At Issue: The Future of Cognitive Rehabilitation of Schizophrenia

Abstract

Cognitive rehabilitation is becoming an increasingly popular intervention in treatment programs for people with schizophrenia. Despite this increased acceptance, however, the evidence base on its effectiveness is not impressive. Moreover, given the evidence of cognitive recovery in treated patients who do not receive cognitive rehabilitation--from newer medications and from other evidence-based psychosocial interventions--it is not clear whether cognitive rehabilitation is worth its expense in time and resources. We believe that the slow progress in the field of cognitive rehabilitation of schizophrenia is related to failure to address several critical issues: (1) the importance of manipulating stimulus and context structure in rehabilitative interventions; (2) the need to base a cognitive rehabilitation of schizophrenia on cognitive neuroscience as opposed to neuropsychology; (3) the importance of systematically addressing motivation, self-esteem, and affective factors when designing cognition-enhancing interventions; (4) the need to move beyond one-size-fits-all interventions and develop individualized treatments; and (5) the need to address abnormalities in the experience of the self when designing interventions to optimize cognitive and behavioral performance. Suggestions for addressing these issues are discussed.

Computer-assisted cognitive remediation in schizophrenia: What is the active ingredient?

“…One potential implication of these findings is that the neurocognitive deficits and negative symptoms of the disorder place such large restrictions on patients social and occupational life, that any type of sustained, goal-directed cognitive activity in the presence of supportive clinicians, regardless of its content, has the potential to elevate neuropsychological function significantly in this patient population. Consistent with this viewpoint, a small but growing number of studies suggest that structured behavioral rehabilitation improves neurocognitive skills in patients with schizophrenia in the absence of any specific cognitive training (e.g., Spaulding et al, 1999;Silverstein & Wilkness, 2004). This possibility also emphasizes the significance of reports showing an advantage of cognitive remediation for a variety of outcome measures, even when cognitive remediation interventions are compared with control interventions that involve considerable non-specific stimulation such as work therapy or supported employment programs (Bell et al, 2001;McGurk et al, 2005).…”

Current Trends in the Empirical Study of Cognitive Remediation for Schizophrenia

“…13,24 By integrating CR with other behavioural interventions, gains in neurocognitive skills may promote functional skills acquisition, and neurocognitive outcomes may be reinforced by concurrent psychosocial skills training. There may also be beneficial nonspecific treatment effects 21,31 that bolster outcomes when CR for schizophrenia is delivered in a structured, prosocial, goal-oriented context [41][42][43][44] that may be lost when CR is solely computer-based. CR has been embedded within the context of other evidence-based programs, such as work therapy and supported employment.…”

Cognitive Remediation in Schizophrenia

“…The definitive purpose of cognitive training is not simply to improve neuropsychological test scores but to generalize improvements to enduring real-world application Lim 2004, Silverstein andWilkniss 2004). The eventual query that always arises in any method or system developed in this field is: what is the mechanism(s) that moves the acquired cognitive gains to non-trained cognitive and functional domains?…”