Volker Roder

Social cognition as a mediator variable between neurocognition and functional outcome in schizophrenia: empirical review and new results by structural equation modeling.

Cognitive impairments are currently regarded as important determinants of functional domains and are promising treatment goals in schizophrenia. Nevertheless, the exact nature of the interdependent relationship between neurocognition and social cognition as well as the relative contribution of each of these factors to adequate functioning remains unclear. The purpose of this article is to systematically review the findings and methodology of studies that have investigated social cognition as a mediator variable between neurocognitive performance and functional outcome in schizophrenia. Moreover, we carried out a study to evaluate this mediation hypothesis by the means of structural equation modeling in a large sample of 148 schizophrenia patients. The review comprised 15 studies. All but one study provided evidence for the mediating role of social cognition both in cross-sectional and in longitudinal designs. Other variables like motivation and social competence additionally mediated the relationship between social cognition and functional outcome. The mean effect size of the indirect effect was 0.20. However, social cognitive domains were differentially effective mediators. On average, 25% of the variance in functional outcome could be explained in the mediation model. The results of our own statistical analysis are in line with these conclusions: Social cognition mediated a significant indirect relationship between neurocognition and functional outcome. These results suggest that research should focus on differential mediation pathways. Future studies should also consider the interaction with other prognostic factors, additional mediators, and moderators in order to increase the predictive power and to target those factors relevant for optimizing therapy effects.

Integrated psychological therapy for schizophrenia patients

‘The recovery outcomes (from schizophrenia) are still poor. This indicates heterogeneous course patterns of schizophrenia, demanding multimodal treatments rather than a single intervention.’ Daniel R. Mueller and Volker Roder Author for correspondence University Psychiatric Services Bern, University Hospital of Psychiatry Bolligenstrasse 111, CH-3000 Bern 60, Switzerland Tel.: +41 319 309 915 Fax: +41 319 309 988 volker.roder@spk.unibe.ch Expert Rev. Neurotherapeutics 7(1), 1–3 (2007)

Effectiveness of Integrated Psychological Therapy (IPT) for Schizophrenia Patients: A Research Update

Standardized recovery criteria go beyond symptom remission and put special emphasis on personal and social functioning in residence, work, and leisure. Against this background, evidence-based integrated approaches combining cognitive remediation with social skills therapy show promise for improving functional recovery of schizophrenia patients. Over the past 30 years, research groups in 12 countries have evaluated integrated psychological therapy (IPT) in 36 independent studies. IPT is a group therapy program for schizophrenia patients. It combines neurocognitive and social cognitive interventions with social skills and problem-solving approaches. The aim of the present study was to update and integrate the growing amount of research data on the effectiveness of IPT. We quantitatively reviewed the results of these 36 studies, including 1601 schizophrenia patients, by means of a meta-analytic procedure. Patients undergoing IPT showed significantly greater improvement in all outcome variables (neurocognition, social cognition, psychosocial functioning, and negative symptoms) than those in the control groups (placebo-attention conditions and standard care). IPT patients maintained their mean positive effects during an average follow-up period of 8.1 months. They showed better effects on distal outcome measures when all 5 subprograms were integrated. This analysis summarizes the broad empirical evidence indicating that IPT is an effective rehabilitation approach for schizophrenia patients and is robust across a wide range of sample characteristics as well as treatment conditions. Moreover, the cognitive and social subprograms of IPT may work in a synergistic manner, thereby enhancing the transfer of therapy effects over time and improving functional recovery.

Development of specific social skills training programmes for schizophrenia patients: results of a multicentre study

Objective: The efficacy of three newly developed cognitive social skills training programmes for residential, vocational and recreational functioning (experimental groups) were compared with a traditional social skills training programme (control group) referring to cognitive and social abilities, psychopathology and generalisation effects.

One-Year Randomized Controlled Trial and Follow-Up of Integrated Neurocognitive Therapy for Schizophrenia Outpatients

OBJECTIVE Cognitive remediation (CR) approaches have demonstrated to be effective in improving cognitive functions in schizophrenia. However, there is a lack of integrated CR approaches that target multiple neuro- and social-cognitive domains with a special focus on the generalization of therapy effects to functional outcome. METHOD This 8-site randomized controlled trial evaluated the efficacy of a novel CR group therapy approach called integrated neurocognitive therapy (INT). INT includes well-defined exercises to improve all neuro- and social-cognitive domains as defined by the Measurement And Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative by compensation and restitution. One hundred and fifty-six outpatients with a diagnosis of schizophrenia or schizoaffective disorder according to DSM-IV-TR or ICD-10 were randomly assigned to receive 15 weeks of INT or treatment as usual (TAU). INT patients received 30 bi-weekly therapy sessions. Each session lasted 90min. Mixed models were applied to assess changes in neurocognition, social cognition, symptoms, and functional outcome at post-treatment and at 9-month follow-up. RESULTS In comparison to TAU, INT patients showed significant improvements in several neuro- and social-cognitive domains, negative symptoms, and functional outcome after therapy and at 9-month follow-up. Number-needed-to-treat analyses indicate that only 5 INT patients are necessary to produce durable and meaningful improvements in functional outcome. CONCLUSIONS Integrated interventions on neurocognition and social cognition have the potential to improve not only cognitive performance but also functional outcome. These findings are important as treatment guidelines for schizophrenia have criticized CR for its poor generalization effects.

Integrated Psychological Therapy and Integrated Neurocognitive Therapy

This chapter contains 2 examples of combined group therapy approaches for schizophrenia patients: the integrated psychological therapy (IPT) and one of its further developments, the integrated neuroco

Integrated Psychological Therapy: Effectiveness in Schizophrenia Inpatient Settings Related to Patients' Age

OBJECTIVE Elderly people with schizophrenia often suffer from cognitive impairments, which affect their social functioning. Today, only a few therapy approaches for middle-aged and older patients are available. The Integrated Psychological Therapy (IPT) combines neurocognitive and social cognitive interventions with social skills approaches. The aim of this study was to evaluate (1) whether IPT is effective in younger patients (age < 40 years) and middle-aged patients (age ≥ 40 years) and (2) whether control conditions (treatment as usual or unspecific group activities) reveal some change in outcome depending on age. METHOD A total of 15 controlled IPT studies with 632 inpatients with schizophrenia were evaluated in a standard meta-analytic procedure. Studies were categorized into two age categories. RESULTS Significant medium to large effect sizes (ES) were evident for IPT independent of age on the global cognitive score (mean score of all cognitive variables), on neurocognition, social cognition, social functioning, psychopathology, and the global therapy effect (mean of all variables). The IPT effects in middle-aged patients were significantly larger on the global cognitive score, on neurocognition, and on social cognition compared with younger patients. Opposite results could be observed in control conditions. Only younger patients participating in the control conditions showed small but significant ES on these variables, but almost middle-aged control patients did not. However, none of the differences in the control conditions were significant between the two age categories. A moderator analysis obtained no evidence for a strong impact of IPT variations, therapy setting, patient characteristics, and methodologic rigor of the research design. CONCLUSIONS These results support evidence for the efficacy of IPT independent of age. Results further indicate the need of goal-oriented specific psychological interventions for middle-aged and older patients with schizophrenia.

Schemazentrierte emotiv-behaviorale Therapie (SET): Eine randomisierte Evaluationsstudie an Patienten mit Persönlichkeitsstörungen aus den Clustern B und C

Hintergrund: Bislang herrscht ein erheblicher Mangel an Gruppentherapieverfahren für Patienten mit unterschiedlichen Persönlichkeitsstörungen. Vor diesem Hintergrund entwickelte unsere Arbeitsgruppe einen neuen manualisierten Therapieansatz, der schematherapeutische, emotionszentrierte, kognitive und verhaltenstherapeutische Methoden integriert, die «Schemazentrierte emotiv-behaviorale Therapie» (SET). Patienten und Methoden: Randomisierter Kontrollgruppenvergleich zwischen der SET und einem Therapieverfahren zur Verbesserung sozialer Fertigkeiten mit insgesamt 93 ambulanten oder teilstationären Patienten mit einer Persönlichkeitsstörung der Cluster B oder C (DSM-IV). Ergebnisse: Signifikant stärkere Verbesserungen lassen sich in der SET-Gruppe bei den interpersonalen Verhaltensweisen, dem emotionalen Coping und den symptomatischen Beeinträchtigungen nachweisen. Klinisch relevante Effekte zugunsten der SET finden sich in der Reduktion des Leidensdrucks, des Störungsgrades und der Hoffnung auf Besserung. Daneben wird in der SET-Gruppe eine hochsignifikant niedrigere Dropout-Rate bzw. eine signifikant stärkere Nutzung des Therapieangebots beobachtet. Vergleichbar sind die Therapieergebnisse beider Gruppen im Bereich des behavioralen Copings und der Selbstwirksamkeit. Diskussion und Schlussfolgerungen: Mit der SET scheint ein Therapieansatz vorzuliegen, der bei Patienten mit Persönlichkeitsstörungen auf hohe Akzeptanz stößt und eine effiziente Behandlung im Gruppensetting ermöglichen könnte. Auch unter klinischen und ökonomischen Gesichtspunkten könnte die SET einen wichtigen Beitrag für die bestehende Krankenversorgung leisten.

Effekte neuer kognitiv-behavioraler Therapieprogramme zur Verbesserung spezifischer sozialer Fertigkeiten bei schizophren Erkrankten Eine kontrollierte Studie

ZusammenfassungAusgehend von dem mehrfach evaluierten “Integrierten Psychologischen Therapieprogramm” für schizophrene Patienten (IPT) entwickelte die Berner Arbeitsgruppe 3 neue Therapieprogramme zur Verbesserung sozialer Fertigkeiten, welche die Rehabilitationsthemen Wohnen, Arbeit und Freizeit (WAF) einbeziehen. Um kritischen Einwänden gegenüber bestehenden Therapieprogrammen zu sozialen Fertigkeiten Rechnung zu tragen, wurden dabei für schizophren Erkrankte besonders geeignete kognitiv-emotionale Interventionsmethoden einbezogen.Im Rahmen der vorliegenden Multi-Center-Studie erfolgte ein Vergleich des Unterprogramms “Soziale Fertigkeiten” des IPT (Kontrollgruppe) mit den neuen Therapieprogrammen (WAF, Experimentalgruppe). Therapie- und Nachbehandlungsphase dauerten jeweils 12 Wochen. Der Katamnesezeitraum betrug knapp ein Jahr. Kontrollmittel wurden zum kognitiven, sozialen und psychopathologischen Bereich erhoben. Die Experimentalgruppen zeigten einen höheren globalen Behandlungseffekt und eine signifikant größere Symptomreduktion als die Kontrollgruppe. Aufgrund der Ergebnislage könnten die neuen Therapieprogramme zum Wohn-, Arbeits- und Freizeitbereich in der Standardversorgung eingesetzt werden und damit herkömmliche Therapieansätze zu sozialen Fertigkeiten ersetzen.SummaryBased on the Integrated Psychological Therapy (IPT) for schizophrenia patients, the Berne group developed three specific cognitive behaviour therapy programmes for treating residential, vocational, and recreational functioning. We added new cognitive-emotional methods to these programmes that were devised especially for schizophrenia patients, taking into consideration the criticism of traditional social skill training methods. In the present multicentre study, these new programmes (experimental group) were compared with a traditional social skills training programme (control group, IPT “Social Skills” subprogramme). Both the therapy and aftercare phase each lasted 12 weeks and the follow-up phase 1 year. Assessment instruments covered psychopathology, cognitive functioning, and social adjustment. Higher ratings of global treatment effects and significant reductions in symptoms were obtained in the experimental group. In view of the favourable results, these newly designed social skill training programmes may replace more conventional therapy approaches in the future.

Teaching schizophrenic patients recreational, residential and vocational skills

Three therapy programs have recently been devised as a further development of the Integrated Psychological Therapy (IPT) for patients with schizophrenia. They offer targeted and structured behavior therapy in residential, vocational and recreational activity-three areas of rehabilitation which have been neglected in Europe, despite evidence from numerous prospective and retrospective studies showing severe impairment in these areas of psychosocial functioning in schizophrenia. The three therapy programs, aimed at enabling patients to lead more independent and satisfying lives in the community, have shown promise but need further research for their empirical validation.