1 June 2012. Dawn Velligan of the Texas Health Science Center, San Antonio, and Shitij Kapur of the Institute of Psychiatry, London, UK, chaired the 15 April opening plenary session of the 2012 Schizophrenia International Research Society meeting in Florence, Italy. The speakers reviewed the research on some of the non-pharmacologic treatments aimed at improving cognitive and social function in people with schizophrenia.
The first speaker, Christos Pantelis of the University of Melbourne, Australia, focused on imaging studies of cognitive remediation techniques (see, e.g., SRF related news story and Webinar). He noted long-standing data indicating that cognitive function is already compromised at disease onset and remains relatively stable through the ups and downs of psychosis. However, given the studies in the last several years reporting brain changes around the time of disease onset, some researchers wonder whether this is associated with loss of cognitive function.
He said that people with schizophrenia show more severe deficits in cognitive function than do even frontal lobe injury patients, yet it appears that not all of these deficits are present in the first episode. Pantelis said that cognitive remediation shows some consistent evidence for changing brain structure, though surprisingly not in the dorsolateral prefrontal cortex, but rather in medial and temporal cortical areas that subserve social cognition (e.g., the anterior cingulate cortex). He noted that these seem to be the areas that change early in illness.
Pantelis hypothesizes that some aspects of cognition are normal at disease onset, or mature normally but then deteriorate, and these might be the most amenable to improvement with cognitive remediation techniques. However, he also believes that cognitive remediation may need to happen during early to late adolescence to have this effect. Conversely, he suggests other cognitive functions never fully mature in schizophrenia, but could be addressed with cognitive adaptation methods, i.e., setting up "workarounds" in a person's environment. The latter may be the more valuable for patients with severe deficits.
Steffen Moritz of the University Medical Centre Hamburg-Eppendorf, Germany, discussed data on "meta-cognitive training," a method he developed with Todd Woodward of the University of British Columbia, Canada, to address delusional thinking in schizophrenia. He defined meta-cognition as "one's knowledge concerning one's own cognitive processes or anything related to them," or, more colloquially, "thinking about thinking." (see brief description at SRF's In Search of Collaborators page).
The computer-based training method (available for free in a number of languages) is intended to reduce jumping to conclusions from minimal data and also to decrease distortions in the perceptions of people with schizophrenia. Moritz reported that, in comparison to the cognitive remediation product COGPACK, the metacognitive training does produce significant results on these measures, and also reduces positive symptoms. In fact, he said, a single session significantly reduced jumping to conclusions and conviction of beliefs. More recently, the researchers have added a cognitive behavioral therapy (CBT) component, and preliminary data from a randomized controlled trial suggest superiority over COGPACK on a number of measures.
In the Q&A session, one audience member wondered whether the training, though targeting high-level cognition, such as beliefs, might not also be exerting beneficial effects by improving working memory or speed of processing. Moritz said that they would not expect this to be the case, and had not found evidence for such effects.
The next speaker, Douglas Turkington of the University of Newcastle, UK, discussed the effectiveness of CBT for positive and negative symptoms in schizophrenia. In his estimation, the evidence base from recent prospective studies shows that there is a long-term benefit of CBT, above and beyond the befriending of the patient by a professional. He notes that CBT and cognitive remediation appear to have comparable results, suggesting that there should be studies including both modalities.
However, these studies were all administered by experts, Turkington noted. What about mental health workers with less training? He presented new, unpublished data indicating that community nurses or case workers, trained and supervised regularly, could achieve lasting improvement in symptomatology and indicators of relapse. Turkington added the heartening possibility that CBT might benefit patients who refuse antipsychotic drugs for their positive symptoms. He reported data that indicated surprising benefits, not only on positive, but also negative symptoms. He interprets this as a function of people actively choosing a course of therapy and benefiting from something that resonates. These patients were not more likely to start to take antipsychotic drugs after the CBT.
Turkington believes that researchers will have to start thinking about which modalities fit best for different patients, for example, those with a strong delusional framework without hallucinations versus those who hear multiple voices but lack prominent delusions.
The final speaker, Michael Green of the University of California, Los Angeles, discussed social cognitive training for people with schizophrenia. He reviewed a large body of data indicating that social cognition, more than non-social cognition, is a major determinant of community functioning for people with schizophrenia. Empathy research, in particular, is an emerging focus in this area. Green made a distinction between lower-level emotional empathy ("I feel your pain") and higher-level, cognitive empathy ("I understand what you're experiencing"). Empathic accuracy depends on both, he said, and is valuable for patients.
In the clinic, Green and his collaborators have developed an intervention called Social Cognitive Skills Training (SCST) that targets emotional processing, social perception, attributional bias, and mental state attribution (or Theory of Mind). In a recent pilot trial, they found that the training significantly improves emotional processing, including facial affect perception and emotion management.
Following Green's lecture, the Chairs and the audience had a lively discussion about the difficulties of choosing between methods. Harking back to Turkington's lecture, one discussant suggested that it would depend on the patients and their current states. Chair Kapur wondered how it will be possible to implement proven, effective treatments on a large scale, and Green suggested that standardization may be a barrier both to research and clinical deployment. Turkington said that the key to broad implementation may be to make the methods more widely available for free. An audience member commented that there will be hard work ahead to convince psychologists in the community, who will be the main implementers, of the effectiveness of given therapies, since a significant portion of them, at least in the United States, believe that the patient-therapist relationship is more important to recovery of function than the particular specialized therapy. She suggested that, if a body like the American Psychological Association evaluated and vetted treatments, it might aid in implementation.—Hakon Heimer.