Using iPads to deliver auditory perceptual training, clinical assessments,

and neuropsychological testing to individuals with schizophrenia

Bruno Biagianti, M.D. 1,2,3, Melissa Fisher,PhD1,2,, Elena Gasparini, BA1,2,, Sophia Vinogradov, M.D.*1,2 & Joshua Woolley, M.D. PhD*1,2
1

Department of Veterans Affairs Medical Center, San Francisco;

BACKGROUND

Cognitive Training (CT) for schizophrenia is effective but limited in its impact
due to inadequate engagement and poor accessibility (Keshavan, 2014).

Mobile devices allow patients to engage in assessment and treatment

remotely anytime, anywhere, on their own schedule

The use of mobile devices can increase accessibility, diminish burden, and
allow for disseminating treatment cost-effectively in a non-stigmatizing
manner.

A recent pilot study of 20 hours of iPad-assisted CT in N-Back tasks showed

significant improvement in N-Back accuracy and reaction time relative to a
treatment as usual group, and good acceptability and adherence of iPadassisted CT (Dang et al., 2014).

No studies have investigated the feasibility and acceptability of remotely

administering clinical interviews, neuropsychological assessments, and
computerized CT to individuals with schizophrenia using provided iPads.

Department of Psychiatry, University of California, San Francisco; 3 Posit Science, Inc. *co-senior authors

1. DO INDIVIDUALS WITH SCHIZOPHRENIA ENGAGE IN

REMOTE CT USING PROVIDED IPADS?

3. DOES IPAD-BASED CT GENERATE COGNITIVE GAINS

SIMILAR TO THOSE INDUCED BY DESKTOP-BASED CT ?

Study is underway

POST HOC COMPARISON

We compared 16 ipad-based CT completers to 17 gender and age-matched
individuals with schizophrenia, who were selected from an ongoing study
and completed the same CT program on desktop computers in the
laboratory.

69 SUBJECTS ENROLLED
11 currently involved in baseline
assessments
11 dropped out before beginining
the training

47 TRAINEES

ARE THEY SIMILAR AT BASELINE?

17 are in progress

groups are matched for gender, duration of illness, years of education,

baseline cognition, baseline symptom severity, and baseline functional
capacity. (T tests: all p >0.05)

14 dropped out during training

DO THEY TRAIN SIMILARLY?

no significant group differences in training hours, while training intensity
approached trend. (T tests: all p >0.05)

16 COMPLETERS

STUDY AIMS
1. DO INDIVIDUALS WITH SCHIZOPHRENIA ENGAGE IN REMOTE CT
USING PROVIDED IPADS?
2. ARE REMOTE NEUROPSYCHOLOGICAL ASSESSMENTS FEASIBLE
AND RELIABLE?
3. DOES IPAD-BASED CT GENERATE COGNITIVE GAINS SIMILAR TO
THOSE INDUCED BY DESKTOP-BASED CT ?

METHODS

36 % dropout rate why?

demands of the training are too high
unable to make time to do the training
no baseline differences between study completers with those who
withdrew

SUBJECTS
DEMOGRAPHICS

USAGE
PATTERNS

CT PROGRAM (BRAINHQ)

Mean

SD

age
years of education
age at psychosis onset
hospitalizations
IQ

37.5
14.19
21.25
5
101.44

14.274
2.994
4.946
3.942
10.52

session length (min)

frequency of access (days)
hours of CT per week
total training time (weeks)

40.18
2.96
2.24
8.73

11.35
1.67
1.49
2.24

iPad-based CT (n=16)

Desktop-based CT (n=17)

Total training hours

39.71 (7.54)

40 (0.00)

Hours completed per week

2.24 (1.49)

3.33 (1.47)

DO THEY SHOW SIMILAR MAGNITUDE OF GAINS?

1. Repeated measures ANOVA: are changes in variables of interest were
similar in the two groups?
2. Effect sizes (Cohens d): are there group differences in effect sizes?
Verbal learning

QLS total

41#

3.4$

40#

3.3$

39#

109.5$
109$

.42

3.2$

108.5$

.36

38#
3.1$

STUDY DESIGN

ACCEPTABILITY
AND
FEASIBILITY

Subjects liked the ability to self-pace training and

being able to avoid travel to receive treatment
iPads were returned undamaged and fully
functional

34#

2.8$

2. ARE REMOTE NEUROPSYCHOLOGICAL ASSESSMENTS

FEASIBLE AND RELIABLE?

.42

32#

Progress with CT is monitored remotely

Weekly FaceTime videocalls, email reminders and phone calls

PANSS total score

r=0.506
70#

22"

65#

20"

60#

FOLLOW-UP IN-PERSON ASSESSMENTS

moderate to high correlations between baseline

in-person (i-p) and remote (r) assessments
Letter Number Seq
r=0.654

HVLT
r=0.537

22"
30#

20"

iPads are retrieved, compensation

45#
40#

30#

Cognition:

MATRICS Consensus Cognitive Battery. Age-adjusted T-scores were

calculated.

HVLT delayed recall trials were used to assess Verbal Memory

Clinical severity:

PANSS 35-item version of the Positive and Negative Symptoms Scale

Functional capacity, social functioning and quality of life:

UPSA UCSD Performance-Based Skills Assessment

mGAF Modified Global Assessment of FunctioningScale

SFS Social Functioning Scale

QLS Quality of life Scale

20#

14"

12"

i-p

8"

INTERNAL
RELIABILITY

12"

15#

10"

35#

ASSESSMENTS

Visual learning

i-p

36#

.43

34#

.26

40#

28#

38#

.11

.15

30#

26#

36#

26#

24#

34#

24#

p-t

p-t

.51

28#

p-t

b = baseline
p-t = post- training

SUMMARY OF FINDINGS

Main effects of time were significant in global cognition, verbal

learning and memory, visual learning, social functioning and quality of
life. There were no significant condition-by-time interactions.

Participants in the iPad-based and desktop-based CT showed a similar

magnitude of gains in verbal learning, social functioning and quality
of life. Effect sizes were small/moderate

Effect sizes were not similar between groups for verbal memory and
visual learning

Within-group gains do not correlate with training intensity or hours of

training completed

10"
10#

44#
42#

p-t

Verbal Memory
38#

desktop-based CT (N = 17)

16"

50#

14"

46#

iPad-based CT (N = 16)

18"

25#

16"

p-t

24"

35#

18"

55#

Tower of London
r=0.81

106$

32#

In a subgroup of 7 participants, we repeated 4 baseline assessments

remotely using Facetime within 2 weeks from the first administration
TEST RETEST
CONSISTENCY

106.5$

30#

40 HOURS OF REMOTE COGNITIVE TRAINING

60 minutes a day, 5 days a week.

p-t

Global cognition
34#

.36

107.5$
107$

2.9$

36#

.43

3$

35#

BASELINE IN-PERSON ASSESSMENTS

iPad are set up and loaned to subjects

.37

36#

.26

108$

37#

- improves speed & accuracy of

_perceptual processing
- targets auditory and social
_cognition domains
- adaptive training
- 3-6 exercises per session

SFS total
110$

i-p

8"

i-p

In person PANSS Cronbach's =.765

Remote PANSS Cronbach's =709

DISCUSSION
1. While iPad-based CT demonstrates similar attrition and engagement , participants demonstrated ition, acceptability, and satisfaction
compared to desktop-based CT (Fisher et al. 2015). While
2. Remote clinical and neuropsychological assessments
can be successfully administered to individuals with schizophrenia, using Facetime on provided iPads
are comparable to the in-person equivalent
3. Remote CT appears to improve neurocognition, aspects of social functioning, and quality of life in individuals with schizophrenia similarly to
in-person delivery of CT