COMPUTER-BASED COGNITIVE TRAINING IN SCHIZOPHRENIA: A PILOT TEST OF “GRADIOR”

Ruiz, J.C.(1), Soler, M.J.(1), Dasí, C.(1), & Tomás, P.(2)

(1) School of Psychology. University of Valencia (Spain) (2) Center for Rehabilitation and Social Integration (CRIS) in Valencia (Spain)

2th International Congress of Biological Psychiatry. Santiago de Chile, 17 - 21 April 2007

INTRODUCTIONCognitive impairment is a key feature of schizophrenia. Deficits in attention, memory and executive functioning are prominent among people with schizophrenia and have an impact on

their social and vocational functioning, quality of life and family burden. These cognitive deficits are also linked to negative symptoms and functional outcome.Evidence of the relation between these basic cognitive processes and daily life functioning skills is strong, and as a consequence, efforts have been directed to the development of

efficient cognitive rehabilitation therapies to be used as a first step in the process of social and vocational skills rehabilitation (Green et al., 2000; Kurtz et al., 2007).Usually, in cognitive rehabilitation programs, a therapist works with a small group of patients practicing cognitive mental tasks under supervision. In this context the use of computers has

been incorporated, and some computer-assisted cognitive rehabilitation programs (CACRP) have been developed, and are used in cognitive rehabilitation interventions (Cogpack: Marker Software; Captain’s Log Software; CogReHab Software: Psychological Software Services).

The characteristics of these programs have advantages in comparison with “traditional” programs: they use standardized well-known laboratory tasks, they give immediate feedback to patients, they make a continuous difficulty adaptation depending on the performance of the patient, they allow a personalized schedule, and can be used with patients reluctant to work with therapists (Bellucci et al., 2002; Suslow et al., 2001).

However, studies on the efficacy of CACRP either show inconsistent results, or show no differences in comparison with non specific cognitive training programs.In view of the outcomes of cognitive rehabilitation and the potential advantages of computer cognitive rehabilitation programs, in this pilot study we examined the effectiveness of the

computer program GRADIOR (Franco et al., 2000), developed as a cognitive rehabilitation program for persons with schizophrenia. Our goal is to analyze improvements in the cognitive tasks used in the program, and improvements in cognitive functioning, measured with external cognitive variables.

METHODParticipants in the study were 10 outpatients from the Center for Rehabilitation and Social Integration in

Valencia, Spain, with a DSM-IV diagnosis of schizophrenia. All patients were receiving antipsychotic medication prior to and throughout the study. Mean age was 38.9, mean years of education was 7.0. Mean duration of illness was 19.1, and mean IQ 85.3 (SD=11.85). All provided informed written consent before participating in the study. The study sample contained patients who met the following criteria: IQ>70, and more than 24 perseverative errors in the WSCT or significant differences between the subtests of a WAIS-III short form (information, block design, arithmetic, and digit symbols) (Blyler et al., 2000).

Participants were administered the WAIS-III short form to estimate IQ before the beginning of the program. Immediately before and after the cognitive computer program all the participants completed a battery of neuropsychological tests (see Table 2) administered and scored by trained psychologists.

Procedure: Patients were told that they were going to participate in a computer-assisted training program. All of them received pre-test and post-test assessment on all measures, and took part in the regular activities of the Center they were attending.

Patients participated in three to four GRADIOR computerized remediation sessions per week. Each session lasted twenty minutes and included a variety of tasks: memory, attention, and problem solving (see Table 1). These tasks were presented in visual and auditory modalities, and subjects input the answers touching the computer screen. The program provided performance feedback and consistent reinforcement. All the patients began with the same difficulty level and every week it was adjusted by a trained psychologist depending on the performance of the subject. As general criteria the level of a specific task was increased if the subject performed the task two or three consecutive times without errors. The level was lowered if the task was not performed correctly in two or three consecutive sessions. On average, patients completed 34.8 cognitive training sessions, and 12.9 tasks in each session.

Data analysis: Two group of analysis were performed. Improvements in the performance of the different tasks used in the GRADIOR program were measured studying the differences between the initial level in the task and the final level the subject achieved in that task. Then, neuropsychological data before and after the intervention program were compared using a t test.

RESULTSThere were significant improvements in performance in the computerized cognitive tasks used in GRADIOR program (Table 1). Results showed significant gains in attention, verbal and

nor verbal memory, and problem solving exercises.However, the analysis of change in scores in the neuropsychological variables between the two measurement moments didn’t showed significant differences except in one measure (Table

2). In the picture completion subtest from the WAIS-III, a measure of attention, the difference between the two measurement moments was near to be significant ( p=0.056).

CONCLUSIONSGRADIOR yielded significant improvements in all the tasks used during the training program. These significant improvements in tasks performance however did not have an impact on

neurocognitive measures when these were measured with instruments different from those used for training. Executive functioning, everyday memory, and attention / speed of processing capacity didn’t showed improvements.

The low power of the study due to its small sample may have prevented the detection of significant effects on neurocognitive functioning. However, the stability of the neurocognitive scores from pre-test to post-test suggests that the benefits observed in the cognitive tasks used in the program do not extend easily to patient’s cognitive functioning. A more powerful design would allow the observation of the efficacy of GRADIOR to enhance cognitive functioning in patients with schizophrenia.

REFERENCESBellucci, D.M., Glaberman, K., Haslam, N. (2002) Computer-assisted cognitive rehabilitation reduces negative symptoms in the severely mentally ill. Schizophrenia Research, 59, 225-232.

Blyler, C.R., Gold, J.M., Iannone, V.N., Buchanan, R.W. (2000) Short form of the WAIS-III for use with patients with schizophrenia. Schizophrenia Research, 46, 209-15.Franco, M.A., Orihuela, T., Bueno, Y., Cid, T.(2000) Programa GRADIOR: Programa de evaluación y rehabilitación cognitiva por ordenador (Cognitive rehabilitation and evaluation computer program). Edintras (Ed), Zamora:

Spain.Green, M.F., Kern, R.S., Braff, D.L., Mintz, J. (2000) Neurocognitive deficits and functional outcome in schizophrenia: are we measuring the ‘right stuff’?. Schizophrenia Bulletin, 26 (1), 119-136.

Kurtz, M.M., Seltzer, J.C., Shagan, D.S., Thime, W.R., Wexler; B.E. (2007) Computer-assisted cognitive remediation in schizophrenia: What is the active ingredient? Schizophrenia Research, 89, 251-260.Suslow, T., Schonauer, K., Arolt, V. (2001) Attention training in the cognitive rehabilitation of schizophrenic patients: a review of efficacy studies. Acta Psychiatrica Scandinavica, 103, 15-23.

(1) Juan Carlos Ruiz: jcruiz@uv.es

Table 2: t test results of differences in pre-post neurolopsychological tests performance. pre

mean (SD) post

mean (SD) t

Memory: Everyday memory (RBMT) 7.2 (2.5) 7.0 (2.4) 0.25 Verbal memory: Immediate recall (RBMT) 1.1 (1.0) 1.5 (0.8) 0.94 Verbal memory: Delayed recall (RBMT) 1.7 (0.5) 1.7 (0.5) 0.01 Working memory: WAIS-I I I digit 8.8 (2.3) 8.7 (2.7) 0.42 Executive functioning: WSCT (categories achieve) 3.9 (2.3) 4.2 (2.5) 0.63 WSCT (perseverative errors) 26.0 (22.6) 22.6 (16.0) 0.71 Attention – Psychomotor speed/ vigilance: WAIS-I I I digit symbol subtest 6.8 (1.0) 7.9 (3.0) 1.15 WAIS-I I I picture completion subtest 8.4 (1.2) 10.4 (1.7) 2.23 * RBMT (Rivermead Behavioural Memory Test); WSCT (Wisconsing shorting card test) *p=0.056

Table 1: t test results of differences (initial - final difficulty level achieved by patients) in the GRADIOR cognitive tasks.

Initial Final t Attention Tasks auditory selective attention 3.0 5.9 29.00 * visual selective attention 1 3.9 5.3 4.12** visual selective attention 2 2.0 2.9 9.00* colour vigilance 3.0 5.1 6.68* signal light vigilance 2.0 4.6 7.65* Problem Solving Tasks calculation 1.5 7.1 15.09* arithmetic problems 2.1 6.3 6.33* Memory Tasks immediate graphic recall 2.0 8.1 26.14* delayed graphic recall (6 sec. delay) 2.5 4.1 5.24** delayed graphic recognition (6 sec. delay) 2.5 4.9 14.70* immediate verbal recall 2.0 4.8 21.00* delayed verbal recall (6 sec. delay) 2.5 3.5 3.35** delayed verbal recognition (6 sec. delay) 2.5 4.6 7.58* direct letters memory span 2.0 3.1 6.13* inverse letters memory span 1.4 2.5 3.50** direct numbers memory span 2.0 3.6 9.80* inverse numbers memory span 1.5 2.8 3.88** *p <0.0001; ** p <0.008 GRADIOR also includes perception tasks not used in this pilot study.