A Mixed-Methods Implementation Evaluation of Virtual Reality Job Interview Training in IPS Supported Employment

OBJECTIVE

Employment rates among individuals with serious mental illness may be improved by engagement in the individual placement and support (IPS) model of supported employment. Results from a recent randomized controlled trial (RCT) indicate that virtual reality job interview training (VR-JIT) improves employment rates among individuals with serious mental illness who have been actively engaged in IPS for at least 90 days. This study reports on an initial implementation evaluation of VR-JIT during the RCT in a community mental health agency.

METHODS

A sequential, complementary mixed-methods design included use of qualitative data to improve understanding of quantitative findings. Thirteen IPS staff trained to lead VR-JIT implementation completed VR-JIT acceptability, appropriateness, and feasibility surveys. Participants randomly assigned to IPS with VR-JIT completed acceptability (N=42) and usability (N=28) surveys after implementation. The authors also conducted five focus groups with IPS staff (N=11) and VR-JIT recipients (N=13) and semistructured interviews with IPS staff (N=9) and VR-JIT recipients (N=4), followed by an integrated analysis process.

RESULTS

Quantitative results suggest that IPS staff found VR-JIT to be highly acceptable, appropriate for integration with IPS, and feasible for delivery. VR-JIT was highly acceptable to recipients. Qualitative results add important context to the quantitative findings, including benefits of VR-JIT for IPS staff as well as adaptations for delivering technology-based interventions to individuals with serious mental illness.

CONCLUSIONS

These qualitative and quantitative findings are consistent with each other and were influenced by VR-JIT's adaptability and perceived benefits. Tailoring VR-JIT instruction and delivery to individuals with serious mental illness may help optimize VR-JIT implementation within IPS.

A Pilot Study of Adjunctive Group Therapy to Enhance Coping With Cognitive Challenges and Support Cognitive Health After Electroconvulsive Therapy

OBJECTIVES

Concerns about the cognitive adverse effects of electroconvulsive therapy (ECT) are common among recipients of the treatment despite its relatively small adverse effects on cognitive functioning. Interventions aimed at remediating or improving coping with cognitive adverse effects of ECT have not been developed. The Enhancing Cognitive Domains after ECT (ENCODE) program is a new group intervention aimed at teaching self-management strategies to cope with the cognitive challenges and associated anxiety that often accompanies ECT.

METHODS

This pilot study used a pretest-posttest design to examine the feasibility and clinical utility of delivering ENCODE to 20 adults who had received ECT in a hospital-based ECT program.

RESULTS

The program was found to be both feasible and acceptable as indicated by the attainment of recruitment targets, high rates of attendance (85% of participants attended at least 5 of the 6 group sessions), and high participant satisfaction ratings (88% reported that ENCODE helped or helped very much to manage their cognitive challenges). The clinical utility of the program was suggested by reductions in depressive symptom severity and subjective memory complaints. Nonsignificant improvements were observed in global cognitive function and cognitive self-efficacy.

CONCLUSIONS

This study provides preliminary evidence for the feasibility and clinical utility of ENCODE based on program demand, strong participant satisfaction, and postgroup reductions in distress and subjective memory complaints.

Critical elements in the experience of virtual reality job interview training for unemployed individuals with serious mental illness: Implications for IPS supported employment

OBJECTIVE

Individuals with serious mental illness (SMI) who re-enter the labor market after extended unemployment may benefit from exposure to job interview training. This study explored the processes and perceived benefits of preparing for interviews using Virtual Reality Job Interviewing Training (VR-JIT) among employment specialists (ESs) and clients within the individual placement and support (IPS) model of supported employment.

METHOD

This study analyzed secondary qualitative data from a randomized controlled trial (RCT) of VR-JIT including qualitative focus groups comprised of IPS employment specialists (n = 11) and IPS clients (n = 13), semistructured interviews with IPS employment specialists (n = 3), and semistructured interviews with IPS clients (n = 3). Additionally, semistructured interviews with IPS employment specialists (n = 8) who naturalistically implemented VR-JIT at four community mental health agencies independent of the RCT. All focus group and interview data were analyzed using grounded theory methodology.

RESULTS

Three main processes were viewed by employment specialists (and their clients) as beneficial for individuals with SMI receiving IPS with VR-JIT: (a) exposure to a simulated interview in a safe environment; (b) practicing and receiving job interviewing feedback; and (c) improved confidence and motivation in job seeking.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

VR-JIT improved IPS participants' confidence in job seeking through proposed mechanisms of exposure to a simulated job interview and repetition and practice of job interview skills. These critical elements indicate that VR-JIT has the potential to improve IPS client engagement particularly with those who have had prolonged periods of unemployment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The impact of early intervention for first episode psychosis on cognitive functioning

IMPORTANCE

Impaired cognitive functioning is a core characteristic of schizophrenia, present from the onset of the illness and relatively stable thereafter. Despite evidence supporting the impact of early intervention services (EIS) on improving symptoms and functioning in first episode psychosis (FEP), controlled research has not examined its impact on cognitive functioning.

OBJECTIVE

To evaluate the longitudinal course of cognitive functioning in FEP patients participating in a large, controlled study comparing EIS with usual services.

METHODS

A total of 404 persons ages 15-40 years old with non-affective FEP participated in the Recovery After Initial Schizophrenia-Early Treatment Program. A cluster randomized controlled trial was conducted with 34 community mental health treatment centers across the U.S. randomized to provide either an EIS program (NAVIGATE) or usual Community Care (CC) to FEP patients for 2 years. Cognitive functioning was assessed with the Brief Assessment of Cognition in Schizophrenia (BACS) at baseline and 1- and 2-years later.

RESULTS

Older participants (≥20 years old) in both treatment groups improved on all BACS tests. Younger participants (15-19) in NAVIGATE improved significantly more on Digit Sequencing (working memory) than those in CC, whereas both groups improved on most of the other BACS tests. Improvements in cognitive functioning occurred mostly over the first year and were correlated with reductions in symptom severity.

DISCUSSION

EIS do not improve cognitive functioning more than usual care for older FEP patients but may improve working memory in younger FEP patients. Interventions targeting cognition may be required to enhance cognitive functioning in most FEP patients.

Comparison of Black and White participants with severe mental illness in response to cognitive remediation as an augmentation of vocational rehabilitation

PURPOSE

Despite evidence that cognitive remediation improves cognitive and employment outcomes in persons with severe mental illnesses (SMI), its effects have not been systematically compared between Black and White participants. Considering that Black adults have more negative experiences receiving mental health treatment, providers may have greater difficulty engaging and retaining Black Americans in cognitive remediation. Due to the effects of structural racism on reducing employment opportunities for Black Americans, it is unclear whether Black participants will reap the same benefits of cognitive remediation on work outcomes as White Americans. This paper addressed this question.

METHODS

A secondary analysis was conducted of five randomized controlled trials comparing cognitive remediation (the Thinking Skills for Work program: TSW) and vocational rehabilitation vs. vocational rehabilitation only in 137 Black and 147 White Americans (64.2% schizophrenia-schizoaffective disorder) who were followed up for two years.

RESULTS

Comparable proportions of Black and White participants were engaged and retained in TSW (>75%). Participants who received TSW improved significantly more in cognition than those receiving vocational services alone, with no racial differences in benefit. Participants in TSW obtained more work, earned more wages, and worked more weeks than those receiving vocational services alone, with no differences between the races.

CONCLUSIONS

The findings indicate that Black Americans with SMI receiving vocational services could be successfully engaged in and benefit from cognitive remediation, highlighting the vital role of healthcare service systems in giving credence to structural racism to more effectively mitigate racial disparities in treatment outcomes.

Psychometric properties of the mock interview rating scale for schizophrenia and other serious mental illnesses

Background

Over the past 10 years, job interview training has emerged as an area of study among adults with schizophrenia and other serious mental illnesses who face significant challenges when navigating job interviews. The field of mental health services research has limited access to assessments of job interview skills with rigorously evaluated psychometric properties.

Objective

We sought to evaluate the initial psychometric properties of a measure assessing job interview skills via role-play performance.

Methods

As part of a randomized controlled trial, 90 adults with schizophrenia or other serious mental illnesses completed a job interview role-play assessment with eight items (and scored using anchors) called the mock interview rating scale (MIRS). A classical test theory analysis was conducted including confirmatory factor analyses, Rasch model analysis and calibration, and differential item functioning; along with inter-rater, internal consistency, and test-retest reliabilities. Pearson correlations were used to evaluate construct, convergent, divergent, criterion, and predictive validity by correlating the MIRS with demographic, clinical, cognitive, work history measures, and employment outcomes.

Results

Our analyses resulted in the removal of a single item (sounding honest) and yielded a unidimensional total score measurement with support for its inter-rater reliability, internal consistency, and test-retest reliability. There was initial support for the construct, convergent, criterion, and predictive validities of the MIRS, as it correlated with measures of social competence, neurocognition, valuing job interview training, and employment outcomes. Meanwhile, the lack of correlations with race, physical health, and substance abuse lent support for divergent validity.

Conclusion

This study presents initial evidence that the seven-item version of the MIRS has acceptable psychometric properties supporting its use to assess job interview skills reliably and validly among adults with schizophrenia and other serious mental illnesses.

Clinical Trial Registration

NCT03049813.

A 1-year prospective study of employment in people with severe mental illnesses receiving public sector psychiatric services in India

OBJECTIVE

Limited research has been conducted on the long-term course of employment in people with severe mental illnesses (SMI) in developing countries such as India. To inform the development of culturally appropriate vocational services in India we prospectively evaluated work status, perceived benefits, and problems related to work in employed participants, and interest in work, barriers to work, and desired job supports among unemployed participants over a 1-year period.

METHODS

We conducted semistructured interviews with 150 individuals with SMI (90% schizophrenia-schizoaffective) receiving psychiatric outpatient services at a public hospital in an urban district in India at baseline and followed up 1 year later. One-hundred-and-seven participants (71.3%) completed the follow-up interviews.

RESULTS

Work status (employed/unemployed) was consistent in 90.7% of participants, with 43.9% working at baseline and 49.5% working at follow-up. Participants who were working in the same job at both assessments were consistent in identifying several work-related problems (e.g., stress) as well as benefits (e.g., money). Interest in work among unemployed participants was consistent, with 78.8% interested at both assessments. Participants who were unemployed but interested in work consistently identified work barriers (e.g., cognitive difficulties) and desired job supports (e.g., assistance with job finding).

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Unemployment rates are moderately high and stable in people with SMI, with most unemployed participants consistently interested in working and desiring job supports. These findings, together with stable employment rates in working participants, suggest that supported employment developed for the Indian context could improve employment in people with SMI. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The relationship between cognitive functioning, age and employment in people with severe mental illnesses in an urban area in India: A longitudinal study

Although there is substantial evidence of the association between cognitive impairment and work in people with severe mental illnesses (SMI) in developed countries, less is known about this relationship in developing countries such as India. Studies showing higher rates of employment in people with SMI in developing countries than developed ones raise the question of whether cognitive functioning is related to work status and characteristics of work (e.g., wages earned). We conducted a one-year follow-up study to investigate the relationship between employment and cognitive functioning, assessed with the Montreal Cognitive Assessment (MoCA), in 150 participants with SMI (92% schizophrenia) living in an urban area and receiving psychiatric outpatient treatment at a public hospital in India. The MoCA had good internal reliability and test-retest reliability over the one-year period. Better cognitive functioning was associated with younger age, shorter duration of illness, higher education, and male gender. Both younger and older participants with higher cognitive functioning at baseline were more likely to be employed at baseline and one year later. Work status at baseline and one year follow-up was consistently related to executive functions among younger participants, and to attention among older participants, suggesting changes over the course of illness in the importance of specific cognitive domains for achieving satisfactory work performance. The findings suggest that cognitive functioning is associated with employment in people with SMI in India. Attention to impaired cognitive functioning may be critical to improving employment outcomes in this population.

An RCT of Virtual Reality Job Interview Training for Individuals With Serious Mental Illness in IPS Supported Employment

OBJECTIVE

Virtual Reality Job Interview Training (VR-JIT) is a computerized interview simulator with efficacy at enhancing interview skills and employment outcomes. A randomized controlled trial assessed VR-JIT effectiveness for participants in individual placement and support (IPS), in which approximately 55% of individuals with serious mental illness obtain employment.

METHODS

Ninety participants with serious mental illness were randomly assigned to IPS+VR-JIT (N=54) or IPS as usual (N=36), completing pretest-posttest assessments and an employment evaluation at 9 months. Intent-to-treat chi-square analysis, multivariable logistic regression, Cox proportional hazards models, and mixed-effects linear regressions were conducted. Fifty-one percent were IPS nonresponders (i.e., no employment within the first 90 days of IPS).

RESULTS

IPS+VR-JIT participants did not have significantly higher employment rates, compared with IPS-as-usual participants (43% versus 28%). IPS nonresponders (N=46) in the IPS+VR-JIT group had greater odds of obtaining employment (odds ratio [OR]=5.82, p=0.014) and shorter time to employment (hazard ratio=2.70, p=0.044) compared with IPS nonresponders in the IPS-as-usual group. Intent-to-treat mixed-effects linear analyses indicated that IPS+VR-JIT, compared with IPS as usual, significantly improved interview skills (p=0.006), interview confidence (p=0.013), and interview anxiety (p=0.019).

CONCLUSIONS

VR-JIT's potential benefits (increased employment in a shorter time) appeared to be specific to IPS nonresponders, whereas employment outcomes for recent IPS enrollees were not affected. VR-JIT could be a valuable resource for employment specialists to support IPS nonresponders, because 47% of participants engaged in mock interview training with their specialist. Future research should focus on evaluating the effectiveness and implementation of VR-JIT among IPS nonresponders.

A randomized controlled trial of Goal Management Training for executive functioning in schizophrenia spectrum disorders or psychosis risk syndromes

BACKGROUND

Executive functioning is essential to daily life and severely impaired in schizophrenia and psychosis risk syndromes. Goal Management Training (GMT) is a theoretically founded, empirically supported, metacognitive strategy training program designed to improve executive functioning.

METHODS

A randomized controlled parallel group trial compared GMT with treatment as usual among 81 participants (GMT, n = 39 versus Wait List Controls, n = 42) recruited from an early intervention for psychosis setting. Computer generated random allocation was performed by someone independent from the study team and raters post-intervention were unaware of allocation. The primary objective was to assess the impact of GMT administered in small groups for 5 weeks on executive functioning. The secondary objective was to explore the potential of the intervention in influencing daily life functioning and clinical symptoms.

RESULTS

GMT improved self-reported executive functioning, measured with the Behavior Rating Inventory of Executive Function - Adult version (BRIEF-A), significantly more than treatment as usual. A linear mixed model for repeated measures, including all partial data according to the principle of intention to treat, showed a significant group x time interaction effect assessed immediately after intervention (post-test) and 6 months after intervention (follow-up), F = 8.40, p .005, r .37. Improvement occurred in both groups in objective executive functioning as measured by neuropsychological tests, functional capacity, daily life functioning and symptoms of psychosis rated by clinicians. Self-reported clinical symptoms measured with the Symptoms Check List (SCL-10) improved significantly more after GMT than after treatment as usual, F = 5.78, p .019, r .29. Two participants withdrew due to strenuous testing and one due to adverse effects.

CONCLUSIONS

GMT had clinically reliable and lasting effects on subjective executive function. The intervention is a valuable addition to available treatment with considerable gains at low cost.

TRIAL REGISTRATION

Registered at clinicaltrials.gov NCT03048695 09/02/2017.

Motor Skill, Motor Planning, and Motor Performance in Adults with Severe Mental Illnesses and Obesity

Motor functioning in persons with serious mental illness (SMI) is not well studied. We assessed motor functioning in people with SMI (n = 15) vs. adults with obesity (n = 15) and healthy controls (n = 15). Motor skills were assessed using balance and coordination tests. Motor planning and performance were assessed in Obstacle and Metronome Walking Tasks. The SMI group scored lower on balance and coordination tests (all ps < 0.001), and took longer steps when approaching obstacles (all ps < 0.001), but had unimpaired motor performance on the Metronome Walking Task. In obesity, excess body mass impairs motor skills, which adversely impacts motor performance. In persons with SMI, motor performance was unimpaired, with cognitive and neuroanatomical abnormalities likely underlying balance, coordination, and motor skill challenges.

Does comprehensive cognitive remediation improve emotion perception?

Background: Social cognition, including emotion perception, is impaired in people with serious mental illnesses (SMI), and is associated with cognitive and community functioning. Cognitive remediation can improve neurocognition, but the impact on emotion perception has been less well studied. The current study aimed to evaluate the efficacy of a cognitive remediation programme in improving emotion perception.Methods: Thirty-seven people with SMI and a history of difficulties obtaining employment were randomised to either vocational rehabilitation only, or vocational rehabilitation combined with cognitive remediation. Participants were assessed at baseline and post-treatment on a neurocognitive battery, work history, and emotion perception.Results: The cognitive remediation group did not improve more than the vocational rehabilitation only group on either measure of emotion perception, despite significantly greater gains in cognitive functioning. Baseline emotion identification, but not discrimination, was significantly associated with cognition and work history.Conclusions: Despite associations between social and neurocognition, there was no evident transfer of cognitive gains to performance on measures of emotion perception. The findings, though limited by a small sample size, are important in expanding the research indicating that the effects of cognitive remediation tend to be limited to the specific cognitive domains targeted in the program.

A randomized controlled trial of exercise on augmenting the effects of cognitive remediation in persons with severe mental illness

BACKGROUND

Preliminary evidence suggests that aerobic exercise may augment the effects of cognitive remediation on improving cognitive functioning in severe mental illness. It has also been hypothesized that increases in cognitive functioning associated with adding exercise are mediated by increases in brain derived neurotrophic factor (BDNF). However, rigorous controlled trials are lacking.

METHODS

A randomized controlled trial was conducted to explore whether adding a 30-h aerobic exercise program over 10 weeks to an equally intensive cognitive remediation program (CR + E) improved cognitive functioning more than cognitive remediation alone (CR-Only). Thirty-four participants with schizophrenia or bipolar disorder were randomly assigned to CR + E or CR-Only, and cognitive functioning was assessed at baseline and post-treatment. Total and mature BDNF were measured in blood serum at baseline, Week-5 pre- and post-exercise, and Week-10 pre- and post-exercise.

RESULTS

Participants in both conditions had high levels of engagement in the interventions and improved significantly in cognitive functioning, but did not differ in amount of cognitive change. The groups also did not differ in changes in BDNF from pre-to post-exercise at Weeks 5 or 10, nor in resting BDNF levels. Exploratory analyses indicated that higher body mass index (BMI) significantly predicted attenuated improvement in cognitive functioning for both groups.

DISCUSSION

Exercise did not augment the effects of cognitive remediation in persons with severe mental illness, possibly because the cognitive remediation program resulted in strong gains in cognitive functioning. Moderate aerobic exercise does not appear to reliably increase BDNF levels in persons with severe mental illness. CLINICALTRIALS.

GOV IDENTIFIER

NCT02326389.

A longitudinal analysis of employment in people with severe mental illnesses in India

PURPOSE

Little is known about the longitudinal trajectories of employment in people with severe mental illnesses (SMI) in developing countries, including India. We examined stability and change in work status, interest in work, problems and benefits related to work among employed participants, and barriers and desired job supports among unemployed participants.

METHODS

We conducted a one-year follow-up with 550 participants with SMI receiving psychiatric outpatient treatment in two hospitals in two districts in India. A total of 459 (83.5%) participants completed follow-up interviews.

RESULTS

Rates of employment were stable across the one-year period, with over 60% employed at baseline and follow-up assessment. More than 80% who worked at both assessments were working in the same job for an average duration of 10 years. Among participants who were unemployed at baseline, 16.9% started working at follow-up, an outcome associated with interest in work and efforts to find work at baseline. Interest in work of those unemployed at both assessments was lower at follow-up than baseline, but over 60% of participants wanted to work across both assessments, and endorsed desired supports for their job search.

CONCLUSIONS

There is considerable stability of work in people with SMI in India. Working in the same job for the long term may have contributed to consistent work. Most unemployed participants who wanted to work at baseline were not working at follow-up, and expressed a desire for help with job search, suggesting the need for vocational services to help people with SMI in developing countries obtain employment.

Employment in people with severe mental illnesses receiving public sector psychiatric services in India

The limited literature on employment in people with severe mental illnesses (SMI) in developing countries suggests higher rates than in developed countries. The present study explored rates and associated characteristics of work in people receiving public psychiatric services. Semi-structured interviews were conducted with 150 individuals with SMI (90% schizophrenia-spectrum) receiving public outpatient psychiatric services in an urban district in western India to evaluate employment. Forty percent of participants were employed, most for independent employers (86.7%), and were working an average of 53 hours/week. Earning money was reported as the primary motivation to work. A high proportion (92.2%) of unemployed participants wanted to work. Common barriers to work for unemployed participants who were interested in working were psychological (e.g., stress), mental illness (e.g., symptoms), and work-related factors (e.g., difficulty finding a job). Help finding a job and managing mental illness were the primary desired supports. Rates of employment in people with SMI living in urban areas in India are higher than in developed countries, but much lower than the general population. The high interest in work coupled with specific barriers and desired supports point to the need for vocational rehabilitation for improving the employment functioning of people with SMI in India.

Employment functioning in people with severe mental illnesses living in urban vs. rural areas in India

PURPOSE

Research on employment in people with severe mental illnesses (SMI) in developing countries is sparse and largely limited to employment rates. We conducted a comprehensive study of work, interest in work, and perceived benefits and barriers to work in people with SMI in India.

METHODS

Semi-structured interviews were conducted with 550 individuals with SMI receiving private psychiatric outpatient services in two districts in western India, one urban (Pune) and the other rural (Ahmednagar).

RESULTS

More than half of the participants were employed, with significantly more men working (79.4%) than women (35.9%). Higher rates of work were found in rural areas (77.8%), where most work was in family agricultural businesses, than in urban areas (48.9%), where most work was for independent employers. Participants in rural areas worked fewer hours and earned less money, and reported fewer benefits and fewer problems related to work than urban participants. Over 45% of participants working for independent employers found jobs with help from families and extended social networks. Most unemployed participants wanted to work, and desired a variety of supports, including assistance with job finding and illness management.

CONCLUSIONS

Gender-specific social role expectations and families play an important role in work in people with SMI in India. Despite higher rates of work in this sample than most studies from developed countries, a significant subgroup was unemployed but wanted to work. Persons with SMI in developing countries may benefit from the adaptation of validated vocational rehabilitation approaches in developed countries to their cultural context.

Compensatory Interventions for Cognitive Impairments in Psychosis: A Systematic Review and Meta-Analysis

OBJECTIVE

Cognitive compensatory interventions aim to alleviate psychosocial disability by targeting functioning directly using aids and strategies, thereby minimizing the impact of cognitive impairment. The aim was to conduct a systematic review and meta-analysis of cognitive compensatory interventions for psychosis by examining the effects on functioning and symptoms, and exploring whether intervention factors, study design, and age influenced effect sizes.

METHODS

Electronic databases (Ovid Medline, PsychINFO) were searched up to October 2018. Records obtained through electronic and manual searches were screened independently by two reviewers according to selection criteria. Data were extracted to calculate estimated effects (Hedge's g) of treatment on functioning and symptoms at post-intervention and follow-up. Study quality was assessed using Cochrane Collaboration's risk of bias tool.

RESULTS

Twenty-six studies, from 25 independent randomized controlled trials (RCTs) were included in the meta-analysis (1654 participants, mean age = 38.9 years, 64% male). Meta-analysis revealed a medium effect of compensatory interventions on functioning compared to control conditions (Hedge's g = 0.46, 95% CI = 0.33, 0.60, P < .001), with evidence of relative durability at follow-up (Hedge's g = 0.36, 95% CI = 0.19, 0.54, P < .001). Analysis also revealed small significant effects of cognitive compensatory treatment on negative, positive, and general psychiatric symptoms, but not depressive symptoms. Estimated effects did not significantly vary according to treatment factors (ie, compensatory approach, dosage), delivery method (ie, individual/group), age, or risk of bias. Longer treatment length was associated with larger effect sizes for functioning outcomes. No evidence of publication bias was identified.

CONCLUSION

Cognitive compensatory interventions are associated with robust, durable improvements in functioning in people with psychotic illnesses.

Brief, Web-Based Interventions to Motivate Smokers With Schizophrenia: Randomized Trial

BACKGROUND

In-person motivational interventions increase engagement with evidence-based cessation treatments among smokers with schizophrenia, but access to such interventions can be limited because of workforce shortages and competing demands in mental health clinics. The use of digital technology to deliver interventions can increase access, but cognitive impairments in schizophrenia may impede the use of standard digital interventions. We developed an interactive, multimedia, digital motivational decision support system for smokers with schizophrenia (Let's Talk About Smoking). We also digitalized a standard educational pamphlet from the National Cancer Institute (NCI Education). Both were tailored to reduce cognitive load during use.

OBJECTIVE

We conducted a randomized trial of Let's Talk About Smoking versus NCI Education to test whether the interactive motivational intervention was more effective and more appealing than the static educational intervention for increasing use of smoking cessation treatment, quit attempts, and abstinence among smokers with schizophrenia, accounting for the level of cognitive functioning.

METHODS

Adult smokers with schizophrenia (n=162) were enrolled in the study from 2014 to 2015, randomly assigned to intervention condition, and assessed in person at 3- and 6-month follow-ups. Interventions were delivered on a laptop computer in a single session. All participants had access to standard, community-delivered cessation treatments during follow-up. Multivariate models were used to evaluate outcomes.

RESULTS

Treatment initiation outcomes were not different between intervention conditions (27/84 [32%] for Let's Talk About Smoking vs 36/78 [46%] for NCI Education; odds ratio [OR] 0.71 [95% CI 0.37-1.33]); 38.9% (63/162) of participants initiated treatment. Older age (OR 1.03 [95% CI 1.00-1.07]; P=.05), higher education (OR 1.21 [95% CI 1.04-1.41]; P=.03), and fewer positive symptoms (OR 0.87 [95% CI 0.80-0.96]; P=.01) predicted cessation treatment initiation, whereas level of cognition did not. The mean satisfaction and usability index score was higher for Let's Talk About Smoking versus NCI Education (8.9 [SD 1.3] vs 8.3 [SD 2.1]; t120.7=2.0; P=.045). Quit attempts (25/84, 30% vs 36/78, 46%; estimate [Est]=-0.093, SE 0.48; P=.85) and abstinence (1/84, 1% vs 6/78, 7%; χ21=3.4; P=.07) were not significantly different between intervention conditions. Cognitive functioning at baseline (Est=1.47, SE 0.47; P=.002) and use of any behavioral or medication cessation treatment (Est=1.43, SE 0.47; P=.003) predicted quit attempts with self-reported abstinence over the 6-month follow-up.

CONCLUSIONS

The interactive, multimedia intervention was not more effective than the static, text-based intervention among smokers with schizophrenia. Both tailored digital interventions resulted in levels of treatment engagement and quit attempts that were similar to findings from previous studies of in-person interventions, confirming the potential role of digital interventions to educate and motivate smokers with schizophrenia to use cessation treatment and to quit smoking. These findings indicate that additional cessation treatment is needed after brief education or motivational interventions, and that cessation treatment should be adjusted for people with cognitive impairment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02086162; https://clinicaltrials.gov/show/NCT02086162.

Cognitive remediation for schizophrenia: An expert working group white paper on core techniques

Cognitive remediation is now widely recognized as an effective treatment for cognitive deficits in schizophrenia. Its effects are meaningful, durable, and related to improvements in everyday functional outcomes. As with many therapies, the evolution of cognitive remediation has resulted in treatment programs that use a variety of specific techniques, yet share common core principles. This paper is the product of a cognitive remediation expert working group consensus meeting to identify core features of the treatment and produce recommendations for its design, conduct, reporting, and implementation. Four techniques were identified as core features of cognitive remediation: facilitation by a therapist, cognitive exercise, procedures to develop problem-solving strategies, and procedures to facilitate transfer to real world functioning. Treatment techniques within each of these core features are presented to facilitate decisions for clinical trials and implementation in clinical settings.

Modifiable Predictors of Supported Employment Outcomes Among People With Severe Mental Illness

OBJECTIVE

Among people with severe mental illnesses, neuropsychological abilities may contribute to vocational outcomes, such as job attainment, job tenure, and wages earned. The current study aimed to determine the strongest neuropsychological and other modifiable predictors of work outcomes in 153 people with severe mental illness (schizophrenia, 38%; bipolar disorder, 24%; and major depression, 38%) who participated in a 2-year supported employment study.

METHODS

Assessments of neuropsychological performance, functional capacity, social skills, and psychiatric symptom severity were administered at baseline; work outcomes (job attainment, weeks worked, and wages earned) were collected weekly for 2 years.

RESULTS

Independent of education, diagnosis, and estimated intellectual functioning, more recent work history and less severe negative symptoms significantly predicted job attainment during the 2-year study. Among the 47% who obtained jobs, better global neuropsychological performance (i.e., lower global deficit score) was a significant predictor of greater weeks worked. Both global neuropsychological performance and more recent work history predicted higher wages earned.

CONCLUSIONS

Modifiable predictors of supported employment outcomes included cognitive functioning and negative symptom severity; thus, interventions to improve these factors may improve work outcomes and decrease the loss of productivity associated with severe mental illness.

Enhancing individual placement and support (IPS) - Supported employment: A Type 1 hybrid design randomized controlled trial to evaluate virtual reality job interview training among adults with severe mental illness

Individual Placement and Support (IPS) is the evidence-based model of supported employment that increases employment rates in adults with severe mental illness (SMI). Although IPS is largely successful, over 80% of adults with SMI remain unemployed. An enhancement to high fidelity IPS could be an evidence-based job interview training component. To meet this training need, our group recently completed a series of randomized controlled efficacy trials funded by the National Institute of Mental Health to develop and test virtual reality job interview training (VR-JIT) in a lab setting. The results demonstrated that the intervention was efficacious at helping trainees improve their job interview skills and receive job offers within six months of completing VR-JIT compared to non-trainees. The overarching goal of this study is to evaluate the effectiveness of VR-JIT as an enhancement to IPS when delivered in a large community-based mental health service provider via a randomized controlled trial and initial process evaluation. Our aims are to: evaluate whether IPS services-as-usual in combination with VR-JIT, compared to IPS services-as-usual alone, enhances IPS outcomes for adults with SMI; evaluate mechanisms of employment outcomes and psychological distress; and conduct a multilevel, multidisciplinary, and mixed-method process evaluation of VR-JIT adoption and implementation to assess the acceptability, scalability, generalizability, and affordability of VR-JIT.

Does social cognition training augment response to computer-assisted cognitive remediation for schizophrenia?

OBJECTIVES

Cognitive remediation therapy (CRT) has shown significant improvement in cognition in schizophrenia. However, effect sizes of CRT have been reported to be modest raising the issue how to augment the effects of CRT on neurocognition and social cognition. Our aim was to examine whether the addition of computerized social cognition training would enhance the effects on neurocognition and social cognition as compared to CRT alone.

METHODS

This is a 12-week, parallel group trial of 131 in- and out-patients with schizophrenia randomized to CRT (COGPACK or Brain Fitness) with computerized social cognition training (MRIGE), or CRT alone for 36 sessions. Participants were assessed at baseline and after 12 weeks of treatment. Assessments included neurocognition, social cognition, psychopathology, and functioning.

RESULTS

The combined intervention, CRT + MRIGE, showed greater improvements in the MCCB indices of Visual Learning, Working Memory, Reasoning and Problem-Solving, and the neurocognitive composite score compared to CRT alone (Bonferroni adjusted p = 0.004, p = 0.005, p = 0.01, respectively), as did social cognition measures (Bonferroni adjusted p = 0.006, p = 0.005, respectively).

CONCLUSIONS

Supplementing CRT with computerized social cognition training produced greater benefits in neurocognition, including visual learning, memory, executive functions, and social cognition relative to cognitive training alone. These findings favoring the combined training may be contributed to both the greater overall amount of cognitive practice, as well as the specific cognitive functions engaged by the social cognition training.

Controversies in Computerized Cognitive Training

Computerized cognitive training (CCT) to improve cognitive functioning is of enormous interest and has been applied in a broad range of populations with goals of improving both cognition and community functioning. Recent reviews presenting negative conclusions about CCT efficacy have inconsistent definitions of the treatment targets and cognitive improvement. They do not present an accurate representation of the typical process of CCT and cognitive remediation (CR), especially as delivered in major mental illnesses such as schizophrenia. This review provides guidance on the definitions of CCT and CR, the uses of CCT and CR, and the definitions and measurements of cognitive and functional gains. The review focuses on schizophrenia and healthy aging, with each population receiving unique CCT or CR approaches and substantial extant literature with which to elucidate fundamental CCT and CR concepts and research findings. It is our conclusion that CCT has been shown in most studies to improve cognitive performance on untrained tests in healthy older people and in people with schizophrenia. Functional gains in schizophrenia appear to be limited to CR studies. Clearly defining CCT, CR, and levels of treatment-related gains will be critical for understanding the benefits of these widely used treatment programs.

What does the Managing Emotions branch of the MSCEIT add to the MATRICS consensus cognitive battery?

The Managing Emotions branch of the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT-ME) was included within the MATRICS Consensus Cognitive Battery (MCCB) as the measure of social cognition, although limited research has examined its associations with psychosocial functioning in people with schizophrenia or other severe mental illnesses. This secondary analysis with 107 participants examined what the MSCEIT-ME contributes to our understanding of functioning in this population, and whether it uniquely predicts psychosocial functioning after controlling for performance on the other MCCB tests and negative symptoms. Performance on the MSCEIT-ME was significantly correlated with all three MCCP factors (processing speed, attention/working memory, learning) within schizophrenia-schizoaffective disorder, bipolar disorder, and other mixed diagnoses groups. Better performance on MSCEIT-ME was associated with better psychosocial functioning on the Quality of Life Scale (QLS) in the schizophrenia-schizoaffective disorder group, but not in the bipolar or other mixed diagnoses groups. In addition, in the schizophrenia-schizoaffective disorder group, after controlling for demographic characteristics in stepwise multiple regression analyses, MSCEIT-ME was the only significant predictor of the QLS total score and the QLS interpersonal relations and intrapsychic foundations subscales, with none of the MCCB factors entering any of the regression models. The MSCEIT-ME may reflect a unique aspect of social cognition that is related to impaired psychosocial functioning in schizophrenia and is not tapped by the other cognitive tests on the MCCB. Further research on the MSCEIT-ME could provide unique insights into the social functioning problems in schizophrenia.

Job Endings and Work Trajectories of Persons Receiving Supported Employment and Cognitive Remediation

OBJECTIVE

This study examined job endings and work trajectories among participants in a study comparing the effects of adding cognitive remediation to supported employment among individuals who had not benefited from supported employment.

METHODS

Data were from a controlled trial of 107 persons with serious mental illness enrolled in supported employment but who had not obtained or sustained competitive work. Participants were randomly assigned to enhanced supported employment only (with employment specialists trained to recognize cognitive difficulties and teach coping strategies) or to the Thinking Skills for Work program (enhanced supported employment plus cognitive remediation). For the 52 participants who worked, the two groups were compared on types of job endings, reasons for job endings, successful versus unsuccessful jobs, and work trajectories over the two-year study period.

RESULTS

The two groups did not differ in types of job ending, although participants in Thinking Skills for Work were less likely than those in enhanced supported employment only to cite dissatisfaction with the job as a reason for the job ending. Participants in Thinking Skills for Work were also less likely to have an overall unsuccessful work trajectory, more likely to have only successful jobs, and more likely to be employed at the end of the study.

CONCLUSIONS

The Thinking Skills for Work program appeared to help participants who had not benefited from supported employment stick with and master their jobs more effectively than those in enhanced supported employment only, resulting in better work trajectories over the course of the study.

Cognitive Predictors of Work Among Social Security Disability Insurance Beneficiaries With Psychiatric Disorders Enrolled in IPS Supported Employment

BACKGROUND

Impaired cognitive functioning is a significant predictor of work dysfunction in schizophrenia. Less is known, however about relationships of cognition and work in people with less severe disorders with relatively normal cognitive functioning.

METHODS

This secondary analysis evaluated cognitive predictors of work in Social Security Disability Insurance (SSDI) beneficiaries with a recent work history who were randomized to receive mental health services, supported employment, and freedom from work disincentives over a 2-year study period in the Mental Health Treatment Study. Of the 1045 participants randomized to the treatment package, 945 (90.4%) received a cognitive assessment at study entry. Competitive work activity was evaluated using a computer-assisted timeline follow-back calendar at baseline and quarterly for 24 months.

RESULTS

Mood disorders were the most common psychiatric diagnoses (64.9%), followed by schizophrenia or schizoaffective disorder (35.1%). Tobit regression analyses predicting the average number of hours worked per week, controlling for demographic characteristics, diagnosis, and work history indicated that the cognitive composite score (P < .01) and verbal learning subscale scores (P < .001) were associated with fewer hours of weekly work over the study period.

CONCLUSIONS

Cognitive functioning predicted work over 2 years in SSDI beneficiaries with mood or schizophrenia-spectrum disorders who were receiving supported employment and mental health interventions, despite a relative absence of cognitive impairment in the study participants. The findings suggest cognitive functioning contributes to competitive work outcomes in persons with psychiatric disorders who have relatively unimpaired cognitive abilities, even under optimal conditions of treatment and vocational support.

Neuropsychological predictors of response to cognitive behavioral therapy for posttraumatic stress disorder in persons with severe mental illness

This study examined whether cognitive functioning was related to treatment outcomes in persons with severe mental illness who received a cognitive behavioral therapy (CBT) program for co-occurring posttraumatic stress disorder (PTSD). The study sample was drawn from a larger controlled trial of 108 persons with severe mental illness and PTSD comparing the effects of CBT with treatment as usual on PTSD and related outcomes, with assessments conducted at baseline, post-treatment, and 3- and 6-month follow-ups. Among the 54 persons in CBT, 49 were administered a neuropsychological battery at baseline and 40 were exposed to the CBT program. Statistical analyses of these 40 participants were conducted to evaluate whether cognitive functioning was related to participation in the CBT program, completion of homework assignments, and improvements in PTSD, and other outcomes. Cognitive functioning was not related to participation in CBT or completion of homework. Lower cognitive functioning predicted less learning of information about PTSD at post-treatment and follow-up, but not less clinical benefit from CBT in PTSD diagnosis or symptoms, other symptoms, or health. The results suggest that cognitive impairment does not attenuate response to the CBT for PTSD program in persons with severe mental illness. Clinical Trials.gov Identifier: NCT00053690.

The relationship of cognitive improvement after cognitive remediation with social functioning in patients with schizophrenia and severe cognitive deficits

BACKGROUND

This study aims to examine the effects of change in neurocognition on functional outcomes and to examine predictors of change in social functions following a 12-week course of cognitive remediation in patients with schizophrenia and schizoaffective disorder with severe cognitive impairments.

METHOD

Level of social functioning was assessed using a performance based measure of functional capacity (PSP) in patients prior to and after the completion of 12-week cognitive remediation treatment (CRT). Participants completed a neuropsychological battery (MCCB-MATRICS) and clinical measures at both time points.

RESULTS

63 subjects with a mean age of 41.4 (SD=12.2) and with 12.2years of education (SD=2.4) were enrolled. There were significant improvements in overall PSP score from baseline to endpoint (p=0.021) as well as in PSP domain A (socially useful activities) (p≤0.001), domain B (personal and social relationships) (p=0.009), and domain D (disturbing and aggressive behaviors) (p=0.003). There was a significant improvement in the composite MCCB score (p=0.020) and the Working Memory (p<0.046). Stepwise logistic regression yielded a significant association for baseline Visual Learning (Wald=6.537, p=0.011, OR=1.195), Speed of Processing (Wald=4.112, p=0.043, OR=0.850) and level of PANSS positive symptoms (Wald=4.087, p=0.043, OR=0.739) with PSP overall improvement.

CONCLUSIONS

Faster speed of processing, better visual and verbal learning and less prominent positive symptoms were associated with greater functional improvement after a systematic cognitive intervention within a rehabilitative setting.

Introduction to special issue on cognitive remediation

This article serves as an introduction to the special issue on the topic of cognitive remediation. The papers comprising this special issue make important contributions to the cognitive remediation field by testing the efficacy of cognitive programs on unique symptom targets of serious mental illness, evaluating novel cognitive program enhancements, demonstrating the feasibility and promise of incorporating cognitive programs into everyday practice, and engaging new populations into cognitive programs. Together, these papers show that cognitive remediation is an important and increasingly common component of comprehensive psychiatric rehabilitation programs that can increase the effectiveness of these programs at helping participants make progress toward and achieve their personal goals. (PsycINFO Database Record

The feasibility of implementing cognitive remediation for work in community based psychiatric rehabilitation programs

OBJECTIVE

Adding cognitive remediation to vocational rehabilitation services improves cognitive and work functioning in people with serious mental illness, but despite interest, the uptake of cognitive programs into community services has been slow. This study evaluated the feasibility of implementing an empirically supported cognitive remediation program in routine rehabilitation services at 2 sites.

METHOD

The Thinking Skills for Work (TSW) program was adapted for implementation at 2 sites of a large psychiatric rehabilitation agency providing prevocational services, but not community-based vocational services, which were provided off-site. Agency staff were trained to deliver TSW to clients with work or educational goals. Cognitive assessments were conducted at baseline and posttreatment, with work and school activity tracked for 2 years.

RESULTS

Eighty-three participants enrolled in TSW, of whom 79.5% completed at least 6 of the 24 computer cognitive exercise sessions (M = 16.7) over an average of 18 weeks. Participants improved significantly from baseline to posttreatment in verbal learning and memory, speed of processing, and overall cognitive functioning. Over the follow-up, 25.3% of participants worked and 47.0% were involved in work or school activity. Higher work rates were observed at the site where participants had easier access to vocational services.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The results support the feasibility of implementing the TSW program by frontline staff in agencies providing psychiatric rehabilitation, and suggest that ease of access to vocational services may influence work outcomes. (PsycINFO Database Record

Predictors of response to cognitive remediation in service recipients with severe mental illness

OBJECTIVE

Cognitive challenges are prominent features of individuals diagnosed with schizophrenia, impairing occupational, social, and economic functioning. These challenges are predictive of social and work outcomes. Cognitive remediation has been shown to be effective in improving both cognitive and social functions. However, cognitive remediation does not produce improvement in all participants. We investigated demographic, neurocognitive, and psychopathological predictors associated with improvement following cognitive remediation interventions in service recipients with severe mental illnesses.

METHOD

One hundred thirty-seven adult participants with a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) were enrolled in 12-week cognitive remediation programs. Assessments of demographic and illness variables, together with baseline and end point assessment of psychopathology (Positive and Negative Syndrome Scale [PANSS]), neurocognition (Measurement and Treatment Research to Improve Cognition in Schizophrenia [MATRICS] Consensus Cognitive Battery [MCBB]), and social functions (Personal and Social Performance Scale [PSP]) were conducted. Change in cognitive domains was calculated using the reliable change index. Logistic regression analysis was used to assess predictors of cognitive improvement after the intervention.

RESULTS

Sixty-two percent of participants improved on at least 1 of the MCCB domains. Higher baseline speed of processing, attention or vigilance, and working memory predicted a positive response to cognitive remediation. Younger age, higher education level, shorter length of stay, and lower PANSS Negative and Disorganized factors were additional predictors.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Our results indicate the clinical usefulness of cognitive remediation and identified a pattern of clinical and cognitive predictors of good response to the intervention. Identification of these predictive factors by clinicians may enhance the outcome and aid in the development of individualized rehabilitative cognitive remediation treatment plans. (PsycINFO Database Record

Confirmatory factor analysis of the quality of life scale and new proposed factor structure for the quality of life scale-revised

The Quality of Life Scale (QLS) is a frequently used semistructured interview for the assessment of functional outcomes in schizophrenia. Despite the use of the QLS for over 30years, the original 4-factor structure of the instrument (Interpersonal Relations, Instrumental Role, Intrapsychic Foundations, and Common Objects and Activities) has not been rigorously examined. Exploratory factor analyses (EFAs) and confirmatory factor analyses (CFAs) were used to evaluate the factor structure of the QLS in two independent datasets, including a mixed diagnostic sample of multi-episode participants (N=247), and a sample of individuals with a first episode of psychosis (N=337). A CFA with the first dataset indicated a poor fit for the 4-factor model of the QLS. Subsequent EFAs on this dataset led to a more promising 3-factor solution including 16/21 of the QLS items, which were similar to the first 3 of 4 factors originally proposed for the QLS. CFAs on the same dataset indicated that the 3-factor model for the QLS-Revised (QLS-R) fit the data well. This factor structure was evaluated with the second dataset using CFA and was also found to be fit the data well. The results support the robustness of the 3-factor model of the QLS-R in schizophrenia and mixed diagnostic samples. Future research should evaluate the validity of the 3-factor model of the QLS-R, and consider the merits of changing the name of the Intrapsychic Foundations factor to Motivation.

A confirmatory factor analysis of the MATRICS consensus cognitive battery in severe mental illness

BACKGROUND

A recent factor analysis of Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus Cognitive Battery (MCCB) data in a sample of schizophrenia-spectrum patients described a three factor model representing processing speed, attention/working memory, and learning; the social cognition measure was excluded from the analysis. The current analyses sought to replicate a three factor structure of the MCCB in a larger, more diagnostically diverse sample of participants.

METHODS

Confirmatory factor analyses were performed to evaluate the factor structure of the MCCB in 300 outpatients with severe mental illness (54.3% schizophrenia-spectrum diagnoses) who were participants in three studies of cognitive remediation. Exploratory analyses were conducted to evaluate the concurrent prediction of symptoms from MCCB factor scores.

RESULTS

The three factor structure of the MCCB demonstrated stronger model fit (χ(2)=14.53, p=0.75, SRMR=0.02, RMSEA=0.0, CFI=1.00, NNFI=1.01) than the unifactoral structure. Poorer cognitive performance across all three MCCB factors was significantly correlated with more severe overall and disorganization symptoms from the PANSS and BPRS, and less severe affective symptoms (e.g., depression, anxiety) in the overall sample.

CONCLUSIONS

A three factor structure of the MCCB-composed of processing speed, attention/working memory, and learning-was replicated in a heterogeneous sample of persons with severe mental illness. Cognitive performance on the MCCB factors is associated with clinical symptoms.

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.

Barriers to Employment Among Social Security Disability Insurance Beneficiaries in the Mental Health Treatment Study

OBJECTIVE

This study examined barriers to employment among Social Security Disability Insurance (SSDI) beneficiaries who received comprehensive vocational and mental health services but were not successful in returning to work.

METHODS

This study examined barriers to employment among 430 SSDI beneficiaries with mental disorders who received evidence-based vocational and mental health services for two years but worked less than one month or not at all. Comprehensive care teams, which included employment specialists, made consensus judgments for each participant, identifying the top three barriers to employment from a checklist of 14 common barriers.

RESULTS

Teams most frequently identified three barriers to employment: poorly controlled symptoms of mental illness (55%), nonengagement in supported employment (44%), and poorly controlled general medical problems (33%). Other factors were identified much less frequently.

CONCLUSIONS

Some SSDI beneficiaries, despite having access to comprehensive services, continued to experience psychiatric impairments, difficulty engaging in vocational services, and general medical problems that limited their success in employment.

COMT genotype and response to cognitive remediation in schizophrenia

BACKGROUND

A functional polymorphism of the catechol-O-methyltransferase (COMT) gene (Val158Met) partially appears to influence cognitive performance in schizophrenia subjects and healthy controls by modulating prefrontal dopaminergic activity. This study evaluated the association of the COMT Val108/158 Met genotype with response to computerized neurocognitive remediation (CRT).

METHOD

145 subjects with DSM-IV-TR schizophrenia or schizoaffective disorder were genotyped via saliva sampling. Subjects were evaluated on neurocognitive assessments (MATRICS) and clinical symptoms (PANSS) at baseline and endpoint after 12weeks of CRT. "Improvement" was defined as ≥67% of cognitive domains (≥4) showing performance increases. If ≤67% (≤2) of domains improved, the change was defined as "minimal improvement." A general linear model was conducted for change of each cognitive domain.

RESULTS

Of 145 subjects, data from 138 subjects were usable. Distribution of COMT genotype: Met/Met: 28 (20.29%), Val/Met: 61 (44.20%), and Val/Val: 49 (35.51%). No significant differences were seen among genotype groups at baseline or across genotype group for "Improvement" vs. "Minimal Improvement." GLM analysis showed significant differences in Verbal Learning (p=0.003), Visual Learning (p=0.014) and Attention/Vigilance (p=0.011) favoring Met/Met and Val/Met groups.

CONCLUSIONS

The low activity Met allele (Met/Met; Val/Met) was associated with significantly greater improvements in the MATRICS domains of Verbal Learning, Visual Learning and Attention/Vigilance after CRT.

Cognitive Enhancement Treatment for People With Mental Illness Who Do Not Respond to Supported Employment: A Randomized Controlled Trial

OBJECTIVE

Cognitive impairment presents a serious and common obstacle to competitive employment for people with severe mental illness, including those who receive supported employment. This study evaluated a cognitive enhancement program to improve cognition and competitive employment in people with mental illness who had not responded to supported employment.

METHOD

In a randomized controlled trial, 107 people with severe mental illness (46% with schizophrenia or schizoaffective disorder) who had not obtained or kept competitive work despite receiving high-fidelity supported employment were assigned to receive either enhanced supported employment (with specialized cognitive training of employment specialists) or enhanced supported employment plus the Thinking Skills for Work program, a standardized cognitive enhancement program that includes practice of computer cognitive exercises, strategy coaching, and teaching of coping and compensatory strategies. Research assistants tracked competitive employment weekly for 2 years, and assessors blind to treatment assignment evaluated cognitive functioning at baseline, at the end of cognitive enhancement training, and 12 and 24 months after baseline.

RESULTS

Participants in the Thinking Skills for Work group improved more than those in the enhanced supported employment only group on measures of cognitive functioning and had consistently better competitive employment outcomes during the follow-up period, including in jobs obtained (60% compared with 36%), weeks worked (23.9 compared with 9.2), and wages earned ($3,421 compared with $1,728).

CONCLUSIONS

The findings suggest that cognitive enhancement interventions can reduce cognitive impairments that are obstacles to work, thereby increasing the number of people who can benefit from supported employment and competitive work.

The NAVIGATE Program for First-Episode Psychosis: Rationale, Overview, and Description of Psychosocial Components

Comprehensive coordinated specialty care programs for first-episode psychosis have been widely implemented in other countries but not in the United States. The National Institute of Mental Health's Recovery After an Initial Schizophrenia Episode (RAISE) initiative focused on the development and evaluation of first-episode treatment programs designed for the U.S. health care system. This article describes the background, rationale, and nature of the intervention developed by the RAISE Early Treatment Program project-known as the NAVIGATE program-with a particular focus on its psychosocial components. NAVIGATE is a team-based, multicomponent treatment program designed to be implemented in routine mental health treatment settings and aimed at guiding people with a first episode of psychosis (and their families) toward psychological and functional health. The core services provided in the NAVIGATE program include the family education program (FEP), individual resiliency training (IRT), supported employment and education (SEE), and individualized medication treatment. NAVIGATE embraces a shared decision-making approach with a focus on strengths and resiliency and on collaboration with clients and family members in treatment planning and reviews. The NAVIGATE program has the potential to fill an important gap in the U.S. health care system by providing a comprehensive intervention specially designed to meet the unique treatment needs of persons recovering from a first episode of psychosis. A cluster-randomized controlled trial comparing NAVIGATE with usual community care has recently been completed.

Supported employment for persons with serious mental illness: current status and future directions

The individual placement and supported (IPS) model of supported employment is the most empirically validated model of vocational rehabilitation for persons with schizophrenia or another serious mental illness. Over 18 randomized controlled trials have been conducted throughout the world demonstrating the effectiveness of supported employment at improving competitive work compared to other vocational programs: IPS supported employment is defined by the following principles: 1) inclusion of all clients who want to work; 2) integration of vocational and clinical services; 3) focus on competitive employment; 4) rapid job search and no required prevocational skills training; 5) job development by the employment specialist; 6) attention to client preferences about desired work and disclosure of mental illness to prospective employers; 7) benefits counseling; and 8) follow-along supports after a job is obtained. Supported employment has been successfully implemented in a wide range of cultural and clinical populations, although challenges to implementation are also encountered. Common challenges are related to problems such as the failure to access technical assistance, system issues, negative beliefs and attitudes of providers, funding restrictions, and poor leadership. These challenges can be overcome by tapping expertise in IPS supported employment, including standardized and tested models of training and consultation. Efforts are underway to increase the efficiency of training methods for supported employment and the overall program, and to improve its effectiveness for those clients who do not benefit. Progress in IPS supported employment offers people with a serious mental illness realistic hope for achieving their work goals, and taking greater control over their lives.

The potential of technology for enhancing individual placement and support supported employment

TOPIC

The potential of technology to enhance delivery and outcomes of Individual Placement and Support (IPS) supported employment.

PURPOSE

IPS supported employment has demonstrated robust success for improving rates of competitive employment among individuals with psychiatric disabilities. Still, a majority of those with serious mental illnesses are not employed (Bond, Drake, & Becker, 2012). The need to promote awareness of IPS and expand services is urgent. In this study, we describe ways that technologies may enhance delivery of IPS supported employment across the care continuum and stakeholder groups. Directions for research are highlighted.

SOURCES USED

published literature, clinical observations, IPS learning collaborative.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Technology has the potential to enhance direct service as well as workflow in the IPS supported employment process, which may lead to improved fidelity and client outcomes. Mobile and cloud technologies open opportunities for collaboration, self-directed care, and ongoing support to help clients obtain and maintain meaningful employment. Research is needed to evaluate efficacy of technology-based approaches for promoting client employment outcomes, to identify provider and organization barriers to using technology for IPS delivery, and to determine effective strategies for implementing technology with IPS in different settings and with diverse client audiences.

Mental health system funding of cognitive enhancement interventions for schizophrenia: summary and update of the New York Office of Mental Health expert panel and stakeholder meeting

TOPIC

A growing research literature indicates that cognitive enhancement (CE) interventions for people with schizophrenia can improve cognitive functioning and may benefit psychosocial functioning (e.g., competitive employment, quality of social relationships). Debate continues regarding the strength of evidence for CE and related policy implications, such as the appropriateness of funding CE services.

PURPOSE

This paper summarizes and updates a meeting of experts and stakeholders convened in 2008 by the New York Office of Mental Health to review evidence on the impact of CE for people with schizophrenia and other serious mental illnesses, and addresses whether the evidence base for CE interventions is sufficient to warrant funding.

SOURCES USED

Specific recommendations based on the extant literature are provided regarding the structure and components of CE programs that should be present in order to improve cognitive and psychosocial outcomes and therefore merit consideration of funding.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

These recommendations may serve as a starting point in developing standards for CE programs. Establishing evidence-based practice standards for implementing CE interventions for people with serious mental illnesses may facilitate dissemination of programs that have the greatest potential for improving individuals' functional outcomes while minimizing incremental costs associated with providing CE services. Important open questions include how the performance of CE programs should be monitored and which individuals might be expected to benefit from CE as evidenced by improved functioning in their everyday lives.

Improving social cognition in schizophrenia: a pilot intervention combining computerized social cognition training with cognitive remediation

BACKGROUND

Social cognition is significantly impaired in schizophrenia and contributes to poor community functioning. This study examined whether cognitive remediation (CR; COGPACK), shown to improve neurocognition, improves an integral component of social cognition, emotion perception, compared with CR combined with a computerized Emotion Perception intervention (Mind Reading: Interactive Guide to Emotions [MRIGE]).

METHODS

59 stable schizophrenia or schizoaffective predominantly inpatients were randomized to either CR (N=27) alone or CR+MRIGE (N=32) for 12 weeks. Assessments included the Facial Emotion Identification Task (FEIT), Facial Emotion Discrimination Task (FEDT), MCCB-MATRICS, Personal and Social Performance Scale, and the Positive and Negative Syndrome Scale.

RESULTS

There was a significant group-by-time effect on FEIT (F=11.509, P=.004); CR+MRIGE demonstrated significantly greater improvement than CR alone (CR+MRIGE, Z=1.89, P=.05; CR alone Z=0.57, P=.13). There was significant group-by-time effect on FEDT (F=5.663, P=.022); CR+MRIGE demonstrated significantly greater improvement than CR alone (CR+MRIGE, Z=1.90, P=.05; CR alone Z=0.67, P=.21). There was also a significant group by time effect for social cognition, measured by the Mayer-Salovey-Caruso Emotional Intelligence Test (F=5.473, P=.050): CR+MRIGE demonstrated significantly greater improvement than CR alone (CR+MRIGE, Z=1.98, P=.02; CR alone, Z=1.00, P=.05).

CONCLUSIONS

Combined CR with emotion perception remediation produced greater improvements in emotion recognition, emotion discrimination, social functioning, and neurocognition compared with CR alone in chronic schizophrenia.

Combined cognitive remediation and functional skills training for schizophrenia: effects on cognition, functional competence, and real-world behavior

OBJECTIVE

Cognitive remediation is an efficacious treatment for schizophrenia and, when used within broader psychosocial treatments, improves transfer to real-world behavior change. The authors examined whether cognitive remediation effectively generalizes to functional competence and real-world functioning as a standalone treatment and when combined with a functional skills treatment.

METHOD

Outpatients with schizophrenia (N=107) were randomly assigned to receive cognitive remediation, functional adaptation skills training, or combined treatment, with cognitive remediation preceding functional skills training. Clinical symptoms, neurocognition, social competence, functional competence, and case-manager-rated real-world behavior were assessed at baseline, at end of treatment, and at a 12-week durability assessment.

RESULTS

Neurocognition improved, with durable effects, after cognitive remediation but not after functional skills training. Social competence improved both with functional skills training and with combined treatment but not with cognitive remediation alone. Improvements in functional competence were greater and more durable with combined treatment. Cognitive remediation alone did not produce significant improvements in real-world behavior, but when combined with functional skills training, statistically significant improvements from baseline to end of treatment and follow-up were observed in community or household activities and work skills. Number-needed-to-treat analyses suggest that as few as three cases are required for treatment to induce a meaningful improvement in functional skills.

CONCLUSIONS

In a short intervention, cognitive remediation produced robust improvements in neurocognition. Generalization to functional competence and real-world behavior was more likely when supplemental skills training and cognitive remediation were combined.

A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes

OBJECTIVE

Cognitive remediation therapy for schizophrenia was developed to treat cognitive problems that affect functioning, but the treatment effects may depend on the type of trial methodology adopted. The present meta-analysis will determine the effects of treatment and whether study method or potential moderators influence the estimates.

METHOD

Electronic databases were searched up to June 2009 using variants of the key words "cognitive," "training," "remediation," "clinical trial," and "schizophrenia." Key researchers were contacted to ensure that all studies meeting the criteria were included. This produced 109 reports of 40 studies in which ≥70% of participants had a diagnosis of schizophrenia, all of whom received standard care. There was a comparison group and allocation procedure in these studies. Data were available to calculate effect sizes on cognition and/or functioning. Data were independently extracted by two reviewers with excellent reliability. Methodological moderators were extracted through the Clinical Trials Assessment Measure and verified by authors in 94% of cases.

RESULTS

The meta-analysis (2,104 participants) yielded durable effects on global cognition and functioning. The symptom effect was small and disappeared at follow-up assessment. No treatment element (remediation approach, duration, computer use, etc.) was associated with cognitive outcome. Cognitive remediation therapy was more effective when patients were clinically stable. Significantly stronger effects on functioning were found when cognitive remediation therapy was provided together with other psychiatric rehabilitation, and a much larger effect was present when a strategic approach was adopted together with adjunctive rehabilitation. Despite variability in methodological rigor, this did not moderate any of the therapy effects, and even in the most rigorous studies there were similar small-to-moderate effects.

CONCLUSIONS

Cognitive remediation benefits people with schizophrenia, and when combined with psychiatric rehabilitation, this benefit generalizes to functioning, relative to rehabilitation alone. These benefits cannot be attributed to poor study methods.

Working Memory Performance in Poor Outcome Schizophrenia: Relationship to Age and Executive Functioning

Performance on the Letter-Number Sequencing (LNS) and Wisconsin Card Sorting Tests (WCST) have been shown to be significantly correlated in patients with schizophrenia, a relationship postulated to be due to working memory demands of the two tests (Gold, Carpenter, Randolph, Goldberg, & Weinberger, 1997). An alternative explanation for the association between these two tests is their sorting demands, in that both require sorting of information albeit in slightly different ways. If the latter explanation is valid, then working memory tasks that do not require sorting or other conceptualization demands should be less predictive of WCST performance than LNS. These hypotheses were examined in 34 poor outcome patients with schizophrenia, one-half of whom were over the age of 65. Patients were evaluated on Digit Span Forward, spatial working memory, LNS, and the WCST. It was found that WCST performance was significantly associated with performance on the LNS but no other working memory task. Age related performance differences were greatest on the WCST Categories and floor effects were noted on this test in one-half of the subjects. Analyses predicting WCST Categories in subjects whose scores were greater than zero (n = 16) also demonstrated that LNS, but not Digit Span or spatial working memory (any delay) predicted WCST performance. These findings indicate that LNS may be an index of executive functioning, particularly in patients who cannot perform the WCST.

Cortical neuritic plaques and hippocampal neurofibrillary tangles are related to dementia severity in elderly schizophrenia patients

Cognitive decline has been described in elderly patients with schizophrenia, but the underlying pathology remains unknown. Some studies report increases in plaques and neurofibrillary tangles, but there is no evidence for an increased risk for Alzheimer's disease (AD) in elderly schizophrenics. Models of a decreased cerebral reserve suggest that increases in AD-related neuropathology below the threshold for a neuropathological diagnosis could be related to dementia severity in elderly schizophrenia patients. We tested this hypothesis in 110 autopsy specimens of schizophrenia patients, without a neuropathological diagnosis of AD or other neurodegenerative disorders. Furthermore, we assessed the effects of apolipoprotein E (ApoE) status, a known genetic risk factor for AD. Measures of density of neuritic plaques were obtained in five cortical regions, and the degree of hippocampal neurofibrillary tangles was rated. Dementia severity was measured prior to postmortem using the Clinical Dementia Rating (CDR) scale. multivariate analyses of variance were conducted with the factors dementia severity, by ApoE4 carrier status. Hippocampal neurofibrillary tangles correlated with increased dementia severity (p<.05). Neuritic plaque density increased with greater dementia severity (p<.005), and ApoE4 carrier status (p<.005), and these differences were magnified by the ApoE4 carrier status (p<.01). Even below the threshold for a neuropathological diagnosis of AD, neuritic plaques and hippocampal neurofibrillary tangles are associated with dementia severity in schizophrenia patients, even more so in the presence of genetic risk factors, suggesting that a decreased cerebral reserve in elderly schizophrenics may increase susceptibility for dementia.