A review of cognitive remediation approaches for schizophrenia: from top-down to bottom-up, brain training to psychotherapy

ABSTRACT

Introduction: Individuals with psychotic disorders experience profound impairment in neurocognition, which is consistently found to be the best predictor of independent community functioning. Several diverse behavioural treatments designed to enhance neurocognitive abilities have been developed, with subtle to stark differences among them. Various approaches, to varying degrees, have demonstrated success across diffuse outcomes: improved brain structure and function, performance on neuropsychological tests, and community activities associated with daily living.

Areas covered: This paper reviews the different approaches to cognitive remediation and the differential effects these approaches have on neurophysiological function, neurocognitive abilities, and real-world community functioning. Cognitive remediation approaches can be broadly classified along two dimensions: 1) treatment target, and 2) treatment modality. Some approaches target more basic perceptual skills, some target higher level executive processes, while some are non-targeted and seek to improve general cognitive ability. With regard to modality, approaches might have little/no therapist involvement and rely exclusively on computerized practice or they may include intensive therapist involvment to generalize neurocognitive change to community functioning.

Expert commentary: Compared to other widely implemented treatments for schizophrenia, cognitive remediation produces better effects on outcome measures. It is time for cognitive remediation to be adopted as a best practice in the treatment of schizophrenia.

KEYWORDS:

• Cognitive remediation
• cognitive training
• psychosocial therapy
• schizophrenia
• severe mental illness

Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Notes

1. We use the terms ‘bottom-up’ and ‘top-down’ to refer to the primary treatment target of an intervention with the acknowledgment that it is unlikely any targeted behavioral intervention activates only a single system. ‘Bottom-up’ approaches likely contain some element of higher-level reasoning, and likewise ‘top-down’ approaches likely contain components of more basic perceptual processing.

2. Hedge’s g was reported in this study which, at large sample sizes such as those used in the meta-analysis, produces identical results to Cohen’s d.

Additional information

Funding

M.W. Best is funded by Vanier Canadian Institutes of Health Research Scholarship. C.R. Bowie is funded by Ontario Ministry of Research and Innovation and National Alliance for Research on Schizophrenia and Depression.