Schizophrenia is among the most severe psychiatric disorders (Jauhar et al., 2022). Its core features include positive symptoms (e.g., delusions and hallucinations), negative symptoms (e.g., impaired motivation and social withdrawal), and cognitive impairment, the latter referring to poorer performance than that of controls across a broad range of cognitive domains (Joyce and Roiser, 2007). Approximately 80–90 % of patients with schizophrenia are unable to support themselves financially (Kooyman et al., 2007). Parents of affected individuals also experience income loss, an increased financial burden (von Kardorff et al., 2016), and premature withdrawal from the labor market (Schneider et al., 2013). In England, schizophrenia was estimated to cost £11.8 billion annually as early as 2012 (Knapp, 2012). Consequently, schizophrenia imposes substantial economic and social burdens on individuals, families, and society. Literature suggests that cognitive deficits contribute significantly to impaired functioning (McCutcheon et al., 2023; Vita et al., 2021), poor real-world outcomes (Maj et al., 2021), and reduced quality of life (Tolman and Kurtz, 2012). Evidence also indicates that cognitive decline often precedes the onset of psychotic symptoms (Kahn and Keefe, 2013; Lewandowski et al., 2011). Individuals with schizophrenia typically show marked deficits in overall cognitive performance, averaging approximately two standard deviations below those of healthy controls (Keefe et al., 2011). Accordingly, the role of cognitive deficits in schizophrenia has received increasing attention in recent decades, and in 2020, the American Psychiatric Association recommended interventions to enhance cognition and social function in this population (Keepers et al., 2020).

Over the past three decades, cognitive impairment has become an increasingly important treatment target in schizophrenia (McCutcheon et al., 2023). Although antipsychotics can significantly improve positive symptoms, no specific agent has shown consistently better cognitive outcomes than placebo (Feber et al., 2025), and the anticholinergic effects of many psychotropic medications can have a clearly detrimental impact on cognition (Joshi et al., 2021). Consequently, cognitive remediation has been recommended as a psychosocial intervention by both the American Psychiatric Association and the European Psychiatric Association (Keepers et al., 2020; Vita et al., 2022). Meta-analyses have shown that cognitive remediation interventions can substantially improve cognitive performance and functional outcomes (Lejeune et al., 2021; Prikken et al., 2019; van Duin et al., 2019; Vita et al., 2021, 2024), as well as quality of life (Fisher et al., 2016).

With recent advances in computer technology, computerized cognitive training has emerged. Based primarily on the English literature on cognitive remediation therapy, a Chinese version of computerized cognitive remediation therapy (CCRT) was developed (Fan et al., 2017). Delivered in a game-based format, CCRT offers several advantages, including strong usability (Mao et al., 2020), unlimited repeatability (Garcia-Fernandez et al., 2019), reduced therapist time (Grynszpan et al., 2011), and lower overall healthcare costs (Chan et al., 2015). It has demonstrated strong effects on both cognition and functional outcomes (Fan et al., 2017; Tan et al., 2020; Zhu et al., 2020). However, other studies have indicated that computerized cognitive training alone may be insufficient to improve daily functioning (Prikken et al., 2019) and suggested that combining it with psychiatric rehabilitation may better enhance both cognitive and functional outcomes (Buonocore et al., 2022; Weiden, 2015; Wykes et al., 2011). This is likely because an integrated approach facilitates the transfer of cognitive gains to real-world contexts (Vita et al., 2021; Wykes et al., 2011), a process identified as a core feature of cognitive remediation by the Cognitive Remediation Experts Workshop (Bowie et al., 2020).

Occupational therapy, which supports and facilitates ongoing participation in daily life through engagement in activities and occupations meaningful to the individual (Morris et al., 2018), is an appropriate approach for addressing everyday life skills. In 1982, the concept of modern rehabilitation medicine was introduced in China, and occupational therapy (OT) has since developed for >40 years, particularly in psychiatric care (Zhang et al., 2023). Studies have shown that OT can aid recovery as a significant therapeutic component by promoting meaningful activities that improve daily functioning, quality of life, and personal well-being (Hohl et al., 2017; Lindström et al., 2012; Lipskaya-Velikovsky et al., 2016). This foundation led to the development of individualized occupational therapy (IOT), which emphasizes goal-oriented observation of patient performance and real-time adjustments to treatment plans. IOT offers individualized psychiatric rehabilitation programs aimed at improving cognition, daily living skills, and quality of life (Shimada et al., 2024, 2016, 2018). Furthermore, a Japanese study found that incorporating IOT into inpatient treatment for schizophrenia significantly enhanced intrinsic motivation (Shimada et al., 2022, 2018). Intrinsic motivation is widely recognized as a critical determinant of cognitive performance (Bryce et al., 2018; Medalia and Saperstein, 2011), and improvements in intrinsic motivation may lead to greater cognitive gains (Fervaha et al., 2014; Reeder et al., 2017; Saperstein and Medalia, 2016).

Given that psychiatric rehabilitation is considered an effective transfer technique (Vita et al., 2021) and that CCRT relies on gamified cognitive training, this study developed an IOT program as a bridging intervention to integrate with CCRT, with the aim of improving both cognitive function and functional outcomes. To our knowledge, this is the first study to investigate such an integration. We hypothesized that the combined intervention would improve cognitive, social, and daily functioning, intrinsic motivation, and quality of life compared with treatment-as-usual (TAU).