Behavior therapy vs insight-oriented therapy for repeated suicide attempters.

A behavior therapy package was compared with insight-oriented therapy in a clinical trial for repeated suicide attempters. Self-report measures of depression, anxiety, and assertiveness were obtained before and after ten days of inpatient treatment and at follow-up intervals for nine moths. Interviews with patients during a two-year follow-up period elicited frequency of suicidal attempts and ideation. Results indicated the superiority of the behavior therapy package, with the structured, brief hospitalization and assertive follow-up likely contributing to the main effects.

Fluphenazine vs placebo supplementation for prodromal signs of relapse in schizophrenia.

BACKGROUND: We studied the effectiveness of treating patients with low doses of fluphenazine decanoate and supplementing them with oral fluphenazine when there was evidence of prodromal symptoms of psychotic exacerbations. METHODS: Eighty schizophrenic patients who were receiving 5 to 10 mg of fluphenazine decanoate every 2 weeks were monitored for prodromal symptoms using an idiosyncratic prodromal rating scale. When patients met our criteria for a prodromal episode, they were randomly assigned to a double-blind comparison of oral fluphenazine hydrochloride (5 mg twice daily) or a placebo for the current and future prodromal episodes. We compared rates of psychotic exacerbations in the two treatment groups. RESULTS: Thirty-six patients (45%) met the criteria for a prodrome at some point during the trial and were randomized to drug or placebo. Using survival analysis during the entire 2 years, we did not find a significant difference between fluphenazine and placebo in the likelihood that a prodrome would continue to an exacerbation. Survival analysis beginning at the start of the second year of treatment did indicate a significant reduction in exacerbation risk for patients receiving drug supplementation (P = .032). Similarly, there was no difference between the two groups in the proportion of time at risk spent in exacerbation during the first year, but patients receiving active drug supplementation spent less time in an exacerbated state in the second year (P = .05). CONCLUSIONS: Our treatment strategy appeared to be effective for some patients, particularly those who were able to remain in the study beyond the first year. Although the occurrence of a prodrome was a fairly good marker that a patient was at high risk of ultimate exacerbation with our low-dose maintenance protocol, prodromes were not highly sensitive indicators of imminent exacerbation.

Behavior therapy in a community mental health center.

Behavioral principles offer an operational model for the services of a community mental health center. A demonstration and clinical research project adapted behavior analysis and therapy to the problems, patients, staff, and setting a typical comprehensive community mental health center. Innovations in the day hospital included a credit incentive system, educational workshops for community adaptation, and a goal-attainment method of planning and evaluating individual treatment. Behavior therapy was introduced for outpatients with anxiety and depression, marital conflict, and deficits in social skills. Consultation and education programs were established for parents, schools, and other community agencies. Experimental and evaluative research has documented the effectiveness of these programs.

Social skills training for schizophrenic individuals at risk for relapse.

Two studies were conducted to evaluate the clinical efficacy of intensive social skills training in medicated schizophrenic inpatients at risk for relapse. In study 1, three patients were treated; two showed reductions in psychopathology and rehospitalization and improved social functioning 9 months following discharge. In study 2, social skills training was compared with holistic health treatment in 28 patients. Both groups showed reduced psychopathology 2 years after discharge; patients treated with social skills training had better social functioning, spent less time hospitalized, and had fewer symptomatic relapses. The results support the utility of social skills training as a psychosocial treatment for schizophrenia.

Comparison of efficacy of social skills training for deficit and nondeficit negative symptoms in schizophrenia.

OBJECTIVE: The purpose of this pilot study was to compare the efficacy of social skills training for individuals with schizophrenia who did or did not have the deficit syndrome. METHOD: Three subjects with the deficit syndrome and three with nondeficit negative symptoms received 12 weeks of social skills training. Social skills and negative symptoms were evaluated before and after training and at 6-month follow-up. RESULTS: Patients with schizophrenia who did not have the deficit syndrome demonstrated significantly better social skills and lower negative symptoms both after training and at follow-up than did those who had the deficit syndrome. CONCLUSIONS: Schizophrenic patients with nondeficit negative symptoms appear amenable to intensive social skills training, but schizophrenic patients with the deficit syndrome may have significant deficits in skill acquisition.

Informed consent: assessment of comprehension.

OBJECTIVE: The authors designed and evaluated a structured and rigorous informed consent procedure involving subjects with schizophrenia. METHOD: Informed consent forms were read and explained to 49 schizophrenic patients participating in ongoing clinical treatment research trials. The subjects answered a questionnaire relating to each research protocol. Protocol procedures were reiterated until the patients answered 100% of the questions correctly. Subjects were asked the same questions 7 days later to ascertain how much of the information they had retained. RESULTS: The patients' median score on the first trial of the informed consent questionnaire was 80% correct. To achieve 100% correct responses, 53% of the patients required a second trial of the questionnaire, and 37% of them required three or more trials. Scores improved between the first trial and the trial on day 7. Ninety-six percent of the subjects felt adequately informed, 66% reported participating in the research protocol for personal reasons, and 34% reported participating at the suggestion of others. CONCLUSIONS: These findings demonstrate that when adequate informed consent procedures are established, schizophrenic research subjects are able to understand and retain critical components of informed consent information.

Effectiveness and replicability of modules for teaching social and instrumental skills to the severely mentally ill.

OBJECTIVE: This study evaluated the effectiveness and replicability of psychoeducational modules designed to improve the social and instrumental competencies of severely mentally ill patients. METHOD: Staff in seven facilities used the modules to teach 108 severely mentally ill patients. Staff received 2 days of formal training followed by periodic consultation. Each module's effectiveness was measured by a test of the patients' knowledge and performance of the skills taught in that module. Staff's adherence to the instructional techniques specified in the modules was measured by directly observing them and assessing the fidelity of their behaviors to those specified in the modules. RESULTS: The patients' skills significantly improved and were maintained during a 1-year follow-up, and staff accurately followed the modules with minimal consultation. CONCLUSIONS: These training modules are effective and replicable techniques for teaching social and instrumental skills to severely mentally ill patients. The modules can be easily disseminated to a variety of facilities and used as components in a comprehensive rehabilitation program.

Skills training versus psychosocial occupational therapy for persons with persistent schizophrenia.

OBJECTIVE: The authors compared the community functioning of outpatients with persistent forms of schizophrenia after treatment with psychosocial occupational therapy or social skills training, with the latter conducted by paraprofessionals. METHOD: Eighty outpatients with persistent forms of schizophrenia were randomly assigned to receive either psychosocial occupational therapy or skills training for 12 hours weekly for 6 months, followed by 18 months of follow-up with case management in the community. Antipsychotic medication was prescribed through "doctor's choice" by psychiatrists who were blind to the psychosocial treatment assignments. RESULTS: Patients who received skills training showed significantly greater independent living skills during a 2-year follow-up of everyday community functioning. CONCLUSIONS: Skills training can be effectively conducted by paraprofessionals, with durability and generalization of the skills greater than that achieved by occupational therapists who provide their patients with psychosocial occupational therapy.

Technique for training schizophrenic patients in illness self-management: a controlled trial.

OBJECTIVE: To determine whether schizophrenic outpatients receiving low-dose neuroleptic therapy could learn and retain complex information and skills related to self-management of their illness, a novel technique of teaching, using cognitive and behavioral methods, was designed to compensate for the patients' learning disabilities. METHOD: The subjects were 41 patients with DSM-III-R schizophrenia who were receiving constant maintenance neuroleptic drug therapy. They were randomly assigned to structured, modularized skills training or to supportive group psychotherapy. RESULTS: The patients who received skills training made significant gains in each of the areas taught, while those participating in group therapy did not. The skills learned during training were retained without significant erosion over a 1-year follow-up period. CONCLUSIONS: The effectiveness of modularized teaching of illness self-management skills to schizophrenic patients appears to be largely independent of baseline psychology and symptom improvement. Such an approach is useful for overcoming or compensating for the enduring cognitive and information processing deficits commonly found in schizophrenia.

Two-year outcome of social skills training and group psychotherapy for outpatients with schizophrenia.

OBJECTIVE: The authors evaluated the effectiveness of behaviorally oriented social skills training and supportive group therapy for improving the social adjustment of schizophrenic patients living in the community and for protecting them against psychotic relapse. METHOD: Eighty male outpatients with schizophrenia were stabilized with a low dose of fluphenazine decanoate (5 to 10 mg every 14 days), which was supplemented with oral fluphenazine (5 mg twice daily) or a placebo when they first met criteria for a prodromal period. (Half of the patients did so at some time during the study.) Patients were randomly assigned to receive either social skills training or supportive group therapy twice weekly for 6 months and then weekly for the next 18 months. Rates of psychotic exacerbation were monitored, as were scores on the Social Adjustment Scale II. RESULTS: There were significant main effects favoring social skills training over supportive group therapy on two of the six Social Adjustment Scale II cluster totals examined (personal well-being and total) and significant interactions between psychosocial treatment and drug treatment for three items (external family, social and leisure activities, and total). In each case, these interactions indicated that the advantage of social skills training over supportive group therapy was greatest when it was combined with active drug supplementation. Social skills training did not significantly decrease the risk of psychotic exacerbation in the full group, but an advantage was observed (post hoc) among patients who received placebo supplementation. CONCLUSIONS: These findings suggest that social skills training resulted in greater improvement in certain measures of social adjustment than supportive group therapy. The greatest improvement in social outcomes occurred when social skills training was combined with a pharmacological strategy of active drug supplementation at the time prodromal worsening of psychotic symptoms was first observed. However, these improvements were modest in absolute terms and confined to certain subgroups of patients.

Optimal drug and behavior therapy for treatment-refractory schizophrenic patients.

Thirteen treatment-refractory schizophrenic patients (10 men and three women) who were receiving more than 50 mg/day of haloperidol and who had been hospitalized for more than 1 year successfully tolerated a mean dose reduction of 63% with consequent improvement in psychopathology and side effects. The addition of intensive behavior therapy to the optimal dose of haloperidol yielded further improvements in functional behavior, such as self-care and social interaction.

Prediction of response to haloperidol dose reduction by Span of Apprehension measures for treatment-refractory schizophrenic patients.

Thirteen treatment-refractory schizophrenic patients participated in a haloperidol reduction study. Two of the subjects were unable to tolerate medication reduction. These subjects were comparable to the other patients in terms of initial clinical variables but were outliers on baseline accuracy and reaction time measures from the Span of Apprehension. The results suggest that aspects of basic visual processing and motor response speed may identify patients who require higher neuroleptic doses.

Achieving effective treatment of patients with chronic psychotic illness and comorbid substance dependence.

OBJECTIVE: The changing effectiveness of a treatment program for dual-diagnosis patients was evaluated over a 2-year period with the use of a sequential study group design. METHOD: The treatment outcome of 179 consecutively enrolled patients with chronic psychotic illness and comorbid substance dependence who entered a specialized day hospital dual-diagnosis treatment program from Sept. 1, 1994, to Aug. 31, 1996, was evaluated. The 24 months were divided into four successive 6-month periods for comparing the evolving effectiveness of the program for groups of patients entering the day hospital during these four periods. Treatment attendance, hospital utilization, and twice weekly urine toxicology analyses were used as outcome measures. RESULTS: The initial treatment engagement rate, defined as at least 2 days of attendance in the first month, increased significantly from group 1 to group 4, more than doubling. Thirty-day and 90-day treatment retention rates also substantially increased from group 1 to group 4. More patients had no hospitalization in the 6 months after entering the day hospital program than in the 6 months before entering the day hospital program. Urine toxicology monitoring indicated that the patients in group 4 were more likely than those in group 1 to remain abstinent at follow-up. CONCLUSIONS: The evolving clinical effectiveness of a developing program can be quantified by using a sequential group comparison design. The sequential outcome improvements may be related to the incremental contributions of assertive case management and skills training for relapse prevention.

CASIG: a consumer-centered assessment for planning individualized treatment and evaluating program outcomes.

This paper reports the psychometric characteristics of a measure that assesses the treatment outcomes of individuals with serious and persistent mental illness. Unlike other outcome measures, this one is designed to be embedded in the clinical process of planning and evaluating treatment. It collects individualized data, structures how the data are used to plan and evaluate a client's treatment, and produces aggregate information relevant for research and program purposes. Two parallel versions were developed: one for the client's self-report, and one for an informant's report. The self-report measure was administered by peer-interviewers to 244 community interviewees, and by inpatient peer-interviewers to 93 inpatient interviewees. The community interviewees also completed the BASIS-32 and SF-36. Informants for 103 of the community interviewees completed the informant version of the measure, and the CCAR. Inpatient staff completed the informant version for 161 inpatient residents without regard for matching the 93 inpatient interviewees. The two versions had acceptable internal consistency, test--retest, and interrater reliabilities. Correlations of the community interviewees' and informants' results with the BASIS-32, SF-36, and CCAR provided evidence of convergent and discriminant validity, as did contrasts between community and inpatients interviewees. The usefulness of the instrument for clinical, program and research purposes is discussed, with emphasis on the characteristics that enhance its value in clinical practice --- assessment of meaningful outcomes, operationalization of client empowerment, comprehensiveness, easy administration, and continuity across time and provider. Also discussed is a computer-based program to summarize and present the results in a rapid, clinically meaningful manner.

Training schizophrenic patients to manage their symptoms: predictors of treatment response to the German version of the Symptom Management Module.

This study examined whether patient demographic and clinical characteristics were predictors of differential treatment response in a sample of 57 schizophrenic patients who received the German version of the Symptom Management Module. Psychopathology, global functioning and knowledge about schizophrenia were assessed as dependent variables. Overall, patients improved over the treatment period on most dimensions of psychopathology as well as knowledge about psychosis. There was little evidence of differential treatment response as a function of either sociodemographic or clinical variables. However, gender was related to changes in psychopathology from pre- to posttreatment, with females improving less than males. Possible implications of these findings were discussed.

Concurrent validity of negative symptom assessments in treatment refractory schizophrenia: relationship between interview-based ratings and inpatient ward observations.

The concurrent validity of interview-based ratings of negative symptoms in 35 inpatients with chronic, treatment refractory schizophrenia was evaluated. Correlations were examined between interview-based ratings of negative symptoms, measured by the Brief Psychiatric Rating Scale and the Positive and Negative Syndrome Scale, and the naturalistic behavior of inpatients as assessed by the Time Sample Behavior Checklist. Higher levels of interview-based negative symptoms were related to reduced interpersonal activity on the inpatient ward, but not to entertainment, instrumental or self-maintenance activities. These findings offer partial support for the concurrent validity of office-based ratings of negative symptoms, and highlight the importance of longitudinal observations of patients for accurate identification of negative symptoms.

Assessment of social skills.

Deficiencies in social skills, important in the functional adjustment and rehabilitation of persons with schizophrenia, derive from inadequate learning experiences, disuse, anxiety, cognitive disturbances, and amotivational states. Social skills training programs should be specifically organized to compensate for these varied sources of deficiency in interpersonal competence. Assessment of social skills deficits can proceed along topographical, functional, and information-processing lines. Assessment technology is in its early stages of development and will require attention to the psychometric properties and multidimensional focus of evaluative instruments.

Psychiatric rehabilitation of schizophrenia: editor's introduction.

Well-planned and conceptualized rehabilitation of psychiatric patients who demonstrate persisting impairments, disabilities, and handicaps begins with assessment of symptoms and psychosocial functioning. Rehabilitation interventions--aimed at building skills and providing supportive and prosthetic environments--are linked to initial and ongoing assessment. The refractoriness of large numbers of psychiatric patients to conventional and customary forms of therapy will fuel the development of psychiatric rehabilitation that is efficacious and empirically based.

Whither cognitive-behavioral therapy for schizophrenia?

Clinical studies of cognitive therapy and rehabilitation for persons with schizophrenia have generated promising findings of improvements in patients' cognitive and clinical status. However, the results do not appear to be specific to a particular form of intervention, and long-term evaluations of cognitive therapy, as an element in a comprehensive system of care, need to be conducted for clinical validation. Rehabilitation efforts should be congruent with laboratory findings of specific cognitive deficits, including those that are "vulnerability indicators" and endure beyond symptomatic episodes. With the demonstration that chronic schizophrenic patients can learn a variety of cognitive and behavioral skills through Integrated Psychological Therapy and other psychosocial treatments, the future appears bright for a profusion of new modalities aimed at cognitive-behavioral rehabilitation, especially those that emerge from what is known about information-processing deficits in schizophrenia.

What is schizophrenia?

One of the main questions related to schizophrenia is, naturally enough, what is it? Such a question may seem obvious, naive, impossible, or any combination of these. And certainly it is a bit demanding to expect that anyone could say what schizophrenia is in 1,000 words. On the other hand, we felt that it was worth the effort. We hope that presenting these brief discussions on "what is schizophrenia" by persons who have worked extensively in the field will allow the reader to note areas of overlap and disagreement as well as variations in emphasis. Although no one may yet be able to provide the definitive answer, at least this collection of informed opinions may help clarify the major questions. The essays by Herbert Y. Meltzer and Robert Paul Liberman are the first in a series. Further collections of these statements will be presented in subsequent issues. Readers' responses and comments are cordially invited.