Cognitive Remediation in a Supported Education Setting

The cognitive challenges experienced by individuals with schizophrenia can have a marked impact on their functioning at work and school. These settings require people to prioritize, multitask, sustain attention, and recall material presented in a range of formats. Finding means to effectively address cognitive difficulties is a priority, given the central role of education and employment in the recovery of persons with mental illness.

Cognitive remediation has in recent years emerged as a promising approach for addressing the cognitive impacts of schizophrenia. Cognitive remediation (CR) refers to interventions in which cognitive tasks are practiced to improve attention, memory, and problem-solving abilities. Randomized controlled trials of CR have shown improvements in attention, memory, and problem solving; modest impacts on psychosocial functioning, with better results when CR is paired with supported employment; and relatively low impacts on symptomatology. Although there have been a number of trials examining CR combined with supported employment, little attention has been paid to integrating CR into supported education settings.

The feasibility study took place in Toronto, Ontario, at the George Brown College Redirection Through Education (RTE) program. In the RTE program, students with mental illness enroll in for-credit courses, which can lead to eligibility for postsecondary programs. Remedial skills in English, supervised study skills classes, and other noncredit courses are provided, and counselors assist students in areas such as learning difficulties and stress management. Outcome studies of supported education programs such as RTE have typically found better enrollment in postsecondary education and longer terms of competitive employment. The RTE instructors were finding, however, that their students with psychosis were generally doing less well due to cognitive difficulties, and the program leadership looked to partner with a psychiatric service provider to examine adjunctive services such as CR.

A ten-week CR program was integrated within the course structure of RTE in the summer 2010 term. Participants took part in a total of 20 computer-based, 45-minute cognitive exercise sessions held twice per week (COGPACK, version 6.0, Marker Software, www.cogpack.de). COGPACK facilitates practice across a range of cognitive functions, including attention, psychomotor speed, learning and memory, and executive functions. In groups of four, participants received assistance and encouragement in completing the cognitive exercises, and they received suggestions about strategies for improving performance on challenging exercises. The small group size was conducive to providing individualized feedback. In addition to completing computer exercises, all participants took part in weekly one-hour group sessions. Topics included the development of compensatory strategies for dealing with cognitive challenges and strategies for managing anxiety and psychosis in school settings.

The findings from the feasibility study were very promising. It was found that the CR could be readily integrated into the curriculum and that students were interested in enrolling. Of the approximately 30 RTE students with psychosis who registered for the summer term, 17 enrolled in CR. Once enrolled, students also stayed in the program, reporting that it was enjoyable and helpful. Of the 17 students who registered, 16 completed the program (12 men and four women; mean age of 30 years, range 18–54). On average, participants attended 16.4 of 20 computer training sessions and 7.7 of ten group meetings. Feedback was positive: “It gives me the tools to improve my memory and my focus, and I can see how much I've improved. I also like the discussion group where people share different ideas, different experiences on how to do well with the computer activities.”

Outcomes were also promising, with significant improvements noted over the course of the academic term in learning, concentration, and some aspects of executive functioning. Improvements in symptomatology were also seen. Although the degree to which these changes might be attributed to CR cannot be determined due to a lack of a control group, the improvements observed are consistent with those seen in controlled trials.

CR was readily integrated into the supported education curriculum, but two major challenges remain. First, randomized trials are needed to assess benefit over and above participation in supported education. Second, the benefits of CR will need to be made compellingly clear to administrators. Because CR requires substantial resources, the benefits to functioning will likewise need to be substantial if this intervention is to be broadly implemented outside of the context of well-funded clinical trials.