Psychosocial treatments for schizophrenia

Using Cognitive Neuroscience to Improve Mental Health Treatment: A Comprehensive Review

Mental health interventions do not yet offer complete, client-defined functional recovery, and novel directions in treatment research are needed to improve the efficacy of available interventions. One promising direction is the integration of social work and cognitive neuroscience methods, which provides new opportunities for clinical intervention research that will guide development of more effective mental health treatments that holistically attend to the biological, social, and environmental contributors to disability and recovery. This article reviews emerging trends in cognitive neuroscience and provides examples of how these advances can be used by social workers and allied professions to improve mental health treatment. We discuss neuroplasticity, which is the dynamic and malleable nature of the brain. We also review the use of risk and resiliency biomarkers and novel treatment targets based on neuroimaging findings to prevent disability, personalize treatment, and make interventions more targeted and effective. The potential of treatment research to contribute to neuroscience discoveries regarding brain change is considered from the experimental-medicine approach adopted by the National Institute of Mental Health. Finally, we provide resources and recommendations to facilitate the integration of cognitive neuroscience into mental health research in social work.

A multicenter, randomized controlled trial of individualized occupational therapy for patients with schizophrenia in Japan

The individualized occupational therapy (IOT) program is a psychosocial program that we developed to facilitate proactive participation in treatment and improve cognitive functioning and other outcomes for inpatients with acute schizophrenia. The program consists of motivational interviewing, self-monitoring, individualized visits, handicraft activities, individualized psychoeducation, and discharge planning. This multicenter, open-labeled, blinded-endpoint, randomized controlled trial evaluated the impact of adding IOT to a group OT (GOT) program as usual for outcomes in recently hospitalized patients with schizophrenia in Japanese psychiatric hospitals setting compared with GOT alone. Patients with schizophrenia were randomly assigned to the GOT+IOT group or the GOT alone group. Among 136 randomized patients, 129 were included in the intent-to-treat population: 66 in the GOT+IOT and 63 in the GOT alone groups. Outcomes were administered at baseline and discharge or 3 months following hospitalization including the Brief Assessment of Cognition in Schizophrenia Japanese version (BACS-J), the Schizophrenia Cognition Rating Scale Japanese version, the Social Functioning Scale Japanese version, the Global Assessment of Functioning scale, the Intrinsic Motivation Inventory Japanese version (IMI-J), the Morisky Medication Adherence Scale-8 (MMAS-8), the Positive and Negative Syndrome Scale (PANSS), and the Japanese version of Client Satisfaction Questionnaire-8 (CSQ-8J). Results of linear mixed effects models indicated that the IOT+GOT showed significant improvements in verbal memory (p <0.01), working memory (p = 0.02), verbal fluency (p < 0.01), attention (p < 0.01), and composite score (p < 0.01) on the BACS-J; interest/enjoyment (p < 0.01), value/usefulness (p < 0.01), perceived choice (p < 0.01), and IMI-J total (p < 0.01) on the IMI-J; MMAS-8 score (p < 0.01) compared with the GOT alone. Patients in the GOT+IOT demonstrated significant improvements on the CSQ-8J compared with the GOT alone (p < 0.01). The present findings provide support for the feasibility in implementing an IOT program and its effectiveness for improving cognitive impairment and other outcomes in patients with schizophrenia.

Outcomes of clients in need of intensive team care in Flexible Assertive Community Treatment in Sweden

BACKGROUND

Flexible Assertive Community Treatment (Flexible ACT) has been implemented in Sweden during recent years due to increasing interest in integrated services for people with severe mental illness. To date, few studies have been done on Flexible ACT effectiveness.

AIMS

The overall aim of this study was to explore the extent to which clients assigned to the Flexible ACT board for ACT intensive care were stabilized with improved everyday functioning, social outcomes, and changes in healthcare use.

METHODS

Ninety-three participants with psychosis, in need of ACT from six newly started Flexible ACT teams, were included. Data were collected using the Social Outcome Index scale (SIX), Practical and Social Functioning Scale, and a healthcare usage questionnaire.

RESULTS

There was a significant positive change in everyday functioning and in the SIX-item 'friendship' at 18-months follow-up. A positive correlation was also found between everyday functioning and the SIX-item 'friendship' and a negative correlation between duration of ACT and everyday functioning. A significant increase in number of inpatient hospital days and psychiatric outpatient visits also occurred.

CONCLUSION

Clients with psychosis who need ACT may benefit from Flexible ACT through improved social functioning. Being involved in meaningful activities and supported by others are key aspects of recovering from mental illness and are enhanced by Flexible ACT.

The interaction of gender and cannabis in early phase psychosis

Cannabis is the third most common recreational drug used world-wide after tobacco and alcohol. Globally, cannabis legalization is becoming more common. In light of its known link to psychosis development, it is imperative that we are well-informed regarding the impact of cannabis on the course of psychosis, in both males and females. However, the majority of the work to date on the role of cannabis in psychosis outcomes has not had a gender focus, important when considering patient specific treatments. This review examines what is currently known, from gender focused studies, about the interaction of gender, cannabis use and psychotic disorders.

The impact of self-stigmatization on medication attitude in schizophrenia patients

Negative attitudes towards medication in schizophrenia patients are one major factor contributing to non-adherence behavior. Besides, self-stigmatization represents another frequent and important obstacle in patients suffering from psychotic disorders. Here, we investigated possible associations between medication adherence attitude and the extent of self-stigmatization, while also exploring factors related to self-stigmatization. Sociodemographic characteristics, clinical variables, medication attitude and self-stigmatization were assessed among 81 subjects with schizophrenia or schizoaffective disorder. The cross-sectional data was then analyzed by multivariate analyses. A more positive attitude towards medication was predicted by better insight into illness, lower degree of self-stigmatization and good subjective knowledge about medication (adjusted R² = 0.23). Furthermore, a higher level of self-stigmatization was associated with lower subjective wellbeing, more severe depressive symptoms and male gender (adjusted R² = 0.58). Other clinical variables had no additional predictive value for medication adherence attitude or the extent of self-stigmatization. Our findings support the notion that self-stigmatization is an influential factor on medication attitude that should therefore be appreciated in clinical practice. Besides this, special emphasis should be taken on depressive symptoms and reduced wellbeing, especially in male patients, to lower the extent of self-stigmatization.

Psychosocial Services for Individuals With Serious Mental Illness/Severe Emotional Disturbance: Clinical Practice Guideline Toolkit

This article presents a short, easy-to-use guideline for clinicians working with people with serious mental illness, particularly those with schizophrenia, schizoaffective disorder, delusional disorders, other psychotic disorders, or depression with significant impact on functioning, and may be of use for those working with individuals with bipolar disorder. This guideline is not meant to supplant the more detailed, excellent clinical practice guidelines that have been developed and published. Rather, the charts and explanation presented here are designed as a step-by-step tool that clinicians can use to ensure they are following the most appropriate course of action and providing the best psychosocial rehabilitation services possible for persons with these disorders. Program managers can use this tool to evaluate the processes used in their system to ensure that appropriate services are offered for the individuals in their care. This guideline is also not meant as a substitute for comprehensive training in the practice of assessment and treatment for individuals with serious mental illness. Very little detail is provided about the disorders, appropriate assessments, and interventions because clinicians providing services to people with these disorders should have received the specialized training necessary to appropriately deliver the services needed by these individuals.

Community-Based Psychosocial Treatment Has an Impact on Social Processing and Functional Outcome in Schizophrenia

Schizophrenic patients have serious impairments in social cognition, which often persists after significant reduction in clinical symptoms. Community-based psychosocial treatments aim to recover social functioning for mentally ill individuals. Our aim was to examine prospective changes in social cognition and functional outcomes in two groups of schizophrenic patients involved in two forms of community-based psychosocial treatments namely case management (CM) and community-based club (CC) compared to a matched, treatment as usual (TAU) group of patients. We hypothesized that CC and CM groups would exhibit better functional and social cognitive outcomes after a 6-month long psychosocial treatment period. Seventy-five patients participated either in CC, CM or TAU. Both CC and CM took part in community-based psychosocial treatment programs including trainings, such as communication and assertiveness trainings. In addition, CC provided group therapeutic treatments and a continuously available day care where patients had the possibility to participate in various social interactions. All participants were in remission, and on maintenance antipsychotic treatment. Participants were assessed on all study variables at two time points: baseline and after 6 months with a battery of questionnaires that examined affective face perception, affective prosody perception, pragmatic language comprehension and ToM. Our results showed that functional outcomes improved significantly in the CC as well as in the CM groups, in contrast to the TAU group. While analyzing summary scores of social cognition, it was found that only the CC group increased its performance in social cognition. In addition, a significant between-group difference in social cognitive function was found after 6 months between the three groups, with the CC group performing best. When investigating associations between changes in social cognition and changes in functional outcomes during a 6-month long treatment period, we found significant correlations between the two variables both in the CC and in the CM groups. Based on our results, we suggest that a rich interpersonal network and social support have highly beneficial effects on social cognition and we would like to emphasize the necessity of offering community-based psychosocial treatments beside antipsychotic medications as early as possible as a crucial part of the complex therapy of schizophrenia.

Effect of Aerobic Exercise on Improving Symptoms of Individuals With Schizophrenia: A Single Blinded Randomized Control Study

Introduction: Antipsychotic treatment can improve the symptoms of schizophrenia; however, residual symptoms after antipsychotic treatment are frequent. The effects of exercise on the symptoms of schizophrenic patients under antipsychotic treatment are inconclusive. The aim of this randomized case-control study was to examine the effects of aerobic exercise (AE) on the symptoms of schizophrenic patients receiving antipsychotic treatment. Methods: In total, 33 and 29 participants being treated with antipsychotics for schizophrenia were randomly assigned into the aerobic exercise (AE) group and the control group, respectively. The severities of schizophrenic symptoms were measured using the Chinese version of the Positive and Negative Syndrome Scale (PANSS) before, immediately after, and 3 months after the intervention in both groups. Results: In total, 24 participants (72.7%) in the AE group and 22 (75.9%) in the control group completed the study. The results indicated that the severities of positive symptoms and general psychopathology in the AE group significantly decreased during the 12 weeks of intervention but did not further significantly change during the 3-month follow-up period. The severities of negative symptoms in the AE group decreased significantly after 12 weeks of intervention and continued decreasing during the 3-month follow-up period. Interaction effects between time and group on the severities of symptoms on the negative and general psychopathology scales were observed. Conclusion: AE can improve the severities of symptoms on the negative and general psychopathology scales in individuals with schizophrenia being treated with antipsychotics.

A 20-Year multi-followup longitudinal study assessing whether antipsychotic medications contribute to work functioning in schizophrenia

To assess the long-term effectiveness of antipsychotic medications in facilitating work functioning in patients with schizophrenia we conducted longitudinal multifollowup research on 139 initially psychotic patients. The 70 patients with schizophrenia and 69 initially psychotic mood disordered control patients were followed up 6 times over 20 years. We compared the influence on work functioning of patients with schizophrenia continuously prescribed antipsychotics with patients with schizophrenia not prescribed antipsychotics, using statistical controls for inter-subject differences. While antipsychotics reduce or eliminate flagrant psychosis for most patients with schizophrenia at acute hospitalizations, four years later and continually until the 20 year followups, patients with schizophrenia not prescribed antipsychotics had significantly better work functioning. The work performance of the patients who were continuously prescribed antipsychotics was at a low rate and did not improve over time. Multiple other factors also interfere with work functioning. The data suggest that some patients with schizophrenia not prescribed antipsychotics for prolonged periods can function relatively well. Multiple other factors are associated with poor post-hospital work performance. The longitudinal data raise questions about prolonged treatment of schizophrenia with antipsychotic medications.

Does Integrated Neurocognitive Therapy (INT) reduce severe negative symptoms in schizophrenia outpatients?

Negative symptoms often inhibit the social integration of people suffering from schizophrenia. Reducing severe negative symptoms (SNS) in a clinically relevant way is a major unmet need. The aim of this study was to investigate whether Integrated Neurocognitive Therapy (INT), a group cognitive remediation therapy (CRT), reduces SNS in schizophrenia outpatients. INT was compared with Treatment As Usual (TAU) in a randomized-controlled trial (RCT). A total of 61 SNS outpatients participated in the study, 28 were allocated to the INT group and 33 to the TAU group. A test-battery was used at baseline, post-treatment at 15weeks, and 1-year-follow-up. Remission rates of SNS after therapy were significantly higher for INT compared to TAU. A trend favoring INT was obtained at follow-up. Furthermore, INT showed significantly higher functional outcome during follow-up compared to TAU. Regarding cognition, the strongest significant effect was found in attention post-treatment. No effects between groups on more complex neurocognition and social cognition were evident. SNS outpatients seem to accept INT group intervention as suggested by the high attendance rate.

Experimental variation of social stress in virtual reality - Feasibility and first results in patients with psychotic disorders

BACKGROUND AND OBJECTIVES

Social interaction might lead to increased stress levels in patients with psychotic disorders. Impaired social stress tolerance is critical for social functioning and closely linked with symptom relapse and hospitalization. We present an interactive office built-up in virtual reality (VR).

METHODS

Patients with psychotic disorders (PP, N = 26 including N = 5 dropouts) and matched healthy controls (HC, N = 20) were examined with a VR simulating an open-plan office. In a randomized, controlled cross-over design, participants were introduced to virtual co-workers (avatars) and requested to ask them for task assistance. Social feedback in each of the two sessions was either cooperative or rejective in randomized order.

RESULTS

The office environment was tolerable for most PP and all HC, five PP and none of the HC dropped out for any reason. Drop-outs reported simulator sickness, influence on thoughts and symptom exacerbations. Statistical trends indicated heightened paranoid ideations for PP after social rejection. State measures of paranoid ideations showed high convergent validity with conventional measures of delusions. Of note, measures of presence were higher for PP than for HC.

LIMITATIONS

The exploratory design limits the robustness of the findings. Only statistical trends on paranoid ideation were found.

CONCLUSION

The use of VR to assess the effects of social rejection is feasible and tolerable for most PP (87%). However, its implementation for PP is challenged by increased simulator sickness and an additional stress load for some patients. Further studies continuing on these first results that point towards an increased paranoid ideation evoked by negative social feedback and generally higher subjective presence are needed.

Effects of Group Cognitive-Behavioral Therapy in Young Patients in the Early Stage of Psychosis

OBJECTIVE

To develop a model of group cognitive-behavioral therapy (CBT) for Korean patients with early psychosis.

METHODS

The group CBT utilized in the present study consisted of metacognitive training, cognitive restructuring, and lifestyle managements. The Subjective Well-being Under Neuroleptics (SWN-K), Ambiguous Intentions Hostility Questionnaire (AIHQ), Drug Attitude Inventory (DAI), Beck Depression Inventory (BDI), Perceived Stress Scale (PSS), and Clinical Global Impression (CGI) were administered prior to and after CBT sessions. The participants were categorized into two groups according to the median duration of untreated psychosis (DUP; 4 months).

RESULTS

A total of 34 patients were included in this analysis. From pre- to post-therapy, there were significant increases in the SWN-K and DAI scores and significant decreases in the hostility subscale of the AIHQ, PSS, and CGI scores. Significant time × DUP interaction effects were observed for the SWN-K, DAI, and BDI scores, such that there were significant changes in patients with a short DUP but not in those with a long DUP.

CONCLUSION

The group CBT program had a positive effect on subjective wellbeing, attitude toward treatment, perceived stress, and suspiciousness of young Korean patients with early psychosis. These effects were particularly significant in patients with a short DUP.

Individualized metacognitive therapy for delusions: A randomized controlled rater-blind study

BACKGROUND

Theory-driven interventions targeting specific factors that contribute to delusions are receiving increased interest. The present study aimed to assess the efficacy of individualized metacognitive therapy (MCT+), a short manualized intervention that addresses delusion-associated cognitive biases.

METHODS

92 patients with current or past delusions were randomized to receive 12 twice-weekly sessions of either MCT+ or a control intervention within a randomized controlled rater-blind design. Psychopathology and cognitive biases were assessed at baseline, 6 weeks and 6 months. ANCOVAs adjusted for baseline scores were used to assess differences between groups regarding outcome variables. Both per-protocol and intention-to-treat analyses were conducted.

RESULTS

At 6 weeks, there was a significant difference in favor of MCT+ regarding decrease in delusion severity and improvement of self-reflectiveness (medium effect size), and a trend-wise difference regarding probability thresholds to decision. These effects increased, when only patients attending a minimum of 4 therapy sessions were considered. Control group patients subsequently showed further improvement while patients in the MCT+ group remained stable, such that there were no differences between groups at the 6-month follow-up.

LIMITATIONS

Lower attendance rates in the control group possibly leading to unequal therapeutic effort; lower baseline delusion severity in the MCT+ group.

CONCLUSIONS

The result pattern suggests that MCT+ led to earlier improvement in delusions and cognitive biases compared to the control intervention. The absence of a long-term effect might reflect floor effects in the MCT+ group, but may also indicate the need for further measures to promote sustainability of MCT+ effects.

Schizophrenia and work: aspects related to job acquisition in a follow-up study

Objective:

Work is considered one of the main forms of social organization; however, few individuals with schizophrenia find work opportunities. The purpose of this study was to evaluate the relationship between schizophrenia symptoms and job acquisition.

Method:

Fifty-three individuals diagnosed with schizophrenia from an outpatient treatment facility were included in an 18-month follow-up study. After enrollment, they participated in a prevocational training group. At the end of training (baseline) and 18 months later, sociodemographic, clinical data and occupational history were collected. Positive and negative symptoms (Positive and Negative Syndrome Scale – PANSS), depression (Calgary Depression Scale), disease severity (Clinical Global Impression – CGI), functionality (Global Assessment of Functioning – GAF), personal and social performance (Personal and Social Performance – PSP) and cognitive functions (Measurement and Treatment Research to Improve Cognition in Schizophrenia – MATRICS battery) were applied at baseline and at the end of the study.

Results:

Those with some previous work experience (n=19) presented lower scores on the PANSS, Calgary, GAF, CGI and PSP scales (p < 0.05) than those who did not work. Among those who worked, there was a slight worsening in positive symptoms (positive PANSS).

Conclusions:

Individuals with less severe symptoms were more able to find employment. Positive symptom changes do not seem to affect participation at work; however, this calls for discussion about the importance of employment support.

Computer-assisted cognitive remediation therapy in schizophrenia: Durability of the effects and cost-utility analysis

The durability of computer-assisted cognitive remediation (CACR) therapy over time and the cost-effectiveness of treatment remains unclear. The aim of the current study is to investigate the effectiveness of CACR and to examine the use and cost of acute psychiatric admissions before and after of CACR. Sixty-seven participants were initially recruited. For the follow-up study a total of 33 participants were enrolled, 20 to the CACR condition group and 13 to the active control condition group. All participants were assessed at baseline, post-therapy and 12 months post-therapy on neuropsychology, QoL and self-esteem measurements. The use and cost of acute psychiatric admissions were collected retrospectively at four assessment points: baseline, 12 months post-therapy, 24 months post-therapy, and 36 months post-therapy. The results indicated that treatment effectiveness persisted in the CACR group one year post-therapy on neuropsychological and well-being outcomes. The CACR group showed a clear decrease in the use of acute psychiatric admissions at 12, 24 and 36 months post-therapy, which lowered the global costs the acute psychiatric admissions at 12, 24 and 36 months post-therapy. The CACR is durable over at least a 12-month period, and CACR may be helping to reduce health care costs for schizophrenia patients.

Secondary negative symptoms - A review of mechanisms, assessment and treatment

Negative symptoms in schizophrenia may be classified as primary or secondary. Primary negative symptoms are thought to be intrinsic to schizophrenia, while secondary negative symptoms are caused by positive symptoms, depression, medication side-effects, social deprivation or substance abuse. Most of the research on secondary negative symptoms has aimed at ruling them out in order to isolate primary negative symptoms. However, secondary negative symptoms are common and can have a major impact on patient-relevant outcomes. Therefore, the assessment and treatment of secondary negative symptoms are clinically relevant. Furthermore, understanding the mechanisms underlying secondary negative symptoms can contribute to an integrated model of negative symptoms. In this review we provide an overview of concepts, evidence, assessment and treatment for the major causes of secondary negative symptoms. We also summarize neuroimaging research relevant to secondary negative symptoms. We emphasize the relevance of recent developments in psychopathological assessment of negative symptoms, such as the distinction between amotivation and diminished expression, which have only rarely been applied in research on secondary negative symptoms.

Differences in Social Decision-Making between Proposers and Responders during the Ultimatum Game: An EEG Study

The Ultimatum Game (UG) is a typical paradigm to investigate social decision-making. Although the behavior of humans in this task is already well established, the underlying brain processes remain poorly understood. Previous investigations using event-related potentials (ERPs) revealed three major components related to cognitive processes in participants engaged in the responder condition, the early ERP component P2, the feedback-related negativity (FRN) and a late positive wave (late positive component, LPC). However, the comparison of the ERP waveforms between the responder and proposer conditions has never been studied. Therefore, to investigate condition-related electrophysiological changes, we applied the UG paradigm and compared parameters of the P2, LPC and FRN components in twenty healthy participants. For the responder condition, we found a significantly decreased amplitude and delayed latency for the P2 component, whereas the mean amplitudes of the LPC and FRN increased compared to the proposer condition. Additionally, the proposer condition elicited an early component consisting of a negative deflection around 190 ms, in the upward slope of the P2, probably as a result of early conflict-related processing. Using independent component analysis (ICA), we extracted one functional component time-locked to this deflection, and with source reconstruction (LAURA) we found the anterior cingulate cortex (ACC) as one of the underlying sources. Overall, our findings indicate that intensity and time-course of neuronal systems engaged in the decision-making processes diverge between both UG conditions, suggesting differential cognitive processes. Understanding the electrophysiological bases of decision-making and social interactions in controls could be useful to further detect which steps are impaired in psychiatric patients in their ability to attribute mental states (such as beliefs, intents, or desires) to oneself and others. This ability is called mentalizing (also known as theory of mind).

Effects of the diagnostic label 'schizophrenia', actively used or passively accepted, on general practitioners' views of this disorder

BACKGROUND

General practitioners (GPs) play a key role in the care of somatic and psychiatric problems in people diagnosed with schizophrenia (PWS). It is probable that, like other health professionals, GPs are not all free of prejudices toward PWS. In clinical practice, GPs sometimes interact with clients diagnosed with schizophrenia by specialists, passively accepting this diagnosis. Other times, GPs interact with clients having symptoms of schizophrenia but who have not been diagnosed. In this case, GPs are expected to actively make a diagnosis. Giving the key role of GPs in the process of care, it is worthwhile examining whether passive acceptance and active usage of the diagnosis schizophrenia have differential effects on GPs' attitudes toward people with this disorder.

AIMS

To investigate GPs' views of schizophrenia and whether they were influenced by a 'schizophrenia' label, passively accepted or actively used.

METHODS

A total of 430 randomly selected GPs were invited to complete a questionnaire about their views of schizophrenia, either after reading a description of this disorder and making a diagnosis, or without being provided with a description but passively accepting the label 'schizophrenia' given in the questionnaire.

RESULTS

The GPs who passively accepted the label schizophrenia ( n = 195) and those who actively identified schizophrenia from the description ( n = 127) had similar views. Compared to the GPs who did not identify schizophrenia in the description ( n = 65), those who used the diagnosis, actively or passively: more frequently reported heredity and less frequently psychosocial factors as causes of the disorder; were more skeptical about recovery; were more convinced of the need for long-term pharmacotherapies; believed more strongly that PWS should be discriminated against when in medical hospital; and perceived PWS as more dangerous and as kept at greater social distance.

CONCLUSION

The diagnosis 'schizophrenia', however used, is associated with pessimistic views. Stigma education should be provided to GPs.

Breaking Through to the Other Side: A Resident Explores the Benefits of Time-Limited Psychodynamic Therapy for Patients with Schizophrenia

This article recounts the case of a patient with schizophrenia engaged in time-limited psychodynamic psychotherapy with a psychiatry resident-the first case history of its type to the author's knowledge. This patient suffered from chronically debilitating schizophrenia with persistent positive and negative symptoms at the time of treatment, despite usual psychiatric management. He benefited significantly from 18 weekly sessions of weekly dynamic therapy, achieving symptom reduction, increased social involvement, and improved functioning-gains that were sustained at 9-month follow-up. The author narrates the patient's therapeutic progress from a clinician-in-training's perspective, commenting on technical aspects of his treatment. The author examines how the time-limited nature of the therapy may have infused the transference and influenced the patient's outcome. The author also reviews the evidence base for psychodynamic treatment of patients with schizophrenia, focusing on short-term therapy specifically. The author invites greater inquiry into time-limited therapeutic approaches with such patients.

An Integrated Recovery-oriented Model (IRM) for mental health services: evolution and challenges

BACKGROUND

Over past decades, improvements in longer-term clinical and personal outcomes for individuals experiencing serious mental illness (SMI) have been moderate, although recovery has clearly been shown to be possible. Recovery experiences are inherently personal, and recovery can be complex and non-linear; however, there are a broad range of potential recovery contexts and contributors, both non-professional and professional. Ongoing refinement of recovery-oriented models for mental health (MH) services needs to be fostered.

DISCUSSION

This descriptive paper outlines a service-wide Integrated Recovery-oriented Model (IRM) for MH services, designed to enhance personally valued health, wellbeing and social inclusion outcomes by increasing access to evidenced-based psychosocial interventions (EBIs) within a service context that supports recovery as both a process and an outcome. Evolution of the IRM is characterised as a series of five broad challenges, which draw together: relevant recovery perspectives; overall service delivery frameworks; psychiatric and psychosocial rehabilitation approaches and literature; our own clinical and service delivery experience; and implementation, evaluation and review strategies. The model revolves around the person's changing recovery needs, focusing on underlying processes and the service frameworks to support and reinforce hope as a primary catalyst for symptomatic and functional recovery. Within the IRM, clinical rehabilitation (CR) practices, processes and partnerships facilitate access to psychosocial EBIs to promote hope, recovery, self-agency and social inclusion. Core IRM components are detailed (remediation of functioning; collaborative restoration of skills and competencies; and active community reconnection), together with associated phases, processes, evaluation strategies, and an illustrative IRM scenario. The achievement of these goals requires ongoing collaboration with community organisations.

CONCLUSIONS

Improved outcomes are achievable for people with a SMI. It is anticipated that the IRM will afford MH services an opportunity to validate hope, as a critical element for people with SMI in assuming responsibility and developing skills in self-agency and advocacy. Strengthening recovery-oriented practices and policies within MH services needs to occur in tandem with wide-ranging service evaluation strategies.

Implementation of a recovery-oriented model in a sub-acute Intermediate Stay Mental Health Unit (ISMHU)

Background

An ongoing service evaluation project was initiated following the establishment of a new, purpose-built, 20-bed sub-acute Intermediate Stay Mental Health Unit (ISMHU). This paper: provides an overview of the targeted 6-week program, operating within an Integrated Recovery-oriented Model (IRM); characterises the clients admitted during the first 16 months; and documents their recovery needs and any changes.

Methods

A brief description of the unit’s establishment and programs is initially provided. Client needs and priorities were identified collaboratively using the Mental Health Recovery Star (MHRS) and addressed through a range of in-situ, individual and group interventions. Extracted client and service data were analysed using descriptive statistics, paired t-tests examining change from admission to discharge, and selected correlations.

Results

The initial 154 clients (165 admissions, average stay = 47.86 days) were predominately male (72.1%), transferred from acute care (75.3%), with schizophrenia or related disorders (74.0%). Readmission rates within 6-months were 16.2% for acute and 3.2% for sub-acute care. Three MHRS subscales were derived, together with stage-of-change categories. Marked improvements in MHRS Symptom management and functioning were identified (z-change = −1.15), followed by Social-connection (z-change = −0.82) and Self-belief (z-change = −0.76). This was accompanied by a mean reduction of 2.59 in the number of pre-action MHRS items from admission to discharge (z-change = 0.98). Clinician-rated Health of the Nation Outcome Scales (HoNOS) improvements were smaller (z-change = 0.41), indicative of illness chronicity. Staff valued the elements of client choice, the holistic and team approach, program quality, review processes and opportunities for client change. Addressing high-levels of need in the 6-week timeframe was raised as a concern.

Conclusions

This paper demonstrates that a recovery-oriented model can be successfully implemented at the intermediate level of care. It is hoped that ongoing evaluations support the enthusiasm, commitment and feedback evident from staff, clients and carers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1939-8) contains supplementary material, which is available to authorized users.

Rehabilitation Interventions to Promote Recovery from Schizophrenia: A Systematic Review

Only one out of seven patients recovers after a first episode of psychosis despite psychiatric care. Rehabilitation interventions have been developed to improve functional outcomes and to promote recovery. We conducted a systematic review of the effectiveness of the main psychiatric rehabilitation interventions following a search of the electronic databases Pubmed, ScienceDirect, and Google Scholar using combinations of terms relating to cognitive remediation, psychoeducation, cognitive-behavioral therapies, and schizophrenia. Eighty articles relevant to the topic of interest were found. According to results, cognitive remediation has been found to be effective in reducing the impact of cognitive impairment, social skills in the learning a variety of skills and to a lesser extent in reducing negative symptoms, psychoeducation in improving compliance and reducing relapses, and cognitive therapy in reducing the intensity of or distress related to positive symptoms. All psychosocial rehabilitation interventions should be considered as evidence-based practices for schizophrenia and need to become a major part of the standard treatment of the disease.

Schizophrenia: Impact on Family Dynamics

In many societies, family members are now the primary caregivers of mental health patients, taking on responsibilities traditionally under the purview of hospitals and medical professionals. The impact of this shift on the family is high, having both an emotional and economic toll. The aim of this paper is to review the main changes that occur in family dynamics for patients with schizophrenia. The article addresses three central themes: (i) changes in the family at the onset of the disorder, (ii) consequences for family members because of their caregiver role, and (iii) family interventions aimed at improving the complex dynamics within the family. After analyzing and discussing these themes, it is observed that despite advances in the field, the viability of taking care of a patient with schizophrenia by the family remains a challenge. Improving care will require commitments from the family, the mental health service system, and local and national governments for greater investments to improve the quality of life of society in general and individuals with schizophrenia in particular.

The treatment of schizophrenia: Can we raise the standard of care?

OBJECTIVE

There is evidence that over time health outcomes of people with schizophrenia are deteriorating rather than improving both in terms of mortality rate and levels of morbidity, even in Australia where service resourcing is substantial. Our objective was to examine the evidence of whether poor outcomes reflect decreases in treatment effectiveness and, if so, what are the barriers to improving standards of care. This review will argue that the confidence of clinicians to diagnose schizophrenia early, and provide assertive and long-term care, may be being undermined by a series of controversies in the published literature and discrepancies in clinical practice guidelines.

METHOD

A critical review was conducted of the evidence regarding six issues of high clinical relevance to the treatment of schizophrenia formulated as questions: (1) Is schizophrenia a progressive disease? (2) Does relapse contribute to disease progression and treatment resistance? (3) When should the diagnosis of schizophrenia be made? (4) Should maintenance antipsychotic medication be discontinued in fully remitted first-episode patients? (5) Do antipsychotic medications cause deleterious reductions in cortical grey matter volumes? and (6) Are long-acting injectable antipsychotics more effective in reducing relapse rate compared to oral formulations?

RESULTS

There is reliable evidence for schizophrenia being a progressive disease with emergent treatment resistance in most cases, that relapse contributes to this treatment resistance, that maintenance antipsychotic medication should not be discontinued in remitted first-episode patients, that antipsychotic medication does not appear to cause deleterious grey matter volume changes, that maintenance antipsychotic medication reduces the mortality rate in schizophrenia and that long-acting injectable antipsychotics are more effective in preventing relapse than oral formulations.

CONCLUSION

There is an urgent need to re-engineer the early management of schizophrenia and to routinely evaluate this type of innovation within practice-based research networks. A proposal for an assertive treatment algorithm is included.

Development of an Individualized Occupational Therapy Programme and its Effects on the Neurocognition, Symptoms and Social Functioning of Patients with Schizophrenia

We described an individualized occupational therapy (IOT) programme and examined the effects of adding IOT to group OT (GOT) on improving neurocognition, symptoms and social functioning among recently hospitalized patients with schizophrenia. The Brief Assessment of Cognition in Schizophrenia-Japanese version (BACS-J), the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning scale were used for outcome evaluations. Fifty-one patients were voluntarily assigned to either the GOT + IOT (n = 30) or GOT alone (n = 21) groups based on their preferences. Retention in the GOT + IOT group was 100%. Three-month baseline to discharge assessments in the GOT + IOT group showed significant improvements in BACS-J verbal memory, working memory, verbal fluency, attention, executive function and composite score, and in PANSS positive subscale, general psychopathology subscale, and total score compared to the GOT alone group. Study limitations notwithstanding, the present findings provide preliminary support for the feasibility of implementing IOT and its effectiveness for improving cognitive impairment and symptoms in patients with schizophrenia. The results of this study indicate that IOT in psychiatric facilities may improve psychosocial treatment of schizophrenia. Additional study is warranted to replicate the effects of IOT as demonstrated in this Japanese study. Copyright © 2016 John Wiley & Sons, Ltd.

Influence of cognition, premorbid adjustment and psychotic symptoms on psycho-social functioning in first-episode psychosis

OBJECTIVE

The aim of this study is to evaluate the relationship between psycho-social functioning and symptoms, cognitive function, and premorbid adjustment, in patients with a first-episode psychosis.

METHOD

Clinical data were obtained from 90 patients, who were assessed with the Disability Assessment Scale (DAS-sv), the Positive and Negative Syndrome Scale (PANSS), the Premorbid Adjustment Scale (PAS-S) and with a battery of cognitive tests including Trail Making Tests A and B (TMTA- B), Continous Performance Test (CPT), some subscales of the Wechler Adult Intelligence Scale (WAIS), and the Verbal Learning Test España-Complutense (TAVEC).

RESULTS

The results of the study suggest that psycho-social functioning in first-episode psychosis is significantly related to: positive, negative, excitative, affective and disorganized symptoms, social premorbid adjustment, cognitive flexibility, working memory, short term and long term memory. Of these, those which best explained psycho-social functioning are the positive and excitative symptoms, premorbid adjustment, flexibility and memory.

CONCLUSIONS

These findings highlight the importance early intervention on cognitive and clinical variables to help provide a better psycho-social functioning in people with a first-episode of psychosis.

The Rise of Primary Care Physicians in the Provision of US Mental Health Care

Primary care physicians have assumed an increasingly important role in US outpatient mental health care. They are providing an increasing volume of outpatient mental health services, prescribing a growing number and variety of psychotropic medications, and treating patients with a broader array of mental health conditions. These trends, which run counter to a general trend toward specialization and subspecialization within US health care, place new strains on the clinical competencies of primary care physicians. They also underscore the importance of implementing more effective models of collaboration between primary care physicians and mental health specialists. Several elements of the Affordable Care Act provide options for financing and organizing the delivery of integrated general medical and behavioral services. Such integrated services have the potential to improve access and quality of outpatient mental health care for a range of psychiatric disorders. Because people with severe and persisting mental disorders commonly require a higher-level medical expertise than is readily available within primary care as well as a complex array of social services, separate specialized mental health will likely continue to play a vitally important role in caring for this population.

A Randomized Controlled Trial of Group Coping-Oriented Therapy vs Supportive Therapy in Schizophrenia: Results of a 2-Year Follow-up

OBJECTIVE

Over the past 30 years, illness management programs and cognitive-behavioral therapy for psychosis have gained prominence in the treatment of schizophrenia. However, little is known about the long-term benefits of these types of programs when delivered during inpatient treatment following a symptom exacerbation. To evaluate this question, we conducted a randomized controlled trial comparing the long-term effects of a group-based coping-oriented program (COP) that combined the elements of illness management with cognitive behavioral-therapy for psychosis, with an equally intensive supportive therapy (SUP) program.

METHOD

196 inpatients with DSM-IV schizophrenia were randomized to COP or SUP, each lasting 12 sessions provided over 6-8 weeks. Outcome measures were collected in the hospital at baseline and post-assessment, and following discharge into the community 1 and 2 years later. We compared the groups on rehospitalizations, symptoms, psychosocial functioning, and knowledge about psychosis.

RESULTS

Intent-to-treat analyses indicated that patients in COP learned significantly more information about psychosis, and had greater reductions in overall symptoms and depression/anxiety over the treatment and follow-up period than patients in SUP. Patients in both groups improved significantly in other symptoms and psychosocial functioning. There were no differences between the groups in hospitalization rates, which were low.

CONCLUSIONS

People with schizophrenia can benefit from short-term COPs delivered during the inpatient phase, with improvements sustaining for 2 years following discharge from the hospital. More research is needed to evaluate the long-term impact of coping-oriented and similar programs provided during inpatient treatment.

Psychoeducational and Cognitive Behavioral Treatment Programs: Implementation and Evaluation From 1995 to 2015 in Kraepelin's Former Hospital

OBJECTIVE

Programs that view individuals as capable of taking an active role in managing their illness have gained importance in Europe and the United States. This article describes the implementation and evaluation of group psychoeducational and cognitive behavioral treatment programs at the Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Munich, Germany, over the past 20 years.

METHODS

Implementing psychoeducational programs was the first step to establish cognitive behavioral psychotherapy and dispel the myth of schizophrenia for patients. Programs are also provided for patients with mood disorders, substance use disorders, or both. These groups include topics such as psychoeducation about the illness, establishing rewarding activities, stress management, cognitive therapy, and relapse prevention.

RESULTS

More than 1000 patients with schizophrenia or mood disorders (380 schizophrenia, 563 major depression, and 110 bipolar) have participated in illness management groups to learn about their illness and its treatment, and to learn skills to manage their illness. Patients have expressed satisfaction with the programs, and research has supported their effectiveness.

CONCLUSIONS

Individuals with severe disorders can benefit from psychoeducational and cognitive treatment programs if the programs are adapted to the level of neuropsychological functioning and compensate for cognitive deficits and emotional overload. These findings suggest that providing information about the illness and coping skills for patients and relatives are important for treatment outcome.

Mental illness sexual stigma: Implications for health and recovery

OBJECTIVE

The majority of people in psychiatric care worldwide are sexually active, and studies have revealed sharply elevated rates of HIV infection in that group compared with the general population. Recovery-oriented treatment does not routinely address sexuality. We examined the relationship between gender, severe mental illness diagnosis, and stigma experiences related to sexuality among people in psychiatric outpatient care.

METHOD

Sexually active adults attending 8 public outpatient psychiatric clinics in Rio de Janeiro (N = 641) were interviewed for psychiatric diagnosis and stigma experiences. Stigma mechanisms well-established in the literature but not previously examined in relation to sexuality were measured with the Mental Illness Sex Stigma Questionnaire, a 27-item interview about stigma in sexual situations and activities.

RESULTS

Experiences of stigma were reported by a majority of participants for 48% of questionnaire items. Most people reported supportive attitudes toward their sexuality from providers and family members. Those with severe mental illness diagnoses showed greater stigma on individual discrimination and structural stigma mechanisms than did those with nonsevere mental illness diagnoses, whereas there was no difference on the social psychological processes (internalized stigma) mechanism. Regardless of diagnosis or gender, a majority of participants devalued themselves as sexual partners.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Adults in psychiatric outpatient care frequently reported stigma experiences related to aspects of their sexual lives. From the perspectives of both HIV prevention and recovery from mental illness, examinations of the consequences of stigma in the sexual lives of people in psychiatric care and improving their measurement would have wide applicability. (PsycINFO Database Record

Feasibility Study of Increasing Social Support to Enhance a Healthy Lifestyle Intervention for Individuals with Serious Mental Illness

OBJECTIVE

Healthy lifestyle interventions addressing obesity in people with serious mental illness (SMI) lead to modest weight losses that tend not to be sustained over time. By augmenting lifestyle interventions with family and peer support targeting health behavior change, greater weight loss might be obtained and sustained in this population. The purpose of this study was to assess the feasibility of increasing support from family and friends to enhance a healthy lifestyle intervention (In SHAPE) adapted for individuals with SMI.

METHOD

A sample of 7 dyads (14 total participants) participated in this small-scale open-feasibility trial of social support strategies to enhance health promotion. Weekly 1-hour health coaching sessions were augmented by sessions designed to increase support for healthy eating and exercise through active learning and didactic instruction. Feasibility was assessed by program participation and by examining participants' satisfaction and exploring suggestions for improving the model post-intervention.

RESULTS

The majority of participants (57%) nominated a friend, followed by adult child-parent pairs (28%) and sibling pairs (14%) to participate as support partners in the study. All participant-partner dyads (100%) completed 12 sessions within 16 weeks. Participants reported high satisfaction and perceived benefits from the program. Recommend modifications by the dyads included more interactive sessions, a combination of group and dyadic sessions, and hands-on cooking classes.

CONCLUSIONS

This formative research showed that the study design is feasible and that the intervention can facilitate social support for health behavior change in people with SMI. Further research is needed to evaluate the effectiveness of this intervention.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders

OBJECTIVES

This guideline provides recommendations for the clinical management of schizophrenia and related disorders for health professionals working in Australia and New Zealand. It aims to encourage all clinicians to adopt best practice principles. The recommendations represent the consensus of a group of Australian and New Zealand experts in the management of schizophrenia and related disorders. This guideline includes the management of ultra-high risk syndromes, first-episode psychoses and prolonged psychoses, including psychoses associated with substance use. It takes a holistic approach, addressing all aspects of the care of people with schizophrenia and related disorders, not only correct diagnosis and symptom relief but also optimal recovery of social function.

METHODS

The writing group planned the scope and individual members drafted sections according to their area of interest and expertise, with reference to existing systematic reviews and informal literature reviews undertaken for this guideline. In addition, experts in specific areas contributed to the relevant sections. All members of the writing group reviewed the entire document. The writing group also considered relevant international clinical practice guidelines. Evidence-based recommendations were formulated when the writing group judged that there was sufficient evidence on a topic. Where evidence was weak or lacking, consensus-based recommendations were formulated. Consensus-based recommendations are based on the consensus of a group of experts in the field and are informed by their agreement as a group, according to their collective clinical and research knowledge and experience. Key considerations were selected and reviewed by the writing group. To encourage wide community participation, the Royal Australian and New Zealand College of Psychiatrists invited review by its committees and members, an expert advisory committee and key stakeholders including professional bodies and special interest groups.

RESULTS

The clinical practice guideline for the management of schizophrenia and related disorders reflects an increasing emphasis on early intervention, physical health, psychosocial treatments, cultural considerations and improving vocational outcomes. The guideline uses a clinical staging model as a framework for recommendations regarding assessment, treatment and ongoing care. This guideline also refers its readers to selected published guidelines or statements directly relevant to Australian and New Zealand practice.

CONCLUSIONS

This clinical practice guideline for the management of schizophrenia and related disorders aims to improve care for people with these disorders living in Australia and New Zealand. It advocates a respectful, collaborative approach; optimal evidence-based treatment; and consideration of the specific needs of those in adverse circumstances or facing additional challenges.

[Integrated management of patients with schizophrenia: beyond psychotropic drugs]

INTRODUCTION

Schizophrenia is a complex disease with severe functional repercussions; therefore it merits treatment which goes beyond drugs.

THEME DEVELOPMENT

It requires an approach that considers a diathesis-stress process that includes rehabilitation, psychotherapeutic strategies for persistent cognitive, negative and psychotic symptoms, psychoeducation of patient and communities, community adaptation strategies, such as the introduction to the work force, and the community model, such as a change in the asylum paradigm.

DISCUSSION

It is necessary to establish private and public initiatives for the integrated care of schizophrenia in the country, advocating the well-being of those with the disease.

CONCLUSIONS

The integrated management of schizophrenic patients requires a global view of the patient and his/her disease, and its development is essential.

Hospitalization of high and low inpatient service users before and after enrollment into Assertive Community Treatment teams: a naturalistic observational study

Background

Assertive Community Treatment (ACT) is more successful in reducing hospitalization when baseline use is high. However, with a growing recovery-focus, ACT may be useful for people with severe mental illness who are difficult to engage but not high users of inpatient services. This study investigated hospitalization 2 years before and 2 years after ACT enrollment amongst patients both with and without high inpatient services use before enrollment into ACT.

Methods

This naturalistic observational study included 142 patients from 12 different ACT teams throughout Norway. Of these, 74 (52 %) were high users of inpatient services before ACT. The teams assessed the patients upon enrollment using clinician-rated and self-reported questionnaires. Hospitalization data from 2 years before and 2 years after enrollment into ACT were obtained from the Norwegian Patient Registry. Linear mixed models were used to assess changes in hospitalization and to explore associations between these changes and patient characteristics.

Results

When the participants enrolled into the ACT teams, high users of inpatient care were younger, more often living alone and more often subject to involuntary outpatient treatment than low users. The participants spent significantly fewer days in hospital during the 2 years of ACT follow-up compared to the 2 years before enrollment. The reduction was more evident amongst high users, whereas low users had an initial increase in inpatient days in the first year of ACT and a subsequent decrease in the second year. More severe negative symptoms and previous high use of inpatient care were associated with a reduction in both total and involuntary inpatient days. Additionally, a reduction in involuntary inpatient days was associated with being subject to involuntary outpatient treatment upon enrollment into ACT.

Conclusion

The findings in this study may suggest that ACT contributes to more appropriate use of inpatient care, possibly by reducing the presumably avoidable hospitalization of high users and increasing the presumably needed inpatient care of low users.

Integrating Evidence-Based Community-Care Services to Improve Schizophrenia Outcomes: A Preliminary Trial

This aim of this preliminary experimental study was to integrate effective evidence-based community-care services that are subjected to heavy caseloads, and to then examine the effects on individuals with schizophrenia. Using a cluster sampling method, four homecare nurses were randomly assigned to either the experimental group or the comparison group. The nurses in the experimental group applied the following six identified effective elements: (1) established an alliance with their patients; (2) assessed patient-care needs; (3) considered both medical and social-care practices; (4) addressed patients' self-management of medication and their daily tasks; (5) provided crisis intervention; and (6) coordinated resources. The patients comprised 85 individuals with schizophrenia. In the experimental group, psychiatric homecare nurses were randomly assigned to implement integrated, evidence-based community-care services during a six-month follow-up period. Patients in the comparison group continued to receive their customary community care. In the experimental group, patient satisfaction scores, medication attitudes, and general functioning levels were significantly higher than in the comparison group. These preliminary findings indicate a potentially effective model for community care in areas where intensive case management cannot be provided.

[Intervention of Schizophrenia From the Community Model]

INTRODUCTION

Schizophrenia is a complex disease for which pharmacological management is an insufficient therapeutic measure to ensure adaptation to the community and restoring the quality of life of the patient, with a multidimensional management and community interventions being necessary.

METHODOLOGY

Case report.

RESULTS

This case report illustrates a multidisciplinary treatment response, based on a community care model for mental health from Envigado, Colombia.

DISCUSSION

The management of schizophrenia requires multimodal interventions that include community screening, psychoeducation of individuals, their families and society, addressing different areas of operation that allow adaptation of the subject to his social environment.

CONCLUSIONS

A integrated intervention that can be provided on a Community scale, with the implementation of policies that allow it to be applied.

Effects of high-intensity aerobic exercise on psychotic symptoms and neurocognition in outpatients with schizophrenia: study protocol for a randomized controlled trial

Background

The focus in recent years on physical inactivity and metabolic disturbances in individuals with schizophrenia raises the question of potential effects of physical activity. Physical activity has shown beneficial effects on cognition in healthy older individuals as well as on symptom severity in depression. However, opinions diverge regarding whether aerobic high-intensity interval training reduces cognition and key symptoms in schizophrenia. The main objective for the trial is to investigate the potential effects of aerobic high-intensity interval training on neurocognitive function and mental symptoms in outpatients with schizophrenia.

Methods/Design

The trial is designed as a randomized controlled, observer-blinded clinical trial. Patients are randomized to 1 of 2 treatment arms with 12-week duration: aerobic high-intensity interval training or computer gaming skills training. All participants also receive treatment as usual. Primary outcome measure is neurocognitive function. Secondary outcome measures will be positive and negative symptoms, wellbeing, tobacco-smoking patterns and physiological/metabolic parameters. Patient recruitment takes place in catchment area-based outpatient clinics.

Trial registration

ClinicalTrials.gov NCT02205684. Registered 29 July 2014.

The Vicious Cycle of Family Atmosphere, Interpersonal Self-concepts, and Paranoia in Schizophrenia-A Longitudinal Study

Recent cognitive models of paranoid delusions highlight the role of self-concepts in the development and maintenance of paranoia. Evidence is growing that especially interpersonal self-concepts are relevant in the genesis of paranoia. In addition, negative interpersonal life-experiences are supposed to influence the course of paranoia. As dysfunctional family atmosphere corresponds with multiple distressing dyadic experiences, it could be a risk factor for the development and maintenance of paranoia. A total of 160 patients with a diagnosis of schizophrenia were assessed twice within 12 months. Standardized questionnaires and symptom rating scales were used to measure interpersonal self-concepts, perceived family atmosphere, and paranoia. Data were analyzed using longitudinal cross-lagged structural equation models. Perceived negative family atmosphere was associated with the development of more pronounced negative interpersonal self-concepts 12 months later. Moreover, paranoia was related to negative family atmosphere after 12 months as well. As tests revealed that reversed associations were not able to explain the data, we found evidence for a vicious cycle between paranoia, family atmosphere, and interpersonal self-concepts as suggested by theoretical/cognitive model of paranoid delusions. Results suggest that broader interventions for patients and their caretakers that aim at improving family atmosphere might also be able to improve negative self-concepts and paranoia.

Converging models of schizophrenia--Network alterations of prefrontal cortex underlying cognitive impairments

The prefrontal cortex (PFC) and its connections with other brain areas are crucial for cognitive function. Cognitive impairments are one of the core symptoms associated with schizophrenia, and manifest even before the onset of the disorder. Altered neural networks involving PFC contribute to cognitive impairments in schizophrenia. Both genetic and environmental risk factors affect the development of the local circuitry within PFC as well as development of broader brain networks, and make the system vulnerable to further insults during adolescence, leading to the onset of the disorder in young adulthood. Since spared cognitive functions correlate with functional outcome and prognosis, a better understanding of the mechanisms underlying cognitive impairments will have important implications for novel therapeutics for schizophrenia focusing on cognitive functions. Multidisciplinary approaches, from basic neuroscience to clinical studies, are required to link molecules, circuitry, networks, and behavioral phenotypes. Close interactions among such fields by sharing a common language on connectomes, behavioral readouts, and other concepts are crucial for this goal.