The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements

Psychosocial Interventions for Adults With Schizophrenia: An Overview and Update of Systematic Reviews

OBJECTIVE

The authors of this systematic review (SR) sought to provide evidence for effects of commonly used psychosocial interventions on several outcomes among adults with schizophrenia.

METHODS

MEDLINE, the Cochrane Library, and PsycINFO databases were searched through July 2020. Eligible studies were SRs and trials of at least 12 weeks duration and with ≥50 participants that compared psychosocial interventions with treatment as usual among adults with schizophrenia. Study design, year, setting, country, sample size, eligibility criteria, population, clinical and intervention characteristics, results, and funding source were extracted, along with quality criteria. The evidence was evaluated on quality and strength of evidence stratified by intervention area and outcome, according to the Evidence-Based Practice Centers Methods Guide of the Agency for Healthcare Research and Quality.

RESULTS

Nine SRs and 30 trials (N=23,921 patients) in 11 intervention areas were included. Trials were mostly of fair quality and had low-to-moderate strength of evidence. Compared with treatment as usual, most psychosocial interventions were more effective in improving intervention-targeted outcomes, including core illness symptoms. Compared with treatment as usual, assertive community treatment, cognitive-behavioral therapy (CBT), family interventions, psychoeducation, social skills training, supported employment, and early interventions for first-episode psychosis (FEP) improved various functional outcomes. CBT and early interventions for FEP improved quality of life. Family interventions, psychoeducation, illness self-management, and early interventions for FEP reduced relapse.

CONCLUSIONS

Compared with treatment as usual, most psychosocial interventions improved functional outcomes, quality of life, and core illness symptoms, and several reduced relapse frequency among adults with schizophrenia.

Integrated Cognitive-Behavioral Social Skills Training and Compensatory Cognitive Training for Negative Symptoms of Psychosis: Effects in a Pilot Randomized Controlled Trial

OBJECTIVE

Negative symptoms and cognitive impairment in schizophrenia (SZ) remain unmet treatment needs as they are highly prevalent, associated with poor functional outcomes, and resistant to pharmacologic treatment. The current pilot randomized controlled trial examined the efficacy of an integrated Cognitive-Behavioral Social Skills Training and Compensatory Cognitive Training (CBSST-CCT) intervention compared to Goal-focused Supportive Contact (SC) on negative symptoms and cognitive performance.

METHODS

Fifty-five adults with SZ or schizoaffective disorder with moderate-to-severe negative symptoms were randomized to receive 25 twice-weekly, 1-h manualized group sessions (12.5 weeks total duration) of either CBSST-CCT or SC delivered by master's level clinicians in five community settings. Assessments of negative symptom severity (primary outcomes) and neuropsychological performance, functional capacity, social skills performance, and self-reported functional ability/everyday functioning, psychiatric symptom severity, and motivation (secondary outcomes) were administered at baseline, mid-treatment, post-treatment, and 6-month follow-up.

RESULTS

Mixed-effects models using baseline, mid-treatment, and post-treatment data demonstrated significant CBSST-CCT-associated effects on negative symptom severity, as assessed by the Scale for the Assessment of Negative Symptoms (p = .049, r = 0.22), with improvements in diminished motivation driving this effect (p = .037, r = 0.24). The CBSST-CCT group also demonstrated improved verbal learning compared to SC participants (p = .026, r = 0.36). The effects of CBSST-CCT appeared to be durable at 6-month follow-up.

CONCLUSIONS

CBSST-CCT improved negative symptom severity and verbal learning in high-negative-symptom individuals relative to SC. CBSST-CCT warrants larger investigations to examine its efficacy in treating negative symptoms, along with other symptoms, cognition, and, ultimately, real-world functional outcomes. Clinical Trial registration number NCT02170051.

Effectiveness of Social Skills Training Groups in Persons with Severe Mental Illness: A Pre-Post Intervention Study

BACKGROUND

The study aimed to evaluate the effectiveness of a social skills training program provided at the occupational therapy unit of a tertiary care center in India.

METHODS

The study used a pre-post interventional design where 101 consecutive patients with a diagnosis of schizophrenia or bipolar affective disorder, between 18 and 60 years, who provided written informed consent, were assessed on the Vellore Assessment of Social Performance (VASP) during the first week of attendance (baseline). Subsequently, they were enrolled in a six-session social skills group training program for two weeks. They were assessed on the VASP after one week (midterm assessment) and at the end (posttest) of the intervention. A follow-up assessment was done two weeks after cessation of the intervention. The participants were also scored on the Brief Psychiatric Rating Scale (BPRS) at four time points.

RESULTS

Repeated measures ANOVA revealed significant differences in the VASP scores between time points, that is, F(baseline, midterm) = -4.34 and P = 0.001; F (baseline, postgroup) = -6.92 and P = 0.001; and F (baseline, follow-up) = -8.71 and P = 0.001. The correlation between the BPRS and VASP scores was also significant at each time point.

CONCLUSION

The social skills group training protocol seems to be effective and feasible for the Indian population. Since conducting multicenter clinical trials might not always be possible in resource-constrained settings, this study might be considered preliminary evidence for context-specific, peer-/family-supported social skills training.

Inpatient Early Intervention for Serious Mental Illnesses Is Associated With Fewer Rehospitalizations Compared With Treatment as Usual in a High-volume Public Psychiatric Hospital Setting

OBJECTIVE

High-acuity publicly funded inpatient psychiatric settings usually feature short lengths of stay and high readmission rates. This study examined the influence of an early intervention program for serious mental illnesses (SMI) on readmissions at 6 and 12 months postdischarge at a high-volume, urban public inpatient psychiatric hospital.

METHODS

The Early Onset Treatment Program (EOTP) is a cost-free, 90-day inpatient multidisciplinary service intervention program for uninsured patients who are within 5 years of SMI onset, funded as a pilot program by the Texas state legislature. Rehospitalization rates at 6 and 12 months were extracted from electronic medical records for EOTP participants (n=165) and comparison patients matched on demographics and diagnosis (n=155). The comparison group received treatment as usual at the same psychiatric hospital. Group re-admission rates were compared using logistic and Poisson regression analyses.

RESULTS

Group membership was a significant predictor of rehospitalization (P<0.0001) at both 6 and 12 months. Expressed as 1/odds ratio (OR), the EOTP group was less likely to readmit once and more than once at 6 months postdischarge (1/OR=3.82 and 4.74, respectively) compared with the non-EOTP group. The EOTP group was also less likely to readmit once and more than once at 12 months postdischarge (1/OR=2.96 and 3.51, respectively).

CONCLUSIONS

The results suggest that participation in the EOTP service in this high-acuity setting was significantly related to reduced likelihood of rehospitalization at 6 and 12 months. Several variables may account for this observation, including length of stay, longer medication adherence, environmental stability, and more individualized and extensive psychotherapy treatment.

Affective lability and social functioning in severe mental disorders

Social functioning is impaired in severe mental disorders despite clinical remission, illustrating the need to identify other mechanisms that hinder psychosocial recovery. Affective lability is elevated and associated with an increased clinical burden in psychosis spectrum disorders. We aimed to investigate putative associations between affective lability and social functioning in 293 participants with severe mental disorders (schizophrenia- and bipolar spectrum), and if such an association was independent of well-established predictors of social impairments. The Affective Lability Scale (ALS-SF) was used to measure affective lability covering the dimensions of anxiety-depression, depression-elation and anger. The interpersonal domain of the Social Functioning Scale (SFS) was used to measure social functioning. Correlation analyses were conducted to investigate associations between affective lability and social functioning, followed by a hierarchical multiple regression and follow-up analyses in diagnostic subgroups. Features related to premorbid and clinical characteristics were entered as independent variables together with the ALS-SF scores. We found that higher scores on all ALS-SF subdimensions were significantly associated with lower social functioning (p < 0.005) in the total sample. For the anxiety-depression dimension of the ALS-SF, this association persisted after controlling for potential confounders such as premorbid social functioning, duration of untreated illness and current symptoms (p = 0.019). Our results indicate that elevated affective lability may have a negative impact on social functioning in severe mental disorders, which warrants further investigation. Clinically, it might be fruitful to target affective lability in severe mental disorders to improve psychosocial outcomes.

Efficacy of Integrated Social Cognitive Remediation vs. Neurocognitive Remediation in Improving Functional Outcome in Schizophrenia: Concept and Design of a Multicenter, Single-Blind RCT (The ISST Study)

BACKGROUND

Although clinically effective treatment is available for schizophrenia, recovery often is still hampered by persistent poor psychosocial functioning, which in turn is limited by impairments in neurocognition, social cognition, and social behavioral skills. Although cognitive remediation has shown general efficacy in improving cognition and social functioning, effects still need to be improved and replicated in appropriately powered, methodologically rigorous randomized controlled trials (RCTs). Existing evidence indicates that effects can most likely be optimized by combining treatment approaches to simultaneously address both social cognitive and social behavioral processes.

OBJECTIVES

To assess whether Integrated Social Cognitive and Behavioral Skill Therapy (ISST) is more efficacious in improving functional outcome in schizophrenia than the active control treatment Neurocognitive Remediation Therapy (NCRT).

METHODS

The present study is a multicenter, prospective, rater-blinded, two-arm RCT being conducted at six academic study sites in Germany. A sample of 180 at least partly remitted patients with schizophrenia are randomly assigned to either ISST or NCRT. ISST is a compensatory, strategy-based program that targets social cognitive processes and social behavioral skills. NCRT comprises mainly drill and practice-oriented neurocognitive training. Both treatments consist of 18 sessions over 6 months, and participants are subsequently followed up for another 6 months. The primary outcome is all-cause discontinuation over the 12-month study period; psychosocial functioning, quality of life, neurocognitive and social cognitive performance, and clinical symptoms are assessed as secondary outcomes at baseline before randomization (V1), at the end of the six-month treatment period (V6), and at the six-month follow-up (V12).

DISCUSSION

This RCT is part of the German Enhancing Schizophrenia Prevention and Recovery through Innovative Treatments (ESPRIT) research network, which aims at using innovative treatments to enhance prevention and recovery in patients with schizophrenia. Because this study is one of the largest and methodologically most rigorous RCTs on the efficacy of cognitive remediation approaches in schizophrenia, it will not only help to identify the optimal treatment options for improving psychosocial functioning and thus recovery in patients but also allow conclusions to be drawn about factors influencing and mediating the effects of cognitive remediation in these patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02678858, German Study Register DRKS 00010033.

Effectiveness of Cognitive Behavioural Therapy for Suicide in Schizophrenia: A Systematic Review

Background:

Suicide is probably one of the worst potential complications for people with schizophrenia. Even though the use of antipsychotic medication is essential in reducing suicidal behaviour, the use of psychological treatments seems to be in the same way necessary. Cognitive Behavioural Therapy (CBT) is an evidence-based form of psychotherapy that is constantly trying to synchronise with the latest recommendations from the research. The goal of the present work is to systematically review the scientific evidence from published studies testing the effectiveness of CBT designed to deal with suicide in patients with schizophrenia.

Methods:

We searched using multiple terms related to suicide prevention based on CBT in schizophrenia. Two databases (Medline and SCOPUS) were scrutinised for the electronic search and different reference lists from previous reviews were also hand checked.

Results:

We identified 5 randomised and controlled trials of CBT that included suicide-related cognitions or behaviours as a primary outcome measure. CBT focusing on suicidal cognitions and behaviours was found to be effective in reducing suicidal ideation. As the number of studies fulfilling the inclusion criteria is small and the assessment of outcomes is heterogeneous, we did not perform a meta-analysis and we present results in a narrative way.

Conclusion:

Research on CBT focused on suicide prevention in patients with schizophrenia is promising but current evidence is notoriously insufficient. Although those therapies seemed to be efficacious in the prevention of suicide, scarcity of randomised clinical trials specifically focusing on suicide is probably the most important issue to be faced. Given the current evidence, clinicians should be familiar with CBT techniques focusing on suicidal cognitions. However, suicide prevention and treatment in those with schizophrenia is complex, and many other factors such as possible earlier use of clozapine, optimizing adherence to medication, and other psychosocial aspects should be addressed. Combination of different strategies appears to be mandatory.

Cognitive behavioural social skills training: Methods of a randomized controlled trial for youth at risk of psychosis

AIM

Poor functioning has become a hallmark of many youth at clinical high-risk (CHR) of psychosis. Even for those who do not make the transition to psychosis remain troubled by functional deficits and a decline in functioning increases the odds of transitioning to psychosis. There are very few treatment studies that have attempted to improve social and role functioning. The aim of this paper is to describe the methods of a treatment study to address social and role functioning in CHR.

METHODS

This was a randomized controlled trial of cognitive-behavioural social skills training (CBSST) versus a supportive therapy. CBSST combines elements of cognitive behaviour therapy (CBT) and social skills training (SST), two evidence-based treatments for schizophrenia. By adding CBT to SST to target functioning outcomes, SST can be used to train new social skills, and thoughts that interfere with skilled performance in the real world can be addressed using CBT. We developed an adapted version of CBSST, more appropriate for the age range and illness severity of typical CHR individuals, to attempt to show improvements in social and role functioning for these young people.

RESULTS

Two hundred and three participants were recruited for this study. Results include initial baseline data.

CONCLUSION

This article describes the baseline methodology of a CHR youth who have difficulties in social and/or role functioning. It is one of the first clinical trials to address this significant problem.

Outcomes frequently specified in Cochrane reviews of community-based psychosocial interventions for adults with severe mental illness: A systematic search and narrative synthesis

Background

Outcome selection in intervention studies is a critical issue for synthesizing evidence. This study is aimed to investigate outcomes used in Cochrane reviews assessing community‐based psychosocial interventions for adults with severe mental illness.

Methods

Cochrane reviews that evaluated a community‐based psychosocial intervention for adults with severe mental illness were searched electronically and manually. We extracted all outcomes specified in the Methods section in each Cochrane review. Outcomes that represent the same concept and context were synthesized into an outcome term. Outcome terms were categorized according to the existing taxonomy.

Results

We included 33 Cochrane reviews. Of the 216 outcome terms identified, 13 were used in more than half of the reviews: quality of life, mental state, admission to hospital, economic outcome, leaving the study early, social functioning, satisfaction, global state, relapse, adverse events/effects, carer satisfaction, employment, and duration of admission. Most outcome terms were categorized into the life impact core area (55%), followed by the resource use area (21%).

Conclusions

Our study provides a candidate outcome list for developing a core outcome set for severe mental illness and offers a basis for comparison for future outcome investigation on mental health research.

Two hundred and sixteen outcome terms were found by investigating all the outcomes used in 33 Cochrane reviews assessing community‐based psychosocial interventions for adults with severe mental illness. Thirteen outcome terms were used in more than half of the reviews: quality of life, mental state, admission to hospital, economic outcome, leaving the study early, social functioning, satisfaction, global state, relapse, adverse events/effects, carer satisfaction, employment, and duration of admission.

Mental health service engagement with family and carers: what practices are fundamental?

BACKGROUND

Substantial and important benefits flow to all stakeholders, including the service user, when mental health services meaningfully engage with carers and family members. Government policies around the world clearly supports inclusiveness however health service engagement with family and carers remains sporadic, possibly because how best to engage is unclear. A synthesis of currently used surveys, relevant research and audit tools indicates seven core ways that families and carers might be engaged by health services. This study sought to confirm, from the perspective of family and carers, the importance of these seven health service engagement practices.

METHODS

In a mixed method online survey, 134 family members and carers were asked what they received and what they wanted from mental health services. Participants also quantified the importance of each of the seven core practices on a 0-100 point likert scale.

RESULTS

Almost 250 verbatim responses were deductively matched against the seven themes, with additional unaligned responses inductively categorised. The findings triangulate with multiple diverse literatures to confirm seven fundamental engagement practices that carers and family want from health services. Conceptually, the seven practices are represented by two broad overarching practice themes of (i) meeting the needs of the family member and (ii) addressing the needs of the service user.

CONCLUSION

Policy, clinical practice, training and future research might encompass the seven core practices along with consideration of the intertwined relationship of family, carers and the service user suggested by the two broader concepts.

Implementation case study: Multifamily group intervention in first-episode psychosis programs

AIM

Family interventions are a core component of first-episode psychosis (FEP) treatment; however, low implementation rates are consistently reported. As such, work is needed to understand the factors impacting real-world treatment delivery. The present paper describes the implementation of the McFarlane-model multifamily psychoeducational groups (MFG) in established FEP early intervention programs within a single state. The aims were to examine (a) training participation and implementation of MFG, (b) barriers and facilitators to implementation, and (c) modifications made to MFG.

METHODS

Practitioners from six established FEP early intervention programs received in-person training and ongoing consultation in MFG. Training participation data were obtained via attendance and implementation outcomes were obtained from practitioner reports. Fifteen months following the initial training, practitioners reported on clinic-specific barriers, facilitators, and modifications across four categories (context, intervention, practitioner, and recipient).

RESULTS

Twenty-three practitioners across six clinics received in-person training and were offered ongoing consultation to support implementation. Difficulties in starting MFG were salient as the earliest group was run 7 months after the initial training, thereby resulting in low overall frequency of groups. A number of barriers spanning context, intervention, practitioner, and recipient domains were noted, the majority of which were clinic-specific. Despite challenges, practitioners identified several facilitators and made modifications to the intervention and its delivery in service of implementation.

CONCLUSIONS

Results from this implementation case study highlighted the challenges of delivering MFG in real-world FEP early intervention programs. Further, this paper emphasizes the value in identifying and addressing clinic-specific factors when implementing MFG.

The role of the behavior analyst on interprofessional mental health teams: opportunities for collaboration and enhancing patient care

Patients living with mental illness have needs that span a range of professional disciplines, settings, and service systems. These needs are best addressed through interprofessional collaboration. Behavior analysts can play a valuable role in enhancing patient care as part of the interprofessional mental health team. We provide information about the field of applied behavior analysis and its contribution to the assessment and treatment of patients living with mental health and substance use challenges. We outline how behavior analysts are trained and touch upon the practice of behavior analysis in North America and beyond. We describe collaborative relationships with other mental health professionals and, as an example, review the role of the behavior analyst on interprofessional teams in our mental health and addiction teaching hospital in Canada. We highlight some of the challenges faced by behavior analysts working in the mental health field and offer suggestions to increase their profile and opportunities for collaboration in clinical programs.

Attachment as a framework to facilitate empowerment for people with severe mental illness

OBJECTIVES

Recovery and empowerment have evolved into key objectives in the treatment and care of people with severe mental illness (SMI), and interest has grown in the role of social relationships in recovery. This study is the first to explore whether attachment styles are related to levels of empowerment, and secondly, whether attachment anxiety and attachment avoidance are associated with lower empowerment levels, independently of quality and frequency of social contact.

DESIGN

We used a cross-sectional design.

METHODS

In a sample of 157 participants with SMI in outpatient care, associations between attachment (Revised Adult Attachment Scale), self-reported social functioning, and empowerment (Netherlands Empowerment List) were assessed.

RESULTS

Attachment anxiety and attachment avoidance were both associated with lower levels of empowerment. A stepwise multiple regression analysis showed that the prediction of empowerment was significantly improved by adding attachment anxiety and attachment avoidance to quality and frequency of social contact. Attachment anxiety, attachment avoidance, and quality of social contact were significant predictors; frequency of social contact was not.

CONCLUSIONS

Although our design does not allow causal conclusions, our results highlight the importance of interpersonal processes and behaviours as routes to improving empowerment for people with SMI. A promising approach might thus consist of securing attachment bonds with significant others so that the self and the other are perceived as reliable resources. Our findings also feature the importance of reciprocity and equality in social relationships. Taken together, our study emphasizes the value of social, contextualized interventions in recovery work for people with SMI.

PRACTITIONER POINTS

Working towards attachment safety in interpersonal relations may be important in recovery-oriented treatment and care for people with severe mental illness (SMI). Helping people with SMI to recognize and change how they tend to relate themselves to others may promote engagement and effectiveness of recovery-oriented treatment and care. Reciprocity and equality in social relationships as vital complements to the more one-sided nature of 'standing alongside' and offering support may be important requisites for empowerment.

Family involvement practices for persons with psychotic disorders in community mental health centres - a cross-sectional fidelity-based study

BACKGROUND

Family involvement for persons with psychotic disorders is supported by scientific evidence, as well as legal and ethical considerations, and recommended in clinical practice guidelines. This article reports a cross-sectional measurement of the level of implementation of such guidelines in fifteen community mental health centre units in Norway, and presents a novel fidelity scale to measure basic family involvement and support. The aim was to investigate current family involvement practices comprehensively, as a basis for targeted quality improvement.

METHODS

We employed three fidelity scales, with 12-14 items, to measure family involvement practices. Items were scored from 1 to 5, where 1 equals no implementation and 5 equals full implementation. Data was analysed using descriptive statistics, a non-parametric test, and calculation of interrater reliability for the scales.

RESULTS

The mean score was 2.33 on the fidelity scale measuring basic family involvement and support. Among patients with psychotic disorders, only 4% had received family psychoeducation. On the family psychoeducation fidelity assessment scale, measuring practice and content, the mean score was 2.78. Among the eight units who offered family psychoeducation, it was 4.34. On the general organizational index scale, measuring the organisation and implementation of family psychoeducation, the mean score was 1.78. Among the units who offered family psychoeducation, it was 2.46. As a measure of interrater reliability, the intra-class correlation coefficient was 0.99 for the basic family involvement and support scale, 0.93 for the family psychoeducation fidelity assessment scale and 0.96 for the general organizational index scale.

CONCLUSIONS

The implementation level of the national guidelines on family involvement for persons with psychotic disorders was generally poor. The quality of family psychoeducation was high, but few patients had received this evidence-based treatment. Our novel fidelity scale shows promising psychometric properties and may prove a useful tool to improve the quality of health services. There is a need to increase the implementation of family involvement practices in Norway, to reach a larger percentage of patients and relatives.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03869177 . Registered 11.03.19.

The Relationships between Health Professionals' Perceived Quality of Care, Family Involvement and Sense of Coherence in Community Mental Health Services

Mental health professionals have a responsibility to ensure the best possible quality of care. Family is strongly involved in the patient's everyday life. The aim of this study was to investigate the relationship between health care professionals' perception of the quality of care, attitudes of family involvement and their own sense of coherence. A descriptive quantitative study with fifty-six health professionals, completed "Quality in Psychiatric Care-Community Outpatient Psychiatric Staff", "Families' Importance in Nursing Care-health professionals' attitudes", "The Sense of Coherence Scale-13". The health professionals perceived quality as high and did not perceive the families as a burden.

Training early psychosis community clinicians in CBT for psychosis: Implementation and feasibility

OBJECTIVE

Cognitive behavioural therapy (CBT) has demonstrated efficacy for treating of psychotic symptoms and is recommended as an evidence-based practice (EBP) in early psychosis services. Despite this recommendation, there is limited information about the feasibility of training community clinicians, working in an early psychosis service, to competence in the delivery of this intervention.

METHOD

Fifty clinicians working in an early psychosis service across five programs in Northern California were trained in CBT for psychosis (CBTp) between 2010 and 2014. Following the training, clinicians attended weekly group consultation and submitted taped sessions for review. Tapes were rated for competency using the Cognitive Therapy Scale-Revised (CTS-R). Clinicians who achieved competence were engaged in a train-the-trainer model to support ongoing sustainability of the training program.

RESULTS

Data from 40 clinicians were reviewed for achievement of competence. Over the training period 18 clinicians achieved competence while 20 clinicians left the service before achieving competence and 12 were still in the process of achieving competence at the point of data analysis. It took on average 54 weeks (range 17-130 weeks) and an average of six tape reviews (range 3-18) to train clinicians to competency.

CONCLUSIONS

Community clinicians working in an early psychosis program can be trained to competence in CBTp following an initial didactic period and ongoing weekly group consultation, although staff turnover hindered implementation. Challenges and opportunities for future implementation in community sites are presented in the context of further expansion of early psychosis services in the United States.

Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults

Pediatricians are often the first physicians to encounter adolescents and young adults presenting with psychotic symptoms. Although pediatricians would ideally be able to refer these patients immediately into psychiatric care, the shortage of child and adolescent psychiatry services may sometimes require pediatricians to make an initial assessment or continue care after recommendations are made by a specialist. Knowing how to identify and further evaluate these symptoms in pediatric patients and how to collaborate with and refer to specialty care is critical in helping to minimize the duration of untreated psychosis and to optimize outcomes. Because not all patients presenting with psychotic-like symptoms will convert to a psychotic disorder, pediatricians should avoid prematurely assigning a diagnosis when possible. Other contributing factors, such as co-occurring substance abuse or trauma, should also be considered. This clinical report describes psychotic and psychotic-like symptoms in the pediatric age group as well as etiology, risk factors, and recommendations for pediatricians, who may be among the first health care providers to identify youth at risk.

A Meta-analysis of Cognitive Remediation for Schizophrenia: Efficacy and the Role of Participant and Treatment Factors

The number of randomized, controlled studies of cognitive remediation (CR) for schizophrenia, a therapeutic approach designed to improve cognitive skills and function, has grown substantially over the past 20 years. Active elements of CR treatment, however, remain unknown. The current meta-analysis investigated treatment, study, and participant factors in the size of observed treatment effects. Electronic databases were searched up to May 2020 using variants of the key words "cognitive remediation," "clinical trials," and "schizophrenia." This search produced 73 unique, randomized, controlled trials. Data were independently extracted by 3 reviewers with excellent reliability. Random-effects models were used to assess primary cognitive and secondary symptom and functional outcomes. Moderator analyses investigated the role of a variety of treatment, study, and participant factors. The meta-analysis (4594 participants) revealed that CR produced significant small-to-moderate size improvements in all domains of cognition studied (Hedge's gs = .19-.33). and a significant small improvement in function (Hedge's g = .21). CR programs that included a discussion ("bridging") group to help apply acquired cognitive skills to everyday life produced larger effects on global cognition and verbal memory. CR programs with strategy-coaching produced larger effects on episodic memory. Sample age, gender, positive, negative, and overall symptoms, and medication dose did not serve as barriers to treatment gains. CR produces small-to-moderate improvements in cognition and function in schizophrenia. Programs of CR that utilize bridging groups and strategy-coaching are more cognitively potent. Future research should focus on ways to modify CR to bolster generalization of cognitive improvements to function.

Key Variables for Effective eHealth Designs for Individuals With and Without Mental Health Disorders: 2^12-4 Fractional Factorial Experiment

BACKGROUND

eHealth applications not only offer the potential to increase service convenience and responsiveness but also expand the ability to tailor services to improve relevance, engagement, and use. To achieve these goals, it is critical that the designs are intuitive. Limited research exists on designs that work for those with a severe mental illness (SMI), many of whom have difficulty traveling for treatments, reject or infrequently seek treatment, and tend to discontinue treatments for significant periods.

OBJECTIVE

This study aims to evaluate the influence of 12 design variables (eg, navigational depth, reading level, and use of navigational lists) on the usability of eHealth application websites for those with and without SMI.

METHODS

A 2^12-4 fractional factorial experiment was used to specify the designs of 256 eHealth websites. This approach systematically varied the 12 design variables. The final destination contents of all websites were identical, and only the designs of the navigational pages varied. The 12 design elements were manipulated systematically to allow the assessment of combinations of design elements rather than only one element at a time. Of the 256 websites, participants (n=222) sought the same information on 8 randomly selected websites. Mixed effect regressions, which accounted for the dependency of the 8 observations within participants, were used to test for main effects and interactions on the ability and time to find information. Classification and regression tree analyses were used to identify effects among the 12 variables on participants' abilities to locate information, for the sample overall and each of the 3 diagnostic groups of participants (schizophrenia spectrum disorder [SSD], other mental illnesses, and no mental illness).

RESULTS

The best and worst designs were identified for each of these 4 groups. The depth of a website's navigation, that is, the number of screens users needed to navigate to find the desired content, had the greatest influence on usability (ability to find information) and efficiency (time to find information). The worst performing designs for those with SSD had a 9% success rate, and the best had a 51% success rate: the navigational designs made a 42% difference in usability. For the group with other mental illnesses, the design made a 50% difference, and for those with no mental illness, a 55% difference was observed. The designs with the highest usability had several key design similarities, as did those with the poorest usability.

CONCLUSIONS

It is possible to identify evidence-based strategies for designing eHealth applications that result in significantly better performance. These improvements in design benefit all users. For those with SSD or other SMIs, there are designs that are highly effective. Both the best and worst designs have key similarities but vary in some characteristics.

[The effectiveness of psychiatric rehabilitation of in-patients with schizophrenia]

OBJECTIVE

To determine clinical and social indicators in in-patients with schizophrenia depending on their participation in psychiatric rehabilitation.

MATERIAL AND METHODS

One hundred in-patients were randomly assigned to receive either rehabilitation along with the standard pharmacological treatment or standard pharmacological treatment alone. Thirty-five patients from the main group and 39 patients from control group completed three-month participation in the study. The Life Skills Profile (LSP-16), HoNOS and PANSS were used at baseline and post-intervention assessment.

RESULTS

There was a statistically significant decrease in scores of almost all LCP-16 subscales and PANSS in the rehabilitation group compared with the control group. No between-group differences in HoNOS scores were observed.

CONCLUSIONS

The findings support implementation of psychiatric rehabilitation programs for in-patients with schizophrenia.

Computerized Conjoint Analysis of the Weight Treatment Preferences of Individuals With Schizophrenia

OBJECTIVE

Innovative approaches are needed for assessing treatment preferences of individuals with schizophrenia. Conjoint analysis methods may help to identify preferences, but the usability and validity of these methods for individuals with schizophrenia remain unclear. This study examined computerized conjoint analysis for persons with schizophrenia and whether preferences for weight management programs predict service use.

METHODS

A computerized, patient-facing conjoint analysis system was developed through iterative consultation with 35 individuals with schizophrenia enrolled at a community mental health clinic. An additional 35 overweight participants with schizophrenia then used the system to choose among psychosocial weight management programs varying in four attributes: location (community or clinic), delivery mode (Internet or in person), leader (clinician or layperson), and training mode (individual or group). A multilevel logit model with partial preference data determined contributions of each attribute to groupwide preferences. Associations were studied between preferences and use of a psychosocial weight management group.

RESULTS

Conjoint analysis system usability was rated highly. Groupwide preferences were significantly influenced by location (p<0.001; clinic was preferred), leader (p=0.02; clinician was preferred), and training mode (p<0.001; group was preferred) but not delivery mode (p=0.68). Preferences did not correlate with age, gender, body mass index, illness severity, or subsequent program use. Participants described barriers to program attendance, including transportation, scheduling, privacy, psychiatric illness, and lack of motivation.

CONCLUSIONS

Computerized conjoint analysis can produce valid assessments of treatment preferences of persons with schizophrenia and inform treatment development and implementation. Although preferences may affect treatment use, they are one of multiple factors.

Impact of Negative Symptom Domains and Other Clinical Characteristics on Functional Outcomes in Patients with Schizophrenia

Negative symptoms of schizophrenia have generally been defined using five factors; however, few studies have examined the relationship between these five factors and functional outcomes. In addition, there is no definitive conclusion regarding the association between negative symptoms and various aspects of functional outcomes (daily living, social, and vocational). This study is aimed at examining the relationship between these five domains of negative symptoms and different functional outcomes. Patients diagnosed with chronic schizophrenia (n = 100) were selected for the evaluation. We used the Brief Negative Symptom Scale to assess negative symptoms, the Brief Psychiatric Rating Scale to assess positive symptoms, the Schizophrenia Cognition Rating Scale to assess cognition, and the Evaluative Beliefs Scale (negative self-assessment) to assess psychological factors. We analyzed their relative impact on Social Functioning Scale domains using hierarchical multiple regression analysis. Concerning the relationship between daily living and negative symptoms, cognitive function showed the highest association with residential outcomes, such as self-care and shopping, while avolition appeared to show an additional contribution; however, for recreational outcomes, avolition showed the main association, whereas cognitive function showed no additional contribution. For social outcomes, asociality and negative self-assessment showed the main associations, while vocational outcomes were determined by both cognitive function and multiple negative symptoms, such as avolition, anhedonia, asociality, and alogia. Since negative symptom domains appear to differentially impact each outcome, specifically daily living outcome, it is important to evaluate the residential outcomes and recreational outcomes separately. Overall, the present study points to the importance of formulating psychosocial treatment strategies specific for each type of preferred outcome in patients with schizophrenia.

Narrative enhancement and cognitive therapy (NECT) to improve social functioning in people with serious mental illness: study protocol for a stepped-wedge cluster randomized controlled trial

Background

Self-stigma is highly prevalent in serious mental illness (SMI) and is associated with poorer clinical and functional outcomes. Narrative enhancement and cognitive therapy (NECT) is a group-based intervention combining psychoeducation, cognitive restructuring and story-telling exercises to reduce self-stigma and its impact on recovery-related outcomes. Despite evidence of its effectiveness on self-stigma in schizophrenia-related disorders, it is unclear whether NECT can impact social functioning.

Methods

This is a 12-centre stepped-wedge cluster randomized controlled trial of NECT effectiveness on social functioning in SMI, compared to treatment as usual. One hundred and twenty participants diagnosed with schizophrenia, bipolar disorder or borderline personality disorder will be recruited across the 12 sites. The 12 centres participating to the study will be randomized into two groups: one group (group 1) receiving the intervention at the beginning of the study (T0) and one group (group 2) being a control group for the first 6 months and receiving the intervention after (T1). Outcomes will be compared in both groups at T0 and T1, and 6-month and 12-month outcomes for groups 1 and 2 will be measured without a control group at T2 (to evaluate the stability of the effects over time). Evaluations will be conducted by assessors blind to treatment allocation. The primary outcome is personal and social performance compared across randomization groups. Secondary outcomes include self-stigma, self-esteem, wellbeing, quality of life, illness severity, depressive symptoms and personal recovery.

Discussion

NECT is a promising intervention for reducing self-stigma and improving recovery-related outcomes in SMI. If shown to be effective in this trial, it is likely that NECT will be implemented in psychiatric rehabilitation services with subsequent implications for routine clinical practice.

Trial registration

ClinicalTrials.gov NCT03972735. Trial registration date 31 May 2019.

The clinical characterization of the patient with primary psychosis aimed at personalization of management

The current management of patients with primary psychosis worldwide is often remarkably stereotyped. In almost all cases an antipsychotic medica-tion is prescribed, with second-generation antipsychotics usually preferred to first-generation ones. Cognitive behavioral therapy is rarely used in the vast majority of countries, although there is evidence to support its efficacy. Psychosocial interventions are often provided, especially in chronic cases, but those applied are frequently not validated by research. Evidence-based family interventions and supported employment programs are seldom implemented in ordinary practice. Although the notion that patients with primary psychosis are at increased risk for cardiovascular diseases and diabetes mellitus is widely shared, it is not frequent that appropriate measures be implemented to address this problem. The view that the management of the patient with primary psychosis should be personalized is endorsed by the vast majority of clinicians, but this personalization is lacking or inadequate in most clinical contexts. Although many mental health services would declare themselves "recovery-oriented", it is not common that a focus on empowerment, identity, meaning and resilience is ensured in ordinary practice. The present paper aims to address this situation. It describes systematically the salient domains that should be considered in the characterization of the individual patient with primary psychosis aimed at personalization of management. These include positive and negative symptom dimensions, other psychopathological components, onset and course, neurocognition and social cognition, neurodevelopmental indicators; social functioning, quality of life and unmet needs; clinical staging, antecedent and concomitant psychiatric conditions, physical comorbidities, family history, history of obstetric complications, early and recent environmental exposures, protective factors and resilience, and internalized stigma. For each domain, simple assessment instruments are identified that could be considered for use in clinical practice and included in standardized decision tools. A management of primary psychosis is encouraged which takes into account all the available treatment modalities whose efficacy is supported by research evidence, selects and modulates them in the individual patient on the basis of the clinical characterization, addresses the patient's needs in terms of employment, housing, self-care, social relationships and education, and offers a focus on identity, meaning and resilience.

Customizing Early Intervention Treatment for Psychosis in the UTHealth - Harris County Psychiatric Center

High-need, high-cost patients include those with diagnosed serious mental illnesses (e.g., schizophrenia; SMI). They often delay or fail to seek treatment. If they receive treatment, care is often sought from generalist settings (e.g., primary care or emergency medicine) or is suboptimal due to the provision of limited, non-evidence-based intervention and lack of communication, integration, and coordination among providers. This results in high aggregate costs and poor outcomes. Value-based health care requires care coordination to address the medical and social needs of this population. We describe a unique early intervention program for SMI that emanates from an inpatient setting: The Early Onset Treatment Program (EOTP) at the University of Texas Health Science Center at Houston-Harris County Psychiatric Center. The EOTP offers free, phase-specific, multidisciplinary treatment to young adults without health insurance with the aim of improving their long-term outcomes and reducing the rate of rehospitalization. An evaluation of the EOTP indicates program participants were significantly less likely to be rehospitalized at six months (4.73 times less likely) and at 12 months (3.5 times less likely) than a comparison group (p <.001), and participants' scores of symptomatology and disability significantly decreased following treatment.

Combined Oxytocin and Cognitive Behavioral Social Skills Training for Social Function in People With Schizophrenia

BACKGROUND

A significant proportion of people with schizophrenia are characterized by impaired ability to socially engage with others. The development of effective interventions for social functioning remains a central therapeutic challenge. Cognitive-behavioral social skills training (CBSST) has been found to improve social functioning in schizophrenia, but with only medium effect sizes. Intranasal oxytocin also has prosocial effects, but also only with modest effect sizes. This study assessed whether the addition of intranasal oxytocin to CBSST can strengthen their impact on social function.

METHODS

Participants (N = 62) with schizophrenia or schizoaffective disorder entered a 24-week, double-blind, placebo-controlled, randomized clinical trial with a 3-month follow-up evaluation at 2 sites: Maryland and San Diego. Participants were randomized to either intranasal oxytocin 36 IU (3 sprays) twice a day (n = 31) or intranasal placebo-oxytocin (3 sprays) twice a day (n = 31). All participants received CBSST plus a social cognition skills training module (48 total sessions).

RESULTS

There were no significant treatment group differences in social functioning, positive symptoms, negative symptoms, defeatist beliefs, or asocial beliefs. The interpretation of treatment effects was complicated by site effects, whereby participants in San Diego began the trial with greater severity of impairments and subsequently showed greater improvements compared with participants in Maryland.

CONCLUSIONS

The results did not support the utility of add-on intranasal oxytocin to psychosocial rehabilitation interventions like CBSST for improvement in social function (ClinicalTrials.gov trial number: NCT01752712).

Implementation of Psychodynamic Multifamily Groups for Severe Mental Illness: A Recovery-Oriented Approach

Background: Among Family-Based Services for the treatment of severe mental illnesses, multi-family models gained particular attention, given the potential usefulness of mutual feed-back, motivation and encouragement among families. Methods: The Psychodynamic Multi-Family Group Model has been proposed since 1997 in some Community Mental Health Services in Rome. Since 2011 multifamily groups are held weekly in all the six Districts of the Department of Mental Health that serves a population of more than one million people, and data have been collected since 2015 in three Districts. A total of 794 individuals attended the meetings in the period 2015-2019. Results: Eighty-six percent of those who started, attended more than one meeting. The mean of occurrences of participation among patients was 18.6, among mothers 25.6 and among fathers 21.6. The 794 participants belonged to 439 family units, among which 180 comprised only the patient, 76 only parent(s) or other close person(s), and 183 comprised parent(s) or close person(s) with the patient. Patients participating alone were older than those of families who participated as a whole. Families including the patient showed the longest duration of attendance and the highest prevalence of a diagnosis of schizophrenia in the index patient. Families who had been attending the multifamily groups since a long time maintained a high rate of attendance. Conclusions: Multifamily groups represent a setting where patients can meet with other people and professionals in a free still structured way, and with not strictly therapeutic objectives. The high number of patients who attended alone suggests that such participation corresponds to a self-perceived need of open and free setting facilitating sharing of problems and solutions. The good tenure of the interventions, the high participation, and the feasibility in the long-term suggest that multifamily groups can be implemented in the mental health services of a large city, are sustainable over many years, and can represent a valuable resource for many patients and families.

Mobile-Assisted Cognitive Behavioral Therapy for Negative Symptoms: Open Single-Arm Trial With Schizophrenia Patients

BACKGROUND

Negative symptoms are an important unmet treatment need for schizophrenia. This study is a preliminary, open, single-arm trial of a novel hybrid intervention called mobile-assisted cognitive behavioral therapy for negative symptoms (mCBTn).

OBJECTIVE

The primary aim was to test whether mCBTn was feasible and could reduce severity of the target mechanism, defeatist performance attitudes, which are associated with experiential negative symptoms and poor functioning in schizophrenia.

METHODS

Participants with schizophrenia or schizoaffective disorder (N=31) who met prospective criteria for persistent negative symptoms were enrolled. The blended intervention combines weekly in-person group therapy with a smartphone app called CBT2go. The app extended therapy group skills, including recovery goal setting, thought challenging, scheduling of pleasurable activities and social interactions, and pleasure-savoring interventions to modify defeatist attitudes and improve experiential negative symptoms.

RESULTS

Retention was excellent (87% at 18 weeks), and severity of defeatist attitudes and experiential negative symptoms declined significantly in the mCBTn intervention with large effect sizes.

CONCLUSIONS

The findings suggest that mCBTn is a feasible and potentially effective treatment for experiential negative symptoms, if confirmed in a larger randomized controlled trial. The findings also provide support for the defeatist attitude model of experiential negative symptoms and suggest that blended technology-supported interventions such as mCBTn can strengthen and shorten intensive psychosocial interventions for schizophrenia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03179696; https://clinicaltrials.gov/ct2/show/NCT03179696.

Psychosocial interventions in schizophrenia: Focus on guidelines

BACKGROUND

Schizophrenia is a lifelong condition with acute exacerbations and varying degrees of functional disability. Acute and long-term treatments are based on antipsychotic drugs, even if some domains of personal and social functioning are not addressed by psychopharmacotherapy. In fact, psychosocial interventions show a positive impact on patient's functioning and clinical outcome. In addition, psychosocial interventions are significantly associated with a lower number of relapses and hospitalizations in schizophrenia.

METHODS

An analytical review of the International Guidelines on Psychosocial Interventions in Schizophrenia has been performed; we included the National Institute for Health and Care Excellence (NICE) guidelines, the Scottish Intercollegiate Guidelines Network (SIGN) guidelines, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) guidelines, the Schizophrenia Patient Outcomes Research Team (PORT) guidelines and the American Psychiatric Association (APA) guidelines.

RESULTS

The international guidelines recommend psychosocial interventions as supportive treatments alongside pharmaceutical or psychotherapeutic ones.

CONCLUSION

More research studies need to be conducted and included in the updated version of the international guidelines to confirm the effectiveness of psychosocial interventions in the long-term outcome of schizophrenia.

Biopsychosocial factors associated with disordered eating behaviors in schizophrenia

BACKGROUND

Recent hypotheses have suggested that schizophrenic patients are more likely to consume unhealthy foods, causing increased rates of mortality and morbidity associated with metabolic syndrome. This raises the need for more in-depth research on disordered eating behaviors (DEBs) in schizophrenic patients. This study, therefore, aimed to investigate biopsychosocial factors associated with DEBs in schizophrenia.

METHODS

In this cross-sectional study, a total of 308 participants (including 83 subjects in the active phase of schizophrenia, 71 subjects in the remission phase of schizophrenia, and 154 control subjects) were recruited through convenience sampling among patients who referred to the Baharan Psychiatric hospital in Zahedan, Iran. Patients were assessed through Eating Attitudes Test (EAT-26), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI-II), and Positive and Negative Syndrome Scale (PANSS). Data were analyzed using SPSS v25 software. Further, the statistical significance level was set at p < 0.05.

RESULTS

The prevalence of DEBs was 41.5% in schizophrenic patients (vs. 10.3% in the control group, p = 0.012). No significant difference was observed in the EAT-26 scores based on gender and phases of schizophrenia. According to multiple linear regression analysis, lack of psychosocial rehabilitation, use of atypical antipsychotics, early stages of psychosis, high level of anxiety and depression, expression of more active psychotic symptoms, tobacco smoking, and suffering from type 2 diabetes were all associated with increased development of DEBs among schizophrenic patients.

CONCLUSIONS

Since the occurrence of DEBs is independent of different phases of schizophrenia, the risk of DEBs is required to be evaluated during the entire course of schizophrenia especially at earlier stages of schizophrenia. Moreover, the use of psychosocial interventions, treatment of affective disorders (i.e., anxiety and depression), antipsychotic medication switching, treatment of tobacco smoking and type 2 diabetes may reduce the risk of DEBs among schizophrenic patients. However, further investigations are required to prove the actual roles of the above factors in developing DEBs among schizophrenic patients.

Factors impacting the implementation of a psychoeducation intervention within the mental health system: a multisite study using the consolidation framework for implementation research

BACKGROUND

Despite a strong evidence base and policy recommendation supporting the implementation of psychoeducation interventions within the mental health system, equitable access for many service users and family members has not been achieved. To enhance translation, developing an evidence-base around the factors that influence implementation of interventions is critical.

METHODS

The aim of the study was to explore the factors influencing implementation of a group cofacilitated recovery focused psychoeducation intervention. The study design was explorative qualitative descriptive, involving the collection of data through individual and focus group interviews with key stakeholders (n = 75) involved with the implementation within 14 mental health sites in the Republic of Ireland. The Consolidation Framework for Implementation Research (CFIR) was used as a conceptual framework to guide data collection and analysis.

RESULTS

Key enablers and barriers were identified across all CFIR domains of the framework with some factors (depending on context) being both an enabler and a barrier. Important factors in the outer setting domain included structural stability within national systems and the peer payment system, while the extent of a recovery-oriented culture, leadership, implementation readiness, and buy-in were influential factors in the inner setting. The characteristics of the intervention in terms of design, evidence-base and adaptability also shaped the intervention's implementation as did the knowledge, beliefs and self-efficacy of facilitators. In terms of processes, implementation was influenced by the degree of engagement of key individuals who championed and supported the programme. The results highlight that while some of the barriers were specific to the programme, many reflected systemic and structural challenges within health services more generally.

CONCLUSION

Findings from this study provide an enhanced understanding of the different layers of determinants to implementation of an intervention. Overcoming challenges will involve positive and ongoing engagement and collaboration across the full range of stakeholders that are active within each domain, including policy and operational levels. The quality of leadership at each domain level is of crucial importance to successful implementation.

How often do US-based schizophrenia papers published in high-impact psychiatric journals report on race and ethnicity?: A 20-year update of Lewine and Caudle (1999)

BACKGROUND

Racial and ethnic disparities have been clearly documented in schizophrenia studies, but it is unclear how much research attention they receive among US-based studies published in high-impact journals.

AIMS

The current paper updates Lewine and Caudle's (1999) and Chakraborty and Steinhauer's (2010) works, which quantified how frequently schizophrenia studies included information on race and ethnicity in their analyses.

METHOD

We examined all US-based papers on schizophrenia-spectrum, first-episode psychosis, and clinical high-risk groups, published between 2014 to 2016 in four major psychiatric journals: American Journal of Psychiatry, Journal of the American Medical Association - Psychiatry, Schizophrenia Bulletin, and Schizophrenia Research.

RESULTS

Of 474 US-based studies, 62% (n = 295) reported analyses by race or ethnicity as compared to 20% in Lewine and Caudle's (1999) study. The majority of papers (59%) reported sample descriptions, a 42% increase from Lewine and Caudle's (1999) study. Additionally, 47% matched or compared the racial/ethnic composition of primary study groups and 12% adjusted for race (e.g., as a covariate). However, only 9% directly analyzed racial and/or ethnic identity in relation to the primary topic of the paper.

CONCLUSIONS

While schizophrenia studies report analyses by race and ethnicity more frequently than 20 years ago, there remains a strong need for systematic, nuanced research on this topic. The authors offer recommendations for how to conceptualize and report upon race and ethnicity in schizophrenia research.

Implementation of guidelines on family involvement for persons with psychotic disorders in community mental health centres (IFIP): protocol for a cluster randomised controlled trial

BACKGROUND

Family involvement for persons with psychotic disorders is under-implemented in mental health care, despite its firm scientific, economic, legal and moral basis. This appears to be the case in Norway, despite the presence of national guidelines providing both general recommendations on family involvement and support in the health- and care services, and specific guidance on family interventions for patients with psychotic disorders. The aim of this project is to improve mental health services and the psychosocial health of persons with psychotic disorders and their relatives, by implementing selected recommendations from the national guidelines in community mental health centres, and to evaluate this process.

METHODS

The trial is cluster randomised, where 14 outpatient clusters from community mental health centres undergo stratified randomisation with an allocation ratio of 1:1. The seven intervention clusters will receive implementation support for 18 months, whereas the control clusters will receive the same support after this implementation period. The intervention consists of: 1. A basic level of family involvement and support. 2. Family psychoeducation in single-family groups. 3. Training and guidance of health care personnel. 4. A family coordinator and 5. Other implementation measures. Fidelity to the intervention will be measured four times in the intervention arm and two times in the control arm, and the differences in fidelity changes between the arms constitute the primary outcomes. In each arm, we aim to include 161 patients with psychotic disorders and their closest relative to fill in questionnaires at inclusion, 6 months and 12 months, measuring psychosocial health and satisfaction with services. Clinicians will contribute clinical data about patients at inclusion and 12 months. Use of health and welfare services and work participation, for both patients and relatives, will be retrieved from national registries. We will also perform qualitative interviews with patients, relatives, health care personnel and leaders. Finally, we will conduct a cost-effectiveness analysis and a political economy analysis.

DISCUSSION

This project, with its multilevel and mixed methods approach, may contribute valuable knowledge to the fields of family involvement, mental health service research and implementation science.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03869177 . Registered 11.03.19.

Nonmedical Interventions for Schizophrenia: A Review of Diet, Exercise, and Social Roles

Schizophrenia is a major mental illness with a disease course that is influenced by lifestyle. The risk-benefit ratio for alternative interventions is more favorable than for antipsychotics in long-term treatment. Dietary interventions may target autoimmune features, vitamin or mineral deficiencies, abnormal lipid metabolism, gluten sensitivity, or others. Examples of interventions involving diet, physical activity, or physical processes or social interventions including talk therapy exist in the literature. Notwithstanding, the general utility of these types of interventions remains inconclusive, awaiting long-term randomized trials. A perspective that separates the cause of the disease from its symptoms may be helpful in treatment planning and is warranted to distinguish between short-term and long-term recovery goals.

The Cal-DSH diversion guidelines

The Cal-DSH Diversion Guidelines provide 10 general guidelines that jurisdictions should consider when developing diversion programs for individuals with a serious mental illness (SMI) who become involved in the criminal justice system. Screening for SMI in a jail setting is reviewed. In addition, important treatment interventions for SMI and substance use disorders are highlighted with the need to address criminogenic risk factors highlighted.

New Tools for Implementing Evidence-Based Care for Serious Mental Illness

More than 11 million adults in the United States have a serious mental illness. Outcomes for these illnesses are good when appropriate treatments are received; however, rates of delivery and utilization of evidence-based care for this population are moderate to low. This article introduces SMI Adviser, a national initiative, supported by the Substance Abuse and Mental Health Services Administration, to advance the use of evidence-based practices and delivery of patient-centered care for the population with serious mental illness. SMI Adviser offers free technical assistance to clinicians caring for this population through accredited educational opportunities, vetted resources, and on-demand consultations.

The Effect of Aerobic Exercise on Physical and Cognitive Outcomes in a Small Cohort of Outpatients with Schizophrenia

Background:

Schizophrenia (SCZ) is a severe, chronic illness characterized by psychotic symptoms and impairments in many cognitive domains. Dysregulation of brain derived neurotrophic factor (BDNF) is associated with the cognitive impairments seen in patients with SCZ. Given the growing literature supporting a positive effect of aerobic exercise on cognition in other populations, we hypothesized that a structured aerobic exercise program would improve cognitive and functional outcomes in subjects with SCZ, potentially mediated by increases in BDNF.

Methods:

The study was a small randomized parallel group clinical trial of subjects with SCZ comparing 12 weeks of aerobic exercise (AE) against control (CON) stretching and balance training. At Baseline, Week 12, and Week 20 we collected serum samples for analysis of brain derived neurotrophic factor (BDNF), and assessed functional, physical, and cognitive outcomes. Linear regression models were used to compare change scores between timepoints.

Results:

We randomized 21 subjects to AE and 17 to CON; however, only 9 AE and 6 CON completed their programs. Subjects in both groups were slower at the 400 m walk in Week 12 compared to Baseline, but the AE group had significantly less slowing than the CON group (B = –28.32, p = 0.011). Between Week 12 and Week 20, the AE group had a significantly greater change score on the Composite and Visual Learning Domain of the MATRICS Consensus Cognitive Battery (B = 5.11, p = 0.03; B = 13.96, p = 0.006).

Conclusion:

These results indicate that participation in a structured aerobic exercise paradigm may modestly blunt physical function decline and enhance cognitive function in individuals with SCZ.

Group acceptance and commitment therapy for patients and caregivers in psychosis services: Feasibility of training and a preliminary randomized controlled evaluation

OBJECTIVE

Psychological interventions reduce the impact of psychosis, but widescale implementation is problematic. We tested the feasibility of group acceptance and commitment therapy for Psychosis (G-ACTp), delivered by frontline staff, and co-facilitated by service-user experts-by-experience (SU-EbyE), for service-users and informal caregivers (ISRCTN: 68540929). We estimated recruitment/retention rates and outcome variability for future evaluation.

METHODS

Staff and SU-EbyE facilitators completed 1-day workshops, then delivered closely supervised G-ACTp, comprising four sessions (weeks 1-4) and two boosters (10 and 12 weeks). Participants recruited from adult community psychosis services were randomized to receive G-ACTp immediately or after 12 weeks, completing outcome assessments at 0, 4, and 12 weeks. Service-use/month was calculated for 1-year pre-randomization, weeks 0-12, and 5-year uncontrolled follow-up.

RESULTS

Of 41 facilitators trained (29 staff, 12 SU-EbyE), 29 (71%; 17 staff, 12 SU-EbyE) delivered 18 G-ACTp courses. Participant refusal rates were low (9% of service-users [10/112]; 5% of caregivers [4/79]); 60% of those invited to participate attended ≥1 G-ACTp session (64% of service-users [39/61]; 56% of caregivers [35/63]). Randomization of facilitators and participants proved problematic and participant follow-up was incomplete (78% [66/85]; 82% of service-users [36/44]; 73% of caregivers [30/41]). Effect sizes ranged from very small to large mostly favouring treatment. Service-use reductions require cautious interpretation, as very few participants incurred costs.

CONCLUSIONS

Implementation appears feasible for service-users; for caregivers, retention needs improving. Outcome variability indicated n = 100-300/arm followed up (α = 0.05, 90% power). Methodological limitations' mean replication is needed: identified sources of potential bias may be reduced in a cluster randomized design with sessional outcome completion.

PRACTITIONER POINTS

Group acceptance and commitment therapy can be successfully adapted for people with psychosis and their caregivers. Implementation (training and delivery) is possible in routine community mental health care settings. Clinical and economic outcomes are promising, but replication is needed. Recommendations are made for future studies.

Building capacity to provide innovative interventions for early psychosis in mental health professionals

Despite international guidelines, cognitive behavioural therapy for early psychosis (CBTep) is still under-used in daily clinical practice, mainly due to the lack of specific skills among mental health professionals. The aim of the study was to evaluate the feasibility and efficacy of a CBTep training course and to investigate the impact of trainees’ variables on the level of skills acquisition. An intensive and graded CBTep training programme consisting of 112 hours of plenary lectures, 30 hours of group supervision and 3 months of practical training was offered to mental health professionals of 65 Italian community Mental Health Centers (CMHCs). CBT expert psychologists were used as the comparison group. Participants underwent pre-planned exams to test the level of skills acquisition and were requested to complete a satisfaction survey. The vast majority of participants (93%) completed the training with medium–high evaluation scores and reported to be highly satisfied with the course. CMHCs staff members achieved high scores in the examinations and no major differences between them and CBT expert psychologists were found in most of the final exam scores. Our results support the feasibility and the efficacy of the training to build specific CBTep capacity in a large cohort of professionals working in Italian Generalist Mental Health Services.

Key learning aims

(1)

Impact of the group intervention "Accept Voices©" for the management of auditory hallucinations

AIM OF THE STUDY

The objective of this study was to evaluate the potential impact of a third wave CBT group intervention for the management of auditory hallucinations in patients with schizophrenia.

METHOD

38 patients with schizophrenia presenting with auditory hallucinations, followed in mental health services, participated in six sessions of a group based on acceptance and engagement therapy (ACT). The study followed a repeated single case experimental design (type A-B-A) based on the principle of a control phase followed by an intervention phase and a follow-up phase of similar duration. The various measurements were administered during the control phase, at pre-/post-group and six weeks after the last group session.

RESULTS

The results show a significant decrease in auditory hallucinations, as measured by the PSYRATS scale, during the treatment and follow-up phase, compared to the control phase. In addition, the participants saw significant reductions in depressive and anxious symptomatology (assessed with CDSS and SEAS), and increases in coping and acceptance in regards to voices (assessed using a study scale and VAAS). The level of Malevolence beliefs about voices (measured with BAVQ-R) also decreased significantly.

CONCLUSIONS

A brief group intervention based acceptance show promise in the reduction of the intensity of auditory hallucinations, depression and anxiety in patients with schizophrenia, while improving their acceptance.

Understanding differences in family engagement and provider outreach in New Journeys: A coordinated specialty care program for first episode psychosis

The present study examined clinician outreach efforts to families and family engagement; and predictors of engagement in a coordinated specialty care (CSC) for first episode psychosis. From 2015 to 2019, 211 clients experiencing their first episode of psychosis and their family members received services from New Journeys, a network of CSC programs in the United States. Analyses examined the association between race/ethnicity, insurance type, referral source, housing stability, and outreach efforts and family attendance. Overall, 70% of client family members attended at least one psychoeducation appointment and in the first month of treatment 40% of family members attended family psychoeducation. Outreach efforts including phone attempts (β=1.09; p = 0.02) and phone contact (β=1.10; p = 0.02) were significantly higher for Black families relative to White families; whereas Black families were scheduled less often for a family psychoeducation (β=-0.28; p = 0.02) compared to Whites families. Significant differences in family attendance based on insurance type were also found (p<0.01). Referral source and housing stability were not significant predictors of outreach or attendance. These findings suggest that alternative engagement efforts that extend beyond in-person contact may be needed to continuously engage families, specifically Black families and those with public and no insurance.

Psychosocial family interventions for relatives of people living with psychotic disorders in the Arab world: systematic review

BACKGROUND

Family interventions in schizophrenia are evidence based and have been adapted to different cultural settings to improve their effectiveness and acceptability. The Arab world has a unique set of socio-cultural norms and values that cannot be ignored when developing or implementing such interventions. There is a lack of research on the feasibility of delivering family interventions for schizophrenia in the Arab region. The aim of this review is to synthesise the available evidence about culturally-adapted psychosocial family interventions in the Arab world. The review identifies the content and characteristics of these interventions, determines the strategies used to adapt them to Arab culture successfully, assesses the feasibility and acceptability of the interventions, and evaluates the effectiveness of these interventions for service users and their families.

METHOD

Five electronic databases were searched including MEDLINE, CINAHL, Cochrane Library, PsycINFO and EMBASE for articles written in Arabic and English from inception to August 2019. Data were extracted and synthesised narratively.

RESULTS

Six studies were retrieved from the search: three randomised control studies, two non-randomised studies and one qualitative study. There is limited evidence about culturally-adapted family interventions in the Arab region. However, the cultural adaptation process was comprehensive, and the implementation was reported to be feasible and acceptable. The methodological quality of the included studies was generally poor, so there is a risk of underestimating the effect size of the interventions due to lack of rigour and the presence of bias.

CONCLUSION

The present review provides the foundation for future work regarding family interventions in the Arab world, and confirms the feasibility of implementing such interventions with some modifications. Furthermore, the data suggests that any family-oriented intervention for schizophrenia is likely to be better than standard care in improving the outcome for patients and their families.

Treating schizophrenia: the quality of evidence behind treatment recommendations and how it can improve

OBJECTIVE

To assess the methodological and reporting quality of systematic reviews that comprise the American Psychiatric Association (APA) Practice Guideline for the Treatment of Patients with Schizophrenia and to determine the extent to which results from Cochrane systematic reviews published after guideline development would alter or confirm current recommendations.

PARTICIPANTS

Systematic reviews that underpinned recommendations in the APA guidelines and Cochrane systematic reviews.

MAIN OUTCOME

Three independent reviewers scored all systematic reviews referenced in the guideline for quality and reporting using AMSTAR and PRISMA checklist, respectively. Items in both tools were individually graded and compared to identify consistently low-performing areas within the systematic reviews. Post hoc analysis of the Cochrane systematic reviews since the latest revision of APA's guidelines were performed to determine whether their findings were congruent with recent recommendations.

RESULTS

The mean score of the 57 reviews on the PRISMA checklist was 70%. The mean AMSTAR score was 6.8, correlating with a moderate quality score. Post hoc analysis revealed that 171 Cochrane reviews had been published since the APA guideline release. Only half of the reviews of pharmacological interventions confirmed current recommendations.

CONCLUSIONS AND RELEVANCE

The methodological quality of the systematic reviews included in the APA guideline was deficient in key areas. Our study brings to light the importance of using high-quality evidence in the development of clinical practice guidelines. An updated APA guideline (last updated in 2009) is necessary to provide the highest quality treatment recommendations for clinicians in the management of schizophrenia.

TRIAL REGISTRATION NUMBER

UMIN-CTR, UMIN000023099.

A systematic review and meta-analysis of cognitive behavioural informed psychological interventions for psychiatric inpatients with psychosis

Psychological interventions such as Cognitive Behavioural Therapy for psychosis (CBTp) are recommended by the National Institute of Health and Care Excellence (NICE) for delivery in the acute phase of people's mental health difficulties. However, the effectiveness of cognitive behavioural informed psychological therapies for psychiatric inpatients is unknown. The aim of this review is to examine the type, quality and efficacy of cognitive behavioural informed psychological interventions for psychiatric inpatients experiencing psychosis. A systematic review and meta-analysis was conducted of randomised controlled trials examining the efficacy of cognitive behavioural informed psychological interventions offered to acute psychiatric inpatients with psychosis on primary (positive symptoms) and secondary outcomes of interest. A total of 23 studies were identified reporting on 18 trials of interventions such as CBTp, Acceptance and Commitment Therapy (ACT) and Metacognitive Therapy (MCT). Cognitive behavioural informed psychological interventions were found not be effective in reducing positive symptoms (primary outcome) at post-therapy and at follow-up but when a one study removed analysis was conducted a positive effect was found at both time points. In regard to secondary outcomes, cognitive behavioural informed psychological interventions demonstrated a significant favourable effect on negative symptoms (post-therapy), total symptoms (post-therapy and follow-up), functioning (post-therapy and follow-up) and readmission (follow-up). These psychological interventions may have potential to be effective for those admitted to psychiatric inpatient care and in acute crisis. However, findings are equivocal with evidence that these interventions have effect on some symptom measures but not others. Further examination of inpatient adapted cognitive behavioural informed psychological interventions is required.

A qualitative study of medication adherence amongst people with schizophrenia

Non-adherence to antipsychotic medication is common among people with schizophrenia, and is associated with an increased risk of relapse. It is important to develop strategies to enhance medication adherence. Few qualitative studies have been undertaken to understand the consumer's perspective. The voice of people who are prescribed these medications is therefore missing from the research literature. Reasons for non-adherence were investigated by directly engaging with consumers and exploring their attitudes, beliefs and experiences concerning antipsychotic medications. Qualitative, semi- structured, one-to-one interviews were conducted with 25 community-dwelling people with schizophrenia from metropolitan Adelaide, Australia. Interviews were audio-recorded, transcribed and analysed, guided by a grounded theory approach. Codes identified in open coding were grouped into categories, reflective of the different aspects of consumers' attitudes and experiences with medication. Interviews continued until there was saturation of themes. Consumer-related factors, medication-related factors and service-related factors were reported to influence adherence behavior. These included poor insight, unpleasant medication side effects, inadequate efficacy and poor therapeutic alliance. Lessons gained during periods of non-adherence were the motivator for future adherence; such as worsening of symptoms if medication was not taken. Potential implications of future adherence described by Interviewees include greater involvement of peer workers, as they were considered to work more effectively with consumers to encourage adherence. Peer workers had more credibility than other service providers due to their lived experience. Multiple factors were identified that impact on antipsychotic medication adherence, providing opportunities for interventions and improvements in services that would enhance adherence.