Addressing the unmet need of cognitive dysfunction in schizophrenia

Impaired cognition has a negative impact on functioning

Impaired cognition in schizophrenia has a negative impact on functioning and quality of life, constituting a ‘glass ceiling’ for rehabilitation, and is the main predictor of total health and social care costs². Despite these functional and societal consequences, patients and their clinicians still need effective interventions, and this important topic was discussed at EPA2020.

Treatment strategies

Gabriele Sachs (Medical University of Vienna, Austria) explained how social cognition is a partial mediator between neurocognition and functional outcome, and is already affected in early stages of schizophrenia. Treatment strategies need to address both neurocognition and social cognition.

The effect of antipsychotic medication on cognitive functioning is still poorly understood suggested Antonia Vita (University of Brescia, Italy), with some studies indicating that they improve cognitive functioning whilst others demonstrate the reverse³. With no effective pharmacological interventions to treat cognition, interest has turned towards CRT.

Role of CRT

CRT uses scientific learning principles to target the cognitive deficit. Til Wykes (King’s College London, UK) presented an up-to-date summary of the 28 meta-analyses in CRT and schizophrenia since 2014, of which 25 found significant cognition and/or functioning improvement and 20 found symptom improvement.

Beyond those patients with chronic schizophrenia, Merete Nordentoft (University of Copenhagen, Denmark) discussed how CRT has shown benefit in those with first episode psychosis⁴ and is being studied in those at ultra-high risk for schizophrenia⁵.

Beyond cognitive improvement to functional outcomes

The goal for patients is not just increases in cognition test scores, but improved functional outcomes

The goal for patients is not just increases in cognition test scores, but improved functional outcomes such as independence, life skills and fulfilling relationships. A recent metanalysis showed that CRT improved functional as well as cognitive and clinical outcomes in patients with schizophrenia⁶.

Cognitive components being measured in earlier studies only partially explained the effect of CRT on functional outcomes⁷, and Dame Wykes suggested that metacognition is the missing link⁸.

Using metacognition in therapy

Importance of the therapist in encouraging metacognitive changes

A recent expert working group have produced a white paper on CRT for schizophrenia⁹, identifying four core techniques, which embrace metacognition:

• Facilitation by a therapist
• Cognitive exercise
• Procedures to develop problem-solving strategies
• Procedures to facilitate transfer to real world functioning

Wykes and colleagues have developed the ‘CIRCuiTS’ programme integrating metacognitive support into CRT¹⁰, which has demonstrated metacognitive improvement over time¹¹. This approach involves setting goals, teaching a new approach to tasks, and reflecting on your own thinking, which can then be integrated into everyday life. She stressed the importance of the therapist in encouraging metacognitive changes⁶.