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Cognitive training at home in schizophrenia is feasible
Schizophrenia Research 143 (2013) 397–398
Contents lists available at SciVerse ScienceDirect
Schizophrenia Research journal homepage: www.elsevier.com/locate/schres
Letter to the Editor Cognitive training at home in schizophrenia is feasible Deficits in cognitive functioning are recognized as important targets for remediation programs because they are widely accepted as a core feature of schizophrenia that is strongly related to poor functioning (Green et al., 2000). Despite these deficits, improvement in neurocognition is a realistic goal and has been associated with better functioning (Lindenmayer et al., 2008). Meta-analytic studies confirm that there is a moderate-sized beneficial effect of cognitive remediation on cognitive functioning in schizophrenia patients (McGurk et al., 2007; Wykes et al., 2011). However, most of the cognitive remediation interventions are being conducted in University-affiliated clinics with highly trained staff administering the treatment. There are practical obstacles to the delivery of treatment, such as motivating patients to participate in these empirically-based treatments that are clinic-based, transportation issues, training and maintaining staff, and lack of available clinic services. These impediments limit access for schizophrenia patients who could potentially benefit from such interventions. Advances in computer technology, the general affordability of personal computers, and the ease of connecting to the Internet have the potential to transform the delivery of home-based health care products and interventions for schizophrenia patients and their families. We aimed to determine the feasibility of using home-based cognitive remediation programs to reach a broader patient group. We used an intent-to-treat recruitment strategy and required the patient's, as well as a relative's in-vivo participation, in a home-based computer training program. We easily recruited nine clinically stable schizophrenia outpatients and a relative who expressed an interest in participating in a cognitive training program. All had agreed to participate even when informed that the cognitive training programs were originally designed for home use by people who are experiencing normal age-related cognitive declines. PositScience's Internet-based Brain Fitness program contains a set of six easy-to-use, self-adjusting computer-based exercises aimed at improving critical cognitive functions primarily through auditory discrimination tasks (Fisher et al., 2009, 2010). Each family received a two-hour in-office training session of the PositScience software that included basic information about the human brain, cognition, and additional information on the role that cognition plays in daily functioning in schizophrenia. The patient was instructed to complete two onehour computer sessions per week for six weeks, to keep in regular phone contact with the study team to discuss progress, and to return for a final follow-up assessment. Relatives were asked to participate in software installation, creating a weekly training session schedule, reminding the patient about his/her scheduled sessions, and providing ongoing emotional and motivational support. Using online progress reports (graphs) provided by PositScience, the study team monitored each patient's progress remotely and provided feedback by phone. Successful adherence was defined as completion of the in-home cognitive training sessions, active participation by a relative, and demonstrated increases in knowledge about cognition. One patient dropped out due to a serious medical illness before the start of the program. However, by the conclusion of the study, 5 of the 8 patients completed 0920-9964/$ – see front matter. Published by Elsevier B.V. http://dx.doi.org/10.1016/j.schres.2012.11.033
12 or more sessions, and one patient each completed 10, 9, and 8 sessions. We considered that 80% adherence (10 sessions) would show feasibility, and 6 out of 8 patients (75%) achieved this criterion. Objective and interview-based measures were used to assess change in neurocognition. Patients improved on the MCCB composite by an average of 7.5 t-score points (moderate effect size, d = .54) and 1-point on an interview-based measure of cognition (large effect size, d = 1.92) (Table 1). In addition, both the patient and his or her relative showed increased knowledge about the role of cognition in daily life (Table 1). Structured assessments showed a moderate improvement in social functioning (d = .56). But, as expected given the short study duration, changes in work functioning were small and there were no changes in symptoms. We conclude that conducting an Internet-based Brain Fitness program at home for schizophrenia patients that includes in vivo support from a relative might be feasible. Using computer technology to make cognitive remediation services available to patients in their homes could allow these beneficial interventions to reach patients who otherwise might not have access. Arguably one of the most important findings is that both the patients and their relatives reported a noticeable improvement in the patient's cognitive functioning (CGI-CogS). Also, increasing the patient's and the relative's knowledge about the role of cognition goes beyond just objective increases in the patient's cognition. Additionally, home-based training might be capable of producing improvements in cognitive functioning as measured by objective tests. The moderate size improvement on the MCCB was meaningful when compared to the published effect size of .45 and when considering the small practice effects noted on the MCCB (Green et al., 2008; Keefe et al., 2011). Although we found evidence of moderate improvement in the patient's social functioning, understandably, there were no significant changes in work behavior or symptoms. Thus, further development and study of home-based cognitive interventions for schizophrenia patients may be warranted.
Contributors Dr. Ventura is the study Principal Investigator who conceived of the initial design, supervised the collection of data, supervised the data analysis process, conducted clinical assessments, conducted cognitive coaching, and wrote the letter. Gerhard Hellemann conducted all of the data analyses and contributed to writing the letter. Sarah Wilson and Rachel Wood consented and interviewed patients, administered neurocognitive tests, collected paper and pencil data, acted as cognitive coaches, and participated in data analysis. All authors have approved the final version of the letter.
Conflict of interest Software and consultation support was provided by PositScience to the study team and Joseph Ventura, Ph.D., was a consultant to Brain Plasticity Inc., a non-profit company affiliated with PositScience.
Acknowledgment This research was supported in part by the National Institute of Mental Health grants R21MH07391 (PI: Joseph Ventura, Ph.D.), MH37705 (PI: Keith H. Nuechterlein, Ph.D.), and P50 MH066286 (PI: Keith H. Nuechterlein, Ph.D.). We would also like to thank our colleagues Robert S. Kern, Ph.D., Shirley Glynn, Ph.D., and Robert Heinssen, Ph.D.
398
Letter to the Editor
Table 1 Change in patient or relative's assessment scores from baseline to 8 weeks.
MCCB composite CGI-CogS — patient CGI-CogS — informant (relative) CGI-CogS — rater BQKC total score — patient BQKC total score — relative SCORS — social functioning SCORS — work functioning
Baseline mean (SD)
Endpoint mean (SD)
Change (p)
Effect size Cohen's d
27.9 (13.8) 3.84 (.54) 4.21 (.62) 4.24 (.52) 1.64 (.69) 2.25 (.73) 1.63 (1.77) .75 (1.39)
35.4 (16.6) 3.08 (.55) 2.95 (.46) 3.24 (.50) 2.64 (.58) 2.92 (.48) 2.63 (1.41) 1.25 (1.49)
+7.5 (p = .006) −.76 (p b .01)a −1.26 (p b .01)a −1.00 (p b .01)a +1.00 (p = .03) +.66 (p = .12) +1.00 (p = .05) +.50 (p = .23)
.54 1.39 2.03 1.92 1.45 .90 .56 .36
MCCB = MATRICS Consensus Cognitive Battery; CGI-CogS = Clinical Global Impression of Cognition in Schizophrenia; BQKC = Brief Questionnaire on Knowledge of Cognition (developed for this study); SCORS = Strauss Carpenter Outcome Rating Scale. a Lower scores reflect improved cognitive functioning.
References Fisher, M., Holland, C., Merzenich, M.M., Vinogradov, S., 2009. Using neuroplasticity-based auditory training to improve verbal memory in schizophrenia. Am. J. Psychiatry 166 (7), 805–811. Fisher, M., Holland, C., Subramaniam, K., Vinogradov, S., 2010. Neuroplasticity-based cognitive training in schizophrenia: an interim report on the effects 6 months later. Schizophr. Bull. 36 (4), 869–879. Green, M.F., Kern, R.S., Braff, D.L., Mintz, J., 2000. Neurocognitive deficits and functional outcome in schizophrenia: are we measuring the “right stuff”? Schizophr. Bull. 26 (1), 119–136. Green, M.F., Nuechterlein, K.H., Kern, R.S., Baade, L.E., Fenton, W.S., Gold, J.M., Keefe, R.S., Mesholam-Gately, R., Seidman, L.J., Stover, E., Marder, S.R., 2008. Functional coprimary measures for clinical trials in schizophrenia: results from the MATRICS Psychometric and Standardization Study. Am. J. Psychiatry 165 (2), 221–228. Keefe, R.S.E., Fox, K.H., Harvey, P.D., Cucchiaro, J., Siu, C., Loebel, A., 2011. Characteristics of the MATRICS Consensus Cognitive Battery in a 29-site antipsychotic schizophrenia clinical trial. Schizophr. Res. 125 (2–3), 161–168. Lindenmayer, J., McGurk, S., Mueser, K., Khan, A., Wance, D., Hoffman, L., Wolfe, R., Xie, H., 2008. A randomized controlled trial of cognitive remediation among inpatients with persistent mental illness. Psychiatr. Serv. 59 (3), 241. McGurk, S.R., Twamley, E.W., Sitzer, D.I., McHugo, G.J., Mueser, K.T., 2007. A metaanalysis of cognitive remediation in schizophrenia. Am. J. Psychiatry 164 (12), 1791–1802.
Wykes, T., Huddy, V., Cellard, C., McGurk, S.R., Czobor, P., 2011. A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. Am. J. Psychiatry 168 (5), 472–485.
Joseph Ventura ⁎ Sarah A. Wilson Rachel C. Wood Gerhard S. Hellemann UCLA Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, United States ⁎Corresponding author at: UCLA Department of Psychiatry, 300 Medical Plaza, Room 2243, Los Angeles, CA 90095-6968, United States. Tel.: + 1 310 206 5225; fax: +1 310 206 3651. E-mail address: [email protected] (J. Ventura). 18 June 2012
Contents lists available at SciVerse ScienceDirect
Schizophrenia Research journal homepage: www.elsevier.com/locate/schres
Letter to the Editor Cognitive training at home in schizophrenia is feasible Deficits in cognitive functioning are recognized as important targets for remediation programs because they are widely accepted as a core feature of schizophrenia that is strongly related to poor functioning (Green et al., 2000). Despite these deficits, improvement in neurocognition is a realistic goal and has been associated with better functioning (Lindenmayer et al., 2008). Meta-analytic studies confirm that there is a moderate-sized beneficial effect of cognitive remediation on cognitive functioning in schizophrenia patients (McGurk et al., 2007; Wykes et al., 2011). However, most of the cognitive remediation interventions are being conducted in University-affiliated clinics with highly trained staff administering the treatment. There are practical obstacles to the delivery of treatment, such as motivating patients to participate in these empirically-based treatments that are clinic-based, transportation issues, training and maintaining staff, and lack of available clinic services. These impediments limit access for schizophrenia patients who could potentially benefit from such interventions. Advances in computer technology, the general affordability of personal computers, and the ease of connecting to the Internet have the potential to transform the delivery of home-based health care products and interventions for schizophrenia patients and their families. We aimed to determine the feasibility of using home-based cognitive remediation programs to reach a broader patient group. We used an intent-to-treat recruitment strategy and required the patient's, as well as a relative's in-vivo participation, in a home-based computer training program. We easily recruited nine clinically stable schizophrenia outpatients and a relative who expressed an interest in participating in a cognitive training program. All had agreed to participate even when informed that the cognitive training programs were originally designed for home use by people who are experiencing normal age-related cognitive declines. PositScience's Internet-based Brain Fitness program contains a set of six easy-to-use, self-adjusting computer-based exercises aimed at improving critical cognitive functions primarily through auditory discrimination tasks (Fisher et al., 2009, 2010). Each family received a two-hour in-office training session of the PositScience software that included basic information about the human brain, cognition, and additional information on the role that cognition plays in daily functioning in schizophrenia. The patient was instructed to complete two onehour computer sessions per week for six weeks, to keep in regular phone contact with the study team to discuss progress, and to return for a final follow-up assessment. Relatives were asked to participate in software installation, creating a weekly training session schedule, reminding the patient about his/her scheduled sessions, and providing ongoing emotional and motivational support. Using online progress reports (graphs) provided by PositScience, the study team monitored each patient's progress remotely and provided feedback by phone. Successful adherence was defined as completion of the in-home cognitive training sessions, active participation by a relative, and demonstrated increases in knowledge about cognition. One patient dropped out due to a serious medical illness before the start of the program. However, by the conclusion of the study, 5 of the 8 patients completed 0920-9964/$ – see front matter. Published by Elsevier B.V. http://dx.doi.org/10.1016/j.schres.2012.11.033
12 or more sessions, and one patient each completed 10, 9, and 8 sessions. We considered that 80% adherence (10 sessions) would show feasibility, and 6 out of 8 patients (75%) achieved this criterion. Objective and interview-based measures were used to assess change in neurocognition. Patients improved on the MCCB composite by an average of 7.5 t-score points (moderate effect size, d = .54) and 1-point on an interview-based measure of cognition (large effect size, d = 1.92) (Table 1). In addition, both the patient and his or her relative showed increased knowledge about the role of cognition in daily life (Table 1). Structured assessments showed a moderate improvement in social functioning (d = .56). But, as expected given the short study duration, changes in work functioning were small and there were no changes in symptoms. We conclude that conducting an Internet-based Brain Fitness program at home for schizophrenia patients that includes in vivo support from a relative might be feasible. Using computer technology to make cognitive remediation services available to patients in their homes could allow these beneficial interventions to reach patients who otherwise might not have access. Arguably one of the most important findings is that both the patients and their relatives reported a noticeable improvement in the patient's cognitive functioning (CGI-CogS). Also, increasing the patient's and the relative's knowledge about the role of cognition goes beyond just objective increases in the patient's cognition. Additionally, home-based training might be capable of producing improvements in cognitive functioning as measured by objective tests. The moderate size improvement on the MCCB was meaningful when compared to the published effect size of .45 and when considering the small practice effects noted on the MCCB (Green et al., 2008; Keefe et al., 2011). Although we found evidence of moderate improvement in the patient's social functioning, understandably, there were no significant changes in work behavior or symptoms. Thus, further development and study of home-based cognitive interventions for schizophrenia patients may be warranted.
Contributors Dr. Ventura is the study Principal Investigator who conceived of the initial design, supervised the collection of data, supervised the data analysis process, conducted clinical assessments, conducted cognitive coaching, and wrote the letter. Gerhard Hellemann conducted all of the data analyses and contributed to writing the letter. Sarah Wilson and Rachel Wood consented and interviewed patients, administered neurocognitive tests, collected paper and pencil data, acted as cognitive coaches, and participated in data analysis. All authors have approved the final version of the letter.
Conflict of interest Software and consultation support was provided by PositScience to the study team and Joseph Ventura, Ph.D., was a consultant to Brain Plasticity Inc., a non-profit company affiliated with PositScience.
Acknowledgment This research was supported in part by the National Institute of Mental Health grants R21MH07391 (PI: Joseph Ventura, Ph.D.), MH37705 (PI: Keith H. Nuechterlein, Ph.D.), and P50 MH066286 (PI: Keith H. Nuechterlein, Ph.D.). We would also like to thank our colleagues Robert S. Kern, Ph.D., Shirley Glynn, Ph.D., and Robert Heinssen, Ph.D.
398
Letter to the Editor
Table 1 Change in patient or relative's assessment scores from baseline to 8 weeks.
MCCB composite CGI-CogS — patient CGI-CogS — informant (relative) CGI-CogS — rater BQKC total score — patient BQKC total score — relative SCORS — social functioning SCORS — work functioning
Baseline mean (SD)
Endpoint mean (SD)
Change (p)
Effect size Cohen's d
27.9 (13.8) 3.84 (.54) 4.21 (.62) 4.24 (.52) 1.64 (.69) 2.25 (.73) 1.63 (1.77) .75 (1.39)
35.4 (16.6) 3.08 (.55) 2.95 (.46) 3.24 (.50) 2.64 (.58) 2.92 (.48) 2.63 (1.41) 1.25 (1.49)
+7.5 (p = .006) −.76 (p b .01)a −1.26 (p b .01)a −1.00 (p b .01)a +1.00 (p = .03) +.66 (p = .12) +1.00 (p = .05) +.50 (p = .23)
.54 1.39 2.03 1.92 1.45 .90 .56 .36
MCCB = MATRICS Consensus Cognitive Battery; CGI-CogS = Clinical Global Impression of Cognition in Schizophrenia; BQKC = Brief Questionnaire on Knowledge of Cognition (developed for this study); SCORS = Strauss Carpenter Outcome Rating Scale. a Lower scores reflect improved cognitive functioning.
References Fisher, M., Holland, C., Merzenich, M.M., Vinogradov, S., 2009. Using neuroplasticity-based auditory training to improve verbal memory in schizophrenia. Am. J. Psychiatry 166 (7), 805–811. Fisher, M., Holland, C., Subramaniam, K., Vinogradov, S., 2010. Neuroplasticity-based cognitive training in schizophrenia: an interim report on the effects 6 months later. Schizophr. Bull. 36 (4), 869–879. Green, M.F., Kern, R.S., Braff, D.L., Mintz, J., 2000. Neurocognitive deficits and functional outcome in schizophrenia: are we measuring the “right stuff”? Schizophr. Bull. 26 (1), 119–136. Green, M.F., Nuechterlein, K.H., Kern, R.S., Baade, L.E., Fenton, W.S., Gold, J.M., Keefe, R.S., Mesholam-Gately, R., Seidman, L.J., Stover, E., Marder, S.R., 2008. Functional coprimary measures for clinical trials in schizophrenia: results from the MATRICS Psychometric and Standardization Study. Am. J. Psychiatry 165 (2), 221–228. Keefe, R.S.E., Fox, K.H., Harvey, P.D., Cucchiaro, J., Siu, C., Loebel, A., 2011. Characteristics of the MATRICS Consensus Cognitive Battery in a 29-site antipsychotic schizophrenia clinical trial. Schizophr. Res. 125 (2–3), 161–168. Lindenmayer, J., McGurk, S., Mueser, K., Khan, A., Wance, D., Hoffman, L., Wolfe, R., Xie, H., 2008. A randomized controlled trial of cognitive remediation among inpatients with persistent mental illness. Psychiatr. Serv. 59 (3), 241. McGurk, S.R., Twamley, E.W., Sitzer, D.I., McHugo, G.J., Mueser, K.T., 2007. A metaanalysis of cognitive remediation in schizophrenia. Am. J. Psychiatry 164 (12), 1791–1802.
Wykes, T., Huddy, V., Cellard, C., McGurk, S.R., Czobor, P., 2011. A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. Am. J. Psychiatry 168 (5), 472–485.
Joseph Ventura ⁎ Sarah A. Wilson Rachel C. Wood Gerhard S. Hellemann UCLA Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, United States ⁎Corresponding author at: UCLA Department of Psychiatry, 300 Medical Plaza, Room 2243, Los Angeles, CA 90095-6968, United States. Tel.: + 1 310 206 5225; fax: +1 310 206 3651. E-mail address: [email protected] (J. Ventura). 18 June 2012