Clare Reeder

Are the effects of Cognitive Remediation Therapy (CRT) durable? Results from an exploratory trial in schizophrenia.

BACKGROUND This paper investigates the durability of the effects of cognitive remediation therapy (CRT). In a randomised control trial, CRT was compared with a control therapy (intensive occupational therapy activities), matched for length of therapist contact. The main three cognitive outcomes, (i) number of categories achieved on the Wisconsin Card Sort Test, (ii) age-scaled score on the Digit Span subtest of the WAIS-R, and (iii) mean number of moves on the Tower of London test, were chosen because they are known to be problematic in schizophrenia. In addition, a wide variety of other outcomes (symptoms, social functioning, self-esteem and cognition) were assessed. At the end of treatment, CRT conferred a benefit to people with schizophrenia in cognition and self-esteem [Schizophr. Bull. 25 (1999) 291]. This study investigates these outcomes 6 months after the therapies were withdrawn. METHOD Participants were assessed at baseline, posttreatment and 6-month follow-up (n=17 for the CRT group; n=16 for the control therapy group). In addition to the functioning measures, data on use of services and cost of therapy were collected. RESULTS The effects of CRT on cognition were still apparent at follow-up, particularly in the memory domain. When these cognitive improvements reached a criterion threshold, there were also improvements in social behaviour and symptoms. The gains made in self-esteem disappeared following the withdrawal of therapy. The economic analysis showed overall reductions in the care packages of both patient groups but there was a significant increase in day-care costs for patients who have received CRT. This additional use of day care may confer further advantages to the CRT group, such as improved social functioning and quality of life. CONCLUSIONS The overall results of this first trial of a novel CRT approach have produced encouraging results which merit further investigation.

Does age matter? Effects of cognitive rehabilitation across the age span.

BACKGROUND Cognitive remediation (CR) therapy in its various disguises can be helpful for people with schizophrenia but it is not clear if patient characteristics are likely to interfere with its effectiveness. METHODOLOGY This paper describes the assessment of one putative moderating variable, age, on the outcome of CRT in a rigorous randomised control trial with memory, cognitive flexibility and planning as primary outcomes and social behaviour, symptoms and self-esteem as secondary outcomes. Calendar age was divided into younger (< 40; N55) and older (40 or more years; N30). There were no differences between the groups at baseline in their cognitive, social or demographic data except on predicted variables. RESULTS Younger people benefited more from cognitive remediation in two of the three cognitive domains tested. In the memory domain both groups benefited. Only negative symptoms showed a moderating effect of age on CRT, where again the younger group showed improvements in the context of CRT but the older group did not. When older people did show a cognitive advantage in memory following therapy this cognitive improvement benefited social behaviour. CONCLUSION CRT needs some modification to increase the benefits to older participants. However, any cognitive improvements do still seem to have a beneficial effect.

Developing models of how cognitive improvements change functioning: Mediation, moderation and moderated mediation

Background Cognitive remediation (CRT) affects functioning but the extent and type of cognitive improvements necessary are unknown. Aim To develop and test models of how cognitive improvement transfers to work behaviour using the data from a current service. Method Participants (N49) with a support worker and a paid or voluntary job were offered CRT in a Phase 2 single group design with three assessments: baseline, post therapy and follow-up. Working memory, cognitive flexibility, planning and work outcomes were assessed. Results Three models were tested (mediation — cognitive improvements drive functioning improvement; moderation — post treatment cognitive level affects the impact of CRT on functioning; moderated mediation — cognition drives functioning improvements only after a certain level is achieved). There was evidence of mediation (planning improvement associated with improved work quality). There was no evidence that cognitive flexibility (total Wisconsin Card Sorting Test errors) and working memory (Wechsler Adult Intelligence Scale III digit span) mediated work functioning despite significant effects. There was some evidence of moderated mediation for planning improvement if participants had poorer memory and/or made fewer WCST errors. The total CRT effect on work quality was d = 0.55, but the indirect (planning-mediated CRT effect) was d = 0.082 Conclusion Planning improvements led to better work quality but only accounted for a small proportion of the total effect on work outcome. Other specific and non-specific effects of CRT and the work programme are likely to account for some of the remaining effect. This is the first time complex models have been tested and future Phase 3 studies need to further test mediation and moderated mediation models.

Resolving Ambiguity in Emotional Disorders: The Nature and Role of Interpretation Biases.

People with emotional disorders, such as social anxiety disorder (SAD), generalized anxiety disorder (GAD), and depression, demonstrate a consistent tendency, or bias, to generate negative interpretations of ambiguous material. This is different from people without emotional disorders who tend, in general, to make positive interpretations of ambiguity. If central components of an emotional disorder have high levels of inherent ambiguity (e.g., concern about the negative perceptions of others in SAD, or worry in GAD), then interpretive bias may have a causal maintaining role, and this has been demonstrated in studies using cognitive bias modification techniques. This research has also shown that interpretation biases combine with other cognitive processes, such as imagery and memory, which could exacerbate distress. Psychological interventions will benefit from effectively targeting negative interpretations, and future experimental research can inform ways to improve facilitation of more benign inferential processing to maximize amelioration of key components of emotional disorders.

Effects of Age and Cognitive Reserve on Cognitive Remediation Therapy Outcome in Patients With Schizophrenia

OBJECTIVE Older people with a diagnosis of schizophrenia seem to show fewer benefits following cognitive remediation therapy (CRT). It is not clear whether cognitive reserve modifies the relationship with age. METHODS A total of 134 individuals with schizophrenia were pooled from one randomized control trial and one observational trial. Eighty-five participants received more than 20 sessions of CRT and 49 participants received fewer than 20 sessions of CRT or treatment as usual. Participants were divided into two groups according to their age (younger than 40 years: younger, N = 77; and 40 years or older: older, N = 57). Cognition (working memory, cognitive flexibility, and planning) was assessed at baseline and posttreatment. Premorbid IQ and vocabulary at baseline were used as cognitive reserve proxies. RESULTS There was a significant effect of CRT on working memory in younger but not older participants. Better premorbid IQ was associated with better working memory performance in younger participants irrespective of treatment. No significant effects of treatment or cognitive reserve were revealed in older participants. Cognitive reserve proxies did not modify CRT treatment effect. CONCLUSION In conclusion, the effects of CRT were limited in older people with schizophrenia. Cognitive reserve could not be shown to influence the relationship of age with CRT efficacy. Better premorbid IQ was associated with increased practice effects on working memory in younger but not older individuals.

Cognitive remediation therapy in schizophrenia: Cost-effectiveness analysis

PURPOSE There is a lack of evidence on the cost-effectiveness of cognitive remediation therapy (CRT). METHODS Randomised controlled trial comparing usual care plus CRT with usual care alone. Participants had a diagnosis of schizophrenia and cognitive and social functioning difficulties. Health/social care and societal costs were estimated at 14 weeks (time 2) and 40 weeks (time 3) after randomisation. The outcome, proportion of participants improving their working memory since baseline, was combined with costs to explore cost-effectiveness. RESULTS 85 participants were recruited. There were no differences in total health/social care or societal costs between the two groups at either time 2 or time 3. An additional 21% of participants in the CRT group improved their working memory at both follow-ups. When placing these cost and outcomes in hypothetical scenarios concerning how much policy-makers would pay for another 1% of participants improving their working memory, there was more than an 80% chance that CRT would be cost-effective compared to usual care; at time 3, the likelihood of cost-effectiveness peaked at 30% even for investments up to pound 5000. CONCLUSIONS CRT can improve memory among people with schizophrenia and cognitive deficits at no additional cost. Although cost-effective in the short term, CRT may have limited potential to save costs in the medium term because it could increase take up of services. This could confer important longer term benefits for the patient group examined here, in terms of improved social functioning and less reliance on services. This can only be ascertained through longer follow-up.

The prevalence and stability of an executive processing deficit, response inhibition, in people with chronic schizophrenia

The current study investigates whether an executive processing measure, response inhibition, is stable over time and across new samples of patients with schizophrenia. Two groups of patients (with and without diagnoses of schizophrenia) were followed up 6 years after baseline data collection. Another separate group of patients with less institutionalized care also completed the same measures to determine whether the response inhibition difficulties had the same prevalence in this new sample.The response inhibition measure was stable over time only in the group of patients with a diagnosis of schizophrenia. The relationship between symptoms and response inhibition difficulties changed over time but was explicable in terms of the interaction between environmental demands and information processing difficulties. The level of response inhibition difficulties (about one-third) was identical in the new sample of patients, which suggests that response inhibition is not dependent on clinical history.

The Effect of Working Alliance on Adherence and Outcome in Cognitive Remediation Therapy

Abstract Cognitive remediation therapy (CRT) for schizophrenia has been effective in improving cognitive and global functioning outcomes. It is now important to determine what factors maximize benefit. The quality of relationship—or working alliance—between clients and therapists may be one such factor that improves outcome. To investigate this, 49 individuals with schizophrenia were recruited into a naturalistic study of the impact of CRT on work and structured activity outcomes. Participant’s cognitive skills, severity of symptoms, and social skills were assessed at baseline. Both client and therapist working alliance ratings were gathered early in therapy. After controlling for depression, clients who rated the alliance more favorably stayed in therapy longer and were more likely to improve on their main target complaint but notably not on working memory performance or self-esteem. Therapist’s ratings of the alliance were not associated with memory outcome. These findings indicate that working alliance is important for client satisfaction with therapy.

Does Change in Cognitive Function Predict Change in Costs of Care for People With a Schizophrenia Diagnosis Following Cognitive Remediation Therapy

Background and Aims: Schizophrenia leads to significant personal costs matched by high economic costs. Cognitive function is a strong predictor of disabilities in schizophrenia, which underpin these costs. This study of cognitive remediation therapy (CRT), which has been shown to improve cognition and reduce disability in schizophrenia, aims to investigate associations between improvements in cognition and cost changes. Methods: Eighty-five participants with schizophrenia were randomized to receive CRT or treatment as usual and were assessed at baseline, posttherapy, and 6 month follow-up. Four structural equation models investigated associations between changes in cognitive function and costs of care. Results: All 4 models provided a good fit. Improvement in 3 individual cognitive variables did not predict total cost changes (model 1). But improvement in a single latent cognition factor was associated with a reduction in depression, which in turn was associated with reduced subsequent total costs (model 2). No significant associations with constituent daycare and special accommodation cost changes were apparent with 3 individual cognitive change variables (model 3). But improvement in a single latent cognitive change variable was associated with subsequent reductions in both daycare and special accommodation costs (model 4). Conclusion: This study exemplifies a method of using cost changes to investigate the effects and mechanisms of CRT and suggests that executive function change may be an important target if we are to reduce disability and resultant health and social care costs.

It is all in the factors: Effects of cognitive remediation on symptom dimensions

BACKGROUND Cognitive remediation (CR) aims primarily to improve cognition and functional outcomes. However, a limited number of studies reported a positive effect on symptoms. This limited effect may be because the symptom clusters considered are too broad and heterogeneous. This study explores, for the first time, the effect of CR on five empirically defined symptom dimensions of schizophrenia. METHOD Participants were patients with schizophrenia taking part in a randomised controlled trial comparing CR plus treatment as usual (CR, N=43) to treatment as usual (TAU, N=42). All participants were assessed at baseline and 14-weeks (i.e. at the conclusion of treatment for the CR group) with the Positive and Negative Symptoms Scale (PANSS). Five symptom dimensions were derived from the PANSS scores: Positive (POS), Negative (NEG), Disorganised (DIS), Excited (EXC) and Emotional Distressed (EMD). RESULTS After CR, the therapy group had a significant reduction in DIS and NEG symptom dimensions compared to the TAU group. The traditional PANSS factors showed no effect of CR on symptoms. CONCLUSION CR can have not only a positive effect on disorganisation but also on negative symptoms. Using detailed symptom dimensions can characterise more accurately the effect of CR on symptom of schizophrenia.