Exploring the role of age as a moderator of cognitive remediation for people with schizophrenia.

BACKGROUND: While Cognitive Remediation (CR) is effective in reducing cognitive and functioning difficulties in people with schizophrenia, there is variability in treatment response. Previous research suggested that participants' age may be a significant moderator of CR response. AIM: To examine the impact of participants' age on CR outcomes. METHOD: Individual participant data were accessed from fourteen CR randomised controlled trials. We tested the moderating effect of participants' age on cognitive and functioning outcomes using multivariate linear models. RESULTS: Data from 1084 people with a diagnosis of schizophrenia were considered. Participants had a mean age of 36.6 years (SD 11), with 11.6 years of education (SD 2.8), and an average duration of illness of 13.5 years (SD 10.7). Multivariate models showed that participants' age, when considered as a continuous variable, was not a significant moderator of treatment effect for cognitive and functioning outcomes. However, when participants were split by median age, younger participants showed higher gains in executive functions following CR compared to older participants (p=0.02). CONCLUSION: These results suggest that participants' age does not moderate most CR outcomes. However, larger age differences may influence the effect of CR on executive function. This may suggest some adaptation of CR practice according to participants' age. These findings inform the CR personalisation agenda.

Can Cognitive Remediation in Groups Prevent Relapses?: Results of a 1-Year Follow-up Randomized Controlled Trial.

International guidelines define relapse prevention for schizophrenia patients as a key therapeutic aim. However, approximately 80% to 90% of schizophrenia patients experience further symptom exacerbation after the first episode. The purpose of this study was to investigate whether group integrated neurocognitive therapy (INT), a cognitive remediation approach, reduces relapse rates in schizophrenia outpatients. INT was compared with treatment as usual (TAU) in a randomized controlled trial. Fifty-eight stabilized outpatients participated in the study with 32 allocated to the INT group and 26 to the TAU group. A test battery was used at baseline, posttreatment at 15 weeks, and a 1-year follow-up. Relapse rates were significantly lower in the INT condition compared with TAU during therapy as well as at follow-up. The relapse rate after therapy was associated with significant reductions in negative and general symptoms, improvements in functional outcome, and overall cognition. Out of these variables, negative symptoms were identified to show the strongest association with relapses after therapy. The primary outcome of this study suggests that INT can prevent relapses in schizophrenia outpatients.

Does Integrated Neurocognitive Therapy (INT) reduce severe negative symptoms in schizophrenia outpatients?

Negative symptoms often inhibit the social integration of people suffering from schizophrenia. Reducing severe negative symptoms (SNS) in a clinically relevant way is a major unmet need. The aim of this study was to investigate whether Integrated Neurocognitive Therapy (INT), a group cognitive remediation therapy (CRT), reduces SNS in schizophrenia outpatients. INT was compared with Treatment As Usual (TAU) in a randomized-controlled trial (RCT). A total of 61 SNS outpatients participated in the study, 28 were allocated to the INT group and 33 to the TAU group. A test-battery was used at baseline, post-treatment at 15weeks, and 1-year-follow-up. Remission rates of SNS after therapy were significantly higher for INT compared to TAU. A trend favoring INT was obtained at follow-up. Furthermore, INT showed significantly higher functional outcome during follow-up compared to TAU. Regarding cognition, the strongest significant effect was found in attention post-treatment. No effects between groups on more complex neurocognition and social cognition were evident. SNS outpatients seem to accept INT group intervention as suggested by the high attendance rate.

One-year randomized controlled trial and follow-up of integrated neurocognitive therapy for schizophrenia outpatients.

OBJECTIVE: Cognitive remediation (CR) approaches have demonstrated to be effective in improving cognitive functions in schizophrenia. However, there is a lack of integrated CR approaches that target multiple neuro- and social-cognitive domains with a special focus on the generalization of therapy effects to functional outcome. METHOD: This 8-site randomized controlled trial evaluated the efficacy of a novel CR group therapy approach called integrated neurocognitive therapy (INT). INT includes well-defined exercises to improve all neuro- and social-cognitive domains as defined by the Measurement And Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative by compensation and restitution. One hundred and fifty-six outpatients with a diagnosis of schizophrenia or schizoaffective disorder according to DSM-IV-TR or ICD-10 were randomly assigned to receive 15 weeks of INT or treatment as usual (TAU). INT patients received 30 bi-weekly therapy sessions. Each session lasted 90min. Mixed models were applied to assess changes in neurocognition, social cognition, symptoms, and functional outcome at post-treatment and at 9-month follow-up. RESULTS: In comparison to TAU, INT patients showed significant improvements in several neuro- and social-cognitive domains, negative symptoms, and functional outcome after therapy and at 9-month follow-up. Number-needed-to-treat analyses indicate that only 5 INT patients are necessary to produce durable and meaningful improvements in functional outcome. CONCLUSIONS: Integrated interventions on neurocognition and social cognition have the potential to improve not only cognitive performance but also functional outcome. These findings are important as treatment guidelines for schizophrenia have criticized CR for its poor generalization effects.

Integrated psychological therapy: effectiveness in schizophrenia inpatient settings related to patients' age.

OBJECTIVE: Elderly people with schizophrenia often suffer from cognitive impairments, which affect their social functioning. Today, only a few therapy approaches for middle-aged and older patients are available. The Integrated Psychological Therapy (IPT) combines neurocognitive and social cognitive interventions with social skills approaches. The aim of this study was to evaluate (1) whether IPT is effective in younger patients (age < 40 years) and middle-aged patients (age ≥ 40 years) and (2) whether control conditions (treatment as usual or unspecific group activities) reveal some change in outcome depending on age. METHOD: A total of 15 controlled IPT studies with 632 inpatients with schizophrenia were evaluated in a standard meta-analytic procedure. Studies were categorized into two age categories. RESULTS: Significant medium to large effect sizes (ES) were evident for IPT independent of age on the global cognitive score (mean score of all cognitive variables), on neurocognition, social cognition, social functioning, psychopathology, and the global therapy effect (mean of all variables). The IPT effects in middle-aged patients were significantly larger on the global cognitive score, on neurocognition, and on social cognition compared with younger patients. Opposite results could be observed in control conditions. Only younger patients participating in the control conditions showed small but significant ES on these variables, but almost middle-aged control patients did not. However, none of the differences in the control conditions were significant between the two age categories. A moderator analysis obtained no evidence for a strong impact of IPT variations, therapy setting, patient characteristics, and methodologic rigor of the research design. CONCLUSIONS: These results support evidence for the efficacy of IPT independent of age. Results further indicate the need of goal-oriented specific psychological interventions for middle-aged and older patients with schizophrenia.

[Efficacy of integrated treatments for schizophrenia patients]. / Wirksamkeit integrierter therapieansätzen bei schizophren erkrankten.

This article outlines two examples of cognitive-behavior group therapy approaches for an integrative treatment of psychosis: the Integrated Psychological Therapy (IPT) and the Integrated Neurocognitive Therapy (INT). We present their theoretical background, content and conceptualization as well as recent empirical evidence for their efficacy. The article concludes that adapting these approaches to early intervention for people with high risk of psychosis seems promising.

Effectiveness of the cognitive differentiation program of the integrated psychological therapy: group versus individual treatment.

The aim of the current pilot study was to compare two strategies in the application of the cognitive differentiation program of Integrated Psychological Therapy for people with schizophrenia. Twenty-six outpatients were randomly assigned to the application of the program in group sessions (CDg), or to its application in individualized sessions (CDi). The program provides cognitive exercises to promote better performance in cognition, and both groups of participants completed the same number of exercises following the same number of sessions per week. Outcomes were assessed on neuropsychological measures of attention, executive functioning and everyday memory, and everyday functioning. Effect sizes showed the absence of effects in everyday memory and social functioning, higher improvements in the CDi group in attention, and a higher improvement in the CDg condition in executive functioning. The results suggest that the program application model could be individualized, depending on patient-specific cognitive deficits.

Social cognition as a mediator variable between neurocognition and functional outcome in schizophrenia: empirical review and new results by structural equation modeling.

Cognitive impairments are currently regarded as important determinants of functional domains and are promising treatment goals in schizophrenia. Nevertheless, the exact nature of the interdependent relationship between neurocognition and social cognition as well as the relative contribution of each of these factors to adequate functioning remains unclear. The purpose of this article is to systematically review the findings and methodology of studies that have investigated social cognition as a mediator variable between neurocognitive performance and functional outcome in schizophrenia. Moreover, we carried out a study to evaluate this mediation hypothesis by the means of structural equation modeling in a large sample of 148 schizophrenia patients. The review comprised 15 studies. All but one study provided evidence for the mediating role of social cognition both in cross-sectional and in longitudinal designs. Other variables like motivation and social competence additionally mediated the relationship between social cognition and functional outcome. The mean effect size of the indirect effect was 0.20. However, social cognitive domains were differentially effective mediators. On average, 25% of the variance in functional outcome could be explained in the mediation model. The results of our own statistical analysis are in line with these conclusions: Social cognition mediated a significant indirect relationship between neurocognition and functional outcome. These results suggest that research should focus on differential mediation pathways. Future studies should also consider the interaction with other prognostic factors, additional mediators, and moderators in order to increase the predictive power and to target those factors relevant for optimizing therapy effects.

Effectiveness of integrated psychological therapy (IPT) for schizophrenia patients: a research update.

Standardized recovery criteria go beyond symptom remission and put special emphasis on personal and social functioning in residence, work, and leisure. Against this background, evidence-based integrated approaches combining cognitive remediation with social skills therapy show promise for improving functional recovery of schizophrenia patients. Over the past 30 years, research groups in 12 countries have evaluated integrated psychological therapy (IPT) in 36 independent studies. IPT is a group therapy program for schizophrenia patients. It combines neurocognitive and social cognitive interventions with social skills and problem-solving approaches. The aim of the present study was to update and integrate the growing amount of research data on the effectiveness of IPT. We quantitatively reviewed the results of these 36 studies, including 1601 schizophrenia patients, by means of a meta-analytic procedure. Patients undergoing IPT showed significantly greater improvement in all outcome variables (neurocognition, social cognition, psychosocial functioning, and negative symptoms) than those in the control groups (placebo-attention conditions and standard care). IPT patients maintained their mean positive effects during an average follow-up period of 8.1 months. They showed better effects on distal outcome measures when all 5 subprograms were integrated. This analysis summarizes the broad empirical evidence indicating that IPT is an effective rehabilitation approach for schizophrenia patients and is robust across a wide range of sample characteristics as well as treatment conditions. Moreover, the cognitive and social subprograms of IPT may work in a synergistic manner, thereby enhancing the transfer of therapy effects over time and improving functional recovery.

Cognitive Rehabilitation Programs in Schizophrenia: Current Status and Perspectives

This study reviews the main rehabilitation programs that have been developed to improve cognitive functioning in patients diagnosed with schizophrenia: it describes their main components and procedures and highlights the most relevant outcomes of each one. Additionally, it highlights which lead to subsequent improvement in social functioning. Cognitive rehabilitation is now being commonly included in treatment of schizophrenic patients with cognitive impairment or cognitive deficit. Hence, it is very important to have empirical data on the efficacy of these programs, data which is not always readily available in current literature (AU)

Este artículo presenta una revisión de los principales programas que se han desarrollado para la mejora del funcionamiento cognitivo en los pacientes con diagnóstico de esquizofrenia. Se describen sus principales componentes, la manera de proceder de cada uno de ellos y sobre que aspectos muestran efectos positivos. Se indica además cuales presentan una mayor relación con la mejora posterior en el funcionamiento social. El entrenamiento cognitivo está pasando a formar parte, de manera habitual, de las de intervenciones que se llevan a cabo con pacientes que presentan déficit o deterioro cognitivo, que son la mayor parte de ellos. Por ello son muy importante los datos empíricos sobre la eficacia de los programas, y no siempre podemos encontrar en la literatura esta información (AU)

[Evaluation of the "Schema-focused Emotive Behavioural Therapy" (SET) for patients with personality disorders: results of a randomised controlled trial]. / Evaluation der "Schemazentrierten emotiv-behavioralen Therapie" (SET) für Patienten mit Persönlichkeitsstörungen: Ergebnisse einer randomisierten Untersuchung.

The "Schema-focussed Emotive Behavioral Therapy" (SET) was developed by our research group as a new group therapy approach for patients with personality disorders from all clusters (A to C; DSM-IV). It was evaluated in a randomised controlled study (n = 93). Data were collected before and after treatment as well as one year after study entry. A completer analysis was conducted with matched subgroups (n = 60). After therapy, SET patients improved in the outcome domains interactional behavior, strain, and symptomatic complaints (IIP-D, GAF, VEV-VW, BSI-P). Furthermore, they showed a significant lower dropout rate. At the follow-up assessment, Cluster C patients of the experimental group deteriorated with regard to symptomatic complaints (BSI-P). In contrast, cluster B patients improved more over time compared to control subjects. SET seems to be an adequate and effective group therapy with effects that seem to be stable over time, especially for patients with Cluster B diagnosis.

[Emotion activation in personality disorders]. / Activation émotionnelle chez les troubles de personnalité.

There are at least six psychotherapeutic treatments of personality disorders having received empirical and clinical validation in terms of their efficacy. These treatments are based on different theoretical models, namely the cognitive-behavioural, psychodynamic and interpersonal models. This article briefly presents these treatments, focusing on the process of therapeutic change. It is assumed that the process of emotional activation is one of the most interesting theoretical psychotherapy ingredient in treatments of these patients. The treatments are discussed regarding this hypothesis and its clinical implications.

Social perception training in schizophrenia: a pilot study

Uno de los factores cognitivos deteriorados en esquizofrénicos es la cognición social. Elobjetivo de este estudio ha sido investigar la mejora de la percepción social, uno de loscomponentes clave de la cognición social, en pacientes crónicos. Dieciocho pacientes externoscon diagnóstico de esquizofrenia fueron aleatoriamente asignados al grupo controly al grupo que recibía la intervención. Los pacientes en el grupo de tratamiento recibieronentrenamiento en el subprograma de percepción social de la IPT. El desempeño de lospacientes en percepción social fue evaluado antes de la intervención, después de la intervencióny tras un periodo de seis meses de seguimiento, utilizando una escala que habíasido desarrollada específicamente para evaluar percepción social (Social Perception Scale-SPS). Los resultados indican que la escala puede diferenciar entre el grupo que ha recibidola intervención y el grupo control. También fueron evaluadas la atención, la psicopatologíay el funcionamiento social. A pesar del pequeño número de pacientes los resultados sonprometedores y sugieren mejoras en las habilidades de percepción social (identificación deestímulos, interpretación y resumen de la información de una fotografía) en los pacientesentrenados con el programa de la IPT respecto a los pacientes del grupo control(AU)

Social cognition has been recognized as one of the key cognitive factors that is impairedin schizophrenia. The aim of this study was to investigate the possibility of improvementsin social perception, which is a key component of social cognition, in chronically ill patients.Eighteen schizophrenic outpatients were randomly assigned to therapy and control groups.The patients in the therapy group followed the social perception subprogram of IPT. Thepatients‘ performance in social perception was assessed before the intervention, after theintervention and at the end of a six-month follow-up period, using a scale that was specificallydeveloped to assess social perception (Social Perception Scale –SPS). The results indicatethat it can differentiate between the group that followed the therapy program and the controlgroup. Attention, psychopathology and social functioning were also evaluated. Althoughonly a small group of patients participated in the study, the results are promising. Theysuggest improvements in the social perception abilities that were trained using the IPTprogram in the therapy group in comparison with the control group. The patients in thetherapy group improved their ability to identify stimuli and to interpret and summariseinformation in a picture(AU)

Integrated psychological therapy (IPT) for schizophrenia: is it effective?

Against the background of evidence-based treatments for schizophrenia, nowadays the implementation of specific cognitive and behavioral interventions becomes more important in the standard care of these patients. Over the past 25 years, research groups in 9 countries have carried out 30 independent evaluations of Integrated Psychological Therapy (IPT), a group program that combines neurocognitive and social cognitive interventions with social skills approaches for schizophrenic patients. The aim of the present study was to evaluate the effectiveness of IPT under varying treatment and research conditions in academic and nonacademic sites. In a first step, all 30 published IPT studies with the participation of 1393 schizophrenic patients were included in the meta-analysis. In a second step, only high-quality studies (HQS) (7 studies including 362 patients) were selected and analyzed to check whether they confirmed the results of the first step. Positive mean effect sizes favoring IPT over control groups (placebo-attention conditions, standard care) were found for all dependent variables, including symptoms, psychosocial functioning, and neurocognition. Moreover, the superiority of IPT continued to increase during an average follow-up period of 8.1 months. IPT obtained similarly favorable effects across the different outcome domains, assessment formats (expert ratings, self-reports, and psychological tests), settings (inpatient vs outpatient and academic vs nonacademic), and phases of treatment (acute vs chronic). The HQS confirmed the results of the complete sample. The analysis indicates that IPT is an effective rehabilitation approach for schizophrenia that is robust across a wide range of patients and treatment conditions.