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.

Prevalence and correlates of diabetes in national schizophrenia samples

People with schizophrenia may be at increased risk for Type II diabetes because of the side effects of antipsychotic medication, poorer overall physical health, less healthy lifestyles, and poorer health care. The present study uses data bases collected by the Schizophrenia Patient Outcomes Research Team (PORT) to assess the prevalence and demographic and clinical correlates of diabetes within large populations of persons receiving treatment for schizophrenia. In the Schizophrenia PORT, Medicaid and Medicare data from 1991 and more recent interview data were collected regarding the comorbidity of schizophrenia and diabetes: prevalence, quality of life, physical health, and services utilization and costs. The study found that rates of diagnosed diabetes exceeded general population statistics well before the widespread use of the new antipsychotic drugs. Risk factors for diabetes were similar to those observed in the general population. The linkage of diabetes to poor physical health, medical morbidity, and increased service use and cost requires attention. This study of diabetes in the early 1990s suggests that even before the widespread use of the atypical antipsychotic drugs, diabetes was a major problem for persons with schizophrenia.

HOOKLESS1, an ethylene response gene, is required for differential cell elongation in the Arabidopsis hypocotyl

Bending in plant tissues results from differential cell elongation. We have characterized Arabidopsis "hookless" mutants that are defective in differential growth in the hypocotyl. HOOKLESS1 was cloned and its predicted protein shows similarity to a diverse group of N-acetyltransferases. HOOKLESS1 mRNA is increased by treatment with ethylene and decreased in the ethylene-insensitive mutant ein2. High level expression of HOOKLESS1 mRNA results in constitutive hook curvature. The morphology of the hookless hypocotyl is phenocopied by inhibitors of auxin transport or by high levels of endogenous or exogenous auxin. Spatial patterns of expression of two immediate early auxin-responsive genes are altered in hookless1 mutants, suggesting that the ethylene response gene HOOKLESS1 controls differential cell growth by regulating auxin activity.

The association of medical comorbidity in schizophrenia with poor physical and mental health

This study determined the prevalence of medical comorbidities in a cohort of persons receiving treatment for schizophrenia and the association of medical comorbidity with physical and mental health status. A total of 719 persons with schizophrenia sampled from a variety of community and treatment settings as part of the schizophrenia Patient Outcomes Research Team (PORT) participated in a survey interview. Multiple regression analyses were used to assess sociodemographic factors associated with the number of current medical comorbidities and the association of medical comorbidity count with patient ratings of physical health, mental health, symptoms, and quality of life. The majority of patients reported at least one medical problem. Problems with eyesight, teeth, and high blood pressure were most common. A greater number of current medical problems independently contributed to worse perceived physical health status, more severe psychosis and depression, and greater likelihood of a history of a suicide attempt. This study underscores the need to attend to somatic health care for persons with schizophrenia as well as the linkage of physical and mental health status.

Prevalence of chronic obstructive pulmonary disease among those with serious mental illness

OBJECTIVE

Individuals with serious mental illness have elevated smoking rates, and smoking is a significant risk factor for chronic obstructive pulmonary disease (COPD). The goal was to determine the prevalence of COPD among those with serious mental illness.

METHOD

The authors surveyed a random sample of 200 adults with serious mental illness with questions from the National Health and Nutrition Examination Study III that were previously used to estimate the national prevalence of COPD. They compared the prevalence of COPD in the sample to a randomly selected matched subset of national comparison subjects.

RESULTS

The prevalence of COPD was 22.6%. Those with serious mental illness were significantly more likely to have chronic bronchitis (19.5% versus 6.1%) and emphysema (7.9% versus 1.5%) than the comparison subjects.

CONCLUSIONS

The prevalence of COPD is significantly higher among those with serious mental illness than comparison subjects. Improved primary and secondary prevention is warranted.

Reliable self-report of health service use by individuals with serious mental illness

The purpose of this study was to determine whether individuals with serious mental illness could consistently report their use of medical services. Twenty-nine individuals with schizophrenia completed a test-retest protocol using a modified version of the Medical Expenditure Panel Survey; there was a one-week interval between the two administrations of the instrument. Consistency of reporting was generally strong and was strongest for items indicating whether a service had been used in the past six months, which suggests that people with schizophrenia can provide reliable information about their use of health services. Continued research in this area will increase understanding of the types and quality of medical care received by persons with schizophrenia.

MRI correlates of suicide attempt history in unipolar depression

BACKGROUND

Suicide represents a major health problem in the United States, and prediction of suicide attempts is difficult. No structural neuroimaging studies have been done to specifically examine findings in patients who have attempted suicide. The objective of this study was to compare MRI findings in unipolar patients with and without a history of a suicide attempt.

METHODS

In this post hoc analysis, 20 unipolar subjects with a history of a suicide attempt were matched by age and gender to unipolar subjects without a history of an attempt. Subjects were also matched on parameters such as cardiovascular history, electroconvulsive treatment history, and history of psychosis. Subjects with a history of any neurologic condition were excluded. There were no significant differences in age of onset of depression, number of episodes of depression, and Hamilton Depression scores between the two groups. T2-weighted magnetic resonance imaging (MRI) scans were rated using the Coffey and Boyko rating scales.

RESULTS

Unipolar patients with a history of a suicide attempt demonstrated significantly more subcortical gray matter hyperintensities compared with patients without such a history.

CONCLUSIONS

Patients with abnormal MRI findings may be at higher risk for mood disorders and suicide attempts because of disruption of critical neuroanatomic pathways. Gray matter hyperintensities in the basal ganglia may be especially associated with risk for suicide attempts.

Prevalence and correlates of obesity in a community sample of individuals with severe and persistent mental illness

Individuals with severe and persistent mental illness (SPMI) have a preponderance of weight problems, possibly even greater than the obesity epidemic in the general population. Although atypical antipsychotics cause weight gain, their contribution to obesity has not been characterized in a community setting where individuals may take multiple psychotropics associated with weight gain. Using survey information including measured height and weight from a random sample of Maryland Medicaid recipients with SPMI, we compared obesity prevalence to the National Health and Nutrition Examination Survey (NHANES III) sample and a Maryland sample (Behavioral Risk Factor Surveillance System) of the general population adjusted to SPMI demographic characteristics. We investigated correlates of obesity in the SPMI sample. The results indicate that both men and especially women with SPMI had a higher prevalence of obesity than the general population; this portends substantial health implications. A fourfold association between atypical antipsychotics and prevalent obesity was found in men but not in women; further work should clarify mechanisms of obesity in the SPMI.

Services to families of adults with schizophrenia: from treatment recommendations to dissemination

OBJECTIVE

Data from the Schizophrenia Patient Outcomes Research Team project were examined to determine the extent to which families of adults with schizophrenia receive services and whether training staff in the provision of family services increases service availability.

METHODS

For patients with a diagnosis of schizophrenia, paid claims for family therapy were identified in 1991 in a nationally representative sample of Medicare data and one state's Medicaid data. In a field study in two states, 530 patients were asked about services received by their families. A quasiexperimental dissemination of a family intervention was done at nine agencies; staff at four agencies received a standard didactic presentation, and staff at five received that standard presentation paired with intensive training.

RESULTS

In the representative national Medicare sample of 15,425 persons with schizophrenia, .7 percent (N=108) had an outpatient claim for family therapy. This figure was 7.1 percent in the Medicaid sample of 5,393 persons with schizophrenia in one state. Of the 530 patients in the field study who reported having contact with their families, 159 (30 percent) reported that their families had received information, advice, or support about their illness, and 40 (8 percent) responded that their families had attended an educational or support program. At the four agencies where staff received only didactic training, no changes in family services were found after one year. Three of the five agencies where staff participated in intensive training enhanced their family services.

CONCLUSIONS

A minority of families of persons with schizophrenia receive information about the illness from providers. Implementation of model family interventions is possible with considerable technical assistance. A gap exists between best practices and standard practices for families of persons with schizophrenia.

Correlates of long-term unemployment among inner-city adults with serious and persistent mental illness

This study identified demographic, clinical, and vocational rehabilitation-related correlates of long-term unemployment among 219 adults with severe mental illness. Fifty-one percent of the sample had been unemployed five or more years before enrollment. Older age, a diagnosis of psychosis, severity of negative symptoms, and more previous hospitalizations were all significantly related to long-term unemployment. Gender, race, education, substance disorder diagnosis, severity of negative symptoms, and vocational training experience were not. The findings underscore the relevance of clinical and neurocognitive impairments to long-term unemployment and point to the need to critically reevaluate the effectiveness of traditional vocational rehabilitation services.

Substance abuse and family relationships of persons with severe mental illness

OBJECTIVE

The authors sought to determine how substance abuse affects family relationships of persons with severe mental illness.

METHOD

Patient reports of family relationships were compared between 101 psychiatric inpatients with a concurrent substance use disorder and 78 subjects with severe mental illness only.

RESULTS

Patients with comorbid substance abuse reported significantly lower family satisfaction and a greater desire for family treatment. Objective indicators of frequency of family contact did not differ.

CONCLUSIONS

Substance abuse is associated with low levels of satisfaction with family relationships among persons with severe mental illness. Family interventions would meet the stated needs of persons with mental illness and a comorbid substance use disorder and might help to engage them in treatment.

Consumers as service providers: the promise and challenge

The importance of consumers in planning, providing and evaluating mental health services has received increasing recognition. Consumer participation as staff members on professional multidisciplinary teams describes one model of consumer involvement in providing services. This report gives the perspective of the professional leadership of such a team which employs two full-time "consumer advocates" (CAs). CAs have made significant and valuable contributions to the clinical work of the team by virtue of their street smarts, engagement skills, peer support, positive role modeling, fighting stigma, and education of co-workers. However, the CA/professional collaboration presented a number of challenging questions for ongoing discussion, including: 1) What is the role of the CA? 2) What are the boundaries between CAs and patients and the implications of these boundaries for the potential effectiveness of CAs? 3) What supervision should the CA have and with whom? 4) What is the impact of the CA's individual experience with mental illness on their work? Examples are presented of both the clinical contribution of CAs and how the importance of addressing the above questions became evident in the work of the team. We found that CAs were extremely important team members; however, an ongoing dialogue between consumers and professionals is essential to operationalize this important collaboration.

Benchmarking treatment of schizophrenia: a comparison of service delivery by the national government and by state and local providers

This study compared treatment of schizophrenia in two types of organization: a national, government-operated health care system, the Department of Veterans Affairs (VA), and in hospitals and clinics operated by state and local providers. Between 1994 and 1996, 746 male patients with a clinical diagnosis of schizophrenia residing in two states in the Southeast and Midwest were surveyed: 192 VA inpatients were compared with 96 non-VA inpatients, and 274 VA outpatients were compared with 184 non-VA outpatients. VA patients were older and had higher incomes than non-VA patients but did not differ significantly on measures of clinical status, satisfaction with providers, or community adjustment. VA outpatients were more likely to have been hospitalized during the previous year than non-VA outpatients and were less likely to have received services from a day hospital, from a case manager or social worker, or to have received crisis intervention services. On 5 of 26 Schizophrenic Patient Outcomes Research Team treatment recommendations, a smaller proportion of VA than non-VA patients adhered to standards. Four of these reflected reduced access among VA patients to psychosocial services such as work therapy, job training, or case management services. Cross-sectional surveys can be used to compare quality of care across service systems. VA care was associated with similar satisfaction and clinical outcomes but greater reliance on hospital treatment and less use of community-based psychosocial services.

The impact of health status on work, symptoms, and functional outcomes in severe mental illness

This study evaluated the relationships between self-ratings of physical role functioning and general health, two components of the MOS SF-36, and a variety of demographic, quality of life, clinical, functional, and attitudinal variables in a cohort of adults living with severe and persistent mental illness (SPMI). We hypothesized that poorer self-perceptions of physical functioning and general health would be significantly related to more severe symptoms and poorer functioning and quality of life. Study subjects were 218 adults with SPMI enrolled in a randomized controlled trial comparing two vocational interventions for persons who were unemployed. Hierarchical regression analysis was used to determine whether psychiatric symptoms, poorer self-perceptions of role limitations due to physical health problems and overall general health independently contributed to more severe symptoms and poorer functioning and quality of life. Psychiatric symptoms were inversely related to size of social network and satisfaction with safety. Increased role limitations were associated with reduced medication compliance, general life satisfaction, and satisfaction with health, daily activities, and safety. Reduced general health was significantly associated with reduced work motivation, self-esteem, current inability to work, self-report of functioning, and almost all subjective life satisfaction domains. Within this group of people with severe mental illness, psychiatric symptoms were minimally associated with outcomes. Physical role limitations contributed more, and an integrated global measure of overall health perception was most important. If we are to help persons with severe mental illness maximize their quality of life and functioning, our clinical interventions should employ an approach that appreciates and recognizes the importance of the patients' experience of a holistic and integrated experience of health.

Cognitive therapy versus fluoxetine in the treatment of dysthymic disorder

We studied the effects of a fixed dose of fluoxetine (20 mg) or cognitive psychotherapy in a 16 week trial of patients with dysthymic disorder. More patients assigned to fluoxetine dropped out of the 16 week treatment (33%) than those assigned to cognitive therapy (9%), but this difference did not attain statistical significance. Both treatments showed improvement over baseline conditions at 8 weeks and further improvement at 16 weeks. There were no statistically significant group differences in treatment response. No follow-up data were collected so the enduring effects of the treatments are unknown. An optimal treatment for dysthymic disorder may be combined psychotherapy and pharmacotherapy for a longer period of time.

Assertive community treatment and medication compliance in the homeless mentally ill

OBJECTIVE

This study describes medication compliance rates among a group of homeless mentally ill subjects who received assertive community treatment.

METHOD

The medication compliance of 77 homeless persons who had been referred to an assertive community treatment program was prospectively evaluated at baseline and quarterly for 1 year.

RESULTS

A minority of the cohort (29%) was compliant at entry into the assertive community treatment program. Compliance significantly increased after 3 months (57%) and remained high through the year. Medication compliance was associated with fewer psychiatric symptoms but not with better housing placements or fewer days in the hospital.

CONCLUSIONS

Medication compliance rates among a cohort of homeless persons with severe mental illness were markedly higher after they entered a program of assertive community treatment.

Consumers as staff in assertive community treatment programs

The last decade has witnessed the increasing importance of consumers as providers of mental health services. Assertive Community Treatment (ACT) teams and ACT variants, with their emphasis on rehabilitation and support in the client's natural environment, have hosted consumer-professional collaborations. The authors discuss one such program in which an ACT program for homeless mentally ill adults employed consumer advocates (CAs). Consumer advocates were found to have a service profile similar to other staff. Further, there is suggestive evidence that the employment of CAs created a more positive attitude toward persons with mental illness. Issues of role definition, boundaries, support with supervision and the importance of CAs' experiences with mental illness are discussed.

A mathematical model for synergistic eukaryotic gene activation

The precise biochemical mechanism underlying the synergistic action of gene activators on eukaryotic transcription has eluded a solution, largely because of the technical difficulties inherent in analyzing the mechanics of a 2.5 MDa complex comprising greater than 50 polypeptide components. To complement the biochemical approach we have employed mathematical modeling as a means to understand the mechanism of synergy. Parameters relevant to activated transcription were varied in a simple biochemical system and the data were compared to the transcriptional response predicted by a multi-component statistical model. We found that the model achieved a consistent, semi-quantitative description of the measured transcriptional response, and enabled the characterization and measurement of thermodynamic parameters in the in vitro system. The results provide evidence for the existence of cooperativity in the activation process beyond what would be predicted from one current model suggesting that activators function solely by simple recruitment of the general transcription machinery to the promoter.

One-year follow-up of secondary versus primary mental disorder in persons with comorbid substance use disorders

OBJECTIVE

Service utilization and outcomes of dually diagnosed patients with independent mental disorders and those with substance-induced mental disorders were compared.

METHOD

Diagnosis, service use, and severity of substance use problems at baseline and 1 year later were assessed in consecutively admitted inpatients with independent mental disorders plus substance use disorders (N = 71), substance-induced mental disorders plus substance use disorders (N = 38), and independent mental disorders only (N = 59).

RESULTS

At follow-up, patients with substance-induced mental disorders at baseline were more likely to have been rehospitalized than the other groups, were more likely to have used outpatient substance abuse services, were less likely to have an independent mental disorder, and had the most severe alcohol- and drug-related impairment.

CONCLUSIONS

Treatment programs for both types of dual diagnosis patients must address mental health concerns.

Sustained outcomes of a peer-taught family education program on mental illness

OBJECTIVE

This study examines 6-month follow-up data from participants in a randomized trial of a peer-driven 12-session family support and education program, called family-to-family (FTF) and offered by the US National Alliance on Mental Illness, to determine whether improvements in distress, family functioning, coping and empowerment were sustained.

METHOD

Individuals randomized to the FTF condition were assessed after program completion and then 3 months later on measures of distress, family functioning, coping, and empowerment. We used a multilevel regression model (sas proc mixed) to test for significant changes over time (baseline, 3 and 9 months).

RESULTS

All significant benefits that FTF participants gained between baseline and immediately post-FTF were sustained at 9 months including reduced anxiety, improved family problem-solving, increased positive coping, and increased knowledge. Greater class attendance was associated with larger increases in empowerment and reductions in depression and displeasure with ill relative.

CONCLUSION

Evidence suggests that benefits of the FTF program were sustained for at least 6 months without any additional boosters or supports. Peer-based programs may produce sustained benefits for individuals seeking help in addressing challenges and stresses related to having a family member with a mental illness.

Relationship of the use of adjunctive pharmacological agents to symptoms and level of function in schizophrenia

OBJECTIVE

Adjunctive pharmacological agents are extensively used in the treatment of patients with schizophrenia. This cross-sectional study examined the prevalence of the use of adjunctive agents, the extent to which their use conforms with Schizophrenia Patient Outcomes Research Team (PORT) recommendations for adjunctive pharmacological treatment and the relationship of conformance with treatment recommendations to demographic and clinical variables and to symptoms and level of function.

METHOD

Outpatients with schizophrenia (N=344) underwent an extensive interview, and their medical records were reviewed. Data on demographic and clinical characteristics, medications, and role functioning were collected.

RESULTS

More than two-thirds of the outpatients received antiparkinsonian agents, and 50% received an adjunctive agent other than an antiparkinsonian agent. Fifty-four (15.7%) outpatients received two or more non-anti-parkinsonian adjunctive agents. Rates of conformance with the PORT treatment recommendations for the use of adjunctive agents ranged from 49% to 65%, depending on the type of agent. Ethnicity and diagnosis were the only two patient characteristics that were consistently related to conformance with PORT treatment recommendations. The treatment recommendation for adjunctive mood stabilizers was the only recommendation for which conformance was related to multiple measures of patients' symptoms and level of function.

CONCLUSIONS

Adjunctive agents are widely used in the pharmacological treatment of patients with schizophrenia, but there is a limited relationship between use of these agents in conformance with treatment recommendations and measures of symptoms and level of function. Longitudinal, prospective studies are needed to demonstrate the clinical utility of adjunctive agents.

Use and costs of ambulatory care services among Medicare enrollees with schizophrenia

OBJECTIVE

The objective of this study was to identify predictors of the use and cost of ambulatory care services among Medicare recipients with schizophrenia.

METHODS

The design was a cross-sectional analysis of Medicare claims in 1991. The study subjects were a 5 percent random sample of all persons in the United States who had at least one Medicare service claim in 1991 and who were diagnosed as having schizophrenia in any care setting. Outcome measures included use and cost of any ambulatory care service, individual therapy, psychiatric somatotherapy, group therapy, or family therapy.

RESULTS

For nearly 25 percent of the total sample of 12,440, no claims were filed for ambulatory care services in 1991. The mean+/-SD number of ambulatory care visits during the year was 7.9+/-21. The most frequently used type of therapy was individual therapy (5+/-14 visits). The mean+/-SD yearly cost of care for persons who received ambulatory care services was $470+/-$1,028. Among persons under 65 years of age, Caucasians were about 1.5 times as likely as African Americans to have received an ambulatory care service and 1.3 times as likely to have received individual therapy. Persons who were 65 or older were less likely to have received any service. Among service recipients, costs of care were lower for African Americans and for older people.

CONCLUSIONS

The use of Medicare-funded ambulatory care services by persons with schizophrenia varied by race and age. Further investigation is required to determine whether subgroups of individuals who do not have additional insurance coverage or access to services are receiving substandard care.

The schizophrenia PORT pharmacological treatment recommendations: conformance and implications for symptoms and functional outcome

This cross-sectional study examines conformance to four of the Schizophrenia Patient Outcomes Research Team (PORT) antipsychotic treatment recommendations, patient and treatment setting characteristics assocated with conformance, and the relationship of conformance with outcome. Two hundred twenty-four inpatients and 358 outpatients with schizophrenia underwent an interview and review of their medical records. Demographic, clinical, and role function data were collected. Almost all inpatients and outpatients with schizophrenia or schizoaffective disorder were prescribed an antipsychotic. The majority of inpatients were prescribed an antipsychotic within the recommended dose range, whereas the majority of outpatients were prescribed an antipsychotic either below or above the recommended dose range. There were no consistent relationships between patient, geographic, and treatment characteristics and antipsychotic dose. Patients treated with conventional antipsychotic doses below the recommended dose range had significantly better role function. Prospective longitudinal studies are required to delineate the factors that may underlie this relationship.