Cognitive Remediation in Severe Mental Illness Susan R. McGurk, Ph.D. Dartmouth Psychiatric Research Center Department of Psychiatry Dartmouth Medical School

What is Cognition Functioning? Mental processes Five major areas –Attention –Psychomotor speed –Memory –Problem-solving –Social cognition

Attention The ability to focus concentration on something for a sustained period of time

Psychomotor Speed Latency of response to environmental demands and the time required to execute tasks that require the processing of information

Memory The acquisition, consolidation, retention of information Short-term memory (“working memory”): what you can keep in your mind for brief periods (e.g., a 7-digit phone number) Long-term memory (retention over longer periods of time, such as days, weeks, etc.)

Executive Functions Conceptual reasoning Planning Abstract thinking Flexible thinking Problem Solving

Why is Cognitive Functioning Important in Psychiatric Illness? Cognitive impairments are common in severe mental illness (SMI) Cognitive impairments increase risk of developing SMI Related to a broad range of functioning (such as self-care and independent living, social relationships, work)

Problem-Solving Performance in Clubhouse Members with Schizophrenia ** **p<0.001 McGurk & Meltzer, 2000

Why is Cognitive Functioning Important in Psychiatric Illness? People report awareness of cognitive problems and effects on functioning

Subjective Reports of Cognitive Impairment “I have something I want to say and then it flies right out of my mind before I say it.” “I forgot what I was supposed to do today at work. My boss got really annoyed with me.” In class, my mind wanders fairly frequently and it’s upsetting. When I’m reading for school, my mind wanders- I would have to reread the sections several times.” “I tend to repeat myself, do things over and over; I forget what my friends tell me. I forget where I put things. I forget about medications.”

Why is Cognitive Functioning Important in Psychiatric Illness? Cognitive Impairment is associated with less benefit from psychiatric rehabilitation

Methods for Conducting Cognitive Remediation Focus on restoration of cognitive functions, & teaching strategies for compensating for cognitive impairments Combination of computer-based training exercises, strategy coaching, group work Most programs last 3-6 months Primary focus on schizophrenia 25+ years of research on cognitive remediation

Effectiveness of Cognitive Remediation Recent meta-analysis of 26 randomized controlled studies 1151 consumers Examined effects on cognitive functioning, symptoms, psychosocial functioning Explored mediators of outcome, including characteristics of consumers & cognitive training program, provision of adjunctive psychiatric rehabilitation

Conclusions from Meta Analysis Cognitive remediation improves cognitive functioning in schizophrenia, as well as symptoms and functioning Most programs involve some sort of task practice of cognitive skills Average hours 20 and duration 13 weeks. Verbal learning and memory is sensitive to amount and type of practice Functional benefits are most effectively achieved by adjunctive psychiatric rehabilitation

“COGPACK” Designed for persons with severe mental illness Audio-visual presentation Contextualized formats Contains practice exercises for a broad range of cognitive functions Provides information regarding speed and accuracy of task performance Has demonstrated efficacy in improving cognition in severe mental illness

Requirements for Participation Reading level of at least 4th grade –Lower reading levels necessitate more help from staff Competency with computer mouse –Less competency can increase frustration levels, and eliminate the ability to use certain exercises

Role of Cognitive Specialist The following attributes of the cognitive specialist are instrumental to participant success in program: 1-interpersonal warmth and empathy 2- high energy and enthusiasm 3- optimistic and hopeful 4- ability to notice and reinforce small improvements (i.e., take a “shaping” approach to rehabilitation) 5- task and goal oriented

Can Cognitive Remediation Improve the Effectiveness of Vocational Rehabilitation? Cognitive remediation alone is unlikely to improve functional outcomes, including work (as shown in meta-analysis) Supported employment (SE) is an evidence- based practice for improving work in persons with severe mental illness Can cognitive remediation improve the effectiveness of SE programs?

Cognitive Functioning and Employment -Increasing literature on relationship between cognitive functioning and work outcomes in schizophrenia: -Studies have included: Vocational rehabilitation participants Cross-sectional comparisons of employed vs. unemployed clients Retrospective analyses in clients with good vs. poor vocational outcome Prospective studies

Better cognitive functioning relates to better employment outcomes, including in participants in supported employment (the only evidence-based practice for vocational rehabilitation in SMI)

Common Work Problems often Related to Cognition 1.Slowness 2.Inattentiveness 3.Poor quality of work (e.g., making mistakes) 4.Forgetting 5.Poor problem solving 6.Lower stamina/Problems with fatigue 7.Being late 8.Not paying attention 9.Disorganization

The Thinking Skills for Work Program Designed for clients not benefiting from supported employment Fully integrated with supported employment Combines computer cognitive training with in vivo applications Is implemented by cognitive specialist who is member of supported employment team

Components of the Program Assessment Computer cognitive training Job search planning Job support consultation

Role of Employment Specialist -Employment specialist gets cognitive performance results -Cognitive specialist meets with employment specialist during cognitive remediation, when job is attained, and provides “follow along” consultation -Cognitive and employment specialists formulate linkages of cognitive impairments with potential work difficulties -Employment specialist attempts generalization of cognitive training to job tasks -Works with cognitive specialist and the individual to develop compensatory strategies for performance of job tasks

Job Performance Problems Related to Attention How to determine whether the problem is related to attention: 1.Is the person making mistakes? 2.Are they not getting the job done because they are “spacing out”? 3.Does the person report being easily distracted? 4.Does the person report problems with attention?

Coping with Attention Problems Self-management techniques: self-verbalization of steps: “One person found it helpful to say out loud the steps of the xeroxing and filing task, such as ‘Put the paper on the plate, put down the lid, push the bottom…’ and so on. Eventually she was able to think the steps to herself without saying them out loud.” More frequent rest breaks: Instead of 15 min every 3 hours, negotiated 5 min per hour

Brooklyn Study Design Baseline Assessment Inclusionary Criteria SMI Enrolled in SE Recent Job Loss Interest in Participation InterventionFollow Up Demographic Characteristics Cognitive Assessment Analysis of Prior Job Loss Clinical Interview Assessment Feedback 24 sessions of Computer Work Consultation with Employ. team Post Intervention Assessment Compensatory Strategies Job Activity: Hours Worked Wages Earned III IIIIV

Post Treatment Cognitive Composite Scores * *p<0.01

Thinking Skills for Work Program: 2-3 Year Employment Outcomes

Conclusions -Cognitive remediation can be successfully implemented in a variety of treatment settings for persons with severe mental illness -Cognitive remediation improved cognitive functioning in participants with wide-ranging educational and vocational backgrounds -Participation in the cognitive remediation program was associated with more work in 2 different types of vocational rehabilitation -Additional work is underway to replicate and further understand the effects of integrating cognitive remediation with vocational rehabilitation