Skip to main content Accessibility help

A naturalistic, randomized, controlled trial combining cognitive remediation with cognitive–behavioural therapy after first-episode non-affective psychosis

  • R. J. Drake (a1) (a2), C. J. Day (a3), R. Picucci (a3), J. Warburton (a3), W. Larkin (a3), N. Husain (a1) (a3), C. Reeder (a4) (a5), T. Wykes (a4) and M. Marshall (a1) (a3)...



Cognitive remediation (CR) preceding cognitive–behavioural therapy for psychosis (CBTp) was trialled within routine clinical services, with the hypothesis that following first-episode non-affective psychosis CR would enhance CBTp efficacy by improving neuropsychological performance.


A total of 61 patients with DSM-IV non-affective psychoses waiting for routine CBTp were randomized to computerized CR over 12 weeks, supported by a trained support worker, or time-matched social contact (SC). Primary outcome was the blind-rated Psychotic Symptoms Rating Scale (PSYRATS). Secondary outcomes included measures of CBTp progress, cognition, symptoms, insight and self-esteem: all at baseline, after CR (12 weeks) and after CBTp (42 weeks). PSYRATS and global neuropsychological efficacy were tested using mixed-effects models with a group × time interaction term. Measures of CBTp progress and some neuropsychological measures were modelled by regression.


There was no significant difference between the CR and SC groups in PSYRATS (group × time coefficient 0.3, 95% confidence interval −0.4 to 1.1, p = 0.39). However, after CR CBTp was shorter [median 7 sessions, interquartile range (IQR) 2–12 after CR; median 13, IQR 4–18 after SC; model p = 0.011] and linked to better insight (p = 0.02). Global cognition did not improve significantly more after CR (p = 0.20) but executive function did (Wisconsin Card Sort, p = 0.012).


CBTp courses preceded by CR were far shorter but achieved the same outcome as CBTp preceded by an active control, consistent with neuropsychological improvement enhancing CBTp. CR was delivered by staff with minimal training, offering the potential to reduce the costs of CBTp considerably.


Corresponding author

* Address for correspondence: R. J. Drake, MRCPsych, PhD, Institute of Brain, Behaviour and Mental Health, University of Manchester, 3.315 Jean McFarlane Building, Oxford Road, Manchester M13 9PL, UK. (Email:


Hide All
Addington, D, Addington, J, Maticka-Tyndale, E (1993). Assessing depression in schizophrenia: the Calgary Depression Scale. British Journal of Psychiatry (Suppl. 22), S39S44.
Bebbington, PE, Craig, T, Garety, P, Fowler, D, Dunn, G, Colbert, S, Fornells-Ambrojo, M, Kuipers, E (2006). Remission and relapse in psychosis: operational definitions based on case-note data. Psychological Medicine 36, 15511562.
Bertelsen, M, Jeppesen, P, Petersen, L, Thorup, A, Øhlenschlaeger, J, le Quach, P, Christensen, , Krarup, G, Jørgensen, P, Nordentoft, M (2008). Five-year follow-up of a randomized multicenter trial of intensive early intervention vs standard treatment for patients with a first episode of psychotic illness: the OPUS trial. Archives of General Psychiatry 65, 762771.
Birchwood, M, Smith, J, Drury, V, Healy, J, Macmillan, F, Slade, M (1994). A self-report Insight Scale for psychosis: reliability, validity and sensitivity to change. Acta Psychiatrica Scandinavica 89, 6267.
Bird, V, Premkumar, P, Kendall, T, Whittington, C, Mitchell, J, Kuipers, E (2010). Early intervention services, cognitive–behavioural therapy and family intervention in early psychosis: systematic review. British Journal of Psychiatry 197, 350356.
Bowie, CR, McGurk, SR, Mausbach, B, Patterson, TL, Harvey, PD (2012). Combined cognitive remediation and functional skills training for schizophrenia: effects on cognition, functional competence, and real-world behavior. American Journal of Psychiatry 169, 710718.
Cohen, JD, Forman, SD, Braver, TS, Casey, BJ, Servan-Schreiber, D, Noll, DC (1993). Activation of the prefrontal cortex in a nonspatial working memory task with functional MRI. Human Brain Mapping 1, 293304.
Cunje, A, Molloy, DW, Standish, TI, Lewis, DL (2007). Alternate forms of logical memory and verbal fluency tasks for repeated testing in early cognitive changes. International Psychogeriatrics 19, 6575.
Dallal, GE (2007). First generator, algorithm displayed from 3 August 2007 ( Accessed 20 January 2009.
Department of Health (2001). The Mental Health Policy Implementation Guide. Department of Health: London.
Department of Health (2005). Research Governance Framework for Health and Social Care, 2nd edn. Department of Health: London.
Dickinson, D, Tenhula, W, Morris, S, Brown, C, Peer, J, Spencer, K, Li, L, Gold, JM, Bellack, AS (2009). A randomized, controlled trial of computer-assisted cognitive remediation for schizophrenia. American Journal of Psychiatry 17, 170180.
Drake, R, Haddock, G, Tarrier, N, Bentall, R, Lewis, S (2007). The Psychotic Symptom Rating Scales (PSYRATS): their usefulness and properties in first episode psychosis. Schizophrenia Research 89, 119122.
Eack, SM, Greenwald, DP, Hogarty, SS, Cooley, SJ, DiBarry, AL, Montrose, DM, Keshavan, MS (2009). Cognitive enhancement therapy for early-course schizophrenia: effects of a two-year randomized controlled trial. Psychiatric Services. 60, 14681476.
First, MB, Spitzer, RL, Gibbon, M, Williams, JB (1997). Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Clinician Version, User's Guide. Arlington, VA: American Psychiatric Press.
Goldman, HH, Skodol, AE, Lave, TR (1992). Revising axis V for DSM-IV: a review of measures of social functioning. American Journal of Psychiatry 149, 11481156.
Greig, TC, Zito, W, Wexler, BE, Fiszdon, J, Bell, M (2007). Improved cognitive function in schizophrenia after one year of cognitive training and vocational services. Schizophrenia Research 96, 156161.
Guo, X, Zhai, J, Liu, Z, Fang, M, Wang, B, Wang, C, Hu, B, Sun, X, Lv, L, Lu, Z, Ma, C, He, X, Guo, T, Xie, S, Wu, R, Xue, Z, Chen, J, Twamley, EW, Jin, H, Zhao, J (2010). Effect of antipsychotic medication alone vs combined with psychosocial intervention on outcomes of early-stage schizophrenia: a randomized, 1-year study. Archives of General Psychiatry 67, 895904.
Haddock, G, Devane, S, Bradshaw, T, McGovern, J, Tarrier, N, Kinderman, P, Baguley, I, Lancashire, S, Harris, N (2001). An investigation into the psychometric properties of the Cognitive Therapy Scale for Psychosis (CTSPsy). Behavioural and Cognitive Psychotherapy 29, 221233.
Haddock, G, McCarron, J, Tarrier, N, Faragher, EB (1999). Scales to measure dimensions of hallucinations and delusions: the Psychotic Symptom Rating Scales (PSYRATS). Psychological Medicine 29, 879889.
Hogarty, GE, Flesher, S, Ulrich, R, Carter, M, Greenwald, D, Pogue-Geile, M, Keshavan, M, Cooley, S, DiBarry, AL, Garrett, A, Parepally, H, Zoretich, R (2004). Cognitive enhancement therapy for schizophrenia: effects of a 2-year randomized trial on cognition and behavior. Archives of General Psychiatry 61, 866876.
Hogarty, GE, Greenwald, D, Eack, S (2006). Durability and mechanism of effects of cognitive enhancement therapy. Psychiatric Services 57, 17511757.
Kay, SR, Fiszbein, A, Opler, LA (1987). The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin 13, 261276.
Koren, D, Seidman, LJ, Poyurovsky, M, Goldsmith, M, Viksman, P, Zichel, S, Klein, E (2004). The neuropsychological basis of insight in first-episode schizophrenia: a pilot metacognitive study. Schizophrenia Research 70, 195202.
Kuipers, E, Fowler, D, Garety, P, Chisholm, D, Freeman, D, Dunn, G, Bebbington, P, Hadley, C (1998). London–East Anglia randomised controlled trial of cognitive–behavioural therapy for psychosis. III: Follow-up and economic evaluation at 18 months. British Journal of Psychiatry 173, 6168.
Kurtz, MM (2011). Neurocognition as a predictor of response to evidence-based psychosocial interventions in schizophrenia: what is the state of the evidence? Clinical Psychology Review 31, 663672.
Lehman, AF, Kreyenbuhl, J, Buchanan, RW, Dickerson, FB, Dixon, LB, Goldberg, R, Green-Paden, LD, Tenhula, WN, Boerescu, D, Tek, C, Sandson, N, Steinwachs, DM (2004). The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. Schizophrenia Bulletin 30, 193217.
Lezak, M (1983). Neuropsychological Assessment, 2nd edn., pp. 395402. Oxford University Press: New York.
Lindenmayer, JP, McGurk, SR, Mueser, KT, Khan, A, Wance, D, Hoffman, L, Wolfe, R, Xie, H (2008). A randomized controlled trial of cognitive remediation among inpatients with persistent mental illness. Psychiatric Services 59, 241247.
McGurk, SR, Mueser, KT, Feldman, K, Wolfe, R, Pascaris, A (2007). Cognitive training for supported employment: 2–3 year outcomes of a randomized controlled trial. American Journal of Psychiatry 164, 437441.
Melle, I, Larsen, TK, Haahr, U, Friis, S, Johannesen, JO, Opjordsmoen, S, Rund, BR, Simonsen, E, Vaglum, P, McGlashan, T (2008). Prevention of negative symptom psychopathologies in first-episode schizophrenia: two-year effects of reducing the duration of untreated psychosis. Archives of General Psychiatry 65, 634640.
National Institute for Health and Clinical Excellence (2009). Schizophrenia Core Interventions in the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care. NICE Clinical Guideline 82. National Institute for Health and Clinical Excellence: Manchester.
Nuechterlein, KH, Green, MF, Kern, RS, Baade, LE, Barch, DM, Cohen, JD, Essock, S, Fenton, WS, Frese, FJ, Gold, JM, Goldberg, T, Heaton, RK, Keefe, RS, Kraemer, H, Mesholam-Gately, R, Seidman, LJ, Stover, E, Weinberger, DR, Young, AS, Zalcman, S, Marder, SR (2008). The MATRICS Consensus Cognitive Battery: part 1. Test selection, reliability, and validity. American Journal of Psychiatry 165, 203213.
Penadés, R, Catalán, R, Pujol, N, Puig, O, Guarch, J, Masana, G, Navarro, V, Gastó, C (2010). Is memory impairment a rate limiter in cognitive behavioural therapy for chronic schizophrenia? Psychotherapy and Psychosomatics 79, 129130.
Rabe-Hesketh, S, Skrondal, A (2005). Multilevel and Longitudinal Modelling using Stata. Stata Press: College Station, TX.
Reeder, C, Smedley, N, Butt, K, Bogner, D, Wykes, T (2006). Cognitive predictors of social functioning improvements following cognitive remediation for schizophrenia. Schizophrenia Bulletin 32 (Suppl. 1), S123S131.
Reeder, C, Wykes, T (2010). Computerised Interactive Remediation of Cognition – Interactive Training for Schizophrenia (CIRCUITS). King's College London: London.
Reitan, RM (1979). Manual for the Administration of Neuropsychological Test Batteries for Adults and Children. Ralph M. Reitan: Tucson, AZ.
Roder, V, Mueller, DR, Mueser, KT, Brenner, HD (2006). Integrated psychological therapy (IPT) for schizophrenia: is it effective? Schizophrenia Bulletin 32 (Suppl. 1), S81S93.
Rorabacher, DB (1991). Statistical treatment for rejection of deviant values: critical values of Dixon's “Q” parameter and related subrange ratios at the 95% confidence level. Analytical Chemistry 63, 139146.
Rosenberg, M (1965) Society and the Adolescent Self-Image. Princeton University Press: Princeton, NJ.
Silverstein, SM, Hatashita-Wong, M, Solak, EA, Uhlhaas, P, Landa, Y, Wilkniss, SM, Goicochea, C, Carpiniello, K, Schenkel, LS, Savitz, A, Smith, TE (2005). Effectiveness of a two-phase cognitive rehabilitation intervention for severely impaired schizophrenia patients. Psychological Medicine 35, 829837.
Silverstein, SM, Osborn, LM, Palumbo, DR (1998). Rey–Osterrieth Complex Figure. Test performance in acute, chronic, and remitted schizophrenia patients. Journal of Clinical Psychology 54, 985994.
Silverstein, SM, Spaulding, WD, Menditto, AA, Savitz, A, Liberman, RP, Berten, S, Starobin, H (2009). Attention shaping: a reward-based learning method to enhance skills training outcomes in schizophrenia. Schizophrenia Bulletin 35, 222232.
Startup, M, Jackson, MC, Evans, KE, Bendix, S (2005). North Wales randomized controlled trial of cognitive behaviour therapy for acute schizophrenia spectrum disorders: two-year follow-up and economic evaluation. Psychological Medicine 35, 13071316.
Tarrier, N, Haddock, G (2001). Cognitive–behavioural therapy for schizophrenia: a case formulation approach. In Treating Chronic and Severe Mental Disorders: A Handbook of Empirically Supported Interventions (ed. Hofmann, S. G. and Thompson, M. C.), pp. 6997. Guilford: New York.
Tarrier, N, Lewis, SW, Haddock, G, Bentall, R, Drake, R, Kinderman, P, Kingdon, D, Siddle, R, Everitt, J, Leadley, K, Benn, A, Grazebrook, K, Haley, C, Akhtar, S, Davies, L, Palmer, S, Dunn, G (2004). 18 month follow-up of a randomised, controlled trial of cognitive–behaviour therapy in first episode and early schizophrenia. British Journal of Psychiatry 184, 231239.
Wechsler, D (1997) WMS-III Manual: Wechsler Memory Scale, third edn. Psychological Corporation: San Antonio.
World Health Organization (2010). International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Version for 2010 ( Accessed 2 December 2012.
World Health Organization (2012). ACT/DDD index ( Accessed 27 October 2012.
Wykes, T, Huddy, V, Cellard, C, McGurk, SR, Czobor, P (2011). A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. American Journal of Psychiatry 168, 472485.
Wykes, T, Newton, E, Landau, S, Rice, C, Thompson, N, Frangou, S (2007 a). Cognitive remediation therapy (CRT) for young early onset patients with schizophrenia: an exploratory randomized controlled trial. Schizophrenia Research 94, 221230.
Wykes, T, Reeder, C, Landau, S, Everitt, B, Knapp, M, Patel, A, Romeo, R (2007 b). Cognitive remediation therapy in schizophrenia: randomised controlled trial. British Journal of Psychiatry 190, 421427.
Wykes, T, Reeder, C (2005). Cognitive Remediation Therapy for Schizophrenia: Theory and Practice. Routledge: London.
Wykes, T, Steel, C, Everitt, B, Tarrier, N (2008). Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin 34, 523537.


Type Description Title
Supplementary materials

Drake et al. Supplementary Material
Supplementary Material

 Word (160 KB)
160 KB


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed