Work, recovery, and comorbidity in schizophrenia: a randomized controlled trial of cognitive remediation

Pharmacologic Augmentation of Computerized Auditory Training in Chronic Psychosis: Preliminary Findings From a Single-Site, Double-Blind Study

BACKGROUND

Computerized auditory training (AT) modestly improves symptoms, cognition, and functioning in schizophrenia. We assessed whether d-amphetamine (AMPH) or memantine (MEM) can enhance gains from 30-h of AT.

METHODS

Antipsychotic-medicated individuals with chronic psychosis (n = 68; mean age 47.03y; M:F = 39:29) completed up to 30 AT sessions (2-3/week; n = 50 completed 30 sessions) in 3 groups: "AMPH group" (AMPH (5 mg po) 1-h before each AT session); "MEM group" (titrated to 10 mg MEM bid and maintained that dose throughout training); "PBO group" (PBO dosed identically to either AMPH or MEM). Primary (PANSS total, MCCB Composite, WHODAS) and secondary (PANSS positive, PANSS negative, YMRS, PHQ-9, PSYRATS) outcome measures were acquired at baseline, after 10, 20, and 30 AT sessions, and 12 weeks post-training. Pill identity (active/PBO) was blind to subjects and staff.

RESULTS

Marginally significant between-group gains for AMPH vs PBO were detected for one of three primary outcomes (WHODAS, P =.050; but not PANSS total or MCCB Composite), and for 3 of 5 secondary clinical outcomes (PANSS positive, YMRS, PSYRATS, P's≤.027-.049). Within-subject gains over time were detected for primary and secondary clinical measures for AMPH (P's≤.014-.004) and MEM (P's≤.02-.001) groups; some of these would not survive conservative correction for multiple comparisons. No measures detected symptom worsening; treatment satisfaction exceeded subjects' expectations.

CONCLUSIONS

Results are mixed; drug-associated gains in several measures vs PBO suggest that these regimens may augment AT-induced functional and clinical improvement in psychosis patients, independent of changes in neurocognition. Assessment in larger samples seems warranted.

Cognitive Remediation to Facilitate Independent Living in Persons With Serious Mental Illness

Many people with serious mental illness (SMI) experience cognitive disabilities and poor independent living skills which limit their ability to live independently in the community. This study examined the feasibility and initial effectiveness of integrating a new cognitive remediation program, Thinking Skills for Life (TSL), into independent living skills training programs in four secure residential treatment facilities (SRTFs) to facilitate discharge to more independent living situations. Participants were 30 individuals in the SRTF, of whom 11 were forensically committed to the SRTF. Results showed the intervention was feasible to implement, with 97% of participants exposed to TSL and 67% completing the program. Initial promise of the TSL program at improving independent living was suggested by post cognitive program discharge to less restrictive living situations of 63% of participants not on forensic commitment, and 55% of those on forensic commitment. These promising findings set the stage for more rigorous evaluation of the efficacy of the TSL program.

Psychosocial and vocational impact of an internship program for people diagnosed with severe mental illnesses

PURPOSE

Unemployment is an obstacle in recovery for people with severe mental illnesses (SMI), both in reducing psychopathological symptoms and in achieving a high quality of life. The aim of this study was to explore the impact of an internship program for people diagnosed with SMI on psychosocial variables using a pre-test and post-test design.

METHOD

Four scales were administered to a sample of 127 study participants, all of whom were diagnosed with SMI. The results of standard and sheltered employment outcomes were obtained by comparing the number and type of contracts gained by participants up to one year after program completion. A repeated measures ANOVA analysis was carried out with intervention being an independent intra-subject variable and type of participant diagnosis being a between-subjects variable.

RESULTS

A limited increase in social functioning was found, as well as a significant decrease in psychiatric distress for users diagnosed with personality disorders. Participants in the internship program obtained a greater number of employment contracts than their peers who did not participate in the program, albeit with a low effect size.

CONCLUSIONS

Though results were positive, extension of internship length and provision of more intensive counselling for participants may be useful.

The Effect of Psychopathology and Cognitive Functions on Caregiver Burden in Patients with Schizophrenia

OBJECTIVE

The caregiver burden in the relatives of patients with schizophrenia increases mental health problems in patients, complicates coping with the illness for families, and adversely affects the course of the illness. This study aims to investigate the effects of patients' psychopathology severity and cognitive functions on caregiver burden.

METHOD

Forty-four patients diagnosed with schizophrenia according to DSM-5 and their primary caregivers were included in this cross-sectional descriptive study. The severity of the caregiver burden in the relatives of the patients was evaluated using the Zarit Caregiver Burden Scale (ZCBS). Symptom severity of the patients was evaluated with the Scale for the Assessment of Positive Symptoms (SAPS) and the Scale for the Assessment of Negative Symptoms (SANS). Wisconsin Card Sorting Test (WCST), Stroop Test, Trail Making Test (TMT), and Rey Auditory Verbal Learning Test (RAVLT) were applied to assess the cognitive functions of the patients.

RESULTS

The mean ZCBS score was 47.7±26.9 in the primary caregivers of the patients. There was a significant negative correlation between ZCBS and patients' education level, time since recent hospitalization, and RAVLT scores, and a significant positive correlation between TMT, Stroop Test, and SANS scores.

CONCLUSION

To reduce the caregiver burden, psychosocial interventions for cognitive dysfunction and negative symptoms involving patients and their families should be considered a priority.

Cognitive Function in Patients with Psychotic and Affective Disorders: Effects of Combining Pharmacotherapy with Cognitive Remediation

Background: Cognitive impairment is a relevant problem in psychiatry and can be well assessed with a cross-diagnostic test such as the Screen for Cognitive Impairment in Psychiatry (SCIP). The aim of our pilot study is to assess cognitive impairment in acute psychiatric inpatients diagnosed with psychotic disorders, bipolar disorder and depression using the German version of the SCIP (SCIP-G). We also investigate whether cognitive dysfunction improves over the course of the inpatient treatment, where patients are offered a combination of pharmacological treatment and cognitive remediation. Methods: A total of 143 adult inpatients were included in the study. Cognitive testing was performed using two different forms of the SCIP-G. All patients received state-of-the-art pharmacotherapy and cognitive remediation using the COGPACK® software package version 6.06. Results: Based on the ICD-10 Criteria for Research, 54 patients were given an F2 diagnosis (schizophrenia and schizotypal and delusional disorders). Thirty-nine patients met the criteria for bipolar disorder (F30 and F31) and fifty for depression (F32 and F33). At baseline, a significant difference was observed between the SCIP total scores of the F2 and F32/33 patients (p < 0.001) and between the F2 and F30/31 groups (p = 0.022). At the second measurement time point, the SCIP total score showed significant improvement in all three groups (p < 0.001), and there was no statistically significant interaction between SCIP total score and diagnostic groups (p = 0.860). Conclusions: Cognitive dysfunction is present in psychiatric disorders and can be easily assessed during an inpatient hospital stay. In our sample, patients with a psychotic disorder were more cognitively impaired at baseline than patients with an affective disorder. Inpatient treatment, consisting of pharmacotherapy and cognitive remediation, improved cognitive deficits. Patients with psychotic disorders, bipolar disorder and depression showed similar improvements in cognitive performance.

Experiences of returning to work in patients with schizophrenia after treatment: A longitudinal qualitative study

BACKGROUND

Returning to work (RTW) has always been regarded as one of the important indicators to evaluate the therapeutic effect of patients with schizophrenia. The existing studies on RTW in patients with schizophrenia are mostly focused on intervention measures, and the qualitative research on RTW is very limited. The purpose of this study was to evaluate the experience of the RTW after treatment in patients with schizophrenia.

METHOD

A longitudinal qualitative study was conducted involving 24 patients with schizophrenia in China. The interviews were held at three time-points during their RTW process, (1) when patients had improved and were close to discharge, (2) within 1 month post-discharge, and (3) 6 months post-discharge. The interview recordings were transcribed by the research team, and transcripts were independently analyzed by two independent coders using reflexive thematic analysis.

RESULTS

A total of 24 patients with schizophrenia participated in 72 personal interviews. The thematic framework based on the experience of patients with schizophrenia reveals a three-phases of the process of RTW: improved, being at a loss, and job crisis. The study identified one theme of the first phase: the expectation and optimism. Two themes in the second phase: (1) psychological distress of upcoming work; (2) expectation of assistance pre-work. And four themes in the third phase: (1) tremendous pressure of RTW; (2) lack of medical and social support; (3) social status and interpersonal relationships change; and (4) high level of financial pressure.

CONCLUSION

The experience of RTW is a dynamic process with great challenges in each phase, patients with schizophrenia have been deeply affected by what they have experienced. There is an urgent need to ensure that existing community and social support is integrated into daily care to support patients with schizophrenia to RTW successful. The findings of this study also suggest relevant departments and employers should be aware of the barriers to RTW for patients with schizophrenia, and take certain measures to change the current situation.

[Effectiveness and Cost-Effectiveness of Individual Placement and Support (Ips) in Germany - A Controlled Trials with Individuals with Psychosis]

OBJECTIVE

To establish the effectiveness of Individual Placement and Support (IPS) to integrate people with mental illness into the general labor market, controlled comparisons with usual rehabilitative practice in terms of employment rates and cost-effectiveness are needed.

METHODS

20 IPS participants with psychoses (primarily schizophrenia spectrum disorders) were compared with 20 controls who were offered usual rehabilitative practices in adjacent counties (rehabilitation as usual, RAU) over 18 months.

RESULTS

IPS was significantly superior to RAU on all job-related criteria with moderate to high effect sizes, with no differences in absenteeism, hospital days, or dropout rates. IPS was significantly superior to RAU on cost-effectiveness.

CONCLUSION

This study provides evidence that IPS is an effective and cost-efficient addition to existing vocational rehabilitation services for people with psychoses.

People with mental illness stigmatize mental illness less: A comparison study between a hospital-based sample of people with mental illness and a non-clinical general population sample in urban India

Evidence shows that stigma negatively influences the quality of life of persons with severe mental illness. Nonetheless, stigma towards mental illness is lower among persons with a lived experience of mental illness compared to the rest of the population. Understanding the association between stigma of mental illness and the mental status of individuals living in urban India and whether this association is moderated by demographic factors opens a new avenue for prevention of social exclusion. Persons diagnosed with schizophrenia, bipolar disorder, or severe unipolar depression (cases, n  =  647) were recruited from among hospital patients in New Delhi between November 2011 and June 2012 and matched with non-psychiatric urban dwellers by age, sex, and location of residence (controls, n  =  649). Propensity score matching with multivariable linear regression was used to test whether stigma towards mental illness, measured by a 13-item Stigma Questionnaire, differed between cases and controls. Cases reported significantly lower stigma scores than controls (b  =  -0.50, p < 0.0001). The strength of the association between mental illness and stigma was not affected after controlling for age, caste, sex, education, and employment status, while wealth marginally reduced the strength of the association. These findings suggest individuals with a lived experience of mental illness, in New Delhi, India, may be more tolerant towards mental illness and support the need to involve persons with lived experience in the development and implementation of health promotional campaigns and programs aimed at reducing stigma towards mental illness.

Mental health and unemployment: A systematic review and meta-analysis of interventions to improve depression and anxiety outcomes

BACKGROUND

Unemployment is associated with substantially greater depression and anxiety, constituting a considerable public health concern. The current review provides the most comprehensive synthesis to date, and first meta-analysis, of controlled intervention trials aimed at improving depression and anxiety outcomes during unemployment.

METHODS

Searches were conducted within PsycInfo, Cochrane Central, PubMed and Embase from their inception to September 2022. Included studies conducted controlled trials of interventions focused on improving mental health within unemployed samples, and reported on validated measures of depression, anxiety, or distress (mixed depression and anxiety). Narrative syntheses and random effects meta-analyses were conducted among prevention- and treatment-level interventions for each outcome.

RESULTS

A total of 39 articles reporting on 33 studies were included for review (sample sizes ranging from 21 to 1801). Both prevention and treatment interventions tended to be effective overall, with treatment interventions producing larger effect sizes than prevention interventions. The clearest evidence for particular intervention approaches emerged for prevention-level Cognitive Therapy/CBT, followed by prevention-level work-related interventions, although neither produced entirely consistent effects.

LIMITATIONS

Risk of bias was generally high across studies. Low numbers of studies within subgroups precluded any comparisons between long-term and short-term unemployment, limited comparisons among treatment studies, and reduced the power of meta-analyses.

CONCLUSIONS

Both prevention- and treatment-level mental health-focused interventions have merit for reducing symptoms of anxiety and depression among those experiencing unemployment. Cognitive Therapy/CBT and work-related interventions hold the most robust evidence base, which can inform both prevention and treatment strategies implemented by clinicians, employment services providers, and governments.

Comparison of Black and White participants with severe mental illness in response to cognitive remediation as an augmentation of vocational rehabilitation

PURPOSE

Despite evidence that cognitive remediation improves cognitive and employment outcomes in persons with severe mental illnesses (SMI), its effects have not been systematically compared between Black and White participants. Considering that Black adults have more negative experiences receiving mental health treatment, providers may have greater difficulty engaging and retaining Black Americans in cognitive remediation. Due to the effects of structural racism on reducing employment opportunities for Black Americans, it is unclear whether Black participants will reap the same benefits of cognitive remediation on work outcomes as White Americans. This paper addressed this question.

METHODS

A secondary analysis was conducted of five randomized controlled trials comparing cognitive remediation (the Thinking Skills for Work program: TSW) and vocational rehabilitation vs. vocational rehabilitation only in 137 Black and 147 White Americans (64.2% schizophrenia-schizoaffective disorder) who were followed up for two years.

RESULTS

Comparable proportions of Black and White participants were engaged and retained in TSW (>75%). Participants who received TSW improved significantly more in cognition than those receiving vocational services alone, with no racial differences in benefit. Participants in TSW obtained more work, earned more wages, and worked more weeks than those receiving vocational services alone, with no differences between the races.

CONCLUSIONS

The findings indicate that Black Americans with SMI receiving vocational services could be successfully engaged in and benefit from cognitive remediation, highlighting the vital role of healthcare service systems in giving credence to structural racism to more effectively mitigate racial disparities in treatment outcomes.

The Arab minority of East Jerusalem: An exploratory study of vocational rehabilitation in mental health

BACKGROUND

The Arab population of East Jerusalem with serious mental illness (SMI) is an ethnic and health status minority that has unique employment issues. Vocational rehabilitation offered to this population is guided by standard regulations that are grounded in knowledge obtained from Western communities on the employment enablers, while negligible research was done to investigate relevance of these enablers for the Arab population.

OBJECTIVE

The study aims to examine the previously well-established association between motor, cognitive, and emotional personal factors, occupation features, environmental characteristics, and vocational outcomes of job satisfaction and performance among the Arab population of East Jerusalem with SMI.

METHODS

Twenty-three men and women, aged 23-58, from this minority group who had received vocational rehabilitation participated in this cross-sectional study. They completed standard assessments of motor and cognitive skills, self-efficacy, work-environment suitability, and job satisfaction. Employers then rated their level of functioning at work.

RESULTS

No correlation was found between the outcome measurements and most of the personal factors and environmental characteristics (p > 0.05), except for an association between job satisfaction, work self-efficacy, and work control. No expected differences were found between vocational rehabilitation programs in the variables of interest (p > 0.05).

CONCLUSION

The disparity from well-established patterns of association between enablers and employment outcomes reveals unique characteristics of the investigated population and suggests the impact cultural issues has on vocational rehabilitation. The findings raise an urgent call for an in-depth investigation of the complex phenomenon of employment in this population to support sustainable employment benefits and recovery journey.

Cognitive Rehabilitation in Schizophrenia-Associated Cognitive Impairment: A Review

Patients suffering from schizophrenia often experience cognitive disturbances. Cognitive rehabilitation-computerized or non-computerized-is widely known as an alternative way to enhance cognitive functioning in patients with schizophrenia. The aim of the present review was to examine the role of cognitive rehabilitation (both computerized and non-computerized) for the alleviation of cognitive impairment in schizophrenia patients. Fourteen relative studies were examined and included in the present review. The results revealed that both computerized and non-computerized cognitive rehabilitation could enhance cognitive functioning and more specifically memory, attention, executive functioning, processing speed and in a few cases, even non-cognitive impairments, such as other schizophrenia symptoms. The present results support the efficacy of cognitive rehabilitation in schizophrenia patients, regardless of whether it is computerized or non-computerized. As the randomized control trials (RCTs) are limited in number, there is urgent need for more RCTs and longitudinal studies combining different kinds of interventions, as well as systematic reviews and meta-analyses, in order to further investigate and confirm the current results.

Cognitive Optimisation and Schizophrenia: Assembling Heterogeneity, Overcoming the Precariousness of Life, and Challenging Public Health Policies in Psychiatry in France

Cognitive remediation therapy (CRT) aims to optimise cognitive abilities of people who suffer from schizophrenia in order to improve their social adaptation. This therapeutic orientation was developed in psychiatry in the 1980s and 1990s, at a time when the disorder was being redefined as a neurocognitive deficit disorder. In this article, I describe CRT as an assemblage that lies at the intersection of multiple, overlapping theories and spaces of mental disorders and psychiatric care. To do so, I draw on 18 months of ethnographic research conducted in a French hospital unit dedicated to the development of CRT. I argue that the focus on cognitive health and cognitive abilities (or deficits) is not only redefining the logics of care and reshaping medical conceptualisations of schizophrenia, but it is also opening up to a new understanding of people's precarious life conditions, where emotional, biological, and cognitive fragility is intertwined with social and economic uncertainty. I then examine the extent to which psychiatrists have extended the goals of CRT to include psychosocial rehabilitation in order to mitigate not only the effects of cognitive deficits, but also the effects of limited social and professional integration encountered by patients. Finally, I conclude with a consideration of how CRT has become, for its proponents in France, a means to develop a policy and organisational project for French psychiatry.

Are remote psychotherapy/remediation efforts accessible and feasible in patients with schizophrenia? A narrative review

Background

Cognitive remediation (CR) therapy provides an effective way to improve cognitive impairments in schizophrenia. With the advent of telehealth services, especially during COVID 19 pandemic, a suitable alternative can be found in computer and cell phone-based mental health interventions. Previous studies have proven that remote mental health interventions have by and large been successful. Remote psychotherapy/CR services can now be accessed through smartphone apps, iPads, laptops and wearable devices. This has the advantage of reaching a wider population in resource-limited settings. The lack of access to technology, difficulty in using these online interventions and lack of privacy provide impediments to the delivery of care through these online platforms. Further, as some previous studies have shown, there may be a high rate of dropout in people using remote mental health resources. We aim to look at the factors, which influence the accessibility of remote mental health interventions in schizophrenia. Additionally, we test the feasibility of these interventions and look at how they compare and the potential they hold for implementation in future clinical settings.

Results

We found remote cognitive remediation to be both accessible and feasible. Concerning features, however, are the high attrition rates and the concentration of the studies in Western populations.

Conclusions

Remote interventions are a viable alternative to in-person psychotherapy when in-person resources may not always be present. They are efficacious in improving health outcomes among patients with schizophrenia. Further research into the widespread implementation of remote CR will be beneficial in informing clinical decision-making.

Cognitive Enhancement Therapy vs social skills training in schizophrenia: a cluster randomized comparative effectiveness evaluation

BACKGROUND

Schizophrenia and related disorders are highly disabling and create substantial burdens for families, communities, and health care systems. Although pharmacological treatments can often lessen the psychotic symptoms that are a hallmark of schizophrenia, they do not lessen the social and cognitive deficits that create the greatest impediments to community engagement and functional recovery. This study builds on prior research on psychosocial rehabilitation by comparing the effectiveness of two treatments demonstrated as efficacious in improving social and community functioning, Cognitive Enhancement Therapy (CET) and a version of Social Skills Training (HOPES/SST).

METHODS

The study uses a randomized cluster design in which a pair of clinicians at community- and hospital-based mental service centers deliver either CET or HOPES to at least one group of 6-8 eligible clients for 12 months. Clinicians are trained and then supervised weekly, with ongoing process measurement of treatment fidelity, attendance, satisfaction, and retention, and use of other services. Measures administered at baseline and at 6 and 12 months while in treatment, and then at 18 and 24 months after treatment include social adjustment, quality of life, social skills, positive and negative symptoms, and neuro- and social cognition. We hypothesize that CET will be associated with greater improvements than SST in both the primary outcome of community functioning and the secondary outcomes of neuro- and social cognition and social skills. Secondarily, we hypothesize that more cognitive impairment at baseline and younger age will predict more benefit from CET compared to HOPES.

DISCUSSION

Resource shortages endemic in mental health services and exacerbated by the pandemic highlight the importance of identifying the most effective approach to improving social and community functioning. We aim to improve understanding of the impact of two efficacious psychosocial treatments and to improve clinicians' ability to refer to both treatments the individuals who are most likely to benefit from them. We expect the result to be programmatic improvements that improve the magnitude and durability of gains in community functioning.

TRIAL REGISTRATION

ClinicalTrial.gov NCT04321759 , registered March 25, 2020.

Prevalence, profile and associations of cognitive impairment in Ugandan first-episode psychosis patients

Introduction

The MATRICS consensus cognitive battery (MCCB) is the gold standard for neuropsychological assessment in psychotic disorders but is rarely used in low resource settings. This study used the MCCB to determine the prevalence, profile and associations of various exposures with cognitive impairment in Ugandan first-episode psychosis patients.

Methods

Patients and matched healthy controls were recruited at Butabika Hospital in Uganda. Clinical variables were first collated, and after the resolution of psychotic symptoms, a neuropsychological assessment of seven cognitive domains was performed using the MCCB. Cognitive impairment was defined as two standard deviations (SD) below the mean in one domain or 1SD below the mean in two domains. Descriptive statistics determined the prevalence and profile of impairment while regression models determined the association between various exposures with cognitive scores while controlling for age, sex and education.

Results

Neuropsychological assessment with the MCCB found the burden of cognitive impairment in first-episode psychosis patients five times that of healthy controls. The visual learning and memory domain was most impaired in first-episode psychosis patients, while it was the working memory domain for the healthy controls. Increased age was associated with impairment in the domains of the speed of processing (p < 0.001) and visual learning and memory (p = 0.001). Cassava-rich diets and previous alternative and complementary therapy use were negatively associated with impairment in the visual learning (p = 0.04) and attention/vigilance domains (p = 0.012), respectively. There were no significant associations between sex, history of childhood trauma, or illness severity with any cognitive domain.

Conclusion

A significant burden of cognitive impairment in Ugandan first-episode psychosis patients is consistent with prior data from other contexts. However, the profile of and risk factors for impairment differ from that described in such work. Therefore, interventions to reduce cognitive impairment in FEP patients specific to this setting, including dietary modifications, are required.

Deinstitutionalization from the perspective of community-dwelling adults with a severe mental illness in Amsterdam: a cohort study protocol

Background

People with a severe mental illness (SMI) increasingly receive ambulatory forms of care and support. The trend of deinstitutionalization accelerated in the Netherlands from 2008 and onwards without sufficient understanding of its consequences. The study protocol herein focuses on deinstitutionalization from the perspective of adults with an SMI living within the community in Amsterdam and aims at delivering better insight into, amongst others, their recovery, quality of life, societal participation and needs for care and support.

Methods

A cohort design will be used. A representative sample of community-dwelling adults with an SMI, including those in care (n = 650) and not in care (n = 150), will be followed over time. During a two-year time period, participants will be interviewed twice using a wide-ranging set of validated instruments. Interview data will be matched with administrative data about the care process, as retrieved from their patient files. Primary outcomes are changes over time in recovery, societal participation and quality of life, controlled for the occurrence of adverse life-events during follow-up. Additionally, prevalence estimates of and associations between social functioning, safety and discrimination, substance use and health indicators will be investigated.

Discussion

The study protocol aims at delivering a comprehensive insight into the needs of community-dwelling adults with an SMI based on which ambulatory care and support can best be provided to optimally promote their social recovery and well-being.

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.

Identifying subgroups based on self-assessment of ability in patients with schizophrenia and its relationship with vocational outcomes

Background/Objectives

People with schizophrenia have defective self-assessment of ability (i.e., loss of introspective accuracy [IA]). Although previous studies grouped people according to the degree of IA, the clinical features of these subgroups have not been clarified. Additionally, the determinants of outcomes depending on self-assessment remain unknown. We aimed to identify the clinical features that can help distinguish these subgroups and whether the determinants of vocational outcomes differed between the groups.

Methods

The self-assessment ability of 100 people with schizophrenia was examined and categorized as accurate, over-, or under-estimators. Multiple discriminant analysis was also performed. After demonstrating statistical validity, the relative effects of positive and negative symptoms, cognitive function, and level of IA on vocational outcomes were also examined for each subgroup.

Results

The symptoms that particularly explained the differences between these subgroups were positive and negative (expressing factors) symptoms: p < .001. Using the determinants of vocational outcomes in each subgroup, the over-estimator subgroup was characterized by positive symptoms: p = .025, the under-estimator group, by the underestimation of their own ability: p = .042, and the accurate estimator group, by cognitive function: p = .006.

Conclusion

Reduced IA can be a core mediator of various symptoms. Thus, tailoring the target and strategy of interventions for vocational outcomes according to the accuracy and quality of IA is important in clinical settings.

Advances in Cognitive Remediation Training in Schizophrenia: A Review

Cognitive Remediation Training (CRT) in schizophrenia has made great strides since its introduction in the 1990s. CRT was developed with the aim of improving the everyday functioning of individuals living with cognitive impairment. MEDLINE, PsychINFO, and Google Scholar were searched to extract peer-reviewed randomized controlled trials to produce the current review article. The aim of the present review is to summarize CRT effects on addressing cognitive changes in patients undergoing CRT as defined by the Cognitive Remediation Experts Workshop and to describe the areas of greatest impact in specific cognitive domains. Another area of this review aims to summarize the modalities of intervention (paper and pencil; computerized; home bound), the persistence of improvements, and their generalization to other domains of functioning. Finally, this review delineates barriers for wider dissemination of CRT, such as the transfer of research findings into clinical everyday practice and future developments of CRT.

Unfinished business: Functional outcomes in a randomized controlled trial of a three-year extension of early intervention versus regular care following two years of early intervention for psychosis

OBJECTIVE

To investigate whether first-episode psychosis patients receiving extended early intervention had better functional outcomes than those in regular care and to examine the predictors of functional outcomes.

METHODS

This is a randomized controlled single-blind trial of 220 patients randomized after 2 years of early intervention to receive early intervention or regular care for the subsequent 3 years. Outcomes included cumulative time in functional recovery during the 3-year trial assessed using the Social and Occupational Functioning Assessment Scale (SOFAS); and employment/education at last assessment which were, respectively, analyzed using multiple linear regression and logistic regression, accounting for well-known predictors. Linear mixed and generalized linear models were also used to examine the course of SOFAS and employment/education over the 3-year period.

RESULTS

The extended early intervention and regular care groups did not differ on time in functional recovery (mean = 50.17 weeks, SD = 46.62 vs. mean = 46.18 weeks, SD = 51.54); percent employed/in school (60.4% vs. 68.8%) or change in SOFAS or employment/education status over time. SOFAS scores were stable between years 2 and 5. Individuals with longer periods of total symptom remission experienced significantly longer periods of functional recovery and were likelier to be employed/in school. Those who had completed high school were nine times likelier to be employed/studying.

CONCLUSION

Most individuals maintained functional gains accrued from 2 years of early intervention with no further improvement whether in extended early intervention or regular care. There was a gap between symptomatic and functional recovery, and one-third were unemployed/not in school at year 5. The lack of additional progress even in extended early intervention suggests that specific interventions addressing functional roles need to be provided beyond the first 2 years of early intervention. Sustaining symptom remission and high-school completion may be additional avenues for targeting functional recovery.

Understanding needs of stakeholders and outcomes desired from a home-based intervention program for "difficult to treat" schizophrenia and related disorders: A qualitative study

BACKGROUND

We aimed to understand the needs of service users - families and patients with schizophrenia and related disorders, and mental health professionals (MHPs) and expectations from a home-based psychosocial intervention program in Indian setting.

MATERIALS AND METHODS

We conducted four focus group discussions (FGDs) with families, patients with schizophrenia and related disorders and MHPs. Two FGDs were conducted with families and one each with the patients and MHPs. Participants in families and MHP group were asked about their primary concerns in caring for the patients, perceived needs of patients and the areas that can be targeted through a home-based psychosocial intervention program. All FGDs were audio-recorded and verbatim transcribed. Content analysis of the data was done to obtain a final list of needs and expected outcomes from a psychosocial intervention supported by families.

RESULTS

Six key priority needs were identified for intervention: medication adherence, activities of daily living, promoting physical health, engagement in meaningful work, building of social and support networks and information about all aspects of illness. Priority outcomes identified by MHPs were mostly clinical like symptom reduction, fewer rehospitalisation while families and patients focused more on psychosocial outcomes, such as improvement of wellbeing, having relationships, engagement in meaningful activities, better organization of the day, increased self-respect, reduced stress, lesser interference, and critical comments. All groups suggested that book or mobile app or video could be used.

CONCLUSION

This qualitative study shows that while both clinicians and service users consider recovery from schizophrenia and related disorders to be important, they differ on what they prioritise.

Extensive variability of work participation outcomes measured in randomized controlled trials: a systematic review

OBJECTIVE

To investigate how work participation outcomes in randomized controlled trials are measured internationally and across disciplines.

STUDY DESIGN AND SETTING

We identified trials that reported on work participation in Medline, Embase, PsycINFO and Cochrane Central published between 2014 and 2019. Screening, selection, and data extraction were done by two authors independently. We grouped outcomes into four categories ("employment status", "absence from work", "at-work productivity loss," and "employability") and created subcategories according to how the outcome was measured.

RESULTS

From 10,022 database hits we selected 269 trials reporting on 435 work participation outcomes. Authors used inconsistent outcome terminology to describe the measured constructs. Grouped in four main categories we identified 70 outcomes that reported on "employment status", 196 on "absence from work" and return-to-work, 132 on "at-work productivity loss," and 37 on "employability" outcomes. Variability in measurement methods existed across all categories. Employment status and absenteeism measures consisted mostly of clinimetrically unvalidated tools. "At-work productivity loss" and "employability" were measured by at least 41 different questionnaires.

CONCLUSION

Extensive variability exists among trials in the measurement of outcomes, measurement methods and measurement instruments that focus on work participation. This study is a first step towards the development of a Core Outcome Set for work participation.

Effects of IPS plus cognitive remediation in early psychosis: 18-month functioning outcomes of a randomized controlled trial

BACKGROUND

After a first episode of psychosis, cognitive impairments present an important barrier to successful (re-)entry into work and education. We assessed whether cognitive remediation (CR) as an add-on to Individual Placement and Support (IPS) can improve participation in regular employment and education.

METHOD

Participants with early psychosis (N = 73) were randomly assigned to receive IPS supplemented with computerized CR, or IPS plus an active control intervention (computer games). The primary outcome was the number of hours spent in competitive employment or regular education, which was assessed every month during the 18-month study period. Secondary outcomes included employment rate, cognitive functioning, mental health (assessed at baseline, 6 and 18 months), and job duration (assessed after 18 months). Both patients and assessors were blind to treatment.

RESULTS

Participants receiving IPS + CR showed greater improvement of competitive employment over time in terms of hours worked (during follow-up period: 38.5 vs. 19.6 h, B = 2.94; Wald χ² = 5.39; P = .02) and employment rate (at T2: 62.1% vs. 25.9%, χ ² = 7.39; df = 1; P = .008), compared with the IPS + control group, particularly in the longer term. The number of hours spent in regular education was lower in the IPS + CR group, with more participants having ended education for a positive reason. There was a significant beneficial effect of adjunctive CR for executive functioning, subjective cognitive functioning, and empowerment.

CONCLUSIONS

Augmenting IPS with CR has a significant impact on competitive employment in people with early psychosis, with beneficial effects being more pronounced after 18 months.

Implementing Evidence-Based Interventions to Improve Vocational Recovery in Early Psychosis: A Quality-Improvement Report

OBJECTIVE

After young adults experience a first episode of psychosis, many express a need for help with education and employment. A quality improvement collaborative (QIC) launched in the Netherlands aimed to reinforce vocational recovery by improving participation in education and employment and by enhancing cognitive skills and self-management. This study examined methods used to implement interventions, barriers and facilitators, and implementation outcomes (fidelity, uptake, and availability).

METHODS

The Breakthrough Series was the model for change. Three evidence-based interventions were implemented to achieve targeted goals: individual placement and support (IPS), cognitive remediation, and shared decision making. Fidelity scores were obtained with fidelity scales.

RESULTS

Eighty-five professionals and 332 patients representing 14 teams treating patients with early psychosis were included in the 24-month QIC. Of this group, 252 patients participated in IPS, 52 in cognitive remediation, and 39 in shared decision making. By month 22, teams attained moderate-to-high mean fidelity scores, with an average of 3.2 on a 4-point scale for cognitive remediation, 3.7 on a 5-point scale for IPS, and 4.9 on a 6-point scale for shared decision making.

CONCLUSIONS

Over 24 months, use of a Breakthrough QIC to implement three interventions aimed at improving vocational recovery in teams delivering services for early psychosis yielded mixed results in terms of uptake and availability and moderate-to-high results in terms of fidelity. When implementing these types of interventions in this population, a multifaceted implementation model and a focused testing phase for computerized interventions appear needed, preferably with a maximum of two interventions implemented simultaneously.

A randomized controlled trial of exercise on augmenting the effects of cognitive remediation in persons with severe mental illness

BACKGROUND

Preliminary evidence suggests that aerobic exercise may augment the effects of cognitive remediation on improving cognitive functioning in severe mental illness. It has also been hypothesized that increases in cognitive functioning associated with adding exercise are mediated by increases in brain derived neurotrophic factor (BDNF). However, rigorous controlled trials are lacking.

METHODS

A randomized controlled trial was conducted to explore whether adding a 30-h aerobic exercise program over 10 weeks to an equally intensive cognitive remediation program (CR + E) improved cognitive functioning more than cognitive remediation alone (CR-Only). Thirty-four participants with schizophrenia or bipolar disorder were randomly assigned to CR + E or CR-Only, and cognitive functioning was assessed at baseline and post-treatment. Total and mature BDNF were measured in blood serum at baseline, Week-5 pre- and post-exercise, and Week-10 pre- and post-exercise.

RESULTS

Participants in both conditions had high levels of engagement in the interventions and improved significantly in cognitive functioning, but did not differ in amount of cognitive change. The groups also did not differ in changes in BDNF from pre-to post-exercise at Weeks 5 or 10, nor in resting BDNF levels. Exploratory analyses indicated that higher body mass index (BMI) significantly predicted attenuated improvement in cognitive functioning for both groups.

DISCUSSION

Exercise did not augment the effects of cognitive remediation in persons with severe mental illness, possibly because the cognitive remediation program resulted in strong gains in cognitive functioning. Moderate aerobic exercise does not appear to reliably increase BDNF levels in persons with severe mental illness. CLINICALTRIALS.

GOV IDENTIFIER

NCT02326389.

The Patient, Investigator, Nurse, Carer Questionnaire (PINC-Q): a cross-sectional, retrospective, non-interventional study exploring the impact of less frequent medication administration with paliperidone palmitate 3-monthly as maintenance treatment for schizophrenia

BACKGROUND

To understand the implications of switching from paliperidone palmitate 1-monthly (PP1M) to paliperidone palmitate 3-monthly (PP3M) treatment of schizophrenia from the perspective of four key stakeholders: patients, physicians, nurses and carers.

METHODS

This was a cross-sectional, retrospective, non-interventional study comprising a one-time questionnaire (PINC-Q) for adult patients (aged ≥18 years) with schizophrenia (International Classification of Diseases; ICD-10) and their physician, nurse and carer. Questionnaires were developed in association with patient and carer advocacy groups (GAMIAN and EUFAMI) and following an advisory board formed of psychiatrists and nurses. The degree of alignment between stakeholders was also examined.

RESULTS

Responses were received from a total of 224 evaluable patients. For most patients (88.4%), responses were received from at least two other stakeholders. Patients were moderately ill with mild-to-moderate lack of insight and had received PP1M for a mean (standard deviation [SD]) of 23.9 (21.28) months before switching to PP3M (duration mean [SD] 12.8 [3.72] months). The most frequently reported reasons to switch from PP1M to PP3M were 'to live life as normally as possible' and 'patient convenience'. Over 79% of responses within each stakeholder group stated that PP3M helped the patients, with increased patient activity and social involvement, improved frequency and quality of physician-patient and nurse-patient communication and decreased perceived stigma.

CONCLUSIONS

The results of this study add to the increasing body of evidence supporting the benefits of PP3M in a population of patients with schizophrenia representative of real-world clinical practice.

Advanced glycation end products and cognitive impairment in schizophrenia

Advanced glycation end products play a key role in the pathophysiology of schizophrenia. Cognitive impairment is one of the central features of schizophrenia; however, the association between advanced glycation end products and cognitive impairment remains unknown. This study investigated whether advanced glycation end products affect the cognitive domain in patients with schizophrenia. A total of 58 patients with chronic schizophrenia were included in this cross-sectional study. Plasma advanced glycation end products were measured using high-performance liquid chromatography (HPLC). Neuropsychological and cognitive functions were assessed using the Wechsler Adult Intelligence Scale, Third Version, and the Wisconsin Card Sorting Test Keio-FS version. Multiple regression analysis adjusted for age, sex, body mass index, educational years, daily dose of antipsychotics, and psychotic symptoms revealed that processing speed was significantly associated with plasma pentosidine, a representative advanced glycation end product (standardized β = -0.425; p = 0.009). Processing speed is the cognitive domain affected by advanced glycation end products. Considering preceding evidence that impaired processing speed is related to poor functional outcome, interventions targeted at reducing advanced glycation end products may contribute to promoting recovery of patients with schizophrenia as well as cognitive function improvement.

Occupational Goal Intervention Method for the Management of Executive Dysfunction in People With Treatment-Resistant Schizophrenia: A Randomized Controlled Trial

IMPORTANCE

The occupational goal intervention (OGI) method has been proven effective in improving executive function (EF) in people with schizophrenia, but it has not yet been tested with those with treatment-resistant schizophrenia (TRS).

OBJECTIVE

To test the efficacy of the OGI in people with TRS.

DESIGN

Single-blind randomized controlled trial.

SETTING

The Schizophrenia Program, Institute of Psychiatry, University of São Paulo General Hospital, Brazil.

PARTICIPANTS

People with TRS according to Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria, ages 18 to 55. Outcomes and Measures: Primary outcome: improvement in EF as measured by the Behavioural Assessment of the Dysexecutive Syndrome (BADS).

SECONDARY OUTCOMES

improvement of functionality, as measured by the Direct Assessment of Functional Status-Revised (DAFS-BR), and improvement in autonomy in activities of daily living (ADLs), as measured by the Independent Living Skills Survey (ILSS-BR), administered to caregivers. The outcomes were measured at baseline, posttreatment, and follow-up.

INTERVENTION

Participants were divided into two groups: OGI and craft activities (control). Each group participated in 30 sessions during 15 wk, with follow-up at 6 mo postintervention.

RESULTS

The OGI group improved significantly compared with the control group, with medium to large effect sizes in posttreatment scores on the BADS and DAFS-BR. The ILSS-BR showed the highest effect sizes at posttreatment and follow-up.

CONCLUSIONS AND RELEVANCE

The OGI method is effective for improving EF, occupational performance and ADLs in people with TRS. What This Article Adds: The OGI method is an important therapeutic tool for use in the occupational therapy clinic.

Cognitive remediation and professional insertion of people with schizophrenia: RemedRehab, a randomized controlled trial

Background

People suffering from schizophrenia cannot easily access employment in European countries. Different types of vocational programs coexist in France: supported employment, sheltered employment (ShE), and hybrid vocational programs. It is now acknowledged that the frequent cognitive impairments constitute a major obstacle to employment for people with schizophrenia. However, cognitive remediation (CR) is an evidence-based nonpharmacological treatment for these neurocognitive deficits.

Methods

RemedRehab was a multicentric randomized comparative open trial in parallel groups conducted in eight centers in France between 2013 and 2018. Participants were recruited into ShE firms before their insertion in employment (preparation phase). They were randomly assigned to cognitive training Cognitive Remediation for Schizophrenia (RECOS) or Treatment As Usual (TAU). The aim of the study was to compare with the benefits of the RECOS program on access to employment and work attendance for people with schizophrenia, measured by the ratio: number of hours worked on number of hours stipulated in the contract.

Results

Seventy-nine patients were included in the study between October 2018 and September 2019. Fifty-three patients completed the study. Hours worked / planned hours equal to 1 or greater than 1 were significantly higher in the RECOS group than in the TAU group.

Conclusions

Participants benefited from a RECOS individualized CR program allows a better rate of work attendance in ShE, compared to the ones benefited from TAU. Traditional vocational rehabilitation enhanced with individualized CR in a population of patients with schizophrenia is efficient on work attendance during the first months of work integration.

Psychometric validation of the Job Satisfaction of Persons with Disabilities Scale in a sample of peer support specialists

OBJECTIVE

The primary purpose of the study was to evaluate the psychometric properties of the Job Satisfaction of Persons with Disabilities Scale in a sample of peer support specialists.

METHOD

A total of 121 employed peer support specialists with lived experience of a serious mental health condition were recruited for this study from statewide peer certification training programs and the International Association of Peer Supporters. Respondents completed an online survey on job satisfaction and related constructs. A principal components analysis was used to explore and identify the instrument subscales.

RESULTS

The findings identified 2 factors: (a) the 9-item job satisfaction with intangible benefits factor and (b) the 5-item job satisfaction with tangible benefits factor.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The Job Satisfaction of Persons with Disabilities Scale demonstrates good-to-excellent psychometrics. The use of this scale among peer support specialists within training and supervision practices in psychiatric rehabilitation settings is warranted. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Vocational Service Models and Approaches to Improve Job Tenure of People With Severe and Enduring Mental Illness: A Narrative Review

Employment is a valued occupation that offers a sense of meaning, identity, and belonging. For people with severe and enduring mental illness, employment has also been associated with personal recovery and decreased use of mental health services. However, this population continues to be underrepresented in the labor market. Sustainable employment is often challenging for people with severe and enduring mental illness, due to a combination of personal, organizational and systemic issues. While Individual Placement and Support is an evidence-based model of employment support known to improve job attainment for people with mental illness, job retention and sustained workforce participation continue to be challenges. This narrative literature review was undertaken to address the question: "What vocational service models and approaches improve job tenure for this population?" CinAHL, Medline, Embase, PsycINFO, and Cochrane Library were searched for the period 2005-2020, using key terms and subject headings, including "severe mental illness," "psychiatric disabilit^*," "job tenure," and "job retention." Several adjunct interventions may enhance job retention, including skills training, cognitive interventions, psychological interventions, and supported education, while social firms offer a different approach focused on creating new, sustainable job opportunities. Peer support and support from family and friends also appear to be important, and emerging evidence suggests that employment specialist practices, technology, self-management, and workplace accommodations may each also influence job tenure. Service providers could make more use of these non-clinical vocational approaches to improve employment retention for people with severe and enduring mental illness.

Effect of Paliperidone Palmitate 3-Month Formulation on Goal Attainment and Disability After 52 Weeks' Treatment in Patients with Clinically Stable Schizophrenia

PURPOSE

This pragmatic clinical study aimed to assess goal attainment among patients with schizophrenia treated with paliperidone palmitate 3-monthly (PP3M) and its relation to their level of disability, and whether patients achieved symptomatic remission at the study endpoint.

PATIENTS AND METHODS

Goal attainment was assessed as a secondary endpoint using Goal Attainment Scaling (GAS) within a 52-week, prospective, single-arm, non-randomized, open-label, international, multicenter study evaluating the impact of transitioning stable patients with schizophrenia from paliperidone palmitate 1-monthly (PP1M) to PP3M. Additional exploratory analyses were performed to investigate the relationship between disability and functioning as measured by the World Health Organization Disability Assessment Schedule (WHODAS), Version 2.0, symptomatic remission, and goal attainment.

RESULTS

Overall, 305 patients were enrolled, of whom 281 (92.1%) provided GAS data at baseline. Of these, 160 achieved symptomatic remission at the last observation carried forward (LOCF) endpoint. The most common category of goals was "self" related, of which work-related was most frequent. Two-thirds of patients (67.7%) achieved at least one goal at the LOCF endpoint. Goal achievement was positively associated with lower baseline symptoms and symptomatic remission at LOCF endpoint, and with lower WHODAS scores at baseline and LOCF endpoint and greater WHODAS score improvements from baseline. Age, duration of disease, and duration of PP1M treatment before the switch did not impact goal setting and goal attainment. The proportion of patients with remunerated work status increased by 11.3% at LOCF endpoint.

CONCLUSION

The results of this secondary endpoint analysis indicate that continued treatment of patients with schizophrenia with PP3M following stabilization with PP1M may facilitate attainment of patients' personal goals and reduce disability, especially, but not exclusively, in patients with symptomatic remission achieved at LOCF.

Personalized cognitive remediation therapy to facilitate return to work or to school in recent-onset psychosis

Cognitive deficits are barriers to job acquisition or return to school, and can be reduced through Cognitive remediation therapy (CRT). The main goal of this multiple case study was to investigate the effect of personalized CRT on occupational status in three participants with a recent-onset psychosis. Two cases improved their occupational status at post-treatment, and showed improvements in cognitive, psychological, and/or clinical variables. This study suggests that personalized CRT may facilitate job acquisition or return to school. However, the different pathways showed by our cases indicate that personalized CRT may influence occupational status through multiple mechanisms, underlining the relevance of treatment personalization.

Design and validation of a brief scale for cognitive evaluation in people with a diagnosis of schizophrenia (BCog-S)

WHAT IS KNOWN ON THE SUBJECT?: Schizophrenia is often related to cognitive deficits. Mental health nurses are involved in health promotion, prevention, treatment and rehabilitation in schizophrenia. However, the nursing literature addressing cognitive rehabilitation from schizophrenia is very limited. Cognition and its domains (communication, information processing, attentiveness, concentration, orientation, memory and calculation skills) are established by the Nursing Outcomes Classification (NOC), but they are difficult to measure. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: We present a new standardized cognitive assessment to be administered by nurses to people diagnosed with schizophrenia. The Brief Cognitive Scale for schizophrenia (BCog-S) was validated in people with a diagnosis of schizophrenia (including people with schizoaffective disorder), using as references both the assessment of controls matched by age, sex and educational level, and another brief cognitive battery as the gold standard. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses can effectively use the BCog-S to measure cognition and its domains in people with a diagnosis of schizophrenia. It is a standardized cognitive assessment consisting of a brief battery to be administered by nurses (and other professionals) to people diagnosed with schizophrenia. It is useful for establishing normative reference values for the outcome and its indicators. Using the BCog-S, nurses can determine the cognitive status of the people diagnosed with schizophrenia they care for, measuring cognitive improvements, lapses or stability attributable to their rehabilitation. Nurses can demonstrate their contribution to cognitive rehabilitation with these measurements of improvement or stability. ABSTRACT: Introduction Nurses play a key role in cognitive rehabilitation programs for people diagnosed with schizophrenia. Aim To design and validate a brief battery to assess the cognitive status of people diagnosed with schizophrenia from the nursing perspective. Method Study developed to evaluate a diagnostic test. The Brief Cognitive Scale for schizophrenia (BCog-S) is a hybrid battery composed of previously validated brief tests, designed to meet the dimensions of cognition considered by the NOC. The psychometric properties of the instrument were measured using the Screening for Cognitive Impairment in Psychiatry-Spanish version (SCIP-S) as the gold standard, and against the scores obtained by matched controls. Results About 100 people diagnosed with schizophrenia and 100 controls participated. The battery's internal consistency was 0.70. The Pearson correlation with the SCIP-S was 0.80 (sensitivity = 0.86, specificity = 0.80). The mean T-score of those diagnosed with schizophrenia was 2.2 standard deviations below that of the controls. There were significant differences in educational level, employment and cohabitation. Discussion The BCog-S showed acceptable psychometric properties. It can discriminate cognitive impairment and could be useful for establishing normative reference values. Implications for practice Nurses can use the BCog-S to measure cognition in people with a diagnosis of schizophrenia.

Randomised controlled trial of Compensatory Cognitive Training and a Computerised Cognitive Remediation programme

Background

Compensation and adaptation therapies have been developed to improve community functioning via improving neurocognitive abilities in people with schizophrenia. Various modes of delivering compensation and adaptation therapies have been found to be effective. The aim of this trial is to compare two different cognitive interventions, Compensatory Cognitive Training (CCT) and Computerised Interactive Remediation of Cognition–Training for Schizophrenia (CIRCuiTS). The trial also aims to identify if mismatch negativity (MMN) can predict an individual’s response to the compensation and adaptation programmes.

Methods

This study will use a randomised, controlled trial of two cognitive interventions to compare the impact of these programmes on measures of neurocognition and function. One hundred clinically stable patients aged between 18 and 65 years with a diagnosis of a schizophrenia spectrum disorder will be recruited. Participants will be randomised to either the CCT or the CIRCuiTS therapy groups. The outcome measures are neurocognition (BACS), subjective sense of cognitive impairment (SSTICS), social functioning (SFS), and MMN (measured by EEG) in people with schizophrenia spectrum disorders.

Discussion

This trial will determine whether different approaches to addressing the cognitive deficits found in schizophrenia spectrum disorders are of comparable benefit using the outcome measures chosen. This has implications for services where cost and lack of computer technology limit the implementation and dissemination of interventions to address cognitive impairment in routine practice. The trial will contribute to the emerging evidence of MMN as a predictor of response to cognitive interventions.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618000161224. Registered on 2 February 2018. Protocol version: 4.0, 18 June 2018.

Compensatory Interventions for Cognitive Impairments in Psychosis: A Systematic Review and Meta-Analysis

OBJECTIVE

Cognitive compensatory interventions aim to alleviate psychosocial disability by targeting functioning directly using aids and strategies, thereby minimizing the impact of cognitive impairment. The aim was to conduct a systematic review and meta-analysis of cognitive compensatory interventions for psychosis by examining the effects on functioning and symptoms, and exploring whether intervention factors, study design, and age influenced effect sizes.

METHODS

Electronic databases (Ovid Medline, PsychINFO) were searched up to October 2018. Records obtained through electronic and manual searches were screened independently by two reviewers according to selection criteria. Data were extracted to calculate estimated effects (Hedge's g) of treatment on functioning and symptoms at post-intervention and follow-up. Study quality was assessed using Cochrane Collaboration's risk of bias tool.

RESULTS

Twenty-six studies, from 25 independent randomized controlled trials (RCTs) were included in the meta-analysis (1654 participants, mean age = 38.9 years, 64% male). Meta-analysis revealed a medium effect of compensatory interventions on functioning compared to control conditions (Hedge's g = 0.46, 95% CI = 0.33, 0.60, P < .001), with evidence of relative durability at follow-up (Hedge's g = 0.36, 95% CI = 0.19, 0.54, P < .001). Analysis also revealed small significant effects of cognitive compensatory treatment on negative, positive, and general psychiatric symptoms, but not depressive symptoms. Estimated effects did not significantly vary according to treatment factors (ie, compensatory approach, dosage), delivery method (ie, individual/group), age, or risk of bias. Longer treatment length was associated with larger effect sizes for functioning outcomes. No evidence of publication bias was identified.

CONCLUSION

Cognitive compensatory interventions are associated with robust, durable improvements in functioning in people with psychotic illnesses.

Clarifying the direction of impact of negative symptoms and neurocognition on prospective work functioning in psychosis: A 20-year longitudinal study

Both neurocognition and negative symptoms have demonstrated strong links to functional outcomes, such as work functioning, among those with severe mental illness (SMI). Prior models have suggested that reduced neurocognition 1) precedes or predicts greater negative symptoms and 2) indirectly influences functional outcomes via its impact on negative symptoms. The current study sought to also test a divergent model: whether greater negative symptoms predict reduced neurocognition and indirectly influence work functioning through their impact on neurocognition. Both models were tested using cross-sectional and prospective data spanning 20-years in a sample of 277 people with a SMI with psychotic features. Results showed that both models were supported in cross-sectional analyses. However, in prospective models predicting work functioning, only the models examining the indirect influence of negative symptoms on work functioning (7.5 to up to 20-years later) through neurocognition demonstrated significant mediation (i.e., a significant indirect effect); further, higher negative symptoms significantly predicted lower prospective neurocognition, while lower neurocognition did not significantly predict greater prospective negative symptoms. Although cross-sectional data were consistent with prior models, our prospective models offered greater support for a putative causal pathway running from negative symptoms to neurocognition-rather than the reverse-to work functioning. Findings have implications for mechanisms contributing to longitudinal work functioning and suggest that targeting negative symptoms prior to neurocognition could be more beneficial for long-term work outcomes.

Cognitive and metacognitive factors predict engagement in employment in individuals with first episode psychosis

BACKGROUND

Research has demonstrated that cognitive abilities predict work outcomes in people with psychosis. Cognitive Remediation Programs go some way in improving work outcomes, but individuals still experience difficulty maintaining employment. Metacognition has been demonstrated to predict work performance in individuals with schizophrenia, but this has not yet been applied to First Episode Psychosis (FEP). This study assessed whether metacognition, intellectual aptitude and functional capacity can predict engagement in work and number of hours of work within FEP.

METHODS

Fifty-two individuals with psychosis, from an Early Intervention in Psychosis service, completed measures of IQ, metacognition (Metacognitive Assessment Interview), functional capacity (UPSA), and functional outcome (hours spent in structured activity per week, including employment).

RESULTS

Twenty-six participants (22 males, 4 females) were employed and twenty-six (22 males, 4 females) were not employed. IQ and metacognition were significantly associated with whether the individual was engaged in employment [IQ (p = .02) and metacognition (p = 006)]. When controlling for IQ, metacognition (differentiation subscale) remained significant (p = .04). Next, including only those employed, no cognitive nor metacognitive factors predicted number of hours in employment.

DISCUSSION

This is the first study to directly assess metacognition as a predictor of work hours for individuals with FEP. This study highlights the importance of enhancing metacognitive ability in order to improve likelihood of, and engagement in, employment for those with FEP.

Group cognitive behaviour therapy for supported employment - Results of a randomized controlled cohort trial

The merging of evidence-based interventions with supported employment programs are being increasingly studied, with encouraging results. The current study is aimed at determining the impact of a brief cognitive behaviour therapy group intervention adapted for supported employment programs (called CBT-SE) on the work outcomes of: obtaining a competitive job, number of weeks worked, and number of hours worked per week. Participants were randomized to either receive the 8-session CBT-SE group on top of their supported employment program, or to only receive their support employment program. The results show that those who received CBT-SE were significantly more likely to obtain a job (75% vs 58%), and worked a significantly greater number of hours (24 vs 18 hours per week). No differences were found in terms of number of weeks worked. Those in the CBT-SE condition also experienced a significant decrease in their negative symptoms over time, compared to the control condition. Although replication is needed, these results suggest that a brief cognitive-behavioural intervention specifically tailored to work-related issues can be greatly beneficial.

Cognitive impairment from early to middle adulthood in patients with affective and nonaffective psychotic disorders

BACKGROUND

Cognitive impairment is a core feature of psychotic disorders, but the profile of impairment across adulthood, particularly in African-American populations, remains unclear.

METHODS

Using cross-sectional data from a case-control study of African-American adults with affective (n = 59) and nonaffective (n = 68) psychotic disorders, we examined cognitive functioning between early and middle adulthood (ages 20-60) on measures of general cognitive ability, language, abstract reasoning, processing speed, executive function, verbal memory, and working memory.

RESULTS

Both affective and nonaffective psychosis patients showed substantial and widespread cognitive impairments. However, comparison of cognitive functioning between controls and psychosis groups throughout early (ages 20-40) and middle (ages 40-60) adulthood also revealed age-associated group differences. During early adulthood, the nonaffective psychosis group showed increasing impairments with age on measures of general cognitive ability and executive function, while the affective psychosis group showed increasing impairment on a measure of language ability. Impairments on other cognitive measures remained mostly stable, although decreasing impairments on measures of processing speed, memory and working memory were also observed.

CONCLUSIONS

These findings suggest similarities, but also differences in the profile of cognitive dysfunction in adults with affective and nonaffective psychotic disorders. Both affective and nonaffective patients showed substantial and relatively stable impairments across adulthood. The nonaffective group also showed increasing impairments with age in general and executive functions, and the affective group showed an increasing impairment in verbal functions, possibly suggesting different underlying etiopathogenic mechanisms.

The importance of clinical normative data for conceptualizing neuropsychological deficits in people with schizophrenia spectrum disorders

OBJECTIVE

To create clinical normative data tables for Norwegian patients with schizophrenia spectrum disorders, to examine whether clinical normative data from Norway differs from similar normative data from Canada and the U.S., and to illustrate the usefulness of such data.

METHOD

A nationally representative sample of 335 patients from psychiatric hospitals in Bergen, Norway was included. Inclusion criteria were 18-39 years of age, Norwegian as first language, and symptoms of schizophrenia, psychosis, or hallucinations. Comorbid substance abuse was recorded in 134 (40.0%). All completed the Norwegian version of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS).

RESULTS

The average scores of patients with schizophrenia spectrum disorders were approximately one to two standard deviations below the mean for healthy adults. There were no significant differences in scores between patients with or without comorbid substance abuse. Men had higher scores than women. Clinical normative reference value look-up tables were created.

CONCLUSIONS

Clinical normative values were very similar to values from Canada and the U.S. Clinical normative data, as a supplement to standard healthy normative data, can be used to describe patients' cognitive performance in terms of expectation for their peer group which can be useful for multidisciplinary treatment planning.

Psychosocial interventions for people with both severe mental illness and substance misuse

BACKGROUND

Even low levels of substance misuse by people with a severe mental illness can have detrimental effects.

OBJECTIVES

To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care.

SEARCH METHODS

The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison.

MAIN RESULTS

Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence).

AUTHORS' CONCLUSIONS

We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.

Cognitive remediation to improve the vocational outcomes of people with severe mental illness

The present study investigates the effects of cognitive remediation (CR) training with Individual Placement and Support (IPS) in people suffering from severe mental illness in European population (Spanish). Sixty-five participants (83% with schizophrenia or bipolar disorder) were recruited from community mental health teams. Fifty-seven met the criteria and agreed to participate in the study. The conditions of cognitive rehabilitation were assigned randomly with support employment CR + IPS (n = 28) and IPS alone (n = 29). Two groups were followed at 8 and 12 months after the baseline. Participants in the CR + IPS group improved more than the IPS only group during the follow-up period in measures of cognitive functioning (significantly higher in executive functions, verbal learning and memory) and obtained higher employment percentages during the follow-up period, including people who got a job after 8 months (52.2% versus 29.2%, p = .023) and after 1 year (60.9% versus 37.5%, p = .025), as well as, in the weekly hours worked (37.2 versus 26.7 h, p = .023). Retention in the CR + IPS program was high (82.14%). The calculated global cognitive score showed that the evolution over time differed significantly between groups (p < .001).

Treatment Adherence in Youth with First-Episode Psychosis: Impact of Family Support and Telehealth Delivery

Mental health-care delivery to young people with first-episode schizophrenia presents significant challenges especially in underserved areas. This chart review reveals the importance of family support as a predictor for medication and treatment adherence with this vulnerable group. An unexpected disengagement rate of 47% was discovered. It was further discovered that receiving care with telehealth delivery was a significant predictor of lost to follow-up or treatment nonadherence. Recommendations include psychoeducation for families during the initial crisis, initiation of long-acting injectable antipsychotics early in care, a hybrid telehealth intervention with in-home medication delivery, and collaboration with educational, vocational county agencies for employment support. A system of care must be developed to support young people with this severe illness for optimum outcome and protection of long-term cognitive functioning.

Costs of inpatient care of depression in 2014 in Polish (Poznan) and German (Kiel) hospital

Objectives: Depression is highly prevalent worldwide and generates significant economic burden. Despite this, there is still insufficient information on hospitalisation costs related to depression. Therefore, this paper presents a comparison of costs of inpatient care of depression among patients hospitalised in 2014 in Kiel (Germany) and in Poznan (Poland).Methods: The retrospective study was conducted from October 2015 to May 2017 in Kiel and in Poznan and concerned all patients (n = 548 and eventually included n = 444; 334 in Kiel and 110 in Poznan) hospitalised in these centres.Results: The annual cost of inpatient care of patients hospitalised due to depression in 2014 was EUR [Formula: see text] = EUR 9397.21 (total EUR 313,8667.2) in Kiel and EUR [Formula: see text] = EUR 2962.90 (total EUR 325,919.38) in Poznan. In Kiel, the most frequently prescribed medicine was mirtazapine while in Poznan it was venlafaxine.Conclusions: The 3-fold difference in average costs of hospitalisation might result from differences in funding of mental health care which in Poland needs urgent amendment. Besides, mental health care was underfunded in Poznan. In general, treatment was comprehensive in both centres. Non-pharmacological treatment, however, was more comprehensive in Kiel.KEY POINTSThe cost of inpatient care of depression was very high both in Kiel and Poznan.Inpatient care of depression is long-lasting, but a reduction in the length of hospital stay seems to be possible.Hospital stay is the main part of costs of inpatient care of depression.Treatment of depression should be comprehensive, but differences e.g. in pharmacotherapy used are possible between hospitals and/or countries.

Multi-outcome meta-analysis (MOMA) of cognitive remediation in schizophrenia: Revisiting the relevance of human coaching and elucidating interplay between multiple outcomes

Cognitive remediation (CR) is nowadays mainly administered in a computerized fashion, yet frequently supplemented by human guidance. The effects of CR on cognitive, functional and clinical outcomes are consistently reported, yet the response is heterogeneous. In order to resolve this heterogeneity, we employed a multi-outcome meta-analytic approach, examined effects of CR on each outcome category separately and estimated directed effects between three outcome categories. We extracted treatment effects from 67 studies that trained patients with schizophrenia (total n = 4067) using either 1) computerized CR modality alone or 2) in combination with supplementary human guidance (SHG). All three outcome domains were significantly improved by CR with small to moderate effect sizes when assessing outcomes across all studies. The comparison between CR administered with SHG revealed largest effects on the cognitive subdomains of working and verbal memory. Structural equation modeling in the single-study data suggests that cognitive gains trigger restoration of psychosocial functioning which in turn facilitates improvement in clinical symptoms.

A systematic review of moderators of cognitive remediation response for people with schizophrenia

Background

There is evidence that cognitive remediation (CR) is moderately effective in improving cognitive and functional difficulties in people with schizophrenia. However, there is still a limited understanding of what influence different treatment responses.

Aim

To identify moderators influencing CR response in people with schizophrenia.

Methods

This systematic review follows PRISMA guidelines. Searches were conducted up to January 2019 on PubMed and PsychInfo to identify randomized controlled trials of CR reporting analyses of moderators of treatment response. All papers were assessed for methodological quality and information on sample size, intervention and control condition, moderators, outcomes, effect of moderator on outcomes and demographic characteristics from each study was extracted and critically summarised.

Results

Thirty-six studies were included, considering 2737 participants. Study participants consisted on average of people in their late-thirties, mostly men, with over 10 years of illness. The review identified moderators that could be grouped into five categories: demographics, biological, cognitive and functional, psychological, and illness-related characteristics. The assessment of methodological quality showed that many studies had a high risk of bias.

Conclusions

There was no high-quality replicated evidence which identifies reliable moderators of CR response. Many moderators were not replicated or presented in single, underpowered studies. Studies also investigated moderators independently despite their potential to overlap (e.g. age and education). Future research should concentrate on evaluating, with sound studies, the role moderators may play in affecting CR treatment response. This information can inform who will benefit most from the therapy and help to improve the benefits of CR.