Cognitive Remediation Therapy In Psychosis Patients
Have you ever felt as if someone following you when there is actually nobody around you? Or have you ever experience seeing something that anyone couldn’t see? These experience of questioning the sense of reality from time to time is involving one under 200 people in Australia. Alteration in the way of thinking is due to neuronal problems in the brain which decreases cognitive abilities. The term to describe this mental disorder is called ‘psychosis’. Patients with psychosis are having a symptoms of hallucinations, delusions, difficulties to construct a thoughts or speech, and also may have a disoriented behavior. The symptoms is reduced using variety of treatment approach that involved community engagement, pharmacotherapy and psychotherapy.
In psychotherapy, one of the popular intervention is Cognitive Remediation Therapy (CRT). The major components of CRT are support groups, individual counseling and computerized training using the PSS CogReHab software. Focusing on improving cognitive function, CRT is believed to have a promising outcome on functional capabilities. Although some promising result may occur through CRT, evidence based treatment for psychosis had not yet been established.
Questions arise on whether CRT is effective enough to treat patients with psychosis as well as the importance of exploring patients preference regarding their treatment. Recommendation on shared-decision making as a two way communication in determining the best treatment is valuable. Two studies with different design explored the efficacy of CRT in psychosis patients. One of them explore the efficacy through quantitative studies and another is through qualitative studies. These different approach to explore CRT is important to broaden clinicians and patients perspectives in choosing the right treatment.
Fiszdon, et al. (2016)1 explored CRT for psychosis on a published article entitled “Cognitive remediation for individuals with psychosis: efficacy and mechanisms of treatment effects”. Fiszdon aimed to evaluate the potential mechanism and efficacy of CRT with the training task performance, neurocognition, and functional capacity during two months CRT intervention and two months follow up. The design of this study is a randomized controlled trials conducted on 75 individuals with psychosis. 25 participants were grouped for treatment as usual and 50 participants were treated with CRT. The results showed there was a statistically distinctive improvements on attention ability, verbal learning memory, and visuospatial memory conducted with computerized cognitive tasks compared to treatment as usual (control group). However, there were no significant improvement on functional capacity involved independent living skills and symptoms of psychosis that directly correlates with CRT. The study concluded that the association between CRT and cognitive function improvement is multifactorial despite the promising outcome of CRT.
Qualitative approach to obtain evidence-based research related with CRT is conducted by Contreras et al. (2016) in her published article entitled “How is cognitive remediation training perceived by people with schizophrenia? A qualitative study examining personal experiences”. Whereas Fiszdon inquire into objective purpose on the efficacy of treatment, Contreras covered subjective impression from participants. The study analyzed a questionnaire-facilitated interview from 20 schizophrenic patients after underwent CRT. There were three themes that is observed using the thematic analysis, which are benefits of CRT, experience of doing CRT, and CRT correlations with real life settings. Contreras reported that 70% of the participants acclaimed to had a better cognitive ability, 45% had developed more confidence and motivation, and 20% stated to had improved their social skills. Role of the person who delivered CRT was highlighted as a key for CRT efficacy in terms of being supportive, adaptive and instructive. Overall, Contreras proved that positive experience is gained from CRT.
Although, Fiszdon stated about the promising result of CRT to improve cognitive abilities, multifactorial relationship between CRT and cognitive function on Fiszdon’s conclusion did not answer the direct mechanism that is mentioned in the background. Evidence-based treatment needs a certain significant result or an exact explanation in order to be conducted on patients. However, Fiszdon study does not magnify CRT as the evidence-based treatment on psychosis patients. There is a lot of measurement that is analyzed in Fiszdon study which may hinder the specific measurement between CRT and a certain cognitive function for example in attention. Further analysis of attention improvement as a functional capacity of the patient may answered the mechanism of CRT. Other exploration in statistically significant result variable such as attention ability, verbal learning memory and visuospatial memory is valuable in order to observe direct correlation in patient’s social life or the brain activity of the patients.
Subjective approach on CRT that was explored by Contreras deserve to be taken into account in shared-decision making. Although the benefit of doing CRT is the improvement of cognitive abilities, patient’s comfort in doing therapy is rather questionable. Contreras highlights the idea of participants and therapist relationship that magnifies the benefits of CRT as a positive experience. Therapist role to support, engage, and motivates participants is significant to increase participant’s self-esteem. However, 20 response of the participants included in the study may differ in other 20 individuals. Therefore these subjective response on CRT may not be representable enough for other groups of individuals such as in low-income country that did not have the privilege to computer access or geriatric patients that couldn’t use computer. Recommendation for further qualitative studies conducted on other groups is mentioned in the article.
Fiszdon and Contreras study mentioned about the minimum relevance of CRT to real-life settings. Fiszdon discussed about insignificant result of independent living skills accordance to CRT whereas Contreras reported irrelevant benefits of CRT in everyday life perceived by patients. Therefore, in shared-decision making between patients and clinician it is noteworthy to state that CRT does not relevant enough for everyday life of psychosis patients. Collective result on quantitative and qualitative measurement provides two sides opinion which should be further reckoned. While self-esteem and cognitive improvements seems to be a valuable result, but the importance to consider the patient’s social life in the community is also needed.
There is a complexity in regards to established evidence-based treatment for psychosis patients. Psychosis itself includes spectrum of reasons and symptoms that needs to be further examined. Both published articles supports the idea of CRT to improve cognitive abilities but failed to explain the insignificant result of CRT on real-life settings. Mixed methods of quantitative and qualitative research answers the success numbers increase and reasoning on the efficacy of CRT as a treatment for psychosis patients. Further research in the specific measurement of cognition improvement and exploration on CRT relevance in independent living is recommended to have a better understanding about the efficacy of CRT for psychosis patients.
- Fiszdon J, Choi K, Bell M, Choi J, Silverstein S. Cognitive remediation for individuals with psychosis: efficacy and mechanisms of treatment effects. Psychological Medicine. 2016;46(16):3275-3289.
- Contreras N, Lee S, Tan E, Castle D, Rossell S. “How is cognitive remediation training perceived by people with schizophrenia? A qualitative study examining personal experiences”. Journal of Mental Health. 2016;25(3):260-266.