Cost Utility of cognition-enhancing interventions for individuals with first-episode psychosis: a naturalistic evaluation.

BACKGROUND: Although effective treatments are available to address the cognitive deficits experienced by individuals with first-episode psychosis, provision of such treatments within Coordinated Specialty Care (CSC) programs is rare. One factor that may contribute to this is uncertainty about the cost implications of providing cognitive-enhancing treatments within the American mental healthcare system. The aim of this study is to complete a naturalistic evaluation of the cost utility of incorporating two different cognitive-enhancing interventions within an American CSC program. METHODS: Participants included 66, predominately white (75.38%), individuals with first-episode psychosis (19 women and 47 men) with a mean age of 22.71 years. Quality adjusted life years (QALYs) and cost of care were tracked among these individuals during their participation in a CSC program. These data were compared among three groups of participants during their first six months of care: (i) individuals who participated in metacognitive remediation therapy (MCR), (ii) individuals who participated in computerized cognitive remediation (CCR), and (iii) individuals who participated in no cognitive-enhancing intervention. RESULTS: Participation in MCR, but not CCR, was associated with larger gains in QALYs than participation in no cognitive-enhancing intervention within a CSC program. Moreover, data support the cost utility of MCR as compared to CCR or no-cognitive enhancing intervention within a CSC program. Conversely, CCR did not appear to be a cost-effective addition to CSC services. CONCLUSIONS: Our results highlight the potential cost utility of incorporating MCR within CSC programs for individuals with first-episode psychosis. However, given study limitations, these results should be interpreted cautiously until replicated by large, randomized controlled trials. Trial Registration ClinicalTrials.gov Identifier NCT01570972, registered April 4, 2012, Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT01570972?term=breitborde&draw=2&rank=6 .

The Early Psychosis Intervention Center (EPICENTER): development and six-month outcomes of an American first-episode psychosis clinical service.

BACKGROUND: There is growing evidence that specialized clinical services targeted toward individuals early in the course of a psychotic illness may be effective in reducing both the clinical and economic burden associated with these illnesses. Unfortunately, the United States has lagged behind other countries in the delivery of specialized, multi-component care to individuals early in the course of a psychotic illness. A key factor contributing to this lag is the limited available data demonstrating the clinical benefits and cost-effectiveness of early intervention for psychosis among individuals served by the American mental health system. Thus, the goal of this study is to present clinical and cost outcome data with regard to a first-episode psychosis treatment center within the American mental health system: the Early Psychosis Intervention Center (EPICENTER). METHODS: Sixty-eight consecutively enrolled individuals with first-episode psychosis completed assessments of symptomatology, social functioning, educational/vocational functioning, cognitive functioning, substance use, and service utilization upon enrollment in EPICENTER and after 6 months of EPICENTER care. All participants were provided with access to a multi-component treatment package comprised of cognitive behavioral therapy, family psychoeducation, and metacognitive remediation. RESULTS: Over the first 6 months of EPICENTER care, participants experienced improvements in symptomatology, social functioning, educational/vocational functioning, cognitive functioning, and substance abuse. The average cost of care during the first 6 months of EPICENTER participation was lower than the average cost during the 6-months prior to joining EPICENTER. These savings occurred despite the additional costs associated with the receipt of EPICENTER care and were driven primarily by reductions in the utilization of inpatient psychiatric services and contacts with the legal system. CONCLUSIONS: The results of our study suggest that multi-component interventions for first-episode psychosis provided in the US mental health system may be both clinically-beneficial and cost-effective. Although additional research is needed, these findings provide preliminary support for the growing delivery of specialized multi-component interventions for first-episode psychosis within the United States. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01570972; Date of Trial Registration: November 7, 2011.

Internal versus external auditory hallucinations in schizophrenia: symptom and course correlates.

INTRODUCTION: The auditory hallucinations associated with schizophrenia are phenomenologically diverse. "External" hallucinations classically have been considered to reflect more severe psychopathology than "internal" hallucinations, but empirical support has been equivocal. METHODS: We examined associations of "internal" versus "external" hallucinations with (1) other characteristics of the hallucinations, (2) severity of other symptoms and (3) course of illness variables, in a sample of 97 stable outpatients with schizophrenia or schizoaffective disorder who experienced auditory hallucinations. RESULTS: Patients with internal hallucinations did not differ from those with external hallucinations on severity of other symptoms. However, they reported their hallucinations to be more emotionally negative, distressing and long-lasting, less controllable and less likely to remit over time. They also were more likely to experience voices commenting, conversing or commanding. However, they also were more likely to have insight into the self-generated nature of their voices. Patients with internal hallucinations were not older, but had a later age of illness onset. CONCLUSIONS: Differences in characteristics of auditory hallucinations are associated with differences in other characteristics of the disorder, and hence may be relevant to identifying subgroups of patients that are more homogeneous with respect to their underlying disease processes.

Predicting social functioning in schizotypy: an investigation of the relative contributions of theory of mind and mood.

Theory of mind (ToM) is an aspect of social cognition that refers to the ability to make inferences about the thoughts, feelings, and intentions of other people. It is believed to be related to social functioning. Previous investigations of ToM in schizotypy have yielded mixed results. Using a correlational approach, the present study explored the relationship between schizotypal traits, ToM, neurocognition, depressed mood, and social functioning in a sample of 50 undergraduate students. Schizotypy was related to poor social functioning. Contrary to predictions, schizotypal traits were not associated with impaired ToM. In fact, schizotypal traits were associated with enhanced performance on a ToM task that involved detection of ironic statements. However, strong relationships emerged among schizotypy, depressed mood, and social functioning, highlighting the need to also examine depression when assessing the relations between elevated schizotypy and poor social functioning.

An uncontrolled trial of multi-component care for first-episode psychosis: Effects on social cognition.

Growing evidence suggests that specialized, multi-component treatment programmes produce improvements in numerous outcomes among individuals with first-episode psychosis. However, these programmes often lack interventions specifically designed to address deficits in social cognition. This raises questions about the effectiveness of such programmes in addressing deficits in social cognition that accompany psychotic disorders. We investigated the effect of participation in a multi-component treatment programme on social cognition among 71 individuals with first-episode psychosis. Participants experienced gains in emotion processing, social knowledge, social perception and theory of mind. However, after controlling for multiple comparisons, these improvements were limited to theory of mind and recognition of social cues in low emotion interactions. Although our findings should be interpreted cautiously, they raise the possibility that individuals participating in multi-component treatment programmes for first-episode psychosis without interventions specifically targeting social cognition may still experience gains in social cognition.

Social cognition and the course of social functioning in first-episode psychosis.

BACKGROUND: Social functioning deficits greatly affect individuals with psychotic disorders resulting in decreased ability to maintain relationships, jobs and pursuit of educational goals. Deficits in social cognition have been hypothesized to be an important contributor to these deficits in social functioning. In particular, 5 domains of social cognition have been suggested to be relevant in the study of psychotic disorders: (1) attributional style, (2) emotion recognition, (3) social knowledge, (4) social perception and (5) theory of mind. Yet, to date, no study has simultaneously investigated the association between these 5 domains of social cognition and social functioning. METHODS: We investigated the cross-section and longitudinal association between social cognition and social functioning among 71 individuals with first-episode psychosis. RESULTS: We found modest cross-sectional associations between social cognition and social functioning that were often in the unexpected direction (ie, greater social cognition associated with worse social functioning). Social cognition at baseline was not associated with the longitudinal course of social functioning. CONCLUSIONS: These unexpected findings fail to align with previous research that has documented a more robust relationship between these 2 constructs, and raise critical questions with regard to the nature of the association between social cognition and social functioning among individuals with first-episode psychosis.

Optimizing psychosocial interventions in first-episode psychosis: current perspectives and future directions.

Psychotic-spectrum disorders such as schizophrenia, schizoaffective disorder, and bipolar disorder with psychotic features are devastating illnesses accompanied by high levels of morbidity and mortality. Growing evidence suggests that outcomes for individuals with psychotic-spectrum disorders can be meaningfully improved by increasing the quality of mental health care provided to these individuals and reducing the delay between the first onset of psychotic symptoms and the receipt of adequate psychiatric care. More specifically, multicomponent treatment packages that 1) simultaneously target multiple symptomatic and functional needs and 2) are provided as soon as possible following the initial onset of psychotic symptoms appear to have disproportionately positive effects on the course of psychotic-spectrum disorders. Yet, despite the benefit of multicomponent care for first-episode psychosis, clinical and functional outcomes among individuals with first-episode psychosis participating in such services are still suboptimal. Thus, the goal of this review is to highlight putative strategies to improve care for individuals with first-episode psychosis with specific attention to optimizing psychosocial interventions. To address this goal, we highlight four burgeoning areas of research with regard to optimization of psychosocial interventions for first-episode psychosis: 1) reducing the delay in receipt of evidence-based psychosocial treatments; 2) synergistic pairing of psychosocial interventions; 3) personalized delivery of psychosocial interventions; and 4) technological enhancement of psychosocial interventions. Future research on these topics has the potential to optimize the treatment response to evidence-based psychosocial interventions and to enhance the improved (but still suboptimal) treatment outcomes commonly experienced by individuals with first-episode psychosis.

Meta-cognitive skills training enhances computerized cognitive remediation outcomes among individuals with first-episode psychosis.

AIM: Meta-cognitive skills training (MST) is a frequent component of cognitive remediation programmes for individuals with psychosis. However, no study has investigated whether incorporating such activities produces increased clinical benefits compared with computerized cognitive remediation alone. METHODS: Individuals with first-episode psychosis who completed computerized cognitive remediation with concurrent meta-cognitive skills training (CCR + MST) were compared with a historical control group who received computerized cognitive remediation alone (CCR) and did not differ from the CCR + MST group with regard to pre-intervention cognition, diagnosis, age, duration of psychotic illness or sex. Participants completed assessments of cognition and real-world functioning before and after 6 months of treatment. RESULTS: Individual receiving CCR + MST experience greater gains in cognition and real-world functioning than individuals who received CCR. CONCLUSIONS: MST may be an important component within cognitive remediation programmes for first-episode psychosis.

A randomized controlled trial of cognitive remediation and d-cycloserine for individuals with bipolar disorder.

BACKGROUND: Cognitive remediation (CR) has shown significant promise in addressing the cognitive deficits that accompany serious mental illness. However, this intervention does not appear to completely ameliorate the cognitive deficits that accompany these illnesses. D-cycloserine (DCS), an NMDA receptor partial agonist, has been shown to enhance the therapeutic benefits of learning-based psychosocial interventions for psychiatric disorders. Thus, the goal of this study is to examine the utility of combining cognitive remediation and d-cycloserine in the treatment of cognitive deficits among individuals with bipolar disorder. METHODS/DESIGN: Approximately forty individuals with bipolar disorder will be recruited to participate in this study. Participants will be randomized to one of two study arms: CR + DCS or CR + placebo. The primary outcome for this study is change in cognitive functioning. We will also examine several secondary outcomes, including the rate of change of cognitive functioning, social functioning, and symptomatology. DISCUSSION: Cognitive deficits are a rate-limiting factor in functional recovery among individuals with bipolar disorder. Unfortunately, treatment options for these deficits are limited. The results of the proposed study may reveal a valuable intervention strategy (i.e., CR with concurrent DCS) to improve cognitive functioning among individuals with bipolar disorder. Ultimately, this treatment strategy may prove useful in addressing the cognitive deficits that are ubiquitous across serious mental illnesses. TRIAL REGISTRATION: ClinicalTrials.gov NCT01934972.