Cognitive Enhancement Therapy for Early Course Schizophrenia: Effects from a Two-Year Randomized Controlled Trial

Background and Purpose: Schizophrenia is a chronic and disabling disorder that is frequently characterized by marked deficits in cognition. These deficits are known to be present at the onset of the disease and significantly predictive of long-term difficulties in functioning and behavior. As such, the early application of cognitive rehabilitation approaches may afford substantial functional benefits to this population. Unfortunately, long-term studies of the effects of cognitive rehabilitation applied early in schizophrenia have yet to be conducted. We examined the two-year effects of a comprehensive cognitive rehabilitation program, Cognitive Enhancement Therapy (CET; www.CognitiveEnhancementTherapy.com), in individuals with early course schizophrenia to evaluate the impact of the early application of this intervention on long-term cognitive and functional outcomes.

Methods: Stabilized, early course outpatients with schizophrenia or schizoaffective disorder were randomly assigned and treated in a two-year trial with CET (n = 31) or an active Enriched Supportive Therapy (EST) control (n = 28). CET is an integrated approach to the remediation of social and non-social cognitive deficits in schizophrenia that makes use of computer-assisted cognitive training and group-based secondary socialization techniques. EST is an individual approach that focuses on illness management and stress reduction. A comprehensive battery of measures was administered annually to assess treatment effects on cognition, functional outcome, and symptomatology. Analyses of covariance confirmed by linear mixed-effects models were used to estimate differential rates of change in cognitive and behavioral outcomes between individuals receiving CET and EST.

Results: Of the 59 individuals randomized and treated, 49 and 46 completed 1 and 2 years of treatment, respectively. Significant differential effects favoring CET were observed on composite measures of social cognition, social adjustment, and cognitive style during the first year of treatment. After two years, moderate effects (d = .65) were observed favoring CET at enhancing neurocognitive function, with younger patients demonstrating the most neurocognitive improvement. Strong differential effects (d ≥ 1.00) on social cognition, cognitive style, and social adjustment composites remained at year 2, and also extended to measures of symptomatology, particularly negative symptoms. Of critical importance, individuals receiving CET made large functional gains compared to those treated with EST, with significant differential improvements observed in the domains of employment, social functioning, and major role adjustment.

Conclusions and Implications: CET is an effective approach to the remediation of cognitive deficits in early schizophrenia that can serve to reduce disability among this population. The remediation of such deficits should be an integral component of early intervention programs treating psychiatrically stable outpatients with schizophrenia. As the primary providers of psychosocial treatments for this population, social work practitioners need to seriously consider adding this approach to their clinical practice as an evidence-based and effective adjunct to routine pharmacotherapy. When combined with previous evidence supporting the efficacy of CET for individuals with chronic schizophrenia, findings indicate that the wider dissemination and implementation of this approach could substantially improve the lives of a large number of individuals living in the community who continue to struggle to recover from this disorder.