While the immediate goal of CR is to improve cognition, the ultimate goal is to improve functioning in daily tasks—including school, work, social interactions, and independent living. CR might be used to help someone become more attentive so that he can better focus on schoolwork, household tasks, or job responsibilities. CR has been most studied as a treatment for people with schizophrenia and schizoaffective disorder, but it is increasingly being applied to other populations as well. Clinical trials are under way to evaluate the effectiveness of CR therapy for patients who have cognitive impairment associated with major depression, anorexia nervosa, ADD, Alzheimer disease, and substance abuse disorders.5-9
The need for cognitive remediation
Patients should be referred to CR therapy when it is apparent that cognitive deficits are interfering with functional outcome. Formal cognitive assessment will help determine whether there are cognitive deficits, but if this is not available, then observation of behavior, a thorough patient history, and inquiries about perceived cognitive symptoms will also identify the need for CR. Unfortunately, because about half of the people with schizophrenia have significant cognitive impairments but are not aware of them, it is not advisable to rely only on a patient’s self-report.10 A careful interview designed to uncover problems following schedules, sustaining attention, or following instructions can also be useful. When formal cognitive testing is available, brief, 45-minute assessments, such as the Brief Assessment of Cognition in Schizophrenia (BACS) or the MATRICS Consensus Cognitive Battery (MCCB), would identify whether CR is indicated and what aspects of cognition should be targeted.
Because significant cognitive impairments are evident at the first episode of schizophrenia, all patients, regardless of age and disease chronicity, should be considered candidates for CR. In people with other psychotic disorders, a good guideline for determining treatment appropriateness is whether cognitive impairment is affecting the ability to achieve functional goals.
Henry had a first psychotic episode while he was a junior in engineering school, and after 2 hospitalizations, schizophrenia was diagnosed. His symptoms were stabilized with risperidone(Drug information on risperidone) and benztropine. Henry now lives with his girlfriend and works part-time at a computer store. His family reports that he is not functioning anywhere near the level he displayed before the onset of symptoms. He forgets to meet friends, loses personal items, and has less problem-solving capacity. Once a proficient cook, he now burns food and uses the wrong proportions of ingredients. He wants to work full-time but has trouble focusing, and he is starting to get discouraged about his future options.
The treatment plan for Henry consists of optimizing cognitive benefits from pharmacotherapy, psychoeducation for Henry and his family about the cognitive symptoms of schizophrenia, and referrals to CR and to supportive employment and educational services.
A context for cognitive remediation
CR is best done within the context of a rehabilitation-oriented program so it is possible to integrate the goals of CR with overall rehabilitation goals.2,11 This integration of therapeutic modalities appreciates the complex interaction of cognitive, emotional, and environmental variables in the recovery process and identifies cognitive deficits not only as a manifestation of brain dysfunction but more specifically as social-cognitive dysfunction.
Rehabilitation programs focus on skills development and seek to give patients the tools to function adaptively and independently in society. Patients can more readily understand the need for CR if they link the benefits of improved cognition with attainment of their recovery goals. For example, CR has been successfully linked with supportive employment. Participants who attend both rehabilitation and CR programs have better vocational outcomes.12