Enhancing return to work or school after a first episode of schizophrenia: the UCLA RCT of Individual Placement and Support and Workplace Fundamentals Module training.

BACKGROUND: This study evaluated in a rigorous 18-month randomized controlled trial the efficacy of an enhanced vocational intervention for helping individuals with a recent first schizophrenia episode to return to and remain in competitive work or regular schooling. METHODS: Individual Placement and Support (IPS) was adapted to meet the goals of individuals whose goals might involve either employment or schooling. IPS was combined with a Workplace Fundamentals Module (WFM) for an enhanced, outpatient, vocational intervention. Random assignment to the enhanced integrated rehabilitation program (N = 46) was contrasted with equally intensive clinical treatment at UCLA, including social skills training groups, and conventional vocational rehabilitation by state agencies (N = 23). All patients were provided case management and psychiatric services by the same clinical team and received oral atypical antipsychotic medication. RESULTS: The IPS-WFM combination led to 83% of patients participating in competitive employment or school in the first 6 months of intensive treatment, compared with 41% in the comparison group (p < 0.005). During the subsequent year, IPS-WFM continued to yield higher rates of schooling/employment (92% v. 60%, p < 0.03). Cumulative number of weeks of schooling and/or employment was also substantially greater with the IPS-WFM intervention (45 v. 26 weeks, p < 0.004). CONCLUSIONS: The results clearly support the efficacy of an enhanced intervention focused on recovery of participation in normative work and school settings in the initial phase of schizophrenia, suggesting potential for prevention of disability.

Group cognitive behavior therapy or social skills training for individuals with a recent onset of psychosis? Results of a randomized controlled trial.

This study aimed at determining the effectiveness of group cognitive behavior therapy (CBT) for recent onset psychosis in comparison with a recognized intervention for individuals with severe mental illness-social skills training. One hundred twenty-nine participants took part in a single-blind randomized controlled trial with repeated measures (baseline, 3 months, and 9 months). Participants were randomized to 1 of 3 conditions: group CBT, group social skills training for symptom management, or a wait-list control group. Both interventions were delivered by mental health staff with minimal training. Both treatments resulted in improvements on positive and negative symptoms compared with the wait-list control group, with the CBT group having significant effects over time on overall symptoms, and post-treatment effects on self-esteem, and active coping skills compared with the wait-list control group and lower drop-out rates than the skills training group. Therapist fidelity was adequate for both treatment conditions. Group CBT for psychosis is a promising intervention for individuals with recent onset of psychosis and their mental health professionals.

The micro-module learning tests: work-sample assessments of responsiveness to skills training.

While outcome of psychiatric rehabilitation has been successfully predicted by cognitive tests, efforts to design a measure to assess responsiveness to rehabilitation have been lacking. In this report, we describe the rationale for and development of a face-valid measure of responsivity to the three core components of skills training: responsiveness to verbal instruction, ability to learn from viewing the behavior of a model, and ability to demonstrate skills observed during a subsequent role-play. Seven alternate forms of the new measure, called the Micro-Module Learning Test (MMLT), demonstrated adequate internal consistency and alternate-form reliability. We also present results from four studies in which the MMLT was used to collect normative data as well as data on relationships with symptoms, cognitive tests, and treatment outcome. Results indicate that the MMLT is associated with cognitive factors found to predict treatment outcome in prior studies (e.g., verbal memory and fluency), as well as lesser investigated functions such as theory of mind ability. In addition, MMLT scores were correlated negatively with psychotic disorganization and positively with performance during a full-length skills training group. The MMLT appears to be a reliable and valid measure for rapidly assessing responsiveness to skills training procedures.

Consumers' goals in psychiatric rehabilitation and their concordance with existing services.

The objective of this study was to describe the rehabilitation goals of 165 consumers with serious mental illness who were living in the community and to assess the level of concordance between the consumers' perceived importance of their goals and the services they received to help them meet those goals. A structured interview was used to facilitate the expression of rehabilitation goals by consumers in the psychiatric rehabilitation program of a hospital in Montreal, Canada. The most frequently mentioned rehabilitation goals pertained to improving consumers' financial situation, physical health, cognitive capacities, and symptoms. Among these goals, the level of concordance was highest for services addressing symptoms and lowest for religious or spiritual goals.

The effectiveness of skills training for improving outcomes in supported employment.

OBJECTIVE: This study evaluated whether a supplementary skills training program improved work outcomes for clients enrolled in supported employment programs. METHODS: Thirty-five recently employed clients with severe mental illness who were receiving supported employment services at a free-standing agency were randomly assigned to participate in either the workplace fundamentals program, a skills training program designed to make work more "successful and satisfying," or treatment as usual. Knowledge of workplace fundamentals (for example, identifying workplace stressors, problem solving, and improving job performance) was assessed at baseline and at nine months; employment outcomes and use of additional vocational services were tracked for 18 months. RESULTS: Clients in the workplace fundamentals group (N=17) improved more in knowledge of workplace fundamentals than those in the control group (N=18) at the nine-month follow-up, but the two groups did not differ in the number of hours or days worked, salary earned, or receipt of additional vocational services over the 18-month period. In general, clients in this study had higher educational levels and better employment outcomes than clients in most previous studies of supported employment, making it difficult to detect possible effects of the skills training intervention on work. CONCLUSIONS: Supplementary skills training did not improve work outcomes for clients who were receiving supported employment.

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.

Further validation of the Client Assessment of Strengths Interests and Goals.

The Client Assessment of Strengths Interests and Goals (CASIG), a measure that assesses the treatment outcomes of individuals with serious and persistent mental illness, has previously shown adequate psychometric properties with an American sample. Since it assesses quite specific skills and needs, it is necessary to assess its cultural relevance and psychometric characteristics before using it in a different country. Hence, the purposes of this study were to (1) adapt CASIG to the culture of a Canadian setting and translate its items and directions into French, (2) determine the psychometric characteristics of the adapted English and French versions of CASIG, and (3) identify its latent constructs via an exploratory factor analysis. The CASIG self-report (CASIG-SR) measure was administered to 224 consumers living in the community, and the CASIG informant (CASIG-I) measure to 31 clinicians answering for 172 consumers. The participating consumers also completed the Behavior and Symptom Identification Scale-32 (BASIS-32), the Short Form Health Survey-36 (SF-36), and the Camberwell Assessment of Needs (CAN). The informants also completed the clinician version of the CAN. The CASIG-SR and the CASIG-I had adequate internal consistency, test-retest, and interrater reliabilities. Correlations of the consumers' and informants' results with the BASIS-32, SF-36, and CAN provided evidence of convergent and discriminant validity, as did contrasts between higher and lower functioning community consumers. The factor analysis also supports the construct validity of the assessment. The results confirm the psychometric adequacy of the adapted and translated CASIG in Canada.

Supplementing supported employment with workplace skills training.

Introduction by the column editors: Supported employment, as designed for persons with serious and persistent mental illness, has been termed individual placement and support. In two randomized controlled trials (1,2), clients who received individual placement and support services were more likely to obtain at least one job in the competitive sector, to work more hours, and to have a higher total income than their counterparts who received more traditional types of vocational rehabilitation. However, individual placement and support did not improve the length of time the employed participants kept their jobs. An adjunctive or additional element of individual placement and support, aimed at improving the job tenure of individuals with mental illness, would be a constructive contribution to the vocational rehabilitation for this population. In a previous Rehab Rounds column, Wallace and colleagues (3) described the development of the workplace fundamental skills module, a highly structured and user-friendly curriculum designed to teach workers with mental illness the social and workplace skills needed to keep their jobs. The workplace fundamental skills module supplements individual placement and support by conveying specific skills that enable workers to learn the requirements of their jobs, anticipate the stressors associated with their jobs, and cope with stressors by using a problem-solving process. The earlier report described the production and validation of the module's content. The purpose of this month's column is to present the preliminary results of a randomized comparison of the module's effects on job retention, symptoms, and community functioning when coupled with individual placement and support. To enable wide generalization of the findings of the study, the program was conducted in a typical community mental health center.

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.