Cognitive remediation for vocational rehabilitation nonresponders

doi:10.1016/j.schres.2016.04.045

Schizophrenia Research

Volume 175, Issues 1–3, August 2016, Pages 48-56

https://doi.org/10.1016/j.schres.2016.04.045 Get rights and content

Abstract

Cognitive remediation in people with severe mental illnesses (SMI) that interfere with work, but less research has evaluated its effects in those who have not benefitted from vocational services. Participants with SMI (83% schizophrenia) who had not benefitted from vocational rehabilitation were randomized to vocational services enhanced by training vocational specialists in recognizing cognitive difficulties and providing job-relevant cognitive coping strategies (Enhanced Vocational Rehabilitation: E-VR), or similarly enhanced vocational services and cognitive remediation (Thinking Skills Work: TSW). Cognition and symptoms were assessed at baseline, post-treatment (9 months), and follow-up (18 months), with work tracked weekly for 3 years. Fifty-four participants were randomized to E-VR (N = 26) or TSW (N = 28). Participants in TSW had high rates of exposure to the program (89%) and improved more than those in E-VR on cognitive functioning post-training, with attenuation of some gains at the 18-months. Participants in TSW and E-VR did not differ significantly in competitive work (57% vs. 48%) or paid employment (61% vs. 48%) over the 3-year study, although those in TSW were more likely to be engaged in any work activity, including paid or volunteer work (75% vs. 50%, p = 0.057), and had more weeks of work activity (23.04 vs. 48.82, p = 0.051), and improved marginally more on the clinical symptoms. The significantly higher education level of participants in E-VR than TSW at baseline may have obscured the effects of TSW. This study supports the feasibility and potential benefits of cognitive remediation for persons who have not benefited from vocational rehabilitation.

Section snippets

Method

A randomized controlled trial was conducted at Brooklyn Community Services, a large nonprofit urban mental health agency that provides treatment services to individuals with SMI and other disabilities. All research procedures were approved by the Dartmouth School of Medicine Committee for Protection of Human Subjects. All participants signed written informed consent for the study, which was conducted from January 2005, through September 2009.

Results

Among the 28 participants randomized to TSW, 25 (89%) were exposed to the cognitive training (i.e., completed 6 or more computerized cognitive sessions). Participants who were exposed to TSW completed an average of 19.28 of the planned 24 cognitive training sessions using Cogpack software.

The results of the GLMM analyses comparing the effects of the two programs on cognitive functioning at post computerized training and the 18-month follow-up are summarized in Table 2. Participants in the TSW

Discussion

Several randomized controlled trials have shown that providing cognitive remediation (e.g., the TSW program) to persons with SMI who are new enrollees in vocational rehabilitation improves both cognitive functioning and work outcomes compared to vocational rehabilitation alone (Chan et al., 2015). The present study differed from these other studies in its evaluation of the effects of adding the TSW program to vocational rehabilitation in people who had previously failed to benefit from those

Authors' notes

This research was supported by grant #H133G050230 from the National Institute on Disability Rehabilitation and Research (NIDRR). This paper is subject to the National Institutes of Health Public Access Policy.

Role of funder

The funder, the National Institute on Disability Rehabilitation and Research (NIDRR), provided grant support to carry out the study, and had no role in the analyses of study data and no input in the final report of the findings.

Conflict of interest

Authors have no conflicts of interest to report.

Acknowledgement

The authors appreciate the contributions of Gary R. Bond, Ph.D., Sue Buchanan, M.A., Lori Tannenbaum, Ph.D., and Katherine Walker to this study.

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Mental health and unemployment: A systematic review and meta-analysis of interventions to improve depression and anxiety outcomes
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Unemployment is associated with substantially greater depression and anxiety, constituting a considerable public health concern. The current review provides the most comprehensive synthesis to date, and first meta-analysis, of controlled intervention trials aimed at improving depression and anxiety outcomes during unemployment.
Searches were conducted within PsycInfo, Cochrane Central, PubMed and Embase from their inception to September 2022. Included studies conducted controlled trials of interventions focused on improving mental health within unemployed samples, and reported on validated measures of depression, anxiety, or distress (mixed depression and anxiety). Narrative syntheses and random effects meta-analyses were conducted among prevention- and treatment-level interventions for each outcome.
A total of 39 articles reporting on 33 studies were included for review (sample sizes ranging from 21 to 1801). Both prevention and treatment interventions tended to be effective overall, with treatment interventions producing larger effect sizes than prevention interventions. The clearest evidence for particular intervention approaches emerged for prevention-level Cognitive Therapy/CBT, followed by prevention-level work-related interventions, although neither produced entirely consistent effects.
Risk of bias was generally high across studies. Low numbers of studies within subgroups precluded any comparisons between long-term and short-term unemployment, limited comparisons among treatment studies, and reduced the power of meta-analyses.
Both prevention- and treatment-level mental health-focused interventions have merit for reducing symptoms of anxiety and depression among those experiencing unemployment. Cognitive Therapy/CBT and work-related interventions hold the most robust evidence base, which can inform both prevention and treatment strategies implemented by clinicians, employment services providers, and governments.
Comparison of Black and White participants with severe mental illness in response to cognitive remediation as an augmentation of vocational rehabilitation
2023, Schizophrenia Research
Citation Excerpt :
The cognitive specialist integrates clients' cognitive remediation activities with vocational services provided by their employment specialist. The TSW program has been shown to improve cognitive and employment outcomes in persons with SMI receiving vocational rehabilitation in multiple controlled trials (Lindenmayer et al., 2008; McGurk and Mueser, 2015; McGurk et al., 2005; McGurk et al., 2007; McGurk et al., 2016; McGurk et al., 2015; McGurk et al., 2009); see Christensen et al. (2019) for a negative study, but also see Mueser and McGurk (2020). Engagement and retention were operationalized as exposure to the TSW program, defined a priori (McGurk et al., 2005) as completion of at least 6 (out of 24) computer cognitive training lessons.
Despite evidence that cognitive remediation improves cognitive and employment outcomes in persons with severe mental illnesses (SMI), its effects have not been systematically compared between Black and White participants. Considering that Black adults have more negative experiences receiving mental health treatment, providers may have greater difficulty engaging and retaining Black Americans in cognitive remediation. Due to the effects of structural racism on reducing employment opportunities for Black Americans, it is unclear whether Black participants will reap the same benefits of cognitive remediation on work outcomes as White Americans. This paper addressed this question.
A secondary analysis was conducted of five randomized controlled trials comparing cognitive remediation (the Thinking Skills for Work program: TSW) and vocational rehabilitation vs. vocational rehabilitation only in 137 Black and 147 White Americans (64.2% schizophrenia-schizoaffective disorder) who were followed up for two years.
Comparable proportions of Black and White participants were engaged and retained in TSW (>75%). Participants who received TSW improved significantly more in cognition than those receiving vocational services alone, with no racial differences in benefit. Participants in TSW obtained more work, earned more wages, and worked more weeks than those receiving vocational services alone, with no differences between the races.
The findings indicate that Black Americans with SMI receiving vocational services could be successfully engaged in and benefit from cognitive remediation, highlighting the vital role of healthcare service systems in giving credence to structural racism to more effectively mitigate racial disparities in treatment outcomes.
Impact of cognitive remediation on the prediction of employment outcomes in severe mental illness
2022, Schizophrenia Research
Cognitive functioning is a potent predictor of work in people with a severe mental illness, including those receiving vocational services. Cognitive remediation has been shown to improve cognitive functioning and work outcomes in people receiving vocational services. However, it is unknown whether it reduces the strength of cognitive functioning as a predictor of work outcomes compared to people receiving vocational services alone.
Data were pooled from five randomized controlled trials evaluating the effects of adding cognitive remediation to vocational rehabilitation vs. vocational services alone. A battery of baseline cognitive functioning measures was examined to identify predictors of competitive work outcomes over the following two years. Study condition (i.e., receipt of cognitive remediation) was included in the analyses to evaluate whether cognitive functioning was a weaker predictor of work outcomes in people receiving cognitive remediation compared to those receiving vocational services alone.
Cognitive functioning was a stronger predictor of wages earned and weeks worked in participants receiving vocational services alone than those who also received cognitive remediation. Cognitive functioning did not predict job acquisition in either study condition.
Cognitive remediation may improve employment outcomes in people receiving vocational services in part by reducing the adverse effects of impaired cognitive functioning on work performance.
Effects of IPS plus cognitive remediation in early psychosis: 18-month functioning outcomes of a randomized controlled trial
2021, Schizophrenia Research
After a first episode of psychosis, cognitive impairments present an important barrier to successful (re-)entry into work and education. We assessed whether cognitive remediation (CR) as an add-on to Individual Placement and Support (IPS) can improve participation in regular employment and education.
Participants with early psychosis (N = 73) were randomly assigned to receive IPS supplemented with computerized CR, or IPS plus an active control intervention (computer games). The primary outcome was the number of hours spent in competitive employment or regular education, which was assessed every month during the 18-month study period. Secondary outcomes included employment rate, cognitive functioning, mental health (assessed at baseline, 6 and 18 months), and job duration (assessed after 18 months). Both patients and assessors were blind to treatment.
Participants receiving IPS + CR showed greater improvement of competitive employment over time in terms of hours worked (during follow-up period: 38.5 vs. 19.6 h, B = 2.94; Wald χ² = 5.39; P = .02) and employment rate (at T2: 62.1% vs. 25.9%, χ ² = 7.39; df = 1; P = .008), compared with the IPS + control group, particularly in the longer term. The number of hours spent in regular education was lower in the IPS + CR group, with more participants having ended education for a positive reason. There was a significant beneficial effect of adjunctive CR for executive functioning, subjective cognitive functioning, and empowerment.
Augmenting IPS with CR has a significant impact on competitive employment in people with early psychosis, with beneficial effects being more pronounced after 18 months.
A randomized controlled trial of exercise on augmenting the effects of cognitive remediation in persons with severe mental illness
2021, Journal of Psychiatric Research
Preliminary evidence suggests that aerobic exercise may augment the effects of cognitive remediation on improving cognitive functioning in severe mental illness. It has also been hypothesized that increases in cognitive functioning associated with adding exercise are mediated by increases in brain derived neurotrophic factor (BDNF). However, rigorous controlled trials are lacking.
A randomized controlled trial was conducted to explore whether adding a 30-h aerobic exercise program over 10 weeks to an equally intensive cognitive remediation program (CR + E) improved cognitive functioning more than cognitive remediation alone (CR-Only). Thirty-four participants with schizophrenia or bipolar disorder were randomly assigned to CR + E or CR-Only, and cognitive functioning was assessed at baseline and post-treatment. Total and mature BDNF were measured in blood serum at baseline, Week-5 pre- and post-exercise, and Week-10 pre- and post-exercise.
Participants in both conditions had high levels of engagement in the interventions and improved significantly in cognitive functioning, but did not differ in amount of cognitive change. The groups also did not differ in changes in BDNF from pre-to post-exercise at Weeks 5 or 10, nor in resting BDNF levels. Exploratory analyses indicated that higher body mass index (BMI) significantly predicted attenuated improvement in cognitive functioning for both groups.
Exercise did not augment the effects of cognitive remediation in persons with severe mental illness, possibly because the cognitive remediation program resulted in strong gains in cognitive functioning. Moderate aerobic exercise does not appear to reliably increase BDNF levels in persons with severe mental illness.
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Cognitive functioning as a predictor of response to comprehensive cognitive remediation
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Citation Excerpt :
The pooled sample size included more participants in the cognitive remediation program than in the largest of the prior studies (Lindenmayer et al., 2017), with approximately an equal number of control participants as well, and therefore had sufficient statistical power to address the research question. Data for the meta-regression were drawn from five randomized controlled trials of the Thinking Skills for Work program, a comprehensive, multi-modal cognitive remediation intervention that is integrated with vocational rehabilitation services (McGurk and Mueser, 2015; McGurk et al., 2005, 2009, 2015, 2016). All five of these studies were implemented in outpatient community mental health treatment settings with baseline and post treatment assessments of cognition and symptoms conducted by raters who were blind to treatment group.
Cognitive remediation is aimed at reducing cognitive impairments in severe mental illnesses such as schizophrenia, but little is known about whether severity of cognitive impairment predicts benefit from this intervention. To address this question, this study aggregated data from five randomized controlled trials (N = 300) of a standardized comprehensive, multimodal outpatient cognitive remediation program, the Thinking Skills for Work program, and evaluated whether baseline level of cognitive impairment differentially predicted improvement in cognitive functioning following cognitive remediation vs. usual services. Using standardized scores of neuropsychological functioning to designate “low average,” “moderate,” and “severe” levels of cognitive impairment, participants with greater cognitive impairment were found to benefit differentially more from cognitive remediation than usual services compared to less cognitively impaired participants. The findings were unaffected by statistically controlling for participant demographic and clinical characteristics. The findings suggest that individuals with the greatest cognitive impairment, for whom cognitive remediation was developed, are also most likely to benefit from this intervention.

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Cognitive remediation for vocational rehabilitation nonresponders

Abstract

Section snippets

Method

Results

Discussion

Authors' notes

Role of funder

Conflict of interest

Acknowledgement

Schizophr. Res.

Schizophr. Res.

J. Psychiatr. Res.

Psychiatry Res.

Psychiatr. Serv.

Clin. Psychol. Rev.

Psychiatry Res.

Schizophr. Res.

Schizophr. Res.

European Psychiatry

Working memory

Science

A Working Life for People with Severe Mental Illness

Work rehabilitation in schizophrenia: does cognitive impairment limit improvement?

Schizophr. Bull.

Neurocognitive enhancement therapy with work therapy: productivity outcomes at 6- and 12-month follow-ups

J. Rehabil. Res. Dev.

Neurocognitive enhancement therapy with work therapy in schizophrenia: 6-month follow-up of neuropsychological performance

J. Rehabil. Res. Dev.

Benefits of cognitive remediation and supported employment for schizophrenia patients with poor community functioning

Psychiatr. Serv.

Cognitive rehabilitation for schizophrenia: problems, prospects, and strategies

Schizophr. Bull.

A simple objective test for measuring flexibility in thinking

J. Gen. Psychol.

Vocational rehabilitation

Initial and final work performance in schizophrenia: cognitive and symptom predictors

J. Nerv. Ment. Dis.

Results of a multisite randomized trial of supported employment interventions for individuals with severe mental illness

Arch. Gen. Psychiatry

The Principles and Practice of Psychiatric Rehabilitation: An Empirical Approach

California Verbal Learning and Memory Test (Manual)

The association between cognitive functioning and occupational status in persons with a recent onset of psychosis

J. Nerv. Ment. Dis.

Applied Longitudinal Analysis

Cognitive correlates of job tenure among patients with severe mental illness

Am. J. Psychiatr.

The Bell Curve: Intelligence and Class Structure in American Life

Predicting vocational functioning and outcome in schizophrenia outpatients attending a vocational rehabilitation program

Soc. Psychiatry Psychiatr. Epidemiol.

A national campaign to finance supported employment

Psychiatric Rehabilitation Journal