The nuts and bolts of Cognitive Remediation:Exploring how different training components relate to cognitive and functional gains

Background: Cognitive Remediation (CR) is an evidence based treatment targeting cognitive and functional difficulties in people with psychosis. Despite the large number of effectiveness studies, only limited evidence exists for the active ingredients of this therapy. This study begins to fill this gap by exploring the relationship between CR ingredients, including alliance with a therapist, and therapy outcomes. Method: This is a secondary analysis based on data from a published randomised controlled trial comparing CR + treatment-as-usual (TAU) to TAU alone. We considered the association between CR active ingredients including errorless learning, massed practice, strategy use and therapeutic alliance on the cognitive, functioning and symptom outcomes that significantly improved following therapy. Results: Forty-six of the 96 participants were randomised to CR. After therapy the CR group showed significant improvement in non-verbal memory, functioning and approaching significance, improvements in executive functions. All therapy ingredients were inter-related but strategy use alone was associated therapeutic alliance. Cognitive improvements were associated with massed practice, number of useful strategies and therapeutic alliance, but improvements in functioning were associated only with therapeutic alliance. Conclusions: These findings build the evidence base for the usefulness of specific therapy components. As for other psychological therapies it appears that therapeutic alliance may be an important factor in driving change for key CR outcomes, particularly functioning, in people with psychosis

Cognitive remediation in schizophrenia-now it is really getting personal

Cognitive problems are consistently documented in people with schizophrenia. They negatively influence functioning and contribute to the long term consequences of the illness. Cognitive remediation (CR) is a psychological intervention developed to target these cognitive difficulties. There is evidence that CR is beneficial but there is still a limited understanding of how the putative active therapy ingredients contribute to changes in the brain and translate into improved functioning. This paper reviews recent research focused on topics that, in our view, will drive future developments such as the identification of translational mechanisms, the personalisation of CR, the best implementation methods and potential augmenting strategies to improve treatment effectiveness.</p

Group cognitive remediation for schizophrenia:Exploring the role of therapist support and metacognition

ObjectivesCognitive remediation (CR) is a therapy targeting cognitive difficulties in psychiatric disorders. We recently develop a novel CR program for people with psychosis with a focus on metacognitive skills individually supported by a therapist. This study aims to assess the acceptability and feasibility of implementing CR in small groups where therapist support is shared amongst service users.DesignControl group design with non-randomized group allocation.MethodTwenty-five service users with a diagnosis of schizophrenia participated. Ten received group CR and 15 individual CR (i.e., one therapist for each service user). Both therapy formats were supported by one therapist. Participants were assessed before and after therapy with neuropsychological tests assessing different cognitive domains, self-assessed cognitive complaints, and psychotic symptoms. Treatment satisfaction questionnaires and therapist's session ratings were also collected for group CR.ResultsDropout rate was 20% for both methods. Session attendance was 74% for group CR and 86% for individual CR. Service users evaluated positively group CR and considered it helpful; therapists rated this delivery format feasible. Exploratory analysis suggested that the two methods have similar effects on cognition. After therapy, service users showed improvements in recall memory, reduced negative symptoms, and reported fewer cognitive complains.ConclusionsIt is feasible and acceptable for people with schizophrenia to take part in small CR therapy groups. The reduced therapist contact compared to individual therapy was well tolerated and may help sustain independent work. The small group format allows therapists to spend sufficient time to support the use of metacognitive strategies.Practitioner pointsCR small groups are feasible and acceptable for service users and therapists.Therapist support can be shared.Metacognitive-based CR can improve cognition and may benefit awareness and negative symptoms

Cognitive Remediation Is an Evidence-Based Psychological Therapy:Isn’t It Time It Was Treated Like One?

Cognitive remediation (CR) is an evidenced-based intervention, but is not consistently included in clinical guidelines, nor implemented widely in mental health services, and is still not fully accepted as a psychological therapy. This is despite demonstrating a boost to recovery, and reductions in health care costs. We describe potential issues as CR matures into a widely accepted and used psychological therapy by drawing on high-quality evidence from reviews and meta-analyses and specifically highlight how CR uses therapeutic formulation, similar to other psychological therapies, to address specific client needs. Most evidence is for those with a diagnosis of schizophrenia, but we also consider CR benefits for other mental health conditions. Data emerging from different health systems are, at last, providing information on how CR is used, disseminated and practice standards maintained. This may be the information needed to support further implementation, expansion, and consolidation of CR use globally.</p

Lessons learnt? The importance of metacognition and its implications for Cognitive Remediation in schizophrenia

The cognitive problems experienced by people with schizophrenia not only impede recovery but also interfere with treatments designed to improve overall functioning. Hence there has been a proliferation of new therapies to treat cognitive problems with the hope that improvements will benefit future intervention and recovery outcomes. Cognitive remediation therapy (CR) that relies on intensive task practice can support basic cognitive functioning but there is little evidence on how these therapies lead to transfer to real life skills. However, there is increasing evidence that CR including elements of transfer training (e.g. strategy use and problem solving schemas) produce higher functional outcomes. It is hypothesised that these therapies achieve higher transfer by improving metacognition. People with schizophrenia have metacognitive problems; these include poor self-awareness and difficulties in planning for complex tasks. This paper reviews this evidence as well as research on why metacognition needs to be explicitly taught as part of cognitive treatments. The evidence is based on research on learning spanning neuroscience to the field of education. Learning programmes, and CRT, may be able to achieve better outcomes if they explicitly teach metacognition including metacognitive knowledge (i.e. awareness of the cognitive requirements and approaches to tasks) and metacognitive regulation (i.e. cognitive control over the different task relevant cognitive requirements). These types of metacognition are essential for successful task performance, in particular, for controlling effort, accuracy and efficient strategy use. We consider metacognition vital for the transfer of therapeutic gains to everyday life tasks making it a therapy target that may yield greater gains compared to cognition alone for recovery interventions

A systematic review with meta-analyses of the association between stigma and chronic pain outcomes

Stigma is common in people experiencing chronic pain and there are indications that it may adversely affect pain outcomes. However, to date, there is no systematic review exploring the impact of stigma on chronic pain-related outcomes. This systematic review and meta-analysis aimed to examine the association between stigma and key chronic pain outcomes and differences in stigma between pain conditions. Seven databases were searched for studies reporting a measure of association between stigma and at least one pain outcome in adults with chronic pain. Studies were screened by 2 independent researchers. Nineteen studies met eligibility criteria and data were extracted, quality-assessed, and narratively synthesised and meta-analysed where possible. Meta-analyses of bivariate cross-sectional correlations demonstrated significant positive correlations between stigma and pain intensity, disability, and depression, with small to moderate effects. Data from 2 prospective studies and those only reporting multivariate analyses that were not included in meta-analyses further supported these findings. There was some evidence that individuals who experience pain conditions with less clear pathophysiology may report greater stigma, although more research is needed. The review highlights that there is a growing number of studies on stigma in the pain field showing an adverse association between stigma and chronic pain outcomes.</p

Predicting inpatient aggression in forensic services using remote monitoring technology:Qualitative study of staff perspectives

Background: Monitoring risk of imminent aggression in inpatient forensic mental health services could be supported by passive remote monitoring technology, but staff attitudes towards the relevance and likelihood of engagement with this technology are unknown. Objective: This study aimed to explore staff views, specifically potential benefits and implementation barriers, towards using this technology for monitoring risk of inpatient aggression.Methods: Five semi-structured focus groups were conducted with 25 nurses in an inpatient forensic mental health service. Thematic analysis with two independent raters was used to identify themes and subthemes related to staff attitudes towards passive remote monitoring. Subsequent member-checking was conducted to ensure the validity of the themes identified by the raters. Results: Five main themes were identified, one of which concerned the potential benefits that passive remote monitoring could provide for monitoring risk of aggression. Staff suggested it could provide an early warning of impending aggression and enable support to be provided earlier. The remaining themes concerned implementation barriers, including risks to the users’ physical and mental wellbeing; data security concerns and potential access by third parties; the negative impact of a constant stream of real-time data on staff workload; and design characteristics and user awareness of the benefits of passive remote monitoring.Conclusions: Passive remote monitoring technology could support existing methods of monitoring inpatient aggression risk, but multiple barriers to implementation exist. Empirical research is required to investigate whether these potential benefits can be realised, and to identify ways of addressing these barriers to ensure acceptability and user-engagement.<br/

Investigating the empirical support for therapeutic targets proposed by the temporal experience of pleasure model in schizophrenia:A systematic review

BackgroundAnhedonia and amotivation are substantial predictors of poor functional outcomes in people with schizophrenia and often present a formidable barrier to returning to work or building relationships. The Temporal Experience of Pleasure Model proposes constructs which should be considered therapeutic targets for these symptoms in schizophrenia e.g. anticipatory pleasure, memory, executive functions, motivation and behaviours related to the activity. Recent reviews have highlighted the need for a clear evidence base to drive the development of targeted interventions.ObjectiveTo review systematically the empirical evidence for each TEP model component and propose evidence-based therapeutic targets for anhedonia and amotivation in schizophrenia.MethodFollowing PRISMA guidelines, PubMed and PsycInfo were searched using the terms “schizophrenia” and “anhedonia”. Studies were included if they measured anhedonia and participants had a diagnosis of schizophrenia. The methodology, measures and main findings from each study were extracted and critically summarised for each TEP model construct.Results80 independent studies were reviewed and executive functions, emotional memory and the translation of motivation into actions are highlighted as key deficits with a strong evidence base in people with schizophrenia. However, there are many relationships that are unclear because the empirical work is limited by over-general tasks and measures.ConclusionsPromising methods for research which have more ecological validity include experience sampling and behavioural tasks assessing motivation. Specific adaptations to Cognitive Remediation Therapy, Cognitive Behavioural Therapy and the utilisation of mobile technology to enhance representations and emotional memory are recommended for future development