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OBJECTIVE: This study examined relationships among family history of alcohol, drug, and psychiatric problems and substance use severity, interpersonal relationships, and service use in individuals with dual diagnosis. METHODS: Data were collected with the family history section of the Addiction Severity Index administered as part of three studies of individuals with dual disorders (N=413). Participants were categorized into family history risk groups for each problem domain based on the number of first and second degree relatives with alcohol, drug, or psychiatric problems. RESULTS: Rates of alcohol, drug, and psychiatric problems were high across family member categories and highest overall for siblings. Over two-thirds of the sample was categorized in the high-risk group in the alcohol problem domain, almost half of the sample was categorized as high-risk in the drug problem domain, and over a third of the sample was categorized as high-risk in the psychiatric problem domain. Across problem domains, individuals in the high-risk group reported more relationship problems with parents and siblings and higher rates of lifetime emotional, physical, and sexual abuse than did those in the low or moderate-risk groups. CONCLUSIONS: Family history of alcohol, drug, and psychiatric problems is associated with greater rates of poor family relationships and history of abuse. Assessment of these different forms of family history in multiple family members can aid treatment providers in identifying individuals with dual disorders who may benefit from trauma-informed care as part of their overall mental health and substance abuse treatment services.
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OBJECTIVE: This study examined patterns and predictors of changes in substance use over one year in individuals with schizophrenia and affective disorders. We examined patterns of cocaine use over time, baseline predictors of continued cocaine use over one year, and predictors of transitions into and out of drug use and treatment. METHODS: We recruited 240 individuals with schizophrenia and affective disorders who met DSM-IV criteria for current cocaine dependence or cocaine dependence in early full or sustained full remission, and assessed them five times over twelve months. RESULTS: There was no change over time in either the proportion of the sample with at least one day of cocaine use in the past month or in the average number of days of cocaine use among those who reported any use. Baseline variables tapping actual substance use were found to predict a decreased likelihood of cocaine use. Several variables tapping actual substance use - including self- reported use of cocaine, positive urinalysis for marijuana, and positive urinalysis for cocaine - were predictive of transitions into and out of outpatient substance abuse treatment. Readiness to change variables such as self-efficacy and temptation to use drugs showed different predictive patterns for the schizophrenia and affective disorder groups. CONCLUSIONS: These findings illustrate how drug use may show a cyclical pattern for those with serious mental illness, in which more severe use - characterized by greater frequency of use and associated problems - is followed by decreased use over time.
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Recovery in schizophrenia is receiving increasing attention. Part of the increased focus is based on the recent working criteria for clinical remission in schizophrenia and the realization that many people with schizophrenia meet these criteria for remission. In this article, we consider whether functional disability can also be evaluated in a "remission" model. In so doing, we evaluate the concept of clinical remission, evaluate the possibility of remission of other generally stable features of schizophrenia such as negative symptoms, and make some heuristic terminological recommendations. We also propose a "level and breadth" model for the definition of functional remission and examine some of the alternate influences that could produce suboptimal everyday functioning, including effort, motivation, and societal barriers toward functional achievement.
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Esquizofrenia/diagnóstico , Psicología del Esquizofrénico , Terminología como Asunto , Actividades Cotidianas , Costo de Enfermedad , Empleo , Estado de Salud , Humanos , Evaluación de Resultado en la Atención de Salud , Evaluación de Procesos y Resultados en Atención de Salud , Participación del Paciente , Pronóstico , Escalas de Valoración Psiquiátrica , Recurrencia , Esquizofrenia/terapia , Índice de Severidad de la Enfermedad , Ajuste Social , Factores de TiempoRESUMEN
Several investigations of cognitive functioning in individuals with schizophrenia and co-occurring cocaine use have yielded mixed results when compared with samples with schizophrenia only. However, no studies have specifically compared remitted and current cocaine dependence in schizophrenia. Such an analysis could help clarify the degree and type of cognitive impairment associated with cocaine dependence in schizophrenia. Two samples of individuals with schizophrenia - those with current cocaine dependence (n = 72) and those with cocaine dependence in remission (n = 48) were compared on a brief neuropsychological test battery. Parallel current dependent and remitted samples with affective disorder (n = 65 and n = 55) were also included in the analyses. Results yielded few neuropsychological differences between remitted and current dependent states across the SZ and AD groups. These findings suggest that cognitive impairment may be relatively static in these populations.
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Trastornos Relacionados con Cocaína/diagnóstico , Trastornos del Conocimiento/diagnóstico , Pruebas Neuropsicológicas/estadística & datos numéricos , Esquizofrenia/diagnóstico , Adulto , Trastornos Relacionados con Cocaína/epidemiología , Trastornos Relacionados con Cocaína/psicología , Trastornos del Conocimiento/epidemiología , Trastornos del Conocimiento/psicología , Comorbilidad , Diagnóstico Dual (Psiquiatría) , Manual Diagnóstico y Estadístico de los Trastornos Mentales , Femenino , Humanos , Estudios Longitudinales , Masculino , Escalas de Valoración Psiquiátrica , Psicometría , Esquizofrenia/epidemiología , Psicología del Esquizofrénico , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: The Inventory of Drug Use Consequences (InDUC) ( [1] ) is a 50-item measure that evaluates lifetime and recent consequences of substance use. OBJECTIVES: This study examined the psychometric properties of a modified version of the Inventory of Drug Use Consequences (InDUC-M) in individuals with serious and persistent mental illness (SPMI) and co-occurring substance use disorders (SUDs). METHODS: We examined self-reported consequences in the sample, evaluated internal consistency, identified items for a brief form of the InDUC-M, and explored relationships with indicators of substance use severity. RESULTS: InDUC-M Lifetime and Recent subscales showed good internal consistency and were related to other measures of substance use and problems. A brief version of the InDUC-M Recent (SIP-M) showed excellent internal consistency and was highly correlated with both Lifetime and Recent subscales. CONCLUSION: The InDUC-M and the SIP-M performed well in individuals with SPMI and SUDs. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: Overall, these findings are a useful first step in determining the utility of the InDUC-M in people with SPMI and SUDs.
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Trastornos Relacionados con Cocaína/psicología , Trastornos Mentales/psicología , Motivación , Adulto , Cocaína/administración & dosificación , Cocaína/orina , Diagnóstico Dual (Psiquiatría) , Emociones , Femenino , Humanos , Estudios Longitudinales , Masculino , Psicometría , Índice de Severidad de la Enfermedad , Detección de Abuso de Sustancias , Centros de Tratamiento de Abuso de Sustancias , Encuestas y CuestionariosRESUMEN
A complicating factor affecting the treatment of individuals with coexisting substance use problems and serious mental illness is their motivation for change and how these interacting, chronic conditions affect the entire process of intentional behavior change. This selective review explores conceptual and assessment issues related to readiness to modify substance use and readiness to initiate behaviors helpful for managing mental illness in the search for a better understanding of patient motivation for change. The recent but limited research on motivation and stages of change among dually diagnosed patients indicates that these individuals appear to access and use an intentional behavior change process. However, it is not completely clear how this process works and what precise adaptations are needed to assess and to access motivation to change to encourage sustained behavior change in this population. Nevertheless, motivation and readiness to change are important dimensions that need to be addressed in treatment and research with dually diagnosed populations.
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Conductas Relacionadas con la Salud , Trastornos Mentales/epidemiología , Motivación , Trastornos Relacionados con Sustancias/epidemiología , Comorbilidad , Humanos , Intención , Trastornos Mentales/diagnóstico , Trastornos Mentales/psicología , Prevalencia , Índice de Severidad de la Enfermedad , Trastornos Relacionados con Sustancias/diagnóstico , Trastornos Relacionados con Sustancias/psicologíaRESUMEN
People with severe mental illness (SMI) have high rates of substance use disorders. The Transtheoretical Model (TTM) is a framework for understanding behavior change. There are five leading measures associated with the TTM - University of Rhode Island Change Assessment, Processes of Change Scale, Decisional Balance Scale, Abstinence Self-Efficacy Scale, and Temptation to Use Drugs Scale. While these measures have been found to be reliable and valid in primary substance abusers, it is unknown if these measures are relevant in people with co-occurring SMI and substance use disorders (SUD). We evaluated the psychometric properties of these measures in a sample (n=240) of people with co-occurring disorders. Participants met DSM-IV criteria for schizophrenia/schizoaffective disorder or non-psychotic affective disorder, and current cocaine dependence or cocaine dependence in remission. All subscales showed good reliability and validity in the total sample. Analyses within diagnostic groups showed good reliability and validity in most groups, with some falling off in the affective disorders and remitted cocaine dependence groups. Overall, findings support the use of these measures in people with co-occurring disorders.
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Terapia Conductista/métodos , Trastornos Relacionados con Cocaína/psicología , Trastornos del Humor/psicología , Psicología del Esquizofrénico , Adulto , Trastornos Relacionados con Cocaína/rehabilitación , Diagnóstico Dual (Psiquiatría) , Manual Diagnóstico y Estadístico de los Trastornos Mentales , Femenino , Humanos , Masculino , Modelos Teóricos , Trastornos del Humor/rehabilitación , Motivación , Psicometría , Rhode Island , Esquizofrenia/rehabilitaciónRESUMEN
Recently, attention to the assessment and treatment of functional disability has increased notably. It is widely understood that impairments in everyday living skills, including independent living skills, social functions, vocational functioning, and self-care, are present in people with schizophrenia. It has also become clear recently that assessment of these skills can pose substantial challenges. These challenges include selection of meaningful short-term outcome measures and avoiding bias and reduced validity in the data. Self-report, direct observation, and informant reports of everyday disability all have certain advantages but appear to be inferior to direct assessment of skills with performance-based measures. This review outlines the issues associated with the assessment of functional skills and everyday functioning and provides a description of the strengths and weaknesses of these approaches. We conclude that direct assessment of functional capacity has substantial advantages over other measures and may actually provide a more direct and valid estimate of functional disability than performance on the more distal neuropsychological assessment measures.
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Actividades Cotidianas/clasificación , Evaluación de la Discapacidad , Esquizofrenia/diagnóstico , Ensayos Clínicos como Asunto/métodos , Trastornos del Conocimiento/diagnóstico , Trastornos del Conocimiento/fisiopatología , Estado de Salud , Humanos , Pruebas Neuropsicológicas/estadística & datos numéricos , Evaluación de Resultado en la Atención de Salud/métodos , Psicometría/métodos , Desempeño Psicomotor/fisiología , Proyectos de Investigación , Esquizofrenia/fisiopatología , Sensibilidad y Especificidad , Ajuste Social , Encuestas y CuestionariosRESUMEN
Deficits in social/communications skills have been documented in schizophrenia, but it is unclear how these deficits relate to cognitive deficits and to everyday functioning. In the current study, social/communication skills performance was measured in 29 schizophrenia patients with a history of good vocational functioning (GVF) and 26 with a history of poor vocational functioning (PVF) using a role-play-based social skills assessment, the Maryland Assessment of Social Competence (MASC). A battery of standard cognitive tasks was also administered. MASC-indexed social skills were significantly impaired in PVF relative to GVF patients (odds ratio = 3.61, P < .001). Although MASC social skills performance was significantly associated with cognitive performance in domains of verbal ability, processing speed, and memory, the MASC nevertheless remained an independent predictor of vocational functioning even after controlling for cognitive performance. Social/communications skills predict vocational functioning history independently of cognitive performance, and social skills measures should be considered for inclusion in test batteries designed to predict everyday functioning in schizophrenia.
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Trastornos del Conocimiento/diagnóstico , Trastornos de la Comunicación/diagnóstico , Ocupaciones , Esquizofrenia/diagnóstico , Psicología del Esquizofrénico , Ajuste Social , Actividades Cotidianas , Adulto , Trastornos del Conocimiento/psicología , Trastornos de la Comunicación/psicología , Femenino , Humanos , Relaciones Interpersonales , Masculino , Pruebas Neuropsicológicas , Pronóstico , Escalas de Valoración Psiquiátrica/estadística & datos numéricos , Psicometría , Proyectos de Investigación , Desempeño de Papel , Escalas de Wechsler/estadística & datos numéricosRESUMEN
People with schizophrenia frequently have significant problems in community functioning. Progress in developing effective interventions to ameliorate these problems has been slowed by the absence of reliable and valid measures that are suitable for use in clinical trials. The National Institute of Mental Health convened a workgroup in September 2005 to examine this issue and make recommendations to the field that would foster research in this area. This article reports on issues raised at the meeting. Many instruments have been developed to assess community functioning, but overall insufficient attention has been paid to psychometric issues and many instruments are not suitable for use in clinical trials. Consumer self-report, informant report, ratings by clinicians and trained raters, and behavioral assessment all can provide useful and valid information in some circumstances and may be practical for use in clinical trials. However, insufficient attention has been paid to when and how different forms of assessment and sources of information are useful or how to understand inconsistencies. A major limiting factor in development of reliable and valid instruments is failure to develop a suitable model of functioning and its primary mediators and moderators. Several examples that can guide thinking are presented. Finally, the field is limited by the absence of an objective gold standard of community functioning. Hence, outcomes must be evaluated in part by "clinical significance." This criterion is problematic because different observers and constituencies often have different opinions about what types of change are clinically important and how much change is significant.
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Trastornos Mentales/diagnóstico , Escalas de Valoración Psiquiátrica/estadística & datos numéricos , Características de la Residencia , Esquizofrenia/diagnóstico , Psicología del Esquizofrénico , Autorrevelación , Ajuste Social , Actividades Cotidianas/psicología , Trastornos del Conocimiento/diagnóstico , Trastornos del Conocimiento/psicología , Evaluación de la Discapacidad , Educación , Humanos , Trastornos Mentales/psicología , National Institute of Mental Health (U.S.) , Pruebas Neuropsicológicas/estadística & datos numéricos , Psicometría/estadística & datos numéricos , Calidad de Vida/psicología , Reproducibilidad de los Resultados , Apoyo a la Investigación como Asunto , Estados UnidosRESUMEN
CONTEXT: Drug abuse by people with severe mental disorder is a significant public health problem for which there is no empirically validated treatment. OBJECTIVE: To evaluate the efficacy of a new behavioral treatment for drug abuse in this population: Behavioral Treatment for Substance Abuse in Severe and Persistent Mental Illness (BTSAS). DESIGN: Participants were randomly assigned to 6 months of treatment in either BTSAS or a manualized control condition: Supportive Treatment for Addiction Recovery (STAR). SETTING: Treatment was conducted in community-based outpatient clinics and a Veterans Affairs medical center in Baltimore, Md. PARTICIPANTS: Participants were 129 stabilized outpatients meeting DSM criteria for drug dependence (cocaine, heroin, or cannabis) and serious mental illness: 39.5% met DSM-IV criteria for schizophrenia or schizoaffective disorder; 55.8%, for major affective disorders; and the remainder met criteria for severe and persistent mental illness and other Axis I disorders. INTERVENTIONS: Both treatments were administered by trained health care professionals in small groups, twice a week for 6 months. The BTSAS program is a social learning intervention that includes motivational interviewing, a urinalysis contingency, and social skills training. The control condition, STAR, is a supportive group discussion treatment. Main Outcome Measure The primary outcome measure was urinalysis results from twice-weekly treatment sessions. RESULTS: The BTSAS program was significantly more effective than STAR in percentage of clean urine test results, survival in treatment, and attendance at sessions. The BTSAS program also had significant effects on important community-functioning variables, including hospitalization; money available for living expenses; and quality of life. CONCLUSIONS: The BTSAS program is an efficacious treatment. Further work needs to be done to increase the proportion of eligible patients who are able to become engaged in treatment.
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Terapia Conductista/métodos , Trastornos Mentales/epidemiología , Trastornos Relacionados con Sustancias/terapia , Atención Ambulatoria , Servicios Comunitarios de Salud Mental , Comorbilidad , Trastorno Depresivo Mayor/diagnóstico , Trastorno Depresivo Mayor/epidemiología , Trastorno Depresivo Mayor/terapia , Diagnóstico Dual (Psiquiatría) , Femenino , Humanos , Masculino , Trastornos Mentales/diagnóstico , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Escalas de Valoración Psiquiátrica , Psicoterapia de Grupo , Trastornos Psicóticos/diagnóstico , Trastornos Psicóticos/epidemiología , Trastornos Psicóticos/terapia , Calidad de Vida , Esquizofrenia/diagnóstico , Esquizofrenia/epidemiología , Esquizofrenia/terapia , Índice de Severidad de la Enfermedad , Detección de Abuso de Sustancias , Trastornos Relacionados con Sustancias/diagnóstico , Trastornos Relacionados con Sustancias/epidemiología , Resultado del TratamientoRESUMEN
Assessment of motivation to change substance use can be helpful in evaluating treatment readiness and outcome. However, the utility of self-report measures of motivation with schizophrenia patients is questionable. In the current study patients with schizophrenia and either concurrent cocaine dependence or remitted dependence completed the University of Rhode Island Change Assessment-Maryland (URICA-M), a self-report inventory that assesses motivation, and an analogous cartoon instrument at baseline and 6-months follow-up. Results demonstrate that the cartoon readiness to change score was related to increased treatment utilization and decreased substance use; results were not as favorable for the URICA-M. Findings suggest that the cartoon measure may be a suitable alternative to assess motivation to change substance use with cognitively impaired patients.
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Motivación , Esquizofrenia/epidemiología , Trastornos Relacionados con Sustancias/epidemiología , Trastornos Relacionados con Sustancias/psicología , Encuestas y Cuestionarios , Adulto , Trastornos Relacionados con Cocaína/epidemiología , Trastornos del Conocimiento/epidemiología , Diagnóstico Dual (Psiquiatría) , Manual Diagnóstico y Estadístico de los Trastornos Mentales , Etnicidad/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas , Recurrencia , Esquizofrenia/diagnóstico , Índice de Severidad de la Enfermedad , Distribución por Sexo , Trastornos Relacionados con Sustancias/diagnósticoRESUMEN
Contingency management (CM) may be a promising component of treatment to help dually-diagnosed patients reduce their substance use. However, most prior studies examining CM with these patients have not examined the relationships among patient variables and contingency rewards received. This study examined whether characteristics of dually-diagnosed patients were related to CM payments received in a multi-faceted program. Fifty-nine dually-diagnosed patients participated in a multimodal behavioral therapy for illicit substance use involving CM. Baseline demographic and clinical characteristics were examined as they related to receipt of payments. Demographic characteristics generally were not related to receipt of payments. Several clinical variables, including diagnosis of schizophrenia, current substance dependence, and co-morbid alcohol dependence were related to payment receipt. These results provide an important step toward understanding the characteristics of dually-diagnosed patients that predict their response to CM.
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Terapia Conductista/métodos , Gastos en Salud , Trastornos Mentales/epidemiología , Trastornos Mentales/terapia , Trastornos Relacionados con Sustancias/epidemiología , Trastornos Relacionados con Sustancias/rehabilitación , Adulto , Trastornos del Conocimiento/diagnóstico , Trastornos del Conocimiento/epidemiología , Diagnóstico Dual (Psiquiatría) , Femenino , Humanos , Masculino , Pruebas Neuropsicológicas , Índice de Severidad de la EnfermedadRESUMEN
Schizophrenia has traditionally been viewed as a chronic condition with a very pessimistic outlook, but that assumption may not be valid. There has been a growing consumer movement among people with schizophrenia that has challenged both the traditional perspective on the course of illness and the associated assumptions about the possibility of people with the illness living a productive and satisfying life. This new conception of the illness is supported by long-term studies that suggest that as much as 50% of people with the illness have good outcomes. There has also been a change in political and public health perspectives of the illness, stimulated in part by the President's New Freedom Commission on Mental Health. The purpose of this article is to provide an overview of some key themes about the recovery concept, as applied to schizophrenia. The article will address 3 questions: (1) What is recovery? (2) Is recovery possible? and (3) What are the implications of a recovery model for a scientific approach to treatment (ie, the use of evidence-based practices)? Scientific and consumer models of recovery are described, and commonalities and differences are discussed. Priorities for future research are suggested.
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Convalecencia , Medicina Basada en la Evidencia/métodos , Servicios de Salud Mental/provisión & distribución , Esquizofrenia/terapia , Apoyo Social , Empleos Subvencionados , Humanos , Servicios de Salud Mental/organización & administración , Psicología , Estados UnidosRESUMEN
Relatives' critical and intrusive behavior with patients, patients' odd or unusual thinking with relatives, and the course of schizophrenia were examined. Seventy-one African American and White patients (each with 1 relative) completed 2 problem-solving discussions. Relatives' critical and intrusive behavior with patients and patients' odd or unusual thinking with relatives were assessed, and patients were followed for 2 years. For African American patients, high levels of relatives' critical and intrusive behavior were associated with better outcome. For White patients, low levels of both relatives' critical and intrusive behavior and patients' odd or unusual thinking with relatives were associated with better outcome. The results suggest that during family interactions, seemingly negative behaviors may be perceived as a sign of caring and concern by African Americans. For Whites, the combination of patients' odd or unusual thinking with relatives and relatives' critical and intrusive behavior toward patients may be especially predictive of an adverse course.
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Negro o Afroamericano/estadística & datos numéricos , Relaciones Familiares , Esquizofrenia/etnología , Población Blanca/estadística & datos numéricos , Adolescente , Adulto , Factores de Edad , Comparación Transcultural , Cultura , Femenino , Humanos , Masculino , Persona de Mediana Edad , Solución de Problemas , Encuestas y CuestionariosRESUMEN
A sociocultural stress, appraisal, and coping model was developed to understand relatives' burden of care and negative affective attitudes toward patients with schizophrenia. Ninety-two African American and 79 White patients and a significant other (80% mothers) completed 2 10-min family problem-solving discussions. In addition, the Kreisman Rejection Scale and a global self-report rating of family burden were administered to relatives, and a self-report rating of substance use was administered to patients. Results indicated that subjective burden of care and patients' odd and unusual thinking during the family discussion each independently predicted relatives' attitudes toward patients, suggesting that negative attitudes are based in part on both patients' symptoms and perceived burden of care. African American relatives' perceived burden was also predicted by patients' substance abuse. Finally, White family members were significantly more likely than African Americans to feel burdened by and have rejecting attitudes toward their schizophrenic relative suggesting that cultural factors play an important role in determining both perceived burden and relatives' attitudes toward patients.
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Adaptación Psicológica , Actitud , Costo de Enfermedad , Cultura , Esquizofrenia , Estrés Psicológico/etnología , Adolescente , Adulto , Población Negra/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Solución de Problemas , Estrés Psicológico/diagnóstico , Estrés Psicológico/psicología , Encuestas y Cuestionarios , Población Blanca/estadística & datos numéricosRESUMEN
This paper provides a description of The Substance Use Event Survey for Severe Mental Illness (SUESS), a brief (20-30 min) interview that assesses clinical issues and domains that are relevant patients with substance use disorders and severe mental illness. First, we discuss the need for a new clinical measure for dual diagnosis patients, as well as our process of creating domains and items and developing the content of the assessment. Second, we provide a first look at the performance of the SUESS in a large sample of dually diagnosed patients from several large scale studies, including how patients responded to the instrument and their ability to complete the items. Third, we present initial reliability data on the SUESS. Finally, we include some initial validity data, including comparison of the self-report of substance use questions to urinalysis results, and verification of the service use information from medical record review. The SUESS appears to be a useful assessment that is tolerated and understood by dual diagnosis patients, and shows good preliminary reliability and validity.
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Trastornos Mentales/diagnóstico , Adulto , Trastornos Psicóticos Afectivos/diagnóstico , Trastornos Psicóticos Afectivos/tratamiento farmacológico , Trastornos Psicóticos Afectivos/terapia , Consumo de Bebidas Alcohólicas , Femenino , Humanos , Entrevista Psicológica , Masculino , Registros Médicos , Trastornos Mentales/tratamiento farmacológico , Trastornos Mentales/terapia , Persona de Mediana Edad , Cooperación del Paciente , Reproducibilidad de los Resultados , Esquizofrenia/diagnóstico , Esquizofrenia/tratamiento farmacológico , Esquizofrenia/terapia , Autoevaluación (Psicología) , Sensibilidad y Especificidad , Trastornos Relacionados con Sustancias/diagnóstico , Trastornos Relacionados con Sustancias/tratamiento farmacológico , Trastornos Relacionados con Sustancias/terapia , UrinálisisRESUMEN
There is an extensive literature documenting that people with schizophrenia have marked impairments in social role functioning and social skill. One of the most widely employed strategies for assessing social skill has been role-play tests: simulated social interactions that are videotaped for subsequent behavioral coding. There has been considerable discussion of the validity of the approach in the literature, but there has not been adequate consideration of other psychometric characteristics of role-play tests. This paper examines the psychometric characteristics of a representative role-play measure: the Maryland Assessment of Social Competence (MASC). Data from 5 large schizophrenia studies that included the MASC were examined: a study of victimization in women who abuse drugs, a study of health care among people with diabetes, a study of vocational outcomes, a study of social skill among drug abusers, and a clinical trial comparing two antipsychotic medications. Data were examined in terms of five questions: (1) Can role-play scenes be rated reliably? (2) How are role-play ratings distributed across populations? (3) How many and which behaviors should be rated? (4) How many role-play scenes are required? (5) Is role-play behavior temporally stable? Overall, the data suggest that the MASC, and by implication other similar role-play procedures, does have good psychometric properties. However, several things often taken for granted in the literature warrant careful consideration in the design of research using role-play. Implications of the results for design of research are discussed.
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Desempeño de Papel , Esquizofrenia/terapia , Conducta Social , Adulto , Antipsicóticos/uso terapéutico , Clozapina/uso terapéutico , Comorbilidad , Víctimas de Crimen , Diabetes Mellitus Tipo 2/epidemiología , Femenino , Conductas Relacionadas con la Salud , Humanos , Solución de Problemas , Psicometría , Risperidona/uso terapéutico , Esquizofrenia/tratamiento farmacológico , Esquizofrenia/epidemiología , Percepción Social , Trastornos Relacionados con Sustancias/epidemiologíaRESUMEN
In the last decade, impairments in several cognitive domains have been recognized as a central feature of schizophrenia. Consistent evidence has accumulated that documents the contribution of these deficits to poor outcome in social and occupational functioning, and thus they are important targets for psychosocial as well as pharmacological intervention. After reviewing the literature on cognitive remediation for brain injury as well as schizophrenia patients, consulting with research groups which have implemented cognitive remediation programs for schizophrenia, and conducting pilot work with patients, our group has developed a broadly-targeted computer-based remediation intervention that is based on using exercises that engage several cognitive capacities simultaneously, teaching of a set of cognitive strategies by a supportive therapist in a one-on-one setting, and addressing many of the treatment issues that are specific to schizophrenia. The strategies that are emphasized in the intervention are derived from the learning and remediation literatures and include the following: 1) Verbalization to enhance encoding and recall of stimuli; 2) Breaking problems down to promote organized problem solving; 3) Articulation of problem solving to encourage deliberate responding and self-monitoring; 4) Self-checking of performance and adjustment as necessary; 5) Strategic probe questions to prompt participants to monitor their work and make planful responses; 6) Scaffolding aids to provide ongoing support as needed. We are currently conducting a randomized trial of the intervention in which patients complete 24 sessions of remediation or an equivalent number of sessions with a therapist using computer games that have minimal cognitive demand. Our initial experience with the intervention is encouraging and suggests that it is feasible, the tasks are extremely well-received and patients are willing to come to the clinic several times per week to work on them. It is premature to assess whether participation in cognitive remediation is effective in improving cognition, but patients have thus far demonstrated improvement on trained computer exercises. The potential of psychosocial and pharmacological interventions, alone and in combination, for cognitive impairment in schizophrenia is a promising research issue.
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Terapia Cognitivo-Conductual/instrumentación , Educación Compensatoria , Esquizofrenia/terapia , Terapia Asistida por Computador , HumanosRESUMEN
OBJECTIVE: The purpose of this investigation was to evaluate the effects of clozapine and risperidone on social skill and problem solving in patients with schizophrenia. METHOD: The Wisconsin Card Sorting Test and the Maryland Assessment of Social Competence were administered at baseline, week 17, and week 29 of a multisite clinical trial. RESULTS: Despite evidence of clinical improvement with both medications, there was virtually no medication effect on either social competence or problem solving. CONCLUSIONS: These findings underscore the circumscribed nature of symptomatic improvement in the broader spectrum of clinical outcomes and suggest that new-generation medications may not be expected to produce substantial changes in social role functioning or social problem-solving capacity in the community. The generalizability of the findings should be viewed cautiously because of the low power of this trial, and replication is warranted.