Cognitive Remediation for Schizophrenia

Cognitive impairments are well-documented among people with schizophrenia. These impairments include reductions in general intellectual capacity and domain-specific areas such as memory, attention, processing speed, executive functions, and social cognition (1, 2). On average, people with schizophrenia show reductions, as much as one to two standard deviations, compared with general population samples in cognitive functions (2). Cognitive deficits appear early in the course of illness (even before the first psychotic episode), persist even during periods of significant symptom remission, and are stronger predictors of functional outcomes among people with schizophrenia (1). Cognitive deficits are critical to the overall gestalt of psychiatric treatment for schizophrenia. They may moderate patients’ ability to actively participate in and adhere to medication management, and they may be critical to the prospects of successful skills training and psychosocial rehabilitation (3). Addressing these deficits should therefore be a consideration in the treatment of patients with schizophrenia. In this column, I discuss one approach, cognitive remediation, which has seen a surge of research interest in the past three decades. I advocate making cognitive remediation available for the service of clinical and patient-centered goals in various treatment settings and at all stages of illness.

What Is Cognitive Remediation?

The Cognitive Remediation Expert Working Group has defined cognitive remediation as

Most cognitive remediation studies target higher-level cognitive functions such as attention, executive functions, social cognition, and meta-cognition. Some closely related cognitive training interventions underscore “bottom-up” remediation by targeting basic auditory or visual sensory abilities and assume a transfer of abilities to higher-order cognitive functions (4, 5). Still others combine cognitive remediation with psychosocial interventions that directly target function, such as social, vocational, and daily living skills (4, 5).

Several studies support the efficacy of cognitive remediation for improving cognitive and psychosocial functioning among people with schizophrenia. Meta-analytic reviews (6, 7) show that this intervention contributes to, on average, medium-sized effects on global cognition and durable effects across several cognitive abilities, with the largest effects on social cognition, reasoning, and problem solving and the smallest effects on visual learning and memory. In addition, sustained effects in the medium-to-large range are obtained with psychosocial function, although these effects are variable and appear to be more robust in studies that have combined cognitive remediation with other psychosocial interventions. Several cognitive remediation programs and therapies have been disseminated and tested among patients with schizophrenia, such as Neuropsychological Educational Approach to Remediation (NEAR), Thinking Skills for Work, neurocognitive enhancement therapy, integrated psychological treatment, cognitive enhancement therapy, neuroplasticity-based auditory training, action-based cognitive remediation, and so forth. The critical elements of cognitive remediation programs are described in greater detail elsewhere (4, 5). These elements include drill-and-practice exercises; strategy learning; the transfer or generalization of cognitive skills to personalized recovery goals, living skills, and community functioning; and coaching and clinical support provided by trained cognitive remediation therapists and coaches.

Drill-and-practice exercises often utilize computer software designed to present drills that necessitate the deployment of cognitive abilities. These exercises are calibrated to be within the range of the patient’s competence, keeping success rate at about 80%. As the patient’s level of competence improves, task demands are gradually increased to match the higher level of competence. Cognitive remediation coaches help patients learn efficient strategies for completing cognitive exercises that can be linked to completion of daily activities and generalized to everyday challenges. Patients learn strategies that they then practice and apply repeatedly to aid performance in drill exercises. These skills are similarly applied to contexts relevant to the patient’s daily functioning and personalized goals. Generalization involves the transfer of cognitive skills and new cognitive strategies acquired through training to various real-world tasks with cognitive demands, such as activities of daily living and tasks that would be encountered in work and school. In some cognitive remediation programs, such as NEAR, generalization is accomplished through the use of therapist-led bridging groups, which create a context for explicit strategy learning, enhancing cognitive awareness and metacognitive skills, and review of the various applications of cognitive skills to routine activities and personal goals. Generalization is also accomplished in programs that provide cognitive remediation in the context of other rehabilitative interventions, such as Thinking Skills for Work.

Therapists play a critical role in assessing cognitive abilities, including areas of strengths and weaknesses, personal and functional goals, barriers to accomplishing those goals, and tracking progress over time. In the intervention, therapists foster engagement, anchor remediation to patient-identified goals, and respond to challenges throughout the intervention. Each of these components serves the overall efficacy of a cognitive remediation program vis-à-vis the improvements of cognitive functions, the deployment of cognitive skills in a functional context, and real-world functioning.

Who Should Be Considered for Cognitive Remediation?

Although a range of patients with schizophrenia may benefit from cognitive remediation services, effects appear to be larger for patients who are younger, have a higher IQ, are more symptomatically stable, and are intrinsically motivated (6, 7). The heterogeneity of benefits does not, however, preclude adapting and making this intervention available to as many patients as possible. For example, although effects are larger in younger patients, cognitive remediation is efficacious in older adults later in the course of illness (8). For older adults, therapists may have to adapt cognitive exercises, taking into account familiarity with computer hardware and personal preferences.

For all patients, comprehensive evaluation of cognitive functions to identify the severity and pattern of deficits, areas of functional impairments, and personally meaningful goals would inform how cognitive remediation is disseminated and integrated into the patient’s overall care. Following is a discussion of groups of patients with schizophrenia who should be considered for cognitive remediation.

Patients at high risk of developing psychosis and patients with early psychosis.

Studies have shown that cognitive impairments are established very early in the course of psychotic illness among individuals at ultra-high risk (UHR) for psychosis, patients in the prodrome phase, and first-episode patients (1, 9). Cognitive deficits are more severe in UHR individuals who go on to experience a psychotic episode and appear to contribute to early functional decline (9, 10). On the basis of evidence from the earliest meta-analyses that younger patients appear to benefit more from cognitive remediation (6, 7), increased consideration of this intervention has been given in the early stages of illness for attenuating subsequent cognitive decline or illness progression.

The effect of cognitive remediation on outcomes among UHR individuals is noteworthy. A systematic review identified five studies that reported cognitive outcomes. Four of the five studies found at least medium range improvements in cognitive measures following cognitive remediation (11). Of the four studies that reported functional outcomes, two found that cognitive remediation contributed to large effects in social functioning. Bechdolf and colleagues (10) provided cognitive remediation as part of an integrative psychological intervention (IPI) that also included cognitive-behavioral therapy, skills training, and multifamily psychoeducation. They examined the effect of IPI relative to supportive counseling on the risk of experiencing a first psychotic episode (i.e., conversion) at 12-month and 24-month follow-up among 128 participants. The IPI group showed significantly lower odds of conversion at 12 months (odds ratio [OR]=6.21) and 24 months (OR=3.69) as well as a longer average for days to conversion (887.1 vs. 784.2 days).

A recent meta-analysis of 11 studies examining patients with early schizophrenia found that cognitive remediation contributed to small-range effects on global cognition, verbal memory, and social cognition (12). Cognitive remediation also contributed to small-range effects on symptoms and global functioning. Remarkably, although significant, these effects were smaller than those found in previous meta-analyses. The authors suggested that the lesser severity of impairments in early illness implies less room for improvement through training. Similar to effects in general psychosis samples, in studies that provided cognitive remediation along with adjunctive psychiatric rehabilitation services there were larger effects on functioning (medium-range effects) compared with the functioning of those who received cognitive remediation alone. These studies suggest that cognitive remediation when provided in the early stages of illness improves cognition and function. There are very few studies of UHR individuals, and little is known about the prospects for preventing conversion in the prodrome.

Patients who are hospitalized long term.

Intermediate to long-term inpatient facilities treat patients who need further psychiatric stabilization and rehabilitation. Psychiatric inpatients with schizophrenia may also present with more severe cognitive deficits (13). Studies of this population have shown associations between cognitive impairments and agitation, limited insight, medication nonadherence, treatment-refractory status, impulsive aggression, and increased length of hospitalization (3, 14). Cognitive deficits are therefore a treatment target for improving the overall clinical picture of patients who are hospitalized long term. The longer length of hospitalization in these settings makes intensive, highly dosed cognitive remediation feasible. Moreover, these settings may also feature structured programs of psychiatric rehabilitation, such as state hospital treatment malls, that feature other evidence-based interventions, activities, and psychoeducational groups to optimize the benefits of cognitive remediation on functional outcomes. In a recent meta-analysis of 20 studies conducted in inpatient settings, Cella and colleagues (15) found that the average number of cognitive remediation sessions provided was 28.6, with sessions ranging from nine to 72. They also found that cognitive remediation contributed to medium-sized effects on working memory, processing speed, and learning and memory; small-range effects on attention and executive functioning; and medium, but not statistically significant, effects on function.

Because cognitive deficits are associated with treatment nonadherence, and because nonadherence is highly predictive of relapse, studies have found that cognitive remediation contributed to fewer hospitalizations compared with control or treatment as usual (16, 17). Evidence that cognitive remediation can support relapse prevention efforts is added justification for considering the intervention for patients who are hospitalized long term.

What about patients receiving electroconvulsive therapy (ECT)?

Patients with schizophrenia that is treatment resistant are frequently considered for ECT, especially when clozapine is ineffective or intolerable. ECT is, however, associated with cognitive side effects, including medium-to-large reductions in executive functioning and verbal memory within 3 days following treatment (18). Most ECT-induced cognitive impairments are acute, and recovery of most abilities is possible within 15 days posttreatment; however, some patients may continue to experience ECT-induced impairments at 3 and 6 months after treatment (18). Cognitive remediation has been suggested as a possible intervention for ECT-induced impairments (19). However, data demonstrating its efficacy are currently lacking.

In the only study to date, Choi and colleagues (19) provided cognitive remediation targeted toward memory deficits among patients with depression receiving ECT, and they found no benefit compared with active control or treatment as usual. The authors provided two sessions of the intervention in the week before ECT and five sessions within 2 weeks of the last ECT session. Because most patients recover nearly all cognitive abilities within 15 days, it is unsurprising that no cognitive remediation benefits were apparent. Cognitive remediation may be less useful for targeting acute cognitive impairments; however, the intervention may be useful for patients who continue to experience impairments more than 2–4 weeks after receiving ECT.

Forensic patients.

Most individuals with schizophrenia who receive care in forensic settings have been legally adjudged as “incompetent to stand trial” or “not guilty by reason of insanity.” These patients undergo competency restoration, which involves symptom management and education in the legal process to enable them to participate in their own defense. Cognitive impairments can be an impediment to successful court-ordered restoration because cognitive skills are required to gain knowledge of the judicial process from court-ordered legal education classes and groups—a critical ingredient of competency adjudication (20, 21). In addition, cognitive impairments are associated with several clinical challenges found in this population, including emotion abnormalities, impulsivity, and aggression (14). Cognitive remediation may therefore serve both clinical and court-mandated treatment objectives if integrated into forensic services (21).

To date, two studies have examined the effects of cognitive remediation among forensic patients with schizophrenia (22, 23). In both studies, cognitive remediation contributed to improvements in cognitive abilities and function. Patients in both studies also showed clinical progress: in one study, decreased aggression, and the other, a move to lower-security units. Given the prevalence of aggression in this population, cognitive remediation should also target social cognition deficits, including facial affect recognition, mentalizing capacity, and attributional biases, found to be especially altered in violent offenders (24). Studies have shown that cognitive remediation that targets both cognitive and social cognitive impairments contributes to even greater improvements in cognition, social cognition, and social functioning than cognitive remediation alone (25). Given the more proximal effects of social cognition on aggression, combined training may be especially efficacious for decreasing aggression risk among this population.

Patients with personal recovery or functional goals.

With several programs embedded within a broader rehabilitative focus, such as employment, social skills, and education, cognitive remediation can be adapted to personal recovery goals that are often of interest to many care recipients. Cognitive skills and newly acquired strategies may be linked to these goals during drill-and-practice exercises and as part of bridging group discussions. Cognitive remediation therapists also engage patients, caregivers, and other providers in discussions about areas of everyday difficulties that can inform concrete treatment objectives, including strategies informed by the patient’s cognitive strengths and weaknesses and cognitive abilities needed during the performance of activities.

To date, no studies have been published regarding personally identified goals among patients with schizophrenia enrolled in cognitive remediation. In a study of people with dementia going through cognitive rehabilitation, Watermeyer and colleagues (26) found that patients’ goals included learning how to use hardware and other technology, improving medication self-management ability, improving memory to stop misplacing items, remembering names of people, finding the right words in conversation, gaining knowledge, and becoming more independent of family members. The range of personal goals addressed in the service shows the adaptability of cognitive remediation. Importantly, tailoring cognitive remediation to personally relevant goals might increase motivation and engagement in the intervention, which may increase the likelihood of successful outcomes.

Conclusions

Cognitive remediation is potentially beneficial for patients with schizophrenia at all stages of illness, especially when provided in broader rehabilitative contexts. In the early stages of illness, cognitive remediation could improve patients’ cognitive and psychosocial functioning and long-term outlook. For patients who are hospitalized long term, cognitive remediation can improve inpatient outcomes by enhancing the capacity to gain from other unit interventions and supporting efforts at relapse prevention. The remediation of ECT-related cognitive impairments is an area of clinical interest, but supportive data are currently lacking. Cognitive remediation seems to improve cognition and clinical outcomes in forensic rehabilitation efforts; however, to date, no studies have been published regarding competency outcomes following cognitive remediation in these settings. Cognitive remediation programs are adaptable to patient-identified goals, which can enhance engagement and treatment outcomes. The preliminary assessment of cognition should focus not only on areas of impairment that may affect function but also on areas of cognitive strength and personal resources that may support the pursuit of stated goals. Assessment will also allow the therapist to tailor remediation to the patient’s preferences, strengths, and learning style, which could serve to increase the patient’s intrinsic motivation to engage in cognitive remediation. This personalized approach should be maintained throughout the course of the intervention regardless of the illness stage or treatment setting.