218. Top-Down or Bottom-Up? Comparison of Two Computer-Assisted Modalities of Cognitive Remediation Therapy for Schizophrenia

Abstract

Background: Cognitive remediation (CRT) designed to improve cognitive function in patients with schizophrenia has shown significant efficacy. Our study was designed to compare 2 computerized CRT programs for improving memory and problem-solving skills in patients with schizophrenia. Each intervention uses a specific theoretical rationale: a top down approach (CogPack), training a broad range of cognitive features and a bottom up approach (PositScience), which targets the discrimination ability in perceptual systems. Goals of this study were (1) to perform a noninferiority comparison of the effects of the two programs in patients with chronic schizophrenia and (2) to examine whether the addition of a social cognition remediation intervention, Mind Reading, would further improve social function outcomes over each intervention alone.

Methods: Both CRT treatments were administered during a 12-week training period. Stable patients with DSM 5 schizophrenia who received either inpatient or outpatient clinical services were recruited. Patients were evaluated on a standardized battery of neuropsychological assessments (MCCB), social emotion measures, auditory and visual discrimination tasks, and a brief assessment of functional skills (PSP) and clinical symptoms (PANSS) at screening and at end point.

Results: 64 subjects were randomized as follows: (1) COGPACK Alone (n = 17), (2) PositScience Brain Fitness Alone (n = 14), (3) COGPACK + Mind Reading (Social cognition program; n = 19), (4) PositScience Brain Fitness + Mind Reading (n = 14). For the initial comparison and due to the small sample size, all subjects receiving COGPACK (n = 36), and all subjects receiving PositScience (n = 28) were each combined. Significant improvements from baseline were found in the COGPACK-treated patients for working memory and attention/vigilance. PositScience-treated patients showed significant improvements from baseline in working memory (P = .046) and visual learning (P = .048). Comparison of differential treatment effects found that patients treated with COGPACK + Mind Reader were significantly more benefited than patients treated with PositScience or COGPACK alone (P = .044). Changes in total PANSS (r = .453, P = .049) and PSP (r = .466, P = .045) scores were correlated with improvement in the MindReader combined groups (PositScience + Mind Reader and COGPACK + Mind Reader).

Conclusion: COGPACK or PositScience was associated with intervention specific improvements in working memory and attention/vigilance, and working memory and visual learning respectively. Cognitive improvement in the Mind Reader augmented groups was associated with changes in psychopathology and functional outcomes. Patients with deficits in specific cognitive domains may benefit differentially from a bottom up versus a top down approach and may therefore be assigned to a specific “deficit associated” program within a personalized therapeutic approach.