Clinical practice guidelines – An overview of cognitive remediation for various neuropsychiatric disorders

PROCESS OF DEVELOPMENT OF THE CLINICAL PRACTICE GUIDELINES The Indian Psychiatry Society Clinical Practice Guideline Sub-committee endeavored to develop a comprehensive review of the research through its clinical practice guideline (CPG) on cognitive remediation in neuropsychiatric disorders. Cognitive function represents a crucial domain affected in psychiatric disorders and significantly impacts the functionality and overall quality of life of the individual.[1] We adhere to a rigorous scientific methodology encompassing the formulation of review questions, systematic literature search, evidence synthesis from meta-analysis, systemic review, randomized controlled trials (RCTs), clinical reviews, various national and international guidelines, and composition of the initial draft. For better local impact, Indian studies and data were considered during the draft process. The preliminary version of the guideline underwent expert evaluation at a national-level workshop. Subsequently, the initial draft was submitted to the Indian Journal of Psychiatry (IJP) for peer review and concurrently published on the India Psychiatry Society website for members’ commentary. Following the incorporation of stakeholder feedback and completion of the peer review process, the guideline authors revised the document and subsequently submitted it for quality checks and additional reviews by the IJP. Scope and limitations of CPG This guideline presents evidence-based recommendations for assessing cognitive impairment and various methodologies and techniques of cognitive remediation (CR) interventions for individuals with major neuropsychiatric disorders across all age groups. Implementing these guidelines in clinical practice can enhance clinical outcomes and recovery; however, due to limited local research, financial constraints, availability issues, and variations in individual needs, strict application may not be feasible in clinical settings. Introduction: Concept of cognition Cognition is the mental action or process by which knowledge and understanding are developed in the mind.[2] It is acquiring knowledge and understanding through thought, attention, language, learning, memory, and perception. It refers to a range of mental processes relating to the acquisition, storage, manipulation, and retrieval of information it underpins many daily activities in health and disease across age span. Cognition can be separated into multiple distinct functions dependent on brain circuits and neuromodulators. Cognition can further be categorized into neurocognition and social cognition.[3] Neurocognition, nonsocial cognitive processes, involves domains such as attention, memory, and executive functioning. Social cognition refers to psychological processes that are involved in perceiving, inferring, and responding in social situations.[4] The ability to evaluate, quantify, and oversee cognitive functions across the lifespan facilitates early patient identification, expedited treatment access, prolonged health, enhanced quality of life, and decreased costs. COGNITION IN INDIAN ANCIENT LITERATURE In the Yajur Veda, the concept of the mind is articulated as the internal illumination of knowledge. In the 34th chapter of the Yajur Veda, the initial six mantras elucidate various dimensions of the mind, posing the inquiry, “What constitutes the mind?” The act of apprehending knowledge is attributed to the mind, which is further characterized as both Yoga and Samadhi (a specific mental state). All our sensory faculties operate under the dominion of the mind, functioning under its governance. A substantial portion of Indian philosophical discourse is dedicated to the exploration of consciousness. The texts Yoga Vasistha and Tripurarahasya purport to elucidate the intrinsic nature of consciousness. This assertion is similarly applicable to a range of texts concerning yoga, the Upanishads, and even the antecedent Vedic scriptures. Cognitive abilities arise from a continuing reflection on the perceived world. One Vedic statement tells us that Atman (Soul) consists of three Elements of Soul (Atman) 1. Mind (maan) 2. Vitality (pran) 3. Matter (vaak) We may see these three elements pervading us as well as the whole world. Our mind represents knowledge (gyan), vitality (pran), action (kriya), and matter (vaak), representing all worldly objects and all literature (sahitya). Knowledge engenders volition, which in turn engenders exertion, and exertion culminates in action, encompassing all that is manifested. In accordance with Sankhya philosophy, the concept of reality can be delineated through a framework comprising 25 distinct categories. These categories constitute the foundational basis for the classification system within Saivism. The categories delineated are as follows: Five fundamental elements of material existence, epitomized by earth, water, fire, air, and ether. Five subtle elements, characterized by the sensory perceptions of smell, taste, form, touch, and sound. Five organs designated for action, which include reproduction, excretion, locomotion, grasping, and speech. Five organs associated with cognition, which correlate to the senses of smell, taste, vision, touch, and hearing. Three internal faculties, namely, the mind, ego, and intellect, alongside inherent nature (prakrti) and consciousness (purusa). Cognition is a set of all mental abilities and processes related to knowledge. The concept of cognition and perception have a detailed description in all the six Indian philosophies, Nyaya (logic), Vaisesika (atomic theory), Sankhya (analysis of matter and spirit), Yoga (the discipline of self-realization), Karma-mimamsa (science of fruitive work), and Vedanta (science of God realization), with slight variations among each of the philosophies.[5] All six schools of Vedic philosophy aim to describe the nature of the external world and its relationship to the individual, to go beyond the world of appearances to ultimate reality, and to describe the goal of life and the means for attaining this goal. Perception and cognition have been described to have a key role in the right means of knowledge.[6] Concept and mechanism of cognition according to Sānkhya It is a complex process: The psyche, which is made up of three faculties—the mind (manas), the intellect (buddhi), and the ego (ahankāra)—cognizes its constituent objects (color and shape) through the physical organs (eye, for example). Using information from the senses, the mind internally develops a representation of the outside world’s things. The ego adds a personal viewpoint to assertions of knowledge. Understanding is a component of knowledge that comes from the intellect. The purușa, which is only a witness to the intellectual processes, gives the result awareness. Perception, inference, and valid testimony are the means. By these, all other means of right cognition too are established.[7] CONCEPT AND MECHANISM OF COGNITION ACCORDING TO YOGA According to Patanjali’s epistemology,[8] cognition is possible only because “chitta” is colored by both the object and the mind itself. Sensory impressions from the external world continually bombard the functions of sight, hearing, smell, taste, and touch. As the mind defines the object, so the object defines the mind. Manas then registers the objects of cognition and controls the response. It does so by drawing from the memory bank of karma stored in the mind. So, the model of cognition according to Sānkhya and Yoga is almost replicable except for the fact that Buddhi in Yoga is represented by Chitta. A schematic presentation of the mechanism of cognition according to ancient Vedic literature is described in Figure 1,[6] and the relation between cognition and consciousness is in Figure 2.[9]Figure 1: Mechanism of cognition according to Sankhya and yogaFigure 2: Connection of cognition and consciousness as per Indian thought systemCOGNITIVE FUNCTION IN MODERN MEDICINE Cognition has served an important function of human existence and has been an area of interest for research for several years. The major cognitive domains are described in DSM-5, as depicted in Figure 3.Figure 3: Cognitive domains as per DSM 5Cognitive domains are subdivided into various subdomains and categories to quantify specific deficits. Table 1 describes the cognitive domain and subcategory.Table 1: Cognitive domains and its subtypesCOGNITIVE IMPAIRMENT IN PSYCHIATRIC DISORDERS Cognitive function plays an important role in daily life. It is commonly known that widespread impairment in cognitive function is an essential feature of many mental disorders.[10] A wide range of prevalence rates of cognitive impairment have been reported in common psychiatric disorders. Cognitive impairment in psychiatric disorders has been reported in most domains and is more pronounced in certain subdomains of cognition in different disorders. Nearly 80% of persons with schizophrenia and 40% of patients with depression have cognitive impairment.[11,12] Cognitive deficits may result in poor attention, problems in processing information, difficulties with remembering and recalling, and response-related problems.[1] Cognitive impairments have an impact on several domains, including everyday living, education, employment, and interpersonal relationships.[13–15] Impaired cognitive function leads to poor quality of life and socio-occupational impairment. The World Health Organization’s disability model states that these cognitive impairments affect social functioning, community integration, and overall quality of life.[16] Schizophrenia is one of the most severe and disabling psychiatric illnesses. Cognitive impairment in schizophrenia is severe, enduring, and associated with poor outcomes. Impairments in social and occupational functioning in schizophrenia were strongly related to the impairments in neurocognition.[15,17–20] In Earlier era, Bleuler and Kraepelin explored cognitive impairment in schizophrenia.[21,22] However, modern psychiatric disorder nosology and diagnostic criteria often focus on emotional and behavioral symptoms of the condition and undermine cognitive function and cognitive impairment. With advancements in medical science, psychiatric interventions and treatment of cognitive symptoms, and cognitive impairment gain further attention in research and clinical practice. Reichenberg et al. studied neurocognitive performance in schizophrenia, schizoaffective disorder, bipolar disorder, and depression. All four groups demonstrated impairments in memory, executive functions, and attention and processing speed. However, more pronounced impairment was noted in the schizophrenia subgroup.[23] Konstantakopoulos et al.[24] in a study of bipolar and schizophrenia patients highlighted significantly impaired in general intellectual ability, verbal memory and learning, and executive functions compared to healthy controls. Patients with schizophrenia performed significantly worse than patients with bipolar on verbal memory tasks, whereas the bipolar group did not have a significantly lower score than schizophrenia in any task. Schizophrenia patients performed worse than a control group on attention, processing speed, and immediate memory tests, while bipolar patients on visuospatial ability and working memory. Both schizophrenia and bipolar groups did not differ from the control group regarding Theory of Mind. Study results of Konstantakopoulos et al.[24] show stable schizophrenia and euthymic bipolar disorder exhibit similar profiles of cognitive impairment, consistent with previous studies, suggesting that the differences are related to the extent and degree of impairments, rather than being qualitative. Cognitive deficits in mood disorders are studied extensively, but the overall pattern of specific cognitive impairment has not always been consistent. Common problems are identified in the areas of attention, executive function, and recall memory.[25] In depression, cognitive impairment can be severe and generalized. Cognition is considered one of the core features of diagnosing depression for a long period.[26] Meta-analysis of the first episode of major depressive disorder showed cognitive deficits in psychomotor speed, attention, visual learning and memory, and all aspects of executive functioning.[27] Depressive symptom improvement and the number of previous depressive episodes moderated the extent of cognitive changes. It demonstrates scar-like features of depressive episodes in cognitive domains.[28] Cognitive function in depression improves marginally with treatment intervention. Working memory, verbal memory, and verbal fluency were most sensitive to change. Executive function, processing speed, and nonverbal memory were less sensitive to change.[29] A study in adolescent patients with depression showed neuropsychological deficits in MDD compared to controls in the cognitive domains of executive function, working memory, psychomotor and processing speed, verbal fluency, and visual (-spatial) memory.[30] In first-episode bipolar disorders, impairment in psychomotor speed, attention and working memory, and cognitive flexibility were identified, whereas smaller deficits were found in the domains of verbal learning and memory, attentional switching, and verbal fluency. Cognitive deficits can be identified during the euthymic or remission state of disorder. Studies have shown structural and functional changes in DLPFC which are consistent with impairment in attention, executive function, and memory.[25] Commonly identified difficulties in OCD are visuospatial and visuoconstructionl areas. Some studies identify impairment in nonverbal memory. However, verbal memory is usually preserved in most cases. Another study by Suhas and Rao reported impairment in response inhibition, impaired set-shifting, processing speed, and verbal memory in the OCD group.[31] Memory problems are the core feature of PTSD; studies show verbal and autobiographical memory impairment in PTSD. Beth Cohen et al.[32] reported impairment in processing speed, categorical fluency, and verbal learning in PTSD. Another study conducted on individuals with acute PTSD revealed deficits in high-level attentional resources, working memory, executive function, and memory.[33] Ramey et al.[34] investigated cognitive impairment in substance misuse and identified attention, response inhibition, working memory, and decision-making function impairment. Impairment of theory of mind and emotional perception in addition to impaired processing speed, verbal learning, and memory are reported by Velikonja.[35] ADHD shows clinical impairment in selective attention, processing speed, and memory subdomains.[36] Cognitive impairment across neuropsychiatric disorders occurs in almost all subdomains but is more pronounced in certain domains in certain disorders. Multiple factors and interactions at a cellular level are responsible for cognitive impairment in psychiatric patients. 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