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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.

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.

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.

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.

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.

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.

Objective Cognitive compensatory interventions aim to alleviate psychosocial disability by targeting functioning directly using aids and strategies, thereby minimizing the impact of cognitive impairment. The aim was to conduct a systematic review and meta-analysis of cognitive compensatory interventions for psychosis by examining the effects on functioning and symptoms, and exploring whether intervention factors, study design, and age influenced effect sizes. Methods Electronic databases (Ovid Medline, PsychINFO) were searched up to October 2018. Records obtained through electronic and manual searches were screened independently by two reviewers according to selection criteria. Data were extracted to calculate estimated effects (Hedge’s g) of treatment on functioning and symptoms at post-intervention and follow-up. Study quality was assessed using Cochrane Collaboration’s risk of bias tool. Results Twenty-six studies, from 25 independent randomized controlled trials (RCTs) were included in the meta-analysis (1654 participants, mean age = 38.9 years, 64% male). Meta-analysis revealed a medium effect of compensatory interventions on functioning compared to control conditions (Hedge’s g = 0.46, 95% CI = 0.33, 0.60, P Conclusion Cognitive compensatory interventions are associated with robust, durable improvements in functioning in people with psychotic illnesses.

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).

Aim 100% of Abdominal x-ray (AXR) requests in the trust should be compliant with iRefer guidelines. Therefore, with this audit we hope to evaluate the compliance of our hospitals with said guidelines. Method This audit was retrospective with AXRs taken between 23 – 29th of November 2020 being analysed for compliance creating our first loop. On the 1st of December we placed our intervention. This came in the form of educational posters in the four areas that request the majority of AXRs. Following this, a further weeks’ worth of AXRs were assessed for compliance between 2nd – 8th of December 2020. Results Between 23-29/11/20 there were 67 AXRs requested. Eight of these were excluded according to our exclusion criteria, leaving a total of 59 AXRs to be assessed. After reviewing the request cards for these AXRs, 17 were non-compliant (28.8%). Following the intervention, AXR requests were re-audited. Between 2-8/12/20 there were 69 AXRs requested. Six were excluded leaving a total of 63 AXRs to be assessed. After review, 22 were non-compliant (34.9%) Conclusions In both loops of this audit, the standard of 100% compliance with iRefer guidelines was not met. There was a high percentage of non-compliance in both loops with a rate of 28.8% and 34.9% respectively – a decrease in compliance. One possible reason to account for this was due the changeover of Junior Doctors within the trust on 2/12/20. Our interventional posters were placed in only half of the Trusts hospitals which may also account for the decrease in compliance.

Purpose Ensuring safety within RT is of paramount importance. To further support and augment patient safety efforts, the purpose of this research was to test and refine a robust methodology for analyzing human errors that defeat individual controls within RT quality assurance (QA) programs. Methods The method proposed for performing Bowtie Analysis (BTA) was based on training and recommendations from practitioners in the field of Human Factors and Ergonomics practice. Multidisciplinary meetings to iteratively develop BTA focused on incorrect site setup instructions was conducted. Results From November 2015 to February 2017, we had 12 reported incidents related to site setup notes that could have led to site setup errors. Based on this data, we conducted five BTA analyses related to incorrect site setup instructions. None of the individual controls within our QA program designed to check for potential errors with site setup instructions met the level of robustness to be classified as key safeguards or barriers. Conclusions The relatively low number of incidents causing patient harm has led us to typically assume that we have sufficient and effective controls in place to prevent serious human errors from leading to severe patient consequences. Based on our BTA, we question how well we truly understand the details of our individual controls. To meet the level of safety achieved by high reliability organizations (HROs), we need to better ensure that our controls are as reliable and robust as we assume.

OBJECTIVE: In people with severe mental illnesses, neuropsychological abilities may contribute to vocational outcomes, such as job attainment, job tenure, and wages earned. The current study aimed to determine the strongest neuropsychological and other modifiable predictors of work outcomes in 153 people with severe mental illness (38% schizophrenia, 24% bipolar disorder, 38% major depression) who participated in a two-year supported employment study. METHODS: Assessments of neuropsychological performance, functional capacity, social skills, and psychiatric symptom severity were administered at baseline; work outcomes (job attainment, weeks worked, and wages earned) were collected weekly for two years. RESULTS: Independent of education, diagnosis, and estimated intellectual functioning, more recent work history and less severe negative symptoms significantly predicted job attainment during the two-year study. Among the 47% who obtained jobs, better global neuropsychological performance (i.e., lower global deficit score) was a significant predictor of greater weeks worked. Both global neuropsychological performance and more recent work history predicted higher wages earned. CONCLUSION: Modifiable predictors of supported employment outcomes included cognitive functioning and negative symptom severity; thus, interventions to improve these factors may improve work outcomes and decrease the loss of productivity associated with severe mental illness.

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.

Background Preliminary evidence suggests that aerobic exercise may augment the effects of cognitive remediation on improving cognitive functioning in severe mental illness. It has also been hypothesized that increases in cognitive functioning associated with adding exercise are mediated by increases in brain derived neurotrophic factor (BDNF). However, rigorous controlled trials are lacking. Methods A randomized controlled trial was conducted to explore whether adding a 30-h aerobic exercise program over 10 weeks to an equally intensive cognitive remediation program (CR + E) improved cognitive functioning more than cognitive remediation alone (CR-Only). Thirty-four participants with schizophrenia or bipolar disorder were randomly assigned to CR + E or CR-Only, and cognitive functioning was assessed at baseline and post-treatment. Total and mature BDNF were measured in blood serum at baseline, Week-5 pre- and post-exercise, and Week-10 pre- and post-exercise. Results Participants in both conditions had high levels of engagement in the interventions and improved significantly in cognitive functioning, but did not differ in amount of cognitive change. The groups also did not differ in changes in BDNF from pre-to post-exercise at Weeks 5 or 10, nor in resting BDNF levels. Exploratory analyses indicated that higher body mass index (BMI) significantly predicted attenuated improvement in cognitive functioning for both groups. Discussion Exercise did not augment the effects of cognitive remediation in persons with severe mental illness, possibly because the cognitive remediation program resulted in strong gains in cognitive functioning. Moderate aerobic exercise does not appear to reliably increase BDNF levels in persons with severe mental illness. ClinicalTrials.Gov Identifier NCT02326389.

We report velocity-delay maps for prominent broad emission lines, Ly_alpha, CIV, HeII and H_beta, in the spectrum of NGC5548. The emission-line responses inhabit the interior of a virial envelope. The velocity-delay maps reveal stratified ionization structure. The HeII response inside 5-10 light-days has a broad single-peaked velocity profile. The Ly_alpha, CIV, and H_beta responses peak inside 10 light-days, extend outside 20 light-days, and exhibit a velocity profile with two peaks separated by 5000 km/s in the 10 to 20 light-day delay range. The velocity-delay maps show that the M-shaped lag vs velocity structure found in previous cross-correlation analysis is the signature of a Keplerian disk with a well-defined outer edge at R=20 light-days. The outer wings of the M arise from the virial envelope, and the U-shaped interior of the M is the lower half of an ellipse in the velocity-delay plane. The far-side response is weaker than that from the near side, so that we see clearly the lower half, but only faintly the upper half, of the velocity--delay ellipse. The delay tau=(R/c)(1-sin(i))=5 light-days at line center is from the near edge of the inclined ring, giving the inclination i=45 deg. A black hole mass of M=7x10^7 Msun is consistent with the velocity-delay structure. A barber-pole pattern with stripes moving from red to blue across the CIV and possibly Ly_alpha line profiles suggests the presence of azimuthal structure rotating around the far side of the broad-line region and may be the signature of precession or orbital motion of structures in the inner disk. Further HST observations of NGC 5548 over a multi-year timespan but with a cadence of perhaps 10 days rather than 1 day could help to clarify the nature of this new AGN phenomenon., 19 pages, 9 figures, ApJ in press

We present geometric and dynamical modeling of the broad line region for the multi-wavelength reverberation mapping campaign focused on NGC 5548 in 2014. The dataset includes photometric and spectroscopic monitoring in the optical and ultraviolet, covering the H$\beta$, C IV, and Ly$\alpha$ broad emission lines. We find an extended disk-like H$\beta$ BLR with a mixture of near-circular and outflowing gas trajectories, while the C IV and Ly$\alpha$ BLRs are much less extended and resemble shell-like structures. There is clear radial structure in the BLR, with C IV and Ly$\alpha$ emission arising at smaller radii than the H$\beta$ emission. Using the three lines, we make three independent black hole mass measurements, all of which are consistent. Combining these results gives a joint inference of $\log_{10}(M_{\rm BH}/M_\odot) = 7.64^{+0.21}_{-0.18}$. We examine the effect of using the $V$ band instead of the UV continuum light curve on the results and find a size difference that is consistent with the measured UV-optical time lag, but the other structural and kinematic parameters remain unchanged, suggesting that the $V$ band is a suitable proxy for the ionizing continuum when exploring the BLR structure and kinematics. Finally, we compare the H$\beta$ results to similar models of data obtained in 2008 when the AGN was at a lower luminosity state. We find that the size of the emitting region increased during this time period, but the geometry and black hole mass remain unchanged, which confirms that the BLR kinematics suitably gauge the gravitational field of the central black hole., Comment: 26 pages, 19 figures, 1 table, accepted for publication in ApJ

The limited literature on employment in people with severe mental illnesses (SMI) in developing countries suggests higher rates than in developed countries. The present study explored rates and associated characteristics of work in people receiving public psychiatric services. Semi-structured interviews were conducted with 150 individuals with SMI (90% schizophrenia-spectrum) receiving public outpatient psychiatric services in an urban district in western India to evaluate employment. Forty percent of participants were employed, most for independent employers (86.7%), and were working an average of 53 hours/week. Earning money was reported as the primary motivation to work. A high proportion (92.2%) of unemployed participants wanted to work. Common barriers to work for unemployed participants who were interested in working were psychological (e.g., stress), mental illness (e.g., symptoms), and work-related factors (e.g., difficulty finding a job). Help finding a job and managing mental illness were the primary desired supports. Rates of employment in people with SMI living in urban areas in India are higher than in developed countries, but much lower than the general population. The high interest in work coupled with specific barriers and desired supports point to the need for vocational rehabilitation for improving the employment functioning of people with SMI in India.

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.

Individual Placement and Support (IPS) is an evidence-based model of supported employment for people with serious mental illness. We assessed the effects and relative contributions of predictors of employment among IPS recipients using measures of baseline client characteristics, local economic context, and IPS fidelity. A recent work history, less time on the Social Security rolls, greater cognitive functioning, and a lower local unemployment rate were associated with greater probability of employment. The ability of the model to discriminate between outcomes was limited, and substantial improvements in our understanding of IPS employment outcomes will require the study of novel client, environmental, and IPS implementation factors.

This study examined whether cognitive functioning was related to treatment outcomes in persons with severe mental illness who received a cognitive behavioral therapy (CBT) program for co-occurring posttraumatic stress disorder (PTSD). The study sample was drawn from a larger controlled trial of 108 persons with severe mental illness and PTSD comparing the effects of CBT with treatment as usual on PTSD and related outcomes, with assessments conducted at baseline, post-treatment, and 3- and 6-month follow-ups. Among the 54 persons in CBT, 49 were administered a neuropsychological battery at baseline and 40 were exposed to the CBT program. Statistical analyses of these 40 participants were conducted to evaluate whether cognitive functioning was related to participation in the CBT program, completion of homework assignments, and improvements in PTSD, and other outcomes. Cognitive functioning was not related to participation in CBT or completion of homework. Lower cognitive functioning predicted less learning of information about PTSD at post-treatment and follow-up, but not less clinical benefit from CBT in PTSD diagnosis or symptoms, other symptoms, or health. The results suggest that cognitive impairment does not attenuate response to the CBT for PTSD program in persons with severe mental illness. Clinical Trials.gov Identifier: NCT00053690.

PURPOSE/OBJECTIVE(S): Incident learning is key to developing and maintaining quality and safety in healthcare. This work aims to quantify how submissions to our incident learning system and contributing factors for events have changed in the time of COVID. MATERIALS/METHODS: Events from our incident learning system were analyzed for the 11 months pre-COVID (March 1, 2019 - January 31, 2020) and compared to 11 months during COVID (March 1, 2020 - January 31, 2021). Descriptive statistics were used to evaluate and compare the reporting rate, incident severity, contributing factors, and where in patient pathway the incident originated and was caught. RESULTS: See Table. CONCLUSION: During COVID the number of reported incidents, particularly incidents reaching the patient, markedly declined. This is perhaps related to a decline in the number of treatments delivered during COVID and the presence of new COVID-related workflows. The site of origin of the incidents was similar pre- vs. during-COVID. However, the locations where incidents were caught (detected) shifted to more near-'end of the line' safeguards (e.g., pre-RT Physics and RTT chart checks & write-up), suggesting a potential degradation of safeguards present earlier in the process (e.g., pre-RT peer review, Dosimetry pre-RT check). Communication, hand-offs, and cross-coverage were more likely to be contributing factors during COVID which is most likely attributable to people working virtually/remotely during the pandemic. This emphasizes the need to reduce inter-provider variations, and consistent standards for communication and treatment.

Purpose/Objective(s) The majority of errors during radiation therapy (RT) treatment planning and associated quality assurance (QA) processes are ascribed to ‘human error’. Most centers typically use in-house QA checklists but without formal human factors engineering evaluations. We herein comprehensively evaluate the perceived usability of a dosimetry-QA checklist and associated cognitive workload, performance, and patient safety in real clinical settings at an academic medical center. Materials/Methods Four dosimetrists (female = 2, male = 2) performed pre-treatment QA tasks on 76 different RT plans with varying degrees of difficulty (low (35), medium (35), and hard (6) based on subjective rating by physicists) in the clinic. For each plan, the perceived usability and workload were assessed using a variety of validated tools (see results). We compare these scores with the recommended standards in human-computer interaction and human factors and ergonomics. Performance was measured using the time taken to complete the QA tasks on 46 different RT plans. Patient safety was measured as the number of errors leading to patient harm. Results See Table 1. The perceived usability of the dosimetry-QA checklist meets only 1 out of 6 standards assessed. The workload assessments are within the recommended standards. The average time taken to complete pre-treatment QA tasks is 37.25 minutes. No errors leading to patient harm were reported. Conclusion Our institutional dosimetry-QA checklist has suboptimal usability, but the associated workload is acceptable. QA checklists should be evaluated for usability and redesigned to reduce the risk of human errors, which are likely, at least in part, to result from the use of sub optimally designed tools. Future studies evaluating the association between usability and workload of QA checklists with patient safety indicators may be helpful.

Neurocognitive impairment is prominent in schizophrenia and a significant predictor of poor occupational outcomes. Vocational rehabilitation (VR) is frequently implemented to counteract high unemployment rates. Individuals with schizophrenia however face numerous challenges such as neurocognitive impairments and psychotic symptoms. Hence, augmenting VR to address illness-related factors may optimize occupational outcomes. The aim of this study was to examine the effects of Cognitive Remediation (CR) combined with VR(CR + VR) compared to techniques from Cognitive Behavioral Therapy (CBT) combined with VR(CBT + VR) on neurocognition and occupational functioning over a 2 year period. A total of 131participants underwent assessment with the MATRICS Consensus Cognitive Battery (MCCB) at baseline, post treatment (after 10 months) and follow-up (2 years after randomization). Occupational status and number of hours worked were recorded at all assessment points. Both groups improved on several neurocognitive domains. All improvements were however in favor of the CR group. There was a significant increase in number of participants working and hours worked in both groups throughout the project period, with no between-group differences. Number of hours worked at follow-up was predicted by change in Working Memory and the Composite Score in the CR group. CR-augmented VR improved several domains, particularly Verbal Learning and Working Memory, which were central in the CR program. The combination of VR and CR or CBT thus enabled a significant proportion of participants to attain and maintain work.

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 In-person motivational interventions increase engagement with evidence-based cessation treatments among smokers with schizophrenia, but access to such interventions can be limited because of workforce shortages and competing demands in mental health clinics. The use of digital technology to deliver interventions can increase access, but cognitive impairments in schizophrenia may impede the use of standard digital interventions. We developed an interactive, multimedia, digital motivational decision support system for smokers with schizophrenia (Let’s Talk About Smoking). We also digitalized a standard educational pamphlet from the National Cancer Institute (NCI Education). Both were tailored to reduce cognitive load during use. OBJECTIVE We conducted a randomized trial of Let’s Talk About Smoking versus NCI Education to test whether the interactive motivational intervention was more effective and more appealing than the static educational intervention for increasing use of smoking cessation treatment, quit attempts, and abstinence among smokers with schizophrenia, accounting for the level of cognitive functioning. METHODS Adult smokers with schizophrenia (n=162) were enrolled in the study from 2014 to 2015, randomly assigned to an intervention condition, and assessed in person at 3- and 6-month follow-ups. Interventions were delivered on a laptop computer in a single session. All participants had access to standard, community-delivered cessation treatments during follow-up. Multivariate models were used to evaluate outcomes. RESULTS Treatment initiation outcomes were not different between intervention conditions (27/84 [32%] for Let’s Talk About Smoking vs 36/78 [46%] for NCI Education; odds ratio [OR] 0.71 [95% CI 0.37-1.33]); 38.9% (63/162) of participants initiated treatment. Older age (OR 1.03 [95% CI 1.00-1.07]; P=.05), higher education (OR 1.21 [95% CI 1.04-1.41]; P=.03), and fewer positive symptoms (OR 0.87 [95% CI 0.80-0.96]; P=.01) predicted cessation treatment initiation, whereas level of cognition did not. The mean satisfaction and usability index score was higher for Let’s Talk About Smoking versus NCI Education (8.9 [SD 1.3] vs 8.3 [SD 2.1]; t 120.7=2.0; P=.045). Quit attempts (25/84, 30% vs 36/78, 46%; estimate [Est]=−0.093, SE 0.48; P=.85) and abstinence (1/84, 1% vs 6/78, 7%; χ21=3.4; P=.07) were not significantly different between intervention conditions. Cognitive functioning at baseline (Est=1.47, SE 0.47; P=.002) and use of any behavioral or medication cessation treatment (Est=1.43, SE 0.47; P=.003) predicted quit attempts with self-reported abstinence over the 6-month follow-up. CONCLUSIONS The interactive, multimedia intervention was not more effective than the static, text-based intervention among smokers with schizophrenia. Both tailored digital interventions resulted in levels of treatment engagement and quit attempts that were similar to findings from previous studies of in-person interventions, confirming the potential role of digital interventions to educate and motivate smokers with schizophrenia to use cessation treatment and to quit smoking. These findings indicate that additional cessation treatment is needed after brief education or motivational interventions, and that cessation treatment should be adjusted for people with cognitive impairment. CLINICALTRIAL ClinicalTrials.gov NCT02086162; https://clinicaltrials.gov/show/NCT02086162

Background In-person motivational interventions increase engagement with evidence-based cessation treatments among smokers with schizophrenia, but access to such interventions can be limited because of workforce shortages and competing demands in mental health clinics. The use of digital technology to deliver interventions can increase access, but cognitive impairments in schizophrenia may impede the use of standard digital interventions. We developed an interactive, multimedia, digital motivational decision support system for smokers with schizophrenia (Let’s Talk About Smoking). We also digitalized a standard educational pamphlet from the National Cancer Institute (NCI Education). Both were tailored to reduce cognitive load during use. Objective We conducted a randomized trial of Let’s Talk About Smoking versus NCI Education to test whether the interactive motivational intervention was more effective and more appealing than the static educational intervention for increasing use of smoking cessation treatment, quit attempts, and abstinence among smokers with schizophrenia, accounting for the level of cognitive functioning. Methods Adult smokers with schizophrenia (n=162) were enrolled in the study from 2014 to 2015, randomly assigned to intervention condition, and assessed in person at 3- and 6-month follow-ups. Interventions were delivered on a laptop computer in a single session. All participants had access to standard, community-delivered cessation treatments during follow-up. Multivariate models were used to evaluate outcomes. Results Treatment initiation outcomes were not different between intervention conditions (27/84 [32%] for Let’s Talk About Smoking vs 36/78 [46%] for NCI Education; odds ratio [OR] 0.71 [95% CI 0.37-1.33]); 38.9% (63/162) of participants initiated treatment. Older age (OR 1.03 [95% CI 1.00-1.07]; P=.05), higher education (OR 1.21 [95% CI 1.04-1.41]; P=.03), and fewer positive symptoms (OR 0.87 [95% CI 0.80-0.96]; P=.01) predicted cessation treatment initiation, whereas level of cognition did not. The mean satisfaction and usability index score was higher for Let’s Talk About Smoking versus NCI Education (8.9 [SD 1.3] vs 8.3 [SD 2.1]; t120.7=2.0; P=.045). Quit attempts (25/84, 30% vs 36/78, 46%; estimate [Est]=−0.093, SE 0.48; P=.85) and abstinence (1/84, 1% vs 6/78, 7%; χ21=3.4; P=.07) were not significantly different between intervention conditions. Cognitive functioning at baseline (Est=1.47, SE 0.47; P=.002) and use of any behavioral or medication cessation treatment (Est=1.43, SE 0.47; P=.003) predicted quit attempts with self-reported abstinence over the 6-month follow-up. Conclusions The interactive, multimedia intervention was not more effective than the static, text-based intervention among smokers with schizophrenia. Both tailored digital interventions resulted in levels of treatment engagement and quit attempts that were similar to findings from previous studies of in-person interventions, confirming the potential role of digital interventions to educate and motivate smokers with schizophrenia to use cessation treatment and to quit smoking. These findings indicate that additional cessation treatment is needed after brief education or motivational interventions, and that cessation treatment should be adjusted for people with cognitive impairment. Trial Registration ClinicalTrials.gov NCT02086162; https://clinicaltrials.gov/show/NCT02086162.

The use of positron emission tomography (PET) in radiation therapy (RT) is rapidly increasing in the areas of staging, segmentation, treatment planning, and response assessment. The most common radiotracer is 18F-fluorodeoxyglucose ([ 18F]FDG), a glucose analog with demonstrated efficacy in cancer diagnosis and staging. However, diagnosis and RT planning are different endeavors with unique requirements, and very little literature is available for guiding physicists and clinicians in the utilization of [ 18F]FDG-PET in RT. The two goals of this report are to educate and provide recommendations. The report provides background and education on current PET imaging systems, PET tracers, intensity quantification, and current utilization in RT (staging, segmentation, image registration, treatment planning, and therapy response assessment). Recommendations are provided on acceptance testing, annual and monthly quality assurance, scanning protocols to ensure consistency between interpatient scans and intrapatient longitudinal scans, reporting of patient and scan parameters in literature, requirements for incorporation of [ 18F]FDG-PET in treatment planning systems, and image registration. The recommendations provided here are minimum requirements and are not meant to cover all aspects of the use of [ 18F]FDG-PET for RT.

Cognitive remediation is now widely recognized as an effective treatment for cognitive deficits in schizophrenia. Its effects are meaningful, durable, and related to improvements in everyday functional outcomes. As with many therapies, the evolution of cognitive remediation has resulted in treatment programs that use a variety of specific techniques, yet share common core principles. This paper is the product of a cognitive remediation expert working group consensus meeting to identify core features of the treatment and produce recommendations for its design, conduct, reporting, and implementation. Four techniques were identified as core features of cognitive remediation: facilitation by a therapist, cognitive exercise, procedures to develop problem-solving strategies, and procedures to facilitate transfer to real world functioning. Treatment techniques within each of these core features are presented to facilitate decisions for clinical trials and implementation in clinical settings.

We model the ultraviolet spectra of the Seyfert 1 galaxy NGC~5548 obtained with the Hubble Space Telescope during the 6-month reverberation-mapping campaign in 2014. Our model of the emission from NGC 5548 corrects for overlying absorption and deblends the individual emission lines. Using the modeled spectra, we measure the response to continuum variations for the deblended and absorption-corrected individual broad emission lines, the velocity-dependent profiles of Ly$\alpha$ and C IV, and the narrow and broad intrinsic absorption features. We find that the time lags for the corrected emission lines are comparable to those for the original data. The velocity-binned lag profiles of Ly$\alpha$ and C IV have a double-peaked structure indicative of a truncated Keplerian disk. The narrow absorption lines show delayed response to continuum variations corresponding to recombination in gas with a density of $\sim 10^5~\rm cm^{-3}$. The high-ionization narrow absorption lines decorrelate from continuum variations during the same period as the broad emission lines. Analyzing the response of these absorption lines during this period shows that the ionizing flux is diminished in strength relative to the far-ultraviolet continuum. The broad absorption lines associated with the X-ray obscurer decrease in strength during this same time interval. The appearance of X-ray obscuration in $\sim\,2012$ corresponds with an increase in the luminosity of NGC 5548 following an extended low state. We suggest that the obscurer is a disk wind triggered by the brightening of NGC 5548 following the decrease in size of the broad-line region during the preceding low-luminosity state., Comment: 50 pages, 30 figures, uses aastex62.cls. Accepted for publication in ApJ, 07/06/2019. High-level products page in MAST will go live after 7/15/2019. Replaced Figure 4 on 7/12/2019 to be more red/green color-blind friendly

Background Research has demonstrated that cognitive abilities predict work outcomes in people with psychosis. Cognitive Remediation Programs go some way in improving work outcomes, but individuals still experience difficulty maintaining employment. Metacognition has been demonstrated to predict work performance in individuals with schizophrenia, but this has not yet been applied to First Episode Psychosis (FEP). This study assessed whether metacognition, intellectual aptitude and functional capacity can predict engagement in work and number of hours of work within FEP. Methods Fifty-two individuals with psychosis, from an Early Intervention in Psychosis service, completed measures of IQ, metacognition (Metacognitive Assessment Interview), functional capacity (UPSA), and functional outcome (hours spent in structured activity per week, including employment). Results Twenty-six participants (22 males, 4 females) were employed and twenty-six (22 males, 4 females) were not employed. IQ and metacognition were significantly associated with whether the individual was engaged in employment [IQ (p = .02) and metacognition (p = 006)]. When controlling for IQ, metacognition (differentiation subscale) remained significant (p = .04). Next, including only those employed, no cognitive nor metacognitive factors predicted number of hours in employment. Discussion This is the first study to directly assess metacognition as a predictor of work hours for individuals with FEP. This study highlights the importance of enhancing metacognitive ability in order to improve likelihood of, and engagement in, employment for those with FEP.

OBJECTIVE. Impaired cognition is a hallmark of schizophrenia and spectrum disorders such as schizotypal personality disorder, and is the best predictor of functional outcome. Cognitive remediation therapy has demonstrated efficacy for improving cognition and augmenting other rehabilitation efforts in schizophrenia, with gains in real-world functioning. Pharmacological augmentation of cognitive remediation has been attempted but the effects of augmentation on combined therapies such as cognitive remediation and social skills training has not been studied. METHOD. Twenty-eight participants with schizotypal personality disorder enrolled in an 8-week, randomized, double-blind, placebo-controlled trial of guanfacine plus cognitive remediation + social skills training (15 guanfacine, 13 placebo). Cognition was assessed with the MATRICS Clinical Consensus Battery (MCCB), social cognition with the Movie for the Assessment of Social Cognition (MASC), and functional capacity with the UCSD Performance Based Skills Assessment (UPSA). RESULTS. There was a statistically significant time (pre- versus post-treatment) effect for MCCB speed of processing, verbal learning, and visual learning, and UPSA total score. There was a significant time x medication condition (guanfacine, placebo) interaction for MCCB reasoning and problem solving, and UPSA total score; the time x treatment condition interaction approached significance for MASC hypomentalizing errors. CONCLUSIONS. In this trial, both the agent guanfacine and our psychosocial intervention of cognitive remediation plus social skills training were well-tolerated, with no side effects or drop-outs. Participants treated with cognitive remediation plus social skills training plus guanfacine demonstrated statistically significant improvements in reasoning and problem solving, as well as in functional capacity and possibly social cognition, compared to those treated with cognitive remediation plus social skills training plus placebo. Cognitive remediation plus social skills training may be an appropriate intervention for individuals with schizotypal personality disorder and guanfacine appears to be a promising agent to augment cognitive remediation plus social skills training in this population.

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.

Contrary to popular belief, many individuals with schizophrenia and other severe mental illnesses want to work, but up to 80 % remain under- or unemployed. Traditional vocational models, which often withhold, or never offer help in finding competitive work until prevocational training, noncompetitive work positions, and other requirements, have been met, ultimately provide little or no benefit in helping people achieve their work goals. To address the need for effective work services, the supported employment model of vocational rehabilitation focusing on rapid attainment of competitive employment has emerged as a compelling alternative to traditional models. Substantial evidence derived from over 30 randomized controlled trials indicates supported employment’s vocational and clinical benefits. More recent research on supported employment has focused on issues of expansion and dissemination. However, access to supported employment remains limited with a substantial need to scale up services in routine clinical and rehabilitation services and to overcome systemic and policy barriers to the funding of supported employment and to fostering work in serious mental illnesses.

This article serves as an introduction to the special issue on the topic of cognitive remediation. The papers comprising this special issue make important contributions to the cognitive remediation field by testing the efficacy of cognitive programs on unique symptom targets of serious mental illness, evaluating novel cognitive program enhancements, demonstrating the feasibility and promise of incorporating cognitive programs into everyday practice, and engaging new populations into cognitive programs. Together, these papers show that cognitive remediation is an important and increasingly common component of comprehensive psychiatric rehabilitation programs that can increase the effectiveness of these programs at helping participants make progress toward and achieve their personal goals. (PsycINFO Database Record

Individual Placement and Support (IPS) is the evidence-based model of supported employment that increases employment rates in adults with severe mental illness (SMI). Although IPS is largely successful, over 80% of adults with SMI remain unemployed. An enhancement to high fidelity IPS could be an evidence-based job interview training component. To meet this training need, our group recently completed a series of randomized controlled efficacy trials funded by the National Institute of Mental Health to develop and test virtual reality job interview training (VR-JIT) in a lab setting. The results demonstrated that the intervention was efficacious at helping trainees improve their job interview skills and receive job offers within six months of completing VR-JIT compared to non-trainees. The overarching goal of this study is to evaluate the effectiveness of VR-JIT as an enhancement to IPS when delivered in a large community-based mental health service provider via a randomized controlled trial and initial process evaluation. Our aims are to: evaluate whether IPS services-as-usual in combination with VR-JIT, compared to IPS services-as-usual alone, enhances IPS outcomes for adults with SMI; evaluate mechanisms of employment outcomes and psychological distress; and conduct a multilevel, multidisciplinary, and mixed-method process evaluation of VR-JIT adoption and implementation to assess the acceptability, scalability, generalizability, and affordability of VR-JIT.

Computerized cognitive training (CCT) to improve cognitive functioning is of enormous interest and has been applied in a broad range of populations with goals of improving both cognition and community functioning. Recent reviews presenting negative conclusions about CCT efficacy have inconsistent definitions of the treatment targets and cognitive improvement. They do not present an accurate representation of the typical process of CCT and cognitive remediation (CR), especially as delivered in major mental illnesses such as schizophrenia. This review provides guidance on the definitions of CCT and CR, the uses of CCT and CR, and the definitions and measurements of cognitive and functional gains. The review focuses on schizophrenia and healthy aging, with each population receiving unique CCT or CR approaches and substantial extant literature with which to elucidate fundamental CCT and CR concepts and research findings. It is our conclusion that CCT has been shown in most studies to improve cognitive performance on untrained tests in healthy older people and in people with schizophrenia. Functional gains in schizophrenia appear to be limited to CR studies. Clearly defining CCT, CR, and levels of treatment-related gains will be critical for understanding the benefits of these widely used treatment programs.

This study examined job endings and work trajectories among participants in a study comparing the effects of adding cognitive remediation to supported employment among individuals who had not benefited from supported employment.Data were from a controlled trial of 107 persons with serious mental illness enrolled in supported employment but who had not obtained or sustained competitive work. Participants were randomly assigned to enhanced supported employment only (with employment specialists trained to recognize cognitive difficulties and teach coping strategies) or to the Thinking Skills for Work program (enhanced supported employment plus cognitive remediation). For the 52 participants who worked, the two groups were compared on types of job endings, reasons for job endings, successful versus unsuccessful jobs, and work trajectories over the two-year study period.The two groups did not differ in types of job ending, although participants in Thinking Skills for Work were less likely than those in enhanced supported employment only to cite dissatisfaction with the job as a reason for the job ending. Participants in Thinking Skills for Work were also less likely to have an overall unsuccessful work trajectory, more likely to have only successful jobs, and more likely to be employed at the end of the study.The Thinking Skills for Work program appeared to help participants who had not benefited from supported employment stick with and master their jobs more effectively than those in enhanced supported employment only, resulting in better work trajectories over the course of the study.

Objectives Cognitive remediation therapy (CRT) has shown significant improvement in cognition in schizophrenia. However, effect sizes of CRT have been reported to be modest raising the issue how to augment the effects of CRT on neurocognition and social cognition. Our aim was to examine whether the addition of computerized social cognition training would enhance the effects on neurocognition and social cognition as compared to CRT alone. Methods This is a 12-week, parallel group trial of 131 in- and out-patients with schizophrenia randomized to CRT (COGPACK or Brain Fitness) with computerized social cognition training (MRIGE), or CRT alone for 36 sessions. Participants were assessed at baseline and after 12 weeks of treatment. Assessments included neurocognition, social cognition, psychopathology, and functioning. Results The combined intervention, CRT + MRIGE, showed greater improvements in the MCCB indices of Visual Learning, Working Memory, Reasoning and Problem-Solving, and the neurocognitive composite score compared to CRT alone (Bonferroni adjusted p = 0.004, p = 0.005, p = 0.01, respectively), as did social cognition measures (Bonferroni adjusted p = 0.006, p = 0.005, respectively). Conclusions Supplementing CRT with computerized social cognition training produced greater benefits in neurocognition, including visual learning, memory, executive functions, and social cognition relative to cognitive training alone. These findings favoring the combined training may be contributed to both the greater overall amount of cognitive practice, as well as the specific cognitive functions engaged by the social cognition training.

Cognitive impairment presents a serious and common obstacle to competitive employment for people with severe mental illness, including those who receive supported employment. This study evaluated a cognitive enhancement program to improve cognition and competitive employment in people with mental illness who had not responded to supported employment.In a randomized controlled trial, 107 people with severe mental illness (46% with schizophrenia or schizoaffective disorder) who had not obtained or kept competitive work despite receiving high-fidelity supported employment were assigned to receive either enhanced supported employment (with specialized cognitive training of employment specialists) or enhanced supported employment plus the Thinking Skills for Work program, a standardized cognitive enhancement program that includes practice of computer cognitive exercises, strategy coaching, and teaching of coping and compensatory strategies. Research assistants tracked competitive employment weekly for 2 years, and assessors blind to treatment assignment evaluated cognitive functioning at baseline, at the end of cognitive enhancement training, and 12 and 24 months after baseline.Participants in the Thinking Skills for Work group improved more than those in the enhanced supported employment only group on measures of cognitive functioning and had consistently better competitive employment outcomes during the follow-up period, including in jobs obtained (60% compared with 36%), weeks worked (23.9 compared with 9.2), and wages earned ($3,421 compared with $1,728).The findings suggest that cognitive enhancement interventions can reduce cognitive impairments that are obstacles to work, thereby increasing the number of people who can benefit from supported employment and competitive work.

Comprehensive coordinated specialty care programs for first-episode psychosis have been widely implemented in other countries but not in the United States. The National Institute of Mental Health's Recovery After an Initial Schizophrenia Episode (RAISE) initiative focused on the development and evaluation of first-episode treatment programs designed for the U.S. health care system. This article describes the background, rationale, and nature of the intervention developed by the RAISE Early Treatment Program project-known as the NAVIGATE program-with a particular focus on its psychosocial components. NAVIGATE is a team-based, multicomponent treatment program designed to be implemented in routine mental health treatment settings and aimed at guiding people with a first episode of psychosis (and their families) toward psychological and functional health. The core services provided in the NAVIGATE program include the family education program (FEP), individual resiliency training (IRT), supported employment and education (SEE), and individualized medication treatment. NAVIGATE embraces a shared decision-making approach with a focus on strengths and resiliency and on collaboration with clients and family members in treatment planning and reviews. The NAVIGATE program has the potential to fill an important gap in the U.S. health care system by providing a comprehensive intervention specially designed to meet the unique treatment needs of persons recovering from a first episode of psychosis. A cluster-randomized controlled trial comparing NAVIGATE with usual community care has recently been completed.