Future Directions for Social Cognitive Interventions in Schizophrenia

Social cognition is increasingly viewed as a viable treatment target. This is in large part due to a growing body of evidence demonstrating that social cognitive abilities contribute to real-world outcomes1,2 and that remediation of social cognitive impairments leads to improvements in functional outcome.3–5 The work of Lindenmayer and colleagues6 represents an important step in efforts to optimize social cognitive interventions and highlights several considerations for moving forward. First, the findings of Lindenmayer and colleagues6 clearly support the efficacy of social cognitive intervention strategies; however, an important open question is whether the same improvements would have resulted from their social cognitive intervention alone. Numerous studies have shown that social cognitive interventions can significantly improve emotion processing abilities,7 suggesting that improvements would be evident without the addition of cognitive remediation. Importantly, however, recent work by Bowie and colleagues8 indicates that cognitive remediation, despite having little effect on functional outcome itself, increased the positive effects of a treatment that specifically targeted functional outcome. With the caveat that this work addressed everyday functional skills and functional outcomes rather than social cognition and social outcomes, it suggests that adding cognitive remediation may result in a magnitude of change that exceeds that which can be achieved by targeted treatments alone. Thus, a critical question moving forward will be to determine whether cognitive remediation is a necessary adjunct to social cognitive interventions in order to produce the most efficient and efficacious interventions. Second, the results of Lindenmayer and colleagues6 also raise the possibility that social cognitive training may benefit neurocognition. The fact that their combined treatment yielded greater improvement in neurocognition than cognitive remediation alone suggests that this may indeed be the case. Strikingly, the combined group showed greater improvement despite receiving 12 fewer hours of cognitive remediation. Traditional models of social cognitive impairment assume a unidirectional relationship between neurocognition and social cognition, and recent work supports this view.9 However, the present results suggest a bidirectional relationship may also be possible within the context of targeted treatment. Investigating this possibility will likely result in intervention programs that are optimized for improving both social and neurocognition. Finally, it is noteworthy that Lindenmayer and colleagues6 used an intervention that was developed for individuals with autism spectrum disorders. This initial evidence showing that an autism intervention can be used profitably in schizophrenia underscores the possible benefits of interchange between these domains. Although autism and schizophrenia are distinct disorders, both manifest significant impairments in social cognition that appear to be qualitatively similar.10 This parallel suggests that treatments found to be efficacious in one disorder may be applied successfully across disorders, as was done here. Indeed, schizophrenia treatments have also been implemented in autism with positive effects. Social Cognition and Interaction Training (SCIT)11 was used with individuals with autism (as SCIT-A) and resulted in significant improvements.12 It should be noted however that some modifications of SCIT were necessary to make the treatment most applicable to the needs and areas of impairments of those with autism. Thus, studies that directly compare autism and schizophrenia are also needed to determine which impairments are shared and which are disorder specific. Doing so will save valuable effort and resources by allowing appropriate interventions to be shared across disorders while also providing a foundation for the development of disorder-specific components that will likely produce the most effective interventions.10