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Therefore, cognitive rehabilitation consists in an “intervention that focuses on improving cognitive functioning by applying repeated practice of cognitive tasks or by the training of strategies for compensating cognitive impairments” 106 . Over the last decade, different cognitive training approaches have been developed to improve cognitive impairments in people with schizophrenia, which have following different methods 106 . • Repetitive exercises of cognitive tasks presented in a computerised or paper and pencil version. • Compensatory strategies, which imply the learning of strategies to organise information (for example, categorization; or adaptative strategies, with use of reminders or other environment aids. • Behavioural and didactic learning techniques, such as positive reinforcement instructions, etc. These methods have been used alone or combined in different training programmes, such as: • IPT (Integrated Psychological Therapy), by Brenner et al {Brenner, 1994 1073 /id} • CRT (Cognitive Remediation Therapy), by Delahunty y Morice 112 • NEAR (Neuropsychological Educational Approach to Rehabilitation), by Medalia et al. 113 • CET (Cognitive Enhancement Therapy), by Hogarty et al 114 • CAT (Cognitive Adaptation Training), by Velligan et al 115 • NET (Neurocognitive Enhancement Therapy), by Bell et al 116 • APT (Attention Process Training) by Sohlberg & Mateer 117 • Attention Shaping, by Silverstein et al 118 • Errorless learning, by Kern et al 119 Question to be answered • Are cognitive rehabilitation interventions efficient in people with SMI and cognitive impairment? • Which is the most adequate format of these interventions for people with SMI and cognitive impairment? The NICE schizophrenia CPG 8 addresses this question and includes the systematic review by Pilling et al 47 , which also contains 5 RCTs. Furthermore, the NICE CPG development group adds another 2 RCTs, making a total of 7 RCT (n = 295). Roder et al 93 carry out a SR of 29 RCTs (n = 1367) where they compare Integrated Psychological Therapy (IPT) with standard treatment and/or placebo. The review differentiates 7 high-quality studies (n = 362) (of which only one is excluded in the NICE CPG 8 ), with controlled studies, including randomisation of patients to different treatment groups, fixed doses of antipsychotics or statistically controlled changes in medication, clearly defined blind assessments and complete explanation of the data of the different symptomatic and functional domains that were assessed. The data referred to in this evidence assessment related to this study will be the data from this high quality group of studies, unless specified otherwise. 12 RCTs are included (n = 543) in the SR by Krabbendam y Aleman 120 and the inclusion criteria of the studies were that they had to assess the efficacy of cognitive remediation in patients 70 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS
with schizophrenia and that the treatment should involve the practice or learning of cognitive skills in individual or group format. Those studies that assessed the impact of operating behavioural techniques such as modelling were excluded, except when some type of behavioural reinforcement was combined with cognitive remediation. Interventions limited to training in one single cognitive task were also excluded. The effects of the intervention were compared with placebo, another intervention or standard treatment. The training method must be different to the tests used to measure. Seven studies were excluded from this review as they did not include control condition (of which 4 had also been excluded by the NICE CPG 8 ), and 12 studies, because the intervention involved training in one single paradigm or the task training was also used as an assessment measure. In the meta-analysis performed by McGurk et al 121 , which included 26 RCTs (n = 1151), the studies included are controlled and randomised, and they use a psychosocial intervention aimed at improving the cognitive function. The assessment had to include neuropsychological measures that had the potential of reflecting generalisation, rather than assessing the trained task. The only RCT 122 included in this question combines data from 121 patients with schizophrenia or schizoaffective disorders, randomly assigned either to Cognitive Enhancement Therapy (CET) (n = 67) or to Enhanced Support Therapy (EST) (n = 54) and they are treated for 2 years. The patients were stabilised and satisfied social-cognitive and neuro-cognitive disability criteria to take part in the study. In the NICE Schizophrenia CPG 8 no consistent evidence was found to suggest that cognitive remediation improved the cognitive functions indicated or the symptoms in people with schizophrenia. It was also observed that the evidence was insufficient to determine improvements in the mental state at the end of the treatment, and suggest that patients with schizophrenia improve at the end of the treatment in areas such as visual memory, verbal memory, independent life or nonverbal reasoning. The final recommendation of that CPG is that there is not sufficient evidence so as to recommend the use of cognitive remediation in routine treatment of people with schizophrenia. However, subsequent reviews, which include more studies and more patients, seem to show more favourable results for cognitive rehabilitation. 26 articles were included in the review by McGurk et al 121 , of which two 123,124 were excluded from the NICE schizophrenia CPG 8 . Of the 7 articles included in the review made by the NICE CPG, 4 are included in the SR by McGurk et al 121 and a total of 14 RCTs are performed after the NICE CPG. There seems to be an overlapping of the studies included between the NICE schizophrenia CPG and the articles by McGurk et al 121 and Krabbendam & Alemán 120 , with greater study inclusion capacity in the last two perhaps because they apply less restrictive criteria, especially in the case of the study by McGurk et al 121 . The review by Roder et al 93 is worth a separate mention, as it deals with IPT, an integrated programme that includes cognitive rehabilitation, social skills and problem-solving strategies, and whose field is clearly different to the field framed by the NICE Schizophrenia CPG 8 . This CPG development group has chosen to use the three reviews mentioned above 93,120,121 as the basis, as they are more recent, including articles that had not been published when the NICE Schizophrenia CPG 8 was written, and because it addresses all types of psychosocial interventions aimed at improving cognitive functioning. There is no homogeneous theoretic framework about the way in which cognitive rehabilitation interventions improve cognition and social functioning areas, so the interventions incorporate CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 71
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Clinical Practice Guidelines for Ps
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This CPG is an aid for decision mak
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Table of Contents Presentation 7 Au
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Presentation Healthcare practice is
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Authorship and collaborators CPG de
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José Manuel Lalana Cuenca. Special
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c) SERVICE LEVEL INTERVENTIONS •
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A B A A B B B C Psychosocial inter
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B B B C A C C 5.3. SERVICE LEV
Page 22 and 23: 20 CLINICAL PRACTICE GUIDELINES IN
Page 24 and 25: independence, quality of life, pers
Page 26 and 27: This guideline is aimed at mental h
Page 28 and 29: Figure 1. Search Strategy Search fo
Page 30 and 31: The highest evidence level found wa
Page 33 and 34: 4. Characteristics of the CPG 4.1.
Page 35 and 36: The main focus of rehabilitation is
Page 37 and 38: 5. Psychosocial type rehabilitation
Page 39 and 40: From another point of view, social
Page 41 and 42: defined as “standard care” or
Page 43 and 44: General global state In the short r
Page 45 and 46: Specific symptoms: when CBT was com
Page 47 and 48: In the systematic review by Kurtz a
Page 49 and 50: Summary of evidence 1- 1- 1- 1- 1-
Page 51 and 52: People with SMI and a diagnosis of
Page 53 and 54: 5.1.3. Interpersonal therapy The li
Page 55 and 56: weekly or fortnightly sessions. The
Page 57 and 58: 5.1.5. Family interventions There a
Page 59 and 60: In the RCT carried out by Hogarty e
Page 61 and 62: A family intervention of more than
Page 63 and 64: After two years’ treatment, and b
Page 65 and 66: Family intervention vs. other psych
Page 67 and 68: 1- 1- 1- 1- 1- 1- 1- 1- 1+ No diffe
Page 69 and 70: Question to be answered • Are pys
Page 71: Summary of evidence Pyschoeducation
Page 75 and 76: With reference to the type of train
Page 77 and 78: would normally receive and which in
Page 79 and 80: Hypnosis vs. relaxation No improvem
Page 81 and 82: Supervised fl ats are a community h
Page 83 and 84: 3 Programmes directed to leisure an
Page 85 and 86: SMI (schizophrenia, affective schiz
Page 87 and 88: When PVT is compared with standard
Page 89 and 90: Patients included in the individual
Page 91 and 92: 1+ 1+ 1++ 1+ 1+ 1+ 1+ The people in
Page 93 and 94: Music therapy Music therapy + stand
Page 95 and 96: A series of Case Management systems
Page 97 and 98: • The satisfaction data originati
Page 99 and 100: Loss of contact With respect to the
Page 101 and 102: There is not sufficient evidence, e
Page 103 and 104: 1+ 1+ 1+ 1+ Respect to ICM teams or
Page 105 and 106: Finally, in the RCT by Cheng et al
Page 107 and 108: 5.4.2. “Homeless” with SMI The
Page 109 and 110: Patients who access housing with no
Page 111: ceptive disorders. This series of c
Page 115 and 116: 7. Recommendations for Future Resea
Page 117: Appendices
Page 120 and 121: Appendix 2. Information obtained fr
Page 122 and 123:
Appendix 4. Information for people
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4. Regulatory and legal framework 1
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Several protocols have been publish
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The coordination of these resources
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Social protection systems Pursuant
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Specifi c regulation • (SPANISH)
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Service Management: The first anti-
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on Mental Health and the future Eur
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Spanish Society of Legal Psychiatry
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Appendix 5. Abbreviations ACT Asser
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Appendix 6. Glossary Therapy adhere
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Appendix 7. Declaration of interest
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15 Rossler W. Psychiatric rehabilit
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53 Graeber DA, Moyers TB, Griffi th
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86 Schooler NR, Keith SJ, Severe JB
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117 Sohlberg MM, Mateer CA. Effecti
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154 López M, García-Cubillana P,
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190 Bond GR, Drake RE. Predictors o
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225 Hurley AD. Individual psychothe
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