Cognitive rehabilitation for patients with schizophrenia in Korea

Asian Journal of Psychiatry 25 (2017) 109–117

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Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp

Review article

Cognitive rehabilitation for patients with schizophrenia in Korea Won Hye Leea , Woo kyeong Lee, PhDb,* a b

National Center for Mental Health, Korea Department of Counseling Psychology, Seoul Cyber University, 193-15, Mia Dong, Gang Buk Gu, Seoul, 142-700 Korea

A R T I C L E I N F O

Article history: Received 1 October 2015 Received in revised form 31 July 2016 Accepted 7 October 2016 Available online xxx Keywords: Cognitive remediation therapy Computerized cognitive rehabilitation Social cognitive programs Functional outcomes

A B S T R A C T

Psychosocial rehabilitation programs received mental health professional support in addition to traditional medication therapy. Many psychosocial programs were developed since the 1990s, including cognitive remediation therapy. In this review, we focus on cognitive remediation therapy in Korea since the 1990s. We review several cognitive rehabilitation programs developed in Korea and their outcome studies and suggest future research directions and prospects. We reviewed cognitive rehabilitation programs including social cognitive training as well as more recent forms of computerized cognitive rehabilitation. Although there are differences in cognitive domains by training targets, almost all neurocognitive remediation trainings in Korea have beneficial effects on early visual processing, various attention types, and executive function. Future studies need to investigate the mechanisms and various mediators underlying the relationships between cognitive functions and functional outcomes. With more comprehensive cognitive and social cognitive programs, we can enhance both cognition and functional outcomes of the patients with schizophrenia. ã 2016 Elsevier B.V. All rights reserved.

Contents 1. 2. 3. 4. 5.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Studies on neurocognitive remediation training in Korea Studies on social cognitive remediation . . . . . . . . . . . . . . Studies on computerized cognitive remediation . . . . . . . Discussion and future direction . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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1. Introduction Cognitive deficits are a core characteristic of schizophrenia and are related to functional outcomes. Researchers started conducting cognitive remediation studies in the 1980s in Western countries. However, development and outcome studies began to be conducted in the mid-1990s in Korea. Patients with schizophrenia show poor performance on most cognitive domains on neurocognitive measures such as psychomotor speed, attention, vigilance, verbal learning, working memory, and executive functions (Green et al., 2004; Keefe et al., 2006; Palmer et al., 1997). Such

* Corresponding author. E-mail addresses: [email protected] (W.H. Lee), [email protected] (W.k. Lee). http://dx.doi.org/10.1016/j.ajp.2016.10.010 1876-2018/ã 2016 Elsevier B.V. All rights reserved.

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109 110 113 115 116 116

cognitive impairments persist during the illness’ acute and remission periods (Heaton et al., 2001; Morrison et al., 2006; Simon et al., 2007) There is little evidence of a relationship between positive symptoms (hallucinations, delusions) and cognitive function (Keefe and Harvey, 2008; Mohamed et al., 1999). However, there is consistent evidence supporting a relationship between cognitive function and negative symptoms (Addington et al., 1991). Cognitive functions are important considering their impact on practical aspects of daily life functioning, social problem solving, interpersonal relationships, and quality of life (Bozikas and Andreou, 2011; Evans et al., 2004; Green et al., 2004; Szoke et al., 2008). Recently, social cognitive functions have also been considered important to functional outcomes. In particular, consistent evidence showed that social cognition can mediate the relationship between neurocognitive function and functional outcomes (Green et al., 2014). Meta-

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analysis showed that neurocognition is related to social skill acquisition such as problem solving, attention, and vigilance. Furthermore, the association between social cognitive domains such as theory of mind, emotional processing, and social perception and functional outcomes including community functioning is stronger than that of neurocognitive function and functional outcomes (Fett et al., 2011). Many studies showed that social cognition has significant relationships to neurocognitive function on one hand and to job function and social community functioning on the other hand. Thus, a direct relationship between neurocognitive function and functional outcomes is reduced when social cognition is entered into a model (Schmidt et al., 2011). In Korea, several studies were also conducted to investigate the relationship between cognition and psychosocial functions of Schizophrenia. These studies (Choi et al., 2002; Sea, 2009; Son et al., 2000) showed that neurocognitive functions, such as auditory-verbal memory and executive function were significant variables to predict social and occupational functions. These neurocognitive functions also significantly predicted the subjective quality of life (Choi et al., 2002). A recent study (Ko and Lee, 2016) showed that the Perceptual Reasoning Index of the WAIS-IV was significant in correlation to the independent living skills in patients with chronic schizophrenia. They also found that the Verbal Comprehension Index and the Working Memory Index of the WAIS-IV were significant in correlation to the insight measured by the Scale to assess Unawareness of Mental Disorder (SUMD). Therefore, cognitive deficit interventions and clinical symptom reduction for daily life adaptation and community functioning of patients with schizophrenia are important. Early researchers suggested that deficit interventions for patients with schizophrenia emphasize problem strategy acquisition (Meichenbaum and Cameron, 1973) or thought provoking (Platt and Spivack, 1972); this did not lead to further studies. Since then, limitations of medical therapy only were suggested and the necessity of cognitive remediation was emphasized, as neurocognitive deficits can cause adaptation problems (Spohn and Strauss, 1989). Brener et al. developed Integrated Psychological Therapy (IPT) to reduce cognitive deficits and improve social function (Brenner et al., 1987; Roder et al., 1987). Bellack (1992) suggested that cognitive deficits should be remediated for effective psychosocial rehabilitation and its prospects were relatively promising. Since then, various cognitive remediation programs have been developed based on evidence showing the relationship between cognitive deficits and functional outcomes. Recently, differences in particular cognitive remediation approaches for patients with schizophrenia are apparent. Almost all focus on behavioral training for improving neurocognition and social cognition (Wyke et al., 2011). As defined by the Cognitive Remediation Experts Workshop (Florence, Italy, April 2010), cognitive remediation approaches are “a behavioral training based intervention that aims to improve cognitive processes such as attention, memory, executive function, social cognition or metacognition, with the goal of durability and generalization.”(Wykes et al., 2011, p472) Neurocognitive remediation remediates deficits of basic information processing, such as attention, memory, and learning executive function, while training for improving social cognition focuses on complex social information processing such as emotional recognition and expression, social perception, and theory of mind (Miller and Porter, 1988; Green, 1999). Meta-analyses of cognitive remediation for patients with schizophrenia have proven its effects (Grynszpan et al., 2010; McGurk et al., 2009; Wyke et al., 2011). When combined with psychosocial rehabilitation programs, it is more effective and generalized to psychosocial function, especially for stable symptom periods of patients with schizophrenia. Effects of cognitive remediation programs on clinical symptoms are weak, but have

reduced negative symptoms and enhanced motivation (Elis et al., 2013; Sanchez et al., 2014; Wyke et al., 2011). In the late 1990s in Korea, the completely revised Mental Health Act shifted the focus for people with chronic mental illness from traditional inpatient programs to community return and adaptation. Psychosocial rehabilitation programs received mental health professional support in addition to traditional medication therapy. Many psychosocial programs were developed since the 1990s, including cognitive remediation therapy. In this review, we focus on cognitive remediation therapy in Korea since the 1990s. We reviewed fourteen articles regarding cognitive rehabilitation programs developed in Korea for patients with schizophrenia and their outcome studies. These articles were identified through a computer-based search of RISS (Korea Education and Research Information Service) and Pubmed from 1990 to 2015 using combinations of the following key words: cogn*, social cognition, emotion* management, rehabilitation, remediation, enhancement, training, schizophrenia and Korea. We also suggest future research directions and prospects (Table 1). 2. Studies on neurocognitive remediation training in Korea Early neurocognitive remediation programs in Korea began in the mid-1990s; most early programs were based on IPT’s Cognitive Differentiation Training (CDT; Brenner et al., 1994). CDT improved cognitive function through card sorting exercises, verbal concept exercises, and object guessing exercises. Lee et al. (1998) developed the Cognitive Rehabilitation Program based on Brenner's IPT and investigated CDT’s effects on cognitive functioning of patients with schizophrenia. They trained three CDT stages for 12 sessions, three times weekly, 60 min each session. The comparison group received psychosocial education for same time and period by psychiatric nurses. There were significant interaction effects between time and group on reaction time (F = 5.18, p < 0.05), decision reaction time (F = 6.00, p < 0.05) on the Vienna Test, and information processing speed. However, there were no significant effects on the General Memory Index, Delayed Memory Index, or attention and concentration measures of the Wechsler Memory Scale-Revised (1987). Lee et al. (1999) modified CDT to a Korean-Cognitive Differentiation Program (K-CDP) and executed an outcome study. The K-CDP combined categorization exercises and crossword puzzles on verbal concept exercises, the three CDT stages, and visual attention exercises, not included in the original CDT. The participants were randomly assigned to K-CDP or control groups. The K-CDP group (N = 14) received it twice weekly for 11 weeks (22 sessions), 60 min each session. The control group (N = 14) received psychosocial education for the same period and number of sessions. There was a significant interaction effect between time and groups on the arithmetic subtest (F = 6.35, p < 0.05) of the Korean-Wechsler Adult Intelligence Scale-Revised (K-WAIS-R), but there were no significant interaction effects between time and group on other subscales of the K-WAIS-R. There was also a significant effect on the problem solving skill subscale (F = 4.88, p < 0.05) of the self-reported Social Problem Solving Inventory. On the other hand, there was no significant interaction effect between time and group on the problem orientation scale. Comparison of the Positive and Negative Syndrome Scale (PANSS) scores showed that the groups did not differ significantly on positive or negative symptoms, or general psychopathology. K-CDP can improve sustained attention, but social problem solving skill and psychopathology did not improve (Table 2). Cho et al. (2004) investigated CDT effects using general neurocognitive measures and a psychosocial function scale. They also investigated the association between cognitive function improvement via cognitive training and psychosocial functioning.

Table 1 Neurocognitive Rehabilitation Program for the patients with Schizophrenia in Korea. Control Condition

Age Gender Duration of Illness (Mean) (% (years) Male)

Intensity of Training (total sessions)

26 inpatients with Lee et al. schizophrenia (1998)

Cognitive Differentiation Training(CDT) of Integrated Psychological Therapy(IPT)

Psychoeducation

28.2

65.4

7.0

Three 60-min sessions per Wechsler Memory Scale-Revised (WMS-R), Decision Reaction Test of wk for 4 wk Vienna Test [12]

28 inpatients with Lee et al. schizophrenia (1999)

Korean-Cognitive DifferentiationProgram(K-CDP)

Psychoeducation

34.2

46.4

10.0

Two 60-min sessions per wk for 11 wk [22]

24 outpatients with Cognitive Differentiation Cho Training(CDT) of Integrated et al. schizophrenia in (2004) community mental Psychological Therapy(IPT) health center

Psychoeducation

33.3

50

8.7

Two 90-min sessions per wk for 12 wk [24]

30inpatientswith Lee et al. schizophrenia (2001)

General psychosocialrehabilitation group, Treatment as usual (TAU)

39.5

50

13.7

One 60-min session per wk for 20 wk [20]

Sample

Cognitive Behavioral Rehabilitation Training (CBRT)

Outcomes Measures

Major Findings

CDT participants improved on reaction time and decision reaction time relative to controls K-CDT participants Arithmetic(AR), Vocabulary(VC), Similarities(SI) and Picture completion improved on AR subtest of K-WAIS and problem (PC) subtests solving skill subscale of of Korean version of Wechsler SPSI relative to controls Intelligence Scale Revised(K-WAIS), Positive and Negative Symptoms Scale (PANSS), Social Problem-Solving Inventory(SPSI) Korean version of Wechsler Intelligence CDT participants Scale Revised(K-WAIS), Stroop Color- improved on measures of attention, problem solving Word Test(STWT), Wisconsin Card and interpersonal Sorting Test(WCST), Behavioral relationships relative to Symptoms Identification Scale-32 controls but not on other (BAIS-32), Relationship Change Scale (RCS), Problem Solving Inventory(PSI) psychosocial skills and symptoms CBRT participants WARD7 Short form-Korean Wechsler improved on SPAN Adult Intelligence Scale (WARD7KWIS), Degraded Stimulus Continuous relative to controls Performance Test (DS-CPT), The Span of Apprehension (SPAN), Word fluency test (Animal category fluency & 3-word Phonemic fluency)

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Cognitive Rehabilitation Training

Study

111

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Table 2 Social Cognitive Rehabilitation Program for the patients with Schizophrenia in Korea. Study

Sample

Cognitive Rehabilitation Training

Control Condition

Age Gender Duration of Illness (Mean) (% (years) Male)

29.0 Emotional management Training Attention placebo group (EMT) (Brenner et al., 1992; received Brenner et al., 1997) psychoeducation

52 outpatients with Won et al. schizophrenia in (2012) community mental health center

Emotional Management Nursing General mental Program (EMNP) Revised Yongin health service Emotional management Training group (Y-EMT) (Lee et al., 2004)

NR

61.5

Social Cognition Enhancement Training (SCET)

Treatment as usual(TAU)

36.3

34

34 outpatients with Choi schizophrenia and in community mental Kwon (2006) health center

Social Cognition Enhancement Training (SCET)

Standard psychosocial rehabilitation

32.0

56

37 outpatients with Kim et al. schizophrenia in (2013) community mental health center

Theory of mind Training (TMT) revised Social Cognition Enhancement Training (SCET)

Standard psychosocial rehabilitation

38.3

75.6

Kwon and Koh (2002)

31 outpatients in community mental health center and inpatients with schizophrenia

51

6.1

Two60min sessions per wk for 12 wk [24] Not One 60Presented min session per wk for 8 wk [8] 13.9 One 60  90min session per wk for 10wk [10] 11.0 Two 90min sessions per wk for 24wk [36] 16.5 Two 60min sessions per wk for 8 wk [16]

Trait Meta-Mood Scale-short form(TMMS-S), Paired Associate Learning of WMS-R, Similarities subtest of K-WAIS, Social Perception Scale(SPS), Social Problem Solving Inventory(SPSI), PANSS

Major Findings

EMT participants improved on visual perception of SPS, SPSI, positive symptoms and general psychopathology of PANSS relative to controls

Berkeley Expressivity Questionnaire(BEQ), Emotional EMNP participants improved on Behavior Scale (EBS), Relationship Change Scale(RCS), emotional expression, emotional behavior, interpersonal relationship Social Behavior Scale(SBS) and social behavior relative to controls Picture Arrangement (PA) subtest Korean Wechsler intelligence Scale for Child-revised(KEDI-WISC), Social Living Skill Scale(SLSS), Independent Living Skill Survey (PEI), Social Perception Scale(SPS)

SCET participants improved on independent living skill relative to controls

Picture Arrangement (PA) subtest of KEDI WISC, Social Behavior Sequencing Task(SBST), Emotion Recognition Test(ERT)

SECT participants improved on PA subtest relative to controls

False Belief task, Faus pax task, Hinting task, Picture TMT participants improved on faux pas task, hinting task, social living Arrangement (PA) subtest of KEDI WISC, Social skill relative to controls Behavior Sequencing Task(SBST), Social Living Skill Scale(SLSS), Independent Living Skill Survey (PEI)

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53 inpatients and Cho et al. outpatients with (1999) schizophrenia

Outcomes Measures Intensity of Training (total sessions)

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The participants were assigned randomly to CDT (N = 12) or control groups (N = 12), and received psychoeducation training twice weekly for three months for 90 min (24 sessions). The pre-post differences showed that the cognitive rehabilitation group only showed improvement on all Wisconsin Card Sort Test subscales (except total number of categories), STROOP test, interpersonal relationship, and problem solving areas. However, there were no effects on other psychosocial functioning and psychiatric symptoms. Green et al. (2000) suggested a new model of the relationship between specific neurocognitions and functional outcomes; social cognition can be mediated by these two variables. Lee et al. (2001) developed a cognitive remediation program, named Cognitive Behavioral Rehabilitation Training (CBRT), based on Green’s model, to target of specific neurocognitive functions enhancement, differently affecting psychosocial functioning, and executed an outcome study. CBRT consists of training low cognitive functioning levels (orientation, attention, concentration, memory) to high levels of cognitive functioning (organization, reasoning). They compared shortcomings of previous cognitive remediation programs and enhanced generalization and ecological validity. First, they included compensatory strategies to minimize refractory cognitive deficits as well as cognitive remediation via repetitive training. Second, CBRT included daily life activities (e.g., shopping, packing a suitcase, planning a route, traditional play, etc.) to enhance generalization of cognitive training effects using the experimental design. They also emphasized the familiarity of daily stimuli reflected in Korean cultures (e.g. clothes, food, toys, furniture, home appliances, etc.). Third, the program focused on the definition, characteristics, and effects of cognition on daily life. They conducted an outcome study with chronic patients who had been ill for at least five years. The inpatients were assigned to CBRT (N = 12), general psychosocial rehabilitation (N = 9), and control groups (N = 9). The CBRT and general psychosocial rehabilitation groups received 20 sessions of 60 min once weekly for five months. The control group received antipsychotic medication and general interviewing routinely for the same period. The CBRT group showed significant interaction effects between time and group on 12 matrices of the Span of Apprehension(SPAN) Program for IBMCompatible Microcomputers Version 5.3 (Asarnow and Nuechterlein, 1999a), whereas there were no significant effects on CPT: Degraded stimulus Continuous Performance Test(DS-CPT) Program for IBM-Compatible Microcomputers Version 8.12 (Asarnow and Nuechterlein, 1999b), Word fluency test: Animal category & phonemic fluency test. In short, the first neurocognitive rehabilitation program for schizophrenia started in Korea was based on Brenner’s CDT. Later on, CBRT was developed by applying stimuli based on Korean culture and lifestyle. It was improved through appliance of generalization and ecological validity. These neurocognitive rehabilitation training groups compared to other psychosocial rehabilitation groups or TAU groups showed significant improvement in early visual processing speed and attention. Some studies identified the improvement of problem solving skills and interpersonal relationships through neurocognitive rehabilitation. However, studies concerning neurocognitive rehabilitation’s effect on functional outcomes are still lacking and more research is needed (Table 3). 3. Studies on social cognitive remediation Increasing evidence shows that social cognitive deficits and cognitive deficits mediate the relationship between neurocognition and functional outcomes in patients with schizophrenia (Kurtz and Richardson, 2012). Therefore, many psychosocial rehabilitation programs emphasize social cognition’s importance

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and include it combined with cognitive training with medical treatment and cognitive rehabilitation (Cameron et al., 2012; Stephen, 2006). In Korea, since the 1990s, the social cognitive domain has been combined with cognitive remediation programs and included social cognitive outcome measures. Cho et al. (1999) modified Emotional Management Training (EMT) developed by Brenner et al. (1992) and Brenner et al. (1997) and conducted an outcome study. Study participants were 53 chronic patients with schizophrenia. The treatment group (N = 30) received EMT twice weekly for 12weeks, 60 min each session. The original EMT by Hodel and Brenner (1997) used still pictures as visual material; Cho et al. used video clips edited via TV drama and cinema to enhance understanding of social situations in the Korean EMT. The video clip included basic emotion cards such as happiness, sadness, surprise, disgust, and contempt; each emotion was displayed by facial expressions and script. The video clip was segmented to 1–2 min each, because attention spans of patients with schizophrenia were short. The eight EMT stages were as follows: description and analysis of depicted emotion in each video clip, description of patient’s emotion similar to presented situations or settings, description of patient’s coping strategies and behavioral consequences about emotional experience, alternative coping strategy elaboration, analysis of coping strategy adequacy, coping strategy individualization and selection, selected strategy role plays, and individual coping strategies. Training outcomes showed significant interaction effects between time and groups on social perception-visual perception of the Social Perception Scale(SPS) (An et al., 1998) (F = 4.56, p < 0.05), verbal fluency (F = 5.45, p < 0.05), PANSS positive symptoms (F = 4.08, p < 0.05), PANSS general psychopathology (F = 4.45, p < 0.05), and social problem solving (F = 4.10, p < 0.05). There were no interaction effects on Trait Meta-Mood Scale-short form (TMMS-S) (Salovey et al., 1995), verbal memory, verbal reasoning, social perception-contextual perception of the Social Perception Scale (SPS) (An et al., 1998), and negative PANSS symptoms. Lee et al. (2004) developed Yongin Emotional Management Training (Y-EMT), based on previous emotional processing deficit research (Bellack et al., 1992; Kerr and Neale, 1992), and subcomponents of emotional intelligence by emotional intelligence model (Mayer et al., 1990). Specifically, Y-EMT consists of four topics, including emotional recognition, emotional expression, emotional transformation, and emotional regulation, five sessions per topic (20 sessions). Won et al. (2012) conducted an outcome study on the Y-EMT short form of eight sessions, 90 min per session. Pre-post outcome measures showed that the Y-EMT group (N = 22) showed significant improvement on emotional expression (t = 3.27, p < 0.05), emotional behavior (F = 61.65, p < 0.001), interpersonal relationship (t = 4.01, 0 < 0.001), and social behavior (t = 8.69, p < 0.001) compared to a general mental health service group. Kwon (2000) developed Social Cognition Enhancement Training (SCET) combined with two social perception and social skill trainings. This program used cartoon stimuli including various social situations. The first training set focused on social perception to understand the expressed cartoon protagonist’s emotion, judge each social situation, and speculate on story development. Later in the program, social skills training for adequate speech and behaviors in each situation was introduced, role plays were performed, feedback was provided, and finally more adaptive and adequate behaviors in certain situations were rehearsed. Kwon and Koh (2002) conducted a pilot study; the SCET group (N = 12) showed significant improvement of social skill ability (F = 13.36, p < 0.001) compared to the medication only group Choi and Kwon (2006) conducted a SCET randomized controlled study with 34 patients with schizophrenia in a community mental health service center. The SCET group participated in

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Table 3 Computer Based Cognitive Rehabilitation Program for the patients with Schizophrenia in Korea. Study

Sample

Cognitive Rehabilitation Training

21 inpatients with RehaCom An et al. schizophrenia in (1997) day care hospital Attention domain Training of PSS CogRehab

Outcomes Measures

Major Findings

Not Two 20-min Presented sessions per wk for 5 wk [10] Not 15.6 Three 40presented min sessionsper wk for 6 wk [19] 50 16.5 Three 45min sessionsper wk for 6 wk [18]

Vigilance version 4.0 of Vienna Test, PANSS

RehaCom participants improved on Vigilance relative to controls

Age Gender (Mean) (% Male)

24.6 Standard psychosocialrehabilitation

Typing exercise combined 39.2 with medical therapy group & only medical therapy group

Intensity of Training (total sessions)

52.4

CogRehab participants improved on ROCF, colorRey-Ostrerrieth Complex Figure Test(ROCF), Korea-California Verbal Learning Test(K-CVLT), word task of SCWT, negative symptoms and general psychopathology of PANSS relative to controls Trail Making Test(TMT), Stroop Color-Word Test(SCWT), WCST, K-WAIS, PANSS CogRehab participants improved on total error and Rey-Ostrerrieth Complex Figure Test(ROCF), Korea-California Verbal Learning Test(K-CVLT), perseverative error of WCST, Forward and Backward of DST relative to controls Trail Making Test(TMT), Stroop Color-Word Test(SCWT), WCST, Digit Span Test(DST), PANSS

30 outpatients with schizophrenia in community mental health system 38inpatients with schizophrenia

General Executive recreationprogram function domain Training of PSS CogRehab Medical Therapy

43.7

52.6

17.2

One30-min sessionper wk for 12 wk [12]

Degraded Stimulus Continuous Performance Test (DS-CPT), The Span of Apprehension (SPAN), Trail Making Test(TMT), Stroop ColorWord Test(SCWT), Digit Span Test(DST),

CogTrainer participants improved most cognitive measures relative to controls, but not on false alarm of DS-CPT

Lee 60inpatients with (2013) schizophrenia in psychiatric rehabilitation units

Usual psychosocial rehabilitation

43.5

55

17.6

Two60-min Degraded Stimulus Continuous Performance sessions per Test (DS-CPT), K-WAIS, PANSS, Work Behavior Inventory(WBI) wk for 12 wk [24]

CogTrainer participants improved hit rate and sensitivity of DS-CPT, Forward and Backward of Digit Span, work quality and work habit of WBI relative to controls, but not on psychiatric symptoms of PANSS

Park and Kim (2015)

Lee et al. (2009)

Computer based Attention Training Program of CogTrainer Computer based Attention Training Program of CogTrainer

40.4

Duration of Illness (years)

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40 inpatients and Jang outpatients with and schizophrenia Kim (2011)

Control Condition

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training twice a week for six months (36 sessions). The SCET group showed significant interaction effects between time and group on picture arrangement scores (PA) compared to a standard psychosocial rehabilitation group, but showed no effects on a social behavior sequencing test (SBST) or an emotional recognition test (ERT). The SCET group showed that PA score increases after two months; this improvement persisted at four and six months. The SBST score enhancement at two months did not persist at four and six months. There were no differences between groups on ERT measures. Previously, the social cognition domain focus was emotional processing and social perception, but the social cognition concept was expanded to attentional bias and theory of mind (Couture et al., 2006). Kim et al. (2013) modified SCET (Kwon, 2000) and re-constructed a 16-session program based on 14 cartoons of Theory of mind(ToMs) about understanding others’ mental states. This program compared cartoon protagonists’ exercises about intentions, appropriateness, and deliberation. An outcome study with patients with schizophrenia in a community mental health center was conducted and compared to a ToMs group combined with a general psychosocial program and a psychosocial program only group. Significant interaction effects between time and groups on faux pas and hint tasks on the ToMs assessment scales and social skills scores, but there were no effects on the false belief task, social behavioral sequencing, and interpersonal function. In summary, social cognitive programs in Korea were developed based on emotional processing, social perception, and theory of mind. These programs proved to improve not only social cognitive functions but also psychosocial functions such as interpersonal relationships, social behavior and skills, and independent living skills. However, most studies only conducted pre-post assessment. In the future, programs including comprehensive social cognitive domains such as Social Cognition and Interaction Training (SCIT) (Comb et al., 2007), Social Cognitive Skills Training (SCST) (Horan et al., 2011) and Korea’s social and cultural context should be developed. Furthermore, longitudinal effects of this program should be confirmed. 4. Studies on computerized cognitive remediation The neurocognitive deficit patterns of patients with schizophrenia is heterogeneous and differs in severity (Ermoli et al., 2005; Weickert et al., 2000). Specific patient-centered cognitive enhancement strategies are suggested (Lee, 2013; Reeder et al., 2006). As an alternative, computer based cognitive training in cognitive remediation is receiving increasing clinical and research interest. In Korea, outcome studies of computerized cognitive remediation programs adapted in other countries and Korea have been conducted. Schuhfried (1994) developed a computerized remediation training program, RehaCom for patients with cognitive disorders from brain damage. Each program was devised to provide specific patient feedback based on performance results; the difficulty level was automatically modulated based on patients’ performances. An et al. (1997) conducted an outcome study of vigilance training with RehaCom with patients with chronic schizophrenia. Participants were randomly assigned; the treatment group (N = 10) received RehaCom combined with standard psychosocial rehabilitation twice weekly for 20 min (10 sessions) and the control group (N = 11) received psychosocial rehabilitation only. There was a significant interaction effect between time and group on a visual vigilance scale. Bracy (1994) developed a computerized cognitive remediation program (PSS CogReHab), targeting attention, memory, problem solving, executive functions, and visuospatial ability with patients

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with schizophrenia. Several Korean researchers conducted outcome studies (Jang and Kim, 2011; Park and Kim, 2015). In particular, Jang and Kim (2011) modified the PSS CogRehab attention domain and reported outcomes. They provided 19 sessions of computerized cognitive remediation training combined with medical therapy three times weekly for six weeks for 40 min, provided a comparison group (N = 10) with a typing exercise combined with medical therapy for the same period, and provided a control group (N = 10) medication only. Significant interaction effects between time and group were shown on visuospatial ability (F = 5.284, p < 0.01), delayed visual memory (F = 4.313, p < 0.05), selective attention (F = 3.341, p < 0.05), negative PANSS symptoms (F = 3.280, p < 0.05), and general PANSS psychopathology (F = 4.869, p < 0.05). More recently, Park and Kim (2015) applied Korean PSS CogRehab versions, specifically executive functioning, and performed an outcome study. The CogRehab group (N = 15) was provided with recreation programs such as singing class, sports, or cooking class combined with CogRehab, three times weekly, six weeks, for 45 min (18 sessions); a control group (N = 15) received recreation only. Significant interaction effects between time and group occurred on WCST total error (F = 4.05, p < 0.05), WCST perseverative errors (F = 4.79, p < 0.05), Digit Span Forward (F = 8.25, p < 0.01) and Digit Span Backward (F = 8.45, p < 0.01). However, there was no interaction effect on symptoms and quality of life. Lee et al. (2008) developed a computerized cognitive remediation program, (CogTrainer) focused on attention modules based on previous research. CogTrainer consisted of 10 units (three steps each) targeting vigilance enhancement, sustained attention, working memory, selective attention, mental tracking, and processing speed. Each step comprises real life-related familiar stimuli provoking interests. This CogTrainer program recorded each participant’s performance and provided feedback. Lee et al. (2009) conducted a CogTrainer outcome study with patients with chronic schizophrenia. The participants were randomly assigned to one of two groups. The treatment group (N = 19) was provided with the CogTrainer program combined with medication once weekly for 30 min (12 sessions); the control group (N = 19) received medication only. Significant interaction effects between time and group occurred on most cognitive measures such as attention span, visual vigilance, sustained attention, mental set shifting, selective attention, and working memory. Another CogTrainer outcome study with chronic schizophrenia (Lee, 2013) was performed. One group (N = 30) was given CogTrainer combined with general psychosocial rehabilitation, once or twice weekly, three months for 60 min. The control group (N = 30) received usual psychosocial rehabilitation. Compared to the usual psychosocial rehabilitation group, Cog-Trainer showed significant improvements in attention, working memory, and work quality and work habits subscales of a work behavior inventory. However, there was no effect of computerized cognitive training on symptoms. Additional analysis showed a significant correlation between changes in sensitivity of the CPT and job quality. From the late 2000s there has been an increase in studies and development of computer based cognitive rehabilitation programs. Studies based on PSS CogRehab were performed along with studies through CogTrainer, a Korean program. These programs were found to improve not only neurocognitive functions but also occupational functions. Up to now computer based cognitive rehabilitation programs have mainly been focused on neurocognitive functions. In the future, it will be necessary to develop computer based social cognitive rehabilitation programs using the virtual reality technology and augmented reality too.

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5. Discussion and future direction This is the first review to analyze controlled cognitive rehabilitation training outcome studies for Korean patients with schizophrenia. We reviewed programs including social cognitive training as well as more recent forms of computerized cognitive rehabilitation. Although there are differences in cognitive domains by training targets, almost all neurocognitive remediation trainings in Korea have beneficial effects on early visual processing and various attention types; several studies proved beneficial effects on executive function. Quality analysis via written feedback questionnaires among patients showed further cognitive rehabilitation program benefits. Participants noted brain activation such as “I feel that my IQ gets better due to cognitive training,” “my brain get softer than before the training,” and self-efficacy expressed in “my brain becomes more sophisticated and get confident in cognitive ability” (Lee, 2013, p.90). Lee (2013) reported beneficial effects on work behavior but the relationship between cognitive function changes and functional outcomes was not sufficiently addressed. Generalizations to functional outcomes are still deficient. Furthermore, using methodologically robust experimental designs, comparison studies with various comparison groups, and various patients (inpatients, community mental health center, outpatients, etc.) will be necessary. More recent forms of computerized neurocognitive remediation training have been applied to chronic patients and showed beneficial effects on a broad range of cognitive function domains compared to traditional offline-based neurocognitive remediation trainings. Some researchers reported improvement of negative symptoms and psychopathology reduction (Jang and Kim, 2011), and job function improvement (Lee, 2013). Computerized cognitive remediation programs tailored to specific patients can be beneficial to functional outcomes. Recently, Green et al. (2014) reported that early visual perception can be a neurocognitive domain affecting social cognition in models testing the relationship of cognition and functional outcomes. Early visual perception tasks can be more easily embodied in computerized cognitive remediation programs in speed, quantity, and temporal accuracy. However, previous computerized cognitive remediation programs used stimuli or activities drawing on neuropsychological assessment paradigms. This aspect provokes generalization issues. In developing cognitive training programs, task should transfer acquired cognitive ability to daily life. Previous studies emphasized social cognitive functions more than neurocognitive functions in improving functional outcomes. However, social cognitive enhancement programs developed in Korea mostly addressed limited areas of social cognition such as emotional processing, social perception, and social cognition. Recently, researchers suggested including attributional style and theory of mind in social cognitive domains (Matthew et al., 2011); outcome studies of social cognitive enhancement programs were conducted (Comb et al., 2007; Horan et al., 2011). Therefore, in Korea, we need to cover various social cognition domains and conduct outcome studies. Various forms of computerized neurocognitive remediation programs were developed and studied, but computerized social cognition programs remain deficient. Recently, IT technology has progressed; therefore, computerized social enhancement programs combined with neurocognitive training can be applied to daily problem solving such as interpersonal and emotional management problems. Defeatist beliefs and negative symptoms can also be important variables that affect motivation and functional outcomes (Green et al., 2014). The feasibility of behavioral activation techniques originally for patients with depression can be applied to reduce negative symptoms of patients with schizophrenia and to enhance

motivation (Mairs et al., 2011; Choi et al., 2012). In applying cognitive skill to real life, cognitive remediation programs combined with behavioral techniques for enhancing motivation can be effective. Among the reviewed studies, only one study (Choi and Kwon, 2006) was a Randomized Controlled Trial and the others were conducted through case-controlled studies. The effectiveness of programs was only shown through pre-post assessment; studies regarding psycho-social function change were relatively small. In the future, studies using RCTs should be conducted and longitudinal and generalized effects should be investigated. Cognitive rehabilitation training programs have made substantial benefits on cognition itself. The current cognitive remediation programs are criticized by researchers, as the effects of training on specific cognitive abilities have not necessarily generalized to psychosocial functioning. Future studies need to investigate the mechanisms and various mediators underlying the relationships between cognitive functions and functional outcomes. With more comprehensive cognitive and social cognitive programs, we can enhance both cognition and functional outcomes of the patients with schizophrenia. References Addington, J., Addington, D., Maticka-Tyndale, E., 1991. Cognitive functioning and positive and negative symptoms in schizophrenia. Schizophr. Res. 5, 123–134. An, S.K., Oh, B.H., Hyun, M.H., Yoo, K.J., 1997. The effect of attention training using computer-aided cognitive rehabilitation program (REHACOM) in Chronic Schizophrenics. J. Korean Neuropsychiatr. Assoc. 36 (1), 72–79. Bellack, A.S., 1992. Cognitive rehabilitation for schizophrenia: is it possible? Is it necessary?. Schizophr. Bull. 18, 43–50. Bozikas, V.P., Andreou, C., 2011. Longitudinal studies of cognition in first episode psychosis: a systematic review of the literature. Aust. N. Z. J. Psychiatry 45, 93– 108. Bracy, O.L., 1994. PSS CogReHAb Attention Manual. Psychological Software Services, Inc., Indianapolis. Brenner, H., Hodel, B., Roder, V., 1987. Cognitive therapy of schizophrenic patients: poblem analysis and empirical result. Nervenarzt 58, 72–83. Brenner, H., Roder, V., Hodel, B., et al., 1994. Integrated Psychological Therapy for Schizophrenic Patients. Hogrefe & Huber, Tronto. Cameron, C.D., Bron-Iannuzzi, J.L., Payne, B.K., 2012. Sequentail priming measures of implicit social cognition: a meta-analysis of associations with behavior and explicit attitudes. Pers. Soc. Psychol. Rev. 16, 330–350. Cho, H.S., Lee, M.H., Choi, M.J., Sohn, S.H., Choe, E.H., Lee, E.C., Choi, T.K., Kim, T.Y., Ahn, H.R., Paik, M.J., Yoo, K.J., 1999. Effects of emotional management training in schizophrenic patients. J. Korean Neuropsychiatr. Assoc. 38 (6), 1223–1233. Cho, S.J., Lee, S.M., Jeong, E.H., Kwon, H.C., 2004. The effects of neurocognitive and social function of cognitive rehabilitation training for schizophrenic patients. Korean J. Clin. Psychol. 23 (3), 559–575. Choi, K.H., Kwon, J.H., 2006. Social cognition enhancement training for schizophrenia: a preliminary randomized controlled trial. Commun. Ment. Health J. 42 (2), 177–187. Choi, S.C., Kim, K.J., Paik, Y.S., Oh, S.W., Kim, J.H., 2002. The relationship of neurocognitive function, symptoms, social cognition and social function in patients with schizophrenia. J. Korean Neuropsychiatr. Assoc. 41 (3), 430–441. Choi, K.H., Saperstein, A.M., Medalia, A., 2012. The relationship of trait to state motivation: the role of self-competency beliefs. Schizophr. Res. 139, 73–77. Comb, D.R., Admas, S.D., Penn, S.L., et al., 2007. Social Cognition and Interaction Training (SCIT) for inpatients with schizophrenia spectrum disorders: preliminary findings. Schizophr. Res. 91, 112–116. Couture, S.M., Penn, D.L., Roberts, D.L., 2006. The functional significance of social cognition in schizophrenia: a review. Schizophr. Bull. 32 (Suppl. 1), S44–S63. Elis, O., Caponigro, J., Kring, A.M., 2013. Psychosocial treatment for negative symptoms in schizophrenia: current practices and futures directions. Clin. Psychol. Rev. 33, 914–928. Ermoli, E., Anselmetti, S., Bechi, M., Cocchi, F., Smerald, I.E., Cavallaro, R., 2005. Assessment of psychosis in schizophrenia: neuropsychological profile of chronic schizophrenia. Clin. Neuropsychiatry 4, 243–249. Evans, J.D., Bond, G.R., Meyer, P.S., et al., 2004. Cognitive and clinical predictors of success in vocational rehabilitation in schizophrenia. Schizophr. Res. 70, 331– 342. Fett, A.-K.J., Viechtbauer, W., Dominguez, M.-G., Penn, D.L., Os, J., &van Krabbendam, L., 2011. The relationship between neurocognition and social cognition with functional outcomes in schizophrenia: a meta-analysis. Neurosci. Biobehav. Rev. 35, 573–588. 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, 119–136.

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