Personalized cognitive remediation therapy to facilitate return to work or to school in recent-onset psychosis.

Cognitive deficits are barriers to job acquisition or return to school, and can be reduced through Cognitive remediation therapy (CRT). The main goal of this multiple case study was to investigate the effect of personalized CRT on occupational status in three participants with a recent-onset psychosis. Two cases improved their occupational status at post-treatment, and showed improvements in cognitive, psychological, and/or clinical variables. This study suggests that personalized CRT may facilitate job acquisition or return to school. However, the different pathways showed by our cases indicate that personalized CRT may influence occupational status through multiple mechanisms, underlining the relevance of treatment personalization.

Common transdiagnostic cognitive deficits among people with psychiatric disorders exposed to childhood maltreatment: a meta-analysis.

INTRODUCTION: Previous meta-analyses have shown a moderate negative impact of maltreatment on the neuropsychological functioning of people with or without psychiatric disorders compared to healthy groups. The objectives of the present meta-analysis were to (1) investigate the impact of maltreatment on neuropsychological functioning of people with psychiatric disorders and to (2) evaluate the moderating effect of age, at the time of the cognitive assessment, on neuropsychological functioning. METHODS: Seventeen studies published between 1970 and July 2017 were included. RESULTS: The results showed a negative impact of maltreatment with a small effect size (g = -0.25) on the neuropsychological performances in the group with psychiatric disorders with a history of exposure to childhood maltreatment compared to the group with psychiatric disorders without a history of exposure to childhood maltreatment. Cognitive domains that are significantly affected by maltreatment are: working memory (g = -0.56), verbal episodic memory (g = -0.39), intelligence (g = -0.27) and processing speed (g = -0.21). The impact of childhood maltreatment on the cognitive profile is greater in adults than young people. CONCLUSIONS: Clinicians should consider these common cognitive deficits using a transdiagnostic approach in cognitive interventions.

A feasibility study of a new computerised cognitive remediation for young adults with schizophrenia.

Cognitive remediation therapy is effective for improving cognition, symptoms and social functioning in individuals with schizophrenia; however, the impact on visual episodic memory remains unclear. The objectives of this feasibility study were: (1) to explore whether or not CIRCuiTS--a new computerised cognitive remediation therapy programme developed in England--improves visual episodic memory and other cognitive domains in young adults with early course schizophrenia; and (2) to evaluate acceptability of the CIRCuiTS programme in French-Canadians. Three participants with visual episodic memory impairments at baseline were recruited from clinical settings in Canada, and consented to participate. Neuropsychological, clinical and social functioning was evaluated at baseline and post-treatment. Intervention involved 40 sessions of cognitive remediation. First, the reliable change index (RCI) revealed that each participant demonstrated significant post-therapy change in episodic memory and in other cognitive domains. The response profile was characterised by the use of organisational strategies. Second, the treatment was considered acceptable to participants in terms of session frequency (number of sessions per week), intensity (hours per week; total hours), and number of missed sessions and total completed sessions. This preliminary study yielded encouraging data demonstrating the feasibility of the CIRCuiTS programme in French-Canadian young adults with schizophrenia.

A systematic review on improving cognition in schizophrenia: which is the more commonly used type of training, practice or strategy learning?

BACKGROUND: The purpose of this article was to conduct a review of the types of training offered to people with schizophrenia in order to help them develop strategies to cope with or compensate for neurocognitive or sociocognitive deficits. METHODS: We conducted a search of the literature using keywords such as "schizophrenia", "training", and "cognition" with the most popular databases of peer-reviewed journals. RESULTS: We reviewed 99 controlled studies in total (though nine did not have a control condition). We found that drill and practice training is used more often to retrain neurocognitive deficits while drill and strategy training is used more frequently in the context of sociocognitive remediation. CONCLUSIONS: Hypotheses are suggested to better understand those results and future research is recommended to compare drill and strategy with drill and practice training for both social and neurocognitive deficits in schizophrenia.

Assessing the fidelity of supported education programs for first-episode psychosis to the supported employment guidelines adapted for education.

INTRODUCTION: Psychotic disorders are associated with academic difficulties. Supported Employment Program (SEP) guidelines have become the gold standard to improve occupational functioning in psychotic disorders. More recently, these guidelines have been adapted to education. In Canada, several community organizations and hospital programs offer supported education to young people with psychotic disorders. However, SEP guidelines are not systematically used. The objective of this study was to assess the fidelity of 6 Canadian (Quebec) organizations offering supported education services to young people with psychotic disorders to the SEP guidelines adapted to education. METHODS: Six sites offering educational services to young people with psychotic disorders were recruited. Semi-structured interviews were conducted with one supported education professional and one manager of each site, using the Quality of Supported Education Implementation Scale (QSEDIS). This new scale has been developed from the Quality of Supported Employment Implementation Scale. The QSEDIS assesses the fidelity of the quality of the implementation of supported education programs, using three subscales (Employees, Organization and Services). RESULTS: Acceptable fidelity scores were observed in the three QSEDIS subscales for all six sites combined. The Services subscale received the highest score of fidelity (4.4/5), followed by the Supported Education Employee (4.1/5) and the Organization (3.7/5). CONCLUSION: The results suggest that supported education services offered to young people with psychotic disorders in the six sites are generally consistent with SEP guidelines adapted to education. Further research is warranted to validate whether acceptable SEP guidelines fidelity according to the QSEDIS translates into educational outcomes.

Associations between theory of mind and clinical symptoms in recent onset schizophrenia spectrum disorders.

Introduction: People with schizophrenia often present with Theory of mind (ToM) deficits, and the link between these deficits and clinical symptoms remains to be refined, for instance through the use of more recent assessment methods. The objective of this study was to examine the associations between a psychometrically sound ToM task and the clinical symptoms of schizophrenia as measured with the five dimensions of the Positive and Negative Syndrome Scale (PANSS) namely positive, negative, cognitive/disorganization, depression/anxiety and excitability/hostility, while controlling for non-social cognitive abilities. Methods: Seventy participants with recent-onset schizophrenia spectrum disorders (SSD) were assessed for ToM using the Combined stories task (COST) and for clinical symptoms using the PANSS. Results: The results revealed significant correlations between ToM and the positive (r = -0.292, p = 0.015) and cognitive/disorganization (r = -0.480, p < 0.001) dimensions when controlling for non-social cognitive abilities. In contrast, the negative symptoms dimension was only significantly correlated with ToM when non-social cognitive abilities were not controlled for (r = -0.278, p = 0.020). Discussion: Very few prior studies used the five-dimensions of the PANSS to examine the link with ToM and this study is the first to rely on the COST, which includes a non-social control condition. This study highlights the importance of taking non-social cognitive abilities into account when considering the relationship between ToM and symptoms.

What areas of everyday functioning are affected by theory of mind deficits in recent-onset schizophrenia spectrum disorders?

AIM: Functional recovery is now a recognized treatment goal for schizophrenia. It is therefore important to better understand the cognitive and psychological factors that influence functioning. Theory of mind (ToM) deficits are common in schizophrenia and have been linked to greater impairments in functioning. The current study aimed to identify which specific areas of functioning are linked to ToM in a group of 54 patients with a recent-onset of a schizophrenia spectrum disorder. METHODS: ToM was assessed with the Combined Stories Test (COST). Several areas of functioning were rated based on an extensive semi-structured interviews. RESULTS: Among the different areas of functioning that were examined, ToM showed a significant, positive relationship with ratings for productive activities (e.g. work or school) as well as with collaboration to psychiatric care. CONCLUSION: These results suggest that ToM can impair functioning especially in situations in which patients need to collaborate with others, including the interactions with the clinical team.

For a structured response to the psychosocial consequences of the restrictive measures imposed by the global COVID-19 health pandemic: the MAVIPAN longitudinal prospective cohort study protocol.

INTRODUCTION: The COVID-19 pandemic and associated restrictive measures have caused important disruptions in economies and labour markets, changed the way we work and socialise, forced schools to close and healthcare and social services to reorganise. This unprecedented crisis forces individuals to make considerable efforts to adapt and will have psychological and social consequences, mainly on vulnerable individuals, that will remain once the pandemic is contained and will most likely exacerbate existing social and gender health inequalities. This crisis also puts a toll on the capacity of our healthcare and social services structures to provide timely and adequate care. The MAVIPAN (Ma vie et la pandémie/ My Life and the Pandemic) study aims to document how individuals, families, healthcare workers and health organisations are affected by the pandemic and how they adapt. METHODS AND ANALYSIS: MAVIPAN is a 5-year longitudinal prospective cohort study launched in April 2020 across the province of Quebec (Canada). Quantitative data will be collected through online questionnaires (4-6 times/year) according to the evolution of the pandemic. Qualitative data will be collected with individual and group interviews and will seek to deepen our understanding of coping strategies. Analysis will be conducted under a mixed-method umbrella, with both sequential and simultaneous analyses of quantitative and qualitative data. ETHICS AND DISSEMINATION: MAVIPAN aims to support the healthcare and social services system response by providing high-quality, real-time information needed to identify those who are most affected by the pandemic and by guiding public health authorities' decision making regarding intervention and resource allocation to mitigate these impacts. MAVIPAN was approved by the Ethics Committees of the Primary Care and Population Health Research Sector of CIUSSS de la Capitale-Nationale (Committee of record) and of the additional participating institutions. TRIAL REGISTRATION NUMBER: NCT04575571.

The role of recollection in source memory: an examination of schizophrenia patients and their first-degree relatives.

Source recognition memory deficits have repeatedly been observed in people with schizophrenia (SZ), and have also recently been observed in their first-degree relatives. These deficits have been hypothesized to result, at least in part, from impairments in the conscious recollection process. Although other processes are clearly also affected in SZ, it has been proposed that impairments in the conscious recollection process could be a parsimonious explanation for the source memory deficits observed in their relatives. Here, we tested 25 patients with SZ and 34 of their non-affected parents, as well as two groups of matched healthy controls, on a short-term associative memory task that shares the characteristics of standard source recognition tasks but minimizes the need for recollection of stored information from memory. This task was administered in order to determine if deficits can still be observed in these people when involvement of the conscious recollection process is minimized. We observed deficits on our short-term source memory task in people with SZ, but their first-degree relatives did not share this deficit. These results support the idea that multiple memory processes supporting associative/source memory are affected in SZ, whereas the source memory deficits previously observed in relatives of SZ seem specific to tasks that rely on the conscious recollection process.

Functional Impairments and Theory of Mind Deficits in Schizophrenia: A Meta-analysis of the Associations.

Schizophrenia is associated with major functioning difficulties. Theory of mind (ToM), the ability to infer the mental states of others, is an important determinant of functioning. However, the contribution of ToM to each specific domain of functioning remains to be better understood. The objectives of this meta-analysis were to document and compare the magnitude of the associations between ToM and (1) different domains of functioning (social functioning, productive activities, and instrumental activities of daily living), each assessed separately for functional performance and functional outcome and (2) different aspects of functioning (functional performance and functional outcome) in schizophrenia. Fifty-nine studies (N = 4369) published between 1980 and May 2019 targeting patients with schizophrenia or schizoaffective disorder aged between 18 and 65 years old were included. Studies were retrieved from seven databases. Correlations were extracted from the articles, transformed into effect sizes Zr and combined as weighted and unweighted means. The strength of the associations between the domains and aspects of functioning were compared using focused tests. A moderate association was observed between ToM and all domains of functioning, with a stronger association between ToM and productive activities compared with social functioning (only for functional outcome [χ2(2) = 6.43, P = 0.040]). Regarding the different aspects of functioning, a stronger association was observed between ToM and functional performance, compared with functional outcome, for overall functioning (χ2(1) = 13.77, P < 0.001) and social functioning (χ2(1) = 18.21, P < 0.001). The results highlight a stronger association of ToM with productive activities and with functional performance, which should be considered in future studies to improve functional recovery in schizophrenia.

[Issues Surrounding Work and School Reintegration for People in the Early Stages of a Psychotic Disorder]. / La réinsertion professionnelle et le retour aux études chez les personnes en début d'évolution d'un trouble psychotique.

Introduction Socio-professional reintegration is an objective that is regularly sought-after by people in the early stages of a psychotic disorder. Despite this, employment rates are low for this population and high school dropout rates remind at a high level. Objectives and method This literature synthesis based on recent meta-analyses and studies aims at presenting the determinants of vocational and school integration for people in the early stages of a psychotic disorder. This will be followed by the presentation of the most studied supported employment and education programs, as well as by complementary interventions to support existing programs. In addition, key concepts are illustrated through clinical vignettes for this clientele. Results. Several barriers to socio-professional reintegration in this population could help explain the lower success rates when compared to the general population, including individual factors (e.g., past employment history, length of absence from the labour market, negative and cognitive symptoms, motivation) and environmental factors (e.g., availability of supported employment or education programs, competence of the employment specialist, social assistance benefits, employer attitude). The program that shows the most accumulated evidence is called Individual Placement and Support (IPS) and is frequently used in Quebec. IPS focuses on competitive job search, rapid placement in the labour market and collaboration between an employment specialist, the client, and the employer. Mowbray's supported education programs, as well as IPS adapted for education, help respond more specifically to the needs of people in the early stages of a psychotic disorder, who often wish to return to school. This article describes two clinical examples of programs offered in Quebec. Despite the interesting results provided by supported programs, socio-professional reintegration and maintaining employment remain difficult for people who are in the early stages of a psychotic disorder. Considering this, several researchers suggest that interventions for people with psychotic disorders should be more individualized, given the great heterogeneity associated with this condition. Combining interventions that are specific to each candidate's pre-existing individual deficits (e.g., cognitive remediation, cognitive-behavioural therapy, social skills training) appears to be an effective solution for optimizing the therapeutic response in supported employment or education programs. Conclusion This article highlights the issues related to the professional or academic reintegration of people in the early stages of a psychotic disorder, in order to guide practitioners in the field and to offer possible solutions to the current limitations of these programs in Quebec, including access to certain interventions.

[Psychosocial Interventions for People with a First-Episode Psychosis: A Narrative and Critical Review]. / Les interventions psychosociales destinées aux personnes composant avec un premier épisode psychotique : une revue narrative et critique.

Objective Treatment guidelines for the treatment of psychotic disorders suggest evidence-based interventions. These interventions target several domains such as self-management of clinical symptoms, social, familial and love relationships as well as cognitive functioning. However, these general guidelines do not provide specific evidence for people with a first-episode psychosis (FEP). The objective of this narrative and critical review is to present evidence supporting the interventions suggested by the treatment guidelines that were validated in people with a FEP, particularly those interventions validated in French. Method Based on the international and national treatment guidelines, a narrative and critical review of the scientific literature conducted in people with FEP and focusing on two recommended interventions for psychotic disorders, cognitive-behavioral therapy for psychosis (CBTp) and cognitive remediation (CR), was performed. Administration modalities adapted to the participant's profile are important to consider in this type of intervention. We thus explored two promising modalities in people with FEP, the group format and the use of digital technologies. Results Several studies support the use of CBTp in people with FEP, including one Quebec study. The effects of CR are less promising in people with FEP compared to those with a chronic evolution of their psychotic illness (e.g. schizophrenia). However, some limitations of the included studies are identified and the specific improvements in people with FEP are presented. Regarding the group format and the digital technologies, most interventions currently available need to be systematically validated, and the results need to be replicated by other groups of researchers to obtain evidence-based results. Conclusion This narrative and critical review of the literature highlights the evidence available for CBTp and CR in people with FEP. The group format used in several interventions with this population reveals encouraging results, while interventions using digital technologies have shown their acceptability and feasibility, but the efficacy remains to be assessed. In addition to contributing to symptomatic recovery, psychosocial interventions also support functional and personal recovery in people with FEP. Nonetheless, some limitations are observed regarding the accessibility of such interventions. While some interventions are currently not available in French, other available evidence-based interventions are not currently systematically used in clinical settings. These limitations call for the importance of developing an implementation science for these interventions to improve the transfer of results from research to clinical settings as well as a service organization model that promote or facilitate access to such interventions.

PLAN-e-PSY, a mobile application to improve case management and patient's functioning in first episode psychosis: protocol for an open-label, multicentre, superiority, randomised controlled trial.

INTRODUCTION: The prognosis of first episode psychosis (FEP), which is a severe disorder, can be notably impaired by patients' disengagement from healthcare providers. Coordinated specialty care with case management is now considered as the gold standard in this population, but there are still challenges for engagement with subsequent functional impairments. Youth-friendly and patient-centred clinical approaches are sought to improve engagement in patients with FEP. Mobile applications are widely used by young people, including patients with FEP, and can increase the youth friendliness of clinical tools. We hypothesise that a co-designed mobile application used during case management can improve functioning in patients with FEP as compared with usual case management practices. METHODS AND ANALYSIS: A mobile case management application for planning and monitoring individualised care objectives will be co-designed with patients, caregivers and health professionals in a recovery-oriented approach. The application will be compared with usual case management practices in a multicentre, two-arm and parallel groups clinical trial. Patients will be recruited by specialised FEP teams. Impact on functioning will be assessed using the Personal and Social Performance Scale; the variation between baseline and 12 months in each group (control and active) will be the primary outcome. ETHICS AND DISSEMINATION: This study has been approved by the Inserm Institutional Review Board IRB00003888 (Comité d'évaluation éthique de l'INSERM, reference number 20-647). The results of the study will be published in a peer-reviewed journal and presented at national and international conferences. We will also communicate the results to patients and family representatives' associations. An optimised version of the application will be then disseminated through the French FEP network (Transition Network). TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT04657380.

Familiarity and recollection processes in patients with recent-onset schizophrenia and their unaffected parents.

Episodic memory deficits are present in patients with schizophrenia (SZ) and their unaffected relatives and could be considered as a cognitive indicator of genetic vulnerability to SZ. The present study, involving patients with SZ as well as their parents, used experimental tasks specifically designed to disentangle the contribution of familiarity and recollection processes to episodic memory. The performance of patients with SZ (n=26) and their unaffected parents (n=35) was compared with that of healthy control groups matched on socio-demographic variables (controls of patients, n=26; controls of parents, n=35) on two memory tasks assessing recollection and familiarity. The first task was designed to investigate item recognition and memory for item-spatial context associations whereas the second targeted item-item associations. The results revealed an overall episodic memory deficit in patients with SZ, encompassing both familiarity and recollection, while unaffected parents showed a dysfunction restricted to the recollection process. Our study highlights differences and similarities in the source of the episodic memory deficit found in patients with SZ and their unaffected parents, and it suggests that recollection could act as a cognitive endophenotype of SZ. The results also suggest that use of experimental tasks represents a promising method in the search of cognitive endophenotypes in SZ.

The effects of acute nicotine administration on cognitive and early sensory processes in schizophrenia: a systematic review.

Nicotine use, which is mostly done through smoking tobacco, is among the most burdensome comorbidities of schizophrenia. However, the ways in which nicotine affects the cognitive and early sensory alterations found in this illness are still debated. After conducting a systematic literature search, 29 studies were selected. These studies involve individuals with schizophrenia who underwent cognitive and/or early sensory function assessments after acute nicotine administration and include 560 schizophrenia subjects and 346 non-schizophrenia controls. The findings highlight that a single dose of nicotine can improve a range of cognitive functions in schizophrenia subjects, such as attention, working memory, and executive functions, with attention being the most responsive domain. In addition, nicotine can modulate early detection of changes in the sensory environment at both the auditory and visual levels. Nevertheless, effects vary strongly depending on the type of neuropsychological assessment and nicotine intake conditions used in each study. The current findings suggest the need to consider a potential decrease of cognitive and early sensory performance when patients with schizophrenia quit smoking.

A meta-analysis of the associations between theory of mind and neurocognition in schizophrenia.

Theory of mind (ToM) refers to the ability to infer the mental states of others. ToM is impaired in schizophrenia and these deficits seem to hinder functional recovery. ToM is thus an important, but complex treatment target, supported by several processes. A large number of studies report significant associations between ToM and neurocognition (e.g. memory, attention), but the neurocognitive domains that are most closely linked to ToM remain to be identified. A meta-analysis was conducted to estimate the magnitude of the associations between ToM and neurocognition in people with schizophrenia. Correlations were extracted from the relevant literature, transformed into effect sizes Zr and pooled as weighted means. Focused-tests were employed to test for differences between neurocognitive domains and for differences linked to the characteristics of ToM tasks. Ninety-one studies (N = 5462) were included. Moderate associations emerged between ToM and each neurocognitive domain (Zrs 0.27-0.43), with no significant difference between domains (χ2(8) = 11.89, p = 0.156). Within the domain of executive functions, abstraction showed a stronger association with ToM (χ2(4) = 18.93, p = 0.001). Several ToM tasks characteristics (e.g. modality of stimuli, type of mental state), were significantly related to the magnitude of the associations between ToM and executive functions, visuospatial/problem solving, attention and episodic memory. These results suggest that ToM is linked to a wide range of neurocognitive abilities in schizophrenia, and that ToM tasks are a significant moderator of these associations. The assessment and treatment of ToM should consider the neurocognitive profile of each patient to understand his difficulties and to tailor interventions.

Insights from the examination of verbal and spatial memory errors in relation to clinical symptoms of patients with recent-onset schizophrenia.

INTRODUCTION: Memory deficits in patients with schizophrenia (SZ) are considered as a key feature of the clinical manifestations of the disease. In order to further examine the role and nature of memory deficits in SZ, the pattern of errors in verbal and spatial serial recall tasks committed by SZ patients was compared to that of healthy controls. We also tested the relationship between these memory errors and clinical symptoms. METHODS: Twenty-seven outpatients with recent-onset SZ and 27 age and gender matched healthy controls had to remember sequences of items (digits or localisations) in a serial recall task. Clinical symptoms were assessed with the PANSS and the SAPS. RESULTS: The results indicate that the number of omissions, intrusions, and transpositions can differentiate patients with SZ from healthy controls. Intrusions and transpositions committed in the verbal domain were associated with the negative subscale of the PANSS. Transposition errors were associated with delusions whether the to-be-remembered information was verbal or spatial. CONCLUSION: The examination of the pattern of errors, in particular that of transpositions, is a more informative cognitive index than the mere analysis of overall performance, and provides a promising target for treatment.

Determinants of occupational outcome in recent-onset psychosis: The role of cognition.

Working or studying is a common goal among people with recent-onset psychosis. Cognitive deficits have been reported to influence occupational outcome, but to date few studies have evaluated if cognitive deficits independently predict occupational outcome when taking into account other important determinants, such as self-esteem, motivation, length of time absent from employment/school, job/school search behaviours, subjective cognitive complaints and psychotic symptoms. Hence, this longitudinal study aimed to evaluate the role of cognition, as well as other key factors relevant to occupational outcome, to predict occupational status six months after baseline in people with recent-onset psychosis. A total of 27 participants receiving treatment in rehabilitation programs were included in the study. Neuropsychological, psychological, clinical and occupational measures were administered at baseline, and occupational status was collected six months later. Ordinal regression indicated that working memory and length of time absent from employment/school at baseline predicted 48.1% of the variance of occupational status at six months, with both variables showing a unique significant contribution to the model. These results suggest that working memory could be integrated in comprehensive models of occupational outcome in people with recent-onset psychosis. In addition, supported employment and education programs could target cognitive deficits and length of time absent from employment/school to help these individuals to acquire a job or return to school given their strong predictive value on occupational outcome.

Reliability of two social cognition tests: The combined stories test and the social knowledge test.

Deficits in social cognition are common in psychiatric disorders. Validated social cognition measures with good psychometric properties are necessary to assess and target social cognitive deficits. Two recent social cognition tests, the Combined Stories Test (COST) and the Social Knowledge Test (SKT), respectively assess theory of mind and social knowledge. Previous studies have shown good psychometric properties for these tests, but the test-retest reliability has never been documented. The aim of this study was to evaluate the test-retest reliability and the inter-rater reliability of the COST and the SKT. The COST and the SKT were administered twice to a group of forty-two healthy adults, with a delay of approximately four weeks between the assessments. Excellent test-retest reliability was observed for the COST, and a good test-retest reliability was observed for the SKT. There was no evidence of practice effect. Furthermore, an excellent inter-rater reliability was observed for both tests. This study shows a good reliability of the COST and the SKT that adds to the good validity previously reported for these two tests. These good psychometrics properties thus support that the COST and the SKT are adequate measures for the assessment of social cognition.

Improving Theory of Mind in Schizophrenia by Targeting Cognition and Metacognition with Computerized Cognitive Remediation: A Multiple Case Study.

Schizophrenia is associated with deficits in theory of mind (ToM) (i.e., the ability to infer the mental states of others) and cognition. Associations have often been reported between cognition and ToM, and ToM mediates the relationship between impaired cognition and impaired functioning in schizophrenia. Given that cognitive deficits could act as a limiting factor for ToM, this study investigated whether a cognitive remediation therapy (CRT) that targets nonsocial cognition and metacognition could improve ToM in schizophrenia. Four men with schizophrenia received CRT. Assessments of ToM, cognition, and metacognition were conducted at baseline and posttreatment as well as three months and 1 year later. Two patients reached a significant improvement in ToM immediately after treatment whereas at three months after treatment all four cases reached a significant improvement, which was maintained through 1 year after treatment for all three cases that remained in the study. Improvements in ToM were accompanied by significant improvements in the most severely impaired cognitive functions at baseline or by improvements in metacognition. This study establishes that a CRT program that does not explicitly target social abilities can improve ToM.