A mental health revolution

Cambridge-led computerised cognitive assessments transform early detection and treatment of neurological and psychiatric disorders.

Acrylic painting of heads.

Impact at a glance

  • The ‘Cambridge Neuropsychological Test Automated Battery’ (CANTAB) was invented to bridge a translational gap between basic neuroscience and classical neuropsychological assessment.
  • Since August 2013, over 1,100 publications have used CANTAB.
  • Since August 2013, CANTAB and related developments have been used in over 33,800 cognitive assessments and 261 clinical trials.
  • CANTAB is available in almost 50 languages and has been used in over 100 countries.
  • CANTAB has improved patient management and contributed to drug development.
“Our dementia diagnosis rate has improved from 39% to over 46%. CANTAB Mobile has raised awareness of mild cognitive impairment in primary care and acted as a stimulus to actively encourage practices to assess patients at an early stage.”
A Dementia Programme manager from a Clinical Commissioning Group (CCG)

“When it comes to cognitive impairments and psychiatric disorders, early detection, and early treatment are key, similar to physical health,” says Barbara Sahakian, Professor of Clinical Neuropsychology in the University’s Department of Psychiatry.

Over thirty years ago, Sahakian co-invented a group of cognitive assessments called the Cambridge Neuropsychological Test Automated Battery (CANTAB), which have gone on to revolutionise clinicians’ ability to diagnose and treat patients, in addition to playing an invaluable role in research and the development of new drugs.

A computerised revolution

The story of CANTAB began in the late 80’s when Sahakian was working in one of the UK’s first clinics for the early detection of Alzheimer’s disease. She explains that there were simply no good assessment tools available, so she decided to create one. She collaborated with her husband Trevor Robbins, Professor of Cognitive Neuroscience in the University’s Department of Psychology, to configure a set of computerised tests that took advantage of a new technology that had just become available in 1987: the touch sensitive screen.

“Although these touch screens were nothing like the ones we use in our everyday life today,” laughs Sahakian, recalling how awkward it was to attach a separate bulky touch sensitive screen to the computer.

33,803 cognitive assessments in primary and private health care used CANTAB

The computerised nature of CANTAB was revolutionary. Unlike the pen and paper language-based cognitive assessments that had long been the standard way of measuring brain functioning, CANTAB was more objective, precise and accessible. The touch-screen technology and the non-verbal nature of the tests reduced the need for the user to have a certain IQ or language skill level. The tests were also less susceptible to experimental bias or human error.

Later, the invention of the iPad meant that specialised equipment and a trained professional to administer the tests were no longer required – the minimal instructions were incorporated into the test. Sahakian and Robbins assisted in the development of CANTAB Mobile for use in general practitioner clinics, making cognitive testing increasingly accessible and cost effective.

CANTAB is available in 50 languages and 100 countries

Impacting lives

The sensitivity of CANTAB means it’s perfectly suited to clinical trials assessing the effectiveness of new drugs. Its ability to be used across languages, cultures and ages adds a richness to datasets, which has huge implications for the progression of international research into cognitive impairments and psychiatric and neurological disorders.

Since August 2013, CANTAB and related tests have been used in over 33,800 cognitive assessments and 261 clinical trials, in over 100 countries. CANTAB has been used in studies of therapeutic agents, for example in depression, attention deficit hyperactivity disorder (ADHD) and Parkinson’s disease.

261 clinical trials use CANTAB

“We’re thrilled CANTAB has had such an impact on people’s lives,” says Sahakian. “We’ve always wanted our research to not only elucidate the neural mechanisms underlying behaviour and cognition but also to have a strong application for individuals, society, and psychological and neurological disorders.

“We wanted CANTAB to be the Gold Standard in the field – I think we’ve achieved that.”

How does CANTAB work?

CANTAB has been validated using patient studies and neuroimaging studies in healthy volunteers and refined over a period of 30 years. It measures specific brain functions across a range of disorders and syndromes.

Whereas many other traditional tests may assess a behavioural outcome, CANTAB correlates with neural networks, meaning that it measures the functioning of a specific area of the brain in a similar way to a neuroimaging scan.

For example, tests may measure decision making and high-level thinking, which are examples of executive-functioning, in order to provide an indication of the functioning of the prefrontal cortex.

An answer to Alzheimer’s disease?

“We often think about the importance of physical health and keeping fit and active, but we rarely think about this in the context of our brains,” says Sahakian.

Sahakian has long advocated for an awareness of the ‘fitness’ of our brains and testing early to identify if our brains are functioning in the way they should do. This could not be more crucial than with Alzheimer’s disease, the most common cause of dementia in the UK.

The cause of this progressive neurological disorder is not fully understood, and a cure has yet to be identified. However, treatments for the cognitive symptoms of Alzheimer’s disease, approved by the National Institute for Health and Care Excellence (NICE), are available, and recently the Food and Drug Administration (FDA) approved a treatment for the underlying disease process. It’s critical that these drugs are administered as early as possible, which is why early detection is crucial.


The sensitivity of the Paired Learning Associate Test (PAL), which forms part of CANTAB, was found to predict probable Alzheimer’s disease 32 months before formal diagnosis in patients with subjective memory complaints. “This is really important because you have to treat the disease at the earliest possible point to have an impact on patients’ quality of life,” says Sahakian.

The commercialisation of CANTAB via the spin out Cambridge Cognition meant that CANTAB PAL could be used in clinics up and down the country and across the world. Excitingly, PAL has been used in a number of clinical trials in the development of new drugs for dementia.

“My journey with CANTAB began with a deep desire to secure a better quality of life and a longer life for those suffering from Alzheimer’s disease,” said Sahakian. “It’s been incredible to see the development of new drugs which could dramatically improve outcomes for patients. We still have a long way to go, but CANTAB means we have the tools we need to get there.”

Acrylic painting of heads.

Tackling gambling disorders

Sahakian holds up a photograph of former Arsenal and England player Paul Merson. It reads ‘thank you for everything.’ The photo shows a young Merson in his Arsenal strip, storming up the pitch in celebration of a goal. The snapshot captures a moment of pure jubilation but hides the reality of the battles he faced. Merson has struggled with addictions throughout his adult life. Of these addictions, he says his gambling disorder was the worst.

Paul Merson photo

 'To Barbara, thank you for everything, love Paul Merson x'

 'To Barbara, thank you for everything, love Paul Merson x'

Sahakian met Merson as part of the upcoming documentary, Paul Merson: Football, Gambling and Me. She explains that disordered gambling is a growing problem, and it’s increasingly occurring in the younger population, which is likely due to betting being available online and betting adverts airing alongside sports matches.

“It begins impulsively,” explains Sahakian “maybe an individual sees their dad going into a betting shop or they see an advert on TV that says: “bet now before the game starts”. At first, they bet just for a bit of fun or to have a heightened experience. They might get a win or a close miss which reinforces false beliefs that they’re going to be lucky. And so, they bet more and more until it becomes habitual. They may also need to escalate bets to get the same dopamine rush.”

CANTAB Cambridge Gambling task

Sahakian, along with others, developed the CANTAB Cambridge Gambling task which was administered to Merson as part of the documentary. The task involves a betting game which assesses risk taking and decision-making behaviour.

“What we find is that pathological gamblers are more likely to place higher bets and to ground out, they also don’t make adjustments based on perceived levels of risk.”

Hot and cold cognition

Sahakian describes these behaviours as examples of ‘hot cognition’, which refers to decisions that are emotion-led as opposed to rational or ‘cold cognition’ decisions. Interestingly, there are advantages to both types of decision making as Sahakian found in her study, published in Nature, investigating entrepreneurs.

“Entrepreneurs are risky decision makers, but unlike pathological gamblers, they also have very good cognitive flexibility and cold planning. Therefore, they are able to take big risks, but if something isn’t working, they are able to switch and try a different way to be successful.”

It’s the interaction between hot and cold cognition that those with problem gambling may struggle with. Cognitive behavioural treatments may involve waiting and not betting immediately when you have the urge to gamble. This time delay can ‘cool down’ hot thinking and bring a more rational perspective.

The CANTAB Cambridge Gambling task can be used by clinicians to assess how excessive the problem behaviours are. As treatment is started and continued it can be used to check on the progress of the patient and their recovery.

To date, the task has been used in nearly 200 publications. “It’s wonderful to see that the Cambridge Gambling task has been instrumental in advancing research in the area of addictive behaviours and dependencies,” says Sahakian. “The more we understand about these disorders the greater the chance we have of developing effective treatments.”

Watch Paul Merson: Football, Gambling and Me at 9pm, 11 October, BBC1.

Infographics by Alison Fair.

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Acrylic painting of heads.