Sequential mixed method evaluation of the acceptability, feasibility, and appropriateness of cognitive behavioral therapy for psychosis stepped care

Background

Cognitive Behavioral Therapy for psychosis (CBTp) is recommended by national treatment guidelines yet remains widely inaccessible in the U.S. A stepped care model, favored and feasible for other scarce interventions, may improve access to CBTp.

Methods

We employed an exploratory sequential mixed method design inclusive of two distinct phases to quantitatively evaluate the acceptability, feasibility, and appropriateness of CBTp Stepped Care (CBTp-SC) among practitioners who were trained in low-intensity CBTp (Step 1), Group-Administered CBTp (Step 2), and Formulation-based CBTp (Step 3). In Phase 1, we queried respondents using the Acceptability of Intervention Measure, Intervention Appropriateness Measure, and the Feasibility of Intervention Measure to ascertain perceptions of these leading indicators of implementation success. In Phase 2, we conducted focus groups with CBTp-SC-trained practitioners (n = 10) and administrators (n = 2) from 2 of the 4 Phase 1 study sites to evaluate the theoretical assumptions of stepped care and to better understand key barriers and facilitators.

Results

Forty-six practitioners trained in all three levels of CBTp-SC completed the online survey in Phase 1. All participants were employed by a community mental health agency currently sustaining CBTp-SC. Respondents endorsed high levels of acceptability, feasibility, and appropriateness for the CBTp-SC model. We found evidence to suggest that licensed practitioners and Step 3 practitioners perceived formulation-based CBTp as more appropriate for their clients. In Phase 2, six themes emerged which affirmed the utility of the model for stakeholders, supported stepped care theoretical assumptions, and revealed key areas for improvement.

Conclusions

Early adopters of CBTp-SC in the U.S. perceive it to be acceptable, feasible, and appropriate in community mental health care settings. Practitioners and administrators identified training and implementation barriers, including the importance of organizational readiness, a CBTp coordinator role, and a desire to adapt the intervention. These early findings will facilitate iterative refinement of the stepped care model for U.S. public behavioral health agencies. Additional research is needed to explore perceptions and clinical outcomes among CBTp service users.

The impact of familial involvement on dropout in a culturally informed group therapy for people diagnosed with 'schizophrenia'

Background

Individuals with schizophrenia diagnoses are high-risk for dropout from mental health treatments, yet few studies have examined whether familial involvement in therapy impacts dropout.

Methods

We examined whether familial involvement and other demographic variables predicted dropout among 101 patients enrolled in culturally informed group therapy for schizophrenia (CIGT-S), which incorporates collectivistic principles and spiritual coping into treatment. We reviewed records and conducted follow-up calls to identify reasons for dropout, and performed survival analyses to identify when dropout was likely.

Results

Familial involvement was linked to greater engagement with treatment and lower dropout, signifying a mechanism for improving treatment attendance in this group. Ethnic minorities and patients with higher symptom severity demonstrated higher rates of dropout. Most patients dropped out of CIGT-S before treatment began. However, significantly lower levels of dropout were observed among those who made it to session 9 (end of the spirituality module). An inability to maintain contact with participants was the most cited reason for dropout within records, and structural reasons (e.g., moving away) were commonly cited among participants who were successfully followed-up with.

Discussion

Future work may identify whether family functioning or the quality of familial relationships may predict familial involvement and, consequently, treatment attendance.

Central Assessment of Psychosis Service: A Tele-evaluation Service to Support Early Identification of Psychosis

Duration of untreated psychosis (DUP) is a reliable predictor of longitudinal psychosis trajectory. The limited availability of specialized assessment needed for early identification contributes to a lengthy average DUP in the United States. This column outlines the development of the Central Assessment of Psychosis Service (CAPS), a novel tele-evaluation service that extends specialized expertise in screening and assessment of psychosis and psychosis risk to publicly funded early psychosis clinics. Preliminary implementation outcomes among the first five CAPS sites suggest that CAPS is acceptable, appropriate, and feasible to implement. Programmatic data collection is underway and will be reported at a future date.

Mental Health Disparities, Treatment Engagement, and Attrition Among Racial/Ethnic Minorities with Severe Mental Illness: A Review

Mounting evidence indicates that there are mental health disparities in the United States that disadvantage racial/ethnic minorities in medical and mental health settings. Less is known, however, about how these findings apply to a particularly vulnerable population, individuals with severe mental illness (SMI). The aim of this paper is to (1) provide a critical review of the literature on racial/ethnic disparities in mental health care among individuals with SMI; (2) identify factors which may contribute to the observed disparities; and (3) generate recommendations on how best to address these disparities. Specifically, this article provides an in-depth review of sociocultural factors that may contribute to differences in treatment engagement and rates of attrition from treatment among racial/ethnic minorities with SMI who present at medical and mental health facilities. This review is followed by a discussion of specific strategies that may promote engagement in mental health services and therefore reduce racial/ethnic disparities in SMI.

Stigma, Expressed Emotion, and Quality of Life in Caregivers of Individuals with Dementia

Expressed emotion (EE) is a measure of a caregiver's critical and emotionally overinvolved (EOI; e.g., intrusive, self-sacrificing) attitudes and behaviors toward a person with a mental illness. Mounting evidence indicates that high levels of these critical and EOI attitudes and behaviors (collectively termed high EE) in family members are associated with a poorer course of illness for people with a range of disorders, including dementia (Nomura et al., 2005). However, less is known about factors that might trigger high EE and how high EE might impact dementia caregivers' own mental health. In this study we propose that caregivers who perceive stigma from their relative's illness may be more likely to be critical or intrusive (high EOI) toward their relative in an attempt to control symptomatic behaviors. We further hypothesized that high EE would partially mediate the link between stigma and quality of life (QoL) as there is some evidence that high EE is associated with poorer mental health in caregivers themselves (Safavi et al., 2015). In line with study hypotheses and using a sample of 106 dementia caregivers, we found that greater caregiver stigma was associated with both high EE (for criticism and EOI) and with poorer QoL. Mediational analyses further confirmed that high EE accounts for much of the association between stigma and poorer QoL. Study results suggest that addressing caregiver stigma in therapy could reduce levels of high EE and indirectly therefore improve caregiver QoL. Intervening directly to reduce high EE could also improve caregiver QoL.

Acculturation styles and their associations with psychiatric symptoms and quality of life in ethnic minorities with schizophrenia

This study examined whether Berry's model of acculturative stress would predict psychiatric symptom severity and quality of life (QoL) in ethnic minorities with schizophrenia. Tested extensively in non-psychiatric populations, Berry's framework generally suggests that integration, or engagement with both the host and minority culture, is most adaptive. Using the Abbreviated Multidimensional Acculturation Scale (AMAS), we tested the hypothesis that individuals with schizophrenia who employed an integrative acculturation strategy would have the highest QoL and lowest symptom severity, followed by the assimilation and enculturation groups, then the marginalized group. Psychiatric symptoms and QoL were regressed on AMAS assimilation scores, enculturation scores, and the interaction term in a sample of 128 Hispanic and Blacks with schizophrenia (M age = 41.28; 70% male). Acculturation strategy was not found to relate to psychiatric symptoms (measured from the Brief Psychiatric Rating Scale). However, acculturation strategy did predict QoL (measured from the Quality of Life Inventory), and results were in line with Berry's model. Marginalization may exacerbate issues surrounding social identity in schizophrenia, including low self-concept clarity and internalized stigma. Encouraging bicultural individuals with schizophrenia to interact with the host culture while also practicing traditions from their minority culture may help improve their quality of life.

The feasibility of a culturally informed group therapy for patients with schizophrenia and their family members

Research suggests that group-based psychosocial treatments for schizophrenia provide benefits to patients and family members alike. However, few existing treatments consider cultural factors that may enhance their efficacy with diverse populations. The current study examined the feasibility of a culturally informed group therapy for schizophrenia (CIGT-S), which incorporates collectivistic principles and spiritual coping into the treatment protocol. The feasibility of the group protocol was tested by examining differences in patient symptom severity and patient and family member depression, anxiety, and stress after completion of the group program. Within-groups analyses were conducted comparing baseline data to group termination data from 12 patients and 11 family members. Additionally, between-groups analyses were conducted comparing waitlist termination data from 20 patients and 13 family members to group termination data from 12 patients and 11 family members. Finally, we examined participant satisfaction with the group protocol, including qualitative reports on components of the protocol that participants deemed most valuable. Results indicated that patients demonstrated lower levels of symptom severity upon completion of the CIGT-S program; however, no other significant effects were found. Results examining overall patient and family member satisfaction with the treatment protocol indicated that patients and family members both reported being highly satisfied by the treatment program. This was also represented in participant's open-ended responses to our satisfaction questionnaire. These findings indicate that CIGT-S may represent a feasible, cost-effective approach that can be flexibly used with patients and family members of diverse racial and ethnic backgrounds. (PsycINFO Database Record

Free will perceptions and psychiatric symptoms in patients diagnosed with schizophrenia

WHAT IS KNOWN ON THE SUBJECT?: Some research suggests that holding a free will perspective may offer mental health and physical health benefits. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This study is the first to examine links between free will perceptions and psychiatric symptoms in patients diagnosed with schizophrenia. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Study results suggest that helping people with a diagnosis of schizophrenia to recognize situations where they do have some freedom of choice over their actions and emotional reactions (free will) may assist them in improving their experiences and better managing their symptoms.

ABSTRACT

Introduction Some research indicates that having a strong sense that one possesses free will may be associated with better psychological and physical health. This study is the first to examine the relationship between free will perceptions and psychiatric symptoms in patients with a diagnosis of schizophrenia. Method Thirty-two participants were interviewed using the Brief Psychiatric Rating Scale to assess symptom severity and the Free Will Subscale of the Free Will and Determinism Scale to assess free will perceptions. Results As hypothesized, a negative association was found between free will perceptions and total symptom severity, though it appears that this was mainly accounted for by positive symptoms. A content analysis was also conducted to qualitatively examine how patients conceptualize the construct of free will and its role in coping with their own mental illness. Discussion Study results suggest that holding a free will perspective may mitigate psychiatric symptoms in patients with a diagnosis of schizophrenia. Thus, psychiatric nurses and other mental health clinicians may improve current treatments for schizophrenia by helping patients recognize situations where they do have some freedom of choice over their actions and emotional reactions (free will) to stressful life events.

A randomized clinical trial to test the efficacy of a family-focused, culturally informed therapy for schizophrenia

Research strongly suggests that family interventions can benefit patients with schizophrenia, yet current interventions often fail to consider the cultural context and spiritual practices that may make them more effective and relevant to ethnic minority populations. We have developed a family focused, culturally informed treatment for schizophrenia (CIT-S) patients and their caregivers to address this gap. Sixty-nine families were randomized to either 15 sessions of CIT-S or to a 3-session psychoeducation (PSY-ED) control condition. Forty-six families (66.7%) completed the study. The primary aim was to test whether CIT-S would outperform PSY-ED in reducing posttreatment symptom severity (controlling for baseline symptoms) on the Brief Psychiatric Rating Scale. Secondary analyses were conducted to test whether treatment efficacy would be moderated by ethnicity and whether patient-therapist ethnic match would relate to efficacy and patient satisfaction with treatment. Patients included 40 Hispanic/Latinos, 14 Whites, 11 Blacks, and 4 patients who identified as "other." In line with expectations, results from an ANCOVA indicated that patients assigned to the CIT-S condition had significantly less severe psychiatric symptoms at treatment termination than did patients assigned to the PSY-ED condition. Patient ethnicity and patient-therapist ethnic match (vs. mismatch) did not relate to treatment efficacy or satisfaction with the intervention. Results suggest that schizophrenia may respond to culturally informed psychosocial interventions. The treatment appears to work equally well for Whites and minorities alike. Follow-up research with a matched length control condition is needed. Further investigation is also needed to pinpoint specific mechanisms of change.