"The Italian Study on Recovery 2" Phase 1: Psychometric Properties of the Recovery Assessment Scale (RAS), Italian Validation of the Recovery Assessment Scale.

BACKGROUND: The achievement of recovery is related to the notion of developing personal potential and restoring a legitimate social role, even against the backdrop of mental illness limitations. It is still difficult to fully understand this highly subjective and dynamic process. Therefore, in order to test the recovery process, specific tools, still only marginally used in our country, are needed. AIMS: The Italian Study on Recovery is the first study aimed at confirming the validity of the Italian version of the Recovery Assessment Scale (RAS), an instrument developed with the goal of detecting recovery among patients. METHOD: This multicentric research involved several Mental Health Services from various parts of Italy. The first phase of the study consisted in the administration of the Italian translation of RAS, previously used in a pilot study conducted in 2009. RAS was administered to 219 patients diagnosed with psychosis, whose mental disorder lasted for at least 5 years. RESULTS: Findings supported the good psychometric properties of the Italian version of RAS, demonstrating its capability of identifying patients matching the "in recovery" operational criteria. CONCLUSIONS: In consideration of the results highlighting the good psychometric properties of RAS, the present study may contribute to the diffusion of instruments to be included in Mental Health Service planning in the Italian context, in order to start a recovery-oriented transformation.

Consistency of Brief Psychiatric Rating Scale factor structure across a broad spectrum of schizophrenia patients.

BACKGROUND: The Brief Psychiatric Rating Scale (BPRS) has been the workhorse of psychopathology assessment in studies of schizophrenia and related psychotic disorders for over 40 years. Our goal was to evaluate the discriminant validity of the BPRS across the broad spectrum of persons with schizophrenia. SAMPLING AND METHODS: The total sample of 565 subjects with schizophrenia (84%) or schizoaffective disorder (16%) came from eight separate studies conducted under the aegis of the UCLA Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation over a period of 15 years. The total sample could be divided into three subsamples based on illness chronicity and degree of refractoriness to treatment: Recent-onset patients had been ill for less than 2 years (n = 178), stable chronic patients between 2 and 19 years (n = 243) and treatment-refractory patients for more than 19 years (n = 144). Exploratory principal components analysis and varimax rotation were performed on the total sample. The results of each of the three subsamples were compared to the total sample using a correlation matrix and by calculating a coefficient of congruence. RESULTS: A 4-factor solution was considered the most interpretable for each subsample, reflecting the same 4 components identified in the total sample: positive symptoms, negative symptoms, agitation-mania and depression-anxiety. Correlation coefficients and coefficient of congruence were very high, ranging from 0.91 to 0.98. CONCLUSIONS: The consistency of the 4-factor solution of the 24-item BPRS across the range of subjects, from first psychotic episode to long-stay, institutionalized patients, supports the use of these factors and this instrument as a whole to track changes over time and with treatment in research and clinical samples.

Recent advances in social skills training for schizophrenia.

Social skills training consists of learning activities utilizing behavioral techniques that enable persons with schizophrenia and other disabling mental disorders to acquire interpersonal disease management and independent living skills for improved functioning in their communities. A large and growing body of research supports the efficacy and effectiveness of social skills training for schizophrenia. When the type and frequency of training is linked to the phase of the disorder, patients can learn and retain a wide variety of social and independent living skills. Generalization of the skills for use in everyday life occurs when patients are provided with opportunities, encouragement, and reinforcement for practicing the skills in relevant situations. Recent advances in skills training include special adaptations and applications for improved generalization of training into the community, short-term stays in psychiatric inpatient units, dually diagnosed substance abusing mentally ill, minority groups, amplifying supported employment, treatment refractory schizophrenia, older adults, overcoming cognitive deficits, and negative symptoms as well as the inclusion of social skills training as part of multidimensional treatment and rehabilitation programs.

Using the theory of planned behavior to improve treatment adherence in Mexican Americans with schizophrenia.

OBJECTIVE: Failure to adhere to treatment with antipsychotic medication is the most common cause of relapse among patients with schizophrenia. A novel multifamily group (MFG) intervention, informed by the Theory of Planned Behavior (TPB), demonstrated efficacy in increasing medication adherence and decreasing rehospitalizations in schizophrenia patients. This report explores the hypothesis that the improved outcomes obtained through the MFG approach were mediated by changes in the patients' attitudes toward medications, subjective norms-social influences, and perceived behavioral control of resources. METHOD: Data from a recently completed, randomized controlled trial of MFG was used to test the hypothesis that the improvement in adherence was mediated by the 3 TPB factors. Subjects were 174 Mexican American adults with schizophrenia-spectrum disorder who had participated in a study of MFG focused on improving medication adherence. Assessments occurred at baseline and at 4, 8, 12, 18, and 24 months. RESULTS: Path analysis revealed that the increased adherence associated with MFG was mediated by improvements in subjective norms but not attitudes toward medications nor perceived behavioral control. CONCLUSION: An MFG treatment specifically tailored to increase medication adherence among Mexican Americans with schizophrenia achieved its benefits by leveraging social influences through teaching family members how to support medication adherence in their ill relatives.

Disease management in Latinos with schizophrenia: a family-assisted, skills training approach.

This study evaluated the effectiveness of a skills training program designed to teach disease management to Latinos with schizophrenia treated at a community mental health center. Ninety-two Latino outpatients with schizophrenia and their designated relatives were randomly assigned to 3 months of skills training (ST) versus customary outpatient care (CC) and followed for a total of 9 months. The skills training approach was culturally adapted mainly by including the active participation of key relatives to facilitate acquisition and generalization of disease management skills into the patients' natural environment. There was a significant advantage for the ST group over the CC group on several symptom measures, skill acquisition and generalization, level of functioning, and rates of rehospitalization. There were no significant differences between the groups on quality of life or caregiver burden. Skills training had a direct effect on skill acquisition and generalization, and utilization of disease management skills led to decreased rates of rehospitalization. Incorporating an intensive, culturally relevant generalization effort into skills training for Latinos with schizophrenia appeared to be effective in teaching disease management and viable in a community mental health center.

Integrating treatment with rehabilitation for persons with major mental illnesses.

Psychiatric treatment and rehabilitation are integrated, seamless approaches aimed at restoring persons with major mental disorders to their best possible level of functioning and quality of life. Driven by a thorough assessment, treatment and rehabilitation are keyed to the stage and type of each individual's disorder. Examples of coordinated treatment and rehabilitation are pharmacotherapy, supported employment, social skills training, family psychoeducation, assertive community treatment, and integrated programs for persons with dual diagnoses. The authors conclude by proposing seven principles to guide mental health practitioners in their integration of pharmacologic and psychosocial interventions.

Rehab rounds: Involving families in rehabilitation through behavioral family management.

Introduction by the column editors: A wide variety of family psychoeducational approaches for persons with serious and persistent mental illness have been developed and used by mental health professionals since the introduction of such approaches in the 1960s (1). From 1970 to 1975, multifamily psychoeducation was implemented for large numbers of clients and relatives at the Oxnard Mental Health Center (2) and was followed by systematic studies of multifamily therapy at the Maudsley Hospital in London in 1976 (3) and Camarillo State Hospital in California in 1978 to 1980 (4). The type of intervention that arose from this work comprised a series of educational sessions followed by training in communication and problem-solving skills. Behavioral learning principles were used to promote acquisition of knowledge, coping skills, and problem solving for families. Other procedures and variants on this theme have proliferated throughout the United States and in many other countries (5). Most of these approaches have in common an adherence to practical goals that are individualized for each family and an educational rather than a "therapeutic" slant. In an attempt to overcome the obstacles to widespread clinical use of family interventions, a variety of dissemination strategies have been tried, including academic detailing, consensus building among all stakeholders (6), and the development of modules consisting of trainers' manuals, consumers' workbooks, slide shows, and video-assisted learning (7,8). This month's column describes one of the variants of family psychoeducation-behavioral family management-and its components, illuminated by case vignettes and results of efficacy studies.

Training persons with schizophrenia in illness self-management: a randomized controlled trial in Japan.

Despite the worldwide shift from inpatient to community-based treatment for individuals with severe mental illness, Japanese psychiatric services remain hospital based. In 1998, Japan had 29 psychiatric beds per 10,000 persons, twice as many as in most European countries and five times as many as in the United States (1). The reasons for Japan's slow transition to a community-based mental health system are both economic and cultural. For instance, 90 percent of psychiatric beds are in private for-profit hospitals. There is little incentive for inpatient facilities to discharge patients promptly, because the Japanese health care system provides universal coverage with virtually unlimited reimbursement for inpatient services, and the government does not have a mechanism for financing the relocation of resources from hospitals to communities (2). In addition, the stigma associated with mental illness in Japanese families is high (3). Thus a patient's primary residence is the psychiatric hospital, and opportunities are provided for periodic visits from the family.However, psychiatric rehabilitation principles and practices are beginning to take root in Japan. Anzai and his colleagues at the Matsuzawa Psychiatric Hospital in Tokyo have adapted an empirically validated skills training program to prepare patients with schizophrenia for life in the community after discharge from the hospital. In this column, they report the results of a randomized controlled trial of this approach in an inpatient facility serving a large urban center.

Rehab rounds: training professionals in use of positive methods for community integration of persons with developmental disabilities.

Mainstream psychiatry has all but ignored the clinical needs of persons with developmental disabilities. With some notable exceptions, individuals in this group have been served in the community by behaviorally oriented psychologists or relegated to long-term institutional care. However, effective interventions are available, beginning with a functional analysis of the antecedents and consequences of targeted problem behaviors. Procedures for building adaptive coping and functional skills or compensating for their deficiency have been developed that are based on skills training, wraparound supports for employment and community living, stimulus control, and contingencies of reinforcement. Applied behavior analysis using task analysis, stimulus control, and contingencies of reinforcement also spawned some of the first techniques--including the token economy--shown to improve functioning and reduce psychopathology among persons with schizophrenia. One of the premier organizations to have documented the efficacy of person-centered, behavior-analytic, and community-based wraparound support services for persons with developmental disabilities is the Institute for Applied Behavior Analysis in Los Angeles. The institute was founded 20 years ago and has served more than 1,000 children, adolescents, and adults with developmental disabilities. Its staff have designed and empirically validated nonaversive techniques for modifying the behaviors that place their clients or others at risk of harm or injury and that often lead to the clients' ejection or isolation from community life. In this Rehab Rounds column the authors describe and evaluate the institute's training and consultation activities.

An evaluation of a hybrid occupational therapy and supported employment program in Japan for persons with schizophrenia.

OBJECTIVE: A vocational rehabilitation program (occupational therapy and supported employment) for promoting the return to the community of long-stay persons with schizophrenia was established at a psychiatric hospital in Japan. The purpose of the study was to evaluate the program in terms of hospitalization rates, community tenure, and social functioning with each individual serving as his or her control. METHODS: Fifty-two participants, averaging 8.9 years of hospitalization, participated in the vocational rehabilitation program consisting of 2 to 6 hours of in-hospital occupational therapy for 6 days per week and a post-discharge supported employment component. Seventeen years after the program was established, a retrospective study was conducted to evaluate the impact of the program on hospitalizations, community tenure, and social functioning after participants' discharge from hospital, using an interrupted time-series analysis. The postdischarge period was compared with the period from onset of illness to the index discharge on the three outcome variables. RESULTS: After discharge from the hospital, the length of time spent by participants out of the hospital increased, social functioning improved, and risk of hospitalization diminished by 50%. Female participants and those with supportive families spent more time out of the hospital than participants who were male or came from nonsupportive families. CONCLUSION: A combined program of occupational therapy and supported employment was successful in a Japanese psychiatric hospital when implemented with the continuing involvement of a clinical team. Interventions that improve the emotional and housing supports provided to persons with schizophrenia by their families are likely to enhance the outcome of vocational services.

Illness self-management for individuals in acute psychiatric care settings in Japan: cross-cultural adaptation of an American program.

OBJECTIVE: To examine whether the challenges of a cross-national adaptation of an American, evidence-based, illness self-management module for people with serious mental illnesses could be met. The UCLA Medication Management Module was adapted for use in Japan with individuals experiencing short-stay, acute care in an inpatient setting. METHOD: Two evaluations were conducted with 37 and 63 persons diagnosed as having schizophrenia and bipolar disorder, respectively, to test the feasibility and impact of the module as an intervention for illness self- management in an academic, Japanese psychiatric unit. RESULTS: The short-term feasibility was demonstrated by consumers' enhanced comprehension of the value and benefits of antipsychotic medication as well as their gaining positive, therapeutic attitudes toward use of medication. A second evaluation of the module revealed that consumers who participated in the skills training developed better understanding of the purposes of medication, more positive attitudes toward medication, and superior coping skills in dealing with medication side effects than their counterparts who received standard treatment. The greater benefits achieved from participating in the module persisted for 7 months postdischarge. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: While preliminary, these studies suggest the applicability of the Medication Management Module for illness management for Japanese hospital practice.

The ability of multifamily groups to improve treatment adherence in Mexican Americans with schizophrenia.

CONTEXT: Evidence-based interventions to improve medication adherence among patients with schizophrenia are lacking. Although family psychoeducation has demonstrated efficacy in improving outcomes in schizophrenia, empirical support for its ability to enhance medication adherence is scarce. OBJECTIVE: To determine whether a culturally adapted, multifamily group (MFG) therapy would increase medication adherence and decrease psychiatric hospitalizations for Spanish-speaking Mexican Americans with schizophrenia. DESIGN: A total of 174 Mexican American adults with schizophrenia-spectrum disorder and their key relatives were studied in a 3-armed, randomized controlled trial of MFG therapy focused on improving medication adherence. Assessments occurred at baseline and at 4, 8, 12, 18, and 24 months. SETTING: Two community mental health centers in Los Angeles, California. PARTICIPANTS: Patients had a diagnosis of schizophrenia or schizoaffective disorder with a recent exacerbation of psychotic symptoms and nonadherence to medication before enrollment. Intervention  Patients participated in 1 of 2 MFGs (MFG-adherence or MFG-standard) or treatment as usual. Groups convened twice monthly in 90-minute sessions for 1 year. MAIN OUTCOME MEASURES: The Treatment Compliance Interview uses multiple sources of information to quantify medication adherence. Computerized records were used to collect information on the use of inpatient resources. RESULTS: At the end of the 1-year treatment, MFG-adherence was associated with higher medication adherence than MFG-standard or treatment as usual only (F = 6.41; P = .003). The MFG-adherence participants had a longer time to first hospitalization (χ(2) = 13.3; P = .001) and were less likely to be hospitalized than those in MFG-standard (χ(2) = 8.2; P = .04) and treatment as usual alone (χ(2) = 11.3; P < .001). Increased adherence accounted for one-third of the overall effect of treatment on the reduced risk for psychiatric hospitalization. CONCLUSION: Multifamily group therapy specifically tailored to improve medication adherence through a focus on the beliefs and attitudes of the target population is associated with improved outcome for Mexican American adults with schizophrenia-spectrum disorders. Trial Registration  clinicaltrials.gov Identifier: NCT01125267.

Commentary: Interventions based on learning principles can supplant seclusion and restraint.

Regulatory and administrative imperatives, when paired with staff training in humanistic, verbally mediated interventions can reduce the frequency of seclusion and restraint but can be associated with increases in the frequency and severity of staff injury, with concomitant tension and apprehension in the treatment setting. Even when educational programs for staff are made available for patient-centered, therapeutic, and persuasion-based modes of de-escalation, aggression, destructiveness and self-injury may continue to occur or even increase. Administrative contingencies can lead to less reporting of such incidents by staff with consequential, adverse effects on their morale and the unit milieu. Given the neurocognitive deficits, learning disabilities and lengthy histories of inadvertent reinforcement of provocative and aggressive behavior among persons with developmental and serious psychiatric disorders, basic principles of learning are needed to teach alternatives for belligerent behavior. Examples of behavior therapies that have been documented as effective in reducing aggression and self-injury include differential reinforcement of other behavior, social skills training, teaching interaction, social learning modalities, and time out from reinforcement. These evidence-based behavioral interventions must be superimposed on optimal, diagnostically driven, and monitored pharmacotherapy. When evidence-based, person-centered, and recovery-oriented biobehavioral interventions are made available to inpatient units, favorable clinical outcomes with reductions in the use of seclusion and restraint are likely.