Robert Paul Liberman

Training and quality assurance with the structured clinical interview for DSM-IV (SCID-I/P)

Accuracy in psychiatric diagnosis is critical for evaluating the suitability of the subjects for entry into research protocols and for establishing comparability of findings across study sites. However, training programs in the use of diagnostic instruments for research projects are not well systematized. Furthermore, little information has been published on the maintenance of interrater reliability of diagnostic assessments. At the UCLA Research Center for Major Mental Illnesses, a Training and Quality Assurance Program for SCID interviewers was used to evaluate interrater reliability and diagnostic accuracy. Although clinically experienced interviewers achieved better interrater reliability and overall diagnostic accuracy than neophyte interviewers, both groups were able to achieve and maintain high levels of interrater reliability, diagnostic accuracy, and interviewer skill. At the first quality assurance check after training, there were no significant differences between experienced and neophyte interviewers in interrater reliability or diagnostic accuracy. Standardization of training and quality assurance procedures within and across research projects may make research findings from study sites more comparable.

Operational criteria and factors related to recovery from schizophrenia

Schizophrenia is often conceptualized by clinicians and researchers alike as a chronic illness with persisting, relapsing or deteriorating symptoms, and no hope for sustained remission and recovery of functioning. Countering this perspective, retrospective and prospective studies with both chronic and recent onset patients suggest that schizophrenia has a heterogeneous course, which can be favorably influenced by comprehensive and continuous treatment as well as personal factors such as family support and good neurocognitive functioning. The factors influencing recovery are mostly malleable through treatment and may often lead to a sustained remission of symptoms and normal or near-normal levels of functioning.To facilitate future research in this area, an operational definition of recovery from schizophrenia is proposed that includes symptom remission; full- or part-time involvement in work or school; independent living without supervision by family or surrogate caregivers; not fully dependent on financial support from disability insurance; and having friends with whom activities are shared on a regular basis. To satisfy the definition of recovery from the long-term illness of schizophrenia, each of the above criteria should be sustained for at least two consecutive years. For validation, these criteria were submitted to focus groups comprising clients, family members, practitioners, and researchers. Using this operational definition, a pilot study was conducted to identify the self-attributions, clinical characteristics and neurocognitive correlates of 23 individuals who have recovered from schizophrenia. The focus groups endorsed most of the criteria as being relevant to the construct of recovery, although there were differences between research investigators and others. The pilot study generated hypotheses for future testing, suggesting that quality of sustained treatment, near-normal neurocognition, and absence of the deficit syndrome were key factors associated with recovery. With operational definitions and variables identified as possible facilitators of recovery, both hypothesis-generating and testing research can proceed with the aim to identify factors that are malleable and can become targets for therapeutic intervention. There are many extant, evidence-based biobehavioral treatments, as well as mental health service systems for their delivery, that could form the basis for rapid progress in promoting recovery. However, obstacles would have to be overcome to the dissemination, re-invention and utilization of empirically validated treatments, while rigorous, controlled research on determinants of recovery are simultaneously begun.

The neurocognitive effects of low-dose haloperidol: a two-year comparison with risperidone

BACKGROUND Neurocognitive deficits are core features of schizophrenia that are linked to functional outcome for the disorder. Recent studies and reviews have concluded that newer antipsychotic medications are better for neurocognitive deficits than conventional antipsychotic medications; however, one difficulty in interpreting this literature is that the comparisons have mainly been with high doses of conventional medications. This study examined the neurocognitive effects of low-dose haloperidol compared with risperidone over a 2-year period. METHODS Sixty-two patients were randomly assigned to medication (starting at 6 mg of each medication) and administered neurocognitive batteries six times over the course of follow-up. At 6 months, the mean dose of haloperidol was 5.0 mg, and the mean dose of risperidone was 6.0 mg. Neurocognitive data were reduced into cluster scores and a global summary score. RESULTS We found no significant overall differences in treatment effects on the cluster scores or the global score. The global score revealed a significant group by time interaction, reflecting the fact that the haloperidol group tended to improve initially and then stay stable, whereas the risperidone group improved more gradually over the follow-up period. CONCLUSIONS This study did not provide support for neurocognitive advantages of a newer antipsychotic medication over a low-dose conventional medication. We speculate that conventional medications may have neurocognitive benefits at low doses that are neutralized or reversed at higher doses.

Teaching medication management skills to schizophrenic patients.

A behaviorally-oriented program for teaching medication management skills to psychiatrically disabled patients was field-tested in a broad range of inpatient and partial-hospitalization clinics representing a wide geographic distribution across the United States. Results indicated that medical practitioners and others in the allied health professions were able to implement the medication management program with a high degree of fidelity. Additionally, patients who participated in the study demonstrated significant gains in cognitive mastery of the program content, high levels of skill attainment, increased utilization of medication management skills, and a significant increase in medication compliance.

Consistency of Brief Psychiatric Rating Scale Factor Structure across a Broad Spectrum of Schizophrenia Patients

Background: The Brief Psychiatric Rating Scale (BPRS) has been the workhorse of psychopathology assessment in studies of schizophrenia and related psychotic disorders for over 40 years. Our goal was to evaluate the discriminant validity of the BPRS across the broad spectrum of persons with schizophrenia. Sampling and Methods: The total sample of 565 subjects with schizophrenia (84%) or schizoaffective disorder (16%) came from eight separate studies conducted under the aegis of the UCLA Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation over a period of 15 years. The total sample could be divided into three subsamples based on illness chronicity and degree of refractoriness to treatment: Recent-onset patients had been ill for less than 2 years (n = 178), stable chronic patients between 2 and 19 years (n = 243) and treatment-refractory patients for more than 19 years (n = 144). Exploratory principal components analysis and varimax rotation were performed on the total sample. The results of each of the three subsamples were compared to the total sample using a correlation matrix and by calculating a coefficient of congruence. Results: A 4-factor solution was considered the most interpretable for each subsample, reflecting the same 4 components identified in the total sample: positive symptoms, negative symptoms, agitation-mania and depression-anxiety. Correlation coefficients and coefficient of congruence were very high, ranging from 0.91 to 0.98. Conclusions: The consistency of the 4-factor solution of the 24-item BPRS across the range of subjects, from first psychotic episode to long-stay, institutionalized patients, supports the use of these factors and this instrument as a whole to track changes over time and with treatment in research and clinical samples.

Recovery from schizophrenia: a challenge for the 21st century

While much professional interest, public advocacy and media attention accompanied the neuroscientific research advances of the Decade of the Brain, much less prominence was accorded to the very considerable progress in psychiatric treatment, rehabilitation and community-based services for persons with schizophrenia. The increasing availability of evidence-based practices and more optimistic views of optimal outcomes possible in schizophrenia are of much practical importance to consumers and practitioners alike. Expectations for substantial improvements in a larger proportion of individuals with schizophrenia than heretofore are emerging on psychiatrys radar screen, especially in symptom control, psychosocial functioning and quality of life. We believe that it is now realistic to set as a goal for professionals and consumers the feasibility of recovery from schizophrenia for half or more of individuals with the first episode of schizophrenia. In this issue of the International Review of Psychiatry, we aim to clarify the rationale for this ambitious clinical objective and stimulate research that will bring it to fruition within a decade. Five domains of advocacy, clinical and empirical work, have converged to bring recovery from schizophrenia to the fore and make it a realistic aim for practitioners and consumers.These include (a) a conceptual framework to guide research and understanding of recovery as a process leading to a defined outcome; (b) new modes of measurement that can permit recovery from schizophrenia to be operationally defined and empirical studies of recovery to proceed; (c) the arrival of a critical mass of evidence-based treatments that can support the progress of consumers to recovery; (d) an emphasis on positive and normative role functioning for treatment and rehabilitation; and (e) empowerment of consumers and their families that has made recovery their personally meaningful goal. The vulnerability-stress-protective factors model of schizophrenia can help researchers to organize data that are heuristic regarding factors that affect recovery or, at the other end of the spectrum, poor outcome. Recovery can be operationally defined by dimensions related to symptom remission and functioning in family, work, friendship, residential and recreational arenas. Considerable evidence-based treatments are available to promote improved functioning of consumers in the domains relevant to recovery. The current state of research on recovery has generated ample hypotheses for planning hypothesistesting studies and for evaluating quality of care and clinical outcomes that will move the important goal of recovery forward.

Social skills training for schizophrenia: Review and future directions

Abstract A significant amount of progress has been made in documenting the effectiveness of social skills training strategies for schizophrenia. In an effort to update the literature, the authors first discuss definitions of social skill, competence, and adjustment. Following this, the skills training studies of the past decade are reviewed. These studies indicate several areas in which skills training approaches are useful, and also many areas wherein further modification of techniques is required. Future directions are proposed, with recommendations made regarding the need for: (a) highly focused training protocols; (b) more rigorous assessment of skill generalization and outcome; (c) strategies for clarifying the interrelationships between schizophrenic symptoms, antipsychotic medications, and social skills; and (d) documentation of the increasingly important role of neurocognition in mediating social skill, skill acquisition, and social competence in schizophrenia.

Vocational outcomes of an integrated supported employment program for individuals with persistent and severe mental illness.

We examined the effectiveness of an integrated supported employment (ISE) program, which augments Individual Placement & Support (IPS) with social skills training (SST) in helping individuals with SMI achieve and maintain employment. A total of 163 participants were randomly assigned to three vocational rehabilitation programs: ISE, IPS, and traditional vocational rehabilitation (TVR). After fifteen months of services, ISE participants had significantly higher employment rates (78.8%) and longer job tenures (23.84 weeks) when compared with IPS and TVR participants. IPS participants demonstrated better vocational outcomes than TVR participants. The findings suggested that ISE enhances the outcomes of supported employment, endorsing the value of SST in vocational rehabilitation.

Evaluating the capacity to work of the mentally ill.

This study explored the relationship between psychiatric symptomatology and the functional capacity to work. Subjects were diagnosed using DSM-III criteria and were grouped into categories of psychotic or nonpsychotic, and disabled or nondisabled, in regard to adjudication for mental impairment from the Social Security Administration (SSA). There were significant relationships between disability status and work capacity, in the direction of better performance for the nondisabled subjects. This finding reflected concordance between the evaluation procedure used in the study and the SSAs disability determination process. There was considerable overlap in work performance among subjects, however, suggesting that a functional assessment of work capacity might improve disability determination in certain cases. Results suggested that these work assessments might be as short as one or two days.

Contingency contracting with families of delinquent adolescents

A program of intensive, brief behavioral treatment was implemented with 28 recidivistic delinquent adolescents and their parents. Treatment, carried out in the home by a masters degree psychologist, consisted of three interventions spaced at weekly intervals. Contingency contracting, communication skills training, and videotape feedback were used with the six families who did not drop out of the program. A within-subject, multiple baseline design for these six families was used to assess the impact of the interventions on school attendance, compliance with curfew and chores, and verbal abusiveness to parents. Reliability of parental report was established for curfew compliance by random calls by a telephone answering service. The experimental group of six adolescents was compared with 16 adolescents who had an initial home visit before dropping out of the study on such measures as school grades, anti-social probationary incidents, and the Jesness Behavior Checklist. Results failed to show any systematic impact of the behavioral interventions on any of the response measures employed except for a possible beneficial effect of contracting on verbal abusiveness. Together with other studies showing a lack of effect of direct, behavioral intervention with families containing delinquent adolescents, the findings from this research should lead behavior therapists to be cautious in their applying contigency contracting in the short-term family treatment of delinquents.