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Individuals with psychotic disorders have deficits in metacognition. Thirty-four adults with schizophrenia were randomized to 2 months of metacognitive training (MCT) or a healthy living skills control group. All participants were enrolled in a work therapy program, followed by a supported employment program. Assessments were conducted at baseline, at the end of the 2-month active intervention, and at 4- and 12-month follow-ups. At the end of active intervention, the MCT group demonstrated greater improvement and better work behavior relative to controls. At follow-up, the MCT group demonstrated significantly greater insight and fewer positive symptoms and a greater percentage were employed in the community. We speculate that being better able to think about one's thoughts, recognize biases in thinking, and correct those thoughts may aid in responding to workplace challenges and hence improve work outcomes.

OBJECTIVE: In a previous report on a randomized clinical trial of a 3-month program of Cognitive Remediation Therapy (CRT) augmented by work therapy (WT) compared with WT alone for older Veterans with substance use disorder (SUD), we reported significantly greater improvements at six- month follow-up on neurocognitive outcomes of working memory and executive functions for the CRT+WT condition. However, no difference was found between conditions on substance use disorder (SUD) outcomes, with both groups showing unusually high levels of abstinence. In the present study, we extended follow-up to 12 months to test whether there was an SUD outcome “sleeper effect” from CRT+WT. To better understand the effects of WT, we added a treatment-as-usual (TAU) comparison sample. METHOD: 48 Veterans with SUD receiving standard outpatient VA care were randomized into CRT+WT or WT. Clinical Global Impression (CGI) ratings were performed on 43/48 participants with up-to-date medical records. TAU comparison group (n = 44) with similar demographic and illness characteristics was added to the analysis. RESULTS: Treatment groups did not differ significantly at 12 months on CGI (p=.27), with 77% receiving CRT+WT showing favorable SUD outcomes compared to 62% in WT. Both groups had better CGI outcomes (p

While there is increasing support for the efficacy of psychosocial interventions for people with SMI, the real-world effectiveness of such treatments is diminished by lack of motivation for treatment, leading to poor treatment engagement/dropout. We sought to evaluate the efficacy of motivational interviewing (MI) in improving attendance in a full course of cognitive training, examine motivation level as a potential mechanism of action, and examine variables associated with initial engagement in the training.One hundred fourteen participants with SMI were randomized to MI or sham control interview (CI), both of which were followed by a 4-month active phase during which participants could attend up to 50 unpaid cognitive training sessions.Fidelity to the MI intervention was high, and MI condition was associated with increases in perceived value of training tasks and, to a lesser extent, how enjoyable/interesting they were rated. Twenty-nine percent of the full sample did not attend any training sessions. In ITT analyses, there was no significant between-group impact of MI on treatment attendance, though one emerged when participants who did not attend any sessions were excluded. Treatment attendance was predicted by the level of motivation achieved after the MI/CI intervention. Those who attended at least one training session (regardless of randomization) were more likely to believe they had cognitive impairments, had higher IQ and had less severe general psychiatric symptoms.MI showed some promise and may be a worthwhile addition to more comprehensive, robust efforts to promote initial treatment engagement and subsequent adherence.

Background IQ and IQ decline are considered risk factors for poor prognosis in people with a diagnosis of schizophrenia. However, it is still not clear if, at least in part, IQ and IQ decline influence long-term outcomes via a negative effect on interventions. Aim To identify whether current IQ, estimated premorbid IQ, or IQ decline moderate the response to cognitive remediation (CR). Method Individual participant data from twelve randomised controlled trials of CR were considered. Hierarchical and k-means analyses were carried out to identify different IQ clusters. The moderating effect of estimated premorbid IQ, current IQ, and different IQ clusters (preserved, deteriorated and compromised trajectories) on cognitive outcomes at post-therapy and follow-up were evaluated using multiple linear regression. Results Data from 984 participants (CR = 544, control = 440) with schizophrenia and schizoaffective disorders were considered. The sample had a mean current IQ of 84.16 (SD 15.61) and estimated premorbid IQ of 95.82 (SD 10.63). Current IQ moderated working memory outcomes: people with higher IQ had larger working memory gains after therapy compared to those with a lower IQ. Those with a preserved IQ had better cognitive outcomes compared to either the deteriorated or compromised IQ groups, and those with a deteriorated IQ had better outcomes compared to those in the compromised IQ group. Conclusion Current IQ is a significant moderator of cognitive gains after CR. These findings highlight the need to evaluate whether therapy adaptations (e.g. offering more sessions) can attenuate this effect so that those with lower IQ may derive benefit similar to those with higher IQ.

We sought to evaluate the influence of demographic, symptom, functional and cognitive factors on task-specific motivation, as well as improvement in task-specific motivation that occurs in response to motivational interviewing. In the absence of any intervention, better task-specific motivation was associated with higher perceived competence and lower symptomatology. Post-motivational enhancement improvement in motivation was predicted by fewer hospitalizations and better cognitive insight, with baseline symptomatology no longer predictive. Findings suggest motivational enhancement is likely to benefit individuals with diverse clinical presentations, though may be particularly well suited to those with lesser disease severity and better cognitive insight.

Defeatist beliefs and amotivation are prominent obstacles in vocational rehabilitation for people with serious mental illnesses (SMI). The CBT-based Indianapolis Vocational Intervention Program (IVIP) was specifically designed to reduce defeatist beliefs related to work functioning. In the current study, we examined the impact of IVIP on defeatist beliefs and motivation for work, hypothesizing that IVIP would be associated with a reduction in defeatist beliefs and greater motivation for work. We also examined the effects of IVIP on these variables as well as work outcomes during a 12-month follow-up. Participants with SMI (n=64) enrolled in a four-month work therapy program were randomized to IVIP or a support therapy group (SG). Assessments were conducted at baseline, post-treatment (4 months), and follow-up (1 year). Compared to those in SG condition, individuals randomized to IVIP condition reported greater reductions in defeatist beliefs and greater motivation for work at follow-up, along with greater supported employment retention rates. Specifically treating and targeting negative expectations for work therapy improves outcomes, even once active supports of the IVIP program and work therapy are withdrawn.

Objective Among individuals at clinical high risk (CHR) for psychosis, processing speed (PS) has been related to social and role functioning regardless of conversion to schizophrenia. This information processing dysfunction is a gateway to broader behavioral deficits such as difficulty executing social behaviors. We examined the feasibility of improving information processing relevant to social situations in CHR, including its sustainability at 2-month follow-up, and its association with concurrent social function. Method This was a double-blind RCT in which 62 CHR participants were randomized to Processing Speed Training (PST) or an active control matched for training format and the same dose and duration of treatment. PST is a tablet-based program that uses pupillometry-based neurofeedback to continually adjust training parameters for an optimal neurocognitive load and to improve visual scanning efficiency by inhibiting selection of nonessential targets and discriminating figure-ground details. Results The PST group showed faster motoric and nonmotoric PS at post training and 2-month follow-up. At 2 month follow-up, the PST group reported better overall social adjustment. Changes in PS from baseline to 2 months were correlated with overall social adjustment and social avoidance in the entire sample. Conclusions and implications for practice This is the first study to test focal neurofeedback-based cognitive training for PS deficits in the putatively prodromal phase of schizophrenia to address associated social morbidity. Targeting PS appears to be a promising pathway to decreasing comorbidity and mitigating a risk factor for psychosis. (PsycINFO Database Record

Cognitive remediation is now widely recognized as an effective treatment for cognitive deficits in schizophrenia. Its effects are meaningful, durable, and related to improvements in everyday functional outcomes. As with many therapies, the evolution of cognitive remediation has resulted in treatment programs that use a variety of specific techniques, yet share common core principles. This paper is the product of a cognitive remediation expert working group consensus meeting to identify core features of the treatment and produce recommendations for its design, conduct, reporting, and implementation. Four techniques were identified as core features of cognitive remediation: facilitation by a therapist, cognitive exercise, procedures to develop problem-solving strategies, and procedures to facilitate transfer to real world functioning. Treatment techniques within each of these core features are presented to facilitate decisions for clinical trials and implementation in clinical settings.

BACKGROUND: Thought to be essential for daily functioning, prospective memory (PM) deficits were found in both adults with established psychosis (Schizophrenia; SCZ) and younger adults recently diagnosed with SCZ (First Episode Psychosis; FEP). Examined further, time-based PM appeared to be more impaired than event-based PM, which may contribute toward various negative symptoms including social withdrawal. It remains unclear if similar PM deficits present at an earlier, prodromal stage of psychosis such as teenagers at clinical high risk for psychosis (CHR) and how they may correlate with negative symptoms and social functioning. METHODS: Participants included 25 teenagers at CHR (16-19yo), 22 young adults with FEP (18-21yo), 42 adults with SCZ (21-55yo), and 29 healthy controls (18-24yo). This cross-sectional assessment included the Cambridge Test of Prospective Memory (CAMPROMPT), Scale of Psychosis-risk Symptoms (SOPS), PANSS, Specific Levels of Functioning Assessment (SLOF), Social Adjustment Scale (SAS), and the Continuous Performance Test-Identical Pairs (CPT-IP). Differences were calculated using pairwise comparisons (Tukey test). RESULTS: CHR performed worse on time-based PM compared to healthy controls (F=2.45, p=0.01) while event-based PM was found to still be relatively intact. Compared to FEP and SCZ, CHR presented with similar time-based PM impairment to FEP, but it was not as severe as SCZ. These time-based PM impairments mirrored performances in attention, as CHR and FEP had similar attentional impairments compared to health controls (F=2.18, p=0.03), but again, not as severe as SCZ. Interestingly, across all three groups, while time-based PM was more impaired, it was event-based PM that was related to negative symptoms (r’s>-0.23, p’s0.26, p’s

BACKGROUND: Physical exercise (PE) is a safe, non-stigmatizing, and side-effect free intervention that has the potential to mitigate neurocognitive dysfunction in psychosis, as well as reduce anxiety and paranoia. Developing and promoting PE programs for people with SMI in the community where participants cannot be paid to participate requires an interdisciplinary approach to activate motivation for exercise. We report the initial development and pilot results of a PE community program developed to enhance motivation and engagement in adults with schizophrenia, merging expertise from the fields of exercise physiology, recreational therapy, virtual reality (VR) gaming technology, and neuropsychiatric rehabilitation. METHODS: Adult outpatients diagnosed with schizophrenia (N=29) were enrolled in 18 hours (40 min session, 3x/week for 3 months) of exergaming. Exergaming uses interactive exercise equipment connected to a computer and monitor so the patient is engaged in a virtual game while exercising. For example, while pedaling on an exergaming stationary bike, the can have the experience of racing or biking through the countryside, either using a virtual reality headset or simply looking at the monitor. The PE regimen was tailored for each participant based on input from a (1) exercise physiologist about optimal methods to achieve volitional exhaustion and reduce the risk for injury, (b) recreational therapist who set up the overall exercise milieu to promote enjoyment, (c) expert in VR technology who calibrated and tailored the virtual experience to each participant (d) psychiatrist who monitored medical risk for strenuous exercise, and (d) psychologist who collected outcome data. Cognition and symptoms were assessed at baseline and post (3 mo.) while motivation and treatment engagement were recorded biweekly. RESULTS: Large effects were seen in working memory from baseline to post (WASI WMI; ES=.53), with medium effects in overall symptoms (PANSS; ES=.30). Importantly, participants reported a high degree of motivation for PE throughout the treatment period (Intrinsic Motivation Inventory total score>35), and 27 out of 29 completed the entire PE regimen of 18 hours although they were not paid to attend. CONCLUSIONS: This study highlights the potential benefits of a PE program developed by an interdisciplinary team combing expertise in exercise, technology, recreation, and neuropsychiatry. Drawing from experience in other fields may help develop new treatments in psychiatric rehabilitation to maximize overall outcome. Funded by a Hartford Hospital Auxiliary Special Projects Grant to JC

The link between cognition and functioning in schizophrenia is well established, and there is a large body of research supporting the efficacy of cognitive remediation (CR) for improving cognitive function in individuals with psychosis. In recent years, the focus of CR research has shifted to better understanding how these interventions work, and factors that influence whether or not an individual is likely to benefit from any such intervention. This line of research is particularly important given the considerable variability in response to this time and labor-intensive intervention, with upwards of 40% of individuals being non-responders. In the current symposium, we present new data exploring specific characteristics of CR interventions, individual participants, and disorder pathology that may influence CR’s impact on outcomes of interest and inform the likelihood of positive response to this intervention. Mr. Best focuses his talk on the impact of differences in CR approaches. He presents data from a trial directly comparing an executive and perceptual skill-focused CR approach. Neurocognitive, symptom, self-report, functional competence and community function outcomes are evaluated, along with their trajectories after the active intervention phase. EEG data is also presented probing the neurophysiological mechanisms underlying specific effects of these two CR approaches. Dr. Choi focuses on how the efficacy of CR delivery methods may be augmented by using neurofeedback. He presents data from a trial examining the impact of augmenting standard performance-based CR with pupillometry, which indexes effort expenditure and task engagement, and may thereby offer a more sensitive measure of parameters relevant to optimizing learning. Effects of CR with and without pupillometric feedback are compared on measures of cognitive function and training motivation, and differences in neurofeedback learning algorithms between individuals with chronic schizophrenia versus first episode and clinical high risk are discussed. Dr. Kurtz focuses on person characteristics that may influence response to CR. He presents data on the influence of demographic factors, cognition, symptoms, and treatment duration/intensity on CR-associated improvements in working memory and functional capacity, and discusses his findings in relation to existing research on predictors of response to CR. Dr. Penades focuses on the genetic contributions to cognition and CR outcomes. He reviews recent literature on the impact of genetic variables on cognitive function and response to CR, presents new data on the impact of two gene polymorphisms (COMT and BDNF) on cognitive function, and discusses how genetic variability may be used to develop predictive models to optimize outcomes of different CR approaches.

BackgroundThe popularity of cognitive remediation (CR) interventions for individuals with psychosis is in part based on the well-established link between cognition and functioning and the assumption that by targeting cognition, function can improve. While numerous trials have reported CR's efficacy, it is still not considered an evidence-based treatment. Importantly, little is known about the mechanisms through which it may affect functioning.MethodIn this study, we evaluated CR's proximal and distal effects, and examined potential mechanisms. A total of 75 individuals with psychotic disorders were randomized to a combination of strategy-based and drill-and-practice CR or wait-list control, with assessments of training task performance, neurocognition, functional capacity, symptoms and functioning conducted at baseline, end of the 2-month intervention, and 2-month follow-up.ResultsCompared with treatment as usual, CR was associated with large post-training improvements on training tasks targeting attention, visuospatial memory, and verbal learning and memory, with persisting group differences at the 2-month follow-up. These generalized to mostly large improvements on neuropsychological measures targeting visuospatial memory, verbal learning and memory, delayed verbal memory and verbal working memory. While there were no CR-associated improvements on measures of functional capacity, symptoms, or a self-report measure of independent living skills, there was an effect on an interviewer-rated measure of functioning (Quality of Life Scale), which appeared primarily driven by the Intrapsychic Foundations subscale. Finally, for those randomized to CR, there were significant, medium-sized correlations between training task improvement, neuropsychological improvement and functioning measures.ConclusionsThis suggests a complex, multifactorial relationship between CR, and cognitive and functional change.

Conceptually, motivation can be separated into two types, intrinsic and extrinsic. Intrinsic motivation involves goal-directed behaviors that meet internal psychological needs, while extrinsic motivation involves behaviors executed to obtain external reward or avoid punishment. Both these types of motivation are diminished in psychosis and are linked to amotivation and anhedonia, two of the negative symptoms seen in schizophrenia. In the last several years, the field of motivation research has advanced by (a) developing better instruments to quantify intrinsic motivation, (b) studying the role of effort in evaluating the importance of rewards, (c) examining the neurobiological and behavioral correlates of deficits in learning from feedback, and (d) honing neurophysiologic and behavioral interventions to directly target motivation impairments. In this review, we examine each of the above topics and comment on how our current understanding of motivation may inform the development and testing of new interventions to optimize psychiatric recovery.

Background The construct, convergent, discriminant, and predictive validity of Learning Potential (LP) was evaluated in a trial of cognitive remediation for adults with schizophrenia-spectrum disorders. LP utilizes a dynamic assessment approach to prospectively estimate an individual's learning capacity if provided the opportunity for specific related learning. Methods LP was assessed in 75 participants at study entry, of whom 41 completed an eight-week cognitive remediation (CR) intervention, and 22 received treatment-as-usual (TAU). LP was assessed in a “test-train-test” verbal learning paradigm. Incremental predictive validity was assessed as the degree to which LP predicted memory skill acquisition above and beyond prediction by static verbal learning ability. Results Examination of construct validity confirmed that LP scores reflected use of trained semantic clustering strategy. LP scores correlated with executive functioning and education history, but not other demographics or symptom severity. Following the eight-week active phase, TAU evidenced little substantial change in skill acquisition outcomes, which related to static baseline verbal learning ability but not LP. For the CR group, LP significantly predicted skill acquisition in domains of verbal and visuospatial memory, but not auditory working memory. Furthermore, LP predicted skill acquisition incrementally beyond relevant background characteristics, symptoms, and neurocognitive abilities. Conclusions Results suggest that LP assessment can significantly improve prediction of specific skill acquisition with cognitive training, particularly for the domain assessed, and thereby may prove useful in individualization of treatment.

In this chapter, we provide an overview of nonpharmacological interventions targeting social cognitive abilities in individuals with psychosis. In addition to describing proof-of-concept, along with single and multidomain interventions, we summarize the evidence base of these nonpharmacological interventions, with a focus on how they impact social cognitive measures. Psychosocial interventions that include social cognitive training as one component of a broader-based intervention (e.g., treatments such as those that concurrently target social skills, neurocognition, or metacognition along with social cognition), or that are augmented by additional treatments (e.g., oxytocin), are not included in this review, as the unique contribution of individual treatment components cannot be discerned. Psychosocial interventions that focus on related, yet somewhat different, skills (e.g., metacognition) are not included in this review. Interventions that focus on improving social function through methods other than social cognitive training are discussed in a separate chapter (Chapter 14).

Music has been demonstrated to improve cognitive test performance in neuropsychiatric populations. However, the impact of music on cognitive training effects, and the importance of music preference, has yet to be studied. This is an essential oversight since many cognitive training programs play music in the background. We sought to determine if participant-preferred or random music would increase the efficacy of computer-based attention training (AT). Forty-eight patients with schizophrenia were randomly assigned to two weeks of either: (a) AT with participants’ choice of background music, (b) AT with random background music, (c) AT without music, or (d) a no training or music control—watching videos without AT or music. All groups except the no training/no music control group demonstrated improvement in reaction time and response accuracy after training, with those participating in AT with their choice of music exhibiting greater gains than either of the other two AT groups. These findings suggest that complimenting AT with music, and allowing participants to choose the music, may increase the efficacy of AT.

On average, cognitive remediation (CR) is effective in improving cognitive function in individuals with psychosis, though there is considerable variability in treatment response. No consensus has emerged to date about the potential influence of patient and illness characteristics on CR efficacy. In the current analyses, we examined baseline demographic, cognitive, clinical, and functional ability variables as potential moderators of cognitive improvements during a randomized, controlled trial of a hybrid drill-and-practice plus strategy training CR intervention.In an attempt to disentangle non-specific vs. CR specific treatment effects, we separately examined potential predictors of cognitive improvement in individuals who received CR versus those in the control condition. Cognitive gains were predicted by a large array of demographic, symptom and cognitive variables, however this was true both in the CR and the control condition. CR-specific cognitive improvement was associated with more severe course of illness as indexed by higher number of hospitalizations, with poorer baseline cognition, and with less severe baseline negative symptoms. Keywords: Psychosis, Schizophrenia, Cognitive remediation, Moderators, Treatment outcome

Cognitive impairment affects more than half of persons with multiple sclerosis (PwMS), and it is associated with difficulties in multiple aspects of daily functioning. There is a growing body of literature that has explored the use of cognitive-focused interventions in PwMS, which aim to improve cognition-related function through drill and practice exercises, training in compensatory strategies, or a combination of the two. The current study aimed to expand upon previously published meta-analyses in this area, exploring the effects of cognitive-focused interventions on objective and subjective functioning in PwMS, as well as determining demographic and treatment-related factors that may influence intervention efficacy. Thirty-three studies, with a total of 1890 participants, were included in the meta-analysis. Outcome measures were categorised based on the domain they presumably assessed. For objective cognitive functioning, weighted effect-size analysis revealed small effects of cognitive-focused interventions on working memory (

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.

Cognitive rehabilitation for mild cognitive impairment (MCI) and early Alzheimer's disease is readily available to the geriatric population. Initial evidence suggests that techniques incorporating motivational strategies to enhance treatment engagement may provide more benefit than computerised training alone. Seventy four adults with subclinical cognitive decline were randomly assigned to computerised cognitive training (CCT), Cognitive Vitality Training (CVT), or an Active Control Group (ACG), and underwent neuropsychological evaluations at baseline and four-month follow-up. Significant differences were found in changes in performance on the Modified Mini Mental State Examination (mMMSE) and measures of verbal learning and memory across treatment groups. Experimental groups showed greater preservation of functioning on the mMMSE than the ACG group, the CVT group performed better than the ACG group on one measure of verbal learning and both measures of verbal memory, and the CCT group performed better than the ACG group on one measure of verbal learning and one measure of verbal memory. There were no significant group differences between the CVT and CCT groups on measures of verbal learning or memory. It was concluded that computerised cognitive training may offer the most benefit when incorporated into a therapeutic milieu rather than administered alone, although both appear superior to more generic forms of cognitive stimulation.

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.

This study introduces a computerized clinical decision-support tool, the Fluid Outpatient Rehabilitation Treatment (FORT), that incorporates individual and ever-evolving patient needs to guide clinicians in developing and updating treatment decisions in real-time. In this proof-of-concept feasibility pilot, FORT was compared against traditional treatment planning using similar behavioral therapies in 52 adults with severe mental illness attending community-based day treatment. At posttreatment and follow-up, group differences and moderate-to-large effect sizes favoring FORT were detected in social function, work readiness, self-esteem, working memory, processing speed, and mental flexibility. Of participants who identified obtaining a General Education Diploma as their goal, 73% in FORT passed the examination compared with 18% in traditional treatment planning. FORT was also associated with higher agency cost-effectiveness and a better average benefit-cost ratio, even when considering diagnosis, baseline symptoms, and education. Although the comparison groups were not completely equivalent, the findings suggest computerized decision support systems that collaborate with human decision-makers to personalize psychiatric rehabilitation and address critical decisions may have a role in improving treatment effectiveness and efficiency.

The Social Attribution Task-Multiple Choice (SAT-MC) tests the ability to extract social themes from viewed object motion. This form of animacy perception is thought to aid the development of social inference, but appears impaired in schizophrenia. The current study was undertaken to examine psychometric equivalence of two forms of the SAT-MC and to compare their performance against social cognitive tests recommended for schizophrenia research. Thirty-two schizophrenia (SZ) and 30 substance use disorder (SUD) participants completed both SAT-MC forms, the Bell-Lysaker Emotion Recognition Task (BLERT), Hinting Task, The Awareness of Social Inference Test (TASIT), Ambiguous Intentions and Hostility Questionnaire (AIHQ) and questionnaire measures of interpersonal function. Test sensitivity, construct and external validity, test-retest reliability, and internal consistency were evaluated. SZ scored significantly lower than SUD on both SAT-MC forms, each classifying ~60% of SZ as impaired, compared with ~30% of SUD. SAT-MC forms demonstrated good test-retest and parallel form reliability, minimal practice effect, high internal consistency, and similar patterns of correlation with social cognitive and external validity measures. The SAT-MC compared favorably to recommended social cognitive tests across psychometric features and, with exception of TASIT, was most sensitive to impairment in schizophrenia when compared to a chronic substance use sample.

Social cognition represents an important treatment target, closely linked to everyday social function. While a number of social cognitive interventions have recently been developed, measures used to evaluate these treatments are only beginning to receive psychometric scrutiny. Study goals were to replicate recently-published psychometrics for several social cognitive measures, and to provide information for additional social cognitive measures not included in recent reports. Forty-eight outpatients with psychotic-spectrum disorders completed measures of emotion perception, theory of mind, and attributional bias on two occasions, one month apart. Measures were tested for distributional characteristics, test-retest reliability, utility as a repeated measure, and relationship to symptoms and functioning. For a subgroup of participants, information about sensitivity to social cognitive treatment was also available. We replicated aspects of prior work, including largely favorable psychometric characteristics for the Bell-Lysaker Emotion Recognition Task, and promising but weaker characteristics for The Awareness of Social Inferences Test subscales and Reading the Mind in the Eyes Task. The Hinting Task had adequate test-retest statistics but a more pronounced ceiling effect. Ambiguous Intentions and Hostility Questionnaire data showed evidence of validity but were limited by inconsistency over time. Our results strongly support the Davos Assessment of Cognitive Biases Scale for future evaluation as a social cognitive treatment outcome measure. Its scores were adequately distributed, consistent over time, related to symptoms and functioning, and sensitive to treatment effects. Other relatively novel assessments of attributional bias and theory of mind showed some promise, although more work is needed.

Background: While numerous trials have reported on the efficacy of cognitive remediation (CR), it is still not considered an evidence-based treatment and very little is known about mechanisms through which it may exert effects on functioning, as well as what variables predict a positive treatment response. In the current study, we evaluated both proximal and distal effects of CR, and examined predictors and potential mechanisms of treatment effects.

Supported employment is an effective intervention for people with serious mental illnesses (SMI) but is underutilized. Clients' desire to work might be heightened by programs that provide counseling about managing one's funds, since money management helps people become more aware of the advantages of having money.To analyze the thoughts of recently homeless or hospitalized persons with SMI concerning their personal finances and employment.We interviewed 49 people with SMI about their finances, reviewed transcripts and analyzed their baseline characteristics.Twenty of the 49 participants spontaneously expressed a desire to work in order to earn more money. Those who expressed a desire to work managed their money significantly better than those who did not.Discussion of finances, such as that fostered by money management programs, may promote engagement in vocational rehabilitation and working for pay.

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.

The Social Attribution Task-Multiple Choice (SAT-MC) uses a 64-second video of geometric shapes set in motion to portray themes of social relatedness and intentions. Considered a test of “Theory of Mind,” the SAT-MC assesses implicit social attribution formation while reducing verbal and basic cognitive demands required of other common measures. We present a comparability analysis of the SAT-MC and the new SAT-MC-II, an alternate form created for repeat testing, in a university sample (n=92). Score distributions and patterns of association with external validation measures were nearly identical between the two forms, with convergent and discriminant validity supported by association with affect recognition ability and lack of association with basic visual reasoning. Internal consistency of the SAT-MC-II was superior (alpha = .81) to the SAT-MC (alpha = .56). Results support the use of SAT-MC and new SAT-MC-II as equivalent test forms. Demonstrating relatively higher association to social cognitive than basic cognitive abilities, the SAT-MC may provide enhanced sensitivity as an outcome measure of social cognitive intervention trials.

Adults with serious mental illness (SMI) may struggle with expectations of failure in vocational rehabilitation. These expectations can be global and trait-like or performance-specific and related to ability.To date, it has not been examined whether global or performance-specific defeatist beliefs are related to functional outcomes.The Indianapolis Vocational Intervention Program (IVIP) is a CBT intervention used to address expectations of failure and improve work performance. We examined the relationships between defeatist beliefs, self-esteem, social functioning, and work behaviors in 54 adults with SMI who completed IVIP within a work therapy program.Baseline work-specific defeatist beliefs were related to baseline self-esteem, employment attitude, and work behaviors. Decline in work-specific defeatist beliefs was associated with better social functioning, self-esteem, and work behaviors. Decline in global defeatist beliefs was only associated with improvements in social functioning.Performance-specific expectations about work may be an appropriate therapeutic target to enhance work outcome in SMI.

Intrinsic motivation is a construct commonly used in explaining goal-directed behavior. In people with schizophrenia, intrinsic motivation is usually subsumed as a feature of negative symptoms or underlying neurocognitive dysfunction. A growing literature reflects an interest in defining and measuring motivational impairment in schizophrenia and in delineating the specific role of intrinsic motivation as both an independent predictor and a mediator of psychosocial functioning. This cross-sectional study examined intrinsic motivation as a predictor of vocational outcomes for 145 individuals with schizophrenia and schizoaffective disorder participating in a 6-month work rehabilitation trial. Correlation and mediation analyses examined baseline intrinsic motivation and negative symptoms in relation to work hours and work performance. Data support a significant relationship between intrinsic motivation and negative symptoms and significant correlations with outcome variables, such that lower negative symptoms and greater intrinsic motivation were associated with better work functioning. Moreover, in this sample, intrinsic motivation fully mediated the relationships between negative symptoms, work productivity, and work performance. These results have significant implications on the design of work rehabilitation interventions for people with schizophrenia and support a role for targeting intrinsic motivation directly to influence vocational functioning. Future directions for research and intervention are discussed.

Learning potential (LP) refers to the ability to improve cognitive performance as a result of training. It is typically assessed by test-train-test administrations of a task, wherein changes in pre-post performance are an index of LP. In schizophrenia research, LP has been suggested as a mediator of the relationship between static neurocognition and functional outcome. While a number of studies do indicate that LP assessment improves prediction of functioning beyond standard administrations of the same task, multiple approaches of computing LP indices have been used in this work. Multiple psychometric issues have been raised with respect to computation of change scores, but have not been widely recognized in LP assessment. To address this issue, the current study aimed to evaluate the test-retest reliability, interrelatedness, construct, and criterion validity of several conventional indices of LP, obtained from a test-train-test version of a list-learning task administered to 43 individuals with chronic schizophrenia. Overall, test-retest and intercorrelation coefficients indicated variable reliability and convergence across methods. While LP indices generally correlated more highly with independent measures of neurocognition and community functioning than pretraining list learning scores, coefficients were comparably small. Recommendations and measurement issues inherent to the LP construct are discussed. (JINS, 2010, 16, 613–620.)

The majority of affect recognition research has used visual stimuli, with only a minority of studies examining auditory affect recognition, and fewer still comparing affect recognition across presentation modalities. In the current study, we evaluated affect recognition between 45 outpatients with schizophrenia or schizoaffective disorder and 56 healthy community controls on an auditory-only affect recognition task, as compared to a multichannel (videotape) version of the same task. We further examined between-group performance differences on auditory versus multichannel presentation modalities for a subset of positive and negative valence items. Results indicated that: 1) in general, healthy controls performed better than schizophrenia patients on affect recognition; 2) schizophrenia patients benefited less from a multichannel task presentation than did healthy controls, and 3) schizophrenia patients did not significantly differ from healthy controls on positive-valenced items presented in the auditory modality. These findings suggest the importance of carefully considering presentation modality and affective valence when assessing affect recognition in schizophrenia.

Cognitive retraining is a promising non-pharmacological approach to the treatment of neurocognitive deficits in schizophrenia. The current study aimed to learn whether people with schizophrenia improve on attention tasks, whether individual performance varies by task, and what task improvement measures relate to pre-post-change in neuropsychological tests of attention. Thirty-two outpatients with schizophrenia or schizoaffective disorder completed at least 40 cognitive training hours on two computerized visual attention training tasks (VT1 and VT2) and pre-post-testing with Digit Span, Digit Symbol Substitution Task, and Continuous Performance Task. Performance slopes indicated significant improvement on both training exercises. Despite apparent similarities between the two training tasks, there were no significant correlations between performance measures on VT1 and VT2. Significant relationships were found between performance improvement variables and change scores on neuropsychological measures, but these relationships varied by training task. Results indicate that cognitive training was effective in improving task performance but that similar tasks can be different in who performs well and what components of attention may be affected. Findings suggest that training should involve multiple exercises within the same domain and that multiple measures may be important in making links between the training process and functional outcomes.

Objectives In this proof-of-concept trial, we examined the feasibility and preliminary efficacy of Understanding Social Situations (USS), a new social-cognitive intervention that targets higher level social-cognitive skills using methods common to neurocognitive remediation, including drill and practice and hierarchically structured training, which may compensate for the negative effects of cognitive impairment on learning. Method Thirty-eight individuals with schizophrenia spectrum disorders completed the same baseline assessment of cognitive and social-cognitive functioning twice over a 1-month period to minimize later practice effects, then received 7-10 sessions of USS training, and then completed the same assessment again at posttreatment. Results USS training was well tolerated and received high treatment satisfaction ratings. Large improvements on the USS Skills Test, which contained items similar to but not identical to training stimuli, suggest that we were effective in teaching specific training content. Content gains generalized to improvements on some of the social-cognitive tasks, including select measures of attributional bias and theory of mind. Importantly, baseline neurocognition did not impact the amount of learning during USS (as indexed by the USS Skills Test) or the amount of improvement on social-cognitive measures. Conclusions and implications for practice USS shows promise as a treatment for higher level social-cognitive skills. Given the lack of relationship between baseline cognition and treatment effects, it may be particularly appropriate for individuals with lower range cognitive function. (PsycINFO Database Record

A year-long program of Neurocognitive Enhancement Therapy (NET) was used to remediate cognitive deficits in people with schizophrenia who were participating in a vocational program. Seventy-two stable outpatients with schizophrenia or schizoaffective disorder, recruited from an urban community mental health center were randomly assigned to a twelve-month vocational program (VOC) or NET+VOC. The vocational program had characteristics of individual placement and support (IPS) programs but also included transitional funding. NET included computer-based cognitive training exercises, a social information processing group and a work feedback group. Sixty-two participants completed a neuropsychological test battery before and after treatment. After one year of treatment, participants receiving NET+VOC had significantly greater improvements on measures of executive function and working memory than did participants in the VOC only condition. Augmenting vocational services with a multifaceted cognitive remediation program may improve cognition in participants with schizophrenia or schizoaffective disorder.

It has been suggested that learning potential (LP), a patient's ability to benefit from training and practice, may mediate the relationship between cognition and functional outcome. Aims of this study were to (1) assess whether performance on a verbal memory-based measure of LP is associated with readiness for psychosocial rehabilitation; and (2) assess whether explicit cognitive training in memory strategies improves task performance beyond any implicit learning of organizational strategies that occurs with repeated exposure to to-be-learned material. Fifty outpatients with schizophrenia or schizoaffective disorder were administered three different versions of a list-learning test, the California Verbal Learning Test (CVLT-II). Some patients also received explicit training in semantic memory strategies before administration of the second word list. Based on performance across the three assessments, participants were categorized as "learners", "high scorers", and "non-learners". Participants were also administered the Micromodule Learning Test (MMLT), a measure that predicts performance in manualized skill training groups. LP categorization was associated with performance on the MMLT. High scorers performed better than the other two groups, and as found in earlier studies, education level was associated with performance for the learners. Explicit semantic clustering training was associated with increases in the use of the trained strategy.

Cognitive remediation has led to improvements for some but not all individuals with schizophrenia. The goal of the current investigation was to determine which variables predicted response to cognitive remediation training. In a sample of 58 patients with DSM-IV schizophrenia or schizoaffective disorder, normalization of performance on a trained memory task was selected as the criterion for successful remediation. The contribution of demographic, symptom, treatment process, and cognitive variables in predicting successful remediation was examined using a series of logistic regressions. A final regression evaluated the combined contribution of these variables. From among patients who were impaired before training, 43% reached normal levels of performance. Measures of attention, immediate verbal memory, hostility, and latency between last training and assessment were retained in the final step of the regression, resulting in 83% classification accuracy. Findings suggest that in addition to cognitive factors, motivational and training variables also significantly affect remediation outcomes.

Studies in schizophrenia suggest that verbal learning and memory may distinguish three subgroups of patients: an unimpaired memory profile group and two groups that have memory profiles similar to those seen in cortical and subcortical dementias. Using the Hopkins Verbal Learning Test, Revised edition (HVLT-R), this study attempted to differentiate patients into three memory profile groups and to examine the validity of these groups with respect to vocational outcomes and neuropsychological functioning. Results from this study replicated previous findings and extended them by demonstrating a link to vocational outcome. In addition, the proportion of patients in each group closely resembled that obtained in previous studies. Specifically, the relatively unimpaired memory group (42%) showed overall better memory and neuropsychological performance than the two impaired groups, the subcortical group (38%) showed impaired recall but intact recognition and deficits in visuospatial functioning, and the cortical group (20%) showed deficits in recall, recognition, and sustained attention/executive functioning. There were no clinical differences between the three groups, but both the unimpaired and subcortical groups increased the number of hours worked following a vocational rehabilitation program. Given these differences, more research is warranted to explore the effect of memory impairment subtypes on vocational outcome measures.

To determine whether older people with schizophrenia or schizoaffective disorder can benefit from work therapy as has been shown with their younger counterparts, 41 older patients (50+) were compared with 104 younger patients on their clinical and vocational outcomes while participating in a 6-month work therapy program. In an intent-to-treat analysis, both groups showed significant improvements in symptoms and quality of life at the conclusion of the active intervention, but there were no significant differences between age groups. In comparisons of biweekly Work Behavior Inventory scores for completers, older workers improved more than younger workers, particularly during the second half of the program. Results are in accord with previous evidence for the clinical and vocational benefits of work therapy and indicate that older people with schizophrenia or schizoaffective disorder can perform at least as well as their younger counterparts and respond similarly with improved symptoms and quality of life.

Patients with schizophrenia have consistently been found to exhibit cognitive deficits, particularly in memory, which have been suggested to mediate functional outcomes. Several recent reviews of cognitive retraining have concluded that these deficits respond to training, although the sustainability of cognitive improvement following completion of training has not been adequately evaluated. Most studies had small samples and very short follow-up periods. As part of a larger study, we examined performance on two memory tasks in two groups of participants: those who received computerized cognitive remediation training in addition to work therapy (n=45), vs. those who only received work therapy (n=49). Computerized cognitive remediation included hierarchical training on a computerized digit span task and a computerized words serial position task. Assessments using the same computerized tasks were made at three time points: baseline, end of active intervention, and 6-month follow-up. Compared to the active control condition (work therapy only), the group receiving computerized cognitive remediation in addition to work therapy showed significantly greater improvements on the trained digit span task following training. These improvements were maintained at the 6-month follow-up. There were no significant group differences on the word serial position task at any time point. Results indicate that computerized training can lead to sustained improvements on some, but not all, training tasks.

There is conflicting evidence regarding the presence and direction of gender differences in verbal memory capacity in schizophrenia. We examined gender differences in verbal memory performance in schizophrenia and their interactions with repeated assessments and psychiatric symptoms. California Verbal Learning Test (CVLT) data were collected from 28 outpatients diagnosed with schizophrenia. The CVLT was administered on five occasions, 3 months apart. CVLT data were examined using repeated measures analyses, using maximum likelihood estimates, with Brief Psychiatric Rating Scale (BPRS) scores at assessments 1-5 as a time-varying covariate. There were significant main effects of time and gender, with scores improving over time, and women performing better than men. There was also a significant time by gender interaction. The BPRS covariate effect was not significant. Results are discussed in terms of implications for gender-informed approaches to rehabilitation treatments.