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Therapy Program Improves Cognition in Patients

A successful program to enhance neurocognition and social cognition in individuals with schizophrenia might make a difference in the lives of many if someone were willing to underwrite it.

Looking at pharmaceutical ads, one could easily get the impression that all it takes to help a person with schizophrenia is a prescription for an atypical antipsychotic. Yet even if an antipsychotic quashes schizophrenia patients' hallucinations and delusions, they may still have trouble remembering, not be able to express their needs, be incapable of negotiating conflicts, lack empathy, or demonstrate other deficits in neurocognition or social cognition.

Thus, there is a pressing need for programs that can enhance the neurocognitive and social-cognitive abilities of individuals with schizophrenia.

Now psychiatric researchers at the University of Pittsburgh have developed just such a program. It is called cognitive enhancement therapy (CET) and has produced some impressive results in schizophrenia patients who have been ill for a long time, a study reported in the September Archives of General Psychiatry revealed. The lead investigator was Gerard Hogarty, M.S.W., a professor of psychiatry at the university.

CET was developed by Hogarty and colleagues in the early and mid 1990s to enhance neurocognitive and social-cognitive abilities in symptomatically stable schizophrenia outpatients—a growing population in this era of atypical antipsychotic medications.

CET is a small-group approach that combines about 75 hours of progressive software training and exercises in attention, memory, and problem solving with 1.5 hours a week of social-cognition group exercises (56 sessions). Group exercises include initiating and maintaining conversations, abstracting themes from the editorial pages of USA Today, and solving real-life social dilemmas.

Hogarty and his coworkers undertook a study to see how well CET could help persons with schizophrenia and to compare results from CET with those of what they considered the other best option available to improve the neurocognitive and social-cognitive abilities of individuals with schizophrenia—enriched supportive therapy (EST).

EST is a kind of personal therapy. It is offered once or twice a week to foster illness management. It includes, for instance, education in the nature and treatment of schizophrenia and helps patients adjust to disability and manage stress. In the study, no attempt was made to match the hours that EST was given with the hours that CET was given, since some researchers have found that artificially increasing the hours of a psychosocial intervention has an adverse effect.

One hundred and twenty-one patients who had had either schizophrenia or schizoaffective disorder for 16 years on average had a reasonable remission of positive symptoms, and an I.Q. of at least 80 were randomized to receive either CET or EST over a two-year period. Each group was assessed with various neurocognitive or social-cognitive measures at the start of training, one year into training, and at two years, when training ended, to see whether they improved in various domains.

(The antipsychotic medications that subjects were taking were also analyzed during the study period to make sure that there were no treatment-group differences in type or dose of medication or in medication compliance that might have confounded psychosocial intervention results.)

By the end of the two years, the EST group demonstrated clinically meaningful improvements on many measures, but the CET group had improved even more.

"The intent was to provide a stringent test of CET," Hogarty said in an interview. "The results made me feel that it was really worth the effort."

The biggest improvement the CET subjects showed was in information processing, which is a prerequisite for learning. "Many had been very, very slow," said Hogarty.

The next biggest improvement that CET subjects displayed was in working memory and verbal memory. After their training ended, the CET subjects also appeared to feel better about themselves and to be more comfortable around people; they were also more likely to assume voluntary jobs or to join vocational rehabilitation groups than they were before.

The researchers likewise followed the CET subjects for a year after training ended and found that they had maintained the skills they had acquired.

Hogarty feared that schizophrenia patients might not be willing to come to the program twice a week for two years to improve their cognitive skills. However, their compliance was "astounding," he said. "They were willing to work hard to get well; they liked it."

"No, our program is not a panacea for schizophrenia," he admitted. "But life is distinctly better for these folks because of it. It is empowering."

"The results give me hope that schizophrenia patients can get better," Haranath Parepally, M.D., a University of Pittsburgh psychiatrist and one of the study investigators, told Psychiatric News. "If we can stabilize patients pharmacologically to the best of our ability and if they can maintain it for a while, an intervention like this can probably make a tremendous amount of difference."

The neurocognition and social-cognition improvement program developed by Hogarty and his coworkers is among only a few such programs in the United States, although hundreds of thousands of schizophrenia patients might well profit from them. The reason, Hogarty explained, is that psychosocial rehabilitation for schizophrenia patients has never received much funding in the United States, and it is not receiving much funding now.

Nonetheless, he remains hopeful that their program might reach more persons with schizophrenia. In fact, he and some colleagues are willing to train people to administer their program so that it can help more individuals.

"The CET study demonstrates the value of targeted psychosocial treatment in helping patients with schizophrenia," Jason Rosenstock, M.D., a University of Pittsburgh psychiatrist not associated with the investigation, said in an interview.

"Cognitive impairment from schizophrenia may be the key factor in overall functional recovery, and any treatment that addresses this directly could make a significant impact in the quality of life for patients. CET is the product of Professor Hogarty's decades of research into psychosocial treatments, and the one that seems to best target schizophrenia-specific deficits (as opposed to the more general effects of social skills training, or family psychoeducation). Most importantly, the results obtained are extremely impressive—effect sizes of this magnitude demonstrate that CET can have a significant positive effect on cognition in this subgroup of patients. I'm most interested in seeing how CET could be replicated in a `real-world' setting for a larger and broader group of patients—it has the potential to revolutionize the care we provide our patients."

The study was funded by the National Institute of Mental Health.

An abstract of the study, "Cognitive Enhancement Therapy for Schizophrenia," is posted online at <http://archpsyc.ama-assn.org/cgi/content/abstract/61/9/866?etoc@eaf>.

Arch Gen Psychiatry 2004 61 866[Abstract/Free Full Text]

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