Figure 21.1

Number of minutes of online homework on a computerized cognitive training program, as a function of treatment response status (defined as magnitude of change in cognitive ability). Each column represents the number of minutes of homework before (black bar) and after (gray bar) treatment for individual cases. Significant differences between groups are displayed within the figure.

Summary of published studies

The above studies represent the diversity of applications of psychotherapeutic attempts to improve cognition in depression. Many of the studies borrow techniques from treatment manuals designed for other disorders, some involve only computerized cognitive activation without a clear role for a therapist to engage patients and facilitate transfer of cognitive gains to everyday functional goals, and there is quite a large variability in patient characteristics, measurement, comparison groups, and length of treatment. Such is the evolving state of cognitive remediation as of the writing of this chapter – not only in depression, but also for use across a range of mental disorders. Indeed the field of cognitive remediation seems to be at a pivotal juncture: some are advocating for an automated approach where cognitive training by computers results in neuroplastic effects. This simple model (see Figure 21.2) is of course economical, but to date we have not seen promising results for improving actual everyday outcomes when we rely on a computer to act as a therapist. Excitement about indexing change in actual brain function or structure should be considered in light of whether the program as a whole induces changes in function that would lead to higher quality of life and reduced disability. Many patients might argue that brain change sounds exciting, but they show up and continue to engage if there is the goal of improved functioning of their brain and their daily lives.

Figure 21.2

A simplistic model of how using cognitive training exercises might lead to changes in brain function, ultimately manifesting in adaptive everyday behavior changes. This model has not been supported by existing literature.

Strategies that rely on all three pillars of cognitive remediation have, in other disorders, resulted in substantially larger improvements in everyday outcomes. The goal in those programs is not only to improve cognitive abilities, but also to help people learn how to more effectively use the cognitive abilities that are already intact and those that are improving throughout the course of treatment. This model, represented by Figure 21.3 uses both direct and supplemental approaches to improving cognition with the goal of improving brain and community function. However, these approaches, too, are limited in several ways. The techniques used to facilitate this transfer of cognitive gains to everyday life are often done in a traditional group therapy setting, where therapists rely on exchange of verbal information and hope that patients (who often have attention, memory, and abstraction deficits) pay attention, remember, and figure out how to adapt in new environments. As we see in the above review of the literature, the efficacy (improving cognition) far exceeds measures of effectiveness (improving everyday functioning), regardless of which of these two models guides treatment choices. So, we are left with some promising but certainly preliminary evidence for cognitive remediation’s usefulness in depression at present. Is there something unique about depression that would inhibit the changes in everyday functioning from cognitive remediation, like we see in other disorders? Or, have we simply not accumulated enough data?

Figure 21.3

A model of cognitive remediation as a psychotherapy that represents the three main pillars of therapist-guided intervention. There is limited evidence that this model results in adaptive behavior changes.

Cognitive remediation as a form of psychotherapy

With the goal of using cognitive enhancing interventions to improve functioning and overcoming the limitations of previous work, a recent development aims to bring the elements of community functioning that we hope to improve directly into the clinic to be part of the treatment. One such treatment, action-based cognitive remediation (ABCR; Bowie et al., in preparation), relies on the three pillars of cognitive remediation, but also includes simulations of real life for bridging (as opposed to verbal discussion), therapist intervention to counter negative beliefs about performance and build confidence in one’s cognitive abilities, and activity scheduling to improve the chance that patients engage in more stimulating activities.

Simulations of real life make the bridging activities more relevant for everyday functioning: they are done immediately after doing computerized cognitive activation, increasing the chance that participants retain the strategies just developed in a real-life environment. In Figure 21.4, an illustration of a real-world simulation with a corresponding computer training exercise is presented.

Figure 21.4

An illustration of how tangible, action-based activities can be used to foster transfer of cognitive skills from computer-based training to everyday functional tasks.

A second unique feature of ABCR is the direct targeting of self-efficacy and motivation to encourage transfer of cognitive gains to functioning. Cognitive remediation participants are asked to challenge their cognitive abilities and are constantly faced with visual and auditory feedback about their performance, often in a group setting. For a population that is defined by having negative self-statements, lower self-esteem and self-efficacy, and pessimistic beliefs about their future, one might argue that asking patients with depression to engage in cognitive training without a trained therapist would violate the Hippocratic Oath. Several occasions can arise within a single session for an individual to confirm negative thoughts, experience emotional distress, and subsequently disengage from treatment. It is counterintuitive to approach a training task with the goal of constantly finding a way to make performance decline, but this is how cognitive training is most effective, by increasing difficulty level as performance improves. Patients with depression, without frequent and close supervision by a trained therapist, might struggle to maintain the outlook that errors in performance are desired in a training environment in order to stimulate effects on brain function and facilitate the development of new strategies. A list of common distortions that may arise can be found in Bowie, Gupta, and Holshausen (2013a). Although cognitive remediation should not transform into a full cognitive restructuring session, therapists conducting groups with those with depression will likely need to have some training in how to identify and address distortions – if at least to maintain engagement with tasks through redirection if not actively reframing statements.

The goal of activity scheduling is to promote a more active behavioral approach to the cognitively challenging activities that many with depression avoid in daily life. Consider the usual cognitive remediation treatment environment. Patients might get as little as one hour per week of training; even in the study that prescribed homework to participants, the prescribed amount of 40 minutes per day is less than 5 percent of one’s time awake if we estimate eight hours of sleep! What is happening for 95 percent of our patients’ days? If people with depression are engaging in cognitive training, but encounter daily challenges to making behavior change due to symptoms of the condition and lack of confidence in their cognitive abilities, we face the possibility that environmental understimulation might limit the effects on brain change and on everyday skill use. Activity scheduling identifies self-defined functional goals and develops plans for engaging in these behaviors in a way that capitalizes on the exact strategies and techniques that are learned in sessions. Figure 21.5 illustrates how these elements that are novel to ABCR might model a feedback loop wherein cognitive training and therapist support in session leads to a more cognitively confident person who engages in more complex everyday activities, thus generating more healthy experiences for the brain and developing new effective strategies for functioning in daily life.

Figure 21.5

The model of psychotherapy known as Action-Based Cognitive Remediation, where the role of the therapist is critical for helping patients with depression apply their cognitive skills in everyday activities, improve self-confidence in their cognition, and schedule activities for increasing cognitive stimulation in everyday life, outside of treatment sessions.

Preliminary evidence suggests that ABCR results in larger and more durable effects on everyday behavior than cognitive remediation with the three pillars presented in the traditional manner. In a sample of patients who were already engaged in a vocational services program and compared with those on a traditional cognitive remediation approach (n = 15), larger improvements were found in verbal memory and verbal fluency in the ABCR group (n = 24). Six months following treatment, patients in ABCR demonstrated more improved functional skills and significantly more were working than in the traditional group (61 percent vs. 27 percent). Speaking to the cognitive confidence mentioned above, patients in ABCR reported less stress on everyday work tasks. Finally, a finding that should not be lost is the retention rate: 92 percent for ABCR compared to 53 percent in traditional cognitive remediation. A critical consideration to balance these positive results, in addition to a small and unique sample study, is the feasibility of rolling a treatment like ABCR out in a routine clinical environment. Two PhD-level therapists worked with nine patients for ten weeks, seeing them for two-hour sessions twice each week. This dose might not appear to be economical in many healthcare systems, but as with many other treatments, it will be important to evaluate long-term cost savings if work and disability outcomes are maintained.

Cognitive remediation for MDD: unique considerations

Symptom profiles and comorbidities

MDD has a heterogeneous symptom presentation across patients and within individuals over time. Comorbid symptoms and disorders make the delivery of psychotherapeutic services a challenge, and the therapist will have to have a keen eye and well-developed set of skills to recognize and address issues in group or even individual sessions. From the perspective of study design, sampling procedures have these issues, as well as remission status, as considerations when recruiting and interpreting results.

Motivational issues

Engaging patients with MDD in cognitive remediation treatment can be challenging. Many will not like the idea of attending a group. Others might not recognize their cognitive impairments, might not prioritize them as a treatment need, or might not be motivated to change behavior through cognitive gains. Individual treatment decisions about the type, duration, and expectations will need to be made when enrolling patients with MDD in cognitively enhancing treatments. Goal setting with a focus on linking the patient’s areas of deficit with the goals they have for functioning is an effective way to demystify what we are asking patients to engage in. Most patients are not going to enter the cognitive remediation environment with a clear set of expectations; by demonstrating the actual training exercises and linking baseline cognitive profiles with what is going to be trained, the therapist can help the patient make a link from deficit → training → goals. In an interesting recent study, Fiszdon and colleagues (manuscript in progress) found that a motivational interviewing procedure using the above-mentioned approach increased attendance across cognitive training sessions ten-fold, and resulted in very large (Cohen’s d = 1.3) improvement in a measure of intrinsic motivation, and treatment outcomes.

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