Effectiveness of cognitive remediation
Numerous randomized controlled trials of a variety of CR techniques have been performed in both laboratory and clinical settings around the world. Most of these studies have been of people who have cognitive deficits secondary to psychotic disorders, such as schizophrenia. These studies have been reviewed in several meta-analyses that, while differing in focus, have generally showed moderate to large effect sizes.13-16
As can be seen in the Figure, the effect sizes vary in accordance with the goals of treatment. When the studies had a highly proximal goal of improvement on a training task, the effect size was large. When the goals of training became more distal and were affected by a multiplicity of variables, the effect sizes diminished. Still, moderate-range effect sizes were found both for CR studies that used neuropsychological test results as an outcome measure and for the studies with the most distal goal of improving daily functioning. Taken together, this literature informs us that remediation effects persist up to 6 months after CR stops and that the cognitive gains generalize to improvements in social behaviors, real-world problem-solving ability, and occupational outcome.4,17-20 Patient populations amenable to remediation programs include those in acute care and institutionalized settings, those in supportive housing and intensive day treatment programs, and higher-functioning people in outpatient treatment.2,21-26
Findings from randomized controlled trials indicate that integration of CR with other psychiatric rehabilitation interventions, such as supported employment and social skills training, is more effective than individual approaches in achieving overall psychiatric rehabilitation.12,27-29 Patients in work therapy programs that incorporated CR maintained greater vocational benefits (were more likely to work, worked longer, and earned more), even at 3-year follow-up, than did those who received work therapy alone.30
An overview of cognitive remediation strategies
While all CR programs focus on cognition, there is considerable diversity in specific approaches. One basic distinction is whether they use a restorative or a compensatory approach, or both. A restorative approach to CR attempts to directly repair impaired cognitive skills by using drill and practice exercises. Compensatory remediation techniques do not attempt to restore the impaired cognitive skill but rather to compensate for, or circumvent, the deficit with reliance on intact cognitive skills. Environmental manipulation is one compensatory technique that refers to changes in the environment that are made to facilitate optimal cognitive functioning. The use of a key hook by the door is an example of environmental manipulation.
Most CR programs use computers, although some programs exclusively use paper and pencil tasks and verbal discussions. While the majority of computer-based CR programs use one designated software package that targets either one or multiple cognitive skills, a few programs employ a range of software packages to target multiple areas of cognitive functioning.2 The Neuropsychological Educational Approach to Remediation (NEAR) is a CR program that developed a rubric for evaluating software exercises. The NEAR rubric takes into account not only the cognitive skill being targeted but also how the exercise works.2 For example, it considers whether the exercise is likely to be engaging and motivating in addition to whether it targets attention or working memory.
CR programs vary, depending on whether they are for individuals or groups. When a group approach is used, there are differences in whether the group does the same activity all together or whether participants work independently on an individualized program of exercises. The sessions are usually held 2 or 3 times a week (range, 1 to 10 hours). Active treatment typically lasts 3 to 6 months but can range from several weeks to 2 years, depending on the treatment setting, goals, and/or severity of deficits.
Another distinction between programs is whether they exclusively focus on neuroscience-based drill and practice exercises assumed to reactivate and restore specific brain regions or whether they additionally provide compensatory and bridging activities to translate neuropsychological gains into real-world change. Bridging is a technique that promotes generalization by making explicit connections between the cognitive skills acquired during sessions and the application of these skills in everyday life.2 Group discussions promote bridging by encouraging patients to talk about the ways in which the skills they are using to complete the software exercises are relevant to daily life. This may be supplemented by in vivo work with a coach, who accompanies the patient into the community to observe and guide the application of cognitive skills to everyday tasks.
CR is an evidenced-based treatment for the neurocognitive deficits seen in schizophrenia and psychotic disorders, and it is increasingly being investigated for use in additional psychiatric disorders. Narrowly defined, CR is a set of cognitive drills or compensatory interventions designed to enhance cognitive functioning. However, from the vantage point of the psychiatric rehabilitation field, CR engages the patient in a learning activity to enhance the neurocognitive skills relevant to overall recovery goals.2,11 CR programs vary in the extent to which they reflect these narrow or broader perspectives, and there is ongoing research to identify the active ingredients that result in a positive response to treatment.
Questions remain about adequate dosing, whether booster sessions are necessary, who is best suited to provide the treatment, and the relative merits of specific instructional techniques. Multisite trials indicate the ease and efficacy of dissemination, yet CR programs are still largely unavailable to patients.31 It is hoped that as more information about CR becomes available, this situation will improve.
Drugs Mentioned in This Article
Benztropine mesylate oral (Cogentin) Risperidone(Drug information on risperidone) (Risperdal)