Combined Cognitive Remediation and Functional Skills Training for Schizophrenia: Effects on Cognition, Functional Competence, and Real-World Behavior

Objective: Cognitive remediation is an efficacious treatment for schizophrenia and, when used within broader psychosocial treatments, improves transfer to real-world behavior change. The authors examined whether cognitive remediation effectively generalizes to functional competence and real-world functioning as a standalone treatment and when combined with a functional skills treatment. Method: Outpatients with schizophrenia (N=107) were randomly assigned to receive cognitive remediation, functional adaptation skills training, or combined treatment, with cognitive remediation preceding functional skills training. Clinical symptoms, neurocognition, social competence, functional competence, and case-manager-rated real-world behavior were assessed at baseline, at end of treatment, and at a 12-week durability assessment. Results: Neurocognition improved, with durable effects, after cognitive remediation but not after functional skills training. Social competence improved both with functional skills training and with combined treatment but not with cognitive remediation alone. Improvements in functional competence were greater and more durable with combined treatment. Cognitive remediation alone did not produce significant improvements in real-world behavior, but when combined with functional skills training, statistically significant improvements from baseline to end of treatment and follow-up were observed in community or household activities and work skills. Number-needed-to-treat analyses suggest that as few as three cases are required for treatment to induce a meaningful improvement in functional skills. Conclusions: In a short intervention, cognitive remediation produced robust improvements in neurocognition. Generalization to functional competence and real-world behavior was more likely when supplemental skills training and cognitive remediation were combined. (Am J Psychiatry 2012; 169:710-718)