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

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 iPad-assisted CT (Dang et al., 2014).

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

calculated. HVLT delayed recall trials were used to assess Verbal MemoryClinical 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

USAGE PATTERNS

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)

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 liked the ability to self-pace training and being able to avoid travel to receive treatment

iPads were returned undamaged and fully functional

ACCEPTABILITY AND

FEASIBILITY

Study is underway

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)

1. Repeated measures ANOVA: are changes in variables of interest were similar in the two groups?

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.

BACKGROUND

STUDY AIMS1. 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 ?

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 ?

DISCUSSION1. 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

METHODSCT PROGRAM (BRAINHQ)

BASELINE IN-PERSON ASSESSMENTS

40 HOURS OF REMOTE COGNITIVE TRAINING60 minutes a day, 5 days a week.

FOLLOW-UP IN-PERSON ASSESSMENTS

Progress with CT is monitored remotely

iPad are set up and loaned to subjects

Weekly FaceTime videocalls, email reminders and phone calls

iPads are retrieved, compensation

STUDY DESIGN

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.

POST HOC COMPARISON

ASSESSMENTS

69 SUBJECTS ENROLLED 11 currently involved in baseline assessments

11 dropped out before beginining the training47 TRAINEES

14 dropped out during training

17 are in progress

16 COMPLETERS

SUBJECTSDEMOGRAPHICS

2. ARE REMOTE NEUROPSYCHOLOGICAL ASSESSMENTS FEASIBLE AND RELIABLE?

In person PANSS Cronbach's =.765 Remote PANSS Cronbach's =709

In a subgroup of 7 participants, we repeated 4 baseline assessments remotely using Facetime within 2 weeks from the first administration

TEST RETEST CONSISTENCY

moderate to high correlations between baseline in-person (i-p) and remote (r) assessments

INTERNAL RELIABILITY

ARE THEY SIMILAR AT BASELINE?

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

DO THEY TRAIN SIMILARLY?

DO THEY SHOW SIMILAR MAGNITUDE OF GAINS?

2. Effect sizes (Cohens d): are there group differences in effect sizes?

Mean SDage 37.5 14.274years of education 14.19 2.994age at psychosis onset 21.25 4.946hospitalizations 5 3.942IQ 101.44 10.52

session length (min) 40.18 11.35frequency of access (days) 2.96 1.67hours of CT per week 2.24 1.49total training time (weeks) 8.73 2.24

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

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PANSS total score Letter Number Seq HVLT Tower of London r=0.506 r=0.654 r=0.537 r=0.81

Global cognition Verbal Memory

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SUMMARY OF FINDINGS

i-p r i-p r i-p r i-p r

b p-t b p-t b p-t

b p-t b p-t b p-t

iPad-based CT (N = 16) desktop-based CT (N = 17)

b = baselinep-t = post- training

- improves speed & accuracy of _perceptual processing - targets auditory and social _cognition domains- adaptive training- 3-6 exercises per session