Relapse prevention through health technology program reduces hospitalization in schizophrenia.

BACKGROUND: Psychiatric hospitalization is a major driver of cost in the treatment of schizophrenia. Here, we asked whether a technology-enhanced approach to relapse prevention could reduce days spent in a hospital after discharge. METHODS: The Improving Care and Reducing Cost (ICRC) study was a quasi-experimental clinical trial in outpatients with schizophrenia conducted between 26 February 2013 and 17 April 2015 at 10 different sites in the USA in an outpatient setting. Patients were between 18 and 60 years old with a diagnosis of schizophrenia, schizoaffective disorder, or psychotic disorder not otherwise specified. Patients received usual care or a technology-enhanced relapse prevention program during a 6-month period after discharge. The health technology program included in-person, individualized relapse prevention planning with treatments delivered via smartphones and computers, as well as a web-based prescriber decision support program. The main outcome measure was days spent in a psychiatric hospital during 6 months after discharge. RESULTS: The study included 462 patients, of which 438 had complete baseline data and were thus used for propensity matching and analysis. Control participants (N = 89; 37 females) were enrolled first and received usual care for relapse prevention followed by 349 participants (128 females) who received technology-enhanced relapse prevention. During 6-month follow-up, 43% of control and 24% of intervention participants were hospitalized (χ2 = 11.76, p<0.001). Days of hospitalization were reduced by 5 days (mean days: b = -4.58, 95% CI -9.03 to -0.13, p = 0.044) in the intervention condition compared to control. CONCLUSIONS: These results suggest that technology-enhanced relapse prevention is an effective and feasible way to reduce rehospitalization days among patients with schizophrenia.

Evaluation of cognitive restructuring for post-traumatic stress disorder in people with severe mental illness.

BACKGROUND: A cognitive-behavioural therapy (CBT) programme designed for post-traumatic stress disorder (PTSD) in people with severe mental illness, including breathing retraining, education and cognitive restructuring, was shown to be more effective than usual services. AIMS: To evaluate the incremental benefit of adding cognitive restructuring to the breathing retraining and education components of the CBT programme (trial registration: clinicaltrials.gov identifier: NCT00494650). METHOD: In all, 201 people with severe mental illness and PTSD were randomised to 12- to 16-session CBT or a 3-session brief treatment programme (breathing retraining and education). The primary outcome was PTSD symptom severity. Secondary outcomes were PTSD diagnosis, other symptoms, functioning and quality of life. RESULTS: There was greater improvement in PTSD symptoms and functioning in the CBT group than in the brief treatment group, with both groups improving on other outcomes and effects maintained 1-year post-treatment. CONCLUSIONS: Cognitive restructuring has a significant impact beyond breathing retraining and education in the CBT programme, reducing PTSD symptoms and improving functioning in people with severe mental illness.

Public mental health clients with severe mental illness and probable posttraumatic stress disorder: trauma exposure and correlates of symptom severity.

Individuals with severe mental illness (SMI) are at greatly increased risk for trauma exposure and for the development of posttraumatic stress disorder (PTSD). This study reports findings from a large, comprehensive screening of trauma and PTSD symptoms among public mental health clients in a statewide community mental health system. In 851 individuals with SMI and probable PTSD, childhood sexual abuse was the most commonly endorsed index trauma, followed closely by the sudden death of a loved one. Participants had typically experienced an average of 7 types of traumatic events in their lifetime. The number of types of traumatic events experienced and Hispanic ethnicity were significantly associated with PTSD symptom severity. Clients reported experiencing PTSD in relation to events that occurred on average 20 years earlier, suggesting the clinical need to address trauma and loss throughout the lifespan, including their prolonged after-effects.

Diagnostic profiles and trauma history among treatment-seeking young adults with positive post-traumatic stress disorder screens: Findings and implications for public mental health care.

OBJECTIVES: This study examined diagnostic profiles and trauma history among treatment-seeking young adults with positive PTSD screens in public mental health care. METHODS: Screening for trauma history and PTSD symptoms was implemented in a community mental health service system. 266 treatment-seeking young adults (aged 18-35) endorsed trauma exposure with a score of at least 45 on the DSM-IV PTSD Checklist, indicating probable PTSD. RESULTS: Young adults with positive PTSD screens were predominantly female, minority, and diagnosed with mood disorders. Of those with positive screens, only 15% had a chart diagnosis of PTSD; 17.3% (ages 18-24) versus 14.1% (ages 25-35). Variables significantly associated with a decreased likelihood of PTSD detection included a diagnosis of schizophrenia or bipolar disorder, exposure to fewer types of traumatic events, male gender, and white race. CONCLUSION: Routine PTSD screening for young adults receiving public mental health care should be prioritized to address long-term impacts of trauma.

Family therapy for schizophrenia: co-occurring psychotic and substance use disorders.

People with schizophrenia have a high prevalence of co-occurring substance use disorders, which is related to a worse course of psychiatric illness, more frequent relapses, and increased depression and suicide, compared with those with schizophrenia alone. The Family Intervention for Dual Diagnosis (FIDD) program, which includes psychoeducation and goal setting and focuses on building communication and problem-solving skills within the family, can aid in decreasing the stress related to having a close relationship with someone with a dual disorder. Here, the case of a young man with psychosis and marijuana dependence is examined. This article describes how the FIDD intervention helped him with his problematic substance use, as well as to build skills within his relationship for increased empathy and reduced interpersonal stress.

Predictors of undocumented PTSD in persons using public mental health services.

Individuals diagnosed with serious mental illness (SMI) have greater trauma exposure and are at increased risk for posttraumatic stress disorder (PTSD). However, PTSD is rarely documented in their clinical records. This study investigated the predictors of PTSD documentation among 776 clients with SMI receiving public mental health services, who had probable PTSD as indicated by a PTSD Checklist score of at least 45. Only 5.3% of clients had PTSD listed as a primary diagnosis, and 8.4% had PTSD as a secondary diagnosis, with a total 13.7% documentation rate. PTSD documentation rate was highest for clients with major depression (18.8%) compared to those with schizophrenia (4.1%) or bipolar disorder (6.3%). Factors that predicted a lower likelihood of having a chart diagnosis of PTSD included being diagnosed with schizophrenia/schizoaffective disorder or bipolar disorder. Factors that predicted a higher likelihood of having a chart diagnosis of PTSD included being of non-white race, being female, and experiencing eight or more types of traumatic events. Findings highlight the need for PTSD screening and trauma informed care for clients with SMI receiving public mental health services.

Outcomes During and After Early Intervention Services for First-Episode Psychosis: Results Over 5 Years From the RAISE-ETP Site-Randomized Trial.

To examine long-term effects of early intervention services (EIS) for first-episode psychosis, we compared Heinrichs-Carpenter Quality of Life (QLS) and Positive and Negative Syndrome Scale (PANSS) scores and inpatient hospitalization days over 5 years with data from the site-randomized RAISE-ETP trial that compared the EIS NAVIGATE (17 sites; 223 participants) and community care (CC) (17 sites; 181 participants). Inclusion criteria were: age 15-40 years; DSM-IV diagnoses of schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, or psychotic disorder not otherwise specified; first psychotic episode; antipsychotic medication taken for ≤6 months. NAVIGATE-randomized participants could receive NAVIGATE from their study entry date until NAVIGATE ended when the last-enrolled NAVIGATE participant completed 2 years of treatment. Assessments occurred every 6 months. 61% of participants had assessments conducted ≥2 years; 31% at 5 years. Median follow-up length was CC 30 months and NAVIGATE 38 months. Primary analyses assumed data were not-missing-at-random (NMAR); sensitivity analyses assumed data were missing-at-random (MAR). MAR analyses found no significant treatment-by-time interactions for QLS or PANSS. NMAR analyses revealed that NAVIGATE was associated with a 13.14 (95%CI:6.92,19.37) unit QLS and 7.73 (95%CI:2.98,12.47) unit PANSS better improvement and 2.53 (95%CI:0.59,4.47) fewer inpatient days than CC (all comparisons significant). QLS and PANSS effect sizes were 0.856 and 0.70. NAVIGATE opportunity length (mean 33.8 (SD = 5.1) months) was not associated (P = .72) with QLS outcome; duration of untreated psychosis did not moderate (P = .32) differential QLS outcome. While conclusions are limited by the low rate of five-year follow-up, the data support long-term benefit of NAVIGATE compared to community care.

Trauma-focused therapies for post-traumatic stress in psychosis: study protocol for the RE.PROCESS randomized controlled trial.

INTRODUCTION: Many people with psychotic disorders experience symptoms of post-traumatic stress disorder (PTSD). In recent years, several trauma-focused therapies (TFTs), including cognitive restructuring (CR), prolonged exposure (PE), and eye movement desensitization and reprocessing (EMDR) have been studied and found to be safe and effective in reducing PTSD symptoms in individuals with psychosis. However, studies were conducted in different countries, with varying inclusion criteria, therapy duration, control groups, and trial outcomes. RE.PROCESS will be the first study to compare the impact of CR, PE, and EMDR with a waiting list control condition within the same context. METHODS AND ANALYSIS: This is the protocol of a pragmatic, single-blind, multicentre, superiority randomized controlled trial, in which CR, PE, and EMDR are compared to a waiting list control condition for TFT (WL) in a naturalistic treatment setting. Inclusion criteria are as follows: age ≥ 16 years; meeting full DSM-5 diagnostic criteria for PTSD on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), with a total CAPS score ≥ 23; and a psychotic disorder in the schizophrenia spectrum confirmed by the Structured Clinical Interview for DSM-5 (SCID-5). Participants (N=200) will be randomly allocated to 16 sessions of one of the TFTs or WL, in addition to receiving treatment as usual (TAU) for psychosis. The primary objective is to compare the effects of CR, PE, and EMDR to WL on researcher-rated severity of PTSD symptoms over time from baseline to 6-month follow-up. Secondary objectives are to examine these effects at the separate time-points (i.e., mid-treatment, post-treatment, and at 6-month follow-up) and to test the effects for clinician-rated presence of PTSD diagnosis, and self-rated severity of (complex) PTSD symptoms. DISCUSSION: This is the first RCT to directly compare the effects of CR, PE, and EMDR within the same context to TAU on PTSD symptoms in individuals with psychosis and PTSD. Secondary effects on clinical and functional outcomes will be investigated both directly after therapy and long term. TRIAL REGISTRATION: ISRCTN ISRCTN56150327 . Registered 18 June 2019.

Psychotic depression, posttraumatic stress disorder, and engagement in cognitive-behavioral therapy within an outpatient sample of adults with serious mental illness.

Depression with psychotic features afflicts a substantial number of people and has been characterized by significantly greater impairment, higher levels of dysfunctional beliefs, and poorer response to psychopharmacologic and psychosocial interventions than nonpsychotic depression. Those with psychotic depression also experience a host of co-occurring disorders, including posttraumatic stress disorder (PTSD), which is not surprising given the established relationships between trauma exposure and increased rates of psychosis and between PTSD and major depression. To date, there has been very limited research on the psychosocial treatment of psychotic depression; and even less is known about those who also suffer from PTSD. The purpose of this study was to better understand the rates and clinical correlates of psychotic depression in those with PTSD. Clinical and symptom characteristics of 20 individuals with psychotic depression and 46 with nonpsychotic depression, all with PTSD, were compared before receiving cognitive-behavioral therapy for PTSD treatment or treatment as usual. Patients with psychotic depression exhibited significantly higher levels of depression and anxiety, a weaker perceived therapeutic alliance with their case managers, more exposure to traumatic events, and more negative beliefs related to their traumatic experiences, as well as increased levels of maladaptive cognitions about themselves and the world, compared with participants without psychosis. Implications for cognitive-behavioral therapy treatment aimed at dysfunctional thinking for this population are discussed.

Prevalence and correlates of PTSD in first episode psychosis: Findings from the RAISE-ETP study.

Posttraumatic stress disorder (PTSD) in young individuals is associated with an increased risk to develop psychosis or mania, and both trauma and PTSD rates are elevated in people with schizophrenia and other severe mental illnesses. However, less research has examined PTSD in people who have recently developed a first episode of psychosis (FEP). The present study is a secondary analysis of the baseline data collected for the National Institute of Mental Health Recovery After an Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study to examine the rates of trauma and PTSD, and to explore the demographic and clinical correlates of PTSD in a representative sample of 404 persons with an FEP. Approximately 80% of the study sample reported experiencing at least one traumatic event during their lives, with females more likely to report childhood sexual abuse and spousal abuse than males. A total of 20 participants (5.0%) met criteria for a lifetime diagnosis of PTSD, while another 15 participants (3.7%) met subthreshold diagnostic criteria for PTSD. Significant correlations were found between lifetime PTSD and the Calgary Depression Scale, the Mental Health Recovery Measure, the Stigma Scale, and duration of untreated psychosis, with higher scores on each variable associated with a diagnosis of PTSD. The association between PTSD and more severe depression, as well as lower perceptions of personal recovery, suggest that PTSD may be an important target for treatment programs for persons recovering from an FEP. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Client predictors of the therapeutic alliance in individual resiliency training for first episode psychosis.

Individuals experiencing their first episode of psychosis (FEP) are often reluctant to seek treatment, and are difficult to engage and retain in mental health services. The therapeutic alliance (TA), or the affective and collaborative bond between therapist and client, is predictive of better treatment outcomes for clients with FEP; thus, it is important to understand the predictors of the TA in order to determine how best to foster a positive alliance with these individuals. The primary aim of the present study was to examine whether baseline client characteristics, including severity of symptoms, social functioning, and insight, were associated with the TA. The exploratory aim was to examine associations between demographic variables (age, race, and gender) and the TA. The present study included a subsample of participants (n = 134) who received Individual Resiliency Training (IRT) as part of the NAVIGATE treatment in the Recovery After An Initial Schizophrenia Episode Early Treatment Program study. Four trained research assistants rated the TA from early audiotaped sessions of IRT. Multilevel modeling was utilized given the nested data structure. Results indicated that more severe positive and less severe negative symptoms were significantly and uniquely associated with a better therapeutic alliance, as was female gender. The findings suggest that client symptom profiles should be considered when developing a TA with FEP clients.

The therapeutic alliance in individual resiliency training for first episode psychosis: Relationship with treatment outcomes and therapy participation.

OBJECTIVE: The therapeutic alliance has long been considered an essential part of treatment. Despite a large body of work examining the alliance-outcome relationship, very few studies have examined it within individuals with first episode psychosis (FEP). METHOD: The present study examined the alliance at Session 3, 4, or 5 and its relationship to 2-year treatment outcomes and therapy participation in a sample of 144 FEP clients who received specialized FEP treatment at U.S. clinics. Furthermore, we examined between-therapist and within-therapist (client) effects of the alliance on outcomes. RESULTS: Results indicated that a better alliance was related to improved mental health recovery, psychological well-being, quality of life, total symptoms, negative symptoms, and disorganized symptoms at the end of treatment. In addition, the between-therapist effect of the alliance was significantly related to better mental health recovery whereas the within-therapist (client) effect of the alliance was related to better quality of life, total symptoms, and negative symptoms at the end of treatment. CONCLUSIONS: A stronger alliance was related to improved treatment outcomes in FEP. Future work should consider examining mediators of the alliance-outcome relationship as well as how changes in the alliance relate to changes in outcomes over time. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Off-hours use of a smartphone intervention to extend support for individuals with schizophrenia spectrum disorders recently discharged from a psychiatric hospital.

INTRODUCTION: Technology-delivered healthcare interventions may enhance dissemination of evidence-based treatments in low-resource areas. These interventions may be accessed 'on-demand,' including after hours. Patients with schizophrenia do engage with technological aids but when/how they would utilize these tools is not known. METHODS: We conducted a large, prospective, ten-site, longitudinal study of four technology-assisted interventions for patients with schizophrenia spectrum disorders within 60 days of psychiatric hospital discharge, a high risk period. One tool employed was a smartphone intervention called 'FOCUS,' which could be used by patients as needed, providing help in five content areas: medications, mood, social, sleep and voices. Each login was date- and time-stamped as occurring during normal clinic hours, or 'off-hours,' and the pattern of use described. RESULTS: 347 of 368 patients utilized FOCUS during the 6-month study. There were a total of 75,447 FOCUS logins; 35,739 (47.4%) were self-initiated and 38,139 (50.6%) were off-hours. 18,450 of the logins during off-hours were self-initiated (24.5%). No differences in average usage per month were found based on race/ethnicity. A subset of 'high utilizers' (n = 152, 43.8%) self-initiated use of all five FOCUS modules both on- and off-hours. They tended to be women, >35 years old, and had a high school diploma or greater. CONCLUSION: Most patients with schizophrenia spectrum disorders recently discharged from the hospital utilized a smartphone intervention targeted to address troublesome residual symptoms. One quarter of the total smartphone utilization was self-initiated off-hours, indicating the potential utility of this tool to extend support for patients during periods of elevated risk.

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.

Once-weekly D-cycloserine effects on negative symptoms and cognition in schizophrenia: an exploratory study.

BACKGROUND: Daily dosing with d-cycloserine has inconsistently improved negative symptoms in schizophrenia patients, whereas intermittent dosing significantly facilitated exposure-based therapy in two studies of patients with phobic anxiety. In animal models, single-dose administration enhances memory consolidation, but tachyphylaxis develops with repeated dosing. The objective of this exploratory study was to assess whether once-weekly dosing with d-cycloserine will produce persistent improvements in negative symptoms and cognition. METHODS: Fifty stable adult schizophrenia outpatients treated with any antipsychotic except clozapine were enrolled and 38 were randomized, double-blind, in a parallel-group, eight-week add-on trial of d-cycloserine 50 mg or placebo administered once-weekly. Symptom rating scales and a cognitive battery were administered at baseline and week 8 before the dose of study drug. As an exploratory analysis of memory consolidation, the Logical Memory Test, modified to measure recall after 7 days, was administered at baseline and after the first weekly dose of d-cycloserine. The primary outcome measures were change from baseline to week 8 on the SANS total score and on a composite cognitive score. RESULTS: Thirty-three subjects (87%) completed the trial. d-cycloserine significantly improved SANS total scores compared to placebo at week 8. Cognitive performance did not improve with d-cycloserine at 8 weeks. Delayed thematic recall on the Logical Memory Test was significantly improved with the first dose of d-cycloserine compared to placebo. Performance on immediate thematic recall and item recall on the Logical Memory Test did not differ between treatments. CONCLUSIONS: Once-weekly dosing with d-cycloserine for 8 weeks produced persistent improvement of negative symptoms compared to placebo, although statistical significance was, in part, the result of worsening of negative symptoms with placebo. Consistent with animal models, a single dose of d-cycloserine facilitated memory consolidation tested after 7 days on a test of thematic recall. These results must be considered preliminary since a number of outcomes were examined without correction for multiple tests. These findings suggest that once-weekly dosing with d-cycloserine for the treatment of negative symptoms merits further study, as do d-cycloserine effects on memory consolidation.

Trauma and posttraumatic stress disorder in Spanish public mental health system clients with severe psychiatric conditions: Clinical and demographic correlates.

OBJECTIVE: Compared with the general population, those with severe psychiatric conditions have a substantially higher likelihood of trauma exposure, increased probability of developing posttraumatic stress disorder (PTSD), and more severe consequences if trauma is left untreated. Nevertheless, identification of trauma/PTSD continues to be a neglected mental health system priority. In Spain, few investigations have examined the prevalence of trauma, particularly in persons with severe psychiatric conditions. METHOD: This study reports findings from a trauma/PTSD screening within a large Madrid public mental health agency serving clients with severe psychiatric conditions. RESULTS: Of the 323 participants, 272 (84.2%) reported at least 1 traumatic event; and 124 (38.4%) met criteria for "probable" PTSD, although none had a medical record diagnosis of PTSD. Those with probable PTSD were predominantly male, were in their mid-40s, had received mental health services for 16 years on average, and endorsed 5.64 types of lifetime traumatic events. The most frequent and distressing traumatic event was the sudden, unexpected death of a loved one. The number of traumatic event types reported was positively correlated with PTSD symptom severity. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Despite lower Spanish general population prevalence of trauma/probable PTSD (compared with the United States and other Western countries), rates within those with co-occurring severe psychiatric conditions are high. These findings reinforce the importance of conducting system-wide screening in public mental health clinics serving persons with severe psychiatric conditions in Spain (and beyond), in order to address this ongoing but neglected issue, and begin to offer much-needed recovery services. (PsycINFO Database Record

Factor structure of therapist fidelity to individual resiliency training in the Recovery After an Initial Schizophrenia Episode Early Treatment Program.

BACKGROUND: Evidence-based approaches and early intervention have improved the long-term prognosis of individuals with schizophrenia. However, little is known about the therapeutic processes involved in individual therapy in first-episode psychosis. A comprehensive psychosocial/psychiatric programme for this population, NAVIGATE, includes an individual therapy component, individual resiliency training (IRT). Fidelity of clinicians' adherence to the IRT protocol has been collected to ensure proper implementation of this manual-based intervention. These data can provide insight into the elements of the therapeutic process in this intervention. MATERIALS AND METHODS: To achieve this goal, we first examined the factor structure of the IRT fidelity scale with exploratory factor analysis. Second, we explored the relationships among the IRT fidelity ratings with clinician years of experience and years of education, as well as client's baseline symptom severity and duration of untreated psychosis. RESULTS AND CONCLUSIONS: Results supported a 2-factor structure of the IRT fidelity scale. Correlations between clinician years of education and fidelity ratings were statistically significant.

Character strengths of individuals with first episode psychosis in Individual Resiliency Training.

Positive psychology interventions that integrate a person's strengths into treatment result in improvements in life satisfaction and well-being. Character strengths classified within six core virtues (wisdom/knowledge, courage, humanity, justice, temperance, and transcendence) have been the subject of substantial research. Though a number of studies have been conducted in the general population, little is known about the character strengths of individuals with first episode psychosis (FEP). Moreover, positive psychology principles, in particular a focus on personal strengths, have been increasingly integrated into FEP treatment and was a core component of Individual Resiliency Training (IRT), the individual therapy component of NAVIGATE tested in the Recovery After an Initial Schizophrenia Episode Early Treatment Program. As such, the present study offers an examination of character strengths among 105 FEP clients in specialized early intervention treatment. The present study included two primary aims: 1) to conduct a descriptive analysis of character strengths of FEP individuals and 2) to examine exploratory associations between character strengths and changes in symptomatic and recovery variables over six months. Results revealed that the most commonly identified strengths were: Honesty, Authenticity, and Genuineness (40.95%), Kindness and generosity (37.14%), Fairness, equity, and justice (29.52%), Gratitude (29.52%), and Humor and playfulness (29.52%). Three virtues (Humanity, Justice, and Transcendence) were significantly associated with improvements in symptoms, psychological well-being, and interpersonal relations over six months. Overall, the present study offers a glimpse into how persons with FEP view their strengths and how certain clusters of strengths are related to important outcomes.

Randomized controlled trial of an internet cognitive behavioral skills-based program for auditory hallucinations in persons with psychosis.

OBJECTIVE: Despite strong evidence supporting the effectiveness of cognitive-behavioral therapy for psychosis (CBTp), most clinicians in the United States have received little or no training in the approach and access remains very low, indicating a potential role for technology in increasing access to this intervention. Coping With Voices (CWV) is a 10-session, interactive, Web-based CBTp skills program that was developed to meet this need, and was shown to be feasible and associated with reduced severity of auditory hallucinations in a previous pilot study. To more rigorously evaluate this program, a randomized controlled trial was conducted comparing the efficacy of CWV to usual care (UC). METHOD: The trial was conducted with a sample of 37 community mental health center clients with schizophrenia and moderate-to-severe auditory hallucinations, with assessments conducted at baseline, posttreatment, and 3-month follow-up. RESULTS: Engagement in and satisfaction with the CWV program were high. Both the CWV and UC groups improved comparably in severity of auditory hallucinations and other symptoms over the treatment and at follow-up. However, participants in the CWV program showed significantly greater increases in social functioning and in knowledge about CBTp. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The results suggest that the CWV program has promise for increasing access to CBTp, and associated benefits in the management of distressing psychotic symptoms and improving social functioning. (PsycINFO Database Record

Cost-Effectiveness of a PTSD Intervention Tailored for Individuals With Severe Mental Illness.

OBJECTIVE: This study examined the cost-effectiveness of a cognitive-behavioral therapy (CBT) intervention for posttraumatic stress disorder (PTSD) that is tailored for adults with a co-occurring severe mental illness. METHODS: Data were from a randomized trial involving 183 adult clients of two outpatient clinics and three partial hospitalization programs. All had a severe mental illness diagnosis (major mood disorder, schizophrenia, or schizoaffective disorder) and severe PTSD. Participants were randomly assigned to the tailored 12- to 16-session CBT intervention for PTSD (CBT-P) or a three-session breathing retraining and psychoeducation intervention (BRF). Cost estimates included intervention costs for training, supervision, fidelity assessment, personnel, and overhead and related mental health care costs for outpatient, inpatient, and emergency department services and for medications. The incremental cost-effectiveness ratio comparing CBT-P with BRF measured the added cost or savings per remission from PTSD at 12 months postintervention. Generalized linear models were used to estimate intervention effects on annual mental health care costs and the likelihood of a remission from PTSD. Ten thousand bootstrap replications were used to assess uncertainty. RESULTS: Annual mean mental health care costs were $25,539 per client (in 2010 dollars) for BRF participants and $29,530 per client for CBT-P participants, a nonsignificant difference. The mean incremental cost-effectiveness ratio was $36,893 per additional PTSD remission yielded by CBT-P compared with BRF (95% confidence interval=-$33,523 to $158,914). Remissions were associated with improvements in quality of life and functioning. CONCLUSIONS: An effective CBT intervention tailored for adults with severe mental illness and PTSD was not found to be more cost-effective than a brief three-session intervention.