Psychopathologic, neuropsychological and functional outcome measures during cognitive rehabilitation in schizophrenia: A prospective controlled study in a real-world setting

Background

Cognitive dysfunction has been demonstrated in patients with schizophrenia, and this may affect patients’ functional outcome. The improvement of such dysfunction by means of cognitive remediation interventions has become a relevant target in the care of schizophrenia.

Objective

To assess the effectiveness of the cognitive subprograms of Integrated Psychological Therapy (IPT) on symptomatological, neuropsychological and functional outcome variables and to analyze the relationships between cognitive and functional outcome changes in schizophrenia.

Methods

Thirty-two patients with schizophrenia were assigned to cognitive remediation (IPT-cog) or usual rehabilitative interventions in a naturalistic setting of care. Clinical, neuropsychological and functional outcome variables were assessed at baseline and after 24 weeks of treatment.

Results

The IPT-cog group improved significantly more than the comparison group with respect to psychopathological and functional outcome variables. Moreover, only the IPT-cog group improved significantly in the neuropsychological domains of verbal and working memory, with specific significant correlations between neurocognitive performance and functional outcome changes.

Conclusions

The results of the study confirm the effectiveness of the cognitive remediation component of IPT in schizophrenia, and indicate that some of the changes in functional outcome may be mediated by improvement in specific cognitive domains.     

认知矫正治疗慢性精神分裂症患者认知功能缺陷的随机对照研究

目的 探讨认知矫正治疗(CRT)和计算机认知矫正治疗(CCRT)对精神分裂症患者认知缺陷的疗效.方法 180例慢性期病情稳定的精神分裂症患者随机分成3组,CCRT组、CRT组和工娱治疗(WAT)组.CCRT组108例,治疗以自主开发的计算机认知矫正治疗系统为工具,每周4次,每次45 min,持续3个月;CRT组36例,以Ann Delahunty和Rodney Morice等制定的神经认知矫正手册(汉化)为治疗工具,在治疗师的指导下进行认知矫正治疗;WAT组36例,接受相同时间的工娱治疗.3组在治疗频度和治疗持续时间上完全一致.治疗前后及治疗结束后第3个月分别进行临床症状和认知功能评定,内容包括阳性和阴性症状量表(PANSS)、精神分裂症认知功能成套测验(MCCB)、威斯康星卡片分类测验(WCST).结果 治疗结束后及随访第3个月时,CCRT组和CRT组在改善WCST完成分类数、连线测验、空间广度方面显著优于WAT组(P均＜0.05);CCRT组在空间广度方面明显优于CRT组(P＜0.05),CRT组在符号编码方面则优于CCRT组(P＜0.05);3组的临床症状在治疗结束及随访阶段无明显变化.结论 CCRT和CRT均能显著改善慢性精神分裂症患者的认知功能,主要表现在记忆、执行功能、精神运动速度方面;CCRT在空间记忆方面较CRT有优势,CRT在精神运动方面较CCRT有优势,CCRT和CRT在执行功能、记忆、精神运动速度等方面的疗效能持续3个月.     

The role of premorbid adjustment in schizophrenia: Focus on cognitive remediation outcome

ABSTRACT

Premorbid adjustment has been associated with several outcomes in schizophrenia and has been proposed as an index of cognitive reserve. This study aims to comprehensively analyse the relation between premorbid adjustment and clinical, neurocognitive, socio-cognitive and functional assessments, as well as to investigate the effect of premorbid adjustment on cognitive improvements after a cognitive remediation therapy protocol. Seventy-nine clinically stabilised outpatients with schizophrenia underwent a combined intervention consisting of cognitive remediation therapy added to standard rehabilitation therapy. All patients were assessed at baseline for psychopathology, premorbid adjustment, intellectual level, cognition and functioning. Cognitive evaluations were also repeated after the intervention. At baseline, significant correlations were observed between premorbid adjustment and working memory. The global cognitive improvement after treatment was significantly predicted by age and premorbid adjustment. This study confirms the association between premorbid adjustment and cognitive impairment and is the first to highlight the possible role of premorbid adjustment on the capacity to recover from cognitive deficits through a cognitive remediation therapy protocol. The data suggest that cognitive remediation may be particularly effective for people in the early course and that the assessment of premorbid adjustment could be of value to design individualised interventions.     

Computer-assisted cognitive remediation for schizophrenia: a randomized single-blind pilot study

Cognitive impairment is a core symptom in schizophrenia that has a significant impact on psychosocial function, but shows a weak response to pharmacological treatment. Consequently, a variety of cognitive remediation strategies have been evaluated to improve cognitive function in schizophrenia. The efficacy of computer-based cognitive remediation as a stand-alone intervention on general measures of neuropsychological function remains unclear. We tested the effectiveness of biweekly training using computerized cognitive remediation programs on neuropsychological and event-related potential outcome measures. Schizophrenia patients were randomly assigned to cognitive remediation training (N=17), active control (TV-watching; N=17), or treatment-as-usual (N=10) groups for ten weeks and run in parallel. Cognitive and ERP measures revealed no differential improvement over time in the cognitive remediation group. Practice effects might explain change over time on several cognitive measures for all groups, consistent with studies indicating task-specific improvement. Computer-assisted cognitive remediation alone may not be sufficient for robust or generalized effects on cognitive and electrophysiological measures in schizophrenia patients.     

Abbreviated neuropsychological assessment in schizophrenia: prediction of different aspects of outcome

The aim of this study was to identify the best subset of neuropsychological tests for prediction of several different aspects of functioning in a large (n = 236) sample of older people with schizophrenia. While the validity of abbreviated assessment methods has been examined before, there has never been a comparative study of the prediction of different elements of cognitive impairment, real-world outcomes, and performance-based measures of functional capacity. Scores on 10 different tests from a neuropsychological assessment battery were used to predict global neuropsychological (NP) performance (indexed with averaged scores or calculated general deficit scores), performance-based indices of everyday-living skills and social competence, and case-manager ratings of real-world functioning. Forward entry stepwise regression analyses were used to identify the best predictors for each of the outcomes measures. Then, the analyses were adjusted for estimated premorbid IQ, which reduced the magnitude, but not the structure, of the correlations. Substantial amounts (over 70%) of the variance in overall NP performance were accounted for by a limited number of NP tests. Considerable variance in measures of functional capacity was also accounted for by a limited number of tests. Different tests constituted the best predictor set for each outcome measure. A substantial proportion of the variance in several different NP and functional outcomes can be accounted for by a small number of NP tests that can be completed in a few minutes, although there is considerable unexplained variance. However, the abbreviated assessments that best predict different outcomes vary across outcomes. Future studies should determine whether responses to pharmacological and remediation treatments can be captured with brief assessments as well.     

Predictors of treatment utilisation at cognitive remediation groups for schizophrenia: the roles of neuropsychological, psychological and clinical variables

The present study highlights the importance of carefully assessing neuropsychological functioning at the outset of cognitive remediation (CR) treatment. The effects of neuropsychological, psychological, and clinical variables on treatment utilisation (TU) in CR groups for individuals with schizophrenia were examined. Data included neuropsychological and psychosocial assessments conducted with 39 adult clients enrolled in CR as part of their ongoing outpatient therapy. TU was calculated using the percentage of sessions attended over a three-month period. Better global neuropsychological functioning (r = .46, p = .007), attention/working memory (r = .39, p = .03), and processing speed (r = .44, p = .01) were each associated with greater TU. Trend-level associations with TU were observed with executive functioning (r = .33, p = .06) and verbal learning (r = .23; p = .07). Higher rates of self-reported cognitive complaints were associated with lower TU (r = -.45, p = .01). Hierarchical regression analyses revealed that both objective and subjective indicators of neuropsychological functioning independently contributed to the prediction of TU. This information can serve to help providers develop empirically informed strategies to support their clients' CR treatment utilisation. The implications from these findings can be used as a way to provide ongoing guidance for service provision and can aid in improving CR treatment utilisation, and thus treatment effectiveness, in clinical settings.     

Autochthonous experience, heightened awareness, and perception distortion in patients with schizophrenia: a symptomatological study

Early symptoms of schizophrenia' (ESS) proposed by Nakayasu, are present during schizophrenic prodromal periods. Some of these symptoms can continue after the florid manifestation of the disease and the patients often experience them with ego-alien feelings. Autochthonous experience, heightened awareness, and perception distortion (AHP) were selected from the list of ESS. The aim of this study was to confirm both prevalence and specificity of AHP in patients with schizophrenia as well as the relevance of the presence of AHP to symptomatology of schizophrenia. A structured interview was conducted to identify the presence of AHP in three groups of subjects; a schizophrenia group (Sc) with 37 patients, an affective disorder group (AD) with 27 patients, and a control group (NC) with 39 people. The prevalence of AHP was compared among the groups. Within the Sc, the relevance of AHP to Brief Psychiatric Rating Scale (BPRS) was assessed. AHP were present significantly more frequently in the Sc. The total scores for BPRS in the schizophrenic patients with AHP were significantly higher than in the patients without AHP. There was close correlation between AHP and BPRS items, with the degree of relevance depending on the form or perceptual domain. In conclusion, AHP were characteristic of patients with frank schizophrenia. To judge whether AHP were adequately specific to frank schizophrenia, further research of larger subjects is needed. Understanding the characteristics of AHP in patients with frank schizophrenia is important in the symptomatological evaluation of schizophrenia.     

Living situation,social network and outcome in schizophrenia: a five-year prospective follow-up study

A representative sample of 227 first-contact schizophrenic patients (according to DSM-III) was followed up for 5 years. The psychiatric teams responsible for the treatment of the patients conducted detailed standardized interviews with the patients at entry and at the end of the first, second and fifth years. Changes in patients’ clinical and functional outcome were analysed according to their living situation and social network. Positive changes in clinical state and functional ability were most prominent among patients who were living with their spouse. The social and functional outcome of men living with their parents was better than that of women in the same situation, while among patients living alone or with some other person the gender difference was reversed. Family environment can be of great importance to schizophrenic patients, supporting their clinical and functional recovery from psychosis. Patients living outside families — and men in particular — are at great risk of poor outcome, perhaps because they often lose their social contacts. In the treatment of such individuals a more active strategy of out-patient and rehabilitative care is therefore needed.     

Cognitive enhancement in schizophrenia: pharmacological and cognitive remediation approaches

This article discusses the measurement of cognition in schizophrenia, its role as a determinant of disability, and treatment efforts to date, including pharmacological and behavioral interventions as well as effective treatments that lead to improved outcomes. The measurement of functioning when patients with schizophrenia receive treatment in the office is addressed. The review focuses on new developments in the creation and adoption of a consensus method for the assessment of cognitive functioning in treatment studies, on the increased appreciation for assessment of functional skills in the prediction of everyday outcomes, and on developments in the basic neuroscience of cognition.     

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

ABSTRACT

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.     

Computerized cognitive remediation training for schizophrenia: an open label, multi-site, multinational methodology study

A recent single-site study (Fisher et al., 2009. Am J Psychiatry. 166 (7) 805-11) showed that repeated training with the Brain Fitness Program (BFP) improved performance on a battery of neuropsychological tasks. If replicated these data suggest an important non-pharmacological method for ameliorating cognitive impairment in schizophrenia. Our study evaluated the BFP training effects in an open-label, multi-site, multinational clinical trial. Fifty-five stable adult patients with schizophrenia on regular antipsychotic medication completed ≥ 32 BFP training sessions over 8-10 weeks. Training effects on cognitive performance and functional capacity outcome measures were measured using CogState? schizophrenia battery, UCSD Performance based Skills Assessment (UPSA-2) and Cognitive Assessment Interview (CAI). BFP training showed a large and significant treatment effect on a training exercise task (auditory processing speed), however this effect did not generalize to improved performance on independent CogState? assessment. There were no significant effects on UPSA-2 or CAI scores. Our study demonstrated the feasibility of implementing BFP training in a multi-site study. However, BFP training did not show significant treatment effects on cognitive performance or functional capacity outcome measures despite showing large and significant effects on a training exercise.     

A cognitive neuropsychological approach to the study of delusions in late-onset schizophrenia

Objective. Hypotheses to explain delusion formation include distorted perceptual processing of meaningful stimuli (eg faces), abnormal reasoning, or a combination of both. The study investigated these hypotheses using standardized neuropsychological tests. Design. A three-patient case-study, compared with a small group (n = 8) of age-matched normal control subjects. Setting. Hospital in- and outpatients. Age-matched normal controls were from local residential homes. Patients. Three subjects with late-onset schizophrenia, two currently deluded and one in remission. Both deluded subjects had persecutory beliefs. One had a delusion of misidentification. Interventions. All subjects were administered standardized neuropsychological tests of facial processing and tests of verbal reasoning. Main outcome measures. The test scores of the three patients were compared with published normal values and the age-matched control data. Results. The tests demonstrated impaired matching of unfamiliar faces in deluded subjects, particularly in the subject with delusional misidentification. Increasing the emotional content of logical reasoning problems had a significant effect on the deluded subjects' reasoning but not that of the normal controls. Conclusion. The findings suggest impaired visual processing plus abnormal reasoning in deluded subjects. However, these impairments are relatively subtle given the severity of psychiatric disorder in the patients studied. © 1997 John Wiley & Sons, Ltd.     

Mild cognitive impairment in different functional domains and incident Alzheimer's disease

BACKGROUND: Little is known about factors that predict transition from mild cognitive impairment to Alzheimer's disease (AD). OBJECTIVE: To examine the relation of impairment in different cognitive systems to risk of developing AD in persons with mild cognitive impairment. METHODS: Participants are 218 older Catholic clergy members from the Religious Orders Study. At baseline, they met criteria for mild cognitive impairment based on a uniform clinical evaluation that included detailed cognitive testing. Evaluations were repeated annually for up to 10 years. Analyses were controlled for age, sex, and education. RESULTS: Eighty two persons (37.6%) developed AD. In separate analyses, episodic memory, semantic memory, working memory, and perceptual speed, but not visuospatial ability, were associated with risk of AD, but when analysed together only episodic memory and perceptual speed were associated with AD incidence, with the effect for episodic memory especially strong. Overall, those with impaired episodic memory were more than twice as likely to develop AD as those with impairment in other cognitive domains (relative risk (RR) = 2.45; 95% confidence interval (CI): 1.53 to 3.92), and they experienced more rapid cognitive decline. Lower episodic memory performance was associated with increased risk of AD throughout the observation period, whereas impairment in other cognitive domains was primarily associated with risk during the following year but not thereafter. CONCLUSION: Among persons with mild cognitive impairment, episodic memory impairment is associated with a substantial and persistent elevation in risk of developing AD compared to impairment in other cognitive systems.     

Determinants of real-world functional performance in schizophrenia subjects: correlations with cognition, functional capacity, and symptoms

OBJECTIVE: Impairments in adaptive life skills are a major source of disability in patients with schizophrenia. The relationship between adaptive life skills in real-world settings and performance on neuropsychological tests may be complicated by other factors that interfere with deployment of skills. Assessment of the ability to perform life skills under optimal conditions (i.e., assessment of functional capacity) has been proposed as a means to clarify these relationships. METHOD: The authors examined cross-sectional data from a study of the course of neuropsychological and adaptive life skills of older (age 50-85) schizophrenia patients (N=78). Functional capacity was examined with a performance-based measure (UCSD Performance-Based Skills Assessment), and case managers rated real-world adaptive functions (i.e., interpersonal skills, work skills, and community activities). Neuropsychological performance was assessed with a comprehensive battery, while symptoms were assessed with patient self-report and clinical ratings. RESULTS: Confirmatory path analyses were used to evaluate the effects of neuropsychological performance, functional capacity, and symptoms on the various domains of real-world functioning. Neuropsychological performance predicted functional capacity, which predicted all three domains of real-world functioning. Depression predicted interpersonal and work skills, while negative symptoms affected interpersonal skills independently of other predictors. CONCLUSIONS: Real-world adaptive life skills are predicted by neuropsychological performance, symptoms, and functional capacity. Neuropsychological performance contributes little to the prediction of real-world performance after accounting for functional capacity. In some domains, negative and depressive symptoms influenced real-world performance while not relating to functional capacity or neuropsychological performance.     

Premorbid adjustment as predictor of outcome in schizophrenia: results of a prospective study

Bailer J, Bräuer W, Rey E-R. Premorbid adjustment as predictor of outcome in schizophrenia: results of a prospective study. Acta Psychiatr Scand 1996: 93: 368–377. © Munksgaard 1996. The present prospective follow-up study of 163 schizophrenic patients admitted to hospital for the first time examined the relationship between premorbid adjustment and different measures of the 3-year course and outcome. The same instruments had been used in all phases of the study. The Premorbid Adjustment Scale was used to assess premorbid social functioning. Outcome measures were positive symptoms, negative symptoms, social disability and number of rehospitalizations. The results of the multiple regression analyses showed that premorbid adjustment was the strongest overall predictor of outcome. Premorbid adjustment was significantly associated with negative symptoms and social disability over the 3-year course of illness. In a further step, we examined the relationship between good, moderate and poor premorbid adjustment and the course of positive symptoms, negative symptoms and social disability within the first 3 years after index admission. The most important finding was that premorbid functioning showed a stronger correlation with the course of negative symptoms and social disability than with the course of positive symptoms. Poor premorbid social functioning implies a poor social course of the illness. Female subjects showed better premorbid functioning than male subjects. Good premorbid adjustment was strongly associated with an acute onset of the illness, and poor premorbid adjustment with an insidious onset.     

Childhood cognitive functioning in schizophrenia patients and their unaffected siblings: a prospective cohort study

While it is known that children of schizophrenia parents perform more poorly on tests of cognitive functioning than children of normal parents, less certain is the degree to which such deficits predict schizophrenia outcome, whether cognitive functioning deteriorates during childhood in preschizophrenia individuals, and whether nongenetic etiologic factors (such as obstetric complications) contribute to these deficits. In the present study, 72 patients with schizophrenia or schizoaffective disorder, 63 of their siblings not diagnosed with schizophrenia, and 7,941 controls with no diagnosis were ascertained from a birth cohort whose members had been evaluated with standardized tests of cognitive functioning at 4 and 7 years of age. Adult psychiatric morbidity was ascertained via a longitudinal treatment data base indexing regional public health service utilization, and diagnoses were made by review of all pertinent medical records according to DSM-IV criteria. Both the patients with schizophrenia and their unaffected siblings performed significantly worse than the nonpsychiatric controls (but did not differ from each other) on verbal and nonverbal cognitive tests at 4 and 7 years of age. Preschizophrenia cases and their siblings were increasingly overrepresented across decreasing quartiles of the performance distributions. There was not significant intra-individual decline, and there were no significant relationships between obstetric complications and test performance among the preschizophrenia subjects. These results suggest that during the period from age 4 to age 7 years, premorbid cognitive dysfunction in schizophrenia represents a relatively stable indicator of vulnerability deriving from primarily genetic (and/or shared environmental) etiologic influences.     

Effect of endoscopic third ventriculostomy on neuropsychological outcome in late onset idiopathic aqueduct stenosis: a prospective study

OBJECTIVE: To undertake a prospective study of the long term neuropsychological outcome in patients with late onset idiopathic aqueduct stenosis (LIAS) after endoscopic third ventriculostomy. METHODS: Six patients with LIAS were evaluated pre- and postoperatively using magnetic resonance imaging (MRI) and standardised psychometric testing procedures. Endoscopic third ventriculostomy was done using standard surgical techniques. The mean long term follow up was 81.2 weeks. RESULTS: Preoperatively, all patients had cognitive impairment, four of them showing deficits in several cognitive domains. After endoscopic third ventriculostomy, all patients improved clinically and had ventricular size reduction on MRI. Postoperative neuropsychological testing showed that five patients achieved normal or near normal cognitive functions, and one improved moderately. CONCLUSIONS: Endoscopic third ventriculostomy caused a substantial improvement in the neuropsychological deficit of LIAS patients. This was also true for patients with enlarged ventricles that might be diagnosed radiologically as "arrested hydrocephalus."     

A feasibility study of a new computerised cognitive remediation for young adults with schizophrenia

Cognitive remediation therapy is effective for improving cognition, symptoms and social functioning in individuals with schizophrenia; however, the impact on visual episodic memory remains unclear. The objectives of this feasibility study were: (1) to explore whether or not CIRCuiTS—a new computerised cognitive remediation therapy programme developed in England—improves visual episodic memory and other cognitive domains in young adults with early course schizophrenia; and (2) to evaluate acceptability of the CIRCuiTS programme in French-Canadians. Three participants with visual episodic memory impairments at baseline were recruited from clinical settings in Canada, and consented to participate. Neuropsychological, clinical and social functioning was evaluated at baseline and post-treatment. Intervention involved 40 sessions of cognitive remediation. First, the reliable change index (RCI) revealed that each participant demonstrated significant post-therapy change in episodic memory and in other cognitive domains. The response profile was characterised by the use of organisational strategies. Second, the treatment was considered acceptable to participants in terms of session frequency (number of sessions per week), intensity (hours per week; total hours), and number of missed sessions and total completed sessions. This preliminary study yielded encouraging data demonstrating the feasibility of the CIRCuiTS programme in French-Canadian young adults with schizophrenia.