The relative contribution of neurocognition and social cognition to 6-month vocational outcomes following Individual Placement and Support in first-episode psychosis

The use of implementation science to close the research-to-treatment gap for cognitive impairment in psychosis

For people living with psychosis, cognitive impairment is common and can have significant impacts for functional recovery, impacting engagement with treatment and quality of life more broadly. There is now strong evidence for the effectiveness of cognition-focused treatments, such as cognitive remediation to improve clinical and functional outcomes for people with psychosis. However, engagement with treatment has been a long-standing issue in mental health care, including for people with psychosis, who often experience difficulties with motivation. While research on clinical effectiveness of cognition-focused treatment is growing, to date there has been little research focused on the implementation of such treatments and it is not clear how best to support uptake and engagement across diverse mental health settings. Implementation science is the study of methods and strategies to promote the adoption, application, and maintenance of evidence-based practices in routine care. To integrate cognition-focused treatments into routine practice, and improve engagement with treatment and the quality and effectiveness of care for people with psychosis, researchers need to embrace implementation science and research. This paper provides a succinct overview of the field of implementation science, current evidence for implementation of cognition-focused treatments for psychosis and practical guidance for using implementation science in clinical research. The future of psychosis research includes multidisciplinary teams of clinical researchers and implementation scientists, working together with providers and consumers to build the evidence that can improve the implementation of cognition-focused treatments.

Effect of combining motivational interviewing with cognitive remediation on personal recovery in patients with schizophrenia

Background/objective

We have been practising the Neuropsychological and Educational Approach to Remediation (NEAR) as cognitive remediation (CR) in a psychiatric hospital and have implemented it in combination with regular interviews based on Motivational Interviewing (MI) approximately 2 years after launching NEAR. In this study, we investigated whether combining MI with CR affected completion of the programme, cognitive functions, global functioning, and personal recovery of patients with schizophrenia by analysing medical records.

Methods

In this retrospective observational study, 14 participants were assigned to the NEAR group and 12 participants were assigned to the NEAR + MI group. Fifteen participants in the NEAR group (n = 6) and NEAR + MI group (n = 9) completed the programme. First, the difference in the completion rate between the groups was examined using the chi-squared test. Second, measures of cognitive functions, global functioning, and personal recovery pre-and post-intervention were examined using the Wilcoxon signed-rank tests for those in each group who completed the programme. Third, therapeutic responses for each group were compared using the Mann-Whitney U tests.

Results

There were no statistically significant differences in completion rates between the groups. In the NEAR group, verbal memory and overall cognition improved after the intervention. On the other hand, not only cognitive functions but also global functioning and personal recovery improved in the NEAR + MI group. Moreover, changes in global functioning and personal recovery were significantly higher in the NEAR + MI group.

Conclusion

Study findings indicated that combining MI with CR improves cognitive functions, global functioning, and personal recovery in patients with schizophrenia.

A Scoping and Systematic Review of Employment Processes and Outcomes for Young Adults Experiencing Psychosis

Young adults who experience psychosis want to work but are less likely to be employed than their peers. Sixty two studies relating to young adults with psychosis and employment were reviewed following a systematic search of five databases: CINAHL, PsycINFO, MEDLINE, SCOPUS and EMBASE. Publication date ranged from 1973 to 2019 with > 70% between 2010 and 2019. Intervention was considered in 29 papers; critical appraisal revealed 90% of these had moderate to good methodological quality with only three RCTs. Of 11 intervention types "Early Intervention" and "Individual Placement and Support" were most common; both demonstrating positive impact on obtaining employment. The review identified minimal participant perspectives and great variability in: terminology used; the reporting of participant attributes; intervention characteristics and ways employment outcomes were measured. Employment processes identified were preparing for, seeking, obtaining, keeping and re-obtaining employment, with current research efforts focused on obtaining work. More focus is required on keeping and re-obtaining employment.

Minds@Work: A New Manualized Intervention to Improve Job Tenure in Psychosis Based on Scoping Review and Logic Model

Introduction A significant proportion of people experiencing psychosis are unemployed, despite a strong desire to work. Current supported employment programs appear effective in helping them obtain employment, yet job tenure remains an arduous challenge. The objective of this study was to review the literature and model the results to inform the development of a new manualized group psychosocial intervention-'Minds@Work'-aimed specifically at improving job tenure in psychosis. Methods The study was registered on the Open Science Framework platform ( https://osf.io/he68z ). The literature was searched in Medline, Embase, PsycInfo and Cochrane Library databases for studies examining predictors of job tenure in psychosis and existing occupational psychosocial interventions. Data were extracted using a pre-established form and synthesized using logic models. Results A total of 94 studies were included and their findings were modeled using different categories: intervention typologies, mechanisms of action, predictors of job tenure, outcomes and contextual factors. The 'Minds@Work' program was built based on these modeled findings and aimed to target specific predictors of job tenure while addressing some of the limitations of existing interventions. The program uses evidence-based techniques and is divided into 9 modules covering 4 themes: positive psychology (motivation, character strengths, self-compassion), neurocognitive remediation (attention, memory, problem-solving), cognitive biases training (jumping to conclusions, defeatists beliefs, theory of mind, attributional styles) and socioemotional coping skills (emotion regulation, communication). Conclusions Once validated, this new program is meant to be used either as a stand-alone intervention or integrated in supported employment initiatives, by employment specialists or healthcare workers.

Cognitive Dysfunction as a Risk Factor for Psychosis

The current chapter summarizes recent evidence for cognition as a risk factor for the development of psychosis, including the range of cognitive impairments that exist across the spectrum of psychosis risk symptoms. The chapter examines several possible theories linking cognitive deficits with the development of psychotic symptoms, including evidence that cognitive deficits may be an intermediate risk factor linking genetic and/or neural metrics to psychosis spectrum symptoms. Although there is not strong evidence for unique cognitive markers associated specifically with psychosis compared to other forms of psychopathology, psychotic disorders are generally associated with the greatest severity of cognitive deficits. Cognitive deficits precede the development of psychotic symptoms and may be detectable as early as childhood. Across the psychosis spectrum, both the presence and severity of psychotic symptoms are associated with mild to moderate impairments across cognitive domains, perhaps most consistently for language, cognitive control, and working memory domains. Research generally indicates the size of these cognitive impairments worsens as psychosis symptom severity increases. The chapter points out areas of unclarity and unanswered questions in each of these areas, including regarding the mechanisms contributing to the association between cognition and psychosis, the timing of deficits, and whether any cognitive systems can be identified that function as specific predictors of psychosis risk symptoms.

Evaluating Educational and Employment Services for Young People With Psychiatric Conditions: A Systematic Review

OBJECTIVE

The authors conducted a systematic review of studies evaluating vocational interventions for young people with psychiatric conditions to determine the extent to which services were adapted for young people and whether services promoted gains in postsecondary education and employment.

METHODS

Five databases (PubMed, PsycINFO, Web of Science, Academic Search Premier, and ERIC) were searched. Sources eligible for inclusion were controlled studies published between 2000 and mid-2020 that evaluated a vocational intervention and examined postsecondary educational or employment outcomes for youths or young adults (ages 14-35 years) with psychiatric conditions.

RESULTS

Ten studies met the inclusion criteria. Several of the studies evaluated services that were adapted for young people, including through the incorporation of educational supports. The most consistent finding was that services based on the individual placement and support (IPS) model improved employment outcomes more effectively than did comparison approaches and treatment as usual. Fewer studies assessed educational outcomes, and they yielded mixed results; however, recent findings from a controlled trial indicate that an enhanced IPS intervention that included well-specified supported education and skills training led to significantly superior outcomes in both education and employment.

CONCLUSIONS

These results provide support for the efficacy of IPS-based services to improve employment outcomes among young people with psychiatric conditions and suggest that adapting IPS to include comprehensive educational supports and skills training may be important for efforts to improve postsecondary educational outcomes. Additional well-controlled intervention studies that examine educational and longer-term outcomes should further inform the development and delivery of vocational services for this population.

Digital technology for addressing cognitive impairment in recent-onset psychosis: A perspective

Cognitive impairments in psychosis negatively impact functional recovery and quality of life. Existing interventions for improving cognitive impairment in recent-onset psychosis show inconsistent treatment efficacy, small effects, suboptimal engagement and limited generalizability to daily life functioning. In this perspective we explore how digital technology has the potential to address these limitations in order to improve cognitive and functional outcomes in recent-onset psychosis. Computer programs can be used for standardized, automated delivery of cognitive remediation training. Virtual reality provides the opportunity for learning and practicing cognitive skills in real-world scenarios within a virtual environment. Smartphone apps could be used for notification reminders for everyday tasks to compensate for cognitive difficulties. Internet-based technologies can offer psychoeducation and training materials for enhancing cognitive skills. Early findings indicate some forms of digital interventions for cognitive enhancement can be effective, with well-established evidence for human-supported computer-based cognitive remediation in recent-onset psychosis. Emerging evidence regarding virtual reality is favorable for improving social cognition. Overall, blending digital interventions with human support improves engagement and effectiveness. Despite the potential of digital interventions for enhancing cognition in recent-onset psychosis, few studies have been conducted to date. Implementation challenges affecting application of digital technologies for cognitive impairment in recent-onset psychosis are sustained engagement, clinical integration, and lack of quality in the commercial marketplace. Future opportunities lie in including motivational frameworks and behavioral change interventions, increasing service engagement in young people and lived experience involvement in digital intervention development.

Impact of cognitive remediation on the prediction of employment outcomes in severe mental illness

OBJECTIVE

Cognitive functioning is a potent predictor of work in people with a severe mental illness, including those receiving vocational services. Cognitive remediation has been shown to improve cognitive functioning and work outcomes in people receiving vocational services. However, it is unknown whether it reduces the strength of cognitive functioning as a predictor of work outcomes compared to people receiving vocational services alone.

METHOD

Data were pooled from five randomized controlled trials evaluating the effects of adding cognitive remediation to vocational rehabilitation vs. vocational services alone. A battery of baseline cognitive functioning measures was examined to identify predictors of competitive work outcomes over the following two years. Study condition (i.e., receipt of cognitive remediation) was included in the analyses to evaluate whether cognitive functioning was a weaker predictor of work outcomes in people receiving cognitive remediation compared to those receiving vocational services alone.

RESULTS

Cognitive functioning was a stronger predictor of wages earned and weeks worked in participants receiving vocational services alone than those who also received cognitive remediation. Cognitive functioning did not predict job acquisition in either study condition.

CONCLUSION

Cognitive remediation may improve employment outcomes in people receiving vocational services in part by reducing the adverse effects of impaired cognitive functioning on work performance.

Neuropsychological predictors of vocational rehabilitation outcomes in individuals with major depression: A scoping review

BACKGROUND

Major depression is one of the leading causes of disability and limited capacity to work. Neuropsychological impairment is a common symptom in acute and remitted major depression and is associated with poor psychosocial functioning. This scoping review aimed to identify research on the role of neuropsychological functioning in outcomes of vocational rehabilitation programs in individuals with depression.

METHODS

We report on the conduct of this pre-registered (https://osf.io/5yrnf) scoping review in accordance with PRISMA-ScR guidelines. PubMed and PsychInfo were systematically searched for English or German research articles published between 1990 and September 2021 that studied objective neuropsychological tests as predictors of vocational rehabilitation interventions and included participants with depression.

RESULTS

The systematic literature search yielded no studies that specifically targeted subjects with major depression. However, eight articles published since 2016 were included in the review, analyzing data from five trials that evaluated the effectiveness of supported employment in North America and Europe in severe mental illnesses. An estimated 31% of the total number of participants included (n = 3,533) had major depression. Using a variety of cognitive tests and covariates, seven articles found that neuropsychological functioning - especially global cognition scores, verbal and visual learning and memory - significantly predicted vocational outcomes of rehabilitation programs.

CONCLUSION

Despite a lack of studies specifically targeting major depressive disorder, the identified literature suggests that higher baseline neuropsychological functioning predicts better vocational outcomes of supported employment programs in individuals with depression. In clinical practice, additional neuropsychological modules during return-to-work interventions might be helpful for vocational outcomes of such programs.

Quality of life in first episode psychosis: a cluster analytic approach

PURPOSE

Quality of life is increasingly recognised as an important outcome for young people with first episode psychosis (FEP). The first aim was to determine whether distinct homogenous subgroups of young people with FEP could be delineated based on profiles on quality of life domains (Physical Health, Psychological, Social relationships and Environmental). The second aim was to examine the discriminant validity of these subgroups with respect to demographic, functioning and clinical features of FEP.

METHOD

Quality of life, demographic characteristics, clinical characteristics, cognition and functioning were assessed in 145 people with FEP. Cluster analysis using Ward's methods and Squared Euclidean Distance with a k-means verification were employed to identify subgroups with homogenous quality of life profiles. The clusters were externally validated using multinomial logistic regressions.

RESULTS

Three distinct quality of life profiles were identified: one with good quality of life across all domains (30%), one with poor quality of life particularly in Psychological and Social relationships domains (28%), and one 'intermediate' group with comparatively low Psychological quality of life (42%). Depression, semantic verbal fluency, social inclusion and social/occupational functioning showed associations with group membership.

CONCLUSION

Our results suggest the potential of maintaining relatively good quality of life despite the experience of FEP. Future research on interventions to improve quality of life may consider the potential of addressing depression, social inclusion and social/occupational functioning.

Cognitive Predictors of Social and Occupational Functioning in Early Psychosis: A Systematic Review and Meta-analysis of Cross-Sectional and Longitudinal Data

Many individuals with early psychosis experience impairments in social and occupational function. Identification of modifiable predictors of function such as cognitive performance has the potential to inform effective treatments. Our aim was to estimate the strength of the relationship between psychosocial function in early psychosis and different domains of cognitive and social cognitive performance. We conducted a systematic review and meta-analysis of peer-reviewed, cross-sectional, and longitudinal studies examining cognitive predictors of psychosocial function. Literature searches were conducted in PsycINFO, PubMed, and reference lists of relevant articles to identify studies for inclusion. Of the 2565 identified, 46 studies comprising 3767 participants met inclusion criteria. Separate meta-analyses were conducted for 9 cognitive domains. Pearson correlation values between cognitive variables and function were extracted. All cognitive domains were related to psychosocial function both cross-sectionally and longitudinally. Importantly, these associations remained significant even after the effects of symptom severity, duration of untreated psychosis, and length of illness were accounted for. Overall, general cognitive ability and social cognition were most strongly associated with both concurrent and long-term function. Associations demonstrated medium effect sizes. These findings suggest that treatments targeting cognitive deficits, in particular those focusing on social cognition, are likely to be important for improving functional outcomes in early psychosis.

Employment programmes for schizophrenia and other severe mental illness in psychosocial rehabilitation: a systematic review

Introduction

Employment programmes for people with mental illness vary widely in range, but nonetheless all share the same objectives of restoring or initiating vocational roles to promote recovery in psychosocial rehabilitation. The current interventions available usually focus on the specific vocational outcomes of the intervention rather than focusing holistically on the client’s needs.

Method

This review aimed to examine the effectiveness of intervention programmes and determine the best intervention for schizophrenia and other severe mental illness, considering both vocational and non-vocational outcomes. Searching five databases – CINAHL, Medline via Ovid, Scopus, OT Seeker and Web of Science – a total of 3108 studies was identified; 24 met the selection criteria and were reviewed. Interventions were categorised into five major programmes of supported employment, integrated supported employment, vocational rehabilitation, cognitive intervention and virtual reality-based vocational training.

Results

Integrated supported employment was found to be the most effective approach for a vocational outcome. However, evidence concerning non-vocational outcomes of employment programmes and the use of cognitive training remains unclear.

Conclusion

Clinicians are advised to consider the needs and preferences of the client before selecting the best intervention programme. More research is needed to determine the applicability and the efficacy of intervention programmes.

Long-Term Effects of the Individual Placement and Support Intervention on Employment Status: 6-Year Follow-Up of a Randomized Controlled Trial

People with mental illness often experience difficulties with reintegration into the workplace, although employment is known to assist these individuals in their recovery process. Traditional approaches of "first train, then place" have been recently replaced by supported employment (SE) methods that carry strategy of "first place, then train." Individual placement and support (IPS) is one of the best-studied methods of SE, which core principles are individualized assistance in rapid job search with consequent placement in a paid employment position. A considerable amount of high-quality evidence supported the superiority of IPS over conventional methods in providing improved employment rates, longer job tenure, as well as higher salaries in competitive job markets. Nonetheless, our knowledge about the IPS-mediated long-term effects is limited. This non-interventional follow-up study of a previously published randomized controlled trial (RCT) called ZhEPP aimed to understand the long-term impact of IPS after 6 years since the initial intervention. Participants from the ZhEPP trial, where 250 disability pensioners with mental illnesses were randomized into either IPS intervention group or treatment as usual group (TAU), were invited to face-to-face interviews, during which employment status, job tenure, workload, and salaries were assessed. One hundred and fourteen individuals agreed to participate in this follow-up study. Although during the first 2 years post-intervention, the IPS group had higher employment rates (40% (IPS) vs. 28% (TAU), p < 0.05 at 24 months), these differences disappeared by the time of follow-up assessments (72 months). The results indicated no substantial differences in primary outcome measures between IPS and TAU groups: employment rate (36 vs. 33%), workload (10.57 vs. 10.07 h per week), job tenure (29 vs. 28 months), and salary (20.21CHF vs. 25.02 CHF). These findings provide important insights regarding the long-term effects of IPS among individuals with mental health illnesses. Further research is required to advance the current knowledge about IPS intervention and its years-long impact.

Verbal memory measurement towards digital perspectives in first-episode psychosis: A review

BACKGROUND

Even in the early phases of psychotic spectrum illnesses such as schizophrenia, patients can experience cognitive decline or deficits prior to the onset of psychotic symptoms such as delusions and hallucinations. In this systematic review, we assessed which verbal memory assessments are most widely used in first-episode psychosis and may be applied via digital technologies (smartphone applications, etc.) for use in early detection.

METHODS

In November 2019, we searched for studies measuring verbal memory in first episode psychosis or schizophrenia over the past 10 years on PubMed and PsycINFO. We screened abstracts of these studies and excluded review studies. Full-texts of included studies were used to identify the verbal memory measurement tests, follow-up frequencies, and sample sizes.

RESULTS

We screened 233 reports and found that 120 original research studies measured verbal memory in first episode psychosis over the past 10 years. Four of these studies specified using a computer, 24 (20%) used a paper-pen format, 1(1%) used both, and 91 (76%) studies did not specify their administration tools or suggest there were offered in digital formats. Thirty-five (30%) studies had follow-up measurements of verbal memory, while 85 (70%) had only a single verbal memory measurement.

DISCUSSION

While many scales are commonly used to measure verbal memory in first episode psychosis, they are not often administered via digital technology. There is an emerging opportunity to administer these and other tests via digital technologies for expanding access to early detection of cognitive decline in clinical high risk and first-episode psychosis.

Social cognition in patients with first episode of psychosis in remission

AIM

The present study aimed to compare the social cognition (SC) deficits in patients with first-episode psychosis (FEP) and healthy controls and evaluate the association of SC deficits with socio-occupational functioning, insight, quality of life, and stigma.

METHODS

This study included 30 patients with FEP in remission phase and 26 healthy controls matched for age, gender, education, and intelligent quotient. SC was assessed on the domains of theory of mind (ToM), social perception, and attributional bias.

RESULTS

Compared to healthy controls, patients with FEP had significantly higher deficits in the domains of second-order ToM (unpaired t = 4.447, P < 0.001) and Faux Pas Composite Index (unpaired t = 2.824, P = 0.007). In the correlation analysis, higher age of patients with FEP was significantly associated with more externalizing bias (Pearson's correlation coefficient = 0.38, P = 0.039) and those with lower level of education had more social cognitive deficits in the domains of Faux Pas Composite Index (Pearson's correlation coefficient = 0.43, P = 0.018), Social Perception Index (Pearson's correlation coefficient = 0.38, P = 0.04), and Nonsocial Perception Index (Pearson's correlation coefficient = 0.5, P = 0.005). Duration of untreated psychosis was associated with higher deficits in the first-order ToM (Pearson's correlation coefficient = -0.38, P = 0.04) and Externalizing Bias Index (Pearson's correlation coefficient = -0.49, P = 0.006). Longer duration of treatment was associated with higher impairment in first-order ToM index (Pearson's correlation coefficient = -0.42, P = 0.02). General psychopathology and total Positive and Negative Syndrome Scale total score correlated significantly with externalizing bias, with a higher level of psychopathology associated with more severe deficits in this domain. There was no correlation of SC with the quality of life, cognitive insight, and stigma (except for occasional correlation of stereotype endorsement and externalizing bias).

CONCLUSION

The present study suggests that compared to healthy controls, patients with FEP have impairment in the domains of second-order ToM and Faux Pas Composite Index. However, social cognitive deficits have only a few correlations with various psychosocial outcomes of FEP.

Psychological interventions for psychosis in adolescents

BACKGROUND

Psychosis is an illness characterised by alterations in thoughts and perceptions resulting in delusions and hallucinations. Psychosis is rare in adolescents but can have serious consequences. Antipsychotic medications are the mainstay treatment, and have been shown to be effective. However, there is emerging evidence on psychological interventions such as cognitive remediation therapy, psycho-education, family therapy and group psychotherapy that may be useful for adolescents with psychosis.

OBJECTIVES

To assess the effects of various psychological interventions for adolescents with psychosis.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's study-based Register of Trials including clinical trials registries (latest, 8 March 2019).

SELECTION CRITERIA

All randomised controlled trials comparing various psychological interventions with treatment-as-usual or other psychological treatments for adolescents with psychosis. For analyses, we included trials meeting our inclusion criteria and reporting useable data.

DATA COLLECTION AND ANALYSIS

We independently and reliably screened studies and we assessed risk of bias of the included studies. For dichotomous data, we calculated risk ratios (RRs) and 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous data, we used mean differences (MDs) and the 95% CIs. We used a random-effects model for analyses. We created a 'Summary of findings' table using GRADE.

MAIN RESULTS

The current review includes 7 studies (n = 319) assessing a heterogenous group of psychological interventions with variable risk of bias. Adverse events were not reported by any of the studies. None of the studies was sponsored by industry. Below, we summarise the main results from four of six comparisons, and the certainty of these results (based on GRADE). All scale scores are average endpoint scores. Cognitive Remediation Therapy (CRT) + Treatment-as-Usual (TAU) versus TAU Two studies compared adding CRT to participants' TAU with TAU alone. Global state (CGAS, high = good) was reported by one study. There was no clear difference between treatment groups (MD -4.90, 95% CI -11.05 to 1.25; participants = 50; studies = 1, very low-certainty). Mental state (PANSS, high = poor) was reported by one study. Scores were clearly lower in the TAU group (MD 8.30, 95% CI 0.46 to 16.14; participants = 50; studies = 1; very low-certainty). Clearly more participants in the CRT group showed improvement in cognitive functioning (Memory digit span test) compared to numbers showing improvement in the TAU group (1 study, n = 31, RR 0.58, 95% CI 0.37 to 0.89; very low-certainty). For global functioning (VABS, high = good), our analysis of reported scores showed no clear difference between treatment groups (MD 5.90, 95% CI -3.03 to 14.83; participants = 50; studies = 1; very low-certainty). The number of participants leaving the study early from each group was similar (RR 0.93, 95% CI 0.32 to 2.71; participants = 91; studies = 2; low-certainty). Group Psychosocial Therapy (GPT) + TAU versus TAU One study assessed the effects of adding GPT to participants' usual medication. Global state scores (CGAS, high = good) were clearly higher in the GPT group (MD 5.10, 95% CI 1.35 to 8.85; participants = 56; studies = 1; very low-certainty) but there was little or no clear difference between groups for mental state scores (PANSS, high = poor, MD -4.10, 95% CI -8.28 to 0.08; participants = 56; studies = 1, very low-certainty) and no clear difference between groups for numbers of participants leaving the study early (RR 0.43, 95% CI 0.15 to 1.28; participants = 56; studies = 1; very low-certainty). Cognitive Remediation Programme (CRP) + Psychoeducational Treatment Programme (PTP) versus PTP One study assessed the effects of combining two types psychological interventions (CRP + PTP) with PTP alone. Global state scores (GAS, high = good) were not clearly different (MD 1.60, 95% CI -6.48 to 9.68; participants = 25; studies = 1; very low-certainty), as were mental state scores (BPRS total, high = poor, MD -5.40, 95% CI -16.42 to 5.62; participants = 24; studies = 1; very low-certainty), and cognitive functioning scores (SPAN-12, high = good, MD 2.40, 95% CI -2.67 to 7.47; participants = 25; studies = 1; very low-certainty). Psychoeducational (PE) + Multifamily Treatment (MFT) Versus Nonstructured Group Therapy (NSGT, all long-term) One study compared (PE + MFT) with NSGT. Analysis of reported global state scores (CGAS, high = good, MD 3.38, 95% CI -4.87 to 11.63; participants = 49; studies = 1; very low-certainty) and mental state scores (PANSS total, high = poor, MD -8.23, 95% CI -17.51 to 1.05; participants = 49; studies = 1; very low-certainty) showed no clear differences. The number of participants needing hospital admission (RR 0.84, 95% CI 0.36 to 1.96; participants = 49; studies = 1) and the number of participants leaving the study early from each group were also similar (RR 0.52, 95% CI 0.10 to 2.60; participants = 55; studies = 1; low-certainty).

AUTHORS' CONCLUSIONS

Most of our estimates of effect for our main outcomes are equivocal. An effect is suggested for only four outcomes in the SOF tables presented. Compared to TAU, CRT may have a positive effect on cognitive functioning, however the same study reports data suggesting TAU may have positive effect on mental state. Another study comparing GPT with TAU reports data suggesting GPT may have a positive effect on global state. However, the estimate of effects for all the main outcomes in our review should be viewed with considerable caution as they are based on data from a small number of studies with variable risk of bias. Further data could change these results and larger and better quality studies are needed before any firm conclusions regarding the effects of psychological interventions for adolescents with psychosis can be made.

An Integrative Review of the Barriers to Job Acquisition for People With Severe Mental Illnesses

This integrative review analyses and synthesizes specialized literature of 20 years up to 2017 studying barriers/obstacles to employment for people with severe mental illnesses. The inclusion and exclusion criteria led to 35 experimental and nonexperimental studies. Results of the prospective studies were analyzed with the evidence synthesis method to isolate the most salient obstacles. Six main themes emerged from the findings, grouped into personal and environmental barriers. Environmental barriers were related to disability benefits and other physical resources, to stigma and social support, and to vocational services. Individual barriers included those related to illness, to work experience and skills, and to self-perception, fears, and motivation. The most prominent obstacles are lack of work experience and lack of use of effective strategies toward employment. Systematically identifying barriers to employment for people with severe mental illnesses will enable employment specialists to better support their clients in overcoming them, thus facilitating their work integration.

Contribution of neurocognition to 18-month employment outcomes in first-episode psychosis

AIM

To examine whether baseline neurocognition predicts vocational outcomes over 18 months in patients with first-episode psychosis enrolled in a randomized controlled trial of Individual Placement and Support or treatment as usual.

METHODS

One-hundred and thirty-four first-episode psychosis participants completed an extensive neurocognitive battery. Principal axis factor analysis using PROMAX rotation was used to determine the underlying structure of the battery. Setwise (hierarchical) multiple linear and logistic regressions were used to examine predictors of (1) total hours employed over 18 months and (2) employment status, respectively. Neurocognition factors were entered in the models after accounting for age, gender, premorbid IQ, negative symptoms, treatment group allocation and employment status at baseline.

RESULTS

Five neurocognitive factors were extracted: (1) processing speed, (2) verbal learning and memory, (3) knowledge and reasoning, (4) attention and working memory and (5) visual organization and memory. Employment status over 18 months was not significantly predicted by any of the predictors in the final model. Total hours employed over 18 months were significantly predicted by gender (P = .027), negative symptoms (P = .032) and verbal learning and memory (P = .040). Every step of the regression model was a significant predictor of total hours worked overall (final model: P = .013).

CONCLUSION

Verbal learning and memory, negative symptoms and gender were implicated in duration of employment in first-episode psychosis. The other neurocognitive domains did not significantly contribute to the prediction of vocational outcomes over 18 months. Interventions targeting verbal memory may improve vocational outcomes in early psychosis.

Psychopathology, cognition and outcome in Dutch and immigrant first-episode psychosis patients

AIM

The primary aim was to examine differences in baseline symptom expression, neurocognition, social cognition and psychosocial functioning between Dutch, first-generation immigrants and second-generation immigrants with a first-episode psychosis (FEP). The secondary aim was to examine functional and symptomatic change and between-group differences at 12-months follow-up. Associations between migration, baseline characteristics and outcome were explored.

METHODS

Forty-six Dutch, 56 second-generation- and 60 first-generation immigrant patients completed baseline measures for 6 symptom dimensions (positive symptoms, negative symptoms, neurocognitive functioning, social cognitive functioning, excitement and emotional distress) and 5 domains of psychosocial functioning (general functioning, work and study, relationships, self-care and disturbing behaviour). Functioning and psychotic symptoms were assessed at baseline and 12-months follow-up. ANCOVA and t tests were used to assess between-group differences. General linear models were used to explore within-group differences. Backward-regression was used to explore predictors of outcome.

RESULTS

Levels of positive symptoms, excitement and emotional distress did not differ between groups at baseline or follow-up. Dutch patients had lower levels of negative symptoms than both immigrant groups at follow-up. On neurocognition and social cognition, Dutch performed better than second-generation immigrants, who in turn performed better than first-generation immigrants. Psychosocial functioning across all domains at baseline and at 12-months follow-up was similar across groups. Baseline levels of general psychosocial functioning and income were the strongest predictors of outcome at follow-up.

CONCLUSIONS

Psychosocial functioning and symptom profiles are comparable between Dutch, first-generation immigrant and second-generation immigrant FEP patients, excluding neurocognitive and social cognitive deficits. A range of baseline characteristics predicted outcome.

Employment Rates in Flexible Assertive Community Treatment Teams in The Netherlands: An Observational Study

We determined the proportions of clients treated in Flexible Assertive Community Treatment teams who were unemployed and gained employment and who were employed and lost employment. Secondly, we explored the demographical and clinical factors associated with employment. Data were collected during routine outcome monitoring. We calculated differences in employment rates over a year and explored differences in demographic characteristics at baseline between patient groups. Logistic regression analysis was used to estimate the role of clinical predictor variables on employment status. Over time, 10% remained employed, 5% lost their employment, 3% gained employment and 82% remained unemployed. Clients who found employment were younger, more often male, and had significantly fewer psychosocial problems and a higher subjective quality of life during follow-up than those who remained unemployed. Problems with motivation for treatment at baseline were related to losing employment or remaining unemployed. Better implementation of vocational services is very important for increasing the number of clients gaining employment.

An examination of sex differences in neurocognition and social cognition in first-episode psychosis

Due to the dearth and conflicting findings of previous research, it is unclear whether males and females with first-episode psychosis (FEP) differ in their neurocognitive and social cognitive abilities. The aims of the current study were to investigate whether: (i) there are sex differences in neurocognition and social cognition among young people with FEP; and (ii) they resemble those observed in age-matched healthy controls. The current study involved secondary analysis of data from a previous study in which a large neurocognitive and social cognitive battery was administered to 146 individuals with FEP and 46 healthy controls aged 15-25 years. Seven two-way between-groups multivariate analysis of variances revealed that FEP participants were impaired relative to controls on all cognitive domains. Only one main effect of sex was found with males, regardless of group, outperforming females on verbal comprehension. A significant interaction effect was found for information processing speed with FEP females outperforming FEP males on the Symbol Digit Modalities Test; however, post-hoc analysis of the mean difference was not significant. Despite few sex differences, the current study highlights that cognitive impairment is a key feature of FEP that should be a treatment target in early intervention.

Interventions for obtaining and maintaining employment in adults with severe mental illness, a network meta-analysis

BACKGROUND

People with severe mental illness show high rates of unemployment and work disability, however, they often have a desire to participate in employment. People with severe mental illness used to be placed in sheltered employment or were enrolled in prevocational training to facilitate transition to a competitive job. Now, there are also interventions focusing on rapid search for a competitive job, with ongoing support to keep the job, known as supported employment. Recently, there has been a growing interest in combining supported employment with other prevocational or psychiatric interventions.

OBJECTIVES

To assess the comparative effectiveness of various types of vocational rehabilitation interventions and to rank these interventions according to their effectiveness to facilitate competitive employment in adults with severe mental illness.

SEARCH METHODS

In November 2016 we searched CENTRAL, MEDLINE, Embase, PsychINFO, and CINAHL, and reference lists of articles for randomised controlled trials and systematic reviews. We identified systematic reviews from which to extract randomised controlled trials.

SELECTION CRITERIA

We included randomised controlled trials and cluster-randomised controlled trials evaluating the effect of interventions on obtaining competitive employment for adults with severe mental illness. We included trials with competitive employment outcomes. The main intervention groups were prevocational training programmes, transitional employment interventions, supported employment, supported employment augmented with other specific interventions, and psychiatric care only.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials, performed data extraction, including adverse events, and assessed trial quality. We performed direct meta-analyses and a network meta-analysis including measurements of the surface under the cumulative ranking curve (SUCRA). We assessed the quality of the evidence for outcomes within the network meta-analysis according to GRADE.

MAIN RESULTS

We included 48 randomised controlled trials involving 8743 participants. Of these, 30 studied supported employment, 13 augmented supported employment, 17 prevocational training, and 6 transitional employment. Psychiatric care only was the control condition in 13 studies. Direct comparison meta-analysis of obtaining competitive employmentWe could include 18 trials with short-term follow-up in a direct meta-analysis (N = 2291) of the following comparisons. Supported employment was more effective than prevocational training (RR 2.52, 95% CI 1.21 to 5.24) and transitional employment (RR 3.49, 95% CI 1.77 to 6.89) and prevocational training was more effective than psychiatric care only (RR 8.96, 95% CI 1.77 to 45.51) in obtaining competitive employment.For the long-term follow-up direct meta-analysis, we could include 22 trials (N = 5233). Augmented supported employment (RR 4.32, 95% CI 1.49 to 12.48), supported employment (RR 1.51, 95% CI 1.36 to 1.68) and prevocational training (RR 2.19, 95% CI 1.07 to 4.46) were more effective than psychiatric care only. Augmented supported employment was more effective than supported employment (RR 1.94, 95% CI 1.03 to 3.65), transitional employment (RR 2.45, 95% CI 1.69 to 3.55) and prevocational training (RR 5.42, 95% CI 1.08 to 27.11). Supported employment was more effective than transitional employment (RR 3.28, 95% CI 2.13 to 5.04) and prevocational training (RR 2.31, 95% CI 1.85 to 2.89). Network meta-analysis of obtaining competitive employmentWe could include 22 trials with long-term follow-up in a network meta-analysis.Augmented supported employment was the most effective intervention versus psychiatric care only in obtaining competitive employment (RR 3.81, 95% CI 1.99 to 7.31, SUCRA 98.5, moderate-quality evidence), followed by supported employment (RR 2.72 95% CI 1.55 to 4.76; SUCRA 76.5, low-quality evidence).Prevocational training (RR 1.26, 95% CI 0.73 to 2.19; SUCRA 40.3, very low-quality evidence) and transitional employment were not considerably different from psychiatric care only (RR 1.00,95% CI 0.51 to 1.96; SUCRA 17.2, low-quality evidence) in achieving competitive employment, but prevocational training stood out in the SUCRA value and rank.Augmented supported employment was slightly better than supported employment, but not significantly (RR 1.40, 95% CI 0.92 to 2.14). The SUCRA value and mean rank were higher for augmented supported employment.The results of the network meta-analysis of the intervention subgroups favoured augmented supported employment interventions, but also cognitive training. However, supported employment augmented with symptom-related skills training showed the best results (RR compared to psychiatric care only 3.61 with 95% CI 1.03 to 12.63, SUCRA 80.3).We graded the quality of the evidence of the network ranking as very low because of potential risk of bias in the included studies, inconsistency and publication bias. Direct meta-analysis of maintaining competitive employment Based on the direct meta-analysis of the short-term follow-up of maintaining employment, supported employment was more effective than: psychiatric care only, transitional employment, prevocational training, and augmented supported employment.In the long-term follow-up direct meta-analysis, augmented supported employment was more effective than prevocational training (MD 22.79 weeks, 95% CI 15.96 to 29.62) and supported employment (MD 10.09, 95% CI 0.32 to 19.85) in maintaining competitive employment. Participants receiving supported employment worked more weeks than those receiving transitional employment (MD 17.36, 95% CI 11.53 to 23.18) or prevocational training (MD 11.56, 95% CI 5.99 to 17.13).We did not find differences between interventions in the risk of dropouts or hospital admissions.

AUTHORS' CONCLUSIONS

Supported employment and augmented supported employment were the most effective interventions for people with severe mental illness in terms of obtaining and maintaining employment, based on both the direct comparison analysis and the network meta-analysis, without increasing the risk of adverse events. These results are based on moderate- to low-quality evidence, meaning that future studies with lower risk of bias could change these results. Augmented supported employment may be slightly more effective compared to supported employment alone. However, this difference was small, based on the direct comparison analysis, and further decreased with the network meta-analysis meaning that this difference should be interpreted cautiously. More studies on maintaining competitive employment are needed to get a better understanding of whether the costs and efforts are worthwhile in the long term for both the individual and society.

Experimental variation of social stress in virtual reality - Feasibility and first results in patients with psychotic disorders

BACKGROUND AND OBJECTIVES

Social interaction might lead to increased stress levels in patients with psychotic disorders. Impaired social stress tolerance is critical for social functioning and closely linked with symptom relapse and hospitalization. We present an interactive office built-up in virtual reality (VR).

METHODS

Patients with psychotic disorders (PP, N = 26 including N = 5 dropouts) and matched healthy controls (HC, N = 20) were examined with a VR simulating an open-plan office. In a randomized, controlled cross-over design, participants were introduced to virtual co-workers (avatars) and requested to ask them for task assistance. Social feedback in each of the two sessions was either cooperative or rejective in randomized order.

RESULTS

The office environment was tolerable for most PP and all HC, five PP and none of the HC dropped out for any reason. Drop-outs reported simulator sickness, influence on thoughts and symptom exacerbations. Statistical trends indicated heightened paranoid ideations for PP after social rejection. State measures of paranoid ideations showed high convergent validity with conventional measures of delusions. Of note, measures of presence were higher for PP than for HC.

LIMITATIONS

The exploratory design limits the robustness of the findings. Only statistical trends on paranoid ideation were found.

CONCLUSION

The use of VR to assess the effects of social rejection is feasible and tolerable for most PP (87%). However, its implementation for PP is challenged by increased simulator sickness and an additional stress load for some patients. Further studies continuing on these first results that point towards an increased paranoid ideation evoked by negative social feedback and generally higher subjective presence are needed.

Social and academic premorbid adjustment domains predict different functional outcomes among youth with first episode mania

BACKGROUND

Premorbid characteristics may help predict the highly variable functional and illness outcomes of young people with early stage Bipolar Disorder (BD). We sought to examine the relationships between premorbid adjustment and short to medium-term outcomes after a first treated episode of mania.

METHODS

We examined the baseline and 18-month follow-up characteristics of 117 participants with first episode of mania, treated at two tertiary early intervention services in Melbourne, Australia. The baseline demographic, family history, diagnoses, comorbidity and clinical features were determined using unstructured questionnaires and structured diagnostic interviews. Premorbid adjustment was determined using the Premorbid Adjustment Scale (PAS), the components of which were identified using a principal component analysis. Eighteen-month follow-up outcome measures included the Clinical Global Impressions scale, Social and Occupational Functioning Assessment Scale and the Heinrichs' Quality of Life Scale (QLS). Correlations and linear regressions were utilised to examine the relationships between component scores and outcomes, while controlling for baseline and follow-up confounders.

RESULTS

The social adjustment component of the PAS correlated with the interpersonal relations (r_s = -0.46, p<0.001) domain of QLS while the academic adjustment component of the PAS correlated with the vocational functioning domain of QLS (r_s =-0.39, p = 0.004). Premorbid adjustment did not predict illness severity or objective functioning.

LIMITATIONS

Lack of information on cognition, personality factors and prodromal symptoms limited the assessment of their impact on outcomes.

CONCLUSIONS

Impairments in domains of premorbid adjustment may be early markers of persistent difficulties in social and vocational functioning and may benefit from targeted interventions.

Cognitive remediation and occupational outcome in schizophrenia spectrum disorders: A 2year follow-up study

Neurocognitive impairment is prominent in schizophrenia and a significant predictor of poor occupational outcomes. Vocational rehabilitation (VR) is frequently implemented to counteract high unemployment rates. Individuals with schizophrenia however face numerous challenges such as neurocognitive impairments and psychotic symptoms. Hence, augmenting VR to address illness-related factors may optimize occupational outcomes. The aim of this study was to examine the effects of Cognitive Remediation (CR) combined with VR(CR+VR) compared to techniques from Cognitive Behavioral Therapy (CBT) combined with VR(CBT+VR) on neurocognition and occupational functioning over a 2year period. A total of 131participants underwent assessment with the MATRICS Consensus Cognitive Battery (MCCB) at baseline, post treatment (after 10months) and follow-up (2years after randomization). Occupational status and number of hours worked were recorded at all assessment points. Both groups improved on several neurocognitive domains. All improvements were however in favor of the CR group. There was a significant increase in number of participants working and hours worked in both groups throughout the project period, with no between-group differences. Number of hours worked at follow-up was predicted by change in Working Memory and the Composite Score in the CR group. CR-augmented VR improved several domains, particularly Verbal Learning and Working Memory, which were central in the CR program. The combination of VR and CR or CBT thus enabled a significant proportion of participants to attain and maintain work.

Heritability of Neuropsychological Measures in Schizophrenia and Nonpsychiatric Populations: A Systematic Review and Meta-analysis

Schizophrenia is characterized by neuropsychological deficits across many cognitive domains. Cognitive phenotypes with high heritability and genetic overlap with schizophrenia liability can help elucidate the mechanisms leading from genes to psychopathology. We performed a meta-analysis of 170 published twin and family heritability studies of >800 000 nonpsychiatric and schizophrenia subjects to accurately estimate heritability across many neuropsychological tests and cognitive domains. The proportion of total variance of each phenotype due to additive genetic effects (A), shared environment (C), and unshared environment and error (E), was calculated by averaging A, C, and E estimates across studies and weighting by sample size. Heritability ranged across phenotypes, likely due to differences in genetic and environmental effects, with the highest heritability for General Cognitive Ability (32%-67%), Verbal Ability (43%-72%), Visuospatial Ability (20%-80%), and Attention/Processing Speed (28%-74%), while the lowest heritability was observed for Executive Function (20%-40%). These results confirm that many cognitive phenotypes are under strong genetic influences. Heritability estimates were comparable in nonpsychiatric and schizophrenia samples, suggesting that environmental factors and illness-related moderators (eg, medication) do not substantially decrease heritability in schizophrenia samples, and that genetic studies in schizophrenia samples are informative for elucidating the genetic basis of cognitive deficits. Substantial genetic overlap between cognitive phenotypes and schizophrenia liability (average rg = -.58) in twin studies supports partially shared genetic etiology. It will be important to conduct comparative studies in well-powered samples to determine whether the same or different genes and genetic variants influence cognition in schizophrenia patients and the general population.

Predictors of functional status at service entry and discharge among young people with first episode psychosis

OBJECTIVE

Most patients with first episode psychosis (FEP) are neither studying nor employed (have a poor functional status) when first accessing care. Knowledge of the characteristics of patients with poor functioning and the features influencing functional status over time may pave the way to better treatment.

METHOD

A medical file audit was used to collect data on premorbid, entry, treatment and 18-month outcome characteristics on 661 FEP patients who consecutively attended the Early Psychosis Prevention and Intervention Centre, Melbourne, Australia, between 1998 and 2000. Functional status was ascertained using the modified vocational status index and was rated at baseline (poor or good) and according to its evolution over the treatment period (stable good, stable poor, deteriorating or improved functional status).

RESULTS

52.0% of patients had a poor functional status at service entry. They were more likely to be male with a non-affective psychosis. They also had lower levels of premorbid global functioning and education, and were more likely to have self-reported histories of learning disability, forensic issues, traumatic experiences and substance use. At service entry, they had more severe symptoms and poorer global functioning. 37% of these patients maintained a poor functional status at discharge, and 18% of those with a good functional status at service entry experienced a decline.

CONCLUSIONS

Although psychosocial interventions might assist a young person with FEP with working towards functional goals, for some, the impact of factors such as ongoing substance use and forensic issues on functional status needs to be addressed.

Psychosocial functioning in first-episode psychosis and associations with neurocognition, social cognition, psychotic and affective symptoms

AIM

Most studies on the determinants of psychosocial functioning in first-episode psychosis used few predictors. This study examines the effects of multiple cognitive domains and multiple symptoms on psychosocial functioning.

METHODS

A total of 162 patients with a first-episode psychosis were assessed within 3 months after referral to an early psychosis treatment department. Four psychopathological subdomains (positive and negative symptoms, depression and anxiety) and five subdomains of psychosocial functioning (work/study, relationships, self-care, disturbing behaviour and general psychosocial functioning) were measured. Neurocognitive and social cognitive factors were identified through principal component analyses (PCA) of a 15-measure cognitive battery. Stepwise backward regression models were computed to identify the determinants of psychosocial functioning.

RESULTS

The three neurocognitive and four social cognitive factors identified through PCA were largely independent of psychopathology. The strongest associations were between cognitive factors and anxiety. Higher levels of negative symptoms, poor general neurocognition and poor general social cognition showed strongest associations with impaired psychosocial functioning, followed by low verbal processing speed and low emotion processing speed. Together, these factors accounted for 39.4% of the variance in psychosocial functioning.

CONCLUSIONS

The results suggest that negative symptoms, impaired neurocognition and poor social cognition are related to psychosocial problems in patients with first-episode psychosis. None of the affective or positive symptoms had a marked impact on psychosocial functioning.

Relationship between duration of untreated psychosis and neurocognition and social cognition in first-episode psychosis

Cognitive impairment is common in first-episode psychosis (FEP); however, the relationship between duration of untreated psychosis (DUP) and neurocognition remains controversial, and no studies have examined the relationship between DUP and social cognition. This study involved secondary data analysis of baseline data from a randomised controlled trial of supported employment; 122 out 146 young people with FEP met inclusion criteria for this study. Results showed that DUP was not associated with neurocognitive or social cognitive performance. Results do not provide support for the neurotoxicity hypothesis of psychosis.

Deficits of cognitive theory of mind and its relationship with functioning in individuals with an at-risk mental state and first-episode psychosis

Disturbance of theory of mind (ToM) and its relationship with functioning in schizophrenia is well documented; however, this is unclear in spectrum disorders like at-risk mental state (ARMS) and first-episode psychosis (FEP). To assess mental state reasoning ability, the total score of the Theory of Mind Picture Stories Task questionnaire was compared among 36 Japanese individuals with ARMS, 40 with FEP, and 25 healthy controls (HC). Pearson's correlations between ToM performance and global and social functioning indices were examined. ToM performance for FEP and ARMS subjects was significantly lower than that for HC, though the significance of the difference between the ARMS and HC disappeared when controlling for premorbid IQ. ToM deficits in ARMS subjects were confirmed only in the comprehension of higher-order false belief. Only among FEP subjects were ToM performance and global functioning significantly correlated, though the significance disappeared when controlling for neurocognitive performance or dose of antipsychotics. No significant correlation between ToM performance and social functioning was observed in the FEP and ARMS groups. The current findings suggest that ToM deficits emerge in ARMS subjects confined within a higher-order domain, and that the relationship between ToM impairment and functional deterioration might be established after psychosis onset.

Influence of cognition, premorbid adjustment and psychotic symptoms on psycho-social functioning in first-episode psychosis

OBJECTIVE

The aim of this study is to evaluate the relationship between psycho-social functioning and symptoms, cognitive function, and premorbid adjustment, in patients with a first-episode psychosis.

METHOD

Clinical data were obtained from 90 patients, who were assessed with the Disability Assessment Scale (DAS-sv), the Positive and Negative Syndrome Scale (PANSS), the Premorbid Adjustment Scale (PAS-S) and with a battery of cognitive tests including Trail Making Tests A and B (TMTA- B), Continous Performance Test (CPT), some subscales of the Wechler Adult Intelligence Scale (WAIS), and the Verbal Learning Test España-Complutense (TAVEC).

RESULTS

The results of the study suggest that psycho-social functioning in first-episode psychosis is significantly related to: positive, negative, excitative, affective and disorganized symptoms, social premorbid adjustment, cognitive flexibility, working memory, short term and long term memory. Of these, those which best explained psycho-social functioning are the positive and excitative symptoms, premorbid adjustment, flexibility and memory.

CONCLUSIONS

These findings highlight the importance early intervention on cognitive and clinical variables to help provide a better psycho-social functioning in people with a first-episode of psychosis.

Cognitive remediation for vocational rehabilitation nonresponders

Cognitive remediation in people with severe mental illnesses (SMI) that interfere with work, but less research has evaluated its effects in those who have not benefitted from vocational services. Participants with SMI (83% schizophrenia) who had not benefitted from vocational rehabilitation were randomized to vocational services enhanced by training vocational specialists in recognizing cognitive difficulties and providing job-relevant cognitive coping strategies (Enhanced Vocational Rehabilitation: E-VR), or similarly enhanced vocational services and cognitive remediation (Thinking Skills Work: TSW). Cognition and symptoms were assessed at baseline, post-treatment (9months), and follow-up (18months), with work tracked weekly for 3years. Fifty-four participants were randomized to E-VR (N=26) or TSW (N=28). Participants in TSW had high rates of exposure to the program (89%) and improved more than those in E-VR on cognitive functioning post-training, with attenuation of some gains at the 18-months. Participants in TSW and E-VR did not differ significantly in competitive work (57% vs. 48%) or paid employment (61% vs. 48%) over the 3-year study, although those in TSW were more likely to be engaged in any work activity, including paid or volunteer work (75% vs. 50%, p=0.057), and had more weeks of work activity (23.04 vs. 48.82, p=0.051), and improved marginally more on the clinical symptoms. The significantly higher education level of participants in E-VR than TSW at baseline may have obscured the effects of TSW. This study supports the feasibility and potential benefits of cognitive remediation for persons who have not benefited from vocational rehabilitation.

Examination of the Positive and Negative Syndrome Scale factor structure and longitudinal relationships with functioning in early psychosis

AIM

We examined the factor structure of the Positive and Negative Syndrome Scale (PANSS) in early-episode psychosis and its relationships with functioning at baseline and follow-up.

METHODS

A total of 240 consecutive admissions to an early intervention in psychosis clinic were assessed at intake to the program with the PANSS, Global Assessment of Functioning (GAF) and Social and Occupational Functioning Assessment Scale (SOFAS). Seventy individuals were reassessed at follow-up. A maximum likelihood factor analysis was conducted on baseline PANSS scores and the ability of each factor to predict baseline and follow-up GAF and SOFAS was examined.

RESULTS

A five-factor model with varimax rotation was the best fit to our data and was largely congruent with factors found previously. The negative symptom factor was the best predictor of GAF and SOFAS at baseline and follow-up.

CONCLUSION

Negative symptoms are the best symptomatic predictor of functioning in individuals with early psychosis and are an important treatment target to improve recovery.

Exploring cognitive heterogeneity in first-episode psychosis: What cluster analysis can reveal

Variable outcomes in first-episode psychosis (FEP) are partly attributable to heterogeneity in cognitive functioning. To aid identification of those likely to have poorer or better outcomes, we examined whether purported cognitive profiles identified through use of cluster analysis in chronic schizophrenia were evident in FEP. We also aimed to assess whether there was a relationship between cognitive profile and factors independent of the solution, providing external validation that the cognitive profiles represented distinct subgroups. Ward's method hierarchical cluster analysis, verified by a k-means cluster solution, was performed using data obtained from a cognitive test battery administered to 128 participants aged 15-25 years. Four cognitive profiles were identified. A continuity element was evident; participants in cluster four were more cognitively impaired compared to participants in cluster three, who appeared more cognitively intact. Clusters one and two were distinguishable across measures of attention and working memory and visual recognition memory, most likely reflecting sample specific patterns of deficit. Participants in cluster four had significantly lower premorbid and current IQ and higher negative symptoms compared to participants in cluster three. The distinct levels and patterns of cognition found in chronic schizophrenia cohorts are also evident across diagnostic categories in FEP.

The RAISE Connection Program for Early Psychosis: Secondary Outcomes and Mediators and Moderators of Improvement

The aims of this study were to explore secondary outcomes of a coordinated specialty care program for persons with early psychosis, including quality of life and recovery, as well as to explore mediators and moderators of improvement in occupational and social functioning and symptoms. Sixty-five individuals across two sites were enrolled and received services for up to 2 years. Trajectories for individuals' outcomes over time were examined using linear and quadratic mixed-effects models with repeated measures. In addition, baseline prognostic factors of participant improvement in social and occupational functioning were explored based on previous literature and expert opinion of the analytic team. Results demonstrate that the program was effective in improving quality of life and recovery over time. Furthermore, processing speed was identified as a significant moderator of improvement in occupational Global Assessment of Function, and treatment fidelity, engagement, and family involvement were identified as mediators of improvement in social and occupational functioning.

Cognition and the prediction of functioning in patients with a first treated episode of psychosis: a prospective study

Past research on the role of cognitive performance in predicting later psychosocial functioning for individuals with first treated episode of a psychotic disorder has yielded inconsistent results. Several factors have been suggested as determining the strength of any such relationship including the type of functioning measured, time of the cognitive assessment, covariates included and the use of global versus specific measures of cognitive functioning. In the current study, we examined the importance of these factors in a five year prospective study of individuals with first episode psychotic disorders. Just over 80% of the sample had a schizophrenia spectrum disorder. Cognitive assessments were carried out after initiation of treatment on 113 patients, and at one year for 79 patients. There was evidence that cognition predicted occupational functioning and use of a disability pension, but not a summary index of functioning or use of supervised housing, at follow-up. Overall I.Q. was a more consistent predictor than measures of specific cognitive functions, and there was evidence that cognition assessed after presentation for treatment, particularly after a year of treatment, was more predictive of later functioning than premorbid I.Q. Cognitive functioning, however, did not add to the prediction of outcomes beyond the level possible using past educational achievement or academic premorbid adjustment.

An update on supported employment for people with severe mental illness

PURPOSE OF REVIEW

Individual Placement and Support (IPS) is an effective intervention for helping people with severe mental illness obtain competitive employment, yet it has not been widely implemented. This review will examine and summarize the latest research on IPS.

RECENT FINDINGS

As the effectiveness of IPS has been well established in the literature, newer research is exploring nonvocational outcomes, such as quality of life and mental health services utilization and expanding the reach of IPS to include different countries and different population groups. There is also a growing literature exploring the cost-effectiveness of IPS compared with traditional vocational services, which has favored IPS. By far, the area of research that has expanded the most is aimed at enhancing IPS outcomes, at both the intervention level and the client level. Researchers are exploring the variance in IPS outcomes as a means of increasing competitive employment rates with IPS.

SUMMARY

Although the field of research continues to expand, it is clear that many barriers remain to broad implementation of IPS. The solution goes beyond further research and involves policies and practices that support a recovery oriented mental healthcare system.