Cognitive deficits in schizophrenia can massively impact functionality and quality of life, furthering the importance of cognitive training. Despite the development of the field in Europe and in the United States, no programmes have been developed and tested in developing countries. Different cultural backgrounds, budget restrictions, and other difficulties may render treatment packages created in high income countries difficult for adoption by developing nations. We performed a pilot double-blind, randomized, controlled trial in order to investigate the efficacy and feasibility of an attention and memory training programme specially created in a developing nation. The intervention used simple, widely available materials, required minimal infrastructure, and was conducted in groups. The sample included seventeen stable Brazilians with schizophrenia. Sessions were conducted weekly during five months. The cognitive training group showed significant improvements in inhibitory control and set-shifting over time. Both groups showed improvements in symptoms, processing speed, selective attention, executive function, and long-term visual memory. Improvements were found in the control group in long-term verbal memory and concentration. Our findings reinforce the idea that cognitive training in schizophrenia can be constructed using simple resources and infrastructure, facilitating its adoption by developing countries, and it may improve cognition. 1. Introduction Impaired cognitive functioning in schizophrenia was early recognized [1, 2] and described as one of the core symptoms [3]. Deficits may be present since the first manifestations of the disease or may appear before the onset of symptoms [4]. Up to 80% of all people with schizophrenia may present significant deficits [5]. Main deficits involve attention, memory, and executive functions, but other domains can also be affected, such as visuospatial ability, language, learning, and motor coordination [3, 6, 7]. Cognitive deficits have been related to impairment in functional abilities [8–10], compromising the ability to lead an independent life, to benefit from psychosocial treatments, to create and maintain social relationships, to find and keep a job, and to maintain academic development [6, 11–13]. Improvements in cognitive functions can increase benefits from other psychosocial rehabilitation programmes [14]; therefore, treatment of schizophrenia could also include cognitive training. A large number of outpatient consultations and re-hospitalization rates [15], difficulty in maintaining a job [6], and
References
[1]
E. Kraepelin, “Dementia praecox,” in Clinical Psychiatry, E. Kraepelin, Ed., Scholar’s Facsimiles & Reprints, New York, NY, USA, 1907.
[2]
E. Bleuler, Dementia Praecox or the Groups of Schizophrenias, International Universities Press, New York, NY, USA, 1950.
[3]
V. P. Bozikas, M. H. Kosmidis, G. Kiosseoglou, and A. Karavatos, “Neuropsychological profile of cognitively impaired patients with Schizophrenia,” Comprehensive Psychiatry, vol. 47, no. 2, pp. 136–143, 2006.
[4]
T. D. Cannon, C. E. Bearden, J. M. Hollister, I. M. Rosso, L. E. Sanchez, and T. Hadley, “Childhood cognitive functioning in Schizophrenia patients and their unaffected siblings: a prospective cohort study,” Schizophrenia Bulletin, vol. 26, no. 2, pp. 379–393, 2000.
[5]
R. S. E. Keefe, C. E. Eesley, and M. P. Poe, “Defining a cognitive function decrement in Schizophrenia,” Biological Psychiatry, vol. 57, no. 6, pp. 688–691, 2005.
[6]
P. D. Harvey and T. Sharma, Understanding and Treating Cognition in Schizophrenia: A Clinician’s Handbook, Martin Dunitz, London, UK, 2002.
[7]
M. Fioravanti, O. Carlone, B. Vitale, M. E. Cinti, and L. Clare, “A meta-analysis of cognitive deficits in adults with a diagnosis of Schizophrenia,” Neuropsychology Review, vol. 15, no. 2, pp. 73–95, 2005.
[8]
D. L. Braff, “Information processing and attention dysfunctions in Schizophrenia,” Schizophrenia Bulletin, vol. 19, no. 2, pp. 233–259, 1993.
[9]
T. Wykes, C. Reeder, J. Corner, C. Williams, and B. Everitt, “The effects of neurocognitive remediation on executive processing in patients with Schizophrenia,” Schizophrenia Bulletin, vol. 25, no. 2, pp. 291–307, 1999.
[10]
M. F. Green, R. S. Kern, D. L. Braff, and J. Mintz, “Neurocognitive deficits and functional outcome in Schizophrenia: are we measuring the 'right stuff'?” Schizophrenia Bulletin, vol. 26, no. 1, pp. 119–136, 2000.
[11]
J. Seltzer, G. Cassens, C. Ciocca, and L. O'Sullivan, “Neuropsychological rehabilitation in the treatment of Schizophrenia,” Connecticut Medicine, vol. 61, no. 9, pp. 597–608, 1997.
[12]
B. López-Luengo and C. Vásquez, “Effects of attention process training on cognitive functioning of Schizophrenic patients,” Psychiatric Research, vol. 119, pp. 41–53, 2003.
[13]
L. C. Monteiro, V. A. Silva, and M. R. Louz？, “Insight, cognitive dysfunction and symptomatology in Schizophrenia,” European Archives of Psychiatry and Clinical Neuroscience, vol. 258, no. 7, pp. 402–405, 2008.
[14]
L. C. Monteiro and M. R. Louz？, “Cognitive deficits in Schizophrenia: functional consequences and therapeutic approaches,” Revista de Psiquiatria Clínica, vol. 34, supplement 2, pp. 179–183, 2007.
[15]
A. P. Werneck, J. C. Hallak, E. Nakano, and H. Elkis, “Time to rehospitalization in patients with Schizophrenia discharged on first generation antipsychotics, non-clozapine second generation antipsychotics, or clozapine,” Psychiatry Research, vol. 188, no. 3, pp. 315–319, 2011.
[16]
A. K. Siano, L. C. Ribeiro, and M. S. Ribeiro, “Concession of sickness benefit to social security beneficiaries due to mental disorders,” Revista Brasileira de Psiquiatria, vol. 33, no. 4, pp. 323–331, 2011.
[17]
W. R？ssler, H. Joachim Salize, J. van Os, and A. Riecher-R？ssler, “Size of burden of Schizophrenia and psychotic disorders,” European Neuropsychopharmacology, vol. 15, no. 4, pp. 399–409, 2005.
[18]
R. J. Leit？o, M. B. Ferraz, A. C. Chaves, and J. J. Mari, “Cost of Schizophrenia: direct costs and use of resources in the State of S？o Paulo,” Revista de Saude Publica, vol. 40, no. 2, pp. 304–309, 2006.
[19]
S. R. McGurk, E. W. Twamley, D. I. Sitzer, G. J. McHugo, and K. T. Mueser, “A meta-analysis of cognitive remediation in Schizophrenia,” The American Journal of Psychiatry, vol. 164, no. 12, pp. 1791–1802, 2007.
[20]
A. Medalia and J. Choi, “Cognitive remediation in Schizophrenia,” Neuropsychology Review, vol. 19, no. 3, pp. 353–364, 2009.
[21]
L. B. Dixon, F. Dickerson, A. S. Bellack et al., “The 2009 Schizophrenia PORT psychosocial treatment recommendations and summary statements,” Schizophrenia Bulletin, vol. 36, no. 1, pp. 48–70, 2010.
[22]
National Institute for Clinical Excellence, “Schizophrenia,” The NICE guideline on core interventions in the treatment and management of schizophrenia in adults in primary and secondary care, Updated edition, London, UK, NICE, 2010.
[23]
T. Wykes, V. Huddy, C. Cellard, S. R. McGurk, and P. Czobor, “A meta-analysis of cognitive remediation for Schizophrenia: methodology and effect sizes,” The American Journal of Psychiatry, vol. 168, no. 5, pp. 472–485, 2011.
[24]
A. Patel, M. Knapp, R. Romeo et al., “Cognitive remediation therapy in Schizophrenia: cost-effectiveness analysis,” Schizophrenia Research, vol. 120, no. 1–3, pp. 217–224, 2010.
[25]
D. I. Velligan, R. S. Kern, and J. M. Gold, “Cognitive rehabilitation for Schizophrenia and the putative role of motivation and expectancies,” Schizophrenia Bulletin, vol. 32, no. 3, pp. 474–485, 2006.
[26]
V. Patel, S. Farooq, and R. Thara, “What is the best approach to treating Schizophrenia in developing countries?” PLoS Medicine, vol. 4, no. 6, pp. 0963–0966, 2007.
[27]
M. J. de Jesus, D. Razzouk, R. Thara, J. Eaton, and G. Thornicroft, “Packages of care for Schizophrenia in low- and middle-income countries,” PLoS Medicine, vol. 6, no. 10, Article ID e1000165, 2009.
[28]
K. T. Mueser and S. R. McGurk, “Schizophrenia,” The Lancet, vol. 363, no. 9426, pp. 2063–2072, 2004.
[29]
P. Deva, “Psychiatric rehabilitation and its present role in developing countries,” World Psychiatry, vol. 5, no. 3, pp. 164–165, 2006.
[30]
C. Kieling, H. Baker-Henningham, M. Belfer et al., “Child and adolescent mental health worldwide: evidence for action,” The Lancet, vol. 378, no. 9801, pp. 1515–1525, 2011.
[31]
T. Rangaswamy and J. Sujit, “Psychosocial rehabilitation in developing countries,” International Review of Psychiatry, vol. 24, no. 5, pp. 499–503, 2012.
[32]
G. Gregório, M. Tomlinson, J. Gerolin et al., “Setting priorities for mental health research in Brazil,” Revista Brasileira de Psiquiatria, vol. 34, pp. 434–439, 2012.
[33]
G. E. Guindon, J. N. Lavis, F. Becerra-Posada et al., “Bridging the gaps between research, policy and practice in low- and middle-income countries: a survey of health care providers,” Canadian Medical Association Journal, vol. 182, no. 9, pp. E362–E372, 2010.
[34]
S. R. Kay, A. Fiszbein, and L. A. Opler, “The positive and negative syndrome scale (PANSS) for Schizophrenia,” Schizophrenia Bulletin, vol. 13, no. 2, pp. 261–276, 1987.
[35]
D. Wechsler, Wechsler Adult Intelligence Scale-Revised, The Psychological Corporation, San Antonio, Tex, USA, 1981.
[36]
O. Spreen and E. A. Strauss, Compendium of Neuropsychological Tests: Administration, Norms and Commentary, Oxford University Press, Oxford, UK, 2ed edition, 1998.
[37]
H. E. Nelson, “A modified card sorting test sensitive to frontal lobe defects,” Cortex, vol. 12, no. 4, pp. 313–324, 1976.
[38]
G. I. de Zubicaray, G. A. Smith, J. B. Chalk, and J. Semple, “The modified card sorting test: test-retest stability and relationships with demographic variables in a healthy older adult sample,” British Journal of Clinical Psychology, vol. 37, no. 4, pp. 457–466, 1998.
[39]
D. Wechsler, Wechsler Memory Scale: Administration and Scoring Manual, The Psychological Corporation, San Antonio, Tex, USA, 3rd edition, 1997.
[40]
G. E. Dallal, “Randomization.com,” 2013, http://www.randomization.com/.
[41]
B. A. Wilson, Case Studies in Neuropsychological Rehabilitation, Oxford University Press, Oxford, UK, 1999.
[42]
L. M. M. Pontes and H. Elkis, Treinamento de Aten？？o e Memória na Esquizofrenia: Um Manual Prático, Artmed, Porto Alegre, Brazil, 2013.
[43]
S. J. Luck and J. M. Gold, “The construct of attention in Schizophrenia,” Biological Psychiatry, vol. 64, no. 1, pp. 34–39, 2008.
[44]
T. Wykes and C. Reeder, Cognitive Remediation Therapy for Schizophrenia: Theory and Practice, Routledge, London, UK, 2005.
[45]
D. R. Muller and V. Roder, “Integrated psychological therapy and integrated neurocognitive therapy,” in Neurocognition and Social Cognition in Schizophrenia Patients: Basic Concepts and Treatment, V. Roder and A. Medalia, Eds., vol. 177, pp. 118–144, Karger, Basel, Switzerland, 2010.
[46]
A. Medalia and J. Choi, “Motivational enhancements in Schizophrenia,” in Neurocognition and Social Cognition in Schizophrenia Patients: Basic Concepts and Treatment, V. Roder and A. Medalia, Eds., vol. 177, pp. 158–172, Karger, Basel, Switzerland, 2010.
[47]
C. R. Green, Total Memory Workout: Eight Easy Steps to Maximum Memory Fitness, Piatkus Books, London, UK, 2000.
[48]
L. P. de Vreese, M. Neri, M. Fioravanti, L. Belloi, and O. Zanetti, “Memory rehabilitation in Alzheimer's disease: a review of progress,” International Journal of Geriatric Psychiatry, vol. 16, no. 8, pp. 794–809, 2001.
[49]
E. Brunner and F. Langer, “Nonparametric analysis of ordered categorical data in designs with longitudinal observations and small sample sizes,” Biometrical Journal, vol. 42, no. 6, pp. 663–675, 2000.
[50]
E. Brunner and M. L. Puri, “Nonparametric methods in factorial designs,” Statistical Papers, vol. 42, no. 1, pp. 1–52, 2001.
[51]
J. M. Singer, F. Z. Poleto, and P. Rosa, “Parametric and nonparametric analyses of repeated ordinal categorical data,” Biometrical Journal, vol. 46, no. 4, pp. 460–473, 2004.
[52]
E. M. P. Barretto, M. Kayo, B. S. Avrichir et al., “A preliminary controlled trial of cognitive behavioral therapy in clozapine-resistant Schizophrenia,” Journal of Nervous and Mental Disease, vol. 197, no. 11, pp. 865–868, 2009.
[53]
D. A. Shah and L. V. Madden, “Nonparametric analysis of ordinal data in designed factorial experiments,” Phytopathology, vol. 94, no. 1, pp. 33–43, 2004.
[54]
J. A. Cohen, “Power Primer,” Psychological Bulletin, vol. 112, no. 1, pp. 155–159, 1992.
[55]
H. Elkis, L. Friedman, A. Wise, and H. Y. Meltzer, “Meta-analyses of studies of ventricular enlargement and cortical sulcal prominence in mood disorders: comparisons with controls or patients with Schizophrenia,” Archives of General Psychiatry, vol. 52, no. 9, pp. 735–746, 1995.
[56]
J. R. Stroop, “Studies of interference in serial verbal reactions,” Journal of Experimental Psychology, vol. 18, no. 6, pp. 643–662, 1935.
[57]
E. W. Twamley, D. V. Jeste, and A. S. Bellack, “A review of cognitive training in Schizophrenia,” Schizophrenia Bulletin, vol. 29, no. 2, pp. 359–382, 2003.
[58]
K. S. Cadenhead and D. L. Braff, “Information processing and attenttion in Schizophrenia: clinical and functional correlates and treatment of cognitive impairment,” in Cognition in Schizophrenia: Impairments, Importance and Treatment Strategies, T. Sharma and P. Harvey, Eds., pp. 92–106, Oxford University Press, New York, NY, USA, 2000.
[59]
R. C. Gur, S. T. Moelter, and D. J. Ragland, “Learning and memory in Schizophrenia,” in Cognition in Schizophrenia: Impairments, Importance and Treatment Strategies, T. Sharma and P. Harvey, Eds., pp. 73–91, Oxford University Press, New York, NY, USA, 2000.
[60]
A. Aleman, R. Hijman, E. H. F. de Haan, and R. S. Kahn, “Memory impairment in Schizophrenia: a meta-analysis,” The American Journal of Psychiatry, vol. 156, no. 9, pp. 1358–1366, 1999.
[61]
D. F. Bjorklund, P. H. Miller, T. R. Coyle, and J. L. Slawinski, “Instructing children to use memory strategies: evidence of utilization deficiencies in memory training studies,” Developmental Review, vol. 17, no. 4, pp. 411–441, 1997.
[62]
H. S. Waters, “Memory strategy development: do we need yet another deficiency?” Child Development, vol. 71, no. 4, pp. 1004–1012, 2000.
[63]
F. S. Pereira, A. M. Oliveira, B. S. Diniz, O. V. Forlenza, and M. S. Yassuda, “Cross-cultural adaptation, reliability and validity of the DAFS-R in a sample of Brazilian older adults,” Archives of Clinical Neuropsychology, vol. 25, no. 4, pp. 335–343, 2010.
[64]
P. D. Harvey and R. S. E. Keefe, “Studies of cognitive change in patients with Schizophrenia following novel antipsychotic treatment,” The American Journal of Psychiatry, vol. 158, no. 2, pp. 176–184, 2001.
[65]
G. E. Hogarty, S. Flesher, R. Ulrich et al., “Cognitive enhancement therapy for Schizophrenia: effects of a 2-year randomized trial on cognition and behavior,” Archives of General Psychiatry, vol. 61, no. 9, pp. 866–876, 2004.
[66]
C. P. Szabo, J. J. Mari, C. Kieling, and H. Herrman, “The role of the World Psychiatric Association in facilitating development of psychiatric publications from low- and middle-income countries,” Revista Brasileira de Psiquiatria, vol. 34, no. 1, pp. 12–15, 2012.
