+ Cognitive Interventions for

Schizophrenia: Compensatory and Restorative Approaches

Sean Kidd, Ph.D.CAMH Schizophrenia DivisionUniversity of Toronto Department of PsychiatryDecember 1st, 2014

+ Funders and Collaborators

Dawn Velligan and Natalie Maples – University of Texas at San Antonio

Jaswant Kaur – George Brown College

Rohan Ganguli, Tony George, Yarissa Herman, Kwame McKenzie, Gursharan Virdee

*There are no competing interests in the work presented

+

presentation overview: a tale of two approaches

What is promising

What is problematic

What is next

+ some general background

Tools are available for addressing positive symptoms (delusions, hallucinations).

But, we have little to offer for cognitive impacts and negative symptoms

+ cognitive impacts

Attention

Memory

Problem Solving

Social Cognition

+ what to do about it?

+ 1. enhance

Practice cognitive tasks

A variable literature (types of tasks, adjunct intervention)

Linking to “real world” contexts and challenges important

+

people working in CR research

Susan McGurk – Boston U

Til Wykes – London Institute of Psychiatry

Matthew Kurtz - Yale

Bruce Wexler – Yale

Chris Bowie – Queen’s U

Alice Medalia - Columbia

+ cognitive remediation – the evidence

Psychosis symptoms (highly

variable, .28 avg) Neurocognition (.41) Psychosocial functioning (.35) Gains are sustained Benefit over comparable tasks Little link between outcome and

intervention duration

+

an example – George Brown College

Built into academic curriculum

Group and individual computer exercises

+ matching with McGurk

+

+ the pilot – summer 2010

People like it!

Turned up and stayed

Improved

Kidd, S.A., Kaur Bajwa, J., Haji-Khamneh, B., McKenzie, K., & Ganguli, R. (2012). Cognitive Remediation for Individuals with Psychosis in a Supported Education Setting: A Pilot Study. Journal of Rehabilitation Research and Practice, 2012, 1-5.

+ the rct

Same intervention model

Randomized in term 1

19 to CR+SE, 18 to SE

Cognitive battery, PANSS, Self Esteem, academic functioning

Baseline, term 1 end, term 2 end follow up

+ rct findings

Again people liked it, only 1 person dropped out

Cognition improved for both groups, but no improvement for CR

PANSS – no change for either group

Self Esteem (.44) sustained at f/u

Academic: More term 1 completers (.74), at f/u better contributions, attitude etc. (.64-.75)

+

challenges and what comes next

Bang for the buck and seeing evidence through the hype

Dismantling

Better screening

Better bridging and focus

Considering setting

+ Compensatory Approaches

+ Compensatory Approaches

Some overlap, but emphasize: Compensatory strategy rather than

improving function Home and non-treatment/education

contexts

+ cognitive adaptation training (CAT) - described

Focus primarily on medication taking and basic functional domains

Builds from assessment

Intensive – typically 9 months

+ 2. adapt - cognitive adaptation training

+

+ cat – the evidence

Compared to control conditions, clients receiving CAT Psychosis Symptoms (mostly ns) Lower relapse rates (65% versus 19%

over 19 months) Higher levels of adaptive functioning

(1.00) Most consistently, better medication

adherence (approx 1.00) Not for everyone

+

+ the revision

9 months

Intensive CAT 4 months, with 5 months case manager follow up

Eval – baseline, 4 months, 9 months

Symptoms (BPRS, NSA), functioning MCAS, SOFAS, GAS

N = 23

+ the outcomes

It worked, people liked it

Symptoms: BPRS .41 - .24; NSA .33 - .33

Functioning:

+ the challenges

Bedbugs

Time and travel

+ next steps

Family CAT

Inpatient CAT

+ where do we go from here?

+ considering...

Sequencing/staging in care pathways approaches

Better screening and providing individualized care

Linkages: CBT, CBSST, MBCT/SR, Supported Voc and Ed, family intervention, concurrent disorders tx

The tool is as only good as the person using it – common factors and fidelity

+ a decent summary paper

McGurk, S.R., Mueser, K.T., Covell, N.H., Cicerone, K.D., Drake, R.E., Silverstein, S.M., Medalia, A., Myers, R., Bellack, A.S., Bell, M.D., Essock, S. M., 2013. Mental health system funding of cognitive enhancement interventions for schizophrenia: Summary and update of the New York Office of Mental Health Expert Panel and Stakeholder

Meeting. Psychiat Rehab J. 36 133-145.