Is cognitive adaptation training (CAT) compensatory, restorative, or both?

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Abstract

Cognitive adaptation training (CAT) is a psychosocial treatment incorporating environmental supports including signs, checklists to bypass the cognitive deficits of schizophrenia. Our objective was to examine the association between CAT, functional outcomes, and cognitive test performance (cognition). The two research questions were as follows: 1) Does cognition mediate the effect of CAT intervention on functional outcome? 2) Does CAT impact cognitive test performance? A total of 120 participants with schizophrenia were randomized to one of three treatments: 1) CAT (weekly for 9 months; monthly thereafter), 2) generic environmental supports (given to participants on clinic visits to promote adaptive behavior), or 3) treatment as usual (TAU). Assessments of cognition and functional outcome were conducted at baseline, 9 and 24 months. Mediation analyses and mixed effects regression were conducted. Mediation analyses revealed that during the initial 9 months, the direct path from treatment group to functional outcome on the primary measure was positive and highly significant. CAT significantly improved functional outcome compared to the other treatments. However, paths involving cognition were negligible. There was no evidence that cognition mediated improvement in functional outcomes. At 24 months, cognition improved more in CAT compared to other treatment groups. The test for cognition mediating improvement in functional outcomes was not significant at this time point. However, improvement in functional outcome led to better performance on cognitive testing. We concluded that improvement in cognition is not a necessary condition for improvement in functional outcome and that greater engagement in functional behavior has a positive impact on cognition.

Introduction

Schizophrenia is a neurobiological disorder characterized by significant impairments in community functioning that are not directly improved by antipsychotic medication (Bellack et al., 2004). Schizophrenia is also associated with impairments in multiple domains of cognitive functioning including psychomotor speed, memory, attention and executive functioning (Saykin et al., 1991, Gold and Harvey, 1993, Nuechterlein et al., 2008, Palmer et al., 2009). These cognitive deficits are considered to be a core feature of the illness (Palmer et al., 2009), and since they are one of the most important predictors of functional outcome, they are an important treatment target (Green, 1996, Velligan et al., 1997, Velligan et al., 2002, Bowie and Harvey, 2005). For example, individuals with cognitive impairments often have trouble focusing their attention on an activity when distracting things are going on around them, and therefore may be unable to fill out a form while people are talking nearby, or they might start to wander after a few minutes. These cognitive impairments can inhibit a person's daily functioning in the community. While medication treatments in schizophrenia are being actively pursued, psychosocial treatments hold particular promise (Goff et al., 2011).

In general, psychosocial treatment strategies that address cognitive impairments in schizophrenia seek either to 1) directly improve cognitive abilities such as attention, and memory through a combination of drill, practice or integrated problem-solving exercises, or 2) bypass cognitive impairments using compensatory strategies (e.g., errorless learning) (Kern et al., 2003). Additionally, environmental supports, capitalizing on the individual's implicit processes, prompting behaviors without relying on effortful conscious initiation have proven beneficial in patients with schizophrenia (Velligan et al., 2006).

In cognitive remediation (CR) there are two main approaches: 1) restorative or cognition-enhancing and 2) compensatory, bypassing impaired cognitive networks to improve functioning (Wexler et al., 2000, Bell et al., 2003, Lindenmayer et al., 2008, Medalia and Choi, 2009, Wykes et al., 2011). The possibilities of cognitive rehabilitation have been expanded after the abandonment of the belief in the immutability of the central nervous system and the growing evidence in favor of a considerable degree of neuroplasticity even in the mature and aged brain by synaptogenesis and modulation of synaptic transmission (Berlucchi G., 2011). CR restorative interventions use computerized or pen-and-paper tasks targeting psychomotor speed, attention, memory and executive functions. There is evidence for the overall effectiveness of restorative cognitive remediation in improving performance on cognitive tasks (Wykes et al., 2007, Wykes et al., 2011, Medalia and Freilich, 2008, Medalia and Choi, 2009).

Moreover, research indicates that improvements in cognitive skills achieved in CR may also generalize to improvements in functioning in real world settings (Medalia and Choi, 2009, Wykes et al., 2011). The best evidence for this is the scientific productivity of Wexler and Bell (2005) and McGurk et al (2007) highlighting the combination of cognitive remediation and vocational services for better work outcomes than those obtained with vocational services alone. Average effect sizes for CR on cognition are moderate, while those for CR on functional outcomes are modest (Wykes et al., 2011). Overall, findings suggest that improving cognitive functioning is one method for improving functional outcome, and that CR is most effective when embedded within the context of other psychosocial treatments (Wykes et al., 2011).

An alternative approach to address the effects of cognitive impairments on functioning is the use of environmental support as a component for cognitive adaptation training (CAT). It is a manually driven, individually tailored, psychosocial treatment using environmental supports such as signs, checklists, pill containers with alarms, cueing and sequencing adaptive behavior in the home environment (Velligan et al., 2000, Velligan et al., 2002, Velligan et al., 2008, Velligan and Gonzalez, 2007). While cognitive remediation seeks to enhance cognitive functioning, CAT uses supports to bypass cognitive impairments so that cognitive impairments no longer negatively affect adaptive behavior (Velligan et al., 2000, Velligan et al., 2002, Velligan et al., 2006, Velligan et al., 2008). CAT has been shown to improve community tenure, increase adherence to medication, and enhance independent living skills (Velligan et al., 2000, Velligan et al., 2008, Velligan and Gonzalez, 2007, Draper et al., 2009). Effect sizes for functional improvements have been large.

In cognitive remediation, improvements in functional outcome are thought to result from improvements in cognition. However improvement in cognition is not a necessary condition for improving functional outcome. For example, Kern et al. (2003) demonstrated that an errorless learning approach to job related tasks improved functional performance on the task without improving cognition. He indicated that errorless learning compensated for deficits in cognition. In this light, the objective of our study was to test the hypothesis that cognition mediates the effect of CAT intervention on functional outcome among outpatients with schizophrenia.

Section snippets

Study subjects

Participants were outpatients recruited for an NIMH-funded trial examining the efficacy of environmental supports for improving outcomes in schizophrenia and reducing the frequency of CAT visits (after the 9 months of initial treatment) from weekly to monthly on maintenance of treatment gains. Participants were identified through chart reviews by research staff credentialed at participating sites. All participants signed a written consent form approved by the University's Institutional Review

Participant characteristics

Out of 120 randomized patients, 113 had some follow-up data and were included in baseline demographics. Mean age of participants was 41.0 (S.D. = 9.1). Out of the 113 participants, 57 subjects were male and 56 were female. Demographic characteristics indicated that 45 were Hispanic, 44 were Non-Hispanic White, 24 were African-American, or from other or mixed ethnic groups.

The data analysis results described below includes 105 cases with data on all variables at baseline and 9 months, 77

Discussion

The study result indicated that improved cognition was seen in CAT group over the course of 24 months resulted from improvement in real-world functioning (on a global measure, the SOFAS). However, the study yielded somewhat different findings for 9-month versus 24-month outcome data. Data from 9-month outcomes failed to support the hypothesis that improvement in cognition mediates improvement in functional outcomes in CAT, or that CAT changes cognition. The lack of mediation was replicated using

Role of Funding Source

There was no funding for the manuscript titled “Is cognitive adaptation training (CAT) compensatory, restorative, or both?”

Contributors

On behalf of our research team, I confirm that the following authors have significantly contributed to the manuscript titled “Is Cognitive Adaptation Training (CAT) Compensatory, Restorative, or Both?”

Megan M Fredrick
[email protected]
(210) 567-5448
Clinical Research Project Manager
Dept. of Psychiatry, UPL, University of Texas Health Science Center, San Antonio, TX 78229
Jim Mintz
[email protected]
(210) 562-6705
Professor in Psychiatry
Dept. of Psychiatry, NWC 13.132, University of Texas Health

Conflict of Interest

On behalf of our research team, I confirm that there are no known conflicts of interest associated with this manuscript titled, “Is cognitive adaptation training (CAT) compensatory, restorative, or both?” There has been no significant financial support for this research that could have influenced its outcome.

The manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. The order of authors listed

Acknowledgements

On behalf of our research team, I confirm that we have no acknowledgements for the manuscript titled, “Is cognitive adaptation training (CAT) compensatory, restorative, or both?”

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