This comment was prepared in collaboration with Matteo Cella, Clare Reeder, Vyv Huddy, and Rumina Taylor.

Cognitive remediation creates many misunderstandings in terms of its breadth (which cognitive domains), the implied impact (on cognition and/or functioning), and by the implied differences (which are not apparent in meta-analyses) by giving the programs different names. This leads to confusion amongst research funders, between applied researchers and those who develop treatment guidance. This study overcomes many of these problems. It provides clear guidance on the treatment it is providing by setting down treatment ingredients, calling it a generic name and testing the specific impact.

Whether cognitive remediation leads by itself to functional gains has been an ongoing debate fuelled by the metaphor of prescribing steroids and seeing whether people build muscle by sitting on the sofa. Clearly, they are much less likely to gain than those who go to the gym, and so the argument goes that they, therefore, need extra training to use the cognitive skill boost...  Read more

This comment was prepared in collaboration with Matteo Cella, Clare Reeder, Vyv Huddy, and Rumina Taylor.

Cognitive remediation creates many misunderstandings in terms of its breadth (which cognitive domains), the implied impact (on cognition and/or functioning), and by the implied differences (which are not apparent in meta-analyses) by giving the programs different names. This leads to confusion amongst research funders, between applied researchers and those who develop treatment guidance. This study overcomes many of these problems. It provides clear guidance on the treatment it is providing by setting down treatment ingredients, calling it a generic name and testing the specific impact.

Whether cognitive remediation leads by itself to functional gains has been an ongoing debate fuelled by the metaphor of prescribing steroids and seeing whether people build muscle by sitting on the sofa. Clearly, they are much less likely to gain than those who go to the gym, and so the argument goes that they, therefore, need extra training to use the cognitive skill boost provided by the remediation therapy. The paper by Bowie and colleagues tries to answer this question, and clearly shows, in a rigorous trial, that cognitive gains are only made by those who receive cognitive remediation, and that the real-world functional gains are only made for those who also receive functional skills training.

What have we learned from this study?
The main conclusion is that, if the outcome of value to a service user (patient) is community functioning, then the choices are clear: a combined treatment is best, cognitive remediation alone second, and functional skills training alone the worst (and for work skills, the bottom CR and FS change places). Cognitive remediation is not currently on anyone's list for treatment guidance, but these data provide the best evidence yet that functional skills training (which is on the treatment list) should not be provided without cognitive remediation, as it is likely that this will be more effective and possibly even more cost effective. It may also reduce failure as shown by McGurk and colleagues (McGurk et al., 2007).

Could we do better?
There will always be arguments about the type of cognitive remediation program adopted in any study, and this one is certainly eclectic. But the authors have pulled out the specific methods of training which have been shown to work in meta-analyses (e.g., Wykes et al., 2011). That is, strategic training is important to establish a more generalized approach to other cognitive tests, and this was added as an extra component to the therapy. However, the computer training programs used in the study (CogPack, etc.) are not geared towards ecologically valid tasks such as shopping, cooking, etc., which were clearly in the domain of functional skills training. Bridging (helping people transfer their skills) was carried out, but separately from the tasks. Social interaction was also limited in the cognitive remediation group.

This study really tells us that what we are doing now is helpful, but perhaps a "third wave" of cognitive remediation treatments are now needed that tie the thinking skills more closely to the actual real-life tasks required and allow practice of those meta-cognitive skills that are so important to treatment generalization. For instance, we could include more real-life, ecologically valid tasks (e.g., reading maps, timetables, planning activities) and increase the types of goal-based interactions between therapist and patient (e.g., how to use CR strategies to complete college work, improve work performance, etc.). In addition to computer tasks, the bridging and cognitive remediation could use patients' own materials to work on in sessions (e.g., magazine articles they'd like to read, college work, etc.), and continue this for homework. This embedding is a logical next step from the data in this paper.

What isn't in this paper?
I would urge the authors to consider an analysis that looks at the models of how they expected change to take place (see, e.g., Wykes and Spaulding, 2012). If we do not try to tease out the way that cognitive remediation has an impact, and how this then impacts real-life functioning, we are unlikely to reap further benefits by devising better training protocols for our patients to improve their valued outcomes.

References:

McGurk SR, Mueser KT, Feldman K, Wolfe R, Pascaris A: Cognitive training for supported employment: 2–3 year outcomes of a randomized controlled trial. Am J Psychiatry 2007; 164: 437-441. Abstract

Wykes T, Huddy V, Cellard C , McGurk SR, Czobor P: A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. Am J Psychiatry 2011; 168:472-485. Abstract

Wykes T and Spaulding W (2012) Thinking About the Future Cognitive Remediation Therapy—What Works and Could We Do Better? Schizophrenia Bulletin 2012.

Chris Bowie and colleagues deserve congratulations on their recent report of a very ambitious and important study. In brief, Bowie and colleagues have shown both differential and synergistic effects of two psychosocial interventions. Their cognitive remediation intervention results in significant cognitive gains, but limited improvements in functional status. Their functional skills training intervention had a positive impact on social competence, but minimal cognitive benefits. However, their combined treatment group had cognitive benefits, social skill benefits, as well as improvements in community function that endured for at least three months after the end of treatment. The data certainly suggest that initial cognitive remediation potentiated the impact of functional skills training, thereby enhancing actual community functioning.

Several aspects of the study bear comment. While the development of pharmacological and psychosocial interventions to improve cognitive performance in schizophrenia remains a central focus of research, the results of Bowie et al. provide an...  Read more

Chris Bowie and colleagues deserve congratulations on their recent report of a very ambitious and important study. In brief, Bowie and colleagues have shown both differential and synergistic effects of two psychosocial interventions. Their cognitive remediation intervention results in significant cognitive gains, but limited improvements in functional status. Their functional skills training intervention had a positive impact on social competence, but minimal cognitive benefits. However, their combined treatment group had cognitive benefits, social skill benefits, as well as improvements in community function that endured for at least three months after the end of treatment. The data certainly suggest that initial cognitive remediation potentiated the impact of functional skills training, thereby enhancing actual community functioning.

Several aspects of the study bear comment. While the development of pharmacological and psychosocial interventions to improve cognitive performance in schizophrenia remains a central focus of research, the results of Bowie et al. provide an important cautionary note: cognitive change, by itself, may not be enough to enhance functioning in patients who have a long history of disability and disengagement from the world of work and fully independent living. Thus, cognitive change is likely a necessary, but not sufficient, condition for clear and substantial improvements in community function. This fact in no way reduces the importance of developing effective treatments for cognitive impairment, but suggests research evidence needs to be evaluated through the lens of clinical realism. Given that schizophrenia is typically associated with lifelong compromise of functional role performance, it is not surprising that multiple interventions may be needed to alter that course. Further, the costs of providing such interventions, if effective in allowing some patients to return to some form of work and independent living, would likely pale against the costs of long-term income and intensive housing support services.

These data are also relevant to larger questions of the state of the art in cognitive remediation in schizophrenia. There are now many positive reports about the efficacy of cognitive remediation in the literature (e.g., McGurk et al., 2007). There are also negative reports (e.g., Murthy et al., 2012; Dickinson et al., 2010), and one suspects that this area of work may have an important “file drawer” of unpublished negative results, given the climate of the field. There are multiple approaches in the literature, multiple software packages in wide use, and the current literature does not provide a clear signal about which approach is “better,” or “better for whom.” These approaches differ in theoretical motivation, in intensity, and likely in cost. The paper by Bowie and colleagues increases the urgency of sorting through current approaches to cognitive remediation in schizophrenia so that approaches that are particularly effective can be paired with appropriate skills training, with the goal of providing the best services that we can to our patients.

References:

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

Murthy NV, Mahncke H, Wexler BE, Maruff P, Inamdar A, Zucchetto M, Lund J, Shabbir S, Shergill S, Keshavan M, Kapur S, Laruelle M, Alexander R. Computerized cognitive remediation training for schizophrenia: An open label, multi-site, multinational methodology study. Schizophr Res. 2012 Feb 17. Abstract

Dickinson D, Tenhula W, Morris S, Brown C, Peer J, Spencer K, Li L, Gold JM, Bellack AS. A randomized, controlled trial of computer-assisted cognitive remediation for schizophrenia. Am J Psychiatry. 2010 Feb;167(2):170-80. Abstract