'App' may improve daily function in schizophrenia

A 'brain training' iPad game developed and tested through research at the University of Cambridge, UK, may improve the memory of patients with schizophrenia.

Schizophrenia is a long-term mental health condition causing a range of psychological symptoms, from behavior changes to hallucinations and delusions. Psychotic symptoms are reasonably well maintained by current medications; however, patients are still left with debilitating cognitive impairments, including inconsistent memory — and are frequently unable to return to school or work.

There are no licensed pharmaceutical treatments to improve cognitive functions for people with schizophrenia. However, there is increasing evidence that computer-assisted training and rehabilitation can help people with schizophrenia overcome some of their symptoms, with better outcomes in daily functioning.

Schizophrenia is estimated to cost £13.1 billion per year in total in the UK, so even small improvements in cognitive functions could help patients make the transition to independent living and working and could therefore substantially reduce direct and indirect costs, besides improving the wellbeing and health of patients.

In a study published in Philosophical Transactions of the Royal Society B, a team of researchers led by Professor Barbara Sahakian from the Department of Psychiatry at Cambridge University, describe how they developed and tested Wizard an iPad game aimed at improving an individual's episodic memory.

Episodic memory is the type of memory required when you have to remember where you parked your car in a multi-storey car park after going shopping for several hours or where you left your keys in home several hours ago, for example. It is one of the facets of cognitive functioning affected in patients with schizophrenia.

Wizard is the result of a nine-month collaboration between psychologists, neuroscientists, a professional game-developer and people with schizophrenia. It is intended to be fun and attention-grabbing while motivating a player to improve episodic memory. A player is rewarded for progress in memory enhancement with additional game activities. It expands a player's sense of independent progress while gaining cognitive training.

Twenty-two participants, who had been given a diagnosis of schizophrenia, were assigned to either a (1) cognitive training group or (2) a control group — at random. Participants in the (1) training group played the memory game for a total of eight hours over a four-week period. Participants in the (2) control group continued their treatment as usual.

At the end of four weeks, researchers tested all participants' episodic memory with the Cambridge Neuropsychological Test Automated Battery (CANTAB) PAL, their level of enjoyment and motivation, and their score on the Global Assessment of Functioning (GAF) scale which doctors use to rate the social, occupational, and psychological functioning of adults.

Professor Sahakian and colleagues found patients who played the memory game made significantly fewer errors and needed significantly fewer attempts to remember the location of different patterns in the CANTAB PAL test relative to the control group. In addition, patients in the cognitive training group saw an increase in their score on the GAF scale.

Participants in the cognitive training group indicated they enjoyed the game and were motivated to continue playing across eight hours of cognitive training. In fact, researchers found that those who were most motivated performed best at the game. This is important, as lack of motivation is another common facet of schizophrenia.

It is not clear exactly how the apps also improved the patients' daily functioning, but researchers suggest it may be because improvements in memory had a direct impact on global functions or that the cognitive training may have had an indirect impact on functionality by improving general motivation and restoring self-esteem. Or indeed, both these explanations may have played a role in terms of the impact of training on functional outcome.

In April 2015, Professor Sahakian and colleagues began a collaboration with the team behind the popular brain training app Peak to produce scientifically-tested cognitive training modules. The collaboration has resulted in the launch today of the Cambridge University & Peak Advanced Training Plan a memory game, available within Peak's iOS app, designed to train visual and episodic memory while promoting learning.

The training module is based on the Wizard memory game, developed by Professor Sahakian and colleague Tom Piercy at the Department of Psychiatry at the University of Cambridge. Rights to the Wizard game were licensed to Peak by Cambridge Enterprise, the University's commercialisation company.

"This new app will allow the Wizard memory game to become widely available, inexpensively. State-of-the-art neuroscience at the University of Cambridge, combined with the innovative approach at Peak, will help bring the games industry to a new level and promote the benefits of cognitive enhancement," says Professor Sahakian.

The game is built for four weeks of training and is priced at $14.99 / £10.99.

Abstract
In addition to causing distress and disability to the individual, neuropsychiatric disorders are also extremely expensive to society and governments. These disorders are both common and debilitating and impact on cognition, functionality and wellbeing. Cognitive enhancing drugs, such as cholinesterase inhibitors and methylphenidate, are used to treat cognitive dysfunction in Alzheimer's disease and attention deficit hyperactivity disorder, respectively. Other cognitive enhancers include specific computerized cognitive training and devices. An example of a novel form of cognitive enhancement using the technological advancement of a game on an iPad that also acts to increase motivation is presented. Cognitive enhancing drugs, such as methylphenidate and modafinil, which were developed as treatments, are increasingly being used by healthy people. Modafinil not only affects ‘cold’ cognition, but also improves ‘hot’ cognition, such as emotion recognition and task-related motivation. The lifestyle use of ‘smart drugs' raises both safety concerns as well as ethical issues, including coercion and increasing disparity in society. As a society, we need to consider which forms of cognitive enhancement (e.g. pharmacological, exercise, lifelong learning) are acceptable and for which groups (e.g. military, doctors) under what conditions (e.g. war, shift work) and by what methods we would wish to improve and flourish.

Reference
Sahakian, BJ et al. The impact of neuroscience on society: Cognitive enhancement in neuropsychiatric disorders and in healthy people. Phil. Trans. R. Soc. B; 3 Aug 2015 (http://dx.doi.org/10.1098/rstb.2014.0214)

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A ‘brain training’ iPad game developed and tested by researchers at the
University of Cambridge may improve the memory of patients with schizophrenia,
helping them in their daily lives at work and living independently.
Image Credit: the Cambridge Neuropsychological Test Automated Battery (CANTAB)