Peter C. Link

Mobile Assessment and Treatment for Schizophrenia (MATS): A Pilot Trial of An Interactive Text-Messaging Intervention for Medication Adherence, Socialization, and Auditory Hallucinations

Mobile Assessment and Treatment for Schizophrenia (MATS) employs ambulatory monitoring methods and cognitive behavioral therapy interventions to assess and improve outcomes in consumers with schizophrenia through mobile phone text messaging. Three MATS interventions were developed to target medication adherence, socialization, and auditory hallucinations. Participants received up to 840 text messages over a 12-week intervention period. Fifty-five consumers with schizophrenia or schizoaffective disorder were enrolled, but 13 consumers with more severe negative symptoms, lower functioning, and lower premorbid IQ did not complete the intervention, despite repeated prompting and training. For completers, the average valid response rate for 216 outcome assessment questions over the 12-week period was 86%, and 86% of phones were returned undamaged. Medication adherence improved significantly, but only for individuals who were living independently. Number of social interactions increased significantly and a significant reduction in severity of hallucinations was found. In addition, the probability of endorsing attitudes that could interfere with improvement in these outcomes was also significantly reduced in MATS. Lab-based assessments of more general symptoms and functioning did not change significantly. This pilot study demonstrated that low-intensity text-messaging interventions like MATS are feasible and effective interventions to improve several important outcomes, especially for higher functioning consumers with schizophrenia.

Social Disinterest Attitudes and Group Cognitive-Behavioral Social Skills Training for Functional Disability in Schizophrenia

The majority of clinical trials of cognitive-behavioral therapy (CBT) for schizophrenia have used individual therapy to target positive symptoms. Promising results have been found, however, for group CBT interventions and other treatment targets like psychosocial functioning. CBT for functioning in schizophrenia is based on a cognitive model of functional outcome in schizophrenia that incorporates dysfunctional attitudes (eg, social disinterest, defeatist performance beliefs) as mediators between neurocognitive impairment and functional outcome. In this report, 18 clinical trials of CBT for schizophrenia that included measures of psychosocial functioning were reviewed, and two-thirds showed improvements in functioning in CBT. The cognitive model of functional outcome was also tested by examining the relationship between social disinterest attitudes and functional outcome in 79 people with schizophrenia randomized to either group cognitive-behavioral social skills training or a goal-focused supportive contact intervention. Consistent with the cognitive model, lower social disinterest attitudes at baseline and greater reduction in social disinterest during group therapy predicted better functional outcome at end of treatment for both groups. However, the groups did not differ significantly with regard to overall change in social disinterest attitudes during treatment, suggesting that nonspecific social interactions during group therapy can lead to changes in social disinterest, regardless of whether these attitudes are directly targeted by cognitive therapy interventions.

Randomized clinical trial of cognitive behavioral social skills training for schizophrenia: improvement in functioning and experiential negative symptoms.

OBJECTIVE Identifying treatments to improve functioning and reduce negative symptoms in consumers with schizophrenia is of high public health significance. METHOD In this randomized clinical trial, participants with schizophrenia or schizoaffective disorder (N = 149) were randomly assigned to cognitive behavioral social skills training (CBSST) or an active goal-focused supportive contact (GFSC) control condition. CBSST combined cognitive behavior therapy with social skills training and problem-solving training to improve functioning and negative symptoms. GFSC was weekly supportive group therapy focused on setting and achieving functioning goals. Blind raters assessed functioning (primary outcome: Independent Living Skills Survey [ILSS]), CBSST skill knowledge, positive and negative symptoms, depression, and defeatist performance attitudes. RESULTS In mixed-effects regression models in intent-to-treat analyses, CBSST skill knowledge, functioning, amotivation/asociality negative symptoms, and defeatist performance attitudes improved significantly more in CBSST relative to GFSC. In both treatment groups, comparable improvements were also found for positive symptoms and a performance-based measure of social competence. CONCLUSIONS The results suggest CBSST is an effective treatment to improve functioning and experiential negative symptoms in consumers with schizophrenia, and both CBSST and supportive group therapy actively focused on setting and achieving functioning goals can improve social competence and reduce positive symptoms.

Neuropsychological predictors of functional outcome in Cognitive Behavioral Social Skills Training for older people with schizophrenia.

Cognitive Behavioral Social Skills Training (CBSST) is a 24-session weekly group therapy intervention to improve functioning in people with schizophrenia. In our prior randomized clinical trial comparing treatment as usual (TAU) with TAU plus group CBSST (Granholm, E., McQuaid, J.R., McClure, F.S., Auslander, L., Perivoliotis, D., Pedrelli, P., Patterson, T., Jeste, D.V., 2005. A randomized controlled trial of cognitive behavioral social skills training for middle-aged and older outpatients with chronic schizophrenia. Am. J. Psychiatry 162, 520-529.), participants with schizophrenia in CBSST showed significantly better functional outcome than participants in TAU. The present study was a secondary analysis of neuropsychological predictors of functional outcome in our prior CBSST trial. We examined (1) whether neuropsychological impairment at baseline moderated functional outcome in CBSST relative to TAU, and (2) whether improvement in neuropsychological abilities mediated improvement in functional outcome in CBSST. Attention, verbal learning/memory, speed of processing, and executive functions were assessed at baseline, end of treatment, and 12-month follow-up. Greater severity of neuropsychological impairment at baseline predicted poorer functional outcome for both treatment groups (nonspecific predictor), but the interaction between severity of neuropsychological impairment and treatment group was not significant (no moderation). Effect sizes for the difference between treatment groups on functional outcome measures at 12-month follow-up were similar for participants with relatively mild (d=.44-.64) and severe (d=.29-.60) neuropsychological impairment. Results also did not support the hypothesis that improvement in neuropsychological abilities mediated improvement in functioning in CBSST. Adding CBSST to standard pharmacologic care, therefore, improved functioning relative to standard care alone, even for participants with severe neuropsychological impairment, and this improvement in functioning was not related to improvement in neuropsychological abilities in CBSST.

Age-related practice effects across longitudinal neuropsychological assessments in older people with schizophrenia.

UNLABELLED The relationship between aging and practice effects on longitudinal neuropsychological assessments was investigated in middle-aged and older people with schizophrenia and healthy controls. METHOD Older people with schizophrenia (n = 107; M age = 56.1) and age-comparable nonpsychiatric controls (n = 107; M age = 57.7) were scheduled to receive annual assessments on a comprehensive battery of neuropsychological tests for an average of 2.5 years (range 11 months to 4 years). Mixed-model analyses were used to separately examine the effects of practice and age on test performance. RESULTS Number of prior assessments (practice) was associated with significant performance improvement across assessments, whereas older age was associated with significant decline in performance. The groups did not differ significantly in extent of age-related cognitive decline, but a three-way interaction among group, age, and practice was found, such that greater age-related decline in practice effects were found for older people with schizophrenia relative to nonpsychiatric participants. CONCLUSIONS This study did not find any evidence of neurodegenerative age-related decline in neuropsychological abilities in middle-aged and older people with schizophrenia, but older age was associated with diminished ability to benefit from repeated exposure to cognitive tasks in people with schizophrenia. Cognitive impairment in schizophrenia may combine with cognitive decline associated with normal aging to reduce practice effects in older patients. These findings have important implications for the design of studies examining the longitudinal trajectory of cognitive functioning across the life span of people with schizophrenia, as well as clinical trials that attempt to demonstrate cognitive enhancement in these individuals.

Pupillary Responses as a Biomarker of Diminished Effort Associated With Defeatist Attitudes and Negative Symptoms in Schizophrenia.

BACKGROUND The hypothesis that defeatist performance attitudes are associated with decreased goal-directed task effort and negative symptoms in consumers with schizophrenia was investigated by using pupillary responses as a biomarker of task effort. Pupillary dilation during cognitive tasks provides a biomarker of effort devoted to the task, with greater dilation indicating greater effort. METHODS Defeatist attitudes were assessed in 149 consumers with schizophrenia or schizoaffective disorder and 50 healthy control subjects, and consumers were divided into three groups (tertile split) with respect to severity of defeatist attitudes. Pupillary dilation responses were recorded during a digit-span task with three-, six-, and nine-digit spans. RESULTS Effort allocation (pupillary responses) to the task increased as the processing load increased from low (three-digit) to moderate (six-digit) demands in healthy control subjects and consumers with schizophrenia with mild and moderate severity of defeatist attitudes. In contrast, consumers with severe defeatist attitudes did not increase their effort when processing demands increased from low to moderate loads. These consumers showed significantly less effort in the six-digit condition relative to consumers with mild defeatist attitudes. Moreover, consumers with severe defeatist attitudes showed significantly greater severity of negative symptoms relative to consumers with mild defeatist attitudes and negative symptoms were significantly correlated with defeatist attitudes. CONCLUSIONS These results suggest a relationship between defeatist performance attitudes, goal-directed task effort indexed by pupillary responses, and negative symptoms in schizophrenia. The findings have implications for using cognitive therapy to reduce defeatist attitudes that may contribute to diminished effort and negative symptoms in schizophrenia.

Insight and Treatment Outcome with Cognitive-Behavioral Social Skills Training for Older People with Schizophrenia

Poor insight (awareness of having a mental illness that requires treatment) is common in schizophrenia and typically predicts poor outcome, yet greater insight has been linked to negative outcomes, including hopelessness. This study focused on two questions: (1) Does insight moderate the effects of cognitive-behavioral social skills training (CBSST) on functional outcomes in schizophrenia? (2) Does a specific type of insight (e.g., awareness of illness, need for treatment) predict benefit from CBSST? We examined insight as a predictor of everyday functioning in a randomized controlled trial of CBSST versus treatment as usual (TAU) for middle-aged and older people with schizophrenia (n = 62). We used linear regression models to examine moderators of the relationship between baseline insight and everyday functioning measured 12 months following completion of the 6-month intervention. Insight, especially insight into the need for treatment, moderated the relationship between treatment group and everyday functioning (Independent Living Skills Survey), such that CBSST offset the negative effect of insight on functioning observed with TAU (wherein greater insight was related to poorer everyday functioning). Post hoc analyses showed that reduction of insight-linked hopelessness may have accounted for the positive effect of CBSST on functioning relative to TAU.

Neuropsychological Functioning and Outcomes of Treatment for Co-occurring Depression and Substance Use Disorders

Background: We previously published findings from our clinical trial comparing treatment outcomes for substance-dependent veterans with co-occurring depression who received Integrated Cognitive Behavioral Therapy (ICBT) or Twelve-Step Facilitation (TSF) Therapy. Objectives: This study is a secondary analysis that examined whether neuropsychological functioning at baseline moderated substance use and depression outcomes in ICBT relative to TSF. Methods: This study was a randomized clinical trial in which 164 veterans with major depressive disorder and comorbid alcohol, cannabinol, and/or stimulant dependence were randomly assigned to either ICBT or TSF group therapy. A comprehensive neuropsychological test battery was administered at baseline. Results: Contrary to our hypothesis, participants with poor neuropsychological functioning had better substance use outcome in ICBT than in TSF, whereas participants with good neuropsychological functioning had comparable substance use outcomes in TSF and ICBT by 18-month follow-up. Depression outcomes, in contrast, were not moderated by neuropsychological functioning by 18-month follow-up. Conclusions and Scientific Significance: The substance use outcomes may suggest that substance-dependent depressed adults with poorer neuropsychological functioning should be offered ICBT over TSF. These individuals may be less able to develop and use novel coping skills for managing substance use and depressive symptoms on their own without formal structured training in cognitive and behavioral skills provided in ICBT.

Neurocognitive and theory of mind deficits and poor social competence in schizophrenia: the moderating role of social disinterest attitudes

Neurocognitive and theory of mind deficits, dysfunctional attitudes, and negative symptoms have all been linked to poor functioning in schizophrenia, but interactions among these factors have not been extensively examined. We investigated whether dysfunctional attitudes (e.g., defeatist performance beliefs and social disinterest attitudes) moderated associations between neurocognition and theory of mind and poor everyday functioning and social competence in 146 participants with schizophrenia. We examined whether cognitive deficits are more likely to influence functioning in participants with more severe dysfunctional attitudes. Social disinterest, but not defeatist performance, attitudes were found to moderate associations between cognitive deficits and social competence but not everyday functioning, such that neurocognition and theory of mind deficits were only associated with poorer social competence in participants with more severe social disinterest attitudes. In contrast, no significant moderation effects were found for defeatist performance beliefs. Findings indicate that deficits in abilities were less likely to impact social competence in participants with greater interest in socializing. It may be that greater motivation for socializing engenders increased practice and engagement in social interactions, which then leads to greater social competence despite poor cognitive abilities. Treatments that target social disinterest attitudes may lead to greater social competence and engagement.