Computerized cognitive remediation therapy on cognitive impairment and social function in patients with chronic schizophrenia

Abstract

BACKGROUND

Patients with schizophrenia may have various disease manifestations, most of which gradually tend toward incurable chronic decline, leading to mental disability. The basic symptoms of the disease can impair social function, whereas long-term hospitalization produces hospitalization syndrome, causing serious damage to social function.

AIM

To investigate the effects of Computerized Cognitive Remediation Therapy (CCRT) on cognitive and social functioning in patients with chronic schizophrenia.

METHODS

A retrospective analysis of 120 patients with chronic schizophrenia in Shanghai Pudong New Area Mental Health Center was performed. They were divided into an intervention group (60 cases treated with CCRT combined with conventional medication) and a control group (60 cases treated with conventional medication). After treatment, effects on cognitive function and social roles were observed in both groups. The Positive and Negative Syndrome Scale (PANSS) was used to assess the patients' psychiatric symptoms. The Wisconsin Card Sorting Test (WCST) was used to assess the patients' cognitive functioning, and the Social Functioning Scale for Psychiatric Inpatients (SSPI) was used to assess the social functioning of the inpatient psychiatric patients.

RESULTS

No significant differences were observed in the PANSS, WCST, and SSPI intergroup scores before treatment (P > 0.05). After 2, 4, and 6 wk of therapy, general psychopathological factors, positive symptoms, negative symptoms, and total PANSS scores of PANSS in the intervention group were lower than in the control group (P < 0.05). After 2, 4, and 6 wk of treatment, the number of false responses, number of persistent bugs, and total responses in the WCST were significantly lower in the intervention group than in the control group (P < 0.05), and the amount of completed classification was significantly higher than in the control group (P < 0.05). After 2, 4, and 6 wk of therapy, the SSPI scores were significantly greater than those of the controls (P < 0.05). After 6 wk of treatment, the efficacy rates of the control and intervention groups were 81.67% and 91.67%, respectively. The curative effect in the intervention group was significantly higher than that in the control group (P < 0.05).

CONCLUSION

CCRT can significantly improve cognitive function and social abilities in patients with chronic schizophrenia.

Key Words: Computerized cognitive correction therapy; Schizophrenia; Cognitive function; Social function; Psychopathological factors

Core Tip: Chronic schizophrenia is generally an unconscious disorder with obvious intellectual disabilities. Insidious onset, prolonged course, repeated aggravation or deterioration, and negative symptoms of mental illness are common manifestations of the disease. Cognitive function and social life ability are severely impaired. In this study, we investigated the effect of Computerized Cognitive Remediation Therapy on cognitive impairment and society using the Patient and Negative Syndrome Scale, Wisconsin Card Sorting Test, and Scale of Social Function in Psychosis Inpatients scores in 120 patients with chronic schizophrenia.

INTRODUCTION

Schizophrenia is a common major mental disorder, the cause of which remains unclear[1]. According to relevant epidemiological investigations, schizophrenia affects a broad spectrum of patients and can occur in individuals of various age groups. It is complicated by mental activity abnormalities in many aspects, such as perception, thinking, behavior, and emotional responses. The disease course is characterized by prolonged and repeated episodes that seriously affect social and cognitive function[2]. More severe patients may also have suicidal and violent tendencies, endangering the lives of patients and others[3].

Currently, in addition to the two core symptoms of schizophrenia-positive and negative-a third symptom group has gradually entered the field of vision and gained attention among scholars in the field of psychiatry: Cognitive dysfunction[4]. Patients with chronic schizophrenia usually experience cognitive dysfunction because they cannot achieve complete remission of their clinical symptoms. Compared with the general population, patients with schizophrenia require long-term hospitalization because of the disease, and their social function is significantly reduced[5].

Clinically, schizophrenia is mainly treated with antipsychotic drugs; however, a single drug treatment can only control the mental symptoms of patients and does not have a significant impact on their cognitive and social features; the treatment requires a long duration and is prone to adverse reactions, resulting in poor treatment compliance[6]. Computerized Cognitive Remediation Therapy (CCRT) is a training method based on behavioral training that improves thinking abilities[7]. Studies have confirmed[8] that applying CCRT for cognitive improvement in patients can effectively improve language, memory, executive power, and other functions. This is because computer cognitive correction therapy is a type of rehabilitation software that is highly targeted for patients with schizophrenia. In the software system, training and intervention are carried out on the patients' working memory, attention, reasoning and problem-solving, processing speed, social cognitive, and computing abilities. The ability of each part of the patient to interfere in a modular manner enhances cognitive performance and social function. In conclusion, as a new therapy, CCRT can effectively enhance the cognitive dysfunction of patients, and the effect is significant; however, few reports are available on CCRT treatment in patients with chronic schizophrenia. Therefore, this study aimed to examine how computerized therapy corrects cognitive deficits and affects the social functioning of patients with chronic schizophrenia.

MATERIALS AND METHODS

General information

One hundred and twenty patients with chronic deficit schizophrenia diagnosed at Shanghai Pudong New Area Mental Health Center between April 2021 and July 2022 were selected as study participants, including 69 males and 51 females, who were divided into an intervention (60 patients) and control groups (60 patients). Inclusion criteria: (1) All participants met the diagnostic criteria for schizophrenia[9]; (2) stable symptoms, current maintenance treatment with comparable antipsychotic medication, and Positive and Negative Symptom Scale (PANSS) scores of ≤ 70; (3) hospitalization > 2 times, with a total duration of illness of 2-10 years; age of 20-58 years old, and age of education > 8 years old; and (4) complete clinical data on patients. The exclusion criteria were as follows: (1) Comorbid chronic organic diseases; (2) mental and learning disabilities; (3) psychoactive substance use disorders or alcohol addiction; and (4) pregnant or lactating women.

Method

The control group was administered a small dose of the atypical antipsychotic drug lorazepam (Jiangsu Enhua Pharmaceutical Co., Ltd., State Pharmaceutical License H20223573, 10 mg) at a dosage of 10 mg/d once daily. Handicrafts, recreational activities, health exercises, playing poker, and watching television were also used for routine treatment. The intervention group used CCRT to provide therapeutic interventions to the patients based on the control group, which comprised four parts: Planning training, social cognition, working memory, and cognitive flexibility, each of which comprised 8-16 exercises, each of which had 8-16 cognitive correction tasks with different levels of difficulty. Patients were first trained by nurses on CCRT-related knowledge and computer operation. Under the therapist's guidance, the CCRT treatment underwent a structured sequence, starting with cognitive flexibility exercises designed to improve the ability to adapt to changing rules and situations. These tasks varied in difficulty and enhanced the patient’s responsiveness to diverse cognitive demands. Next, the working memory was targeted with exercises like n-back tasks, where the complexity increased as patients demonstrated improved recall capabilities. This was followed by planning training, using strategic tasks such as the Tower of London, gradually intensifying the challenge to bolster problem-solving skills. The final component, social cognition, involved identifying emotions and interpreting social cues through progressively complex scenarios to enhance interpersonal understanding and interactions. Each session was tailored to the individual patient’s level, ensuring consistent cognitive engagement. The intervention was administered over 12 wk, with sessions held five times per week, each lasting 45 min. This structured approach, detailed in Figure 1, evaluated the sustained impact of CCRT on improving cognitive and social outcomes, offering insights into its long-term efficacy and broader applicability in non-pharmacological interventions for chronic schizophrenia.

Figure 1 Technical route flow chart. PANSS: Positive and Negative Syndrome Scale; WCST: Wisconsin card sorting test; SSPI: Scale of social function in psychosis inpatients.

Index evaluation

Efficacy, PANSS, Scale of Social Function in Psychosis Inpatients (SSPI), and Wisconsin Card Sorting Test (WCST) scores.

Judging standard

Psychiatric symptom: Patients’ mental symptoms were evaluated using the three-factor model of the PANSS[10], which has 30 items and a total score between 30 and 210 points. There were 7 positive signs, 7 negative signs, and 16 general psychopathology signs. The higher the number, the more severe the condition.

Cognitive function: All patients were assessed for function using the WCST[11]. The WCST is a neuropsychological test comprising 128 responses and four stimulus cards. This test measures error responses (RE), perseverative response errors (RPE), response answers (RA), and categories completed (CC). Among them, the scores of the three indexes (RE, RPE, and RA) were inversely proportional to the cognitive operation score, and the higher the score, the worse the cognitive function. The index of CC is proportional to cognitive function rating, and the greater the score, the better cognitive function.

Social function: SSPI[12] assesses the social functioning of the two groups of patients. This scale comprises three factors: Daily living ability, activity and communication status, and social activity skills. The higher the total score on the SSPI and each factor score, the lower the social functional deficits.

Statistical method

Data were analyzed using SPSS version 26.0 statistical software. For measurement data, mean ± SD was used (± SD), and for inter-group comparisons, t-test was applied. Counting data are shown as percentages, and comparisons between groups were assessed using a chi-square test. Correlations were analyzed using Pearson's coefficients, and P < 0.05 displays a significant difference.

RESULTS

Comparison of clinical data gap in two groups

The general data of the two patient groups were compared, and the differences were not statistically significant (P > 0.05; Table 1).

Table 1 Comparison of general data between the two groups, n (%).

Item	Intervention group (n = 60)	Control group (n = 60)	t	P value
Sex ratio			1.67	1.96
Male	38 (63.3)	31 (51.67)
Female	22 (36.7)	29 (48.33)
Age (yr)	45.11 ± 10.37	46.14 ± 9.97	-0.58	0.57
Nation			0	1
Han nationality	55 (91.67)	55 (91.67)
Other	5 (8.33)	5 (8.33)
Duration of disease (yr)	9.26 ± 3.02	9.36 ± 3.74	-0.16	0.87
Number of hospitalizations (times)	3.97 ± 1.63	4.13 ± 1.42	-0.58	0.56
Years of schooling (yr)	9.97 ± 1.71	10.03 ± 1.36	-0.23	0.82
Smoking history			0.13	0.72
Exist	32 (53.33)	30 (50.00)
None	28 (46.67)	30 (50.00)
Drinking history			0.33	0.56
Exist	22 (36.67)	19 (31.67)
None	38 (66.3)	41 (68.33)		0.56
Marital status			0.33	0.67
Married	41 (68.33)	38 (63.33)
Unmarried	19 (31.67)	22 (36.67)
Fertility			0.19	0.66
Infertile	13 (21.67)	16 (26.67)
Rear	47 (78.33)	44 (73.33)
SBP (mmHg)	128.06 ± 15.03	129.81 ± 18.28	-0.57	0.56
DBP (mmHg)	80.53 ± 12.41	83.15 ± 11.40	-1.2	0.23
HR	75.09 ± 15.98	77.51 ± 14.78	-0.87	0.39
Educational level			0.39	0.53
Less than high school	27 (45.00)	24 (40.00)
High school and above	33 (55.00)	36 (60.00)
BMI (kg/m2)	21.16 ± 1.23	21.31 ± 1.41	-0.64	0.53
Family history of mental illness			0.87	0.35
Exist	26 (43.33)	21 (35.00)
None	34 (56.67)	39 (65.00)
Professional status			0.3	0.58
Incumbency	28 (46.67)	25 (41.67)
Non-working	32 (53.33)	35 (58.33)
Residence			0.03	0.85
Towns	33 (55.00)	34 (56.67)
Countryside	27 (45.00)	26 (43.33)
Forms of onset			0.55	0.46
Acute onset	23 (38.33)	27 (45.00)
Chronic onset	37 (61.67)	33 (55.00)

SBP: Systolic blood pressure; DBP: Diastolic blood pressure; HR: Heart rate; BMI: Body mass index.

Comparison of PANSS scores before and after therapy gap in the two groups

The differences in PANSS scores between the control and intervention groups before treatment were not statistically significant (P > 0.05). After 2, 4, and 6 wk of treatment, significant decreases were observed in positive symptoms, negative symptoms, common psychopathological symptoms, and total PANSS scores in both groups compared to those before treatment (P < 0.05), and the decreases in the intervention group were greater than those in the control group. Differences were considered statistically significant (Table 2 and Figure 2).

Figure 2 Comparison of positive and negative syndrome scale scores before and after treatment between the two groups of patients. A: Changes in general psychopathological symptom scores before and after treatment in both groups; B: Changes in scores of positive symptoms before and after treatment; C: Changes in scores of negative symptoms before and after treatment; D: Changes in total positive and negative syndrome scale scores before and after treatment in both groups. ^aP < 0.05. PANSS: Positive and Negative Syndrome Scale.

Table 2 Comparison of positive and negative syndrome scale scores before and after treatment between the two groups of patients (mean ± SD).

Times	Groups	General pathology	Positive symptom	Negative symptom	Totals
Pre-treatment	Intervention group (n = 60)	35.63 ± 2.03	17.77 ± 1.50	22.58 ± 1.95	68.65 ± 7.63
	Control groups (n = 60)	36.02 ± 1.31	17.63 ± 1.58	22.28 ± 1.33	66.25 ± 6.94
2 wk of treatment	Intervention group (n = 60)	26.22 ± 2.49a	11.85 ± 2.29 a	15.63 ± 1.59a	53.70 ± 3.46a
	Control groups (n = 60)	33.42 ± 3.34	15.12 ± 1.84	18.18 ± 3.65	64.72 ± 5.53
4 wk of treatment	Intervention group (n = 60)	20.39 ± 2.08a	10.35 ± 2.91a	10.13 ± 1.55a	48.65 ± 2.67a
	Control groups (n = 60)	30.28 ± 1.44	12.45 ± 3.08	17.31 ± 3.26	61.50 ± 2.17
6 wk of treatment	Intervention group (n = 60)	12.21 ± 5.72a	7.18 ± 6.48a	9.12 ± 1.79a	43.02 ± 7.62a
	Control groups (n = 60)	23.85 ± 5.67	10.90 ± 2.36	11.91 ± 2.09	56.95 ± 6.94

^aP < 0.05, compared with pretreatment.

PANSS: Positive and negative syndrome scale.

Comparison of WCST pre- and post-therapy gap in the two groups

Before treatment, no significant difference was observed between the control and intervention groups in the RE, RPE, RA, and CC levels (P > 0.05); however, after 2-6 wk of continuous treatment, the amount of CC gradually increased. The RE, RPE, and RA scores of the intervention group gradually decreased, and the intervention group was significantly lower than the control group (P < 0.05), and the difference was statistically significant. Further details are provided in Table 3 and Figure 3.

Figure 3 Comparison of Wisconsin Card Sorting Test scores before and after treatment between the two groups of patients. A: Change in the number of errors responses after treatment in both groups; B: Changes in the perseverative responses errors scores before and after treatment in both groups; C: Score changes in the number of patients with response answers before and after treatment in both groups; D: Changes in the number of categories completed before and after treatment in both groups. ^aP < 0.05. RE: Errors responses; RPE: Perseverative responses errors; RA: Response answers; CC: Categories completed.

Table 3 Comparison of Wisconsin Card Sorting Test scores before and after treatment between the two groups of patients (mean ± SD, n = 60).

Times	Groups	RE	RPE	RA	CC
Pre-treatment	Intervention group	62.38 ± 1.76	37.28 ± 1.26	103.60 ± 1.76	3.33 ± 0.89
	Control groups	62.85 ± 3.63	37.48 ± 1.20	103.35 ± 1.88	3.28 ± 0.80
2 wk of treatment	Intervention group	53.23 ± 2.06a	25.07 ± 2.39a	90.20 ± 4.28a	4.03 ± 0.84a
	Control groups	56.73 ± 3.68	32.62 ± 4.39	97.65 ± 5.43	3.97 ± 0.89
4 wk of treatment	Intervention group	47.04 ± 1.66a	18.21 ± 3.19a	82.46 ± 3.53a	5.86 ± 2.07a
	Control groups	54.35 ± 1.20	29.47 ± 2.82	95.88 ± 2.34	4.78 ± 2.76
6 wk of treatment	Intervention group	39.92 ± 2.29a	10.50 ± 3.68a	75.89 ± 1.58a	7.42 ± 2.24a
	Control groups	52.24 ± 3.71	25.41 ± 1.36	91.92 ± 4.39	6.23 ± 1.72

^aP < 0.05, compared with pretreatment.

RE: Errors responses; RPE: Perseverative responses errors; RA: Responses answer; CC: Categories completed; WCST: Wisconsin card sorting test.

Comparison of the curative effect gap in the two groups

In the control group, after 6 wk of treatment, 10 cases were cured, 22 cases were improved, 17 cases were better, and 11 cases were invalid, with an effective rate of 81.67%. In the intervention group, after 6 wk of treatment, 24 cases were cured, 18 were significantly improved, 13 were improved, and 5 were invalid, with an effective rate of 91.67%. The treatment efficiency in the intervention group was significantly better than that in the control group (P < 0.05), and the difference was statistically significant (P < 0.05; Table 4).

Table 4 Comparison of therapeutic efficacy between the two groups of patients, n (%).

Groups	Precedent	Heal	Significant progress	Progress	Null
Intervention group	60	24 (40.00)	18 (30.00)	13 (21.67)	5 (8.33)
Control groups	60	10 (16.67)	22 (36.67)	17 (28.33)	11 (18.33)
t					8.95
P value					0.03

Comparison of SSPI scoring before and after treatment for the two groups

Before treatment, no statistically significant difference was observed between the SSPI scores of the two groups (P > 0.05); after treatment, the daily living skills, motivation and socialization, social mobility skills, and SSPI total scores of the two groups were higher than those before treatment, and the intervention group had significantly higher scores than the control group (P < 0.05). After treatment, the daily living skills, motivation and socialization, social mobility skills, and SSPI total scores of both groups were higher than before treatment, and the intervention group had higher scores than the control group (Table 5 and Figure 4).

Figure 4 Comparison of Social Functioning Scale for Psychiatric Inpatients scores before and after treatment between the two groups of patients. A: Changes in daily living skills scores before and after treatment in both groups; B: Changes in the mobility and interaction scores before and after treatment in both groups; C: Changes in the social activity skill scores before and after treatment in both groups; D: Changes in the total Social Functioning Scale for Psychiatric Inpatients scores before and after treatment in both groups. ^aP < 0.05; SSPI: Scale of Social Function in Psychosis Inpatients.

Table 5 Comparison of Social Functioning Scale for Psychiatric Inpatients scores before and after treatment between the two groups of patients.

Times	Groups	Daily living skills	Motivation and socialization	Social mobility skills	SSPI total score
Pre-treatment	Intervention group (n = 60)	6.15 ± 2.22	9.15 ± 2.31	7.04 ± 1.14	9.15 ± 2.31
	Control groups (n = 60)	6.52 ± 1.99	8.81 ± 2.44	6.62 ± 3.59	8.81 ± 2.44
2 wk of treatment	Intervention group (n = 60)	11.06 ± 4.56a	15.96 ± 3.80a	11.99 ± 4.47a	15.96 ± 3.80a
	Control groups (n = 60)	8.00 ± 3.29	12.19 ± 3.78	8.03 ± 2.21	12.19 ± 3.78
4 wk of treatment	Intervention group (n = 60)	14.97 ± 3.29a	18.85 ± 2.68a	13.01 ± 2.95a	18.85 ± 2.68a
	Control groups (n = 60)	11.32 ± 2.79	15.72 ± 2.63	10.79 ± 2.78	15.72 ± 2.63
6 wk of treatment	Intervention group (n = 60)	21.32 ± 1.29a	27.92 ± 5.80a	19.13 ± 4.68a	25.66 ± 5.45a
	Control groups (n = 60)	14.78 ± 3.77	17.69 ± 3.51	14.13 ± 4.29	18.84 ± 3.98

^aP < 0.05, compared with pretreatment.

SSPI: Scale of Social Function in Psychotic Inpatients.

DISCUSSION

Deficit schizophrenia is a distinct subtype of schizophrenia that is characterized by primary and persistent negative symptoms[13]. Currently, cognitive dysfunction in patients with schizophrenia and impairment mainly includes four types: Attention, abstract thinking, memory, and information integration disorders[14]. Cognitive impairment not only affects the rehabilitation of patients but also causes various aggressive behaviors in severe cases, which has important implications for patients' social skills and future well-being[15].

The study found that following 6 wk of CCRT treatment, significant improvement was observed in the general psychopathological factors and positive symptoms. The surgery group had lower PANSS scores and fewer negative symptoms than the control group, and the negative symptom score of the intervention group was more significantly decreased than that in the control group (P < 0.05). Currently, the primary treatment methods are modified electroconvulsive therapy and antipsychotic medication; however, the clinical efficacy of these two methods is limited. Compared with conventional treatment, computer cognitive correction therapy combined with drug therapy can not only significantly improve the cognitive and social functions of patients with schizophrenia but also improve their negative symptoms of patients[16,17]. After 6 wk of treatment, the number of false responses, sustained mistakes, and the total number of responses were substantially reduced in the treated group compared to the uncontrolled group (P < 0.01). Computer cognitive correction therapy has been suggested to effectively improve the cognitive function of patients with chronic schizophrenia and is superior to conventional treatment. This indicates that patients with schizophrenia have greatly improved in many aspects of sensory perception after CCRT, which can significantly improve their working memory, task execution ability, and episodic memory ability and positively impact their attention and information processing efficiency[18]. After 6 wk of CCRT, the intervention group's SSPI score was significantly higher than that before treatment (P < 0.05); however, no significant change was observed in the control group (P > 0.05), and the curative effect in the intervention group was significantly higher than that in the control group (P < 0.05). Studies have shown that this treatment can improve brain activation and gray matter density, fundamentally altering neurobiological abnormalities that may be the root cause of cognitive dysfunction, suggesting that after significant improvement in cognitive correction therapy, patients significantly improve their social and cognitive abilities. It can also alleviate clinical symptoms, improve daily living abilities, and improve social activities[19,20]. After 6 wk of treatment, the actual rate of the control group was 81.67%. The effective rate of the intervention group was 91.67%. The curative effect of the intervention group was significantly higher than that of the control group (P < 0.05). These results indicate that CCRT can significantly improve clinical efficacy in patients with schizophrenia.

Summarily, CCRT treatment for patients with chronic deficit schizophrenia can not only improve their mental symptoms and cognitive function but also help improve their social function, which is worthy of clinical promotion and application. However, additional research is needed to understand its long-term effectiveness and applicability across different settings fully. Future studies should investigate the use of CCRT in varied demographic and geographic populations to determine its generalizability and effectiveness in diverse clinical environments. Moreover, the durability of the cognitive improvements post-treatment needs to be assessed. Long-term follow-up studies can help in determining whether the cognitive and social gains are sustained over extended periods, providing additional insights into the potential of CCRT as a routine intervention in the management of schizophrenia. This study had some limitations. First, because of the limitations of manpower, material resources, and other factors, this study only selected patients with schizophrenia from one hospital for research investigation; therefore, the sampling was not comprehensive enough. Second, the duration of computer cognitive correction therapy for patients was limited, with a maximum of six weeks. In subsequent studies, the duration of treatment should be extended, and patients should be followed up continuously after treatment to clarify the impact of long-term computer-assisted cognitive correction therapy on cognitive improvement in patients.

Additionally, in a follow-up study, the number of enrolled patients should continue to increase, and the sample size should be expanded to further increase the certainty of the treatment effect.

CONCLUSION

CCRT can effectively improve cognitive and social functions in patients with chronic schizophrenia and has a significant therapeutic effect.