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Thai H, Audet ÉC, Koestner R, Lepage M, O'Driscoll GA. The role of motivation in clinical presentation, treatment engagement and response in schizophrenia-spectrum disorders: A systematic review. Clin Psychol Rev 2024; 113:102471. [PMID: 39111125 DOI: 10.1016/j.cpr.2024.102471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 06/28/2024] [Accepted: 07/27/2024] [Indexed: 09/09/2024]
Abstract
Schizophrenia, a debilitating psychiatric disorder, has a long-term impact on social and occupational functioning. While negative symptoms, notably amotivation, are recognized as poor prognostic factors, the positive force of patient motivation (autonomous motivation) remains underexplored. This systematic review, guided by Self-Determination Theory (SDT), investigated the impact of motivation on clinical presentation, and treatment engagement and response in schizophrenia-spectrum disorders. Fifty-five independent studies (N = 6897), using 23 different motivation scales, met inclusion criteria. Results were categorized into cross-sectional and longitudinal correlates of autonomous motivation, and the effects of motivational interventions. Cross-sectionally, autonomous motivation was positively associated with social/occupational functioning, and negatively associated with negative and positive symptom severity. In longitudinal studies, baseline autonomous motivation predicted engagement in and response to social/occupational treatments, with mixed results in cognitive interventions. In the 16 randomized controlled trials (RCTs), the most common motivational interventions were individualized goal setting and goal attainment support, followed by increasing sense of competence by challenging defeatist beliefs, and enhancing relatedness by increasing contact time. Motivational interventions consistently increased autonomous motivation, treatment engagement and response. More studies are needed, particularly studies that monitor motivation during treatment: proximal assessments could facilitate the identification of treatment elements that impact motivation and engagement and inform treatment modifications to enhance the patient experience and improve treatment efficacy.
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Affiliation(s)
- Helen Thai
- Department of Psychology, McGill University, Montreal, Quebec, Canada; Prevention and Early Intervention Program for Psychoses, Douglas Mental Health University Institute, Montreal, Quebec, Canada.
| | - Élodie C Audet
- Department of Psychology, McGill University, Montreal, Quebec, Canada.
| | - Richard Koestner
- Department of Psychology, McGill University, Montreal, Quebec, Canada.
| | - Martin Lepage
- Department of Psychology, McGill University, Montreal, Quebec, Canada; Prevention and Early Intervention Program for Psychoses, Douglas Mental Health University Institute, Montreal, Quebec, Canada; Department of Psychiatry, McGill University, Montreal, Quebec, Canada.
| | - Gillian A O'Driscoll
- Department of Psychology, McGill University, Montreal, Quebec, Canada; Department of Psychiatry, McGill University, Montreal, Quebec, Canada.
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Zbukvic I, Bryce S, Moullin J, Allott K. The use of implementation science to close the research-to-treatment gap for cognitive impairment in psychosis. Aust N Z J Psychiatry 2023; 57:1308-1315. [PMID: 36964703 PMCID: PMC10517591 DOI: 10.1177/00048674231160987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Abstract
For people living with psychosis, cognitive impairment is common and can have significant impacts for functional recovery, impacting engagement with treatment and quality of life more broadly. There is now strong evidence for the effectiveness of cognition-focused treatments, such as cognitive remediation to improve clinical and functional outcomes for people with psychosis. However, engagement with treatment has been a long-standing issue in mental health care, including for people with psychosis, who often experience difficulties with motivation. While research on clinical effectiveness of cognition-focused treatment is growing, to date there has been little research focused on the implementation of such treatments and it is not clear how best to support uptake and engagement across diverse mental health settings. Implementation science is the study of methods and strategies to promote the adoption, application, and maintenance of evidence-based practices in routine care. To integrate cognition-focused treatments into routine practice, and improve engagement with treatment and the quality and effectiveness of care for people with psychosis, researchers need to embrace implementation science and research. This paper provides a succinct overview of the field of implementation science, current evidence for implementation of cognition-focused treatments for psychosis and practical guidance for using implementation science in clinical research. The future of psychosis research includes multidisciplinary teams of clinical researchers and implementation scientists, working together with providers and consumers to build the evidence that can improve the implementation of cognition-focused treatments.
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Affiliation(s)
- Isabel Zbukvic
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Shayden Bryce
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Joanna Moullin
- enAble Institute, Curtin University, Perth, WA, Australia
| | - Kelly Allott
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
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3
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Le TP, Ventura J, Ruiz-Yu B, McEwen SC, Subotnik KL, Nuechterlein KH. Treatment engagement in first-episode schizophrenia: Associations between intrinsic motivation and attendance during cognitive training and an aerobic exercise program. Schizophr Res 2023; 251:59-65. [PMID: 36577235 PMCID: PMC10163954 DOI: 10.1016/j.schres.2022.12.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 09/21/2022] [Accepted: 12/16/2022] [Indexed: 12/28/2022]
Abstract
Systematic cognitive training and aerobic exercise programs have emerged as promising interventions to improve cognitive deficits in first-episode schizophrenia, with successful outcomes closely linked with greater treatment engagement (e.g., higher attendance and homework completion rates). Unfortunately, treatment disengagement from these services remains a persistent issue. Intrinsic motivation, or the willingness to exert effort because a task is inherently interesting or meaningful, has emerged as a promising malleable personal factor to enhance treatment engagement. This study investigated whether early task-specific intrinsic motivation and its domains (e.g., interest, perceived competence, and value) predicted treatment engagement within the context of intensive cognitive training and aerobic exercise interventions over a 6-month period. Thirty-nine participants with first-episode schizophrenia were administered baseline measures of task-specific intrinsic motivation inventories, one for cognitive training and one for exercise, and completed a 6-month randomized clinical trial comparing a neuroplasticity-based cognitive training plus aerobic exercise program against the same cognitive training alone. Results indicated that higher baseline scores of intrinsic motivation for cognitive training, specifically early perceptions of task interest and value, were predictive of greater cognitive training and exercise group attendance. Scores for exercise-specific intrinsic motivation were generally unrelated to indices of exercise participation, with the exception that the gain over time in perceived choice for exercise was linked with greater exercise homework completion and a similar directional tendency for greater in-clinic exercise attendance. This study provides support for monitoring and enhancing motivation early during service delivery to maximize engagement and the likelihood of successful treatment outcomes.
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Affiliation(s)
- Thanh P Le
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA.
| | - Joseph Ventura
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | - Bernalyn Ruiz-Yu
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | | | - Kenneth L Subotnik
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | - Keith H Nuechterlein
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA; Department of Psychology, University of California, Los Angeles, CA, USA
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4
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Lozano P, Butcher HK, Serrano C, Carrasco A, Lagares C, Lusilla P, O'Ferrall C. Motivational interviewing: Validation of a proposed NIC nursing intervention in persons with a severe mental illness. Int J Nurs Knowl 2021; 32:240-252. [PMID: 33533195 DOI: 10.1111/2047-3095.12317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/17/2021] [Accepted: 01/18/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Low adherence to treatment is a common problem in the care of patients with severe mental illnesses. Motivational interviewing is a directive, client-centered counseling therapeutic approach designed to elicit behavior change by helping clients to explore and resolve ambivalence. Nurses use motivational interviewing, although it has not been defined from a nursing perspective nor with nursing language. Thus, nursing research on the use of these techniques is being carried out, supported by their effectiveness in many health problems. The development of motivational interviewing as a standardized nursing intervention for inclusion in the Nursing Interventions Classification (NIC) may promote its use by mental health nurses in their daily work and thus improve the quality of care. OBJECTIVES To validate a proposed motivational interviewing nursing intervention for inclusion in the NIC. MATERIALS AND METHODS We followed the validation methodology of the NIC of the Iowa and the Intervention Normalization for Nursing Practice projects. The study comprised theoretical (scientific and expert validation) and empirical (terminological and clinical validation) phases. RESULTS There is ample evidence supporting the efficiency of the motivational interviewing to improve the therapeutic adherence of people with severe mental illness. The group of experts agreed on the label name "motivational interviewing" for the NIC based on the modified model by Miller & Röllnick (2015), which includes 28 associated activities through the phases of engaging, focusing, evoking, and planning. Development of the NANDA International and the Nursing Outcomes Classification nursing language was completed. Knowledge and drug attitude improved in the motivational intervention group. CONCLUSIONS We validated the nursing intervention motivational interviewing for inclusion in the NIC that will help improve therapeutic adherence. The intervention may be used for other behavioral changes.
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Affiliation(s)
- Pilar Lozano
- Therapeutic Community of Mental Health, Cádiz, School of Nursing and Physiotherapy, University Hospital of Puerto Real, University of Cádiz, Cádiz, Spain
| | - Howard K Butcher
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida
| | - Cecilia Serrano
- Community Mental Health UnitVejer, Cádiz, University Hospital of Puerto Real, Spain
| | - Aurelio Carrasco
- University Hospital of Puerto Real, Therapeutic Community of Mental Health, Cádiz, Spain
| | | | - Pilar Lusilla
- Psychiatric Service, University General Hospital, CIBERSAM, Autonomous University of Barcelona, Barcelona, Spain
| | - Cristina O'Ferrall
- Departament of Nursing and Physiotherapy, School of Nursing and Physiotherapy, University of Cádiz, Cádiz, Spain
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Saperstein AM, Lynch DA, Qian M, Medalia A. How does awareness of cognitive impairment impact motivation and treatment outcomes during cognitive remediation for schizophrenia? Schizophr Res 2020; 218:70-75. [PMID: 32156497 PMCID: PMC7299790 DOI: 10.1016/j.schres.2020.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/27/2020] [Accepted: 02/29/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is concern that awareness of cognitive deficit among people with schizophrenia receiving Cognitive Remediation (CR) might undermine motivation, engagement, and CR outcomes. We therefore examined the relationship of subjective awareness of cognitive deficit to aspects of motivation and cognitive learning during an efficacious CR program. METHODS Individuals with schizophrenia/schizoaffective disorder who completed 30 sessions of CR (N = 67) were evaluated on cognitive performance, self-reported cognitive difficulties, intrinsic motivation and perceived competency for cognitive training tasks at the beginning and end of treatment. RESULTS We found no relationship between actual and perceived cognitive functioning when measured cross-sectionally or as difference scores, pre/post treatment. Greater awareness of cognitive problems was associated with lower perceived competency for cognitive tasks at treatment beginning and end-point (p-values < .05). The significant relationship between awareness of cognitive problems and perceived value of the treatment at end-point was fully mediated by perceived competency. While greater perceived competency was associated with shorter time to treatment completion (p = .0025), it was intrinsic motivation measured at end-point that was associated with cognitive change (p = .02). DISCUSSION While awareness of cognitive problems may not be a prerequisite for cognitive improvement during CR, it could impact engagement in, and how one values treatment via its effect on perceived competency. Results also highlighted the importance of intrinsic motivation for doing cognitive learning activities, given its relationship to cognitive gain. Further study is needed to understand how best to assess and address awareness of cognitive abilities within the CR setting.
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Affiliation(s)
- Alice M Saperstein
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, 1051 Riverside Drive, New York, NY 10032, United States.
| | - David A Lynch
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, 1051 Riverside Drive, New York, NY 10032, United States.
| | - Min Qian
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY 10032, United States.
| | - Alice Medalia
- New York State Psychiatric Institute, Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, and New York-Presbyterian, 1051 Riverside Drive, New York, NY 10032, United States.
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Nakamura R, Asami T, Yoshimi A, Kato D, Fujita E, Takaishi M, Yoshida H, Yamaguchi H, Shiozaki K, Kase A, Hirayasu Y. Clinical and brain structural effects of the Illness Management and Recovery program in middle-aged and older patients with schizophrenia. Psychiatry Clin Neurosci 2019; 73:731-737. [PMID: 31353759 DOI: 10.1111/pcn.12919] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 07/17/2019] [Accepted: 07/23/2019] [Indexed: 01/11/2023]
Abstract
AIMS In this study, we implemented the Illness Management and Recovery (IMR) program for middle-aged and older patients with schizophrenia hospitalized for long periods and assessed the effect of the IMR program on psychiatric symptoms and psychosocial function. The effects of the IMR program on brain structure were also evaluated. METHODS The IMR program was implemented for 19 patients with schizophrenia; 17 patients with schizophrenia receiving treatment as usual (TAU) were also recruited as controls. In all patients, mean age was 61.4 years (range, 50-77 years) and mean hospitalization duration was 13.1 years (range, 1-31 years) at enrollment. Structural magnetic resonance images and Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) scores as clinical variables were obtained at the beginning and end of the IMR program. Longitudinal analyses were performed to compare the effects of the IMR program on clinical symptoms and cortical thickness in the superior temporal gyrus (STG) between the IMR and TAU groups. RESULTS Significant improvements in GAF scores and the total, Insight and Judgment, and Positive components of the PANSS were found in the IMR group compared with the TAU group. Cortical thickness in the left STG was preserved in the IMR group compared with the TAU group. CONCLUSIONS This is the first report demonstrating the effectiveness of the IMR program for improving psychotic symptoms and psychosocial function and protecting brain structure in middle-aged and older inpatients with schizophrenia hospitalized for long periods.
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Affiliation(s)
- Ryota Nakamura
- Department of Psychiatry, Graduate School of Medicine, Yokohama City University, Yokohama, Japan.,Department of Psychiatry, Yokohama Maioka Hospital, Yokohama, Japan
| | - Takeshi Asami
- Department of Psychiatry, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Asuka Yoshimi
- Department of Psychiatry, Graduate School of Medicine, Yokohama City University, Yokohama, Japan.,Department of Psychiatry, Yokohama Maioka Hospital, Yokohama, Japan
| | - Daiji Kato
- Totsuka Nishiguchi Rindou Clinic, Yokohama, Japan
| | - Emi Fujita
- Division of Clinical Psychology, Yokohama City University Hospital, Yokohama, Japan
| | - Masao Takaishi
- Department of Psychiatry, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Haruhisa Yoshida
- Department of Psychiatry, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Hiroyuki Yamaguchi
- Department of Psychiatry, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Kazumasa Shiozaki
- Department of Psychiatry, Yokohama Comprehensive Care Continuum, Yokohama, Japan
| | - Akihiko Kase
- Department of Psychiatry, Yokohama Maioka Hospital, Yokohama, Japan
| | - Yoshio Hirayasu
- Department of Psychiatry, Graduate School of Medicine, Yokohama City University, Yokohama, Japan.,Department of Psychiatry, Hirayasu Hospital, Urasoe, Japan
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