Shaping attention span: an operant conditioning procedure to improve neurocognition and functioning in schizophrenia.

The high prevalence of neurocognitive deficits in schizophrenia, and their association with poorer outcomes, has created interest in treatments that can improve neurocognitive functioning in this illness. While a variety of rehabilitation interventions have been developed, many are not appropriate for the most severely ill patients, whose attention spans are so short that they cannot attend to the material being presented. For this population, the only neurocognitive rehabilitation methods with demonstrated effectiveness are those that involve the operant conditioning technique known as shaping. In this article, we review the rationale for the use of shaping-based methods as neurocognitive retraining techniques for treatment-refractory schizophrenia patients, review published reports using this intervention, and offer suggestions for the future development of this method from both clinical and research perspectives.

Effectiveness of clozapine and a social learning program for severely disabled psychiatric inpatients.

OBJECTIVE: This study examined the combined effectiveness of clozapine and a comprehensive inpatient psychosocial rehabilitation program on the clinical functioning and aggressive behaviors of patients with chronic schizophrenia. METHODS: Two groups of 11 subjects each were selected from among patients being treated in the social learning program at Fulton (Mo.) State Hospital. Group 1 subjects were placed on clozapine at various times after the introduction of the program, while group 2 subjects remained on traditional antipsychotics throughout the study period. Group 1 and group 2 subjects were matched on clinical functioning as measured by the Time-Sample Behavioral Checklist (TSBC). For each subject, scores on six TSBC subscales were examined at five time points. Data were analyzed using repeated-measures multiple analysis of variance and univariate analyses of variance. Data on frequency of aggressive behaviors were aggregated into three six-month time periods and were analyzed using Wilcoxon signed-rank tests. RESULTS: Both groups demonstrated significant improvement on several measures. However, the addition of clozapine resulted in accelerated improvement for group 1 subjects, especially in aggressive behaviors. CONCLUSIONS: Comprehensive psychosocial treatment programming resulted in significant improvements in clinical functioning for many inpatients. Clozapine may enhance responsiveness to such programming for some patients.

Risperidone in the management of violent, treatment-resistant schizophrenics hospitalized in a maximum security forensic facility.

This study examines the effectiveness of risperidone compared with traditional neuroleptic medications in the areas of clinical functioning and aggressive behaviors in a sample of inpatients diagnosed with chronic schizophrenia. Similar to the methodology of Menditto et al. (Psychiatr Serv 47:46-51, 1996), two groups of 10 patients were selected from those being treated in a comprehensive psychosocial rehabilitation program. Group 1 subjects were placed on risperidone at various times during their treatment. Group 2 subjects, who were matched with Group 1 subjects on pre-study levels of clinical functioning as measured by the Time-Sample Behavioral Checklist (TSBC), remained on traditional neuroleptics throughout the study period. For each subject, scores on six TSBC subscales were examined at four time points; data were analyzed with repeated-measures multivariate analyses of variance and univariate analyses of variance. Frequency counts of aggressive behaviors (threats and assaults) were compiled into two six-month time periods and analyzed with nonparametric techniques. The risperidone group did not differ from the traditional neuroleptic group on measures of clinical functioning and aggressiveness measured over time. Both groups evidenced improvements in bizarre motor behaviors over the study period. The risperidone group evidenced some deterioration in measures of appropriate interpersonal interaction over time. No differences in aggressive behaviors were noted for either group. The study concludes that for forensic patients with chronic schizophrenia, risperidone failed to produce therapeutic effects in overall clinical functioning and aggressive behaviors that were significantly different from traditional neuroleptics. Descriptive comparisons are made between the receptor-binding profiles and clinical effectiveness of risperidone and clozapine in an attempt to explain these findings.

State hospitals in the new millennium: rehabilitating the "not ready for rehab players".

Over the past ten years, FSH has seen the initial implementation of the SLP grow from a single ward in the maximum-security forensic unit to include three additional wards within that unit, two wards on the medium-security forensic unit, and two wards within the general adult psychiatric service. There are now four FSH group homes, which admit clients from the hospital's forensic as well as nonforensic populations. Six to eight clients live in each home and function in a relatively self-sufficient manner, and many more (including forensic clients) have been discharged from the group homes and now live independently in the community. They work in supported employment or competitive job settings and manage their own households. Several of our discharged clients even return to visit us from time to time. The FSH administration remains solidly committed to being a rehabilitation-ready facility. We have had a number of positive outcomes over the years (Baldwin and others, 1992; Beck and others, 1991; Beck and others, 1997; Finnell, Card, and Menditto, 1997; Menditto, Baldwin, O'Neal, and Beck, 1991; Menditto, Valdes, and Beck, 1994; Menditto and others, 1996; Menditto, Beck, and Stuve, in press; Pestle, Card, and Menditto, 1998), and we regularly host visitors from other state hospitals seeking consultation on how to make their own facilities rehabilitation-ready. Recently, we were featured on a segment of the nationally broadcast medical education program psychLINK (Glazer, 1998), where it was suggested that rehabilitation programming models such as ours represent the future of state hospitals. The "Not Ready for Rehab Players" think so too.

Trends in the rural community mental health work force: a case study.

A case study of the community mental health work force in Nebraska over a seven-year period beginning in 1981 examined changes in the professional makeup, overall staffing levels, extent of professional training, and number of medical staff in both metropolitan and nonmetropolitan agencies. The study found significantly more bachelor's-level staff in metropolitan agencies and more master's-level staff in nonmetropolitan agencies. The proportions of doctoral-, master's-, and bachelor's-level staff did not change significantly in metropolitan or nonmetropolitan agencies during the study period. However, beginning in fiscal year 1982, nonmetropolitan agencies had significantly fewer full-time-equivalent positions than metropolitan agencies, and metropolitan agencies experienced significant decreases in medical personnel. The loss of positions in rural agencies portends a crisis in their ability to respond effectively to the needs of rural residents. Special approaches may be needed to facilitate the recruitment and retention of quality mental health professionals in nonmetropolitan areas.