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Background: People with post-traumatic stress disorder (PTSD) exhibit negative cognitions, predictive of PTSD severity. The Post-Traumatic Cognitions Inventory (PTCI) is a widely used instrument measuring trauma-related cognitions and beliefs with three subscales: negative thoughts of self (SELF), negative cognitions about the world (WORLD), and self-blame (BLAME). Aims: The current study attempted to validate the use of the PTCI in people with serious mental illness (SMI), who have greater exposure to trauma and elevated rates of PTSD, using confirmatory factor analysis (CFA) and examining convergent and divergent correlations with relevant constructs. Method: Participants were 432 individuals with SMI and co-occurring PTSD diagnosis based on the Clinician Administered PTSD Scale, who completed PTCI and other clinical ratings. Results: CFAs provided adequate support for Foa’s three-factor model (SELF, WORLD, BLAME), and adequate support for Sexton’s four-factor model that also included a COPE subscale. Both models achieved measurement invariance at configural, metric and scalar levels for three diagnostic groups: schizophrenia, bipolar and major depression, as well as for ethnicity (White vs Black), and gender (male vs female). Validity of both models was supported by significant correlations between PTCI subscales, and self-reported and clinician assessed PTSD symptoms and associated symptoms. Conclusions: Findings provide support for the psychometric properties of the PTCI and the conceptualization of Sexton’s four-factor and Foa’s three-factor models of PTCI among individuals diagnosed with SMI (Foa et al., 1999).

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.

Individuals with mental health challenges are at particularly high risk of experiencing negative outcomes (e.g., worsening of mental health, increased risk of mortality) due to the coronavirus disease (COVID-19) pandemic. Peer specialists may have the benefit of several protective factors, including higher levels of social support and better illness self-management skills that buffer against negative effects of the pandemic. In this study, we compared the differences in the impact of COVID-19 on those trained as peer specialists (e.g., certified peer specialists, recovery coaches) to those not trained in this role.Participants with self-reported mental health and/or substance use challenges completed an online survey to collect information on their experiences during COVID-19 (Epidemic-Pandemic Impacts Inventory [EPII]), loneliness (3-item Loneliness Scale), and access to and satisfaction with mental health support. Respondents self-identified as peer specialists or not.One hundred seventy-three U.S. resident participants from 23 states were included in the final analysis: 109 were peer specialists and 64 were nonpeer specialists. Those who were trained as peer specialists reported fewer negative outcomes during the pandemic, including less disruption in employment, less loneliness, and less worsening of mental health, while reporting more positive attitudes in the face of difficulties. Peer specialists were also likely to report more access to and satisfaction with mental health services.Possibly as a function of their role, peer specialists reported better mental health outcomes during COVID-19, providing key, empirical evidence to support the benefits of helping others. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Virtual Reality Job Interview Training (VR-JIT) is a computerized interview simulator with efficacy at enhancing interview skills and employment outcomes. A randomized controlled trial assessed VR-JIT effectiveness for participants in individual placement and support (IPS), in which approximately 55% of individuals with serious mental illness obtain employment.Ninety participants with serious mental illness were randomly assigned to IPS+VR-JIT (N=54) or IPS as usual (N=36), completing pretest-posttest assessments and an employment evaluation at 9 months. Intent-to-treat chi-square analysis, multivariable logistic regression, Cox proportional hazards models, and mixed-effects linear regressions were conducted. Fifty-one percent were IPS nonresponders (i.e., no employment within the first 90 days of IPS).IPS+VR-JIT participants did not have significantly higher employment rates, compared with IPS-as-usual participants (43% versus 28%). IPS nonresponders (N=46) in the IPS+VR-JIT group had greater odds of obtaining employment (odds ratio [OR]=5.82, p=0.014) and shorter time to employment (hazard ratio=2.70, p=0.044) compared with IPS nonresponders in the IPS-as-usual group. Intent-to-treat mixed-effects linear analyses indicated that IPS+VR-JIT, compared with IPS as usual, significantly improved interview skills (p=0.006), interview confidence (p=0.013), and interview anxiety (p=0.019).VR-JIT's potential benefits (increased employment in a shorter time) appeared to be specific to IPS nonresponders, whereas employment outcomes for recent IPS enrollees were not affected. VR-JIT could be a valuable resource for employment specialists to support IPS nonresponders, because 47% of participants engaged in mock interview training with their specialist. Future research should focus on evaluating the effectiveness and implementation of VR-JIT among IPS nonresponders.

To examine long-term effects of early intervention services (EIS) for first-episode psychosis, we compared Heinrichs-Carpenter Quality of Life (QLS) and Positive and Negative Syndrome Scale (PANSS) scores and inpatient hospitalization days over 5 years with data from the site-randomized RAISE-ETP trial that compared the EIS NAVIGATE (17 sites; 223 participants) and community care (CC) (17 sites; 181 participants). Inclusion criteria were: age 15–40 years; DSM-IV diagnoses of schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, or psychotic disorder not otherwise specified; first psychotic episode; antipsychotic medication taken for ≤6 months. NAVIGATE-randomized participants could receive NAVIGATE from their study entry date until NAVIGATE ended when the last-enrolled NAVIGATE participant completed 2 years of treatment. Assessments occurred every 6 months. 61% of participants had assessments conducted ≥2 years; 31% at 5 years. Median follow-up length was CC 30 months and NAVIGATE 38 months. Primary analyses assumed data were not-missing-at-random (NMAR); sensitivity analyses assumed data were missing-at-random (MAR). MAR analyses found no significant treatment-by-time interactions for QLS or PANSS. NMAR analyses revealed that NAVIGATE was associated with a 13.14 (95%CI:6.92,19.37) unit QLS and 7.73 (95%CI:2.98,12.47) unit PANSS better improvement and 2.53 (95%CI:0.59,4.47) fewer inpatient days than CC (all comparisons significant). QLS and PANSS effect sizes were 0.856 and 0.70. NAVIGATE opportunity length (mean 33.8 (SD = 5.1) months) was not associated (P = .72) with QLS outcome; duration of untreated psychosis did not moderate (P = .32) differential QLS outcome. While conclusions are limited by the low rate of five-year follow-up, the data support long-term benefit of NAVIGATE compared to community care.

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.

Psychosocial functioning impairment is prevalent in first-episode psychosis and chronic schizophrenia. The Quality of Life Scale (QLS) is a widely used tool to measure psychosocial functioning; however, given the overlap between negative symptoms and functioning, along with the QLS being conceptualized initially as a measure of the deficit syndrome, it is unclear whether summing QLS items into a total score is an appropriate measure of overall psychosocial functioning. This study aimed to examine the centrality of QLS items and the appropriateness of using a QLS total score. Participants with first-episode psychosis (n = 404) completed the QLS. Item centrality was assessed using a network analysis approach, while reliability and dimensionality of the QLS total score and subscales were measured using bifactor modeling and related psychometric indices. Network analysis results showed that an item relating to motivation was the most central item within the scale. Moreover, bifactor modeling results found that motivation and other items relating to negative symptoms may reflect the QLS total score more strongly than other functioning (i.e., Interpersonal, Instrumental) domains. Based on these findings, we urge researchers to use caution when using a QLS total score, as it may unequally confound functional domains and motivation. Moreover, our results continue to underscore the importance of negative symptoms, particularly motivational impairment, in psychosocial functioning. Future studies should aim to examine the centrality of other functioning measures in psychosis and schizophrenia, as our results suggest that psychosocial functioning may be greatly influenced by motivation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Author(s): Srivastava, Akanksha; Miller, Alexandria N; Coles, Mandy S; Brigham, Rebecca; Peterson, Erin R; Kreida, Ellen; Mueser, Kim T; Ng, Lauren C

Evidence-based lifestyle interventions tailored to young adults with serious mental illness are needed to reduce their cardiometabolic risk. This study evaluated the effectiveness of a group lifestyle intervention ("PeerFIT") enhanced with mobile health (mHealth) compared with one-on-one mHealth coaching (basic education supported by activity tracking [BEAT]) for young adults with serious mental illness who were overweight or obese.Participants were young adults ages 18-35 years with serious mental illness and a body mass index ≥25 kg/mParticipants were 150 young adults with a mean ± SD body mass index of 37.1±7.4. Intent-to-treat analyses revealed no significant between-group difference for weight-loss, CRF, or CVD outcomes at 6 and 12 months. Participants in both conditions achieved clinically significant CVD risk reduction, weight loss, and CRF from baseline to 6 and 12 months, and all these improvements were statistically significant (p0.01).The PeerFIT group lifestyle intervention was not superior to one-on-one mHealth coaching in achieving clinically significant changes in weight, CRF, and CVD risk reduction. Although both interventions improved outcomes, low-intensity mHealth coaching may be a more scalable approach for addressing modifiable cardiometabolic risk factors among young adults with serious mental illness.

BackgroundOver the past 10 years, job interview training has emerged as an area of study among adults with schizophrenia and other serious mental illnesses who face significant challenges when navigating job interviews. The field of mental health services research has limited access to assessments of job interview skills with rigorously evaluated psychometric properties.ObjectiveWe sought to evaluate the initial psychometric properties of a measure assessing job interview skills via role-play performance.MethodsAs part of a randomized controlled trial, 90 adults with schizophrenia or other serious mental illnesses completed a job interview role-play assessment with eight items (and scored using anchors) called the mock interview rating scale (MIRS). A classical test theory analysis was conducted including confirmatory factor analyses, Rasch model analysis and calibration, and differential item functioning; along with inter-rater, internal consistency, and test-retest reliabilities. Pearson correlations were used to evaluate construct, convergent, divergent, criterion, and predictive validity by correlating the MIRS with demographic, clinical, cognitive, work history measures, and employment outcomes.ResultsOur analyses resulted in the removal of a single item (sounding honest) and yielded a unidimensional total score measurement with support for its inter-rater reliability, internal consistency, and test-retest reliability. There was initial support for the construct, convergent, criterion, and predictive validities of the MIRS, as it correlated with measures of social competence, neurocognition, valuing job interview training, and employment outcomes. Meanwhile, the lack of correlations with race, physical health, and substance abuse lent support for divergent validity.ConclusionThis study presents initial evidence that the seven-item version of the MIRS has acceptable psychometric properties supporting its use to assess job interview skills reliably and validly among adults with schizophrenia and other serious mental illnesses.Clinical Trial RegistrationNCT03049813.

Motor functioning in persons with serious mental illness (SMI) is not well studied. We assessed motor functioning in people with SMI (

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

This study aimed to identify factors associated with implementation of cognitive behavioral social skills training (CBSST) on assertive community treatment (ACT) teams in a large public sector behavioral health system. This study used concept mapping (a mixed-method approach) and involved a sample including diverse stakeholder participants including patients, ACT team members, team leaders, organization leaders, and system leaders. We identified 14 distinct issues related to implementing CBSST on ACT teams: (a) CBSST fit with ACT structure, (b) CBSST fit with ACT process, (c) provider perceptions about CBSST, (d) staff pressures/other demands; (e) CBSST and ACT synergy, (f) client characteristics, (g) benefits of CBSST, (h) coordination/interaction among ACT providers, (i) government/regulatory factors, (j) integration of CBSST into ACT, (k) training support, (l) training resources, (m) multilevel agency leadership, and (n) provider characteristics. Each of these dimensions were rated in regard to importance and changeability with the top 5 rated dimensions including effective training support; alignment of leadership across levels of the community-based organizations delivering services; perceived benefits of CBSST, CBSST and ACT synergy; and provider perceptions of CBSST. The most critical issues for CBSST implementation on ACT teams should be addressed in future studies. Implementation strategies that capitalize on enhancing leadership and organizational climate hold promise to address all of these issues. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Mental health clients with serious mental illness in urban settings experience multiple chronic stresses related to poverty, unemployment, discrimination, homelessness, incarceration, hospitalization, posttraumatic stress disorder, pain syndromes, traumatic brain injury, and other problems. Substance use disorder exacerbates these difficulties. This study examined the efficacy of algorithm-driven substance use disorder treatments for 305 inner-city mental health clients with multiple challenges. Researchers assessed substance use quarterly using a combination of standardized self-reports and case manager ratings. Of the 305 multiply impaired clients who began treatment, 200 (66%) completed 2 years of treatment. One fourth (n = 53) of the completers were responders who developed abstinence and improved community function; one half (n = 97) were partial responders, who reduced substance use but did not become abstinent; and one fourth (n = 50) were nonresponders. Evidence-based interventions for substance use disorder can be effective for multiply impaired, inner-city clients, but numerous complications may hinder recovery.

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.

African Americans are at increased risk for trauma exposure and the development of posttraumatic stress disorder (PTSD) relative to other racial groups. Among African Americans with Serious Mental Illness (SMI), PTSD is frequently underdiagnosed and untreated. The primary objective of this study was to investigate trauma exposure, PTSD symptom severity, and the rate of undocumented PTSD in medical records among African Americans diagnosed with SMI.Screening for trauma exposure and PTSD symptoms was implemented among 404 clients receiving community mental health services. Participants endorsed at least 1 traumatic event, had a score of at least 45 on the DSM-IV PTSD Checklist indicating probable PTSD, and had a chart diagnosis of an Axis I disorder.Around 18.3% of participants had PTSD diagnosed in their medical chart. A diagnosis of schizophrenia/schizoaffective disorder was inversely related to the detection of PTSD in the chart. Client age and gender did not adversely affect the detection of PTSD, and detection rates remained low overall. Childhood sexual abuse was the most commonly endorsed index trauma, followed closely by sudden death of a loved one (including violent death). Participants typically experienced an average of 8 types of traumatic events in their lifetime. Cumulative total trauma exposure significantly predicted PTSD severity. Clients with mood disorders reported more severe PTSD.Findings highlight the low detection rate of PTSD and related symptoms in African American clients with SMI. There is a need for early intervention, grief counseling, culturally sensitive trauma screening, and culturally informed treatment options for this population. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Background Schizophrenia and related disorders are highly disabling and create substantial burdens for families, communities, and health care systems. Although pharmacological treatments can often lessen the psychotic symptoms that are a hallmark of schizophrenia, they do not lessen the social and cognitive deficits that create the greatest impediments to community engagement and functional recovery. This study builds on prior research on psychosocial rehabilitation by comparing the effectiveness of two treatments demonstrated as efficacious in improving social and community functioning, Cognitive Enhancement Therapy (CET) and a version of Social Skills Training (HOPES/SST). Methods The study uses a randomized cluster design in which a pair of clinicians at community- and hospital-based mental service centers deliver either CET or HOPES to at least one group of 6-8 eligible clients for 12 months. Clinicians are trained and then supervised weekly, with ongoing process measurement of treatment fidelity, attendance, satisfaction, and retention, and use of other services. Measures administered at baseline and at 6 and 12 months while in treatment, and then at 18 and 24 months after treatment include social adjustment, quality of life, social skills, positive and negative symptoms, and neuro- and social cognition. We hypothesize that CET will be associated with greater improvements than SST in both the primary outcome of community functioning and the secondary outcomes of neuro- and social cognition and social skills. Secondarily, we hypothesize that more cognitive impairment at baseline and younger age will predict more benefit from CET compared to HOPES. Discussion Resource shortages endemic in mental health services and exacerbated by the pandemic highlight the importance of identifying the most effective approach to improving social and community functioning. We aim to improve understanding of the impact of two efficacious psychosocial treatments and to improve clinicians’ ability to refer to both treatments the individuals who are most likely to benefit from them. We expect the result to be programmatic improvements that improve the magnitude and durability of gains in community functioning. Trial registration ClinicalTrial.gov NCT04321759, registered March 25, 2020.

Self-efficacy (belief in one’s ability to complete activities or manage symptoms) is often poor in people with schizophrenia. Low self-efficacy is associated with negative symptoms and neurocognition which, together, may worsen psychosocial functioning. This study explores causal patterns between these variables by assessing their temporal associations and their combined role in predicting functioning using cross-sectional and longitudinal data. This study is a secondary analysis of data from 103 older adults with schizophrenia-spectrum disorders engaged in a randomized controlled trial (Helping Older People Experience Success or Treatment As Usual). Cross-sectional and longitudinal measures included neurocognition, positive and negative symptoms, self-efficacy, and three measures of functioning (Independent Living Skills Survey [ILSS], The Multnomah Community Ability Scale (MCAS), University of California, San Diego Performance-Based Skills Assessment [UPSA]). Self-efficacy was associated with self-reported functional skills (ILSS) only. The impact of self-efficacy on functioning was partially mediated by negative symptoms. This mediation was also present when predicting functioning at one year, unaffected when depression and positive symptoms were controlled. This study suggests direct and indirect effects of self-efficacy, via negative symptoms, on functioning in older adults with schizophrenia. Self-efficacy and negative symptoms should be intervention targets to improve functional difficulties in older adults with schizophrenia.

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.

Research on employment in people with severe mental illnesses (SMI) in developing countries is sparse and largely limited to employment rates. We conducted a comprehensive study of work, interest in work, and perceived benefits and barriers to work in people with SMI in India. Semi-structured interviews were conducted with 550 individuals with SMI receiving private psychiatric outpatient services in two districts in western India, one urban (Pune) and the other rural (Ahmednagar). More than half of the participants were employed, with significantly more men working (79.4%) than women (35.9%). Higher rates of work were found in rural areas (77.8%), where most work was in family agricultural businesses, than in urban areas (48.9%), where most work was for independent employers. Participants in rural areas worked fewer hours and earned less money, and reported fewer benefits and fewer problems related to work than urban participants. Over 45% of participants working for independent employers found jobs with help from families and extended social networks. Most unemployed participants wanted to work, and desired a variety of supports, including assistance with job finding and illness management. Gender-specific social role expectations and families play an important role in work in people with SMI in India. Despite higher rates of work in this sample than most studies from developed countries, a significant subgroup was unemployed but wanted to work. Persons with SMI in developing countries may benefit from the adaptation of validated vocational rehabilitation approaches in developed countries to their cultural context.

Diminished motivation (e.g., low drive, curiosity, and engagement in activities) is associated with robust impairment in psychosocial functioning in schizophrenia, yet even the most effective evidence-based interventions rarely effect meaningful change in motivation. Individual Resiliency Training (IRT) is a psychosocial treatment for individuals following a first episode of psychosis, supporting motivation through recovery goal setting and pursuit. The extent to which such an approach might improve motivation over time is unknown. We tested the impact of exposure to IRT modules focused on goal setting and attainment on motivation and functional outcomes among participants in the Recovery After an Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP). In the sample of 404 individuals with a first episode of psychosis receiving treatment across 34 community sites, we ran mixed-effect models with group (exposed to four or more goal-focused IRT sessions vs. Community Care (CC)), time (baseline, six- and 12-month follow-up), and the group-by-time interaction as predictors of motivation, role and social functioning. We also ran these analyses with those exposed to three or fewer goal-focused IRT sessions compared to CC. Controlling for gender, ethnicity, baseline cognition, and total number of outpatient mental health visits, exposure to four or more goal-focused IRT sessions was associated with greater improvements in motivation and role functioning compared to CC; effects were not observed for social functioning. Participants receiving three or fewer goal-focused IRT sessions did not differ from those in CC in these outcomes. Further, sensitivity analysis showed that general exposure to IRT was not associated with differential outcomes. Findings suggest that sufficient focus on recovery goal setting and support in psychosocial intervention for first-episode psychosis may have specific impact on motivation.

Neuropsychological functioning turns out to be a rate-limiting factor in psychiatry. However, little is known when comparing neuropsychological and psychosocial functioning in inpatients with schizophrenia or severe depression in their treatment pathways including add-on psychoeducation or the latter combined with cognitive behavioral therapy up to 2-year follow-up. To evaluate this question, we investigated these variables in two randomised controlled trials including 196 patients with DSM-IV schizophrenia and 177 patients with major depression. Outcome measures were assessed in the hospital at pre- and posttreatment and following discharge until 2-year follow-up. We focused on neuropsychological and psychosocial functioning regarding its differences and changes over time in data of two pooled trials. There were significant time effects indicating gains in knowledge about the illness, short and medium-term memory (VLMT) and psychosocial functioning (GAF), however, the latter was the only variable showing a time x study/diagnosis interaction effect at 2-year follow-up, showing significant better outcome in depression compared to schizophrenia. Moderator analysis showed no changes in psychosocial and neuropsychological functioning in schizophrenia and in affective disorders due to age, duration of illness or sex. Looking at the rehospitalisation rates there were no significant differences between both disorders. Both groups treated with psychoeducation or a combination of psychoeducation and CBT improved in neuropsychological and psychosocial functioning as well as knowledge about the illness at 2-year follow-up, however, patients with major depression showed greater gains in psychosocial functioning compared to patients with schizophrenia. Possible implications of these findings were discussed. Electronic supplementary material The online version of this article (10.1007/s00406-020-01118-x) contains supplementary material, which is available to authorized users.

People with schizophrenia and schizoaffective disorder (SZ) often struggle with social impairment, including small social networks and loneliness. Limitations in social skills and reduced social motivation—effort to engage in social connection—are key contributors to social impairment. While evidence-based approaches to improving social outcomes are available, including social skills training and cognitive behavioral therapy for psychosis, ongoing access to these interventions is often limited. Mobile technologies, including smartphone applications (apps), may address some of this need. In this paper, we describe the development of a smartphone app designed to address social skill and motivation deficits in SZ: the Motivation and Skills Support (MASS) app. We discuss the incorporation of stakeholder input into intervention design as well as results from usability pilot testing of the app in a sample of people with SZ. Finally, we describe next steps in the development and testing process of the MASS app.

Substance use is associated with poor outcomes for individuals with early psychosis. Community Reinforcement and Family Training (CRAFT) is an evidence-based approach that helps families to reduce substance use, engage in treatment, and improve family wellbeing, but it has not yet been studied for psychosis and substance use. The present study aimed to develop and evaluate a telehealth intervention utilizing CRAFT for families experiencing early psychosis and substance use. Twenty family members completed six to eight telehealth sessions of CRAFT adapted for early psychosis (CRAFT-EP). Participants completed an assessment battery at baseline, mid- and post-intervention, a three-month follow-up, surveys after each session, and a focus group to measure mean percentage of sessions completed, mean program satisfaction ratings, telehealth preference, and qualitative feedback. Participants had 100% session completion, and program satisfaction was at or near excellent for 99% of sessions. Half of participants preferred a primarily virtual hybrid program, whereas 45% preferred exclusively virtual visits. Communication was the most helpful topic, and participants requested additional written examples and resources. CRAFT-EP is feasible and acceptable to serve as the active intervention in a pilot randomized controlled trial comparing treatment as usual plus CRAFT-EP to treatment as usual.

PCL-5 is a self-report measure consisting of 20 items that are used to assess the symptoms of Post-Traumatic Stress Disorder (PTSD) according to the DSM-5.This study evaluated the factor structure of the Post-Traumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5) in people with serious mental illness.The sample in Study 1 included 536 participants with serious mental illness who were receiving supported employment services through community mental health agencies or supported housing programmes. Confirmatory factor analysis assessed the fit of six different models of PTSD.Results indicated that Armour's Hybrid 7-factor model composed of re-experiencing, avoidance, dysphoria, dysphoric arousal, anxious arousal, negative affect, anhedonia, and externalizing behaviours demonstrated the best fit. Study 2 found support for convergent validity for PCL-5 among 132 participants who met criteria for PTSD.Findings provide support for the psychometric properties of the PCL-5 and the conceptualization of the 7-factor hybrid model and the 4-factor DSM-5 model of PTSD among persons living with serious mental illness.

Background Organizational readiness is a known barrier to implementing evidence-based practices (EBPs) in community mental health services. A robust methodology for enhancing organizational readiness for implementation (ORI) has the potential to improve implementation outcomes of EBPs and ensure better services for people with a psychiatric disability. Prior work established a framework of implementation strategies targeting ORI enhancement by asking a group of implementation experts from various fields to categorize strategies from the “Expert Recommendations for Implementing Change” (ERIC) Project into three readiness stages, consistent with the pre-action stages of the Transtheoretical Model of behavioral change: Pre-contemplation, Contemplation, and Preparation. The current study provides initial confirmation and refinement to this expert-driven typology based on community mental health field experiences. Methods We conducted in-depth interviews with stakeholders involved in a recent EBP implementation project. Participants included staff (n=9) from four community mental health agencies and the implementation team who facilitated the project (n=3). Their pre-implementation experiences were compared with the experts’ typology to identify consistencies and discrepancies. Results The participants’ experiences were congruent with two thirds of the strategies identified by the experts for specific ORI stages. The refinements included 12 strategies used in additional stages beyond the experts’ classification, four strategies from the ERIC list that were not included in the ORI typology, and five new strategies. Conclusions This study provides initial confirmation and refinements to the previously published ORI typology. The results offer guidance as to how ORI could be enhanced in the community mental health field.

Limited research has been conducted on the long-term course of employment in people with severe mental illnesses (SMI) in developing countries such as India. To inform the development of culturally appropriate vocational services in India we prospectively evaluated work status, perceived benefits, and problems related to work in employed participants, and interest in work, barriers to work, and desired job supports among unemployed participants over a 1-year period.We conducted semistructured interviews with 150 individuals with SMI (90% schizophrenia-schizoaffective) receiving psychiatric outpatient services at a public hospital in an urban district in India at baseline and followed up 1 year later. One-hundred-and-seven participants (71.3%) completed the follow-up interviews.Work status (employed/unemployed) was consistent in 90.7% of participants, with 43.9% working at baseline and 49.5% working at follow-up. Participants who were working in the same job at both assessments were consistent in identifying several work-related problems (e.g., stress) as well as benefits (e.g., money). Interest in work among unemployed participants was consistent, with 78.8% interested at both assessments. Participants who were unemployed but interested in work consistently identified work barriers (e.g., cognitive difficulties) and desired job supports (e.g., assistance with job finding).Unemployment rates are moderately high and stable in people with SMI, with most unemployed participants consistently interested in working and desiring job supports. These findings, together with stable employment rates in working participants, suggest that supported employment developed for the Indian context could improve employment in people with SMI. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Digital mental health interventions, such as those provided by smartphone applications (apps), show promise as cost-effective approaches to increasing access to evidence-based psychosocial interventions for psychosis. Although it is well known that limited financial resources can reduce the benefits of digital approaches to mental healthcare, the extent to which cognitive functioning in this population could impact capacity to engage in and benefit from these interventions is less studied. In the current study we examined the extent to which cognitive functioning (premorbid cognitive abilities and social cognition) were related to treatment engagement and outcome in a standalone digital intervention for social functioning. Premorbid cognitive abilities generally showed no association with aggregated treatment engagement markers, including proportion of notifications responded to and degree of interest in working on app content, though there was a small positive association with improvements in social functioning. Social cognition, as measured using facial affect recognition ability, was unrelated to treatment engagement or outcome. These preliminary findings suggest that cognitive functioning is generally not associated with engagement or outcomes in a standalone digital intervention designed for and with people with schizophrenia spectrum disorders.

Individuals diagnosed with serious mental illness (SMI) have greater trauma exposure and are at increased risk for posttraumatic stress disorder (PTSD). However, PTSD is rarely documented in their clinical records. This study investigated the predictors of PTSD documentation among 776 clients with SMI receiving public mental health services, who had probable PTSD as indicated by a PTSD Checklist score of at least 45. Only 5.3% of clients had PTSD listed as a primary diagnosis, and 8.4% had PTSD as a secondary diagnosis, with a total 13.7% documentation rate. PTSD documentation rate was highest for clients with major depression (18.8%) compared to those with schizophrenia (4.1%) or bipolar disorder (6.3%). Factors that predicted a lower likelihood of having a chart diagnosis of PTSD included being diagnosed with schizophrenia/schizoaffective disorder or bipolar disorder. Factors that predicted a higher likelihood of having a chart diagnosis of PTSD included being of non-white race, being female, and experiencing eight or more types of traumatic events. Findings highlight the need for PTSD screening and trauma informed care for clients with SMI receiving public mental health services.

BACKGROUND Schizophrenia is a lifelong illness that requires long-term treatment and caregiving. Family psychoeducation (FP) has been shown to lessen caregiver burden, improve caregiver functioning, and improve outcomes in patients. However, the impact of FP delivered specifically to caregivers on patient outcomes has not been well explored, particularly for early schizophrenia. Furthermore, there is a lack of research examining the benefits of telehealth-based psychoeducation for caregivers on either patient or caregiver outcomes. OBJECTIVE The Family Intervention in Recent-Onset Schizophrenia Treatment (FIRST) study is a randomized controlled trial of patients with schizophrenia spectrum disorders and their caregivers, which is designed to evaluate the effect of telehealth-based, caregiver-focused, study-provided psychoeducation versus usual care (UC) on patient treatment failure (TF). The impact of study-provided psychoeducation on caregiver burden is also investigated. METHODS Eligible patients and their designated caregivers were randomly assigned to either the study-provided psychoeducation (≤16 sessions of telehealth-based psychoeducation over 6 months) or UC group, stratified by antipsychotic treatment (paliperidone palmitate or oral antipsychotic). The major TF events (ie, psychiatric hospitalization or intervention, arrest or incarceration, and suicide attempts) were assessed at 3, 6, and 12 months after baseline. A proportional means model using mean cumulative function was used to assess between-group differences in the mean cumulative number of TF events over 12 months. Caregiver burden was assessed using the Involvement Evaluation Questionnaire and 12-item Short Form Health Survey. RESULTS A total of 148 pairs of participants were enrolled in the study, of whom 96 (64.9%) patients and 94 (63.5%) caregivers completed the 12-month follow-up. The mean number of sessions in the study-provided psychoeducation group was 7.7 (SD 5.9). No differences were observed between the study-provided psychoeducation and UC groups in patient outcomes (rates of TF: 70% vs 67%; P=.90) or measures of caregiver burden (assessment of caregiver distress and physical and mental health). However, post hoc analyses revealed lower relapse rates in patients who received paliperidone palmitate than in those who received oral antipsychotics at all time points. Although the FIRST study did not meet the primary end point, several key lessons were identified to inform future caregiver-focused, telehealth-based FP interventions. Lack of study-provided psychoeducation, focus on caregiver-only intervention, difficulties with enrollment, and caregiver–treatment team coordination may have affected the outcomes of the FIRST study. CONCLUSIONS Key insights from the FIRST study suggest the potential importance of supporting sufficient caregiver engagement; communication between clinicians, patients, and family members regarding treatment plans; and solidifying the relationship between clinicians providing psychoeducation to the caregiver and patient treatment team. CLINICALTRIAL ClinicalTrials.gov NCT02600741; http://clinicaltrials.gov/ct2/show/NCT02600741

Background Schizophrenia is a lifelong illness that requires long-term treatment and caregiving. Family psychoeducation (FP) has been shown to lessen caregiver burden, improve caregiver functioning, and improve outcomes in patients. However, the impact of FP delivered specifically to caregivers on patient outcomes has not been well explored, particularly for early schizophrenia. Furthermore, there is a lack of research examining the benefits of telehealth-based psychoeducation for caregivers on either patient or caregiver outcomes. Objective The Family Intervention in Recent-Onset Schizophrenia Treatment (FIRST) study is a randomized controlled trial of patients with schizophrenia spectrum disorders and their caregivers, which is designed to evaluate the effect of telehealth-based, caregiver-focused, study-provided psychoeducation versus usual care (UC) on patient treatment failure (TF). The impact of study-provided psychoeducation on caregiver burden is also investigated. Methods Eligible patients and their designated caregivers were randomly assigned to either the study-provided psychoeducation (≤16 sessions of telehealth-based psychoeducation over 6 months) or UC group, stratified by antipsychotic treatment (paliperidone palmitate or oral antipsychotic). The major TF events (ie, psychiatric hospitalization or intervention, arrest or incarceration, and suicide attempts) were assessed at 3, 6, and 12 months after baseline. A proportional means model using mean cumulative function was used to assess between-group differences in the mean cumulative number of TF events over 12 months. Caregiver burden was assessed using the Involvement Evaluation Questionnaire and 12-item Short Form Health Survey. Results A total of 148 pairs of participants were enrolled in the study, of whom 96 (64.9%) patients and 94 (63.5%) caregivers completed the 12-month follow-up. The mean number of sessions in the study-provided psychoeducation group was 7.7 (SD 5.9). No differences were observed between the study-provided psychoeducation and UC groups in patient outcomes (rates of TF: 70% vs 67%; P=.90) or measures of caregiver burden (assessment of caregiver distress and physical and mental health). However, post hoc analyses revealed lower relapse rates in patients who received paliperidone palmitate than in those who received oral antipsychotics at all time points. Although the FIRST study did not meet the primary end point, several key lessons were identified to inform future caregiver-focused, telehealth-based FP interventions. Lack of study-provided psychoeducation, focus on caregiver-only intervention, difficulties with enrollment, and caregiver–treatment team coordination may have affected the outcomes of the FIRST study. Conclusions Key insights from the FIRST study suggest the potential importance of supporting sufficient caregiver engagement; communication between clinicians, patients, and family members regarding treatment plans; and solidifying the relationship between clinicians providing psychoeducation to the caregiver and patient treatment team. Trial Registration ClinicalTrials.gov NCT02600741; http://clinicaltrials.gov/ct2/show/NCT02600741

The aim of this study was to adapt Acceptance and Commitment Therapy for Inpatients (ACT-IN) for implementation in a typical hospital setting to prepare for a larger clinical trial. The sample consisted of 26 inpatients diagnosed with psychotic-spectrum disorders. Using an open trial design, patients received individual and group ACT-IN sessions during their stay. We assessed the feasibility/acceptability of ACT-IN and preliminary changes on patient outcomes at baseline, discharge, and 4-month follow-up. We successfully recruited and retained participants as planned. Patients reported satisfaction with treatment, and routine hospital staff showed adoption and fidelity to the intervention. Relative to baseline, patients demonstrated significant improvements in symptoms and functioning across the 4-month follow-up. The current study shows that ACT-IN may be feasible and acceptable for inpatients with psychotic disorders in a psychiatric intensive care setting and should be tested in a future effectiveness-implementation trial.

Objective To evaluate the relationships between perceived stigma and duration of untreated psychosis (DUP), demographic characteristics, and clinical and psychosocial functioning in persons with a first episode of psychosis (FEP). Method A total of 399 participants with FEP presenting for treatment at 34 sites in 21 states throughout the United States were evaluated using standardized instruments to assess diagnosis, symptoms, psychosocial functioning, perceived stigma, wellbeing, and subjective recovery. Results Perceived stigma was correlated with a range of demographic and clinical variables, including DUP, symptoms, psychosocial functioning, and subjective experience. After controlling for symptom severity, perceived stigma was related to longer DUP, schizoaffective disorder diagnosis, more severe depression, and lower wellbeing and recovery. The associations between stigma and depression, wellbeing, and recovery were stronger in individuals with long than short DUP, suggesting the effects of stigma on psychological functioning may be cumulative over the period of untreated psychosis. Conclusion The findings suggest that independent of symptom severity, perceived stigma may contribute to delay in seeking treatment for FEP, and this delay may amplify the deleterious effects of stigma on psychological functioning. The results point to the importance of reducing DUP and validating interventions targeting the psychological effects of stigma in people with FEP.

Objectives: The integration of behavioral health and primary care services may be a way to reduce racial and ethnic inequities in medical and behavioral health care services and outcomes fo...

Objective The therapeutic alliance has long been considered an essential part of treatment. Despite a large body of work examining the alliance-outcome relationship, very few studies have examined it within individuals with first episode psychosis (FEP). Method The present study examined the alliance at Session 3, 4, or 5 and its relationship to 2-year treatment outcomes and therapy participation in a sample of 144 FEP clients who received specialized FEP treatment at U.S. clinics. Furthermore, we examined between-therapist and within-therapist (client) effects of the alliance on outcomes. Results Results indicated that a better alliance was related to improved mental health recovery, psychological well-being, quality of life, total symptoms, negative symptoms, and disorganized symptoms at the end of treatment. In addition, the between-therapist effect of the alliance was significantly related to better mental health recovery whereas the within-therapist (client) effect of the alliance was related to better quality of life, total symptoms, and negative symptoms at the end of treatment. Conclusions A stronger alliance was related to improved treatment outcomes in FEP. Future work should consider examining mediators of the alliance-outcome relationship as well as how changes in the alliance relate to changes in outcomes over time. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Cognitive remediation is aimed at reducing cognitive impairments in severe mental illnesses such as schizophrenia, but little is known about whether severity of cognitive impairment predicts benefit from this intervention. To address this question, this study aggregated data from five randomized controlled trials (N = 300) of a standardized comprehensive, multimodal outpatient cognitive remediation program, the Thinking Skills for Work program, and evaluated whether baseline level of cognitive impairment differentially predicted improvement in cognitive functioning following cognitive remediation vs. usual services. Using standardized scores of neuropsychological functioning to designate “low average,” “moderate,” and “severe” levels of cognitive impairment, participants with greater cognitive impairment were found to benefit differentially more from cognitive remediation than usual services compared to less cognitively impaired participants. The findings were unaffected by statistically controlling for participant demographic and clinical characteristics. The findings suggest that individuals with the greatest cognitive impairment, for whom cognitive remediation was developed, are also most likely to benefit from this intervention.

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.