Effects of a Multifaceted Cognitive Remediation Program on Cognitive Abilities in Patients with Schizophrenia: A Mixed Methods Study

doi:10.21203/rs.3.rs-3888601/v1

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Effects of a Multifaceted Cognitive Remediation Program on Cognitive Abilities in Patients with Schizophrenia: A Mixed Methods Study

https://doi.org/10.21203/rs.3.rs-3888601/v1

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Introduction

Cognitive remediation is an effective treatment for deficits in schizophrenia. A multifaceted cognitive remediation programme (MCRP) including relaxation, orientation, attention, memory, executive function, and social participation may promote cognitive function. This study aimed to investigate the effects of MCRP on cognition and the experiences of patients with schizophrenia.

Methods

Using mixed methods, a randomized controlled trial was implemented. The experimental group (n = 10) underwent MCRP for 12 sessions (3 days/week for 4 weeks) and conventional occupational therapy (OT), while the control group (n = 10) only received conventional OT. The dynamic Lowenstein occupational therapy cognitive assessment (DLOTCA) was used to evaluate the outcomes. A Mann–Whitney U test was used to calculate group differences. MCRP group demonstrated better outcomes in the orientation (p = 0.005) and verbal mathematic questions (p = 0.003) compared to the control group. A Wilcoxon signed-rank test was used to compare the before and after outcomes within the same groups.

Results

The MCRP group showed significant differences in orientation, visual perception, visuomotor construction, and thinking (p ≤ 0.05), while the control group only exhibited significant differences in visual perception (p ≤ 0.05). In the phenomenological study, nine participants in the MCRP group were interviewed through semistructured interviews and analyzed using thematic analysis. Five themes emerged: (1) understanding insight into activities and rehabilitation; (2) interest in and satisfaction with performing activities; (3) level of performance when performing activities; (4) management skills suitable for one's context; and (5) engagement in activities with others.

Conclusion

This study could provide information on implementing combined intervention-incorporated occupational therapy to improve cognitive function in patients with schizophrenia.

Trial registration

ClinicalTrials.gov, TCTR20190123002, Registered January 23, 2019

Schizophrenia

Cognitive rehabilitation

Occupational therapy

Mixed methods

Schizophrenia is a chronic neurobiological illness that repeatedly impacts individuals’ cognitive, psychosocial, and work-related abilities, resulting in serious mental impairment [1]. It is known for its symptoms, such as blunted emotions, disordered speech, hallucinations, delusions, reality detachment, low motivation, and inadequate planning [2]. Schizophrenia is a lifelong condition that affects more than 20 million individuals globally [3]. While the disease course is constant, psychotic episodes are known to occur, particularly during moments of loss or change [4]. Clients with schizophrenia often face stress and chronic disabilities, and the stigma and discrimination related to these conditions can negatively affect their quality of life and that of their families [5].

In Thailand, the Department of Mental Health reported that schizophrenia was the most common mental disorder in 2021 and 2022, with 284,273 and 314,250 recorded cases, respectively [6]. Patients with schizophrenia may struggle to understand the consequences of their actions and may live isolated lives, often lacking social engagement [7]. The typical time for a client to receive treatment for schizophrenia is during an active phase characterized by psychosis, typically manifested as hallucinations and delusions [8]. Antipsychotics are the primary treatment for those with schizophrenia [9]. However, mental health services also provide comprehensive interventions that involve multiple healthcare professionals, including occupational therapists, to address the psychosocial and cognitive impairments experienced by these patients [10].

A decrease in these cognitive skills can result in difficulties in basic and advanced daily activities such as activities of daily living, work, learning, leisure activities, and rest [11]. These impairments have a significant impact on patients and their families, especially patients with mental illnesses. To address these cognitive impairments, occupational therapy services, including activities such as handcrafting, art, woodworking, gardening, and music therapy, are provided. These activities are considered the result of the rehabilitation process and aim to improve patients’ cognitive skills and quality of life [12]. Occupational therapy is based on the utilization of meaningful occupations, considering physical, psychological, cultural, spiritual, and social aspects and contexts [13]. Clients with schizophrenia face not only psychological issues but also the challenges of inpatient hospitalization expenses, job loss, disrupted education, and homelessness, which can negatively impact their physical health [14]. Engaging in purposeful activities and meaningful occupations can enhance physical and mental well-being and lead to improved health outcomes for those with schizophrenia [15].

In general, patients with this condition receive assessments and rehabilitation to promote their skills and abilities in daily life and activities. Patients with mental illness exhibit cognitive impairments, particularly in terms of processing speed, attention/vigilance, working memory, verbal and visual learning and memory, reasoning and problem solving, and social cognition [16]. Cognition refers to the act of acquiring knowledge and encompasses several steps, such as the ability to identify relevant information, retain and understand it, and apply it in a suitable context. Cognitive impairment can manifest as a decline in processing speed, decreased efficiency in performing daily tasks, or difficulty adapting to new or challenging situations [17]. Using cognitive strategies, individuals gain a deeper understanding of themselves and their surroundings. The ability to comprehend and verify daily life information about people and events is facilitated by social cognition [18].

The trend in providing cognitive skill training programs for individuals with mental illnesses in other countries has been shown to be beneficial for improving cognitive function and understanding. A review of the literature indicates that there have been developments and studies on the effectiveness of cognitive training programs for individuals with mental illnesses in the form of neurocognitive training, social cognitive training, emotion perception training, and combined training. The type of rehabilitation chosen depends on the specific cognitive impairment of the individual with a mental illness [19]. Schizophrenia is related to neurocognitive deficits [20]. Cognitive remediation (CR) is an evidence-based practice for increasing neurocognitive processes and real-life activities in people with schizophrenia [21].

There are two types of training methods for CR, namely, bottom-up and top-down approaches. The bottom-up approach enhances component cognitive abilities, such as sensory discrimination, perceptual processing, and attention, which are linked to higher-order cognitive dysfunctions, including complex functions, executive functions, and metacognition. These abilities are improved through individual or group sessions [22]. This approach focuses on areas of cognition that may be compromised to boost cognitive functions. In this type of training, drill-and-practice and strategy-based techniques gradually increase in difficulty as a person's performance improves [23]. Various studies have shown the efficacy of drill-and-practice restorative cognitive remediation for improving cognitive deficits [24, 25]. An instance of a drill-and-practice exercise involves repeatedly displaying a series of numbers on a screen that participants must reproduce accurately in the correct order. As participants succeed in this task, the level of difficulty gradually rises, allowing for progressive cognitive improvement.

On the other hand, the top-down approach emphasizes the enhancement of higher-order cognitive functions while also training the component cognitive abilities. This approach should involve real-life activities or work-related contexts rather than focusing solely on specific cognitive domains [26]. This CR programme involves compensatory cognitive training that employs as well as strategy coaching to enhance effectiveness [27]. This approach helps patients learn how to apply newly acquired cognitive skills and habits in their daily lives. For instance, they may use a planner to keep track of appointments and tasks. Compensatory cognitive skills and habits are intended to extend their benefits to real-life situations and outcomes [28].

According to Ahmed et al. [29], cognitive remediation therapy (CRT) in patients with schizophrenia in the United States resulted in reductions in negative symptoms, agitation/excitement, emotion dysregulation, and verbal and physical aggression. Moreover, CRT can improve neurocognition in long-term hospitalized forensic patients. Consistent with Bowie et al. [20], cognitive remediation for schizophrenia and other severe mental illnesses has undergone significant development in the past few decades. Despite some variations in various programs, a team of specialists has pinpointed core elements of cognitive remediation. These include therapist-led support, practicing cognitive exercises, integrating cognitive and problem-solving strategies, and incorporating methods that facilitate the transfer of cognitive abilities to real-life functioning.

In Thailand, cognitive remediation and vocational rehabilitation services are combined for individuals with severe mental illness. The existing evidence indicates that individuals who concurrently receive both cognitive remediation and vocational intervention tend to exhibit better cognitive functioning, including attention and working memory, as well as better work-related outcomes, than do those who only receive vocational intervention [30]. According to Wannasework [31], cognitive remediation therapy (CRT) has been implemented for job seekers with neuropsychiatric disorders. The study demonstrated that the use of CRT enhanced the cognitive processes of the participants, resulting in better cognitive performance and improved employment-related outcomes. This study is based on cognitive training programs [32] that have been found to be effective for stroke patients. Stroke patients who engaged in the program showed significant improvements in four cognitive abilities: orientation, attention, memory, and executive functions (p ≤ 0.05). This cognitive training program was utilized in an experimental design and subsequently as a common method of treatment for stroke patients and for mental disorders in general, including schizophrenia.

In Thailand, few evidence-based studies have been carried out regarding cognitive rehabilitation for patients with schizophrenia. We implemented an MCRP that integrated cognitive remediation with essential life skills, such as orientation, relaxation, attention, memory, and executive function, as well as social cognitive training that emphasized interactive learning, social interaction, and adaptation to society. Hence, the MCRP is a comprehensive rehabilitation tool that encompasses various aspects of cognitive development and utilizes appropriate tools and assessments that are well suited for the Thai context.

This study explored the effects of MCRP and the experiences of patients with schizophrenia. The explanatory sequential mixed methods design [33] involved collecting quantitative data and then explaining the quantitative results with in-depth qualitative data. In this study, qualitative findings were used to explain and interpret primarily the results of the quantitative study. This study provided a deeper understanding of the quantitative outcomes that were reflected in the findings of clients with schizophrenia. Participants were selected from a mental health hospital in Bangkok using a randomized controlled trial. These methods were prospective studies that measured the effectiveness of MCRP intervention. A qualitative interpretation could provide insight into how people with schizophrenia perceive the use of MCRP that emerged from this intervention. Ethical approval for this study was obtained from the Institutional Review Board, Department of Mental Health, Ministry of Public Health (DMH.IRB.COA007/2562), and Mahidol University Central Institutional Review Board (MU-CIRB 2018/251.1712). The trial is registered under www.clinicaltrials.org/show/TCTR20190123002. Written informed consent was obtained from legally authorized representatives before the study.

Participants

The participants were limited to patients with schizophrenia. In Thailand, the Thai Government defined six target groups: pregnant women, postpartum women, children aged 0-5 years, adolescents aged 6-17 years, adults aged 18-59 years, and seniors (60 years and older) [34]. The inclusion criterion for adults was a diagnosis of schizophrenia, a mental illness affecting adult males or females aged 18 to 59 years, by a psychiatrist. The sample group was in the recovery phase, as assessed by the psychiatrist using the Brief Psychiatric Rating Scale, for which the score was lower than 30 points. This confirmed that patients with schizophrenia could answer questions and participate in various activities [35]. The psychiatrist's evaluation also included an assessment of the patient's mental state, which revealed that the patient was calm and not overwhelmed, worried, or depressed. The participants never received treatment with electroconvulsive therapy and could read and write in the Thai language. Patients were scored ≤ 17 points on the Mini-Mental State Examination-Thai version (MMSE-Thai, 2002), indicating impaired cognitive function [36].

The exclusion criteria for this study were participants who were receiving treatment with drugs that affect cognitive ability, such as donepezil, rivastigmine, galantamine, and memantine; psychotropic drugs that cause drowsiness, such as chlopromazine and thioridanzine; or drugs that have side effects on motor function, such as flupentixol, fluphennazine, haloperidol, perphenazine, trifluoperazine, and zullopenthixol. Additionally, participants with acute exacerbations during the study period were excluded.

Data gathering

This study used mixed methods with an embedded design and two methods. With respect to the quantitative method, a randomized controlled trial was implemented. In this study, four occupational therapists who work with mental illness clients were recruited from a mental health hospital. Two occupational therapists were trained to administer the MCRP intervention. Therefore, twenty participants with schizophrenia were randomly assigned to an experimental group (MCRP group) or a control group. For the MCRP group (n=10), participants received MCRP for 12 sessions (three days/week for four weeks) and conventional occupational therapy daily for 45 minutes from two occupational therapists. A portion of the control group (n=10) received conventional occupational therapy administered by two occupational therapists. Before participating in either intervention, participants signed consent forms and were informed that the study was for research purposes.

Quantitative procedure

Intervention program

The MCRP was adapted and tailored to the needs of patients with psychiatric disorders, and various activities were designed, based on reviews of the literature, to stimulate and train neurocognitive and social cognitive skills using a combined approach. The programme included various individual and group interventions aimed at enhancing neurocognitive and social cognitive skills.

The MCRP’s core content utilized a blend of restorative and adaptive approaches, as well as educational interventions, and included the following strategies and activities:

Education was provided to a sample group about cognitive impairments and their impact on daily life activities and occupations, including basic and advanced daily routines, work, learning, leisure activities, and rest.
Activities about exercise drills, paper–pencil tasks, table-top activities, games, or activities that aim to enhance cognitive skills related to orientation, memory, attention, and executive functions.
Various strategies are taught to improve cognitive skills related to orientation, memory, attention, and executive functions.
The program's activities were adjusted to suit each sample group by using activity analysis and synthesis. The format of the activities, aimed at promoting thinking and understanding skills, became more challenging and complex based on the sample group's increased abilities.
The use of social participation skills through group activities or games played together, as well as team sports.
Environmental modification to make the program suitable for activities. This is related to participation in occupational therapy activities. In this regard, therapists consider and identify which context and environment are related to an occupation that can promote or hinder engagement in activities [37].

The use of an MCRP aims to improve and restore cognitive skills that are inadequate. This approach involved the use of a comprehensive treatment program that covered 37 different activities spread across eight domains, namely, orientation, attention, memory, relaxation, concentration, executive function, and social participation, as indicated in Table 1. A schedule showing each activity and session three times a week for four weeks. The program was administered, resulting in a group of participants who participated in the intervention. As part of the assessment and evaluation process, this study was evaluated by an occupational therapist who acted independently as a blind assessor.

Table 1. A multifaceted cognitive remediation program for participants with schizophrenia

Statistical analysis

The data were analyzed using SPSS version 25.0 for Windows. To assess the assumption of normality, the Shapiro–Wilk test was used. The results of the test indicated that the data were not normally distributed. Therefore, nonparametric tests were conducted to compare the pre- and postintervention test scores between the MCRP group and control group. The Mann–Whitney U test was used to compare the differences between groups (p ≤0.05). The Wilcoxon signed-rank test was performed to compare the scores of individuals in both groups before and after the intervention (p ≤ 0.05).

Qualitative procedure

The qualitative phenomenological study, via semistructured interviews, explored contributing factors through the experiences of clients with schizophrenia who used an MCRP. Research design, methodology and methods alignment, rigor strategies, and analytical lens were all considered in this study.

Interview

The interview questions were designed and drawn from participants who used MCRP. We developed interview guidelines through iterative processes. A pilot interview was conducted prior to implementation. To validate the pilot questions, the researcher ensured that the study's setting, participant selection, and interview methods aligned with the study's objectives. Mock interviews were designed to reflect the content and concepts of the study, and pilot participants were chosen via an interview process. Each question included prompts to encourage further discussion. Pilot study feedback and participant feedback were useful in refining and revising the semistructured interviews. The interviews were conducted by a research assistant who was instructed on the interview techniques. In an isolated room, the trainee practiced a mock interview for 45 to 60 minutes. This mock interview served not only as an evaluation of the interviewer's skills but also as an opportunity for the research assistant to practice and receive feedback. The researcher validated the pilot questions by ensuring that the study's setting, participants who were experiencing the use of MCRP, and interview methods were aligned with the goals. The participants signed consent forms before the interview and were informed that voice recordings had been recorded for research purposes. We used pseudonyms to identify participants and kept private information confidential. A single interview was conducted with participants in a quiet area of the mental health hospital. The semistructured interviews included the following:

Orientation: (i) During your rehabilitation program with occupational therapists in the past, what activities did you participate in? (ii) How much time do you spend practicing these activities? What time of day do you typically practice them? (iii) Can you tell me which building (or building) is used to hold the rehabilitation activity?
Attention: (iv) As you participate in your rehabilitation program, what games or activities do you enjoy the most? (v) Why do you enjoy that game or activity? (vi) How do you motivate yourself to engage in an activity when you recognize its importance and have an interest in it?
Memory: (vii) Which rehabilitation activities or games do you consider simple and easy to perform? (viii) Is there a rehabilitation activity or game you find particularly challenging and have difficulty performing? Can you tell me which specific activity it is?
Executive function: (ix) Can you adjust your approach to challenging activities or games to best suit you? Do you have any ideas on how to do so? (x) Can you tell me how you plan to address this problem?
Social participation in activities: (xi) Is there any rehabilitation activity or game that you enjoy most when you are played with friends? (xii) As a group member, what did you do to contribute to group activities?

Qualitative analysis

The qualitative inquiry was guided by thematic analysis, which involved audio recording and transcription of one-time, semistructured interviews. Using Braun and Clarke's six-step approach for thematic analysis, the qualitative data were analyzed (4). This analytical process involved six steps: 1) becoming familiar with the data, 2) generating initial codes, 3) searching for themes, 4) reviewing themes, 5) defining and naming themes, and 6) producing the report. To analyze the data, the transcriptions were read thrice to extract the meaning shared by the participants concerning the MCRP. Initial codes were generated based on the meanings conveyed from the texts, phrases, and sentences. The codes were then organized into initial themes, which were connected or separated through an iterative analytical process to develop final themes. Quotations were identified, named, and defined to support the themes and subthemes. Finally, the authors reviewed whether the themes addressed the research aim.

Rigor and trustworthiness

We strengthened the credibility, transferability, dependability, and confirmability of the findings in this study [38]. To achieve triangulation, interviews were conducted with nine participants, ensuring credibility was upheld. Research assistants followed specific guidelines during these interviews. To ensure transferability, the study provided a comprehensive description of the sample, setting, interview questions, and results. Dependability was established through multiple researchers who participated in the data analysis and peer debriefing, where the first author discussed emerging insights with the interviewing author during the data collection. Member checking was also performed, with the researcher revisiting participants to confirm that identified themes aligned with their experiences and intentions, which all participants verified.

Confirmability was achieved through recording and transcribing all interviews, documenting meetings between researchers discussing coding and themes, and holding a final decision-making meeting among all the researchers. This approach allowed external researchers to understand the reasoning behind the findings. Additionally, the study's trustworthiness was enhanced by a thorough translation process that provided more accurate data. This approach promoted inclusiveness, consistency, and transparency in the analytical process [39]. The researcher considered the challenges of translation, maintaining semantic equivalence with both realistic and textual meanings.

This study examined potential translation-related problems that might interfere with trustworthiness. Word-for-word transcripts were analyzed in the native language (Thai), translated into English [40] and checked by two academics fluent in both Thai and English. When translating and analyzing the data, we considered the challenges of translation. To maintain semantic equivalence with realistic and textual meanings, linguistic differences are important; for example, an expression that may exist in one language may not be present in another [41]. A trustworthiness audit trail was created by our research team to provide support for interpretations and analyses [42].

In addition, an adequate translation contributes to the trustworthiness of the study since it contributes to accurate data collection, inclusivity, consistency, and transparency during the analytical process [39]. As part of increasing data transferability, the research team documented the process and peer-reviewed the transcripts. Three independent reviewers spent a significant amount of time on data translation, illustrating the rigor of the research. Moreover, participants were invited to validate the findings by confirming or suggesting variant meanings that could then be incorporated into the final statement.

In this study, a total of twenty individuals diagnosed with schizophrenia were recruited. The patients were randomly assigned to either the control group or the MCRP group. Table 2 presents their general characteristics. In the control group, there were 9 males and 1 female, with a mean age of 37.4 ± 6.1 years. For the MCRP group, there were 8 males and 2 females, with a mean age of 45± 10.1 years. The participants' cognitive function was assessed using the MMSE, and there was no significant difference observed between the control and MCRP groups. Furthermore, no significant differences were found between the two groups regarding their baseline general characteristics.

Table 2. Baseline demographic characteristics of the control and MCRP treatment groups.

The Wilcoxon signed-rank test was used to compare the pre- and postintervention results within the control group. The analysis demonstrated significant differences in the DLOTCA subtests specifically associated with visual perception (p < 0.05). However, no significant differences were observed in other subtests within the control group, including orientation, awareness of the reason for hospitalization, awareness of cognitive disabilities before and after testing, spatial perception, praxis, visuomotor construction, thinking operations, verbal mathematical questions, or ROC structured tasks. In the MCRP group, there were significant differences in the scores on the DLOTCA subtests related to orientation, visual perception, visuomotor construction, and thinking about the operation (p < 0.05), as indicated in Table 3.

Table 3. D-LOTCA scores in the control group (n=10) and MCRP group (n=10) based on the pretest and posttest.

The Mann‒Whitney U test was utilized to compare the MCRP and control groups. The analysis showed significant differences in the DLOTCA scores on the subtests of orientation and verbal mathematics questions (p < 0.05), as indicated in Table 4.

Table 4. The LOTCA scores of the MCRP and control groups before and after the assessment.

The quantitative results presented above led to a qualitative analysis of the challenges. A total of nine participants who had undergone the MCRP were willing to be interviewed within two weeks of completing the follow-up visit, as shown in Table 5. The qualitative data obtained from these interviews revealed five distinct themes: understanding insight into activities and rehabilitation, interest in and satisfaction with performing activities, and level of performance when performing activities.

Table 5. Demographic characteristics of the MCRP participants in the individual interviews

Management skills are suitable for one's context, and engagement in activities with others. Analysis guided by these themes provided further explanation of the relevant concepts identified by the participants. The use of pseudonyms or pretend names for confidentiality was implemented in the findings. These findings are presented in Figure 1.

Theme 1: Understanding insight into activities and rehabilitation

Understanding insight refers to an individual’s continuous ability to receive and process information about time, location, and other people. It is a skill that relies on both interest and memory. In this context, it involves the acquisition of knowledge about rehabilitation through an MCRP. This includes perceiving information about rehabilitative activities and the locations where they take place. Mok described how he engaged in activities to reflect his understanding of his experiences:

“We engaged in playing Bingo and Mount Everest, as well as keeping up with the news through reading newspapers. Additionally, we expanded the body of knowledge about memory and mathematics. We enjoy listening to various types of music, including Thai genres, and challenge ourselves with jigsaw puzzles.” (Mok)

Similarly, Kaew recounted her understanding of activities and rehabilitation in which she had used the various activities and how to engage in these kinds of therapeutic media.

“I engaged in a variety of activities, including linking images, letters, and pictures of various vehicles such as cars, airplanes, trains, and rivers. We also played Bingo, read news articles, and summaries.” (Kaew)

Pradu's account highlighted the importance of considering the environmental conditions and timing of engaging in activities and rehabilitation at an occupational therapy clinic in a practical rehabilitation context. He stated:

“I have been practicing doing activities, and if I practice in the morning, I will not practice in the afternoon. Similarly, if I practice in the afternoon, I will not practice in the morning. Additionally, I had the opportunity to practice activities at a rehabilitation center, which was a great experience for me” (Pradu).

As part of rehabilitation, these activities provide support to participants. A variety of therapeutic activities for cognitive rehabilitation involve engaging participants at different levels of engagement and reflecting different preferences and understandings. There were valuable insights shared by participants regarding the rules and duration of the game and activities.

Theme 2: Interest in and satisfaction with performing activities

The capacity to concentrate on certain things while selectively receiving information is what defines interest. This process allows individuals to filter out irrelevant information and identify experiences that are necessary for their life. When individuals are deeply interested in a certain activity, they can make decisions and reflect which activities are the most satisfying. Based on interviews about preferred activities, it was found that each patient has different activities they enjoy and reasons for doing them. Through their interest in these activities, it can be seen how important the activity is in promoting their satisfaction. This is evident in Inthinin’s responses.

“I continue to practice jigsaw puzzles, and when I complete a picture, I feel victorious. It makes my brain work and improves my cognitive abilities. Practicing this activity helps my brain function better and prevents anxiety.” (Inthinin)

According to Kajorn, another participant in the MCRP, he found value in playing Bingo as a practice activity. He enjoyed it more than any other activity offered in the program and commented on the benefits it provided. He expressed positive feelings about how the game increases his abilities.

“I enjoy and love playing Bingo. I pick numbers and arrange them according to the ones announced by the caller. It feels like my brain is working well when I play, and it helps me to improve my abilities. (Kajorn)

Another participant was interested in cooking photographs and cooking activities. Cooking different menus was a passion for Mok, and the cooking activities provided a means to engage in this passion, as evident from the interview excerpts below.

“I enjoy cooking because I love selecting different menus to prepare. Some dishes I have made before at home. Familiarizing myself with cooking techniques and ingredients and following each step of the recipe helps to enhance my memory recall.” (Mok).

As illustrated in the above section, rehabilitation involves activities that bring satisfaction and interest. Most participants expressed their favorite games and activities, good experiences, and enjoyment in different ways.

Theme 3: Level of Performance when Performing Activities

The ability to remember information can occur when input enters the memory system in the brain. When memory is maintained, it may result in various behaviors. Memory is defined as the ability to recall or recognize past information that has been stored in the brain (Paller & Wagner, 2002). As a result, participants with schizophrenia who have undergone MCRP therapy can demonstrate their memory ability through the activities they are able to perform and the challenging activities they can undertake. After completing all twenty activities in the MCRP program, participants were able to reflect on their memory of the activities they were able to perform and provide reasons for their recollection. As Boonnak expresses,

“I played a very entertaining game called ‘Bingo’ using a four-square grid. All I need to do is remember the numbers called out by the announcer and place them on your grid. This game does not involve complex calculations, making it a fun and easy activity for everyone.” (Boonnak)

Part of Pradu's story is similar in terms of what motivated her to memorize. It was discovered that playing games involving letter images and sounds of letters helped her to practice memorizing images or words. She learned and participated in these activities to enhance her memory, as described in the following section:

“Well, there are games like Letter Images and Sounds of Letters that require relying on memory because I must remember all the announcers' names and then recall them. It feels difficult because I must remember, but it is also fun and challenging.” (Pradu)

According to Pai, he identified some barriers concerning his engagement in activities. This involved difficulty with his attention span and memories when games became challenging. The maze game encouraged him to increase his skill and performance in dealing with challenges, as he expressed:

“I think that the maze game presents a significant challenge due to its complexity. I need to analyze an image and find a way out by drawing a line from the starting point to the exit point. There are five images to complete, and it requires both concentration and attention to detail” (Pai).

As revealed in the above quotes, participants developed skills and abilities through various games and activities. As a result of the games and activities they participated in as part of the challenge, they were able to use many senses to meet the challenge, affecting their learning abilities. Participants adapted as best as they could and still identified many related obstacles in the games and shared them with friends.

Theme 4: Management skills suitable for one's context

Individuals utilize critical thinking, problem solving, planning, and other diverse skills to accomplish successful outcomes in various activities. This process is demonstrated or performed through the process of intellectual reasoning. Interviews with participants revealed that they shared experiences of problem solving or adjusting activities to fit their context using diverse methods that differed among individuals and activities. Jaran was a participant whose account showed relevant links between management skill and circumstance:

“I planned how to make it come out well by taking notes. I noted which topics to address first and the various issues to cover. After reading, I also made notes. Therapists provided me with a paper note, which I used to write it.” (Jaran)

From the account of another participant, Kem, it seemed that she had found a solution. When confronted with a complicated task that she could not perform, Kem searched for solutions or steps to follow. Her usual approach was to tackle the problem gradually and seek help from fellow participants or the facilitator.

“I attempted to solve the problem on my own initially, but if my efforts were unsuccessful, I sought assistance from friends and therapists who could do it. Sometimes, I had to learn through trial and error. If I truly could not do it, I would ask for advice from someone who had succeeded and then apply it to myself” (Kem).

It is evident from the above section that the quotes involve solving problems and managing participants to participate in both individual and group activities. Various games and activities help participants in difficult situations and encourage them to find solutions. It is possible for participants to choose techniques for overcoming obstacles.

Theme 5: Engagement in activities with others

Engaging in group activities with others is considered a training activity to develop social skills in participants with social cognition impairments. Group activities provide an opportunity for participants to improve their social participation skills by helping them collaborate, helping each other, and sharing experiences. Additionally, participants expressed their emotions about their involvement in group activities and games, which serves as a valuable means of promoting the development of social skills. Pai’s interview regarding his emotional state after participating in group activities revealed that there was an activity in which he had collaborated with others and that brought him happiness, as stated in the following comment:

“I participated in a group activity that involved reading newspapers with my friends. I enjoyed it and felt that we were able to share our emotions and actively listen to each other's news stories. My friends also paid attention when I shared my news with them. Most importantly, this activity helped us become more aware of various important events that were taking place.” (Pai)

Similarly, Mok's experience involved playing a game with a team where he collaborated with others and developed a sense of teamwork while attempting to solve problems. This experience promoted a feeling of unity within the team, as he worked together with his friends to overcome the challenges in the game or activity and achieve success.

“I enjoy group games and activities that involve teamwork to solve problems. My friends and I collaborate to solve challenges within our group, which allows us to understand each other's perspectives. We do not divide ourselves and have fun when we play audio games (music) and participate in activities such as cooking” (Mok).

As illustrated in the above section, the quotes involved a proportion of participants working on games and activities in the group. This situation involved participants sharing their ideas and learning from the lesson, as well as negotiating with friends. In this way, participants can develop social skills to work together.

This study used an experimental design to investigate the impact of MCRP levels on patients with schizophrenia before and after intervention. The efficacy of the intervention on cognitive performance was evaluated through outcome measures by using the DLOTCA. At the 4-week postintervention assessment, participants in the MCRP group showed significant differences in the scores on the DLOTCA subtests associated with orientation (P = 0.01), visual perception (P = 0.04), visuomotor construction (0.02), and thinking operation (0.02). These results were subsequently compared with those of the control group, which demonstrated significant differences in the DLOTCA subtest scores, which are specifically associated with visual perception (p < 0.05).

The cognitive training group showed significant improvements in orientation at eight weeks and in verbal fluency at sixteen weeks for people with early-stage dementia [43]. A previous study revealed that four sessions of mindfulness-based cognitive therapy (MBCT) for female schizophrenia patients improved their stigma-coping orientation (P < 0.05) (56). In visual perception, it was reported that neuroplasticity-based targeted cognitive training (TCT) in schizophrenia patients resulted in better visual perception, verbal learning, and memory [44]. However, computer-assisted cognitive remediation alone does not provide robust visual perception in schizophrenia patients [45]. Regarding visuomotor construction, a previous study revealed that cognitive remediation techniques with 70 CogPack tasks improved cognitive functioning in schizophrenia patients, particularly attention, memory, numeracy, and visuomotor skills [46]. In thinking operations, implementing computer-assisted cognitive remediation (CACR) improved the cognitive domain and social skills of schizophrenia patients, with significant differences in executive function and reasoning ability between baseline and follow-up [47, 48].

Lindenmayer et al. [49] discovered that using cognitive remediation treatment (CRT) led to a significant improvement in the composite score of the MATRICS Consensus Cognitive Battery (MCCB) of working memory in participants with schizophrenia. Fazeli et al. [50] examined the impact of cognitive rehabilitation (CR) on patients with chronic schizophrenia in Iran. The findings indicated that the use of CRs resulted in a significant improvement in patients’ working memory performance (P = 0.05) and an increase in the number of correct responses. The efficacy of cognitive rehabilitation in aiding individuals with schizophrenia was supported by their findings in a 10-year follow-up study. This finding is consistent with the evidence indicating that visual memory and visual perception share common neural substrates. These findings support the idea that visual memory is a constructive process [51].

Wykes et al. [27] studied RCTs between conventional rehabilitation and cognitive remediation therapy (CRT). They found that, compared with the control treatment, CRT improved cognitive flexibility in young early-onset patients with schizophrenia according to the Wisconsin Card Sort Test at 14 weeks postintervention. Grant [52] compared the efficacy of cognitive therapy (CT) along with standard treatment versus standard treatment alone in low-functioning patients with schizophrenia. The study showed that patients who received CT had significantly greater improvement in global functioning (GAS score) than did those who received only standard treatment. Deste et al. [53] conducted a study involving 56 patients with schizophrenia. These patients were administered cognitive remediation therapy during the early phase of their illness, in contrast to chronic patients who received therapy later during their illness. The results of the present study showed that cognitive remediation was significantly effective (p < 0.05) at improving clinical, neurocognitive, and functional parameters in both the early course group and the chronic group, as demonstrated by paired sample t tests.

Krzystanek et al. [54] studied cognitive training conducted through a smartphone-based application on a regular basis for an extended period. They determined that the technique was viable and has the potential to enhance cognitive functioning in individuals with schizophrenia. However, D’Amato et al. [55] performed an RCT on the effectiveness of computer-assisted cognitive remediation for patients with schizophrenia. They evaluated the treatment’s impact on various neuropsychological composites, such as episodic memory, working memory, attention, executive functioning, and processing speed, along with proxy measures of community functioning. The study’s results indicated that there were no significant improvements in any neuropsychological or functional outcome measures, either immediately after the treatment or at the three-month follow-up. Previous studies have shown that cognitive rehabilitation is effective for patients with schizophrenia. However, this study filled these gaps in understanding by interviewing participants and gaining insights into their involvement in an MCRP.

In this study, the theme of understanding insight into activities and rehabilitation was aligned with the structure of sessions of experience carrying out cognitive remediation [56] (Contreras et al., 2016). In this study, participants with schizophrenia reported that cognitive remediation training was meaningful for them, as it provided them with opportunities to engage in activities with a sense of action and confidence. This finding was consistent with the findings of Bryce et al. [57], who explored the lived experience of cognitive remediation in patients with schizophrenia and found that participants who comprehended the activity program perceived benefits from it. Faith et al. [58] demonstrated that a positive therapeutic relationship was crucial for participants with serious mental illness, including schizophrenia. Participants demonstrated that having a positive relationship helped them learn and comprehend cognitive rehabilitation and cope with challenging activities during their recovery journey.

In this study, an MCRP made it possible for participants with schizophrenia to become actively interested and to be satisfied with the games and activities offered by the program. Earlier studies have shown that cognitive remediation training can enhance interest and motivation among participants with schizophrenia by facilitating their unique learning styles as well as their emotional and psychological needs [59]. Thus, cognitive rehabilitation must be motivating so that people with schizophrenia are interested in the use of treatment, are engaged, and are satisfied with meaningful training outcomes [57].

The use of an MCRP by participants with schizophrenia resulted in favorable enhancement of their memory, possibly due to the stimulating games and activities intended to encourage pleasure and activate cognitive capabilities. In a study by Reeder et al. [59], computerized interactive remediation of cognition (CIRCuiTS) for schizophrenia presented the theme of perceived cognitive changes. Participants in the study reported that CIRCuiTS helped them to enhance their attention and concentration, leading to better memory. Additionally, the participants gained confidence in their ability to carry out everyday activities. According to a study by Contreras et al. [56], participants reported positive cognitive development, such as novel thinking, compensatory strategies, elevated confidence, and self-efficacy, after receiving cognitive remediation intervention.

During the use of an MCRP, participants diagnosed with schizophrenia demonstrated an increase in their planning and problem-solving abilities as they engaged in challenging games and activities. The combined cognitive remediation and general functional skills training among individuals with schizophrenia resulted in improved learning, concentration, and executive functioning [60]. Similarly, Bowie et al. [61] discovered that cognitive remediation techniques, which included computer-based training, strategic monitoring, and verbal discussion groups utilizing cognitive remediation techniques, led to improved adaptive skills in activities of daily living for individuals with schizophrenia in the home and community. Rodewald et al. [62] discovered that cognitive remediation interventions were associated with successful improvements in problem-solving performance among patients with schizophrenia. In a study by Park and Kim [63], cognitive remediation included recreation programs for participants with schizophrenia, such as singing classes, sports, or cooking classes, combined with CogRehab. The program was provided 3 times weekly for 6 weeks, with each session being 45 minutes long. The treatment led to noteworthy enhancements in executive functioning.

The implementation of this MCRP played a special role in promoting social cognition and peer group participation. The study demonstrated the establishment of group interaction and participation through games and activities aimed at developing social skills. This approach appears to be particularly encouraging due to its user-friendly nature. Kidd et al. [60] observed that the integration of cognitive remediation and functional skills training in individuals with schizophrenia enhanced social skills. Participants were motivated to participate in role-playing activities to address social situations, such as greeting new acquaintances and managing landlord issues. These activities have the potential to improve social skills in community or household activities, as well as in work settings. In accordance with Peyroux and Frahave [64], the use of the cognitive remediation of social cognition in cognitive remediation programs has the potential to enhance the social cognition of those with schizophrenia and related disorders. By replicating real-life social settings, this approach enables patients to practice essential skills and engage in targeted social interactions. Consequently, this immersive environment may produce a more profound impact on social cognitive functions.

Strengths and limitations

This study's main strength lies in its mixed-methods approach, which facilitates triangulation of the results and, consequently, addresses the inherent constraints associated with single-method studies. This study has several limitations. The sample size was relatively small, and most of the participants were males. Future research could include a larger sample of schizophrenia patients from various mental health hospitals. Additionally, it would be beneficial to extend the intervention duration beyond 4 weeks to potentially observe more significant enhancements in different subtests of the DLOTCA. Furthermore, a study design incorporating multiple measurement outcomes should be considered. This approach can provide a more comprehensive understanding of intervention effectiveness. Conducting qualitative studies in both public and private hospitals is advised. Moreover, to gain deeper insights into the outcomes of the MCRP in clients' daily lives at home and in their communities, interviewing their family members is recommended as part of the research process.

Multifaceted cognitive training (MCRP) is a cognitive remediation approach tailored for patients with schizophrenia. Compensatory and behavioral interventions are integrated into this program to enhance neuropsychological functioning and social skills. The MCRP focuses on improving the cognitive functioning of schizophrenia patients by improving attention, orientation, perception, memory, executive function, and social participation. A significant difference existed between individuals in terms of treatment response. The program was designed to enhance intervention efficacy by considering baseline, pre- and post- ability levels, instructional techniques, and motivational factors. The statistical and textual data presented in the responses showed that meaningful activities help patients with schizophrenia increase their cognitive skills and capacity, indicating the comparative advantages of instructional techniques.

DLOTCA Dynamic Lowenstein Occupational Therapy Cognitive Assessment

CR Cognitive Remediation

CRT Cognitive Remediation Therapy

MCRP Multifaceted Cognitive Remediation Programme

MMSE Mini-Mental State Examination

OT Occupational Therapy

Funding

This research was supported by the Research Grant, National Science and Technology Development Agency (NSTDA), Thailand under Grant 5401/11652.

Author contributions

AK, KP, and PT conceptualized the study and secured the funding. AK, KP, and PT construction of cognitive intervention, construction of cognitive tasks, recruitment, organization of data acquisition, and intervention. KP contributed to the initial and final program evaluation. The interview information was analysed with the data with supervisory support from AK and PT. AK and PT contributed to writing the first draft of the manuscript. PM, PC, WS, and SP contributed to the reviewing and editing of the manuscript. AK, KP, and PT approved the final version.

Data availability

Datasets generated and analysed during this study are not publicly available due to sensitive information and the extent of informed consent provided by participants but are available upon reasonable request from the corresponding author.

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

In this study, the researchers followed the guidelines established by the Central Intuitional Review Board of Mahidol University (MU-CIRB 2018/251.1712) and Department of Mental Health's Institutional Review Board (DMH.IRB.COA007/2562). In accordance with the Helsinki Declaration and national guidelines, this study was carried out. It was evaluated and approved by the Central Intuitional Review Board at Mahidol University. On February 15, 2019, the ethics committee provided an ethics approval statement. The Institutional Review Board, Department of Mental Health, Ministry of Public Health also reviewed and approved the research plan. The ethics committee provided an ethics approval statement on June 27, 2019. The participants engaged in this study with written informed consent after they were told about their rights and the ways in which their data would be stored and used. In addition, the updated version of the data privacy policy for the whole research project and an updated version of the consent form for participation in both quantitative and qualitative studies were sent to the participants, along with a link to the data protection description.

Consent for publication

Not applicable

Acknowledgements

This work was supported by a Research Grant by the National Science and Technology Development Agency (NSTDA) of Thailand. The authors would like to thank all the patients with schizophrenia who participated and took the time to complete the research.

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Effects of a Multifaceted Cognitive Remediation Program on Cognitive Abilities in Patients with Schizophrenia: A Mixed Methods Study

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