Clinical practice guidelines – An overview of cognitive remediation for various neuropsychiatric disorders
2025; Medknow; Volume: 67; Issue: 1 Linguagem: Inglês
10.4103/indianjpsychiatry.indianjpsychiatry_1191_24
ISSN1998-3794
AutoresShiv Gautam, Naresh Nebhinani, Jigneshchandra Chaudhary, Manisha Gaur,
Tópico(s)Neurology and Historical Studies
ResumoPROCESS OF DEVELOPMENT OF THE CLINICAL PRACTICE GUIDELINES The Indian Psychiatry Society Clinical Practice Guideline Sub-committee endeavored to develop a comprehensive review of the research through its clinical practice guideline (CPG) on cognitive remediation in neuropsychiatric disorders. Cognitive function represents a crucial domain affected in psychiatric disorders and significantly impacts the functionality and overall quality of life of the individual.[1] We adhere to a rigorous scientific methodology encompassing the formulation of review questions, systematic literature search, evidence synthesis from meta-analysis, systemic review, randomized controlled trials (RCTs), clinical reviews, various national and international guidelines, and composition of the initial draft. For better local impact, Indian studies and data were considered during the draft process. The preliminary version of the guideline underwent expert evaluation at a national-level workshop. Subsequently, the initial draft was submitted to the Indian Journal of Psychiatry (IJP) for peer review and concurrently published on the India Psychiatry Society website for members' commentary. Following the incorporation of stakeholder feedback and completion of the peer review process, the guideline authors revised the document and subsequently submitted it for quality checks and additional reviews by the IJP. Scope and limitations of CPG This guideline presents evidence-based recommendations for assessing cognitive impairment and various methodologies and techniques of cognitive remediation (CR) interventions for individuals with major neuropsychiatric disorders across all age groups. Implementing these guidelines in clinical practice can enhance clinical outcomes and recovery; however, due to limited local research, financial constraints, availability issues, and variations in individual needs, strict application may not be feasible in clinical settings. Introduction: Concept of cognition Cognition is the mental action or process by which knowledge and understanding are developed in the mind.[2] It is acquiring knowledge and understanding through thought, attention, language, learning, memory, and perception. It refers to a range of mental processes relating to the acquisition, storage, manipulation, and retrieval of information it underpins many daily activities in health and disease across age span. Cognition can be separated into multiple distinct functions dependent on brain circuits and neuromodulators. Cognition can further be categorized into neurocognition and social cognition.[3] Neurocognition, nonsocial cognitive processes, involves domains such as attention, memory, and executive functioning. Social cognition refers to psychological processes that are involved in perceiving, inferring, and responding in social situations.[4] The ability to evaluate, quantify, and oversee cognitive functions across the lifespan facilitates early patient identification, expedited treatment access, prolonged health, enhanced quality of life, and decreased costs. COGNITION IN INDIAN ANCIENT LITERATURE In the Yajur Veda, the concept of the mind is articulated as the internal illumination of knowledge. In the 34th chapter of the Yajur Veda, the initial six mantras elucidate various dimensions of the mind, posing the inquiry, "What constitutes the mind?" The act of apprehending knowledge is attributed to the mind, which is further characterized as both Yoga and Samadhi (a specific mental state). All our sensory faculties operate under the dominion of the mind, functioning under its governance. A substantial portion of Indian philosophical discourse is dedicated to the exploration of consciousness. The texts Yoga Vasistha and Tripurarahasya purport to elucidate the intrinsic nature of consciousness. This assertion is similarly applicable to a range of texts concerning yoga, the Upanishads, and even the antecedent Vedic scriptures. Cognitive abilities arise from a continuing reflection on the perceived world. One Vedic statement tells us that Atman (Soul) consists of three Elements of Soul (Atman) 1. Mind (maan) 2. Vitality (pran) 3. Matter (vaak) We may see these three elements pervading us as well as the whole world. Our mind represents knowledge (gyan), vitality (pran), action (kriya), and matter (vaak), representing all worldly objects and all literature (sahitya). Knowledge engenders volition, which in turn engenders exertion, and exertion culminates in action, encompassing all that is manifested. In accordance with Sankhya philosophy, the concept of reality can be delineated through a framework comprising 25 distinct categories. These categories constitute the foundational basis for the classification system within Saivism. The categories delineated are as follows: Five fundamental elements of material existence, epitomized by earth, water, fire, air, and ether. Five subtle elements, characterized by the sensory perceptions of smell, taste, form, touch, and sound. Five organs designated for action, which include reproduction, excretion, locomotion, grasping, and speech. Five organs associated with cognition, which correlate to the senses of smell, taste, vision, touch, and hearing. Three internal faculties, namely, the mind, ego, and intellect, alongside inherent nature (prakrti) and consciousness (purusa). Cognition is a set of all mental abilities and processes related to knowledge. The concept of cognition and perception have a detailed description in all the six Indian philosophies, Nyaya (logic), Vaisesika (atomic theory), Sankhya (analysis of matter and spirit), Yoga (the discipline of self-realization), Karma-mimamsa (science of fruitive work), and Vedanta (science of God realization), with slight variations among each of the philosophies.[5] All six schools of Vedic philosophy aim to describe the nature of the external world and its relationship to the individual, to go beyond the world of appearances to ultimate reality, and to describe the goal of life and the means for attaining this goal. Perception and cognition have been described to have a key role in the right means of knowledge.[6] Concept and mechanism of cognition according to Sānkhya It is a complex process: The psyche, which is made up of three faculties—the mind (manas), the intellect (buddhi), and the ego (ahankāra)—cognizes its constituent objects (color and shape) through the physical organs (eye, for example). Using information from the senses, the mind internally develops a representation of the outside world's things. The ego adds a personal viewpoint to assertions of knowledge. Understanding is a component of knowledge that comes from the intellect. The purușa, which is only a witness to the intellectual processes, gives the result awareness. Perception, inference, and valid testimony are the means. By these, all other means of right cognition too are established.[7] CONCEPT AND MECHANISM OF COGNITION ACCORDING TO YOGA According to Patanjali's epistemology,[8] cognition is possible only because "chitta" is colored by both the object and the mind itself. Sensory impressions from the external world continually bombard the functions of sight, hearing, smell, taste, and touch. As the mind defines the object, so the object defines the mind. Manas then registers the objects of cognition and controls the response. It does so by drawing from the memory bank of karma stored in the mind. So, the model of cognition according to Sānkhya and Yoga is almost replicable except for the fact that Buddhi in Yoga is represented by Chitta. A schematic presentation of the mechanism of cognition according to ancient Vedic literature is described in Figure 1,[6] and the relation between cognition and consciousness is in Figure 2.[9]Figure 1: Mechanism of cognition according to Sankhya and yogaFigure 2: Connection of cognition and consciousness as per Indian thought systemCOGNITIVE FUNCTION IN MODERN MEDICINE Cognition has served an important function of human existence and has been an area of interest for research for several years. The major cognitive domains are described in DSM-5, as depicted in Figure 3.Figure 3: Cognitive domains as per DSM 5Cognitive domains are subdivided into various subdomains and categories to quantify specific deficits. Table 1 describes the cognitive domain and subcategory.Table 1: Cognitive domains and its subtypesCOGNITIVE IMPAIRMENT IN PSYCHIATRIC DISORDERS Cognitive function plays an important role in daily life. It is commonly known that widespread impairment in cognitive function is an essential feature of many mental disorders.[10] A wide range of prevalence rates of cognitive impairment have been reported in common psychiatric disorders. Cognitive impairment in psychiatric disorders has been reported in most domains and is more pronounced in certain subdomains of cognition in different disorders. Nearly 80% of persons with schizophrenia and 40% of patients with depression have cognitive impairment.[11,12] Cognitive deficits may result in poor attention, problems in processing information, difficulties with remembering and recalling, and response-related problems.[1] Cognitive impairments have an impact on several domains, including everyday living, education, employment, and interpersonal relationships.[13–15] Impaired cognitive function leads to poor quality of life and socio-occupational impairment. The World Health Organization's disability model states that these cognitive impairments affect social functioning, community integration, and overall quality of life.[16] Schizophrenia is one of the most severe and disabling psychiatric illnesses. Cognitive impairment in schizophrenia is severe, enduring, and associated with poor outcomes. Impairments in social and occupational functioning in schizophrenia were strongly related to the impairments in neurocognition.[15,17–20] In Earlier era, Bleuler and Kraepelin explored cognitive impairment in schizophrenia.[21,22] However, modern psychiatric disorder nosology and diagnostic criteria often focus on emotional and behavioral symptoms of the condition and undermine cognitive function and cognitive impairment. With advancements in medical science, psychiatric interventions and treatment of cognitive symptoms, and cognitive impairment gain further attention in research and clinical practice. Reichenberg et al. studied neurocognitive performance in schizophrenia, schizoaffective disorder, bipolar disorder, and depression. All four groups demonstrated impairments in memory, executive functions, and attention and processing speed. However, more pronounced impairment was noted in the schizophrenia subgroup.[23] Konstantakopoulos et al.[24] in a study of bipolar and schizophrenia patients highlighted significantly impaired in general intellectual ability, verbal memory and learning, and executive functions compared to healthy controls. Patients with schizophrenia performed significantly worse than patients with bipolar on verbal memory tasks, whereas the bipolar group did not have a significantly lower score than schizophrenia in any task. Schizophrenia patients performed worse than a control group on attention, processing speed, and immediate memory tests, while bipolar patients on visuospatial ability and working memory. Both schizophrenia and bipolar groups did not differ from the control group regarding Theory of Mind. Study results of Konstantakopoulos et al.[24] show stable schizophrenia and euthymic bipolar disorder exhibit similar profiles of cognitive impairment, consistent with previous studies, suggesting that the differences are related to the extent and degree of impairments, rather than being qualitative. Cognitive deficits in mood disorders are studied extensively, but the overall pattern of specific cognitive impairment has not always been consistent. Common problems are identified in the areas of attention, executive function, and recall memory.[25] In depression, cognitive impairment can be severe and generalized. Cognition is considered one of the core features of diagnosing depression for a long period.[26] Meta-analysis of the first episode of major depressive disorder showed cognitive deficits in psychomotor speed, attention, visual learning and memory, and all aspects of executive functioning.[27] Depressive symptom improvement and the number of previous depressive episodes moderated the extent of cognitive changes. It demonstrates scar-like features of depressive episodes in cognitive domains.[28] Cognitive function in depression improves marginally with treatment intervention. Working memory, verbal memory, and verbal fluency were most sensitive to change. Executive function, processing speed, and nonverbal memory were less sensitive to change.[29] A study in adolescent patients with depression showed neuropsychological deficits in MDD compared to controls in the cognitive domains of executive function, working memory, psychomotor and processing speed, verbal fluency, and visual (-spatial) memory.[30] In first-episode bipolar disorders, impairment in psychomotor speed, attention and working memory, and cognitive flexibility were identified, whereas smaller deficits were found in the domains of verbal learning and memory, attentional switching, and verbal fluency. Cognitive deficits can be identified during the euthymic or remission state of disorder. Studies have shown structural and functional changes in DLPFC which are consistent with impairment in attention, executive function, and memory.[25] Commonly identified difficulties in OCD are visuospatial and visuoconstructionl areas. Some studies identify impairment in nonverbal memory. However, verbal memory is usually preserved in most cases. Another study by Suhas and Rao reported impairment in response inhibition, impaired set-shifting, processing speed, and verbal memory in the OCD group.[31] Memory problems are the core feature of PTSD; studies show verbal and autobiographical memory impairment in PTSD. Beth Cohen et al.[32] reported impairment in processing speed, categorical fluency, and verbal learning in PTSD. Another study conducted on individuals with acute PTSD revealed deficits in high-level attentional resources, working memory, executive function, and memory.[33] Ramey et al.[34] investigated cognitive impairment in substance misuse and identified attention, response inhibition, working memory, and decision-making function impairment. Impairment of theory of mind and emotional perception in addition to impaired processing speed, verbal learning, and memory are reported by Velikonja.[35] ADHD shows clinical impairment in selective attention, processing speed, and memory subdomains.[36] Cognitive impairment across neuropsychiatric disorders occurs in almost all subdomains but is more pronounced in certain domains in certain disorders. Multiple factors and interactions at a cellular level are responsible for cognitive impairment in psychiatric patients. We have enlisted some prominent molecular changes responsible for cognitive impairment in Table 2.[37]Table 2: Molecular Mechanism for Cognitive Impairment in Psychiatric Disorder[ 37 ]ASSESSMENT AND QUANTIFICATION OF COGNITIVE IMPAIRMENT Assessment of cognitive function is a challenging yet integral component of psychological, psychiatric, and neurological evaluation. Cognitive assessment tests, tools, scales, and batteries are used for screening for the presence of any cognitive impairment, differential diagnosis, quantifying the severity of the disorder, monitoring disease progression, and determining treatment efficacy. Cognitive impairments include reductions in general intellectual capacity and domain-specific areas such as memory, attention, processing speed, executive functions, and social cognition.[38] Assessment in the particular domain of cognition helps us to understand and quantify cognitive impairment in a better way. It is imperative to utilize appropriate normative data to assess an individual's cognitive status and draw empirical conclusions based on well-established theoretical foundations of psychometrics and neuroscience. Since the recognition that populations with differing demographic characteristics exhibit variations in test performance, population-based normative studies have become essential. However, even ostensibly homogeneous populations demonstrate intragroup differences, thus rendering the development and application of theoretically and ecologically valid instruments for the empirical assessment of cognitive function in a known heterogeneous population, such as India, a significant challenge for researchers and clinicians. The Indian demographic landscape is characterized not only by linguistic and religious diversity but also by a multitude of cultural and socioeconomic confounding factors, some of which have yet to be identified as potential confounders. The NIH-funded MATRIC project developed a tool for an assessment and quantified changein cognitive impairment in clinical trials. Seven distinct cognitive parameters were identified for measurement: speed of processing, attention/vigilance, working memory, verbal learning and memory, visual learning and memory, reasoning and problem solving, and verbal comprehension.[39] As a result of growing interest in social cognition and further data supporting its applicability to clinical trials assessing the effects of potential cognitive enhancers on cognitive function and performance, the eighth domain—social cognition—was added later.[40] Verbal comprehension was not considered appropriate for a cognitive battery intended to be sensitive to cognitive change due to its resistance to change. The remaining seven domains were recommended for inclusion in the MATRICS-NIMH consensus cognitive battery and will serve as the basic structure for that battery.[39,40] Speedofprocessing, Attention/vigilance, Working memory, Verbal learning, Visual learning, Reasoning and problem-solving, Socialcognition Common cognitive subdomain-specific neuropsychiatric tests are listed in Table 3.Table 3: Common cognitive domain and test for assessment[ 41 , 42 ]Specific guidelines chapters for the specific disorders cover detailed assessment tools and methods. An overview of commonly used cognitive instruments is in Table 4 [Indian validated instrument highlighted in bold letters].Table 4: Disease-wise commonly used cognitive instruments to measure cognitive impairment in neuropsychiatric disordersCOGNITIVE REMEDIATION: BASIC PRINCIPLES Cognitive remediation is also known as cognitive enhancement or cognitive rehabilitation. Its training-based behavioral intervention operates on learning principles.[43] The "Cognitive Remediation Expert Working Group" has defined cognitive remediation as a behavioral training intervention targeting cognitive deficit using scientific principles of learning, with the ultimate goal of improving functional outcomes.[44] The primary aim of cognitive remediation should be individualized to the patient's needs, tailored to enhanced patient participation, and should focus on meaningful recovery. Its effectiveness is enhanced when provided in a context (formal or informal) that provides support and opportunity for extending to everyday functioning,[45] specifically targeting improvement in memory, attention, executive functions, thinking, processing speed, motor tasks, and metacognition. Studies have shown cognitive remediation improved self-care, social relations, and functionality in the individual. Cognitive remediation acts as a complement to medication and psychological therapies, which constitute the core methods of treatment for schizophrenia.[46] The history of cognitive remediation or rehabilitationtechniques dates back to times when drill and practice restoration methods were the only behavioral modification techniques in use.[47] The primary goal of the intervention though is the effective use of the obtained skill in independent daily living.[48] Keshavan et al.[49] define cognitive training as behavioral training affecting cognitive or social learning, which can be scalable and reproducible, to potentially improve function. Features and benefits of cognitive remediation are described in Figure 4 and Table 5, respectively.Figure 4: Features of cognitive remediation treatmentTable 5: Impact of Cognitive Deficits and Potential Benefits of Cognitive Remediation in Psychiatric Disorders[ 47 ]Cognitive remediation is sometimes used as an umbrella term and may include cognitive training and other methods. Different methods of cognitive improvement are documented in Figure 5.[50]Figure 5: Different type of cognitive improvement methodsCognitive training can be done via various models as described by Malhotra et al.[51] in Figure 6.Figure 6: Theoretical models of cognitive trainingPrimarily, two main approaches are used in cognitive remediation as described in Figure 7: top-down (or executive) and bottom-up (or perceptual) approaches.[40]Figure 7: Cognitive remediation approachThe top-down processing strategy concentrates on higher-level cognitive processes that integrate and coordinate lower-level processes.[40] The bottom-up processing approach focuses on enhancing lower-level cognitive processes (like attention) and progresses toward higher-level processes.[40] TECHNIQUES OF COGNITIVE REMEDIATION[43] Various techniques used to improve cognitive function via mental exercise, learning strategies, skills, and awareness are listed in Table 6.Table 6: Techniques of Cognitive RemediationsHowever, the efficacy of cognitive remediation on neurocognition and functional outcome has been demonstrated, with inconstant continuation of benefits after completion of treatment.[46,52] Over the past few years, several programs that were created—like IPT, CRT, NEAR, CET, NET, CRT, and CAT—are starting to be utilized more often. A few commonly used remediation approaches and therapies are listed in Table 7, including digital app-based approaches.Table 7: Commonly Used Remediation Approach and Therapy[ 48 ]Steps to improve the effects of cognitive remediation[53] Identify the patient in need Assess for cognitive deficits Consider augmentation of CR with different components: social cognition training, combined with physical exercise, focusing on CR to improve clinical symptoms Having fun activities to improve motivation and develop a positive state Consider utilizing hot cognitions (through tasks based on emotionally relevant stimuli) Encourage metacognition (thinking about thinking) Helping to build bridges (to improve functioning) Training for appropriate periods and observing for long-term benefits PREDICTORS OF RESPONSE IN COGNITIVE REMEDIATION The effectiveness of cognitive remediation (CR) differs greatly from person to person and is impacted by both the treatment and the patient's features. Comprehending these factors can improve CR's efficacy and direct individualized treatment plans. A] Patient-Related Predictors[53–56] Age Young individuals, particularly adolescents and those in early adulthood exhibit a better response to cognitive remediation. The brain's plasticity during these developmental stages may contribute to greater adaptability and improved cognitive outcomes. Genotype Genetic predispositions play a crucial role in cognitive remediation outcomes. For example, carriers of the COMT Met allele and older adults with the BDNF polymorphism show enhanced responses to CR in schizophrenia. These genetic markers may influence neuroplasticity and cognitive recovery processes. Cognitive reserve Individuals with higher cognitive or brain reserve, faster processing speeds, and superior visual or verbal learning capabilities are more likely to benefit from CRT. A robust cognitive reserve provides a stronger foundation for compensatory mechanisms and adaptive learning during therapy. Illness-related factors Several illness-related factors are associated with better cognitive remediation outcomes: Duration and Phase of Illness: Patients in the earlier phases of their illness and those with a shorter duration of symptoms tend to show greater improvement. Symptomatology: Lower baseline levels of symptoms and symptomatic stability are significant predictors of success. Motivation High intrinsic motivation is a critical determinant of successful cognitive remediation. Motivated patients are more likely to engage actively in therapeutic exercises, fostering cognitive improvements. Emotional state A positive mood state enhances engagement and responsiveness to cognitive remediation. Emotional wellbeing may facilitate the cognitive processes required for learning and adaptation during therapy. Evidence suggests a greater role of therapist-related factors in the form of expertise, training, active engagement, and a plan of integrated intervention for the better response of cognitive remediation.[53] Hence, it should be delivered by trained mental health professionals and clinical psychologists with expertise in the area. B] Treatment-related predictors in cognitive remediation[54–60] Treatment-related factors significantly influence the success of cognitive remediation. The use of precognitive agents may improve cognitive outcomes by modulating neural activity, but evidence is not significant enough to recommend. Neuromodulation techniques, including transcranial magnetic stimulation and vagal nerve stimulation, promote neural plasticity. Adjunctive interventions, like aerobic exercise and healthy lifestyles, may further amplify CR effectiveness. Therapists play a crucial role; trained professionals fostering strong therapeutic alliances yield better engagement. Strategic and integrated therapy approaches outperform generic methods. Last, minimizing antipsychotic and anticholinergic medication burdens optimizes cognitive improvements, highlighting the need for tailored pharmacological support. The rationale for combining cognitive-enhancing drugs and cognitive remediation Cognitive-enhancing drugs have not as yet been successful, and cognitive remediation has shown modest success. Therefore, in suitable cases, the optimal approach may require a combination of cognitive-enhancing drugs with cognitive remediation. Though there is a theoretical rationale and preliminary evidence available, there are practical challenges that exist in this approach.[61] The rationale for combining cognitive rehabilitation with psychiatric rehabilitation Research indicates that when cognitive training and other psychosocial rehabilitation programs are used in conjunction with the adoption of a strategy coaching approach based on learning techniques, there is a considerable increase in social functioning.[62] A meta-analysis by Duin et al.[63] included 23 studies on 1819 patients and found enhancing effects of psychiatric rehabilitation (PR) with cognitive rehabilitation (CR) with significant beneficial effects on vocational outcomes (e.g., employment rate: SMD = 0.41) and social skills (SMD = 0.24). No significant effects were found on relationships and outcomes of community functioning. Effects on vocational outcomes were moderated by years of education, intensity of the intervention, type of CR approach, and integration of treatment goals for PR and CR. Studies, where cognitive remediation was combined with other forms of rehabilitation and when it included strategy coaching, demonstrated significantly better functional outcomes. Rationale of combining cognitive rehabilitation with neuromodulation techniques Brain stimulation modalities, such as repetitive transcranial magnetic stimulation (rTMS), are found to be effective in improving cognitive impairment as well as clinical symptoms of depression.[64] Transcranial direct current stimulation (tDCS) is effective in improving cognitive functions as well as clinical symptoms in patients with schizophrenia.[65,66] However, a meta-analysis by Anika Poppe et al.[67] examining cognitive training in comparison with mental training and noninvasive brain stimulation demonstrates only improvement in memory function, with the effect not sustained for a longer period. EVIDENCE OF COGNITIVE REMEDIATION IN MAJOR PSYCHIATRY AND NEUROPSYCHIATRY DISORDERS The biological basis of cognitive remediation is shown by increased brain activation in regions associated with working memory, particularly the fronto-cortical areas.[44,52] Cognitive impairment is prominent in high-risk individuals and the early stages of psychosis (prodrome). It is more responsive to remediation techniques during the early stages of psychosis.[59,68] Cognitive remediation (CR) has been found effective in improving cognitive impairment, community functioning, emotional regulation, and clinical symptoms in early-stage psychosis.[49] CR also influences brain plasticity by targeting neural functions and restoring neural networks in early psychosis.[14] Cognitive remediation produces small to moderate improvements in cognition and depressive symptoms in mood disorders.[69] Models examining the effects of cognitive remediation versus control at post-treatment showed medium to large effects of cognitive remediation on processing speed, visual learning, and memory. Cognitive remediation was not associated with change in community functioning, although cognitive change was associated with functional change across the sample.[70] Meta-analysis cognitive rehabilitation for improving cognitive functions and reducing the severity of depressive symptoms in adult patients with major depressive disorder concluded moderate and significant effects on the executive function, verbal learning, and working memory of MDD patients. However, there were no significant differences between intervention and control groups in attention or depressive symptoms.[12] Cognitive remediation interventions can improve social cognition and cognitive functioning in autistic spectrum disorder. RCTs supported the efficacy of CR interventions in improving social cognition and executive functioning.[71] Cognitive remediation effectiveness was demonstrated in children and adolescents with attention deficit hyperactivity disorder (ADHD), anorexia nervosa, specific learning disorder, intellectual disability, and early onset psychosis.[72–76] CR in patients with dementia has reported improvement in cognitive functions, behavioral problems, and quality of life. Several techniques have been used, including validation therapy, reality orientation therapy, and digital interventions.[77] Vast evidence suggests the beneficial effects of CR along with a holistic rehabilitation approach through manualized, digital, and in-person training to improve functional outcomes and cognitive deficits in persons with traumatic brain injury (TBI).[55,78] The study by Alice Medalia et al.[79] to examine factors influencing positive responses to cognitive remediation in schizophrenia includes patients' motivation, work style, chronicity of illness, intensity, type of treatment, and clinician's experience. The results of an ongoing randomized control study of virtual compensatory cognitive training for schizophrenia in the Tamil community may be available in early 2026.[80] CONCLUSION The benefits of cognitive remediation are especially relevant for chronic and severe patients with psychiatric disorders. Current evidence indicates that it significantly improves many outcomes, including memory, attention, problem-solving, cognition, social cognition, independent living skills, and social adjustment. Pharmacological treatment falls short of bringing noticeable changes in cognitive and socioaffective processing. Cognitive training-based interventions are safe, preventive remedial measures for individuals at younger ages and at earlier stages of illness. Considering cognitive heterogeneity in psychiatric disorders, it is crucial to identify whether particular groups of patients benefit from cognitive remediation therapy. Hence, early detection of psychiatric disorders and timely intervention for illness (with comprehensive management) and cognitive symptoms (through remedial measures) may restrict the development of stable deficits and disability and are likely to improve overall illness course, prognosis, and functioning. Comprehensive assessment of cognition should focus not only on areas of impairment that may affect function but also on areas of cognitive strength and personal resources that may support the pursuit of stated goals. Assessment will also allow the therapist to tailor remediation to the patient's preferences, strengths, and learning style, which could serve to increase the patient's intrinsic motivation to engage in cognitive remediation. This personalized approach should be maintained throughout the course of the intervention regardless of the illness stage or treatment setting. Evidence also exists that even after cognitive intervention, there is no noticeable improvement in the outcomes. Also, psychiatric disorders are heavily influenced by social-emotional experiences and developmental context. This also calls to improve our understanding mechanism of cognitive defects, training of content, and response time. Gap areas and directions for future research For effective cognitive remediation interventions, it is essential to identify the specific impairments that will be targeted in each patient presenting a distinct pattern of deficits. Consequently, validated and customized neuropsychological assessments are necessary. Subsequently, cognitive remediation programs must be tailored to each patient's individual needs to enhance motivation for participation. Furthermore, long-term effects must be evaluated to determine whether reinforcement is required. Following these protocols, the majority of studies demonstrate an improvement in the wellbeing of patients with psychiatric disorders. These recommendations are also applicable to cognitive remediation programs as well as treatments utilizing cognitive assistive devices. A significant challenge impeding the advancement of cognitive assistive technology programs is the lack of coordinated efforts among different research groups, who often work independently to improve and validate existing programs. Furthermore, the necessity for additional research is evident due to the paucity of long-term data, inconsistent findings across various studies, and uncertainty surrounding the mechanism of action, which requires further investigation. Augmented reality, artificial intelligence, and the utilization of neurostimulation may present novel opportunities for cognitive remediation in psychiatry. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
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