Effort-based decision-making as a determinant of supported employment outcomes in psychotic disorders

Schizophrenia is associated with a heavy economic burden in the United States that is partly due to the high rates of chronic unemployment. Individual Placement and Support (IPS) is an evidenced-based type of supported employment that can improve job obtainment and work outcomes in psychotic disorders. Outcomes vary widely and a persistent challenge for IPS is low levels of engagement in the initial job search phase. Past studies have focused on interview-based motivation deficits as a key determinant of poor treatment engagement and work outcomes in schizophrenia. New validated performance-based measures of motivation, including effort-based decision-making (EBDM) tasks, may explain supported employment outcomes and provide insights into individual differences in IPS outcomes. This study investigated the degree to which IPS engagement (i.e., number of sessions attended during the first four months of service delivery) was related to baseline interview-based motivation deficits and performance on three EBDM tasks - two tasks of physical effort and one of cognitive effort (i.e., Balloon Task, Effort Expenditure for Rewards Task, Deck Choice Effort Task) - in a sample (N = 47) of people with a psychotic disorder. Results indicated that the level of EBDM performance, specifically on the Balloon Task, predicted IPS engagement, accounting for an additional 17 % of the variance above and beyond interview-based motivation deficits (total R2 = 24 %). Overall, these findings suggest that addressing motivational deficits in effort-based decision-making may be beneficial to IPS engagement, which in turn may improve the trajectory of work outcomes.

Promotore-Led Versus Registered Nurse-Led Diabetes Self-Management Education in Mexican Americans: A Randomized Clinical Trial

PURPOSE

The purpose of this study is to compare the benefits of a diabetes self-management program led by registered nurses (RNs) versus community health workers (promotores) for Spanish-speaking Mexican Americans with type 2 diabetes (T2DM).

METHODS

Three hundred thirty Spanish-speaking Mexican American adults with T2DM were randomly assigned to "Tomando Control de Su Diabetes" delivered for six 2.5-hour sessions either by promotores or RNs. The primary outcome measure was the Summary of Diabetes Self-Care Activities (SDSCA). Evaluations were made at baseline, 6 weeks, and at 3, 6, and 12 months. Mixed-effects regression models were fit to test if participants had differential changes in the SDSCA total score by group over time, controlling for demographic and clinical factors.

RESULTS

SDSCA scores were significantly higher at all time points compared to baseline and not statistically different between the 2 groups. Only years of education correlated with improvement in diabetes self-management behaviors. No moderating variables predicted improvement between groups.

CONCLUSIONS

Spanish-speaking Mexican American adults with T2DM who participated in a diabetes educational program with promotores or RNs demonstrated similar improvements. Promotores may increase the accessibility of effective diabetes self-management training for this difficult-to-reach population.

The duration of untreated psychosis among U.S. Latinxs and social and clinical correlates

Purpose

This study (a) documents the duration of untreated psychosis (DUP) and (b) examines both social and clinical correlates of DUP in a sample of U.S. Latinxs with first-episode psychosis (FEP).

Methods

Data were collected for a longitudinal study evaluating a community education campaign to help primarily Spanish-speaking Latinxs recognize psychotic symptoms and reduce the DUP, or the delay to first prescribed antipsychotic medication after the onset of psychotic symptoms. Social and clinical variables were assessed at first treatment presentation. A sequential hierarchical regression was conducted using √DUP to identify independent predictors of the DUP. A structural equation model was used to explore the association between DUP predictors, DUP, and clinical and social correlates.

Results

In a sample of 122 Latinxs with FEP, the median DUP was 39 weeks (M = 137.78, SD = 220.31; IQR = 160.39-5.57). For the full sample, being an immigrant and having self-reported relatively poor English-speaking proficiency and self-reported strong Spanish-speaking proficiency were related to a longer delay to first prescribed medication after psychosis onset. For the immigrant subgroup, being older at the time of migration was related to a longer delay. Self-reported English-speaking proficiency emerged as an independent predictor of the DUP. Although the DUP was not related to symptomatology, it was associated with poorer social functioning. Low self-reported English-speaking ability is associated with poorer social functioning via the DUP.

Conclusion

Latinxs with limited English language skills are especially at high risk for experiencing prolonged delays to care and poor social functioning. Intervention efforts to reduce the delay in Latinx communities should pay particular attention to this subgroup.

Evaluation of an Audio-Visual Novela to Improve COVID-19 Knowledge and Safe Practices Among Spanish-Speaking Individuals with Schizophrenia

In the United States, the health and economic consequences of the COVID-19 pandemic have disproportionately affected the Latinx community. Within the Latinx community, people with schizophrenia-spectrum disorders are more susceptible to exposure to the virus. Given their increased risk of contracting and getting sick from the virus, efforts targeting the Latinx population should focus on increasing knowledge and safe practices associated with COVID-19. We developed a 10 min animated, Spanish-language audio-visual novela designed to improve knowledge, attitudes, and behaviors regarding COVID-19. Latinx adults with schizophrenia (N = 100) at a community mental health center in Los Angeles were randomly assigned to watch the novela or a non-COVID video (control group). Participants completed surveys immediately before and one month after viewing the material. One month after watching the audio-visual novela, subjects endorsed a greater likelihood of seeking a COVID-19 vaccine than control subjects. No other significant differences were observed between the two conditions. The findings of this study suggest that the presentation of health information in a relevant, engaging, and appealing manner may be useful way to improving salutary health behaviors of Latinx people with schizophrenia-spectrum disorders.

Toward reducing the duration of untreated psychosis in a Latinx community

OBJECTIVE

To carry out and evaluate a communications campaign (La CLAve) to reduce the duration of untreated psychosis (DUP) in a U.S. Latinx community.

METHOD

We employed evidence-based messaging in multiple media outlets. We recruited 132 Latinxs with first-episode psychosis (FEP) and caregivers seeking mental health care within a high-density Latinx community. We evaluated the campaign's dissemination, the extent to which the community received the campaign message, and the campaign outcome. We tested whether DUP (number of weeks) changed across three time periods (16-month baseline, 2-year campaign, and 16-month postcampaign) and whether participants' language background (primarily Spanish speaking or English speaking) moderated change in DUP.

RESULTS

The campaign was disseminated widely. During the height of the campaign over a 1-year period, our team distributed 22,039 brochures and performed 740 workshops. The campaign message was received by the community as noted for example by increases in the number of unduplicated weekly calls to the campaign's 1-800 number. Applying square root transformations to DUP, we found a significant main effect for language background but not for campaign period nor their interaction. The unadjusted mean DUP for Spanish-speaking persons with FEP was more than twice as high as the mean DUP for English-speaking persons with FEP.

CONCLUSION

Spanish-speaking Latinxs with FEP are especially in need of early psychosis treatment. The campaign reached the community but additional steps are needed to reduce treatment delay. Greater attention is needed to increase access to early intervention services for communities of color. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Reminder-Focused Positive Psychiatry: Suicide Prevention Among Youths With Comorbid Posttraumatic Stress Disorder and Suicidality

OBJECTIVE

This study aimed to investigate the effect of brief reminder-focused positive psychiatry and suicide prevention (RFPP-S) on suicidal ideation, posttraumatic stress disorder (PTSD) symptoms, and clinical outcomes among youths with PTSD treated in psychiatric emergency rooms.

METHODS

This study included youths with PTSD and suicidality who received either RFPP-S (N=50) or treatment as usual (N=150). The Columbia Suicide Severity Rating Scale (C-SSRS), Clinician-Administered PTSD Scale for children and adolescents, University of California, Los Angeles Trauma Reminder Inventory, Patient Health Questionnaire-9, Positive Emotion, Engagement, Relationships, Meaning, and Accomplishment Scale, and positive psychiatry test batteries were administered at baseline, on day 2, and 1 week and 1 month after discharge.

RESULTS

On day 2, the RFPP-S group showed a greater reduction in PTSD symptoms (55%) and reactivity to trauma and loss reminders (80%) compared with the control group (10% for both) (p=0.001). A significantly greater reduction in C-SSRS score for RFPP-S (80%), compared with treatment as usual (15%), was noted (p=0.001), and RFPP-S showed more rapid stabilization (mean±SD=2.0±0.5 days) and enhanced postdischarge follow-up (100%) compared with treatment as usual (5.0±2.0 days and 50%, respectively) (p<0.05). RFPP-S, but not treatment as usual, was associated with significant increases in well-being, flexible thinking, and coping skills (p<0.05). Hospital readmission due to suicidality 1 month after discharge was 0% for the RFPP-S group and 20% for the control group.

CONCLUSIONS

RFPP-S was associated with reduced PTSD symptoms, enhanced coping skills while experiencing trauma reminders, adoption of safety skills, rapid stabilization of acute crises of PTSD with suicidality, adherence to post-emergency room visits and treatment, and favorable clinical outcomes.

Prevalence of COVID 19 Positive Cases Presenting to a Psychiatric Emergency Room

To explore the prevalence of SARS-CoV2 infection in the psychiatric emergency room setting. A Cross-sectional retrospective chart review was used to determine the point-prevalence of SARS-CoV2 infection and the characteristics of those infected. Of the patients tested for SARS-CoV2, 23/1057 (2.2%) were positive. Most of these patients were homeless (living on the street) or came from congregate living settings. The high percentage of SARS-CoV2 positive psychiatric patients coming from congregate living settings stresses the importance of asymptomatic screening in this vulnerable population.

Social Identities of Persons With Schizophrenia and Social Functioning: Individual and Family Caregiver Perspectives

ABSTRACT

We apply social identity theory and self-categorization theory to examine the role of social identities in relation to the recovery of persons with schizophrenia. We assess whether illness-based and non-illness-based identities held by both those with schizophrenia and their caregivers explain additional variance in social functioning in persons with schizophrenia beyond the previously established predictors of negative symptoms and theory of mind. Sixty Mexican-origin adults diagnosed with schizophrenia and their family caregivers were obtained through an outpatient mental health clinic located in either Los Angeles, CA, or in Puebla, Mexico. A three-step hierarchical regression indicated that identity endorsements, from both the perspective of the person with schizophrenia and their caregiver, and negative symptomatology are significant independent predictors of social functioning. Specifically, greater endorsement of nonillness identities both for the person with schizophrenia and also their caregiver is associated with higher social functioning. Illness identity plays an important role in the path to recovery.

Defining and assessing key behavioral indicators of the Shifting Cultural Lenses model of cultural competence

Models of cultural competence highlight the importance of the sociocultural world that is inhabited by patients, and the question of how best to integrate sociocultural factors into clinical assessment and intervention. However, one significant limitation of such approaches is that they leave unclear what type of in-session therapist behaviors actually reflect cultural competence. We draw on the Shifting Cultural Lenses model to operationalize culturally competent in-session behaviors. We argue that a key component of cultural competence is the collaborative relationship between therapists and patients, in which therapists shift between their own cultural lenses and those of their clients, as they co-construct shared narratives together. Accordingly, we propose that culturally competent therapist behaviors include accessing the client's views, explicitly presenting their own views as mental health care professionals, and working towards a shared understanding. We further specify the latter set of behaviors as including the practitioner's integration of the patient's view, their encouragement of the patient to consider their professional view, and the negotiation of a shared view. We developed a coding system to identify these therapist behaviors and examined the reliability of raters across 11 couple and 4 individual therapy sessions. We assessed whether the behavioral codes varied in expected ways over the first 3 sessions of 2 therapists' couple therapy as well. Operationalizing the behavioral indicators of the Shifting Cultural Lenses model opens the door to the integration of both process- and content-oriented approaches to cultural competence.

Measuring Congruence in Problem Definition of Latino Patients and Their Psychotherapists: An Exploratory Study

The current study developed a mixed-methods coding scheme to explore the degree of correspondence between Latino patients’ and their psychotherapists’ descriptions of the presenting problems. We interviewed 34 patients and clinicians (17 dyads) following an initial therapy session. Using a theoretical thematic approach, we generated a list of problem areas reported in participants’ descriptions. Independent coders reliably rated the presence and salience of these problems using a quantitative index. We then statistically estimated the fit between corresponding narratives. We found poor congruence across dyads’ descriptions of all problem areas, with two exceptions. We also noted patterns of incongruences, primarily characterized by therapists providing explanations that went beyond what their patients said. This study provides an innovative objective approach to estimate the nuanced degrees of concordance within dyads’ narratives. Our findings provide initial evidence of poor match between views held by Latino patients and their clinicians.

Lessons Learned in Clinical Research Recruitment of Immigrants and Minority Group Members with First-Episode Psychosis

Recruitment of immigrants and racial and ethnic minorities with first-episode psychosis (FEP) for research studies presents numerous challenges. We describe methods used to recruit 43 U.S. Latinos with FEP and their family caregivers (n = 41) participating in a study to reduce duration of untreated psychosis. A key challenge was that patients were not continuing treatment at an outpatient clinic, as initially expected. To facilitate identification of patients prior to outpatient care, we collaborated with clinic and hospital administrators. Many patients and families were grappling with the aftermath of a hospitalization or adjusting to a diagnosis of a serious mental illness. A considerable amount of time was devoted to addressing participants' concerns and when possible, facilitating needed services. Our experience underscores the importance of establishing long-term relationships through multiple contacts with patients, families, and stakeholders to address recruitment barriers among underserved groups with FEP.

Psychosis Literacy Among Latinos With First-Episode Psychosis and Their Caregivers

OBJECTIVE

The study examined psychosis literacy among Latinos with first-episode psychosis (FEP) and their caregivers. The authors tested a model that knowledge of psychosis and attribution of illness to psychosis predicted professional help seeking in a cross-sectional design.

METHODS

The sample (N=148) consisted of 79 Latino consumers who met criteria for a clinical diagnosis of a psychotic disorder and 69 family caregivers. Participants watched a four-minute narrative about a woman with psychosis and were asked to identify the symptoms of serious mental illness (knowledge of psychosis), describe the character's problem and whether she had a serious mental illness (illness attribution), and offer suggestions about what the parents should do (help seeking). Responses to the open-ended questions were reliably coded by two trained raters.

RESULTS

Consumers reported low psychosis literacy across all indices (e.g., only 8% included delusions in their knowledge of serious mental illness). Compared with consumers, caregivers reported significantly greater psychosis literacy across most indices, although relatively few reported knowledge of delusions (28%) and disorganized speech (36%). Logistic regression analyses found that caregivers were more than twice as likely as consumers to suggest that the parents seek professional help. Among both consumers and caregivers, greater knowledge of psychosis and attribution of symptoms to serious mental illness were associated with increased likelihood of recommending professional help seeking.

CONCLUSIONS

Community campaigns and psychoeducation interventions within clinical settings are needed to improve psychosis literacy among Latinos with FEP. Increasing knowledge of psychosis and facilitating attributions of psychotic symptoms to serious mental illness have the potential to promote professional help seeking.

Comparative Effectiveness of a Technology-Facilitated Depression Care Management Model in Safety-Net Primary Care Patients With Type 2 Diabetes: 6-Month Outcomes of a Large Clinical Trial

BACKGROUND

Comorbid depression is a significant challenge for safety-net primary care systems. Team-based collaborative depression care is effective, but complex system factors in safety-net organizations impede adoption and result in persistent disparities in outcomes. Diabetes-Depression Care-management Adoption Trial (DCAT) evaluated whether depression care could be significantly improved by harnessing information and communication technologies to automate routine screening and monitoring of patient symptoms and treatment adherence and allow timely communication with providers.

OBJECTIVE

The aim of this study was to compare 6-month outcomes of a technology-facilitated care model with a usual care model and a supported care model that involved team-based collaborative depression care for safety-net primary care adult patients with type 2 diabetes.

METHODS

DCAT is a translational study in collaboration with Los Angeles County Department of Health Services, the second largest safety-net care system in the United States. A comparative effectiveness study with quasi-experimental design was conducted in three groups of adult patients with type 2 diabetes to compare three delivery models: usual care, supported care, and technology-facilitated care. Six-month outcomes included depression and diabetes care measures and patient-reported outcomes. Comparative treatment effects were estimated by linear or logistic regression models that used generalized propensity scores to adjust for sampling bias inherent in the nonrandomized design.

RESULTS

DCAT enrolled 1406 patients (484 in usual care, 480 in supported care, and 442 in technology-facilitated care), most of whom were Hispanic or Latino and female. Compared with usual care, both the supported care and technology-facilitated care groups were associated with significant reduction in depressive symptoms measured by scores on the 9-item Patient Health Questionnaire (least squares estimate, LSE: usual care=6.35, supported care=5.05, technology-facilitated care=5.16; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.02); decreased prevalence of major depression (odds ratio, OR: supported care vs usual care=0.45, technology-facilitated care vs usual care=0.33; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.007); and reduced functional disability as measured by Sheehan Disability Scale scores (LSE: usual care=3.21, supported care=2.61, technology-facilitated care=2.59; P value: supported care vs usual care=.04, technology-facilitated care vs usual care=.03). Technology-facilitated care was significantly associated with depression remission (technology-facilitated care vs usual care: OR=2.98, P=.04); increased satisfaction with care for emotional problems among depressed patients (LSE: usual care=3.20, technology-facilitated care=3.70; P=.05); reduced total cholesterol level (LSE: usual care=176.40, technology-facilitated care=160.46; P=.01); improved satisfaction with diabetes care (LSE: usual care=4.01, technology-facilitated care=4.20; P=.05); and increased odds of taking an glycated hemoglobin test (technology-facilitated care vs usual care: OR=3.40, P<.001).

CONCLUSIONS

Both the technology-facilitated care and supported care delivery models showed potential to improve 6-month depression and functional disability outcomes. The technology-facilitated care model has a greater likelihood to improve depression remission, patient satisfaction, and diabetes care quality.

Improving Work Outcome in Supported Employment for Serious Mental Illness: Results From 2 Independent Studies of Errorless Learning

BACKGROUND

Heterogeneity in work outcomes is common among individuals with serious mental illness (SMI).

OBJECTIVE

In 2 studies, we sought to examine the efficacy of adding errorless learning, a behavioral training intervention, to evidence-based supported employment to improve SMI work outcomes. Work behavior problems were targeted for intervention. We also explored associations between early work behavior and job tenure.

METHODS

For both studies (VA: n = 71; community mental health center: n = 91), randomization occurred at the time of job obtainment with participants randomized (1:1) to either errorless learning plus ongoing supported employment or ongoing supported employment alone and then followed for 12 months. Dependent variables included job tenure, work behavior, and hours worked and wages earned per week. For the primary intent-to-treat analyses, data were combined across studies.

RESULTS

Findings revealed that participants in the errorless learning plus supported employment group stayed on their jobs significantly longer than those in the supported employment alone group (32.8 vs 25.6 wk). In addition, differential treatment effects favoring errorless learning were found on targeted work behavior problems (50.5% vs 27.4% improvement from baseline to follow-up assessment). There were no other differential treatment effects. For the prediction analyses involving work behavior, social skills explained an additional 18.3% of the variance in job tenure beyond levels of cognition, symptom severity, and past work history.

CONCLUSIONS

These data support errorless learning as an adjunctive intervention to enhance supported employment outcomes and implicate the relevance of workplace social difficulties as a key impediment to prolonged job tenure.

Caregiver criticism, help-giving, and the burden of schizophrenia among Mexican American families

OBJECTIVES

This study tested an attribution model of help-giving in family caregivers of persons with schizophrenia as it relates to caregivers' reported burden. We hypothesized (a) that caregivers' attributions of their ill relatives' responsibility for their symptoms would be associated with more negative and less positive affective reactions, (b) that affective reactions would be related to perceptions of administered support, and (c) that support would in turn predict greater burden.

METHODS

We examined 60 family caregivers of Mexican origin living in Southern California. Mexican Americans were chosen because of their high degree of contact with their ill relative, thereby facilitating the examination of help-giving and burden. Contrary to past studies, caregivers' attributions and affective stance were assessed independently, the former based on self-report and the latter based on codes drawn from the Camberwell Family Interview. Caregiver burden was assessed at baseline and one year later.

RESULTS

Path analyses showed partial support for the attribution model of help-giving. Specifically, attributions of responsibility negatively predicted caregiver's warmth, which in turn predicted more administered support. Contrary to hypotheses, attributions were not associated with caregiver criticism, and criticism was positively related to administered support. In addition, caregiver support was not related to burden at either baseline or a year later. Criticism was a significant predictor of burden at follow-up through burden at baseline.

CONCLUSION

The emotional stance of caregivers predicts burden independent of the help they provide. Caregiver criticism not only predicts negative patient outcomes but can predict negative caregiver outcomes as well.

PRACTITIONER POINTS

Positive clinical implications In family treatment, it is important to address caregiver criticism not only because of its relationship to poor clinical outcomes of ill relatives but also because of its relationship to greater caregiver burden. Integrating a balanced rationale for family interventions - to improve ill relatives' and caregivers' outcomes - may promote further engagement of both parties as some caregivers may be additionally motivated to improve their own well-being, and some ill relatives may appreciate more equitably distributing the treatment focus. Limitations The caregiver sample was in general low in criticism; therefore, the findings may not be generalizable to families with a higher degree of criticism. There was a 35% sample attrition at the one-year follow-up.

A multicenter, open-label, pilot study evaluating the functionality of an integrated call center for a digital medicine system to optimize monitoring of adherence to oral aripiprazole in adult patients with serious mental illness

BACKGROUND

Medication nonadherence is common in the treatment of serious mental illness (SMI) and leads to poor outcomes. The digital medicine system (DMS) objectively measures adherence with oral aripiprazole in near-real time, allowing recognition of adherence issues. This pilot study evaluated the functionality of an integrated call center in optimizing the use of the DMS.

MATERIALS AND METHODS

An 8-week, open-label, single-arm trial at four US sites enrolled adults with bipolar I disorder, major depressive disorder, and schizophrenia on stable oral aripiprazole doses and willing to use the DMS (oral aripiprazole + ingestible event marker [IEM], IEM-detecting skin patch, and software application). Integrated call-center functionality was assessed based on numbers and types of calls. Ingestion adherence with prescribed treatment (aripiprazole + IEM) during good patch wear and proportion of time with good patch wear (days with ≥80% patch data or detected IEM) were also assessed.

RESULTS

All enrolled patients (n=49) used the DMS and were included in analyses; disease duration overall approached 10 years. For a duration of 8 weeks, 136 calls were made by patients, and a comparable 160 calls were made to patients, demonstrating interactive communication. The mean (SD) number of calls made by patients was 2.8 (3.5). Approximately half of the inbound calls made by patients occurred during the first 2 weeks and were software application- or patch-related. Mean ingestion adherence was 88.6%, and corresponding good patch wear occurred on 80.1% of study days.

CONCLUSION

In this pilot study, the integrated call center facilitated DMS implementation in patients with SMI on stable doses of oral aripiprazole. In clinical practice, the call center and the DMS will facilitate objective measurement of adherence and potentially improve rates of adherence in patients with SMI.

Comparison of Injectable and Oral Antipsychotics in Relapse Rates in a Pragmatic 30-Month Schizophrenia Relapse Prevention Study

OBJECTIVE

In a pragmatic clinical trial, this study sought to compare relapses among patients receiving either long-acting injectable or oral second-generation antipsychotics.

METHODS

PROACTIVE (Preventing Relapse Oral Antipsychotics Compared to Injectables Evaluating Efficacy), a prior 30-month relapse prevention study, compared use of a long-acting injectable second-generation antipsychotic with use of an oral second-generation antipsychotic by 305 patients with schizophrenia or schizoaffective disorder and found similar rates of first relapse between groups (42% with injectable medication, 32% with oral medication). This study examined subsequent relapses among patients who had relapsed in PROACTIVE and who continued in treatment, follow-up, or both.

RESULTS

Thirty-two patients (11%) experienced two relapses, and 13 patients (4%) had three relapses. Neither rate of relapse nor time to successive relapses differed between treatment groups.

CONCLUSIONS

There was an impressively low rate of subsequent relapses in this pragmatic clinical trial. Because all patients had a clinic visit according to the biweekly long-acting injectable medication administration schedule, frequent contact may have contributed to low relapse rates. Maintaining frequent clinical contact may be a valid psychosocial relapse prevention treatment.

Report on ISCTM Consensus Meeting on Clinical Assessment of Response to Treatment of Cognitive Impairment in Schizophrenia

If treatments for cognitive impairment are to be utilized successfully, clinicians must be able to determine whether they are effective and which patients should receive them. In order to develop consensus on these issues, the International Society for CNS Clinical Trials and Methodology (ISCTM) held a meeting of experts on March 20, 2014, in Washington, DC. Consensus was reached on several important issues. Cognitive impairment and functional disability were viewed as equally important treatment targets. The group supported the notion that sufficient data are not available to exclude patients from available treatments on the basis of age, severity of cognitive impairment, severity of positive symptoms, or the potential to benefit functionally from treatment. The group reached consensus that cognitive remediation is likely to provide substantial benefits in combination with procognitive medications, although a substantial minority believed that medications can be administered without nonpharmacological therapy. There was little consensus on the best methods for assessing cognitive change in clinical practice. Some participants supported the view that performance-based measures are essential for measurement of cognitive change; others pointed to their cost and time requirements as evidence of impracticality. Interview-based measures of cognitive and functional change were viewed as more practical, but lacking validity without informant involvement or frequent contact from clinicians. The lack of consensus on assessment methods was viewed as attributable to differences in experience and education among key stakeholders and significant gaps in available empirical data. Research on the reliability, validity, sensitivity, and practicality of competing methods will facilitate consensus.

Toward the early recognition of psychosis among Spanish-speaking adults on both sides of the U.S.-Mexico border

Lack of knowledge about psychosis, a condition oftentimes associated with serious mental illness, may contribute to disparities in mental health service use. Psychoeducational interventions aimed at improving psychosis literacy have attracted significant attention recently, but few have focused on the growing numbers of ethnic and linguistic minorities in countries with large immigrant populations, such as the United States. This paper reports on 2 studies designed to evaluate the effectiveness of a DVD version of La CLAve, a psychoeducational program that aims to increase psychosis literacy among Spanish-speaking Latinos. Study 1 is a randomized control study to test directly the efficacy of a DVD version of La CLAve for Spanish speakers across a range of educational backgrounds. Fifty-seven medical students and 68 community residents from Mexico were randomly assigned to view either La CLAve or a psychoeducational program of similar length regarding caregiving. Study 2 employed a single-subjects design to evaluate the effectiveness of the DVD presentation when administered by a community mental health educator. Ninety-three Spanish-speakers from San Diego, California completed assessments both before and after receiving the DVD training. Results from these 2 studies indicate that the DVD version of La CLAve is capable of producing a range of psychosis literacy gains for Spanish-speakers in both the United States and Mexico, even when administered by a community worker. Thus, it has potential for widespread dissemination and use among underserved communities of Spanish-speaking Latinos and for minimizing disparities in mental health service use, particularly as it relates to insufficient knowledge of psychosis.

Using the theory of planned behavior to improve treatment adherence in Mexican Americans with schizophrenia

OBJECTIVE

Failure to adhere to treatment with antipsychotic medication is the most common cause of relapse among patients with schizophrenia. A novel multifamily group (MFG) intervention, informed by the Theory of Planned Behavior (TPB), demonstrated efficacy in increasing medication adherence and decreasing rehospitalizations in schizophrenia patients. This report explores the hypothesis that the improved outcomes obtained through the MFG approach were mediated by changes in the patients' attitudes toward medications, subjective norms-social influences, and perceived behavioral control of resources.

METHOD

Data from a recently completed, randomized controlled trial of MFG was used to test the hypothesis that the improvement in adherence was mediated by the 3 TPB factors. Subjects were 174 Mexican American adults with schizophrenia-spectrum disorder who had participated in a study of MFG focused on improving medication adherence. Assessments occurred at baseline and at 4, 8, 12, 18, and 24 months.

RESULTS

Path analysis revealed that the increased adherence associated with MFG was mediated by improvements in subjective norms but not attitudes toward medications nor perceived behavioral control.

CONCLUSION

An MFG treatment specifically tailored to increase medication adherence among Mexican Americans with schizophrenia achieved its benefits by leveraging social influences through teaching family members how to support medication adherence in their ill relatives.

A demonstration project involving peers as providers of evidence-based, supported employment services

OBJECTIVE

The present demonstration project involved development of a training program designed to teach recovering consumers employed as peer advocates how to provide evidence-based supported employment services to consumers with severe mental illness.

METHODS

A training curriculum was developed to teach the core competencies of the Individual Placement and Support (IPS) model of supported employment. Three peers participated in training and provided work outcome data from their caseloads. Assessments were conducted of peers' competence in implementing IPS and effectiveness in promoting job placements. Peer competency was assessed by the following: (a) a formal IPS fidelity review performed by two external reviewers to evaluate service implementation, and (b) the Kansas Employment Specialist Job Performance Evaluation, an objective measure of employment specialist attitudes and skills. Program efficacy was assessed by examining the number of job placements and corresponding tenure.

RESULTS

The fidelity review revealed that peers met IPS standards of implementation on 7 of 14 items assessing service delivery. The Kansas scale results revealed attitudes to be a relative strength and job performance competency ratings fell in the average to above average range across skill areas assessed (e.g., vocational assessment, job development). Thirty-three percent of consumers from the peers' caseloads got competitive jobs; mean tenure was 26.1 weeks.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This demonstration project provides a starting point for future efforts aimed at expanding the role of peers as providers of evidence-based mental health services and provides a measured degree of optimism that this is a realistic, attainable goal.

From documenting to eliminating disparities in mental health care for Latinos

The U.S. Surgeon General's report Mental Health: Culture, Race and Ethnicity--A Supplement to Mental Health: A Report of the Surgeon General (U.S. Department of Health and Human Services, 2001) identified significant disparities in mental health care for Latinos and recommended directions for future research and mental health services. We update that report by reviewing five groundbreaking research projects on the mental health of Latinos that were published since 2001. National studies of adults and children, longitudinal designs, and analyses of Latino subgroups characterize these investigations. Despite the increasing sophistication of disparities research, these landmark studies, as well as the research in the supplemental report, can be characterized as documenting disparities in care. We argue that the next wave of research should give greater attention to reducing and eliminating disparities. Accordingly, we apply Rogler and Cortes's (1993) framework of pathways to care to the study of Latinos with schizophrenia. Specifically, we draw on research regarding the recognition of illness, social networks (families) and their association with the course of illness, and interventions. We illustrate examples at each pathway that have the potential to reduce disparities. We argue that implementing interventions synchronously across multiple pathways has considerable potential to reduce and eventually eliminate disparities in mental health care.

The ability of multifamily groups to improve treatment adherence in Mexican Americans with schizophrenia

CONTEXT

Evidence-based interventions to improve medication adherence among patients with schizophrenia are lacking. Although family psychoeducation has demonstrated efficacy in improving outcomes in schizophrenia, empirical support for its ability to enhance medication adherence is scarce.

OBJECTIVE

To determine whether a culturally adapted, multifamily group (MFG) therapy would increase medication adherence and decrease psychiatric hospitalizations for Spanish-speaking Mexican Americans with schizophrenia.

DESIGN

A total of 174 Mexican American adults with schizophrenia-spectrum disorder and their key relatives were studied in a 3-armed, randomized controlled trial of MFG therapy focused on improving medication adherence. Assessments occurred at baseline and at 4, 8, 12, 18, and 24 months.

SETTING

Two community mental health centers in Los Angeles, California.

PARTICIPANTS

Patients had a diagnosis of schizophrenia or schizoaffective disorder with a recent exacerbation of psychotic symptoms and nonadherence to medication before enrollment. Intervention  Patients participated in 1 of 2 MFGs (MFG-adherence or MFG-standard) or treatment as usual. Groups convened twice monthly in 90-minute sessions for 1 year.

MAIN OUTCOME MEASURES

The Treatment Compliance Interview uses multiple sources of information to quantify medication adherence. Computerized records were used to collect information on the use of inpatient resources.

RESULTS

At the end of the 1-year treatment, MFG-adherence was associated with higher medication adherence than MFG-standard or treatment as usual only (F = 6.41; P = .003). The MFG-adherence participants had a longer time to first hospitalization (χ(2) = 13.3; P = .001) and were less likely to be hospitalized than those in MFG-standard (χ(2) = 8.2; P = .04) and treatment as usual alone (χ(2) = 11.3; P < .001). Increased adherence accounted for one-third of the overall effect of treatment on the reduced risk for psychiatric hospitalization.

CONCLUSION

Multifamily group therapy specifically tailored to improve medication adherence through a focus on the beliefs and attitudes of the target population is associated with improved outcome for Mexican American adults with schizophrenia-spectrum disorders. Trial Registration  clinicaltrials.gov Identifier: NCT01125267.

Expressed emotion and sociocultural moderation in the course of schizophrenia

This study examined whether the sociocultural context moderates the relationship between families' expressed emotion (EE) and clinical outcomes in schizophrenia. In a sample of 60 Mexican American caregivers and their ill relatives, we first assessed whether EE and its indices (criticism, emotional overinvolvement [EOI], and warmth) related to relapse. Second, we extended the analysis of EE and its indices to a longitudinal assessment of symptomatology. Last, we tested whether bidimensional acculturation moderated the relationship between EE (and its indices) and both relapse and symptom trajectory over time. Results indicated that EOI was associated with increased relapse and that criticism was associated with increased symptomatology. Additionally, as patients' Mexican enculturation (Spanish language and media involvement) decreased, EE was increasingly related to relapse. For symptomatology, as patients' U.S. acculturation (English language and media involvement) increased, EE was associated with increased symptoms longitudinally. Our results replicate and extend past research on how culture might shape the way family factors relate to the course of schizophrenia.

Outcomes of the Chinese Basic Conversation Skill Module (CBCSM) for people with schizophrenia having mild to moderate symptoms and dysfunction in Hong Kong

Abstract This study tested the effectiveness of a culturally adapted Chinese Basic Conversation Skill Module (CBCSM) for Hong Kong Chinese with schizophrenia. A total of 106 participants with schizophrenia who had mild to moderate levels of symptoms and dysfunction were recruited between January 2004 and September 2005. After random allocation, 35 participants were assigned to the CBCSM group with skill generalization training (SGT), 35 participants were assigned to the CBCSM group without SGT, and 36 participants were assigned to the placebo group. All participants were assessed by a blind rater at baseline, 5 weeks after commencement of skills training, and 3 and 6 months after completion of skills training on conversation skill mastery, subjective personal well being, and self esteem. After 15 sessions of intervention, the CBCSM group with SGT and the CBCSM group outperformed the placebo group in social skills. At the 6-month follow-up, social skill of CBCSM group with SGT was better than the CBCSM group and the placebo group. CBCSM with SGT was found to be effective in improving conversation skill of people with schizophrenia in Hong Kong. This combined strategy was also shown to be better than mere application of CBCSM in helping conversation skill mastery.

La CLAve to increase psychosis literacy of Spanish-speaking community residents and family caregivers

The authors developed and tested a 35-min psychoeducational program with the goal of increasing Spanish-speaking persons' literacy of psychosis. The program uses popular cultural icons derived from music, art, and videos, as well as a mnemonic device--La CLAve (The Clue)--to increase (a) knowledge of psychosis, (b) efficacy beliefs that one can identify psychosis in others, (c) attributions to mental illness, and (d) professional help-seeking. Assessments were conducted before and after administering the program to both community residents (n = 57) and family caregivers of persons with schizophrenia (n = 38). For community residents, the authors observed increases across the 4 domains of symptom knowledge, efficacy beliefs, illness attributions, and recommended help-seeking. For caregivers, increases were observed in symptom knowledge and efficacy beliefs. La CLAve is a conceptually informed psychoeducational tool with a developing empirical base aimed at helping Spanish-speaking Latinos with serious mental illness obtain care in a timely manner.

Cultural variability in the manifestation of expressed emotion

We examined the distribution of expressed emotion (EE) and its indices in a sample of 224 family caregivers of individuals with schizophrenia pooled from 5 studies, 3 reflecting a contemporary sample of Mexican Americans (MA 2000, N = 126), 1 of an earlier study of Mexican Americans (MA 1980, N = 44), and the other of an earlier study of Anglo Americans (AA, N = 54). Chi-square and path analyses revealed no significant differences between the 2 MA samples in rates of high EE, critical comments, hostility, and emotional over-involvement (EOI). Only caregiver warmth differed for the 2 MA samples; MA 1980 had higher warmth than MA 2000. Significant differences were consistently found between the combined MA samples and the AA sample; AAs had higher rates of high EE, more critical comments, less warmth, less EOI, and a high EE profile comprised more of criticism/hostility. We also examined the relationship of proxy measures of acculturation among the MA 2000 sample. The findings support and extend Jenkins' earlier observations regarding the cultural variability of EE for Mexican Americans. Implications are discussed regarding the cross-cultural measurement of EE and the focus of family interventions.

Family problem solving interactions and 6-month symptomatic and functional outcomes in youth at ultra-high risk for psychosis and with recent onset psychotic symptoms: a longitudinal study

This study prospectively examined the relationship between social problem solving behavior exhibited by youths at ultra-high risk for psychosis (UHR) and with recent onset psychotic symptoms and their parents during problem solving discussions, and youths' symptoms and social functioning six months later. Twenty-seven adolescents were administered the Structured Interview for Prodromal Syndromes and the Strauss-Carpenter Social Contact Scale at baseline and follow-up assessment. Primary caregivers participated with youth in a ten minute discussion that was videotaped, transcribed, and coded for how skillful participants were in defining problems, generating solutions, and reaching resolution, as well as how constructive and/or conflictual they were during the interaction. Controlling for social functioning at baseline, adolescents' skillful problem solving and constructive communication, and parents' constructive communication, were associated with youths' enhanced social functioning six months later. Controlling for symptom severity at baseline, we found that there was a positive association between adolescents' conflictual communications at baseline and an increase in positive symptoms six months later. Taken together, findings from this study provide support for further research into the possibility that specific family interventions, such as problem solving and communication skills training, may improve the functional prognosis of at-risk youth, especially in terms of their social functioning.

Gun laws and the involuntarily committed: a California road map

The 2007 incident at Virginia Tech brought the question of gun ownership by the mentally ill to the forefront of public attention. Moreover, it underscored the potentially devastating consequences of the imperfect connection between federal and state laws that apply to the right of gun ownership by a psychiatric patient. The laws are complex, and, as demonstrated in this article, conflicting. We present a case report of an involuntarily committed patient in the state of California, and discuss details of state and federal laws that applied to him.

Parent attitudes and parent adolescent interaction in families of youth at risk for psychosis and with recent-onset psychotic symptoms

AIM

This study investigated the behavioural correlates of caregiver attitudes among parents of youth at risk for psychosis and with recent-onset psychotic symptoms.

METHODS

Forty adolescents identified as ultra-high-risk (UHR) for psychosis using the Structured Interview for Prodromal Syndromes, and their primary caregivers, participated in the Family Interaction Task (FIT), a 10-minute discussion of meaningful shared experiences that allowed families to demonstrate supportive as well as conflict-engaging behaviour. At the same assessment, caregivers were administered the Camberwell Family Interview (CFI). We examined cross-sectional relationships between these measures, as well as their association with youth symptom severity and functioning at 4-month follow-up.

RESULTS

As predicted, caregivers who provided more positive remarks regarding their UHR and recent-onset adolescents during the CFI were also more likely to exhibit constructive behaviour during the FIT. Similarly, CFI critical comments were positively associated with caregivers' conflict-engaging behaviour during the FIT. Parents' positive remarks predicted a decrease in negative symptoms, and parent warmth predicted an increase in social functioning at follow-up assessment.

CONCLUSIONS

The ability to maintain a constructive attitude and approach towards youth predicted symptomatic and functional improvement, and may be a teachable skill.

A qualitative inquiry into the Taiwanese mentally ill persons' difficulties living in the community

Community care has been a paradigm shift for psychiatric treatment worldwide; however, it has not been successfully implemented in many developing countries, including Taiwan. This qualitative study aimed to explore the Taiwanese mentally ill persons' difficulties living in the community. Social disadvantages and illness adaptation were recognized as two domains of difficulties encountered by Taiwanese mentally ill patients living in the community, while six themes were identified: getting a "shameful" illness, unmet needs for community care, being overcome by a distorted world, denying the illness, living with the illness, and adapting to changed level of functioning. Related cultural issues were also discussed.

Consistency of Brief Psychiatric Rating Scale factor structure across a broad spectrum of schizophrenia patients

BACKGROUND

The Brief Psychiatric Rating Scale (BPRS) has been the workhorse of psychopathology assessment in studies of schizophrenia and related psychotic disorders for over 40 years. Our goal was to evaluate the discriminant validity of the BPRS across the broad spectrum of persons with schizophrenia.

SAMPLING AND METHODS

The total sample of 565 subjects with schizophrenia (84%) or schizoaffective disorder (16%) came from eight separate studies conducted under the aegis of the UCLA Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation over a period of 15 years. The total sample could be divided into three subsamples based on illness chronicity and degree of refractoriness to treatment: Recent-onset patients had been ill for less than 2 years (n = 178), stable chronic patients between 2 and 19 years (n = 243) and treatment-refractory patients for more than 19 years (n = 144). Exploratory principal components analysis and varimax rotation were performed on the total sample. The results of each of the three subsamples were compared to the total sample using a correlation matrix and by calculating a coefficient of congruence.

RESULTS

A 4-factor solution was considered the most interpretable for each subsample, reflecting the same 4 components identified in the total sample: positive symptoms, negative symptoms, agitation-mania and depression-anxiety. Correlation coefficients and coefficient of congruence were very high, ranging from 0.91 to 0.98.

CONCLUSIONS

The consistency of the 4-factor solution of the 24-item BPRS across the range of subjects, from first psychotic episode to long-stay, institutionalized patients, supports the use of these factors and this instrument as a whole to track changes over time and with treatment in research and clinical samples.

Psychoeducational multi-family group treatment with adolescents at high risk for developing psychosis

AIM

In this study, we investigate the feasibility and acceptability of a 9-month psychoeducational multi-family group (PMFG) intervention for adolescents who are at ultra-high-risk (UHR) for developing psychosis.

METHODS

The treatment programme was adapted from those previously shown to be effective in patients with established psychotic illness, but emphasizes content relevant to adolescence and to a pre-onset phase of illness.

RESULTS

Participants report that psychoeducational presentations are highly useful, they attend the PMFG group sessions regularly and report feeling comfortable in meetings and benefiting from them, and adolescents demonstrate improvement in symptoms and functional outcome.

CONCLUSIONS

This study was not a randomized controlled trial and multiple interventions were introduced simultaneously; thus, changes in outcome cannot be attributed to the PMFG intervention per se. Nonetheless, these results establish the acceptability of PMFG to adolescents and families, and encourage further research into the potential positive impact of PMFG with this at-risk population.

Stress and coping responses to a natural disaster in people with schizophrenia

Investigations of how individuals with schizophrenia differ from non-patients in their responses to stressful life events are subject to the criticism that any between-group differences might merely reflect differences in the types of stressful events that each group experiences. This report presents new analyses of data collected from schizophrenia patients (n=96), bipolar disorder patients (n=18), and healthy controls (n=18) immediately after the Northridge Earthquake that struck Southern California in 1994, a natural experiment that confronted all groups with the same stressful event. Participants completed the Impact of Events Scale (IES; [Horowitz, M.J., Wilner, N., Alvarez, W., 1979. Impact of Events Scale. A measure of subjective stress. Psychosomatic Medicine 41, 209-218]) at 1 week and 5 weeks post-earthquake. At the 5-week follow-up, measures of coping, social support, and self-esteem were also completed. Both patient groups reported higher IES avoidance symptoms than controls immediately after the earthquake. The schizophrenia group also reported lower approach coping, self-esteem, and social support than controls, with the bipolar group reporting intermediate levels. Within the schizophrenia group, higher levels of avoidance coping predicted higher residual stress symptoms at follow-up. Results support the validity of prior reports of altered responses to stressful life events in schizophrenia and demonstrate the clinical relevance of individual differences in coping among affected individuals.

Research issues for improving treatment of U.S. Hispanics with persistent mental disorders

This article reports on the outcome of an expert consensus meeting in August 2005 sponsored by the National Institute of Mental Health, which assembled 15 senior researchers with a background in treatment and services research with the Hispanic population. The purpose of the workshop was to identify research issues most pertinent for improving quality and effectiveness of treatment for Hispanics experiencing persistent mental disorders, defined as psychiatric syndromes that are of sufficient severity and duration to cause long-term impairment in social and occupational functioning and significant disability. The spectrum of ideas and recommendations advanced at the one-day meeting was wide and overlapping; therefore, the rich body of material was subsequently organized into five topics: diagnosis, quality of care and culturally appropriate services, psychosocial intervention development, psychopharmacologic interventions, and access to care. Although the authors recognize that the review was broad and the agenda presented is ambitious and in many instances generalizes to priority areas in overall mental health services and treatment research, the recommendations are intended to stimulate research for addressing the unique problems and research deficits that affect Hispanics with persistent mental disorders.

Recent advances in social skills training for schizophrenia

Social skills training consists of learning activities utilizing behavioral techniques that enable persons with schizophrenia and other disabling mental disorders to acquire interpersonal disease management and independent living skills for improved functioning in their communities. A large and growing body of research supports the efficacy and effectiveness of social skills training for schizophrenia. When the type and frequency of training is linked to the phase of the disorder, patients can learn and retain a wide variety of social and independent living skills. Generalization of the skills for use in everyday life occurs when patients are provided with opportunities, encouragement, and reinforcement for practicing the skills in relevant situations. Recent advances in skills training include special adaptations and applications for improved generalization of training into the community, short-term stays in psychiatric inpatient units, dually diagnosed substance abusing mentally ill, minority groups, amplifying supported employment, treatment refractory schizophrenia, older adults, overcoming cognitive deficits, and negative symptoms as well as the inclusion of social skills training as part of multidimensional treatment and rehabilitation programs.

Expressed emotion and family interactions in Mexican Americans with schizophrenia

Patients with schizophrenia who are exposed to family environments high in expressed emotion (EE) are at increased risk of relapse. EE is usually measured by an interview with one family member and does not include a direct assessment of family interaction. To understand better the key processes that underlie the relationship between EE and course of illness, we applied a well-validated measure of family interaction, the Structural Family Systems Ratings (SFSR), to 28 Mexican-Americans with schizophrenia and their families. The relationships among EE indices, SFSR components, and relapse were examined. Although measures of EE and family interactions were not related, both EE and one component of the SFSR, family resonance, were associated with a psychotic relapse within 1 year of the assessment. The results suggest that Mexican Americans with schizophrenia benefit from living with families that are able to adapt to the ever-changing circumstances and needs of their ill relatives.

Positive family environment predicts improvement in symptoms and social functioning among adolescents at imminent risk for onset of psychosis

This study investigated whether family factors, such as criticism, emotional over-involvement (EOI), warmth, and positive remarks, as measured by the Camberwell Family Interview (CFI), predict symptom change and social outcome for individuals identified as at imminent risk for conversion to psychosis. Twenty-six adolescent patients were administered the Structured Interview for Prodromal Syndromes and the Strauss-Carpenter Outcome Scale at baseline and follow-up assessment approximately three months later. Patients' primary caregivers were administered the CFI at baseline. After controlling for symptom severity at baseline, there were significant associations between caregivers' EOI at baseline and improvement in high-risk youths' negative symptoms and social functioning at follow-up. Similarly, caregivers' positive remarks at baseline were associated with improvement in negative and disorganized symptoms at follow-up, and warmth expressed by caregivers was associated with improved social functioning at follow-up. Although family members' critical comments were not related to patients' symptoms, the majority of critical remarks were focused on patients' negative symptoms and irritability/aggression, which may be important targets for early intervention. These preliminary results provide a first glimpse into the relationship between family factors and symptom development during the prodrome and suggest that positive family involvement predicts decreased symptoms and enhanced social functioning at this early stage. The finding that four-fifths of the youth enrolled in this early intervention clinical research program have shown symptomatic improvement by the three-month assessment point is very encouraging from an early detection/early intervention standpoint.

Neurocognitive correlates of recovery from schizophrenia

BACKGROUND. Evidence has mounted that some patients with schizophrenia experience remission of symptoms and restoration of social and vocational functioning. The purpose of this study was to identify neurocognitive variables associated with recovery from schizophrenia.

METHOD

Twenty-eight patients diagnosed with DSM-IV schizophrenia or schizoaffective disorder and who met our operational definition of recovery from schizophrenia underwent a battery of neurocognitive tests. These subjects were matched with schizophrenia patients who did not meet recovery criteria ('non-recovered') and with normal controls.

RESULTS

On tests of executive functioning, verbal fluency and verbal working memory, recovered subjects performed significantly better than non-recovered subjects and were comparable to normal controls. Patient groups did not differ on a test that assessed early visual processing, but both groups performed significantly worse than normal controls.

CONCLUSIONS

Three measures of frontal lobe functioning appear to be neurocognitive domains associated with recovery from schizophrenia. These findings help narrow the search for targets for cognitive remediation that may have implications for improving community functioning.