Effort-based decision-making as a determinant of supported employment outcomes in psychotic disorders.

Schizophrenia is associated with a heavy economic burden in the United States that is partly due to the high rates of chronic unemployment. Individual Placement and Support (IPS) is an evidenced-based type of supported employment that can improve job obtainment and work outcomes in psychotic disorders. Outcomes vary widely and a persistent challenge for IPS is low levels of engagement in the initial job search phase. Past studies have focused on interview-based motivation deficits as a key determinant of poor treatment engagement and work outcomes in schizophrenia. New validated performance-based measures of motivation, including effort-based decision-making (EBDM) tasks, may explain supported employment outcomes and provide insights into individual differences in IPS outcomes. This study investigated the degree to which IPS engagement (i.e., number of sessions attended during the first four months of service delivery) was related to baseline interview-based motivation deficits and performance on three EBDM tasks - two tasks of physical effort and one of cognitive effort (i.e., Balloon Task, Effort Expenditure for Rewards Task, Deck Choice Effort Task) - in a sample (N = 47) of people with a psychotic disorder. Results indicated that the level of EBDM performance, specifically on the Balloon Task, predicted IPS engagement, accounting for an additional 17 % of the variance above and beyond interview-based motivation deficits (total R2 = 24 %). Overall, these findings suggest that addressing motivational deficits in effort-based decision-making may be beneficial to IPS engagement, which in turn may improve the trajectory of work outcomes.

Promotore-Led Versus Registered Nurse-Led Diabetes Self-Management Education in Mexican Americans: A Randomized Clinical Trial.

PURPOSE: The purpose of this study is to compare the benefits of a diabetes self-management program led by registered nurses (RNs) versus community health workers (promotores) for Spanish-speaking Mexican Americans with type 2 diabetes (T2DM). METHODS: Three hundred thirty Spanish-speaking Mexican American adults with T2DM were randomly assigned to "Tomando Control de Su Diabetes" delivered for six 2.5-hour sessions either by promotores or RNs. The primary outcome measure was the Summary of Diabetes Self-Care Activities (SDSCA). Evaluations were made at baseline, 6 weeks, and at 3, 6, and 12 months. Mixed-effects regression models were fit to test if participants had differential changes in the SDSCA total score by group over time, controlling for demographic and clinical factors. RESULTS: SDSCA scores were significantly higher at all time points compared to baseline and not statistically different between the 2 groups. Only years of education correlated with improvement in diabetes self-management behaviors. No moderating variables predicted improvement between groups. CONCLUSIONS: Spanish-speaking Mexican American adults with T2DM who participated in a diabetes educational program with promotores or RNs demonstrated similar improvements. Promotores may increase the accessibility of effective diabetes self-management training for this difficult-to-reach population.

The duration of untreated psychosis among U.S. Latinxs and social and clinical correlates.

Purpose: This study (a) documents the duration of untreated psychosis (DUP) and (b) examines both social and clinical correlates of DUP in a sample of U.S. Latinxs with first-episode psychosis (FEP). Methods: Data were collected for a longitudinal study evaluating a community education campaign to help primarily Spanish-speaking Latinxs recognize psychotic symptoms and reduce the DUP, or the delay to first prescribed antipsychotic medication after the onset of psychotic symptoms. Social and clinical variables were assessed at first treatment presentation. A sequential hierarchical regression was conducted using √DUP to identify independent predictors of the DUP. A structural equation model was used to explore the association between DUP predictors, DUP, and clinical and social correlates. Results: In a sample of 122 Latinxs with FEP, the median DUP was 39 weeks (M = 137.78, SD = 220.31; IQR = 160.39-5.57). For the full sample, being an immigrant and having self-reported relatively poor English-speaking proficiency and self-reported strong Spanish-speaking proficiency were related to a longer delay to first prescribed medication after psychosis onset. For the immigrant subgroup, being older at the time of migration was related to a longer delay. Self-reported English-speaking proficiency emerged as an independent predictor of the DUP. Although the DUP was not related to symptomatology, it was associated with poorer social functioning. Low self-reported English-speaking ability is associated with poorer social functioning via the DUP. Conclusion: Latinxs with limited English language skills are especially at high risk for experiencing prolonged delays to care and poor social functioning. Intervention efforts to reduce the delay in Latinx communities should pay particular attention to this subgroup.

Evaluation of an Audio-Visual Novela to Improve COVID-19 Knowledge and Safe Practices Among Spanish-Speaking Individuals with Schizophrenia.

In the United States, the health and economic consequences of the COVID-19 pandemic have disproportionately affected the Latinx community. Within the Latinx community, people with schizophrenia-spectrum disorders are more susceptible to exposure to the virus. Given their increased risk of contracting and getting sick from the virus, efforts targeting the Latinx population should focus on increasing knowledge and safe practices associated with COVID-19. We developed a 10 min animated, Spanish-language audio-visual novela designed to improve knowledge, attitudes, and behaviors regarding COVID-19. Latinx adults with schizophrenia (N = 100) at a community mental health center in Los Angeles were randomly assigned to watch the novela or a non-COVID video (control group). Participants completed surveys immediately before and one month after viewing the material. One month after watching the audio-visual novela, subjects endorsed a greater likelihood of seeking a COVID-19 vaccine than control subjects. No other significant differences were observed between the two conditions. The findings of this study suggest that the presentation of health information in a relevant, engaging, and appealing manner may be useful way to improving salutary health behaviors of Latinx people with schizophrenia-spectrum disorders.

Improving Self-management of Type 2 Diabetes in Latinx Patients: Protocol for a Sequential Multiple Assignment Randomized Trial Involving Community Health Workers, Registered Nurses, and Family Members.

BACKGROUND: The rate of Type 2 diabetes mellitus (T2DM) among Mexican American individuals is 16.3%, about twice that of non-Hispanic White individuals. While a number of education approaches have been developed and shown to improve diabetes self-management behaviors and glycemic control for Spanish-speaking Latinx patients with T2DM, there is little research to guide health practitioners regarding which interventions to apply and when so that resources are used efficiently, and treatment outcomes are maximized. OBJECTIVE: This study aimed to describe an adaptive intervention that integrates community mental health workers, diabetes nurse educators, family members, and patients as partners in care while promoting diabetes self-management for Mexican American individuals with T2DM. The project incorporates four evidence-based, culturally tailored treatments to determine what sequence of intervention strategies work most efficiently and for whom. Given the increasing prevalence of T2DM, achieving better control of diabetes and lowering the associated medical complications experienced disproportionally by Mexican American individuals is a public health priority. METHODS: Funded by the National Institute of Nursing Research (National Institutes of Health grant R01 NR015809), this project used a sequential multiple assignment randomized trial and included 330 Spanish-speaking Latinx patients with T2DM. In the first phase of the study, subjects were randomly assigned to an evidence-based diabetes self-management educational program called Tomando Control delivered in a group format for 6, biweekly 1.5-hour sessions, led either by a community health worker or a diabetes nurse educator. In the second phase of the study, those subjects who did not improve their diabetes self-management behaviors were rerandomized to receive either an augmented version of Tomando Control or a multifamily group treatment focused on problem-solving. The primary outcome measure was the "Summary of Diabetes Self-Care Activities." Evaluations were made at baseline and at 3, 6, and 12 months. RESULTS: This study was funded in June 2016 for a period of 5 years. Institutional review board approval was obtained in November 2016. Between March 2017 and September 2020, a total of 330 patients were recruited from the outpatient primary care clinics of Olive View-UCLA Medical Center, with a brief hiatus between May 2020 and July 2020 due to COVID-19 restrictions. The study interventions were completed in December 2020. Data collection began in March 2017 and was completed in December 2021. Data analysis is expected to be completed in Spring 2023, and results will be published in Fall 2023. CONCLUSIONS: The results of this trial should help practitioners in selecting the optimal approach for improving diabetes self-management in Spanish-speaking, Latinx patients with T2DM. TRIAL REGISTRATION: ClinicalTrials.gov NCT03092063; https://clinicaltrials.gov/ct2/show/NCT03092063. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/44793.

Reminder-Focused Positive Psychiatry: Suicide Prevention Among Youths With Comorbid Posttraumatic Stress Disorder and Suicidality.

OBJECTIVE: This study aimed to investigate the effect of brief reminder-focused positive psychiatry and suicide prevention (RFPP-S) on suicidal ideation, posttraumatic stress disorder (PTSD) symptoms, and clinical outcomes among youths with PTSD treated in psychiatric emergency rooms. METHODS: This study included youths with PTSD and suicidality who received either RFPP-S (N=50) or treatment as usual (N=150). The Columbia Suicide Severity Rating Scale (C-SSRS), Clinician-Administered PTSD Scale for children and adolescents, University of California, Los Angeles Trauma Reminder Inventory, Patient Health Questionnaire-9, Positive Emotion, Engagement, Relationships, Meaning, and Accomplishment Scale, and positive psychiatry test batteries were administered at baseline, on day 2, and 1 week and 1 month after discharge. RESULTS: On day 2, the RFPP-S group showed a greater reduction in PTSD symptoms (55%) and reactivity to trauma and loss reminders (80%) compared with the control group (10% for both) (p=0.001). A significantly greater reduction in C-SSRS score for RFPP-S (80%), compared with treatment as usual (15%), was noted (p=0.001), and RFPP-S showed more rapid stabilization (mean±SD=2.0±0.5 days) and enhanced postdischarge follow-up (100%) compared with treatment as usual (5.0±2.0 days and 50%, respectively) (p<0.05). RFPP-S, but not treatment as usual, was associated with significant increases in well-being, flexible thinking, and coping skills (p<0.05). Hospital readmission due to suicidality 1 month after discharge was 0% for the RFPP-S group and 20% for the control group. CONCLUSIONS: RFPP-S was associated with reduced PTSD symptoms, enhanced coping skills while experiencing trauma reminders, adoption of safety skills, rapid stabilization of acute crises of PTSD with suicidality, adherence to post-emergency room visits and treatment, and favorable clinical outcomes.

Toward reducing the duration of untreated psychosis in a Latinx community.

OBJECTIVE: To carry out and evaluate a communications campaign (La CLAve) to reduce the duration of untreated psychosis (DUP) in a U.S. Latinx community. METHOD: We employed evidence-based messaging in multiple media outlets. We recruited 132 Latinxs with first-episode psychosis (FEP) and caregivers seeking mental health care within a high-density Latinx community. We evaluated the campaign's dissemination, the extent to which the community received the campaign message, and the campaign outcome. We tested whether DUP (number of weeks) changed across three time periods (16-month baseline, 2-year campaign, and 16-month postcampaign) and whether participants' language background (primarily Spanish speaking or English speaking) moderated change in DUP. RESULTS: The campaign was disseminated widely. During the height of the campaign over a 1-year period, our team distributed 22,039 brochures and performed 740 workshops. The campaign message was received by the community as noted for example by increases in the number of unduplicated weekly calls to the campaign's 1-800 number. Applying square root transformations to DUP, we found a significant main effect for language background but not for campaign period nor their interaction. The unadjusted mean DUP for Spanish-speaking persons with FEP was more than twice as high as the mean DUP for English-speaking persons with FEP. CONCLUSION: Spanish-speaking Latinxs with FEP are especially in need of early psychosis treatment. The campaign reached the community but additional steps are needed to reduce treatment delay. Greater attention is needed to increase access to early intervention services for communities of color. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Social Identities of Persons With Schizophrenia and Social Functioning: Individual and Family Caregiver Perspectives.

ABSTRACT: We apply social identity theory and self-categorization theory to examine the role of social identities in relation to the recovery of persons with schizophrenia. We assess whether illness-based and non-illness-based identities held by both those with schizophrenia and their caregivers explain additional variance in social functioning in persons with schizophrenia beyond the previously established predictors of negative symptoms and theory of mind. Sixty Mexican-origin adults diagnosed with schizophrenia and their family caregivers were obtained through an outpatient mental health clinic located in either Los Angeles, CA, or in Puebla, Mexico. A three-step hierarchical regression indicated that identity endorsements, from both the perspective of the person with schizophrenia and their caregiver, and negative symptomatology are significant independent predictors of social functioning. Specifically, greater endorsement of nonillness identities both for the person with schizophrenia and also their caregiver is associated with higher social functioning. Illness identity plays an important role in the path to recovery.

Prevalence of COVID 19 Positive Cases Presenting to a Psychiatric Emergency Room.

To explore the prevalence of SARS-CoV2 infection in the psychiatric emergency room setting. A Cross-sectional retrospective chart review was used to determine the point-prevalence of SARS-CoV2 infection and the characteristics of those infected. Of the patients tested for SARS-CoV2, 23/1057 (2.2%) were positive. Most of these patients were homeless (living on the street) or came from congregate living settings. The high percentage of SARS-CoV2 positive psychiatric patients coming from congregate living settings stresses the importance of asymptomatic screening in this vulnerable population.

Defining and assessing key behavioral indicators of the Shifting Cultural Lenses model of cultural competence.

Models of cultural competence highlight the importance of the sociocultural world that is inhabited by patients, and the question of how best to integrate sociocultural factors into clinical assessment and intervention. However, one significant limitation of such approaches is that they leave unclear what type of in-session therapist behaviors actually reflect cultural competence. We draw on the Shifting Cultural Lenses model to operationalize culturally competent in-session behaviors. We argue that a key component of cultural competence is the collaborative relationship between therapists and patients, in which therapists shift between their own cultural lenses and those of their clients, as they co-construct shared narratives together. Accordingly, we propose that culturally competent therapist behaviors include accessing the client's views, explicitly presenting their own views as mental health care professionals, and working towards a shared understanding. We further specify the latter set of behaviors as including the practitioner's integration of the patient's view, their encouragement of the patient to consider their professional view, and the negotiation of a shared view. We developed a coding system to identify these therapist behaviors and examined the reliability of raters across 11 couple and 4 individual therapy sessions. We assessed whether the behavioral codes varied in expected ways over the first 3 sessions of 2 therapists' couple therapy as well. Operationalizing the behavioral indicators of the Shifting Cultural Lenses model opens the door to the integration of both process- and content-oriented approaches to cultural competence.

Lessons Learned in Clinical Research Recruitment of Immigrants and Minority Group Members with First-Episode Psychosis.

Recruitment of immigrants and racial and ethnic minorities with first-episode psychosis (FEP) for research studies presents numerous challenges. We describe methods used to recruit 43 U.S. Latinos with FEP and their family caregivers (n = 41) participating in a study to reduce duration of untreated psychosis. A key challenge was that patients were not continuing treatment at an outpatient clinic, as initially expected. To facilitate identification of patients prior to outpatient care, we collaborated with clinic and hospital administrators. Many patients and families were grappling with the aftermath of a hospitalization or adjusting to a diagnosis of a serious mental illness. A considerable amount of time was devoted to addressing participants' concerns and when possible, facilitating needed services. Our experience underscores the importance of establishing long-term relationships through multiple contacts with patients, families, and stakeholders to address recruitment barriers among underserved groups with FEP.

Psychosis Literacy Among Latinos With First-Episode Psychosis and Their Caregivers.

OBJECTIVE: The study examined psychosis literacy among Latinos with first-episode psychosis (FEP) and their caregivers. The authors tested a model that knowledge of psychosis and attribution of illness to psychosis predicted professional help seeking in a cross-sectional design. METHODS: The sample (N=148) consisted of 79 Latino consumers who met criteria for a clinical diagnosis of a psychotic disorder and 69 family caregivers. Participants watched a four-minute narrative about a woman with psychosis and were asked to identify the symptoms of serious mental illness (knowledge of psychosis), describe the character's problem and whether she had a serious mental illness (illness attribution), and offer suggestions about what the parents should do (help seeking). Responses to the open-ended questions were reliably coded by two trained raters. RESULTS: Consumers reported low psychosis literacy across all indices (e.g., only 8% included delusions in their knowledge of serious mental illness). Compared with consumers, caregivers reported significantly greater psychosis literacy across most indices, although relatively few reported knowledge of delusions (28%) and disorganized speech (36%). Logistic regression analyses found that caregivers were more than twice as likely as consumers to suggest that the parents seek professional help. Among both consumers and caregivers, greater knowledge of psychosis and attribution of symptoms to serious mental illness were associated with increased likelihood of recommending professional help seeking. CONCLUSIONS: Community campaigns and psychoeducation interventions within clinical settings are needed to improve psychosis literacy among Latinos with FEP. Increasing knowledge of psychosis and facilitating attributions of psychotic symptoms to serious mental illness have the potential to promote professional help seeking.

Recovery From Schizophrenia: The Case of Mexican-Origin Consumers and Family Caregivers.

This study examined the views about the future of persons with schizophrenia and their caregivers to understand what is at stake in engaging in recovery. The views of 60 Mexican-origin consumer-caregiver dyads were coded by three independent raters using a recovery literature-based coding system of recovery components: social relations, caregiving burden relief, independence, self-responsibility, and empowerment. General recovery expectations were also rated. Interrater reliability, component frequency, and congruence between the consumers and caregivers' expectations were statistically examined. Dominant recovery components for consumers and caregivers were independence (72.5%), general expectations for recovery (51%), and social relations (43%). Relatives differed in two important ways. Consumers held significantly greater expectations for independence (p < 0.01), whereas caregivers focused more on general recovery (p < 0.001). What matters for recovery for this sample of Mexican-origin consumers and caregivers differs. Addressing differences in views may facilitate person-centered treatment that considers the views of consumers and caregivers.

Comparative Effectiveness of a Technology-Facilitated Depression Care Management Model in Safety-Net Primary Care Patients With Type 2 Diabetes: 6-Month Outcomes of a Large Clinical Trial.

BACKGROUND: Comorbid depression is a significant challenge for safety-net primary care systems. Team-based collaborative depression care is effective, but complex system factors in safety-net organizations impede adoption and result in persistent disparities in outcomes. Diabetes-Depression Care-management Adoption Trial (DCAT) evaluated whether depression care could be significantly improved by harnessing information and communication technologies to automate routine screening and monitoring of patient symptoms and treatment adherence and allow timely communication with providers. OBJECTIVE: The aim of this study was to compare 6-month outcomes of a technology-facilitated care model with a usual care model and a supported care model that involved team-based collaborative depression care for safety-net primary care adult patients with type 2 diabetes. METHODS: DCAT is a translational study in collaboration with Los Angeles County Department of Health Services, the second largest safety-net care system in the United States. A comparative effectiveness study with quasi-experimental design was conducted in three groups of adult patients with type 2 diabetes to compare three delivery models: usual care, supported care, and technology-facilitated care. Six-month outcomes included depression and diabetes care measures and patient-reported outcomes. Comparative treatment effects were estimated by linear or logistic regression models that used generalized propensity scores to adjust for sampling bias inherent in the nonrandomized design. RESULTS: DCAT enrolled 1406 patients (484 in usual care, 480 in supported care, and 442 in technology-facilitated care), most of whom were Hispanic or Latino and female. Compared with usual care, both the supported care and technology-facilitated care groups were associated with significant reduction in depressive symptoms measured by scores on the 9-item Patient Health Questionnaire (least squares estimate, LSE: usual care=6.35, supported care=5.05, technology-facilitated care=5.16; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.02); decreased prevalence of major depression (odds ratio, OR: supported care vs usual care=0.45, technology-facilitated care vs usual care=0.33; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.007); and reduced functional disability as measured by Sheehan Disability Scale scores (LSE: usual care=3.21, supported care=2.61, technology-facilitated care=2.59; P value: supported care vs usual care=.04, technology-facilitated care vs usual care=.03). Technology-facilitated care was significantly associated with depression remission (technology-facilitated care vs usual care: OR=2.98, P=.04); increased satisfaction with care for emotional problems among depressed patients (LSE: usual care=3.20, technology-facilitated care=3.70; P=.05); reduced total cholesterol level (LSE: usual care=176.40, technology-facilitated care=160.46; P=.01); improved satisfaction with diabetes care (LSE: usual care=4.01, technology-facilitated care=4.20; P=.05); and increased odds of taking an glycated hemoglobin test (technology-facilitated care vs usual care: OR=3.40, P<.001). CONCLUSIONS: Both the technology-facilitated care and supported care delivery models showed potential to improve 6-month depression and functional disability outcomes. The technology-facilitated care model has a greater likelihood to improve depression remission, patient satisfaction, and diabetes care quality.

Improving Work Outcome in Supported Employment for Serious Mental Illness: Results From 2 Independent Studies of Errorless Learning.

Background: Heterogeneity in work outcomes is common among individuals with serious mental illness (SMI). Objective: In 2 studies, we sought to examine the efficacy of adding errorless learning, a behavioral training intervention, to evidence-based supported employment to improve SMI work outcomes. Work behavior problems were targeted for intervention. We also explored associations between early work behavior and job tenure. Methods: For both studies (VA: n = 71; community mental health center: n = 91), randomization occurred at the time of job obtainment with participants randomized (1:1) to either errorless learning plus ongoing supported employment or ongoing supported employment alone and then followed for 12 months. Dependent variables included job tenure, work behavior, and hours worked and wages earned per week. For the primary intent-to-treat analyses, data were combined across studies. Results: Findings revealed that participants in the errorless learning plus supported employment group stayed on their jobs significantly longer than those in the supported employment alone group (32.8 vs 25.6 wk). In addition, differential treatment effects favoring errorless learning were found on targeted work behavior problems (50.5% vs 27.4% improvement from baseline to follow-up assessment). There were no other differential treatment effects. For the prediction analyses involving work behavior, social skills explained an additional 18.3% of the variance in job tenure beyond levels of cognition, symptom severity, and past work history. Conclusions: These data support errorless learning as an adjunctive intervention to enhance supported employment outcomes and implicate the relevance of workplace social difficulties as a key impediment to prolonged job tenure.

A multicenter, open-label, pilot study evaluating the functionality of an integrated call center for a digital medicine system to optimize monitoring of adherence to oral aripiprazole in adult patients with serious mental illness.

BACKGROUND: Medication nonadherence is common in the treatment of serious mental illness (SMI) and leads to poor outcomes. The digital medicine system (DMS) objectively measures adherence with oral aripiprazole in near-real time, allowing recognition of adherence issues. This pilot study evaluated the functionality of an integrated call center in optimizing the use of the DMS. MATERIALS AND METHODS: An 8-week, open-label, single-arm trial at four US sites enrolled adults with bipolar I disorder, major depressive disorder, and schizophrenia on stable oral aripiprazole doses and willing to use the DMS (oral aripiprazole + ingestible event marker [IEM], IEM-detecting skin patch, and software application). Integrated call-center functionality was assessed based on numbers and types of calls. Ingestion adherence with prescribed treatment (aripiprazole + IEM) during good patch wear and proportion of time with good patch wear (days with ≥80% patch data or detected IEM) were also assessed. RESULTS: All enrolled patients (n=49) used the DMS and were included in analyses; disease duration overall approached 10 years. For a duration of 8 weeks, 136 calls were made by patients, and a comparable 160 calls were made to patients, demonstrating interactive communication. The mean (SD) number of calls made by patients was 2.8 (3.5). Approximately half of the inbound calls made by patients occurred during the first 2 weeks and were software application- or patch-related. Mean ingestion adherence was 88.6%, and corresponding good patch wear occurred on 80.1% of study days. CONCLUSION: In this pilot study, the integrated call center facilitated DMS implementation in patients with SMI on stable doses of oral aripiprazole. In clinical practice, the call center and the DMS will facilitate objective measurement of adherence and potentially improve rates of adherence in patients with SMI.

Caregiver criticism, help-giving, and the burden of schizophrenia among Mexican American families.

OBJECTIVES: This study tested an attribution model of help-giving in family caregivers of persons with schizophrenia as it relates to caregivers' reported burden. We hypothesized (a) that caregivers' attributions of their ill relatives' responsibility for their symptoms would be associated with more negative and less positive affective reactions, (b) that affective reactions would be related to perceptions of administered support, and (c) that support would in turn predict greater burden. METHODS: We examined 60 family caregivers of Mexican origin living in Southern California. Mexican Americans were chosen because of their high degree of contact with their ill relative, thereby facilitating the examination of help-giving and burden. Contrary to past studies, caregivers' attributions and affective stance were assessed independently, the former based on self-report and the latter based on codes drawn from the Camberwell Family Interview. Caregiver burden was assessed at baseline and one year later. RESULTS: Path analyses showed partial support for the attribution model of help-giving. Specifically, attributions of responsibility negatively predicted caregiver's warmth, which in turn predicted more administered support. Contrary to hypotheses, attributions were not associated with caregiver criticism, and criticism was positively related to administered support. In addition, caregiver support was not related to burden at either baseline or a year later. Criticism was a significant predictor of burden at follow-up through burden at baseline. CONCLUSION: The emotional stance of caregivers predicts burden independent of the help they provide. Caregiver criticism not only predicts negative patient outcomes but can predict negative caregiver outcomes as well. PRACTITIONER POINTS: Positive clinical implications In family treatment, it is important to address caregiver criticism not only because of its relationship to poor clinical outcomes of ill relatives but also because of its relationship to greater caregiver burden. Integrating a balanced rationale for family interventions - to improve ill relatives' and caregivers' outcomes - may promote further engagement of both parties as some caregivers may be additionally motivated to improve their own well-being, and some ill relatives may appreciate more equitably distributing the treatment focus. Limitations The caregiver sample was in general low in criticism; therefore, the findings may not be generalizable to families with a higher degree of criticism. There was a 35% sample attrition at the one-year follow-up.