Implementation of Cognitive Health Services in Large Systems of Care: Highlights From Coordinated Specialty Care for First Episode Psychosis.

BACKGROUND AND HYPOTHESIS: With increasing recognition of the importance of cognitive health for recovery in people with psychosis, questions arise as to how to implement cognitive health services in large systems of care. This paper describes the implementation of cognitive health services in OnTrackNY (OTNY), a network of clinics delivering a Coordinated Specialty Care treatment model for early psychosis, with the goal of documenting the processes, challenges, and useful adaptations. STUDY DESIGN: In 2018, OTNY piloted a Cognitive Health Toolkit for implementation across 18 affiliated clinics. The toolkit intended to identify the cognitive health needs of individuals early in the course of psychosis and to integrate cognitive health into the vocabulary of wellness and recovery. Implementation involved creating mechanisms for staff training and support to, in turn, help participants improve how they use cognitive skills in daily life. STUDY RESULTS: The toolkit was disseminated to all 28 OTNY programs throughout New York state by 2023. When simple assessment and decision-making tools were embedded in routine care practices, the majority of participants identified that improving memory, attention, and critical thinking skills would be helpful. Consistently, about 70% of those asked wanted to learn more about how to better their cognitive health. CONCLUSIONS: Cognitive health services can be implemented in large systems of care that provide a multi-level system of implementation supports. Organizational facilitators of implementation include a training program to educate about cognitive health and the delivery of cognitive health interventions, and embedded quality assurance monitoring and improvement activities.

Hearing Loss in Older People With Schizophrenia: Audiologic Characteristics and Association With Psychosocial Functioning.

OBJECTIVE: The severity and impact of hearing deficits among adults with schizophrenia spectrum disorders may become increasingly relevant with advancing age. This study evaluated hearing ability and associated psychosocial functioning among older adults aged 50-70. DESIGN: Cross-sectional analysis. SETTING: Four outpatient psychiatry clinics in New York City. PARTICIPANTS: Individuals aged 50-70 years with diagnoses of schizophrenia or schizoaffective disorder. MEASUREMENTS: Unaided pure tone air conduction audiometry conducted using a portable audiometry system determined the pure tone average (PTA) hearing threshold across four frequencies: 500, 1k, 2k, and 4k Hz. Better ear PTA defined the hearing threshold. Audiometry data retrieved from the U.S. National Health and Nutrition Examination Survey aided interpretation of sample hearing loss rates. Standard measures evaluated psychiatric symptoms, perceived impact of hearing impairment, loneliness, and quality of life. RESULTS: Among audiometry completers (N = 40), 35% (n = 14) demonstrated subclinical hearing loss (16-25 dB) and 35% (n = 14) had mild or worse hearing loss (≥26 dB). Rates were higher than expected based on age-based population data. Those who perceived hearing handicap rated it moderate (12.2%) or severe (7.3%); those who perceived tinnitus rated the impact as mild to moderate (12.2%) or catastrophic (2.4%). Neither psychiatric symptoms nor interviewer-rated quality of life was associated with hearing ability. Greater loneliness was significantly correlated with worse audiologic performance (r = 0.475, p <0.01) and greater perceived hearing handicap (r = 0.480, p <0.01). CONCLUSION: Identifying the need for hearing loss treatment among aging adults with schizophrenia spectrum disorders is important given the potential implications for social functioning, cognitive, and mental health.

Correlates of hearing loss among adults with schizophrenia.

BACKGROUND: Hearing loss (HL) is associated with adverse cognitive, mental, and physical health outcomes. There is evidence that across age groups HL is more prevalent in people with schizophrenia than the general population. Given that people with schizophrenia may already be vulnerable to cognitive and psychosocial disability, we sought to examine how hearing ability relates to concurrent levels of cognitive, mental and daily functioning. METHODS: Community-dwelling adults with schizophrenia (N = 84) ages 22-50 completed pure tone audiometry assessments. Hearing threshold (in decibels) was defined as the lowest detectable pure tone at 1000 Hz. Pearson correlation was used to test the hypothesis that higher hearing thresholds (worse hearing) would be significantly associated with poorer performance on the Brief Assessment of Cognition in Schizophrenia (BACS). Additional analyses explored the relationships between audiometric threshold and functional capacity measured with the Virtual Reality Functional Capacity Assessment Tool (VRFCAT) and symptoms severity rated on the Positive and Negative Syndrome Scale (PANSS). RESULTS: Hearing threshold was inversely and significantly correlated with the BACS composite score (r = -0.27, p = 0.017). This relationship was reduced but remained significant after controlling for age (r = -0.23, p = 0.04). Hearing threshold was not associated with VRFCAT or psychiatric symptom measures. CONCLUSIONS: While schizophrenia and HL are independently associated with cognitive impairment, the magnitude of impairment in this sample was greater among those with poorer hearing. Findings warrant further mechanistic study of the relationship between hearing impairment and cognition and have implications for addressing modifiable health risk factors for higher morbidity and mortality in this vulnerable population.

Dose-Dependent Augmentation of Neuroplasticity-Based Auditory Learning in Schizophrenia: A Double-Blind, Placebo-Controlled, Randomized, Target Engagement Clinical Trial of the NMDA Glutamate Receptor Agonist d-serine.

BACKGROUND: Patients with schizophrenia show reduced NMDA glutamate receptor-dependent auditory plasticity, which is rate limiting for auditory cognitive remediation (AudRem). We evaluate the utility of behavioral and neurophysiological pharmacodynamic target engagement biomarkers, using a d-serine+AudRem combination. METHODS: Forty-five participants with schizophrenia or schizoaffective disorder were randomized to 3 once-weekly AudRem visits + double-blind d-serine (80, 100, or 120 mg/kg) or placebo in 3 dose cohorts of 12 d-serine and 3 placebo-treated participants each. In AudRem, participants indicated which paired tone was higher in pitch. The primary outcome was plasticity improvement, operationalized as change in pitch threshold between AudRem tones [(test tone Hz - reference tone Hz)/reference tone Hz] between the initial plateau pitch threshold (mean of trials 20-30 of treatment visit 1) to pitch threshold at the end of visit(s). Target engagement was assessed by electroencephalography outcomes, including mismatch negativity (pitch primary). RESULTS: There was a significant overall treatment effect for plasticity improvement (p = .014). Plasticity improvement was largest within the 80 and 100 mg/kg groups (p < .001, d > 0.67), while 120 mg/kg and placebo-treated participants showed nonsignificant within-group changes. Plasticity improvement was seen after a single treatment and was sustained on subsequent treatments. Target engagement was demonstrated by significantly larger mismatch negativity (p = .049, d = 1.0) for the 100 mg/kg dose versus placebo. CONCLUSIONS: Our results demonstrate sufficient proof of principle for continued development of both the d-serine+AudRem combination and our target engagement methodology. The ultimate utility is dependent on the results of an ongoing larger, longer study of the combination for clinically relevant outcomes.

Early auditory processing dysfunction in schizophrenia: Mechanisms and implications.

Schizophrenia is a major mental disorder that affects approximately 1% of the population worldwide. Cognitive deficits are a key feature of the disorder and a primary cause of long-term disability. Over the past decades, significant literature has accumulated demonstrating impairments in early auditory perceptual processes in schizophrenia. In this review, we first describe early auditory dysfunction in schizophrenia from both a behavioral and neurophysiological perspective and examine their interrelationship with both higher order cognitive constructs and social cognitive processes. Then, we provide insights into underlying pathological processes, especially in relationship to glutamatergic and N-methyl-D-aspartate receptor (NMDAR) dysfunction models. Finally, we discuss the utility of early auditory measures as both treatment targets for precision intervention and as translational biomarkers for etiological investigation. Altogether, this review points out the crucial role of early auditory deficits in the pathophysiology of schizophrenia, in addition to major implications for early intervention and auditory-targeted approaches.

Hearing Loss Among People With Schizophrenia: Implications for Clinical Practice.

OBJECTIVE: The authors characterized hearing loss among individuals diagnosed as having schizophrenia to inform provision of routine behavioral health services to this population. METHODS: Audiometry data collected between October 2019 and December 2021 from 84 community-dwelling adults with schizophrenia and 81 age-matched participants without the condition were analyzed. Rates of hearing loss were identified within groups and across age decades (20-50 years). Hearing threshold and rates of hearing loss were compared between groups. RESULTS: Participants with schizophrenia had significantly higher mean hearing thresholds (p=0.006), indicating worse hearing. This difference remained significant after controlling for age (p=0.01). A significantly larger proportion of participants with schizophrenia had mild hearing loss (24%) compared with age-matched participants (6%) (p=0.002), with higher rates of mild hearing loss observed across all ages. CONCLUSIONS: Screening for and detection of hearing loss among adults with schizophrenia may be an unmet need. Hearing loss is a treatable source of cognitive and psychosocial disability, warranting scalable assessment and intervention practices.

Feasibility and acceptability of remotely accessed cognitive remediation for schizophrenia in public health settings.

Cognitive remediation (CR) is an evidence-based therapy used to improve cognition in people with schizophrenia. However, it often requires multiple in-person clinic sessions per week, which can limit scalability. This mixed methods study considered the feasibility and acceptability of a hybrid approach, which allowed for half the sessions to be conducted remotely as homework, without the clinician present. Individuals with schizophrenia were randomized to either all in-clinic or hybrid conditions and completed questionnaires and individual interviews about their experience. CR clinicians provided feedback in complement. Because of limited access to technology, most Hybrid CR participants had to come to clinic to access computers and often sought clinician support to do their homework. Participants in the two conditions were equally satisfied per the Client Satisfaction Questionnaire, and the majority reported perceived benefit and enjoyment. Both CR participants and clinicians identified access to technology as a barrier to program feasibility, while availability of clinician support positively impacted acceptability. Suggestions to improve CR highlighted adopting a flexible approach to providing CR that accounts for participant access to technology, potential benefit from peer interaction, and need for clinician support.

Predicting response to cognitive training for schizophrenia using results from two studies with different outcomes.

BACKGROUND: Collaborative data sharing between research groups provides an opportunity to explore the basis for the heterogeneity in cognitive training outcomes reported in the schizophrenia literature. The current analyses focused on the contribution of site and participant characteristics to these heterogeneous outcomes. METHODS: Data from two independent studies, from New York (NY) and Los Angeles (LA), were combined to yield a sample of 132 outpatient adults with schizophrenia/schizoaffective disorder. While similar treatment doses, cognitive exercises and outcome measures were used, sites differed in use of coaching, group discussion and compensation. Between-site differences in participant demographic and baseline clinical characteristics were tested. Regression examined predictors of change in cognition (MCCB) and functional capacity (UPSA) which could explain site differences in treatment effects. RESULTS: Medium to large treatment effect size differences in MCCB and UPSA favored the NY site over LA. When the studies were combined, the effect of site was significant for both outcomes with a medium effect size difference. After controlling for background characteristics, the effect of site was reduced for both outcomes, but remained significant for cognition. Improvement in UPSA was associated with better baseline MCCB (p < 0.001), lower baseline UPSA (p < 0.001) and younger age (p = 0.019). The overall model with site, baseline scores, and participant background characteristics explained about 30% to 40% of the variance in outcomes. DISCUSSION: Participant and treatment characteristics are both predictive of outcomes, but treatment characteristics may be more consequential to cognitive gain, while participant characteristics may be more consequential to change in functional capacity.

Toolkit for assessing and addressing cognitive health in early psychosis: Evaluation of feasibility and utility in a coordinated specialty care setting.

AIM: Methods to identify and harness individual cognitive strengths while addressing relative weaknesses have the potential to complement recovery services for first-episode psychosis but systematic implementation is needed. We developed a cognitive health toolkit, trained teams from OnTrackNY, a network of coordinated specialty care (CSC) programs and examined toolkit feasibility and clinical utility during the first year of roll-out. METHODS: The toolkit includes a clinician manual, assessment and decision-making tools, and a menu of cognitive health service options. Assessment uses the WRAT5-Reading subtest and a new Self-Assessment of Cognitive Functioning which, together, determine participant- and clinician-perceived cognitive health need. Program-level data were analysed for rates of assessment, identification of cognitive health needs and cognitive health service provision. RESULTS: Data from 18 OnTrackNY teams included 933 participants, including 310 new admissions. Across teams, 43.9% of newly admitted participants received a WRAT5-Reading and 41.3% received a self-assessment. Of all assessments completed in the study period, 50.7% were at or within 3-months of admission and 69.1% were within the first year of program participation. Cognitive health need was identified by self-report (57.6%) and clinician-report (69.9%) and led to provision of specific services, including psychoeducation, compensatory skills training and in some cases restorative cognitive training. CONCLUSIONS: Preliminary feasibility data are encouraging but barriers to assessment need to be identified and addressed. Rates of identified cognitive health need warrant further study of the implementation process and outcomes so that cognitive health assessment and treatment practices may ultimately be disseminated to CSC programs more broadly.

Addressing cognitive health in coordinated specialty care for early psychosis: Real-world perspectives.

AIM: Addressing cognitive health during the early phase of psychosis has the potential to enhance recovery outcomes, yet methods to assess and treat cognitive problems are not a systematic part of Coordinated Specialty Care (CSC) in the United States. We sought to understand how CSC providers perceive cognitive health and gauge the acceptability and appropriateness of cognitive interventions to inform the development and implementation of a cognitive health toolkit for OnTrackNY, a CSC program. METHODS: Electronic surveys were sent to clinicians from 22 OnTrackNY teams. One unstructured and 10 structured questions assessed knowledge and beliefs about cognition, current cognitive health practices, the likelihood of adopting new practices, perceived facilitators, and barriers to assessing and treating cognitive health. RESULTS: Fifty-three clinicians responded. Clinicians identified a range of terms associated with cognitive impairment with specific neurocognitive deficits cited most frequently. The majority perceived the evidence for cognitive impairment at the time of first episode to be moderate to strong, that specific interventions for cognition are warranted, and that there is a significant link between cognition and community functioning. While current practices vary, 88% indicated a high likelihood of integrating tools to address cognitive problems if provided. Compensatory approaches to aid cognitive functioning were viewed most favourably. CONCLUSIONS: Results suggest that addressing cognitive health is acceptable and appropriate for OnTrackNY but there is a need for systematic training to integrate empirically supported interventions with existing recovery-oriented practices. Piloting a cognitive health toolkit will inform the potential uptake of assessment and treatment practices more broadly.

How does awareness of cognitive impairment impact motivation and treatment outcomes during cognitive remediation for schizophrenia?

BACKGROUND: There is concern that awareness of cognitive deficit among people with schizophrenia receiving Cognitive Remediation (CR) might undermine motivation, engagement, and CR outcomes. We therefore examined the relationship of subjective awareness of cognitive deficit to aspects of motivation and cognitive learning during an efficacious CR program. METHODS: Individuals with schizophrenia/schizoaffective disorder who completed 30 sessions of CR (N = 67) were evaluated on cognitive performance, self-reported cognitive difficulties, intrinsic motivation and perceived competency for cognitive training tasks at the beginning and end of treatment. RESULTS: We found no relationship between actual and perceived cognitive functioning when measured cross-sectionally or as difference scores, pre/post treatment. Greater awareness of cognitive problems was associated with lower perceived competency for cognitive tasks at treatment beginning and end-point (p-values < .05). The significant relationship between awareness of cognitive problems and perceived value of the treatment at end-point was fully mediated by perceived competency. While greater perceived competency was associated with shorter time to treatment completion (p = .0025), it was intrinsic motivation measured at end-point that was associated with cognitive change (p = .02). DISCUSSION: While awareness of cognitive problems may not be a prerequisite for cognitive improvement during CR, it could impact engagement in, and how one values treatment via its effect on perceived competency. Results also highlighted the importance of intrinsic motivation for doing cognitive learning activities, given its relationship to cognitive gain. Further study is needed to understand how best to assess and address awareness of cognitive abilities within the CR setting.

The cognitive training version of the MUSIC® model of motivation inventory: A follow-up validity study.

Further validation of the MUSIC® Model of Motivation Inventory (MMI) for use in Cognitive Remediation (CR) for schizophrenia is needed. The MMI was compared to the Intrinsic Motivation Inventory - Schizophrenia Research and Perceived Competency Scale following early treatment exposure in a CR clinical trial. MMI Usefulness, Success, and Interest scales were significantly correlated with corresponding comparison scales. The MMI was not correlated with pre-morbid cognitive ability. Higher expectancy for success and perceived usefulness were significantly associated with greater intensity of session attendance. Results support the convergent, divergent, and predictive validity of the MMI for CR research and clinical use.

Cognitive remediation for schizophrenia: An expert working group white paper on core techniques.

Cognitive remediation is now widely recognized as an effective treatment for cognitive deficits in schizophrenia. Its effects are meaningful, durable, and related to improvements in everyday functional outcomes. As with many therapies, the evolution of cognitive remediation has resulted in treatment programs that use a variety of specific techniques, yet share common core principles. This paper is the product of a cognitive remediation expert working group consensus meeting to identify core features of the treatment and produce recommendations for its design, conduct, reporting, and implementation. Four techniques were identified as core features of cognitive remediation: facilitation by a therapist, cognitive exercise, procedures to develop problem-solving strategies, and procedures to facilitate transfer to real world functioning. Treatment techniques within each of these core features are presented to facilitate decisions for clinical trials and implementation in clinical settings.

Impact of baseline early auditory processing on response to cognitive remediation for schizophrenia.

BACKGROUND: Early auditory processing (EAP) has increasingly become a focus of efforts to identify biomarkers of treatment response in schizophrenia. EAP deficits lead to poor functional outcome via impaired cognition, and treatments that target EAP may drive downstream cognitive improvements. Assessment of baseline need provides an opportunity for cognitive remediation (CR) programs that give EAP training to personalize treatment and optimize its impact. This initial efficacy study examined the differential benefit of EAP training for those with and without baseline EAP deficits as defined by performance on the Tone Matching Test. METHODS: 103 outpatient adults diagnosed with schizophrenia or schizoaffective disorder were classified as having intact (48.5%) or impaired (51.5%) EAP and randomized to a CR program with restorative exercise plans that either included EAP training (N = 49) or did not (N = 54). Cognitive and functional outcomes were measured post-treatment and 3 months later. RESULTS: Only in EAP impaired participants was there a significant benefit from EAP training on verbal learning. Treatment condition did not significantly impact global cognitive or functional outcomes for either EAP group. Cognitive gains partially mediated the relationship between gains in EAP and functional capacity. CONCLUSION: These findings support the importance of addressing basic auditory deficits when attempting to remediate higher order auditory impairments such as verbal learning. In addition, they highlight the need for routine assessment of EAP in cognitive remediation participants, as well as the need for more effective programs to reverse these impairments.

Translating cognitive behavioral interventions from bench to bedside: The feasibility and acceptability of cognitive remediation in research as compared to clinical settings.

Cognitive remediation (CR) research typically addresses internal validity, and few studies consider CR in a real-world context. This study evaluated the fit between the program conditions and treatment model in research and clinical settings, with the goal of informing future research on the contextual challenges associated with the implementation of CR. Data was drawn from an initiative by New York State's Office of Mental Health (OMH), to implement CR programs for adults with Serious Mental Illness (SMI) in 16 state operated outpatient clinics. One of these clinics first became a research site for a CR randomized clinical trial, which allowed for a comparison of the feasibility and acceptability of CR in a research as compared to a clinical setting. RESULTS: The research site averaged almost triple the number of referrals as the clinical sites. Over nine months 46.51% of clinic referrals were enrolled in the CR program whereas 64.29% of research referrals were enrolled. Clinical site utilization averaged 70.53% while research site utilization averaged 90.47%. At the clinical sites, 97% of respondents reported CR was an excellent or good experience. There was high treatment fidelity for program structure and content across sites. CONCLUSIONS: This comparison of CR in clinical and research sites highlights the decrease in referrals, enrollment and utilization that occurs when a program moves from a highly controlled setting to the real world. Still, the acceptability, fill rates and utilization indicated that CR can be successfully implemented in large scale, geographically diverse, publically funded clinic settings.

Cognitive remediation in large systems of psychiatric care.

IntroductionWith the increasing enthusiasm to provide cognitive remediation (CR) as an evidence-based practice, questions arise as to what is involved in implementing CR in a large system of care. This article describes the first statewide implementation of CR in the USA, with the goal of documenting the implementation issues that care providers are likely to face when bringing CR services to their patients. METHODS: In 2014, the New York State Office of Mental Health set up a Cognitive Health Service that could be implemented throughout the state-operated system of care. This service was intended to broadly address cognitive health, to assure that the cognitive deficits commonly associated with psychiatric illnesses are recognized and addressed, and that cognitive health is embedded in the vocabulary of wellness. It involved creating a mechanism to train staff to recognize how cognitive health could be prioritized in treatment planning as well as implementing CR in state-operated adult outpatient psychiatry clinics. RESULTS: By 2017, CR was available at clinics serving people with serious mental illness in 13 of 16 adult Psychiatric Centers, located in rural and urban settings throughout New York state. The embedded quality assurance program evaluation tools indicated that CR was acceptable, sustainable, and effective. CONCLUSIONS: Cognitive remediation can be feasibly implemented in large systems of care that provide a multilevel system of supports, a training program that educates broadly about cognitive health and specifically about the delivery of CR, and embedded, ongoing program evaluation that is linked to staff supervision.

Validation of the MUSIC Model of Motivation Inventory for use with cognitive training for schizophrenia spectrum disorders: A multinational study.

AIM: Low motivation is a core symptom of schizophrenia which significantly impacts successful engagement in and benefit from psychosocial treatments. Therefore, it is important for clinicians to design psychosocial treatments to effectively motivate and engage patients during the treatment. The MUSIC® Model of Academic Motivation Inventory (MMI) is an 18-item instrument with five scales that assess students' motivation during academic tasks. The objective of the current study was to validate the MMI for use with schizophrenia-spectrum patients undergoing cognitive training. METHODS: Participants included 181 people with schizophrenia spectrum disorders enrolled in cognitive training in four countries. A confirmatory factor analysis (CFA) assessed construct validity. Quality of fit was determined using the Comparative Fit Index (CFI), the Standardized Root Mean Square Residual (SRMR), and the Root Mean Square Error of Approximation (RMSEA). Pearson's correlation coefficients assessed construct validity and Cronbach's alphas assessed reliability. Furthermore, we examined factor loadings for each inventory item and assessed predictive validity by analyzing MMI scales with attendance outcomes. RESULTS: Consistent with the original MMI validation studies used in academic settings, we found CFI values indicated a good fit, as did the SRMR and RMSEA values. The scales were correlated yet distinct. Cronbach's alpha values ranged from good to excellent and factor loadings showed that all items loaded very well onto their intended factors. The MMI had a positive relationship to treatment intensity. CONCLUSION: The MMI is a valid and reliable tool to use with individuals with schizophrenia spectrum disorders undergoing a cognitive training intervention.

Personalised treatment for cognitive dysfunction in individuals with schizophrenia spectrum disorders.

Cognitive deficits are a well-recognised issue for individuals diagnosed with schizophrenia spectrum disorders. Despite positive group findings for the use of cognitive remediation (CR) interventions, there are substantial individual differences in response to treatment. In addition, the aggregate CR literature reports low moderate effect sizes for cognitive and functional outcomes. Based on personalised medicine theory, this paper uses extant CR literature to examine the individual characteristics determined to predict treatment response. These characteristics, which fall into the broad categories of cognitive, psychological, and biological can be used as tailoring variables to personalise CR to an individual's unique profile. Personalisation through the use of these tailoring variables has the potential to improve the delivery of CR to maximise treatment outcomes.

Cognitive Skills Training for Homeless Transition-Age Youth: Feasibility and Pilot Efficacy of a Community Based Randomized Controlled Trial.

Cognitive impairments are common in homeless youth and negatively impact academic and vocational outcomes. We examined the feasibility and efficacy of cognitive interventions provided to 18- to 22-year-old homeless youth living in urban supportive housing. Ninety-one homeless youth were randomized to receive either targeted cognitive training (cognitive remediation) or general cognitive activation (computer skills training). Cognitive and psychological outcomes were assessed at baseline, after 13 and 26 sessions, and 1 month postintervention. A high dropout rate highlighted the feasibility challenges of treating this population. Intent-to-treat analysis found significant improvements across groups in specific and global measures of cognition and psychological distress, with no significant group differences. Transition-age homeless youth show improvements in cognitive and psychological functioning when engaged in interventions that address their cognitive development. This speaks to the malleability of cognitive skills in this cohort and lays the groundwork for future research to address their cognitive health.