It is widely recognised that cognitive impairments are a core feature of psychosis-spectrum (Catalan et al., Reference Catalan, De Pablo, Aymerich, Damiani, Sordi, Radua and Stone2021; Fioravanti, Bianchi, & Cinti, Reference Fioravanti, Bianchi and Cinti2012) and major depressive (Goodall et al., Reference Goodall, Fisher, Hetrick, Phillips, Parrish and Allott2018) disorders, with significant implications for both everyday (Meier et al., Reference Meier, Caspi, Reichenberg, Keefe, Fisher, Harrington and Moffitt2014) and long-term (Cowman et al., Reference Cowman, Holleran, Lonergan, O'Connor, Birchwood and Donohoe2021; Santesteban-Echarri et al., Reference Santesteban-Echarri, Paino, Rice, González-Blanch, McGorry, Gleeson and Alvarez-Jimenez2017) functional outcomes. In clinical practice, however, the primary focus of early intervention services is often the stabilisation of mental health symptoms. Though current clinical guidelines for the treatment of both psychosis (e.g. Early Psychosis Guidelines Working Group, 2016) and depression (e.g. Malhi et al., Reference Malhi, Bell, Bassett, Boyce, Bryant, Hazell and Porter2021) recommend that cognition is assessed, and interventions offered when impairments are impacting upon recovery, cognition is often not addressed in treatment. In Douglas et al.'s commentary on our original paper (Stainton et al., Reference Stainton, Chisholm, Griffiths, Kambeitz-Ilankovic, Wenzel, Bonivento and PRONIA Consortium2023, this issue), they discuss the clinical implications of our findings for cognitive intervention. The authors advocate for the importance of early intervention for cognition in psychosis and depression. Such early intervention may help to prevent further cognitive or functional decline which may occur in the years following the first episode of psychosis, or with repeated depressive episodes. Our recent work also shows that such early intervention for cognition is also aligned with the preferences of young people. Cognition is a high treatment priority for young people with mental illness, alongside the treatment of mental health symptoms (Bryce et al., Reference Bryce, Cheng, Dalton, Ojinnaka, Stainton, Zbukvic and Allott2023).
In our ‘Your Mind, Your Choice’ survey (Bryce et al., Reference Bryce, Cheng, Dalton, Ojinnaka, Stainton, Zbukvic and Allott2023), we asked young people who had recently received mental health treatment to rate the importance of 20 different recovery domains. Respondents were 243 young people (mean age = 20.07, s.d. = 3.25, range = 15–25, 74% female) with self-reported mental illnesses including depression, anxiety disorders, personality disorders and psychosis. Cognition was rated as the sixth most important recovery domain (following mental health, emotions, stress management, family problems and sleep). This finding is pertinent given that, as mentioned, mental health and stress symptoms are already addressed in early intervention services. Therefore, greater focus on cognition as a priority to enable recovery is required as part of standard care. Indeed, 70% of survey respondents reported experiencing cognitive difficulties, but only 31% indicated receiving treatment for the same, highlighting that less than half of those who felt that they were struggling with their cognition had received a targeted, evidence-based treatment to assist them with these important skills (Bryce et al., Reference Bryce, Cheng, Dalton, Ojinnaka, Stainton, Zbukvic and Allott2023). Douglas et al. highlight the importance of incorporating a strengths-based approach into cognitive intervention. This also aligns with the findings of the Your Mind, Your Choice survey, in which cognitive strengths were rated in the top five of 14 evidence-based cognitive interventions (alongside compensatory training, sleep interventions, psychoeducation and exercise). We have found through a theoretical review (Allott et al., Reference Allott, Steele, Boyer, de Winter, Bryce, Alvarez-Jimenez and Phillips2020) and a series of qualitative studies with young people, experts in the field and clinicians (Bryce et al., Reference Bryce, Boyer, Phillips, Parrish, Alvarez-Jimenez and Allott2022a, Reference Bryce, de Winter, Phillips, Cheng, Alvarez-Jimenez and Allott2022b; Steele et al., Reference Steele, Cheng, Phillips, Bryce, Alvarez-Jimenez and Allott2021), that explicitly focusing on strengths alongside difficulties is likely to support treatment engagement, motivation and enhanced functioning. This premise remains theoretical and requires further empirical evidence.
Our findings also underscore that cognitive impairments are prevalent in the early course of mental illness, but not ubiquitous (Bryce et al., Reference Bryce, Cheng, Dalton, Ojinnaka, Stainton, Zbukvic and Allott2023; Stainton et al., Reference Stainton, Chisholm, Griffiths, Kambeitz-Ilankovic, Wenzel, Bonivento and PRONIA Consortium2023). One method to enhance early identification and intervention for cognitive functioning that is advocated for by Douglas et al. is the use of routine cognitive screening. At present, interventions for cognitive impairments often result from a full neuropsychological assessment by a qualified clinical neuropsychologist. Such assessments account for the individual's current presentation, full developmental history and cognitive test performance, providing a detailed overview of the individual's cognitive profile, as well as any potential neurodevelopmental disorders (Lezak, Reference Lezak2004). Though such assessments represent the current gold standard, they are often subject to lengthy waitlists and, depending on the health service, potentially expensive private fees. These factors could make addressing cognition less accessible to many young people requiring treatment. Cognitive screening, the use of a brief tool to triage cognitive needs, offers a promising adjunct to the current system. While cognitive screening is used routinely in other contexts, such as detecting mild cognitive impairment and dementia (Roebuck-Spencer et al., Reference Roebuck-Spencer, Glen, Puente, Denney, Ruff, Hostetter and Bianchini2017), no valid screening tools exist for younger individuals in the early course of mental illness (Bryce, Bowden, Wood, & Allott, Reference Bryce, Bowden, Wood and Allott2021). This is despite cognitive screening being recognised by experts as critical for psychiatric care (McIntyre et al., Reference McIntyre, Anderson, Baune, Brietzke, Burdick, Fossati and Harvey2019). We are working to close this gap in clinical practice by conducting a hybrid effectiveness-implementation study to validate a brief cognitive screening tool for young people with first-episode psychosis (‘CogScreen’; ACTRN12623000236695). At the end of the study, we hope to deliver a validated cognitive screening tool for this population, as well as a suite of resources and training to ensure that early intervention services can incorporate screening into routine clinical care. We expect these findings will have broad implications for youth mental health in general.
In summary, we agree with Douglas et al. who argued for a focus on early intervention for cognition, which includes both a deficit- and strengths-based approach. In our recent work, we have seen that cognitive impairments are prevalent in the early course of psychosis and depression, but that there is also a significant subsample of individuals who demonstrate unimpaired, or even above average performance. The profile of impairment, unimpaired performance and strengths may also vary widely according to the individual. Young people want to have their cognitive needs addressed during treatment, alongside their mental health symptoms, and they are open to a range of different intervention types. We also saw that young people were open to a wide range of potential cognitive interventions to both remediate deficits and build upon strengths. Cognitive screening offers a promising avenue to promote such interventions, whereby those people with the greatest need are captured at service entry. Subjective cognitive complaints must also be considered, and these can be quickly assessed via a self-report questionnaire, of which there are many options. Clinicians can then use this information to tailor treatments and inform further referrals. Ultimately, we hope that this leads to timely and individualised focus on the cognitive needs of young people in the early course of mental illness.
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It is widely recognised that cognitive impairments are a core feature of psychosis-spectrum (Catalan et al., Reference Catalan, De Pablo, Aymerich, Damiani, Sordi, Radua and Stone2021; Fioravanti, Bianchi, & Cinti, Reference Fioravanti, Bianchi and Cinti2012) and major depressive (Goodall et al., Reference Goodall, Fisher, Hetrick, Phillips, Parrish and Allott2018) disorders, with significant implications for both everyday (Meier et al., Reference Meier, Caspi, Reichenberg, Keefe, Fisher, Harrington and Moffitt2014) and long-term (Cowman et al., Reference Cowman, Holleran, Lonergan, O'Connor, Birchwood and Donohoe2021; Santesteban-Echarri et al., Reference Santesteban-Echarri, Paino, Rice, González-Blanch, McGorry, Gleeson and Alvarez-Jimenez2017) functional outcomes. In clinical practice, however, the primary focus of early intervention services is often the stabilisation of mental health symptoms. Though current clinical guidelines for the treatment of both psychosis (e.g. Early Psychosis Guidelines Working Group, 2016) and depression (e.g. Malhi et al., Reference Malhi, Bell, Bassett, Boyce, Bryant, Hazell and Porter2021) recommend that cognition is assessed, and interventions offered when impairments are impacting upon recovery, cognition is often not addressed in treatment. In Douglas et al.'s commentary on our original paper (Stainton et al., Reference Stainton, Chisholm, Griffiths, Kambeitz-Ilankovic, Wenzel, Bonivento and PRONIA Consortium2023, this issue), they discuss the clinical implications of our findings for cognitive intervention. The authors advocate for the importance of early intervention for cognition in psychosis and depression. Such early intervention may help to prevent further cognitive or functional decline which may occur in the years following the first episode of psychosis, or with repeated depressive episodes. Our recent work also shows that such early intervention for cognition is also aligned with the preferences of young people. Cognition is a high treatment priority for young people with mental illness, alongside the treatment of mental health symptoms (Bryce et al., Reference Bryce, Cheng, Dalton, Ojinnaka, Stainton, Zbukvic and Allott2023).
In our ‘Your Mind, Your Choice’ survey (Bryce et al., Reference Bryce, Cheng, Dalton, Ojinnaka, Stainton, Zbukvic and Allott2023), we asked young people who had recently received mental health treatment to rate the importance of 20 different recovery domains. Respondents were 243 young people (mean age = 20.07, s.d. = 3.25, range = 15–25, 74% female) with self-reported mental illnesses including depression, anxiety disorders, personality disorders and psychosis. Cognition was rated as the sixth most important recovery domain (following mental health, emotions, stress management, family problems and sleep). This finding is pertinent given that, as mentioned, mental health and stress symptoms are already addressed in early intervention services. Therefore, greater focus on cognition as a priority to enable recovery is required as part of standard care. Indeed, 70% of survey respondents reported experiencing cognitive difficulties, but only 31% indicated receiving treatment for the same, highlighting that less than half of those who felt that they were struggling with their cognition had received a targeted, evidence-based treatment to assist them with these important skills (Bryce et al., Reference Bryce, Cheng, Dalton, Ojinnaka, Stainton, Zbukvic and Allott2023). Douglas et al. highlight the importance of incorporating a strengths-based approach into cognitive intervention. This also aligns with the findings of the Your Mind, Your Choice survey, in which cognitive strengths were rated in the top five of 14 evidence-based cognitive interventions (alongside compensatory training, sleep interventions, psychoeducation and exercise). We have found through a theoretical review (Allott et al., Reference Allott, Steele, Boyer, de Winter, Bryce, Alvarez-Jimenez and Phillips2020) and a series of qualitative studies with young people, experts in the field and clinicians (Bryce et al., Reference Bryce, Boyer, Phillips, Parrish, Alvarez-Jimenez and Allott2022a, Reference Bryce, de Winter, Phillips, Cheng, Alvarez-Jimenez and Allott2022b; Steele et al., Reference Steele, Cheng, Phillips, Bryce, Alvarez-Jimenez and Allott2021), that explicitly focusing on strengths alongside difficulties is likely to support treatment engagement, motivation and enhanced functioning. This premise remains theoretical and requires further empirical evidence.
Our findings also underscore that cognitive impairments are prevalent in the early course of mental illness, but not ubiquitous (Bryce et al., Reference Bryce, Cheng, Dalton, Ojinnaka, Stainton, Zbukvic and Allott2023; Stainton et al., Reference Stainton, Chisholm, Griffiths, Kambeitz-Ilankovic, Wenzel, Bonivento and PRONIA Consortium2023). One method to enhance early identification and intervention for cognitive functioning that is advocated for by Douglas et al. is the use of routine cognitive screening. At present, interventions for cognitive impairments often result from a full neuropsychological assessment by a qualified clinical neuropsychologist. Such assessments account for the individual's current presentation, full developmental history and cognitive test performance, providing a detailed overview of the individual's cognitive profile, as well as any potential neurodevelopmental disorders (Lezak, Reference Lezak2004). Though such assessments represent the current gold standard, they are often subject to lengthy waitlists and, depending on the health service, potentially expensive private fees. These factors could make addressing cognition less accessible to many young people requiring treatment. Cognitive screening, the use of a brief tool to triage cognitive needs, offers a promising adjunct to the current system. While cognitive screening is used routinely in other contexts, such as detecting mild cognitive impairment and dementia (Roebuck-Spencer et al., Reference Roebuck-Spencer, Glen, Puente, Denney, Ruff, Hostetter and Bianchini2017), no valid screening tools exist for younger individuals in the early course of mental illness (Bryce, Bowden, Wood, & Allott, Reference Bryce, Bowden, Wood and Allott2021). This is despite cognitive screening being recognised by experts as critical for psychiatric care (McIntyre et al., Reference McIntyre, Anderson, Baune, Brietzke, Burdick, Fossati and Harvey2019). We are working to close this gap in clinical practice by conducting a hybrid effectiveness-implementation study to validate a brief cognitive screening tool for young people with first-episode psychosis (‘CogScreen’; ACTRN12623000236695). At the end of the study, we hope to deliver a validated cognitive screening tool for this population, as well as a suite of resources and training to ensure that early intervention services can incorporate screening into routine clinical care. We expect these findings will have broad implications for youth mental health in general.
In summary, we agree with Douglas et al. who argued for a focus on early intervention for cognition, which includes both a deficit- and strengths-based approach. In our recent work, we have seen that cognitive impairments are prevalent in the early course of psychosis and depression, but that there is also a significant subsample of individuals who demonstrate unimpaired, or even above average performance. The profile of impairment, unimpaired performance and strengths may also vary widely according to the individual. Young people want to have their cognitive needs addressed during treatment, alongside their mental health symptoms, and they are open to a range of different intervention types. We also saw that young people were open to a wide range of potential cognitive interventions to both remediate deficits and build upon strengths. Cognitive screening offers a promising avenue to promote such interventions, whereby those people with the greatest need are captured at service entry. Subjective cognitive complaints must also be considered, and these can be quickly assessed via a self-report questionnaire, of which there are many options. Clinicians can then use this information to tailor treatments and inform further referrals. Ultimately, we hope that this leads to timely and individualised focus on the cognitive needs of young people in the early course of mental illness.
Financial support
K. A. is supported by a Dame Kate Campbell Fellowship from the University of Melbourne.