Cognitive Training Augments Benefits of Supported Employment

Augmenting supported employment with cognitive remediation can improve vocational outcomes for schizophrenia patients with lower levels of community functioning, according to a report published online in Psychiatric Services in Advance January 2.

However, cognitive remediation—comprising various kinds of “brain training” computer software—may not be necessary for schizophrenia patients who are functioning better in their communities, according to the report.

Morris Bell, Ph.D., and colleagues at Yale University School of Medicine analyzed data from two related randomized, controlled trials. Unemployed outpatients with diagnoses of schizophrenia or schizoaffective disorder were recruited at a large urban community mental health center. Between 2000 and 2012, a total of 174 participants completed the study; because of the high degree of engagement engendered by the vocational program, the follow-up rate for determining employment outcome was 100 percent.

They received either supported employment (SE) or supported employment plus cognitive remediation (SE plus CR). Supported employment included “individual placement and support” provided by the community mental health center and weekly groups led by the research staff in which participants could discuss work-related problems and issues, as well as social concerns such as how to handle newly earned income. Participants in the augmented (SE plus CR) condition received identical employment services to participants in the SE condition plus up to 10 hours per week of computerized cognitive exercises using two forms of commercially available software specifically designed for people with compromised brain function.

Participants were also classified into higher or lower community functioning according to baseline scores on the Quality of Life Scale, a 21-item structured interview. Primary outcome measures were competitive employment rates and total hours of work.

Bell and colleagues found that employment rates over two years for participants with lower functioning were significantly different for the two conditions—20 percent for supported employment and 49 percent for remediation, while participants with higher functioning showed approximately equivalent rates of employment (62 percent and 54 percent). Among lower-functioning participants, those who received CR also worked significantly more hours over two years than those who received SE only, but higher-functioning participants worked similar amounts of hours in both conditions.

The researchers also used statistical analysis to examine three possible moderating variables that may explain the effect of CR on employment: neurocognition, intrinsic motivation, and negative symptoms. That analysis found that the lower-functioning group receiving SE plus CR improved on measures of neurocognition and intrinsic motivation, suggesting that those are variables that may account for the effect; however, no significant interactions were found for negative symptoms, indicating that participants improved on negative symptoms regardless of study condition.

“This finding has important clinical implications for service providers,” the researchers said. “It may be that cognitive remediation is not necessary to boost vocational outcomes for all participants in supported employment, but it is a service that may help those who are most impaired in their overall community functioning. To have additional services that improve functional outcomes for those who need it most is a powerful reason to continue to investigate the benefits of cognitive remediation programs for persons with serious mental illness.”

Philip Harvey, Ph.D., who specializes in research on cognition in schizophrenia, told Psychiatric News that the study by Bell offers an important contribution. “Only those patients who manifested poor cognitive functioning prior to receiving CRT therapy in addition to a vocational intervention manifested improved vocational performance after the intervention,” said Harvey, who is Leonard M. Miller Professor of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine. “These findings suggest that patients whose cognitive performance is less impaired may have other reasons for poor vocational functioning. An important clinical implication is that pre-intervention screening might be helpful for the selection of patients who might receive the greatest benefit from cognitive remediation therapy in the event that not every patient could be treated because of scare resources.” ■