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BACKGROUND: Current computerized cognitive training (CT) programs adjust difficulty level solely using a correct or incorrect response. This is the sole method of titrating difficulty because there is only one avenue of input. This is an inherent weakness in how learning is gauged since a correct or incorrect response only conveys one part of the story, so to speak, and does not capture effort expenditure nor level of task engagement, both of which impact performance scores. Neurofeedback provides information about these additional variables and has been used in a number of cognitive therapies to improve domains such as cognitive control in college students and children with ADHD. Neurofeedback offers CT programs for psychosis a technological step toward maximizing training gains. More specifically, neurofeedback that uses pupillometry can be used as an index of cognitive load and task engagement in CT to generate an algorithm that adjusts task difficulty to remain optimally challenging and arousing while not too frustrating or too easy. METHODS: We compared CT with and without pupillometer-based neurofeedback in three groups of psychosis--established psychosis (n=42), first episode (n=31), and clinical high risk (n=27). This was a double-blind study that used the same tablet-based processing speed training program and the same head-mounted pupillometer but with the pupillometer not syncing with the control box (essentially, turned off), so task difficulty and learning progression were based on either performance (correct/incorrect responses) or pupillometric feedback. CT consisted of sixteen 50-minute sessions over the course of 2 months, with assessments at baseline and post. RESULTS: The results show a clear advantage when pupillometric neurofeedback is incorporated into the titration algorithm in all three groups. While CT with and without pupillometry improved processing speed, greater gains were noted in the neurofeedback groups on both motorical and non-motorical processing speed. The neurofeedback groups, regardless of psychosis stage, also reported greater motivation/interest for treatment, with 90% completing the entire training compared to just 72% in the group without neurofeedback. CONCLUSIONS: This shows that CT can be quite taxing for people at any stage of psychosis, and correct/incorrect responses do not fully gauge the level of cognitive resources one commits to a task. Pupil dilation betrays underlying neurophysiologic engagement and serves as a precursor to disengagement on a behavioral task. We know that there is a “sweet spot” for the optimal load placed on cognitive resources, in terms of whether a training task is not stimulating enough (constricted pupils), ideally stimulating, or if there is too much information and the task has become overwhelming (dilated pupils). Pupillometry allows us to optimize the training exercises by providing biofeedback to the training software that then uses this information, along with task performance data, to automatically adjust training task parameters and levels for a personalized and efficient training program. In this manner, pupillometric neurofeedback can provide a concise index of how much the person is actively involved in the exercise at that very moment, even before performance can be registered as a correct or incorrect response.

Adherence to treatment in psychiatric populations is notoriously low. In this randomized, controlled, proof-of-concept study, we sought to examine whether motivational interviewing (MI) could be used to enhance motivation for, adherence to, and benefit obtained from cognitive rehabilitation. Dual diagnosis MI, developed specifically for individuals with psychotic symptoms and disorganization, was further adapted to focus on cognitive impairments and their impact. Sixty-four outpatients diagnosed with schizophrenia spectrum disorders completed baseline assessments and were randomized to receive either the 2-session MI focused on cognitive functioning or a 2-session sham control interview focused on assessment and feedback about preferred learning styles. Next, all participants were given 4 weeks during which they could attend up to 10 sessions of a computer-based math training program, which served as a brief analog for a full course of cognitive rehabilitation. As hypothesized, MI condition was associated with greater increases in task-specific motivation along with greater training program session attendance. Moreover, postinterview motivation level predicted session attendance. There were no significant differences in improvement on a measure of cognitive training content, which may have been due to the abbreviated nature of the training. While the literature on the efficacy of MI for individuals with psychosis has been mixed, we speculate that our positive findings may have been influenced by the adaptations made to MI as well as the focus on a nonpharmacological intervention.

Background Cognitive deficits are common in people with schizophrenia and have a negative impact on functioning. Cognitive Remediation (CR) is an effective approach to reduce the burden of cognitive difficulties however there are individual differences in therapy response. Previous research suggests that participants age may be a significant moderator of therapy efficacy but results are inconclusive. This study attempts to fill this gap by exploring how age may influence CR outcomes. Methods Data from ten trials from the NIMH Database of Cognitive Training and Remediation Studies (DoCTRS) were used. We considered the following therapy outcomes: Executive function as assessed by the Trail making test part B (TMTB), the Wisconsin Card Sorting Test (WCST) and Verbal fluency (FAS) scores. Working memory was assessed with the Letter-Number Span (LNS) and the Digit span. Symptoms were evaluated with the Positive, Negative and General scores from the Positive and Negative Syndrome Scale (PANSS). Functioning was assessed using the Heinrichs-Carpenter quality of life (HCQOL) scale. To evaluate the effect of age on outcomes we classified participants into under 40 and over 40 years old. We compared outcomes across age groups using mixed linear models. Results We considered data from 711 people with schizophrenia (407 received CR and 304 the control condition). For the under 40 group the average age was 29.26 (SD 6.83) while the average yeas spent in education was 12.11 (2.61). The over 40 group had a mean age of 40.09 (SD 6.09) and 12.11 (2.54) years of education. We found a significant interaction between age and working memory and functioning improvement for the over 40 group. The younger group showed a larger effect of CR in term of general symptoms reduction. We did not find an effect of age on executive function, positive and negative symptom. Discussion The results indicate that CR may benefit people with schizophrenia in different way depending on their age. Age may represent a large number of complex factors and more work is needed in this area to better understand how individual characteristics and illness history may influence CR response. Work in this sense will help to reduce CR response heterogeneity and improve therapy personalisation.

Background: Emerging research highlights the potential cognitive benefits of physical fitness programs for schizophrenia. Physical exercise (PE) is a safe, nonstigmatizing, and side effect-free intervention that has the potential to mitigate neurocognitive dysfunction in psychosis. To date, only two recent studies have explored the possibility of combining PE and cognitive training therapy (CT). While both studies found a signal showing that combining PE and CT may improve cognition more than CT alone, the conclusions were limited by lack of randomization, no examination of biological factors, no study arm with PE only, low power due to small sample size (N < 22), or significant attrition during the physical exercise intervention (i.e., only 75% completed the PE regimen). Methods: In our randomized pilot with 82 outpatients, we examined the individual and synergistic effects of PE and/or CT using treatments designed to improve motivation for treatment and retain patients for the entire PE (and CT) intervention. This 3-arm study employed a self-determined PE regimen intended to improve motivation for exercising and neurofeedback-aided CT that monitored a biophysiologic gauge of motivation to maximize cognitive gains. Participants were allocated to 18 hours of either: (A) PE regimen where patients chose from a menu of activities for 12 weeks with each activity designed so participants would reach volitional exhaustion—a commonly accepted physiological gauge of strenuous exercise—at least twice per week; (B) tablet-based neurofeedback CT focused on processing speed and working memory, or (C) a combination of PE and CT, matched for total duration and treatment time. Assessments of cognition and symptoms were conducted at baseline, post (3 months), and follow-up (5 montha). Results: At post, all three groups showed significant improvements in working memory, with the PE group surpassing the other two in working memory and processing speed improvements. However, at 2-month follow-up, gains in the PE only group disappeared, and it was the PE+CT group that showed significant improvements in both cognition and negative symptoms. Notably, attrition for all three groups was only 4%–7% and even those with low baseline motivation attended as many sessions as those with high motivation while both saw improvements in cognition and negative symptoms. Conclusion: This pilot is the first study to show that combining PE and CT leads to lasting effects that are superior to those of either intervention alone. Moreover, our approach to PE and CT was well tolerated, and the low dropout rate may have further maximized the benefits of both types of interventions.

Background: Social cognitive deficits play an important role in social functioning in adults with established psychosis (schizophrenia), young adults recently diagnosed with schizophrenia in the last 2 years (first episode psychosis; FEP), and teenagers at clinical high risk for developing psychosis (CHR). In particular, the ability to infer other people’s mental states has been shown to be compromised in those with psychosis, albeit less so in earlier stages. Recent studies have shown that processing speed (PS) may be upstream to social cognitive abilities in psychosis. If such were the case, remediating PS may in turn have beneficial effects on social cognition. This study examined whether improving PS would lead to subsequent improvements in social cognition in individuals with schizophrenia, FEP, and/or CHR. We examined whether (a) improving PS was related to improvements in social cognition, and (b) if so, whether these social cognitive improvements would in turn lead to fewer symptoms and better social function.