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Psychiatric Rehabilitation Journal

2013, Vol. 36, No. 3, 133–145

© 2013 American Psychological Association
1095-158X/13/$12.00 DOI: 10.1037/prj0000020

Mental Health System Funding of Cognitive Enhancement Interventions for
Schizophrenia: Summary and Update of the New York Office of Mental
Health Expert Panel and Stakeholder Meeting
Susan R. McGurk and Kim T. Mueser

Nancy H. Covell

Boston University

Division of Mental Health Services and Policy Research,
New York State Psychiatric Institute, New York, New York

Keith D. Cicerone

Robert E. Drake

New Jersey Neuroscience Institute, JFK Medical Center,
Edison, New Jersey

Dartmouth Medical School

Steven M. Silverstein

Alice Medalia

Rutgers-University Behavioral HealthCare, Piscataway,
New Jersey

Columbia University Medical Center, New York, New York

Robert Myers

Alan S. Bellack

New York State Office of Mental Health, Albany, New York

University of Maryland School of Medicine

Morris D. Bell

Susan M. Essock

Yale University School of Medicine

Columbia University and New York State Psychiatric Institute,
New York, New York

Topic: A growing research literature indicates that cognitive enhancement (CE) interventions for people with
schizophrenia can improve cognitive functioning and may benefit psychosocial functioning (e.g., competitive
employment, quality of social relationships). Debate continues regarding the strength of evidence for CE and
related policy implications, such as the appropriateness of funding CE services. Purpose: This paper
summarizes and updates a meeting of experts and stakeholders convened in 2008 by the New York Office of
Mental Health to review evidence on the impact of CE for people with schizophrenia and other serious mental
illnesses, and addresses whether the evidence base for CE interventions is sufficient to warrant funding.
Sources Used: Specific recommendations based on the extant literature are provided regarding the
structure and components of CE programs that should be present in order to improve cognitive and
psychosocial outcomes and therefore merit consideration of funding. Conclusions and Implications
for Practice: These recommendations may serve as a starting point in developing standards for CE
programs. Establishing evidence-based practice standards for implementing CE interventions for
people with serious mental illnesses may facilitate dissemination of programs that have the greatest
potential for improving individuals’ functional outcomes while minimizing incremental costs
associated with providing CE services. Important open questions include how the performance of CE
programs should be monitored and which individuals might be expected to benefit from CE as
evidenced by improved functioning in their everyday lives.
Keywords: cognitive remediation, cognitive rehabilitation, severe mental illness, psychiatric rehabilitation, traumatic brain injury

Susan R. McGurk and Kim T. Mueser, Center for Psychiatric Rehabilitation, Departments of Occupational Therapy, Psychology, and Psychiatry Boston University; Nancy H. Covell, Department of Mental
Health Services and Policy Research, New York State Psychiatric
Institute, New York, New York; Keith D. Cicerone, Department of
Physical Medicine, Robert Wood Johnson Medical School of Medicine
University of Medicine and Dentistry, New Jersey Neuroscience Institute, JFK Medical Center, Edison, New Jersey; Robert E. Drake,
Departments of Psychiatry, and Community and Family Medicine,
Dartmouth Psychiatric Research Center, Dartmouth Medical School;
Steven M. Silverstein, Division of Schizophrenia Research, Violence
Institute of NJ, UMDNJ-University Behavioral HealthCare, Rutgers-

University Behavioral HealthCare, Piscataway, New Jersey; Alice
Medalia, Department of Psychiatry, Columbia University Medical Center, New York, New York; Robert Myers, New York State Office of
Mental Health, Albany, NY; Alan S. Bellack, University of Maryland
School of Medicine; Morris D. Bell, Department of Psychiatry, Yale
University School of Medicine; Susan M. Essock, Department of Psychiatry, Columbia University and New York State Psychiatric Institute,
New York, New York.
Correspondence concerning this article should be addressed to Susan
R. McGurk, Center for Psychiatric Rehabilitation, Boston University,
940 Commonwealth Avenue West, Boston, MA 02215. E-mail:

. & Nuernberger. Schenkel. the development of interventions to improve cognitive functioning as a means of improving real-world functioning is a much-aspired-to goal. This paper summarizes the material presented at that meeting. Sergi et al. & van Kammen. CE). with subsequent programs specifically designed for people . or meta cognition) using scientific principles of learning with the ultimate goal of improving functional outcomes. organizing and arranging someone’s clothes for them to wear for the week). such as errorless learning (Kern et al. The goal was to examine the evidence as to whether these interventions improve cognitive functioning. We then provide a synthesis of research on CE following traumatic brain injury. & West. We begin by defining CE in order to distinguish which types of interventions are included as CE and which are not. McGurk & Mueser. 1996. the New York State Office of Mental Health (NYSOMH) convened a panel of experts to summarize the evidence base on CE. Social cognition (e. Bell. the use of alternative strategies for teaching psychosocial skills (e.. followed by a description of the methods used to enhance cognitive functioning in this population. 2007. and less benefit from psychosocial treatments (Kurtz. and note that review of the growing research literature on enhancing social cognition is beyond the scope of this paper. Kurtz. and similarly review controlled research on CE for persons with serious mental illnesses. 2007). social cognition appears to be relatively independent of most “traditional” domains of cognition. as a reflection of the broader issue of whether social cognition should be considered a target of CE as it has traditionally been defined. 1994. collectively referred to herein as cognitive enhancement (hereafter. social relationships. Velligan et al. & Bryson. 2005).134 MCGURK ET AL. Because many treatment methods used for people with schizophrenia were developed from those used for people with traumatic brain injury or stroke. and people with schizophrenia-spectrum disorders typically experience deterioration in cognitive functioning before their first psychotic episode (MacCabe et al.. Impaired cognitive functioning increases the likelihood of developing a serious mental illness (Zammit et al. For example.. Tsang.. Next. Silverstein. McGurk & Mueser. the panel also included an expert in CE for these conditions. A growing number of treatment programs and small businesses have been developed to address this need. Silverstein. 1998. Because of the relationship between cognitive and psychosocial functioning in schizophrenia and other serious mental illnesses. Heaton et al. work skills). and future avenues for clinical applications and research. 2012). cognitive rehabilitation. CE is distinguished from programs that endeavor to reduce the impact of cognitive impairment on learning or psychosocial functioning without trying to improve cognitive functioning or the self-management of cognitive difficulties. Included in this panel were experts in CE in schizophrenia and psychiatric rehabilitation for persons with serious mental illnesses. 2004). where it was included as one of the seven core domains of cognition in schizophrenia (Green & Nuechterlein. Definition of Cognitive Enhancement (CE) We adopt the most recent definition for CE proposed by a group of international cognitive investigators at the 2012 meeting of the Schizophrenia International Research Society: “Cognitive remediation is an intervention targeting cognitive deficit (attention. Pierce et al. in terms of correlations between scores on social cognition and neurocognition measures (Allen. Cognitive functioning has high relevance to interventions for people with schizophrenia and other serious mental illnesses. and then address the implications of empirical evidence for the funding of CE services for people living with serious mental illnesses. the recommendations of the panel for potential payers of CE services. and cognitive training. as exemplified by the MATRICS initiative. Social cognition is routinely included in discussions of cognition in schizophrenia. we provide a brief history of CE for persons with serious mental illnesses. The issue of whether to include social cognition in our discussion of CE at this point. 2008). we provide some further discussion on this topic in the Future Directions for Clinical Research section. and self-care and independent living skills (Green.g. Similarly excluded are interventions in which the environment is modified to cue more adaptive psychosocial behaviors (e. 2013). such as in Cognitive Adaptive Therapy (CAT. Its effectiveness is enhanced when provided in a context (formal or informal) that provides support and opportunity for improving everyday functioning” (Cognitive Remediation Expert Working Group..g.. 2004). social cognition. with associated requests by providers for payment for such interventions. which subsequently stabilizes (Addington & Addington. inferring the thoughts of others) has been a focus of much recent investigation and intervention in schizophrenia. is excluded from this definition of CE. 2009. However. the extent to which more recent research is consistent with the findings of that panel. Donohue.. 2005). and whether the evidence on the functional impact of these interventions was sufficient to warrant including them among rehabilitative services paid for by NYSOMH.. executive function. We discuss methodological issues regarding this research literature. In the Spring of 2008. generated much debate within the panel. Silverstein. Impaired cognitive functioning in people with serious mental illnesses is strongly related to poorer functioning in areas such as work and school. This definition of CE is very broad and includes programs ranging from those using only computer-based exercises without human interaction to behavioral interventions such as the use of modeling and reinforcement to shape attention in individual or group skills training sessions without computerized or other practice of cognitive exercises. the extent to which enhancements in cognitive functioning improve psychosocial functioning. Early applications were adapted from programs targeting cognitive sequelae of traumatic brain injury. are also called cognitive remediation. Strauss.. Maxey. which is distinguished from other compensatory strategy approaches where the clients are taught to modify their environments for optimal functioning. 2004. 1994. We conclude by suggesting future directions for research on CE interventions for this population.g. memory. These interventions. 2011. While we do not try to resolve the debate here. 2008. 1998). History and Methods of Cognitive Enhancement for People With Serious Mental Illnesses A rich history of clinical research dating at least back to the 1960s has aimed at developing and evaluating approaches to CE for people with schizophrenia. Valone. 2004). Greig. emotion recognition.

while others are stand-alone interventions for use at home or in a clinician’s office.cogpack.. Across the years. can be used to facilitate drill and practice. and facilitating group processes. 2009). and duration. 2005. the individual’s attention and concentration may improve. such as COGPACK. rather than computer programs. McGurk et al.. Drill-and-practice methods are based on an “exercise model” of remediation positing that repeated practice of basic cognitive tasks improves cognitive functioning. Some drill-and-practice programs are provided with little or no facilitation (e. programs differ regarding the relationship of the CE intervention to other psychiatric rehabilitation services. COGPACK. 2009). 2009). Some drill-and-practice programs take a hierarchical approach. with program length ranging from a few weeks to years. Silverstein et al. Psychological Software Services. as in Cognitive Remediation Therapy (CRT. & Vinogradov. & Wexler. Fisher. and possibly of greatest interest to the current paper. 2003. 2005. For example. others fully integrate the psychiatric rehabilitation into the CE. Mueser. 2004).cogpack... research on traumatic brain injury suggests that such approaches can also improve cognitive functioning on neuropsychological assessments (Cicerone et al. On the other hand. most programs involve a facilitator with a variety of responsibilities. Practice standards. use of ancillary group processes. Lastly. such as the training of problem-solving skills in CET (Eack et al. as described below. as used in the Thinking Skills for Work program (TSW. 2009). Bell. Other programs use a standard training curriculum of exercises for all participants. 2012). 1995). Some programs adapt the level of difficulty of the exercises to participants’ specific levels of impairment.. like CRT (Wykes & Reeder. Twamley. 2009) the facilitator engages an individual in computer-based drill-and-practice exercises supplemented by strategy coaching. strategy coaching. 2009). CE programs vary in the degree to which they are provided in combination with a psychiatric rehabilitation approach. nonfood items). Holland. 2005). such as the CogRehab software (Bracy.. as used in Neuropsychology Enhancement Training (NET. & Herlands. 2009).g. seasons.. For example. some programs. Another approach is to teach cognitive skills to participants in a group format. Merzenich. beginning the practice with exercises that engage early perceptual processes and proceed to engagement of “higher order” skills (e. Most approaches to improving cognitive functioning are based on drill and practice. vehicles. have been offered as standalone interventions. which may serve to help keep the person on task and avoid lapses in concentration that lead to inefficient work or study. with associated cost implications.. The individualized nature of strategy coaching requires the use of a program facilitator. & Pascaris. individual or group format. While the primary focus of compensatory strategies is improving cognitive performance in daily work or living tasks. www. an individual might use an alarm to prompt the beginning of a rest break from a task. providing strategy coaching. Fisher et al. 1994). McGurk. POSIT Science.. food vs. For example. Marker Software. such as in the NEAR program (Medalia et al.g. such as monitoring and encouraging on-task behavior.g. 2005) and PositScience (Fisher et al. Bryson. 135 For example. 2011). 2011).g. a wide variety of programs have been developed to enhance cognition with the goal of improving psychosocial functioning. the cognitive domains targeted for enhancement.. 2004) or Integrated Psychological Therapy (IPT. 1998. a person may be taught to group the items into categories based on salient characteristics (e. McGurk. in the Neuropsychological and Educational Approach to Remediation (NEAR) program (Medalia. Some CE programs are intended to be paired with a specific intervention such as supported employment. Some CE programs involve groups and the potential efficiencies therein... whereas CET integrates the practice of social problem solving and social– cognitive skills training (Eack et al. demonstrating a list learning strategy). some CE programs also teach compensatory strategies designed to reduce the impact of cognitive impairment on functioning and optimize performance on everyday cognitive tasks (Krabbendam & Aleman. Yet another variation is to have groups designed to foster the generalization of gains made in CE to real-life situations (Lindenmayer et al. One approach is for individuals to work at their own pace in small groups. For example. Lastly. For example. Hogarty et al. Brenner et al. tools).. These reviews assessed 370 studies. Vella. although they could be combined with psychiatric rehabilitation in future applications. et al. By gradually extending the periods of work or study between rest breaks.. Wykes & Reeder. Silverstein. practice of sustained attention is accomplished in the COGPACK software program (Marker Software. Revheim. As the most stringent criteria were .FUNDING COGNITIVE ENHANCEMENT INTERVENTIONS with schizophrenia. DeRosa. with the participant required to respond each time the category changes. the TSW program is provided in combination with vocational rehabilitation (McGurk et al. although it can also be run as a standalone intervention. with a facilitator addressing individual issues (e. PositScience. McGurk et al. Heaton.. in order to learn a list of shopping items without the use of paper and pencil. people who are disorganized and have difficulty remembering appointments can be taught to use a personal calendar. 2009. whereas others are considered “top down” approaches by use of tasks that engage broad range cognitive skills (e. However. Programs providing both drill-andpractice and strategy coaching tend to involve more facilitation time per individual than those providing drill-and-practice alone. www.. Burton. guidelines. & Jeste. & Wolfe. CE programs also differ in the methods and technology used to improve cognitive functioning. Research on CE Following Traumatic Brain Injury Cicerone and colleagues (2000...g. 2009). 2005. Strategy coaching involves providing individually tailored suggestions to improve performance on cognitive exercises. 2009). Hogarty et al. 2003) and Cognitive Enhancement Therapy ( through an exercise involving the rapid presentation of words belonging to different categories (e.. 2005. including 65 that were either randomized controlled trials (RCTs) or prospective quasirandomized trials. and the use of a facilitator. have published three comprehensive reviews of research on the effects of CE on people who have experienced a traumatic brain injury or stroke.. teaching compensatory strategies. and options were put forth based on these reviews. 2008.g. and attention shaping is typically delivered within the context of skills training groups to promote learning of skills (Silverstein et al. CE interventions vary in their intensity. Paper-and-pencil exercises. or a combination of both. In addition to providing drill-and-practice and/or strategy coaching.. 2005). Mueser. ranging from daily to weekly sessions.

McHugo.. interpersonal functioning.g. many of whom were several years postinjury and had been unsuccessful in attempts to resume aspects of functioning prior to rehabilitation (Cicerone et al. with additional support from less rigorously designed studies). and life skills (e. development of monitoring strategies for home and the community). including teaching compensatory strategies. & Czobar. The research points most strongly to the importance of strategy coaching. 2006). group and videotape feedback. Eleven hours per week were devoted to group therapies that focused on three specific themes. relating the individual and group treatments to everyday functioning... Pilling et al. . and interpersonal interventions in order to promote adaptation to any persisting effects related to the traumatic brain injury and to optimize everyday functioning. practice of functional and social problem-solving tasks). over a 16-week period (Cicerone et al. Research on CE for People With Serious Mental Illness Over 40 randomized controlled trials have been conducted evaluating CE programs for people with serious mental illnesses. For example. Twamley et al. 2008). one comprehensive. Drill-and-practice exercises are not included as a practice standard for improving memory functioning. & Sherer. Huddy. People with traumatic brain injury are more likely than those with schizophrenia to have unimpaired premorbid cognitive functioning. using a memory notebook). brainstorming solutions. self-monitoring) to facilitate the development of compensatory strategies and foster generalization to daily living. & Gur. including attention.) is included as a practice guideline (Cicerone et al.. educational. Kurtz. and to identify and address needs related to cognitive difficulties.. and only when combined with other CE methods such as strategy coaching and developing compensatory skills. practice of interpersonal skills through role playing. holistic approaches provide a combination of individual and group-based interventions to address cognitive challenges and improve metacognitive skills. 2007.42. analysis of social situations). self-awareness. training in metacognition.. Only one practice standard is established for improving executive functioning—metacognitive training—although training in formal problem-solving strategies (e. respectively). & Mueser. The needs of persons with traumatic brain injury and schizophrenia for interventions targeting cognition might be very different. the practice standards recommend providing both attention training using drill-and-practice exercises and training in metacognitive skills (e. 2002. and executive functions. The primary findings of these meta-analyses were very similar. 2011). etc. and embedding CE efforts within a more individualized. but require further empirical determination from studies of people with schizophrenia. memory. and developing a meaningful life despite any persistent impairments.. Sole reliance on computer-based practice of attention without the involvement of a clinician is not recommended. 2003).g.. emotion self-regulation. Both found moderate effect sizes for CE on cognitive functioning (ds ⫽ . comprehensive. teaching compensatory skills. 3 days per week. 2001. respectively) and small but significant effect sizes for symptoms (ds ⫽ . 2011). and holistic program aimed at facilitating interpersonal functioning. including cognition (e. Wykes et al.36 and . The individual and group work emphasized the integration of the cognitive. 1999). Struchen.. including 26 and 40 studies (McGurk. 2011). or psychological issues.. & Bellack. There were no consistent moderators across both meta-analyses of the effects of CE on cognitive functioning or symptoms (McGurk. holistic programs following traumatic brain injury or stroke (Ben-Yishay et al. Roebuck-Spencer.g.. However. Three hours per week of individual meetings with a primary therapist were provided that included a combination of CE. Comprehensive CE programs for traumatic brain injury have been shown to improve cognitive functioning. It is interesting that in the traumatic brain injury literature.41 and 45.. People with traumatic brain injury who are provided training in compensatory memory strategies even decades postinjury show a significant decrease in memory problems (Ownsworth & McFarland. the “boosting” of cognitive functioning via computer-based (or other) exercises may be a way to obtain maximum gains from other CE strategies. problem recognition. respectively) and psychosocial adjustment (ds ⫽ . drill-and-practice cognitive exercises are recommended as a practice standard only for the enhancement of attention. productivity. and their remaining intact cognitive skills may facilitate greater learning of compensatory strategies. Wykes. 2011). Two meta-analyses have recently been conducted of this controlled research. As impaired cognitive functioning typically is of longer duration and more pervasive in people with schizophrenia.g. Clients also met individually with a neuropsychologist 1 hour per week to review progress.136 MCGURK ET AL. holistic program for traumatic brain injury included a total of 15 hours per week of group and individual programming. Gur. Moberg. teaching compensatory skills such as note taking. 2008). Although people show substantial gains within the first 6 months postinjury related to the natural course of recovery. Twamley. Medalia & Choi. In short. comprehensive. For the enhancement of impaired memory. visual imagery) and teaching compensatory strategies using externally based techniques (e. Sander.g. In summary. Twamley.. the practice standards for treating cognitive deficits in schizophrenia can be informed by those for traumatic brain injury. as well as comprehensive programs. the practice standards recommend a combination of strategy coaching on internally based techniques (e. communication (e. and life satisfaction of people who are more than 1 year post injury. Recently. applied to research for establishing practice standards (at least one RCT or prospective quasi-RCT with an adequate sample size. McGurk. significant improvements in community functioning continue to be evident several years after injury (High. Jeste. emotional. Cellard.. 1985) have been recommended as a practice standard for reducing cognitive and functional disability in individuals with moderate or severe traumatic brain injury or stroke (Cicerone et al. we briefly summarize those standards for the enhancement of cognitive functioning in those areas most relevant to people with serious mental illnesses. In order to improve attention following traumatic brain injury. with frequent reviews of this literature (Krabbendam & Aleman.g. 2007. and emotion regulation. 2009. 2003. and counseling to address vocational. Rather than narrowly focusing on the remediation of specific cognitive impairments. controlled research with people with traumatic brain injury or stroke supports the effectiveness of CE for improving cognitive and psychosocial functioning. Sitzer..28 and 18.g. Research also suggests that CE is effective both during the acute period after traumatic brain injury or stroke and many years later.

including individual and small group-based computerassisted cognitive training. and found no relationship between study quality and treatment outcomes. While two studies have been conducted comparing CET to rehabilitation programs that did not include CE (Hogarty et al.. 1994). a few studies have paid people for completing CE exercises. lack of blinded assessors.FUNDING COGNITIVE ENHANCEMENT INTERVENTIONS there was an important moderator of the impact of CE on psychosocial functioning: the provision of adjunctive or integrated psychiatric rehabilitation (e. The role and importance of teaching compensatory strategies is especially unclear. Cognitive Enhancement Therapy (CET. 2010). 2004) was developed based on many of the principles and procedures of comprehensive. social skills training. and social skills. (2011) meta-analysis evaluated the impact of methodological rigor on CE study findings. how they may complement one another. the aspects of their involvement that could be classified as psychosocial rehabilitation could be essential to improved outcomes (e. strategy coaching.. Seltzer. Neither of the meta-analyses found significant differences in cognitive effect sizes between studies using an “active” control (e. Ramanelli. and the extent to which an adequate psychosocial platform may be a prerequisite for obtaining gains in real-world functioning via CE. Mueser. Marder. teaching compensatory strategies). with expected modifications in the vocational program from usual practice (McGurk et al. Second.. group sessions providing psychoeducation on different topics. This is consistent with research showing that cognitive impairment in people with serious mental illnesses is associated with diminished response to rehabilitation approaches such as supported employment (McGurk. Thime. Fleming et al.. 2003) and social skills training (Mueser. Smith. 2006).. 2011). Methodological Limitations and Considerations As in all research. respectively) than studies that examined the effects of adding CE to usual services versus usual services alone (ds ⫽ . holistic interventions for traumatic brain injury as previously described (Ben-Yishay et al. First. Reeder.g.47 and . For example.. and teaching compensatory strategies... the integration of CE into a preexisting rehabilitation program is designed to modify those rehabilitation services. we know less about the extent to which the incorporation of such strategies may be critical to the success of CE interventions for people with serious mental illnesses. 1999).. Thus. Specifically.28. In addition. raising questions about the generalizability of findings to “real world” mental health treatment settings where payment for participation in treatment is not customary. However. In addition to providing CE using a variety of methods (e.. Williams. Douglas.g.. leaving unclear whether simply . and collaborates with other team members on tasks such as planning the job search. there were differences across studies in the choice of a control group. 2007.. by intention. Harvey. the rehabilitation provided in the programs being compared clearly differed. Fertuck. Bellack.. The apparent moderating effect of psychiatric rehabilitation on the impact of CE on psychosocial functioning raises the questions of how the two intervention approaches may overlap. or whether specific program components (e. 1998. et al. 2005) and others including a study arm controlling for either computer training time (Kurtz. The use of treatment as usual as a control condition is not necessarily a methodological limitation. 2007. 1999). Aside from methodological rigor. (2011) meta-analysis that provided CE and psychiatric rehabilitation. Improved cognitive functioning due to CE may facilitate the ability of people to learn in psychiatric rehabilitation programs.. 2008) or staff time (Wykes. ⬍ 10 per group). drill-and-practice exercises.. and lack of follow-up assessment after the program ended (Dickinson et al. 1985) and earlier integrated programs for schizophrenia (Brenner et al. Shagan. 2009). watched videos or treatment as usual) (McGurk. Silverstein.. CE and psychiatric rehabilitation are inextricably linked in some programs. CET includes a broad range of program elements. & Wexler. vocational rehabilitation) in addition to the CE program.g. & Everitt. For example. respectively). The range of comparison/control groups in this literature underscores the different research questions posed. socialcognition. While research on CE programs for people with traumatic brain injury suggests that teaching such strategies may improve both cognitive functioning and psychosocial adjustment (Cicerone et al. there are methodological limitations of controlled studies of CE. 2005). and facilitating the ability of vocational counselors to help clients implement coping strategies for managing cognitive challenges in work-related situations (McGurk & Mueser. there are methodological issues to consider in studies that evaluated the effects of combining CE with psychiatric rehabilitation that make it unclear whether the addition of CE is responsible for the improved outcomes.05 and . Some limitations include studies with small sample sizes (e. Eack et al. received computer training or computer games) or a “passive” control group (e.. such as whether the program produces a benefit over usual services.g. identifying supports and skills for promoting job retention. 2004. However. Wykes et al. with some using treatment as usual (McGurk et al. one cannot determine the extent to which the additional gains are attributable to the combination of CE and the additional psychiatric rehabilitation or either component alone.. Hogarty et al. There is also significant heterogeneity across CE studies in approaches to improving cognitive functioning. but rather reflects the lack of consensus as to what should be controlled. 1999).. Lindenmayer et al. While the cognitive specialist’s role in TSW focuses on CE. & LaPuglia. there are other aspects of programs that combine CE and psychiatric rehabilitation that may also contribute to improved functioning. Schenkel. studies that evaluated the effect of either adding CE to psychiatric rehabilitation or integrating the two together versus psychiatric rehabilitation alone demonstrated significantly greater improvements in psychosocial functioning (ds ⫽ . strategy coaching. 1991.g. limited outcome measures. the cognitive specialist serves as a member of the vocational team. which in turn leads to greater improvements in psychosocial functioning (Spaulding. Further. Hull. additional input/intervention for particularly challenging individuals). and the practice of cognitive. in the TSW program the cognitive specialist serves as the key person responsible for integrating CE with vocational rehabilitation. 2011). Twamley et al. the Wykes et al. including drill and practice. Corner. as discussed in the next section.. the results of studies comparing CE and psychiatric rehabilitation to rehabilitation alone suggest that the combination of both approaches may be beneficial. & Weiss.59.g.g. & Wade. discussion groups to augment computer-based exercises) are crit- 137 ical to producing desired effects. which means that when such a service outperforms psychosocial rehabilitation alone.. Table 1 summarizes all of the programs from the Wykes et al.

and environmental modifications in simulated work environments The thinking skills for work program: 24 hours of computerized drill & practice (COGPACK) with strategy coaching over 12 weeks.Cognitive enhancement program: 24 hours over 8 weeks of teaching coping strategies. 2007)/ McGurk et al. (1999) Studies Social skills training based on UCLA program Psychiatric rehabilitation program Inpatients/outpatients Unemployed outpatients Unemployed outpatients Inpatients Outpatients with early course schizophrenia Inpatients Outpatients Unemployed VA patients Outpatients Inpatients Subject populations studied Integrated Integrated Integrated Parallel Sequential: cognitive remediation program followed by vocational rehabilitation Staged: Computerized cognitive practice followed by small group CE. strategy coaching Neurocognitive enhancement therapy: 36– 126 hours of computerized drill & practice (Odie Bracie) over 26–52 weeks. (2007) Vauth et al. and then social cognitive and social skills training Parallel Parallel Timing of cognitive enhancement and psychosocial rehabilitation Table 1 Characteristics of Cognitive Enhancement Programs That Also Provided Psychiatric Rehabilitation From Wykes et al. (2009) Control: Enriched supportive therapy Social skills training based on UCLA program Internship-based vocational rehabilitation Supported employment Silverstein et al. and weekly social and work processing groups Cognitive enhancement therapy: 60–75 hours of drill & practice plus strategy coaching over 104 weeks. (2007. Subsidized and competitive work over 2 years Social functioning over 12 months Functional outcomes/ follow-up period 138 MCGURK ET AL. (2011) Meta-Analysis Social skills over 6 months Paid work over 2 years Competitive work over 2–3 years Paid work over 1 year All paid work over 2 years Psychosocial functioning over 2 years Paid work in VA over 1 year. . (2005) Bell et al. collaboration of cognitive and employment specialists regarding the use of compensatory strategies during job search and job performance Attention training: 18–24 hours over 6–17 weeks shaping attention to skills training content through active practice in social skills training groups Integrated psychological therapy. 2009) Lindenmeyer et al. (2008) McGurk et al. McGurk. Mueser et al. (2009) Hogarty et al. Reed et al. (2004) Control: Personal therapy Inpatient worker program Bell et al. (2005.. Cognitive subprograms: 26 hours over 96 weeks of drill & practice.45 groups (1. (2005. 2008) Greig et al.5 hrs each) of social cognitive and social skills group sessions Cognitive enhancement program Eack et al. computerized drill & practice (COGPACK). 2005) Inpatient compensated work therapy Outpatient vocational rehabilitation Vocational rehabilitation Spaulding. (2001.

As reviewed in Table 1. 2009). Kissling. the magnitude of the effect sizes of CE. and some teach compensatory strategies as well. we consider next the components of programs that may need to be present in order to improve both areas of functioning. (2005.g. When appropriate based on the research previously reviewed. 2001).. CE programs should provide one or more of drill-and-practice exercises. 2008. such as a categorization task. if so. or educational software as applied in the NEAR program (Medalia et al. strategy coaching.. and the impact of social skills training on psychosocial functioning (Kurtz & Mueser. Bryson. Therefore. 139 Examples include the Odie Bracy software program as applied in NET (Bell. which were supplemented with drill and practice of executive functions. Vauth et al. The role of CE in helping people achieve specific goals needs to be documented in the treatment plan. 3. 9. social relationships. 2008). Groetzinger. both the Spauld- Table 2 Recommendations to Potential Funders of CE Interventions 1. pertaining to which CE programs should be paid for and for whom. can be integrated into the actual provision of social skills training without utilizing these three CE methods. and what type of program monitoring could determine whether a specific CE intervention is benefitting people in their everyday lives. CE interventions should be standardized in a manual. for whom. Bäuml. raises the question of the core ingredients of effective CE programs. or teaching compensatory strategies. Steel. Since CE programs aim to improve both cognitive and psychosocial functioning. Zorn.. functional goal. the effect of family psychoeducation on rehospitalization (PitschelWalz. such as linking it to his or her functional goal(s). and who the target population should be. 2005). functional goal.. 2009). Cognitive Enhancement Methods Most of the CE programs for people with serious mental illnesses have employed drill-and-practice exercises. Everitt.. Training in a broad range of social cognition skills was an explicit emphasis of CET. Funding Implications and Recommendations for Implementing Effective CE Programs Considering the evidence from the two previously described meta-analyses.. as well as how the CE intervention will interface with other ongoing treatments. it is reasonable for program administrators and payers to ask. In addition. Positive effects were reported on cognitive functioning and a performance-based measure of social competence. work. on psychosocial functioning are in the general range of the effect sizes of most other established psychiatric rehabilitation approaches. & Windgassen. many of these programs are supplemented with strategy coaching. Twamley et al. Greig. & Tarrier. Wykes et al. The data are too scant at this point to make recommendations regarding what types of psychiatric rehabilitation CE should be linked to. CE that was provided in the context of a specific psychiatric rehabilitation program had a stronger impact on community functioning. which also included some social skills training (Hogarty et al. 6. and for whom?” The answer to the first question involves speculation as to the degree to which the significant effects of CE translate into meaningful real-world benefits. 4. we recommend that CE be linked to a psychiatric rehabilitation approach in order to target a clearly defined. Several computer-based drill-and-practice programs have demonstrated efficacy for improving cognitive functioning in this population. The effect of the CE program on an individual’s cognitive functioning should be formally monitored to determine whether the anticipated gains are occurring. which CE interventions should I pay for. or teaching compensatory strategies. CE programs should employ a facilitator and concerted effort be made to integrate CE with psychiatric rehabilitation. However. 2012).. strategy coaching. 2005. such as the impact of cognitive– behavioral therapy for psychosis on symptoms and psychosocial functioning (Wykes. The primary target population for CE programs should be individuals with schizophrenia or schizoaffective disorder or people with another serious mental illness for whom there is some evidence of cognitive impairment. 2011). Corcoran. However. The second and third parts of the question.FUNDING COGNITIVE ENHANCEMENT INTERVENTIONS adding CE to an existing rehabilitation program is sufficient to improve psychosocial functioning. A recently published controlled study has evaluated the effects of a group-based CE program focused primarily on teaching compensatory strategies for managing cognitive difficulties using noncomputer-based practice and exercises (Twamley et al. independent living skills) that are the focus of the CE and psychiatric rehabilitation interventions should be measured and monitored routinely over the course of treatment. Examples of compensatory strategies included using a calendar. than CE programs that were simply added to usual services (McGurk. especially work or social functioning. Sartory. CE programs that have targeted social functioning have generally been integrated into a broader program that also provides training in some combination of social cognition and social skills. There should be formal documentation of how the CE intervention will be individualized to the person. Therefore. “Do CE interventions result in clinically meaningful improvements in real-world functioning and. 2007. We also note that an attention-shaping procedure developed by Silverstein et al. COGPACK software as applied in the TSW (McGurk et al. 2001). & Wexler. Leucht. some trends are worthy of mention. given the limited data available. For studies that compared the effects of CE and psychiatric rehabilitation to rehabilitation alone. 7. as broadly defined here. note taking. CE should be linked to a psychiatric rehabilitation approach in order to target a clearly defined. 2004). 8. and teaching a 6-step problem-solving method. we provide specific recommendations for funders related to these issues (summarized in Table 2). Improving Psychosocial Functioning In both meta-analyses. self-talk.. .. 2. 2009. 2008). & Engel. Specific targeted domains of psychosocial functioning (e. we recommend that CE programs provide one or more of drill-and-practice exercises. 5. 2005) and other programs (Lindenmayer et al.

it appears premature for payers to cover CE that is limited to computer-based practice (without an active facilitator). 2008). Vauth et al. Wykes et al. & Wesler. Together. A cautious extrapolation from research on participant factors and response to CE yields a recommendation that the primary target population for CE be individuals with schizophrenia or schizoaffective disorder. Lindenmayer et al. The frequency of practice sessions and duration of CE varies as well. with the remaining three programs being much longer. Although two studies have reported that older participants improve less in cognitive functioning from CE (McGurk & Mueser. as such programs were found to have the strongest impact on functional outcomes. An additional variable related to improving psychosocial functioning is the active participation of a facilitator (e. ing. there was a trend for greater baseline symptom severity to be associated with less improvement in cognitive functioning. cognitive impairment as a study inclusion criterion was not related to improvements in cognitive or psychosocial functioning. 2008. & Wexler.g. As the development of schizophrenia is frequently associated with some decline in cognitive functioning. The relationship between baseline cognitive impairment and response to CE has been examined in some studies. with mixed findings.g. the only evidence-based practice for improving competitive work in people with SMI (Drake. with the other two programs providing more than twice as many hours. Three programs lasted between 8 and 12 weeks. although some studies have also included people with other serious mental illnesses. it seems prudent to recommend that CE programs employ a facilitator and that concerted effort be given to integrating the CE component with psychiatric rehabilitation. there is no definitive answer to this question. a social skills training approach that includes training in social perception.. or people with another serious mental illness for whom there is evidence of cognitive impairment. Medalia and Richardson (2005) compared clients who demonstrated a reliable improvement in at least one area of cognitive functioning following CE to those who did not across three studies of NEAR.140 MCGURK ET AL. & Becker. and duration may be drawn from studies of CE that also provided psychiatric rehabilitation included in Wykes et al. combining CE with supported employment appears to have the greatest promise for improving competitive work. Vauth et al. Choi. participants whose symptoms are less severe may be expected to benefit more from CE. . Greig. 2005). CE programs targeting social functioning would appear to be effective when combined with psychosocial programs that focus on social skills and social cognition. However. There is a less consistent pattern in the CE programs that have targeted work. 2009).. and the average age of participants in the Wykes et al. McGurk. Thus. improves functioning more than rehabilitation alone. 2005. In the Wykes et al. Reed. Greig. and Weiler (1999) and Silverstein et al. and in most studies there was an attempt to integrate the CE and rehabilitation programs (see Table 1)... The remaining five studies evaluated other vocational rehabilitation approaches. and Bell (2006) reported that individuals with schizophrenia who had intermediate levels of intellectual impairment benefitted more from the addition of CE to a vocational program than those with less or more severe intellectual impairment. CE studies that included only participants with schizophrenia or schizoaffective disorder had significantly larger effects on improving cognitive functioning than those also including participants with other disorders. However. Bell. It remains to be seen whether providing CE without facilitation by such an individual. nonverbal. cognitive– behavioral therapy for psychosis. Feldman. in addition to psychiatric rehabilitation. Finally.. Wykes et al. It should be noted that briefer training periods have been reported in some CE programs provided to inpatients (Silverstein et al. This raises the question of.. Bond. choosing appropriate responses from alternatives.. Richardson. 2007). some broad parameters for program components. Participants’ symptom severity and age have also been explored as potential moderators of the effectiveness of CE. Mueser. Fiszdon. five out of the six programs provided more than weekly sessions. one study was conducted in a supported employment program (McGurk et al. In the Wykes et al. ranging from a minimum of weekly practice to a maximum of daily practice. Clinically. these findings suggest that a CE program should provide at least 20 hours of CE over at least 10 weeks. and paralinguistic skills. a third did not (Medalia & Richardson. and others providing less than 20 hours.. Sullivan.. and training periods ranging from as little as several weeks to over a year. 2005. (2011) metaanalysis. Thus. 2008. & Pascaris. Target Population Most research on CE for psychiatric disorders has focused on individuals with schizophrenia. 2009) studies evaluated CE when combined with the UCLA Skills for Independent Living program (Liberman. 2005). preferably with multiple training sessions scheduled per week. Bryson. 2012). are the most appropriate candidates for CE. 2008. (2011) meta-analysis. and typically examined all paid work rather than competitive work outcomes (Bell. and found baseline neuropsychological assessments were generally not related to improvement. facilitator-based CE to rehabilitation improves functional outcomes more than rehabilitation alone. meta-analysis was not related to cognitive change. Bryson. Inspection of the programs summarized in Table 1 indicates that four of the six programs provided 21–24 hours of training. Among the CE programs that focused on work summarized in Table 1. Duration and Intensity of Program There are substantial differences in the intensity and duration of CE programs. (2011). All of the programs that combined CE and rehabilitation involved a facilitator. 2007).. McGurk et al. little is known about whether adding nonintegrated. clinician) for the CE activities. 2009. “What defines a minimally effective program of CE?” As with many other interventions for people with serious mental illnesses (e. While these studies provide limited guidance to CE programs targeting work. Similarly. with some providing over 100 hours of training. Wolfe. the dominant assumption in the field has been that people with cognitive impairments. 2005). suggesting that clients with less severe symptoms benefit more from CE. with three programs providing approximately two sessions per week. In the absence of such evidence. Fiszdon. intensity. most notably those with schizophrenia (or schizoaffective disorder). 2005. Zito. and verbal. based on the available research. (2005.

Gibel. As noted earlier (in the section on Definition of Cognitive Enhancement). inform treatment of individual participants in the program. 2012) and rehabilitation outcome (Bell et al. including distinctions between capacity-based performance measures (e. well-defined psychiatric rehabilitation programs can improve psychosocial outcomes.or otherrated scales (e. and methods for combining CE with other rehabilitation services.. 2004) and IPT (Brenner et al. Ritsner. 2013). and what psychosocial rehabilitation platforms are sufficient? How should the quality and extent of psychosocial rehabilitation services be assessed before the funder agrees to pay for the implementation of CE services? 141 Future Directions for Clinical Research The synthesis of research on CE. Research aimed at understanding how and why CE works would also benefit the field. such as linking it to his or her functional goal(s). computer-based exercises plus the selection of associated software. the CE intervention should be standardized in a manual. An emerging body of research focuses on training in social cognition (Kurtz & Richardson. whether social cognition should be viewed as a component of cognition.. & Jeste. Corrigan.FUNDING COGNITIVE ENHANCEMENT INTERVENTIONS Program Monitoring The broadly accepted long-term goal of CE is to improve psychosocial functioning. specific.g. Broadly speaking. Social cognition is an important predictor of psychosocial adjustment (Couture. there is a need to document how the CE intervention will be individualized to the person. 2001) versus clinician. suggest several avenues for future research... this leads to the question of “What program monitoring should be required for CE interventions to ensure the greatest impact on functional outcomes?” We have several recommendations to address this question. Quality of Life Scale. How and by whom programs might be monitored is a question for funders. Fundamental to all research in this area is the use of improved technology for measuring functional outcomes. training in social cognition (and social skills) is integrated into comprehensive CE programs focusing on social functioning such as CET (Hogarty et al. Identifying whether such program components are effective but interchangeable could provide program administrators with important options. and one recent study reported that adding social cognition training to CE led to greater improvements in social functioning than CE alone (Lindenmayer et al. and outcomes. Quality of Life Enjoyment and Satisfaction Questionnaire. Davidson. 2013). 1994). social relationships. & Endicott. 2009).. and recommendations to potential funders of CE services. Requiring the identification and tracking of program treatment targets. Green. Statucka & Walder. Critical components that may deserve consideration include strategy coaching to improve performance on cognitive exercises. & Roberts. intermediate steps will be needed in the transition from the current status of services to an embedded system for tracking targets. Racenstein. And fifth.. Third. Second. teaching compensatory strategies for cognitive difficulties. the field must continue to evaluate the circumstances under which CE can impact real-world functioning for people with SMI. Hoe. Penn. if any. there was debate among the panel members as to whether social cognition should be included as a target of CE and. and may partly mediate the relationship between cognitive impairment and social functioning (Fett et al. and outcomes helps protect payers and persons receiving services from such poor investments of time and resources. in improving . 2012. independent living skills) that are the focus of the CE and psychiatric rehabilitation interventions should be routinely measured and monitored over the course of treatment. Kurs. Relatively brief. Many payers today understandably have concerns that a wide range of effective and ineffective interventions are being paid for in the name of “psychotherapy. and the CE research to date currently indicates that such improvements are most likely to occur when CE is combined with a specific psychiatric rehabilitation approach. the role of CE in helping people achieve specific goals needs to be documented in the treatment plan. 2011. as well as what range in outcomes would be acceptable for continued funding.g. one wants to pay for effective treatment. as well as how the CE intervention will interface with other ongoing treatments. 1984) versus subjective life satisfaction measures (e.. 1997). First. Several open policy questions remain: How minimal can the CE addition be and still be effective. From the perspective of a funder. Penn. as by definition it is a critical target for CE. and to monitor performance of the program itself. Social Skills Performance Assessment. & Newman. Fourth.. Heinrichs. At this point in time. enhancement of sensory processing in addition to exercises focused on higher cognitive functions.” and one wants to avoid a situation where virtually anything may be called “CE” and billed for. at a more fundamental level. This includes examining which CE interventions (and components therein) are most effective when combined with which psychosocial rehabilitation programs (when distinct from CE) and who is most likely to benefit (Wykes & Spaulding. of components that differ across programs. There is clearly a need for more research on the role of social cognition training. and these can be used to document whether expected gains in cognitive functioning are occurring. the data support the conclusion that CE programs that include a facilitator and are implemented in combination with specific. targeted domains of psychosocial functioning (e. From a funder’s perspective. 2006. Furthermore. standardized cognitive assessments can be conducted that require a minimum of training and cost. and the performance monitoring entity should have the ability to provide rapid feedback and ongoing monitoring to ward off slippage. Yael Ratner. an objective evaluation of the impact of the CE program on cognitive functioning is important. & Carpenter. there was agreement that social cognition was an important target for treatment (whether construed as CE or psychiatric rehabilitation). However. McKibbin. interventions.. work. Hanlon.g. In addition. Research is needed to disaggregate the bundle of treatment components included in CE programs in order to determine their relative utility for improving cognitive and functional outcomes and to determine the significance. Roberts & Velligan. Moscona. in the way that the latter term has traditionally been defined. 2011). Clearly. 2005). training in metacognition. in combination with CE and/or psychiatric rehabilitation. interventions. Nakagami. staff training standards and objective fidelity assessments should be established that would serve to identify significant deviations from the treatment delivery model. 2012. Patterson. Bentall.g. & Brekke.

There is no empirical guidance for these issues. Bajwa. 1993). 2011) and self-esteem and self-efficacy (Wykes & Spaulding. there is the associated risk that the marketing of CE may exceed the evidence base. as reflected by the contrasting conclusions of the latest meta-analysis (that broadly defined CE interventions when imbedded in psychosocial rehabilitation programs are effective in improving functional outcomes) and the most recent treatment PORT guidelines for schizophrenia (where CE was not among the interventions endorsed as effective. This debate has continued unabated in the 5 years since the meeting. 2008. Conclusions CE is a rapidly growing field of treatment for persons with serious mental illnesses. While some evidence suggests that stabilizing psychiatric symptoms prior to CE may facilitate benefit (Wykes et al.g. Foster. While it is easy to highlight the differences of opinion among panel members. McKenzie. 2011). & McGorry. especially when it is combined with specific psychiatric rehabilitation. but rather usually in the context of a therapeutic relationship. Numerous theories have been advanced regarding how CE may improve cognitive and psychosocial functioning (Brenner et al.g. as previously discussed (in the section on Improving Psychosocial Outcomes). further research is needed to evaluate the mechanisms underlying the beneficial effects of CE interventions. Saunders. Some comprehensive CE-rehabilitation programs are offered to all individuals with impaired functioning in specific areas. and specific targeting of nonresponders. such as vocational rehabilitation (Bell et al. with respect to efforts to improve vocational outcomes. 2009. Medalia & Saperstein.g. parallel.142 MCGURK ET AL. learning opportunities). 2005). A related topic is the potential impact of CE on improving the effectiveness of supported education programs for this population. their intensity and duration. 2011). such as: What domains of social cognition are most important to target? Are some domains of social cognition more critical to some types of psychosocial functioning than other domains? How should training in social cognition be integrated into the CE and psychiatric rehabilitation components of treatment? The field also needs research to examine more closely the characteristics of psychiatric rehabilitation programs most critical to improving psychosocial functioning when combined with CE. Wykes & Spaulding. 2008).. 2008. Fisher et al. As with all interventions.. Finally. 2013... and the relative merits of investing program resources in CE interventions versus other treatments or services.. McGurk et al. 2012). 2012). broadly defined. Similarly. While the extent to which CE interventions contribute to improved psychosocial functioning remains unclear. Lindenmeyer et al. Vauth et al. and the purchasers of such services need to be mindful of the old adage caveat emptor (Mueser & Herbert. and environmental processes (e. CE programs vary widely in the methods and personnel used to improve cognitive functioning. 1995). as described in a recent pilot study (Kidd. the implications for clinical practice.. integrated.. Nuechterlein et al. & Stang. An improved understanding of how CE works could lead to refinements in CE interventions that permit more efficient and streamlined programs. considerable debate continues about how to interpret research results. Jackson. too. is an area for further development. levels of analysis. contributing to worse employment outcomes (Mueser. an evidence-based practice for improving competitive work outcomes for people with serious mental illnesses (Drake et al. such as motivation (Medalia & Richardson. such as biological (e. Hogarty et al. this. Salyers. how the performance of such programs should be monitored.g. suggesting that the measurement of treatment characteristics such as the working alliance may be important (Wykes & Spaulding. There was a unanimous call among the experts for more research on the effectiveness of CE for people with serious mental illnesses. brain plasticity). many other questions could be addressed. and their relationship to other psychiatric rehabilitation programs (e. 1994. Hogarty et al. The theories address different.. 2012). and integrated). & Mueser. Other CE programs have been offered to individuals enrolling in (or already enrolled in) a particular psychosocial program.. there is a lack of evidence concerning whether people with diagnoses other than schizophrenia benefit from CE and whether any benefit such individuals derive is dependent upon them having impaired cognitive functioning.. 2005. More research is needed to evaluate whether participant characteristics can be identified that predict benefit from CE. none.. As with any new and evolving treatment approach. The early onset of schizophrenia often curtails educational attainment (Kessler. such as social functioning (e. Aside from evaluating the effects of adding social cognition training to CE and/or psychiatric rehabilitation. or have focused on those who have experienced past failures in achieving a rehabilitation goal. This included the questions of whether and under what circumstances CE interventions should be funded as a treatment. individual tailoring. While it is beyond the scope of this paper to review specific theories and recommend next steps.. cognitive (e. motivation). The discussion among the panel of experts assembled by NYSOMH in 2008 was a microcosm of the ongoing debate about CE in the broader scientific community.. and which individuals might . The addition of CE to supported education. There was diversity of opinion about the next steps to be taken regarding the funding of CE interventions. greater attention to individual nonclinical factors may be more productive.g. more research is needed on combining CE with supported employment. Some related questions are whether people with certain types of functional impairments are more likely to benefit from particular approaches to CE and whether such individuals should first be engaged in rehabilitation services targeting those impairments before providing CE. Ganguli. 2011). there was a consensus that significant progress has been made in the development of an intervention approach that targets one of the most stubborn and disabling features of many mental illnesses— cognitive impairment. 2008. & Khamneh. comprehensive.g. An additional issue is that change in CE does not occur in a vacuum. Dixon et al. could result in a greater impact on educational outcomes and long-term employment in this population. efficient processing of social contextual information). 2005). such as employment (McGurk et al. 2004... psychological (e. psychosocial outcomes.. Recent efforts to integrate supported education into supported employment programs for individuals recovering from a first episode of psychosis have shown promising effects (Killackey. 2001). Currently. 2011).. but there is still a lack of evidence for the effects of these types of programs on helping people achieve important educational milestones and establish rewarding careers (Mueser & Cook.. 2004). mounting evidence does suggest beneficial effects for CE.. but overlapping. 2010).

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