CPG for Psychosocial Interventions in Severe Mental ... - GuíaSalud

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