Richard W. Goldberg

The 2009 Schizophrenia PORT Psychosocial Treatment Recommendations and Summary Statements

The Schizophrenia Patient Outcomes Research Team (PORT) psychosocial treatment recommendations provide a comprehensive summary of current evidence-based psychosocial treatment interventions for persons with schizophrenia. There have been 2 previous sets of psychosocial treatment recommendations (Lehman AF, Steinwachs DM. Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophr Bull. 1998;24:1-10 and Lehman AF, Kreyenbuhl J, Buchanan RW, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. Schizophr Bull. 2004;30:193-217). This article reports the third set of PORT recommendations that includes updated reviews in 7 areas as well as adding 5 new areas of review. Members of the psychosocial Evidence Review Group conducted reviews of the literature in each intervention area and drafted the recommendation or summary statement with supporting discussion. A Psychosocial Advisory Committee was consulted in all aspects of the review, and an expert panel commented on draft recommendations and summary statements. Our review process produced 8 treatment recommendations in the following areas: assertive community treatment, supported employment, cognitive behavioral therapy, family-based services, token economy, skills training, psychosocial interventions for alcohol and substance use disorders, and psychosocial interventions for weight management. Reviews of treatments focused on medication adherence, cognitive remediation, psychosocial treatments for recent onset schizophrenia, and peer support and peer-delivered services indicated that none of these treatment areas yet have enough evidence to merit a treatment recommendation, though each is an emerging area of interest. This update of PORT psychosocial treatment recommendations underscores both the expansion of knowledge regarding psychosocial treatments for persons with schizophrenia at the same time as the limitations in their implementation in clinical practice settings.

Comorbidity of medical illnesses among adults with serious mental illness who are receiving community psychiatric services.

We studied the medical comorbidity among individuals with serious mental illness who were receiving community-based psychiatric treatment. A total of 200 psychiatric outpatients divided between those with schizophrenia and affective disorder diagnoses were recruited from samples receiving outpatient care at two psychiatric centers. Interviews used questions from national health surveys. Logistic regression analyses compared responses from each sample with those of matched subsets of individuals from the general population. Both patient groups had greater odds of having many medical conditions. The odds of respiratory illnesses remained elevated in the patient groups even after controlling for smoking, as did the odds of diabetes in the affective disorder group after controlling for weight. Persons with serious mental illness who are in outpatient care are more likely to have comorbid medical conditions than persons in the general population. The odds of diabetes, lung diseases, and liver problems are particularly elevated. These findings underscore the need for intensified preventive health interventions and medical services for this population.

THE LEARNABILITY AND ACQUISITION OF THE DATIVE ALTERNATION IN ENGLISH

A contactless motion detector, comprising an output thyristor controlled by a switching network, has an oscillator coupled to the switching network via a pre-amplifier. The oscillator and the pre-amplifier are energized from a source of pulsating direct current via a supply circuit which is part of the switching network and includes a constant-current unit in parallel with the output thyristor. To prevent untimely switching of the thyristor when power is connected to the system, a delay unit retards the energization of the pre-amplifier until the oscillator has reached its operating condition. The delay unit may include one or more semiconductive devices, such as cascaded transistors or diodes, connected across a capacitor of a resistive/capacitive series circuit which bridges a smoothing capacitor inserted between a pair of bus bars.

A Behavioral Weight-Loss Intervention in Persons with Serious Mental Illness

BACKGROUND Overweight and obesity are epidemic among persons with serious mental illness, yet weight-loss trials systematically exclude this vulnerable population. Lifestyle interventions require adaptation in this group because psychiatric symptoms and cognitive impairment are highly prevalent. Our objective was to determine the effectiveness of an 18-month tailored behavioral weight-loss intervention in adults with serious mental illness. METHODS We recruited overweight or obese adults from 10 community psychiatric rehabilitation outpatient programs and randomly assigned them to an intervention or a control group. Participants in the intervention group received tailored group and individual weight-management sessions and group exercise sessions. Weight change was assessed at 6, 12, and 18 months. RESULTS Of 291 participants who underwent randomization, 58.1% had schizophrenia or a schizoaffective disorder, 22.0% had bipolar disorder, and 12.0% had major depression. At baseline, the mean body-mass index (the weight in kilograms divided by the square of the height in meters) was 36.3, and the mean weight was 102.7 kg (225.9 lb). Data on weight at 18 months were obtained from 279 participants. Weight loss in the intervention group increased progressively over the 18-month study period and differed significantly from the control group at each follow-up visit. At 18 months, the mean between-group difference in weight (change in intervention group minus change in control group) was -3.2 kg (-7.0 lb, P=0.002); 37.8% of the participants in the intervention group lost 5% or more of their initial weight, as compared with 22.7% of those in the control group (P=0.009). There were no significant between-group differences in adverse events. CONCLUSIONS A behavioral weight-loss intervention significantly reduced weight over a period of 18 months in overweight and obese adults with serious mental illness. Given the epidemic of obesity and weight-related disease among persons with serious mental illness, our findings support implementation of targeted behavioral weight-loss interventions in this high-risk population. (Funded by the National Institute of Mental Health; ACHIEVE ClinicalTrials.gov number, NCT00902694.).

Somatic healthcare utilization among adults with serious mental illness who are receiving community psychiatric services.

Background/Objective.Somatic health care utilization was studied among individuals with serious mental illness who were receiving community-based psychiatric services. Research Design.Cross-sectional study. SubjectsA total of 200 outpatients, 100 with schizophrenia and 100 with affective disorder, were recruited from randomly selected samples receiving care at two psychiatric centers. Measures.Patients were interviewed using questions from national health surveys. Multiple logistic regression analyses were used to compare responses from each sample to those of matched subsets of individuals from the general population. Results.The psychiatric samples were more likely to report receiving some medical care services in the past year than were individuals in the general population including having visited a general medical doctor (Odds ratio, schizophrenia sample = 2.04; Odds ratio, affective disorder sample = 2.37) and having a complete physical examination (Odds ratio, schizophrenia sample = 2.69; Odds ratio, affective disorder sample = 1.74). However, our samples were less likely to receive routine dental care (Odds ratio, schizophrenia sample = 0.46; Odds ratio, affective disorder sample = 0.60). Perceived barriers to receiving medical care were reported significantly more often by the patient groups than the comparison groups (Odds ratios > 3). Conclusions. General health services are widely utilized by individuals with serious mental illness who are in outpatient psychiatric care. Dental services remain underutilized, however, and there is a high rate of perceived barriers to receiving medical care in this population.

Obesity among individuals with serious mental illness

Objective:  To study the distribution and correlates of body mass index (BMI) among individuals with serious mental illness.

Supported Employment: Assessing the Evidence

OBJECTIVE Supported employment is a direct service with multiple components designed to help adults with mental disorders or co-occurring mental and substance use disorders choose, acquire, and maintain competitive employment. This article describes supported employment and assesses the evidence base for this service. METHODS Authors reviewed meta-analyses, research reviews, and individual studies from 1995 through 2012. Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature. Authors chose from three levels of evidence (high, moderate, and low) based on benchmarks for the number of studies and quality of their methodology. They also described the evidence for service effectiveness. RESULTS The level of research evidence for supported employment was graded as high, based on 12 systematic reviews and 17 randomized controlled trials of the individual placement and support model. Supported employment consistently demonstrated positive outcomes for individuals with mental disorders, including higher rates of competitive employment, fewer days to the first competitive job, more hours and weeks worked, and higher wages. There was also strong evidence supporting the effectiveness of individual elements of the model. CONCLUSIONS Substantial evidence demonstrates the effectiveness of supported employment. Policy makers should consider including it as a covered service. Future research is needed for subgroups such as young adults, older adults, people with primary substance use disorders, and those from various cultural, racial, and ethnic backgrounds.

Clinical factors associated with employment among people with severe mental illness: Findings from the employment intervention demonstration program

Research has shown that supported employment programs are effective in helping psychiatric outpatients achieve vocational outcomes, yet not all program participants are able to realize their employment goals. This study used 24 months of longitudinal data from a multisite study of supported employment interventions to examine the relationship of patient clinical factors to employment outcomes. Multivariate random regression analysis indicated that, even when controlling for an extensive series of demographic, study condition (experimental versus control), and work history covariates, clinical factors were associated with individuals’ ability to achieve competitive jobs and to work 40 or more hours per month. Poor self-rated functioning, negative psychiatric symptoms, and recent hospitalizations were most consistently associated with failure to achieve these employment outcomes. These findings suggest ways that providers can tailor supported employment programs to achieve success with a diverse array of clinical subpopulations.

Correlates of Insight in Serious Mental Illness

This study extends research into insight by examining its relationship to a variety of demographic, clinical, neurocognitive, and psychosocial variables among a broad diagnostic sample of 211 adults with serious mental illness. Participants completed a full battery of instruments measuring these variables. Results support a relationship between ratings of poor insight and a psychotic (vs. mood) diagnosis, increased psychiatric symptoms, poorer social skills, and negative medication attitudes. Minorities and those with a substance abuse diagnosis were also more likely to be rated as having poor insight. No relationship was found between level of insight and age, gender, education level, neurocognitive deficits, hospitalization history, size of ones social network, or quality of life measures. Results are discussed in the context of improving the measurement and assessment of insight, conceptualizing interventions aimed at addressing level of insight, and improving outcomes for patients with severe and persistent mental illness. Findings also support a need for continued investigation of how mental illness is understood, experienced, and expressed across diverse groups of people living with mental illness.

Demographic Characteristics and Employment Among People with Severe Mental Illness in a Multisite Study

People with psychiatric disabilities experience disproportionately high rates of unemployment. As research evidence is mounting regarding effective vocational programs, interest is growing in identifying subgroup variations. Data from a multisite research and demonstration program were analyzed to identify demographic characteristics associated with employment outcomes, after adjusting for the effects of program, services, and study site. Longitudinal analyses found that people with more recent work history, younger age, and higher education were more likely to achieve competitive employment and to work more hours per month, while race and gender effects varied by employment outcome. Results provide strong evidence of demographic subgroup variation and need.