The FOCUS study failed to show neuro- and social-cognitive benefits of cognitive remediation in people with ultra-high risk of psychosis.1 Are we over-promising on cognitive remediation or does it just need to be better designed?
In patients with schizophrenia, cognitive remediation has shown beneficial effects on functioning.2 Whether or not people with ultra-high risk (UHR) of psychosis would also benefit from this therapy is less clear. Professor Merete Nordentoft, University of Copenhagen, Denmark reported results from the recent FOCUS trial at EPA Virtual 2021.
Whether or not people with ultra-high risk of psychosis would benefit from cognitive remediation is unclear
A systematic review of studies showed that cognitive remediation using computer-based drill and practice programs improved cognition in the domains of verbal memory, attention, and processing speed, as well as social functioning and social adjustment in subjects with UHR of psychosis, but had no effect on clinical symptoms.1
A large study of cognitive remediation in ultra-high-risk individuals
FOCUS was a randomized, single-blind trial in which 146 people with UHR of psychosis were assigned to 20 weeks of cognitive remediation as add‐on to treatment as usual (TAU) or to TAU alone and is the largest trial to report the effects of cognitive remediation on individuals in the UHR state.3
Cognitive remediation comprised two hours of group training - neurocognitive and social cognitive training using Neuropsychological & Educational Approach to Remediation (NEAR) and Social Cognition and Interaction Training (SCIT). 1 The TAU consisted of regular contact with health professionals at in‐ and out-patient facilities, involving monitoring of medication and supportive counselling.1
No benefits of cognitive remediation in ultra-high-risk individuals
After 20 weeks, there was no significant difference between groups for the primary or secondary outcomes of neurocognition and social cognition1
However, there was a significant treatment effect for the exploratory outcomes on the Emotion Recognition Test (ERT) latency total score and ERT latency happiness, sadness, and fear for TAU+ cognitive remediation compared with TAU alone.1
Cognitive remediation needs to be better designed for individuals with ultra-high risk of psychosis
"So, in these UHR individuals, cognitive remediation did not result in improvements in global measures of cognition, functioning and symptoms said Professor Nordentoft. It is important to note, however, that adherence to the intervention regimen was poor, with an average of 11/20 sessions attended and on average 11.9 hours of neurocognitive training, so the intervention may have been ‘underdosed’" she said.
Cognitive remediation needs to be better designed, recommended Professor Nordentoft. Therapy needs to be made interactive, appealing, and engaging, and needs to be highly targeted and individualized for people at UHR of psychosis.
Have we been over-promising in cognitive remediation?
It’s our job now to re-think and re-design what’s delivered with cognitive remediation, how it’s delivered, and who it is for
We have been over-promising in cognitive remediation and we have not been thinking about evidence-based benefits, said Dame Til Wykes, Institute of Psychiatry, Psychology, and Neuroscience, Kings, College London, UK, during her presentation on cognitive remediation in the era of new technologies.
Dame Wykes stated that health services and treatment should:4
- Offer evidence-based treatments
- Guard against unintended consequences
- Reduce (not increase) disparities
The need for digital tools in mental health is not simply to add scale and efficiency to existing care models. The goal cannot be to have services similar to face-to-face care, but cheaper. Rather, digital innovation is needed at every stage of the system - to re-think and re-design what is delivered, how it is delivered, who it is for, and how we know if it works.4
FOCUS: Function and Overall Cognition in Ultra-high risk States
EPA: European Psychiatric Association
UK: United Kingdom
UHR: Ultra-High risk
TAU: Treatment as usual
NEAR: Neuropsychological & Educational Approach to Remediation
SCIT: Social Cognition and Interaction Training
ERT: Emotion Recognition Test
BE-NOTPR-0041; approval date 08/2021
