This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Cognitive remediation aims to help people with psychosis improve their cognitive abilities (such as problem-solving) and daily function, so that they can maintain a job and relationships, for example.
National Institute for Health and Care Excellence (NICE) guidelines recommend cognitive remediation for psychosis which is severe and resistant to other approaches (complex psychosis), but not yet for people with early psychosis.
Among people with early psychosis, researchers compared group delivery of cognitive remediation with 1-to-1 sessions. They found that both approaches were more effective in the short-term than treatment as usual and offered good value for money.
The findings suggest that cognitive remediation, delivered either via groups or 1-to-1 sessions, is effective and cost-effective as an early intervention in psychosis.
More information on psychosis can be found on the NHS website.
The issue: is 1-to-1 or group cognitive remediation best for psychosis?
People with psychosis lose some contact with reality. They might see or hear things that do not exist (hallucinations) or have an unshakeable belief in something untrue (delusion). Most people with a diagnosis of psychosis also have cognitive problems (such as poor memory or problem-solving skills) that interfere with their recovery and with achieving personal goals.
Early Intervention in Psychosis services support people who are at risk of, or who have had a first episode of psychosis. Intervening early can improve people’s long-term outcomes, and, for example, improve physical health and educational performance. The service aims to improve functional recovery (the ability to carry out everyday tasks or achieve personal goals) as well as preventing relapse.
Improved cognitive skills allow people to achieve their goals. In cognitive remediation, a therapist works with someone with psychosis to improve their cognitive and meta-cognitive skills (thinking about thinking, which includes attention, memory, and planning). The therapy helps people translate these skills to everyday life to achieve their recovery goals (such as staying in work or education).
In this study, researchers compared cognitive remediation delivered individually, in group sessions or carried out independently. They wanted to identify which approach was most effective and offered better value for money.
What’s new?
The researchers invited people with first episode psychosis (aged 16 to 45) from 11 Early Intervention for Psychosis services in England. Most participants (73%) were men, and their average age was 26 years.
All participants received standard care, which involves education and employment support, along with medication. Some received cognitive remediation, in addition. Cognitive remediation was delivered digitally using CIRCuiTSTM. This therapy programme sets exercises and real-life tasks to help people learn strategies and practice using new cognitive and metacognitive skills to solve problems. A trained therapist provided different levels of support.
The study compared groups who received standard care plus:
- cognitive remediation in 1-to-1 sessions with a therapist twice weekly for 10 and a half weeks (112 people)
- cognitive remediation in group sessions 3 times weekly for 12 weeks, in groups of up to 4 (134 people)
- cognitive remediation independently with access to a therapist for up to half an hour per week for 12 weeks (65 people)
- no extra intervention (66 people).
The primary outcome at 15 weeks was functional recovery: participants rated how successfully they had met personal goals such as returning to work or education.
At 15 weeks, functional recovery:
- was better among those who received cognitive remediation in 1-to-1 or group sessions than among those who received standard care
- was similarly improved among people who had 1-to-1 versus group sessions
- was no better among people who had cognitive remediation delivered independently, compared with those who received standard care alone.
At 6 months, there was no difference in functional recovery between those who had cognitive remediation (1-to-1 and group session combined average score) and those who had standard care.
Cognitive remediation cost slightly more than standard care. The cost of an extra quality-adjusted life-year (equivalent to 1 year in perfect health) was £4,306 extra for group and £3,170 more for 1-to-1 cognitive remediation sessions, compared with treatment as usual. Calculations were based on 2018 to 2020 figures.
Adverse events were similar between groups and there were no serious adverse events related to cognitive remediation.
Why is this important?
Cognitive remediation helped people achieve personal goals and offered value for money for those with first-episode psychosis. It could be delivered in 1-to-1 sessions or in a group. Both approaches had similar costs for the extra quality-adjusted life years, below the NICE threshold for new therapies (£20,000), meaning both are likely to be cost-effective. The impact of cognitive remediation on functional recovery declined over time.
People were initially less enthusiastic about group sessions, but once they engaged with the therapy, they found both approaches acceptable. However, overall, the independent delivery group did not engage sufficiently with cognitive remediation for it to be any more effective than standard care alone.
Full attendance was low. Most participants received 1 therapy session (93%). Those who failed to attend 6 sessions (38% for groups; 23% for 1-to-1 sessions) were considered to have dropped out.
What’s next?
In further research, the team found that remote delivery of cognitive remediation for people with psychosis using CIRCuiTSTM was acceptable and convenient; the authors concluded that it may help people continue with treatment.
You may be interested to read
This is a summary of: Wykes T, and others. Cognitive Remediation Works But How Should We Provide It? An Adaptive Randomized Controlled Trial of Delivery Methods Using a Patient Nominated Recovery Outcome in First-Episode Participants. Schizophrenia Bulletin 2023; 49: 614 – 625.
A video explaining cognitive remediation and the Circuits app.
A larger report on the study’s findings: Wykes T, and others. Cognitive remediation therapy to enhance cognition and improve recovery in early psychosis: the ECLIPSE research programme including an RCT. Programme Grants for Applied Research 2024; 12: 1 – 84.
Information on the cognitive remediation software used in this study.
Contacts for support with psychosis.
Information on taking part in NIHR research on psychosis.
Funding: This study was funded by funded by an NIHR Applied Programme Grant and the NIHR Maudsley Biomedical Research Centre.
Conflicts of Interest: Til Wykes and Clare Reeder developed a cognitive remediation software used in this study.
Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
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