Improving Accessibility and Personalization of CR for Schizophrenia

Cognitive remediation (CR) is an evidence-based practice to treat the pervasive and
significant cognitive deficits that contribute to functional decline in schizophrenia. The
New York State Office of Mental Health (OMH) has teamed with the Principal Investigator to be
the first, and largest state system of care to implement a statewide program of CR tied to
recovery programming. Through Cognitive Remediation to Promote Recovery (CR2PR), CR is now
offered in outpatient programs throughout the state, with plans to expand to more services
and further adapt implementation to improve treatment outcomes. To proceed systematically,
this project will work directly with CR2PR programs, guided by practice-based evidence
gathered during CR2PR to build upon and improve current CR delivery methods in two ways.

1. Ongoing program evaluation indicates that the burden of attending clinic twice per week
for CR limits the number of people who enroll. This project will test the feasibility
and collect preliminary data on the effectiveness of personalized CR delivery that
involves one clinic visit and one remote session per week. Demonstrating the
effectiveness of incorporating remotely delivered CR would double the number of patients
who could access the OMH CR program and reduce treatment costs.

2. Current effect sizes for cognition and functional outcomes may remain limited if
personalization, mechanisms of action, and relevant targets are not better addressed.
Given evidence that early auditory information processing ability (EAP) works as a
neurobehavioral marker of need for sensory processing training, this study will test the
potential to use baseline EAP assessment to tailor CR, incorporating EAP with other
cognitive skills training as clinically indicated. The ultimate goal of integrating
scalable assessment practices to personalize CR is to improve recovery outcomes.

The study will use a repeated measures, randomized design. Eligible participants who are
referred to CR2PR will complete a routine baseline neurocognitive assessment with the
addition of a EAP measure, and will then be randomized to either all-clinic CR (Clinic) or
clinic+remote (Hybrid) CR. The Clinic research arm consists of 30 sessions delivered twice
weekly in a group format of up to 8 participants with rolling admission. The Hybrid condition
consists of 15 clinic sessions in the above format, and independent homework on cognitive
exercises for 60 minutes per week for 15 weeks using a laptop, PC or tablet available to
them. All clinic sessions consist of 45 minutes of working on 3-4 computerized exercises
selected by a clinician from a menu of web-based programs to improve the cognitive functions
identified as impaired on the assessment. Computer exercises are followed by 15 minute
manualized discussion groups based on the concept of "Bridging".

All participants will complete a treatment satisfaction survey and will be re-tested on
outcome measures approximately 1 week following end of treatment. Additional data on the
feasibility and acceptability of the Hybrid approach will be gathered through a qualitative
interview with participants at treatment endpoint.

Inclusion Criteria:

- Referred for participation in Cognitive Remediation to Promote Recovery by outpatient
clinic teams

- A primary DSM-5 diagnosis of schizophrenia or schizoaffective disorder

- Verbal IQ estimate of 70 or above

- Stabilized on any psychotropic medication

- English-speaking

Exclusion Criteria:

- Unremitted substance dependence

- Neurological illness affecting brain functioning

- Traumatic brain injury within 2 years

- Auditory or visual impairment (uncorrected)