1. Cognitive Interventions for Schizophrenia: Compensatory and Restorative Approaches
Sean Kidd, Ph.D.
CAMH Schizophrenia Division
University of Toronto Department of Psychiatry
December 1st, 2014

2. 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

3. presentation overview: a tale of two approaches
What is promising
What is problematic
What is next

4. some general background
Tools are available for addressing positive symptoms (delusions, hallucinations).
But, we have little to offer for cognitive impacts and negative symptoms

5. cognitive impacts
Attention
Memory
Problem Solving
Social Cognition

6. what to do about it?

7. 1. enhance Practice cognitive tasks
A variable literature (types of tasks, adjunct intervention)
Linking to “real world” contexts and challenges important

8. 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

9. 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

10. an example – George Brown College
Built into academic curriculum
Group and individual computer exercises

11. matching with McGurk

13. 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.

14. 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

15. 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. ( )

16. challenges and what comes next
Bang for the buck and seeing evidence through the hype
Dismantling
Better screening
Better bridging and focus
Considering setting

17. Compensatory Approaches

18. Compensatory Approaches
Some overlap, but emphasize:
Compensatory strategy rather than improving function
Home and non-treatment/education contexts

19. cognitive adaptation training (CAT) - described
Focus primarily on medication taking and basic functional domains
Builds from assessment
Intensive – typically 9 months

20. 2. adapt - cognitive adaptation training

22. 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

24. 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

25. the outcomes It worked, people liked it
Symptoms: BPRS ; NSA
Functioning:

26. the challenges
Bedbugs
Time and travel

27. next steps
Family CAT
Inpatient CAT

28. where do we go from here?

29. 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

30. 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., 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