Cognitive remediation therapies seem to ameliorate cognitive impairments in patients with schizophrenia. Interestingly, some improvement in daily functioning can also be expected as a result. However, to achieve these results it is necessary that cognitive remediation is carried out in the context of broader psychosocial rehabilitation involving the learning of other communication, social, and self-control skills. Unfortunately, little is known about how to integrate these different rehabilitation tools in broader rehabilitation programs. Based on both the neurocognitive behavioral approach and the action theory framework, a hierarchical flowchart is represented in this paper to integrate CRT with other evidence-based psychological therapies in outpatient settings. Finally, some evidence is provided in which cognitive abilities need to be targeted in remediation programs to improve functioning. In summary, to improve daily functioning, according to these studies, cognitive remediation needs to include the teaching of some cognitive strategies that target executive skills. 1. Introduction Cognitive remediation therapy (CRT) has been defined as a behavioral training-based intervention that aims to improve cognitive processes (attention, memory, executive function, social cognition, or metacognition) with the general aim of durable benefits in community functioning (Cognitive Remediation Experts Workshop, Florence, April, 2010). Nonetheless, the majority of empirical findings on cognitive remediation therapies, including the meta-analysis, challenge the assumption that simply improving cognitive functioning in schizophrenia will spontaneously lead to better psychosocial outcomes. Moreover, the results of previous studies suggest that cognitive recovery is probably the best option to optimize the response of some patients to psychiatric rehabilitation programs. So CRT is not likely to be implemented as a stand-alone therapy but as a part of a broader psychosocial rehabilitation program. Unfortunately, little is known about how to integrate the different rehabilitation tools in a broader rehabilitation program. Regrettably, they are neither standardized nor available in routine care in the majority of clinical settings. The aim of this paper is to provide an evidence-based, person-centered method for integrating CRT into the psychosocial rehabilitation process in outpatient settings. 2. Effects of Cognitive Remediation on Cognition and Functioning Fortunately, convincing data about CRT efficacy in cognition and functioning can currently be found in
References
[1]
S. R. McGurk, E. W. Twamley, D. I. Sitzer, G. J. McHugo, and K. T. Mueser, “A meta-analysis of cognitive remediation in schizophrenia,” American Journal of Psychiatry, vol. 164, no. 12, pp. 1791–1802, 2007.
[2]
T. Wykes, C. Reeder, J. Corner, C. Williams, and B. Everitt, “The effects of neurocognitive remediation on executive processing in patients with schizophrenia,” Schizophrenia Bulletin, vol. 25, no. 2, pp. 291–307, 1999.
[3]
M. Bell, G. Bryson, T. Greig, C. Corcoran, and B. E. Wexler, “Neurocognitive enhancement therapy with work therapy: effects on neuropsychological test performance,” Archives of General Psychiatry, vol. 58, no. 8, pp. 763–768, 2001.
[4]
M. Van der Gaag, R. S. Kern, R. J. Van den Bosch, and R. P. Liberman, “A controlled trial of cognitive remediation in schizophrenia,” Schizophrenia Bulletin, vol. 28, no. 1, pp. 167–176, 2002.
[5]
W. D. Spaulding, D. Reed, M. Sullivan, C. Richardson, and M. Weiler, “Effects of cognitive treatment in psychiatric rehabilitation,” Schizophrenia Bulletin, vol. 25, no. 4, pp. 657–676, 1999.
[6]
A. Medalia, M. Aluma, W. Tryon, and A. E. Merriam, “Effectiveness of attention training in schizophrenia,” Schizophrenia Bulletin, vol. 24, no. 1, pp. 147–152, 1998.
[7]
T. Wykes, V. Huddy, C. Cellard, S. R. McGurk, and P. Czobor, “A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes,” American Journal of Psychiatry, vol. 168, no. 5, pp. 472–485, 2011.
[8]
J. Kreyenbuhl, R. W. Buchanan, F. B. Dickerson, and L. B. Dixon, “The schizophrenia patient outcomes research team (PORT): updated treatment recommendations 2009,” Schizophrenia Bulletin, vol. 36, no. 1, pp. 94–103, 2010.
[9]
National Institute for Health and Clinical Excellence (NICE), “Schizophrenia. core interventions in the treatment and management of schizophrenia in adults in primary and secondary care,” NICE Clinical Guideline 82. London: National Institute for Health and Clinical Excellence, 2009, http://www.nice.org.uk/CG82.
[10]
M. Linden, “Therapeutic standards in psychopharmacology and medical decision-making,” Pharmacopsychiatry, Supplement, vol. 27, no. 1, pp. 41–45, 1994.
[11]
M. Linden and L. Pyrkosch, “How to review the medication history to find the next best drug: the pretreatment-next treatment algorithm and checklist,” Current Psychopharmacology, vol. 1, pp. 61–66, 2012.
[12]
M. M. Kurtz and K. T. Mueser, “A meta-analysis of controlled research on social skills training for Schizophrenia,” Journal of Consulting and Clinical Psychology, vol. 76, no. 3, pp. 491–504, 2008.
[13]
M. M. Kurtz and C. L. Richardson, “Social cognitive training for schizophrenia: a meta-analytic investigation of controlled research,” Schizophrenia Bulletin. In press.
[14]
T. Wykes, C. Steel, B. Everitt, and N. Tarrier, “Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor,” Schizophrenia Bulletin, vol. 34, no. 3, pp. 523–537, 2008.
[15]
M. M. Kurtz, J. Rose, and B. E. Wexler, “Predictors of participation in community outpatient psychosocial rehabilitation in Schizophrenia,” Community Mental Health Journal, pp. 1–6, 2010.
[16]
K. T. Mueser, A. S. Bellack, M. S. Douglas, and J. H. Wade, “Prediction of social skill acquisition in schizophrenic and major affective disorder patients from memory and symptomatology,” Psychiatry Research, vol. 37, no. 3, pp. 281–296, 1991.
[17]
R. Penadés, R. Catalán, N. Pujol et al., “Is memory impairment a rate limiter in cognitive behavioural therapy for chronic schizophrenia?” Psychotherapy and Psychosomatics, vol. 79, no. 2, pp. 129–130, 2010.
[18]
S. R. McGurk, K. T. Mueser, P. D. Harvey, R. LaPuglia, and J. Marder, “Cognitive and symptom predictors of work outcomes for clients with schizophrenia in supported employment,” Psychiatric Services, vol. 54, no. 8, pp. 1129–1135, 2003.
[19]
C. R. Bowie, W. W. Leung, A. Reichenberg et al., “Predicting Schizophrenia patients' real-world behavior with specific neuropsychological and functional capacity measures,” Biological Psychiatry, vol. 63, no. 5, pp. 505–511, 2008.
[20]
R. W. Heinrichs, N. Ammari, A. A. Miles, and S. McDermid Vaz, “Cognitive performance and functional competence as predictors of community independence in schizophrenia,” Schizophrenia Bulletin, vol. 36, no. 2, pp. 381–387, 2010.
[21]
T. Wykes and V. Huddy, “Cognitive remediation for schizophrenia: it is even more complicated,” Current Opinion in Psychiatry, vol. 22, no. 2, pp. 161–167, 2009.
[22]
M. Fisher, C. Holland, K. Subramaniam, and S. Vinogradov, “Neuroplasticity-based cognitive training in schizophrenia: an interim report on the effects 6 months later,” Schizophrenia Bulletin, vol. 36, no. 4, pp. 869–879, 2010.
[23]
N. J. Preston, S. Kisely, and J. Xiao, “Assessing the outcome of compulsory psychiatric treatment in the community: epidemiological study in Western Australia,” British Medical Journal, vol. 324, no. 7348, pp. 1244–1246, 2002.
[24]
M. Prytys, P. A. Garety, S. Jolley, J. Onwumere, and T. Craig, “Implementing the NICE guideline for schizophrenia recommendations for psychological therapies: a qualitative analysis of the attitudes of CMHT staff,” Clinical Psychology and Psychotherapy, vol. 18, no. 1, pp. 48–59, 2011.
[25]
A. Patel, M. Knapp, R. Romeo et al., “Cognitive remediation therapy in schizophrenia: cost-effectiveness analysis,” Schizophrenia Research, vol. 120, no. 1–3, pp. 217–224, 2010.
[26]
A. Medalia and R. Richardson, “What predicts a good response to cognitive remediation interventions?” Schizophrenia Bulletin, vol. 31, no. 4, pp. 942–953, 2005.
[27]
C. Bouvet and C. Cleach, “Early dropout patients in psychiatric psychosocial rehabilitation treatment and their bindings with relational skills, object relation and intensity of psychopathology,” Encephale, vol. 37, no. 1, pp. S19–S26, 2011.
[28]
A. Medalia and A. Saperstein, “The role of motivation for treatment success,” Schizophrenia Bulletin, vol. 37, supplement 2, pp. S122–S128, 2011.
[29]
R. Penadés and C. Gastó, El Tratamiento de Rehabilitación Neurocognitiva en la Esquizofrenia, Editorial Herder, Barcelona, Spain.
[30]
T. Wykes and W. D. Spaulding, “Thinking about the future cognitive remediation therapy—what works and could we do better,” Schizophrenia Bulletin, vol. 37, supplement 2, pp. S80–S90, 2011.
[31]
C. Reeder, E. Newton, S. Frangou, and T. Wykes, “Which executive skills should we target to affect social functioning and symptom change? A study of a cognitive remediation therapy program,” Schizophrenia Bulletin, vol. 30, no. 1, pp. 87–100, 2004.
[32]
C. Reeder, N. Smedley, K. Butt, D. Bogner, and T. Wykes, “Cognitive predictors of social functioning improvements following cognitive remediation for schizophrenia.,” Schizophrenia bulletin, vol. 32, pp. S123–131, 2006.
[33]
R. Penadés, R. Catalán, O. Puig et al., “Executive function needs to be targeted to improve social functioning with Cognitive Remediation Therapy (CRT) in schizophrenia,” Psychiatry Research, vol. 177, no. 1-2, pp. 41–45, 2010.
[34]
R. Penadés, R. Catalán, M. Salamero et al., “Cognitive Remediation Therapy for outpatients with chronic schizophrenia: a controlled and randomized study,” Schizophrenia Research, vol. 87, no. 1–3, pp. 323–331, 2006.
