The role of negative symptoms in the context of cognitive remediation for schizophrenia Aida Farreny a, ⁎, Jaume Aguado a,b , Susana Ochoa a , Josep Maria Haro a , Judith Usall a a Parc Sanitari Sant Joan de Déu, Fundació Sant Joan de Déu, CIBERSAM 1 , Spain b University of Barcelona, Barcelona, Spain abstract article info Article history: Received 5 April 2013 Received in revised form 24 July 2013 Accepted 10 August 2013 Available online 29 August 2013 Keywords: Cognitive remediation Schizophrenia Neurocognition Negative symptoms Functional outcome Mediated effects Background: It has been suggested that the effect of cognitive remediation (CR) on functioning is mediated by the improvement in neurocognitive domains; especially executive function. However, the correlations are generally moderate and this has prompted the search for other mediators including negative symptoms (NS). Aims: To investigate whether the effect of CR on functioning could be mediated by executive function and/or NS. Method: In a previous study, 62 outpatients with schizophrenia were randomized to 32 group sessions of REPYFLEC CR or leisure activities. Functioning (Life Skills Profile; LSP), NS (PANSS) and executive function (Behavioral Assessment of the Dysexecutive Syndrome; BADS) were measured at baseline and post-therapy. To assess how the effect of REPYFLEC CR is expressed in functioning at post-treatment, an autoregressive mediation model was employed. Results: There was a significant effect of the REPYFLEC CR compared with the control group in improving BADS total score and PANSS NS. There was also a significant association between NS and functioning while executive function was not significantly related to functioning. Finally, there was a significant intervention effect on functioning mediated by NS but not by executive function. Conclusion: It is apparent that improving executive function does not lead directly to improved functional out- come and that NS might be closely linked to functioning in the context of our study. © 2013 Elsevier B.V. All rights reserved. 1. Introduction Cognitive remediation (CR) treatments in schizophrenia were designed to improve neurocognition on the assumption that progress in functioning might be mediated in this way. It has been suggested that the effect of CR on functioning is mediated by the improvement in specific neurocognitive domains (Vita et al., 2011), especially through executive function (Wykes et al., 2007; Penadés et al., 2010) and in particular, by planning improvement (Wykes et al., 2012). However, the correlations are generally moderate; accounting only for 20%–60% of the variance in functional outcome (Green et al., 2000), this has prompted a search for other variables that may account for the effect on real world performance such as negative symptoms (Greenwood et al., 2005; Bowie et al., 2008; Ventura et al., 2009; Bowie et al., 2010; Lin et al., 2013). Some theoretical grounding has proposed that negative symptoms (NS) could be an important moderating (Greenwood et al., 2005) or mediating (Lipkovich et al., 2009; Ventura et al., 2009; Lin et al., 2013) mechanism in the relationship between neurocognition and functional outcomes in schizophrenia. However, to the best of our knowledge, the role of NS in the context of CR has not yet been explored. One possible explanation for this may be the small effect that is found in psychiatric symptoms after CR treatments (McGurk et al., 2007; Wykes et al., 2011) that no longer seem significant at follow-up (Wykes et al., 2011). Nevertheless, some authors have stated that even very small improvements may have an impact on learning skills or future function- ing (Wykes and Spaulding, 2011). In addition, CR meta-analyses tend to study psychiatric symptoms without distinguishing between positive, negative and general psychopathology despite the likely heterogeneity within their expression and phenomenology that could complicate the understanding of symptoms in the context of CR. There is evidence to suggest that patients with higher NS severity have poorer social competence and quality of life (i.e. Harvey et al., 2006; Kirkpatrick et al., 2006; Bowie et al., 2008; Klingberg et al., 2011), as well as neurocognitive deficits, and these have been a consistent determinant of psychosocial functioning in several studies (i.e. Green et al., 2000; Bowie et al., 2008; Penadés et al., 2010; Vita et al., 2011). As such, in the light of their collective impact on outcome, the link between NS and neurocognition in schizophrenia has also garnered considerable attention. Some authors have argued that NS Schizophrenia Research 150 (2013) 58–63 ⁎ Corresponding author at: Parc Sanitari Sant Joan de Déu, Research Unit, Dr. Antoni Pujadas, 42, Sant Boi de Llobregat, 08830 Barcelona, Spain. Tel.: +34 936406350; fax: +34 935569674. E-mail address: afarreny@pssjd.org (A. Farreny). 1 Centro de investigación biomédica en red de salud mental. 0920-9964/$ – see front matter © 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.schres.2013.08.008 Contents lists available at ScienceDirect Schizophrenia Research journal homepage: www.elsevier.com/locate/schres