By Emalee Gillis, NAMI Spokane Blog Editor.
Training the brain to improve cognition of people with schizophrenia and other neuropsychiatric illnesses was the subject of a NAMI Ask the Expert series aired on December 12, 2024. Improving cognition is important for people with neuropsychiatric illness because research has documented that the cognition or the brain’s ability of process information can be damaged by illnesses like schizophrenia and bipolar disorder.
The presentation was given by Dr. Matcheri Keshavan who is a full professor at Harvard and the academic head of psychiatry at the Massachusetts Mental Health Center and the Beth Israel Deaconess Medical Center.
According to Dr. Keshavan, people with schizophrenia have different symptoms, “but the most common set of symptoms, which is present in over nearly 90% of the individuals with this illness is cognitive impairment. And it is the cognitive impairments that lead to the disability in this illness. Why is it that the majority of people with schizophrenia are unable to have full-time employment and are functionally disabled? It’s because of cognitive difficulties, not because of psychosis.”
Dr. Keshavan continued, “An important and unmet need for schizophrenia is on how to improve cognition. There are no medications so far on improving cognition.
The key elements of cognition include speed, memory, attention reasoning, emotional recognition or tact, and also synthesis,
Dr. Kashavan explained, “Cognitive enhancement is an approach that is effective and is a comprehensive way of improving functional recovery. So there are many studies now probably over 100 around the world, showing that cognitive remediation works better than treatment as usual in improving community functioning.”
Cognitive training harnesses the inherent neuroplastic capacities of the brain, targeting brain function across psychiatric disorders.
Dr. Keshavan said, “Traditionally, over the initial few decades of this line of work, we were using simple things like a paper and pencil, crossword, and brain-teasers, and Sudoku and so forth, which are still useful.”
Over time there are more and more online approaches available for this kind of brain practice, practice of attention, memory, and executive function and so on. So there are many such online programs available. One approach is called Lumosity, which has hundreds of exercises. And it costs a little bit of money, it’s about $70 per year. Then there’s another one called PositScience, which is now has got a new name called Brain Headquarters.
Dr. Keshavan stressed, “But one point I want to say is you also need a therapist or a coach. Coaches can take the individual through thinking skills themselves. Simply doing this kind of practice on a computer is not enough to produce benefits.“
Another important aspect of strategic thinking is helping individuals to get the big picture, or getting the gist. So in training sessions, people are given a complex paragraph and they are asked to point out the gist of it in one sentence.
Thinking about the other person’s perspective is another important aspect of cognition. Trainers help participants help the individual think about the other person’s perspective.
Dr. Keshavan explained, “All of those were combined in this approach, which we call cognitive enhancement therapy. We help individuals to first learn ways of managing one’s own stress, identifying symptoms, learning relaxation techniques, and so on, through individual psychotherapy and coaching. This is followed by computer-based exercises, neurocognitive remediation, which involves attention modules, memory, and problem-solving modules. And we do it in pairs. Two people with the illness get together, and they develop a collaborative approach and solve computer-based exercises with coaching by the clinician. We combine neurocognitive remediation with also developing social cognition by learning to collaborate, learning to criticize in a constructive way, learning to learn from mistakes and so.”
He continued, “And then we have in parallel groups that focus on social cognition, where we take participants through various aspects of social cognition, metacognition and so forth, using exercises. We use both homework exercises, as well as exercises in groups themselves, about how to act wisely in social situations, how to appraise social context, how to take the other person’s emotional temperature and so on. These are one and a half hour group sessions for a total of about 45 sessions. We are able to do that now in one year. We’re developing at this time a six-month version of this as well. So there are three components, individual coping, computer exercises, and group exercises. “
Dr. Keshavan said that research shows that this approach is effective. “We have done three independent trials, first in a chronic schizophrenia study, and then in an early course study, and then in an independent early course study again. So, all of those have shown that cognitive enhancement therapy is better than treatment as usual. We also found that when followed up, even after the end of the treatment, the beneficial effects persisted We scanned individuals before and after receiving the intervention, and we found that some of the gray matter reductions that we had seen at the beginning were actually reversed in people who were treated with cognitive enhancement therapy, compared to those who received supportive therapy alone. So, it is not only improving cognition but also protecting against gray matter loss. The more the brain changes, the larger was the improvement in cognition.
Research has also shown that early intervention is important. Physical exercise and sleep also help cognition and are incorporated into the approach.
When asked by audience members of where they can find cognitive enhancement therapy, Dr. Keshavan explained that SAMHSA has certified it as an evidence-based treatment and it is reimbursable. There are a number of academic sites and some non-academic sites which participated in studies, and they are in discussion on how they can implement it in a non-research way going forward. He encouraged anyone who is interested to write to him to see if he could point you in the right direction. He also mentioned a program in Cleveland that does train different site settings for cognitive enhancement therapy around the country called the PLAN program. You can reach Dr. Keshavan at this email address. You can view the full webinar here.
Dr. Matcheri Keshavan is a full professor at Harvard and the academic head of psychiatry at the Massachusetts Mental Health Center and the Beth Israel Deaconess Medical Center.
Emalee Gillis is a writer and blog editor. She is the author of the memoir Adventures on the Path to Living Well with a Mental Illness and has a related TEDx Talk.