Metacognitive Remediation Therapy

Transcription

1 Metacognitive Remediation Therapy

2 Global Burden of Disease Study 2010 Illness/Injury Disability Weight Schizophrenia: Acute State Multiple Sclerosis: Severe Spinal Cord Lesion at Neck: Untreated Epilepsy: Severe MDD: Severe Episode Heroin/Other Opioid Depend TBI: Long Term Consequences Severe Musculoskeletal Problems: Severe Schizophrenia: Residual State End Stage Renal Disease: On Dialysis Salomon et al., 2013

3 Disease-Related Burden of Psychotic Disorders Symptomatology 1% 3 Moe et al., In Progress

4 100% Prevalence of Cognitive Deficits in Schizophrenia 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Cognitive Deficits (Keefe et al., 2005) Hallucinations (Breier et al., 1999) Tobacco Us (de Leon et al., 2005) Any Negative Symptom (Bobes et al., 2010) Non-Tobacco Substance Use (Swofford et al., 2000) Delusions (Breier et al., 1999) Thought Disorder (Breier et al., 1999) 4 Breitborde et al., 2016

5 Severity of Cognitive Deficits in Schizophrenia Meshalom-Gately et al., 2009

6 Cognitive Contributions to Work Performance Work Habits Personal Presentation Cooperativeness Work Quality Cognitive Factors 6 Bell and Bryson, 2001; Adapted from Wykes, 2011

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8 Glutamate and Dendritic Sprouting Smith et al., 1992

9 Pharmacological Treatments for Cognition Effect Size (Cohen's d ) Antipsychotics (Keefe et al., 2007) d-cycloserine (Buchanan et al., 2007) Glycine (Buchanan et al., 2007) Galantamine (Buchanan et al., 2008) Practice Effect (Goldberg et al., 2007) Duckworth et al., 2013

10 Cognitive Remediation Produces improvements in cognition (d = 0.45) and functioning (d = 0.42) among individuals with schizophrenia Effect on cognition is greater when paired with psychosocial interventions (d = 0.59) than when delivered alone (d = 0.28) Effects are durable after treatment completion Wykes et al., 2011

11 Frontal Lobe Functioning after Cognitive Remediation Wexler et al., 2000

12 Frontal Lobe Functioning after Cognitive Remediation Ramsay et al., 2015

13 Cost Savings of Cognitive Improvement Reeder et al., 2014

14 Limitations of Cognitive Remediation

15 Partial Remediation of Cognitive Deficits Percent Overlap = 82%

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19 Improving Cognitive Remediation: Targeting Metacognition Cognitive abilities can be enhanced through improving metacognitive awareness/abilities (Schraw et al., 2006) Metacognition Metacognitive abilities may moderate association between cognitive functioning and real-world functioning (Koren et al., 2006) Knowledge of Cognition Regulation of Cognition

20 20 Breitborde & Moe, 2016

21 Metacognitive Remediation Therapy Individual therapy as opposed to drill and practice Cognitive remediation exercises from PSSCogRehab (Bracy, 2008) Therapist-guided metacognitive discussion Develop metacognitive abilities/awareness Apply skills to real-world situations

22 MCR Sessions Metacognitive Discussion i. Review of Knowledge of Cognition with Regard to the Activity ii. Exploration of Intervening Factors that May Interfere with or Enhance Task Performance iii. Identification of Strategies to Enhance Regulation of Cognition During Task Completion iv. Real-World Application of Skills 22

23 Does MCR Produce Improvements in Metacognition? Total Score Breitborde, 2015 * * * Knowledge of Cognition *p < 0.05 Regulation of Cognition Baseline 6-months

24 Cognitive Functioning: CCR MCCB T-Score * * * * Baseline 6-Months * p < 0.05 Breitborde et al., 2015a

25 Cognitive Functioning: MCR MCCB T-Score * * * * * * * Baseline 6-Months * p < 0.05 Breitborde et al., 2015a

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28 Social Functioning: CR * * SFS Baseline 6-Months * p < 0.05 Breitborde et al., 2015a

29 Social Functioning: MCR * * * * * * * SFS Baseline 6-Months * p < 0.05 Breitborde et al., 2015a

30 100% MCR and Educational/Vocational Functioning 90% 80% 70% 60% 50% 40% 30% Unemployed / Not in School Employed / In School 20% 10% 0% Baseline At Present McNemar s Χ 2 = 4.00; p < 0.05

31 Breitborde et al., 2015b Cost of Care

32 MCR Cost Savings Per Person Cost Savings $40, $35, $30, $25, $20, $15, $10, $5, $0.00 No Cognitive Intervention Cognitive Intervention 32

33 MCR Cost Savings $40, * Per Person Cost Savings $35, $30, $25, $20, $15, $10, * No CR CCR MCR $5, $0.00 * p <

34 34 Demonstration

35 Integration with WRAP/Recovery Model Wellness Recovery Action Plan Evidence-based treatment to engage people in their treatment and recovery Introduced to Harding Inpatient Units in

36 Evolution of Inpatient Treatment of Psychosis at Harding Hospital New services introduced since 2016 at: WRAP/Recovery Groups Social Skills Group Intervention Individualized Behavior Plans Brain Games Group MCR 36

37 MCR Delivery in Inpatient Setting Recent modification and implementation of MCR in inpatient psychiatric unit at OSU Harding Hospital Exercises and discussion focused around reducing impulsivity and related factors (e.g., sustained attention) Goal is to reduce incidents of violence on inpatient unit 37

38 MCR Delivery in Inpatient Setting Unable to offer service to all individuals due to staffing limitations Individuals identified as at elevated risk for aggression/violence given priority for MCR Referrals made directly by inpatient staff or during behavioral planning sessions 38

39 MCR Delivery in Inpatient Setting Referred individuals approached daily and offered option of participating in 30 minute MCR session Should they decline, session is offered to other individuals to ensure staff productivity 39