Reliability and validity of the Personal and Social Performance scale in patients with schizophrenia

Exploring engagement with the CBT-informed Actissist smartphone application for early psychosis

BACKGROUND

Individuals with psychosis report favourable attitudes towards psychological interventions delivered via smartphone apps. Evidence for acceptability, safety, feasibility and efficacy is promising but in-depth reporting of app engagement in trials is sparse.

AIMS

To examine how people with psychosis engaged with the cognitive behaviour therapy (CBT)-informed Actissist app over a 12-week intervention period, and to examine factors associated with app engagement.

METHODS

Secondary data from participants in the intervention arm (n = 24) of a proof-of-concept randomised controlled trial of the Actissist app were analysed. The app prompted participants to engage with app-based CBT-informed material in five domains (voices, socialization, cannabis use, paranoia, perceived criticism) at pseudo-random intervals (three notifications per day, six days per week). Participants could self-initiate use any time. App use was financially incentivised.

RESULTS

Participants responded to 47% of app notifications. Most app engagements (87%) were app-initiated rather than self-initiated. Participants engaged most with the voices domain, then paranoia. Age and employment status were significantly associated with overall app engagement.

CONCLUSION

Individuals with psychosis engaged well with Actissist, particularly with areas focussing on voice-hearing and paranoia. App-generated reminders successfully prompted app engagement. As financial incentives may have increased app engagement, future studies of non-incentivized engagement in larger samples are needed.

Community-based rehabilitation interventions on quality of care for people with schizophrenia in China (CRISC): study protocol for a cluster-randomized controlled trial

BACKGROUND

International consensus shows that community-based rehabilitation (CBR) service is an effective way to improve functioning and negative symptoms and address the treatment gap for schizophrenia. Rigorous trials are needed in China to demonstrate effective and scalable CBR interventions to significantly improve outcomes for people with schizophrenia and to provide evidence of the economic benefits. The objectives of this trial are to examine the effectiveness of CBR as an adjunct to test the usual facility-cased care (FBC) in comparison to FBC alone in improving a range of outcomes in people with schizophrenia and their caregivers.

METHODS

This trial is a cluster randomized controlled trial design in China. The trial will be conducted at three districts of Weifang city, Shandong province. Eligible participants will be identified from the psychiatric management system where community-dwelling patients with schizophrenia have been registered. Participants will be recruited after providing informed consent. 18 sub-districts will be randomly allocated in a 1:1 ratio to facility-based care (FBC) plus CBR (intervention arm) or FBC alone (control arm). The structured CBR intervention will be delivered by trained psychiatric nurses or community health workers. We aim to recruit 264 participants. The primary outcomes include symptoms of schizophrenia, personal and social function, quality of life, family burden of caring, etc. The study will be conducted according to good ethical practice, data analysis and reporting guidelines.

DISCUSSION

If the hypothesized clinical benefit and cost-effectiveness of CBR intervention are confirmed, this trial will provide significant implications for policy makers and practitioners to scale up rehabilitation services, as well as for people with schizophrenia and their family to promote recovery and social inclusion, and to alleviate the burden of care.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2200066945). Registered December 22, 2022.

Treatment of Depression with Vortioxetine and Second Generation Antipsychotics During the Period of Remission Formation in Schizophrenia (Interim Data Analysis)

BACKGROUND

Depression in patients with schizophrenia worsens the course of the disease by increasing the risk of suicide, by complicating the clinical picture of the disorder, and by reducing the quality of the social functioning; its treatment is difficult, since monotherapy, even when involving modern antipsychotics, does not always prove successful. While the prescription of additional antidepressants (ADs) can improve the likelihood of a better outcome, the effectiveness of such augmentation in many cases is yet to be proven. Therefore, it is still important that one weighs the effectiveness of various combinations between most of the known ADs and some second-generation antipsychotic (SGA) in the treatment of depression that occurs at different stages of schizophrenia. In previous studies, the use of vortioxetine as an adjunct to an antipsychotic yielded a reduction in negative symptoms, a clinically significant improvement in cognitive functions that differed from its antidepressant effect, and good tolerability, which affects how committed to treatment a patient remains.

AIM

To study the changes that occur over time in the clinical manifestations of depression, negative and cognitive impairment, as well as the social adequacy of patients receiving a combination therapy with second-generation antipsychotics and vortioxetine, which were prescribed in real clinical practice at doses approved in the Russian Federation.

METHODS

We performed a comparative analysis of the changes in depression symptoms and negative symptoms, cognitive impairment, as well as function of 78 patients with severe manifestations of depression at the stage of exacerbation reduction and subsequent remission of paranoid schizophrenia. Combination treatment with SGA and vortioxetine was used in 39 patients, and 39 patients who had similar clinical manifestations received just SGA. During the observation period, the mental disorder severity and depression symptom severity were assessed 3 times (before the start of treatment, after three months, and after six months) using the Clinical Global Impression (CGI) scale and Calgary Depression Scale for Schizophrenia (CDSS), respectively; patients were also assessed using the Negative Symptoms Assessment-5 (NSA-5) scale, Perceived Deficits Questionnaire-20 items (PDQ-20) scale, and Personal and Social Performance (PSP) scale.

RESULTS

According to the ANOVA results, by the end of the observation period, patients, regardless of their therapeutic group, showed a statistically significant decrease in the level of depression on the CDSS scale, the severity of negative symptoms on the NSA-5 scale, cognitive symptoms on the PDQ-20 scale, as well as an improvement in personality and society, judging by the increase in the total PSP scores. There were also significant differences between the compared main (SGA + vortioxetine) and control (SGA) groups in terms of the changes in the total score on the CDSS and PSP scales. An interesting aspect of the changes in the clinical scores was a noticeable improvement in the SGA + vortioxetine group after 3 months of treatment, in the absence of a similar improvement in the control group, and the achievement of approximately the same scores in both groups after 6 months. In particular, there were significant differences between the SGA + vortioxetine and SGA groups in terms of the mean CDSS (p 0.001), NSA-5 (p=0.003), PDQ-20 (p 0.001), and PSP (p=0.004) scores after 3 months. Analysis of the time before early withdrawal from the study showed that significantly more patients in the SGA + vortioxetine group completed the study program (n=27, 69.23%) compared with the SGA group (n=13, 33.33%) (2 =14.618, df=1, p 0.001, log-rank test. The mean survival time in the SGA group was significantly (p 0.001) less and amounted to 101.436 days (95% CI: 81.518121.354), and in the SGA + vortioxetine group it amounted to 161.744 days (147.981175.506). The relative risk of full study completion in the vortioxetine + SGA group compared with that in SGA was 3.618 (1.8716.994).

CONCLUSION

The addition of vortioxetine to the SGA therapy accelerates the reduction of the depression symptoms that occur at the stage of psychosis regression and early remission, contributes to the accelerated reduction in negative symptoms, positively affects the subjective assessment of cognitive impairment severity, and has a significant positive effect on the level of psychosocial functioning.

Predictors of Return to Work for People with Anxiety or Depression Participating in a Randomized Trial Investigating the Effect of a Supported Employment Intervention

Purpose Common mental disorders have a severe impact on society and individuals; rates of unemployment and disability pensions are high. Knowing which factors facilitate or hinder people's return to work is important when designing effective vocational rehabilitation interventions. Methods We conducted secondary analyses on data from 289 participants with depression or anxiety included in the Individual Placement and Support modified for people with mood and anxiety disorders (IPS-MA) trial. Associations of baseline characteristics and employment or education after 24 months were tested in univariate logistic regression analyses, variables with a p-value below 0.1 were included in multivariate analyses. Results In the univariate analyses, self-reported level of functioning (p = 0.032), higher age (p = 0.070), and higher level of readiness to change (p = 0.001) were associated with the outcome and included in the multivariate analysis. Only age (p = 0.030) and readiness to change (p = 0.003) remained significantly associated with return to work or education after 24 months in the multivariate analysis. Conclusion Higher age and lower readiness to change were associated with a lower chance of having returned to work or education. Factors modifying the effect of higher age should be identified, just as vocational rehabilitation should focus on improving factors related to people's readiness to change.

Influence of positive and negative symptoms on hedonic and eudaemonic well-being in people with schizophrenia: A longitudinal analysis from the EuroSc study

BACKGROUND

Subjective well-being in people with schizophrenia is likely to be impaired by positive and negative psychotic symptoms. However, these may impact differentially on hedonic (satisfaction and interest in life) and eudaemonic (optimal psychological and social functioning) components.

AIMS

We hypothesized that positive symptoms would influence the hedonic component, while negative symptoms would be linked to eudaemonic well-being.

METHODS

We tested this using longitudinal data (N = 1208) from the EUROSC study. Measures were repeated after 6, 12, 18 and 24 months. Hedonic and eudaemonic features were identified using the Quality of Life Interview. Positive and negative symptoms were assessed with the Positive and Negative Syndrome Scale. We used latent variable structural equation modelling to investigate the impact of positive and negative symptoms at each of the four data points on well-being components 6 months later, controlling for depressed mood.

RESULTS

The measurement model yielded acceptable fit. People with higher scores on positive symptoms at a given time-point were more likely to report lower scores for hedonic components six months later (6-, 12-, and 24-month), whereas we found no significant paths from negative symptoms to hedonic or eudaemonic features.

CONCLUSIONS

Although we found a longitudinal influence of positive symptoms on hedonic well-being, negative symptoms had no effect on either hedonic or eudaemonic components. While symptom reduction strategies may be helpful for hedonic well-being, the amelioration of eudaemonic features may require targeted psychosocial programmes to help individuals attain more rewarding lives.

Add-On MEmaNtine to Dopamine Antagonism to Improve Negative Symptoms at First Psychosis- the AMEND Trial Protocol

BACKGROUND

Antipsychotic drugs are primarily efficacious in treating positive symptoms by blocking the dopamine D2 receptor, but they fail to substantially improve negative symptoms and cognitive deficits. The limited efficacy may be attributed to the fact that the pathophysiology of psychosis involves multiple neurotransmitter systems. In patients with chronic schizophrenia, memantine, a non-competitive glutamatergic NMDA receptor antagonist, shows promise for ameliorating negative symptoms and improving cognition. Yet, it is unknown how memantine modulates glutamate levels, and memantine has not been investigated in patients with first-episode psychosis.

AIMS

This investigator-initiated double-blinded randomized controlled trial is designed to (1) test the clinical effects on negative symptoms of add-on memantine to antipsychotic medication, and (2) neurobiologically characterize the responders to add-on memantine.

MATERIALS AND EQUIPMENT

Antipsychotic-naïve patients with first-episode psychosis will be randomized to 12 weeks treatment with [amisulpride + memantine] or [amisulpride + placebo]. We aim for a minimum of 18 patients in each treatment arm to complete the trial. Brain mapping will be performed before and after 12 weeks focusing on glutamate and neuromelanin in predefined regions. Regional glutamate levels will be probed with proton magnetic resonance spectroscopy (MRS), while neuromelanin signal will be mapped with neuromelanin-sensitive magnetic resonance imaging (MRI). We will also perform structural and diffusion weighted, whole-brain MRI. MRS and MRI will be performed at an ultra-high field strength (7 Tesla). Alongside, participants undergo clinical and neuropsychological assessments. Twenty matched healthy controls will undergo similar baseline- and 12-week examinations, but without receiving treatment.

OUTCOME MEASURES

The primary endpoint is negative symptom severity. Secondary outcomes comprise: (i) clinical endpoints related to cognition, psychotic symptoms, side effects, and (ii) neurobiological endpoints related to regional glutamate- and neuromelanin levels, and structural brain changes.

ANTICIPATED RESULTS

We hypothesize that add-on memantine to amisulpride will be superior to amisulpride monotherapy in reducing negative symptoms, and that this effect will correlate with thalamic glutamate levels. Moreover, we anticipate that add-on memantine will restore regional white matter integrity and improve cognitive functioning.

PERSPECTIVES

By combining two licensed, off-patent drugs, AMEND aims to optimize treatment of psychosis while investigating the memantine response. Alongside, AMEND will provide neurobiological insights to effects of dual receptor modulation, which may enable future stratification of patients with first-episode psychosis before initial antipsychotic treatment.

CLINICAL TRIAL REGISTRATION

[ClinicalTrials.gov], identifier [NCT04789915].

The Effect of Therapeutic Alliance on Attitudes Toward Psychiatric Medications in Schizophrenia

PURPOSE/BACKGROUND

The differential influence of therapeutic alliance with different health care professionals on patients' medication adherence has never been examined.

METHODS/PROCEDURES

Ninety-five stable outpatients (91 patients with schizophrenia and 4 patients with schizoaffective disorder) were recruited. Individual, clinical, and medication factors were assessed, along with drug attitude (10-item Drug Attitude Inventory). Comparison on these factors was made between outpatients who identified psychiatrists as the health care professional most involved in their care, as compared with other health care professionals.

FINDINGS/RESULTS

Older age, longer duration of illness, presence of medical comorbidities, lower levels of internalized stigma, higher levels of insight, higher levels of functioning, lesser severity of depressive symptoms, and positive symptoms were found to be significantly associated with greater levels of drug attitude (small to moderate associations). Only therapeutic alliance had a large correlation with drug attitude (ρ = 0.503, P < 0.001). The therapeutic alliance scores between the 2 health care professionals groups are not significantly different. However, participants who have identified psychiatrists as the health care professional that contributed the most to their recovery reported a significantly more positive attitude (μ = 6.18, SD = 3.42) toward psychiatric medication as compared with the other health care professionals group (μ = 3.11, SD = 5.32, P = 0.004). Only 2 factors, the Revised Helping Alliance Questionnaire (β = 0.424, P < 0.001) and Personal and Social Performance scale (β = 0.272, P = 0.006), were statistically significant predictors of drug attitude.

IMPLICATIONS/CONCLUSIONS

Therapeutic alliance is found to be the lead factor associated with drug attitude in patients with schizophrenia. Identifying psychiatrists as the health care professional most involved in the patients' recovery can greatly increase patients' drug attitudes. Maintaining individuals' functioning also contributes to drug attitude.

Consistency checks to improve measurement with the Personal and Social Performance Scale (PSP)

International Society for CNS Clinical Trials and Methodology convened an expert Working Group that assembled consistency/inconsistency flags for the Personal and Social Performance Scale (PSP). One hundred and forty seven flags were identified, 16 flag errors in deriving the PSP decile (i.e., total) score from the four individual domain scores, 74 flag inconsistencies between domain scores relative to Positive and Negative Symptom Scale (PANSS) item ratings and 57 flag inconsistencies between PSP decile score and PANSS items ratings. The flags were applied to assessments from randomized clinical trial data of antipsychotics in schizophrenia from almost 18,000 ratings. Twenty-two flags were raised in at least 5 of 1000 ratings. Nearly 20% of the PSP ratings had at least one inconsistency flag raised. Application of flags to clinical ratings may improve the reliability of ratings and validity of trials.

Defining Occupational Competence and Occupational Identity in the Context of Recovery in Schizophrenia

IMPORTANCE

The Occupational Self Assessment (OSA) measures two constructs from the Model of Human Occupation: occupational competence and occupational identity. In the field of mental health, the recovery movement has sparked discussions about what constitutes personal, clinical, and functional recovery. However, how occupation-based terminologies are related to the recovery framework is unclear.

OBJECTIVE

To elucidate how domains of recovery and psychological constructs are related to the OSA's constructs of occupational competence and occupational identity in order to inform occupational therapy practice in the recovery arena.

DESIGN

Cross-sectional study.

SETTING

Outpatient mental health unit.

PARTICIPANTS

Sixty-six community-dwelling adults with schizophrenia recruited through convenience sampling.

OUTCOMES AND MEASURES

Participants completed the OSA and clinical, functional, and personal recovery assessments. They also completed five scales that measured psychological constructs of recovery such as hope, resilience, empowerment, internalized stigma, and subjective well-being. Participants also identified up to four OSA items that were priorities for change. Tests of association and multiple regression analyses were conducted to identify predictors of occupational competence and occupational identity.

RESULTS

Personal recovery predicted occupational competence, whereas depressive symptoms and hope predicted occupational identity. Functional and clinical recovery did not predict occupational competence. The top three OSA priorities for change were performance items: "managing my finances," "concentrating on my tasks," and "taking care of myself."

CONCLUSIONS AND RELEVANCE

Occupational therapy interventions should not be limited to functional improvement. Instead, they should account for clients' affective states and seek to instill recovery-oriented psychological states such as hope and efficacy.

WHAT THIS ARTICLE ADDS

Occupational competence is achieved by enhancing personal states of self-efficacy in fulfilling valued occupations rather than through functional improvement. The top three occupations prioritized for change were performance tasks that were observable by service users and immediate caregivers. Empowering clients to partake in these everyday performance tasks such as finance management, concentrating on tasks, and self-care may pave the way to enhancing occupational competence and identity.

Duration of untreated psychosis and response to treatment: an analysis of response in the OPTiMiSE cohort

Some, but not all, studies have found longer duration of untreated psychosis (DUP) to be associated with poor response to treatment and more severe negative symptoms in schizophrenia. The aim of the current analysis was to investigate these parameters in a large cohort of patients in their first psychotic episode. The OPTiMiSE cohort included 446 patients with DUP up to two years, who were administered amisulpride for 4 weeks (Phase I). Patients who did not meet Andreasen remission criteria were randomized to double-blind continuation of amisulpride or olanzapine for 6 additional weeks in a blinded study (Phase II). Analyses showed that shorter DUP was associated with lower baseline CGI scores (p<0.001, r = 0.184), PANSS total (p = 0.025, r = 0.106) and PANSS negative subscale scores (p = 0.023, r = 0.107). Remitters had a significantly shorter mean DUP compared to non-remitters both in Phase I (24.5 weeks ±24.3 vs. 35 weeks ± 32.2, p = 0.01, t=-2.521) and in Phase II (24.3 weeks ± 26.4 vs. 38.3 weeks ± 31.3, p = 0.031, t=-2.194). Logistic regression analyses showed a significant effect of DUP on treatment response both in phase I (p = 0.008) and phase II (p = 0.041). Linear regression analyses found that DUP significantly affects PANSS Total change at the end of phase I (p = 0.028) but not at the end of phase II (p = 0.236). Based on these findings, it is possible to conclude that shorter DUP is associated with better response to treatment, particularly during the first weeks after treatment initiation. These findings highlight the need for early identification of the first psychotic episode.

An Asian study on clinical and psychological factors associated with personal recovery in people with psychosis

BACKGROUND

Despite the rising recognition of personal recovery, there is a lack of research on personal recovery in individuals with psychosis in Singapore. This study aims to evaluate the psychometric properties of the QPR-15 using the CHIME personal recovery framework and to examine its associations with clinical recovery factors.

METHODS

Sixty-six stable outpatients were recruited and assessed at two time points approximately 2 weeks apart. Convergent validity was examined through Spearman correlations with scores on CHIME-related psychological factors: connectedness (Ryff subscale- positive relations with others), hope (Herth Hope Index- abbreviated), identity (Ryff subscale- self-acceptance, Internalized Stigma of Mental Illness- Brief), meaning (World Health Organization Quality of Life Assessment-Brief Form), empowerment (Empowerment Scale). Pearson's correlation was used to examine the test-retest reliability, while Cronbach's alpha was used to examine internal consistency. The initial factor structure was evaluated via principal component analysis, Velicer's minimum average partial (MAP) criteria, parallel analysis, and a scree plot. Spearman correlations and hierarchical multiple linear regression (controlling for age and gender) were employed to examine the association of clinical (symptoms and functioning) and psychological factors with the QPR-15.

RESULTS

The QPR-15 demonstrated convergent validity with all CHIME-related psychological factors (r_s ranged from 0.472 to 0.687). Internal consistency was excellent (Cronbach's alpha = 0.934), and test-retest reliability was adequate (r = 0.708). Initial factor structure evaluations revealed a one-factor model. Correlations of clinical factors with the QPR-15 were mostly low (r_s ranged from - 0.105 to - 0.544) but significant, except for depressive symptoms (CDSS: r_s = - 0.529 to - 0.544), while correlations were moderate for psychological factors. Clinical factors significantly explained 28.3-31.8% of the variance of the QPR-15. Adding psychological factors significantly increased the model variance at baseline (∆ adjusted R² = 0.369, F change < 0.001) and at time point 2 (∆ adjusted R² = 0.208, F change < 0.001).

CONCLUSION

Our results provide preliminary evidence that the QPR-15 has adequate psychometric properties in Singapore and encompasses the CHIME personal recovery framework. In addition, our results suggest that clinical recovery and personal recovery are not substitutes for each other but rather are complementary, thereby promoting a more holistic evaluation of recovery in people with psychosis. Implications are discussed.

Systematic review of global functioning and quality of life in people with psychotic disorders

AimsPeople with psychotic disorders face impairments in their global functioning and their quality of life (QoL). The relationship between the two outcomes has not been systematically investigated. Through a systematic review, we aim to explore the presence and extent of associations between global functioning and QoL and establish whether associations depend on the instruments employed.

METHODS

In May 2016, ten electronic databases were searched using a two-phase process to identify articles in which associations between global functioning and QoL were assessed. Basic descriptive data and correlation coefficients between global functioning and QoL instruments were extracted, with the strength of the correlation assessed according to the specifications of Cohen 1988. Results were reported with reference to the Meta-analysis of Observational Studies in Epidemiology guidelines and PRISMA standards. A narrative synthesis was performed due to heterogeneity in methodological approaches.

RESULTS

Of an initial 15 183 non-duplicate articles identified, 756 were deemed potentially relevant, with 40 studies encompassing 42 articles included. Fourteen instruments for measuring global functioning and 22 instruments for measuring QoL were used. Twenty-nine articles reported linear associations while 19 assessed QoL predictors. Correlations between overall scores varied in strength, primarily dependent on the QoL instrument employed, and whether QoL was objectively or subjectively assessed. Correlations observed for objective QoL measures were consistently larger than those observed for subjective measures, as were correlations for an interviewer than self-assessed QoL. When correlations were assessed by domains of QoL, the highest correlations were found for social domains of QoL, for which most correlations were moderate or higher. Global functioning consistently predicted overall QoL as did depressive and negative symptoms.

CONCLUSIONS

This review is the first to explore the extent of associations between global functioning and QoL in people with psychotic disorders. We consistently found a positive association between global functioning and QoL. The strength of the association was dependent on the QoL instrument employed. QoL domains strongly associated with global functioning were highlighted. The review illustrates the extensive array of instruments used for the assessment of QoL and to a lesser extent global functioning in people with psychotic disorders and provides a framework to understand the different findings reported in the literature. The findings can also inform the future choice of instruments by researchers and/or clinicians. The observed associations reassure that interventions for improving global functioning will have a positive impact on the QoL of people living with a psychotic disorder.

Functional remission in schizophrenia: A FROGS-based definition and its convergent validity

Functional remission concerns only one third of schizophrenia patients who achieved symptomatic remission. We previously developed a scale devoted to functional remission, named the FROGS (Functional Remission Of General Schizophrenia). This instrument encompasses three clinically relevant dimensions. The aim of this study is to provide a threshold for functional remission relying on these three dimensions, and to compare its psychometric properties with other scales devoted to functional remission. We tested the characteristics of functional remission according to the FROGS. The FROGS was used in different European countries and compared to other valid scales (GAF, PSP and PSRS) in a sample of 295 schizophrenia patients. The association with different parameters as external validators was assessed, including clinical remission. A comparison of the classifying properties of each scale compared to the others was made. The four instruments were equally influenced by the PANSS score, the clinical remission according Andreassen's criteria, the number of past hospitalizations and the presence of a paid working activity. These findings provide a simple threshold for the FROGS, tightly linked to the definition of functional remission, with a good convergent validity. This instrument might be easily used to facilitate the assessment of functional remission in schizophrenia.

Actissist: Proof-of-Concept Trial of a Theory-Driven Digital Intervention for Psychosis

BACKGROUND

Timely access to intervention for psychosis is crucial yet problematic. As such, health care providers are forming digital strategies for addressing mental health challenges. A theory-driven digital intervention that monitors distressing experiences and provides real-time active management strategies could improve the speed and quality of recovery in psychosis, over and above conventional treatments. This study assesses the feasibility and acceptability of Actissist, a digital health intervention grounded in the cognitive model of psychosis that targets key early psychosis domains.

METHODS

A proof-of-concept, single, blind, randomized controlled trial of Actissist, compared to a symptom-monitoring control. Thirty-six early psychosis patients were randomized on a 2:1 ratio to each arm of the trial. Actissist was delivered via a smartphone app over 12-weeks; clinical and functional assessment time-points were baseline, post-treatment and 22-weeks. Assessors' blind to treatment condition conducted the assessments. Acceptability was examined using qualitative methods.

RESULTS

Actissist was feasible (75% participants used Actissist at least once/day; uptake was high, 97% participants remained in the trial; high follow-up rates), acceptable (90% participants recommend Actissist), and safe (0 serious adverse events), with high levels of user satisfaction. Treatment effects were large on negative symptoms, general psychotic symptoms and mood. The addition of Actissist conferred benefit at post-treatment assessment over routine symptom-monitoring and treatment as usual.

CONCLUSIONS

This is the first controlled proof-of-concept trial of a theory-driven digital health intervention for early psychosis. Actissist is feasible and acceptable to early psychosis patients, with a strong signal for treatment efficacy. Trial Registration: ISRCTN: 34966555.

Self-Reported Graphic Personal and Social Performance Scale (SRG-PSP) for measuring functionality in patients with bipolar disorder

OBJECTIVES

The self-reported graphic version of the Personal and Social Performance Scale (SRG-PSP) is the first graphic, self-reported rating scale that assesses functioning, and its reliability and validity have been documented in patients with schizophrenia. This study investigated the validity of SRG-PSP in patients with bipolar disorder (BD).

METHODS

Patients with BD were recruited from psychiatric outpatient clinics, and assessed with the Young Mania Rating Scale (YMRS), the Montgomery-Åsberg Depression Rating Scale (MADRS), the Clinical Global Impression Scale (CGI)-Bipolar and CGI-Depression, the Positive and Negative Symptom Scale (PANSS), the Global assessment of function (GAF), and the PSP. All participants completed the self-rating questionnaires: the SRG-PSP, the 36-Item Short-Form Health Survey (SF-36), and the Sheehan disability Scale (SDS).

RESULTS

In total, 114 patients with BD were enrolled. The criterion-related validities between the SRG-PSP and the PSP were all significantly correlated with their counterparts. The global score of the SRG-PSP was significantly correlated with the scores of the YMRS, MADRS, PANSS, CGI-Depression, GAF, SF-36, and SDS. Three SRG-PSP domains (socially useful activities, personal and social relationships, and self-care) were negatively correlated with the scores of the MADRS, PANSS, CGI-depression, and SDS; and were positively correlated with the GAF, SF-36 scores. The disturbing and aggressive behavior domain was positively correlated with the scores of the YMRS, MADRS, PANSS, CGI-Bipolar, CGI-Depression, and SDS; and was negatively correlated with the GAF, SF-36 scores (all p<0.01).

CONCLUSION

The SRG-PSP is a validated self-reported scale for assessing functionality in patients with BD.

Effect on return to work or education of Individual Placement and Support modified for people with mood and anxiety disorders: results of a randomised clinical trial

OBJECTIVES

The effect of Individual Placement and Support (IPS) on return to work or education among people with mood or anxiety disorders is unclear, while IPS increases return to work for people with severe mental illness. We examined the effect of IPS modified for people with mood and anxiety disorders (IPS-MA) on return to work and education compared with services as usual (SAU).

METHODS

In a randomised clinical superiority trial, 326 participants with mood and anxiety disorders were centrally randomised to IPS-MA, consisting of individual mentor support and career counselling (n=162) or SAU (n=164). The primary outcome was competitive employment or education at 24 months, while weeks of competitive employment or education, illness symptoms and level of functioning, and well-being were secondary outcomes.

RESULTS

After 24 months, 44.4% (72/162) of the participants receiving IPS-MA had returned to work or education compared with 37.8% (62/164) following SAU (OR=1.34, 95% CI: 0.86 to 2.10, p=0.20). We found no difference in mean number of weeks in employment or education (IPS-MA 32.4 weeks vs SAU 26.7 weeks, p=0.14), level of depression (Hamilton Depression 6-Item Scale score IPS-MA 5.7 points vs SAU 5.0 points, p=0.12), level of anxiety (Hamilton Anxiety 6-Item Scale score IPS-MA 5.8 points vs SAU 5.1 points, p=0.17), level of functioning (Global Assessment of Functioning IPS-MA 59.1 points vs SAU 59.5 points, p=0.81) or well-being measured by WHO-Five Well-being Index (IPS-MA 49.6 points vs SAU 48.5 points, p=0.83) at 24 months.

CONCLUSION

The modified version of IPS, IPS-MA, was not superior to SAU in supporting people with mood or anxiety disorders in return to work at 24 months.

TRIAL REGISTRATION NUMBER

NCT01721824.

A systematic review of clinician-rated instruments to assess adults' levels of functioning in specialised public sector mental health services

BACKGROUND

Functioning is one of the key domains emphasised in the routine assessment of outcomes that has been occurring in specialised public sector mental health services across Australia since 2002, via the National Outcomes and Casemix Collection. For adult consumers (aged 18-64), the 16-item Life Skills Profile (LSP-16) has been the instrument of choice to measure functioning. However, review of the National Outcomes and Casemix Collection protocol has highlighted some limitations to the current approach to measuring functioning. A systematic review was conducted to identify, against a set of pre-determined criteria, the most suitable existing clinician-rated instruments for the routine measurement of functioning for adult consumers.

METHOD

We used two existing reviews of functioning measures as our starting point and conducted a search of MEDLINE and PsycINFO to identify articles relating to additional clinician-rated instruments. We evaluated identified instruments using a hierarchical, criterion-based approach. The criteria were as follows: (1) is brief (<50 items) and simple to score, (2) is not made redundant by more recent instruments, (3) relevant version has been scientifically scrutinised, (4) considers functioning in a contemporary way and (5) demonstrates sound psychometric properties.

RESULTS

We identified 20 relevant instruments, 5 of which met our criteria: the LSP-16, the Health of the Nation Outcome Scales, the Illness Management and Recovery Scale-Clinician Version, the Multnomah Community Ability Scale and the Personal and Social Performance Scale.

CONCLUSION

Further work is required to determine which, if any, of these instruments satisfy further criteria relating to their appropriateness for assessing functioning within relevant service contexts, acceptability to clinicians and consumers, and feasibility in routine practice. This should involve seeking stakeholders' opinions (e.g. about the specific domains of functioning covered by each instrument and the language used in individual items) and testing completion rates in busy service settings.

Minimal detectable change of the Personal and Social Performance scale in individuals with schizophrenia

The minimal detectable change (MDC) of the Personal and Social Performance scale (PSP) has not yet been investigated, limiting its utility in data interpretation. The purpose of this study was to determine the MDCs of the PSP administered by the same rater or different raters in individuals with schizophrenia. Participants with schizophrenia were recruited from two psychiatric community rehabilitation centers to complete the PSP assessments twice, 2 weeks apart, by the same rater or 2 different raters. MDC values were calculated from the coefficients of intra- and inter-rater reliability (i.e., intraclass correlation coefficients). Forty patients (mean age 36.9 years, SD 9.7) from one center participated in the intra-rater reliability study. Another 40 patients (mean age 44.3 years, SD 11.1) from the other center participated in the inter-rater study. The MDCs (MDC%) of the PSP were 10.7 (17.1%) for the same rater and 16.2 (24.1%) for different raters. The MDCs of the PSP appeared appropriate for clinical trials aiming to determine whether a real change in social functioning has occurred in people with schizophrenia.

Usability of a novel digital medicine system in adults with schizophrenia treated with sensor-embedded tablets of aripiprazole

OBJECTIVE

Digital medicine system (DMS) is a novel drug-device combination that objectively measures and reports medication ingestion. The DMS consists of medication embedded with an ingestible sensor (digital medicine), a wearable sensor, and software applications. This study evaluated usability of the DMS in adults with schizophrenia rated by both patients and their health care providers (HCPs) during 8-week treatment with prescribed doses of digital aripiprazole.

METHODS

Six US sites enrolled outpatients into this Phase IIa, open-label study (NCT02219009). The study comprised a screening phase, a training phase (three weekly site visits), and a 5-week independent phase. Patients and HCPs independently rated usability of and satisfaction with the DMS.

RESULTS

Sixty-seven patients were enrolled, and 49 (73.1%) patients completed the study. The mean age (SD) of the patients was 46.6 years (9.7 years); the majority of them were male (74.6%), black (76.1%), and rated mildly ill on the Clinical Global Impression - Severity scale (70.1%). By the end of week 8 or early termination, 82.1% (55/67) of patients had replaced the wearable sensor independently or with minimal assistance, based on HCP rating. The patients used the wearable sensor for a mean (SD) of 70.7% (24.7%) and a median of 77.8% of their time in the trial. The patients contacted a call center most frequently at week 1. At the last visit, 78% (47/60) of patients were somewhat satisfied/satisfied/extremely satisfied with the DMS.

CONCLUSION

A high proportion of patients with schizophrenia were able to use the DMS and reported satisfaction with the DMS. These data support the potential utility of the DMS in clinical practice.

The longitudinal trends in the relationship between drug-induced extrapyramidal symptoms and personal and social performance in a population of the patients with schizophrenia: A latent growth model

The aim of this study was to explore the longitudinal trends in the relationship between personal and social functioning and drug-induced extrapyramidal symptoms (DIEPS). The baseline sample included 484 patients with schizophrenia. Participants were assessed at baseline, weeks 4 (time 2), 8 (time 3), and 12 (time 4) regarding social functioning, and DIEPS. In latent growth analysis, the path coefficient between the intercept for the DIEPSS and the intercept for the PSP indicated a significant cross-sectional relationship between these two variables. And the path coefficient between the intercept of the DIEPSS and the slope of the PSP was also significant, indicating that patients who initially had more serious side effects tended to exhibit less improvement in their personal and social functioning over time. Similarly, a significant path coefficient between the slopes of the two variables indicated a dynamic and possibly reciprocal association over time. In addition, K-PSP scale showed good construct validity and reliability. Based on the standardized PSP scale, our results demonstrate DIEPSS induced by antipsychotic treatment dynamically affect personal and social functioning over time, a negative association between psychosocial aspects and the DIEPS.

Risperidone (depot) for schizophrenia

BACKGROUND

Risperidone is the first new generation antipsychotic drug made available in a long-acting injection formulation.

OBJECTIVES

To examine the effects of depot risperidone for treatment of schizophrenia or related psychoses in comparison with placebo, no treatment or other antipsychotic medication.To critically appraise and summarise current evidence on the resource use, cost and cost-effectiveness of risperidone (depot) for schizophrenia.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Register (December 2002, 2012, and October 28, 2015). We also checked the references of all included studies, and contacted industry and authors of included studies.

SELECTION CRITERIA

Randomised clinical trials comparing depot risperidone with other treatments for people with schizophrenia and/or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed trial quality and extracted data. For dichotomous data, we calculated the risk ratio (RR), with 95% confidence interval (CI). For continuous data, we calculated mean differences (MD). We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE.

MAIN RESULTS

Twelve studies, with a total of 5723 participants were randomised to the following comparison treatments: Risperidone depot versus placebo Outcomes of relapse and improvement in mental state were neither measured or reported. In terms of other primary outcomes, more people receiving placebo left the study early by 12 weeks (1 RCT, n=400, RR 0.74 95% CI 0.63 to 0.88, very low quality evidence), experienced severe adverse events in short term (1 RCT, n=400, RR 0.59 95% CI 0.38 to 0.93, very low quality evidence). There was however, no difference in levels of weight gain between groups (1 RCT, n=400, RR 2.11 95% CI 0.48 to 9.18, very low quality evidence). Risperidone depot versus general oral antipsychotics The outcome of improvement in mental state was not presented due to high levels of attrition, nor were levels of severe adverse events explicitly reported. Most primary outcomes of interest showed no difference between treatment groups. However, more people receiving depot risperidone experienced nervous system disorders (long-term:1 RCT, n=369, RR 1.34 95% CI 1.13 to 1.58, very-low quality evidence). Risperidone depot versus oral risperidoneData for relapse and severe adverse events were not reported. All outcomes of interest were rated as moderate quality evidence. Main results showed no differences between treatment groups with equivocal data for change in mental state, numbers leaving the study early, any extrapyramidal symptoms, weight increase and prolactin-related adverse events. Risperidone depot versus oral quetiapine Relapse rates and improvement in mental state were not reported. Fewer people receiving risperidone depot left the study early (long-term: 1 RCT, n=666, RR 0.84 95% CI 0.74 to 0.95, moderate quality evidence). Experience of serious adverse events was similar between groups (low quality evidence), but more people receiving depot risperidone experienced EPS (1 RCT, n=666, RR 1.83 95% CI 1.07 to 3.15, low quality evidence), had greater weight gain (1 RCT, n=666, RR 1.25 95% CI 0.25 to 2.25, low quality evidence) and more prolactin-related adverse events (1 RCT, n=666, RR 3.07 95% CI 1.13 to 8.36, very low quality evidence). Risperidone depot versus oral aripiprazoleRelapse rates, mental state using PANSS, leaving the study early, serious adverse events and weight increase were similar between groups. However more people receiving depot risperidone experienced prolactin-related adverse events compared to those receiving oral aripiprazole (2 RCTs, n=729, RR 9.91 95% CI 2.78 to 35.29, very low quality of evidence). Risperidone depot versus oral olanzapineRelapse rates were not reported in any of the included studies for this comparison. Improvement in mental state using PANSS and instances of severe adverse events were similar between groups. More people receiving depot risperidone left the study early than those receiving oral olanzapine (1 RCT, n=618, RR 1.32 95% CI 1.10 to 1.58, low quality evidence) with those receiving risperidone depot also experiencing more extrapyramidal symptoms (1 RCT, n=547, RR 1.67 95% CI 1.19 to 2.36, low quality evidence). However, more people receiving oral olanzapine experienced weight increase (1 RCT, n=547, RR 0.56 95% CI 0.42 to 0.75, low quality evidence). Risperidone depot versus atypical depot antipsychotics (specifically paliperidone palmitate)Relapse rates were not reported and rates of response using PANSS, weight increase, prolactin-related adverse events and glucose-related adverse events were similar between groups. Fewer people left the study early due to lack of efficacy from the risperidone depot group (long term: 1 RCT, n=749, RR 0.60 95% CI 0.45 to 0.81, low quality evidence), but more people receiving depot risperidone required use of EPS-medication (2 RCTs, n=1666, RR 1.46 95% CI 1.18 to 1.8, moderate quality evidence). Risperidone depot versus typical depot antipsychoticsOutcomes of relapse, severe adverse events or movement disorders were not reported. Outcomes relating to improvement in mental state demonstrated no difference between groups (low quality evidence). However, more people receiving depot risperidone compared to other typical depots left the study early (long-term:1 RCT, n=62, RR 3.05 95% CI 1.12 to 8.31, low quality evidence).

AUTHORS' CONCLUSIONS

Depot risperidone may be more acceptable than placebo injection but it is hard to know if it is any more effective in controlling the symptoms of schizophrenia. The active drug, especially higher doses, may be associated with more movement disorders than placebo. People already stabilised on oral risperidone may continue to maintain benefit if treated with depot risperidone and avoid the need to take tablets, at least in the short term. In people who are happy to take oral medication the depot risperidone is approximately equal to oral risperidone. It is possible that the depot formulation, however, can bring a second-generation antipsychotic to people who do not reliably adhere to treatment. People with schizophrenia who have difficulty adhering to treatment, however, are unlikely to volunteer for a clinical trial. Such people may gain benefit from the depot risperidone with no increased risk of extrapyramidal side effects.

The impact of psychotic disorders and co-morbid substance abuse on vocational rehabilitation: results from an Australian national survey of psychosis

Introduction

It is unclear from prior research whether or not substance abuse co-morbid with psychosis is an added barrier to success in vocational rehabilitation. The aim of this study was to examine the relationships among three types of co-morbid substance abuse or dependence, by type of employment assistance received (disability employment services, mainstream unemployment services, other government programmes, and own resources), and by type of employment attained (competitive and non-competitive).

Method

Data were drawn from the Australian National Survey of High Impact Psychosis ( N = 1825). The survey was conducted in seven Australian catchment areas March to December 2010. Descriptive statistics and logistic regression methods were used.

Results

There were no added effects of lifetime substance abuse or dependence on any employment. However, there were some minor substance-specific effects. Past year cannabis use was negatively associated, while alcohol use was positively associated with being employed. All categories of lifetime substance abuse or dependence were associated with reduced utilisation of intensive forms of employment assistance.

Conclusion

At a population level, lifetime substance abuse or dependence had no added impact on current employment status. Those with psychosis co-morbid with lifetime substance abuse or dependence could benefit from greater utilisation of evidence-based supported employment.

Cognitive impairment in schizophrenia: the great unmet need

Cognitive impairment in schizophrenia is present in almost all persons with the disorder and can be a substantial obstacle to efforts in the recovery process. In clinical research, cognition is assessed through neuropsychological testing as well as by different types of structured instruments focusing on function. Although nonpharmacological interventions such as cognitive remediation have been therapeutic, particularly in combination with vocational rehabilitation and supported employment, these modalities are not always easy to access. Pharmacological interventions are in development and have principally focused on the dopamine, glutamate, and acetylcholine neurotransmitter systems, aiming to target the dorsolateral prefrontal cortex and its interactions with other brain regions.

The development of a self-reported scale for measuring functionality in patients with schizophrenia--self-reported version of the graphic Personal and Social Performance (SRG-PSP) scale

BACKGROUND

The Personal and Social Performance (PSP) scale is used for the assessment of patient function by mental health professionals. This study aimed to evaluate the internal reliability and validity of a self-reported graphic version of the PSP (SRG-PSP) scale and its correlations with psychiatric symptoms, daily life ability and quality of life.

METHODS

The SRG-PSP scale was developed following the four PSP domains: socially useful activities, personal and social relationships, self-care, and disturbing and aggressive behavior. In total, 108 patients with schizophrenia were enrolled. All participants completed the SRG-PSP, the Activities of Daily Living Rating Scale II (ADLRS-II), and the World Health Organization Quality of Life-BREF (WHOQOL). They were also assessed using the PSP and the Positive and Negative Syndrome Scale (PANSS). Spearman's ρ was used to examine the correlations between SRG-PSP scores and other variables.

RESULTS

The results of the SRG-PSP were significantly correlated to those of their corresponding criteria on the PSP. The global score of the SRG-PSP and the scores of three domains, socially useful activities, personal and social relationships, and self-care, were positively correlated with most sub items of the ADLRS-II and WHOQOL, and were negatively correlated with the PANSS scores. The disturbing and aggressive behavior domain of the SRG-PSP was negatively correlated with most sub items of the ADLRS-II and WHOQOL (ρ=-0.19 to -0.36, all p<0.05) and positively correlated with the PANSS (ρ=0.24-0.30, all p<0.05), with the exception of negative symptoms (ρ=0.09, p=0.40).

CONCLUSION

The SRG-PSP is a valid self-reported scale for the assessment of functionality in patients with schizophrenia.

A comparison of thought and perception disorders in borderline personality disorder and schizophrenia: psychotic experiences as a reaction to impaired social functioning

BACKGROUND

Although previous studies suggest a high frequency of psychotic symptoms in DSM-IV Borderline Personality Disorder (BPD) there is currently no consensus on their prevalence and characteristics (type, frequency, duration, location etc.). Similarly, there are few papers addressing psychotic reactivity, the crucial aspect of BPD included in the ninth criterion for DSM-IV BPD, which remained unchanged in DSM-IV-TR and DSM-5. The purposes of the present study were to compare thought and perception disorders in patients with DSM-IV BPD and schizophrenia (SC), investigating their relationship with social functioning.

METHODS

Thought and perception disorders and social functioning over the previous two years were assessed by the Diagnostic Interview for Borderline Revised (DIB-R) and Personal and Social Performance scale (PSP) respectively in outpatients with DSM-IV BPD (n = 28) or DSM-IV SC (n = 28).

RESULTS

Quasi-psychotic thought (i.e. transient, circumscribed and atypical psychotic experiences) was more frequent in BPD (BPD = 82.1%, SC = 50%, p = 0.024); whereas true psychotic thought (i.e. Schneiderian first-rank, prolonged, widespread and bizarre psychotic symptoms) was more frequent in SC (SC = 100%, BPD = 46.4%, p < 0.001). However both types of psychotic features were prevalent in both groups. Non-delusional paranoia (e.g. undue suspiciousness and ideas of references) was ubiquitous but was more severe in BPD than SC patients (U(54) = 203.5, p = 0.001). In the BPD group there was a strong negative correlation between personal and social functioning and non-delusional paranoia (τ(28) = 0.544, p = 0.002) and level of personal and social functioning was a significant predictor of the severity of non-delusional paranoia only in the BPD group (β = -0.16, t(23) = 2.90, p = 0.008).

CONCLUSIONS

BPD patients reported less severe psychotic experiences with more frequent quasi-psychotic thought, less frequent true psychotic thought and more severe non-delusional paranoia than SC patients. Interpersonal functioning seems to predict non-delusional paranoia in BPD, which would validate the "stress-related paranoid ideation", included in the ninth diagnostic criterion for DSM-IV and DSM-5 BPD. PBD patients had higher scores on the psychotic experiences subscale that support the use of a dimensional assessment of the severity of thought and perception disorders, for example the Clinician-Rated Dimensions of Psychosis Symptom Severity introduced in DSM-5, Section III.

Obsessive-compulsive symptoms in at-risk mental states for psychosis: associations with clinical impairment and cognitive function

OBJECTIVE

Obsessive-compulsive symptoms (OCS) constitute a major comorbidity in schizophrenia. Prevalence estimations of OCS for patients with at-risk mental states (ARMS) for psychosis vary largely. It is unclear how ARMS patients with or without comorbid OCS differ regarding general psychosocial functioning, psychotic and affective symptoms and neurocognitive abilities.

METHOD

At-risk mental states patients (n = 233) from the interventional trial PREVENT (Secondary Prevention of Schizophrenia) were stratified according to the presence or absence of comorbid OCS and compared on several clinical variables.

RESULTS

Patients, who fulfilled the criteria for obsessive-compulsive disorder (OCD) or presented with subclinical OCS (ARMSposOCS sample), did not significantly differ from patients without OCS (ARMSnegOCS) with regard to gender, age, premorbid verbal intelligence and levels of education. Furthermore, similar severity of depressive syndromes, basic cognitive, attenuated psychotic and brief limited intermittent psychotic symptoms were found. However, ARMSposOCS patients showed more impairment of psychosocial functioning and higher general psychopathology. In contrast, they scored higher in cognitive tasks measuring working memory and immediate verbal memory.

CONCLUSION

Findings extend upon previous results due to the multidimensional assessment. Subsequent longitudinal studies might elucidate how comorbid OCS influence differential treatment response, especially to cognitive behavioural interventions and the transition rates to psychosis.

Towards a framework for treatment effectiveness in schizophrenia

INTRODUCTION

Prompt administration of antipsychotic treatment that is adhered to is essential for the optimal treatment of schizophrenia. Many patients have benefited from the advent of second-generation antipsychotics, which can offer good symptomatic control with reduced incidence of extrapyramidal symptoms, although with higher risk of metabolic side effects. It is unsurprising that accounts as to whether first- and second-generation antipsychotics differ in their efficacy vary, since treatment effectiveness is a broad notion and difficult to define.

OBJECTIVES

Numerous factors may be used to gauge treatment effectiveness and, while it has largely been defined in terms of improvements in four domains (symptoms of disease, treatment burden, disease burden, and health and wellness), the real-world clinical utility of this consensus is unclear. Therefore, this article aims to provide a framework that can aid psychiatrists in making assessments about treatment effectiveness.

METHODS AND RESULTS

A panel of 12 psychiatrists and psychopharmacologists convened to develop and propose an accessible and globally-applicable framework for assessing the effectiveness of antipsychotic treatments in patients with schizophrenia. Following presentation of a preliminary proposal to a wider group of psychiatrists from across Europe, it was refined into a framework comprising five domains: symptomatic remission and retention of treatment; affective symptoms; cognitive functioning; treatment satisfaction; and personal and social functioning - each of which is discussed in this article.

CONCLUSIONS

This article provides a framework that can aid psychiatrists in making assessments about treatment effectiveness. It is anticipated that the framework outlined here may contribute to improving clinical practice through the promotion of a patient-centered approach to the assessment of treatment effectiveness, using five specified domains, in patients with schizophrenia.

The effect of IPS-modified, an early intervention for people with mood and anxiety disorders: study protocol for a randomised clinical superiority trial

BACKGROUND

Anxiety and affective disorders can be disabling and have a major impact on the ability to work. In Denmark, people with a mental disorder, and mainly non-psychotic disorders, represent a substantial and increasing part of those receiving disability pensions. Previous studies have indicated that Individual Placement and Support (IPS) has a positive effect on employment when provided to people with severe mental illness. This modified IPS intervention is aimed at supporting people with recently diagnosed anxiety or affective disorders in regaining their ability to work and facilitate their return to work or education.

AIM

To investigate whether an early modified IPS intervention has an effect on employment and education when provided to people with recently diagnosed anxiety or affective disorders in a Danish context.

METHODS/DESIGN

The trial is a randomised, assessor-blinded, clinical superiority trial of an early modified IPS intervention in addition to treatment-as-usual compared to treatment-as-usual alone for 324 participants diagnosed with an affective disorder or anxiety disorder living in the Capital Region of Denmark. The primary outcome is competitive employment or education at 24 months. Secondary outcomes are days of competitive employment or education, illness symptoms and level of functioning including quality of life at follow-up 12 and 24 months after baseline.

DISCUSSION

If the modified IPS intervention is shown to be superior to treatment-as-usual, a larger number of disability pensions can probably be avoided and long-term sickness absences reduced, with major benefits to society and patients. This trial will add to the evidence of how best to support people's return to employment or education after a psychiatric disorder.

TRIAL REGISTRATION

NCT01721824.