by Dr Margherita Bechi, Psychotherapist based at the San Raffaele Hospital in Milan
My interest in the quality of life for patients affected by schizophrenia began very early in my clinical and research career. I started working and studying psychosis before my university degree at the psychiatry department of San Raffaele Hospital, Milan. From the beginning, I found the clinical, psychopathological, and functional heterogeneity of psychosis interesting and intriguing.
M.F. Green’s paper 'Neurocognitive Deficits and Functional Outcome in Schizophrenia: Are We Measuring the “Right Stuff"?' published in 2000 (1) was the first look for a neuropsychological explanation of daily functioning capabilities in schizophrenia.
Neurocognitive impairments in schizophrenia mainly affect memory, attention and vigilance, working memory, verbal fluency and executive functioning. Cognitive impairments are present in more than 75% of patients, representing core disturbance symptoms. However, they are not distributed homogeneously in the schizophrenic population. Therefore, the different manifestations of neurocognitive deficits could contribute to explaining the heterogeneity of the illness.
Daily functioning in schizophrenia seems to be deeply affected by neurocognitive dysfunctions. Taking some examples from everyday life, you can have difficulties in grocery shopping if you have a memory deficit (that affect you memory of the list of products to buy) or if you have an attention impairment (and you can't find the product you're looking for on the shelves). In addition, executive dysfunctions affect the planning ability and it could lead to an inability to complete simple tasks such as cooking, planning a pleasant activity up to working activity.
The work structure of San Raffaele hospital’s psychiatry department is characterized by a strong relationship between research activities driven by clinical observations.
Our group started a first cognitive remediation therapy (CRT) clinical trial in the 2002 with the aim to investigate the efficacy and the generalization of the effect of CRT on cognition and functioning. We enrolled 100 patients affected by schizophrenia and after a neurocognitive, psychopathological and daily functioning assessment we started a randomized-control study.
Patients participated in personalised sessions of computerised CRT three times a week for a maximum of 36 sessions. We utilized a computerized intervention (CogPack software) because of its flexibility, accessibility and easy practice both for therapists and patients.
CRT from therapist’ point of view
It was my first experience with CRT and, after a training period, I practiced it with patients. I was pleasantly surprised by the possibility of a tailored intervention based on the current deficits observed in patients. Many exercises are adaptive and the real capacity of the patients drives the difficulty of the exercises online.
One of the main building block of the CRT is the principle of 'errorless learning'. It consists on an intervention focused on the avoidance of patients ‘dissatisfaction' leading to increase therapy compliance. Patients show an increasing self-confidence combined with the feeling of a therapeutic 'embrace'. In fact, the therapists’ role is fundamental in order to understand the needs and difficulties of patients and to drive them to correct and new strategies.
The action of support is associated with a constant activity of assessing the needs and the levels of competence achieved from time to time, as the support must always be adequate and adapted (adaptive) to progress, until the manifestation of the performance in full autonomy.
Moreover, one of the main characteristic of CRT is the usability from patients with different psychopathological and clinical severity. Even inpatients could benefit from CRT integrated with rehabilitation program.
From the first publication and subsequent confirmation, the CRT efficacy on cognitive deficits was evident, as it was the cascade effect on the daily functioning of patients.
The literature highlights how CRT combined with a cognitive rehabilitation program could give patients the opportunity to improve their functioning also by the creation of a positive ecological loop. By the way, patients could be more enthusiastic to take part of a dinner with friends if they feel more confident with their cognitive and sociocognitive capacity, or they could reach more pleasure from a movie night out if they are able to maintain attention as long as a movie requests.
In other words, CRT is the starting point that allows patients to take their daily life into their hands and to be satisfied with their lives.
After nearly twenty years of experiences with CRT in schizophrenia, I can sustain how the cognitive and functional improvement for patients could be rewarding also for the therapists’ work. The goals achieved from patients feed the therapists’ motivation and they represent a drive to increase the research activity and clinical application in order to decrease the burden cause by the disturb.
Currently, CRT is considered one of the best practice for the treatment of schizophrenia and it represent a core rehabilitation treatment for every patients affected by schizophrenia in our department.
In conclusion, for our group, this represents a great result given the time and energy invested for many years, but above all, the real success for us is represented by the well-being achieved by patients, even in the most serious conditions.
(1) Green, M.F., Kern, R. S., Braff, D.L., & Mintz, J. (2000). Neurocognitive Deficits and Functional Outcome in Schizophrenia: Are We Measuring the “Right Stuff"?. Schizophrenia Bulletin, 26(1), 119-136.
(2) Cavallaro, R., Anselmetti, S., Poletti, S., Bechi, M., Ermoli, E., Cocchi, F., Stratta, P., Vita, A., Rossi, A., & Smeraldi, E. (2009). Computer-aided neurocognitive remediation as an enhancing strategy for schizophrenia rehabilitation, Psychiatry Research, 169(3), 191-196.
(3) Buonocore, M., Spangaro, M., Bechi, M., Baraldi, M.A., Cocchi, F., Guglielmino, C., Bianchi, L., Mastromatteo, A., Bosia, M., & Cavallaro, R. (2018). Integrated cognitive remediation and standard rehabilitation therapy in patients of schizophrenia: persistence after 5 years. Schizophrenia Research, 192, 335-339.
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