Cognitive remediation for schizophrenia: Clinician perspectives on implementation barriers and facilitators.

Abstract

Objectives: Neurocognitive deficits in schizophrenia have a major impact on functioning; however, they remain poorly targeted by available treatment offerings. Cognitive remediation (CR) is effective in improving neurocognition and functioning. Despite clinical guidelines for schizophrenia recommending CR, it is still not readily available in clinical services and sizeable attrition rates are reported in clinical trials. Method: To elucidate the barriers and facilitators of CR access and engagement, we conducted a mixed methods qualitative-dominant study with 12 clinicians in Australia, in 2021, with 1 hr interviews and additional rating scales completed. Results: Thematic analysis highlighted four themes (cognitive symptoms, CR intervention, motivation and engagement in CR, and CR implementation), and 14 subthemes. Clinicians emphasized the broad impact of cognitive deficits and outlined pros and cons of different CR approaches. Several factors were suggested as impacting engagement, including motivation assessments/techniques, neurocognitive insight, illness, and demographic factors. Lack of routine implementation in Australia was unanimously espoused and partly explained by a need for cost-effectiveness analyses, remote and flexible delivery, and increasing service resource provision and staff training in CR. Conclusions: This study offers key insights into CR access, while recommending methods for optimizing CR implementation and dissemination to improve recovery outcomes of people diagnosed with schizophrenia. Impact and ImplicationsThis study highlights that clinicians in our sample were highly aware of the pervasive impact of cognitive symptoms in schizophrenia and advocated for the implementation and dissemination of cognitive remediation (CR) in routine mental health services, locally and across the world. To optimize both access and engagement, clinicians suggest greater flexibility of delivery and greater contextualization in available programs, notably with consideration to consumer preferences, goals, and barriers. Increasing cognitive literacy in consumers-through psychoeducation, for example-is also key. Our results suggest that clinical services may not provide access to CR to people perceived at higher risk for dropout notably because of a lack of appropriate resources to support them; yet, these patients could benefit. Suggested improvements in access to staff training, increased funding, and advocacy of CR benefits in clinical services and to policy makers, as well as further cost-effectiveness and implementation research, would improve CR dissemination.