Effects of cognitive remediation therapies on psychotic symptoms and cognitive complaints in patients with schizophrenia and related disorders: A randomized study
Introduction
Patients with schizophrenia and related disorders present a wide range of cognitive deficits on measures of memory, attention and executive functions. Recent reviews argue for a positive effect of cognitive remediation therapy (CRT) on cognitive performances and daily-living functioning (Wykes and van der Gaag, 2001, Pilling et al., 2002, Krabbendam and Aleman, 2003, Twamley et al., 2003, Medalia and Richardson, 2005, McGurk et al., 2007). On the other hand, CRT displays a small impact on positive or negative symptoms (in McGurk et al., 2007, cognitive remediation was associated with a small effect size (0.28) for symptoms) in spite of the fact that some studies have independently reported positive effects of this kind of therapy on clinical symptoms (Medalia et al., 2000, Bellucci et al., 2002, Lindenmayer et al., 2008). Even though the symptoms do not constitute the main target of CRT, their decrease should express changes in the cognitive functioning of patients. Thus, some positive symptoms, such as delusions, have been shown to be related to dysfunctional cognitive processes (Moritz and Woodward, 2007), and their remediation could consequentially diminish positive symptoms. In addition, it has been demonstrated that patients are aware of their cognitive impairments, and their insight could have an important impact on their mood and self-esteem (Stip et al., 2003, Lecardeur et al., 2009). As a consequence, CRT can first play a role in the decrease of cognitive deficits and related psychotic symptoms, but may also act on clinical symptoms by subjective improvement of cognitive functioning. Towards this aim, it is of interest to promote the CRT of specific cognitive processes reported to be related to clinical symptoms, such as mental state attribution (Brüne, 2005, Moritz and Laudan, 2007). To date, only one study (Kayser et al., 2006) proposed to precisely remediate mental state attribution, while several others evaluated the effects of CRT on executive functions in patients with schizophrenia (Wykes et al., 1999, Reeder et al., 2004, Penades et al., 2006). Among these studies, the therapeutic impact was principally assessed by changes in performance on selected cognitive tasks.
The aim of our investigation was to observe the impact of CRT on cognitive complaints and psychotic symptoms. Towards this aim, and as suggested earlier (Wykes and Reeder, 2005, Koren et al., 2006), we contrasted the performances of 2 groups receiving 2 new CRTs, one targeting mental state attribution (MSAT), and the other, mental flexibility (MFT) with the performances of a psychiatric control group given their usual treatment (treatment as usual, TAU). First, we hypothesized that psychotic symptoms should diminish in patients on CRT, notably positive symptoms, since cognitive impairments have been related to their appearance. According to the literature (Moritz and Woodward, 2007), we assumed that MSAT would be more effective in decreasing symptoms in patients compared to TAU and MFT. Second, we supposed that trained patients would be aware of the benefits of CRT on their cognitive functioning, leading to a reduction of their complaints relative to their cognitive deficits.
Section snippets
Participants
Potential participants were recruited in the Pavillon Albert-Prévost, Hôpital du Sacré-Coeur de Montréal (Canada). The CONSORT flow diagram in Fig. 1 shows the initial referral rate and drop out from main outcome assessment.
Inclusion criteria: Individuals were eligible if aged between 18 and 55 years, were fluent in French, met DSM-IV diagnostic criteria (American Psychiatric Association, 1994) for schizophrenia (n = 15), schizoaffective disorder (n = 8) or delusional disorder (n = 1). Participants
Results
No difference was found between groups for age, educational level, duration of illness, premorbid intellectual quotient and medication (cf. Table 1).
ANCOVA revealed a significant difference between the 3 groups (F(2, 20) = 4.81, p = .020) for positive PANSS scores (Table 2). Paired comparisons showed that the MFT group had a significantly lower score than the MSAT group (p = .012) and the control group (p = .017). ANCOVA also disclosed significant differences between the 3 groups (F(2, 20) = 5.12, p =
Discussion
In this study, we compared the effects of 2 CRTs – one targeting mental state attribution, and the other, mental flexibility – on cognitive complaints and psychotic symptoms, in schizophrenia and related disorders.
Limitations
We reported the results of a randomized study of 3 groups each comprised of 8 subjects. Our encouraging findings will need to be replicated with a larger sample size. All patients completed the full 9 sessions of both CRT types. Patients highly appreciated the programs, and the global format of the therapies, such as session duration, number of participants and the exercise proposed (Lecardeur et al., 2008). The Ethics Committee requested that we compensate patients for their transport fees
Role of funding source
Funding for the study was provided by Fonds de la recherche en santé du Québec (FRSQ) to MCL. LL was supported by the Chaire de Schizophrénie Eli Lilly de l'Université de Montréal (Québec, Canada). These funding sources were neither involved in the study design, nor in the collection, analysis and interpretation of data, writing of the report and the decision to submit this manuscript for publication.
Contributors
LL, ES and MCL designed the study and wrote the protocol. GB and JPR recruit participants. LL, ES and MCL managed the manuscript preparation, undertook the data analysis and wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
None.
Acknowledgements
The authors would like to acknowledge I. Landry, M.F. Turgeon, J. St-Onge, F. Bérubé, M. Noel and D. Baugé for patient recruitment, D. Tassy, J. Bouchard and G. Martel for their technical assistance, and S. Moritz and the MetaCognitive Training Group for allowing the authors to use some MetaCognitive Training sessions.
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