Translation, cross-cultural adaptation and preliminary validation of the Dutch version of the TOGETHER questionnaire - a tool designed to assess how family members of patients perceive their involveme

Schizophrenia is probably the most severe mental illness with high levels of disability due to early onset, course of illness and clinical manifestations, including positive, negative and cognitive symptoms (). Positive symptoms, including delusions and hallucinations, are often clinically prominent, due to their overt nature and need for a timely management. However, negative and cognitive symptoms, including affective flattening, alogia, abulia, executive function compromission, social withdrawal, difficulties in attention, working and episodic memory, processing speed, and language, represent a central, although often neglected, core of the disorder, especially during the chronic phase of illness. Negative and cognitive symptoms are typically resistant to classic antipsychotics and negatively affect global functioning and quality of life (). Cognitive rehabilitation has recently gained attention for the management of individuals with schizophrenia, with the goal of improving cognitive processes through structured and personalized interventions (). Personalization may represent a promising component of cognitive remediation to address the interindividual response variability (). However, the extent to which personalization itself may influence treatment outcomes has not yet been sufficiently established by meta-analytic evidence. Through repeated cognitive practice, progressive task difficulties, feedback-based learning, and strategy acquisition, cognitive remediation may promote adaptive changes in the neural systems supporting cognition (). fMRI studies reported training-related changes in frontal activation after cognitive exercises and cognitive remediation therapy (; ) and an increase in task-relevant prefrontal activation after computerized cognitive training (). Also, a neuroprotective effect was associated with cognitive enhancement therapy, supported by a reduced gray matter loss in early schizophrenia after a 2-year follow-up (). Although these findings may support the biological plausibility of neuroplasticity-based mechanisms, it remains unclear whether cognitive remediation can directly influence synaptic plasticity in schizophrenia (). Several studies proved the efficacy of cognitive rehabilitation for improving cognitive performance, social and working functioning, and overall quality of life (; ), thanks to the ‘generalization’ of the abilities achieved within the rehabilitation setting. In recent years, new technologies in the rehabilitative interventions have been increasingly employed. Among these, Immersive Virtual Reality (IVR) has gained growing interest because it allows patients to engage with simulated, interactive environments that reproduce real-world activities in a controlled context. The advantages of the IVR includes the potential for a controlled and gradual stimulation, simulating real-life scenarios in a safe and supervised environment, with an ability-adaptive model that allows for different complexity based on the individual capability (). IVR includes several daily life scenarios that allows for a personalization of the stimulus, based on the specific impaired cognitive domains, such as memory, attention, and social cognition (). IVR has been applied to several mental disorders, including individuals with schizophrenia-spectrum disorders. Although preliminary findings suggest potential benefits across several domains, including auditory verbal hallucinations, cognitive deficits, and impaired social skills, the available evidence remains limited, due to the small number and methodological heterogeneity of existing studies (). Controlled evidence on IVR-assisted cognitive remediation remains limited. In a randomized proof-of-concept study, Jespersen et al. evaluated immersive VR-based cognitive training in patients with mood or psychosis-spectrum disorders, showing high satisfaction, minimal simulator sickness, and improvement in processing/psychomotor speed, whereas no significant effects emerged on traditional neuropsychological outcomes (). However, evidence in schizophrenia remains limited, as in the Jespersen et al. study, the psychosis-spectrum subgroup mainly included individuals with schizotypal disorder. Based on this rationale, we aimed to evaluate a 12-week IVR-based cognitive rehabilitation protocol in clinically stable outpatients with chronic schizophrenia, appraising feasibility, cognitive outcomes, psychomotor speed, and psychotic symptoms. The current trial was a prospective, randomized, parallel-groups, single blind, twelve-week trial conducted in a community-based psychiatric service in Italy. The procedures followed the current revision of the Declaration of Helsinki () and all eligible participants had to accept to participate and provide a written informed consent prior to participation. The trial was registered after the approval of the protocol by the local Ethical committee (Comitato Etico Campania Sud, registration code: 29475–02/03/2025) and re