John is now 23 years old. At 17, he developed schizophrenia, a serious and persistent mental illness that typically interferes with a person's ability to function in school, work and in the family. At first, his symptoms were very obvious and troubling: He was paranoid, heard voices telling him bad things about himself, and isolated himself from family and friends, often behaving oddly. Over time, with medication and supportive care, these symptoms improved but his problems with memory, attention, processing and organizing information kept him from making a life like we all want -- with relationships, work and purpose.
Amelie is 42 and has had a serious mental illness for over a decade, sometimes identified as bipolar disorder, sometimes as schizoaffective disorder (where psychotic and mood symptoms both appear). While her moods are considerably helped by medications and psychotherapy she has had trouble functioning in her job in a restaurant or meeting the many responsibilities that come with being a wife and mother of two. It is difficult to maintain social relationships when you cannot pay attention to or remember what someone has said to you. Work and independent living tasks can become insurmountable when a person cannot process, remember and organize information.
However, we now have treatments, really more like training programs, to improve the cognitive deficits associated with serious mental illnesses. Cognitive remediation (CR) is an example of such an innovative treatment in psychiatry, and if you are ill or have a loved one with a mental illness you want to know about it, and see if it can help.
The principal goal of CR is to reduce cognitive difficulties, which are different from the symptoms of psychosis or severe mood swings. Other treatments, including medication and certain forms of psychotherapy, only partially reduce symptoms, often not touching difficulties in concentrating or distractibility. CR is focused on reducing the disability caused by impaired attention, memory, and planning abilities.
We define CR as a training intervention that targets cognitive deficits using scientific principles of learning. Its goal is to improve the functioning of those people with deficits. Its primary methods are drill and practice, strategy coaching, and developing ways to compensate or work around limitations.
CR can be done using different -- and now available -- programs. These programs consist of repetitive practice sessions, some of which can actually be fun (like computer games) (1). People who engage in CR actually like doing it. In addition to the programmed mental exercises, CR can help people develop better strategies for solving the complex, or multistep, problems we encounter everyday in going from one place to another, when shopping, or attending school or at our jobs. In addition, CR programs often give patients greater confidence -- in themselves as well as in their cognitive capabilities.
It is important that the cognitive improvements achieved in a program's sessions be transferred into the tasks of everyday life. Indeed, the gains of CR can enable individuals to better use psychological rehabilitation programs specifically aimed to help them stay in school, return to school, get jobs or retain the jobs they have (2,3).
An important benefit of CR is how it can improve a person's capacities to interact in social situations, including participating in a conversation and appreciating the intentions and emotions of other people; sometimes this is called "emotional intelligence," which is associated with success for all people, not just those with serious mental conditions. Moreover, CR can help individuals with mental illness who underestimate the degree of their disability to better appreciate their problems -- and their consequences for their personal and work lives.
A CR program is recommended to a patient, and family, by a mental health team after a thorough evaluation. CR is only recommended after patients have stabilized clinically from an acute episode of illness, and when they agree to participate. Mental health clinicians can increase patient motivation by offering programs that answer to the wishes of the people they treat -- like wanting friends, good pay, and a social life (4).
We also know that CR programs work better when they are integrated into rehabilitation goals and programs (5,6). CR programs generally last three to six months, and are best done when the program has a coach or facilitator, which requires investment. That investment is worth the cost when CR provides a stepping stone to improved functioning. Ideally, thus, each CR program should be connected to a rehabilitation program that offers skills training to help someone return to work, school or to live independently (7). What this means is that with a CR program, and rehabilitation, a person improves their chances of functioning independently, and meeting their goals of finishing school, working, socializing and managing their home life.
While CR is now especially focused on people with schizophrenia and related psychotic illnesses, there are programs for bipolar patients who suffer with cognitive disabilities. In Europe and the US, work is also underway for young adolescents suffering from rare metabolic or genetic diseases that produce cognitive symptoms (e.g., Velocardiofacial Syndrome) or for the cognitive problems seen in anorexia nervosa (8). In child psychiatry, CR programs have been developed for children with "dysexecutive" problems (similar to the executive cognitive problems described above) that occur with Attention Deficit Hyperactivity Disorder (ADHD), youth with higher functioning autism spectrum disorders, and serious learning disabilities.
The benefits of CR can also be seen in clinical and neurological ways. Clinically, depressive symptoms can be reduced, possibly through a gain in self-esteem or self-confidence. Even when cognitive improvements per se are modest, the improvement in depressive symptoms can be robust and have been replicated in a number of studies (9). Cerebral imaging studies also demonstrate that: Crucial brain structures located in the frontal lobe, which showed hypoactivation (decreased activity) before CR had increased activation after the program, paralleling an improvement in working memory (10), and loss of cerebral grey matter (brain cells) was observed to have been arrested, even two years after treatment with a cognitive behavioral therapy program that included CR (11).
CR is relatively new to psychiatry and mental health. But its scientific roots are not: It derives from the explosion of new knowledge from cognitive neuroscience. It is time for psychiatric programs to include CR as a standard part of the array of services needed for the comprehensive and quality treatment of persons with serious mental illnesses, especially schizophrenia and schizoaffective disorders. This will require first incubation in innovative and leadership clinical programs and then dissemination throughout a system of care on the basis of what is learned about how to best engage patients (and families) and train staff to deliver CR in mental health settings.
Cognitive remediation can remarkably change the lives of people who were previously disabled, or may become so, because of mental diseases. We owe this opportunity to them and their families.
Isabelle Amado, M.D., Ph.D., is a psychiatrist and director of the Reference Center for Cognitive Remediation and Rehabilitation (C3RP) in Sainte Anne Hospital in Paris (France).
Lloyd I. Sederer, M.D., is medical director of the NYS Office of Mental Health, adjunct professor at the Columbia/Mailman School of Public Health, and author of The Family Guide to Mental Health Care (WW Norton, 2013).
I would like to thank Drs. Alice Medalia, Lisa Dixon and Matthew Erlich for their contributions to this post.
The opinions offered here are those of the authors not their respective organizations.
1. Medalia A, Saperstein A. Does cognitive remediation for schizophrenia improve functional outcomes? Curr Opi Psychiatry, 2013;26 (2): 151-7.
2. Bell MD, Bryson GJ, Greig TC, Fiszdon JM , Wexler BE. Neurocognitive enhancement with work therapy: Productivity outcomes at 6 and 12 months follow-ups. J Rehab Res Dev 2005;42(6):829-38.
3. Killackey E, Jackson HJ, McGorry PD. Vocational intervention in first episode psychosis: individual placement and support versus treatment as usual. Br J Psychiatry 2008;193(2):114-20
4. Choi J, Fiszdon JM, Medalia A. Expectancy value theory in persistence of learning effects in schizophrenia: role of task value and perceived competency. Schizophrenia Bulletin 2010; 36(5):957-965.
5. Amado I, Krebs MO, Gaillard R, Olié JP, Lôo H. Les principes de la remédiation cognitive dans la schizophrénie.Bulletin de l'Académie. Nationale de Médecine, 2011,195 (6),1319-1333.
6. Lehman, A: Making A Difference, Am J Psychiatry. 2012 Jul 1;169(7):678-80.
7. McGurk SR, Wykes T. Cognitive remediation and vocational rehabilitation. Psychiatr Rehabil J 2008; 31(4):350-9
8. Tchanturia K, Lloyd S, Lang K. Cognitive remediation therapy for anorexia nervosa: current evidence and future research directions. Int J Eat Disord. 2013;46(5):492-5.
9. Wykes T, Huddy V, Cellard C, McGurk SR, Czobor P . A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. Am J Psychiatry 2011;168(5):472-85
10. Penades, R., et al., Brain effects of cognitive remediation therapy in schizophrenia: a structural and functional neuroimaging study. Biol Psychiatry, 2013. 73(10): p. 1015-23.
11. Eack SM, Hogarty GE, Cho RY, Prasad KM, Greenwald DP, Hogarty SS, Keshavan MS. Neuroprotective effects of cognitive enhancement therapy against gray matter loss in early schizophrenia: results from a 2-year randomized controlled trial. Arch Gen Psychiatry 2010;67(7):674-82.