Psychological Medicine (2011), 41, 533544. f Cambridge University Press 2010 doi:10.

1017/S0033291710001029

O R I G I N A L AR T I C LE

Neurocognitive prediction of illness knowledge after psychoeducation in schizophrenia: results from the Munich COGPIP study
T. Jahn*, G. Pitschel-Walz, A. Gsottschneider, T. Frobose, S. Kraemer and J. Bauml
Department of Psychiatry and Psychotherapy, Technical University Munich, Munich, Germany

Background. Many patients with schizophrenia exhibit neurocognitive impairments, namely, in attentional, mnestic and executive functions. While these decits limit psychosocial rehabilitation, their eect on psychoeducation is unknown. Within the framework of the longitudinal Munich Cognitive Determinants of Psychoeducation and Information in Schizophrenic Psychoses (COGPIP) study, we examined : (a) whether illness knowledge after psychoeducation could be predicted more precisely from the neurocognitive than from the psychopathological status of the patients ; (b) which neurocognitive domains are best predictors. Method. A total of 116 in-patients with schizophrenic or schizoaective disorders were randomized to a neurocognitive training or control condition (2 weeks) followed by a manualized psychoeducational group programme (4 weeks) and then observed over a 9-month follow-up. Repeated measurements included among others the Positive and Negative Syndrome Scale and a comprehensive neuropsychological test battery from which normative T scores were used to calculate one global and ve domain-specic neurocognitive composite scores. Illness knowledge was measured by a questionnaire (WFB-52) tailored to the psychoeducational programme. Results. Multiple linear regression analyses showed that, apart from baseline illness knowledge, neurocognition signicantly predicted knowledge outcome as well as knowledge gain (measured by reliable change indices) after psychoeducation. This was not true for psychopathology. Among the domain-specic neurocognitive composite scores, only memory acquisition was a signicant predictor of knowledge outcome and gain. Conclusions. Neurocognition, not psychopathology, is a signicant predictor of illness knowledge after psychoeducation in schizophrenia. This nding should guide eorts to tailor psychoeducational interventions more closely to the patients needs and resources. Received 14 May 2009 ; Revised 6 April 2010 ; Accepted 13 April 2010 ; First published online 19 May 2010 Key words : Illness knowledge, neurocognition, psychoeducation, schizophrenia.

Introduction Although there is evidence for neurocognitive heterogeneity in patients with schizophrenia (MacCabe et al. 2002 ; Joyce & Roiser, 2007), comprehensive metaanalyses conrm that these patients, as a group, show substantial neuropsychological impairments (Heinrichs & Zakzanis, 1998 ; Fioravanti et al. 2005 ; Dickinson et al. 2007). Decits range between 1.5 and 2.0 S.D. below healthy controls on key dimensions such as attention, working memory, psychomotor speed, verbal and non-verbal memory and executive functions including verbal uency (Barch, 2005 ; Keefe et al.
* Address for correspondence : Professor T. Jahn, Clinical and Experimental Neuropsychology, Department of Psychiatry and Psychotherapy, Technische Universitat Munchen, Ismaninger Strae 22, D-81675 Munich, Germany. (Email : th.jahn@lrz.tum.de)

2006). Although many of these impairments do remain fairly stable over the rst years of the illness (Townsend & Norman, 2004 ; Ho et al. 2005), there might be uctuations with more diculties during the acute phase. Since cognitive impairments characterize, however, to a lesser extent, many rst-degree relatives of the patients (Snitz et al. 2006), they are discussed as candidate endophenotypes that may be useful in genetic studies of schizophrenia (Gur et al. 2007 ; Allen et al. 2009). Cognitive decits in schizophrenia are clinically important in that they play a crucial role in case management (challenging clinicians and other professionals communication skills ; McGurk & Mueser, 2006 ; Priebe & McCabe, 2008) and may limit rehabilitation eorts. For example, an increasing number of studies have observed poor insight, which itself is essential for treatment adherence, to be a reection of

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T. Jahn et al. of psychoeducation, the level of illness knowledge achieved : (Q1) Does the neurocognitive or the psychopathological status of patients shortly before they enter a psychoeducational treatment programme better predict the level of illness knowledge after psychoeducation ? (Q2) If neurocognition predicts a signicant amount of variance of the patients illness knowledge after psychoeducation, which cognitive domains are most relevant for such a prediction ? Our hypotheses were : (H1) The neurocognitive status prior to psychoeducation is a signicant and at least just as important predictor of illness knowledge after psychoeducation as is the psychopathological status. (H2) The most relevant cognitive domains for this prediction are attention and verbal memory. Methods Study design The design of the COGPIP study is shown in Fig. 1. After the patients had given informed consent, basic sociodemographic and anamnestic information was collected and the ICD-10 diagnoses provided by the patients attending physicians were independently conrmed by means of the Structured Clinical Interview for the DSM-IV. As soon as at least six patients formed a recruitment group , the baseline assessment (t1) was conducted. Patients were then randomly allocated to either a computerized cognitive training or to routine occupational therapy. After repeating most of the t1 assessments at t2, study patients were motivated to attend a psychoeducational group intervention. This was followed by t3 assessments (without neuropsychological tests). Approximately 9 months later, the study participants were assessed again (t4) on their functional and psychopathological status, psychoeducational outcome variables and on the number of intermediate rehospitalizations and days in hospital. In addition to the study procedures mentioned above, all participants received the routine treatment of our hospital including non-restricted, individualized antipsychotic medication (mainly second generation antipsychotics), supporting psychotherapy sessions, art, music and occupational therapy, relaxation training and supplementary psychosocial group activities according to the rules of evidencebased medicine and good clinical practice following the schizophrenia treatment guidelines of the German Society for Psychiatry, Psychotherapy and Neurology (DGPPN, 2006).

neurocognitive dysfunctions, mainly of those mediated by the frontal and the parietal cortex (Shad et al. 2006 ; although a number of studies did not nd these connections ; for example, Collins et al. 1997 ; Simon et al. 2009). Similarly, psychosocial rehabilitation outcome is associated primarily with both the amount and pattern of neurocognitive decits (Green et al. 2000 ; Brekke et al. 2007). Considering this background, the assumption that neurocognitive decits can limit therapeutical use and the eects of psychosocial interventions for patients with schizophrenia appears mandatory. One such intervention is psychoeducation, which has been dened as systematic, didactic psychotherapeutic interventions, which are capable of informing patients and their relatives about the illness and the treatment options available and of fostering the understanding of and coping with the illness (Bauml & Pitschel-Walz, 2008, p. 13). Studies have shown that patients with schizophrenia who receive psychoeducation know more about their illness, are more compliant and experience fewer relapses or rehospitalizations (Barbato & dAvanzo, 2000 ; Pitschel-Walz et al. 2001 ; Pekkala & Merinder, 2002 ; Lincoln et al. 2007 ; Rummel-Kluge & Kissling, 2008). The positive eects of the relatively short interventions are retained over several years (Tarrier et al. 1994 ; Bauml et al. 2007). Although psychoeducation is now considered a state-of-the-art intervention in treatment guidelines for schizophrenia (APA, 2004 ; DGPPN, 2006), it is still unknown how much its short- and long-term eects may depend on the neurocognitive status of the patients at the time they enter the treatment, which neurocognitive domains have the strongest inuence on the outcome and whether even patients with severe decits can derive any prot from psychoeducational interventions [as was, for example, shown for the integrated psychological therapy (IPT), which works well even in post acute patients with large attentional impairments ; Roder et al. 2006]. To shed some light on these and related questions, we undertook the Munich Cognitive Determinants of Psychoeducation and Information in Schizophrenic Psychoses (COGPIP) study, supported by the German Research Foundation. This longitudinal study combined a neurocognitive training or control condition with a subsequent psychoeducational group programme and a 9-month follow-up, evaluating the two interventions and their short- and longterm eects by means of sociodemographic, anamnestic, psychopathological, pharmacological, neurological and neuropsychological data. In this paper, we try to answer the following research questions on the most important short-term eect measure

Prediction of knowledge after psychoeducation

Social functioning
Demographic

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P S Neurology
NES

characteristics
GAF

Functioning and clinical course during 9 months

GAF Number and

Study information

Neurology
NES

Y C H O E D U C A T I O N Psychoeducation

duration of readmissions Psychopathology PANSS CGI-SCH CDSS-G ESI Psychopathology

Psychopathology Informed consent

PANSS CGI-SCH CDSS-G ESI

Routine treatment plus cognitive training COGPACK

Psychopathology

PANSS CGI-SCH CDSS-G ESI

PANSS CGI-SCH CDSS -G ESI

Neuropsychology Anamnesis

Neuropsychology

Psychiatric diagnostics (SCID-I)

Laboratory diagnostics

EHI CVLT (A or B) WMS-R subtest TAP subtests TMT -A/B FWIT mWCST PERSEV MLS subtests Handwriting Test experience

Randomisation

Routine treatment without cognitive training, but with more art and occupational therapy

EHI CVLT (B or A) WMS-R subtest TAP subtests TMT -A/B FWIT mWCST PERSEV MLS subtests Handwriting Test experience

Premorbid adjustment and IQ PAS SPM ZVT

Psychoeducation

Psychoeducation

Psychoeducation

Compliance KK-Scale MARS Satisfaction

time
t0 t1 2 weeks

Compliance KK-Scale MARS Satisfaction WFB

Compliance KK-Scale MARS Satisfaction WFB

Compliance KK-Scale MARS Satisfaction WFB

t2

4 weeks

t3

9 months

t4

Continuous medication control with scales about side effects (AIMS, Barnes-Scale, EPS)

Fig. 1. Design of the Cognitive Determinants of Psychoeducation and Information in Schizophrenia Psychoses (COGPIP) study : procedures, assessment points and measures. Abbreviations of tests, scales and questionnaires are from English or German names of the measurement instruments (see text).

Subjects Patients were recruited from three wards of the psychiatric hospital of the Technical University of Munich, Germany, between February 2006 and March 2008. Follow-up assessments were nished in April 2009. In total, 242 patients with schizophrenia spectrum disorders (ICD-10 : F20F29) were screened during the 25-month recruitment period. Patients who met the following inclusion criteria were informed about the study and asked to participate : (1) age between 18 and 60 years ; (2) absence of any serious somatic illness or mental retardation ; (3) German as rst language or a satisfactory command of the German language. Of the 122 patients (50.4 %) who fullled the inclusion criteria and agreed to participate, six dropped out before the t1 assessments could be completed, due to withdrawal of informed consent or transfer to another hospital. Descriptive data on the remaining 116 study patients are reported in Table 1. There were no signicant dierences between the intervention and the control group on the variables shown in Table 1 (x2-tests for categorical variables : 0.34fpf0.65 ; t tests for continuous variables : 0.15f pf1.00). Between t1 and t3 assessments, another 19 patients dropped out (eight of the intervention group and 11 of the control group) because of withdrawal of informed consent (n=7), attendance at fewer than four

psychoeducational sessions (n=5), early discharge (n=5) or sudden need for electroconvulsive treatment (n=1) or chemotherapy (n=1). Drop-out reasons were similar for both subgroups. From the remaining 97 subjects, one refused to ll in the knowledge questionnaire at t2 ; leaving 96 subjects for data analyses. Computerized cognitive training The intervention group attended a maximum of 10 daily training sessions of 60 min each over a 2-week period using the COGPACK software package (Marker, 2003). Each session consisted of a sequence of computerized exercises designed to improve ve cognitive domains : attention ; verbal and non-verbal memory ; psychomotor speed ; language processing ; visuomotor skills. The training was supervised by a trained psychologist (A.G.), who explained the tasks to the patients and helped them to overcome diculties. Task diculty varied depending on the individual performance and was gradually increased. This part of the study will be reported in detail elsewhere. Psychoeducational groups Psychoeducation was performed in accordance with the APES manual (Bauml et al. 2005). Interactive de livery of information and emotional relief are the basic

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Table 1. Sociodemographic and clinical characteristics of the study patients at t1 Intervention group (n=59) Gender, n ( %) Male Female Age, mean (S.D.) Education completed, n ( %) No qualication Elementary/Grade Preparatory High School Diagnosis, n ( %) Schizophrenia Persistent delusional disorder Schizoaective disorder Duration of illness, mean (S.D.) Number of psychiatric admissions, mean (S.D.) GAF, mean (S.D.) CGI-SCH, n ( %) Mildly ill Moderately ill Markedly ill Severely ill PANSS, mean (S.D.) Total Positive Negative General Antipsychotics, n ( %) Typical Atypical Combined Chlorpromazine dosage equivalents, mean (S.D.) Control group (n=57) Total sample (n=116)

29 (49.2) 30 (50.8) 35.9 (10.6) 1 (1.7) 15 (25.4) 25 (42.4) 18 (30.5) 33 (55.9) 1 (1.7) 25 (42.4) 9.3 (8.2) 4.6 (4.0) 48.5 (11.1) 2 (3.4) 30 (50.8) 25 (42.4) 2 (3.4) 66.5 (14.3) 15.7 (4.2) 15.8 (4.9) 35.0 (7.1) 2 (3.4) 46 (78.0) 11 (18.6) 466.1 (272.1)

23 (40.4) 34 (59.6) 33.1 (10.2) 3 (5.3) 14 (24.6) 20 (35.1) 20 (35.1) 36 (63.2) 0 (0.0) 21 (36.8) 7.8 (7.0) 5.5 (6.6) 48.5 (11.9) 1 (1.8) 29 (50.9) 21 (36.8) 6 (10.5) 68.4 (15.6) 15.9 (4.3) 16.6 (5.0) 35.9 (8.0) 3 (5.3) 40 (70.2) 14 (24.6) 506.6 (315.3)

52 (44.8) 64 (55.2) 34.5 (10.5) 4 (3.4) 29 (25.0) 45 (38.8) 38 (32.8) 69 (59.5) 1 (0.9) 46 (39.7) 8.6 (7.7) 5.1 (5.5) 48.5 (11.4) 3 (2.6) 59 (50.9) 46 (39.7) 8 (6.9) 67.4 (14.9) 15.8 (4.3) 16.2 (4.9) 35.4 (7.5) 5 (4.3) 86 (74.1) 25 (21.6) 486.0 (293.6)

GAF, global assessment of functioning ; CGI-SCH, Clinical Global Impression Scale Schizophrenia Version ; PANSS, Positive and Negative Syndrome Scale.

elements of this psychoeducational concept (Bauml et al. 2006). Eight 1-h group sessions were held, with two sessions per week. Information was given about symptoms, aetiology, acute treatment, relapse prevention and psychosocial treatment of schizophrenia. Adequate coping strategies were discussed and individual crisis plans were drawn up. Furthermore, patients had the opportunity to discuss current questions or day-to-day problems concerning the illness. In total, 14 psychoeducational groups were run for the study patients. Their relatives were invited to separate psychoeducational groups, which were designed similarly, according to the APES manual, in order to

assist the family in speaking the same language as the patient. In addition, separate but complementary crisis plans were worked out, both with the patients and their relatives. Clinical measures From the various measures applied within the COGPIP study (Fig. 1), only those relevant to this paper will be described. Illness severity was rated with the Clinical Global Impression Scale Schizophrenia Version (Haro et al. 2003), ranging from 0 (normal, not ill) to 7 (among the

Prediction of knowledge after psychoeducation most severely ill). Functional level was determined by the global assessment of functioning (GAF), with possible values between 1 and 100. Psychiatric symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS ; Kay et al. 1987), which contains 30 items rated on a 7-point severity scale. All interviews were carried out by a clinically experienced PANSS rater (T.F.), repeatedly trained and certied within several international multi-centre-studies on the pharmacological treatment of schizophrenia. The Knowledge of Illness Questionnaire [ Wissensfragebogen (WFB-52) ; Pitschel-Walz, 1997] was originally created for the German Psychoses Information Project (PIP) study (Pitschel-Walz et al. 2006 ; Bauml et al. 2007). Its 107 questions (yes/no answers required) are related to those topics discussed in the psychoeducational groups, concerning symptoms, causes, treatment and warning signs. Examples are : While suering from schizophrenia, one might experience reality quite dierent from how other people do ; For an eective treatment of schizophrenia, regular intake of antipsychotic medications is crucial ; Nervousness is a frequent warning sign that indicates danger of illness relapse . Having completed the COGPIP study we calculated an item analysis on the pooled PIP-II/COGPIP WFB data (n=187) and excluded questions with item diculties >0.80 or item test correlations <0.20. With the resulting 52-item version of the knowledge questionnaire (Cronbachs a=0.94 ; testretest reliability rtt=0.74 ; KaiserMeyer Olkin=0.87) a maximum knowledge total score of 52 could be achieved. Neuropsychological assessment Subjects were assessed twice with a comprehensive neuropsychological test battery. The 11 psychometric tests took between 2.5 and 3.0 h to complete. Paper pencil tests were the California Verbal Learning Test (German version ; Niemann et al. 2008), subtest Digit Span (forward and backward) from the Wechsler Memory Scale Revised (German version ; Harting et al. 2000), Trail Making Tests A and B from the HalsteadReitan Neuropsychological Test Battery (HRNTB ; Heaton et al. 2004), the modied Wisconsin Card Sorting Test (mWCST, Nelson, 1976) and the Stroop-Paradigm as measured by the Colour Word Interference Test ( Farbwort-Interferenztest; Baumler, 1985). Computer-based tests were subtests Alertness and Divided Attention from the Test for Attentional Performance [ Testbatterie zur Aufmerksamkeitsprufung (TAP), version 1.7c ; Zimmermann & Fimm, 2002] and from the Vienna Test System (Schuhfried, 2005) the Perseveration Test (PERSEV, version 21.00) as well as the subtests Tapping, Steadiness and Placing

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Long Sticks of the Motor Performance Series ( Motorische Leistungsserie , version 24.00). Raw scores were transformed into age, sex and/or education corrected standard scores according to the normative data published in the test manuals. Agecorrected normative data for the mWCST (Nelson, 1976) was drawn from literature (de Zubicaray & Ashton, 1996 ; Lineweaver et al. 1999). For the trailmaking test, norms were used, provided by Engel (2007), who combined data from 17 studies, and the latest HRNTB handbook (Heaton et al. 2004) by metaanalytic techniques. In order to express all test variables in a common metric, T scores (mean=50, S.D.= 10) were used as standard scores. Where T scores were not the primary outcome format of a test variable, percentiles (or some other scores) were transformed into T scores using the standard normal distribution. A global neurocognitive performance index (GNPI) was calculated as the average T score from 40 out of 60 test variables. Variables that could not be classied into meaningful cognitive subdomains (see below) or showed reduced variance or insucient item-scale correlations were excluded. Five domain-specic neurocognitive composite scores were calculated following Zakzanis et al. (1999 ; pp. 2431), who dened seven neurocognitive domains within their comprehensive meta-analyses of neurocognitive decits in various neuropsychiatric disorders. While our battery included no variables for two of their domains (verbal skill and performance skill), we had to sort some of our variables not mentioned by Zakzanis and coworkers into the remaining ve domains, namely, the TAP variables (sorted into the attention/concentration composite score) and the second order redundancy score from the PERSEV (sorted into cognitive exibility/abstraction). Internal consistencies (Cronbachs a) of the GNPI and the ve composite scores (attention/concentration, memory acquisition, delayed recall, cognitive exibility/abstraction, manual dexterity) ranged from 0.74 to 0.92. Testretest reliabilities were 0.72frttf0.87. Data analyses A series of 2 (treatment groups)r2 (time points) repeated measurement analyses of variance indicated signicant main eects of time on neurocognitive performance (improvement from t1 to t2 in the GNPI and in four of the ve domain-specic composite scores), as well as on illness knowledge (improvement in WFB-52 total scores from t2 to t3), but not any signicant main or interaction eects of patient subgroup (preceding cognitive training versus no training). While these somewhat disappointing results of the COGPIP study are relevant for another set of hypotheses, in the

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(a)
60

(b)
60 50 40 30 20 10
y = 10.32 + 0.81 x 2 R = 0.81/R = 0.66 y = 3.76 + 0.98 x R = 0.50/R 2 = 0.25

(c)
60 50 40 30 20 10
y = 45.73 0.10 x R = 0.12/R 2 = 0.01

Knowledge post psychoeducation (WFB-52 total score t3)

50 40 30 20 10 0 0 10 20 30 40 50 60

0 0 30 40 50 60

0 0 30 40 50 60 70 80 90 100

Knowledge pre psychoeducation (WFB-52 total score t2)

Neurocognition pre psychoeducation (GNPI T-score t2)

Psychopathology pre psychoeducation (PANSS total score t2)

Fig. 2. Bivariate scatter plots with zero-order correlations and linear ts between illness knowledge after psychoeducation at t3 (y-axes) as the criterion variable and three potential predictor variables before psychoeducation at t2 (x-axes) : baseline illness knowledge (a), neurocognition (b) and psychopathology (c). Note the x-axis breaks in plots (b) and (c). WFB-52 (The Knowledge of Illness Questionnaire ; Wissensfragebogen ) ; GNPI, global neurocognitive performance index ; PANSS, Positive and Negative Syndrome Scale.

context of the present paper they justify our pooling of data from both patient subgroups in order to test H1 and H2 within the total sample by calculating blockwise and stepwise multiple linear regression analyses. According to our hypotheses, the criterion variable was knowledge outcome (WFB-52 total scores at t3) and the pre-selected predictor variables were neurocognition (GNPI or, for more ne-grained analyses, domain-specic composite scores at t2) and psychopathology (PANSS total scores at t2). We also included baseline knowledge (WFB-52 scores at t2) as a predictor variable, since illness knowledge was highly correlated between t2 and t3 (which means good testretest reliability of the WFB-52 questionnaire : rtt=0.81). Stepwise (forward/backward) analysis was used for the determination of the predictive power of the domain-specic neurocognitive composite scores, as this approach is more appropriate for inter-correlated predictors to avoid misinterpretation due to multi-collinearity (Streiner, 1994). Both regression analyses were then repeated using reliable change indices (RCI ; Jacobson & Truax, 1992) as a measure of knowledge gain (intra-individual change in WFB-52 total score from t2 to t3) as criterion variables. RCI were also used to dene a subsample of patients with signicant knowledge gain (one-directional RCIo1.645 ; Hafkenscheid, 2000), whose clinical and neuropsychological characteristics were compared with patients without such gain. For all regression analyses, a levels for variable inclusion or exclusion were set at <0.05 and o0.10, respectively. For all other tests, the level of statistical signicance was af0.05 (two-tailed). SPSS versions 15.0.1 and 18.0.1 for Windows were used (SPSS Inc., USA).

Results Within the total sample, the global level of psychopathology as measured by the PANSS total score diminished from mean=67.8 (S.D.=14.0, range 38101) at t1 to mean=51.1 (S.D.=13.9, range 3188) at t3, demonstrating a clear symptomatic improvement [t=13.95, degrees of freedom (df)=95, p<0.001]. Mean illness knowledge (WFB-52 total score) increased from 36.7 (S.D.=11.4, range 851) at t2 to 40.1 (S.D.=11.4, range 652) at t3. Although the corresponding mean dierence of 3.5 (S.D.=6.9) was clearly signicant (paired t test : t=4.92, df=95, p<0.001), this is only a small to medium eect (Cohens d=0.31). Figure 2 shows the bivariate zero-order correlations of illness knowledge after psychoeducation with illness knowledge, neurocognition and psychopathology before psychoeducation. There was a strong relationship between illness knowledge at both measurement points (Fig. 2a), a medium correlation between knowledge and global neurocognitive performance (Fig. 2 b) and a very small, close to zero correlation between knowledge and level of psychopathology (Fig. 2 c). Results of the blockwise and stepwise multiple linear regression analyses for knowledge outcome at t3 are shown in Table 2. The multiple correlation from the blockwise regression analysis (model A) was substantial, indicating that 69 % of the variance in the criterion variable could be explained. While baseline knowledge and neurocognitive performance (GNPI) were both signicant predictors, the global level of psychopathology (PANSS total score) had no predictive value.

Prediction of knowledge after psychoeducation

Table 2. Results of a blockwise (model A) and stepwise (model B) multiple linear regression analysis with illness knowledge (WFB-52) after psychoeducation (t3) as the criterion variable (n=96) Predictor Model A R=0.83 R2=0.69 F=69.51 p<0.001 Model B R=0.83 R2=0.69 F=102.58 p<0.001 WFB-52, The Knowledge of Illness Questionnaire ( Wissensfragebogen ). Corrected R2 : 0.68 (model A) ; 0.68 (model B). In model A, predictor variables were baseline illness knowledge (WFB-52), neurocognition (Global Neurocognitive Performance Index) and psychopathology (Positive and Negative Syndrome Scale total score). In model B, predictor variables were baseline illness knowledge and ve domain-specic neurocognitive composite scores. All predictor variables were measured before psychoeducation (t2). B
S.E.

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Baseline knowledge Neurocognition Psychopathology

0.735 0.389 0.021

0.063 0.128 0.048

0.736 0.197 0.026

11.58 3.04 0.45

<0.001 0.003 0.657

Baseline knowledge Memory acquisition

0.768 0.240

0.060 0.088

0.769 0.165

12.75 2.74

<0.001 0.007

The multiple correlation from the stepwise regression analysis (model B) was equally high. From the ve domain-specic neurocognitive composite scores, only memory acquisition was selected as a signicant predictor variable together with baseline knowledge. Mean knowledge gain (RCI) from pre- to postpsychoeducation was 0.87 (S.D.=1.73, range x5.49 to 5.24). Blockwise and stepwise regression analyses with RCI as the dependent variable revealed the results given in Table 3. In spite of much lower multiple correlations, R2 was signicant in both models (C and D), which replicated ndings from Table 2. Apart from baseline knowledge, neurocognition, not psychopathology, was a signicant predictor of knowledge gain and among the ve domain-specic neurocognitive composite scores only memory acquisition was selected. According to the RCIo1.645 criterion, 28 patients (29.2 %) signicantly improved their illness knowledge from t2 to t3, while 68 patients (70.8 %) remained more or less stable (n=60) or even deteriorated (n=8). Comparing both patient subgroups, no signicant dierences were found with regard to age, duration of illness, number of hospitalizations, GAF at t1, PANSS summary or subscale scores at t2 or t3, level of intelligence (SPM ; Schuhfried, 2005) at t3 and neurocognitive global and domain-specic composite scores at t1 or t2, except that patients with signicant individual knowledge gain had somewhat better memory

acquisition at t1 (mean T scores=45.0, S.D.=8.0) as compared with patients without such gain (mean= 41.7, S.D.=7.5, t=1.96, df=94, p=0.053).

Discussion In recent years, psychoeducation has become an integral part of the non-pharmacological treatment of schizophrenia and related psychoses (Rummel-Kluge et al. 2006 ; Getachew et al. 2009), yet little is known about factors that might inuence the outcome of psychoeducational interventions. Findings reported here conrmed H1, that in a heterogeneous sample of patients with schizophrenic disorders the neurocognitive performance before psychoeducation predicts illness knowledge after psychoeducation. In fact, in addition to baseline knowledge, neurocognition was the only signicant predictor, while the level of psychopathology was insignicant. H2, speculating that the most relevant neurocognitive domains for such a prediction would be attention and verbal memory, was only partially conrmed. Within a stepwise regression approach with baseline illness knowledge and ve domain-specic neurocognitive composite scores as independent variables, only memory acquisition was selected as an additional predictor apart from baseline knowledge. This appears reasonable as, beyond the knowledge already acquired by a

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Table 3. Results of a blockwise (model C) and stepwise (model D) multiple linear regression analysis with reliable change indices of illness knowledge (WFB-52) change from pre- (t2) to post- (t3) psychoeducation as the criterion variable (n=96) Predictor Model C R=0.42 R2=0.18 F=6.59 p<0.001 Model D R=0.40 R2=0.16 F=8.94 p<0.001 B
S.E.

Baseline knowledge Neurocognition Psychopathology

x0.066 0.097 0.005

0.016 0.032 0.012

x0.435 0.323 0.043

x4.18 3.04 0.45

<0.001 0.003 0.657

Baseline knowledge Memory acquisition

x0.058 0.060

0.015 0.022

x0.381 0.270

x3.86 2.74

<0.001 0.007

WFB-52, The Knowledge of Illness Questionnaire ( Wissensfragebogen ). Corrected R2 : 0.15 (model C) ; 0.14 (model D). In model C, predictor variables were baseline illness knowledge (WFB-52), neurocognition (Global Neurocognitive Performance Index), and psychopathology (Positive and Negative Syndrome Scale total score). In model D, predictor variables were baseline illness knowledge and ve domain specic neurocognitive composite scores. All predictor variables were measured before psychoeducation (t2).

patient, his or her ability to encode new information should determine the nal level of knowledge. Findings were similar for knowledge gain, using RCI (Jacobson & Truax, 1992) as a measure of individual change in illness knowledge from pre- to post psychoeducation, yet the amount of variance explained was far smaller in these analyses, probably due to the ceiling eect in the knowledge questionnaire (Fig. 2a). Baseline knowledge had a negative eect on knowledge gain, meaning that the higher the baseline knowledge, the smaller the gain. Thus, it may be concluded that among various neuropsychological performance measures, memory acquisition signicantly predicts knowledge outcome after psychoeducation as well as knowledge gain during psychoeducation, even if baseline illness knowledge (the most important predictor) is taken into account. It should be mentioned that among the other neurocognitive composite scores, exibility/abstraction and attention/concentration had even higher zero order correlations than memory acquisition with knowledge outcome. But since they were also closer correlated to baseline knowledge, they were outperformed by memory acquisition in the stepwise regression analyses due to redundancy eects. We would like to discuss these ndings in relation to other studies on the role of neurocognition for psychoeducation, but we are not aware of any such study. Therefore, our results must be treated with caution and as preliminary for as long as they have not been replicated.

Since the mean prepost dierence of illness knowledge was although highly signicant rather small in our study sample (Cohens d=0.31), one could ask whether being able to answer three or four more questions of the illness questionnaire correctly after the intervention could be meaningful for a single patient. As was shown by means of the RCI analyses, nearly one-third of our patients showed an increase in illness knowledge greater than random change and this alone might be worth the eort. In fact, the amount of knowledge gain was quite considerable in some cases (up to a maximum of +21 WFB-52 points), but these cases were counterbalanced by others who showed a substantial drop (up to x22 points). While we do not know which amount of increase in illness knowledge might be clinically signicant in any single patient (i.e. making a dierence in the short- or even long-term outcome of the illness itself), the withingroup variance of the knowledge scale was large enough to search for possible predictors of knowledge outcome after psychoeducation, which was our focus here. With regard to sample size, the COGPIP study is not underpowered, but it could be questioned whether the study design was ideal in order to identify neurocognitive predictors of illness knowledge following psychoeducation, as a preceding neurocognitive training aimed at increasing neurocognition before psychoeducation. The inclusion of a preceding neurocognitive training was motivated by our hope that trained patients with increased neurocognitive

Prediction of knowledge after psychoeducation performance might prot more from psychoeducation than untrained patients. Obviously, this was not the case. One could speculate that the training period was too short. Yet, there is evidence that the nature of a neurocognitive training intervention is much more important than its length, with interventions that aim at compensation rather than restitution (such as COGPACK) yielding higher eects (Krabbendam & Aleman, 2003 ; McGurk et al. 2007). Without dierential eects of COGPACK training, pooling of the data from trained and untrained patients seemed adequate for the purposes of this report. To be sure about that point, we tried subgroup membership as an additional predictor variable within the regression analyses, which led to nearly identical results with those described above. In therapy studies, outcome measures are of great importance. As our measure of illness knowledge might have lost discriminative power since it was introduced in the early 1990s and successfully used in several studies (see references cited in Pitschel-Walz et al. 2006 ; Bauml et al. 2007), we modied the original WFB to a shortened version with enhanced psychometric properties (see Method). Nevertheless, a ceiling eect remained obvious in the WFB-52 total scores (Fig. 2). We are currently occupied with further modications to the WFB-52 in order to solve this problem. In recent years, considerable eorts have been made to identify the factorial structure of neurocognitive decits in schizophrenia by employing comprehensive neuropsychological test batteries to large patient samples (Gladsjo et al. 2004 ; Nuechterlein et al. 2004 ; Dickinson et al. 2006 ; Keefe et al. 2006 ; Genderson et al. 2007). The question remains as to which tests should be used for which research purposes. We have not been able to simply adopt recently recommended test batteries, for instance, those of the CATIE and MATRICS initiatives (Keefe et al. 2006 ; Kern et al. 2008 ; Nuechterlein et al. 2008), since several of their components are not yet adapted to German conditions. Furthermore, the CATIE and the MATRICS batteries dier in that they have been optimized for several purposes (pharmacological treatment versus neurocognitive rehabilitation research, respectively) and it is likely that an optimal battery for psychoeducation research may dier from each of them. Our calculation of composite scores according to the classication of neuropsychological test variables, as suggested by Zakzanis et al. (1999), is based on empirical evidence as well as on neuropsychological expertise. Factor analysing our own data (unpublished) underpinned this approach as suitable for our purposes. A clinician who wants his or her patient to attend a psychoeducational treatment group will very likely focus on the patients current psychopathological

541

status in order to decide if and when the patient is ready for such an intervention and able to prot from it. Results of our study demonstrate that the patients neurocognitive status, as measured by standardized neuropsychological tests, might be a more important predictor of psychoeducation outcome than is psychopathology, at least with regard to illness knowledge, which has been our focus here. Of course, a patient with extreme psychomotor excitement or strong preoccupation caused by hearing voices will probably be unable to attend a psychoeducational treatment group, let alone take advantage of it. But, except for such conditions, it is our clinical experience that even patients with acute symptoms can successfully participate in such groups. Even after the psychoeducational programme, 25 % of our patient sample could be qualied as still moderate to markedly ill (PANSS total scores o62 ; Leucht et al. 2005), due to persisting positive and negative symptoms. Thus, dispersion of PANSS total scores would have been sucient to uncover a substantial correlation with knowledge outcome or gain, if such a correlation had existed. In conclusion, we found evidence that neurocognition (particularly memory acquisition) is a signicant predictor of illness knowledge after psychoeducation, while the level of psychopathology is not. This nding, if replicable, might be somewhat counterintuitive, but it would have important clinical implications. If neurocognitive decits limit the benet of psychoeducation, it would be reasonable to shape existing treatment programmes for neurocognitively more impaired patients in order to be able to target their needs better and enable them to prot from such an intervention as much as possible. The critical role of decits in memory acquisition, which might be an indicator of the patients general learning capacity, points to the necessity to start the psychoeducation programme not too early, to provide not too much information at once and to present all facts as clearly as possible, to use graphical presentations of the learning material in addition to spoken words and to repeat all material as often as possible. If, for a given treatment programme, distinct versions are developed for the neurocognitively more intact vs. more handicapped patients, neuropsychological data could then serve as a tool for the assignment of certain patients to specic treatments. Acknowledgements The COGPIP study (ClinicalTrials.gov identier : NCT00646256) was supported by the German Research Foundation (Deutsche Forschungsgemeinschaft : DFG Ja 680/42, 43). We are grateful to all participants,

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patients as well as relatives, and to Zasu Keller, Tanja Sonnfeld, and Andreas Ulitsch for their temporary assistance in the data collection and preparation.

Declaration of Interest None.

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