|Year : 2017 | Volume
| Issue : 2 | Page : 68-75
Cognitive rehabilitation in psychiatry
Urvashi Rupin Shah
Department of Neurology, K.E.M Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||8-Dec-2017|
Urvashi Rupin Shah
Department of Neurology, K.E.M Hospital, Parel, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Cognitive impairments in mental disorders are common, poorly recognized, and largely unaddressed despite their significant impact on daily life functioning. Today, the treatment of psychiatric disorders goes beyond only symptom management and emphasizes optimizing functional abilities. Cognitive Rehabilitation or Cognitive Remediation(CR) is the nonpharmacological intervention that has received attention over the last few decades and is steadily emerging as a potentially strong tool to manage cognitive issues that impact functional outcomes. A large body of research has studied role of CR in schizophrenia populations, and the role in other disorders is now being explored. This review looks at the various studies from across the globe and in India to understand the types of programs, their theoretical underpinnings, imaging data, and efficacy of CR. There is considerable heterogeneity across studies in terms of methods, materials, and approaches, and it is challenging to identify the key active ingredients that ensure success. Overall, the meta-analysis studies have identified strategy coaching by an expert therapist and use of CR in conjunction with psychosocial and vocational programs as important factors to ensure best results. Despite promising results in enhancing cognition across most studies, generalization and transfer of this improvement to real-life functioning still remains elusive. Other moderators that can possibly influence outcomes such as motivation factors, therapist-patient relationship, personal goals of the patient and families, and the socioeconomic milieu of the patient need to be studied more extensively in the future studies to develop a comprehensive model of cognitive rehabilitation.
Keywords: Cognitive rehabilitation, cognitive remediation, cognitive training, mental disorders, psychiatry
|How to cite this article:|
Shah UR. Cognitive rehabilitation in psychiatry. Ann Indian Psychiatry 2017;1:68-75
Over a 100 years ago, in 1887, Emile Kraepelin distinguished psychotic disorders from affective disorders by the presence of dementia and used the term “dementia praecox” to describe schizophrenia. Today, a large body of evidence suggests that cognitive deficits are in fact ubiquitous with all psychiatric disorders and the dichotomy proposed by Kraepelin stands challenged. In mental illness, beyond the reduction of symptoms, the greatest concern is functional recovery, and it is the cognitive impairments along with deficits in social cognition and metacognition that significantly affect the ability to work, live independently, social functioning, and even impact outcomes of psychosocial rehabilitation. Cognitive dysfunction has been regarded as one of the strongest predictors for functional outcome.
These findings underscore the importance of detecting and addressing the cognitive issues to optimize management and improve quality of life.
The use of pharmacological agents to enhance cognition has not met with much success. The newer atypical antipsychotics and adjunct therapies of cholinergic and glutamatergic agents have only small effects on cognition and studies with specific cognitive enhancing agents such as D-cycloserine and Modafinil have revealed effects mainly on task-specific learning while improvements in daily life functioning still remain elusive.,,
Hence, in the recent years, there has been an increased focus on understanding the efficacy of nonpharmacological cognitive rehabilitation (CR) therapies.
| Cognitive Impairments|| |
Magnitude and spectrum
Cognitive impairments occur across psychiatric disorders, in schizophrenia, major depression, bipolar, obsessive-compulsive, personality, and substance abuse disorders  but the magnitude and spectrum of impairments may vary.
An epidemiological survey in the Suffolk County Mental Health Project documented neuropsychological impairments in first-admission patients. Up to 84% of people with schizophrenia, 58.3% with major depressive disorder (MDD), and 57.7% of persons with bipolar disorders had cognitive impairments (scores <1 standard deviation below the normal on standardized tests or a decline from premorbid levels) in at least two cognitive domains. The key domains affected were processing speed, attention, memory, and executive function, but this study highlighted a greater frequency and severity in patients with schizophrenia.
There is a variable degree and duration of the cognitive impairments. In schizophrenia, the cognitive problems can predate the clinical symptoms, persist despite reduced symptoms, and significantly affect daily life functioning and long-term functional outcomes. In the mood disorders, on the other hand, the cognitive dysfunction is less severe, more often seen at the onset of mood symptoms and is variable being affected by a number of factors such as phase of the disease, demographics, and medications. The different presentations influence the selection of the CR programs.
| Cognitive Rehabilitation|| |
The terms cognitive rehabilitation, cognitive remediation, and cognitive re-training (CR) have been variously used in the research literature to represent nonpharmacological interventions that target the cognitive impairments with the goal of ameliorating the same and more importantly, improving functional behaviors to optimize the quality of life. The genesis of cognitive intervention programs can be traced to the World War I and II when soldiers suffered gunshot wounds resulting in traumatic brain injuries. In mental illness, the use of the cognitive remediation methods dates to about 40 years back and most of the research, to date, has primarily focused on schizophrenia populations.
In 2010, the experts consensus group at the Cognition Remediation Experts Workshop defined cognitive remediation therapy for schizophrenia as “a behavioral training-based intervention that aims to improve cognitive processes (attention, memory, executive function, social cognition, or metacognition) with the goal of durability and generalization.”
Since the goal is to bring about long-lasting improvements in daily functioning, it is important that appropriate measures be selected for evaluating outcomes. Shifts in neuropsychological test scores do not always occur, as the paper-pencil tests may not capture functional abilities and the nuances of daily life demands. It has also been suggested that sometimes the CR strategies taught to the patient may emphasize deliberate, well thought out responses, and during testing, the patient may be slow to avoid errors resulting in a decline in time scores in neuropsychological testing. The use of the training task itself as an outcome measure may show improved performance but would merely reflect task-specific learning. Daily life functioning is influenced by multiple variables and requires dealing with unpredictable novel situations. It is postulated that for the generalization of learning to daily functioning, training in metacognition may be required, and outcome evaluations should include functional measures.
Models and methods for cognitive rehabilitation
Two broad models, compensatory and restorative have been proposed in brain injury literature that are not always mutually exclusive and can be used in combination. In the compensatory model, the deficits per se are not addressed but are compensated for, using the intact cognitive abilities and environmental resources for optimizing daily functioning and skill learning. The use of planners/reminders/diary writing and training persons to use specific strategies are examples of this approach. These methods are regarded as “prosthetic” and are considered useful in addressing the residual deficits that do not appear amenable to change.
The restorative model, on the other hand, is based on the concept of neuroplasticity that suggests the potential of the brain to learn throughout life. In the mental health literature, the term “cognitive enhancement” has been preferred as not all programs aim at restoring a function in its entirety or to premorbid levels but rather focus on improving the cognitive functioning.
The specific deficits are worked on using exercises through either a “Bottoms Up” or the “Top Down” approach. In the former, cognitive functions such as perception and attention, regarded as basic building blocks, are targeted first to form a base for the subsequent development of higher-level functions. In the latter, training of higher-order executive functions such as problem-solving and metacognition are targeted first.
The various cognitive exercises are administered using either paper-pencil tasks and/or computer-based exercises. The latter has gained in popularity, as they resemble games that are appealing and being standardized they also reduce the need for a specialist therapist to administer the exercises. The self-administered, computerized programs are useful where there is a paucity of trained therapists but may not be optimal. The one-on-one mediation and dynamic feedback provided by a trained, expert therapist during the exercises is a powerful ingredient for teaching strategies that help generalization of learning to daily activities. Further, the therapist also trains the patient using specialized techniques such as “errorless learning,” “scaffolding,” “massed practice,” and information processing strategies such as verbalization, mnemonics, and chunking to enhance learning.
| Types Of CR Programs|| |
The search for the active ingredients
A number of evidence-based programs using a heterogeneous array of ingredients and different theoretical underpinnings have been developed over the years, and some of these programs have been extensively studied and replicated [Table 1]. However, there is still no consensus about what constitutes the most effective method that will ensure generalization of learning into daily life activities. The programs have used different types of interventions such as (1) “drill and practice” that involves rehearsal to reinforce learning by repetitive, paper-pencil, or computer-based exercises, (2) “strategy coaching” to learn effective strategies to solve cognitive tasks, or (3) a combination of drill plus strategy coaching. There is considerable variability regarding the number of hours and duration of sessions to ensure long-term sustained benefits. There are also differences regarding the setting of the programs; within clinics/rehabilitation centers or home-based and in dyadic or group settings, and finally programs that may or may not have adjunct psychosocial, social skill, or vocational rehabilitation program.
Role of motivation
It is also now being recognized that besides the cognitive targets, there are certain noncognitive variables that impact the success of an intervention. Velligan et al. have emphasized the role of motivation in optimizing cognitive remediation outcomes. Intrinsic motivation appears to be affected in schizophrenia and Velligan uses the term “incentive salience” to postulate that decreased firing in dopamine cells compromises the “reward pathways” leading to reduced incentive/drive to seek reward and pursue goals. Hence, despite improvement in cognition after the remediation, the improvements in daily functioning are not optimal unless strategies to increase motivation are not incorporated. Some of the strategies that may help increase motivation include making the task more attractive and engaging for the patient, tailoring the program as per interests and goals of the patient, and forging an effective client-therapist partnership, in which the patient works along with the therapist to select the activities.
Benefits of add-on therapies
Meta-analysis studies on CR have found that the effect size on psychosocial outcomes is relatively small but if CR is combined with psychosocial rehabilitation programs the effect size increases. Thus, improving cognitive functioning appears to facilitate increased participation in psychosocial and work programs, thereby improving functional outcomes.,
| Efficacy Of Cognitive Rehabilitation|| |
There is now growing evidence from several meta-analysis studies regarding the efficacy of CR programs. In 2007, McGurk et al. analyzed data from 26 studies to evaluate effects of CR for schizophrenia patients on symptoms, cognitive performance, and functional outcomes and found significant improvements in all three outcomes. However, the mean effect size was varied. There was a medium effect (0.41) for overall cognitive performance on the standardized tests, slightly less for psychosocial outcomes (0.36) and least for the symptoms outcome (0.28). The authors also found that there was an increased effect size for psychosocial functioning in programs, wherein CR was combined with adjunct psychiatric rehabilitation and where a combination of drill plus strategy coaching interventions were used. However, it was unclear if it was the combination that facilitated transfers of learning from the session to the daily life activities or the strategies taught to the patients that helped them compensate for residual deficits.
In 2010, Hodge et al. in a randomized control trial (RCT) of 40 schizophrenia patients, using the NEAR program found significant improvement in cognitive functioning. In this study, the medication regime remained stable through the program period, and during the posttreatment analysis, thus ruling out the possibility of any medicine effect. The cognitive outcomes were measured by the pre-to-postperformance scores on alternate forms of the standardized tests and were greater than what would be expected by “practice effects.” The improvement was seen in visual and verbal memory, sustained attention, and executive “set shifting.” Moreover, the improvement was found to persist even after 4-month posttreatment. Significant improvements were also seen in self-esteem and also psychosocial functioning as measured by the Social Occupational Function Assessment (SOFA) scale, but the authors commented on the need for the future studies to measure outcomes in the performance in actual daily life activities.
In 2011, Wykes et al. in one of the most comprehensive meta-analysis evaluated results from 40 independent studies of CR in schizophrenia and reported an overall medium effect (0.45) for cognitive functioning and psychosocial functioning (0.41). Overall, the analysis reported that for improved functional outcomes a combination of CR using strategy-based training with adjunct psychosocial interventions has the largest effect size.
In terms of patient characteristics, although age was not found to be significant, the authors reported that the studies included in their analysis had an age range of 30–40 years while other studies with older age groups  had reported smaller size effects suggesting that older age may possibly not respond as well to CR.
In this meta-analysis, although there were smaller effects associated with increased symptoms, the authors still recommended CR having some benefits for all patients with varying severity. With regards to the type of intervention, the authors found that it was not about the material used, (paper-pencil versus computers) but the method of using strategy coaching that facilitated transfer to daily life. Also, cognitive interventions were more effective when adjunct psychosocial rehabilitation was added.
Brain imaging and CR
Imaging has emerged as a powerful tool to understand the efficacy of CR. The early studies between 1998 and 2002 using mainly PET and SPECT imaging and analyzing primarily regions of interest in the prefrontal cortex confirmed the “hypofrontality hypothesis” of cognitive impairment in schizophrenia and found that CR increased the perfusion in this region. However, these studies were not RCT's and had small sample sizes ranging from 2 to 8 patients.,,, In these studies, not all patients showed an increase in prefrontal blood flow suggesting that there may be certain other variables that modulate individual responses to CR.
Subsequently, functional magnetic resonance imaging (fMRI) was used as a tool and Wykes et al. found increased activation in a working memory task after a structured CR program. These findings were replicated by other studies that had control groups and relatively larger sample sizes and the interesting finding was that CR increases activation not only in prefrontal regions but also other connected areas., In a different design, Rowland et al. examined whole-brain activation and included a sample of healthy volunteers as the control group who also underwent CR. This study showed that in normal individuals, in fact, there was decreased activation in certain areas after CR that resulted in successful learning. This whole-brain analysis suggested that CR effect may well beyond just improvements in prefrontal regions, but is spread across several regions, and there may be a role for even decreased activation in some areas for the improved cognitive processing.
Another important longitudinal study examined the effect of CR on the morphology of the brain over a 2-year period with annual evaluations. In this RCT with early schizophrenia and schizoaffective patients, a voxel-based, volumetric analysis of gray matter in the frontal and temporal region showed greater preservation in the experimental group after computerized CR modules, and the authors suggested the possibility of a neuroprotective role of CR.
Combining fMRI with diffusion tensor imaging (DTI) data, in an RCT, Penadés et al. studied the impact of a strategy-based, paper-pencil CR module on an experimental schizophrenia group compared to an active control group and the third group of healthy volunteers. They found that the central executive and default networks in the experimental group were overactive as compared to the healthy volunteer group but after CR, the networks of the experimental group significantly changed with deactivation in the default and activation in the central executive networks resembling the more efficient networks of the healthy volunteers. The DTI data analysis also revealed increased fractional anisotropy index. The authors postulated that CR possibly resulted in increased interhemispheric information transfer between the bilateral prefrontal regions.
Currently, the understanding from the various imaging studies suggests that CR not only increases activation in the prefrontal regions but also in several other connected regions. CR also affects the resting default mode networks allowing for deactivation of these networks while engaged in a task to enhance cognitive processing. The most common networks identified are in the prefrontal and thalamus regions and reorganization of the networks for increased efficiency after CR is seen irrespective of whether a compensatory or restorative approach is used.
Evidence for different types of disorders
CR research in mental illness has primarily and largely been focused on schizophrenia and it is only in the recent years that studies of CR in other psychiatric conditions have been published.
Major depression disorder
In MDD, cognitive deficits and functional impairment persist even after a positive response to treatment, and the prefrontal network connections to the limbic areas have been implicated as dysfunctional with increased activation in limbic structures and decreased activation in the dorsolateral prefrontal executive regions.,
The pattern of neuropsychological deficits has been found to vary depending on different clinical states. In severe depression, episodic memory is affected but not semantic memory and visuospatial functioning. As clinical states improve, there is an improvement in verbal memory but not in executive function and attention, and in late-onset depression, in older age populations, processing speed improves with response to treatment.
The studies using CR in MDD have had small sample sizes but benefits in cognitive functioning have been reported. A number of methods such as the NEAR program have been employed ,, and also computer-based cognitive retraining in others.,,
A metacognitive therapy, attention training technique developed by Wells has also been used to address the specific symptom of rumination seen in anxiety and depression,, and in a small set of cases, Choi et al. have explored the use of CR for reducing the cognitive impairments after electroconvulsive therapy in severely depressed patients.
The preliminary research in MDD has highlighted that the type of approach may change depending on the phase of the illness with simple drill and practice exercises in the severe phase where it is difficult for the patient to engage while other methods such as strategy coaching may be used later as mood stabilizes. The level of difficulty of the program and therapist feedback has also been explored in MDD and setting the success rate of the task at 80%–90% with positive feedback has been recommended so that there is decreased the sense of frustration and failure. Further, in MDD research, the need for improved outcome measures has been suggested with tasks other than the training tasks to be used for measuring cognitive outcomes. It also remains unclear if the improved cognitive functioning is generalizing to improve functioning in real life as most studies have measured these outcomes on mood rating scales and not daily life tasks.
In bipolar disorders, cognitive impairments persist even in the euthymic stage, and there is a paucity of CR research for this disorder.,,
In the only multicenter RCT for CR in bipolar disorders, Torrent et al. compared bipolar I and II patients in remission with two other groups, one that received only psychoeducation and another who received treatment, as usual, the treatment as usual (TAU) group. The special CR program called functional remediation included paper-pencil cognitive exercises, problem-solving, and ecologically valid tasks that were performed both in the clinic and at home. The results showed significantly improved global psychosocial functioning for the group undergoing the functional remediation, and the improvement was more than that observed for the other two groups. There were no significant improvements in neuropsychological test scores, but the authors postulated that the novel CR program taught the patients compensatory strategies to cope better and manage their daily activities more effectively.
Substance use disorders
Cognitive impairments in substance use disorder (SUD) are common , and it has been suggested that cognitive impairments may not be caused by the SUD but rather preexisting inflexibility, impulsivity, and poor decision-making puts a person at risk for developing SUD. Cognitive enhancement therapies possibly facilitate the response to behavior therapies used for SUD. Recent studies have found that the program of cognitive enhancement therapy is useful in improving frontolimbic regulation  in SUD associated with schizophrenia ,, and also in a veteran alcohol abuse group.
Borderline personality disorder
Borderline personality disorder (BPD) is one of the most challenging mental disorders to treat and recent evidence from imaging and other studies suggests that there are cognitive impairments in BPD in attention, processing speed, and cognitive flexibility and frontal-limbic pathways have been implicated. It is postulated that the cognitive impairments affect psychosocial functioning and CR may be a possible treatment modality to reduce the cognitive dysfunction and improve psychosocial functioning. In a recent RCT, Pascual et al. compared a group of patients who received group CR to another group of patients who received only psychoeducation and found that psychosocial functioning improved in both groups and the CR did not improve the psychopathology or the performance on cognitive tests. Hence, in BPD, the current evidence for CR appears limited and not as it is for schizophrenia.
In obsessive-compulsive disorders (OCD), cognitive impairments have been identified and primarily involve difficulties in executive functioning, specifically cognitive flexibility and involvement of dysfunctional frontal striatal pathways.,, Research evidence for CR in OCD is sparse. In a single small study, the effect of CR on reducing executive dysfunction in OCD was studied, and the authors reported that scores on executive function tests improved significantly in the experimental group. Another major prospective study on the efficacy of CR in OCD is currently underway, but overall, there is still no clear evidence to suggest a role of CR in OCD.
The interest in CR for mental illness is recent in India with only five evidence-based studies being published on schizophrenia populations.,,,,
The authors of recent reviews , have highlighted that despite the heterogeneity of methods CR appears to be effective for improving cognitive functions in schizophrenia. Certain indigenous methods such as Yoga therapy have been introduced for the first time as adjunct CR for schizophrenia. Bhatia et al., compared two groups, an experimental group who received 21 sessions of yoga therapy and the control group who received TAU and found significant improvement in performance on neuropsychological tests after 2 months in attention and mental flexibility in the experimental group.
In another study, Hegde et al. addressed the challenge of affordability of CR in a resource-poor country like India by studying the efficacy of a home-based, paper-pencil CR tasks in improving cognitive deficits, symptoms, and global functioning. The results of this RCT suggested improvements in cognitive functions and reduction of negative symptoms but no significant changes in psychosocial functioning as compared to the TAU group. One Indian study evaluated the effect of CR as adjunct with pharmacotherapy  while another adapted the content of the integrated psychological therapy program to make it culture specific. The use of CR in mental illness in India is in its nascent stage, but the few studies have demonstrated some efficacy and have discussed culture-specific, novel approaches. However, more studies are required to provide evidence for improved psychosocial functioning.
| Future Directions|| |
In April 2012, a group of experts at the NIMH convened meeting on the efficacy of cognitive training (CT) expressed the hope that; “…One day in the not-too-distant future, we will be able to identify the key neural system impairments unique to individual patients, and prescribe personalized CT programs in order to enhance cognition, improve community functioning, and optimize well-being.”
Today, a vast body of evidence suggests that overall CR is a beneficial therapy, but it is still unclear which are the most important ingredients or methods and also if it is equally efficacious in all types of mental disorders. Improvements in psychosocial functioning and generalization from paper-pencil or computerized task-specific learning, to real-life activities, is not completely robust and sustaining benefits into the long-term still needs further research. However, despite this, across studies, there appears to be a consensus that using CR programs in conjunction with vocational or psychosocial programs results in improved functional outcomes and using strategy coaching is superior to only drill and practice exercises.
The future research needs to focus on understanding the various moderators that influence the outcome. There is a need to develop evidence-based programs, but these must be customized to address the individual's personal goals and be relevant to the cultural and socioeconomic milieu of the patient. A dynamic interactive partnership between the expert therapist and patient is a very important ingredient to mediate learning and facilitate generalization from clinic-based cognitive tasks to real-life activities. Overall, cognitive rehabilitation has the potential to become a powerful tool to help patients become participative and productive members of society.
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Conflicts of interest
There are no conflicts of interest.
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