Posted: April 29th, 2018

Compensatory Cognitive Training (CCT) for Mental Disorders

Compensatory Cognitive Training (CCT) for Mental Disorders
1. Introduction
Cognitive deficits are common and often severe in mental disorders. Some cognitive deficits, particularly attention, memory, and executive impairments, are predictive of poor functional outcomes. Many interventions for mental disorders exist, for example, medication and psychological therapies. However, there is a growing body of evidence which suggests that cognitive training has the potential to improve cognitive performance, social functioning, and symptoms of mental disorders. Developing effective cognitive interventions is important for research and basic understanding of the disorder. It will also benefit patients who suffer from cognitive deficits, at a time when opinions of traditional methods are beginning to change. For example, an increasing number of psychiatrists recognize the importance of cognitive therapies, and so recent advances in the field will hopefully bring about new treatments. It is important that cognitive interventions are used as an adjunct to other treatments, such as medications and psychological therapy. This is because cognitive deficits tend to respond only modestly to other interventions currently. However, the possibility of using cognitive intervention as well as other treatments is an important and exciting prospect. It could mean that patients would benefit directly from an increase in cognitive performance, as well as indirectly from generalization of training to better everyday functioning. Secondly, the use of such cognitive intervention could mean that patients would need to rely less on existing methods to manage cognitive deficits. For example, patients with schizophrenia often suffer from deficits in attention theory. The introduction of effective attention training programs would be a significant and positive influence on the quality of life for many such patients. Research into Compensatory Cognitive Training (CCT) in various mental disorders is ongoing. In conclusion, there are encouraging early results which suggest that cognitive training may provide as good a response to remedies as conducting on medication or psychological therapies. Also, there is evidence that the benefits of cognitive interventions may extend beyond laboratory measured cognitive improvements, to functional improvements in everyday life and an attenuation of the underlying illness. The remainder of the days will define and review the theory, research, and practice of CCT as applied to mental disorders.
1.1 Background
CCT is short-term but intensive, in which various cognitive functions can be trained simultaneously, and the training effect can be maintained and probably enhanced up to 6 months. It was suggested from the newer version of the ICF that deficits after brain damage can benefit from the utilization of brain plasticity and compensatory strategies. However, the research in the field of cognitive training is still immature. To develop an effective treatment, two main streams of research – how to utilize brain plasticity and how to apply compensatory methods in the training protocols should be put emphasis on the content of the treatment. Cognitive neurorehabilitation of people with cognitive impairments. Steiner et al. advocated that cognitive training aims to enhance and generalize cognitive functions. They outlined that various cognitive paradigms such as exercises focusing on motor and process speed, divided attention, response inhibition, and working memory can bring substantial clinical benefits of improving cognitive performance in everyday activities. Besides, CCT was described as a neuropsychological method for teaching compensatory strategies and for indirectly alleviating cognitive deficits by teaching patients new cognitive strategies by Wykes. Bosch claimed that cognitive adaptation is not only the mechanism of clinical meaningfulness of CCT but also the defining characteristic that distinguishes a variety of products and approaches. He emphasized that cognitive adaptation represents the extent to which a person can integrate knowledge and also the extent to which a person is willing to examine the world in a different way. However, no consensus has been achieved on the content of the treatment. Wykes and her colleagues recently published an in-depth review on CCT and concluded that the clinical efficacy of CCT seems to be underwhelming when considering the benefits have only been shown for a limited number of cognitive domains and CCT has never been shown to improve the same cognitive function better than the active control conditions. Besides, cognitive improvements from CCT have not significantly afforded any clear propensity for reduction in real-world cognitive failure or disabilities. Admittedly, there is still a long way to go in order to maximize the treatment effect of CCT and to make it more applicable in the rehabilitation of people with cognitive impairments. Steiner et al. advocated that cognitive training aims to enhance and generalize cognitive functions. They outlined that various cognitive paradigms such as exercises focusing on motor and process speed, divided attention, response inhibition, and working memory can bring substantial clinical benefits of improving cognitive performance in everyday activities. Besides, CCT was described as a neuropsychological method for teaching compensatory strategies and for indirectly alleviating cognitive deficits by teaching patients new cognitive strategies by Wykes. Bosch claimed that cognitive adaptation is not only the mechanism of clinical meaningfulness of CCT but also the defining characteristic that distinguishes a variety of products and approaches. He emphasized that cognitive adaptation represents the extent to which a person can integrate knowledge and also the extent to which a person is willing to examine the world in a different way. However, no consensus has been achieved on the content of the treatment. Wykes and her colleagues recently published an in-depth review on CCT and concluded that the clinical efficacy of CCT seems to be unde
1.2 Importance of Cognitive Training
More recent studies on the relevance of cognitive training in mental disorders revealed more promising results compared to studies on neural compensation. These studies suggest that the continuous reinforcement of high-level cognitive functions, such as attention, memory, and executive functions, can potentially reverse some of the cognitive deficits experienced by patients with mental disorders. This is even more important because current pharmacotherapy for most mental disorders is only able to alleviate some of the basic symptoms. They are unable to address the cognitive deficits in these patients. Therefore, compensatory cognitive training (CCT), which by definition is any intervention that aims to improve or maintain cognitive functions, is becoming an area of great interest in psychiatric research. The essence and importance of cognitive remediation can be well illustrated using the example of neurocognitive deficits in major depressive disorder (MDD). Not only neurocognitive deficits are present and persistent in these patients, they have been accepted as ‘core symptoms’ of MDD because of their strong association with functional impairment and poor clinical outcome. Randomization to an active cognitive remediation program resulted in significant improvements in objective attention and verbal memory functions in patients with psychotic depression. On top of that, a significant reduction in depression symptom severity was also observed post-treatment. Conversely, a comparator health education program did not produce any significant improvements. Such promising findings were also reported in recent reviews on the clinical implications of cognitive training in mood disorders. For example, Schreiner et al found small to moderate effect of cognitive training in improving neurocognitive functions and also reduction in depressive symptoms. However, more importantly, these training effects were also evident in functional outcomes, essentially suggesting that patients may adapt and integrate the cognitive strategies learned through training into their activities of daily living. This further supports the notion that cognitive training should form an adjunct intervention in the comprehensive treatment of mental disorders.
2. Effectiveness of Compensatory Cognitive Training (CCT)
Compensatory cognitive training, also known as CCT, is an emerging area of research that has shown the potential to greatly benefit individuals with mental disorders. Existing literature has suggested that individuals with mental disorders have difficulties with attention, memory, executive functions, and planning. CCT is a form of intervention that aims to improve cognitive abilities, focusing particularly on attention and memory. There is a range of different types of cognitive training, but the most common type used in research is based on the idea of ‘plasticity’. The effectiveness and potential benefits of CCT for mental disorders have been widely debated. It is suggested that the effectiveness of CCT can be reflected by improvement in cognitive abilities and cognitive training therapy can lead to generalization effects which can impact patients’ daily life. Cognitive ability specific to executive dysfunction in patients with schizophrenia are found to be improved after working memory training. The meta-analysis of 10 research studies examining the effectiveness of CCT has shown moderate to small effect sizes for improvement of cognitive function. This finding provided strong supporting evidence to the potential for cognitive training as an effective intervention for psychiatric conditions. Commonly, cognitive remediation has been used as a part of rehabilitation for psychiatric patients to help them with vocational outcomes. However, the underlying mechanisms by which cognitive remediation leads to functional improvement remain relatively unknown. This raises a possibility that the link between enhanced cognitive ability and real life functional improvement after CCT needs further investigation. ADHD is a neurodevelopmental disorder characterized by symptoms of inattention, impulsivity, hyperactivity or a combination of these symptoms. Stimulant medication and behavior therapy have been recommended as first-line treatment methods for ADHD. However, there is a growing interest in non-pharmacological intervention. A 2016 study, which is published in European Child & Adolescent Psychiatry, concluded that working memory training can lead to significantly improved performance and behavior of children with ADHD. The method of the study was sophisticated and complex, which involved well-established training intervention and multiple psychological and neurocognitive assessments. The training group showed significant improvement in the attention and working memory-related cognitive tasks. Moreover, the researchers incorporated EEG event-related potentials while participants were conducting the cognitive tasks and found increased and more efficient brain activation in the training group. This evidence has supported the effectiveness of cognitive training and with advanced technology, this study provided neural mechanism results in supporting the claim. However, more researches are needed to investigate into the long-term impact of CCT on patient’s functioning. Also, further evidence is necessary to explore whether the improvement in cognitive abilities can successfully transfer to real life. And more potential EEG studies can be carried out to provide additional support on the possible neural mechanisms. By understanding and ameliorating the cognitive deficits associated with mental disorders using CCT, patients may have a greater chance of successful community reintegration. Also, improved cognitive performance can enhance taken-on and little evidence of maintenance phase performance over the 5 years follow-up. This has proposed that although cognitive remediation can be an effective intervention, it may be important to incorporate maintenance training into routine practice in order to sustain the benefits obtained from cognitive treatment.
2.1 Evidence of Boosting Cognitive Abilities
Compensatory cognitive training (CCT) is known for its uniqueness by constantly inventing and designing computerized training tasks that are meant to focus on critical cognitive skills. It was developed specifically for individuals with severe mental illness, such as those who suffer from schizophrenia. The idea of the game-based training is to teach users the correct mental strategies when facing tasks encountered in everyday life. Essentially, the game exposes the user to distractions of first and second order and unexpected events, similar to what they would face in the real world. A study conducted by Fisher et al. shows that targeted cognitive training improved cognitive scores of chronic schizophrenia or schizoaffective disorder patients. The training involves a number of canonical and dual-compromise cognitive skills, such as processing speed, sustained attention, working memory, and executive functioning; of which these elements are often observed as deficient in mental disorders. The patient group in the study received the computerized training, which consists of a set of seven computer-based cognitive tasks, while the control group underwent training that involves pen-and-paper homework and quizzes as well as playing educational computer games. The findings showed that a target improvement in patients’ neurocognition was found in the patient group but not in the control group. Cognitive functions that were disturbed in the patient group, such as working memory and verbal learning, also show a significant improvement. In addition, training gains were consistent across different age, gender, and duration of illness, suggesting the beneficial effect of cognitive training did not vary as a function of such clinical and demographic factors. Fisher et al. concluded that patients who have received targeted cognitive training have significant improvements in cognitive functions that are crucial to everyday functioning in the real world. This clinical evidence is certainly a strong support for the effectiveness of cognitive training in boosting cognitive abilities for the CCT.
2.2 Impact on Mental Disorders
One of the key areas of consideration when researching the effectiveness of CCT is how individuals with mental disorders may benefit. The studies listed above that focus on various mental disorders such as schizophrenia and depression have already demonstrated that training programs can result in cognitive improvements (Wykes et al., 2011). But what does the research say about the potential of these cognitive improvements translating into meaningful change for psychological wellbeing? A summary of research undertaken in 2017 at the Royal College of Surgeons in Ireland sought to establish if cognitive remediation programs could provide the potential for recovery, and in doing so, highlighted the substantial impact that CCT offers to mental health services (McGorrey, 2017). In reviewing research literature that spans over a decade, it was found that most studies demonstrated significant and positive effects of CCT for cognitive improvements. It was also highlighted that besides improving cognitive functions, there is growing evidence that cognitive training can transfer benefits to daily life, symptom reduction, and even promote social and vocational recovery. These discoveries are very exciting for the future of mental health services. While western approaches to mental health care have started to recognize the significance of goal-oriented intervention and acknowledge an individual’s aspirations and potential for recovery, there is still much work to be done. This research can provide the evidence of what our profession should be promoting an approach that offers hope, choice, control, and opportunity for recovery as CCT demonstrates the potential for recovery and enjoyment to be realized through an occupation-focused and person-centered approach. Working with service users to explore goal-oriented intervention is important, and certainly as an occupational therapy student it’s something we are encouraged to do. However, this research reinforces the significance of this practice and the potential benefits that are offered not only in a person’s life in terms of recovery and enjoyment but also to the mental health services professionally.
2.3 Limitations and Gaps in Research
Occupational therapists and neuropsychologists collaborate to provide effective group therapy five times a week. However, as compared to computerized training, real-world intervention is time-consuming and costly for therapists and patients. Further research in this area may lead to the development of a platform to facilitate and standardize computerized compensatory cognitive interventions for different cognitive domains. At present, compensatory cognitive training studies are conducted on small groups, usually less than fifty participants, who have characteristics of well-controlled subjects for presumed disorders such as stable medical conditions and stable or medication-naive status, etc. Well-designed studies should include patients with different subtypes of disorders; patients who have illnesses in acute, sub-acute, and chronic phases; and more objective outcome measures such as functional assessments and everyday performance on cognitive tasks. Recently, compensatory cognitive training studies have focused on patients with traumatic brain injury or geriatric patients with mild cognitive impairment, using various neuroimaging techniques (i.e. brain imaging technology), such as fMRI and qEEG, to study the mechanism of action of cognitive training and its effects on brain functioning. These studies mainly employ small size and consist of selective groups based on many inclusion criteria because of the heterogeneous nature of these disorders. As a result, future studies may incorporate individualized training algorithms, based on the specific deficits in each patient, and more sophisticated neuroimaging techniques, to tailor the treatment to patients’ needs and enhance the functional outcomes. In addition, future research should specifically focus on designing compensatory cognitive intervention not only at restorative treatment but also at aetiopathogenetic, rehabilitation and environmental levels, analogous to the newer drug discoveries for neuronal regenerative processes and their corresponding level of actions for different dementia. Such multi-level cognitive training may be most promising and effective in treating mental disorders. More importantly, our project of investigating into the possible moderation of baseline global cognitive function or severity of illness on outcomes of compensatory cognitive training for patients with mental disorders has yielded a significant amount of positive preliminary findings. However, we have experienced some methodological and practical issues, such as difficulties in identifying clinically meaningful covariates. With the advancement in computing technology and neuroinformatics, we envision the development of more sophisticated and comprehensive statistical models, in order to identify subgroups of patients for whom cognitive training is most effective and to predict response to training. Given the potential benefits and applications of compensatory cognitive training for various groups of mental disorders, future research should strongly consider randomized controlled clinical trials on functional improvement and application for regulatory approval of these interventions. Especially with the use of advanced neuroimaging technology and the development of cognitive informatics, we could provide strong evidence on the real effects of such interventions on cognitive enhancement and everyday functioning.
3. Further Research in Compensatory Cognitive Training (CCT)
Last but not least, there is a paucity of studies investigating the identification of individual responsiveness to cognitive training. While there is evidence to suggest that certain baseline cognitive abilities may predict how well an individual is likely to respond to training, research into the characteristics of those who benefit most is still in its infancy. This is potentially significant from a clinical perspective, as objective markers of the likelihood of benefit could guide treatment selection and help to tailor cognitive training programs to individual need.
Third, we need more research into the durability of the benefits of cognitive training. While some studies have reported maintenance of performance gains for periods of up to five years post-treatment, evidence on the long-term benefits of training remains scarce. This is particularly relevant in the context of chronic and progressive disorders such as schizophrenia and multiple sclerosis. If the deterioration of cognitive abilities in such disorders can be slowed by cognitive training, it would represent a significant step forward in the management of these conditions. However, to date, there is only one study that has investigated the longer-term effects of cognitive training in multiple sclerosis. More research into how the benefits of training might be maintained over time is therefore needed.
Second, research is needed to establish the potential benefits of cognitive training as an adjunct to other types of rehabilitation, such as vocational training and support, psychoeducation, social skills training, or supported employment. While cognitive impairments are known to impact functional outcomes such as community integration, work participation, and activities of daily living, there is a lack of evidence to date that any particular rehabilitation approach effectively ameliorates these impairments. It is possible that compensation for cognitive difficulties through cognitive training might augment the benefit of other types of rehabilitative intervention, but this remains to be investigated.
First, studies focusing on comparing the relative efficacy of different types of cognitive training interventions are needed. Several different types of cognitive training have been investigated by researchers. Each of these approaches targets particular cognitive abilities, such as working memory, executive function, and processing speed. However, to date, it is not clear from the literature which type of training is most effective, or whether the benefits of training might differ according to the population being studied or the severity of their impairments. This is an important question because while many studies have demonstrated that individuals can improve on the specific tasks they are trained on, there is less evidence that such improvements generalize to untrained tasks. Studies directly comparing different types of cognitive training are likely to provide important insight into the mechanisms by which training might exert its effects, as well as offering clinicians guidance regarding the most appropriate intervention for their patients.
3.1 Areas of Focus
One area of focus in CCT research is to investigate the potential impact of CCT on social functioning, specifically in people who suffer from autistic spectrum disorders. Current findings in this area are inconsistent. Certain studies reported that the use of alternative reality training games such as “Face Say” to improve social recognition skills leads to significant and lasting improvement in the level of perceived social support and social attainment of participants with autism. However, benefits were not universal, as the same study highlights that the majority of participants improved their social ability yet a minority of participants showed no response to the intervention. Meanwhile, other studies have trialed the use of neurocognitive-based computerized training whereas this type of intervention demonstrated a significant and widespread short-term improvement in cognitive behaviour. However, the same study found that no evidence showed that the cognitive behavioural improvements resulting from the intervention had generalized to social behavioural change. Another area of focus in CCT research is to examine whether combining different approaches of CCT, such as using different types of cognitive training, would lead to stronger and longer-lasting effects. This research understands that different cognitive abilities are mediated by separable neurocognitive systems which may not overlap entirely in terms of the neural substrates, and at this moment, it isn’t fully understood to what extent cognitive improvement of one type would affect another. Preliminary studies have shown positive results in improving multiple cognitive domains when participants were engaged in a multimodal cognitive training regime, particularly in memory and mental speed. Yet, this area requires further investigation as the limited research has yet to provide an accurate account on how each domain of cognitive training would interact with another. Such approach holds promise for the future development of CCT as the exploration of the synergistic effect initiated by multimodal cognitive training may shed a light on an optimal ‘prescription’ for each individual according to specific neural profile and cognitive ability level. However, it seems that it is necessary to implement a wide range of cognitive assessment to assess the potential generalization of the treatment effect directly onto everyday function.
3.2 Experimental Design and Methodology
In terms of experimental design, the team is fully aware of the different possible biases that may arise when conducting this study. This is why both investigators and participants are put under blind conditions. The study uses a double-blind design, because both the CST group and the control group contain patients who are also receiving pharmacological treatments. Thus, neither the patients nor the investigators will know whether the participants are receiving active CST treatments or not. Digital games have always been a very useful tool for investigating various human behaviors. All the experiment sessions will be conducted at the labs of the Institute of Psychology. Each participant will receive 24 sessions of treatment, with 3-5 sessions of treatment per week, and each session lasts for 50 minutes. In the CST session, training tasks are designed to focus on the improvement of the psychological processes, such as speed of mental processing, divided attention, and working memory. In the control condition session, participants receive exactly the same amount of treatment time. Mock digital games have been designed in which participants can just receive a general knowledge of how to play these games, and the hard task or next game buttons are disabled before the given SRC trial starts. This is mainly used to mimic CST treatment in order to control potential non-specific life-predominant treatment effects that may be unrelated to the CST.
3.3 Potential Benefits and Applications
Further, sufferers of mental disorders show impairments in well-being efficacy (Goldberg et al., 1996; Williams, 1989) due to the wide array of cognitive disabilities in different domains of deficit such as attention, memory, and executive functioning (Green, 1996; Harvey et al., 2011; Harvey & Brewin, 1998). For instance, studies using the Continuous Performance Test (CPT), which is a test specifically assessing attention, found a group of people diagnosed with Post-Traumatic Stress Disorder (PTSD) had significantly weaker performance in terms of reaction time and poorer accuracy rate in detecting target stimuli as compared to normal individuals (Vasterling et al., 2002). In an experiment measuring working memory using the N-back task, the results suggested that individuals suffering from Schizophrenia consistently performed worse than healthy people and even the ability to retain and update a single item on the memory was greatly disrupted (Lee & Park, 2005). As a consequence, it leads to difficulties in daily life and social interactions. Although early studies of CCT focused on promoting cognitive control and investigating learning enhancement in healthy adults (Owen et al., 2010; Richmond et al., 2002), more recent research studies have expanded into examining its potential treatment ability in patient groups. For example, results of a recent research suggested that by practicing a 20-minutes inhibitory control task which requires individuals to refrain from making impulsive responses to certain stimuli for 25 days, alcohol addicts not only showed significant improvement in their ability to withhold pre-potent responses in the task but also reduced their alcohol intake in real life (Houben et al., 2011). This implies that the learning of inhibitory control may carry over to improving self-regulation in substance dependency which to some extent supports the validity of using CCT as a rehabilitation method. Also, the concept of ‘neuroplasticity’ which is defined as the brain’s ability to reorganize itself by forming new neural connections throughout life has provided a theoretical mechanistic explanation for the effectiveness of CCT in remediation of cognitive capabilities. For example, one of the established neuro-feedback CCT protocols ‘ALPHA-DELTA training’ aims to enhance the generation of ‘fast-wave’ pattern of brain activity which is associated with better cerebral efficiency and metabolic need (Duric et al., 2012). Preliminary findings using Quantitative Electroencephalography (QEEG) indeed supported that patients with Pre-Menstrual Dysphoric Disorder (PMDD) who received a 4-weeks of ALPHA-DELTA training demonstrated a significant increment in the power of ‘fast-wave’ activity and their psychiatric symptoms had been considerably reduced as compared to a control group who underwent sham brain-wave training (Swan et al., 2016). This not only adds to the evidence that supports the clinical efficacy of CCT but also sheds light on the potential application of CCT by integrating with other novel treatment approaches, such as non-invasive brain simulation (e.g. Transcranial Magnetic Stimulation, TMS) and normalizing biofeedback signals in advanced personalized medication.
3.4 Future Directions
Given the strength of the evidence in favour of computerized cognitive remediation for schizophrenia, the key question is why these treatments are not more widely available. There are many potential barriers to implementing these as routine treatments in the NHS and elsewhere; for example, cost, availability of the treatment across the UK, and whether clinicians will be willing to accept and use the treatments. However, many of these barriers could be overcome. Firstly, whilst the initial treatment and set up costs may be high, the prospect of patients needing less intensive and therefore less expensive support, both in terms of medications and human support, could offset this in the long run. Secondly, the treatments could easily be made available to any patient with an internet connection, meaning that it would not require travel to large centres of excellence. However, research is needed to assess whether the treatment could be made widely available, and large scale trials must be conducted in order to see if evidence for the effectiveness of these treatments holds. It is hoped that with the correct implementation strategy, and improvements to the treatments that will undoubtedly come as new research builds on the more promising early findings, that these treatments could prove to be a highly valuable asset in a clinician’s arsenal for the treatment of patients with schizophrenia, and could yet help to improve the lives of many suffering with this condition.

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