The assessment and treatment of neurocognition and social cognition in early psychosis

Background: Cognitive impairment is a core feature at all stages of the psychotic illness and significantly predicts functional outcomes. Targeting cognition early is theoretically attractive as a means to reverse the functional impairment before it is fully realized and thus improve the long-term outcome and quality of life of patients with psychotic disorders. Cognitive remediation is an effective treatment of cognitive deficits in schizophrenia, but generalization to everyday functioning remains a challenge. Interventions, such as strategy training combined with computerized training, and socialcognitive training have shown promise in bridging the gap between cognitive gains and functional outcomes. However, relatively little is known about the effects of integrated neuro- and social-cognitive remediation in early psychosis and what may aid in implementing these interventions into standard care for early psychosis. Objectives: The overall aim of this thesis was to assess and treat the neuroand social-cognitive impairment among individuals seeking treatment at an early intervention in psychosis (EIP) service in Iceland. In addition, to examine implementation outcomes of the intervention with regards to attendance, fidelity and acceptability. The specific aims of the first study were to investigate the nature of neuro- and social-cognitive impairment and explore the relationship between social cognition and neurocognition, clinical symptoms, and functional outcome. In addition, we sought to investigate the role of neuro- and social-cognitive domains in predicting variance in informant-reported and self-reported functional outcomes. the specific aims of the second study were to evaluate the effects of a novel integrative neuroand social-cognitive remediation on cognition, clinical symptoms and functional outcome. The specific aims of the third study were to evaluate the long-term effects of the intervention on cognition, clinical symptoms, and functional outcomes. Method: All patients between the ages of 18 and 30, who had experienced their first psychotic episode in the past five years and in seeking treatment at the EIP service between 2015-2017, were offered participation in the first study. A total of 70 patients, 82% of the total patient population receiving care agreed to participate. Cognition, clinical symptoms and functional outcome were assessed, and the results were compared to healthy comparison groups. Participants that performed one half a standard deviation below healthy norms in at least one cognitive domain were offered participation in vi the second study. Participants (n=49) were randomly assigned to either a treatment group (n=25) that received integrated neuro- and social-cognitive remediation in addition to their standard treatment, or a wait-list control group (n=24) that continued their standard treatment. Assessments from the first study were used as baseline assessments in the second study, and both groups were reassessed with the measures at post-treatment. In the third study, all participants that received ICR during the trial (n=37) were reassessed on the same variables 12-months after treatment ended. Implementation outcomes were assessed with attendance data, fidelity checks, and feedback from participants and facilitators. Results: Results suggested that, compared to healthy comparison samples, this group of early psychosis patients demonstrated broad cognitive impairments that were maximal in delayed recall and theory of mind (ToM) (<1SD below the mean). A model including both neuro- and social-cognitive domains predicted variance in informant-reported community functioning, whereas attributional style was the single predictor for self-reported functional outcomes. ICR was associated with improvements on measures of immediate verbal memory, delayed recall, working memory, cognitive flexibility, ToM, and hostile attributional style. No significant between-group differences were found on measures of functional outcomes or clinical symptoms. However, ICR participants demonstrated significant improvements on multiple measures, including cognitive, clinical symptom, and functional outcome measures at post-treatment. Performance at 12- month follow-up was significantly better than performance at baseline for most cognitive measures, and there were further significant increases in performance on processing speed, immediate verbal memory and delayed recall. The intervention had good attendance rates (77.6%), received high treatment satisfaction ratings from participants, and the fidelity to treatment manuals was high (86.6%). Conclusions: The findings of this thesis provide a better understanding of cognitive functioning of early psychosis patients and lend support to the relevance of implementing integrated neuro- and social-cognitive remediation at EIP services. ICR may improve both neuro- and social-cognitive domains and long-term functioning, but further conclusions on the efficacy of the intervention will require replication of the results in a larger randomized controlled trial that includes a control group at the long-term follow-up.