Review Cognitive remediation therapy for schizophrenia: what is it and does it work? Gary Donohoe, Heike Schmidt, Ian H Robertson Ir J Psych Med 2011; 28(4): 217-221 Abstract Impaired cognition is a core feature of schizophrenia (SZ) that precedes, accompanies, and often outlasts a patient’s clinical symptoms. The success of new genera- tion antipsychotics, as well as their failure to ameliorate the persistent disabilities associated with the disorder are well documented. Consequently, a number of psycho- social and cognitive interventions have been developed to address specific aspects of disability not adequately alleviated by medication. Among these, interventions adapted from the acquired brain literature that target cognitively based disability (cognitive remediation therapy; CRT) have received signif- icant empirical support both for ameliorating specific deficits in memory, attention and executive function, and improving real world outcome. CRT strategies have focused either on providing drill-based training aimed at increasing capacity or providing behavioural strategies for compensating for cognitive deficits, or a mixture of both. Nonetheless, these interventions have varied widely and several questions remain. This review provides a brief overview of cognitive reme- diation therapies in psychosis, discusses evidence for its success, and outlines a number of questions that remain about its implementation. Given the current unavailability of cognitive remediation as part of standard care in Irish mental health services, we conclude by describing one such intervention developed within our clinical research group and the questions we hope to address in making this programme more widely available to Irish patients. Introduction Schizophrenia (SZ) is one of the most disabling disorders in medicine. In a recent World Health Organisation 14-coun- try study of physical and mental disability, active psychosis ranked as the third most disabling condition ahead of paraple- gia and blindness. 1 SZ has been estimated to cost between 1.6-2.6% of total healthcare expenditure in western countries and for Ireland has recently been estimated conservatively as e460m in 2006. 2 Irish mental health patients have the lowest employment rate of all disability groups; 3 in schizophrenia, only one in four patients are in full-time employment. Impairments in motivation and cognition, which are strongly associated with long-term disability, respond poorly to current drug treatments, and are a major focus of current pharmaco- logical research. 4 A drought in new drug discovery for SZ is widely acknowledged 5 and has resulted in increased interest in non-pharmacological therapies that can be used in addition to existing pharmacological strategies to minimise the effects of disability in this patient group. 6 Cognitive remediation therapy (CRT) training has repeat- edly been shown to confer significant advantages over current treatments by providing a mechanism for directly treating these deficits in a manner suitable for use by current mental services. Successfully providing CRT in a community-based service represents an important step towards responding to what patients repeatedly articulate as a central cause of disability for them. Public spending on cognitive remediation therapy research remains low, however, and not just in Ireland. According to Wykes, 7 of the $350m spent on research into SZ by Ameri- can National Institutes of Health in 2009, only $4.1m (1%) went to cognitive remediation therapy studies. This is to say that by comparison with clinical trials of other therapies for SZ, in particular pharmacological therapies, cognitive reme- diation therapy has received less focus and attention. Despite this, since the 1990s more than 100 trials of CRT have been reported, with benefits to neuropsychological functions such as attention and memory, and level of social and functional output both reported. In Ireland and the UK, psychological therapies for psychosis in general have only recently begun to form part of the mental health strategy, with cognitive behavioural therapy (CBT) still not widely available in many services despite significant inter- est amongst healthcare workers across disciplines. Whether and what place CRT can expect to have given the limited resources available to deliver these services is unclear. However, as with any form of therapy, this discussion must begin with understanding this treatment option, what the ‘active ingredients’ associated with response are, and what factors explain differences in treatment benefit. Cognitive remediation therapy Adapted primarily from interventions developed for acquired brain injuries, cognitive rehabilitation in SZ has aimed to achieve durable improvements in cognition using a number of techniques. These can be broadly classified into two approaches: 8 •฀฀ Cognitive฀remediation฀approaches •฀฀ Cognitive฀adaptation฀approaches.฀ 217 *Gary Donohoe, Senior Lecturer in Clinical Psychology, Department of Psychiatry and Institute of Neuroscience, St James’s Hospital, Dublin 8, Ireland. Email: donoghug@tcd.ie Heike Schmidt, Research Fellow, Department of Psychiatry, School of Medicine, Trinity College Dublin Ian H Robertson, Professor of Psychology, School of Psychology and Institute of Neuroscience, Trinity College, Dublin 2, Ireland. *Correspondence SUBMITTED: JANUARY 20, 2011. ACCEPTED: AUGUST 26, 2011.