Cognitive Remediation Therapy for outpatients with chronic schizophrenia: A controlled and randomized study
Introduction
Schizophrenia is generally viewed as a chronic disorder characterized by psychotic symptoms and relatively stable neurocognitive and interpersonal deficits. Frequently, residual cognitive impairments stand as impediments to full recovery from schizophrenia (Bell and Berson, 2001). Antipsychotic medication has made it possible to reduce psychotic symptoms and to prevent relapses, but it is yet to have the same convincing impact on cognitive or functional impairments.
Cognitive Remediation Therapy (CRT) is a promising new treatment designed to improve neurocognitive abilities such as attention, memory and executive functioning. Despite this broadening acceptance, evidence regarding its effectiveness is still inconclusive. Two meta-analyses have recently been conducted (Krabbendam and Aleman, 2003, Twanley et al., 2003) showing that the effect sizes of the trials are approximately intermediate and that they differed slightly over the different studies. Moreover, it is not clear whether cognitive rehabilitation can justify its cost in terms of resources (Silverstein and Wilkiniss, 2004). To partially solve this difficulty, comparison groups with ‘active’ psychological treatments have been proposed as appropriate controls in CRT trials (Spaulding, 1992). Finally, beyond the assessment of change in cognitive tests, measurement of change in everyday functioning could be critical. Surprisingly, less than one-third of the CRT studies published include any assessment of everyday functioning in their outcomes measures (Twanley et al., 2003).
For the present study, our global aim was to examine the effects of neurocognitive intervention in treating chronic schizophrenia outpatients in a clinical setting. It was hypothesized that CRT would significantly improve neurocognition and social functioning, and would have a slight positive effect on symptomatology. Cognitive Behavioural Therapy (CBT) was used as a control condition because it aims to improve emotional problems and positive symptoms, focusing on modification of maladaptive beliefs and schemas, but neurocognition is not targeted.
Section snippets
Subjects
All the participants were recruited from the Hospital Clinic Mental Health Centre which serves part of the Barcelona area. The inclusion criteria were (a) age less than 55 years, (b) DSM-IV diagnosis of schizophrenia confirmed following the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) (First et al., 1997) (c) prevalence of negative symptoms confirmed by the Positive and Negative Syndrome Scale (PANSS) (Kay et al., 1987), and (d) presence of cognitive impairments confirmed
Sample characteristics
There were no differences between groups on any of the demographic or chronicity measures (Table 1) and the groups were also comparable in their severity of symptoms as assessed during a 2-week period prior to psychological treatment (range = 5–15 days). No significant correlations were found between positive symptoms and baseline performance in any of the cognitive domains (all p > 0.50), but there was a significant negative correlation between severity of negative symptoms and baseline Working
Discussion
The present study showed significant improvements in individual test performance after the CRT. Even when using covariance analyses, patients receiving CRT showed greater mean differences and larger effect-size changes than did patients receiving CBT. These results support the efficacy of CRT and it might be concluded that this treatment is useful in targeting neurocognitive impairment because it increased functioning to a degree not achievable from the non-specific stimulation. These results
Acknowledgements
The authors thank Dr. Ann Delahunty for her generous advice. This study was partially supported by the “Fundació La Marató de TV-3” (N-2001-TV1510-O).
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