Abstract
Substance use disorders are associated with diverse neuropsychological impairments, with deficits in memory and executive functioning commonly observed. Cognitive remediation has been shown to be effective in other populations with cognitive impairments in these domains, including those with psychiatric disorders and acquired brain injuries, and it has been hypothesised to be similarly effective for those in treatment for substance use disorders. We aimed to systematically review the evidence for cognitive remediation interventions administered as an adjunct treatment to substance use rehabilitation. Studies were included if participants were receiving substance use treatment, if improving cognitive functioning was the main focus of the intervention and if they used an experimental design with a control condition receiving treatment-as-usual or an active control intervention. Two independent reviewers agreed on the final selection of 32 studies, encompassing cognitive remediation for working memory, memory, executive functioning and general cognition. Significant differences between intervention and control groups for cognitive test results and treatment outcomes were extracted and compared across treatment approaches. The review found considerable heterogeneity across studies, including in the types of interventions, the nature of participants and the outcome measures used. Further, a lack of quality studies with sufficient power meant that limited conclusions could be drawn, highlighting a need for further replication and research. However, findings indicate that cognitive remediation remains a promising potential avenue for improving cognition and treatment outcomes for those in treatment for substance use disorders. Protocol submitted prospectively to PROSPERO 30.09.2019, CRD42020150978.
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Research conducted by Talia Nardo is supported by an Australian Government Research Training Program Scholarship.
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TN wrote article, completed search strategy, study screening and full-text review, data extraction, and synthesis. JeB, JaB and HF provided expert guidance, supervision, and editing of writing. DJ completed study screening and full-text review, and editing of writing. TB completed risk of bias assessment and editing of writing.
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Appendices
Appendix 1
Detailed Summary of Systematic Search Strategy
A scoping review was initially completed in order to identify relevant subject headings and thesaurus terms used across different databases, including Thesaurus of Psychological Index Terms®, Emtree, CINAHL Thesauris & MeSH terms. These terms are summarised for the subject of Substance Use and Cognitive Remediation in the table below (1a and 2a, respectively). Secondly, key words were combined to create terms relevant for substance use disorder (1b) and cognitive rehabilitation (2b). For cognitive remediation, proximity operators (“adj”) were used to identify terms even if they were separated by one word (e.g. Attention process training). Wildcard operators (*) were used to search word stems with different endings (e.g. drug abuse/abuser/abusers). Thirdly key words not otherwise specified were identified by reviewing the available literature, and included as search terms (1c and 2c). The three search strings were then combined with OR for the two key topics. Finally, the two key topics were combined with AND {(1a OR 1b or 1c) AND (2a OR 2b OR 2c)}. Details of search terms are outlined in Table 4.
Appendix 2
NIH Study Quality Assessment of Controlled Intervention Studies Tool
1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT? |
2. Was the method of randomization adequate (i.e., use of randomly generated assignment)? |
3. Was the treatment allocation concealed (so that assignments could not be predicted)? |
4. Were study participants and providers blinded to treatment group assignment? |
5. Were the people assessing the outcomes blinded to the participants' group assignments |
6. (Demographics) Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? |
7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? |
8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? |
9. Was there high adherence to the intervention protocols for each treatment group? |
10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)? |
11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? |
12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power? |
13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? |
14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis? |
Appendix 3
Risk of Bias Checklist and Decisions
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Nardo, T., Batchelor, J., Berry, J. et al. Cognitive Remediation as an Adjunct Treatment for Substance Use Disorders: A Systematic Review. Neuropsychol Rev 32, 161–191 (2022). https://doi.org/10.1007/s11065-021-09506-3
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DOI: https://doi.org/10.1007/s11065-021-09506-3