Motivational interviewing to improve insight and treatment adherence in schizophrenia

Sexual Well-Being in Individuals with Schizophrenia: A Pilot Study on the Role of Self-Esteem and Acceptance of Illness

Schizophrenia is one of the most severe chronic mental illnesses. It drastically changes an individual's life and well-being. Sexual well-being in schizophrenia is often sidelined, even though it is one of the main areas for maintaining quality of life. Based on the conservation of resources theory (COR) and empirical data, we assume that self-esteem and acceptance of illness help in coping with schizophrenia and maintaining sexual well-being. This pilot study aimed to determine the relationship between self-esteem, acceptance of illness, and sexual well-being in Polish individuals with schizophrenia. The results of 60 individuals were included in this study. In the present study, the Self-Esteem Scale (SES), Acceptance of Illness Scale (AIS), and Short Sexual Well-Being Scale (SSWBS) were used. The study showed a significant association between self-esteem, acceptance of illness, and sexual well-being. Self-esteem (β = 0.62) and acceptance of illness (β = 0.55) acted as positive and significant predictors of sexual well-being in individuals with schizophrenia. Acceptance of illness was also found to play a mediating role between self-esteem and sexual well-being in people with schizophrenia (indirect effect: β = 0.34; LLCI = 0.063; ULCI = 0.839). The current pilot study demonstrates the relationship between self-esteem, acceptance of illness, and sexual well-being. Our findings highlight the significant role of acceptance of illness in maintaining sexual well-being among individuals with schizophrenia.

Drivers of shared decision making in inpatient psychiatry: An exploratory survey of patients' and multi-disciplinary team members' perspectives

OBJECTIVE

To assess the prevalence and predictors of Shared Decision Making (SDM) in an adult, inpatient psychiatric setting.

METHOD

Multi-disciplinary clinician focus groups and patient pre-testing informed the development of a survey on 4 SDM and 11 factors hypothesized to interfere with SDM. The survey was administered to 89 adult inpatients (80% response rate) and their treatment team psychiatrists, nurses, and social workers (n = 338 ratings, 95% response rate). Group differences and predictors were estimated using t and F-tests.

RESULTS

Patients' mean SDM score (n = 64, standardized Cronbach alpha = 0.858) was 3.35 ± 1.13 (5 = highest agreement), and correlated with overall satisfaction with care (n = 61, r = 0.399, p = 0.001). Patients' disagreement with clinician's diagnosis (44% of patients) correlated with lower SDM ratings by patients (t = 2.55, df = 62, p = 0.013) and by clinicians (t = 2.99, df = 69, p = 0.004). Psychotic diagnoses were not a significant determining factor for SDM. Overall, clinicians rated SDM more favorably than patients (t = -5.43, df = 63, p < 0.001), with nurses and social workers rating SDM higher than physicians (p < 0.001).

CONCLUSIONS

Diagnostic agreement / disagreement is a key predictor of SDM for patients and clinicians, while presence of psychosis is not. SDM was rated higher by clinicians than patients. SDM ratings vary significantly between clinical disciplines.

Motivational interviewing to enhance psychosocial treatment attendance in people with SMI

BACKGROUND

While there is increasing support for the efficacy of psychosocial interventions for people with SMI, the real-world effectiveness of such treatments is diminished by lack of motivation for treatment, leading to poor treatment engagement/dropout. We sought to evaluate the efficacy of motivational interviewing (MI) in improving attendance in a full course of cognitive training, examine motivation level as a potential mechanism of action, and examine variables associated with initial engagement in the training.

METHODS

One hundred fourteen participants with SMI were randomized to MI or sham control interview (CI), both of which were followed by a 4-month active phase during which participants could attend up to 50 unpaid cognitive training sessions.

RESULTS

Fidelity to the MI intervention was high, and MI condition was associated with increases in perceived value of training tasks and, to a lesser extent, how enjoyable/interesting they were rated. Twenty-nine percent of the full sample did not attend any training sessions. In ITT analyses, there was no significant between-group impact of MI on treatment attendance, though one emerged when participants who did not attend any sessions were excluded. Treatment attendance was predicted by the level of motivation achieved after the MI/CI intervention. Those who attended at least one training session (regardless of randomization) were more likely to believe they had cognitive impairments, had higher IQ and had less severe general psychiatric symptoms.

CONCLUSIONS

MI showed some promise and may be a worthwhile addition to more comprehensive, robust efforts to promote initial treatment engagement and subsequent adherence.

Integration of biological and psychological illness attributional belief in association with medication adherence behaviour: A path analysis

AIM

This study aimed to determine the association of biological (BAB) and psychological illness attributional beliefs (PAB) with medication adherence behaviour in patients with psychosis in Hong Kong.

METHODS

A cross-sectional survey of 301 outpatients with psychosis in Hong Kong was conducted from August to October 2016. The survey included a set of questionnaires examining patient medication adherence behaviours (using five behavioural items from the Medication Adherence Rating Scale), illness attributional belief, insight into the illness, and attitudes towards antipsychotics and medical professionals. The associations between these variables were analysed using path analysis and adjusted for covariates of perceived social support, experience of side-effects, and gender.

RESULTS

The data fit a model in which medication adherence behaviour was associated with illness attributional belief, insight, and attitudes (chi-square = 32.33, p = .26; RMSEA = 0.02; SRMR = 0.04; and CFI = 0.97). BAB was positively and directly associated with medication adherence behaviour. PAB was positively and indirectly associated with medication adherence behaviour through insight into the illness and attitude towards medical professionals. PAB can strengthen the relationship between BAB and insight, and only the high PAB group exhibited a positive relationship between BAB and attitude towards medical professionals.

CONCLUSIONS

An integration of biological and psychological attributional beliefs in patients with psychosis is essential for better medication adherence behaviour. Future interventions should aim to modify patients' illness attributional beliefs by integrating both biological and psychological illness attribution to improve medication adherence.

Personality in Autism Spectrum Disorder: Associations With Face Memory Deficit and Theory of Mind

OBJECTIVE

To examine the personality profiles of adults with autism spectrum disorder (ASD) using a standard personality assessment and to investigate the association between personality, ASD-related face memory deficit (FMD), and theory of mind (ToM). In a broader context, to examine whether there are distinct clinical phenotypes in the ASD population that have implications for personality development and treatment.

METHOD

Fifty-five adults with ASD and 22 neurotypical (NT) adults underwent a battery of neuropsychological tests, including measures of personality, face memory, and ToM. We compared ASD and NT groups in terms of their Personality Assessment Inventory (PAI) profiles. Additional analyses focused on the association between specific PAI scales and FMD. Performance on the Eyes Test was compared across groups and was examined in relation to FMD.

RESULTS

Adults with ASD demonstrated significant elevations on several PAI scales compared with NT adults. The presence of FMD was associated with differing PAI profiles among the ASD adults. The ASD adults with FMD scored significantly higher on scales that are sensitive to positive impression management and treatment rejection and significantly lower on scales that are sensitive to borderline personality, anxiety, depression, schizophrenia, and stress. There was a significant association between performance on the Eyes Test and FMD in the ASD group.

CONCLUSION

Adults with ASD have a unique personality profile. Further, ASD adults with FMD have reduced insight into their difficulties with emotional processing and may not be as sensitive as ASD adults without FMD to the emotions of others.

Cognitive insight, medication adherence and methamphetamine cessation in people enrolled in a pharmacotherapy trial for methamphetamine use

BACKGROUND

The current study examined correlates of cognitive insight in people enrolled in a methamphetamine pharmacotherapy trial; whether cognitive insight at the start of the trial predicted medication adherence and reductions in methamphetamine use during the trial; and, whether insight would remain stable over the trial or improve with reductions in methamphetamine use.

METHODS

A subset of people enrolled in a 12-week randomised placebo-controlled pharmacotherapy trial for methamphetamine dependence completed the Beck Cognitive Insight Scale, comprising subscales for Self-Reflection and Self-Certainty, at baseline (n = 152) and at week 12 (n = 79). Medication adherence was expressed as the percentage of non-missed doses measured using eCAP™ technology. Methamphetamine use days were assessed using the Timeline Followback.

RESULTS

At baseline, greater Self-Reflection was correlated with more severe methamphetamine withdrawal, and hostility, whereas Self-Certainty was correlated with less education and longer duration of methamphetamine use. No relationship was found between BCIS subscales at baseline and medication adherence (Self-Reflection b[SE] = -0.73 [0.43] p = .09; Self-Certainty b[SE] = -0.31 [0.48] p = .52,). Neither BCIS subscale was predictive of reduced methamphetamine use at 12 weeks (Self-Reflection b[SE] = 0.001 [0.01] p = .95 Self-Certainty b[SE] = -0.003 [0.01], p = .74). Self-Reflection decreased over the trial (t = 3.42, p = .001) but this was unrelated to change in methamphetamine use (Self-Reflection, b[SE] = -1.68 [1.16] p = .15) Change in methamphetamine use was found to be a significant predictor of Self-Certainty at 12 weeks (b [SE] = -2.71 [1.16] p = .02).

CONCLUSIONS

We found no evidence that cognitive insight predicted medication adherence or methamphetamine reduction in people engaged in this trial. Ongoing or increased methamphetamine use predicted increased Self-Certainty at 12 weeks.

Suicidal Behavior and Medication Adherence in Schizophrenic Patients

Suicide is one of the potential complications in the Schizophrenic patient population. This review article deals with the significance of antipsychotic medication compliance in decreasing suicidal behavior and hospitalizations in Schizophrenic patients. The medication adherence with second-generation antipsychotics (SGA) like clozapine and long-acting injectables (LAIs) like paliperidone is associated with decrease suicidal behavior and all-cause mortality in Schizophrenic patients. Concomitant treatment of depression and substance abuse disorder in this patient population is also associated with decreasing all-cause mortality and hospitalizations. On the other hand, long-term benzodiazepine use is associated with increase mortality in Schizophrenic patients. We also discuss some important physician intervention strategies to improve medication adherence in Schizophrenic patients like motivational interviewing (MI), behavioral tailoring (BT), and psychosocial interventions like cognitive behavior therapy (CBT).

Reducing negative symptoms in schizophrenia: Feasibility and acceptability of a combined cognitive-behavioral social skills training and compensatory cognitive training intervention

The current study examined the feasibility and acceptability of an integrated Cognitive-Behavioral Social Skills Training and Compensatory Cognitive Training (CBSST-CCT) intervention compared with Goal-Focused Supportive Contact (SC) in a pilot randomized controlled trial for people with schizophrenia with high negative symptom severity. The sample included 55 participants from five community settings; masters-level study clinicians delivered interventions on-site. Participants completed assessments of cognitive, functional, and psychiatric symptoms at baseline, mid-treatment, post-treatment (12.5 weeks), and 6-month follow-up. Enrollment goals were not initially met, necessitating the addition of a fifth site; however, all groups and assessments were completed on-site. Study procedures were acceptable, as evidenced by 100% enrollment and completion of baseline assessments following informed consent; however, over 1/3rd of participants dropped out. No modifications were necessary to the intervention procedures and CBSST-CCT fidelity ratings were acceptable. The intervention was deemed acceptable among participants who attended ≥1 session, as evidenced by similar attendance rates in CBSST-CCT compared to SC. Among CBSST-CCT participants, lower positive symptoms were significantly associated with better attendance. Overall, we found mixed evidence for the feasibility and acceptability of the CBSST-CCT protocol in people with schizophrenia with high negative symptoms. Challenges are highlighted and recommendations for future investigations are provided.

Promoting insight into delusions: Issues and challenges in therapy

During recent years, the role of non-pharmacological interventions in the management of psychotic symptoms, including delusions, has received increased recognition. However, a few factors such as the client's cognitive impairments and poor insight into the illness may create challenges for the therapist in conducting these interventions. Present paper discusses some of these issues and the steps a therapist can take to deal with them.

Mental illness stigma: Concepts, consequences, and initiatives to reduce stigma

Persons with mental illness frequently encounter public stigma and may suffer from self-stigma. This review aims to clarify the concept of mental illness stigma and discuss consequences for individuals with mental illness. After a conceptual overview of stigma we discuss two leading concepts of mental illness stigma and consequences of stigma, focussing on self-stigma/empowerment and fear of stigma as a barrier to using health services. Finally, we discuss three main strategies to reduce stigma - protest, education, and contact – and give examples of current anti-stigma campaigns. Well-designed anti-stigma initiatives will help to diminish negative consequences of mental illness stigma.

Antipsychotic Adherence Intervention for Veterans over 40 with Schizophrenia: Results of a Pilot Study

This pilot study tested the feasibility, acceptability, and effect-sizes of a multimodal, individual intervention designed to optimize antipsychotic medication use in patients >/=40 years of age with schizophrenia or schizoaffective disorder. METHODS: We randomized 40 patients into two groups: usual care (UC) or a nine-session, manualized, antipsychotic adherence intervention (AAI). The AAI attempted to improve adherence by combining three psychosocial techniques: a) education, b) skills training, and c) alliance building. Sessions employed a semi-structured format to facilitate open communication. The primary outcome was antipsychotic adherence at study end. We obtained qualitative data regarding patient preferences for the duration and modality for receiving the adherence intervention. RESULTS: Compared to the UC group, a greater proportion of the AAI group was adherent post-intervention (65% vs. 55.6%; OR=1.49), a difference that was statistically not significant. The entire AAI group reported that they intended to take medications, and 75% were satisfied with the intervention. CONCLUSIONS: The AAI was feasible and acceptable. Preliminary data on its effectiveness warrant a larger study. Qualitative data shows that patients prefer brief adherence interventions and accept telephone strategies.

Explaining Differences Between Sibling Relationships in Schizophrenia and Nonclinical Sibling Relationships

BACKGROUND

Good sibling relationships in adulthood are known to be a protective factor for mental health. The quality of these relationships is influence by the sibship's inherent characteristics (e.g., birth order, number of brothers and sisters, sex composition, age gaps). The present study explored whether these same determinants can help to explain how individuals experience their relationship with a sibling who has been diagnosed with schizophrenia.

METHOD

A total of 374 adults completed the Adult Sibling Relationship Questionnaire, a scale that probes the quality of these relationships on three dimensions: warmth, conflict, and rivalry. We also collected sociodemographic data and information about family structure from each of the participants. Participants were divided into two matched groups: nonclinical sibling group (n = 187) or schizophrenia sibling group (n = 187). Regression analyses were conducted to extract possible predictors of sibling relationship quality for each group. Further regression analyses then focused exclusively on relationships with an ill sibling, in order to study the role of disease-related variables in explaining each of the three dimensions.

RESULTS

Results showed that sociodemographic and family structure data explained a significant proportion of variance in the sibling relationship, but solely for nonclinical siblings. When participants had a sibling with schizophrenia, we found that disease-related variables (symptom severity, frequency of treatment) also had to be included to predict the conflict dimension.

CONCLUSIONS

Our results suggest that feelings of conflict experienced by the schizophrenia sibling group were fueled by the symptoms the ill person displayed. Healthy brothers and sisters probably have only a poor understanding of these symptoms. This could be improved by supporting them and helping them learn more about the disease. Future research will have to prove that providing such support for siblings does indeed improve the quality of their sibling relationships and, by so doing, enhance the wellbeing of both members of a sibling dyad.

Poor awareness of IADL deficits is associated with reduced regional brain volume in older adults with cognitive impairment

Performance of instrumental activities of daily living (IADLs) can become compromised in older adults with mild cognitive impairment (MCI). Patients' level of insight into their everyday functioning varies both amongst individuals and across domains assessed, with some individuals exhibiting complete unawareness of deficits. The current cross-sectional study examined the neuroanatomical substrates of self-awareness in order to help explain the variability in this phenomenon in older adults across a continuum of cognitive impairment. Eighty-five participants (ages 54-88, mean age = 73 years, 57% female, 89% Caucasian) diagnosed with MCI or mild probable dementia underwent structural magnetic resonance imaging. Level of self-awareness was assessed by calculating the discrepancy between objective and subjective performance across six IADLs (Financial Management, Driving, Grocery Shopping, Nutrition Evaluation, Medication Management, and Telephone Use). Over-estimation of current abilities occurred in 13-31% of the sample depending on which IADL was evaluated. Poor awareness was significantly related to reduced volume in the bilateral medial prefrontal cortex, middle and posterior cingulate cortex, right insular cortex, and cerebellum. No associations were found with total white matter lesion load. These findings were broadly consistent across all functional domains assessed, supporting the theory that cortical midline and cerebellar structures are involved in self-referential processing across a variety of different cognitive and behavioral skills. Longitudinal studies are needed to confirm this association.

Randomized controlled trial of cognitive-motivational therapy program (PIPE) for the initial phase of schizophrenia: Maintenance of efficacy at 5-year follow up✰

AIM

The main goal of this study was to evaluate the effectiveness of a cognitive motivational treatment program.

METHOD

A randomized, controlled, single-blind clinical trial was carried out. A total of 104 patients were recruited to take part in the trial, of whom ultimately 62 patients were allocated into two groups and finished the study. An initial assessment was carried out before patients were randomly placed in one of two groups for the clinical trial: (a) PIPE program plus routine care; and (b) routine care only. Clinical assessments were performed at baseline at 6 months, 1 year and follow-ups, at 18 months and 5 years).

RESULTS

MANCOVA analysis of tests repeated 18 months after the start of the intervention detected significant differences between the two groups in terms of clinical variables, everyday functioning and relapses. These differences remained upon follow-up measurements taken five years after the start of the trial.

CONCLUSIONS

The present study offers scientific evidence for cognitive-motivational therapy's effectiveness as a treatment for clinical symptoms in the early stages of psychosis. PIPE intervention may contribute to long-term clinical improvement and stability.

The effect of motivational interviews on treatment adherence and insight levels of patients with schizophrenia: A randomized controlled study

PURPOSE

To examine the effect of motivational interview (MI) on treatment adherence and insight of the patients diagnosed with schizophrenia at a hospital in Turkey.

DESIGN AND METHODS

Individuals with schizophrenia, who match with the sample characteristics, were assigned to intervention (20) and control groups (20) according to the randomization schedule. Personal Information Form, Self-Reported Measure of Medication Adherence, and Schedule for Assessing the Three Components of Insight were used.

FINDINGS

Group-wise examinations showed that mean scores of "three component scales of insight" yielded statistically significant difference for the intervention group. Analysis of the Treatment Adherence Scale Mean Scores showed a significant difference for interval mean scores of the intervention group.

PRACTICE IMPLICATIONS

Both the pyschiatric patients and the health institutions can benefit from increased levels of treatment adherence and insight by the adoption of the MI methods starting with a patient's first registration to a psychiatric outpatient clinic.

IMPLICATIONS FOR NURSING PRACTICE

MI can be included during any of the patient visits to establish treatment collaboration with psychiatric patients at psychiatric facilities, outpatient clinics, and community mental health centers.

Exploring predictors of medication adherence among inpatients with schizophrenia in Singapore's mental health settings: A non-experimental study

Schizophrenia is a mental disorder, which is marked by frequent relapses. The main reason for relapse is nonadherence to antipsychotics. A cross-sectional, correlational research study was conducted with a convenience sample of 92 participants. The primary aim of this study was to explore the predictors of medication adherence among inpatients with schizophrenia hospitalised at tertiary hospitals in Singapore. Post-hoc analysis revealed that insight, religion, side effects, types of antipsychotics, social support from significant others, nurse-client relationship, were significant predictive factors. Results from this study added knowledge to the nursing literature about medication adherence of schizophrenia patients and in Singapore setting.

A Randomized, Controlled Multisite Study of Behavioral Interventions for Veterans with Mental Illness and Antipsychotic Medication-Associated Obesity

BACKGROUND

Weight gain and other metabolic sequelae of antipsychotic medications can lead to medication non-adherence, reduced quality of life, increased costs, and premature mortality. Of the approaches to address this, behavioral interventions are less invasive, cost less, and can result in sustained long-term benefits.

OBJECTIVE

We investigated behavioral weight management interventions for veterans with mental illness across four medical centers within the Veterans Affairs (VA) Healthcare System.

DESIGN

We conducted a 12-month, multi-site extension of our previous randomized, controlled study, comparing treatment and control groups.

PARTICIPANTS

Veterans (and some non-veteran women) diagnosed with mental illness, overweight (defined as having a BMI over 25), and required ongoing antipsychotic therapy.

INTERVENTIONS

One group received "Lifestyle Balance" (LB; modified from the Diabetes Prevention Program) consisting of classes and individual nutritional counseling with a dietitian. A second group received less intensive "Usual Care" (UC) consisting of weight monitoring and provision of self-help.

MAIN MEASURES

Participants completed anthropometric and nutrition assessments weekly for 8 weeks, then monthly. Psychiatric, behavioral, and physical assessments were conducted at baseline and months 2, 6, and 12. Metabolic and lipid laboratory tests were performed quarterly.

KEY RESULTS

Participants in both groups lost weight. LB participants had a greater decrease in average waist circumference [F(1,1244) = 11.9, p < 0.001] and percent body fat [F(1,1121) = 4.3, p = 0.038]. Controlling for gender yielded statistically significant changes between groups in BMI [F(1,1246) = 13.9, p < 0.001]. Waist circumference and percent body fat decreased for LB women [F(1,1243) = 22.5, p < 0.001 and F(1,1221) = 4.8, p = 0.029, respectively]. The majority of LB participants kept food and activity journals (92%), and average daily calorie intake decreased from 2055 to 1650 during the study (p < 0.001).

CONCLUSIONS

Behavioral interventions specifically designed for individuals with mental illness can be effective for weight loss and improve dietary behaviors. "Lifestyle Balance" integrates well with VA healthcare's patient-centered "Whole Health" approach. ClinicalTrials.gov identifier NCT01052714.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Motivational and Behavioral Activation as an Adjunct to Psychiatric Rehabilitation for Mild to Moderate Negative Symptoms in Individuals with Schizophrenia: A Proof-of-Concept Pilot Study

Few psychosocial approaches address the negative symptoms of schizophrenia, which shares common features with depression and anxiety. Behavioral activation (BA) is effective for addressing depression and anxiety in adults with various mental disorders. Motivational interviewing (MI) has been successfully applied to address ambivalence or lack of motivation toward treatment. Motivational and behavioral activation (mBA) has been developed by incorporating the core principles from BA and MI with recent findings on the negative symptoms of schizophrenia. In this study, we aimed to examine the feasibility and preliminary efficacy of mBA in a non-randomized controlled pilot study that included individuals with schizophrenia with mild to moderate negative symptoms receiving psychiatric rehabilitation. A total of 73 individuals with schizophrenia were recruited. Forty-seven of the participants who met the study inclusion and exclusion criteria were assigned to either an mBA + usual psychiatric rehabilitation group (mBA) or a usual psychiatric rehabilitation only group (treatment as usual, TAU). Administering mBA to individuals with schizophrenia with mild to moderate negative symptoms was feasible in a community mental health setting. Relative to TAU, mBA was associated with large effects in reducing negative symptoms measured using the Positive and Negative Syndrome Scale (PANSS) and the Brief Negative Symptom Scale (BNSS). However, after considering PANSS cognitive deficits and marital status as covariates due to significant differences in their baseline levels, the treatment effects on the BNSS were partially observed. In addition, participants in the mBA group showed improved verbal learning and memory compared with those in the TAU group. In individuals with schizophrenia receiving the usual forms of psychiatric rehabilitation in a community mental health setting, mBA appears to offer a promising adjunctive approach for addressing mild to moderate negative symptoms. Further investigations are needed to replicate the current findings in a randomized controlled trial.

Motivational Interviewing and Rehabilitation Counseling Practice

This article explores commonalities between rehabilitation counseling and the counseling approach known as motivational interviewing. Motivational interviewing is an empirically supported, client-centered, directive counseling approach designed to promote client motivation and reduce motivational conflicts and barriers to change. The underpinnings of motivational interviewing are related to several principles that drive rehabilitation counseling practice. Motivational interviewing focuses on issues that have been emphasized in the rehabilitation literature: clients' sense of the importance of potential changes, their confidence that change can be successful, and their readiness to make changes. Current and potential uses of motivational interviewing in rehabilitation counseling practice are outlined, and additional research directions are recommended.

Motivational Interviewing to Increase Cognitive Rehabilitation Adherence in Schizophrenia

Adherence to treatment in psychiatric populations is notoriously low. In this randomized, controlled, proof-of-concept study, we sought to examine whether motivational interviewing (MI) could be used to enhance motivation for, adherence to, and benefit obtained from cognitive rehabilitation. Dual diagnosis MI, developed specifically for individuals with psychotic symptoms and disorganization, was further adapted to focus on cognitive impairments and their impact. Sixty-four outpatients diagnosed with schizophrenia spectrum disorders completed baseline assessments and were randomized to receive either the 2-session MI focused on cognitive functioning or a 2-session sham control interview focused on assessment and feedback about preferred learning styles. Next, all participants were given 4 weeks during which they could attend up to 10 sessions of a computer-based math training program, which served as a brief analog for a full course of cognitive rehabilitation. As hypothesized, MI condition was associated with greater increases in task-specific motivation along with greater training program session attendance. Moreover, postinterview motivation level predicted session attendance. There were no significant differences in improvement on a measure of cognitive training content, which may have been due to the abbreviated nature of the training. While the literature on the efficacy of MI for individuals with psychosis has been mixed, we speculate that our positive findings may have been influenced by the adaptations made to MI as well as the focus on a nonpharmacological intervention.

Adherence therapy versus routine psychiatric care for people with schizophrenia spectrum disorders: a randomised controlled trial

BACKGROUND

Current practice guidelines for schizophrenia care recommend that antipsychotic medication is essential for patients' long-term maintenance treatment but their non-adherence to this medication is still a main obstacle to relapse prevention. This study evaluated the effects of a motivational-interviewing-based adherence therapy for people with schizophrenia spectrum disorders.

METHODS

This randomised controlled trial was conducted with 134 outpatients with schizophrenia spectrum disorders; 67 of them received a six-session adherence therapy (in addition to usual care) and 67 received usual psychiatric care alone. Participants' outcome measures included symptom severity, medication adherence, hospitalisation rates, insight into illness/treatment, and functioning.

RESULTS

The adherence therapy group reported significantly greater improvements in symptom severity (p < 0.003), insight into illness/treatment (p < 0.001), functioning (p < 0.005), duration of re-hospitalisations (p < 0.005), and medication adherence (p < 0.005) over 18 months follow-up, when compared with usual care alone.

CONCLUSIONS

Motivational-interviewing-based adherence therapy can be an effective approach to treatment for people with early stage of schizophrenia who poorly adhere to medication regimen.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01780116, registration date January 29, 2013.

Motivational Interviewing Approach Used by a Community Mental Health Team

The current study aimed to (a) evaluate the effectiveness of motivational interviewing, as applied by a community mental health team (CMHT) based in Singapore; (b) reduce hospital admissions and length of hospital stay; and (c) improve global functioning and satisfaction of individuals with mental illness. The current study used a quasi-experimental method. A convenience sample of 120 participants was selected from the caseload of the CMHT. Participants received motivational interviewing sessions at least once every month for 1 year. Data on the number of hospital admissions, length of hospitalization, Global Assessment of Functioning, and patient satisfaction were collected at baseline and 6 and 12 months. Participants who underwent the CMHT services with motivational interviewing were more compliant to treatment, resulting in significant reduction in hospitalization and improvement in functionality. Motivational interviewing is effective in facilitating better illness management for patients in the community. Adoption of the motivational interviewing approach may potentially provide significant benefits for psychiatric support services in the community.

Nonadherence with antipsychotic medication in schizophrenia: challenges and management strategies

Nonadherence with medication occurs in all chronic medical disorders. It is a particular challenge in schizophrenia due to the illness's association with social isolation, stigma, and comorbid substance misuse, plus the effect of symptom domains on adherence, including positive and negative symptoms, lack of insight, depression, and cognitive impairment. Nonadherence lies on a spectrum, is often covert, and is underestimated by clinicians, but affects more than one third of patients with schizophrenia per annum. It increases the risk of relapse, rehospitalization, and self-harm, increases inpatient costs, and lowers quality of life. It results from multiple patient, clinician, illness, medication, and service factors, but a useful distinction is between intentional and unintentional nonadherence. There is no gold standard approach to the measurement of adherence as all methods have pros and cons. Interventions to improve adherence include psychoeducation and other psychosocial interventions, antipsychotic long-acting injections, electronic reminders, service-based interventions, and financial incentives. These overlap, all have some evidence of effectiveness, and the intervention adopted should be tailored to the individual. Psychosocial interventions that utilize combined approaches seem more effective than unidimensional approaches. There is increasing interest in electronic reminders and monitoring systems to enhance adherence, eg, Short Message Service text messaging and real-time medication monitoring linked to smart pill containers or an electronic ingestible event marker. Financial incentives to enhance antipsychotic adherence raise ethical issues, and their place in practice remains unclear. Simple pragmatic strategies to improve medication adherence include shared decision-making, regular assessment of adherence, simplification of the medication regimen, ensuring that treatment is effective and that side effects are managed, and promoting a positive therapeutic alliance and good communication between the clinician and patient. These elements remain essential for all patients, not least for the small minority where vulnerability and risk issue dictate that compulsory treatment is necessary to ensure adherence.

Development of a Patient-Centered Antipsychotic Medication Adherence Intervention

OBJECTIVE

A substantial gap exists between patients and their mental health providers about patient's perceived barriers, facilitators, and motivators (BFMs) for taking antipsychotic medications. This article describes how we used an intervention mapping (IM) framework coupled with qualitative and quantitative item-selection methods to develop an intervention to bridge this gap with the goal of improving antipsychotic medication adherence.

METHODS

IM is a stepwise method for developing and implementing health interventions. A previous study conducted in-depth qualitative interviews with patients diagnosed with schizophrenia and identified 477 BFMs associated with antipsychotic medication adherence. This article reports the results of using a variety of qualitative and quantitative item reduction and intervention development methods to transform the qualitative BFM data into a viable checklist and intervention.

RESULTS

The final BFM checklist included 76 items (28 barriers, 30 facilitators, and 18 motivators). An electronic and hard copy of the adherence progress note included a summary of current adherence, top three patient-identified barriers and top three facilitators and motivators, clarifying questions, and actionable adherence tips to address barriers during a typical clinical encounter.

DISCUSSION

The IM approach supplemented with qualitative and quantitative methods provided a useful framework for developing a practical and potentially sustainable antipsychotic medication adherence intervention. A similar approach to intervention development may be useful in other clinical situations where a substantial gap exists between patients and providers regarding medication adherence or other health behaviors.

The effectiveness of discharge planning on the knowledge, clinical symptoms and hospitalisation frequency of persons with schizophrenia: a longitudinal study in two hospitals in Tehran, Iran

AIMS AND OBJECTIVES

To investigate the effectiveness of discharge planning on the knowledge, clinical symptoms and frequency of hospitalisation of persons with schizophrenia.

BACKGROUND

Discharge planning is associated with decreases in the duration of hospitalisation, readmission to hospitals and decreases in medical costs. Yet, there is little known about the effectiveness of discharge planning among persons with schizophrenia in Iran.

DESIGN

Longitudinal clinical trial.

METHODS

In this longitudinal clinical trial, 46 persons with schizophrenia admitted to psychiatric hospitals were selected and classified into either intervention or control groups. For the intervention group, the discharge planning was designed using the nursing process model. The intervention was implemented across six sessions in the hospital and six sessions in patient's home (up to three months after discharge). Friedman test, independent t-tests, chi-squared test, Mann-Whitney U-test and Mc-Nemar's test were used to analyse demographic characteristics, knowledge scores, clinical symptoms and the frequency of hospitalisation.

RESULTS

The intervention group demonstrated improved clinical symptoms between the time of discharge and three months after discharge and had higher knowledge levels compared with the control group. In addition, the frequency of patients' hospitalisation preintervention and three months postintervention was statistically significantly lower in the intervention group, while no such differences were found among the control group during this same time period.

CONCLUSION

This study suggests that there are a number of advantages to discharge planning including an increase in the knowledge of patients, a decline in clinical symptoms and a reduction in the frequency of admission to hospitals.

RELEVANCE TO CLINICAL PRACTICE

Due to high frequency of relapse, rehospitalisation and high remedial costs of persons with schizophrenia, it is important to consider discharge planning as a therapeutic approach for patients.

Changes in motivation for treatment in precontemplating dually diagnosed patients receiving assertive community treatment

In a population of dually diagnosed patients receiving assertive community treatment we used the theoretical framework of the transtheoretical model to establish (a) the proportions and characteristics of patients who were not motivated for treatment for psychiatric symptoms and substance use, (b) the proportion of patients who moved towards behavioral change after about 1 year, and examine how this change was related with clinical outcome; and (c) the sequence of change processes. Chi square tests and T tests were used to compare the patient characteristics and outcomes of patients who remained in precontemplation with those who progressed. During follow-up, 47 % of the patients came out of the precontemplation phase for treatment of psychiatric symptoms and 38 % for substance use behavior. Those who remained in precontemplation benefited less from treatment. Of those who did move forward, most appeared to become motivated for psychiatric treatment before becoming motivated to reduce substance use.

Shame-Focused Attitudes Toward Mental Health Problems

The purpose of this study was to examine the effects of gender and culture on shame-focused attitudes toward mental health problems. Two hundred and ninety-three university students from Asian, Latino, and Caucasian American cultural backgrounds participated in the study. The Attitudes Toward Mental Health Problems Scale was used to measure shame-focused attitudes. A 2 (gender) × 3 (culture) multivariate analyses of variance was performed. Results indicated that there was no significant gender difference in shame-focused attitudes toward mental health problems. Of the three ethnic cultural groups, Latino American students had the highest mean score on how shameful they would feel if they had mental health problems. Asian American students had the lowest mean score on how negative their families would view themselves if they had mental health problems. Implications of the results for rehabilitation research and practice are discussed.

Predictors of outcomes for users of mental health rehabilitation services: a 5-year retrospective cohort study in inner London, UK

OBJECTIVE

There have been few recent studies reporting on the outcomes for users of psychiatric rehabilitation services. This group has complex, longer-term mental health problems. We aimed to investigate 5-year outcomes for this group and identify factors associated with outcome.

METHOD

Clinical outcome data on 141 users of a mental health rehabilitation service in inner London, UK, surveyed in 2005, were collected retrospectively 5 years later. Positive outcome was defined for those who were inpatients in 2005 as achieving and sustaining community discharge, and for those who were community patients, as progressing to and sustaining a less supported community placement. Negative outcome was defined as remaining in the same placement, moving to more supported placement or having a psychiatric admission.

RESULTS

Over 5 years, 17 (12 %) people died, 50 (40 %) had a positive outcome, 33 (27 %) remained in a placement with a similar level of support and 41 (38 %) moved to a more supported placement and/or had a psychiatric admission. Thirteen (10 %) people moved to independent accommodation and sustained their tenancy successfully. Those with a record of non-adherence with medication during the 5 years were more likely to have a negative outcome (OR 8.60, 95 % CI 3.41 to 21.70).

CONCLUSION

Adherence to medication is an important factor in facilitating successful community discharge for people with complex mental health problems who require psychiatric rehabilitation.

[Motivational interviewing in psychiatry]

Motivational Interviewing and associated communication techniques and intervention methods have been widely applied in patients with substance use disorder and other psychiatric disorders in the last twenty years. Intensive research on effectiveness and underlying mechanisms as well as the increasing efforts to apply MI in other psychiatric disorders has lead to a large number of scientific publications in this field. MI has been shown to be effective in situations where the patient's ambivalence seems to impede the therapeutic process. Communication skills and the ability of the care taker to induce the so called "change talk" by the patient play a particularly important role and correlate with the positive effects of MI. Those groups of patients in which other factors than ambivalence affect the therapeutic process seem to benefit much less from this intervention method. MI hallmarks the substantial change that gradually took place during the last two decades in caretakers' attitude towards patients with dependence and other psychiatric patients: away from "prescriptive" towards "supportive" treatment and communication style. Therefore, it seems to be reasonable to implement the basics of MG in the training curricula for psychiatrists.

The efficacy of a brief psycho-educational intervention to improve awareness of cognitive dysfunction in schizophrenia

People with schizophrenia have neuro-cognitive deficits that are associated with poor functional outcome, yet their awareness of their cognitive deficiencies is variable. As new treatments for cognition are developed, it will be important that patients are receptive to the need for more therapy. Since insight into symptoms has been associated with treatment compliance, it may be of value to provide psycho-education to improve understanding about cognition in schizophrenia. We report a randomized controlled trial that enrolled 80 subjects in either a brief psycho-education intervention about cognition, or a control condition. Subjects in the two conditions did not differ at baseline in insight or receptiveness to treatment, or on demographic, cognitive, or psychiatric variables. Current cognitive impairment of subjects was evidenced by the indice of working memory, attention and executive functioning abilities, (X=77.45 intervention group; 82.50 control condition), that was significantly below both the normative mean and estimated average premorbid IQs (X=101.3 intervention group; X=104.57 control condition). Multivariate repeated measures ANOVAs indicated that subjects who received the psycho-education did not improve insight into their cognitive deficits or willingness to engage in treatment for cognitive dysfunction. While the failure to find a significant impact of this intervention on awareness of cognitive deficit and receptiveness to cognitive treatment raises questions about the malleability of insight into neuro-cognitive deficits, the intervention was briefer than most reported psycho-education programs and multi-session formats may prove to be more effective.

Health Behavior Theories and Research: Implications for Suicidal Individuals' Treatment Linkage and Adherence

Treatment linkage and adherence to psychotherapeutic interventions can be challenging with suicidal individuals. Health behavior theories, specifically the Health Belief Model, Stages of Change, and Theory of Planned Behavior, focus on individuals' beliefs, their readiness to change, their perceptions of illness severity and "threat," their perceptions of significant others' attitudes toward illness and treatment, and their behavioral intentions to change. These constructs have relevance both for understanding suicidal individuals' behaviors related to treatment utilization and for understanding cultural variations in these behaviors. Furthermore, these theories have implications for clinical practices aimed at facilitating improved treatment follow-through and adherence. After describing the theories and their constructs, clinical examples are provided to illustrate applications to practice with suicidal individuals.

Motivational interviewing: addressing ambivalence to improve medication adherence in patients with bipolar disorder

Poor adherence to psychotropic medication is a significant issue for patients with bipolar disorder. The effectiveness of medication treatment is limited by high rates of medication non-adherence among this population. Motivational Interviewing is an evidence-based intervention that has been efficacious in promoting behavioral health regimens and treatment recommendations, including medication adherence. By using a patient-centered approach, Motivational Interviewing has been shown to enhance patients' insight and attitudes toward treatment. This article aims to describe to mental health nurses how to use Motivational Interviewing with bipolar patients to address ambivalence and improve adherence to psychotropic medication regimens.

Randomized controlled trial of the self-stigma reduction program among individuals with schizophrenia

Research evidence suggests that individuals with schizophrenia are prone to self-stigmatization, which reduces their psychosocial treatment adherence. A self-stigma reduction program was developed based on a theoretical framework proposed by our team. The effectiveness of such program to reduce self-stigma, enhance readiness for change, and promote adherent behaviors among individuals with schizophrenia was investigated. This program consisted of 12 group and four individual follow-up sessions. An integrative approach including psychoeductaion, cognitive behavioral therapy, motivational interviewing, social skills training, and goal attainment program was adopted. Sixty-six self-stigmatized individuals with schizophrenia were recruited. They were randomly allocated to the self-stigma reduction program (N=34; experimental protocol) or the newspaper reading group (N=32; comparison protocol). Measures on participants' level of self-stigma, readiness for change, insight, general self-efficacy, and treatment adherence were taken for six assessment intervals. The findings suggested that the self-stigma reduction program has potential to reduce self-esteem decrement, promote readiness for changing own problematic behaviors, and enhance psychosocial treatment adherence among the self-stigmatized individuals with schizophrenia during the active interventional stage. However, there was a lack of therapeutic maintenance effects during the 6-month follow-up period. Recommendations for further improving the effectiveness of self-stigma reduction program are suggested.

International Organization of Physical Therapy in Mental Health consensus on physical activity within multidisciplinary rehabilitation programmes for minimising cardio-metabolic risk in patients with schizophrenia

PURPOSE

The excess cardiovascular morbidity associated with schizophrenia is attributed to an interplay between behavioural (physical inactivity, unhealthy diet, substance abuse), genetic and illness related factors, as well as the effects of antipsychotic treatment. Patients have limited access to physical healthcare with less opportunity for cardiovascular risk prevention and treatment programmes than the non-psychiatric population. The aim of this paper is to improve physical activity (PA) within rehabilitation programmes for people with schizophrenia.

METHOD

The development process consisted of: a) systematic literature review on PA in schizophrenia in eight databases up to May 2010; b) review on existing national and international guidelines; c) consensus meetings, and d) formulation of the final consensus document.

RESULTS

There is insufficient evidence for the relative contribution of PA reducing cardio-metabolic risks in people with schizophrenia. Demographical, biological, psychological, cognitive-behavioural, emotional, social and environmental barriers for PA could be identified.

CONCLUSIONS

Although PA outcomes on cardio-metabolic parameters are still unknown, the benefits of physical activity as part of a larger lifestyle programme are sufficient for the recommendation that persons with schizophrenia follow the 2008 U.S. Department of Health and Human Services PA Guidelines with specific adaptations based on disease and treatment-related adverse effects.

The Evolution of Vocational Psychology: Questions for a Postmodern Applied Discipline

Vocational psychology has a long history of acting as a lens that focuses research in basic sciences on the particular experience of work in people’s lives. This article presents several areas on the ascendancy in the broader scientific literature and ask how vocational psychology might apply them to issues of work in people’s lives. The authors’ observations tend to revolve around the growing view of humans as less rational and more intuitive than our earlier understanding. In that vein, the authors discuss (a) differences between the environment in which we evolved and the one in which we currently exist; (b) the singularity of our evolutionary impetus to survive and reproduce (that excludes our current emphasis on happiness); (c) the modular, two-system brain that includes our unconscious/intuitive system and our conscious/rational system; and (d) several recent developments in psychotherapy that recognize and respond to some of these new understandings. For simplicity sake, our questions might be subsumed under the larger question: How do we apply post-rational theory to hyperrational humans? Rejuvenation of the field might be tied to our willingness to listen to science being done around us, and not relying too heavily on the excellent work accomplished by those who came before us.

Self-stigma and stages of change as predictors of treatment adherence of individuals with schizophrenia

The current study aimed at exploring the relationship between self-stigma, readiness for change and psychosocial treatment adherence among individuals with schizophrenia. Between March 2007 and January 2008, 105 adults with schizophrenia were recruited for this cross-sectional study. Face-to-face interviews were conducted to assess participants' level of self-stigma, readiness for change, insight, and general self-efficacy. The corresponding case therapists reported participants' level of treatment adherence, psychopathology, and global functioning. Findings of stepwise multiple regression suggested that individuals with higher global functioning, better readiness for action, and lower level of self-stigma demonstrated better treatment participation. Individuals with lesser severity of psychiatric symptoms and female participants had better treatment attendance. The results of discriminant function analysis showed the combined score of self-stigma, stages of change, and global functioning measures correctly classified 76.2% participants into adherent/nonadherent group membership. Suggestions for further studies and development of self-stigma reduction program to facilitate recovery and treatment adherence were made.

VATA-L: visual-analogue test assessing anosognosia for language impairment

Lack of awareness (anosognosia) for one's own language impairments has rarely been investigated, despite hampering language rehabilitation. Assessment of anosognosia by means of self-report is particularly complex, as a patient's language difficulties may seriously prevent or bias the assessment. Other methods, such as measures of self-correction and error detection, have provided valuable information, although they are an indirect form of assessment of anosognosia and are not exempt from methodological criticisms. In this study we report on a new tool, the VATA-L (Visual-Analogue Test for Anosognosia for Language impairment), geared at assessing explicit anosognosia for aphasia. The VATA-L compares the patient's self-evaluation with caregivers' evaluations of the patient's verbal communication abilities in a series of common situations. By means of non-verbal support and a system of check questions, this test minimizes some of the methodological limitations of existing diagnostic tools (e.g., structured interviews), enhancing reliability, and enabling assessment of patients with aphasia. Finally, normative data provided in the study allow a clearer interpretation of the patient's performance and facilitate assessment of anosognosia.

Insight in schizophrenia: a review

About 30% to 50% of people with schizophrenia experience lack of insight, meaning they may not acknowledge their illness or the need for treatment. Researchers have developed valid tools for measuring insight. Accordingly, a great deal of descriptive and correlational research has been done on insight, treatment adherence, symptom severity, and other associated variables. Several possible etiologic models and treatment modalities for lack of insight have been proposed. Possible brain dysfunctions causing lack of insight are being investigated. Cognitive-behavioral therapy and motivational interviewing have been successful in teaching patients to cope with the symptoms and make changes in health-related behaviors. Ultimately, people with schizophrenia need to know how to ask for help with coping with their symptoms.

Fewer symptoms vs. more side-effects in schizophrenia? Opposing pathways between antipsychotic medication compliance and quality of life

BACKGROUND

Non-compliance with medication often has long-term detrimental effects in patients with schizophrenia. However, when patients are compliant, it is not certain whether they experience short-term improved quality of life. By simultaneously reducing symptoms and increasing side-effects, compliance with antipsychotics may have opposing effects on a patient's perceived quality of life.

AIM

This study aimed to identify any clinical-empirical evidence for two pathways between compliance and quality of life.

METHOD

To evaluate various pathways between compliance (Service Engagement Scale plus a one-item rating), psychotic symptoms (Positive and Negative Syndromes Scale), adverse medication effects (Subjective Wellbeing under Neuroleptics scale), and quality of life (EQ-5D), we used Structural Equation Modeling on cross-sectional data of 114 patients with a psychotic disorder.

RESULTS

Compliance was not directly related to quality of life (r=0.004). The best-fitting model (chi(2)=1.08; df=1) indicated that high compliance was associated with fewer psychotic symptoms (beta=-0.23) and more adverse medication effects (beta=0.22). Symptoms (beta=-0.17) and adverse medication effects (beta=-0.48) were both related to lower quality of life.

DISCUSSION

Our results suggest that compliance with antipsychotics has two opposing pathways towards quality of life, albeit indirect ones. While compliance was associated with less severe psychotic symptoms, and was thus related to higher quality of life, it was also associated with more adverse medication effects, and was thus related to lower quality of life. However, due to our study design, we cannot draw firm conclusions on causality. Two possible clinical implications of the results for compliance and interventions are discussed.

Implicit versus explicit attitudes toward psychiatric medication: Implications for insight and treatment adherence

Implicit attitudes are automatically activated evaluative impulses that are difficult to control and potentially outside conscious awareness. The association of implicit attitudes toward psychiatric medication with treatment adherence and insight was investigated in 85 persons with schizophrenia, schizoaffective, or affective disorders using the Brief Implicit Association Test. Explicit attitudes, insight, perceived need for treatment and adherence were measured by self-report. Implicit, but not explicit, positive attitudes predicted increased insight and perceived need for treatment. Explicit, but not implicit, positive attitudes predicted self-reported adherence. Implicit measures can improve our understanding of medication attitudes and evaluation of interventions to increase treatment adherence.