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<p class="ltrs-br-ltr-br-title"><span class="bold"><a id="_idTextAnchor000"></a>Cognitive Remediation Therapy for Psychotic Major Depressive Disorder</span></p>
<p class="ltrs-br-ltr-br-body-text">To the Editor: Recent studies<span class="htm-cite"><a href="#ref1">1</a></span> demonstrate that cognitive remediation therapy (CRT) improves cognition and psychosocial functioning in people with depression. However, none of these studies<span class="htm-cite"><a href="#ref1">1</a></span> appeared to include people with psychotic major depressive disorder, which from early episodes is associated with greater cognitive impairment than other mood disorders.<span class="htm-cite"><a href="#ref2">2</a></span> Here, we present a case of first-episode psychotic major depressive disorder treated with CRT.</p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold-ital">Case report.</span> Following a 4-day admission to an acute ward, Ms A, a 27-year-old, female physician, was referred to CAMEO Early Intervention in Psychosis Service in Cambridge, United Kingdom, with a <span class="italic">DSM-5</span> diagnosis of major depressive disorder with psychotic features. Despite treatment with quetiapine XL 600 mg and venlafaxine XL 225 mg, Ms A still suffered from occasional auditory hallucinations, and her mood remained low for several months after discharge. The patient received 8 sessions of cognitive-behavioral therapy for psychosis over 4 months but continued to complain of difficulties in planning tasks and lack of concentration that impeded her return to work. She was offered CRT as part of a training case for a therapist (S.A.), who was part of a team of investigators conducting a randomized controlled trial of CRT in nonaffective first-episode psychosis.<span class="htm-cite"><a href="#ref3">3</a></span> The therapist was supervised by a CRT specialist senior clinical psychologist (M.C.).</p>
<p class="ltrs-br-ltr-br-body-text">Ms A attended 15 sessions over 3 months for a total of 18 hours including homework. She set the following CRT goals: to appraise and present a journal article as part of her research, plan routine tasks in optimal order, and improve mental arithmetic. She had no difficulties with these tasks premorbidly. Approximately half of the sessions involved completing tasks on a computer program,<span class="htm-cite"><a href="#ref4">4</a></span> focusing on cognitive strategies and how to apply these to daily activities; the other half was devoted to in-vivo tasks. All of these activities were supported by the therapist.</p>
<p class="ltrs-br-ltr-br-body-text">Measures of goals (Goal Attainment Scale<span class="htm-cite"><a href="#ref5">5</a></span>), cognition (Wechsler Digit Span Task,<span class="htm-cite"><a href="#ref6">6</a></span> Rey Auditory and Verbal Learning Test<span class="htm-cite"><a href="#ref7">7</a></span> part 1, and Measure of Insight into Cognition Self-Report<span class="htm-cite"><a href="#ref8">8</a></span>), and symptoms (Calgary Depression Scale<span class="htm-cite"><a href="#ref9">9</a></span> and Rosenberg Self-Esteem Scale<span class="htm-cite"><a href="#ref10">10</a></span>) were obtained at baseline, after the last session, and 4 months after the end of therapy. All outcome measures demonstrated clinically reliable improvement<span class="htm-cite"><a href="#ref11">11</a></span> sustained over time (<span class="callout"><a href="#" onclick="createFigure('t1'); return false;">Table 1</a></span>). Ms A achieved all of her CRT goals and returned to work 11 months after her referral to the psychosis service. She is now near successful completion of her training program.</p>
<div id="figure" class="right"> <a href="#" onclick="createFigure('t1'); return false;"><img src="17l02180T1.gif" alt="Table 1" id="t1" border="0" /></a>
<p class="click-to-enlarge">Click figure to enlarge</p>
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<p class="ltrs-br-ltr-br-body-text">Ms A completed the Negative Incidents and Effects of Psychological Treatment Scale<span class="htm-cite"><a href="#ref12">12</a></span> and a feedback form. No negative effects were reported, except mildly unpleasant memories of being bullied when she found tasks difficult. She reported that CRT helped her break down tasks to make their cognitive demand more manageable and felt that CRT was instrumental in rebuilding her confidence.</p>
<p class="ltrs-br-ltr-br-body-text"> </p>
<p class="ltrs-br-ltr-br-body-text">Ms A improved with a CRT program for nonaffective psychosis. However, she required fewer therapy hours (18) than that previously reported for people with schizophrenia (approximately 32).<span class="htm-cite"><a href="#ref13">13</a></span> This need for fewer therapy hours may partly be due to milder cognitive impairment, higher levels of motivation, cognitive reserve, or premorbid functioning in psychotic major depressive disorder. Thus, there may be some scope to tailor CRT for this specific disorder. Additionally, given that psychotic major depressive disorder may be recurrent, maintenance sessions might be recommended.</p>
<p class="ltrs-br-ltr-br-body-text">This case study indicates that CRT can be effective and well tolerated in psychotic major depressive disorder. CRT could potentially be used to treat people with this condition in clinical settings such as early intervention in psychosis services. Further studies are required to confirm this finding.</p>
<p class="references_references-heading"><span class="bold">References</span></p>
<p class="references-references-text-1-9"><a name="ref1"></a><span class="htm-ref"> 1.	</span>Motter JN, Pimontel MA, Rindskopf D, et al. Computerized cognitive training and functional recovery in major depressive disorder: a meta-analysis. <span class="italic">J Affect Disord</span>. 2016;189:184–191. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=26437233&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
https://doi.org/10.1016/j.jad.2015.09.022"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-1-9"><a name="ref2"></a><span class="htm-ref"> 2.	</span>Zanelli J, Reichenberg A, Morgan K, et al. Specific and generalized neuropsychological deficits: a comparison of patients with various first-episode psychosis presentations. <span class="italic">Am J Psychiatry</span>. 2010;167(1):78–85. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=19952077&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
https://doi.org/10.1176/appi.ajp.2009.09010118"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-1-9"><a name="ref3"></a><span class="htm-ref"> 3.	</span>ISRCTN registry. ECLIPSE Study 9: Building resilience and recovery through enhancing cognition and quality. <span class="italic">ISRCTN Regist</span>.
http://www.isrctn.com/ISRCTN14678860. Accessed June 5, 2018. <a href="
https://doi.org/10.1186/isrctn14678860"><span class="pubmed-crossref">CrossRef</span></a><span class="pubmed-crossref">
http://www.isrctn.com/ISRCTN14678860 </span></p>
<p class="references-references-text-1-9"><a name="ref4"></a><span class="htm-ref"> 4.	</span>Reeder C, Pile V, Crawford P, et al. The feasibility and acceptability to service users of CIRCuiTS, a computerized cognitive remediation therapy program for schizophrenia. <span class="italic">Behav Cogn Psychother</span>. 2016;44(3):288–305. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=26004421&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
https://doi.org/10.1017/S1352465815000168"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-1-9"><a name="ref5"></a><span class="htm-ref"> 5.	</span>Kiresuk TJ, Sherman RE. Goal attainment scaling: a general method for evaluating comprehensive community mental health programs. <span class="italic">Community Ment Health J</span>. 1968;4(6):443–453. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=24185570&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
https://doi.org/10.1007/BF01530764"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-1-9"><a name="ref6"></a><span class="htm-ref"> 6.	</span>Wechsler D. <span class="italic">Manual for the Wechsler Adult Intelligence Scale</span>. New York, NY: Psychological Incorporation; 1955.</p>
<p class="references-references-text-1-9"><a name="ref7"></a><span class="htm-ref"> 7.	</span>Schmidt M. <span class="italic">Rey Auditory and Verbal Learning Test: A Handbook</span>. Los Angeles, CA: Western Psychological Association; 1996.</p>
<p class="references-references-text-1-9"><a name="ref8"></a><span class="htm-ref"> 8.	</span>Medalia A, Thysen J, Freilich B. Do people with schizophrenia who have objective cognitive impairment identify cognitive deficits on a self-report measure? <span class="italic">Schizophr Res</span>. 2008;105(1-3):156–164. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=18718740&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
https://doi.org/10.1016/j.schres.2008.07.007"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-1-9"><a name="ref9"></a><span class="htm-ref"> 9.	</span>Addington D, Addington J, Maticka-Tyndale E, et al. Reliability and validity of a depression rating scale for schizophrenics. <span class="italic">Schizophr Res</span>. 1992;6(3):201–208. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1571313&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
https://doi.org/10.1016/0920-9964(92)90003-N"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-10-99"><a name="ref10"></a>10.	Rosenberg M. <span class="italic">Society and the Adolescent Self-Image</span>. Princeton, NJ: Princeton University Press; 1965.</p>
<p class="references-references-text-10-99"><a name="ref11"></a>11.	 Morley S, Dowzer CN. <span class="italic">Manual for the Leeds Reliable Change Indicator: Simple Excel(tm) Applications for the Analysis of Individual Patient and Group Data</span>. Leeds, United Kingdom: University of Leeds; 2014.</p>
<p class="references-references-text-10-99"><a name="ref12"></a>12.	Rozental A, Kottorp A, Boettcher J, et al. Negative effects of psychological treatments: an exploratory factor analysis of the negative effects questionnaire for monitoring and reporting adverse and unwanted events. <span class="italic">PLoS One</span>. 2016;11(6):e0157503. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=27331907&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
https://doi.org/10.1371/journal.pone.0157503"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-10-99"><a name="ref13"></a>13.	Wykes T, Huddy V, Cellard C, et al. A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. <span class="italic">Am J Psychiatry</span>. 2011;168(5):472–485. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=21406461&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
https://doi.org/10.1176/appi.ajp.2010.10060855"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Sophie Allan, MSc</span><span class="superscript">a</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Matteo Cella, PhD</span><span class="superscript">b</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Til Wykes, PhD</span><span class="superscript">b,c</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Jesus Perez, PhD</span><span class="superscript">a,d,e,f</span></p>
<p class="ltrs-br-ltr-br-author"><a href="
mailto:jp440@cam.ac.uk">
jp440@cam.ac.uk</a></p>
<p class="end-matter"><span class="superscript">a</span>Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, United Kingdom</p>
<p class="end-matter"><span class="superscript">b</span>Department of Psychology, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, United Kingdom</p>
<p class="end-matter"><span class="superscript">c</span>South London and Maudsley NHS Foundation Trust, London, United Kingdom</p>
<p class="end-matter"><span class="superscript">d</span>Department of Psychiatry, University of Cambridge, United Kingdom</p>
<p class="end-matter"><span class="superscript">e</span>Norwich Medical School, University of East Anglia, United Kingdom</p>
<p class="end-matter"><span class="superscript">f</span>Department of Neuroscience, Instituto de Investigacion Biomedica de Salamanca (IBSAL), University of Salamanca, Spain</p>
<p class="end-matter"><span class="bold-italic">Potential conflicts of interest:</span> None.</p>
<p class="end-matter"><span class="bold-italic">Funding/support:</span> The authors acknowledge funding support from the National Institute for Health Research Programme Grant for Applied Research (NIHR PGfAR) RP-PG-0612-20002: “Building Resilience and Recovery through Enhancing Cognition and quality of LIfe in the early PSychosEs (ECLIPSE).” Dr Wykes acknowledges the support of the NIHR Biomedical Research Centre for Mental Health at the South London and Maudsley NHS Foundation Trust and King’s College London as well as the support of her NIHR Senior Investigator award. Dr Perez acknowledges support from the NIHR PGfAR RP-PG-0606-1335.</p>
<p class="end-matter"><span class="bold-italic">Role o</span><span class="bold-italic">f t</span><span class="bold-italic">he sponsor:</span> The NIHR had no further role in the study design; the collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the paper for publication.</p>
<p class="end-matter"><span class="bold-italic">Patient consent:</span> Permission was received from the patient to publish this case, and information has been de-identified to protect anonymity.</p>
<p class="end-matter"><span class="bold-italic">Published online:</span> June 14, 2018.</p>
<p class="end-matter"><span class="italic">Prim Care Companion CNS Disord 2018;20(3):17l02180</span></p>
<p class="front-matter-rule"><span class="bold-italic">To cite:</span> Allan S, Cella M, Wykes T, et al. Cognitive remediation therapy for psychotic major depressive disorder. <span class="italic">Prim Care Companion CNS Disord.</span> 2018;20(3):17l02180.</p>
<p class="doi-line"><span class="bold-italic">To share: </span>
https://doi.org/<span class="doi">10.4088/PCC.17l02180</span></p>
<p class="end-matter"><span class="italic">© Copyright 2018 Physicians Postgraduate Press, Inc.</span></p>
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