EPA 2020 – Metacognition could be key for improving people’s overall functioning, according to Professor Dame Til Wykes who discussed new developments in cognitive remediation for schizophrenia during a symposium held at the virtual 28^th European Congress of Psychiatry.

It has been known for more than six decades that people with a diagnosis of schizophrenia have cognitive problems. People with schizophrenia may recognise these problems themselves and tell their doctors about their inability to concentrate, being easily distracted, or having difficulty remembering things. They may even recognise, and have come to terms with, having a learning difficulty.

The presence of cognitive problems not only affects the cost of care but is also linked to people’s future recovery, said Prof. Wykes, who works at the Institute of Psychiatry, Psychology and Neuroscience, which is part of King’s College London in the UK. Despite this knowledge, clinicians and researchers have taken a long time to recognise the potential for improving cognition via targeted treatment, such as cognitive remediation.

According to the Cognitive Remediation Expert Working Group, cognitive remediation “is a behavioural training intervention targeting cognitive deficit (attention, memory, executive function, social cognition, or metacognition) using scientific principles of learning with the ultimate goal of improving functional outcomes.” The Expert Working Group goes on to say that the effectiveness of cognitive remediation “is enhanced when provided in a context (formal or informal) that provides support and opportunity for extending everyday functioning.”¹

It took quite a long time to develop cognitive remediation and there have been many studies and meta-analyses performed to determine how it works, Prof. Wykes observed during her presentation. Since 2014 and up to the start of 2020, she noted, there have been 106 trial reports and 28 meta-analyses. Of the latter, 25 found that cognitive remediation resulted in significant cognitive and functioning improvements, and 20 had found that there was also symptom improvement.

Citing a recent meta-analysis that had included 67 studies and more than 4,000 participants,² Prof. Wykes noted that, with the exception of visual memory, cognitive remediation improved many of the cognitive symptoms people reported. That included improved attention, verbal memory, reasoning, working memory, processing speed, social cognition, and an overall improvement in a global cognitive score.

So, cognitive remediation works, Prof. Wykes said. However, which cognitive remediation programme works best? There are multiple types of cognitive remediation interventions and there is a need to work out what the components of these are that work best for an individual.

Cognition predicts functional outcomes and problems with cognition can limit the effectiveness of rehabilitation or recovery programmes, Prof. Wykes said. Efforts have thus far focussed on trying to improve cognition but is it the improvement in cognition that directly causes the functional and clinical improvements seen, she queried.

Studies have indicated that improving cognitive abilities, such as working memory, planning, verbal memory and processing speed, do improve things like work quality and functioning skills, but they only do so partially. There is something else that is having a significant effect and is not being accounted for in those studies, Prof. Wykes said.

One of the things that might be coming into play here is metacognition. This refers to three types of knowledge that someone has, which can be declarative, procedural or conditional. Declarative knowledge is that which someone knows, such as a mathematical equation. Procedural knowledge is knowing how to do something, such as how to use that equation to perform a calculation. Conditional knowledge is then knowing when to use the information, so when to use the equation to do the calculation.

Conditional knowledge is really important, Prof. Wykes said. While procedural knowledge can be improved, such as learning a recipe or learning a telephone number, it is the conditional knowledge of knowing when to do something that is more critical. For example, a person may know that rehearsing something will help them remember it, but they may not know when to do it.

In a meta-analysis of seven studies, involving 645 participants, metacognition was linked to better functional outcome.³ More importantly perhaps is that a separate study showed that metacognition was the main predictor of whether people who had a first-episode of schizophrenia were in work or not 1 year later.⁴ Cognition and functional outcome did add into the equation, Prof. Wykes said, but not as much.

It is possible to have a metacognitive approach to cognitive remediation. It means that people need to engage with their therapy and to do that they need to set their own goals. These should be cognitively smart goals so that it is possible to see if treatment will lead to an improvement in an important outcome. Then people need to be taught new ways to approach tasks, this is called metacognition regulation. They also need to be given metacognitive knowledge; that describes how to think about their thoughts and what affects their thinking, such as if they feel stressed and how that will affect their ability to do things. Then this knowledge needs to be transferred and integrated into everyday life.

Prof. Wykes described how she had helped co-create the CIRCuiTS (Computerised Interactive Remediation of Cognition – a Training for Schizophrenia) program. This had metacognition support built into the program by considering people’s goals, strengths and difficulties, and strategies for building knowledge. The program emphasised the selection and evaluation of strategies for building on self-reflection in particular, which is part of metacognitive processing. CIRCuiTS was a recovery-based program that focussed on real-world goals important to the individual, Prof. Wykes noted. The program had been shown to increase metacognition compared to treatment as usual.³ Metacognition could therefore be an important mechanism for explaining how cognitive remediation works and affects overall functioning in people with psychosis.

In a recent White Paper,⁴ metacognition was recognised as being an important component of cognitive remediation for schizophrenia. Recommendations were that procedures to develop problem-solving strategies should be included in cognitive remediation programmes and that there needed to be a process for helping transfer knowledge into real-world practice. The White Paper also emphasised the importance of cognitive exercises and the role of therapists. Concluding her presentation, Prof. Wykes showed evidence of the important role that therapists make in delivering cognitive remediation programmes. They need support and appropriate training, she highlighted, but therapists are the people who can encourage metacognition changes.