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Accessing Cognitive Remediation in Australia

by Rosalie Altman, PhD candidate at Swinburne University

Three years ago, I started my PhD at the Centre for Mental Health & Brain Sciences at Swinburne University in Melbourne, Australia, with Professor Susan Rossell, head of the Cognitive Neuropsychiatry Lab, and Dr Eric Tan. Together we designed a research project to investigate access to cognitive remediation for schizophrenia. We noted that cognitive remediation is yet to be readily available in mental health services, especially in Australia, despite strong evidence for its efficacy. Being from France myself, I knew it was not just an Australian issue; there seemed to be a lack of utilisation of cognitive remediation in France too. One of the studies included in my PhD is presented below.


Research shows that cognitive challenges are often present in people with schizophrenia and associated with difficulties in daily functioning, educational/work outcomes, and recovery. While considerable research has demonstrated cognitive remediation efficacy in improving both cognition and functioning, translation into real-world clinical settings is limited. In Australia, cognitive remediation is still primarily only accessible through clinical trials. Understanding access to cognitive remediation in Australia as well as service user perspectives on how to best address cognitive difficulties are both key gaps in the current literature. Through an online survey, we asked 61 people with a diagnosis of schizophrenia, living in Australia, about their subjective cognitive challenges as well as knowledge of, access to, and interest in accessing cognitive remediation.


We found that demand for accessing cognitive remediation was high but was not related to cognitive complaints. Negative affect, however, was a significant predictor of people's interest in cognitive remediation. As seen in Figure 1, more than half of our participants had also never heard about cognitive remediation despite almost 70% reporting experiencing cognitive challenges. Critically, only 8.5% of respondents had previously completed cognitive remediation.

Figure 1. Participant responses relating to cognitive difficulties, knowledge of and access to cognitive remediation, and interest in cognitive remediation participation * Question displayed only to participants who answered "yes" to "Have you ever heard of cognitive remediation?"

Our results suggest that awareness of, and access to, cognitive remediation in Australia is limited. Despite this, people with schizophrenia display help-seeking intentions regardless of their subjective cognitive complaints. Cognitive complaints might play a role in therapy engagement, but our results suggest that it may not be an indicator of people's initial willingness to engage. For clinicians, this potentially implies that subjective cognitive functioning should only be considered when using strategies to keep participants at higher risk for dropout engaged, but not to initially select clients. Our results also show that affective dispositions should be considered when looking at help-seeking behaviours for cognition in schizophrenia.


Our paper contributes preliminary evidence of access to cognitive remediation and supports the need for large-scale national studies to comprehensively assess its utilisation in Australia, and indeed across the world. We further highlight the importance of incorporating service user preferences into the design and use of cognitive remediation, as has been done in relation to participation. Given that cognitive remediation is an evidence-based practice, we suggest its implementation be routinised across mental health services as outlined in recent national guidelines to improve the recovery of people with schizophrenia.


For more information about this research and other contributions from our research group:

 

References

1. Kharawala S, Hastedt C, Podhorna J, Shukla H, Kappelhoff B, Harvey PD. The relationship between cognition and functioning in schizophrenia: A semi-systematic review. Schizophrenia Research: Cognition 2022;27:100217-100217.

2. Wykes T, Huddy V, Cellard C, McGurk SR, Czobor P. A Meta-Analysis of Cognitive Remediation for Schizophrenia: Methodology and Effect Sizes. The American Journal of Psychiatry 2011;168(5):472-485.

3. Vita A, Barlati S, Ceraso A, Nibbio G, Ariu C, Deste G, Wykes T. Effectiveness, Core Elements, and Moderators of Response of Cognitive Remediation for Schizophrenia: A Systematic Review and Meta-analysis of Randomized Clinical Trials. JAMA Psychiatry Aug 1 2021;78(8):848-858.

4. Altman RAE, Tan EJ, Rossell SL. Factors Impacting Access and Engagement of Cognitive Remediation Therapy for People with Schizophrenia: A Systematic Review. Canadian Journal of Psychiatry Mar 2023;68(3):139-151.

5. Bryce SD, Warren N, Ponsford J, Rossell S, Lee S. Understanding the lived experience of cognitive remediation in schizophrenia: A qualitative comparison with an active control. Psychiatric Rehabilitation Journal Dec 2018;41(4):302-311.

6. APA. The American Psychiatric Association Practice Guideline for the Treatment of Patients with Schizophrenia. 3 ed. Washington, D.C: American Psychiatric Association Publishing; 2020.

7. Galletly C, Castle D, Dark F, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Australian & New Zealand Journal of Psychiatry 2016;50(5):410-472.


 

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