By:  Les Ruthven, Ph.D.  clinical psychology/health management

Health blog: 

Email:  [email=lruthven.mafinearts@gmail.com]lruthven.mafinearts@gmail.com[/email]

Medscape psychiatry on 5/5/2021 reported on new research of remediation of cognitive skills in schizophrenic patients which substantially improved their daily functioning vs. randomly selected schizophrenic patients who received no cognitive training.  Antipsychotic drugs have become so identified with treating the psychotic disorders that the Medscape reviewer described the research as a novel treatment of schizophrenia. Dr. Ruthven, in the comment section, wrote the following to the readers of the article.

I would put another slant and a minority view on the research in question which finds that cognitive remediation (training substantially improves the functioning of schizophrenics.  If the research subjects were or had been on neuroleptic medication the therapy may have been decreasing the brain impairing effects of the drugs and not the effects of the psychopathology!  Other research evidence is quite clear, the longer psychotic patients are on these drugs the worse the outcome and this is due to the brain impairing effects of the drugs!  Most psychiatrists believe that for the psychotic disorders treatment with psychiatric medications must be life long. A small minority of psychiatrists believe, however, that these drugs with psychotic patients should be uses as sparingly as possible, only when the patient is dangerous to self or others. All mental and even many “medical” disorders are at least to some degree partly and at times fully self-limiting, which may arise from the patients ability to learn.  Brain impairing treatment side effects (drugs, ECT, lobotomy and others) may explain why the long term outcome for such treated patients is very unfavorable.

The researches in the above research might consider tapering neuroleptics off all subjects and determine differential improvement of those continuing drugs and remediation vs. those drug free during their cognitive training.  This is one way of determining the source of the brain impairment in research subjects, that is, the drugs or the disorder?

In the comment section a Dr. Reyes commented that this novel therapy would never see the light of day in clinical practice because it would cost too much money! I agreed with him in part, that it would never see the light of day, but to most physicians this approach is so foreign to customary medical practice that it would be rejected out of hand! As an example, I was the first psychologist years ago with a large NIMH research grant on remediating cognitive abilities of substantially impaired subjects with structural brain damage 4 to 8 years post injury/disease.  Control subjects tested on the Halstead battery and retested on the battery 6 months later without any rehabilitation were virtually cognitively and socially stable over the period. The randomly selected experimental subjects received 6 months of individual remediation of a variety of cognitive skills, including sheltered workshop experiences several hours each day. 

Control subjects were stable in their performance on the tests and stable in their social adjustment (continuing to live with their parents) while four of the fifteen experimental subjects achieved gainful employment and were no longer living with their parents! On the tests measuring higher level adaptive abilities the treated patients substantially improved in their ability to master the more complex demands of normal living while the untreated subjects only remained stable during this period. My research, as in the above research being discussed, was against the conventional wisdom and too often in healthcare the faulty conventional wisdom wins out.

For my research not one neurologist or neurosurgeon referred any of their patients for this experimental and free training because as we all know “Rehabilitation is only effective one year or at most two years post injury or disease” according to neurologists and other neuroscientists.  After the study came out at an annual APA meeting several psychologists (Charles Golden was one) went forward with this new field but I doubt this research has had any lasting effect on practice today, which is the point of much of the above. Such approaches as the above (Cognitive remediation with schizophrenics and those with static brain damage) do not fit in with physician training and their concept of health/illness and what physicians consider to be effective treatment.  The writer has found that deeply held beliefs are very resistant to change despite any evidence to the contrary and unfortunately healthcare has much more than its share of false beliefs! Remember it took over 3,000 years for healers to finally give up the practice of bloodletting as a favored treatment.