Social Skills Training for Highly Aggressive Children

Four highly aggressive children who were inpatients in a psychiatric hospital were treated with social skills training. Treatment was applied to each child in multiple baseline fashion across behaviors. Results indicated that the treatment was highly effective for each child. However, generalization and maintenance patterns varied substantially across subjects. The results were discussed in regard to the idiosyncratic deficits and treatment needs typically found in clinical populations. The need for individualized treatment planning was highlighted, along with the role of the therapeutic relationship.

Grandma's Rule with Group Contingencies—A Cost-Efficient Means of Classroom Management

A stop watch and a stop clock were utilized in two different versions of a classroom incentive program designed to reduce student disruptions and increase on-task behavior during a small group instructional format, in this case a reading circle. The present study investigated: (a) whether the two procedures would be effective in reducing disruptions and increasing task orientation among those students outside the reading circle who are relatively unsupervised by the teacher without being intrusive into the teacher's conducting his or her lesson and (b) whether the more expensive stop clock would be incrementally effective compared to the stop watch in order to justify the additional cost of the stop clock. A multiple baseline design with a reversal of the stop clock condition was employed with students of five regular elementary classrooms serving as subjects. Results indicated that both techniques reduced disruptions and that there was no systematic difference in effectiveness between the two procedures.

Perspectives in the Behavioral Treatment of Depression

In this article we critically consider the efficacy of psychotherapeutic strategies for the treatment of depressed outpatients. Problems with the design of each of the recent major studies are identified; suggestions for improved methodologies are offered. Comments on the current "status of the art" by leading experts in the field are considered. Finally, advances in the social skills treatment of depression are discussed. Factors requiring further research attention in the next decade are identified.

Treatment of Unipolar Depression with Social Skills Training

Five unipolar nonpsychotic female depressives were treated with social skills training consisting of instructions, role-playing, feedback, modeling, positive reinforcement, social perception instruction, correct self-evaluation, and home-work assignments. Each of the five patients received 12 one-hour sessions during the initial treatment phase. Three of the patients were then given maintenance treatment once a month for six months; one patient received maintenance treatment once a month for three months. Self-report scales, psychiatric rating scales, and behavioral measures for depression and assertiveness indicated marked improvements in each of the patients. Data adduced suggest that this social skills treatment package appears to be effective in ameliorating both the interpersonal and vegetative signs of unipolar nonpsychotic depression.

Effects of Social Disruption, Stimulus Interference, and Aversive Conditioning on Auditory Hallucinations

The effects of social disruption (talking with another individual), interference from a loud bell, and faradic aversion in suppressing auditory hallucinations were examined in a single case experimental design. Verbal exchange with another individual and contingent bell ringing produced only temporary results. However, faradic aversion appeared to produce more lasting results. The effects of treatment were maintained at 20- and 25-week follow-ups.

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.

Impact of Family History in Persons With Dual Diagnosis

OBJECTIVE

This study examined relationships among family history of alcohol, drug, and psychiatric problems and substance use severity, interpersonal relationships, and service use in individuals with dual diagnosis.

METHODS

Data were collected with the family history section of the Addiction Severity Index administered as part of three studies of individuals with dual disorders (N=413). Participants were categorized into family history risk groups for each problem domain based on the number of first and second degree relatives with alcohol, drug, or psychiatric problems.

RESULTS

Rates of alcohol, drug, and psychiatric problems were high across family member categories and highest overall for siblings. Over two-thirds of the sample was categorized in the high-risk group in the alcohol problem domain, almost half of the sample was categorized as high-risk in the drug problem domain, and over a third of the sample was categorized as high-risk in the psychiatric problem domain. Across problem domains, individuals in the high-risk group reported more relationship problems with parents and siblings and higher rates of lifetime emotional, physical, and sexual abuse than did those in the low or moderate-risk groups.

CONCLUSIONS

Family history of alcohol, drug, and psychiatric problems is associated with greater rates of poor family relationships and history of abuse. Assessment of these different forms of family history in multiple family members can aid treatment providers in identifying individuals with dual disorders who may benefit from trauma-informed care as part of their overall mental health and substance abuse treatment services.

Patterns and Predictors of Changes in Substance Use in Individuals with Schizophrenia and Affective Disorders

OBJECTIVE: This study examined patterns and predictors of changes in substance use over one year in individuals with schizophrenia and affective disorders. We examined patterns of cocaine use over time, baseline predictors of continued cocaine use over one year, and predictors of transitions into and out of drug use and treatment. METHODS: We recruited 240 individuals with schizophrenia and affective disorders who met DSM-IV criteria for current cocaine dependence or cocaine dependence in early full or sustained full remission, and assessed them five times over twelve months. RESULTS: There was no change over time in either the proportion of the sample with at least one day of cocaine use in the past month or in the average number of days of cocaine use among those who reported any use. Baseline variables tapping actual substance use were found to predict a decreased likelihood of cocaine use. Several variables tapping actual substance use - including self- reported use of cocaine, positive urinalysis for marijuana, and positive urinalysis for cocaine - were predictive of transitions into and out of outpatient substance abuse treatment. Readiness to change variables such as self-efficacy and temptation to use drugs showed different predictive patterns for the schizophrenia and affective disorder groups. CONCLUSIONS: These findings illustrate how drug use may show a cyclical pattern for those with serious mental illness, in which more severe use - characterized by greater frequency of use and associated problems - is followed by decreased use over time.

Assessing recovery of people with serious mental illness: development of a new scale

OBJECTIVES

The authors describe the development of the Maryland Assessment of Recovery in People with Serious Mental Illness, or MARS, a 25-item self-report instrument that measures recovery of people with serious mental illness, and report a study of its psychometric properties.

METHODS

Doctoral-level scientists with expertise in serious mental illness drafted a set of survey items about the recovery process. Items reflected recovery domains outlined by the Substance Abuse and Mental Health Services Administration. After consultation with a panel of experts on recovery that included consumers and clinical scientists and with a small group of consumers, the instrument was narrowed to 67 items and administered to 166 individuals recruited from outpatient mental health clinics in two states. Item response theory and classical item analysis were used to select best-fitting items, reduce item redundancy, and improve the psychometric properties of the scale. Principal components analysis and confirmatory factor analysis were conducted to further examine dimensions of recovery measured by the scale.

RESULTS

The MARS is quite practical for use with individuals with serious mental illness. It demonstrated excellent internal consistency (Cronbach's α=.95) and test-retest reliability (r=.898) and good face and content validity.

CONCLUSIONS

The data provide initial support for use of the MARS to measure recovery of people with serious mental illness.

Predictors of initiation and engagement in substance abuse treatment among individuals with co-occurring serious mental illness and substance use disorders

Research has documented the significant challenges of engaging individuals with comorbid serious mental illness (SMI) and substance use disorders (SUDs) in substance abuse treatment. To date it is unclear which factors predict treatment initiation and engagement in this group of individuals with SUDs. In this study we conducted two analyses using data from a randomized trial of substance abuse treatment in outpatients with SMI: the first examining predictors (collected during screening) of completing an initial intake assessment and the second examining predictors (collected during the intake assessment) of becoming engaged in treatment. Results indicated that males and those with schizophrenia spectrum diagnoses were less likely to complete the intake assessment. Participants who reported more positive feelings about their family were more likely to engage in substance abuse treatment. Participants who were recently arrested were less likely to engage in treatment. Those who met criteria for current drug dependence were less likely to engage in treatment. Overall, these findings are a useful step in determining factors that predict substance abuse treatment initiation and engagement in individuals with SMI and SUDs.

Examination of the inventory of drug use consequences with individuals with serious and persistent mental illness and co-occurring substance use disorders

BACKGROUND

The Inventory of Drug Use Consequences (InDUC) ( [1] ) is a 50-item measure that evaluates lifetime and recent consequences of substance use.

OBJECTIVES

This study examined the psychometric properties of a modified version of the Inventory of Drug Use Consequences (InDUC-M) in individuals with serious and persistent mental illness (SPMI) and co-occurring substance use disorders (SUDs).

METHODS

We examined self-reported consequences in the sample, evaluated internal consistency, identified items for a brief form of the InDUC-M, and explored relationships with indicators of substance use severity.

RESULTS

InDUC-M Lifetime and Recent subscales showed good internal consistency and were related to other measures of substance use and problems. A brief version of the InDUC-M Recent (SIP-M) showed excellent internal consistency and was highly correlated with both Lifetime and Recent subscales.

CONCLUSION

The InDUC-M and the SIP-M performed well in individuals with SPMI and SUDs.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

Overall, these findings are a useful first step in determining the utility of the InDUC-M in people with SPMI and SUDs.

A randomized, controlled trial of computer-assisted cognitive remediation for schizophrenia

OBJECTIVE

There is considerable interest in cognitive remediation for schizophrenia, but its essential components are still unclear. The goal of the current study was to develop a broadly targeted computer-assisted cognitive remediation program and conduct a rigorous clinical trial in a large group of schizophrenia patients.

METHOD

Sixty-nine people with schizophrenia or schizoaffective disorder were randomly assigned to 36 sessions of computer-assisted cognitive remediation or an active control condition. Remediation broadly targeted cognitive and everyday performance by providing supportive, graduated training and practice in selecting, executing, and monitoring cognitive operations. It used engaging computer-based cognitive exercises and one-on-one training. A total of 61 individuals (34 in remediation group, 27 in control group) engaged in treatment, completed posttreatment assessments, and were included in intent-to-treat analyses. Primary outcomes were remediation exercise metrics, neuropsychological composites (episodic memory, working memory, attention, executive functioning, and processing speed), and proxy measures of community functioning.

RESULTS

Regression modeling indicated that performance on eight of 10 exercise metrics improved significantly more in the remediation condition than in the control condition. The mean effect size, favoring the remediation condition, was 0.53 across all 10 metrics. However, there were no significant benefits of cognitive remediation on any neuropsychological or functional outcome measure, either immediately after treatment or at the 3-month follow-up.

CONCLUSIONS

Cognitive remediation for people with schizophrenia was effective in improving performance on computer exercises, but the benefits of training did not generalize to broader neuropsychological or functional outcome measures. The evidence for this treatment approach remains mixed.

The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements

The Schizophrenia Patient Outcomes Research Team (PORT) psychosocial treatment recommendations provide a comprehensive summary of current evidence-based psychosocial treatment interventions for persons with schizophrenia. There have been 2 previous sets of psychosocial treatment recommendations (Lehman AF, Steinwachs DM. Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophr Bull. 1998;24:1-10 and Lehman AF, Kreyenbuhl J, Buchanan RW, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. Schizophr Bull. 2004;30:193-217). This article reports the third set of PORT recommendations that includes updated reviews in 7 areas as well as adding 5 new areas of review. Members of the psychosocial Evidence Review Group conducted reviews of the literature in each intervention area and drafted the recommendation or summary statement with supporting discussion. A Psychosocial Advisory Committee was consulted in all aspects of the review, and an expert panel commented on draft recommendations and summary statements. Our review process produced 8 treatment recommendations in the following areas: assertive community treatment, supported employment, cognitive behavioral therapy, family-based services, token economy, skills training, psychosocial interventions for alcohol and substance use disorders, and psychosocial interventions for weight management. Reviews of treatments focused on medication adherence, cognitive remediation, psychosocial treatments for recent onset schizophrenia, and peer support and peer-delivered services indicated that none of these treatment areas yet have enough evidence to merit a treatment recommendation, though each is an emerging area of interest. This update of PORT psychosocial treatment recommendations underscores both the expansion of knowledge regarding psychosocial treatments for persons with schizophrenia at the same time as the limitations in their implementation in clinical practice settings.

Substance dependence and remission in schizophrenia: A comparison of schizophrenia and affective disorders

The present study examined psychiatric functioning, substance use and consequences, and motivation to change in people with schizophrenia and affective disorders and current or remitted cocaine dependence. Data were collected as part of a naturalistic, longitudinal study examining substance use, motivation to change, and the process of change in people with schizophrenia and affective disorders who were currently dependent or in remission from cocaine dependence. We examined the following questions: (1) Do those in remission show better psychiatric functioning than those who are currently dependent? (2) How do people with schizophrenia and current cocaine dependence differ in terms of substance use and consequences from people with schizophrenia in remission and people with affective disorders and current drug dependence? (3) What internal factors and external factors are associated with changes in substance use in schizophrenia and how do these compare to those in nonpsychotic affective disorders? Results indicated that people with schizophrenia and current dependence reported higher levels of positive and negative symptoms than those in remission. Remission status was related to less use of other drugs, fewer days of drug problems, less distress from drug problems, and more lifetime drug-related consequences. Those with current dependence reported more days of drinking and drinking to intoxication, as well as higher rates of current alcohol use disorders than the remitted group. When compared to those with affective disorders and cocaine dependence, those with schizophrenia and current dependence reported fewer days of problems associated with their drug use, less distress from drug problems, and fewer recent and lifetime consequences associated with their drug use. The schizophrenia dependent group generally showed the lowest readiness to change, fewest efforts being made to change, and lowest confidence in the ability to change. Implications of these findings are discussed.

Toward a terminology for functional recovery in schizophrenia: is functional remission a viable concept?

Recovery in schizophrenia is receiving increasing attention. Part of the increased focus is based on the recent working criteria for clinical remission in schizophrenia and the realization that many people with schizophrenia meet these criteria for remission. In this article, we consider whether functional disability can also be evaluated in a "remission" model. In so doing, we evaluate the concept of clinical remission, evaluate the possibility of remission of other generally stable features of schizophrenia such as negative symptoms, and make some heuristic terminological recommendations. We also propose a "level and breadth" model for the definition of functional remission and examine some of the alternate influences that could produce suboptimal everyday functioning, including effort, motivation, and societal barriers toward functional achievement.

Application of the Transtheoretical Model of change: psychometric properties of leading measures in patients with co-occurring drug abuse and severe mental illness

People with severe mental illness (SMI) have high rates of substance use disorders. The Transtheoretical Model (TTM) is a framework for understanding behavior change. There are five leading measures associated with the TTM - University of Rhode Island Change Assessment, Processes of Change Scale, Decisional Balance Scale, Abstinence Self-Efficacy Scale, and Temptation to Use Drugs Scale. While these measures have been found to be reliable and valid in primary substance abusers, it is unknown if these measures are relevant in people with co-occurring SMI and substance use disorders (SUD). We evaluated the psychometric properties of these measures in a sample (n=240) of people with co-occurring disorders. Participants met DSM-IV criteria for schizophrenia/schizoaffective disorder or non-psychotic affective disorder, and current cocaine dependence or cocaine dependence in remission. All subscales showed good reliability and validity in the total sample. Analyses within diagnostic groups showed good reliability and validity in most groups, with some falling off in the affective disorders and remitted cocaine dependence groups. Overall, findings support the use of these measures in people with co-occurring disorders.

A scientific agenda for the concept of recovery as it applies to schizophrenia

Recovery is now a widely discussed concept in the field of research, treatment, and public policy regarding schizophrenia. As it has increasingly become a focus in mainstream psychiatry, however, it has also become clear both that the concept is often used in multiple ways, and that it lacks a strong scientific basis. In this review, we argue that such a scientific basis is necessary for the concept of recovery to have a significant long-term impact on the way that schizophrenia is understood and treated. The discussion focuses on key issues necessary to establish this scientific agenda, including: 1) differences in definitions of recovery and their implications for studying recovery processes and outcomes; 2) key research questions; 3) the implications of data from outcome studies for understanding what is possible for people diagnosed with schizophrenia; 4) factors that facilitate recovery processes and outcomes, and methods for studying these issues; and 5) recovery-oriented treatment, including issues raised by peer support. Additional conceptual issues that have not received sufficient attention in the literature are then noted, including the role of evidence-based practices in recovery-oriented care, recovery-oriented care for elderly people with schizophrenia, trauma treatment and trauma-informed care, and the role of hospitals in recovery-oriented treatment. Consideration of these issues may help to organize approaches to the study of recovery, and in doing so, improve the impact of recovery-based initiatives.

Motivation and the stages of change among individuals with severe mental illness and substance abuse disorders

A complicating factor affecting the treatment of individuals with coexisting substance use problems and serious mental illness is their motivation for change and how these interacting, chronic conditions affect the entire process of intentional behavior change. This selective review explores conceptual and assessment issues related to readiness to modify substance use and readiness to initiate behaviors helpful for managing mental illness in the search for a better understanding of patient motivation for change. The recent but limited research on motivation and stages of change among dually diagnosed patients indicates that these individuals appear to access and use an intentional behavior change process. However, it is not completely clear how this process works and what precise adaptations are needed to assess and to access motivation to change to encourage sustained behavior change in this population. Nevertheless, motivation and readiness to change are important dimensions that need to be addressed in treatment and research with dually diagnosed populations.

Performance-based measures of functional skills: usefulness in clinical treatment studies

Recently, attention to the assessment and treatment of functional disability has increased notably. It is widely understood that impairments in everyday living skills, including independent living skills, social functions, vocational functioning, and self-care, are present in people with schizophrenia. It has also become clear recently that assessment of these skills can pose substantial challenges. These challenges include selection of meaningful short-term outcome measures and avoiding bias and reduced validity in the data. Self-report, direct observation, and informant reports of everyday disability all have certain advantages but appear to be inferior to direct assessment of skills with performance-based measures. This review outlines the issues associated with the assessment of functional skills and everyday functioning and provides a description of the strengths and weaknesses of these approaches. We conclude that direct assessment of functional capacity has substantial advantages over other measures and may actually provide a more direct and valid estimate of functional disability than performance on the more distal neuropsychological assessment measures.

Assessment of motivation to change substance use in dually-diagnosed schizophrenia patients

Assessment of motivation to change substance use can be helpful in evaluating treatment readiness and outcome. However, the utility of self-report measures of motivation with schizophrenia patients is questionable. In the current study patients with schizophrenia and either concurrent cocaine dependence or remitted dependence completed the University of Rhode Island Change Assessment-Maryland (URICA-M), a self-report inventory that assesses motivation, and an analogous cartoon instrument at baseline and 6-months follow-up. Results demonstrate that the cartoon readiness to change score was related to increased treatment utilization and decreased substance use; results were not as favorable for the URICA-M. Findings suggest that the cartoon measure may be a suitable alternative to assess motivation to change substance use with cognitively impaired patients.

Social/communication skills, cognition, and vocational functioning in schizophrenia

Deficits in social/communications skills have been documented in schizophrenia, but it is unclear how these deficits relate to cognitive deficits and to everyday functioning. In the current study, social/communication skills performance was measured in 29 schizophrenia patients with a history of good vocational functioning (GVF) and 26 with a history of poor vocational functioning (PVF) using a role-play-based social skills assessment, the Maryland Assessment of Social Competence (MASC). A battery of standard cognitive tasks was also administered. MASC-indexed social skills were significantly impaired in PVF relative to GVF patients (odds ratio = 3.61, P < .001). Although MASC social skills performance was significantly associated with cognitive performance in domains of verbal ability, processing speed, and memory, the MASC nevertheless remained an independent predictor of vocational functioning even after controlling for cognitive performance. Social/communications skills predict vocational functioning history independently of cognitive performance, and social skills measures should be considered for inclusion in test batteries designed to predict everyday functioning in schizophrenia.

Examination of contingency payments to dually-diagnosed patients in a multi-faceted behavioral treatment

Contingency management (CM) may be a promising component of treatment to help dually-diagnosed patients reduce their substance use. However, most prior studies examining CM with these patients have not examined the relationships among patient variables and contingency rewards received. This study examined whether characteristics of dually-diagnosed patients were related to CM payments received in a multi-faceted program. Fifty-nine dually-diagnosed patients participated in a multimodal behavioral therapy for illicit substance use involving CM. Baseline demographic and clinical characteristics were examined as they related to receipt of payments. Demographic characteristics generally were not related to receipt of payments. Several clinical variables, including diagnosis of schizophrenia, current substance dependence, and co-morbid alcohol dependence were related to payment receipt. These results provide an important step toward understanding the characteristics of dually-diagnosed patients that predict their response to CM.

Assessment of community functioning in people with schizophrenia and other severe mental illnesses: a white paper based on an NIMH-sponsored workshop

People with schizophrenia frequently have significant problems in community functioning. Progress in developing effective interventions to ameliorate these problems has been slowed by the absence of reliable and valid measures that are suitable for use in clinical trials. The National Institute of Mental Health convened a workgroup in September 2005 to examine this issue and make recommendations to the field that would foster research in this area. This article reports on issues raised at the meeting. Many instruments have been developed to assess community functioning, but overall insufficient attention has been paid to psychometric issues and many instruments are not suitable for use in clinical trials. Consumer self-report, informant report, ratings by clinicians and trained raters, and behavioral assessment all can provide useful and valid information in some circumstances and may be practical for use in clinical trials. However, insufficient attention has been paid to when and how different forms of assessment and sources of information are useful or how to understand inconsistencies. A major limiting factor in development of reliable and valid instruments is failure to develop a suitable model of functioning and its primary mediators and moderators. Several examples that can guide thinking are presented. Finally, the field is limited by the absence of an objective gold standard of community functioning. Hence, outcomes must be evaluated in part by "clinical significance." This criterion is problematic because different observers and constituencies often have different opinions about what types of change are clinically important and how much change is significant.

Psychometric characteristics of role-play assessments of social skill in schizophrenia

There is an extensive literature documenting that people with schizophrenia have marked impairments in social role functioning and social skill. One of the most widely employed strategies for assessing social skill has been role-play tests: simulated social interactions that are videotaped for subsequent behavioral coding. There has been considerable discussion of the validity of the approach in the literature, but there has not been adequate consideration of other psychometric characteristics of role-play tests. This paper examines the psychometric characteristics of a representative role-play measure: the Maryland Assessment of Social Competence (MASC). Data from 5 large schizophrenia studies that included the MASC were examined: a study of victimization in women who abuse drugs, a study of health care among people with diabetes, a study of vocational outcomes, a study of social skill among drug abusers, and a clinical trial comparing two antipsychotic medications. Data were examined in terms of five questions: (1) Can role-play scenes be rated reliably? (2) How are role-play ratings distributed across populations? (3) How many and which behaviors should be rated? (4) How many role-play scenes are required? (5) Is role-play behavior temporally stable? Overall, the data suggest that the MASC, and by implication other similar role-play procedures, does have good psychometric properties. However, several things often taken for granted in the literature warrant careful consideration in the design of research using role-play. Implications of the results for design of research are discussed.

Development of a comprehensive measure to assess clinical issues in dual diagnosis patients: The Substance Use Event Survey for Severe Mental Illness

This paper provides a description of The Substance Use Event Survey for Severe Mental Illness (SUESS), a brief (20-30 min) interview that assesses clinical issues and domains that are relevant patients with substance use disorders and severe mental illness. First, we discuss the need for a new clinical measure for dual diagnosis patients, as well as our process of creating domains and items and developing the content of the assessment. Second, we provide a first look at the performance of the SUESS in a large sample of dually diagnosed patients from several large scale studies, including how patients responded to the instrument and their ability to complete the items. Third, we present initial reliability data on the SUESS. Finally, we include some initial validity data, including comparison of the self-report of substance use questions to urinalysis results, and verification of the service use information from medical record review. The SUESS appears to be a useful assessment that is tolerated and understood by dual diagnosis patients, and shows good preliminary reliability and validity.

Scientific and consumer models of recovery in schizophrenia: concordance, contrasts, and implications

Schizophrenia has traditionally been viewed as a chronic condition with a very pessimistic outlook, but that assumption may not be valid. There has been a growing consumer movement among people with schizophrenia that has challenged both the traditional perspective on the course of illness and the associated assumptions about the possibility of people with the illness living a productive and satisfying life. This new conception of the illness is supported by long-term studies that suggest that as much as 50% of people with the illness have good outcomes. There has also been a change in political and public health perspectives of the illness, stimulated in part by the President's New Freedom Commission on Mental Health. The purpose of this article is to provide an overview of some key themes about the recovery concept, as applied to schizophrenia. The article will address 3 questions: (1) What is recovery? (2) Is recovery possible? and (3) What are the implications of a recovery model for a scientific approach to treatment (ie, the use of evidence-based practices)? Scientific and consumer models of recovery are described, and commonalities and differences are discussed. Priorities for future research are suggested.

A sociocultural stress, appraisal, and coping model of subjective burden and family attitudes toward patients with schizophrenia

A sociocultural stress, appraisal, and coping model was developed to understand relatives' burden of care and negative affective attitudes toward patients with schizophrenia. Ninety-two African American and 79 White patients and a significant other (80% mothers) completed 2 10-min family problem-solving discussions. In addition, the Kreisman Rejection Scale and a global self-report rating of family burden were administered to relatives, and a self-report rating of substance use was administered to patients. Results indicated that subjective burden of care and patients' odd and unusual thinking during the family discussion each independently predicted relatives' attitudes toward patients, suggesting that negative attitudes are based in part on both patients' symptoms and perceived burden of care. African American relatives' perceived burden was also predicted by patients' substance abuse. Finally, White family members were significantly more likely than African Americans to feel burdened by and have rejecting attitudes toward their schizophrenic relative suggesting that cultural factors play an important role in determining both perceived burden and relatives' attitudes toward patients.

Family interactions and the course of schizophrenia in African American and White patients

Relatives' critical and intrusive behavior with patients, patients' odd or unusual thinking with relatives, and the course of schizophrenia were examined. Seventy-one African American and White patients (each with 1 relative) completed 2 problem-solving discussions. Relatives' critical and intrusive behavior with patients and patients' odd or unusual thinking with relatives were assessed, and patients were followed for 2 years. For African American patients, high levels of relatives' critical and intrusive behavior were associated with better outcome. For White patients, low levels of both relatives' critical and intrusive behavior and patients' odd or unusual thinking with relatives were associated with better outcome. The results suggest that during family interactions, seemingly negative behaviors may be perceived as a sign of caring and concern by African Americans. For Whites, the combination of patients' odd or unusual thinking with relatives and relatives' critical and intrusive behavior toward patients may be especially predictive of an adverse course.

A Randomized Clinical Trial of a New Behavioral Treatment for Drug Abuse in People With Severe and Persistent Mental Illness

CONTEXT

Drug abuse by people with severe mental disorder is a significant public health problem for which there is no empirically validated treatment.

OBJECTIVE

To evaluate the efficacy of a new behavioral treatment for drug abuse in this population: Behavioral Treatment for Substance Abuse in Severe and Persistent Mental Illness (BTSAS).

DESIGN

Participants were randomly assigned to 6 months of treatment in either BTSAS or a manualized control condition: Supportive Treatment for Addiction Recovery (STAR).

SETTING

Treatment was conducted in community-based outpatient clinics and a Veterans Affairs medical center in Baltimore, Md.

PARTICIPANTS

Participants were 129 stabilized outpatients meeting DSM criteria for drug dependence (cocaine, heroin, or cannabis) and serious mental illness: 39.5% met DSM-IV criteria for schizophrenia or schizoaffective disorder; 55.8%, for major affective disorders; and the remainder met criteria for severe and persistent mental illness and other Axis I disorders.

INTERVENTIONS

Both treatments were administered by trained health care professionals in small groups, twice a week for 6 months. The BTSAS program is a social learning intervention that includes motivational interviewing, a urinalysis contingency, and social skills training. The control condition, STAR, is a supportive group discussion treatment. Main Outcome Measure The primary outcome measure was urinalysis results from twice-weekly treatment sessions.

RESULTS

The BTSAS program was significantly more effective than STAR in percentage of clean urine test results, survival in treatment, and attendance at sessions. The BTSAS program also had significant effects on important community-functioning variables, including hospitalization; money available for living expenses; and quality of life.

CONCLUSIONS

The BTSAS program is an efficacious treatment. Further work needs to be done to increase the proportion of eligible patients who are able to become engaged in treatment.

The development of a computer-assisted cognitive remediation program for patients with schizophrenia

In the last decade, impairments in several cognitive domains have been recognized as a central feature of schizophrenia. Consistent evidence has accumulated that documents the contribution of these deficits to poor outcome in social and occupational functioning, and thus they are important targets for psychosocial as well as pharmacological intervention. After reviewing the literature on cognitive remediation for brain injury as well as schizophrenia patients, consulting with research groups which have implemented cognitive remediation programs for schizophrenia, and conducting pilot work with patients, our group has developed a broadly-targeted computer-based remediation intervention that is based on using exercises that engage several cognitive capacities simultaneously, teaching of a set of cognitive strategies by a supportive therapist in a one-on-one setting, and addressing many of the treatment issues that are specific to schizophrenia. The strategies that are emphasized in the intervention are derived from the learning and remediation literatures and include the following: 1) Verbalization to enhance encoding and recall of stimuli; 2) Breaking problems down to promote organized problem solving; 3) Articulation of problem solving to encourage deliberate responding and self-monitoring; 4) Self-checking of performance and adjustment as necessary; 5) Strategic probe questions to prompt participants to monitor their work and make planful responses; 6) Scaffolding aids to provide ongoing support as needed. We are currently conducting a randomized trial of the intervention in which patients complete 24 sessions of remediation or an equivalent number of sessions with a therapist using computer games that have minimal cognitive demand. Our initial experience with the intervention is encouraging and suggests that it is feasible, the tasks are extremely well-received and patients are willing to come to the clinic several times per week to work on them. It is premature to assess whether participation in cognitive remediation is effective in improving cognition, but patients have thus far demonstrated improvement on trained computer exercises. The potential of psychosocial and pharmacological interventions, alone and in combination, for cognitive impairment in schizophrenia is a promising research issue.

Affectivity in the problem-solving interactions of schizophrenia patients and their family members

This study sought to examine the relationship between symptomatology and the affect expressed between individuals with schizophrenia and their family members. It was hypothesized that, because of their impact on patient social behavior and potential burden on relatives, greater negative symptoms would be associated with less emotional expression in patients but would be related to the greater expression of negative emotions in their relatives within a problem-solving discussion. Informed by research on the structure of emotion, a broad assessment of affect, including Negativity, Positivity, and Disengagement, was utilized to examine affect expressed by patients with schizophrenic disorders (N=91) and their family members during videotaped problem-solving discussions. Although individuals with schizophrenia were comparable to their family members in displays of Negativity, patients displayed less Positivity and greater Disengagement. Greater negative symptoms (in particular blunted or flat affect) were related to a general diminution of affective expression in the schizophrenia group. However, negative symptoms were unrelated to the emotional expression of family members. Other symptoms such as thought disorder and mood symptoms of anxiety, depression, and hostility were not related to displays of affect by either patients or their family members. The findings indicate the importance of examining domains of affect other than negativity and demonstrate that negative symptoms are related to interpersonal displays of affect in schizophrenia. Additionally, these results suggest that schizophrenic symptoms, by themselves, may contribute little to the conflict between patients and their family members.

Behavioral consequences of methyllycaconitine in mice: a model of alpha7 nicotinic acetylcholine receptor deficiency

Diminished expression of the alpha(7) nicotinic acetylcholine receptor occurs in selected brain regions of patients with schizophrenia, which may account for pathophysiological abnormalities and some of the deficits in attention and information processing. In view of this neurotransmitter receptor deficit, we wished to characterize the behavioral consequences associated with the administration of methyllycaconitine (MLA), a competitive alpha(7) nicotinic acetylcholine receptor antagonist, in mice. In this study, we injected groups of 12 outbred NIH Swiss male mice intraperitoneally with MLA (1.0, 3.2 and 10.0 mg/kg) and its saline vehicle. Thereafter, individual mice were observed over a one-hour interval and the intensity of a variety of behaviors were rated on a 4-point scale. The observed behaviors included: gnawing/chewing, rearing, grooming, sniffing, climbing, Straub tail, locomotion and ataxia. MLA produced statistically significant changes in the following observed behaviors: rearing, sniffing, climbing, and locomotion. A profile of the behavioral changes related to MLA administration in mice could lead to the development of a screening paradigm for alpha(7) nicotinic acetylcholine receptor agonist interventions. Ideally, an effective alpha(7) nicotinic acetylcholine receptor agonist intervention would target domains of psychopathology, especially cognitive symptoms that contribute to the profound functional disability that is often associated with schizophrenia.

Preliminary reliability and validity of the Clinician-Administered PTSD Scale for schizophrenia

This study provides preliminary psychometric support for a version of the Clinician-Administered Posttraumatic Stress Disorder (PTSD) Scale (CAPS; D. D. Blake et al., 1990) adapted for use with patients with schizophrenia (CAPS-S; J. S. Gearon. S. Thomas-Lohrman, & A. S. Bellack, 2001). Nineteen women with schizophrenia and co-occurring illicit drug use disorders were administered the CAPS-S, the Structured Clinical Interview for DSM-IV diagnoses (SCID). and scales measuring trauma-related psychopathology. The results indicate that the CAPS-S can distinguish between those with and without PTSD and that the symptom clusters measure unified constructs. Interrater and test-retest reliability were high for PTSD diagnosis and symptom clusters. Solid convergent validity was demonstrated between the CAPS-S and SCID-based PTSD diagnoses and the Impact of Event Scale. There is also preliminary evidence of discriminant validity. These results support the use of the CAPS-S in women with schizophrenia.

Do clozapine and risperidone affect social competence and problem solving?

OBJECTIVE

The purpose of this investigation was to evaluate the effects of clozapine and risperidone on social skill and problem solving in patients with schizophrenia.

METHOD

The Wisconsin Card Sorting Test and the Maryland Assessment of Social Competence were administered at baseline, week 17, and week 29 of a multisite clinical trial.

RESULTS

Despite evidence of clinical improvement with both medications, there was virtually no medication effect on either social competence or problem solving.

CONCLUSIONS

These findings underscore the circumscribed nature of symptomatic improvement in the broader spectrum of clinical outcomes and suggest that new-generation medications may not be expected to produce substantial changes in social role functioning or social problem-solving capacity in the community. The generalizability of the findings should be viewed cautiously because of the low power of this trial, and replication is warranted.

A review of cognitive training in schizophrenia

Empirically supported treatments for schizophrenia now include a variety of psychosocial interventions, such as social skills training, vocational rehabilitation, and psychotherapy. As awareness of the functional importance of neurocognitive impairments in schizophrenia has increased, interest in treatments to improve cognition has grown. We review the literature on cognitive training (CT), which has been studied in 17 published randomized, controlled trials to date. The differential effectiveness of noncomputerized and computer-assisted interventions, with and without strategy coaching, and an environmental adaptation intervention, is examined. We conclude that the different types of approaches, whether computer assisted or not, all have effective components that hold promise for improving cognitive performance, symptoms, and everyday functioning. Our recommendations for further research, including the use of functional outcome measures and long-term followup, highlight the importance of improving ecological validity in this area of treatment research.

Skills training for people with severe mental illness

There is a growing empirical literature on psychosocial rehabilitation strategies for schizophrenia and other severe mental illnesses. Three of the best-supported and most promising approaches were reviewed: social skills training (SST), cognitive behavior therapy (CBT), and cognitive remediation (CR). Of the three, SST has the strongest empirical support and can be considered an evidence-based treatment. However, it is appropriate as a targeted treatment for social impairment, not as a broad based treatment for schizophrenia. CBT has only recently been applied to patients with psychotic disorders and the preliminary results are promising for reducing distress associated with residual psychotic symptoms. All but a handful of trials have been carried out in the context of the public health system in the UK with specially selected patients. Consequently, it is not yet clear if it would be effective in public health systems in the US, with highly impaired patients, or for patients with comorbid substance abuse. There is an extensive literature documenting that a variety of training techniques can improve performance on neuropsychological tests, and there is a growing literature of more clinically relevant CR trials that have produced small to medium effect sizes. No studies have yet demonstrated a clinically significant effect on community functioning. This is a promising area for further research, but CR, like CBT, does not have a sufficient evidentiary base for widespread dissemination to the public mental health system at this time.

Race, Family Interactions, and Patient Stabilization in Schizophrenia

This study examined family interactions associated with a failure to stabilize in schizophrenia. Fifty-eight patient and parent dyads completed a problem-solving task soon after an acute episode. Stabilization was assessed over the following 6 months. African American patients' self-initiated discussions of substance use and increased anxiety during the interaction were associated with a failure to stabilize. Nonstabilization in White patients was associated with high levels of both the patients' odd thinking and the parents' criticism. White patients who were depressed during the interaction were also less likely to stabilize. Findings suggest that family relationships may play in important role in determining whether patients stabilize after an acute episode. Results also point to the importance of cultural factors in predicting patient stabilization.

Modulation of MK-801-elicited mouse popping behavior by galantamine is complex and dose-dependent

The ability of phencyclidine (PCP), a noncompetitive antagonist of NMDA receptor-mediated neurotransmission, to precipitate a schizophreniform psychosis in susceptible individuals is consistent with the hypothesized pathologic occurrence of NMDA receptor hypofunction in this disorder. Because the psychosis caused by PCP resembles schizophrenia in all of the relevant domains of psychopathology, investigators have sought to characterize animal models of NMDA receptor hypofunction. MK-801 (dizocilpine) binds to the same hydrophobic channel domain in the NMDA receptor-associated ionophore as PCP, and has been shown to elicit intense irregular episodes of jumping behavior in mice, termed "popping." MK-801-elicited mouse popping is an animal model of NMDA receptor hypofunction that has been used to screen novel candidate compounds for the treatment of schizophrenia. Recently, a selective abnormality in the transduction of the acetylcholine signal at the level of the alpha 7 nicotinic receptor has been described in schizophrenia. The existence of a nicotinic cholinergic abnormality in schizophrenia has stimulated interest in a potential therapeutic role for positive allosteric modulation of nicotinic receptors. Galantamine is a compound that possesses two interesting properties: inhibition of acetylcholinesterase and positive allosteric modulation of nicotinic neurotransmission. Theoretically, galantamine would be expected to increase the efficiency or likelihood that acetylcholine will promote channel opening and ionic conductance at nicotinic receptors. As expected, in the current investigation statistically significant popping behavior was elicited by MK-801 in mice (T(22) = 2.16, P < 0.05). This MK-801-elicited popping was significantly attenuated by 100 mg/kg of galantamine (T(22) = 2.24, P < 0.05). The data show that nicotinic interventions can influence NMDA receptor-mediated neurotransmission in the intact mouse.

Traumatic life events and PTSD among women with substance use disorders and schizophrenia

OBJECTIVE

The authors assessed the prevalence of traumatic life events and posttraumatic stress disorder (PTSD) among women with schizophrenia or schizoaffective disorder and co-occurring substance abuse or dependence. The association between PTSD and specific traumatic life events was also examined.

METHODS

Fifty-four drug-addicted women with schizophrenia or schizoaffective disorder participated in the study. All women were psychiatric outpatients and completed a large battery of structured clinical assessments.

RESULTS

High rates of trauma, particularly physical abuse (81 percent), and revictimization--being abused both as a child and as an adult--were reported. The average number of traumatic life events reported was eight, and almost three-quarters of the sample reported revictimization. Rates of current PTSD were considerably higher than those documented in previous study samples of persons with serious mental illness and of drug-addicted women in the general community. PTSD was significantly associated with childhood sexual abuse and revictimization.

CONCLUSIONS

The high levels of trauma and revictimization observed in the study highlight the need for the development of evidence-based interventions to treat trauma and its aftermath among women with schizophrenia or schizoaffective disorder. Given the overlap in symptoms between PTSD and schizophrenia, a better understanding is needed of how PTSD is expressed among people with schizophrenia. Recommendations and standards for the assessment of PTSD among this population need to be articulated. Finally, the comparatively high rates of PTSD suggest that the combination of schizophrenia or schizoaffective disorder and substance use disorder makes these women particularly vulnerable to adverse outcomes.

Methyllycaconitine fails to inhibit electrically precipitated tonic hindlimb extension in mice

Abnormalities of the transduction of the acetylcholine signal in the brain by the alpha(7) nicotinic receptor are thought to contribute substantially to a fundamental pathophysiologic mechanism in schizophrenia. Abnormal or diminished expression of the alpha(7) nicotinic receptor polypeptide subunit in the brains of patients with schizophrenia has encouraged consideration of the development of alpha(7) nicotinic receptor agonist strategies for the treatment of this disorder. These strategies would target negative symptoms, and attentional and cognitive abnormalities, which are domains of psychopathology that are associated with very poor functional outcomes and disability. Unfortunately, a major theoretic limitation to the development of alpha(7) nicotinic receptor agonist interventions for the pharmacotherapy of schizophrenia is the development of seizures. In the current study, intraperitoneally administered methyllycaconitine, a selective alpha(7) nicotinic receptor antagonist, was shown to be unable to antagonize electrically precipitated seizures in mice. These data suggest that the alpha(7) nicotinic receptor does not mediate this type of seizure activity in mice. Also, although the medication-induced emergence of seizure activity remains a real concern with the development of alpha(7) nicotinic receptor agonist strategies, the data suggest that there should be lessened concern about precipitating seizures related to electrically precipitated tonic hindlimb extension in mice.

Interaction of stress and strain on glutamatergic neurotransmission: relevance to schizophrenia

Psychosis caused by phencyclidine (PCP) stimulated interest in characterizing rodent behaviors elicited by PCP and its analogues. We have shown that MK-801 antagonizes electrically precipitated seizures (defined as tonic hindlimb extension) and elicits episodes of intense jumping behavior, referred to as "popping," in mice. Moreover, 24 h after stress, MK-801's ability to antagonize electrically precipitated seizures is reduced in outbred NIH Swiss mice. Inbred BALBc mice are more resistant to electrically precipitated seizures than the NIH Swiss strain, and are more sensitive to both MK-801's anticonvulsant effect and ability to elicit popping. In the current experiments, we examined the influence of stress and genetic mouse strain on both MK-801's ability to antagonize electrically precipitated seizures and elicit popping. Stress significantly reduced the threshold voltage for precipitation of seizures in BALBc mice and the anticonvulsant properties of MK-801 in both strains. These data show that factors relevant to schizophrenia and its exacerbation (i.e., acute stress and genetics) influence N-methyl-D-aspartic acid (NMDA) receptor-mediated neurotransmission in intact mice. The BALBc inbred strain of mouse may possess advantages in preclinical screening paradigms designed to assess NMDA receptor agonist interventions for disorders such as schizophrenia. Specifically, stressed BALBc mice showed the greatest behavioral sensitivity to MK-801 with regard to electrically precipitated seizures in the incremental electroconvulsive shock (IECS) paradigm, whereas unstressed BALBc showed the greatest behavioral sensitivity to MK-801 in the "popping" paradigm, relative to BALBc and NIH Swiss mice in the appropriate comparison conditions.

Interpersonal control, expressed emotion, and change in symptoms in families of persons with schizophrenia

This study examined the relationships of expressed emotion (EE), change in symptoms in schizophrenia, and interpersonal control patterns in relatives over a 2-year period. Subjects were 56 persons with schizophrenia and their relatives who participated in the NIMH Treatment Strategies in Schizophrenia (TSS) longitudinal study. The relationships among EE, interpersonal control as measured by the Relational Control Coding System (RCCS), and levels of symptoms at each assessment point were analyzed longitudinally with hierarchical linear modeling (HLM). No relationship was found between EE and symptoms, nor did control appear to contribute to symptoms. High-EE relatives reacted more strongly to symptom change than low-EE relatives and in opposite directions. EE may be an indicator of responsiveness rather than either a cause or result of symptoms. Understanding how EE attitudes impact the struggles patients and relatives have in coping with schizophrenia is crucial to knowing how clinicians can support these families most effectively.