计算机认知矫正治疗对不同程度认知功能损害精神分裂症患者的临床效应差异

The clinical effect of computerized cognitive remediation therapy in schizophrenic patients with different levels of cognitive impairment

目的探讨计算机认知矫正治疗(computerized cognitive remediation therapy,CCRT)对精神分裂症患者认知功能的改善率以及不同程度认知功能损害的患者对CCRT的临床效应差异。方法采用随机数字表法将311例精神分裂症患者分成CCRT组(n=196)和工娱治疗(work and amusement therapy,WAT)组(n=115),分别给予自主开发的CCRT、操作性音乐和舞蹈治疗12周。在治疗前、后采用精神分裂症认知功能成套测验(MATRICS Consensus Cognitive Battery,MCCB)对患者的认知功能进行评估,按基线时MCCB总分将患者认知功能分为4个水平:严重认知功能损害、中度认知功能损害、轻度认知功能损害、认知功能正常,根据MCCB总分的变化将患者的疗效分为3种情况:无改善(≤0分),改善(0~9.57分),显著改善(>9.57分),最后比较2组认知功能改善率的差异。结果CCRT组认知功能显著改善19例,改善105例,无改善46例;WAT组显著改善7例,改善39例,无改善41例。CCRT组认知功能的改善优于WAT组(Z=2.978,P=0.003)。CCRT组较WAT组严重认知功能损害的患者有较高的改善率(Z=1.860,P=0.032)。CCRT组中度认知功能损害的患者无改善率低于WAT组(Z=-1.817,P=0.035)。CCRT组轻度认知功能损害的患者较WAT组无改善率低(Z=-3.294,P=0.001),而改善率和显著改善率均升高(Z=2.084,P=0.019;Z=1.969,P=0.025)。认知功能正常的患者CCRT组与WAT组改善率差异无统计学意义。将改善和显著改善的患者合并统称为有改善后,2组比较结果显示轻度认知功能损害的患者经CCRT后改善率较WAT升高[77.2%(44/57)与41.4%(12/29),χ^2=10.853,P=0.001];而基线时存在严重认知功能损害、中度认知功能损害或认知功能正常的患者,经CCRT后改善率同WAT相比差异均无统计学意义。不同程度认知功能损害患者经CCRT后认知功能改善的等级按照Cohen′d分别为:轻度认知功能损害(0.59)>中度认知功能损害(0.48)>正常认知功能(-0.12)>重度认知功能损害(-0.24)。结论CCRT对精神分裂症患者认知功能的改善率优于WAT,轻度认知功能损害的患者经CCRT后认知功能改善率更高。

Objective To explore the improvement rate of the cognitive function of computerized cognitive remediation therapy(CCRT)on patients with schizophrenia and the clinical effect of CCRT in patients with different levels of cognitive impairment.Methods A random number table was used to divide 311 patients with schizophrenia into CCRT group(n=196)and work and amusement therapy(WAT)group(n=115).The independently developed CCRT and operational music and dance therapy were given for 12 weeks to two treatment groups respectively.All patients were assessed using the MATRICS Consensus Cognitive Battery(MCCB)before and after treatment.According to the total score of MCCB at baseline,the patient′s cognition function was divided into 4 levels:severe cognitive impairment,moderate cognitive impairment,mild cognitive impairment and normal cognitive function.According to the change of MCCB total score,the efficacy of the treatment was divided into 3 levels:no improvement(≤0 points),improvement(0-9.57 points),superior improvement(>9.57 points).The improvement rate of cognitive function between two treatment groups was compared.Results In the CCRT group,there were 19 cases with superior improvement,105 cases with improvement,and 46 cases with no improvement.In the WAT group,there were 7 cases with superior improvement,39 cases with improvement,and 41 cases with no improvement.The improvement of cognitive function of CCRT group was better than that of WAT group,and the difference was statistically significant(Z=2.978,P=0.003).The patients with serious cognitive impairment in the CCRT group had a higher improvement rate than those in the WAT group(Z=1.860,P=0.032).The patients with moderate cognitive impairment in the CCRT group had a lower no improvement rate than those in the WAT(Z=-1.817,P=0.035).The patients with mild cognitive impairment in the CCRT group had a lower no improvement rate(Z=-3.294,P=0.001)and higher improvement rate and superior improvement rate(Z=2.084,P=0.019;Z=1.969,P=0.025)than those in the WAT group.There was no statistically significant difference in improvement rate between patients with normal cognitive function in the CCRT group and in the WAT group(P>0.05).The patients with improvement and superior improvement of cognition were combined as responder,and the two treatment groups were compared.The patients with mild cognitive impairment in the CCRT group had a higher improvement rate than those in the WAT group(77.2%(44/57)vs.41.4%(12/29),χ^2=10.853,P=0.001).However,for patients with serious and moderate cognitive impairment or with normal cognitive function at baseline,rates of improvement after treatment did not differ significantly between CCRT group and WAT group.According to Cohen′s d,the level of effect size in cognition improvement after CCRT treatment in patients with different cognitive dysfunction level was:mild cognitive impairment(0.59)>moderate cognitive impairment(0.48)>normal cognitive function(-0.12)>serious cognitive impairment(-0.24).Conclusions Schizophrenic patients treated with CCRT had a higher improvement rate of cognitive function than those with WAT,and the improvement rate of cognitive function is higher in patients with mild cognitive impairment after CCRT treatment.