Effects of cognitive remediation therapies on psychotic symptoms and cognitive complaints in patients with schizophrenia and related disorders: A randomized study

https://doi.org/10.1016/j.schres.2009.03.029Get rights and content

Abstract

Background

Cognitive remediation therapy (CRT) has proven to be effective in treating cognitive deficits in schizophrenia. The current study aimed to assess the efficacy of CRT on psychotic symptoms and cognitive complaints.

Methods

We contrasted the changes in symptoms and cognitive complaints in patients with schizophrenia and related disorders who received 2 novel CRTs, one targeting mental state attribution, and the other, mental flexibility, compared with a control group given treatment as usual. Twenty-four patients with schizophrenia and related disorders were pseudo-randomly assigned to 1 of 3 groups. Psychotic symptoms and subjective complaints about their cognitive deficits were evaluated twice in each group, before and after therapy. Scores obtained pre- and post-therapy were compared between the groups.

Results

The therapies were well-tolerated by the participants, and no one dropped out of the study. Symptoms decreased after therapy, but not in the control group. The mental flexibility group showed the most improvement. Moreover, patients in this group described a subjective diminution of their cognitive deficits.

Conclusions

Our results demonstrate that CRT can be useful to reduce clinical symptoms while they suggest an impact of CRT on cognitive complaints in patients with schizophrenia.

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.

References (40)

  • WykesT. et al.

    Are the effects of cognitive remediation therapy (CRT) durable? Results from an exploratory trial in schizophrenia

    Schizophr. Res.

    (2003)
  • WykesT. et al.

    Is it time to develop a new cognitive therapy for psychosis — cognitive remediation therapy (CRT)?

    Clin. Psychol. Rev.

    (2001)
  • American Psychiatric Association

    DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, 4th edition

    (1994)
  • Baillargeon-Fournelle, A., Joanette, Y., and Champagne-Lavau, M., 2004. Effet du vieillissement sur l'habileté de...
  • BellackA.S. et al.

    Assessment of community functioning in people with schizophrenia and other severe mental illnesses: a white paper based on an NIMH-sponsored workshop

    Schizophr. Bull.

    (2007)
  • BellucciD.M. et al.

    Computer-assisted cognitive rehabilitation reduces negative symptoms in the severely mentally ill

    Schizophr. Res.

    (2002)
  • BentallR.P. et al.

    The cognitive and affective structure of paranoid delusions: a transdiagnostic investigation of patients with schizophrenia spectrum disorders and depression

    Arch. Gen. Psychiatry.

    (2009)
  • BrüneM.

    Theory of mind in schizophrenia: a review of the literature

    Schizophr. Bull.

    (2005)
  • HakeD.L. et al.

    Self-report of cognitive functioning and learning in schizophrenia

    J. Am. Psychiatr. Nurses Assoc.

    (2007)
  • KayS.R. et al.

    The positive and negative syndrome scale (PANSS) for schizophrenia

    Schizophr. Bull.

    (1987)
  • Cited by (35)

    • How does awareness of cognitive impairment impact motivation and treatment outcomes during cognitive remediation for schizophrenia?

      2020, Schizophrenia Research
      Citation Excerpt :

      Subjective reports of cognitive impairment in schizophrenia often underestimate objective findings, whether report is to a clinician or on a self-report measure (Saperstein et al., 2012). Studies that measure subjective awareness of cognitive ability in the context of cognitive remediation (CR) find that cognitive complaints generally decrease over the course of treatment (Lecardeur et al., 2009) but awareness of cognitive deficit remains poor, even in the face of objective improvement (Treichler et al., 2019). Some studies have begun to examine the clinical impact of baseline awareness of cognitive deficit on motivation and treatment outcomes.

    • Effects of peer social interaction on performance during computerized cognitive remediation therapy in patients with early course schizophrenia: A pilot study

      2019, Schizophrenia Research
      Citation Excerpt :

      In the interventions that opted for an individualized treatment, participants either interacted only with the computer (Fisher et al., 2009a, 2009b), were coached by a clinician throughout the training (Dickinson et al., 2009), or engaged in a combination of computerized intervention with individual coaching (Medalia et al., 1998). Group settings included interactions in smaller groups, such as triadic groups (Wölwer et al., 2005) or larger groups containing between six and ten participants (Cavallaro et al., 2009; Lecardeur et al., 2009). Nonetheless, the quality and characteristics of these group interactions are not specified in these manuscripts.

    • Room to move: Plasticity in early auditory information processing and auditory learning in schizophrenia revealed by acute pharmacological challenge

      2018, Schizophrenia Research
      Citation Excerpt :

      Because AP treatment largely fails to enhance function in SZ patients, alternative, non-pharmacologic treatments for SZ have been the focus of intensive investigation. Cognitive, behavioral and social therapies modestly reduce symptoms and improve function in SZ (Demily and Franck, 2008; Klingberg et al., 2009; Lecardeur et al., 2009; McGurk et al., 2007; Medalia and Choi, 2009; Tai and Turkington, 2009), with sustained benefits in many cases lasting years (Eack et al., 2010; Granholm et al., 2007; McGurk et al., 2009). In Targeted Cognitive Training (TCT), SZ patients train on auditory processing tasks concomitant with domain-specific attention and working-memory operations; this “bottom-up” approach seeks to improve speed and accuracy of auditory information processing, to generate “upstream” gains in cognition and function.

    • A randomized study of cognitive remediation for forensic and mental health patients with schizophrenia

      2015, Journal of Psychiatric Research
      Citation Excerpt :

      By improving neurocognition, cognitive remediation may have enhanced participants' emotion regulation capacity and aggression control. It is also possible that cognitive remediation may have potentiated the capacity of participants to gain from other ongoing psychopharmacological and psychosocial interventions at the hospital (Bowie et al., 2012; Lecardeur et al., 2009). Although not evaluated in the current study, cognitive remediation may contribute to improvements in insight including an awareness of mental illness and the benefits of treatment (Lalova et al., 2013).

    • Neurocognitive insight, treatment utilization, and cognitive training outcomes in schizophrenia

      2015, Schizophrenia Research
      Citation Excerpt :

      One recent study demonstrated that, contrary to expectation, higher rates of cognitive complaints were associated with lower treatment utilization (Gooding et al., 2012). Another study found that cognitive complaints generally decreased from baseline to post-treatment (Lecardeur et al., 2009). Given the limited literature in this area, the current study examined awareness of cognitive dysfunction among participants in a randomized controlled trial of cognitive training, and whether awareness was related to treatment utilization or outcome.

    • An Overview of Social Cognitive Treatment Interventions

      2014, Social Cognition and Metacognition in Schizophrenia: Psychopathology and Treatment Approaches
    View all citing articles on Scopus
    View full text