Improved cognition and insight into thinking: can we help these to be transferred to everyday life?

There’s ‘thinking’, and there’s ‘thinking about thinking’. Metacognition is now being explored as a way of improving the transfer of skills learned through cognitive remediation (CR) to patients’ everyday lives. Meanwhile, there is growing evidence for the potential cost-effectiveness of CR, and a groundbreaking trial in people at ultra-high risk of transition to psychosis.

A focus on metacognition – understanding how to monitor and evaluate cognitive performance, and use and describe strategies to optimize thinking -- may maximize the transfer of improved cognitive skills to everyday life. At least, that is the aim of Matteo Cella (King’s College, London, UK) and colleagues who have developed a computerized program to encourage patients to think about thinking.

Cognitive remediation is not an end in and of itself, but a means of improving function – which is what many patients care about the most.

Many people with schizophrenia have widespread deficits in cognitive skills and, on average, score around one standard deviation below the general population on standard cognitive testing measures. These deficits contribute to difficulties in attaining and maintaining education, employment and quality in social life.

Attempts at cognitive remediation aim not only to restore cognitive skills but also – through that – to improve function, which is what people with schizophrenia care about the most. And cognitive remediation does achieve that to a modest degree: meta-analyses show effect sizes of around 0.45 in relation to cognitive performance and of around 0.42 in relation to improved function six months after the intervention.

Encouraging transfer of skills to everyday life

Crucial to the efficacy of cognitive remediation (CR) is the transfer of improved skills to everyday life. And this is mediated by a number of factors, including motivation and metacognition – which includes insights into the need for planning, monitoring and evaluation of performance, and awareness of the possible effects of changes in mood, for example – and the role of compensatory strategies.

Cognitive problems strongly predict poor function and are a barrier to functional recovery

Dr Cella and colleagues have developed the CIRCuiTS program which encourages people to reflect on their goals and strategies, and develop insights into their cognitive skills. The program, partly therapist-led and partly computer-based, is tailored to the goals of the individual patient and aims to achieve a minimum of twenty hours engagement.

In a small randomized trial of adding CIRCuiTS to treatment- ‘as- usual’, this novel intervention significantly improved patients’ functioning in the community at the end of the program, however, results were not maintained at a six-month follow-up, suggesting that patients need continuous support following the end of the program. Even so, these initial results are sufficiently encouraging and point to the need for larger evaluative studies.

Cognitive remediation increases interest in rehabilitation

Investigators in Italy have found that cognitive remediation (CR) in people with schizophrenia has effects on utilization of psychiatric services that persist for at least three years. The pattern is one of the reduced need for acute phase treatment, notably hospitalization, and increased engagement with outpatient rehabilitation services, Antonio Vita (University of Brescia, Italy) told the EPA’s annual meeting in Nice.

The reduced need for acute phase treatment, notably hospitalization, and increased engagement with outpatient rehabilitation services may reflect improved cognitive abilities

These new data come from long-term follow-up of a randomized trial of adding CR to treatment-as-usual. In the CR arm of the study, days of hospitalization in an acute care unit were substantially lower than pre-treatment at three and five years. While days in hospital also fell among patients with treatment-as-usual, the differences vs pre-treatment were not significant.

In the CR group, total number of outpatient interventions per month was significantly higher than pre-treatment levels, three years after CR (but not at five years). Among patients assigned to treatment-as-usual, there was no substantial increase.

The shift to community-based care, including complex rehabilitation efforts, may reflect the improved cognitive abilities of the intervention group, Dr Vita suggested.

Groundbreaking trial involves people at ultra-high risk

Ultra-high risk of psychosis has been found to be associated with poorer recognition of emotions

People at ultra-high risk of psychosis show deficits in social cognition, social skills and ability to recognize emotions such as anger, disgust and fear when compared with healthy controls, Merete Nordentoft (Mental Health Center, Copenhagen, Denmark) and her colleagues have found. In an effort to tackle these problems, she and her colleagues are engaged in a randomized controlled trial of neurocognitive and social cognitive remediation plus standard treatment vs standard treatment alone.

This study, termed FOCUS, is thought to be the first such targeted intervention in the ultra-high risk population – around a third of whom will develop psychosis within three years. Enrollment stands at 140 people, and follow-up data should be available by the end of 2018.