Alice M. Saperstein

Does cognitive remediation for schizophrenia improve functional outcomes

Purpose of review Cognitive deficits are recognized as key determinants of functional outcome in schizophrenia. Cognitive remediation for schizophrenia, which is intended to improve both cognition and functional outcome, has been shown to impact cognition regardless of quality of trial methodology used. However, the impact of cognitive remediation on functional outcomes is more variable. A number of recently published articles specifically address the issues impacting the effectiveness of cognitive remediation at improving psychosocial outcomes. Recent findings In this review, studies published since 2011 have been summarized, with a particular focus on psychosocial outcomes. Cognitive remediation may include a focus on neurocognition and/or social cognition, but is increasingly integrative, targeting a range of cognitive skills. Psychosocial outcomes include quality of life, employment outcomes, academic functioning, and social functioning. Summary The reviewed literature indicates that cognitive remediation is most likely to impact functional outcome when individuals are given opportunities to practice the cognitive skills in real-world settings. By integrating a cognitive remediation program with psychosocial rehabilitation programs, functional outcomes are enhanced. Cognitive remediation programs that do not solely rely on drill and practice, but instead incorporate strategy teaching and methods to address beliefs and motivation, are associated with better psychosocial outcomes.

The Role of Motivation for Treatment Success

Learning during skills-based psychosocial treatments for schizophrenia is influenced by the motivating properties of the treatment context and the motivational orientation of the client. Given that motivational impairment is a core feature of schizophrenia with significant functional implications, intervention strategies emphasizing extrinsic and/or intrinsic goals may be prescribed to enhance skill learning and treatment outcomes. The purpose of this article is to consider the role that motivation plays in treatment success by evaluating the relationship between motivation and learning during cognitive remediation for schizophrenia. As intrinsic motivation (IM) is most often associated with learning, we will integrate research findings which address 3 main questions: (1) is IM in schizophrenia static or dynamic, (2) is it possible to manipulate the state of being intrinsically motivated and if so do manipulations of IM affect learning? and (3) can motivation theory be translated into clinical practice? This knowledge can facilitate treatment strategies to address the low base rate of IM that is characteristic of schizophrenia and can be applied to cognitive remediation as well as other psychosocial interventions which require learning for treatment success.

The relationship of trait to state motivation: The role of self-competency beliefs

Even when people with schizophrenia describe themselves as generally motivated and eager to engage in activities, they may not actually be motivated in the present moment. In order to better understand the relationship between trait and state motivation, we aimed to assess trait motivation and state intrinsic motivation, and investigate their relations to each other and to criterion-related variables including cognition, negative symptoms, and beliefs about ones own competency-also known as perceived competency (PC). Further, we investigated whether PC mediates the relationships between state intrinsic motivation (IM) and trait motivation dimensions. Forty individuals with schizophrenia or schizoaffective disorders were administered two self-report measures of motivation, the Motivational Trait Questionnaire (Kanfer, R., Ackerman, P., 2000. Individual differences in work motivation: further explorations of a trait framework. Appl. Psychol. 49 (3), 470-482) and the Intrinsic Motivation Inventory for Schizophrenia Research (Choi, J., Medalia, A., 2010. Intrinsic motivation and learning in a schizophrenia spectrum sample. Schizophr. Res. 118, 12-19), as well as measures of PC, cognition and symptoms. The results showed that in people with schizophrenia, trait approach motivation, but not trait avoidance motivation, is positively correlated with state intrinsic motivation and PC. There was evidence that PC partially mediates the relationship between trait approach motivation and state intrinsic motivation to do the task. These results support the role of therapies that directly address self-competency beliefs and set the groundwork for future investigations on the impact of such treatments on motivation.

The Measure of Insight into Cognition: Reliability and validity of clinician-rated and self-report scales of neurocognitive insight for schizophrenia

Poor insight into the neurocognitive deficits in schizophrenia-spectrum disorders may have significant clinical implications for treatment. The purpose of this study was to replicate and extend the psychometric findings initially reported on the Measure of Insight into Cognition Clinician-Rated (MIC-CR) and Self-Report (MIC-SR) which assess awareness, attribution, and frequency of neurocognitive deficits. Assessments conducted one week apart allowed for internal consistency, test-retest reliability, concurrent validity, and administration order effects to be determined. In this study sample (N=80), 73 demonstrated significant neurocognitive impairment, yet on the MIC-CR, the average awareness and attribution scores indicated only partial awareness and attribution of neurocognitive deficits. The average MIC-SR score indicated rare frequency of cognitive difficulty in everyday life. Cronbachs alphas for the MIC-CR (0.83) and MIC-SR (0.93) were consistent with the initial validation study; test-retest reliability for both MIC assessments was significant (p<0.001). In new analyses, concurrent validity was demonstrated by significant correlations between the MIC-CR and MIC-SR in the first validation sample: r=-0.75 (p<0.001) and the current replication sample: r=-0.70 (p<0.001). Effect sizes were large when frequencies of neurocognitive complaints (MIC-SR) were compared between subjects with good versus poor awareness on the MIC-CR. Reliability and concurrent validity results were similar and significant regardless of order of MIC-CR and MIC-SR administration. The MIC-CR and MIC-SR are thus reliable and valid complementary instruments to assess neurocognitive insight in people with schizophrenia spectrum disorders.

Depressed mood in individuals with schizophrenia: A comparison of retrospective and real-time measures

Depressed mood is prevalent among individuals with schizophrenia, leading to difficulties in functioning. Typically, depressed mood is evaluated using retrospective assessments during which individuals are asked to recall their mood during the past week or month. However, as individuals with schizophrenia may display memory difficulties, the results of such assessments may be biased, potentially leading to inaccurate clinical characterizations and/or suboptimal treatment. Our aim was to assess the potential impact of long-term memory on depressed mood in individuals with schizophrenia. Employing an Experience Sampling Method (ESM) approach, 51 individuals with schizophrenia and 22 healthy controls rated their momentary emotions up to 10 times/day over a two-day period, along with retrospective measures of depressed mood, long-term memory, quality of life, social functioning, and symptoms. ESM assessment of real-time depressed mood demonstrated discriminant and convergent validity. Among the schizophrenia group, there was a significant correlation between the real-time and retrospective measures of depressed mood. However, once variance due to long-term memory was controlled, the relationship between the real-time and retrospective measure was no longer significant. The findings suggest that a real-time measure of depressed mood may allow overcoming some of the limitations associated with long-term memory difficulties common among individuals with schizophrenia.

Cognitive deficit and mental health in homeless transition-age youth.

BACKGROUND AND OBJECTIVES: There is increasing recognition of the cognitive consequences of socioeconomic adversity during childhood, which can impair learning and negatively affect social and emotional development. However, there is a paucity of research on cognitive functioning and mental health among transition-age homeless youth. This study aimed to address this knowledge gap by examining the prevalence and functional significance of cognitive impairment and mental health disorders in a sample of 18- to 22-year-old homeless youth. METHODS: Participants (N = 73) were recruited from a vocational support program at Covenant House New York, a care agency for homeless youth. Assessments included diagnostic assessment for mental health disorders and evaluation of neurocognition and vocational outcomes. RESULTS: Youth demonstrated histories of academic instability, academic achievement below expectation, and high rates of untreated psychiatric disorders, the most prominent of which were anxiety, substance use, and mood disorders. Of those who had a mental health diagnosis, more than half demonstrated cognitive deficits. Performance on measures of working memory and verbal memory was <70% of that of the age-matched normative population. Cognitive impairment was associated with a significant risk for making a wage insufficient for independent living. CONCLUSIONS: These data confirm the need to focus on cognitive as well as emotional and physical health in transition-age youth. Comprehensive intervention at this later developmental stage has the potential to facilitate the acquisition of skills needed for academic, vocational, and independent living success in adulthood.

Integrating psychopharmacology and cognitive remediation to treat cognitive dysfunction in the psychotic disorders

Cognitive deficits are a prominent and enduring aspect of schizophrenia, which pose a significant barrier to achieving functional goals. The most promising intervention for treating cognitive impairment is cognitive remediation (CR), a behaviorally based therapy associated with medium effect sizes for cognitive and functional outcomes. However, there is a sizeable group of nonresponders whose CR outcomes become limited when the therapeutic approach fails to address individual differences in baseline cognition, motivation variables, and the extent to which CR offers opportunities for generalization. This speaks to a need to develop cognitive interventions that are both personalized and scalable. Emerging data suggest that specific pharmacological agents have the potential to enhance and accelerate behaviorally based CR effects. This article will review the rationale and preliminary evidence to support combining CR and pharmacotherapy. We will review crucial aspects of cognitive interventions that offer the most promise for improving not only cognitive outcomes, but also for enhancing improvement in real-world functioning. Finally, we will address methodological issues to be considered for future research on combined pharmacological and CR interventions.

The efficacy of a brief psycho-educational intervention to improve awareness of cognitive dysfunction in schizophrenia.

People with schizophrenia have neuro-cognitive deficits that are associated with poor functional outcome, yet their awareness of their cognitive deficiencies is variable. As new treatments for cognition are developed, it will be important that patients are receptive to the need for more therapy. Since insight into symptoms has been associated with treatment compliance, it may be of value to provide psycho-education to improve understanding about cognition in schizophrenia. We report a randomized controlled trial that enrolled 80 subjects in either a brief psycho-education intervention about cognition, or a control condition. Subjects in the two conditions did not differ at baseline in insight or receptiveness to treatment, or on demographic, cognitive, or psychiatric variables. Current cognitive impairment of subjects was evidenced by the indice of working memory, attention and executive functioning abilities, (X=77.45 intervention group; 82.50 control condition), that was significantly below both the normative mean and estimated average premorbid IQs (X=101.3 intervention group; X=104.57 control condition). Multivariate repeated measures ANOVAs indicated that subjects who received the psycho-education did not improve insight into their cognitive deficits or willingness to engage in treatment for cognitive dysfunction. While the failure to find a significant impact of this intervention on awareness of cognitive deficit and receptiveness to cognitive treatment raises questions about the malleability of insight into neuro-cognitive deficits, the intervention was briefer than most reported psycho-education programs and multi-session formats may prove to be more effective.

Translating cognitive behavioral interventions from bench to bedside: The feasibility and acceptability of cognitive remediation in research as compared to clinical settings

Cognitive remediation (CR) research typically addresses internal validity, and few studies consider CR in a real-world context. This study evaluated the fit between the program conditions and treatment model in research and clinical settings, with the goal of informing future research on the contextual challenges associated with the implementation of CR. Data was drawn from an initiative by New York States Office of Mental Health (OMH), to implement CR programs for adults with Serious Mental Illness (SMI) in 16 state operated outpatient clinics. One of these clinics first became a research site for a CR randomized clinical trial, which allowed for a comparison of the feasibility and acceptability of CR in a research as compared to a clinical setting. RESULTS: The research site averaged almost triple the number of referrals as the clinical sites. Over nine months 46.51% of clinic referrals were enrolled in the CR program whereas 64.29% of research referrals were enrolled. Clinical site utilization averaged 70.53% while research site utilization averaged 90.47%. At the clinical sites, 97% of respondents reported CR was an excellent or good experience. There was high treatment fidelity for program structure and content across sites. CONCLUSIONS: This comparison of CR in clinical and research sites highlights the decrease in referrals, enrollment and utilization that occurs when a program moves from a highly controlled setting to the real world. Still, the acceptability, fill rates and utilization indicated that CR can be successfully implemented in large scale, geographically diverse, publically funded clinic settings.