1. Medicine, Nursing and Health Sciences Cognitive impairment and cognitive recovery in substance related disorders A/Prof. Antonio Verdejo-Garcia Catania, July 2015

2. Cognition and Outcomes2 Outline 1.Cognition -- What is it (for)? 2.Subtyping/Matching 3.Prediction 4.Cognitive remediation

3. Cognition and Outcomes3 Updating and management OF input-independent info FOR goal-achievement and decision-making

4. Cognition and Outcomes4 3 D 5 B 1 H / 1 3 5 B D H D X D RED GREEN BLUE

5. Cognition and Outcomes5 Moreno-López et al. (2012)

6. 6 Gray Matter White Matter Moreno-López et al. (2012)

7. Factor Analysis of Executive Functions ComponentsMeasuresFactor Load h2h2 UpdatingLetter Number Sequencing 0.5-0.80.53-0.73 InhibitionStroop0.7-0.80.51-0.63 SwitchingWisconsin Card Sorting Test 0.5-0.90.45-0.74 Decision-makingIowa Gambling Task 0.90.83 Verdejo-García & Perez-Garcia (2007)

8. Stimulants vs Opiate users Verdejo-García & Perez-Garcia (2007)

9. Cognition and Outcomes9 ComponentsPrevalence RateDrug of choice w/greater deficits Working memory62.2 %C=H Response Inhibition38.3 %C>H Shifting27.3 %C>H Global Impairment68.8 %

10. Focus of current interventions (MI or CBT)  Life goals  Self-control and self-monitoring  Avoid risk Cognition and Outcomes10

11. Focus of current interventions (MI or CBT)  Life goals  Self-control and self-monitoring  Avoid risk Cognition and Outcomes11 Mismatch between impaired working memory, inhibition or decision-making and treatment requisites

12. What cognition may add…  Subtyping/Matching  Prediction  Focused interventions Cognition and Outcomes12 Neuropsychological Assessment Cognitive Rehabilitation

13. Cognition and Outcomes13 Albein-Urios et al. (2013, 2014)

14. Cognition and Outcomes14 LCA of trait and cognitive impulsivity scores in 96 addiction clients Albein-Urios et al. (2014)

15. Cognition and Outcomes15 Z scores Albein-Urios et al. (2013)

16. Cognition and Outcomes16 Z scores Albein-Urios et al. (2013)

17. Cognition and Outcomes17 Z scores Albein-Urios et al. (2013)

18. Cognition and Outcomes18 Z scores Albein-Urios et al. (2013)

19. Medicine, Nursing and Health Sciences Prediction of at risk clients

20. Key cognitive processes  Delay Discounting  Decision-making Cognition and Outcomes20

21. Delay discounting 28th February 2011Presentation title21 Marshmallows! http://www.youtube.com/watch?v=QX_oy9614HQ http://www.youtube.com/watch?v=QX_oy9614HQ Peters and Buchel (2011) TICS: 11(5)

22. 22 Christakou et al. (2011)

23. Delay discounting in addiction Presentation title23 Albein-Urios et al. (2014)

24. Delay Discounting longitudinally predicts who stay in treatment Cognition and Outcomes24 Stevens, Verdejo-Garcia et al. (2014)

25. Treatment readiness correlate with brain fitness 28th February 2011Cognition and Outcomes25 Moreno-Lopez et al. (2014)

26. Bechara et al. (2005) Decision-making

27. Bechara et al. (2005)

28. Decision-making in addiction 28 Verdejo-Garcia et al. (2007)

29. Association with severity of cocaine use 29 Verdejo-Garcia et al. (2007)

30. Using the Iowa Gambling Task to predict relapse  Baseline assessments (~2 weeks after treatment commencement) and classification:  Insensitivity to future consequences  Hypersensitivity to reward  Intact  Follow-up –3 months after baseline assessments, to provide a 3 cm hair sample to assess drug relapse. Cognition and Outcomes30 Verdejo-Garcia et al. (2014)

31. Outcome: Cocaine hair concentrations 3 months after treatment onset 31 Verdejo-Garcia et al. 2014

32. 32 Verdejo-Garcia et al. 2014 Outcome: Cocaine hair concentrations 3 months after treatment onset

33. Medicine, Nursing and Health Sciences Cognitive enhancement interventions Cognition Clinical Outcomes Amenable to Interventions ✔ ✔ ?

34. 28th February 2011Presentation title34

35. Wiers and colleagues

38.  Cognitive training of skills needed to: Set personal goals – tailored (“mental blackboard”) Resist interference (“automatic pilot”)  Boredom  Stress  Habits Quality control – from external to self-generated feedback  Practice when and how utilise them in daily life

39. D B C A Automatic pilot  STOP!  Present Mindedness Back to Goal State your Decision Quality control! GMT Alfonso et al. (2011)

40. D B C A Automatic pilot  STOP!  Present Mindedness Meditation motives (e.g., endurance, willpower) When distracted  Back to motive Interoceptive scanning  Decision- making MFN Alfonso et al. (2011)

41. STOP! ** Goal Management Training Long-term goals Decision-making in the Iowa Gambling Task Alfonso et al. (2011)

42. Conclusions  Most substance dependent clients have executive thinking deficits  Deficient skills are paradoxically prerequisites of addiction treatments we currently apply  There is potential to recovery, and cognitive training can improve treatment outcomes TP Nov 2013Cognition and Outcomes42

43. Acknowledgements  Funding –Monash Strategic Grant Scheme –Red de Trastornos Adictivos, Universidad de Granada  Turning Point Drug and Alcohol Centre –Dan Lubman –Victoria Manning  Verdejo-Garcia’s group: –MJ Fernandez-Serrano –Laura Moreno-Lopez –Jose M Martinez-Gonzalez –Jose C Perales –Oscar Lozano –Natalia Albein 43

44. Thank you! 44