The CIRCuiTS™ Trial
by Professor Eileen Joyce, Emeritus Professor of Neuropsychiatry at UCL Queen Square Institute of Neurology
The NIHR ‘ECLIPSE’ (Enhancing Cognition and Quality of Life in the Early Psychoses) programme grant investigated facilitators and barriers to implementing cognitive remediation into services. A large part was a randomised controlled trial, the CIRCuiTS™ study. The aim was to investigate different methods of delivering cognitive remediation therapy (CR) in UK NHS early intervention for psychosis services. Early intervention teams are multi-disciplinary and provide evidence-based care quickly, including antipsychotic medication, as well as access to Cognitive Behavioural Therapy, social and occupational support, and physical health interventions. We used the well-established CIRCuiTS™ programme to deliver therapist-supported computerised CR. All trial arms received their usual care (treatment as usual or TAU). All volunteer participants were randomly allocated to one of 4 groups: just TAU, one-to-one CR, group CR, and independent CR. All had contact with a therapist, but the independent group had minimal contact. Although the computerised therapy was the same, there were different costs associated with therapist time between the various methods of CR delivery. We wanted to know if the CR effect on cognition for the different methods was the same or different. Our design, developed with the help of service users, enabled us to calculate the ‘cost-effectiveness’ of each method and to make recommendations about providing CR in NHS settings.
Six English NHS Mental Health Trusts in the South and Midlands took part, representing a good mix of ethnic and rural/urban environments. Participants in the three treatment groups had 12 weeks of access to CR and underwent a range of assessments before, immediately after treatment, and at six months. This included detailed assessments of cognition, positive and negative symptoms, and social function. The primary measure used to gauge the benefit of CR was self-reported personal recovery goals using the Goal Attainment Scale. This is different from many studies that only use one measure. Our outcome allowed each individual to say what their goals were rather than assuming they all wanted the same one.
We found that receiving one-to-one and group therapy both benefitted recovery goals and cognition, and these two methods were significantly better on both measures than the individuals who only received usual treatment or who carried out CR at home. This means that CR with a therapist, either singly or in a group, had a beneficial effect on cognitive function and achieving personal goals. Both treatment methods were also more cost-effective than usual treatment and were not different from each other.
Cognitive and recovery goal benefits reduced at six months, suggesting that first-episode patients would benefit from intermittent booster CIRCuiTS™ sessions after their more intensive therapy or from thinking skills coaching by the mental health team.
All in all, our recommendation is that the presence of a therapist improves the benefits of computerised CR and that service user’s users should be given a choice between them.
A paper about the programme grant titled 'Cognitive remediation therapy to enhance cognition and improve recovery in early psychosis: the ECLIPSE research programme including an RCT' is pending publication.
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