May 24, 2023
Cognitive Health Matters: Screen to Intervene
By Assoc. Prof Kelly Allott and Prof. Alice Medalia
What is cognitive health? A common definition is that cognitive health is the ability to think clearly, learn, remember, and problem-solve. Thinking clearly can include planning, organizing, concentrating, problem-solving, memory, creativity, and judgment. When people across ethnic, socio-economic, and geographic groups are asked what cognitive health means they usually say things like, “the thinking processes you use in daily life”, “being mentally alert”, “attentive”, “able to keep track and remember”, and “being socially engaged”.
Cognitive health is most often talked about in the context of being very young or very old. Parents watch their child develop cognitive skills and are mindful of ways to foster better concentration, language, learning, memory, and problem-solving. And then, when people turn 65, there is increased attention on staying alert and remembering. But what about all those intervening years – why don’t we talk about cognitive health when people are in their teens, 20’s, 30’s, 40’s and 50’s? Lots can happen then to impact cognitive health and so it is important to consider cognitive health across the lifespan, at all ages.
Cognitive functioning and psychosis Psychiatric disorders are a common but poorly recognized reason why people at any age can develop cognitive problems2. More severe, widespread, and persistent cognitive impairments are seen in psychotic disorders compared with any other psychiatric disorder. Research shows that cognitive problems are experienced by approximately 70-80% of people with psychotic disorders such as schizophrenia3, and that these cognitive problems emerge early, often before a psychosis diagnosis is made4. While cognitive symptoms may fluctuate with mental health symptoms, for many people with psychosis, cognitive difficulties persist even during periods of symptom remission. These cognitive problems can contribute to feelings of inadequacy, frustration, and difficulties with daily and role functioning 1,5. Thus, early detection, followed by intervention is essential.
Quotes from young people with psychosis.1
Screen to Intervene Just as with any health condition, a cognitive health ‘check-up’ (i.e., cognitive screening) is an important first step for addressing the cognitive issues experienced by people with psychosis. Screening can range from an informal discussion about cognitive health with a health professional, completion of a self-report questionnaire about cognitive symptoms, through to completing a formal brief (i.e., <30 minute) screening assessment using an objective screening tool6-8. International experts agree that cognitive screening that is developmentally, culturally, and linguistically appropriate should form part of routine mental health care 8. Mental health clinicians also recognise this need for assessing cognitive health, but many do not feel they have the confidence or knowledge in cognitive screening9. Some may even worry that talking about cognition could be upsetting. Yet people with schizophrenia say they want their concerns about cognition addressed 10,11.
· Cognitive impairment is commonly experienced by people with psychosis but is frequently identified as an area of unmet need within services.
· Cognitive screening is an important first step in identifying those in need of interventions targeting cognitive functioning but is not routinely conducted.
Resources have been developed to support clinicians in cognitive screening 12 and research is underway to validate cognitive screening in people with psychosis and determine the barriers and facilitators to routine screening in practice.
Here are some guidelines for clinicians to be responsive to cognitive health needs:
1. Ask about cognitive health using positive language. Instead of asking “Do you have problems paying attention” ask “Would it be helpful if you could pay attention better?”
2. Link cognition to functioning in areas the person values. For example, if employment is valued ask, “Would it be easier for you to do your job if your memory were better?”
3. Ask about cognitive health concerns on multiple occasions since the concerns might change.
4. Ask about and establish the course/timeline of cognitive health concerns. This will help identify the cause of cognitive difficulties.
5. Find out about strengths and strategies that help functioning. For example, “What thinking skills have you used to help you with that?”
6. Convey hope and confidence that cognitive health can be optimized.
Steps following cognitive screening might include monitoring, psychoeducation, more comprehensive cognitive assessment, or interventions addressing cognitive health.
A more detailed cognitive assessment may be helpful for treatment planning and obtaining educational /workforce accommodations. Cognitive or neuropsychological testing provides a comprehensive objective assessment using normed and validated standardised tests. The resultant profile identifies the individual’s cognitive strengths and difficulties relative to their same age peers and to their own estimated premorbid functioning, providing a baseline for future comparison.
Our organisations are working to support clinicians in cognitive screening.
Orygen in Australia and Columbia University in the United States offer a range of resources on assessing and addressing cognitive functioning in youth and adult mental health, including psychosis. See Orygen’s Youth Risk of Cognitive Impairment Toolkit, OnTrack New York’s Cognitive Health Toolkit, a clinician manual Cognitive Remediation for Psychological Disorders and a free handbook for families Dealing with Cognitive Dysfunction, for more detailed tips and strategies on cognitive screening and treatment. Working together we can address Cognitive Health across the lifespan.
Associate Professor Kelly Allott is a Principal Research Fellow at Orygen and the Centre for Youth Mental Health, The University of Melbourne. She is also a Clinical Neuropsychologist in private practice. Kelly leads the Cognition Research Program at Orygen, which focuses on understanding cognition in early-stage mental illness in youth and testing and developing treatments for supporting optimal cognitive health and functional recovery. Her work also focuses on upskilling the youth mental health workforce in assessing and addressing cognition in clinical practice.
You can follow Kelly on
Google: Scholar: https://scholar.google.com.au/citations?user=7cvZW9QAAAAJ&hl=en
Dr. Medalia is a Professor in the Department of Psychiatry at Columbia University Irving Medical Center and Director of Cognitive Health Services for the New York State Office of Mental Health. She is also a member of the Columbia University Academy of Clinical Excellence, and the founding director of the Lieber Recovery and Rehabilitation Clinic, a comprehensive psychiatric rehabilitation program for individuals with persistent mental illness. Professor Medalia brought the concept of Cognitive Health to the field of Psychiatry and identified the need for the treatment of cognition to embrace an understanding of how motivation and learning interact. She developed the widely used Neuropsychological & Educational Approach to Remediation (NEAR) model of cognitive remediation, which has been disseminated worldwide. In 1998 she started Cognitive Remediation in Psychiatry, the largest annual international conference devoted to addressing cognitive health for people with psychiatric disorders. Professor Medalia is the founding director of www.teachrecovery.com, a website devoted to facilitating training of mental health professionals in cognitive health interventions for people with psychiatric disorders. She is a NIMH funded researcher, prolific author, and the recipient of numerous awards for outstanding leadership in psychiatric rehabilitation.
You can follow Dr Medalia
Research Gate: https://www.researchgate.net/profile/Alice-Medalia
Google Scholar: https://scholar.google.com/scholar?hl=en&as_sdt=0%2C33&q=alice+medalia
1 Wright, Phillips, Bryce, Morey-Nase, Allott 2019 Subjective experiences of cognitive functioning in early psychosis: a qualitative study. Psychosis 11:63-74.
2 Abramovitch, Short, Schweiger 2021 The C Factor: Cognitive dysfunction as a transdiagnostic dimension in psychopathology. Clinical Psychology Review 86:102007.
3 Allen, Goldstein, Warnick 2003 A consideration of neuropsychologically normal schizophrenia. Journal of the International Neuropsychological Society 9:56-63.
4 Catalan, et al 2021 Neurocognitive functioning in individuals at clinical high risk for psychosis: A systematic review and meta-analysis. JAMA Psychiatry 78:859-67.
5 Cowman, Holleran, Lonergan, O’Connor, Birchwood, Donohoe 2021 Cognitive predictors of social and occupational functioning in early psychosis: A systematic review and meta-analysis of cross-sectional and longitudinal data. Schizophrenia Bulletin 47:1243-53.
6 Bryce, Allott 2019 Cognitive screening: A significant unmet need in youth mental health. Australian And New Zealand Journal Of Psychiatry 53:813.
7 Bryce, Bowden, Wood, Allott 2021 Brief, performance-based cognitive screening in youth aged 12-25: A systematic review. Journal of the International Neuropsychological Society 27:835-54.
8 McIntyre, et al 2019 Expert Consensus on Screening and Assessment of Cognition in Psychiatry. CNS Spectrums 24:154-62.
9 Saperstein, Medalia, Bello, Dixon 2021 Addressing cognitive health in coordinated specialty care for early psychosis: Real-world perspectives. Early Intervention in Psychiatry 15:374-9.
10 Bryce, S., Cheng, N., Dalton, A., Ojinnaka, A., Stainton, A., Zbukvic, I., Ratheesh, A., O’Halloran, C., Uren, J., Gates, J., Daglas-Georgiou, R., Wood, S.J., & Allott, K. (2023). Cognitive health treatment priorities and preferences among young people with mental illness: The Your Mind, Your Choice survey. Early Intervention in Psychiatry, Accepted 5 May 2023.
11. Moritz, Berna, Jaeger, Westermann, Nagel 2017 The customer is always right? Subjective target symptoms and treatment preferences in patients with psychosis. European Archives of Psychiatry and Clinical Neuroscience 267:335-9.
12 Saperstein, Medalia, Malinovsky, Bello, Dixon 2021 Toolkit for assessing and addressing cognitive health in early psychosis: Evaluation of feasibility and utility in a coordinated specialty care setting. Early Intervention in Psychiatry 15:1376-81.
Declaration of Interest
Associate Professor Allott is funded by the Medical Research Future Fund from the Australian Government to conduct a study to validate cognitive screening in first-episode psychosis.
Professor Medalia consults to Sumitomo and Boehringer Ingelheim and receives royalties from Oxford University Press
The World Schizophrenia Day 2023 IEPA Project has been sponsored by H. Lundbeck A/S