This document summarizes a presentation on cognitive remediation for schizophrenia. Cognitive remediation aims to improve cognitive processes like attention, memory, and executive function through behavioral training interventions. It relies on neuroplasticity to strengthen connections in the brain. Exercises target basic sensory skills, discrete cognitive abilities, and more complex skills. Studies find cognitive remediation improves cognition, functioning, and motivation, especially when treatment is more intensive, motivational factors are incorporated, and exercises are personalized. Typical programs involve cognitive assessment, goal setting, group sessions 2+ times per week for 3-4 months using drill and strategy practice, and bridging to real-world skills.

1. Cognitive Remediation 2012
Alice Medalia, PhD
Professor of Psychology (in Psychiatry),
College of Physicians and Surgeons
Director of Psychiatric Rehabilitation,
Columbia University Medical Center
New York, New York

2. Disclosure: Alice Medalia, PhD
Type Company
Grant/Research Support Eli Lilly and Company; SunovionPharmaceuticals Inc.
• This presentation will not include discussion of
off-label, experimental, and/or investigational
uses of drugs or devices

3. Cognitive Remediation
“is a behavioral training based intervention that aims to
improve cognitive processes
(attention, memory, executive function, social
cognition, or metacognition) with the goal of durability
and generalization.
…where social cognition is defined as “the mental
operations that underlie social interactions, including
perceiving, interpreting, and generating responses to the
intentions, dispositions, and behaviors of others.”
Cognitive Remediation Experts Workshop 2010

4. Cognitive Remediation
Is a Learning Activity
• Learning relies on neuroplasticity
Neurons in the brain adjust their activity
and organization in response to new situations
or to changes in the environment
• Schizophrenia and neuroplasticity
Patients receiving CR demonstrated a decelerated
loss of and, in some cases,
increase in gray matter volume
Eack SM, et al. Arch Gen Psychiatry. 2010;67(7):674-682.

5. Cognitive Remediation:
Restorative Approaches
Target basic Target discrete Target complex
sensory processes cognitive skills cognitive skills
eg, auditory eg, memory tasks eg, problem
processing solving

6. Examples of Computer based
Cognitive Exercises

7. Cognitive Remediation and
Computers
• Many different software companies make exercises to
improve cognition
• There have been no head-to-head studies comparing
software within and between companies
• Some CR programs use one software
and others use a combination of software
• Engaging software has better outcomes

8. Who Participates in Cognitive
Remediation Research?
36 years old Mild-moderate symptoms
12 years of education In- and outpatients
N >2700
17 weeks of treatment 2-3 times a week
32 hours Drill and strategy
Wykes T, et al. Am J Psychiatry. 2011. Kurtz & Richardson Schz Bull 2011

9. Impact of Cognitive Remediation:
Effect Sizes from Meta-Analyses
Daily Functioning
N-Cog:0.45 N-Cog:0.36 N-Cog:0.28
S-Cog:0.46 - S-Cog:0.78 S-Cog: 0.68
1.01
WykesT, et al. Am J Psychiatry. 2011; McGurk SR, et al. Am J Psychiatry. 2007;
Kurtz & Richardson Schiz Bull 2011

10. Variables That Significantly Moderate Impact
of Cognitive Remediation
Cognitive Functional
Outcome Outcome
Treatment
Intensity
Context
Strategy +
Motivation
practice
Medalia &Choi . Neuropsych Review. 2009 Wykes T, et al. Am J Psychiatry. 2011

11. Impact of Treatment Intensity on
Cognitive Enhancement in
Schizophrenia
Medalia & Richardson Schiz Bull 2005

12. Effect Size of Motivational
Enhancements on Learning &
Motivation Outcomes
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Attention Math Skill Intrinsic Perceived
Motivation Competency
Choi and Medalia; ScizResch2009

13. Promote Intrinsic Motivation
• Use engaging activities
• Contextualize
• Personalize
• Offer Learner Control

14. Personalizing Treatment
• Link cognitive remediation to personally relevant
goals
• Different training exercises for different people
• Find the sweet spot of challenge
• Combine with therapies that are relevant to
recovery goals

15. Cognitive Remediation Programs
Typical Components Where They Are Found
• Assessment of • Outpatient clinics that offer
baseline cognition psychosocial rehabilitation
programming
• Set cognitive goals as they relate
to recovery goals • Long-term residential/
inpatient care settings
• Groups 2+/week;
3-4 months; drill practice strategy
• Include bridging activities
• Track progress
Medalia A, et al. Cognitive Remediation in Psychological Disorders. Oxford University Press: New York; 2009.

16. Alice Medalia, PhD
E-mail: amedalia@aol.com
www.cognitive-remediation.org