Implementing computer assisted cognitive remediation in a high secure forensic psychiatric setting
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Introduction This thesis has two aims. The first was to systematically review the literature on the effect of computer assisted cognitive remediation (CACR) for schizophrenia on psychosocial functioning, with a focus on methodological quality and efficacy. The second aim was to evaluate the implementation of CACR in a high secure forensic setting. Method Database searches and hand searches returned 16 randomised controlled trials of CACR that included a functional outcome measure. These were reviewed against predefined quality criteria and effect sizes were calculated. In addition, an uncontrolled pre-post test design was used to evaluate the implementation of CACR in a high secure forensic hospital. Attrition rates, predictors of attrition, and participant feedback were evaluated, along with symptom and functional outcomes. Results The systematic review found a range of methodological limitations. Studies that did not share these limitations did not provide evidence that CACR improves psychosocial functioning. However, CACR may be effective in improving functional outcomes when delivered alongside interventions targeting functional skills. The experimental study found a high attrition rate; poor adherence to the treatment protocol; no clinical, risk or demographic factors to distinguish treatment completers from those dropping out during treatment; and few improvements to performance on treatment activities or functional outcome measures. Conclusion The systematic review indicates that more methodologically rigorous research is required. Future studies with a general psychiatric population should examine the effect of CACR delivered in conjunction with interventions that aim to develop functional skills. Motivational deficits may have undermined the outcomes of the experimental study and it will be important to ensure the delivery of CACR in forensic psychiatric settings is designed to incorporate strategies for enhancing motivation. In addition, using CACR to target functional outcomes may be inappropriate within a high secure forensic setting. The role of CACR as in managing risk and enhancing the outcomes of other interventions should be explored.