Clinical and demographic correlates of stigma in first-episode psychosis: the impact of duration of untreated psychosis.

OBJECTIVE: To evaluate the relationships between perceived stigma and duration of untreated psychosis (DUP), demographic characteristics, and clinical and psychosocial functioning in persons with a first episode of psychosis (FEP). METHOD: A total of 399 participants with FEP presenting for treatment at 34 sites in 21 states throughout the United States were evaluated using standardized instruments to assess diagnosis, symptoms, psychosocial functioning, perceived stigma, wellbeing, and subjective recovery. RESULTS: Perceived stigma was correlated with a range of demographic and clinical variables, including DUP, symptoms, psychosocial functioning, and subjective experience. After controlling for symptom severity, perceived stigma was related to longer DUP, schizoaffective disorder diagnosis, more severe depression, and lower wellbeing and recovery. The associations between stigma and depression, wellbeing, and recovery were stronger in individuals with long than short DUP, suggesting the effects of stigma on psychological functioning may be cumulative over the period of untreated psychosis. CONCLUSION: The findings suggest that independent of symptom severity, perceived stigma may contribute to delay in seeking treatment for FEP, and this delay may amplify the deleterious effects of stigma on psychological functioning. The results point to the importance of reducing DUP and validating interventions targeting the psychological effects of stigma in people with FEP.

Cognitive-behaviour therapy for post-traumatic stress in schizophrenia. A randomized controlled trial.

BACKGROUND: There is limited evidence for effective interventions in the treatment of post-traumatic stress symptoms within individuals diagnosed with schizophrenia. Clinicians have concerns about using exposure treatments with this patient group. The current trial was designed to evaluate a 16-session cognitive restructuring programme, without direct exposure, for the treatment of post-traumatic stress symptoms specifically within individuals diagnosed with schizophrenia. METHOD: A multicentre randomized controlled single-blinded trial with assessments at 0 months, 6 months (post-treatment) and 12 months (follow-up) was conducted. A total of 61 participants diagnosed with schizophrenia and exhibiting post-traumatic stress symptoms were recruited. Those randomized to treatment were offered up to 16 sessions of cognitive-behaviour therapy (CBT, including psychoeducation, breathing training and cognitive restructuring) over a 6-month period, with the control group offered routine clinical services. The main outcome was blind rating of post-traumatic stress symptoms using the Clinician Administered PTSD Scale for Schizophrenia. Secondary outcomes were psychotic symptoms as measured by the Positive and Negative Symptom Scale and the Psychotic Symptom Rating Scale. RESULTS: Both the treatment and control groups experienced a significant decrease in post-traumatic stress symptoms over time but there was no effect of the addition of CBT on either the primary or secondary outcomes. CONCLUSIONS: The current trial did not demonstrate any effect in favour of CBT. Cognitive restructuring programmes may require further adaptation to promote emotional processing of traumatic memories within people diagnosed with a psychotic disorder.

Supported employment for persons with serious mental illness: current status and future directions.

The individual placement and supported (IPS) model of supported employment is the most empirically validated model of vocational rehabilitation for persons with schizophrenia or another serious mental illness. Over 18 randomized controlled trials have been conducted throughout the world demonstrating the effectiveness of supported employment at improving competitive work compared to other vocational programs: IPS supported employment is defined by the following principles: 1) inclusion of all clients who want to work; 2) integration of vocational and clinical services; 3) focus on competitive employment; 4) rapid job search and no required prevocational skills training; 5) job development by the employment specialist; 6) attention to client preferences about desired work and disclosure of mental illness to prospective employers; 7) benefits counseling; and 8) follow-along supports after a job is obtained. Supported employment has been successfully implemented in a wide range of cultural and clinical populations, although challenges to implementation are also encountered. Common challenges are related to problems such as the failure to access technical assistance, system issues, negative beliefs and attitudes of providers, funding restrictions, and poor leadership. These challenges can be overcome by tapping expertise in IPS supported employment, including standardized and tested models of training and consultation. Efforts are underway to increase the efficiency of training methods for supported employment and the overall program, and to improve its effectiveness for those clients who do not benefit. Progress in IPS supported employment offers people with a serious mental illness realistic hope for achieving their work goals, and taking greater control over their lives.

Comparison of Black and White participants with severe mental illness in response to cognitive remediation as an augmentation of vocational rehabilitation.

PURPOSE: Despite evidence that cognitive remediation improves cognitive and employment outcomes in persons with severe mental illnesses (SMI), its effects have not been systematically compared between Black and White participants. Considering that Black adults have more negative experiences receiving mental health treatment, providers may have greater difficulty engaging and retaining Black Americans in cognitive remediation. Due to the effects of structural racism on reducing employment opportunities for Black Americans, it is unclear whether Black participants will reap the same benefits of cognitive remediation on work outcomes as White Americans. This paper addressed this question. METHODS: A secondary analysis was conducted of five randomized controlled trials comparing cognitive remediation (the Thinking Skills for Work program: TSW) and vocational rehabilitation vs. vocational rehabilitation only in 137 Black and 147 White Americans (64.2% schizophrenia-schizoaffective disorder) who were followed up for two years. RESULTS: Comparable proportions of Black and White participants were engaged and retained in TSW (>75%). Participants who received TSW improved significantly more in cognition than those receiving vocational services alone, with no racial differences in benefit. Participants in TSW obtained more work, earned more wages, and worked more weeks than those receiving vocational services alone, with no differences between the races. CONCLUSIONS: The findings indicate that Black Americans with SMI receiving vocational services could be successfully engaged in and benefit from cognitive remediation, highlighting the vital role of healthcare service systems in giving credence to structural racism to more effectively mitigate racial disparities in treatment outcomes.

A Randomized Controlled Trial of the Effects of Early Intervention Services On Insight in First Episode Psychosis.

BACKGROUND AND HYPOTHESIS: Impaired insight into one's illness is common in first episode psychosis (FEP), is associated with worse symptoms and functioning, and predicts a worse course of illness. Despite its importance, little research has examined the effects of early intervention services (EIS) on insight. DESIGNS: This paper evaluated the impact of EIS (NAVIGATE) on insight compared to usual community care (CC) in a large cluster randomized controlled trial. Assessments were conducted at baseline and every 6 months for 2 years. RESULTS: A multilevel regression model including all time points showed a significant time by treatment group interaction (P < .001), reflecting greater improvement in insight for NAVIGATE than CC participants. Impaired insight was related to less severe depression but worse other symptoms and functioning at baseline for the total sample. At 6 months, the same pattern was found within each group except insight was no longer associated with depression among NAVIGATE participants. Impaired insight was more strongly associated with worse interpersonal relationships at 6 months in NAVIGATE than in CC, and changes in insight from baseline to 6 months were more strongly correlated with changes in relationships in NAVIGATE than CC. CONCLUSIONS: The NAVIGATE program improved insight significantly more than CC. Although greater awareness of illness has frequently been found to be associated with higher depression in schizophrenia, these findings suggest EIS programs can improve insight without worsening depression in FEP. The increased association between insight and social relationships in NAVIGATE suggests these 2 outcomes may synergistically interact to improve each other in treatment.

Positive symptoms of psychosis in posttraumatic stress disorder.

The possible presence of hallucinations and delusional thoughts in posttraumatic stress disorder (PTSD) was investigated. Other symptom clusters were also assessed in order to further clarify the nature of PTSD. Twenty combat veterans with PTSD were compared to 18 combat veterans without PTSD on symptom rating scales. The subjects with PTSD exhibited a greater degree of depression, anxiety, agitation, anhedonia, and positive symptoms of psychosis than the comparison group. Specifically, the PTSD group manifested increased hallucinations, delusions, and bizarre behavior. Some of these positive symptoms did not appear to be due to reexperiencing of the trauma. The groups were not significantly different on indices of mania, thought disorder, or inertia. The clinical and diagnostic implications of the results are discussed. A diagnosis of PTSD should be considered with patients who have positive symptoms in the absence of thought disorder.

Auditory hallucinations in combat-related chronic posttraumatic stress disorder.

Intrusive images have been reported to occur in a broad range of people with posttraumatic stress disorder, but the frequency of intrusive auditory perceptions has rarely been addressed. This study compared five posttraumatic stress disorder veterans experiencing auditory hallucinations with 31 nonhallucinating veterans on demographic, military, postmilitary, and symptom variables. Veterans who reported auditory hallucinations had higher combat exposure and more intense posttraumatic stress disorder symptoms than the other veterans. These veterans also tended to be more refractory to treatment than veterans with no hallucinations. Clinical vignettes of the veterans with auditory hallucinations are given, and the implications of the results for a subgroup of chronic posttraumatic stress disorder veterans are discussed.

Research update on the psychosocial treatment of schizophrenia.

OBJECTIVE: This review is an update on the research evidence supporting psychosocial treatment for schizophrenia. It extends previous review articles by summarizing the literature on social skills training, family interventions, cognitive rehabilitation, and coping with residual positive symptoms. METHOD: The authors reviewed controlled treatment outcome studies of social skills training and family interventions. Different models of family therapy were contrasted. The current literature on cognitive rehabilitation and coping with residual positive symptoms was also examined. RESULTS: Social skills training produces improvement on specific behavioral measures, although changes in symptoms and community functioning are less pronounced. Family interventions (i.e., family psychoeducation and behavioral family therapy) are highly effective for reducing families' expressed emotion and improving patients' relapse rates and outcomes. Furthermore, family interventions are also associated with reduced family burden. Cognitive rehabilitation and training in coping with positive symptoms appear to be promising interventions, but more controlled, group trials are needed before definite conclusions can be drawn. CONCLUSIONS: The efficacy of a variety of different family intervention models, as well as social skills training, is supported by a large body of research. Future work needs to address improving delivery of existing psychosocial interventions, integrating these interventions with other psychosocial approaches (e.g., vocational rehabilitation and case management), identifying which patients will benefit from which treatments, isolating the "active" ingredients of family interventions (i.e., psychoeducation versus behavioral intervention), and identifying the amount of treatment (e.g., number of sessions) needed before treatment response is expected.

Social skills training for schizophrenic individuals at risk for relapse.

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

A multisite investigation of the reliability of the Scale for the Assessment of Negative Symptoms.

OBJECTIVE: The Scale for the Assessment of Negative Symptoms is a widely used instrument for measuring negative symptoms in schizophrenia, but few studies have examined its reliability. This study examined the interrater, internal, and test-retest reliabilities of the scale and its factor structure in the context of a multisite study. METHOD: Two hundred seven patients with schizophrenia who were participating in the Treatment Strategies in Schizophrenia study were assessed with the Scale for the Assessment of Negative Symptoms following a symptom exacerbation and again 3-6 months later. All assessments were performed by trained psychiatrists who were treating the patients. RESULTS: Interrater reliabilities ranged from low to high for the items on the Scale for the Assessment of Negative Symptoms but were statistically significant in most cases. Most correlations between individual items and subscale total scores were moderate to high, as were coefficient alphas for each subscale, indicating adequate internal consistency. Test-retest correlations were of moderate magnitude. Few differences in reliability statistics between sites were found, although differences in mean scale ratings between sites were present. A factor analysis indicated three factors corresponding to the Affective Flattening or Blunting subscale, the Avolition-Apathy and Anhedonia-Asociality subscales, and the Alogia and Inattention subscales. CONCLUSIONS: The results suggest that the Scale for the Assessment of Negative Symptoms has good reliability and is a useful instrument for the measurement of negative symptoms in multisite clinical studies. The internal reliability of the Alogia, Avolition-Apathy, and Inattention subscales could be improved by replacing some items and including additional items.

Remediation of cognitive deficits in schizophrenia.

Studies have suggested that schizophrenia is characterized by an impairment in the dorsolateral prefrontal cortex that prevents learning of some elementary information processing tasks. To test this hypothesis, the authors administered the Wisconsin Card Sorting Test to 16 schizophrenic inpatients with standard instructions and either contingent or noncontingent reinforcement. Performance was markedly impaired under each condition. A second cohort (N = 12) was tested after receiving instructions plus rehearsal and feedback. These subjects' performance was comparable to nonpatient norms and was maintained on a subsequent day. The results indicate that deficits in performance on the Wisconsin Card Sorting Test are remediable, whether or not they are due to neurological impairment.

Dartmouth Assessment of Lifestyle Instrument (DALI): a substance use disorder screen for people with severe mental illness.

OBJECTIVE: Despite high rates of co-occurring substance use disorder in people with severe mental illness, substance use disorder is often undetected in acute-care psychiatric settings. Because underdetection is related to the failure of traditional screening instruments with this population, the authors developed a new screen for detection of substance use disorder in people with severe mental illness. METHOD: On the basis of criterion ("gold standard") diagnoses of substance use disorder for 247 patients admitted to a state hospital, the authors used logistic regression to select the best items from 10 current screening instruments and constructed a new instrument. They then tested the validity of the new instrument, compared with other screens, on an independent group of 73 admitted patients. RESULTS: The new screening instrument, the Dartmouth Assessment of Lifestyle Instrument (DALI), is brief, is easy to use, and exhibits high classification accuracy for both alcohol and drug (cannabis and cocaine) use disorders. Receiver operating characteristic curves showed that the DALI functioned significantly better than traditional instruments for both alcohol and drug use disorders. CONCLUSIONS: Initial findings suggest the DALI may be useful for detecting substance use disorder in acutely ill psychiatric patients. Further research is needed to validate the DALI in other settings and with other groups of psychiatric patients.

A generalized signal detection model to predict rational variation in base rate use.

The predominant models of rational behavior currently used to analyze a large class of experiments imply that subjects neglect or place insufficient weight on base rates when making probabilistic judgments. We argue that the evidence is inadequate for this conclusion because the models make needlessly restrictive assumptions about how base rates should be used. The restrictive assumptions stem from a misuse of Bayes' rule that ignores specific aspects of how the proportions arose. We develop a model of rational behavior that generalizes signal detection theory to reflect the environment subjects routinely face and we reexamine the relevant experimental literature. Variation observed in subjects' responses to base rate information is explained by the present rational model more fully than by extant models.

Positive and negative symptom behaviors and caregiver burden in the relatives of persons with schizophrenia.

OBJECTIVE: The relationships of perceived severity and responsibility attribution for positive and negative symptom behaviors to caregiver burden were investigated. Two types of burden were studied: objective burden (i.e., negative consequences such as physical problems, financial difficulties, and household tension), and subjective burden (i.e., emotional distress about disturbing behaviors). METHOD: Self-report measures were completed by 70 primary caregivers of persons with schizophrenia. RESULTS: Subjective burden was related to both the severity of positive and negative symptom behaviors, whereas objective burden was related only to the severity of negative symptom behaviors. Responsibility attribution for negative symptom behaviors was related only to objective burden. Caregivers who perceived patients as being less responsible for their negative symptom behaviors reported higher levels of objective burden. The relationship between responsibility attribution for negative symptom behaviors and objective burden remained significant, even after controlling for the severity of negative symptom behaviors. Caregivers' perceptions of patients' responsibility for positive symptom behaviors were not related to objective burden. CONCLUSIONS: As expected, perceived severity of negative symptom behaviors was related to objective caregiver burden, whereas severity of positive symptom behaviors was not. These findings suggest that negative symptoms may have a greater impact on role functioning that positive symptoms, leading to greater burden. However, contrary to expectations, less responsibility attribution for negative symptom behaviors was related to higher levels of objective caregiver burden. Caregivers who perceive patients as incapable of altering their negative symptom behaviors and meeting certain role obligations may assume extra responsibilities, leading to higher levels of objective burden. The results indicate that there may be disadvantages for caregivers associated with assuming that patients have no control over their negative symptom behaviors.

Social functioning, psychopathology, and medication side effects in relation to substance use and abuse in schizophrenia.

OBJECTIVE: To identify correlates of self-reported substance use and problems associated with that use in people with schizophrenia. METHODS: A sample of 404 patients with schizophrenia, schizoaffective disorder, or schizophreniform disorder and longitudinal assessments of substance use were examined. Three groups were formed according to consistency of substance use over time: No/Low Alcohol, Alcohol Only, and Drug Use (with or without alcohol use). Similar groups were formed regarding problems associated with alcohol use. Groups were compared on demographics, psychiatric history, psychopathology, medication side effects, and social functioning. RESULTS: Substance users were more likely to be young, male, and to have lower levels of education. Substance users generally had fewer negative symptoms, more social contacts, and better social-leisure functioning. However, substance users, especially drug users, also were rated as having more interpersonal and family problems, had an earlier age at first psychiatric hospitalization, and were more likely to have been recently hospitalized. Patients reporting problems with alcohol use reported more frequent alcohol and drug use, greater severity of akathisia, and problems in interpersonal, family, and self-efficacy domains. CONCLUSIONS: Many of the same variables that correlate with substance use disorder also correlated with moderate substance use in this sample of people with schizophrenia. Although moderate users of alcohol and drugs may have better social functioning in some areas, they also are likely to have substantial problems in interpersonal relationships, especially those involving family members.

Symptomatology and the prediction of social skills acquisition in schizophrenia.

The relationship between patient symptomatology and the acquisition of social skills during an inpatient social skills training program, and the maintenance of skills at a one-month followup, were examined in a sample of recently hospitalized schizophrenic and schizoaffective disorder patients. Subtypes of patients with enduring Thought Disorder (vs. no enduring Thought Disorder) or enduring Anergia (vs. no enduring Anergia) on the BPRS during the treatment period were compared in their response to the social skills training intervention. Patients with enduring Thought Disorder acquired skills at the same rate as patients without Thought Disorder, but were unable to retain their skills at followup, in contrast to their counterparts. Enduring Anergia was not related to either the acquisition or maintenance of social skills. The results were unaffected when memory was statistically controlled. The findings suggest that patient symptomatology may be an important factor mediating the efficacy of social skills training interventions.

Relations between social skills and ward behavior in chronic schizophrenia.

The relationship between social skills and ward behavior among chronic schizophrenia patients was investigated. Twenty-eight inpatients participated in an unstructured role play test and were rated by staff members on a number of indices of ward behavior (e.g., social interactions, inappropriate behavior). Overall, there was a relationship between social skill on the role play and social behavior on the ward. Speech clarity was the social skill most strongly related to ward behavior, even when controlling for symptomatology. However, several other social skill variables (e.g., gaze, affect) were not related to social adjustment. The results are discussed in terms of the validity of social skill assessments in patients with chronic schizophrenia, and their implications for psychosocial treatment of this population.

A comparative study of elderly patients with schizophrenia and bipolar disorder in nursing homes and the community.

This study compared the functioning of 188 elderly schizophrenic and bipolar disorder patients living in nursing homes and the community. Residential status and diagnostic groups were compared on measures of symptomatology, cognitive impairment, functional impairment, and behavior problems. In general, the diagnostic groups differed in symptoms, while most differences in living setting were related to cognition, functioning, and behavior. Nursing home status was significantly associated with more severe overall symptom ratings, worse cognitive impairment, greater functional impairment, more aggressive behaviors, and marital status of having never married. Self-care skills, community living skills, and marital status were most uniquely predictive of nursing home residence. However, cognitive deficits were strongly predictive of both self-care and community living skills, explaining approximately half of the variance in these variables. The implications of these findings for the treatment of elderly patients with schizophrenia and other severe mental illnesses are discussed.

Educational Family Therapy for schizophrenia: a new treatment model for clinical service and research.

A new family therapy model for schizophrenia is described, Educational Family Therapy (EFT). This model employs didactic teaching methods and 'user friendly' educational handouts and is provided in a flexible, interactive manner. The results of pilot data show that the model is feasible and suggest family members improve in their understanding of the illness. Data are also presented demonstrating that EFT can be distinguished from another model of family therapy for schizophrenia, Behavioral Family Therapy. The need for research comparing EFT and other family therapy models for schizophrenia is discussed. Such research may have implications for the dissemination of effective family interventions, matching treatment models to family needs and understanding the mechanisms underlying the impact of family therapy on the course of schizophrenia and on family burden.