| BackgroundSchizophrenia is a serious mental illness characterized by cognitive deficits.Most patients with schizophrenia experience significant cognitive impairments,especially in attention/vigilance,working memory,verbal memory,executive functions,motor speed and verbal fluency.These dimensions are closely related to social function,quality of life and disease outcomes in patients with schizophrenia.Acute attack accelerates the decline of brain function in patients with schizophrenia,which brings a heavy burden of disease to patients,families,and society.Therefore,it is significant to improving cognitive function in patients with schizophrenia in the acute phase for optimizing the disease outcome and reducing the burden of disease.Compensatory cognitive training(CCT)is a "compensatory" cognitive remediation treatment by teaching patients to master the "compensation" strategies and form new habits to improve memory,attention,and problem solving ability.At present,CCT is still in the exploratory stage in the field of cognitive remediation therapy.The studies on CCT are mostly concentrated in European and American countries,and its application in China has not been reported in the literature.Although studies have confirmed that CCT can effectively improve the cognitive function of patients with mental illness,the cognitive function in patients with schizophrenia is affected by many factors,which may have a potential impact on the effect of CCT.We believe that improving the cognitive function in patients with schizophrenia should not be limited to cognitive remediation therapy.It is necessary to clarify the influencing factors of cognitive function and reduce the damage of risk factors to improve the cognitive function in patients with schizophrenia.Although previous studies have been explored on the influencing factors of cognitive function in patients with schizophrenia,these studies have focused on several specific aspects such as genetics,psychiatric symptoms,and antipsychotic drugs.Few studies have explored the influencing factors of cognitive function in patients with acute schizophrenia from the multiple levels of individual traits,behavioral characteristics,interpersonal network,and living environment,which may have an adverse effect on identifying and controlling risk factors on cognitive function in patients with schizophrenia.Scientists in the field of cognitive remediation therapy have generally recognized that integrating cognitive remediation therapy,especially the combination of cognitive strategy training and psychological rehabilitation therapy,will achieve better effects in improving the cognitive function in patients with schizophrenia.Medication self-management skills training(MSST)aims to improve medication adherence by teaching patients to master the knowledge about the role of antipsychotics,self-management and effect evaluation of antipsychotics,identification and dispose of side effects,and negotiation of medication issues with medical staff.On the basis of clarifying that medication adherence is a key influencing factor of cognitive function,this study combined CCT with MSST to formulate a joint intervention programs,hoping to achieve better effects in improving the cognitive function in patients with schizophrenia.Objectives This study provides a theoretical basis for developing the joint intervention programs by clarifying the key influencing factor of cognitive function in patients with schizophrenia;it provides effective and feasible intervention programs for improving the cognitive function in patients with schizophrenia by evaluating the effects of the CCT and joint intervention;it provides theoretical support for performing personalized treatments in clinical settings by clarifying the predictors of intervention effects.MethodsThe first part is a cross-sectional survey to explored the relationships between individual traits,behavioral characteristics,interpersonal network,living environment and cognitive function.The survey was conducted at a psychiatric hospital in Ningxia,China.A total of 329 in-patients with schizophrenia were enrolled from acute admissions to the inpatient department from April 2016 to December 2017.The survey included sociodemographic characteristics,clinical characteristics,cognitive function,behavioral characteristics,social support,stress,etc.,and assessments were performed using Brief Assessment of Cognition in Schizophrenia(BACS),Montreal Cognitive Assessment(MoCA),Positive and Negative Syndrome Scale(PANSS),Insight and Treatment Attitudes Questionnaire(ITAQ),Morisky Medication Adherence Questionnaire(MAQ),Social Support Rating Scale(SSRS),and Social Readjustment Rating Scale(SRRS).Multiple linear regression analysis in SPSS 20.0 were performed to determine the possible correlations between these factors and cognitive function.The second part is a randomized controlled trail.The trail was conducted at a psychiatric hospital in Ningxia,China.Eighty-seven inpatients with schizophrenia were enrolled from acute admissions to the inpatient department from April to November 2017.Participants were randomly assigned to the TAU,CCT,or CCT+MSST groups.Assessments of cognitive function using the BACS,psychiatric symptoms using the PANSS,and medication adherence outside the hospital using the MAQ,were administered to all participants at baseline and at post-intervention.Linear mixed models in SPSS 20.0 were performed to determine whether changes in cognition,psychiatric symptoms,and medication adherence were due to the intervention(between subjects)or time(within subjects).The third part is a analysis of predictive factors of intervention effects.Multiple linear regression analysis in SPSS 20.0 was performed to identify predictors of intervention effects.In this analysis,changes in verbal fluency,total cognitive function,positive symptoms,and medication adherence were regarded as the dependent variables,while age,course of disease,antipsychotic dose(chlorpromazine equivalent),baseline positive symptoms,baseline negative symptoms,baseline total cognitive function,baseline medication adherence,cognitive strategies practice frequencies,and grouping were regarded as the independent variables.Results1.A total of 335 inpatients with schizophrenic were investigated in this study,and 329 valid questionnaires were collected,with an effective recovery rate of 98.2%.Among the 329 respondents,160 were male,accounting for 48.6%,169 were female,accounting for 51.4%,68 patients with normal cognitive function accounted for 20.7%,and 261 patients with cognitive impairment accounted for 79.3%.2.The influencing factors of cognitive functionMultiple linear regression showed:years of formal education and stress were related to working memory;age,gender,years of formal education,duration of disease,medication adherence were related to attention;gender,years of formal education,duration of disease,drinking alcohol,and medication adherence were related to executive function;marital or not,years of formal education and duration of disease were related to verbal memory;gender,years of formal education,duration of disease,and medication adherence were related to motor speed;gender,years of formal education,occupation and residence were related to verbal fluency;gender,years of formal education,duration of disease,medication adherence,objective support,and occupation were related to total cognitive function.3.Change in cognitive function at post-interventionAll of the three groups exhibited a general improvement in attention,verbal memory,motor speed,verbal fluency and total cognitive function at post-intervention.There were significant differences in verbal fluency and total cognitive function between groups.There were significant group by time interactions for verbal fluency(p<0.001,rlp2=0.373)and total cognitive function(p<0.001,?p2=0.275),with large effect sizes.The CCT group showed greater performance on verbal fluency and total cognitive function compared with the TAU group(verbal fluency:p<0.001;total cognitive function:p<0.05).The CCT+MSST group showed greater performance after intervention on both verbal fluency and total cognitive function compared with the TAU group(p<0.001).The CCT+MSST group showed greater performance after intervention on total cognitive function compared with the CCT group(total cognitive function:p<0.001).4.Change in psychiatric symptoms at post-interventionAll of the three groups exhibited a universal improvement in positive symptoms,negative symptoms and general psychopathological symptoms after intervention.There were statistically differences in positive symptoms and general psychopathological symptoms between groups.There were significant group by time interactions for positive symptoms(p<0.001,?p2=0.211)and negative symptoms(p<0.05,?p2=0.164),with large effect sizes.The CCT and TAU groups did also not differ in positive symptoms and negative symptoms(p>0.05).The CCT+MSST group showed a larger improvement after intervention on positive symptoms compared with the TAU group(p<0.05).The CCT+MSST and CCT groups did not differ in positive symptoms and negative symptoms(p>0.05).5.Change in medication adherence at post-interventionAll of the three groups exhibited a universal improvement in medication adherence at post-intervention.There were significant differences in medication adherence between groups.There were significant group by time interactions for medication adherence(p<0.05,?p2=0.127),with large effect sizes.The CCT group showed greater performance on medication adherence compared with the TAU group(p<0.05).The CCT+MSST group showed greater performance after intervention on medication adherence compared with the TAU group(p<0.001).The CCT+MSST and CCT groups did not differ in medication adherence(p>0.05).6.Predictors of intervention effectsThe frequency of cognitive strategy practice has a positive predictive effect on the improvement of the verbal fluency and total cognitive function;the baseline total cognitive function has a negative predictive effect on the improvement of the total cognitive function;baseline positive symptoms have a negative predictive effect on the improvement of positive symptoms;the baseline medication adherence has a negative predictive effect on the improvement of medication adherence.Conclusion1.Cognitive function in patients with schizophrenia in the acute phase is generally poor,and the incidence of cognitive impairment is relatively high,which is affected by the individual traits,behavioral characteristics,interpersonal network,living environment.Significantly,medication adherence has a positive predictive effect on multiple cognitive domains such as attention,executive function,motor speed and total cognitive function.The joint intervention programs combining CCT and MSST should be performed to improve the cognitive function in patients with schizophrenia.2.The CCT could effectively improve verbal fluency,total cognitive function,and medication adherence in patients with schizophrenia in the acute phase,and the CCT+MSST could effectively improve verbal fluency,total cognitive function,positive symptoms and medication adherence in patients with schizophrenia in the acute phase.The CCT+MSST may be more advantageous than CCT alone in improving total cognitive function and positive symptoms.3.The frequency of cognitive strategy practice,total cognitive function,positive symptoms,and medication adherence are key predictors of the intervention effects.The implementation of personalized interventions and recommending suitable patients to receive such treatments may be important to improve the intervention effects. |
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