Cognitive Enhancement Therapy for Schizophrenia.

Effects of a 2-Year Randomized Trial on Cognition and Behavior Hogarty GE, Flesher S, Ulrich R, Carter M, Greenwald D, Pogue-Geile M, et al.; Archives of General Psychiatry 61 (9); 866-876 Commented by Dr Stefan Leucht, 23 Sep 2004 Aim of the study While antipsychotic medications are powerful tools to reduce the positive symptoms of schizophrenia, a major problem are the cognitive dysfunctions that are associated with the disorder. Although it seems that the "atypical" antipsychotics improve cognitive functions somewhat more than conventional compounds, they do not resolve the issue. Therefore, a number of psychotherapeutic strategies have been developed. The current study is the first large-scale randomised controlled trial to assess the effectiveness of cognitive enhancement therapy on cognition and behaviour compared with usual care enriched by supportive psychotherapy. Methods The authors randomised 121 chronic outpatients with schizophrenia or schizoaffective disorder who were symptomatically stable and who were not substance abusing, but who suffered from cognitive dysfunction, to either cognitive enhancement therapy or "enriched supportive therapy". Cognitive enhancement therapy is a multidimensional approach that combines computer-assisted cognitive training and group exercises on social cognition. The control condition "enriched supportive therapy" focuses on coping strategies and psychoeducation. Medication was given as considered necessary by the treating physicians. The duration of the trial was two years. The main outcome variables were Processing Speed, Neurocognition, Cognitive Style, Social Cognition, Social Adjustment and Symptoms which were assessed at baseline and at 12 and 24 months. Results After 24 years of treatment cognitive enhancement therapy showed statistically significant effects on all above mentioned outcome measures with the exception of symptoms. The latter finding was expected, because to be included the patients had to be in stable remission and therefore only suffered from residual symptoms. The type of antipsychotic medication received (e.g. "typical" vs. "atypical" antipsychotics) did not affect the results. Enriched supportive therapy also showed statistically significant improvements compared to baseline suggesting that

supportive psychotherapy can also have positive effects on cognitive deficits. However, the effect sizes of the latter finding were small. Discussion This large randomised controlled trial clearly showed that a specially tailored psychotherapeutic intervention can improve cognitive deficits of patients with schizophrenia. This is very good news, because cognitive deficits are major obstacles to social and vocational reintegration and are considered to be among the most difficult to treat symptoms of schizophrenia. Furthermore, although the "atypical" antipsychotics are probably somewhat more effective than conventional drugs to alleviate cognitive deficits, effect sizes in trials were modest. A problem may be that cognitive enhancement therapy may not be a single, easy to learn and easy to apply intervention, but rather a combination of computer based small-group sessions and weekly larger-group sessions. The concept is based on a program for traumatic brain-injured patients (ref. 1), the cognitive approach of Brenner and colleagues (ref. 2), and a "contemporary theory of cognitive development" (ref. 3). One goal of future research therefore must show whether it is possible to to integrate the programme in clinical routine. References 1. Ben-Yishay Y, Rattok J, Lakin P, Piasetsky E, Ross B, Silver S, Zide E, Ezrachi O (1985). Neuro-rehabilitation: quest for a holistic approach. Semin Neurol 5:252-259 2. Brenner HD, Hodel B, Roder V, Corrigan P (1992).Treatment of cognitive dysfunctions and behaviour deficits in schizophrenia. Schizophrenia Bulletin 18:21-26 3. Brainerd CJ, Reyna VF. Gist is the grist: fuzzy trace theory and the new intuitionism (1990). Dev Rev 10:3-47