218. Top-Down or Bottom-Up? Comparison of Two Computer-Assisted Modalities of Cognitive Remediation Therapy for Schizophrenia

Abstract

Background: Cognitive remediation (CRT) designed to improve cognitive function in patients with schizophrenia has shown signifcant effcacy. Our study was designed to compare 2 computerized CRT programs for improving memory and problem-solving skills in patients with schizophrenia. Each intervention uses a specifc theoretical rationale: a top down approach (CogPack), training a broad range of cognitive features and a bottom up approach (PositScience), which targets the discrimination ability in perceptual systems. Goals of this study were (1) to perform a noninferiority comparison of the effects of the two programs in patients with chronic schizophrenia and (2) to examine whether the addition of a social cognition remediation intervention, Mind Reading, would further improve social function outcomes over each intervention alone. Methods: Both CRT treatments were administered during a 12-week training period. Stable patients with DSM 5 schizophrenia who received either inpatient or outpatient clinical services were recruited. Patients were evaluated on a standardized battery of neuropsychological assessments (MCCB), social emotion measures, auditory and visual discrimination tasks, and a brief assessment of functional skills (PSP) and clinical symptoms (PANSS) at screening and at end point. Results: 64 subjects were randomized as follows: (1) COGPACK Alone (n = 17), (2) PositScience Brain Fitness Alone (n = 14), (3) COGPACK + Mind Reading (Social cognition program; n = 19), (4) PositScience Brain Fitness + Mind Reading (n = 14). For the initial comparison and due to the small sample size, all subjects receiving COGPACK (n = 36), and all subjects receiving PositScience (n = 28) were each combined. Signifcant improvements from baseline were found in the COGPACK-treated patients for working memory and attention/vigilance. PositScience-treated patients showed signifcant improvements from baseline in working memory (P =.046) and visual learning (P =.048). Comparison of differential treatment effects found that patients treated with COGPACK + Mind Reader were signifcantly more benefted than patients treated with PositScience or COGPACK alone (P =.044). Changes in total PANSS (r =.453, P =.049) and PSP (r =.466, P =.045) scores were correlated with improvement in the MindReader combined groups (PositScience + Mind Reader and COGPACK + Mind Reader). Conclusion: COGPACK or PositScience was associated with intervention specifc improvements in working memory and attention/vigilance, and working memory and visual learning respectively. Cognitive improvement in the Mind Reader augmented groups was associated with changes in psy-chopathology and functional outcomes. Patients with defcits in specifc cognitive domains may beneft differentially from a bottom up versus a top down approach and may therefore be assigned to a specifc “defcit associated” program within a personalized therapeutic approach.