Cognitive Remediation in Severe Mental Illness

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Cognitive Remediationin Severe Mental Illness

• Susan R. McGurk, Ph.D.
• Dartmouth Psychiatric Research Center
• Department of Psychiatry
• Dartmouth Medical School

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What is Cognition Functioning?

• Mental processes
• Five major areas
• Attention
• Psychomotor speed
• Memory
• Problem-solving
• Social cognition

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Attention

• The ability to focus concentration on something
  for a sustained period of time

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Psychomotor Speed

• Latency of response to environmental demands and
  the time required to execute tasks that require
  the processing of information

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Memory

• The acquisition, consolidation, retention of
  information
• Short-term memory (working memory) what you
  can keep in your mind for brief periods (e.g., a
  7-digit phone number)
• Long-term memory (retention over longer periods
  of time, such as days, weeks, etc.)

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Executive Functions

• Conceptual reasoning
• Planning
• Abstract thinking
• Flexible thinking
• Problem Solving

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Why is Cognitive Functioning Important in
Psychiatric Illness?

• Cognitive impairments are common in severe mental
  illness (SMI)
• Cognitive impairments increase risk of developing
  SMI
• Related to a broad range of functioning (such as
  self-care and independent living, social
  relationships, work)

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Problem-Solving Performance in Clubhouse Members
with Schizophrenia

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McGurk Meltzer, 2000
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Why is Cognitive Functioning Important in
Psychiatric Illness?

• People report awareness of cognitive problems and
  effects on functioning

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Subjective Reports of Cognitive Impairment

• I have something I want to say and then it flies
  right out of my mind before I say it.
• I forgot what I was supposed to do today at
  work. My boss got really annoyed with me.
• In class, my mind wanders fairly frequently and
  its upsetting. When Im reading for school, my
  mind wanders- I would have to reread the sections
  several times.
• I tend to repeat myself, do things over and
  over I forget what my friends tell me. I forget
  where I put things. I forget about medications.

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Why is Cognitive Functioning Important in
Psychiatric Illness?

• Cognitive Impairment is associated with less
  benefit from psychiatric rehabilitation

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Methods for Conducting Cognitive Remediation

• Focus on restoration of cognitive functions,
  teaching strategies for compensating for
  cognitive impairments
• Combination of computer-based training exercises,
  strategy coaching, group work
• Most programs last 3-6 months
• Primary focus on schizophrenia
• 25 years of research on cognitive remediation

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Effectiveness of Cognitive Remediation

• Recent meta-analysis of 26 randomized controlled
  studies
• 1151 consumers
• Examined effects on cognitive functioning,
  symptoms, psychosocial functioning
• Explored mediators of outcome, including
  characteristics of consumers cognitive training
  program, provision of adjunctive psychiatric
  rehabilitation

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Conclusions from Meta Analysis

• Cognitive remediation improves cognitive
  functioning in schizophrenia, as well as symptoms
  and functioning
• Most programs involve some sort of task practice
  of cognitive skills
• Average hours 20 and duration 13 weeks.
• Verbal learning and memory is sensitive to amount
  and type of practice
• Functional benefits are most effectively achieved
  by adjunctive psychiatric rehabilitation

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COGPACK

• Designed for persons with severe mental illness
• Audio-visual presentation
• Contextualized formats
• Contains practice exercises for a broad range of
  cognitive functions
• Provides information regarding speed and accuracy
  of task performance
• Has demonstrated efficacy in improving cognition
  in severe mental illness

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Requirements for Participation

• Reading level of at least 4th grade
• Lower reading levels necessitate more help from
  staff
• Competency with computer mouse
• Less competency can increase frustration levels,
  and eliminate the ability to use certain
  exercises

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Role of Cognitive Specialist

• The following attributes of the cognitive
  specialist are instrumental to participant
  success in program
• 1-interpersonal warmth and empathy
• 2- high energy and enthusiasm
• 3- optimistic and hopeful
• 4- ability to notice and reinforce small
  improvements (i.e., take a shaping approach to
  rehabilitation)
• 5- task and goal oriented

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Can Cognitive Remediation Improve the
Effectiveness of Vocational Rehabilitation?

• Cognitive remediation alone is unlikely to
  improve functional outcomes, including work (as
  shown in meta-analysis)
• Supported employment (SE) is an evidence-based
  practice for improving work in persons with
  severe mental illness
• Can cognitive remediation improve the
  effectiveness of SE programs?

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Cognitive Functioning and Employment

• -Increasing literature on relationship between
  cognitive functioning and work outcomes in
  schizophrenia
• -Studies have included
• Vocational rehabilitation participants
• Cross-sectional comparisons of employed vs.
  unemployed clients
• Retrospective analyses in clients with good vs.
  poor vocational outcome
• Prospective studies

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• Better cognitive functioning relates to better
  employment outcomes, including in participants
  in supported employment (the only evidence-based
  practice for vocational rehabilitation in SMI)

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Common Work Problems often Related to Cognition

• Slowness
• Inattentiveness
• Poor quality of work (e.g., making mistakes)
• Forgetting
• Poor problem solving
• Lower stamina/Problems with fatigue
• Being late
• Not paying attention
• Disorganization

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The Thinking Skills for Work Program

• Designed for clients not benefiting from
  supported employment
• Fully integrated with supported employment
• Combines computer cognitive training with in vivo
  applications
• Is implemented by cognitive specialist who is
  member of supported employment team

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Components of the Program

• Assessment
• Computer cognitive training
• Job search planning
• Job support consultation

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Role of Employment Specialist

• Employment specialist gets cognitive performance
  results
• Cognitive specialist meets with employment
  specialist during cognitive remediation, when job
  is attained, and provides follow along
  consultation
• Cognitive and employment specialists formulate
  linkages of cognitive impairments with potential
  work difficulties
• Employment specialist attempts generalization of
  cognitive training to job tasks
• Works with cognitive specialist and the
  individual to develop compensatory strategies for
  performance of job tasks

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Job Performance Problems Related to Attention

• How to determine whether the problem is related
  to attention
• Is the person making mistakes?
• Are they not getting the job done because they
  are spacing out?
• Does the person report being easily distracted?
• 4. Does the person report problems with
  attention?

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Coping with Attention Problems

• Self-management techniques self-verbalization of
  steps
• One person found it helpful to say out loud the
  steps of the xeroxing and filing task, such as
  Put the paper on the plate, put down the lid,
  push the bottom and so on. Eventually she was
  able to think the steps to herself without saying
  them out loud.
• More frequent rest breaks
• Instead of 15 min every 3 hours, negotiated 5 min
  per hour

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Brooklyn Study Design
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III
IV
Baseline Assessment
Inclusionary Criteria
Intervention
Follow Up
Assessment Feedback 24 sessions of Computer
Work Consultation with Employ. team Post
Intervention Assessment Compensatory Strategies
Demographic Characteristics Cognitive
Assessment Analysis of Prior Job Loss Clinical
Interview
SMI Enrolled in SE Recent Job Loss Interest in
Participation
Job Activity Hours Worked Wages Earned
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Post Treatment Cognitive Composite Scores

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Thinking Skills for Work Program 2-3 Year
Employment Outcomes
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Conclusions

• Cognitive remediation can be successfully
  implemented in a variety of treatment settings
  for persons with severe mental illness
• Cognitive remediation improved cognitive
  functioning in participants with wide-ranging
  educational and vocational backgrounds
• Participation in the cognitive remediation
  program was associated with more work in 2
  different types of vocational rehabilitation
• Additional work is underway to replicate and
  further understand the effects of integrating
  cognitive remediation with vocational
  rehabilitation