Multi-outcome meta-analysis (MOMA) of cognitive remediation in schizophrenia: Revisiting the relevance of human coaching and elucidating interplay between multiple outcomes

•Cognitive remediation is helpful in improving multiple outcome domains including cognitive, clinical and functioning in schizophrenia.•However, supplementary human guidance is suggested to be additionally beneficial in improving verbal and working memory.•Structured equation modeling suggests that cognitive gains trigger restoration of functioning which in turn facilitates clinical improvement. Cognitive remediation (CR) is nowadays mainly administered in a computerized fashion, yet frequently supplemented by human guidance. The effects of CR on cognitive, functional and clinical outcomes are consistently reported, yet the response is heterogeneous. In order to resolve this heterogeneity, we employed a multi-outcome meta-analytic approach, examined effects of CR on each outcome category separately and estimated directed effects between three outcome categories. We extracted treatment effects from 67 studies that trained patients with schizophrenia (total n = 4067) using either 1) computerized CR modality alone or 2) in combination with supplementary human guidance (SHG). All three outcome domains were significantly improved by CR with small to moderate effect sizes when assessing outcomes across all studies. The comparison between CR administered with SHG revealed largest effects on the cognitive subdomains of working and verbal memory. Structural equation modeling in the single-study data suggests that cognitive gains trigger restoration of psychosocial functioning which in turn facilitates improvement in clinical symptoms.