Archives of Psychiatric Nursing xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Archives of Psychiatric Nursing journal homepage: www.elsevier.com/locate/apnu
A Pilot Study of iPad-Assisted Cognitive Training for Schizophrenia Jin Dang a, Jiangtao Zhang b, Zhongwei Guo b, Weihong Lu a, Jun Cai a, Zhongying Shi a, Chen Zhang a, c,⁎ a
Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China c Key Laboratory of Animal Models and Human Disease Mechanisms of the Chinese Academy of Sciences & Yunnan Province, Kunming Institute of Zoology, Kunming 650223, Yunnan, China b
a b s t r a c t In this pilot study, we aimed to examine whether iPad-assisted cognitive training could be beneficial in ameliorating some of the cognitive impairment that accompany schizophrenia. Totally, 20 first-episode schizophrenia patients were randomly assigned to an experiment group (with cognitive training) or to a control group (without cognitive training). The N-back task was assessed at baseline and after intervention, to see what effects iPad-assisted training might have (week 4). The experimental group exhibited significant improvement in the accuracy rate at 2-back, and reaction time at 0, 1 and 2-back tasks. These findings suggest that iPad- or other technically-assisted cognitive training may potentially be a valid strategy for pursuing cognitive rehabilitation among those with schizophrenia. © 2014 Elsevier Inc. All rights reserved.
Schizophrenia is a chronic, severe and disabling mental disorder with clinical manifestations of a disruption in cognition along with positive and negative symptoms (Fatemi & Folsom, 2009). Our previous work revealed a wide range of cognitive functions substantially impaired among antipsychotic-naïve patients with first-episode schizophrenia (Lu et al., 2012), which supports the view that cognitive impairment is at the core of this disorder (Elvevag & Goldberg, 2000). Accumulated data indicate that cognitive impairment is among the most important factors in contributing to the social deficits and the functional outcome for schizophrenia patients (Keefe & Harvey, 2012). As such, finding viable methods of cognitive improvement has become an increasingly important target for research on schizophrenia treatment (Marder & Fenton, 2004). To date, trials of cognitive medications in schizophrenia have not provided sufficiently satisfactory results. While unfortunate, these results have highlighted the idea that cognitive enrichment strategies may be necessary to drive meaningful clinical improvements among patients with schizophrenia (Vinogradov, Fisher, & Nagarajan, 2013). Several lines of evidence have demonstrated that cognitive training exercises can improve certain and specific aspects of cognition in patients with schizophrenia, in particular, working memory—a core neuropsychological dysfunction exhibited in this disorder (Genevsky, Garrett, Alexander, & Vinogradov, 2010; Silver, Feldman, Bilker, & Gur, 2003). These findings suggest that cognitive training may be a valid strategy for improving cognition among patients with schizophrenia, but to date no effective cognitive training paradigm has been introduced or tested for clinical application. ⁎ Corresponding Author: Chen Zhang MD, PhD, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China. E-mail addresses: [email protected] (Z. Shi), [email protected] (C. Zhang).
While there is a dearth of clinical programs aimed at facilitating cognitive training, the private sector has provided a few options. One popular variant is the iPad, which includes a line of popular touch screen tablet-style devices (Apple, Cupertino, CA, USA) with an accompanying “App Store” that already has a number of cognitive training games available to download. This user-friendly tablet has been widely adopted in entertainment, education and health care service sectors, and is quite familiar to consumers across the globe, especially in China. We hypothesized that as the device is familiar and the software is already available, the iPad may prove an ideal test-case technology for cognitive training and may be beneficial for cognitive impairment among patients with schizophrenia. It is well-established that schizophrenia patients suffer from a wide range of cognitive functions. Given the essential role of working memory deficit in cognitive impairment of schizophrenia (Lee & Park, 2005), in this pilot study, we aimed to evaluate the effects of an iPad-assisted cognitive training on working memory in a group of male, first-episode (FEP) schizophrenia patients.
METHODS Study design Designed as a pilot study, FEP patients (drug-naïve prior to study) were recruited to a group parallel-randomized clinical trial. Assessments were carried out at baseline (week 0) and follow-up (week 4). The main treatment outcome measure was the N-back task. This is a continuous performance task that has become a standard working memory measure in cognitive neuroscience (Kane, Conway, Miura, & Colflesh, 2007).
0883-9417/1801-0005$34.00/0 – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.apnu.2014.01.003
Please cite this article as: Dang, J., et al., A Pilot Study of iPad-Assisted Cognitive Training for Schizophrenia, Archives of Psychiatric Nursing (2014), http://dx.doi.org/10.1016/j.apnu.2014.01.003
2
J. Dang et al. / Archives of Psychiatric Nursing xxx (2014) xxx–xxx
Subjects All procedures for this study were reviewed and approved by the Institutional Review Boards of the Shanghai Mental Health Center and other participating institutions. A total of 20 male FEP patients were recruited from the Inpatient Unit of Shanghai Mental Health Center and Tongde Hospital of Zhejiang Province, because we assumed that iPad-assisted cognitive training may be more acceptable for males than it is for females (Chou et al., 2013). Details on the recruitment procedures are described in our previous study (Lu et al., 2012). After written informed consent was given, patients were randomly assigned to either experiment or control group. During the course of the study, all patients were treated with olanzapine monotherapy. Cognitive assessments The Wechsler Memory Scale-Revised (WMS-R) and full versions of the Wechsler Adult Intelligence Scale-Revised (WAIS-R) were administrated to all participants at baseline, and the N-back task was measured to the participants at baseline and 4 weeks, as described previously (Zhang, Cai et al., 2014). N-back performance was recorded as an accuracy rate, that is a percent of correct responses (%) and reaction time (ms). Cognitive training was performed on iPads provided by the research team. We provided four user-friendly iPad games for cognitive training in the experiment group, (recommended from http://www.teachthought.com) which included Chinese versions of “Shanghai Mahjong”, “Little Ace and the Ten Commandments”, “Math vs. Brains” and “Brain Teaser Extreme”. The cognitive training program was carried out under the assistance of nurses. After patients were taught how to play the games by nurses, participants were free to select their favorite games at each exercise session. Participants engaged in the cognitive training for 60 minutes a day, 5 days a week (Mahncke et al., 2006). Participants were monitored to ensure a consistent amount of training time. Statistical analysis All statistical analyses were performed using SPSS 17.0 (SPSS Inc., Chicago, IL, USA). Group comparisons of demographic variables at baseline were assessed using a t-test. We calculated standardized effect sizes by examining changes in test scores (post-test score minus pre-test score) in order to investigate the magnitude of the cognitive training's effect on working memory. Due to significant deviation of the data from the normal distribution, non-parametric tests were used in our analyses. The effect of cognitive training on six working memory measures was analyzed using Mann–Whitney U test. To correct for multiple testing using the Bonferroni test, corrected P values were set at an uncorrected P value multiplied by k (independent significance tests) (Zhang, Zhang et al., 2013). All P values are two-tailed, and P values less than 0.05 were considered statistically significant after Bonferroni correction. RESULTS Of the 20 participant enrolled in this study, 3 were dropped from the study (2 from the experiment group; 1 from the control group). The major reasons being discharged from hospital (n = 2) and switching to other medication due to the side effects induced by olanzapine (n = 1). This left a total of 8 participants that completed the experiment and 9 that remained in the control group. Demographic, clinical and cognitive variables for all remaining participants are presented in Table 1, but in general the two groups were equivalent across all measures at baseline. Changes for each N-back test and results of the Mann–Whitney U test are displayed in Fig. 1. Patients in the experiment group improved
Table 1 Demographic and Clinical Characteristics of the Patients in Experiment and Control Groups. Exp. (n = 8) Age (years) Education (years) Intelligence quotient (IQ) Memory quotient (MQ) N-back Accuracy rate (%) 0-back 1-back 2-back Reaction times (ms) 0-back 1-back 2-back
t
P
(2.8) (2.8) (5.0) (5.8)
0.22 0.12 −0.16 −0.18
0.83 0.90 0.87 0.86
96.6 (1.6) 87.5 (7.1) 76.0 (8.7)
95.3 (2.0) 91.0 (5.3) 78.9 (9.3)
1.45 −1.17 −0.66
0.17 0.26 0.52
919.5 (76.6) 870.7 (31.6) 1272.2 (151.0)
972.3 (105.6) 871.1 (19.8) 1184.5 (100.6)
−1.16 −0.03 1.43
0.26 0.97 0.17
25.4 12.7 96.1 89.1
(2.9) (2.2) (5.8) (6.0)
Ctl. (n = 9) 25.0 12.5 96.8 89.3
NOTE. Data presented as mean (SD). NOTE. Exp. = experiment group; Ctl. = control group.
significantly in accuracy rate at 2-back (Z = − 3.27, Pcorrected b 0.01), and reaction time in 0, 1 and 2-back (Z = − 2.89, Pcorrected = 0.012; Z = − 2.60, Pcorrected = 0.048; Z = − 2.98, Pcorrected = 0.012, respectively) from baseline to week 4, as compared with those in the control group. DISCUSSION In this pilot trial, the effect of an iPad-assisted cognitive training for working memory was evaluated among FEP patients with schizophrenia. As expected, we found that this training resulted in significant improvement in the test results of N-back task. It has been widely acknowledged that highly intelligent individuals with high cognitive reserve tend to perform well on individual cognitive tests (Rentz et al., 2007). Our results showed no significant differences in the demographic, clinical and cognitive variables between the two groups, which suggests that cognitive reserve likely does not influence the results of N-back performance. Our findings are consistent with prior studies that have shown cognitive improvement in schizophrenia patients using computerized exercises (D'Souza et al., 2013; Murthy et al., 2012; Rass et al., 2012). Although a great deal of effort has been made to explore the methods of cognitive training, these cognitive training paradigms tend to be self-designed and hard to spread in clinical practice (Franck et al., 2013; Lee, 2013; Pontes et al., 2013). As a popular electronic product, the iPad possesses various advantages for clinical exercise, such as strong operability, comparatively low-cost and ease of use, etc. While other platforms may offer similar results, the advantages of using the iPad make it an interesting test-case technology for these types of treatments. Plausibly, there would be little difference if another technology was used, but that can only be confirmed by similar studies trying to replicate our results. To the best of our knowledge, this is the first attempt to use iPads or similar technologies for cognitive rehabilitation of patients with schizophrenia. In this study, we observed that no patient dropped due to not accepting the usage of the iPad. This suggests that iPad-assisted cognitive training may be an acceptable paradigm for treating cognitive deficits in schizophrenia. Accordingly, our findings indicate that iPad-assisted cognitive training may be a valid strategy for cognitive rehabilitation in schizophrenia. LIMITATIONS When interpreting the results of this study, some methodological limitations should be noted. First, the sample size was relatively small and consisted predominantly of men. Obviously, our decision to focus on male patients and the results from their training using
Please cite this article as: Dang, J., et al., A Pilot Study of iPad-Assisted Cognitive Training for Schizophrenia, Archives of Psychiatric Nursing (2014), http://dx.doi.org/10.1016/j.apnu.2014.01.003
J. Dang et al. / Archives of Psychiatric Nursing xxx (2014) xxx–xxx
3
Fig. 1. Mean changes of the six factors at N-back task from baseline to week 4. (A) Changes of accuracy rate; (B) changes of reaction time. *P b 0.05; **P b 0.01 vs. Ctl. Exp. = experiment group; Ctl. = control group.
the iPad may not be entirely consistent with the experience and results that female patients with schizophrenia might have when undertaking similar training. Again, there is no clear way to know if this is the case or not, hence further follow-up studies that can replicate our findings or test them against different scenarios would be highly beneficial. This decision in the design of the study thereby presents a hypothesis-generating rather than a confirmatory character. Consequently, our results should be viewed as preliminary, and large-scale investigations will be needed in the near-future. Power analyses suggest that sample size of at least 42 would be needed when using the test employed in this study. Second, this study employed a cognitive test designed specifically for working memory. Whether these results generalize to other cognitive domains requires further studies with a similar methodology. Lastly, the present study does have an open-label design, and despite randomization, this design feature may affect judgment. CONCLUSION This pilot study is the first randomized controlled trial to investigate the effect of iPad-assisted cognitive training on cognitive rehabilitation among schizophrenia patients. Our findings suggest that an iPad-assisted cognitive training may potentially be a valid strategy for cognitive rehabilitation in schizophrenia, prompting us to recommend further clinical expansion and application. Acknowledgment We are deeply grateful to all participants. This work was supported by the National Natural Science Foundation of China (81000581), China Postdoctoral Science Foundation (2013 M530410), Shanghai Science & Technology Development Foundation (12140904200) and National Key Clinical Disciplines at Shanghai Mental Health Center (OMA-MH, 2011–873). References Chou, Y. H., Yang, B. H., Hsu, J. W., Wang, S. J., Lin, C. L., Huang, K. L., et al. (2013). Effects of video game playing on cerebral blood flow in young adults: A SPECT study. Psychiatry Research, 212, 65–72. D'Souza, D. C., Radhakrishnan, R., Perry, E., Bhakta, S., Singh, N. M., Yadav, R., et al. (2013). Feasibility, safety, and efficacy of the combination of D-serine and computerized cognitive retraining in schizophrenia: An international collaborative pilot study. Neuropsychopharmacology, 38, 492–503.
Elvevag, B., & Goldberg, T. E. (2000). Cognitive impairment in schizophrenia is the core of the disorder. Critical Reviews in Neurobiology, 14, 1–21. Fatemi, S. H., & Folsom, T. D. (2009). The neurodevelopmental hypothesis of schizophrenia, revisited. Schizophrenia Bulletin, 35, 528–548. Franck, N., Duboc, C., Sundby, C., Amado, I., Wykes, T., Demily, C., et al. (2013). Specific vs general cognitive remediation for executive functioning in schizophrenia: A multicenter randomized trial. Schizophrenia Research, 147, 68–74. Genevsky, A., Garrett, C. T., Alexander, P. P., & Vinogradov, S. (2010). Cognitive training in schizophrenia: A neuroscience-based approach. Dialogues in Clinical Neurosciences, 12, 416–421. Kane, M. J., Conway, A. R., Miura, T. K., & Colflesh, G. J. (2007). Working memory, attention control, and the N-back task: A question of construct validity. Journal of Experimental Psychology Learning Memory and Cognition, 33, 615–622. Keefe, R. S., & Harvey, P. D. (2012). Cognitive impairment in schizophrenia. Handbook of Experimental Pharmacology, 213, 11–37. Lee, W. K. (2013). Effectiveness of computerized cognitive rehabilitation training on symptomatological, neuropsychological and work function in patients with schizophrenia. Asia-Pacific Psychiatry, 5, 90–100. Lee, J., & Park, S. (2005). Working memory impairments in schizophrenia: A meta-analysis. Journal of Abnormal Psychology, 114, 599–611. Lu, W. H., Zhang, C., Yi, Z. H., Li, Z. Z., Wu, Z. G., & Fang, Y. R. (2012). Association between BDNF Val66Met polymorphism and cognitive performance in antipsychotic-naive patients with schizophrenia. Journal of Molecular Neuroscience, 47, 505–510. Mahncke, H. W., Connor, B. B., Appelman, J., Ahsanuddin, O. N., Hardy, J. L., Wood, R. A., et al. (2006). Memory enhancement in healthy older adults using a brain plasticity-based training program: A randomized, controlled study. Proceedings of the National Academy of Science of the United States of America, 103, 12523–12528. Marder, S. R., & Fenton, W. (2004). Measurement and treatment research to improve cognition in schizophrenia: NIMH MATRICS initiative to support the development of agents for improving cognition in schizophrenia. Schizophrenia Research, 72, 5–9. Murthy, N. V., Mahncke, H., Wexler, B. E., Maruff, P., Inamdar, A., Zucchetto, M., et al. (2012). Computerized cognitive remediation training for schizophrenia: An open label, multi-site, multinational methodology study. Schizophrenia Research, 139, 87–91. Pontes, L. M., Martins, C. B., Napolitano, I. C., Fonseca, J. R., Oliveira, G. M., Iso, S. M., et al. (2013). Cognitive training for schizophrenia in developing countries: A pilot trial in Brazil. Schizophrenia Research and Treatment, 2013, 321725. Rass, O., Forsyth, J. K., Bolbecker, A. R., Hetrick, W. P., Breier, A., Lysaker, P. H., et al. (2012). Computer-assisted cognitive remediation for schizophrenia: A randomized single-blind pilot study. Schizophrenia Research, 139, 92–98. Rentz, D. M., Huh, T. J., Sardinha, L. M., Moran, E. K., Becker, J. A., Daffner, K. R., et al. (2007). Intelligence quotient-adjusted memory impairment is associated with abnormal single photon emission computed tomography perfusion. Journal of the International Neuropsychological Society, 13, 821–831. Silver, H., Feldman, P., Bilker, W., & Gur, R. C. (2003). Working memory deficit as a core neuropsychological dysfunction in schizophrenia. American Journal of Psychiatry, 160, 1809–1816. Vinogradov, S., Fisher, M., & Nagarajan, S. (2013). Cognitive training in schizophrenia: Golden age or wild west? Biological Psychiatry, 73, 935–937. Zhang, C., Cai, J., Zhang, J., Li, Z., Guo, Z., Zhang, X., et al. (2014). Genetic modulation of working memory deficits by ankyrin 3 gene in schizophrenia. Progress in Neuropsychopharmacology & Biological Psychiatry, 50, 110–115. Zhang, X., Zhang, C., Wu, Z., Wang, Z., Peng, D., Chen, J., et al. (2013). Association of genetic variation in CACNA1C with bipolar disorder in Han Chinese. Journal of Affective Disorders, 150, 261–265.
Please cite this article as: Dang, J., et al., A Pilot Study of iPad-Assisted Cognitive Training for Schizophrenia, Archives of Psychiatric Nursing (2014), http://dx.doi.org/10.1016/j.apnu.2014.01.003
Contents lists available at ScienceDirect
Archives of Psychiatric Nursing journal homepage: www.elsevier.com/locate/apnu
A Pilot Study of iPad-Assisted Cognitive Training for Schizophrenia Jin Dang a, Jiangtao Zhang b, Zhongwei Guo b, Weihong Lu a, Jun Cai a, Zhongying Shi a, Chen Zhang a, c,⁎ a
Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China c Key Laboratory of Animal Models and Human Disease Mechanisms of the Chinese Academy of Sciences & Yunnan Province, Kunming Institute of Zoology, Kunming 650223, Yunnan, China b
a b s t r a c t In this pilot study, we aimed to examine whether iPad-assisted cognitive training could be beneficial in ameliorating some of the cognitive impairment that accompany schizophrenia. Totally, 20 first-episode schizophrenia patients were randomly assigned to an experiment group (with cognitive training) or to a control group (without cognitive training). The N-back task was assessed at baseline and after intervention, to see what effects iPad-assisted training might have (week 4). The experimental group exhibited significant improvement in the accuracy rate at 2-back, and reaction time at 0, 1 and 2-back tasks. These findings suggest that iPad- or other technically-assisted cognitive training may potentially be a valid strategy for pursuing cognitive rehabilitation among those with schizophrenia. © 2014 Elsevier Inc. All rights reserved.
Schizophrenia is a chronic, severe and disabling mental disorder with clinical manifestations of a disruption in cognition along with positive and negative symptoms (Fatemi & Folsom, 2009). Our previous work revealed a wide range of cognitive functions substantially impaired among antipsychotic-naïve patients with first-episode schizophrenia (Lu et al., 2012), which supports the view that cognitive impairment is at the core of this disorder (Elvevag & Goldberg, 2000). Accumulated data indicate that cognitive impairment is among the most important factors in contributing to the social deficits and the functional outcome for schizophrenia patients (Keefe & Harvey, 2012). As such, finding viable methods of cognitive improvement has become an increasingly important target for research on schizophrenia treatment (Marder & Fenton, 2004). To date, trials of cognitive medications in schizophrenia have not provided sufficiently satisfactory results. While unfortunate, these results have highlighted the idea that cognitive enrichment strategies may be necessary to drive meaningful clinical improvements among patients with schizophrenia (Vinogradov, Fisher, & Nagarajan, 2013). Several lines of evidence have demonstrated that cognitive training exercises can improve certain and specific aspects of cognition in patients with schizophrenia, in particular, working memory—a core neuropsychological dysfunction exhibited in this disorder (Genevsky, Garrett, Alexander, & Vinogradov, 2010; Silver, Feldman, Bilker, & Gur, 2003). These findings suggest that cognitive training may be a valid strategy for improving cognition among patients with schizophrenia, but to date no effective cognitive training paradigm has been introduced or tested for clinical application. ⁎ Corresponding Author: Chen Zhang MD, PhD, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China. E-mail addresses: [email protected] (Z. Shi), [email protected] (C. Zhang).
While there is a dearth of clinical programs aimed at facilitating cognitive training, the private sector has provided a few options. One popular variant is the iPad, which includes a line of popular touch screen tablet-style devices (Apple, Cupertino, CA, USA) with an accompanying “App Store” that already has a number of cognitive training games available to download. This user-friendly tablet has been widely adopted in entertainment, education and health care service sectors, and is quite familiar to consumers across the globe, especially in China. We hypothesized that as the device is familiar and the software is already available, the iPad may prove an ideal test-case technology for cognitive training and may be beneficial for cognitive impairment among patients with schizophrenia. It is well-established that schizophrenia patients suffer from a wide range of cognitive functions. Given the essential role of working memory deficit in cognitive impairment of schizophrenia (Lee & Park, 2005), in this pilot study, we aimed to evaluate the effects of an iPad-assisted cognitive training on working memory in a group of male, first-episode (FEP) schizophrenia patients.
METHODS Study design Designed as a pilot study, FEP patients (drug-naïve prior to study) were recruited to a group parallel-randomized clinical trial. Assessments were carried out at baseline (week 0) and follow-up (week 4). The main treatment outcome measure was the N-back task. This is a continuous performance task that has become a standard working memory measure in cognitive neuroscience (Kane, Conway, Miura, & Colflesh, 2007).
0883-9417/1801-0005$34.00/0 – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.apnu.2014.01.003
Please cite this article as: Dang, J., et al., A Pilot Study of iPad-Assisted Cognitive Training for Schizophrenia, Archives of Psychiatric Nursing (2014), http://dx.doi.org/10.1016/j.apnu.2014.01.003
2
J. Dang et al. / Archives of Psychiatric Nursing xxx (2014) xxx–xxx
Subjects All procedures for this study were reviewed and approved by the Institutional Review Boards of the Shanghai Mental Health Center and other participating institutions. A total of 20 male FEP patients were recruited from the Inpatient Unit of Shanghai Mental Health Center and Tongde Hospital of Zhejiang Province, because we assumed that iPad-assisted cognitive training may be more acceptable for males than it is for females (Chou et al., 2013). Details on the recruitment procedures are described in our previous study (Lu et al., 2012). After written informed consent was given, patients were randomly assigned to either experiment or control group. During the course of the study, all patients were treated with olanzapine monotherapy. Cognitive assessments The Wechsler Memory Scale-Revised (WMS-R) and full versions of the Wechsler Adult Intelligence Scale-Revised (WAIS-R) were administrated to all participants at baseline, and the N-back task was measured to the participants at baseline and 4 weeks, as described previously (Zhang, Cai et al., 2014). N-back performance was recorded as an accuracy rate, that is a percent of correct responses (%) and reaction time (ms). Cognitive training was performed on iPads provided by the research team. We provided four user-friendly iPad games for cognitive training in the experiment group, (recommended from http://www.teachthought.com) which included Chinese versions of “Shanghai Mahjong”, “Little Ace and the Ten Commandments”, “Math vs. Brains” and “Brain Teaser Extreme”. The cognitive training program was carried out under the assistance of nurses. After patients were taught how to play the games by nurses, participants were free to select their favorite games at each exercise session. Participants engaged in the cognitive training for 60 minutes a day, 5 days a week (Mahncke et al., 2006). Participants were monitored to ensure a consistent amount of training time. Statistical analysis All statistical analyses were performed using SPSS 17.0 (SPSS Inc., Chicago, IL, USA). Group comparisons of demographic variables at baseline were assessed using a t-test. We calculated standardized effect sizes by examining changes in test scores (post-test score minus pre-test score) in order to investigate the magnitude of the cognitive training's effect on working memory. Due to significant deviation of the data from the normal distribution, non-parametric tests were used in our analyses. The effect of cognitive training on six working memory measures was analyzed using Mann–Whitney U test. To correct for multiple testing using the Bonferroni test, corrected P values were set at an uncorrected P value multiplied by k (independent significance tests) (Zhang, Zhang et al., 2013). All P values are two-tailed, and P values less than 0.05 were considered statistically significant after Bonferroni correction. RESULTS Of the 20 participant enrolled in this study, 3 were dropped from the study (2 from the experiment group; 1 from the control group). The major reasons being discharged from hospital (n = 2) and switching to other medication due to the side effects induced by olanzapine (n = 1). This left a total of 8 participants that completed the experiment and 9 that remained in the control group. Demographic, clinical and cognitive variables for all remaining participants are presented in Table 1, but in general the two groups were equivalent across all measures at baseline. Changes for each N-back test and results of the Mann–Whitney U test are displayed in Fig. 1. Patients in the experiment group improved
Table 1 Demographic and Clinical Characteristics of the Patients in Experiment and Control Groups. Exp. (n = 8) Age (years) Education (years) Intelligence quotient (IQ) Memory quotient (MQ) N-back Accuracy rate (%) 0-back 1-back 2-back Reaction times (ms) 0-back 1-back 2-back
t
P
(2.8) (2.8) (5.0) (5.8)
0.22 0.12 −0.16 −0.18
0.83 0.90 0.87 0.86
96.6 (1.6) 87.5 (7.1) 76.0 (8.7)
95.3 (2.0) 91.0 (5.3) 78.9 (9.3)
1.45 −1.17 −0.66
0.17 0.26 0.52
919.5 (76.6) 870.7 (31.6) 1272.2 (151.0)
972.3 (105.6) 871.1 (19.8) 1184.5 (100.6)
−1.16 −0.03 1.43
0.26 0.97 0.17
25.4 12.7 96.1 89.1
(2.9) (2.2) (5.8) (6.0)
Ctl. (n = 9) 25.0 12.5 96.8 89.3
NOTE. Data presented as mean (SD). NOTE. Exp. = experiment group; Ctl. = control group.
significantly in accuracy rate at 2-back (Z = − 3.27, Pcorrected b 0.01), and reaction time in 0, 1 and 2-back (Z = − 2.89, Pcorrected = 0.012; Z = − 2.60, Pcorrected = 0.048; Z = − 2.98, Pcorrected = 0.012, respectively) from baseline to week 4, as compared with those in the control group. DISCUSSION In this pilot trial, the effect of an iPad-assisted cognitive training for working memory was evaluated among FEP patients with schizophrenia. As expected, we found that this training resulted in significant improvement in the test results of N-back task. It has been widely acknowledged that highly intelligent individuals with high cognitive reserve tend to perform well on individual cognitive tests (Rentz et al., 2007). Our results showed no significant differences in the demographic, clinical and cognitive variables between the two groups, which suggests that cognitive reserve likely does not influence the results of N-back performance. Our findings are consistent with prior studies that have shown cognitive improvement in schizophrenia patients using computerized exercises (D'Souza et al., 2013; Murthy et al., 2012; Rass et al., 2012). Although a great deal of effort has been made to explore the methods of cognitive training, these cognitive training paradigms tend to be self-designed and hard to spread in clinical practice (Franck et al., 2013; Lee, 2013; Pontes et al., 2013). As a popular electronic product, the iPad possesses various advantages for clinical exercise, such as strong operability, comparatively low-cost and ease of use, etc. While other platforms may offer similar results, the advantages of using the iPad make it an interesting test-case technology for these types of treatments. Plausibly, there would be little difference if another technology was used, but that can only be confirmed by similar studies trying to replicate our results. To the best of our knowledge, this is the first attempt to use iPads or similar technologies for cognitive rehabilitation of patients with schizophrenia. In this study, we observed that no patient dropped due to not accepting the usage of the iPad. This suggests that iPad-assisted cognitive training may be an acceptable paradigm for treating cognitive deficits in schizophrenia. Accordingly, our findings indicate that iPad-assisted cognitive training may be a valid strategy for cognitive rehabilitation in schizophrenia. LIMITATIONS When interpreting the results of this study, some methodological limitations should be noted. First, the sample size was relatively small and consisted predominantly of men. Obviously, our decision to focus on male patients and the results from their training using
Please cite this article as: Dang, J., et al., A Pilot Study of iPad-Assisted Cognitive Training for Schizophrenia, Archives of Psychiatric Nursing (2014), http://dx.doi.org/10.1016/j.apnu.2014.01.003
J. Dang et al. / Archives of Psychiatric Nursing xxx (2014) xxx–xxx
3
Fig. 1. Mean changes of the six factors at N-back task from baseline to week 4. (A) Changes of accuracy rate; (B) changes of reaction time. *P b 0.05; **P b 0.01 vs. Ctl. Exp. = experiment group; Ctl. = control group.
the iPad may not be entirely consistent with the experience and results that female patients with schizophrenia might have when undertaking similar training. Again, there is no clear way to know if this is the case or not, hence further follow-up studies that can replicate our findings or test them against different scenarios would be highly beneficial. This decision in the design of the study thereby presents a hypothesis-generating rather than a confirmatory character. Consequently, our results should be viewed as preliminary, and large-scale investigations will be needed in the near-future. Power analyses suggest that sample size of at least 42 would be needed when using the test employed in this study. Second, this study employed a cognitive test designed specifically for working memory. Whether these results generalize to other cognitive domains requires further studies with a similar methodology. Lastly, the present study does have an open-label design, and despite randomization, this design feature may affect judgment. CONCLUSION This pilot study is the first randomized controlled trial to investigate the effect of iPad-assisted cognitive training on cognitive rehabilitation among schizophrenia patients. Our findings suggest that an iPad-assisted cognitive training may potentially be a valid strategy for cognitive rehabilitation in schizophrenia, prompting us to recommend further clinical expansion and application. Acknowledgment We are deeply grateful to all participants. This work was supported by the National Natural Science Foundation of China (81000581), China Postdoctoral Science Foundation (2013 M530410), Shanghai Science & Technology Development Foundation (12140904200) and National Key Clinical Disciplines at Shanghai Mental Health Center (OMA-MH, 2011–873). References Chou, Y. H., Yang, B. H., Hsu, J. W., Wang, S. J., Lin, C. L., Huang, K. L., et al. (2013). Effects of video game playing on cerebral blood flow in young adults: A SPECT study. Psychiatry Research, 212, 65–72. D'Souza, D. C., Radhakrishnan, R., Perry, E., Bhakta, S., Singh, N. M., Yadav, R., et al. (2013). Feasibility, safety, and efficacy of the combination of D-serine and computerized cognitive retraining in schizophrenia: An international collaborative pilot study. Neuropsychopharmacology, 38, 492–503.
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Please cite this article as: Dang, J., et al., A Pilot Study of iPad-Assisted Cognitive Training for Schizophrenia, Archives of Psychiatric Nursing (2014), http://dx.doi.org/10.1016/j.apnu.2014.01.003
