Systematic Literature Review of General Health Care Interventions Within Programs of Assertive Community Treatment.

OBJECTIVE: Assertive community treatment (ACT) is one of the few evidence-based practices for adults with severe mental illness. Interest has slowly waned for ACT implementation. Yet ACT remains an appealing services platform to achieve the triple aim of health care reform (improved health outcomes, reduced cost, and improved satisfaction) through integration of primary care and behavioral health services. This review highlights the evidence for ACT to improve general medical outcomes, reduce treatment costs, and increase access to treatment. METHODS: Using a comprehensive list of relevant search terms, the authors performed a systematic literature database search for articles published through November 2015, resulting in ten articles for inclusion. RESULTS: No studies reported on clinical outcomes of general medical comorbidities or on mortality of ACT clients. Half of the studies reporting utilization (three of six) found a decrease in emergency room usage, and three of four studies identified an increase in outpatient primary care visits. Most studies found no increase in overall medical care costs. Of the few studies reporting on quality of life, most found mild to moderate improvements. CONCLUSIONS: To date, rigorous scientific examination of the effect of ACT on the general health of the populations it serves has not been undertaken. Given ACT's similarity to emerging chronic illness medical management models, the approach seems like a natural fit for improving general medical outcomes of persons with severe mental illnesses. More research is needed that investigates the current effect of ACT teams on general medical outcomes, treatment costs, and access to care.

Feasibility, Acceptability, and Impact of a Web-based Gratitude Exercise among Individuals in Outpatient Treatment for Alcohol Use Disorder.

This mixed-methods pilot study examined the feasibility, acceptability, and impact of a web-based gratitude exercise (the 'Three Good Things' exercise (TGT)) among 23 adults in outpatient treatment for alcohol use disorder (AUD). Participants were randomized to TGT or a placebo condition. The intervention was feasible with high rates of completion. Participants found TGT acceptable and welcomed the structure of daily emails; however, they found it difficult at times and discontinued TGT when the study ended. Participants associated TGT with gratitude, although there were no observed changes in grateful disposition over time. TGT had a significant effect on decreasing negative affect and increasing unactivated (e.g., feeling calm, at ease) positive affect, although there were no differences between groups at the 8 week follow up. Qualitative results converged on quantitative findings that TGT was convenient, feasible, and acceptable, and additionally suggested that TGT was beneficial for engendering positive cognitions and reinforcing recovery.

An investigation of the relationship between therapist characteristics and alliance in group therapy for individuals with treatment-resistant auditory hallucinations.

BACKGROUND: Alliance is a well-studied construct; however, little research has investigated predictors of alliance in a group context. AIMS: This study investigates the relationship between therapist characteristics and group alliance in 65 individuals with schizophrenia receiving outpatient group therapy for treatment-resistant auditory hallucinations. METHODS: Raters coded 120 sessions of cognitive behavioral therapy or supportive therapy for therapist warmth and friendliness, therapist exploration and negative therapist attitude. Alliance was assessed at week six. RESULTS: Higher average levels of therapist warmth and friendliness and lower average levels of negative therapist attitude in sessions one to five were associated with stronger alliance at week six at the trend level (p < 0.10). Therapist exploration did not predict alliance at week six. Higher negative therapist attitude at treatment engagement was associated with higher post-treatment symptom scores. CONCLUSIONS: Our results suggest that therapist attributes but not therapist techniques are associated with client's perceptions of alliance and that negative therapist behaviors are associated with higher symptom levels at post-treatment. Implications for clinical practice are discussed.

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.

A pilot study of loving-kindness meditation for the negative symptoms of schizophrenia.

This pilot study examined loving-kindness meditation (LKM) with 18 participants with schizophrenia-spectrum disorders and significant negative symptoms. Findings indicate that the intervention was feasible and associated with decreased negative symptoms and increased positive emotions and psychological recovery.

Upward spirals of positive emotions counter downward spirals of negativity: insights from the broaden-and-build theory and affective neuroscience on the treatment of emotion dysfunctions and deficits in psychopathology.

This review integrates Fredrickson's broaden-and-build theory of positive emotions with advances in affective neuroscience regarding plasticity in the neural circuitry of emotions to inform the treatment of emotion deficits within psychopathology. We first present a body of research showing that positive emotions broaden cognition and behavioral repertoires, and in so doing, build durable biopsychosocial resources that support coping and flourishing mental health. Next, by explicating the processes through which momentary experiences of emotions may accrue into self-perpetuating emotional systems, the current review proposes an underlying architecture of state-trait interactions that engenders lasting affective dispositions. This theoretical framework is then used to elucidate the cognitive-emotional mechanisms underpinning three disorders of affect regulation: depression, anxiety, and schizophrenia. In turn, two mind training interventions, mindfulness and loving-kindness meditation, are highlighted as means of generating positive emotions that may counter the negative affective processes implicated in these disorders. We conclude with the proposition that positive emotions may exert a countervailing force on the dysphoric, fearful, or anhedonic states characteristic of psychopathologies typified by emotional dysfunctions.

The effects of antipsychotic medications on emotion perception in patients with chronic schizophrenia in the CATIE trial.

Few pharmacological intervention studies have examined the impact of medication on social cognition, particularly emotion perception. The goal of this randomized, double-blind study is to compare the effects of several second generation antipsychotics and a first generation antipsychotic, perphenazine, on emotion perception in individuals with schizophrenia. Patients were assigned to receive treatment with olanzapine, queitapine fumarate, risperidone, ziprasidone or perphenazine for up to 18 months. Eight hundred and seventy three patients completed an emotion perception test immediately prior to randomization and after 2 months of treatment. We also examined baseline predictors of emotion perception change. Most treatments were associated with a small, non-statistically significant improvement in emotion perception at two months, although they did not differ from one another. Greater improvement in emotion perception at 2 months was significantly predicted by lower baseline emotion perception and higher baseline neurocognitive functioning, and marginally predicted by less time on an antipsychotic.

Loving-kindness meditation to enhance recovery from negative symptoms of schizophrenia.

In this article, we describe the clinical applicability of loving-kindness meditation (LKM) to individuals suffering from schizophrenia-spectrum disorders with persistent negative symptoms. LKM may have potential for reducing negative symptoms such as anhedonia, avolition, and asociality while enhancing factors consistent with psychological recovery such as hope and purpose in life. Case studies will illustrate how to conduct this group treatment with clients with negative symptoms, the potential benefits to the client, and difficulties that may arise. Although LKM requires further empirical support, it promises to be an important intervention since there are few treatments for clients afflicted with negative symptoms.

A randomized controlled trial of group cognitive-behavioral therapy vs. enhanced supportive therapy for auditory hallucinations.

There has been little research examining group cognitive-behavioral therapy (CBT) for schizophrenia, especially compared to an active control treatment. The purpose of this study was to investigate the effectiveness of group CBT for auditory hallucinations compared to an enhanced supportive therapy (ST). Sixty five participants with schizophrenia spectrum disorders and persistent hallucinations were randomly assigned to group CBT or enhanced group ST. Primary outcomes focused on beliefs about voices and global auditory hallucinations severity. Secondary outcomes included psychotic symptoms, self-esteem, social functioning, insight, depression, and hospitalization. Controlling for baseline levels, these outcomes were evaluated across post-treatment, 3 month and 12 month follow-ups. Participants who received enhanced ST were less likely to both resist voices and to rate them as less malevolent through 12-month follow-up relative to participants who received CBT. Group CBT was associated with lower general and total symptom scores on the PANSS through 12-month-followup relative to participants who received enhanced ST. Outcomes improved through 12-month follow-up in both therapy groups, with enhanced ST having more specific impact on auditory hallucinations, and CBT impacting general psychotic symptoms.

A comparison of assertive community treatment and intensive case management for patients in rural areas.

OBJECTIVE: This article reviews the evidence for the effectiveness of community-based services for rural areas, specifically assertive community treatment and intensive case management. Service delivery to persons with severe mental illness in rural areas is challenged by low population densities, limited services, and shortages of professionals. METHODS: A comprehensive literature search identified six studies of rural assertive community treatment, only two of which were controlled studies, and four rural intensive case management studies, only one of which was a controlled study. Assertive community treatment would seem ideally suited to areas lacking services because of its self-contained multidisciplinary treatment team approach. However, rural programs have been forced to make several adaptations to the assertive community treatment model, including smaller teams, less comprehensive staff, and less intensive services. There is no published evidence that these adaptations are able to produce the same results as full-fidelity teams. Some believe that intensive case management may be an alternative to assertive community treatment in rural settings because intensive case management emphasizes individual caseloads, fewer staff, less intensive contacts, and brokered services. CONCLUSIONS: The evidence suggests that intensive case management programs are effective only in community settings where there is an ample supply of treatment and support services. To build the evidence base for the effectiveness of these models, much more attention needs to be focused on evaluating the current wave of assertive community treatment and intensive case management dissemination in rural areas.

How many assertive community treatment teams do we need?

OBJECTIVE: Assertive community treatment (ACT) reduces hospitalizations for persons with severe mental illness. However, not everyone who needs ACT receives it. Without empirical guidelines for ACT planning, communities are likely to underestimate or overestimate the number of teams they need; thus the capacity of the programs will not meet current needs. In this study, administrative data were used to develop empirical estimates for the number of required ACT teams. These estimates were then used to examine current conceptual guidelines for developing the number of ACT teams that communities need. METHODS: Administrative data from a large, urban county were used to enumerate all persons with a severe mental illness who had three or more hospitalizations within one year (ACT eligible). RESULTS: Fifty-one percent of persons with a severe mental illness were found to be eligible for ACT (743 of 1,453 persons). This figure represents 2.2 percent of the county's mental health users and .06 percent of its adult population. CONCLUSIONS: Communities should develop enough ACT teams to serve approximately 50 percent of their populations of persons with severe mental illness or roughly .06 percent of their adult populations.

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.

Cognitive and clinical predictors of success in vocational rehabilitation in schizophrenia.

Cognitive impairments in schizophrenia appear to be associated with social problem solving, social and vocational functioning, and psychosocial skill acquisition. The present study examined the relationship of cognitive functioning, as well as clinical symptoms, to vocational outcomes among individuals with schizophrenia. One hundred and twelve participants with DSM-IV schizophrenia spectrum diagnoses underwent a comprehensive neuropsychiatric evaluation after enrolling in one of several employment programs. The neuropsychological evaluation examined verbal learning and memory, attention, speed of information processing, and executive functioning. Clinical symptoms were evaluated with the Positive and Negative Syndrome Scale (PANSS). Vocational outcomes were assessed 4 months after baseline assessment and included both measures of employment outcome (e.g., earnings) and of work performance as assessed by the Work Behavior Inventory (WBI). Negative symptoms, learning and memory performance, processing speed, and executive functioning were related to hours, weeks, and wages earned on the job. Stepwise multiple regression analyses found that among baseline clinical and cognitive predictors, only verbal learning and memory and cognitive disorganization symptoms were significant predictors of work behaviors 4 months later. Learning and memory were the only significant predictors of integrated employment at 4 months. These results suggest specific aspects of cognition may be modestly predictive of vocational outcomes.

Barriers to assessment and treatment of posttraumatic stress disorder and other trauma-related problems in people with severe mental illness: clinician perspectives.

We conducted a state-wide survey of 251 clinicians serving people with severe mental illness (SMI) in community support programs, to identify barriers to the diagnosis and treatment of PTSD and other trauma-related problems. Most clinicians did not feel competent to effectively treat these problems. Competence/confidence and belief in utility of intervention were positively related to the percentage of clients with whom trauma and PTSD had been discussed, documented in charts, and addressed directly in treatment. Clinicians need training that develops skills and knowledge as well as conveys the value of addressing PTSD and other trauma-related problems in people with SMI.

Response to vocational rehabilitation during treatment with first- or second-generation antipsychotics.

OBJECTIVE: Second-generation antipsychotics may enhance the rehabilitation of individuals with schizophrenia. The authors hypothesized that clients receiving second-generation antipsychotics would use vocational rehabilitation services more effectively and would have better employment outcomes than those receiving first-generation antipsychotics. METHODS: Ninety unemployed clients with schizophrenia and related disorders who were beginning a vocational rehabilitation program were followed for nine months. Three groups were defined according to the medication in use at study entry: olanzapine (N=39), risperidone (N=27), or first-generation antipsychotics only (N=24). Participants were interviewed monthly. RESULTS: The olanzapine and risperidone groups did not differ on any employment outcomes. On most vocational indicators, clients receiving second-generation agents did not differ from those receiving first-generation agents. However, at nine months the second-generation group had a significantly higher rate of participation in vocational training; a trend was found toward a higher rate of paid employment. All groups showed substantial improvement in employment outcomes after entering a vocational program. CONCLUSIONS: The hypothesis that second-generation antipsychotics promote better employment outcomes than first-generation antipsychotics was not upheld. However, second-generation agents appear to be associated with increased participation in vocational rehabilitation.

Comparison between the effects of atypical and traditional antipsychotics on work status for clients in a psychiatric rehabilitation program.

BACKGROUND: Although many studies have compared the impact of atypical antipsychotics with that of traditional antipsychotics on psychiatric symptoms, few have compared the impact on work status, especially in the context of best-practices psychiatric rehabilitation. METHOD: A cross-sectional design examined symptom and employment status for 82 clients with DSM-IV schizophrenia-spectrum disorders who had attended a psychiatric rehabilitation program for a mean of 5 years. Using chart review and client interviews, we examined the relationship between type of antipsychotic prescribed and symptom and work status in 59 clients prescribed an atypical antipsychotic (olanzapine or risperidone) for a mean of 20 months and 23 clients prescribed a traditional antipsychotic for a mean of 75 months. Measures included the Positive and Negative Syndrome Scale and 2 work status measures: an 8-point employment status scale (the Work Placement Scale) and percentage of clients working in independent employment. RESULTS: The atypical group had significantly fewer symptoms of cognitive impairment and hostility/excitement than the traditional group (p < .05). However, self-reported adverse events were similar in the 2 medication groups, and the 2 groups did not differ significantly on work status. Less severe negative, cognitive, and hostility/excitement symptoms were associated with more independent employment status. CONCLUSION: For long-term clients in a psychiatric rehabilitation program, type of medication prescribed was associated with better symptom control but not better work status. The association between symptoms and work status, however, may suggest an indirect link favoring atypical antipsychotics for achieving paid employment.