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Online Discussions

Updated 16 December 2011 E-mail discussion
Printable version

Live Discussion: Cognitive Remediation in Schizophrenia: Ready for Widespread Use?


Angus MacDonald

Alice Medalia

Sophia Vinogradov

Morris Bell

On 15 December 2011, SRF hosted a Webinar event co-sponsored by the International Congress on Schizophrenia Research and moderated by Angus MacDonald III of the University of Minnesota. The presenters—Alice Medalia of Columbia University, Sophia Vinogradov of the University of California, Los Angeles, and Morris Bell of Yale University—gave brief slide presentations and participated in a panel discussion.

Listen to the Webinar

View Comments By:
David Yates — Posted 2 December 2011
Til Wykes — Posted 15 December 2011


Background Text
By Angus MacDonald III

One of the most exciting developments in the treatment of schizophrenia in the past decade has been the rise of cognitive remediation. Cognitive remediation refers to a collection of approaches that share the goal of strengthening patients’ capacity to think. In this, it is distinct from cognitive behavior therapy (CBT), which emphasizes interpretations of experience. Cognitive remediation has grown in popularity largely because problems with thinking are a prominent aspect of the disorder, yet these symptoms are largely not addressed by available pharmaceuticals. Cognitive remediation is non-pharmacological, but it does affect the brain. Building on evidence from stroke, normal aging, and animal models, cognitive remediation is designed to leverage the brain’s own plasticity to build capacity. Several popular approaches to cognitive remediation emphasize drill and practice, in particular, the use of computer tasks to provide immediate feedback and adapt to people’s current abilities.

Discussion topics
While a growing database suggests the promise of such techniques, the proverbial cognitive remediation jury is out. One of the reasons for this is that most studies have been of a limited scale; many are only beginning to incorporate double-blind, placebo-controlled designs and long-term follow-up. In this Webinar, we will address the question, What is the latest knowledge about the internal validity of cognitive remediation experiments?

Another challenge to cognitive remediation is generalization. While it is clear that patients can improve on the tasks for which they train, to what extent does training in one domain extend to other domains, and, most importantly, to functioning in life? Furthermore, how long should the effects of training endure?

Given the plurality of approaches, are we closer to knowing which are most effective from a cost-benefit standpoint? Do these various approaches affect brain systems differently? And is it possible to know beforehand who will have a positive response to the treatment?

Finally, and crucially, what are the vital questions that still need to be addressed, technologies that need to be developed, or policies that need to be implemented before cognitive remediation can become part of the comprehensive care for patients with schizophrenia?

Suggested reading
McGurk SR, Twamley EW, Sitzer DI, McHugo GJ, Mueser KT. A meta-analysis of cognitive remediation in schizophrenia. Am J Psychiatry . 2007 Dec 1 ; 164(12):1791-802. Abstract

Medalia A, Choi J. Cognitive remediation in schizophrenia. Neuropsychol Rev . 2009 Sep 1 ; 19(3):353-64. Abstract

Bell MD, Zito W, Greig T, Wexler BE. Neurocognitive enhancement therapy with vocational services: work outcomes at two-year follow-up. Schizophr Res . 2008 Oct 1 ; 105(1-3):18-29. Abstract

Kurtz MM, Seltzer JC, Fujimoto M, Shagan DS, Wexler BE. Predictors of change in life skills in schizophrenia after cognitive remediation. Schizophr Res . 2009 Feb 1 ; 107(2-3):267-74. Abstract

McGurk SR, Mueser KT, DeRosa TJ, Wolfe R. Work, recovery, and comorbidity in schizophrenia: a randomized controlled trial of cognitive remediation. Schizophr Bull . 2009 Mar 1 ; 35(2):319-35. Abstract

Eack SM, Hogarty GE, Cho RY, Prasad KM, Greenwald DP, Hogarty SS, Keshavan MS. Neuroprotective effects of cognitive enhancement therapy against gray matter loss in early schizophrenia: results from a 2-year randomized controlled trial. Arch Gen Psychiatry . 2010 Jul 1 ; 67(7):674-82. Abstract

Vinogradov S, Fisher M, Holland C, Shelly W, Wolkowitz O, Mellon SH. Is serum brain-derived neurotrophic factor a biomarker for cognitive enhancement in schizophrenia? Biol Psychiatry . 2009 Sep 15 ; 66(6):549-53. Abstract

Haut KM, Lim KO, MacDonald A. Prefrontal cortical changes following cognitive training in patients with chronic schizophrenia: effects of practice, generalization, and specificity. Neuropsychopharmacology . 2010 Aug 1 ; 35(9):1850-9. Abstract


Comments on Online Discussion
Comment by:  David Yates
Submitted 1 December 2011 Posted 2 December 2011

I hope the presenters and discussants at the meeting take into account in their presentations the strong evidence for poor working memory capacity already at the onset of schizophrenia, and continuing thereafter (Schobel et al., 2009; Reif et al., 2006; Gold et al., 2010; van Raalten et al., 2008), which limits the ability to rehearse and practice in new situations. This becomes the block to further development in capability.

Van Raalten et al. (van Raalten et al., 2008) suggest that a simplified setting can be successfully managed with a reduced working memory capacity, by simplifying, as in chunking, and by rehearsal and by mentoring, but that meeting more complicated demands fails.

It seems to me that the results from cognitive remediation in practice so far are better explained as obtained by reducing the demands upon memory...  Read more


View all comments by David Yates

Comment by:  Til Wykes
Submitted 14 December 2011 Posted 15 December 2011

The possibility of drill and practice influencing brain plasticity has little support. The most recent (and most rigorous) meta-analysis showed that the cognitive remediation evidence is most supportive of strategy training to influence functioning outcomes, and the difference compared with drill and practice was significant. So even if drill and practice influences brain plasticity (and at the moment we have no strong support for this), it is strategy type training that influences recovery. More recent drill and practice studies have also shown no improvement in drill and practice.

In terms of the internal validity of the cognitive remediation studies, this was investigated in the same meta-analysis. Despite previous findings that poor internal validity inflated effect sizes, this was not the case for cognitive remediation, and this was probably because the outcome measures in terms of cognitive tests were designed not to be influenced by such factors as rater bias. So methodological rigor (internal and external validity) does not seem to have an influence on cognitive...  Read more


View all comments by Til Wykes
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