Cognitive Remediation & Mental Health

Definitions

• Cognitive remediation : an intervention which

engages the participant in learning activities that

improve cognitive skills (Medalia & Choi, 2009, Medalia et al, 2009)

• Cognitive skills: the skills that allow one to

recognize, acquire, comprehend, and respond to

information (Medalia & Revehiem, 2002).

• Metacognition: thinking about thinking

History of Cognitive Remediation

Traumatic Brain

Injuries in

WWI & WWII

(Goldstein, 1942; Parente & Herrmann, 2003)

Approaches

• Remediation Techniques

• Compensatory Strategies

• Adaptive Approaches

(Medalia & Revehiem, 2002)

Cognitive Dysfunction in Mental Illness

• Treatment of the cognitive aspects of

mental illness are often placed secondary

to the emotional aspects (Medalia & Revehiem,

2002)

• ADHD originates from problems in the

development or functions of the frontal

cortex (Barkley, 2005)

• Cognitive concerns are common in

bipolar and recurrent depression. (Medalia &

Revehiem, 2002)

• In Schizophrenia, cognitive declines are

often the first recognized symptom.

Neural basis for brain training

Neuroplasticity and the environment

▫ Childhood examples

▫ Adult examples

(Rabipour & Raz, 2012)

Psychiatric Disorders &

Cognitive Remediation

• ADHD

• Tourette’s Syndrome

• Anorexia nervosa

• Affective Disorders

• Substance Abuse

• Psychosis

ADHD

• Neurofeedback programs are particularly promising for ADHD

in regards to attentional and behavioral control

• Only one program has been used to repeatedly demonstrate improvements in working memory in both children and adults with ADHD (5 days a week, 5-6 weeks)

• Most outcomes for cognitive training programs are not as promising

(Rabipour & Raz, 2012; Rapport et al, 2013)

Tourette’s Syndrome

• Pilot study with 12 controls and 12 experimental participants

• Controls watched popular children’s videos, relaxing tapes, and video games

• Attention training showed similar results to habit-reversal training

• Decreased visible tics and impulsivity

• Increased their ability to regulate emotions and persist with goals in the face of distractions

(Rabipour & Raz, 2012)

Anorexia nervosa

• Individuals with anorexia

nervosa are often characterized by difficulties with flexibility in thinking

• Early data showing improvements in cognitive flexibility

• No direct links in decreases of eating disorder pathology

(Berg & Wonderlich, 2013)

Affective Disorders

• The types of cognitive deficits seen in bipolar and MDD with psychosis are similar to those seen in populations with schizophrenia

• First meta-analysis showing moderate effect sizes for improvements in cognition

• Cautionary note: limited number of randomized studies and 35% of participants had a diagnosis of schizoaffective disorder

(Anaya et al, 2012)

Substance Abuse

• Delay discounting

• Correlation

Working Memory Delay Discounting

• Recent studies have been inconclusive

Wexler, 2011

Psychosis

• Most notable effects in Schizophrenia (McGurk et al, 2007)

• Research most prolific in the area of psychosis

• Most recent research has been focusing on

functional outcomes and the impact of

motivation

Comparative Effect Sizes from Recent Meta-

analyses

(McGurk, Twamley et al. ,2007 & Wykes, Huddy et al, 2011)

00.05

0.10.150.2

0.250.3

0.350.4

0.450.5

OverallCognition

Symptoms Functioning

Mcgurk et al, 2007

Wykes et al, 2011

Populations clinical at risk for psychosis

• Those at risk demonstrate similar but less marked neurocognitive

functioning declines to those observed in psychosis (Niedam et al, 2009;

Jahshan et al, 2010; Fusar-Poli et al, 2012)

• Although early in the research phase, cognitive remediation is

showing promising results in high risk and prodromal patients (Barlati et

al, 2013; Zaytseva, 2013)

• Greater cognitive gains are evidenced in those in the earlier phases

of the disorder than those with more chronic forms (Rauchensteiner et al, 2011)

• Cognitive remediation used as an adjunct to other treatments may

disrupt or delay the conversion to psychosis (Bechdolf et al, 2012)

Additional psychosocial interventions

as moderator for functional outcomes

0

0.1

0.2

0.3

0.4

0.5

0.6

McGurk et al,2007

Wykes et al, 2011

No additionalpsychosocialinterventions

Additional psychosocialinterventions

(McGurk, Twamley et al. ,2007 & Wykes, Huddy et al, 2011)

Cognitive Remediation &

Therapy Outcomes

0

2

4

6

8

10

12

14

Cog Rem SC (control)

# of Sessions

# of Sessions

Evidence of Neuroplasticity

fMRI shows:

Increased activation in the frontal lobes

compared to TAU

a) Regions associated with working memory

(Wykes et al., 2002)

b) Broca’s area (Vianin et al., 2014)

This was in addition to improvements on

cognitive measures.

What are the key ingredients?

• Stable on medication for cognitive improvement

• Adding cognitive remediation to rehabilitation programs with strategic rather than just drill and practice for improving functional outcomes**

• Number of hours (dosing) does not seem to be related to

overall cognitive functioning, but seems related to improvement in verbal learning and memory

(McGurk, Twamley et al. ,2007 & Wykes, Huddy et al, 2011)

Techniques using Computers

• Drill and practice

• Drill and practice

plus strategy

• As adjunct psychosocial treatments

(Krabbendam & Aleman, 2003)

Adult Day Treatment Program

• Seating for 10 patients

• Meet three times a week for one hour

• First 35-40 minutes computer activities

• Last 10-15 minutes bridging groups

• Program intended to last 16 weeks

• We use cognitive testing for treatment planning

and retest to look at progress

Current Interventions Used in Fairview

Day Treatment • Brain HQ by Posit Science

• Scientific Brain Training Pro by Happy Neuron

• Hot Dog Stand: The Works

Let’s give them a try!

• https://brainhq.positscience.com/default/start

• http://www.scientificbraintrainingpro.com/

Future Directions for our Site

• An program that offers cognitive remediation for

adolescents at risk for psychosis

• Hoping to expand program to include more

mental health concerns

Computer based cognitive remediation

is not the only game in town

(Rabipour & Raz, 2012)

Resources

• http://psyberguide.org/

PsyberGuide is a consumer-friendly resource for finding out

about the software and apps available for help in managing

mental health conditions, and the research and views of

experts on the usefulness of these products.

• Dealing with cognitive dysfunction associated with psychiatric

disabilities: A handbook for families and friends of individuals

with psychiatric disorders. By Medalia & Revehiem

http://www.omh.state.ny.us/omhweb/resource

References

Anaya, C., Aran, A.M., Ayuso-Mateos, J.L., Wykes, T., Vieta, E., Scott, J. (2012). A systematic

review of cognitive remediation for schizo-affective and affective disorders. Journal of Affective

Disorders 142: 13-21.

Barkley, R. (2005). Adhd and the nature of self-control. New York, NY: The Guilford Press.

Barlati, S., Deste, G., De Peri, L., Ariu, C., & Vita, A. (2013). Cognitive remediation in schizophrenia:

Current status and future perspectives. Schizophrenia Research and Treatment, 2013, 1-12. doi:

10.11552013156084

Bechdolf A, Wagner M, Ruhrmann S, et al (2012): Preventing progression to first-episode psychosis

in early initial prodromal states. Br J Psychiatry 200:22-9.

Berg, K.C. & Wonderlich, S.A. (2013). Emerging psychological treatments in the field of eating

disorders. Current Psychiatry Rep 15: 407

Fusar-Poli P, Deste G, Smieskova R, et al (2012): Cognitive functioning in prodromal psychosis: a

meta-analysis. Arch Gen Psychiatry 69:562-71.

Goldstein, K. (1942). Aftereffects of brain injuries in war (p. 244). New York: Grune & Stratton.

Jahshan C, Heaton RK, Golshan S, Cadenhead KS (2010): Course of neurocognitive deficits in the

prodrome and first episode of schizophrenia. Neuropsychology 24:109-20.

References (cont) Krabbendam L, Aleman A (2003): Cognitive rehabilitation in schizophrenia: a quantitative analysis of

controlled studies. Psychopharmacology (Berl) 169:376-82.

Drake et al. (2014). A naturalistic, randomized, controlled trial combining cognitive remediation with cognitive–behavioural therapy after first-episode non-affective psychosis . Psychological Medicine, 44, pp 1889-1899. doi:10.1017/S0033291713002559.

McGurk SR, Twamley EW, Sitzer DI, McHugo GJ, Mueser KT (2007): A meta-analysis of cognitive remediation in schizophrenia. Am J Psychiatry 164:1791-802.

Medalia A, Choi J (2009): Cognitive remediation in schizophrenia. Neuropsychol Rev 19:353-64. Medalia A, Revheim N, Herlands T (2009): Cognitive Remediation for Psychological Disorders:

Therapist Guide. New York: Oxford University Press, USA.

Medalia, A. & Revehiem, N. (2002). Dealing with cognitive dysfunction associated with psychiatric disabilities: A handbook for families and friends of individuals with psychiatric disorders. Retrieved from http://www.omh.state.ny.us/omhweb/resource

Niendam TA, Jalbrzikowski M, Bearden CE (2009): Exploring predictors of outcome in the psychosis prodrome: implications for early identification and intervention. Neuropsychol Rev 19:280-93.

Parente, R. & Herrmann, D.J. (2010). History and systems of cognitive rehabilitation. In Retraining cognition: Techniques and applications, third edition (pp. 7-11). Dallas, ProEd.

Reference (cont)

Rabipour, S & Raz, A. (2012). Training the brain: Fact and fad in cognitive and behavioral remediation. Brain and Cognition 79: 159-179.

Rapport, M.D., Orban, S.A., Kofler, M.J., & Friedman, L.M. (2013) Do programs designed to train working memory, other executive functions, and attention benefit children with ADHD? A meta-analytic review of cognitive, academic , and behavioral outcomes. Clinical Psychology Review 33 (pp. 1237-1252)

Rauchensteiner S, Kawohl W, Ozgurdal S, et al (2011): Test-performance after cognitive training in persons at risk mental state of schizophrenia and patients with schizophrenia. Psychiatry Res 185:334-9.

Vianin, P., Urben, S., Magistretti, P., Marquet, P., Fornari, E., & Jaugey, L. (2014). Increased activation in Broca's area after cognitive remediation in schizophrenia. Psychiatry Research: Neuroimaging, 221, 204-209. Retrieved October 30, 2014.

Wexler, B.E. (2011). Computerized cognitive remediation treatment for substance abuse disorders. Bioological Psychiatry 69: 197-198.

Wykes T, Brammer M, Mellers J, Bray P, Reeder C, Williams C, Corner J (2002): Effects on the brain of a psychological treatment: cognitive remediation therapy: functional magnetic resonance imaging in schizophrenia. Br J Psychiatry 181: 144–152.

Wykes T, Huddy V, Cellard C, McGurk SR, Czobor P (2011): A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. Am J Psychiatry 168:472-85.

Zaytseva, Y., Korsakova, N., Agius, M., & Gurovich, I. (2013). Neurocognitive functioning in schizophrenia and during the early phases of psychosis: Targeting cognitive remediation interventions. BioMed Reseach International, 2013, 1-8. doi: 10.11552013819587