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Effects of a 2-Year Randomized Trial on Cognition and Behavior

Gerard E. Hogarty, MSW; Samuel Flesher, PhD; Richard Ulrich, MS; Mary Carter, PhD; Deborah Greenwald, PhD; Michael Pogue-Geile, PhD; Matcheri Kechavan, MD; Susan Cooley, MSN; Ann Louise DiBarry, MSN; Ann Garrett, PhD; Haranath Parepally, MD; Rebecca Zoretich, MSEd

Arch Gen Psychiatry. 2004;61:866-876.

Background  Deficits in social cognition and neurocognition are believed to underlie schizophrenia disability. Attempts at rehabilitation have had circumscribed effects on cognition, without concurrent improvement in broad aspects of behavior and adjustment.

Objective  To determine the differential effects of cognitive enhancement therapy (a recovery-phase intervention) on cognition and behavior compared with state-of-the-art enriched supportive therapy.

Design  A 2-year, randomized controlled trial with neuropsychological and behavioral assessments completed at baseline and at 12 and 24 months.

Setting  An outpatient research clinic housed in a medical center's comprehensive care service for patients with severe mental illness.

Patients  A total of 121 symptomatically stable, non–substance-abusing but cognitively disabled and chronically ill patients with schizophrenia or schizoaffective disorder.

Interventions  Cognitive enhancement therapy is a multidimensional, developmental approach that integrates computer-assisted training in neurocognition with social cognitive group exercises. Enriched supportive therapy fosters illness management through applied coping strategies and education.

Main Outcome Measures  Six highly reliable summary measures—Processing Speed, Neurocognition, Cognitive Style, Social Cognition, Social Adjustment and Symptoms—were tested using analysis of covariance and linear trend analysis.

Results  At 12 months, robust cognitive enhancement therapy effects were observed on the Neurocognition and Processing Speed composites (P<.003), with marginal effects observed on the behavioral composites. By 24 months, differential cognitive enhancement therapy effects were again observed for the 2 neuropsychological composites and for Cognitive Style (P=.001), Social Cognition (P=.001), and Social Adjustment (P=.01). As expected, no differences were observed on the residual Symptoms composite. Effects were unrelated to the type of antipsychotic medication received. Enriched supportive therapy also demonstrated statistically significant within-group effect sizes, suggesting that supportive psychotherapy can also have positive, although more modest, effects on cognitive deficits.

Conclusion  Many cognitive deficits and related behaviors of patients with stable schizophrenia are improved when sufficient exposure to relevant rehabilitation is provided.

From the University of Pittsburgh Medical Center, Western Psychiatric Institute and Clinic, Pittsburgh, Pa. Dr Flesher is now with Planned Life Assistance Network (PLAN) of Northeast Ohio, Cleveland Heights.

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