Gerard E. Hogarty

Neuroprotective Effects of Cognitive Enhancement Therapy Against Gray Matter Loss in Early Schizophrenia Results From a 2-Year Randomized Controlled Trial

CONTEXT Cognitive rehabilitation has shown efficacy in improving cognition in patients with schizophrenia but the underlying neurobiologic changes that occur during these treatments and support cognitive improvement are not well known. OBJECTIVE To examine differential changes in brain morphology in early course schizophrenia during cognitive rehabilitation vs supportive therapy. DESIGN Randomized controlled trial. SETTING An outpatient research clinic at a university-based medical center that provides comprehensive care services for patients with severe mental illness. PATIENTS A total of 53 symptomatically stable but cognitively disabled outpatients in the early course of schizophrenia or schizoaffective disorder. INTERVENTIONS A 2-year trial with annual structural magnetic resonance imaging and cognitive assessments. Cognitive enhancement therapy is an integrated approach to the remediation of cognitive impairment in schizophrenia that uses computer-assisted neurocognitive training and group-based social-cognitive exercises. Enriched supportive therapy is an illness management approach that provides psychoeducation and teaches applied coping strategies. MAIN OUTCOME MEASURES Broad areas of frontal and temporal gray matter change were analyzed with longitudinal, voxel-based morphometry methods using mixed-effects models followed by volumetric analyses of regions that demonstrated significant differential changes between treatment groups. RESULTS Patients who received cognitive enhancement therapy demonstrated significantly greater preservation of gray matter volume over 2 years in the left hippocampus, parahippocampal gyrus, and fusiform gyrus, and significantly greater gray matter increases in the left amygdala (all corrected P < .04) compared with those who received enriched supportive therapy. Less gray matter loss in the left parahippocampal and fusiform gyrus and greater gray matter increases in the left amygdala were significantly related to improved cognition and mediated the beneficial cognitive effects of cognitive enhancement therapy. CONCLUSION Cognitive enhancement therapy may offer neurobiologic protective and enhancing effects in early schizophrenia that are associated with improved long-term cognitive outcomes.

The limited effects of antipsychotic medication on schizophrenia relapse and adjustment and the contributions of psychosocial treatment

Abstract Whether psychosocial treatment adds substantially to the prophylactic efficacy of maintenance antipsychotic monotherapy requires a more accurate estimate of relapse risks than those contained in recent reviews. A reappraisal of the literature suggests a 1-year, post- hospital, relapse rate of 40% on medication, and a substantially higher rate among patients who live in stressful environments, rather than earlier estimates of 16%. Relapse rates of 65% at 1 year and over 80% by 2 years among drug discontinued or placebo substituted outpatients are also more accurate than the 53% relapse rate previously estimated. When psychosocial treatment is added to maintenance chemotherapy, there is compelling evidence that relapse rates are reduced by as much as 50% compared with relapse associated with medication and standard care. However, psychosocial treatment without medication is as ineffective as placebo. The additive effects appear greater for recent, theoretically based psychosocial approaches than earlier atheoretical, altruistic forms of caring. However, effects vary according to the patients clinical state, the nature and timing of the intervention, and the presence of environmental stressors. Regarding adjustment, very little definitive information regarding psychosocial treatment effects has existed until recently. A novel, disorder-relevant approach has now been shown to have broad and significant effects on social adjustment compared with medication and support. However, the magnitude of effects is not fully realized until a third year of treatment: a distinct challenge in the era of managed care. Atypical antipsychotics and more definitive psychosocial strategies that target social cognitive deficits hold promise for enhanced outcomes in the next generation of studies.

Differences in the nature of relapse and subsequent inpatient course between medication-compliant and noncompliant schizophrenic patients

Two subgroups of relapsed and rehospitalized schizophrenic patients were separated on the basis of preadmission compliance or noncompliance with prescribed antipsychotic medications. Noncompliant patients had a gradual onset of episode with prominent psychotic features, required involuntary commitment, and remained in hospital longer. Compliant patients had a rapid onset of symptoms with prominent affective features (anxiety and depression) which were frequently associated with environmental stressors independent of the patient. Compliant patients were usually voluntary admissions and recovered quickly with minimal or no change in their antipsychotic pharmacotherapy. The pathogenesis of relapse among drug-compliant patients remains unknown, but likely includes aspects of environmental stress, an emergent affective syndrome, and, to some less clear extent, akinesia and akathisia. Implications for the inpatient and community treatment of these patients are discussed.

Information processing and communication deviance in schizophrenic patients and their mothers

Tests of attention/information processing, the continuous performance test (CPT) and the span of apprehension task (SAT), were given to 25 schizophrenic patients and their mothers. Measures of communication deviance also were obtained from the mothers. Comparison of these assessments in the mothers revealed different transactional profiles for good attenders and poor attenders on the CPT and on the SAT. The relationships between generations (patient and mother) differ from the within-individual relationships. CPT performance by the patient is not significantly correlated with scores from the mother. However, SAT performance by the patient could be related to SAT performance by the mother and specific communication deviance factor scores.

Effects of Cognitive Enhancement Therapy on Employment Outcomes in Early Schizophrenia: Results from a 2-Year Randomized Trial.

Objective: To examine the effects of psychosocial cognitive rehabilitation on employment outcomes in a randomized controlled trial for individuals with early course schizophrenia. Method: Early course schizophrenia outpatients (N = 58) were randomly assigned to cognitive enhancement therapy (CET) or an enriched supportive therapy (EST) control and treated for 2 years. Comprehensive data on cognition and employment were collected annually. Results: Individuals treated with CET were significantly more likely to be competitively employed, had greater earnings from employment, and were more satisfied with their employment status by the end of treatment compared to EST recipients. Mediator analyses revealed that improvements in both social and nonsocial cognition mediated CET effects on employment. Conclusion: CET can help facilitate employment in early schizophrenia by addressing the cognitive impairments that limit functioning in the disorder. Inclusion of cognitive rehabilitation in social work practice can support more optimal functional recovery from schizophrenia.

Pharmacogenic depression among outpatient schizophrenic patients: a failure to substantiate

Impaired affect in recovering schizophrenic patients has been viewed as either an integral part of the disease, a postpsychotic depression, or, increasingly, as a pharmacogenically determined effect secondary to the use of antipsychotics. Two months following hospital discharge, operationally defined groups of “depressed” and “not depressed” drug-treated and nonrelapsed schizophrenic patients were randomly assigned to chlorpromazine or placebo and followed for 4 months. Among depressed schizophrenic patients, there was no evidence that drug either contributes to the depression or that depressive signs are primarily extrapyramidal symptom phenomena (akinesia). Equal numbers of nondepressed patients on drug and placebo manifested a subsequent postpsychotic depression.

An Evaluation of Community-based Mental Health Programs: Long-range Effects

Patients randomly assigned and treated at two community facilities, a psychiatric day hospital and an outpatient clinic, are evaluated two and 12 months following termination of treatment. An earlier advantage for schizophrenic patients treated at the day hospital is maintained over time, provided aftercare service is utilizied. Judiciously-used outpatient chemotherapy appears less expensive than, and as effective as, day hospital treatment for non-schizophrenic patients.

L’alleanza con le famiglie

II compito maggiore della fase associativa del trattamento e lo sviluppo di una relazione operativa tra il terapeuta e tutti i membri della famiglia, compreso il paziente. Questo e raggiunto utilizzando le sedute per riesaminare il decorso della malattia e il suo trattamento e per discutere dell’azione di entrambi sulla vita dei familiari. Viene facilitato facendo comprende re ai membri delle famiglie che il terapeuta non crede che siano loro la causa della malattia, e che anzi le famiglie hanno la capacita di influenzare positivamente il suo decorso. Durante la fase associativa, il terapeuta gioca il ruolo di rappresentante della famiglia, la prepara per le sedute successive e stabilisce un contratto terapeutico con il paziente e la famiglia che contenga obiettivi specifici, raggiungibili e reciproci. Il contratto si differenzia tra le sedute che immediatamente seguono a un episodio acuto e che si concentrano sulla sopravvivenza del paziente nel mondo esterno, e le ultime sedute che trattano di questioni a lungo termine come il graduale ritorno al lavoro e nel sociale. In tutte le sedute della fase associativa, bisogna dare un senso di speranza nel futuro, senza incoraggiare aspettative irrealistiche. I terapeuti dovrebbero aspettarsi una certa riluttanza, da parte di alcune famiglie, nel farsi coinvolgere nel trattamento ed un certo scetticismo verso la loro competenza e capacita di aiuto. Se queste sfide vengono accettate come normali, date le particolari circostanze, e se il terapeuta evita di mettersi sulla difensiva, il processo di associazione con i pazienti e le famiglie potra di gran lunga rafforzarsi.

Life History Characteristics of Responders to Drug and Social Therapy in Schizophrenia

The study to be described here begun in 1968 and involving some 370 patients in three clinics, has been partially reported in separate papers dealing with selected points of focus. Here we will take the opportunity to present the results of the study as a whole and to offer an integration that was not possible in the individual papers.