Cognition in Schizophrenia: The Missing Piece of the Therapeutic Puzzle

What kind of mental image springs to mind upon reading the word ‘schizophrenia’? Many envisage individuals locked in dark institutions, plagued by non-existent voices and vivid hallucinations. Fortunately, modern antipsychotic drugs combating symptoms like hallucinations have allowed many patients to successfully function and flourish within their communities. So, why do so many schizophrenia patients still fail to achieve independent living, find employment, and form relationships? Even more alarmingly, why are rates of symptomatic relapse so high? The answer lies in the debilitating cognitive disturbances suffered by patients, too often overlooked by research and – crucially – neglected by current drug therapies.

Schizophrenia is a staggeringly heterogeneous disorder, with symptoms manifesting very differently in each patient. Patients often struggle in areas of verbal learning, processing speed, and working memory. But do these impairments really have a major impact? In the context of a disorder characterized by terrifying hallucinations and debilitating delusions, cognitive difficulties might not seem like an urgent therapeutic priority.

“…for many patients, cognitive difficulties make antipsychotic drugs a futile intervention, leading to symptomatic remission and a substantial waste of resources.”

In fact, the true impact of cognition upon disease outcomes in schizophrenia is only recently coming to light. A plethora of studies have drawn links between poor cognitive performance and impaired psychosocial functioning. One might argue that this is a rather obvious association. But closer consideration reveals the enormous impact this has on daily life: if a schizophrenia patient is unable to speak clearly, perform hygiene-related tasks, or keep up with their medications, they have little hope of finding employment or successfully integrating into community living. Indeed, a 2015 review calculated employment rates in schizophrenia ranging from 4% to 50.4%.

As recently as January 2020, research has emphasized the detrimental effects of impaired cognition. An Ecuadorian study conducted at the psychiatric Kennedy Hospital used the SCIP (Screening of Cognitive Deterioration in Psychiatry), which is a test of cognitive functioning that requires patients to complete tasks like remembering a list of words or naming all the words they can think of in a specific category that start with a certain letter. This test, along with questionnaires about their experiences, revealed that patients suffering greater cognitive difficulties had a poorer quality of life.

Even considering the impact of untreated cognitive symptoms upon quality of life, it is still reasonable to pose the question: so what? The sad reality is that for many patients, cognitive difficulties make antipsychotic drugs a futile intervention, leading to symptomatic remission and a substantial waste of resources. Beyond material concerns, a Swedish study following over 500 schizophrenia patients made the staggering finding that executive function independently predicted premature death.

In the face of such alarming data, it is unsurprising that the cognitive deficits of schizophrenia have become an urgent therapeutic target. But how can cognition be elevated? Amongst the most promising interventions are drugs targeting NMDA receptors. These receptors are located on the surface of neuronal cells and mediate signaling crucial for learning and memory functions. One such NMDA-inhibiting medication is memantine, which has shown some promise in schizophrenia patients.

“As research continues to search for successful schizophrenia treatment strategies, one thing is becoming worryingly clear: one size does not fit all.”

Unfortunately, using pharmacological treatments to improve cognition is far from straightforward. It is critical to remember that these patients still rely upon antipsychotics to manage positive symptoms, which often interfere with the activity of cognition-targeting drugs. Even without this complication, is it rational to expect modifying a single receptor to be effective in treating such a complex, multi-faceted disorder? This is where cognitive remediation therapy comes in. Using behavioral training, this technique is not only shown to improve performance across numerous cognitive domains, but also delay the relapse of symptoms.

As research continues to search for successful schizophrenia treatment strategies, one thing is becoming worryingly clear: one size does not fit all. A particular cocktail of drugs and behavioral therapies allowing one patient to thrive may be completely unsuccessful in another. Encouragingly, current efforts are directed toward identifying patients most likely to benefit from certain treatment strategies, using biological indicators or ‘biomarkers’.

There is an undeniably long way to go before schizophrenia patients will be able to make a complete recovery, with a low risk of relapse and a satisfactory quality of life. But recognizing cognition as the wrongly neglected aspect of schizophrenia is certainly a step in the right direction.

A version of this article was originally published on the British Association for Psychopharmacology’s website.

What are your thoughts on how we should be developing therapeutic approaches to complex neurological disorders, such as schizophrenia? Let us know in the comments below.


Feature image depicting the profile of a person's head with puzzle pieces where the brain would be, centered on a background with wavy stripes to represent hallucinations associated with schizophrenia. Designed by Alexa Erdogan.

— Written by Jessica Brown. Feature image designed by Alexa Erdogan.

  • J, Avila, Villacrés L, Rosado D, and Loor E. ‘Cognitive Deterioration and Quality of Life in Patients with Schizophrenia: A Single Institution Experience’. Cureus 12, no. 1 (25 January 2020).
  • Molina, Juan, and Ming T. Tsuang. ‘Neurocognition and Treatment Outcomes in Schizophrenia’. In Schizophrenia Treatment Outcomes: An Evidence-Based Approach to Recovery, edited by Amresh Shrivastava and Avinash De Sousa, 35–41. Cham: Springer International Publishing, 2020.
  • Schaefer, Jonathan, Evan Giangrande, Daniel R. Weinberger, and Dwight Dickinson. ‘The Global Cognitive Impairment in Schizophrenia: Consistent over Decades and around the World’. Schizophrenia Research 150, no. 1 (October 2013): 42–50.
  • Evans, Jovier D., Robert K. Heaton, Jane S. Paulsen, Barton W. Palmer, Thomas Patterson, and Dilip V. Jeste. ‘The Relationship of Neuropsychological Abilities to Specific Domains of Functional Capacity in Older Schizophrenia Patients’. Biological Psychiatry 53, no. 5 (1 March 2003): 422–30.
  • Semkovska, Maria, Marc-André Bédard, Lucie Godbout, Frédérique Limoge, and Emmanuel Stip. ‘Assessment of Executive Dysfunction during Activities of Daily Living in Schizophrenia’. Schizophrenia Research 69, no. 2–3 (1 August 2004): 289–300.
  • Tsai, G. E. ‘Ultimate Translation: Developing Therapeutics Targeting on N-Methyl-d-Aspartate Receptor’. Advances in Pharmacology (San Diego, Calif.) 76 (2016): 257–309.
  • Thomas, Michael L., Michael F. Green, Gerhard Hellemann, Catherine A. Sugar, Melissa Tarasenko, Monica E. Calkins, Tiffany A. Greenwood, et al. ‘Modeling Deficits From Early Auditory Information Processing to Psychosocial Functioning in Schizophrenia’. JAMA Psychiatry 74, no. 1 (1 January 2017): 37–46.
  • Trapp, Wolfgang, Michael Landgrebe, Katharina Hoesl, Stefan Lautenbacher, Bernd Gallhofer, Wilfried Günther, and Goeran Hajak. ‘Cognitive Remediation Improves Cognition and Good Cognitive Performance Increases Time to Relapse–Results of a 5 Year Catamnestic Study in Schizophrenia Patients’. BMC Psychiatry 13 (9 July 2013): 184.
  • Helldin, Lars, Fredrik Hjärthag, Anna-Karin Olsson, and Philip D. Harvey. ‘Cognitive Performance, Symptom Severity, and Survival among Patients with Schizophrenia Spectrum Disorder: A Prospective 15-Year Study’. Schizophrenia Research 169, no. 1–3 (December 2015): 141–46.
  • Bouwmans, Clazien, Caroline de Sonneville, Cornelis L Mulder, and Leona Hakkaart-van Roijen. ‘Employment and the Associated Impact on Quality of Life in People Diagnosed with Schizophrenia’. Neuropsychiatric Disease and Treatment 11 (18 August 2015): 2125–42.

Become a Patron!

Jessica Brown

Jessica is a first-year PhD student in Pharmacology at the University of Manchester. She previously graduated from the University of Bath with a BSc in Biology, which involved a research placement at Eli Lilly investigating the role of neuroinflammation in Alzheimer’s disease. Currently, her PhD research focuses on the cognitive impairment associated with schizophrenia, assessing the mGluR5 receptor as a potential pharmacological target. She is ultimately interested in exploring neurological disorders to allow more effective therapeutic targeting. Beyond her research, Jess is passionate about making the joys of science accessible for all through getting involved in public engagement projects, widening participation programmes for younger generations and writing research articles such as this one.