Narrative enhancement and cognitive therapy (NECT) to improve social functioning in people with serious mental illness: study protocol for a stepped-wedge cluster randomized controlled trial

Background

Self-stigma is highly prevalent in serious mental illness (SMI) and is associated with poorer clinical and functional outcomes. Narrative enhancement and cognitive therapy (NECT) is a group-based intervention combining psychoeducation, cognitive restructuring and story-telling exercises to reduce self-stigma and its impact on recovery-related outcomes. Despite evidence of its effectiveness on self-stigma in schizophrenia-related disorders, it is unclear whether NECT can impact social functioning.

Methods

This is a 12-centre stepped-wedge cluster randomized controlled trial of NECT effectiveness on social functioning in SMI, compared to treatment as usual. One hundred and twenty participants diagnosed with schizophrenia, bipolar disorder or borderline personality disorder will be recruited across the 12 sites. The 12 centres participating to the study will be randomized into two groups: one group (group 1) receiving the intervention at the beginning of the study (T0) and one group (group 2) being a control group for the first 6 months and receiving the intervention after (T1). Outcomes will be compared in both groups at T0 and T1, and 6-month and 12-month outcomes for groups 1 and 2 will be measured without a control group at T2 (to evaluate the stability of the effects over time). Evaluations will be conducted by assessors blind to treatment allocation. The primary outcome is personal and social performance compared across randomization groups. Secondary outcomes include self-stigma, self-esteem, wellbeing, quality of life, illness severity, depressive symptoms and personal recovery.

Discussion

NECT is a promising intervention for reducing self-stigma and improving recovery-related outcomes in SMI. If shown to be effective in this trial, it is likely that NECT will be implemented in psychiatric rehabilitation services with subsequent implications for routine clinical practice.

Trial registration

ClinicalTrials.gov NCT03972735. Trial registration date 31 May 2019.

Towards an improved access to psychiatric rehabilitation: availability and effectiveness at 1-year follow-up of psychoeducation, cognitive remediation therapy, cognitive behaviour therapy and social skills training in the FondaMental Advanced Centers of Expertise-Schizophrenia (FACE-SZ) national cohort

Psychosocial Interventions (PIs) have shown positive effects on clinical and functional outcomes of schizophrenia (SZ) in randomized controlled trials. However their effectiveness and accessibility remain unclear to date in "real world" schizophrenia. The objectives of the present study were (i) to assess the proportion of SZ outpatients who benefited from PIs between 2010 and 2015 in France after an Expert Center Intervention in a national multicentric non-selected community-dwelling sample; (ii) to assess PIs' effectiveness at 1-year follow-up. 183 SZ outpatients were recruited from FondaMental Advanced Centers of Expertise for Schizophrenia cohort. Baseline and 1-year evaluations included sociodemographic data, current treatments, illness characteristics and standardized scales for clinical severity, adherence to treatment, quality of life, a large cognitive battery, and daily functioning assessment. Only 7 (3.8%) received a PI before the evaluation, and 64 (35%) have received at least one PI during the 1-year follow-up. Having had at least one PI during the follow-up has been associated in multivariate analyses with significantly higher improvement in positive and negative symptoms (respectively p =0.031; p = 0.011), mental flexibility (TMT B, p = 0.029; C-VF, p = 0.02) and global functioning (p =0.042). CBT and SST were associated with higher cognitive improvements, while CRT was associated with clinical improvement. These results have not been demonstrated before and suggest that the effect of each PI is larger than its initial target. The present study has confirmed the PIs' effectiveness in a large sample of community-dwelling SZ outpatients at 1 year follow-up. Efforts to improve access to PI should be reinforced in public health policies.

Influence of Venus and Mars in the cognitive sky of schizophrenia. Results from the first-step national FACE-SZ cohort

OBJECTIVES

Sex differences can yield important clues regarding illness pathophysiology and its treatment. Schizophrenia (SZ) has a lower incidence rate, and a better prognosis, in women versus men. The present study investigated the cognitive profiles of both sexes in a large multi-centre sample of community-dwelling SZ patients.

METHOD

544 community-dwelling stable SZ subjects (141 women and 403 men; mean age 34.5±12.1 and 31.6±8.7years, respectively) were tested with a comprehensive battery of neuropsychological tests.

RESULTS

Although community-dwelling SZ men had more risk factors for impaired cognition (including first-generation antipsychotics administration and comorbid addictive disorders), women had lower scores on a wide range of cognitive functions, including current and premorbid intellectual functioning, working memory, semantic memory, non-verbal abstract thinking and aspects of visual exploration. However, women scored higher in tests of processing speed and verbal learning, as well as having a lower verbal learning bias. No sex difference were evident for visuospatial learning abilities, cued verbal recall, sustained attention and tests of executive functions, including cognitive flexibility, verbal abstract thinking, verbal fluency and planning abilities.

CONCLUSION

Sex differences are evident in the cognitive profiles of SZ patients. The impact on daily functioning and prognosis, as well as longitudinal trajectory, should be further investigated in the FACE-SZ follow-up study. Sex differences in cognition have implications for precision-medicine determined therapeutic strategies.

LIMITS

Given the restricted age range of the sample, future research will have to determine cognitive profiles across gender in late onset SZ.

Akathisia: prevalence and risk factors in a community-dwelling sample of patients with schizophrenia. Results from the FACE-SZ dataset

The main objective of this study was to determine the prevalence of akathisia in a community-dwelling sample of patients with schizophrenia, and to determine the effects of treatments and the clinical variables associated with akathisia. 372 patients with schizophrenia or schizoaffective disorder were systematically included in the network of FondaMental Expert Center for Schizophrenia and assessed with validated scales. Akathisia was measured with the Barnes Akathisia Scale (BAS). Ongoing psychotropic treatment was recorded. The global prevalence of akathisia (as defined by a score of 2 or more on the global akathisia subscale of the BAS) in our sample was 18.5%. Patients who received antipsychotic polytherapy were at higher risk of akathisia and this result remained significant (adjusted odd ratio=2.04, p=.025) after controlling the influence of age, gender, level of education, level of psychotic symptoms, substance use comorbidities, current administration of antidepressant, anticholinergic drugs, benzodiazepines, and daily-administered antipsychotic dose. The combination of second-generation antipsychotics was associated with a 3-fold risk of akathisia compared to second-generation antipsychotics used in monotherapy. Our results indicate that antipsychotic polytherapy should be at best avoided and suggest that monotherapy should be recommended in cases of akathisia. Long-term administration of benzodiazepines or anticholinergic drugs does not seem to be advisable in cases of akathisia, given the potential side effects of these medications.

Retour sur expérience en Rhône-Alpes, réflexion sur le panier de soin

L’ARS Rhône-Alpes a eu la volonté de structurer l’offre de soins et de parcours en réhabilitation psychosociale à partir d’expériences locales et de données probantes issues des expériences étrangères. Des centres référents ont été labellisés pour des missions spécifiques et dotés en conséquences, un centre ressource a été créé pour dynamiser et aider à la construction de relais au sein des secteurs de psychiatrie. La question des équipements nécessaires et indispensables à la pratique de la réhabilitation en intégrant la dimension centrale du rétablissement a été largement discutée et tranchée selon des arguments cliniques, organisationnels.

Metabolic syndrome, abdominal obesity and hyperuricemia in schizophrenia: Results from the FACE-SZ cohort

OBJECTIVE

Abdominal obesity was suggested to be a better predictor than Metabolic Syndrome (MetS) for cardiovascular mortality, however this is has not been extensively studied in schizophrenia. Hyperuricemia (HU) was also suggested to be both an independent risk factor for greater somatic comorbidity and a global metabolic stress marker in patients with schizophrenia. The aim of this study was to estimate the prevalence of MetS, abdominal obesity and HU, to examine the association between metabolic parameters with HU in a cohort of French patients with schizophrenia or schizo-affective disorder (SZ), and to estimate the prevalence rates of treatment of cardio-vascular risk factors.

METHOD

240 SZ patients (age=31.4years, male gender 74.3%) were systematically included. Metabolic syndrome was defined according to the International Diabetes Federation and HU if serum uric acid level was above 360μmol/L.

RESULTS

MetS, abdominal obesity and HU were found respectively in 24.2%, 21.3% and 19.6% of patients. In terms of risk factors, multiple logistic regression showed that after taking into account the potential confounders, the risk for HU was higher in males (OR=5.9, IC95 [1.7-21.4]) and in subjects with high waist circumference (OR=3.1, IC95 [1.1-8.3]) or hypertriglyceridemia (OR=4.9, IC95 [1.9-13]). No association with hypertension, low HDL cholesterol or high fasting glucose was observed. Only 10% of patients with hypertension received a specific treatment, 18% for high fasting glucose and 8% for dyslipidemia.

CONCLUSIONS

The prevalence of MetS, abdominal obesity and hyperuricemia is elevated in French patients with schizophrenia, all of which are considerably under-diagnosed and undertreated. HU is strongly associated with abdominal obesity but not with psychiatric symptomatology.

Un parcours de soins aménagé pour le rétablissement

Orienter les soins et les services vers le rétablissement réalise un nouvel enjeu qui bouleverse les schémas de soins habituellement centrés sur l’institution et la maladie. Le mouvement de la réhabilitation a fait connaître le concept de rétablissement qui traduit l’expression des choix des usagers. Ce concept de rétablissement illustre des données connues mais peu valorisées : le pronostic des maladies mentales est favorable pour la moitié des personnes atteintes et dépend aussi de facteurs subjectifs et sociaux. Les objectifs jugés primordiaux par les soignants doivent alors être confrontés aux objectifs personnels des patients et usagers dans une nouvelle alliance thérapeutique, dans une éthique tenant compte de la vulnérabilité et de l’autonomie des personnes handicapées psychiques. Les soins orientés vers le rétablissement développeront des stratégies privilégiant les soins ambulatoires et les interventions écologiques, la qualité de vie immédiate, la préservation du pronostic fonctionnel et la déstigmatisation.

[Persons suffering from schizophrenia and relapses]

INTRODUCTION

In schizophrenia, relapse is a common event that affects more than half the patients within 2 years after a first episode. It is a real setback for them and their relatives. Surprisingly, we do not have much information on how patients and their relatives experience the relapse.

METHOD

A national survey was conducted among 316 schizophrenic outpatients treated with antipsychotics, and 82 of their relatives. The survey assessed the following four aspects: disease history, last relapse history, hospitalization experiences, and relapse prevention.

RESULTS

Regarding the disease history, the average psychiatric follow-up was 13 years and patients had been hospitalized five times on average. Relatives reported approximately the same history. Regarding the last relapse, 9/10 of relatives reported that this relapse led to hospitalization and 69% of patients understood that their hospitalizations were due to relapse. 4% of patients and 7% of relatives identified the end of the treatment as a precursor to relapse. While a lack of compliance was found in about four relapses out of 10. It has also been shown that patients confided primarily in the medical team and the relatives thought to be the first confidant of patients. Regarding the experience of hospitalization, 87% of patients and 86% of relatives judged the hospitalization useful. For both, hospitalization represented a solving step to manifestations of relapse. Regarding the relapse prevention, almost three patients out of four thought they knew what to do in order to avoid a new relapse, while only 52% of the relatives thought patients knew what to do for this matter. For more than one third of the patients, the last relapse (3 years ago) was still a painful event. Avoiding a new relapse was considered very important or important by 91% of patients and 100% of relatives. Relatives felt that regular appointments with the medical team helped avoid relapses. Fifty-nine per cent of relatives have said it was difficult to verify whether or not the treatment was taken by a schizophrenic patient. Relatives' opinion on the injectable treatment was favorable and approximately 50% of the patients declared knowing of injectable treatments. Among these 72% felt that such treatment was reassuring, 69% said it was simpler than oral therapy, and 67% thought it was the most suitable to check the compliance. Only 31% considered it restricting for the patient, against 54% who were considering it not restricting. Finally 57% of patients were willing to take an injectable treatment in order to prevent further hospitalization.

CONCLUSION

This study brings us a better understanding of patients' and relatives' experience of relapse. These results demonstrate the potential impact of relapse on the patients and their relatives and highlight their motivation to avoid further relapses. Also revealed, the lack of importance given to the link between compliance and relapse by patients and relatives. These results underscore the complexity of this disease management in which each player has a key role.

[Treatment adherence as a social ability: a case of patients with schizophrenia]

Psychosocial rehabilitation programs are available for schizophrenic patients to develop social abilities. Taking into account deficits in drug compliance of such patients, psycho-educational programs have been developed to tackle patients' abilities to take their drugs. One year after discharge from psychiatric facilities however, only 50% of the psychotic patients are still compliant with their drug treatment. The aim of our paper is to describe concepts associated with drug adherence as a social ability, and to illustrate these concepts with a program designed for psychotic patients. First, we define the concept of social rehabilitation, second, we describe strategies available to enhance adherence to drug treatment, third, we present a psycho-educational program developed at St. Egrève Hospital, France. This program is centered on the patient's own capacities to become adherent. Individual in-patient consultations, developed by a team of 3 professionals (psychiatrist, pharmacist, nurse) are linked to indiviual follow-up at home. Their scope is to identify specific targets for the patient's self-efficacy to run his drug treatment in an autonomous way.

[Why psychotic patients are not drug compliant?]

Improving patient's compliance with antipsychotics is a major issue in psychosis management. As the point is to convince patients to take their drugs, we have to better understand why they should want or not want to do that. Compliance is actually a complex behavior, involving many psychosocial factors. Thus, we conducted a survey to assess compliance rate and to investigate determinant compliance factors of psychotic outpatients (according to CIM-10 diagnosis). Method - Investigated factors were selected according both to biomedical researches and to psychosocial theories (Health Belief Model). Around 20 influential factors, described in publication, were investigated. The questionnaire design conformed to sociological survey's rules. More, in order to promote patients frankness, the investigator was independent of the medical team. We processed the answers of 63 patients (61% men, average age 40 years), having presented with psychotic disorders for an average of 10 years, without addictive comorbidity (CIM-10). Results - The compliance rate was only 47%. Biomedical factors related to patients (sex, age, social way of life, professional state, and study level), as well as those related to treatment (complexity, duration, side effects occurring), don't affect compliance behavior. The psychosocial factors investigation reveals more interesting results. If the patient trusts his medicines, and do not subscribe to drug's negative beliefs , compliance rate is significantly improved (p=0,0062). It appears to be the survey's best factor for a good compliance, but it concerns only 29% of the investigated patients. When patients aknowledge the whole positive effects of their medicines, compliance is also inclined to improved (p=0,075). But compliance significantly decreases when patients felt that adverse effects are difficult to undergo or unbearable (p=0,04). It also inclined to decrease when family or friends have a negative opinion or are hostile to the pharmacological treatment. None of the other factors influence patient's compliance. Conclusion - These results demonstrate that convincing psychotic patients to be compliant is mandatory. As determinant compliance factors appear to be complex psychosocial ones, it also demonstrates that information procedure needs to be extensively structured.