The non-pharmaceutical approach to a potential “game changer” in schizophrenia?

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Cognitive remediation (CR), a therapy that includes non-pharmacological approaches to improve cognitive function in patients with severe mental illness, can lead to significant improvement in patients with schizophrenia, suggests new research.

A systematic review of 130 studies worldwide that included nearly 9,000 participants showed that CR significantly improved cognition and overall functioning. In addition, the researchers identified key patient characteristics that indicated ideal candidates for therapy.

“Because pharmacological treatment exerts limited effects on cognitive deficits and clinical remission does not necessarily result in functional recovery, widespread implementation of CR could change the game to achieve the patient’s personal recovery goals,” the researchers write. .

“We hope this systematic review can help physicians understand how to make CR even more effective and even more personalized,” explained lead author Antonio Vita, Ph.D., Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy. Medscape Medical News.

Vita noted that he would also encourage doctors to consider “proposing it for clinical practice.”

The findings were presented at the Schizophrenia International Research Society (SIRS) Virtual Congress 2021 and were published simultaneously inside Psychiatry JAMA.

The resistance continues

Cognition “should be a focus of treatment because most disability and functional consequences of the disease are related to … neurocognitive impairment and impairment of social cognition,” Vita said.

He noted that cognition-focused treatments are crucial for the recovery of patients with schizophrenia.

However, while there is a “solid corpus of evidence” that supports the effectiveness of CR and the recommendations in the guidelines for RC to be included in psychiatric services, reluctance remains, the researchers note.

The aim of the study was to determine the optimal candidates for CR and to evaluate the results of therapy and its four basic elements. These basics include

  • The presence of an active and trained therapist

  • Repeated practice of cognitive exercises

  • Structured development of cognitive strategies

  • Techniques to improve the transfer of cognitive gains to the real world, such as integrated psychosocial rehabilitation

The researchers conducted a systematic bibliography search of the PubMed, Scopus, and PsychInfo databases to find relevant CR studies published between January 2011 and February 2020. They also conducted “manual searches” for meta-analyzes, reviews, and reference lists. .

Ultimately, the analysis included 130 randomized clinical trials comparing CR with a control condition in 8851 patients with schizophrenia spectrum disorders.

Of these studies, 57 were conducted in Europe, 38 in the United States, 22 in Asia, four in Canada, four in Middle Eastern countries, three in Australia, and two in Brazil.

The mean age of the participants was 36.7 years and 68% were male. The mean age at the onset of schizophrenia was 23.3 years and the mean duration of the disease was 13.8 years.

The mean duration of RC treatment was 15.2 weeks. The four elements were well represented; each was offered to at least 71% of patients.

Comparative therapy was the usual treatment (TAU), in 34.3% of cases, or active TAU with multidisciplinary rehabilitation, in 15.2% of cases. The rest of the interventions were nonspecific (30.8%) or were designed specifically for the study (19.9%).

The results showed that CR had a significant, albeit moderate, effect on global cognition (Cohen’s d effect size, 0.29; P .001) and overall operation (effect size, 0.22; Pg <.01).

Having an active and trained therapist had a significant impact on cognition and functioning (Pg = 0.04 for both), as well as the structured development of cognitive strategies (Pg = .002 for cognition; Pg = .004 to work).

The integration of psychosocial rehabilitation also had a significant effect on functioning (Pg = .003).

Interventions that included all basics had a “highly significant” association with global cognition (Pg = .02) and global operation (Pg <.001), the researchers report. Longer treatments were significantly associated with greater functional improvement (Pg = .006).

The researchers found that improvements were greater among patients with fewer years of education (Pg = 0.03 for cognition; Pg = 0.02 for operation), lowest premorbid IQ scores (Pg = 0.04 for operation), and more severe symptoms at first (Pg = .005 for cognition).

Researchers point out that CR should be more widely available because it has the “potential to be a standard element of care rather than an optional intervention targeted at selected individuals”.

A treatment option with a view

Commenting on the findings of Medscape Medical News, Alice Medalia, Ph.D., director of the Lieber Recovery Clinic at Columbia University’s Irving Medical Center in New York City, noted that this study is the second large-scale analysis of the use of RC for patients with schizophrenia to be published this year. The other was published inside Schizophrenia Newsletter.

“So this is an important year for big reviews,” he said. “It’s great to have two studios like this [that] it tells a very coherent story. “

Medalia, who was not involved in the research, said people “don’t really talk much about cognition.”

CR, he added, is “one of the services that should be offered and the big picture is that each person should take into account their cognitive needs.

“If someone has problems and is preventing them from being the kind of person they want to be and want to do, we have to intervene. The way we intervene must always be in the least harmful and intense way,” she said.

These measures may include examining sleep hygiene, adjusting medications, or introducing exercise.

“But there really comes a time for some people where cognitive remediation will be helpful, so it should be more available,” Medalia said.

While the increase in availability depends in part on having enough therapists trained, the main reason why RC is no longer available is because “people just don’t think about cognition and don’t know how to talk about it,” he noted. . In addition, he said, even when available, doctors do not refer patients.

“That tells you something. The solution here is not to put a cognitive remediation program everywhere but … to make people feel comfortable talking about cognition and identifying when an intervention is needed,” Medalia said.

One author of the study received grants from the National Institute for Health Research during the conduct of the study and was the creator of CIRCuiTs, a cognitive remediation software. The other researchers and Medalia have not reported any relevant financial relationships.

Congress of the Schizophrenia International Research Society (SIRS) 2021: Abstract 3006850. Presented April 20, 2021.

Psychiatry JAMA. Published online April 20, 2021. Full article

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