Cognitive Remediation Therapy (CRT) is a treatment option for people with schizophrenia to improve cognitive abilities essential to functioning in social or professional settings, such as attention, memory and planning.
While schizophrenia only affects one percent of the general population, many with the disorder struggle to find and maintain effective treatment over the course of their chronic illness. Factors such as care inaccessibility, housing insecurity, unemployment and limited resources in a community, can determine a person’s ability to receive effective treatment. There is a growing trend to attempt to computerize therapy options to increase availability and decrease the cost and timeline needed for relief.
The following studies investigate the use and effects of computerized and computer-assisted cognitive remediation programs. Awareness of these emerging options may allow psychologists and other professionals to provide treatment to a wider and more at-risk population.
In addition to reviewing the following research summaries, psychologists are encouraged to explore the literature more completely to determine what may be useful to them in practice.
Subramaniam, K., Luks, T.L., Garrett, C., Chung, C., Fisher, M., Nagarajan, S., & Vinogradov, S. (2014). Intensive cognitive training in schizophrenia enhances working memory and associated prefrontal cortical efficiency in a manner that drives long-term functional gains. NeuroImage, 99, 281-292.
Working memory is a universal deficit in the lives of people with schizophrenia, taking extreme tolls on functional competency. The location of necessary activation in the brain has been pinpointed and mapped to the middle front gyri (MFG), and now researchers are attempting to develop a program that will not only reactivate these areas, but will also train and repair those pathways in a clinical application. The authors of this study claim that computerized cognitive remediation training in schizophrenia can improve working memory performance and increase signal efficiency of associated MFG circuits for lasting effects.
Thirty people with schizophrenia and thirteen healthy control participants performed a cognitive task involving working memory while undergoing a Functional Magnetic Resonance Imaging (fMRI) scan. Participants with schizophrenia were then randomly assigned to the computerized cognitive training (SZ-AT) or to a control condition of commercial computer games for 80 hours of training sessions over 16 weeks. The same cognitive task was done under an fMRI at the end of treatment and again at a six-month follow up to assess changes over time and estimate lasting effects. In the time between the end of treatment and the six-month follow up, participants did not practice the cognitive tasks, but continued with other, existing treatment such as medication. The researchers also used the Positive and Negative Syndrome Scale (PANSS), the Letter-Number Span from the MATRICS neurocognitive battery, and the Quality of Life Scale (QLS) before and after treatment to understand the participant’s change in symptoms, verbal working memory and real-life functioning.
The treatment group that received computerized cognitive remediation therapy saw significant results in cognitive functioning and restored brain activity. While the computer game condition group did not have significant improvements, SZ-AT had improved verbal working memories, occupational functioning and a decrease in disorganized symptoms. This was correlated with an increased efficiency in the right middle front gyri and enhanced connectivity in the prefrontal neural networks. By the end of treatment there were no quantitative differences in activation levels between the healthy control participants and the participants with schizophrenia. These cognitive and neurological improvements remained strong at the six-month follow up and imply permanent repairs in their neurology.
Buonocore, M., Bosia, M., Bechi, M., Spangaro, M., Cavedoni, S., & Cocchi, F., … Cavallaro, R. (2017). Is longer treatment better? A comparison study of 3 versus 6 months cognitive remediation in schizophrenia. Neuropsychology, 31(4), 467-473.
Clinical scientists in Japan noticed that there was often a gap in the way cognitive functioning and social functioning were addressed in schizophrenia research and treatment, leaving people with deficits in real world competence and preparedness. Both components are necessary for success in relationships and work environments. The following study proposed that if the computerized cognitive remediation therapy program was supplemented with psychiatric rehabilitation, the cognitive skills gained from the program could be grounded in a foundation of social application, improving social functioning beyond baseline cognitive abilities.
The study, taking place at six different psychiatric facilities throughout Japan, consisted of 60 participants with schizophrenia, not currently taking first generation antipsychotics, being randomized into the cognitive remediation group or the treatment as usual group (TAU). The CRT group participated in 24 cognitive training sessions for 45 to 60 minutes twice a week, as well as a weekly group session that applied the skills they learned to practical applications. The TAU group received standard outpatient treatment, consisting of medication and voluntary programs like psychoeducation, social skills training, work therapy and group activities in the same six hospitals offered six hours a day, five days a week. Both groups were assessed in cognitive functioning, social functioning, and symptom severity before and after treatment using the Brief Assessment of Cognition in Schizophrenia-Japan (BACS-J), the Interpersonal Relations and Work subscales of the Life Assessment Scale for Mental Illness, and the PANSS.
The CRT group showed significantly greater improvement than the TAU group, especially in the domains of general cognitive functioning, processing speed, executive functioning, interpersonal relationships, work skills and overall psychiatric symptoms. There was a significant correlation between increased cognitive functioning and social functioning, suggesting computer-assisted therapy paired with group rehabilitation may provide an opportunity for individuals to practice and integrate new skills.
Iwata, K., Matsuda, Y., Sato, S., Furukawa, S., Watanabe, Y., Hatsuse, N., & Ikebuchi, E. (2017). Efficacy of cognitive rehabilitation using computer software with individuals living with schizophrenia: A randomized controlled trial in Japan. Psychiatric Rehabilitation Journal, 40(1), 4-11.
While computer-assisted cognitive remediation (CACR) shows promise as a treatment option for people with schizophrenia, it becomes important to understand what dose under what circumstances seems to produce change. The authors of this study evaluated the degree of improvement in the patient’s quality of life and cognitive functioning from different treatment durations.
Eighty-three participants followed, for at least six months, a Standard Rehabilitation Treatment (SRT) that focused on social and vocational skills, problem solving, and psychoeducation. From there, participants were randomly assigned to either a protocol consisting of 36 computerized sessions over three months and returning to SRT for three months; or were assigned to the group requiring 72 computerized sessions over six months. CACR sessions had a frequency of three times a week, each one lasting about 45 minutes. The computer training aimed to develop cognitive speed and attention, memory, and executive function. Participants were assessed for psychopathology, cognitive performance, and daily functioning before and after treatment using the BACS, the QLS, and the Wechsler Adult Intelligence Scale-Revised.
Both groups saw significant improvements in cognitive functioning and quality of life with no significant differences between the two treatment groups. Significant general change in cognition was achieved at the three-month mark of CACR sessions, and not further improved at six months. Three months of CACR was sufficient to address impaired cognitive functions and participants didn’t seem to benefit from additional training. The only function that significantly improved from the longer treatment with CACR was planning ability, an executive function. This finding suggests complex and abstract cognition takes longer to address in cognitive remediation therapy. However, it also implies that higher-level functions cannot be improved without addressing simpler cognitive skills like memory and attention first.
Clinical implications
Psychologists who work with individuals with schizophrenia are more likely to be in organizational settings with responsibilities to implement and oversee treatment. For those not already using computer assisted cognitive training in some fashion, the psychologist may wish to investigate different programs to support other ongoing treatment. The three studies suggest that such programs have the potential to convey important, lasting benefits that would likely complement the goals of group and individual therapy and rehabilitation. While less is known about characteristics of patients that seem to benefit the most from these programs, the studies provide some ideas regarding length of training and relationship to other kinds of interventions. In selecting computerized cognitive remediation programs, or making referrals to organizations that offer such care, psychologists may wish to consider what types of skills most need to be addressed and how improvements in those areas would support social and workrelated goals. More research is needed to better understand these relationships but these studies point to additional resources that hold promise for individuals struggling with disordered thinking and cognitive deficits.
APA’s Task Force on Serious Mental Illness and Severe Emotional Disturbance (TFSMI/SED) has many resources available for psychologists who work with these populations.