Cognitive-Behavioral Social Skills Training for patients with late-life schizophrenia and the moderating effect of executive dysfunction

Evidence-based psychosocial interventions in schizophrenia: a critical review

PURPOSE OF REVIEW

Schizophrenia Spectrum Disorders (SSD) are severe conditions that frequently produce significant impairment in cognitive performance, social skills and psychosocial functioning. As pharmacological treatment alone often provides only limited improvements on these outcomes, several psychosocial interventions are employed in psychiatric rehabilitation practice to improve of real-world outcomes of people living with SSD: the present review aims to provide a critical overview of these treatments, focusing on those that show consistent evidence of effectiveness.

RECENT FINDINGS

Several recent systematic reviews and meta-analyses have investigated in detail the acceptability, the effectiveness on several specific outcomes and moderators of response of different psychosocial interventions, and several individual studies have provided novel insight on their implementation and combination in rehabilitation practice.

SUMMARY

Cognitive remediation, metacognitive training, social skills training, psychoeducation, family interventions, cognitive behavioral therapy, physical exercise and lifestyle interventions, supported employment and some other interventions can be fully considered as evidence-based treatments in SSD. Psychosocial interventions could be of particular usefulness in the context of early intervention services. Future research should focus on developing newer interventions, on better understanding the barriers and the facilitators of their implementation in clinical practice, and exploring the opportunities provided by novel technologies.

Overview of late-onset psychoses

BACKGROUND

Several etiologies can underlie the development of late-onset psychosis, defined by first psychotic episode after age 40 years. Late-onset psychosis is distressing to patients and caregivers, often difficult to diagnose and treat effectively, and associated with increased morbidity and mortality.

METHODS

The literature was reviewed with searches in Pubmed, MEDLINE, and the Cochrane library. Search terms included "psychosis," "delusions," hallucinations," "late onset," "secondary psychoses," "schizophrenia," bipolar disorder," "psychotic depression," "delirium," "dementia," "Alzheimer's," "Lewy body," "Parkinson's, "vascular dementia," and "frontotemporal dementia." This overview covers the epidemiology, clinical features, neurobiology, and therapeutics of late-onset psychoses.

RESULTS

Late-onset schizophrenia, delusional disorder, and psychotic depression have unique clinical characteristics. The presentation of late-onset psychosis requires investigation for underlying etiologies of "secondary" psychosis, which include neurodegenerative, metabolic, infectious, inflammatory, nutritional, endocrine, and medication toxicity. In delirium, psychosis is common but controlled evidence is lacking to support psychotropic medication use. Delusions and hallucinations are common in Alzheimer's disease, and hallucinations are common in Parkinson's disease and Lewy body dementia. Psychosis in dementia is associated with increased agitation and a poor prognosis. Although commonly used, no medications are currently approved for treating psychosis in dementia patients in the USA and nonpharmacological interventions need consideration.

CONCLUSION

The plethora of possible causes of late-onset psychosis requires accurate diagnosis, estimation of prognosis, and cautious clinical management because older adults have greater susceptibility to the adverse effects of psychotropic medications, particularly antipsychotics. Research is warranted on developing and testing efficacious and safe treatments for late-onset psychotic disorders.

New horizons in schizophrenia in older people

People aged 65 years and older will soon constitute more than a quarter of the total population with schizophrenia, challenging the existing systems of care. For a long time, research into schizophrenia in later life was very limited. However, recent years have seen an encouraging surge in novel and high-quality studies related to this stage of life. Older people with schizophrenia consist of those who had an early onset and aged with the disorder, and of a smaller but sizeable group with a late onset or a very late onset. With ageing, physical needs gain importance relative to psychiatric needs. Medical comorbidity contributes to a markedly higher mortality compared to the general population. In many persons, symptoms and functioning fluctuate with time, leading to deterioration in some but improvement in others. Of note, a substantial number of older people may experience subjective well-being in spite of ongoing symptoms and social impairments. The majority of individuals with schizophrenia reside in the community, but when institutionalization is required many are placed in residential or nursing homes where staff is often ill-equipped to address their complex needs. There is a clear need for implementation of new models of care in which mental health and general health systems cooperate. This review provides a state-of-the-art overview of current knowledge in late life schizophrenia and related disorders, with a focus on themes with clinical relevance.

Dementia among older people with schizophrenia: an update on recent studies

PURPOSE OF REVIEW

This narrative review examines recently published research that examines the prevalence, underlying causes, and treatments for dementia among people with schizophrenia.

RECENT FINDINGS

People with schizophrenia have high rates of dementia, compared with the general population, and cognitive decline has been observed 14 years prior to onset of psychosis with accelerated decline in middle age. Underlying mechanisms of cognitive decline in schizophrenia include low cognitive reserve, accelerated cognitive aging, cerebrovascular disease and medication exposure. Although pharmacologic, psychosocial and lifestyle interventions show early promise for preventing and mitigating cognitive decline, few studies have been conducted in older people with schizophrenia.

SUMMARY

Recent evidence supports accelerated cognitive decline and brain changes in middle-aged and older people with schizophrenia, relative to the general population. More research in older people with schizophrenia is needed to tailor existing cognitive interventions and develop novel approaches for this vulnerable and high-risk group.

Increasing social and community participation in veterans living with schizophrenia: A treatment outcome study

People living with schizophrenia often face challenges engaging in social and community activities. A critical barrier is negative symptoms that reflect diminished feelings and thoughts that support social interaction. Several years ago, we began a process of specifying an intervention for individuals with schizophrenia and clinically meaningful negative symptoms that could be delivered in an integrated fashion with mental health services offered in VA medical centers with the primary focus of improving social and community engagement. In the present study, we examined the impact of a multi-component intervention to improve social and community participation in a group of Veterans living with schizophrenia and negative symptoms. We compared an intervention called Engaging in Community Roles and Experiences (EnCoRE) - a 12-week program of individual and group meetings that support learning and implementing skills with the goal of helping participants increase engagement in personally-relevant social and community activities - to an active wellness education control condition. Participants in both conditions attended on average of at least half of the groups that were offered, indicating that many individuals living with negative symptoms are willing to participate in an intervention to improve social and community participation. Although there were no significant differences on the two primary outcomes, those in EnCoRE showed better social and general functioning at post treatment and improved social motivational negative symptoms and decreases in perceived limitations at a 3-month follow-up. EnCoRE may be especially beneficial for participants who endorsed more dysfunctional attitudes about their abilities.