Training individuals with schizophrenia to gain volitional control of the theory of mind network with real-time fMRI: A pilot study.

Individuals diagnosed with schizophrenia spectrum disorders (SSDs) often demonstrate alterations in the Theory of Mind Network (ToM-N). Here, in this proof-of-concept, single-arm pilot study, we investigate whether participants with an SSD (N = 7) were able to learn to volitionally control regions of the ToM-N (dorso/middle/ventromedial prefrontal cortex [D/M/VMPFC], left temporoparietal junction [LTPJ], precuneus [PC], right superior temporal sulcus [RSTS], and right temporoparietal junction [RTPJ]) using real-time fMRI neurofeedback (rtfMRI-NF). Region-of-interest analyses demonstrate that after neurofeedback training, participants were able to gain volitional control in the following ToM-N brain regions during the transfer task, where no active feedback was given: right temporoparietal junction, precuneus, and dorso/ventromedial prefrontal cortex (neurofeedback effect Fs > 6.17, ps < .05). These findings suggest that trained volitional control over the ToM-N is tentatively feasible with rtfMRI neurofeedback in SSD, although findings need to be replicated with more robust designs that include a control group and larger samples.

Lifestyle and mood correlates of cardiometabolic risk in people with serious mental illness on second-generation antipsychotic medications.

INTRODUCTION: Cardiovascular morbidity and mortality are high in people with serious mental illness (SMI). This problem is mediated, at least in part, by metabolic side effects of second-generation antipsychotics (SGAs) and by unhealthy lifestyle behaviors. We asked whether oral glucose tolerance testing (oGTT) or hemoglobin A1c (HbA1c) is superior in identifying people with SMI at high cardiometabolic risk and whether this risk is shaped by mood, cognition, or lifestyle habits. METHODS: We evaluated 40 patients with schizophrenia, schizoaffective, or bipolar disorder receiving SGAs by oGTT, HbA1c, comprehensive metabolic and lipid panels, and CRP. Mood was assessed using the Patient Health Questionnaire (PHQ-9), and cognition was assessed using the Saint Louis University Mental Status examination. Diet was assessed using the UK Diabetes and Diet Questionnaire (UKDDQ), and physical activity was assessed using daily step counts. RESULTS: Most patients had prediabetes (preDM) or diabetes mellitus (DM), 72.5% by oGTT, and 52.5% by HbA1c criteria. Pulse rates and insulin resistance indices (Homeostatic Model Assessment of Insulin Resistance, HOMA IR; Matsuda) were significantly different between patients classified as normal or with preDM/DM, using either oGTT or HbA1c criteria. Patients with preDM/DM by HbA1c but not oGTT criteria also had higher waist/hip ratios, triglyceride, and CRP levels (p<0.05). A strong negative correlation was found between average daily step counts and CRP levels (rho = -0.62, p<0.001). Higher UKDDQ scores, or unhealthier diet habits, were associated with higher fasting plasma glucose (rho = 0.28, p = 0.08), triglyceride levels (rho = 0.31, p = 0.05), and insulin resistance (HOMA IR: rho = 0.31, p = 0.06). Higher PHQ-9 scores correlated with lower 2h-oGTT glucose levels (rho = -0.37, p<0.05). CONCLUSIONS: OGTT screening is superior to HbA1c screening in detecting preDM and DM early. Patients identified with preDM/DM by oGTT or HbA1c screening are insulin-resistant and have higher pulse rates. Abdominal obesity, unfavorable lipid profiles, and higher CRP levels were noted in patients screened by HbA1c, but not by oGTT. Low physical activity, low depression scores, and unhealthy diet habits were associated with higher CRP and higher glucose and triglyceride levels, respectively. Future studies should assess the impact of specifically tailored individual lifestyle counseling and medical management interventions in this high-risk population.

Decision-making under risk and its correlates in schizophrenia.

Schizophrenia spectrum disorders (SSD) are associated with pervasive cognitive impairments, including deficits in decision-making under risk. However, there is inconclusive evidence regarding specific mechanisms underlying altered decision-making patterns. In this study, participants (33 SSD and 28 non-SSD) completed the Columbia Card Task, an explicit risk-taking task, to better understand risk preference and adjustment in dynamic decision-making. We found that while there is no group difference in overall risk-taking, risk preference, or optimal decision-making, risk adjustment to contextual factors (e.g., loss probability) is blunted in SSD. We also found associations between risk-taking/suboptimal decision-making and disorganized symptoms, excited symptoms, and role functioning, but no associations between decision-making and working memory. These results suggest that during a complex, dynamic risk-taking task, individuals with SSD exhibit less adaption to changing information about risk, which may reflect risk imperception.

Training volitional control of the theory of mind network with real-time fMRI neurofeedback.

Is there a way improve our ability to understand the minds of others? Towards addressing this question, here, we conducted a single-arm, proof-of-concept study to evaluate whether real-time fMRI neurofeedback (rtfMRI-NF) from the temporo-parietal junction (TPJ) leads to volitional control of the neural network subserving theory of mind (ToM; the process by which we attribute and reason about the mental states of others). As additional aims, we evaluated the strategies used to self-regulate the network and whether volitional control of the ToM network was moderated by participant characteristics and associated with improved performance on behavioral measures. Sixteen participants underwent fMRI while completing a task designed to individually-localize the TPJ, and then three separate rtfMRI-NF scans during which they completed multiple runs of a training task while receiving intermittent, activation-based feedback from the TPJ, and one run of a transfer task in which no neurofeedback was provided. Region-of-interest analyses demonstrated volitional control in most regions during the training tasks and during the transfer task, although the effects were smaller in magnitude and not observed in one of the neurofeedback targets for the transfer task. Text analysis demonstrated that volitional control was most strongly associated with thinking about prior social experiences when up-regulating the neural signal. Analysis of behavioral performance and brain-behavior associations largely did not reveal behavior changes except for a positive association between volitional control in RTPJ and changes in performance on one ToM task. Exploratory analysis suggested neurofeedback-related learning occurred, although some degree of volitional control appeared to be conferred with the initial self-regulation strategy provided to participants (i.e., without the neurofeedback signal). Critical study limitations include the lack of a control group and pre-rtfMRI transfer scan, which prevents a more direct assessment of neurofeedback-induced volitional control, and a small sample size, which may have led to an overestimate and/or unreliable estimate of study effects. Nonetheless, together, this study demonstrates the feasibility of training volitional control of a social cognitive brain network, which may have important clinical applications. Given the study's limitations, findings from this study should be replicated with more robust experimental designs.

Affordability of Forensic Assertive Community Treatment Programs: A Return-on-Investment Analysis.

OBJECTIVE: In this study, the authors assessed return on investment (ROI) associated with a forensic assertive community treatment (FACT) program. METHODS: A retrospective secondary data analysis of a randomized controlled trial comprising 70 legal-involved patients with severe mental illness was conducted in Rochester, New York. Patients were randomly assigned to receive either FACT or outpatient psychiatric treatment including intensive case management. Unit of service costs associated with psychiatric emergency department visits, psychiatric inpatient days, and days in jail were obtained from records of New York State Medicaid and the Department of Corrections. The total dollar value difference between the two trial arms calculated on a per-patient-per-year (PPPY) basis constituted the return from the FACT intervention. The FACT investment cost was defined by the total additional PPPY cost associated with FACT implementation relative to the control group. ROI was calculated by dividing the return by the investment cost. RESULTS: The estimated return from FACT was $27,588 PPPY (in 2019 dollars; 95% confidence interval [CI]=$3,262-$51,913), which was driven largely by reductions in psychiatric inpatient days, and the estimated investment cost was $18,440 PPPY (95% CI=$15,215-$21,665), implying an ROI of 1.50 (95% CI=0.35-2.97) for FACT. CONCLUSIONS: The Rochester FACT program was associated with approximately $1.50 return for every $1 spent on its implementation, even without considering potential returns from other sources, including reductions in acute medical care, crime-related damages, and public safety costs. ROI estimates were highly dependent on context-specific factors, particularly Medicaid reimbursement rates for assertive community treatment and hospital stays.

Social affective forecasting and social anhedonia in schizophrenia-spectrum disorders: a daily diary study.

Social anhedonia (SA) is a trait-like phenomenon observed across schizophrenia-spectrum disorders (SSDs). While in-the-moment social pleasure experiences are intact in SSDs, anticipatory pleasure experiences may be disrupted. Thus, the prediction of future emotions in social situations, or social affective forecasting (SAF), may play a role in SA. Therefore, we utilized daily diary methods to examine SAF in SSD and the association between SAF and SA in 34 SSD and 43 non-SSD individuals. SAF was calculated as the absolute difference between anticipatory and consummatory ratings of 13 positive and negative emotions for daily social interactions reported across eight days. Results suggest that individuals with SSDs are less accurate in forecasting negative, but not positive emotions, for future social interactions. Further, poorer forecasting accuracy of negative emotions were associated with elevated levels of SA and lower social pleasure. Together, these data suggest that inaccuracies in forecasting negative emotions may be a worthwhile intervention target for reducing SA in SSDs.

Promoting Mental Health and Criminal Justice Collaboration Through System-Level Partnerships.

Recent high-profile deaths of unarmed individuals in police custody have raised concerns about the role of police officers in responding to people who are experiencing mental health crises. Of further concern, people with serious mental illness are highly over-represented throughout the entire criminal justice system including within jail, prison and community corrections populations. It is widely accepted that promoting mental health and criminal justice collaboration is a key to addressing these concerns. Promoting effective collaboration is challenging, however, due to fundamental differences in cultures and methods that exist between mental health and criminal justice service providers. To promote effective collaboration between service providers, a conceptual framework was recently published that divides the collaborative process into separate steps and outlines respective responsibilities at each step. Yet optimal collaboration between mental health and criminal justice service providers requires the support of their respective supervisors and agency heads. This paper extends previous work at the service provider level by applying the conceptual framework to promote effective collaboration at the systems level (i.e., between agencies). Barriers to inter-agency collaboration are discussed, and strategies for facilitating collaboration at each step of the collaborative process are presented.

Essential Elements of Forensic Assertive Community Treatment.

LEARNING OBJECTIVE: After participating in this activity, learners should be better able to:• Assess characteristics of forensic assertive community treatment programs. ABSTRACT: Forensic assertive community treatment (FACT) has emerged internationally as an intervention strategy for people with serious mental disorders who are involved with the criminal justice system. Studies to date have shown marked variability, however, in FACT program design and operation. Based upon a literature review and relevant experience, the authors present their perspective on the essential elements of FACT. Given that FACT is an adaptation of the evidence-based assertive community treatment (ACT) model, it is recommended that FACT programs maintain a high-fidelity ACT component. FACT programs should also have both mental health and criminal justice admission criteria because service recipients are involved in both service systems. For optimal effectiveness, FACT team clinicians must partner with criminal justice agencies that provide community-based supervision to their patients. Prospective FACT enrollees should receive a clear explanation of the program, including how their respective mental health and criminal justice service providers will work collaboratively with them to prevent incarceration. FACT programs should also use risk/need assessment to inform treatment planning, evidence-based mental health and community correctional practices to promote both wellness and public safety, and shared training to promote effective collaboration. Additional elements to consider include housing, medical care, and transitional services. These elements are presented and discussed, including a rationale and evidence to support each component. The article concludes with introduction of a FACT fidelity scale, the Rochester Forensic Assertive Community Treatment Scale (R-FACTS). By operationalizing essential FACT elements, the R-FACTS is designed to support FACT program development, implementation, and dissemination in a more consistent and measurable manner.

Psychosis, Mania and Criminal Recidivism: Associations and Implications for Prevention.

People with mental illness are overrepresented throughout the criminal justice system, including jail, prison, probation, and parole populations. Yet much disagreement remains about why this problem exists and how best to address it. This article specifically examines empirical evidence regarding the question of whether psychosis and mania are associated with criminal recidivism, and whether this association is predictive or causal in nature. Review of the current literature suggests that psychotic and manic symptoms are associated with increased likelihood of arrest and incarceration. In addition, current evidence shows that pharmacotherapy can reduce criminal recidivism among justice-involved adults with psychosis or mania. However, the extent to which the association between psychosis, mania, and criminal justice system involvement is causal remains uncertain. Also, the literature suggests that most crimes committed by people with schizophrenia spectrum disorders or bipolar I disorder may be driven by factors other than their psychotic or manic symptoms. These established "criminogenic needs" are more common among people with severe mental disorders than in the general population. For optimal prevention, those who serve justice-involved adults with psychosis or mania in community settings should consider addressing the full range of factors that potentially drive their criminal justice system involvement.

Glucagon-Like Peptide Analogs Are Superior for Diabetes and Weight Control in Patients on Antipsychotic Medications: A Retrospective Cohort Study.

OBJECTIVE: Glucagon-like peptide (GLP-1) analogs promote diabetes control and weight loss. Most GLP-1 analogs also lower adverse cardiovascular outcomes, making them ideal agents for patients with severe mental illness. The objective of this study was to analyze diabetic patients taking antipsychotic medications, comparing those on GLP-1 analogs with those on other diabetes treatments. METHODS: A total of 46 patients referred to outpatient diabetes clinics between July 2010 and April 2017 who were prescribed antipsychotic medications during the entire study period were included in this retrospective analysis. Eleven (24%) patients were started on a GLP-1 analog (cases), and 35 (76%) were treated with alternative antidiabetic agents (controls). RESULTS: Cases and controls did not differ in age, sex, height, weight, or medical therapies at the time of referral. Within 1 year, a reduction in mean ± SE glycosylated hemoglobin (HbA1c) levels was noted for both groups (cases: -1.26% ± 0.17%, controls: -1.47% ± 0.45%). However, while patients on GLP-1 analogs lost 7.07 ± 2.62 kg, control patients gained 1.93 ± 1.14 kg (P < .05). Blunted HbA1c reductions were also noted in patients who took antipsychotic medication in addition to antidepressant medication (on antidepressant medication [n = 22]: -0.77% ± 0.29%, off antidepressant medication [n = 9]: -2.97% ± 0.6%, P < .001). This observation did not apply to patients treated with GLP-1 analogs, as they had larger HbA1c reductions than patients on alternative regimens (controls [n = 15]: -0.46% ± 0.4%, cases [n = 7]: -1.43% ± 0.15%, P < .05). CONCLUSIONS: GLP-1 analogs promote both diabetes and weight control in diabetic patients on antipsychotic medications with or without antidepressant medications.

Feasibility of peer support services among people with severe mental illness in China.

BACKGROUND: Peer-delivered services potentially provide broad, multifaceted benefits for persons suffering severe mental illness. Most studies to date have been conducted in countries with well-developed outpatient mental health systems. The objective of this study was to examine the feasibility for developing a community-based peer service in China. METHODS: Thirteen peer service providers and 54 consumers were recruited from four communities in Beijing. We initiated the program in two communities, followed by another two in order to verify and add to our understanding of potential scalable feasibility. Semi-structured face-to-face interviews were conducted 12 month after initiation at each site to measure satisfaction and perceived benefits from perspectives of peer service providers, and consumers and their caregivers. RESULTS: Key stakeholders reported that peer support services were satisfying and beneficial. Eleven of 13 peer service providers were willing to continue in their roles. Ten, 8, and 7 of them perceived improvements in working skills, social communication skills, and mood, respectively. Among consumers, 39 of 54 were satisfied with peer services. Improvements in mood, social communication skills, illness knowledge, and illness stability were detected among 23, 18, 13, and 13 consumers, respectively. For caregivers, 31 of 32 expressed a positive view regarding peer services. Caregivers reported improvement in their own mood, confidence in recovery of their family members, and reduction in caretaker burdens. CONCLUSIONS: The findings highlight that peer-delivered services have promise in China for benefiting persons with severe mental illness and their family caregivers, as well as the peer service providers themselves.

Evaluation of a plasticity-based cognitive training program in schizophrenia: Results from the eCaesar trial.

OBJECTIVE: Cognitive impairment in schizophrenia is a core feature of the disorder. Computerized cognitive training has shown promise in pilot studies. A 26-week randomized blinded placebo-controlled trial was conducted to investigate the effect of a novel computerized cognitive training program on cognitive and functional capacity outcomes. METHOD: The study followed MATRICS guidelines for the evaluation of interventions designed to improve cognitive function in schizophrenia. Participants (N = 150) were randomized to experimental (computerized cognitive training in a game-like format) or active control (computer games) groups. Training was conducted in-clinic, with an intended training schedule of 5 days per week, 1 h per day, for 26 weeks. Co-primary outcome measures were the MATRICS Consensus Cognitive Battery (MCCB) composite score and the UCSD Performance-Based Skills Assessment (UPSA-2) total score, secondary outcome measures included the Cognitive Assessment Interview (CAI) and the Short-Form-12 Mental Composite Score (SF-12 MCS). Target engagement was assessed with task-learning based assessment. RESULTS: At baseline, the groups were well matched. No significant effect of the experimental treatment was seen on the primary or secondary outcome measures compared to the active control. Review of the task learning/target engagement data suggested inadequate target engagement. CONCLUSIONS: Results do not support a cognitive or functional capacity benefit from this implementation of a computerized cognitive training program in people with schizophrenia. In future trials, careful consideration is merited of the assessment of task learning/target engagement, the effects of making the cognitive training game-like on motivation, and the implicit effects of trial requirements on participant selection.

A Randomized Controlled Trial of the Rochester Forensic Assertive Community Treatment Model.

OBJECTIVE: Forensic assertive community treatment (FACT) is an adaptation of the assertive community treatment model and is designed to serve justice-involved adults with serious mental illness. This study compared the effectiveness of a standardized FACT model and enhanced treatment as usual in reducing jail and hospital use and in promoting engagement in outpatient mental health services. METHODS: Seventy adults with psychotic disorders who were arrested for misdemeanor crimes and who were eligible for conditional discharge were recruited from the Monroe County, New York, court system. Participants were randomly assigned to receive either FACT (N=35) or enhanced treatment as usual (N=35) for one year. Criminal justice and mental health service utilization outcomes were measured by using state and county databases. RESULTS: Forty-nine participants (70%) completed the full one-year intervention period. Nineteen (27%) were removed early by judicial order, one was removed by county health authorities, and one died of a medical illness. Intent-to-treat analysis for all 70 participants showed that those receiving the FACT intervention had fewer mean±SD convictions (.4±.7 versus .9±1.3, p=.023), fewer mean days in jail (21.5±25.9 versus 43.5±59.2, p=.025), fewer mean days in the hospital (4.4±15.1 versus 23.8±64.2, p=.025), and more mean days in outpatient mental health treatment (305.5±92.1 versus 169.4±139.6, p<.001) compared with participants who received treatment as usual. CONCLUSIONS: The Rochester FACT model was associated with fewer convictions for new crimes, less time in jail and hospitals, and more time in outpatient treatment among justice-involved adults with psychotic disorders compared with treatment as usual.

Physical Health, Medication, and Healthcare Utilization among 70-Year-Old People with Schizophrenia: A Nationwide Danish Register Study.

OBJECTIVES: In light of the excess early mortality in schizophrenia, mainly due to physical illnesses, we investigated medical comorbidity, use of medication, and healthcare utilization among individuals with schizophrenia who survived into older ages to uncover potential factors contributing to their longevity. DESIGN: A nationwide register-based case-control study comparing 70-year-olds with and without schizophrenia. SETTING: Cases were drawn from the Danish Psychiatric Central Register. Age- and sex-matched controls were drawn from the general population via the Civil Registration System. PARTICIPANTS: All Danish inhabitants who were diagnosed and registered with early onset schizophrenia in 1970-1979 and still alive at age 70 years. Controls alive at age 70 years. MEASUREMENTS: Chronic medical comorbidity, medications, and inpatient and outpatient healthcare utilization extracted from Danish healthcare registers. RESULTS: Older adults with schizophrenia did not differ from controls with regard to registered chronic medical illnesses, but were significantly less likely to receive medication for cardiovascular diseases (OR: 0.65; 99.29% CI: 0.50, 0.83) and more likely to be treated with analgesics (OR: 1.46; 99.29% CI: 1.04, 2.05). Overall, hospital admissions and number of days hospitalized were equal to controls, but with significantly fewer general medical outpatient contacts (RR: 0.37; 98.75% CI: 0.24, 0.55). CONCLUSIONS: Because the literature suggests that excess mortality continues into old age, it is possible that medical diseases were under-registered and/or under-treated. Focus on adequate medical treatment, in particular for cardiovascular disease, is needed. Future integration of psychiatric and general medical healthcare, especially outpatient care, might further optimize health outcomes for older adults with schizophrenia.

Preventing Criminal Recidivism Through Mental Health and Criminal Justice Collaboration.

Criminal justice system involvement is common among persons with serious mental illness in community treatment settings. Various intervention strategies are used to prevent criminal recidivism among justice-involved individuals, including mental health courts, specialty probation, and conditional release programs. Despite differences in these approaches, most involve the use of legal leverage to promote treatment adherence. Evidence supporting the effectiveness of leverage-based interventions at preventing criminal recidivism is mixed, however, with some studies suggesting that involving criminal justice authorities in mental health treatment can increase recidivism rates. The effectiveness of interventions that utilize legal leverage is likely to depend on several factors, including the ability of mental health and criminal justice staff to work together. Collaboration is widely acknowledged as essential in managing justice-involved individuals, yet fundamental differences in goals, values, and methods exist between mental health and criminal justice professionals. This article presents a six-step conceptual framework for optimal mental health-criminal justice collaboration to prevent criminal recidivism among individuals with serious mental illness who are under criminal justice supervision in the community. Combining best practices from each field, the stepwise process includes engagement, assessment, planning and treatment, monitoring, problem solving, and transition. Rationale and opportunities for collaboration at each step are discussed.

Patient experiences of autonomy and coercion while receiving legal leverage in forensic assertive community treatment.

Legal leverage is broadly defined as the use of legal authority to promote treatment adherence. It is widely utilized within mental health courts, drug courts, mandated outpatient treatment programs, and other intervention strategies for individuals with mental illness or chemical dependency who have contact with the criminal justice system. Nonetheless, the ethics of using legal authority to promote treatment adherence remains a hotly debated issue within public and professional circles alike. While critics characterize legal leverage as a coercive form of social control that undermines personal autonomy, advocates contend that it supports autonomy because treatment strategies using legal leverage are designed to promote health and independence. Despite the controversy, there is little evidence regarding the impact of legal leverage on patient autonomy as experienced and expressed by patients themselves. This report presents findings from a qualitative study involving six focus groups with severely mentally ill outpatients who received legal leverage through three forensic assertive community treatment (FACT) programs in Northeastern, Midwestern, and West Coast cities. Findings are discussed in the context of the self-determination theory of human motivation, and practical implications for the use of legal leverage are considered.