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Purpose Despite evidence that cognitive remediation improves cognitive and employment outcomes in persons with severe mental illnesses (SMI), its effects have not been systematically compared between Black and White participants. Considering that Black adults have more negative experiences receiving mental health treatment, providers may have greater difficulty engaging and retaining Black Americans in cognitive remediation. Due to the effects of structural racism on reducing employment opportunities for Black Americans, it is unclear whether Black participants will reap the same benefits of cognitive remediation on work outcomes as White Americans. This paper addressed this question. Methods A secondary analysis was conducted of five randomized controlled trials comparing cognitive remediation (the Thinking Skills for Work program: TSW) and vocational rehabilitation vs. vocational rehabilitation only in 137 Black and 147 White Americans (64.2% schizophrenia-schizoaffective disorder) who were followed up for two years. Results Comparable proportions of Black and White participants were engaged and retained in TSW (>75%). Participants who received TSW improved significantly more in cognition than those receiving vocational services alone, with no racial differences in benefit. Participants in TSW obtained more work, earned more wages, and worked more weeks than those receiving vocational services alone, with no differences between the races. Conclusions The findings indicate that Black Americans with SMI receiving vocational services could be successfully engaged in and benefit from cognitive remediation, highlighting the vital role of healthcare service systems in giving credence to structural racism to more effectively mitigate racial disparities in treatment outcomes.

Impaired social functioning contributes to reduced quality of life and is associated with poor physical and psychological well-being in schizophrenia, and thus is a key psychosocial treatment target. Low social motivation contributes to impaired social functioning, but is typically examined using self-report or clinical ratings, which are prone to recall biases and do not adequately capture the dynamic nature of social motivation in daily life. In the current study, we examined the utility of global positioning system (GPS)-based mobility data for capturing social motivation and behavior in people with schizophrenia. Thirty-one participants with schizophrenia engaged in a 60-day mobile intervention designed to increase social motivation and functioning. We examined associations between twice daily self-reports of social motivation and behavior (e.g., number of social interactions) collected via Ecological Momentary Assessment (EMA) and passively collected daily GPS mobility metrics (e.g., number of hours spent at home) in 26 of these participants. Findings suggested that greater mobility on a given day was associated with more EMA-reported social interactions on that day for four out of five examined mobility metrics: number of hours spent at home, number of locations visited, probability of being stationary, and likelihood of following one’s typical routine. In addition, greater baseline social functioning was associated with less daily time spent at home and lower probability of following a daily routine during the intervention. GPS-based mobility thus corresponds with social behavior in daily life, suggesting that more social interactions may occur at times of greater mobility in people with schizophrenia, while subjective reports of social interest and motivation are less associated with mobility for this population.

Cognitive functioning is a potent predictor of work in people with a severe mental illness, including those receiving vocational services. Cognitive remediation has been shown to improve cognitive functioning and work outcomes in people receiving vocational services. However, it is unknown whether it reduces the strength of cognitive functioning as a predictor of work outcomes compared to people receiving vocational services alone.Data were pooled from five randomized controlled trials evaluating the effects of adding cognitive remediation to vocational rehabilitation vs. vocational services alone. A battery of baseline cognitive functioning measures was examined to identify predictors of competitive work outcomes over the following two years. Study condition (i.e., receipt of cognitive remediation) was included in the analyses to evaluate whether cognitive functioning was a weaker predictor of work outcomes in people receiving cognitive remediation compared to those receiving vocational services alone.Cognitive functioning was a stronger predictor of wages earned and weeks worked in participants receiving vocational services alone than those who also received cognitive remediation. Cognitive functioning did not predict job acquisition in either study condition.Cognitive remediation may improve employment outcomes in people receiving vocational services in part by reducing the adverse effects of impaired cognitive functioning on work performance.

Purpose Little is known about the longitudinal trajectories of employment in people with severe mental illnesses (SMI) in developing countries, including India. We examined stability and change in work status, interest in work, problems and benefits related to work among employed participants, and barriers and desired job supports among unemployed participants. Methods We conducted a one-year follow-up with 550 participants with SMI receiving psychiatric outpatient treatment in two hospitals in two districts in India. A total of 459 (83.5%) participants completed follow-up interviews. Results Rates of employment were stable across the one-year period, with over 60% employed at baseline and follow-up assessment. More than 80% who worked at both assessments were working in the same job for an average duration of 10 years. Among participants who were unemployed at baseline, 16.9% started working at follow-up, an outcome associated with interest in work and efforts to find work at baseline. Interest in work of those unemployed at both assessments was lower at follow-up than baseline, but over 60% of participants wanted to work across both assessments, and endorsed desired supports for their job search. Conclusions There is considerable stability of work in people with SMI in India. Working in the same job for the long term may have contributed to consistent work. Most unemployed participants who wanted to work at baseline were not working at follow-up, and expressed a desire for help with job search, suggesting the need for vocational services to help people with SMI in developing countries obtain employment.

While people with serious mental illness (SMI) endorse clinical pain at rates on par or exceeding those in the general population, the association between pain and functioning remains unclear. In this paper we present data on the cross-sectional association between clinical pain and global functioning in a large, mixed diagnostic sample of people with SMI. Eight-hundred ninety-eight people diagnosed with bipolar disorder, major depressive disorder, or schizophrenia were administered the Global Assessment Scale and the 12-item Short Form Survey, which includes an assessment of the extent to which the experience of pain interfered with daily activities over the past month. People with major depressive disorder reported higher pain interference than those with schizophrenia and bipolar disorder. The presence of physical health conditions and psychiatric symptoms were also assessed. After controlling for age, gender, psychiatric symptoms, education level, and physical health problems, pain interference in the past month was associated with significantly lower global functioning. The findings suggest that the experience of pain is associated with poorer global functioning across major SMI diagnoses. Moreover, the impact of pain in global functioning appears independent of physical health problems, and thus may warrant routine screening from mental health providers.

Introduction Technology-delivered healthcare interventions may enhance dissemination of evidence-based treatments in low-resource areas. These interventions may be accessed ‘on-demand,’ including after hours. Patients with schizophrenia do engage with technological aids but when/how they would utilize these tools is not known. Methods We conducted a large, prospective, ten-site, longitudinal study of four technology-assisted interventions for patients with schizophrenia spectrum disorders within 60 days of psychiatric hospital discharge, a high risk period. One tool employed was a smartphone intervention called ‘FOCUS,’ which could be used by patients as needed, providing help in five content areas: medications, mood, social, sleep and voices. Each login was date- and time-stamped as occurring during normal clinic hours, or ‘off-hours,’ and the pattern of use described. Results 347 of 368 patients utilized FOCUS during the 6-month study. There were a total of 75,447 FOCUS logins; 35,739 (47.4%) were self-initiated and 38,139 (50.6%) were off-hours. 18,450 of the logins during off-hours were self-initiated (24.5%). No differences in average usage per month were found based on race/ethnicity. A subset of ‘high utilizers’ (n = 152, 43.8%) self-initiated use of all five FOCUS modules both on- and off-hours. They tended to be women, >35 years old, and had a high school diploma or greater. Conclusion Most patients with schizophrenia spectrum disorders recently discharged from the hospital utilized a smartphone intervention targeted to address troublesome residual symptoms. One quarter of the total smartphone utilization was self-initiated off-hours, indicating the potential utility of this tool to extend support for patients during periods of elevated risk.

The NAVIGATE program was developed for the Recovery After Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study, which compared NAVIGATE to usual Community Care in a cluster randomized design involving 34 sites and 404 patients. This article describes the approach to training and implementing the NAVIGATE program at the 17 sites (including 134 practitioners) randomized to provide it, and to evaluating the fidelity of service delivery to the NAVIGATE model. Fidelity was evaluated to five different components of the program, all of which were standardized in manuals in advance of implementation. The components included four interventions (Individualized Resiliency Training, Family Education Program, Supported Employment and Education, Personalized Medication Management) and the overall organization (staffing and structure) of the NAVIGATE team. Most of the sites demonstrated acceptable or higher levels of fidelity in their implementation of the four interventions and the organization of the program, with all 17 sites demonstrating at least acceptable overall fidelity to the NAVIGATE program. The results indicate that the NAVIGATE program can be implemented with good fidelity to the treatment model in a diverse array of community mental health care settings serving persons with a first episode psychosis.

Individuals experiencing their first episode of psychosis (FEP) are often reluctant to seek treatment, and are difficult to engage and retain in mental health services. The therapeutic alliance (TA), or the affective and collaborative bond between therapist and client, is predictive of better treatment outcomes for clients with FEP; thus, it is important to understand the predictors of the TA in order to determine how best to foster a positive alliance with these individuals. The primary aim of the present study was to examine whether baseline client characteristics, including severity of symptoms, social functioning, and insight, were associated with the TA. The exploratory aim was to examine associations between demographic variables (age, race, and gender) and the TA. The present study included a subsample of participants (n = 134) who received Individual Resiliency Training (IRT) as part of the NAVIGATE treatment in the Recovery After An Initial Schizophrenia Episode Early Treatment Program study. Four trained research assistants rated the TA from early audiotaped sessions of IRT. Multilevel modeling was utilized given the nested data structure. Results indicated that more severe positive and less severe negative symptoms were significantly and uniquely associated with a better therapeutic alliance, as was female gender. The findings suggest that client symptom profiles should be considered when developing a TA with FEP clients.

The therapeutic alliance, or client-provider relationship, has been associated with better treatment engagement and outcomes for persons with schizophrenia-spectrum disorders (SSDs) and early psychosis in some studies, but not others. We conducted a meta-analysis of the research on alliance in SSDs and early psychosis across a range of interventions and outcomes. Parallel literature searches were conducted in PubMed and PsycINFO databases for articles between inception and 6/11/2020. English-language studies were included if they evaluated the relationship between alliance and a prospective outcome (treatment engagement, medication adherence, functioning, or total, positive, negative, or depressive symptoms) in an individual clinical treatment for SSDs/early psychosis and contained analyzable data. Correlations and partial correlations were meta-analyzed with random effects models to calculate mean across-study correlations and to carry out subsequent homogeneity and moderator variable analyses. Fourteen studies consisting of 2968 participants that assessed six outcomes across six psychosocial treatments were included. Results indicated that better client-rated (r = 0.20) and other-rated (i.e., provider- or observer-rated; r = 0.25) alliance were associated with better treatment engagement. Treatment type and sample race/ethnicity, but not age, gender, or timing of alliance rating moderated the association between other-rated alliance and engagement. Further, better other-rated alliance was related to improvements in positive (r = -0.14) and negative (r = -0.22) symptoms. A strong therapeutic alliance is important for both engaging clients with SSDs and early psychosis in treatment and facilitating improvements in positive and negative symptoms. Delivery and monitoring of treatments for this population should include assessment of the therapeutic alliance from multiple perspectives.

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

Background Schizophrenia is a chronic disabling disorder for which current treatments are only partially effective. While the evaluation of novel interventions is a high priority, loss to follow-up is a major threat to validity. Methods Pattern mixture modeling is a statistical technique that incorporates information on patterns of retention that may bias comparisons between randomized treatment groups. This study used pattern mixture mixed model (PMMM) in the analysis of outcomes of a two-year cluster-randomized trial, the Recovery after an Initial Schizophrenia Episode-Early Treatment Program, which compared a coordinated specialty care intervention called NAVIGATE to usual community care (CC). PMM-adjusted outcome differences between NAVIGATE and CC were estimated by the weighted-average of effects across the retention patterns. Results Compared to the original analysis, PMMM improved model fit and the estimated effectiveness of NAVIGATE as compared to CC. On the Quality of Life Scale NAVIGATE effectiveness increased by 1.50 points (25.4%); on the Positive and Negative Syndrome Scale, by 1.72 points (39.8%), and on the Calgary Depression Scale by 0.49 points (62.1%). PMMM did not improve model fit for employment days, substance use days, or hospital days. Conclusion Use of PMMM improved model fit and increased the estimated differences between NAVIGATE and CC for major outcomes. Patients with differential retention patterns may have different outcome trajectories. PMMM is a useful tool for addressing potential biases arising from these differences.

Background We assessed the prevalence and correlates of lifetime substance use disorders in people with first episode psychosis using the baseline data from the Recovery After an Initial Schizophrenia Episode (RAISE) Early Treatment Program study. Methods Research staff assessed 404 first episode patients at 34 community mental health centers across the United States with the Structured Clinical Interview for DSM-IV for diagnoses of psychotic and substance use disorders. Logistic regression was used to evaluate the relationships between participant characteristics and lifetime substance use disorders, followed with generalized linear mixed-effects regression models to identify unique predictors of lifetime substance use disorders. Results Approximately one-third of participants reported recent alcohol use (36.6%) and cannabis use (30.7%), and one half (51.7%) met criteria for any lifetime alcohol or drug use disorder. Lifetime substance use disorders were associated with male gender, White race, higher excited (hyperactivity, mood lability, impulsivity, hostility, and uncooperativeness), psychotic and depressive symptoms, less impaired cognition, and greater perceived stigma. Gender, race, and excited symptoms were the most consistent unique predictors of lifetime substance use disorders found in multivariate analyses. Conclusions Half of first episode psychosis patients have co-occurring substance use disorders, which are associated with both more severe symptoms and greater perceptions of stigma. Programs aiming to serve these patients must have the skills and clinical strategies to help people with these unique characteristics.

Recovery-oriented practices that promote client-centered care, collaboration, and functional outcome have been recommended to improve treatment engagement, especially for individuals with serious mental illness (SMI). Psychological well-being (PWB) is related to recovery and refers to experiencing purpose and meaning in life through realizing one's potential. The recently completed Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE ETP) study sought to improve quality of life, functional outcome, and well-being in individuals with first episode psychosis (FEP). Therefore, the primary aims of the present analysis were: 1) to examine the impact of treatment on PWB and mental health recovery trajectories, 2) to examine the impact of duration of untreated psychosis (DUP) on these outcomes, and 3) to examine the relationships among these outcomes and quality of life. Multilevel modeling was used given the nested data structure. Results revealed that PWB and mental health recovery improved over the course of the 2-year treatment; there were no significant treatment differences. In addition, DUP was associated with the Positive Relationships and Environmental Mastery dimensions of PWB. Finally, PWB, mental health recovery, and quality of life were all significantly correlated at baseline while controlling for depressive symptoms. Overall, the findings indicate that PWB and mental health recovery can improve in FEP, are related to yet distinct from quality of life, and that DUP may play a role in certain facets of these constructs.

Background Participation in work and school are central objectives for first episode psychosis (FEP) programs, but evidence effectiveness has been mixed in studies not focused exclusively on supported employment and education (SEE). Requirements for current motivation to work or go to school limit the generalizability of such studies. Methods FEP participants (N = 404) at thirty-four community treatment clinics participated in a cluster randomized trial that compared usual Community Care (CC) to NAVIGATE, a comprehensive, team-based treatment program that included ≥ 5 h of SEE services per week, , grounded in many of the principles of the Individual Placement and Support model of supported employment combined with supported education services. All study participants were offered SEE regardless of their initial interest in work or school. Monthly assessments over 24 months recorded days of employment and attendance at school, days of participation in SEE, and both employment and public support income (including disability income). General Estimation Equation models were used to compare CC and NAVIGATE on work and school participation, employment and public support income, and the mediating effect of receiving ≥ 3 SEE visits on these outcomes. Results NAVIGATE treatment was associated with a greater increase in participation in work or school (p = 0.0486) and this difference appeared to be mediated by SEE. No group differences were observed in earnings or public support payments. Conclusion A comprehensive, team-based FEP treatment approach was associated with greater improvement in work or school participation, and this effect appears to be mediated, in part, by participation in SEE.

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

Background A recent factor analysis of Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus Cognitive Battery (MCCB) data in a sample of schizophrenia-spectrum patients described a three factor model representing processing speed, attention/working memory, and learning; the social cognition measure was excluded from the analysis. The current analyses sought to replicate a three factor structure of the MCCB in a larger, more diagnostically diverse sample of participants. Methods Confirmatory factor analyses were performed to evaluate the factor structure of the MCCB in 300 outpatients with severe mental illness (54.3% schizophrenia-spectrum diagnoses) who were participants in three studies of cognitive remediation. Exploratory analyses were conducted to evaluate the concurrent prediction of symptoms from MCCB factor scores. Results The three factor structure of the MCCB demonstrated stronger model fit (χ2 = 14.53, p = 0.75, SRMR = 0.02, RMSEA = 0.0, CFI = 1.00, NNFI = 1.01) than the unifactoral structure. Poorer cognitive performance across all three MCCB factors was significantly correlated with more severe overall and disorganization symptoms from the PANSS and BPRS, and less severe affective symptoms (e.g., depression, anxiety) in the overall sample. Conclusions A three factor structure of the MCCB—composed of processing speed, attention/working memory, and learning—was replicated in a heterogeneous sample of persons with severe mental illness. Cognitive performance on the MCCB factors is associated with clinical symptoms.

A growing body of research shows that cognitive remediation (Cog Rem), consisting of drill- and-practice and/or strategy training in neurocognitive functions, produces moderate improvements in neurocognition. These improvements generalize to functioning when Cog Rem is provided with other rehabilitation interventions (Wykes et al., 2011) The number of studies using Cog Rem as an adjunct to other behavioral-based rehabilitation interventions however remains small and consists of widely varying interventions with few active control conditions. This study compared the effects of an extended (6-month), standardized, computer-assisted cognitive remediation intervention, administered along with a standardized program of social skills-training (SST), with those of an active control condition that included participation in the same SST program and a computer skills training program (Computer Skills). Sixty-four individuals with schizophrenia recruited from two treatment sites were randomly assigned to one of two conditions and were assessed by blinded raters on neurocognitive measures, performance-based measures of social skill, and ratings of psychosocial function before and after treatment. Results revealed that the Cog Rem group improved significantly more in attention, working memory, and empathy than the Computer Skills group, but there were no differences between groups on other measures of psychosocial functioning or skills. Taken together, these findings suggest that Cog Rem used in the context of other evidence-based psychosocial interventions (SST) improves working memory in schizophrenia and suggests that this effect may generalize to improved empathy.

This study compared baseline characteristics of Black Americans and Caucasians with first-episode psychosis in the Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP). Black American (N = 152) and Caucasian (N = 218) participants were compared on demographic, psychosocial, clinical, and neurocognitive measures. Results indicated several notable racial differences in baseline characteristics: a greater proportion of Black Americans than Caucasians were female, and Black Americans reported less personal and parental education than Caucasians. Black Americans were also less likely to have private insurance, more likely to be homeless or transient, had significantly poorer quality of life, more severe disorganized symptoms, worse neurocognition, and were less likely to abuse alcohol than Caucasians. The implications of these findings are discussed, and suggestions are provided for future avenues of treatment and research on racial disparities in first-episode psychosis.

Psychotic symptoms, coercive interventions, and other negative treatment experiences have been found to lead to posttraumatic stress disorder (PTSD) symptoms. However, prior research has not examined the importance of the DSM-IV A1 (perception of threat) and A2 (negative emotion at time of event) criteria for a traumatic event due to a psychotic episode. To address this question, 50 clients with a history of multiple episodes of psychosis were interviewed to identify distressing experiences related to past episodes, with PTSD assessed (including A1/A2 criteria) related to those events, and other psychiatric symptoms, psychosocial functioning, and coping style. Participants reported intense distress related to psychotic symptoms (66%), treatment experiences (25%), and their combination (8%), with 69% meeting symptom criteria for PTSD (excluding A1/A2 criteria), and 31% meeting full diagnostic criteria for PTSD (including A1/A2 criteria). Clients meeting symptom criteria for PTSD, as well as those meeting full diagnostic criteria for PTSD were similar, with both groups reporting more severe symptoms and distress, and more problems in daily functioning, than clients with fewer or no PTSD symptoms. The results are similar to a previous study of PTSD in persons with recent onset of psychosis (Mueser et al., 2010), and suggest that individuals with PTSD symptoms related to psychosis and coercive treatment may benefit from interventions designed to help them integrate their experiences into their lives and reduce PTSD symptoms, regardless of whether the triggering event(s) meet DSM-IV A1/A2 criteria for a traumatic event.

Cognitive remediation in people with severe mental illnesses (SMI) that interfere with work, but less research has evaluated its effects in those who have not benefitted from vocational services. Participants with SMI (83% schizophrenia) who had not benefitted from vocational rehabilitation were randomized to vocational services enhanced by training vocational specialists in recognizing cognitive difficulties and providing job-relevant cognitive coping strategies (Enhanced Vocational Rehabilitation: E-VR), or similarly enhanced vocational services and cognitive remediation (Thinking Skills Work: TSW). Cognition and symptoms were assessed at baseline, post-treatment (9months), and follow-up (18months), with work tracked weekly for 3years. Fifty-four participants were randomized to E-VR (N=26) or TSW (N=28). Participants in TSW had high rates of exposure to the program (89%) and improved more than those in E-VR on cognitive functioning post-training, with attenuation of some gains at the 18-months. Participants in TSW and E-VR did not differ significantly in competitive work (57% vs. 48%) or paid employment (61% vs. 48%) over the 3-year study, although those in TSW were more likely to be engaged in any work activity, including paid or volunteer work (75% vs. 50%, p=0.057), and had more weeks of work activity (23.04 vs. 48.82, p=0.051), and improved marginally more on the clinical symptoms. The significantly higher education level of participants in E-VR than TSW at baseline may have obscured the effects of TSW. This study supports the feasibility and potential benefits of cognitive remediation for persons who have not benefited from vocational rehabilitation.

The construct of self-efficacy has been hypothesized to mediate the relationship between efforts at coping with psychiatric illness and functional outcome. This study examined whether self-efficacy mediated the relationships between psychosocial functioning and important predictors of functioning: premorbid functioning, negative symptoms, and cognitive functioning. Although self-efficacy was positively associated with psychosocial functioning, it did not mediate the relationships between functioning and the other established predictors. Rather, negative symptoms were the strongest predictor of functioning and mediated the relationship between self-efficacy and functioning. The findings suggest that negative symptoms, and not self-efficacy, are the most critical determinants of psychosocial functioning in schizophrenia, and that psychosocial treatment should focus on the amelioration of these symptoms.

Background: The feasibility and preliminary efficacy of a novel cognitive behavioral treatment for decreasing psychotic symptoms and improving social functioning was evaluated in a pilot study. This represents the first treatment outcome study of CBT for psychosis with a manualized, active comparison condition. Methods: Thirty outpatients with schizophrenia or schizoaffective disorder, depressed type with residual psychotic symptoms were randomly assigned to either 16 weekly sessions of functional cognitive behavioral therapy (fCBT) or psychoeducation (PE) with assessments conducted at baseline and post-treatment by blind evaluators. Results: Attrition was only 7% and did not differ between fCBTand PE, indicating good tolerability of both treatments. For this sample with persistent symptoms, between groups effects were not significantly different, but within group effect sizes indicated greater treatment benefit for fCBT on positive symptoms, particularly for the PSYRATS voices subscale. Conclusion: The results suggest that fCBT is well tolerated and holds promise for reducing persistent positive symptoms. D 2004 Elsevier B.V. All rights reserved.

Objective: Supported employment has been shown to improve the employment outcomes of clients with severe mental illness (SMI), but many clients who receive this service still fail to achieve their vocational goals. There is a need to better understand how illness-related impairments interfere with work, and how supported employment services deal with those impairments in order to improve the employment outcomes of clients with SMI. Method: We conducted a review of research on the relationship between cognitive functioning, symptoms, and competitive employment in clients with SMI. Based on this review, we developed a heuristic model of supported employment that proposes specific interactions between cognitive factors, symptoms, vocational services, and employment outcomes. Results: The review indicated that cognitive functioning and symptoms were strongly related to work in studies of general psychiatric samples. In studies of clients participating in vocational rehabilitation programs, associations between cognitive functioning, symptoms, and work were also present, but were attenuated, suggesting that vocational rehabilitation compensates for the effects of some cognitive impairments and symptoms on work. We describe a heuristic model of supported employment that posits specific and testable effects of cognitive domains and symptoms on vocational services and employment outcomes. Conclusions: Supported employment appears to work by compensating for the effects of cognitive impairment and symptoms on work. The model may serve as a guide for research aimed at understanding how supported employment works, and for developing supplementary strategies designed to improve the effectiveness and cost-effectiveness of supported employment services.

Objectives: To evaluate the differences between two cohorts of patients with severe mental illness (schizophrenia-spectrum or bipolar disorder) and co-occurring substance-use disorders, living in either predominantly rural areas or urban areas. Methods: Two study groups of patients with a dual diagnosis, recruited using the same criteria, were evaluated, including 225 patients from New Hampshire and 166 patients from two cities in Connecticut. The two study groups were compared on demographic characteristics, housing, legal problems, psychiatric and substance use diagnoses, substance use and abuse, psychiatric symptoms, and quality of life. Results: Patients in the Connecticut study group had higher rates of cocaine-use disorder, more involvement in the criminal justice system, more homelessness, and were more likely to be from minority backgrounds. The Connecticut group also had a higher proportion of patients with schizophrenia and more severe symptoms, as well as lower rates of marriage, educational attainment, and work than the New Hampshire study group. Alcohol-use disorder was higher in the New Hampshire group. Subsequent analyses within the Connecticut group indicated that although African American patients had higher rates of cocaine-use disorder than white patients, cocaine disorder and not minority status was most strongly related to criminal involvement and homelessness. Conclusions: Because of the substances abused and the greater degree of psychiatric illness severity, patients with a dual diagnosis who are living in urban areas may require greater ancillary services, such as residential programs, Assertive Community Treatment, and jail diversion programs in order to treat their disorders successfully.

Objective: To identify correlates of self-reported substance use and problems associated with that use in people with schizophrenia. Methods: A sample of 404 patients with schizophrenia, schizoaffective disorder, or schizophreniform disorder and longitudinal assessments of substance use were examined. Three groups were formed according to consistency of substance use over time: No/Low Alcohol, Alcohol Only, and Drug Use (with or without alcohol use). Similar groups were formed regarding problems associated with alcohol use. Groups were compared on demographics, psychiatric history, psychopathology, medication side effects, and social functioning. Results: Substance users were more likely to be young, male, and to have lower levels of education. Substance users generally had fewer negative symptoms, more social contacts, and better social-leisure functioning. However, substance users, especially drug users, also were rated as having more interpersonal and family problems, had an earlier age at first psychiatric hospitalization, and were more likely to have been recently hospitalized. Patients reporting problems with alcohol use reported more frequent alcohol and drug use, greater severity of akathisia, and problems in interpersonal, family, and self-efficacy domains. Conclusions: Many of the same variables that correlate with substance use disorder also correlated with moderate substance use in this sample of people with schizophrenia. Although moderate users of alcohol and drugs may have better social functioning in some areas, they also are likely to have substantial problems in interpersonal relationships, especially those involving family members.

Caregivers of persons with severe mental illness often experience a significant burden in coping with patients' symptoms. Several factors have been hypothesized to mediate the impact of caring for a mentally ill relative, including cognitive appraisal, coping strategies, and social support. The present study examined the relationships between these factors, and subjective burden and well-being in caregivers of persons with a severe mental illness. Higher levels of subjective burden were related to (1) greater perceived frequency of positive and negative symptom behaviors, (2) a tendency to use problem-focused oriented coping for dealing with negative symptom behaviors, and (3) a tendency not to use problem-solving oriented coping for dealing with positive symptom behaviors. Well-being was also related to lower perceived frequency of positive symptom behaviors and social support, but not to coping style. The implications of the findings for interventions designed to reduce caregiver subjective burden are discussed.

This study compared the functioning of 188 elderly schizophrenic and bipolar disorder patients living in nursing homes and the community. Residential status and diagnostic groups were compared on measures of symptomatology, cognitive impairment, functional impairment, and behavior problems. In general, the diagnostic groups differed in symptoms, while most differences in living setting were related to cognition, functioning, and behavior. Nursing home status was significantly associated with more severe overall symptom ratings, worse cognitive impairment, greater functional impairment, more aggressive behaviors, and marital status of having never married. Self-care skills, community living skills, and marital status were most uniquely predictive of nursing home residence. However, cognitive deficits were strongly predictive of both self-care and community living skills, explaining approximately half of the variance in these variables. The implications of these findings for the treatment of elderly patients with schizophrenia and other severe mental illnesses are discussed.

The relationship between social skills and ward behavior among chronic schizophrenia patients was investigated. Twenty-eight inpatients participated in an unstructured role play test and were rated by staff members on a number of indices of ward behavior (e.g., social interactions, inappropriate behavior). Overall, there was a relationship between social skill on the role play and social behavior on the ward. Speech clarity was the social skill most strongly related to ward behavior, even when controlling for symptomatology. However, several other social skill variables (e.g., gaze, affect) were not related to social adjustment. The results are discussed in terms of the validity of social skill assessments in patients with chronic schizophrenia, and their implications for psychosocial treatment of this population.

CBT for Psychosis (CBTp) is an empirically-supported intervention for schizophrenia, but few people have access to it in the U.S. "Coping with Voices" is an interactive, computerized self-directed web-based CBTp program developed to increase access to CBTp with the objective of reducing the severity, distress, and functional impairment caused by auditory hallucinations. This open pilot study tested the feasibility and effects of this new intervention. Twenty-one individuals with schizophrenia spectrum disorders and auditory hallucinations were enrolled in the individual-based 10-session Coping with Voices program at one of 4 community mental health centers. High levels of participant satisfaction with the program were found, with most reporting that the program was engaging and helped them manage their symptoms. Seventeen participants (81%) completed more than 50% of the scheduled program sessions (i.e., 6 or more sessions), and were defined as "exposed" to the program. Exposed participants showed statistically significant reductions from baseline to post-treatment in several measures of auditory hallucinations, including overall severity and the perception of voices as an "outside entity" and intensity of "negative commentary," as well as reductions in other psychotic symptoms, and overall psychopathology. This study supports the feasibility of the web-based Coping with Voices program and its potential clinical benefits, and suggests that more rigorous research is warranted to evaluate its effects.

A new family therapy model for schizophrenia is described, Educational Family Therapy (EFT). This model employs didactic teaching methods and ‘user friendly’ educational handouts and is provided in a flexible, interactive manner. The results of pilot data show that the model is feasible and suggest family members improve in their understanding of the illness. Data are also presented demonstrating that EFT can be distinguished from another model of family therapy for schizophrenia, Behavioral Family Therapy. The need for research comparing EFT and other family therapy models for schizophrenia is discussed. Such research may have implications for the dissemination of effective family interventions, matching treatment models to family needs and understanding the mechanisms underlying the impact of family therapy on the course of schizophrenia and on family burden.

The relationship between patient symptomatology and the acquisition of social skills during an inpatient social skills training program, and the maintenance of skills at a one-month followup, were examined in a sample of recently hospitalized schizophrenic and schizoaffective disorder patients. Subtypes of patients with enduring Thought Disorder (vs. no enduring Thought Disorder) or enduring Anergia (vs. no enduring Anergia) on the BPRS during the treatment period were compared in their response to the social skills training intervention. Patients with enduring Thought Disorder acquired skills at the same rate as patients without Thought Disorder, but were unable to retain their skills at followup, in contrast to their counterparts. Enduring Anergia was not related to either the acquisition or maintenance of social skills. The results were unaffected when memory was statistically controlled. The findings suggest that patient symptomatology may be an important factor mediating the efficacy of social skills training interventions.

Clinical investigators have argued that the experience of a recent onset of psychosis is an event of such severity that it can lead to posttraumatic stress disorder (PTSD), or at least to PTSD symptoms. The traumagenic elements of the psychotic experience may relate to the distressing nature of psychotic symptoms, components of treatment, or both. However, this hypotheses has not been fully empirically evaluated. In particular, the importance of the DSM-IV A1 (perception of threat) and A2 (negative emotion at time of event) criteria for a traumatic event due to a psychotic episode has not been assessed. To address this question, 38 clients in treatment for recent onset of psychosis were interviewed to identify distressing experiences related to the episode, with PTSD assessed (including A1/A2 criteria) related to those events. More than one-half of the participants reported intense distress related to psychotic symptoms or treatment experiences, with 66% meeting symptom criteria for the PTSD syndrome (regardless of A1/A2), and 39% meeting full diagnostic criteria for PTSD (including A1/A2). Both participants with the PTSD syndrome and full PTSD reported more problems in daily functioning and more severe symptoms than those without PTSD. Participants with the PTSD syndrome were also more likely to have an integrative rather than sealing over coping style compared to those without the PTSD syndrome. The results suggest that individuals with PTSD symptoms related to a recent onset of psychosis may benefit from intervention designed to help them integrate their experience into their lives and address potentially stigmatizing beliefs that could contribute to distress and impaired functioning.

The prevalence of social skill deficits in schizophrenia was examined by comparing patients assessed over a 1 year period with a group of non-patient controls recruited from the community. Social skills were assessed using a role play test and were considered deficient when they were below the range of the control sample. Approximately 50% of the patients were consistently unskilled over the one year, whereas 11% were consistently skilled. Deficits in specific social skills were relative rare. Consistent deficits were present for only one of six specific skills: 14% of the patients were consistently less appropriate in their conversational turn-taking (Meshing) than the controls. Patients' social skills were relatively stable over time. The implications of these results for the assessment and remediation of social skill impairments in schizophrenia are discussed.

I recently discovered some aberrant values in the data for the Quality of Life (QOL) Social and Vocational subscales from our Penn et al. (2011) study that compared the Graduated Recovery Intervention Program (GRIP)+Treatment as Usual (TAU) to TAU alone for individuals with first episode psychosis. These values were replaced with the mean item score for the corresponding scale, and the data were recomputed. The updated findings (descriptive statistics, within-group analyses, and effect sizes) are summarized in Table 1. The pattern of findings is generally unchanged. In regard to GRIP+ TAU, none of the with-in group analyses from baseline to post-test

Traumatic life events, as defined by DSM-IV, are common among persons with severe mental illnesses (SMI) such as schizophrenia. Limited evidence suggests concomitantly high rates of posttraumatic stress disorder (PTSD) in this population. However, conceptual models do not exist for understanding the interactions between trauma, PTSD, and SMI. We propose a model, which is an extension of the stress-vulnerability model, in which PTSD is hypothesized to mediate the negative effects of trauma on the course of SMI. Our model posits that PTSD influences psychiatric disorders both directly, through the effects of specific PTSD symptoms including avoidance, overarousal, and re-experiencing the trauma, and indirectly, through the effects of common correlates of PTSD such as retraumatization, substance abuse, and difficulties with interpersonal relationships. We discuss the evidence supporting this model, and consider several intervening variables that are hypothesized to moderate the proposed relationships between PTSD and SMI, including social support, coping and competence, and antisocial personality disorder. Theoretical and clinical implications of the model are considered, as well as several methodological and nosological issues. We conclude with a brief discussion of directions for future research aimed at evaluating components of the model.

We conducted a meta-analysis using all available controlled treatment outcome studies of cognitive therapy (CT) for psychotic symptoms in schizophrenia. Effect sizes were calculated for seven studies involving 340 subjects. The mean effect size for reduction of psychotic symptoms was 0.65. The findings suggest that cognitive therapy is an effective treatment for patients with schizophrenia who have persistent psychotic symptoms. Follow-up analyses in four studies indicated that patients receiving CT continued to make gains over time (ES=0.93). Further research is needed to determine the replicability of standardized cognitive interventions, to evaluate the clinical significance of cognitive therapy for schizophrenia, and to determine which patients are most likely to benefit from this intervention.

This study examined whether patient demographic and clinical characteristics were predictors of differential treatment response in a sample of 57 schizophrenic patients who received the German version of the Symptom Management Module. Psychopathology, global functioning and knowledge about schizophrenia were assessed as dependent variables. Overall, patients improved over the treatment period on most dimensions of psychopathology as well as knowledge about psychosis. There was little evidence of differential treatment response as a function of either sociodemographic or clinical variables. However, gender was related to changes in psychopathology from pre- to posttreatment, with females improving less than males. Possible implications of these findings were discussed.

Objective: The relationships of perceived severity and responsibility attribution for positive and negative symptom behaviors to caregiver burden were investigated. Two types of burden were studied: objective burden (i.e., negative consequences such as physical problems, financial difficulties, and household tension), and subjective burden (i.e., emotional distress about disturbing behaviors). Method: Self-report measures were completed by 70 primary caregivers of persons with schizophrenia. Results: Subjective burden was related to both the severity of positive and negative symptom behaviors, whereas objective burden was related only to the severity of negative symptom behaviors. Responsibility attribution for negative symptom behaviors was related only to objective burden. Caregivers who perceived patients as being less responsible for their negative symptom behaviors reported higher levels of objective burden. The relationship between responsibility attribution for negative symptom behaviors and objective burden remained significant, even after controlling for the severity of negative symptom behaviors. Caregivers' perceptions of patients' responsibility for positive symptom behaviors were not related to objective burden. Conclusions: As expected, perceived severity of negative symptom behaviors was related to objective caregiver burden, whereas severity of positive symptom behaviors was not. These findings suggest that negative symptoms may have a greater impact on role functioning that positive symptoms, leading to greater burden. However, contrary to expectations, less responsibility attribution for negative symptom behaviors was related to higher levels of objective caregiver burden. Caregivers who perceive patients as incapable of altering their negative symptom behaviors and meeting certain role obligations may assume extra responsibilities, leading to higher levels of objective burden. The results indicate that there may be disadvantages for caregivers associated with assuming that patients have no control over their negative symptom behaviors.

Thirty-four schizophrenic patients in an acute in-patient hospital were compared with 24 in-patients with major affective disorder and 19 non-patient controls on a role-play test of social skills and a test of affect perception. The role-play test consisted of 12 simulated conversations in which the subject was confronted by parents and friends expressing high-EE criticism or non-critical dissatisfaction. Schizophrenic patients lacked assertiveness and social skills in all conditions, but they did not show any differential impairment when presented with high EE. They consistently lied and denied errors rather than responding assertively or apologising, whether confronted with high-EE or benign criticisms. On the affect perception test, schizophrenic patients consistently underestimated the intensity or negativeness of negative emotions, but they were not deficient in perception of positive emotional displays. The data do not support the hypothesis that schizophrenic patients are poor at dealing with high-EE behaviours, but do indicate that their ability to cope with even mild negative affect is impaired. Possible explanations for this impairment include limited attentional capacity, a neurologically based perceptual deficit, and a self-protective mechanism to reduce or avoid stress.

Social skill and role functioning were assessed in matched groups of patients with DSM-III-R schizoaffective disorder, bipolar disorder, and schizophrenia. Schizophrenics were categorized as negative syndrome or non-negative on the basis of the SANS. The negative schizophrenics were significantly more impaired on almost every measure of social functioning. The other three groups were not consistently different from one another. The results suggest that when patients are comparable on dimensions such as duration and severity of illness, schizoaffectives do not occupy an intermediate position between schizophrenics without negative syndrome and bipolar patients. Rather, the three groups exhibit similar degrees of social disability. In contrast, negative syndrome schizophrenics were more impaired even when they were similar in chronicity and severity.