Compensatory cognitive training for people with severe mental illnesses in supported employment: A randomized controlled trial
Introduction
Cognitive impairment is common, persistent, and associated with impaired functioning in people with severe mental illnesses (SMI; Millan et al., 2012). Impairments may occur in multiple cognitive domains, including processing speed, attention/vigilance, working memory, learning, memory, and executive functioning, and are known to occur in schizophrenia (Fioravanti et al., 2012, Mesholam-Gately et al., 2009), bipolar disorder (Lee et al., 2013a, Lee et al., 2013b, Bora and Pantelis, 2015, Sanches et al., 2014), and major depression (Rock et al., 2014, Porter et al., 2014). These impairments affect vocational outcomes and other aspects of everyday functioning (Green et al., 2004, Bowie et al., 2008, Mora et al., 2013, Depp et al., 2012, Jaeger et al., 2006, Baune et al., 2010). For example, cognitive difficulties with attention, learning, problem-solving, and pacing may affect individuals' ability to find and keep competitive work (McGurk and Wykes, 2008). Increased understanding of the relationships between cognition and work have sparked interest in cognitive training interventions to improve cognition, functioning, and work outcomes over the last several years (Anaya et al., 2012, Bowie et al., 2013, Bowie et al., 2014, Fisher et al., 2014, Lee et al., 2013a, Lee et al., 2013b, McGurk et al., 2009, McGurk et al., 2015, McGurk et al., 2016, Bell et al., 2005, Bell et al., 2008).
Meta-analyses of cognitive training in schizophrenia samples have found moderate, but durable, training effects in cognition as well as functioning (McGurk et al., 2007, Wykes et al., 2011). In terms of work outcomes, cognitive training techniques have been used to enhance employment outcomes in the context of employment interventions such as supported employment (Bell et al., 2005, Bell et al., 2008, McGurk et al., 2005, but also see Au et al., 2015). Cognitive training has been applied both during and separate from employment interventions, to both all supported employment participants and to supported employment non-responders (McGurk et al., 2015, McGurk et al., 2016). Multiple types of cognitive training interventions exist, ranging from computer-based, drill-and-practice oriented training of specific cognitive domains (e.g., Fisher et al., 2014) to compensatory-strategy-based approaches (Twamley et al., 2012, Mendella et al., 2015, Wykes et al., 2005). The bulk of cognitive training studies have been conducted with individuals having schizophrenia-spectrum disorders (Wykes et al., 2011), but there have been several recent studies of cognitive interventions for individuals with mood disorders (see meta-analysis by Motter et al., 2016). Most of the interventions studied in participants with mood disorders have been computerized (e.g., Bowie et al., 2013); some have been compensatory strategy-based (e.g., Priyamvada et al., 2015, Venza et al., 2016, Deckersbach et al., 2010), but there have been few controlled studies of compensatory strategy-based interventions, and no known trials of purely compensatory strategy-based interventions combined with employment interventions.
The present study used Compensatory Cognitive Training (CCT; Twamley et al., 2012), a 12-session compensatory strategy-based intervention which included four modules of training to address: 1) prospective memory (i.e., remembering to do things in the future), 2) conversational and task vigilance, 3) learning and memory, and 4) cognitive flexibility and problem-solving (i.e., executive functioning). CCT has previously been shown to improve attention, verbal memory, functional capacity, subjective quality of life, and negative symptom severity in people with primary psychotic disorders (Twamley et al., 2012, Mendella et al., 2015), but has not previously been studied in individuals with mood disorders or in the context of employment interventions. The employment intervention used in our study was Individual Placement and Support (IPS), also known as evidence-based supported employment. IPS emphasizes rapid, individualized searching for competitive work, integrated mental health and employment services, and time-unlimited follow-along support, and has a competitive work attainment rate of 61% across 11 randomized controlled trials (Bond et al., 2008). Across international trials, IPS resulted in competitive work 2.4 times more often than control condition programs (Modini et al., 2016). We hypothesized that CCT, delivered individually by an employment specialist over the first 12 weeks of IPS, compared to a control condition involving extra supported employment sessions, would result in improved work outcomes, cognition, functioning, and symptomatology.
Section snippets
Study participants and procedures
This study included 153 outpatients with SMI (58 with schizophrenia or schizoaffective disorder and 95 with a mood disorder [37 with bipolar disorder, 58 with major depressive disorder]). Inclusion criteria included: (1) DSM-IV diagnosis confirmed by Structured Clinical Interview for DSM-IV (First et al., 2002) or Mini International Neuropsychiatric Interview (Sheehan et al., 1997); (2) unemployed for at least one month and stating a goal of work; (3) 18 years old or older; and (4) literate and
Baseline group differences
Table 1 shows the baseline demographic, clinical, and assessment characteristics. When comparing the CCT and ESE groups, there were no significant differences in any of these variables, except for the UPSA-Brief financial subscale, such that the CCT group performed higher at baseline. Overall, the CCT group had significantly more intervention sessions in the first 12 weeks than did the ESE group. When comparing the mood and schizophrenia-spectrum diagnostic groups, the mood disorder group had
Discussion
This randomized controlled trial compared cognitive, functional, and clinical outcomes over two years for participants in a supported employment program receiving either Compensatory Cognitive Training or Enhanced Supported Employment as an active control. The fact that CCT participants attended more treatment sessions in the first 12 weeks of the study may reflect the dual purpose of initial meetings (i.e., receipt of CCT and supported employment rather than supported employment services
Role of the funding source
This work was supported by grants from NIMH (R01MH080150 to E.W.T., and T32MH018399 to C.Z.B. and D.V.J.).
Contributors
E.W.T. designed the study, oversaw data analyses, drafted parts of the manuscript, and edited the manuscript. K.R.T conducted the primary data analyses and drafted parts of the manuscript. C.Z.B. conducted literature searches and drafted parts of the manuscript. L.V. assisted with data interpretation and edited the manuscript. D.V.J., R.K.H., and S.R.M. provided assistance with data interpretation and edited the manuscript.
Conflict of interest
The authors report no conflicts of interest.
Acknowledgements
The authors would like to thank all of the study participants and Gabrielle Garmsen Golden, Mary Linges, and Barbara Johnson for their assistance with study data collection and management.
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