Shinshu Med J, 70⑶：145～156, 2022

Sustainability of Cognitive Improvement in Schizophrenic
Patients with a Neuropsychological Educational Approach
Tatsuro Iwane1）, Takeshi Shimada2） and Masayoshi Kobayashi3）＊1） Department of Rehabilitation, Kyoto Prefectural Rakunan Hospital2） Department of Rehabilitation, Mental Support Soyokaze Hospital3） Department of Health Sciences, Graduate School of Medicine, Shinshu University

Objectives : This study aimed to investigate the effects of the Neuropsychological Educational Approach to
Cognitive Remediation (NEAR) in improving cognitive function and its sustainability in patients with schizophrenia
or schizoaffective disorders.
Methods : The z-scores of the Brief Assessment of Cognition in Schizophrenia (BACS) of patients who had expe­
rienced NEAR during psychiatric day care in the past were compared using results at the baseline, post-NEAR,
and a follow-up evaluation. To investigate changes in cognitive function over time, a correlation analysis was
conducted between the number of days from post-NEAR to follow-up and the degree of change in z-scores.
Living conditions were compared between the group with maintained z-scores and the group with declined
z-scores.
Results : 34 patients (22 men) participated. Repeated-measures analysis of variance showed that participants had
significantly higher z-scores at the post-NEAR stage than at the baseline (p＜.01). The follow-up evaluation
showed a slow decline in z-scores. Participants in the group that had declined z-scores tended to be younger
and had a longer follow-up period. Of them, 52.94 ％ were admitted to a psychiatric hospital during the followup period.
Conclusion : The increase in z-scores post-NEAR suggests that NEAR is effective in improving cognitive function.
Decline in cognitive function during the follow-up period was slight and gradual over subsequent years. In thecase of participants whose z-scores had decreased, it is likely that unstable disease conditions had affected thedecline in their cognitive function because over half of them were hospitalised during the follow-up period.
Shinshu Med J 70 : 145―156, 2022
(Received for publication November 22, 2021 ; accepted in revised form January 6, 2022)
Key words : schizophrenia, cognitive rehabilitation, Neuropsychological Educational Approach to Cognitive
Remediation (NEAR)
Ⅰ Introductionof cognitive impairment on the standardized neuro­cognitive battery (MATRICS Consensus Cognitive

In recent years, cognitive impairment has been

Battery ; MCCB) (1.5 standard deviations below

acknowledged as the core symptom of schizophre­

the performance of healthy individuals), and only

1）
2）

. In a study of patients with first-episode schizo­

17 ％ were in the non-impaired range3）. Therefore,

phrenia, 59 ％ showed moderate to severe levels

most schizophrenic patients demonstrate clinicallyniasignificant impairment of cognition overall at the＊Corresponding author : Masayoshi Kobayashi
Department of Health Sciences, Graduate School of
Medicine, Shinshu University, 3-1-1 Asahi, Matsumoto,
Nagano 390-8621, Japan
E-mail : mkobaya@shinshu-u ac.jp

No. 3, 2022

onset, with a decline in memory function being espe­
cially conspicuous4）. Reports have shown that anti­
psychotic drugs have only limited effects against
cognitive impairment and that atypical antipsychotic
145

Iwane・Shimada・Kobayashi

drugs do not improve cognitive impairment5）. Fur­ported that the participants’ speed of processing, re­thermore, their improvement effects are no different

action time, and memory improved significantly. Choi

6）

from those of typical formulations . However, there

and Medalia14） conducted NEAR with 48 outpatients

is some evidence that antipsychotics may partiallywith a mood disorder and reported that their pro­

improve cognitive function in schizophrenia, and thecessing speed and attention improved significantly.

effects of antipsychotics on cognitive function are not

Hodge et al.15）performed a multicenter RCT targeting

entirely clear7）. Researchers have also noted that the

40 patients with schizophrenia and found that in thesocial outcomes of schizophrenia (for example, em­

NEAR group, attention, speed of processing, execu­

ployment, school attendance, participation in commu­

tive function, verbal memory, and visual memory im­

nity activities, etc.) are more strongly related to cog­

proved significantly, and the effects remained evennitive impairment than positive symptoms such as

after four months. In a Japanese study, Ikezawa et al.16）

hallucinations and delusions. Additionally, the severi­

conducted NEAR with 51 patients diagnosed withty of cognitive impairment is a predictive factor for

either schizophrenia or schizoaffective disorder andlong-term prognosis8）9）. This improves cognitive

reported that compared to the control group, those infunction, a vital goal in the rehabilitation of patients

the NEAR group had a more significant improve­with schizophrenia.

ment in their overall cognitive function, verbal memory,

According to the Measurement and Treatment Re­

working memory, verbal fluency, attention, and proc­

search to Improve Cognition in Schizophrenia Project,essing speed. A meta-analysis found that the size ofthe significant cognitive impairments of patients withcognitive remediation effects against schizophrenia

schizophrenia are within the following seven areas―

was about 0.45, and the program had no impact on

working memory, attention/vigilance, verbal learning

mental symptoms17）.

and memory, visual learning and memory, reasoning,

Although studies show that NEAR can improveand problem-solving speed of processing, and social

cognitive function, it is not evident how long this im­

cognition10）. Of these, the first six are collectively called

provement lasts. Several follow-ups have shown thatneurocognition. This is different from social cognition,

cognitive improvement persists after cognitive reme­

which is related to understanding other people’s inten­

diation therapy, but follow-up periods are usuallytions and feelings, such as theory-of-mind and attri­

within 6 months to 1 year18）-22）. For further long-

bution bias11）.

term effects, a two-year follow-up study has shown

The Neuropsychological Educational Approach tothat cognitive rehabilitation training may reduce re­

Cognitive Remediation (NEAR) is a neurocognition

currence rates, improve employment rates, and im­training program. NEAR has educational psychology

prove social functioning in schizophrenia23）. Further­and ethology as its basic theories, and cognitive cor­more, it has been pointed out that the combined use

rection therapy normally implements it in the formof cognitive remediation therapy and a standard re­of 6-month-long group counseling sessions12）13）. The

habilitation program may sustain the improvement

program includes computer and language sessionsof cognitive function for 5 years. Then the continua­that last 60 minutes each. In the computer sessions

tion of the standard rehabilitation program may im­

held twice a week, participants tackle tasks thatprove the quality of life24）. However, NEAR was notstimulate cognitive function. In the once-a-week lan­

used in these follow-up studies18）-24）. Therefore, theguage sessions, they learn about the relationshiplong-term effects of NEAR on cognitive improve­

between cognitive function and daily living.

ment remain unclear.

Several studies on the effects of NEAR have been
13）

Once the duration of sustained cognitive improve­

conducted NEAR with 12

ment through NEAR is known and the factors that

individuals with mental illness referred from a hous­

influence cognitive decline, strategies for maintaining

ing support program for homeless people. They re­cognitive function can be formulated, leading to

published. Medalia et al.

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ol. 70Sustainability of cognitive improvement in schizophrenic patients

further rehabilitation for patients diagnosed with

ing NEAR were designated as the post-evaluation,schizophrenia and/or schizoaffective disorder. We

and tests performed during follow-up surveys were

specifically investigate two hypotheses―1) Cognitive

designated as the follow-up evaluation. All evalua­function decreases as the duration of the post-NEAR

tions were conducted for individual participants

period increases ; 2) Cognitive function is maintained

between 15 : 00-16 : 00. To investigate the secularby those who find employment and those who arechanges in cognitive function, we established thesatisfied with their lives. This study aimed to investi­

period from the post-evaluation after completion ofgate the sustainability of neurocognitive function

NEAR to the follow-up evaluation as the follow-up

after NEAR in patients with schizophrenia or schi­

period. A correlation analysis was conducted using

zoaffective disorder and to explore the factors associ­the scores of cognitive function tests that had chang­

ated with cognitive decline.

ed during this period. The degree of change in the

Ⅱ
Ａ

Methods

composite score of cognitive function tests was
divided into half at the median-the participants weredivided into a cognitive function-maintained group

ParticipantsParticipants were recruited from current and pre­and a cognitive function-declined group. The scoresvious patients who have undergone NEAR in theof the baseline information and follow-up evaluation

Kyoto Prefectural Rakunan Hospital Day Care. The

scales were then compared.

inclusion criteria were―(1) at least six months elapsedＣ

Measurements

since the completion of NEAR ; (2) aged between 14-

The primary outcome was the Brief Assessment

60 years, (3) diagnosed with schizophrenia or schi­

of Cognition in Schizophrenia Scale or BACS26）, which

zoaffective disorder according to the diagnostic

includes six subscales-verbal memory, working

criteria of DSM-525）

and (4) agreed to participate inmemory, motor speed, verbal fluency, attention, andour follow-up survey. Moreover, patients diagnosed

executive function. They were evaluated accordingwith intellectual disability, substance abuse and de­to age group-specific standardized scores that set

pendence, dementia, epilepsy, head injury, and com­the average score of healthy adults as zero. The

plications of cerebrovascular diseases, as well as thosehigher the z-score, the higher was the level of cogni­

judged unfit by the psychiatrists or occupational

tive function. The composite score was the averagetherapists in charge were excluded. We explainedof the z-scores of the six domains. The data of thethe study’s objectives to the participants, both orally

baseline and post-evaluations were obtained fromand in writing, and obtained their consent. This

the day care facilities’ medical records.

study was conducted after receiving the approval of

The secondary outcomes were psychosocial function,

Shinshu University’s Medical Ethics Committee

subjective well-being, self-efficacy, and living condi­(Approval No. : 4443) and the Ethical Review Board

tions during the follow-up period. The psychosocialof Kyoto Prefectural Rakunan Hospital (Approval

function was measured using the Global Assessment

No. : Gen-4).

of Functioning (GAF) (APA, 2000) (range : 0-100).

Ｂ

Subjective well-being was measured using the Sub­

Procedures and study design
This was a single-arm longitudinal study. Baseline

jective Well-being under Neuroleptic drug treatment

data were collected between March 2010 and January

Short form (SWNS)27）, which involves answering 20

2019, post-evaluation data were collected between

questions on a six-point scale. The higher the score,

September 2010 and August 2019, and the follow-up

the higher is a person’s subjective sense of well-evaluation was conducted between October 2019 andbeing (range : 20-120). Finally, self-efficacy was mea­

March 2020. Before implementing NEAR, the partici­

sured using the Self-Efficacy for Community Life

pants’ cognitive function tests were treated as the

Scale (SECL)28）. SECL requires a patient with a men­baseline evaluation. Those conducted after complet­tal disability to answer, using an 11-point scale, how

No. 3, 2022

147

Iwane・Shimada・Kobayashi

much confidence they have in the 18 actions and be­

divided into two groups based on BACS z-scores―

haviors needed to perform while living in a regional

the cognitive function-maintained and cognitive func­

community. The higher the score, the higher is thetion-declined groups. Either the t-test or the χ 2-test

person’s sense of self-efficacy (range : 0-180). In addi­

was used to compare these groups. Finally, we employ­tion to basic information such as age and sex, an oc­

ed the Bell Curve for Excel (version 3.21) to perform

cupational therapist interviewed the participants tostatistical analysis, with the two-sided level of signif­

understand their living conditions better. Data col­icance set at 5 ％ or below.

lected for the follow-up period included the presence

Ⅲ Results

or absence of cohabitation, main places of activities(for example, home, office, welfare center, etc.), pres­Ａ

Participant demographic informationence or absence of employment and hospital stays,

In all, 90 patients had previously undergone NEAR

the use of medical care services, medication compli­

at a psychiatric day care center. After assessing theance, satisfaction with life and living, and living ex­

eligibility of these individuals, we excluded 56 survey

penses.

participants. These included 29 patients who had

Ｄbeen diagnosed with diseases other than schizophre­

Statistical analysis
We first confirmed the normality of data to com­

nia or schizoaffective disorder, six who had declinedpare BACS z-scores at the baseline, post-, and follow-

to participate, and 21 for other reasons (for example,

up evaluations. We then used repeated-measureschanged physicians, duration was less than six

analysis of variance (ANOVA) and multiple compari­months after completion of NEAR, difficulty taking

sons (Bonferroni). Next, Pearson’s correlation coeffi­

tests, etc.). Ultimately, 34 individuals (22 men and 12

cient was used to conduct a correlation analysis be­

women ; 30 with schizophrenia and 4 with schizoaf­

tween the follow-up period and the degree of change

fective disorder) participated in the follow-up evalua­in BACS z-scores. Additionally, the participants weretions (Fig. 1).

Fig. 1 Flowchart of research participants
Data collection period : Baseline (March 2010-January 2019), (September 2010-August 2019),
Follow-up (October 2019-March 2020). Follow-up period : 1639.29±990.18 days
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ol. 70Sustainability of cognitive improvement in schizophrenic patients

tween Baseline and Follow-up.

Table 1 shows the basic information of the 34 par­ticipants that had been collected at the follow-up

Ｂ

Changes in BACS z-score

evaluation. Additionally, during the six months when

At baseline, all subscales and composite scores

NEAR was implemented, some participants had usedshowed mild to moderate cognitive impairments

other day care programs in which they engaged in(Table 2). The results of repeated-measures ANOVA

sports, psychology education, employment prepara­

showed a significant difference in all subscales (ption, and group or individual activities. There was no＜.001) ; the variance ratio of the total scores of BACS

significant difference in daily antipsychotic use be­(F) was 84.14, and the effect size (η 2) was .20. A large

Table 1

Participants’ demographic characteristics (N＝34)

Variable

Frequency/ Mean (SD)Age (years), mean (SD)42.65 (8.57)

Sex (Male / Female)

22 / 12

Diagnosis (F20 / F25)

30 / 4

Disease period (years), mean (SD)18.68 (9.07)

Number of hospital stays (times), mean (SD)3.68 (3.41)

Participation rate in NEAR sessions (％), mean (SD)95.9 (0.03)

Antipsychotic (mg/day)a, mean (SD)・Baseline

947.44 (716.91)

・Follow-up

857.68 (573.28)

Follow-up period (days)

1639.29 (990.18)

Living conditions during the follow-up period
・Cohabitant (with / without)

23 / 11・Main places of activity (Home / Other)5 / 29・Employment (Yes / No)

24 / 10・Hospital stays (Yes / No)

9 / 25・Outpatient visit (Yes / No)

34 / 0・Use of day care (Yes / No)

13 / 21・Use of home-visit nursing (Yes / No)

11 / 23・Use of home help service (Yes / No)

3 / 31

・Life satisfaction mean (SD)a3.21 (1.25)

Chlorpromazine equivalent dose
Table 2Comparison of BACS z-score at baseline, post-NEAR and at follow-up
Baseline

Post

Follow-up

Mean (SD)

Mean (SD)

Mean (SD)

Verbal memory－1.21 (1.18)－0.47 (1.16)－0.70 (1.33)

15.64

＜.001

.07

Working memory－0.74 (1.11)

0.09 (1.24)－0.46 (1.32)

21.33

＜.001

.08

Motor speed－1.33 (1.15)－0.31 (1.22)－0.79 (1.21)

19.61

＜.001

.14

Verbal fluency－0.25 (0.95)

0.39 (1.00)

0.45 (1.16)

22.07

＜.001

.10

Subscales

F

p

η2

Attention－1.37 (0.79)－0.75 (0.89)－1.20 (0.79)

24.58

＜.001

.11

Executive function－0.48 (1.32)

0.64 (0.76)

0.47 (0.78)

24.34

＜.001

.28

Composite score－0.90 (0.73)－0.07 (0.68)－0.37 (0.75)

84.14

＜.001

.20

N＝34
Repeated-measures ANOVA
Estimated effect size (η 2) : .01 (small), .06 (medium), .14 (large)
No. 3, 2022

149

Fig. 2

Changes in BACS z-score at baseline, post-NEAR and at follow-up

Iwane・Shimada・Kobayashi

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ol. 70Sustainability of cognitive improvement in schizophrenic patients

Fig. 3

Correlation between follow-up period and cognitive function

increase in z-scores was seen in multiple compari­stays was considerably higher in the cognitive func­

sons between the baseline and post-NEAR periods ;tion-declined group (p＝.00). No other significant dif­a significant difference was seen in all subscales (pferences were observed between the two groups.

＜.01). Further, an effect size of r＝.845 was seen in

No differences were seen in GAF, SECL, or SWNS

terms of increases in composite scores. During thescores between the two groups (Table 4). However,follow-up period, z-scores declined in all subscales

the BACS scores tended to be higher in the cognitive

except verbal fluency with significant differences

function-maintained group, with a significant differ­seen in working memory (p＜.01), motor speed (pence in the composite scores (p＜.05).

＜.05), attention (p＜.01), and composite score (p＜.01).
Fig. 2 shows the results of multiple comparisons (Bon­ferroni).

Ⅳ

Discussion

As indicated by the findings of the evaluations at

The duration of the follow-up period, BACS com­

baseline, the participants in this study were patients

posite scores (differences), and Pearson’s correlation

with schizophrenia or schizoaffective disorder andcoefficients were calculated. The regression equation

mild to moderate cognitive impairment. As a result2

y＝－0.0002x, R ＝0.4794 (p＜.05) was obtained from aof NEAR, which they had undergone for six months

linear approximation with a fixed zero intercept,

at a psychiatric day care center, their z-scores werewhich revealed that the longer the period after thefound to have increased in all the BACS subscales.

completion of NEAR, the lower was the BACS com­

Namely verbal memory, working memory, motor

posite score (Fig. 3).

speed, verbal fluency, attention, and executive func­

Ｃ Comparison between the cognitive function-tion. Their composite scores had increased to themaintained and the cognitive function-declined

standard score (0) post-evaluation. As with previous

groupsstudies13）-16）, this increase in scores appeared to have

Table 3 compares the basic information between

been caused due to NEAR’s cognitive function im­

the cognitive function-maintained and the cognitive

provement effects. However, in the follow-up evalua­function-declined groups. Notably, age was signifi­tion, cognitive function declined in all areas except

cantly higher in the cognitive function-maintained

the verbal fluency category in BACS. The averagegroup (p＝.03), and the cumulative number of hospitalfollow-up period was long ― 1,639.29 (SD＝990.18)

No. 3, 2022

151

Iwane・Shimada・Kobayashi
Table 3 Demographic characteristics of the cognitive function-maintained and the cognitive
function-declined groups
Variable

Maintained group

Declined group(n＝17)(n＝17)p

Age (years), mean (SD)45.24 (6.70)

40.06 (9.61).03＊

Sex (Male / Female)

12 / 5

10 / 7.4796.2 (0.020)

95.6 (0.034).56

Antipsychotic drugs dosage (mg/day) , mean (SD)876.47 (685.31)

838.88 (455.46).85

Disease period (years), mean (SD)19.71 (9.77)

17.65 (8.49).51

Number of hospital stays (times), mean (SD)3.94 (3.92)

3.41 (2.90).65

Follow-up period (days)

1330.64 (1000.23)

1947.94 (905.15).06

・Cohabitant (with / without)

11 / 6

12 / 5.71

・Main places of activity (Home / Other)3 / 142 / 15.63・Employment (Yes / No)

11 / 6

13 / 4.45

・Hospital stays (Yes / No)

0 / 179/8.00＊＊

・Outpatient visit (Yes / No)

17 / 017 / 0―・Use of day care (Yes / No)

7 / 106 / 11.72

・Use of home-visit nursing (Yes / No)

4 / 137 / 10.27

・Use of home help service (Yes / No)

2 / 151 / 16.55

・Medication adherence (Yes / No)

16 / 114 / 3.29

・Life satisfaction, mean (SD)3.29 (1.40)

3.12 (1.24).68

Family income, n

7

4

Own income, n45Disability pension, n44Livelihood protection expenses, n24Participation rate in NEAR sessions (％), mean (SD)a

Living conditions during the follow-up period

・Living expenses.66＊

t-test, p＜.05
Chi-squared test, ＊＊p＜.01aChlorpromazine equivalent dosedays or approximately 4 years and 6 months. Varia­

groups (created based on the change in the BACS

tions were seen within the range of 6 months tocomposite score during the follow-up period), those

9 years. However, the change in BACS composite

in the cognitive function-declined group tended to bescores during the follow-up period was only 0.3 on

significantly younger (p＝.03) and had a slightly more

average. The regression equation of a linear approxi­

extended follow-up period (p＝.06), with 9 out of 17

mation with a fixed zero intercept was y＝－0.0002x,

participants (53 ％ ) having experienced either hos­confirming the gradual decline in cognitive function

pitalization or re-hospitalization during the sameover time after the completion of NEAR. To the bestperiod. No differences were observed between the twoof our knowledge, this is the first study to investi­

groups in their scores related to living conditions

gate the long-term sustainability of cognitive func­

such as main places of activity, employment status,tion after the implementation of NEAR.

use of home-visit nursing and home help services,

In a comparison between the cognitive function-

dosage of antipsychotic drugs, and medication com­maintained and the cognitive function-declined

pliance, and scales such as psychosocial function,

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ol. 70Sustainability of cognitive improvement in schizophrenic patients
Table 4Comparison between cognitive function-maintained group and cognitive function-declined group

Scales and subscales

Total

Maintained

Declined(n＝34)

group (n＝17)

group (n＝17)

p

Mean

(SD)

Mean

(SD)

Mean

(SD)

61.5

(11.03)62.65(11.16)60.35(11.11).55

Verbal memory－0.70(1.33)－0.37(1.25)－1.02(1.35).15

Working memory－0.46(1.32)－0.16(1.36)－0.75(1.25).19

Motor speed－0.79(1.21)－0.43(1.05)－1.15(1.28)

.08

GAF
BACS

Verbal fluency

0.45(1.16)

0.81(1.23)

0.10(1.00).07－1.20(0.79)－0.98(0.70)－1.43(0.82).08

Executive function

0.47(0.78)

0.64(0.82)

0.29(0.73).20

Composite score－0.37(0.75)－0.08(0.66)－0.66(0.75).02＊

Daily life

63.47

(21.77)65.53(14.41)

61.41(27.58).59

Treatment behaviour

73.53(22.09)75.15(18.08)71.91(25.96).67

Symptom coping

62.21(24.35)65.59(19.42)

58.82(28.66).42

Social life

66.19

(26.43)69.22(18.88)63.16(32.63).51

Interpersonal relations

50.15(28.46)47.35(27.05)52.94(30.37).57

Total score

115.91(38.53)119.29(27.11)112.53(47.99).61

Mental function

14.24(3.92)

14.12(3.06)

14.35(4.73).86

Self-control

15.18(4.39)

14.82(4.28)

15.53(4.60).64

Emotional regulation

15.18(4.20)

15.41(3.14)

14.94(5.13).75

Physical function

15.35(4.54)

15.12(4.70)

15.59(4.50).77

Social integration

14.41(3.87)

13.88(3.86)

14.94)(3.93).43

Total score74.35(18.67)73.35(16.65)75.35(5.08).76

Attention

SECL

SWNS

＊

t-test, p＜.05
GAF, Global Assessment of Functioning ; BACS, Brief Assessment of Cognition in Schizophrenia ; SECL,
Self-Efficacy for Community Life Scale ; SWANS, Subjective Well-being under Neuroleptic drug
treatment Short form. BACS shows the result of follow-up evaluation.

subjective well-being, and sense of self-efficacy.

the younger age groups might have reacted moreThus, the results did not support our hypothesized

sensitively to cognitive interventions. The cognitive

relationships between cognitive function and employ­decline group included more individuals fromment or life satisfaction. The decrease in cognitive

younger age groups who may have responded

function seen in the cognitive function-declined

sensitively to cognitive intervention by NEAR andgroup may have been related to changes in the par­the removal of cognitive intervention. Further, given

ticipants’ disease condition as shown by age, length ofthat over half of the participants in the cognitive

the follow-up period, and high hospitalization rate.

function-declined group had experienced hospital

A meta-analysis investigating the non-specific effects

stays during the follow-up period, it is likely that thein the improvement of cognitive function in schizo­

instability of their disease and behavioral restrictions

phrenia29）

showed that the improvement was nega­tively correlated with age, suggesting that people in
No. 3, 2022

during hospitalization promoted a decline in cognitive
function.
153

Iwane・Shimada・Kobayashi

Limitations

necessary to pay full attention to these limitations,carry out RCTs and prospective cohort surveys using

This study has several limitations. First, there wasa control group, ensure a sufficient sample size, anda selection bias in recruiting participants. The decision

identify factors related to the maintenance of cogni-

to undergo NEAR at a day care center depended ontive function.

the patients’ desire to participate and their availabilityⅤin real life, which were not controlled for. Moreover,Conclusion

patients who participated in the follow-up survey

The findings suggested that there was a slight de-mainly were those who had continued to undergocline in cognitive function after NEAR. However, theoutpatient treatment. Further, they did not include

follow-up period was as long as 1,639.29 (SD＝990.18)

those who discontinued their treatment. Second, it

days, and it was not possible to identify the factors

could not be asserted that the improvement of cogni-that contribute to the maintenance of cognitive func-

tive function seen in the post-evaluation was the soletion. Compared to the group whose cognitive func-

effect of NEAR. Multiple rehabilitation programs aretion had been maintained, participants in the groupsometimes used simultaneously at day care centers ;that showed a decline in cognitive function during

there is a possibility that participants’ cognitive func-

the follow-up period tended to be significantly young-tion had improved due to program(s) other thaner. Further, they had a slightly more extended follow-

NEAR. Third, there was a considerable variation inup period. Moreover, 53 ％ of them were either hos-the participants’ follow-up period, and the patients’pitalized or re-hospitalized during the study period.

course during the follow-up period was not moni-

However, it remains unclear whether cognitive de-tored in detail. For example, items on starting work,

cline affected recurrence or readmission. Cognitiveentering school, taking other training programs, andimprovement by NEAR and its persistence should be

the frequency of actions and behaviors when playing

demonstrated by RCTs with controls. Therefore, further

ordinary social roles might also support the mainte-

research is needed to obtain sufficient sample size andnance of the participants’ cognitive function. This

identify factors that influence the maintenance or

study could not thoroughly investigate the underly-

decline of cognitive function.

ing factors related to the maintenance and improve-

Acknowledgments

ment of cognitive functions. Therefore, the “relationship between employment and/or life satisfaction

The authors wish to thank the participants andand maintenance of cognitive function” that we hy-

staff of the day care center. Additionally, we would

pothesized remains unclear and needs further inves-like to thank Editage (www.editage.com) for English

tigation. Fourth, psychiatric symptoms were notlanguage editing.

included as a secondary endpoint. More than half of

Declarations of conflicting interest

the cognitive function-declined group were hospitalized during the follow-up period and may have hadworsening psychiatric symptoms. Deterioration of

The authors declare that there is no conflict of interest.

psychiatric symptoms can affect cognitive function,

Funding

so psychiatric symptoms had to be considered to assess the sustainability of cognitive improvement. Fi-

This work was supported by the Japanese Associ-nally, due to the small sample size, the generalization

ation of Occupational Therapists［grant numberof the results was limited. In future studies, it will be

202002］.

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Sustainability of cognitive improvement in schizophrenic patients

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