Cognitive Remediation and Psychosocial Rehabilitation for Individuals with Severe Mental Illness

Objective . The e ﬀ ectiveness of an individualized and everyday approach to cognitive rehabilitation for schizophrenia was examined in a case study. Method . After cognitive and functional assessment, concrete objectives were targeted for the person’s everyday complaints. Strategies were constructed based on an analysis of the cognitive proﬁle, daily life functioning, and processes involved in activities. They included a memory strategy for reading, a diary to compensate memory di ﬃ culties, and working memory exercises to improve immediate processing of information when reading and following conversations. E ﬃ cacy was assessed with outcome measures. Results . The program had beneﬁcial e ﬀ ects on the person’s cognitive and everyday functioning, which persisted at a 3-year follow-up. Conclusion . Findings provide suggestive evidence that an individualized and everyday approach may be a useful alternative in order to obtain a meaningfully lasting transfer of training to daily life, compared to the nomothetic ones which dominate the ﬁeld. Cognitive remediation therapies seem to ameliorate cognitive impairments in patients with schizophrenia. Interestingly, some improvement in daily functioning can also be expected as a result. However, to achieve these results it is necessary that cognitive remediation is carried out in the context of broader psychosocial rehabilitation involving the learning of other communication, social, and self-control skills. Unfortunately, little is known about how to integrate these di ﬀ erent rehabilitation tools in broader rehabilitation programs. Based on both the neurocognitive behavioral approach and the action theory framework, a hierarchical ﬂowchart is represented in this paper to integrate CRT with other evidence-based psychological therapies in outpatient settings. Finally, some evidence is provided in which cognitive abilities need to be targeted in remediation programs to improve functioning. In summary, to improve daily functioning, according to these studies, cognitive remediation needs to include the teaching of some cognitive strategies that target executive skills. to supported employment programs and workforce reentry, through implementation of the Health Optimisation Program for Employment (HOPE). Such programs assist with gaining and maintaining employment. However, they do not address the cognitive issues that often prevent persons with SMI from e ﬀ ectively participating in work. Thus, optimising current interventions, with work-focused cognitive skills development is critical to enhancing employment rates that remain low for persons with SMI. E ﬀ orts to use cognitive remediation in psychosocial intervention for schizophrenia have increasingly incorporated social cognition as a treatment target. A distinction can be made in this work between “broad-based” interventions, which integrate social cognitive training within a multicomponent suite of intervention techniques and “targeted” interventions; which aim to enhance social cognition alone. Targeted interventions have the potential advantage of being more e ﬃ cient than broad-based interventions; however, they also face di ﬃ cult challenges. In particular, targeted interventions may be less likely to achieve maintenance and generalization of gains made in treatment. A novel potential solution to this problem is described which draws on the social psychological literature on social cognition. Topic . Additional interventions used to enhance the e ﬀ ectiveness of individual placement and support (IPS). Aim . To establish whether additional interventions improve the vocational outcomes of IPS alone for people with severe mental illness. Method . A rapid evidence assessment of the literature was conducted for studies where behavioural or psychological interventions have been used to supplement standard IPS. Published and unpublished empirical studies of IPS with additional interventions were considered for inclusion. Conclusions . Six published studies were found which compared IPS alone to IPS plus a supplementary intervention. Of these, three used skills training and three used cognitive remediation. The contribution of each discrete intervention is di ﬃ cult to establish. Some evidence suggests that work-related social skills and cognitive training are e ﬀ ective adjuncts, but this is an area where large RCTs are required to yield conclusive evidence. Cognitive remediation (CR) is a treatment approach that is being increasingly examined as a means through which the cognitive impacts of schizophrenia might be ameliorated. While CR has demonstrated good outcomes when paired with supported employment, little is known regarding how it might be integrated within supported education contexts. In this study CR was examined in a supported education context with 16 individuals with psychosis. The ﬁndings indicated that CR aligned well with the academic curriculum with very low attrition, was found useful by students, and showed similar pre-post di ﬀ erences on cognitive measures as those found in previous work.

Individuals with severe mental illnesses (SMI) such as schizophrenia are more likely to have impaired cognitive functioning in areas such as attention and concentration, psychomotor speed, memory, executive functions, and social cognition. These cognitive challenges are strongly associated with reduced psychosocial adjustment, such as the capacity for independent living, work or school, and social relationships, as well as the ability to benefit from rehabilitation programs targeted at improving outcome in these areas of adjustment. Cognitive remediation is the systematic use of methods aimed at improving cognitive functioning through the practice of cognitive exercises on either computer-based or paper and pencil tests, teaching more effective strategies for addressing cognitive challenges, and teaching coping or compensatory skills to reduce the effects of cognitive impairment on psychosocial functioning.
For over 30 years, research has examined the feasibility and effects of cognitive remediation on cognitive functioning and psychosocial adjustment in people with SMI. Recent meta-analyses of controlled research have shown that cognitive remediation is associated with significant improvements in both cognitive functioning and psychosocial adjustment. However, these reviews of research have also found that the impact of cognitive remediation on psychosocial adjustment is contingent upon the provision of adjunctive or integrated psychiatric rehabilitation, such as supported employment or social skills training. That is, studies that have added or integrated cognitive remediation and psychiatric rehabilitation programs have been found to improve psychosocial functioning more than psychiatric rehabilitation alone, whereas studies that have added cognitive remediation to usual services have found little to no differences in psychosocial outcomes compared to usual services alone. This issue on cognitive remediation and psychiatric rehabilitation brings together six papers addressing topics critical to improving the long-term psychosocial functioning of people with SMI.
Four of these papers provide pertinent reviews of research that point the field in important new directions, and two papers are original research contributions. While the research suggests that combining cognitive remediation with psychiatric rehabilitation is more effective at improving psychosocial outcomes, very little is known about how such programs should be combined. The review by R. Penadés and colleagues addresses this question by providing a framework and hierarchical flowchart for integrating cognitive remediation with other evidence-based psychosocial interventions. D. L. Roberts and D. L. Velligan review relevant research suggesting that programs specifically developed for and targeting social cognition (e.g., emotion recognition, ability to infer other's mental states) may be more effective and efficient than broad-based cognitive remediation programs. This review has important implications for developing or refining cognitive remediation and psychiatric rehabilitation interventions in order to maximize their cost effectiveness.
N. Contreras and colleagues provide a theoretical review of strategies for improving workforce participation in people with a SMI, with a particular focus on the Australian context. The review highlights the Individual Placement and Support (IPS) model of vocational rehabilitation, the most empirically validated program for improving employment outcomes in people with SMI, which has recently been combined with cognitive remediation in the USA. The authors suggest that Australia may be in a prime position to implement such combined interventions.
N. Boycott and colleagues also focused in their review on the IPS model, with a particular aim at evaluating the effects of supplementary interventions on work outcomes, including cognitive remediation. While prior research has evaluated the impact of adding cognitive remediation to vocational rehabilitation for people with SMI, scant attention has been paid to integrating cognitive remediation with supported education for this population. The paper by S. A. Kidd and colleagues addresses this lacuna by providing encouraging pilot data from such an integrated program, supporting both the feasibility of integrating cognitive remediation with supported education, and suggesting benefits in educationrelated outcomes. Finally, the research paper by M. N. Levaux and colleagues provides a useful case illustration of how cognitive remediation can be individually integrated and tailored into helping a person accomplish everyday life tasks.
We believe that the papers compiled in this issue make an important contribution to the cognitive remediation field by providing useful syntheses of the research literature, suggesting new directions for research and clinical implementation, and presenting new data on promising programs and approaches to integrate cognitive remediation and psychiatric rehabilitation into people's daily lives.