UPDATE ON COGNITIVE REMEDIATION THERAPY

1. UPDATE ON COGNITIVE
REMEDIATION
Assoc. Prof. Dr. Muhammad Najib Mohamad Alwi
KLMH 2014

2. FEATURES OF SCHIZOPHRENIA
Positive symptoms
- Delusions
- Hallucinations
- Disorganization
• speech
• behaviour
Cognitive deficits
Functional Impairments
Work
Interpersonal relationships
Self-care
Negative symptoms
-  emotional range
-  expression of emotion
-  motivation/drive
-  interests
-  social drive
- poverty of speech
Mood symptoms
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3. COGNITIVE DEFICITS AND OUTCOME
Cognitive Deficits
Functional Outcome
occupational
social
psychosocial
rehabilitation
(Wykes 1998; Green 1996; Velligan et al 2000)
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4. COGNITIVE DEFICITS IN
SCHIZOPHRENIA
Main impairments identified include:
 Attention and vigilance
 Problem solving and reasoning
 Processing Speed
 Memory and Learning (Verbal and Visual)
 Working Memory
 Social Cognition
(Keefe et al 2006; Wilk et al 2005)
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5. STRATEGIES TO IMPROVE COGNITIVE DEFICITS
FOR SCHIZOPHRENIA
Pharmacological approaches:
 Atypical antipsychotics: ES=0.24 (Woodward et al 2005)
 Adjunctive cholinesterase inhibitors ES=NS (Sharma et al 2006)
 3rd generation antipsychotics (?)
Psychosocial approaches:
 Cognitive rehabilitation/remediation/training
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Cohen’s Effect Size (ES)
> 0.8 Large
0.5 Moderate
0.2 Small

6. COGNITIVE REMEDIATION THERAPY
(CRT)
The term “cognitive remediation therapy” refers to
several evidence-based psychosocial programmes
aiming to ameliorate cognitive deficits associated
with schizophrenia and other mental disorders.
Originated from works on traumatic brain injury
which have begun in the 1970s.
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7. COGNITIVE REMEDIATION THERAPY FOR
MENTAL ILLNESS
Currently has several versions/models but all aiming
to improve cognitive functions in schizophrenia.
More recently, some works have been started to
adopt CRT for bipolar disorder, depressive disorder,
ADHD/autism, anorexia nervosa, and dementia.
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8. TWO MAIN APPROACHES
Cognitive Remediation
Restorative Approach Adaptive Approach
Paper &
Pencil
Exercises
Table
Top Tasks
Computer
Software
Graded
Occupations
Internal
Strategies
External
Strategies

9. 9
•Uses pencil-and-paper and other
types of drills to target cognitive skills
Task Drill
•Task drill with facilitation by a
therapist
Task Drill and Strategy
Coaching
•Task drill with computer assisted
instructions
Computer Assisted
Task Drill
•Computer assisted task drill with
therapist facilitation
Computer Assisted
Task Drill with Strategy
Coaching
TYPES OF CRT (Twamley et al, 2003)

10. WHAT DOES THE EVIDENCE SAY?
 Efficacy for cognition
 ES=0.32 (Twamley et al 2003)
 ES=0.41 (McGurk et al 2007)
 ES=0.45 (Wykes et al 2011)
 Efficacy for psychosocial functioning (ES: 0.37).
 Less pronounced in patients’ psychopathology.
 Benefits especially relevant for chronic and severe patients
with schizophrenia.
Stefano Barlati, et al (2013) Cognitive Remediation in Schizophrenia: Current Status and Future Perspectives
Schizophrenia Research and Treatment http://dx.doi.org/10.1155/2013/156084
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Cohen’s Effect Size (ES)
> 0.8 Large
0.5 Moderate
0.2 Small

11. COGNITIVE REMEDIATION PROGRAMS
APPEAR TO BE MORE SUCCESSFUL:
 if they are embedded in comprehensive rehabilitation
programs where they are used in combination with
psychosocial groups or work rehabilitation programs.
 to impact functional outcome when individuals are given
opportunities to practice the cognitive skills in real-world
settings.
Stefano Barlati, et al (2013) Cognitive Remediation in Schizophrenia: Current Status and Future Perspectives
Schizophrenia Research and Treatment http://dx.doi.org/10.1155/2013/156084
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12. Drop Out
n=25
n=112
Screening
Baseline
n=85
Random-
ization
CRT
n=57
WL
n=28
Drop Out
n=3
Post Test
n=32
Post Test
n=25
Randomised Controlled Trial
MALAYSIAN STUDY
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N Alwi et al (2009)

13. Attention
Processing Speed
Visual L Memory
Verbal L
Memory
p=.34
d=.32 (small ES)
p=.03
d=.59 (moderate
ES)
p=.002
d=.83 (large ES)
p=.007
d=.61 (moderate
ES)
McGurk et al
(2007)
ES=.41
McGurk et al
(2007)
ES=.48
McGurk et al
(2007)
ES=.09
McGurk et al
(2007)
ES=.39
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14. ADDITIONAL FINDINGS
•There was no difference
after inclusion of booster
sessions
•However improvements
noted at the end of
treatment were maintained
at 5 weeks post treatment
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15. BRAIN EFFECTS OF COGNITIVE REMEDIATION
THERAPY IN SCHIZOPHRENIA: A STRUCTURAL AND
FUNCTIONAL NEUROIMAGING STUDY
 Comparison: patients with schizophrenia receiving CRT
(n=17), an active control group of schizophrenia patients
receiving social skills training (SST, n=18), and a control
group of healthy individuals (n=15)
 After treatment, CRT patients showed during task-related
responses:
 decreased activation in the central executive network in
 decreased activation of its anticorrelated default mode network
 suggesting an improvement in the efficiency of both
functional networks.
Penadés R, et al (2013) Biological Psychiatry
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16. EFFICACY OF CRT IN OTHER MENTAL
DISORDERS?
First Episode Psychosis
Dementia
Mood Disorders
Others?
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17. FIRST EPISODE PSYCHOSIS (FEP) AND CRT
Targeting cognitive impairments in the early
course of schizophrenia:
Significant functional benefits: social functioning,
employment, and role functioning.
Euland & Rand (2005)
Eack et al (2007)
Hodge et al (2010)
Zaytseva et al (2013)
Marshall & Rathbone (2011)
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18. FIRST EPISODE PSYCHOSIS (FEP) AND CRT
CRT may be integrated into treatment programs of
young people with schizophrenia within the “critical
period” for early intervention:
 opportunity to alter the course of the disease.
? The “protective” role of early effective intervention
on the neurobiological and clinical deteriorating
course of the disease => may be extended to
cognitive remediation.
Euland & Rand (2005)
Eack et al (2007)
Zaytseva et al (2013)
Marshall & Rathbone (2011)
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19. Cognitive changes for the whole sample (cognitive remediation therapy [CRT] = 25 / treatment as usual [TAU] = 25) and for the completers subgroup (CRT = 15 /
TAU = 14).
Cognitive Remediation Therapy in Adolescents With Early-Onset Schizophrenia: A Randomized Controlled Trial
Puig, Olga, MSc, Journal of the American Academy of Child & Adolescent Psychiatry,
Copyright © 2014 American Academy of Child and Adolescent Psychiatry

20. CRT for Alzheimer’s Disease
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Jimmy Choi & Elizabeth W. Twamley, Neuropsychol Rev. Published online Feb 12, 2013. doi:
10.1007/s11065-013-9227-4

21. CRT FOR MILD COGNITIVE IMPAIRMENT (MCI)
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Huckans et al (2013)

22. COGNITIVE VITALITY TRAINING (CVT) –
FOR DEMENTIA
 Computer-based memory training in a motivational milieu:
 Incorporated CBT to target hopelessness defeatist behaviour
 Focus: Exercising mental skills / optimizing mental ‘acuity’
instead of “remediating deficits”
 Early results (Choi et al, 2014 in press):
 CVT + AChI drugs vs CVT alone (4 months)
 objective memory performance
  depressive symptoms
  QoL
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23. COMPENSATORY MEMORY TRAINING
(MCI AND TRAUMATIC BRAIN INJURY)
Focus on compensatory cognitive strategies to
improve cognition and functioning (10-12
sessions):
 Target: prospective memory, attention, learning
and executive functioning
 Strategy: individual / group + workbooks
 Initial Results:
 Promising for both MCI and TBI (Huckens et al, 2010;
Twamley et al, 2012)
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24. CRT AND DEPRESSION
Patients with major depressive disorder (MDD) present
with significant cognitive impairment : may not resolve
with treatment.
The studies are small and inconclusive:
 There was a significant time by treatment interaction for
attention/processing speed and verbal memory.
 Changes in functioning were not significant, although
improved cognition predicted improvements in functioning.
Porter RJ, Bowie CR, Jordan J, Malhi GS - Aust N Z J Psychiatry 2013; 47(12); 1165-75
Bowie CR, Gupta M, Holshausen K, Jokic R, Best M, Milev R - J. Nerv. Ment. 2013;
201(8); 680-5
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25. BIPOLAR DISORDER
 Despite periods of symptomatic recovery, individuals
with bipolar disorder often continue to experience
impairments in psychosocial functioning, particularly
occupational functioning.
 Two determinants of psychosocial functioning of
euthymic (neither fully depressed nor manic)
individuals:
 residual depressive symptoms and cognitive impairment
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26. BIPOLAR DISORDER
Early results with CRT:
 Uncontrolled Open trial:
 Results indicated that at the end of treatment, as
well as at the 3-months follow-up, patients showed
lower residual depressive symptoms, and increased
occupational, as well as overall psychosocial
functioning.
Deckersbach et al (2010)
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27. ANOREXIA NERVOSA (AN)
 Identified problems: Style of information processing (set-
shifting & extreme attention to detail could be one of the
maintaining factors of AN
 Technique: Twice-weekly CRT module aimed at reflecting on
information-processing styles and increasing cognitive
flexibility and gistful, holistic thinking.
 Aim: Target basic processes of thinking rather than the
content of thinking, such as issues of food, shape and weight
concern, or emotions.
 CRT gives patients a sense of achievement and helps them to
adapt new behavioural strategies in real life.
Tchanturia et al 2007
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28. Natalie Pretorius &
Kate Tchanturia
(2007)
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29. EVIDENCE SO FAR:
 Patients’ self report on cognitive strategies improved.
 Overall positive feedback about this package was received from
patients and therapists.
 Evidence also shows long-term benefits of CRT.
Tchanturia et al (2008}
Davies and Tchanturia (2005)
Tchanturia & Hambrook (2009)
Tchanturia & Whitneyet al (2008)
Genders et al (2008)
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30. ADULT ADHD
1 RCT (Stevenson et al, 2002):
 ADHD symptomatology (effect size (d) = 1.4),
improved organizational skills (d = 1.2), reduced
levels of anger (d = 0.5) and organizational skills (d
= 1.3)
 Results were maintained one year after the
intervention.
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31. CHILDREN WITH ADHD
 Meta-analysis 25 studies of facilitative intervention
training:
 studies training short-term memory alone resulted in
moderate magnitude improvements in short-term memory (d
= 0.63)
 whereas training attention did not significantly improve
attention and training mixed executive functions did not
significantly improve the targeted executive functions
 Transfer effects of cognitive training on academic
functioning:
 d = 0.14 (NS)
Rapport et al (2013). Clinical Psychology Review 33(8) 1237-1252
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32. CONCLUSIONS
 Cognitive Remediation Therapy (CRT) has a lot of
potential for research and therapeutic work.
 The basic principles of CRT programme can be
modified to suit various clinical conditions which
manifest with cognitive deficits.
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