Subjective and Objective Executive Function in People With Early Schizophrenia or Psychosis Risk: A Clinical Trial of Goal Management Training

Abstract

Background Executive function is a cognitive domain important for daily life function. People with schizophrenia spectrum disorders or with a risk of developing these disorders, often experience challenges with executive function. The present study evaluates Goal Management Training (GMT), a metacognitive strategy training specifically targeting executive function, delivered in early detection and intervention for psychosis clinics. Evidence supporting this type of cognitive remediation as an early intervention for psychosis is limited. Since this is the first study of GMT for early psychosis, knowledge of who benefited the most was investigated. Methods A randomized, controlled trial with masked raters was conducted at Innlandet Hospital in Norway comparing the effects of GMT (N =81; GMT n = 39) to treatment as usual (TAU n = 42), among people with early schizophrenia spectrum disorders or psychosis risk syndromes. Outcomes were improved objective executive function (performance on neuropsychological tasks) and subjective (self-reported) executive function from baseline (0 weeks), to after intervention (5 weeks) and follow-up (30 weeks/ six months). In addition, effects on functional capacity, daily life function and clinical symptoms was explored. The severity of objective executive dysfunction and the discrepancy between objective and subjective executive function, were explored as potential obstacles to successful remediation using GMT. Symptoms of psychosis, depression, and self-efficacy were explored as potential predictors of the discrepancy between subjective and objective executive function in schizophrenia spectrum disorders. Results GMT led to significant and clinically reliable improvement in self-reported executive function for participants in everyday situations. Self-reported symptoms of anxiety and depression significantly improved more after GMT than TAU. Objective executive function, functional capacity and daily life function improved in both treatment groups. GMT was equally effective in improving subjective executive function regardless of performance on neuropsychological tasks at baseline. Participants with both subjective and objective executive dysfunction, and participants with mostly subjective executive complaints, experienced the largest improvement in subjective executive function after GMT. Participants with mostly objective executive dysfunction showed little improved subjective executive function after GMT. In participants with a schizophrenia spectrum disorder, a pattern of mostly objective executive function unaccompanied by subjective complaints was associated with having more disorganized symptoms of psychosis, but also better self-efficacy. Conclusions The first trial of GMT in people recently diagnosed with schizophrenia spectrum disorders or psychosis risk syndromes found clinically reliable improvement in subjective executive function in everyday situations lasting at least six months after treatment. People with schizophrenia who have more severe disorganized psychotic symptoms are more likely to have a pattern of poor objective executive function, but few subjectively experienced executive difficulties. This pattern of scores may be a challenge GMT, but more evidence is needed to support this finding.