Re: Can Cognitive Remediation improve subsequent response to low-intensity Cognitive Behaviour Therapy for Psychosis in people with schizophrenia?

An interesting and timely debate article in the current volume of this journal argues that cognitive behavioural therapy for psychosis (CBTp) could be made more effective by treating clients with brief complementary cognitive remediation (CR) prior to psychotherapy (Naeem, 2017). The field requires such discussion and debate, particularly when considering current estimates from the Schizophrenia Research Institute that schizophrenia will cost Australia AUD2.6 billion per annum unless treatments are optimised. While the recommendations of the author that CBTp and CR programmes should be combined are indeed valid (e.g. both interventions are evidence-based, target distinct but complementary symptoms, and cognitive impairment can impede suitability for CBTp), there is need for more research before any firm recommendations can be made about the benefit of combining them. For example, the Drake et al. (2014) trial cited in the manuscript found that participants who received 12-weeks of CR (i.e. CIRCUITS) prior to CBTp made the same progress on the Psychotic Symptoms Rating Scale in half the amount of CBTp sessions as those who received 12-weeks of Social Contact prior to CBTp; better clinical insight was also linked to the CR group. However, there were ultimately no differences between groups on psychotic symptoms at follow-up, implying that CR may improve the efficiency (and possibly cost) of CBTp, but it does not seem to enhance treatment outcomes. Moreover, this trial is still the only RCT that has investigated the efficacy of combing CBTp with CR, and the participants in the trial were relatively young (18–35 years), which further limits interpretability and highlights the need for more rigorous replication.

Directions for future research could potentially focus on: (1) the amount of CR required prior to CBTp (e.g. is 12-weeks equivalent to 6-weeks or is a longer period required before enhancement of CBTp occurs?), (2) the order of treatments (e.g. CR could precede CBTp to help maximise its efficacy, but it could also be applied simultaneously or post-CBTp to maintain or even enhance any long-term benefit), (3) the types of patients who might benefit most (e.g. patients with first-episode psychosis or those with more severe cognitive impairments). More generally, the field would also benefit from studies that aim to ‘dismantle’ and identify the driving mechanisms/components of CR (i.e. the ‘active ingredients’) responsible for any improvement patients yield. If studies were able to identify the distinct components of CR that impart the greatest benefit (e.g. particular cognitive domains, behavioural activation) then such interventions could be made even more effective.

It is also worth noting that the recently published Royal Australian and New Zealand College of Psychiatrists (RANZCP) clinical practice guidelines for the management of schizophrenia and related disorders (Galletly et al., 2016) listed a number of evidence-based psychosocial interventions, in addition to CBTp, which might be particularly suitable for combination with CR. For example, metacognitive training (MCT) for psychosis has its roots in cognitive behavioural therapy (CBT) and specifically targets delusional symptoms; however, it focuses on the underlying cognitive processes (i.e. cognitive biases or problematic thinking styles, such as overconfidence, incorrigibility and hasty decision-making) that could be responsible for delusional symptoms, rather than targeting idiosyncratic delusional content (Moritz et al., 2014). A hybrid combination of MCT and CR that focuses on cognitive biases (which contribute to the development and maintenance of psychotic symptoms and may impact motivation in seeking treatment) and neurocognitive deficits (which impact capacity for new learning) may therefore be particularly beneficial to individuals with psychosis. For example, the MCT module dedicated to overconfidence may help to improve the minimal cognitive insight patients have regarding their cognitive deficits (see Balzan et al., 2014) and provide further motivation for improving these deficits with CR. The added benefit of MCT over more traditional CBTp is that it is typically administered in groups, and the modules and training manuals are easily available online across multiple languages (www.uke.de/mct). This greatly improves availability to patients and clinicians (a common critique of CBTp; see Naeem, 2017).

In sum, the combination of psychosocial treatments is overdue. We now have adequate evidence that both CBTp/MCT and CR interventions work on their respective treatment domains of positive symptoms and neurocognitive deficits, respectively; now is the time to focus on enhancing their efficacy even further by investigating combination ‘hybrid’ approaches with vigour.