The Cost-Effectiveness of a Novel Online Social Therapy to Maintain Treatment Effects From First-Episode Psychosis Services: Results From the Horyzons Randomized Controlled Trial.

BACKGROUND: Digital interventions have potential applications in promoting long-term recovery and improving outcomes in first-episode psychosis (FEP). This study aimed to evaluate the cost-effectiveness of Horyzons, a novel online social therapy to support young people aged 16-27 years following discharge from FEP services, compared with treatment as usual (TAU) from a healthcare sector and a societal perspective. STUDY DESIGN: A cost-effectiveness analysis (CEA), based on the change in social functioning, and a cost-utility analysis (CUA) using quality-adjusted life years were undertaken alongside a randomized controlled trial. Intervention costs were determined from study records; resources used by patients were collected from a resource-use questionnaire and administrative data. Mean costs and outcomes were compared at 18 months and incremental cost-effectiveness ratios were calculated. Uncertainty analysis using bootstrapping and sensitivity analyses was conducted. STUDY RESULTS: The sample included 170 participants: Horyzons intervention group (n = 86) and TAU (n = 84). Total costs were significantly lower in the Horyzons group compared with TAU from both the healthcare sector (-AU$4789.59; P < .001) and the societal perspective (-AU$5131.14; P < .001). In the CEA, Horyzons was dominant, meaning it was less costly and resulted in better social functioning. In the CUA, the Horyzons intervention resulted in fewer costs but also yielded fewer QALYs. However, group differences in outcomes were not statistically significant. When young people engaged more with the platform, costs were shown to decrease and outcomes improved. CONCLUSIONS: The Horyzons intervention offers a cost-effective approach for improving social functioning in young people with FEP after discharge from early intervention services.

Performance-based assessment of social skills in a large sample of participants with schizophrenia, bipolar disorder and healthy controls: Correlates of social competence and social appropriateness.

INTRODUCTION: Performance-based assessments of social skills have detected impairments in people with severe mental illness and are correlated with functional outcomes in people with schizophrenia and bipolar disorder. The most common of these assessments, the Social Skills Performance Assessment (SSPA), has two communication scenarios and items measuring both social competence and appropriateness. As real-world competence and appropriateness appear to have different correlates, we hypothesized that SSPA Items measuring competence and appropriateness would be distinct and have different correlations with other outcomes. METHODS: We aggregated data from 557 people with schizophrenia, 106 with bipolar disorder, and 378 well controls from 4 separate research studies. All participants were assessed with both SSPA scenarios and other performance based and clinician-rated measures. A single expert rated the SSPA interactions for competence and appropriateness while blind to participant diagnoses. RESULTS: Participants with bipolar disorder and schizophrenia performed more poorly on every item of the SSPA than healthy controls. Items measuring social competence and appropriateness in communication were intercorrelated across scenarios, as were elements of socially competent communication, although the items measuring competence did not correlate substantially with appropriateness. Items assessing social competence, but not social appropriateness, correlated with better cognitive and functional performance and residential and financial independence. DISCUSSION: Social competence and social appropriateness were distinct elements of performance-based social skills with potential differences in their functional correlates. As both social competence and appropriateness impact functional outcomes, improvement in the measurement and treatment of appropriate communication seems to be an important goal.

Confidence, performance, and accuracy of self-assessment of social cognition: A comparison of schizophrenia patients and healthy controls.

Impairments in self-assessment in schizophrenia have been shown to have functional and clinical implications. Prior studies have suggested that overconfidence can be associated with poorer cognitive performance in people with schizophrenia, and that reduced awareness of performance may be associated with disability. However, overconfidence is common in healthy individuals as well. This study examines the correlations between performance on a social cognitive test, confidence in performance, effort allocated to the task, and correlates of confidence in patients with schizophrenia and healthy controls (HC). Measures included self-reports of depression, social cognitive ability, and social functioning. A performance-based emotion recognition test assessed social cognitive performance and provided the basis for confidence judgments. Although schizophrenia patients had reduced levels of overall confidence, there was a substantial subset of schizophrenic patients who manifested extreme overconfidence and these people had the poorest performance and reported the least depression. Further, a substantial number of HC over-estimated their performance as well. Patients with schizophrenia, in contrast to HC, did not adjust their effort to match task difficulty. Confidence was minimally related to task performance in patients but was associated with more rapid decisions in HC, across both correct and incorrect responses. Performance on social cognitive measures was minimally related to self-reports of social functioning in both samples. These data suggest global self-assessments are based on multiple factors, with confidence affecting self-assessments in the absence of feedback about performance.

Depression predicts self assessment of social function in both patients with schizophrenia and healthy people.

BACKGROUND: Impairments in social functioning are central to Schizophrenia (SCZ). Patients with SCZ have challenges in the ability to evaluate their functioning. A correlate of self-assessments in SCZ is depression, wherein negligible depression predicts overestimation. Healthy individuals misestimate their functioning, but mild dysthymia predicts accuracy. We examined depression, gender, and schizophrenia as predictors of self-reported everyday functioning. METHODS: 218 people with SCZ and 154 healthy controls self-reported their social functioning. They self-reported their depression with the Beck Depression Inventory (BDI) and their social cognitive ability on the Observable Social Cognition Rating Scale (OSCARS). RESULTS: 64% of subjects were male. Schizophrenia patients reported more depression, poorer social functioning, and worse social cognition. Linear regression analyses revealed significant correlations between self-reported social functioning and BDI scores, which also predicted self-reported social cognition. There was no significant effect of sex on self-reports of social functioning or social cognition. Finally, when BDI and OSCARS were directly compared to diagnosis and sex for prediction of self-reported social functioning, there was no impact of diagnosis or sex. IMPLICATIONS: Self-reported interpersonal functioning is determined by current depression. Both healthy people and people with schizophrenia index their social functioning and their social cognitive by their level of depression.

Implementation and fidelity assessment of the NAVIGATE treatment program for first episode psychosis in a multi-site study.

The NAVIGATE program was developed for the Recovery After Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study, which compared NAVIGATE to usual Community Care in a cluster randomized design involving 34 sites and 404 patients. This article describes the approach to training and implementing the NAVIGATE program at the 17 sites (including 134 practitioners) randomized to provide it, and to evaluating the fidelity of service delivery to the NAVIGATE model. Fidelity was evaluated to five different components of the program, all of which were standardized in manuals in advance of implementation. The components included four interventions (Individualized Resiliency Training, Family Education Program, Supported Employment and Education, Personalized Medication Management) and the overall organization (staffing and structure) of the NAVIGATE team. Most of the sites demonstrated acceptable or higher levels of fidelity in their implementation of the four interventions and the organization of the program, with all 17 sites demonstrating at least acceptable overall fidelity to the NAVIGATE program. The results indicate that the NAVIGATE program can be implemented with good fidelity to the treatment model in a diverse array of community mental health care settings serving persons with a first episode psychosis.

Self-assessment of social cognitive ability in schizophrenia: Association with social cognitive test performance, informant assessments of social cognitive ability, and everyday outcomes.

BACKGROUND: Impairments in self-assessment are common in people with schizophrenia and impairments in self-assessment of cognitive ability have been found to predict impaired functional outcome. In this study, we examined self-assessment of social cognitive ability and related them to assessments of social cognition provided by informants, to performance on tests of social cognition, and to everyday outcomes. The difference between self-reported social cognition and informant ratings was used to predict everyday functioning. METHODS: People with schizophrenia (n=135) performed 8 different tests of social cognition. They were asked to rate their social cognitive abilities on the Observable Social Cognition Rating Scale (OSCARs). High contact informants also rated social cognitive ability and everyday outcomes, while unaware of the patients' social cognitive performance and self-assessments. Social competence was measured with a performance-based assessment and clinical ratings of negative symptoms were also performed. RESULTS: Patient reports of their social cognitive abilities were uncorrelated with performance on social cognitive tests and with three of the four domains of functional outcomes. Differences between self-reported and informant rated social cognitive ability predicted impaired everyday functioning across all four functional domains. This difference score predicted disability even when the influences of social cognitive performance, social competence, and negative symptoms were considered. IMPLICATIONS: Mis-estimation of social cognitive ability was an important predictor of social and nonsocial outcomes in schizophrenia compared to performance on social cognitive tests. These results suggest that consideration of self-assessment is critical when attempting to evaluate the causes of disability and when trying to implement interventions targeting disability reduction.

Self-assessment of social cognitive ability in individuals with schizophrenia: Appraising task difficulty and allocation of effort.

Patients with severe mental illnesses manifest substantial deficits in self-assessment of the abilities that impact everyday functioning. This study compares patients with schizophrenia to healthy individuals on their social cognitive performance, their assessment of that performance, and the convergence between performance and indicators of effort in solving tasks. Patients with schizophrenia (n=57) and healthy controls (HC; n=47) completed the Bell-Lysaker Emotion Recognition Test (BLERT), a psychometrically sound assessment of emotion recognition. Participants rated their confidence in the accuracy of their responses after each item. Participants were instructed to respond as rapidly as possible without sacrificing accuracy; the time to complete each item was recorded. Patients with schizophrenia performed less accurately on the BLERT than HC. Both patients and HC were more confident on items that they correctly answered than for items with errors, with patients being less confident overall; there was no significant interaction for confidence between group and accuracy. HC demonstrated a more substantial adjustment of response time to task difficulty by taking considerably longer to solve items that they got wrong, whereas patients showed only a minimal adjustment. These results expand knowledge about both self-assessment of social cognitive performance and the ability to appraise difficulty and adjust effort to social cognitive task demands in patients with schizophrenia.

Assessment of attachment in psychosis: A psychometric cause for concern.

Attachment has recently been proposed as a key developmental construct in psychosis, in particular with respect to interpersonal functioning and social cognition. The current study examined the latent structure of the self-report Psychosis Attachment Measure (PAM) and its relationship to lower-level perceptual and higher-order inferential social cognitive processes. The PAM was administered to 138 psychiatrically stable outpatients with schizophrenia alongside a battery of symptom, social cognitive, and functional measures. PAM responses were analyzed using latent variable measurement models, which did not yield evidence of the coherent two-dimensional structure predicted by previous literature. A unidimensional subscale comprising 6 of the 16 original PAM items possessed the strongest psychometric properties. This subscale was generally uncorrelated with social cognitive measures and showed weak correlations with some symptoms measures and with community functioning. These results suggest that either the PAM may not measure attachment in psychosis or it may measure only attachment anxiety but demonstrate little construct validity in this population. These results tell a cautionary tale regarding making theoretical inferences on the basis of measures without coherent latent structure. Attachment measures with stronger psychometric properties will help clarify putative relationships between attachment and social cognitive processes in psychosis.

Cost-Effectiveness of Comprehensive, Integrated Care for First Episode Psychosis in the NIMH RAISE Early Treatment Program.

This study compares the cost-effectiveness of Navigate (NAV), a comprehensive, multidisciplinary, team-based treatment approach for first episode psychosis (FEP) and usual Community Care (CC) in a cluster randomization trial. Patients at 34 community treatment clinics were randomly assigned to either NAV (N = 223) or CC (N = 181) for 2 years. Effectiveness was measured as a one standard deviation change on the Quality of Life Scale (QLS-SD). Incremental cost effectiveness ratios were evaluated with bootstrap distributions. The Net Health Benefits Approach was used to evaluate the probability that the value of NAV benefits exceeded its costs relative to CC from the perspective of the health care system. The NAV group improved significantly more on the QLS and had higher outpatient mental health and antipsychotic medication costs. The incremental cost-effectiveness ratio was $12 081/QLS-SD, with a .94 probability that NAV was more cost-effective than CC at $40 000/QLS-SD. When converted to monetized Quality Adjusted Life Years, NAV benefits exceeded costs, especially at future generic drug prices.

Observable Social Cognition--A Rating Scale: an interview-based assessment for schizophrenia.

INTRODUCTION: Individuals with schizophrenia consistently show impairments in social cognition (SC). SC has become a potential treatment target due to its association with functional outcomes. An alternative method of assessment is to administer an observer-based scale incorporating an informant's "first hand" impressions in ratings. METHODS: The present study used the Observable Social Cognition: A Rating Scale (OSCARS) in 62 outpatients and 50 non-psychiatric controls (NPCs) to assess performance in domains of SC (e.g. emotion perception, theory of mind). RESULTS: The OSCARS demonstrated sufficient internal consistency and test-retest reliability. Construct validity was assessed through an exploratory factor analysis. Patient OSCARS indices were not significantly correlated with measures of SC with the exception of aggressive attributional style. Individuals with less impairment in SC reacted more aggressively to ambiguous situations. NPC OSCARS were significantly correlated with measures of theory of mind and attributional style. In a combined sample of patients and controls, six of eight items were significantly correlated with the SC task assessing the same domain, providing modest evidence of convergent validity. In patients, the OSCARS was significantly correlated with measures of functional outcome and neurocognition. Last, the OSCARS was found to be significantly associated with functional outcome after the influence of objective measures of SC was statistically removed. CONCLUSIONS: The present study provides preliminary evidence that the OSCARS may be useful for clinicians in collecting data about patients' potential real-world SC deficits, in turn increasing the degree to which these impairments may be targeted in treatment.

The use of narrative sampling in the assessment of social cognition: the Narrative of Emotions Task (NET).

Social cognitive deficits in schizophrenia are well documented and related to functional outcome. Current social cognition measures are often not psychometrically validated, too heterogeneous for standardization, and focus principally on one domain of social cognition rather than the simultaneous activation of multiple domains. Also, few if any allow for personalization of stimuli and interpretation of personally evocative events. An alternative methodology that addresses these limitations is the analysis of samples of personal narratives. The present study evaluates the psychometric properties of a measure called the Narrative of Emotions Task (NET). The NET was used to assess the performance of participants with a diagnosis of schizophrenia or schizoaffective disorder and nonclinical controls. Use of the NET revealed significant impairments in the emotional narratives of participants with schizophrenia. Various NET indices were significantly related to current measures of theory of mind and emotion perception, as well as a social skills role-play, but were not related to measures of attributional style or clinician-rated functioning scales. Overall, the NET׳s psychometric properties justify further use of the narrative sampling method of social cognition assessment in this population.

Development of the Contextual Assessment of Social Skills (CASS): a role play measure of social skill for individuals with high-functioning autism.

This study piloted a role play assessment of conversational skills for adolescents and young adults with high-functioning autism/Asperger syndrome (HFA/AS). Participants completed two semi-structured role plays, in which social context was manipulated by changing the confederate's level of interest in the conversation. Participants' social behavior was rated via a behavioral coding system, and performance was compared across contexts and groups. An interaction effect was found for several items, whereby control participants showed significant change across context, while participants with HFA/AS showed little or no change. Total change across contexts was significantly correlated with related social constructs and significantly predicted ASD. The findings are discussed in terms of the potential utility of the CASS in the evaluation of social skill.

Assessment of social judgments and complex mental states in the early phases of psychosis.

OBJECTIVES: Social cognition plays an important role in the functioning of individuals with psychosis. In this study, we explored two areas of social cognition not previously investigated early in the course of psychosis. METHOD: Eighty-eight clinical high risk participants, 26 participants diagnosed with schizophrenia for less than 5 years, and 41 non-clinical control participants completed two measures of social cognition. RESULTS: Clinical high risk participants demonstrated biased responses to untrustworthy faces compared to both of the other groups. Early schizophrenia participants performed more poorly on an advanced theory of mind task compared to the clinical high risk and control groups. CONCLUSIONS: There are different patterns of performance on social cognitive tasks in these groups, which require further examination in longitudinal studies.

Social cognition in schizophrenia: an NIMH workshop on definitions, assessment, and research opportunities.

Social cognition has become a high priority area for the study of schizophrenia. However, despite developments in this area, progress remains limited by inconsistent terminology and differences in the way social cognition is measured. To address these obstacles, a consensus-building meeting on social cognition in schizophrenia was held at the National Institute of Mental Health in March 2006. Agreement was reached on several points, including definitions of terms, the significance of social cognition for schizophrenia research, and suggestions for future research directions. The importance of translational interdisciplinary research teams was emphasized. The current article presents a summary of these discussions.

The Illness Management and Recovery program: rationale, development, and preliminary findings.

The Illness Management and Recovery (IMR) program was developed based on a comprehensive review of research on teaching illness self-management strategies to clients with schizophrenia and other severe mental illnesses and "packaged" in a resource kit to facilitate dissemination. Despite growing dissemination of this program, it has not yet been empirically validated. This article describes the development and theoretical underpinnings of the IMR program and presents pilot data from the United States and Australia (N = 24, 88% schizophrenia or schizoaffective) on the effects of individual-based and group-based treatment over the 9-month program and over a 3-month follow-up. High satisfaction was reported by participants. Strong improvements over treatment and at follow-up were found in clients' self-reported effectiveness in coping with symptoms and clinicians' reports of global functioning and moderate improvements in knowledge about mental illness, distress related to symptoms, hope, and goal orientation. These findings support the feasibility and promise of the IMR program and point to the need for controlled research to rigorously evaluate its effects.