Update on cognitive remediation

UPDATE ON COGNITIVE

REMEDIATIONAssoc. Prof. Dr. Muhammad Najib Mohamad Alwi

KLMH 2014

FEATURES OF SCHIZOPHRENIA

Positive symptoms- Delusions- Hallucinations- Disorganization

• speech

• behaviour

Cognitive deficits

Functional ImpairmentsWork

Interpersonal relationshipsSelf-care

Negative symptoms- emotional range

- expression of emotion

- motivation/drive

- interests

- social drive

- poverty of speech

Mood symptoms

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COGNITIVE DEFICITS AND OUTCOME

Cognitive Deficits

Functional Outcome

occupational

social

psychosocial

rehabilitation

(Wykes 1998; Green 1996; Velligan et al 2000)

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COGNITIVE DEFICITS IN

SCHIZOPHRENIA

Main impairments identified include: Attention and vigilance

Problem solving and reasoning

Processing Speed

Memory and Learning (Verbal and Visual)

Working Memory

Social Cognition

(Keefe et al 2006; Wilk et al 2005)

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STRATEGIES TO IMPROVE COGNITIVE DEFICITS

FOR SCHIZOPHRENIA

Pharmacological approaches:

Atypical antipsychotics: ES=0.24 (Woodward et al 2005)

Adjunctive cholinesterase inhibitors ES=NS (Sharma et al 2006)

3rd generation antipsychotics (?)

Psychosocial approaches:

Cognitive rehabilitation/remediation/training

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Cohen’s Effect Size (ES)

> 0.8 Large

0.5 Moderate

0.2 Small

COGNITIVE REMEDIATION THERAPY

(CRT)

The term “cognitive remediation therapy” refers to

several evidence-based psychosocial programmes

aiming to ameliorate cognitive deficits associated

with schizophrenia and other mental disorders.

Originated from works on traumatic brain injury

which have begun in the 1970s.

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COGNITIVE REMEDIATION THERAPY FOR

MENTAL ILLNESS

Currently has several versions/models but all aiming

to improve cognitive functions in schizophrenia.

More recently, some works have been started to

adopt CRT for bipolar disorder, depressive disorder,

ADHD/autism, anorexia nervosa, and dementia.

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TWO MAIN APPROACHES

Cognitive Remediation

Restorative Approach Adaptive Approach

Paper &

Pencil

Exercises

Table

Top Tasks

Computer

Software

Graded

Occupations

Internal

Strategies

External

Strategies

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• Uses pencil-and-paper and other types of drills to target cognitive skills

Task Drill

• Task drill with facilitation by a therapist

Task Drill and Strategy Coaching

• Task drill with computer assisted instructions

Computer Assisted Task Drill

• Computer assisted task drill with therapist facilitation

Computer Assisted Task Drill with Strategy

Coaching

TYPES OF CRT (Twamley et al, 2003)

WHAT DOES THE EVIDENCE SAY?

Efficacy for cognition

ES=0.32 (Twamley et al 2003)

ES=0.41 (McGurk et al 2007)

ES=0.45 (Wykes et al 2011)

Efficacy for psychosocial functioning (ES: 0.37).

Less pronounced in patients’ psychopathology.

Benefits especially relevant for chronic and severe patients

with schizophrenia.

Stefano Barlati, et al (2013) Cognitive Remediation in Schizophrenia: Current Status and Future Perspectives Schizophrenia Research and Treatment http://dx.doi.org/10.1155/2013/156084

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Cohen’s Effect Size (ES)

> 0.8 Large

0.5 Moderate

0.2 Small

COGNITIVE REMEDIATION PROGRAMS

APPEAR TO BE MORE SUCCESSFUL:

if they are embedded in comprehensive rehabilitation

programs where they are used in combination with

psychosocial groups or work rehabilitation programs.

to impact functional outcome when individuals are given

opportunities to practice the cognitive skills in real-world

settings.

Stefano Barlati, et al (2013) Cognitive Remediation in Schizophrenia: Current Status and Future Perspectives Schizophrenia Research and Treatment http://dx.doi.org/10.1155/2013/156084

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Drop Outn=25

n=112

Screening

Baselinen=85

Random-

ization

CRTn=57

WLn=28

Drop Outn=3

Post Testn=32

Post Testn=25

Randomised Controlled Trial

MALAYSIAN STUDY

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N Alwi et al (2009)

Attention

Processing Speed

Visual L Memory

Verbal L

Memory

p=.34d=.32 (small ES)

p=.03d=.59 (moderate

ES)

p=.002d=.83 (large ES)

p=.007d=.61 (moderate

ES)

McGurk et al

(2007)

ES=.41

McGurk et al

(2007)

ES=.48

McGurk et al

(2007)

ES=.09

McGurk et al

(2007)

ES=.39

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ADDITIONAL FINDINGS

•There was no difference

after inclusion of booster

sessions

•However improvements

noted at the end of

treatment were maintained

at 5 weeks post treatment

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BRAIN EFFECTS OF COGNITIVE REMEDIATION

THERAPY IN SCHIZOPHRENIA: A STRUCTURAL AND

FUNCTIONAL NEUROIMAGING STUDY

Comparison: patients with schizophrenia receiving CRT (n=17), an active control group of schizophrenia patients receiving social skills training (SST, n=18), and a control group of healthy individuals (n=15)

After treatment, CRT patients showed during task-related responses:

decreased activation in the central executive network in

decreased activation of its anticorrelated default mode network

suggesting an improvement in the efficiency of both functional networks.

Penadés R, et al (2013) Biological Psychiatry

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EFFICACY OF CRT IN OTHER MENTAL

DISORDERS?

First Episode Psychosis

Dementia

Mood Disorders

Others?16

FIRST EPISODE PSYCHOSIS (FEP) AND CRT

Targeting cognitive impairments in the early

course of schizophrenia:

Significant functional benefits: social functioning,

employment, and role functioning.

Euland & Rand (2005)Eack et al (2007)Hodge et al (2010)Zaytseva et al (2013)Marshall & Rathbone (2011)

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FIRST EPISODE PSYCHOSIS (FEP) AND CRT

CRT may be integrated into treatment programs of

young people with schizophrenia within the “critical

period” for early intervention:

opportunity to alter the course of the disease.

? The “protective” role of early effective intervention

on the neurobiological and clinical deteriorating

course of the disease => may be extended to

cognitive remediation.

Euland & Rand (2005)Eack et al (2007)Zaytseva et al (2013)Marshall & Rathbone (2011)

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Cognitive changes for the whole sample (cognitive remediation therapy [CRT] = 25 / treatment as usual [TAU] = 25) and for the completers subgroup (CRT = 15 /

TAU = 14).

Cognitive Remediation Therapy in Adolescents With Early-Onset Schizophrenia: A Randomized Controlled Trial

Puig, Olga, MSc, Journal of the American Academy of Child & Adolescent Psychiatry,

Copyright © 2014 American Academy of Child and Adolescent Psychiatry

CRT for Alzheimer’s Disease

20Jimmy Choi & Elizabeth W. Twamley, Neuropsychol Rev. Published online Feb 12, 2013. doi:

10.1007/s11065-013-9227-4

CRT FOR MILD COGNITIVE IMPAIRMENT (MCI)

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Huckans et al (2013)

COGNITIVE VITALITY TRAINING (CVT) –

FOR DEMENTIA

Computer-based memory training in a motivational milieu:

Incorporated CBT to target hopelessness defeatist behaviour

Focus: Exercising mental skills / optimizing mental ‘acuity’

instead of “remediating deficits”

Early results (Choi et al, 2014 in press):

CVT + AChI drugs vs CVT alone (4 months)

objective memory performance

depressive symptoms

QoL

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COMPENSATORY MEMORY TRAINING

(MCI AND TRAUMATIC BRAIN INJURY)

Focus on compensatory cognitive strategies to improve cognition and functioning (10-12 sessions):

Target: prospective memory, attention, learning and executive functioning

Strategy: individual / group + workbooks

Initial Results:

Promising for both MCI and TBI (Huckens et al, 2010; Twamley et al, 2012)

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CRT AND DEPRESSION

Patients with major depressive disorder (MDD) present

with significant cognitive impairment : may not resolve

with treatment.

The studies are small and inconclusive:

There was a significant time by treatment interaction for

attention/processing speed and verbal memory.

Changes in functioning were not significant, although

improved cognition predicted improvements in functioning.

Porter RJ, Bowie CR, Jordan J, Malhi GS - Aust N Z J Psychiatry 2013; 47(12); 1165-75

Bowie CR, Gupta M, Holshausen K, Jokic R, Best M, Milev R - J. Nerv. Ment. 2013; 201(8); 680-5

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BIPOLAR DISORDER

Despite periods of symptomatic recovery, individuals

with bipolar disorder often continue to experience

impairments in psychosocial functioning, particularly

occupational functioning.

Two determinants of psychosocial functioning of

euthymic (neither fully depressed nor manic)

individuals:

residual depressive symptoms and cognitive impairment

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BIPOLAR DISORDER

Early results with CRT:

Uncontrolled Open trial:

Results indicated that at the end of treatment, as

well as at the 3-months follow-up, patients showed

lower residual depressive symptoms, and increased

occupational, as well as overall psychosocial

functioning.

Deckersbach et al (2010)

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ANOREXIA NERVOSA (AN)

Identified problems: Style of information processing (set-

shifting & extreme attention to detail could be one of the

maintaining factors of AN

Technique: Twice-weekly CRT module aimed at reflecting on

information-processing styles and increasing cognitive

flexibility and gistful, holistic thinking.

Aim: Target basic processes of thinking rather than the

content of thinking, such as issues of food, shape and weight

concern, or emotions.

CRT gives patients a sense of achievement and helps them to

adapt new behavioural strategies in real life.

Tchanturia et al 2007

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Natalie Pretorius &

Kate Tchanturia

(2007)

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EVIDENCE SO FAR:

Patients’ self report on cognitive strategies improved.

Overall positive feedback about this package was received from

patients and therapists.

Evidence also shows long-term benefits of CRT.

Tchanturia et al (2008}

Davies and Tchanturia (2005)Tchanturia & Hambrook (2009)

Tchanturia & Whitneyet al (2008)

Genders et al (2008)29

ADULT ADHD

1 RCT (Stevenson et al, 2002):

ADHD symptomatology (effect size (d) = 1.4),

improved organizational skills (d = 1.2), reduced

levels of anger (d = 0.5) and organizational skills (d

= 1.3)

Results were maintained one year after the

intervention.

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CHILDREN WITH ADHD

Meta-analysis 25 studies of facilitative intervention

training:

studies training short-term memory alone resulted in

moderate magnitude improvements in short-term memory (d

= 0.63)

whereas training attention did not significantly improve attention and training mixed executive functions did not

significantly improve the targeted executive functions

Transfer effects of cognitive training on academic

functioning:

d = 0.14 (NS)

Rapport et al (2013). Clinical Psychology Review 33(8) 1237-1252

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CONCLUSIONS

Cognitive Remediation Therapy (CRT) has a lot of

potential for research and therapeutic work.

The basic principles of CRT programme can be

modified to suit various clinical conditions which

manifest with cognitive deficits.

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