Where next for cognitive remediation in Australasian mental health care?

Cognitive remediation (CR) is a therapeutic approach aimed at improving cognitive functions such as attention, memory and problem-solving skills. CR uses structured training exercises and strategies designed to enhance cognitive abilities. CR aims to help individuals regain or improve their cognitive functioning, leading to better everyday functioning and quality of life.

There is considerable evidence demonstrating that CR can significantly enhance cognition (d = 0.29, 95% confidence interval [CI] = [0.24, 0.34]) and psychosocial functioning (d = 0.22, 95% CI = [0.16, 0.29]) in schizophrenia (Vita et al., 2021). Emerging evidence also supports the efficacy of CR in treating mood disorders. A growing body of literature has informed the recommendation of CR as a treatment for cognitive challenges in the Australian and New Zealand guidelines for managing schizophrenia and related disorders (Galletly et al., 2016). Importantly, Australia’s National Disability Insurance Agency (NDIA) published an evidence snapshot concluding that CR is a safe and cost-effective strategy to support everyday functioning, work, independence and wellbeing for National Disability Insurance Scheme (NDIS) participants with psychosocial disabilities.

Despite its potential, the implementation of CR into mental health clinical practice remains limited, both globally and in Australasia. While there are a few public mental health service settings that offer CR expertise, primarily located in New South Wales (NSW) and Queensland (QLD), access remains restricted. As does the availability among private mental health professionals, university clinics, not-for-profit organisations, rehabilitation services and vocational services. Unfortunately, the truth is, there has not been a widespread rollout of CR. The availability of CR often hinges on the presence of a passionate and informed clinician who champions the approach.

In light of this situation, Australasian experts in cognition in mental health convened the inaugural Australasian Cognitive Remediation in Mental Health Conference in Brisbane, 2024. The primary aim of the meeting was to unite the community and discuss the latest in CR research findings and perceptions and real-world implementation experiences from informed clinicians, as well as hear insights from individuals with lived experience who have engaged in CR. During the meeting, attendees (N = 70) identified key priorities for enhancing the implementation of CR in Australasia. The following priorities were highlighted.

Increased awareness of the importance of cognitive health across the mental health community

There is a significant lack of awareness about CR among mental health professionals, with many clinicians unaware of its potential benefits (Altman et al., 2024). In addition, there is a concerning level of poor mental health literacy regarding the cognitive difficulties experienced by individuals with mental health conditions (Altman et al., 2023). This lack of understanding is prevalent not only among patients but also among some clinicians themselves.

As a result, people with mental health conditions may be unaware of the need to inquire about interventions for cognitive issues, leading to missed opportunities for effective treatment. Moreover, clinicians may not know to assess for cognitive difficulties or recommend such interventions, perpetuating a cycle of untreated cognitive impairment. This situation is particularly troubling given the substantial evidence supporting CR as a valuable therapeutic approach.

The lack of awareness and understanding can contribute to a stigma surrounding cognitive difficulties in mental health, further discouraging individuals with mental health conditions from discussing these issues. Fostering an environment that emphasises cognitive health is essential, not only for treatment outcomes but also for promoting holistic mental health care.

Training for clinicians

At present, there is no standardised training for clinicians to assist with their implementation of CR in Australasia. As an example, three major professional associations, the Australian Psychological Society (APS), the New Zealand Psychologists Board and the Royal Australian and New Zealand College of Psychiatrists (RANZCP), currently do not offer continuing education specifically focused on CR.

A significant gap exists in the training of new clinicians; CR is often delivered by psychologists, occupational therapists or nurses but is not incorporated into the curriculum of most professional training degrees at major universities across Australia and New Zealand. This lack of exposure during foundational training can lead to a generational gap in knowledge and skills related to CR. As a result, new clinicians may enter the workforce without adequate awareness of CR’s benefits or the ability to assess and address cognitive difficulties in their patients. This absence of training creates a barrier to the effective implementation of CR in clinical settings and underscores the urgent need for the development and standardisation of training resources. Addressing the gaps in clinician training needs to be coupled with organisational commitment and leadership to embed CR into routine mental health care.

Australasian COgnitive Recovery in Mental Health Network

The conclusions drawn from the conference, along with the collective insights from the mental health CR community, indicate that while CR for mental health has considerable promise and is highly valued by those with lived experience (Bryce et al., 2024), systemic barriers (including the focus on case management in care plans, organisational support and fit of CR, as well as timing of implementation of CR and leadership to ensure CR success), along with gaps in awareness and education, significantly contribute to its limited availability in Australasia. In response to these challenges, local experts have come together to form the Australasian COgnitive Recovery in Mental Health Network (ACORN).

ACORN aims to promote, advocate and facilitate research and raise awareness to enhance the implementation of CR within mental health service settings. Recognising that systemic change is necessary, ACORN’s initiatives focus on several key areas.

In the first instance, ACORN recognises that it is essential for mental health service settings to prioritise the integration of CR in professional training, ongoing education and clinical practices. By advocating for the embedding of CR principles into the training of future clinicians and providing current practitioners with the necessary resources, ACORN will contribute to fostering a more knowledgeable workforce equipped to address cognitive difficulties effectively in mental healthcare.

In addition, ACORN will prioritise public awareness campaigns about CR. These campaigns will aim to empower people with mental health conditions by providing them with information about cognitive challenges and available interventions. Increased awareness will enable people with mental health conditions to actively advocate for their cognitive health, fostering a more collaborative approach to their treatment that includes discussions of CR with their healthcare providers.

Moreover, ACORN seeks to establish partnerships with academic institutions, organisations delivering mental health services and professional associations to support research initiatives aimed at evaluating the effectiveness of CR and promoting evidence-based practices. By working together, ACORN aims to create a robust network of resources and support that will enhance the understanding and implementation of CR across Australasia. ACORN will develop a website that will host a range of resources that can be accessed by clinicians, host professional development webinars with national and international experts and run an annual conference to facilitate networking and ongoing priority setting (for more information including upcoming webinars and conference dates, see the website: www.acorn-mh.org).

In conclusion, the concerted efforts of ACORN represent a significant step towards overcoming barriers to CR access, ultimately benefitting individuals with mental health conditions by integrating CR into standard mental health clinical practice and enhancing their overall quality of care.