Natalie Maples

Comparing the Efficacy of Interventions that use environmental supports to Improve Outcomes in Patients with Schizophrenia

We examined the efficacy of 2 treatments using environmental supports (e.g. signs, alarms, pill containers, checklists) to improve functional outcomes in individuals with schizophrenia. 120 participants were randomized into one of 3 treatment groups 1) Cognitive Adaptation Training (CAT; supports customized to individual cognitive impairments and behaviors and maintained on weekly home visits 2) Generic Environmental Supports (GES; a generic set of supports given to patients at a routine clinic visit and replaced on a monthly basis) and 3) treatment as usual (TAU). Functional outcomes, positive symptoms and motivation were assessed at baseline, 3, 6, 9, 18 and 24 months. After 9 months of intensive treatment with CAT, visits were decreased from weekly to monthly to examine whether treatment gains could be maintained. Results of a mixed effects regression model with repeated measures indicated a significant main effect of group (CAT>GES>TAU) with non-significant time and group by time interactions. Post-hoc analyses indicated that while individuals in CAT remained significantly better than those in TAU when treatment frequency was reduced, gains in CAT decreased to the level of those seen in GES. While group differences for positive symptoms were not significant, motivation improved in CAT and GES relative to TAU. The highest intensity treatment produced the best outcomes with respect to functioning. However, some improvements were seen with a relatively inexpensive, clinic-based treatment using a package of generic environmental supports.

The reliability and validity of the Test of Adaptive Behavior in Schizophrenia (TABS)

Performance-based tests of functional capacity are important to utilize in schizophrenia where global measures may underestimate community functioning in the context of impoverished environments and disincentives to return to work. The Test of Adaptive Behavior in Schizophrenia (TABS) is a performance-based measure of adaptive functioning designed to address limitations of other available measures including limited assessment of the ability to initiate and of the ability to identify problems that occur in the course of performing functional activities. The TABS and a variety of symptom, functional outcome, and cognitive measures were administered to 264 outpatients with schizophrenia/schizoaffective disorders at an initial assessment. At 3 months, 110 subjects received a follow-up assessment. Results indicated that the TABS had very good test-retest reliability (0.80) and inter-item consistency (0.84). Moreover, TABS scores were moderately to strongly correlated with other measures of functional outcome, negative symptoms and neuropsychological test scores (convergent validity). Measures of positive symptoms were not found to be related to TABS performance (discriminate validity). The data provide preliminary evidence for the reliability and validity of the TABS. Further studies of the psychometric properties of the TABS including those examining the sensitivity of the TABS to treatments with different pharmacological agents or psychosocial treatments are encouraged.

A Randomized Trial Comparing In Person and Electronic Interventions for Improving Adherence to Oral Medications in Schizophrenia

Poor adherence to medication leads to symptom exacerbation and interferes with the recovery process for patients with schizophrenia. Following baseline assessment, 142 patients in medication maintenance at a community mental health center were randomized to one of 3 treatments for 9 months: (1) PharmCAT, supports including pill containers, signs, alarms, checklists and the organization of belongings established in weekly home visits from a PharmCAT therapist; (2) Med-eMonitor (MM), an electronic medication monitor that prompts use of medication, cues the taking of medication, warns patients when they are taking the wrong medication or taking it at the wrong time, record complaints, and, through modem hookup, alerts treatment staff of failures to take medication as prescribed; (3) Treatment as Usual (TAU). All patients received the Med-eMonitor device to record medication adherence. The device was programmed for intervention only in the MM group. Data on symptoms, global functioning, and contact with emergency services and police were obtained every 3 months. Repeated measures analyses of variance for mixed models indicated that adherence to medication was significantly better in both active conditions than in TAU (both p<0.0001). Adherence in active treatments ranged from 90-92% compared to 73% in TAU based on electronic monitoring. In-person and electronic interventions significantly improved adherence to medication, but that did not translate to improved clinical outcomes. Implications for treatment and health care costs are discussed.

A randomized pilot study of MOtiVation and Enhancement (MOVE) Training for negative symptoms in schizophrenia

INTRODUCTION Among individuals with schizophrenia, those who have persistent and clinically significant negative symptoms (PNS) have the poorest functional outcomes and quality of life. The NIMH-MATRICS Consensus Statement indicated that these symptoms represent an unmet therapeutic need for large numbers of individuals with schizophrenia. No psychosocial treatment model addresses the entire constellation of PNS. METHOD 51 patients with PNS were randomized into one of two groups for a period of 9 months: 1) MOtiVation and Enhancement (MOVE) or 2) treatment as usual. MOVE is a home based, manual-driven, multi-modal treatment that employs a number of cognitive and behavioral principles to address the broad range of factors contributing to PNS and their functional consequences. The components of MOVE include: Environmental supports to prompt initiation and persistence, in-vivo skills training to ameliorate deficits and encourage interaction, cognitive behavioral techniques to address self-defeating attitudes, in-vivo training in emotional processing to address affective blunting and problems in identifying emotions, and specific techniques to address the deficits in anticipatory pleasure. Patients were assessed at baseline and each 3 months with multiple measures of negative symptoms. RESULTS Repeated measures analyses of variance for mixed models indicated significant Group by Time effects for the Negative Symptom Assessment (NSA; p<.02) and the Clinical Assessment Interview for Negative Symptoms (CAINS; p<.04). Group differences were not significant until 9 months of treatment and were not significant for the Brief Negative Symptom Scale (BNSS). CONCLUSION Further investigation of a comprehensive treatment for PNS, such as MOVE, is warranted.

Cognitive Adaptation Training: Establishing Environmental Supports to Bypass Cognitive Deficits and Improve Functional Outcomes

Several approaches to the treatment of cognitive impairments and their functional consequences for persons diagnosed with schizophrenia and schizoaffective disorder have been developed in recent years. This article focuses on the use of Cognitive adaptation training (CAT), a psychosocial intervention that seeks to bypass cognitive impairments in schizophrenia in an effort to improve functional outcomes. CAT relies on the use of environmental supports, such as signs, calendars, hygiene supplies, and pill containers, to cue and sequence adaptive behavior in the clients home environment. This article outlines the specific components of CAT, reviews the results from several previous studies utilizing CAT, and discusses the feasibility and recommendations for the use of CAT in everyday community care.

Cognitive adaptation training for outpatients with schizophrenia

Schizophrenia is a complex neurodevelopmental disorder characterized by cognitive deficits. These deficits in cognitive functioning have been shown to relate to a variety of functional and treatment outcomes. Cognitive adaptation training (CAT) is a home-based, manual-driven treatment that utilizes environmental supports and compensatory strategies to bypass cognitive deficits and improve target behaviors and functional outcomes in individuals with schizophrenia. Unlike traditional case management, CAT provides environmental supports and compensatory strategies tailored to meet the behavioral style and neurocognitive deficits of each individual patient. The case of Ms. L. is presented to illustrate CAT treatment.

Barriers to, and Strategies for, Starting a Long Acting Injection Clinic in a Community Mental Health Center

As many as 50% of patients with schizophrenia do not take oral antipsychotic medications as prescribed, yet long acting injections are rarely utilized. Community agencies that serve this population are often over-burdened and poorly funded. There are negative attitudes on the part of both physicians and consumers about injections. Transportation and logistics are often problematic. We describe the unique opportunity provided by the need for bi-weekly or monthly injections to establish a recovery-oriented group around injection visits. Our approach discusses methods and resources to help overcome some of the common barriers by establishing advocates within the agency, establishing necessary infrastructure, providing education for consumers, providers, and staff, sharing information about successful outcomes with clinic staff and working through billing issues. We also recommend public advocacy on the part of the clinic and consumers to work with state funding sources to change regulations that may limit appropriate clinical care.

Integrated Psychosocial Treatment for Negative Symptoms

Negative symptoms, including restricted affect, diminished emotional range, poverty of speech, decreased motivation and interests, diminished sense of purpose, and diminished social drive, contribute substantially to lost productivity, poor quality of life, social deficits, poor occupational and educational attainment, and generally poor outcomes observed for many individuals with schizophrenia. Although these symptoms may develop from neurobiological factors or as reactions to overstimulation in the acute psychotic phase, they are thought to be maintained by a confluence of biological, cognitive, behavioral, and environmental factors that are not adequately addressed by available treatments. We have developed a multicomponent set of intervention strategies to address persistent negative symptoms called the motivation and engagement (MOVE) program. MOVE builds on research on emotional processing as well as techniques from a variety of behavioral and skill-building approaches to specifically target a broad range of negative symptoms and their functional consequences in an integrated program delivered in the individuals home environment. In this manuscript, we describe an integrated theory for the development and maintenance of negative symptoms, available treatments that target aspects of the syndrome, and evidence supporting the components of MOVE for those with persistent negative symptoms.

Testing a modification of cognitive adaptation training: streamlining the model for broader implementation.

Cognitive adaptation training (CAT) is a home-based, manualized treatment that utilizes environmental supports to improve target behaviors and functional outcomes in persons with schizophrenia. Although clinical trials have shown CAT to be effective across functional, clinical, and treatment adherence domains, when the intervention is withdrawn clients experience significant declines. The aim of the current study was to test a modified version of CAT, which decreases the duration of intensive CAT intervention while utilizing ongoing case management-supported CAT to maintain the fundamental components of the treatment. Twenty-three people participated in an outcome study of the modified version of CAT, evaluating improvements after 4months of CAT specialist intervention and after an additional 5months of case manager support. Analysis revealed significant improvements in adaptive functioning, psychiatric symptomatology, and goal attainment, which were maintained throughout case management follow-up. This suggests that an intervention that has previously demonstrated good functional outcomes in randomized trials might sustain its impacts in an abbreviated format with support from existing case managers.

Is cognitive adaptation training (CAT) compensatory, restorative, or both?

Cognitive adaptation training (CAT) is a psychosocial treatment incorporating environmental supports including signs, checklists to bypass the cognitive deficits of schizophrenia. Our objective was to examine the association between CAT, functional outcomes, and cognitive test performance (cognition). The two research questions were as follows: 1) Does cognition mediate the effect of CAT intervention on functional outcome? 2) Does CAT impact cognitive test performance? A total of 120 participants with schizophrenia were randomized to one of three treatments: 1) CAT (weekly for 9months; monthly thereafter), 2) generic environmental supports (given to participants on clinic visits to promote adaptive behavior), or 3) treatment as usual (TAU). Assessments of cognition and functional outcome were conducted at baseline, 9 and 24months. Mediation analyses and mixed effects regression were conducted. Mediation analyses revealed that during the initial 9months, the direct path from treatment group to functional outcome on the primary measure was positive and highly significant. CAT significantly improved functional outcome compared to the other treatments. However, paths involving cognition were negligible. There was no evidence that cognition mediated improvement in functional outcomes. At 24months, cognition improved more in CAT compared to other treatment groups. The test for cognition mediating improvement in functional outcomes was not significant at this time point. However, improvement in functional outcome led to better performance on cognitive testing. We concluded that improvement in cognition is not a necessary condition for improvement in functional outcome and that greater engagement in functional behavior has a positive impact on cognition.