Rehab Rounds: Cognitive Remediation in the Supportive Housing Setting

A total of 46 consumers were referred to the learning center in the first year of operation (2000-2001). Of these consumers, 40 (87 percent) were accepted into the program and six (13 percent) were not enrolled because of scheduling conflicts. The average rate of kept appointments for the first year was 82 percent, which is considerably higher than the national average for this population.

Twelve consumers agreed to complete cognitive measures to track their progress. All consumers who participated in the program were formerly homeless and had histories of chronic psychiatric illness or substance abuse, or both. The distribution of men and women in this group of consumers was even. One-third of the consumers were African American, one-third were Caucasian, and one-third were Hispanic or from other ethnic groups. The consumers' mean age was 48.3 years, and the mean number of years of education was 12.6.

Cognition was measured with the Cognitive Stability Index, a computerized test with multiple versions that measures memory, reaction time, attention, and processing speed (7), before cognitive remediation as well as six months later. Results were analyzed with paired t tests. The group of consumers showed significant or nearly significant improvement in three of four outcome factors: processing speed, reaction time, and memory. Mean processing speed scores decreased from 6.096 seconds to 4.814 seconds (t=2.82, df=11, p=.008), mean reaction time scores decreased from 6.096 seconds to 4.814 seconds (t=2.40, df=11, p=.019), and mean memory slope scores increased from 7.139 to 7.194 (t=1.74, df=11, p=.055). Memory slope represents the change in number of correct responses over four trials of a memory recognition test and reflects an individual's ability to retain information over the short term. Improvements in attention were not significant.

After one year of the program's operation, 27 consumers had completed a six-month course of cognitive remediation at the rate of two sessions per week. Of those 27 consumers, 14 (52 percent) enrolled in educational programs such as writing and reading programs, computer classes, and General Educational Development (GED) equivalency programs. Another six consumers (22 percent) subsequently became involved in vocational training programs. Before cognitive remediation, none of these consumers had ever successfully engaged in educational or vocational programs. While engaged in the cognitive remediation program, the consumers continued to receive other, regular services offered at the Prince George, including medication and case management.

Mr. S, a 44-year-old single man, was periodically homeless before coming to the Prince George. Mr. S had diagnoses of schizoaffective disorder, dementia due to HIV, and polysubstance abuse. His medication regimen included methadone maintenance, clonazepam, fluphenazine, and azidothymidine (AZT). Although he had graduated from high school, he acknowledged that he was pushed through despite his failing grades. He read at a seventh-grade level, and his work history included sporadic employment in construction.

Mr. S was referred for cognitive remediation because he was forgetful, highly disorganized, and inattentive; had poor frustration tolerance; and did not follow through on activities. Considerable staff time was being devoted to crisis management for Mr. S, because his disorganized, forgetful behavior repeatedly precipitated problems. For example, he would forget to take his medications for several days in a row, which would precipitate psychotic symptoms and associated disruptive behaviors, such as trashing his room.

Over the course of his treatment, Mr. S became increasingly able to complete tasks, focus, process, and remember information, as evidenced by the change in his ability to stay on task. At first he could tolerate only ten-minute sessions, but after several weeks this increased to one hour. His scores in various cognitive domains as measured by the Cognitive Stability Index improved significantly from baseline to six months: a Reliable Change Index (8) of 2.29 for reaction time, 2.42 for processing speed, 1.71 for memory, and 2.19 for attention. (The Reliable Change Index is a method for assessing change between test scores that adjusts for the reliability of the test and has the ability to take practice effects into account.) Staff also noted improvement in his organization, attention, and behavioral control. Mr. S was better able to keep his appointments, remember to take his medication, and maintain his grooming and hygiene. He took on new responsibilities in the learning center, including showing training tasks to other clients, writing for a newsletter, and giving tours to guests who visited the program. He also became an active member of various tenant groups and was able to successfully handle the maintenance of his room and other tenant responsibilities.

The authors thank Andrea White, C.S.W.

Dr. Medalia and Dr. Herlands are affiliated with the department of psychiatry and behavioral sciences of Albert Einstein College of Medicine in the Bronx, New York. Ms. Baginsky is with the Center for Urban Community Services, Inc., in New York City. Send correspondence to Dr. Herlands at Montefiore Medical Center, Department of Psychiatry, 111 East 210th Street, Bronx, New York 10467 (e-mail, [email protected]). Robert Paul Liberman, M.D., and Alex Kopelowicz, M.D., are editors of this column.