this article we describe and discuss the feasibility of using CAT treatment in a randomized clinical trial in Denmark. The treatment period was shorter and the patients were instructed in prompting for specific actions by using newer tools such as schedules in their mobile phones. Social functioning, symptoms and quality of life were assessed using instruments validated in a Danish context. It was judged that, after some adjustments to fit the Danish assertive community treatment, CAT treatment was feasible in a Danish setting.

Computer-assisted cognitive remediation therapy: cognition, self-esteem and quality of life in schizophrenia

BACKGROUND

Quality of life (QoL) is an important outcome in the treatment of schizophrenia. Cognitive deficits have an impact on functional outcomes. Cognitive remediation therapy is emerging as a psychological intervention that targets cognitive impairment, but the effect of computer-assisted cognitive remediation on neuropsychology and social functioning and wellbeing remains unclear. The aim of the current study is to investigate the neurocognitive outcomes of computer-assisted cognitive remediation (CACR) therapy in a sample of schizophrenia patients, and to measure the quality of life and self-esteem as secondary outcomes.

METHODS

Sixty-seven people with schizophrenia were randomly assigned to computer-assisted cognitive remediation or an active control condition. The main outcomes were neuropsychological measures and secondary outcomes (self-esteem and quality of life). Measurements were recorded at baseline and post-treatment.

RESULTS

The CACR therapy group improved in speed of processing, working memory and reasoning and problem-solving cognitive domains. QoL and self-esteem measures also showed significant improvements over time in this group.

CONCLUSIONS

Computer-assisted cognitive remediation therapy for people with schizophrenia achieved improvements in neuropsychological performance and in QoL and self-esteem measurements.

Current trends in the empirical study of cognitive remediation for schizophrenia

Cognitive remediation (CR) for schizophrenia is a learning-based behavioural skills training intervention designed to enhance neuro and (or) social cognitive skills, with the ultimate goal of generalization to improve psychosocial outcomes. This review summarizes conceptual approaches to CR for schizophrenia and the evidence for efficacy in clinical research settings. Four issues are at the forefront of ongoing research: the identification of techniques that produce the largest cognitive change, delineation of techniques that enhance transfer of cognitive skills to functional skills, the identification of CR methods that can be personalized to meet the specific cognitive and functional needs of each individual, and, all the while, ensuring that when CR methods are developed in a research setting, they remain scalable for delivery in the larger clinical community. In response to these issues, 3 prominent research trends have emerged: the rise of a new generation of computerized restorative cognitive training, the integration of CR with skills training to promote generalization, and the application of techniques to enhance motivation and learning during CR. As data on the neural basis of learning in people with schizophrenia become available, new technologies that harness the ability of the brain to make sustainable, functional changes may be integrated within a therapeutic context that promotes a personalized approach to learning. The development of transportable and scalable methods of CR that maximize the ability of people with schizophrenia to improve cognition will help them achieve personal goals for recovery.

A virtual reality-based vocational training system (VRVTS) for people with schizophrenia in vocational rehabilitation

Employment provides schizophrenic patients with a positive identity and hope. Cognitive impairments have been suggested to slow down the progress in work rehabilitation. The purpose of this study was to investigate the efficacy and effectiveness of VR as a cognitive intervention for enhancing vocational outcomes. 95 inpatients with schizophrenia were randomly assigned to a virtual reality-based vocational training group (VRG), a therapist-administered group (TAG) and a conventional group (CG). Twenty-five of them in each group had completed the study. Their performances were evaluated, before and after interventions, by Brief Neuropsychological Cognitive Examination, Digit Vigilance Test, Rivermead Behavioural Memory Test, Wisconsin Card Sorting Test (WCST) and Vocational Cognitive Rating Scale. Patients in the VRG were found to perform better than patients in the TAG and CG in cognitive functioning, as shown by the WCST-percentage of error (F (2, 72)=7.146, p<0.001) and the WCST-percentage of conceptual level response (F (2, 72)=8.722, p<0.001). The post-hoc test revealed that the VRG showed a better performance than both the TAG (p=0.03) and the CG (p<0.001) in the WCST-percentage of error. The VRG also showed a better performance than patients in both the TAG (p=0.01) and the CG (p<0.001) in the WCST-percentage of conceptual level response. The VRG also showed a better self-efficacy score than CG. Both VRG and TAG showed a better work performance as reflected by the on-site tests. Further studies on the use of VR in schizophrenia rehabilitation and for vocational success are discussed.

Executive functions rehabilitation for schizophrenia: a critical systematic review

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Cognitive remediation for schizophrenia: current status, biological correlates and predictors of response

Cognitive remediation (CR) is an increasingly studied behavioral intervention for improving illness-linked cognitive deficits in schizophrenia, with considerable promise for improving the disease outcome when offered in concert with other therapies. We present findings from a comprehensive, critical review of the extant literature on CR for schizophrenia. Conclusions from six meta-analyses presented to date are summarized, and existing CR interventions are categorized into three major classes: restorative, strategy-based and hybrid approaches. The crucial elements and empirical support for each class are presented. Studies of predictors of treatment response suggest that attention, motivation and clinician expertise, along with the measures of 'brain reserve', are key features of a positive treatment response. Lastly, findings from studies of neuroimaging indicate that CR is accompanied by structural and functional neural changes in key frontal and temporal brain regions.

[What perspectives for cognitive remediation in schizophrenia?]

Cognitive deficits are routinely evident in schizophrenia, and are of sufficient magnitude to influence functional outcomes in work, social functioning and illness management. Cognitive remediation is an evidenced-based non-pharmacological treatment for the neurocognitive deficits seen in schizophrenia. Narrowly defined, cognitive remediation is a set of cognitive drills or compensatory interventions designed to enhance cognitive functioning, but from the vantage of the psychiatric rehabilitation field, cognitive remediation is a therapy which engages the patient in learning activities that enhance the neurocognitive skills relevant to their chosen recovery goals. Cognitive remediation programs vary in the extent to which they reflect these narrow or broader perspectives but a metaanalytic study reports moderate range effect sizes on cognitive test performance, and daily functioning. Reciprocal interactions between baseline ability level, the type of instructional techniques used, and motivation provide some explanatory power for the heterogeneity in patient response to cognitive remediation. Recent studies indicate that intrinsic motivation mediates the relationship between neurocognition and functional outcomes. Results of these studies suggest that intrinsic motivation should be a viable treatment target in cognitive remediation intervention. In this perspective, NEAR (Neuropsychological Educational Approach to Remediation) program was created to enhance intrinsic motivation by employing more engaging and interesting software packages for cognitive practice, involving consumers in choosing the focus of training and having the NEAR leader serve as a coach to engage the consumers in active guidance of their own treatment program.

Is there any impact of cognitive remediation on an ecological test in schizophrenia?

INTRODUCTION

Cognitive deficits are commonly reported in schizophrenia and have a significant impact on the daily life of patients and on their social and work inclusion. Cognitive remediation therapies (CRT) may enhance the capabilities of schizophrenia patients. Although social and work integration is the ultimate goal of CRT, previous studies have failed to carry out a detailed assessment of the effects on everyday life.

METHODS

Fifty-nine schizophrenia patients were randomised into two groups (remediation or usual treatment) to test the effects of a new remediation programme, which included both rehearsal and strategy learning, on cognitive functions. An ecological test was used to evaluate its transfer to daily living skills.

RESULTS

Cognitive improvements are revealed in CRT patients, mainly in memory and executive functions. Patients showing some deficiencies to perform the ecological test had better scores after the CRT. Moreover, they significantly improve their social activity scores.

CONCLUSIONS

CRT would facilitate mental load monitoring by enhancing or reallocating cognitive resources, facilitating the patient's organisation and autonomy. The rehearsal learning approach improves the ability to carry out automatic operations that are less demanding in terms of cognitive resources, thereby increasing the resources available for acquisition and efficient use of strategies provided during the strategy learning approach.

Thinking about the future cognitive remediation therapy--what works and could we do better?

This article reviews progress in the development of effective cognitive remediation therapy (CRT) and its translational process. There is now enough evidence that cognitive difficulties experienced by people with schizophrenia can change and that the agenda for the next generation of studies is to increase these effects systematically through cognitive remediation. We examine the necessary steps and challenges of moving CRT to treatment dissemination. Theories which have been designed to explain the effects of cognitive remediation, are important but we conclude that they are not essential for dissemination which could progress in an empirical fashion. One apparent barrier is that cognitive remediation therapies look different on the surface. However, they still tend to use many of the same training procedures. The only important marker for outcome identified in the current studies seems to be the training emphasis. Some therapies concentrate on massed practice of cognitive functions, whereas others also use direct training of strategies. These may produce differing effects as noted in the most recent meta-analyses. We recommend attention to several critical issues in the next generation of empirical studies. These include developing more complex models of the therapy effects that take into account participant characteristics, specific and broad cognitive outcomes, the study design, as well as the specific and nonspecific effects of treatment, which have rarely been investigated in this empirical programme.

Planning and problem-solving training for patients with schizophrenia: a randomized controlled trial

BACKGROUND

The purpose of this study was to assess whether planning and problem-solving training is more effective in improving functional capacity in patients with schizophrenia than a training program addressing basic cognitive functions.

METHODS

Eighty-nine patients with schizophrenia were randomly assigned either to a computer assisted training of planning and problem-solving or a training of basic cognition. Outcome variables included planning and problem-solving ability as well as functional capacity, which represents a proxy measure for functional outcome.

RESULTS

Planning and problem-solving training improved one measure of planning and problem-solving more strongly than basic cognition training, while two other measures of planning did not show a differential effect. Participants in both groups improved over time in functional capacity. There was no differential effect of the interventions on functional capacity.

CONCLUSION

A differential effect of targeting specific cognitive functions on functional capacity could not be established. Small differences on cognitive outcome variables indicate a potential for differential effects. This will have to be addressed in further research including longer treatment programs and other settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00507988.

Efficacy and specificity of computer-assisted cognitive remediation in schizophrenia: a meta-analytical study

BACKGROUND

Cognitive remediation is frequently based on computerized training methods that target different cognitive deficits. The aim of this article was to assess the efficacy of computer-assisted cognitive remediation (CACR) in schizophrenia and to determine whether CACR enables selective treatment of specific cognitive domains.

METHOD

A meta-analysis was performed on 16 randomized controlled trials evaluating CACR. The effect sizes of differences between CACR and control groups were computed and classified according to the cognitive domain assessed. The possible influences of four potential moderator variables were examined: participants' age, treatment duration, weekly frequency, and control condition type. To test the domain-specific effect, the intended goal of each study was determined and the effect sizes were sorted accordingly. The effect sizes of the cognitive domains explicitly targeted by the interventions were then compared with those that were not.

RESULTS

CACR enhanced general cognition with a mean effect size of 0.38 [confidence interval (CI) 0.20-0.55]. A significant medium effect size of 0.64 (CI 0.29-0.99) was found for Social Cognition. Improvements were also significant in Verbal Memory, Working Memory, Attention/Vigilance and Speed of Processing with small effect sizes. Cognitive domains that were specifically targeted by the interventions did not yield higher effects than those that were not.

CONCLUSIONS

The results lend support to the efficacy of CACR with particular emphasis on Social Cognition. The difficulty in targeting specific domains suggests a 'non-specific' effect of CACR. These results are discussed in the light of the possible bias in remediation tasks due to computer interface design paradigms.

Bridging the gap between extrinsic and intrinsic motivation in the cognitive remediation of schizophrenia

An important development in cognitive remediation of schizophrenia is a focus on motivation. However, following a distinction between the concepts of intrinsic motivation (IM) and extrinsic motivation, discussions of IM-based methods have downplayed or misrepresented the role that extrinsic rewards can, and actually do, serve to promote positive treatment outcomes in cognitive remediation. Therefore, the purpose of this article is to explore the rationale for using techniques incorporating extrinsic rewards into cognitive treatment of people with schizophrenia. To do this, evidence is presented on each of the following points: (1) there is a long history of research demonstrating that delivery of extrinsic reward is associated with positive outcomes in both behavioral and cognitive rehabilitation; (2) basic human brain systems respond strongly to tangible rewards, and this can directly enhance attention, working memory, and other cognitive functions; (3) nearly all data on the negative effects of extrinsic reward on IM have come from studies of healthy children and adults in school or work settings who have adequate IM for target tasks; these findings do not generalize well to cognitive remediation settings for people with schizophrenia, who often have abnormally low levels of IM and low base rates of attentive behaviors; and (4) in real-world situations, cognitive remediation interventions already utilize a combination of intrinsic and extrinsic reinforcers. Future studies are needed to clarify state and trait factors responsible for individual differences in the extent to which extrinsic rewards are necessary to set the conditions under which IM can develop.

In search of a theoretical structure for understanding motivation in schizophrenia

This themed issue considers different ways to conceptualize the motivational impairment that is a core negative symptom of schizophrenia. Motivational impairment has been linked to poor functional outcome, thus it is important to understand the nature and causes of motivational impairment in order to develop better treatment strategies to enhance motivation and engage patients in the process of recovery. Motivation refers to the processes whereby goal-directed activities are instigated and sustained and can be thought of as the product of a complex interaction of physiological processes and social contextual variables. In this issue, the physiological processes of motivation are the focus of Barch and Dowd, who highlight the role of prefrontal and subcortical mesolimbic dopamine systems in incentive-based learning and the difficulties people with schizophrenia have using internal representations of relevant experiences and goals to drive the behavior that should allow them to obtain desired outcomes. The articles in this issue by Choi et al., Nakagami et al., and Silverstein, focus on social contextual or environmental variables that can shape behavior and motivation. Together, these articles highlight the impact of external cues and goal properties on the expectations and values attached to goal outcomes. Expectancy-value and Self-Determination theories provide an overarching framework to accommodate the perspectives and data provided in all these articles. In the following introduction we show how the articles in this themed issue both support the role of expectancies and value in motivation in schizophrenia and elucidate possible deficiencies in the way expectations and value get assigned.

Measurement of functional capacity: a new approach to understanding functional differences and real-world behavioral adaptation in those with mental illness

The measurement of functional capacity in mental illness is an important recent development. Determination of functional capacity may serve as a surrogate marker for real-world functioning, thereby aiding clinicians in making important treatment determinations. This article provides an overview of a model of functioning, discusses the various areas of functioning relevant to real-world performance in persons with mental illness, and reviews existing measures that assess functional capacity. Limitations of existing methods of assessing functional capacity are discussed, and future areas of research are suggested.

A randomized controlled trial of cognitive remediation in schizophrenia

Individuals with schizophrenia have consistently been found to exhibit cognitive deficits, which have been identified as critical mediators of psychosocial functional outcomes. Recent reviews of cognitive remediation (CRT) have concluded that these deficits respond to training. This multi-site community study examined 40 individuals with schizophrenia who underwent cognitive remediation using the Neuropsychological Educational Approach to Remediation(1) (NEAR). Assessments using the same neuropsychological tests and measures of psychosocial outcome were made at four time points: baseline, before start of active intervention, end of active intervention and 4 months after end of active intervention. Dose of antipsychotic medication remained constant throughout the study period. After participating in NEAR, individuals showed significant improvements in verbal and visual memory, sustained attention and executive functioning. This effect persisted 4 months after the treatment ceased. The average effect size was mild to moderate. Social and occupational outcomes also improved from baseline to post-treatment, which persisted 4 months later. Our findings replicate those of previous studies that suggest that NEAR is effective in improving cognition in individuals with schizophrenia in a naturalistic and ecologically valid setting. Further it extends such findings to show a generalisation of effects to social/occupational outcomes and persistence of effects in the short term.

Computer-aided neurocognitive remediation as an enhancing strategy for schizophrenia rehabilitation

Cognitive dysfunction is a chronically disabling feature of schizophrenia, associated with limits in obtaining rehabilitation improvements. The purpose of this study is to assess the effectiveness of intensive computer-aided cognitive remediation treatment (CRT) added to a standard rehabilitation treatment (SRT), in enhancing neuropsychological performances and daily functioning in patients with schizophrenia. A 12-week, randomized, controlled, single-blind trial of neurocognitive remediation was carried out on 86 patients with clinically stabilized DSM-IV schizophrenia. Patients were assessed on cognitive and daily functioning before and after either CRT or placebo training that had been added to their SRT. After 3 months the repeated measure ANOVA showed a significant time x treatment interaction for executive function and attention performances and in daily functioning assessment in favour of patients in the SRT+CRT treatment. Results confirmed that cognitive remediation added to the SRT of schizophrenia enhanced its neuropsychological effects and increased the effects of a long-term rehabilitation programme in terms of functional outcomes.