Cognitive Remediation
Christopher R. Bowie, Ph.D., C.Psych.
Associate Professor
Psychology & Psychiatry
Queen’s University
Kingston, ON
-------------------------------------------Head Consulting Psychologist
Head’s Up Early Psychosis Program
Kingston, ON
-------------------------------------------Independent Scientist
Centre for Addiction and Mental Health
Toronto, ON
1
Functional Recovery in Schizophrenia:
Historical Pessimism
• Kraepelin
• DSM-III: “a complete return to premorbid
levels of functioning…is so rare as to cast
doubt upon the accuracy of the diagnosis”
• DSM-IV:TR “Complete remission is probably
not common”
Proposed Criteria for Recovery
1. Sustained remission of psychotic Sx
2. At least part-time engagement in
instrumental role (worker, student,
volunteer)
3. Living independently and handling all aspects
of daily living
4. Participating in an active friendship or other
recreational interests
Adapted from Liberman et al, 2002
Outcome in the Hillside
First Episode Study
100
90
80
70
60
50
40
30
20
10
0
Remission:Ever
Remission:Sustained
Functional
Full recovery
Recovery Rates
Adapted from Robinson et al., 1999; Robinson et al., 2002
ISoS Results: Remission versus Recovery ≥ 15y
No Psychosis
No Psychosis & Live Independently
& Socializing
Remitted
31%
Disabled Remitted
50%
50%
Disabled
69%
No Psychosis & Live Independently
Remitted
37%
No Psychosis & Live Independently
& Socializing & Working
Remitted
16%
Disabled
63%
Disabled
84%
Adapted from ISOS
Number of Inpatient Psychiatric Beds
per 100,000 Civilians
6
Functional Assessment Domains and
their Limitations
• Objective information
– Availability; Relevance; low rate of occurrence
• Self-report
– Bias; Cognitive limitations
• Observation
– Situation-specificity of behavior
• Performance-based
– Practicality; content validity
What predicts (in)accurate clinician
ratings of cognition?
Harvey et al, 2001
40
35
30
25
20
15
10
5
0
Sample 1
Negative Symptoms
Sample 2
Perceived Cognitive Ability
8
Functional Assessment:
Why not just ask?
Pearson’s r
Convergence of Participant and Case Manager Ratings
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Interpersonal
Work
Activities
Bowie et al, J Psychiatric Research, 2007
Sadder…but Wiser
Accurate
Underestimate
0
-0.2
-0.4
Overestimate
15
Z-Score
Total Score
20
10
5
0
BDI
Cognitive Composite
-0.6
-0.8
-1
-1.2
-1.4
-1.6
-1.8
-2
Bowie et al, J Psychiatric Research, 2007
Cognitive Complaints in BPD
• Self-reports were not significantly correlated
with any of the objective measures.
• Relationship between self-reports and mood
with ↑ cognitive complaints with depression
and ↓ cognitive complaints with mania.
Burdick et al. 2005
Description of Functional Capacity
Measures
• Performance of skilled acts associated with
independent, community living
• Directly measurable and objective
• Proxy for adaptive community behavior
• Most common instrument ranges from 10
minutes (UPSA-Brief) to 25 minutes (UPSA)
• Newer, computerized measures entering the
literature
Performance-Based Measures
Balancing Merits & Issues
1. Mediate the cognition –
functioning relationship
1. Indirect relationship to cognitive
change
1. Easy to administer, well tolerated
1. Issues with cultural adaptability?*
1. Very good psychometric
properties (comparable to
cognition)
1. Intrapersonal, Interpersonal, and
Extrapersonal factors limit the
relationship with actual
community functioning
1. Superior to cognition for
predicting independent living and
work
1. No direct assessment of work*