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Training engagement, baseline cognitive functioning, and cognitive gains with computerized cognitive training: A cross-diagnostic study

  • Skyland Trail

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Computerized cognitive training (CCT) interventions are increasing in their use in outpatient mental health settings. These interventions have demonstrated efficacy for improving functional outcomes when combined with rehabilitation interventions. It has recently been suggested that patients with more cognitive impairment have a greater therapeutic response and that reduced engagement in training can identify cases who manifest low levels of benefit from treatment. Participants were psychiatric rehabilitation clients, with diagnoses of major depression, bipolar disorder and schizophrenia. Newly admitted cases received CCT, delivered via Brain HQ, with cognitive functioning divided into groups on the basis of a BACS t-score of 40 or less vs. more. Training engagement was indexed by the number of training levels achieved per day trained. Forty-nine cases trained on average for 17 days and completed a mean of 150 levels. Overall, patients improved by an average of 4.4 points (0.44 SD) in BACS t-scores (p < .001). Improvements were positively correlated with training engagement (r = 0.30, p < .05), but not with days trained (r = 0.09) or levels earned (r = 0.03) alone. Patients with higher levels of baseline cognitive performance had reduced cognitive gains (p < .003), but did not have less training engagement (p = .97). Diagnoses did not predict cognitive gains (p = .93) or target engagement (p = .74). Poorer performance at baseline and higher levels of training engagement accounted for >10% in independent variance in cognitive gains. The mean level of cognitive improvement far exceeded practice effects. The index of engagement, levels achieved per training day, is easily extracted from the training records of patients, which would allow for early and continuous monitoring of treatment engagement in CCT activities and therapist intervention as needed to improve engagement.
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Schizophrenia Research: Cognition
journal homepage:
Research Paper
Training engagement, baseline cognitive functioning, and cognitive gains
with computerized cognitive training: A cross-diagnostic study
Philip D. Harvey
, Alexandra M. Balzer
, Raymond J. Kotwicki
University of Miami Miller School of Medicine, USA
Skyland Trail, USA
Computerized cognitive training (CCT) interventions are increasing in their use in outpatient mental health settings. These interventions have demonstrated efficacy
for improving functional outcomes when combined with rehabilitation interventions. It has recently been suggested that patients with more cognitive impairment
have a greater therapeutic response and that reduced engagement in training can identify cases who manifest low levels of benefit from treatment. Participants were
psychiatric rehabilitation clients, with diagnoses of major depression, bipolar disorder and schizophrenia. Newly admitted cases received CCT, delivered via Brain
HQ, with cognitive functioning divided into groups on the basis of a BACS t-score of 40 or less vs. more. Training engagement was indexed by the number of training
levels achieved per day trained. Forty-nine cases trained on average for 17 days and completed a mean of 150 levels. Overall, patients improved by an average of 4.4
points (0.44 SD) in BACS t-scores (p< .001). Improvements were positively correlated with training engagement (r= 0.30, p< .05), but not with days trained
(r= 0.09) or levels earned (r=0.03) alone. Patients with higher levels of baseline cognitive performance had reduced cognitive gains (p< .003), but did not have
less training engagement (p= .97). Diagnoses did not predict cognitive gains (p= .93) or target engagement (p= .74). Poorer performance at baseline and higher
levels of training engagement accounted for >10% in independent variance in cognitive gains. The mean level of cognitive improvement far exceeded practice
effects. The index of engagement, levels achieved per training day, is easily extracted from the training records of patients, which would allow for early and
continuous monitoring of treatment engagement in CCT activities and therapist intervention as needed to improve engagement.
1. Introduction
Computerized cognitive training (CCT), often delivered with con-
current psychosocial rehabilitation as cognitive remediation therapy
(CRT) has been widely used in healthy older people and in patients with
schizophrenia. The evidence base for these two populations is quite
broad (Harvey et al., 2018) and CRT in particular has been shown to be
associated with functional gains. Meta-analyses have suggested that
CCT has cognitive benefits and when delivered as CRT also has con-
sistent functional gains (Wykes et al., 2011). The evidence base in other
psychiatric conditions is less substantial and there are many fewer CCT
and CRT studies in mood disorders, including bipolar disorder and
major depression.
Although supported by the results of meta-analyses, there have been
negative results. For instance, several trials have shown negative results
(Goff et al., 2007;Kantrowitz et al., 2016;Murthy et al., 2012;Rass
et al., 2012), even when paired with pharmacological interventions. It
has been suggested that one possibility for some of the negative results
has been failure of the training participants to actively participate in the
intervention, failing to manifest engagement with training and make
progress on the training procedures. It had been suggested that it would
be possible to increase training engagement by adding game-like
features to make the training procedures compelling (Fleming et al.,
2017;Lumsden et al., 2016). However, one study found that gamifi-
cation elements specifically lowered learning rates, perhaps by dis-
tracting users from the cognitive tasks themselves (Katz et al., 2014).
Recently it was also reported that there may be a specific threshold
for improvement on the central training task that is required to induce
transfer to untrained cognitive tasks. A previous study quantitatively
analyzed the relationship between gains in auditory processing during
training and overall cognitive gains and concluded that the final level of
auditory speed performance predicted the magnitude of cognitive gain,
and participants who did not achieve a level faster than ~85 ms did not
show generalized cognitive gains (Biagianti et al., 2016).
Another possible factor associated with training gains in CRT may
be baseline levels of cognitive performance. In a simple face-valid way,
it would appear that individuals with psychiatric conditions who do not
manifest cognitive impairments at baseline might not be candidates for
interventions aimed at cognitive enhancement. In the absence of cog-
nitive impairments, other factors might be responsible for disability.
Several studies have addressed this issue. For example, Strassnig et al.
(2018) reported that for schizophrenia patients with MCCB t-scores
>40, there was no significant correlation between MCCB performance
and independently rated indices of functional disability; whereas, for
Received 19 January 2019; Received in revised form 25 April 2019; Accepted 3 May 2019
Corresponding author at: University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 1450, Miami, FL 33136, USA.
E-mail address: (P.D. Harvey).
Schizophrenia Research: Cognition 19 (2020) 100150
Available online 13 May 2019
2215-0013/ © 2019 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
the sample of patients with more severe cognitive deficits, disability in
everyday functioning was correlated with cognitive test performance.
In an aggregated set of data across four cognitive training trials, Detore
et al. (2019) reported that, in the entire database and across all of the
studies, patients with more severe cognitive impairments had a greater
benefit from CRT than patients with less impairment.
In this study, we examine cognitive gains associated with CCT in a
sample of patients with mood and psychotic disorders. All patients re-
ceived treatment at a psychiatric rehabilitation facility and patients
were trained with CCT with the Posit Science Brain HQ training pro-
gram. This program has shown efficacy in single site (Ahmed et al.,
2015;Fisher et al., 2009, 2010;Loewy et al., 2016;Surti et al., 2011)
and multi-site trials (Fisher et al., 2014;Keefe et al., 2012) targeting
people with schizophrenia, with some negative trials as described
above. Further, in a large-scale (n= 150), long term (26 week; 5 days
per week) randomized clinical trial (Mahncke et al., in press), active
training did not separate from placebo training. However, there was
evidence of substantial failure to engage in training in the active
treatment group. In contrast to previous successful studies (Fisher et al.,
2009;Keefe et al., 2012), performance on the index of target engage-
ment described above was at 121 ms in the active treatment group. This
is much slower than the other two studies (70 and 71 ms respectively)
and the threshold suggested by Biagianti et al. (2016) of 85 ms.
We examined cognitive gains for the sample as a whole, gains in
cases with greater and lesser cognitive impairments, and in each di-
agnostic group, as well as measuring training engagement in CCT and
its association with cognitive gains on an untrained cognitive assess-
ment measure to index near transfer. Our hypothesis was that the extent
of engagement in training would be associated with cognitive gains
from pretreatment to post-test. We also expected that patients with
more cognitive impairment would manifest greater gains. In order to
assess these variables, we performed exploratory comparative analyses
of the impact on cognitive change of training engagement and baseline
cognitive performance.
2. Method
2.1. Treatment site and participants
Participants were clients admitted to care at Skyland Trail, a non-
profit residential, partial hospitalization, and intensive out-patient
psychiatric rehabilitation facility located in Atlanta, GA. The center has
a continuum of care, where more symptomatic individuals were in-
itially placed in residential facilities and with planned transitions into
day treatment, intensive outpatient, and transitional treatment tracks as
symptomology and functionality improves. Less symptomatic in-
dividuals are directly admitted into outpatient services. The average
length of treatment for patients in all levels of care at Skyland Trail is
about 4 months. The data collected in this study were extracted from
medical records and there was no additional contact with clients and no
modifications of their care. At admission, all clients signed a general
consent form agreeing that data in their electronic medical records may
be used for research and quality improvement projects without re-
vealing their identities. As a result, these data analyses were not sub-
mitted as a research project to an institutional review board, because all
of the data collection procedures were part of ongoing standard clinical
care at the facility and these analyses were aimed at determining which
cases should be referred to CCT in the future.
These data were collected from May 2016 to December 2017,
during which time all admissions to treatment services were adminis-
tered a battery of assessments as part of the standard admissions pro-
cess. All patients received a diagnosis with a structured procedure that
has been previously published (Kotwicki and Harvey, 2013). This pro-
cedure included a structured interview with the MINI International
Neuropsychiatric Inventory (MINI; Sheehan et al., 1998). During this
time, all admissions were also tested with a neuropsychological
assessment. The distribution of all diagnoses for the consecutive ad-
missions was 23% bipolar disorder, 47% major depression, and 15%
schizophrenia, with other diagnoses less common. We did not analyze
data from patients whose primary diagnoses were substance abuse or
personality disorders. We also examined data only from cases between
the ages of 18 and 50. Cases with incomplete assessment data and those
who were referred to CCT, but refused to participate, were also ex-
The eventual sample was 52% female and 53% young adult, ages 18
to 25 years old (Mean age = 28.6, SD = 11.6). A total of 49 cases met
the diagnostic criteria, completed baseline and post treatment assess-
ments with the BACS and completed at least one day of CCT training.
The diagnostic distribution of the cases was major depression (39%),
bipolar disorder (39%), and schizophrenia (22%). The Brief Assessment
of Cognition for Schizophrenia, paper version, (BACS; Keefe et al.,
2004) was used to measure cognitive ability. CCT was delivered to
patients via the online computer program Posit Science Brain HQ. The
participants were instructed to practice at least 3 h of training each
week, available either through the CRT group which met for 45 min
each day or as independent homework.
2.2. BACS
The following 6 tests constitute the BACS. All tests with alternative
forms were administered with form A first and B second.
List Learning (Verbal Memory): Patients are presented with 15 words
and then asked to recall as many as possible. This procedure is re-
peated 5 times. There are 8 alternate forms, of which 2 were used in
this study.
Digit Sequencing Task (Working Memory): Patients are presented with
strings of numbers of increasing length. They are asked to tell the
experimenter the numbers in order, from lowest to highest.
Token Motor Task (Motor Speed): Patients are given 100 plastic to-
kens and asked to place them into a container as quickly as possible
for 60 s.
Verbal Fluency,Category Instances (Semantic Fluency): Patients are
given 60 s to name as many words as possible within the animal
Controlled Oral Word Association Test (Letter Fluency): In two separate
trials, patients are given 60 s each to generate as many words as
possible that begin with the letters F and S.
Tower of London Test (Executive Functions) Patients look at two pic-
tures simultaneously. Each shows 3 different-colored balls arranged
on 3 pegs, with the balls in a unique arrangement in each picture.
The patient is required to accurately estimate the fewest number of
times the balls in one picture would have to be moved in order to
make the arrangement of balls identical to that of the other, op-
posing picture.
Symbol Coding (Attention and Motor Speed) In this test, the numbers
1–9 are coded to symbols and drawn on a response sheet for 90 s.
A composite score using previously published procedures was the
primary outcome variable because the sample size did not allow for
analyses of the subtests. This composite is a t-score with a mean of 50
and a standard deviation of 10. Standard interpretations of this com-
posite score would suggest that scores of 40 or less reflect “possible
cognitive impairment.”
2.3. Computerized cognitive training
Participants self-administered the training after receiving instruc-
tions, with a proctor in the room to answer questions and encourage
adherence. All training used the commercially available Posit Science
Brain HQ system. Participants were asked to train at least 30 min per
session three days per week and to prioritize training on the “double
P.D. Harvey, et al. Schizophrenia Research: Cognition 19 (2020) 100150
decision” training task for at least half of the time. The rest of the
training was self-selected, but if the participants asked what they should
train on, they were told to prioritize brain speed, working memory, and
attention tasks. Training information was taken directly from the Brain
HQ portal and consisted of days spent training and levels achieved, with
all information collected after the participants had completed their
training. There was no attempt to directly monitor adherence with
these indices during training.
2.4. Statistical methods
Total scores on the BACS composite score at baseline and endpoint
were the dependent measures. We created an engagement score which
was the number of levels achieved per training day and a change score
which was the difference of baseline and endpoint scores on the BACS
composite. We divided the patients into subgroups on the basis of their
baseline composite BACS score (40 or less vs. higher). We used a two-
way analysis of variance (Diagnosis × cognitive status) to examine
differences in BACS change scores and target engagement. We then
correlated the BACS change scores with days trained, levels achieved,
and the ratio of the two. Finally, regression models were used to
identify independent contributions of all variables found to be corre-
lated with changes in cognitive performance.
3. Results
Table 1 presents the results of the BACS Composite at baseline and
endpoint, days trained, levels achieved, and target engagement as a
function of diagnosis and cognitive status. A paired t-test found that the
BACS scores improved significantly from baseline to endpoint, t
(48) = 3.38, p< .001 in the sample as a whole. The effect size for the
change was d = 0.44. The two-way ANOVA examining the effect of
diagnosis × cognitive status on BACS change scores found a significant
effect of baseline cognitive status, F(1,48) = 10.21, p< .005, but no
significant effect of diagnosis, F(2,47) = 0.08, p> .90 or diag-
nosis × cognitive status interactions F(2,47) = 2.24, p> .10. The two-
way ANOVA examining the effect of diagnosis × cognitive status on
training engagement scores found no significant effect of cognitive
status, F(1,48) = 0.00, p> .95, no significant effect of diagnosis, F
(2,47) = 0.31, p> .70 and no diagnosis × cognitive status interactions
F(2,47) = 1.39 p> .20.
Pearson correlations between changes in BACS performance from
baseline to endpoint, days trained, levels achieved, and the training
engagement variable are presented in Table 2. Changes in the BACS
from baseline to endpoint were significantly correlated with training
engagement, p< .05, but not with either days trained or levels
achieved. Days trained correlated with levels attained, but not with
levels per day and levels per day correlated with levels attained but not
with days trained.
A final analysis used the two variables found to predict cognitive
improvement with training, baseline cognitive status and levels
achieved per day, in a regression model. Since the two variables were
not related to each other, we used a stepwise entry procedure to predict
changes in cognition (Difference of BACS from Baseline to endpoint).
The overall analysis was significant, F(2,46) = 8.73, p< .001. Both
predictors entered with equation, with baseline cognitive status en-
tering first, t(46) = 3.42, p< .001, accounting for 18% of the variance,
followed by levels achieved per day, t(46) = 2.47, p= .02, accounting
for an additional 10% of the variance.
4. Discussion
In this study in a diverse sample of psychiatric patients receiving
rehabilitation therapy, two separate predictors of cognitive gains with
CCT were identified. Patients with higher levels of cognitive perfor-
mance made fewer training gains than patients with lower baseline
performance. Further, training engagement during training was a sig-
nificant and independent predictor of cognitive gains with training. The
amount of variance accounted for by these two predictors in treatment-
related gains in cognitive performance was quite substantial and there
were several other variables that did not predict treatment gains, in-
cluding diagnosis and the number of days spent training. The effect size
for change was training is considerably larger than expected with
practice alone (about 0.1–0.2 SD with one retest; Keefe et al., 2017),
suggesting that gains are associated with training and not reassessment
or placebo effects. Further, the systematic correlations with training
engagement, but not simple exposure to the training program as in-
dexed by days trained alone, support the idea that this is a CCT related
cognitive gain and not an artifact of a nonrandomized research design.
Both of these predictors had been identified previously in more
homogenous samples of patients (Biagianti et al., 2016;Detore et al.,
2019;Fisher et al., 2009;Keefe et al., 2012). However, these data
suggest that both engagement and baseline impairments are simulta-
neously applicable to the prediction of treatment-related cognitive
gains in CCT. Conveniently, both of these variables are quite easy to
measure, both prior to and during treatment. Further, these findings
also suggest that, at least for patients with psychiatric diagnoses and
persistent disability evidenced by rehabilitation treatment, patients
Table 1
Scores on the BACS and cognitive training process and engagement variables: Presented by diagnosis and baseline cognitive status.
Major depression Bipolar disorder Schizophrenia Overall
N = 19 N = 19 N = 11 n = 49
BACS baseline 47.15 11.08 38.79 8.92 41.40 6.79 42.00 9.71
BACS endpoint 50.38 8.25 44.74 10.88 45.60 5.97 46.69 9.28
Training days 23.85 20.58 11.74 8.92 15.60 9.17 16.40 14.32
Levels achieved 209.54 150.51 98.95 117.28 135.10 88.21 141.79 129.15
Levels/training day 9.53 3.91 8.44 4.41 8.44 3.70 8.78 4.03
Baseline BACS <41 Baseline BACS >40
BACS baseline 34.26 5.80 49.08 5.99
BACS endpoint 42.35 8.55 50.23 7.49
Training days 14.48 11.34 18.46 15.49
Levels achieved 137.91 138.50 160.31 128.04
Levels/training day 8.94 4.43 9.01 3.71
P.D. Harvey, et al. Schizophrenia Research: Cognition 19 (2020) 100150
with higher levels of cognitive performance do not benefit from treat-
ment even with exertion of adequate effort.
There are a couple of important clinical points from these data.
First, baseline assessment seems critical in populations where cognitive
impairments may not be ubiquitous and severe. Second, monitoring of
engagement should begin immediately after treatment starts. Third, it
should not be expected that engagement will covary with baseline
cognitive performance. Finally, as there is considerable evidence of
enhanced treatment gains associated with combined skills training and
CCT (Bowie et al., 2012), as well as combined CCT and social cognition
training (Lindenmayer et al., 2013, 2018), CCT in mental health po-
pulations should probably not be offered without other training ser-
vices. Although subjective reports of motivation have also previously
been found to relate to training gains in CCT (Saperstein and Medalia,
2015), the current study uses a direct measure of efficiency of training
gains to predict cognitive improvements with training.
The limitations of the study include the small sample size and un-
derpowered diagnostic-group comparisons. With larger samples, the
patients with MDD would likely, as expected, be found to have sig-
nificantly less cognitive impairment. We also did not examine the time
course of engagement in treatment, so we cannot tell if patients with
poor engagement can be identified immediately. In a previous study at
this site, we found that lack of treatment engagement identified im-
mediately after admission was not amenable to targeted interventions
using tangible rewards aimed at increasing engagement (Kotwicki et al.,
2017). Immediate lack of engagement also predicted worse treatment
outcomes. We did not have patients train on a single training proce-
dure, so we cannot isolate the specific training that led to gains.
However, the fact that training engagement with a heterogeneous
training procedure led to cognitive gains may actually be a positive
feature of the study, because of the ease of calculation of general
training engagement. The number of training sessions is less than some
previous studies with Brain HQ (Mahncke et al., in press;Fisher et al.,
2009), but the effect size for gains on untrained tasks was similar to
several previous studies for both Brain HQ (Fisher et al., 2010) and
other strategies, including the studies reviewed in the Detore et al.
(2019) meta-analysis. Finally, a randomized design could be more de-
finitive, but even in this open study there was considerable variance in
treatment outcomes that was systematically predicted by previously
identified predictors.
These data suggest that assessment of baseline cognitive perfor-
mance should be considered as a practice standard before engaging in
CCT and CRT interventions. Further, monitoring of treatment engage-
ment, either with task-specific indices such as those used by Fisher et al.
(2009),Keefe et al. (2012),Biagianti et al. (2016), and Mahncke et al.
(in press) or with more general indicators of training-related engage-
ment such as the current study, should commence early in treatment
and continuation decisions should be made quickly. Our previous
findings of failures of tangible rewards to improve general engagement
in rehabilitation treatment are consistent with previous suggestions that
CRT interventions are not facilitated by extrinsic rewards (Saperstein
and Medalia, 2015). Anecdotally, leveraging social interactions through
pairing CCT participants during training sessions, and providing a
therapist-led process group after training each day seemed to bolster
engagement. The results of this study suggest that intrinsic motivation
may not be adequate to induce CCT-related gains in patients whose
baseline scores are in the unimpaired range. Although these findings
replicate those of Detore et al. (2019), at least one other study has re-
ported that higher levels of performance in certain cognitive domains
leads to better gains (Lindenmayer et al., 2017). However, these pa-
tients had much more severe cognitive impairments on average than
the patients in this study, being institutionalized people with schizo-
phrenia. For example, our baseline mean cognitive performance score
was a t-score of 42 (21st percentile) and mean baseline t-score in
Lindenmayer et al. (2017) was 16 (0.1st percentile). Given the dis-
tributions of scores in that study, it appears as few of the participants
would be expected to have had a baseline t-score of 40 or more
(baseline score = 16; SD = 13; baseline plus 2 SD = 42). The reduced
benefits of training in patients with higher levels of cognitive perfor-
mance could be examined through re-analysis of existing datasets, as
this appears to be an important topic.
In conclusion, a treatment intervention that was successful overall,
leading to cognitive gains that notably exceed the expectations based
on retesting alone, was maximally effective in participants with base-
line levels of cognitive performance in the impaired range and in those
patients who exerted consistent effort across training sessions while
receiving CCT. These findings also suggest a trans-diagnostic effect of
CCT in cases whose cognitive impairments are substantial enough and
suggest that, particularly in patients with MDD whose cognitive im-
pairments may be both less common and less severe, baseline assess-
ment may be productive. Previous studies of CCT in people with MDD
have reported successes (Bowie et al., 2013), particularly in treatment
resistant MDD where cognitive impairments are likely to be more sig-
This research was not supported by external funding. Dr. Kotwicki
and Ms. Balzer are full time employees of Skyland Trail. The CCT
software and Cognitive assessment materials were purchased from their
Conflict of interest
In the last three years, Dr. Harvey has received consulting fees or
travel reimbursements from Allergan, Alkermes, Akili, Biogen,
Boehringer Ingelheim, Forum Pharma, Genentech, Intra-Cellular
Therapies, Jazz Pharma, Lundbeck Pharma, Minerva Pharma, Otsuka
America (Otsuka Digital Health), Roche Parma, Sanofi Pharma,
Sunovion Pharma, Takeda Pharma, and Teva. He receives royalties
from the Brief Assessment of Cognition in Schizophrenia and the
MATRICS Consensus Battery. He has a research grant from Takeda and
from the Stanley Medical Research Foundation.
Dr. Kotwicki and Ms. Balzer are full-time employees of Skyland
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Table 2
Intercorrelations of change scores on the BACS and cognitive training process and engagement variables.
Training days Levels achieved Levels per day
Change in BACS scores over the training period −0.09 0.03 0.30
Training days 0.79
Levels achieved 0.47
p< .05.
p< .01.
p< .001.
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P.D. Harvey, et al. Schizophrenia Research: Cognition 19 (2020) 100150
... Evaluable patients were separated into two groups based on cognitive impairment at study baseline using a CBB composite Z-score cutoff of -1 SD, relative to the normative mean. This cutoff was selected based on its previous use to differentiate clinically significant cognitive impairment from non-/minimal impairment in both patients with schizophrenia and more broadly in clinical neuropsychological assessment [30][31][32]. Patients with CBB composite Z-scores equal to or above this cutoff (Z-score ≥ -1) were designated as minimally impaired, whereas patients below the cutoff (Z-score < -1) were designated as clinically impaired. ...
... For example, patients who exhibit minimal to no cognitive impairment have been shown to respond differentially to both pharmacological and behavioural treatments for CIAS. Higher baseline cognitive performance has been associated with reduced gains in cognitive training [31,38], with different findings in extremely chronic and currently institutionalised patients [39]. Additionally, differing relationships with functional outcomes in these two groups have been observed. ...
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The muscarinic receptor agonist xanomeline improved cognition in phase 2 trials in Alzheimer’s disease and schizophrenia. We present data on the effect of KarXT (xanomeline–trospium) on cognition in schizophrenia from the 5-week, randomised, double-blind, placebo-controlled EMERGENT-1 trial (NCT03697252). Analyses included 125 patients with computerised Cogstate Brief Battery (CBB) subtest scores at baseline and endpoint. A post hoc subgroup analysis evaluated the effects of KarXT on cognitive performance in patients with or without clinically meaningful cognitive impairment at baseline, and a separate outlier analysis excluded patients with excessive intraindividual variability (IIV) across cognitive subdomains. ANCOVA models assessed treatment effects for completers and impairment subgroups, with or without removal of outliers. Sample-wide, cognitive improvement was numerically but not statistically greater with KarXT (n = 60) than placebo (n = 65), p = 0.16. However, post hoc analyses showed 65 patients did not exhibit clinically meaningful cognitive impairment at baseline, while eight patients had implausibly high IIV at one or both timepoints. Significant treatment effects were observed after removing outliers (KarXT n = 54, placebo n = 63; p = 0.04). Despite the small sample size, a robust (d = 0.50) and significant effect was observed among patients with cognitive impairment (KarXT n = 23, placebo n = 37; p = 0.03). These effects did not appear to be related to improvement in PANSS total scores (linear regression, R2 = 0.03). Collectively, these findings suggest that KarXT may have a separable and meaningful impact on cognition, particularly among patients with cognitive impairment.
... P = 0.002) were unique contributors to the model, accounting for 48% of TU variance (P < 0.001). 60 Harvey et al. 63 examined the single effects and interaction of diagnosis and cognitive status (i.e., BACS <41 and BACS >41) on training engagement and found no significant effects (all P > 0.20). ...
Objectives Neurocognitive deficits are central in schizophrenia. Cognitive remediation has proven effective in alleviating these deficits, with medium effect sizes. However, sizeable attrition rates are reported, with the reasons still uncertain. Furthermore, cognitive remediation is not part of routine mental health care. We conducted a systematic review to investigate factors that influence access and engagement of cognitive remediation in schizophrenia. Methods We systematically searched the PubMed, Web of Science, and PsycINFO databases for peer-reviewed articles including a cognitive remediation arm, access, and engagement data, and participants with schizophrenia spectrum disorders aged 17–65 years old. Duplicates and studies without a distinct cognitive remediation component, protocol papers, single case studies, case series, and reviews/meta-analyses were excluded. Results We included 67 studies that reported data on access and engagement, and extracted quantitative and qualitative data. Access data were limited, with most interventions delivered on-site, to outpatients, and in middle- to high-income countries. We found a median dropout rate of 14.29%. Only a small number of studies explored differences between dropouts and completers ( n = 5), and engagement factors ( n = 13). Dropouts had higher negative symptomatology and baseline self-efficacy, and lower baseline neurocognitive functioning and intrinsic motivation compared to completers. The engagement was positively associated with intrinsic motivation, self-efficacy, perceived usefulness, educational level, premorbid intelligence quotient, baseline neurocognitive functioning, some neurocognitive outcomes, and therapeutic alliance; and negatively associated with subjective cognitive complaints. Qualitative results showed good acceptability of cognitive remediation, with some areas for improvement. Conclusions Overall, access and engagement results are scarce and heterogeneous. Further investigations of cognitive remediation for inpatients, as well as remote delivery, are needed. Future clinical trials should systematically explore attrition and related factors. Determining influential factors of access and engagement will help improve the implementation and efficacy of cognitive remediation, and thus the recovery of people with schizophrenia.
... One factor that may mediate the effect of dose is the extent of training engagement. Several studies have suggested that training engagement predicts the extent of training gains in CCT (149,150). Even large doses of CCT may be ineffective if participants are not actually participating in the procedure (151). ...
Technology is ubiquitous in society and is now being extensively used in mental health applications. Both assessment and treatment strategies are being developed and deployed at a rapid pace. The authors review the current domains of technology utilization, describe standards for quality evaluation, and forecast future developments. This review examines technology-based assessments of cognition, emotion, functional capacity and everyday functioning, virtual reality approaches to assessment and treatment, ecological momentary assessment, passive measurement strategies including geolocation, movement, and physiological parameters, and technology-based cognitive and functional skills training. There are many technology-based approaches that are evidence based and are supported through the results of systematic reviews and meta-analyses. Other strategies are less well supported by high-quality evidence at present, but there are evaluation standards that are well articulated at this time. There are some clear challenges in selection of applications for specific conditions, but in several areas, including cognitive training, randomized clinical trials are available to support these interventions. Some of these technology-based interventions have been approved by the U.S. Food and Drug administration, which has clear standards for which types of applications, and which claims about them, need to be reviewed by the agency and which are exempt.
... It remains to be seen whether improvements in short-term memory may be observed in a healthy young adult population in such a short amount of time, as their short-term memory ability typically has less room for improvement. Prior research has indicated that the benefits of behavioral interventions may be most pronounced in populations with the greatest need (93,94). It is possible that longer durations of training may be needed as ability approaches ceiling. ...
Playing a musical instrument engages numerous cognitive abilities, including sensory perception, selective attention, and short-term memory. Mounting evidence indicates that engaging these cognitive functions during musical training will improve performance of these same functions. Yet, it remains unclear the extent these benefits may extend to nonmusical tasks, and what neural mechanisms may enable such transfer. Here, we conducted a preregistered randomized clinical trial where nonmusicians underwent 8 wk of either digital musical rhythm training or word search as control. Only musical rhythm training placed demands on short-term memory, as well as demands on visual perception and selective attention, which are known to facilitate short-term memory. As hypothesized, only the rhythm training group exhibited improved short-term memory on a face recognition task, thereby providing important evidence that musical rhythm training can benefit performance on a nonmusical task. Analysis of electroencephalography data showed that neural activity associated with sensory processing and selective attention were unchanged by training. Rather, rhythm training facilitated neural activity associated with short-term memory encoding, as indexed by an increased P3 of the event-related potential to face stimuli. Moreover, short-term memory maintenance was enhanced, as evidenced by increased two-class (face/scene) decoding accuracy. Activity from both the encoding and maintenance periods each highlight the right superior parietal lobule (SPL) as a source for training-related changes. Together, these results suggest musical rhythm training may improve memory for faces by facilitating activity within the SPL to promote how memories are encoded and maintained, which can be used in a domain-general manner to enhance performance on a nonmusical task.
... Several studies have investigated the cognitive and social functioning of patients with schizophrenia. Improvements in cognitive function have been reported to affect social function in schizophrenia [11][12][13][14]. According to Green prognosis in schizophrenia is influenced by cognitive functions, such as attention, language, memory, and information processing [15]. ...
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Background: Social dysfunction is associated with decreased activity, employment difficulties, and poor prognosis in patients with schizophrenia. Cognitive functions, such as attention and processing speed, have been implicated in the social functions of schizophrenia patients; however, the relationship between cognitive functions and social functions remains unclear. Thus, understanding the factors that influence social functioning can aid the development of therapeutic strategies for schizophrenia. Herein, we retrospectively analyzed factors that influence social functioning in patients with schizophrenia. Methods: Patient background, intelligence quotient (IQ) scores, Japanese version of the Brief Assessment of Cognition in Schizophrenia (BACS-J) scores, the dose of antipsychotic drugs, Positive and Negative Syndrome Scale (PANSS) scores, and the factors influencing each subscale of the Japanese version of the Social Functioning Scale (SFS-J) were evaluated using univariate and multivariate analyses. The Bonferroni correction was applied to evaluate the correlation between each factor in the univariate analysis. In multivariate analysis, independent variables were selected using a stepwise method. In each model, considering the sample size, the maximum number of variables extracted using the stepwise method was set to three. We then calculated the standard partial regression coefficient (standard β) between the SFS-J subscale scores and each factor. Results: Data from 36 patients were analyzed. The average age, illness duration, and total length of hospitalization were 57.8 years, 34.8 years, and 196.7 months, respectively. Of the seven significant correlations with the SFS-J subscale in the univariate analysis, only three were significant in the multivariate analysis model. According to the multivariable model, BACS-J verbal fluency positively correlated with SFS-J withdrawal, interpersonal communication, and employment/occupation. Moreover, BACS-J token motor and educational history were positively correlated with SFS-J recreation and SFS-J employment/occupation, respectively. PANSS scores, IQ scores, and doses of antipsychotic drugs did not show clear associations with SFS-J scores. Conclusions: In conclusion, there were significant correlations between BACS-J subscale scores for cognitive functioning and SFS-J subscale scores for social functioning in patients with schizophrenia.
... A non-commercial attentional control CCT improved selective attention, WM, and decision-making [147]. In this vein, some researchers in their clinical trials conclude that the effect of distant transfer after EF training is far from clear [148].In young adults with schizophrenia, training with Brain HQ affected processing speed, WM, and attention [149], with more significant changes and better effects in patients with low or impaired initial performance, than in patients with high performance [150]. In patients with mood disorders, the intervention with Cogtrain improved executive functioning and processing speed, with a decrease in cognitive depressive symptoms, but without improvements in the mood [151]. ...
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This article presents a systematic review of studies on cognitive training programs based on artificial cognitive systems and digital technologies and their effect on executive functions. The aim has been to identify which populations have been studied, the characteristics of the implemented programs, the types of implemented cognitive systems and digital technologies, the evaluated executive functions, and the key findings of these studies. The review has been carried out following the PRISMA protocol; five databases have been selected from which 1889 records were extracted. The articles were filtered following established criteria, to give a final selection of 264 articles that have been used for the purposes of this study in the analysis phase. The findings showed that the most studied populations were school-age children and the elderly. The most studied executive functions were working memory and attentional processes, followed by inhibitory control and processing speed. Many programs were commercial, customizable, gamified, and based on classic tasks. Some more recent initiatives have begun to incorporate user-machine interfaces, robotics, and virtual reality, although studies on their effects remain scarce. The studies recognize multiple benefits of computerized neuropsychological stimulation and rehabilitation programs for executive functions in different age groups, but there is a lack of studies in specific population sectors and with more rigorous research designs. Supplementary information: The online version contains supplementary material available at 10.1007/s13369-022-07292-5.
... It is very difficult to determine the level of effectiveness of an intervention to treat this impairment [20]. Primarily the focus of this rehabilitation is on restoring the lost brain functions and CBCI proved it's the best efficacy for this work [21]. To our knowledge, no other study exists comparing CBCI through ...
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Objective: The main purpose of this study was to investigate the effectiveness of computer based cognitive intervention (CBCI) on the functional independence level, anxiety and depression level and disability levels in post stroke patients in comparison with conventional cognitive intervention (CCI). Methods: This study includes sample of 80 acute (up to 6 months) post stroke patients. No recurrent stroke patients were included. Cognitive impairment with MMSE score>10, age between 18 to 65 years, were selected as inclusion criteria. Both groups (N=40 in each group) were trained in session of 30 minutes per day, 5 days a week, for 4 weeks. One group named as Group A performing the computer based cognitive intervention and the other group performing conventional cognitive intervention named as Group B. The main outcome Measures-The relative levels of functional independence, anxiety and depression and disability were measured before and after intervention (after 4 weeks) using the Barthel Index (BI),Hospital Anxiety and Depression Scale (HADS), World Health Organization Disability Assessment Scale 2.0 (WHODAS 2.0). Findings: After 4 weeks of intervention both the groups showed significant improvement in levels of functional independence, anxiety and depression and disability. The group A showed better therapeutic effects in a time-dependent manner in comparison to the group B on levels of anxiety and depression and disability but there was no significant difference observed in the levels of functional independence. Conclusion: These findings suggest that computer based cognitive intervention may have effects on the improvements of levels of functional independence, anxiety and depression and disability in comparison with conventional cognitive intervention in stroke.
... training was a significant independent predictor of cognitive gains, irrespective of simple exposure (Harvey et al., 2020). Given that individuals with PD experience decreased reward sensitivity in an off-dopaminergic medication state, as well as increased apathy (Muhammed et al., 2016), this may be a particularly relevant concern for use of CT in this population. ...
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Technological Advancements in Aging and Neurological Conditions to Improve Physical Activity, Cognitive Functions, and Postural Control.
... training was a significant independent predictor of cognitive gains, irrespective of simple exposure (Harvey et al., 2020). Given that individuals with PD experience decreased reward sensitivity in an off-dopaminergic medication state, as well as increased apathy (Muhammed et al., 2016), this may be a particularly relevant concern for use of CT in this population. ...
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Whilst Parkinson's disease (PD) is typically thought of as a motor disease, a significant number of individuals also experience cognitive impairment (CI), ranging from mild-CI to dementia. One technique that may prove effective in delaying the onset of CI in PD is cognitive training (CT); however, evidence to date is variable. This may be due to the implementation of CT in this population, with the motor impairments of PD potentially hampering the ability to use standard equipment, such as pen-and-paper or a computer mouse. This may, in turn, promote negative attitudes toward the CT paradigm, which may correlate with poorer outcomes. Consequently, optimizing a system for the delivery of CT in the PD population may improve the accessibility of and engagement with the CT paradigm, subsequently leading to better outcomes. To achieve this, the NeuroOrb Gaming System was designed, coupling a novel accessible controller, specifically developed for use with people with motor impairments, with a "Serious Games" software suite, custom-designed to target the cognitive domains typically affected in PD. The aim of the current study was to evaluate the usability of the NeuroOrb through a reiterative co-design process, in order to optimize the system for future use in clinical trials of CT in individuals with PD. Individuals with PD (n = 13; mean age = 68.15 years; mean disease duration = 8 years) were recruited from the community and participated in three co-design loops. After implementation of key stakeholder feedback to make significant modifications to the system, system usability was improved and participant attitudes toward the NeuroOrb were very positive. Taken together, this provides rationale for moving forward with a future clinical trial investigating the utility of the NeuroOrb as a tool to deliver CT in PD.
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Studies indicate that neuroscience-informed digital cognitive training can remediate cognitive impairments in schizophrenia, but the factors contributing to these deficits and response to treatment remain unclear. Toxoplasma gondii is a neuroinvasive parasite linked to cognitive decline that also presents a higher prevalence in schizophrenia. Here, we compared the cognition and symptom severity of IgG seropositive (TOXO+; n = 25) and seronegative (TOXO−; n = 35) patients who participated in a randomized controlled trial of digital cognitive training. At baseline, TOXO+ subjects presented lower global cognition than TOXO− ( F = 3.78, p = 0.05). Specifically, TOXO+ subjects showed worse verbal memory and learning ( F = 4.48, p = 0.03), social cognition ( F = 5.71, p = 0.02), and higher antibody concentrations were associated with increased negative ( r = 0.42, p = 0.04) and total ( r = 0.40, p = 0.04) schizophrenia symptoms. After training, the TOXO+ group showed higher adherence to the intervention ( X ² = 9.31, p = 0.03), but there were no differences in changes in cognition and symptoms between groups. These findings highlight the association between seropositivity to T. gondii and deteriorated cognition and symptoms in schizophrenia. Further research is needed to assess the specific efficacy of digital cognitive training on this population.
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Objective: Cognitive impairment in schizophrenia is a core feature of the disorder. Computerized cognitive training has shown promise in pilot studies. A 26-week randomized blinded placebo-controlled trial was conducted to investigate the effect of a novel computerized cognitive training program on cognitive and functional capacity outcomes. Method: The study followed MATRICS guidelines for the evaluation of interventions designed to improve cognitive function in schizophrenia. Participants (N = 150) were randomized to experimental (computerized cognitive training in a game-like format) or active control (computer games) groups. Training was conducted in-clinic, with an intended training schedule of 5 days per week, 1 h per day, for 26 weeks. Co-primary outcome measures were the MATRICS Consensus Cognitive Battery (MCCB) composite score and the UCSD Performance-Based Skills Assessment (UPSA-2) total score, secondary outcome measures included the Cognitive Assessment Interview (CAI) and the Short-Form-12 Mental Composite Score (SF-12 MCS). Target engagement was assessed with task-learning based assessment. Results: At baseline, the groups were well matched. No significant effect of the experimental treatment was seen on the primary or secondary outcome measures compared to the active control. Review of the task learning/target engagement data suggested inadequate target engagement. Conclusions: Results do not support a cognitive or functional capacity benefit from this implementation of a computerized cognitive training program in people with schizophrenia. In future trials, careful consideration is merited of the assessment of task learning/target engagement, the effects of making the cognitive training game-like on motivation, and the implicit effects of trial requirements on participant selection.
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Cognitive remediation is aimed at reducing cognitive impairments in severe mental illnesses such as schizophrenia, but little is known about whether severity of cognitive impairment predicts benefit from this intervention. To address this question, this study aggregated data from five randomized controlled trials (N = 300) of a standardized comprehensive, multimodal outpatient cognitive remediation program, the Thinking Skills for Work program, and evaluated whether baseline level of cognitive impairment differentially predicted improvement in cognitive functioning following cognitive remediation vs. usual services. Using standardized scores of neuropsychological functioning to designate “low average,” “moderate,” and “severe” levels of cognitive impairment, participants with greater cognitive impairment were found to benefit differentially more from cognitive remediation than usual services compared to less cognitively impaired participants. The findings were unaffected by statistically controlling for participant demographic and clinical characteristics. The findings suggest that individuals with the greatest cognitive impairment, for whom cognitive remediation was developed, are also most likely to benefit from this intervention.
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Computer games are ubiquitous and can be utilized for serious purposes such as health and education. “Applied games” including serious games (in brief, computerized games for serious purposes) and gamification (gaming elements used outside of games) have the potential to increase the impact of mental health internet interventions via three processes. First, by extending the reach of online programs to those who might not otherwise use them. Second, by improving engagement through both game-based and “serious” motivational dynamics. Third, by utilizing varied mechanisms for change, including therapeutic processes and gaming features. In this scoping review, we aim to advance the field by exploring the potential and opportunities available in this area. We review engagement factors which may be exploited and demonstrate that there is promising evidence of effectiveness for serious games for depression from contemporary systematic reviews. We illustrate six major categories of tested applied games for mental health (exergames, virtual reality, cognitive behavior therapy-based games, entertainment games, biofeedback, and cognitive training games) and demonstrate that it is feasible to translate traditional evidence-based interventions into computer gaming formats and to exploit features of computer games for therapeutic change. Applied games have considerable potential for increasing the impact of online interventions for mental health. However, there are few independent trials, and direct comparisons of game-based and non-game-based interventions are lacking. Further research, faster iterations, rapid testing, non-traditional collaborations, and user-centered approaches are needed to respond to diverse user needs and preferences in rapidly changing environments.
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Significant numbers of individuals with severe mental illnesses are difficult to engage in treatment services, presenting challenges for care. To be able to assess the relationship between engagement and discharge outcomes, we modified the ?Milestones of Recovery Scale?. This scale was modified for content to match the current clinical setting, evaluated for inter-rater reliability after modification in a sample of 233 cases receiving psychiatric rehabilitation, and then was administered to 423 additional psychiatric rehabilitation clients over a 24-month study period. In an effort to determine whether provision of financial incentives lead to sustained increases in client engagement, a cut off for client eligibility for financial incentives was evaluated on the basis of the reliability study and the course of engagement was related to receipt of this incentive and successful completion of treatment in a new sample of 423 patients. Of this sample, 78?% received an initial financial incentive during treatment (were initially engaged), and 93.3?% of that subgroup sustained this level of engagement it over their entire course of treatment. Of the 22?% of cases not receiving an initial incentive, only 5.4?% improved in their engagement to levels required for the incentive. Longitudinal analysis demonstrated that individuals who maintained or increased their level of engagement over time were more likely to complete treatment in accordance with planned treatment goals. The initial engagement and the course of engagement in treatment predicted successful completion, but incentives did not lead to increased engagement in initially poorly engaged patients. These data are interpreted in terms of the likely success of extrinsic rewards to increase engagement in mental health services.
Background: Negative symptoms and cognitive impairments predict difficulties in aspects of everyday functioning in schizophrenia, with little research to date attempting to determine if there are threshold levels of impairment required to predict the severity of functional deficits. Methods: People diagnosed with chronic schizophrenia (n = 821) were assessed with the MCCB and PANSS, and rated by high contact informants with SLOF. Negative symptoms of reduced emotional experience were specifically targeted for analysis because of their previously identified relationships with social outcomes. We identified patients with moderate negative symptoms (at least one PANSS item ≥4) versus less severe symptoms (PANSS items ≤3) and divided patients on the basis of a single latent-trait global cognition score (neuropsychologically normal vs neuropsychologically impaired; performance at or below 1.0 SD from the normative population mean, T = 40), then examined correlations between cognition, negative symptoms and everyday functioning in the groups with lower and higher negative symptoms and those with/without cognitive impairment. Results: Even low levels of negative symptoms were correlated with ratings of social functioning. Cognitive performance in the neuropsychologically normal range, in contrast, was not correlated with any aspects of everyday functioning while more impaired performance predicted greater functional impairments. Conclusions: Even minimal symptoms may be a target for clinical attention in the domains of negative symptoms, consistent with previous findings regarding social deficits in populations with modest negative symptoms (e.g., schizotypal personality disorder). Cognitive rehabilitation treatments might not improve social functioning if even low levels of negative symptoms (social amotivation) are present.
Computerized cognitive training (CCT) to improve cognitive functioning is of enormous interest and has been applied in a broad range of populations with goals of improving both cognition and community functioning. Recent reviews presenting negative conclusions about CCT efficacy have inconsistent definitions of the treatment targets and cognitive improvement. They do not present an accurate representation of the typical process of CCT and cognitive remediation (CR), especially as delivered in major mental illnesses such as schizophrenia. This review provides guidance on the definitions of CCT and CR, the uses of CCT and CR, and the definitions and measurements of cognitive and functional gains. The review focuses on schizophrenia and healthy aging, with each population receiving unique CCT or CR approaches and substantial extant literature with which to elucidate fundamental CCT and CR concepts and research findings. It is our conclusion that CCT has been shown in most studies to improve cognitive performance on untrained tests in healthy older people and in people with schizophrenia. Functional gains in schizophrenia appear to be limited to CR studies. Clearly defining CCT, CR, and levels of treatment-related gains will be critical for understanding the benefits of these widely used treatment programs.
Objectives: Cognitive remediation therapy (CRT) has shown significant improvement in cognition in schizophrenia. However, effect sizes of CRT have been reported to be modest raising the issue how to augment the effects of CRT on neurocognition and social cognition. Our aim was to examine whether the addition of computerized social cognition training would enhance the effects on neurocognition and social cognition as compared to CRT alone. Methods: This is a 12-week, parallel group trial of 131 in- and out-patients with schizophrenia randomized to CRT (COGPACK or Brain Fitness) with computerized social cognition training (MRIGE), or CRT alone for 36 sessions. Participants were assessed at baseline and after 12 weeks of treatment. Assessments included neurocognition, social cognition, psychopathology, and functioning. Results: The combined intervention, CRT + MRIGE, showed greater improvements in the MCCB indices of Visual Learning, Working Memory, Reasoning and Problem-Solving, and the neurocognitive composite score compared to CRT alone (Bonferroni adjusted p = 0.004, p = 0.005, p = 0.01, respectively), as did social cognition measures (Bonferroni adjusted p = 0.006, p = 0.005, respectively). Conclusions: Supplementing CRT with computerized social cognition training produced greater benefits in neurocognition, including visual learning, memory, executive functions, and social cognition relative to cognitive training alone. These findings favoring the combined training may be contributed to both the greater overall amount of cognitive practice, as well as the specific cognitive functions engaged by the social cognition training.
Importance Patients’ previous experience with performance-based cognitive tests in clinical trials for cognitive impairment associated with schizophrenia can create practice-related improvements. Placebo-controlled trials for cognitive impairment associated with schizophrenia are at risk for these practice effects, which can be difficult to distinguish from placebo effects. Objectives To conduct a systematic evaluation of the magnitude of practice effects on the Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery (MCCB) in cognitive impairment associated with schizophrenia and to examine which demographic, clinical, and cognitive characteristics were associated with improvement in placebo conditions. Design, Setting, and Participants A blinded review was conducted of data from 813 patients with schizophrenia who were treated with placebo in 12 randomized placebo-controlled clinical trials conducted mostly in outpatient clinics in North America, Europe, Asia, and Latin America from February 22, 2007, to March 1, 2014. A total of 779 patients provided data for the primary outcome measure at baseline and at least 1 follow-up. Seven trials had prebaseline assessments wherein the patients knew that they were not receiving treatment, allowing a comparison of practice and placebo effects in the same patients. Interventions Placebo compared with various experimental drug treatments. Main Outcomes and Measures Composite score on the MCCB. Results Of the 813 patients in the study (260 women and 553 men; mean [SD] age, 41.2 [11.5] years), the mean MCCB composite score at baseline was 22.8 points below the normative mean, and the mean (SEM) total change in the MCCB during receipt of placebo was 1.8 (0.2) T-score points (95% CI, 1.40-2.18), equivalent to a change of 0.18 SD. Practice effects in the 7 studies in which there was a prebaseline assessment were essentially identical to the postbaseline placebo changes. Baseline factors associated with greater improvements in the MCCB during receipt of placebo included more depression/anxiety (F1,438 = 5.41; P = .02), more motivation (F1,272 = 4.63; P = .03), and less improvement from screening to baseline (F1,421 = 59.32; P < .001). Conclusions and Relevance Placebo effects were minimal and associated with the number of postbaseline assessments and several patient characteristics. Given that the patients performed 2.28 SDs below normative standards on average at baseline, a mean placebo-associated improvement of less than 0.2 SD provides evidence that ceiling effects do not occur in these trials. These minimal changes in the MCCB could not be responsible for effective active treatments failing to separate from placebo.
Objective: Cognitive challenges are prominent features of individuals diagnosed with schizophrenia, impairing occupational, social, and economic functioning. These challenges are predictive of social and work outcomes. Cognitive remediation has been shown to be effective in improving both cognitive and social functions. However, cognitive remediation does not produce improvement in all participants. We investigated demographic, neurocognitive, and psychopathological predictors associated with improvement following cognitive remediation interventions in service recipients with severe mental illnesses. Method: One hundred thirty-seven adult participants with a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) were enrolled in 12-week cognitive remediation programs. Assessments of demographic and illness variables, together with baseline and end point assessment of psychopathology (Positive and Negative Syndrome Scale [PANSS]), neurocognition (Measurement and Treatment Research to Improve Cognition in Schizophrenia [MATRICS] Consensus Cognitive Battery [MCBB]), and social functions (Personal and Social Performance Scale [PSP]) were conducted. Change in cognitive domains was calculated using the reliable change index. Logistic regression analysis was used to assess predictors of cognitive improvement after the intervention. Results: Sixty-two percent of participants improved on at least 1 of the MCCB domains. Higher baseline speed of processing, attention or vigilance, and working memory predicted a positive response to cognitive remediation. Younger age, higher education level, shorter length of stay, and lower PANSS Negative and Disorganized factors were additional predictors. Conclusions and implications for practice: Our results indicate the clinical usefulness of cognitive remediation and identified a pattern of clinical and cognitive predictors of good response to the intervention. Identification of these predictive factors by clinicians may enhance the outcome and aid in the development of individualized rehabilitative cognitive remediation treatment plans. (PsycINFO Database Record
Individuals with schizophrenia who engage in targeted cognitive training (TCT) of the auditory system show generalized cognitive improvements. The high degree of variability in cognitive gains maybe due to individual differences in the level of engagement of the underlying neural system target. 131 individuals with schizophrenia underwent 40 hours of TCT. We identified target engagement of auditory system processing efficiency by modeling subject-specific trajectories of auditory processing speed (APS) over time. Lowess analysis, mixed models repeated measures analysis, and latent growth curve modeling were used to examine whether APS trajectories were moderated by age and illness duration, and mediated improvements in cognitive outcome measures. We observed significant improvements in APS from baseline to 20 hours of training (initial change), followed by a flat APS trajectory (plateau) at subsequent time-points. Participants showed interindividual variability in the steepness of the initial APS change and in the APS plateau achieved and sustained between 20 and 40 hours. We found that participants who achieved the fastest APS plateau, showed the greatest transfer effects to untrained cognitive domains. There is a significant association between an individual's ability to generate and sustain auditory processing efficiency and their degree of cognitive improvement after TCT, independent of baseline neurocognition. APS plateau may therefore represent a behavioral measure of target engagement mediating treatment response. Future studies should examine the optimal plateau of auditory processing efficiency required to induce significant cognitive improvements, in the context of interindividual differences in neural plasticity and sensory system efficiency that characterize schizophrenia. (PsycINFO Database Record