Addressing the unmet need of cognitive dysfunction in schizophrenia

Metacognition needs to be an important component of cognitive remediation therapy (CRT) to successfully address the problem of impaired cognition for patients with schizophrenia. ‘Thinking about your thinking’ helps patients to not just learn strategies, but also know when to and when not to use them1.

Impaired cognition has a negative impact on functioning

Impaired cognition in schizophrenia has a negative impact on functioning and quality of life, constituting a ‘glass ceiling’ for rehabilitation, and is the main predictor of total health and social care costs2. Despite these functional and societal consequences, patients and their clinicians still need effective interventions, and this important topic was discussed at EPA2020.

Treatment strategies

Gabriele Sachs (Medical University of Vienna, Austria) explained how social cognition is a partial mediator between neurocognition and functional outcome, and is already affected in early stages of schizophrenia. Treatment strategies need to address both neurocognition and social cognition.

The effect of antipsychotic medication on cognitive functioning is still poorly understood suggested Antonia Vita (University of Brescia, Italy), with some studies indicating that they improve cognitive functioning whilst others demonstrate the reverse3. With no effective pharmacological interventions to treat cognition, interest has turned towards CRT.

Role of CRT

CRT uses scientific learning principles to target the cognitive deficit. Til Wykes (King’s College London, UK) presented an up-to-date summary of the 28 meta-analyses in CRT and schizophrenia since 2014, of which 25 found significant cognition and/or functioning improvement and 20 found symptom improvement.

Beyond those patients with chronic schizophrenia, Merete Nordentoft (University of Copenhagen, Denmark) discussed how CRT has shown benefit in those with first episode psychosis4 and is being studied in those at ultra-high risk for schizophrenia5.

Beyond cognitive improvement to functional outcomes

The goal for patients is not just increases in cognition test scores, but improved functional outcomes

The goal for patients is not just increases in cognition test scores, but improved functional outcomes such as independence, life skills and fulfilling relationships. A recent metanalysis showed that CRT improved functional as well as cognitive and clinical outcomes in patients with schizophrenia6.

Cognitive components being measured in earlier studies only partially explained the effect of CRT on functional outcomes7, and Dame Wykes suggested that metacognition is the missing link8.

Using metacognition in therapy

Importance of the therapist in encouraging metacognitive changes

A recent expert working group have produced a white paper on CRT for schizophrenia9, identifying four core techniques, which embrace metacognition:

  • Facilitation by a therapist
  • Cognitive exercise
  • Procedures to develop problem-solving strategies
  • Procedures to facilitate transfer to real world functioning

Wykes and colleagues have developed the ‘CIRCuiTS’ programme integrating metacognitive support into CRT10, which has demonstrated metacognitive improvement over time11. This approach involves setting goals, teaching a new approach to tasks, and reflecting on your own thinking, which can then be integrated into everyday life. She stressed the importance of the therapist in encouraging metacognitive changes6.



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Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

  1. Wykes T, Reeder C. Brunner-Routledge, London 2005.
  2. Patel A, et al. Schizophr Bull 2006;32:776-85.
  3. Albert N, et al. Psychol Med 2019;49:1138-47.
  4. Østergaard Christensen T, et al. Acta Psychiatrica Scandinavica 2014;130:300-10.
  5. Glenthøj LB, et al. Trials 2015;16:25.
  6. Kambeitz-Ilankovic L, et al. Neurosci Biobehav Rev 2019;107:828-45.
  7. Wykes T, et al. Schizophr Res 2012;138:88-93.
  8. Davies G, Greenwood K. J Ment Health 2018; 1-11.
  9. Bowie CR, et al. Schizophr Res 2020;215:49-53
  11. Cella M, et al. J Exp Psychopathol 2019;10(2):1-9.
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