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Cognitive Remediation to Improve Functional Outcomes in Schizophrenia
Background and Objective
People with schizophrenia typically perform between one and a half to two standard deviations below normal population in cognitive functioning (Bilder et al., 1995; Goldberg & Gold, 1995). Cognitive remediation is an intervention to overcome the effects of cognitive difficulties through re-training and use of compensatory strategies. Research has shown that cognitive remediation can improve cognitive functioning amongst people with schizophrenia (Wykes, Huddy, Cellard, McGurk, & Czobor, 2011). However, many of these studies have control arms which consist of interventions that are non-therapeutic in nature. Therefore, functional gains could not be directly attributed to the active ingredients of cognitive remediation.
At the Institute of Mental Health (IMH) in Singapore, cognitive remediation is provided as part of an outpatient day rehabilitation and a vocational training program. A study was conducted to test if cognitive remediation could improve cognition and functioning of people with schizophrenia, using physical exercise program as the comparison arm, due to its benefits on people with psychiatric disorders (Richardson et al., 2005).
Patients with schizophrenia were randomized to receive either Cognitive Remediation (CR) or Physical Exercise (PE). CR consisted of computer-assisted cognitive exercises for up to 5 hours each week for 12 weeks. In addition, cognitive-based counseling was carried out to transfer skills learned to their day rehabilitation or vocational training programs. PE consisted of physical exercise of the same intensity and physical exercise-based counseling was also conducted to transfer skills learned. Cognitive function, physical fitness, symptomatology and quality of life were measured at baseline, post-intervention and at six month and one year follow-up. Community abilities and employment outcomes were also obtained.
Cognitive remediation produced significant differential improvement in all neurocognitive measures over one year. In addition, the CR group displayed better vocational and community ability outcomes at the end of one year follow-up. Negative symptoms also improved significantly more amongst the CR group, which was predicted by better functional outcomes. However, improved functional outcome was not significantly associated with better quality of life.
When compared against a credible intervention such as physical exercise, cognitive remediation showed significantly greater positive effects on both neurocognition and functional outcomes. Following positive outcomes from this study, IMH has trained its staff to provide Neuropsychological and Educational Approach to Remediation (NEAR), a structure cognitive remediation program that emphasises on contextualised learning and generalisation of cognitive strategies through bridging groups.