1. Maree Reser Doctorate of Psychology (clinical) candidate Swinburne University of Technology

2. Currently recruiting people with a diagnosis of schizophrenia or schizoaffective disorder to participate in a 24 session course of cognitive training. Recruitment will continue throughout 2016. Contact Maree Reser: crtprogram@gmail.comcrtprogram@gmail.com Phone: 9214 3604 or 0451 169 656

3. Maree Reser Doctorate of Psychology (clinical) candidate Swinburne University of Technology Supervisors: Professor Susan Rossell Dr Neil Thomas Associate Researchers: Dr Caroline Gurvich (MAPrc) Dr Wei Lin Toh (MAPrc) Professor David Castle (St Vincent’s) Dr Kiymet Bozaoglu (Baker IDI) Dr Eric Tan (MAPrc) Mr Sean Carruthers (Swinburne University of Technology) Mr Phil Sumners (Swinburne University of Technology)

4.  Understanding the need ◦ The link between cognition and everyday functioning  Cognitive Remediation Therapy ◦ What is it? ◦ Does it work?  Current research ◦ Aim of research ◦ BrainHQ (by Posit Science) ◦ Observations from participants to-date  Question time

5.  Individuals with psychotic illness: Morgan et al., 2010 Australian national survey “People living with psychotic illness 2010”, p. 4. Level of occupational and social functioning and activities of daily living (e.g., self care)

6.  A majority of individuals diagnosed with schizophrenia experience difficulties in at least one area of cognition.  Processing speed  Attention  Working memory  Learning and memory  Reasoning and problem solving Nuechterlein et al., 2008 Heinrichs et al. 2013

7. Adapted from Bowie et al., 2008 (pathways between clinical symptoms & functioning not shown) Figure 1. Predictors of real-world social functioning  Link between cognition and social functioning: (Social Competence = Social Skills Performance Assessment. Real-world social functioning as measured on the Specific Level of Function Scale. Observer rated scale considering initiating, accepting & maintaining social contacts; effectively communicating.)

8. Figure 2. Predictors of real-world community functioning  Link between cognition and community functioning: (Social Competence = Social Skills Performance Assessment [SSPA]. Functional Competence = UCSD Performance Based Skills Assessment [UPSA]. Real-world community functioning as measured on the Specific Level of Function Scale. Observer rated scale considering shopping, using telephone, paying bills, use of leisure time, use of public transportation.) Adapted from Bowie et al., 2008 (pathways between clinical symptoms & functioning not shown)

9.  Link between cognition and work skills: Adapted from Bowie et al., 2008 (pathways between clinical symptoms & functioning not shown) (Social Competence = Social Skills Performance Assessment [SSPA]. Functional Competence = UCSD Performance Based Skills Assessment [UPSA]. Real-world work skills as measured on the Specific Level of Function Scale. Observer rated scale considering employable skills, level of supervision required to complete tasks, ability to stay on task, punctuality.) Figure 3. Predictors of real-world work skills

10.  Importance of cognition understated  Central role of cognition in skills acquisition

11. “To… foster functional recovery, it will be important to view cognitive remediation and enhancement as a platform upon which skills could be more easily taught and later generalized when facing dynamic social and occupational demands.” Bowie et al., 2008

12. “…an intervention targeting cognitive deficits (attention, memory, executive function, social cognition, or meta- cognition) using scientific principles of learning with the ultimate goal of improving functional outcomes.” Cognitive Remediation Expert Working Group, 2012

13. McGurk et al., 2013 CRT MethodologyVariations in Approach TypeRestorative (drill & practice) Strategy Compensatory Duration & intensityFrom 2-5 days/week From 4-52 weeks TechnologyPen & paper vs computer-based FormatIndividual vs Group Mix of individual & group Within wider rehabilitation program Cognitive TargetTop-down vs bottom-up processing Single vs multiple domains

14.  Meta-analyses ◦ Global cognition: Moderately effective (Cohen’s d = 0.41 1 -0.45 2 ) ◦ Cog. @ follow-up: Moderately effective (Cohen’s d = 0.43 2 ) ◦ Functioning: Moderately effective (Cohen’s d = 0.42 2 ) ◦ Funct. @ follow-up: Small-moderate (Cohen’s d = 0.37 2 ) 1 McGurk et al., 2007; 2 Wykes et al., 2011 incorporating 40 independent studies involving over 2,000 participants

15.  Success rates: 50% - 60% do not realise improvements Hodge et al., 2010; Medalia & Richardson, 2005; Vita et al., 2013 ◦ Suggestive that those who do respond, enjoy greater benefits than what is reported…

16.  Predictors of outcome: response to CRT TypeFactorSupport (Yes / No) DemographicAge Gender Education ✓ -- ✗✗✗✗✗✗ CognitiveBaseline functioning IQ trajectory ✓✓✓✓ ✗ ClinicalBaseline symptom severity Medication type/dosage ✓✓✓✓ ✗✗✗✗ Treatment engagementAttendance (no. sessions) Intensity (ave. hrs/mth) ✓✓✓✓ ✗✗✗✗ Learning PotentialTraining task progress ✓✗

17.  To increase our understanding of factors that influence the effectiveness of cognitive remediation therapy in people diagnosed with schizophrenia. ◦ More considered approach about who is referred to CRT – one size does not fit all ◦ Potential changes to CRT programs−or the way in which they are delivered−to increase the number of positive responses

18.  Computer-based, drill & practice  Individual focus but can be delivered in small groups  Bottom-up approach that incorporates training on higher order processes  Specifically targets visual learning & memory (Surti et al. 2012; est. ES: d = 0.43 * small sample size )  Specifically targets verbal learning & memory ( Fisher et al. 2009; ES: d = 0.86 and 0.89 respectively)

19. The science of learning and neuroplasticity  To optimise training outcomes, training should be: Intensive Attentionally engaging Adaptive Rewarding Adcock et al., 2009

20.  Optimises training outcomes: Intensive

21.  Optimises training outcomes: Attentionally engaging

22.  Optimises training outcomes: Adaptive

23.  Optimises training outcomes: Rewarding

24.  Flexibility  Control  Support  Potential benefits

25. 2014  Ethics approval  Select cognitive remediation therapy tool 2015-2016  Recruit participants  Facilitate cognitive remediation sessions 2017  Data analysis and dissemination of results

26. TimingDuration Pre-assessment20 minutes Participant briefing and consent 30 minutes Pre-intervention2 x 3 hour sessions 24 session visual CRT module Mid-intervention1 hour 24 session (optional) auditory CRT module Post-intervention3 hours Follow-up (12 weeks)1 hour

27.  Engagement  Attendance from 1 to 3 times per week  85% retention rate  23% committed to completing more than minimum number of sessions  Variable level of task engagement

28.  Reported improvements in aspects of cognition Concentration Processing speed Visual processing

29.  Observable improvements in aspects of cognition  Selective attention  Sustained attention

30.  Reported improvements in untrained tasks  Reconnected with old hobbies  Able to focus on writing tasks for longer periods of time  Increased confidence in social conversations

31.  Participant goals and sources of motivation  Reducing isolation  Sharpening thinking skills  Stepping stone to further training  Helping to improve the quality of life of people living with psychotic illness  Supporting research

33.  Adcock, R. A., Dale, C., Fisher, M., Aldebot, S., Genevsky, A., Simpson, G. V, … Vinogradov, S. (2009). When top- down meets bottom-up: auditory training enhances verbal memory in schizophrenia. Schizophrenia Bulletin, 35(6), 1132–1141. doi:10.1093/schbul/sbp068  Bowie, C. R., Leung, W. W., Reichenberg, A., McClure, M. M., Patterson, T. L., Heaton, R. K., & Harvey, P. D. (2008). Predicting schizophrenia patients’ real-world behavior with specific neuropsychological and functional capacity measures. Biological Psychiatry, 63(5), 505–11. doi:10.1016/j.biopsych.2007.05.022  Fisher, M., Holland, C., Merzenich, M. M., & Vinogradov, S. (2009). Using neuroplasticity-based auditory training to improve verbal memory in schizophrenia. The American Journal of Psychiatry, 166(7), 805–811. doi:10.1176/appi.ajp.2009.08050757  Heinrichs, R. W., Miles, A. A., Ammari, N., & Muharib, E. (2013). Cognition as a central illness feature in schizophrenia. In P. Harvey (Ed.), Cognitive Impairment in Schizophrenia: Characteristics, Assessment, and Treatment (pp. 1–23). Cambridge, UK: Cambridge University Press.  Hodge, M. A. R., Siciliano, D., Withey, P., Moss, B., Moore, G., Judd, G., … Harris, A. (2010). A randomized controlled trial of cognitive remediation in schizophrenia. Schizophrenia Bulletin, 36(2), 419–27. doi:10.1093/schbul/sbn102  McGurk, S. R., Mueser, K. T., Covell, N. H., Cicerone, K. D., Drake, R. E., Silverstein, S. M., … 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. Psychiatric Rehabilitation Journal, 36(3), 133–45. doi:10.1037/prj0000020  Medalia, A., & Richardson, R. (2005). What predicts a good response to cognitive remediation interventions? Schizophrenia Bulletin, 31(4), 942–53. doi:10.1093/schbul/sbi045  Morgan, V. A., Waterreus, A., Jablensky, A., Mackinnon, A., McGrath, J. J., Carr, V. J., … Saw, W. (2010). People living with psychotic illness 2010 second Australian national survey.  Nuechterlein, K. H., Green, M. F., Kern, R. S., Baade, L. E., Barch, D. M., Cohen, J. D., … Marder, S. R. (2008). The MATRICS Consensus Cognitive Battery, part 1: test selection, reliability, and validity. The American Journal of Psychiatry, 165(2), 203–13. doi:10.1176/appi.ajp.2007.07010042  Surti, T. S., & Wexler, B. E. (2012). A pilot and feasibility study of computer-based training for visual processing deficits in schizophrenia. Schizophrenia Research, 142(1-3), 248–249. doi:10.1016/j.schres.2012.09.013  Vita, A., Deste, G., De Peri, L., Barlati, S., Poli, R., Cesana, B. M., & Sacchetti, E. (2013). Predictors of cognitive and functional improvement and normalization after cognitive remediation in patients with schizophrenia. Schizophrenia Research, 150(1), 51–57. doi:10.1016/j.schres.2013.08.011  Wykes, T., Huddy, V., Cellard, C., McGurk, S. R., & Czobor, P. (2011). A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. The American Journal of Psychiatry, 168(5), 472–85. doi:10.1176/appi.ajp.2010.10060855