Psychosocial treatments for schizophrenia

Sex differences in prolactin levels and clinical outcomes in patients with a first psychotic episode

AIM

To analyze the clinical, neurocognitive, and functional impact of prolactin levels according to sex in patients with a First Episode Psychosis (FEP).

METHODS

We measured prolactin levels in 221 non-affective FEP patients treated with antipsychotics (AP) and 224 healthy controls, at baseline and 2-year follow-up. We examined whether the relationships between clinical and functional variables were mediated by prolactin, controlling for antipsychotic use, according to sex.

RESULTS

Prolactin levels were higher in patients when compared to controls at both time points. Baseline factors associated with prolactin were chlorpromazine equivalents, attention, and executive functioning. In the FEP group, prolactin levels were associated with functioning and diminished expression in males, and with working memory in females. Prolactin levels (p=0.0134) played a role as a mediator between negative symptomatology (p=0.086) and functional outcome (p=0.008) only in FEP male patients at baseline.

CONCLUSIONS

Prolactin plays a role in the functionality and clinical symptomatology of FEP patients. Our results suggest that pharmacological counselling in patients with hyperprolactinemia at baseline and negative symptomatology might improve their functional and clinical outcomes.

Comparing outcomes of psychiatric rehabilitation between ethnic-religious groups in Israel

Psychiatric rehabilitation for people with severe mental illness (SMI) has many documented benefits, but less is known about cultural related aspects. To date, no comparison of psychiatric rehabilitation outcomes between Israeli Jews and Israeli Arabs has been carried out. Thus, the purpose of the present study was to compare the outcome measures of Israeli Arabs and Israeli Jews consuming psychiatric rehabilitation services. As part of the Israeli Psychiatric Rehabilitation Reported Outcome Measurement project (PR-ROM), a cross-sectional study comparing different ethnic-religious groups was performed. Data is based on 6,751 pairs of psychiatric rehabilitation consumers and their service providers. The consumers filled questionnaires on quality of life (QoL) and functioning, and their providers completed mirroring instruments. The findings revealed that QoL and functioning ratings were lower among Muslim Arabs compared to Jews on both consumers' and providers' ratings. Among Muslim Arabs, differences in outcomes according to the service's location were indicated. The observed differences between Israeli Arabs and Israeli Jews with SMI in the PR-ROM point to the need for culturally adapted rehabilitation services that take into account how cultural differences may affect the benefits of such services.

Systematic Review and Meta-analysis of Exercise Interventions for Psychotic Disorders: The Impact of Exercise Intensity, Mindfulness Components, and Other Moderators on Symptoms, Functioning, and Cardiometabolic Health

BACKGROUND AND HYPOTHESIS

Exercise therapy has been shown to be an effective complementary treatment for patients with psychotic disorders. However, the specific impacts of different training modalities remain poorly understood. This article aims to quantitatively review the moderating influence of different exercise modalities, hypothesizing that higher exercise intensity as well as utilization of mindfulness-based exercise (MBE) components, will improve intervention outcomes.

STUDY DESIGN

PubMed, Web of Science, and PsycINFO were searched from 2010 to March 2022 for randomized controlled trials investigating exercise interventions in patients with psychotic disorders (preregistration: https://doi.org/10.17605/OSF.IO/J8QNS). Outcomes considered were positive/negative symptoms, Positive and Negative Syndrome Scale (PANSS) General Psychopathology/Total scores, depressive symptoms, psychosocial functioning, quality of life, cardiorespiratory fitness, and body mass index. Separate meta-analyses, including moderator analyses, were performed to evaluate the moderating influence of different training modalities.

STUDY RESULTS

Of 6653 studies, 40 (n = 2111 patients) were included in the meta-analysis. The effects of moderate-intensity exercise exceed low-intensity approaches for PANSS Total scores (P = .02) and depressive symptoms (P = .04). The presence of MBE components was associated with improvements in positive symptoms (P = .04) and PANSS General Psychopathology subscores (P = .04) but also with higher error and between-study heterogeneity. Our analysis also shows improved intervention effects on depression in younger patients (P = .012) and improved psychosocial functioning scores following more frequent sessions (P < .01).

CONCLUSIONS

A minimum of moderate intensity should be considered. More frequent training sessions per week also seem to be beneficial. While adding mindfulness elements is promising, it increases heterogeneity and requires caution in terms of generalization.

Staff supported community outings among forensic mental health patients: patient characteristics, rehabilitative goals, and (the absence of) adverse outcomes

Mental health professionals are tasked with making difficult clinical decisions in treatment settings. In the forensic system, decision making regarding staff supervised community outings (SSCOs) provides a significant challenge due to the need to balance patient liberties, mental health recovery, and public safety. This study explored the characteristics and rehabilitative nature of SSCOs, characteristics of patients attending SSCOs, and any adverse events that occurred during the outings. Employing a cross-sectional design, 110 patients who participated in SSCOs over a one-year period from a Canadian Forensic Psychiatric Hospital were included. Clinical records were reviewed to capture patient and SSCO variables. Descriptive analyses were used to calculate participant, risk, SSCO, and adverse event characteristics. Qualitative analysis was used to explore the purpose of SSCOs and rehabilitative progress that occurred during the outings. Patients attending SSCOs were comprised of long-stay patients with over half having committed a violent index offence. Almost 75% of patients had a moderate/high risk for violence and 50% of the patients had a moderate/high risk of absconding. During the study period, 463 SSCOs were completed. Most outings focused on developing skills for daily living and staff comments suggested many patients developed skills in these areas. Despite considerable risk profiles and public concern regarding forensic patients having community access, there was a single occurrence of unauthorized leave and no instances of violence or substance use. This research can disrupt stigma, demonstrating that SSCOs support a specific rehabilitative intent, promote community reintegration, and maintain public safety.

Diverse elements comprising studies of peer support complicate evidence synthesis

BACKGROUND

Innovative approaches to care, such as peer support, are needed to address the substantial and frequently unmet needs of people with serious mental illnesses such as schizophrenia. Although peer support services continue to expand in mental healthcare, findings of effectiveness from systematic reviews are mixed. However, the studies evaluated in these reviews consisted of diverse elements which the review methods neglected to consider.

AIMS

This review aims to demonstrate the substantial diversity in intervention components and measured outcomes among studies of peer support and lay the groundwork for more focused reviews of individual intervention components.

METHODS

As part of a realist review of the literature, here we synthesize evidence in a way that examines the substantial diversity in intervention components and measured outcomes comprising studies of peer support.

RESULTS

Seven categories of outcomes were represented, including recovery, symptoms and functioning, and care utilization. Importantly, seven distinct intervention components were represented in 26 studies: "being there," assistance in self-management, linkage to clinical care and community resources, social and emotional support, ongoing support, explicit utilization of shared lived experience or peer support values, and systems advocacy. Reflecting diversity in approaches, no study reported all intervention components, and no component was found among all studies.

IMPLICATIONS

Peer support services constitute a category of intervention approaches far too varied to evaluate as a single entity. Results suggest intervention components deserving more focused research, including assistance in self-management, "being there," and explicit utilization of shared lived experience or peer support values.

PRISMA/PROSPERO

As this article reports results from a realist review of the literature, we did not follow the PRISMA guidance which is suitable for systematic reviews. We did follow the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidelines.This review was not registered on PROSPERO as it is not a systematic review.

The revised Psychosis Attachment Measure: further psychometric evidence

PURPOSE

Disorganised attachment is a key concept in understanding the development of psychosis. However, existing questionnaires of adult attachment do not adequately measure this construct hindering future research into the psychosocial causes of psychosis. The most widely measure of adult attachment in people experiencing psychosis is the Psychosis Attachment Measure (PAM). The measure has recently been revised to include disorganised attachment items. This study develops previous research by providing a rigorous examination the psychometric properties of the revised questionnaire (PAM-R).

METHODS

A total of 407 participants with self-reported experiences of psychosis completed a battery of questionnaires which included the PAM-R and other measures which were conceptually related to the concept of disorganised attachment.

RESULTS

Confirmatory factor analysis (CFA) indicated a three-factor solution with factors corresponding to anxious, avoidant, and disorganised attachment. The majority of the fit statistics were acceptable with the exception of the RMSEA statistic. Internal consistency and test-retest reliability were good for all subscales. The disorganised subscale correlated in expected directions with other measures of attachment, dissociation, trauma, and psychotic experiences.

CONCLUSION

The PAM-R is a valid and reliable measure of adult attachment. It is a practical assessment tool for clinicians and researchers to measure insecure and disorganised attachment patterns that is acceptable to people experiencing psychosis.

Which psychological interventions improve quality of life in patients with schizophrenia-spectrum disorders? A meta-analysis of randomized controlled trials

Quality of life (QoL) is a major patient reported outcome used to measure the psychological treatments success in people with schizophrenia-spectrum disorders. To date, the specific impact of different interventions on QoL remains undefined. A meta-analysis of Randomized Controlled Trials (RCTs) was carried out for this purpose. We searched Proquest, PUBMED/MEDLINE, PsycINFO, WOS, Scopus, the Cochrane Library for RCTs published until January 2023. We used multilevel meta-analysis to examine differences between intervention effectiveness of experimental and control conditions whilst accounting for data dependencies. By means of subgroup analyses, we investigated influences of intervention types (i.e. psychoeducation v. CBT v. cognitive v. combination of several types v. other, such as psychodynamic, systemic, etc.) and continuous moderators were examined with precision-weighted meta-regressions. The generalizability of results across moderators, their combinations, and analytical approaches was investigated with multiverse meta-analyses. We examined data of 60 independent studies, reporting intervention effects for objective and subjective QoL (k = 19 and 70 effect sizes based on N = 1024 and 6254 participants, respectively). Overall, psychological interventions seemed to be more effective for objective than for subjective QoL. However, specific intervention results were differentiated, suggesting largest effects of psychoeducation on objective and combined interventions on subjective QoL. Our findings suggest that QoL is a valid outcome criterion for testing intervention effectiveness, as it is sensitive to change. Additionally, psychological interventions can improve patients' QoL, though the effects are small. Further testing of less widely used interventions and a shift toward the multidimensional nature of QoL is still necessary.

Enhancing educational and vocational recovery in adolescents and young adults with early psychosis through Supported Employment and Education (SEEearly): study protocol for a multicenter randomized controlled trial

BACKGROUND

Psychotic disorders often develop a chronic course with devastating consequences for individuals, families, and societies. Early intervention programs for people in the first 5 years after the initial psychotic episode (early psychosis) can significantly improve the outcome and are therefore strongly recommended in national and international guidelines. However, most early intervention programs still focus on improving symptoms and relapse prevention, rather than targeting educational and vocational recovery. The aim of the present study is to explore the effects of Supported Employment and Education (SEE) following the Individual Placement and Support (IPS) model in people with early psychosis.

METHODS

The SEEearly trial compares treatment as usual (TAU) plus SEE to TAU alone in outpatient psychiatric settings. The study is a six-site, two-arm, single-blinded, superiority randomized controlled trial (RCT). Participants are randomly assigned (1:1) to the intervention or control group. Aiming to recruit 184 participants, with an assumed drop-out rate of 22%, we will be able to detect a 24% difference in the main outcome of employment/education with 90% power. We make assessments at baseline and at 6- and 12-month follow-ups. Outcome data on employment/education, medication, and current psychiatric treatment is obtained monthly through phone based short assessments. The primary outcome is steady participation for at least 50% of the 12-month follow-up in competitive employment and/or mainstream education. Secondary employment outcomes capture length of employment/education, time to first employment/education, monthly wages/educational attainment, and social return on investment (SROI). Secondary non-employment outcomes include subjective quality of life, psychopathology, substance use, relapse, hospitalization, and functional impairment. To be eligible, participants must be between 16 and 35 years, fulfill diagnostic criteria for early psychosis, and be interested in competitive employment and/or mainstream education.

DISCUSSION

In SEEearly, we hypothesize that participants with psychosis, who receive TAU plus SEE, present with better primary and secondary outcomes than participants, who receive TAU alone. Positive results of this study will justify SEE as an evidence-based strategy for clinical routine treatment in people with early psychosis.

TRIAL REGISTRATION

SEEearly was registered nationally and internationally in the German Clinical Trials Register (DRKS; identifier: DRKS00029660) on October 14, 2022.

Development of a Digital Program for Training Community Health Workers in the Detection and Referral of Schizophrenia in Rural India

This study aimed to develop and assess the acceptability of a digital program for training community health workers (CHWs) in the detection and referral of patients with schizophrenia in community settings in rural India. An iterative design process was employed. First, evidence-based content from existing community programs for schizophrenia care was incorporated into the curriculum, and reviewed by experts to ensure clinical utility and fidelity of the adapted content. Second, CHWs provided feedback on the appropriateness of language, content, and an initial prototype of the digital training program to ensure relevance for the local context. Focus group discussions were then used to understand the acceptability of the digital training prototype and to inform modifications to the design and layout. Qualitative data was analysed using a rapid thematic analysis approach based on predetermined topics pertaining to acceptability of the training content and digital platform. Development of the initial prototype involved content review by 13 subject matter experts with clinical expertise or experience accessing and receiving mental health services, and engagement of 23 CHWs, of which 11 provided feedback for contextualization of the training content and 12 participated in focus group discussions on the acceptability of the prototype. Additionally, 2 service-users with lived experience of schizophrenia contributed to initial testing of the digital training prototype and offered feedback in a focus group discussion. During contextualization of the training content, key feedback pertained to simplifying the language and presentation of the content by removing technical terms and including interactive content and images to enhance interest and engagement with the digital training. During prototype testing, CHWs shared their familiarity with similar symptoms but were unaware of schizophrenia as a treatable illness. They shared that training can help them identify symptoms of schizophrenia and connect patients with specialized care. They were also able to understand misconceptions and discrimination towards people with schizophrenia, and how to address these challenges by supporting others and spreading awareness in their communities. Participants also appreciated the digital training, as it could save them time and could be incorporated within their routine work. This study shows the acceptability of leveraging digital technology for building capacity of CHWs to support early detection and referral of schizophrenia in community settings in rural India. These findings can inform the subsequent evaluation of this digital training program to determine its impact on enhancing the knowledge and skills of CHWs.

The Patient Journey of Schizophrenia in Mental Health Services: Results from a Co-Designed Survey by Clinicians, Expert Patients and Caregivers

BACKGROUND

The Patient Journey Project aims to collect real-world experiences on schizophrenia management in clinical practice throughout all the phases of the disorder, highlighting virtuous paths, challenges and unmet needs.

METHODS

A 60-item survey was co-designed with all the stakeholders (clinicians, expert patients and caregivers) involved in the patient's journey, focusing on three areas: early detection and management, acute phase management and long-term management/continuity of care. For each statement, the respondents expressed their consensus on the importance and the degree of implementation in clinical practice. The respondents included heads of the Mental Health Services (MHSs) in the Lombardy region, Italy.

RESULTS

For early diagnosis and management, a strong consensus was found; however, the implementation degree was moderate-to-good. For acute phase management, a strong consensus and a good level of implementation were found. For long-term management/continuity of care, a strong consensus was found, but the implementation level was slightly above the cut-off, with 44.4% of the statements being rated as only moderately implemented. Overall, the survey showed a strong consensus and a good level of implementation.

CONCLUSIONS

The survey offered an updated evaluation of the priority intervention areas for MHSs and highlighted the current limitations. Particularly, early phases and chronicity management should be further implemented to improve the patient journey of schizophrenia patients.

Digital health innovation to prevent relapse and support recovery in young people with first-episode psychosis: A pilot study of Horyzons-Canada

Digital health innovations may help to improve access to psychosocial therapy and peer support; however, the existence of evidence-based digital health interventions for individuals recovering from a first-episode psychosis (FEP) remains limited. This study aims to investigate the feasibility, acceptability, safety, and pre-post outcomes of Horyzons-Canada (HoryzonsCa), a Canadian adaptation of a digital mental health intervention consisting of psychosocial interventions, online social networking, and clinical and peer support moderation. Using a convergent mixed-methods research design, we recruited participants from a specialized early intervention clinic for FEP in Montreal, Canada. Twenty-three participants (mean age = 26.8) completed baseline assessments, and 20 completed follow-up assessments after 8 weeks of intervention access. Most participants provided positive feedback on general experience (85%, 17/20) and the utility of Horyzons for identifying their strengths (70%, 14/20). Almost all perceived the platform as easy to use (95%, 19/20) and felt safe using it (90%, 18/20). There were no adverse events related to the intervention. Participants used HoryzonsCa to learn about their illness and how to get better (65%, 13/20), receive support (60%, 12/20), and access social networking (35%, 7/20) and peer support (30%, 6/20). Regarding adoption, 65% (13/20) logged in at least 4 times over 8 weeks. There was a nonsignificant increase in social functioning and no deterioration on the Clinical Global Impression Scale. Overall, HoryzonsCa was feasible to implement and perceived as safe and acceptable. More research is needed with larger sample sizes and using in-depth qualitative methods to better understand the implementation and impact of HoryzonsCa.

A critical review of children's culinary nutrition interventions, the methodologies used and their impact on dietary, psychosocial and wellbeing outcomes

Diet quality has been associated with numerous health outcomes, resulting in nutrition education to improve children's diet quality. Culinary nutrition interventions have been emphasised as a promising approach for enhancing children's food preferences and behaviours. Recently, there has been an increase in such interventions, and it is essential to understand their effectiveness and the specific methods used. Therefore, this review aimed to critically investigate methodological approaches in a range of children's culinary nutrition interventions and experiments. A secondary aim was to investigate the impact of these interventions on dietary, psychosocial and wellbeing outcomes. A systematic and pragmatic search strategy was developed and implemented using two electronic databases. Data extraction of the relevant content of eligible studies and a narrative synthesis were conducted. A total of 12 312 articles were identified from the search and 38 studies on children's culinary nutrition interventions or experiments were included. Most studies (n = 25) were conducted in North America. Only two studies had an RCT design. Less than half the studies (n = 16) used an underpinning theory, model or framework. Only four studies conducted sample size calculations. Some validated measurement tools were used. Despite the methodological concerns, most studies found some positive changes in dietary and/or psychosocial outcomes, while only two studies assessed wellbeing. Therefore, the area warrants further in-depth research anchored in methodological rigor to strengthen the validity of the research. The strengthening of the evidence in children's culinary nutrition could have a significant beneficial impact on public health if it resulted in widespread interventions and, in the long-term, reduce the impact on health systems.

Factors Influencing the Level of Depression and Anxiety of Community-Dwelling Patients with Schizophrenia in China during the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) poses a huge challenge to global public health. People with schizophrenia living in communities urgently need effective interventions to help them adjust to life and work, but they have not received enough attention. This study aims to assess the prevalence of anxiety and depression symptoms in community-dwelling patients with schizophrenia in China during the epidemic and to explore the possible influencing factors.

METHODS

Using a cross-sectional survey, we collected 15,165 questionnaires. Assessments included demographic information, concern about COVID-19-related information, sleep status, anxiety and depressive symptoms, and accompanying illnesses. The 7-item Generalized Anxiety Disorder (GAD-7) and the 9-item Patient Health Questionnaire (PHQ-9) were used to evaluate depression and anxiety levels. Group comparison was conducted by t-test, ANOVA, or chi-square test wherever suitable, with Bonferroni pairwise correction. Multivariate logistic regression was performed to identify predictors for anxiety and depression.

RESULTS

16.9% of patients had at least moderate anxiety, and 34.9% had at least moderate depression. T-test showed that females scored higher on GAD-7 and PHQ-9 than males, and patients without accompanying long-standing diseases, who were not concerned about COVID-19, had lower GAD-7 and PHQ-9 scores. ANOVA showed that participants aged from 30 to 39, with higher education scored higher on GAD-7, and patients with better sleep, and having less concern about COVID-19, had lower GAD-7 and PHQ-9 scores. Regression analysis indicated that participant ages of 30-39 and 40-49 positively predicted anxiety, whereas patient ages of 30-39 years positively predicted depression. Patients with poor sleep, accompanying diseases, and concern about the COVID-19 pandemic were more likely to experience anxiety and depression.

CONCLUSION

During the pandemic, Chinese community-dwelling patients with schizophrenia had high rates of anxiety and depression. These patients deserve clinical attention and psychological intervention, especially those with risk factors.

Organisational change to integrate self-management into specialised mental health services: Creating collaborative spaces

INTRODUCTION

Self-management support for schizophrenia has become expected practice leaving organisations to find ways for feasible implementation. Self-management support involves a foundational cultural shift for traditional disease-based services, new ways of clients-providers working together, coupled with delivering a portfolio of tools and techniques. A new model of self-management support embedded into traditional case management services, called SET for Health (Self-management Engaging Together for Health),  was designed and tailored to make such services meaningfully accessible to clients of a tertiary care centre. This paper describes the proof of concept demonstration efforts, the successes/challenges, and initial organisational changes.

METHOD

An integrated knowledge translation approach was selected as a means to foster organisational change grounded in users' daily realities. Piloting the model in two community case management programmes, we asked two questions: Can a model of self-management support be embedded in existing case management and delivered within routine specialised mental health services? What organisational changes support implementation?

RESULTS

Fifty-one clients were enroled. Indicators of feasible delivery included 72.5% completion of self-management plans in a diverse sample, exceeding the 44% set minimum; and an attrition rate of 21.6%, less than 51% set maximum. Through an iterative evaluation process, the innovation evolved to a targeted hybrid approach revolving around client goals and a core set of co-created reference tools, supplemental tools and resources. Operationalisation by use of tools was implemented to create spaces for client-provider collaborations. Monitoring of organisational changes identified realignment of practices. Changes were made to procedures and operations to further spread and sustain the model.

CONCLUSION

This study demonstrated how self-management support can be implemented, within existing resources, for routine delivery of specialised services for individuals living with schizophrenia. The model holds promise as a hybrid option for supporting clients to manage their own health and wellness.

Preparing an integrated self-management support intervention for people living with schizophrenia: Creating collaborative spaces

INTRODUCTION

This article describes the planning and development of a novel self-management support protocol, self-management engaging together (SET) for Health, purposefully designed and embedded within traditional case management services to be accessible to people living with schizophrenia and comorbidities. Drawing on established self-management principles, SET for Health was codesigned by researchers, healthcare providers and clients, to create a practical and meaningful intervention to support the target group to manage their own health and wellness. Decision making is described behind tailoring the self-management innovation to meet the needs of an at risk, disadvantaged group served by tertiary, public health care in Canada.

METHOD

This integrated knowledge translation (IKT) study used a descriptive approach to document the process of planning and operationalizing the SET for Health intervention as a part of routine care in two community-based teams providing predominantly schizophrenia services. Diffusion of innovations literature informed planning. The setting was strategically prepared for organizational change. A situational assessment and theoretical frameworks identified contextual elements to be addressed. Existing established self-management approaches for mental illness were appraised.

RESULTS

When a review of established approaches revealed incongruence with the aims and context of service delivery, common essential elements were distilled. To facilitate collaborative client-provider self-management conversations and self-management learning opportunities, core components were operationalized by the use of tailored interactive tools. The materials coproduced by clients and providers offered joint reference tools, foundational for capacity-building and recognition of progress.

CONCLUSION

Planning and developing a model of self-management support for integration into traditional schizophrenia case management services required attention to the complex social ecological nature of the treatment approach and the workplace context. Demonstration of proof of concept is described in a separate paper.

Women involvement in the informal caregiving field: A perspective review

The patient recovery process of individual with mental health disorder is reinforced if they are connected with their community and supported by relatives. The literature has shown that caregivers are important, although their roles can lead to alterations in their own health; and women are the most involved in this role. The present review investigated women's involvement in the informal caregiver scientific field. A literature review indicated gender differences; researchers who are women are more interested in this field than men. Even with a good representation of women in this scientific field, the results showed a statistically significant gender difference for the first and second authors, whereas there was no significant gender difference among the last authors. More efforts must be made to recognize the importance of women's involvement in research because they raise a specific important field. Family caregivers are key players in the healthcare system, but to date, there has been little recognition of their enormous contribution. Our results also indicated the informal caregiver role is filled more by women than by men, which creates social inequalities in many domains, especially in opportunities at the professional level. Tailored interventions are required to address the specific needs and issues of family caregivers. A better redistribution of unpaid work, such as informal caregiving, compared to paid work must be made to respect gender in social existence.

Smoking and attention in schizophrenia spectrum disorders: What are we neglecting?

Introduction

Individuals with schizophrenia spectrum disorders (SSDs) record elevated rates of smoking, which is often attributed to their effort to self-medicate cognitive and attentional symptoms of their illness. Empirical evidence for this hypothesis is conflicting, however. In this study, we aimed to test predictions derived from the cognitive self-medication hypothesis. We predicted that cigarette smoking status and extent would predict the attentional performance of participants with SSDs. Simultaneously, we wished to address methodological gaps in previous research. We measured distinct attentional components and made adjustments for the effects of other, attention-modulation variables.

Methods

Sixty-one smokers (82.0% males, 26.73 ± 6.05 years) and 61 non-smokers (50.8% males, 27.10 ± 7.90 years) with recent-onset SSDs completed an X-type Continuous Performance Test, which was used to derive impulsivity and inattention component scores. Relationships between the two component scores and cigarette smoking status and extent were assessed using hierarchical regression. Effects of estimated premorbid intellectual functioning and antipsychotic medication dosage were held constant.

Results

Smokers had significantly higher inattention component scores than non-smokers when covariates were controlled (p = 0.026). Impulsivity remained unaffected by smoking status (p = 0.971). Cigarette smoking extent, i.e., the number of cigarettes smoked per day, was not associated with either inattention (p = 0.414) or impulsivity (p = 0.079).

Conclusion

Models of smoking-related attentional changes can benefit from the inclusion of sample-specific component scores and attention-modulating covariates. Under these conditions, smokers with SSDs can show a partial attentional benefit. However, the limited scope of this benefit suggests that the cognitive self-medication hypothesis requires further testing or reconsidering.

Psychiatric rehabilitation patterns in Italy: Results from the Italian Society of Psychosocial Rehabilitation (SIRP) survey

INTRODUCTION

Psychiatric rehabilitation can be considered a bidirectional technique, designed to allow patients to achieve their personal target, focusing on the individuals' strengths and challenges related to these targets and also on the community organizations in which they will live them out. Unfortunately, psychiatric rehabilitation is too often not considered a first line treatment. Moreover, rehabilitation has been confused with a generic and rough practice, consisting of extemporary actions and aimless entertainments designed to fill "the time passing".

METHODS

The aim of this study was to increase the knowledge and awareness about the state of the art of different systems of management and funding of psychosocial rehabilitation in the Italian "real-world" rehabilitative settings, using a specifically developed questionnaire.

RESULTS

The data obtained are positive for some aspects of the rehabilitation interventions, in particular for the use of validated tools for the evaluation and revision of projects and for the trend to work on a team, even though the scarcity of evidence-based rehabilitation interventions applied in Italian psychiatric services is less encouraging.

CONCLUSION

This survey presents, at least partially, the "real-world" of rehabilitation in Italy so that we can lay the foundations for the definition of an updated, validated and shared network of what is implemented in the context of psychiatric rehabilitation.

The Use of Second-Generation Antipsychotics in Patients with Severe Schizophrenia in the Real World: The Role of the Route of Administration and Dosage-A 5-Year Follow-Up

To assess the impact of the route of administration and doses of second-generation antipsychotics (SGAs) on treatment adherence, hospital admissions, and suicidal behaviour in patients with severe schizophrenia (Clinical Global Impression−Severity−CGI-S ≥ 5), we implemented an observational 5-year follow-up study. A total of 37.5% of the patients on oral antipsychotics (Aps) and 11.5% of those on long-acting injectables (LAIs) abandoned the treatment (p < 0.001). There were no differences in treatment discontinuation between the LAI-AP standard and high-dose groups. A total of 28.1% of the patients on oral Aps had at least one hospitalisation, as well as 13.1% of patients on LAIs (p < 0.001). There were fewer hospitalisations of patients on LAIs in the high-dose group (p < 0.05). Suicide attempts were recorded for 18% of patients on oral Aps but only for 4.6% of patients on LAIs (p < 0.001). No differences were found between the dosage groups on LAIs. Tolerability was good for all Aps and somewhat better for LAIs than oral Aps in terms of side effects (p < 0.05). There were no differences between the standard and high-dose groups. More patients discontinued treatment due to side effects in the oral AP group (p < 0.01). LAI SGA treatment was more effective than oral AP in terms of adherence and treatment outcomes for managing people with severe schizophrenia. Moreover, significant improvements were found that favour high-dose LAI SGA treatment for some of these patients. This study highlights the need to consider LAI antipsychotics and high-dose strategies for patients with severe schizophrenia.

Depression Mediates the Relationships between Hallucinations, Delusions, and Social Isolation in First-Episode Psychosis

Social isolation is common among individuals with schizophrenia spectrum and other psychotic disorders. Research indicates that social isolation relates to poorer mental health outcomes, depression, and negative symptoms, with less known about its relationship with positive symptoms. This study examined depression as a mediator in the relationships between positive symptoms (i.e., hallucinations and delusions) and social isolation among an early treatment phase sample in the United States. Data were obtained from the Recovery After an Initial Schizophrenia Episode project of the National Institute of Mental Health's Early Treatment Program. Participants (N = 404) included adults between ages 15 and 40 in a first episode of psychosis. Data were analyzed using structural equation modeling in Mplus (Version 8). The study showed that delusions (b = .095, SE = 0.04, p < .05) and hallucinations (b = .076, SE = 0.03, p < .01) were directly related to depression, and that both delusions (b = .129, SE = 0.06, p < .05) and depression (b = .254, SE = 0.09, p < .05) were directly related to social isolation. Findings of this study determined that depression functioned as a mediator in the relationships between positive symptoms and social isolation. Targeting psychosis symptomatology and depression in treatment, improving social skills and social support networks, and considering the role of stigma in social isolation are of great importance in the prevention of poorer mental health outcomes.

A Community Navigation Scale for Persons With Serious Mental Illnesses

OBJECTIVE

The recovery paradigm in the context of serious mental illnesses pertains to several characteristics of community functioning, adjustment, and integration, among other constructs. Additional rating scales would be beneficial for measuring various facets of community functioning for research that is recovery oriented as opposed to symptom focused. The Community Navigation Scale was developed as part of the Opening Doors to Recovery project to address several aspects of navigating community resources.

METHODS

After item development, the 21-item Community Navigation Scale was used across two studies with 340 participants who had serious mental illnesses. Factor analysis revealed three potential factors, and subscales were computed.

RESULTS

The social and physical well-being subscale (seven items, Cronbach's α=0.82) addressed community involvement, volunteering, finding enjoyable activities, and engaging in positive health behaviors. The accessing external resources subscale (nine items, Cronbach's α=0.80) tapped one's ability to obtain needed resources, ranging from medications to housing and from small appliances to classes in the community. The home and self-maintenance subscale (five items, Cronbach's α=0.73) measured abilities around shopping, cooking, cell phone use, house cleaning, and personal grooming and hygiene. Initial validity of the subscales was suggested through correlations with the Multnomah Community Ability Scale (r=0.65, 0.55, and 0.41 for social and physical well-being, accessing external resources, and home and self-maintenance, respectively).

CONCLUSIONS

The Community Navigation Scale assesses dimensions of community functioning among persons with serious mental illnesses and may add to the array of research and clinical measures pertinent to recovery outcomes. Additional research on its psychometric properties is warranted.

A qualitative exploration of perceived needs and barriers of individuals with schizophrenia, caregivers and clinicians in using mental health applications in Madhya Pradesh, India

Introduction

About 3.5 million people are living with schizophrenia in India, with most failing to receive minimally adequate care. Digital mental health applications could potentially decrease this treatment gap; however, these applications should be tailored to meet the needs and overcoming barriers of its end-users to ensure their adoption and sustained usage. Few studies in India have explored the perspectives of target stakeholders to understand how digital tools could be viable for supporting care. Therefore, this study explores the perceived needs and barriers of patients with schizophrenia, caregivers and clinicians in using digital mental health applications.

Methods

Focus group discussions (FGDs) were conducted with patients having schizophrenia attending outpatient clinics at a government tertiary hospital, and their caregivers, and mental health clinicians in Bhopal, Madhya Pradesh, India. FGDs were audio-recorded and coded. Framework analysis was employed to guide the analysis, involving deductive and inductive generation of themes, data triangulation and comparison of perspectives between participant groups.

Results

Six FGDs were conducted with individuals with schizophrenia (n ​= ​11), their caregivers (n ​= ​14), and mental health clinicians (n ​= ​19). Four a priori themes were established: a) Prior experiences with health applications; b) Content of a mental health application; c) Involvement of caregivers in mental health application usage and d) Supporting doctors' work through mental health applications. Additionally, two themes were generated inductively: a) Qualities of a mental health application and b) Data privacy and confidentiality.

Conclusion

Exploration of stakeholder perspectives on the content, features, and uses of mental health applications is crucial to yield initial insights about the use of these digital programs in India. This study generated a multitude of suggestions on app functionality and components, which can guide ongoing efforts to develop and deliver digital mental health applications for patients living with schizophrenia in low-resource settings, with limited access to mental health services.

Bringing Psychology Students Closer to People with Schizophrenia at Pandemic Time: A Study of a Distance Anti-stigma Intervention With In-presence Opportunistic Control Group

Psychology students are a target population to increase the likelihood that Persons With Schizophrenia (PWS) will receive evidence-based psycho-social interventions in the future. The willingness of future psychologists to care for PWS can be supported through anti-stigma educational interventions. During the pandemic, university education was delivered largely at-distance, which was later combined with in-presence education. This study explored whether an At-Distance Educational Intervention (ADEI), addressing stigma in schizophrenia via scientific evidence and testimony: would improve psychology students' views of PWS, at the one-month post intervention re-assessments; would be more effective of the same In-Presence Educational Intervention (IPEI). ADEI was delivered online to students of two Master's degrees in Psychology at the University of Campania "Luigi Vanvitelli", Caserta, Italy. IPEI was administered to a similar group of 76 students in the pre-pandemic era. Participants completed an anonymous questionnaire about their views on schizophrenia before the intervention (two three-hour sessions one week apart) and one month after its completion. Compared to their pre-intervention assessments, at post-intervention reassessments the 65 ADEI students were: more confident in the recovery and the usefulness of psychological therapies; surer of the PWS awareness and capability to report health problems to professionals; more skeptical about PWS dangerousness, social distance, and affective difficulties; more uncertain on the opportunity to discriminate PWS in hospital and psychology practices. ADEI was more effective than IPEI in five of the ten dimensions analyzed and similarly effective in the remaining others. ADEI may represent a valuable alternative to IPEI for improving future psychologists' view of PWS.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40737-022-00308-1.

Barriers and facilitators when implementing family involvement for persons with psychotic disorders in community mental health centres - a nested qualitative study

Background

The uptake of family involvement in health care services for patients with psychotic disorders is poor, despite a clear evidence base, socio-economic and moral justifications, policy, and guideline recommendations. To respond to this knowledge-practice gap, we established the cluster randomised controlled trial: Implementation of guidelines on Family Involvement for persons with Psychotic disorders in community mental health centres (IFIP). Nested in the IFIP trial, this sub-study aims to explore what organisational and clinical barriers and facilitators local implementation teams and clinicians experience when implementing family involvement in mental health care for persons with psychotic disorders.

Methods

We performed 21 semi-structured focus groups, including 75 participants in total. Implementation team members were interviewed at the initial and middle phases of the intervention period, while clinicians who were not in the implementation team were interviewed in the late phase. A purposive sampling approach was used to recruit participants with various engagement in the implementation process. Data were analysed using manifest content analysis.

Results

Organisational barriers to involvement included: 1) Lack of shared knowledge, perceptions, and practice 2) Lack of routines 3) Lack of resources and logistics. Clinical barriers included: 4) Patient-related factors 5) Relative-related factors 6) Provider-related factors. Organisational facilitators for involvement included: 1) Whole-ward approach 2) Appointed and dedicated roles 3) Standardisation and routines. Clinical facilitators included: 4) External implementation support 5) Understanding, skills, and self-efficacy among mental health professionals 6) Awareness and attitudes among mental health professionals.

Conclusions

Implementing family involvement in health care services for persons with psychotic disorders is possible through a whole-ward and multi-level approach, ensured by organisational- and leadership commitment. Providing training in family psychoeducation to all staff, establishing routines to offer a basic level of family involvement to all patients, and ensuring that clinicians get experience with family involvement, reduce or dissolve core barriers. Having access to external implementation support appears decisive to initiate, promote and evaluate implementation. Our findings also point to future policy, practice and implementation developments to offer adequate treatment and support to all patients with severe mental illness and their families.

Trial registration

ClinicalTrials.gov Identifier NCT03869177. Registered 11.03.19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08489-y.

Effectiveness of More Personalized, Case-Managed, and Multicomponent Treatment for Patients with Severe Schizophrenia Compared to the Standard Treatment: A Ten-Year Follow-Up

Case management is a model of personalized intervention in people with severe mental illness. To explore the treatment adherence and effectiveness of patients with severe schizophrenia (Clinical Global Impression Severity, CGI-S ≥ 5) undergoing treatment in a community-based, case-managed program (CMP) with an integrated pharmacological and psychosocial approach compared with the standard treatment, an observational, ten-year follow-up study was conducted on patients treated in mental health units (MHUs) or a CMP (n = 688). Treatment discontinuation, hospitalizations, suicide attempts, and antipsychotic (AP) medications were recorded. Clinical severity was assessed with the CGI-S. Adherence to the CMP was higher than adherence to standard treatment (p < 0.001). There were fewer hospitalizations and suicide attempts in the CMP (p < 0.001). The clinical severity decreased more in the CMP (p < 0.005). Long-acting injectable (LAI) antipsychotic medication was more closely related to these outcomes than oral antipsychotics (APs) were (p < 0.001). Patients with severe schizophrenia in an integrated CMP recorded higher treatment compliance and better outcomes compared with standard care. Treatment with LAI APs was linked to these outcomes. A personalized combination of case management and LAI AP medication was more effective in these patients than standard treatment and oral APs.

Clinical Approaches to Late-Onset Psychosis

Psychosis can include schizophrenia, mood disorders with psychotic features, delusional disorder, active delirium, and neurodegenerative disorders accompanied by various psychotic symptoms. Late-onset psychosis requires careful intervention due to the greater associated risks of secondary psychosis; higher morbidity and mortality rates than early-onset psychosis; and complicated treatment considerations due to the higher incidence of adverse effects, even with the black box warning against antipsychotics. Pharmacological treatment, including antipsychotics, should be carefully initiated with the lowest dosage for short-term efficacy and monitoring of adverse side effects. Further research involving larger samples, more trials with different countries working in consortia, and unified operational definitions for diagnosis will help elaborate the clinical characteristics of late-onset psychosis and lead to the development of treatment approaches.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Dropout Rates in Psychosocial Interventions for People With Both Severe Mental Illness and Substance Misuse: A Systematic Review and Meta-Analysis

INTRODUCTION

Over the years, many psychosocial interventions for individual having both a psychotic spectrum disorder and a substance use disorder diagnoses have been developed and studied. However, there is a high dropout rate among this clinical population.

OBJECTIVES

This meta-analysis aims to replicate a previous meta-analysis on the effects of psychosocial treatment for dual disorders, while including and determining the dropout rates in those type of interventions.

METHOD

Based on a Cochrane systematic review conducted in 2019, we conducted a meta-analysis including 40 randomized clinical trials on psychosocial treatment among persons suffering from schizophrenia spectrum disorder and substance use disorder.

RESULTS

A dropout rate of 27,2% was obtained. Stimulants use significantly affected dropout rates. Age, gender, diagnosis, alcohol and cannabis abuse, and duration of treatment did not affect dropout rates.

CONCLUSION

The 27,2% rate of dropout from psychosocial treatment highlights the need to engage participants having a dual diagnosis from the start by focusing on therapeutic alliance and motivation for treatment.

Group therapy via videoconferencing for individuals with early psychosis: A pilot study

AIM

The COVID-19 pandemic has introduced many mental health professionals to therapy via videoconferencing. Mostly individual teletherapy has been offered and studied, although group therapy is often offered in clinics. In fact, little is known regarding group therapy's acceptability, feasibility, and potential impact when offered via videoconferencing.

METHODS

This pilot study offered group cognitive-behavioural therapy for psychosis via videoconferencing to 14 individuals with early psychosis either living in remote areas or confined during the pandemic.

RESULTS

The rate of consenting to the study (79%) and actual participation rates were acceptable (18.5 sessions out of 24). Although some technological obstacles were encountered, solutions offered allowed the videoconferencing group to be considered feasible for most participants and therapists. Prepost results on symptoms and self-esteem were comparable to those of other studies using the same group treatment but in-person. Alliance scores seemed similar as well.

CONCLUSIONS

More studies are warranted on the efficacy of group therapy via videoconferencing. This pilot study does offer promising results, suggesting that a wider range of people with early psychosis can be reached and benefit from the advantages of receiving an evidence-based group intervention.

Psychosocial and Pharmacological Approaches for Improving Treatment Adherence and Outcomes in People With Severe Schizophrenia: A 10-Year Follow-up

The objective of this study was to understand the psychosocial and pharmacological approaches linked to better treatment adherence and outcomes (psychiatric hospitalizations, clinical severity, and suicide attempts) among patients with schizophrenia receiving the standard treatment in mental health units (MHUs) compared with patients in a community-based, case-managed program (CMP). An observational, prospective (10 y) study was conducted involving patients with severe schizophrenia (N=688). The treatment adherence of patients in the CMP was higher than among those in the MHUs (12.2% vs. 84.3% abandoning treatment; P<0.0001). Hospital admissions and suicide attempts were significantly lower among those treated in the CMP than among those receiving standard care in the MHUs (P<0.001). Scores on the clinical severity scale decreased significantly more in the group in the CMP than in the group in the MHUs (P<0.005). Treatment with long-acting injectable antipsychotic medication was closely linked with higher treatment retention (P<0.001) and fewer hospital admissions and suicide attempts compared with treatment with oral antipsychotics in both patient groups, with the effect greater in the group in the CMP (P<0.001). We highlight how patients with severe schizophrenia treated in a CMP with integrated treatment showed a higher retention rate, fewer psychiatric hospital admissions and suicide attempts, and less clinical severity compared with those receiving standard treatment in MHUs. Treatment with long-acting antipsychotics was also clearly related to these outcomes. A combination of intensive case-managed integrated treatment and treatment with long-acting antipsychotic medication facilitated the achievement of clinical and rehabilitation goals in patients with schizophrenia with severe symptoms and impairment compared with standard care and treatment with oral antipsychotics.

Group Cognitive-Behavioral Therapy via Telebehavioral Health for Those With Psychotic Spectrum Disorders: A Case Series

Telebehavioral health emerged as an important practice during the coronavirus disease 2019 (COVID-19) pandemic as an opportunity for continued evidence-based mental health intervention, while minimizing exposure to coronavirus contagion. Though preliminary research suggests feasibility and positive outcomes of telebehavioral health practice for people with schizophrenia spectrum and other psychotic disorders, there is limited research about implementation and effectiveness of this practice (Kasckow et al., 2014). This case series highlights the transition from in-person to telebehavioral health practice of a Cognitive Behavioral Social Skills Training for Schizophrenia group due to the COVID-19 pandemic. This article summarizes: (a) the staff procedures needed to transition the group from in-person to telebehavioral health, (b) participant outcome data, (c) session attendance data, and (d) survey results from facilitators and participants about barriers and facilitators of the transition to telebehavioral health, and about how the virtual platform altered the therapeutic relationship and engagement. Participant outcome and engagement data suggest that, not only were two participants able to transition to telehealth and complete the program, but both participants also showed notable improvement in treatment engagement, goal progress, and skill acquisition. Surveys of six facilitators and one participant highlight how the transition to telebehavioral health had treatment advantages (e.g., therapeutic relationship, treatment engagement, group dynamics). Though survey results highlighted several implementation challenges in using the new virtual platform (e.g., technological connectivity, confidential space for engagement), no survey respondents reported that participation in this program resulted in harm to facilitators or participants. All facilitators and one participant agreed that the transition from in-person to virtual services was easy and reduced transportation barriers. Given the limited treatment engagement for this population (Lora et al., 2012) and the importance of early intervention to maximize clinical outcomes (Black et al., 2001; Bottlender et al., 2003), unanimous facilitator and participant report about improved patient attendance and participation in treatment after the transition to telebehavioral health was critically important. Though results of this case study are promising in suggesting telebehavioral health could be a viable modality for providing psychosocial treatment to people with schizophrenia spectrum and other psychotic disorders, more rigorous study is needed.

Functioning Problems in Persons with Schizophrenia in the Russian Context

Assessing functionality in schizophrenia from a biopsychosocial perspective is essential to generate treatments that respond to the needs of the individual in his/her context. This research aims to assess the prevalence of functioning problems and their association with socio-demographic and clinical variables in a sample of Russian individuals with schizophrenia, using the International Classification of Functioning, Disability, and Health as a framework. An empirical cross-sectional study assessed the functioning of 40 individuals with schizophrenia using the International Classification of Functioning, Disability, and Health Core Set for schizophrenia. For the Body functions component, the highest prevalence of problems was found in b144 Memory functions (75%) and b140 Attention functions (70%). In the Activities and participation component, the greatest limitations were in d770 Intimate relationships (79.3%) and d240 Handling stress and other psychological demands (82.5%). In the Environmental factors, the most frequent problems were in e110 Products or substances for personal consumption (25%) and e460 Societal attitudes (22.5%); when scored as facilitators, the highest rated categories were e125 Products and technology for communication (100%) and e165 Assets (100%). These results may guide the design of specific treatments for these individuals and serve as a starting point for further studies in similar contexts and in other regions in Russia.

Interventions to Improve Medication Adherence in Patients with Schizophrenia or Bipolar Disorders: A Systematic Review and Meta-Analysis

Adherence to prescribed medication regimes improves outcomes for patients with severe mental illness such as schizophrenia or bipolar disorders. The aim of this systematic review and meta-analysis was to compare the effectiveness among interventions to improve medication adherence in patients with schizophrenia or bipolar disorders. Literature published in the last decade was searched for interventions studies to improve adherence in patients with schizophrenia or a bipolar disorder. Interventions were categorised on the basis of type, and the context and effectiveness of the interventions were described. Two review authors independently extracted and assessed data, following criteria outlined by the Cochrane Handbook for Systematic Reviews of Interventions. The GRADEPro (McMaster University, 2020, Ontario, Canada) was used for assessing the quality of the evidence. Twenty-three publications met the selection criteria. Different types of interventions aiming to improve adherence were tested: educational, behavioural, family-based, technological, or a combination of previous types. Meta-analysis could be performed for 10 interventions. When considered separately by subgroups on the basis of intervention type, no significant differences were found in adherence among interventions (p = 0.29; I2 = 19.9%). This review concluded that successful interventions used a combination of behavioural and educational approaches that seem easy to implement in daily practice.

Effectiveness, Core Elements, and Moderators of Response of Cognitive Remediation for Schizophrenia: A Systematic Review and Meta-analysis of Randomized Clinical Trials

Importance

Cognitive impairment is a core feature of schizophrenia, with negative consequences on functional outcomes. Although cognitive remediation (CR) is effective and mentioned in treatment guidance for schizophrenia, its active ingredients and ideal candidates are still debated.

Objective

To provide a comprehensive update on CR effectiveness for cognition and functioning in schizophrenia and analyze the core ingredients of efficacy and role of patient characteristics.

Data Sources

The reference list of the last comprehensive meta-analysis in 2011 was screened against eligibility criteria. Then, electronic databases (PubMed, Scopus, and PsycInfo) were systematically searched for articles published from January 2011 to February 2020. Reference lists of included articles and relevant reviews were hand searched, and Google Scholar was manually inspected.

Study Selection

Eligible studies were randomized clinical trials comparing CR with any other control condition in patients diagnosed with schizophrenia spectrum disorders (with an unrestricted clinical status). Screening was performed by at least 2 independent reviewers.

Data Extraction and Synthesis

The PRISMA guidelines were followed. Study data were independently extracted and pooled using random-effect models. Cohen d was used to measure outcomes. Trial methodological quality was evaluated with the Clinical Trials Assessment Measure.

Main Outcomes and Measures

Primary outcomes were changes in global cognition and overall functioning from baseline to after treatment, subsequently investigated through metaregressions, subgroup, and sensitivity analyses based on prespecified hypotheses, to identify potential moderators of response associated with treatment modality and patient characteristics.

Results

Of 1815 identified reports, 358 full texts were assessed and 194 reports on 130 studies were included. Based on 130 studies with 8851 participants, CR was effective on cognition (d, 0.29 [95% CI, 0.24-0.34]) and functioning (d, 0.22 [95% CI, 0.16-0.29]). An active and trained therapist (cognition: χ21, 4.14; P = .04; functioning: χ21, 4.26; P = .04), structured development of cognitive strategies (cognition: χ21, 9.34; P = .002; functioning: χ21, 8.12; P = .004), and integration with psychosocial rehabilitation (cognition: χ21, 5.66; functioning: χ21, 12.08) were crucial ingredients of efficacy. Patients with fewer years of education (global cognition: coefficient, -0.055 [95% CI, -0.103 to -0.006]; P = .03; global functioning: coefficient, -0.061 [95% CI, -0.112 to -0.011]; P = .02), lower premorbid IQ (global functioning: coefficient, -0.013 [-0.025 to -0.001]; P = .04), and higher baseline symptom severity (global cognition: coefficient, 0.006 [95% CI, 0.002 to 0.010]; P = .005) emerged as optimal candidates.

Conclusions and Relevance

These findings show that CR is an evidence-based intervention that should be included consistently into clinical guidelines for the treatment of individuals with schizophrenia and implemented more widely in clinical practice.

Neuroepigenetics of psychiatric disorders: Focus on lncRNA

Understanding the pathology of psychiatric disorders is challenging due to their complexity and multifactorial origin. However, development of high-throughput technologies has allowed for better insight into their molecular signatures. Advancement of sequencing methodologies have made it possible to study not only the protein-coding but also the noncoding genome. It is now clear that besides the genetic component, different epigenetic mechanisms play major roles in the onset and development of psychiatric disorders. Among them, examining the role of long noncoding RNAs (lncRNAs) is a relatively new field. Here, we present an overview of what is currently known about the involvement of lncRNAs in schizophrenia, major depressive and bipolar disorders, as well as suicide. The diagnosis of psychiatric disorders mainly relies on clinical evaluation without using measurable biomarkers. In this regard, lncRNA may open new opportunities for development of molecular tests. However, so far only a small set of known lncRNAs have been characterized at molecular level, which means they have a long way to go before clinical implementation. Understanding how changes in lncRNAs affect the appearance and development of psychiatric disorders may lead to a more classified and objective diagnostic system, but also open up new therapeutic targets for these patients.

Personal narratives of learning self-management: Lessons for practice based on experiences of people with serious mental illness

INTRODUCTION

Clinicians are challenged to deliver self-management interventions in recovery-oriented services for individuals living with serious mental illnesses. Little is known about how people learn self-management skills and questions remain about how best to deliver support. To offer insights for delivery, this research describes the lived experiences of learning self-management and the meaning of those experiences within recovery journeys and the context of health-care delivery.

METHODS

Design followed van Manen's approach of phenomenology through an occupational therapist's lens. Using purposeful criterion sampling until saturation, 25 adults with psychosis experiences (8-40 years) from six community-based specialised mental health programs were interviewed. Conceptual maps were cocreated depicting key learning experiences, intersections with services, and recommendations. Data reduction, reconstruction and explication of meaning occurred concurrently, and multiple strategies were used to transparently support an open, iterative, reflexive process.

FINDINGS

Participants described eight essential tasks to live well, learned often serendipitously, taking up to 15-30 years to find the right combination of supports and self-management strategies to achieve what they felt was a life of quality. Self-management needs were not routinely addressed by services and extended beyond illness or crisis management while participants grappled with emotions, self-concept, relationships, and occupational issues. Participants asked providers to "teach us to teach ourselves"; "invite clients" to the decision table; and deal directly with emotions of fear, shame, and trust with respect to self and relationships. Findings challenge conventional conceptualisations of self-management to consider clients living interdependent lives with tasks performed in context, dynamically influenced by complex personal, socio-ecological relationships.

CONCLUSIONS

Participants' narratives compel increasing access to strategic personalised self-management learning opportunities as an effort to shorten the prolonged recovery paths. Findings offer ways providers can understand and address eight self-management learning tasks from the perspective of lived experiences. Self-management was enmeshed with recovery, health, and building a life.

Digital gaming interventions: a novel paradigm in mental health? Perspectives from India

The mental health gap has been a persistent concern globally, especially in low and middle-income countries (LMIC). In an attempt to mitigate resource limitations, the psychiatric practice has been undergoing a paradigm shift into digitalized mental health interventions. One such innovation involves digital gaming utilizing the principles of 'gamification' to incorporate both the playfulness component of online gaming as well as the domain-targeted design of gaming elements. Digital gaming-based interventions have been to deliver psychotherapy, biofeedback, cognitive training and rehabilitation, as well as behavioural modification and social skills training. Research shows their utility in autism spectrum disorders, attention deficit disorders, schizophrenia, depression, anxiety disorders, post-traumatic stress, eating disorders, neurocognitive disorders and also to promote healthy aging. Though promising in scope, these interventions face pragmatic challenges for implementation in developing countries. Even though increased use of technology, internet penetration and growing digital literacy have enhanced their accessibility and feasibility, various factors like socio-cultural diversity, lack of standardization, poor infrastructural support, bandwidth issues and lack of practice can impair their use and acceptability. Keeping this in the background, this commentary critically discusses the scope, applications and challenges of digital gaming in mental healthcare delivery in one of the rapidly globalizing LMIC nations, India.

Strategies for Psychiatric Rehabilitation and their Cognitive Outcomes in Schizophrenia: Review of Last Five-year Studies

BACKGROUND

Cognitive deficits are core features of Schizophrenia, showing poor response to antipsychotic treatment, therefore non-pharmacological rehabilitative approaches to such a symptom domain need to be identified. However, since not all patients with Schizophrenia exhibit the same cognitive impairment profile, individualized rehabilitative approaches should be set up.

OBJECTIVES

We explored the last five-year literature addressing the issue of cognitive dysfunction response to rehabilitative methodologies in Schizophrenia to identify possible predictors of response and individualized strategies to treat such a dysfunction.

CONCLUSION

A total of 76 studies were reviewed. Possible predictors of cognitive rehabilitation outcome were identified among patient-specific and approach-specific variables and a general overview of rehabilitative strategies used in the last five years has been depicted. Studies suggest the existence of multifaced and multi-domain variables that could significantly predict pro-cognitive effects of cognitive rehabilitation, which could also be useful for identifying individual-specific rehabilitation trajectories over time.An individualized rehabilitative approach to cognitive impairment in Schizophrenia is possible if taking into account both patient and approach specific predictors of outcomes.

Testing Kumpfer’s Resilience Model Among Adults With Serious Mental Illness

Having a serious mental illness (SMI) is often associated with significant adversities, and people respond differently to adversities. The existing research supports that people with SMI can achieve and maintain positive life outcomes despite experiencing adversities. Resilience, the ability to cope with (or bounce back quickly from) crisis, can help buffer the negative effects of various types of adversities, including chronic illness and disability, and facilitate the psychosocial adaptation process to SMI. Kumpfer’s resilience model, a person-process-context framework, has been widely used to conceptualize, and assess for, resilience in various populations, including people with chronic illnesses and disabilities. However, the research in resilience among people with SMI is very limited. The purpose of this study was to empirically assess the utility of Kumpfer’s resilience model and its proposed predictive components for conceptualizing the adaptation process to SMI. One hundred forty-four participants completed a Qualtrics survey containing demographic questions and a series of validated instruments representing the major components of Kumpfer’s resilience model. Hierarchical regression analysis was used to analyze the data, and the final model explained 71% of the variance of the dependent variable—adaptation to disability. Avoidance coping, internalized stigma, and optimism were significant independent predictors of adaptation to disability. This study supports the utilization of Kumpfer’s resilience model to conceptualize the adaptation to disability process among people with SMI. Implications for rehabilitation counseling practices are discussed.

Well-Being and Cooking Behavior: Using the Positive Emotion, Engagement, Relationships, Meaning, and Accomplishment (PERMA) Model as a Theoretical Framework

The prevalence of psychosocial distress is increasing in the United States. At the same time, the American default lifestyle has steadily displaced household food production with industrial food production, despite increased cultural interest in cooking. An important focus of cooking research to date has been on cooking's association with nutrition and dietary quality. Less focus has been placed on how cooking might foster the qualities that allow for mitigation of psychosocial distress and promote well-being. Rooted in its evolutionary role in the human experience, cooking requires skills and knowledge that have the capacity to encourage aspects of well-being as described by Seligman as flourishing. Evidence for a beneficial role of cooking in psychosocial health exists, but the exploration is limited, potentially due to lack of a theoretical context to explain these benefits. From this perspective, we review the current literature showing the application of Seligman's prominent well-being model, Positive emotion, Engagement, Relationships, Meaning, and Accomplishment (PERMA), to cooking, defined as the activity related to the preparation of food or a meal. We propose that the PERMA model as applied to cooking may function as a theoretical framework to explore psychosocial outcomes associated with cooking. Broader application of this approach may also help to further the application of positive psychology in the developing literature around psychosocial health and nutrition-related chronic diseases.

The Recovery Process for Individuals With Schizophrenia in the Context of Evidence-Based Psychotherapy and Rehabilitation

Abstract. This systematic review aimed to evaluate the efficacy of Cognitive Behavioral Therapy (CBT), META Cognitive Therapy (MCT), Metacognitive Training (MCTR), Metacognitive Reflection and Insight Therapy (MERIT), of various rehabilitation programs and of recovery programs in schizophrenia. Medline/Pubmed was searched for studies published in English from January 2010 to August 2018, which were screened against inclusion criteria by two reviewers. The methodological quality of the included studies was evaluated by two independent raters, which are the Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies and the fidelity criteria. The study included 41 RCTs and 12 case studies with n = 3,059 persons with schizophrenia. Cognitive Behavioral Therapy (CBT) proved to be superior in terms of the improvement of primary and secondary outcomes. MCT decreased positive symptoms and improved metacognitive capacity and insight. MCTR reduced positive symptoms and socially disruptive behavior. MERIT improved metacognitive capacity and insight. Rehabilitation programs were efficacious in the improvement of cognition, symptoms, and functional outcome. The recovery programs enhanced illness-management knowledge, attitudes toward medication and insights related to negative symptoms. It is recommended to combine the above evidence based psychotherapeutic interventions. Limitations of this systematic review are discussed toward the end of the essay. Some important factors have to be considered in the future have been mentioned.

Barriers to Family Resilience in Caregivers of People Who Have Schizophrenia

PURPOSE

To explore the barriers to family resilience in caregivers of people who have schizophrenia.

DESIGN

A qualitative descriptive approach was used.

METHODS

Semistructured interviews were conducted with family caregivers of patients with schizophrenia registered at the psychiatry outpatient unit of a hospital center. Content analysis was performed on audio-recorded and verbatim-transcribed interviews. The consolidated criteria for reporting qualitative research (COREQ) checklist was applied to this study.

RESULTS

A total of 31 family caregivers participated, the majority of whom were female (71%) with an average age of 57.5 years. Most participants lived with and cared for their relative (90.3%). The caregiver role was assumed mostly by mothers (54.8%) and fathers (22.6%). Barriers to family resilience in caregivers of people experiencing schizophrenia broadly fall under five categories: lack of knowledge about the disease, social stigma, expressed emotion, involvement in the relationship, and blame.

CONCLUSIONS

In view of the paucity of studies exploring and understanding the barriers to family resilience, this study presents itself as one of the first in this area. There are different barriers to family resilience. This research provides an overview and an understanding of key barriers to family resilience in caregivers of people experiencing schizophrenia.

CLINICAL RELEVANCE

There is a need for nurses to help families to be resilient. By understanding the barriers to resilience, nurses are able to focus on these factors and help families to remove or reduce their influence.

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

ASHP Therapeutic Position Statement on the Use of Antipsychotic Medications in the Treatment of Adults with Schizophrenia and Schizoaffective Disorder

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Personalized cognitive remediation therapy to facilitate return to work or to school in recent-onset psychosis

Cognitive deficits are barriers to job acquisition or return to school, and can be reduced through Cognitive remediation therapy (CRT). The main goal of this multiple case study was to investigate the effect of personalized CRT on occupational status in three participants with a recent-onset psychosis. Two cases improved their occupational status at post-treatment, and showed improvements in cognitive, psychological, and/or clinical variables. This study suggests that personalized CRT may facilitate job acquisition or return to school. However, the different pathways showed by our cases indicate that personalized CRT may influence occupational status through multiple mechanisms, underlining the relevance of treatment personalization.