The consequences of mental illness that nobody talks about

June 11th, 2020   |   By Andrew Stewart

The onset of schizophrenia is almost always accompanied by significant and disabling cognitive losses.1

Unfortunately, these cognitive deficits often persist, even though more florid symptoms such as hallucinations and delusions may respond well to antipsychotic medications.

Well-researched cognitive problems include difficulties with short-term and working memory, focusing, sequencing (essential for planning), judgment, and problem-solving.2

You may not have heard much about these cognitive symptoms. Sadly, neither have most people with schizophrenia who are struggling to cope with them. While patients with Alzheimer’s or brain injuries (or almost all other disorders) are informed about their symptoms, there are very few psycho-education programs for adults with schizophrenia.

Not only are people with these illnesses not receiving important information they need to cope, but family members—who very often provide care and support—don’t learn about these common problems, either.

This lack of knowledge has extremely negative consequences. For instance, families who are not informed about cognitive deficits may mistakenly interpret an ill relative’s difficulty keeping their room clean or forgetting to relay phone messages as laziness or defiance. Parents and siblings respond very differently to these kinds of situations once they understand that such behaviour isn’t willful, but symptomatic of the serious brain disorder the person is struggling with. 

Why aren’t people learning about these important cognitive losses?

One reason may be this: people with the most severe mental illnesses often cannot advocate for themselves. However, their interests are assumed to be represented by “psychiatric consumer/survivor” groups, which have become very powerful in recent years. The opinion of such groups is expressed by the Empowerment Council at Toronto’s Centre for Addictions and Mental Health, which is convinced that trauma is the key to understanding mental illness.

Research scientists and psychiatrists do not agree. Current medical understanding of causation includes genetic and other prenatal factors that affect the complex development of the human brain.

Besides failing to advocate for comprehensive education programs for people with psychotic illnesses, “consumer/survivor” groups fail to acknowledge cognitive remediation programs. These have been a focus for research funding from the U.S. National Institute of Mental Health in recent years. Numerous programs now have considerable evidence attesting to their benefits.3 Canada shares the same problems with the U.S. regarding advocacy for people with the most severe illnesses. However, there are some programs that incorporate actual evidence-based approaches. The most internationally well-known is Columbia University’s Lieber Recovery Clinic, which focuses on people with psychotic disorders.

During a visit to the Lieber Center in New York, I was inspired by the accomplishments of the Clinic and its Director, Dr. Alice Medalia. Because cognitive deficits are the major obstacle in my daughter’s difficulty in managing some tasks of daily life, I tried to locate Canadian cognitive remediation programs. I was unsuccessful, but learned through Dr. Medalia about Queen’s University professor, researcher, and clinician Dr. Christopher Bowie.

Dr. Bowie’s research, like that of Dr. Medalia, uses computer-based programs to help people improve cognitive skills necessary for daily living.4 Both clinicians are part of a growing number of researchers who have seen the limits of computer programs used in isolation—i.e., clients may get faster at specific computer tasks or better at using their working memory—but this doesn’t translate into improvements in coping with tasks of daily life such as managing a bank account, learning a new bus route, or persuading a landlord to fix broken plumbing.

Both Dr. Medalia and Dr. Bowie embed computer-based activities into broader psycho-social rehabilitation programs. And their research projects show significant improvements for participants.5

The Mental Health Commission of Canada’s guidelines for promoting family involvement emphasize the need for mental health services to actively involve families in planning programs.6 We know that family members are often overwhelmed by the extensive and complex care their ill relatives need.

However, if we want our ill relatives to have the best opportunities to rebuild their lives, it is up to us to push for the improvements we want to see.

Adapted from original article by Susan Inman, Author – After Her Brain Broke: Helping My Daughter Recover Her Sanity. 08/10/2014. Huffington Post. Updated October 9, 2014.

REFERENCES

  1. “Cognitive Deficits in Schizophrenia” https://www.bcss.org/education/about-mental-illness/schizophrenia/ ↩︎
  2. Cognitive Sequencing: the ability to perceive, represent and execute a set of actions that follow a particular order. This ability underlies vast areas of human activity, and is necessary for us to be able to make plans and follow them through. ↩︎
  3. Subramaniam K, Luks TL, Fisher M, Simpson GV, Nagarajan S, Vinogradov S. Neuron. Computerized cognitive training restores neural activity within the reality monitoring network in schizophrenia.2012 Feb 23;73(4):842-53.doi:10.1016/j.neuron. www.ncbi.nlm.nih.gov/pubmed/22365555 ↩︎
  4. Philip D. Harvey, PhD and Christopher R. Bowie, PhD. Cognitive Remediation in Severe Mental Illness. Innovations in Clinical Neuroscience 2012 Apr; 9(4): 27–30. www.ncbi.nlm.nih.gov/pmc/articles/PMC3366453/ ↩︎
  5. Medalia A, Saperstein AM. Does cognitive remediation for schizophrenia improve functional outcomes? Current Opinion in Psychiatry. 2013 Mar;26(2):151-7. https://www.ncbi.nlm.nih.gov/pubmed/23318663 ↩︎
  6. https://www.mentalhealthcommission.ca/English/article/8821/june-27-2013-mental-health-commission-canada-releases-national-guidelines-improve-suppo ↩︎